Attachment and Survival of Salmonella enterica and Listeria monocytogenes on Tomatoes (Solanum lycopersicum) as Affected by Relative Humidity, Temperature, and Storage Time.

ABSTRACT: Tomatoes (Solanum lycopersicum) are one of the most commonly consumed fruits worldwide. The fruit can become contaminated with Salmonella and Listeria monocytogenes at various stages of the production and supply chain, and these pathogens may survive under various storage conditions. The effects of relative humidity, temperature, and duration of storage on the attachment and survival of both pathogens on the surface of tomatoes were investigated. Fresh whole Roma tomatoes were inoculated with a cocktail of Salmonella or L. monocytogenes strains and stored at 5, 12, 25, 30, or 35°C for up to 10 days. Every day during storage, relative humidity and temperature were measured and tomatoes were removed to enumerate pathogens cells that were loosely attached (LA; cells were detached from the tomato surface by rinsing) and strongly attached (SA; sonication was required to detach cells from the tomato surface). The attachment strength (SR) was calculated to express the proportion of surviving SA cells on the tomato surface. The initial levels of Salmonella and L. monocytogenes on the tomato surface after inoculation were 6.6 and 6.5 log CFU per tomato for LA cells and 5.1 and 5.6 log CFU per tomato for SA cells, respectively. For both pathogens, the LA levels were higher (P < 0.05) than the SA levels. The LA and SA levels differed significantly as a function of temperature, relative humidity, and duration of storage. The SR for Salmonella was affected by storage time but not temperature, whereas the SR for L. monocytogenes was affected by storage time and temperature and relative humidity (P < 0.05). An understanding of the attachment and survival of Salmonella and L. monocytogenes on tomatoes stored under various temperature conditions may be useful for preventing or reducing the establishment of pathogens and for designing improved decontamination methods.

Simultaneous and individual quantitative estimation of Salmonella, Shigella and Listeria monocytogenes on inoculated Roma tomatoes (Lycopersicon esculentum var. Pyriforme) and Serrano peppers (Capsicum annuum) using an MPN technique.

Simultaneous and individual enumeration of Salmonella, Shigella and Listeria monocytogenes was compared on inoculated Roma tomatoes and Serrano peppers using an Most Probable Number (MPN) technique. Samples consisting of tomatoes (4 units) or peppers (8 units) were individually inoculated with a cocktail of three strains of Salmonella, Shigella or L. monocytogenes, or by simultaneous inoculation of three strains of each pathogen, at low (1.2-1.7 log CFU/sample) and high (2.2-2.7 log CFU/sample) inocula. Samples were analyzed by an MPN technique using universal pre-enrichment (UP) broth at 35 °C for 24 ±â€¯2 h. The UP tubes from each MPN series were transferred to enrichment and plating media following adequate conventional methods for isolating each pathogen. Data were analyzed using multifactorial analysis of variance (p < 0.05) and LSD multiple rang test. There were differences (p < 0.05) in recovery of simultaneous and individual bacteria inoculated (individual > simultaneous), type of bacteria (Salmonella > Shigella and L. monocytogenes), type of sample (UP broth > pepper and tomato), and inoculum level (high > low). The MPN technique was effective for Salmonella on both commodities. Shigella counts were higher on tomatoes compared to peppers, (p < 0.05), and for L. monocytogenes on peppers (p < 0.05).

Prenatal Maternal Depressive Symptoms Predict Early Infant Health Concerns.

