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Background: Transmission of carbapenemase-producing organisms (CPO) threatens patient safety in healthcare facilities. As a result of a 2011 outbreak of blaKPC+ Klebsiella pneumoniae, the NIH Clinical Center (NIHCC) has prioritized early detection and isolation of CPO carriers, using point-prevalence surveys and targeted high-risk ward surveillance since 2011 and admission surveillance since 2013. We describe our experience over 6 years of admission surveillance. Methods: The NIHCC is a 200-bed research hospital that provides care for a highly immunocompromised patient population. From September 2013 to September 2019, perirectal swabs were ordered automatically for all patients on admission to nonbehavioral health wards. Swabs were ordered twice weekly for ICU patients, weekly in other high-risk wards, and monthly for hospital-wide point prevalence (excluding behavioral health). Patients hospitalized in the United States in the previous week or abroad in the previous 6 months were considered high risk for carriage and isolated pending results from 2 swabs. Most swabs (n = 37,526) were cultured onto HardyCHROM CRE. If gram-negative bacilli (GNB) were present, a molecular screen for carbapenemases was performed on a sweep of cultured material (day 1) pending organism isolation. GNB were identified by MALDI-TOF MS. Prior to June 2019, isolates were screened by blaKPC/blaNDM PCR. Starting in June 2019, Enterobacteriaceae and Pseudomonas aeruginosa were screened using the phenotypic modified carbapenem inactivation method (mCIM), reflexing to the GeneXpert CARBA-R molecular assay if positive; other GNB were tested directly with CARBA-R. Selected GNB underwent susceptibility testing (Sensititre). Whole-genome sequencing was used to assess relatedness among CPO isolates. Swabs from high-risk patients were tested directly by blaKPC PCR (n = 699) until August 2019 (most in parallel with culture) and thereafter by CARBA-R (n = 13). Results: Among 54,188 orders for perirectal swabs, 38,238 were collected from 14,497 patients (compliance 71%). Among 33 CPO-colonized patients identified from September 2013 through September 2019, 15 were identified on admission, 6 were identified in point-prevalence surveys, 8 were identified from high-risk ward surveillance, and 4 were identified from clinical cultures. Sequencing demonstrated no relatedness among CPO isolates. Although only 1.4% of patients sampled on admission were colonized with CPO, those meeting high-risk criteria were 21 times as likely to be colonized. Conclusion: Admission surveillance for CPO identified a low rate of colonization, but it detected nearly half of known CPO-colonized NIHCC patients over the past 6 years. Modest compliance with swab collection leaves room for improvement and likely results in missed instances of colonization. Although we cannot determine its effectiveness, we view our strategy as one of several key safety measures for our highly vulnerable patient population.
We estimate the ecosystem service value of water supplied by the San Bernardino National Forest in Southern California under climate change projections through the 21st century. We couple water flow projections from a dynamic vegetation model with an economic demand model for residential water originating from the San Bernardino National Forest. Application of the method demonstrates how estimates of consumer welfare changes due to variation in water supply from public lands in Southern California can inform policy and land management decisions. Results suggest variations in welfare changes over time due to alterations in the projected water supply surpluses, shifting demand limited by water supply shortages or surpluses, and price increases. Results are sensitive to future climate projections—in some cases large decreases in welfare due to supply shortages—and to assumptions about the demand model.
Pathological gambling is a behavioural addiction with negative economic, social, and psychological consequences. Identification of contributing genes and pathways may improve understanding of aetiology and facilitate therapy and prevention. Here, we report the first genome-wide association study of pathological gambling. Our aims were to identify pathways involved in pathological gambling, and examine whether there is a genetic overlap between pathological gambling and alcohol dependence.
Four hundred and forty-five individuals with a diagnosis of pathological gambling according to the Diagnostic and Statistical Manual of Mental Disorders were recruited in Germany, and 986 controls were drawn from a German general population sample. A genome-wide association study of pathological gambling comprising single marker, gene-based, and pathway analyses, was performed. Polygenic risk scores were generated using data from a German genome-wide association study of alcohol dependence.
No genome-wide significant association with pathological gambling was found for single markers or genes. Pathways for Huntington's disease (P-value = 6.63 × 10−3); 5′-adenosine monophosphate-activated protein kinase signalling (P-value = 9.57 × 10−3); and apoptosis (P-value = 1.75 × 10−2) were significant. Polygenic risk score analysis of the alcohol dependence dataset yielded a one-sided nominal significant P-value in subjects with pathological gambling, irrespective of comorbid alcohol dependence status.
The present results accord with previous quantitative formal genetic studies which showed genetic overlap between non-substance- and substance-related addictions. Furthermore, pathway analysis suggests shared pathology between Huntington's disease and pathological gambling. This finding is consistent with previous imaging studies.
The Northeast Greenland Ice Stream (NEGIS) is an important dynamic component for the total mass balance of the Greenland ice sheet, as it reaches up to the central divide and drains 12% of the ice sheet. The geometric boundary conditions and in particular the nature of the subglacial bed of the NEGIS are essential to understand its ice flow dynamics. We present a record of more than 8000 km of radar survey lines of multi-channel, ultra-wideband radio echo sounding data covering an area of 24 000 km2, centered on the drill site for the East Greenland Ice-core Project (EGRIP), in the upper part of the NEGIS catchment. Our data yield a new detailed model of ice-thickness distribution and basal topography in the region. The enhanced resolution of our bed topography model shows features which we interpret to be caused by erosional activity, potentially over several glacial–interglacial cycles. Off-nadir reflections from the ice–bed interface in the center of the ice stream indicate a streamlined bed with elongated subglacial landforms. Our new bed topography model will help to improve the basal boundary conditions of NEGIS prescribed for ice flow models and thus foster an improved understanding of the ice-dynamic setting.
