Preoperative axillary nodal staging of invasive lobular breast cancer with ultrasound guided fine needle aspiration in patients with suspicious ultrasound findings versus aspiration in all patients - A retrospective single institutional analysis.

INTRODUCTION: - At present, surgical strategies for breast cancer patients with >2 lymph nodes (LN) involved differ from those with no or lower degree of nodal involvement. Preoperative assessment of the axilla is less sensitive in patients with lobular carcinoma (ILC) than patients with other histological tumour types. MATERIALS AND METHODS: - A retrospective analysis of axillary staging by palpation, axillary ultrasound (AXUS) and AXUS-guided fine-needle aspiration cytology (FNAC) of 153 patients with ILC diagnosed and operated on between January 2013 and December 2020 was performed. Patients had either sentinel node biopsy or axillary lymph node dissection according to current practice. In period 1, patients had FNAC only when AXUS suggested nodal involvement (n = 106), and in period 2, all ILC patients had axillary FNAC (n = 47). RESULTS: - Of the factors associated with >2LNs involvement, logistic regression suggested only AXUS/FNAC based staging as independent variable for all patients. Patients with AXUS-guided FNAC had a significantly higher proportion of true negative and lower proportion of true positive cases in the P2 period (0 vs 55% and 72% vs 11% for >2 LNs involvement, respectively; both p < 0.0001). CONCLUSIONS: - AXUS-guided FNAC of all ILC patients did not result in improved preoperative identification of patients with >2 metastatic LNs but increased the false-negative rate of the assessment by producing false-negative results in patients who would not have undergone a biopsy due to negative AXUS findings.

Inactivation of enteric microbes in water by electro-chemical oxidant from brine (NaCl) and free chlorine.

Oxidant solutions of mostly free chlorine can be electrochemically produced on-site from brine (NaCl) solution and used to disinfect water at the household or community level. In this study electrochemical oxidant (ECO) from brine and free chlorine were evaluated under laboratory conditions for inactivation of test microbes. Purified suspensions of Escherichia coli, the rugose strain of Vibrio cholerae, Clostridium perfringens spores, MS2 coliphage and Cryptosporidium parvum oocysts were treated with 2 mg/L or 5 mg/L solutions of ECO or free chlorine at 5 degrees C and 25 degrees C and pH 6, 8, and 10 (pH 7 and 25 degrees C only for C. parvum oocysts) for contact times <60 min. Under nearly all conditions, inactivation kinetics were more rapid for E. coli, V. cholerae, C. perfringens spores and MS2 coliphage with ECO than with free chlorine. ECO reduced E. coli, V. cholerae and MS2 by >4 log10 within 30 min and C. perfringens spores by >2 log10 within 10 min at pH 8 and 25 degrees C. Contrary to previous results, however, C. parvum oocysts were not inactivated by ECO, and the reasons for this difference are uncertain. The on-site electrolytic generation of oxidants from brine provided a convenient and inexpensive disinfectant containing free chlorine that was effective against many enteric microbes, for the treatment of household and community drinking-water supplies worldwide. However, the effectiveness of such oxidants for inactivating C. parvum oocysts was variable and sometimes ineffective.

Chlorination and safe storage of household drinking water in developing countries to reduce waterborne disease.

Simple, effective and affordable methods are needed to treat and safely store non-piped, gathered household water. This study evaluated point-of-use chlorination and storage in special plastic containers of gathered household water for improving microbial quality and reducing diarrhoeal illness of consumers living under conditions of poor sanitation and hygiene. Community families were recruited and randomly divided into intervention (household water chlorination and storage in a special container) and control (no intervention) households. Microbes in stored household water were extensively inactivated by 1-5-mg/L doses of hypochlorite. Escherichia coli levels in stored household waters were < 1/100 mL in most intervention households but readily detectable at high levels in control households. Stored water of intervention households was also lower in Clostridium perfringens and heterotrophic plate count bacteria than in control households. The intervention reduced household diarrhoeal illness. In Bolivia, monthly episodes of household diarrhoeal illness were 1.25 and 2.2 in intervention and control families, respectively (P = < 0.002) indicating that 43% of community diarrhoea was preventable by using the intervention. In Bangladesh, mean episodes of child diarrhoea/1,000 d were 19.6 and 24.8 in intervention and control groups respectively (P = < 0.03) indicating that about 24% of observed diarrhoea was preventable by using the intervention. Chlorine disinfection and storage in an appropriate container significantly improved the microbiological quality of non-piped household drinking water and reduced community diarrhoeal disease. Widespread use of this simple treatment and storage system for non-piped domestic water has the potential to dramatically reduce the global burden of waterborne diarrhoeal disease.

