text:
Low transmission risk of Pseudomonas aeruginosa in a bronchiectasis clinic based on the knowledge of bacterial population biology
Nina Cramer, Ludwig Sedlacek, Burkhard Tümmler, Tobias Welte
European Respiratory Journal 2019 53: 1802191; DOI: 10.1183/13993003.02191-2018
Nina Cramer
1Clinic for Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
Ludwig Sedlacek
2Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
Burkhard Tümmler
3Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), German Center for Lung Research, Hannover, Germany
Tobias Welte
4Dept for Respiratory Medicine, Hannover Medical School, Hannover, Germany
This study suggests that the risk of cross-infection with P. aeruginosa in bronchiectasis is small http://ow.ly/itUa30nrgET
The nosocomial acquisition of opportunistic pathogens, particularly Pseudomonas aeruginosa, has been repeatedly documented in individuals with cystic fibrosis (CF) [1]. Cross-infection is also a concern in bronchiectasis not due to CF [2]. This issue was not addressed by the European Respiratory Society 2017 guidelines for the management of adult bronchiectasis [3] but the European Bronchiectasis Network (EMBARC), the EMBARC Patient Advisory Group and the European Reference Network (ERN-Lung) Bronchiectasis Network released a position statement in the European Respiratory Journal in 2018 [4]. Based on the available evidence, the risk of cross-infection with P. aeruginosa was judged to be small.
The position statement explicitly refers to the three most recently published multicentre and single-centre studies, which reported the genotypes of, in total, 704 P. aeruginosa isolates collected from 177 patients seen at "non-CF bronchiectasis centres" in the UK [5–7]. Unlike CF, where the Liverpool epidemic strain had spread among the CF community in the UK [8, 9], whole-genome sequencing of strains from 16 centres detected no widespread transmissible strain in the UK bronchiectasis community [5]. However, the two single-centre studies identified one duo and one trio among 86 patients who shared strains likely to have been acquired through cross-infection [6, 7].
During the last 35 years, we in Hannover (Germany) have set up one of the largest strain collections worldwide of >5000 P. aeruginosa isolates, mainly from aquatic habitats in the environment and from human infections, particularly ventilation-associated acute pneumonia and chronic airway infections with COPD or CF [10]. Since our current knowledge of the epidemiology of airway infections with P. aeruginosa in non-CF bronchiectasis is based on data gathered in the UK, we reasoned that a further surveillance study in another country backed up by the largest database of transcontinental P. aeruginosa genotypes should provide added value to clarify the issue of cross-infection in bronchiectasis.
From November 2017 to May 2018, all P. aeruginosa isolates that had been retrieved from respiratory secretions of patients attending the local "Bronchiectasis outpatient clinic" were genotyped using a custom-made microarray following the published protocol [11]. This low-resolution microarray represents clone types of the conserved P. aeruginosa core genome with 16 informative single-nucleotide polymorphisms and intraclonal variants with 42 marker genes of the variable accessory genome [11].
Of the 143 bronchiectasis patients who were seen during the study period, P. aeruginosa was cultured from the respiratory secretions of 49 (34%) patients. Thus, the prevalence of P. aeruginosa-positive patients is significantly higher at our local clinic (p=0.006, Fisher's exact test) than that of 21.7% calculated from the meta-analysis of 21 observational cohort studies [12]. One patient was co-colonised with two clone types but the other 48 patients were carrying just one clone type in their airways. P. aeruginosa isolates were collected from eight patients on two or more occasions. The microarray always yielded identical genotypes, suggesting that during a short period of 6 months, the turnover of clones is low in bronchiectasis patients.
We compared the spectrum of clone types in bronchiectasis patients with those in the global P. aeruginosa populations in the environment, acute pulmonary infection and chronic airway infections in patients with CF (figure 1). 22%, 28% and 24% of the local bronchiectasis patient population were carrying P. aeruginosa clones in their lungs that belong to the 15 most common clones in the environment, acute infection and CF, respectively [10], including the most prevalent clones worldwide, C and PA14 [13]. These proportions of 20–30% match with results from the adult bronchiectasis service in the north-east of England, which employed the same microarray for strain genotyping [6].
