A comprehensive analysis of Staphylococcus aureus superantigen (SAG) genes was undertaken in isolates from a major hospital and compared with isolates from patients with toxic shock syndrome (TSS). Polymerase chain reaction (PCR) analysis included recently discovered SAGs. Staphylococcal enterotoxin (SE) G and SEI were uniquely expressed in genital isolates. Genital isolates were similar to TSS isolates, although the latter frequently expressed TSS toxin 1. Both had a high frequency of SEG/SEI and a high number of SAG genes per bacterium. Detection of an SAG gene by PCR correlated with positive results in functional assays for SAG activity. Levels of serum antibodies to SEG and SEI, but not to other superantigens, were higher in healthy women than in men and served as an independent measure of the higher frequency of exposure to SEG/SEI among women. Together, the data suggest a role for SEG/SEI or closely linked genes in the adaptation of S. aureus to the genital mucosa environment.

Purpose of Review Anesthesia workforce gaps in low-and middle-income countries (LMICs) can hinder safe surgical care. Several countries have fewer than one anesthesiologist per million population and some have fewer than two anesthesiologists nationally. Limited apprenticeship opportunities and inadequate supervision present serious challenges in these locations. Although simulation training could help disseminate expert guidance, the high cost, technical challenges, and varied approaches limit application. We reviewed the literature on cost-efficient and effective simulation training programs for anesthesia workforces in LMICs. Recent Findings Publications relevant to anesthesia simulation in these countries are limited but include anesthesia skill gap identification, technical skill training, and scenario management. Summary High-cost, high-technology simulation available in high-resource countries is often impractical in LMICs. We identified low-cost approaches that are typically used to assess skill deficiencies and develop nontechnical and technical skills. Future studies should evaluate optimal modalities and equipment for greatest impact.

Introduction: The growth in number of medical schools and increased numbers of faculty tracks have combined with evolving criteria for promotion to trigger a call for greater transparency of academic appointment and promotion processes. Most vulnerable to confusion about these changes are firstgeneration and diverse medical students and residents, the upstream pipeline of the academic medicine workforce. Diverse medical students have expressed diminished interest in academia because of perceived obstacles in appointment and promotion processes. Methods: This workshop was designed to utilize didactics and career reflection exercises to help trainees learn: (1) how to define core terms related to academic appointment and promotion processes, (2) how to compare data elements for different CVs and portfolios, (3) common steps in submitting a promotion package, and (4) that they can immediately begin to document content for academic CVs, portfolios, and promotion packages. Results: One hundred forty-five diverse participants completed an evaluation at eight conferences across the U.S. More than 90% strongly agreed or agreed that the aforementioned objectives were met. Participants commented that the workshop was "illuminating," was "very informative," and "provided an inside look of how faculty are evaluated." Results showed an immediate impact on participants' self-reported confidence to negotiate appointment and promotion processes. Discussion: Increases in self-rated confidence to negotiate appointment and promotion processes may help sustain trainees' interest in becoming future faculty. Further monitoring will be needed to determine if early exposure to these concepts improves probability of seeking, obtaining, and maintaining appointments.

Staphylococcal toxic shock syndrome (TSS) is an acute life threatening disease. The diagnosis can be made clinically based on diagnostic criteria. The clinical manifestations are caused in large part by there lease of high levels of T-cell-derived cytokines as a result of potent toxins, also called superantigens (SAg), produced by Staphylococcus aureus, but it is not clear which clinical symptoms/signs are strictly T-cell dependent. Here, we report on three adults with multiple myeloma (MM) presenting with S.aureus sepsis/shock, and two patients with typical TSS. The MM patients had compromised humoral immunity because of depression of normal immunoglobulin (Ig) levels at the expense of the M protein. In addition, their T cells were absent due to high dose chemotherapy initiated for bone marrow trans-plantation. The MM cases lacked mucosal hyperemia, erythroderma and desquamation, but were otherwise indistinguishable from the TSS cases. All patients grew S. aureus and in each case, SAg genes were detected by PCR. In several cases, the plasma contained biological SAg activity resulting in VP specific proliferation of indicator T cells in vitro. The same specific activity was observed with the supernatant fluids of S. aureus broth cultures from the respective bacterial isolates. This confirms the presence of bio-active toxins in the plasma but did not lead to full blown TSS when T cells were lacking.Thus, S. aureus sepsis/shock can be clinically distinguished from typical TSS, and we suggest that mucocutaneous manifestations of TSS are the most telling signs of massive T-cell-dependent cytokine release.