The hardest part is knowing I will survive: The use of music and creative mediums to enhance empathy and facilitate life-long distance learning in professionally qualified clinicians

© Redfame Publishing Inc.Music is an experience that can cross personal and professional domains alongside cultural, gender, age and generational boundaries; it can also enhance the learning process through emotional processing and connection. This paper focuses on the learning experience of qualified clinical psychologists (CPs) working in the United Kingdom. This group of CPs had experience of undertaking experiential learning and reflective writing during their professional training. It considers the potential to continue a learning process, 3 years post qualification, through long distance methods using vignette-based material. Empathising with, and understanding, the position of others from differing backgrounds is an important competency within the therapeutic work of CPs and this comes alongside acknowledging and understanding ones‟ own experiences, both past and present. CPs work with difficult life experiences and complex issues; connecting constantly can be exhausting and, perhaps, unrealistic. Yet, to truly empathise one must connect with, and understand, the lived experiences of others. We will consider what helps and hinders this process, and how music and other creative mediums can be effectively used in learning even via long distance methods. We will further consider how CPs may be well placed to enhance the learning about, and processing of, difficult emotional experiences for themselves, other clinicians and the people they might work with.Peer reviewe

Risk perception of antimicrobial resistance by infection control specialists in Europe: a case-vignette study

Background Using case-vignettes, we assessed the perception of European infection control (IC) specialists regarding the individual and collective risk associated with antimicrobial resistance (AMR) among inpatients. Methods In this study, sixteen case-vignettes were developed to simulate hospitalised patient scenarios in the field of AMR and IC. A total of 245 IC specialists working in different hospitals from 15 European countries were contacted, among which 149 agreed to participate in the study. Using an online database, each participant scored five randomly-assigned case-vignettes, regarding the perceived risk associated with six different multidrug resistant organisms (MDRO). The intra-class correlation coefficient (ICC), varying from 0 (poor) to 1 (perfect), was used to assess the agreement for the risk on a 7-point Likert scale. High risk and low/neutral risk scorers were compared regarding their national, organisational and individual characteristics. Results Between January and May 2017, 149 participants scored 655 case-vignettes. The perceptions of the individual (clinical outcome) and collective (spread) risks were consistently lower than other MDRO for extended spectrum beta-lactamase producing Enterobacteriaceae cases and higher for carbapenemase producing Enterobacteriaceae (CPE) cases. Regarding CPE cases, answers were influenced more by the resistance pattern (93%) than for other MDRO. The risk associated with vancomycin resistant Enterococci cases was considered higher for the collective impact than for the individual outcome (63% vs 40%). The intra-country agreement regarding the individual risk was globally poor varying from 0.00 (ICC: 0–0.25) to 0.51 (0.18–0.85). The overall agreement across countries was poor at 0.20 (0.07–0.33). IC specialists working in hospitals preserved from MDROs perceived a higher individual (local, p = 0.01; national, p < 0.01) and collective risk (local and national p < 0.01) than those frequently exposed to bacteraemia. Conversely, IC specialists working in hospitals with a high MDRO clinical burden had a decreased risk perception. Conclusions The perception of the risk associated with AMR varied greatly across IC specialists and countries, relying on contextual factors including the epidemiology. IC specialists working in high prevalence areas may underestimate both the individual and collective risks, and might further negatively promote the MDRO spread. These finding highlight the need to shape local and national control strategies according to risk perceptions and contextual factors

Estimating the number of infections caused by antibiotic-resistant Escherichia coli and Klebsiella pneumoniae in 2014: a modelling study

