An international outbreak of salmonellosis associated with raw almonds contaminated with a rare phage type of Salmonella enteritidis

During the winter of 2000 to 2001, an outbreak due to Salmonella Enteritidis (SE) phage type 30 (PT30), a rare strain, was detected in Canada. The ensuing investigation involved Canadian and American public health and food regulatory agencies and an academic research laboratory. Enhanced laboratory surveillance, including phage typing and pulsed-field gel electrophoresis, was used to identify cases. Case questionnaires were administered to collect information about food and environmental exposures. A case-control study with 16 matched case-control pairs was conducted to test the hypothesis of an association between raw whole almond consumption and infection. Almond samples were collected from case homes, retail outlets, and the implicated processor, and environmental samples were collected from processing equipment and associated farms for microbiological testing. One hundred sixty-eight laboratory-confirmed cases of SE PT30 infection (157 in Canada, 11 in the United States) were identified between October 2000 and July 2001. The case-control study identified raw whole almonds as the source of infection (odds ration, 21.1; 95% confidence interval, 3.6 to infinity). SE PT30 was detected in raw whole natural almonds collected from home, retail, distribution, and warehouse sources and from environmental swabs of processing equipment and associated farmers' orchards. The frequent and prolonged recovery of this specific organism from a large agricultural area was an unexpected finding and may indicate significant diffuse contamination on these farms. Identification of almonds as the source of a foodborne outbreak is a previously undocumented finding, leading to a North American recall of this product and a review of current industry practices.

Orbital embryonal rhabdomyosarcoma in Karachi (1998-2002)

OBJECTIVE

To study the epidemiology of ocular Rhabdomyosarcoma (ORMS) in Karachi.

METHODS

Incident ORMS cases resident of Karachi, registered at Karachi Cancer Registry (KCR) during 1st January 1998 to 31st December 2002 were included in the study. The data were classified using ICD-O2; computerized with Canreg-3, and analyzed using SPSS 10.0.

RESULTS

Ten cases of ORMS were reported to KCR during 1998-2002. RMS originated in the orbit in eight cases, conjunctiva in one and eyelid in one. Nine cases presented with proptosis, associated with conjunctivitis in four cases. One case presented with eyelid swelling. The crude annual incidence rate was 0.13/100,000, the age standardized rate was 0.3/100,000. The mean age of childhood cases was 10.4 years (95% CI 4.0; 16.7); and adult cases was 24.8 years (95% CI 12.8; 36.7). At presentation, eight patients were older than 10 years and three were older than 20 years. Five cases were categorized as childhood malignancies. Tumors were a TNM stage III disease at presentation in eight cases; survival at the end of one year was 70%, and at the end of two years 20%. There were no survivors at the end of three years.

CONCLUSION

ORMS in Karachi is a disease with a dismal survival. It may reflect a late presentation, or shorter adult ORMS survival or a manifestation of a different genetic pattern, associated with rapid evolution and poor prognosis. Health education for the population, especially parents and health providers is essential for early ORMS diagnosis. Pediatricians, ophthalmologists and health professionals, can play a vital role. Healthcare planning should focus on capacity building for ophthalmologic screening. Cytogenetic studies are advised to determine the genetic pattern.

Bethanechol provocation testing does not predict symptom relief after cholecystectomy for acalculous biliary pain

BACKGROUND

The currently accepted hypothesis to explain acalculous gallbladder pain is the lack of contractile co-ordination between the body and neck. We have previously shown that bethanechol, a muscarinic stimulant causes differential stimulation of these two regions.

AIM

To evaluate the reliability of bethanechol-induced gallbladder contraction in predicting symptom relief after cholecystectomy in patients with acalculous gallbladder disease.

METHODS

Fifty-one patients underwent a bethanechol provocation test together with serial ultrasound to determine gallbladder emptying. McGill pain questionnaires were completed, and patients positive for pain (bethanechol provocation test +ve) were offered cholecystectomy, and patients negative for pain (bethanechol provocation test -ve) were reassessed at 6 months and offered cholecystectomy if symptoms persisted. All patients answered pain questionnaires either 6 months after surgery or as follow-up.

RESULTS

There was no difference in the percentage of gallbladder emptying between the bethanechol provocation test +ve and bethanechol provocation test -ve groups. Fifty-three percent of bethanechol provocation test +ve patients and 54% of bethanechol provocation test -ve patients still remained symptomatic 6 months after surgery. Conclusion. Gallbladder pain provoked by bethanechol does not predict symptom relief after cholecystectomy.

