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Background: In Canada, injuries represent 21% of Emergency Department (ED) visits. Faced with occupational injuries, physicians may feel pressured to provide urgent imaging to facilitate expedited return to work. There is not a body of literature to support this practice. Twenty percent of adult ED injuries involve workers compensation. Aim Statement: Tacit pressures were felt to impact imaging rates for patients with workplace injuries, and our aim was to determine if this hypothesis was accurate. We conducted a quality review to assess imaging rates among injuries suffered at work and outside work. A secondary aim was to reduce the harm resulting from non-value-added testing. Measures & Design: Information was collected from the Emergency Department Information System on patients with acute injuries over the age of 16-years including upper limb, lower limb, neck, back and head injuries. Data included both workplace and non-work-related presentations, Canadian Triage and Acuity Scale (CTAS) levels and age at presentation. Imaging included any of X-ray, CT, MRI, or Ultrasound ordered in EDs across the central zone of Nova Scotia from July 1, 2009 to June 30, 2019. A total of 282,860 patient-encounters were included for analysis. Comparison was made between patients presenting under the Workers’ Compensation Board of Nova Scotia (WCB) and those covered by the Department of Health and Wellness (DOHW). Imaging rates for all injuries were also trended over this ten-year period. Evaluation/Results: In patients between 16 and 65-years, the WCB group underwent more imaging (55.3% of visits) than did the DOHW group (43.1% of visits). In the same cohort, there was an overall decrease of over 10% in mean imaging rates for both WBC and DOHW between the first five-year period (2009-2013) and the second five-year study period (2013-2018). Imaging rates for WCB and DOHW converged with each decade beyond 35 years of age. No comparison was possible beyond 85-years, due to the absence of WCB presentations. Discussion/Impact: Patients presenting to the ED with workplace injuries are imaged at a higher rate than those covered by the DOHW. Campaigns promoting value-added care may have impacted imaging rates during the ten-year study period, explaining the decline in ED imaging for all injuries. While this 10% decrease in overall imaging is encouraging, these preliminary data indicate the need for further education on resource stewardship, especially for patients presenting to the ED with workplace injuries.
When 2017 Hurricane Harvey struck the coastline of Texas on August 25, 2017, it resulted in 88 fatalities and more than US $125 billion in damage to infrastructure. The floods associated with the storm created a toxic mix of chemicals, sewage and other biohazards, and over 6 million cubic meters of garbage in Houston alone. The level of biohazard exposure and injuries from trauma among persons residing in affected areas was widespread and likely contributed to increases in emergency department (ED) visits in Houston and cities receiving hurricane evacuees. We investigated medical surge resulting from these evacuations in Dallas–Fort Worth (DFW) metroplex EDs.
We used data sourced from the North Texas Syndromic Surveillance Region 2/3 in ESSENCE to investigate ED visit surge following the storm in DFW hospitals because this area received evacuees from the 60 counties with disaster declarations due to the storm. We used the interrupted time series (ITS) analysis to estimate the magnitude and duration of the ED surge. ITS was applied to all ED visits in DFW and visits made by patients residing in any of the 60 counties with disaster declarations due to the storm. The DFW metropolitan statistical area included 55 hospitals. Time series analyses examined data from March 1, 2017–January 6, 2018 with focus on the storm impact period, August 14–September 15, 2017. Data from before, during, and after the storm were visualized spatially and temporally to characterize magnitude, duration, and spatial variation of medical surge attributable to Hurricane Harvey.
During the study period overall, ED visits in the DFW area rose immediately by about 11% (95% CI: 9%, 13%), amounting to ~16 500 excess total visits before returning to the baseline on September 21, 2017. Visits by patients identified as residing in disaster declaration counties to DFW hospitals rose immediately by 127% (95% CI: 125%, 129%), amounting to 654 excess visits by September 29, 2017, when visits returned to the baseline. A spatial analysis revealed that evacuated patients were strongly clustered (Moran’s I = 0.35, P < 0.0001) among 5 of the counties with disaster declarations in the 11-day window during the storm surge.
The observed increase in ED visits in DFW due to Hurricane Harvey and ensuing evacuation was significant. Anticipating medical surge following large-scale hurricanes is critical for community preparedness planning. Coordinated planning across stakeholders is necessary to safeguard the population and for a skillful response to medical surge needs. Plans that address hurricane response, in particular, should have contingencies for support beyond the expected disaster areas.
