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Outpatient Healthcare Settings and Transmission of Clostridium difficile
Lucy A. Jury, Brett Sitzlar, Sirisha Kundrapu, Jennifer L. Cadnum, Kim M. Summers, Christine P. Muganda, Abhishek Deshpande, Ajay K. Sethi, Curtis J. Donskey
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0070175
Abstract: Background Recent reports suggest that community-associated Clostridium difficile infection (CDI) (i.e., no healthcare facility admission within 90 days) may be increasing in frequency. We hypothesized that outpatient clinics could be an important source for acquisition of community-associated CDI. Methods We performed a 6-month prospective study of CDI patients to determine frequency of and risk factors for skin and environmental shedding during outpatient visits and to derive a prediction rule for positive cultures. We performed a point–prevalence culture survey to assess the frequency of C. difficile contamination in outpatient settings and evaluated the frequency of prior outpatient visits in patients with community-associated CDI. Results Of 67 CDI patients studied, 54 (81%) had 1 or more outpatient visits within 12 weeks after diagnosis. Of 44 patients cultured during outpatient visits, 14 (32%) had skin contamination and 12 (27%) contaminated environmental surfaces. Decreased mobility, fecal incontinence, and treatment with non-CDI antibiotics were associated with positive cultures, whereas vancomycin taper therapy was protective. In patients not on CDI therapy, a prediction rule including incontinence or decreased mobility was 90% sensitive and 79% specific for detection of spore shedding. Of 84 clinic and emergency department rooms cultured, 12 (14%) had 1 or more contaminated environmental sites. For 33 community-associated CDI cases, 31 (94%) had an outpatient visit during the 12 weeks prior to onset of diarrhea. Conclusions Patients with recent CDI present a significant risk for transmission of spores during outpatient visits. The outpatient setting may be an underappreciated source of community-associated CDI cases.
Metabolomics Analysis Identifies Intestinal Microbiota-Derived Biomarkers of Colonization Resistance in Clindamycin-Treated Mice
Robin L. P. Jump, Alex Polinkovsky, Kelly Hurless, Brett Sitzlar, Kevin Eckart, Myreen Tomas, Abhishek Deshpande, Michelle M. Nerandzic, Curtis J. Donskey
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0101267
Abstract: Background The intestinal microbiota protect the host against enteric pathogens through a defense mechanism termed colonization resistance. Antibiotics excreted into the intestinal tract may disrupt colonization resistance and alter normal metabolic functions of the microbiota. We used a mouse model to test the hypothesis that alterations in levels of bacterial metabolites in fecal specimens could provide useful biomarkers indicating disrupted or intact colonization resistance after antibiotic treatment. Methods To assess in vivo colonization resistance, mice were challenged with oral vancomycin-resistant Enterococcus or Clostridium difficile spores at varying time points after treatment with the lincosamide antibiotic clindamycin. For concurrent groups of antibiotic-treated mice, stool samples were analyzed using quantitative real-time polymerase chain reaction to assess changes in the microbiota and using non-targeted metabolic profiling. To assess whether the findings were applicable to another antibiotic class that suppresses intestinal anaerobes, similar experiments were conducted with piperacillin/tazobactam. Results Colonization resistance began to recover within 5 days and was intact by 12 days after clindamycin treatment, coinciding with the recovery bacteria from the families Lachnospiraceae and Ruminococcaceae, both part of the phylum Firmicutes. Clindamycin treatment caused marked changes in metabolites present in fecal specimens. Of 484 compounds analyzed, 146 (30%) exhibited a significant increase or decrease in concentration during clindamycin treatment followed by recovery to baseline that coincided with restoration of in vivo colonization resistance. Identified as potential biomarkers of colonization resistance, these compounds included intermediates in carbohydrate or protein metabolism that increased (pentitols, gamma-glutamyl amino acids and inositol metabolites) or decreased (pentoses, dipeptides) with clindamycin treatment. Piperacillin/tazobactam treatment caused similar alterations in the intestinal microbiota and fecal metabolites. Conclusions Recovery of colonization resistance after antibiotic treatment coincided with restoration of several fecal bacterial metabolites. These metabolites could provide useful biomarkers indicating intact or disrupted colonization resistance during and after antibiotic treatment.
