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Background: Reflectance confocal microscopy (RCM) is a noninvasive technique that provides real-time in vivo images of the epidermal layer. Imiquimod has been recommended as an alternative treatment in lentigo maligna (LM) when surgical excision is not the treatment of choice. In the present study we compare the results of in vivo RCM to the histopathological examination before and after treatment of LM with topical imiquimod.Methods: Thirty-four patients with confirmed LM were included. Imiquimod 5% was applied until a weeping erosion appeared in the LM-affected skin. Evaluation was performed by clinical examination, dermatoscopy, histopathology and RCM.Results: During the follow-up, 27 of 34 patients (79.42%) demonstrated a total tumor clearance by imiquimod treatment. In the treated area, a significant decrease of atypical cells was detected using RCM (p < 0.0001). Furthermore, a significant positive correlation in the detected atypical cells was shown using confocal microscopy and histology (p = 0.0001, r = 0.7335, respectively).Conclusion: In patients not suitable for surgical intervention imiquimod treatment is an appropriate treatment alternative. Thereby, in vivo RCM was demonstrated to be an excellent examining device, which not only allows diagnosis of LM, but also therapy and follow-up examinations. An important benefit of RCM, in contrast to conventional histopathology, is the simple handling with in vivo examination of epidermal skin without any pain for the patient. [ABSTRACT FROM AUTHOR]

Abstract Spatially explicit simulations of gene flow within complex landscapes could help forecast the responses of populations to global and anthropological changes. Simulating how past climate change shaped intraspecific genetic variation can provide a validation of models in anticipation of their use to predict future changes. We review simulation models that provide inferences on population genetic structure. Existing simulation models generally integrate complex demographic and genetic processes but are less focused on the landscape dynamics. In contrast to previous approaches integrating detailed demographic and genetic processes and only secondarily landscape dynamics, we present a model based on parsimonious biological mechanisms combining habitat suitability and cellular processes, applicable to complex landscapes. The simulation model takes as input (a) the species dispersal capacities as the main biological parameter, (b) the species habitat suitability, and (c) the landscape structure, modulating dispersal. Our model emphasizes the role of landscape features and their temporal dynamics in generating genetic differentiation among populations within species. We illustrate our model on caribou/reindeer populations sampled across the entire species distribution range in the Northern Hemisphere. We show that simulations over the past 21 kyr predict a population genetic structure that matches empirical data. This approach looking at the impact of historical landscape dynamics on intraspecific structure can be used to forecast population structure under climate change scenarios and evaluate how species range shifts might induce erosion of genetic variation within species.

Digital twin technology is a virtual depiction of a physical product and has been utilized in many fields. Digital twin patient model in healthcare is a virtual patient that provides opportunities to test the outcomes of various interventions virtually without subjecting an actual patient to possible harm. This can serve as a decision aid in the complex environment of the intensive care unit (ICU). Our objective is to develop consensus among a multidisciplinary expert panel on statements regarding respiratory pathophysiology contributing to respiratory failure in the medical ICU. We convened a panel of 34 international critical care experts. Our group modeled elements of respiratory failure pathophysiology using directed acyclic graphs (DAGs) and derived expert statements describing associated ICU clinical practices. The experts participated in three rounds of modified Delphi to gauge agreement on 78 final questions (13 statements with 6 substatements for each) using a Likert scale. A modified Delphi process achieved agreement for 62 of the final expert rule statements. Statements with the highest degree of agreement included the physiology, and management of airway obstruction decreasing alveolar ventilation and ventilation-perfusion matching. The lowest agreement statements involved the relationship between shock and hypoxemic respiratory failure due to heightened oxygen consumption and dead space. Our study proves the utility of a modified Delphi method to generate consensus to create expert rule statements for further development of a digital twin-patient model with acute respiratory failure. A substantial majority of expert rule statements used in the digital twin design align with expert knowledge of respiratory failure in critically ill patients.

