Pancreatic neuroendocrine tumour resection in circumportal pancreas: a rare anatomical anomaly with important surgical implications

Various congenital anomalies of the pancreas have been reported due to its complex embryological development involving the fusion of two separate buds. Circumportal pancreas is a rare anatomical anomaly where the pancreatic head and uncinate process fuse abnormally with the pancreatic body, encasing the portal vein and/or superior mesenteric vein completely. This anomaly poses several challenges to hepatobiliary surgeons, as the encasement of the portal vein by the abnormal pancreatic tissue makes an additional parenchymal transection necessary. Vascular variants have also been reported with circumportal pancreas, which, if not recognised preoperatively, can be catastrophic. Therefore, careful preoperative evaluation and planning are essential, to ensure safe pancreatic resection and recovery in a patient with circumportal pancreas. We present a case of a successful subtotal pancreatectomy and splenectomy in a patient with circumportal pancreas, for a suspected pancreatic duct adenocarcinoma. The aim of this case report is to contribute valuable insights that can aid hepatobiliary surgeons in enhancing their preoperative planning when encountered with patients with similar anatomical variances.

Novel Benchmark Values for Open Major Anatomic Liver Resection in Non-cirrhotic Patients: A Multicentric Study of 44 International Expert Centers

OBJECTIVE

This study aims at establishing benchmark values for best achievable outcomes following open major anatomic hepatectomy for liver tumors of all dignities.

BACKGROUND

Outcomes after open major hepatectomies vary widely lacking reference values for comparisons among centers, indications, types of resections, and minimally invasive procedures.

METHODS

A standard benchmark methodology was used covering consecutive patients, who underwent open major anatomic hepatectomy from 44 high-volume liver centers from 5 continents over a 5-year period (2016-2020). Benchmark cases were low-risk non-cirrhotic patients without significant comorbidities treated in high-volume centers (≥30 major liver resections/year). Benchmark values were set at the 75th percentile of median values of all centers. Minimum follow-up period was 1 year in each patient.

RESULTS

Of 8044 patients, 2908 (36%) qualified as benchmark (low-risk) cases. Benchmark cutoffs for all indications include R0 resection ≥78%; liver failure (grade B/C) ≤10%; bile leak (grade B/C) ≤18%; complications ≥grade 3 and CCI ® ≤46% and ≤9 at 3 months, respectively. Benchmark values differed significantly between malignant and benign conditions so that reference values must be adjusted accordingly. Extended right hepatectomy (H1, 4-8 or H4-8) disclosed a higher cutoff for liver failure, while extended left (H1-5,8 or H2-5,8) were associated with higher cutoffs for bile leaks, but had superior oncologic outcomes, when compared to formal left hepatectomy (H1-4 or H2-4). The minimal follow-up for a conclusive outcome evaluation following open anatomic major resection must be 3 months.

CONCLUSION

These new benchmark cutoffs for open major hepatectomy provide a powerful tool to convincingly evaluate other approaches including parenchymal-sparing procedures, laparoscopic/robotic approaches, and alternative treatments, such as ablation therapy, irradiation, or novel chemotherapy regimens.

Migrated Laparoscopic Surgical Clips Causing Acute Cholangitis 32 Years After Laparoscopic Cholecystectomy

Surgical clip migration post-laparoscopic cholecystectomy is a rare but important complication to consider in patients presenting with biliary obstruction. Titanium surgical clips are widely used in laparoscopic surgery to ligate vessels and ducts and are particularly important in laparoscopic cholecystectomy to ligate the cystic duct. More common complications associated with clips involve dislodgement, however, there are reported cases of migration into visceral structures causing an obstruction. We describe a case that demonstrated an acute migration of surgical clips into the common bile duct (CBD) within a three-week period, which occurred 32 years after laparoscopic cholecystectomy, likely attributed to erosion. On the patient's first presentation, she had acute pancreatitis with a CT demonstrating clips in the correct position. Three weeks later, the patient presented a second time with acute cholangitis and the repeat CT demonstrated the clips in the CBD. We hypothesize that the erosion of the bile duct is due to the pressure effects from either intra-abdominal organ movements or subtle clip movements, and eventually, persistent erosion leading to intra-ductal migration of the clips with the passage of the clips along the path of least resistance into the CBD, resulting in biliary obstruction. Management included standard treatment for biliary obstruction with intravenous broad-spectrum antibiotics and endoscopic retrograde cholangiopancreatography with excellent outcomes.

Managing Infected Pancreatic Necrosis

The management of infected pancreatic necrosis has historically been based on early, open necrosectomy, associated with significant mortality. In recent years, an evidence based transformation has occurred towards the step-up approach consisting of percutaneous catheter drainage, if necessary, followed by minimally invasive necrosectomy. More recently the endoscopic step-up approach has gained popularity. This review evaluates the diagnosis, prevention and treatment of infected necrotizing pancreatitis. Key points in managing infected pancreatic necrosis: - multidisciplinary team approach in tertiary level centres; - no indication for prophylactic antibiotics or probiotics; - nasogastric, enteral nutrition indicated after 72 hours, if oral feeding is insufficient; - only intervene in infected necrosis; - delay intervention until "walled-off necrosis"; - step-up approach of percutaneous or endoscopic catheter drainage, followed by minimally invasive necrosectomy, if required; - endoscopic strategies are preferable where possible.

