Inhaled antibiotics for hospital- acquired and ventilator- associated pneumonia

To the Editor—We would like to comment on the hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) guidelines recently published in Clinical Infectious Diseases [1]. These guidelines recommend inhaled antibiotics for patients with VAP due to gram-negative bacilli susceptible only to aminoglycosides or polymyxins and for patients not responding to intravenous (IV) antibiotics. It also suggests adjunctive inhaled colistin for HAP or VAP due to Acinetobacter strains susceptible only to polymyxins. Several important considerations related to inhaled antibiotics were not addressed

High export via small particles before the onset of the North Atlantic spring bloom

Sinking organic matter in the North Atlantic Ocean transfers 1-3 Gt carbon year?1 from the surface ocean to the interior. The majority of this exported material is thought to be in form of large, rapidly sinking particles that aggregate during or after the spring phytoplankton bloom. However, recent work has suggested that intermittent water column stratification resulting in the termination of deep convection can isolate phytoplankton from the euphotic zone, leading to export of small particles. We present depth profiles of large (>0.1mm equivalent spherical diameter, ESD) and small (300m depth, leading to deep mixing of particles as deep as 600m. Subsequent re-stratification could trap these particles at depth and lead to high particle fluxes at depth without the need for aggregation (‘mixed layer pump'). Overall we suggest that pre-bloom fluxes to the mesopelagic are significant, and the role of small sinking particles requires careful consideration

Near-Surface Interface Detection for Coal Mining Applications Using Bispectral Features and GPR

The use of ground penetrating radar (GPR) for detecting the presence of near-surface interfaces is a scenario of special interest to the underground coal mining industry. The problem is difficult to solve in practice because the radar echo from the near-surface interface is often dominated by unwanted components such as antenna crosstalk and ringing, ground-bounce effects, clutter, and severe attenuation. These nuisance components are also highly sensitive to subtle variations in ground conditions, rendering the application of standard signal pre-processing techniques such as background subtraction largely ineffective in the unsupervised case. As a solution to this detection problem, we develop a novel pattern recognition-based algorithm which utilizes a neural network to classify features derived from the bispectrum of 1D early time radar data. The binary classifier is used to decide between two key cases, namely whether an interface is within, for example, 5 cm of the surface or not. This go/no-go detection capability is highly valuable for underground coal mining operations, such as longwall mining, where the need to leave a remnant coal section is essential for geological stability. The classifier was trained and tested using real GPR data with ground truth measurements. The real data was acquired from a testbed with coal-clay, coal-shale and shale-clay interfaces, which represents a test mine site. We show that, unlike traditional second order correlation based methods such as matched filtering which can fail even in known conditions, the new method reliably allows the detection of interfaces using GPR to be applied in the near-surface region. In this work, we are not addressing the problem of depth estimation, rather confining ourselves to detecting an interface within a particular depth range

High export via small particles before the onset of the North Atlantic spring bloom

Sinking organic matter in the North Atlantic Ocean transfers 1-3 Gt carbon year?1 from the surface ocean to the interior. The majority of this exported material is thought to be in form of large, rapidly sinking particles that aggregate during or after the spring phytoplankton bloom. However, recent work has suggested that intermittent water column stratification resulting in the termination of deep convection can isolate phytoplankton from the euphotic zone, leading to export of small particles. We present depth profiles of large (&gt;0.1mm equivalent spherical diameter, ESD) and small (&lt;0.1mm ESD) sinking particle concentrations and fluxes prior to the spring bloom at two contrasting sites in the North Atlantic (61°30N, 11°00W and 62°50N, 02°30W) derived from the Marine Snow Catcher and the Video Plankton Recorder. The downward flux of organic carbon via small particles ranged from 23-186 mg C m?2 d?1, often constituting the bulk of the total particulate organic carbon flux. We propose that these rates were driven by two different mechanisms: In the Norwegian Basin, small sinking particles likely reached the upper mesopelagic by disaggregation of larger, faster sinking particles. In the Iceland Basin, a storm deepened the mixed layer to &gt;300m depth, leading to deep mixing of particles as deep as 600m. Subsequent re-stratification could trap these particles at depth and lead to high particle fluxes at depth without the need for aggregation (‘mixed layer pump'). Overall we suggest that pre-bloom fluxes to the mesopelagic are significant, and the role of small sinking particles requires careful consideration. <br/

Bezlotoxumab: A Novel Agent for the Prevention of Recurrent Clostridium difficile Infection

