Post-translational modification by the Pgf glycosylation machinery modulates Streptococcus mutans OMZ175 physiology and virulence.

Streptococcus mutans is commonly associated with dental caries and the ability to form biofilms is essential for its pathogenicity. We recently identified the Pgf glycosylation machinery of S. mutans, responsible for the post-translational modification of the surface-associated adhesins Cnm and WapA. Since the four-gene pgf operon (pgfS-pgfM1-pgfE-pgfM2) is part of the S. mutans core genome, we hypothesized that the scope of the Pgf system goes beyond Cnm and WapA glycosylation. In silico analyses and tunicamycin sensitivity assays suggested a functional overlap between the Pgf machinery and the rhamnose-glucose polysaccharide synthesis pathway. Phenotypic characterization of pgf mutants (ΔpgfS, ΔpgfE, ΔpgfM1, ΔpgfM2, and Δpgf) revealed that the Pgf system is important for biofilm formation, surface charge, membrane stability, and survival in human saliva. Moreover, deletion of the entire pgf operon (Δpgf strain) resulted in significantly impaired colonization in a rat oral colonization model. Using Cnm as a model, we showed that Cnm is heavily modified with N-acetyl hexosamines but it becomes heavily phosphorylated with the inactivation of the PgfS glycosyltransferase, suggesting a crosstalk between these two post-translational modification mechanisms. Our results revealed that the Pgf machinery contributes to multiple aspects of S. mutans pathobiology that may go beyond Cnm and WapA glycosylation.

Involvement of the Streptococcus mutans PgfE and GalE 4-epimerases in protein glycosylation, carbon metabolism, and cell division.

Streptococcus mutans is a key pathogen associated with dental caries and is often implicated in infective endocarditis. This organism forms robust biofilms on tooth surfaces and can use collagen-binding proteins (CBPs) to efficiently colonize collagenous substrates, including dentin and heart valves. One of the best characterized CBPs of S. mutans is Cnm, which contributes to adhesion and invasion of oral epithelial and heart endothelial cells. These virulence properties were subsequently linked to post-translational modification (PTM) of the Cnm threonine-rich repeat region by the Pgf glycosylation machinery, which consists of 4 enzymes: PgfS, PgfM1, PgfE, and PgfM2. Inactivation of the S. mutans pgf genes leads to decreased collagen binding, reduced invasion of human coronary artery endothelial cells, and attenuated virulence in the Galleria mellonella invertebrate model. The present study aimed to better understand Cnm glycosylation and characterize the predicted 4-epimerase, PgfE. Using a truncated Cnm variant containing only 2 threonine-rich repeats, mass spectrometric analysis revealed extensive glycosylation with HexNAc2. Compositional analysis, complemented with lectin blotting, identified the HexNAc2 moieties as GlcNAc and GalNAc. Comparison of PgfE with the other S. mutans 4-epimerase GalE through structural modeling, nuclear magnetic resonance, and capillary electrophoresis demonstrated that GalE is a UDP-Glc-4-epimerase, while PgfE is a GlcNAc-4-epimerase. While PgfE exclusively participates in protein O-glycosylation, we found that GalE affects galactose metabolism and cell division. This study further emphasizes the importance of O-linked protein glycosylation and carbohydrate metabolism in S. mutans and identifies the PTM modifications of the key CBP, Cnm.

Nutritional markers for predicting lower extremity free tissue transfer outcomes in the chronic wound population.

