A scoping review of Lyme disease research relevant to public health.

Lyme disease (LD) is an emerging infectious disease in Canada associated with expansion of the geographic range of the tick vector Ixodes scapularis in eastern and central Canada. A scoping review of published research was prioritized to identify and characterize the scientific evidence concerning key aspects of LD to support public health efforts. Prior to initiation of this review, an expert advisory group was surveyed to solicit insight on priority topics and scope. A pre-tested search strategy implemented in eight databases (updated September 2016) captured relevant research. Pre-tested screening and data characterization forms were completed by two independent reviewers and descriptive analysis was conducted to identify topic areas with solid evidence and knowledge gaps. Of 19,353 records screened, 2,258 relevant articles were included in the review under the following six public health focus areas: a) surveillance/monitoring in North America (n=809); b) evaluation of diagnostic tests (n=736); c) risk factors (n=545); d) public health interventions (n=205); e) public knowledge, attitudes and/or perceptions in North America (n=202); and f) the economic burden of LD or cost-benefit of interventions (n=32). The majority of research investigated Borrelia burgdorferi (n=1,664), humans (n=1,154) and Ixodes scapularis (n=459). Sufficient research was identified for potential systematic reviews in four topic areas: a) accuracy of diagnostic tests; b) risk factors for human illness; c) efficacy of LD intervention strategies; and d) prevalence and/or incidence of LD in humans or B. burgdorferi sensu stricto in vertebrate reservoirs or ticks in North America. Future primary research could focus on closing knowledge gaps, such as the role of less studied vertebrate reservoirs in the transmission cycle. Results of this scoping review can be used to quickly identify and summarize relevant research pertaining to specific questions about LD or B. burgdorferi sensu lato in humans, vertebrate hosts or vectors, providing evidence-informed information within timelines that are conducive for public health decision-making.

A review of nosocomial Salmonella outbreaks: infection control interventions found effective.

OBJECTIVE: To review nosocomial salmonellosis outbreaks to identify: mode of transmission; morbidity and mortality patterns; and recommendations for control and prevention. DESIGN: Documented nosocomial salmonellosis outbreaks in hospitals published from January 1995 to November 2011, written in the English language, were systematically reviewed. METHODS: The study methodology incorporated steps from the PRISMA statement for a high quality review process. Computer-aided searches of Scopus, CAB Global Health and CINAHL(®), the Cumulative Index to Nursing and Allied Health Literature were completed to identify relevant outbreak reports written in English. To validate the electronic search methodology, bibliographies and reference lists of relevant review articles were hand-searched. Public health and government websites were searched for nosocomial salmonellosis. RESULTS: Fifty-two relevant reports were identified. The most frequently reported routes of transmission were food 31/52 (59.6%) and person-to-person transmission 7/52 (13.5%). Actions taken during the outbreak to control transmission included improvements to: 1) infection control practices (41.8% of actions); isolation or cohorting patients, hand hygiene practices, and enhancing cleaning and disinfection in patient care areas; and 2) food handling practices (24.4% of actions); reviewing food preparation practices, enhancing cleaning and sanitation of the kitchen, and controlling food temperatures. Investigators made recommendations retrospectively in outbreak reports to provide direction to health centees but these recommendations were not statistically evaluated for effectiveness. CONCLUSIONS: More emphasis should be placed on improving food handling practices, such as training food workers, monitoring food temperatures, and not using raw foods of animal origin, to prevent nosocomial salmonellosis outbreaks in hospitals because almost 60% of the outbreaks were foodborne.

A review of nosocomial norovirus outbreaks: infection control interventions found effective.

The purpose of this study was to review documented outbreaks of enteric illness associated with nosocomial norovirus infections and to identify modes of transmission, morbidity and mortality patterns, and recommendations for control. Searches of electronic databases, public health publications, and federal, state/provincial public health websites were completed for 1 January 2000 to 31 December 2010. Computer-aided searches of literature databases and systematic searches of government websites identified 54 relevant outbreak reports. Transmission routes included person-to-person (18.5%), foodborne (3.7%) and in the majority (77.8%) the route was unknown. Actions taken during the outbreak to control infection included restricting the movements of patients and staff (22.5%), enhanced environmental cleaning (13.6%) and hand hygiene (10.3%). Rapid identification of norovirus outbreaks in hospitals is vital for the immediate implementation of infection control measures and isolation of infected individuals in this mainly immunocompromised population. Studies that statistically evaluate infection control measures are needed.

