Does Inclusion of Emergency Medicine (EM) Residents in ECG Screening for STEMI Change the Time to Catheterization Lab Activation?

BACKGROUND: Emergency medicine physicians must rapidly obtain and interpret an electrocardiogram (ECG) to quickly identify life-threatening cardiac emergencies such as ST-elevation myocardial infarction (STEMI). Although ECG interpretation is a critical component of residency education, few high-powered studies exploring the accuracy of resident ECG interpretation exist. OBJECTIVES: This study aims to evaluate whether or not the inclusion of Third Year Emergency Medicine Resident ECG interpretations is noninferior to attending-only ECG interpretations in regard to time to STEMI activation. METHODS: This was a retrospective noninferiority study of STEMI activation times before and after the inclusion of Third Year Emergency Medicine Resident resident ECG interpretations into the workflow at an academic, urban tertiary care center between November 2020 and April 2022, excluding prehospital activations. The primary outcome was the proportion of successful STEMI activations initiated within 5 minutes of ECG completion. An absolute decrease of 10% between groups was chosen as the noninferiority margin. RESULTS: In the attending-only group, 26 (66.7%) cases resulted in successful STEMI activations compared to 31 cases (77.5%) in the combined group. The proportion of successful STEMI activations did not differ with resident screening, X 2 = 1.15, P = 0.28. The absolute difference between groups' successful activations was an increase of 11%, which lies within the noninferiority margin (+11%, 95% confidence interval, -8.68% to 30.7%). Average times to STEMI activation in the attending-only and combined groups were 7.59 minutes (Standard Deviation [SD], 10.19) and 5.13 minutes (SD, 6.95), respectively. Average door-to-balloon times for those undergoing Percutaneous Coronary Intervention were 72.74 minutes (SD, 20.76) in the attending-only group and 89.90 minutes (SD, 67.74) in the combination group. Two sample t-test showed no statistically significant difference between the 2 groups for average time to STEMI activation (difference = 2.46 minutes, 95% CI, -1.46 to 6.38) and average door-to-balloon time (difference = 17.16, 95% CI, -39.73 to 5.41). CONCLUSION: The inclusion of emergency medicine PGY-3 residents in the ECG screening workflow is noninferior to attending-only interpretation of ECGs with regard to STEMI activation time.

Does the Electrocardiogram Machine Interpretation Affect the Ability to Accurately Diagnose ST-Elevation Myocardial Infarction by Emergency Physicians?

INTRODUCTION: An ST-elevation myocardial infarction (STEMI) can portend significant morbidity and mortality to the patient and therefore must be rapidly diagnosed by an emergency medicine (EM) physician. The primary aim of this study is to determine whether EM physicians are more or less likely to accurately diagnose STEMI on an electrocardiogram (ECG) if they are blinded to the ECG machine interpretation as opposed to if they are provided the ECG machine interpretation. METHODS: We performed a retrospective chart review of adult patients over 18 years of age admitted to our large, urban tertiary care center with a diagnosis of STEMI from January 1, 2016, to December 31, 2017. From these patients' charts, we selected 31 ECGs to create a quiz that was presented twice to a group of emergency physicians. The first quiz contained the 31 ECGs without the computer interpretations revealed. The second quiz, presented to the same physicians 2 weeks later, contained the same set of ECGs with the computer interpretations revealed. Physicians were asked "Based on the ECG above, is there a blocked coronary artery present causing a STEMI?" RESULTS: Twenty-five EM physicians completed two 31-question ECG quizzes for a total of 1550 ECG interpretations. On the first quiz with computer interpretations blinded, the overall sensitivity in identifying a "true STEMI" was 67.2% with an overall accuracy of 65.6%. On the second quiz in which the ECG machine interpretation was revealed, the overall sensitivity was 66.4% with an accuracy of 65.8 % in correctly identifying a STEMI. The differences in sensitivity and accuracy were not statistically significant. CONCLUSION: This study demonstrated no significant difference in physicians blinded versus those unblinded to computer interpretations of possible STEMI.

