A twist on Tarasoff: is there a duty to warn one's client?

Describes a famous legal case in which the court's decision obligates a therapist to protect potential victims from harm that may be done to them by the therapist's client and relates it to the issue of confidentiality as frequently understood by pastoral counseling specialists.

Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in healthy controls

The purpose of this study was to introduce a new method of bedside assessment of both the motor and sensory components of swallowing called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). This approach combines the established bedside endoscopic swallowing evaluation with a more recently described technique that allows objective determination of laryngopharyngeal (LP) sensory discrimination thresholds by delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a flexible endoscope. A prospective study was conducted of FEESST in 20 healthy control subjects, mean age of 34 +/- 11 years. LP sensory thresholds were defined as either normal (< 4.0 mmHg air pulse pressure [APP]), moderate deficit (4.0-6.0 mmHg APP), or severe deficits (> 6.0 mmHg APP). Subsequent to LP sensory testing, food of varying consistencies, mixed with green food coloring, was given and attention was paid to spillage, laryngeal penetration, pharyngeal residue, aspiration, and reflux. Therapeutic maneuvers such as postural changes and airway protection techniques were performed on each subject to determine if the assessed swallowing parameters were affected by maneuvers. All patients completed the study; all had normal LP sensory discrimination thresholds (2.9 +/- 0.7 mmHg APP). There were no instances of spillage, laryngeal penetration, or aspiration. Two of 20 subjects had pharyngeal residue and 2 of 20 had reflux. Institution of therapeutic maneuvers resulted in a predictable change in the endoscopic view of the laryngopharyngeal anatomy. FEESST provides comprehensive, objective sensory and motor information about deglutition in the bedside setting and might have implications for the bedside diagnosis and management of patients with dysphagia.

Restoration of laryngopharyngeal sensation by neural anastomosis

OBJECTIVE

To demonstrate that sensory nerve transposition may be used to reestablish sensation of the laryngopharynx after central nervous system injury and vagal deficit.

DESIGN

Prospective preliminary report of 2 patients following brain-stem stroke with aspiration pneumonia confirmed on chest radiography, severe dysphagia and inability to tolerate oral alimentation, and modified barium swallow that demonstrated cricopharyngeal spasm and impaired laryngeal elevation. Both patients also had severe, bilateral laryngopharyngeal sensory deficits as determined by delivery of air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a fiberoptic telescope. Each patient underwent surgery as part of management of dysphagia after failure of aggressive nonsurgical treatment.

INTERVENTION

During a cricopharyngeal myotomy and laryngeal suspension, a unilateral microneurorrhaphy between the greater auricular nerve and the superior laryngeal nerve was performed.

OUTCOME MEASURES

Ability to tolerate oral diet without development of aspiration pneumonia and postoperative laryngopharyngeal sensory capacity.

RESULTS

By 12 months after surgery, both patients had ipsilateral restoration of laryngopharyngeal sensation, with no further episodes of aspiration pneumonia.

CONCLUSIONS

In select cases of severe dysphagia after central nervous system injury, sensory nerve transposition may be a useful adjunct to the surgical rehabilitation of the patient with dysphagia.

Effects of spray-dried porcine plasma protein on growth traits and nitrogen and energy balance in mice

Energy and nitrogen balances of mice receiving a dried skim milk-based control diet were compared to a similar group of mice receiving a diet containing 8% spray-dried plasma protein (SDPP). Mice were housed in pairs in metabolism cages with feed and water available for ad libitum intake. Five cages were assigned to each diet for a 21-d feeding period. Mice fed SDPP gained more weight (P < .01), consumed more feed (P < .01), and had higher gain: feed ratios (G:F) (P < .01) than mice fed the control diet during wk 1. No significant differences in growth, feed intake, or G:F were detected during wk 2. During wk 3, mice receiving the control diet tended to gain more (P < .10) and had a higher G:F (P < .01). Nitrogen intake and retention were greater for mice fed SDPP (P < .02). Energy intake was greater for mice fed SDPP (P < .01); however, energy retention was not different between treatment groups due to greater (P < .01) metabolic energy losses (urinary energy+heat production). Empty gut weight was greater for control mice on an absolute basis (P < .05) and when expressed as a percentage of BW (P < .02). Liver weights of mice fed SDPP were greater on an absolute basis (P < .02) and as a percentage of BW (P < .01). Feed intake, growth rate, and G:F were increased by dietary addition of SDPP.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of spray-dried porcine plasma protein on feed intake, growth rate, and efficiency of gain in mice

