SKIN TEMPERATURE, COLOUR, and WARMTH FELT, IN HYDROCOLLATOR PACK APPLICATIONS TO THE LUMBAR REGION

The application of hydrocollator packs carries an inherent danger of overheating, which must be avoided. While a variety of temperatures and coverings for the packs has been reported, it has been stated that a bright red skin colour may be indicative of skin damage. It has also been stated that a therapeutically desirable rise in skin temperature would be one to over 40°C during the treatment. In this study hydro-pack applications to the lumbar region of the back were assessed for onset of sensation after application, and at intervals thereafter for skin temperature, skin colour, and subjective sensation of warmth. The lack of co-relation found between these variables suggests that in clinical work an observation of the skin and also a subjective report, should be obtained at frequent intervals for at least the first nine minutes after application. The need for a rise in skin temperature above 40°C is questioned.

Can UK healthcare workers remotely support medical education in the developing world?: Focus group evaluation

Objectives

To evaluate the feasibility of providing regular, live, text-based teaching to medical students and junior doctors in Somaliland using a dedicated case-based medical education website (www.MedicineAfrica.com).

Design

Review of MedicineAfrica database for details of teaching sessions held in Somaliland from December 2008-October 2010 and evaluation of user experiences through focus groups.

Setting

King's College Hospital, London, UK and Ahmoud University, Borama, Somaliland.

Participants

Final year medical students, newly graduated interns and second year interns at Ahmoud University, Borama, Somaliland.

Main outcome measures

Qualitative and quantitative user rating of online case-based tutorials in the context of pre-existing educational opportunities available to them.

Results

Regular online teaching sessions are received enthusiastically by students and junior doctors and are reported to improve their clinical practice.

Conclusions

Despite technological limitations in Somaliland, a live text-based teaching service can be delivered effectively and streamlined with local curricula. This represents an alternative to traditional static teaching methodologies currently used in international medical education.

Cryptococcus gattii infections on Vancouver Island, British Columbia, Canada: emergence of a tropical fungus in a temperate environment

BACKGROUND

Cryptococcus gattii causes disease among immunocompetent individuals in the tropics and subtropics. We document the appearance of C. gattii infections on Vancouver Island (VI), a temperate region, and discuss reasons for this emergence.

METHODS

Data on Cryptococcus hospitalizations for the calendar years 1995 through 2004 were reviewed. Viable historic isolates stored at the provincial public health laboratory between 1987 and 2000 were serotyped. Human cases were mapped by place of residence.

RESULTS

Cryptococcosis among HIV negative individuals diagnosed on VI increased sharply after 1999. C. gattii was not detected in stored isolates prior to 1999. C. gattii cases lived in a specific biogeoclimatic zone on VI. Higher rates of illness were associated with exposure to the central region of VI.

CONCLUSIONS

The emergence of C. gattii in a temperate region is unprecedented. Clinicians should consider C. gattii in the differential diagnosis of individuals who travelled to certain areas in British Columbia.

Drinking water consumption patterns in British Columbia: an investigation of associations with demographic factors and acute gastrointestinal illness

A cross-sectional telephone survey was performed in the province of British Columbia, Canada, to investigate drinking water consumption patterns and their associations with various demographic characteristics and acute gastrointestinal illness (AGI). Water consumption included plain water and water used in the preparation of cold beverages. The median amount of water consumed daily was four-250 mL servings (1.0 L), although responses were highly variable (0 to 9.0 L). Alternative water use was common: bottled water was the primary source of drinking water (i.e. >or=75% of the total daily water intake) for 23% of respondents and 47% of households used in-home water treatment methods. Approximately 10% of respondents reported an episode of AGI (vomiting or diarrhea) in the previous 4-week period. Such illness was associated with age (continuous variable in years, OR=-0.98), sex (male vs. female, OR=0.8) and the amount of water consumed (continuous variable in 250-mL servings, OR=1.06); however, a causal relationship with water consumption cannot be established based on this study alone. Overall, the associations of drinking water patterns with age, sex, education, and household income serve as important reminders to researchers and public health professionals of the non-uniform nature of drinking water consumption, and indicate potential differences in exposure to waterborne hazards in this population.

Emergence of Cryptococcus gattii in a novel environment provides clues to its incubation period

Cryptococcus gattii emerged in 1999 in a distinct ecologic environment on Vancouver Island, Canada. Estimates of incubation period were derived from an analysis of travelers with discreet exposures to this region. Individual case incubation periods ranged from 2 to 11 months, with a median of 6 to 7 months.

