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Now that you are clear on what you really want to do with your career, and have a sense of purpose, here are a number of things you might want to consider when deciding where and how to find that elusive 'ideal work'. Firstly has to be your ideal location: are you willing/able to relocate? Major finance and insurance companies tend to be located in London at the present. If you need to commute then what is the longest commute you're willing to take? And can you rely on public transport to get you to work? Do you prefer rural work? What about a Hebridean island? Don't rule anything out until you've considered it carefully.
Secondly, how much do you need to earn? That will depend on your personal and family circumstances as well as the level of your ambition. There's plenty of information available to help you to find out what the average earnings levels are in your preferred field, but travel costs or additional family commitments can eat up a new salary very quickly.
Thirdly, think about the hours of work – do you want to work full time, part time, flexibly, job-share? All of these will have an impact on where and how you start to look for work.
If you are unemployed or faced with the prospect of losing your current role, there are significant psychological and practical issues that you will face. It is essential that you stay totally focused on the hunt for your next job; here's how.
There are many different ways in which you can go about looking for a new job. Here are some detailed ideas of where to start and how to approach it.
Somewhere between employment and running your own business, freelancing is an option that some people choose as their preferred way of working or as a temporary stop-gap. There are clear advantages but also some very real drawbacks. Would your circumstances and attitude to work make it the right choice for you?


The 1.9% budget increase ($15,669) passed 222-43.
David Lemon & Gail Robinson are our new HPL trustees.
We truly appreciate the support of our community!
The icing on the cake: the community's newest mural will be revealed at 2 PM on the South Cedar St. library wall!
Proceeds of the raffle will help purchase new library furniture.
& at HPL after we re-open.
* Trustees leaving the Board after over 10 years of service to the community.
The Howland Public Library hopes to reopen on Monday, May 24th.
HPL items that were due May 17th are now due on June 1st.
Please return HPL items after we re-open.
Our book return will be locked until we re-open.
fine AMNESTY on all HPL items returned before June 1, 2010.
The Reconfiguration Project is almost finished. People who've stopped in have been thrilled with what's been accomplished!
The cost of moving books and shelving, repainting and carpeting came from donations and a generous bequest, grants from state legislators, and a $51,000 matching grant from NYS Library Construction funds.
No local taxes were requested to fund this project.
We regret any hardship or inconvenience that you've experienced while we've been closed.
We look forward to serving you again!


text:
A Senior Year Like No Other
The Class of 2021 opens up about what it's like being a senior during a pandemic.
Melissa Ponce
SENIOR YEAR DURING A PANDEMIC- During previous years, seniors looked forward to activities such as grad night, homecoming, and prom as they reached their final months as highschoolers. Yet due to the pandemic, numerous senior activities have been cancelled, leaving the Class of 2021 with mixed feelings. "I was looking forward to prom because that's the big event we are all looking forward to and saving money for," Daniela Gonzalez, a senior, said.
Melissa Ponce, Editor in Chief of Design
Many students imagine senior year to be the best year of high school. However, for seniors all across the country, the coronavirus pandemic created a drastic shift and stirred feelings of disappointment.
Because of online learning, seniors are removed from daily interactions with both friends and teachers. Being at home also means that students find themselves more easily distracted. "We are not face-to-face and there are so many distractions [at home]. My phone is right next to me and I have to remember to put it away so I can focus on the lessons," Daniela Gonzalez, a senior, said.
Paired with the distractions of a home environment, some seniors are faced with additional responsibilities. Kenneth Lara, a senior, assists his younger sister who just began middle school with online learning. On top of that, he works anywhere from four to eight hours at a fast-food chain restaurant on school days and on the weekends. "Schools have to realize that with everything going on, for some people, school isn't their main priority; they have other personal matters to take care of," Lara said.
Were you looking forward to prom?
Lara describes that with the added stresses of distance learning, he would much rather participate in a hybrid-model. "At school, I would be able to focus more and I think it would be better because learning is about having that connection with the person who is teaching you, and over a screen, you don't get that," Lara said.
Before the pandemic hit, many seniors were looking forward to events such as grad night, homecoming, and prom. Yet, with the current number of coronavirus cases, these activities seem unlikely to take place. "I was looking forward to prom because that's the big event we are all looking forward to and saving money for," Gonzalez said.
Instead, students are left to tackle the stresses of senior year such as applying to colleges during unprecedented conditions. "There are those moments where you just need help, but you can't go after school to talk to the college counselor. But I am glad I was able to get those [college applications] done, and I am proud of all the seniors," Anahy Barajas, a senior, said.
There are those moments where you just need help, but you can't go after school to talk to the college counselor…"
— Anahy Barajas
Mr. Velasco, the senior counselor, agrees that distance learning poses new obstacles for seniors applying to college. "The [MACES] Class of 2021 is by far the largest class applying to college and the fact you have to do everything online takes away the personal interaction," Velasco said.
With the high amount of students applying to college, Velasco believes it is fair to give seniors the priority of returning to campus should conditions allow schools to adopt a hybrid model. "[Seniors] should be given priority because from a counselor standpoint it will help the student and counselor cooperate efficiently," Mr.Velasco said.
There is no doubt that the Class of 2021 faces a year unlike any other. "In the end, it would be great to have an in-person graduation because you've been going to school for that one moment, and honestly, that one moment is something no one can ever take away from you," Lara said.
classof2021
Melissa Ponce is a senior and the Editor in Chief of Design for the Wolfpack Times. This is her second year participating in the school newspaper and she...
All Restrooms Need to be Operational
Graffiti In Maywood
Thoughts On The Prom Theme
The Importance Of Student Inclusivity
Wolfpack Familia Wants more Uniform Options
The Safety of Students
How has social media changed you?
Thoughts on Halloween costumes
Should we go trick or treating this year?
Emotions run high in AP English Literature,

