A Large Esophageal Leiomyoma: Thoraco-Laparoscopic Enucleation or Esophagectomy and Reconstruction?

BACKGROUND Esophageal leiomyoma is a rare condition, with an estimated incidence rate of 0.4% of all esophageal neoplasms. These tumors are typically small, rarely more than 5 cm. The treatment depends on symptoms and the size and location of the tumor, with enucleation as the standard treatment of esophageal leiomyomas. Esophagectomy is performed only in very few cases, such as when the tumor is too large, there are multiple leiomyomas, there is a horseshoe shape or circumference, or the tumor is inextricably adhering to the esophageal mucosa. In such complex cases, it is often difficult to perform enucleation. However, with the risks of esophagectomy and intra-thoracic anastomosis, namely reflux, stenosis, leakage, abscess, and infection, attempting to perform enucleation for these cases should still be considered. CASE REPORT We reported a case of a large, multi-lobed, circumferential esophageal thoracoabdominal leiomyoma with successfully performed enucleation and esophageal preservation. A Dor fundoplication and Witzel jejunostomy tube were also performed. Follow-up 3 months postoperatively showed no appearance of reflux or dysphagia. The postoperative esophagogram visualized no obstruction or leakage. Histopathological results gave us concrete evidence of a leiomyoma: elongated cells with eosinophilic cytoplasm and rhomboid nuclei with uniform size. CONCLUSIONS The thoraco-laparoscopic enucleation approach is the method that should be considered first in the treatment of large, multi-lobed, circumferential esophageal leiomyomas, before contemplating esophagectomy and reconstruction.

An Overview of Foodborne Sample-Initiated Retrospective Outbreak Investigations and Interagency Collaboration in the United States.

Foodborne outbreak investigations have traditionally included the detection of a cluster of illnesses first, followed by an epidemiologic investigation to identify a food of interest. The increasing use of whole genome sequencing (WGS) subtyping technology for clinical, environmental, and food isolates of foodborne pathogens, and the ability to share and compare the data on public platforms, present new opportunities to identify earlier links between illnesses and their potential sources. We describe a process called sample-initiated retrospective outbreak investigations (SIROIs) used by federal public health and regulatory partners in the United States. SIROIs begin with an evaluation of the genomic similarity between bacterial isolates recovered from food or environmental samples and clusters of clinical isolates while subsequent and parallel epidemiologic and traceback investigations are initiated to corroborate their connection. SIROIs allow for earlier hypothesis generation, followed by targeted collection of information about food exposures and the foods and manufacturer of interest, to confirm a link between the illnesses and their source. This often leads to earlier action that could reduce the breadth and burden of foodborne illness outbreaks. We describe two case studies of recent SIROIs and present the benefits and challenges. Benefits include insight into foodborne illness attribution, international collaboration, and opportunities for enhanced food safety efforts in the food industry. Challenges include resource intensiveness, variability of epidemiologic and traceback data, and an increasingly complex food supply chain. SIROIs are valuable in identifying connections among small numbers of illnesses that may span significant time periods; detecting early signals for larger outbreaks or food safety issues associated with manufacturers; improving our understanding of the scope of contamination of foods; and identifying novel pathogen/commodity pairs.

Gender differences and cooperation in medical authorships - an analysis of the recent ten years in five key medical disciplines.

BACKGROUND: Career prospects in academic medicine are strongly linked to scientific authorship and this marker has been widely used as an indicator of gender equity in academia. However, direct comparisons of medical disciplines regarding their proportion of female physicians (FP) in different countries are missing. This study examines the gender parity and gender cooperation using first authorships (FA) and senior authorships (SA) of scientific publications in five medical disciplines and six different OECD countries over a 10-year time-trend. METHODS: Articles from three high-impact journals in each of the medical discipline radiology, urology, surgery, gynecology, and pediatrics from the years 2007/8 and 2017/18 were retrospectively reviewed. The gender and affiliation location of the FA and SA of original research articles and reviews were assigned and compared with the proportion of in each discipline for the United States of America, Canada, United Kingdom, France, Germany, and Japan. Mantel-Haenszel test and multinomial logistic regression models were used to calculate differences in proportions of women authors and FP and to assess trends and proportions of FA and SA. RESULTS: 30,803 articles were evaluated. Equally, with rising proportions of FP in all disciplines, the number of women authors increased across years. The shares of women FAs were either significantly higher (urology/surgery/gynecology) or balanced (pediatrics/radiology) compared to the proportion of FP. In contrast, the shares of women SA were balanced only in disciplines with a low proportion of FP (urology and surgery) and otherwise reduced. Women same-gender cooperation was as common as men same-gender cooperation and preferred over a women-led mixed gender cooperation in disciplines where this seemed to be practicable due to the high proportions of FP. CONCLUSION: In contrast to FA, a significant disparity persists in SA, particularly in disciplines with a high proportion of FP. The discrepancy between FA and SA may reflect, among others, dropout from an academic career in early or mid-academic levels, for example, due to structural inequality; together with the findings on gender preference in authorship collaborations, this may inform future strategies for promoting equal career advancement for women physicians.

