It is not well understood why strains of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), a major cause of skin and soft tissue infections, became successful so quickly, overtaking the place of methicillin-sensitive S. aureus (MSSA) in many communities. To evaluate the genetic basis of differences in their virulence traits, 293 S. aureus isolates consisting of three cohorts, genotypically defined clinical CA-MRSA (n ‫؍‬ 77), clinical MSSA (n ‫؍‬ 103), and nasal carriage MSSA (n ‫؍‬ 113), collected over a 19-year period in two Midwestern states in the United States, were (i) extensively genotyped and (ii) screened for 40 known virulence genes which included those for enterotoxins, leukocidins, hemolysins, and surface proteins and several newly identified putative toxin genes from the USA400 lineage of CA-MRSA. Genotypically, nasal carriage and clinical MSSA isolates were much more diverse than was the CA-MRSA group, which was found to be of USA400 lineage only. Virulence gene profiles of the three groups showed that CA-MRSA strains harbored significantly higher percentages (>95%; P value, <0.05) of the sea, sec, sec4, seg2, seh, sek, sel, sel2, ear, ssl1, lpl10, lukSF-PV, lukD, lukE, and clfA genes than did the carriage and the clinical MSSA group (range, 0% to 58%). Genes of the enterotoxin gene cluster, seg, sei, sem, sen, and seo, were present in the clinical and carriage isolates but not in the CA-MRSA group. These results suggest that the presence of additional virulence factors in USA400 CA-MRSA strains compared to the nasal carriage and clinical MSSA strains probably contributed to their enhanced virulence.

Benign papular eruption on the left leg of a 72-year-old diabetic man developed into rapidly spreading necrotizing fasciitis despite antimicrobial therapy and surgical debridements. This led to eventual amputation to control the infection. The etiological agent was a Staphylococcus aureus isolate harboring the enterotoxin gene cluster seg, sei, sem, sen, and seo but lacked all common toxin genes, including PantonValentine leukocidin. CASE REPORTA 72-year-old man presented to his local physician with a 1-day history of swelling and erythematous papular eruption on his left ankle. Despite doing yard work when he noticed the rash, he did not remember trauma to the area. At the initial visit he was febrile and was diagnosed with cellulitis.

A retrospective investigation of skin and soft tissue infections caused by community-associated methicillin-resistant Staphylococcus aureus (MRSA) strains among inmates in a Wisconsin correctional facility suggested a shift in MRSA genotype. Case timeline indicated a displacement of USA400 clone by USA300 clone. The USA300 index case was associated with an infected new tattoo.

he Intermittent Exotropia Questionnaire (IXTQ) is a patientderived, intermittent exotropia-specific instrument designed to evaluate health-related quality of life (HRQOL) in children with intermittent exotropia and their parents. 1,2 The IXTQ consists of 3 parts: the 12-item child IXTQ (completed by the child to assess the child's HRQOL), the 12-item proxy IXTQ (completed by the parent to assess the child's HRQOL), and the 17-item parent IXTQ (completed by the parent regarding his or her own HRQOL). 1 The child and proxy questionnaires each have a single subscale. The parent questionnaire contains 3 subscales: psychosocial, function, and surgery. The IXTQ is reliable and valid for assessing HRQOL in children with intermittent exotropia. [1][2][3] It is available for download free of charge at http://pedig.jaeb.org/.The IXTQ was originally developed using classical test theory. Rasch analysis may be used to modify and improve existing HRQOL instruments. [4][5][6][7][8][9] In the present study, Rasch analysis was used to refine the existing IXTQ, removing items that do not contribute meaningful information to the instrument and ensuring that response options are properly interpreted. Methods Patient CohortParents gave written informed consent, and children gave written assent when required. The protocol was approved by the institutional review boards of the Mayo Clinic, Jaeb Center for Health Research, and other local sites involved in the study. Data were collected and analyzed in accordance with the Health Insurance Portability and Accountability Act guidelines. The IXTQ was completed by 575 parents of 575 children aged 1 through 16 years with intermittent exotropia at the time of their child's clinic examination, enrolled from May 15, 2008, through July 24, 2013. The 295 children aged 5 years or older completed the age-appropriate child IXTQ. Parents and children completed the IXTQ as part of routine care in the strabismus practice of one of the authors (J.M.H., n = 110) or at the enrollment examination for 1 of 2 ongoing randomized clinical trials being conducted by the Pediatric Eye Disease Investigator Group (NCT 01032603 [n = 69] and NCT 01032330 [n = 396]). Child questionnaires were administered to children aged 5 through 7 years by study personnel. All 8-to 17-year-old child, proxy, and parent questionnaires were self-administered. Patient demographics are reported in eTable 1 in the Supplement. Statistical AnalysisBefore Rasch analysis, items with floor and ceiling effects on the child, proxy, and parent IXTQs were eliminated as described in the eMethods in the Supplement. Rasch analysis was performed on each of the 4 IXTQs using the analytic methods that we have applied previously (eMethods in the Supplement). 9 The performance and structure of the Rasch-IMPORTANCE The Intermittent Exotropia Questionnaire (IXTQ) is a patient, proxy, and parental report of quality of life specific to children with intermittent exotropia. We refine the IXTQ using Rasch analysis to improve reliability and validity.OBSERVATI...

