Unusually high illness severity and short incubation periods in two foodborne outbreaks of Salmonella Heidelberg infections with potential coincident Staphylococcus aureus intoxication.

We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5·8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4·5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.

Environmental Survey of Drinking Water Sources in Kampala, Uganda, during a Typhoid Fever Outbreak.

In 2015, a typhoid fever outbreak began in downtown Kampala, Uganda, and spread into adjacent districts. In response, an environmental survey of drinking water source types was conducted in areas of the city with high case numbers. A total of 122 samples was collected from 12 source types and tested for Escherichia coli, free chlorine, and conductivity. An additional 37 grab samples from seven source types and 16 paired large volume (20 liter) samples from wells and springs were also collected and tested for the presence of Salmonella enterica serovar Typhi. Escherichia coli was detected in 60% of kaveras (drinking water sold in plastic bags) and 80% of refilled water bottles; free chlorine was not detected in either source type. Most jerry cans (68%) contained E. coli and had free chlorine residuals below the WHO-recommended level of 0.5 mg/liter during outbreaks. Elevated conductivity readings for kaveras, refilled water bottles, and jerry cans (compared to treated surface water supplied by the water utility) suggested that they likely contained untreated groundwater. All unprotected springs and wells and more than 60% of protected springs contained E. coli Water samples collected from the water utility were found to have acceptable free chlorine levels and no detectable E. coli While S Typhi was not detected in water samples, Salmonella spp. were detected in samples from two unprotected springs, one protected spring, and one refilled water bottle. These data provided clear evidence that unregulated vended water and groundwater represented a risk for typhoid transmission.IMPORTANCE Despite the high incidence of typhoid fever globally, relatively few outbreak investigations incorporate drinking water testing. During waterborne disease outbreaks, measurement of physical-chemical parameters, such as free chlorine residual and electrical conductivity, and of microbiological parameters, such as the presence of E. coli or the implicated etiologic agent, in drinking water samples can identify contaminated sources. This investigation indicated that unregulated vended water and groundwater sources were contaminated and were therefore a risk to consumers during the 2015 typhoid fever outbreak in Kampala. Identification of contaminated drinking water sources and sources that do not contain adequate disinfectant levels can lead to rapid targeted interventions.

Notes from the Field: Clostridium perfringens Gastroenteritis Outbreak Associated with a Catered Lunch - North Carolina, November 2015.

During November 2015, the North Carolina Division of Public Health was notified by the Pitt County Health Department (PCHD) that approximately 40 persons who attended a catered company Thanksgiving lunch the previous day were ill with diarrhea and abdominal pain. The North Carolina Division of Public Health and PCHD worked together to investigate the source of illness and implement control measures. Within hours of notification, investigators developed and distributed an online survey to all lunch attendees regarding symptoms and foods consumed and initiated a cohort study. A case of illness was defined as abdominal pain or diarrhea in a lunch attendee with illness onset <24 hours after the event. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated for all menu items. Among 80 attendees, 58 (73%) completed the survey, including 44 respondents (76%) who reported illnesses meeting the case definition; among these, 41 (93%) reported diarrhea, and 40 (91%) reported abdominal pain. There were no hospitalizations. Symptom onset began a median of 13 hours after lunch (range = 1-22 hours). Risk for illness among persons who ate turkey or stuffing (38 of 44; 86%), which were plated and served together, was significantly higher than risk for illness among those who did not eat turkey or stuffing (six of 14; 43%) (RR = 2.02; 95% CI = 1.09-3.73).

[Clinical efficacy of prostatic biopsy. Experience in our center from 1990 to 2002]. / Eficacia clínica de la biopsia prostática. Experiencia en nuestro centro 1990-2002.