Managing Postpartum Complications in the Emergency Department.

Postpartum patients may present to the emergency department with complaints ranging from minor issues, requiring only patient education and reassurance, to severe, life-threatening complications that require prompt diagnosis and multidisciplinary consultation and management. At times, vague presentations or overlapping conditions can make it difficult for the emergency clinician to recognize an emergent condition and initiate proper treatment. This issue reviews the major common emergencies that present in postpartum patients, by chief complaint, including hemorrhage, infection, pre-eclampsia, eclampsia, headache, and cardiopulmonary conditions, and reviews the most recent evidence and guidelines.

Does the Removal of Textbook Reading from Emergency Medicine Resident Education Negatively Affect In-Service Scores?

INTRODUCTION: In-service exam scores are used by residency programs as a marker for progress and success on board exams. Conference curriculum helps residents prepare for these exams. At our institution, due to resident feedback a change in curriculum was initiated. Our objective was to determine whether assigned Evidence-Based Medicine (EBM) articles and Rosh Review questions were non-inferior to Tintinalli textbook readings. We further hypothesized that the non-textbook assigned curriculum would lead to higher resident satisfaction, greater utilization, and a preference over the old curriculum. METHODS: We collected scores from both the allopathic In-training Examination (ITE) and osteopathic Emergency Medicine Residency In-service Exam (RISE) scores taken by our program's residents from both the 2015-2016 and 2016-2017 residency years. We compared scores pre-curriculum change (pre-CC) to scores post-curriculum change (post-CC). A five-question survey was sent to the residents regarding their satisfaction, preference, and utilization of the two curricula. RESULTS: Resident scores post-CC were shown to be non-inferior to their scores pre-CC for both exams. There was also no significant difference when we compared scores from each class post-CC to their respective class year pre-CC for both exams. Our survey showed significantly more satisfaction, utilization, and preference for this new curriculum among residents. CONCLUSION: We found question-based learning and Evidence-Based Medicine articles non-inferior to textbook readings. This study provides evidence to support a move away from textbook readings without sacrificing scores on examinations.

The Impact of a Concierge Medicine Model on Door to Doctor Time and Patient Flow in an Urban Emergency Department.

INTRODUCTION: Emergency Department (ED) crowding negatively impacts patient outcomes, patient satisfaction, and patient safety. One solution involves introducing a Concierge Physician (CP) whose sole purpose is to provide a brief initial assessment (BIA) and aid patient navigation through the ED. The goal of this study was to quantify the impact of a CP on patient flow dynamics in an urban ED setting. METHODS: We performed a retrospective observational cohort study in an urban academic ED over a 6-month period. Initially, the CP was present in the treatment area during weekdays; during the last half of the observation period, an additional CP was added to the waiting room on weekends. We identified four major milestones in the ED visit with regards to patient throughput. Adult patients presenting to the ED with a triage level of Urgent (ESI 3) were analyzed for this study. Data were stratified based on the patient's ultimate disposition (admitted or discharged) and presented as means with predictive analysis. RESULTS: Between August 2016 and January 2017, the ED evaluated 42,397 adult patients. Of those, 26,976 (64%) were triage level Urgent (3). Of the level 3 patients, 10,279 (38%) received a BIA from a CP. Patients evaluated by a CP were seen approximately 30 mins faster (40% reduction in Door to Doctor time), but stayed 30 mins longer in the ED on average, because the medical decision-making process took >1 hr longer when the patient was initially evaluated by a CP. CONCLUSION: Adapting a concierge medicine model to rapidly evaluate patients resulted in a dramatically reduced Door to Doctor time, but an increase in overall time spent in the ED. This discrepancy was a direct result of the delay in physician disposition.

Molecular Characterization and Detection of 16SrIII Group Phytoplasma Associated with Huanglongbing Symptoms.

