Sources and survival of Listeria monocytogenes on fresh, leafy produce.

Listeria monocytogenes is an intracellular human pathogen which enters the body through contaminated food stuffs and is known to contaminate fresh leafy produce such as spinach, lettuce and rocket. Routinely, fresh leafy produce is grown and processed on a large scale before reaching the consumer through various products such as sandwiches and prepared salads. From farm to fork, the fresh leafy produce supply chain (FLPSC) is complex and contains a diverse range of environments where L. monocytogenes is sporadically detected during routine sampling of produce and processing areas. This review describes sources of the bacteria in the FLPSC and outlines the physiological and molecular mechanisms behind its survival in the different environments associated with growing and processing fresh produce. Finally, current methods of source tracking the bacteria in the context of the food supply chain are discussed with emphasis on how these methods can provide additional, valuable information on the risk that L. monocytogenes isolates pose to the consumer.

Fate of Escherichia coli O145 present naturally in bovine slurry applied to vegetables before harvest, after washing and simulated wholesale and retail distribution.

AIMS: To determine the fate of Escherichia coli on vegetables that were processed through commercial wash treatments and stored under simulated retail conditions at 4°C or wholesale at fluctuating ambient temperatures (0-25°C, dependent on season). METHODS AND RESULTS: Bovine slurry that was naturally contaminated with E. coli O145 was applied without dilution or diluted 1:10 using borehole water to growing potatoes, leeks or carrots. Manure was applied 1 week prior to harvest to simulate a near-harvest contamination event by manure deposition or an application of contaminated water to simulate a flooding event or irrigation from a contaminated water source. At harvest, crops were contaminated at up to 2 log cfu g-1 . Washing transferred E. coli into the water of a flotation tank used for potato washing and did not completely remove all traces of contamination from the crop. Manure-contaminated potatoes were observed to contain 0·72 cfu E. coli O145 g-1 after processing and retail storage. Manure-contaminated leeks harboured 0·73-1·55 cfu E. coli O145 g-1 after washing and storage. There was no cross-contamination when leeks were spray washed. Washing in an abrasive drum resulted in less than perfect decontamination for manure-contaminated carrots. There were five post-distribution isolations from carrots irrigated with contaminated water 24 h prior to harvest. CONCLUSIONS: Standard commercial washing and distribution conditions may be insufficient to reliably control human pathogenic E. coli on fresh produce. SIGNIFICANCE AND IMPACT: Previous speculation that the cause of a UK foodborne disease outbreak was soil from imperfectly cleaned vegetables is plausible.

Ineffective hand washing and the contamination of carrots after using a field latrine.

UNLABELLED: A study was undertaken to simulate the likely effects of a field worker with poor hygienic practices that had returned to work too soon after recovering from an infection by an enteric pathogen. The studies simulated a variety of hand-washing practices from no washing to washing with soap and water followed by an application of alcohol gel after using a field latrine. The numbers of generic Escherichia coli isolated from workers' hands declined with increasing thoroughness of hand-washing treatments with unwashed hands > water > water and soap > water, soap and alcohol gel. Where gloves were worn the counts obtained for the treatments were significantly reduced, but it was observed that unwashed hands contaminated gloves during the process of putting them on. Hand contamination following the use of a field latrine transferred contamination to carrots. These results suggest that if no gloves are worn it would be best practice to wash hands with water and soap and apply alcohol gel after using a field latrine. Wearing gloves reduced the risk of contaminating handled produce but workers should still wash their hands after using a field latrine before applying gloves. SIGNIFICANCE AND IMPACT OF THE STUDY: This study shows that inadequate hand hygiene in the field following the use of a field latrine can transfer bacterial contamination to hand-harvested carrots. Where fresh produce crops are to be handled by workers, wearing gloves reduces the risk of contaminating produce but workers should still wash their hands after using a field latrine before applying gloves. If no gloves are worn it would be best practice to wash hands with water and soap and apply alcohol gel after using a field latrine.

Risk Assessment or Assessment of Risk? Developing an Evidence-Based Approach for Primary Producers of Leafy Vegetables To Assess and Manage Microbial Risks.