BACKGROUND: Optimizing nutritional status is critical to maximize flap success and healing. Prealbumin and albumin have been utilized as easily obtained proxies for overall nutritional status. The aim of this study was to investigate whether these markers are correlated with healing time and overall flap healing after lower extremity (LE) free tissue transfer (FTT) in the chronic wound population. METHODS: A retrospective review of LE chronic wound FTT patients treated by a single surgeon at our institution from 2011 to 2020 was performed. Data collected included demographics, comorbidities, flap characteristics, and perioperative labs. The outcomes of interest were flap healing (FH) and time to flap healing (TFH). RESULTS: We identified 69 patients undergoing LE FTT for limb salvage meeting our inclusion criteria. When using a threshold of <3.5 g/dl for low albumin and < 20 mg/dl for low prealbumin, no significance was found between FH or TFH and preoperative albumin or preoperative prealbumin. With low albumin defined as <2.7 g/dl with the prealbumin threshold unchanged, TFH was significantly increased, and FH was significantly decreased compared with the defined normal preoperative albumin group. CONCLUSIONS: Low preoperative albumin, when defined as <3.5 g/dl, and prealbumin did not correlate with TFH or FH. Contrarily, when defined as <2.7 g/dl, low preoperative albumin correlated significantly with increased TFH and decreased FH rates. Further investigation into validated biomarkers and their thresholds is needed to assess the effect of nutritional status on wound healing and guide perioperative optimization.

Trends in Craniofacial Fellowship Career Outcomes: A Call for Expanding Professional Opportunities in Craniofacial Surgery.

PURPOSE: Limited available pediatric plastic surgery positions fail to accommodate the increasing number of craniofacial fellows trained annually. However, many adult indications have increased the demand for craniofacial expertise. Given new opportunities available to craniofacial surgeons, the authors aim to evaluate career prospects for recent craniofacial graduates and explore additional career opportunities. METHODS: Upon approval from the American Society of Craniofacial Surgeons (ASCFS), an anonymous online survey invitation was sent to craniofacial fellows who graduated from 2016 to 2021. Respondents were queried regarding their craniofacial fellowship and subsequent career prospects. RESULTS: A total of 124 eligible participants were identified, of which 30 (24.2%) responded. Craniomaxillofacial case distribution at respondents' current practices varied, with 42.3% reporting a 50% to 75% craniofacial caseload and 38.5% reporting less than 25%. Craniofacial trauma reconstruction was performed most at current positions (92.3%), followed by general reconstruction (92.3%) and breast surgery (69.2%); the least commonly performed was facial feminization (23.1%). Most respondents desired an increased craniomaxillofacial caseload (65.4%). However, 26.9% were unable to secure their current position before fellowship completion, and 80.0% cited limited craniofacial job availability. Recommendations to improve fellowship comprehensiveness and increase candidate competitiveness included increased facial feminization, facial esthetic, and microsurgical experience. CONCLUSION: To adapt to trends in craniomaxillofacial surgery, ASCFS should encourage developing fellowships that increase exposure to gender-affirming, adult craniofacial reconstruction, orthognathic, and skeletal facial esthetic surgery. Expanding training beyond congenital deformities can provide additional employment opportunities while maintaining excellence and innovation in facial plastic surgery.

Botulinum Toxin to Improve Scar Quality in Cleft Lip Repair: A Systematic Review.

OBJECTIVE: Cleft lip repair (CLR) can be complicated by hypertrophic scar or keloid. Botulinum toxin type A (BTA) may improve postoperative scarring by reducing muscle tension and cytokine activity at the scar site. This systematic review analyzes the available evidence regarding the effect of BTA on scar quality after CLR. DESIGN: The search was conducted in 6 different databases in accordance with PRISMA guidelines (PubMed, Scielo, Embase, Scopus, Web of Science, and Cochrane) using "botulinum toxin" and "cleft lip" as keywords. SETTING: Academic hospital. PATIENTS: Exclusive to patients who underwent CLR and BTA injection. OUTCOME MEASURES: Mean visual analog scores (VAS), mean Vancouver scar scale (VSS), scar width, and BTA or CLR-related complications. RESULTS: Five studies for a total of 216 patients met inclusion criteria. Four studies reported on primary CLR during infancy while 1 study recruited older patients seeking revision. All patients had BTA (range: 1-2 units/kg) injected in the orbicularis oris muscle. One study documented BTA injections in additional perioral muscles. All 4 studies that measured scar width and had a saline control arm found a significant decrease in width with BTA injection. Improvement of VAS and VSS with BTA was reported in 3 of 5 studies and 2 of 5 studies, respectively. There were no reports of complications associated with BTA or CLR. CONCLUSION: The existing studies support the use of BTA injection to improve scar quality following CLR with low concern for complication. Further investigations with a greater number of patients are necessary.