The immune imbalance in the second hit of pancreatitis is independent of IL-17A

BACKGROUND

Severe acute pancreatitis (SAP) is characterised by two distinct clinical phases. Organ dysfunction and death is initially as a result of a systemic inflammatory response syndrome (SIRS). Systemic sepsis from infected pancreatic necrosis characterises the second phase, the so called 'second hit' of acute pancreatitis (AP). An immune imbalance during the second hit is postulated to contribute to the formation of the septic complications that occur in these patients. The pro-inflammatory T-helper (Th) 17 pathway has been shown to be an initiator of early SIRS in AP, however to date its role has not been established in the second hit in AP.

METHODS

Thirty-six patients with mild (n = 16), moderate (n = 10) and severe (n = 10) acute pancreatitis were enrolled. Peripheral blood samples were drawn on days 7, 9, 11 and 13 of illness for analysis of routine clinical markers as well as cytokine analysis. Flow cytometry and a IL-17A ELISA was performed to determine cytokine concentrations.

RESULTS

There were no significant differences between days 7, 9, 11 and 13 for either the mild/moderate or SAP groups for IL-17A (CBA assay or ELISA), IFN-γ, TNF-α, IL-2 or IL-4. For each of the study days, the mean IL-6 and IL-10 concentrations were significantly higher in the SAP group compared to the mild/moderate group. WCC, CRP and PCT were all significantly higher in severe acute pancreatitis over the study days.

CONCLUSIONS

An immune imbalance exists in patients with SAP, however secreted IL-17A is not responsible for the second hit in AP.

Effects of dietary fiber on the ideal standardized ileal digestible threonine:lysine ratio for twenty-five to fifty kilogram growing gilts

Four experiments were conducted to determine effects of fiber on the ideal Thr:Lys ratio for 25- to 50-kg gilts. In Exp. 1, the objective was to determine the requirement for standardized ileal digestible Lys for gilts from 25 to 50 kg BW. Seventy gilts (24.54 ± 3.28 kg BW) were used in a growth assay with 2 pigs per pen, 5 diets, and 7 replicate pens per diet. The 5 diets were based on corn and soybean meal and contained between 0.80 and 1.32% SID Lys. Results indicated that 1.09% SID Lys was needed to optimize ADG and G:F. In Exp. 2, the objective was to determine the standardized ileal digestibility of AA in corn, soybean meal, field peas, fish meal, and soybean hulls. Six ileal-cannulated gilts (26.5 ± 0.74 kg BW) were allotted to a 6 × 6 Latin square design with 6 diets and 6 periods. Values for standardized ileal digestibility of AA were calculated for all ingredients. In Exp. 3, the objective was to determine the effect of fiber on the ideal SID Thr:Lys ratio for gilts from 25 to 50 kg BW. A total of 192 gilts (26.29 ± 4.64 kg BW) were used in a growth assay with 2 pigs per pen and 8 replicate pens per treatment. Six low-fiber diets and 6 high-fiber diets were formulated using the same batches of ingredients as in Exp. 2. Within each level of fiber, diets with SID Thr:Lys ratios ranging from 45:100 to 90:100 were formulated using the SID values calculated in Exp. 2. In both types of diets, ADG and G:F linearly and quadratically ( < 0.05) increased as the Thr:Lys ratio increased. Regression analysis estimated the ideal SID Thr:Lys ratio at 0.66 and 0.63 for ADG and G:F, respectively, for pigs fed low-fiber diets and at 0.71 and 0.63, respectively, for pigs fed high-fiber diets. In Exp. 4, the objective was to determine the N balance in pigs fed low-fiber or high-fiber diets that were formulated to have SID Thr:Lys ratios of 45:100 or 60:100. The 4 diets were formulated using the same batches of ingredients as in Exp. 2, and the SID values determined in Exp. 2 were used in diet formulations. Thirty-six gilts (29.0 ± 0.74 kg BW) were individually housed in metabolism crates with 9 replicate pigs per diet. Retention of N (% of intake) was greater (P < 0.05) for pigs fed the low-fiber diets compared with pigs fed the high-fiber diets regardless of the Thr:Lys ratio. Results of these experiments indicate that increased fiber levels in diets fed to growing gilts increase the requirement for Thr and that diets with higher fiber levels should be formulated to a greater SID Thr:Lys ratio.

Laparoscopic versus open surgery for complicated appendicitis: a randomized controlled trial to prove safety

BACKGROUND

To date, no randomized control trial has been performed comparing open appendectomy (OA) to laparoscopic appendectomy (LA) in complicated appendicitis. A systematic review and meta-analysis in 2010 concluded LA is advantageous to OA with less surgical site sepsis in complicated appendicitis; however, the level of evidence is weak (level 3a). The aim of the study was to determine whether LA is safe in the treatment of complicated appendicitis. Primary outcome included all-cause mortality and procedure-related mortality; secondary outcomes included intra-operative duration, rates of wound sepsis and re-intervention, length of hospital stay and re-admission rates.

METHODS

One hundred and fourteen patients were randomized prospectively to either OA or LA using a computer-generated blind method. Patients who were either less than 12 years of age, had previous abdominal surgery or were pregnant were excluded. A team of senior surgeons capable of doing both OA and LA performed all procedures.

RESULTS

The intra-operative duration, the rate of wound sepsis, the number of re-operations, the length of hospital stay and the rate of re-admissions between the OA and LA groups did not differ statistically.

