Descriptive analysis of targeted carbapenemase genes and antibiotic susceptibility profiles among carbapenem-resistant Acinetobacter baumannii tested in the Antimicrobial Resistance Laboratory Network-United States, 2017-2020.

Acinetobacter baumannii is a Gram-negative bacillus that can cause severe and difficult-to-treat healthcare-associated infections. A. baumannii can harbor mobile genetic elements carrying genes that produce carbapenemase enzymes, further limiting therapeutic options for infections. In the United States, the Antimicrobial Resistance Laboratory Network (AR Lab Network) conducts sentinel surveillance of carbapenem-resistant Acinetobacter baumannii (CRAB). Participating clinical laboratories sent CRAB isolates to the AR Lab Network for characterization, including antimicrobial susceptibility testing and molecular detection of class A (Klebsiella pneumoniae carbapenemase), class B (Active-on-Imipenem, New Delhi metallo-ß-lactamase, and Verona integron-encoded metallo-ß-lactamase), and class D (Oxacillinase, blaOXA-23-like, blaOXA-24/40-like, blaOXA-48-like, and blaOXA-58-like) carbapenemase genes. During 2017‒2020, 6,026 CRAB isolates from 45 states were tested for targeted carbapenemase genes; 1% (64 of 5,481) of CRAB tested for targeted class A and class B genes were positive, but 83% (3,351 of 4,041) of CRAB tested for targeted class D genes were positive. The number of CRAB isolates carrying a class A or B gene increased from 2 of 312 (<1%) tested in 2017 to 26 of 1,708 (2%) tested in 2020. Eighty-three percent (2,355 of 2,846) of CRAB with at least one of the targeted carbapenemase genes and 54% (271 of 500) of CRAB without were categorized as extensively drug resistant; 95% (42 of 44) of isolates carrying more than one targeted gene had difficult-to-treat susceptibility profiles. CRAB isolates carrying targeted carbapenemase genes present an emerging public health threat in the United States, and their rapid detection is crucial to improving patient safety.IMPORTANCEThe Centers for Disease Control and Prevention has classified CRAB as an urgent public health threat. In this paper, we used a collection of >6,000 contemporary clinical isolates to evaluate the phenotypic and genotypic properties of CRAB detected in the United States. We describe the frequency of specific carbapenemase genes detected, antimicrobial susceptibility profiles, and the distribution of CRAB isolates categorized as multidrug resistant, extensively drug-resistant, or difficult to treat. We further discuss the proportion of isolates showing susceptibility to Food and Drug Administration-approved agents. Of note, 84% of CRAB tested harbored at least one class A, B, or D carbapenemase genes targeted for detection and 83% of these carbapenemase gene-positive CRAB were categorized as extensively drug resistant. Fifty-four percent of CRAB isolates without any of these carbapenemase genes detected were still extensively drug-resistant, indicating that infections caused by CRAB are highly resistant and pose a significant risk to patient safety regardless of the presence of one of these carbapenemase genes.

Every Tube Counts: reducing extra tubes drawn in the emergency department.

A common practice exists in hospitals where extra tubes of blood are collected for possible add-on testing, this practice contributes to wastage of consumables. Baseline estimates from a 5-month local lab information system audit revealed that ~65 extra tubes per day were being collected, with an additional 2-week manual audit of all extra tubes received in the laboratory confirming the practice. The audits showed that the majority of the tubes (~99%) were being drawn from the adult emergency department (ED). Furthermore, only 5% of the extra tubes were being used for add-on testing, whereas the remaining tubes had no testing performed on them and were discarded at the end of the day. This translates to over 23 000 extra tubes being wasted annually.After initial discussion with ED leadership, the practice was identified as primarily nurse driven. An educational intervention was created and entitled 'Every Tube Counts', with the aim to reduce extra tube collections in the adult ED by 50% within the first month of intervention. First, a memo with initial findings and a request to stop the practice of extra tube collection was sent out to all ED staff. After 2 weeks of additional data collection, it was noticed that extra tubes were still being collected. A second intervention, which consisted of another communication and utilisation of nurse educators to disseminate the information to nursing staff, saw a remarkable ~80% reduction in collection of extra tubes in the following few months after the second intervention. The practice was followed for an additional 15 months, which saw a slight increase of extra tube collections over time with a levelling off towards the latter period of the study. However, the target goal was maintained over the entire study period.

