Search

Background: We aimed to determine the prevalence of genes associated with high-level mupirocin and biocide resistance in methicillin-resistant Staphylococcus aureus (MRSA) isolates among hospitalized patients and to characterize their genomic and epidemiologic features., Methods: Study conducted on an integrated health system. Clinical cultures with MRSA from hospitalized patients collected between March 1, 2023, and January 20, 2024 underwent prospective whole-genome sequencing, including assessment for the presence of markers of resistance against mupirocin (mupA) and biocides (qac). Demographic and clinical characteristics were reviewed., Results: We analyzed 463 MRSA isolates. The overall prevalence of mupA(+), qacA(+), and qacC(+) genes was 22.0%, 2.4%, and 19.0%, respectively. Most mupA(+) isolates belonged to ST8, but ST8732 (a novel variant of ST8) had the highest prevalence of mupA(+) isolates at 95%. Patients mupA(+) were older, and none of the isolates from pediatric patients harbored this gene., Discussion: Through prospective whole-genome sequencing of MRSA isolates, we detected a prevalence of genes conferring mupirocin resistance considerably higher than previously reported, particularly among MRSA ST8 variants., Conclusions: Our findings highlight the need for monitoring resistance to agents used for the prevention of S aureus infections, as these trends have implications for infection prevention programs and public health at large., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

There has been tremendous progress in reducing disability and death from ACS. But many patients still die before reaching the hospital because patients and family members fail to recognize the signs of ACS and fail to activate the EMS system. Once the patient with ACS contacts the healthcare system, providers must focus on support of cardiorespiratory function, rapid transport, and early classification of the patient based on ECG characteristics. Patients with STEMI require prompt reperfusion; the shorter the interval from symptom onset to reperfusion, the greater the benefit. In the STEMI population, mechanical reperfusion with percutaenous coronary intervention improves survival and decreases major cardiovascular events compared to fibrinolysis. Patients with UA/NSTEMI (non-STEMI ACS) or nonspecific or normal ECGs require risk stratification and appropriate monitoring and therapy. Healthcare providers can improve survival rates and myocardial function of patients with ACS by providing skilled, efficient, and coordinated out-of-hospital and in-hospital care.

Objective: The physical examination of the abdomen is crucial to emergency department (ED) management of patients with abdominal pain. We sought to determine the interrater variation between attending and resident physicians in detecting abdominal exam findings., Methods: Research enrollers surveyed attending and resident physicians on abdominal exam findings in the ED in patients with abdominal pain. Strength of agreement was calculated using the kappa statistic., Results: A convenience sample of 122 surveys was completed. Calculated kappa results are in parentheses. There was almost perfect agreement on the presence of masses and substantial agreement on the need for imaging studies. There was moderate agreement on guarding, distension, tenderness, and need for laboratory tests and surgical consultation. For 88 (72%) patients with tenderness, substantial agreement was calculated for epigastric tenderness, moderate agreement on right upper quadrant, supraumbilical, suprapubic, left lower quadrant, right lower quadrant tenderness, and fair agreement on left upper quadrant tenderness. Sixty-one (50%) patients received pain medicine in the ED. Among those, there was fair agreement on a presence of a surgical abdomen. Upper level resident physicians noted a higher level of agreement with the attending physician for tenderness than junior resident physicians., Conclusions: There was moderate agreement between resident and attending physicians for most of the findings in patients with abdominal pain. Recognition that selected findings are more variable than others should encourage careful confirmation of resident physicians' assessments in teaching settings.

