Effects of Intertidal Harvest Practices on Levels of Vibrio parahaemolyticus and Vibrio vulnificus Bacteria in Oysters.

UNLABELLED: Vibrio parahaemolyticus and Vibrio vulnificus can grow rapidly in shellfish subjected to ambient air conditions, such as during intertidal exposure. In this study, levels of total and pathogenic (tdh(+) and/or trh(+)) V. parahaemolyticus and total V. vulnificus were determined in oysters collected from two study locations where intertidal harvest practices are common. Samples were collected directly off intertidal flats, after exposure (ambient air [Washington State] or refrigerated [New Jersey]), and after reimmersion by natural tidal cycles. Samples were processed using a most-probable-number (MPN) real-time PCR method for total and pathogenic V. parahaemolyticus or V. vulnificus In Washington State, the mean levels of V. parahaemolyticus increased 1.38 log MPN/g following intertidal exposure and dropped 1.41 log MPN/g after reimmersion for 1 day, but the levels were dependent upon the container type utilized. Pathogenic V. parahaemolyticus levels followed a similar trend. However, V. vulnificus levels increased 0.10 log MPN/g during intertidal exposure in Washington but decreased by >1 log MPN/g after reimmersion. In New Jersey, initial levels of all vibrios studied were not significantly altered during the refrigerated sorting and containerizing process. However, there was an increase in levels after the first day of reimmersion by 0.79, 0.72, 0.92, and 0.71 log MPN/g for total, tdh(+) and trh(+) V. parahaemolyticus, and V. vulnificus, respectively. The levels of all targets decreased to those similar to background after a second day of reimmersion. These data indicate that the intertidal harvest and handling practices for oysters that were studied in Washington and New Jersey do not increase the risk of illness from V. parahaemolyticus or V. vulnificus IMPORTANCE: Vibrio parahaemolyticus and Vibrio vulnificus are the leading causes of seafood-associated infectious morbidity and mortality in the United States. Vibrio spp. can grow rapidly in shellfish subjected to ambient air conditions, such as during periods of intertidal exposure. When oysters are submersed with the incoming tide, the vibrios can be purged. However, data on the rates of increase and purging during intertidal harvest are scarce, which limits the accuracy of risk assessments. The objective of this study was to help fill these data gaps by determining the levels of total and pathogenic (tdh(+) and/or trh(+)) V. parahaemolyticus and V. vulnificus in oysters from two locations where intertidal harvest practices are common, using the current industry practices. The data generated provide insight into the responses of Vibrio spp. to relevant practices of the industry and public health, which can be incorporated into risk management decisions.

Together.

Dr. Lester Johnson, MD, delivered the commencement address to the Louisiana State University Health Sciences Center-Monroe's 2011 Family Practice Class. The following text is Dr. Johnson's speech in its entirety.

Three new MHC haplotypes in broiler breeder chickens.

Six distinct serotypes of the chicken B blood group system (which encodes the major histocompatibility complex) were identified in a commercial broiler breeder line (Line C). The B serotypes were compared by B-G restriction fragment length polymorphism (RFLP) analysis, allele-specific PCR typing test for B-LBII family genes and nucleotide sequence analysis of expressed B-F and B-LBII family genes. The results indicated the existence of seven distinct B haplotypes. Nucleotide sequence analysis demonstrated that three of the Line C haplotypes encode new B-F and B-LB alleles.

Diverticulitis in the young patient.

Although predominantly a disease in older adults diverticulitis does affect younger patients. The disease has been described as not only rare but virulent by some authors, and a young patient age is considered to be a relative indication for early sugery. The goal of this study was to evaluate the experience of the Louisiana State University Health Sciences Center-Shreveport and affiliated hospitals with diverticulitis in young patients. This study was a retrospective chart review of 22 patients with diverticulitis age 40 years and younger over the past 20 years. Inclusion criteria were either a diagnosis of diverticulitis confirmed at surgery or positive CT findings and/or a positive contrast enema. The mean age in this study was 32.1 years (range 16-40). All 22 patients presented with abdominal pain. The next most common symptom was nausea and/or vomiting in 45 per cent followed by fever and chills in 36 per cent. Twelve patients had abdominal CTs on admission, and 87 per cent had positive findings. Eighteen patients underwent an operation. Four patients were treated nonoperatively. Nineteen patients had diverticulitis of the sigmoid colon. The remaining three had right-sided diverticulitis. Two patients underwent right hemicolectomy, and one underwent cecectomy. Of the 15 patients with sigmoid diverticulitis 12 (80%) underwent a two-stage procedure of sigmoid colectomy, end colostomy, and Hartmann's pouch. Three patients (20%) underwent a one-stage procedure of sigmoid colectomy and primary anastomosis. Two of three patients undergoing a one-stage procedure required reoperation. Postoperative complications occurred in 10 of 18 patients for an overall incidence of 56 per cent. Two of these patients had septic complications. Both of these patients had a delay in time from admission until operation: one for 7 days and the other for 10 days. There was one death in the series. Colostomy closure was performed successfully in nine of 12 (75%) patients. The mean time interval before closure was 7.7 months, (range 3-14). Patients with two-stage procedures on initial admission fared better than those with one-stage procedures. The overall mortality was 4.5 per cent. There was a high overall complication rate of 56 per cent in patients undergoing an operation. Two patients who had a delay in time from admission to operation had septic complications. Early surgical intervention should be considered in this clinical setting. In summary, although rare, diverticulitis in the young patient is often a fulminant illness requiring operation early in the disease process.

Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review.

Traumatic and iatrogenic extrahepatic biliary tract injuries are rare but may lead to exceedingly morbid complications. Traumatic extrahepatic biliary tract injuries represent less than 1 per cent of all traumatic injuries. Iatrogenic injuries result in 0.2 to 1 per cent of laparoscopic or open cholecystectomies. The objective of this study was to review the incidence of biliary tract injuries--iatrogenic as well as traumatic--and their subsequent management. A multi-institutional chart review was done including Louisiana State University Health Sciences Center (LSUHSC)-Shreveport, LSUHSC-Monroe, and Richland Parish medical centers. Charts were reviewed for patients with iatrogenic biliary tract injuries and those with biliary tract injuries related to noniatrogenic trauma. The etiology of the biliary tract injury, symptoms of injury, pertinent laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, days hospitalized, intensive care unit stay, and complications were reviewed. There are 1500 trauma patients admitted to LSUMC-Shreveport each year. The incidence of biliary tract injury in trauma patients admitted to LSUMC is 0.1 per cent. Traumatic injuries were classified according to the injury scale by Mattox et al. (Trauma 1996; Vol 515). There were five Type II, four Type IV, and two Type V injuries. Five patients underwent cholecystectomy, three had endoscopic retrograde cholangiopancreatography with stent placement, and two had choledochojejunostomy; one patient died from associated injuries. There were no complications of repair. Approximately 220 cholecystectomies are done at LSUMC-Shreveport each year. Eighty-eight per cent are laparoscopic, and 12 per cent are open. The incidence of iatrogenic biliary tract injuries at LSUMC-Shreveport during the past 8 years was 0.2 per cent. Immediate diagnosis of iatrogenic injuries was made in five of 17 cases and eight of 11 trauma cases. Laparoscopic injuries were classified by the Way injury classification (Stewart L, Way LW. Arch Surg 1995;130:1123). There were one Type I, one Type II, and nine Type III injuries. Treatment included suturing of the laceration (n = 1), hepaticojejunostomy (n = 8), and primary repair (n = 2). Open injuries were classified using the Bismuth classification. There were one Type I and three Type III injuries. All were treated with hepaticojejunostomy. There were two iatrogenic injuries unrelated to cholecystectomy. One patient suffered a perforation of the gallbladder during laparoscopic nephrectomy. This patient subsequently underwent cholecystectomy and has done well. The second patient suffered ligation of the intraduodenal portion of the common bile duct during hemigastrectomy and oversewing of a duodenal ulcer. This patient underwent hepaticojejunostomy and has done well. Complications of iatrogenic injury repair included leaking of a repaired laceration (n = 1), failed hepaticojejunostomy (n = 1), and an anastomotic stricture after hepaticojejunostomy (n = 1). Laparoscopic injuries by LSUMC hospitals is 0.2 per cent. Extrahepatic biliary tract injuries resulting from open cholecystectomy were diagnosed later than those occurring during laparoscopic cholecystectomy and were most likely to result in stricture formation. Repair of Way Type II and III injuries is associated with a higher complication rate. Hepaticojejunostomy has a complication rate of 15 per cent. Minor common duct lacerations are amenable to conservative therapy with oversewing and/or endoscopic retrograde cholangiopancreatography with stent placement. Repair of extrahepatic biliary tract injuries with hepaticojejunostomy at a level of good blood supply remains our gold standard for treatment of more severe injuries and strictures.

Surgical management for chronic pancreatitis.

