Helping Patients to Help Themselves after Breast Cancer Treatment.

There is a rise in the number of women living with the long-term consequences of cancer and continuing to suffer unmet need as breast cancer survival improves. This paper includes an introduction to self-management and a discussion of the evidence around the effectiveness of the key intervention types that could help patients to help themselves after treatment. Self-management interventions are particularly beneficial in reducing bother from symptoms, without patients having to take on the additional burden of more unwanted side-effects frequently seen with pharmacological interventions. There is a need to prioritise the funding of these financially viable self-management strategies to ensure equity of access and that these interventions are available for those in need.

Menopausal hot flushes after breast cancer.

The study aimed to improve understanding of the natural history and impact of hot flushes after breast cancer. Data were collected from women participating in an RCT of relaxation to reduce the incidence of flushes from breast cancer follow-up clinics from two hospitals in South-East England. Repondents were 150 women experiencing hot flushes following completion of primary treatment for breast cancer. This study utilized a flush diary, the Hot Flushes and Night Sweats Questionnaire (HFNSQ), Functional Assessment of Cancer Therapy with Endocrine Subscale (FACT-ES) and Spielberger State/Trait Anxiety Index (STAI) as the main outcome measures. The study found that in this sample, 51 (34%) women experienced flushes more than five years after diagnosis and 75 (50%) more than 5 years after menopause. Sleep disruption occurred in 90 women (72% of those that returned diaries), affecting half of the nights they recorded. The mean problem rating on the HFNSQ was 4.85 out of 10. A peak incidence of flushes was apparent around 10 a.m. in women taking tamoxifen. It was concluded that hot flushes after breast cancer may be long-lasting and cause sleeping difficulties for many women. Tamoxifen may affect the diurnal pattern of flushes. After breast cancer, the duration of flushes, potential distress and disruption to women's lives should not be underestimated and appropriate interventions should be offered.

The experience of hot flushes after breast cancer.

As survival from breast cancer increases, there is a corresponding rise in the number of women living with the long-term consequences of its treatment. Distressing menopausal hot flushes occur in many of these women. This article reports on interviews conducted with 8 women, exploring the experience of hot flushes after breast cancer. Women's accounts of hot flushes varied from being a mild sensation to an intensely unpleasant sensation affecting the whole body and accompanied by drenching perspiration. Flushes affected all aspects of the women's lives, including sleeping, clothing, social situations, intimate relationships, and ability to work. Emotionally, women talked about being out of control. Having cancer and menopause simultaneously made it more difficult for the women to cope, and cancer treatment could cause flushing. The women used many strategies to help relieve their difficulties. Some resorted to hormone replacement therapy, whereas others turned to herbal medications and other alternative interventions such as acupuncture. Most women adopted behavioral strategies to try to regain control. Ultimately, they found that control was gained by attitude of mind. Cognitive behavioral techniques may enhance the sense of control and contribute to coping during hot flushes.

Transfer of antibiotic resistance between commensal and pathogenic members of the Enterobacteriaceae under ileal conditions.

AIM: To determine the rate of antibiotic resistance transmission between commensal and pathogenic representatives of the Enterobacteriaceae. METHODS AND RESULTS: Through the use of a validated in vitro simulation of the porcine ileum, the transmission of antibiotic resistance was detected between commensal Escherichia coli, E. coli O157 and Salmonella spp. Countable transconjugant populations arose readily and, in one example, proved capable of indefinite persistence. CONCLUSIONS: Genetic material conferring antibiotic resistance is readily transmissible between members of the Enterobacteriaceae under ileal conditions. Recipient phenotype influences the persistence of multi-resistant transconjugants. SIGNIFICANCE AND IMPACT OF THE STUDY: The observation that the conjugal transmission of antibiotic resistance is commonplace under ileal conditions impacts primarily on the risk of food contamination by multi-resistant bacteria. The establishment of a multi-resistant transconjugant population as a dominant member of the microflora maintains a genetic reservoir of antimicrobial resistance.

Influence of tetracycline exposure on tetracycline resistance and the carriage of tetracycline resistance genes within commensal Escherichia coli populations.

