Plasmid-Mediated Antibiotic Resistant Escherichia coli in Sarawak Rivers and Aquaculture Farms, Northwest of Borneo.

BACKGROUND: The emergence of plasmid-mediated antibiotic resistance in Escherichia coli in water resources could pose a serious threat to public health. The study aims to investigate the dispersion of plasmid-mediated antibiotic-resistant E. coli from six rivers in Sarawak and two aquaculture farms in Borneo. METHODS: A total of 74 water samples were collected for the determination of their bacteria colony count. An IMViC test identified 31 E. coli isolates and tested their susceptibility against twelve clinically important antibiotics. The extraction of plasmid DNA was done using alkali lysis SDS procedures. Characteristics, including plasmid copy number, molecular weight size, resistance rate and multiple antibiotic resistance (MAR), were assessed. RESULTS: Our findings revealed that bacterial counts in rivers and aquaculture farms ranged from log 2.00 to 3.68 CFU/mL and log 1.70 to 5.48 cfu/mL, respectively. Resistance to piperacillin (100%) was observed in all E. coli; resistance to amoxicillin (100%) and ampicillin (100%) was observed in E. coli found in aquaculture farms; resistance to streptomycin (93%) was observed in E. coli found in rivers. All E. coli were resistant to ≥2 antibiotics and formed 26 MAR profiles, ranging from an index of 0.17 to 0.83, indicating that there are high risks of contamination. Some (48.4%) of the E. coli were detected with plasmids (1.2 to >10 kb), whereas 51.6% of the E. coli did not harbor any plasmids. The plasmid copy numbers reported were one plasmid (n = 7), two plasmids (n = 4), ≥ two plasmids (4). E. coli isolated from the Muara Tuang River showed the highest-molecular-weight plasmids. A statistical analysis revealed that there is no significant correlation (r = 0.21, p = 0.253) between the number of plasmids and the MAR index of the tested isolates. CONCLUSION: The distribution of MAR in E. coli from rivers is higher compared to the aquaculture environment. Our study suggests that MAR in isolates could be chromosome-mediated. Our results suggest that riverbed sediments could serve as reservoirs for MAR bacteria, including pathogens, under different climatic conditions, and their analysis could provide information for public health concerns.

Antiplatelet strategies in acute coronary syndromes: design and methodology of an international collaborative network meta-analysis of randomized controlled trials.

INTRODUCTION: The optimal choice of oral P2Y12 receptor inhibitors has the potential to significantly influence outcomes. We seek to compare the safety and efficacy of the three most commonly used oral P2Y12 receptor inhibitors (clopidogrel, prasugrel, and ticagrelor) in acute coronary syndromes (ACS) via a comprehensive systematic review and network meta-analysis. EVIDENCE ACQUISITION: In line with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines, we performed a comprehensive search for RCTs which compared cardiovascular and hemorrhagic outcomes after use of at least two of the distinct oral P2Y12 receptor inhibitors (i.e. clopidogrel, prasugrel, and ticagrelor). A search strategy has been designed to systematically search multiple databases, including MEDLINE with PubMed interface, The Cochrane Central Register of Controlled Trials, and Embase. In addition, key inclusion criteria will be trial size of at least 100 patients and at least 1 month of follow-up time. Several prespecified subgroups will be explored, including Asian patients, patients presenting with ST-elevation myocardial infarction, patients of advanced age, and others. EVIDENCE SYNTHESIS: Exploratory frequentist pairwise meta-analyses will be based primarily on a random-effects method, relying on relative risks (RR) for short-term outcomes and incidence rate ratios (IRR) for long-term outcomes. Inferential frequentist network meta-analysis will be based primarily on a random-effects method, relying on RR and IRR as specified above. Results will be reported as point summary of effect, 95% CI, and P values for effect, and graphically represented using forest plots. CONCLUSIONS: An international collaborative network meta-analysis has begun to comprehensively analyze the safety and efficacy of prasugrel, ticagrelor and clopidogrel, each on a background of aspirin, for management of patients with ACS. It is our hope that the rigor and breadth of the undertaking described herein will provide novel insights that will inform optimal patient care for patients with ACS treated conservatively, or undergoing revascularization.

