Effect of Variable Lower Extremity Immobilization Devices on Emergency Brake Response Driving Outcomes.

The effect of lower extremity pathologic features and surgical intervention on automobile driving function has been a topic of contemporary interest in the orthopedic medical literature. The objective of the present case-control investigation was to assess 3 driving outcomes (i.e., mean emergency brake response time, frequency of abnormally delayed brake responses, and frequency of inaccurate brake responses) in a group of participants with 3 variable footwear conditions (i.e., regular shoe gear, surgical shoe, and walking boot). The driving performances of 25 participants without active right-sided lower extremity pathology were evaluated using a computerized driving simulator. Both the surgical shoe (0.611 versus 0.575 second; p < .001) and the walking boot (0.736 versus 0.575 second; p < .001) demonstrated slower mean brake response times compared with the control shoe gear. Both the surgical shoe (18.5% versus 2.5%; p < .001) and the walking boot (55.5% versus 2.5%; p < .001) demonstrated more frequent abnormally delayed brake responses compared with the control shoe gear. The walking boot (18.0% versus 2.0%; p < .001) demonstrated more frequent inaccurate brake responses compared with the control shoe gear. However, the surgical shoe (4.0% versus 2.0%; p = .3808) did not demonstrate a difference compared with the control shoe gear. The results of the present investigation provide physicians working with the lower extremity with a better understanding on how to assess the risk and appropriately advise their patients who have been prescribed lower extremity immobilization devices with respect to the safe operation of an automobile.

Hospital-wide survey of bacterial contamination of point-of-care ultrasound probes and coupling gel.

OBJECTIVES: The purpose of this study was to determine the hospital-wide incidence of bacterial contamination of point-of-care (bedside) ultrasound probes and coupling gel at a single academic medical center to predict the risk of nosocomial spread of infection. METHODS: Bacterial cultures were performed on all point-of-care ultrasound probe surfaces and associated gel bottles in our institution (82 total probes in 9 separate departments). This process was repeated every 2 weeks for a total of 8 weeks; therefore, each probe was cultured 4 times during the study period. RESULTS: Of the 320 probe cultures, 18 (5.6%), resulted in positive growth, all of which identified nonpathogenic organisms common to human skin flora and the environment. No methicillin-resistant Staphylococcus aureus or other notable pathogens were identified. No gel cultures resulted in bacterial growth. CONCLUSIONS: Bacterial contamination of point-of-care ultrasound probes and coupling gel is low at this single academic medical center and involves nonpathogenic organisms only.

Assessment of a novel continuous cleaning device using metatranscriptomics in diverse hospital environments.

Introduction: Despite routine implementation of cleaning and disinfection practices in clinical healthcare settings, high-touch environmental surfaces and contaminated equipment often serve as reservoirs for the transmission of pathogens associated with healthcare-associated infections (HAIs). Methods: The current study involved the analysis of high-touch surface swabs using a metatranscriptomic sequencing workflow (CSI-Dx™) to assess the efficacy of cleanSURFACES® technology in decreasing microbial burden by limiting re-contamination. This is a non-human single center study conducted in the Emergency Department (ED) and on an inpatient Oncology Ward of Walter Reed National Military Medical Center that have followed hygienic practices during the COVID-19 pandemic environment. Results: Although there was no difference in observed microbial richness (two-tailed Wilcoxon test with Holm correction, P > 0.05), beta diversity findings identified shifts in microbial community structure between surfaces from baseline and post-intervention timepoints (Day 1, Day 7, Day 14, and Day 28). Biomarker and regression analyses identified significant reductions in annotated transcripts for various clinically relevant microorganisms' post-intervention, coagulase-negative staphylococci and Malassezia restricta, at ED and Oncology ward, respectively. Additionally, post-intervention samples predominantly consisted of Proteobacteria and to a lesser extent skin commensals and endogenous environmental microorganisms in both departments. Discussion: Findings support the value of cleanSURFACES®, when coupled with routine disinfection practices, to effectively impact on the composition of active microbial communities found on high-touch surfaces in two different patient care areas of the hospital (one outpatient and one inpatient) with unique demands and patient-centered practices.

Rare Multidrug-resistant Pseudomonas aeruginosa Identified in a U.S. Deployed Service Member Following Host-nation Medical Treatment.

Decision-making related to the utilization of host-nation medical resources in austere forward-deployed environments is complex. Clinical circumstances, local medical intelligence availability, transportation assets, uncertainty regarding standard-of-care variations, military/host-nation funding complications, and regional security concerns all factor into consideration. A case of a U.S. active duty military service member who suffered a cardiac arrest on a military base in Southwest Asia is described in this report. After return of circulation following defibrillation, he was administered thrombolytic therapy for an electrocardiogram-identified ST-elevation myocardial infarction and transported to a local host-nation cardiac hospital for emergent percutaneous coronary intervention. During his subsequent transportation back to the USA, surveillance testing identified that he was colonized with a rare strain of Pseudomonas aeruginosa, demonstrating New Delhi metallo-beta-lactamase-1 and 16S RNA methyltransferase-2 enzymes, which confer significant resistance to carbapenem and aminoglycoside antibiotics, respectively.1-3 This combination of antibiotic resistance has been reported very rarely in the medical literature and has never been reported within the deployed military health system until now. The risk of exposure to multidrug-resistant organisms was not a factor initially considered in the decision to utilize host-nation medical resources in this case, which provided lesson learned and raised new questions, for future operational medical planning.