redpajama_set_name: RedPajamaCommonCrawl


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text:
Multidrug resistant Pseudomonas aeruginosa in Estonian hospitals
Kaidi Telling ORCID: orcid.org/0000-0002-7467-09421,
Mailis Laht2,
Age Brauer3,
Maido Remm3,
Veljo Kisand2,
Matti Maimets4,
Tanel Tenson2 &
Irja Lutsar1
We aimed to identify the main spreading clones, describe the resistance mechanisms associated with carbapenem- and/or multidrug-resistant P. aeruginosa and characterize patients at risk of acquiring these strains in Estonian hospitals.
Ninety-two non-duplicated carbapenem- and/or multidrug-resistant P. aeruginosa strains were collected between 27th March 2012 and 30th April 2013. Clinical data of the patients was obtained retrospectively from the medical charts. Clonal relationships of the strains were determined by whole genome sequencing and analyzed by multi-locus sequence typing. The presence of resistance genes and beta-lactamases and their origin was determined. Combined-disk method and PCR was used to evaluate carbapenemase and metallo-beta-lactamase production.
Forty-three strains were carbapenem-resistant, 11 were multidrug-resistant and 38 were both carbapenem- and multidrug-resistant. Most strains (54%) were isolated from respiratory secretions and caused an infection (74%). Over half of the patients (57%) were ≥ 65 years old and 85% had ≥1 co-morbidity; 96% had contacts with healthcare and/or had received antimicrobial treatment in the previous 90 days.
Clinically relevant beta-lactamases (OXA-101, OXA-2 and GES-5) were found in 12% of strains, 27% of which were located in plasmids. No Ambler class B beta-lactamases were detected. Aminoglycoside modifying enzymes were found in 15% of the strains. OprD was defective in 13% of the strains (all with CR phenotype); carbapenem resistance triggering mutations (F170 L, W277X, S403P) were present in 29% of the strains. Ciprofloxacin resistance correlated well with mutations in topoisomerase genes gyrA (T83I, D87N) and parC (S87 L). Almost all strains (97%) with these mutations showed ciprofloxacin-resistant phenotype.
Multi-locus sequence type analysis indicated high diversity at the strain level – 36 different sequence types being detected. Two sequence types (ST108 (n = 23) and ST260 (n = 18)) predominated. Whereas ST108 was associated with localized spread in one hospital and mostly carbapenem-resistant phenotype, ST260 strains occurred in all hospitals, mostly with multi-resistant phenotype and carried different resistance genotype/machinery.
Diverse spread of local rather than international P. aeruginosa strains harboring multiple chromosomal mutations, but not plasmid-mediated Ambler class B beta-lactamases, were found in Estonian hospitals.
This trial was registered retrospectively in ClinicalTrials.gov (NCT03343119).
Pseudomonas aeruginosa (PA) is an opportunistic pathogen present in many ecological settings. It can survive in living (humans, animals, plants) and non-living (water, soil, artificial surfaces) sources [1], but is rarely found in the microbiota of healthy humans [2]. The colonization rate by PA significantly increases (reaching up to 80%) in patients with chronic illnesses (e.g. cystic fibrosis, severe burns) or extensive exposure to healthcare facilities involving interruption of protective barriers [3,4,5].
PA is exceptionally flexible, using different regulatory and metabolic mechanisms to adapt to antibiotic pressure. It has an intrinsic resistance to wide range of antimicrobial agents, and a high capacity to attain resistance mutations and mobile genetic elements [6].
According to the European Centre for Disease Prevention and Control (ECDC) in 2016, resistance of PA in most European countries exceeded 10% of all antimicrobials investigated. Furthermore, the prevalence of MDR-PA is rising globally, a phenomenon mainly associated with the spread of high-risk clones (e.g. multi-locus sequence types ST235, ST111, ST175) associated with nosocomial outbreaks and transferable resistance mechanisms, especially horizontally-acquired beta-lactamases [7]. Despite the low antibiotic consumption comparable to other North European countries [8], the resistance rates of PA in Estonia, especially to carbapenems, are much higher than in other low-end usage countries, with the trends becoming alarming. In 2012, 12.5% of the strains reported to the ECDC were carbapenem-resistant (CR), but this had risen above 20% by 2016 [9, 10].
Although main trigger associated with CR in PA is production of plasmid-mediated beta-lactamases/carbapenemases, mutational resistance mechanisms in chromosomal genes – e.g. altered expression of outer membrane porins or efflux systems and increased chromosomal cephalosporinase (AmpC) activity, may all have affected the development of resistance [7].
Unfortunately data provided by the ECDC reflects just a fraction of the actual situation, as only invasive strains and the phenotypic resistance are reported. This leaves a gap in terms of non-invasive infections, and in genetic information of the spreading bacterial lineages and resistance machinery they carry. Previous studies conducted in Estonia are no exception; they have included only certain patient groups (intensive care units) [11] or blood-stream infections [12] without any information at the molecular level. Both knowledge of main risk groups and genetic data of strains is essential in understanding resistance transfer, and to take actions needed to stop it.
We aimed to characterize hospitalized patients carrying carbapenem- or/and multidrug- resistant P. aeruginosa (CR/MDR-PA), identifying the main spreading clones and describing the most important resistance mechanisms, including the occurrence of clinically relevant beta-lactamases.
Study design and settings
The study was conducted in 5 major Estonian hospitals treating both pediatric and adult patients - 2 3rd level multidisciplinary referral hospitals (Tartu University Hospital and North Estonia Medical Centre), 2 central hospitals (West Tallinn Central Hospital and East-Tallinn Central Hospital) and 1 private hospital specializing in plastic and vascular surgery (The Hospital of Reconstructive Surgery).
During the study period all consecutive PA strains isolated from hospitalized patients taken by discretion of treating physicians on suspicion or confirmed infection and identified as CR and/or MDR by the microbiology laboratories of the hospitals were collected, with a target of 100 strains. Only one strain was included from each patient (invasive strain or firstly isolated strain). Strains from ambulatory patients and clinics were excluded. The collection lasted from 27th of March 2012 to 30th of April 2013.
Clinical data collection
Hospital records of patients with eligible PA strains were reviewed retrospectively to obtain demographic data (age, gender), the presence of major co-morbidities and predisposing clinical conditions, date and reason of admission, site of infection, in-hospital movement, presence of infection or colonization caused by CR/MDR-PA, and the outcome.
Specifically, we recorded the presence of invasive devices, surgery within the previous 30 days, hospitalization, or time spent in a long-term care facility, and antimicrobial therapy in the previous 90 days.
Sampling and microbiological methods
Standard clinical laboratory methods were used to isolate and identify PA from clinical specimens. Briefly, urine was plated on cysteine lactose electrolyte-deficient agar, respiratory samples on blood and chocolate agar, which were incubated at 37 °C for 24 to 48 h. Tissue biopsies were homogenized and incubated in thioglycolate broth at 37 °C for 14 days. Blood, cerebrospinal, pleural and abdominal fluids were processed and monitored with a BACTEC 9240 blood culture system (Becton Dickinson, Sparks, MD, USA). One colony with Pseudomonas-like morphology was identified using classical biochemical tests (catalase and oxidase reactions) and VITEK2 Compact or API tests (bioMérieux, Marcy l'Etoile, France).
Finally, all PA isolates were confirmed by using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (Bruker Daltonics, Bremen, Germany). Only one isolate per patient was included in the final analysis, giving preference to more invasive strains (blood or cerebrospinal fluid).
Phenotypic susceptibility testing
The MIC for 9 antipseudomonal antibiotics (ceftazidime, cefepime, meropenem, imipenem, piperacillin/tazobactam, amikacin, gentamicin, tobramycin and ciprofloxacin) for each strain was measured with an epsilometer (E-test, bioMérieux, Marcy l'Etoile, France), with the quality control strain ATCC® 27,853™ being routinely used. Antibiotic susceptibility was determined using EUCAST breakpoints and definitions [13, 14]. Strains non-susceptible to at least one tested carbapenem were designated CR, whereas those not susceptible to 3 or more antibiotic classes were defined as MDR [13].
Forty-seven CR strains were screened for Klebsiella pneumoniae carbapenemase (KPC) and metallo-beta-lactamase (MBL) production by combined-disk method using disks containing 10 μg imipenem, 10 μg imipenem with phenylboronic acid, 10 μg imipenem with cloxacillin high, 10 μg imipenem with dipicolinic acid and imipenem with EDTA (Rosco Diagnostica, Taastrup, Denmark). Quality control strains were P. aeruginosa CCUG59626, K. pneumoniae BAA1705 and E. coli ATCC® 25,922™.
PCR-based test for detection of genes encoding carbapenemases was used according to Poirel et al. [15] on the same 47 strains for double-control. Three different multiplex reaction mixtures were defined and evaluated for the detection of MBL-encoding genes (blaIMP, blaVIM, blaGIM and blaNDM), class A carbapenemase gene blaKPC and class D carbapenemase gene blaoxa-48. The following control strains were used - Swedish Institute for Communicable Disease Control (Sweden) carbapenemases detection control set: OXA-48-positive K. pneumoniae Oxa241, KPC-positive K. pneumoniae K271, NDM-1-positive K. pneumoniae K275, IMP-positive P. aeruginosa CCUG59626, VIM-positive K. pneumoniae CCUG58547, GIM-positive P. aeruginosa; and KPC-positive K. pneumoniae BAA1705.
A modified GuSCN-silica protocol was used for the DNA extraction from a single colony [16]. Briefly, cells were transferred into a solution containing 570 μl TE (pH 7.6) buffer (TRIS-EDTA) and 30 μL 10% SDS, with ~ 0.5 g zirconium beads (0.1 mm diameter), which was processed by 5 min on bead beater (Minibead beater, Bio-Spec Products, Bartlesville, USA), followed by centrifugation at 10000 rpm for 1 min. Cells were lysed by combining the supernatant with lysis buffer L6 (5.25 M GuSCN, 100 mM Tris – HCl, pH 6.4, 20 mM EDTA, 1.3% Triton X-100). Custom-prepared silica suspension (40 μl) was added before incubation for 5 min at room temperature and centrifugation at 5000 rpm for 10 s. The supernatant was discarded and the pellet washed with buffer L2 (5 M GuSCN) and 50% ethanol. The silica pellet was briefly dried and the DNA eluted in ultra-pure water (milli-Q). The extracted DNA was stored at − 20 °C until analyzed.