No instrument has been developed to explicitly assess the professional culture of mental health workers interacting with severely mentally ill people in publicly or privately run mental health care services. Because of theoretical and methodological concerns, we designed a self-administered questionnaire to assess the professional culture of mental health services workers. The study aims to validate this tool, named the Mental Health Professional Culture Inventory (MHPCI). The MHPCI adopts the notion of ‘professional culture’ as a hybrid construct between the individual and the organisational level that could be directly associated with the professional practices of mental health workers.
The MHPCI takes into consideration a multidimensional definition of professional culture and a discrete number of psychometrically derived dimensions related to meaningful professional behaviour. The questionnaire was created and developed by a conjoint Italian-Canadian research team with the purpose of obtaining a fully cross-cultural questionnaire and was pretested in a pilot study. Subsequently, a validation survey was conducted in northern Italy and in Canada (Montreal area, Quebec). Data analysis was conducted in different steps designed to maximise the cross-cultural adaptation of the questionnaire through a recursive procedure consisting of performing a principal component analysis (PCA) on the Italian sample (N = 221) and then testing the resulting factorial model on the Canadian sample (N = 237). Reliability was also assessed with a test-retest design.
Four dimensions emerged in the PCA and were verified in the confirmatory factor analysis: family involvement, users' sexuality, therapeutic framework and management of aggression risk. All the scales displayed good internal consistency and reliability.
This study suggests the MHPCI could be a valid and reliable instrument to measure the professional behaviour of mental health services workers. The content of the four scales is consistent with the literature on psychosocial rehabilitation, suggesting that the instrument could be used to evaluate staff behaviour regarding four crucial dimensions of mental health care.
A systematic review and network meta-analysis were conducted to assess the relative efficacy of internal or external teat sealants given at dry-off in dairy cattle. Controlled trials were eligible if they assessed the use of internal or external teat sealants, with or without concurrent antimicrobial therapy, compared to no treatment or an alternative treatment, and measured one or more of the following outcomes: incidence of intramammary infection (IMI) at calving, IMI during the first 30 days in milk (DIM), or clinical mastitis during the first 30 DIM. Risk of bias was based on the Cochrane Risk of Bias 2.0 tool with modified signaling questions. From 2280 initially identified records, 32 trials had data extracted for one or more outcomes. Network meta-analysis was conducted for IMI at calving. Use of an internal teat sealant (bismuth subnitrate) significantly reduced the risk of new IMI at calving compared to non-treated controls (RR = 0.36, 95% CI 0.25–0.72). For comparisons between antimicrobial and teat sealant groups, concerns regarding precision were seen. Synthesis of the primary research identified important challenges related to the comparability of outcomes, replication and connection of interventions, and quality of reporting of study conduct.
A systematic review and meta-analysis were conducted to determine the efficacy of selective dry-cow antimicrobial therapy compared to blanket therapy (all quarters/all cows). Controlled trials were eligible if any of the following were assessed: incidence of clinical mastitis during the first 30 DIM, frequency of intramammary infection (IMI) at calving, or frequency of IMI during the first 30 DIM. From 3480 identified records, nine trials were data extracted for IMI at calving. There was an insufficient number of trials to conduct meta-analysis for the other outcomes. Risk of IMI at calving in selectively treated cows was higher than blanket therapy (RR = 1.34, 95% CI = 1.13, 1.16), but substantial heterogeneity was present (I2 = 58%). Subgroup analysis showed that, for trials using internal teat sealants, there was no difference in IMI risk at calving between groups, and no heterogeneity was present. For trials not using internal teat sealants, there was an increased risk in cows assigned to a selective dry-cow therapy protocol, compared to blanket treatment, with substantial heterogeneity in this subgroup. However, the small number of trials and heterogeneity in the subgroup without internal teat sealants suggests that the relative risk between treatments may differ from the determined point estimates based on other unmeasured factors.
