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Nasopharyngeal carriage of staphylococci spreads potentially pathogenic strains into (peri)oral regions and increases the chance of cross-infections. Some laboratory strains can also move rapidly on hydrated agar surfaces, but the biological relevance of these observations is not clear. Using soft-agar [0.3% (wt/vol)] plate assays, we demonstrate the rapid surface dispersal of (peri)oral isolates of Staphylococcus aureus and Staphylococcus epidermidis and closely related laboratory strains in the presence of mucin glycoproteins. Mucin-induced dispersal was a stepwise process initiated by the passive spreading of the growing colonies followed by their rapid branching (dendrites) from the colony edge. Although most spreading strains used mucin as a growth substrate, dispersal was primarily dependent on the lubricating and hydrating properties of the mucins. Using S. aureus JE2 as a genetically tractable representative, we demonstrate that mucin-induced dendritic dispersal, but not colony spreading, is facilitated by the secretion of surfactant-active phenol-soluble modulins (PSMs) in a process regulated by the agr quorum-sensing system. Furthermore, the dendritic dispersal of S. aureus JE2 colonies was further stimulated in the presence of surfactant-active supernatants recovered from the most robust (peri)oral spreaders of S. aureus and S. epidermidis . These findings suggest complementary roles for lubricating mucins and staphylococcal PSMs in the active dispersal of potentially pathogenic strains from perioral to respiratory mucosae, where gel-forming, hydrating mucins abound. They also highlight the impact that interspecies interactions have on the co-dispersal of S. aureus with other perioral bacteria, heightening the risk of polymicrobial infections and the severity of the clinical outcomes., Importance: Despite lacking classical motility machinery, nasopharyngeal staphylococci spread rapidly in (peri)oral and respiratory mucosa and cause cross-infections. We describe laboratory conditions for the reproducible study of staphylococcal dispersal on mucosa-like surfaces and the identification of two dispersal stages (colony spreading and dendritic expansion) stimulated by mucin glycoproteins. The mucin type mattered as dispersal required the surfactant activity and hydration provided by some mucin glycoproteins. While colony spreading was a passive mode of dispersal lubricated by the mucins, the more rapid and invasive form of dendritic expansion of Staphylococcus aureus and Staphylococcus epidermidis required additional lubrication by surfactant-active peptides (phenol-soluble modulins) secreted at high cell densities through quorum sensing. These results highlight a hitherto unknown role for gel-forming mucins in the dispersal of staphylococcal strains associated with cross-infections and point at perioral regions as overlooked sources of carriage and infection by staphylococci., Competing Interests: The authors declare no conflict of interest.

The identification of a diverse microbiome in otic secretions from healthy young adults challenged the entrenched dogma of middle ear sterility and underscored previously unknown roles for oral commensals in the seeding of otic biofilms. We gained insights into the selective forces that enrich for specific groups of oral migrants in the middle ear mucosa by investigating the phylogeny and physiology of 19 strains isolated previously from otic secretions and representing otic commensals ( Streptococcus ) or transient migrants ( Staphylococcus, Neisseria and actinobacterial Micrococcus and Corynebacterium ). Phylogenetic analyses of full length 16S rRNA sequences recovered from partially sequenced genomes resolved close relationships between the isolates and (peri)oral commensals. Physiological functions that facilitate mucosal colonization (swarming motility, surfactant production) and nutrition (mucin and protein degradation) were also widespread among the cultivars, as was their ability to grow in the presence or absence of oxygen. Yet, streptococci stood out for their enhanced biofilm-forming abilities under oxic and anoxic conditions and ability to ferment host-derived mucosal substrates into lactate, a key metabolic intermediate in the otic trophic webs. Additionally, the otic streptococci inhibited the growth of common otopathogens, an antagonistic interaction that could exclude competitors and protect the middle ear mucosa from infections. These adaptive traits allow streptococcal migrants to colonize the otic mucosa and grow microcolonies with syntrophic anaerobic partners, establishing trophic interactions with other commensals that mirror those formed by the oral ancestors in buccal biofilms., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Gemma Reguera reports financial support was provided by Office of Naval Research. Kristin J Jacob reports a relationship with Michigan Department of Health and Human Services that includes: non-financial support., (© 2022 The Authors.)