This study reviewed the results of surgery for chronic pancreatitis. We also attempted to identify any factors that may influence outcome. A 10-year retrospective chart review was carried out on all patients undergoing surgery for the diagnosis of chronic pancreatitis. Twenty-three patients were identified. Alcohol was the most common etiology, but other causes were identified. All but two patients had abnormal ductal anatomy on endoscopic retrograde cholangiopancreatography. A total of 23 patients underwent six different operations. There were five complications and no perioperative deaths. Only one patient had to be readmitted for pancreatitis during follow-up. The majority of patients reported some improvement with their pain. Patients who continued to use alcohol had the worst results in regard to weight gain and pain control. The results of our study are consistent with the current literature in regard to morbidity and mortality. Surgical treatment had minimal effect on endocrine and exocrine function. Weight loss was avoided in the majority of patients. Addition of biliary bypass to the Puestow procedure did not increase morbidity. Poorest results were obtained in patients who continued to use alcohol. A basic algorithm for management of this disease process is given.

Mirizzi's syndrome: experience from a multi-institutional review.

P.L. Mirizzi described in 1948 a partial or spastic obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct or infundibulum of the gallbladder. The modern definition of Mirizzi's syndrome is thought to include four components: anatomic arrangement of the cystic duct at the gallbladder neck such that it runs parallel to the common hepatic duct; impaction of a stone in the cystic duct or neck of the gallbladder; mechanical obstruction of the common hepatic duct by the stone itself or by secondary inflammation; and intermittent or constant jaundice causing possible recurrent cholangitis and, if longstanding, secondary biliary cirrhosis. Intermittent symptomatology may make Mirizzi's syndrome difficult to diagnose preoperatively or intraoperatively. Bilio-biliary fistulas may or may not be present. Diagnosis and choice of operative repair may be best accomplished by open operative technique. Over a 24-year period two faculty members from Louisiana State University (LSU) Medical Center-Shreveport at Monroe and LSU Baton Rouge treated 4180 cases of cholelithiasis at six Louisiana university and private hospitals. Eleven cases of Mirizzi's syndrome were diagnosed on the basis of operative and preoperative notes with detailed description of size and extent of biliobiliary fistulas when they were present. These 11 cases were reviewed and followed from one to 20 years. Presentation, workup, operative findings, choice of operative repair, choice of operative approach, and complications were evaluated by retrospective chart review. Review of the pertinent literature for informative and comparative purposes was also completed. These 11 cases ranged from Csendes Type I to III. There were no Type IV cases. They were ultimately diagnosed and managed by classical open technique. Four laparoscopic procedures were converted to open technique following initial inspection. All four were converted to open as a result of inability to delineate structures in and adjacent to the triangle of Calot due to marked scarring in the subhepatic space. No iatrogenic injuries or major complications occurred. Mirizzi's syndrome occurs in fewer than 0.5 per cent of patients with cholelithiasis. Removal of stones with partial cholecystectomy and use of gallbladder or cystic duct remnant to oversew or repair Mirizzi fistulas should be considered. Roux-en-y hepaticojejunostomy becomes the procedure of choice when the vascularity or viability of the hepatic duct or tissues available for duct repair is questionable. Review of the literature reveals the increase in complications with laparoscopic versus open technique in Mirizzi's syndrome. Although very little direct evidence exists we believe that when this syndrome is diagnosed or strongly suspected open biliary operation is the procedure of choice because the increased potential for major complications with the use of laparoscopic technique far outweighs the potential slight increase in morbidity of an open procedure.

Use of the sestamibi scan to identify hyperplastic parathyroid tissue in the forearm of a patient with MEN1 syndrome.

Hyperparathyroidism is the most common presenting symptom in patients with MEN1 syndrome. Sestamibi scanning is not routinely used in the preoperative evaluation of this type of patient prior to their initial operation. It has been useful, however, in the preoperative evaluation of patients with recurrent hypercalcemia prior to reexploration. We present a case, which illustrates the application of its use during the preoperative evaluation of a patient with MEN1 syndrome and recurrent hypercalcemia.

Diagnosis and management of a painful thyroid nodule in a patient with systemic sarcoidosis.

Painful thyroid nodules caused by sarcoid are exceedingly rare. Painless involvement of the thyroid by sarcoid in patients with systemic sarcoidosis is not. Several autoimmune thyroid illnesses are closely linked to sarcoid. These illnesses may form thyroid nodules which may or may not be painful. We present only the second reported case of a painful thyroid nodule caused by direct sarcoid involvement. Fine needle aspiration may not provide a definitive diagnosis in patients whose appropriate therapy would vary greatly depending on this diagnosis. When an open surgical procedure is indicated, total unilateral thyroid lobectomy should be considered. Multi-centric involvement of a lobe with postoperative recurrence in remaining ipsi-lateral thyroid tissue would be very likely if the entire lobe is not removed.