Unlabelled: Acute myocardial infarction (AMI) is one of many causes of ST-segment elevation (STE) in emergency department (ED) chest pain (CP) patients. The morphology of STE may assist in the correct determination of its cause, with concave patterns in non-AMI syndromes and non-concave waveforms in AMI., Objectives: To determine the impact of STE morphologic analysis on AMI diagnosis and the ability of this technique to separate AMI from non-infarction causes of STE., Methods: The electrocardiograms (ECGs) of consecutive ED adult CP patients (with three serial troponin I determinations) were interpreted in two-step fashion by six attending emergency physicians (EPs): 1) the determination of STE by three EPs followed by 2) STE morphologic analysis (either concave or non-concave) in those patients with STE. The impact of STE morphology analysis was investigated in the identification of AMI and non-AMI causes of STE. Acute myocardial infarction was diagnosed by abnormal serum troponin I values (>0.1 mg/dL) followed by a rise and fall of the serum marker; STE diagnoses of non-AMI causes were determined by medical record review. Interobserver reliability concerning STE morphology was determined. Study inclusion criteria included at least three troponin values performed in serial fashion no more frequently than every three hours, initial ED ECG, ED diagnosis, and final hospital diagnosis., Results: Five hundred ninety-nine CP patients were entered in the study, with 171 (29%) individuals having STE on their ECGs. Of the 171 patients who had STE, 56 had AMI, 50 had unstable angina pectoris (USAP), and 65 had non-coronary final diagnoses. Forty-nine patients had non-concave STE, 46 with AMI and three with USAP; no patient with a non-coronary diagnosis had a non-concave STE morphology. The sensitivity and specificity of the non-concave STE morphology for AMI diagnoses were 77% and 97%, respectively; the positive and negative predictive values for non-concave morphology in AMI diagnoses were 94% and 88%, respectively. Interobserver reliability in the STE morphology determination revealed a kappa coefficient of 0.87., Conclusions: A non-concave STE morphology is frequently encountered in AMI patients. While the sensitivity of this pattern for AMI diagnosis is not particularly helpful, the presence of this finding in adult ED chest pain patients with STE strongly suggests AMI. This technique produces consistent results among these EPs.

The accurate assessment and triage of patients with potential ACS is a complex decision-making process based on information that is not entirely reliable. The knowledgeable EP recognizes that assessment of patients with chest pain requires an understanding of the various clinical presentations of ACS and high-risk patient types, as well as careful use of the available modalities to diagnose these syndromes efficiently while incurring minimal risk to the patients safety. The busy EP is faced with sick patients with chest pain daily, so that it behoove anyone in emergency medicine to familiarize themselves with these diagnostic pitfalls.

The aim of this study was to develop, for the first time in the human spinal dorsal horn (DH), an in vivo method for the study of amino acids (AAs). A microdialysis technique was used to sample AAs in the extracellular fluid of the DH apex in eight patients in whom surgery in the dorsal root entry zone (DREZ) was performed. Before making microsurgical lesions, specific concentric-type microdialysis probes were implanted over a 60-minute period in the DREZ and directed to the DH apex (10 implantations). The AA concentrations in the dialysates were determined using high-performance liquid chromatography with fluorescence detection. The concentrations of excitatory AAs (glutamate and aspartate) and inhibitory AAs (gamma-aminobutyric acid and glycine) decreased and were stabilized by 45 minutes after probe implantation, whereas the levels of nonneurotransmitter AAs (alanine and threonine) were not stabilized at 60 minutes. The ability of the probe to track the changes of extracellular AAs was demonstrated. Neither intra- nor postoperative microdialysis-related complications were observed (with a follow up of 18 months). The present study demonstrates that microdialysis can be performed safely in the human DH during DREZ lesioning. Despite technical and analytical limitations related to the intraoperative conditions, this technique offers new possibilities for clinical research on neurotransmitters involved in some relevant pathological states, especially in chronic pain and spasticity.

A specific microdialysis probe combined with high performance liquid chromatography analysis was used to compare the basal levels of extracellular amino acids (AAs) in the dorsal horn (DH) between two groups of patients undergoing spinal surgery for the treatment of peripheral neuropathic pain (n = 5) or disabling spasticity (n = 5). A stabilized concentration was reached in the dialysates 45 min after probe implantation for excitatory AAs (glutamate and aspartate) and inhibitory AAs (GABA and glycine). A significant increase in the ratios aspartate/GABA and aspartate/glycine was found in the group of patients suffering from neuropathic pain. This study shows the feasibility of a microdialysis investigation in the DH of patients during a neurosurgical operation and supports in humans the hypothesis of an imbalance between excitatory AAs and inhibitory AAs within the DH in neuropathic pain states, as suggested by previous animal studies.