Amputation Acceptance: A Survey of Factors Influencing the Decision to Undergo Lower Extremity Amputation.

Accepting to undergo amputation is an arduous process often fraught with confusion, fear, and uncertainty. To assess how to best facilitate discussions with at-risk patients, we surveyed lower extremity amputees about their experiences surrounding this decision-making process. Patients who underwent lower extremity amputation at our institution from October 2020 to October 2021 were asked to complete a 5-item telephone survey assessing their decision to undergo amputation and postoperative satisfaction. Retrospective chart review of respondent demographics, comorbidities, operative details, and complications was conducted. Of 89 lower extremity amputees identified, 41 (46.07%) responded to the survey, with the majority undergoing below-knee amputations (n = 34, 82.93%). At a mean follow-up of 5.90 ± 3.45 months, 20 patients (48.78%) were ambulatory. Surveys were completed at a mean of 7.74 ± 4.03 months since amputation. Factors that helped patients decide to undergo amputation included discussions with doctors (n = 32, 78.05%) and concern for worsening health (n = 19, 46.34%). Deteriorating ability to walk (n = 18, 45.00%) was the most common concern prior to surgery. Recommendations by survey respondents to ease the decision-making process included speaking with amputees (n = 9. 22.50%), more discussions with doctors (n = 8, 20.00%), and access to mental health and social services (n = 2, 5.00%); however, many had no recommendations (n = 19, 47.50%), and most were pleased with their decision to undergo amputation (n = 38, 92.68%). Despite most patients primarily citing satisfaction with their decision to undergo lower extremity amputation, it is critical to consider factors that affect patient decisions and recommendations to improve this decision-making process.

TeleNeuroICU: Expanding the Reach of Subspecialty Neurocritical Care.

Telemedicine is a rapidly growing field of medicine due to a combination of high-speed global telecommunication systems and accessibility of small, fast mobile computing platforms with bidirectional audiovisual camera capabilities. Teleneurology is a subset of telemedicine. TeleNeuroICU, one form of teleneurology, is the practice of virtually consulting on patients in the ICU setting with neurological and neurosurgical conditions. Given the current and future shortage of neurologists and neurointensivists, there is a high demand for TeleNeuroICU services around the globe and this is expected to increase in the future. This review summarizes the state of the art around the TeleNeuroICU practice for practitioners in the field, emerging research in this area, and new technologies and integrations that enhance the value of TeleNeuroICU to health care systems.

Risk factors for bacteremia and central line-associated blood stream infections in children with acute myelogenous leukemia: A single-institution report.

BACKGROUND: Central line-associated blood stream infections (CLABSIs) are a source of high morbidity and mortality in children with acute myelogenous leukemia (AML). PROCEDURE: To understand the epidemiology and risk factors associated with the development of CLABSI in children with AML. METHODS: We retrospectively reviewed all patients with AML over a 5-year period between 2007 and 2011 at the Children's Hospital Colorado. Cases and controls were classified on the basis of the presence of a CLABSI as defined by the National Healthcare Safety Network. RESULTS: Of 40 patients in the study, 25 (62.5%) developed at least one CLABSI during therapy. The majority of CLABSIs were due to oral or gastrointestinal organisms (83.0%). Skin organisms accounted for 8.5%. In a multivariable analysis, the strongest risk factors associated with CLABSI were diarrhea (odds ratio [OR] 6.7, 95% confidence interval [CI] 1.6-28.7), receipt of blood products in the preceding 4-7 days (OR 10.0, 95%CI 3.2-31.0), not receiving antibiotics (OR 8.3, 95%CI 2.8-25.0), and chemotherapy cycle (OR 3.5, 95%CI 1.4-8.9). CLABSIs led to increased morbidity, with 13 cases (32.5%) versus two controls (1.9%) requiring transfer to the pediatric intensive care unit (P < 0.001). Three (7.5%) of 40 CLABSI events resulted in or contributed to death. CONCLUSIONS: Intensified line care efforts cannot eliminate all CLABSIs in the patients with AML. Exploring the role of mucosal barrier breakdown and/or the use of antibiotic prophylaxis may be effective strategies for further prevention of CLABSIs, supporting ongoing trials in this patient population.

