Laboratory-based investigation of suspected mumps cases submitted to the German National Reference Centre for Measles, Mumps, and Rubella, 2008 to 2013.

From 2008 to 2013, sample sets from 534 patients displaying clinical symptoms of mumps were submitted to the German Reference Centre for Measles, Mumps and Rubella. Mumps virus infection was confirmed in 216 cases (40%) by PCR and/or serology. Confirmed cases were more frequently seen in male than in female patients (128 vs. 81); the age group predominantly affected was 15 to 29 years old (65%, median age: 26.4 years). The majority of the confirmed cases had a remote history of vaccination with one or two doses of a mumps-containing vaccine (69%). Our results indicate that mumps virus caused two outbreaks in Bavaria in 2008 and 2010/2011 and a third one in Lower Saxony in 2011. Mumps virus genotype G was preponderantly detected from 2008 to 2013. For 107 of the 216 patients with a confirmed mumps infection, we correlated the results from PCR and serology. PCR detected cases during the first week after onset of symptoms (74% positive results). PCR worked best with throat swabs and oral fluids (61% and 60% positive results, respectively). IgM was more reliable with a longer time after onset of symptoms (67%), but indirect IgM serology was of insufficient sensitivity for vaccinated mumps cases (30%); the IgM µ-capture assay detected more cases in this group. Mumps virus is able to initiate an infection in vaccinated patients (secondary vaccine failure, SVF) although it is unclear to what extent. Since SVF does occur in highly vaccinated populations and IgM will not increase to detectable levels in all SVF patients, we strongly recommend using PCR plus serology tests to avoid false-negative diagnoses in vaccinated individuals with clinical signs of mumps.

Associations between fecal indicator bacteria prevalence and demographic data in private water supplies in Virginia.

Over 1.7 million Virginians rely on private water sources to provide household water. The heaviest reliance on these systems occurs in rural areas, which are often underserved with respect to available financial resources and access to environmental health education. This study aimed to identify potential associations between concentrations of fecal indicator bacteria (FIB) (coliforms, Escherichia coli) in over 800 samples collected at the point-of-use from homes with private water supply systems and homeowner-provided demographic data (household income and education). Of the 828 samples tested, 349 (42%) of samples tested positive for total coliform and 55 (6.6%) tested positive for E. coli. Source tracking efforts targeting optical brightener concentrations via fluorometry and the presence of a human-specific Bacteroides marker via quantitative real-time polymerase chain reaction (qPCR) suggest possible contamination from human septage in over 20 samples. Statistical methods implied that household income has an association with the proportion of samples positive for total coliform, though the relationship between education level and FIB is less clear. Further exploration of links between demographic data and private water quality will be helpful in building effective strategies to improve rural drinking water quality.

Quantitative analysis of microbial contamination in private drinking water supply systems.

Over one million households rely on private water supplies (e.g. well, spring, cistern) in the Commonwealth of Virginia, USA. The present study tested 538 private wells and springs in 20 Virginia counties for total coliforms (TCs) and Escherichia coli along with a suite of chemical contaminants. A logistic regression analysis was used to investigate potential correlations between TC contamination and chemical parameters (e.g. NO3(-), turbidity), as well as homeowner-provided survey data describing system characteristics and perceived water quality. Of the 538 samples collected, 41% (n = 221) were positive for TCs and 10% (n = 53) for E. coli. Chemical parameters were not statistically predictive of microbial contamination. Well depth, water treatment, and farm location proximate to the water supply were factors in a regression model that predicted presence/absence of TCs with 74% accuracy. Microbial and chemical source tracking techniques (Bacteroides gene Bac32F and HF183 detection via polymerase chain reaction and optical brightener detection via fluorometry) identified four samples as likely contaminated with human wastewater.

Prevalence of Cryptosporidium species in wildlife populations within a watershed landscape in southeastern New York State.

A cross-sectional study was conducted to determine the prevalence of Cryptosporidium in wildlife in the New York City (NYC) Watershed in southeastern New York State. A total of 6227 fecal samples were collected and evaluated from 5892 mammals (38 species), 263 birds (14 species), 2 reptiles (2 species), 8 amphibians (4 species), and 62 fish (15 species). Cryptosporidium was detected in 30 species. Of the species found positive for Cryptosporidium, 16 represented new records for this parasite-Alosa pseudoharengus, Larus delawarensis, Blarina brevicauda, Sorex cinereus, Parascalops breweri, Myotis lucifugus, Peromyscus maniculatus, Microtus pennsylvanicus, Clethrionomys gapperi, Tamiasciurus hudsonicus, Marmota monax, Erethizon dorsatum, Canis latrans, Mustela erminea, Mustela vison, and Lynx rufus. Factors such as age, sex, season, and land use were evaluated to determine if there was any association with infection by this parasite. Animals were more likely to be positive for Cryptosporidium during spring and in agricultural land use.

