Hemolytic-Uremic Syndrome and Escherichia coli O121 at a Lake in Connecticut, 1999.

OBJECTIVE: Non-O157 Shiga toxin-producing Escherichia coli (STEC) have emerged as an important public health problem. Outbreaks attributed to non-O157 STEC rarely are reported. In 1999, follow-up of routine surveillance reports of children with hemolytic- uremic syndrome (HUS) identified a small cluster of 3 cases of HUS, all of whom had spent overlapping time in a Connecticut lake community in the week before onset of symptoms. We conducted an investigation to determine the magnitude and source of the outbreak and to determine risk factors associated with the transmission of illness. METHODS: We conducted a cohort study and an environmental investigation. The study population included all people who were at the lake in a defined geographic area during July 16-25, 1999. This time and area were chosen on the basis of interviews with the 3 HUS case-patients. A case was defined as diarrhea (>/=3 loose stools/d for >/=3 days) in a person who was at the lake during July 16-25, 1999. Stool samples were requested from any lake resident with diarrheal illness. Stools were cultured for Salmonella, Shigella, Campylobacter, and E coli O157. Broth cultures of stools were tested for Shiga toxin. Case-patients were asked to submit a serum specimen for antibody testing to lipopolysaccharides of selected STEC. Environmental samples from sediment, drinking water, lake water, and ice were obtained and cultured for E coli and tested for Shiga toxin. An environmental evaluation of the lake was conducted to identify any septic, water supply system, or other environmental condition that could be related to the outbreak. RESULTS: Information was obtained for 436 people from 165 (78%) households. Eleven (2.5%) people had illnesses that met the case definition, including the 3 children with HUS. The attack rate was highest among those who were younger than 10 years and who swam in the lake on July 17 or 18 (12%; relative risk [RR]: 7.3). Illness was associated with swimming (RR = 8.3) and with swallowing water while swimming (RR = 7.0) on these days. No person who swam only after July 18 developed illness. Clinical characteristics of case-patients included fever (27%), bloody diarrhea (27%), and severe abdominal cramping (73%). Only the 3 children with HUS required hospitalization. No bacterial pathogen was isolated from the stool of any case-patient. Among lake residents outside the study area, E coli O121:H19 was obtained from a Shiga toxin-producing isolate from a toddler who swam in the lake. Serum was obtained from 7 of 11 case-patients. Six of 7 case-patients had E coli O121 antibody titers that ranged from 1:320 to >1:20 480. E coli indicative of fecal contamination was identified from sediment and water samples taken from a storm drain that emptied into the beach area and from a stream bed located between 2 houses, but no Shiga toxin-producing strain was identified. CONCLUSIONS: Our findings are consistent with a transient local beach contamination in mid-July, probably with E coli O121:H19, which seems to be able to cause severe illness. Without HUS surveillance, this outbreak may have gone undetected by public health officials. This outbreak might have been detected sooner if Shiga toxin screening had been conducted routinely in HUS cases. Laboratory testing that relies solely on the inability of an isolate to ferment sorbitol will miss non-O157 STEC, such as E coli O121. Serologic testing can be used as an adjunct in the diagnosis of STEC infections. Lake-specific recommendations included education, frequent water sampling, and alternative means for toddlers to use lake facilities.

West Nile virus serosurvey and assessment of personal prevention efforts in an area with intense epizootic activity: Connecticut, 2000.

West Nile virus (WNV) can cause large outbreaks of febrile illness and severe neurologic disease. This study estimates the seroprevalence of WNV infection and assesses risk perception and practices regarding potential exposures to mosquitoes of persons in an area with intense epizootics in 1999 and 2000. A serosurvey of persons aged > or = 12 years was conducted in southwestern Connecticut during October 10-15, 2000, using household-based stratified cluster sampling. Participants completed a questionnaire regarding concern for and personal measures taken with respect to WNV and provided a blood sample for WNV testing. Seven hundred thirty persons from 645 households participated. No person tested positive for WNV (95% CI: 0-0.5%). Overall, 44% of persons used mosquito repellent, 56% practiced > or = two personal precautions to avoid mosquitoes, and 61% of households did > or = two mosquito-source reduction activities. In multivariate analyses, using mosquito repellent was associated with age < 50 years, using English as the primary language in the home, being worried about WNV, being a little worried about pesticides, and finding mosquitoes frequently in the home (P<0.05). Females (OR = 2.0; CI = 1.2-2.9) and persons very worried about WNV (OR = 3.8; CI = 2.2-6.5) were more likely to practice > or = two personal precautions. Taking > or = two mosquito source reductions was associated with persons with English as the primary language (OR = 2.0; CI = 1.1-3.5) and finding a dead bird on the property (OR = 1.8; CI = 1.1-2.8). An intense epizootic can occur in an area without having a high risk for infection to humans. A better understanding of why certain people do not take personal protective measures, especially among those aged > or = 50 years and those whose primary language is not English, might be needed if educational campaigns are to prevent future WNV outbreaks.

