Uterine perforation resulting in bowel infarction: sharp traumatic bowel and mesenteric injury at the time of pregnancy termination.

BACKGROUND: By law, elective terminations of pregnancy are not performed in U.S. military institutions. However, in the civilian sector, more than a million abortions are performed each year, some of which are on military beneficiaries. Although complications are relatively rare, patients not uncommonly present for follow-up care to their military installation. We report the case of a patient who presented after a second-trimester elective abortion and was found to have suffered uterine perforation with mesenteric and bowel injury that required bowel resection. CASE: An 18-year-old gravida 1 para 0 female presented from an outlying facility 1 week after elective termination at 18 weeks of gestation with complaints of severe abdominal pain, nausea, and vomiting. Exploratory laparotomy for presumed bowel obstruction revealed uterine perforation and bowel devitalization and necrosis, which required small bowel resection. Fetal bones were discovered within the surgical specimen. CONCLUSION: Morbid, even potentially fatal, complications can occur as a result of pregnancy termination. With second-trimester procedures, perforation can result in injury to abdominal viscera from the perforating instruments or even from sharp fetal bony structures. Military gynecologic surgeons, who are not in abortion practice, must nevertheless be cognizant of the potential for perforation leading to serious visceral injury.

Cheese-associated outbreaks of human illness in the United States, 1973 to 1992: sanitary manufacturing practices protect consumers.

To identify contributing factors for cheese-associated outbreaks, we reviewed all cheese-associated outbreaks of human illness reported to the Centers for Disease Control and Prevention (CDC) with onsets during 1973 to 1992. The infrequency of large, cheese-associated outbreaks was notable because such outbreaks had been a frequent public health problem before the mid-20th century. Of 32 reported cheese-associated outbreaks, 11 attributed to manufacturing errors caused most of the illnesses and hospitalizations and all 58 deaths. Important factors in these 11 outbreaks were manufacturing cheese with raw or improperly pasteurized milk and postpasteurization contamination. If current Food and Drug Administration sanitary requirements for cheesemaking had been met, these outbreaks would have been preventable. In two outbreaks of Salmonella infections, fewer than 10 Salmonella per 100 g of cheese were detected. In two outbreaks of Brucella infections, efforts to recover the pathogen from the implicated cheese were unsuccessful, emphasizing the inadequacy of end product testing for assuring consumer safety. Curing cheeses kills most bacteria present in cheeses; however, evidence from sources other than the CDC Foodborne Disease Outbreak Surveillance System suggests that curing alone may not be a sufficient pathogen control step to eliminate Salmonella, Listeria, and E. coli O157:H7 from cheese.

Crayfish: a newly recognized vehicle for vibrio infections.

We conducted a 1-year case-control study of sporadic vibrio infections to identify risk factors related to consumption of seafood products in two coastal areas of Louisiana and Texas. Twenty-six persons with sporadic vibrio infections and 77 matched controls were enrolled. Multivariate analysis revealed that crayfish (P < 0.025) and raw oysters (P < 0.009) were independently associated with illness. Species-specific analysis revealed an association between consumption of cooked crayfish and Vibrio parahemolyticus infection (OR 9.24, P < 0.05). No crayfish consumption was reported by persons with V. vulnificus infection. Although crayfish had been suspected as a vehicle for foodborne disease, this is the first time to our knowledge that consumption of cooked crayfish has been demonstrated to be associated with vibrio infection.

The epidemiology of raw milk-associated foodborne disease outbreaks reported in the United States, 1973 through 1992.

OBJECTIVES: This study describes the epidemiology of raw milk-associated outbreaks reported to the Centers for Disease Control and Prevention from 1973 through 1992. METHODS: Surveillance data for each reported raw milk-associated outbreak were reviewed. A national survey was conducted to determine the legal status of intrastate raw milk sales for the period 1973 through 1995. RESULTS: Forty-six raw milk-associated outbreaks were reported during the study period; 40 outbreaks (87%) occurred in states where the intrastate sale of raw milk was legal. CONCLUSIONS: Consumption of raw milk remains a preventable cause of foodborne disease outbreaks.

Therapeutic antibiotics in animal feeds and antibiotic resistance.

Recent statutory changes involving animal drugs are expected to facilitate the therapeutic use of antibiotics in animal feeds in the United States of America. The use of antibiotics in animal feeds is controversial due to the potential development of resistant bacterial pathogens in food-producing animals which are exposed to the antibiotics and the resultant public health risk. Zoonotic micro-organisms can be transmitted to humans through contact with animal populations, either directly or through the consumption of contaminated food. Recommendations to address the public health concerns include the strengthening of professional education in the areas of infectious diseases and the appropriate selection and use of antimicrobial agents, the development of a comprehensive food safety education programme for food-animal veterinarians and animal producers, and the development of surveillance programmes to monitor antimicrobial resistance among zoonotic pathogens. Early identification of emerging resistance can facilitate a timely and appropriate public health response.