Considerations in the use of slit lamp shields to reduce the risk of respiratory virus transmission in coronavirus disease 2019.

PURPOSE OF REVIEW: The use of slit lamp shields has been recommended by the American Academy of Ophthalmology as an infection control measure during the coronavirus disease 2019 pandemic. However, there is limited evidence regarding its efficacy to reduce viral transmission risks. We aim to provide an evidence-based approach to optimize the use of slit lamp shields during clinical examination. RECENT FINDINGS: Respiratory droplets from coughing and sneezing can travel up to 50 m/s and over a distance of 2 m, with a potential area of spread of 616 cm. Slit lamp shields confer added protection against large droplets but are limited against smaller particles. A larger shield curved toward the ophthalmologist and positioned closer to the patient increases protection against large droplets. A potential improvement to the design of such shields is the use of hydrophilic materials with antiviral properties which may help to minimize splashing of infectious droplets, reducing transmission risks. These include gold or silver nanoparticles and graphene oxide. SUMMARY: Slit lamp shields serve as a barrier for large droplets, but its protection against smaller droplets is undetermined. It should be large, positioned close to the patient, and used in tandem with routine basic disinfection practices.

Pre-Operative Embolisation of Musculoskeletal Tumours - A Single Centre Experience.

INTRODUCTION: The management of musculoskeletal tumours is complex and requires a multi-disciplinary approach. Preoperative embolisation can be often employed to reduce intra-operative blood loss and complication rates from surgery. We report our experience with the safety, technical success and efficacy of pre-operative embolisation in musculoskeletal tumours. MATERIALS AND METHODS: Thirteen consecutive patients who underwent pre-operative embolisation of a musculoskeletal tumour followed by surgical intervention at our institution from May 2012 to January 2016 were enrolled into the study. Patient demographics, tumour characteristics, embolisation techniques and type of surgery were recorded. Technical success of embolisation, amount of blood loss during surgery and transfusion requirements were estimated. RESULTS: There were five female and eight male patients who underwent pre-operative embolisation during the study period. The age ranged between 16 to 68 years, and the median age was 54. Technical success was achieved in all patients. Mean intra-operative blood loss was 1403ml, with a range of 150ml to 6900ml. Eight patients (62%) required intra-operative blood products of packed red blood cells and fresh frozen plasma. No major complications occurred during embolisation. CONCLUSION: Pre-operative trans-arterial embolisation is feasible and safe for a variety of large and hypervascular musculoskeletal tumours. Our small series suggests that preoperative embolisation could contribute to the reduction of the intra-operative and post-operative blood product transfusion. It should be considered as a pre-operative adjunct for major tumour resections with a high risk of bleeding. The use of the haemoglobin gap complemented the assessment of perioperative blood loss.

Risk of preterm birth in the subsequent pregnancy following caesarean section at full cervical dilatation compared with mid-cavity instrumental delivery.

BACKGROUND: Expediting delivery in the second stage of labour often involves a choice between a caesarean section at full dilatation or mid-cavity instrumental delivery. Accumulating evidence suggests that the mode of delivery may influence the risk of preterm birth in the subsequent pregnancy. AIMS: To directly compare first birth caesarean section at full dilatation with mid-cavity instrumental delivery for the risk of preterm birth in the subsequent pregnancy (second birth). A further aim was to identify predictive factors associated with these index modes of delivery. MATERIALS AND METHODS: This is a retrospective cohort study involving three maternity hospitals in western Sydney over the period of 2006-2017. Inclusion criteria were nulliparous women with a singleton term cephalic first birth delivered by caesarean section at full dilatation or mid-cavity instrumental delivery, and whose second birth also occurred under our care. Data were analysed separately for first and second births. RESULTS: There were 425 caesarean section at full dilatation and 874 mid-cavity instrumental cases which met inclusion criteria. The risk of preterm birth in the second birth was 5.7% compared to 3.2%, respectively (risk ratio 1.76; 95% CI 1.04-3.00; P = 0.035). After excluding causes of preterm birth not related to previous mode of delivery, the risk of spontaneous preterm birth was 4.3% compared to 2.0%, respectively (risk ratio 2.18; 1.14-4.19; P = 0.019). CONCLUSION: Caesarean section at full dilatation is associated with a significantly higher rate of preterm birth in the subsequent pregnancy compared to a mid-cavity instrumental delivery. This should be considered in second-stage mid-cavity decision-making.

