Open Access

Effectively communicating pain is crucial for human beings. Facial expressions are one of the most specific forms of behavior associated with pain, but the way culture shapes expectations about the intensity with which pain is typically facially conveyed, and the visual strategies deployed to decode pain intensity in facial expressions, is poorly understood. The present study used a data-driven approach to compare two cultures, namely East Asians and Westerners, with respect to their mental representations of pain facial expressions (experiment 1, N=60; experiment 2, N=74) and their visual information utilization during the discrimination of facial expressions of pain of different intensities (experiment 3; N=60). Results reveal that compared to Westerners, East Asians expect more intense pain expressions (experiments 1 and 2), need more signal, and do not rely as much as Westerners on core facial features of pain expressions to discriminate between pain intensities (experiment 3). Together, those findings suggest that cultural norms regarding socially accepted pain behaviors shape the expectations about pain facial expressions and decoding visual strategies. Furthermore, they highlight the complexity of emotional facial expressions and the importance of studying pain communication in multicultural settings.

Introduction: The Enterobacter cloacae complex (ECC) species are potential neonatal pathogens, and ECC strains are among the most commonly encountered Enterobacter spp. associated with nosocomial bloodstream infections. Outbreaks caused by ECC can lead to significant morbidity and mortality in susceptible neonates. At the molecular level, ECC exhibits genomic heterogeneity, with six closely related species and subspecies. Genetic variability poses a challenge in accurately identifying outbreaks by determining the clonality of ECC isolates. This difficulty is further compounded by the limitations of the commonly used molecular typing methods, such as pulsed field gel electrophoresis, which do not provide reliable accuracy in distinguishing between ECC strains and can lead to incorrect conclusions. Next-generation sequencing (NGS) offers superior resolution in determining strain relatedness. Therefore, we investigated the clinical pertinence of incorporating NGS into existing bundle measures to enhance patient management during an outbreak of ECC in a level-3 neonatal intensive care unit (NICU) in Germany. Methods: As the standard of care, all neonates on the NICU received weekly microbiological swabs (nasopharyngeal and rectal) and analysis of endotracheal secretion, where feasible. During the 2.5-month outbreak, colonisation with ECC was detected in n = 10 neonates. The phylogenetic relationship and potential antimicrobial resistance genes as well as mobile genetic elements were identified via bacterial whole-genome sequencing (WGS) using Illumina MiSeq followed by in silico data analysis. Results: Although all ECC isolates exhibited almost identical antimicrobial susceptibility patterns, the WGS data revealed the involvement of four different ECC clones. The isolates could be characterised as Enterobacter hormaechei subspecies steigerwaltii (n = 6, clonal), subsp. hoffmannii (n = 3, two clones) and subsp. oharae (n = 1). Despite the collection of environmental samples, no source of this diffuse outbreak could be identified. A new standardised operating procedure was implemented to enhance the management of neonates colonised with MRGN. This collaborative approach involved both parents and medical professionals and successfully prevented further transmission of ECC. Conclusions: Initially, it was believed that the NICU outbreak was caused by a single ECC clone due to the similarity in antibiotic resistance. However, our findings show that antibiotic susceptibility patterns can be misleading in investigating outbreaks of multi-drug-resistant ECC. In contrast, bacterial WGS accurately identified ECC at the clonal level, which significantly helped to delineate the nature of the observed outbreak.