Venn diagram of the number of habitat-specific and shared clone types in the Pseudomonas aeruginosa population [10]. Habitats are differentiated by environment (red, 1), acute human infections (green, 2) and chronic airway infections in people with cystic fibrosis (blue, 3) or bronchiectasis (yellow, 4). Numbers in italic indicate the five clone types (hexadecimal code [11] 0C2A, EA0A, EC29, F429 and F469) in the local outpatient bronchiectasis population with identical genotypes of core and accessory genome detected by multimarker microarray [11] in two or more patients.
Of the 49 patients, five patient pairs and four patient trios shared the same clone with each other. Thereof, an identical genotype in both core and accessory genome markers was observed in three pairs and two trios, pointing to the possibility that these 12 patients could have acquired their P. aeruginosa strains by transmission from shared sources. To clarify this point, we next extracted strain genotypes collected in the CF clinics Munich (Germany) and Hannover from our database. Of 313 isolates collected from 221 CF patients seen at the CF clinic in Munich, 174 strains belonged to clones detected in two patients or more and 77(44%) strains thereof shared an identical genotype in all markers with at least one other strain. Similarly, of 1112 isolates collected from 134 CF patients from the CF clinic Hannover, the clone type of 191 strains was identified in isolates from two or more patients. 117 (61%) of the 191 strains shared an identical genotype in all markers of the core and accessory genome with at least one other strain. When we removed the 10 most common P. aeruginosa clones that are found worldwide in biotic and abiotic environments [10], 99 strains with shared clone type remained 29 of which having partners with identical genotype. This example demonstrates that knowledge of the population structure of a bacterial species (figure 1) is necessary for the proper interpretation of the abundance and transmission of clones and genotypes.
In the case of the Hannover CF patient population, we had robust epidemiological data to discriminate between transmission and coincidental acquisition of the same genotype. Of the 117 cases of shared P. aeruginosa clones, patient-to-patient transmission or nosocomial acquisition from a common source could not be excluded for 36 cases, 17 of which were CF siblings [14]. Of the 19 remaining nosocomial transmissions, 14 cases happened in the 1980s prior to the introduction of patient segregation and hygienic control measures [15] and five cases happened during the last 30 years [16]. These data demonstrate that only a small portion of shared genotypes could be ascribed to nosocomial transmission.
Considering this background, we examined the epidemiology of the cases from the outpatient bronchiectasis clinic with shared genotypes, all of which but one belonged to abundant clones in environment and disease (figure 1) [10]. First of all, all pairs and trios of patients never had an appointment at the same day during the last 4 years. Nine of the 12 patients were already chronically colonised with P. aeruginosa at their first visit to the bronchiectasis clinic. Four samples in the study that showed matching P. aeruginosa genotypes were collected at this first visit. These data from the patients' records provide strong evidence that none of the 12 patients had acquired P. aeruginosa from a source at the bronchiectasis clinic. Most likely, the patients became colonised with P. aeruginosa on independent occasions. This interpretation is in line with the conclusion drawn from the genotyping of 2921 isolates from 1448 independent habitats that the P. aeruginosa population is dominated by few epidemic clone types [10]. Nine of the 10 shared genotypes of the bronchiectasis patients belong to the 20 most frequent clones that have an absolute share of 44% in the population [10].
In summary, shared P. aeruginosa genotypes need to be discussed in the context of the bacterial population biology (figure 1) and the patient's records. No evidence for patient-to-patient transmission was identified in this study. Consistent with the position statement [4], our data suggest that the risk of cross-infection with P. aeruginosa in bronchiectasis is small.
Conflict of interest: N. Cramer has nothing to disclose.