Professionalism education of OB/GYN resident physicians: What makes a difference?  [PDF]
Brett Worly
Open Journal of Obstetrics and Gynecology (OJOG) , 2013, DOI: 10.4236/ojog.2013.31A026

Objective: The aim of this study was to evaluate the efficacy of a new Professionalism curriculum in an Obstetrics and Gynecology (OB/GYN) residency after introducing Narrative Medicine and Professional Development/Support Group (PDSG) programs. Methods: 32 OB/GYN residents participated in this IRB approved pilot study. Twenty residents were assessed with the Barry Challenges to Professionalism Questionnaire (Barry), the Jefferson Scale of Empathy-Physician Version (JSE), and the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (JSAT) in August 2010, as controls. Five Narrative Medicine sessions and four PDSG sessions were then used from August 2010-May 2011, for resident physician professionalism education. Seventeen residents then underwent post-testing with the Barry, JSE, and JSAT in May 2011. Results: The pre-test/post-test Barry comparison showed an improvement in scores after introduction of the new Narrative Medicine and PDSG curriculum (7.6 +/- 2.1 versus 8.4 +/- 1.6; p = 0.10) though this was not statistically significant. Pre-test/post-test comparison of JSAT scores showed a statistically significant decline in collaboration (52.3 +/- 4.1 versus 49.7 +/- 3.7; p = 0.028) while JSE scores showed a downward trend in empathy (109.3 +/- 10.0 versus 104.8 +/- 9.2; p = 0.086). Conclusion: Narrative Medicine and PDSG small group sessions could be an effective component of OB/GYN resident physician Professionalism curriculum. This pilot project was underpowered, due to limited resources.

Incorporating Uncertain Costs within a Series of Sequential Probability Ratio Tests  [PDF]
Conor McMeel, Brett Houlding
Open Journal of Statistics (OJS) , 2016, DOI: 10.4236/ojs.2016.65073
Abstract: We consider an extension to Sequential Probability Ratio Tests for when we have uncertain costs, but also opportunity to learn about these in an adaptive manner. In doing so we demonstrate the effects that allowing uncertainty has on observation cost, and the costs associated with Type I and Type II error. The value of information relating to modelled uncertainties is derived and the case of statistical dependence between the parameter affecting decision outcome and the parameter affecting unknown cost is also examined. Numerical examples of the derived theory are provided, along with a simulation comparing this adaptive learning framework to the classical one.
Human Health, Rights and Wind Turbine Deployment in Canada  [PDF]
Carmen Krogh, Brett Horner
Open Journal of Social Sciences (JSS) , 2017, DOI: 10.4236/jss.2017.55012
Abstract: Canada has ratified international conventions which recognize the individual’s right to the enjoyment of the highest attainable standard of health. Despite the adoption of these covenants governments sometimes support policies and practises which trade off individual human health with other conflicting interests. This review evaluates the individual’s right to health against government policies and practices which support wind energy deployment in Canada. Our analysis presents government documents, peer reviewed literature, and other references which support the conclusion that wind energy deployment in Canada can be expected to result in avoidable harm to human health. This harm conflicts with contemporary health and social justice principles. Governments have a responsibility to help Canadians maintain and improve their health by generating effective responses for the prevention of avoidable harm. Individuals have a right to make informed decisions about their health. Knowledge gaps and potential risks to health should be fully disclosed. Individuals should not be exposed to industrial wind turbines without their informed consent.
The Influence of Morinda citrifolia (Noni) Fruit Juice on Collagen Deposition in the Skin: A Minireview  [PDF]
Brett J. West
Journal of Biosciences and Medicines (JBM) , 2018, DOI: 10.4236/jbm.2018.69001
Abstract: The fruit of Morinda citrifolia, commonly known as noni, has an extensive history of use as a food and medicine throughout the tropics. Among its many uses, noni was believed to promote skin health. In vivo wound healing studies reveal that noni fruit juice ingestion increases collagen production and deposition via increased expression of extracellular matrix protein genes. Noni juice also appears to promote fibroblast proliferation. In vitro studies indicate that noni juice also protects fibroblasts via activation of the transcription factor Nrf2 and protects extracellular matrix collagen by inhibiting matrix metalloproteinases. In vitro and in vivo study findings are corroborated by a clinical trial where hospitalization times were reduced, and wound granulation quality was improved in pediatric burn patients. The findings of other human studies also indicate that noni juice has the potential to protect skin collagen. These include reduced plasma reactive oxygen species in cigarette smokers, lowered skin glycation levels in overweight and obese adults, as well as reduced skin glycation levels among noni juice consumers within the general population. These in vitro, in vivo and human studies reveal that there are multiple mechanisms of action through which noni juice promotes collagen synthesis and inhibits collagen degradation. The procollagen properties of noni juice aid wound healing, increase skin elasticity, and improve the overall appearance of the skin.