Review of enteric outbreaks in prisons: effective infection control interventions.

OBJECTIVES: To identify documented outbreaks, worldwide, of enteric illness in correctional facilities over the last 10 years to understand the epidemiology of the outbreaks and explicitly identify effective infection control measures. STUDY DESIGN: Review of literature and outbreak investigation reports. METHODS: Computer-aided searches of literature databases and systematic searches of government websites were completed to identify relevant outbreak reports. Reference lists were hand-searched to validate the electronic search methodology. Reports identified through personal communications with public health officials were also included. RESULTS: Of the 72 outbreaks meeting the inclusion criteria, 76% and 21% were associated with bacterial agents and viral agents, respectively. The majority of outbreaks were associated with Salmonella (n=20), Clostridium perfringens (n=14), norovirus (n=14), pathogenic Escherichia coli (n=10) and Campylobacter spp. (n=5). Transmission was primarily foodborne (67%). During an outbreak, the most common control measures included limiting movements of ill inmates and staff, and their exclusion from kitchen duty. The most common retrospectively reported preventative recommendations included monitoring food temperatures and effective infection control procedures. CONCLUSIONS: It is essential to monitor food temperatures to prevent enteric outbreaks in prisons. Training in safe food handling should be offered to inmates who work in the kitchen. Enteric outbreaks are best controlled by effective infection control practices, while active surveillance and early diagnosis may prevent further spread of illness.

Analysis of foodborne outbreak data reported internationally for source attribution.

Analysis of foodborne outbreak data is one approach to estimate the proportion of human cases of specific enteric diseases attributable to a specific food item (food attribution). Although we recognize that for a variety of reasons reported outbreaks represent only a small portion of all actual outbreaks, using outbreak data for food attribution is the only methodological approach where, theoretically, there is an actual direct link between the pathogen, its source and each infected person. The purpose of this study was to explore the usefulness of foodborne outbreak data extracted from publicly available international electronic reports and publications to provide estimates of food attribution, to derive and compare these estimates between regions, while improving the understanding of the pathogen/food vehicle combination. Electronic reports and publications of foodborne outbreaks that occurred globally since the 1980s were systematically scanned and their data were extracted and compiled in a database. A system of food categorization was developed and food vehicles assigned accordingly. The association between the aetiology and the food source was statistically described for outbreaks with both reported aetiology and incriminated food vehicle. Differences in associations between Australia and New Zealand, Canada, the European Union (EU) and the United States (US) were explored using multiple correspondence analysis and were formally tested between the EU and the US for selected pathogens and food sources. As a result, the food and aetiology cross tabulation of 4093 foodborne outbreaks that occurred globally between 1988 and 2007 is presented and discussed. For a few aetiologies and some foods the association is very specific. The lack of a specific association between the other foods and aetiologies highlights the potential roles of cross-contamination, environmental contamination and the role of the infected foodhandler along the food chain from farm to fork. Detailed analysis of the four regions highlighted some specific associations: Salmonella Enteritidis outbreaks occurred relatively often in the EU states with eggs as the most common source; Campylobacter associated outbreaks were mainly related to poultry products in the EU and to dairy products in the US; there was an association between Escherichia coli outbreaks and beef in Canada; and while Salmonella Typhiumurium outbreaks were relatively common in Australia and New Zealand, across all regions, Salmonella was associated with a variety of food groups. The value and limitations of the study are discussed, as well as the extrapolation of the food attribution estimates beyond their outbreak context.

Enteric outbreaks in long-term care facilities and recommendations for prevention: a review.

Outbreaks of enteric illness in long-term care facilities (LTCFs) were reviewed to identify preventative recommendations. Systematic review methodology identified outbreak reports of gastrointestinal illness in LTCFs either published or that occurred from January 1997 to June 2007. The inclusion criteria captured 75 outbreaks; 23 (31%) associated with bacterial agents and 52 (69%) with viral agents. Transmission was mainly foodborne (52%) for those of bacterial origin and person-to-person (71%) for viral outbreaks. Norovirus infection was associated with 58% of hospitalizations. Sixty deaths were reported, about half from Salmonella infections. Recommendations for foodborne outbreaks emphasized appropriate sourcing and preparation of eggs, staff training, and temperature control during food preparation. Recommendations from outbreaks transmitted person-to-person centred on controlling residents' movements, effective environmental cleaning and disinfection, cancelling social events and restricting visitors, excluding ill staff, encouraging effective hand hygiene, and preventing cross-contamination through gloving and gowning. In none of the 75 published outbreak reports were the suggested recommendations evaluated for effectiveness in controlling the outbreak. Applied research of this type could greatly help in the acceptance of prevention and control strategies.