Conflict of interest: L. Sedlacek has nothing to disclose.
Conflict of interest: B. Tümmler reports grants from the Bundesministerium für Bildung und Forschung during the conduct of the study; and personal fees for consultancy and lectures from, and that he has been an investigator in clinical trials for Vertex Pharmaceuticals, and personal fees for lectures from Gilead, outside the submitted work.
Conflict of interest: T. Welte reports grants from the Bundesministerium für Bildung und Forschung during the conduct of the study; and personal fees from AstraZeneca and Basilea, Infectofarm, Boehringer, Berlin Chemie, Mundipharma and Insmed, and grants and personal fees from Bayer, Grifols, Novartis and Pfizer, outside the submitted work.
Support statement: This study was supported by Bundesministerium für Bildung und Forschung (grant 82DZL002A1). Funding information for this article has been deposited with the Crossref Funder Registry.
Accepted December 19, 2018.
Copyright ©ERS 2019
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. Epidemiology, biology, and impact of clonal Pseudomonas aeruginosa infections in cystic fibrosis. Clin Microbiol Rev 2018; 31: e00019-18.
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. Risk of bacterial transmission in bronchiectasis outpatient clinics. Curr Pulmonol Rep 2018; 7: 72–78.
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European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J 2017; 50: 1700629.
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Cross-infection risk in patients with bronchiectasis: a position statement from the European Bronchiectasis Network (EMBARC), EMBARC/ELF patient advisory group and European Reference Network (ERN-Lung) Bronchiectasis Network. Eur Respir J 2018; 51: 1701937.
Hilliam Y,
Moore MP,
Lamont IL, et al.
Pseudomonas aeruginosa adaptation and diversification in the non-cystic fibrosis bronchiectasis lung. Eur Respir J 2017; 49: 1602108.
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Perry A,
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Molecular epidemiological analysis suggests cross-infection with Pseudomonas aeruginosa is rare in non-cystic fibrosis bronchiectasis. Eur Respir J 2014; 43: 900–903.
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Molecular epidemiology of Pseudomonas aeruginosa in an unsegregated bronchiectasis cohort sharing hospital facilities with a cystic fibrosis cohort. Thorax 2018; 73: 677–679.
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. Transmissible strains of Pseudomonas aeruginosa in cystic fibrosis lung infections. Eur Respir J 2012; 40: 227–238.
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Transmission and lineage displacement drive rapid population genomic flux in cystic fibrosis airway infections of a Pseudomonas aeruginosa epidemic strain. Microb Genom 2018; 4: https://doi.org/10.1099/mgen.0.000167.
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. Habitat-associated skew of clone abundance in the Pseudomonas aeruginosa population. Environ Microbiol Rep 2015; 7: 955–960.
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Population structure of Pseudomonas aeruginosa. Proc Natl Acad Sci USA 2007; 104: 8101–8106.
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European Respiratory Journal Mar 2019, 53 (3) 1802191; DOI: 10.1183/13993003.02191-2018
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Winter time is my favorite time of the year in Southern California, its normal to see seals, dolphins and whales swimming right offshore. This time of the year its not unusual to see dolphins and seals riding waves, but on Friday I saw something amazing. A juvenile gray whale took a close up look at the waves at torrance beach and even tried to ride a couple believe it or not!
Now its not unusual as I mentioned to see them up close near shore, sometimes half a dozen or more, but they are on the move. This Whale was swimming right at the shore line trying to catch waves right at me. Unfortunately the waves were not big enough so it was forced to turn back under the waves since it was too shallow where the waves were breaking.
At one point the whale met up with a small pod of dolphins and it was interesting that the dolphins at first stopped swimming and waited for the whale to approach. Then they reversed direction and swam with the way and continued down the beach at one point swimming right by a surfer. You can see the group waiting for the whale in the image below.