During the past decade, the incidence and severity of Clostridium difficile infection (CDI) have significantly increased, leading to a rise in CDI-associated hospitalizations, health care costs, and mortality. Although treatment options exist for CDI, recurrence is frequent following treatment. Furthermore, patients with at least one CDI recurrence are at an increased risk of developing additional recurrences. A novel approach to the prevention of recurrent CDI is the use of monoclonal antibodies directed against the toxins responsible for CDI as an adjunct to antibiotic treatment. Bezlotoxumab, a human monoclonal antibody that binds and neutralizes C. difficile toxin B, is the first therapeutic agent to receive United States Food and Drug Administration approval for the prevention of CDI recurrence. Clinical studies have demonstrated superior efficacy of bezlotoxumab in adults receiving antibiotic therapy for CDI compared with antibiotic therapy alone for the prevention of CDI recurrence. Bezlotoxumab was well tolerated in clinical trials, with the most common adverse effects being nausea, vomiting, fatigue, pyrexia, headache, and diarrhea. The demonstrated efficacy, safety, and characteristics of bezlotoxumab present an advance in prevention of CDI recurrence

Past-month cannabis use among U.S. individuals from 2002–2015: An age-period-cohort analysis

Background: Cannabis is the most commonly used illicit drug among U.S. adolescents and adults, but little is known about factors that drive trends in cannabis use prevalence. To better understand drivers of these trends, we aimed to estimate age, period, and cohort effects on past-month cannabis use among U.S. individuals age 12 and older from 2002 to 2015. Methods: We conducted an age-period-cohort analysis on past-month cannabis use among participants ages 12 and older using the National Survey on Drug Use and Health (NSDUH), an annual cross-sectional nationally-representative survey of drug use. Additionally, we examined how age, period, and cohort effects differed across gender. Participants (n = 779,799) self-reported cannabis patterns using a computer-assisted telephone interview (CATI). Results: Past-month cannabis use in this population increased from 6.0% in 2002 to 8.1% in 2015. Distinct age, period, and cohort effects were observed. Compared to participants ages 12–13, participants ages 18–21 (PR: 16.8, 95% CI: 15.6, 18.1) and 22–25 (PR: 13.2, 95% CI: 12.2, 14.4) had dramatically higher prevalence of past-month cannabis use. Compared to participants in 2002, participants in 2014 (PR: 1.2, 95% CI: 1.1, 1.4) and 2014 (PR: 1.2, 95% CI: 1.1, 1.4) had slightly higher prevalence of past-month cannabis use. Compared to the 1940s birth cohort, the 1950s birth cohort (PR: 1.8, 95% CI: 1.5, 2.2) had a higher prevalence of past-month cannabis use. Conclusions: Past-month cannabis use is prevalent and increasing among U.S. adults. Distinct age, period, and cohort effects are at play, though age effects are strongest

Impact of health care organization on surgical lung cancer care

ObjectivesOrganization and governance of national healthcare might play an important role in decision-making and outcomes in patients with lung cancer. Both Denmark and the Netherlands have a high level of healthcare but a different financial coverage, governance and level of centralization. By using both national databases we analyzed the consequences of these differences on patterns of care and outcomes with a focus on morbidity, mortality and clinical staging.Materials and methodsGeneral numbers on both healthcare systems were requested. All patients who had surgery for lung cancer from 2013 to 2016 were included. Mortality, morbidity and clinical staging were analyzed for patients with NSCLC without metastases, only one operation and no neo-adjuvant therapy.ResultsIn 2016 annual budget as share of gross national product was 10.4% for both countries. In Denmark 4 hospitals performed lung surgery in 2016, compared to 43 hospitals in the Netherlands. We included 4030 Danish and 8286 Dutch patients. In the subgroup 30-day mortality was 1.5% in Denmark compared to 1.9% in the Netherlands. The percentage of patients with a complicated course was 24.4% and 34.8% respectively (p ConclusionSurgery for lung cancer is at a high level in both countries, reflected by low mortality-rates. Centralization has been implemented successfully in Denmark, which might explain the lower rate of patients with a complicated post-operative course, although different definitions preclude firm conclusions. In both countries correct clinical staging of lung cancer remains a challenge.</div

The role of surgery for stage I non-small cell lung cancer in octogenarians in the era of stereotactic body radiotherapy in the Netherlands

ObjectivesResection is the standard treatment for stage I non-small cell lung cancer (NSCLC) in operable patients. Stereotactic body radiotherapy (SBRT) is recommended for inoperable patients. A shift from surgery to SBRT is expected in elderly patients due to increased frailty and competing risks. We assessed the current influence of age on treatment decision-making and overall survival (OS).Materials and methodsWe performed a retrospective cohort study using data from patients with clinical stage I NSCLC diagnosed in 2012–2016 and treated with lobectomy, segmentectomy, wedge resection, or SBRT, retrieved from the Netherlands Cancer Registry. Patient characteristics and OS were compared between SBRT and (sub)lobar resection for patients aged 18−79 and ≥80 years.Results and Conclusion8764 patients treated with lobectomy (n = 4648), segmentectomy (n = 122), wedge resection (n = 272), or SBRT (n = 3722) were included. In 2012–2016, SBRT was increasingly used for octogenarians and younger patients from 75.3% to 83.7% and from 30.8% to 43.2%, respectively. Five-year OS in the whole population was 70% after surgery versus 39% after SBRT and 50% versus 27% in octogenarians. After correction for age, gender, year of diagnosis, and clinical T-stage, OS was equal after lobectomy and SBRT in the first 2 years after diagnosis. However, after >2 years, OS was better after lobectomy than after SBRT.SBRT is the prevailing treatment in octogenarians with stage I NSCLC. While surgery is associated with better OS than SBRT, factors other than treatment modality (e.g. comorbidity) may have had a significant impact on survival. The wider application of SBRT in octogenarians likely reflects the frailty of this group. Registries and trials are required to identify key determinants of frailty in this specific population to improve patient selection for surgery or SBRT.Stem cells & developmental biolog