The role of child care in a community-wide outbreak of hepatitis A.

OBJECTIVE: To evaluate the role of child care centers in a community-wide hepatitis A epidemic. METHODS: We analyzed surveillance data during an epidemic in Maricopa County, Arizona, from January to October 1997 and conducted a case-control study using a sample of cases reported from June to November. Cases were physician-diagnosed and laboratory confirmed; control subjects were frequency matched by age and neighborhood. Information regarding hepatitis A risk factors, including child care-related exposures, was collected. Characteristics of all licensed child care centers in the county were obtained through review of computerized lists from the Arizona Office of Child Day Care Licensing. Surveillance data were linked to the child care list to determine which centers had reported hepatitis A cases. We conducted univariate and multivariate conditional logistic analyses and calculated population attributable risks (PAR). RESULTS: In total, 1242 cases (50/100 000 population) were reported. The highest rates occurred among people aged 0 to 4 (76/100 000), 5 to 14 (95/100 000), and 15 to 29 (79/100 000) years. The most frequently reported risk factor was contact with a hepatitis A patient (45%). However, nearly 80% of these contacts were with individuals who attended or worked in a child care center. Overall, child care center-related contact could have been the source of infection for 34% of case-patients. In the case-control study, case-patients (n = 116) and control subjects (n = 116) did not differ with respect to demographic characteristics. A total of 51% of case-patients compared with 18% of control subjects reported attending or working in a child care setting (direct contact; adjusted odds ratio [OR]: 6.0; 95% confidence interval [CI]: 2.1-23.0) or being a household contact of such a person (indirect contact; OR: 3.0; 95% CI: 1.3-8.0). In age-stratified analyses, the association between hepatitis A and direct or indirect contact with child care settings was strongest for children <6 years old and adults aged 18 to 34 years. Household contact with a person with hepatitis A also was associated with hepatitis A (OR: 9.2; 95% CI: 2.6-58.2). The presence of a child <5 years old in the household was not associated with hepatitis A. The estimated PAR for direct child care contact was 23% (95% CI: 16-34), for indirect child care contact was 21% (95% CI: 13-35), and for any child care contact was 40% (95% CI: 30-53). Information on 1243 licensed child care centers was obtained, with capacity ranging from 5 to 479 slots (mean: 87). Thirty-four (2.7%) centers reported hepatitis A cases. Centers that had a mean capacity of >50 children were more than twice as likely to have had a reported case of hepatitis A (OR: 2.6; 95% CI: 1.1-6.7). Among the 747 centers that accepted >50 children, having infant (OR: 3.7; 95% CI: 1.6-8.3), toddler (OR: 6.3; 95% CI: 2.2-20.0), or full-day service (OR; undefined; 95% CI: 1.7- ~) was associated with having a reported case of hepatitis A. CONCLUSIONS: In Maricopa County, people associated with child care settings are at increased risk of hepatitis A, and child care attendees may be an appropriate target group for hepatitis A vaccination. Considering the estimated proportion of children who attended child care and were old enough to receive hepatitis A vaccine (>/=2 years of age) and the calculated PAR, approximately 40% of cases might have been prevented if child care center attendees and staff had been vaccinated. However, epidemiologic studies indicate that the proportion of cases that are attributable to child care center exposure varies considerably among counties, suggesting that this exposure may be associated with an increased risk of hepatitis A in some communities but not in others. To prevent and control hepatitis A epidemics in communities, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics have adopted a long-term strategy of routine vaccination of children who live in areas with consistently elevated hepatitis A rates. After demonstrating cost-effectiveness, a rule was implemented in January 1999 to require hepatitis A vaccination of all children who are aged 2 to 5 years and enrolled in a licensed child care facility in Maricopa County. Other communities with similar epidemiologic features might consider routine vaccination of child care center attendees as a long-term hepatitis A prevention strategy. Consistent with current recommendations, in communities with persistently elevated hepatitis A rates where child care center attendance does not play an important role in hepatitis A virus transmission in the community, child care centers may nonetheless provide a convenient access point for delivering hepatitis A as well as other routine childhood vaccinations.

[Poliomyelitis outbreak caused by vaccine-derived virus in Haiti and the Dominican Republic]. / Brote de poliomielitis en Haití y la República Dominicana debido a un virus derivado de la vacuna antipoliomielítica oral.