What an experience to be able to watch the whale play around in the surf, it something I know I wont forget. Not only were the actions of the whale interesting to see but it was good to see the whale swimming strongly, rolling and swimming to catch waves and not at all distressed or dragging any man made objects.
If you are in Southern California there are still good conditions out there for macro photography I am glad to report. Last week we had a rare foggy/overcast fall morning and I was very lucky to find a flower spider on a fresh clean seaside daisy (these small lavender and yellow flowers are found naturally along the coast from Baja California up to Oregon). You need to hurry if you want to photograph flower spiders in California since they only live for one year they will be getting harder and harder to find in fall. Last month I watched one create a funnel shaped nest in the petals of a flower. This is the last stage in their short lifespan, once they create a nest they lay eggs they die. So if you are in California get out there and shoot with your macro lens.
Over the next weeks I will be spending as much time as possible field testing the new Sigma 180mm f2.8 OS macro and comparing it to my current favorites the Sigma 180mm f3.5 and the 150 f2.8 OS macros.
California Brown Pelican bathed in early morning light, La Jolla cliffs, Southern California. Nikon D700 with Sigma 150-500mm @ 290mm, 1/1250 sec, f/7.1 ISO 1250 in Manual mode with Auto ISO at zero compensation, handheld.
After a couple of days in the field with this lens it looks like it will be my favorite lens for flight at the La Jolla cliffs. This is my first time photographing flight here with a Sigma 150-500 and due to it's small size and light weight it makes photography much easier and flexible than a fixed focal length 500 or larger and heavier 200-400 zoom.
Southern California this time of the year means tons of tame California Brown Pelicans, Double-crested cormorants and Brandt's cormorants in breeding plumage, Peregrine falcons flying over head with prey, and whales, seals, and dolphins just offshore. I spent the last couple of days photographing in La Jolla in San Diego and some of the opportunities were very very good. If you have never been here you really should make some time to try it. Winter time in Southern California is the best time time of the year, the weather is beautiful, the crowds are down, and in Jan-Feb the birds are all in amazing breeding colors. The photography can be epic and staying in the area is reasonable. If you would like to attend a workshop here sometime, I will be leading a photo tour to this area in 2013, more details coming soon but let me know if you would like more information.


Information about the schema location is in the Schema Location.
For older release notes, see the Release Notes archive.
See the Site Status Updates for bug fixes related to this release.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 777.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 777 and Changed Functionality - 777.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 775.
If BestOffer is tagged in GetPublicAlerts as an event type to retrieve, it is sent to a seller when a bidder makes a best offer on an item opted into the Best Offer feature by the seller.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 775 and Changed Functionality - 775.
New types were added to the schema, but none are used by Client Alerts at this time.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 691.
Note that this feature is only available if you set your request version to 705. It is eBay's recommendation to test the use of this field in Sandbox before implementing it in production code.
OrderLineItemID field introduced in Trading API calls that use ItemID and TransactionID. OrderLineItemID is a concatenation of ItemID and TransactionID with a hyphen in between these two IDs. For Trading calls that take ItemID and TransactionID as input, OrderLineItemID can be used as a replacement for these two fields.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 691 and Changed Functionality - 691.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 677.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 677 and Changed Functionality - 677.
See the Site Statue Updates for bug fixes related to this release.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 675.
A new event alert for sellers, ItemListed, is added for GetUserEvents. This alert confirms to a seller that an item has been listed successfully.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 675 and Changed Functionality - 675.
As of this release, Client Alerts Release Notes will no longer be released for every version. Release Notes will only appear when Client Alerts functionality changes or when there is an announcement about Client Alerts. As a result, you may see version numbers in your Client Alerts calls that are later than the version of these release notes.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 665.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 665 and Changed Functionality - 665.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 663.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 663 and Changed Functionality - 663.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 661.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 661 and Changed Functionality - 661.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 659.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 659 and Changed Functionality - 659.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 657.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 657 and Changed Functionality - 657.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 655.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 655 and Changed Functionality - 655.