A systematic review and network meta-analysis were conducted to assess the relative efficacy of antimicrobial therapy given to dairy cows at dry-off. Eligible studies were controlled trials assessing the use of antimicrobials compared to no treatment or an alternative treatment, and assessed one or more of the following outcomes: incidence of intramammary infection (IMI) at calving, incidence of IMI during the first 30 days in milk (DIM), or incidence of clinical mastitis during the first 30 DIM. Databases and conference proceedings were searched for relevant articles. The potential for bias was assessed using the Cochrane Risk of Bias 2.0 algorithm. From 3480 initially identified records, 45 trials had data extracted for one or more outcomes. Network meta-analysis was conducted for IMI at calving. The use of cephalosporins, cloxacillin, or penicillin with aminoglycoside significantly reduced the risk of new IMI at calving compared to non-treated controls (cephalosporins, RR = 0.37, 95% CI 0.23–0.65; cloxacillin, RR = 0.55, 95% CI 0.38–0.79; penicillin with aminoglycoside, RR = 0.42, 95% CI 0.26–0.72). Synthesis revealed challenges with a comparability of outcomes, replication of interventions, definitions of outcomes, and quality of reporting. The use of reporting guidelines, replication among interventions, and standardization of outcome definitions would increase the utility of primary research in this area.
Prenatal exposure to persistent organic pollutants (POPs) has been associated with the development of metabolic syndrome-related diseases in offspring. According to epidemiological studies, father’s transmission of environmental effects in addition to mother’s can influence offspring health. Moreover, maternal prenatal dietary folic acid (FA) may beneficially impact offspring health. The objective is to investigate whether prenatal FA supplementation can overcome the deleterious effects of prenatal exposure to POPs on lipid homeostasis and inflammation in three generations of male rat descendants through the paternal lineage. Female Sprague-Dawley rats (F0) were exposed to a POPs mixture (or corn oil) +/− FA supplementation for 9 weeks before and during gestation. F1 and F2 males were mated with untreated females. Plasma and hepatic lipids were measured in F1, F2, and F3 males after 12-h fast. Gene expression of inflammatory cytokines was determined by qPCR in epididymal adipose tissue. In F1 males, prenatal POPs exposure increased plasma lipids at 14 weeks old and hepatic lipids at 28 weeks old and prenatal FA supplementation decreased plasma total cholesterol at 14 weeks old. Prenatal POPs exposure decreased plasma triglycerides at 14 weeks old in F2 males. No change was observed in inflammatory markers. Our results show an impact of the paternal lineage on lipid homeostasis in rats up to the F2 male generation. FA supplementation of the F0 diet, regardless of POPs exposure, lowered plasma cholesterol in F1 males but failed to attenuate the deleterious effects of prenatal POPs exposure on plasma and hepatic lipids in F1 males.
Introduction: Royal College Emergency Medicine (EM) trainees at the University of Ottawa participate in weekly Academic Full Days (AFD) that consist of didactic activities, simulation-based learning, and core content sessions referred to as Core Rounds (CR). Despite CR being intentioned for all EM trainees, an attendance attrition has been noted as trainees progress towards their senior (SR) years (PGY3-5). The objectives of this study were to (1) identify barriers to SR trainee CR attendance and (2) identify areas for CR improvement. Methods: An on-line survey was administered to SR EM trainees (PGY3-5, n = 28) and recent graduates from our program (practice year 1-2, n = 20) to explore perceptions of the value of AFDs, CR attendance barriers, and areas for CR improvement. The survey consisted of 5-point Likert scales and free-text responses. Quantitative responses were analyzed using Microsoft Excel. Free-text responses were analyzed qualitatively using thematic analysis. Each free-text response was reviewed independently by two investigators (JML, MCL) and underwent line-by-line coding. Through joint discussions, the codes from each response were synthesized and themes were identified. Results: Of the 48 trainees and attendings surveyed, 32 responded (response rate 67%). Most respondents (90%) stated they benefited from SR trainee attendance when they were at a junior (JR) level. The majority perceived they benefited less from CR as a SR trainee compared to when they were a JR trainee (85%). Further, 87% responded that CR were not tailored to a SR level, and that they would attend more frequently if sessions were geared to their level (81%). From our thematic analysis, three themes emerged relating to SR trainee absenteeism: 1) CR quality, 2) External Factors (eg. trainee fatigue) and 3) Malalignment with trainees’ own education plan. We also identified three themes relating to areas for CR improvement: 1) CR content, 2) CR format and 3) SR trainee involvement. Conclusion: Respondents indicated a benefit to having SR trainee presence at CR. This study identified barriers to SR resident attendance at CR and areas for improvement. With the transition to competency based medical education it is critical that trainees engage in effective educational experiences, especially as the RCPSC does not mandate AFDs for EM training in this new curriculum. A culture-change initiative and CR reformat is now underway at our institution with planned post-implementation analysis.