One hundred eight mice were weaned at 21 +/- 1 d and allotted to four dietary treatments: 1) control, 2) control + 4% spray-dried porcine plasma protein (SDPP), 3) control + 8% SDPP, and 4) control + 12% SDPP. Daily gain for males increased with increasing SDPP during wk 1 (P < .01), wk 2 (P < .01), and for the entire 3 wk (P < .01). Daily gain increased quadratically with increasing SDPP for females during wk 1 (P < .05). During the 3rd wk, ADG decreased for females with increasing SDPP (P < .05). Daily feed intake increased linearly (P < .01) with increasing SDPP in all periods. Gain-to-feed ratio (G/F) increased with increasing SDPP during wk 1 (P < .01) and for the first 2 wk (P < .05). During wk 3, G/F decreased with increasing SDPP level (P < .01). Gain-to-feed ratio of females responded quadratically to increasing SDPP during wk 1 (P < .05), whereas G/F of males increased linearly with increasing SDPP level. Gain-to-feed ratio for the entire trial was unaffected by treatment among females (P = .82) but increased linearly with increasing SDPP levels among males (P < .01). Liver weight increased quadratically with increasing SDPP levels for males (P < .05) and females (P < .05). Treatment effect on liver weight per kilogram BW.75 approached significance (P < .10) in females. Male liver weight/100 g BW and liver weight per kilogram BW.75 responded quadratically to increasing SDPP levels (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Antitachycardia pacing with cardioverter-defibrillator backup for malignant ventricular dysrhythmias

This article provides a summary of the history of antitachydysrhythmic devices and their current application in patients with ventricular dysrhythmias. Future trends are also discussed, followed by a case study illustrating the nursing care required for a patient with a combination antitachycardia pacemaker and automatic implantable cardioverter-defibrillator for slow ventricular tachycardia. The basic principles provided can be incorporated into the teaching plans of patients with antidysrhythmic devices for malignant ventricular dysrhythmias.

Myasthenia gravis and Schmidt syndrome

We describe a 47 year old woman with a 30-year history of generalized myasthenia gravis whose condition had been stable and well controlled on a combination of pyridostigmine and ephedrine until she presented. At this time she gave a 2 month history of weakness, nausea, vomiting and more recently intermittent confusion. Investigations confirmed both primary hypothyroidism and primary adrenal failure (Schmidt syndrome). The autoimmune aetiology of these three conditions was confirmed by positive acetylcholine receptor, adrenal and thyroid microsomal antibodies.

Recovery of inoculated Salmonella from poultry feed containing furazolidone

It was determined that the presence of furazolidone, a common feed additive, prevented detection of Salmonella in feed samples. Artificially inoculated Salmonella were not recovered from feed samples containing furazolidone when buffered peptone broth (BP) was used as an enrichment medium, but Salmonella were recovered from all feed samples containing furazolidone when thiol broth was used as a substitute for BP.

Identification of Enterobacteriaceae in Foods with the AutoMicrobic System

Stock cultures (136) and fresh isolates (163) of Enterobacteriaceae from ground beef, processed chickens, frozen pot pies and commercial poultry feeds were identified to species with the AutoMicrobic System (AMS). All stock cultures and fresh isolates were also concurrently tested with two other identification systems (Micro-ID and API), previously evaluated and proven accurate for identification of Enterobacteriaceae . The AMS correctly identified to species 135/136 (99.3%) of the stock cultures and 160/163 (98.2%) of the fresh isolates. All Salmonella cultures tested (74) were correctly identified by AMS.

