Sea-level rise and storm surges structure coastal forests into persistence and regeneration niches.

The retreat of coastal forests as sea level rises is well documented; however, the mechanisms which control this retreat vary with the physical and biological setting of the interface between tidal marsh and forest. Tidal flooding and saltwater intrusion as well as flooding and wind associated with storms can kill trees. Even if these processes do not kill stands, they may halt regeneration because seedlings are more sensitive to stress. We present a case study of a coastal pine forest on the Delmarva Peninsula, United States. This forest contains a persistent but nonregenerating zone of mature trees, the size of which is related to the sea level rise experienced since forest establishment. The transgression of coastal forest and shrub or marsh ecosystems is an ecological ratchet: sea-level rise pushes the regeneration boundary further into the forest while extreme events move the persistence boundary up to the regeneration boundary.

Adopting universal testing for HIV in intensive care for patients admitted with severe pneumonia: results from our change in practice.

Early identification of HIV infection is of obvious benefit to patients' health, yet many remain unaware of their diagnosis, with detrimental consequences. Current guidelines suggest patients with pneumonia are offered an HIV test. Early diagnosis of HIV infection in critically ill patients within intensive care is vital in reducing mortality and morbidity. In 2015, we established automated HIV testing for patients with pneumonia admitted to our intensive care unit. Prior to our change in practice, our HIV testing rate in patients with pneumonia was 29% within two weeks of admission. After implementation, 80% of patients with pneumonia were tested for HIV within 48 h (73% with 24 h). This intervention also facilitated an early and unexpected HIV diagnosis in one patient, which then allowed prompt tailored therapy and was a significant factor in their survival. Based on our success, we suggest other centres may benefit from employing a similar automated HIV testing system, especially in targeted patient groups such as severe pneumonia.

Comparative performance of culture using swabs transported in Amies medium and the Aptima Combo 2 nucleic acid amplification test in detection of Neisseria gonorrhoeae from genital and extra-genital sites: a retrospective study.

BACKGROUND: Nucleic acid amplification tests are being increasingly used for the routine diagnosis of Neisseria gonorrhoeae (GC), although culture remains essential for monitoring antimicrobial resistance. The authors investigated how symptoms and infection site influenced test sensitivity. METHODS: This was a retrospective study at two centres of patients diagnosed as having GC by Aptima Combo 2 (AC2) confirmed with Aptima GC and/or culture. RESULTS: The study included 251 men (71%) and 105 women (29%). The sensitivity for AC2 and culture in the lower genital tract of men with symptoms was 99% (95% CI 95% to 100%) and 79% (95% CI 71% to 85%) and for asymptomatic men was 94% (95% CI 69% to 100%) and 29% (95% CI 11% to 56%), respectively. At the rectum, the sensitivity in symptomatic men was 91% (95% CI 57% to 100%) and 55% (95% CI 25% to 82%) and in asymptomatic men 75% (95% CI 47% to 92%) and 44% (95% CI 21% to 69%) for AC2 and culture, respectively. In symptomatic women, the sensitivity from the genital site was 100% (95% CI 95% to 100%) and 53% (95% CI 38% to 68%) and for asymptomatic women 100% (95% CI 87% to 100%) and 47% (95% CI 30% to 65%) for AC2 and culture, respectively. CONCLUSIONS: The AC2 with AGC confirmation performs well at genital and extra-genital sites for detecting GC. Culture for GC using transport swabs performs poorly in asymptomatic men, symptomatic and asymptomatic women and at extra-genital sites. With the improved performance of nucleic acid amplification tests and the increase in GC antimicrobial resistance, research is needed into how best to optimise GC culture in settings where direct plating is not feasible.

UK National Audit of chlamydial infection management in sexual health clinics. case notes audit: information-giving, partner notification and follow-up.