Innovation Concept: Ventilator management is an essential skill and a training objective for emergency medicine (EM) specialists in Canada. EM trainees obtain the majority of this training during off-service rotations. Previous attempts to strengthen ventilator knowledge include lectures and simulation – both of which are time and resource intensive. Given the unique features of ventilator management in the ED, we developed an ED-specific ventilator curriculum. The purpose of this study is to 1) identify resident needs regarding ventilator curricula and 2) assess resident response to this pilot curriculum. Methods: A needs-assessment survey administered to RCPSC- and CCFP-EM residents at The Ottawa Hospital (TOH) showed the majority of residents (87%, n = 31 respondents) believe there is a need for more ED-focused ventilator management training, and only 13% felt confident in ventilator management. Ten on-line modules were prepared by an EM-Critical Care attending, and distributed on-line to all EM trainees at TOH (n = 52). Mid- and post-implementation surveys are used to assess residents’ confidence in ventilator management, and perceived usefulness of the curriculum. User feedback from focus groups constitutes part of the curriculum evaluation. Curriculum, Tool or Material: Employing a flipped classroom approach, ten on-line modules were distributed to RCPSC- and CCFP-EM trainees at TOH. Each module requires less than ten minutes to complete and focuses on a single aspect of ventilation. The modules are available for residents to complete at their own pace and convenience. At curriculum completion, an EM-Critical Care attending physician facilitates an interactive session. Conclusion: Mid-implementation survey results demonstrate increased confidence in independently managing ventilated patients in the ED (13% pre- vs. 56% mid-implementation), and an increased perception of having sufficient ventilator training (26% pre- vs. 78% mid-implementation). All respondents felt the modules were of appropriate length, content was easy to follow, and that the modules should be part of the residency curriculum. Our ED-specific online ventilator modules area a viable tool to increase residents’ confidence in ventilator management. This novel curriculum could be adopted by other residency programs and continuing professional development initiatives. Future work will include post-implementation data-gathering, and formal curriculum evaluation.
Glioblastomas (GBMs) account for nearly half of all primary malignant brain tumours, and current therapies are often only marginally effective. Our understanding of the underlying biology of these tumours and the development of new therapies have been complicated in part by widespread inter- and intratumoural heterogeneity. To characterize this heterogeneity, we performed regional subsampling of primary glioblastomas and derived organoids from these tissue samples. We then performed single-cell RNA-sequencing (scRNA-seq) on these primary regional subsamples and 1-3 matched organoids per sample. We have profiled samples from six tumour sets to date and have obtained sequencing data for 21,234 primary tissue cells and 14,742 organoid cells. While the most apparent differences in gene expression appear to be between individual tumours, we were also able to identify similar cellular subpopulations across tissue samples and across organoids. Importantly, organoids derived from the same tissue sample appeared to be composed of similar cellular subpopulations and were highly comparable to each other, indicating that replicate organoids faithfully represent the original tumour tissue. Overall, our scRNA-seq approach will help evaluate the utility of tumour-derived organoids as model systems for GBM and will aid in identifying cellular subpopulations defined by gene expression patterns, both in primary GBM regional subsamples and their associated organoids. These analyses will allow for the characterization of clonal or subclonal populations that are likely to respond to different therapeutic approaches and may also uncover novel therapeutic targets previously unrevealed through bulk analyses.
Introduction: Studies suggest that there is a significant discrepancy between emergency physicians diagnosis of TIA and confirmation by neurologists. The objectives of our study were to identify factors associated with neurologists confirmation of TIA in patients referred from the emergency department. Methods: Data were obtained from a prospective cohort study across more than 8 university-affiliated Canadian hospitals from 2006-2017 of adult patients diagnosed with a TIA or non-disabling stroke in the ED. Patients presenting after 1 week of symptom onset, receiving TPA as part of a stroke code, with a GCS<15 at baseline, and without a neurology assessment within 90 days were excluded. Univariate analyses were performed with t-tests or chi-square tests as indicated. Multivariate analysis with backward elimination was performed to identify unique predictors of TIA confirmation. Results: Of 8,669 patients diagnosed with TIA in the ED, 7,836 (90%) were assessed by neurology. The mean age of patients was 68.2 years and 71.1% presented with their first ever TIA. The rate of confirmation of TIA by neurology was 56%. The most common alternate diagnoses included migraines (26%), peripheral vertigo (10%), syncope (6%), and seizure (4%). The 3 strongest predictors of confirmation of TIA were infarct on imaging (OR 2.31, 2.03-2.63), history of weakness (OR 2.19, 1.95-2.48), and history of language disturbance (OR 2.05, 1.79-2.34). The 3 strongest predictors of an alternate diagnosis were syncope (OR 0.51, 0.39-0.67), history of bilateral weakness (or 0.51, 0.31-0.84), and confusion (OR 0.57, 0.48-0.67). Conclusion: The rate of TIA confirmation by neurology in our study was 56%. Emergency physicians should have a high index of suspicion of TIA in patients with history of weakness and language disturbance, and should resist referring to a stroke prevention clinic, patients with syncope, bilateral findings, or confusion.