Epidemiology of foodborne diseases: tools and applications.

Food safety is a complex matter that depends on a number of interrelated environmental, cultural, and socioeconomic factors. The purpose of epidemiology and surveillance is to define these factors, how they interact, and their relative importance in foodborne infections. The tools epidemiologists use to study foodborne disease include surveillance of specific infections in humans, monitoring of contamination with specific pathogens in foods and animals, intensive outbreak investigations, collecting reports of outbreaks at the regional or national level, and studies of sporadic infections. With sufficiently elaborate systems of surveillance and investigation, it is possible to provide quantitative risk data for foodborne diseases that will permit the wisest allocation of food safety resources.

Secondary cytoreduction in ovarian cancer: pro or con?

During a symposium in the therapy for ovarian cancer as a prelude to the Gynecologic Oncology Group meeting in July 1992, the relative merits of secondary cytoreductive surgery were debated. The author presented part of the con argument. The content of that position is presented.

The influence of staging laparotomy for cervical cancer on patterns of recurrence and survival.

A matched paired study of surgically staged and non-surgically staged patients with stage II and III cervical carcinoma from October 1974 through August 1987 was retrospectively performed. Eight of 55 (13.8%) had para-aortic lymph node involvement. After tailored extended field radiation 2/8 (25%) remain alive without evidence of disease. Patient survival although slightly in favor of the unstaged group was similar. Patterns of recurrence were similar amongst treatment groups. Para-aortic nodal recurrence, despite tailored radiation therapy, was identical (5.4%) in the staged and unstaged groups. Only one patient (not surgically staged) had an isolated para-aortic recurrence. With the morbidity of an operative procedure and similar survival rates and para-aortic nodal recurrence rates, the value of staging laparotomy in improved patient survival is questioned. Pelvic failure and other distant metastases continue to be the major sites of recurrences.

Second-look laparotomy and salvage therapy: a research modality only?

Two hundred twelve patients who underwent second-look laparotomy as part of their treatment for epithelial ovarian cancer were evaluated. Factors associated with positive second looks were initial stage, tumor grade, age, and residual disease (P less than 0.05). One factor not of significance was whether adjuvant therapy was platinum based. Initial stage only was associated with recurrence after a negative second look (P less than 0.001). When controlled for volume of disease no difference in survival between various salvage therapies could be demonstrated. Survival between patients with recurrence after negative second look and patients with microscopic residual disease was similar even though the former group was not treated until recurrence (P = 0.75). Second-look laparotomy does not improve survival with currently existing salvage modalities and should primarily be confined to those patients willing to participate in research protocols evaluating new second-line therapy.

Rationale for using pathologic tumor dimensions and nodal status to subclassify surgically treated stage IB cervical cancer patients.

Between 1969 and 1988, 401 patients were treated by radical hysterectomy and pelvic lymphadenectomy for Stage IB cervical carcinoma at the University of Alabama at Birmingham. In multivariate analysis, pathological tumor diameter (P less than 0.0001) and the presence of lymph node metastasis (P = 0.0005) proved to be the dominant two histopathologic features that significantly correlated with overall survival. Although 5-year survival for the overall group was 85%, 5-year survival in patients with lesions greater than 3.0 cm in diameter and with regional nodal metastasis was less than 30%. This discrepancy in survival in surgically treated early-stage cervical cancer patients supports a need for subcategorization by risk factors such as pathologic tumor dimensions and nodal status and for further investigation of alternative neoadjuvant and adjuvant therapies in those early-stage cervical cancer patients deemed at high risk for poor overall survival.

Primary surgical therapy of ovarian cancer: how much and when.

From July 1975 through December 1985, 328 patients with ovarian malignancies were treated. Of these, 302 had epithelial invasive malignancies and constitute the study group. The impact of the operative procedure, findings, and subsequent treatment is evaluated. Patients who underwent extensive debulking procedures such as bowel resection and peritoneal stripping did not have improved survival compared with those patients who did not undergo these procedures and yet had residual disease remaining (P = 0.7 and P = 0.34). Reoperating patients felt to be unresectable at the time of referral did not increase survival over reoperating patients after an attempt at chemotherapeutic reduction (P = 0.34).

Pure primary osteosarcoma of the ovary presenting as an extensively calcified adnexal mass: a case report and review of the literature.

A case of primary ovarian osteosarcoma is reported with a review of the literature. A perimenopausal woman presented with a calcific adnexal mass seen on abdominal radiography, surgical exploration revealed no gross evidence of metastatic disease. Adjuvant chemotherapy was administered due to the reported aggressiveness of this rare tumor. Following eight courses of cisplatin-doxorubicin combination chemotherapy, the patient is without evidence of disease. A differential diagnosis for extensively calcified adnexal masses is provided. Additionally, a rationale for adjuvant chemotherapy is discussed.

