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Microlitter is a widespread contaminant with implications for aquatic health; however, knowledge of its distribution in fresh waters is limited. We examined microlitter in surface water, sediment, and mussels within the Saint John River and four major tributaries. Microlitter was present at all 89 sites, with concentrations in water equivalent to other Canadian watersheds. Microlitter concentrations likely reflected differences in land use and development. Comparisons between rivers generally revealed distinct water microlitter particle compositions, suggesting that input sources were specific to each river, while microlitter in sediments and mussels was largely homogeneous among rivers. There was little similarity in concentration and composition of microlitter among the three matrices sampled. Microlitter in sediments and mussels may not reliably track concentration and composition in aquatic environments. Microlitter concentration was not significantly greater downstream of wastewater treatment plants. Airborne microlitter transportation was evident, as remote sites in two tributary rivers demonstrated the highest concentrations of microlitter. Our data highlights the prevalence of microlitter in rural rivers, underscoring the ubiquity of this emerging contaminant and its integration into food webs.

Background Clostridioides difficile was listed as an urgent antimicrobial resistance (AMR) threat in a report by the CDC in 2019. AMR drives the evolution of C. difficile and facilitates its emergence and spread. The C. difficile Antimicrobial Resistance Surveillance (CDARS) study is nationwide longitudinal surveillance of C. difficile infection (CDI) in Australia. Objectives To determine the antimicrobial susceptibility of C. difficile isolated in Australia between 2015 and 2018. Methods A total of 1091 strains of C. difficile were collected over a 3 year period by a network of 10 diagnostic microbiology laboratories in five Australian states. These strains were tested for their susceptibility to nine antimicrobials using the CLSI agar incorporation method. Results All strains were susceptible to metronidazole, fidaxomicin, rifaximin and amoxicillin/clavulanate and low numbers of resistant strains were observed for meropenem (0.1%; 1/1091), moxifloxacin (3.5%; 38/1091) and vancomycin (5.7%; 62/1091). Resistance to clindamycin was common (85.2%; 929/1091), followed by resistance to ceftriaxone (18.8%; 205/1091). The in vitro activity of fidaxomicin [geometric mean MIC (GM) = 0.101 mg/L] was superior to that of vancomycin (1.700 mg/L) and metronidazole (0.229 mg/L). The prevalence of MDR C. difficile, as defined by resistance to ≥3 antimicrobial classes, was low (1.7%; 19/1091). Conclusions The majority of C. difficile isolated in Australia did not show reduced susceptibility to antimicrobials recommended for treatment of CDI (vancomycin, metronidazole and fidaxomicin). Resistance to carbapenems and fluoroquinolones was low and MDR was uncommon; however, clindamycin resistance was frequent. One fluoroquinolone-resistant ribotype 027 strain was detected.

Background The American Shoulder and Elbow Surgeons (ASES) shoulder score and the Single Assessment Numeric Evaluation (SANE) measure shoulder function. Relative to the ASES questionnaire, the SANE questionnaire is shorter and easier to score. We sought to determine (1) the correlation between ASES and SANE scores preoperatively and at 2 years postoperatively in patients undergoing rotator cuff repair (RCR) or shoulder arthroplasty and (2) the correlation between the change in ASES scores and change in SANE scores. Methods We reviewed the records of 107 patients who underwent RCR (n = 74) or shoulder arthroplasty (n = 33), which included patients undergoing total shoulder arthroplasty (n = 18) and reverse total shoulder arthroplasty (n = 15), at our institution from 2014 to 2015 and who completed the ASES and SANE questionnaires preoperatively and at least 2 years postoperatively. Pearson correlation coefficients were calculated to determine the relationship between SANE and ASES scores in RCR patients and arthroplasty patients (both total shoulder arthroplasty and reverse total shoulder arthroplasty) at each time point. Results In the RCR group, correlations between SANE and ASES scores were moderately positive preoperatively (r = 0.30) and strongly positive postoperatively (r = 0.86). In the arthroplasty group, correlations between SANE and ASES scores were moderately positive preoperatively (r = 0.46) and strongly positive postoperatively (r = 0.78). Conclusion SANE scores correlate positively with ASES scores postoperatively in patients undergoing RCR. Therefore, SANE scores, together with clinician-based and combination scores, can be used to assess postoperative shoulder function in these patients.

