Benign Enhancing Foramen Magnum Lesions.

Benign enhancing foramen magnum lesions have been previously described as T2-hyperintense small, enhancing lesions located posterior to the intradural vertebral artery. We present the first case with pathologic correlation. These lesions are fibrotic nodules adhering to the spinal accessory nerve. While they can enlarge with time on subsequent examinations, on the basis of the imaging characteristics and location, they do not necessitate surgical resection.

The Monro-Kellie Doctrine: A Review and Call for Revision.

The Monro-Kellie doctrine is a well-accepted principle of intracranial hemodynamics. It has undergone few consequential revisions since it was established. Its principle is straightforward: The combined volume of neuronal tissue, blood, and CSF is constant. To maintain homeostatic intracranial pressure, any increase or decrease in one of these elements leads to a reciprocal and opposite change in the others. The Monro-Kellie doctrine assumes a rigid, unadaptable calvaria. Recent studies have disproven this assumption. The skull expands and grows in response to pathologic changes in intracranial pressure. In this review, we outline what is known about calvarial changes in the setting of pressure dysregulation and suggest a revision to the Monro-Kellie doctrine that includes an adaptable skull as a fourth component.

Diffuse Calvarial Hyperostosis and Spontaneous Intracranial Hypotension: A Case-Control Study.

BACKGROUND AND PURPOSE: Diagnosing spontaneous intracranial hypotension and associated CSF leaks can be challenging, and additional supportive imaging findings would be useful to direct further evaluation. This retrospective study evaluated whether there was a difference in the prevalence of calvarial hyperostosis in a cohort of patients with spontaneous intracranial hypotension compared with an age- and sex-matched control population. MATERIALS AND METHODS: Cross-sectional imaging (CT of the head or brain MR imaging examinations) for 166 patients with spontaneous intracranial hypotension and 321 matched controls was assessed by neuroradiologists blinded to the patient's clinical status. The readers qualitatively evaluated the presence of diffuse or layered calvarial hyperostosis and measured calvarial thickness in the axial and coronal planes. RESULTS: A significant difference in the frequency of layered hyperostosis (31.9%, 53/166 subjects versus 5.0%, 16/321 controls, P < .001, OR = 11.58) as well as the frequency of overall (layered and diffuse) hyperostosis (38.6%, 64/166 subjects versus 13.2%, 42/321 controls, P < .001, OR = 4.66) was observed between groups. There was no significant difference in the frequency of diffuse hyperostosis between groups (6.6%, 11/166 subjects versus 8.2%, 26/321 controls, P = .465). A significant difference was also found between groups for calvarial thickness measured in the axial (P < .001) and coronal (P < .001) planes. CONCLUSIONS: Layered calvarial hyperostosis is more prevalent in spontaneous intracranial hypotension compared with the general population and can be used as an additional noninvasive brain imaging marker of spontaneous intracranial hypotension and an underlying spinal CSF leak.

Comparison of Radiologists and Other Specialists in the Performance of Lumbar Puncture Procedures Over Time.

BACKGROUND AND PURPOSE: Lumbar punctures may be performed by many different types of health care providers. We evaluated the percentages of lumbar punctures performed by radiologists-versus-nonradiologist providers, including changes with time and discrepancies between specialties. MATERIALS AND METHODS: Lumbar puncture procedure claims were identified in a 5% sample of Medicare beneficiaries from 2004 to 2017 and classified by provider specialty, site of service, day of week, and patient complexity. Compound annual growth rates for 2004 versus 2017 were calculated; t test and χ2 statistical analyses were performed. RESULTS: Lumbar puncture use increased from 163.3 to 203.4 procedures per 100,000 Medicare beneficiaries from 2004 to 2017 (overall rate, 190.3). Concurrently, the percentage of lumbar punctures performed by radiologists increased from 37.1% to 54.0%, while proportions performed by other major physician specialty groups either declined (eg, neurologists from 23.5% to 10.0%) or were largely unchanged. While radiologists saw the largest absolute increase in the percentage of procedures, the largest relative increase occurred for nonphysician providers (4.2% in 2004 to 7.5% in 2017; +78.6%). In 2017, radiologists performed most procedures on weekdays (56.2%) and a plurality on weekends (38.2%). Comorbidity was slightly higher in patients undergoing lumbar puncture by radiologists (P < .001). CONCLUSIONS: Radiologists now perform most lumbar puncture procedures for Medicare beneficiaries in both the inpatient and outpatient settings. The continuing shift in lumbar puncture responsibility from other specialists to radiologists has implications for clinical workflows, cost, radiation exposure, and postgraduate training.

