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Background: Carbapenem-resistant Enterobacteriaceae (CRE) represent a significant antibiotic resistance threat, in part because carbapenemase genes can spread on mobile genetic elements. Here, we describe the molecular epidemiology and outcomes of patients with CRE bacteriuria from the same city in a nonoutbreak setting. Methods: The Georgia Emerging Infections Program performs active, population-based CRE surveillance in Atlanta. We studied a cohort of patients with CRE (resistant to all tested third-generation cephalosporins and ≥1 carbapenem, excluding ertapenem) first identified in urine, and not in a prior or simultaneous sterile site, between 2012 and 2015. Whole-genome sequencing (WGS) was performed on a convenience sample. We obtained epidemiologic and outcome data through chart review and Georgia Vital Statistics records (90-day mortality). Using WGS, we created a core-genome alignment-based phylogenetic tree of the Klebsiella pneumoniae isolates and calculated the SNP difference between each sample. Using SAS version 9.4 software, we performed the Fisher exact test and univariable odds ratios (OR) with 95% CI to compare patient isolates with and without a carbapenemase gene. Results: Among 81 patients included, the median age was 68 (IQR, 57–74) years, and most were female (58%), black (60%), and resided in a long-term care facility 4 days prior to culture isolation (53%). Organisms isolated were K. pneumoniae (84%), Escherichia coli (7%), Enterobacter cloacae (7%), and Klebsiella oxytoca (1%). WGS identified at least 1 β-lactamase gene in 91% of the isolates; 85% contained a carbapenemase gene, the most frequent of which was blaKPC-3 (94%). Patients with CRE containing a carbapenemase gene were more likely to be black (OR, 3.7; 95% CI, 1.0–13.8) and to have K. pneumoniae (OR, 8.9; 95% CI, 2.2–35.0). Using a core-genome alignment of 3,708 genes (~63% of the complete genome), we identified a median of 67 (IQR, 23–3,881) SNP differences between each K. pneumoniae isolate. A phylogenetic tree identified clustering around carbapenemase gene and multilocus sequence type (84% were ST 258) but not based on referring laboratory or county of residence (Fig. 1). Although 7% of patients developed an invasive CRE infection within 1 year and 21% died within 90 days, having a carbapenemase gene was not associated with these outcomes. Conclusions: Molecular sequencing of a convenience sample of CRE bacteriuria support K. pneumoniae ST258 harboring blaKPC-3 being distributed throughout the Atlanta area, across the healthcare continuum. Overall mortality was high in this population, but the presence of carbapenemase genes was not associated with worse outcomes.
Two kinds of war have characterized the development of US Air Force culture. The first has involved struggles for air supremacy and decisive impact against a series of opponents, from Germany to Japan to Vietnam to Iraq. The second has involved bureaucratic fights against the US Army and the US Navy in the halls of Congress and the Pentagon. Combined, these fights have led to emphasis on recurring elements across the history of Air Force culture, including information precision, technological dominance, and decisive effect. These concentrations have structured how the US Air Force has fought its opponents, foreign and domestic, from before organizational independence in 1947 to the present day.
In our efforts to make blogging an acceptable component of an academic career in political science, we ought not tame the practice of blogging beyond recognition. Multiple models exist under which blogging can contribute to the discipline of political science and through which political scientists can contribute to the public sphere.
The smallpox virus is a high-priority, Category-A agent that poses a global, terrorism security risk because it: (1) easily can be disseminated and transmitted from person to person; (2) results in high mortality rates and has the potential for a major public health impact; (3) might cause public panic and social disruption; and (4) requires special action for public health preparedness. In recognition of this risk, the Los Angeles County Department of Health Services (LAC-DHS) developed the Smallpox Preparedness, Response, and Recovery Plan for LAC to prepare for the possibility of an outbreak of smallpox.