Microfibers are now ubiquitous in the environment largely due to the widespread use of natural and synthetic textiles. Many enter aquatic systems through wastewater treatment plant (WWTP) effluent, surface water runoff, and atmospheric deposition, where they persist and may be ingested by filter-feeding organisms. In addition to causing physical damage (e.g., digestive and respiratory obstructions), microfibers are often carriers of chemical pollutants that may also harm biota. This exploratory study aimed to determine whether freshwater mussel (Margaritifera margaritifera L.) microfiber content varied between two rural tributaries of the Saint John River, whether microfiber content was related to WWTP discharge points or potential diffuse microfiber sources, and whether mussel size was associated with microfiber content. Mussels were collected both upstream and downstream of five WWTP discharge points and at 11 other points along two rivers within rural watersheds of maritime Canada. Microfiber content differed significantly between the two rivers; however, no trends were observed in microfiber content in relation to WWTP discharge points on either river. Smaller mussels contained significantly more microfibers than larger mussels, despite differences in mussel size ranges between tributaries. These results reveal a potential pathway for microfibers to enter aquatic food webs and highlight important implications for the use of freshwater mussels as bioindicators of microfiber contamination.

In the early 2000s, a binary toxin (CDT)-producing strain of Clostridium difficile, ribotype 027 (RT027), caused extensive outbreaks of diarrheal disease in North America and Europe. This strain has not become established in Australia, and there is a markedly different repertoire of circulating strains there compared to other regions of the world. The C. difficile Antimicrobial Resistance Surveillance (CDARS) study is a nationwide longitudinal surveillance study of C. difficile infection (CDI) in Australia. Here, we describe the molecular epidemiology of CDI in Australian health care and community settings over the first 5 years of the study, 2013 to 2018. Between 2013 and 2018, 10 diagnostic microbiology laboratories from five states in Australia participated in the CDARS study. From each of five states, one private (representing community) and one public (representing hospitals) laboratory submitted isolates of C. difficile or PCR-positive stool samples during two collection periods per year, February-March (summer/autumn) and August-September (winter/spring). C. difficile was characterized by toxin gene profiling and ribotyping. A total of 1,523 isolates of C. difficile were studied. PCR ribotyping yielded 203 different RTs, the most prevalent being RT014/020 (n = 449; 29.5%). The epidemic CDT(+) RT027 (n = 2) and RT078 (n = 6), and the recently described RT251 (n = 10) and RT244 (n = 6) were not common, while RT126 (n = 17) was the most prevalent CDT(+) type. A heterogeneous C. difficile population was identified. C. difficile RT014/020 was the most prevalent type found in humans with CDI. Continued surveillance of CDI in Australia remains critical for the detection of emerging strain lineages.

