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In wild aquatic birds and poultry around the world, influenza A viruses carrying 15 antigenic subtypes of hemagglutinin (HA) and 9 antigenic subtypes of neuraminidase (NA) have been described. Here we describe a previously unidentified antigenic subtype of HA (H16), detected in viruses circulating in black-headed gulls in Sweden. In agreement with established criteria for the definition of antigenic subtypes, hemagglutination inhibition assays and immunodiffusion assays failed to detect specific reactivity between H16 and the previously described subtypes H1 to H15. Genetically, H16 HA was found to be distantly related to H13 HA, a subtype also detected exclusively in shorebirds, and the amino acid composition of the putative receptor-binding site of H13 and H16 HAs was found to be distinct from that in HA subtypes circulating in ducks and geese. The H16 viruses contained NA genes that were similar to those of other Eurasian shorebirds but genetically distinct from N3 genes detected in other birds and geographical locations. The European gull viruses were further distinguishable from other influenza A viruses based on their PB2, NP, and NS genes. Gaining information on the full spectrum of avian influenza A viruses and creating reagents for their detection and identification will remain an important task for influenza surveillance, outbreak control, and animal and public health. We propose that sequence analyses of HA and NA genes of influenza A viruses be used for the rapid identification of existing and novel HA and NA subtypes.

Guillemots banded in the northern Baltic Sea were screened for influenza A virus (IAV). Three out of 26 sampled birds tested positive by RT-PCR. Two of these were characterized as subtype H6N2. Phylogenetic analyses showed that five gene segments belonged to the American avian lineage of IAVs, whereas three gene segments belonged to the Eurasian lineage. Our findings indicate that avian IAVs may have a taxonomically wider reservoir spectrum than previously known and we present the first report of a chimeric avian IAV with genes of American and Eurasian origin in Europe.

Background When surgical treatment of dysplastic hip osteoarthrosis is necessary, osteotomy is preferable to fusion or THR. We evaluated periacetabular osteotomy as a method of choice. Patients and methods We treated 36 symptomatic dysplastic hip joints (32 patients) with the Bernese periacetabular osteotomy (PAO) between 1994 and 2001. We used the ilio-inguinal (I-I) approach in 32 hips and a modified Smith-Petersen (S-P) approach in 4. The patients were followed for mean 4 (1.5-8) years. In 1 patient with coxa valga, a varus femoral osteotomy was performed 1 year after PAO. 2 hips, in which we used the modified S-P approach, necessitated a capsulotomy. Results The median Merle d'Aubigne score increased from 13 points preoperatively to 16 points postoperatively. This improvement in terms of pain, motion and ambulation was accompanied by spatial reorientation and correction. The lateral center edge angle of Wiberg (CE) improved from an average of 7 degrees to 28 degrees. The anterior center edge angle of Lequesne (FP) improved from an average of 18 degrees to 28 degrees. The acetabular index angle (AC) improved from an average of 22 degrees to 10 degrees. Major complications included 1 partial lesion of the sciatic nerve, 1 malunion and 1 combined nonunion of the pubic and ischiatic osteotomy. 2 patients underwent subsequent total hip replacement (THR) for progressive osteoarthrosis with pain. Interpretation We found good radiographic correction of deformities, improvement of hip function and pain relief with an acceptable complication rate. With appropriate patient selection, this procedure is the most physiological treatment of symptomatic hip dysplasia in young adults. In addition to relieving symptoms, it may prevent and postpone the development of secondary osteoarthrosis.

Operationsziel Dreidimensionale Osteotomie um das Azetabulum zur Wiederherstellung der Uberdachung des Femurkopfs zur Schmerzverminderung ohne Gefahrdung der Beckenstabilitat.

Proven transmission of Chlamydia psittaci between humans has been described on only one occasion previously. We describe an outbreak which occurred in Sweden in early 2013, where the epidemiological and serological investigation suggests that one patient, severely ill with psittacosis after exposure to wild bird droppings, transmitted the disease to ten others: Two family members, one hospital roommate and seven hospital caregivers. Three cases also provided respiratory samples that could be analysed by PCR. All the obtained C. psittaci sequences were indistinguishable and clustered within genotype A. The finding has implications for the management of severely ill patients with atypical pneumonia, because these patients may be more contagious than was previously thought. In order to prevent nosocomial person-to-person transmission of C. psittaci, stricter hygiene measures may need to be applied.