A cavernous sinus lesion clinically responsive to steroids.

Tolosa Hunt syndrome (THS) is characterized by painful ophthalmoplegia secondary to idiopathic granulomatous inflammation of the cavernous sinus. The characteristic finding on MRI is an enhancing T1 isointense and T2 hypo- or hyperintense cavernous sinus mass lesion, which may result in focal narrowing of the ipsilateral internal carotid artery. Although the incidence is quite rare, it is a common diagnostic consideration in cases that present with multiple cranial neuropathies. However, the differential diagnosis for a unilateral cavernous sinus lesion in adults is broad and includes neoplastic, inflammatory (such as sarcoidosis and immunoglobulin G4-related disease [IgG4-RD]), infectious etiologies (such as syphilis and leprosy), as well as vascular lesions. We describe a patient presenting with neurologic symptoms referable to a persistent unilateral cavernous sinus MRI abnormality, initially thought to be consistent with Tolosa-Hunt syndrome, that was clinically but not radiographically responsive to steroids. Following reevaluation due to the presence of new symptoms, pathology revealed that the abnormality was most consistent with chordoma, a rare skull based tumor. In patients with a presumed diagnosis of Tolosa-Hunt syndrome, close clinical and radiographic follow-up is imperative, with early consideration for biopsy in patients that fail to respond to treatment both clinically and radiographically.

Enzyme-linked immunosorbent assay for group A Streptococcal anti-DNase B in human sera, using recombinant proteins - Comparison to the DNA methyl green micromethod.

Among the four known Streptococcal nucleases comprising of DNase A, B, C and D; DNase B is the most common, and determination of the levels of antibody to DNase B (ADB) is often used to confirm a clinical diagnosis of Streptococcus pyogenes/group A Streptococcal (GAS) infection. The commonly used assays for antibodies that neutralize DNase B or streptolysin O activity use partially purified antigens that often fail to detect antibody changes subsequent to culture documented infections. Therefore, an enzyme-linked immunosorbent assay (ELISA) was developed employing his-tagged recombinant DNase B as plate antigen for comparison to the commonly used DNA methyl green micromethod (DMGM). DNAs from various Streptococcal species were screened for presence of dnaseB gene by PCR. Measurements of ADB in sera collected from subjects belonging to different ages, and ethnic groups were used to compare the two methods. dnaseB was not detected by PCR in DNA samples isolated from different strains of group B (GBS), C (GCS) and G (GGS) Streptococci. The ADB based ELISA proved to be highly sensitive and more responsive to changes in antibody concentration than DMGM. Use of recombinant DNase B eliminates the variability associated with the enzyme, partially purified from Streptococcal culture supernatants from various commercial sources and may provide a more reliable source of antigen to a wider group of laboratories concerned with GAS diagnosis.

Comparing the Resistance, Resilience, and Stability of Replicate Moving Bed Biofilm and Suspended Growth Combined Nitritation-Anammox Reactors.

Combined partial nitritation-anammox (PN/A) systems are increasingly being employed for sustainable removal of nitrogen from wastewater, but process instabilities present ongoing challenges for practitioners. The goal of this study was to elucidate differences in process stability between PN/A process variations employing two distinct aggregate types: biofilm [in moving bed biofilm reactors (MBBRs)] and suspended growth biomass. Triplicate reactors for each process variation were studied under baseline conditions and in response to a series of transient perturbations. MBBRs displayed elevated NH4+ removal rates relative to those of suspended growth counterparts over six months of unperturbed baseline operation but also exhibited significantly greater variability in performance. Transient perturbations led to strikingly divergent yet reproducible behavior in biofilm versus suspended growth systems. A temperature perturbation prompted a sharp reduction in NH4+ removal rates with no accumulation of NO2- and rapid recovery in MBBRs, compared to a similar reduction in NH4+ removal rates but a high level of accumulation of NO2- in suspended growth reactors. Pulse additions of a nitrification inhibitor (allylthiourea) prompted only moderate declines in performance in suspended growth reactors compared to sharp decreases in NH4+ removal rates in MBBRs. Quantitative fluorescence in situ hybridization demonstrated a significant enrichment of anammox in MBBRs compared to suspended growth reactors, and conversely a proportionally higher AOB abundance in suspended growth reactors. Overall, MBBRs displayed significantly increased susceptibility to transient perturbations employed in this study compared to that of suspended growth counterparts (stability parameter), including significantly longer recovery times (resilience). No significant difference in the maximal impact of perturbations (resistance) was apparent. Taken together, our results suggest that aggregate architecture (biofilm vs suspended growth) in PN/A processes exerts an unexpectedly strong influence on process stability.