Measurement of the three-dimensional distribution of radiation dose in grid therapy

A single large dose of megavoltage x-rays delivered through a grid is currently being utilized by some centres for palliative radiotherapy treatments of large tumours. In this note, we investigate the dosimetry of grid therapy using two-dimensional film dosimetry and three-dimensional gel dosimetry. It is shown that the radiation dose is attenuated more rapidly with depth in a grid field than an open field, and that even shielded regions receive approximately 25% of the dose to the unshielded areas.

Molecular typing and distribution of Staphylococcus aureus isolates in Eastern Canadian dairy herds

Macrorestriction analysis of SmaI-digested chromosomal DNA, using pulsed field gel electrophoresis (PFGE) was performed to type and estimate genetic relationships among 288 Staphylococcus aureus isolates recovered from 58 Eastern Canadian dairy herds. In addition, a subset of the collection was phage typed and evaluated for sensitivity to 10 antimicrobial compounds. Of 288 isolates recovered, 29 distinct PFGE types were identified. Based on estimates of genetic relationships, the PFGE types were assigned to six lineage groups, designated A through F. Of all of the isolates, ca. 93% were assigned to lineage groups A, D, or F. In 58.6% of herds, only a single PFGE type was recovered, while the remainder had two to four types. Of the 212 isolates evaluated for antimicrobial resistance, 24.5% were resistant to one or more antimicrobials. Resistance to penicillin (9.9%) was most common, followed by resistance to sulfadimethoxine (7.5%). Isolates resistant to multiple antibiotics were rare. A total of 63% of isolates responded to phages from groups 1 and 3, and 32.8% could not be typed with any of the phage strains used. The other 4.1% belonged to a variety of phage types. Most of the PFGE lineage group A and F isolates corresponded to phage groups 3 and 1, respectively, and most group D isolates were not typeable. PFGE typing had better discriminatory power than phage typing in defining the relatedness of the S. aureus isolates. Distribution of PFGE types and phage types was independent across regions and within herds.

Cancer esophagus Karachi 1995-2002: epidemiology, risk factors and trends

OBJECTIVE

To study the trends of cancer esophagus in Karachi South during 1995-2002 and identify risk factors.

METHODS

Incident esophageal cancer cases recorded at the Karachi Cancer Registry for Karachi South, during 1st January 1995 to 31st December 2003 were reviewed. For maximum completion of data, incident cases registered from 1st January 1995 to 31st December 2002 were included for final analyses.

RESULTS

The Age Standardized Incidence Rates (ASIRs) of cancer esophagus in Karachi South for males were 6.5/100,000 (1995-1997) and 6.4/100,000 (1998-2002). In females the observed rates were 7.0/100,000 (1995-1997) and 8.6/100,000 (1998-2002).

CONCLUSION

In the moderately high incidence, cancer esophagus zone of Karachi, the ASIRs in males remained stable during the last decade, but in females, an upward trend was observed suggesting a progressively higher exposure to risk factors in the latter. The potential risk factors in Karachi are use of all forms of tobacco, areca nut, infrequent consumption of raw fruits and vegetables and diet deficiencies. There is a necessity to actively control the proven risk factors and address the existence of other risk factors. The primary recommended strategy for the control of cancer esophagus would therefore be legislation against tobacco and areca nut in Pakistan and public health education. The risk factors of cancer esophagus identified in this article need to be further confirmed.

Risk factors for Salmonella typhimurium DT104 and non-DT104 infection: a Canadian multi-provincial case-control study

To identify risk factors for sporadic Salmonella Typhimurium definitive phage-type 104 (DT104) and non-DT104 diarrhoeal illness in Canada, we conducted a matched case-control study between 1999 and 2000. Cases were matched 1:1 on age and province of residence. Multivariate analysis suggested that recent antibiotic use [odds ratio (OR) 5.2, 95% confidence interval (CI) 1.8-15.3], living on a livestock farm (OR 4.9, 95% CI 1.9-18.9), and recent travel outside Canada (OR 4.1, 95% CI 1.2-13.8) are independent risk factors for DT104 illness. Similar analyses suggested that recent travel outside North America is a sizable risk factor for non-DT104 illness (OR 66.8, 95% CI 6.7-665.3). No food exposure was a risk factor in either analysis. Educating health-care providers and the public about appropriate antibiotic use and antimicrobial resistance is important. Appropriate administration of antibiotics to livestock, particularly cattle, and hygienic measures such as handwashing after contact with farm animals may reduce risk. Travel represents an important and probably underestimated risk factor for sporadic illness with S. Typhimurium. Improved national surveillance and detailed investigation of travel-related illness are required.