Experimental analysis of the lower cervical spine in flexion with a focus on facet tracking.

Cervical traumas are among the most common events leading to serious spinal cord injuries. While models are often used to better understand injury mechanisms, experimental data for their validation remain sparse, particularly regarding articular facets. The aim of this study was to assess the behavior of cervical FSUs under quasi-static flexion with a specific focus on facet tracking. 9 cadaveric cervical FSUs were imaged and loaded under a 10 Nm flexion moment, exerted incrementally, while biplanar X-rays were acquired at each load increment. The relative vertebral and facet rotations and displacements were assessed using radio-opaque markers implanted in each vertebra and CT-based reconstructions registered on the radiographs. The only failures obtained were due to specimen preparation, indicating a failure moment of cervical FSUs greater than 10 Nm in quasistatic flexion. Facet motions displayed a consistent anterior sliding and a variable pattern regarding their normal displacement. The present study offers insight on the behavior of cervical FSUs under quasi-static flexion beyond physiological thresholds with accurate facet tracking. The data provided should prove useful to further understand injury mechanisms and validate models.

Respiratory virus infection among hospitalized adult patients with or without clinically apparent respiratory infection: a prospective cohort study.

OBJECTIVES: To determine the viral epidemiology and clinical characteristics of patients with and without clinically apparent respiratory tract infection. METHODS: This prospective cohort study was conducted during the 2018 winter influenza season. Adult patients with fever/respiratory symptoms (fever/RS group) were age- and sex-matched with patients without fever/RS (non-fever/RS group) in a 1:1 ratio. Respiratory viruses were tested using NxTAG™ Respiratory Pathogen Panel IVD, a commercially-available multiplex PCR panel. RESULTS: A total of 214 acutely hospitalized patients were included in the final analysis, consisting of 107 with fever/RS (fever/RS group), and 107 age- and sex-matched patients without fever/RS (non-fever/RS group). Respiratory viruses were detected in 34.1% (73/214) of patients, and co-infection occurred in 7.9% (17/214) of patients. The incidence of respiratory virus was higher in the fever/RS group than in the non-fever/RS group (44.9% (48/107) versus 23.4% (25/107), p 0.001). Influenza B virus, enterovirus/rhinovirus and coronaviruses were detected more frequently in the fever/RS group, whereas parainfluenza virus 4B and adenovirus were detected more frequently in the non-fever/RS group. Among the non-fever/RS group, chest discomfort was more common among patients tested positive for respiratory viruses than those without respiratory virus detected (44% (11/25) versus 22% (18/82), p 0.04). CONCLUSIONS: Respiratory viruses can be frequently detected among hospitalized patients without typical features of respiratory tract infection. These patients may be a source of nosocomial outbreaks.

Point-of-care measurement of fetal blood lactate - Time to trust a new device.

BACKGROUND: Point-of-care lactate devices are used worldwide for intrapartum decision making. Current practice is often based on Lactate Pro (Arkray) but its imminent product discontinuation necessitates determination of an optimal replacement device. AIMS: To evaluate the performance of Lactate Pro and two other point-of-care devices, Lactate Pro 2 (Arkray) and StatStrip (Nova Biomedical), and to derive scalp lactate cut-offs equivalent to the current intervention trigger of >4.8 mmol/L. MATERIALS AND METHODS: Paired umbilical cord arterial and venous blood samples from 109 births were tested on the three point-of-care products (two devices each), cross-compared with the reference method blood gas analyser. RESULTS: All brands deviate from the blood gas analyser, with Lactate Pro and StatStrip results consistently lower and Lactate Pro 2 consistently higher. Standard deviation from the blood gas analyser was smallest for StatStrip (0.78 mmol/L, cord artery), and largest for Lactate Pro 2 (1.03 mmol/L, cord artery). Within-brand variation exists and is similar for all brands (mean absolute difference on cord artery 0.23-0.30 mmol/L). Equivalent values to the 4.8 mmol/L intervention threshold based on Lactate Pro are 4.9-5.0 mmol/L for StatStrip and 5.3-5.9 mmol/L for Lactate Pro 2, calculated by receiver-operating characteristic analysis. CONCLUSIONS: StatStrip appears superior to Lactate Pro 2 to replace the original Lactate Pro. Using StatStrip, the 4.8 mmol/L intervention threshold equivalent was 4.9-5.0 mmol/L. The variation in accuracy of point-of-care lactate devices may exceed the small increments (eg <4.2 mmol/L vs >4.8 mmol/L) that guide obstetric decisions.