Pathological alterations in the expression status of rotator cuff tendon matrix components in hyperlipidemia.

Hyperlipidemia is an important risk factor in the development and progression of tendon pathology, however its role in aggravating rotator cuff tendon injury (RCTI) is largely unknown. We aimed to assess the expression status of key extracellular matrix (ECM) components in the tendon tissues and tenocytes under hyperlipidemia. Shoulder rotator cuff (RC) tendon tissues harvested from the swine model of hyperlipidemia displayed alterations in histomorphometry and the expression status of major ECM component proteins including COL-I, COL-III, COL-IV, COL-V, COL-VI, MMP2, and MMP9. Similarly, the LDL- and oxLDL-challenged tenocytes displayed altered expression of the same proteins at both transcriptional and translational levels. In addition, the lipid uptake and cellular reactive oxygen radicals predominated in the lipid-challenged tenocytes compared to the control. Overall, the LDL-treated cells displayed predominant pathological alterations compared to the ox-LDL-treated cells. Further understanding regarding the underlying molecular mechanisms driving the tendon matrisome alteration and subsequent aggravated RCTI pathology in hyperlipidemia could open novel translational avenues in the management of RCTI.

Intelligent Hydrogels in Myocardial Regeneration and Engineering.

Myocardial infarction (MI) causes impaired cardiac function due to the loss of cardiomyocytes following an ischemic attack. Intelligent hydrogels offer promising solutions for post-MI cardiac tissue therapy to aid in structural support, contractility, and targeted drug therapy. Hydrogels are porous hydrophilic matrices used for biological scaffolding, and upon the careful alteration of ideal functional groups, the hydrogels respond to the chemistry of the surrounding microenvironment, resulting in intelligent hydrogels. This review delves into the perspectives of various intelligent hydrogels and evidence from successful models of hydrogel-assisted treatment strategies.

Right Upper Quadrant Pain Following Endoscopic Retrograde Cholangiopancreatography; a Case Report.

Endoscopic retrograde cholangiopancreatography (ERCP) is a standard for diagnosing and treating hepato-pancreatico-biliary (HPB) diseases in clinical settings. ERCP-related complications are relatively common, ranging from 4 to 30%. The most common one is acute pancreatitis. ERCP-related necrotizing pancreatitis accounts for 7.7% of ERCP-related pancreatitis cases. This complication may still be misdiagnosed, which might lead to inappropriate treatment with a worse prognosis. Here, we report a 34-year-old case with ERCP-related necrotizing pancreatitis who was successfully managed, but initially misdiagnosed with biliary peritonitis.

The impact of COVID-19 economic crisis on the speed of adjustment toward target leverage ratio: An international analysis.

This paper investigates changes in the speed of adjustment toward target leverage ratio under the impact of COVID-19 economic crisis. Using an international sample of publicly listed firms, we find that, on average, firms tend to adjust their capital structure more rapidly in the period following the breakout of COVID-19. Furthermore, we find that firms domiciled in countries in which COVID-19 causes more severe damage, adjust their target leverage quicker than firms domiciled in less severely affected countries. Overall, our study aims at developing a better understanding of the impact of COVID-19 on corporate financing decisions.

Gender trends in authorships and publication impact in Academic Radiology-a 10-year perspective.