INTRODUCTION: Recent research suggests that health disparities among low-SES and ethnic minority populations may originate from prenatal and early life exposures. Postpartum maternal depressive symptoms have been linked to poorer infant physical health, yet prenatal depressive symptoms not been thoroughly examined in relation to infant health. METHODS: In a prospective study of low-income Mexican American mothers and their infants, women (N = 322, median age 27.23, IQR = 22.01-32.54) completed surveys during pregnancy (median gestation 39.50, IQR = 38.71-40.14 weeks) and 12 weeks after birth. We investigated (1) if prenatal depressive symptoms predicted infant physical health concerns at 12 weeks of age, (2) whether these associations occurred above and beyond concurrent depressive symptoms, and (3) if birth weight, gestational age, and breastfeeding were mediators of prenatal depression predicting subsequent infant health. RESULTS: Higher prenatal depressive symptoms were associated with more infant physical health concerns at 12 weeks (p < .001), after accounting for 12-week maternal depressive symptoms, breastfeeding, gestational age, and birth weight. Twelve-week maternal depressive symptoms were concurrently associated with more infant health concerns (p < .01). Birth weight, gestational age, and breastfeeding were not associated with maternal depression or infant health concerns. DISCUSSION: Results establish a link between prenatal depressive symptoms and an elevated risk of poor health evident shortly after birth. These findings underscore the importance of the prenatal period as a possible sensitive period for infants' health, and the need for effective interventions for depression during pregnancy to mitigate potentially teratogenic effects on the developing fetus and reduce risks for later health concerns.

Multiple domains of stress predict postpartum depressive symptoms in low-income Mexican American women: the moderating effect of social support.

Prenatal stress can have a lasting effect on women's mental health after childbirth. The negative effects may be particularly salient in women from low income and ethnic minority backgrounds, who are at increased risk for postpartum depression. However, social support may have the potential to attenuate the negative impact of stress. The present study evaluated 269 Mexican American women (ages 18-42; 83 % Spanish-speaking; median income $10,000-$15,000) for prenatal stress (daily hassles, family stress, partner stress, and culture-specific stress) in relation to depressive symptoms 6 weeks postpartum. Prenatal social support was examined as a buffer against the impact of prenatal stress. Partner stress, family stress, and daily hassles uniquely predicted depressive symptoms. Moderate and high levels of social support attenuated risk for depression due to family stressors. Prenatal interpersonal and daily stressors negatively impact the mental health of women after birth, but social support can mitigate some of these effects. Among Mexican American pregnant women, effective interpersonal support and stress management may be associated with reduced risk for postpartum depression.

Use of a novel medium, the Polymyxin Ceftazidime Oxford Medium, for isolation of Listeria monocytogenes from raw or non-pasteurized foods.

Polymyxin Ceftazidime Oxford Medium (PCOM), a novel selective and differential plating medium for Listeria monocytogenes was compared with Modified Oxford Agar (MOX) for efficacy to isolate L. monocytogenes and other Listeria spp. naturally present in non-pasteurized Mexican-style cheese (n = 50), non-pasteurized fresh squeezed orange juice (n = 50), raw beef chunks (n = 36), and fresh cabbage (n = 125). Samples were collected from retail markets and farms in Mexico and tested following the US Department of Agriculture enrichment technique. Listeria spp. were isolated from 23.4% of analyzed samples, and from those, 75.0% corresponded to raw beef chunks, 38.0% to non-pasteurized Mexican-style cheese, and 30.0% to fresh squeezed orange juice. No Listeria spp. were isolated from fresh cabbage samples. L. monocytogenes was recovered from 15.3% of food samples analyzed. Non-pasteurized Mexican-style cheese showed the highest proportion of L. monocytogenes positive samples (36.0%), followed by orange juice (26.0%) and raw beef (25.0%). The frequency of isolation of Listeria spp. and L. monocytogenes was not different (P > 0.05) between PCOM and MOX. The advantages of using PCOM when comparing to MOX, include the easier way to identify Listeria species, the lower cost per plate and the availability of its ingredients for Latin-American countries.

THE COMBINED USE OF HONEY, GARLIC (ALLIUM SATIVUM L.) AND SKIMMED MILK AS AN EXTENDER FOR CHILLING SHEEP SEMEN.

BACKGROUND: Sugars are the energetic source for sperm to maintain the metabolic process, and the antibiotics slow down sperm degradation. OBJECTIVE: To study the effects of rosemary honey as energy source and cryoprotectant in combination with garlic as a natural antibiotic on the quality of ram spermatozoa upon cooling. MATERIALS AND METHODS: The ejaculates from three rams were evaluated at different times during cooling to determine its post-dilution quality. RESULTS: Glycerol and dimethylformamide in conjunction with honey and garlic significantly improve the survival of spermatozoa. CONCLUSION: The addition of honey and garlic reduces sperm deterioration when stored at 4 degree C.