In October 2000, the Ministries of Health of the Dominican Republic and Haiti notified two cases of acute flaccid paralysis (AFP) in rural areas, one of them in a 9-month-old female, and the other in a 2-year-old female, respectively. Stool samples that were obtained from these cases, which occurred in July and August 2000, after a 9-year interruption of wild poliovirus circulation in the Western Hemisphere, revealed the presence of type 1 poliovirus. Genetic sequencing, which was later performed at the Centers for Disease Control and Prevention, in Atlanta, Georgia, United States of America, revealed an atypical descendant of the virus used in the manufacture of the oral polio vaccine (OPV), but with 3% genetic divergence with respect to the parent strain. Normally, viral isolates that derive from vaccine components show 99.5% genetic agreement with the parent strain; in wild polioviruses, on the other hand, this agreement is usually less than 82.0%. Thus, the 3% genetic divergence detected in this study suggests that, in areas with low vaccine coverage, the virus used in the vaccine remained in circulation for at least two years, during which it recovered the neurovirulence and communicability of wild poliovirus type 1. This report describes the characteristics and results of the active search for cases of AFP that was sparked by the detection of the two index cases. It also looks at the public health implications of this outbreak for the entire Region of the Americas.

Evaluation of occupational transmission of hepatitis A virus among wastewater workers.

To provide information concerning potential occupational transmission of hepatitis A virus (HAV) among wastewater workers in a large city in the United States, a cross-sectional survey was performed using a saliva test to detect antibodies to HAV (anti-HAV). Fifty-nine (20%) of 302 participants tested positive for anti-HAV. After controlling for the confounding effects of age and race, wastewater work was not significantly associated with an increase in the prevalence of anti-HAV (prevalence ratio = 1.3; 95% confidence interval 0.7 to 2.4). Additionally, when examining only the wastewater workers, no statistically significant occupational risk factors for anti-HAV were identified. The results of this survey are consistent with the position of the Centers for Disease Control and Prevention regarding groups at risk for HAV infection.

Epidemiologic studies of Cyclospora cayetanensis in Guatemala.

In 1996 and 1997, cyclosporiasis outbreaks in North America were linked to eating Guatemalan raspberries. We conducted a study in health-care facilities and among raspberry farm workers, as well as a case-control study, to assess risk factors for the disease in Guatemala. From April 6, 1997, to March 19, 1998, 126 (2.3%) of 5, 552 surveillance specimens tested positive for Cyclospora; prevalence peaked in June (6.7%). Infection was most common among children 1.5 to 9 years old and among persons with gastroenteritis. Among 182 raspberry farm workers and family members monitored from April 6 to May 29, six had Cyclospora infection. In the case-control analysis, 62 (91%) of 68 persons with Cyclospora infection reported drinking untreated water in the 2 weeks before illness, compared with 88 (73%) of 120 controls (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4, 10.8 by univariate analysis). Other risk factors included water source, type of sewage drainage, ownership of chickens or other fowl, and contact with soil (among children younger than 2 years).

Diarrhoea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy.

A novel water quality intervention that consists of point-of-use water disinfection, safe storage and community education was field tested in Bolivia. A total of 127 households in two periurban communities were randomized into intervention and control groups, surveyed and the intervention was distributed. Monthly water quality testing and weekly diarrhoea surveillance were conducted. Over a 5-month period, intervention households had 44% fewer diarrhoea episodes than control households (P = 0.002). Infants < 1 year old (P = 0.05) and children 5-14 years old (P = 0.01) in intervention households had significantly less diarrhoea than control children. Campylobacter was less commonly isolated from intervention than control patients (P = 0.02). Stored water in intervention households was less contaminated with Escherichia coli than stored water in control households (P < 0.0001). Intervention households exhibited less E. coli contamination of stored water and less diarrhoea than control households. This promising new strategy may have broad applicability for waterborne disease prevention.

Panorama of acute diarrhoeal diseases in Mexico.

We examined the recent panorama of ADD related deaths in Mexico in an effort to assess the overall impact of control measures that may vary in space and time. We pay particular attention to mortality rates recorded between 1985-1995, that is, before and after the cholera emergency. The aim is to focus on the social groups at risk, using time series data represented in the form of images and produced by a geographic information system (GIS). We show the potential of such methods to define populations at risk and support the decision process.

Inactivation of Cryptosporidium parvum oocysts and Clostridium perfringens spores by a mixed-oxidant disinfectant and by free chlorine.

