What are bloodstream infections?

Definition

A bloodstream infection involves the presence of large numbers of infectious
microorganisms in circulating blood. The causative infectious agents are most
often bacteria (leading to bacteremia) but may also be viruses,
fungi, or parasites. Bacteria and other microorganisms multiplying in the
bloodstream release harmful toxins, creating conditions sometimes referred to as
blood poisoning. Infectious organisms in circulating blood may spread
infection throughout the body (leading to sepsis), but
not all bacteremia develops into widespread infection.

Initially, blood flow near an existing infected area may carry infective
organisms into the bloodstream. Capillaries, the smallest blood vessels in the
vascular
system, may then transport microorganisms into organ tissue,
sometimes affecting the function of body organs such as the heart, lungs, and
kidneys (leading to systemic infection). Other biological factors can accelerate
this process, including immune mediators, special infection-activated white blood
cells, pro-inflammatory mediators, and coagulation factors.

Rapidly spreading bloodstream infection may overwhelm the body’s
immune
system, resulting in a systemic inflammatory response (sepsis) with
abnormal blood coagulation and interruption of oxygen delivery to body tissues.
Sepsis is a serious complication of bloodstream infection that can progress to
organ failure, severe hypotension (septic shock), and death. The seriousness and progression of bloodstream
infection depends on a person’s underlying health status and immune response.

Causes

Bloodstream infection may begin with bacteria migrating from an existing infection site, such as an open wound, a puncture wound, a burn, an ulcer, an infected prosthetic device, or a urinary tract infection. Other causes of bloodstream infection include infection of the skin (such as soft tissue infection or cellulitis), heart (endocarditis), lungs (such as pneumonia or a lung abscess), or kidneys (such as pyelonephritis). Even a tooth abscess or dental work may cause oral infection that enters the bloodstream.

Common external sources of infection are indwelling intravascular and urinary catheters that are used frequently in persons in acute and long-term care. Central venous catheters are the most frequent cause of hospital-acquired (nosocomial) bloodstream infection; hemodialysis catheters are also causes.

Causative bacteria that have been identified in bloodstream infection include Pseudomonas aeruginosa, Staphylococcus aureus, pneumococcal and streptococcal organisms, and Acinetobacter, Klebsiella, and Bacteroides species. A definite source of infection is found in only 30 to 50 percent of all cases.

Risk Factors

Surgery, injury, and placement of indwelling catheters present high risk for bloodstream infection. Risk is increased in persons with existing acute or chronic infection, chronic disease (such as diabetes), or chronic alcoholism, and with persons who use IV (intravenous) drugs. People with compromised immune response, including the elderly, young children, persons with human immunodeficiency virus (HIV) infection or other immune disorders, and those being treated with chemotherapy, corticosteroids, or immunosuppressive drugs following transplantation, are at greater risk for bloodstream infection.

Symptoms

Alternating chills and fever with prostration are early symptoms of bloodstream infection. Other symptoms vary depending on the primary infection site and overall health status. Progressive symptoms include mental confusion, changes in breathing and heart rate, and reduced urine output. Increased heart rate or low blood pressure may develop if the condition progresses rapidly toward sepsis.

Screening and Diagnosis

Early confirmation of bloodstream infection is crucial, and finding the
infection source is important to treatment. A physical examination and the
person’s symptoms and history may help to locate existing infections. Infection
derived from an intravenous catheter is suspected in hospitalized patients when no
open wounds, urinary tract infection, or other obvious sources exist, especially
if the intravenous line has been in place for one week or more. A history of
kidney infection, kidney stones, or prostate disease suggests urinary tract
infection, as does decreased mental function or confusion in the elderly.

Blood culture is the primary diagnostic measure in confirming bacteremia. The presence of any type of infection, fever of unknown origin, recent surgery, or placement of indwelling catheters, calls for a blood culture. The doctor will order a complete blood count with white-cell differential and will likely order an elevated white-blood-cell count. If routine urinalysis points to urinary tract infection, the doctor will order a urine culture and a urine Gram’s stain.

Chest X rays may be taken to exclude lung tumor, pneumonia, or other lung
infection. Diagnostic imaging such as ultrasound, computed tomography
(CT), and magnetic resonance imaging (MRI) may
help to identify or exclude an infection source, especially intra-abdominal
infection. Hospitalized persons who have abnormal vital signs and respiratory or
cardiac symptoms will need to be evaluated for evidence of sepsis.