INTRODUCTION: The prostate biopsy is the only valid tool to diagnose the existence of cancer of prostate. The indications of the biopsy, according with EAU, are the existence of high PSA, increased velocity PSA and a rectal suspicious tact. OBJECTIVES: validation of the utility of the prostate biopsy, to know the value of the PSA as a marker of prostate cancer in our way and to value the indication and efficiency of repeated biopsies. MATERIAL AND METHODS: we practice a manual review of the biopsies in our hospital, between the years 1990 and 2002. We study the level of PSA before the biopsy, number of prostatic cores and histologic information of the biopsy. A statistical descriptive and inferencial study has been performed by SPSS 12.0 package. RESULTS: The total number of biopsies registered was a 1202, with 36.96% of biopsy positive. The PSA before the biopsy (available in the biopsies realized between the year 1999 and 2002: 578 biopsies, 48.08% of the whole) was > 10 ng/ml in 55,88% of these patients, 4-10 ng/ml in 39.27% and 0-4 ng/ml in 4.84%. The average and PSA's median is of 19.09 (standard error: 1.87) and 10.6, respectively. The positividad of the biopsy increases with PSA's level: 48,61% with PSA > 10; 25.11% with PSA 4-10 and 21,4% in patients with PSA < 4. There was realized prostate rebiopsy (2 or more biopsies) in 132 patients (21.97% positive) 88,36% of the cancers was diagnosed in the first biopsy, and 6.62% in the second one (94,98% of the diagnoses of cancer of prostate carried out with the first 2 biopsies). CONCLUSIONS: The information obtained in the study by means of the descriptive analysis of our series meets in conformity the published in other studies and publications. There exists a need to increase the diagnostic profitability of the biopsy of prostate, for which we have introduced a protocol of biopsy under local anesthesia in order to be able to increase the number of obtained cylinders.

Circulating colony-forming cells in different stages of chronic myelocytic leukemia.

The incidence of circulating granulocyte-macrophage colony-forming cells (CFU-c) was determined in 60 patients in different stages of chronic myelocytic leukemia (CML). Like others, we found uniformly increased circulating CFU-c during the uncontrolled chronic stage, decreasing to values indistinguishable from those of healthy controls during remission. Unlike some investigators who described grossly deficient colony formation during the blastic stage of CML, we found normal to greatly increased colony formation in the accelerated-resistant and blastic stages. The fact that laboratories using somewhat different culture techniques obtain similar results with specimens from the chronic stage of CML but divergent results with specimens from terminal stage disease suggests that CFU-c from blastic disease have more fastidious growth requirements than do those from chronic stage disease or from normal subjects. In contrast to the correlation between CFU-c and disease status in the chronic stage of CML, CFU-c incidence in the accelerated-resistant and blastic stages of the disease did not correlate with white blood cell count, percentage of immature cells, clinical status, or survival. There was no correlation between the percentage of myeloblasts and promyelocytes in circulating blood and the incidence of CFU-c in any stage of CML, which suggests that no direct relationship exists between clonogenic units and the number of identifiable proliferating cells.

Bone marrow infiltration patterns and their prognostic significance in chronic lymphocytic leukemia: correlations with clinical, immunologic, phenotypic, and cytogenetic data.

Bone marrow biopsies were prospectively performed on 75 patients with chronic lymphocytic leukemia (CLL). There was a highly significant relationship (p less than 0.002) between clinical stages and bone marrow infiltration patterns. Ten (50%) of 20 patients with diffuse patterns died; the estimated median survival time for these patients was 87 months. In contrast, only six (11%) of 55 patients with nondiffuse patterns died; the estimated median survival time for these patients could not be computed. When both clinical stage and infiltration pattern were evaluated for survival, a highly significant association between clinical stage and survival time was still observed (p less than 0.003) whereas bone marrow infiltration pattern was no longer significant. A significant association was also observed between bone marrow infiltration patterns and absolute lymphocyte counts (p less than 0.0005), Fc-receptor-positive cells (p less than 0.002), 3H-thymidine uptake of leukocytes (p less than 0.01), serum alkaline phosphatase levels (p less than 0.05), monoclonal urinary-free light chain status (p less than 0.05), and cytogenetics of leukemic cells (p less than 0.05). These observations lead to the conclusion that in an overall prognostic evaluation of patients with CLL, although bone marrow histopathology may have no additional value over a well-established clinical staging system, as a whole, it may be of clinically predictive value in disease progression of patients with stage I and II.

Cytogenetic studies in 77 patients with chronic lymphocytic leukemia: correlations with clinical, immunologic, and phenotypic data.

