Risk factors for community-associated multidrug-resistant Pseudomonas aeruginosa in veterans with spinal cord injury and disorder: a retrospective cohort study.

STUDY DESIGN: Retrospective cohort studyObjectives:To identify independent risk factors associated with community-associated multidrug-resistant Psedomonas aeruginosa (MDRPA) in a population of veterans with spinal cord injury and disorders (SCI/D). SETTING: A total of 127 Veterans Affairs healthcare facilities. METHODS: Laboratory results from 1 January 2012 to 31 December 2013 were collected, and MDRPA cultures were compared with non-MDRPA cultures. RESULTS: One thousand four hundred forty-one cultures were collected from Veterans with SCI/D, including 227 cultures with MDRPA isolates. Characteristics associated with an increased odds of MDRPA include age 50-64 (adjusted odds ratio (aOR)=1.80, 95% confidence interval (CI)=1.13-2.87), MDRPA culture in the past 365 days (aOR=9.12, 95% CI=5.88-14.15) and carbapenem exposure in the past 90 days (aOR=2.56, 95% CI=1.35-4.87). In contrast, paraplegia was associated with a 53% decreased odds of MDRPA compared with those with tetraplegia (aOR=0.47, 95% CI=0.32-0.69). CONCLUSIONS: Risk factors for community-associated MDRPA include prior history of MDRPA and exposure to carbapenems. Awareness of these factors is important for targeted prevention and treatment of MDRPA in patients with SCI/D.

Differential proteomics reveals the hallmarks of seed development in common bean (Phaseolus vulgaris L.).

UNLABELLED: Common bean (Phaseolus vulgaris L.) is one of the most consumed staple foods worldwide. Little is known about the molecular mechanisms controlling seed development. This study aims to comprehensively describe proteome dynamics during seed development of common bean. A high-throughput gel-free proteomics approach (LC-MS/MS) was conducted on seeds at 10, 20, 30 and 40days after anthesis, spanning from late embryogenesis until desiccation. Of the 418 differentially accumulated proteins identified, 255 were characterized, most belonging to protein metabolism. An accumulation of proteins belonging to the MapMan functional categories of "protein", "glycolysis", "TCA", "DNA", "RNA", "cell" and "stress" were found at early seed development stages, reflecting an extensive metabolic activity. In the mid stages, accumulation of storage, signaling, starch synthesis and cell wall-related proteins stood out. In the later stages, an increase in proteins related to redox, protein degradation/modification/folding and nucleic acid metabolisms reflect that seed desiccation-resistance mechanisms were activated. Our study unveils new clues to understand the regulation of seed development mediated by post-translational modifications and maintenance of genome integrity. This knowledge enhances the understanding on seed development molecular mechanisms that may be used in the design and selection of common bean seeds with desired quality traits. SIGNIFICANCE: Common bean (P. vulgaris) is an important source of proteins and carbohydrates worldwide. Despite the agronomic and economic importance of this pulse, knowledge on common bean seed development is limited. Herein, a gel-free high throughput methodology was used to describe the proteome changes during P. vulgaris seed development. Data obtained will enhance the knowledge on the molecular mechanisms controlling this grain legume seed development and may be used in the design and selection of common bean seeds with desired quality traits. Results may be extrapolated to other pulses.

Expanded infectious diseases screening program for Hispanic transplant candidates.

Most guidelines for pre-transplant screening recommend enhanced screening among patients with potential exposure to such pathogens as Strongyloides stercoralis and Trypanosoma cruzi, the cause of Chagas disease. The incidence of these diseases in the Hispanic immigrant population has not been extensively studied. Transplant candidates who were evaluated by our program's Hispanic Transplant Program were referred for expanded infectious disease screening including Mycobacterium tuberculosis, S. stercoralis, Leishmania, and T. cruzi. Between December 2006 and December 2008, 83 patients were screened. Most were from Mexico but we also screened patients from Ecuador, Puerto Rico, and Peru. Most patients lived in urban locations before moving to the United States. Latent tuberculosis infection (LTBI) was found in 20%, and 6.7% had serologic evidence of S. stercoralis infection. These patients underwent treatment of latent infection without difficulty. To date, 14 patients have undergone living-donor kidney transplantation. Two of these patients had positive Leishmania titers and are being followed clinically, 1 was treated for S. stercoralis, and 2 were treated for LTBI pre-transplant. All have done well without evidence of screened pathogens an average of 348 days (range 65-766 days) post transplant. Expanded screening identifies endemic infections in the Hispanic immigrant population that can be treated before transplant, thereby minimizing post-transplant infectious complications.

Improvement of bone disease by imiglucerase (Cerezyme) therapy in patients with skeletal manifestations of type 1 Gaucher disease: results of a 48-month longitudinal cohort study.

