Utilization of Computer-Aided Detection for Digital Screening Mammography in the United States, 2008 to 2016.

PURPOSE: Computer-aided detection (CAD) for screening mammography is a software technology designed to improve radiologists' reading performance. Since 2007, multiple Breast Cancer Surveillance Consortium research papers have shown that CAD decreases performance by increasing recalls and decreasing the detection of invasive cancer while increasing the detection of ductal carcinoma in situ. The aim of this study was to test the hypothesis that CAD use by digital mammography facilities would decrease over time. METHODS: In August 2007, August 2011, and March 2016, the FDA database of certified mammography facilities was accessed, and a random sample of 400 of approximately 8,500 total facilities was generated. In 2008 and 2011, a telephone survey was conducted of the facilities regarding digital mammography and CAD use. In 2016, facility websites were reviewed before calling the facilities. Bonferroni-corrected P values were used to assess statistical differences in the proportion of CAD at digital facilities for the three surveys. RESULTS: The mean proportion of digital facilities using CAD was 91.4%, including 91.4% (128 of 140) in 2008, 90.2% (238 of 264) in 2011, and 92.3% (358 of 388) in 2016. The difference for 2008 versus 2011 was 1.3% (95% confidence interval [CI], -0.5% to 7.7%), for 2011 versus 2016 was -2.1% (95% CI, -6.9% to 2.7%), and for 2008 versus 2016 was -0.8% (95% CI, -6.7% to 5.0%). CONCLUSIONS: In three national surveys, it was found that CAD use at US digital screening mammography facilities was stable from 2008 to 2016. This persistent utilization is relevant to the debate on the value of targeting ductal carcinoma in situ in screening.

Reduced lentivirus susceptibility in sheep with TMEM154 mutations.

Visna/Maedi, or ovine progressive pneumonia (OPP) as it is known in the United States, is an incurable slow-acting disease of sheep caused by persistent lentivirus infection. This disease affects multiple tissues, including those of the respiratory and central nervous systems. Our aim was to identify ovine genetic risk factors for lentivirus infection. Sixty-nine matched pairs of infected cases and uninfected controls were identified among 736 naturally exposed sheep older than five years of age. These pairs were used in a genome-wide association study with 50,614 markers. A single SNP was identified in the ovine transmembrane protein (TMEM154) that exceeded genome-wide significance (unadjusted p-value 3×10(-9)). Sanger sequencing of the ovine TMEM154 coding region identified six missense and two frameshift deletion mutations in the predicted signal peptide and extracellular domain. Two TMEM154 haplotypes encoding glutamate (E) at position 35 were associated with infection while a third haplotype with lysine (K) at position 35 was not. Haplotypes encoding full-length E35 isoforms were analyzed together as genetic risk factors in a multi-breed, matched case-control design, with 61 pairs of 4-year-old ewes. The odds of infection for ewes with one copy of a full-length TMEM154 E35 allele were 28 times greater than the odds for those without (p-value<0.0001, 95% CI 5-1,100). In a combined analysis of nine cohorts with 2,705 sheep from Nebraska, Idaho, and Iowa, the relative risk of infection was 2.85 times greater for sheep with a full-length TMEM154 E35 allele (p-value<0.0001, 95% CI 2.36-3.43). Although rare, some sheep were homozygous for TMEM154 deletion mutations and remained uninfected despite a lifetime of significant exposure. Together, these findings indicate that TMEM154 may play a central role in ovine lentivirus infection and removing sheep with the most susceptible genotypes may help eradicate OPP and protect flocks from reinfection.

Phylogeny of Shiga toxin-producing Escherichia coli O157 isolated from cattle and clinically ill humans.

