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Recent data suggest direct oral anticoagulants are as safe and efficacious as warfarin among select patients with valvular heart disease and atrial fibrillation (AF). However, real-world treatment patterns of AF stroke prophylaxis in the setting of valvular AF are currently unknown. Accordingly, using the prospective, ambulatory National Cardiovascular Data Registry Practice Innovation and Clinical Excellence (PINNACLE) Registry, we sought to characterize overall use, temporal trends in use, and the extent of practice-level variation in the use of any direct oral anticoagulant and warfarin among patients with valvular AF from January 1, 2013, to March 31, 2019.

The Himalayan region are home to the world’s youngest and largest mountains, and origins of major rivers systems of South Asia. The present work highlight the importance of remote sensing (RS) data based precipitation and terrain products such as digital elevation models, glacier lakes, drainage morphology along with limited ground data for improving the accuracy of hydrological and hydrodynamic (HD) models in various Himalayan river basins such as Upper Ganga, Beas, Sutlej, Teesta, Koshi etc. The satellite based rainfall have mostly shown under prediction in the study area and few places have are also showing over estimation of rainfall. Hydrological modeling results were most accurate for Beas basin, followed by Upper Ganga basin and were least matching for Sutlej basin. Limited ground truth using GNSS measurements showed that digital elevation model (DEM) for carto version 3.1 is most accurate, followed by ALOS-PALSAR 12.5 DEM as compared to other open source DEMs. Major erosion and deposition was found in Rivers Bhagirathi, Alakhnanda, Gori Ganga and Yamuna in Uttarakhand state and Beas and Sutlej Rivers in Himachal Pradesh using pre and post flood DEM datasets. The terrain data and river cross section data showed that river cross sections and water carrying capacity before and after 2013 floods have changed drastically in many river stretches of upper Ganga and parts of Sutlej river basins. The spatio-temporal variation and evolution of glacier lakes was for lakes along with GLOF modeling few lakes of Upper Chenab, Upper Ganga, Upper Teesta and Koshi river basin was done using time series of RS data from Landsat, Sentinel-1 and Google earth images.

Theoretical studies using Computational Fluid Dynamics (CFD) modeling have been established in the field of polymer electrolyte membrane fuel cells (PEMFCs) and oxygen ion solid oxide fuel cells (O2-SOFCs). However, its implementation in the proton ceramic fuel cell (PCFC) development is still in progress and very limited literature can be found. Thus, in this simulation study, ANSYS 2022 CFD software has been employed to predict hydrogen mass fraction distribution and power density of a single-channel PCFC operating in 100 % hydrogen fuel. This simulation utilized input data based on previously published experimental works. The mass fraction of H2 was 0.0 at the cathode area indicating that the electrolyte layer is fully dense and no leakage of H2 from the anode area into the cathode area. The maximum power density in 100 % H2 was 0.34 W/cm2 at 800° C. This is in agreement with the power density produced by the in-house fabricated button cell with the configuration of NiO-BCZY|BCZY|LSCF (BCZY=BaCe0.54Zr0.36Y0.1O2.95, LSCF=La0.6Sr0.4Co0.2Fe0.8O3-δ.) that showed a maximum power density of 0.33W/cm2 in 100 % H2. This analysis will contribute to insight information on the relationship between fuel mass fraction distribution and fuel cell performance for future improvements in the field of PCFC.

The world is now demanding other sustainable energy that can help explore new technologies, especially energy conversion and storage. Hydrogen is regarded as one of the most promising oils and gas successors as a fuel due to its high energy content per unit mass and it burns completely free of pollutants. A widely used method for hydrogen production is steam reforming methane (SRM) from biogas. In the SRM process, using a catalyst is crucial, and, if compared to the available metal-based catalysts, Ni-based catalysts provide an acceptable high activity and a lower cost. In addition, the support material of a catalyst significantly affects its stability, especially for catalysts exposed to elevated temperatures. In this work, porous alumina support was used as a support material for the preparation of a nickel-based catalytic hollow membrane reactor. Porous alumina support was fabricated using a double-step anodization method. The presence of large pores (≈120 nm) on support material contributes to decreasing the resistance to mass transfer. The study also highlights the recent progress on methane steam reforming reaction, giving a short overview of catalyst utilization and the fundamentals of SRM through the developed membrane reactor.