Case-chaos methodology is a proposed alternative to case-control studies that simulates controls by randomly reshuffling the exposures of cases. We evaluated the method using data on outbreaks in Sweden. We identified 5 case-control studies from foodborne illness outbreaks that occurred between 2005 and 2012. Using case-chaos methodology, we calculated odds ratios 1,000 times for each exposure. We used the median as the point estimate and the 2.5th and 97.5th percentiles as the confidence interval. We compared case-chaos matched odds ratios with their respective case-control odds ratios in terms of statistical significance. Using Spearman's correlation, we estimated the correlation between matched odds ratios and the proportion of cases exposed to each exposure and quantified the relationship between the 2 using a normal linear mixed model. Each case-control study identified an outbreak vehicle (odds ratios = 4.9-45). Case-chaos methodology identified the outbreak vehicle 3 out of 5 times. It identified significant associations in 22 of 113 exposures that were not associated with outcome and 5 of 18 exposures that were significantly associated with outcome. Log matched odds ratios correlated with their respective proportion of cases exposed (Spearman ρ = 0.91) and increased significantly with the proportion of cases exposed (b = 0.054). Case-chaos methodology missed the outbreak source 2 of 5 times and identified spurious associations between a number of exposures and outcome. Measures of association correlated with the proportion of cases exposed. We recommended against using case-chaos analysis during outbreak investigations.

Norovirus outbreaks severely disrupt healthcare systems. We evaluated whether Websok, an internet-based surveillance system using search engine data, improved norovirus surveillance and response in Sweden. We compared Websok users' characteristics with the general population, cross-correlated weekly Websok searches with laboratory notifications between 2006 and 2013, compared the time Websok and laboratory data crossed the epidemic threshold and surveyed infection control teams about their perception and use of Websok. Users of Websok were not representative of the general population. Websok correlated with laboratory data (b = 0.88-0.89) and gave an earlier signal to the onset of the norovirus season compared with laboratory-based surveillance. 17/21 (81%) infection control teams answered the survey, of which 11 (65%) believed Websok could help with infection control plans. Websok is a low-resource, easily replicable system that detects the norovirus season as reliably as laboratory data, but earlier. Using Websok in routine surveillance can help infection control teams prepare for the yearly norovirus season.

Methicillin-resistant Staphylococcus aureus (MRSA) was found in a dog for the first time in Sweden in 2006. Between October 2006 and May 2007, MRSA was diagnosed in 7 more dogs that had been treated in 3 different small animal hospitals, located 150-200 km apart, in different counties of Sweden. Screening of the animal hospital staff and environment in these small animal hospitals showed 20 of 152 staff to be positive for MRSA, with rates between 2% and 18% in the different hospitals, while all 128 environmental samples were negative. All MRSA isolates from dogs and staff belonged to spa type t032, were Panton-Valentine leukocidin (PVL)-negative, and had indistinguishable pulsed-field gel electrophoresis patterns, except for 2 isolates with closely related patterns. To our knowledge, this is the first report of multiple outbreaks of MRSA in dogs caused by the same strain within a short time frame, and appearing in a country with low prevalence of MRSA in both humans and dogs. This highlights the importance of infection control programs in animal hospitals and in animal health care. Awareness of MRSA as an occupational risk for veterinary personnel is essential.

In June-July 2013, six counties notified the Swedish Institute for Communicable Disease Control of enterohaemorrhagic E.coli (EHEC) infections among attendees at a hotel in Dalarna, Sweden. An outbreak control team investigated to identify the source and implement control measures. We included individuals who attended the hotel between June 19th-25th in a cohort. We asked them about animal contact, swimming, and consumption of food items during this time using a questionnaire. A confirmed case was an EHEC O157:H7 outbreak strain positive individual who developed abdominal pain or diarrhoea between June 20th-July 2nd. We described the outbreak in time, place and person, calculated risk ratios (RR) and 95% confidence intervals (CI). We investigated the kitchen, tested and traced back implicated food items. 172 individuals responded. We identified 19 confirmed cases (Median age: 17 years, 64% female) with symptom onset between June 22nd-27th. Eating green salad on June 20th was associated with illness (RR:3.7;CI:1.3-11). The kitchen mixed green salads without records and destroyed leftovers immediately. Hence we could not conduct trace-back or obtain microbiological confirmation. Green salad contaminated before entering the kitchen was the likely outbreak source. We recommended early collaboration with food agencies and better restaurant records to facilitate future investigations.

In November 2010, approximate to 27,000 (approximate to 45%) inhabitants of Östersund, Sweden, were affected by a waterborne outbreak of cryptosporidiosis. The outbreak was characterized by a rapid onset and high attack rate, especially among young and middle-aged persons. Young age, number of infected family members, amount of water consumed daily, and gluten intolerance were identified as risk factors for acquiring cryptosporidiosis. Also, chronic intestinal disease and young age were significantly associated with prolonged diarrhea. Identification of Ctyptosporidium hominis subtype lbA10G2 in human and environmental samples and consistently low numbers of oocysts in drinking water confirmed insufficient reduction of parasites by the municipal water treatment plant. The current outbreak shows that use of inadequate microbial barriers at water treatment plants can have serious consequences for public health. This risk can be minimized by optimizing control of raw water quality and employing multiple barriers that remove or inactivate all groups of pathogens.