Introduction: Well-being, both psychological and emotional, is crucial to the development of the competent, caring physician. The ACGME calls on sponsoring institutions to educate learners about topics related to well-being. Trauma exposure response, also known as secondary trauma, is a common phenomenon experienced by physicians. It is important to recognize and mitigate the effects of trauma exposure response, as it can have profound effects on personal and professional lives. We found no MedEdPORTAL resources on trauma exposure response or secondary trauma that include physicians as the audience., Methods: This 1-hour, interactive session was developed to embed a wellness program into protected time for residents and fellows across the institution. The session was led by a faculty member and consisted of an interactive presentation and a small-group discussion., Results: Twenty-eight of 32 programs at our institution participated in the sessions. This included a total of 292 residents and fellows to whom this session was offered. The session was successful in meeting the educational objectives and was rated as valuable or extremely valuable by most residents and fellows. Trainees appreciated protected time for this discussion and valued the opportunity to have open, honest conversations with their colleagues., Discussion: This effective session delivered meaningful content about trauma exposure response and reviewed coping strategies. Institutional support of protected time was a success factor. The sessions were well received by residents and fellows and can be used across disciplines., (© 2021 Jacob and Lambert.)

The entrenched dogma of a sterile middle ear mucosa in health is incongruent with its periodic aeration and seeding with saliva aerosols. To test this, we sequenced 16S rRNA-V4 amplicons from otic secretions collected at the nasopharyngeal orifice of the tympanic tube and, as controls, oropharyngeal and buccal samples. The otic samples harbored a rich diversity of oral keystone genera and similar functional traits but were enriched in anaerobic genera in the Bacteroidetes ( Prevotella and Alloprevotella ), Fusobacteria ( Fusobacterium and Leptotrichia ) and Firmicutes ( Veillonella ) phyla. Facultative anaerobes in the Streptococcus genus were also abundant in the otic and oral samples but corresponded to distinct, and sometimes novel, cultivars, consistent with the ecological diversification of the oral migrants once in the middle ear microenvironment. Neutral community models also predicted a large contribution of oral dispersal to the otic communities and the positive selection of taxa better adapted to growth and reproduction under limited aeration. These results challenge the traditional view of a sterile middle ear in health and highlight hitherto unknown roles for oral dispersal and episodic ventilation in seeding and diversifying otic biofilms., Competing Interests: The authors declare that they have no competing interests., (© 2020 The Author(s).)

DNA methylation is pervasive across all domains of life. In bacteria, the presence of N6-methyladenosine (m6A) has been detected among diverse species, yet the contribution of m6A to the regulation of gene expression is unclear in many organisms. Here we investigated the impact of DNA methylation on gene expression and virulence within the human pathogen Streptococcus pyogenes, or Group A Streptococcus. Single Molecule Real-Time sequencing and subsequent methylation analysis identified 412 putative m6A sites throughout the 1.8 Mb genome. Deletion of the Restriction, Specificity, and Methylation gene subunits (ΔRSM strain) of a putative Type I restriction modification system lost all detectable m6A at the recognition sites and failed to prevent transformation with foreign-methylated DNA. RNA-sequencing identified 20 genes out of 1,895 predicted coding regions with significantly different gene expression. All of the differentially expressed genes were down regulated in the ΔRSM strain relative to the parent strain. Importantly, we found that the presence of m6A DNA modifications affected expression of Mga, a master transcriptional regulator for multiple virulence genes, surface adhesins, and immune-evasion factors in S. pyogenes. Using a murine subcutaneous infection model, mice infected with the ΔRSM strain exhibited an enhanced host immune response with larger skin lesions and increased levels of pro-inflammatory cytokines compared to mice infected with the parent or complemented mutant strains, suggesting alterations in m6A methylation influence virulence. Further, we found that the ΔRSM strain showed poor survival within human neutrophils and reduced adherence to human epithelial cells. These results demonstrate that, in addition to restriction of foreign DNA, gram-positive bacteria also use restriction modification systems to regulate the expression of gene networks important for virulence., Competing Interests: The authors have declared that no competing interests exist.

