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During a pandemic when hospitals are stretched and patients need isolation, the role of hospital‐in‐the‐home (HITH) providing acute medical care at home has never been more relevant. We aimed to define and address the challenges to acute home care services posed by the COVID‐19 pandemic. Planning for service operation involves staffing, equipment availability and cleaning, upskilling in telehealth and communication. Planning for clinical care involves maximising cohorts of patients without COVID‐19 and new clinical pathways for patients with COVID‐19. The risk of SARS‐CoV‐2 transmission, specific COVID‐19 clinical pathways and the well‐being of patients and staff should be addressed in advance.

BackgroundAlphaviruses, such as Ross River (RRV) and chikungunya virus (CHIKV), cause significant global morbidity, with outbreaks of crippling joint inflammation and pain, leaving patients incapacitated for months to years. With no available vaccine or specific therapeutic for any alphaviral disease, and a growing economic and public health burden, there is a serious need for the development of specific therapies.MethodsThis study evaluated the safety and efficacy of pentosan polysulfate sodium (PPS) in subjects with RRV-induced arthralgia in a double-blind, placebo-controlled trial. Twenty subjects were randomized 2:1 to subcutaneous PPS (2 mg/kg) or placebo (sodium chloride 0.9%) twice weekly for 6 weeks. Safety evaluation included physical examination, concomitant medications, and laboratory findings. Efficacy assessments included change from baseline in joint function (hand grip strength and RAPID3) and quality of life (SF-36) at Days 15, 29, 39 and 81 after treatment initiation. Inflammatory and cartilage degradation biomarkers were exploratory endpoints.ResultsPPS was well tolerated, with a similar proportion of subjects reporting at least one treatment-emergent adverse event (TEAE) in the treatment and placebo groups. Injection site reactions were the most common TEAE and occurred more frequently in the PPS group. Dominant hand grip strength and SF-36 scores improved with PPS at all time points assessed, with hand grip strength improvement of 6.99 kg (p = 0.0189) higher than placebo at Day 15. PPS showed significant improvements versus placebo in adjusted mean relative change from baseline for RAPID3 Pain (p = 0.0197) and Total (p = 0.0101) scores at Day 15. At the conclusion of the study overall joint symptoms, assessed by RAPID3, showed near remission in 61.5% of PPS subjects versus 14.3% of placebo subjects. Additionally, PPS treatment improved COMP, CTX-II, CCL1, CXCL12, CXCL16 and CCL17 biomarker levels versus placebo.ConclusionsOverall, the improvements in strength and joint symptoms warrant further evaluation of PPS as a specific treatment for RRV-induced and other forms of arthritis.Trial registrationThis trial is registered at the Australian New Zealand Clinical Trials Registry #ACTRN12617000893303.

BackgroundAntimicrobial stewardship programmes are important in driving safety and quality of antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is a point-prevalence audit of inpatient antimicrobial prescribing in Australian hospitals.ObjectivesTo design and adapt the NAPS tool for use in the outpatient parenteral antimicrobial therapy (OPAT) and hospital-in-the-home (HITH) setting.MethodsAn inter-disciplinary working group with expertise in OPAT and HITH services was established to adapt the NAPS template for use in the OPAT setting—called HITH-NAPS. This was initially trialled in 5 HITH services, subsequently adapted following participant feedback, then offered nationally to 50 services in 2017.ResultsThere were 1154 prescriptions for 715 patients audited via the HITH-NAPS. The most common antimicrobials prescribed were cefazolin (22%), flucloxacillin (12%), piperacillin/tazobactam (10%) and ceftriaxone (10%). The most common infections treated were cellulitis (30%) and respiratory tract infections (14%). Eighty-seven percent of prescriptions were assessed as appropriate, 11% inappropriate and 2% not assessable. Prolonged durations of antimicrobials and unnecessarily broad-spectrum antibiotics were used in 9% of prescriptions.ConclusionsThe HITH-NAPS pilot project revealed that auditing of this type is feasible in HITH. It showed that antibiotic use in these HITH services was generally appropriate, but there are some areas for improvement. A national OPAT/HITH-NAPS can facilitate benchmarking between services, identify potentially inappropriate prescribing and help guide quality improvement.