CONCLUSION

Laparoscopic appendectomy is safe in complicated appendicitis. Current Control Trials (ISRCTN92257749).

The Greenock medical martyrs of 1864-65

In the nineteenth century it was not uncommon for doctors to die from infectious diseases, but the death of five young physicians in Greenock--one third of the medical profession in a medium-sized Scottish town--from epidemic typhus, during four consecutive months in 1864-65, was an unusual event. This paper describes the lives and backgrounds of these five doctors, whose deaths in the line of duty earned them the description 'medical martyrs'.

The place of spiritual well-being in hospice patients' overall quality of life

There is an increasing awareness of, and interest in the relationship between spirituality and health. This research examines spiritual well-being as one of six components of hospice patients' overall quality of life. Patients admitted over a four-month period were surveyed, using the Functional Assessment of Cancer Therapy scale (FACT-G), at admission, one month later, three months later, and six months later. Data showed spiritual well-being to be an important contributor to overall quality of life. The article concludes by advocating that providing spiritual care to hospice patients makes good business sense.

The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): an analysis of 500 consecutive evaluations

We assessed the safety of a new office or bedside method of evaluating both the motor and sensory components of swallowing called flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air-pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of laryngopharyngeal sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 500 times in 253 patients with dysphagia over a 2.5-year period in a tertiary care center. The patients had a variety of underlying diagnoses, with stroke and chronic neurological disease predominating (n = 155). To determine the safety of FEESST, the presence of epistaxis, airway compromise, and significant changes in heart rate before and after the evaluation were assessed. Patients were also asked to rate the level of discomfort of the examination; 498 evaluations were completed. There were three instances of epistaxis that were self-limited. There were no cases of airway compromise. There were no significant differences in heart rate between pre- and posttest measurements (p > 0.05). Eighty-one percent of patients noted either no discomfort or mild discomfort as a result of the examination. In conclusion, FEESST is a safe method of evaluating dysphagia in the tertiary care setting and may also have application for the chronic care setting.

Laryngopharyngeal sensory discrimination testing and the laryngeal adductor reflex

Laryngopharyngeal sensory capacity has been determined by endoscopically administering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve and asking the patient if he or she feels the stimulus. A potential shortcoming of this psychophysical testing (PT) procedure is that it is a subjective test, and patients with impaired cognition may not be able to perform the required task. In the search for an objective measure of laryngeal sensory function, we have observed that the laryngeal adductor reflex (LAR) is evoked at stimulus intensities similar to those capable of eliciting the psychophysical, or perceptual, response. The purpose of this study is to determine if the threshold for eliciting the LAR is the same as that of the sensory threshold. A specially designed endoscope was used to present air pulse stimuli (range 0.0 to 10 mm Hg) to the laryngopharynx in 20 healthy subjects and in 80 patients with dysphagia, using both PT and the LAR. The patients had a variety of underlying diagnoses, with stroke and chronic neurologic disease predominating (n = 65). In the control group and in the group of patients with dysphagia, there was no statistically significant difference between the median laryngopharyngeal sensory thresholds whether we used PT or the LAR (p>.05, Wilcoxon signed-rank test). The intraclass correlation for the total sample was .999 (U = .999, L = .998). Since psychophysical and sensorimotor reflex thresholds were not statistically significantly different and the intraclass correlation was close to a perfect correlation, we conclude that the LAR can be used as an objective and accurate clinical method of endoscopically assessing laryngopharyngeal sensory capacity.

Pastoral counseling in a hospice: have you considered it?

Claims that hospices provide a challenging setting for pastoral counselors but one in which they do not appear to be practicing. Offers some personal experiences of working in a hospice and urges counselors to become more involved in this form of specialized ministry.

A twist on Tarasoff: is there a duty to warn one's client?

Describes a famous legal case in which the court's decision obligates a therapist to protect potential victims from harm that may be done to them by the therapist's client and relates it to the issue of confidentiality as frequently understood by pastoral counseling specialists.

Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in healthy controls

The purpose of this study was to introduce a new method of bedside assessment of both the motor and sensory components of swallowing called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). This approach combines the established bedside endoscopic swallowing evaluation with a more recently described technique that allows objective determination of laryngopharyngeal (LP) sensory discrimination thresholds by delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a flexible endoscope. A prospective study was conducted of FEESST in 20 healthy control subjects, mean age of 34 +/- 11 years. LP sensory thresholds were defined as either normal (< 4.0 mmHg air pulse pressure [APP]), moderate deficit (4.0-6.0 mmHg APP), or severe deficits (> 6.0 mmHg APP). Subsequent to LP sensory testing, food of varying consistencies, mixed with green food coloring, was given and attention was paid to spillage, laryngeal penetration, pharyngeal residue, aspiration, and reflux. Therapeutic maneuvers such as postural changes and airway protection techniques were performed on each subject to determine if the assessed swallowing parameters were affected by maneuvers. All patients completed the study; all had normal LP sensory discrimination thresholds (2.9 +/- 0.7 mmHg APP). There were no instances of spillage, laryngeal penetration, or aspiration. Two of 20 subjects had pharyngeal residue and 2 of 20 had reflux. Institution of therapeutic maneuvers resulted in a predictable change in the endoscopic view of the laryngopharyngeal anatomy. FEESST provides comprehensive, objective sensory and motor information about deglutition in the bedside setting and might have implications for the bedside diagnosis and management of patients with dysphagia.