AIMS: To assess the influence of incremental tetracycline exposure on the genetic basis of tetracycline resistance within faecal Escherichia coli. METHODS AND RESULTS: Through the adoption of a novel combination of multiple breakpoint selection, phenotypic characterization and the application of a polymerase chain reaction based gene identification system it proved possible to monitor the influence of antibiotic exposure on resistance gene possession. Using tetracycline as a case study a clear hierarchy was revealed between tet genes, strongly influenced by host antimicrobial exposure history. CONCLUSIONS: The antimicrobial exposure regime under which an animal is produced affects both the identity and magnitude of resistance gene possession of a selected bacterial population within its enteric microflora. Among the ramifications associated with such resistance gene selection is the degree of resistance conferred and the carriage of linked resistance determinants. This selection is applied by exposure to antibiotic concentrations well below recognized minimum inhibitory tetracycline concentration breakpoints widely adopted to characterize bacterial 'susceptibility'. SIGNIFICANCE AND IMPACT OF THE STUDY: This study confirms the ability of minimal antibiotic exposure to select for the continued persistence of resistance genes within the enteric microflora. It is clearly demonstrated that different antimicrobial regimes select for different resistance genes, the implications of which are discussed.

Long-term survival of Escherichia coli O157 on pasture following an outbreak associated with sheep at a scout camp.

AIMS: To monitor the decay of E. coli O157 in soil (loamy sand) on a scout campsite following an outbreak in humans. METHODS AND RESULTS: Samples of soil and sheep faeces were collected from the campsite and tested for the presence of E. coli O157 by immunomagnetic separation (IMS) after enrichment in buffered peptone water + vancomycin at 42 degrees C for 6 h. Enumeration of target was carried out by direct plating onto sorbitol MacConkey agar plates supplemented with cefixime and tellurite (CTSMAC) incubated at 37 degrees C for 24 h. Low numbers (< 100 g(-1)) were estimated by the most probable number (3-tube MPN) technique. CONCLUSIONS: Survival was observed for 15 weeks. SIGNIFICANCE AND IMPACT OF THE STUDY: A number of laboratory studies have followed the decay of E. coli O157 in soil, animal faeces and water. This study follows (for the first time) the decay of the organism in soil after an outbreak associated with sheep. It demonstrates the long-term persistence of the organism in the environment and the results will be potentially important in performing risk assessments for both human and animal infection.

Modelling the vector pathway and infection of humans in an environmental outbreak of Escherichia coli O157.

Quantifying the transfer of Escherichia coli O157 from the environment to humans is essential for understanding outbreaks, establishing the infectious dose of the organism and proposing safeguards. We modelled the pathogen loading shed onto a field by sheep immediately prior to a scout camp where 18 scouts and two adults were infected with E. coli O157. We estimated the dose ingested (4-24 organisms) which is in agreement with the low infective dose reported previously for this organism in food outbreaks. These data closely fit a surrogate Shigella dose-response model which can be used as a basis for risk assessment.

The fate of Escherichia coli O157 in soil and its potential to contaminate drinking water.

The survival and transport of Escherichia coli and E. coli O157 after cattle slurry application were studied on drained plots in both grassland and arable stubble at three sites in Scotland. Leaching losses were between 0.2% and 10% of total E. coli and were dependent on rainfall. Recovery of E. coli in grass and soil declined with approximately first order kinetics. Residual numbers, in excess of background declined more slowly. The pattern was similar for both grass and arable plots. Laboratory incubations of soil cores, with applied slurry containing E. coli and E. coli O157 were performed in soils with different moisture contents at two temperatures for clay loam and sandy loam soils. Both E. coli populations were measured over a 4-week period. Using a dual population approach, the die off of the susceptible pool was linear with a half-life of 3-4 days, and was faster at the higher temperature and lowest moisture content. The resistant pool was not strongly affected by temperature or moisture and had a half-life for die off of between 18 and 24 days. After a 4-week period, < 100 cfu g/soil of E. coli and E. coli O157 remained. The die off rate of E. coli O157 was the same or slightly faster than that of the commensal E. coli population, indicating that the field behaviour of E. coli O157 can be studied by monitoring the total population of E. coli applied with slurry. The risk of significant pollution of water by E. coli is highest immediately after application of slurry, and the first increments of drainflow carry significant concentrations. Thereafter, the risk of pollution is very low. If weather conditions are dry after application on well-drained sandy soils, it is unlikely that any significant losses of organisms to drains will occur. Such data can be used to control and minimise the risk of E. coli O157 contaminating drinking water.

The fate of Escherichia coli and E. coli O157 in cattle slurry after application to land.