DNA polymerases have revolutionized the biotechnology field due to their ability to precisely replicate stored genetic information. Screening variants of these enzymes for unique properties gives the opportunity to identify polymerases with novel features. We have previously developed a single-molecule DNA sequencing platform by coupling a DNA polymerase to a α-hemolysin pore on a nanopore array. Here, we use this approach to demonstrate a single-molecule method that enables rapid screening of polymerase variants in a multiplex manner. In this approach, barcoded DNA strands are complexed with polymerase variants and serve as templates for nanopore sequencing. Nanopore sequencing of the barcoded DNA reveals both the barcode identity and kinetic properties of the polymerase variant associated with the cognate barcode, allowing for multiplexed investigation of many polymerase variants in parallel on a single nanopore array. Further, we develop a robust classification algorithm that discriminates kinetic characteristics of the different polymerase mutants. As a proof of concept, we demonstrate the utility of our approach by screening a library of ~100 polymerases to identify variants for potential applications of biotechnological interest. We anticipate our screening method to be broadly useful for applications that require polymerases with unique or altered physical properties.

Background 360° virtual reality (VR) video is an exciting and evolving field. Current technology promotes a totally immersive, 3-dimensional (3D), 360° experience anywhere in the world using simply a smart phone and virtual reality headset. The potential for its application in the field of surgical education is enormous. The aim of this study was to determine knot tying skills taught with a 360-degree VR video compared to conventional 2D video teaching. Material and methods This trial was a prospective, randomised controlled study. 40 foundation year doctors (first year postgraduate) were randomised to either the 360-degree VR video (n = 20) or 2D video teaching (n = 20). Participants were given 15 min to watch their allocated video. Ability to tie a single handed reef knot was then assessed against a marking criteria developed for the Royal College of Surgeons, England, (RCSeng) Basic Surgical Skills (BSS) course, by a blinded assessor competent in knot tying. Each candidate then underwent further teaching using Peyton's four step model. Knot tying technique was then re-assessed. Results Knot tying scores were significantly better in the VR video teaching arm when compared with conventional (median knot score 5.0 vs 4.0 p = 0.04). When used in combination with face to face skills teaching this difference persisted (median knot score 9.5 vs 9.0 p = 0.01). More people in the VR arm constructed a complete reef knot than in the 2D arm following face to face teaching (17/20 vs 12/20). No difference between the groups existed in the time taken to construct a reef knot following video and teaching (median time 31.0s vs 30.5s p = 0.89). Conclusion This study shows there is significant merit in the application of 360-degree VR video technology in surgical training, both as an independent teaching aid and when used as an adjunct to traditional face to face teaching.

Graphical abstract, Highlights • NDRA emits geogenic dusts that are comprised of a mineral-metal mixture. • Exposure to NDRA geogenic dusts suppressed immune function in a mouse model. • Similar desert surfaces emit dust in southern Nevada and elsewhere in the world. • This study represents a desert environment; dust composition may vary by source., Systemic health effects from exposure to a complex natural dust containing heavy metals from the Nellis Dunes Recreation Area (NDRA) near Las Vegas, NV, were evaluated. Several toxicological parameters were examined following lung exposure to emissive dust from three geologic sediment types heavily used for recreational off-road activities: yellow sand very rich in arsenic (termed CBN 5); a shallow cover of loose dune sand overlying a gravelly subsoil bordering dune fields (termed CBN 6); and brown claystone and siltstone (termed CBN 7). Adult female B6C3F1 mice were exposed by oropharyngeal administration to these three types of geogenic dusts at 0.01–100 mg of dust/kg of body weight, once per week for four weeks. The median grain sizes were 4.6, 3.1, and 4.4 μm, for CBN 5, 6, and 7, respectively. Each type of dust contained quantifiable amounts of aluminum, vanadium, chromium, manganese, iron, cobalt, copper, zinc, arsenic, strontium, cesium, lead, uranium, and others. Descriptive markers of immunotoxicity, neurotoxicity, hematology, and clinical chemistry parameters were assessed. Notable among all three CBN units was a systemic, dose-responsive decrease in antigen-specific IgM antibody responses. Geogenic dust from CBN 5 produced more than a 70% suppression in IgM responses, establishing a lowest adverse effect level (LOAEL) of 0.01 mg/kg. A suppression in IgM responses and a corresponding increase in serum creatinine determined a LOAEL of 0.01 mg/kg for CBN 6. The LOAEL for CBN 7 was 0.1 mg/kg and also was identified from suppression in IgM responses. These results are of concern given the frequent off-road vehicle traffic and high visitor rates at the NDRA, estimated at 300,000 each year.

