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Animals can act as a reservoir and source for the emergence of novel meticillin-resistant Staphylococcus aureus (MRSA) clones in human beings. Here, we report the discovery of a strain of S aureus (LGA251) isolated from bulk milk that was phenotypically resistant to meticillin but tested negative for the mecA gene and a preliminary investigation of the extent to which such strains are present in bovine and human populations. Isolates of bovine MRSA were obtained from the Veterinary Laboratories Agency in the UK, and isolates of human MRSA were obtained from diagnostic or reference laboratories (two in the UK and one in Denmark). From these collections, we searched for mecA PCR-negative bovine and human S aureus isolates showing phenotypic meticillin resistance. We used whole-genome sequencing to establish the genetic basis for the observed antibiotic resistance. A divergent mecA homologue ( mecA LGA251) was discovered in the LGA251 genome located in a novel staphylococcal cassette chromosome mec element, designated type-XI SCC mec. The mecA LGA251 was 70% identical to S aureus mecA homologues and was initially detected in 15 S aureus isolates from dairy cattle in England. These isolates were from three different multilocus sequence type lineages (CC130, CC705, and ST425); spa type t843 (associated with CC130) was identified in 60% of bovine isolates. When human mecA-negative MRSA isolates were tested, the mecA LGA251 homologue was identified in 12 of 16 isolates from Scotland, 15 of 26 from England, and 24 of 32 from Denmark. As in cows, t843 was the most common spa type detected in human beings. Although routine culture and antimicrobial susceptibility testing will identify S aureus isolates with this novel mecA homologue as meticillin resistant, present confirmatory methods will not identify them as MRSA. New diagnostic guidelines for the detection of MRSA should consider the inclusion of tests for mecA LGA251. Department for Environment, Food and Rural Affairs, Higher Education Funding Council for England, Isaac Newton Trust (University of Cambridge), and the Wellcome Trust.

Use of personal mobile devices to record patient data appears to be increasing, but remains poorly studied. We sought to determine the extent and reasons that Canadian emergency physicians (EPs) and emergency medicine residents use personal mobile devices to record patient data in the emergency department (ED). A national survey was distributed to Canadian EPs and residents between 27/02/17 and 23/03/17. This captured demographics, frequency, and purpose of personal mobile device use to record patient data in the ED. It also asked about obtaining consent, security of information, implications for patient care, and knowledge of relevant regulations. The response rate was 23.1% (406 participants). A third (31.5%) reported using personal mobile devices to record patient data. Most (78.1%) did so more than once a month, and 7.0% did so every shift. Reasons cited included beliefs that using personal mobile devices to record patient data improves care by consultants (36.7%), expedites care (31.3%), and advances medical education (32.8%). Consent was rarely or never documented and a minority of participants (10.9%) indicated they did not obtain consent. More than half of participants (53.2%) reported being unaware of applicable regulations. This is the first Canadian study on the use of personal mobile devices to record patient data in the ED. Our findings demonstrate current practice may risk privacy breaches. Personal mobile device use to record patient data in the ED is common and Canadian EPs and residents believe that this practice enhances patient care.

This study examines experiences of living with chronic illness for haemodialysis patients. In order to Understand these experiences the paper takes an existential-phenomenological approach. Interviews of seven participants (five males, two females) were collected in a haemodialysis clinic. Based upon the participants experiences three core themes emerged: (1) the challenges of living with chronic renal failure; (2) body changes and embodiment; (3) their illness experience and social relationships. The findings suggest that the illness experience of chronic renal failure is an on-going struggle to attain a sense of control. We suggest that where a sense of control is limited this can create a sense of powerlessness. Further, the illness experience was not solely restricted to the individual, but also affected wider social relationships. It is only through taking into account the context of patients experience of illness that clinicians/nurses can meaningfully draw on all aspects of evidence to reach integrated clinical judgement.

Departments around the world are sharing their protocols for managing patient surges, conducting protected intubations, and preserving ventilator capacity and personal protective equipment (PPE). 3,4 Learning from observable tests of change incorporates local intangibles such as team composition, performance, and anxiety, and it allows us to make decisions based on outcomes. Areas of emphasis may include donning and doffing PPE safely, communicating from within negative-pressure rooms, respiratory arrests in low-acuity areas, and system-wide simulations that include emergency medical services and intensive care unit services. Despite this, the question of broad implementation of these concepts requires scaled testing or PDSA cycles.6,7 These repetitive tests should be done with differing teams, in multiple environments, and often with several simulations happening simultaneously to model advanced pandemic scenarios and identify the largest number of latent safety threats.

Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home. Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED. Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months. A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use. HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.

Lindsay Heather was HOD of Health and Physical Education for 9 years. Since moving into Teacher Education at UC, her interests and research have been in the area of emotions in teaching and learning, submitting her thesis towards to a Master in Education in November this year. Recently, as a lecturer in the Graduate Diploma of teaching Health and Physical Education curriculum paper, Heather's passion is developing critical thinkers who can connect with the curriculum underlying concepts in their teaching.

Peptide natural products have diverse, elaborate scaffolds and are important leads in the development of new drugs. A complete understanding of the natural biosynthetic pathways of these compounds can improve chemical syntheses and boost bioengineering efforts. There are two classes of peptide natural products: ribosomal and nonribosomal peptides. Ribosomally produced and posttranslationally modified peptides (RiPPs) are produced by the ribosome using the 20 canonical amino acids and undergo extensive tailoring to yield the active natural products. Nonribosomal peptides (NRPs) are assembled through an enzyme dependent system and can incorporate over 500 different amino and acyl building blocks to impart complexity. These peptides can also undergo additional tailoring to further modify the core peptide. The microviridins are a class of RiPPs that are modified by two ATP dependent ligases to create a total of three macrocyclic bonds. We have solved the three dimensional protein structures of each of these ligases to establish the mechanism of substrate recognition and cyclization. Vancomycin is a NRP that contains five nonproteinogenic aromatic amino acids that are necessary for biological activity. One of these amino acids is derived from a polyketide pathway and undergoes a four-electron oxidation by a cofactor independent dioxygenase, DpgC. We have solved the structure of this enzyme and have established a radical mechanism. We have investigated this mechanism using synthetic probes and mutagenesis. We have examined O2 binding using molecular dynamics and mutagenesis. NRPs are synthesized by the multidomain, modular nonribosomal peptide synthetases (NRPSs) in an enzyme templated, ATP-dependent manner. We have synthesized domain specific probes to study the structures and mechanisms of these pathways. Our continued work will provide the insight necessary to manipulate these pathways to provide biologically active compounds.