Faculty Bibliography

Objectives/UNASSIGNED:To examine the epidemiology of β-lactam resistance in 'clonal group 258' (CG258), a successful KPC clonal group, over 14 years. Methods/UNASSIGNED:Isolates were collected from 1999 to 2013 for a study of antibiotic resistance in Enterobacteriaceae in New York City; 515 bloodstream isolates had antibiotic susceptibility data available and 436 were available for a CG258 PCR assay. The 56 resulting CG258 isolates were characterized by MLST, capsular type and ESBL and KPC carriage. KPC-positive isolates were assessed for common KPC plasmid types, KPC subtype and Tn4401 isoform. Results/UNASSIGNED:RT-PCR revealed 56 isolates were CG258. Seventeen of the 56 CG258 isolates were phenotypically susceptible to all carbapenems (all KPC negative). Five out of 17 susceptible isolates were of the cps-2 (wzi154) capsule type; none was cps-1 (wzi29). Nineteen out of 28 KPC-2 isolates were cps-1 (wzi29) and 8/10 KPC-3 isolates carried cps-2 (wzi154); however, cps-2 (wzi154) predominated among KPC-2-positive isolates in 2003 and 2004. KPC-2 was first detected in 2003 and KPC-3 was first detected in 2006. KPC-harbouring plasmids pKpQIL (all Tn4401a) and pBK30683 (all Tn4401d) were detected in 16/38 and 6/38 carbapenem-resistant isolates, respectively. Discussion/UNASSIGNED:CG258-lineage Klebsiella pneumoniae isolates were completely absent in 1999, but common in 2003. Twenty-one percent of CG258 isolates were susceptible to carbapenems in addition to lacking both common ESBL and blaKPC-mediated resistance. The cps-2 (wzi154) capsule type was common in both these susceptible isolates and in early KPC-2-harbouring isolates, suggesting it was the initial capsule type in CG258. Carbapenem-resistant isolates carried common KPC-harbouring plasmids with the same KPC and Tn4401 isoforms, suggesting frequent clonal spread.

CONTEXT/BACKGROUND:Corticosteroid-binding globulin (CBG) and albumin transport circulating cortisol. Cleavage of high-affinity CBG (haCBG) by neutrophil elastase at inflammatory sites causes cortisol release into tissues, facilitating immunomodulatory effects. OBJECTIVE:To determine whether depletion of haCBG is related to mortality in septic shock. DESIGN/METHODS:A single-center prospective observational cohort study of patients recruited with critical illness or septic shock, using serum samples collected at 0, 8, 24, 48 and 72 hours. Serum total and haCBG, and total and free cortisol were assayed directly. Glucocorticoid treatment was an exclusion criterion. Mortality was assessed at 28 days from Intensive Care Unit admission. RESULTS:Thirty septic shock (SS) and 42 nonseptic critical illness (CI) patients provided 195 serum samples. SS/CI patients had lower total CBG, haCBG and low-affinity CBG (laCBG) than controls. Total CBG and haCBG were significantly lower in septic shock patients who died than in those that survived (P < 0.009, P = 0.021, respectively). Total and free cortisol were higher in septic than nonseptic individuals. Free/total cortisol fractions were higher in those with low haCBG as observed in septic shock. However, cortisol levels were not associated with mortality. Albumin levels fell in sepsis but were not related to mortality. CONCLUSIONS:Low circulating haCBG concentrations are associated with mortality in septic shock. These results are consistent with an important physiological role for haCBG in cortisol tissue delivery in septic shock.

Common in-flight emergencies include syncope, respiratory symptoms, nausea/vomiting, cardiac symptoms, and seizures. Flight conditions, such as changes in air pressure and humidity, can exacerbate existing chronic medical conditions. In 2017, US airlines carried 849.3 million passengers. Undoubtedly, there were many requests for in-flight medical assistance. Whenever a medical event occurs, it is standard procedure that an announcement be made by a flight attendant, requesting medical personnel to identify themselves. The 1998 Aviation Medical Assistance Act provides liability protection for a healthcare professional (HCP) acting as a good Samaritan. Nevertheless, HCPs may initially experience trepidation providing care in an aircraft. They may be unaware that a first aid kit, a emergency medical kit, and an automatic external defibrillator are on every plane. Flight crews have been trained in cardiopulmonary resuscitation, and a support system, including a ground-based consultation service, is available to provide radio assistance from an on-call physician. When multiple HCPs volunteer, the most experienced should assume leadership of care. After evaluating the ill passenger, the HCP communicates the assessment to the crew and, when necessary, to the ground-based physician. The goal of in-flight care is to medically stabilize the ill passenger and facilitate the individual's arrival at the scheduled destination for continued medical care. When unable to stabilize the passenger's condition, the decision to divert the plane rests with the flight's captain. Our article helps HCPs to best understand their resources, structured support, liability, and role during an in-flight medical event. With this knowledge of resources, a good Samaritan can confidently attend to an ill airline passenger in flight.