Restoration of laryngopharyngeal sensation by neural anastomosis

OBJECTIVE

To demonstrate that sensory nerve transposition may be used to reestablish sensation of the laryngopharynx after central nervous system injury and vagal deficit.

DESIGN

Prospective preliminary report of 2 patients following brain-stem stroke with aspiration pneumonia confirmed on chest radiography, severe dysphagia and inability to tolerate oral alimentation, and modified barium swallow that demonstrated cricopharyngeal spasm and impaired laryngeal elevation. Both patients also had severe, bilateral laryngopharyngeal sensory deficits as determined by delivery of air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a fiberoptic telescope. Each patient underwent surgery as part of management of dysphagia after failure of aggressive nonsurgical treatment.

INTERVENTION

During a cricopharyngeal myotomy and laryngeal suspension, a unilateral microneurorrhaphy between the greater auricular nerve and the superior laryngeal nerve was performed.

OUTCOME MEASURES

Ability to tolerate oral diet without development of aspiration pneumonia and postoperative laryngopharyngeal sensory capacity.

RESULTS

By 12 months after surgery, both patients had ipsilateral restoration of laryngopharyngeal sensation, with no further episodes of aspiration pneumonia.

CONCLUSIONS

In select cases of severe dysphagia after central nervous system injury, sensory nerve transposition may be a useful adjunct to the surgical rehabilitation of the patient with dysphagia.

Effects of spray-dried porcine plasma protein on growth traits and nitrogen and energy balance in mice

Energy and nitrogen balances of mice receiving a dried skim milk-based control diet were compared to a similar group of mice receiving a diet containing 8% spray-dried plasma protein (SDPP). Mice were housed in pairs in metabolism cages with feed and water available for ad libitum intake. Five cages were assigned to each diet for a 21-d feeding period. Mice fed SDPP gained more weight (P < .01), consumed more feed (P < .01), and had higher gain: feed ratios (G:F) (P < .01) than mice fed the control diet during wk 1. No significant differences in growth, feed intake, or G:F were detected during wk 2. During wk 3, mice receiving the control diet tended to gain more (P < .10) and had a higher G:F (P < .01). Nitrogen intake and retention were greater for mice fed SDPP (P < .02). Energy intake was greater for mice fed SDPP (P < .01); however, energy retention was not different between treatment groups due to greater (P < .01) metabolic energy losses (urinary energy+heat production). Empty gut weight was greater for control mice on an absolute basis (P < .05) and when expressed as a percentage of BW (P < .02). Liver weights of mice fed SDPP were greater on an absolute basis (P < .02) and as a percentage of BW (P < .01). Feed intake, growth rate, and G:F were increased by dietary addition of SDPP.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of spray-dried porcine plasma protein on feed intake, growth rate, and efficiency of gain in mice

One hundred eight mice were weaned at 21 +/- 1 d and allotted to four dietary treatments: 1) control, 2) control + 4% spray-dried porcine plasma protein (SDPP), 3) control + 8% SDPP, and 4) control + 12% SDPP. Daily gain for males increased with increasing SDPP during wk 1 (P < .01), wk 2 (P < .01), and for the entire 3 wk (P < .01). Daily gain increased quadratically with increasing SDPP for females during wk 1 (P < .05). During the 3rd wk, ADG decreased for females with increasing SDPP (P < .05). Daily feed intake increased linearly (P < .01) with increasing SDPP in all periods. Gain-to-feed ratio (G/F) increased with increasing SDPP during wk 1 (P < .01) and for the first 2 wk (P < .05). During wk 3, G/F decreased with increasing SDPP level (P < .01). Gain-to-feed ratio of females responded quadratically to increasing SDPP during wk 1 (P < .05), whereas G/F of males increased linearly with increasing SDPP level. Gain-to-feed ratio for the entire trial was unaffected by treatment among females (P = .82) but increased linearly with increasing SDPP levels among males (P < .01). Liver weight increased quadratically with increasing SDPP levels for males (P < .05) and females (P < .05). Treatment effect on liver weight per kilogram BW.75 approached significance (P < .10) in females. Male liver weight/100 g BW and liver weight per kilogram BW.75 responded quadratically to increasing SDPP levels (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Antitachycardia pacing with cardioverter-defibrillator backup for malignant ventricular dysrhythmias

This article provides a summary of the history of antitachydysrhythmic devices and their current application in patients with ventricular dysrhythmias. Future trends are also discussed, followed by a case study illustrating the nursing care required for a patient with a combination antitachycardia pacemaker and automatic implantable cardioverter-defibrillator for slow ventricular tachycardia. The basic principles provided can be incorporated into the teaching plans of patients with antidysrhythmic devices for malignant ventricular dysrhythmias.

Myasthenia gravis and Schmidt syndrome

We describe a 47 year old woman with a 30-year history of generalized myasthenia gravis whose condition had been stable and well controlled on a combination of pyridostigmine and ephedrine until she presented. At this time she gave a 2 month history of weakness, nausea, vomiting and more recently intermittent confusion. Investigations confirmed both primary hypothyroidism and primary adrenal failure (Schmidt syndrome). The autoimmune aetiology of these three conditions was confirmed by positive acetylcholine receptor, adrenal and thyroid microsomal antibodies.