Validation and interlaboratory comparison of anticoagulant rodenticide analysis in animal livers using ultra-performance liquid chromatography-mass spectrometry.

Anticoagulant rodenticides (ARs) are used to control rodent populations. Poisoning of non-target species can occur by accidental consumption of commercial formulations used for rodent control. A robust method for determining ARs in animal tissues is important for animal postmortem diagnostic and forensic purposes. We evaluated an ultra-performance liquid chromatography coupled with mass spectrometry (UPLC-MS) method to quantify 8 ARs (brodifacoum, bromadiolone, chlorophacinone, coumachlor, dicoumarol, difethialone, diphacinone, warfarin) in a wide range of animal (bovine, canine, chicken, equine, porcine) liver samples, including incurred samples. We further evaluated UPLC-MS in 2 interlaboratory comparison (ILC) studies; one an ILC exercise (ICE), the other a proficiency test (PT). The limits of detection of UPLC-MS were 0.3-3.1 ng/g, and the limits of quantification were 0.8-9.4 ng/g. The recoveries obtained using UPLC-MS were 90-115%, and relative SDs were 1.2-13% for each of the 8 ARs for the 50, 500, and 2,000 ng/g spiked liver samples. The overall accuracy from the laboratories participating in the 2 ILC studies (4 and 11 laboratories for ICE and PT studies, respectively) were 86-118%, with relative repeatability SDs of 3.7-11%, relative reproducibility SDs of 7.8-31.2%, and Horwitz ratio values of 0.5-1.5. Via the ILC studies, we verified the accuracy of UPLC-MS for AR analysis in liver matrices and demonstrated that ILC can be utilized to evaluate performance characteristics of analytical methods.

Comprehensive Evaluation of an HPLC-MS-MS Method for Quantitation of Seven Anti-Coagulant Rodenticides and Dicoumarol in Animal Serum.

Anti-coagulant rodenticides (ARs) are commonly utilized for controlling rodent populations; however, non-target companion and wildlife animals are also exposed. A method was developed for quantitation of seven ARs (chlorophacinone, coumachlor, bromadiolone, brodifacoum, difethialone, diphacinone and warfarin) and dicoumarol (a naturally occurring anti-coagulant) in animal serum. Analytes were extracted with 10% (v/v) acetone in methanol and analyzed by reverse phase high-performance liquid chromatography-tandem mass spectrometry using electrospray ionization (negative mode) combined with multiple reaction monitoring. In-house method validation in the originating laboratory using non-blinded samples revealed method limits of quantitation at 2.5 ng/mL for all analytes. The inter-assay accuracy ranged from 99% to 104%, and the relative standard deviation ranged from 3.5% to 20.5%. Method performance was then verified in the originating laboratory during an exercise organized by an independent party using blinded samples. The method was successfully transferred to two naïve laboratories and further evaluated for reproducibility among three laboratories by means of Horwitz ratio (HorRat(R)) values. Such extensive validation provides a high degree of confidence that the method is rugged, robust, and will perform as expected if used by others in the future.

A Multiple-Serotype Outbreak of Salmonella Infections Linked to Kratom, United States, 2017-2018.