Quantitative distribution of Salmonella spp. and Escherichia coli on beef carcasses and raw beef at retail establishments.

Salmonella is a foodborne pathogen that commonly inhabits the gastrointestinal tract of a healthy feedlot cattle and can be transferred to the carcass surface during hide removal and evisceration procedures. Numerous investigations on Salmonella prevalence throughout different stages of the beef chain have been conducted. In contrast, limited studies are available on quantitative determinations of Salmonella at different steps in raw meat production. Quantitative data, particularly for pathogenic bacteria such as Salmonella are important for quantitative risk assessment. Salmonella spp. and Escherichia coli populations were enumerated on beef carcass samples collected at abattoirs and also in beef chunks and ground beef samples collected from butcher's shops at retail in Jalisco State, Mexico. Sponge samples from beef carcass sides (n=142) were collected immediately after final water wash and before chilling at three non-federally inspected abattoirs following USDA-FSIS sampling protocols. Beef chunks (n=84) and ground beef (n=65) samples were obtained from 86 butcher's shops. Salmonella enumeration was conducted by the Most Probable Number method and E. coli counts were determined using Petrifilm plates. Salmonella was isolated from 18% of beef carcasses, 39% of beef chunks and 71% of ground beef samples. Salmonella mean counts were 1.3±0.9 Log MPN/300 cm(2) on beef carcasses, 1.9±0.9 and 2.3±1.1 Log MPN/25 g in beef chunks and ground beef samples, respectively. Twenty-six Salmonella serotypes and 11 serogroups were identified among 432 isolates recovered. Salmonella typhimurium (14%), Salmonella sinstorf (12%) and S. Group E1 monophasic (10%) were the most frequent. Escherichia coli was present on 97, 84 and 100% of beef carcasses, beef chunks and ground beef samples, respectively. Escherichia coli mean counts were 3.2±0.7 Log CFU/300 cm(2), 3.9±1.1 and 4.5±1.2 Log CFU/25 g on beef carcasses, beef chunks and ground beef, respectively. Salmonella prevalence and mean counts found in raw beef were higher than previously reported in studies from other countries. The data collected in this study show a trend in the prevalence of Salmonella to be higher as meat processing is extended at retail. This, together with the diversity of serotypes found, indicates that raw meat is exposed to multiple contamination sources during slaughter and retail processing and highlights the necessity to implement Sanitation Standard Operating Procedures for those establishments. Finally, this study provides quantitative information for future risk assessments associated with the risk of human salmonellosis.

The Polymyxin Ceftazidime Oxford Medium as an alternative selective and differential medium for isolation of Listeria monocytogenes from raw or unpasteurized food.

The Polymyxin Ceftazidime Oxford Medium (PCOM) was developed to recover Listeria monocytogenes from raw or unpasteurized foods. It contains esculin-ferric ammonium citrate as indicator system for Listeria growth, and ceftazidime and polymyxin B as selective agents, which are available in several Latin American countries. Comparison of PCOM, Modified Oxford Medium (MOX) and Tryptic Soy agar with 0.6% yeast extract (TSAYE) indicated that both selective media were equally effective at recovering four individual strains of L. monocytogenes (Scott A, V7, California and broccoli), and a mixture of these strains (LMM) (P > 0.05). The ability of PCOM, MOX, TSAYE and TSAYE supplemented with 4% NaCl to recover heat, acid and freeze-damaged LMM was similar for all media (P > 0.05). The PCOM proved to be effective at isolating colonies of LMM from inoculated raw beef chunks, unpasteurized orange juice, cabbage, and Mexican-style cheese by direct plating and by the US Department of Agriculture's Food Safety and Inspection Service enrichment method. Differentiation of L. monocytogenes colonies was easier on PCOM than on MOX for foods with high levels of background microbiota. Based on the evaluations performed on foods naturally contaminated with L. monocytogenes, PCOM was a more economical alternative than MOX for selective and differential isolation of Listeria from raw or unpasteurized foods.

Oral health assessment in the San Blas and Santa Ana populations of Nicaragua.