Introduction: Reported cases of inferior dislocation in the literature are found under several names (inferior, anteroinferior, obturator, or erecta), which may be source of confusion. The purpose of this comprehensive review of the literature is to collect as many cases of inferior dislocation as possible to determine better therapeutic strategies, outcome after reduction, complications, and prognostic factors., Methods: In April 2020, a literature search was performed in Pubmed, Medline, Scopus, Cochrane, and Embase databases. The MeSH keywords were "OBTURATOR DISLOCATION HIP" or "ANTERIOR DISLOCATION HIP" or "INFERIOR DISLOCATION HIP." Authors independently selected articles that met the selection criteria, with no time limit., Results: Out of the 97 articles selected, there were 119 cases of primary inferior hip dislocations. This review of the literature has allowed us to differentiate 3 radiographic subtypes of inferior dislocations, which correspond to 3 different anatomical positions of the femoral head: "obturator" dislocation, "proximal anterior-inferior" dislocation, and "distal anterior-inferior" dislocation. Our subtype classification yielded 39 obturator subtype inferior dislocations (32.8%), 66 proximal anteroinferior subtypes (55.4%), and 14 distal anteroinferior (11.8%). The obturator subtype is at risk of reduction failure and femoral neck fracture during the reduction manoeuver., Conclusions: Our study identified 3 subtypes with different prognosis, with obturator and distal anteroinferior dislocations having a poorer prognosis because of their pre- and post-reduction complications. We were unable to determine the correct manoeuver to reduce inferior dislocations without taking the risk of femoral neck fracture, but each of these subtypes may require a different manoeuver., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Shotgun and targeted metagenomic sequencing have been shown in separate studies to be potentially useful for culture-free pathogen identification in blood and/or plasma of patients with infective endocarditis (IE). However, the 2 approaches have not been directly compared. The aim of this study was to compare shotgun metagenomic sequencing with targeted metagenomic sequencing (tMGS) for organism identification in blood or plasma of patients with IE., Methods: Patients with possible or definite IE were prospectively enrolled from October 2020 to July 2021. Shotgun metagenomic sequencing was performed with the Karius test, which uses microbial cell-free DNA (mcfDNA) sequencing to detect, identify, and quantitate DNA-based pathogens in plasma. tMGS was performed using a 16S ribosomal RNA (rRNA) polymerase chain reaction assay targeting the V1 to V3 regions of the 16S rRNA gene. Results were compared using the McNemar test of paired proportions., Results: Samples from 34 patients were investigated. The Karius test was positive in 24/34 (71%), including 3/6 (50%) with blood culture-negative endocarditis (BCNE), which was not significantly different from the positivity rate of tMGS ( P = .41). Results of the Karius test were concordant with tMGS in 75% of cases. The Karius test detected 2 cases of methicillin-resistant Staphylococcus aureus among the 7 S. aureus detections, in accordance with results of phenotypic susceptibility testing. The combination of blood cultures, the Karius test, and tMGS found a potential causative pathogen in 33/34 (97%), including 5/6 with BCNE., Conclusions: The Karius test and tMGS yielded comparable detection rates; however, beyond organism identification, the Karius test generated potentially useful antibiotic resistance data., Competing Interests: Potential conflicts of interest. L.F., C.R.F., and M.W. have no conflicts of interest. R.P. reports grants from ContraFect, TenNor Therapeutics Limited, and BioFire. R.P. is a consultant to Curetis, Specific Technologies, Next Gen Diagnostics, PathoQuest, Selux Diagnostics, 1928 Diagnostics, PhAST, Torus Biosystems, Day Zero Diagnostics, Mammoth Biosciences, and Qvella; monies are paid to Mayo Clinic. Mayo Clinic and Dr. Patel have relationships with Adaptive Phage Therapeutics and Pathogenomix. R.P. is also a consultant to Netflix and CARB-X. In addition, R.P. has a patent on Bordetella pertussis/parapertussis PCR issued, a patent on a device/method for sonication with royalties paid by Samsung to Mayo Clinic, and a patent on an antibiofilm substance issued. R.P. receives honoraria from the NBME, Up-to-Date, and the Infectious Diseases Board Review Course. All other authors report no potential conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Sequencing is increasingly used for infective endocarditis (IE) diagnosis. Here, the performance of 16S rRNA gene PCR/sequencing of heart valves utilized in routine clinical practice was compared with conventional IE diagnostics. Subjects whose heart valves were sent to the clinical microbiology laboratory for 16S rRNA gene PCR/sequencing from August 2020 through February 2022 were studied. A PCR assay targeting V1 to V3 regions of the 16S rRNA gene was performed, followed by Sanger and/or next-generation sequencing (NGS) (using an Illumina MiSeq), or reported as negative, depending on an algorithm that included the PCR cycle threshold value. Fifty-four subjects, including 40 with IE, three with cured IE, and 11 with noninfective valvular disease, were studied. Thirty-one positive results, 11 from NGS and 20 from Sanger sequencing, were generated from analysis of 16S rRNA gene sequence(s). Positivity rates of blood cultures and 16S rRNA gene PCR/sequencing of valves were 55% and 75%, respectively ( P  = 0.06). In those with prior antibiotic exposure, positivity rates of blood cultures and 16S rRNA gene PCR/sequencing of valves were 11% and 76%, respectively ( P < 0.001). Overall, 61% of blood culture-negative IE subjects had positive valve 16S rRNA gene PCR/sequencing results. 16S rRNA gene-based PCR/sequencing of heart valves is a useful diagnostic tool for pathogen identification in patients with blood culture-negative IE undergoing valve surgery in routine clinical practice., Competing Interests: The authors declare no conflict of interest.

Abstract: Objective: To identify and describe characteristics of patients with sepsis who could be treated with minimally invasive sepsis (MIS) approach without intensive care unit (ICU) admission and to develop a prediction model to select candidates for MIS approach. Methods: A secondary analysis of the electronic database of patients with sepsis at Mayo Clinic, Rochester, MN. Candidates for the MIS approach were adults with septic shock and less than 48 hours of ICU stay, who did not require advanced respiratory support and were alive at hospital discharge. Comparison group consisted of septic shock patients with an ICU stay of more than 48 hours without advanced respiratory support at the time of ICU admission. Results: Of 1795 medical ICU admissions, 106 patients (6%) met MIS approach criteria. Predictive variables (age >65 years, oxygen flow >4 L/min, temperature <37°C, creatinine >1.6 mg/dL, lactate >3 mmol/L, white blood cells >15 × 10 9 /L, heart rate >100 beats/min, and respiration rate >25 breaths/min) selected through logistic regression were translated into an 8-point score. Model discrimination yielded the area under the receiver operating characteristic curve of 79% and was well fitted (Hosmer-Lemeshow P = 0.94) and calibrated. The MIS score cutoff of 3 resulted in a model odds ratio of 0.15 (95% confidence interval, 0.08-0.28) and a negative predictive value of 91% (95% confidence interval, 88.69-92.92). Conclusions: This study identifies a subset of low-risk septic shock patients who can potentially be managed outside the ICU. Once validated in an independent, prospective sample our prediction model can be used to identify candidates for MIS approach., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Shock Society.)