Over the last 10 years, some high-profile foodborne illness outbreaks have been linked to the consumption of leafy greens. Growers are required to complete microbiological risk assessments (RAs) for the production of leafy crops supplied either to retail or for further processing. These RAs are based primarily on qualitative judgements of hazard and risks at various stages in the production process but lack many of the steps defined for quantitative microbiological RAs by the Codex Alimentarius Commission. This article is based on the discussions of an industry expert group and proposes a grower RA approach based on a structured qualitative assessment, which requires all decisions to be based on evidence and a framework for describing the decision process that can be challenged and defended within the supply chain. In addition, this article highlights the need for evidence to be more easily available and accessible to primary producers and identifies the need to develop hygiene criteria to aid validation of proposed interventions.

Spot urinary protein analysis for excluding significant proteinuria in pregnancy.

The aim of this research was to compare the accuracy of urinary protein/creatinine ratio (PCR) and albumin/creatinine ratio (ACR) in defining optimal cut-off points to rule-out significant proteinuria (>300 mg/24 h) in pregnancy. The secondary outcome measure was to determine the investigation of choice to evaluate proteinuria used by maternity units in the UK. PCR and ACR were calculated on first (PCR1, ACR1) void urine samples of the 24-hour urinary protein collection (24UP). Sensitivity and specificity was calculated for different cut-off points for PCR1 and ACR1 to rule-out significant proteinuria. An online survey was sent to RCOG members questioning them on their investigation of choice to evaluate proteinuria. We concluded from our results that both PCR and ACR are good rule-out tests for significant proteinuria in pregnancy using cut-off points of <20 mg/mmol and <2.5 mg/mmol. PCR is the investigation of choice in 56% of UK units studied.

Distribution and decline of human pathogenic bacteria in soil after application in irrigation water and the potential for soil-splash-mediated dispersal onto fresh produce.

AIMS: To improve our understanding of the survival and splash-mediated transfer of zoonotic agents and faecal indicator bacteria introduced into soils used for crop cultivation via contaminated irrigation waters. METHODS AND RESULTS: Zoonotic agents and an Escherichia coli marker bacterium were inoculated into borehole water, which was applied to two different soil types in early-, mid- and late summer. Decline of the zoonotic agents was influenced by soil type. Marker bacteria applied to columns of two soil types in irrigation water did not concentrate at the surface of the soils. Decline of zoonotic agents at the surface was influenced by soil type and environmental conditions. Typically, declines were rapid and bacteria were not detectable after 5 weeks. Selective agar strips were used to determine that the impact of water drops 24-87 µl could splash marker bacteria from soil surfaces horizontal distances of at least 25 cm and heights of 20 cm. CONCLUSIONS: Soil splash created by rain-sized water droplets can transfer enteric bacteria from soil to ready-to-eat crops. Persistence of zoonotic agents was reduced at the hottest part of the growing season when irrigation is most likely. SIGNIFICANCE AND IMPACT OF THE STUDY: Soil splash can cause crop contamination. We report the penetration depths and seasonally influenced declines of bacteria applied in irrigation water into two soil types.

The air-borne distribution of zoonotic agents from livestock waste spreading and microbiological risk to fresh produce from contaminated irrigation sources.

AIMS: To assess the risks of zoonotic agents in dissemination of livestock wastes into the environment by airborne distribution. To subsequently assess the survival time of zoonotic agents, introduced in irrigation water, on the phylloplane of produce. METHODS AND RESULTS: An Escherichia coli marker was introduced into pig slurry which was spread using a rain gun sprayer. Air sampling was undertaken to determine the distance reached by the marker. No recoveries were observed at a distance of 250 m. Borehole water, contaminated with zoonotic agents, was used to irrigate field plots sown with lettuce and spinach. Decline in bacterial numbers on the phylloplane was observed with time. After initial rapid decreases, we were unable to detect any pathogen from the phylloplane, 1 month after contamination. CONCLUSIONS: These preliminary results suggest that the risks to public health from the aerosolized spread of bacteria during slurry spreading by rain gun are low. Although, zoonotic agents on crop phylloplanes perish quickly, the risks of overhead irrigation of fresh produce 3 weeks before harvest should still be considered. SIGNIFICANCE AND IMPACT OF THE STUDY: These preliminary results improve our understanding on the fate of zoonotic agents in the environment. Spreading liquid livestock wastes by an airborne mechanism may not pose a significant public health risk. Detection of zoonotic agents 3 weeks after contamination of lettuce and spinach means that consideration should be given by the farmers until the time of harvest, when irrigating fresh produce with water that may have been directly or indirectly contaminated by livestock wastes.