AIM: The aim of this study was to assess the oral health of a population in rural Nicaragua. METHODS: A total of 241 individuals were recruited from areas around San Blas and Santa Ana, Nicaragua. A demographic questionnaire assessing income, access to oral health care, means of transportation and presence of dental/health insurance was collected for each patient. Oral screenings were also conducted to assess for evidence of untreated decayed teeth, restorations, missing/extracted teeth and presence/absence of periodontal disease. RESULTS: The majority of residents in San Blas and Santa Ana, Nicaragua, have little income if any, no medical or dental insurance of any kind and no means of transportation. There was a very high prevalence of untreated decayed teeth among the population studied where 51.1% of our sample had three or more dental caries. Children aged fewer than 20 years had five times the prevalence of dental decay than those in the United States. No statistically significant difference was found in untreated decayed teeth by age or gender. A smaller percentage (25.2%) of all patients had restorations with a statistically significant difference found between genders (P < 0.0001). There was also a relationship between gender and number of missing/extracted teeth (P < 0.001). There was no significant difference in amount of untreated decayed teeth among those who reported having been seen by a dentist within the previous one-to-three, greater than 3 years or never at all. CONCLUSION: Among a population of individuals from San Blas and Santa Ana, Nicaragua, there are major socio-economic barriers present, and a significant burden of oral pathology is evident.

Effect of pasteurized egg and Rosmarinus officinalis supplementation on quality of cryopreserved ram semen.

The aim was to assess the in vitro effect of pasteurized egg (PE) and rosemary (Rosmarinus officinalis) on frozen-thawed ram semen. Ejaculates from three mature rams of the Rasa Aragonesa breed were cryopreserved using a 2-step dilution method (Fraction 1: F1; Fraction 2: F2). In Experiment 1, semen was frozen in egg yolk (EY) or PE extenders. After thawing, similar results were obtained in terms of total and progressive motility, viability, hypo-osmotic swelling test (HOST) and acrosome integrity after 2 h incubation. In Experiment 2, addition of rosemary to F1, F2 or both fractions to EY extenders was evaluated. Rosemary in F1 decreased progressive motility (p = 0.013) after 2 h incubation. Finally, PE can be used as a substitute for EY to reduce hygienic risks in extenders and is easier to standardize. Supplementation of EY extender with rosemary in F1 reduced progressive motility. Rosemary supplementation in F2 does not affect semen quality.

Effect of the use of a neutralizing step after antimicrobial application on microbial counts during challenge studies for orange disinfection.

The effects of using a neutralizer after applying antimicrobial treatments and the effect of time lapse between treatment application and subsequent recovery and enumeration of Escherichia coli O157:H7 and Salmonella were investigated in Valencia oranges. Inoculated oranges surfaces were washed with distilled water for 15 s and then sprayed with a solution containing 200 mg/liter sodium hypochlorite (pH 6.5) for 15 s; they were then dipped in L-lactic acid (2.0% at 55°C) for 1 min or in distilled water at 80°C for 1 min. Posttreatment, oranges were divided into two groups. In the first group, oranges were dipped in neutralization treatment: 270 ml of buffered peptone water for 2 min for lactic acid-treated oranges, 270 ml of Dey-Engley broth for 2 min for chlorine-treated oranges, or 3.7 liters of tap water (25°C) for 10 s for hot water-treated oranges. The second group of treated oranges was not subjected to any neutralizer. All oranges then were kept at room temperature (average 26.2°C) and sampled at 0, 7.5, and 15 min for enumeration of surviving Salmonella and E. coli O157:H7. The orange surface (30 cm(2)) was excised for pathogen enumeration. The presence of free chlorine and changes in pH and temperature on the orange surface were determined in uninoculated, treated oranges. Free chlorine was detected on oranges after treatment; the change in temperature of orange surfaces was greater during treatment with hot water than with lactic acid. Nevertheless, pathogen enumeration did not show any impact of neutralizer use on the residual activity of antimicrobials or any impact of the time elapsed between antimicrobial treatment and recovery of bacterial pathogens from inoculated oranges (P ≥ 0.05). The results of this study indicate that the lack of a neutralizing step before enumeration of pathogens is not likely to affect the accuracy of results during challenge studies to test pathogen reduction strategies on oranges.