Genetically Defined Oligodendroglioma Is Characterized by Indistinct Tumor Borders at MRI.

BACKGROUND AND PURPOSE: In 2016, the World Health Organization revised the brain tumor classification, making IDH mutation and 1p/19q codeletion the defining features of oligodendroglioma. To determine whether imaging characteristics previously associated with oligodendroglial tumors are still applicable, we evaluated the MR imaging features of genetically defined oligodendrogliomas. MATERIALS AND METHODS: One hundred forty-eight adult patients with untreated World Health Organization grade II and III infiltrating gliomas with histologic oligodendroglial morphology, known 1p/19q status, and at least 1 preoperative MR imaging were retrospectively identified. The association of 1p/19q codeletion with tumor imaging characteristics and ADC values was evaluated. RESULTS: Ninety of 148 (61%) patients had 1p/19q codeleted tumors, corresponding to genetically defined oligodendroglioma, and 58/148 (39%) did not show 1p/19q codeletion, corresponding to astrocytic tumors. Eighty-three of 90 (92%) genetically defined oligodendrogliomas had noncircumscribed borders, compared with 26/58 (45%) non-1p/19q codeleted tumors with at least partial histologic oligodendroglial morphology (P < .0001). Eighty-nine of 90 (99%) oligodendrogliomas were heterogeneous on T1- and/or T2-weighted imaging. In patients with available ADC values, a lower mean ADC value predicted 1p/19q codeletion (P = .0005). CONCLUSIONS: Imaging characteristics of World Health Organization 2016 genetically defined oligodendrogliomas differ from the previously considered characteristics of morphologically defined oligodendrogliomas. We found that genetically defined oligodendrogliomas were commonly poorly circumscribed and were almost always heterogeneous in signal intensity.

Evolution of Microwave Spectroscopy at the National Bureau of Standards (NBS) and the National Institute of Standards and Technology (NIST).

This paper describes the beginning and evolution of microwave rotational spectroscopic research starting in 1954 at the National Bureau of Standards (NBS), located at that time in Washington, DC, through the present at NIST in Gaithersburg, MD. David Lide was hired in 1954 to start this research employing Stark modulated waveguide septum cells. When Donald R. Johnson joined the lab in 1968, he developed parallel plate cells coupled with rf and DC discharge methods to study free radicals and transient species. In the mid 1980s Lovas and Suenram constructed a pulsed molecular beam Fourier Transform microwave (FTMW) spectrometer to study hydrogen bonded and van der Waals dimers and trimers. This article describes the types of molecules studied and the type molecular properties derived from these measurements as well as some of the instruments developed for these studies. The two major areas of application described are atmospheric chemistry and molecular radio astronomy.

A modified acid digestion procedure for extraction of tungsten from soil.

Interest in tungsten occurrence and geochemistry is increasing due to increased use of tungsten compounds and its unknown biochemical effects. Tungsten has a complex geochemistry, existing in most environmental matrices as the soluble and mobile tungstate anion, as well as poly- and heteropolytungstates. Because the geochemistry of tungsten is substantially different than most trace metals, including the formation of insoluble species under acidic conditions, it is not extracted from soil matrices using standard acid digestion procedures. Therefore, the current work describes a modification to a commonly used acid digestion procedure to facilitate quantification of tungsten in soil matrices. Traditional soil digestion procedures, using nitric and hydrochloric acids with hydrogen peroxide yield <1 up to 50% recovery on soil matrix spike samples, whereas the modified method reported here, which includes the addition of phosphoric acid, yields spike recoveries in the 76-98% range. Comparison of the standard and modified digestion procedures on National Institute of Standards and Technology Standard Reference Materials yielded significantly improved tungsten recoveries for the phosphoric acid modified method. The modified method also produces comparable results for other acid extractable metals as the standard methods, and therefore can be used simultaneously for tungsten and other metals of interest.