Cytogenetic analyses by G-banding and/or Q-banding techniques of polyclonal B cell mitogen-stimulated peripheral blood lymphocytes in 77 patients with chronic lymphocytic leukemia were carried out in the present study. Adequate metaphases were obtained in 65 patients (84%). Of 29 patients with abnormal karyotypes, ten (34%) had trisomy 12 as the sole abnormality, eight (28%) had trisomy 12 in combination with other karyotypic changes, and the remaining 11 had various karyotypic changes other than trisomy 12. There was a significant relationship between the abnormal karyotype and disease status, clinical stage, lymphocyte count, bone marrow infiltration pattern, monoclonal IgM gammopathy, and urinary monoclonal-free light chain status. Six of seven patients (87%) with trisomy 12 only had stage 0-11 disease, whereas all eight patients with trisomy 12 with other changes had stage III or IV disease (P less than .02). However, of nine patients with other karyotypic changes without trisomy 12, five had stage 0-II and four had stage III or IV disease. These observations suggest that trisomy 12 may be the primary or the earliest karyotypic change in a majority of aneuploid patients with chronic lymphocytic leukemia, and that other karyotypic changes in addition to trisomy 12 may develop as a result of clonal evolution, dedifferentiation, or therapy. Of nine patients in whom autopsy studies were carried out, four were found to have diffuse histiocytic lymphoma or Richter's syndrome (three with trisomy 12 in combination with other chromosome changes and one with normal karyotype). Our findings clearly demonstrate that cytogenetic study may be of value in the clinical and prognostic evaluation of patients with chronic lymphocytic leukemia.

Successful treatment of meningeal myeloma with combination of radiation therapy, chemotherapy, and intrathecal therapy.

Meningeal involvement is a rare complication of multiple myeloma. None of the previously described patients presenting this syndrome had responded to treatment. We describe a 64-year-old man with meningeal myelomatosis. A favorable response to treatment was produced by radiation therapy administered to the head and by intrathecal and systemic chemotherapy including high-dose corticosteroids.

Acute tumor lysis syndrome in prolymphocytic leukemia.

Prolymphocytic leukemia is characterized by a low response rate to agents that are effective in the treatment of chronic lymphocytic leukemia. A 75-year-old man with prolymphocytic leukemia was followed up over a period of 69 months. During that time, he was treated with high-dose chlorambucil plus prednisone; cyclophosphamide administered daily; combinations of vincristine sulfate, prednisone, and cyclophosphamide; irradiation to the spleen; and alpha-interferon without substantial antitumor effect. The patient had a brief response after splenectomy. When he received low-dose vincristine therapy daily with high-dose prednisone therapy given on alternate days, a fatal tumor lysis syndrome occurred. Although rare, this complication should be kept in mind, particularly in patients who had rapid reduction of tumor cells.

Xanthine nephropathy during chemotherapy in deficiency of hypoxanthine-guanine phosphoribosyltransferase.

We describe an episode of obstructive uropathy produced by xanthine precipitation in the tubules of the kidney of a patient with histiocytic lymphoma during intensive chemotherapy, despite allopurinol therapy. Urinary oxypurine-uric acid ratio suggested a subclinical deficiency of hypoxanthine-guanine phosphoribosyltransferase. Results of an assay of this enzyme confirmed the abnormality. Both parents and three brothers of the patient had normal enzyme activity. The continued importance of adequate hydration for patients who receive allopurinol during initial periods of cancer therapy is emphasized.

Coexistence of myeloid metaplasia with myelofibrosis and hairy-cell leukemia.

A 42-year-old man with severe pancytopenia and myelofibrosis underwent splenectomy seven months after onset of his symptoms; the leukocyte, platelet, and hematocrit levels became normal. Myeloid metaplasia was identified in the liver and spleen. Progressive lymphocytosis started eight months after splenectomy, and after 66 months a florid hairy-cell leukemia was diagnosed; the circulating cells were B type with micro K surface markers. Anemia and thrombocytopenia reappeared and were controlled initially with daily prednisone; chlorambucil was later added. At that time, the peripheral blood had more than 150 megaloblastoid-appearing normoblasts per 100 leukocytes. The PAS stain was positive in 95% to 100% of these cells; the B-cell surface markers were no longer identified. Further treatment failed to control the lymphoproliferative and myeloproliferative syndromes; the patient died 99 months after splenectomy. On autopsy, infiltration by hairy-cell leukemia cells and erythroid precursors was observed in the bone marrow, liver, lymph nodes, and other organs.

Primary chemotherapy for localized non-Hodgkin's lymphomas with diffuse histologic characteristics. Preliminary report of a prospective study.

Thirty-three patients with diffuse non-Hodgkin's lymphoma (stages I and II) received intermediate doses of oral methotrexate followed by leucovorin calcium every four weeks, on days 1 and 8, followed on day 15 by intravenous cyclophosphamide and vincristine sulfate. Prednisone was given for four weeks on alternate courses of treatment. A total of six such four-week courses was planned. Involved-field radiation (3000 or 3600 rad [30 or 36 Gy]) was given between three courses of chemotherapy to 18 patients who presented with tumors exceeding 7 cm in greatest diameter and who had responded to the initial chemotherapy. On completion of treatment, 27 patients (82%) were in complete remission; all the failures were in patients with large intra-abdominal masses. The presence of high lactate dehydrogenase levels, large tumor size, and age over 60 years had a suggestive negative correlation with the achievement of complete remission. The median follow-up was 26 months (range, ten to 59 months). At 48 months, the actuarial disease-free survival, remission duration, and overall survival were 53%, 72%, and 68% respectively. No deaths from toxic effects and no septic episodes were observed during treatment. The complete remission rate achieved with this program is comparable with those of other intensive programs of treatment reported previously.

