Cumulative Exposure to Metabolic Syndrome Components and the Risk of Dementia: A Nationwide Population-Based Study

Background@#Metabolic disturbances are modifiable risk factors for dementia. Because the status of metabolic syndrome (MetS) and its components changes over time, we aimed to investigate the association of the cumulative exposure to MetS and its components with the risk of dementia. @*Methods@#Adults (n=1,492,776; ≥45-years-old) who received health examinations for 4 consecutive years were identified from a nationwide population-based cohort in Korea. Two exposure-weighted scores were calculated: cumulative number of MetS diagnoses (MetS exposure score, range of 0 to 4) and the composite of its five components (MetS component exposure score, range of 0 to 20). Hazard ratio (HR) and 95% confidence interval (CI) values for dementia were analyzed using the multivariable Cox proportional-hazards model. @*Results@#Overall, 47.1% of subjects were diagnosed with MetS at least once, and 11.5% had persistent MetS. During the mean 5.2 years of follow-up, there were 7,341 cases (0.5%) of incident dementia. There was a stepwise increase in the risk of all-cause dementia, Alzheimer’s disease, and vascular dementia with increasing MetS exposure score and MetS component exposure score (each P for trend <0.0001). The HR of all-cause dementia was 2.62 (95% CI, 1.87 to 3.68) in subjects with a MetS component exposure score of 20 compared with those with a score of 0. People fulfilling only one MetS component out of 20 already had an approximately 40% increased risk of all-cause dementia and Alzheimer’s disease. @*Conclusion@#More cumulative exposure to metabolic disturbances was associated with a higher risk of dementia. Of note, even minimal exposure to MetS components had a significant effect on the risk of dementia.

Cumulative Exposure to Metabolic Syndrome Components and the Risk of Dementia: A Nationwide Population-Based Study

Background@#Metabolic disturbances are modifiable risk factors for dementia. Because the status of metabolic syndrome (MetS) and its components changes over time, we aimed to investigate the association of the cumulative exposure to MetS and its components with the risk of dementia. @*Methods@#Adults (n=1,492,776; ≥45-years-old) who received health examinations for 4 consecutive years were identified from a nationwide population-based cohort in Korea. Two exposure-weighted scores were calculated: cumulative number of MetS diagnoses (MetS exposure score, range of 0 to 4) and the composite of its five components (MetS component exposure score, range of 0 to 20). Hazard ratio (HR) and 95% confidence interval (CI) values for dementia were analyzed using the multivariable Cox proportional-hazards model. @*Results@#Overall, 47.1% of subjects were diagnosed with MetS at least once, and 11.5% had persistent MetS. During the mean 5.2 years of follow-up, there were 7,341 cases (0.5%) of incident dementia. There was a stepwise increase in the risk of all-cause dementia, Alzheimer’s disease, and vascular dementia with increasing MetS exposure score and MetS component exposure score (each P for trend <0.0001). The HR of all-cause dementia was 2.62 (95% CI, 1.87 to 3.68) in subjects with a MetS component exposure score of 20 compared with those with a score of 0. People fulfilling only one MetS component out of 20 already had an approximately 40% increased risk of all-cause dementia and Alzheimer’s disease. @*Conclusion@#More cumulative exposure to metabolic disturbances was associated with a higher risk of dementia. Of note, even minimal exposure to MetS components had a significant effect on the risk of dementia.

Evaluation of Analytical Performance of an Automated Glycated Hemoglobin Analyzer, HLC-723 G11

Changes in Metabolic Profile Over Time: Impact on the Risk of Diabetes

No abstract available.

Quality Assurance of Diagnostic Immunologic Tests for Screening of Transfusion-Transmissible Infections at Korean Blood Centers / 대한수혈학회지

The Korean government previously established a national blood policy and national blood system based on basic and essential legislation. This achievement was the result of collaborative efforts between the Korean Centers for Disease Control and Prevention, the Korean Society of Blood Transfusion, the Korean Society for Laboratory Medicine, the Laboratory Medicine Foundation, and/or the Korean Association of External Quality Assessment Service. To ensure a safe and effective transfusion, a comprehensive quality assurance (QA) system to assess every process from donor selection to transfusion is mandatory. From a blood safety perspective, selection of appropriate donor blood screening tests for transfusion-transmissible infections (TTI) and the QA program is of great importance. In this article, we review legislation regarding the national blood policy and national blood system as well as the selection logic regarding diagnostic immunologic tests for TTI and quality assurance efforts for TTI of each blood center.

