Role of Host Type IA Phosphoinositide 3-Kinase Pathway Components in Invasin-Mediated Internalization of Yersinia enterocolitica.

Many bacterial pathogens subvert mammalian type IA phosphoinositide 3-kinase (PI3K) in order to induce their internalization into host cells. How PI3K promotes internalization is not well understood. Also unclear is whether type IA PI3K affects different pathogens through similar or distinct mechanisms. Here, we performed an RNA interference (RNAi)-based screen to identify components of the type IA PI3K pathway involved in invasin-mediated entry of Yersinia enterocolitica, an enteropathogen that causes enteritis and lymphadenitis. The 69 genes targeted encode known upstream regulators or downstream effectors of PI3K. A similar RNAi screen was previously performed with the food-borne bacterium Listeria monocytogenes The results of the screen with Y. enterocolitica indicate that at least nine members of the PI3K pathway are needed for invasin-mediated entry. Several of these proteins, including centaurin-α1, Dock180, focal adhesion kinase (FAK), Grp1, LL5α, LL5ß, and PLD2 (phospholipase D2), were recruited to sites of entry. In addition, centaurin-α1, FAK, PLD2, and mTOR were required for remodeling of the actin cytoskeleton during entry. Six of the human proteins affecting invasin-dependent internalization also promote InlB-mediated entry of L. monocytogenes Our results identify several host proteins that mediate invasin-induced effects on the actin cytoskeleton and indicate that a subset of PI3K pathway components promote internalization of both Y. enterocolitica and L. monocytogenes.

In the Aftermath: Attitudes of Anesthesiologists to Supportive Strategies After an Unexpected Intraoperative Patient Death.

BACKGROUND: Although most anesthesiologists will have 1 catastrophic perioperative event or more during their careers, there has been little research on their attitudes to assistive strategies after the event. There are wide-ranging emotional consequences for anesthesiologists involved in an unexpected intraoperative patient death, particularly if the anesthesiologist made an error. We used a between-groups survey study design to ask whether there are different attitudes to assistive strategies when a hypothetical patient death is caused by a drug error versus not caused by an error. First, we explored attitudes to generalized supportive strategies. Second, we examined our hypothesis that the presence of an error causing the hypothetical patient death would increase the perceived social stigma and self-stigma of help-seeking. Finally, we examined the strategies to assist help-seeking. METHODS: An anonymous, mailed, self-administered survey was conducted with 1600 consultant anesthesiologists in Australia on the mailing list of the Australian and New Zealand College of Anaesthetists. The participants were randomized into "error" versus "no-error" groups for the hypothetical scenario of patient death due to anaphylaxis. Nonparametric, descriptive, parametric, and inferential tests were used for data analysis. P' is used where P values were corrected for multiple comparisons. RESULTS: There was a usable response rate of 48.9%. When an error had caused the hypothetical patient death, participants were more likely to agree with 4 of the 5 statements about support, including need for time off (P' = 0.003), counseling (P' < 0.001), a formal strategy for assistance (P' < 0.001), and the anesthesiologist not performing further cases that day (P' = 0.047). There were no differences between groups in perceived self-stigma (P = 0.98) or social stigma (P = 0.15) of seeking counseling, whether or not an error had caused the hypothetical patient death. Finally, when an error had caused the patient death, participants were more likely to agree with 2 of the 5 statements about help-seeking, including the need for a formal, hospital-based process that provides information on where to obtain professional counseling (P' = 0.006) and the availability of after-hours counseling services (P' = 0.035). CONCLUSIONS: Our participants were more likely to agree with assistive strategies such as not performing further work that day, time off, counseling, formal support strategies, and availability of after-hours counseling services, when the hypothetical patient death from anaphylaxis was due to an error. The perceived stigma toward attending counseling was not affected by the presence or absence of an error as the cause of the patient death, disproving our hypothesis.

Barriers to adverse event and error reporting in anesthesia.