Molecular heterogeneity of the cDNA encoding a 74-kDa regulatory subunit (B" or delta) of human protein phosphatase 2A.

Two cDNAs for possible splicing variants of a 74-kDa regulatory subunit (B" or delta) of human protein phosphatase 2A, were isolated. These variants were identified from human cerebral cortex by library screening and PCR, and designated delta1 and delta3 isoforms, while the previously reported isoform [Tanabe et al. (1996) FEBS Lett. 379, 107-1111 was designated delta2. Compared with the delta2 isoform, the delta1 isoform contained a 32-residue insertion beginning at residue 84, and consisted of 602 amino acids in all. The delta3 isoform lacked a 74-residue sequence corresponding to residues 1083 of the delta2 isoform, and consisted of 496 amino acids. Using isoform-specific antipeptide antisera, the 74-kDa subunit (B" or delta) originally purified from human erythrocytes was identified as the delta1 isoform.

Splenectomy for palliation of chronic myelocytic leukemia.

Sixty patients with chronic myelocytic leukemia (CML) (most, in the "terminal phase" of the disease) were subjected to splenectomy because of symptomatic splenomegaly, thrombocytopenia or anemia for which they required frequent transfusions. Surgical morbidity and mortality were high when the procedure was performed on a "casual" basis, but both were reduced sharply after care of these patients was restricted to a single medical-surgical-nursing team and improved technics of surgery and perioperative management were developed. Significant hematologic and clinical benefit was achieved in half of the patients and temporary arrest of the disease was often observed, but in most patients, the basic evolution of CML was not greatly altered. In eight patients, however, long-lasting improvement (one to nine years) was recorded. Measurement of the doubling time of circulating leukemic cells and other observations were consistent with the hypothesis that, in some patients, the spleen contains a more rapidly proliferating and "more malignant" population of leukemic cells than the marrow. We conclude that splenectomy is often a useful palliative procedure in advanced stages of CML, and that it may be strikingly beneficial in 10 to 15 per cent of such cases.

Staging laparotomy and splenectomy in early Hodgkin's disease. No therapeutic benefit.

In a prospective randomized study of treatment for early-stage Hodgkin's disease presenting above the diaphragm, 76 patients had staging by laparotomy (Group I) and 28 had staging by closed techniques (Group II). Treatment consisted of involved-field radiotherapy alone (44 patients), involved-field radiotherapy followed by chemotherapy (38 patients), total nodal radiotherapy alone (15 patients), or total nodal radiotherapy followed by chemotherapy (seven patients). On presentation, both groups had similar clinical features and similar treatment distribution. With similar follow-up (87 months), no significant differences in remission or survival were observed between Groups I and II: remission 59 versus 68 percent; survival 74 versus 92 percent; p value 0.27 and 0.09, respectively. Multiple areas of relapse were more frequently observed in Group I (11 of 32 had relapse) as compared with Group II (none of nine had relapse, p less than 0.082). In Group I, relapse in the abdomen was observed as an isolated event or as part of disseminated relapse in 12 percent of patients compared with 3 percent (one patient) in Group II with abdominal relapse alone. Seven patients in Group I and two patients in Group II died with Hodgkin's disease. Six other patients in Group I died with complete remission of non-Hodgkin's lymphoma (one patient), leukoencephalopathy (one patient), sepsis during chemotherapy (two patients), myocardial infarction (one patient), and cerebrovascular accident (one patient). Three other patients in this group had other secondary malignancies successfully controlled (histiocytic lymphoma, squamous cell carcinoma of the cervix, and malignant schwannoma). No second primary lesions or death with complete remission were observed in Group II. Staging laparotomy with splenectomy in early-stage Hodgkin's disease did not improve the duration of remission or survival or decrease the number of abdominal relapses compared with closed staging.

Survival in Ph1-positive chronic myelocytic leukemia: relationship to findings at diagnosis and to disease kinetics after the first course of treatment.