Recovery of inoculated Salmonella from poultry feed containing furazolidone

It was determined that the presence of furazolidone, a common feed additive, prevented detection of Salmonella in feed samples. Artificially inoculated Salmonella were not recovered from feed samples containing furazolidone when buffered peptone broth (BP) was used as an enrichment medium, but Salmonella were recovered from all feed samples containing furazolidone when thiol broth was used as a substitute for BP.

Identification of Enterobacteriaceae in Foods with the AutoMicrobic System

Stock cultures (136) and fresh isolates (163) of Enterobacteriaceae from ground beef, processed chickens, frozen pot pies and commercial poultry feeds were identified to species with the AutoMicrobic System (AMS). All stock cultures and fresh isolates were also concurrently tested with two other identification systems (Micro-ID and API), previously evaluated and proven accurate for identification of Enterobacteriaceae . The AMS correctly identified to species 135/136 (99.3%) of the stock cultures and 160/163 (98.2%) of the fresh isolates. All Salmonella cultures tested (74) were correctly identified by AMS.

Identification of Enterobacteriaceae from Foods with the Spectrum-10

Spectrum-10, a newly developed miniaturized identification system, was analyzed for its ability to accurately and rapidly identify members of the Enterobacteriaceae family. This study, conducted at two separate laboratories, tested freshly isolated organisms from raw and frozen foods (180) and stock cultures (144). For comparison purposes, the Micro-ID and API-20E identification systems were concurrently inoculated with the test organisms. In comparison to the Micro-ID and the API-20E systems, the Spectrum-10 identified 95 to 96% of the stock cultures to genus and species, whereas 93% of the fresh isolates were identified to genus and 82% to species.

Comparison of Aerobic and Anaerobic Incubation Conditions for Optimal Recovery of Salmonella

Effects of aerobic and anaerobic incubation of selenite-cystine and TT enrichment broth incubated at 37 and 34°C on the growth of Salmonella were determined. Pure cultures of four serotypes of Salmonella were enumerated at 0, 4, 8 and 24 h of incubation and no significant differences related to incubation conditions were found. The effect of microflora other than Salmonella , in pure and mixed cultures and from chicken and feed samples, on the recovery rate of Salmonella after incubation in enrichment media was evaluated and no significant effects were found; however, aerobic incubation usually gave higher Salmonella counts. Greater recovery of Salmonella was obtained by incubating selective plating media aerobically rather than anaerobically. Aerobic incubation of liquid enrichment media and differential plating media is therefore recommended for optimal recovery of Salmonella .

Survival of Salmonella in Dry Food and Feed

The survival of Salmonella Montevideo and Salmonella heidelberg in dry milk, cocoa powder, poultry feed, and meat and bone meal was studied at three water activities (a_w) in the range of 0.4 to 0.75. S. montevideo was more resistant to the various dry environments than S. heidelberg . Salmonellae were enumerated immediately after inoculation, after 2 d, and after 1, 3, 7 and 14 wk. Survival was greater at a_w of 0.43 and 0.52 than at 0.75 a_w. Based on these findings and due to the marked differences in survival observed in the different products equilibrated at a specific a_w value, it is concluded that the survival of salmonellae in a dry product cannot be predicted on the basis of the a_w alone.

Comparison of Brands of Media for Isolating Bacteria from Poultry, Beef and Shrimp

Five brands of media (BBL, Difco, Gibco, Oxoid and Scott) were evaluated for enumerating microorganisms by the aerobic plate count and by Enterobacteriaceae , Escherichia coli , and coliform counts, and for determining Salmonella incidence. Microbiological evaluations were done on raw chickens, raw beef and raw shrimp, except that Salmonella incidence was not determined on shrimp samples. There were statistically significant differences in total plate counts (with chicken, beef and shrimp), Enterobacteriaceae counts (with shrimp) coliforms (with chicken) and E. coli counts (with chicken) by the five brands of media, but these differences were too small to be of practical significance. It was concluded that no differences of practical significance were found among the five brands of media.

Recovery of Salmonella from Artificially Contaminated Poultry Feeds in Non-Selective and Selective Broth Media

The efficacy of four preenrichment media (lactose broth, lactose broth with Tergitol, buffered peptone and M-9) and of direct enrichment in selenite cystine and modified tetrathionate broths for recovering two Salmonella serotypes from dry poultry feed was determined. The salmonellae, artificially inoculated and stored for 7 wk in the dry feed (1.5 to 2.2 cells of salmonellae/g of feed analyzed), were recovered from significantly more samples after preenrichment with M-9 or buffered peptone than with any of the other procedures tested.

Effect of Reduced Processing on Recovery of Foodborne Pathogens from Hot-Boned Broiler Meat and Skin

Recovery of pathogens from breast meat, thigh meat and skin from scalded, defeathered but uneviscerated broiler carcasses with and without spray washing was compared to recovery from breast meat, thigh meat and skin from fully processed, chilled carcasses (controls). The incidence of coagulase-positive staphylococci was not significantly different on meat and skin from both uneviscerated carcasses with and without a spray washing compared to meat and skin from fully processed carcasses. The incidence of Clostridium perfringens was not significantly different on skin, breast and thigh meat for any of the sampling sources except that incidence on meat from control breasts was lower than on breast meat from uneviscerated carcasses without spray-washing; and incidence on meat from control thighs was lower than on meat from spray-washed, uneviscerated carcasses. Salmonella incidence was higher on both breast and thigh meat from fully processed control carcasses than from uneviscerated unwashed carcasses. When uneviscerated carcasses were spray-washed after defeathering, the incidence of Salmonella was not significantly different on breast meat, and significantly lower on thigh meat than on these meats from fully processed control carcasses. Skin from fully processed control carcasses had a higher incidence of Salmonella than did skin from uneviscerated, unwashed carcasses, but not skin from uneviscerated, spray-washed carcasses. Reducing the number of stages of processing significantly reduced the incidence of Salmonella but not of coagulase-positive staphylococci or Clostridium perfringens .