The potential for acquiring cryptosporidiosis or giardiosis from consumption of mung bean sprouts in Norway: a preliminary step-wise risk assessment.

The current work evolved from a microbial survey of fruits and vegetables conducted in Norway between 1999 and 2001. This survey found that mung bean sprouts were more likely to be contaminated with Cryptosporidium and Giardia than the other produce included in the survey. To support this observation and to demonstrate to public health officials that this might be a risk warranting further attention, a simple risk assessment was initiated. Assuming that 60,000 people in Norway consume a single serving of bean sprouts per week, and contamination levels are similar to those found in the survey, it was calculated that there could be in the order of 20 cases of Giardia or Cryptosporidium infection per 100,000 population attributable to consumption of mung bean sprouts. A number of assumptions were made for the calculations, including parasite factors (e.g. viability, genotype), product factors (e.g. extent of product contamination) and host factors (e.g. composition and extent of consumer group). These assumptions and areas of uncertainty, where further data would improve the risk assessment, are highlighted throughout. Not only does the risk assessment identify new areas of research, but it also demonstrates how risk assessment can be used as a tool to try to influence public health surveillance.

A descriptive analysis of giardiasis cases reported in Ontario, 1990-1998.

Cases of giardiasis in Ontario were described using notifiable disease data from the Ontario Ministry of Health for the years 1990-1998 inclusive. The mean annual age- and sex-adjusted incidence rate was 25.77 cases per 100,000 population for the 25,289 cases reported. Children under five years of age had the highest incidence of disease. Males had a higher mean annual incidence in all age groups. Four deaths occurred among cases. The most frequently reported symptoms were loose stools or watery diarrhea (50.1%). A seasonal pattern was noted, peaking in late summer and early autumn. The most frequently reported probable risk settings were the home (40.1%) and travel (39.1%). The study findings suggest that a high proportion of cases occur in urban areas and spatial analysis showed the highest incidence around Lake Huron and Georgian Bay. Unfiltered water and person-to-person contact are believed to be important sources of infection.

Technique of laparoscopic splenectomy with a powered vascular linear stapler.

The spleen may be removed by a laparoscopic technique, although the benefits and associated morbidity of this approach are unknown. This study reports a series of 28 consecutive patients (15 women; median age 39 (range 17-84) years) considered for laparoscopic splenectomy, because of idiopathic thrombocytopenia in 14, human immunodeficiency virus-related thrombocytopenia in seven, autoimmune haemolytic anaemia in four, lymphoma in two and chronic lymphocytic leukaemia in one. In 23 cases dissection was completed laparoscopically, with the patient in the right lateral position, using a four-cannula technique. Vascular isolation was achieved with an Endo-GIA (powered vascular linear stapler). The spleen was removed by morselation within a retrieval bag (18 patients) or via either a Pfannenstiel or subcostal incision (five). The last 14 procedures have all been completed successfully in a mean operating time of 105 min with discharge from hospital within a median of 3 days. One patient developed a clinically apparent deep venous thrombosis 23 days after operation, for which he required readmission. Elective laparoscopic splenectomy is a feasible although technically demanding operation which may be performed safely and without associated mortality by surgeons experienced in laparoscopic techniques.

Comparison of manual and ultrasonographic evaluation of bladder size in patients prior to laparoscopy.

BACKGROUND: Catheterization of the bladder may reduce laparoscopic complications although an enlarged bladder may be impalpable in overweight patients or following previous lower abdominal surgery. METHODS: This study assessed bladder size by manual examination and transcutaneous ultrasound (US). Consecutive patients (n = 90; median age 55 years [20-85]; 61 females) undergoing laparoscopy were studied prospectively. All patients voided preoperatively and catheterization was performed if estimated US bladder volumes exceeded 300 ml. RESULTS: Manual assessment failed to detect bladder enlargement in any patients (sensitivity: 0%; specificity: 4.4%), whereas ultrasound identified four patients at risk of bladder injury due to unsuspected enlargement (4.4%). Three of these patients were either overweight or obese and one patient had previous lower abdominal surgery. Of 12 patients (13%) catheterized, three had or developed urinary tract infections. CONCLUSIONS: Preoperative voiding does not guarantee bladder emptying. Manual examination does not detect bladder enlargement reliably in the obese patient. Ultrasonography may improve patient selection for catheterization.