Comparison of different washing treatments for reducing pathogens on orange surfaces and for preventing the transfer of bacterial pathogens to fresh-squeezed orange juice.

The objectives of this study were to compare the effectiveness of various washing treatments for reducing Escherichia coli O157:H7, Salmonella sp., and Listeria monocytogenes populations on orange surfaces and to measure the effect of some of these treatments in preventing the transfer of pathogens during juice extraction. Orange surfaces inoculated with L. monocytogenes or a mixture of E. coli O157:H7 and Salmonella Typhimurium were washed by water spray and then sprayed with or dipped in water at 80°C for 1 min, 70% ethanol for 15, 30, or 45 s or 1, 2, or 4 min, 2 or 4% lactic acid solution at 55°C for 15, 30, or 45 s or 1, 2, or 4 min, or 200 mg/liter hypochlorite at pH 6.5 or 10 for 15 s. The surviving populations of these pathogens on the oranges were enumerated after each treatment. In a further stage, the ability of these pathogens to be transferred to the juice during extraction was tested. Juice was obtained from inoculated oranges that were subjected to selected treatments using chlorine, lactic acid, ethanol, and hot water as described above, and then bacterial counts in orange juice were determined. The application of these treatments reduced the populations of pathogens on orange surfaces by 1.9 to >4.9 log, 1.9 to >4.6 log, and 1.4 to 3.1 log cycles for E. coli O157:H7, Salmonella Typhimurium, and L. monocytogenes, respectively. The treatments using hot water or lactic acid showed greater reductions than other treatments. The time, antimicrobial concentration, and form of application affected the bacterial reduction. All treatments resulted in undetectable counts in the juice. Nevertheless, pathogens were recovered by the enrichment-plating method. Treatment of oranges before juice extraction may reduce the risk associated with consuming orange juice.

Safety of high doses of urokinase and reteplase for acute ischemic stroke.

BACKGROUND AND PURPOSE: ET is considered in selected patients with AIS with persistent arterial occlusion after receiving IVT. Limited data exist on the safety of IA high doses of UK and RT for ET. We investigated any correlation between IA doses of UK or RT and safety outcomes in patients who underwent ET. MATERIALS AND METHODS: We identified all patients from our stroke registry who received UK or RT for ET from 1998 to 2008. Demographics, baseline National Institutes of Health Stroke Scale scores, recanalization rates, rates of attempted MT, mortality, SICH, and discharge modified Rankin Scale scores were collected. RESULTS: Of 197 patients; 72 received UK and 125 received RT. More than 90% of patients in both groups had received prior IVT. The median IA dose of UK was 200,000 U (range, 25,000-1,500,000 U) and of RT was 2 mg (range, 1-8 mg). Concurrent MT was attempted in 59.7% of UK-treated patients and 72.0% of RT-treated patients, with SICH rates of 4.2% and 8.0%, respectively. Logistic regression adjusting for prior IVT and MT revealed no correlation between SICH and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .94) or RT (OR, 0.803; 95% CI, 0.48-1.33; P = .39). There was no correlation between mortality and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .51) or RT (OR, 1.048; 95% CI, 0.77-1.42; P = .75). CONCLUSIONS: High IA doses of UK and RT may be safe when given with or without MT in patients with AIS despite receiving a full dose of intravenous recombinant tissue plasminogen activator. These results need prospective validation.

Validation of a washing and sanitizing procedure for cantaloupes at a mexican packing facility.