Outcomes and survivorship of unicondylar knee arthroplasty in patients with severe deformity.

Purpose Patients with severe deformity beyond the standard indications for unicompartmental knee arthroplasty (UKA) may be suitable and benefit from UKA. This study investigated their outcomes to determine whether good function and quality of life (QOL) can be achieved. MATERIALS AND METHODS: Fifty-three patients with severe deformity (40 patients with FFD ≥15° and 13 patients with varus deformity ≥15°, Group A) were matched with 53 patients with less severe deformities who underwent UKA (Group B/controls) in terms of age, sex, BMI and duration of follow-up. Their flexion range, Knee Society scores (KSS), Oxford knee scores (OKS) and SF-36 QOL scores were analysed pre-operatively and at 2 years. RESULTS: Group A patients were largely similar to Group B patients pre-operatively in terms of maximum flexion angle, OKS and SF-36 scores except for knee score and mental health component of SF-36. At 2 years, Group A reported largely similar results compared with Group B in all outcome scores (OKS, KSS, SF-36) and flexion angle. Post-operative mechanical alignment was better for the control group though it is not statistically significant. There were no revisions in the patients with severe pre-operative deformity at 5 years post-operatively. (Survivorship 100 % at 5 years). CONCLUSION: Selected patients with severe deformity can achieve good function and QOL with UKA if satisfactory mechanical alignment is restored. This study supports a broadening of the indications of UKA; however, further follow-up is needed to assess the longer-term durability of the operation. LEVEL OF EVIDENCE: IV.

Survey of neonatal unit outbreaks in North London: identifying causes and risk factors.

BACKGROUND: This survey was undertaken after a number of neonatal unit (NNU) outbreaks were reported to the North London health protection teams (HPTs). AIM: To determine the diversity of the outbreaks, ascertain potential sources and contributing factors, and identify the investigative procedures followed and control measures implemented. METHODS: Using a structured questionnaire, information from the HPT database was collected for all NNU outbreaks reported between January 2010 and February 2011. FINDINGS: Ten outbreaks were identified from seven hospitals in 14 months. There was one para-influenza outbreak, seven Staphylococcus aureus [including six meticillin-resistant S. aureus (MRSA)] outbreaks, and two Gram-negative outbreaks. Potential sources of transmission identified for the MRSA outbreaks were healthcare worker (HCW)-assisted transmission (N = 2) and mother-to-baby transmission with onward HCW-assisted transmission (N = 3). An environmental source with onward HCW-assisted transmission was documented for one of the Gram-negative outbreaks. Interventions included patient screening and enhanced cleaning (N = 10), isolating/cohorting affected neonates (N = 9), barrier nursing (N = 6), staff movement restrictions (N = 5), hand hygiene audits (N = 4), staff screening (N = 4), household contact screening (N = 3) and environmental sampling (N = 3). Potential contributing factors included inadequate staffing levels, cluttered unit, inadequate sterilization of communal milk-expressing equipment and inappropriate follow-up of MRSA results. CONCLUSION: This survey determined the diversity of NNU outbreaks in North London, and highlighted the importance of a multi-faceted approach to outbreak control. These data will assist in the development of clinical standards for the prevention, control and reporting of NNU outbreaks, and guidance for best practice in NNUs.

Rapid identification of group B streptococcus carriage by PCR to assist in the management of women with prelabour rupture of membranes in term pregnancy.