Cryptosporidium spp. from small mammals in the New York City watershed.

The objective of this study was to assess the potential role that wildlife plays in environmental degradation of watersheds through the contamination of the water supply with zoonotic genotypes of Cryptosporidium. Cryptosporidium isolates recovered from wildlife in the New York City (NYC) watershed were examined to determine genotype using a polymerase chain reaction protocol targeting the 18-Small Subunit (SSU) rRNA locus. Seventy-seven DNA samples recovered from 12 wildlife host species captured in the NYC watershed were amplified and sequenced. Data on risk factors associated with the perpetuation of these genotypes also were collected and analyzed. Although many genotypes appeared to be host-specific, 38% of the samples examined were identified as Cryptosporidium parvum, indicating the presence of zoonotic Cryptosporidium. Adult animals were more likely to shed the zoonotic strains of Cryptosporidium spp. Animals captured in the fall and winter were more likely to be infected with C. parvum than those captured in spring and summer.

An outbreak of cryptosporidiosis among alpaca crias and their human caregivers.

CASE DESCRIPTION: 6 alpaca crias from a single farm were examined because of diarrhea (n = 4) or decreased fecal production (n = 2). CLINICAL FINDINGS: Cryptosporidium parvum was identified by means of fecal flotation in samples from 5 of the 6 crias, and a diagnosis of cryptosporidiosis was made. In the remaining cria, a presumptive diagnosis of cryptosporidiosis was made. Three people involved in caring for the crias from this farm were subsequently confirmed to have cryptosporidiosis, and 3 other people were suspected to have cryptosporidiosis. Sequence analysis of the ssu rDNA gene loci confirmed C parvum as the causative agent in 4 of the 6 crias. Subsequent evaluation of the farm revealed 2 additional crias confirmed to have cryptosporidiosis. Stocking densities on the farm were high, with approximately 20 adults/acre in some pastures. TREATMENT AND OUTCOME: All 6 hospitalized crias were given supportive treatment consisting of antimicrobials, gastroprotectants, and fluids. All but 1 survived. Farm owners were advised to decrease stocking density on the farm. CLINICAL RELEVANCE: Findings suggested that zoonotic transmission of C parvum from alpacas to humans can occur.

Evaluation of polymerase chain reaction diagnosis of Cryptosporidium spp in dairy cattle and wildlife.

This study investigated the utility of the polymerase chain reaction (PCR) protocol as a screening test for Cryptosporidium spp in 125 fecal samples from dairy cattle and wild rodents. Samples initially examined by fecal flotation and ELISA were evaluated using four PCR protocols (18S SSU rRNA, TRAP-C2, HSP70, and COWP), and the relative accuracy and agreement of PCR protocols was assessed. Although PCR can be both highly sensitive and accurate, the ability of these protocols to accurately detect DNA in samples can vary. A combination of techniques may be the best choice for to screen samples for this parasite.

Dual-energy CT angiography in peripheral arterial occlusive disease.

We sought to study the accuracy of dual-energy computed tomographic angiography (DE-CTA) for the assessment of symptomatic peripheral arterial occlusive disease of the lower extremity by using the dual-energy bone removal technique compared with a commercially available conventional bone removal tool. Twenty patients underwent selective digital subtraction angiography and DE-CTA of the pelvis and lower extremities. CTA data were postprocessed with two different applications: conventional bone removal and dual-energy bone removal. All data were reconstructed and evaluated as 3D maximum-intensity projections. Time requirements for reconstruction were documented. Sensitivity, specificity, accuracy, and concordance of DE-CTA regarding degree of stenosis and vessel wall calcification were calculated. A total of 359 vascular segments were analyzed. Compared with digital subtraction angiography, sensitivity, specificity, and accuracy, respectively, of CTA was 97.2%, 94.1%, and 94.7% by the dual-energy bone removal technique. The conventional bone removal tool delivered a sensitivity of 77.1%, a specificity of 70.7%, and an accuracy of 72.0%. Best results for both postprocessing methods were achieved in the vascular segments of the upper leg. In severely calcified segments, sensitivity, specificity, and accuracy stayed above 90% by the dual-energy bone removal technique, whereas the conventional bone removal technique showed a substantial decrease of sensitivity, specificity, and accuracy. DE-CTA is a feasible and accurate diagnostic method in the assessment of symptomatic peripheral arterial occlusive disease. Results obtained by DE-CTA are superior to the conventional bone removal technique and less dependent on vessel wall calcifications.