In-plant validation of an alternative washing and sanitizing method was conducted at a cantaloupe packing operation in Mexico. This method consisted of a spray water wash followed by spraying warm (55 to 60 degrees C) 2% (L)-lactic acid solution and was compared with the existing method of spray washing the melons with tap water followed by immersion in a chlorinated water tank. Surface samples (100 cm(2)) were collected from 160 melons subjected to each processing method and tested for counts of aerobic bacteria, coliforms, and Escherichia coli. The aerobic plate counts from cantaloupes washed in the dump tank ranged from 3.6 to 5.2 log CFU/cm(2) and were significantly higher (P < 0.05) than those from melons treated with the alternative spray method, which ranged from 1.8 to 2.6 log CFU/cm(2). Coliform counts for cantaloupes treated in the dump tank were 0.2 to 2.2 log CFU/cm(2) and were below the detection level (-6.0 log CFU/cm(2)) on cantaloupes treated by the spray method. Growth of E. coli was observed in 2.5% of the samples of cantaloupes treated in the dump tank and in none of the samples of cantaloupes treated by lactic acid spray (P < 0.05). These results support the elimination of dump tanks in cantaloupe packing operations established by the Mexican government for certification of firms exporting cantaloupes to the United States. When a sanitizer is to be applied to the product, lactic acid seems to be a viable option, at least for products such as cantaloupes whose quality is not affected by an acid wash.

The New Beginnings Program for Divorcing and Separating Families: Moving from Efficacy to Effectiveness.

This article describes a program of research on effectively transporting the New Beginnings Program (NBP), a university-tested prevention program for divorced families, to community settings. The status of four steps in this research are described: (1) Selecting a community partner; (2) Developing effective methods of engaging parents; (3) Redesigning the NBP to be easily delivered with high quality and fidelity in community agencies, and (4) Adapting the NBP to meet the needs of the full population of divorcing families. The article concludes with a discussion of plans for an effectiveness trial to evaluate the NBP when delivered in community settings.

Outcomes of the first 2 American hand transplants at 8 and 6 years posttransplant.

PURPOSE: The feasibility of hand allotransplantation has been demonstrated. The purpose of the article is to report the (1) functional return, (2) psychosocial outcomes, (3) clinical and histological assessment for rejection, (4) complications, and (5) graft survival in the 2 American hand transplant recipients. METHODS: We present 2 patients 106 and 81 months, respectively, after unilateral transplantation of an allogeneic hand and forearm. We analyzed clinical course, number of rejection episodes, adverse events, function of the allograft, and quality of life. Clinical laboratory results, biopsy histology, and patient clinical examinations were used to compare the clinical course. Standard hand function tests were used to evaluate function. Psychological interviews were used to assess acceptance and quality of life. RESULTS: Our patients have allograft survival with improvements in intrinsic muscle activity, total active motion and return of functional grip, pinch strength, and sensibility. Rejection episodes were restricted primarily to the first 6 months after transplantation, and all responded to treatment. The major posttransplantation complications were a cytomegalovirus infection in patient 1 and osteonecrosis of the hip requiring both hips to be replaced, 1 at year 4 and the other at year 6, as well as transient immunosuppression-related diabetes in patient 2. Recently we have weaned both patients off maintenance steroids. Current Carroll scores are fair for patient 1 (72/99) and fair for patient 2 (55/99), although patient 2 has not had good recovery of intrinsic function. Both patients are back at work and report an excellent quality of life at nearly 9 and 7 years, respectively, after transplantation. CONCLUSIONS: Our intermediate long-term results of hand transplants have demonstrated functional return similar to that of replants. Graft survival and quality of life after hand transplantation has far exceeded initial expectations. We conclude that allogeneic hand transplant is feasible and holds promise as a treatment modality for catastrophic upper extremity loss. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Intraventricular hemorrhage: Anatomic relationships and clinical implications.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is frequently associated with intraventricular hemorrhage (IVH), which is an independent predictor of poor outcome. The purpose of this study was to examine the relationship between ICH volume and anatomic location to IVH, and to determine if ICH decompression into the ventricle is truly beneficial. METHODS: We retrospectively analyzed the CT scans and charts of all patients with ICH admitted to our stroke center over a 3-year period. Outcome data were collected using our prospective stroke registry. RESULTS: We identified 406 patients with ICH. A total of 45% had IVH. Thalamic and caudate locations had the highest IVH frequency (69% and 100%). ICH volume and ICH location were predictors of IVH (p < 0.001). Within each location, decompression ranges (specific volume ranges where ventricular rupture tends to occur) were established. Patients with IVH were twice as likely to have a poor outcome (discharge modified Rankin scale of 4 to 6) (OR 2.25, p = 0.001) when compared to patients without IVH. Caudate location was associated with a good outcome despite 100% incidence of IVH. Spontaneous ventricular decompression was not associated with better outcome, regardless of parenchymal volume reduction (p = 0.72). CONCLUSIONS: Intraventricular hemorrhage (IVH) occurs in nearly half of patients with spontaneous intracerebral hemorrhage (ICH) and is related to ICH volume and location. IVH is likely to occur within the "decompression ranges" that take into account both ICH location and volume. Further, spontaneous ventricular decompression does not translate to better clinical outcome. This information may prove useful for future ICH trials, and to the clinician communicating with patients and families.