A randomized phase II trial of indole-3-carbinol in the treatment of vulvar intraepithelial neoplasia.

The aim of this study was to determine the potential therapeutic benefits of indole-3-carbinol (I3C) in the management of vulvar intraepithelial neoplasia (VIN). Women with histologically confirmed high-grade VIN were randomized to receive 200 and 400 mg/day of I3C. Symptomatology by visual analog scale and vulvoscopic appearance were assessed at recruitment, 6 weeks, 3 months, and 6 months. Tissue biopsy to determine histologic response was obtained at completion of the study period. Urine samples were obtained at each visit to determine 2-hydroxyestrone to 16-alpha-hydroxyestrone ratios. Data from 12 women were suitable for analysis. There was a significant improvement in symptomatology with the introduction of I3C (itch, P= 0.018; pain, P= 0.028). Lesion size and severity were also significantly reduced (size, P= 0.005; appearance, P= 0.046). In addition, there was a significant increase in 2-hydroxyestrone to 16-alpha-hydroxyestrone ratio following commencement of I3C, P= 0.05. However, tissue biopsy from the worst-affected vulval areas revealed no improvement in grade of VIN during the 6-month period, P= 0.317. There were no significant differences in results between those women taking 200 mg/day of I3C and those on 400 mg/day. This study has shown significant clinical improvement in symptomatology and vulvoscopic appearance of VIN with I3C therapy. Further clinical and scientific investigations are required to support these preliminary findings.

Risk of malignancy index for referral of ovarian cancer cases to a tertiary center: does it identify the correct cases?

Characterization of adnexal masses to identify patients with malignant ovarian tumors preoperatively for referral to a cancer center for treatment has been extensively studied. A simple algorithm called "risk of malignancy index" (RMI) reported by Jacobs incorporated the serum CA125 level, menopausal status, and ultrasound morphologic features. This algorithm has subsequently been tested on retrospective and prospective data with encouraging results. However, these studies did not include cases that had had both their serum CA125 measurements and ultrasound examinations from a diverse range of laboratories and sonographers. The purpose of this study was to determine the effectiveness of the RMI algorithm for identifying cases of ovarian malignancy presenting at cancer units for subsequent referral to a cancer center. All cases of suspected ovarian malignancy referred to the Northern Gynaecological Oncology Centre (NGOC) during an 18-month period were identified from the NGOC database. A case note review was performed, and the following data were extracted: patient demographics, the referring physician and the operating surgeon, ultrasound morphology, serum CA125 levels, and menopausal status. All patients had their ultrasound performed by sonographers at the peripheral unit according to local protocols. A total of 182 patients with a pelvic mass were referred to the center for surgery. A total of 24% patients had benign tumors, 6% had tumors of borderline malignancy, and 70% had invasive tumors. A total of 145 cases had an RMI >200; 125 of these had ovarian or peritoneal cancers. An RMI >200 had a sensitivity of 88.5% for diagnosing invasive lesions. The overall sensitivity of this algorithm for diagnosing all borderline, invasive ovarian, or primary peritoneal lesions was 87.4%, and the positive predictive value was 86.8%. Our data confirm the effectiveness of the RMI algorithm in clinical practice for the identification and subsequent referral to cancer centers of cases of potential ovarian malignancy. We therefore recommend its continued use.

Gonadotropins mediate DNA synthesis and protection from spontaneous cell death in human ovarian surface epithelium.

Gonadotropins have been implicated in the development of epithelial ovarian cancers. These tumors are derived from ovarian surface epithelium (OSE). The purpose of this study was to determine the effects of these hormones on DNA synthesis and spontaneous cell death in primary cultures of OSE and three immortalized OSE cultures. Primary cultures of OSE cells were generated from the ovaries of women with benign disease. The effects of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) on DNA synthesis and cell death were determined using [(3)H]thymidine incorporation and JAM assays. Significant inductions of DNA synthesis were demonstrated with LH in 4/12 (33%) primary cultures of OSE and 2/3 OSE cell lines and with FSH in 4/11 (36%) primary cultures of OSE and 2/3 OSE cell lines. A significant protection from cell death was also observed in the presence of FSH in 2/4 primary cultures of OSE and 1/3 OSE cell lines and in the presence of LH in 1/4 primary cultures of OSE and 2/3 OSE cell lines. The results indicate that while gonadotropins have the potential to induce cell proliferation and protect from cell death in OSE cells in vitro, their effects are variable in OSE cells from different women.