Outbreak of cyclosporiasis in British Columbia associated with imported Thai basil

Sporadic outbreaks of cyclosporiasis, a common cause of protracted diarrhoea in underdeveloped countries, are often undetected and undiagnosed in industrial countries. In May 2001, an outbreak of Cyclospora cayetanensis gastroenteritis was identified in British Columbia, Canada, with 17 reported cases. We conducted a case-control study involving 12 out of the 17 reported and confirmed case patients. Eleven (92%) of the patients had consumed Thai basil, an essential ingredient in Vietnamese cuisine, compared to 3 out of 16 (19%) of the control patients (P = 0.003). Trace-back investigations implicated Thai basil imported via the United States as the vehicle for this outbreak. This is the first documented sporadic outbreak of cyclosporiasis linked to Thai basil in Canada, and the first outbreak of cyclosporiasis identified in an ethnic immigrant population. This outbreak provides the opportunity to increase our understanding of this emerging pathogen and improve on our prevention and control for future outbreaks.

A rare genotype of Cryptococcus gattii caused the cryptococcosis outbreak on Vancouver Island (British Columbia, Canada)

Cryptococcus gattii causes life-threatening infection of the pulmonary and central nervous systems in hosts with normal immunity and traditionally has been considered to be restricted geographically to tropical and subtropical climates. The recent outbreak of C. gattii in the temperate climate of Vancouver Island, BC, Canada, led to a collaborative investigation. The objectives of the current study were to ascertain the environmental source of the outbreak infections, survey the molecular types of the outbreak and environmental cryptococcal isolates, and determine the extent of genetic diversity among the isolates. PCR-fingerprinting and amplified fragment length polymorphism (AFLP) were used to examine the genotypes, and mating assays were performed to determine the mating type of the isolates. All outbreak and environmental isolates belonged to C. gattii. Concordant results were obtained by using PCR-fingerprinting and AFLP analysis. The vast majority of clinical and veterinary infections were caused by isolates of the molecular type VGII/AFLP6, but two were caused by molecular type VGI/AFLP4. All environmental isolates belonged to molecular type VGII/AFLP6. Two or three subtypes were observed within VGII/AFLP6 among outbreak and environmental isolates. All mating-competent isolates were of the alpha-mating type. The emergence of this usually tropical pathogen on Vancouver Island highlights the changing distribution of this genotype and emphasizes the importance of an ongoing collaborative effort to monitor the global epidemiology of this yeast.

An outbreak due to peanuts in their shell caused by Salmonella enterica serotypes Stanley and Newport--sharing molecular information to solve international outbreaks

Salmonellosis is a global problem caused by the international movement of foods and high incidence in exporting countries. In September 2001, in an outbreak investigation Australia isolated Salmonella Stanley from imported peanuts, which resulted in a wider investigation in Canada, England & Wales and Scotland. Patients infected with Salmonella serotypes known to be isolated from peanuts and reported to surveillance systems were interviewed to determine exposure histories. Tagged image file format (TIFF) images of pulsed-field gel electrophoresis (PFGE) patterns of Salmonella isolates were shared electronically amongst laboratories. Laboratories tested packets of 'Brand X' peanuts from various lots and product lines. In total, 97 cases of S. Stanley and 12 cases of S. Newport infection were found. Seventy-three per cent (71/97) of S. Stanley cases were in persons of Asian ethnicity. Twenty-eight per cent of cases recalled eating Brand X peanuts and a further 13% had peanuts in their house in the previous month or had eaten Asian-style peanuts. Laboratories isolated S. Stanley, S. Newport, S. Kottbus, S. Lexington and S. Unnamed from Brand X peanuts. Isolates of S. Stanley from peanuts and human patients were indistinguishable by PFGE. This international outbreak resulted from a product originating from one country affecting several others. Rapid sharing of electronic DNA images was a crucial factor in delineating the outbreak; multinational investigations would benefit from a harmonized approach.

