Biofilm formation in invasive Staphylococcus aureus isolates is associated with the clonal lineage.

The contribution of the genetic background of Staphylococcus aureus to biofilm formation is poorly understood. We investigated the association between the genetic background and the biofilm forming ability of clinical invasive S. aureus isolates. Secondary objectives included investigating any correlation with biofilm formation and methicillin resistance or the source of bacteraemia. The study was conducted at a 1300-bed tertiary hospital in Cape Town, South Africa. S. aureus isolates obtained from blood cultures between January 2010 and January 2012 were included. Genotypic characterization was performed by PFGE, spa typing, SCCmec typing and MLST. Thirty genotypically unique strains were assessed for phenotypic biofilm formation with the microtitre plate assay. All isolates were tested in triplicate and an average optical density, measured at a wavelength of 490 nm, was determined. The biofilm forming ability of isolates with A490 ≤ 0.17 were considered non-adherent, A490 > 0.17 'weak positive' and A490 > 0.34 'strong positive'. Fifty seven percent of isolates formed biofilms. Weak biofilm formation occurred in 40% (n = 12) and strong biofilm formation in 17% (n = 5) of isolates. All 5 isolates capable of strong biofilm formation belong to one spa clonal complex (spa-CC 064). Strains from spa-CC 064 were capable of higher biofilm formation than other spa clonal complexes (p = 0.00002). These 5 strains belonged to MLST CC5 and CC8. Biofilm formation correlates with the spa clonal lineage in our population of invasive S. aureus strains. Biofilm formation did not correlate with methicillin resistance and was not related to the source of bacteraemia.

The yield of different pleural fluid volumes for Mycobacterium tuberculosis culture.

We prospectively compared the culture yields of two pleural fluid volumes (5 and 100 ml) inoculated in liquid culture medium in 77 patients of whom 58 (75.3%) were diagnosed with pleural tuberculosis. The overall fluid culture yield was high (60.3% of cases with pleural tuberculosis). The larger volume had a faster time to positivity (329 vs 376 h, p=0.055) but its yield was not significantly higher (53.5% vs 50%; p=0.75). HIV-positive patients were more likely to have positive cultures (78.9% vs 51.5%; p=0.002).

Alienation and engagement in postgraduate training at a South African medical school.

BACKGROUND: The importance of contextual factors, such as the learning environment and sociocultural characteristics of the student, are becoming increasingly evident. Mann [2001. Alternative perspectives on the student experience: Alienation and engagement. Stud High Educ 26(1):7-19.] proposed that all learning experiences can be viewed as either alienating or engaging and Case expanded on this work. AIM: The purpose of this study was to explore perceptions of alienation or engagement as experienced by residents in anatomical pathology at one South African university. METHOD: A cross-sectional case study, with 16 semi-structured interviews was conducted. Residents were categorised as either alienated or engaged, based mainly on workplace experiences. RESULTS: Four relevant dimensions were identified; individual, home, workplace and institution. The personal attributes, strategies for coping and reasons for choosing pathology of alienated residents differed from those with engaged experiences. Poor socioeconomic background and schooling did not lead to predominantly alienating experiences, but this group still lacked some generic skills. In the workplace, two main factors resulting in alienated experiences were the interaction between residents and consultants and residents' comprehension of workplace-based learning. CONCLUSIONS: We present a simple model which may be used to identify factors that engage and alienate students in the learning experience in the workplace-based setting. Addressing these factors can contribute towards a more engaging experience for all residents.

Etiology and STI/HIV coinfections among patients with urethral and vaginal discharge syndromes in South Africa.

BACKGROUND: This study was undertaken to establish the etiology of the male urethral discharge (MUDS) and vaginal discharge (VDS) syndromes, to determine the prevalence of other sexually transmitted infections (STI) and human immunodeficiency virus (HIV) coinfections, and to examine associations between STIs and HIV serostatus among STI patients in South Africa. METHODS: A total of 507 MUDS and 300 VDS patients were recruited in Cape Town (CPT) and Johannesburg (JHB). A multiplex polymerase chain reaction assay detected Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium infections. Bacterial vaginosis and candidiasis were detected by microscopy. Sera were screened for syphilis, HSV-2, and HIV antibodies. RESULTS: Etiological diagnoses were made for 92% of MUDS patients and 85% of VDS patients. Gonorrhoea accounted for 85% (CPT) and 71% (JHB) of MUDS presentations. Chlamydia was the second most frequently detected MUDS pathogen (CPT, 13%; JHB, 24%). Among VDS patients, bacterial vaginosis was the most common cause (CPT, 46%; JHB, 36%) and trichomoniasis the most frequently detected STI pathogen (CPT, 19%; JHB, 34%). Few patients (4%) had serological evidence of syphilis. The HSV-2 and HIV seroprevalence were higher in Johannesburg compared to Cape Town and among women compared to men. HIV infection was statistically significantly associated with HSV-2 seropositivity at both sites and with the presence of N. gonorrhoeae and absence of C. trachomatis in Cape Town MUDS patients. CONCLUSIONS: Gonorrhoea and bacterial vaginosis were confirmed as the most frequent causes of MUDS and VDS. The high HIV seroprevalence in STI patients emphasizes the need to address HIV testing among this population.