Ischemic Stroke After Wasp Sting.

BACKGROUND: Despite the common occurrence of hymenopteran stings worldwide, primary neurologic manifestations including stroke are rare. We report a case of a healthy male who developed a right middle cerebral artery (MCA) territory ischemic stroke after getting stung by a wasp. CASE REPORT: A 44-year-old man with hypertension presented to the hospital with sudden-onset left hemiparesis, left facial weakness, and dysarthria after being stung by a wasp. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) scans of the brain revealed a right MCA territory infarct and a lack of flow in the distal right internal carotid artery and MCA. He was treated with intravenous tissue plasminogen activator. A computed tomography angiography scan of the brain performed 24 hours later revealed multiple regions of vasoconstriction in the territory of the bilateral MCA. Evaluations for causes of stroke, including echocardiography and telemetry, were not revealing. Immunologic testing showed significantly elevated levels of serum wasp immunoglobulin E. Therapy with aspirin and atorvastatin was started. At discharge, the patient had a mild left facial droop but normal strength in his left arm and leg. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians encounter large numbers of hymenopteran sting cases each year. These patients typically present with local reactions, such as itching, pain, and erythema. Systemic manifestations, such as anaphylaxis causing severe hypotension and bronchospasm, are less common but deadly. Neurologic complications, such as ischemic stroke, are extremely rare. This manuscript highlights the pathophysiology and management of stroke after a hymenopteran sting. There are no guidelines for the management of stroke after a hymenopteran sting, and therefore we intend to provide some guidance to physicians for treating stroke after a hymenopteran sting.

A Retrospective Review of Patient-reported Outcomes after Postaxial Polydactyly Ligation and Surgical Excision.

Background: Interventions for type B postaxial polydactyly include suture ligation and surgical excision, yet there is a paucity of literature comparing the outcomes of these procedures. This study sought to compare patient-reported long-term outcomes of postaxial digit excision. Methods: A six-question survey was distributed from January 2021 to March 2022 to patients who underwent treatment for type B postaxial polydactyly at a single pediatric institution from 2010 to 2016. Patients were queried about the incidence of pain sensitivity, keloid healing, and/or persistent presence of bump ("nubbin") at the treatment site. Results: A total of 158 responses accounting for 258 digits were attained for a 53% response rate. The majority of digits (67.4%, n = 174) were surgically excised. Median age at procedure was 49 days: 13.0 days for ligation, 63.0 days for surgical excision. Median age at survey was 8 [IQR 5.4-10.2] years. Short-term (<30 days after procedure) complications rate was 1.6%. The rate of a raised or sensitive scar was 39.5% (ligation 51.5% versus surgery 35.4%, P < 0.05). The likelihood of postoperative sensitivity (P = 0.80) was similar among groups. However, the odds of a residual bump or raised scar at the surgical site was significantly higher in the ligation group (P = 0.001). These findings remained significant in the adjusted analysis. Conclusion: This study suggests that suture ligation can be used in select cases without increasing the prevalence of long-term pain or sensitivity, albeit with greater risk of a bump or raised scar at the excision site compared with surgical excision.

Racial and Ethnic Disparities in Inpatient Interventional Pain Management for Lumbar Radiculopathy.