OBJECTIVES: To analyze the development of publication numbers of female authors in high-, medium-, and low-impact radiological journals. METHODS: In this bibliometric analysis, gender of the first (FA) and senior author (SA) was assigned to all original research articles and reviews, published in 10 high-, medium-, and low-impact radiological journals in 2007/8 and 2017/18. The adjusted event rate (AER) and adjusted odds ratio (AOR) were calculated using mixed logistic and multinomial logistic regression models to assess and compare female publications according to impact factor, journal, author position, and combination. RESULTS: The proportion of female FA and female SA in N = 6979 (2007/2008) and N = 7383 (2017/2018) articles increased to 29.1% and 16.1% in 2017/2018, respectively. While most female authorships were continuously observed in medium-impact journals, the strongest increase occurred for both female FA (AOR 2.0; p < .0001) and SA (AOR 2.1; p < .0001) in low-impact journals. Female SA published significantly more often in a low- (AOR 1.5) or medium- (AOR 1.8) than in a high-ranking journal. Among the high-ranking journals, female FA published most frequently in European Radiology (32.4%; 95% CI [29.3-35.8]; p < .0001), female SA in Investigative Radiology (15.9%; 95% CI [13.7-18.4]; p < .0001). Male same-sex authorships decreased (AOR 0.9), but remained at least twice as common as all-female or mixed authorships. CONCLUSION: The increase in female authorship is reflected in all impact areas. Female FA and SA increased most in low-ranking journals but are most common in medium-ranking journals. Female SA remain rare, especially in high impact journals. KEY POINTS: • Compared to the proportion of female radiologists worldwide, female senior authors are underrepresented in all impact areas, in particular in high-impact journals. • Among the included high-ranking radiological journals, female first authors and senior authors were strongest represented in European Radiology and Investigative Radiology, while across all impact areas they mostly published in medium-ranking journals. • Female author combinations were more frequent in low- and medium- than in high-ranking journals, whereas male author combinations remained more common than female senior author collaborations in all impact areas.

Investigations of Possible Multistate Outbreaks of Salmonella, Shiga Toxin-Producing Escherichia coli, and Listeria monocytogenes Infections - United States, 2016.

PROBLEM/CONDITION: Salmonella, Shiga toxin-producing Escherichia coli (STEC), and Listeria monocytogenes are the leading causes of multistate foodborne disease outbreaks in the United States. Responding to multistate outbreaks quickly and effectively and applying lessons learned about outbreak sources, modes of transmission, and risk factors for infection can prevent additional outbreak-associated illnesses and save lives. This report summarizes the investigations of multistate outbreaks and possible outbreaks of Salmonella, STEC, and L. monocytogenes infections coordinated by CDC during the 2016 reporting period. PERIOD COVERED: 2016. An investigation was considered to have occurred in 2016 if it began during 2016 and ended on or before March 31, 2017, or if it began before January 1, 2016, and ended during March 31, 2016-March 31, 2017. DESCRIPTION OF SYSTEM: CDC maintains a database of investigations of possible multistate foodborne and animal-contact outbreaks caused by Salmonella, STEC, and L. monocytogenes. Data were collected by local, state, and federal investigators during the detection, investigation and response, and control phases of the outbreak investigations. Additional data sources used for this report included PulseNet, the national molecular subtyping network based on isolates uploaded by local, state, and federal laboratories, and the Foodborne Disease Outbreak Surveillance System (FDOSS), which collects information from state, local, and territorial health departments and federal agencies about single-state and multistate foodborne disease outbreaks in the United States. Multistate outbreaks reported to FDOSS were linked using a unique outbreak identifier to obtain food category information when a confirmed or suspected food source was identified. Food categories were determined and assigned in FDOSS according to a classification scheme developed by CDC, the Food and Drug Administration (FDA), and the U.S. Department of Agriculture Food Safety and Inspection Service (FSIS) in the Interagency Food Safety Analytics Collaboration. A possible multistate outbreak was determined by expert judgment to be an outbreak if supporting data (e.g., temporal, geographic, demographic, dietary, travel, or food history) suggested a common source. A solved outbreak was an outbreak for which a specific kind of food or animal was implicated (i.e., confirmed or suspected) as the source. Outbreak-level variables included number of illnesses, hospitalizations, cases of hemolytic uremic syndrome (HUS), and deaths; the number of states with illnesses; date of isolation for the earliest and last cases; demographic data describing patients associated with a possible outbreak (e.g., age, sex, and state of residence); the types of data collected (i.e., epidemiologic, traceback, or laboratory); the outbreak source, mode of transmission, and exposure location; the name or brand of the source; whether the source was suspected or confirmed; whether a food was imported into the United States; the types of regulatory agencies involved; whether regulatory action was taken (and what type of action); whether an outbreak was publicly announced by CDC via website posting; beginning and end date of the investigation; and general comments about the investigation. The number of illnesses, hospitalizations, cases of HUS, and deaths were characterized by transmission mode, pathogen, outcome (i.e., unsolved, solved with suspected source, or solved with confirmed source), source, and food or animal category. RESULTS: During the 2016 reporting period, 230 possible multistate outbreaks were detected and 174 were investigated. A median of 24 possible outbreaks was under investigation per week, and investigations were open for a median of 37 days. Of these 174 possible outbreaks investigated, 56 were excluded from this analysis because they occurred in a single state, were linked to international travel, or were pseudo-outbreaks (e.g., a group of similar isolates resulting from laboratory media contamination rather than infection in patients). Of the remaining 118 possible multistate outbreaks, 50 were determined to be outbreaks and 39 were solved (18 with a confirmed food source, 10 with a suspected food source, 10 with a confirmed animal source, and one with a suspected animal source). Sprouts were the most commonly implicated food category in solved multistate foodborne outbreaks (five). Chicken was the source of the most foodborne outbreak-related illnesses (134). Three outbreaks involved novel food-pathogen pairs: flour and STEC, frozen vegetables and L. monocytogenes, and bagged salad and L. monocytogenes. Eleven outbreaks were attributed to contact with animals (10 attributed to contact with backyard poultry and one to small turtles). Thirteen of 18 multistate foodborne disease outbreaks with confirmed sources resulted in product action, including 10 outbreaks with recalls, two with market withdrawals, and one with an FSIS public health alert. Twenty outbreaks, including 11 foodborne and nine animal-contact outbreaks, were announced to the public by CDC via its website, Facebook, and Twitter. These announcements resulted in approximately 910,000 webpage views, 55,000 likes, 66,000 shares, and 5,800 retweets. INTERPRETATION: During the 2016 reporting period, investigations of possible multistate outbreaks occurred frequently, were resource intensive, and required a median of 37 days of investigation. Fewer than half (42%) of the 118 possible outbreaks investigated were determined to have sufficient data to meet the definition of a multistate outbreak. Moreover, of the 50 outbreaks with sufficient data, approximately three fourths were solved. PUBLIC HEALTH ACTION: Close collaboration among CDC, FDA, FSIS and state and local health and agriculture partners is central to successful outbreak investigations. Identification of novel outbreak sources and trends in sources provides insights into gaps in food safety and safe handling of animals, which helps focus prevention strategies. Summarizing investigations of possible multistate outbreaks can provide insights into the investigative process, improve future investigations, and help prevent illnesses. Although identifying and investigating possible multistate outbreaks require substantial resources and investment in public health infrastructure, they are important in determining outbreak sources and implementing prevention and control measures.