OBJECTIVE:The objective of the study is to examine the validity of body mass index z score (zBMI) as a measure of percent body fat in prepubertal children. METHODS:One hundred eleven multiethnic, healthy, Tanner 1 children aged 6-12 years had fat percent and fat mass measured by the four-compartment method as part of the Paediatric Rosetta Body Composition Cohort. Multiple regression models were developed with fat percent as the dependent variable and zBMI, age, sex and ethnicity as independent variables. RESULTS:0.81). The average percent error was 7.2% in girls and 8.7% in boys. Age was associated with percentage body fat (P < 0.01), while ethnicity was not (P > 0.05). CONCLUSIONS:scores are associated with significantly lower absolute percent errors in girls and boys.

Activity of the siderophore cephalosporin cefiderocol, targeted for activity against carbapenem resistant Gram-negatives, was determined by microdilution in iron-depleted Mueller Hinton broth against characterized carbapenem resistant Acinetobacter baumannii complex, Stenotrophomonas maltophilia, Pseudomonas aeruginosa and Enterobacteriaceae MIC₉₀s against A. baumannii, S. maltophilia and P. aeruginosa were 1, 0.25 and 0.5 mg/L, respectively. Against Enterobacteriaceae, MIC₉₀ was 1 mg/L for OXA-48-like group, 2 mg/L for KPC-3 group, and 8 mg/L for TEM/SHV ESBL, NDM and KPC-2 groups.

Introduction/UNASSIGNED:Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract (GIT) but have a low incidence. Arising from the interstitial cells of Cajal, GISTs occur at different sites in the GIT with stomach being the most common. They can rarely be seen at sites outside the GIT such as omentum, retroperitoneum and are called as extraintestinal GISTs (EGIST). They have a spindle or epithelioid cell morphology and show positivity by immunohistochemistry (IHC) for CD117. Our aim was to study the clinicopathological and immunohistochemical profile of our cases of EGISTs. Materials and Methods/UNASSIGNED:A cross-sectional study of EGISTs received from 2010 to 2015 was done. IHC with CD117 and discovered on GIST1 (DOG1) was performed and tumors were scored based on the percentage of cells that stained positive. Thirteen abdominal non-GIST spindle cell tumors were included in the study as controls. Results/UNASSIGNED:Seven cases of EGIST were included (four-omental, three-retroperitoneal). All cases stained positive for CD117 and DOG1. One case of epithelioid EGIST scored 4 + with DOG1 and 2 + with CD117. Another case with mixed morphology scored 2 + with DOG1 and 4 + with CD117. All controls were negative for both markers. Conclusion/UNASSIGNED:EGISTs are one of the rare differentials for spindle cell lesions outside the GIT. Although both markers stain positive, DOG1 showed higher score with epithelioid GISTs.

This retrospective cohort study sought to assess the effectiveness of comprehensive geriatric assessment (CGA) for older patients at an HIV clinic in a large US city. We systematically reviewed medical records of all patients who underwent CGA from June 2013 to July 2017. In addition, physicians and social workers completed an anonymous survey about the impact of CGA on their patients. For the 76 patients (median age 67.2; Q1, Q3 = 60.9, 72.6) seen by geriatricians at the clinic, there were 184 recommendations, 54 instances of counseling, and 11 direct actions. Overall adherence to recommendations was 32.8%, 34.9% for patient-directed, and 31.7% for provider-directed recommendations. No demographic or CGA variables were associated with adherence. Despite this lack of adherence, surveyed providers reported that they usually or always followed recommendations; the most frequently cited barrier to implementation was lack of feasibility. Further research will be needed to determine how CGA can improve outcomes for this population.

Corticosteroid management for patients with sarcoidosis requires the need for close monitoring to detect and manage any complications that may arise during treatment.