Pathogen-specific risk factors and protective factors for acute diarrheal illness in children aged 12-59 months in São Paulo, Brazil.

Diarrheal diseases are a leading cause of childhood morbidity and mortality in Latin America. Most studies have focused on infants but not on older children. We enrolled 505 children (age, 12-59 months) with diarrhea and age-matched controls in a case-control study in Sao Paulo, Brazil. Independent risk factors for diarrhea included another household member with diarrhea (matched odds ratio [mOR], 8.1; attributable fraction [AF], 0.17; P<.001) and consumption of homemade juice (mOR, 1.8; AF, 0.10; P=.01); protective factors included boiling of the baby bottle or nipple (mOR, 0.60; AF, 0.19; P=.026), childcare at home (mOR, 0.58; AF, 0.12; P=.004), and piped sewage (mOR, 0.58; AF, 0.05; P=.047). Hand washing by the caretaker after helping the child defecate protected against Shigella infection (mOR, 0.35; P<.05). Preparation of rice, beans, or soup in the morning and serving it to children after noon were associated with enterotoxigenic Escherichia coli infection (mOR, 8.0; P<.05). In these poor households, 28% of cases of diarrhea in 1-4-year-old children was attributable to easily modifiable exposures.

Comparing the costs of three sealant delivery strategies.

We analyzed the cost-effectiveness of 3 sealant delivery strategies: Seal all (SA), seal children assessed to be at risk by screening (TARGET), and seal none (SN). We assumed a nine-year analytic horizon, a 3% discount rate, and zero screening costs. Estimates for sealant costs ($27.00) and restoration costs ($73.77), annual caries increment (0.0624 surfaces), sealant failure rate (20% in yr 1 and 3% thereafter), annual amalgam failure rate (4.6%), and sensitivity (0.635) and specificity (0.795) of screening were obtained from published studies. Under baseline assumptions, TARGET dominated (cost less and reduced caries) SA and SN. If annual caries increment exceeded 0.095 surfaces, SA dominated TARGET, and if increment exceeded 0.05 surfaces, TARGET dominated SN. If sealant costs decreased to $6.00 (reported cost for school programs), TARGET dominated SN for caries increments exceeding 0.007 surfaces, and SA dominated TARGET for caries increments exceeding 0.034 surfaces.

Escherichia coli O157:H7 diarrhea in the United States: clinical and epidemiologic features.

BACKGROUND: Escherichia coli O157:H7 is increasingly recognized as a cause of bacterial diarrhea in the United States, but the frequency of its isolation and the clinical and epidemiologic features of E. coli O157:H7 infection in a large, geographically diverse population of patients have not been well described. OBJECTIVE: To determine the frequency of isolation of E. coli O157:H7 relative to that of other bacterial enteric pathogens in a nationwide sample of patients and to identify the clinical and epidemiologic features of E. coli O157:H7 infection. DESIGN: Population prevalence study from October 1990 to October 1992. SETTING: 10 U.S. hospitals. PATIENTS: Both inpatients and outpatients who had stool samples submitted to 1 of 10 laboratories for routine pathogen identification. MEASUREMENTS: Clinical, epidemiologic, and laboratory information was collected for infected and uninfected patients. Isolates of E. coli O157:H7 were tested for production of Shiga toxin. Patient charts were then reviewed. RESULTS: Escherichia coli O157:H7 was isolated from 118 (0.39%) of the 30463 fecal specimens tested. The proportion of fecal specimens with isolates was higher at northern sites (0.57%) than at southern sites (0.13%) (P < 0.001). Escherichia coli O157:H7 was more likely to be isolated from visibly bloody stool specimens than from specimens without visible blood (odds ratio [OR], 59.2 [95% CI, 36.6 to 96.0) and was the pathogen most commonly isolated from visibly bloody stool specimens that yielded a bacterial enteric pathogen (39% of such specimens). The highest age-specific isolation proportions from fecal specimens for E. coli O157:H7 were in patients 5 to 9 years of age (0.90%) and 50 to 59 years of age (0.89%). Clinical features independently associated with E. coli O157:H7 infection compared with the other enteric pathogens included a history of bloody diarrhea (OR, 18.6 [CI, 7.4 to 48.6]), visibly bloody stool specimens (OR, 8.1 [CI, 3.6 to 18.3]), no reported fever (OR, 8.3 [CI, 1.6 to 50.0]), leukocyte count greater than 10 x 10(9)/L (OR, 4.0 [CI, 1.7 to 9.5]), and abdominal tenderness on physical examination (OR, 2.9 [CI, 1.2 to 7.2]). CONCLUSIONS: In some geographic areas and some age groups, isolation proportions from fecal specimens for E. coli O157:H7 surpassed those of other common enteric pathogens. One third of isolates of this organism came from nonbloody specimens. Because person-to-person transmission of E. coli O157:H7 is not uncommon and infection with this organism may cause severe disease, stool specimens from all patients with a history of acute bloody diarrhea should be cultured for E. coli O157:H7.