Selecting a Miniaturized System for Identification of Enterobacteriaceae

The most commonly used commercial diagnostic kits for identification of Enterobacteriaceae are API, Enteric-Tek, Enterotube II, Micro-ID, Minitek and Spectrum-10. The accuracy of identification by all systems does not vary significantly, and falls within the acceptable range. Therefore, a bacteriologist who is considering the use of these products should evaluate factors other than accuracy when making a choice. Twenty-three professional microbiologists who had previous experience with these systems listed advantages and disadvantages of each system, and evaluated the conventional procedure for identification. The comments were summarized and presented in tabular form. The current cost per isolate of each system and the cost of the identification manual, reagents and incidental costs were also determined. These data provide the potential user with comparative information on price, shelf-life, versatility, time required for inoculation, incubation and manipulation after incubation, possible difficulties in determining positive and negative reactions, and potential safety factors for laboratory personnel.

Salmonella and other Enterobacteriaceae found in commercial poultry feed

Poultry feed (mash and pelleted) and meat and bone meal samples were collected from commercial mills. All samples were analyzed for Enterobacteriaceae count (ENT) and Salmonella. The genus and species of the various Enterobacteriaceae present were also determined. The average ENT for mash, pelleted, and meal samples was log 4.1, .8, and 1.8/g, respectively. Enterobacteriaceae were present in 100, 60, and 92% and Salmonella in 58, 0, and 92% of the mash, pelleted, and meal samples, respectively. Overall, the Enterobacteriaceae most frequently isolated from all samples were Enterobacter agglomerans, Enterobacter cloacae, and Klebsiella pneumoniae. Although no Salmonella were found in the pelleted samples, the presence of other Enterobacteriaceae suggests that commercial pelleting may not totally destroy Salmonella since their heat resistance is similar to the other organisms found.

Evaluation of Five Miniaturized Systems for Identifying Enterobacteriaceae from Stock Cultures and Raw Foods

Five miniaturized systems (API, Enteric-Tek, Enterotube II, Micro-ID and Minitek) were compared to conventional procedures for identification of Enterobacteriaceae from stock cultures and freshly isolated from food sources, The accuracy of identification to genus was 98% for Micro-ID; 95%, Minitek; 94%, Enteric-Tek; 93%, API; and 86%, Enterotube II, Accuracy of identification to species was 97% for Micro-ID; 94%, Minitek; 93%, Enteric-Tek; 91 %, API; and 79%, Enterotube II, The 124 organisms tested in this study were from 11 genera of the Enterobacteriaceae family. All systems accurately identified to species the most pathogenic members of the family ( Arizona hinshawii , Salmonella typhi , Salmonella typhimurium and Shigella flexneri ). Most of the inaccuracies in identification occurred with Enterobacter and Serratia species.

Heating by microwave, hot air, and flowing steam to eliminate inoculated Salmonella from poultry feed

Poultry feed samples (mash) obtained from a commercial mill were inoculated with either 100 or 5,000 cells/g of a marker strain of Salmonella montevideo. Samples (125 g) were then placed in a microwave oven at power settings of 1.5 or 2.0 kW for 60, 90, or 120 sec; a hot air oven at 99 C (210 F) or 110 C (230 F) for 15, 30, 45, or 60 min; or a flowing steam chamber for 1, 5, 10, or 20 min. Temperature, moisture, and presence of the inoculated S. montevideo were determined in all samples before and after treatment. Feed samples placed in the microwave oven reached a maximum temperature of 186 C (367 F) and had a final moisture content as low as .8%. About 25% of the samples inoculated with 100 cells/g and about 40% of those inoculated with 5,000 cells/g remained positive after treatment. In the hot air oven, feed reached a maximum temperature of 93 C (200 F) with a moisture level after heating of about 4%. Salmonellae were recovered from 35 and 60% of the low and high inoculum level samples, respectively. In flowing steam, maximum feed temperature was 90 C (194 F) with a final moisture level of 15%. After 1, 5, 10, and 20 min of flowing steam, 100, 90, 60, and 0% of the samples were found to contain salmonellae, respectively. All treatments occasionally eliminated salmonellae from the samples, but results were inconsistent and unpredictable.

Rapid Procedure for Biochemical Characterization and Serological Confirmation of Suspect Salmonella Isolates

Fifty-two freshly processed broiler carcasses were examined for the presence of Salmonella by using a rinse method. Three selective plating media (bismuth sulfite, brilliant green sulfa and Hektoen enteric) were compared. After 24 h of incubation, typical colonies were picked from each selective plate. An 8-h procedure to biochemically characterize (Micro ID) and serologically (poly O and poly H) confirm Salmonella was then compared with a conventional procedure. Suspect Salmonella isolates were correctly classified from 63% of the carcasses with both the 8-h and conventional procedures. Of the 244 isolates confirmed to be Salmonella by conventional testing, 236 (97%) were also confirmed by the 8-h procedure. Brilliant green sulfa and Hektoen enteric agar were superior to bismuth sulfite agar for Salmonella recovery. The 8-h procedure required less incubation time (8 h vs. 48 h) after colony formation, less incubation space, and less media preparation and cleanup than the conventional procedure.