The aim of the study was to compare the efficacy of periarticular injection of a cocktail of analgesic drugs (PIC) with epidural infiltration (EA), in providing postoperative pain relief and early functional improvement following Total Hip Arthroplasty (THA)., Methods: 50 patients undergoing unilateral THA were randomized to receive either EA or PIC for postoperative pain control. Postoperative pain relief, as determined by the visual analogue scale (VAS), functional recovery and side effects related to EA and PIC were assessed., Results: PIC resulted in significantly lower VAS scores [0.48(0.71) vs 3.04(2.07)] in the first 24 h after surgery [mean (SD)], when compared to EA. The pain relief continued to be significantly lower even on the 10th postoperative day. Functional recovery was significantly better in the PIC group, with patients being able to walk longer distances and climb steps more quickly following THA. EA, unlike PIC was associated with side effects like nausea, vomiting, motor weakness, back pain and urinary retention. The overall satisfaction rate with treatment was significantly better in PIC group (9.04/10) than those who received EA (7.76/10)., Conclusion: PIC provides significantly better pain control and functional recovery in the early postoperative period, with less side effects when compared with EA. PIC should be the choice for pain control following THA.

Rheumatoid Arthritis can present with consistent pain over peripheral joints. The manner of presentation of a subcutaneous tumour such as Myopericytoma may be very similar to that of an inflamed joint leading to the high frequency of it being overlooked and inadequately treated. Knowing the radiological and pathological differences will direct us in the right road to timely and adequate treatment., (© Journal of the Association of Physicians of India 2011.)

We report the complete genome assembly of the Streptococcus pyogenes type emm4 strain MEW427 (also referred to as strain UM001 in the Pediatric Acute-Onset Neuropsychiatric Syndrome [PANS] Research Consortium), a throat isolate from a child with acute-onset neuropsychiatric symptoms meeting clinical criteria for PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcus). The genome length is 1,814,455 bp with 38.51% G+C%., (Copyright © 2016 Jacob et al.)

We present here the complete genome sequence of Streptococcus pyogenes type emm28 strain MEW123, a streptomycin-resistant derivative of a pediatric throat isolate. The genome length is 1,878,699 bp, with 38.29% G+C% content. The genome sequence adds value to this virulent emm28 representative strain and will aid in the investigation of streptococcal pathogenesis., (Copyright © 2016 Jacob et al.)

Radiofrequency ablation (RFA) has now become a preferred treatment option for osteoid osteoma. Accurate placement of RFA probe into the nidus of osteoid osteoma is important for good clinical outcome. Various methods and techniques have been described in the literature available. We describe the technique of using a vascular access sheath for introduction of RFA probe after bone drilling, which prevents loss of access to drill track and also serves as a pathway for accurate placement of RFA probe, thereby reducing the risk of damage to the RFA probe tip itself and the surrounding soft tissue.

