Attributable costs of enterococcal bloodstream infections in a nonsurgical hospital cohort

BACKGROUND: Vancomycin-resistant enterococcal (VRE) bloodstream infections (BSI) are associated with increased morbidity and mortality. OBJECTIVE: To determine the attributable costs of vancomycin-sensitive (VSE) and VRE BSI and the independent impact of vancomycin-resistance on hospital costs. METHODS: A retrospective cohort study was conducted of 21,154 non-surgical patients admitted to an academic medical center between 2002 and 2003. Using administrative data, attributable hospital costs (inflation adjusted to $2007) and length of stay were estimated with multivariate generalized least squares (GLS) models and propensity score matched-pairs. RESULTS: The cohort included 182 VSE and 94 VRE BSI cases. After adjustment for demographics, comorbidities, procedures, non-enterococcal BSI, and early mortality, the attributable costs of VSE BSI were$2,250 (95% confidence interval [CI], $1,758–$2,880) in the standard GLS model and $2,023 (95$1,588–$2,575) in the propensity-score weighted GLS model and the attributable costs of VRE BSI were$4,479 (95% CI, $3,500–$5,732) in the standard GLS model and $4,036 (95$3,170–$5,140) in the propensity-score weighted GLS model. The median of the difference in costs between matched-pairs was$5,282 ($2,042–$8,043) for VSE BSI and $9,949 (95$1,579–$24,693) for VRE BSI. The attributable costs of vancomycin-resistance were$1,713 (95% CI, $1,338–$2,192) in the standard GLS model and $1,546 (95$1,214–$1,968) in the propensity-score weighted GLS model. Attributable length of stay ranged from 1.1–2.2 days for VSE BSI and 2.2–3.5 days for VRE BSI cases. CONCLUSIONS: VSE and VRE BSI were independently associated with hospital costs and length of stay. Vancomycin-resistance was associated with increased costs

Morally Respectful Listening and its Epistemic Consequences

What does it mean to listen to someone respectfully, that is, insofar as they are due recognition respect? This paper addresses that question and gives the following answer: it is to listen in such a way that you are open to being surprised. A specific interpretation of this openness to surprise is then defended

AN ULTRA-FAINT GALAXY CANDIDATE DISCOVERED in EARLY DATA from the MAGELLANIC SATELLITES SURVEY

We report a new ultra-faint stellar system found in Dark Energy Camera data from the first observing run of the Magellanic Satellites Survey (MagLiteS). MagLiteS J0644-5953 (Pictor II or Pic II) is a low surface brightness (μ = 28.5+1 -1 mag arcsec-2 within its half-light radius) resolved overdensity of old and metal-poor stars located at a heliocentric distance of 45+5 -4 kpc. The physical size (r1/2 = 46+15 -11) and low luminosity (Mv = -3.2+0.4 -0.5 mag) of this satellite are consistent with the locus of spectroscopically confirmed ultra-faint galaxies. MagLiteS J0644-5953 (Pic II) is located 11.3+3.1 -0.9 kpc from the Large Magellanic Cloud (LMC), and comparisons with simulation results in the literature suggest that this satellite was likely accreted with the LMC. The close proximity of MagLiteS J0644-5953 (Pic II) to the LMC also makes it the most likely ultra-faint galaxy candidate to still be gravitationally bound to the LM

A Novel Anti-Inflammatory and Pro-Resolving Role for Resolvin D1 in Acute Cigarette Smoke-Induced Lung Inflammation

Introduction: Cigarette smoke is a profound pro-inflammatory stimulus that contributes to acute lung injuries and to chronic lung disease including COPD (emphysema and chronic bronchitis). Until recently, it was assumed that resolution of inflammation was a passive process that occurred once the inflammatory stimulus was removed. It is now recognized that resolution of inflammation is a bioactive process, mediated by specialized lipid mediators, and that normal homeostasis is maintained by a balance between pro-inflammatory and pro-resolving pathways. These novel small lipid mediators, including the resolvins, protectins and maresins, are bioactive products mainly derived from dietary omega-3 and omega-6 polyunsaturated fatty acids (PUFA). We hypothesize that resolvin D1 (RvD1) has potent anti-inflammatory and pro-resolving effects in a model of cigarette smoke-induced lung inflammation. Methods: Primary human lung fibroblasts, small airway epithelial cells and blood monocytes were treated with IL-1β or cigarette smoke extract in combination with RvD1 in vitro, production of pro-inflammatory mediators was measured. Mice were exposed to dilute mainstream cigarette smoke and treated with RvD1 either concurrently with smoke or after smoking cessation. The effects on lung inflammation and lung macrophage populations were assessed. Results: RvD1 suppressed production of pro-inflammatory mediators by primary human cells in a dose-dependent manner. Treatment of mice with RvD1 concurrently with cigarette smoke exposure significantly reduced neutrophilic lung inflammation and production of pro-inflammatory cytokines, while upregulating the anti-inflammatory cytokine IL-10. RvD1 promoted differentiation of alternatively activated (M2) macrophages and neutrophil efferocytosis. RvD1 also accelerated the resolution of lung inflammation when given after the final smoke exposure. Conclusions: RvD1 has potent anti-inflammatory and pro-resolving effects in cells and mice exposed to cigarette smoke. Resolvins have strong potential as a novel therapeutic approach to resolve lung injury caused by smoke and pulmonary toxicants

