Troubleshooting high laboratory pasteurization counts in organic raw milk requires characterization of dominant thermoduric bacteria, which includes nonsporeformers as well as sporeformers.

Laboratory pasteurization count (LPC) enumerates thermoduric bacteria and is one parameter used to assess raw milk quality. No regulatory limit has presently been set for LPC, but LPC data are used by some dairy processors and cooperatives to designate raw milk quality premiums paid to farmers and may also be used for troubleshooting bacterial contamination issues. Although it is occasionally used as a proxy for levels of bacterial spores in raw milk, limited knowledge is available on the types of organisms that are enumerated by LPC in contemporary raw milk supplies. Although historical studies have reported that thermoduric bacteria quantified by LPC may predominantly represent gram-positive cocci, updated knowledge on microbial populations enumerated by LPC in contemporary organic raw milk supplies is needed. To address this gap, organic raw milk samples from across the United States (n = 94) were assessed using LPC, and bacterial isolates were characterized. LPC ranged from below detection (<0.70 log cfu/mL) to 4.07 log cfu/mL, with a geometric mean of 1.48 log cfu/mL. Among 380 isolates characterized by 16S rDNA sequencing, 52.6%, 44.5%, and 2.4% were identified as gram-positive sporeformers, gram-positive nonsporeformers, and gram-negatives, respectively; 0.5% could not be categorized into those groups because they could only be assigned a higher level of taxonomy. Isolates identified as gram-positive sporeformers were predominantly Bacillus (168/200), and gram-positive nonsporeformers were predominantly Brachybacterium (56/169) and Kocuria (47/169). To elucidate if the LPC level can be an indicator of the type of thermoduric (e.g., sporeforming bacteria) present in raw milk, we evaluated the proportion of sporeformers in raw milk samples with LPC of ≤100 cfu/mL, 100 to 200 cfu/mL, and ≥200 cfu/mL (51%, 67%, and 35%), showing a trend for sporeformers to represent a smaller proportion of the total thermoduric population when LPC increases, although overall linear regression showed no significant association between the proportion of sporeformers and the LPC concentration. Hence, LPC level alone provides no insight into the makeup of the thermoduric population in raw milk, and further characterization is needed to elucidate the bacterial drivers of elevated LPC in raw milk. We therefore further characterized the isolates from this study using MALDI-TOF mass spectrometry (MALDI-TOF MS), a rapid microbial identification tool that is more readily available to dairy producers than 16S rDNA PCR and sequencing. Although our data indicated agreement between 16S rDNA sequencing and MALDI-TOF MS for 66.6% of isolates at the genus level, 24.2% and 9.2% could not be reliably identified or were mischaracterized using MALDI-TOF MS, respectively. This suggests that further optimization of this method is needed to allow for accurate characterization of thermoduric organisms commonly found in raw milk. Ultimately, our study provides a contemporary perspective on thermoduric bacteria selected by the LPC method and establishes that the LPC alone is not sufficient for identifying the bacterial drivers of LPC levels. Further development of rapid characterization methods that are accessible to producers, cooperatives, and processors will support milk quality troubleshooting efforts and ultimately improve outcomes for dairy industry community members.

Bladder metastasis from inflammatory breast cancer presenting with hematuria and hydronephrosis.

We report a rare case of a 56-year-old Ukrainian female with inflammatory breast cancer (IBC) who underwent neoadjuvant chemoradiation and left radical mastectomy with her clinical course complicated by disease recurrence with bone and bladder metastases 2.5 years after her initial diagnosis. We highlight the presentation and diagnosis of genitourinary involvement of metastatic IBC, which has not previously been described in the literature.

A narrative review on surgical treatment options for male stress urinary incontinence.