BackgroundOpioid prescribing has contributed to a North American epidemic with increasing trends in several European countries1. Rheumatic and musculoskeletal diseases (RMDs) are one of the most common indications for prescribed opioids despite there being little evidence on opioid prescribing and the benefit of long-term use in RMDs.ObjectivesTo investigate national UK opioid prescribing trends by studying the patterns of opioid prescribing in new users with the following six RMDs: rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (AxSpA), systemic lupus erythematosus (SLE), osteoarthritis (OA) and fibromyalgia.MethodsPatients aged 18 years and older with a diagnosis of RA, PsA, AxSpA, SLE and OA with a new episode of opioid use without cancer in the Clinical Practice Research Datalink (CPRD) were included between 01/01/2006 and 31/12/2020. CPRD is a database of anonymised UK primary care electronic health records representative of the national population. New opioid users were defined as individuals with RMDs who had a new episode of opioid use in a 2-year time window up to 6 months before or after an RMD diagnosis. Rates of new opioid users were calculated by dividing the number of new opioid users with an RMD per year by the number of eligible patients registered in CPRD per year. Age- and gender-standardised rates for new opioid users were obtained using direct standardisation for each RMD. Rates of opioid prescriptions among new users for each RMD were calculated by dividing the number of opioid prescriptions among new users with an RMD in the year they had new opioid episodes by patient-years of the new users with an RMD. Trends for the rates in the study period were tested using negative binomial regression. Significant change points were identified by looking at the points where the derivative (i.e. rate of change) of the trends for the rates crossed zero. Recurrent opioid users were defined as patients who had at least 3 opioid prescriptions issued within 3 months after a new opioid episode.ResultsThis study included 21,505 RA patients, 8,392 PsA patients, 4,491 AxSpA patients, 4,508 SLE patients, 944,078 OA patients, and 33,829 fibromyalgia patients, who had new opioid episodes between 2006-2020. Whilst the overall trend for RA (2.7* vs 3.9*), PsA (1.0* vs 1.8*) and fibromyalgia (3.7* vs 8.3*) has significantly increased over 15 years, from 2018 onwards, trends of new opioid users appeared to stabilise/decrease (Figure 1). The year 2018 was found to be a significant decreasing change point in the trends of new opioid users for RA, AxSpA, and SLE, whilst this was 2013 in OA and 2019 for fibromyalgia. Opioid prescription rates among new opioid users increased in SLE (4.3# vs 5.4#), OA (4.6# vs 4.9#) and fibromyalgia (5.6# vs 6.5#) but decreased in RA (5.7# vs 5.3#) from 2006 to 2020, despite fluctuations in the rates observed in this period. The highest proportions of recurrent opioid users among the 6 RMDs were patients with RA (32.6%) and fibromyalgia (31.9%).* The number of new opioid users per 10000 persons# The number of opioid prescriptions in new users per patient yearsFigure 1.Trends of new opioid users by RMD, 2006-2020.ConclusionRA, PsA and fibromyalgia had an overall increase in new opioid users since 2006. The slight decrease in the trends of new opioid users among most of the RMDs after 2018 may reflect an increasing awareness of the opioid epidemic. The high proportions of recurrent opioid users in RA and fibromyalgia patients highlight the importance of exploring the safety of long-term opioid use and effective pain interventions for patients with RMDs.References[1]Jani M et al (2020) Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study. PLoS Med 17(10): e1003270AcknowledgementsThis work was funded by a FOREUM grant (grant ID: 125059), MJ is funded through an NIHR Advanced Fellowship (NIHR301413). Thanks to the CPRD fob holders in our centre, Ruth Costello and Ramiro Bravo, for downloading the data.Disclosure of InterestsJoyce (Yun-Ting) Huang: None declared, David Jenkins: None declared, Belay Birlie Yimer: None declared, Jose Benitez-Aurioles: None declared, Niels Peek: None declared, Mark Lunt: None declared, William Dixon Consultant of: WGD has received consultancy fees from Abbvie and Google., Meghna Jani: None declared.

The growing demand for rice as a staple food by the expanding human population forces farmers to use substantial pesticide pest control on their crops. Water pollution is a serious problem as a result of overuse of agrochemical pesticides. Nominee-M, a recently created post-emergence formulation herbicide that has been investigated, contains the active component metamifop. Herbicides that protect crops from weed infestation frequently contain this chemical. The purpose of this study was to examine the effectiveness and potential of foxtail palm fruits as a potential source of activated carbon for the elimination of metamifop. Nitric acid (HNO3) was used in the chemical process of chemical activation to create the activated carbon from the foxtail palm fruits. The effect of adsorbent dose used (2 g, 3 g, 4 g and 5 g), contact time (60 mins, 90 mins, 120 mins and 150 mins) and initial metamifop concentration (10 mg/L, 12 mg/L, 14 mg/L, 16 mg/L and 18 mg/L) toward the efficiency of the prepared activated carbon in removing metamifop was studied in this research. The highest percentage removal was 86.65%, obtained at optimized value of 3 g of activated carbon used at 60 minutes of contact time and 10 ppm of initial concentration of metamifop. The study has proven that activated carbon produce from foxtail palm fruit potentially reduce metamifop in water resources that has been contaminated.

Over the past few years, the issue of pollution from the grave is often taken into account and always become a study material and research. The most commonly used method for disposal of dead bodies and limbs is incineration. Incineration has been used for decades. Previously, biological specimen at the Hospital University of Sains Malaysia (HUSM) was disposed of through incinerators. Given that the majority of HUSM patients are Muslim societies, a method to dispose biological waste in an Islamic-compliant through burial method is proposed. In addition, incineration of dead bodies will have a bad impact on the environment and human health through the emission of toxic gases. New way has been introduced to overcome this problem by burial of formalin fixed specimen onto the soil. However, formalin preservation on specimen is a main concern. This study was done to determine the effect of the formaldehyde on the growth of the Jasminum sambac plant and the physical characteristic of the plant. The height of plant, surface area of leaf, number of leaves and flowers, colour of leaves and chlorophyll content of leaf were observed before and after the plants was treated with formaldehyde. The results obtained from this research will give valuable information on the effect of formaldehyde on the environment specifically on the plant. This study also determines whether the formalin fixed specimen by burial method give negative or positive effect to the environment. The physical characteristics of the plant after treated with formaldehyde shows a negative growth with decrease in number of leaves and flowers as well as in the surface area of leaf. Other than that, the colors of leaves changed from dark green to brownish color for the plants that treated with formaldehyde. In conclusion, formaldehyde application affected the plant and cause the physical characteristic of the plants does not grow well even with the lower concentration.