Background: The number of infections caused by resistant organisms is largely unknown. We estimated the number of infections worldwide that are caused by the WHO priority pathogens third-generation cephalosporin-resistant and carbapenem-resistant Escherichia coli and Klebsiella pneumoniae. Methods: We calculated a uniform weighted mean incidence of serious infections caused by antibiotic-susceptible E coli and K pneumoniae using data from 17 countries. Using this uniform incidence, as well as population sizes and country-specific resistance levels, we estimated the number of infections caused by third-generation cephalosporin-resistant and carbapenem-resistant E coli and K pneumoniae in 193 countries in 2014. We also calculated interval estimates derived from changing the fixed incidence of susceptible infections to 1 SD below and above the weighted mean. We compared an additive model with combination models in which resistant infections were replaced by susceptible infections. We distinguished between higher-certainty regions (those with good-quality data sources for resistance levels and resistance ≤30%), moderate-certainty regions (those with good-quality data sources for resistance levels and including some countries with resistance &gt;30%), and low-certainty regions (those in which good-quality data sources for resistance levels were unavailable for countries comprising at least 20% of the region's population, regardless of resistance level). Findings: Using the additive model, we estimated that third-generation cephalosporin-resistant E coli and K pneumoniae caused 6·4 million (interval estimate 3·5–9·2) bloodstream infections and 50·1 million (27·5–72·8) serious infections in 2014; estimates were 5·5 million (3·0–7·9) bloodstream infections and 43·1 million (23·6–62·2) serious infections in the 25% replacement model, 4·6 million (2·5–6·6) bloodstream infections and 36·0 million (19·7–52·2) serious infections in the 50% replacement model, and 3·7 million (2·0–5·3) bloodstream infections and 28·9 million (15·8–41·9) serious infections in the 75% replacement model. Carbapenem-resistant strains caused 0·5 million (0·3–0·7) bloodstream infections and 3·1 million (1·8–4·5) serious infections based on the additive model, 0·5 million (0·3–0·7) bloodstream infections and 3·0 million (1·7–4·3) serious infections based on the 25% replacement model, 0·4 million (0·2–0·6) bloodstream infections and 2·8 million (1·6–4·1) serious infections based on the 50% replacement model, and 0·4 million (0·2–0·6) bloodstream infections and 2·7 million (1·5–3·8) serious infections based on the 75% replacement model. Interpretation: To our knowledge, this study is the first to report estimates of the global number of infections caused by antibiotic-resistant priority pathogens. Uncertainty stems from scant data on resistance levels from low-income and middle-income countries and insufficient knowledge regarding resistance dynamics when resistance is high. Funding: Innovative Medicines Initiative

MRSA decolonization failure - are biofilms the missing link?

Background: Device-associated infections due to biofilm-producing methicillin-resistant Staphylococcus aureus (MRSA) have been recently associated with the failure of antibiotic treatment and decolonization measures. The goal of our study was to evaluate the extent to which the formation of biofilms influenced the efficacy of topical decolonization agents or disinfectants such as mupirocin (MUP), octenidine (OCT), chlorhexidine (CHG), polyhexanide (POL), and chloroxylenol (CLO). Methods: Bacterial killing in biofilms by the disinfectants and MUP was determined as the reduction [%] in metabolic activity determined by a biofilm viability assay that uses kinetic analysis of metabolic activity. The test substances were diluted in water with standardized hardness (WSH) at 25 °C at the standard concentration as well as half the standard concentration to demonstrate the dilution effects in a practical setting. The tested concentrations were: CHG 1%, 2%; OCT 0.1%, 0.05%; PH 0.04%, 0.02%; and CLO 0.12%, 0.24%. A test organism suspension, 1 mL containing ~1 × 109 bacterial cells/mL, and 1 mL of sterile WSH were mixed and incubated for six different exposure times (15 s, 1, 3, 5, 10 and 20 min) after the test substance was added. Additionally, the bactericidal effects of all substances were tested on planktonic bacteria and measured as the log10 reduction. Results: The disinfectants OCT and CHG showed good efficacy in inhibiting MRSA in biofilms with reduction rates of 94 ± 1% and 91 ± 1%, respectively. POL, on the other hand, had a maximum efficacy of only 81 ± 7%. Compared to the tested disinfectants, MUP showed a significantly lower efficacy with &lt;20% inhibition (p &lt; .05). Bactericidal effects were the greatest for CHG (log10 reduction of 9.0), followed by OCT (7.7), POL (5.1), and CLO (6.8). MUP, however, showed a very low bactericidal effect of only 2.1. Even when the exposure time was increased to 24 h, 2% MUP did not show sufficient bactericidal effect. Conclusions: Our data provide evidence that OCT and CHG are effective components for disinfection of MRSA-biofilms. On the other hand, exposure to MUP at the standard concentrations in topical preparations did not effectively inhibit MRSA-biofilms and also did not show adequate bactericidal effects. Combining an MUP-based decolonization regimen with a disinfectant such as OCT or CHG could decrease decolonization failure