Background: Physicians in training are at high risk for depression, and physicians in practice have a substantially elevated risk of suicide compared to the general population. The graduate medical education community is currently mobilizing efforts to improve resident wellness., Objective: We sought to provide a trainee perspective on current resources to support resident wellness and resources that need to be developed to ensure an optimal learning environment., Methods: The ACGME Council of Review Committee Residents, a 29-member multispecialty group of residents and fellows, conducted an appreciative inquiry exercise to (1) identify existing resources to address resident wellness; (2) envision the ideal learning environment to promote wellness; and (3) determine how the existing infrastructure could be modified to approach the ideal. The information was aggregated to identify consensus themes from group discussion., Results: National policy on resident wellness should (1) increase awareness of the stress of residency and destigmatize depression in trainees; (2) develop systems to identify and treat depression in trainees in a confidential way to reduce barriers to accessing help; (3) enhance mentoring by senior peers and faculty; (4) promote a supportive culture; and (5) encourage additional study of the problem to deepen our understanding of the issue., Conclusions: A multispecialty, national panel of trainees identified actionable goals to broaden efforts in programs and sponsoring institutions to promote resident wellness and mental health awareness. Engagement of all stakeholders within the graduate medical education community will be critical to developing a comprehensive solution to this important issue.

Background: Stress fractures of the naviculum bone are uncommon injuries occurring predominantly in athletes. These fractures are usually treated nonoperatively with a nonweight bearing cast for a minimum of 6 weeks followed by rehabilitation. Further, there is a paucity of literature on the long term clinical followup of these patients. These fractures do not heal predictably with conservative management, which does not inspire great compliance and their clinical outcome is variable. We report on the outcome of these fractures following early operative intervention by minimally invasive fixation and early weight bearing and rehabilitation. We propose that this is reliable and a successful treatment regimen and its role as the definitive management of this clinical problem should be explored., Materials and Methods: Nine athletes with ten stress fractures of the navicular treated at our institution between April 1991 and October 2000. The mean age of the patients was 22.8 years (range 18-50 years). All patients were treated by minimally invasive screw fixation and early weight bearing mobilization without a cast. The average followup was 7 years (range 2-11 years)., Results: Seven of the nine patients returned to their pre-fracture level of sporting activity at an average of 5 months (range 3-9 months). One patient returned to full sporting activity following a delay of 2 years due to an associated tibial stress fracture and one patient had an unsatisfactory result. Long term review at an average of 7 years showed that six of these eight patients who returned to sports remained symptom free with two patients experiencing minimal intermittent discomfort after prolonged activity., Conclusions: We recommend percutaneous screw fixation as a reliable, low morbidity procedure allowing early return to full sporting activity without long term complications or recurrences.

Bipolar fracture dislocations of the clavicle are rare injuries, usually the result of high-energy direct trauma. Since the original description by Porral in 1831, only a handful of individual case reports and case series by Beckman and Sanders have been reported in the literature. Management of these injuries has remained controversial ranging from nonoperative to aggressive surgery. We report on the case of a young army cadet who had a fracture of the lateral end of the clavicle, with an anterior dislocation of the sternoclavicular joint. Despite being planned for surgery, at the patients request, it was decided to manage the lesion conservatively with graded physiotherapy. At one-year follow-up, he had full pain-free, functional range of movement of the shoulder. This young high demand patient had a good outcome with conservative management, despite going against the current trend towards surgical treatment. We present this case with a review of the literature, highlighting the various management options for this rare lesion.

Background: The association of meniscal cartilage injury with anterior cruciate ligament (ACL) injury is well documented in literature. The aim of this study was to examine the relative risk factors for meniscal pathology at the time of arthroscopic ACL reconstruction., Materials and Methods: A review of the case records including both in-patient and out-patient charts of all patients who underwent arthroscopic ACL reconstruction during the preceding 3 years was performed by either of the authors. The relative incidences of associated meniscal pathologies were analyzed in correlation with age, side of injury, time to surgery, mode of injury, and gender as the risk factors. Statistical analysis was performed to obtain individual data correlation., Results: A total of 192 patients underwent ACL reconstruction during the 3-year time frame. Of these, complete data sets were available for 129 patients. Analysis revealed that the only factor that was statistically significant in raising the risk of meniscal pathology was the time to surgery (P = 0.001). There was a significant increase in medial, lateral, and both meniscal tears noted in cases operated beyond 24 weeks. Further, the incidence of medial meniscal tears as well as lateral meniscal tears increased with delay in presentation for surgery (P = 0.004). Mode of injury, age at presentation, sex, and side were not significantly associated with an increased incidence of meniscal pathology., Conclusion: The single factor that significantly affects incidence of meniscal co-morbidity in ACL injury is the delay in presentation (i.e. the time to surgery). The incidence of lateral meniscal tears as well as medial meniscal tears increased with delay in surgery. This should guide us toward recommending all patients irrespective of age, gender, or mode of injury to undergo early reconstruction, thereby reducing the likelihood of developing meniscal pathology.

