Screening for multi-drug-resistant Gram-negative bacteria: what is effective and justifiable?

Effectiveness is a key criterion in assessing the justification of antibiotic resistance interventions. Depending on an intervention's effectiveness, burdens and costs will be more or less justified, which is especially important for large scale population-level interventions with high running costs and pronounced risks to individuals in terms of wellbeing, integrity and autonomy. In this paper, we assess the case of routine hospital screening for multi-drug-resistant Gram-negative bacteria (MDRGN) from this perspective. Utilizing a comparison to screening programs for Methicillin-Resistant Staphylococcus aureus (MRSA) we argue that current screening programmes for MDRGN in low endemic settings should be reconsidered, as its effectiveness is in doubt, while general downsides to screening programs remain. To accomplish justifiable antibiotic stewardship, MDRGN screening should not be viewed as a separate measure, but rather as part of a comprehensive approach. The program should be redesigned to focus on those at risk of developing symptomatic infections with MDRGN rather than merely detecting those colonised

Demographic, clinical and antibody characteristics of patients with digital ulcers in systemic sclerosis: data from the DUO Registry

OBJECTIVES: The Digital Ulcers Outcome (DUO) Registry was designed to describe the clinical and antibody characteristics, disease course and outcomes of patients with digital ulcers associated with systemic sclerosis (SSc). METHODS: The DUO Registry is a European, prospective, multicentre, observational, registry of SSc patients with ongoing digital ulcer disease, irrespective of treatment regimen. Data collected included demographics, SSc duration, SSc subset, internal organ manifestations, autoantibodies, previous and ongoing interventions and complications related to digital ulcers. RESULTS: Up to 19 November 2010 a total of 2439 patients had enrolled into the registry. Most were classified as either limited cutaneous SSc (lcSSc; 52.2%) or diffuse cutaneous SSc (dcSSc; 36.9%). Digital ulcers developed earlier in patients with dcSSc compared with lcSSc. Almost all patients (95.7%) tested positive for antinuclear antibodies, 45.2% for anti-scleroderma-70 and 43.6% for anticentromere antibodies (ACA). The first digital ulcer in the anti-scleroderma-70-positive patient cohort occurred approximately 5 years earlier than the ACA-positive patient group. CONCLUSIONS: This study provides data from a large cohort of SSc patients with a history of digital ulcers. The early occurrence and high frequency of digital ulcer complications are especially seen in patients with dcSSc and/or anti-scleroderma-70 antibodies

Nutrient cycling in Lake Kivu

This chapter summarizes the knowledge on mixing and transport processes in Lake Kivu. Seasonal mixing, which varies in intensity from year to year, influences the top ∼65 m. Below, the lake is permanently stratified, with density increasing stepwise from ∼998 kg m−3 at the surface to ∼1,002 kg m−3 at the maximum depth of 485 m. The permanently stratified deep water is divided into two distinctly different zones by a main gradient layer. This gradient is maintained by a strong inflow of relatively fresh and cool water entering at ∼250 m depth which is the most important of several subaquatic springs affecting the density stratification. The springs drive a slow upwelling of the whole water column with a depth-dependent rate of 0.15–0.9 m year−1. This upwelling is the main driver of internal nutrient recycling and upward transport of dissolved gases. Diffusive transport in the deep water is dominated by double-diffusive convection, which manifests in a spectacular staircase of more than 300 steps and mixed layers. Double diffusion allows heat to be removed from the deep zone faster than dissolved substances, supporting the stable stratification and the accumulation of nutrients and gases over hundreds of years. The stratification in the lake seems to be near steady-state conditions, except for a warming trend of ∼0.01°C year−1.