Catfish Puncture Wound and Retained Spine Management in the ED Setting: A Case Report.

Fishing is a common recreational activity in the United States, with over 29 million registered fishers. Although not inherently dangerous, commonly seen injuries from fishing include embedded fishhooks and injury from flora and fauna. Emergency department (ED) physicians need a basic understanding of how to treat these less-than-frequent injuries. We present a case report of a patient who presented with a catfish spine lodged in her leg. These spines not only cause puncture wounds but can result in lacerations and venom release as well. Our patient presented 6 hours after the initial injury for spine removal and symptom management. Plain radiographs of the affected extremity demonstrated a 2 cm foreign body consistent with a catfish spine. The wound was expanded, and the spine successfully removed. The patient was discharged on levofloxacin and reported a healing wound without complications nearly 2 weeks after the injury.

Flight Teams' Learning Needs Assessment on Ultrasound: A Mixed Methods Approach.

OBJECTIVE: The goal of this study was to understand flight clinicians' learning needs and attitudes with regard to a prehospital ultrasound curriculum. METHODS: In this convergent mixed methods study, 21 prehospital clinicians completed a questionnaire, and 20 attended a 1-hour focus group to explore attitudes regarding learning ultrasound. These participants were from a single emergency medical service agency. RESULTS: Five themes emerged from the focus group transcripts and were supported by the quantitative data: 1) theme 1, hands-on training in ultrasound is a highly preferred modality; 2) theme 2, emergency medical service providers desire learning integrated into shifts and real-life practice; 3) theme 3, prehospital providers express concerns about training and maintenance of competency; 4) theme 4, participants recognize the need for quality control during the training phase and after; and 5) theme 5, participants were enthusiastic about how ultrasound could help guide clinical decision making and potentially improve patient outcomes. CONCLUSION: Those who participated in an evidence-based assessment of prehospital ultrasound needs and barriers were experienced flight clinicians who would use prehospital ultrasound if made available. These adult learners indicated their preferred learning method would be using standardized patients, simulators, and hands-on in the field with physicians. They preferred follow-up courses and simulators to maintain competency.

Genome Sequences of Two Pseudomonas aeruginosa Isolates with Defects in Type III Secretion System Gene Expression from a Chronic Ankle Wound Infection.

Effector proteins translocated into host cells by the Pseudomonas aeruginosa type III secretion system (T3SS) are critical for phagocytic avoidance and systemic spread of the microorganism. The T3SS genes are present in virtually all P. aeruginosa strains. When examined in environmental isolates and clinical specimens, expression of the T3SS genes is the rule. Isolates from the airways of cystic fibrosis (CF) patients are one exception, and these isolates usually carry mutations that disable T3SS gene expression. In this study, we describe two P. aeruginosa isolates, one pigmented brown and one green, from a keratitis-ichthyosis-deafness (KID) syndrome patient with a chronic cutaneous ankle wound. Similar to most isolates from CF, both of the KID isolates were defective for T3SS gene expression. Providing the primary activator of T3SS transcription (exsA) in trans restored T3SS function. Since the exsA sequences were identical to that of a reference strain with active T3SS gene expression, we examined the cAMP-Vfr system, a critical regulator of T3SS gene expression. Vfr is a cAMP-dependent transcription factor that activates exsA expression. Whereas T3SS activity was corrected in the brown isolate by restoring cAMP synthesis, the same was not observed for the green isolate. These findings suggest that distinct mechanisms resulted in loss of T3SS gene expression in the KID isolates. The mutations responsible for the T3SS defects were not clearly evident by comparison of the whole-genome sequences to a reference strain. Our findings suggest that loss of T3SS gene expression may be a trait common to both CF and non-CF chronic infections. IMPORTANCE A common feature of microorganisms that cause chronic infections is a stealthy lifestyle that promotes immune avoidance and host tolerance. During chronic colonization of cystic fibrosis (CF) patients, Pseudomonas aeruginosa acquires numerous adaptations that include reduced expression of some factors, such as motility, O antigen, and the T3SS, and increased expression of other traits, such as biofilm formation. In this study, we report loss of T3SS gene expression in non-CF chronic isolates. This finding suggests that loss of the T3SS may be a common and important trait that contributes to persistence and may open avenues to explore the significance further using non-CF chronic infection models.

Hfq and sRNA 179 Inhibit Expression of the Pseudomonas aeruginosa cAMP-Vfr and Type III Secretion Regulons.

Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen causing skin and soft tissue, respiratory, and bloodstream infections. The type III secretion system (T3SS) is one important virulence factor. Production of the T3SS is controlled by ExsA, a transcription factor that activates expression of the entire T3SS regulon. Global regulators including Vfr, RsmA, and Hfq also contribute to regulation of the T3SS. Vfr is a cAMP-responsive transcription factor that activates exsA transcription. RsmA, an RNA-binding protein, inversely controls expression of the T3SS and the type VI secretion system (T6SS). Hfq is an RNA chaperone that functions by stabilizing small noncoding RNAs (sRNAs) and/or facilitating base pairing between sRNAs and mRNA targets. A previous study identified sRNA 1061, which directly targets the exsA mRNA and likely inhibits ExsA synthesis. In this study, we screened an sRNA expression library and identified sRNA 179 as an Hfq-dependent inhibitor of T3SS gene expression. Further characterization revealed that sRNA 179 inhibits the synthesis of both ExsA and Vfr. The previous finding that RsmA stimulates ExsA and Vfr synthesis suggested that sRNA 179 impacts the Gac/Rsm system. Consistent with that idea, the inhibitory activity of sRNA 179 is suppressed in a mutant lacking rsmY and rsmZ, and sRNA 179 expression stimulates rsmY transcription. RsmY and RsmZ are small noncoding RNAs that sequester RsmA from target mRNAs. Our combined findings show that Hfq and sRNA 179 indirectly regulate ExsA and Vfr synthesis by reducing the available pool of RsmA, leading to reduced expression of the T3SS and cAMP-Vfr regulons.IMPORTANCE Control of gene expression by small noncoding RNA (sRNA) is well documented but underappreciated. Deep sequencing of mRNA preparations from Pseudomonas aeruginosa suggests that >500 sRNAs are generated. Few of those sRNAs have defined roles in gene expression. To address that knowledge gap, we constructed an sRNA expression library and identified sRNA 179 as a regulator of the type III secretion system (T3SS) and the cAMP-Vfr regulons. The T3SS- and cAMP-Vfr-controlled genes are critical virulence factors. Increased understanding of the signals and regulatory mechanisms that control these important factors will enhance our understanding of disease progression and reveal potential approaches for therapeutic intervention.