Recurrent smear abnormalities where repeat loop treatment is not possible: is hysterectomy the answer?

OBJECTIVE: The objective of this study was to determine the outcome of women who underwent hysterectomy for recurrent cytological abnormalities where repeat loop treatment was considered not to be technically possible because of insufficient remaining cervical tissue. METHODS: Women undergoing a hysterectomy for the above indication at the Northern Gynaecological Cancer Centre over a period of 10 years (1992-2001) were identified from a prospectively collected database. Case notes were then reviewed and women undergoing hysterectomy for other indications were excluded. Relevant demographic and clinical data were then extracted. RESULTS: 33 patients meeting the above criteria were identified. The overall hysterectomy rate for this indication was 0.73%. 20 out of the 33 women had significant pathology on the hysterectomy specimen. 95% of these had high-grade disease with one having a Stage 1A1 squamous carcinoma. None of the patients required more radical treatment than a simple hysterectomy. There were no major complications following the hysterectomy. Positive endocervical margins on the previous loop specimen (P = 0.05) was an important correlating factor predicting the presence of CIN on the hysterectomy specimen. One out of the thirty hysterectomies (3.3%) performed using the vaginal route had incomplete excision compared to one of three (33%) using the abdominal route. Hysterectomy was successful in treating 85.2% of the women; only 4 women subsequently developed vaginal intraepithelial neoplasia. CONCLUSION: Simple hysterectomy appears to be a suitable diagnostic and treatment option for women with recurrent high-grade cytological abnormalities where further loop treatment is technically not possible. Incomplete excision at the endocervical margin on the previous loop specimen was the main factor associated with the presence of cervical intraepithelial neoplasia at hysterectomy.

Improving patient and carer communication, multidisciplinary team working and goal-setting in stroke rehabilitation.

OBJECTIVE: To determine the extent to which three forms of multidisciplinary team (MDT) care in stroke rehabilitation meet the standards set by the United Kingdom National Service Framework (NSF). DESIGN: Consecutive assessment of the three forms of care was completed. SUBJECTS: The study included three groups of 25 stroke inpatients on the stroke rehabilitation ward. INTERVENTION: (1) A standard weekly MDT meeting using a standard form for documentation; (2) a standard MDT meeting using a newly devised form; and (3) a novel MDT ward round using the new form, and attended by doctors. RESULTS: MDT ward rounds result in significantly better consideration of patients' needs (median 7 per patient compared with 0 and 5 in phases one and two), enhanced SMART (specific, measurable, achievable, realistic and time framed) goal-setting (median 3 per patient compared to 1 in phases one and two); greater patient involvement (12 patients compared to 0 and 4 in phases one and two); and improved team working (measured using the team climate inventory) than do MDT meetings. CONCLUSIONS: In the present study, standard weekly MDT meetings did not meet the standards set for MDT care by the NSF. The use of a MDT ward round allows these standards to be achieved.

The role of human papillomavirus type 16 and the fragile histidine triad gene in the outcome of cervical neoplastic lesions.

The presence of high-risk human papillomavirus, loss of heterozygosity on chromosome 3p and fragile histidine triad gene expression were assessed as potential markers of cancer and CIN progression in 83 cervical cancers and 74 cervical intraepithelial neoplasia grade 1 lesions. Human papillomavirus type 16 was an indicator of vascular involvement in cancers. Loss of heterozygosity, especially in the fragile histidine triad gene intron 5, was an indicator of high-grade tumours, greater tumour depth and lymph node involvement. Abnormal fragile histidine triad gene expression was more frequent in cervical intraepithelial neoplasia grade 1 lesions with increased risk of disease progression.

Laparoscopically assisted radical vaginal hysterectomy vs. radical abdominal hysterectomy for cervical cancer: a match controlled study.