Cattle are a major reservoir for Shiga toxin-producing Escherichia coli O157 (STEC O157) and harbor multiple genetic subtypes that do not all associate with human disease. STEC O157 evolved from an E. coli O55:H7 progenitor; however, a lack of genome sequence has hindered investigations on the divergence of human- and/or cattle-associated subtypes. Our goals were to 1) identify nucleotide polymorphisms for STEC O157 genetic subtype detection, 2) determine the phylogeny of STEC O157 genetic subtypes using polymorphism-derived genotypes and a phage insertion typing system, and 3) compare polymorphism-derived genotypes identified in this study with pulsed field gel electrophoresis (PFGE), the current gold standard for evaluating STEC O157 diversity. Using 762 nucleotide polymorphisms that were originally identified through whole-genome sequencing of 189 STEC O157 human- and cattle-isolated strains, we genotyped a collection of 426 STEC O157 strains. Concatenated polymorphism alleles defined 175 genotypes that were tagged by a minimal set of 138 polymorphisms. Eight major lineages of STEC O157 were identified, of which cattle are a reservoir for seven. Two lineages regularly harbored by cattle accounted for the majority of human disease in this study, whereas another was rarely represented in humans and may have evolved toward reduced human virulence. Notably, cattle are not a known reservoir for E. coli O55:H7 or STEC O157:H(-) (the first lineage to diverge within the STEC O157 serogroup), which both cause human disease. This result calls into question how cattle may have originally acquired STEC O157. The polymorphism-derived genotypes identified in this study did not surpass PFGE diversity assessed by BlnI and XbaI digestions in a subset of 93 strains. However, our results show that they are highly effective in assessing the evolutionary relatedness of epidemiologically unrelated STEC O157 genetic subtypes, including those associated with the cattle reservoir and human disease.

Repeated testing by use of culture and PCR assay to detect Tritrichomonas foetus carrier bulls in an infected Nebraska herd.

OBJECTIVE: To compare methods for identification of bulls that were carriers for Tritrichomonas foetus during an outbreak on a large beef ranch and determine whether the percentage of nonpregnant cows was associated with the percentage of bulls infected with T foetus. DESIGN: Epidemiological study. ANIMALS: 121 Angus and Hereford bulls (1.5 to 6 years old) and 2,960 Angus-cross cows (2.5 to 14 years old) managed as 5 herds on a Nebraska beef ranch. PROCEDURES: 3 sequential preputial scrapings collected from the bulls at 12- to 27-day intervals were cultured, and cultures were examined for live T foetus daily for 5 days. On day 5, aliquots of the culture fluid were tested by means of T foetus-specific gel and real-time PCR assays. Cows were tested for pregnancy by means of rectal palpation. RESULTS: For 361 preputial scrapings obtained from 121 bulls, results of culture and gel PCR assay were in close agreement. The real-time PCR assay had similar sensitivity to culture and the gel PCR assay but generated more false-positive results. Twenty-four of the 121 (19.8%) bulls were identified as infected with T foetus. For the 5 ranch herds, there was a positive linear correlation between percentage of infected bulls (range, 0% to 40%) and percentage of nonpregnant cows (range, 8.3% to 19.2%). CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that a combination of culture and the gel PCR assay performed on 3 sequential preputial scrapings was the best method for identifying bulls that were carriers for T foetus during this herd outbreak.

Distribution of Shiga-toxigenic Escherichia coli O157 in the gastrointestinal tract of naturally O157-shedding cattle at necropsy.

Shiga-toxigenic Escherichia coli (STEC) O157 occurrence was determined along the entire gastrointestinal tract (GIT) of each of four naturally shedding cattle and at three sites in 61 slaughter cattle. STEC O157 was distributed along the entire GIT, though interanimal distribution was variable. Neither feces nor rectoanal-junction samples accurately predicted the STEC O157-negative status of any particular animal.

Animal-to-animal variation in fecal microbial diversity among beef cattle.

The intestinal microbiota of beef cattle are important for animal health, food safety, and methane emissions. This full-length sequencing survey of 11,171 16S rRNA genes reveals animal-to-animal variation in communities that cannot be attributed to breed, gender, diet, age, or weather. Beef communities differ from those of dairy. Core bovine taxa are identified.