BACKGROUND: Although anesthesiologists are leaders in patient safety, there has been little research on factors affecting their reporting of adverse events and errors. First, we explored the attitudinal/emotional factors influencing reporting of an unspecified adverse event caused by error. Second, we used a between-groups study design to ask whether there are different perceived barriers to reporting a case of anaphylaxis caused by an error compared with anaphylaxis not caused by error. Finally, we examined strategies that anesthesiologists believe would facilitate reporting. Where possible, we contrasted our results with published findings from other physician groups. METHODS: An anonymous, self-administered, mailed survey was conducted of 629 consultant anesthesiologists and 263 anesthesiology residents on the mailing list of the Australian and New Zealand College of Anaesthetists in Victoria, Australia. Participants were randomized into "Error" versus "No Error" groups for the specified anaphylaxis adverse event section of the survey. Data were analyzed using nonparametric descriptive and inferential tests. RESULTS: There were 433 usable returned surveys, a usable response rate of 49%. First, there was only 1 of 13 statements on attitudinal/emotional factors that influenced reporting of an unspecified adverse event caused by error with which more anesthesiologists agreed/strongly agreed than disagreed/strongly disagreed: "Doctors who make errors are blamed by their colleagues." Second, when an error rather than no error had caused anaphylaxis, participants were more likely to agree/strongly agree that 6 statements about litigation, getting into trouble, disciplinary action, being blamed, unsupportive colleagues, and not wanting the case discussed in meetings, were perceived as reporting barriers. Finally, the most favored assistive strategies for reporting were generalized deidentified feedback about adverse event and error reports, role models such as senior colleagues who openly encourage reporting, and legislated protection of reports from legal discoverability. CONCLUSION: The majority of anesthesiologists in our study did not agree that the attitudinal/emotional barriers surveyed would influence reporting of an unspecified adverse event caused by error, with the exception of the barrier of being concerned about blame by colleagues. The probable influence of 6 perceived barriers to reporting a specified adverse event of anaphylaxis differed with the presence or absence of error. Anesthesiologists in our study supported assistive reporting strategies. There seem to be some differences between our results and previously published research for other physician groups.

Prevalence of Shiga toxin-producing and enteropathogenic Escherichia coli marker genes in diarrhoeic stools in a New Zealand catchment area.

BACKGROUND: Shiga toxin-producing (STEC) and enteropathogenic (EPEC) Escherichia coli are gastrointestinal pathogens causing diarrhoeal and extraintestinal disease. Due to lack of EPEC screening and use of Sorbitol-MacConkey (SMAC) agar in faecal screening, the true prevalence of EPEC and non-O157 STEC in New Zealand diarrhoeal cases is unknown. METHODS: Diarrhoeic stools sourced from Dunedin hospital were pre-enriched, DNA extracted with Chelex-100 resin and screened using a multiplex TaqMan quantitative PCR assay amplifying stx1, sxt2 and EPEC (eae) gene markers. RESULTS: Of the 522 diarrhoeic samples surveyed, 8 (1.53%) were PCR positive for stx1/stx2 and 23 (4.41%) were positive for eae. Six (75%) of the stx+ samples were uncommon non-O157 serotypes, and the remainder were found to be positive for both O103 and O157 STEC somatic antigens. CONCLUSIONS: Results revealed shortcomings in current screening protocols for pathogenic E. coli; SMAC is not sufficiently discriminatory to detect emergent STEC serotypes and EPEC likely has an unappreciated role in cases of diarrhoea in New Zealand.

The prevalence and development of digenean parasites within their intermediate snail host, Galba truncatula, in a geographic area where the presence of Calicophoron daubneyi has recently been confirmed.

During the past decade, rumen fluke (Calicophoron daubneyi) has established as a prominent parasite of livestock within numerous European countries. Its development and spread is enabled by the presence of its intermediate snail host G. truncatula. However, the dynamics of this stage of the C. daubneyi lifecycle is yet to be recorded in numerous northern European countries including the UK. Here, the prevalence of C. daubneyi along with F. hepatica, H. cylindracea and other parasites infecting G. truncatula snails on 10 Welsh farms was recorded using morphological and PCR techniques. A total of 892 G. truncatula snails were collected between May and October 2016. The prevalence of C. daubneyi in sampled G. truncatula snails (4%) was lower compared to F. hepatica (5.6%). No association in prevalence between these species was recorded. Haplometra cylindracea was found infecting 8.2% of G. truncatula snails, with its prevalence within G. truncatula populations negatively associated with F. hepatica cercariae prevalence (P=0.004). Generalized estimation equation (GEE) linear regression models identified the levels of respective fluke eggs shed onto pasture as the main significant association between prevalence levels of both C. daubneyi and F. hepatica within G. truncatula populations (P<0.001). However, equivalent prevalence levels of C. daubneyi and F. hepatica within G. truncatula populations were associated with higher C. daubneyi egg outputs and lower F. hepatica egg outputs from livestock grazing the G. truncatula habitats. Only one of 36C. daubneyi infected G. truncatula snails was found harbouring its cercarial stages, a significantly lower proportion compared to the 29 of 50 F. hepatica infected G. truncatula harbouring its respective cercariae (P<0.05). These results signify that C. daubneyi may be less adept at infecting and developing in the UK's native G. truncatula populations in comparison with F. hepatica. However, C. daubneyi has previously demonstrated its ability to progressively adapt to an intermediate host in a new environment. If C. daubneyi were to adapt to infect and develop more efficiently in UK G. truncatula populations, paramphistomosis risk would significantly increase leading to increased livestock losses. Questions are also raised regarding potential interaction between digenean species at intermediate snail host level, which could impact subsequent livestock trematodosis risk.

