The higher prevalence of autoimmune diseases in women compared to men could be due to effects of ovarian hormones, pregnancy and/or the presence of a 2nd X chromosome. To elucidate the role of these factors, we investigated the prevalence and spectrum of autoimmune diagnoses in women with primary ovarian insufficiency associated with X chromosome monosomy (Turner syndrome, TS, n=244) and women with karyotypically normal (46,XX) primary ovarian insufficiency (POI, n=457) in a prospective study, conducted at the National Institutes of Health. We compared the study group prevalence to normative data for the U.S. population of women. Chronic lymphocytic (Hashimoto’s) thyroiditis (HT) occurred in 37% of women with TS vs. 15% with POI (P<0.0001); HT prevalence in both ovarian insufficiency groups significantly exceeded that in U.S. population of women (5.8%). Inflammatory bowel (IBD, 4%) and celiac disease (CD, 2.7%) were significantly increased in TS, but not in POI. No other autoimmune diagnosis, including Graves’ disease or Type 1 diabetes appears to be significantly increased in either group. Women with TS had higher pro-inflammatory IL6 and TGF β1 levels (p<0.0001 for both), and lower anti-inflammatory IL10 and TGF β2 levels (p<0.005 for both) compared to POI and to normal volunteers. Lifetime estrogen exposure and parity were significantly lower in TS compared to POI, which were in turn lower than the general population of women. The finding that lymphocytic thyroiditis is greatly increased in both women with TS and POI suggests that factors associated with ovarian insufficiency per se promote this form of autoimmunity. The absence of a normal second X-chromosome further contributes to increased autoimmunity in TS.

eIn published studies, cohorts of patients with bacteremia due to vancomycin-resistant Enterococcus (VRE) have predominantly been infected with Enterococcus faecium. Little is known about the epidemiology and outcomes associated with bacteremia due to VR Enterococcus faecalis. A retrospective study of isolates obtained from January 2008 to October 2010 was conducted at Detroit Medical Center (DMC). Unique patients with blood cultures positive for VRE were reviewed. Outcomes were analyzed using logistic regression. During the study period, 105 cases of bacteremia due to VR E. faecalis and 197 cases of bacteremia due to VR E. faecium were identified. The mean age in the study cohort was 61.5 ؎ 15 years; 162 subjects (53.6%) were male. After controlling for a propensity score, bacteremia due to VR E. faecalis was associated with >2-fold-lower in-hospital mortality than bacteremia due to VR E. faecium. Interestingly, bacteremia due to VR E. faecalis was associated with longer hospital stay after VRE isolation, although total length of stay was similar for groups with VR E. faecalis and VR E. faecium. Bacteremia due to VR E. faecalis was associated with a >2-fold-lower risk for mortality than bacteremia due to VR E. faecium, possibly due to the availability of ␤-lactam therapeutics for treatment of VR E. faecalis. Enterococci are the third most common type of health careassociated pathogen in the United States (17). The two most common species responsible for enterococcal infections in humans are Enterococcus faecalis and Enterococcus faecium. Enterococci are inherently resistant to several antimicrobials and also have an ability to acquire mobile genetic resistance determinants (22). The emergence of resistance to various antimicrobial agents, specifically to vancomycin, has become a major clinical and epidemiological threat. Vancomycin-resistant Enterococcus (VRE) infections are associated with increased morbidity, mortality, and costs compared to vancomycin-susceptible enterococcal infections (3).VRE infections impose a huge burden on facilities in metropolitan Detroit. At Detroit Medical Center (DMC) in 2009, 530 of 4,377 (12.1%) isolates of E. faecalis and 846 of 1,150 (73.6%) isolates of E. faecium were VRE (16). Both the proportion of total VREs accounted for by VR E. faecalis and the total absolute number of unique clinical isolates of VR E. faecalis increased significantly from 2003 to 2009 (16). The prevalence of VR E. faecalis at DMC is much higher than in other regions in North America and worldwide. According to National Healthcare Safety Network (NHSN) data, 6.9% of E. faecalis isolates reported in 2006 and 2007 were VRE, compared to over 12% of E. faecalis isolates reported at DMC (17).Past studies of the epidemiology and outcomes associated with VRE infections were conducted with cohorts consisting predominantly of E. faecium, and relatively little is known about the epidemiology of vancomycin-resistant E. faecalis (5). Only a few studies with small sample sizes have compared the epidemiology of infec...

Introduction: Despite the increasing use of permanent cardiac pacemakers in a younger patient population, there are little data related to pregnancy. We present our experience in managing a pregnant patient with a pre-existing pacemaker and review the existing literature to establish management guidelines. Case: A 27-year-old G1 P0 presented for prenatal care in the first trimester of pregnancy. She had a past medical history of bradycardia, hypotension and syncope that required dual chamber cardiac pacemaker placement 6 years earlier, and one episode of left upper extremity venous thrombosis related to replacement of the pacemaker wire 4 years earlier. In the early second trimester, the patient began experiencing light-headedness and breathlessness with exertion. The rate settings of the pacemaker were increased with resolution of the patient's symptoms. The patient underwent primary cesarean section at 39 weeks gestation with delivery of a healthy term infant. Preoperative anesthesia consultation was obtained. The postoperative course was uneventful. Pre-pregnancy pacemaker settings were re-established after the postpartum period. Discussion: The current literature on managing pregnant patients with pre-existing pacemakers is quite limited. Such patients require a multidisciplinary approach to care. Normal physiologic changes in pregnancy may necessitate rate adjustments. Other than routine thromboprophylaxis, no other anticoagulation is needed. Route of delivery is generally based on obstetric indications. During surgery consider using bipolar electrocautery in place of unipolar electrocautery, to reduce electromagnetic interference. Also, the placement of the grounding pad should be as far away from the pacemaker as possible. It should be anticipated that the patient will return to her baseline cardiac status postpartum and therefore pacemaker settings can be adjusted accordingly.