Comparison of Quantitation of Cytomegalovirus DNA by Real-Time PCR in Whole Blood with the Cytomegalovirus Antigenemia Assay

BACKGROUND: Quantitation of cytomegalovirus (CMV) DNA using real-time PCR has been utilized for monitoring CMV infection. However, the CMV antigenemia assay is still the 'gold standard' assay. There are only a few studies in Korea that compared the efficacy of use of real-time PCR for quantitation of CMV DNA in whole blood with the antigenemia assay, and most of these studies have been limited to transplant recipients. METHOD: 479 whole blood samples from 79 patients, falling under different disease groups, were tested by real-time CMV DNA PCR using the Q-CMV real-time complete kit (Nanogen Advanced Diagnostic S.r.L., Italy) and CMV antigenemia assay (CINA Kit, ArgeneBiosoft, France), and the results were compared. Repeatedly tested patients were selected and their charts were reviewed for ganciclovir therapy. RESULTS: The concordance rate of the two assays was 86.4% (Cohen's kappa coefficient value=0.659). Quantitative correlation between the two assays was a moderate (r=0.5504, P<0.0001). Among 20 patients tested repeatedly with the two assays, 13 patients were transplant recipients and treated with ganciclovir. Before treatment, CMV was detected earlier by real-time CMV DNA PCR than the antigenemia assay, with a median difference of 8 days. After treatment, the antigenemia assay achieved negative results earlier than real-time CMV DNA PCR with a median difference of 10.5 days. CONCLUSIONS: Q-CMV real-time complete kit is a useful tool for early detection of CMV infection in whole blood samples in transplant recipients.

Effect of interleukin-29 on interferon- alpha secretion by peripheral blood mononuclear cells

The effect of interleukin [IL]-29, a new therapeutic agent similar to type I interferons [IFNs], on IFN- alpha secretion of human plasmacytoid dendritic cells [pDCs] has not been studied. Therefore, in this study, we aimed to clarify the effect of IL-29 on IFN- alpha secretion of pDCs using human peripheral blood mononuclear cells [PBMCs] in the presence of cytosine-phosphate-guanosinemotif-containing oligodeoxy nucleotides [CpG]. In this experimental and prospective study, PBMCs were obtained from 11 healthy volunteers and divided into four culture conditions: I. control, II. CpG treatment, III. IL-29 treatment and IV. CpG plus IL-29 treatment. The amount of IFN- alpha secretion was measured from each culture supernatant by flow cytometry using the flowcytomix apparatus [eBioscience, Vienna, Austria]. Fractional IFN- alpha production of the cultured PBMCs was measured by intracellular staining using the cytomics FC 500 system [Beckman Coulter, Brea, CA, USA] with CXP Software. The mean +/- standard deviation [SD] of supernatant IFN- alpha secretion per pDC/ micro L was 5.7 +/- 9.3 pg/mL/count/ micro L for condition I, 1071.5 +/- 1026.6 pg/mL/count/ micro L for condition II, 14.1 +/- 21.1 pg/mL/count/ micro L for condition III, and 1913.9 +/- 1525.9 pg/mL/count/ micro L for condition IV. There were statistically significant differences between conditions I and II as well as betweenconditions II and IV. Intracellular IFN- alpha production was only detectable in the pDC fraction from one culture; the production amount was similar between the cells treated with CpG and those treated with CpG plus IL-29. Natural killer [NK] cell production of IFN- alpha was observed in two out of three cultures and one culture showed IFN- alpha production in the monocyte fraction. IL-29 alone did not show any effect on IFN- alpha secretion of PBMCs. However, the addition of CpG along with IL-29 enhanced IFN- alpha secretion of PBMCs. Given that pDCs are the major secretors of IFN- alpha in peripheral blood, this result has suggested the possibility that IL-29 has an enhancing effect in human pDC IFN- alpha secretion. Although the supernatant IFN- alpha secretion was not directly correlated with pDCs's intracellular IFN- alpha production in this study, prolonged incubation of pDC and other PB subsets with CpG or IL-29 for over 4 hours could be applied in future studies. These studies would help to elucidate the mechanism of action of IL-29 in human pDCs associated with viral infections