Growth and mortality of coccolithophores during spring in a temperate Shelf Sea (Celtic Sea, April 2015)

Coccolithophores are key components of phytoplankton communities, exerting a critical impact on the global carbon cycle and the Earth’s climate through the production of coccoliths made of calcium carbonate (calcite) and bioactive gases. Microzooplankton grazing is an important mortality factor in coccolithophore blooms, however little is currently known regarding the mortality (or growth) rates within non-bloom populations. Measurements of coccolithophore calcite production (CP) and dilution experiments to determine microzooplankton (≤63 µm) grazing rates were made during a spring cruise (April 2015) at the Central Celtic Sea (CCS), shelf edge (CS2), and within an adjacent April bloom of the coccolithophore Emiliania huxleyi at station J2. CP at CCS ranged from 10.4 to 40.4 µmol C m−3 d−1 and peaked at the height of the spring phytoplankton bloom (peak chlorophyll-a concentrations ∼6 mg m−3). Cell normalised calcification rates declined from ∼1.7 to ∼0.2 pmol C cell−1 d−1, accompanied by a shift from a mixed coccolithophore species community to one dominated by the more lightly calcified species E. huxleyi and Calciopappus caudatus. At the CCS, coccolithophore abundance increased from 6 to 94 cells mL−1, with net growth rates ranging from 0.06 to 0.21 d−1 from the 4th to the 28th April. Estimates of intrinsic growth and grazing rates from dilution experiments, at the CCS ranged from 0.01 to 0.86 d−1 and from 0.01 to 1.32 d−1, respectively, which resulted in variable net growth rates during April. Microzooplankton grazers consumed 59 to >100% of daily calcite production at the CCS. Within the E. huxleyi bloom a maximum density of 1986 cells mL−1 was recorded, along with CP rates of 6000 µmol C m−3 d−1 and an intrinsic growth rate of 0.29 d−1, with ∼80% of daily calcite production being consumed. Our results show that microzooplankton can exert strong top-down control on both bloom and non-bloom coccolithophore populations, grazing over 60% of daily growth (and calcite production). The fate of consumed calcite is unclear, but may be lost either through dissolution in acidic food vacuoles, and subsequent release as CO2, or export to the seabed after incorporation into small faecal pellets. With such high microzooplankton-mediated mortality losses, the fate of grazed calcite is clearly a high priority research direction

Risk of heart failure in survivors of Hodgkin lymphoma: Effects of cardiac exposure to radiation and anthracyclines

Hodgkin lymphoma (HL) survivors treated with radiotherapy and/or chemotherapy are known to have increased risks of heart failure (HF), but a radiation dose-response relationship has not previously been derived. A case-control study, nested in a cohort of 2617 five-year survivors of HL diagnosed before age 51 years during 1965 to 1995, was conducted. Cases (n 5 91) had moderate or severe HF as their first cardiovascular diagnosis. Controls (n 5 278) were matched to cases on age, sex, and HL diagnosis date. Treatment and follow-up information were abstracted from medical records. Mean heart doses and mean left ventricular doses (MLVD) were estimated by reconstruction of individual treatments on representative computed tomography datasets. Average MLVD was 16.7 Gy for cases and 13.8 Gy for controls (Pdifference 5 .003). HF rate increased with MLVD: relative to 0 Gy, HF rates following MVLD of 1-15, 16-20, 21-25, and ≥26 Gy were 1.27, 1.65, 3.84, and 4.39, respectively (Ptrend < .001). Anthracycline-containing chemotherapy increased HF rate by a factor of 2.83 (95% CI: 1.43-5.59), and there was no significant interaction with MLVD (Pinteraction 5 .09). Twenty-five–year cumulative risks of HF following MLVDs of 0-15 Gy, 16-20 Gy, and ≥21 Gy were 4.4%, 6.2%, and 13.3%, respectively, in patients treated without anthracycline-containing chemotherapy, and 11.2%, 15.9%, and 32.9%, respectively, in patients treated with anthracyclines. We have derived quantitative estimates of HF risk in patients treated for HL following radiotherapy with or without anthracycline-containing chemotherapy. Our results enable estimation of HF risk for patients before treatment, during radiotherapy planning, and during follow-up