Cryptosporidium parvum oocysts and Clostridium perfringens spores are very resistant to chlorine and other drinking-water disinfectants. Clostridium perfringens spores have been suggested as a surrogate indicator of disinfectant activity against Cryptosporidium parvum and other hardy pathogens in water. In this study, an alternative disinfectant system consisting of an electrochemically produced mixed-oxidant solution (MIOX; LATA Inc.) was evaluated for inactivation of both Cryptosporidium parvum oocysts and Clostridium perfringens spores. The disinfection efficacy of the mixed-oxidant solution was compared to that of free chlorine on the basis of equal weight per volume concentrations of total oxidants. Batch inactivation experiments were done on purified oocysts and spores in buffered, oxidant demand-free water at pH 7 an 25 degrees C by using a disinfectant dose of 5 mg/liter and contact times of up to 24 h. The mixed-oxidant solution was considerably more effective than free chlorine in activating both microorganisms. A 5-mg/liter dose of mixed oxidants produced a > 3-log10-unit (> 99.9%) inactivation of Cryptosporidium parvum oocysts and Clostridium perfringens spores in 4 h. Free chlorine produce no measurable inactivation of Cryptosporidium parvum oocysts by 4 or 24 h, although Clostridium perfringens spores were inactivated by 1.4 log10 units after 4 h. The on-site generation of mixed oxidants may be a practical and cost-effective system of drinking water disinfection protecting against even the most resistant pathogens, including Cryptosporidium oocysts.

Inactivation of Cryptosporidium parvum Oocysts and Clostridium perfringens Spores by a Mixed-Oxidant Disinfectant and by Free Chlorine.

Volume 63, no. 4, p. 1600: The caption to Table 2 should read as follows: "Inactivation of Clostridium perfringens spores by 5-mg/liter doses of mixed oxidants or free chlorine in buffer at pH 7 at 25(deg)C." [This corrects the article on p. 1598 in vol. 63.].

Narrow-mouthed water storage vessels and in situ chlorination in a Bolivian community: a simple method to improve drinking water quality.

Epidemiologic investigations of the Latin America cholera epidemic have repeatedly implicated untreated drinking water and water touched by hands during storage as important vehicles for disease transmission. To prevent such transmission, we provided a new narrow-mouthed, plastic, water storage vessel and 5% calcium hypochlorite solution for home disinfection of stored water to a Bolivian Aymara Indian community at risk for cholera. We evaluated acceptance of this intervention and its effect on water quality. Each of 42 families in the study obtained water from a household well; fecal coliform bacteria were found in water from 39 (93%) of 42 wells and 33 (79%) of 42 usual water storage vessels. One group of families received the special vessels and chlorine (group A), a second received only the special vessels (group B), and a third served as a control group (group C). Water samples collected every three weeks from group A special vessels had lower geometric mean fecal coliform colony counts (P < 0.0001) and lower geometric mean Escherichia coli colony counts (P < 0.0001) than water from group B or C vessels. Adequate levels of free chlorine persisted in these vessels for at least 5 hr. The special vessels and chlorine solution were well accepted and continued to be used for at least six months. Use of the vessel and chlorine solution produced drinking water from nonpotable sources that met World Health Organization standards for microbiologic quality.

Low-cost safe water for the world: a practical interim solution.

A very large segment of the world's population is without a microbiologically safe water supply. It is estimated that in Latin America more than 40% of the population is utilizing water of dubious quality for human consumption. This figure is probably even higher in Africa and areas of southeast Asia. Water used for drinking and food preparation can be an important route of transmission for many of the most widespread and debilitating of the diseases that afflict humans. The cholera pandemic which struck Latin America in January 1991, and has become endemic in many of the countries, continues to exemplify the public health significance of contaminated drinking water. Ideally, this neglected segment of the world's population should be served with piped water systems that provide a continuous supply of microbiologically safe water, but this would require such enormous investments of financial and human resources that it is not reasonable to expect that it will be accomplished. Interim practical measures to assure microbiologically safe water are necessary. The public health intervention to accomplish this is described in this paper and has an annual per family cost of which ranges between $1.50 and $4. It consists of providing individual households with one or preferably two suitable water containers in which to disinfect and store the essential quantities of water that need to be free of pathogens, with the containers of a design that will preclude recontamination of the contents and enable the production and distribution of the water disinfectants to be managed at the local level. It includes the necessary component of public education, promotion and involvement to establish the sustainability of the measures as a community-based endeavor. Investigation and demonstration projects are being carried out in II countries to determine and perfect and appropriate intervention, and it has been proven that it is economically, technically and socially feasible to assure microbiologically safe water for the world's population that is threatened by waterborne diseases. Carefully controlled microbiological analysis of the untreated and treated water shows that waterborne pathogens can be destroyed or inactivated, and carefully controlled epidemiological studies being carried out by the Centers for Disease Control and Prevention show that this intervention achieves considerable reduction in the incidence of water borne disease. It is recommended that all developing countries initiate programs to replicate the health measure described in this paper in order to test its validity and to adapt it to their local conditions.