Total bacterial DNA was quantified using a Qubit® 2.0 Fluorometer (Invitrogen, Grand Island, USA) and 2200 TapeStation (Agilent Technologies, Santa Clara, USA). Ten nanograms of sample DNA was processed using an Illumina Nextera XT sample preparation kit (Illumina, San Diego, USA). The resulting DNA libraries were validated by qPCR using a Kapa Library Quantification Kit (Kapa Biosystems, Woburn, USA) to optimize cluster generation.
Ninety-two ssDNA Nextera XT libraries originating from 92 different clones were pooled and sequenced in one rapid-output run of HiSeq2500 (Illumina, San Diego, USA), with paired-end, 150-bp reads. Demultiplexing was done with CASAVA 1.8.2. (Illumina, San Diego, USA), allowing one mismatch in the index reads.
Draft assembly of whole genome sequences (WGS), multi-locus sequence typing (MLST) and phylogeny analysis
All Illumina reads were assembled de novo using the SPAdes genome assembler (ver 3.5.0), together with the MismatchCorrector [17].
A BLAST-based tool from https://cge.cbs.dtu.dk/services/MLST/ was run to annotate the MLST fragments within the WGS data [18]. To identify the sequence types (ST), the batch profile query from the pubMLST website for PA (http://pubmlst.org/paeruginosa) together with their locus/sequence definitions was used.
Sequences were aligned using global genome alignment to determine the core genomes. Thereafter, recombinations in the core genomes were detected using BratNextGen software [19]. For phylogenetic analysis, recombination-free alignments were created by masking all significant recombinant segments as missing data in the input alignment. These alignments were used to reconstruct a maximum likelihood phylogenetic tree with RaxML, using the GTR-GAMMA model.
As core genome alignment and MLST analysis resulted in similar clustering, the data are presented according to STs of MLST.
Identifying resistance genes
Antibiotic resistance genes were identified using a homology search against the collection of antibiotic resistance protein sequences from The Comprehensive Antibiotic Resistance Database (CARD, http://arpcard.mcmaster.ca/, version 1.1.0) and beta-lactamases from http://www.lahey.org/studies/. GyrA, ParC, OprD, Rmt and Arm sequences were retrieved from the NCBI protein database. Identity and coverage thresholds were set to 90%.
Clinical relevance of found beta-lactamases was assessed as suggested by Potron et al. [20]
The chromosomal or plasmid origin of beta-lactamase genes was determined using a blastn search of corresponding contigs against the NCBI nt/nr database. Top matches were also examined manually to determine whether they were plasmid or chromosomal sequences. We could not decide whether the beta-lactamase gene was located in plasmid or chromosome for very short contigs and/or contigs with low coverage matches, or matches against both chromosomal and plasmid sequences. Contigs matching only against chromosomal genome sequences were not considered to be plasmid-related, whereas contigs matching with high coverage (> 95%) and identity (> 98%) to only plasmid sequences were considered as possibly originating from the plasmids.
Definitions and statistical analysis
For the analysis of demographic and clinical characteristics, patients were categorized as infected and colonized according to following criteria. Colonization was defined as absence of clinical signs of infection on day of isolation PA in the anatomical site were microorganism was detected. Infections were classified by their most probable origin of acquisition to community and hospital-acquired. ECDC definitions for hospital-acquired infections were used [21]. The Charlson weighted index of comorbidity was calculated using an updated (ICD-10 diagnosis-based) version [22].
Descriptive analysis used R 2.8.1 [23]. Chi-square or Fisher's exact tests were run where appropriate for categorical and the Kolmogorov-Smirnov test for continuous variables. Adjustment for multiple testing was made using the Bonferroni method.
The local microbiology laboratories identified a total of 118 CR/MDR-PA strains, of which 26 were excluded from the final analysis (16 from ambulatory patients, 6 were duplicates from the same patient, and 4 were not PA according to MALDI-TOF). Of the 92 strains, 43 were CR, 11 were MDR, and 38 were both MDR and CR.
The most frequently represented sources were respiratory secretions (n = 50; 54%), followed by wound aspirates (n = 22; 24%), urine (n = 12; 13%) and materials retrieved during intra-abdominal or vaginal procedures or surgeries (n = 7; 8%). One strain originated from the bloodstream.
The median time elapsed between hospital admission and CR/MDR-PA isolation was 13 days (IQR: 6–27 days).
Study population and characteristics
Sixty-eight (74%) patients had infections, whereas 24 (26%) were classified as asymptomatic carriers. The most common infections were pneumonia (n = 34; 50%), skin and soft tissue (n = 14; 21%), surgical site (n = 6; 9%), and intra-abdominal infections (n = 5; 7%). About half the patients (n = 44; 47%) had hospital-acquired infections (Additional file 1: Table S1).
The demographic and clinical characteristics of patients that had CR/MDR-PA are presented in Table 1.
Table 1 The most important clinical characteristics of patients with CR/MDR-PA infection or colonization
Over half of the patients were elderly (≥65 years) with multiple co-morbidities (average (±SD), Charlson co-morbidity index (2.6 ± 2.1). About 85% patients had at least one co-morbidity. There were no patients < 18 years old.
Congestive cardiac insufficiency was commonly present (32%), followed by renal failure (23%) and diabetes mellitus (22%). Although 17 patients had chronic pulmonary disease, none had cystic fibrosis.
Most of the patients (n = 88; 96%) had preceding contact with the healthcare and/or received antibacterial treatment within the previous 90 days; beta-lactams were by far the most commonly used antibiotics (Additional file 2: Table S2).
There were no statistically significant differences detected in risk factors of colonized and infected patients probably due to small sample size and great variety in population analyzed. It might be assumed that factors affecting exposure to PA and leading from colonization to infection are quite diverse and need further research in more precisely selected groups to draw adequate conclusions.
Eighteen patients (20%) died during their hospital stay. The mortality rates in the 7 day, 30 day and 1 year after PA isolation were 2, 14 and 44%, respectively.
Antibiotic susceptibility of PA
The MIC values together with the interpretations are shown in Table 2. The highest resistance rates were observed to imipenem and the lowest to amikacin (59.8 and 7.6%, respectively).
Table 2 Minimal inhibitory concentrations and antibiotic susceptibility interpretations of PA (n = 92)
CR was detected in 81 (88%) strains but no production of KPC or MBL was found by using combined-disk method and PCR in 47 randomly selected CR strains (Fig. 1).
Analysis of 92 sequenced carbapenem or/and multiresistant P.aeruginosa genomes. A maximum-likelihood tree and MLST analysis, presence of beta-lactamases and their location (either in plasmid or chromosome) and aminoglycoside modifying enzymes, selected mutations in quinolone resistance-determining region (QRDR) and OprD. Tested antimicrobial susceptibilities are presented as follows: green color – susceptible; orange color – intermediate and red – resistant strain. CARBA represents coordinated results of phenotypic testing of class B beta-lactamases by combined-disk method and PCR where tested strains are marked with a dark blue color
Genetic relationship and spread
Ninety-two CR/MDR-PA strains were assigned to 36 different sequence types (Fig. 1), of which 9 strains were novel to the MLST database.
The most prevalent sequence types were ST108 (n = 23; 25%) and ST260 (n = 18; 20%). ST108 strains were found throughout the study, indicating an endemic spread in 6 different wards (mostly in 2 ICUs) of one hospital. Eleven patients carrying ST108 had nosocomial infection, mostly ventilator-associated pneumonia (10 cases). All ST108 strains were CR (22 resistant to imipenem and 18 to meropenem) and 9 strains were MDR.
ST260 was found in all participating hospitals, but almost half of the strains (n = 7; 39%) belonging to this ST were isolated from a single hospital that was linked to one ICU. In most of cases (n = 14; 78%) ST260 caused infection and was phenotypically tested as MDR.
Only one strain belonged to the so-called high-risk international clone (ST235).
Resistance genes
Clinically relevant beta-lactamases (OXA-101, OXA-2 and GES-5) were found in 12% of the strains. Oxacillinases belonging to class D were found in 10 isolates, with OXA-101 (n = 9; 10%) being the most frequent and isolated only in ST260. No class B beta-lactamases (IMP, VIM; SPM; GIM, NDM, FIM) were present. None of the strains produced carbapenemases.
Plasmid encoded β-lactamases were present in 3 (3%) of the strains. Only one plasmid encoded class A beta-lactamase, GES-5; an isolate that belongs to the previously well-known high-risk, clone ST235.
Aminoglycoside modifying enzymes (AME) and 16S rRNA methyltransferases
Clinically relevant AME genes were found in 14 (15%) strains, the most frequent being ANT(2″)-Ia, present in 11 (12%) strains, 9 of which belonged to ST260.
The AAC(6′)-Ib-cr cassette mediating resistance to both aminoglycosides and fluoroquinolones was found in one isolate belonging to ST235 phenotypically resistant to ciprofloxacin and amikacin, but sensitive to gentamicin and tobramycin.
No 16S rRNA methyltransferase coding genes were found.
Mutational resistance mechanisms
The oprD gene was defective in 12 strains (13%; 8 resistant to both imipenem and meropenem; 1 imipenem and 1 meropenem resistant, and 2 with carbapenem-susceptible) and mutated in 77 strains (84%). We found 3 previously described mutations triggering CR – F170 L (n = 18; 20%), S403P (n = 8; 9%) and W277X (n = 2; 2%). Statistical analysis showed an association between defective oprD and non-susceptibility to meropenem (9 meropenem resistant vs 3 meropenem sensitive strains; p < 0.05).
