Universal screening or a universal risk assessment combined with risk-based screening for multidrug-resistant microorganisms upon admission:Comparing strategies

OBJECTIVE: Timely identification of patients who carry multidrug-resistant microorganisms (MDRO) is needed to prevent nosocomial spread to other patients and to the hospital environment. We aimed to compare the yield of a universal screening strategy upon admission to the currently installed universal risk assessment combined with risk-based screening upon admission. METHODS: This observational study was conducted within a prospective cohort study. From January 1, 2018, until September 1, 2019, patients admitted to our hospital were asked to participate. Nasal and perianal samples were taken upon admission and checked for the presence of MDRO. The results of the universal risk assessment and risk-based screening were collected retrospectively from electronic health records. RESULTS: In total, 1017 patients with 1069 separate hospital admissions participated in the study. Universal screening identified 38 (3.6%) unknown MDRO carriers upon admission (37 individual patients), all carrying extended-spectrum beta-lactamase-producing Enterobacterales. For 946 of 1069 (88.5%) patients, both the universal risk assessment and universal screening were performed. For 19 (2.0%) admissions, ≥1 risk factor was identified. The universal risk assessment identified one (0.1%) unknown carrier, compared to 37 out of 946 carriers for the universal screening (P&lt;0.001). Of the 37 carriers identified through the universal screening, 35 (94.6%) reported no risk factors. CONCLUSIONS: Our results show that in our low endemic setting, a universal screening strategy identified significantly more MDRO carriers than the currently implemented universal risk-assessment. When implementing a universal risk-assessment, risk factors should be carefully selected to be able to identify ESBL-E carriers. While the universal screening identified more MDRO carriers, further research is needed to determine the cost-effectiveness of this strategy.</p

Dynamics of Staphylococcus aureus in patients and the hospital environment in a tertiary care hospital in the Netherlands

Background: The dynamics of Staphylococcus aureus in patients and the hospital environment are relatively unknown. We studied these dynamics in a tertiary care hospital in the Netherlands. Methods: Nasal samples were taken from adult patients at admission and discharge. Isolates cultured from clinical samples taken before and during hospitalization from these patients were included. Environmental samples of patient rooms were taken over a three-year period. Finally, isolates from clinical samples from patients with an epidemiological link to S. aureus positive rooms were included. Staphylococcal protein A (spa) typing was performed. Results: Nasal samples were taken from 673 patients. One hundred eighteen (17.5%) were positive at admission and discharge, 15 (2.2%) patients acquired S. aureus during hospitalization. Nineteen patients had a positive clinical sample during hospitalization, 15.9% of the S. aureus were considered as from an exogenous source. One hundred and forty (2.8%) environmental samples were S. aureus positive. No persistent contamination of surfaces was observed. Isolates were highly diverse: spa typing was performed for 893 isolates, identifying 278 different spa types, 161 of these spa types were observed only once. Conclusion: Limited transmission could be identified between patients and the hospital environment, and from patient-to-patient. Exogenous acquisition was assumed to occur in 15% of clinical samples. Environmental contamination was infrequent, temporarily, and coincided with the strain from the patient admitted to the room at that time. MRSA was rare and not found in the environment.</p

Presence of procoagulant peripheral blood mononuclear cells in severe COVID-19 patients relate to ventilation perfusion mismatch and precede pulmonary embolism

PURPOSE: Pulmonary emboli (PE) contribute substantially to coronavirus disease 2019 (COVID-19) related mortality and morbidity. Immune cell-mediated hyperinflammation drives the procoagulant state in COVID-19 patients, resulting in immunothrombosis. To study the role of peripheral blood mononuclear cells (PBMC) in the procoagulant state of COVID-19 patients, we performed a functional bioassay and related outcomes to the occurrence of PE. Secondary aims were to relate this functional assay to plasma D-dimer levels, ventilation perfusion mismatch and TF expression on monocyte subsets. METHODS: PBMC from an ICU biobank were obtained from 20 patients with a computed tomography angiograph (CTA) proven PE and compared to 15 COVID-19 controls without a proven PE. Functional procoagulant properties of PBMC were measured using a modified fibrin generation time (MC-FGT) assay. Tissue factor (TF) expression on monocyte subsets were measured by flow cytometry. Additional clinical data were obtained from patient records including end-tidal to arterial carbon dioxide gradient. RESULTS: MC-FGT levels were highest in the samples taken closest to the PE detection, similar to the end-tidal to arterial carbon dioxide gradient (ETCO2 - PaCO2), a measurement to quantify ventilation-perfusion mismatch. In patients without proven PE, peak MC-FGT relates to an increase in end-tidal to arterial carbon dioxide gradient. We identified non-classical, CD16 positive monocytes as the subset with increased TF expression. CONCLUSION: We show that the procoagulant state of PBMC could aid in early detection of PE in COVID-19 ICU patients. Combined with end-tidal to ETCO2 - PaCO2 gradient, these tests could improve early detection of PE on the ICU.</p

Development and socialization of self-regulation from infancy to adolescence:A meta-review differentiating between self-regulatory abilities, goals, and motivation