We describe phenotypic and genotypic traits of a group of methicillin-resistant Staphylococcus aureus (MRSA) clones that are either remnants of unsuccessful community-associated MRSA (CA-MRSA) clones or represent a transitional state with some yet-to-be-acquired characteristics of CA-MRSA. These rare strains (n ‫؍‬ 20) were identified during a 10-year period (1990-1999) from 13 unrelated health care facilities in Wisconsin. The isolates were recovered from patients in nosocomial or long-term chronic care facilities (60%) and outpatient settings (40%). Sixty percent (n ‫؍‬ 12) of the isolates were recovered from skin and soft tissue infections, whereas the remaining isolates (n ‫؍‬ 8) were from invasive infections. Ninety percent of isolates were susceptible to all antibiotic classes tested or resistant to erythromycin and clindamycin. Pulsed-field gel electrophoresis, multilocus sequence typing, and spa typing clustered these isolates into 8, 8, and 14 clonal groups, respectively. Eight plasmid profiles were represented in these strains. All four agr types were represented, with type IV being predominant (40%). All strains harbored subtypes of type IV staphylococcal cassette chromosome mec but lacked genes for the virulence factor Panton-Valentine leukocidin (PVL). The strains harbored one or more of the following toxin genes: sea, seb, sec, sed, see, seh, sej, sek, sel, seg, sei, sem, sen, and seo. Individual clonal groups maintained the same set of enterotoxin genes even though they were isolated over extended time periods, suggesting significant genomic stability. The potential role of PVL-carrying phages and plasmids in the success of CA-MRSA clones has been discussed.

Background: Tracheal intubation (TI) is one of the most important interventions for the stabilization of critically ill neonates. Competency in airway management is essential for neonatal fellows. No studies have assessed which educational models, techniques, or instructions are perceived by neonatal fellows as the most beneficial for achieving competency in TI. Objectives: This study identifies which factors are considered most helpful in achieving intubation competency. Method: This was a mixed-method study. Semi-structured phone interviews addressed training experience for neonatal intubation. Through qualitative analysis, common themes were identified. RedCap electronic surveys and procedure logs were used to assess procedural experience. Results: Forty-two fellows from 5 programs completed phone interviews. Fellows recalled 6–10 intubation attempts before fellowship. Independent statements related to achieving intubation competency were analyzed and coded into 5 main themes (Procedure, Practice, Perceptual Environment, Personnel, and Preparation). A large proportion of the statements focused on the use of video laryngoscopy. Conclusions: The themes identified by neonatal-perinatal medicine (NPM) fellows as being the most beneficial in achieving proficiency in neonatal TI are categorized as “The 5 Ps.” Careful review of these themes may be utilized to develop validated curriculums that enhance the teaching of TI and optimize the achievement of TI competency among NPM fellows.

Despite high risk of developmental delay in infants with severe bronchopulmonary dysplasia, neonatal follow-up rates are suboptimal. Careful review of parent-identified barriers could be utilised to develop targeted strategies to improve neonatal follow-up attendance in this high-risk population.

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