BACKGROUND: Anchored transosseous equivalent suture-bridge technique (TOE) is widely used for arthroscopic rotator cuff repair. It is unknown how patient outcomes scores, ROM, and integrity of the rotator cuff after repair using this anchored technique compare with those after repair using an anchorless transosseous technique (TO). QUESTIONS/PURPOSES: (1) What are the differences in patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES] score) and shoulder ROM between TO and TOE rotator cuff repair techniques at 1 and 2 years after surgery? (2) What is the difference in repair integrity as measured by the re-tear rate, assessed ultrasonographically at 1 year, between these two techniques? (3) What is the difference in procedure duration between the two techniques when performed by a surgeon familiar with each? METHODS: We reviewed 331 arthroscopic rotator cuff repairs performed by one surgeon from December 2011 to July 2016 in this retrospective, matched-pair study. Of these patients, 63% (208 of 331) underwent repair with standard anchored technique (anchors placed in a double-row, TOE manner) and 37% (123 of 331) underwent anchorless TO repair, with the same indications for surgery between groups. Forty-four percent (91 of 208) of patients in the TOE group and 61% (75 of 123) of patients in the TO group met the inclusion criteria. Eighty percent (73 of 91) of patients in the TOE group and 88% (66 of 75) in the TO group had minimum 2-year follow-up. We matched each group to a cohort of 50 patients by sex, age, smoking status, and tear size (by Cofield classification: small, < 1 cm; medium, 1-3 cm; large, > 3-5 cm; or massive, > 5 cm). The resulting cohorts did not differ in mean age (TO, 62 years [range 53-65 years]; TOE, 58 years [range 53-65 years]; p = 0.79), mean BMI value (TO, 30 [range 27-33]; TOE, 29 [range 27-35]; p = 0.97), or dominant arm involvement (TO, 80%; TOE, 78%; p = 0.81). The cohorts were followed for at least 2 years (median, 3.2 years [interquartile range (IQR) 2.2-4.3] for TO and 2.9 years [IQR 2.0-3.5 years] for TOE). ASES scores and ROM were evaluated before surgery and at follow-up visits and were recorded in a longitudinally maintained institutional database. Repair integrity was assessed using ultrasonography at 1 year, as is standard in our practice. For each tear-size group, we calculated the proportion of intact tendon repairs versus the proportion of re-tears. Duration of surgery was recorded for each patient. RESULTS: At 1 year, we observed no difference in median ASES scores (90 [IQR 92-98] for TO and 88 [IQR 72-98] for TOE; p = 0.44); external rotation (50° [IQR 45°-60°) for TO and 50° [IQR: 40°-60°] for TOE; p = 0.58); forward flexion (165° [IQR 160°-170°] for both groups; p = 0.91); or abduction (100° [IQR 90°-100°] for TO and 90° [IQR 90°-100°] for TOE; p = 0.06). Fourteen percent of shoulders (seven of 50) in each treatment group had evidence of re-tear at 1 year (p > 0.99): 0 of 2 small tears in each group, 0 of 7 medium tears in each group, five of 32 large tears in each group, and two of 9 massive tears in each group (all, p > 0.99). At 2 years, we found no differences in median ASES scores (92 [IQR 74-98)] for TO and 90 [IQR 80-100] for TOE; p = 0.84); external rotation (60° [IQR 50°-60°] for both groups; p = 0.74); forward flexion (170° [IQR 160°-170°] for both groups; p = 0.69); or abduction (100° [IQR 90°-100°] for both groups; p = 0.95). We found no differences between groups in mean ± SD procedure time, which was 103 ± 20 minutes for TO repair and 99 ± 20 minutes for TOE repair (p = 0.45). CONCLUSIONS: TO and TOE techniques for arthroscopic rotator cuff repair results in no differences in ROM, ASES scores, re-tear rates, and surgical time. Randomized control trials are needed to confirm these similarities or determine a superior method of repair. Future cost analyses may also help to determine the relative value of each technique. LEVEL OF EVIDENCE: Level III, therapeutic study.

BACKGROUND: Hip fractures are associated with 1-year mortality rates as high as 19% to 33%. Nonwhite patients have higher mortality and lower mobility rates at 6 months postoperatively than white patients. Studies have extensively documented racial disparities in hip fracture outcomes, but few have directly assessed racial disparities in the timing of hip fracture care. QUESTIONS/PURPOSES: Our purpose was to assess racial disparities in the care provided to patients with hip fractures. We asked, (1) do racial disparities exist in radiographic timing, surgical timing, length of hospital stay, and 30-day hospital readmission rates? (2) Does the hospital type modify the association between race and the outcomes of interest? METHODS: We retrospectively reviewed the records of 1535 patients aged 60 years or older who were admitted to the emergency department and treated surgically for a hip fracture at one of five hospitals (three community hospitals and two tertiary hospitals) in our health system from 2015 to 2017. Multivariable generalized linear models were used to assess associations between race and the outcomes of interest. RESULTS: After adjusting for patient characteristics, we found that black patients had a longer mean time to radiographic evaluation (4.2 hours; 95% confidence interval, -0.6 to 9.0 versus 1.2 hours; 95% CI, 0.1-2.3; p = 0.01) and surgical fixation (41 hours; 95% CI, 34-48 versus 34 hours 95% CI, 32-35; p < 0.05) than white patients did. Hospital type only modified the association between race and surgical timing. In community hospitals, black patients experienced a 51% (95% CI, 17%-95%; p < 0.01) longer time to surgery than white patients did; however, there were no differences in surgical timing between black and white patients in tertiary hospitals. No race-based differences were observed in the length of hospital stay and 30-day hospital readmission rates. CONCLUSIONS: After adjusting for patient characteristics, we found that black patients experienced longer wait times to radiographic evaluation and surgical fixation than white patients. Hospitals should consider evaluating racial disparities in the timing of hip fracture care in their health systems. Raising awareness of these disparities and implementing unconscious bias training for healthcare providers may help mitigate these disparities and improve the timing of care for patients who are at a greater risk of delay. LEVEL OF EVIDENCE: Level III, therapeutic study.