In early 2018, we investigated a large national multiple-serotype Salmonella outbreak linked to contaminated kratom, a raw minimally processed botanical substance. Kratom is a plant consumed for its stimulant effects and as an opioid substitute. A case was defined as a laboratory-confirmed Salmonella infection with one of the outbreak strains (serotypes I 4,[5],12:b:-, Heidelberg, Javiana, Okatie, Weltevreden, or Thompson) with illnesses onset during January 11, 2017-May 8, 2018. State and local officials collected detailed information on product consumption and sources. Suspected products were tested for Salmonella and traceback was conducted to determine product distribution chains and suppliers. We identified 199 cases from 41 states; 54 patients were hospitalized. Early interviews indicated kratom was an exposure of interest. Seventy-six (74%) of 103 people interviewed reported consuming kratom in pills, powders, or teas. Multiple serotypes of Salmonella were detected in samples of kratom collected from the homes of the patients and from retail locations. Several companies issued recalls of kratom products due to Salmonella contamination. To the authors' knowledge, this investigation is the first to establish kratom as a vehicle for Salmonella infection. Our findings underscore the serious safety concerns regarding minimally processed botanical substances intended for oral consumption and the challenges in investigating outbreaks linked to novel outbreak vehicles.

Multistate outbreak of Salmonella Mbandaka infections linked to sweetened puffed wheat cereal - United States, 2018.

In May of 2018, PulseNet, the national molecular subtyping network for enteric pathogens, detected a multistate cluster of illnesses caused by an uncommon molecular subtype of Salmonella serovar Mbandaka. A case was defined as an illness in a person infected with the outbreak strain of Salmonella Mbandaka with illness onset on or after 3 March 2018 and before 1 September 2018. One-hundred thirty-six cases from 36 states were identified; 35 hospitalisations and no deaths were reported. Ill people ranged in age from <1 year to 95 years (median: 57 years). When standardised questionnaires did not generate a strong hypothesis, opened-ended interviews were performed. Sixty-three of 84 (75%) ultimately reported consuming or possibly consuming a specific sweetened puffed wheat cereal in the week before illness onset. Environmental sampling performed at the cereal manufacturing facility yielded the outbreak strain. The outbreak strain was also isolated from open cereal samples from ill people's homes and from a sealed retail sample. Due to these findings, the brand owner of the product issued a voluntary recall of the cereal on 14 June 2018. Additional investigation of the manufacturing facility identified persistent environmental contamination with Salmonella Mbandaka that was closely genetically related to other isolates in the outbreak. This investigation highlights the ability of Salmonella to survive in low-moisture environments, and the potential for prolonged outbreaks linked to products with long shelf lives and large distribution areas.

Infection control response to an outbreak of OXA-23 carbapenemase-producing carbapenem-resistant Acinetobacter baumannii in a skilled nursing facility in Utah.

BACKGROUND: Antibiotic-resistant Acinetobacter species are a growing public health threat, yet are not nationally notifiable, and most states do not mandate reporting. Additionally, there are no standardized methods to detect Acinetobacter species colonization. METHODS: An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) was identified at a Utah ventilator unit in a skilled nursing facility. An investigation was conducted to identify transmission modes in order to control spread of CRAB. Culture-based methods were used to identify patient colonization and environmental contamination in the facility. RESULTS: Of the 47 patients screened, OXA-23-producing CRAB were detected in 10 patients (21%), with 7 patients (15%) having been transferred from out-of-state facilities. Of patients who screened positive, 60% did not exhibit any signs or symptoms of active infection by chart review. A total of 38 environmental samples were collected and CRAB was recovered from 37% of those samples. Whole genome sequencing analyses of patient and environmental isolates suggested repeated CRAB introduction into the facility and highlighted the role of shared equipment in transmission. CONCLUSIONS: The investigation demonstrated this ventilated skilled nursing facility was an important reservoir for CRAB in the community and highlights the need for improved surveillance, strengthened infection control and inter-facility communication within and across states.

Postnatal Effects of Gestational and Lactational Gavage Exposure to Boric Acid in the Developing Sprague Dawley Rat.