The fate of both faecal Escherichia coli and E. coli O157 in slurry following application to arable and grass plots on a clay loam soil was studied. Slurry (5% dry matter) containing 5.3 x 10(4) ml(-1) E. coli and 30 E. coli O157 100 ml(-1) was spread in early March. Initially, almost all E. coli were retained in the upper layers of the soil. Escherichia coli numbers steadily declined to less than 1% of those applied by day 29, and E. coli O157 were only detected in the soil and on the grass for the first week after application. There was some transport of bacteria to deeper layers of the soil, but this was approximately 2% of the total; transport to drains over the same period was mainly associated with rainfall events and amounted to approximately 7% of applied E. coli. However, there were indications that periods of heavy rainfall could cause significant losses of E. coli by both leaching and run-off. Experimental studies showed that E. coli O157 on grass, which was subsequently ensiled in conditions allowing aerobic spoilage, could multiply to numbers exceeding 10(6) g(-1) in the silage.

Growth of Escherichia coli O157 in poorly fermented laboratory silage: a possible environmental dimension in the epidemiology of E. coli O157.

Laboratory silages, inoculated with either c. 1000 cfu g-1, an atoxigenic Escherichia coli O157 or a toxigenic E. coli O157 isolate, were made in plastic bags which permitted limited aerobic spoilage. Replicate bags of each treatment were opened at weekly intervals after incubation at 20 degrees C. In all silages the fermentation was slow and aerobic spoilage with visible moulding ocurred at the tie ends after 7 d. In all the aerobically spoiled silages Enterobacteriaceae reached over 107 cfu g-1 within 1 week. The E. coli in control silages increased from barely detectable levels to 104 cfu g-1 within 13 d; over the same period both strains of E. coli O157 increased from 103 to 107 cfu g-1. The increases in the poorly fermented interior of the silage bags were initially similar but declined slightly as the pH fell. It is suggested that faecal contamination of grass followed by poor silage management may be a factor in the persistence of E. coli O157 carriage in ruminants.

The incidence and level of Listeria monocytogenes contamination of food sources at primary production and initial processing.

Listeria monocytogenes was isolated in low numbers from a variety of environmental samples associated with the primary production of food, including vegetation, faeces and meat. The organism was rarely detected on growing grass and vegetables prior to processing. The excretion of L. monocytogenes by farm animals was linked to their diet, with animals fed entirely on hay or manufactured diets not excreting detectable levels of Listeria (i.e. absence in 25 g). However, animals fed on silage, which is frequently contaminated with L. monocytogenes, commonly excreted the organism. Transport of live animals over long distances (> 100 km) significantly increased the level of excretion of Listeria, but the contamination of carcasses of sheep and cattle was not high. Pigs and poultry faeces were free of Listeria prior to slaughter and pig carcasses were not found to have Listeria present. Frozen and chilled chicken did show detectable levels reflecting the greater potential for contamination during poultry processing. Samples of minced beef were tested and 21 of 23 samples were positive for L. monocytogenes, demonstrating that processing significantly increases the level of contamination compared to whole carcasses. Multilocus enzyme electrophoresis of a representative selection of the isolates showed that there was a wide range of electrophoretic types present in the primary production environment, relatively few of which have been linked to cases of human listeriosis. However, these types do arise on farms and occasional contamination of food raw material by potentially virulent strains may be sufficient to allow adaptable strains to become established in the processing environment and thus be responsible for more widespread contamination of the food available to the consumer.

The relationship between ecophysiology, indigenous microflora and growth of Listeria monocytogenes in grass silage.

The combined effect of the physical and chemical parameters (oxygen tension, pH and dry matter) influencing Listeria monocytogenes growth and survival in silage were simultaneously studied in a model in vitro system. Ensiled grass was exposed to a range of low oxygen concentrations, 0-5% v/v, and their effect was recorded with respect to acidification and microbial population dynamics of the epiphytic microflora, i.e. lactic acid bacteria, enterobacteria, yeasts, moulds and L. monocytogenes in grasses pre-inoculated with the latter. Listeria monocytogenes survival depended on the establishment of a fine balance between the physico-chemical and microbiological characteristics, i.e. oxygen tension, dry matter, pH, grass and microbiological quality. In all grasses ensiled, an oxygen concentration of 1.0% or greater sustained L. monocytogenes growth, below this level growth was shown to be principally dependent on the rate and quality of the fermentation. In most grasses 0.5% oxygen prolonged survival, whereas 0.1% and 0% oxygen caused L. monocytogenes to die off. In very poor quality grass with a restricted fermentation L. monocytogenes survival was prolonged even under anaerobic conditions.

Rapid RAPD analysis for distinguishing Listeria species and Listeria monocytogenes serotypes using a capillary air thermal cycler.

Using a novel capillary thermal cycler, randomly amplified polymorphic DNA (RAPD) generated DNA fingerprints were obtained in 3 h. The RAPD profiles were produced using a random 10-mer primer (5'-ACCGCCTGCT-3') which discriminated between different Listeria spp. Unique fragment profiles of Listeria monocytogenes serotypes were produced from serotypes 1a, 2, 3a, 4ab, 4a and 4c but serotypes, 1/2a, 4b, 4d and 7 had similar profiles.