Identification of Enterobacteriaceae from Foods with the Spectrum-10

Spectrum-10, a newly developed miniaturized identification system, was analyzed for its ability to accurately and rapidly identify members of the Enterobacteriaceae family. This study, conducted at two separate laboratories, tested freshly isolated organisms from raw and frozen foods (180) and stock cultures (144). For comparison purposes, the Micro-ID and API-20E identification systems were concurrently inoculated with the test organisms. In comparison to the Micro-ID and the API-20E systems, the Spectrum-10 identified 95 to 96% of the stock cultures to genus and species, whereas 93% of the fresh isolates were identified to genus and 82% to species.

Comparison of Aerobic and Anaerobic Incubation Conditions for Optimal Recovery of Salmonella

Effects of aerobic and anaerobic incubation of selenite-cystine and TT enrichment broth incubated at 37 and 34°C on the growth of Salmonella were determined. Pure cultures of four serotypes of Salmonella were enumerated at 0, 4, 8 and 24 h of incubation and no significant differences related to incubation conditions were found. The effect of microflora other than Salmonella , in pure and mixed cultures and from chicken and feed samples, on the recovery rate of Salmonella after incubation in enrichment media was evaluated and no significant effects were found; however, aerobic incubation usually gave higher Salmonella counts. Greater recovery of Salmonella was obtained by incubating selective plating media aerobically rather than anaerobically. Aerobic incubation of liquid enrichment media and differential plating media is therefore recommended for optimal recovery of Salmonella .

Survival of Salmonella in Dry Food and Feed

The survival of Salmonella Montevideo and Salmonella heidelberg in dry milk, cocoa powder, poultry feed, and meat and bone meal was studied at three water activities (a_w) in the range of 0.4 to 0.75. S. montevideo was more resistant to the various dry environments than S. heidelberg . Salmonellae were enumerated immediately after inoculation, after 2 d, and after 1, 3, 7 and 14 wk. Survival was greater at a_w of 0.43 and 0.52 than at 0.75 a_w. Based on these findings and due to the marked differences in survival observed in the different products equilibrated at a specific a_w value, it is concluded that the survival of salmonellae in a dry product cannot be predicted on the basis of the a_w alone.

Comparison of Brands of Media for Isolating Bacteria from Poultry, Beef and Shrimp

Five brands of media (BBL, Difco, Gibco, Oxoid and Scott) were evaluated for enumerating microorganisms by the aerobic plate count and by Enterobacteriaceae , Escherichia coli , and coliform counts, and for determining Salmonella incidence. Microbiological evaluations were done on raw chickens, raw beef and raw shrimp, except that Salmonella incidence was not determined on shrimp samples. There were statistically significant differences in total plate counts (with chicken, beef and shrimp), Enterobacteriaceae counts (with shrimp) coliforms (with chicken) and E. coli counts (with chicken) by the five brands of media, but these differences were too small to be of practical significance. It was concluded that no differences of practical significance were found among the five brands of media.

Recovery of Salmonella from Artificially Contaminated Poultry Feeds in Non-Selective and Selective Broth Media

The efficacy of four preenrichment media (lactose broth, lactose broth with Tergitol, buffered peptone and M-9) and of direct enrichment in selenite cystine and modified tetrathionate broths for recovering two Salmonella serotypes from dry poultry feed was determined. The salmonellae, artificially inoculated and stored for 7 wk in the dry feed (1.5 to 2.2 cells of salmonellae/g of feed analyzed), were recovered from significantly more samples after preenrichment with M-9 or buffered peptone than with any of the other procedures tested.

Effect of Reduced Processing on Recovery of Foodborne Pathogens from Hot-Boned Broiler Meat and Skin

Recovery of pathogens from breast meat, thigh meat and skin from scalded, defeathered but uneviscerated broiler carcasses with and without spray washing was compared to recovery from breast meat, thigh meat and skin from fully processed, chilled carcasses (controls). The incidence of coagulase-positive staphylococci was not significantly different on meat and skin from both uneviscerated carcasses with and without a spray washing compared to meat and skin from fully processed carcasses. The incidence of Clostridium perfringens was not significantly different on skin, breast and thigh meat for any of the sampling sources except that incidence on meat from control breasts was lower than on breast meat from uneviscerated carcasses without spray-washing; and incidence on meat from control thighs was lower than on meat from spray-washed, uneviscerated carcasses. Salmonella incidence was higher on both breast and thigh meat from fully processed control carcasses than from uneviscerated unwashed carcasses. When uneviscerated carcasses were spray-washed after defeathering, the incidence of Salmonella was not significantly different on breast meat, and significantly lower on thigh meat than on these meats from fully processed control carcasses. Skin from fully processed control carcasses had a higher incidence of Salmonella than did skin from uneviscerated, unwashed carcasses, but not skin from uneviscerated, spray-washed carcasses. Reducing the number of stages of processing significantly reduced the incidence of Salmonella but not of coagulase-positive staphylococci or Clostridium perfringens .