Human exposure to boron occurs primarily through diet and drinking water sources. Animal studies have found that reduced fetal weight following gestational exposure to boron (as boric acid) is the most sensitive toxicological effect. However, recent studies suggest that newborns in areas with elevated boron in drinking water may receive levels of exposure that exceed the U.S. EPA oral reference dose for B. Currently, there are no data to inform a boron risk assessment accounting for this developmental window. To address this knowledge gap, the National Toxicology Program evaluated developmental toxicity following pre- and postnatal boron exposure. Time-mated female Sprague Dawley (Hsd: Sprague Dawley SD) rats were administered 0-20 mg B/kg/day (as boric acid) via gavage from gestation day 6 to 21; offspring were dosed via gavage at the same respective dose level from postnatal day (PND) 1 to 28. There were no dose-related effects on dam bodyweight, bodyweight gain, or feed consumption. Clinical findings were limited to low incidences of umbilical hernia in the 20 mg B/kg pups which resolved by study completion. Pup plasma boron concentrations increased in dose-proportional manner and were similar between PND 4 and PND 28. Postnatal weight gain was significantly reduced at 20 mg B/kg, with male and female pups weighing 23% less than the controls on PND 28. These findings demonstrate that postnatal growth in the Sprague Dawley rat is sensitive to boron exposure and highlights the importance of evaluating the potential toxicity of agents with known human exposures during early life stages.

Interlaboratory comparison of heavy metal testing in animal diagnostic specimens and feed using inductively coupled plasma-mass spectrometry.

We compared inductively coupled plasma-mass spectrometry (ICP-MS) test results for the analysis of heavy metals (As, Ba, Cd, Hg, Pb, and Se) in pet foods and routine veterinary diagnostic specimens using intralaboratory and interlaboratory comparisons. Four laboratories, 1 principal laboratory and 3 collaborating laboratories, conducted instrument comparison (limit of detection [LOD], limit of quantification [LOQ], and linear dynamic range [LDR] on 24 data sets), in-house method comparison (accuracy and precision on 120 data sets), and interlaboratory comparison (reproducibility on 528 data sets using Horwitz equation analysis). Matrices tested included 2 types of pet food jerky treats (chicken and sweet potato), bovine blood, and bovine liver and kidney. The instrument comparison study confirmed that ICP-MS provided the sensitivity necessary for the analysis of all heavy metals tested at concentrations below the level of concern for routine diagnostic testing. The "in-house" method comparison samples, spiked at low (0.04 µg/g), medium (0.4 µg/g), and high (8.0 µg/g; note: the high validation level spike for mercury was 2 µg/g) concentration levels, indicated that ICP-MS can meet U.S. FDA acceptance criteria for both accuracy (90-105% recovery) and precision (< 6% coefficient of variation). The interlaboratory comparison studies showed that ICP-MS is a reproducible method for the analysis of heavy metals (HorRat value of 0.5-2.0) except for mercury in one laboratory, which used a different sample preparation method (open block rather than microwave digestion). Overall, our study showed that ICP-MS is a reproducible method for the analysis of heavy metals in spite of minor differences in methodology.

Change over time in patient-reported symptoms and quality of life in Edmonton interdisciplinary menopause clinics: preliminary cohort study of clinic patients and waitlist patients.

OBJECTIVE: Specialized interdisciplinary menopause clinics in Edmonton provide care for women suffering from severe menopausal symptoms. Our objectives were to evaluate changes over time in patient-reported menopause symptoms and quality of life (QOL) in a cohort of clinic patients, compared to a cohort of women recruited from the clinic waitlists. METHODS: We conducted a prospective study of consecutive new patients in two clinics. Consenting women completed a generic menopause symptom severity questionnaire (MSSQ) and the menopause-specific quality of life (MENQOL) questionnaire at their first clinic and at a follow-up visit. Demographics, medical and obstetric histories, and medication use were extracted from patient charts. Women on the clinics' waitlists were enrolled as controls; corresponding data for baseline and follow-up were collected in mailed-in surveys. Descriptive and paired statistics were used for data analysis. Agreement plot was created to visualize the agreement between MSSQ and MENQOL scores. RESULTS: A total of 139 women were recruited: 98 attended the clinic and 41 were from the waitlist. Follow-up data were available for 99 women (71 clinic and 28 waitlist). There were no significant differences between clinic and waitlist patient characteristics. Women attending the clinics experienced significant reduction in symptom severity (mean MSSQ scores) and improvement in QOL (reduced MENQOL "bother" scores). Women on the clinic waitlist did not demonstrate significant changes over a similar timeframe. MENQOL correlated well with menopause symptom severity assessment. CONCLUSION: Women attending specialized menopause clinics experienced improvement in symptoms and QOL, whereas women on the waitlists did not experience these changes. : Video Summary: Supplemental Digital Content 1, http://links.lww.com/MENO/A418.