Introduction: Digital twins, a form of artificial intelligence, are virtual representations of the physical world. In the past 20 years, digital twins have been utilized to track wind turbines' operations, monitor spacecraft's status, and even create a model of the Earth for climate research. While digital twins hold much promise for the neurocritical care unit, the question remains on how to best establish the rules that govern these models. This model will expand on our group's existing digital twin model for the treatment of sepsis., Methods: The authors of this project collaborated to create a Direct Acyclic Graph (DAG) and an initial series of 20 DELPHI statements, each with six accompanying sub-statements that captured the pathophysiology surrounding the management of acute ischemic strokes in the practice of Neurocritical Care (NCC). Agreement from a panel of 18 experts in the field of NCC was collected through a 7-point Likert scale with consensus defined a-priori by ≥ 80% selection of a 6 ("agree") or 7 ("strongly agree"). The endpoint of the study was defined as the completion of three separate rounds of DELPHI consensus. DELPHI statements that had met consensus would not be included in subsequent rounds of DELPHI consensus. The authors refined DELPHI statements that did not reach consensus with the guidance of de-identified expert comments for subsequent rounds of DELPHI. All DELPHI statements that reached consensus by the end of three rounds of DELPHI consensus would go on to be used to inform the construction of the digital twin model., Results: After the completion of three rounds of DELPHI, 93 (77.5%) statements reached consensus, 11 (9.2%) statements were excluded, and 16 (13.3%) statements did not reach a consensus of the original 120 DELPHI statements., Conclusion: This descriptive study demonstrates the use of the DELPHI process to generate consensus among experts and establish a set of rules for the development of a digital twin model for use in the neurologic ICU. Compared to associative models of AI, which develop rules based on finding associations in datasets, digital twin AI created by the DELPHI process are easily interpretable models based on a current understanding of underlying physiology., (© 2023. The Author(s).)

Background: Next-generation sequencing (NGS) is increasingly used for periprosthetic joint infection (PJI) diagnosis, but its clinical utility is poorly defined. Shotgun metagenomic sequencing (sNGS) has been reported to identify PJI pathogens undetected by culture in sonicate fluid. However, sNGS is complex and costly. Here, 16S ribosomal RNA (rRNA) gene-based targeted metagenomic sequencing (tNGS) was compared to sNGS of sonicate fluid for microbial detection and identification in patients with total hip arthroplasty (THA) and total knee arthroplasty (TKA) failure., Methods: A convenience sample of sonicate fluids derived from patients who had undergone THA or TKA removal, enriched with culture negative PJI cases, was tested. Samples had been previously tested by sNGS. For tNGS, samples were extracted, amplified by polymerase chain reaction targeting the V1 to V3 regions of the 16S rRNA gene, and sequenced on an Illumina MiSeq., Results: A total of 395 sonicate fluids, including 208 from subjects with PJI, were studied. Compared with sonicate fluid culture, tNGS had higher positive percent agreement (72.1 vs 52.9%, P < .001), detecting potential pathogens in 48.0% of culture-negative PJIs. There was no difference between the positive percent agreement of tNGS (72.1%) and sNGS (73.1%, P = .83)., Conclusions: 16S rRNA gene-based tNGS is a potential diagnostic tool for PJI pathogen identification in sonicate fluid from failed THAs and TKAs in culture-negative cases, with similar performance characteristics to sNGS., Competing Interests: Potential conflicts of interest. R. P. reports grants from ContraFect, TenNor Therapeutics Limited, and BioFire. R. P. is a consultant to Curetis, Next Gen Diagnostics, PathoQuest, Selux Diagnostics, 1928 Diagnostics, PhAST, Torus Biosystems, Day Zero Diagnostics, Mammoth Biosciences, and Qvella; monies are paid to Mayo Clinic. Mayo Clinic and R. P. have a relationship with Pathogenomix. R. P. is a consultant to Specific Technologies. R. P. has research supported by Adaptive Phage Therapeutics. Mayo Clinic has a royalty-bearing know-how agreement and equity in Adaptive Phage Therapeutics. R. P. is also a consultant to Netflix and CARB-X. In addition, R. P. has a patent on Bordetella pertussis/parapertussis PCR issued, a patent on a device/method for sonication with royalties paid by Samsung to Mayo Clinic, and a patent on an anti-biofilm substance issued. R. P. receives honoraria from the NBME, Up-to-Date and the Infectious Diseases Board Review Course. M. A. reports royalties related to hip and knee implants from Stryker and a leadership or fiduciary role on the AAOS Board of Directors. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The activity of a hypochlorous acid-producing electrochemical bandage (e-bandage) in preventing methicillin-resistant Staphylococcus aureus infection (MRSA) infection and removing biofilms formed by MRSA was assessed using a porcine explant biofilm model. e-Bandages inhibited S. aureus infection (p = 0.029) after 12 h (h) of exposure and reduced 3-day biofilm viable cell counts after 6, 12, and 24 h exposures (p = 0.029). Needle-type microelectrodes were used to assess HOCl concentrations in explant tissue as a result of e-bandage treatment; toxicity associated with e-bandage treatment was evaluated. HOCl concentrations in infected and uninfected explant tissue varied between 30 and 80 µM, decreasing with increasing distance from the e-bandage. Eukaryotic cell viability was reduced by an average of 71% and 65% in fresh and day 3-old explants, respectively, when compared to explants exposed to nonpolarized e-bandages. HOCl e-bandages are a promising technology that can be further developed as an antibiotic-free treatment for wound biofilm infections., (© 2022 The Authors. Biotechnology and Bioengineering published by Wiley Periodicals LLC.)

Chronic wound biofilm infections represent a major clinical challenge which results in a substantial burden to patients and healthcare systems. Treatment with topical antibiotics is oftentimes ineffective as a result of antibiotic-resistant microorganisms and biofilm-specific antibiotic tolerance. Use of biocides such as hypochlorous acid (HOCl) has gained increasing attention due to the lack of known resistance mechanisms. We designed an HOCl-generating electrochemical bandage (e-bandage) that delivers HOCl continuously at low concentrations targeting infected wound beds in a similar manner to adhesive antimicrobial wound dressings. We developed a battery-operated wearable potentiostat that controls the e-bandage electrodes at potentials suitable for HOCl generation. We demonstrated that e-bandage treatment was tunable by changing the applied potential. HOCl generation on electrode surfaces was verified using microelectrodes. The developed e-bandage showed time-dependent responses against in vitro Acinetobacter baumannii and Staphylococcus aureus biofilms, reducing viable cells to non-detectable levels within 6 and 12 hours of treatment, respectively. The developed e-bandage should be further evaluated as an alternative to topical antibiotics to treat wound biofilm infections., Competing Interests: Conflict of Interests Dr. Patel reports grants from ContraFect, TenNor Therapeutics Limited, and BioFire. Dr. Patel is a consultant to PhAST, Torus Biosystems, Day Zero Diagnostics, Mammoth Biosciences, and HealthTrackRx; monies are paid to Mayo Clinic. Mayo Clinic and Dr. Patel have a relationship with Pathogenomix. Dr. Patel has research supported by Adaptive Phage Therapeutics. Mayo Clinic has a royalty-bearing know-how agreement and equity in Adaptive Phage Therapeutics. Dr. Patel is also a consultant to Netflix, Abbott Laboratories, and CARB-X. In addition, Dr. Patel has a patent on Bordetella pertussis/parapertussis PCR issued, a patent on a device/method for sonication with royalties paid by Samsung to Mayo Clinic, and a patent on an anti-biofilm substance issued. Dr. Patel receives honoraria from the NBME, Up-to-Date and the Infectious Diseases Board Review Course.