For logical or functional changes to existing features and calls, including code list changes, see Changed Functionality - 653.
This section lists additional documentation changes and corrections that were made with this release and that are not already mentioned in New Features - 653 and Changed Functionality - 653.
No 651 schema was released.


If you are waking up with jaw pain, tension headaches, or facial pain, you may be suffering from a condition known as bruxism. This means you could be grinding or clenching your teeth while you sleep. Some people aren't even aware they are grinding or clenching their teeth at night, until a visit to us reveals significant tooth enamel loss. Fortunately, there is a non-invasive and effective solution for teeth grinding, and the tooth enamel damage it can cause, in custom-fabricated nightguards.
Tension, stress, and anxiety experienced during the daytime can carry over to an individual's sleep, and lead the person to grind his or her teeth together or clench the teeth unknowingly. Sleep apnea is another condition that can result in bruxism. Regardless of the cause, however, frequent clenching and teeth grinding wears down the chewing surfaces of the teeth, reduces tooth enamel, and can result in a cracked or chipped tooth, crown, or filling.
Custom nightguards are fabricated to fit like a glove and protect your teeth from the adverse effects of bruxism. Nightguards are created through a non-invasive process that simply takes an impression of the bottom and top rows of teeth. The result is a nightguard that is flexible, comfortable, and personalized to your mouth.
Nightguards are helpful to reduce or eliminate the symptoms of dental damage incurred as a result of teeth grinding. They can reduce the discomfort associated with a sore jaw, headaches, tooth sensitivity, ear pain, and facial pain that many patients experience as a result of clenching or grinding of their teeth. In severe cases of bruxism, patients can develop loss of hearing, jawbone misalignment, and TMJ. Therefore, customized nightguards can help prevent the progression of teeth grinding into these more serious conditions.
Although it's important to wear your nightguard faithfully if you grind your teeth at night, you can follow a few self-care tips to help to prevent your teeth grinding from worsening.
Reduce tension and stress. Whether you take a warm bath before bed, listen to soothing music, or exercise, practice stress-relieving activities to wash away the tensions of the day.
Avoid alcohol. In some patients, alcohol increases teeth grinding tendencies.
Avoid caffeine. In some individuals, caffeine increases the likelihood of teeth grinding.
Focus on relaxing jaw muscles. Make a conscious effort to keep your jaw relaxed. A warm washcloth against your cheek, sticking your tongue between your teeth, and avoiding chewing pencils, pens, and gum are all ways to train the muscles of your jaw to stay relaxed.
If you suspect you may be grinding your teeth at night, visit Dr. Sarah Jockin and Dr. Nicole Morganti and our team at Lake Park Dental for an evaluation at our convenient Tampa, FL office.


Opinion leaders play a crucial role in closely interconnecting groups and help achieve better group performances in online learning communities. Weighted LeaderRank is superior to other methods in identifying opinion leaders, but there are some limitations in its weighted mechanism. This study further optimizes the weighted mechanism of weighted LeaderRank by introducing users' initial comprehensive influence and the number of user interactivity. Experimental results show that the improved weighted LeaderRank algorithm can improve the accuracy of opinion leader identification in online learning communities compared with the other two typical algorithms.


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HAWICK HOOKER ROSS GRAHAM SIGNS TWO YEAR DEAL WITH YORKSHIRE CARNEGIE
27 April 2016 David Barnes News, Tennent's Premiership Comments Off on HAWICK HOOKER ROSS GRAHAM SIGNS TWO YEAR DEAL WITH YORKSHIRE CARNEGIE
Ross Graham is heading to the Greene King IPA Championship next season, but not with London Scottish. Image courtesy: Scottish Rugby/SNS Group
Images courtesy of Scottish Rugby/SNS Group
YORKSHIRE CARNEGIE have signed Hawick and Scotland club international hooker Ross Graham on a two year contract after being identified by head coach Bryan Redpath and forwards coach Dave Baldwin as a player with outstanding potential.