Antisense inhibition of epidermal growth factor receptor decreases expression of human surfactant protein A.

Epidermal growth factor (EGF) stimulates surfactant protein A (SP-A) synthesis in fetal lung tissue through ligand binding to the EGF receptor. We hypothesized that inhibition of EGF receptor messenger RNA (mRNA) would block SP-A expression in human fetal lung tissue during alveolar type II cell differentiation in vitro. Midtrimester human fetal lung explants were maintained in serum-free Waymouth's medium for 3 to 5 d in the presence or absence of an antisense 18-mer phosphorothioate oligonucleotide (ON) complementary to the initiation codon region of EGF receptor mRNA. Sense and scrambled ONs similarly modified were used as additional controls. The concentration of EGF receptor mRNA was semiquantitatively determined by reverse transcriptase/polymerase chain reaction (RT-PCR). We found a significant 3-fold decrease in EGF receptor mRNA levels in the antisense-treated groups compared with the control group with no effect in the sense condition. Immunohistochemical staining revealed a decrease in the amount of staining for EGF receptor protein in distal pulmonary epithelial cells in the antisense-treated groups compared with either control or sense conditions. Treatment with antisense EGF receptor ON decreased both SP-A mRNA and protein compared with controls with no effect in the sense condition. The ONs did not affect tissue viability as measured by the release of lactate dehydrogenase. We conclude that selective degradation of EGF receptor mRNA with antisense ON treatment results in a decrease in SP-A expression in human fetal lung. These findings support the critical importance of the EGF receptor for the regulation of SP-A gene expression during human alveolar type II cell differentiation.

Effect of tyrosine kinase inhibition on surfactant protein A gene expression during human lung development.

Epidermal growth factor (EGF) stimulates surfactant protein (SP) A synthesis in human fetal lung explants. Ligand binding to the EGF receptor stimulates an intrinsic receptor tyrosine kinase with subsequent activation of second messengers. We hypothesized that inhibition of EGF-receptor tyrosine kinase activity would block SP-A expression in spontaneously differentiating cultured human fetal lung tissue. Midtrimester fetal lung explants were exposed for 4 days to genistein (a broad-range inhibitor of tyrosine kinases) and tyrphostin AG-1478 (a specific inhibitor of EGF-receptor tyrosine kinase). Genistein significantly decreased SP-A and SP-A mRNA levels without affecting either tissue viability or the morphological differentiation of alveolar type II cells. Tyrphostin AG-1478 also decreased SP-A content and SP-A mRNA levels in cultured fetal lung explants. Treatment with EGF could not overcome the inhibitory effects of either genistein or tyrphostin on SP-A; however, only tyrphostin inhibited EGF-receptor tyrosine phosphorylation. We conclude that specific inhibition of EGF-receptor tyrosine kinase with tyrphostin AG-1478 blocks the expression of SP-A during spontaneous differentiation of cultured human fetal lung tissue. Furthermore, exposure to genistein also decreases SP-A expression and blocks the effects of EGF in human fetal lung tissue without inhibiting EGF-receptor tyrosine phosphorylation. These findings support the importance of tyrosine kinase-dependent signal transduction pathways in the regulation of SP-A during human fetal lung development.

Inhibition of tyrosine kinase activity decreases expression of surfactant protein A in a human lung adenocarcinoma cell line independent of epidermal growth factor receptor.