Preoperative pathogen identification in patients with periprosthetic joint infection (PJI) is typically limited to synovial fluid culture. Whether sequencing-based approaches are of potential use in identification of pathogens in PJI, and if so which approach is ideal, is incompletely defined. The objective of the study was to analyze the accuracy of a 16S rRNA (rRNA) gene-based PCR followed by Sanger sequencing and/or targeted metagenomic sequencing approach (tMGS) performed on synovial fluid for PJI diagnosis. A retrospective study was conducted, analyzing synovial fluids tested between August 2020 and May 2021 at a single center. Subjects with hip, knee, shoulder, and elbow arthroplasties who had synovial fluid aspirated and clinically subjected to sequence-based testing and conventional culture were studied. A total of 154 subjects were included in the study; 118 had noninfectious arthroplasty failure (NIAF), while 36 had PJI. Clinical sensitivity and specificity for diagnosis of PJI were 69% and 100%, respectively, for the sequencing-based approach and 72% and 100%, respectively, for conventional culture ( P  = 0.74). The combination of both tests was more sensitive (83%) than culture alone ( P  = 0.04). Results of sequencing-based testing led to changes in treatment in four of 36 (11%) PJI subjects. Microbial identification was achieved using Sanger and next generation sequencing in 19 and 6 subjects, respectively. When combined with culture, the described 16S rRNA gene sequencing-based approach increased sensitivity compared to culture alone, suggesting its potential use in the diagnosis of PJI when synovial fluid culture is negative. IMPORTANCE Periprosthetic joint infection (PJI) is a dreadful complication of joint replacement. Noninvasive identification of infectious pathogens has been traditionnally limited to culture-based testing of synovial fluid which has poor sensitivity. Sanger and Next-generation sequencing (NGS) may be used for synovial fluid testing in PJI, but experience in routine practice is sparse. We used a targeted metagenomic sequencing approach for routine testing of synovial fluid involving NGS when Sanger sequencing had failed or was likely to fail. The objective of this study was to analyze the approach's performance for diagnosis of PJI in comparison to culture for testing synovial fluid. Overall, the sequencing-based approach was not superior to culture for diagnosis of PJI, but yielded positive results in some culture-negative samples.

Previously, an electrochemical bandage (e-bandage) that uses a three-electrode system to produce hydrogen peroxide (H 2 O 2 ) electrochemically on its working electrode was developed as a potential strategy for treating biofilms; it showed activity in reducing biofilms in an agar biofilm model. Xanthan gum-based hydrogel, including NaCl, was used as the electrolyte. While H 2 O 2 generated at the working electrode in the vicinity of a biofilm is a main mechanism of activity, the role of the counter electrode was not explored. The goal of this research was to characterize electrochemical reactions occurring on the counter electrode of the e-bandage. Counter electrode potential varied between 1.2 and 1.5 V Ag/AgCl ; ∼125 µM hypochlorous acid (HOCl) was generated within 24 h in the e-bandage system. When HOCl was not produced on the counter electrode (achieved by removing NaCl from the hydrogel), reduction of Acinetobacter baumannii BAA-1605 biofilm was 1.08 ± 0.38 log 10 CFU/cm 2 after 24 h treatment, whereas when HOCl was produced, reduction was 3.87 ± 1.44 log 10 CFU/cm 2 . HOCl inhibited catalase activity, abrogating H 2 O 2 decomposition. In addition to H 2 O 2 generation, the previously described H 2 O 2 -generating e-bandage generates HOCl on the counter electrode, enhancing its biocidal activity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Aims: Effects of H 2 O 2 producing electrochemical-bandages (e-bandages) on methicillin-resistant Staphylococcus aureus colonization and biofilm removal were assessed using a porcine explant biofilm model. Transport of H 2 O 2 produced from the e-bandage into explant tissue and associated potential toxicity were evaluated., Methods and Results: Viable prokaryotic cells from infected explants were quantified after 48 h treatment with e-bandages in three ex vivo S. aureus infection models: (1) reducing colonization, (2) removing young biofilms and (3) removing mature biofilms. H 2 O 2 concentration-depth profiles in explants/biofilms were measured using microelectrodes. Reductions in eukaryotic cell viability of polarized and nonpolarized noninfected explants were compared. e-Bandages effectively reduced S. aureus colonization (p = 0.029) and reduced the viable prokaryotic cell concentrations of young biofilms (p = 0.029) with limited effects on mature biofilms (p > 0.1). H 2 O 2 penetrated biofilms and explants and reduced eukaryotic cell viability by 32-44% compared to nonpolarized explants., Conclusions: H 2 O 2 producing e-bandages were most active when used to reduce colonization and remove young biofilms rather than to remove mature biofilms., Significance and Impact of Study: The described e-bandages reduced S. aureus colonization and young S. aureus biofilms in a porcine explant wound model, supporting their further development as an antibiotic-free alternative for managing biofilm infections., (© 2022 The Authors. Journal of Applied Microbiology published by John Wiley & Sons Ltd on behalf of Society for Applied Microbiology.)