Survival in 73 patients with Ph1-positive chronic myelocytic leukemia was correlated with remission duration and leukocyte doubling time after initial treatment with busulfan and also, with clinical and laboratory features recorded at the time of diagnosis. There was a significant relationship between remission duration and leukocyte doubling time (correlation coefficient 0.94). On multivariate analysis, the most important factor influencing remission duration (and doubling time) was the percentage of circulating blasts (p less than 0.001). The spleen size (p less than 0.02), Liver size (p less than 0.03) and WBC (p less than 0.03) also added significantly to model fit; however, once a second variable was entered into the model no other factor produced significant improvement in model fit. In univariate analyses, the remission duration, doubling time, percentage of circulating blasts, spleen and liver size correlated significantly with survival. Multivariate analysis indicated that the percentage of circulating blasts was the most important factor affecting survival (p less than 0.001), with the liver size adding significantly to model fit (p less than 0.05). Remission duration, leukocyte doubling time and spleen size did not significantly influence survival once the percentage of blasts was included in the model. Thus, evaluation of clinical and laboratory data at the time of diagnosis is more important for prognostic classification of patients than the measurement of relapse kinetics after initial treatment with busulfan.

The use of an absorbable mesh wrap in the management of major liver injuries.

Uncontrollable hemorrhage remains the predominant cause of death in patients with complex liver injuries. In view of the recently reported success in control of hemorrhage from and salvage of the injured spleen and kidney with an absorbable mesh wrap, we have begun to use a similar technique in the management of major hepatic parenchymal injuries, as an alternative to suture hepatorrhaphy, lobar resection, and perihepatic packing. The technique of mesh-wrap hepatorrhaphy is described in detail. Our initial experience with four cases is reported, demonstrating the unique features of the mesh and the technical ease with which it can be applied. Advantages over conventional techniques are discussed. These include avoidance of reoperation for removal of perihepatic packing, avoidance of hepatic necrosis after wide suture hepatorrhaphy, and avoidance of the morbidity associated with lobar resections.

Transvenous interruption of the inferior vena cava.

Transvenous interruption of the inferior vena cava was successful in 45 of 47 consecutive patients treated during a 41/2-year period. Greenfield filters were used in 40, and Mobin-Uddin umbrellas in 5 others. Technical details of the insertion procedure are of particular importance for successful implantation of the Greenfield device. Follow-up data were available for 34 of 36 surviving patients and autopsy findings for 4 of the 11 who had died. Patency of the vena cava was assessed by radionuclide scan, venography, or autopsy. Of 33 patients with Greenfield filters who were evaluated, only one had an occluded filter, for a patency rate of 97%. One of the three patients with a Mobin-Uddin umbrella had caval thrombosis. Severe postoperative venous stasis was seen in one patient with a Greenfield filter and one with a Mobin-Uddin umbrella. Significant distal migration or angulation of Greenfield filters was observed in six patients and is a theoretical cause for recurrent embolization. The 30-day mortality rate for the patients who had transvenous procedures was 13%, but no deaths were attributed to the procedure itself. There were no clinically evident pulmonary emboli during the follow-up period. In the present study we have documented low operative morbidity and mortality rates as well as complete protection from recurrent pulmonary embolism using transvenous interruption of the inferior vena cava. Although the Greenfield filter is somewhat bulkier and more difficult to insert than the Mobin-Uddin umbrella, it has a clear advantage because of its superior long-term patency.

Acute appendicitis during pregnancy. Diagnosis and management.

Twelve patients underwent appendectomy during pregnancy or in the puerperium. The clinical presentation of acute appendicitis is altered during gestation, and diagnosis becomes increasingly difficult when close to term. Abdominal pain, nausea, and vomiting are important symptoms. Peritoneal signs occur in the right lower quadrant early in pregnancy, but the upper quadrant or entire right side are more common locations, as the appendix is displaced upward by the enlarging uterus. Delay in treatment is common because of uncertainty in making the diagnosis and hesitancy to proceed with surgery. In the group of six patients with perforation, there was one maternal death and a loss of three fetuses. There were no complications in the absence of perforation. Prompt diagnosis is the cornerstone of a good outcome, and early surgical intervention is indicated if acute appendicitis is suspected. Pregnancy is not a reason to delay surgery. We review the literature on this topic and present and analyze principles of management.

Primary prostatic involvement in non-Hodgkin lymphoma.

We report 3 cases of primary extranodal lymphoma of the prostate, an unusual extranodal presentation rarely diagnosed antemortem. Symptoms of prostatism associated with an enlarged hard prostate with pyuria and hematuria in younger patients should suggest the diagnosis. Urine cytologic examination should aid in the diagnosis of this condition.