Having researched fluoroquinolone resistance-associated mutations in topoisomerase genes gyrA (T83I, D87N) and parC (S87 L), we found T83I mutation was present in 27 (29%) strains, of which 23 were ciprofloxacin resistant. D87N was found in one and parC S87 L substitution in 6 ciprofloxacin resistant strains. Both gyrA T83I and parC S87 L mutations correlated well with ciprofloxacin resistance (23 resistant vs 4 sensitive strains; p < 0.0001, and 4 resistant vs 2 sensitive strains; p < 0.01, respectively).
This is the first study that addresses clinical risk factors alongside with the presence of resistance mechanisms in a mixed population of hospitalized patients infected or colonized with CR/MDR-PA and covers all major Estonian hospitals. The observations show that: (1) the vast majority of affected patients were elderly and had a history of previous contact with healthcare institutions and/or multiple co-morbidities confirming results of previous studies [24]; (2) the 2 predominant STs (ST108 and ST260) we described had good spreading potential and have rarely been recorded in previous studies, suggesting high ST variability within PA and minimal entry of internationally spreading strains into Estonian hospitals; (3) most of the CR strains lacked clinically relevant beta-lactamases including carbapenemases and metallo-beta-lactamases, suggesting that CR is encoded by a selection of mutations in chromosomal genes; (4) correlation between gyrA T83I and parC S83 L mutations and quinolone resistance were in support of previous studies [25,26,27].
Considering the high rate of patients with advanced age, the high rate of contact with healthcare facilities, and association with multiple courses of prior antibiotic therapy, it is not unsurprising that they have been previously described as risk factors for PA infection [28]. However, none of these patients belonged to typical risk groups, such as burns, cystic fibrosis or febrile neutropenia, but more commonly had congestive cardiac insufficiency. Similarly, other studies have shown decreasing trends of PA in burn and oncologic patients in Europe and North-America [29]. The reason for these trends is not entirely clear, but the fact that most of the empirical treatment regimens include anti-pseudomonal antibiotics may be a contributing factor.
The high rate of patients with congestive heart disease is more difficult to explain. It may be a concomitant finding and not directly related to the colonization of CR/MDR-PA. This also highlights the fact that PA infection is not a disease strictly associated with people that have severe disturbances of immune or barrier systems, because it can also affect patients without obvious immune defects, such as the elderly.
We found that the pattern of antibiotic resistance is largely driven but 2 STs (ST108 and ST265) causing hospital-acquired infections (mainly ventilator-associated pneumonia) and at least 2 outbreaks. Neither of these strains belonged to well-known internationally spreading clones [7]. ST108 was mostly associated with a singularly CR phenotype and spread only in one hospital. On the other hand, ST260 strains were much more diffused in hospitals. These strains usually had multiresistant phenotypes and carried some resistance machinery (ANT(2″)-Ia, OXA-101 and GyrA T83I mutation). Hence ST may have the potential for becoming a new high-risk clone. ST260 has been previously described in different human settings and in different geographical regions; it is mostly associated with MDR or XDR phenotype, but never with outbreaks [30,31,32,33].
CR of PA, reaching up to 20.4% has been a problem within Estonian hospitals for years [34]; however, potential resistance mechanisms have remained unidentified [11], and unfortunately we do not have definite answers from this study. In contrast to other European studies in which the most important trigger of resistance is the production of horizontally-acquired beta-lactamases (mainly belonging to Ambler class B), we found none of these strains, only a few clinically relevant beta-lactamases, of which only one (GES-5) has been described as having carbapenemase activity [20]. We detected a correlation between defective oprD and meropenem-resistance in 10 strains and a single mutation previously associated with carbapenem resistance in 25 strains [27]. These mechanisms, however, did not explain resistant phenotype of the remaining 46 strains. Probably a cascade of mutations that were not addressed in this study, including structural modifications in AmpC, peptidoglycan recycling genes and mutations leading to efflux pump overexpression, are required to facilitate phenotypic resistance.
Our data indicates the importance of 2 locally spread resistant clones in spite of low antibiotic consumption; tackling the main spreading routes of these clones could significantly reduce the burden of CR/MDR-PA. Because both the spreading clones had been isolated from respiratory secretions and associated with mechanical ventilation or bronchoscopy, the procedures related to the maintenance of the airway should be the focal point in the prevention of colonization and infections with CR/MDR-PA. Updating both the knowledge and skills of basic hand hygiene and isolation methods, improving oral hygiene practices, and revising bronchoscope cleaning techniques, including disinfection processes, can be effective in aborting PA outbreaks [35]. Infection control measures could be significantly improved by implementing high resolution molecular identification techniques (egg. WGS, MLVA) into everyday practice for rapid detection of outbreaks and stopping the spread of multiresistant microorganism and thus should be encouraged [36].
Some limitations of our study should be noted. Because samples were identified by microbiology laboratories and taken on discretion of treating physicians, there is a possibility that some patients, especially asymptomatic carriers, were not sampled. This leaves a gap in our understanding of how MDR-PA circulates in Estonian hospitals. Secondly, E-test was used for susceptibility measurement instead of microdilution that is EUCAST suggested reference method. Still, E-test results have correlated well with MICs generated by the dilution methods [37] and thus we believe that our results are reliable. Despite these limitations we believe that our results allow us to draw adequate conclusions.
PA is a pathogen that affects not only immunocompromised, but also elderly multi-morbid patients. It is characterized by wide genetic diversity and spread via local rather than global clones in Estonian hospitals. The resistance machinery of PA is complex with only few certain correlations between genotypic and phenotypic resistance. Many different genetic changes may be required to develop the resistance pattern observed in phenotypic tests. High resolution genotyping methods are very valuable for tracking the spread of outbreaks, and therefore it is crucial to encourage the use of sequence-based methods in everyday practice.
AME:
Aminoglycoside modifying enzymes
Carbapenem resistant
CR/MDR-PA:
Carbapenem and/or multidrug resistant P. aeruginosa
ECDC:
EUCAST:
European Committee on Antimicrobial Susceptibility Testing
Intermediately susceptible
KPC:
K.pneumoniae carbapenemase
MBL:
Metallo-beta-lactamase
MDR:
MDR-PA:
Multidrug-resistant Pseudomonas aeruginosa
Minimal inhibitory concentration
MIC50 :
Minimal inhibitory concentration at 50%
MLST:
Multi-locus sequence typing
PA:
QRDR:
Quinolone resistance-determining region
Sequence type
XDR:
Extremely drug resistant
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We are grateful to all infection control specialists and microbiologists involved in this project from the Tartu University Hospital, North Estonia Medical Centre, West Tallinn Central Hospital, and East-Tallinn Central Hospital. We are especially thankful to Anastasia Pavelkovich. Marina Ivanova, Paul Naaber and Tiiu Rööp for their help with quality control strains and methodology for carbapenemase testing. We thank BioMedES UK (www.biomedes.biz) for improvement of the final manuscript.
This work was supported by Estonian Research Council (IUT2–22) and the European Union from the European Regional Development Fund through the Centre of Excellence in Molecular Cell Engineering and Estonian Program for Health Sciences (ABRESIST). Age Brauer and Maido Remm were funded by institutional grant IUT34–11 from the Estonian Ministry of Education and Research and the European Regional Development Fund through Centre of Excellence in Genomics and Translational Medicine (grant No. 2014–2020.4.01.15–0012). Veljo Kisand was funded by a personal research grant (PUT-134) from the Estonian Ministry of Education and Research. The funder had no role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript.
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
Novel sequences of the MLST alleles and new ST-s as combinations of previously reported allele sequences were reported to the pubMLST database (https://pubmlst.org/paeruginosa/, ID: BIGSdb_20170406141628_85178_50416). All WGS data have been deposited into the NCBI (PRJNA244279).
Department of Microbiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Ravila 19, 50411, Tartu, Estonia
Kaidi Telling
& Irja Lutsar
Institute of Technology, University of Tartu, Tartu, Estonia
Mailis Laht
, Veljo Kisand
& Tanel Tenson
Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia
Age Brauer
& Maido Remm
Department of Infection Control, Tartu University Hospital, Tartu, Estonia
Matti Maimets
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KT was a principal investigator and has contributed to all sections (implementation of study protocol, data collection, laboratory analyses, statistical analyses, first draft manuscript, final manuscript revision). ML participated in laboratory analyses and manuscript revision. AB did bioinformatical analysis, contributed to the results and discussion sections, as also to manuscript revision. MR gave bioinformatical advice and participated in manuscript revision. VK participated in laboratory analyses (WGS, MLST) and manuscript revision. MM contributed to developing the study protocol and revision of manuscript. TT and IL helped developing the study protocol, drafting first version of the manuscript, and revising all sections in the manuscript. All authors have read and approved the final manuscript
Correspondence to Kaidi Telling.
The study protocol was approved with a waiver of informed consent by the Ethics Committee of the University of Tartu.
Additional file 1:
Table S1. Characteristics of patients with hospital-acquired infections. (DOC 34 kb)
Table S2. Antibiotic groups used in prior 90 days before resistant CR/MDR-PA isolation. (DOC 36 kb)
Carbapenem resistance
WGS (whole-genome sequencing)
Bacterial and fungal diseases