BackgroundIn March 2020, as part of the UK’s COVID-19 prevention strategy, those identified as ‘clinically extremely vulnerable’, were advised to shield. This included a number of patients prescribed anti-rheumatic drugs, who were asked to continue their current treatment unless they developed symptoms of infection. Suboptimal treatment adherence (16.0%-81.0%) has been reported in patients with arthritic diseases, and is associated with psychological factors, including anxiety (1). Previous literature in non-UK cohorts has highlighted suboptimal adherence levels in immunosuppressed patients during the pandemic, although many were single centre studies (2,3).ObjectivesThe aim of this multi-centre study is to investigate the impact of the COVID-19 pandemic on adherence to anti-rheumatic medications in patients with established rheumatoid (RA) and psoriatic (PsA) arthritis in the UK who had recently commenced a biologic or targeted synthetic DMARD.MethodsBetween September 2020 and May 2021, RA and PsA patients prescribed biologic or targeted synthetic anti-rheumatic drugs from two multi-centre observational studies (BRAGGSS and OUTPASS) were sent a questionnaire on medication usage, adherence, and perceptions to establish the impact of COVID-19 on these parameters. Patients were asked about compliance during the COVID-19 pandemic using a 5-point Likert scale (always, often, sometimes, rarely, and never) and the reason for non-adherence. Adherence was defined as never missing or delaying a dose, unless medically advised. Descriptive summary statistics were calculated, and logistic regression and Pearson’s chi-squared tests were employed to investigate variables associated with self-reported non-adherence.ResultsIn total 159 questionnaires were returned (81.1% RA and 18.9% PsA). Methotrexate (53.5%) was the most frequently prescribed agent, followed by etanercept (25.2%), sulfasalazine (22.6%), hydroxychloroquine (21.4%) and adalimumab (19.5%). Furthermore, 68.6% of patients were prescribed ≥2 drugs. During the pandemic, 42.1% of patients reported missing or delaying a treatment dose for any reason. Adherence information was available for 97.5% of patients with 25.8% reporting non-adherence which was not medically advised. Methotrexate non-adherence was 27.1%, with similar levels reported for etanercept (20.0%), sulfasalazine (27.8%), hydroxychloroquine (35.3%) and adalimumab (29.0%). No drugs had significantly different adherence compared to methotrexate. Furthermore, there was no association between disease type or perception of disease control and adherence. Of non-adherent patients, 17.5% reported increased anxiety, fear, and increased risk due to the COVID-19 pandemic as an influencing factor. Meanwhile, 37.5% of non-adherent patients listed non-COVID-19 intentional reasons and 45.0% reported non-intentional reasons, with forgetting and running out of treatment listed most frequently.ConclusionIn a UK cohort self-reported non-adherence was reported in 25.8% of patients during the COVID-19 pandemic, despite medical advice, with reasons including increased anxiety due to COVID-19.References[1]Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review. Patient Prefer Adherence. 2018;12:1483–503.[2]Vakirlis E, Bakirtzi K, Papadimitriou I, Vrani F, Sideris N, Lallas A, et al. Treatment adherence in psoriatic patients during COVID-19 pandemic: Real-world data from a tertiary hospital in Greece. J Eur Acad Dermatology Venereol. 2020;34(11):e673–5.[3]Polat Ekinci A, Pehlivan G, Gökalp MO. Surveillance of psoriatic patients on biologic treatment during the COVID-19 pandemic: A single-center experience. Dermatol Ther. 2020;(December 2020):19–22.Acknowledgementson behalf of the BRAGGSS consortiumDisclosure of InterestsPhilippa Curry: None declared, Hector Chinoy Speakers bureau: UCB, Biogen, Consultant of: Novartis, Eli Lilly, Orphazyme, Astra Zeneca, Grant/research support from: Eli Lilly, UCB, Meghna Jani: None declared, Darren Plant: None declared, Kimme Hyrich Consultant of: consultancy/honoraria from AbbVie, Grant/research support from: Pfizer, BMS, Ann Morgan Speakers bureau: Roche, Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anthony G Wilson: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Andrew Morris: None declared, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb., James Bluett Grant/research support from: Pfizer Limited. JB has received travel/conference fees from UCB, Pfizer and Eli Lilly

A 52-year-old man presented with a 2-week history of exertional chest discomfort, described as a sensation of fullness in the center of his chest without radiation, and dyspnea. He reported no chest discomfort at rest, light-headedness, or syncope.

The textile industry is a sub-industry that contributes to our country’s economy, and as a result, it is expanding on a daily basis. The processes that are involved in the textile industry are fibre production, spinning, twisting, weaving, knitting, scorching and dyeing, which involve colours or dyes. The combination of processes and products causes waste from the textile industry to contain a wide range of pollutants.The presence of even trace amounts of dye in water (less than 1 ppm) is highly visible and will affect water transparency and gas (carbon dioxide, oxygen) solubility in water bodies where waste is discharged. Dyes are usually resistant to conventional biodegradation. Therefore, adsorption is an effective alternative for dye removal treatment. Therefore, a study has been conducted to find a low-cost raw material for an alternative method of treating textile wastewater. In this study, the capability of activated carbon derived from coconut shells to remove malachite green dye was investigated. Three parameters were studied, such as activated carbon with different chemical impregnation and carbonization time, contact time and initial concentrations of dye. From the results acquired, 99.9% of malachite green dye was removed by the activated carbon impregnated with phosphoric acid solution of 5 minutes carbonization time. The optimum contact time and initial concentration of dye were 1 hour and 10 mg/L, respectively. Therefore, this result can contribute to some knowledge of using low-cost raw material impregnation with some chemicals to remediate textile wastewater.