OBJECTIVES: The technical feasibility of laparoscopically assisted radical vaginal hysterectomy has been well described, but its advantages over the open technique remain largely unproven. We reviewed and compared our experiences with both approaches. METHODS: All patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) between 1996 and 2003 were identified and matched for age, FIGO stage, histological subtype and nodal metastases using a control group of women who underwent radical abdominal hysterectomy (RAH) during the same time period. RESULTS: Fifty-seven women were listed for LARVH, resulting in five conversions. Fifty cases were matched successfully using the criteria above. The majority of cases were FIGO stage 1B1. Statistically significant differences (P < 0.05) were present when the following were compared for LARVH vs. RAH: duration of surgery (median 180 vs. 120 min), blood loss (median 350 vs. 875 ml), hospital stay (median 5 days vs. 8 days) and duration of continuous bladder catheterisation (median 3 days vs. 7 days). There were no statistically significant differences with regard to nodal yield, completeness of surgical margins or perioperative complication rate. Four major complications (8%, three cystotomies and one enterotomy) occurred in the LARVH group and three in the RAH group (6%, one pulmonary embolism, one ureteric injury and one major haemorrhage). Three women in LARVH group had seen a specialist regarding postoperative bladder dysfunction, versus 12 in the RAH group (P = 0.04). No patients in the LARVH group reported constipation requiring regular laxatives, versus six in the RAH group (P = 0.03). Median follow-up was 52 months for LARVH and 49 months for RAH. There was no significant difference between recurrence rates or overall survival (94% for LARVH vs. 96% for RAH). CONCLUSIONS: Despite the inherent limitations of LARVH and its associated learning curve, the procedure conveys many advantages over the open technique in terms of blood loss, transfusion requirement and hospital stay. In addition, the incidence of postoperative bladder and bowel dysfunction appears low-suggesting improved quality of life-without compromising survival.

Uterine inversion by a mixed müllerian tumor of the corpus.

Mixed müllerian tumors (MMT) of the uterus have been reported following the use of tamoxifen. Rarely, these tumors lead to an uterine inversion. The surgical approach of a uterine inversion forms a therapeutic challenge. In this article, a case of uterine inversion due to a MMT is reported, together with a literature review regarding the developing mechanisms and management.

Contralateral groin node metastasis following ipsilateral groin node dissection in vulval cancer: a case report.

BACKGROUND: The majority of vulval cancers are of the squamous cell type. Current operative management strategies are based on modifications of radical vulvectomy and groin node dissection, enabling a more individualised and conservative approach to surgery. This has led to interesting dilemmas regarding the most appropriate management in certain individuals. CASE: We describe a case of a contralateral recurrence following unilateral groin node dissection for vulval cancer, with an initial single microscopically positive node. The patient did not receive adjuvant treatment. Evidence regarding the safety of this approach is discussed. CONCLUSION: The subject remains controversial, and further such cases should be recorded in the literature in order to gather more information on this difficult problem.

The human ovarian surface epithelium is an androgen responsive tissue.

The pathogenesis of epithelial ovarian cancer remains unclear. From epidemiological studies raised levels of androgens have been implicated to increase the risk of developing the disease. The purpose of this study was to determine the responses of normal human ovarian surface epithelium to androgens. We have established primary cultures of human ovarian surface epithelium from patients undergoing oophorectomy for benign disease. Total RNA was isolated from these cultures and expression of mRNA encoding for the androgen receptor was demonstrated using reverse transcriptase polymerase chain reaction. The presence of androgen receptor in sections of normal ovary was also investigated using an antibody against androgen receptor. The effects of androgens on DNA synthesis and cell death were determined. Eight out of eight (100%) cultures expressed mRNA encoding the androgen receptor. The presence of androgen receptor in ovarian surface epithelium of sections of normal ovaries was demonstrated in all sections. Mibolerone, a synthetic androgen, caused a significant stimulation of DNA synthesis in 5 out of 9 (55%) cultures when used at a concentration of 1 nM. Mibolerone also caused a significant decrease in cell death in 2 out of 5 (40%) cultures tested. We have demonstrated that the ovarian surface epithelium is an androgen responsive tissue and that androgens can cause an increase in proliferation and a decrease in cell death. These findings have important implications for the pathophysiology of ovarian carcinogenesis.