A stage three player in the BT Sport Scottish Rugby Academy set-up this season, Graham appeared in all five of Scotland under-20 games in the 2015 Six Nations, starting in the number two shirt for three of those five matches. He was also a member of the squad which competed in the Junior World Cup in 2015, starting in the fifth place play-off against Australia.
He came off the bench for Edinburgh A when they took on their Glasgow Warriors counterparts at Broadwood Stadium back in November – but has decided to try his hand south of the Border after finding his route into the Edinburgh set-up blocked by Ross Ford, Stuart McInally, Neil Cochrane and George Turner. Elite Development Player Jake Kerr, who is now back from long-term injury, is also highly rated by capital coach Alan Solomons.
Glasgow are also well covered at hooker, with former All Black Corey Flynn arriving in the summer to compete against Fraser Brown, Pat MacArthur and James Malcolm for the number two jersey next season – although it was confirmed yesterday that three more hookers will leave the club at the end of the current campaign in the shape of Kevin Bryce [going to Edinburgh as a tight-head prop], Fergus Scott and Shalva Mamukashvili.
"Ross is a young man from Hawick who has been playing some tough rugby up there in the Scottish leagues. That league is tough for a front rower. He has a small stature but has the ambition and drive to test himself. He is a project for us but he is someone we feel has real potential that we can develop and nurture here at Yorkshire Carnegie," said Redpath.
"He comes into our environment with a point to prove having missed out on the Pro 12 teams and I am sure he will kick on in the next few years with us. "
"My brother coaches in Scotland and has coached against him, and I have also spoken to George Graham about him, as he has seen Ross whilst coaching at Gala, and he says he is someone who could thrive in a full time environment."
"I am pleased he is committed to us. I know a lot of young players in Scotland want to stay north of the border and be involved at Glasgow and Edinburgh but there are only so many opportunities and I admire Ross' ambition and drive to come down to England and test himself," he added.

redpajama_set_name: RedPajamaCommonCrawl


This is the description of the C/C++ API bindings for the Moisture Bricklet. General information and technical specifications for the Moisture Bricklet are summarized in its hardware description.
Removes the device object moisture from its IPConnection and destroys it. The device object cannot be used anymore afterwards.
If you want to get the moisture value periodically, it is recommended to use the MOISTURE_CALLBACK_MOISTURE callback and set the period with moisture_set_moisture_callback_period().
Returns the length moving average as set by moisture_set_moving_average().
For getter functions this is enabled by default and cannot be disabled, because those functions will always send a response. For callback configuration functions it is enabled by default too, but can be disabled by moisture_set_response_expected(). For setter functions it is disabled by default and can be enabled.
See moisture_set_response_expected() for the list of function ID defines available for this function.
Sets the period in ms with which the MOISTURE_CALLBACK_MOISTURE callback is triggered periodically. A value of 0 turns the callback off.
The MOISTURE_CALLBACK_MOISTURE callback is only triggered if the moisture value has changed since the last triggering.
Returns the period as set by moisture_set_moisture_callback_period().
Sets the thresholds for the MOISTURE_CALLBACK_MOISTURE_REACHED callback.
Returns the threshold as set by moisture_set_moisture_callback_threshold().
Returns the debounce period as set by moisture_set_debounce_period().
This callback is triggered periodically with the period that is set by moisture_set_moisture_callback_period(). The parameter is the moisture value of the sensor.
This callback is triggered when the threshold as set by moisture_set_moisture_callback_threshold() is reached. The parameter is the moisture value of the sensor.
If the threshold keeps being reached, the callback is triggered periodically with the period as set by moisture_set_debounce_period().
The moisture_get_identity() function and the IPCON_CALLBACK_ENUMERATE callback of the IP Connection have a device_identifier parameter to specify the Brick's or Bricklet's type.