This research aims to identify the concentration of formaldehyde in groundwater by using UV-Vis spectrophotometer and to assess the physico-chemical parameters of water quality in groundwater. The samples were collected from a cemetery of Kampung Darat Demit, Kubang Kerian, Kota Bharu where the formalin-based specimen/pathological waste was buried. The unknown concentration of the formaldehyde was determined by using chromotropic acid method for the analysis of formaldehyde. A calibration curve was prepared with six different concentrations to determine the unknown concentration of formaldehyde in the samples. Seven parameters of water quality were analyzed using respective methods and the relationship with the presence of formaldehyde in water were discussed. By using the National Water Quality Standard (NWQS) of Malaysia 2008 the class of water for all samples were determined. A statistical study of one-way analysis of variance (ANOVA) was conducted using SPSS 20th version software. The results showed the different concentration of formaldehyde found in all four samples for four consecutive weeks. The classes of water samples for each physical-chemical parameter vary and in range between Class II and III. The presence of formaldehyde in water may has significant effect on the water quality parameters physically, biological and chemically.

Plasma samples collected in tubes containing separator gels have replaced serum samples for most chemistry tests in many hospital and commercial laboratories. Use of plasma samples for blood tests in the dialysis population eliminates delays in sample processing while waiting for clotting to complete, laboratory technical issues associated with fibrin formation, repeat sample collection, and patient care issues caused by delay of results because of incompletely clotted specimens. Additionally, a larger volume of plasma is produced than serum for the same amount of blood collected. Plasma samples are also acceptable for most chemical tests involved in the care of patients with ESRD. This information becomes very important when United States regulatory requirements for ESRD inadvertently limit the type of sample that can be used for government reporting, quality assessment, and value–based payment initiatives. In this narrative, we summarize the renal community experience and how the subsequent resolution of the acceptability of phosphorus levels measured from serum and plasma samples may have significant implications in the country’s continued development of a value–based Medicare ESRD Quality Incentive Program.

The photocatalyst of TiO2/Al2O3/CNT nanocomposite was prepared by hydrothermal process. Its performance was evaluated based on the efficiency in degrading metamifop, an active ingredient in the commercial formulation herbicide. The effect of initial concentration metamifop, the dosage of photocatalyst used during photocatalytic degradation of metamifop and the effect of air flow rate were investigated for the evaluation of its performance. The highest percentage degradation of 10 mg/l metamifop obtained from this study was 95.0% using 20 mg of TiO2/Al2O3/CNT nanocomposite photocatalyst with the air flow rate of 2 l/min. The prepared photocatalyst can be potentially used in environmental application.

One of the biggest challenges faced by technology based Small and Medium Enterprises SME companies in Malaysia is to prototype their casing or housing for their customized electronic products such as embedded control systems, power supplies etc. One of the SME company from Malaysia involved in this case study also have faced the similar problem for their upcoming R&D products. Since the emerging of 3D printer’s technology, rapid prototyping is becoming more superior for their fast, cheap, and reliable compared to conventional or traditional manufacturing technology. The SME company used this as opportunity and used it for their prototype products and have saved time up to 75% and cost by 72% by decreasing the weight of the casing up to 77% using 3D printers.

The validity of hemoglobin A1c (HgbA1c) is undergoing increasing scrutiny in the advanced CKD/ESRD (chronic kidney disease/end-stage renal disease) population, where it appears to be discordant from other glycemic indices. In the Glycemic Indices in Dialysis Evaluation (GIDE) Study, we sought to assess correlation of HgbA1c with casual glucose, glycated albumin, and serum fructosamine in a large group of diabetic patients on dialysis. From 26 dialysis facilities in the United States, 1758 diabetic patients (hemodialysis = 1476, peritoneal dialysis = 282) were enrolled in the first quarter of 2013. The distributions of HgbA1c and the other glycemic indices were analyzed. Intra-patient coefficients of variation and correlations among the four glycemic indices were determined. Patients with low HgbA1c values were both on higher erythropoietin (ESA) doses and more anemic. Serum glucose exhibited the highest intra-patient variability over a 3-month period; variability was modest among the other glycemic indices, and least with HgbA1c. Statistical analyses inclusive of all glycemic markers indicated modest to strong correlations. HgbA1c was more likely to be in the target range than glycated albumin or serum fructosamine, suggesting factors which may or may not be directly related to glycemic control, including anemia, ESA management, and iron administration, in interpreting HgbA1c values. These initial results from the GIDE Study clarify laboratory correlations among glycemic indices and add to concerns about reliance on HgbA1c in patients with diabetes and advanced kidney disease.

Key Clinical Message Deep brain stimulation in an awake patient presents several unique challenges to the anesthesiologist. It is important to understand the various stages of the procedure and the complexities of anesthetic management in order to have a successful surgical outcome and provide a safe environment for the patient.

In modern chemical plants, it is essential to establish an effective maintenance strategy which will deliver financially driven results at optimised conditions, that is, minimum cost and time, by means of a criticality review of equipment in maintenance. In this article, a fuzzy logic-based criticality assessment system (FCAS) for the management of a local company’s equipment maintenance is introduced. This fuzzy system is shown to improve the conventional crisp criticality assessment system (CCAS). Results from case studies show that not only can the fuzzy logic-based system do what the conventional crisp system does but also it can output more criticality classifications with an improved reliability and a greater number of different ratings that account for fuzziness and individual voice of the decision-makers.

Fundamentally, ceria particle had ability to store, transport and release oxygen, which was identified as oxygen storage capacity (OSC). Due to this OSC ability, ceria became the most important component in the three-way catalyst. With the addition of zirconia into the ceria resulting in better performance in three-way catalyst as it increased or improved thermal stability and also promotes the redox properties. This study was conducted to investigate the effects of heat treatment on the structure and physical property of nanocrystalline Ce-Zr-O solid solution. Microemulsion method was used for preparation of Ce-Zr-O solid solution, and heat treatment investigation was applied towards the synthesized nanocrystalline Ce-Zr-O solid solution. The phase and crystal structure of Ce-Zr-O solid solution were determined using XRD analysis. While, the modification of surface area and porosity size over the wide range of calcination temperatures range from 300°C to 700°C was investigated using BET Analyzer. XRD analysis confirmed the Ce0.75Zr0.25O2 solid solution was succesfully synthesized in the research. The results exhibited the effect of heat treatment on the decreasing of surface areas and porosity profiles of the Ce0.75Zr0.25O2. Despite of the reduction of surface areas at elevated temperatures, the study found the promising results that the enhancement of thermal stability of ceria by addition of zirconia.

