Large Salmonella Enteritidis outbreak with prolonged transmission attributed to an infected food handler, Texas, 2002.

In March 2002, an outbreak of Salmonella Enteritidis (SE) infections occurred at a convention centre in Dallas, Texas and continued for 6 weeks. We conducted epidemiological studies, obtained clinical and environmental cultures, and interviewed employees to identify risk factors for infection. From 17 March-25 April 2002, the implicated hotel kitchen catered 41 multi-day conferences attended by 9790 persons. We received 617 illness reports from residents of 46 states. Sauces or items served with sauces were implicated in three cohort studies. SE phage-type 8 was identified as the agent. Eleven food service employees, including one who prepared sauces and salsa, had stool cultures that yielded SE. Although the original source was not determined, prolonged transmission resulted in the largest food handler-associated outbreak reported to date, affecting persons from 46 US states. Transmission ended with implementation of policies to screen food handlers and exclude those whose stool cultures yielded salmonellas.

Sporadic paediatric diarrhoeal illness in urban and rural sites in Nyanza Province, Kenya.

OBJECTIVE: Investigate differences in the infectious aetiology, health seeking behaviour, and provider practices with regard to diarrhoeal illness among children presenting to urban versus rural clinics in Western Kenya. DESIGN: Laboratory-based, passive surveillance. SETTING: The urban portion of the study was conducted at the paediatric outpatient clinic of Nyanza Provincial Hospital in Kisumu. The rural portion of the study was conducted at four outpatient clinics in the Asembo Bay community approximately 20 kilometers west of Kisumu. SUBJECTS: Children aged less than five years presenting to medical facilities for the treatment of diarrhoea from October 2001-October 2003 at the urban site and May 1997-April 2003 for the rural sites. RESULTS: Among the 1303 urban and 1247 rural specimens collected, 24% of specimens yielded a bacterial pathogen (24% urban, 25% rural). Campylobacter was the predominant bacterial pathogen (17% urban, 15% rural), followed by Shigella and nontyphoidal Salmonella (both 4% urban and 5% rural). In both communities, susceptibilities of these pathogens to the most commonly prescribed antibiotics was low (< or = 50%); 70% of all episodes of diarrhoea were prescribed antibiotic treatment. Urban health practitioners prescribed fewer antibiotics, chose drugs more likely to be effective, and were more likely to prescribe oral rehydration therapy for bloody diarrhoea. CONCLUSION: Most characteristics of diarrhoeal disease and their causes were similar in paediatric patients presenting to urban and rural clinics. Urban providers were more compliant with WHO recommendations.

Alfalfa sprouts and Salmonella Kottbus infection: a multistate outbreak following inadequate seed disinfection with heat and chlorine.

Raw sprouts have been implicated in a number of foodborne disease outbreaks. Because contaminated seeds are usually responsible, many sprout producers attempt to disinfect seeds before germination and detect sprout contamination during production. In March 2001, we detected an increased number of Salmonella serotype Kottbus isolates in California. Overall, we identified 31 cases from three western states. To identify the cause, we conducted a case-control study with the first 10 identified case-patients matched to 20 controls by age, sex, and residential area. Our case-control study found illness to be statistically associated with alfalfa sprout consumption. The traceback investigation implicated a single sprouter, where environmental studies yielded Salmonella Kottbus from ungerminated seeds and floor drains within the production facility. Pulsed-field gel electrophoresis patterns of all patient, seed, and floor drain Salmonella Kottbus isolates were indistinguishable. Most implicated sprouts were from seeds that underwent heat treatment and soaking with a 2,000-ppm sodium hypochlorite solution rather than the Food and Drug Administration (FDA)-recommended 20,000-ppm calcium hypochlorite soak. Other implicated seeds had been soaked in a calcium hypochlorite solution that, when tested, measured only 11,000 ppm. The outbreak might have been averted when screening tests of sprout irrigation water detected Salmonella in January; however, confirmatory testing of these samples was negative (but testing improperly utilized refrigerated irrigation water). Producers should use the enrichment broth of positive screening samples, not refrigerated irrigation water, for confirmatory testing. Until other effective disinfection technologies are developed, producers should adhere to FDA recommendations for sprout seed disinfection.

Fructose-1,6-diphosphatase deficiency and glyceroluria: one possible etiology for GIS.

Fructose-1,6-diphosphatase (FDPase) deficiency is characterized by episodes of lactic acidemia, hypoglycemia, and ketonuria. Liver biopsy and subsequent enzyme analysis most reliably make the diagnosis. Review of the literature reveals 85 cases. Glycerol intolerance syndrome (GIS) is less well defined. There are only a handful of cases reported. We describe a patient with FDPase deficiency and significant glyceroluria and propose that GIS may be caused by partial deficiency of FDPase.

Paratesticular inflammatory pseudotumor.

A large paratesticular inflammatory pseudotumor (IPT) is presented with the ultrasound, gross, and microscopic findings. A review of paratesticular IPT in the literature is provided with a discussion regarding the etiology and natural history of the lesion.

Adolescent contraceptive counseling and gynecology: a deficiency in pediatric office-based care.