When huanglongbing (HLB) was found in Brazil in 2004, 'Candidatus Liberibacter americanus' was infecting most of the trees while 'Ca. L. asiaticus' was present in a minor proportion. Currently, 'Ca. L. asiaticus' is the predominant bacterium associated with HLB in citrus trees in São Paulo (SP) and Minas Gerais (MG) States, the major citrus-growing regions in Brazil. A phytoplasma from the 16SrIX group was associated with HLB symptoms in Brazil in 2007, in plants free of Liberibacter spp. In this report, HLB samples testing negative for 'Ca. L. asiaticus', 'Ca. L. americanus', and 16SrIX phytoplasma were infected with 16SrIII phytoplasmas. Coinfection with 'Ca. L. asiaticus' and 16SrIII was also found. The 16S ribosomal RNA (rRNA) gene sequences from 22 samples were obtained and sequenced, confirming that the 16SrIII group phytoplasma is associated with HLB symptoms in SP and MG States. Ten single-nucleotide polymorphisms (SNPs) were found in the 1,427-bp 16S rRNA gene sequences from 16SrIII phytoplasmas from citrus, whereas none was detected in 16S rRNA gene sequences among 16SrIX phytoplasma from citrus. Ribosomal protein (rp) rpsSrplVrpsC gene sequences were amplified with 16SrIII group-specific primers, sequenced from a subset of nine samples, and assembled into three groups based on eight SNPs. SNPs in 16S rRNA gene and rp gene sequences are common in 16SrIII phytoplasmas from other hosts and this phytoplasma group is widespread in South America. 16SrIII phytoplasmas highly related are commonly found in Melia azedarach, a widespread tree in Brazil and Argentina. The finding of a new phytoplasma associated with HLB symptoms belonging to the 16SrIII group reinforces the need to develop diagnostic tools to assess HLB-associated microbiomes.

JAK2V617F detection and allele burden measurement in saliva vs. peripheral blood in patients with myelofibrosis.

We previously demonstrated that peripheral blood (PB) is a reliable source for testing JAK2V617F mutation in patients with myelofibrosis (MF); saliva has also been tested to detect such mutation, however its diagnostic accuracy as compared to PB has not been validated. In this study, we prospectively tested 167 patients with MF for JAK2V617F mutation, using both saliva and PB collected at the same time from each patient. The concordance between the 2 sources was 96%, with a sensitivity of 100% and a specificity of 90%. The only factor associated with false positivity on saliva was ongoing transfusion dependency. JAK2V617F testing using saliva is a simple, non-invasive, and potentially a more reliable method than PB for measuring JAK2 status and assessing V617F allelic burden in patients with transfusion dependency.

Effectiveness of 2-hour Troponin in High-risk Patients With Suspected Acute Coronary Syndrome.

BACKGROUND: Research has shown the safety and effectiveness of drawing a standard troponin level at presentation and again at 2 hours in only low-risk patients. Because high-sensitivity troponins are not currently approved in the United States, we studied the utility of a standard troponin that is presently in use. Our goal was to determine if 2-hour standard troponin would be safe and effective in the evaluation of a high-risk cohort of patients never studied previously. METHODS: We conducted a single-center prospective observational study of adult patients presenting to the emergency department with signs and symptoms suggestive of acute coronary syndrome. Patients were defined as high risk if the attending physician planned to admit or transfer the patient to the observation unit. History, Electrocardiography, Age, Risk factors, Troponin scores were calculated on all patients to provide verification that the individuals were high risk. The primary outcome was a composite of 30-day myocardial infarction, death, cardiac arrest with return of spontaneous circulation, or dysrhythmia. The secondary outcome was 30-day revascularization. RESULTS: We included a total of 122 patients with an average follow-up of 112 days (minimum 30 days). A total of 86% of cases had History, Electrocardiography, Age, Risk factors, Troponin scores ≥4. The primary outcome was met in 22 (18%) patients, and the secondary outcome occurred in 7 (5.7%) patients. The negative predictive value of negative 2-hour troponins along with no significant delta troponin rise was 98.7%. CONCLUSIONS: Discharging patients thought to be high risk who have negative troponins at 0 and 2 hours and no delta troponin rise appears safe. No deaths occurred in follow-up. Larger studies are warranted.