Background In April 2017, the Maryland Department of Health (MDH) began screening healthcare contacts of confirmed cases of carbapenemase-producing carbapenem-resistant organisms (CP-CROs) to identify potential transmission, per guidance published by the Centers for Disease Control and Prevention. The results of MDH’s CP-CRO colonization screening surveys (CSSs) conducted as of April 1, 2018, are summarized. Methods Rectal swabs were collected on epidemiologically linked CP-CRO contacts and sent to the MDH Laboratories Administration, where the Cepheid Xpert® Carba-R assay was used to detect five carbapenemases: Klebsiella pneumoniae carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), Verona integron encoded metallo-β-lactamase (VIM), imipenemase (IMP), and oxacillinase-48-like carbapenemase (OXA-48). Identification of CP-CROs in contacts sometimes resulted in additional CSSs to ensure complete case detection. Non-KPC cases were combined for analysis. Results During April 1, 2017–April 1, 2018, MDH received reports of 278 incident cases of confirmed CP-CROs. Of these, 16 (6%) expressed non-KPC carbapenemases. The 7 (3%) cases with healthcare contacts prompting CSSs led to screening of 132 first-round contacts, with additional CP-CROs identified in 13 (10%), all of which had KPC. Of these, 12 (92%) resided in ventilator units of skilled nursing facilities (vSNFs). In the first-round CSS at one vSNF, 64% of screened contacts were positive for KPC, which had not been identified in the index case. Weekly follow-up CP-CRO admission screenings and serial follow-up CSSs at the vSNF resulted in screening of a total of 72 unique patients; 38 (53%) were KPC-positive. Of these 38 cases, 32 (89%) were previously unidentified and were placed on contact precautions if not already on them. Staff were re-trained in infection prevention (IP) techniques, and staff and KPC-positive patients were cohorted. Conclusion Detection of CP-CROs that express non-KPC carbapenemases in Maryland is rare, and transmission of these carbapenemases has not been identified. However, CSSs identified previously unknown cases of KPC, most commonly in vSNFs, demonstrating the utility of CSSs to detect CP-CROs, and resulting in important IP interventions. Disclosures All authors: No reported disclosures.

Diabetes is the most common cause of end-stage renal disease and an important risk factor for morbidity and mortality in dialysis patients. Glycemic control, utilizing serial measurement of glycosylated hemoglobin (HbA1c), is generally recommended to limit end-organ damage, including cardiovascular morbidity and mortality. We, along with others, have previously suggested that HbA1c may not be a reliable measure of glycemic control in dialysis patients, and have therefore explored the use of serum fructosamine (SF) as an alternative marker. The objective of this study was to compare HbA1c levels with SF in monitoring glycemic control and associated morbidity (infection and hospitalization) in diabetic patients in a large urban hemodialysis (HD) center. We enrolled 100 diabetic HD patients and followed them up prospectively for 3 years. Data on demographics, as well as biochemical and clinical data, including hospitalizations and infections, were recorded. The mean age was 63 years. In all 54% were women and the majority were African Americans (72%). As expected, HbA1c and albumin-corrected fructosamine (AlbF) levels were highly correlated and both were significantly associated with serum glucose. AlbF, however, was more highly correlated with mean glucose values when less than 150 mg/dl and was a more useful predictor of morbidity. By univariate logistic regression and by Poisson regression analysis, AlbF, but not HbA1c, was a significant predictor of hospitalization. Additionally, in patients dialyzed by arteriovenous (AV) access (that is, excluding those dialyzed via vascular catheters), AlbF, but not HbA1c, was a significant predictor of infection. In conclusion, AlbF is as reliable a marker as HbA1c for glycemic control in diabetic patients on HD, and may be advantageous for patients with serum glucose in a desirable therapeutic range (150 mg/dl). In addition, AlbF, but not HbA1c, is associated with morbidity (hospitalizations and infections) in diabetic patients on HD.

Objectives This study sought to evaluate the prevalence, risk factors, outcomes, and predictors of mortality of retroperitoneal hematoma (RPH) following percutaneous coronary intervention. Background Retroperitoneal hematoma is a serious complication of invasive cardiovascular procedures. Methods The study sample included 112,340 consecutive patients undergoing percutaneous coronary intervention in a large, multicenter registry between October 2002 and December 2007. End points evaluated included the development of RPH and mortality. Results Retroperitoneal hematoma occurred in 482 (0.4%) patients. Of these, 92.3% were treated medically and 7.7% underwent surgical repair. Female sex, body surface area Conclusions Retroperitoneal hematoma is an uncommon complication of contemporary percutaneous coronary intervention associated with high morbidity and mortality. The identification of risk factors for the development of RPH could lead to modification of procedure strategies aimed toward reducing its incidence.

Aim: To evaluate the performance of an automated BACTEC MGIT 960, a non-radioactive, non-invasive liquid culture system for cultivation of M. tuberculosis complex in terms of recovery rate and time. Materials and Methods: From March 2005 to December 2007, 14,597 specimens were processed using the MGIT 960 system and the results were compared with conventional L.J medium. We standardised ρ-nitro benzoic acid (PNBA) assay on MGIT 960 TB system for identification of M. tuberculosis complex and evaluated its usefulness by comparing the results with an in-house molecular assay and sequencing. Results and Discussion: Of the total 6143 (42%) isolates positive for M. tuberculosis complex, 6015 (41%) were positive by MGIT 960 TB system. In contrast, 3526 (24%) M. tuberculosis complex isolates grew on the conventional L.J medium. The mean turn around time for mycobacterial growth in smear-positive specimens was nine days for MGIT 960, and 38 days for L.J. medium whereas in smear negative specimens it was 16 days by MGIT vs. 48 days by L.J. Conclusion: MGIT 960 system with PNBA assay for identification of M. tuberculosis complex is a rapid and useful method in laboratories processing a large number of specimens.