Presentation of endometriosis to general surgeons: a 10-year experience.

The presentation and management of 24 patients with endometriosis (median age 34 (range 21-68)years) presenting to general surgeons over a period of 10 years (1985-1994) was reviewed. Patients presented with an abdominal wall swelling related to a previous Pfannenstiel incision (seven patients), umbilical swelling (four), inguinal canal swelling (two), incidentally following appendicectomy (five), terminal ileal obstruction (two), rectal bleeding (two) and urinary symptoms (two). Endometriosis was not suspected in most patients but was confirmed by surgical excision or resection with minimal morbidity. No recurrence occurred during a median follow-up of 53 (range 9-113) months. Endometriosis is a disease rarely seen by general surgeons and is often diagnosed incidentally or on histological examination. Cyclical symptoms associated with menstruation are present in 50 per cent of patients and should suggest the diagnosis in those presenting with scar-related and/or subcutaneous swellings. Simple excision or resection of the presenting lesion provides adequate treatment but, since pelvic endometriosis may be present, referral to a gynaecologist is recommended in every case.

Transurethral resection of the prostate in 539 patients at a district general hospital.

This study audited length of hospital stay, mortality and morbidity associated with transurethral resection of the prostate (TURP) in a district general hospital over a 4-year period between 1990 and 1993. Five hundred and thirty-nine TURPs (409 benign and 130 malignant; median age 69 years) were carried out, which represented a twofold increase over the 4-year period. Although the mean duration of stay was 5 days, 92.5% of patients had a hospital stay of less than 7 days. One (0.2%) death occurred in a patient with ischaemic heart disease on the first postoperative day. The commonest cause of morbidity and delayed discharge from hospital was presence of outflow symptoms in nine (1.7%) patients. Transurethral resection of the prostate is a safe procedure in an ever-increasing elderly population with concomitant medical illness, but improved identification of 'at-risk' patients is required in order to further lower the morbidity associated with this procedure.

Raised carcinoembryonic antigen level as an indicator of recurrent disease in follow up of patients with colorectal cancer.

BACKGROUND: Serum carcinoembryonic antigen level is raised in 80% of patients undergoing colonic resection for cancer. Subsequent elevation in the follow-up period may precede signs and symptoms as an indicator of recurrent disease. there is little evidence that "classical" follow up of patients in the general surgical outpatient clinic improves either survival or quality of life. Regular carcinoembryonic antigen level estimation requested by the general practitioner, allied to day-case colonoscopic surveillance may be a more rational approach. AIM: A study was undertaken to investigate the relationship between raised carcinoembryonic antigen level and the recurrence of colorectal cancer in patients following a curative primary resection. METHOD: Retrospective analysis was carried out on the notes of 125 patients who had attended a dedicated hospital colorectal follow-up clinic between 1988 and 1992. Carcinoembryonic antigen level data were obtained by subsequent examination of the University of Edinburgh Department of Clinical Chemistry (immunoassay section) carcinoembryonic antigen database. RESULTS: A single carcinoembryonic level result of more than 100 ul-1 (normal range less than 60 ul-1) was found to be a highly sensitive (87%), specific (89%), and accurate (88%) indicator of recurrent disease. Raised carcinoembryonic antigen level preceded symptoms in 72% of patients with recurrence of colorectal cancer. CONCLUSION: Sequential laboratory estimation of carcinoembryonic antigen level organized by the general practitioner may represent an accurate method of detecting recurrent colorectal disease. Hospital review could be limited to colonoscopic surveillance and restaging of patients referred with evidence of recurrent disease.

Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography.

OBJECTIVE: The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region. SUMMARY BACKGROUND DATA: Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy. METHODS: A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region). RESULTS: "Occult" metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively). CONCLUSIONS: Staging laparoscopy is indispensable in the detection of "occult" intra-abdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.