An accurate, simple prognostic model consisting of age, JAK2, CALR, and MPL mutation status for patients with primary myelofibrosis.

In most patients with primary myelofibrosis, one of three mutually exclusive somatic mutations is detected. In approximately 60% of patients, the Janus kinase 2 gene is mutated, in 20%, the calreticulin gene is mutated, and in 5%, the myeloproliferative leukemia virus gene is mutated. Although patients with mutated calreticulin or myeloproliferative leukemia genes have a favorable outcome, and those with none of these mutations have an unfavorable outcome, prognostication based on mutation status is challenging due to the heterogeneous survival of patients with mutated Janus kinase 2. To develop a prognostic model based on mutation status, we screened primary myelofibrosis patients seen at the MD Anderson Cancer Center, Houston, USA, between 2000 and 2013 for the presence of Janus kinase 2, calreticulin, and myeloproliferative leukemia mutations. Of 344 primary myelofibrosis patients, Janus kinase 2V617F was detected in 226 (66%), calreticulin mutation in 43 (12%), and myeloproliferative leukemia mutation in 16 (5%); 59 patients (17%) were triple-negatives. A 50% cut-off dichotomized Janus kinase 2-mutated patients into those with high Janus kinase 2V617F allele burden and favorable survival and those with low Janus kinase 2V617F allele burden and unfavorable survival. Patients with a favorable mutation status (high Janus kinase 2V617F allele burden/myeloproliferative leukemia/calreticulin mutation) and aged 65 years or under had a median survival of 126 months. Patients with one risk factor (low Janus kinase 2V617F allele burden/triple-negative or age >65 years) had an intermediate survival duration, and patients aged over 65 years with an adverse mutation status (low Janus kinase 2V617F allele burden or triple-negative) had a median survival of only 35 months. Our simple and easily applied age- and mutation status-based scoring system accurately predicted the survival of patients with primary myelofibrosis.

The complete genome sequence of 'Candidatus Liberibacter americanus', associated with Citrus huanglongbing.

Liberibacter spp. form a Rhizobiaceae clade of phloem-limited pathogens of limited host range. Two obligately parasitic species have been sequenced: 'Candidatus Liberibacter asiaticus', which causes citrus huanglongbing (HLB) worldwide, and 'Ca. L. solanacearum', which causes potato "zebra chip" disease. A third (proposed) species, Liberibacter crescens, was isolated from mountain papaya, grown in axenic culture, and sequenced. In an effort to identify common host determinants, the complete genomic DNA sequence of a second HLB species, 'Ca. L. americanus' strain 'São Paulo' was determined. The circular genome of 1,195,201 bp had an average 31.12% GC content and 983 predicted protein encoding genes, 800 (81.4%) of which had a predicted function. There were 658 genes common to all sequenced Liberibacter spp. and only 8 genes common to 'Ca. L. americanus' and 'Ca. L. asiaticus' but not found in 'Ca. L. solanacearum'. Surprisingly, most of the lipopolysaccharide biosynthetic genes were missing from the 'Ca. L. americanus' genome, as well as OmpA and a key regulator of flagellin, all indicating a 'Ca. L. americanus' strategy of avoiding production of major pathogen-associated molecular patterns present in 'Ca. L. asiaticus' and 'Ca. L. solanacearum'. As with 'Ca. L. asiaticus', one of two 'Ca. L. americanus' prophages replicated as an excision plasmid and carried potential lysogenic conversion genes that appeared fragmentary or degenerated in 'Ca. L. solanacearum'.

Scope-assisted release of the cubital tunnel.

We report on a technique of endoscopic release of the cubital tunnel, which is a modification of Bruno and Tsai's technique. This article covers the history, complications, indications, and postoperative management of ulnar nerve entrapments treated endoscopically, with a special focus on our technique. This minimally invasive alternative to transposition requires no mobilization of the ulnar nerve, which could potentially reduce iatrogenic trauma to the nerve and its vascularity.