There were 113,100 jobs in Topeka, Kansas in February 2019 according to the CES survey of employers. The CPS survey of households showed 116,328 employed persons for the month. Topeka added 100 jobs in February 2019 according to the CES survey while the broader CPS measure of employment rose by 500 (Comparing CES and CPS employment numbers.). You can also compare Topeka job growth to job growth in other cities.
The charts below show the monthly job growth for Topeka as measured by the CES and CPS surveys. To illustrate the trend, the 3 month moving average change in employment is shown in green.
CES employment for Topeka peaked in July 2002 at 116,100. Since then 3,000 jobs have been lost in Topeka according to the employer survey. From a trough of 107,500 in July 2006, Topeka has gained 5,600 jobs according to CES employment figures.
CPS employment reached a maximum of 118,594 for Topeka in November 2004. 2,266 jobs have been lost in Topeka since then according to the household survey. From a August 2006 low of 113,068, Topeka has added 3,260 jobs according to the CPS survey.


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Ava is a 21-year-old college student who unexpectedly lost her mom due to a cardiac incident related to COVID-19 exposure. Ava and her mother were extremely close; while Ava helped support the household, which included her grandmother and her brother, with her job as a home health aide, her mom was the main provider for the whole family, including the apartment. After her mom's passing, Ava received some assistance from HRA, but most of her savings went to the funeral expenses. Thanks to a Gerstner Helping Hands grant, Ava was able to pay first month's rent and security to secure a new affordable apartment for her and her brother, enabling them to remain stable as they recover from their tragic loss. Ava works full-time and will be able to support herself and her brother moving forward.
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Coalition for the Homeless
Lucy and her two daughters came to a Safe Horizon Child Advocacy Center after raising allegations of sexual abuse of the two daughters by Lucinda's ex-partner, Due to unexpected expenses and financial pressures resulting from income loss during COVID-19 Lucy had fallen behind on rent. Although she has returned to work, she was unable to cover the full arrears that she had accrued. Safe Horizon was able to provide a Gerstner Helping Hands grant of $2,500 toward reducing the arrearage, and Lucy worked extra shifts to pay off the remaining arrears and resolve her case.
Ken received an emergency housing grant from Queens Community House in September 2019. At the time, he was without stable work and struggling to pay his rent. Now he reports that he remains stably housed in the same apartment and has a full-time job as a recruiter with a non-profit organization in Manhattan. He said that he is up to date on his rent and is making enough money to put some away for a "rainy day", thankful to still have his job despite the pandemic. He is grateful for the rental assistance Queens Community House was able to give him.
United Neighborhood Houses
Amy was in need of legal representation after she received an eviction notice from her landlord. Amy had struggled financially since losing her employment. Amy's young son is disabled and the care his disability required, and multiple doctors' appointments limited her ability to maintain gainful employment. Once the courts put a hold on evictions, we advised our client to continue setting aside her payments for rent and save any additional she could manage. She applied for disability for her son and for rental assistance from DSS to assist her going forward. With the assistance from the Bridge Fund, DSS, and the Gerstner Helping Hands funds, our client was able to keep her apartment and maintain her family's stability
Legal Services of the Hudson Valley
After Virginia's spouse became violent, was incarcerated, and eventually deported, Virginia reached out to Adopt-A-Family's Housing Stabilization Program in June 2019 for homeless prevention assistance. Virginia had to relocate from the apartment she shared with her spouse because she could no longer afford the monthly rent along with the other household expenses. Virginia's oldest son moved in with his mother to help her with the bills and his younger siblings because they are both affected by autism. A year after receiving this life-changing assistance, Virginia reported that she and her family have remained stably housed, maintained employment despite COVID-19, and remained current with household bills.
Adopt-a-Family of the Palm Beaches
Juanita and her husband have lived in their current apartment for 23 years and have never fallen behind on their rent. Her husband has maintained a quality job in the same restaurant for many years which has allowed them to cover their monthly rent and utilities without a problem. In mid-March when the majority of restaurants shut down, Juanita's husband was let go with the promise, in writing from his employer, that he would be brought back in June when the restaurant re-opened. They used savings to cover their April rent and utilities but were unable to cover May and were not eligible for unemployment or other benefits due to their immigration status. Queens Community House was able to provide a Helping Hands grant of $1,703 to cover one month of rent and utilities to get the family through until they returned to work in June.
Mrs. R was 8 months pregnant when she was diagnosed with COVID. She had to have a C-section to protect her child, who was born healthy. She then had to be quarantined in the basement of the family home. Her husband had to take a month off from his job to take care of the baby and the other children. He was not paid for this month and thus could not pay his rent, so he was helped with a grant from the Gerstner fund, allowing the family to remain stably housed during this stressful time. The wife has now recovered, and the husband has been able to return to his job.
The Jewish Board
Linda is a hardworking fulltime employee at a local hospital, a single mother with one child. Linda and her son moved to Massachusetts to escape a domestic violence situation and start over. She had stressful custody disputes with her child's father that also affected her working hours and changed her income for the worse. At the time that she applied for funding, this family had exhausted every option available to them for funding and housing, including sleeping on friends' couches and sleeping in her car. In March 2019, she was granted $1,150 to assist with rent payments. When her caseworker from a partner agency followed up with her in December 2019, she stated that, thanks to the funding, her family was stably housed and was able to get back in good standing with her rental payments and maintain full time employment.
Ms. W is a single mother of a 2-year-old and 8-month-old. She was a sales executive at a women's clothing wholesaler. All employees were laid off as a result of COVID-19 following the cancellation of current and future orders from every major customer as well as the shutdown of their California warehouse as a nonessential business. Ms. W has never been behind on her rent before but did not have the means to pay. She applied for unemployment benefits through the Department of Labor's online portal but had not yet heard a response at the time she came to BronxWorks for assistance. A Helping Hands grant of $1,850 kept her up-to-date with rent until she could get unemployment
Bronxworks
AB and her two children entered AVDA's emergency shelter after fleeing her abusive partner. She was pregnant, unemployed, and afraid of what would come next. After settling in for a few days and receiving supportive counseling and assistance with emotional safety planning, she enrolled her children in daycare and attended a few courses that would help her secure employment. After securing employment, she found an apartment, and with the help of Gerstner funds towards her move-in costs, she was able to move into her new home, prepare for the arrival of her newborn and live violence-free with her children.
Aid to Victims of Domestic Abuse
JC came to Project Home for rental arrears assistance because she experienced a decrease in employment hours and wages while taking time off to assist her five-year-old son who suffers from a chronic illness. Since working with Project Home, JC's rent has been reduced, she received assistance from the Human Resources of Administration (HRA) One Shot Deal process, and she is receiving supplemental nutrition assistance program (SNAP) benefits. The majority of JC's rental arrears were covered by a One Shot Deal from HRA and a Helping Hands grant from Project Home. JC has returned to work full-time and her five-year-old child is doing much better.
CB and JB are proud parents of four beautiful children. JB suffered an injury on the job that rendered him unable to work for over six weeks. The family exhausted their savings to stay afloat, but they fell behind on one month of rent and their landlord filed a court ordered eviction. With help from the Gerstner Family Foundation, we were was able to pay the family's past due rent and prevent them from becoming homeless. During the course of agency intervention, JB completed physical therapy and returned to work. Additionally, CB received resume building assistance and was able to obtain a higher paying job. The family has remained current on rent since agency intervention and the parents are working to rebuild their savings.
AVDA provided a grant to a survivor for her extensive dental needs from the physical abuse at the hands of her abuser. She needed 10 teeth to be repaired and felt uncomfortable interviewing for jobs until the work was completed. AVDA referred the survivor to Genesis Health, a community health center that provides low-cost dental services. With the grant provided through this funding, she was able to pay the $40 per tooth fee that is required by Genesis Health. After the dental work was completed, the survivor secured a very good job, got a car, and moved into her own apartment.
The client, Betty R., is an immigrant from Ecuador who worked in a clothing factory for many years before becoming disabled due to a deterioration of her spinal column. Her husband works as a cab driver and together they could afford a one-bedroom apartment in the Bronx. One of the deadliest fires in New York City history tore through their apartment building, killing 12 of her neighbors and leaving her and her husband with only the clothes on their backs. The next day we reached out to Betty and gave them free donated clothing and extra food to take to their temporary lodging with friends. We used Gerstner funds to buy additional clothing for her and her husband as most of their belongings have been destroyed by fire and water.
Part of the Solution
Rennie and her two sons fled domestic violence. They moved in with Rennie's sister, but the apartment soon became overcrowded and the landlord ordered her family to leave. Through her own resourcefulness, Rennie found both an apartment and a job that enabled her to pay rent moving forward. However, she did not have enough savings to pay for her security deposit and moving costs. With the help of a grant the family was able to pay the deposit and moving costs. Rennie and her boys are now safe and happy in their new home.
Ireri and her husband Erick live with their two young children in a single shared room. The family has a difficult time making ends meet and was devastated when Law Enforcement raided and destroyed their home wrongfully in an attempt to evict a different family. This left them with a home full of broken furniture and nowhere to sleep. With a Helping Hands grant, we were able to purchase beds and linens for the family; they now each have their own bed to sleep in and can focus on maintaining the stability and well-being of their children.
Lenox Hill Neighborhood House
AW is a hard-working young lady. She is currently pregnant. She has only six classes left to obtain her bachelor's degree. She missed two days of work, and when she returned, she did not have a doctor's note so her employer terminated her employment. AW was quickly hired by another company but the gap in employment left her short with paying her rent. Thanks to the generosity of the Gerstner Family Foundation, we were able to pay for one month of rent for this client.
Catholic Charities of the Diocese of Palm Beach
info@gerstner.org