BACKGROUND: Management of prelabour rupture of membranes at term (37 weeks gestation or later) (TPROM) remains complicated in the absence of a rapid assay for group B streptococcus (GBS) colonisation. AIMS: To evaluate the accuracy and clinical utility of a commercial PCR assay, compared with culture, for detection of GBS colonisation in pregnant women presenting with TPROM. METHODS: A prospective study of women presenting with TPROM conducted in a large tertiary hospital (Westmead Hospital, Australia). Five hundred and seventy-four consecutive women with TPROM were enrolled between July 2006 and November 2007. Paired low vaginal and anal swabs were collected from women presenting with TPROM for PCR and culture on GBS selective agar following broth enrichment. Primary outcomes were sensitivity and specificity of PCR compared with GBS selective enrichment culture. Secondary analyses included comparison with a historical but otherwise similar cohort regarding clinical utility, maternal and neonatal outcomes. RESULTS: PCR sensitivity and specificity were 89.0% (95% CI - 82.8-93.6%) and 97.9% (95% CI - 96.0-99.0%), respectively, compared with culture. 72.3% of women were aware of their GBS PCR status within 3 h of presentation. Compared with the historical cohort, PCR reduced the requirement for intrapartum antibiotics by 25.6% (P < 0.001). There were no significant differences in maternal outcomes or combined rates of admissions to neonatal intensive care or special care nursery. CONCLUSIONS: Group B streptococcus PCR is an accurate, rapid, safe and practical alternative to culture for detection of GBS colonisation in pregnant women at the time of TPROM. This method has the potential advantage to reduce costs associated with length of hospital stay.

Cost-Effectiveness of Linezolid versus Vancomycin among Patients with Methicillin-Resistant Staphylococcus aureus Confirmed Nosocomial Pneumonia in China.

OBJECTIVE: To estimate the cost-effectiveness of intravenous linezolid as a first-line agent against intravenous vancomycin in treating methicillin-resistant Staphylococcus aureus-confirmed nosocomial pneumonia in four Chinese cities. METHODS: A decision-analytic model of 4-week time horizon was used to conduct cost-effectiveness analyses from the payer's perspective. Clinical outcomes and resource use data were derived from a head-to-head trial, supplemented with local cost estimates based on hospital data via an expert panel. A series of scenario analyses were conducted to evaluate the impact of uncertainty around model inputs. All results were reported in 2012 Chinese Renminbi. RESULTS: The predicted probability of overall treatment success was 0.629 and 0.602 for linezolid and vancomycin, respectively. Total inpatient costs varied across the four cities, ranging from ¥58,835 to ¥86,894 for linezolid and ¥58,390 to ¥87,033 for vancomycin, respectively. Linezolid was demonstrated to be a dominant treatment strategy in Guangzhou. In Beijing, Nanjing, and Xi'an, incremental cost-effectiveness ratios in terms of additional successfully treated patient were ¥1,861, ¥163, and ¥16,509, respectively. Dominance by linezolid was observed in some scenario analyses with parameters such as treatment duration, inclusion of cost of managing adverse events, and drug acquisition costs being the main drivers of cost-effectiveness results. CONCLUSIONS: Despite linezolid's higher drug acquisition cost, its superior clinical efficacy renders it a likely cost-effective alternative for the treatment of methicillin-resistant Staphylococcus aureus-confirmed nosocomial pneumonia as compared with branded vancomycin from the payer perspectives of Beijing, Guangzhou, Nanjing, and Xi'an.

Effects of co-substrate and biomass acclimation concentration on the bioregeneration of azo dye-loaded mono-amine modified silica.

Bioregeneration of mono-amine modified silica gel (MAMS) adsorbent loaded with Acid Orange 7 (AO7), Acid Yellow 9 (AY9) and Acid Red 14 (AR14), respectively, was investigated under two different operational conditions, namely absence/presence of sucrose/bacto-peptone as the co-substrate and different biomass acclimation concentrations. The results revealed that the AY9- and AR14-loaded MAMS adsorbents could almost be completely bioregenerated but only in the presence of co-substrate whereas the bioregeneration of AO7-loaded MAMS could achieve up to 71% in the absence of the co-substrate. These differences could be related to the structural properties of the investigated azo dyes. In addition, the results showed that the bioregeneration duration of AO7-loaded MAMS could be progressively shortened by using biomass acclimated to increasingly higher AO7 concentration. However, the bioregeneration efficiencies were found to be relatively unchanged under different biomass acclimation concentrations.