BACKGROUND: Chronic pain is a common reason adults seek care; patients often feel that their pain is inadequately managed. Spine-related pain is the most common chronic pain concern, and lumbar radiculopathy is often the cause. Racial and ethnic disparities in the pharmacologic management of pain are well described, but less is known about these disparities regarding interventional procedures. OBJECTIVE: To study the utilization rates of physical therapy, epidural steroid injection, surgery, and spinal cord stimulation in hospitalized patients with lumbar radiculopathy across different races, ethnicities, and genders. STUDY DESIGN: A retrospective cross-sectional study design. METHODS: The National Inpatient Sample was used to identify 252,790 patients with lumbar radiculopathy, after sample weighting, from 2016-2019. Independent variables were race, ethnicity, age, gender, insurance, geography, year, and severity. Dependent variables were physical therapy, epidural steroid injection, spinal cord stimulator, or surgery (reference group). Conservative management was defined as nonoperative treatment ranging from physical therapy to epidural steroid injection. Data were analyzed with a logistic regression for complex surveys. Regressions were adjusted for age, insurance, geography, and other socioeconomic factors. RESULTS: Most patients were white (78.3%) and received surgery (95.0%). Severe disease was most common among African Americans (9.3%), but was similar across other races, ethnicities, and genders. Medicaid was more common among African Americans and Hispanics. An adjusted analysis showed that African Americans and Hispanics received more epidural steroid injections (odds ratio [OR] = 1.52; 95%CI, 1.3 - 1.8) and (OR = 1.43; 95%CI, 1.1 - 1.8) respectively; and physical therapy (OR = 1.65; 95%CI, 1.1 - 2.5) and (OR = 1.83; 95%CI, 1.2 - 2.8) respectively, than whites compared to surgery. African Americans received a spinal cord stimulator less often than whites compared to surgery (OR = 0.63; 95%CI. 0.4 - 0.9). Women received an epidural steroid injection more frequently than men compared to surgery (OR = 1.29; 95%CI, 1.2 - 1.4). LIMITATIONS: Generalizability is limited because conservative therapies are often outpatient treatments. CONCLUSION: Disparities were observed in lumbar radiculopathy treatment after independent variable adjustment. African Americans received conservative therapy more often than whites despite increased disease severity. Hispanics and women had similar disease severity compared to whites and men, respectively, but received more conservative therapies. Further investigation in outpatient settings is needed to definitively describe these disparities. KEY WORDS: Chronic pain, pain management, back pain, lumbar radiculopathy, epidural steroid injection, spinal cord stimulation, low back surgery, physical therapy, racial disparities, gender disparities.

Prevalence of Prohibited Questions during Plastic Surgery Residency Interviews.

Despite rules set forth by the National Resident Matching Program and American Association of Medical Colleges (AAMC), prohibited questions during the residency interview process are well documented. This study describes the prevalence of these encounters by surveying residency applicants to integrated plastic and reconstructive surgery (PRS) programs for the 2022 match cycle. Methods: An anonymous 16-question REDCap survey was distributed to 2022 cycle applicants of a single PRS program. The applicants were queried about demographic information, interview experience, and questions deemed illegal by the AAMC/NRMP guidelines. Results: One hundred survey responses were attained for a 33.1% response rate. The majority of respondents were aged 26-30 (76%), women (53%), and white (53%); 33% received 15+ interviews for the application cycle. Seventy-eight percent of respondents reported being asked a prohibited question during at least one interview, with the most common "illegal" question categories being number/ranking of interviews (42%), marital status (33%), career balance (25%), and race/ethnicity (22%). Only 25.6% of applicants considered the subject matter inappropriate, whereas 42.3% were unsure. Although no applicant took action to report the potentially illegal scenarios, 30% said that their experiences influenced their rank list. Conclusions: Our survey study revealed that prohibited interview questions in PRS residency interviews are common. Permissible lines of questioning and discussion between programs and applicants during residency interviews have been defined by AAMC. Institutions should provide guidance and training to all participants. Applicants should be made aware of and empowered to utilize available anonymous reporting tools.

Examining the unmet needs of chronic wound patients with common mental disorders.