Background and purpose The purpose of this article is to describe student perceptions of implementation of digital badges in a drug information and literature evaluation course. Educational activity and setting Two digital badges were developed as voluntary learning opportunities. Student perceptions were obtained through pre- and post-survey instruments consisting of selected questions from the Motivated Strategies for Learning Questionnaire. Findings The response rate was 69% (106/153). At baseline, 53% of respondents agreed that digital badges could help them better understand course material. More students agreed they would share earned digital badges on LinkedIn (68%) than Facebook (19%). Most students who earned digital badges agreed that badges helped increase their confidence in course material (73%), focus on specific learning objectives (55%), look deeper into course competencies (64%), and were a useful adjunct to the traditional teaching method (82%). Discussion and summary Digital badges were perceived by students as a positive adjunct to learning and may provide a novel mechanism for development of an electronic skills-based portfolio.

Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is “surgery delay” (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P =.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [ Orthopedics . 2020;43(6):e609–e615.]

The societal burden of rotator cuff disease continues to increase with the aging of our population. Rotator cuff repairs have also become increasingly common over the last 2 decades. In our current cost conscious health care environment it is imperative to understand the value delivered to patients

Halicephalobus gingivalis (previously Micronema deletrix ) is a free-living nematode known to cause opportunistic infections, mainly in horses. Human infections are very rare, but all cases described to date involved fatal meningoencephalitis. Here we report the first case of H. gingivalis infection in an Australian human patient, confirmed by nematode morphology and sequencing of ribosomal DNA. The implications of this case are discussed, particularly, the need to evaluate real-time PCR as a diagnostic tool.

To the Editor: Human diphyllobothriosis associated with the Pacific broad tapeworm Adenocephalus pacificus (syn. Diphyllobothrium pacificum) is a reemerging, global parasitic disease (1). Infection with the adult tapeworm occurs widely in piscivorous mammals, including humans, with various species of marine fish acting as intermediate hosts (1,2). In the Southern Hemisphere, the organism is well described in the coastal waters of South America, southern Africa, and Oceania (2). A. pacificus tapeworms have been recorded in pinnipeds in Australian territory as far back as 1923 (3). To our knowledge, no human case has been reported from this region to date.

The purpose of this paper is to examine the cross institutional use of a quantified-self application called Pattern, which is designed to promote self-regulation and reflective learning in learners. This paper provides a brief look into how learners report spending their time and react to in-app recommendations. Initial data is encouraging; however, there are limitations of Pattern, and additional research and development must be undertaken.

The aim of this study was to compare liposomal bupivacaine and interscalene nerve block (ISNB) for analgesia after shoulder arthroplasty. We compared 37 patients who received liposomal bupivacaine vs 21 who received ISNB after shoulder arthroplasty by length of hospital stay (LOS), opioid consumption, and postoperative pain. Pain was the same in both groups for time intervals of 1 hour and 8 to 14 hours postoperatively. Compared with ISNB patients, liposomal bupivacaine patients reported less pain at 18 to 24 hours (P = .001) and 27 to 36 hours (P = .029) and had lower opioid consumption on postoperative days 2 (P = .001) and 3 (P = .002). Mean LOS for liposomal bupivacaine patients was 46 ± 20 hours vs 57 ± 14 hours for ISNB patients (P = .012). Sixteen of 37 liposomal bupivacaine patients vs 2 of 21 ISNB patients were discharged on the first postoperative day (P = .010). Liposomal bupivacaine was associated with less pain, less opioid consumption, and shorter hospital stays after shoulder arthroplasty compared with ISNB.

This chapter introduces instructional design considerations for digital badges. Designing instructional badges presents unique opportunities and challenges, and proper preparation and planning are necessary for the success of the badge. Passport by Purdue is introduced as a system which integrates digital badges with elements of learning management and content management. Passport combines mastery-based progression through designed instructional tasks, with supplementary embedded multimedia resources and a semi-gamified interface built on a badge metaphor—all culminating in certification by a highly portable, information-rich digital badge. In this chapter, we will offer a tour of Passport as an instructional tool, along with theory-informed guidelines for designing effective learning experiences within such an integrated, digital-badge-based learning system.