Treatment and Therapy

An aggressive approach is crucial when bloodstream infection is suspected or
confirmed. The core treatment for infection is intravenous broad-spectrum
antibiotics, administered to eliminate the causative
organism and prevent progression to sepsis. Ideally, antibiotic therapy is begun
within two hours of a physical examination. Culture results may suggest a change
in the type of antibiotics used in treatment.

Removing an infected catheter can be a critical step. Intravenous fluids, including blood transfusion, may be given dependent on urinary output. A respirator or oxygen may be needed to assist with breathing difficulty. Surgery is sometimes needed to drain an abscess or other localized infection. Oral antibiotics will be given for some time after the infection has diminished. Rarely, if kidney infection results in subsequent kidney failure, hemodialysis may be required.

Prevention and Outcomes

Bloodstream infection cannot always be avoided, but seeking treatment early is important if fever or other signs of infection develop, particularly after injury or surgery, or in IV drug users. Hospital infection-control measures help prevent catheter-related bloodstream infection. These measures include the aseptic catheter insertion technique, the use of antibiotic-coated catheters, the use of chlorhexidine in central venous catheter protocols, and a reduction in the number of days catheters remain in place.

Bibliography

Barie, Philip S., and Steven M. Opal. “Infectious Complications Following Surgery and Trauma: Bloodstream Infection.” In Cohen and Powderly Infectious Diseases, edited by Jonathan Cohen, Steven M. Opal, and William G. Powderly. 3d ed. Philadelphia: Mosby/Elsevier, 2010. Addresses the risk of opportunistic infection, especially bloodstream infection, following surgery or injury.

Centers for Disease Control and Prevention. “Prevention and Control of Intravascular Catheter-Related Bloodstream Infections.” Available at http://www.cdc.gov/ncidod/dhap/dpac_iv.html. An online article on preventing bloodstream infections caused by misuse or poor use of intravascular catheters in health care settings.

Girard, T. D., and E. Wesley Ely. “Bacteremia and Sepsis in Older Adults.” Clinical Geriatric Medicine 23, no. 3 (2007): 633-647. Examines the causes, diagnosis, and treatment of bacteremia and the outlook for elderly persons.

Goede, Matthew R., and Craig M. Coopersmith. “Catheter-Related Bloodstream Infection.” Surgical Clinics of North America 89, no. 2 (2009): 463-474. A comprehensive look at catheter-related bloodstream infection and its treatment and prevention.

Que, Yok-Ai, and Philippe Moreillon. “Bloodstream Infections.” In Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, edited by Gerald L. Mandell, John F. Bennett, and Raphael Dolin. 7th ed. New York: Churchill Livingstone/Elsevier, 2010. A discussion of bloodstream infection caused by staphylococcal organisms and of treatment to prevent sepsis as a consequence of bloodstream infection.

Strand, Calvin L., and Jonas A. Shulman. Bloodstream Infections: Laboratory Detection and Clinical Considerations. Chicago: American Society of Clinical Pathologists, 1988. A technical monograph reviewing the concepts and factors important in the selection and development of optimal blood culture systems for the detection of blood infection.

Zucker-Franklin, D., et al. Atlas of Blood Cells: Function and Pathology. 3d ed. Philadelphia: Lea & Febiger, 2003. An excellent pictorial presentation of blood components in different stages of function and disease.

How would you compare and contrast Stacey's friendship with Jeremy to his friendship with T.J., as represented in the following quote from Roll of...

In Chapter 7, Stacey gives his new coat away to T.J. after T.J. makes fun of it and says that Stacey looks like a preacher while wearing it. Uncle Hammer lectures Stacey:

"If you ain't got the brains of a flea to see that this T.J. fellow made a fool of you, then you’ll never get anywhere in this world. It's tough out there, boy, and as long as there are people, there's gonna be somebody trying to take what you got and trying to drag you down. It's up to you whether you let them or not" (page numbers vary by edition).

T.J. is clearly not a very good friend because he lies to Stacey to get Stacey's new coat for himself. When Mr. Avery tries to have T.J. return the coat to Stacey, Stacey says that T.J. can keep it. T.J. then boasts about his new coat continuously. Therefore, it is clear that T.J. was lying about what he thought of the coat on Stacey so that he could have it for himself. He is selfish in addition to being a liar.