Selecting a Miniaturized System for Identification of Enterobacteriaceae

The most commonly used commercial diagnostic kits for identification of Enterobacteriaceae are API, Enteric-Tek, Enterotube II, Micro-ID, Minitek and Spectrum-10. The accuracy of identification by all systems does not vary significantly, and falls within the acceptable range. Therefore, a bacteriologist who is considering the use of these products should evaluate factors other than accuracy when making a choice. Twenty-three professional microbiologists who had previous experience with these systems listed advantages and disadvantages of each system, and evaluated the conventional procedure for identification. The comments were summarized and presented in tabular form. The current cost per isolate of each system and the cost of the identification manual, reagents and incidental costs were also determined. These data provide the potential user with comparative information on price, shelf-life, versatility, time required for inoculation, incubation and manipulation after incubation, possible difficulties in determining positive and negative reactions, and potential safety factors for laboratory personnel.

Salmonella and other Enterobacteriaceae found in commercial poultry feed

Poultry feed (mash and pelleted) and meat and bone meal samples were collected from commercial mills. All samples were analyzed for Enterobacteriaceae count (ENT) and Salmonella. The genus and species of the various Enterobacteriaceae present were also determined. The average ENT for mash, pelleted, and meal samples was log 4.1, .8, and 1.8/g, respectively. Enterobacteriaceae were present in 100, 60, and 92% and Salmonella in 58, 0, and 92% of the mash, pelleted, and meal samples, respectively. Overall, the Enterobacteriaceae most frequently isolated from all samples were Enterobacter agglomerans, Enterobacter cloacae, and Klebsiella pneumoniae. Although no Salmonella were found in the pelleted samples, the presence of other Enterobacteriaceae suggests that commercial pelleting may not totally destroy Salmonella since their heat resistance is similar to the other organisms found.

Evaluation of Five Miniaturized Systems for Identifying Enterobacteriaceae from Stock Cultures and Raw Foods

Five miniaturized systems (API, Enteric-Tek, Enterotube II, Micro-ID and Minitek) were compared to conventional procedures for identification of Enterobacteriaceae from stock cultures and freshly isolated from food sources, The accuracy of identification to genus was 98% for Micro-ID; 95%, Minitek; 94%, Enteric-Tek; 93%, API; and 86%, Enterotube II, Accuracy of identification to species was 97% for Micro-ID; 94%, Minitek; 93%, Enteric-Tek; 91 %, API; and 79%, Enterotube II, The 124 organisms tested in this study were from 11 genera of the Enterobacteriaceae family. All systems accurately identified to species the most pathogenic members of the family ( Arizona hinshawii , Salmonella typhi , Salmonella typhimurium and Shigella flexneri ). Most of the inaccuracies in identification occurred with Enterobacter and Serratia species.

Heating by microwave, hot air, and flowing steam to eliminate inoculated Salmonella from poultry feed

Poultry feed samples (mash) obtained from a commercial mill were inoculated with either 100 or 5,000 cells/g of a marker strain of Salmonella montevideo. Samples (125 g) were then placed in a microwave oven at power settings of 1.5 or 2.0 kW for 60, 90, or 120 sec; a hot air oven at 99 C (210 F) or 110 C (230 F) for 15, 30, 45, or 60 min; or a flowing steam chamber for 1, 5, 10, or 20 min. Temperature, moisture, and presence of the inoculated S. montevideo were determined in all samples before and after treatment. Feed samples placed in the microwave oven reached a maximum temperature of 186 C (367 F) and had a final moisture content as low as .8%. About 25% of the samples inoculated with 100 cells/g and about 40% of those inoculated with 5,000 cells/g remained positive after treatment. In the hot air oven, feed reached a maximum temperature of 93 C (200 F) with a moisture level after heating of about 4%. Salmonellae were recovered from 35 and 60% of the low and high inoculum level samples, respectively. In flowing steam, maximum feed temperature was 90 C (194 F) with a final moisture level of 15%. After 1, 5, 10, and 20 min of flowing steam, 100, 90, 60, and 0% of the samples were found to contain salmonellae, respectively. All treatments occasionally eliminated salmonellae from the samples, but results were inconsistent and unpredictable.