Flexible and stretchable capacitive pressure sensors have been developed in recent years due to their potential applications in health monitoring, robot skins, body activity measurements and so on. In order to enhance sensor sensitivity, researchers have changed structure of the dielectric of parallel plate capacitive sensor . Here we enhance the sensor sensitivities by changing electrode composition and explore the use of a woven electrode structure sensor with silver coated nylon yarn and EcoflexTM. The woven structure enhanced sensitivity 2.3 times relative to a simple cross-grid geometry (sensitivity was 0.003 kPa-1). Furthermore, it is also observed that the sensor with the woven electrode also had better repeatability and showed less creep than a device using carbon black electrodes. The woven structure of the electrodes enabled the device to be compliant, despite the presence of the stiff nylon fibres – thereby enabling good sensitivity without the creep seen in softer electrodes.
Neonatal aortic thrombosis is a rare occurrence but can be life-threatening. Most aortic thrombosis in neonates is related to umbilical artery catheters. A case of a neonate with a spontaneous aortic thrombosis is described here along with a comprehensive review of the literature for cases of neonatal aortic thrombosis not related to any intravascular device or procedure. The aetiologies of these spontaneous thromboses and the relevance of hypercoagulable disorders are discussed. The cases were analysed for odds of death by treatment method adjusted for era. The reference treatment method was thrombolysis and anticoagulation. No other treatment modality had significantly lower odds than the reference. Surgery alone had higher odds for death than the reference, but this may be confounded by severity of case. The management recommendations for clinicians encountering neonates with spontaneous neonatal aortic thrombosis are discussed.
Despite some improvements in access to evidence-based medications for opioid use disorder, treatment rates remain low at under a quarter of those with need. High costs for brand name products in these medication markets have limited the volume of drugs purchased, particularly through public health insurance and grant programs. Brand firm anti-competitive practices around the leading buprenorphine product Suboxone — including product hops, citizen petitions and Risk Evaluation and Mitigation Strategy abuses — helped to maintain high prices by extending brand exclusivity periods and hindering generic drug entry. Remedies to address costly anti-competitive activities include adoption of the proposed CREATES Act and modernization of the Hatch-Waxman Act by the Congress, and implementation of substantive modifications to the Food and Drug Administration citizen petition filing procedures. Given the persistence of these abuses, prescriptive changes are favorable to the procedural and clarifying steps thus far favored by the federal government. Extrapolating from the 37% price declines attributable to generic entry for buprenorphine tablets in 2011, our calculations suggest that implementing these remedies to facilitate generic competition with Suboxone film would have resulted in savings of approximately $703 million overall and $203 million to Medicaid in 2017.
This chapter provides an ethical framework to guide decision making about periviable birth.
Viability in professional ethics in obstetrics and gynecology is a function of both fetal physiology and available resuscitation and life-sustaining treatment. Viability is therefore the biological capacity of a live-born infant to survive even if full technological support is needed. This is the concept of viability used by the United States Supreme Court in its landmark ruling, Roe v. Wade, in 1973.
This chapter provides an ethical framework for decision making about initiation of pregnancy.
Obstetrician-gynecologists play two important roles in the initiation of pregnancy. The first is the medically assisted initiation of pregnancy, usually to manage infertility in the female patient or her partner or both. The second is preconception counseling to anticipate and prevent ethical challenges in assisted initiation of pregnancy.
This chapter provides guidance on deliberative clinical judgment and decision making about preventing pregnancy in professional ethics in gynecology.
The biologic concept of sex is an essential component of the biologic concept of fertility. It is used to categorize human beings according to reproductive role: only the capacity to produce gametes, or the capacity to produce gametes and initiate a pregnancy. Sex was once thought to be dimorphic, but modern genomics of chromosomes has abandoned dimorphism for a concept of biologic sex as ranging along a continuum between these two productive roles. In other words, like all other human traits, biologic sex displays variation.
This chapter provides an introduction to professional ethics in obstetrics and gynecology based on the ethical concept of medicine as a profession and the ethical concepts of the female patient, pregnant patient, and fetal patient. There is also an introduction to professional ethics in perinatal medicine.
This chapter provides an ethical framework for offering, recommending, performing, and referring for induced abortion and feticide.
Counseling pregnant women about induced abortion and feticide presents the obstetrician with a distinct set of challenges., The American Medical Association and the American College of Obstetricians and Gynecologists have provided general guidance. Based on the ethical principles of beneficence and respect for autonomy in professional ethics in obstetrics and gynecology (see Chapter 2), this chapter provides practical, clinically comprehensive ethical guidance on when to offer, recommend, perform, and refer for abortion and feticide.
This chapter provides an ethical framework to guide decision making about fetal analysis.
The ethical principle of respect for autonomy in professional ethics in obstetrics creates the obstetrician’s prima facie ethical obligation to empower the pregnant patient to make informed and voluntary decisions about obstetric management. This ethical obligation has two components. The first is providing her with clinical information about options for fetal analysis using nomenclature that is precise.
This chapter provides an ethical framework for setting justified limits on life-sustaining treatment.
Sometimes a patient’s condition has deteriorated to such a degree that in deliberative clinical judgment the prediction of imminent death becomes reliable. When death is imminent patients are transferred to a critical care unit in which they receive life-sustaining treatment. Life-sustaining treatment deploys a range of interventions, including physical intervention such as cardiopulmonary resuscitation; intravenous administration of drugs, fluids, and nutrition; and mechanical devices such as circulation devices, extracorporeal membrane oxygenation, dialysis, and ventilators. These interventions are designed to support or replace organ functions in the absence of which the risk of mortality will rapidly approach 100%.