text:
module Resolvers
  module ErrorTracking
    class SentryErrorsResolver < BaseResolver
      def resolve(**args)
        args[:cursor] = args.delete(:after)
        project = object.project

        result = ::ErrorTracking::ListIssuesService.new(
          project,
          context[:current_user],
          args
        ).execute

        next_cursor = result[:pagination]&.dig('next', 'cursor')
        previous_cursor = result[:pagination]&.dig('previous', 'cursor')
        issues = result[:issues]

        # ReactiveCache is still fetching data
        return if issues.nil?

        Gitlab::Graphql::ExternallyPaginatedArray.new(previous_cursor, next_cursor, *issues)
      end
    end
  end
end

redpajama_set_name: RedPajamaGithub


Bec Judd says there's one room every woman needs in her home.
The one room Bec Judd says every woman needs in her home.
Bec Judd sees your Man Cave and raises her Good Front Room.
On Monday's episode of the 3pm Pick-Up, the radio host revealed she has one room in her house that exists purely to look good.
Yep, it's her Good Front Room or GFR.
During the show, her co-host Monty Dimond said she'd noticed that Bec had a 'good room' in her house.
"Yeah I do – it's the GFR, the Good Front Room," Bec replied.
"So many people have a GFR that's not used much – but it's like a pretty room where you put your pretty things, right?" her co-host Yumi Stynes asked.
"Yeah, it's like the female equivalent of a Man Cave," Bec replied.
Listen: Bec Judd speaks with podcast producer Monique Bowley about everything that happens during the birthing process, from start to finish. Post continues after audio.
"It's quite an old school thing to do," Monty said. "It's like parents who had the good dining room that you'd only use when guests would come over and you'd get out the good china. And you'd have a good couch and they'd yell: 'Don't wear your shoes in that room'".
"Yeah that's like me and the good room," Bec explained. "I have these two pink chairs that no one is allowed to sit on. And then we got this friggin' cat who decided those two good pink chairs – which I waited six months for when I imported them from Italy – would be her scratching post.
"Safe to say the cat is gone," she added.
Bec does use the Good Front Room for one thing – changing her children's nappies. That hasn't always gone to plan, though.
"I put so much effort into styling this room. It has this bay window with these velvet cushions – and I could only afford to velvet one side of the cushions," Bec explained to her co-hosts.
"So when I brought Billie home, I changed her nappy on one of the cushions and she sharted all over the velvet," she laughed.
"When you have new babies they just squirt everywhere and you just forget," she added.
"At least you haven't gone as far as putting plastic on your chairs yet," Monty laughed.
Do you have a 'good room'?