Is Transdermal Multivitamin Patch Effective in Gastric Bypass Patients?

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) patients are recommended to take multiple oral vitamin supplements daily. Transdermal multivitamin patches are being advertised as an alternative for use in bariatric patients with no data to support their efficacy. The purpose of this study was to evaluate response to daily transdermal use of multivitamin patch after LRYGB and to compare them with a control group of similar patients who used oral supplements. METHODS: A retrospective review was carried out on patients who had LRYGB at a community hospital from February 2015 to February 2019. Patients who had completed preoperative and annual postoperative bariatric laboratory tests were included. They were divided into patch and pill (control) group. RESULTS: Seventeen patients were included in the patch and 27 in the pill group. Patients in each group used either patch or pills for 12 months and they were 1 year post LRYGB. Fourteen patients (82.35%) in patch group and 11 patients (40.74%) in pill group had at least 1 deficiency at annual postoperative blood work (P = .0116). Vitamin D deficiency was seen in 81% patients in patch group vs 36% in the pill group (P = .0092). Statistically significant lower postoperative serum concentrations of vitamin D, B1, and B12 were seen in the patch group. CONCLUSIONS: Multivitamin patch users are more likely to have vitamin D deficiency and lower serum concentration of various vitamins and minerals. Future large studies are needed on the efficacy of multivitamin patches before they can be recommended to bariatric patient population.

Evaluation of a Diagnostic Method to Quantify Aflatoxins B1 and M1 in Animal Liver by High-Performance Liquid Chromatography with Fluorescence Detection.

Background: Aflatoxins (AFs) are secondary metabolites of fungi and are one of the causes of toxin-related pet food recalls. An intralaboratory method was previously developed to quantify aflatoxin B1 (AFB1) and aflatoxin M1 (AFM1) in animal liver by HPLC with fluorescence detection. Objective: The aim of this study was to extensively evaluate the method performance with a single-laboratory blinded method test (BMT-S) and a multilaboratory blinded method test (BMT-M). Methods: Blinded tissue samples were prepared by a third-party laboratory and sent out to participating laboratories for both BMT-S and BMT-M. Results: In both tests, participants analyzed blinded samples prepared by an independent laboratory. In the BMT-S, accuracy ranged between 111 and 154% for AFB1 and 113 and 159% for AFM1 within the quantitation range of 0.1-0.5 ng/g. The HorRat values for repeatability ranged between 0.1 and 0.3 for AFB1 and 0.3 and 0.6 for AFM1. In the BMT-M, the interlaboratory accuracy ranged between 77 and 81% for AFB1 and 83 and 85% for AFM1 within the quantitation range of 0.2-10 ng/g. The HorRat values for reproducibility ranged between 0.4 and 0.7 for AFB1 and 0.4 and 0.9 for AFM1. Both recovery and reproducibility were acceptable. Conclusions: BMT-M evaluation demonstrated that the method was suitable for quantitation of aflatoxins B1 and M1 in animal liver between laboratories. Highlights: The BMT-S and BMT-M results demonstrated that the method is rugged and reproducible among the participating laboratories.

Outbreak of E. coli O157:H7 Infections Associated with Exposure to Animal Manure in a Rural Community - Arizona and Utah, June-July 2017.