A unique feature of the LAC-DHS plan is its explicit use of the Standardized Emergency Management System (SEMS) framework for detailing the functions needed to respond to a smallpox emergency. The SEMS includes the Incident Command System (ICS) structure (management, operations, planning/intelligence, logistics, and finance/administration), the mutual-aid system, and the multi/interagency coordination required during a smallpox emergency. Management for incident command includes setting objectives and priorities, information (risk communications), safety, and liaison. Operations includes control and containment of a smallpox outbreak including ring vaccination, mass vaccination, adverse events monitoring and assessment, management of confirmed and suspected smallpox cases, contact tracing, active surveillance teams and enhanced hospital-based surveillance, and decontamination. Planning/intelligence functions include developing the incident action plan, epidemiological investigation and analysis of smallpox cases, and epidemiological assessment of the vaccination coverage status of populations at risk. Logistics functions include receiving, handling, inventorying, and distributing smallpox vaccine and vaccination clinic supplies; personnel; transportation; communications; and health care of personnel. Finally, finance/administration functions include monitoring costs related to the smallpox emergency, procurement, and administrative aspects that are not handled by other functional divisions of incident command systems.
The plan was developed and is under frequent review by the LAC-DHS Smallpox Planning Working Group, and is reviewed periodically by the LAC Bioterrorism Advisory Committee, and draws upon the Smallpox Response Plan and Guidelines of the Centers for Disease Control and Prevention (CDC) and recommendations of the Advisory Committee on Immunization Practices (ACIP). The Smallpox Preparedness, Response, and Recovery Plan, with its SEMS framework and ICS structure, now is serving as a model for the development of LAC-DHS plans for responses to other terrorist or natural-outbreak responses.
Novel bile acid sequestrants based on a polyammonium backbone were synthesized using molecular imprinting technique. These imprinted polymer networks were prepared by crosslinking different polymeric amines with crosslinking agents in the presence of sodium cholate as the template. The template molecules were completely removed from the polymer matrices by repeated washings. The bile acid sequestration properties of these polymeric resins were evaluated under both in vitro and in vivo conditions. Adsorption isotherms performed in physiologically relevant media revealed that molecular imprinting led to improvement in bile acid sequestration with about a twofold increase in the Ka (association constant). More importantly, hamsters fed with imprinted polymers in their diet excreted more bile acids than the non-imprinted control polymer. These results suggest that molecular imprinting may be potentially an interesting approach to prepare novel polymer therapeutics.
Cholestyramine, the first bile acid sequestrant to be marketed, has been in use for over 20 years. Despite its low potency, requiring 16-24 g of polymer to achieve 20% LDL cholesterol reduction in hypercholesterolemic individuals, only one other sequestrant, colestipol, has come to market in the ensuing period. GelTex Pharmaceuticals has been involved for over six years in the discovery and development of new, more potent polymeric sequestrants. Two binding mechanisms are presented — one that operates via an aggregate binding structure and one that is effective via a defined site binding structure. These two binding mechanisms are compared and contrasted through bile acid binding isotherms. The best of these new sequestrants bind bile acids through a combination of hydrophobicity and ion exchange. Optimization and balancing of each of these interactions led us to more potent materials. The first of these, colesevelam hydrochloride is expected to be three to four times more potent than cholestyramine. A third generation product is still in research at GelTex. With another twofold increase in potency possible, single tablet therapy may become a reality.
Measles (rubeola; hard measles; red measles; 9-day measles; morbilli) is a common, acute, viral infectious disease, principally of children, with worldwide distribution, that is clinically characterized by fever and a typical red, blotchy rash combined with cough, coryza, or conjunctivitis. It is a vaccine-preventable disease, and its vaccine is one of the vaccines included in the Expanded Programme on Immunization (EPI) of the World Health Organization (WHO). The disease is known by many local names throughout the world.
Etiology and Epidemiology
Measles is caused by a virus, which is in the genus Morbillivirus of the family Paramyxoviridae. Although the virus does not survive drying on a surface, it can survive drying in microdroplets in the air.
Measles is one of the most highly communicable diseases, transmitted by contact of susceptible individuals with the nose and throat secretions of infected persons, primarily by droplet spread. Infection also occurs by direct contact, and by indirect contact through freshly soiled articles and airborne transmission. There is no reservoir for measles other than human beings, which means that a continuous chain of susceptible contacts is necessary to sustain transmission. The period of communicability is from slightly before the beginning of the prodromal phase of the disease to 4 days after the start of the rash. There is no carrier state. Measles has an incubation period from time of exposure to onset of fever of about 10 days with a range from 8 to 13 days. The incubation period from time of exposure to rash onset is about 14 days.