Collaboration to partnerships.

Partnerships are at the center of the Hospital of the University of Pennsylvania Nursing Excellence Professional Practice (HUP-NEPP) model. Through the use of collaboration, skilled communication, and respectful workplace, partnerships can be formed, leading ultimately to world-class patient care. At HUP, interdisciplinary partnerships are evidenced by the clinical nurses through shared governance. This article describes the components necessary to form successful partnerships.

Use of light-emitting diode fluorescence microscopy to detect acid-fast bacilli in sputum.

BACKGROUND: Fluorescence microscopy offers well-described benefits, compared with conventional light microscopy, for the evaluation of sputum smear samples for tuberculosis. However, its use in resource-limited settings has been limited by the high cost of the excitatory light source. We evaluated the diagnostic performance of fluorescence microscopy, using novel light-emitting diode (LED) technology as an alternative to the conventional mercury vapor lamp (MVP). METHODS: Routinely collected sputum specimens from persons suspected to have tuberculosis who attended community clinics were stained with auramine O and were evaluated using 2 different excitatory light sources (MVP and LED); these specimens were then Ziehl-Neelsen stained and reexamined using light microscopy. Two microscopists independently evaluated all smears. Bacterial culture provided the gold standard. RESULTS: Of the 221 sputum specimens evaluated, 36 (16.3%) were positive for Mycobacterium tuberculosis by culture. Sensitivity and specificity documented for the different modalities were 84.7% and 98.9%, respectively, for the LED assessment; 73.6% and 99.8%, respectively, for the MVP assessment; and 61.1% and 98.9%, respectively, for light microscopy. kappa values for interreader variation were 0.87 for the LED assessment, 0.79 for the MVP assessment, and 0.77 for light microscopy. The mean time to read a negative smear was 1.4 min with fluorescence microscopy and 3.6 min with light microscopy, reflecting a time savings of 61% with fluorescence microscopy. CONCLUSION: LED fluorescence microscopy provides a reliable alternative to conventional methods and has many favorable attributes that facilitate improved, decentralized, diagnostic services.

High incidence of antimicrobial resistant organisms including extended spectrum beta-lactamase producing Enterobacteriaceae and methicillin-resistant Staphylococcus aureus in nasopharyngeal and blood isolates of HIV-infected children from Cape Town, South Africa.

BACKGROUND: There is little information on nasopharyngeal (NP) flora or bacteremia in HIV-infected children. Our aim was to describe the organisms and antimicrobial resistance patterns in children enrolled in a prospective study comparing daily and three times weekly trimethoprim-sulfamethoxazole (TMP-SMX) and isoniazid (INH) or placebo prophylaxis. METHODS: NP swabs were taken at baseline from HIV-infected children enrolled in the study. Standard microbiological techniques were used. Children were grouped according to previous or current exposure to TMP-SMX and whether enrolled to the study during a period of hospitalization. Blood culture results were also recorded within 12 months of baseline. RESULTS: Two hundred and three children, median age 1.8 (Interquartile [IQ]: 0.7-4) years had NP swabs submitted for culture. One hundred and eighty-four (90.7%) had either stage B or C HIV disease. One hundred and forty-one (69.8%) were receiving TMP-SMX and 19 (9.4%) were on antiretroviral therapy. The majority, 168 (82%) had a history of hospitalization and 91 (44.8%) were enrolled during a period of hospitalization. Thirty-two subjects (16.2%) died within 12 months of study entry. One hundred and eighty-one potential pathogens were found in 167 children. The most commonly isolated organisms were Streptococcus pneumoniae (48: 22.2%), Gram-negative respiratory organisms (Haemophilus influenzae and Moraxella catarrhalis) (47: 21.8%), Staphylococcus aureus (44: 20.4%), Enterobacteriaceae 32 (14.8%) and Pseudomonas 5 (2.3%). Resistance to TMP-SMX occurred in > 80% of pathogens except for M. catarrhalis (2: 18.2% of tested organisms). TMP-SMX resistance tended to be higher in those receiving it at baseline (p = 0.065). Carriage of Methicillin resistant S. aureus (MRSA) was significantly associated with being on TMP-SMX at baseline (p = 0.002). Minimal inhibitory concentrations (MIC) to penicillin were determined for 18 S. pneumoniae isolates: 7 (38.9%) were fully sensitive (MIC or=2 microg/ml). Fifty percent of Enterobacteriaceae produced extended spectrum beta-lactamases (ESBL) (resistant to third generation cephalosporins) and 56% were resistant to gentamicin. Seventy-seven percent of S. aureus were MRSA. Carriage of resistant organisms was not associated with hospitalization.On multivariate logistic regression, risk factors for colonization with Enterobacteriaceae were age