Graphical abstract, The specific health effects of direct inhalation of fine minerogenic dusts generated by natural soil surfaces remain poorly known and relatively little researched. To learn more about this exposure and its contribution to human health effects, we surveyed surface sediment and characterized dust from the Nellis Dunes Recreation Area (NDRA) in Clark County, Nevada, a popular off-road vehicle (ORV) recreational site. Dry drainage systems at NDRA are commonly used as natural trail systems for ORV recreation; these surfaces also are characterized by high concentrations of heavy metals. Geogenic dust with a median diameter of 4.05 μm, collected from drainage surfaces at NDRA contained a total elemental concentration of aluminum (79,651 μg/g), vanadium (100 μg/g), chromium (54 μg/g), manganese (753 μg/g), iron (33,266 μg/g), cobalt (14 μg/g), copper (37 μg/g) zinc (135 μg/g), arsenic (71 μg/g), strontium (666 μg/g), cesium (15 μg/g), lead (34 μg/g), and uranium (54.9 μg/g). Adult female B6C3F1 mice exposed via oropharyngeal aspiration to 0.01–100 mg dust/kg body weight, four times, a week apart, for 28-days, were evaluated for immuno- and neurotoxicological outcomes 24 h after the last exposure. Antigen-specific IgM responses were dose-responsively suppressed at 0.1, 1.0, 10 and 100 mg/kg. Splenic lymphocytic subpopulations, hematological and clinical chemistry parameters were affected. In brain tissue, antibodies against NF-68, and GFAP were not affected, whereas IgM antibodies against MBP were reduced by 26.6% only in the highest dose group. A lowest observed adverse effect level (LOAEL) of 0.1 mg/kg/day and a no observed adverse effect level (NOAEL) of 0.01 mg/kg/day were derived based on the antigen primary IgM responses after subacute exposure to this geogenic dust.

Cytomegalovirus can cause severe disease in immunocompromised patients including encephalomyelitis, hepatitis, pneumonitis, colitis and retinitis. CMV induced myelitis and hepatitis are rare in immunocompetent patients. Following a thorough search on the literature using pubmed, there were only 10 well documented CMV-induced transverse myelitis cases reported worldwide. We report a healthy young male who developed longitudinal extensive transverse myelitis and acute hepatitis secondary to CMV infection. Our case is different from the other cases as our patient had concurrent acute hepatitis and received plasma exchange therapy (PLEX) in addition to pulsed steroids and antivirals. The patient recovered well and had an excellent outcome.

Background The diagnosis of cellulitis is made clinically without a gold standard diagnostic test, and cellulitis has many disease mimics. There is currently no consensus for optimal antimicrobial treatment duration or method of antimicrobial delivery. Methods This was a randomized controlled open-label multicenter trial to determine the safety and efficacy of 24 hours of intravenous (IV) therapy compared with ≥72 hours of IV therapy, both followed by oral therapy to a maximum of 7–10 days’ duration for the treatment of lower limb cellulitis. Results Over 40 months, 80 patients were recruited. Thirty-nine patients were assigned to 24 hours of IV antibiotics and 41 to ≥72 hours of IV antibiotics. The mean duration (range) of IV antibiotics in the 24-hour group was 25.5 (17–40) hours, and in the ≥72-hour group it was 78 (41.5–210) hours. Three patients in the 24-hour arm and 4 patients in the ≥72-hour arm were excluded from the analysis due to withdrawal from the trial. Analysis of the remaining patients revealed that 6 patients (4 in the intervention arm and 2 in the control arm) did not achieve an adequate response to therapy. Only 1 patient experienced self-limiting adverse effects of treatment. Conclusions The noninferiority of short-course IV therapy cannot be determined from this trial. Challenges included resource limitations for recruitment, misdiagnosis, participant withdrawal, and subjective responses to therapy based on visual assessment by treating clinicians. Further studies are needed to determine if short-course IV therapy is a suitable treatment option. Australia Council of Clinical Trials Registry No ACTRN12613001366741.