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

Between 1982 and 1985, 23 Kessel total shoulder arthroplasties were performed on 22 patients with rheumatoid arthritis. A clinical and radiographic review of the 5-year experience was evaluated in 1988 and published in 1992. Ten years later a followup study was done. Of the 22 patients, 11 have died and two were seriously ill and could not participate. Of the remaining nine patients, one had revision surgery after 2 years, leaving eight patients with a mean age of 61 years for this followup study. Shoulder function was evaluated subjectively using the Simple Shoulder Test, and pain was evaluated using a visual analog scale. New radiographs were taken. In general, the patients had a low functional level, but they were able to sleep on the surgically treated side and to manage daily hygiene. Five patients were pain free, and the worst recorded pain during the day was 35 mm on the visual analog scale. Two patients had their scapular component cemented at primary surgery. The radiographs showed no radiolucent zones around these components. The six other scapular components had radiolucent zones of 1 to 3 mm. No radiolucent zones were detected around the humeral components.

The name of Delphi still has a magical ring. Thousands of years after the famed Oracle ceased to deliver its ambiguous replies, it still attracts thousands of tourists. For anyone interested in Del...

The concept of partial rupture of the anterior cruciate ligament (ACL) has been confirmed by arthroscopic examination and palpation. We present a prospective study of 43 patients who were diagnosed arthroscopically as suffering from a partial rupture of the ACL by the same surgeon. The patients followed a rehabilitation protocol and were examined by an independant observer after 5 years. Twenty-five patients had a stable knee, whereas 18 eventually suffered a complete ACL rupture. ACL partial rupture is easily recognizable with arthroscopy, but the quantity and state of the still intact fibres is difficult to assess.

Faire une offrande à une divinité était une démarche très répandue de la pratique religieuse des Grecs. Le geste était donc banal et la nature du don extrêmement variable, pouvant aller d’une modeste terre cuite à une somptueuse intervention architecturale dans le sanctuaire du dieu ou de la déesse. Si l’offrande était variée, les intentions du donateur ou de la donatrice ne l’étaient pas moins, et s’affirmaient déjà dans le choix d’une divinité spécifique au sein d’un monde divin pluriel. Dès lors, un large éventail de questions s’offre à l’interprète moderne des pratiques religieuses antiques. Comment le fidèle choisissait-il telle divinité plutôt que telle autre ? Existe-t-il un lieu spécifique entre la divinité en question et le type d’offrande choisie ? Peut-on déduire le profil du destinataire divin de ta nature des offrandes mises au jour lors de la fouille d’un sanctuaire ? Et qu’en est-il du profil du dédicant ? Les distinctions « homme-femme » et « dieu-déesse » opèrent-t- elle au niveau de la pratique dédicatoire et peut-on déceler un effet de miroir entre elles ? L’ensemble des contributions ici publiées aborde ces différentes questions, en fixant plus précisément le regard sur les sanctuaires de divinités féminines. Quant aux fidèles, la donatrice était au centre des réflexions qui furent menées dans le colloque à l’origine de ce livre, mais le donateur trouve place également dans cette réflexion pluridisciplinaire sur les sanctuaires de déesses grecques.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Background Vascular endothelial growth factor (VEGF), epidermal growth factor (EGF) and monocyte chemotactic protein-1 (MCP-1) have previously been suggested to be potential biomarkers for chronic stress induced exhaustion. The knowledge about VEGF has increased during the last decades and supports the contention that VEGF plays an important role in stress and depression. There is scarce knowledge on the possible relationship of EGF and MCP-1 in chronic stress and depression. This study further examines the role of VEGF, EGF and MCP-1 in women with chronic stress induced exhaustion and healthy women during a follow-up period of two years. Methods and Findings Blood samples were collected from 105 women with chronic stress induced exhaustion on at least 50% sick leave for at least three months, at inclusion (T0), after 12 months (T12) and after 24 months (T24). Blood samples were collected at inclusion (T0) in 116 physically and psychiatrically healthy women. The plasma levels of VEGF, EGF and MCP-1 were analyzed using Biochip Array Technology. Women with chronic stress induced exhaustion had significantly higher plasma levels of VEGF and EGF compared to healthy women at baseline, T12 and at T24. There was no significant difference in plasma levels of MCP-1. Plasma levels of VEGF and EGF decreased significantly in women with chronic stress induced exhaustion during the two years follow-up. Conclusions The replicated findings of elevated levels of VEGF and EGF in women with chronic stress induced exhaustion and decreasing plasma levels of VEGF and EGF during the two years follow-up add important knowledge to the pathophysiology of chronic stress induced exhaustion.

