Lessons Learned from a Decade of Investigations of Shiga Toxin-Producing Escherichia coli Outbreaks Linked to Leafy Greens, United States and Canada.

Shiga toxin-producing Escherichia coli (STEC) cause substantial and costly illnesses. Leafy greens are the second most common source of foodborne STEC O157 outbreaks. We examined STEC outbreaks linked to leafy greens during 2009-2018 in the United States and Canada. We identified 40 outbreaks, 1,212 illnesses, 77 cases of hemolytic uremic syndrome, and 8 deaths. More outbreaks were linked to romaine lettuce (54%) than to any other type of leafy green. More outbreaks occurred in the fall (45%) and spring (28%) than in other seasons. Barriers in epidemiologic and traceback investigations complicated identification of the ultimate outbreak source. Research on the seasonality of leafy green outbreaks and vulnerability to STEC contamination and bacterial survival dynamics by leafy green type are warranted. Improvements in traceability of leafy greens are also needed. Federal and state health partners, researchers, the leafy green industry, and retailers can work together on interventions to reduce STEC contamination.

Outbreak of Foodborne Botulism Associated with Improperly Jarred Pesto--Ohio and California, 2014.

On July 28, 2014, the Cincinnati Health Department was notified of suspected cases of foodborne botulism in two women admitted to the same hospital 12 days apart. Patient A had been treated for 12 days for suspected autoimmune disease. When patient B, the roommate of patient A, was evaluated at the same medical center for similar symptoms, it was learned that on July 13, patient A and patient B had shared a meal that included prepackaged pesto from a jar; clinicians suspected botulism and notified the local health department. The pesto had been purchased from company A's farm stand in San Clemente, California. Laboratory testing detected botulinum toxin type B by enzyme-linked immunosorbent assay (ELISA) in leftovers of pasta with pesto. A culture of these food samples yielded Clostridium spp. that produced botulinum toxin type B; polymerase chain reaction (PCR) testing also was positive for type B toxin gene. Environmental assessment of company A identified improper acidification and pressurization practices and lack of licensure to sell canned products commercially, including products in hermetically-sealed jars. On July 30, the vendor voluntarily recalled all jarred products, and the California Department of Public Health (CDPH) warned the public not to consume company A's jarred foods. This report describes the two cases and the public health investigation that traced the source of the outbreak.

Overview of Leafy Greens-Related Food Safety Incidents with a California Link: 1996 to 2016.

An increase in the number of foodborne illness outbreaks associated with produce has been noted in the literature, and leafy greens have been the most common produce category associated with these outbreaks. California is the largest leafy greens producer in the United States, and many related foodborne illness incidents were traced to this state. A systematic overview of leafy greens incidents linked to California was conducted by the California Department of Public Health, Food and Drug Branch through analysis of complaints, routine surveillance sampling, disease outbreaks, and investigations covering 1996 to 2016. The goal was to develop a risk assessment tool to modernize emergency response efforts to foodborne illnesses related to leafy greens. A database including environmental, epidemiologic, and laboratory information for each incident was developed, and descriptive analysis was performed to identify trends. In the 21-year period analyzed, 134 incidents were identified, the majority of which were surveillance related. Approximately 2,240 U.S. cases of confirmed illness were reported (298 California cases resulting in 50 hospitalizations). Romaine lettuce and spinach were the most commonly implicated vehicles. The most prevalent hazard type was microbiological, in particular bacterial, specifically associated with pathogenic strains of Escherichia coli. In California, the overview provided the Food and Drug Branch with a platform to (i) enhance its Food Safety Program, Emergency Response Unit, and California Food Emergency Response Team; (ii) assist in more efficient investigation, response, control, and prevention of California-linked foodborne illness incidents; and (iii) identify knowledge gaps and develop effective definitions, procedures, training, guidelines, and policies that will be used to help prevent future outbreaks. Outcomes provide insight into the situation in the largest leafy greens-producing state and may be used to prioritize limited national food safety resources and aid in future leafy greens-related research and foodborne incident investigations.

Outbreak of Foodborne Botulism Associated With Prepackaged Pouches of Liquid Herbal Tea.

BACKGROUND: In 2017, local public health authorities in California received reports of 2 elderly patients with suspected botulism who knew each other socially. A multijurisdictional investigation was conducted to determine the source. METHODS: Investigators reviewed medical records, interviewed family to establish food and drink histories, and inspected a facility that produced liquid herbal tea. Clinical specimens and product were tested for botulinum neurotoxin (BoNT). RESULTS: A total of 2 confirmed botulism cases were identified with BoNT type A; both were hospitalized, 1 died. Botulism was not suspected until several days after hospital admission. Case-patients ingested single-serving prepackaged liquid herbal tea. Inspection of the tea production facility identified conditions conducive to product contamination with C botulinum and toxin production. Samples of tea tested negative for botulinum toxin. Local and state public health authorities issued alerts and the facility recalled the liquid herbal tea. CONCLUSIONS: Liquid herbal tea prepackaged in sealed pouches was the likely source of this type A botulism outbreak because the 2 cases were linked socially and shared no other foods. This type of product has not previously been described in the foodborne botulism literature. In the absence of known risk factors for botulism at the time of presentation, suspicion based on clinically compatible findings is critical so that and treatment with botulinum antitoxin is not delayed. A coordinated response by public health authorities is necessary in identifying a potential food source, inspecting facilities producing the product, alerting medical providers and the public, and preventing further illness.

A Primary Care Telehealth Experience in a US Army Correctional Facility in Germany.