Risk factors for Salmonella typhimurium DT104 and non-DT104 infection: a Canadian multi-provincial case-control study

To identify risk factors for sporadic Salmonella Typhimurium definitive phage-type 104 (DT104) and non-DT104 diarrhoeal illness in Canada, we conducted a matched case-control study between 1999 and 2000. Cases were matched 1:1 on age and province of residence. Multivariate analysis suggested that recent antibiotic use [odds ratio (OR) 5.2, 95% confidence interval (CI) 1.8-15.3], living on a livestock farm (OR 4.9, 95% CI 1.9-18.9), and recent travel outside Canada (OR 4.1, 95% CI 1.2-13.8) are independent risk factors for DT104 illness. Similar analyses suggested that recent travel outside North America is a sizable risk factor for non-DT104 illness (OR 66.8, 95% CI 6.7-665.3). No food exposure was a risk factor in either analysis. Educating health-care providers and the public about appropriate antibiotic use and antimicrobial resistance is important. Appropriate administration of antibiotics to livestock, particularly cattle, and hygienic measures such as handwashing after contact with farm animals may reduce risk. Travel represents an important and probably underestimated risk factor for sporadic illness with S. Typhimurium. Improved national surveillance and detailed investigation of travel-related illness are required.

Escherichia coli O157:H7 outbreak linked to salami, British Columbia, Canada, 1999

An outbreak of E. coli O157:H7 infections was identified in November 1999 with a fivefold increase in the occurrence of laboratory-confirmed cases of E. coli O157:H7 infection. A matched case-control study was conducted. Samples of food from cases and from retailers were analysed for the presence of E. coli O157:H7. A total of 143 cases were identified over a 12-week period with the same pulsed-field gel electrophoresis (PFGE) pattern. The case-control study found that Company A salami was significantly associated with illness (Mantel-Haenszel matched odds ratio 10.0%, 95% CI 1.4-434, P=0.01). Company A salami tested positive for E. coli O157:H7 and isolates had the same PFGE pattern as case isolates. An immediate voluntary national recall of Company A dry fermented meat products took place. Findings from the investigation of this outbreak suggest that the hold-and-test option may not be adequate to prevent shiga-toxigenic Escherichia coli (STEC) infection in salami consumers.

Clinical and microbiological follow-up of an outbreak of Yersinia pseudotuberculosis serotype Ib

Yersinia pseudotuberculosis, a food-borne pathogen, causes infection that commonly presents as gastroenteritis and mesenteric lymphadenitis. Post-infectious complications include erythema nodosum, reactive arthritis and, less commonly, uveitis and nephritis. Six serotypes of Y. pseudotuberculosis have been identified, and post-infectious complications have been identified following infection with some, but not all, serotypes. The first recognized outbreak of Y. pseudotuberculosis serotype lb occurred in British Columbia in November 1998. We documented the incidence of post-infectious complications and the effect of antibiotic use on the clinical course. Four months after the outbreak, a standardized questionnaire asking about symptoms and antibiotic use was administered by telephone to laboratory-confirmed cases. Stool samples were collected to examine for chronic carriage of Y. pseudotuberculosis and 59 of 74 eligible cases participated. The most common post-infectious symptoms were rash (8/59) and joint pain (7/59). Microbiological analysis, at follow-up, revealed 0/36 stools positive for Y. pseudotuberculosis. Seventy-eight percent of cases had taken antibiotics during their acute illness. There was no significant difference in the frequency of post-infectious symptoms between cases who had or had not taken antibiotics. The post-infectious pathogenicity of Y. pseudotuberculosis serotype lb is lower than that documented for other serotypes. Antibiotic use did not significantly alter the reported clinical course of illness.

An outbreak of mumps among young adults in Vancouver, British Columbia, associated with 'rave' parties

In early 1997 an unexpectedly high number of cases of mumps was reported in Vancouver, British Columbia.

METHODS

A case control study was conducted to address four objectives: 1) Describe the outbreak and the population at risk, 2) examine the impact of mumps on this population, 3) identify personal risk factors for infection, and 4) test the hypothesis that social gatherings, 'rave' parties in particular, were a risk factor in this outbreak.

RESULTS

Mumps infection was associated with: attending a rave party [OR = 17; 95% CI: 2.7-710], residing in Vancouver [OR = 3.7; 95% CI: 1.4-10], and contact with a person with mumps [OR = 13; 95% CI: 2-552], during the 'exposure' period. Vaccine effectiveness, ascertained by self-reported immunization status, was 80% [95% CI: 29%-96%].

CONCLUSIONS

Attendance at rave parties was associated with mumps infection during this outbreak. Many persons aged 17-40 may remain susceptible to mumps; in BC these persons are eligible for one dose of MMR and should be encouraged to be vaccinated.