BACKGROUND: Common mental disorders (CMD) are highly morbid conditions not routinely screened for in chronic wound care. A comorbid psychiatric condition's influence on a patient with chronic wounds' quality of life (QoL) is unknown. This study investigates the implications of CMD on QoL in patients with chronic lower extremity (LE) wounds. METHODS: This cross-sectional study surveyed patients with chronic LE wounds evaluated in our multidisciplinary clinic between June-July 2022. Surveys included validated physical and social QoL questionnaires, including the Lower Extremity Functional Scale (LEFS), Patient-Reported Outcomes Measurement Information System (PROMIS-3a) Scale v2.0, 12-Item Short-Form (SF-12), and a screening tool for common mental disorders, the Self-Reporting Questionnaire 20 (SRQ-20). Data regarding patient demographics, comorbidities, psychiatric diagnoses, and wound care history were retrospectively collected. RESULTS: Of the 265 identified patients, 39 (14.7%) had documented psychiatric diagnoses, most often depression or anxiety. The diagnosed cohort had higher median SRQ-20 scores (6, IQR: 6 vs. 3, IQR: 5; P < 0.001) and a higher proportion of positive screens for CMD (30.8% vs. 15.5%; P = 0.020) than non-diagnosed patients. There were no differences in physical or social QoL in patients with and without a psychiatric diagnosis. However, individuals screening positively for CMD experienced significantly more pain (T-score 60.2 vs. 51.4, P = 0.0052) and reduced function (LEFS 26.0 vs. 41.0, P < 0.0000). CONCLUSION: This study illustrates that patients with chronic LE wounds experience potentially meaningful psychologic distress. Further, symptoms of a CMD (SRQ-20 ≥8), rather than a previous diagnosis, may influence pain and functional outcomes. These findings emphasize the potential relevance of psychological distress in this population and reinforce the need for further investigation of actionable responses to this apparent need.

Evolution of Anomaly-Specific Techniques in Infant Ear Molding: A 10-Year Retrospective Study.

BACKGROUND: Congenital ear anomalies occur in at least one-third of the population, and less than one-third of cases self-correct. Ear molding is an alternative to surgery that spares operative morbidity and allows for significantly earlier intervention. In this retrospective study, the senior author (S.B.B.) developed a tailored approach to each specific type of ear deformity. The use of modifications to adapt standard ear molding techniques for each unique ear are described. METHODS: The authors conducted a retrospective, institutional review board-approved study of 246 patients who underwent ear molding performed by a single surgeon. The procedure reports for each case were reviewed to develop stepwise customization protocols for existing EarWell and InfantEar systems. RESULTS: This review included 385 ears in 246 patients. Patient age at presentation ranged from less than 1 week to 22 weeks. Presenting ear deformities were subclassified into mixed (37.4 percent), helical rim (28.5 percent), prominent (10.6 percent), lidding/lop (9.3 percent), Stahl ear (3.6 percent), conchal crus (3.3 percent), and cupping (2.8 percent). Two patients (0.8 percent) had cryptotia. Deformity subclass could not be obtained for 11 patients (4.5 percent). Recommended modifications to existing ear correction systems are deformity-specific: cotton-tip applicator/setting material (Stahl ear), custom dental compound mold (lidding/lop and cupping), scaphal wire (helical rim), cotton-tip applicator/protrusion excision (prominent), and custom dental compound stent (conchal crus). CONCLUSIONS: Presentation of ear anomalies is heterogenous. This 10-year experience demonstrates that the approach to ear molding should be dynamic and customized, using techniques beyond those listed in system manuals to complement each ear and to improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A 10-Year Retrospective Review of the Nonsurgical Treatment of Infant Ear Anomalies.

BACKGROUND: A review of a single surgeon's 10-year experience treating congenital ear anomalies using nonsurgical ear molding is presented. This study assesses the efficacy of treating a variety of anomalies in infants with age ranging from younger than 1 week to 22 weeks and identifies potential barriers to care. METHODS: A retrospective chart and photographic review of 246 consecutive infants treated with ear molding between 2010 and 2019 was undertaken. Data regarding patient demographics, anomaly classification, device selection, treatment duration, adverse events, and satisfaction with outcomes were collected. RESULTS: This study included 385 infant ear anomalies in 246 patients. Median age at initiation of treatment was 16 days and median treatment duration was 29.5 days. A median number of three devices was needed to complete bilateral treatment. Treated anomalies included mixed deformity, helical rim, prominent, lidding/lop, Stahl ear, conchal crus, cupping, and cryptotia. Complications occurred in 47 patients, with skin breakdown being the most common [26 patients (55.3 percent)]. Satisfaction rate was 92 percent in 137 surveyed parents. Median patient household income was approximately $112,911, and treatment was covered by insurance for 244 of 246 patients. CONCLUSIONS: The study outcomes demonstrate that ear molding can be effective in patients as old as 22 weeks without compromising treatment duration or complexity. In addition, in the authors' experience, molding is an effective treatment for the majority of infant ear deformities. Despite a steady increase in patient volume over the past 10 years and consistent coverage of treatment by insurance, the authors' catchment area continues to be largely limited to affluent households. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Relationship Between Autoimmune Disease and Disease-Modifying Antirheumatic Drugs on Wound Healing.