Glycopeptide resistance among coagulase- negative staphylococci that cause bacteremia: epidemiological and clinical findings from a case-control study

A 1-year prospective case-control study (ratio of control patients to case patients, 3:1) was performed to assess the incidence, risk factors, and genotypic patterns of bacteremia caused by glycopeptide-resistant coagulasenegative staphylococci (CoNS) and their correlation with hospital glycopeptide use. Among 535 subjects with CoNS bacteremia, 20 subjects had a glycopeptide-resistant strain (19 strains were resistant to teicoplanin and 1 was resistant to both teicoplanin and vancomycin). The percentage of resistant isolates recovered in 1 year was 8% in intensive care units and 3% and 2% in medical and surgical wards, respectively. Genotypic analysis of resistant strains showed different patterns with a high degree of polymorphism. Use of glycopeptides in individual wards was not statistically associated with the percentage of resistance. Previous exposure to β-lactams and glycopeptides, multiple hospitalization in the previous year, and concomitant pneumonia were significantly associated with the onset of glycopeptide-resistant CoNS bacteremia. Mortality rates were 25% among case patients and 18% among control patients, and they were significantly higher among patients who presented with concomitant pneumonia and a high Acute Physiology and Chronic Health Evaluation III score

CD4 intragenic SNPs associate with HIV-2 plasma viral load and CD4 count in a community-based study from Guinea-Bissau, West Africa.

OBJECTIVES: The human genetics of HIV-2 infection and disease progression is understudied. Therefore, we studied the effect of variation in 2 genes that encode products critical to HIV pathogenesis and disease progression: CD4 and CD209. DESIGN: This cross-sectional study consisted of 143 HIV-2, 30 HIV-1 + HIV-2 and 29 HIV-1-infected subjects and 194 uninfected controls recruited from rural Guinea-Bissau. METHODS: We genotyped 14 CD4 and 4 CD209 single nucleotide polymorphisms (SNPs) that were tested for association with HIV infection, HIV-2 plasma viral load (high vs. low), and CD4 T-cell count (high vs. low). RESULTS: The most significant association was between a CD4 haplotype rs11575097-rs10849523 and high viral load [odds ratio (OR): = 2.37, 95% confidence interval (CI): 1.35 to 4.19, P = 0.001, corrected for multiple testing], suggesting increased genetic susceptibility to HIV-2 disease progression for individuals carrying the high-risk haplotype. Significant associations were also observed at a CD4 SNP (rs2255301) with HIV-2 infection (OR: = 2.36, 95% CI: 1.19 to 4.65, P = 0.01) and any HIV infection (OR: = 2.50, 95% CI: 1.34 to 4.69, P = 0.004). CONCLUSIONS: Our results support a role of CD4 polymorphisms in HIV-2 infection, in agreement with recent data showing that CD4 gene variants increase risk to HIV-1 in Kenyan female sex workers. These findings indicate at least some commonality in HIV-1 and HIV-2 susceptibility

A Decision Support Tool: Integrating Wildlife Occupancy Models with Stand Projections