Verbal information-giving is good, but only half of cases were reportedly given written information on chlamydia. Follow-up by 'phoning or texting (43%) was as common as follow-up in clinics (39%). About one-fourth of cases did not have follow up, with no recall for around 60% of these cases. Advice about partner notification (PN) was provided by a health adviser or other suitably trained health professional to 91% of cases, and the method of PN was documented for 92% of these cases. PN outcome was not documented for about 25% of these cases. There was no information on the chlamydial status of sexual contacts of about half of cases, and no information about the treatment status of sexual contacts of about 40% of cases. The average number of contacts screened per index was 0.52 outside London and 0.29 for the London Regions, levels below those suggested in the National Guideline.

UK National Audit of chlamydial infection management in sexual health clinics. clinic policies audit.

There was a wide range of activity and chlamydial diagnoses between the 177 clinics that responded. Most (92%) clinics have nucleic acid tests for chlamydial diagnosis. Different practitioners largely share roles in providing advice to patients about partner notification, treatment adherence, safer sex advice and abstinence. Most (97%) clinics have information leaflets about chlamydia, although about 30% of clinics lack leaflets containing information about antibiotics and hormonal contraception. About two-third clinics follow the National Guideline recommended interval for providing a test of cure where this is indicated. Only 18% of clinics routinely ask patients to reattend, with 40% having a policy of no routine follow-up and 62% using telephone or text follow-up. These categories were not mutually exclusive. Most (86%) of the 146 English clinics had a local Chlamydia Screening Programme coordinator for their Primary Care Trust area, although cooperation varies, with cooperation over treatment of 70% and Programme policy of 62%.

UK National Audit of chlamydial infection management in sexual health clinics. case notes audit: demography, diagnosis and treatment.

The case notes of cases of genital chlamydial infection were audited against the UK National Guideline. This was the first web-based and the largest national audit to date, with 193 clinics in all UK Regions contributing data. About half of all cases had no symptoms, with about one-third attending for routine or asymptomatic screens; suggesting significant provision of screening by clinics that might be managed differently to reduce workload. Nucleic acid amplification tests (NAATs) are now well established for chlamydial detection in UK clinics, with 93% of cases having genital NAATs. Azithromycin is now more commonly used than doxycycline (54% vs. 37%). Of 26 pregnant women, 20 were treated with azithromycin, suggesting that most prescribers treating pregnant women consider that erythromycin is not an adequate alternative to azithromycin. Most women had NAATs obtained from sites recommended by the Guideline, with 93% of women who had genital NAATs having these from the cervix or vulvovaginal area.

A novel bacterial mucinase, glycosulfatase, is associated with bacterial vaginosis.

The modifications to the vaginal habitat accompanying a change to vaginal flora in bacterial vaginosis (BV) are poorly understood. In this study enzymes involved in mucin degradation were measured, including a novel glycosulfatase assay. Women attending an emergency walk-in sexually transmitted disease clinic were studied. One high vaginal swab (HVS) was used to prepare a gram-stained smear to determine BV status, using Ison and Hay's criteria, and a separate swab was used for the purposes of the assays. The median glycosulfatase activity was 8.5 (range, -1.2 to 31.9) nmol h(-1) 1.5 ml(-1) of HVS suspension in patients with BV compared to 0.5 (range, -0.7 to 9.4) nmol h(-1) 1.5 ml(-1) of HVS suspension in patients without BV (P = <0.001). The median glycoprotein sialidase activity was 29.2 (range, -17 to 190) nmol h(-1) 1.5 ml(-1) of HVS suspension in patients with BV compared to -1.1 (range, -41 to 48) nmol h(-1) 1.5 ml(-1) of HVS suspension in patients without BV (P < 0.001). A rapid spot test for sialidase was positive in 22/24 patients with BV (sensitivity, 91.7%; 95% confidence interval [CI], 73 to 99%) and negative in 32/35 patients without BV (specificity, 91.4%; 95% CI, 76.9 to 98.2%) (P < 0.001). Glycosulfatase activity significantly correlated with both glycoprotein sialidase activity and the sialidase spot test (P = 0.006 and P < 0.001, respectively). The results are consistent with the hypothesis that the consortium of bacteria present in BV requires the ability to break down mucins in order to colonize the vagina and replace the normal lactobacilli.