Background and Objective: Stress urinary incontinence (SUI) can occur due to a variety of etiologies. For male patients specifically, SUI is typically thought of as iatrogenic secondary to intrinsic sphincter deficiency occurring after prostate surgery. Given the noted negative impact that SUI can have on a man's quality of life, multiple treatment options have been developed to improve symptoms. However, there is no "One-Size-Fits-All" approach to management of male SUI. In this narrative review, we sought to highlight some of the various procedures and devices available to treat men with bothersome SUI. Methods: This narrative review gathered primary resources through Medline search, and secondary resources by cross-referencing citations used in articles of interest. We started our investigation by searching for previous systematic reviews on male SUI and treatments for male SUI. Furthermore, we reviewed societal guidelines, such as the American Urological Association and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction guidelines and the recently published European Urological Association guidelines. Our review focused on English-language full-length manuscripts when available. Key Content and Findings: We present multiple surgical options for men with SUI. This review focuses on surgical options including 5 fixed male slings, 3 adjustable male slings, 4 artificial urinary sphincters (AUS), and an adjustable balloon device. This review includes treatment options from across the globe, although not all included devices are available in the United States. Conclusions: A great variety of treatment options exist for men with SUI, although not all Federal Drug Administration (FDA) approved. Shared decision making is paramount to generate the greatest satisfaction for patients.

Squamous cell carcinoma of the renal pelvis masquerading as xanthogranulomatous pyelonephritis.

We report a rare case of a 56-year-old male with a history of hypertension who initially presented to the emergency department with abdominal pain and was radiologically diagnosed with left xanthogranulomatous pyelonephritis (XGP) in a non-functioning kidney with a staghorn calculus. Pathological evaluation of his kidney revealed squamous cell carcinoma (SCC) of the renal pelvis with invasion into the renal parenchyma. We highlight the presentation, diagnosis, and management of this rare condition.

Stretchable and Electroactive Crosslinked Gelatin for Biodevice and Cell Culture Applications.

Biomimetic substrates that incorporate functionality such as electroactivity and mechanical flexibility, find utility in a variety of biomedical applications. Toward these uses, nature-derived materials such as gelatin offer inherent biocompatibility and sustainable sourcing. However, issues such as high swelling, poor mechanical properties, and lack of stability at biological temperatures limit their use. The enzymatic crosslinking of gelatin via microbial transglutaminase (mTG) yields flexible and robust large area substrates that are stable under physiological conditions. Here, we demonstrate the fabrication and characterization of strong, stretchable, conductive mTG crosslinked gelatin thin films. Incorporation of the conductive polymer poly(3,4-ethylenedioxythiophene) polystyrene sulfonate in the gel matrix with a bioinspired polydopamine surface coating is used to enable conductivity with enhanced mechanical properties such as extensibility and flexibility, in comparison to plain gelatin or crosslinked gelatin films. The electroconductive substrates are conducive to cell growth, supporting myoblast cell adhesion, viability, and proliferation and could find use in creating active cell culture systems incorporating electrical stimulation. The substrates are responsive to motion such as stretching and bending while being extremely handleable and elastic, making them useful for applications such as electronic skin and flexible bioelectronics. Overall, this work presents facile, yet effective development of bioinspired conductive composites as substrates for bio-integrated devices and functional tissue engineering.

Factors associated with recurrent urinary tract infections in spinal cord injured patients who use intermittent catheterization.

INTRODUCTION: Urinary Tract Infection (UTI) has been cited as the primary cause of morbidity in patients with history of spinal cord injury (SCI). Despite the significance of recurrent UTI (rUTI) in this population, the causative physiologic and patient characteristics are not well described. We sought to assess associations between demographic, clinical and urodynamic variables and rUTI. MATERIALS AND METHODS: The records of 136 individuals with SCI who perform clean intermittent catheterization (CIC) were retrospectively reviewed. All had a video urodynamics study (VUDS) available for analysis. Individuals were divided into non-recurrent (< 3/year) or rUTI (≥ 3/year) groups. Differences between the cohorts were analyzed. Multivariable logistic regression was performed to determine associations between various demographic, clinical, and VUDS variables and rUTI. RESULTS: Self-reported rUTI were noted in 58 of 136 individuals. Of 124 individuals with urinary culture results, African American race (43.3% vs. 22.3%) and 'Other' race (13.3% vs. 8.5%) made up larger proportions in the rUTI group. Female gender (OR 4.96, 95% CI [1.44-17.13]) and African American race (OR 5.16, 95% CI [1.80-14.79]) were increasingly associated with rUTI on multivariable logistic regression. Shorter interval since injury was also significantly associated with recurrent infections with each year since injury indicating diminished likelihood (OR 0.91, 95% CI [0.82-0.99]). There were no significant differences in VUDS variables between groups and none were significant on regression as potential determinants of rUTI. CONCLUSIONS: Patient race, gender, and time since SCI appear to have significant associations with rUTI in individuals with SCI using CIC. However, VUDS variables were not found to be significantly associated with rUTI.