Longitudinal study of Escherichia coli O157:H7 in a beef cattle feedlot and role of high-level shedders in hide contamination.

The objectives of the study described here were (i) to investigate the dynamics of Escherichia coli O157:H7 fecal and hide prevalence over a 9-month period in a feedlot setting and (ii) to determine how animals shedding E. coli O157:H7 at high levels affect the prevalence and levels of E. coli O157:H7 on the hides of other animals in the same pen. Cattle (n = 319) were distributed in 10 adjacent pens, and fecal and hide levels of E. coli O157:H7 were monitored. When the fecal pen prevalence exceeded 20%, the hide pen prevalence was usually (25 of 27 pens) greater than 80%. Sixteen of 19 (84.2%) supershedder (>10(4) CFU/g) pens had a fecal prevalence greater than 20%. Significant associations with hide and high-level hide (>/=40 CFU/100 cm(2)) contamination were identified for (i) a fecal prevalence greater than 20%, (ii) the presence of one or more high-density shedders (>/=200 CFU/g) in a pen, and (iii) the presence of one or more supershedders in a pen. The results presented here suggest that the E. coli O157:H7 fecal prevalence should be reduced below 20% and the levels of shedding should be kept below 200 CFU/g to minimize the contamination of cattle hides. Also, large and unpredictable fluctuations within and between pens in both fecal and hide prevalence of E. coli O157:H7 were detected and should be used as a guide when preharvest studies, particularly preharvest intervention studies, are designed.

Phylogenetic classification of Escherichia coli O157:H7 strains of human and bovine origin using a novel set of nucleotide polymorphisms.

BACKGROUND: Cattle are a reservoir of Shiga toxin-producing Escherichia coli O157:H7 (STEC O157), and are known to harbor subtypes not typically found in clinically ill humans. Consequently, nucleotide polymorphisms previously discovered via strains originating from human outbreaks may be restricted in their ability to distinguish STEC O157 genetic subtypes present in cattle. The objectives of this study were firstly to identify nucleotide polymorphisms in a diverse sampling of human and bovine STEC O157 strains, secondly to classify strains of either bovine or human origin by polymorphism-derived genotypes, and finally to compare the genotype diversity with pulsed-field gel electrophoresis (PFGE), a method currently used for assessing STEC O157 diversity. RESULTS: High-throughput 454 sequencing of pooled STEC O157 strain DNAs from human clinical cases (n = 91) and cattle (n = 102) identified 16,218 putative polymorphisms. From those, 178 were selected primarily within genomic regions conserved across E. coli serotypes and genotyped in 261 STEC O157 strains. Forty-two unique genotypes were observed that are tagged by a minimal set of 32 polymorphisms. Phylogenetic trees of the genotypes are divided into clades that represent strains of cattle origin, or cattle and human origin. Although PFGE diversity surpassed genotype diversity overall, ten PFGE patterns each occurred with multiple strains having different genotypes. CONCLUSIONS: Deep sequencing of pooled STEC O157 DNAs proved highly effective in polymorphism discovery. A polymorphism set has been identified that characterizes genetic diversity within STEC O157 strains of bovine origin, and a subset observed in human strains. The set may complement current techniques used to classify strains implicated in disease outbreaks.

What is the point: will screening mammography save my life?