Self-regulation has been intensely studied across developmental science disciplines in virtue of its significance to understanding and fostering adaptive functioning throughout life. Whereas research has predominantly focused on self-regulatory abilities, age-related changes in goals and motivation that underlie self-regulation have been largely neglected. In a systematic meta-review, we disentangle the development of self-regulatory abilities from age-related goals and motivation between infancy and adolescence. We further investigate the roles of parents, teachers, and peers in the socialization of self-regulatory abilities separately from the socialization of goals and motivation. We searched reviews and meta-analyses on self-regulation in typical development (0–18 years), identifying 1,935 records, from which 136 articles were included. Results show that self-regulation develops from being largely co-regulated in infancy to an independent yet socially-calibrated process in adolescence. We further demonstrate continuity as well as age-related transitions in the abilities, goals, and motivation employed for self-regulation, and pinpoint the exact role of various social agents involved in these processes. Our meta-review yields a detailed description of self-regulation development between infancy and adolescence, providing a starting point for future developmental and intervention work regarding key processes and social agents to be considered when targeting self-regulation in a particular age group.</p

Variable loss of functional activities of androgen receptor mutants in patients with androgen insensitivity syndrome

Androgen receptor (AR) mutations in androgen insensitivity syndrome (AIS) are associated with a variety of clinical phenotypes. The aim of the present study was to compare the molecular properties and potential pathogenic nature of 8 novel and 3 recurrent AR variants with a broad variety of functional assays. Eleven AR variants (p.Cys177Gly, p.Arg609Met, p.Asp691del, p.Leu701Phe, p.Leu723Phe, p.Ser741Tyr, p.Ala766Ser, p.Arg775Leu, p.Phe814Cys, p.Lys913X, p.Ile915Thr) were analyzed for hormone binding, transcriptional activation, cofactor binding, translocation to the nucleus, nuclear dynamics, and structural conformation. Ligand-binding domain variants with low to intermediate transcriptional activation displayed aberrant Kd values for hormone binding and decreased nuclear translocation. Transcriptional activation data, FxxFF-like peptide binding and DNA binding correlated well for all variants, except for p.Arg609Met, p.Leu723Phe and p.Arg775Leu, which displayed a relatively higher peptide binding activity. Variants p.Cys177Gly, p.Asp691del, p.Ala766Ser, p.Phe814Cys, and p.Ile915Thr had intermediate or wild type values in all assays and showed a predominantly nuclear localization in living cells. All transcriptionally inactive variants (p.Arg609Met, p.Leu701Phe, p.Ser741Tyr, p.Arg775Leu, p.Lys913X) were unable to bind to DNA and were associated with complete AIS. Three variants (p.Asp691del, p.Arg775Leu, p.Ile915Thr) still displayed significant functional activities in in vitro assays, although the clinical phenotype was associated with complete AIS. The data show that molecular phenotyping based on 5 different functional assays matched in most (70%) but not all cases. Copyrigh

A Next Step in Disruption Management: Combining Operations Research and Complexity Science

Railway systems occasionally get into a state of out-of-control, meaning that there is barely any train is running, even though the required resources (infrastructure, rolling stock and crew) are available. These situations can either be caused by large disruptions or unexpected propagation and accumulation of delays. Because of the large number of aected resources and the absence of detailed, timely and accurate information, currently existing methods cannot be applied in out-of-control situations. Most of the contemporary approaches assume that there is only one single disruption with a known duration, that all information about the resources is available, and that all stakeholders in the operations act as expected. Another limitation is the lack of knowledge about why and how disruptions accumulate and whether this process can be predicted. To tackle these problems, we develop a multidisciplinary framework aiming at reducing the impact of these situations and - if possible - avoiding them. The key elements of this framework are (i) the generation of early warning signals for out-of-control situations using tools from complexity science and (ii) a set of rescheduling measures robust against the features of out-of-control situations, using tools from operations research

A next step in disruption management: combining operations research and complexity science

Railway systems occasionally get into a state of being out-of-control, meaning that barely any train is running, even though the required resources (infrastructure, rolling stock and crew) are available. Because of the large number of affected resources and the absence of detailed, timely and accurate information, currently existing disruption management techniques cannot be applied in out-of-control situations. Most of the contemporary approaches assume that there is only one single disruption with a known duration, that all information about the resources is available, and that all stakeholders in the operations act as expected. Another limitation is the lack of knowledge about why and how disruptions accumulate and whether this process can be predicted. To tackle these problems, we develop a multidisciplinary framework combining techniques from complexity science and operations research, aiming at reducing the impact of these situations and—if possible—avoiding them. The key elements of this framework are (i) the generation of early warning signals for out-of-control situations, (ii) isolating a specific region such that delay stops propagating, and (iii) the app

Veenoxidatie in het gebied Daarle-Vriezenveen : Onderdeel van de uitwerking advies over planMER voorkeurslocaties drinkwaterwinning Twente-Achterhoek

Als onderdeel van het project ‘Uitwerking advies over planMER voorkeurslocaties drinkwaterwinning Twente-Achterhoek’ heeft Wageningen Environmental Research (Alterra) in opdracht van Tauw het onderdeel veenoxidatie in het gebied Daarle-Vriezenveen onderzocht. Dit verslag geeft een overzicht van de ingrepen die in het gebied hebben plaatsgevonden, de actuele maaivelddaling van het resterende veen en toename daarvan onder invloed van 4 varianten met grondwaterwinningen