The clinical anatomy of variations of the pectoralis minor.

Shoulder pathology is a very common medical presentation and can be due to anatomical variations. Therefore, knowledge of variants is important for the clinician treating patients with such complaints so that misdiagnosis is minimized and iatrogenic injury prevented. A review of the literature was performed of the variant anatomy of the pectoralis minor muscle. The aim of this review is to better inform clinicians who might treat patients with shoulder pathology so that if identified, variants of the pectoralis minor muscle are better appreciated.

The new onset of dysphagia four years after anterior cervical discectomy and fusion: Case report and literature review.

BACKGROUND: Dysphagia is a common complication immediately following anterior cervical spine surgery. However, its onset more than 1-year postoperatively is rare. CASE DESCRIPTION: A 45-year-old male initially underwent a C3-4 and C5-6 anterior cervical discectomy and fusion (ACDF). At age 49, 4 years later, he presented with worsening dysphagia accompanied by neck and right upper extremity pain. Radiographs demonstrated an extruded left C3 screw, which had migrated into the prevertebral soft tissues at the C4-C5 level; there was also loosening of the right C3 screw. The subsequent barium swallow study revealed that the screw was embedded in the pharyngeal wall. The patient required a two-stage operation; first, to remove the anterior instrumentation, and second, to perform a posterior instrumented C2-T2 fusion. CONCLUSION: A barium swallow study and other dynamic imaging are a valuable component of the diagnostic workup and therapeutic intervention to evaluate the delayed onset dysphagia following an ACDF.

Tulip-Screw Head Disjunction from Posterior C2 Fracture Fixation Instrumentation.

This report presents an unusual case of instrumentation failure after posterior fixation of a C2 fracture and reviews currently available treatment alternatives. The patient, a 53-year-old female, initially presented to the emergency department at an outside facility with acute alcohol intoxication and acute neck pain following a fall from a ladder. CT demonstrated bilateral C2 pars fractures and unstable posteroinferior displacement of the posterior elements. She underwent an emergent C2 open-reduction internal fixation (ORIF) at the outside facility with 3.5 mm polyaxial synapse pedicle screws (DePuy Synthes, Switzerland). There were no known complications and the patient was discharged. Two years after the index operation, cervical CT scan at a different facility revealed that although the fracture was fully healed, bilateral tulip caps had detached from the pedicle screw heads at C2. All implants were removed without postoperative complications. Industry review of alternate lag screws approved for the cervical spine demonstrated that there is not currently an ideal implant for fixation of C2 fractures without fusion. Cannulated trauma screws, which are low profile and would have avoided the instrumentation failure seen here, are not currently FDA approved for the cervical spine.

Gleason Probability Maps: A Radiomics Tool for Mapping Prostate Cancer Likelihood in MRI Space.