Bone Mineral Density, Biochemical Bone Turnover Markers and Factors associated with Bone Health in Young Korean Women

PURPOSE: This study was done to assess the bone mineral density (BMD), biochemical bone turnover markers (BTMs), and factors associated with bone health in young Korean women. METHODS: Participants were 1,298 women, ages 18-29, recruited in Korea. Measurements were BMD by calcaneus quantitative ultrasound, BTMs for Calcium, Phosphorus, Osteocalcin, and C-telopeptide cross-links (CTX), body composition by physical measurements, nutrients by food frequency questionnaire and psychosocial factors associated with bone health by self-report. RESULTS: The mean BMD (Z-score) was -0.94. 8.7% women had lower BMD (Z-score or =0) and low-BMD (Z-score<0) women. However, Osteocalcin and CTX were higher in women preferring caffeine intake, sedentary lifestyle and alcoholic drinks. Body composition and Calcium intake were significantly higher in high-BMD. Low-BMD women reported significantly higher susceptibility and barriers to exercise in health beliefs, lower bone health self-efficacy and promoting behaviors. CONCLUSION: Results of this study indicate that bone health of young Korean women is not good. Development of diverse strategies to intervene in factors such as exercise, nutrients, self-efficacy, health beliefs and behaviors, shown to be important, are needed to improve bone health.

Performance of the Elecsys HIV combi PT Assay Compared to the ARCHITECT HIV Ag/Ab Combo Assay

BACKGROUND: The aim of this study was to compare the analytical sensitivity and specificity of the recently updated 4th generation Elecsys HIV combi PT assay (Roche Diagnostics GmbH, Germany) to those of the ARCHITECT HIV Ag/Ab Combo assay (Abbott Laboratories, Germany). METHODS: A total of 2,003 fresh random clinical samples, 4 HIV seroconversion panels, a WHO International Standard p24 antigen sensitivity panel, 5 HIV-1 subtype viral lysates, and 5 HIV-1 subtype antibodies were tested in comparative studies with the Elecsys HIV combi PT and ARCHITECT HIV Ag/Ab Combo assays. Samples were assayed with both tests on the same day. The MP Diagnostics HIV Western Blot 2.2 Assay, the Elecsys HIV p24 Ag Test and Confirmatory Test, and the COBAS AmpliPrep/COBAS TaqMan HIV-1 Test were performed as supplementary tests. RESULTS: Both the Elecsys and ARCHITECT assays detected viral antigens in all four seroconversion panels on the same bleed days, and had lower limits of detection of <1 IU/mL with the p24 antigen sensitivity panel. The ARCHITECT assay showed slightly higher sensitivity in detecting viral antigens with some HIV-1 subtype viral lysates, while the Elecsys assay was more sensitive in detecting each of the 5 HIV-1 subtype antibodies. Both assays detected 5/5 HIV+ clinical samples correctly. The analytical specificities of the Elecsys and ARCHITECT assays were 99.90% and 99.80%, respectively. CONCLUSIONS: The Elecsys HIV combi PT assay performed comparably to the ARCHITECT HIV Ag/Ab Combo assay. Thus, the Elecsys HIV combi PT assay is suitable for diagnostic testing in university hospital settings.

Therapy-Related Acute Megakaryoblastic Leukemia in a Lung Cancer Patient

No abstract available.

Factors Affecting the Freshness of Transfused Packed Red Blood Cells / 대한수혈학회지

BACKGROUND: The relationship between the storage age of packed red blood cells (pRBCs) and clinical outcomes is controversial. However, no systematic study regarding how fresh pRBCs were transfused to patients have been available so far. Therefore, we newly defined concepts for supply age (period from blood collection to supply to hospital), storage age (period from supply to transfusion to patient), and transfusion age (supply age plus storage age) and investigated them. The factors affecting each age were also analyzed. METHODS: A retrospective analysis for three ages of pRBCs was performed for patients who were transfused > or =1 pRBCs unit at three university hospitals between January 2009 and December 2013. Inventory age (period from blood collection to inventory check point at each blood bank) was prospectively checked on a daily basis for 30 days. Four blood centers and blood groups of transfused pRBCs were included. RESULTS: The mean supply, storage, and transfusion ages of pRBCs were 6.2, 6.0, and 12.0 days, respectively. 58%, 61%, and 66% of total transfused pRBCs were in a fresh category of supply, storage, and transfusion ages correspondingly. Storage and transfusion ages were affected by ABO blood group, hospitals, and years in listing orders. Inventory age was mainly affected by ABO blood group and hospitals. CONCLUSION: The freshness of transfused pRBCs was affected by hospitals and blood centers. Therefore, using the supply, storage, transfusion, and inventory ages as new norms can be useful to establishment of inventory and supply policies of hospitals and blood centers.