Jeremy Simms, on the other hand, visits the Logan family on Christmas and gives freely of what he has to them. He gives them a bag of nuts and gives Stacey a wooden flute that he made himself. Stacey has not given Jeremy anything, but Jeremy still wants to be friends with him. Jeremy, unlike T.J., is a true friend who likes Stacey no matter what Stacey gives him materially in return. While the other members of the Simms family are racist, Jeremy is not. He even endures beatings from his family to visit the Logan children. 

Papa tells Stacey, "Now you could be right 'bout Jeremy making a much finer friend than T.J. ever will be. The trouble is, down here in Mississippi, it costs too much to find out... So I think you'd better not try" (page numbers vary by edition). Papa says this to Stacey because relationships between white and black people were too complicated at that time and place, and Papa fears that Jeremy will grow up to turn on Stacey, even though Stacey thinks he won't do so. While Jeremy is clearly a better friend to Stacey, they simply can't be friends in Mississippi at that time because of the difficulties of having inter-racial friendships. 

Why should Juliet postpone her marriage with Paris? When should the marriage occur? What options should Juliet be given? Why should Juliet...

In Act 1, Scene 2, the audience witnesses the private conversation between Lord Capulet (Juliet's father) and the County Paris, a man of high status who wishes to marry Juliet immediately.  Lord Capulet says, "My child is yet a stranger in the world" (I.2.8).  He believes Juliet to be too young (she is not yet fourteen years old) to marry now, and he wants to "Let two more summers wither in their pride / Ere we may think her ripe to be a bride" (I.2.10-11).  He asks Paris to wait for two more years before he thinks of marrying her because Lord Capulet believes young girls who are forced to marry and become wives and mothers so early are "too soon marred" (I.2.13).  He believes that, when Juliet is nearly sixteen, she will be of a better age to make such a momentous decision and better equipped to handle the responsibilities of marriage and motherhood. 

Further, Capulet advises Paris to use this time to

woo her; get her heart;

[because Capulet's] will to her consent is but a part.

And, she agreed, within her scope of choice

Lies [his] consent and fair according voice (I.2.16-19).

Capulet tells Paris to court Juliet and try to win her affections because, in addition to receiving Lord Capulet's permission to marry Juliet, Paris must also convince Juliet to marry him.  Capulet makes it sound as though Juliet will have a great deal of choice in who she will marry.  He says that if she chooses Paris when those two years are up, then he will agree to her choice.

How did Bear prove his devotion to the priest in Lodgecot?

Though the people of Lodgecot are not used to boisterous travelers entering town playing flutes, Bear is able to win over the priest of the village. He kneels before the priest and very respectfully explains that he is Crispin's father, and together they travel and perform to earn money. He asks permission to perform for the villagers, but the priest wants to know if Bear sings religious music. Luckily, Bear had studied in his youth with the intent to become a priest, and he sings a song devoted to the Virgin Mary. The song emphasizes Mary's mercy and how she is a champion of people who suffer—a sly reminder that Bear and Crispin are some of those faithful who suffer.

With his display of piety, Bear impresses the priest and they are allowed to perform.

What is autogenic training?

Overview

Autogenic (“generated from within”) training, or AT, is one of the oldest
biobehavioral methods used in clinical psychology and
stress
management. Developed in the 1920s by Johannes H. Schultz as
a self-hypnotic procedure, it drew on the observation that under hypnosis,
persons often reported a sensation of heaviness (muscle relaxation) and warmth
(vascular dilation) in their limbs.

A firm believer in the self-regulatory capacities of the human body, Schultz considered that hypnosis occurred not only because the patient allowed it but also because he or she induced it. Consequently, Schultz looked for an autogenic “trigger,” or formula, that could be used to enter this state. Ultimately, he perfected a series of simple mental exercises that allow the mind to calm itself by turning off the body’s stress responses.