Early care limitations independently predict mortality after intracerebral hemorrhage.

OBJECTIVE: Intracerebral hemorrhage (ICH) is associated with a high early mortality rate. We examined the impact of early do not resuscitate (DNR) orders and other limitations in aggressive care on mortality after ICH in a community-based study. METHODS: Cases of spontaneous ICH from 2000 to 2003 were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project, with deaths ascertained through 2005. Charts were reviewed for early (<24 hours from presentation) DNR orders, withdrawal of care, or deferral of other life sustaining interventions, analyzed together as combined DNR (C-DNR). Multivariable Cox-proportional hazards models were used to examine the association between short- and long-term all-cause mortality and early C-DNR, adjusted for demographics and established predictors of mortality after ICH. RESULTS: Of 18,393 subjects screened for cerebrovascular disease, 270 non-traumatic ICH cases were included. Cumulative mortality risk was 0.43 at 30 days and 0.55 over the study course. Early C-DNR was noted in 34% of cases and was associated with a doubling in the hazard of death both at 30 days (hazard ratio [HR] 2.17, 95% CI 1.38, 3.41) and at end of follow-up (HR 1.92, 95% CI 1.29, 2.87) despite adjustment for age, gender, ethnicity, Glasgow Coma Scale, ICH volume, intraventricular hemorrhage, and infratentorial hemorrhage. CONCLUSIONS: Early care limitations are independently associated with both short- and long-term all-cause mortality after intracerebral hemorrhage (ICH) despite adjustment for expected predictors of ICH mortality. Physicians should carefully consider the effect of early limitations in aggressive care to avoid limiting care for patients who may survive their acute illness.

Comparison of rinsing and sanitizing procedures for reducing bacterial pathogens on fresh cantaloupes and bell peppers.

Increased consumption of fruits and vegetables is linked to health benefits but also to an increase in the number of outbreaks of foodborne illness. To determine the effectiveness of different sanitizing treatments for reducing bacterial pathogens on fresh produce, fresh cantaloupes and bell peppers were harvested and inoculated with suspensions of Salmonella Typhimurium and Escherichia coli O157:H7. The inoculated fruits were treated with water wash alone or were washed and then waxed or rinsed with 200 mg/liter hypochlorite, 10% Ca(OH)2, or 2% lactic acid solutions applied by dipping for 15 s or spraying for 15 s. Preliminary experiments with chlorine treatments indicated that spraying with a 200, 600, or 1,000 mg/liter hypochlorite solution reduced populations of both pathogens by 2.1 to 2.6 and 1.5 to 2.1 log CFU for Salmonella Typhimurium and E. coli O157:H7, respectively. In general, no differences were observed between chlorine solutions without pH adjustment (pH 9.2) and those with pH adjusted to 6.0. When different wash regimes were applied to inoculated cantaloupes or bell peppers, water wash alone produced significantly lower counts of both pathogens on bell peppers in comparison to untreated controls. However, this reduction was not observed on cantaloupes, indicating a possible surface effect. Application of 2% L-lactic acid by spray was the treatment that resulted in the lowest bacterial counts on both cantaloupes and bell peppers. This treatment did not produce any deleterious change in the sensorial characteristics of the products tested. None of the pathogens studied was able to grow during refrigerated storage (5 degrees C for cantaloupes and 10 degrees C for bell peppers), although numbers close to the detection limit of the counting method were found in randomly tested individual samples at days 14 and 28 of storage, indicating that these pathogens can survive for long periods on the produce surface. These results indicate that selected produce commodities could be sanitized at the packing facility. However, these interventions should not be applied as a replacement for but only as a complement to good hygiene practices.