On June 26, 2017, a hospital in southern Utah notified the Utah Department of Health of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections in two children from a small community on the Arizona-Utah border. Both children developed hemolytic uremic syndrome, characterized by hemolytic anemia, acute kidney failure, and thrombocytopenia and died within a few days of illness onset. Over the next few days, several more STEC-associated illnesses were reported in residents of the community. A joint investigation by local and state health agencies from Arizona and Utah and CDC was initiated to identify the outbreak source and prevent additional cases; a total of 12 cases were identified, including the two children who died. Investigators initially explored multiple potential sources of illness; epidemiologic and environmental information revealed cow manure contact as the likely initial cause of the outbreak, which was followed by subsequent person-to-person transmission. One of the outbreak strains was isolated from bull and horse manure collected from a yard near a community household with two ill children. Local health agencies made recommendations to the public related to both animal contact and hand hygiene to reduce the risk for STEC transmission. Animal or animal manure contact should be considered a potential source of STEC O157:H7 during outbreaks in communities where ruminants are kept near the home.

Husbandry of wild-caught song sparrows (Melospiza melodia).

Conservation and research efforts occasionally rely upon bringing wild animals into human care to establish breeding programs and to understand their biology. Wild-caught birds may have husbandry requirements that differ from captive-reared animals due, in part, to their social development in the wild and potential exposure to novel pathogens. We developed husbandry techniques to minimize stress and monitor health in a population of wild-caught song sparrows (Melospiza melodia). We describe enclosure conditions, diet and enrichment, and best practices for stress reduction. In addition, we describe several health monitoring strategies, including assessing feces quality, body condition scores, and specific signs of infection. These techniques led to successful housing of song sparrows during formal behavioral and developmental studies. This information will be useful for guiding the husbandry of wild-caught passerine birds in the future.

Multistate Outbreak of Salmonella Virchow Infections Linked to a Powdered Meal Replacement Product-United States, 2015-2016.

Background: Nontyphoidal Salmonella is the leading cause of bacterial gastroenteritis in the United States. Meal replacement products containing raw and "superfood" ingredients have gained increasing popularity among consumers in recent years. In January 2016, we investigated a multistate outbreak of infections with a novel strain of Salmonella Virchow. Methods: Cases were defined using molecular subtyping procedures. Commonly reported exposures were compared with responses from healthy people interviewed in the 2006-2007 FoodNet Population Survey. Firm inspections and product traceback and testing were performed. Results: Thirty-five cases from 24 states were identified; 6 hospitalizations and no deaths were reported. Thirty-one of 33 (94%) ill people interviewed reported consuming a powdered supplement in the week before illness; of these, 30 (97%) reported consuming product A, a raw organic powdered shake product consumed as a meal replacement. Laboratory testing isolated the outbreak strain of Salmonella Virchow from leftover product A collected from ill people's homes, organic moringa leaf powder (an ingredient in product A), and finished product retained by the firm. Firm inspections at 3 facilities linked to product A production did not reveal contamination at the facilities. Traceback investigation identified that the contaminated moringa leaf powder was imported from South Africa. Conclusions: This investigation identified a novel outbreak vehicle and highlighted the potential risk with similar products not intended to be cooked by consumers before consuming. The company issued a voluntary recall of all implicated products. As this product has a long shelf life, the recall likely prevented additional illnesses.

Development and Validation of Quantitative Ultraperformance Liquid Chromatography-Tandem Mass Spectrometry Assay for Anticoagulant Rodenticides in Liver.

