Initial therapy received by <i>Cryptococcus gattii</i> patients.

<p>Initial therapy received by <i>Cryptococcus gattii</i> patients.</p

The EU Strategy for the Baltic Sea Region and the Presence of Russia

The aim of this paper is to reveal how the European – Russian political cooperation in the common Baltic Sea Region developed over the last twenty years, ending up at the recently adopted European Union Strategy for the Baltic Sea Region, which excludes Russian participation. This single case study is divided into two well-defined historical periods: starting from the fall of the Berlin Wall until the Eastern Bloc European enlargement and from 2004 to the adoption of the European Union Strategy for the Baltic Sea region in 2009; where comparison and process-tracing methods are applied to connect different variables that matter for clarifying the current state of relations. Furthermore, the analysis is conducted with the help of Constructivist and Neo-Realist theories for two purposes – to achieve stronger scientific explanation and to avoid too loose interpretation of the events. The results show that the Strategy for the Baltic Sea Region is often seen and understood differently by the various political actors, but consequently this leads to a situation in which the role of Russia in the common region remains unclear. When it comes to defining the Russian position today, the Baltic Sea Region provides a good climate for collaboration but so far, the European Union has failed to recognize that the Russian Federation although with a limited access to the sea, remains an actor that should not be ignored. Russia, as well appears confused about its overall foreign policy towards the European Union. Nevertheless, another significant outcome reveals that the levels of regional cooperation have been continuously increasing over the last twenty years, which is an indicator that the Russian presence did not diminish. Finally, the study suggests the European Union Strategy for the Baltic Sea Region is perhaps the beginning of a new tendency towards macro-regional policy development, which will play a future important role in the international relations

Three-month mortality among patients by site of infection and by initial therapy received^*.

<p>*Mortality measured from date of diagnosis; 4 patients died prior to diagnosis and receipt of antifungal therapy and are not included in this table.</p

Characteristics of patients with invasive <i>Cryptococcus gattii</i> infection in United States Pacific Northwest who survived to diagnosis (N = 70).

a<p>VGII molecular type isolates include isolates from the three outbreak genotypes, VGIIa, VGIIb, and VGIIc.</p>b<p>n = 69.</p>c<p>Categories not mutually exclusive.</p

Phylogenetic analysis of VGIII isolates.

<p>The neighbor-joining tree was constructed using the maximum-likelihood model and reveals two well supported clades. Bootstrap values (1000 replicates) are shown next to the branches. CA isolates are blue, Pacific Northwest isolates are red and Southeast US isolates are green.</p

<i>Cryptococcus</i><i> gattii</i> in the United States: Genotypic Diversity of Human and Veterinary Isolates

<div><p>Background</p><p><i>Cryptococcus</i><i>gattii</i> infections are being reported in the United States (US) with increasing frequency. Initially, US reports were primarily associated with an ongoing <i>C</i><i>. gattii</i> outbreak in the Pacific Northwest (PNW) states of Washington and Oregon, starting in 2004. However, reports of <i>C</i><i>. gattii</i> infections in patients from other US states have been increasing since 2009. Whether this is due to increasing frequency of disease, greater recognition within the clinical community, or both is currently unknown.</p> <p>Methodology/Principal Findings</p><p>During 2005–2013, a total of 273 <i>C</i><i>. gattii</i> isolates from human and veterinary sources in 16 US states were collected. Of these, 214 (78%) were from the Pacific Northwest (PNW) and comprised primarily the clonal <i>C</i><i>. gattii</i> genotypes VGIIa (64%), VGIIc (21%) and VGIIb (9%). The 59 isolates from outside the PNW were predominantly molecular types VGIII (44%) and VGI (41%). Genotyping using multilocus sequence typing revealed small clusters, including a cluster of VGI isolates from the southeastern US, and an unrelated cluster of VGI isolates and a large cluster of VGIII isolates from California. Most of the isolates were mating type MATα, including all of the VGII isolates, but one VGI and three VGIII isolates were mating type MAT<b>a</b>.</p> <p>Conclusions/Significance</p><p>We provide the most comprehensive report to date of genotypic diversity of US <i>C</i><i>. gattii</i> isolates both inside and outside of the PNW. <i>C</i><i>. gattii</i> may have multiple endemic regions in the US, including a previously-unrecognized endemic region in the southeast. Regional clusters exist both in California and the Southeastern US. VGII strains associated with the PNW outbreak do not appear to have spread substantially beyond the PNW.</p> </div

US map showing <i>C</i><i>. gattii</i> distribution.