BACKGROUND: We analyzed the claim "mammography saves lives" by calculating the life-saving absolute benefit of screening mammography in reducing breast cancer mortality in women ages 40 to 65. METHODS: To calculate the absolute benefit, we first estimated the screen-free absolute death risk from breast cancer by adjusting the Surveillance, Epidemiology and End Results Program 15-year cumulative breast cancer mortality to account for the separate effects of screening mammography and improved therapy. We calculated the absolute risk reduction (reduction in absolute death risk), the number needed to screen assuming repeated screening, and the survival percentages without and with screening. We varied the relative risk reduction from 10%-30% based on the randomized trials of screening mammography. We developed additional variations of the absolute risk reduction for a screening intervention, including the average benefit of a single screen, as well as the life-saving proportion among patients with earlier cancer detection. RESULTS: Because the screen-free absolute death risk is approximately 1% overall but rises with age, the relative risk reduction from repeated screening mammography is about 100 times the absolute risk reduction between the starting ages of 50 and 60. Assuming a base case 20% relative risk reduction, repeated screening starting at age 50 saves about 1.8 (overall range, 0.9-2.7) lives over 15 years for every 1000 women screened. The number needed to screen repeatedly is 1000/1.8, or 570. The survival percentage is 99.12% without and 99.29% with screening. The average benefit of a single screening mammogram is 0.034%, or 2970 women must be screened once to save one life. Mammography saves 4.3% of screen-detectable cancer patients' lives starting at age 50. This means 23 cancers must be found starting at age 50, or 27 cancers at age 40 and 21 cancers at age 65, to save one life. CONCLUSION: The life-saving absolute benefit of screening mammography increases with age as the absolute death risk increases. The number of events needed to save one life varies depending on the prospective screening subset or reference class. Less than 5% of women with screen-detectable cancers have their lives saved.

How does age affect baseline screening mammography performance measures? A decision model.

BACKGROUND: In order to promote consumer-oriented informed medical decision-making regarding screening mammography, we created a decision model to predict the age dependence of the cancer detection rate, the recall rate and the secondary performance measures (positive predictive values, total intervention rate, and positive biopsy fraction) for a baseline mammogram. METHODS: We constructed a decision tree to model the possible outcomes of a baseline screening mammogram in women ages 35 to 65. We compared the single baseline screening mammogram decision with the no screening alternative. We used the Surveillance Epidemiology and End Results national cancer database as the primary input to estimate cancer prevalence. For other probabilities, the model used population-based estimates for screening mammography accuracy and diagnostic mammography outcomes specific to baseline exams. We varied radiologist performance for screening accuracy. RESULTS: The cancer detection rate increases from 1.9/1000 at age 40 to 7.2/1000 at age 50 to 15.1/1000 at age 60. The recall rate remains relatively stable at 142-157/1000, which varies from 73-236/1000 at age 50 depending on radiologist performance. The positive predictive value of a screening mammogram increases from 1.3% at age 40 to 9.8% at age 60, while the positive predictive value of a diagnostic mammogram varies from 2.9% at age 40 to 19.2% at age 60. The model predicts the total intervention rate = 0.013*AGE2 - 0.67*AGE + 40, or 34/1000 at age 40 to 47/1000 at age 60. Therefore, the positive biopsy (intervention) fraction varies from 6% at age 40 to 32% at age 60. CONCLUSION: Breast cancer prevalence, the cancer detection rate, and all secondary screening mammography performance measures increase substantially with age.

Bacteriophage isolated from feedlot cattle can reduce Escherichia coli O157:H7 populations in ruminant gastrointestinal tracts.

Escherichia coli O157:H7 can live undetected in the gut of food animals and be spread to humans directly and indirectly. Bacteriophages are viruses that prey on bacteria, offering a natural, nonantibiotic method to reduce pathogens from the food supply. Here we show that a cocktail of phages isolated from commercial cattle feces reduced E. coli O157:H7 populations in the gut of experimentally inoculated sheep. A cocktail of phages was used in order to prevent the development of resistance to the phages. In our first in vivo study we found that our cocktail of phages reduced E. coli O157:H7 populations in the feces of sheep (p < 0.05) by 24 hours after phage treatment. Upon necropsy, populations of inoculated E. coli O157:H7 were reduced by phage treatment in both the cecum (p < 0.05) and rectum (p < 0.1). In our second in vivo study, several ratios of phage plaque-forming units (PFU) to E. coli O157:H7 colony-forming units (CFU) were used (0:1, 1:1, 10:1, and 100:1 PFU/CFU) to determine the most efficacious phage dose. A 1:1 ratio of phage to bacteria was found to be more effective (p < 0.05) than either of the higher ratios used (10:1 or 100:1). Ruminal levels of E. coli O157:H7 were not significantly reduced (p > 0.10) in any of the studies due to relatively low inoculated E. coli O157:H7 ruminal populations. Our results demonstrate that phage can be used as a preharvest intervention as part of an integrated pathogen reduction scheme.