DNA sequencing by synthesis (SBS) offers a robust platform to decipher nucleic acid sequences. Recently, we reported a single-molecule nanopore-based SBS strategy that accurately distinguishes four bases by electronically detecting and differentiating four different polymer tags attached to the 5'-phosphate of the nucleotides during their incorporation into a growing DNA strand catalyzed by DNA polymerase. Further developing this approach, we report here the use of nucleotides tagged at the terminal phosphate with oligonucleotide-based polymers to perform nanopore SBS on an α-hemolysin nanopore array platform. We designed and synthesized several polymer-tagged nucleotides using tags that produce different electrical current blockade levels and verified they are active substrates for DNA polymerase. A highly processive DNA polymerase was conjugated to the nanopore, and the conjugates were complexed with primer/template DNA and inserted into lipid bilayers over individually addressable electrodes of the nanopore chip. When an incoming complementary-tagged nucleotide forms a tight ternary complex with the primer/template and polymerase, the tag enters the pore, and the current blockade level is measured. The levels displayed by the four nucleotides tagged with four different polymers captured in the nanopore in such ternary complexes were clearly distinguishable and sequence-specific, enabling continuous sequence determination during the polymerase reaction. Thus, real-time single-molecule electronic DNA sequencing data with single-base resolution were obtained. The use of these polymer-tagged nucleotides, combined with polymerase tethering to nanopores and multiplexed nanopore sensors, should lead to new high-throughput sequencing methods.

This study was designed to evaluate markers of systemic oxidative stress and lung histopathology following subacute exposure to geogenic dust with varying heavy metal content collected from a natural setting prone to wind erosion and used heavily for off-road vehicle recreation. Adult female B6C3F1 mice were exposed to several concentrations of dust collected from seven different types of surfaces at the Nellis Dunes Recreation Area in Clark County, Nevada, designated here as CBN 1-7. Dust representing each of the seven surface types, with an average median diameter of 4.2 μm, was selected and administered via oropharyngeal aspiration to mice at concentrations from 0.01 to 100 mg of dust kg(-1) of body weight. Exposures were given four times spaced a week apart over a 28 day period to mimic a month of weekend exposures. Lung pathology was evaluated while plasma markers of oxidative stress included levels of reactive oxygen and nitrogen species, superoxide dismutase, total antioxidant capacity and total glutathione. Overall, results of these assays to evaluate markers of oxidative stress indicate that no single CBN surface type was able to consistently induce markers of systemic oxidative stress at a particular dose or in a dose-response manner. All surface types were able to induce some level of lung inflammation, typically at the highest exposure levels. These data suggest that dust from the Nellis Dunes Recreation Area may present a potential health risk, but additional studies are necessary to characterize the full extent of health risks to humans. Copyright © 2016 John Wiley & Sons, Ltd.

We present the case of a fit and well 12-year-old boy who presented with signs and symptoms suggestive of appendicitis. On laparoscopy, he was found to have a sinister-looking right iliac fossa mass with associated mesenteric lymphadenopathy. He proceeded to have an oncological right hemicolectomy, while the subsequent histology returned an unexpected result. The aim of this report is to highlight an unusual and complex clinical presentation in a young patient presenting with right iliac fossa pain.

Background Hypervirulent strains of Klebsiella pneumoniae are a recognized cause of a distinct invasive syndrome that results in pyogenic liver abscesses and metastatic complications, particularly in the Asia Pacific region. Reports of hypervirulent K.pneumoniae in Europe, the Americas and Australia indicate worldwide spread. We present a case of multi-focal osteomyelitis, a rarely described complication of hypervirulent K.pneumoniae in the medical literature. The prevalence of this condition in countries outside Asia may be expected to rise with increasing travel. Case presentation A 20-year-old Chinese man residing in Australia for 2 years presented with a 2-week history of gradually worsening leg pain preceded by 2 weeks of constitutional symptoms. Imaging with computerized axial tomography (CT) and other modalities revealed bilateral tibial lesions described as lattice-like linear lucencies involving the cortices with scalloping of the outer involved cortex. Cultures of tissue from a left tibial bone biopsy were positive cultures for K.pneumoniae. Whole-genome sequencing identified the isolate as K1 serotype ST23, a well-recognized hyper virulent strain capable of causing invasive disease. An abdominal CT revealed a 27x22mm liver abscess. The patient had no other metastatic manifestations of the disease, and responded to 6 weeks of intravenous ceftriaxone followed by 3 months of oral Ciprofloxacin. Conclusions Increased awareness of the manifestations and subsequent management of hyper virulent strains of K.pneumoniae by clinicians is important to assist early recognition and help minimize serious sequelae. Cases with overseas links, such as previous residence in the Asia Pacific area, are at higher risk for infection with the hyper virulent strain. This case highlights the need for clinicians to be able to recognize this important disease, especially in patients with the right epidemiological links, and to investigate and treat appropriately to prevent severe metastatic complications.