<p>The map shows the distribution of <i>C</i><i>. gattii</i> molecular types by the state of origin. Because complete travel histories are not known for all patients contributing isolates, it is possible that some infections were acquired in states other than the ones in which they were recognized.</p

Incidence of Norovirus and Other Viral Pathogens That Cause Acute Gastroenteritis (AGE) among Kaiser Permanente Member Populations in the United States, 2012–2013

<div><p>Noroviruses and other viral pathogens are increasingly recognized as frequent causes of acute gastroenteritis (AGE). However, few laboratory-based data are available on the incidence of AGE caused by viral pathogens in the U.S. This study examined stool specimens submitted for routine clinical diagnostics from patients enrolled in Kaiser Permanente (KP) health plans in metro Portland, OR, and the Maryland, District of Columbia, and northern Virginia geographic areas to estimate the incidence of viral enteropathogens in these populations. Over a one-year study period, participating laboratories randomly selected stools submitted for routine clinical diagnostics for inclusion in the study along with accompanying demographic and clinical data. Selected stools were tested for norovirus, rotavirus, sapovirus, and astrovirus using standardized real-time RT-PCR protocols. Each KP site provided administrative data which were used in conjunction with previously published data on healthcare utilization to extrapolate pathogen detection rates into population-based incidence rates. A total of 1,099 specimens collected during August 2012 to September 2013 were included. Mean age of patients providing stool specimens was 46 years (range: 0–98 years). Noroviruses were the most common viral pathogen identified among patients with AGE (n = 63 specimens, 6% of specimens tested). In addition, 22 (2%) of specimens were positive for rotavirus; 19 (2%) were positive for sapovirus; and 7 (1%) were positive for astrovirus. Incidence of norovirus-associated outpatient visits was 5.6 per 1,000 person-years; incidence of norovirus disease in the community was estimated to be 69.5 per 1,000 person-years. Norovirus incidence was highest among children <5 years of age (outpatient incidence = 25.6 per 1,000 person-years; community incidence = 152.2 per 1,000 person-years), followed by older adults aged >65 years (outpatient incidence = 7.8 per 1,000 person-years; community incidence = 75.8 per 1,000 person-years). Outpatient incidence rates of rotavirus, sapovirus, and astrovirus were 2.0, 1.6, 0.6 per 1,000 person-years, respectively; community incidence rates for these viruses were 23.4, 22.5, and 8.5 per 1,000 person-years, respectively. This study provides the first age-group specific laboratory-based community and outpatient incidence rates for norovirus AGE in the U.S. Norovirus was the most frequently detected viral enteropathogen across the age spectrum with the highest rates of norovirus disease observed among young children and, to a lesser extent, the elderly. These data provide a better understanding of the norovirus disease burden in the United States, including variations within different age groups, which can help inform the development, targeting, and future impacts of interventions, including vaccines.</p></div

Estimated community incidence of norovirus AGE among outpatients in Kaiser Permanente Northwest and Mid-Atlantic Health Plans, by age group, 2012–2013.

<p>Estimated community incidence of norovirus AGE among outpatients in Kaiser Permanente Northwest and Mid-Atlantic Health Plans, by age group, 2012–2013.</p

Characteristics of randomly selected stool specimens submitted by outpatients, by age group, to Kaiser Permanente Northwest and Mid-Atlantic Health Plans, 2012–2013.

<p>Characteristics of randomly selected stool specimens submitted by outpatients, by age group, to Kaiser Permanente Northwest and Mid-Atlantic Health Plans, 2012–2013.</p