Endogenous antibody production to botulinum toxin in an adult with intestinal colonization botulism and underlying Crohn's disease.

A patient with obstruction of the terminal ileum from Crohn's disease developed complete paralysis in week 1 of hospitalization. Features initially suggested Guillain-Barre syndrome, but botulinum toxin was identified in serum and stool specimens from week 1 and type A toxin-producing Clostridium botulinum in stool specimens from weeks 3 to 19, confirming botulism due to intestinal colonization. In week 19, the inflamed small bowel was resected, and C. botulinum disappeared from the stool. In week 31, the patient was able to breath without assistance. Testing for an active immune response with neutralizing antibodies to C. botulinum at week 19 was positive; these antibodies remained at a protective level for >1 year. Intestinal colonization botulism, rare in adults, should be considered for patients with descending paralysis, especially those with a preceding alteration in small bowel function. An active immune response to botulinum toxin with production of protective antibodies has not been demonstrated previously in a patient with botulism and may have contributed to this patient's recovery.

Colonic epithelial lymphocytosis associated with an epidemic of chronic diarrhea.

The term Brainerd diarrhea has been applied to outbreaks of chronic watery diarrhea of unknown etiology characterized by acute onset and prolonged duration. Our aim was to describe the histologic changes in gastrointestinal biopsy specimens from patients with Brainerd diarrhea. We examined 52 colonic and 12 small bowel biopsy specimens from 22 patients who were involved in an outbreak of Brainerd diarrhea that was linked to the water supply of a cruise ship visiting the Galapagos Islands. Small bowel biopsy specimens from seven patients were histologically normal. One patient had a duodenal biopsy specimen that resembled celiac sprue. Colonic biopsy specimens from 20 patients revealed surface epithelial lymphocytosis without distortion of mucosal architecture, surface degenerative changes, or thickened subepithelial collagen plates. The degree of surface epithelial lymphocytosis was greater than that seen in control groups of persons with normal colons, acute colitis, and ulcerative colitis (p < 0.001), similar to that seen with collagenous colitis, and less than that seen with lymphocytic colitis (p < 0.001). Three patients showed focal active colitis similar to that described in acute infectious-type colitis in addition to the epithelial lymphocytosis. Two patients had colonic biopsy specimens that were histologically normal. In summary, histologic abnormalities in the small bowel are generally absent in Brainerd diarrhea. Colonic biopsy specimens in Brainerd diarrhea frequently show epithelial lymphocytosis similar to that seen in collagenous and lymphocytic colitis. Although currently Brainerd diarrhea can be diagnosed only with epidemiologic data indicating an epidemic and a point source, the lack of surface degenerative changes and the relatively lower lymphocyte counts seen in our cases of Brainerd diarrhea may serve to distinguish it from lymphocytic colitis, and the lack of a thickened subepithelial collagen plate distinguishes it from collagenous colitis.

Screening for Escherichia coli O157:H7--a nationwide survey of clinical laboratories.

The Association of State and Territorial Public Health Laboratory Directors has recommended that clinical laboratories screen at least all bloody stools for Escherichia coli O157:H7. We contacted the microbiology supervisors of 230 randomly selected clinical laboratories in the United States and administered a standardized questionnaire regarding stool culture practices. Of the 129 laboratories that performed stool cultures, only 70 (54%) reported screening either all stools or all bloody stools submitted for culture for E. coli O157:H7.

Interferon gamma inhibits luteinized human granulosa cell steroid production in vitro.