text:
Review of Philosophical Theology and Christian Doctrine [Book Review]
Kevin Timpe
Faith and Philosophy 25 (3):329-331 (2008)
Calvin College
Abstract This article has no associated abstract. (fix it)
Keywords Contemporary Philosophy Philosophy and Religion Book Review
Christianity, Misc in Philosophy of Religion
ISBN(s) 0739-7046
DOI 10.5840/faithphil200825332
pdcnet.org (no proxy)
pdcnet.org [2] (no proxy)
place.asburyseminary.edu (no proxy)
Paradox and Mystery in Theology.Bruce P. Baugus - 2013 - Heythrop Journal 54 (2):238-251.
Discerning the Divine: God in Christian Theology.Barry L. Callen - 2004 - Westminster John Knox Press.
Christian Philosophical Theology.Stephen T. Davis - 2006 - Oxford University Press.
Divine Simplicity.Mohammad Saeedimehr - 2007 - Topoi 26 (2):191-199.
Which Trinity? Whose Monotheism? Philosophical and Systematic Theologians on the Metaphysics of Trinitarian Theology.Thomas H. McCall - 2010 - W.B. Eerdmans Pub. Co..
Doctrine.Howard Wettstein - 1997 - Faith and Philosophy 14 (4):423-443.
The Drama of Doctrine: A Canonical-Linguistic Approach to Christian Theology. By Kevin J. Vanhoozer.Adonis Vidu - 2007 - Heythrop Journal 48 (5):838–840.
The Vision of God: The Christian Doctrine of the Summum Bonum.Kenneth E. Kirk - 1931 - Longmans, Green and Co..
The Trinity.Michael C. Rea - 2009 - In Thomas P. Flint & Michael C. Rea (eds.), The Oxford Handbook of Philosophical Theology. Oxford University Press. pp. 403--429.
Philosophical Theology and the Christian Traditions: Russian and Western Perspectives.David Bradshaw (ed.) - 2012 - Council for Research in Values and Philosophy.
Speaking of a Personal God: An Essay in Philosophical Theology.Vincent Brümmer - 1992 - Cambridge University Press.
Trinity.Jeffrey Brower - 2004 - In Jeffrey E. Brower & Kevin Guilfoy (eds.), _The Cambridge Companion to Abelard_. Cambridge University Press. pp. 223-257.


The elbows, knees, hips, wrists, ankles, and shoulders – the body's major joints – are incorporated in the motion required to perform even the most basic tasks. Major pain in even one of these areas can be a significant deterrent to a person's ability to perform work-related activities such as pushing, pulling, climbing, walking, and lifting. For individuals with chronic pain in these areas, maintaining employment can be difficult or impossible. When a medical condition prohibits someone from continuing their line of work, it may be appropriate to seek long-term disability benefits.
The Indiana long-term disability attorneys of Hankey Law Office, have the experience and skill necessary to help individuals who are suffering from disabling conditions to get the benefits they need. If you are suffering from joint dysfunction due to an underlying condition, we may be of assistance. Contact our offices at (800) 520-3633.
No matter what the underlying cause, if someone's joint pain prohibits their physical abilities, it could qualify them for long-term disability benefits.
If you or someone you love has chronic joint pain and is unable to work, an Indiana long-term disability attorney of Hankey Law Office, can help you seek the benefits that you are due and which will help you to cope with the financial effects of this painful condition. Contact us by calling (800) 520-3633 today.


Aloo Pakoda / Potato Fritters Please find the recipe here.
Palak Paneer Please find the recipe here.
Mixed vegetable curry Please find the recipe here.
Chayote Sambar Please find the recipe here.
Gulab Jamun Please find the recipe here.


In the moment of conception, we enter into this world alone unaware of what is happening around us. We are oblivious to our surroundings, and of all the newness that is about to occur. The five senses—taste, sight, touch, smell and hearing become a journey of discovery throughout the aging process as children. We are at complete peace, oneness with the experience of life.
There is such an innocence and pureness when we are young. Happiness, confidence and self-worth are etched into our core. We are fearless, speak our mind and have no concern to what others think about us. There is a sense of resilience and creativity is what makes the soul blossom. We see at a young age how children are painters, chefs, writers and teachers. As one develops from being a toddler to adolescence and finally an adult there are many twists and turns. We sometimes forget who we once were and what truly made us content.
Let us liberate ourselves from any form of control. Let us focus at the inner drum, where the rhythm aligns with that of our heart. The measure of responsibility, equals to the need for evolution. Just listen, the inner child, let it whisper in your ear.
Are we born happy or do we have to work at it? Is it a conscious choice we make? These are the questions that have been pondering over the past few months. I believe happiness is an internal process and there are times we have to work towards creating it. There are numerous times when I would mask emotions of fear, anger or envy in order to keep that happy momentum. I was not being authentic whatsoever, and felt like I was avoiding parts of myself. I do believe happiness comes naturally when we are in alignment and we follow our hearts desires. When those moments happen, I bask in them and remind myself of the simple pleasures of life.
Our we a product of our environment and does epigenetics play a role in our development? I'm in no way a physician, however believe we absorb characteristics from our family relationships that determine some of our innate behaviours. Becoming an emotionally intelligent adult is clearing those blockages and experiences we endured as children. We are cleansing our spirits as we gain self awareness and personal power. We may blame our parents however there will be a time that you will see them as your teachers who gave you unconditional love. As they say the spiritual journey is coming home to yourself.
As we get older finish our education and follow a certain path, we live a certain way even though internally we have a deeper longing. We get caught up in the routine, work-life balance and forget about the importance of connecting to others. Is happiness in a job, car, relationship, or material status? Is that what makes life meaningful or is there something more?
There is something more! I attended a Buddhist Monk Meditation in February and it gave me the direction I have been seeking, along with inspiration for the remainder of this article. What I learned from that significant meditation is that INNER PEACE = HAPPINESS! Meditation brings you back to your core of who you are and that stillness is the key to your happiness. I'm in the process of applying the principle of non-attachment to situations and outcomes . By just being still is the source to happiness.
I leave you with the story of Gautama Buddha. He was born into a wealthy upper class family in India surrounded by prestige and influence. Buddha was inquisitive spirit and knew there was a deeper meaning to life and would ultimately forge his own path. One day, he decided to leave and became a humble man who lived the life of ascetic. As Buddha detached from everything, is when he felt truly rich. Meditation, prayer and living a simple life is what transformed his soul. Remember its your internal happiness that makes your soul light up just like the stars in the galaxy.
Is there a simple remedy for happiness? Why are we always searching? The concept of searching finally made sense – I had an epiphany! Happiness is not a destination, its a choice we make daily. It truly is the little things which add up to making us smile. Come back to your inner child, remember who you once were at that young age. Embrace that care-free, radiant soul who lived in pure joy. Make time and space for mediation, the more you practice you will settle into peace.