Background: The yield of next-generation sequencing (NGS) added to a Sanger sequencing-based 16S ribosomal RNA (rRNA) gene polymerase chain reaction (PCR) assay was evaluated in clinical practice for diagnosis of bacterial infection., Methods: PCR targeting the V1 to V3 regions of the 16S rRNA gene was performed, with amplified DNA submitted to Sanger sequencing and/or NGS (Illumina MiSeq) or reported as negative, depending on the cycle threshold value. A total of 2146 normally sterile tissues or body fluids were tested between August 2020 and March 2021. Clinical sensitivity was assessed in 579 patients from whom clinical data were available., Results: Compared with Sanger sequencing alone (400 positive tests), positivity increased by 87% by adding NGS (347 added positive tests). Clinical sensitivity of the assay that incorporated NGS was 53%, which was higher than culture (42%, P < .001), with an impact on clinical decision-making in 14% of infected cases. Clinical sensitivity in the subgroup that received antibiotics at sampling was 41% for culture and 63% for the sequencing assay (P < .001)., Conclusions: Adding NGS to Sanger sequencing of the PCR-amplified 16S rRNA gene substantially improved test positivity. In the patient population studied, the assay was more sensitive than culture, especially in patients who had received antibiotic therapy., Competing Interests: Potential conflicts of interest. R.P. reports grants from ContraFect, TenNor Therapeutics Limited, and BioFire; is a consultant to Curetis, Specific Technologies, Next Gen Diagnostics, PathoQuest, Selux Diagnostics, 1928 Diagnostics, PhAST, Torus Biosystems, Day Zero Diagnostics, Mammoth Biosciences, and Qvella; monies are paid to Mayo Clinic. Mayo Clinic and R.P. have relationships with Adaptive Phage Therapeutics and Pathogenomix. R.P. is a consultant to Netflix and CARB-X; has a patent on Bordetella pertussis/parapertussis polymerase chain reaction issued, a patent on a device/method for sonication with royalties paid by Samsung to Mayo Clinic, and a patent on an antibiofilm substance issued; receives honoraria from the National Board of Medical Examiners, Up-to-Date, and the Infectious Diseases Board Review Course; reports being Chair, ASM Governance Committee and Member, Finance Committee (ASM); and reports an editor’s stipend from the Infectious Diseases Society of America. N.W. reports royalties or licenses from Roche Diagnostics; and a leadership or fiduciary role for Clinical and Laboratory Standards Institute working groups and document development committees. All authors are employees of Mayo Clinic. M.W. reports having a relationship with Pathogenomix through Mayo Clinic. All remaining authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Initial microbiologic diagnosis of infective endocarditis (IE) relies on blood cultures and Bartonella and Coxiella burnetii serology. Small case series and one prospective study have preliminarily reported application of metagenomic sequencing on blood or plasma for IE diagnosis. Here, results of a prospective pilot study evaluating targeted metagenomic sequencing (tMGS) for blood-based early pathogen detection and identification in IE are reported. Subjects diagnosed with possible or definite IE at a single institution were prospectively enrolled with informed consent from October 2020 to July 2021. Blood was drawn and separated into whole blood and plasma. Both specimen types were subjected to nucleic acid extraction and PCR targeting the V1-V3 region of the 16S ribosomal RNA gene, followed by next-generation sequencing on an Illumina MiSeqTM platform. 35 subjects, 28 (80%) with definite and 7 (20%) with possible IE were enrolled, including 6 (17%) with blood culture-negative endocarditis (BCNE). Overall, 20 whole blood (59%) and 16 plasma (47%) samples tested positive ( P  = 0.47). When results of whole blood and plasma testing were combined, a positive tMGS result was found in 23 subjects (66%). tMGS identified a potential pathogen in 5 of 6 culture-negative IE cases. Although further study is needed, the results of this pilot study suggest that blood-based tMGS may provide pathogen identification in subjects with IE, including in culture-negative cases.

To date, no study has described the microbiological profile of surgical site infections (SSIs) after spine surgery in a tropical environment. The main objective of this study is to describe the microbiology and the risk factors of SSI after spinal surgery in a tropical climate. Our hypothesis is that the microbiology of SSIs in tropical areas is different to what is mainly described in temperate countries. As a consequence, the recommendation for antibiotic prophylaxis administered in the operative room, which mainly relays on the literature, might not be adequate in such countries. We included 323 consecutive patients who underwent a spinal intervention between 2017 and 2019, with a 2-year minimum follow-up. Objective ISO criteria were established in accordance with the criteria accepted by the Center of Disease Control in Atlanta. The identification of risk factors for SSI was carried out by uni- and multivariate analysis with a significance threshold of P < 0.05. The incidence of SSI was 7.7%. A total of 54.8% were in favor of a predominantly digestive origin of germs with an average of 1.68 bacteria found by ISO. Inadequate antibiotic prophylaxis was found in 54.8%. Age and body mass index were found to be independent risk factors for SSI. We report here an unusual microbiological profile of SSI with a predominance of gram-negative bacteria and a low proportion of Staphylococcus aureus and Staphylococcus epidermidis.