In populated areas with no or low vaccination coverage, measles is primarily an endemic disease of children, with epidemics occurring every 2 to 5 years. In such areas, the greatest incidence is in children under 2 years of age. Epidemic measles has a winter-spring seasonality in temperate climates and a less marked hot-dry seasonality in equatorial regions.
Mumps (infectious parotitis; epidemic parotitis) is a common, acute, viral infectious disease, principally of children, with worldwide distribution. It is frequently clinically characterized by fever and painful enlargement of one or more salivary glands. Inapparent infection is common and occurs in about onethird of infections. Sometimes postpubertal males with mumps may develop painful swelling of the testicles, usually only on one side, with sterility an extremely rare complication. Mumps is a vaccinepreventable disease, but the vaccine is not yet widely used on a global basis.
Etiology and Epidemiology
Mumps is caused by the mumps virus, a member of the genus Paramyxovirus of the family Paramyxoviridae. Mumps virus has an irregular spherical shape averaging about 200 nanometers in diameter and contains a single-stranded RNA genome.
Mumps is a contagious disease, only slightly less contagious than rubella and measles, transmitted from infected persons to susceptible individuals by droplet spread and by direct contact with saliva. Mumps virus has also been shown to be transmitted across the placenta to the fetus. There is no natural reservoir for mumps other than human beings, which means that a continuous chain of susceptible contacts is necessary to sustain transmission. Although the period of communicability may be from 6 days before salivary gland symptoms to 9 days afterwards, the period of greatest infectivity is about 48 hours before salivary gland involvement. There is no carrier state. Mumps has an incubation period from time of exposure to onset of salivary gland swelling of about 18 days with a range of 2 to 3 weeks.
Rubella (German measles; 3-day measles) is a common, acute, viral infectious disease, principally of children and young adults, with worldwide distribution frequently characterized clinically as a mild rash illness. Inapparent infection is common and may occur in as many as half of infections. Rubella has special significance when a pregnant woman contracts the disease in early pregnancy because fetal infection can ensue and result in developmental abnormalities known as the congenital rubella syndrome (CRS). Rubella is a vaccine-preventable disease, but the vaccine is not yet widely used on a global basis.
Etiology and Epidemiology
Rubella is caused by the rubella virus, which is in he genus Rubivirus of the family Togaviridae. Rubella virus is 50 to 60 nanometers in diameter and contains a single-stranded RNA genome.
Rubella is a highly contagious disease transmitted by contact of susceptible individuals with the nose and throat secretions of infected persons, primarily by droplet spread. Infection also occurs by direct contact, by indirect contact through freshly soiled articles, and by airborne transmission. There is no reservoir for rubella other than human beings, which means that a continuous chain of susceptible contacts is necessary to sustain transmission. The period of communicability is from about 1 week before rash onset to at least 4 days after. There is no carrier state except for infants with congenital rubella, who may shed virus for many months after birth. Rubella’s incubation period from time of exposure to onset of rash is 16 to 18 days, with a range of 14 to 23 days.
Since 1962, a series of studies have appeared in the psychiatric literature which define hysteria with increasing precision, differentiating that syndrome from the presence of conversion symptoms alone. Hysteria was described in a recognizable fashion more than a century ago by Briquet (1859). Some fifty years later, the syndrome was redescribed by Savill (1909). After a further period of nearly fifty years, Purtell, Robins and Cohen described hysteria as it occurred in a controlled series of patients (1951). Working from Purtell's clinical data, Perley and Guze introduced specific checklist criteria for the diagnosis of hysteria in 1962. These criteria defined a female population homogeneous in prognosis, a population to be distinguished from that defined by conversion symptoms alone. Conversion symptoms are seen in a variety of medical and psychiatric illnesses, and by themselves, conversion symptoms are of little prognostic value (Gatfield and Guze, 1962; Perley and Guze, 1962; Slater and Glithero, 1965).
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