Phosphatidylinositol is an important membrane lipid in Saccharomyces cerevisiae and other eukaryotes. Phosphatidylinositol and its metabolites (phosphoinositides, inositol polyphosphates, etc.) affect many cellular processes with implications in human diseases. Phosphatidylinositol synthesis in S. cerevisiae requires the essential PIS1 gene. Recent studies reveal that PIS1 expression is regulated at the level of transcription in response to carbon source, oxygen, and zinc. However, the consequence of this regulation on phosphatidylinositol levels and functions has not been thoroughly studied. To investigate this, we created a strain with a galactose-inducible GAL1-PIS1 gene. In this strain, the amount of phosphatidylinositol correlated with PIS1 expression but did not exceed c. 25% of the total phospholipid composition. Interestingly, we found that 4% phosphatidylinositol was sufficient for cell growth. We also found that reduced PIS1 expression yielded derepression of two phospholipid biosynthetic genes (INO1 and CHO1) and the INO2 regulatory gene. Consistent with this derepression, reduced PIS1 expression also yielded an overproduction of inositol (Opi(-)) phenotype. The effect on transcription of the INO1, CHO1, and INO2 genes is consistent with the accepted model that phosphatidic acid (PA) is the signal for regulation of these genes because decreased phosphatidylinositol synthesis would affect PA levels.

Summary In Saccharomyces cerevisiae, transcription of most of the phospholipid biosynthetic genes (e.g. INO1, CHO1, CHO2 and OPI3) is repressed by growth in the presence of inositol and choline and derepressed in their absence. This regulation requires the Ino2p and Ino4p activators and the Opi1p repressor. The PIS1 structural gene is required for the synthesis of the essential lipid phosphatidylinositol. Previous reports show that PIS1 expression is uncoupled from inositol/choline regulation, but is regulated by carbon source, hypoxia and zinc. However, in this study we found that the expression of PIS1 is induced twofold by inositol. This regulation did not require Ino2p and Ino4p, although Ino4p was required for full expression. Ino4p is a basic helix-loop-helix protein that requires a binding partner. Curiously, none of the other basic helix-loop-helix proteins affected PIS1 expression. Inositol induction did require another general regulator of phospholipid biosynthesis, Ume6p. Ume6p was found to be a positive regulator of PIS1 gene expression. Ume6p, and several associated factors, were required for inositol-mediated induction and chromatin immunoprecipitation analysis showed that Ume6p directly regulates PIS1 expression. Thus, we demonstrate novel regulation of the PIS1 gene by Ume6p.

Background The American College of Cardiology's Guidelines Applied in Practice (GAP) initiative for acute myocardial infarction (AMI) has been shown to increase the use of guideline-based therapies and improve outcomes in patients with AMI. It is unknown whether hospitals that are more successful in using the standard discharge contract—a key component of GAP that emphasizes guideline-based medications, lifestyle modification, and follow-up planning—experience a proportionally greater improvement in patient outcomes. Methods Medicare patients treated for AMI in all 33 participating GAP hospitals in Michigan were enrolled. We aggregated the hospitals into 3 tertiles based on the rates of discharge contract use: 0% to 8.4% (tertile 1), >8.4% to 38.0% (tertile 2), and >38.0% to 61.1% (tertile 3). We analyzed 1-year follow-up mortality both pre- and post-GAP and compared the mortality decline post-GAP with discharge contract use according to tertile. Results There were 1368 patients in the baseline (pre-GAP) cohort and 1489 patients in the post-GAP cohort. After GAP implementation, mortality at 1 year decreased by 1.2% (P = .71), 1.2% (P = .68), and 6.0% (P = .03) for tertiles 1, 2, and 3, respectively. After multivariate adjustment, discharge contract use was significantly associated with decreased 1-year mortality in tertile 2 (odds ratio 0.43, 95% CI 0.22-0.84) and tertile 3 (odds ratio 0.45, 95% CI 0.27-0.75). Conclusions Increased hospital utilization of the standard discharge contract as part of the GAP program is associated with decreased 1-year mortality in Medicare patient populations with AMI. Hospital efforts to promote adherence to guideline-based care tools such as the discharge contract used in GAP may result in mortality reductions for their patient populations at 1 year.

The validity of hemoglobin A1c (HgbA1c) is undergoing increasing scrutiny in the advanced CKD/ESRD (chronic kidney disease/end-stage renal disease) population, where it appears to be discordant from other glycemic indices. In the Glycemic Indices in Dialysis Evaluation (GIDE) Study, we sought to assess correlation of HgbA1c with casual glucose, glycated albumin, and serum fructosamine in a large group of diabetic patients on dialysis. From 26 dialysis facilities in the United States, 1758 diabetic patients (hemodialysis = 1476, peritoneal dialysis = 282) were enrolled in the first quarter of 2013. The distributions of HgbA1c and the other glycemic indices were analyzed. Intra-patient coefficients of variation and correlations among the four glycemic indices were determined. Patients with low HgbA1c values were both on higher erythropoietin (ESA) doses and more anemic. Serum glucose exhibited the highest intra-patient variability over a 3-month period; variability was modest among the other glycemic indices, and least with HgbA1c. Statistical analyses inclusive of all glycemic markers indicated modest to strong correlations. HgbA1c was more likely to be in the target range than glycated albumin or serum fructosamine, suggesting factors which may or may not be directly related to glycemic control, including anemia, ESA management, and iron administration, in interpreting HgbA1c values. These initial results from the GIDE Study clarify laboratory correlations among glycemic indices and add to concerns about reliance on HgbA1c in patients with diabetes and advanced kidney disease.