Anticoagulant rodenticides (ARs) are used to control rodent populations; however, exposure to nontarget animals occurs. A sensitive and rugged quantitative method was developed, optimized, and validated for eight ARs in liver. Target analytes comprised two chemical classes: hydroxycoumarins (warfarin, coumachlor, dicoumarol, bromadiolone, brodifacoum, and difethialone) and indanediones (diphacinone and chlorophacinone). In this method, liver extracts were cleaned using dispersive solid phase extraction (d-SPE) to remove matrix interferences and analyzed by reverse phase ultraperformance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Electrospray ionization in negative ion mode combined with multiple reaction monitoring (MRM) using a triple quadrupole mass spectrometer provided simultaneous confirmation and quantitation. Detection limits spanned 0.75-25 ng/g, and lower quantitation limits were established as 50 ng/g. Interassay method accuracy ranged from 92 to 110% across the analytical range (50-2500 ng/g) using matrix-matched calibrants with good repeatability (relative standard deviations 2-16%). Successful method transfer to another laboratory utilizing an Orbitrap mass analyzer, providing high mass accuracy, was assessed by good method reproducibility during blinded study analyses (6-29%; Horwitz ratios (HORRAT) ≤ 1.5).

Quantitation of fumonisin B1 and B2 in feed using FMOC pre-column derivatization with HPLC and fluorescence detection.

Pre-column derivatization with 9-fluorenylmethyl chloroformate (FMOC-Cl) was determined to be effective for quantitation of fumonisins B1 and B2 in feed. Liquid-solid extraction, clean-up using immunoaffinity solid phase extraction chromatography, and FMOC-derivatization preceded analysis by reverse phase HPLC with fluorescence. Instrument response was unchanged in the presence of matrix, indicating no need to use matrix-matched calibrants. Furthermore, high method recoveries indicated calibrants do not need to undergo clean-up to account for analyte loss. Established method features include linear instrument response from 0.04-2.5µg/mL and stable derivatized calibrants over 7days. Fortified cornmeal method recoveries from 0.1-30.0µg/g were determined for FB1 (75.1%-109%) and FB2 (96.0%-115.2%). Inter-assay precision ranged from 1.0%-16.7%. Method accuracy was further confirmed using certified reference material. Inter-laboratory comparison with naturally-contaminated field corn demonstrated equivalent results with conventional derivatization. These results indicate FMOC derivatization is a suitable alternative for fumonisins B1 and B2 quantitation in corn-based feeds.

Outbreak of Botulism Due to Illicit Prison-Brewed Alcohol: Public Health Response to a Serious and Recurrent Problem.

Background: Botulism is a rare, sometimes lethal neuroparalytic illness. On 2 October 2011, an inmate at prison A developed symptoms compatible with botulism after drinking pruno, an illicit, prison-brewed alcoholic beverage. Additional illnesses were identified within several days. We conducted an investigation to determine the cause and extent of the outbreak. Methods: A case was defined as signs or symptoms of botulism in a prison A inmate with onset during 30 September-9 October 2011. Cases were identified through medical evaluations and interviews with inmates about recent pruno consumption. Laboratory testing was performed for Clostridium botulinum and botulinum neurotoxin. Ingredients, preparation, and sharing of the implicated pruno were investigated. Results: Eight prisoners developed botulism; all drank pruno made with a potato. Three received mechanical ventilation. Culture of fluid from a sock that inmates reported using to filter the implicated pruno yielded C. botulinum type A. The implicated batch may have been shared between cells during delivery of meal trays. Challenges of the investigation included identifying affected inmates, overcoming inaccuracies in histories, and determining how the illicit beverage was shared. Costs to taxpayers were nearly $500000 in hospital costs alone. Conclusions: Pruno made with potato has emerged as an important cause of botulism in the United States. This public health response illustrates the difficulties of investigating botulism in correctional facilities and lessons learned for future investigations.

Long-Term Effects of Postoperative Delirium in Patients Undergoing Cardiac Operation: A Systematic Review.

Delirium is an acute syndrome that involves fluctuating changes in attention and cognition. Although delirium is the most common neurologic complication after cardiac operation, data about its impact on long-term outcomes are lacking. The purpose of this systematic review was to examine the effect of postoperative delirium (PoD) on long-term outcomes, including morbidity, probability of death, cognitive decline, institutionalization, and health-related quality of life (HRQoL) in patients undergoing cardiac operation. After performing this systematic review we determined that PoD after cardiac operation is associated with an increased risk of probability of death and readmission to the hospital and a decrease in cognitive function, overall function, and HRQoL.