Citrus Sudden Death Is Transmitted by Graft-Inoculation and Natural Transmission Is Prevented by Individual Insect-Proof Cages.

Citrus sudden death (CSD) transmission was studied by graft-inoculation and under natural conditions. Young sweet orange trees on Rangpur rootstock were used as indicator plants. They were examined regularly for one or two characteristic markers of CSD: (i) presence of a yellow-stained layer of thickened bark on the Rangpur rootstock, and (ii) infection with the CSD-associated marafivirus. Based on these two markers, transmission of CSD was obtained, not only when budwood for graft-inoculation was taken from symptomatic, sweet orange trees on Rangpur, but also when the budwood sources were asymptomatic sweet orange trees on Cleopatra mandarin, indicating that the latter trees are symptomless carriers of the CSD agent. For natural transmission, 80 young indicator plants were planted within a citrus plot severely affected by CSD. Individual insect-proof cages were built around 40 indicator plants, and the other 40 indicator plants remained uncaged. Only two of the 40 caged indicator plants were affected by CSD, whereas 17 uncaged indicator plants showed CSD symptoms and were infected with the marafivirus. An additional 12 uncaged indicator plants became severely affected with citrus variegated chlorosis and were removed. These results strongly suggest that under natural conditions, CSD is transmitted by an aerial vector, such as an insect, and that the cages protected the trees against infection by the vector.

Emergency department crowding: factors influencing flow.

BACKGROUND: THE OBJECTIVE OF THIS STUDY WAS TO EVALUATE THOSE FACTORS, BOTH INTRINSIC AND EXTRINSIC TO THE EMERGENCY DEPARTMENT (ED) THAT INFLUENCE TWO SPECIFIC COMPONENTS OF THROUGHPUT: "door-to-doctor" time and dwell time. METHODS: We used a prospective observational study design to determine the variables that played a significant role in determining ED flow. All adult patients seen or waiting to be seen in the ED were observed at 8pm (Monday-Friday) during a three-month period. Variables measured included daily ED volume, patient acuity, staffing, ED occupancy, daily admissions, ED boarder volume, hospital volume, and intensive care unit volume. Both log-rank tests and time-to-wait (survival) proportional-hazard regression models were fitted to determine which variables were most significant in predicting "door-to-doctor" and dwell times, with full account of the censoring for some patients. RESULTS: We captured 1,543 patients during our study period, representing 27% of total daily volume. The ED operated at an average of 85% capacity (61-102%) with an average of 27% boarding. Median "door-to-doctor" time was 1.8 hours, with the biggest influence being triage category, day of the week, and ED occupancy. Median dwell time was 5.5 hours with similar variable influences. CONCLUSION: The largest contributors to decreased patient flow through the ED at our institution were triage category, ED occupancy, and day of the week. Although the statistically significant factors influencing patient throughput at our institution involve problems with inflow, an increase in ED occupancy could be due to substantial outflow obstruction and may indicate the necessity for increased capacity both within the ED and hospital.

Partial chromosome sequence of Spiroplasma citri reveals extensive viral invasion and important gene decay.