Evidence for participation of the macrophage in Shiga-like toxin II-induced lethality in mice.

Seven strains of inbred mice were compared for their susceptibility to the lethal effects of Shiga-like toxin II (SLT II). A/J mice, which are unable to produce the C5 component of complement, did not differ from C5 normal mice in susceptibility to SLT II. CBA/NJ mice (hemizygous for X-linked immunodeficiency) did not differ from the B-cell sufficient CBA/J strain. C3H/HeJ mice, defective in macrophage response to lipopolysaccharide (Lpsd), showed a consistently and significantly longer mean time to death than did the normally responsive C3H/HeN strain. C57BL/10ScN mice, which also carry the Lpsd allele, showed a similar but smaller difference in mean time to death compared with the C57BL/10SnJ strain. Production of tumor necrosis factor could be induced in vitro by SLT II treatment of C3H/HeN, but not C3H/HeJ macrophages. These results imply that antibody and complement production do not modulate SLT II lethality in mice, but that the macrophage may contribute to SLT II-induced injury.

Early invasive cervical cancer with pelvic lymph node involvement: to complete or not to complete radical hysterectomy?

The completion of radical hysterectomy in the face of pelvic lymph node involvement presents a dilemma for the surgeon. Some believe it is appropriate to abort the hysterectomy to avoid the excessive morbidity of combined treatment; others believe that completion of the hysterectomy enhances survival. This study was undertaken to define the impact of completing radical hysterectomy followed by adjuvant radiation therapy upon patient survival or pelvic control. Fifteen patients with stage IB and IIA invasive cervical cancer whose radical hysterectomies were aborted solely for reasons of pelvic lymph node involvement were compared to a control group of 15 patients matched for tumor size and number of lymph nodes involved whose radical hysterectomies were completed. Both groups were treated with radiation therapy postoperatively. Survival was not different between groups (P = 0.81). Unexpectedly, local control was slightly improved in the group treated by radiation only (P = 0.127). If radiation therapy is anticipated, completion of radical hysterectomy followed by radiation therapy appears to offer no advantage over radiation therapy with the uterus in place in patients with early-stage invasive cervical cancer and pelvic lymph node involvement.

Optimal therapy for pelvic recurrence after radical hysterectomy for early-stage cervical cancer.

Forty-eight patients with pelvic recurrence after radical hysterectomy were evaluated. The influence of location of pelvic recurrence (sidewall versus central), histological grade, histological type, and interval from hysterectomy to recurrence had no influence upon curability by radiotherapy. Ten of twenty-eight patients treated by primary radiation therapy for recurrent disease remain without evidence of disease a minimum of 12 months post-therapy, with a projected 5-year disease-free survival in excess of 30%. No patient treated with adjuvant radiation after initial surgery was rendered disease free by subsequent treatment with radiotherapy. Eleven patients were explored for exenterative surgery. Three of six in whom exenteration was technically feasible remain alive without evidence of disease. None of 15 patients treated with chemotherapy remain free of disease. Radiation therapy remains the treatment of choice in post-radical hysterectomy recurrences confined to the pelvis. As exenterative therapy will result in the cure of a small number of patients with disease confined to the pelvis, exenteration should be considered in patients treated previously by radiotherapy. If these efforts fail, chemotherapy is unlikely to result in cure.

Bacterial endotoxin both enhances and inhibits the toxicity of Shiga-like toxin II in rabbits and mice.

The ability of bacterial lipopolysaccharide (LPS) to enhance the toxicity of Shiga-like toxin II (SLT-II) was investigated in rabbits and mice. Rabbits were continuously infused with 0.5 50% lethal dose (LD50) of SLT-II per day. Rabbits that received a 30-micrograms/kg dose of LPS (0.02 LD50) on day 3 of infusion were significantly more likely to die than were rabbits receiving SLT-II only. Rabbits receiving SLT-II and a lower dose of LPS (3 micrograms/kg) did not die but lost an average 3.3% +/- 1.0% of initial body weight during the first 5 days of infusion, compared with weight gains of 4.2% +/- 0.6% and 17.1% +/- 0.9% for rabbits receiving only SLT-II or LPS, respectively. Rabbits that were pretreated with LPS 20 h before challenge with a single dose of SLT-II showed highly significant protection from both the diarrheagenic and lethal effects of SLT-II. Pretreatment of endotoxin-responsive C3H/HeN mice protected the animals from challenge with an LD50 but not an LD100 of SLT-II. LPS enhanced the lethal toxicity of SLT-II for C3H/HeN mice when it was given at 8 or 24 h but not 0 or 72 h after SLT-II challenge. LPS did not affect the lethal toxicity of SLT-II for endotoxin-resistant C3H/HeJ mice. These results suggest that LPS enhances the effects of SLT-II in vivo. Since cecal changes that increase mucosal permeability occur in response to SLT in rabbits, this synergy may be directly relevant to disease processes.