Objective: To evaluate the role of disease-modifying antirheumatic drugs (DMARDs) on wound healing outcomes of patients with autoimmune disease at our tertiary wound care center. Approach: Retrospective review of patients presenting to our wound care center between 2014 and 2018 with both chronic wounds and a history of inflammatory disease. Patient demographics, comorbid conditions, and progression to complete wound healing were compared between those taking DMARDs or not at the time of wound onset. The study adheres to the STROBE statement. Results: Fifty-eight patients with a total of 296 wounds were retrospectively reviewed. Patients were taking at least one DMARD at wound onset in 217 (73.3%) of these wounds. The average number of DMARDs at wound onset was 1.5 (standard deviation 1.2). Two hundred ten wounds progressed to heal (70.9%), with a median time to healing of 229.5 days (interquartile range 71.0-490.0). Of the 210 wounds that healed, patients taking at least one DMARD had a significantly shorter time to healing relative to patients who were not on any DMARDs (median 190.5 days vs. 340.0 days, p = 0.0156). Innovation: Characterizing wound healing outcomes at a tertiary hospital with a dedicated wound care center and analyzing the role of DMARDs in wound healing progression. Conclusions: The median time to healing in the studied cohort was 229.5 days, which is much longer than the healing time for noninfected diabetic foot ulcers at our institution. These findings highlight the wound healing challenges posed by underlying autoimmune disease.10.

Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions.

OBJECTIVES: To compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time. PATIENTS AND METHODS: A retrospective analysis was performed using data from Florida's Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks. RESULTS: In 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P<.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005). CONCLUSION: This study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.

Development, Phenotypic Characterization and Genomic Analysis of a Francisella tularensis Panel for Tularemia Vaccine Testing.

Francisella tularensis is one of several biothreat agents for which a licensed vaccine is needed to protect against this pathogen. To aid in the development of a vaccine protective against pneumonic tularemia, we generated and characterized a panel of F. tularensis isolates that can be used as challenge strains to assess vaccine efficacy. Our panel consists of both historical and contemporary isolates derived from clinical and environmental sources, including human, tick, and rabbit isolates. Whole genome sequencing was performed to assess the genetic diversity in comparison to the reference genome F. tularensis Schu S4. Average nucleotide identity analysis showed >99% genomic similarity across the strains in our panel, and pan-genome analysis revealed a core genome of 1,707 genes, and an accessory genome of 233 genes. Three of the strains in our panel, FRAN254 (tick-derived), FRAN255 (a type B strain), and FRAN256 (a human isolate) exhibited variation from the other strains. Moreover, we identified several unique mutations within the Francisella Pathogenicity Island across multiple strains in our panel, revealing unexpected diversity in this region. Notably, FRAN031 (Scherm) completely lacked the second pathogenicity island but retained virulence in mice. In contrast, FRAN037 (Coll) was attenuated in a murine pneumonic tularemia model and had mutations in pdpB and iglA which likely led to attenuation. All of the strains, except FRAN037, retained full virulence, indicating their effectiveness as challenge strains for future vaccine testing. Overall, we provide a well-characterized panel of virulent F. tularensis strains that can be utilized in ongoing efforts to develop an effective vaccine against pneumonic tularemia to ensure protection is achieved across a range F. tularensis strains.