Outbreaks of Human Salmonella Infections Associated with Live Poultry, United States, 1990-2014.

Backyard poultry flocks have increased in popularity concurrent with an increase in live poultry-associated salmonellosis (LPAS) outbreaks. Better understanding of practices that contribute to this emerging public health issue is needed. We reviewed outbreak reports to describe the epidemiology of LPAS outbreaks in the United States, examine changes in trends, and inform prevention campaigns. LPAS outbreaks were defined as ≥2 culture-confirmed human Salmonella infections linked to live poultry contact. Outbreak data were obtained through multiple databases and a literature review. During 1990-2014, a total of 53 LPAS outbreaks were documented, involving 2,630 illnesses, 387 hospitalizations, and 5 deaths. Median patient age was 9 years (range <1 to 92 years). Chick and duckling exposure were reported by 85% and 38% of case-patients, respectively. High-risk practices included keeping poultry inside households (46% of case-patients) and kissing birds (13%). Comprehensive One Health strategies are needed to prevent illnesses associated with live poultry.

Multistate outbreak of human Salmonella Typhimurium infections linked to live poultry from agricultural feed stores and mail-order hatcheries, United States 2013.

Live poultry-associated salmonellosis is an emerging public health issue in the United States. Public and animal health officials collaborated to investigate one of the largest (356 cases, 39 states) of these outbreaks reported to date. A case was defined as illness in a person infected with the outbreak strain of Salmonella Typhimurium with illness onset between 1 March and 22 October 2013. The median patient age was seven years (range: < 1-87 years); 58% of ill persons were children ≤ 10 years, 51% were female, 25% were hospitalized; 189 (76%) of 250 patients reported live poultry exposure in the week before illness; and 149 (95%) of 157 reported purchasing live poultry from agricultural feed stores. Traceback investigations identified 18 live poultry sources, including 16 mail-order hatcheries. Environmental sampling was conducted at two mail-order hatcheries. One (2.5%) of 40 duplicate samples collected at one hatchery yielded the outbreak strain. Live poultry are an important source of human salmonellosis, particularly among children, highlighting the need for educational campaigns and comprehensive interventions at the mail-order hatchery and agricultural feed store levels. Prevention and control efforts depend on a One Health approach, involving cooperation between public and animal health officials, industry, health professionals, and consumers.