Lactate study using umbilical cord blood: agreement between Lactate Pro hand-held devices with blood gas analyser and evaluation of lactate stability over time.

BACKGROUND: Lactate measurements have become increasingly preferred over pH analysis in the evaluation of fetal acidaemia in labour. In a busy labour ward, often the umbilical cord may be sampled late and as a result yield unreliable lactate values. AIM: To investigate the agreement of hand-held device Lactate Pro with a reference method blood gas analyser and evaluate the stability of umbilical cord lactate values over time. METHODS: Prospective study carried out at elective caesarean section. Sixteen umbilical cords were double clamped immediately after delivery with paired arterial and venous blood samples collected by an independent researcher, at varying time intervals, and processed by two Lactate Pro devices and a reference method blood gas analyser. RESULTS: A significant difference of -0.41 to 0.10 mmol/L was found when different groups of Lactate Pro devices were compared with blood gas analyser at lactate values up to 5.70 mmol/L, with average lactate value of 2.45 mmol/L. Over time, there is progressive rise in lactate samples obtained from the umbilical cord. CONCLUSION: Lactate Pro devices have a significant difference, but when used in clinical practice on cord blood after delivery, this is unlikely to be meaningful. In intrapartum fetal surveillance, a systematic overestimation might lead to unnecessary intervention. It is possible to retrospectively predict the likely level of lactate at birth in delayed cord samples.

Impact of glaucoma severity and laterality on vision-specific functioning: the Singapore Malay eye study.

PURPOSE: We determined the impact of glaucoma severity and laterality on vision-specific functioning (VF) in an Asian population. METHODS: The Singapore Malay Eye Study (SiMES) was a population-based cross-sectional study of 3280 Malays aged 40 to 80 years. VF was assessed using the VF-11 questionnaire. Associations between VF-11 score and glaucoma clinical indices (glaucoma severity in better and worse eyes, and laterality) were determined by multivariate regression modeling. Glaucoma severity was defined as mild, moderate, advanced, and severe based on the Hodapp-Anderson-Parish system. Rasch analysis was used to validate the VF-11 and determine its psychometric properties. RESULTS: Of 926 persons analyzed, 123 had glaucoma (13.3% glaucoma prevalence in analyzed sample). The mean ± SD VF score was 3.64 ± 1.05 log of odds units (Logits). In multivariate models adjusting for sociodemographic, ocular, and systemic variables, poorer VF was associated with increasingly worse eye visual field loss (ß = 0.016, 95% confidence interval [CI] 0.004-0.029, P < 0.001), but not that of the better eye (P > 0.05). Compared to controls, VF was reduced in individuals with worse eye advanced and severe glaucoma (ß = -0.65, 95% CI -1.03 to -0.28, P < 0.05), but not mild or moderate glaucoma (P > 0.05). Compared to controls, VF was reduced in unilateral (ß = -0.29, 95% CI -0.54 to -0.04, P < 0.05), but not bilateral glaucoma (P > 0.05). These associations remained significant after adjusting for presenting and best-corrected visual acuity. CONCLUSIONS: Among Singaporean Malays, unilateral, and advanced and severe glaucoma in the worse eye significantly impacts on VF. Identifying early-stage glaucoma, preventing progression, and visual rehabilitation in advanced glaucoma are important aspects of glaucoma management.

Initial results with (11)C-acetate positron emission tomography/computed tomography (PET/CT) in the staging of urinary bladder cancer.