Introduction: We present a case report highlighting the unusual location and atypical imaging characteristics of an osteoid osteoma in the juxta-articular region of the femoral head, and treatment of the condition with radiofrequency ablation. This treatment option is low in both risk and morbidity and is therefore the best option in lesions that are difficult to access surgically because of the risks involved., Case Presentation: A 40-year-old Indian man from West Bengal presented to our facility with a history of progressively severe left hip pain of insidious onset, requiring analgesics. Imaging with plain radiographs, computed tomography and magnetic resonance imaging confirmed findings of osteoid osteoma in a subarticular location in the femoral head, although imaging features were atypical due to the intra-articular subchondral location., Conclusion: Radiofrequency ablation is a newer treatment modality for osteoid osteoma that, being minimally invasive, offers comparable results to surgery with a significantly lower morbidity. To the best of our knowledge, treatment of osteoid osteoma in the foveal region of the femoral head with radiofrequency ablation has not been reported to date. We wish to highlight the successful outcome in our index case using this technique.

Background: We evaluated 46 patients who underwent surgical repair of the Achilles tendon at our institution during a 4.5-year period, followed by early weight bearing, aiming to assess their return to activities, rerupture rate and satisfaction., Methods: A cohort of 46 patients who underwent Achilles tendon repair at our institution during a 4.5-year period, with a modified triple mini-Becker suture technique, for both acute as well as chronic Achilles tendon ruptures were studied. These patients were reviewed at a minimum of 2.5 years follow up (average 4.5 years ranging from 2.5 to 6.5 years), by chart review and questionnaire, to determine the functional outcome as well as patient satisfaction following an active postoperative protocol involving full weight-bearing ambulation in a controlled ankle motion walker and active stretching, followed by a graduated strengthening programme., Results: We found a very high level of satisfaction, with few minor complications and no reruptures in either the early or the delayed repair groups., Conclusion: We believe that surgical repair using this technique associated with an early return to protected full weight-bearing ambulation and an active early rehabilitation programme provides not only excellent functional results, patient satisfaction and a zero rerupture rate, but also much less morbidity in the first 3 months and a quicker overall recovery compared with non-operative treatment.

Objective: We designed a prospective study to determine the frequency of retroperitoneal air after endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. We sought to elucidate the relationship of retroperitoneal air with endoscopic maneuvers, clinical findings, the length of sphincterotomy, and the time spent during the procedure. We also endeavored to determine the importance of retroperitoneal air and its most appropriate clinical management., Methods: Twenty-one consecutive patients who had undergone ERCP with sphincterotomy had abdominal computed tomography (CT) examinations within 24 h after completion of the procedure. The CT findings were unknown to the clinicians, and none of the patients received postprocedural antibiotics., Results: Six (29%) of 21 patients exhibited CT findings of retroperitoneal air. All six patients had uneventful postprocedural courses, and none had abnormal clinical signs or symptoms. The occurrence of retroperitoneal air was not influenced by the presence of hyperamylasemia, the duration of the procedure, or the length of the sphincterotomy., Conclusions: Retroperitoneal air is not an uncommon finding after ERCP with sphincterotomy. Moreover, the finding of retroperitoneal air in the absence of physical findings, is not a cause for alarm and does not require surgical intervention.