Factors associated with the risk of Giardia species infection in two sympatric species of Peromyscus mice.

An epidemiologic case-control study was conducted to identify factors that predispose Peromyscus spp. to the risk of infection with Giardia sp. in watersheds. A total of 200 Giardia sp.-positive mice (cases) and a similar number of Giardia sp.-negative mice (controls) were selected from a population 2,528 mice captured in a watershed in southeastern New York State. The Giardia sp. infection status of the mice was determined by centrifugation concentration flotation and an enzyme-linked immunosorbent assay. The mice were later classified into 2 species, Peromyscus maniculatus and P. leucopus, using cellulose acetate electrophoresis of individual saliva samples. The risk of infection was evaluated while controlling for indigenous factors (age and sex) and exogenous factors (habitat and land use) that were hypothesized to influence the likelihood of infection with Giardia sp. The study population consisted of 257 (59%) P. leucopus and 165 (41%) P. maniculatus. Peromyscus leucopus mice were at a higher risk of becoming infected with Giardia in comparison to P. maniculatus (adjusted odds ratio = 40). The risk of Giardia sp. infection varied with the age of the animals, since adult animals were at higher risk than juvenile animals. This study suggested a difference in susceptibility to Giardia sp. between different species of mice.

Branched iliac bifurcation: 6 years experience with endovascular preservation of internal iliac artery flow.

OBJECTIVE: The objective of the current study was to share a 6-year experience with the iliac bifurcation device (IBD) and determine its safety and effectiveness in patients with common iliac artery aneurysms. METHODS: Between 2001 and 2006, 46 patients were prospectively enrolled in a single institution study on the IBD. Indications included unilateral or bilateral common iliac artery aneurysms (CIAA) (combined or not with abdominal aortic aneurysm endovascular repair). The first 26 patients were intended to receive a first generation unibody IBD and the following 20 patients the second generation, modular, IBD. RESULTS: In 33 patients out of 46 attempted (technical success per patient 72%), 35 iliac bifurcated devices (2 patients received bilateral IBD) out of 51 attempted (technical success per vessel 69%), were successfully implanted. The technical success rate (per vessel) was 58% for the first generation device and 85% for the second generation device. Inability to introduce the side branch into the IIA and intraoperative occlusions were the main reasons for technical failure. Among these failures, only two patients required open conversions. The mean +/- SD follow-up (radiological and clinical) of the 33 patients with a total of 35 successful IBD implantations was 26 +/- 17 months (median 24, range 3 to 60). During the follow-up period out of 35 successfully-implanted iliac bifurcation devices, four (11%) hypogastric side branch occlusions occurred, all within the first 12 months. Cumulative IBD side branch patency was 87% at 60 months. Comparing the first with the second generation IBD outcomes, cumulative patency rates at 2 years revealed no statistical difference (P = .774). No endoleak, and particularly no IBD, modular side branch disconnection, no late rupture, or deaths have yet been encountered. CONCLUSIONS: Preservation of pelvic circulation in high risk patients treated for bilateral or unilateral common iliac aneurysms combined or without AAA is feasible and secure exclusively by endovascular repair. New generation iliac bifurcated devices show a favourable intraoperative performance and long-term outcomes.

Hemangiosarcoma after endovascular aortic aneurysm repair.

PURPOSE: To report a rare case of hemangiosarcoma after endovascular aneurysm repair (EVAR). CASE REPORT: A 50-year-old man with Klinefelter syndrome presented 5 years after EVAR with a mass at the infrarenal aorta outside the stent-graft. Radiomorphologic and clinical signs were misleading because there had been evidence of an inflammatory process for more than a year. The stent-graft with the surrounding aorta was removed and replaced by a conventional tube graft. Systemic chemotherapy followed. The tumor recurred after 12 months, with pulmonary metastases and tumor embolic occlusion of his left femoral artery. Thrombectomy was performed, and a second course of chemotherapy was administered. The patient died 24 months after the conversion procedure. CONCLUSION: Morphological changes of the aneurysm wall seen on computed tomographic scans of EVAR patients may not be incidental or signs of infection; rather, a malignant tumor of the aorta or lymphatic disease, although rare, have to be taken into consideration as well.