Use of watershed factors to predict consumer surfactant risk, water quality, and habitat quality in the upper Trinity River, Texas.

Surfactants are high production volume chemicals that are used in a wide assortment of "down-the-drain" consumer products. Wastewater treatment plants (WWTPs) generally remove 85 to more than 99% of all surfactants from influents, but residual concentrations are discharged into receiving waters via wastewater treatment plant effluents. The Trinity River that flows through the Dallas-Fort Worth metropolitan area, Texas, is an ideal study site for surfactants due to the high ratio of wastewater treatment plant effluent to river flow (>95%) during late summer months, providing an interesting scenario for surfactant loading into the environment. The objective of this project was to determine whether surfactant concentrations, expressed as toxic units, in-stream water quality, and aquatic habitat in the upper Trinity River could be predicted based on easily accessible watershed characteristics. Surface water and pore water samples were collected in late summer 2005 at 11 sites on the Trinity River in and around the Dallas-Fort Worth metropolitan area. Effluents of 4 major waste water treatment plants that discharge effluents into the Trinity River were also sampled. General chemistries and individual surfactant concentrations were determined, and total surfactant toxic units were calculated. GIS models of geospatial, anthropogenic factors (e.g., population density) and natural factors (e.g., soil organic matter) were collected and analyzed according to subwatersheds. Multiple regression analyses using the stepwise maximum R(2) improvement method were performed to develop prediction models of surfactant risk, water quality, and aquatic habitat (dependent variables) using the geospatial parameters (independent variables) that characterized the upper Trinity River watershed. We show that GIS modeling has the potential to be a reliable and inexpensive method of predicting water and habitat quality in the upper Trinity River watershed and perhaps other highly urbanized watersheds in semi-arid regions.

Investigations of tungsten mobility in soil using column tests.

The geochemistry of tungsten has recently gained attention in the scientific and regulatory communities. Tungsten has a complex geochemistry, existing in many environmental matrices as the soluble and mobile tungstate anion, as well as a series of ill-defined polymeric species. Previous work has shown that soluble tungsten leached from a metallic tungsten-spiked Grenada Loring soil will reach an equilibrium concentration >150 mgL(-1), and the concentration is greatly influenced by co-occurring analytes in the matrix, such as calcium and phosphate. In the present work, the mobility of tungsten compounds was investigated in a model soil with a range of aqueous leach solutions using column experiments. The relative column leachate concentrations measured followed trends from previously reported tungstate and polytungstate partition coefficients determined in the model soil under identical aqueous matrix conditions. Neutral to alkaline conditions produced maximum effluent tungsten concentrations >40 mgL(-1), whereas acid leach eluents produced concentrations in the <1-3 mgL(-1) range. The change in leached tungsten speciation over time was also measured as monomeric and polymeric tungsten species have different sorptive behaviors.

Tungsten effects on microbial community structure and activity in a soil.

Tungsten, once deposited onto a soil as a result of private, industrial, and military activities, may persist as tungstate anion or, via polymerization, as a variety of poly-tungstate species, each with varying solubility and soil sorption characteristics. In this study, the impact of weathered tungsten on a soil microbial community was measured. Fatty acid analyses indicated that weathered tungsten at < or =2500 mg kg(-1) was associated with a significant increase in microbial biomass and that concentrations up to 6500 mg kg(-1) did not result in a significant decrease in measured biomass, relative to the control. Analysis of cellular fatty acids also identified significant microbial community shifts between 0 and 325, 1300 and 2600, and 3900 and 6500 mg W kg(-1) soil. In general, the positive effect of tungsten on microbial biomass coincided with an increase in Gram-negative bacterial fatty acids, whereas fatty acids indicative of actinomycetes and Gram-positive bacteria were more abundant at the highest soil tungsten concentrations. The weathered tungsten also inhibited N2 fixing activity of a free living diazotroph at > or =1300 mg W kg(-1) soil. These results indicate that tungsten in soil can alter both the structure and the function of an indigenous soil microbial community.

Up-regulated expression of the alpha7 nicotinic acetylcholine receptor subunit on inflammatory infiltrates during Dictyocaulus viviparus infection.