Risk behaviors for disease transmission among petting zoo attendees.

OBJECTIVE: To evaluate risk behaviors for transmission of zoonotic diseases at petting zoos during a period without a recognized disease outbreak. DESIGN: Observational survey with environmental microbiologic sampling. SAMPLE POPULATION: 6 petting zoos in Tennessee. PROCEDURES: Attendees were observed for animal and environmental contact, eating or drinking, hand-to-face contact, and use of a hand sanitizer. Hands were examined via bacteriologic culture on some attendees. Environmental samples were collected at three petting zoos. RESULTS: 991 attendees were observed; of these, 74% had direct contact with animals, 87% had contact with potentially contaminated surfaces in animal contact areas, 49% had hand-to-face contact, and 22% ate or drank in animal contact areas. Thirty-eight percent used hand sanitizer; children had better compliance than adults. Results of bacteriologic cultures of hands were negative for Salmonella spp and Escherichia coli O157; Salmonella spp were isolated from 63% and E coli O157 from 6% of the environmental samples. CONCLUSIONS AND CLINICAL RELEVANCE: High risk behaviors were common among petting zoo visitors, and disease prevention guidelines were inconsistently followed. This is an example of the importance of one-medicine, one-health initiatives in protecting the public health. Veterinarians, venue operators, and public health authorities must work together on targeted education to improve implementation of existing disease prevention guidelines.

Association of Escherichia coli O157:H7 tir polymorphisms with human infection.

BACKGROUND: Emerging molecular, animal model and epidemiologic evidence suggests that Shiga-toxigenic Escherichia coli O157:H7 (STEC O157) isolates vary in their capacity to cause human infection and disease. The translocated intimin receptor (tir) and intimin (eae) are virulence factors and bacterial receptor-ligand proteins responsible for tight STEC O157 adherence to intestinal epithelial cells. They represent logical genomic targets to investigate the role of sequence variation in STEC O157 pathogenesis and molecular epidemiology. The purposes of this study were (1) to identify tir and eae polymorphisms in diverse STEC O157 isolates derived from clinically ill humans and healthy cattle (the dominant zoonotic reservoir) and (2) to test any observed tir and eae polymorphisms for association with human (vs bovine) isolate source. RESULTS: Five polymorphisms were identified in a 1,627-bp segment of tir. Alleles of two tir polymorphisms, tir 255 T>A and repeat region 1-repeat unit 3 (RR1-RU3, presence or absence) had dissimilar distributions among human and bovine isolates. More than 99% of 108 human isolates possessed the tir 255 T>A T allele and lacked RR1-RU3. In contrast, the tir 255 T>A T allele and RR1-RU3 absence were found in 55% and 57%, respectively, of 77 bovine isolates. Both polymorphisms associated strongly with isolate source (p < 0.0001), but not by pulsed field gel electrophoresis type or by stx1 and stx2 status (as determined by PCR). Two eae polymorphisms were identified in a 2,755-bp segment of 44 human and bovine isolates; 42 isolates had identical eae sequences. The eae polymorphisms did not associate with isolate source. CONCLUSION: Polymorphisms in tir but not eae predict the propensity of STEC O157 isolates to cause human clinical disease. The over-representation of the tir 255 T>A T allele in human-derived isolates vs the tir 255 T>A A allele suggests that these isolates have a higher propensity to cause disease. The high frequency of bovine isolates with the A allele suggests a possible bovine ecological niche for this STEC O157 subset.

Molecular serotyping of Escherichia coli O111:H8.

