Impact of antibiotic treatment and host innate immune pressure on enterococcal adaptation in the human bloodstream

Multidrug-resistant enterococcal strains emerged in the early 1980s and are now among the leading causes of drug-resistant bacterial infection worldwide. We used functional genomics to study an early bacterial outbreak in patients in a Wisconsin hospital between 1984 and 1988 that was caused by multidrug-resistantEnterococcus faecalis. The goal was to determine how a clonal lineage ofE. faecalisbecame adapted to growth and survival in the human bloodstream. Genome sequence analysis revealed a progression of increasingly fixed mutations and repeated independent occurrences of mutations in a relatively small set of genes. Repeated independent mutations suggested selection within the host during the course of infection in response to pressures such as host immunity and antibiotic treatment. We observed repeated independent mutations in a small number of loci, including a little studied polysaccharide utilization pathway and thecydABDClocus. Functional studies showed that mutating these loci renderedE. faecalisbetter able to withstand antibiotic pressure and innate immune defenses in the human bloodstream. We also observed a shift in mutation pattern that corresponded to the introduction of carbapenem antibiotics in 1987. This work identifies pathways that allow enterococci to survive the transition from the human gut into the bloodstream, enabling them to cause severe bacteremia associated with high mortality.

An Efficient Feed Foreword Network Model with Sine Cosine Algorithm for Breast Cancer Classification

This article describes how breast cancer is the most common invasive cancer in females worldwide and is major cause of deaths. The diagnoses of breast cancer include mammograms, breast ultrasound, magnetic resonance imaging (MRI), ductogram and biopsy. Biopsy is best and only way to know if the breast tumour is cancerous. Reports say that positive detection of breast cancer through biopsy can reach as low as 10%. So many statistical techniques and cognitive science approaches like artificial intelligence are being used to detect the type of breast cancer in a patient. This article presents the breast cancer classification using a feed foreword neural network trained by a sine-cosine algorithm. The superiority of the SCA-NN is shown by experimenting on the Wisconsin Hospital data set and comparing with the recently reported results. The evaluations show that the proposed approach is very robust, effective and gives better correct classification as compared to other classifiers.

Outreach syncope clinic managed by a nurse practitioner: Outcome and cost effectiveness

Introduction The purpose of this study was to assess the clinical and financial outcomes of a novel outreach syncope clinic. Methods We compared the clinical outcome of the Faint and Fall Clinic at the American Center (January–June 2016) with that of the University of Wisconsin Health and Clinics Faint and Fall Clinic (January 2013–December 2014). The American Center-Faint and Fall Clinic is run solely by a nurse practitioner, assisted by online faint-decision software and consultancy of a faint specialist through video-conferencing. Results Five hundred and twenty-eight consecutive patients were seen at the University of Wisconsin Hospital and Clinics-Faint and Fall Clinic and 68 patients at the American Center-Faint and Fall Clinic. The patients’ clinical characteristics were similar except for a lower age in the American Center patients (45 ± 18 vs 51 ± 22, p = 0.03). Overall, a diagnosis was made within 45 days in 70% (95% confidence interval 66–74%) of the University of Wisconsin Hospital and Clinics patients and 69% (95% confidence interval 58–80%) of the American Center patients, ( p = 0.9). A mean of 3.0 ± 1.6 tests per patient was used in the University of Wisconsin Hospital and Clinics group compared to 1.5 ± 0.8 tests per patient in the American Center group, p = 0.001. Over the six-month study period, the total revenue at the American Center was US$152,597 (contribution margin of US$122,393 plus professional revenue of US$30,204). The total cost of the nurse practitioner including benefits was US$66,662 ((US$98,466 salary/year + 35.4% benefits)/2). Total revenue minus expenses resulted in a net profit of US$85,935. Discussion A nurse practitioner-run outreach syncope-clinic equipped with online faint-decision software and consultancy of a faint specialist through vedio-conferencing is feasible and financially self-sustainable. It allows the dissemination of standardized high-quality syncope care to patients who have no immediate access to a tertiary teaching hospital.

An Outbreak of Legionnaires Disease Associated with a Decorative Water Wall Fountain in a Hospital

Objective.To detect an outbreak-related source of Legionella, control the outbreak, and prevent additional Legionella infections from occurring.Design and Setting.Epidemiologic investigation of an acute outbreak of hospital-associated Legionnaires disease among outpatients and visitors to a Wisconsin hospital.Patients.Patients with laboratory-confirmed Legionnaires disease who resided in southeastern Wisconsin and had illness onsets during February and March 2010.Methods.Patients with Legionnaires disease were interviewed using a hypothesis-generating questionnaire. On-site investigation included sampling of water and other potential environmental sources for Legionella testing. Case-finding measures included extensive notification of individuals potentially exposed at the hospital and alerts to area healthcare and laboratory personnel.Results.Laboratory-confirmed Legionnaires disease was diagnosed in 8 patients, all of whom were present at the same hospital during the 10 days prior to their illness onsets. Six patients had known exposure to a water wall-type decorative fountain near the main hospital entrance. Although the decorative fountain underwent routine cleaning and maintenance, high counts of Legionella pneumophila serogroup 1 were isolated from cultures of a foam material found above the fountain trough.Conclusion.This outbreak of Legionnaires disease was associated with exposure to a decorative fountain located in a hospital public area. Routine cleaning and maintenance of fountains does not eliminate the risk of bacterial contamination. Our findings highlight the need to evaluate the safety of water fountains installed in any area of a healthcare facility.Infect Control Hosp Epidemiol 2012;33(2):185-191

Use of Failure Mode and Effects Analysis for Proactive Identification of Communication and Handoff Failures from Organ Procurement to Transplantation

A multidisciplinary team from the University of Wisconsin Hospital and Clinics transplant program used failure mode and effects analysis to proactively examine opportunities for communication and handoff failures across the continuum of care from organ procurement to transplantation. The team performed a modified failure mode and effects analysis that isolated the multiple linked, serial, and complex information exchanges occurring during the transplantation of one solid organ. Failure mode and effects analysis proved effective for engaging a diverse group of persons who had an investment in the outcome in analysis and discussion of opportunities to improve the system's resilience for avoiding errors during a time-pressured and complex process.