The number of sporadic cases of Cryptosporidium identified in the Stockholm county area increased above the expected limit during October 2010. Additionally, two food-borne outbreaks of cryptosporidiosis occurred in two other Swedish cities: Umea (4 October) and Orebro (9 October). The outbreak investigations did not reveal any responsible food item, however fresh herbs were suspected. Thirty stool samples, originating from all three events, tested positive for Cryptosporidium oocysts. Polymerase chain reaction (PCR) and subsequent restriction fragment length polymorphism (RFLP) revealed that 27 individuals were infected with C. parvum, two with C. hominis, and one with C. felis. Using sequence analysis of the GP60 glycoprotein gene, a polymorphic marker with high intra-species diversity, we identified the same C. parvum subtype IIdA24G1 in samples from both the Umea outbreak and the Stockholm area cases, thus indicating a possible outbreak in the Stockholm area and establishing a link between these two events. C. parvum IIdA24G1 has not previously been described in connection with a food-borne outbreak. For the outbreak in Orebro, another subtype was identified: C. parvum IIdA20G1e. These findings demonstrate that subtyping C. parvum isolates using GP60 gene amplification can be used to link cases in an outbreak investigation and we recommend its use in future similar events.

Every year people from all over the Mediterranean set out for the Attic town of Eleusis to celebrate secret rites in honor of the goddess Demeter and her daughter Kore. All Greek-speaking men and women (not tainted by blood-guilt) could participate, and these Eleusinian Mysteries, promising a better afterlife for the initiated, came to enjoy immense popularity. Keywords: folkore and mythology; Greek history; religious history

Echinococcus multilocularis is a parasite that can cause alveolar echinococcosis disease. After the first positive finding of E. multilocularis in Sweden in 2011, a consulting group with representatives from relevant authorities was summoned. In this group, all relevant information was shared, strategies for information dissemination and any actions to be taken due to the finding of E. multilocularis were discussed and decided. The present paper describes the actions taken during 2011 and the results thereof, including surveillance in animals, risk assessment for humans to become infected and recommendations given to the public. Further discussion about whether the parasite was introduced, and if so, how, as well as possible future development of the infection in animals and humans in Sweden and future actions are included.

Until August, 161 cases of tick-borne encephalitis (TBE) were recorded in Sweden for 2011, leading to an incidence of 1.7 per 100,000 population. Fifty to 59 year-olds (24%) were most affected, 55% of the cases were males. An increase in TBE in Sweden has occurred in the last decade and might be explained by enlarged tick populations, more contact between TBE virus infected ticks and man, and also by growing awareness of the disease. Climatic conditions may have contributed to the increase.

The use of epithets was a fundamental component of Greek polytheism. The present study brings attention to a small subgroup of such divine bynames, referred to as individual epithets because they stem from the names of mortal individuals. The function of these epithets is to designate a deity specifically concerned with the individual in question, thereby providing a close relationship and personal benefits for the eponymous worshipper and his or her close kin. The article exemplifies the phenomenon through the investigation of a goddess Isis Aphrodite Dikaia identified in Hellenistic Delos. Through the epithet Dikaia, two Athenian brothers, Dikaios and Asklepiades, sons of Dikaios, intimately tie the deity to themselves and their family. It is moreover proposed that a positioning of the epithet in its historical and physical context furthers our understanding of its origins and significance. L’usage des épithètes était une composante fondamentale du polythéisme grec. Cet article se penche sur un petit groupe de surnoms de ce genre, que l’on appelle des épithètes individuelles, dans la mesure où elles dérivent du nom d’individus mortels. Ces épithètes ont pour fonction de montrer qu’une divinité est particulièrement concernée par l’individu en question, fournissant dès lors une relation étroite et des bienfaits personnels pour le fidèle éponyme et sa famille proche. L’étude illustre le phénomène en investigant la déesse Isis Aphrodite Dikaia que l’on rencontre dans la Délos hellénistique. Par l’épithète Dikaia, deux frères athéniens, Dikaios et Asklépiadès, fils de Dikaios, associent intimement la divinité à eux-mêmes et à leur famille. Il est en outre proposé qu’un replacement de l’épithète dans son contexte historique et physique approfondit notre compréhension de ses origines et de sa signification.