OBJECTIVE: To assess the feasibility of using telehealth (TH) equipment and infrastructure within the US Army's European Theater to evaluate and treat inmates with general medical complaints, and perform physicals and medical safety checks in a US Army Correctional Facility (CORFAC). METHODS AND MATERIALS: Synchronous TH encounters were performed using Polycom RealPresence software on providers' computers with high definition cameras on monitors at distant sites and PolyCom HDX9000 Practitioner Cart along with AMD Global Telemedicine devices at the originating site within the CORFAC. These devices included an AMD-2500 General Exam Camera, AMD Fiber optic Otoscope, and AMD Telephonic Stethoscope. Patient consent for TH was obtained, and they were seen in the Medical Dispensary with Army Medics presenting the patients to the providers via TH. RESULTS: From May 22, 2014, to January 12, 2015, a physician assistant, nurse practitioner, and 4 physicians completed 177 synchronous TH encounters primarily at a CORFAC in Mannheim, Germany. Of these 177 encounters, 114 were Special Housing Unit (SHU) safety checks and 63 encounters were for physicals, medication management, and a variety of medical complaints including acute infections, abdominal pain, and musculoskeletal and dermatological complaints. CONCLUSION: Synchronous TH was an effective option for the delivery of high quality routine medical care for minor illnesses, injuries, and other nonurgent conditions, as well as for general physicals and SHU checks in a correctional facility. Acceptance by providers and clinic staff was found to be high. Inmates were generally satisfied with their TH encounters. However, some inmates reported a preference to see providers in-person, highlighting one of the challenges with acceptance of telehealth programs.

Comparative pulmonary function and pharmacokinetics of fluticasone propionate and salmeterol xinafoate delivered by two dry powder inhalers to patients with asthma.

BACKGROUND: This report presents results of the first human study of a new dry powder inhaler (DPI-C). DPI-C uses reverse flow cyclone technology to retain larger particles in the device and to increase efficiency of respirable drug release. The study was conducted to determine comparative pharmacokinetics (not bioequivalence) of DPI-C and DPI-A (Advair Diskus®, GlaxoSmithKline) and to establish preliminary efficacy and safety of DPI-C. METHODS: Nineteen patients with mild-moderate asthma received two treatments (randomized crossover design). Treatments were one inhalation from DPI-A labeled to deliver 100 µg fluticasone propionate and 50 µg salmeterol, or one inhalation from DPI-C which contained ∼10% less of each drug per metered dose. Prior to dosing, 10 g of charcoal was administered. FEV1 increase over baseline (measured over 12 h), plasma concentrations of fluticasone and salmeterol (measured over 12.5 h), and occurrence of adverse events were the primary measures of device performance and safety. RESULTS: Seventeen patients were evaluable. Response profiles of percent increase in FEV1 over baseline showed no statistically significant differences between devices. Peak plasma concentrations of both fluticasone (p=0.003) and salmeterol (p=0.084) were higher from DPI-C. Mean extent of absorption [area under the curve (AUC)] of fluticasone was approximately 30% greater with DPI-C, whereas AUC of salmeterol was approximately 40% greater with DPI-A. CONCLUSIONS: DPI-C provided similar improvement in pulmonary function compared with DPI-A. Pharmacokinetic results showed a greater initial absorption of salmeterol with DPI-C but greater continued absorption and a 40% greater AUC with DPI-A, which we attribute to slower but more extensive oral absorption because of the greater mass of swallowed large particles of salmeterol generated by DPI-A. No patient reported any treatment-related adverse event or use of rescue medication during this study. Determination of the significance of the observed differences in pharmacokinetics from this single-dose study requires further exploration in studies using clinically relevant dosing regimens.

Radiostability of florfenicol in the solid state.

The effect of ionizing radiation on florfenicol (FF), an antibiotic with wide antibacterial properties was investigated to determine whether it can be sterilized using high-energy radiation. FF was irradiated by E-beam radiation to doses of 25-800 kGy, and then changes in the physico-chemical properties were examined using chromatographic methods (TLC and HPLC), spectroscopic methods (NMR and MS) and hyphenated methods (HPLC-MS). It was found that a standard sterilizing dose of 25 kGy led to the formation of two new products of radiolysis as well as lowering the content of FF by 0.95%. With higher doses of radiation, the content of FF further decreased (by 12.27% with a dose of 800 kGy), and new products of radiolysis appeared (up to five with a dose of 800 kGy). However, there were no differences between the NMR and MS spectra of irradiated and non-irradiated samples of FF. A linear dependence was found between the dose of radiation and the FF content (correlation coefficient of 0.9951) as well as between the melting point and the sum of products of radiolysis (correlation coefficient of 0.9975). It was found that a radiodegradation of FF took place by the breaking of an amide bond, leading to the formation of an aliphatic amine, which was subsequently oxidized to 4-methylsulfonylbenzoic acid. The radiolytic yield for the radiodegradation of FF was calculated to be 10.24 molecules/100 eV for a dose of 25 kGy. As a result of our investigation, we can conclude that FF shows a reasonably good radiostability in the range of doses used for sterilization, i.e. 25 kGy and below, and therefore it can be sterilized using high-energy radiation without changing its physicochemical, properties and hence its therapeutic efficacy.

A mechanism of polarized light sensitivity in cone photoreceptors of the goldfish Carassius auratus.

An integrated laser tweezer and microphotometry device has been used to characterize in detail how individual, axially orientated goldfish photoreceptors absorb linearly polarized light. This work demonstrates that the mid-wavelength sensitive members of double cone photoreceptors display axial differential polarization sensitivity. The polarization contrast was measured to be 9.2 +/- 0.4%. By comparison, rod photoreceptors only exhibit isotropic absorbance. These data, combined with the square cone mosaic of double cones in the retina, suggest that intrinsic axial dichroism forms part of the underlying biophysical detection mechanism for polarization vision in this species.