Laboratory, Environmental, and Epidemiologic Investigation and Regulatory Enforcement Actions in Response to an Outbreak of Salmonella Bredeney Infections Linked to Peanut Butter.

Background. In September 2012, the Centers for Disease Control and Prevention (CDC), U.S. Food and Drug Administration (FDA), and state and local partners investigated an outbreak of Salmonella enterica serovar Bredeney linked to peanut butter (PB). Methods. A case was defined as infection with the outbreak strain of Salmonella Bredeney between June 1, 2012 and October 31, 2012. Food exposure questionnaires were analyzed by the CDC to determine the food vehicle. The FDA reviewed production information from Retail Chain A's sole supplier of PB, Company A. The PB samples collected from case-patients and Company A were tested for Salmonella. Results. Forty-two case-patients from 20 states were identified. Of 33 case-patients from whom food exposure information was obtained, 25 (76%) shopped at Retail Chain A and 25 (100%) purchased Company A PB. Three state health departments isolated the outbreak strain from opened jars of PB collected from case-patients. The FDA investigators identified multiple deficiencies in current Good Manufacturing Practices (cGMPs) in Company A's manufacturing facility and determined that internal controls were insufficient to prevent shipment of contaminated product. The FDA isolated the outbreak strain of Salmonella Bredeney from implicated product collected at the firm and the environment of the firm's food production facility. Conclusions. Timely laboratory, investigational, and epidemiologic data led to the voluntary recall of PB by Company A. The FDA suspended Company A's food facility registration, prohibiting the firm from introducing food into interstate commerce. This outbreak underscores the need for effective preventive controls, including robust internal environmental monitoring programs, appropriate action in response to contamination findings, and an improved understanding of food safety at the managerial and corporate levels.

Notes from the field: multistate outbreak of human salmonella infections linked to live poultry from a mail-order hatchery in Ohio--February-October 2014.

In early 2014, five clusters of human Salmonella infections were identified through PulseNet, the national molecular subtyping network for foodborne disease surveillance. Many ill persons in each of these clusters reported contact with live poultry, primarily chicks and ducklings, from a single mail-order hatchery; therefore, the clusters were merged into a single investigation. During February 3-October 14, 2014, a total of 363 persons infected with outbreak strains of Salmonella serotypes Infantis, Newport, and Hadar were reported from 43 states and Puerto Rico, making it the largest live poultry-associated salmonellosis outbreak reported in the United States.

Outbreak of Salmonella Newport infections linked to cucumbers--United States, 2014.

In August 2014, PulseNet, the national molecular subtyping network for foodborne disease surveillance, detected a multistate cluster of Salmonella enterica serotype Newport infections with an indistinguishable pulse-field gel electrophoresis (PFGE) pattern (XbaI PFGE pattern JJPX01.0061). Outbreaks of illnesses associated with this PFGE pattern have previously been linked to consumption of tomatoes harvested from Virginia's Eastern Shore in the Delmarva region and have not been linked to cucumbers or other produce items. To identify the contaminated food and find the source of the contamination, CDC, state and local health and agriculture departments and laboratories, and the Food and Drug Administration (FDA) conducted epidemiologic, traceback, and laboratory investigations. A total of 275 patients in 29 states and the District of Columbia were identified, with illness onsets occurring during May 20-September 30, 2014. Whole genome sequencing (WGS), a highly discriminating subtyping method, was used to further characterize PFGE pattern JJPX01.0061 isolates. Epidemiologic, microbiologic, and product traceback evidence suggests that cucumbers were a source of Salmonella Newport infections in this outbreak. The epidemiologic link to a novel outbreak vehicle suggests an environmental reservoir for Salmonella in the Delmarva region that should be identified and mitigated to prevent future outbreaks.

Multistate outbreak of human Salmonella infections linked to live poultry from a mail-order hatchery in Ohio--March-September 2013.

In early 2013, four clusters of human Salmonella infections were identified through PulseNet, the national molecular subtyping network for foodborne bacteria. Many of the ill persons in these four clusters reported contact with live poultry, primarily chicks and ducklings, from a single mail-order hatchery; therefore, these investigations were merged. During March 4-October 9, 2013, a total of 158 persons infected with outbreak strains of Salmonella serotypes Infantis, Lille, Newport, and Mbandaka were reported from 30 states.