Background— The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention (PCI). Methods and Results— Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline (January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention (January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10 287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case ( P P Conclusions— Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a “causal” or a “casual” relationship.

OBJECTIVES We sought to assess the impact of the American College of Cardiology's Guidelines Applied in Practice (GAP) project for acute myocardial infarction (AMI) care, encompassing 33 acute-care hospitals in southeastern Michigan, on rates of mortality in Medicare patients treated in Michigan. BACKGROUND The GAP project increases the use of evidence-based therapies in patients with AMI. It is unknown whether GAP also can reduce the rate of mortality in patients with AMI. METHODS Using a before (n = 1,368) and after GAP implementation (n = 1,489) cohort study, 2,857 Medicare patients with AMI were studied to assess the influence of the GAP program on mortality. Multivariate models tested the independent impact of GAP after controlling for other conditions on in-hospital, 30-day, and one-year mortality. RESULTS Average patient age was 76 years, 48% were women, and 16% represented non-white minorities. The rate of mortality decreased after GAP for each interval studied: hospital, 10.4% versus 13.6%; 30-day, 16.7% versus 21.6%; and one-year, 33.2% versus 38.3%; all p < 0.02. After multivariate adjustment, GAP correlated with a 21% to 26% reduction in mortality, particularly at 30 days (odds ratio of GAP to baseline 0.74; 95% confidence interval [CI] 0.59 to 0.94; p = 0.012) and one year (odds ratio 0.78; 95% CI 0.64 to 0.95; p = 0.013), particularly in the patients for whom a standard discharge tool was used (1-year mortality, odds ratio 0.53; 95% CI 0.36 to 0.76; p = 0.0006). CONCLUSIONS Embedding AMI guidelines into practice was associated with improved 30-day and one-year mortality. This benefit is most marked when patients are cared for using standardized, evidence-based clinical care tools.

Phosphatidylinositol (PI) is a ubiquitous membrane lipid in eukaryotes. It is becoming increasingly obvious that PI and its metabolites play a myriad of very diverse roles in eukaryotic cells. The Saccharomyces cerevisiae PIS1 gene is essential and encodes PI synthase, which is required for the synthesis of PI. Recently, PIS1 expression was found to be regulated in response to carbon source and oxygen availability. It is particularly significant that the promoter elements required for these responses are conserved evolutionarily throughout the Saccharomyces genus. In addition, several genome-wide strategies coupled with more traditional screens suggest that several other factors regulate PIS1 expression. The impact of regulating PIS1 expression on PI synthesis will be discussed along with the possible role(s) that this may have on diseases such as cancer.

OBJECTIVES The purpose of this research was to determine the potential effect of public reporting on case selection for percutaneous coronary intervention (PCI). BACKGROUND Previous studies have suggested that public reporting of coronary artery bypass graft surgery (CABG) mortality might result in case selection bias and in denial of care to or out migration of high-risk patients. The potential effect of public reporting on case selection for PCI is unknown. METHODS We compared demographics, indications, and outcomes of 11,374 patients included in a multicenter (eight hospitals) PCI database in Michigan where no public reporting is present, with 69,048 patients in a statewide (34 hospitals) PCI database in New York, where public reporting is present. The primary end point was in-hospital mortality. RESULTS Patients in Michigan more frequently underwent PCI for acute myocardial infarction (14.4% vs. 8.7%, p < 0.0001) and cardiogenic shock (2.56% vs. 0.38%, p < 0.0001) than those in New York. The Michigan cohort also had a higher prevalence of congestive heart failure and extracardiac vascular disease. The unadjusted in-hospital mortality rate was significantly lower in New York than in Michigan (0.83% vs. 1.54%, p < 0.0001; odds ratio [OR] 0.54, 95% confidence interval [CI] 0.45 to 0.63). However, after adjustment for comorbidities, there was no significant difference in mortality between the two groups (adjusted OR 1.05, 95% CI 0.84 to 1.31, p = 0.70, c-statistic 0.88). CONCLUSIONS There are significant differences in case mix between patients undergoing PCI in Michigan and New York that result in marked differences in unadjusted mortality rates. A propensity in New York toward not intervening on higher-risk patients because of fear of public reporting of high mortality rates is a possible explanation for these differences.

Most commonly seen in the knee, elbow and ankle, osteochondritis dissecans (OCD) represents an underlying bony fragment separation from the subchondral region with or without articular involvement. Osteochondral or chondral injuries are associated with trauma and can occur in any joint. Unstable OCD and traumatic osteochondral or chondral lesions demand operative treatment, particularly if displaced. Principles of treatment include anatomic reduction, rigid fixation, enhancement of blood supply, and restoration of articular congruity. Internal fixation can be achieved through open or arthroscopic approaches with one of many devices including cannulated screws, metal pins, and bioabsorbable pins. Cannulated screws can provide rigid fixation and compression across lesions. AO screws must eventually be removed to avoid articular damage and allow weightbearing. Headless, variable pitch screws, however, can be placed below the articular margin, do not need to be removed, and provide compression because of their differential pitch designs. Metal pins in the form of Kirschner wires (K-wire) can be placed antegrade through the lesion, or retrograde from behind the lesion. K-wires can potentially migrate, bend or break, and they must eventually be removed. Bioabsorbable pins have several advantages including bioresorbable properties obviating the need to remove them, low-profile designs, and a decrease in stress-shielding compared with metal implants. The most common reported complication with bioabsorbable pins is a reactive synovitis. Newer devices recently described for OCD lesions of the capitellum include pull-out wires and dynamic staples. The purpose of this article is to present different options for operative fixation of these lesions.