Summary Statement: The Checklist for Early Recognition and Treatment of Acute Illness and iNjury program is a well-established, interactive, and simulation-based program designed to improve the quality of care delivered in intensive care units. The COVID-19 pandemic created an overwhelming surge of critically ill patients worldwide, and infection control concerns limited healthcare providers' access to in-person and hands-on simulation training when they needed it the most. Virtual simulation offers an alternative to in-person training but is often complex and expensive. We describe our successful development and initial implementation of an inexpensive, simulation-based virtual Checklist for Early Recognition and Treatment of Acute Illness and iNjury program to address the pressing need for effective critical care training in various resource-limited settings both within and outside of the United States. The overall satisfaction rate ("excellent" or "very good" responses) was 94.4% after the virtual simulation workshop. Our initial experience suggests that virtual interactions can be engaging and build strong relationships, like in-person continuing professional education, even using relatively simple technology. This knowledge-to-practice improvement platform can be readily adapted to other disciplines beyond critical care medicine., Competing Interests: Y.D. received remote simulation research grant from Mayo Clinic. O.G. has financial conflict of interest with CERTAIN software platforms licensed to Ambient Clinical Analytics. O.G. also received an education grant from the World Health Organization Office in Sarajevo, Bosnia and Herzegovina. R.K. receives funding from the National Institutes of Health/National Heart, Lung and Blood Institute (R01HL 130881, UG3/UH3HL 141722), Gordon and Betty Moore Foundation, and Janssen Research & Development, LLC; and royalties from Ambient Clinical Analytics, Inc. They had no influence on acquisition, analysis, interpretation, and reporting of pooled data for this article. The other authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society for Simulation in Healthcare.)

Central line-associated bloodstream infection (CLABSI) contributes to mortality and cost. While aseptic dressings and antibiotic-impregnated catheters prevent some extraluminal infections, intraluminal infections remain a source of CLABSIs. In this proof-of-concept study, an electrochemical intravascular catheter (e-catheter) prototype capable of electrochemically generating hypochlorous acid intraluminally using platinum electrodes polarized at a constant potential of 1.5 electrode potential relative to saturated silver/silver chloride reference electrode measured in volts (V Ag/AgCl ) was developed. After 24 h of prepolarization at 1.5 V Ag/AgCl , their activity was tested against clinical isolates of Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecium, and Escherichia coli derived from catheter-related infections. e-catheters generated a mean HOCl concentration of 15.86 ± 4.03 μM and had a mean pH of 6.14 ± 0.79. E-catheters prevented infections of all four species, with an average reduction of 8.41 ± 0.61 log 10 CFU/ml at 48 h compared to controls. Polarized e-catheters which generate low amounts of HOCl continuously should be further developed to prevent intraluminal infection. IMPORTANCE Catheter-related infections constitute an economic and mortality burden in health care. Several options are available to reduce the risk of infection, but only a few focus on preventing intraluminal infection, which occurs in long-term catheters, most often used for dialysis, prolonged treatment, or chemotherapy. A prototype of a catheter called an "e-catheter" composed of three electrodes, capable of producing hypochlorous acid (HOCl) electrochemically in its lumen, was developed. When polarized at 1.5 V, chloride ions in the solution are oxidized to continuously produce low amounts of HOCl, which exhibits antibacterial activity in the lumen of the catheter. Here, this prototype was shown to be able to generate HOCl as well as prevent infection in a preliminary in vitro catheter model. This approach is a potential strategy for catheter infection prevention.

16S ribosomal RNA (rRNA) gene PCR followed by next-generation sequencing (NGS) was compared to culture of sonicate fluid derived from total elbow arthroplasty for periprosthetic joint infection (PJI) diagnosis. Sonicate fluids collected from 2007 to 2019 from patients who underwent revision of a total elbow arthroplasty were retrospectively analyzed at a single institution. PCR amplification of the V1-V3 region of the 16S rRNA gene was performed, followed by NGS using an Illumina MiSeq. Results were compared to those of sonicate fluid culture using McNemar's test of paired proportions. Forty-seven periprosthetic joint infections and 58 non-infectious arthroplasty failures were studied. Sensitivity of targeted NGS was 85%, compared to 77% for culture (P = 0.045). Specificity and positive and negative predictive values of targeted NGS were 98, 98 and 89%, respectively, compared to 100, 100 and 84%, respectively, for culture. 16S rRNA gene-based targeted metagenomic analysis of sonicate fluid was more sensitive than culture., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Biofilms formed by antibiotic-resistant bacteria in wound beds present unique challenges in terms of treating chronic wound infections; biofilms formed by one or more than one bacterial species are often involved. In this work, the in vitro anti-biofilm activity of a novel electrochemical bandage (e-bandage) composed of carbon fabric and controlled by a wearable potentiostat, designed to continuously deliver low amounts of hydrogen peroxide (H 2 O 2 ) was evaluated against 34 mono-species and 12 dual-species membrane bacterial biofilms formed by Staphylococcus aureus , S. epidermidis , Enterococcus faecium , E. faecalis , Streptococcus mutans , Escherichia coli , Pseudomonas aeruginosa , Acinetobacter baumannii , Klebsiella pneumoniae , Cutibacterium acnes , and Bacteroides fragilis . Biofilms were grown on polycarbonate membranes placed atop agar plates. An e-bandage, which electrochemically reduces dissolved oxygen to H 2 O 2 when polarized at -0.6 V Ag/AgCl , was then placed atop each membrane biofilm and polarized continuously for 12, 24, and 48 h using a wearable potentiostat. Time-dependent decreases in viable CFU counts of all mono- and dual-species biofilms were observed after e-bandage treatment. 48 h of e-bandage treatment resulted in an average reduction of 8.17 ± 0.40 and 7.99 ± 0.32 log 10  CFU/cm 2 for mono- and dual-species biofilms, respectively. Results suggest that the described H 2 O 2 producing e-bandage can reduce in vitro viable cell counts of biofilms grown either in mono- or dual-species forms, and should be further developed as a potential antibiotic-free treatment strategy for treating chronic wound infections., Competing Interests: This research was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under the grant number R01 AI091594. The authors would like to thank Henry Chambers III (University of California, San Francisco) for providing S. aureus USA100, USA200, and USA300; Caliper Life Sciences for providing S. aureus Xen 30, S. epidermidis Xen 43, and P. aeruginosa Xen 5; Daniel Hassett (University of Cincinnati) for providing P. aeruginosa PAO1, PA14, and PA14 Δkat AB; and the Antibacterial Resistance Leadership Group (supported by a grant from the National Institutes of Health through Duke University) for providing A. baumannii ARLG-1268. R.P. reports grants from CD Diagnostics, Merck, Hutchison Biofilm Medical Solutions, Accelerate Diagnostics, ContraFect, TenNor Therapeutics Limited, and Shionogi. R.P. is a consultant for Curetis, Specific Technologies, Next Gen Diagnostics, PathoQuest, Selux Diagnostics, 1928 Diagnostics, and Qvella; monies are paid to Mayo Clinic. In addition, R.P. has patents on Bordetella pertussis/parapertussis PCR, a device/method for sonication with royalties paid by Samsung to Mayo Clinic, and an antibiofilm substance. R.P. receives travel reimbursement from ASM and IDSA, an editor's stipend from IDSA, and honoraria from the NBME, Up-to-Date, and the Infectious Diseases Board Review Course. H.B. holds a patent (US20180207301A1), “Electrochemical reduction or prevention of infections,” which refers to the electrochemical scaffold described herein., (© 2021 The Authors.)