Effect of various media and incubation conditions on recovery of inoculated Salmonella from poultry feed

Samples of commercially pelleted poultry feed (30 g) were inoculated with nalidixic acid-resistant marker strains of Salmonella heidelberg or S. montevideo at levels of 1 (low), 20 (medium), or 40 (high) cells/g of feed, then 100 ml of either a nonselective preenrichment medium (lactose broth) or a selective enrichment medium [selenite cystine (SC) or tetrathionate brilliant green (TT) broth] was added and incubated at either 37 or 43 C for 24 or 48 hr in different experiments. Four selective plating media [MacConkey with 100 ppm nalidixic acid, brilliant green (BG) sulfa, modified BG, bismuth sulfite] were then streaked. MacConkey agar with nalidixic acid served as a control to which the other three plating media were compared. After 24 hr incubation at 37 C, colonies with characteristics typical of Salmonella were selected from the plates and examined biochemically and serologically to determine if they were the marker organism. In this study, preenrichment was counterproductive, because the marker organisms were recovered much more often with direct enrichment in SC or TT broth than with reenrichment in lactose broth. The TT broth produced 135 positive recoveries, whereas only 88 positive recoveries were made with SC. No differences were observed between 37 and 43 C or 24 and 48 hr incubation of the selective enrichment media. Overall efficiency of the plating media for Salmonella recovery from feed, when compared to the control (MacConkey), was BG sulfa, 65%;modified BG, 64%; and bismuth sulfite, 40%. The most effective enrichment broth-plating medium combination was TT-BG sulfa, yielding 86% positive recoveries when compared to the control.

Minimizing Salmonella Contamination on Broiler Carcasses with Poly (Hexamethylenebiguanide Hydrochloride)

Broiler carcasses, each inoculated with 30 cells of marker Salmonella heidelberg , were prechilled and chilled together with uninoculated carcasses in a simulated commercial chilling system. When either 10 or 25 ppm of PHMB [poly(hexamethylenebiguanide hydrochloride)] was added to the prechill water, cross-contamination (uninoculated carcasses showing contamination with marker Salmonella after chilling) was prevented, and no viable Salmonella were found on the inoculated carcasses. When carcasses, each inoculated with 60,000 cells of marker Salmonella , were similarly chilled, and 10 ppm of PHMB was added to the prechill water, cross-contamination was not prevented, and viable Salmonella were found on the inoculated carcasses. With 60,000 cells, and 25 ppm PHMB, cross-contamination was prevented, but viable Salmonella remained on the inoculated carcasses.

Comparison of Micro-ID and Minitek-Serology Systems for Rapid Identification of Salmonella

A 4-h biochemical identification system (Micro-ID) and a rapid confirmation 24-h biochemical and serological procedure (RC) involving the Minitek system were compared for accuracy of Salmonella identification. Of 144 known Salmonella stock cultures, RC correctly classified all, and Micro-ID correctly classified 141. Both systems correctly classified all the Salmonella isolates obtained from four artificially inoculated broiler carcasses. When 113 suspect- Salmonella isolates from naturally contaminated samples were examined, RC correctly classified all, and Micro-ID correctly classified all except one.

Minitek Inoculum Broth for Testing Indole Production by Enterobacteriaceae

With 73 members of the Enterobacteriaceae family, detection of indole production with Minitek inoculum broth (MIB) correlated more closely with the results of the conventional method than did detection with the Minitek H₂S/indole disk.

Sampling of broiler carcasses for Salmonella with low volume water rinse

The uneven distribution and low numbers of salmonella usually present on broiler carcasses make whole carcass rinsing the most sensitive sampling procedure for detecting this organism on the raw product. However, 270 ml of water or medium has been the smallest volume used in past published research. We found that 100 ml was adequate to recover Salmonella typhimurium, S. california, or S. montevideo from freshly processed broiler carcasses that had been inoculated with the organism at the rate of 50 cells/carcass. When carcasses were inoculated with 20 cells or S. heidelberg, then stored at -23 C for 3 or 6 months, sampling with 100 ml was adequate to detect the organism on all carcasses. The advantages of using the smallest volume of rinsing medium that will consistently lead to detection of salmonella present are: 1) less enrichment medium is required, 2) less incubator space is required, and 3) the concentration of cells in the selective enrichment medium at the end of incubation is greater; hence, the greater are the chances of salmonella detection when a drop is subsequently transferred to the selective plating medium.

Modified Procedure to Inoculate Micro-ID

The accuracy of a miniaturized Enterobacteriaceae system (Micro-ID) was evaluated with 10 different genera grown on 11 selective plating media. Whenever growth occurred, the correct identification was made. In addition, 12 serotypes of Salmonella and 22 other strains of Enterobacteriaceae were grown on the two most common selective media used by food microbiologists for isolation of Salmonella [Brilliant Green Sulfa Agar (BGS) and Bismuth Sulfite Agar (BiS)]. The correct identification was made in all instances. The manufacturer of Micro-ID originally recommended that several colonies be picked for inoculation of the system. We modified the inoculation procedure so that only one colony was selected from a plate; this minimized the chances of having a mixed-culture inoculum. With this procedure, all 21 Enterobacteriaceae tested were correctly identified.