text:
The intergenerational transmission of childhood maltreatment: Nonspecificity of maltreatment type and associations with borderline personality pathology
Sarah E. Paul, Michael J. Boudreaux, Erin Bondy, Jennifer L. Tackett, Thomas F. Oltmanns, Ryan Bogdan*
One generation's experience of childhood maltreatment is associated with that of the next. However, whether this intergenerational transmission is specific to distinct forms of maltreatment and what factors may contribute to its continuity remains unclear. Borderline personality pathology is predicted by childhood maltreatment and characterized by features (e.g., dysregulated emotion, relationship instability, impulsivity, and inconsistent appraisals of others) that may contribute to its propagation. Among 364 older adults and 573 of their adult children (total n = 937), self-reported exposure to distinct forms of childhood maltreatment (i.e., emotional, physical, and sexual abuse, and emotional and physical neglect as assessed by the Childhood Trauma Questionnaire) showed homotypic and heterotypic associations across generations with little evidence that latent factors unique to specific forms of maltreatment show generational continuity. General nonspecific indices of childhood maltreatment showed evidence of intergenerational transmission after accounting for demographic factors and parent socioeconomic status (b = 0.126, p = 9.21 × 10-4). This continuity was partially mediated by parental borderline personality pathology (assessed longitudinally through a variety of measures and sources, indirect effect: b = 0.031, 95% confidence interval [0.003, 0.060]). The intergenerational continuity of childhood maltreatment may largely represent general risk for nonspecific maltreatment that may, in part, be propagated by borderline personality pathology and/or shared risk factors.
Development and psychopathology
borderline personality
childhood maltreatment
intergenerational transmission
10.1017/S095457941900066X
Dive into the research topics of 'The intergenerational transmission of childhood maltreatment: Nonspecificity of maltreatment type and associations with borderline personality pathology'. Together they form a unique fingerprint.
Childhood Maltreatment Psychology 100%
Maltreatment Psychology 66%
Borderline Personality Disorder Psychology 66%
pathology INIS 66%
transmission INIS 50%
risks INIS 33%
adults INIS 33%
Socioeconomic Status Psychology 16%
Paul, S. E., Boudreaux, M. J., Bondy, E., Tackett, J. L., Oltmanns, T. F., & Bogdan, R. (2019). The intergenerational transmission of childhood maltreatment: Nonspecificity of maltreatment type and associations with borderline personality pathology. Development and psychopathology, 31(3), 1157-1171. https://doi.org/10.1017/S095457941900066X
Paul, Sarah E. ; Boudreaux, Michael J. ; Bondy, Erin et al. / The intergenerational transmission of childhood maltreatment : Nonspecificity of maltreatment type and associations with borderline personality pathology. In: Development and psychopathology. 2019 ; Vol. 31, No. 3. pp. 1157-1171.
@article{2098629d8f8e45b0aa8b9c97e22249e7,
title = "The intergenerational transmission of childhood maltreatment: Nonspecificity of maltreatment type and associations with borderline personality pathology",
abstract = "One generation's experience of childhood maltreatment is associated with that of the next. However, whether this intergenerational transmission is specific to distinct forms of maltreatment and what factors may contribute to its continuity remains unclear. Borderline personality pathology is predicted by childhood maltreatment and characterized by features (e.g., dysregulated emotion, relationship instability, impulsivity, and inconsistent appraisals of others) that may contribute to its propagation. Among 364 older adults and 573 of their adult children (total n = 937), self-reported exposure to distinct forms of childhood maltreatment (i.e., emotional, physical, and sexual abuse, and emotional and physical neglect as assessed by the Childhood Trauma Questionnaire) showed homotypic and heterotypic associations across generations with little evidence that latent factors unique to specific forms of maltreatment show generational continuity. General nonspecific indices of childhood maltreatment showed evidence of intergenerational transmission after accounting for demographic factors and parent socioeconomic status (b = 0.126, p = 9.21 × 10-4). This continuity was partially mediated by parental borderline personality pathology (assessed longitudinally through a variety of measures and sources, indirect effect: b = 0.031, 95% confidence interval [0.003, 0.060]). The intergenerational continuity of childhood maltreatment may largely represent general risk for nonspecific maltreatment that may, in part, be propagated by borderline personality pathology and/or shared risk factors.",
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author = "Paul, {Sarah E.} and Boudreaux, {Michael J.} and Erin Bondy and Tackett, {Jennifer L.} and Oltmanns, {Thomas F.} and Ryan Bogdan",
note = "Publisher Copyright: Copyright {\textcopyright} Cambridge University Press 2019.",
doi = "10.1017/S095457941900066X",
journal = "Development and Psychopathology",
publisher = "Cambridge University Press",
Paul, SE, Boudreaux, MJ, Bondy, E, Tackett, JL, Oltmanns, TF & Bogdan, R 2019, 'The intergenerational transmission of childhood maltreatment: Nonspecificity of maltreatment type and associations with borderline personality pathology', Development and psychopathology, vol. 31, no. 3, pp. 1157-1171. https://doi.org/10.1017/S095457941900066X
The intergenerational transmission of childhood maltreatment : Nonspecificity of maltreatment type and associations with borderline personality pathology. / Paul, Sarah E.; Boudreaux, Michael J.; Bondy, Erin et al.
In: Development and psychopathology, Vol. 31, No. 3, 01.08.2019, p. 1157-1171.
T1 - The intergenerational transmission of childhood maltreatment
T2 - Nonspecificity of maltreatment type and associations with borderline personality pathology
AU - Paul, Sarah E.
AU - Boudreaux, Michael J.
AU - Bondy, Erin
AU - Tackett, Jennifer L.
AU - Oltmanns, Thomas F.
AU - Bogdan, Ryan
N1 - Publisher Copyright: Copyright © Cambridge University Press 2019.
N2 - One generation's experience of childhood maltreatment is associated with that of the next. However, whether this intergenerational transmission is specific to distinct forms of maltreatment and what factors may contribute to its continuity remains unclear. Borderline personality pathology is predicted by childhood maltreatment and characterized by features (e.g., dysregulated emotion, relationship instability, impulsivity, and inconsistent appraisals of others) that may contribute to its propagation. Among 364 older adults and 573 of their adult children (total n = 937), self-reported exposure to distinct forms of childhood maltreatment (i.e., emotional, physical, and sexual abuse, and emotional and physical neglect as assessed by the Childhood Trauma Questionnaire) showed homotypic and heterotypic associations across generations with little evidence that latent factors unique to specific forms of maltreatment show generational continuity. General nonspecific indices of childhood maltreatment showed evidence of intergenerational transmission after accounting for demographic factors and parent socioeconomic status (b = 0.126, p = 9.21 × 10-4). This continuity was partially mediated by parental borderline personality pathology (assessed longitudinally through a variety of measures and sources, indirect effect: b = 0.031, 95% confidence interval [0.003, 0.060]). The intergenerational continuity of childhood maltreatment may largely represent general risk for nonspecific maltreatment that may, in part, be propagated by borderline personality pathology and/or shared risk factors.
AB - One generation's experience of childhood maltreatment is associated with that of the next. However, whether this intergenerational transmission is specific to distinct forms of maltreatment and what factors may contribute to its continuity remains unclear. Borderline personality pathology is predicted by childhood maltreatment and characterized by features (e.g., dysregulated emotion, relationship instability, impulsivity, and inconsistent appraisals of others) that may contribute to its propagation. Among 364 older adults and 573 of their adult children (total n = 937), self-reported exposure to distinct forms of childhood maltreatment (i.e., emotional, physical, and sexual abuse, and emotional and physical neglect as assessed by the Childhood Trauma Questionnaire) showed homotypic and heterotypic associations across generations with little evidence that latent factors unique to specific forms of maltreatment show generational continuity. General nonspecific indices of childhood maltreatment showed evidence of intergenerational transmission after accounting for demographic factors and parent socioeconomic status (b = 0.126, p = 9.21 × 10-4). This continuity was partially mediated by parental borderline personality pathology (assessed longitudinally through a variety of measures and sources, indirect effect: b = 0.031, 95% confidence interval [0.003, 0.060]). The intergenerational continuity of childhood maltreatment may largely represent general risk for nonspecific maltreatment that may, in part, be propagated by borderline personality pathology and/or shared risk factors.
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KW - neglect
KW - stress
U2 - 10.1017/S095457941900066X
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JO - Development and Psychopathology
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Paul SE, Boudreaux MJ, Bondy E, Tackett JL, Oltmanns TF, Bogdan R. The intergenerational transmission of childhood maltreatment: Nonspecificity of maltreatment type and associations with borderline personality pathology. Development and psychopathology. 2019 Aug 1;31(3):1157-1171. doi: 10.1017/S095457941900066X