With the large and increasing numbers of sexually active adolescents, pediatricians must learn to deal with the issues of adolescent pregnancy and sexually transmitted diseases (STD). This is particularly true at a time when health care reform will encourage primary care physicians to assume a greater role in general medical management of their patients. One hundred Connecticut general practice pediatricians were randomly selected to examine the frequency, level of comfort, and rationale for involvement regarding sexual history taking, contraceptive counseling, and performance of pelvic examinations. This represents 9% of all Connecticut pediatricians. The response rate was 54%. The results were as follows: Seventy-nine percent of responding pediatricians counseled on STDs, 39% counseled on family planning, and only 62% almost always took a sexual history from the their adolescent patients, ages 10 and up. Thirty-one percent of respondents stated they would refer a male inquiring about contraception to a family planning clinic. Thirty-eight percent never do pelvic examinations on their sexually active adolescent patients. Connecticut pediatricians are providing adolescents with counseling on other high-risk behaviors such as drug and alcohol use, but provide inadequate care related to adolescent sexual activity.

Digital subtraction arthrography of the wrist.

Digital subtraction arthrography of the wrist was used to identify abnormalities in eighty-six (60 per cent) of 139 patients during a fifteen-month period. Multiple abnormalities were noted in thirty-four (25 per cent) of the wrists. The clinical signs and symptoms in the eighty-six wrists did not always correlate with the defects that were seen on the arthrograms. Three of five patients who had an isolated tear of the scapholunate ligament, six of thirteen who had an isolated tear of the lunotriquetral ligament, and seven of nineteen who had an isolated tear of the triangular fibrocartilage complex also had signs and symptoms on the opposite side of the wrist. Many of the lesions that were seen on arthrography may have been serendipitous, degenerative, or unrelated to a specific injury. There was a high prevalence of positive ulnar variance in patients who had at least one ulnar abnormality. Capsular tears, most often seen on the radiovolar aspect of the wrist, were best outlined by contrast medium injected into the radiocarpal joint. The arthroscopic findings differed from the arthrographic findings in five of the twenty patients in whom both studies were done. The three-compartment technique of injection is a valuable diagnostic tool. Injections of contrast medium into the distal radio-ulnar joint outlined five of thirteen tears of the triangular fibrocartilage complex that were not seen after injection into the radiocarpal joint. Of the eleven tears that were seen after injection into the radiocarpal joint, five were not seen when contrast medium was injected into the distal radio-ulnar joint.

Hand and microvascular surgery. Evolution to present practice.

Over the past 25 years, hand and microvascular surgery have emerged and flourished as a super specialty plastic surgery. Successful replantation of a completely amputated extremity on position is now not enough without adequate functional outcome. Free tissue transfer has evolved into a reliable reconstructive option in the treatment of complicated wounds.

Soft tissue coverage for lower-extremity trauma: current practice and techniques. A review.

The development and refinement of the free flap have revolutionized lower limb salvage. Excellent fixation of lower extremity fractures is often marred by the lack of adequate soft tissue coverage. In this article, we discuss the indications for and techniques of soft tissue coverage procedures for the exposed lower extremity fracture.

Second toe transfer for thumb reconstruction in multiple digit amputations including thumb and basal joint.

Amputation of the thumb, including the basal joint, is a disabling injury that leaves limited reconstructive options. Three cases of multiple digit amputation including the thumb and basal joint are presented in which a second toe transfer was used to reconstruct the thumb. All patients have functional pinch with an average pinch strength of 27% of the opposite uninjured extremity. The average grip strength for two patients is 44% of the opposite hand. Average motion of the transfer at the MP, PIP, and DIP is 25 degrees, 37 degrees, and 9 degrees, respectively. Adduction and abduction are obtained, the degree depending on the site of proximal bony fixation. No patient has morbidity at the donor site and all are happy with their reconstruction. In selected cases we feel second toe transfer is an excellent choice to reconstruct the thumb amputated at a proximal level.

Grain auger injuries: the replacement of the corn picker injury?

Corn picker injuries, although more infamous, are less frequent than those produced by the grain auger. The former rarely occurs in other than adult males who are responsible for their carelessness, whereas the grain auger injury frequently involves innocent and uninformed youths. We report 4 arms, 4 forearms, 5 hands, 24 digits, 2 legs, 4 feet, and 4 toes injured by a grain auger in 24 patients. Multiple-level injuries accounted for the larger number of injuries than patients. Twelve amputations or devascularizations were reattached or revascularized successfully. Not all amputations had attempts at reattachment because of the severe crushing of the part and/or stump that was present in all patients to varying degrees. All wounds were heavily contaminated and were treated with voluminous irrigation and adequate debridement. Serial debridements were needed prior to coverage in several patients. Prevention is the best treatment, but given early aggressive care, many injured can regain a high level of function.

Anatomy and physiology of the perionychium: a review of the literature and anatomic study.

The perionychium includes the nail and surrounding structures. The anatomy and physiology of the perionychium is presented in detail. Microscopic examination reveals the nail production to take place on the dorsal roof of the nail fold, the ventral floor of the nail fold, and on the nailbed to the free margin of the nail. The arterial supply is by two dorsal terminal branches of the proper digital artery and the nerve innervation by dorsal terminal branches of the proper digital nerve.

De novo cutaneous neoplasm: biologic behavior in an immunosuppressed patient.

The treatment of cutaneous squamous cell carcinoma in patients who are immunosuppressed should include early and adequate excision and extremely close follow-up. If the patients' tumor is aggressive, treatment should be aggressive even with discontinuation of the immunosuppression, which may lead to the death of the allograft. Sacrifice of the allograft in such an instance will lead to survival of the patient. In our patient, the continuous survival of the allograft with good renal function, in spite of the discontinuation of the immunosuppressive agents, can be interpreted only on the basis of graft adaptation.