The assembly of 20,000 sequencing reads obtained from shotgun and chromosome-specific libraries of the Spiroplasma citri genome yielded 77 chromosomal contigs totaling 1,674 kbp (92%) of the 1,820-kbp chromosome. The largest chromosomal contigs were positioned on the physical and genetic maps constructed from pulsed-field gel electrophoresis and Southern blot hybridizations. Thirty-eight contigs were annotated, resulting in 1,908 predicted coding sequences (CDS) representing an overall coding density of only 74%. Cellular processes, cell metabolism, and structural-element CDS account for 29% of the coding capacity, CDS of external origin such as viruses and mobile elements account for 24% of the coding capacity, and CDS of unknown function account for 47% of the coding capacity. Among these, 21% of the CDS group into 63 paralog families. The organization of these paralogs into conserved blocks suggests that they represent potential mobile units. Phage-related sequences were particularly abundant and include plectrovirus SpV1 and SVGII3 and lambda-like SpV2 sequences. Sixty-nine copies of transposases belonging to four insertion sequence (IS) families (IS30, IS481, IS3, and ISNCY) were detected. Similarity analyses showed that 21% of chromosomal CDS were truncated compared to their bacterial orthologs. Transmembrane domains, including signal peptides, were predicted for 599 CDS, of which 58 were putative lipoproteins. S. citri has a Sec-dependent protein export pathway. Eighty-four CDS were assigned to transport, such as phosphoenolpyruvate phosphotransferase systems (PTS), the ATP binding cassette (ABC), and other transporters. Besides glycolytic and ATP synthesis pathways, it is noteworthy that S. citri possesses a nearly complete pathway for the biosynthesis of a terpenoid.

Index radial collateral ligament repair with titanium mini-suture anchor: osteolysis complication of an underreported injury.

We are reporting on a case of an index radial collateral ligament tear repaired with a titanium Mitek bone suture anchor. The development of cystic radiographic changes and increased pain and weakness led to suture anchor removal at 10 months post-repair. Periprosthetic osteolysis due to titanium-induced osteoclastogenesis and micromotion was suspected to be the cause. This case report provides a dual focus by stressing the importance of the diagnosis and treatment of this underreported ligament tear and highlighting our osteolysis complication via the mechanism of titanium-induced osteoclastogenesis for future therapeutic preventive measures.

Treatment of distal radius fractures with a nonbridging cross-pin fixator (the CPX system).

Many treatment methods exist for patients presenting with a fracture of the distal radius. With the evolution of innovative procedures and devices, treatment of these particular fractures is shifting to more contemporary approaches. The minimally invasive technique with the cross-pin fixator (CPX) system offers a new biomechanical concept for relatively rigid fixation of distal radius fractures (DRF). The CPX system uses percutaneous cross Kirschner wire fixation in combination with a nonbridging external fixator. The stability of the model is derived from the external unilateral frame and the positioning of multiple 1.6 mm Kirschner wires at various angles and planes to each other. This allows for maintenance of DRF reduction, early wrist mobilization, and a prompt return to the usual activities. Between September 2004 and September 2008, there were 54 patients with 56 DRF who were treated with the CPX system. Excluded from the report are 2 patients who had a bone graft and 1 patient who was not willing to adhere to the postoperative protocol. Of the 51 patients with 53 DRF, no major complications were reported. This article describes the CPX surgical technique, the indications, the complications, and the postoperative management.

Distribution and quantification of Candidatus Liberibacter americanus, agent of huanglongbing disease of citrus in São Paulo State, Brasil, in leaves of an affected sweet orange tree as determined by PCR.

Huanglongbing (HLB), an insect-transmitted disease of citrus, known for many years in Asia and Africa, has appeared in the state of São Paulo State (SSP), Brazil, in 2004, and the state of Florida, USA, in 2005. HLB endangers the very existence of citrus, as trees infected with the bacterial pathogen, irrevocably decline. In the absence of curative procedures, control of HLB is difficult and only based on prevention. Even though not available in culture, the HLB bacterium could be shown to be Gram-negative and to represent a new candidate genus, Candidatus Liberibacter, in the alpha subdivision of the Proteobacteria. Three Candidatus (Ca.) L. species occur: Ca. L. africanus in Africa, Ca. L. asiaticus in Asia, SSP, and Florida, and Ca. L. americanus in SSP. The liberibacters occur exclusively in the phloem sieve tubes. On affected trees, HLB symptoms are often seen on certain branches only, suggesting an uneven distribution of the Liberibacter. Occurrence of Ca. L. americanus, the major HLB agent in SSP, has been examined in 822 leaf samples from an affected sweet orange tree by two conventional PCR techniques and a newly developed real time (RTi) PCR, also used for quantification of the Liberibacter in the leaves. Even though RTi-PCR was able to detect as few as 10 liberibacters per gram of leaf tissue (l/g), no liberibacters could be detected in any of the many leaf samples from a symptomless branch, while in blotchy mottle leaves from symptomatic branches of the same tree, the Liberibacter titer reached values as high as 10(7)l/g. These results demonstrate the uneven distribution of the Liberibacter in HLB-affected trees.