Rapid Procedure for Biochemical Characterization and Serological Confirmation of Suspect Salmonella Isolates

Fifty-two freshly processed broiler carcasses were examined for the presence of Salmonella by using a rinse method. Three selective plating media (bismuth sulfite, brilliant green sulfa and Hektoen enteric) were compared. After 24 h of incubation, typical colonies were picked from each selective plate. An 8-h procedure to biochemically characterize (Micro ID) and serologically (poly O and poly H) confirm Salmonella was then compared with a conventional procedure. Suspect Salmonella isolates were correctly classified from 63% of the carcasses with both the 8-h and conventional procedures. Of the 244 isolates confirmed to be Salmonella by conventional testing, 236 (97%) were also confirmed by the 8-h procedure. Brilliant green sulfa and Hektoen enteric agar were superior to bismuth sulfite agar for Salmonella recovery. The 8-h procedure required less incubation time (8 h vs. 48 h) after colony formation, less incubation space, and less media preparation and cleanup than the conventional procedure.

Effect of various media and incubation conditions on recovery of inoculated Salmonella from poultry feed

Samples of commercially pelleted poultry feed (30 g) were inoculated with nalidixic acid-resistant marker strains of Salmonella heidelberg or S. montevideo at levels of 1 (low), 20 (medium), or 40 (high) cells/g of feed, then 100 ml of either a nonselective preenrichment medium (lactose broth) or a selective enrichment medium [selenite cystine (SC) or tetrathionate brilliant green (TT) broth] was added and incubated at either 37 or 43 C for 24 or 48 hr in different experiments. Four selective plating media [MacConkey with 100 ppm nalidixic acid, brilliant green (BG) sulfa, modified BG, bismuth sulfite] were then streaked. MacConkey agar with nalidixic acid served as a control to which the other three plating media were compared. After 24 hr incubation at 37 C, colonies with characteristics typical of Salmonella were selected from the plates and examined biochemically and serologically to determine if they were the marker organism. In this study, preenrichment was counterproductive, because the marker organisms were recovered much more often with direct enrichment in SC or TT broth than with reenrichment in lactose broth. The TT broth produced 135 positive recoveries, whereas only 88 positive recoveries were made with SC. No differences were observed between 37 and 43 C or 24 and 48 hr incubation of the selective enrichment media. Overall efficiency of the plating media for Salmonella recovery from feed, when compared to the control (MacConkey), was BG sulfa, 65%;modified BG, 64%; and bismuth sulfite, 40%. The most effective enrichment broth-plating medium combination was TT-BG sulfa, yielding 86% positive recoveries when compared to the control.

Minimizing Salmonella Contamination on Broiler Carcasses with Poly (Hexamethylenebiguanide Hydrochloride)

Broiler carcasses, each inoculated with 30 cells of marker Salmonella heidelberg , were prechilled and chilled together with uninoculated carcasses in a simulated commercial chilling system. When either 10 or 25 ppm of PHMB [poly(hexamethylenebiguanide hydrochloride)] was added to the prechill water, cross-contamination (uninoculated carcasses showing contamination with marker Salmonella after chilling) was prevented, and no viable Salmonella were found on the inoculated carcasses. When carcasses, each inoculated with 60,000 cells of marker Salmonella , were similarly chilled, and 10 ppm of PHMB was added to the prechill water, cross-contamination was not prevented, and viable Salmonella were found on the inoculated carcasses. With 60,000 cells, and 25 ppm PHMB, cross-contamination was prevented, but viable Salmonella remained on the inoculated carcasses.