Epidermal growth factor (EGF) enhances fetal lung development in vivo and in vitro. Ligand binding to the EGF receptor stimulates an intrinsic receptor tyrosine kinase initiating a signal transduction cascade. We hypothesized that blocking EGF receptor function with tyrosine kinase inhibitors would decrease the expression of surfactant protein A in human pulmonary epithelial cells. Human pulmonary adenocarcinoma cells (NCI-H441) were exposed to genistein (a broad range inhibitor of tyrosine kinases) and tyrphostin AG1478 (a specific inhibitor of EGF receptor tyrosine kinase). Genistein significantly decreased surfactant protein A (SP-A) and SP-A mRNA levels in H441 cells without affecting cell viability. The inhibitory effect of genistein on SP-A content was reversible. In contrast, tyrphostin AG1478 had no effect on SP-A levels despite a greater inhibitory effect than genistein on EGF receptor tyrosine autophosphorylation. Furthermore, treatment of H441 cells with exogenous EGF did not increase SP-A content or mRNA levels beyond baseline. We conclude that inhibition of tyrosine kinase activity other than the EGF receptor decreases the expression of surfactant protein A at a pretranslational level in human pulmonary adenocarcinoma cells. These results suggest the importance of tyrosine kinases in modulating human SP-A synthesis.

Localization of epidermal growth factor receptor in alveolar epithelium during human fetal lung development in vitro.

Epidermal growth factor (EGF) enhances alveolar type II cell differentiation. In human fetal lung explants, EGF stimulates surfactant protein A (SP-A) synthesis. This effect may occur through a direct interaction of the ligand on EGF receptors located within distal pulmonary epithelium during alveolar type II cell differentiation. To determine if EGF receptor is present in alveolar epithelium, immunostaining for EGF receptor and in situ hybridization for EGF receptor mRNA were performed in human fetal lung explants undergoing alveolar type II cell differentiation in vitro. After 4 days in culture, EGF receptor immunostaining was present in alveolar epithelium from human fetal lung explants compared to minimal immunostaining in undifferentiated human fetal lung epithelium prior to culture. In situ hybridization revealed increased EGF receptor mRNA in differentiated type II cells from cultured explants, with minimal EGF receptor mRNA detected in undifferentiated epithelium from tissue prior to culture. Immunogold staining revealed EGF receptors on the cytoplasmic membranes of epithelial cells lining the prealveolar ducts in human fetal lung explants after 2 days in culture. Alveolar type II cell differentiation in vitro was confirmed ultrastructurally by the presence of lamellar bodies and biochemically by an increase in SP-A content. Thus, EGF receptor is found in alveolar epithelium during differentiation, which suggests an important role for EGF during human fetal lung development.

Role of the Q-tip test in evaluating stress urinary incontinence.

The Q-tip test was applied on 105 patients. Fifty-one had stress urinary incontinency (SUI), 28 had bladder instability by clinical and urodynamic criteria, and 36 had mild or moderate pelvic relaxation without urinary pathology. More than 90% of the patients with SUI and no previous surgery had a positive Q-tip test, with 90% test sensitivity in this group. More than one-third of the patients with bladder instability and almost one-half of the patients with pelvic relaxation and no urinary incontinence had a positive Q-tip test, for low test specificity. The Q-tip test is a simple clinical tool for diagnosing pelvic relaxation, which at times leads to SUI. Almost all patients with primary SUI have pelvic relaxation. The Q-tip test alone does not stand as a diagnostic test. When it is positive, the diagnosis of genuine stress incontinence is possible although not absolute. A negative test should cause one to question the diagnosis of genuine stress incontinence, and sophisticated and more expensive tests should be ordered before establishing a final diagnosis.

Urodynamic changes after successful operation for stress urinary incontinence.

Urethral closure pressure profiles were evaluated in 18 patients who had surgical cure of stress urinary incontinence. Functional length and maximal closure pressures were compared before and after the operation to determine what effect, if any, successful surgical intervention had on these parameters. No apparent differences were identified. The reasons for successful surgical treatment of stress urinary incontinence are unrelated to any change in urethral functional length or closure pressure.

Antibiotic prophylaxis after instrumentation for urodynamic testing.

This study of 96 women shows that there is doubtful value in routine antibiotic prophylaxis after urodynamic investigation. An unexpectedly high number of women harboured unsuspected infections at the time of evaluation despite prior screening, which suggests prophylaxis would be more useful if given before the tests.

Diagnostic procedures in female urology.

Diagnostic procedures in gynecologic urology are no longer limited to the medical history, physical examination, and Marshall test. Newer diagnostic procedures include urethroscopy, urodynamics with cystometry, urethral closure pressure profiles, uroflowmetry, electromyography of the pelvic floor musculature, and radiologic procedures. All are designed to provide a dynamic assessment of the functional capabilities of the lower urinary tract. Many of these procedures are complex and require sophisticated equipment to provide accurate measurements and are unsuitable for general office applications. This article describes these new diagnostic procedures.