Molecular epidemiology of cryptosporidiosis outbreaks and transmission in British Columbia, Canada

Isolates from 25 (13 sporadic and 12 outbreak) cryptosporidiosis cases, 24 of which were from British Columbia, Canada, were characterized using nested polymerase chain reaction amplification of the polymorphic internal transcribed spacer 1 locus. Two predominant Cryptosporidium parvum genotypes were found. Twelve (8 sporadic and 4 outbreak) isolates amplified with the cry7/cry21 primer pair and 12 (5 sporadic and 7 outbreak) isolates amplified with the cry7/cryITS1 primer pair. Multi-locus gene analysis using sequence polymorphisms on 3 other loci, i.e., the thrombospondin-related adhesion protein gene, the dihydrofolate reductase gene, and the 18S rRNA gene on 8 (4 outbreak and 4 sporadic) isolates showed non-random association among the human and animal alleles of the 4 different C. parvum gene loci. Associations between these 2 parasite genotypes and different routes of cryptosporidiosis transmission such as zoonotic, anthroponotic, and waterborne transmission were studied using municipal population and agricultural information, as well as detection of C. parvum oocysts in municipal drinking water specimens of the residential communities of sporadic and outbreak cases.

Epidemic and endemic seroprevalence of antibodies to Cryptosporidium and Giardia in residents of three communities with different drinking water supplies

This study was carried out to compare cryptosporidiosis and giardiasis seroprevalence rates in residents of three communities. Community (Com 1) uses drinking water from deep wells, community 2 (Com 2) uses surface water from a protected watershed, and community 3 (Com 3) uses surface water frequently containing Cryptosporidium oocysts and Giardia cysts. Unfiltered drinking water from each community was collected at the tap and tested for Cryptosporidium oocysts and Giardia cysts during the 12 months in which sera were collected for testing. No oocysts or cysts were detected in the water from the Com 1 deep wells; oocysts and cysts were detected intermittently in the drinking water from the other two communities. A waterborne outbreak of cryptosporidiosis occurred in a municipality adjacent to Com 3 six months into this 12-month study. Sera from residents of each of the communities were collected proportionately by month and by population size. Coded sera were tested for IgG to Cryptosporidium using a previously developed Western blotting method. The presence or absence of bands at 15-17 kD and/or 27 kD was recorded for the 1,944 sera tested. Definite bands at 15-17 kD and/or 27 kD were detected in 981 (50.5%) of the sera. A total of 33.2% of sera from Com 1 (community using deep wells) were positive using the same criteria compared with 53.5% (Com 2) and 52.5% (Com 3) of sera from the two communities using surface drinking water. Both bands (15-17 kD plus 27 kD) were detected in 582 sera (29.9%) from the three communities: 14.1% of sera from Com 1 compared with 32.7% from Com 2 and 31.5% from Com 3. These findings are consistent with a lower risk of exposure to Cryptosporidium from drinking water obtained from deep well sources. However, analysis of results by calendar quarter showed a significant (P < 0.001) increase in the number of Com 3 positive sera (compared with Com 1) following the waterborne outbreak. Without this outbreak-related observation, a significant overall difference in seropositivity would not have been seen. We also observed that in sera from the community affected by the outbreak, the presence on immunoblots of both Cryptosporidium bands appeared to be the best indicator of recent infection. Seroprevalence rates using an ELISA to detect IgG to Giardia were estimated using the same sera. Overall 30.3% (590 of 1,944) of sera were positive by the ELISA. A total of 19.1% of sera from Com 1, 34.7% from Com 2 and 16.0% from Com 3 were seropositive. Rates for both Com 3 and Com 1 did not change significantly over time. In Com 2, rates decreased significantly (P < 0.001) during the last half of the study period (third and fourth calendar quarters). The reasons for the decrease in seroprevalence in Com 2 sera are presently not known. These studies show intriguing associations between seroprevalence, outbreak-related laboratory serologic data, and patterns of parasite contamination of drinking water. Further studies are required to validate the serologic approach to risk assessment of waterborne parasitic infections at a community level.

An outbreak of Escherichia coli O157:H7 infection from unpasteurized commercial apple juice

BACKGROUND

Escherichia coli O157:H7 infections have traditionally been associated with animal products, but outbreaks associated with produce have been reported with increasing frequency. In fall 1996, a small cluster of E. coli O157:H7 infections was epidemiologically linked to a particular brand (brand A) of unpasteurized apple juice.