Fenestrated and branched grafts for para-anastomotic aortic aneurysm repair.

PURPOSE: To investigate the use of fenestration and branch artery stenting during endovascular stent-graft repair of para-anastomotic aneurysms (PAA). METHODS: A retrospective review was conducted of 9 patients (all men; mean age 71 years, range 60-80) who received custom-designed fenestrated endoprostheses for PAA repair. Eight tubular fenestrated devices and 1 composite device (fenestrated tube plus modular bifurcated body) with a total of 31 fenestrations were used. RESULTS: The mean operating time was 318+/-93 minutes (range 220-485); the mean fluoroscopy time was 77+/-38 minutes (range 39-158), during which a mean 121+/-81 mL (range 33-300) of contrast was used. Technical success was achieved in all cases. Over a mean follow-up of 12+/-5.5 months (range 6-24), 1 secondary intervention was carried out due to a break in a side branch stent-graft; 2 transient renal impairments and 1 permanent renal insufficiency unrelated to renal artery patency were observed. So far, no vessel loss has emerged. CONCLUSION: Conventional repair of PAA has been a standard procedure for many years, though it carries high surgical risk as well as perioperative mortality. Fenestrated endografts may be a promising alternative in selected patients.

Fenestrated endografting for aortic aneurysm repair: a 7-year experience.

PURPOSE: To present a 7-year single-center clinical experience with fenestrated endografts and side branches. METHODS: Between April 1999 and August 2006, 63 patients (57 men; mean age 70.5+/-11.6 years, range 25-89) received custom-designed Zenith fenestrated endoprostheses for a variety of aneurysms (59 abdominal, 1 thoracoabdominal, and 3 thoracic). They were all unsuitable for standard EVAR owing to short aortic necks and high risk for open surgery. RESULTS: Nineteen tube grafts and 44 composite bifurcated grafts with a total of 122 fenestrations and 58 side branches were used. Technical success was achieved in 55 (87.3%) patients and in 118 (96.7%) vessels. Treatment success was 93.7%. The mean follow-up was 23+/-18 months (median 14, range 6-77). Overall, 9 (7.4%) visceral branches were lost: 4 intraoperative, 2 perioperative, and 3 late. There were 12 (19.0%) endoleaks identified: 5 (7.9%: 4 type Ia and 1 fenestration-related type III) primary and 7 (11.1%: 4 type II, 1 type I, and 2 type III) secondary endoleaks; 4 resolved, 4 were treated, and 4 are under observation. At 77 months, 75.3% of patients were free of a reintervention. All reinterventions were performed within the first 14 months. Fourteen cases of renal impairment were seen [6 permanent (only 1 on dialysis) and 8 transient]. One (1.6%) conversion and 1 (1.6%) rupture were recorded; aneurysm-related mortality was 4.8% (3/63). CONCLUSION: The favorable outcomes in this study, which encompasses the team's learning curve with fenestrated endografts and side branches, support the use of these devices in selected patients.

Improving endograft stability by accommodation onto the aortic bifurcation.

PURPOSE: To report the technique for deploying a 3-part endovascular graft onto the native aortic bifurcation for greater stent-graft stability. TECHNIQUE: The Zenith Composite Endovascular Graft is a 3-part system consisting of a proximal tubular body with an uncovered Gianturco Z stent, a distal bifurcated body, and a contralateral leg. Proximally, 8-mm flexible interstent gaps facilitate precise infrarenal aortic placement, even in angulated necks. Technically, the bifurcated part is deployed first and pulled down to the aortic bifurcation, while the tubular main body and contralateral leg deployment follow. Using this technique to accommodate the graft onto the natural aortic bifurcation, distal stability can be enhanced and graft migration minimized. CONCLUSION: The Composite configuration can be an alternative to ensure a higher security index in difficult anatomies. It may be beneficial in patients with short (10-15 mm), angulated (>60 degrees ), or conical necks and deserves investigation in these patient populations.