Prostate cancer is the most common noncutaneous cancer in men in the United States. The current paradigm for screening and diagnosis is imperfect, with relatively low specificity, high cost, and high morbidity. This study aims to generate new image contrasts by learning a distribution of unique image signatures associated with prostate cancer. In total, 48 patients were prospectively recruited for this institutional review board-approved study. Patients underwent multiparametric magnetic resonance imaging 2 weeks before surgery. Postsurgical tissues were annotated by a pathologist and aligned to the in vivo imaging. Radiomic profiles were generated by linearly combining 4 image contrasts (T2, apparent diffusion coefficient [ADC] 0-1000, ADC 50-2000, and dynamic contrast-enhanced) segmented using global thresholds. The distribution of radiomic profiles in high-grade cancer, low-grade cancer, and normal tissues was recorded, and the generated probability values were applied to a naive test set. The resulting Gleason probability maps were stable regardless of training cohort, functioned independent of prostate zone, and outperformed conventional clinical imaging (area under the curve [AUC] = 0.79). Extensive overlap was seen in the most common image signatures associated with high- and low-grade cancer, indicating that low- and high-grade tumors present similarly on conventional imaging.

Race Is Associated With Burden of Anal Condyloma and Need for Operative Intervention.

BACKGROUND: Human papillomavirus is a common sexually transmitted infection that may affect the oropharynx, genitalia, or anus. Some strains of this virus may cause bulky growths around the anus known as giant anal condylomas. These can become large, disfiguring, and may cause bleeding, as well as difficulty with defecation and hygiene. Surgical management is usually necessary for large condylomas, whereas office-based procedures are common for smaller lesions. It is unclear why some develop large anal margin tumors, whereas others develop limited disease. The aim of the present study was to evaluate for risk factors that may play a role in the development of extensive disease warranting operative management. MATERIALS AND METHODS: A retrospective chart review of patients seen within the Anal Dysplasia Clinic at the Medical College of Wisconsin was undertaken. Clinic encounters for patients with anogenital condyloma were abstracted for demographic information, operative interventions, Human Immunodeficiency Virus status, and smoking history to determine risk factors that predicted operative intervention for giant anal condylomas. RESULTS: A total of 239 patients met inclusion criteria; 211 (88.3%) were male and 28 (11.7%) were female. Racial makeup of the cohort included 49% Caucasian, 38.9% African-American, 9.2% Hispanic, and 2.9% were identified as another ethnicity. One hundred forty-three patients (60.1%) were current or past smokers. One hundred ninety-eight (82.8%) patients tested positive for human immunodeficiency virus (HIV), whereas 41 (17.2%) were negative. Multiple linear regression identified only African-American race as predictive of greater disease burden. CONCLUSIONS: African-American race was associated with increased size of anal condyloma. As the size of anal condylomas increase, management shifts from topical treatments to operative intervention. This is the first study to correlate race with burden of disease in the general population.

Abrupt skin lesion border cutoff measurement for malignancy detection in dermoscopy images.

BACKGROUND: Automated skin lesion border examination and analysis techniques have become an important field of research for distinguishing malignant pigmented lesions from benign lesions. An abrupt pigment pattern cutoff at the periphery of a skin lesion is one of the most important dermoscopic features for detection of neoplastic behavior. In current clinical setting, the lesion is divided into a virtual pie with eight sections. Each section is examined by a dermatologist for abrupt cutoff and scored accordingly, which can be tedious and subjective. METHODS: This study introduces a novel approach to objectively quantify abruptness of pigment patterns along the lesion periphery. In the proposed approach, first, the skin lesion border is detected by the density based lesion border detection method. Second, the detected border is gradually scaled through vector operations. Then, along gradually scaled borders, pigment pattern homogeneities are calculated at different scales. Through this process, statistical texture features are extracted. Moreover, different color spaces are examined for the efficacy of texture analysis. RESULTS: The proposed method has been tested and validated on 100 (31 melanoma, 69 benign) dermoscopy images. Analyzed results indicate that proposed method is efficient on malignancy detection. More specifically, we obtained specificity of 0.96 and sensitivity of 0.86 for malignancy detection in a certain color space. The F-measure, harmonic mean of recall and precision, of the framework is reported as 0.87. CONCLUSIONS: The use of texture homogeneity along the periphery of the lesion border is an effective method to detect malignancy of the skin lesion in dermoscopy images. Among different color spaces tested, RGB color space's blue color channel is the most informative color channel to detect malignancy for skin lesions. That is followed by YCbCr color spaces Cr channel, and Cr is closely followed by the green color channel of RGB color space.

Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study.

OBJECTIVES: Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS. DESIGN: This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation. SETTING: Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital. PARTICIPANTS: Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days. INTERVENTION: Implementation of a CDSS. OUTCOME MEASURES: The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence. MAIN RESULTS: Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31). CONCLUSIONS: Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality. TRIAL REGISTRATION NUMBER: ISRCTN54598675.

Outbreak of carbapenem-resistant Pseudomonas aeruginosa infection in a surgical intensive care unit.

Infection control personnel performing surveillance activities noticed a cluster of patients with isolates of carbapenem-resistant Pseudomonas aeruginosa (CRPA) in the surgical intensive care unit (SICU) of a German University Hospital. An outbreak investigation including a descriptive analysis, a case-control study comparing 15 CRPA case patients with 18 patients with carbapenem-susceptible P. aeruginosa, environmental sampling and pulsed-field gel electrophoresis (PFGE) typing of P. aeruginosa isolates was carried out. Fifteen patients acquired CRPA in the SICU during the outbreak period between 1 July 2006 and 31 October 2006 and PFGE typing of 11 available patient isolates revealed two outbreak strains as well as sporadic CRPA isolates. Both outbreak strains were resistant to penicillins, cephalosporins, carbapenems, aminoglycosides and quinolones, and remained susceptible only to colistin. The most likely mode of transmission was cross-transmission between patients during postoperative wound care with abdominal and/or thoracic drains (odds ratio: 64.33; 95% confidence interval: 5.32-999) and therapy with quinolones (48.37; 3.71-999) being independent risk factors for acquisition of CRPA. No further clusters of CRPA cases were observed after implementation of contact isolation precautions and after healthcare workers were made aware of the likely mode of transmission. This study shows the complex epidemiology of CRPA in a SICU including cross-transmission of two CRPA strains related to postoperative wound care.

Computer-assisted decision support for changing practice in severe sepsis and septic shock.

Computer-assisted decision support systems (CDSS) are designed to improve infection management. The aim of this prospective, clinical pre- and post-intervention study was to investigate the influence of CDSS on infection management of severe sepsis and septic shock in intensive care units (ICUs). Data were collected for a total of 180 days during two study periods in 2006 and 2007. Of the 186 patients with severe sepsis or septic shock, 62 were stratified into a low adherence to infection management standards group (LAG) and 124 were stratified into a high adherence group (HAG). ICU mortality was significantly increased in LAG versus HAG patients (Kaplan-Meier analysis). Following CDSS implementation, adherence to standards increased significantly by 35%, paralleled with improved diagnostics, more antibiotic-free days and a shortened time until antibiotics were administered. In conclusion, adherence to infection standards is beneficial for patients with severe sepsis or septic shock and CDSS is a useful tool to aid adherence.

Fluorescence in situ hybridization to improve the diagnosis of endocarditis: a pilot study.

Infective endocarditis is a rare but life-threatening disease associated with high mortality. Early diagnosis of the causative microorganism is critical to patient outcome. However, conventional diagnostic methods are often unsatisfactory in achieving this goal. As a proof of concept, we applied fluorescence in situ hybridization (FISH) for detection and identification of bacteria in histological sections of heart valves. Biopsy specimens from 54 suspected endocarditis patients were obtained during valve surgery and analysed via FISH. Specimens were screened with a probe panel that identifies the most common bacteria implicated in endocarditis. Results were compared with those of culture-based diagnostics and clinical data. Discrepant results were subjected to comparative sequence analysis of PCR-amplified 16S rRNA genes. FISH detected bacteria in 26 of the 54 heart valves. FISH allowed successful diagnosis of infective endocarditis in five of 13 blood culture-negative cases and in 11 of 37 valve culture-negative cases, showing the bacteria within their histological context. This technique allows the simultaneous detection and identification of microorganisms at the species or genus level directly from heart valves and might be a valuable tool for diagnosis of endocarditis.