Anal duct carcinoma: case report and review of the literature.

This report details the clinical course of two patients with true anal duct carcinoma. The incidence of this malignancy is low. The tissues of origination are the glands of the anal duct. The features that differentiate this tumor from the usual rectal carcinoma are prominent ductal structures, abundant mucin production with organized mucinous pools, and infiltration into the perirectal soft tissue. The clinical management of anal duct carcinoma remains a surgical challenge. The extent of surgical resection must be radical because of the infiltrative nature of the tumor. This report describes treatment of two patients with anal duct carcinoma. The first patient was a black woman with no previous history of rectal disease. Her operative procedure was an abdominoperineal resection with posterior vaginectomy. Nine months after initial surgery a local recurrence was resected. The second patient was a white man with a previous history of hemorrhoidectomy and anal fissure. He underwent an abdominoperineal resection but had positive dermal skin margins on permanent sections despite wide perirectal soft tissue resection. A secondary resection with confirmed clear margins of the skin was performed 2 weeks postoperatively. One management aspect of anal duct carcinoma that needs emphasis is the need for wide local excision of the perirectal soft tissues.

Dimensions of patient empowerment: implications for professional services marketing.

The focus on preventive health care and self care coupled with the public's improved access to health care information has pushed patient empowerment to the forefront. This has prompted several medical scholars to identify and stipulate the multiple dimensions of patient empowerment. These dimensions (patient participation, patient control and patient education) have already been recognised on an individual basis by service marketers. What is proposed here is to consider all three dimensions simultaneously to manage clients of professional services that demand a significant amount of client input.

Splenectomy for idiopathic thrombocytopenic purpura: a five-year retrospective review.

Idiopathic thrombocytopenic purpura is a condition that is characterized by persistently low platelet counts. Idiopathic thrombocytopenic purpura results from splenic sequestration and accelerated platelet destruction mediated by antiplatelet antibody. Most cases arise in previously healthy patients, mostly women ages 20 to 40. Clinical symptoms consist of bruising, petechiae, mucosal bleeding, menorrhagia, and intracranial bleeding. Platelet-associated immunoglobulin G can be detected in 90 per cent of patients. Therapy for adults and children is somewhat different. Splenectomy in adults should be considered in patients who fail to respond to steroids, develop thrombocytopenia after taper, or develop steroid toxicity. Ninety per cent of children will maintain normal platelet counts in 9 to 12 months. Some will recover spontaneously without medical therapy. Splenectomy in children is recommended if idiopathic thrombocytopenic purpura persists for more than one year or fails to respond to steroids. Our purpose was to determine whether management of idiopathic thrombocytopenic purpura in patients who undergo splenectomy at our institutions is appropriate and effective. We undertook a 5-year retrospective review of 27 patients with idiopathic thrombocytopenic purpura which have undergone splenectomy. All of the 27 patients were referred to surgeons after initial medical management. The patients were divided into two groups on the basis of length of therapy: longer than 6 months and less than 6 months. The longer than 6 months group contained 15 patients. This group had a postoperative complication rate of 40 per cent. Those in the group with <6 months therapy had a complication rate of 7 per cent. Average follow-up for all patients was 20 months. Eighty-eight per cent of the patients had complete response. Three per cent had a partial response with platelet counts >50,000. The partial response group did not respond well to preoperative steroid boluses with a great rise in platelet counts. Eighteen per cent of patients received platelet transfusions. Sixty per cent of the transfusions were given for inappropriate reasons. A large percentage of our patients had prolonged medical therapy before splenectomy. The inappropriate use of platelets was a common error in management. Patients treated for more than 6 months had more postoperative complications. An initial increase in platelets after steroid bolus is a good indicator for favorable response to splenectomy. We conclude that splenectomy is a safe and effective method of treatment for idiopathic thrombocytopenic purpura with no deaths or postsplenectomy sepsis to date.

Isolation and microinjection of somatic cell-derived mitochondria and germline heteroplasmy in transmitochondrial mice.