Further delineation of Hennekam syndrome

We report four children from four inbred Arab families with varying manifestations of Hennekam syndrome and additional features that have not been previously reported. These include abnormalities of the middle ear, anomalous pulmonary venous drainage, interrupted inferior vena cava, polysplenia, crossed renal ectopia, median position of the liver and multiple cavernous haemangiomas. In addition, in one case lymphoedema was absent and oedema due to hypoproteinaemia appeared at 6 years of age. Since anomalies of the veins and the consequent developmental abnormalities of the lymphatics might lead to alterations in the fluid balance of the embryo, we hypothesize that altered fluid dynamics due to defective vascular and lymphatic development might disrupt critical events in craniofacial morphogenesis resulting in Hennekam syndrome.

Determinants of quality of life in first-episode psychosis

OBJECTIVE

To assess patient and/or illness characteristics associated with aspects of quality of life (QOL) in first-episode psychosis (FEP).

METHOD

Patient characteristics, symptom ratings and Wisconsin QOL scale (client version) were assessed. Data were analysed with correlation coefficients and a hierarchical regression analysis.

RESULTS

Patients presented with varying levels of QOL on different domains. The level of 'general satisfaction' was related to age of onset and social premorbid adjustment; 'weighted index of QOL' to social premorbid adjustment and inversely to educational premorbid adjustment; 'social relations' inversely to duration of untreated psychosis (DUP), length of prodrome and negative symptoms; 'psychological well-being' inversely to depression and educational premorbid adjustment; 'activities of daily living' to social premorbid adjustment and inversely to negative symptoms; and 'outlook on symptoms' to level of depression.

CONCLUSION

Domains of self-rated QOL in FEP patients are differentially associated with malleable and non-malleable aspects of patient and illness characteristics.

Pro CR global: an effective screening test for thrombophilia

In the present study, the Pro C(R) Global test was evaluated as a screening test for estimation of the activity of the main plasma components of the anticoagulant protein C (PC) / protein S (PS) pathway; 300 patients with a history of thrombosis were investigated for Pro C(R) Global. It was positive in 74 patients. Tests for estimation of PC, PS, activated protein C resistance (APCR), and lupus anticoagulant (LAC) were performed in all the patients with abnormal Pro C(R) Global and in 10 patients with normal Pro C(R) Global. In all, 66 of the 74 patients had a defect in PC/PS/APCR or LAC; 18 patients had both PC and PS deficiency, 25 had PS deficiency alone, 10 had PC deficiency alone, one had APCR alone, eight had PS, PC deficiency with APCR, and four had PS deficiency with APCR. In the 10 patients who tested negative with the Pro C(R) Global test, PC, APCR, and LAC were negative in all. However, PS deficiency was seen in two of them. The sensitivity and specificity of Pro C(R) Global, calculated with respect to positivity of PC, PS, LAC, or APCR as the gold standard, were 97% and 50%, respectively. The diagnostic accuracy of the assay was 88.1%. It is thus recommended that Pro C(R) Global can be used effectively as a screening test to detect abnormality in the PC/PS/APCR/LAC pathway.

The Bcl-2 family pro-apoptotic molecule, BNIP3 regulates activation-induced cell death of effector cytotoxic T lymphocytes

BNIP3 is a recently described pro-apoptotic member of the Bcl-2 family and in BNIP3 cDNA-transfected cell lines, cell death occurs via a caspase-independent pathway with opening of the mitochondrial permeability transition (PT) pore and rapid loss of mitochondrial transmembrane potential (Delta psi m). However, its expression or function in physiologic cell types is not known. Our results using the T-cell receptor transgenic mice P14, specific for lymphocyte choreomeningitis virus (LCMV) glycoprotein, show that in contrast to the other Bcl-2 family pro-apoptotic molecules, BNIP3 is transcriptionally highly up-regulated in effector cytotoxic T lymphocytes (CTL). Because CTL have a propensity to undergo activation-induced cell death (AICD) upon restimulation, we tested for other features associated with BNIP3-induced cell death. AICD of CTL was caspase-independent as determined by measuring caspase activation during target cell killing as well as by lack of inhibition with caspase inhibitors. Moreover, similar to BNIP3-induced cell death, CTL apoptosis was associated with increased production of reactive oxygen species and decreased Delta psi m. Finally, retroviral transduction of BNIP3 antisense RNA diminished AICD in effector CTL. These results suggest that BNIP3 may play an important role in T-cell homeostasis by regulating effector CTL numbers.