OBJECTIVE: The purpose of this study was to determine whether interferon gamma affects luteinized human granulosa cell progesterone, estrone, and estradiol production in the presence and absence of associated white blood cells by either cytotoxic or antiproliferative mechanisms. STUDY DESIGN: Luteinized granulosa cells were isolated by Percoll centrifugation from women during in vitro fertilization cycles. Some cell suspensions were further treated with anti-CD45 magnetic immunobeads to remove associated white blood cells. Granulosa cells with and without white blood cells were cultured in the presence of interferon gamma (0.5 to 50 ng/ml) for 48 hours. Medium was changed at 24-hour intervals, and spent medium was assayed for progesterone, estrone, and estradiol. In separate experiments granulosa cell viability was assessed with the tetrazolium salt reduction assay. RESULTS: Interferon gamma significantly inhibited granulosa cell progesterone production in both basal and human chorionic gonadotropin-stimulated cells cocultured with white blood cells in a concentration-dependent manner, whereas cells cultured free of white blood cells demonstrated less inhibition. In the absence of interferon gamma a more profound increase in granulosa cell progesterone synthesis was found in human chorionic gonadotropin-stimulated cultures without associated white blood cells. Interferon gamma inhibited granulosa cell estrone and estradiol production in basal cultures containing white blood cells in both a time- and concentration-dependent manner. Estrone production was not affected by interferon gamma in human chorionic gonadotropin-stimulated granulosa cell cultures containing white blood cells, whereas estradiol secretion was decreased at 48 hours with 50 ng/ml interferon gamma. Both estrone and estradiol synthesis were inhibited by 50 ng/ml interferon gamma in granulosa cell cultures free of white blood cells. In cultures free of interferon gamma, granulosa cell estrone and estradiol secretion was not affected by human chorionic gonadotropin stimulation compared with basal controls regardless of the presence or absence of white blood cells. All concentrations of interferon gamma used had no effect on granulosa cell viability at any time point tested. CONCLUSIONS: Our data suggest that interferon gamma affects granulosa cell steroid production both independently and in synergy with associated white blood cells and further supports the hypothesis that interferon gamma may be an important intraovarian regulator of ovarian steroid production during the luteal phase.

Adenocarcinomas of the colon and rectum in persons under 40 years old. A population-based study.

Data collected by nine population-based tumor registries participating in the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute were analyzed to characterize the epidemiology of noncarcinoid adenocarcinomas of the colon and rectum in young adults. Tumors diagnosed in persons under 40 years old between 1973 and 1984 (n = 1736) were compared with those in persons 40 years and older (n = 106,760). This first large U.S. population-based study of colorectal adenocarcinomas in the young shows a higher incidence in blacks than whites and later detection in black males. It also shows a higher proportion of tumors of mucinous and signet ring histological type than in older age groups. Among the younger group, the average annual age-adjusted incidence rate was 34% higher in black males than in white males (12.6 vs. 9.4 per million persons) and 46% higher in black females than in white females (13.0 vs 8.9 per million persons). The proportion of tumors that were right-sided varied by age: 0-29 years, 30%; 30-39 years, 26%; 40-49 years, 22%; 50-59 years, 21%; 60-69 years, 24%; 70-79 years, 30%; and 80+ years, 35%. Males under age 40 were less likely to present with localized disease (whites, 27%; blacks, 21%) than were those aged 40 and older (whites, 39%; blacks, 36%). The proportion of tumors classified as mucinous decreased with age, from 28% among those aged 0-19 years to 5% among those 40 years and older. A similar trend was observed for signet ring tumors. Although this latter type accounted for 10% of large-bowel tumors among subjects aged 0-19 years, this proportion decreased with age to 0.2% in those 40 years and older.

Escherichia coli O157:H7-associated colitis. A clinical and histological study of 11 cases.

Hemorrhagic colitis is characterized by abdominal cramps, bloody diarrhea, and no or low-grade fever. Most cases are caused by the Shiga-like toxin-producing bacteria, Escherichia coli O157:H7. Nineteen colonic biopsy specimens and one resection specimen were reviewed from 11 patients with E. coli O157:H7-associated colitis to determine whether histologic features could be useful in diagnosis or in suggesting pathogenesis. All specimens showed hemorrhage and edema in the lamina propria. Specimens from nine patients were focally necrotic and showed hemorrhage and acute inflammation in the superficial mucosa with preservation of the deep crypts, similar to the pattern of injury associated with acute ischemic colitis. Specimens from five patients showed neutrophils focally infiltrating the lamina propria and crypts, resembling the pattern of injury seen in infectious colitis. One or both of these histologic patterns were observed in specimens from all but one patient. Specimens from four patients had poorly formed inflammatory pseudomembranes. It is concluded that the histologic features of E. coli O157:H7-associated colitis resemble a combination of ischemic and infectious injuries similar to those described in toxin-mediated Clostridium difficile-associated colitis. This suggests that the toxin(s) produced by these E. coliplay a role in the colonic injury. Infection with E. coli O157:H7 should be considered in the differential diagnosis of ischemic and infectious colitis.