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In the National Institutes of Health (NIH) Clinical Center, patients colonized or infected with vancomycin-resistant Enterococcus (VRE) are placed in contact isolation until they are deemed “decolonized,” defined as having 3 consecutive perirectal swabs negative for VRE. Some decolonized patients later develop recurrent growth of VRE from surveillance or clinical cultures (ie, “recolonized”), although that finding may represent recrudescence or new acquisition of VRE. We describe the dynamics of VRE colonization and infection and their relationship to receipt of antibiotics.
In this retrospective cohort study of patients at the National Institutes of Health Clinical Center, baseline characteristics were collected via chart review. Antibiotic exposure and hospital days were calculated as proportions of VRE decolonized days. Using survival analysis, we assessed the relationship between antibiotic exposure and time to VRE recolonization in a subcohort analysis of 72 decolonized patients.
In total, 350 patients were either colonized or infected with VRE. Among polymerase chain reaction (PCR)-positive, culture (Cx)-negative (PCR+/Cx−) patients, PCR had a 39% positive predictive value for colonization. Colonization with VRE was significantly associated with VRE infection. Among 72 patients who met decolonization criteria, 21 (29%) subsequently became recolonized. VRE recolonization was 4.3 (P = .001) and 2.0 (P = .22) times higher in patients with proportions of antibiotic days and antianaerobic antibiotic days above the median, respectively.
Colonization is associated with clinical VRE infection and increased mortality. Despite negative perirectal cultures, re-exposure to antibiotics increases the risk of VRE recolonization.
Evelyn was 80 years old. Her childhood sweetheart, lifelong partner and soul mate – her husband – had recently died. I went to see her on a bereavement visit soon after the funeral. Evelyn invited me in and said there was something ‘embarrassing’ she needed to share with me, even more embarrassing given her generation and gender, and considering I was 30 and male. She tugged the leg of her trousers and said, ‘I started wearing these before women generally wore trousers, before the Second World War. My parents beat me badly as a child; my legs are scarred so I don't like people seeing them’. Then she nudged me, smiled and winked and said ‘My husband was always good to me – in the “bedroom department”’. But Evelyn's womb had dropped (her words), a uterine procidentia or prolapse, after her only child was born, and she had never told anyone in the 50 years since. She said that although her husband was always ‘good’ to her, sex always hurt and she never enjoyed it. She saw sex as an obligation, her marital duty.
‘Last week, a new lady doctor came to our surgery and she came out to visit me. I told her about my womb – the first person I have ever told – and she put something up inside me. I've been walking round with a smile on my face all week: do you think it's a sin?’
As we discussed this further, it became clear that Evelyn was having multiple orgasms associated with a newly fitted vaginal ring pessary. The bigger picture was that she had never had an orgasm before and felt guilty at the sense of dishonouring her husband's memory, as ‘this thing is giving me better feelings than the old man ever did!’ She was tempted to have it taken out – until I recommended she keep it and enjoy it!
(At the time of this visit, I was a registered nurse and Evelyn's local Catholic priest.)
The trouble with women…
The French philosopher Michel Foucault (1984) once asked poignantly ‘why we burden ourselves today with so much guilt for having once made sex a sin’. Various mental health fields of practice, across times and peoples, show how women have frequently been dogged by negative assumptions and treatment based solely on gender and/or sexual identity.
We comment on the conjecture by Parker et al. (2016) that Antarctic
toothfish recently returned to McMurdo Sound, arguing that this species never
departed. Instead, as deduced from a 40-year fishing effort, toothfish water column
prevalence became markedly reduced where bottom depths are <500 m, with research
continuing to show their presence on the bottom or above the bottom where depths are
deeper. We also counter arguments that toothfish departed, and remained absent,
during and following a five-year presence of mega-icebergs residing near the opposite
coast of Ross Island, the icebergs inhibiting or fomenting conditions that
discouraged toothfish presence in the Sound. Available analyses reveal that toothfish
movement into the Sound was probably not significantly affected, and additionally
that neither changes in hydrography nor in primary productivity in the Sound would
have been sufficient to impact toothfish presence through food web alteration. We
hypothesize that the local effect of predation by seals and whales and the regional
effect of a fishery targeting the largest toothfish (those neutrally buoyant and thus
capable of occupying upper levels of the water column) has resulted in the remaining
toothfish now being found predominantly closer to the bottom at greater depths.
The transition to the diverse and complex biosphere of the Ediacaran and early Paleozoic is the culmination of a complex history of tectonic, climate, and geochemical development. Although much of this rise occurred in the middle and late intervals of the Neoproterozoic Era (1000–541 million years ago [Ma]), the foundation for many of these developments was laid much earlier, during the latest Mesoproterozic Stenian Period (1200–1000 Ma) and early Neoproterozoic Tonian Period (1000–720 Ma). Concurrent with the development of complex ecosystems, changes in the composition, configuration, and tectonic interaction between continental plates have been proposed as major shapers of both climate and biogeochemical cycling, but there is little support in the geologic record for overriding tectonic controls. Biogeochemical evidence, however, suggests that an expansion of marine oxygen concentrations may have stabilized nutrient cycles and created more stable environmental conditions under which complex, eukaryotic life could gain a foothold and flourish. The interaction of tectonic, biogeochemical, and climate processes, as described in this paper, resulted in the establishment of habitable environments that fostered the Ediacaran and early Phanerozoic radiations of animal life and the emergence of complex, modern-style ecosystems.
Gram-negative bacilli frequently cause epidemics in high-risk newborn intensive care units. Recently, an epidemic caused by a multiply-resistant K. pneumoniae, serotype 21, occurred in the Vanderbilt University intensive care nursery. The background of this outbreak included an increasing endemic nosocomial sepsis rate, operation of the facility in excess of rated capacity, and increasingly inadequate nurse-to-patient staffing ratios. The epidemic lasted 11 weeks; 26 (12%) of the 232 infants at risk in the unit became colonized. Five infants developed systemic illness and one died. Cohorting, reinforcement of strict handwashing and isolation procedures, and closure of the unit to outborn admissions resulted in rapid termination of the outbreak. Followup studies performed on infants colonized with the epidemic bacterium demonstrated persistent fecal shedding up to 13 months following discharge from the hospital. This epidemic had a detrimental influence on high-risk newborn and obstetric health care delivery in an area encompassing portions of three states. Under a system of progressively more sophisticated referral units, nosocomial infections occurring at a tertiary center can have an impact on other hospitals within the network.
High quality dilute nitride subcells for multijunction solar cells are achieved using GaInNAsSb. The effects on device performance of Sb composition, strain and purity of the GaInNAsSb material are discussed. New world records in efficiency have been set with lattice-matched InGaP/GaAs/GaInNAsSb triple junction solar cells and a roadmap to 50% efficiency with lattice-matched multijunction solar cells using GaInNAsSb is shown.
An organic molecular beam deposition system coupled to a soft x-ray excitation source has been developed to monitor the growth of organic semiconductor thin films in-situ and in real-time. Rapid collection of photoelectron spectra has been enabled using a multichannel array detector coupled to a hemispherical analyzer. The organic semiconductor tin phthalocyanine (SnPc) exhibits a Stranski-Krastanov growth mode on a polycrystalline gold substrate where the transition thickness between layered and clustered growth has been determined to be comparable to the thickness of a single molecular layer within which the molecules are standing on edge relative to the substrate plane.