Endodontic treatment enhances the regenerative potential of teeth with advanced periodontal disease with secondary endodontic involvement

PURPOSE: The aim of this study was to identify a role for endodontic intervention in enhancing the regenerative potential of the periodontal ligament when combined with periodontal treatment in seriously involved teeth with a secondary endodontic component. METHODS: Patients who exhibited radiolucency extending to the periapical region, abnormal electric pulp testing values, and deep probing depth derived from primary periodontal disease with secondary endodontic involvement were included. Intentional root canal treatment was applied to those teeth in which the apical lesions were presumed to communicate with those of the periodontal lesion of the teeth that remained vital. In all three selected cases, regenerative periodontal therapy incorporating either bone graft or guided tissue regeneration was instituted 3 months after the endodontic intervention. RESULTS: Remarkable enhancement in radiographic density was noticeable around the affected teeth as evidenced by changes in radiopacity. There was a significant reduction in the probing pocket depth and gain in the clinical attachment level. Chewing discomfort gradually disappeared from the commencement of the combined treatment. CONCLUSIONS: An intentional endodontic intervention may be a worthwhile approach for the sophisticated management of teeth suffering from serious attachment loss and alveolar bone destruction with concomitant secondary endodontic involvement.

Epidemiologic Features of Parainfluenza Virus Type 1, 2 and 3 Infection in Seoul and a Neighboring Area, 2008-2011 / 대한임상미생물학회지

BACKGROUND: Parainfluenza virus (PIV) is a significant cause of acute respiratory infections. Epidemiological information on PIV infection could be very helpful for patient management. The aim of this study was to investigate the epidemiology of PIV infection in Seoul and a neighboring area with regard to PIV type. METHODS: The diagnosis of PIV infection was made by virus isolation. The R-mix Too cell system (Diagnostic Hybrids, Inc., Athens, OH, USA) and D3 Ultra DFA Respiratory Virus Screening & ID kits (Diagnostic Hybrids, Inc.) were used for virus culture and identification. The medical records of patients with positive virus cultures were reviewed retrospectively. RESULTS: Seven hundred and ten PIV viruses (5.6%) were isolated from 12,723 specimens. The number of subjects with PIV type III, I and II was 357, 304 and 49, respectively. PIV infection showed a peak incidence in the first year of life regardless of subtypes. The most common diagnosis among all PIV subtypes was pneumonia. Lower respiratory tract infections constituted the majority (76.3%) of PIV infections. The most common diagnosis of PIV type I and II was croup and that of PIV type III was pneumonia. A difference in seasonal variation between subtypes was observed. PIV I (62.2%) was mainly isolated from July to September while PIV type III (86.8%) was isolated from April to July. CONCLUSION: Lower respiratory infection was most commonly found in hospitalized patients with PIV infection. Clinical features of PIV infection were similar those seen in Western PIV reports, with the exception of the seasonal outbreak pattern.

A Case of Atypical Chronic Myeloid Leukemia with the JAK2V617F Mutation

Atypical chronic myeloid leukemia (aCML) is a rare leukemic disorder that shows myelodysplastic and myeloproliferative features simultaneously. The Janus kinase 2 gene V617F mutation (JAK2V617F) in aCML has been the source of much controversy. Some JAK2V617F positive cases have been reported but others observed no JAK2V617F mutation in aCML as defined by WHO classification. Recently, we experienced a case of aCML with JAK2V617F mutation with typical myelodysplastic/myeloproliferative features in peripheral blood and bone marrow aspirates. The karyotype was normal and no BCR/ABL1, PDGFRA or PDGFRB gene rearrangement was noted with FISH analysis. JAK2V617F mutation of the case was identified with amplification refractory mutation system PCR and direct sequencing. We also studied JAK2V617F mutation status in 3 additional cases of previously diagnosed aCML in our institution, but no mutation was identified.