PURPOSE: To investigate the utility of (11)C-acetate positron emission tomography/computed tomography (PET/CT) for staging of bladder cancer and response assessment after neoadjuvant chemotherapy. PROCEDURES: Seventeen patients underwent (11)C-acetate PET/CT ≤1 month before radical cystectomy (RC) and pelvic lymph node dissection (PLND). Ten patients had undergone neoadjuvant chemotherapy prior to PET. Histopathology from RC and PLND (n = 16) or nodal biopsy (n = 1) served as gold standard. RESULTS: Eight of 10 residual tumors showed abnormal (11)C-acetate uptake; two cases of residual TiS were false negative, three cases were false positive, and three true negative. Three patients showed true positive uptake in LN. False positive uptake occurred in 14 LN regions secondary to granulomatous disease after prior intravesical Bacillus Calmette-Guerin (BCG) therapy. CONCLUSIONS: (11)C-acetate has good sensitivity for bladder cancer and LN metastases. However, false positive uptake due to inflammation or granulomatous infection can occur, limiting the staging utility of (11)C-acetate after prior intravesical BCG therapy.

Thyroid incidentalomas on fluorine-18-fluorodeoxyglucose positron emission tomography-computed tomography: incidence, malignancy risk, and comparison of standardized uptake values.

INTRODUCTION: To determine the incidence of fluorine-18-fluorodeoxyglucose (FDG) avid thyroid incidentalomas detected on positron emission tomography (PET) with integrated computed tomography (CT), and correlate the FDG-PET-CT findings to cytology. METHODS: A total of 942 FDG-PET-CT reports were retrospectively reviewed. Patients with FDG-avid thyroid incidentalomas were further reviewed for correlative cytology. RESULTS: The incidence of FDG-avid thyroid incidentalomas is 2.2%. Thyroid malignancies were identified in 3 of 6 patients who underwent cytologic correlation, with a positive predictive value of 50% (95% confidence interval, 14%-86%). The mean maximum standardized uptake values of benign and malignant FDG-avid thyroid incidentalomas were 5.6 and 6.6, respectively. CONCLUSION: A FDG-avid thyroid incidentaloma may predict underlying malignancy. Cytologic assessment should be considered for FDG-avid thyroid incidentalomas.

Five hepatitis B outbreaks in care homes in the UK associated with deficiencies in infection control practice in blood glucose monitoring.

Healthcare-associated hepatitis B virus (HBV) outbreaks have been reported in the USA and from several countries in Europe. Patient-to-patient transmission of HBV in these settings has been linked to several different types of exposure but one of the most common exposures implicated is the use of 'finger-stick' lancet devices for blood glucose testing. This article is an account of the investigations into a series of HBV outbreaks linked to the use of lancing devices in community healthcare settings in the UK. Between February 2004 and December 2006, nine individuals with acute HBV infection were reported to five local units of the Health Protection Agency. Investigations identified a further 12 individuals with HBV infection in residents in these settings. The epidemiological and environmental evidence suggests that HBV transmission occurred mostly from a significant breakdown in infection control measures in blood glucose testing. The occurrence of these outbreaks has highlighted the confusion that exists and the need for clear recommendations regarding the use of such devices in the UK.

The effects of nickel(II) and chromium(VI) on oxygen demand, nitrogen and metal removal in a sequencing batch reactor.

The objective of this study was to evaluate the effects ofNi(II) and Cr(VI) individually and in combination on the simultaneous removal of chemical oxygen demand (COD), nitrogen and metals under a sequencing batch reactor (SBR) operation. Three identical laboratory-scale SBRs were operated with FILL, REACT, SETTLE, DRAW and IDLE periods in a ratio of 1:12:1:2:8 for a cycle time of 24 h until the steady state was achieved. Nickel(II) at increasing concentrations up to 35 mg/L was added to one of the reactors; Cr(VI) at increasing concentrations up to 25 mg/L was added to a second reactor; while a combination of Ni(II) and Cr(VI) in equal concentrations up to 10 mg/L was added to a third reactor. The results demonstrate that both Ni(II) and Cr(VI) exerted a more pronounced inhibitory effect on the removal of ammonia nitrogen (AN) than on COD removal. Synergistic and antagonistic inhibitory effects on the rates of COD and AN removal, respectively, were observed for the 50% Ni(II) and 50% Cr(VI) (w/w) mixture in the concentration range between 10 and 20 mg/L. The simultaneous presence of 50% Ni(II) and 50% Cr(VI) at a concentration of 20 mg/L resulted in system failure.