Background: Oligodendroglioma (ODG), a molecularly defined subtype of glioma, is a treatment responsive, slow growing tumour strongly associated with IDH mutation and 1p19q co-deletion. Mutations in Capicua (CIC), located on chromosome 19q, have been found in up to 70% of IDH mutated, 1p19q co-deleted ODGs; suggesting that loss or altered function of CIC may be crucially associated with ODG’s unique biology. CIC and ATXN1L have previously been implicated in neurodegeneration, however, this interaction has not been studied in cancer. Methods: Transcriptome profiling of CIC knockout HEK293 cell lines generated using CRISPR was performed using microarray. CIC and ATXN1L interaction was confirmed using immunoprecipitation and immunofluorescence. Transcript and protein changes of CIC targets were tested using RT-qPCR and Western blot following ATXN1L siRNA knockdown. Results: Transcriptomic profiling of CIC knockout cell lines resulted in a list of candidate CIC target genes validated against clinical samples. Immunoprecipitation and immunofluorescence confirmed CIC and ATXN1L interaction. Derepression of candidate CIC targets at transcript and protein levels was seen upon siRNA knockdown of ATXN1L. Conclusions: The interaction between CIC and ATXN1L is necessary for the repression of CIC target genes, including known oncogenes. Further research into the relationship between CIC and ATXN1L may lead potentially novel avenues of therapeutic approaches for less favorable gliomas.
Much can be learned from terrestrial planets that appear to have had the potential to be habitable, but failed to realize that potential. Mars shows evidence of a once hospitable surface environment. The reasons for its current state, and in particular its thin atmosphere and dry surface, are of great interest for what they can tell us about habitable zone planet outcomes. A main goal of the MAVEN mission is to observe Mars’ atmosphere responses to solar and space weather influences, and in particular atmosphere escape related to space weather ‘storms’ caused by interplanetary coronal mass ejections (ICMEs). Numerical experiments with a data-validated MHD model suggest how the effects of an observed moderately strong ICME compare to what happens during a more extreme event. The results suggest the kinds of solar and space weather conditions that can have evolutionary importance at a planet like Mars.
Somatic mutations in the Capicua (CIC) gene were first identified in Type I low-grade gliomas (LGGs), which are characterized by 1p/19q co-deletions and IDH mutations. They are found at frequencies of ~50-70% in this glioma subtype, and have since been identified in ~40% of stomach adenocarcinomas (STADs) of the microsatellite instability (MSI) subtype; however, the role of these somatic mutations in malignancy has yet to be established. In Drosophila, CIC functions as a transcriptional repressor whose activity is inhibited upon activation of the mitogen-activated protein kinase (MAPK) signalling pathway. Though mammalian CIC appears to retain these functions, only three of its target genes have been established in human cells: ETV1, ETV4, and ETV5 (ETV1/4/5). To further probe CIC’s transcriptional network, we developed CIC knockout cell lines and performed transcriptomic and proteiomic analyses in these and in control cell lines expressing wild type CIC, identifying a total of 582 differentially expressed genes. We also used RNA-seq data from The Cancer Genome Atlas (TCGA) for Type I LGGs and STADs to perform additional differential expression analyses between CIC-deficient and CIC-expressing samples. Though gene-level overlap was limited between the three contexts, we found that CIC appears to regulate the expression of genes involved in cell-cell adhesion, metabolism, and developmental processes in all three contexts. These results shed light on the pathological role of CIC mutations and may help explain why these have been associated with poorer outcome within Type I LGGs.
It has been previously shown that Lactobacillus plantarum CRL 2130 is able to produce riboflavin in soyamilk. The aim of the present study was to evaluate the efficiency of this riboflavin-bio-enriched soyamilk to revert and/or prevent the nutritional deficiency of riboflavin using different animal models. When used to supplement the diets of previously depleted animals, it was shown that the growth, riboflavin status and morphology of the small intestines reverted to normal parameters and were similar to animals supplemented with commercial riboflavin. In the prevention model, the same tendency was observed, where animals that received soyamilk fermented with L. plantarum CRL 2130 did not show signs of riboflavin deficiency. This new bio-fortified soya-based product could be used as part of normal diets to provide a more natural alternative to mandatory fortification with riboflavin for the prevention of its deficiency.