Background Ex vivo studies have established that arrow fixation of meniscal tears is inferior to vertical sutures and is dependent on arrow length, although the influence of tear location is not known. Hypothesis Arrow length and tear location influence the mechanical properties of meniscal arrows. Study Design Controlled laboratory study. Methods A longitudinal incision was created either 2 mm or 7 mm from the periphery in 70 bovine medial menisci. Each was repaired with a meniscal arrow (10, 13, or 16 mm) or a single vertical suture and subjected to load-to-failure testing and video- graphic analysis. Results Mode of failure (P < .0001), maximum force (P < .0001), stiffness (P < .01), 2-mm gap force (P < .03), and ultimate gap formation (P < .002) were all directly related to arrow length. Sixteen-mm arrows and suture exhibited similar, superior mechanical properties. Tear location significantly influenced properties of 10-mm and 16-mm but not 13-mm arrows. Ten-millimeter arrows displayed the worst performance. Conclusions Mechanical properties of meniscal arrows depend on tear location and arrow length. Clinical Relevance Sixteen-millimeter arrows are a possible alternative to suture for repair of central tears. Thirteen-millimeter arrows may be effective for central and peripheral tears. Ten-millimeter arrows should not be used.

Purpose: Injury to the intestinal mucosa with loss of epithelial barrier integrity is a pathophysiologic hallmark of necrotizing enterocolitis (NEC). Several key mediators of gastrointestinal wound healing have been identified including prostanoids synthesized via cyclooxygenase 2 (COX-2). 5-hydroxytryptamine (5-HT, serotonin) may also regulate wound healing as recent evidence suggests that 5-HT is a pro-inflammatory paracrine signaling molecule. Intestinal mucosal 5-HT is synthesized in the enterochromaffin (EC) cell from tryptophan by tryptophan hydroxylase type 1 (TPH1). 5-HT is released from the EC cell and its clearance and extracellular levels …

Several novel oral anticoagulants (NOA) have been FDA-approved for stroke prevention in patients with non-valvular atrial fibrillation (AF), but clinical trials have excluded patients with valvular AF. The rate of off-label adoption of NOAs for valvular AF is unknown. Using the NCDR-PINNACLE

Background: Classic bladder exstrophy is a developmental defect presenting at birth with a wide pubic separation and an exposed bladder; cloacal exstrophy involves, in addition, intestinal prolapse. Reconstruction requires several surgical procedures. The use of anterior iliac osteotomies in this process has not been reviewed in a large series. Methods: We reviewed the results of eighty-six anterior innominate osteotomies performed in conjunction with genitourinary repair of classic and cloacal bladder exstrophy in eighty-two patients. Clinical outcome measures were successful bladder closure, achievement of continence, and maintenance of a normal gait. Radiographs of the pelvis were reviewed, and the pubic intersymphyseal diastasis (a measure of the reduction in tension on the anterior closure) was measured preoperatively and at three time-points postoperatively. Children with classic exstrophy who had undergone osteotomy and bladder neck reconstruction but not bladder augmentation were divided into four groups on the basis of the degree of continence. In addition, children with classic exstrophy were stratified according to age at the time of the osteotomy. The mean postoperative percent reduction in the amount of the original diastasis was determined for all groups. Results: Children with classic exstrophy and those with cloacal exstrophy had correction of the diastasis after the osteotomy, with greater correction in those with classic exstrophy, presumably because of better bone quality. Daytime continence was achieved with anterior osteotomy and bladder neck reconstruction in 74% of the children for whom continence was a goal. However, no difference in the symphyseal diastasis or in the percentage of pubic reduction was detected among the four continence groups. Children who were older at the time of the osteotomy maintained better correction over time. Wound dehiscence or bladder prolapse occurred in 4% of the patients who had osteotomy and primary closure, and the only important complication of the osteotomies was transient palsy of the left femoral nerve in seven children. Conclusions: Anterior innominate osteotomy is an effective part of reconstructive repair of bladder exstrophy. The primary goals of the osteotomy are to reduce the tension in the closed bladder and the lower abdominal wall and to promote continence by restoring the sling of the pelvic floor muscles. These goals can be achieved in the majority of patients.

We studied the untreated pelvic deformity in 14 adult patients with bladder exstrophy to determine the relative hip-joint force and stress and their effects on the clinical status of the hip. Pelvic radiographs were used for biomechanical analysis to calculate joint force and joint stress (force/area) relative to partial body weight, which allowed comparison between patients and age-matched controls. IOWA hip ratings were used for clinical evaluation, and hips were scored radiographically for degenerative joint disease. The mean relative joint force and joint stress was significantly higher for exstrophy patients (p < 0.001). In addition, the mean distance from the body center to the center of the femoral head was significantly increased (p < 0.001) in bladder exstrophy patients. An increase in diastasis correlated with an approximate 30% increase in the distance from the center of the femoral head to the body midline. The mean distance from the greater trochanter to the femoral head center was significantly less (p < 0.02) and the center-edge angle was significantly decreased in exstrophy patients (p < 0.05). Two patients' hips showed significant subluxation, and one of these showed degenerative hip disease in association with poor IOWA and radiographic scores. The force and stress on the hip joint are increased in untreated adult bladder exstrophy patients. Further longitudinal study is indicated to validate these findings and to determine whether clinically important degenerative changes are occurring. This could affect treatment recommendations in childhood.