Background: Choosing the right size of the stem is crucial for uncemented hip arthroplasty. Undersizing can lead to early loosening, peri-prosthetic fracture due to femoral implant insertion, and/or osteointegration failure. The main objective of this study was to find a correlation between the surgical approach and the intramedullary prosthetic canal fill ratio (CFR) of the uncemented femoral implant. The hypothesis of this work was that the surgical approach does not influence the stem sizing during hip arthroplasty., Methods: In this consecutive series, we analyzed the radiological images of 183 patients who underwent primary hip arthroplasty with 4 different surgical approaches. Dimensions of the implant were evaluated by radiographic measurement of the CFR. In order to assess the shape of the femur, we measured the canal flare index on the preoperative radiographs, and the canal calcar ratio was also measured to establish the shape of the femur according to Dorr's classification., Results: No significant difference was found between the surgical approach and the CFR measured at 4 different levels (CFR 1, 2, 3, and 4) on the postoperative radiograph. When the shape of the femur was assessed by canal flare index, there was no significant difference in implant, whether the femur had a stovepipe canal shape or a champagne-fluted canal shape., Conclusion: This study showed that the surgical approach in hip arthroplasty does not influence the canal fill. Therefore, the surgical approach does not factor in undersizing the femoral implant. Despite some difficulties in the exposure of the medullary shaft described by some authors, the anterior approach is not a risk factor for undersizing an anatomical femoral stem., Level of Evidence: 4., (© 2021 The Authors.)

Background: Periprosthetic joint infection (PJI) is a relatively frequent and oftentimes devastating complication after total elbow arthroplasty (TEA). Its microbiologic diagnosis is usually based on periprosthetic tissue culture (hereafter referred to as tissue culture), but the sensitivity of tissue culture is variable. Although implant sonication culture has been shown to be superior to tissue culture for the diagnosis of hip and knee PJI, only a single small study (of fewer than 10 infected implants) has assessed sonication for PJI diagnosis after elbow arthroplasty., Methods: We retrospectively analyzed 112 sonicate fluid cultures from patients who underwent revision of a TEA at a single institution between 2007 and 2019, comparing results to those of tissue cultures. We excluded patients who had fewer than 2 tissues submitted for culture. Using the Infectious Diseases Society of America guidelines to define PJI, there were 49 infected and 63 non-infected cases. Median ages in the PJI and non-infected groups were 66 and 61 years, respectively. In the non-infected group, 65% were female vs. 63% in the PJI group. We reviewed clinical characteristics and calculated the sensitivity and specificity of tissue compared with sonicate fluid culture. In addition, we compared the sensitivity of tissue culture to the combination of tissue and sonicate fluid culture., Results: The most common pathogens were coagulase-negative Staphylococcus sp (49%), followed by Staphylococcus aureus (12%). Sensitivity of tissue culture was 63%, and sensitivity of sonicate fluid culture was 76% (P = .109). Specificity of tissue culture was 94% and specificity of sonicate fluid culture was 100%. Sensitivity of sonicate fluid culture in combination with tissue culture was 84% (P = .002 compared to tissue culture alone)., Conclusion: In this study, we found that the combination of sonicate fluid and tissue culture had a greater sensitivity than tissue culture alone for microbiologic diagnosis of PJI after TEA., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Artificial intelligence (AI) and digital twin models of various systems have long been used in industry to test products quickly and efficiently. Use of digital twins in clinical medicine caught attention with the development of Archimedes, an AI model of diabetes, in 2003. More recently, AI models have been applied to the fields of cardiology, endocrinology, and undergraduate medical education. The use of digital twins and AI thus far has focused mainly on chronic disease management, their application in the field of critical care medicine remains much less explored. In neurocritical care, current AI technology focuses on interpreting electroencephalography, monitoring intracranial pressure, and prognosticating outcomes. AI models have been developed to interpret electroencephalograms by helping to annotate the tracings, detecting seizures, and identifying brain activation in unresponsive patients. In this mini-review we describe the challenges and opportunities in building an actionable AI model pertinent to neurocritical care that can be used to educate the newer generation of clinicians and augment clinical decision making., Competing Interests: Conflict-of-interest statement: All authors declare no conflict of interest., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Chronic wound infections caused by biofilm-forming microorganisms represent a major burden to healthcare systems. Treatment of chronic wound infections using conventional antibiotics is often ineffective due to the presence of bacteria with acquired antibiotic resistance and biofilm-associated antibiotic tolerance. We previously developed an electrochemical scaffold that generates hydrogen peroxide (H 2 O 2 ) at low concentrations in the vicinity of biofilms. The goal of this study was to transition our electrochemical scaffold into an H 2 O 2 -generating electrochemical bandage (e-bandage) that can be used in vivo. The developed e-bandage uses a xanthan gum-based hydrogel to maintain electrolytic conductivity between e-bandage electrodes and biofilms. The e-bandage is controlled using a lightweight, battery-powered wearable potentiostat suitable for use in animal experiments. We show that e-bandage treatment reduced colony-forming units of Acinetobacter buamannii biofilms (treatment vs. control) in 12 h (7.32 ± 1.70 vs. 9.73 ± 0.09 log 10 [CFU/cm 2 ]) and 24 h (4.10 ± 12.64 vs. 9.78 ± 0.08 log 10 [CFU/cm 2 ]) treatments, with 48 h treatment reducing viable cells below the limit of detection of quantitative and broth cultures. The developed H 2 O 2 -generating e-bandage was effective against in vitro A. baumannii biofilms and should be further evaluated and developed as a potential alternative to topical antibiotic treatment of wound infections., (© 2021 Wiley Periodicals LLC.)