A Case of Anti-Sda Proven by Urine Neutralization Test

Anti-Sda is of no clinical significance, because it rarely causes hemolytic transfusion reactions. Even when its presence is suspected during antibody screening test, further identification of the antibody is usually not performed. We experienced a case of anti-Sda in 73 yr-old male patient showing mixed field agglutination by microcolumn agglutination. Antibody specificity could not be identified by conventional antibody identification test, and it was proven to be anti-Sda by urine neutralization test. In spite of its little clinical significance, it may give incompatible crossmatching results reacting with Sda antigen, which occurs at a high frequency in general population. When incompatible crossmatch results arising from anti-Sda are suspected, the problem may be solved by using the urine-neutralized serum of in crossmatching test.

Immune Hemolytic Anemia after ABO-mismatched Liver Transplantation: A Case Report / 대한수혈학회지

Limitations due to lack of appropriate available donors for liver transplantation necessitates the use of ABO-mismatched donors. Transplantation of ABO-mismatched solid organs is sometimes associated with the development of immune hemolytic anemia, which is caused by production of antibodies by the donor B lymphocytes in a primary or secondary immune response against the recipient's red blood cell antigens. This condition is referred to as Passenger Lymphocyte Syndrome (PLS). PLS is more frequent in heart and lung transplants than in liver and kidney transplants with incidence of PLS in liver transplantation at 30~40%. When present, PLS typically manifests 1~3 weeks after transplantation, and subsides within 3 months after symptoms are first detected. In most patients, PLS is self-limiting and exhibits mild symptoms, but in some cases PLS can be life-threatening. We report a case of immune hemolytic anemia after an ABO-mismatched liver transplantation involving a blood group O donor and a blood group A recipient, and successful treatment of the resulting PLS symptoms by transfusion of gamma-irradiated group O Red Blood Cells (RBCs) accompanied by administration of 60 mg/day of methylprednisolone for 1 week.

Carbapenem Resistance Mechanisms and Molecular Epidemiology of Acinetobacter spp. from Four Hospitals in Seoul and Gyeonggi Province in 2006 / 대한임상미생물학회지

BACKGROUND: Increasing numbers of Acinetobacter spp. resistant to multiple drugs, including carbapenem, has been a serious problem. The aims of this study were to determine carbapenem resistance patterns and mechanisms, as well as to study the molecular epidemiology of Acinetobacter spp. METHODS: Clinical isolates of Acinetobacter spp. were collected from May to November in 2006. Antimicrobial susceptibility testing was performed using CLSI disk diffusion and agar dilution methods. Metallo-beta-lactamase- and OXA carbapenemase-producing isolates were detected by PCR. Carbapenem resistance and hydrolytic activities were compared according to OXA type and presence of ISAba1. Pulsed-field gel electrophoresis (PFGE) was performed to determine the epidemiologic features. RESULTS: The imipenem non-susceptible rates were variable from 10% to 67%. Among 151 isolates carrying bla(OXA-51-like), 75 isolates carried both bla(OXA-51-like) and ISAba1, and 25 isolates had both bla(OXA-51-like), bla(OXA-23-like), and ISAba1. Carbapenem MICs of both bla(OXA-51-like) and ISAba1-carrying isolates were higher than those with bla(OXA-51-like) only. Carbapenem MICs of bla(OXA-23-like)-carrying isolates were higher than those with both bla(OXA-51-like) and ISAba1. Both bla(OXA-51-like) and ISAba1-carrying isolates and blaOXA-51-like, blaOXA-23-like, and ISAba1-carrying isolates demonstrated higher hydrolysis activities in oxacillin and carbapenems. Most of the tested isolates were susceptible to tigecycline, and all of them were susceptible to colistin. Pulsed-field gel electrophoresis suggested that there had been several outbreaks of bla(OXA-23-like) and bla(OXA-51-like)-positive strains. CONCLUSION: Carbapenem non-susceptible Acinetobacter isolates and OXA carbapenemase-producing isolates were prevalent. Dissemination of bla(OXA)-harboring isolates may make it difficult to treat infections due to carbapenem-resistant Acinetobacter spp. Further surveillance studies are required to prevent the spread of carbapenem resistance.