Accurate Escherichia coli serotyping is critical for pathogen diagnosis and surveillance of non-O157 Shiga-toxigenic strains, however few laboratories have this capacity. The molecular serotyping protocol described in this paper targets the somatic and flagellar antigens of E. coli O111:H8 used in traditional serotyping, and can be performed routinely in the laboratory.

Isolation of Salmonella enterica and Shiga-toxigenic Escherichia coli O157 from feces of animals in public contact areas of United States zoological parks.

The fecal prevalence of subclinical Salmonella enterica and Shiga-toxigenic Escherichia coli O157 among animals in human-animal contact exhibits at institutions in the United States accredited by the Association of Zoos and Aquariums was estimated to assess public health risk. The prevalence was less than 0.6% for both zoonotic pathogens among 997 animals sampled at 36 exhibits.

Shiga-toxigenic Escherichia coli O157 in agricultural fair livestock, United States.

Agricultural fairs exhibiting livestock are increasingly implicated in human Shiga-toxigenic Escherichia coli O157:H7 (STEC O157:H7) outbreaks. To estimate livestock STEC O157:H7 prevalence at US fairs, we collected 2,919 fecal specimens at 29 county fairs in 2 states and at 3 state fairs in 2002. Fly pools were also collected. STEC O157:H7 was isolated from livestock at 31 (96.9%) of 32 fairs, including 11.4% of 1,407 cattle, 1.2% of 1,102 swine, 3.6% of 364 sheep and goats, and 5.2% of 154 fly pools. Cattle, swine, and flies at some fairs shared indistinguishable STEC O157:H7 isolate subtypes. In 2003, a total of 689 ambient environmental samples were collected at 20 fairgrounds 10-11 months after 2002 livestock sampling while fairgrounds were livestock-free. Four beef barn environmental samples at 3 fairgrounds yielded STEC O157:H7. These data suggest that STEC O157 is common and transmissible among livestock displayed at agricultural fairs and persists in the environment after the fair.

Association of neonatal serum immunoglobulin G1 concentration with health and performance in beef calves.

OBJECTIVE: To evaluate associations between neonatal serum IgG1 concentration and pre- and postweaning morbidity and mortality rates and average daily gains (ADGs) in beef calves and define a cutoff point for serum IgG1 concentration necessary for optimal health and performance of beef calves. DESIGN: Nonconcurrent cohort study. ANIMALS: 1,568 crossbred beef calves. PROCEDURE: Single radial immunodiffusion was used to quantitate IgG1 concentration in sera collected from calves between 24 and 72 hours after birth. Logistic regression, ANCOVA, and likelihood ratios were used to analyze data. RESULTS: In the preweaning period, lower perinatal IgG1 concentrations were significantly associated with higher morbidity rates, higher mortality rates, and lower ADGs. Calves with serum IgG1 concentration < 2,400 mg/dL were 1.6 times as likely to become ill before weaning and 2.7 times as likely to die before weaning as calves with higher serum IgG1 concentrations. Calves with serum IgG1 concentration of at least 2,700 mg/dL weighed an estimated 3.35 kg (7.38 lb) more at 205 days of age than calves with lower serum IgG1 concentration. No significant association of serum IgG1 concentration with feedlot morbidity, death, or ADG was identified. CONCLUSIONS AND CLINICAL RELEVANCE: By use of likelihood ratios, the threshold of serum IgG1 concentration for optimal health and performance of calves was higher than values reported previously. Implementation and maintenance of management and intervention strategies designed for early detection and treatment of calves at risk for failure of passive transfer will likely result in increases in preweaning health and performance parameters.

Molecular serotyping of Escherichia coli O26:H11.

Serotyping is the foundation of pathogenic Escherichia coli diagnostics; however, few laboratories have this capacity. We developed a molecular serotyping protocol that targets, genetically, the same somatic and flagellar antigens of E. coli O26:H11 used in traditional serotyping. It correctly serotypes strains untypeable by traditional methods, affording primary laboratories serotyping capabilities.