SDS interferes with SaeS signaling of Staphylococcus aureus independently of SaePQ.

The Staphylococcus aureus regulatory saePQRS system controls the expression of numerous virulence factors, including extracellular adherence protein (Eap), which amongst others facilitates invasion of host cells. The saePQRS operon codes for 4 proteins: the histidine kinase SaeS, the response regulator SaeR, the lipoprotein SaeP and the transmembrane protein SaeQ. S. aureus strain Newman has a single amino acid substitution in the transmembrane domain of SaeS (L18P) which results in constitutive kinase activity. SDS was shown to be one of the signals interfering with SaeS activity leading to inhibition of the sae target gene eap in strains with SaeS(L) but causing activation in strains containing SaeS(P). Here, we analyzed the possible involvement of the SaeP protein and saePQ region in SDS-mediated sae/eap expression. We found that SaePQ is not needed for SDS-mediated SaeS signaling. Furthermore, we could show that SaeS activity is closely linked to the expression of Eap and the capacity to invade host cells in a number of clinical isolates. This suggests that SaeS activity might be directly modulated by structurally non-complex environmental signals, as SDS, which possibly altering its kinase/phosphatase activity.

Accreditation of undergraduate medical training programs: practices in nine developing countries as compared with the United States.

CONTEXT AND OBJECTIVES: Undergraduate medical training program accreditation is practiced in many countries, but information from developing countries is sparse. We compared medical training program accreditation systems in nine developing countries, and compared these with accreditation practices in the United States of America (USA). METHODS: Medical program accreditation practices in nine developing countries were systematically analyzed using all available published documents. Findings were compared to USA accreditation practices. FINDINGS: Accreditation systems with explicitly defined criteria, standards and procedures exist in all nine countries studied: Argentina, India, Kenya, Malaysia, Mongolia, Nigeria, Pakistan, Philippines and South Africa. Introduction of accreditation processes is relatively recent, starting in 1957 in India to 2001 in Malaysia. Accrediting agencies were set up in these countries predominantly by their respective governments as a result of legislation and acts of Parliament, involving Ministries of Education and Health. As in the USA, accreditation: (1) serves as a quality assurance mechanism promoting professional and public confidence in the quality of medical education, (2) assists medical schools in attaining desired standards, and (3) ensures that graduates' performance complies with national norms. All nine countries follow similar accreditation procedures. Where mandatory accreditation is practiced, non-compliant institutions may be placed on probation, student enrollment suspended or accreditation withdrawn. CONCLUSION: Accreditation systems in several developing countries are similar to those in the developed world. Data suggest the trend towards instituting quality assurance mechanisms in medical education is spreading to some developing countries, although generalization to other areas of the world is difficult to ascertain.

Edema agudo de pulmäo em hipertensäo severa na gravidez: apresentaçäo de um caso / Pulmonary edema in severe hypertension and pregnancy: a case report

Os autores descrevem caso de doença hipertensiva vascular crônica que complicou com edema agudo de pulmäo. Para melhora do quadro clínico respiratório optou-se porcesariana "in extremis", que trouxe reversäo imediata da petologia pulmonar. Evoluiu bem nos 30 dias subsequentes, mas no 31º dia fez novo edema agudo e faleceu, fato que, concordante com literatura, é complicaçäo comum