Science review: The use of proton pump inhibitors for gastric acid suppression in critical illness
Stephen Brett
Critical Care , 2004, DOI: 10.1186/cc2980
Abstract: Stress-related mucosal damage (SRMD) is an erosive gastritis of unclear pathophysiology, which can occur rapidly after a severe insult such as trauma, surgery, sepsis or burns. SRMD is apparent in 75–100% of critically ill patients within 24 hours of admission to an intensive care unit (ICU) [1,2]. Clinically important bleeding, defined as macroscopic bleeding resulting in hemodynamic instability or the need for red blood cell transfusion, occurs as a result of SRMD in about 3.5% of ICU patients who are mechanically ventilated for 48 hours or more [3]. Along with mechanical ventilation, risk factors for clinically important bleeding from SRMD include coagulopathy, shock, severe burns, a history of gastrointestinal (GI) ulceration, and multiple organ failure [4,5]. Bleeding is associated with a 20–30% increase in absolute risk of mortality, and with an increase of 1–4 in relative risk [3]. In addition, it increases the demand on limited blood stocks and extends the length of ICU stay by about 4–8 days [3], thereby adding to overall management costs.To avert these consequences, prophylaxis has been recommended for all ICU patients at high risk of SRMD [4,5]. Stress ulcer prophylaxis is included in the care bundle for critically ill patients on mechanical ventilation recommended by the Institute for Healthcare Improvement and adopted by the National Health Service Modernization agency in the UK [6]. The Surviving Sepsis Campaign, an international initiative founded by the European Society of Intensive Care Medicine, the Society of Critical Care Medicine and the International Sepsis Forum, has also recommended that prophylaxis be a part of critical care [7]. Specific risk factors for SRMD include: mechanical ventilation (more than 48 hours), coagulopathy, neurosurgery, any kind of shock, respiratory failure, sepsis, polytrauma, tetraplegia, severe burns (more than 30%) and multiple organ failure [4,5]. Patients in the ICU with a history of gastric or duodenal ulceration
A bill of wron
Brett, Guy;
ARS (S?o Paulo) , 2009, DOI: 10.1590/S1678-53202009000100007
Abstract: the author discusses the procedures of accumulation and serialization on the production of brazilian artist jac leirner, focusing works from the late nineteen eighties, such as "os cem" the hundreds (1985-7), "pulm?o" lung (1987) and "primeiros erros" first errors.
Neutrino Beam Constraints on Flavor-Diagonal Lorentz Violation
Altschul, Brett
High Energy Physics - Phenomenology , 2013,
Abstract: Breaking of isotropy and Lorentz boost invariance in the dynamics of second-generation leptons would lead to direction-dependent changes in the lifetimes of charged pions. This would make the intensity of a neutrino beam produced via pion decay a function of the beam orientation. The experimental signature of this phenomenon--sidereal variations in the event rate at a downstream neutrino detector--has already been studied, in searches for Lorentz-violating neutrino oscillations. Existing analyses of MINOS near detector data can be used to constrain the flavor-diagonal Lorentz violation coefficients affecting muon neutrino speeds at roughly the 10^(-5) level.
Bound on the Photon Charge from the Phase Coherence of Extragalactic Radiation
Altschul, Brett
High Energy Physics - Phenomenology , 2007, DOI: 10.1103/PhysRevLett.98.261801
Abstract: If the photon possessed a nonzero charge, then electromagnetic waves traveling along different paths would acquire Aharonov-Bohm phase differences. The fact that such an effect has not hindered interferometric astronomy places a bound on the photon charge estimated to be at the 10^(-32) e level if all photons have the same charge and 10^(-46) e if different photons can carry different charges.
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