The abundant extrachromosomal DNA content of the Spiroplasma citri GII3-3X genome.

BACKGROUND: Spiroplama citri, the causal agent of citrus stubborn disease, is a bacterium of the class Mollicutes and is transmitted by phloem-feeding leafhopper vectors. In order to characterize candidate genes potentially involved in spiroplasma transmission and pathogenicity, the genome of S. citri strain GII3-3X is currently being deciphered. RESULTS: Assembling 20,000 sequencing reads generated seven circular contigs, none of which fit the 1.8 Mb chromosome map or carried chromosomal markers. These contigs correspond to seven plasmids: pSci1 to pSci6, with sizes ranging from 12.9 to 35.3 kbp and pSciA of 7.8 kbp. Plasmids pSci were detected as multiple copies in strain GII3-3X. Plasmid copy numbers of pSci1-6, as deduced from sequencing coverage, were estimated at 10 to 14 copies per spiroplasma cell, representing 1.6 Mb of extrachromosomal DNA. Genes encoding proteins of the TrsE-TraE, Mob, TraD-TraG, and Soj-ParA protein families were predicted in most of the pSci sequences, in addition to members of 14 protein families of unknown function. Plasmid pSci6 encodes protein P32, a marker of insect transmissibility. Plasmids pSci1-5 code for eight different S. citri adhesion-related proteins (ScARPs) that are homologous to the previously described protein P89 and the S. kunkelii SkARP1. Conserved signal peptides and C-terminal transmembrane alpha helices were predicted in all ScARPs. The predicted surface-exposed N-terminal region possesses the following elements: (i) 6 to 8 repeats of 39 to 42 amino acids each (sarpin repeats), (ii) a central conserved region of 330 amino acids followed by (iii) a more variable domain of about 110 amino acids. The C-terminus, predicted to be cytoplasmic, consists of a 27 amino acid stretch enriched in arginine and lysine (KR) and an optional 23 amino acid stretch enriched in lysine, aspartate and glutamate (KDE). Plasmids pSci mainly present a linear increase of cumulative GC skew except in regions presenting conserved hairpin structures. CONCLUSION: The genome of S. citri GII3-3X is characterized by abundant extrachromosomal elements. The pSci plasmids could not only be vertically inherited but also horizontally transmitted, as they encode proteins usually involved in DNA element partitioning and cell to cell DNA transfer. Because plasmids pSci1-5 encode surface proteins of the ScARP family and pSci6 was recently shown to confer insect transmissibility, diversity and abundance of S. citri plasmids may essentially aid the rapid adaptation of S. citri to more efficient transmission by different insect vectors and to various plant hosts.

Transtracheal 2-d ultrasound for identification of esophageal intubation.

This prospective, blinded, observational, efficacy study is one of the first to evaluate ultrasound in detecting esophageal intubation, a significant source of morbidity and mortality. We utilized a convenience sample of patients undergoing elective surgery during July 2004 in an urban teaching hospital. Trained Emergency Physician sonographers performed transtracheal ultrasounds of intubations to identify esophageal intubation. In 35 of the 40 patients enrolled, there was intubation of the trachea, whereas esophageal intubation occurred in five patients. Sonographers correctly identified all five esophageal intubations, for a sensitivity of 100% (95% confidence interval [CI] 48-100). Ultrasound correctly identified 34 of 35 tracheal intubations and misidentified one resulting in a specificity of 97% (95% CI 90-100). It seems that transtracheal ultrasound may be an efficacious adjunct for detecting esophageal intubation.