The ACS Nearby Galaxy Survey Treasury

The ACS Nearby Galaxy Survey Treasury (ANGST) is a systematic survey to establish a legacy of uniform multi-color photometry of resolved stars for a volume-limited sample of nearby galaxies (D<4 Mpc). The survey volume encompasses 69 galaxies in diverse environments, including close pairs, small & large groups, filaments, and truly isolated regions. The galaxies include a nearly complete range of morphological types spanning a factor of ~10^4 in luminosity and star formation rate. The survey data consists of images taken with ACS on HST, supplemented with archival data and new WFPC2 imaging taken after the failure of ACS. Survey images include wide field tilings covering the full radial extent of each galaxy, and single deep pointings in uncrowded regions of the most massive galaxies in the volume. The new wide field imaging in ANGST reaches median 50% completenesses of m_F475W=28.0 mag, m_F606W=27.3 mag, and m_F814W=27.3 mag, several magnitudes below the tip of the red giant branch (TRGB). The deep fields reach magnitudes sufficient to fully resolve the structure in the red clump. The resulting photometric catalogs are publicly accessible and contain over 34 million photometric measurements of >14 million stars. In this paper we present the details of the sample selection, imaging, data reduction, and the resulting photometric catalogs, along with an analysis of the photometric uncertainties (systematic and random), for both the ACS and WFPC2 imaging. We also present uniformly derived relative distances measured from the apparent magnitude of the TRGB.Comment: 54 pages, including 24 pages of figures and 16 pages of tables. Project website and data available at http://www.nearbygalaxies.org/ . Data is also available through MAST. Scheduled to appear in the Astrophysical Journal Supplements. (Replaced to fix several figures that were damaged during compression

Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

Objective: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. Participants: A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine. Design/Methods: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members. Results: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60min of < 9 g/dL) after cosyntropin (250 g) administration and a random plasma cortisol of < 10 g/dL may be used by clinicians. We suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using IV hydrocortisone < 400mg/day for 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO(2) < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence). Conclusions: Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force

Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM)

Objective: To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). Participants: A multi-specialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Data Sources: Medline, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews. Results: Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity. Conclusions: Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI

Bichromatic beam splitter for three-level atoms

We investigate schemes for the clean splitting of beams of three-level atoms using two standing-wave laser fields within an optical cavity. The proposed beam splitter is shown to work for atoms in the Λ ladder, and ssV configurations. For appropriate values of Rabi frequencies and detunings, we obtain a triangular type of potential for the atomic states of interest. As well as modeling the coherent evolution of the systems, we have used quantum Monte Carlo wave-function methods to model the effects of spontaneous emission on the resulting diffraction pattern, finding significant differences between the three configurations. We also investigate the limits of the Raman-Nath approximation for our systems, using the symmetric split-operator technique to include the effects of the kinetic term in the Hamiltonian. We also present the results of calculations in which the split output beams are recombined, demonstrating the expected interference for differently prepared input beams. In comparison with two-level beam splitters using a single standing wave, we obtain a superior splitting, while, in comparison with magneto-optical beam splitters, our system possesses the worthwhile practical advantages of experimental simplicity

Emergence of contact injuries in invasion team sports : an ecological dynamics rationale

The incidence of contact injuries in team sports is considerable, and injury mechanisms need to be comprehensively understood to facilitate the adoption of preventive measures. In Association Football, evidence shows that the highest prevalence of contact injuries emerges in one-on-one interactions. However, previous studies have tended to operationally report injury mechanisms in isolation, failing to provide a theoretical rationale to explain how injuries might emerge from interactions between opposing players. In this position paper, we propose an ecological dynamics framework to enhance current understanding of behavioural processes leading to contact injuries in team sports. Based on previous research highlighting the dynamics of performer–environment interactions, contact injuries are proposed to emerge from symmetry-breaking processes during on-field interpersonal interactions among competing players and the ball. Central to this approach is consideration of candidate control parameters that may provide insights on the information sources used by players to reduce risk of contact injuries during performance. Clinically, an ecological dynamics analysis could allow sport practitioners to design training sessions based on selected parameter threshold values as primary and/or secondary preventing measures during training and rehabilitation sessions