OBJECTIVE

To define the extent of the outbreak, confirm the source, and determine how the apple juice became contaminated.

DESIGN

Descriptive epidemiologic study and traceback investigation.

SETTING

Western United States and British Columbia, Canada.

PATIENTS

Patients with E. coli O157:H7 infection who were exposed to brand A apple juice.

MEASUREMENTS

Clinical outcome and juice exposure histories of case-patients, pulsed-field gel electrophoresis of case and juice isolates, and juice production practices.

RESULTS

Seventy persons with E. coli O157:H7 infection and exposure to brand A unpasteurized apple juice were identified. Of these persons, 25 (36%) were hospitalized, 14 (20%) developed the hemolytic uremic syndrome, and 1 (1%) died. Recalled apple juice that was produced on 7 October 1996 grew E. coli O157:H7 with a pulsed-field gel electrophoresis pattern indistinguishable from that of case isolates. Apple juice produced on 7 October 1996 accounted for almost all of the cases, and the source of contamination was suspected to be incoming apples. Three lots of apples could explain contamination of the juice: Two lots originated from an orchard frequented by deer that were subsequently shown to carry E. coli O157:H7, and one lot contained decayed apples that had been waxed.

CONCLUSIONS

Standard procedures at a state-of-the-art plant that produced unpasteurized juices were inadequate to eliminate contamination with E. coli O157:H7. This outbreak demonstrated that unpasteurized juices must be considered a potentially hazardous food and led to widespread changes in the fresh juice industry.

Does forced air heating exacerbate asthma?

Asthma morbidity increases in the Canadian autumn coincident with the beginning of home heating. To test the hypothesis that forced air heating exacerbates asthma, 51 subjects were randomly assigned to one of two groups: the intervention (off1-on2) group was instructed to keep their home forced air heating off from September 9 to 17 and then to set the thermostat to 22 degrees C from 8 PM to 8 AM between September 18 and 25. The concurrent control (off1-off2) group was instructed to keep their forced air heating off during the entire study period. Forty-eight of the 51 subjects randomized recorded morning peak flows, asthma symptoms, and bronchodilator use during the study period. For the intervention group, results before compared with during home heating, respectively, were as follows: mean nocturnal awakenings 0.36 versus 0.36; any breathing difficulties an awakening 82% versus 73%; mean morning peak flows 406 lpm versus 409 lpm, a difference of 3.3% +/- 6.7% (SEM), p = 0.6. There was a 95% probability that the true change in peak flows with forced air was less than 2%. For the control group, the comparable results were as follows: mean nocturnal awakening 0.40 versus 0.47; breathing difficulties on awakening 40% versus 47%; mean morning peak flows 400 lpm versus 399 lpm (p = 0.9). The commencement of forced air heating did not exacerbate asthma in this clinical population and is therefore unlikely to be an important problem for most people suffering from asthma.

Production of monoclonal antibodies against the N-terminal glycopeptide of porcine pro-opiomelanocortin: their use for solid-phase radioimmunoassay, western blotting, and immunogold cytochemistry

We have prepared two monoclonal antibodies for the N-terminal glycopeptide of pro-opiomelanocortin 1-77 (N-POMC(1-77)) purified from porcine pituitaries. Antibody 1-244 recognizes an epitope located within the gamma 3-melanotropin (gamma 3-MSH or POMC(51-77)) sequence, whereas antibody 2-197 binds specifically to a determinant in the 1-49 region of N-POMC. These monoclonal antibodies were used to construct a two-site solid-phase radioimmunoassay that can detect as little as 50 pg of N-POMC(1-77). The assay is linear between 0.5 and 5 ng of porcine peptide and recognizes equally well the homologous peptides purified from human and bovine pituitaries. The assay has been used to analyze reversed-phase high pressure liquid chromatography fractions of crude bovine pituitary extracts and detected a peptide with chromatographic properties identical to those of N-POMC(1-77). When used to stain immunoblots of bovine intermediate pituitary extracts, both the 2-197 and 1-244 antibodies could recognize a major peptide comigrating with purified N-POMC(1-77). In addition, antibody 2-197 also detected a peptide with a mobility similar to that of standard N-POMC(1-49). When used in conjunction with a second anti-mouse antibody coupled to colloidal gold particles, antibody 2-197 stained N-POMC immunoreactive material located in granules in thin sections of pituitary.