A Randomized Controlled Trial of Ultrasound Versus Nerve Stimulator Guidance for Axillary Brachial Plexus Block.

BACKGROUND: Ultrasound-guided techniques improve outcomes in regional anesthesia when compared with traditional techniques; however, this assertion has not been studied with novices. The primary objective of this study was to compare sensory and motor block after axillary brachial plexus block when performed by novice trainees allocated to an ultrasound- or nerve-stimulator-guided group. A secondary objective was to compare the rates of skill acquisition between the 2 groups. METHODS: This study was a prospective, randomized, observer-blinded, 2-arm controlled trial. Anesthesia trainees participating in this trial were novices to axillary brachial plexus block and sonography. All trainee participants underwent a standardized training program. The primary outcome was combined sensory and motor block in the relevant territories 30 minutes after completion of block. A global rating scale was used to assess trainee block performance. RESULTS: The study was ceased after 12 trainees completed 153 blocks. There was no difference between groups in combined motor/sensory score (P = 0.28) or as a function of block number (P = 0.38). There was no difference in onset between groups (P = 0.38). In both groups, there was an increase in the global rating scale score (P < 0.0001) and reduced preblock survey and block performance times (P = 0.001) with experience. CONCLUSIONS: We were unable to demonstrate a difference in the efficacy of axillary brachial plexus block performed by novices when ultrasound guidance was compared with a nerve stimulator technique. There was evidence of similarly improved clinical performance of novices in both groups.

Sonographic location of the radial nerve confirmed by nerve stimulation during axillary brachial plexus blockade.

BACKGROUND AND OBJECTIVES: : Visualization of the radial nerve can be a challenge during ultrasound-guided axillary blockade. The objective of this study was to plot the location and examine the sonographic appearance of the radial nerve in the axilla using both ultrasound visualization and nerve stimulator verification in patients undergoing axillary blockade. METHODS: : Fifty-one patients requiring an axillary block for surgery were enrolled. Sonograms of the radial nerve at the point of best nerve stimulator response were recorded. The needle tip and center of the radial nerve were both plotted on a 2-dimensional scattergram using coordinates relative to the center of the axillary artery. A video tracing the path of the radial nerve was also recorded. RESULTS: : The radial nerve location was confirmed with both ultrasound imaging and nerve stimulation in 46 patients (90%). Five nerves (11%) were immediately deep to the axillary artery (ie, at a 6-o'clock position), 6 (13%) were cephalad, and the remaining 35 (76%) were caudad to the axillary artery. The 2-dimensional (2D) scattergrams reveal the variability in radial nerve location and clarity, of which 14 (30%) of the 46 visible nerves were difficult to trace precisely. A fascial plane between the medial and long heads of the triceps containing the radial nerve could be imaged clearly in 41 (91%) of the videos. CONCLUSIONS: : The radial nerve uncommonly lies immediately deep to the axillary artery. It is frequently located on the caudad side of the artery.

Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications.

BACKGROUND AND OBJECTIVES: Peripheral nerve blockade is associated with excellent patient outcomes after surgery; however, neurologic and other complications can be devastating for the patient. This article reports the development and preliminary results of a multicenter audit describing the quality and safety of peripheral nerve blockade. METHODS: From January 2006 to May 2008, patients who received peripheral nerve blockade had data relating to efficacy and complications entered into databases. All patients who received nerve blocks performed by all anesthetists during each hospital's contributing period were included. Patients were followed up by phone to detect potential neurologic complications. The timing of follow-up was either at 7 to 10 days or 6 weeks postoperatively, depending on practice location and time period. Late neurologic deficits were defined as a new onset of sensory and/or motor deficit consistent with a nerve/plexus distribution without other identifiable cause, and one of the following: electrophysiologic evidence of nerve damage, new neurologic signs, new onset of neuropathic pain in a nerve distribution area, paresthesia in relevant nerve/plexus distribution area. RESULTS: A total of 6950 patients received 8189 peripheral nerve or plexus blocks. Of the 6950 patients, 6069 patients were successfully followed up. In these 6069 patients, there were a total of 7156 blocks forming the denominator for late neurologic complications. Thirty patients (0.5%) had clinical features requiring referral for neurologic assessment. Three of the 30 patients had a block-related nerve injury, giving an incidence of 0.4 per 1000 blocks (95% confidence interval, 0.08-1.1:1000). The incidence of systemic local anesthetic toxicity was 0.98 per 1000 blocks (95% confidence interval, 0.42-1.9:1000). CONCLUSIONS: These results indicate that the incidence of serious complications after peripheral nerve blockade is uncommon and that the origin of neurologic symptoms/signs in the postoperative period is most likely to be unrelated to nerve blockade.