At present, there are no means for creation of relevant animal models of human mitochondrial DNA (mtDNA)-based diseases in a directed fashion. As an initial step towards this end, we have developed a microinjection technique for transfer of isolated, viable mitochondria between two mouse species. Previously, we reported detection, by nested PCR with species-specific primer sets, of Mus spretus mtDNA in Mus musculus domesticus blastocyts following zygote microinjection and culture. We now report the production of transmitochondrial founder mice, and germline transmission of the heteroplasmic state in a maternal lineage. Heteroplasmic mice produced by this technique will be useful in the study of mitochondrial dynamics and may hasten the creation of animal models of human mtDNA-based diseases.

A PCR method for typing B-L beta II family (class II MHC) alleles in broiler chickens.

Certain haplotypes of the major histocompatibility (B) complex are strongly associated with resistance or susceptibility to several infectious diseases in Leghorn chickens. Identification of chicken haplotypes based on the nucleotide sequence of B complex loci could provide more precise identification of haplotypes than traditional serological methods. We report the development and application of polymerase chain reaction with sequence specific primers (PCR-SSP) to type broiler chicken B haplotypes based on the DNA sequence of B-L beta II family genes. Five well-defined standard B haplotypes from White Leghorns and 12 recently characterized B haplotypes from a broiler breeder line were used to develop the test system. The B-L beta II family loci were amplified from genomic DNA by B-L beta II family specific primers and then characterized by PCR-SSP. In total, ten pairs of primers, derived from the sequences of expressed B-L beta II family alleles, were used in the PCR typing test to discriminate the chicken B haplotypes identified previously by serological means. The PCR-SSP showed that each haplotype had a different amplification pattern, except those haplotypes known or suspected to have the same B-L beta alleles. Cloning and sequencing of the family specific PCR products indicated that two loci in the B-L beta II family, presumably B-L beta I and B-L beta II, were amplified. Finally, B-L beta PCR-SSP typing was used in combination with B-G RFLP analyses to characterize unusual (variant) B serotypes; the results indicate that some of these are natural recombinants within the B complex.

Potential utility of sentinel node biopsy in the original surgical assessment of Hürthle cell tumors of the thyroid: 23-year institutional review of Hürthle cell neoplasms.

BACKGROUND AND OBJECTIVES: Great difficulty still exists in determining the potential malignancy of Hürthle cell tumors of the thyroid gland. Indications for the extent of resection vary greatly in the reported literature. Sentinel node biopsy has shown its usefulness as a prognostic indicator in both melanoma and breast cancer. The feasibility of using it as an integral part of Hürthle cell tumor surgery was investigated and is discussed. METHODS: Eleven patients diagnosed with Hürthle cell tumors between the years of 1975 and 1998 were reviewed. The last three patients had sentinel node biopsy with isosulfan blue dye as an integral part of their procedure. RESULTS: Sentinel node biopsy was accomplished without difficulty or complication in our last three patients. Two patients were considered to be benign by frozen section and final pathology. Their sentinel nodes were benign. One patient was considered malignant on both frozen and final pathology. His sentinel nodes as well as central node dissection revealed no lymphatic spread. CONCLUSIONS: Malignancy of Hürthle cell tumors of the thyroid is difficult to determine even on final pathological examination. The addition of nodal sampling may add valuable prognostic information. Sentinel node biopsy with isosulfan blue dye, although not previously reported for these tumors, appears to be a logical next step in the evolution of surgical management.

The MHC of a broiler chicken line: serology, B-G genotypes, and B-F/B-LB sequences.

Although the major histocompatibility complex of chickens (encoded in the B complex) has been studied for a number of years, almost all work has focused on the White Leghorn breed. Broiler (meat-type) chickens were derived from other breeds, including Cornish and Plymouth Rock. It was our hypothesis that new B haplotypes, not previously identified in White Leghorns, might be present in lines of broiler chickens. Furthermore, alloantisera used to identify B serotypes in Leghorn lines reportedly do not work well outside the line in which they were raised, with the result that broiler B haplotypes have not been incorporated into the universal nomenclature system. Our approach was to use a panel of B alloantisera produced to identify B serotypes within a commercial broiler breeder line (designated line A). B homozygotes identified serologically were compared by B-G genotyping using restriction fragment length polymorphism analysis. Furthermore, reverse transcription-polymerase chain reaction was used to amplify variable domains of expressed B-LB and B-F genes of homozygotes of most of the B serotypes in Line A, followed by cloning and nucleotide sequence determination. Comparison of B-LB and B-F sequences with standard Leghorn haplotypes demonstrated the existence of new alleles of B-L and B-F in a broiler breeder line, as well as the presence of alleles previously identified in Leghorns. In some cases, Leghorn-type alleles were in linkage with different B-G alleles in the broiler line than the common haplotypic associations found in Leghorn lines.