The technique uses autosuggestion to establish a new mind/body balance through
changes in the autonomic nervous system. Unlike progressive muscular
relaxation and biofeedback, AT does not involve a
conscious attempt to relax the muscles or control physiological functions. Rather,
through passive self-suggestion (“observing” concentration and nonforcing), the
person tries to render specific body regions warm and heavy. The training process
involves focusing on, and subvocally repeating, one of six basic autogenic
phrases, or orientations, several minutes each day, for one week or more. These
phrases (with many possible variations) are “My arms and legs are heavy,” “My arms
and legs are warm,” “My heartbeat is calm and regular,” “My lungs are breathing
for me,” “My abdomen is warm,” and “My forehead is cool.” The words can be changed
without altering the effectiveness of the method, to suit the practitioner’s mind
and circumstances. Within months of training, achieving a state of deep relaxation
and beneficial physiological changes will take only seconds.

Mechanism of Action

The AT verbal suggestions represent a form of self-hypnosis, very powerful in inducing deep relaxation. Autogenic training uses selective awareness (SA), which represents the receptivity of the conscious mind to receive and acknowledge specific thoughts. Under SA circumstances, the censorship exerted by the ego should be annihilated, and thoughts should be allowed to travel freely from the conscious to the unconscious realm. The absence of censorship can improve dramatically the mind’s ability to influence physiological processes as desired. In this receptive state, pain sensations are also significantly reduced.

Worldwide, abundant anecdotal reports of persons accomplishing daunting
physical tasks while severely injured bear witness to the power of this
phenomenon. Still insufficiently understood, the interplay between conscious and
unconscious can nevertheless play important roles in maintaining physiological and
psychological homeostasis. The method appears to exert a balancing effect upon the
two branches of the autonomic nervous system (sympathetic and parasympathetic,
fight-or-flight and rest-and-digest, respectively).

During AT training sessions, sudden physical and emotional reactions, such as numbness, muscle twitching, or tears, may result from the release of unconscious thoughts. The manifestation, considered normal and even beneficial, is called autogenic discharge.

Uses and Applications

Autogenic training is most commonly used to reduce anxiety,
fatigue, chronic pain, and stress. The
sensations of warmth and heaviness can induce sleep, thus rendering the method
useful in persons with insomnia.

Additional proposed uses for the method include constipation and diarrhea,
gastritis, ulcers, headaches, high blood pressure, hyperventilation, asthma,
irregular and rapid heartbeat, and Raynaud’s phenomenon (episodic vasospasm of
fingers and toes). Evidence also suggests that AT may enhance mental well-being
and clinical outcome in persons with Ménière’s disease (an inner-ear
disorder that affects hearing and balance).

Scientific Evidence

Thousands of studies have been conducted on the effects and clinical applications of AT, both in Europe since the introduction of the method and in the United States beginning in the 1980s. A wealth of data remains in languages other than English.

Ample experimental support exists for the hypothesis that AT affects sympathetic tone and even parasympathetic function (that is, increased cardiac parasympathetic tone, with beneficial results). There is considerable difficulty in standardizing the technique, selecting participants, and measuring outcomes, so rigorous clinical studies are notoriously difficult to perform. Many studies have serious methodological flaws. Nevertheless, randomized-controlled trials have been conducted, with significant results indicating AT effectiveness in reducing anxiety and chronic pain, improving the symptoms of migraine headaches, and alleviating the symptoms of irritable bowel syndrome and other conditions.

Choosing a Practitioner

AT is more popular in Europe and Japan than in North America. The British Autogenic Society offers therapist training courses and maintains a directory of practitioners in the United Kingdom and abroad. These practitioners have various backgrounds and may be doctors, nurses, psychotherapists, psychologists, complementary therapists, social workers, or teachers. Interested persons can learn the technique from numerous books, Web sites, or, preferably, from AT therapists. A specialist can confirm the quality of the practice, monitor progress, provide feedback, and implement variations from the standard.

Safety Issues

AT is generally safe and can be used by most people, except children younger
than school age and persons with severe psychiatric disorders. Before
implementing the technique, however, persons should undergo a physical examination
and should discuss potential effects with a health care practitioner. It has been
suggested that rapid autonomic rebound can lead to dizziness, disorientation,
anxiety, panic, and even hallucinations in certain persons. Finally, persons with
cardiovascular diseases, diabetes, or other severe disorders should use AT under
medical supervision only.

Bibliography

British Autogenic Society. http://www.autogenic-therapy.org.uk.

Edlin, Gordon, and Eric Golanty. Health and Wellness. 10th ed. Sudbury, Mass.: Jones and Bartlett, 2010. Covers multiple aspects of health and discusses stress management techniques, including AT.