With the increase in consumptive trends of wood products there is greater push for ecosystem management. Ecosystem management is a process that aims to conserve major ecological services and restore natural resources while meeting the socioeconomic, political and cultural needs of current and future generations, and more efficient natural resource management. Forests provide natural resources for consumption; however, they also support wildlife and provide many other ecosystem services. Therefore, it is increasingly common that natural resource managers are asked to balance multiple objectives on a single property. The main objective of this study was to show how the theoretical outcomes from growth and yield models and wildlife occupancy models could be combined to give land managers an idea of what to expect before management is executed. A growth and yield model, the Forest Vegetation Simulator (FVS), is used for stand projection. The resulting stand structures are input into species-specific wildlife occupancy models to estimate probability of occurrence. A simplified example from the Barbour Wildlife Management Area in Alabama is used to illustrate this approach. Area managers wish to convert existing mixed loblolly pine-hardwood stands into an open-canopy, fire maintained, longleaf pine ecosystem. Though species specific occupancy models are used here for simplification, other species or objectives can be used for other properties. Three management scenarios were projected 100-years into the future: no treatment; immediate conversion through clearcutting, site preparation, and planting at three different densities; and long-term conversion through single-tree selection. Regression models were developed to predict reproductive and ground cover, variables not projected by FVS which are important parameters for occupancy of species. At five-year intervals, projected stand structure was input into occupancy models developed for four species of migratory songbirds; wood thrush, pine warbler, yellow-breasted chat, and prairie warbler. Stand structure varied through time for each of the scenarios, but there was little difference between reproductive cover and ground cover between scenarios. The pine warbler was predicted to occupy stands under both the no management and single-tree selection scenarios throughout the entire projection period. Under the even-aged management scenarios, the pine warbler has a probability of use between 80 and 100% throughout the projection cycle. The yellow-breasted chat’s probability of use varies between management scenarios. The wood thrush has less than a 30% probability of use under any management scenario. The prairie warbler has the highest probability of use in the even-aged scenarios over time, but will still use the other management scenarios between 20 to 30% of the time. While there seems to be little difference in the probability of use between management scenarios for each species, there is still predictive power for this decision support tool. Only three management alternatives were simulated in this example. There are an infinite number of other possible alternatives that were not reviewed here. By integrating these two models (stand projection and habitat occupancy) a unique tool is available for land managers to gauge the efficacy of their management plans while also developing a timeline of predicted forest structure that can be compared with future inventory for use in adaptive management

Clinical epidemiology, treatment and prognostic factors of extensively drug-resistant Acinetobacter baumannii ventilator-associated pneumonia in critically ill patients

Limited data exist regarding prognostic factors and optimal antimicrobial treatment of infections caused by extensively drug-resistant Acinetobacter baumannii (XDR-AB). This retrospective cohort study included 93 adult patients who developed ventilator-associated pneumonia (VAP) due to XDR-AB in the ICU of the University Hospital of Heraklion, Greece, from October 2012 to April 2015. XDR-AB isolates were mainly susceptible to colistin (93.5%) and tigecycline (25.8%), whereas 6 (6.5%) were pandrug-resistant. Prior to infection, patients had long durations of mechanical ventilation and hospital stay and multiple exposures to antibiotics. Median Charlson co-morbidity and APACHE II scores were 2 and 17, respectively. Mortality at 28 days of infection onset was high (34.4%) despite high rates of in-vitro-active empirical (81.7%) and definitive (90.3%) treatment. Active colistin-based combination therapy (n = 55) and monotherapy (n = 29) groups had similar 28-day mortality (27.6% vs. 30.9%, respectively) and Kaplan–Meier survival estimates over time. In multivariable Cox regression, advanced age (aHR = 1.05 per year increase, 95% CI 1.02–1.09), rapidly fatal underlying disease (aHR = 2.64, 95% CI 0.98–9.17) and APACHE II score (aHR = 1.06 per unit increase, 95% CI 0.99–1.14) were identified as independent predictors of 28-day mortality, but no difference in mortality hazards between the active colistin-based combination therapy and monotherapy groups was produced (aHR = 0.88, 95% CI 0.35–2.38). These results support the use of colistin as a first-line agent against VAP in settings where XDR-AB is endemic, but oppose the introduction of colistin-based combination therapy as standard treatment