Acute multi-vessel coronary stent thrombosis.

BACKGROUND: Coronary artery stent thrombosis is a rare but often fatal complication associated with percutaneous coronary intervention (PCI) using both bare-metal stents and drug-eluting stents. Although strict adherence to dual anti-platelet therapy (aspirin plus clopidogrel) minimizes this risk, stent thrombosis will still occur in rare patients, leading to acute, subacute, or late life-threatening acute coronary syndromes. OBJECTIVES: To present a rare case of acute stent thrombosis involving multiple vessels to increase awareness of this life-threatening condition among emergency physicians, and to review the current guidelines for anti-platelet therapy in this patient population. CASE REPORT: A 52-year-old man who underwent PCI using drug-eluting stents in two separate coronary vessels presented to the Emergency Department within 2 h of discharge from the hospital with chest pain, dynamic electrocardiogram changes, and elevated cardiac markers. Despite compliance with the current recommendations for post-PCI anti-platelet therapy, urgent repeat catheterization revealed total thrombotic occlusion of both stents, requiring urgent repeat intervention. CONCLUSION: Despite patient compliance with the currently recommended anti-platelet regimen after stent therapy for coronary artery disease, acute stent thrombosis remains a rare but life-threatening risk in both the immediate and delayed post-intervention period. In addition, premature cessation of this anti-platelet therapy stands as the greatest risk factor for such thrombotic events. This case is presented to inform emergency physicians of the current post-PCI anticoagulation recommendations to help mitigate the risk of such complications.

Effect of Implementation of HEART Chest Pain Protocol on Emergency Department Disposition, Testing and Cost.

BACKGROUND: Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms. METHODS: This was a retrospective chart review of two cohorts. We identified ED charts from six-month periods prior to and after adoption of our HEART score-based protocol. Patients in whom an electrocardiogram and troponin were ordered were eligible for inclusion. We analyzed data for patients with typical symptoms (chest pain) and atypical symptoms both together and separately. RESULTS: We identified 1546 charts in the pre-adoption cohort and 1623 in the post-adoption cohort that met criteria. We analyzed the first 900 charts in each group. Discharges from the ED increased (odds ratio [OR[1.56, P<.001), and admissions for cardiac workup decreased (OR 0.46, P <.001). ED length of stay was 17 minutes shorter (P = .01). Stress testing decreased (OR 0.47, P<.001). We estimate a cost savings for our hospital system of over $4.5 million annually. There was no significant difference in inpatient length of stay or catheterization rate. When analyzing typical and atypical patients separately, these results held true. CONCLUSION: After adoption of a HEART score-based protocol, discharges from the ED increased with a corresponding decrease in admissions for cardiac evaluations as well as cost. These effects were similar in patients presenting without chest pain but with presentations concerning for ACS.

Identification of yin-yang regulators and a phosphorylation consensus for male germ cell-associated kinase (MAK)-related kinase.

MAK (male germ cell-associated protein kinase) and MRK/ICK (MAK-related kinase/intestinal cell kinase) are human homologs of Ime2p in Saccharomyces cerevisiae and of Mde3 and Pit1 in Schizosaccharomyces pombe and are similar to human cyclin-dependent kinase 2 (CDK2) and extracellular signal-regulated kinase 2 (ERK2). MAK and MRK require dual phosphorylation in a TDY motif catalyzed by an unidentified human threonine kinase and tyrosine autophosphorylation. Herein, we establish that human CDK-related kinase CCRK (cell cycle-related kinase) is an activating T157 kinase for MRK, whereas active CDK7/cyclin H/MAT1 complexes phosphorylate CDK2 but not MRK. Protein phosphatase 5 (PP5) interacts with MRK in a complex and dephosphorylates MRK at T157 in vitro and in situ. Thus, CCRK and PP5 are yin-yang regulators of T157 phosphorylation. To determine a substrate consensus, we screened a combinatorial peptide library with active MRK. MRK preferentially phosphorylates R-P-X-S/T-P sites, with the preference for arginine at position -3 (P-3) being more stringent than for prolines at P-2 and P+1. Using the consensus, we identified a putative phosphorylation site (RPLT(1080)S) for MRK in human Scythe, an antiapoptotic protein that interacts with MRK. MRK phosphorylates Scythe at T1080 in vitro as determined by site-directed mutagenesis and mass spectrometry, supporting the consensus and suggesting Scythe as a physiological substrate for MRK.

Alzheimer's disease biomarkers: another tool for FAA pilot screening?

Research advancements to improve the accuracy of diagnosing Alzheimer's disease (AD) have altered clinicians and researchers' understanding of the disease process. The discovery of amyloid and tau biomarkers as measures of disease pathology supports early identification of disease risk that precedes symptom onset. As a result, AD is now understood to be an underlying pathology that causes a spectrum of clinical syndromes, beginning with preclinical AD. Future clinical implementation of biomarkers will raise novel employment and professional licensure discrimination risks based on AD biomarker status. This article evaluates the potential consequences of biomarker status for commercial pilots within Federal Aviation Administration pilot licensing procedures. The article argues for a careful implementation of AD biomarker status in licensing procedures to emphasize public safety, integrate accurate scientific knowledge, and limit unjustified and adverse consequences for individual pilots.