Hydrogen peroxide (H 2 O 2 ) and hypochlorous acid (HOCl) are biocides used for cleaning and debriding chronic wound infections, which often harbor drug resistant bacteria. Here, we evaluated the in vitro activity of H 2 O 2 and HOCl against 27 isolates of eight bacterial species involved in wound infections. Minimum inhibitory concentrations (MICs) and minimum biofilm bactericidal concentrations (MBBCs) were measured. When compared to their respective MICs, MBBCs of isolates exposed to H 2 O 2 were 16- to 1,024-fold higher and those exposed to HOCl were 2- to 4-fold higher. We evaluated selection of resistance after exposure of Staphylococcus aureus and Pseudomonas aeruginosa biofilms to 10 iterations of electrochemically generated HOCl or H 2 O 2 delivered using electrochemical scaffolds (e-scaffolds), observing no decrease in anti-biofilm effects with serial exposure to e-scaffold-generated H 2 O 2 or HOCl. 24-hour exposure to H 2 O 2 -generating e-scaffolds consistently decreased colony forming units (CFUs) of S. aureus and P. aeruginosa biofilms by ∼5.0-log 10 and ∼4.78-log 10 through 10 iterations of exposure, respectively. 4-hour exposure to HOCl-generating e-scaffolds consistently decreased CFUs of S. aureus biofilms by ∼4.9-log 10 , and 1-hour exposure to HOCl-generating e-scaffolds consistently decreased CFUs of P. aeruginosa biofilms by ∼1.57-log 10 These results suggest that HOCl has similar activity against planktonic and biofilm bacteria, whereas the activity of H 2 O 2 is less against biofilm than planktonic bacteria, and that repeat exposure to either biocide, generated electrochemically under the experimental conditions studied, does not lessen antibiofilm effects., (Copyright © 2021 American Society for Microbiology.)

Oxidizing agents like hypochlorous acid (HOCl) have antimicrobial activity. We developed an integrated electrochemical scaffold, or e-scaffold, that delivers a continuous low dose of HOCl aimed at targeting microbial biofilms without exceeding concentrations toxic to humans as a prototype of a device being developed to treat wound infections in humans. In this work, we tested the device against 33 isolates of bacteria (including isolates with acquired antibiotic resistance) grown as in vitro biofilms alongside 12 combinations of dual-species in vitro biofilms. Biofilms were grown on the bottoms of 12-well plates for 24 h. An integrated e-scaffold was placed atop each biofilm and polarized at 1.5 V for 1, 2, or 4 h. HOCl was produced electrochemically by oxidizing chloride ions (Cl - ) in solution to chlorine (Cl 2 ); dissolved Cl 2 spontaneously dissociates in water to produce HOCl. The cumulative concentration of HOCl produced at the working electrode in each well was estimated to be 7.89, 13.46, and 29.50 mM after 1, 2, and 4 h of polarization, respectively. Four hours of polarization caused an average reduction of 6.13 log 10 CFU/cm 2 (±1.99 log 10 CFU/cm 2 ) of viable cell counts of monospecies biofilms and 5.53 log 10 CFU/cm 2 (±2.31 log 10 CFU/cm 2 ) for the 12 dual-species biofilms studied. The described integrated e-scaffold reduces viable bacterial cell counts in biofilms formed by an array of antibiotic-susceptible and -resistant bacteria alone and in combination., (Copyright © 2021 American Society for Microbiology.)

Hip dysplasia is an important cause of osteoarthritis in young adults. For these patients, conservative treatment is an interesting alternative to arthroplasty. The current literature suggests better clinical and functional outcomes when shelf acetabuloplasty is performed for a moderate joint pinch (<50%) associated with an important external coverage defect of the acetabular cup (<25°). Compared with open surgical procedures, minimally invasive surgical techniques or arthroscopy tend to reduce morbidity. To date, the major intraoperative difficulty remains the positioning of the graft. This Technical Note aims to outline a minimally invasive shelf acetabuloplasty, with optimization of the position of the autologous iliac crest bone graft using 3-dimensional navigation., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Prosthetic joint infection (PJI) is a rare but challenging complication of arthroplasty. Herein, we describe the epidemiology and microbiology of PJI, with a focus on analyzing differences between the microbiology of polymicrobial versus monomicrobial infection of hip, knee, and shoulder prostheses. In addition, we report the most frequent co-pathogens in polymicrobial infections, as detected by culture. A total of 373 patients diagnosed with PJI at Mayo Clinic were studied. For hip and knee arthroplasties, a higher proportion of fractures (P = 0.02) and a shorter time between the implantation and symptom onset (P < 0.0001) were noted in polymicrobial versus monomicrobial PJI. The most common microorganism detected, Staphylococcus epidermidis, was more frequently detected in polymicrobial (60%) versus monomicrobial (35%) PJI (P = 0.0067). Among polymicrobial infections, no co-pathogens were more frequently found than others, except S. epidermidis and Enterococcus faecalis which were found together in 5 cases. In addition to coagulase-negative staphylococci and enterococci, Corynebacterium species and Finegoldia magna were common in polymicrobial infections. Conversely, there was no difference between the prevalence of Staphylococcus aureus, Gram-negative bacilli, or Cutibacterium acnes between the polymicrobial and monomicrobial groups. The microbiology of polymicrobial PJI is different from that of monomicrobial PJI., (Copyright © 2019 Elsevier Inc. All rights reserved.)