Gastroenteritis outbreak associated with unpasteurized tempeh, North Carolina, USA.

During an investigation of an outbreak of gastroenteritis caused by Salmonella enterica serovar Paratyphi B variant L(+) tartrate(+), we identified unpasteurized tempeh as a novel food vehicle and Rhizopus spp. starter culture as the source of the contamination. Safe handling of uncooked, unpasteurized tempeh should be emphasized for prevention of foodborne illnesses.

A national outbreak of Salmonella serotype Tennessee infections from contaminated peanut butter: a new food vehicle for salmonellosis in the United States.

BACKGROUND: Salmonella serotype Tennessee is a rare cause of the estimated 1 million cases of salmonellosis occurring annually in the United States. In January 2007, we began investigating a nationwide increase in Salmonella Tennessee infections. METHODS: We defined a case as Salmonella Tennessee infection in a patient whose isolate demonstrated 1 of 3 closely related pulsed-field gel electrophoresis patterns and whose illness began during the period 1 August 2006 through 31 July 2007. We conducted a case-control study in 22 states and performed laboratory testing of foods and environmental samples. RESULTS: We identified 715 cases in 48 states; 37% of isolates were from urine specimens. Illness was associated with consuming peanut butter more than once a week (matched odds ratio [mOR], 3.5 [95% confidence interval {95% CI}, 1.4-9.9]), consuming Brand X peanut butter (mOR, 12.1 [95% CI, 3.6-66.3]), and consuming Brand Y peanut butter (mOR, 9.1 [95% CI, 1.0-433]). Brands X and Y were produced in 1 plant, which ceased production and recalled products on 14 February 2007. Laboratories isolated outbreak strains of Salmonella Tennessee from 34 Brands X and Y peanut butter jars and 2 plant environmental samples. CONCLUSIONS: This large, widespread outbreak of salmonellosis is the first linked to peanut butter in the United States; a nationwide recall resulted in outbreak control. Environmental contamination in the peanut butter plant likely caused this outbreak. This outbreak highlights the risk of salmonellosis from heat-processed foods of nonanimal origin previously felt to be low risk for Salmonella contamination.

2008 outbreak of Salmonella Saintpaul infections associated with raw produce.

BACKGROUND: Raw produce is an increasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008. METHODS: We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted. RESULTS: Among the 1500 case subjects, 21% were hospitalized, and 2 died. In three case-control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8), corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano peppers were an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source. CONCLUSIONS: Although an epidemiologic association with raw tomatoes was identified early in this investigation, subsequent epidemiologic and microbiologic evidence implicated jalapeño and serrano peppers. This outbreak highlights the importance of preventing raw-produce contamination.

Transmission risk factors and treatment of pediatric shigellosis during a large daycare center-associated outbreak of multidrug resistant Shigella sonnei: implications for the management of shigellosis outbreaks among children.

BACKGROUND: Shigellosis outbreaks in daycare centers result in substantial disease and economic burdens in the United States. The emergence of multidrug resistant Shigella strains raises questions regarding control of transmission within daycare centers and treatment for children. From May to October 2005, 639 Shigella sonnei cases were reported in northwest Missouri, mostly among persons exposed to daycare centers. METHODS: We conducted a case-control investigation among licensed daycare centers (LDCs) in northwest Missouri to determine transmission risk factors, tested isolates for antimicrobial resistance, and described treatment practices. Case LDCs had secondary attack rates of shigellosis>or=2% (range, 2%-25%) and control LDCsor=1 sink in every room (odds ratio [OR]: 0.1; 95% confidence interval [CI]: 0.02-0.5) or a diapering station in every room (OR: 0.1; 95% CI: 0.01-0.6) were less likely to be case-LDCs. Resistance to ampicillin and trimethoprim-sulfamethoxazole was found in 90% of the outbreak strains. Among 210 children treated with antimicrobial agents, azithromycin was used in 92 (44%) while a fluoroquinolone was used in 11 (5%) children. CONCLUSIONS: During a large daycare center-associated shigellosis outbreak, strains were highly resistant to ampicillin and trimethoprim-sulfamethoxazole. Children were frequently treated with azithromycin and occasionally fluoroquinolones. Appropriate handwashing and diapering infrastructure are necessary to minimize spread of shigellosis within daycare centers, and could reduce use of antimicrobial agents.