The incidence, numbers and types of Listeria monocytogenes isolated from farm bulk tank milks.

Bulk tank milk from 160 producers was tested for Listeria monocytogenes at three monthly intervals over 1 year. Twenty-five producers were positive, most on a single occasion, only seven were positive on three or more of the four samplings. Listeria monocytogenes numbers were low, usually < 1 ml-1, the highest was 35 ml-1. All isolates were serotype 1, the use of multilocus enzyme electrophoresis on representative isolates gave nine different electrophoretic types, two have been associated with listeriosis in humans or animals, a further two had only been isolated from one other source (silage or faeces), while the majority (5) were unique to milk.

A study of mastitis bacteria and herd management practices to identify their relationship to high somatic cell counts in bulk tank milk.

Thirty dairy herds, selected to cover a wide range of bulk tank somatic cell count (BTSCC) values, were used to study the relationship between the levels of the principal species of mastitis-causing bacteria, herd management practices and the BTSCC. A good correlation was found between the number of mastitis streptococci (Streptococcus agalactiae, S. dysgalactiae and S. uberis) found in bulk tank milk and the BTSCC. Staphylococcus aureus was less significantly correlated to BTSCC, but was of increasing importance in borderline BTSCC herds, where lower excretion levels into milk were unlikely to trigger hygiene penalties and so alert producers to the presence of a significant mastitis problem. High BTSCC herds had significantly lower yields and were less likely to use a post-milking teat dip or to have a regular programme of milking machine maintenance or automatic cluster removal. These herds also tended to buy in replacements rather than breed their own. Overall the management of high BTSCC herds showed less commitment to implementing mastitis control procedures than herds with a consistently low BTSCC.

The incidence of Listeria monocytogenes in raw milk from farm bulk tanks in north-east Scotland.

Over 180 farm bulk milk tanks were tested for the presence of Listeria monocytogenes on three separate occasions which included periods when cows were grazing and confined inside on a silage diet. The incidence of L. monocytogenes contamination was low, ranging from 3.8% in the summer samples to 1.0% in October. The level of contamination was estimated to be lower than one L. monocytogenes bacterium per ml in positive samples, as most required cold enrichment of 10-20 ml volumes before recovery. The distribution was sporadic; only one farm gave positive isolations on all three sampling occasions, one other on two, and all others were from different farms. No correlation between the presence of L. monocytogenes and hygiene standards or the feeding of silage was found.

The incidence of Listeria monocytogenes in farm bulk milks in NE Scotland.

Raw milk samples (c. 20 ml) were taken from approximately 180 farm bulk tanks in the NE of Scotland on 3 occasions over a period from August 1987 to February 1988 and tested for the presence of Listeria monocytogenes. The maximum incidence of L. monocytogenes (3.8%) was found in the August sampling, with incidences of 1.02% and 2.7% in October and February. Direct enrichment of 0.1 ml was negative and only 2 of the total of 14 positives were obtained by direct enrichment using 1.0 ml of milk, the remainder requiring cold enrichment over a period up to 8 weeks. These findings are similar to two recent USA surveys which suggest that is positive milks the number of L. monocytogenes per ml is in the order of 1 organism per ml.

Rapid quantitative assessment of the distribution of Listeria in silage implicated in a suspected outbreak of listeriosis in calves.

A silage clamp was sampled for the presence of Listeria species. Even though covered by a heavy duty black plastic sheet the top few centimetres of silage were heavily contaminated with Listeria species. In the areas nearest the edges of the sheet the pathogenic species Listeria monocytogenes was found in numbers in excess of 12,000 organisms/g silage. Using the methods of isolation described, pathogenic species of Listeria could be differentiated from non-pathogenic species in three to four days.

Wild birds and silage as reservoirs of Listeria in the agricultural environment.

A method for the isolation of listeria which enabled a more rapid detection of the organism was used to examine samples of silage and bird faeces. Faecal samples indicated that seagulls feeding at sewage works had a higher rate of carriage than those elsewhere. Faecal samples from rooks generally suggested a low incidence of listeria except on one occasion when eight of twenty samples contained Listeria monocytogenes: this coincided with the nesting season and the peak period for listeriosis in sheep. The incidence of L. monocytogenes in clamp silages ranged from 2.5-5.9%, but in samples of big bale silages the incidence was 22.2% and, when mouldy samples were selected, 44%.