Cholinergic signalling is known to affect immune cell function, but few studies have addressed its relevance during nematode infection. We therefore analysed the anatomical distribution and expression pattern of the nicotinic acetylcholine receptor (nAChR) alpha7 subunit in lungs obtained from Dictyocaulus viviparus-infected and uninfected control cattle. The analysis was performed on trachea and lung parenchyma from uninfected animals and animals necropsied at 15, 22 and 43 days post-infection (DPI). Localization of the alpha7 nAChR was evaluated by immunohistology and mRNA expression analysed by gene-specific reverse transcription-polymerase chain reaction (RT-PCR). In uninfected animals, tracheal, bronchial and bronchiolar epithelium and smooth muscle cells constitutively expressed the alpha7 nAChR, as did type I and II alveolar epithelial cells and alveolar macrophages and a few infiltrating leucocytes. By 15 DPI, immunohistology revealed a massive influx of alpha7 nAChR+ inflammatory cells into the lung parenchyma and tracheal wall. This was reflected in the RT-PCR results. At later time points, both parenchyma and tracheal wall contained large numbers of alpha7 nAChR+ leucocytes, but detection of transcript was restricted to the trachea. Recruitment of nAChR-containing leucocytes to the lungs of D. viviparus-infected cattle suggests that these cells may represent possible downstream targets for parasite-secreted acetylcholinesterases.

Local cytokine responses in Dictyocaulus viviparus infection.

The high degree of immunity induced by the bovine lungworm, Dictyocaulus viviparus, makes it an ideal model in which to study nematode-induced protective immune responses. Here, cytokine responses were measured over the course of an experimental infection of D. viviparus. Local cytokine messenger RNA (mRNA) transcripts were measured in lung parenchyma, tracheal rings and draining lymph nodes using semi-quantitative reverse transcriptase-polymerase chain reaction. Responses were measured in animals necropsied at 15, 22 and 43 days post-infection (DPI). The responses elicited at these time points were compared with cytokine levels observed in uninfected animals. Interleukin (IL)-4, IL-5, IL-10, IL-12p35, IL-13 and interferon gamma (IFNgamma) mRNA levels were measured in duplicate at each site. By 42 DPI, very few parasites were recovered, either from faeces or lungs. Transcripts of all cytokines increased in the lung parenchyma, tracheal rings and caudal mesenteric lymph nodes by 15 DPI. The response was rapid and peaked during the time of larval migration through the lungs. By 42 DPI, expression levels of most cytokines were reduced to levels similar to, or below, base line values measured in uninfected animals. Highest levels of IL-10, IL-12p35, IL-13 and IFNgamma transcript were measured in the bronchial lymph nodes of uninfected animals. IgG1 levels were negatively correlated with expression levels of all cytokines. The results demonstrate that a mixed cytokine response occurs over the course of a primary infection during which the parasites were eliminated by day 43 DPI. These results agree with those obtained for other helminths in cattle and challenge the hypothesis that polarised Th2 responses are essential for protection against nematodes in this species. These observations are important in the development of recombinant vaccines, particularly when considering adjuvant choice.

Clinical response augments NK cell activity independent of treatment modality: a randomized double-blind placebo controlled antidepressant trial.

BACKGROUND: Major depressive disorder (MDD) has been associated with alterations in immune function. Suppression of natural killer (NK) cell activity (NKCA) reliably characterizes immunological alterations observed in MDD. Antidepressant pharmacotherapy has been associated with modulation of NKCA. Previous investigations into antidepressant modulation of NKCA have not employed randomized double-blind placebo controlled designs. Thus, it is unknown whether treatment-associated changes in immune function are due to drug, placebo, or spontaneous remission effects. The present investigation examined the effect of antidepressant treatment on NKCA utilizing a randomized double-blind placebo controlled experimental design. METHOD: Patients (N = 16) met DSM-IV criteria for MDD and were randomly assigned to drug (N = 8; citalopram, 20 mg/day) or placebo (N = 8) under double-blind conditions. Severity and pattern of depressive symptoms were assessed by the Hamilton Depression Rating Scale (HDRS). NK cell function was measured using a standard chromium-release assay and NK cell number assessed by flow cytometry. HDRS scores, NK cell function, and NK cell numbers were collected at 0, 1, 2 and 4 weeks of treatment. RESULTS: Clinical response was associated with augmented NKCA independent of treatment condition. Failure to respond to treatment resulted in significantly reduced NKCA over treatment interval. CONCLUSIONS: The present results suggest that alterations in the depressive syndrome, regardless of therapeutic modality, may be sufficient to modulate NKCA during antidepressant trials and thus may significantly impact on co-morbid health outcomes in MDD.