Introduction: The incidence of delirium following hip fracture is near 60%. The use of regional anesthesia (RA) with ultrasound (U/S) guidance has suggested a decrease in delirium incidence. In this pilot study, we propose to include the use of femoral block with U/S guidance in the management of the elderly population with hip fracture in the emergency department (ED) to lower the risk of delirium. Methods: This paired control case study was conducted from December 2013 to April 2015, and includes patients seen by emergency doctors from the ED of Hospital Enfant Jesus in Quebec City. Patients of the intervention and control groups were paired by age. Inclusion Criteria: Patients with(1) a hip fracture; (2) admitted to the hospital after their ED management; (3) and surgically repaired. Exclusion Criteria: Patients (1) with delirium upon arrival or a known mental/cognitive status (dementia, unconsciousness or severely ill status) (2) less than 60 years old (3) not able to speak English or French. Intervention group: Patients with hip fracture who received femoral blocks by the five emergency doctors who were trained and performed with U/S guidance. Control group: Patients with hip fracture who received standard pain control care by emergency doctors and who did not receive a femoral block. Analysis: Incidence of delirium and blocks performed by EM doctors were tallied. A comparison of absolute pain reduction at 30 minutes was also done. Odd ratios were derived and adjusted for age, sex, total opiates dose, delay before surgery and morbidity scores. Results: A total of 29 femoral blocks were performed through the analysis period. Groups were similar for age, sex and APACHE II and CHARLSON scores. A 30 minutes absolute pain reduction of 3/10 was noted. Two thirds of the blocks were performed by two ED doctors. Need for rescue medication was needed for 7% of patients for pain control at 30 minutes. Adjusted odd ratios for age, sex, morbidity scores, total opiate doses and delay before surgery revealed no decrease in delirium. Conclusion: Ten out of 26 patients hospitalized for hip fracture who received a femoral block under U/S guidance from the ED doctors were diagnosed with delirium. A Canadian prospective study «EDURAPID» is underway to demonstrate more the impact of R/A under U/S guidance on the incidence de delirium in this population.
The purpose of this study was to: (1) Establish whether or not specific rehabilitation for mild brain injury is effective for return to work; and (2) compare the efficacy of an impairment-focused model of treatment versus an early education approach in respect to ability to return to work. Two different approaches to intervention and treatment for those with a suspected concussion from a work-related injury were utilised by an urban, interdisciplinary, outpatient rehabilitation facility. The first approach, Group Treatment (GT), provided minimal early education at time of initial intake, emphasising an extensive group-focused interdisciplinary assessment and treatment. The second approach, Individualized Education and Treatment, (IET) emphasised early education, instead coupled with specific individualised services. Both groups received employment services. Post-discharge, GT (N = 26) resulted in 46% (n = 12) of individuals returning to competitive employment, while IET (N = 23) resulted in 78% (n = 18) of individuals returning to competitive employment. An asset-oriented early individualised educational approach appears to be a more effective for employment re-engagement.
Listeria monocytogenes is a foodborne pathogen that can cause bacteraemia, meningitis, and complications during pregnancy. In July 2012, molecular subtyping identified indistinguishable L. monocytogenes isolates from six patients and two samples of different cut and repackaged cheeses. A multistate outbreak investigation was initiated. Initial analyses identified an association between eating soft cheese and outbreak-related illness (odds ratio 17·3, 95% confidence interval 2·0–825·7) but no common brand. Cheese inventory data from locations where patients bought cheese and an additional location where repackaged cheese yielded the outbreak strain were compared to identify cheeses for microbiological sampling. Intact packages of imported ricotta salata yielded the outbreak strain. Fourteen jurisdictions reported 22 cases from March–October 2012, including four deaths and a fetal loss. Six patients ultimately reported eating ricotta salata; another reported eating cheese likely cut with equipment also used for contaminated ricotta salata, and nine more reported eating other cheeses that might also have been cross-contaminated. An FDA import alert and US and international recalls followed. Epidemiology-directed microbiological testing of suspect cheeses helped identify the outbreak source. Cross-contamination of cheese highlights the importance of using validated disinfectant protocols and routine cleaning and sanitizing after cutting each block or wheel.