Viridans streptococcus bacteremia in children on chemotherapy for cancer: an underestimated problem

The authors discuss the morbidity associated with viridans streptococcus bacteremia, and its implications on the choice of antibiotics used as prophylaxis and treatment. They retrospectively studied the case notes of 38 children who were being treated for various malignant conditions in their unit and developed 40 episodes of bacteremia with viridans streptococci between October 1995 and January 1999. Viridans streptococci were the third commonest blood culture isolate during this period, after coagulase-negative staphylococci and Staphylococcus aureus. The majority of the isolates were Streptococcus mitis (55%). Others were S. sanguis (25%), S. oralis (12.5%), S. salivarius (5%), and S. acidominimus (2.5%). Twenty-five percent of the patients had been treated with regimens that included cytosine arabinoside, 60% were receiving prophylactic co-trimoxazole, and 87.5% were neutropenic. Thirty percent of patients had abnormal chest X-rays, and 15% were hypotensive; 2 patients required admission to the intensive care unit. Initial antibiotic therapy was changed because of failure of clinical response in 60% of cases, despite the infecting organism being sensitive in vitro. This study confirms the importance of viridans streptococci as a cause of bacteremia in pediatric hematology and oncology patients, leading to significant morbidity. Further work is required to establish the optimal treatment for viridans streptococcus bacteremia.

D-dimer test: diagnostic role in clinical and sub-clinical DIC

D-dimer test is used as a diagnosis test for acute disseminated intravascular coagulation (DIC). This study was undertaken to find out its sensitivity and specificity in the diagnosis of acute DIC and its role in diagnosis of sub-clinical DIC, as there is limited data available on the subject. Of the 29 patients of clinically acute DIC, all had positive D-dimer test, and markedly prolonged PT, APTT and TT were seen in 24 (83%) of these patients. D-dimer test was found to be highly specific but less sensitive for the diagnosis of acute DIC. Of the 29 patients predisposed to sub-clinical DIC. D-dimer was positive is 26 (90%) patients and PT, APTT and TT were mildly prolonged in 11 patients. It is suggested that D-dimer positivity for the diagnoses of sub-clinical DIC need to be considered with caution and to be supplemented by other coagulation test including serial follow up with d-dimer and coagulation tests.

Familial hyperhomocysteinemia: multiple venous thrombosis in four generations of a family

We describe a family in which four generations (eight members) had deep vein thrombosis of the lower limb and three of the alive members had documented hyperhomocysteinemia. In addition, one of the family members had evidence of arterial thrombosis in the form of cerebral infarcts. Interestingly, all affected members in the family were males.

Active relaxation of human gallbladder muscle is mediated by ATP-sensitive potassium channels

BACKGROUND

Active and significant relaxation of the human gallbladder must be one of the facets of its motility during both the filling and emptying cycle. Conflicting reports about the presence or significance of nitric oxide have been reported in the literature. The aim of this study was to investigate the role of nitric oxide and K(ATP) channels in human gallbladder muscle using isolated strips from human gallbladder.

METHODS

Full thickness strips were obtained from 56 human gallbladders and suspended under isometric tension in organ baths. The effect of nitric oxide donors and inhibitors on cholecystokinin octapeptide- and carbachol-induced contraction was examined. In separate experiments the effect of the K(ATP) channel activator, cromakalim, and the inhibitor, glibenclamide, were determined.

RESULTS

Cromakalim induced a significant relaxation of agonist-induced contraction in human gallbladder in vitro, an effect which was abolished by the K(ATP) channel inhibitor glibenclamide. No evidence of significant nitric oxide involvement in relaxation was observed.

CONCLUSIONS

This study has demonstrated the presence of K(ATP) channels in human gallbladder for the first time. These are capable of causing significant relaxation in the presence of hormonal and muscarinic agonists and may represent a major pathway for gallbladder relaxation.

Metachronous Wilms tumor associated with pulmonary embolism: how can we detect these cases early? A case report and literature review

A 4-year-old girl developed right metachronous Wilms tumor 2 years after completing treatment for a left-sided stage I Wilms tumor. The original treatment included 7 weeks of chemotherapy, delayed nephrectomy, and another 3 weeks of chemotherapy. The metachronous tumor on the right side extended into the inferior vena cava and right atrium. She developed pulmonary embolism as a result. She received chemotherapy and developed liquifaction of the tumor and toxic shock. She also had surgery. The patient is alive 3 years after the original diagnosis and 10 months after the relapse. The authors report this unusual case and discuss whether these cases can be identified early.

Varicella pneumonia: another 'steroid responsive' pneumonia?

Varicella-zoster virus (VZV) pneumonitis remains an often-fatal complication of VZV infection. Antiviral agents and supportive care are widely accepted therapies. Cautious use of corticosteroids in life-threatening VZV pneumonitis may be justified. Appropriate patient selection factors are as yet unidentified and the decision to commence corticosteroid therapy in this setting is clinical.