Evaluation of Automated Architect Syphilis TP as a Diagnostic Laboratory Screening Test for Syphilis / 대한진단검사의학회지

BACKGROUND: The aim of the study was to establish a new syphilis test algorithm using Architect Syphilis TP (Abbott Japan, Japan: AST), a fully automated treponemal antibody test, as a screening test in a university hospital laboratory. We evaluated performance characteristics of AST in various patient groups. METHODS: A total of 1,357 serum samples obtained from patients at a university hospital from June to August, 2008 were categorized into checkup, preoperative, other diseases, diagnosis (clinically suspected of syphilis), and follow up groups. We compared the results of AST with those of RPR (N=1,276) or Treponema pallidum hemagglutination assay (TPHA, N=81). Samples with discrepant results between RPR or TPHA and AST were retested by fluorescent treponemal antibody absorption test (FTA-ABS) and all patients' clinical records were thoroughly reviewed. RESULTS: The positive rate of AST was significantly higher than that of RPR in preoperative and other diseases groups and was the same as that of RPR in diagnosis group. There were no significant differences in check up and follow up groups. The results of AST showed 97.4% (1,243/1,276) and 97.5% (79/81) concordance rates with those of RPR and TPHA, respectively. Among 26 RPR-AST discrepant and FTA-ABS confirmed cases, there were 20 RPR false-negatives, 4 RPR false-positives, 1 AST false-negative, and 1 AST false-positive. CONCLUSIONS: Based on the results and literature review, we established a new syphilis test algorithm using AST as a screening test, which would be helpful for detection of more syphilis patients including latent infections.

Disseminated Histoplasmosis and Tuberculosis in a Patient with HIV Infection

Histoplasmosis is a very rare disease in Korea. Clinical manifestations are very similar to those of tuberculosis. This is the first case report of combined disseminated histoplasmosis and tuberculosis in a patient with HIV infection in Korea. A 42-year-old Korean with Acquired Immunodeficiency Syndrome (AIDS) was diagnosed with tuberculosis. He had lived in Guatemala for the past five years. Upon diagnosis of disseminated tuberculosis with HIV infection, he was treated with anti-tuberculosis medications and anti-retroviral agents. Fever, weakness, hepatosplenomegaly and pancytopenia were persistent despite treatment. The patient's history of living in Guatemala caused us to seek opportunistic infectious organisms other than tuberculosis. Bone marrow aspiration and biopsy were performed and the result revealed numerous intracellular organisms consistent with Histoplasma capsulatum; therefore, the diagnosis of disseminated histoplasmosis was made.

A Case of Peritonitis due to Listeria Monocytogenes Pomplicating on Continuous Ambulatory Peritonial Dialysis Patient / 대한신장학회잡지

Peritonitis in continuous ambulatory peritoneal dialysis is a major cause of technical failure in peritoneal dialysis. The major pathogen is gram positive bacteria, and other main pathogens include gram negative bacteria, mixed infection and fungal infection actively involved in the order named. Coagulate-negative Staphylococcus, Streptococcus, Staphylococcus aureus and Enterococcus cause most of the gram positive bacterial infections, and cases with other pathogens are very rare. We hereby report a case of peritonitis by Listeria Monocytogenes that was not responsive to the usual antibiotics for CAPD-associated peritonitis. A 58-year-old male who has been treated with CAPD for 17 years visited our hospital for abdominal pain, fever and turbid peritoneal fluid. He was diagnosed as diabetes mellitus 20 years ago. White blood cell and neutrophil count increased at the initial peritoneal fluid analysis, so we diagnosed him as CAPD-associated peritonitis. Antibiotic therapy was initiated with intraperitoneal injections of cefazolin/tobramycin, which were soon changed to vancomycin/ceftazidime. However, vancomycin/ceftazidime regimen was also proven ineffective. On the sixth hospital day, L. Monocytogenes was cultured in the peritoneal fluid sampled on the first visiting day. So we accordingly changed the antibiotics for ampicillin/sulbactam, which led to clinical and laboratory improvement. In the cases of CAPD associated peritonitis in immunosuppressive patients such as the elderly, caused either by diabetes or by taking immunosuppressive agent, if they do not respond to the usual antibiotics, we should consider the possible infection by unusual pathogens. Gram positive rod in peritoneal fluid is a supporting evidence of peritonitis by L. monocytogenes.