Linden, Wolfgang. “The Autogenic Training Method of J. H. Schultz.” In Principles and Practice of Stress Management, edited by Paul M. Lehrer, Robert L. Woolfolk, and Wesley E. Sime. 3d ed. New York: Guilford Press, 2009. A clear and authoritative discussion of AT, written for health practitioners and dedicated general readers.

Seaward, Brian L. Managing Stress: Principles and Strategies for Health and Well-Being. 6th ed. Sudbury, Mass.: Jones and Bartlett, 2009. An excellent work on stress management that includes a discussion of AT.

Is Faustus's tragedy shaped by the heroic defiance of religion or despair born out of confusing signals in Protestant doctrine?

Faustus does not heroically defy religion at the end of Marlowe's play. In fact, his embrace of a Christian worldview causes him deep anguish because he wishes he could go to heaven and yet knows that he will go to hell. He longs to be like an animal and  simply dissolve on death.

It is despair, and (ironically in a man so puffed up and proud of his knowledge) confusion about the Protestant doctrine of repentance that leads Faustus to his tragic end. Up until the end, he could have been saved if had fully repented and truly believed he could be saved. He does repent in the sense that he wishes he could be reconnected with God and spared hell, but since he can't believe that is possible, he can't truly repent. Mephistophilis  of course, tries to divert him: the devil is worried because he knows, in a way Faustus doesn't, that Faustus could still be saved. At the end, the second scholar, among others, urges him to repentance: 

Yet, Faustus, look up to heaven; remember God's
mercies are infinite.

The sin of despair condemns Faustus by confusing him about the extent of God's mercy towards sinners. He says to those begging him to repent:

But Faustus' offence can ne'er be pardoned: the serpent
that tempted Eve may be saved, but not Faustus.

Underlying the sin of despair is the sin of pride. Faustus, in essence, thinks his sin is too big and important for God to forgive. Even at the very end, he finds it impossible to shed his sense of  his own wisdom and importance. He, Faustus, chooses despair and decides he can't be saved--and that act of putting himself in the place of God condemns him.

How are the UN and the USA involved in the Israel v Palestine conflict? What are they doing to help?

The UN and the US have had a vital role in the Israel-Palestine conflict since the beginning, though it is controversial whether they have made the situation better or worse. Some people blame the UN for creating the conflict in the first place, while others believe that UN support is what has kept the conflict from conflagration into a much larger and bloodier war.

The US government considers Israel a vital ally, and as a result supports them with huge amounts of foreign aid, much of it in the form of military equipment and technology. The US also frequently uses its veto power in the UN Security Council to veto UN resolutions that US officials perceive to be against Israel's interests.

The UN on the other hand is quite divided on the issue, probably because the UN consists of over 200 member nations whose people and governments often have wildly diverging opinions. Sometimes the UN passes resolutions that favor Israel, other times resolutions that favor Palestine, and still other times resolutions that seek compromise between both sides. When resolutions favor Israel they are almost always supported by the US (though sometimes vetoed by other countries), while resolutions that favor Palestine are almost always vetoed by the US.

The UN has passed only a handful of resolutions directly related to the conflict: In 1947 they endorsed the plan to partition Israel and Palestine. After the Six-Day War in 1967, they also passed a resolution requiring Israel to withdraw from occupied territories and establish a "just settlement"---but this was too vague to carry any real force. Similarly in 1978, the UN ordered Israel to withdraw from Lebanon. In 1990 the UN held a peace conference in the Middle East hoping to reconcile Israel and Palestine and prevent the rise of the Gulf War... which obviously they failed to do on both counts.

Because the US has such global military and economic hegemony, they are frequently called upon to negotiate peace treaties between Israel and Palestine, but Palestinians usually perceive them as adopting a pro-Israel bias, and not without reason, given how much aid the US gives to Israel. As political leaders have come and gone in each country, relations between the three nations have ranged from conciliatory to ambivalent to outright hostile. In good times the US has successfully negotiated a number of ceasefires and peace treaties between different Israeli and Palestinian factions, but they never seem to last in bad times.

Overall I think the US and the UN are genuinely trying to achieve peace, but aren't really sure how to do so, and are subject to their own interests and internal conflicts. There's so much bitterness and distrust between the two sides, and such a long history of violence, that achieving a lasting peace has remained out of reach.