A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X STOP interspinous implant: 1-year results.

Patients suffering from neurogenic intermittent claudication secondary to lumbar spinal stenosis have historically been limited to a choice between a decompressive laminectomy with or without fusion or a regimen of non-operative therapies. The X STOP Interspinous Process Distraction System (St. Francis Medical Technologies, Concord, Calif.), a new interspinous implant for patients whose symptoms are exacerbated in extension and relieved in flexion, has been available in Europe since June 2002. This study reports the results from a prospective, randomized trial of the X STOP conducted at nine centers in the U.S. Two hundred patients were enrolled in the study and 191 were treated; 100 received the X STOP and 91 received non-operative therapy (NON OP) as a control. The Zurich Claudication Questionnaire (ZCQ) was the primary outcomes measurement. Validated for lumbar spinal stenosis patients, the ZCQ measures physical function, symptom severity, and patient satisfaction. Patients completed the ZCQ upon enrollment and at follow-up periods of 6 weeks, 6 months, and 1 year. Using the ZCQ criteria, at 6 weeks the success rate was 52% for X STOP patients and 10% for NON OP patients. At 6 months, the success rates were 52 and 9%, respectively, and at 1 year, 59 and 12%. The results of this prospective study indicate that the X STOP offers a significant improvement over non-operative therapies at 1 year with a success rate comparable to published reports for decompressive laminectomy, but with considerably lower morbidity.

Group a streptococcal serotypes isolated from healthy schoolchildren in iran.

Serotypes of group A streptococci are still a major cause of pharyngitis and some post-infectious sequelae such as rheumatic fever. As part of the worldwide effort to clarify the epidemiological pattern of group A streptococci in different countries, the present study was conducted to assess the prevalence of Streptococcus pyogenes serotypes in Iran. A total of 1588 throat swabs were taken from healthy school children in the city of Gorgan during February and March 1999. Of those isolates, 175 resulted positive for group A streptococci. The distribution pattern was similar for girls and boys, with 10.8% and 11.2%, respectively. Urban school children showed a higher rate of colonization compared to those in rural areas. Serotyping was performed on 65 of the positive isolates using standard techniques, and only 21 (32%) were M-type isolates. Their profiles fell into four types with M1 predominating, which could reflect the presence of rheumatic fever in the region. However, when isolates were challenged for T-antigen types, nearly all were positive (94%). The pattern of T types was diverse (18 types), with the most common T types being T1 (26%), TB3264 (15%), TB\1-19 & B\25\1-19 (9.2%) and T2 & 2\28 (7.7%). When isolates were tested for opacity factor, only 23 (35%) were positive while 34 (52%) responded to the serum opacity reaction test. Although the number of isolates in this study was not sufficient to make any epidemiological conclusions, the scarcity of serotyping studies in Iran could render these data useful for future attempts to develop a streptococcal vaccine.

Epidemiologic analysis of invasive and noninvasive group a streptococcal isolates in Hong Kong.

Since the mid-1980s, there has been a resurgence of severe forms of invasive group A streptococcal (GAS) disease in many Western countries. In Hong Kong, a similar increase has also been observed in recent years. One hundred seven GAS isolates collected from 1995 to 1998 from individuals with necrotizing fasciitis, toxic shock syndrome, meningitis, or other type of bacteremic sepsis (invasive group, n = 24) as well as from individuals with minor skin and throat infections (noninvasive group, n = 83) were characterized through serologic and/or emm sequence typing. Thirty-two M protein gene sequence types were identified. Types M1, M4, and M12 were the most prevalent in both the invasive group and the noninvasive group; together they accounted for 70.8 and 37.3% of the isolates, respectively. No clear pattern of skin and throat infection M types was observed. Type M1 was overrepresented in the invasive and pharyngeal isolates. The same pulsed-field gel electrophoresis pattern was shared by most invasive and all pharyngeal M1 isolates. Overall, resistance to erythromycin (32%) and tetracycline (53%) was high, but M1 isolates were significantly less likely to have resistance to either antimicrobial agent than non-M1 isolates. One novel emm sequence type, stHK, was identified in an isolate from a patient with necrotizing fasciitis. Minor emm gene sequence alterations were noted for 31 isolates, and for 13 of these isolates, deletion, insertion, or point mutations were seen in the hypervariable 50 N-terminal residues.