Progressive skeletal disease accounts for some of the most debilitating complications of type 1 Gaucher disease. In this 48-month, prospective, non-randomized, open-label study of the effect of enzyme replacement therapy on bone response, 33 imiglucerase-naïve patients (median age 43 years with one or more skeletal manifestations such as osteopenia, history of bone crisis, or other documented bone pathology) received imiglucerase 60 U/kg/2 weeks. Substantial improvements were observed in bone pain (BP), bone crises (BC), and bone mineral density (BMD). Improvements in BP were observed at 3 months (p < 0.001 vs baseline) and continued progressively throughout the study, with 39% of patients reporting pain at 48 months vs 73% at baseline. Eleven of the 13 patients with a pre-treatment history of BC had no recurrences. Biochemical markers for bone formation increased; markers for bone resorption decreased. Steady improvement of spine and femoral neck BMD, measured using dual-energy X-ray absorptiometry was noted. Mean Z score for spine increased from -0.72 +/- 1.302 at baseline to near-normal levels (-0.09 +/- 1.503) by month 48 (p = 0.042) and for femoral neck from -0.59 +/- 1.352 to -0.17 +/- 1.206 (p = 0.035) at month 36. This increase was sustained at 48 months. With imiglucerase treatment, patients should anticipate resolution of BC, rapid improvement in BP, increases in BMD, and decreased skeletal complications.

Collective bargaining: a vulnerability assessment.

When it comes to the "soft side" of health care, employees want to be informed, respected, and included in decisions that affect their ability to care for patients with pride and satisfaction. Union vulnerability is low when staff satisfaction and morale are high.

Do management algorithms improve chest pain triage?

OBJECTIVE: To audit the use of management algorithms for chest pain in an emergency department. DESIGN AND SETTING: Prospective study of all patients with chest pain presenting to the emergency department of an urban teaching hospital between 12 January and 4 May 1997. Staff were asked to complete a standardised admission form that incorporated the risk stratification algorithms for managing patients with suspected acute coronary syndrome. MAIN OUTCOME MEASURES: Compliance with the use of management algorithms; concordance with a cardiologist's review of the triage grouping and admission/discharge decision; and major cardiovascular events over four months. RESULTS: Emergency department staff documented the triage group in 223 of 503 cases (45%). Concordance with the group assigned by a cardiologist was 70% (kappa = 0.73; SE kappa = 0.04). When the management algorithm was applied correctly, 92% of triage decisions were correct (95% confidence interval [CI], 87%-96%). The triage decision was less often correct when risk stratification was not done (78% [73%-83%], P < 0.001), overestimated (77% [66%-88%], P < 0.01), or underestimated (50% [18%-82%], P < 0.001). The proportion of patients free of major cardiovascular events at four-month follow-up was 50% for those with myocardial infarction with ST-segment elevation, 47% for those with a high short-term risk of an adverse cardiac event, 82% for those with intermediate risk, and 99% for those with a low risk or non-coronary chest pain (P < 0.001). CONCLUSIONS: Use of management algorithms by emergency staff was poor. When used, triage decisions were more likely to be correct. Subsequent outcome confirms that the NHMRC risk stratification algorithms are useful for prognostic stratification of patients with suspected acute coronary syndrome.

Immunosurveillance of alglucerase enzyme therapy for Gaucher patients: induction of humoral tolerance in seroconverted patients after repeat administration.

Alglucerase, a macrophage-targeted enzyme replacement therapy for Gaucher disease, has been successfully used for several years to improve clinical symptoms and reverse disease progression. As part of an immunosurveillance program, 1,122 Gaucher patients were monitored for antibody response to glucocerebrosidase, the active component of alglucerase. Seroconversion was detected in 142 patients (12.8%) by enzyme-linked immunosorbent assay (ELISA) and confirmed by radioimmunoprecipitation. The majority (75%) of the seroconverted population had no detectable levels of circulating inhibitory antibody as assessed by in vitro inhibition of enzymatic activity of the therapeutic molecule. Of the remaining patients with putative inhibitory antibodies, the majority had only low levels of serum inhibitory activity, which was transient. A very small number of patients were identified as developing true neutralizing antibodies, as defined by the development of antibodies that impacted clinical efficacy. Many of the patient antibody responses were also diminished with time. Eighty-two of the 142 seroconverted patients have stopped producing antibody to the molecule and appear tolerized. The mean time for humoral tolerization was 28 months from initiation of therapy. Of 64 seroconverted patients followed for at least 30 months of therapy, the tolerization rate was 93%. These results show that although 12.8% of the patients on therapy developed antibodies to the molecule, 90% of these patients became tolerized over time.

Sharing your culture with a new partner. Catholic system implements plan to integrate values when it acquires a for-profit hospital.

In 1994 Orange County, CA's St. Joseph Health System (SJHS), aiming to strengthen its position in the regional market, acquired Mission Hospital Regional Medical Center, a for-profit hospital believed to be the premier healthcare facility in the southern part of the county. SJHS's leaders began integrating the two cultures at the top, replacing Mission's board but keeping its top managers in place. A member of the Sisters of St. Joseph joined the managers as the hospital's new vice president of sponsorship. In a series of orientation meetings, the hospital's leaders explained SJHS's mission and values to the staff, announcing that Mission would add a pastoral care department, emphasize care of the medically underserved, and discontinue abortion and sterilization procedures. Some Mission staff were disappointed when the hospital terminated a project that offered assisted reproductive technologies. In addition, capitation and exclusive contracting has caused conflict among area physicians, which affects the hospital. And Mission needs to further educate physicians and staff about bioethical issues. On the other hand, Mission has launched a center to help strengthen area families, a transportation system for senior citizens, and a dental clinic for underserved children. It has also taken over sponsorship of a clinic for underserved families. And, in 1994, the hospital opposed Proposition 187, which called for denying state services to illegal immigrants. Many Mission staff have been heartened to learn that the hospital considers justice a core value.