Effect of carbohydrate restriction on lipoprotein abnormalities in maturity-onset diabetes mellitus

Hyperlipoproteinemia occurs commonly in diabetics and may contribute to early atherosclerosis in these patients. The effect of dietary carbohydrate restriction on lipid abnormalities has been examined in 42 newly diagnosed maturity-onset diabetics, in whom plasma lipoproteins were measured before treatment was started and at regular intervals during ten months of dietary therapy. Twenty-four patients (57%) had abnormal lipids when diabetes was first diagnosed. Nine were classed as Type II and 15 as Type IV hyperlipoproteinemia. Plasma lipids reverted to normal in half these patients after dietary treatment for one month. Only 8 diabetics (19%) showed persistent lipid abnormality after ten months' treatment: all had been unable to diet satisfactorily as judged by persisting obesity and hyperglycemia. The common lipoprotein abnormalities of maturity-onset diabetes can usually be returned to normal by the simplest possible carbohydrate-restricted diet, if patients adhere to this. Specialized and complex diets or lipid-lowering drugs are unncessary in the majority of patients.

Salmonella on Broiler Carcasses as Affected by Fresh Water Input Rate and Chlorination of Chiller Water

Broiler carcasses, each inoculated with about 1000 cells of a marker strain of Salmonella typhimurium , and uninoculated carcasses were prechilled and chilled in a simulated commercial chilling process. For each experiment, fresh water input was either 1.90 liters (0.50 gal) or 0.95 liters (0.25 gal) per carcass, and the chlorine level was 0, 20 or 50 ppm. The rate of fresh water input had no significant effect on either cross-contamination (uninoculated carcasses showing contamination with marker organisms after chilling) or elimination of Salmonella from the inoculated carcasses. Fewer uninoculated carcasses showed marker Salmonella contamination after chilling with 50 ppm of chlorine than 0 ppm, but cross-contamination was not eliminated. Chlorine in the chilling water decreased rapidly due to the effect of organic matter.

Types of Bacteria and Shelf-Life of Evacuated Carbon Dioxide-Injected and Ice-Packed Broilers

Broiler carcasses were packed in low-permeability film bags that were evacuated, injected with CO₂, then held at 2 C. Broilers were examined microbiologically and for off-odor to determine the shelf-life and types of bacteria. Vacuum level did not significantly affect bacterial counts. Broilers stored in 65% CO₂ had a 1-day longer shelf-life than those held in 20% CO₂ and about a 5-day longer shelf-life than ice-packed broilers. Spoiled carcasses from either 20 or 65% CO₂ packages had an acid-sour off-odor, and more than 90% of the bacteria present were Lactobacillus . Ice-packed broilers had the typical putrid off-odor at spoilage, and more than 95% of the bacteria were non-pigmented Pseudomonas .

Phosphate and heat treatments to control Salmonella and reduce spoilage and rancidity on broiler carcasses

Broiler chicken carcasses were inoculated with about 300 cells of a naladixic acid resistant strain of Salmonella typhimurium, then treated for 3 min with highly agitated water with or without 6% phosphate added, at 65, 70, 75, 80, 85, or 90 C. Other broiler carcasses were inoculated with about 60 cells, then similarly treated at 65 or 70 C. All carcasses were chilled after the hot water treatment in a system simulating commerical chilling. When inoculum was 300 cells, at least 5% of the carcasses remained contaminated with Salmonella, even when hot water treatment was at 90 C. When inoculum was 60 cells, Salmonella were eliminated by hot water treatment at 65 or 70 C. Carcasses showed a partially cooked appearance after hot water treatment. Total bacterial counts on carcasses treated at 70 and 90 C, with or without added phosphate, and then chilled were lower than on control carcasses throughout storage at 2 C for up to 26 days. Phosphates did not consistently or significantly affect either Salmonella survival or total bacterial counts. Oxidative deterioration as measured by the thiobarbituric acid test was significantly retarded throughout 26 days of storage by the addition of 6% phosphate to a 70 or 90 C hot water treatment.

Mesterolone: thrombosis during treatment, and a study of its prothrombotic effects

1. We describe a patient who developed deep vein thrombosis after commencing treatment with the synthetic androgen, mesterolone (Pro-Viron). 2. To investigate the potential thrombogenic action of this drug, a 21 day course of mesterolone (100 mg/day) was given to nine healthy male volunteers. 3. No significant change after treatment occurred in any of the blood tests performed (clotting times, Factor VIII coagulant activity, Factor VIII related antigen, antithrombin III activity, fibrinogen, fibrinogen-fibrin degradation products, plasminogen, euglobulin lysis time, urokinase sensitivity, platelet count, haematocrit, whole blood viscosity and plasma viscosity). 4. We conclude that in a conventional dose taken for 3 weeks mesterolone does not produce a consistent measurable prothrombotic state, nor does it enhance fibrinolysis.

The effect of intravenous heparin infusions on the thyroid stimulating hormone response to thyrotrophin releasing hormone

1 The TSH response to TRH is suppressed 24 h after the commencement of i.v. heparin infusion in euthyroid subjects, as compared to repeat testing, both after 7 days of continuous i.v. heparin and after 7 days without heparin but while on warfarin. 2 This suggests that the rise in serum free thyroid hormones, which heparin produces, has a 'metabolic effect'. Possible clinical effects of this action must be considered. 3 Heparin has no effect on the radio-immunoassay of TSH.