Background and objective: Refugees in Australia present with conditions different to those of the general population. The aim of this study was to review the reasons for referral, prevalence of conditions and treatment outcomes for refugee patients attending a specialist referral clinic in regional Victoria. Methods: A retrospective review was undertaken of patients attending the refugee health clinic at University Hospital Geelong from January 2007 to December 2012. Results: Two hundred and ninety-one refugee patients attended the clinic over the six-year period. Latent tuberculosis infection (LTBI) (54.6%), vitamin deficiencies (15.8%), hepatitis B (11%) and schistosomiasis (11%) were the most common diagnoses. Less than two-thirds of the patients completed LTBI treatment; 35.4% of patients attended all scheduled clinic appointments. Discussion: LTBI, vitamin deficiencies, parasitic infections and hepatitis B were the most common diagnoses among refugees referred to the University Hospital Geelong (UHG) Refugee Health Clinic from January 2007 to December 2012. General practitioners play an important role in the care of refugees, guiding referral to specialist services when necessary and recognising the potential implications of suboptimal clinic attendance and treatment completion.

OBJECTIVES: To determine trends in and predictors of early treatment for people newly diagnosed with human immunodeficiency virus (HIV) infection in Australia. DESIGN, SETTING: Retrospective cohort analysis of routinely collected longitudinal data from 44 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) program. PARTICIPANTS: Patients diagnosed with HIV infections, January 2004 - June 2015. MAIN OUTCOME MEASURES: Commencement of antiretroviral therapy within 6 months of HIV diagnosis (early treatment); demographic, clinical, and risk group characteristics of patients associated with early treatment; trends in early treatment, by CD4+ cell count at diagnosis. RESULTS: 917 people were diagnosed with HIV infections, their median age was 34 years (interquartile range [IQR]: 27-43 years), and 841 (92%) were men; the median CD4+ cell count at diagnosis was 510 cells/μL (IQR, 350-674 cells/μL). The proportion of patients who received early treatment increased from 17% (15 patients) in 2004-06 to 20% (34 patients) in 2007-09, 34% (95 patients) in 2010-12, and 53% (197 patients) in 2013-15 (trend, P

This study examined the complex relationships of fitness and hypoxic sensitivity with submaximal exercise responses and acute mountain sickness (AMS) at altitude. Determining these relationships is necessary before fitness or hypoxic sensitivity tests can be recommended to appraise individuals' readiness for altitude. Forty-four trekkers (26 men; 18 women; 20-67 years) completed a loaded walking test and a fitness questionnaire in normoxia to measure and estimate sea-level maximal aerobic capacity (maximum oxygen consumption [[Formula: see text]O2max]), respectively. Participants also completed a hypoxic exercise test to determine hypoxic sensitivity (cardiac, ventilatory, and arterial oxygen saturation responses to acute hypoxia, fraction of inspired oxygen [Fio2] = 0.112). One month later, all participants completed a 3-week trek to 5085 m with the same ascent profile. On ascent to 5085 m, ratings of perceived exertion (RPEascent), fatigue by Brunel Mood Scale, and AMS were recorded daily. At 5085 m, RPE during a fixed workload step test (RPEfixed) and step rate during perceptually regulated exercise (STEPRPE35) were recorded. Greater sea-level [Formula: see text]O2max was associated with, and predicted, lower sense of effort (RPEascent; r = -0.43; p < 0.001; RPEfixed; r = -0.69; p < 0.001) and higher step rate (STEPRPE35; r = 0.62; p < 0.01), but not worse AMS (r = 0.13; p = 0.4) or arterial oxygen desaturation (r = 0.07; p = 0.7). Lower RPEascent was also associated with better mood, including less fatigue (r = 0.57; p < 0.001). Hypoxic sensitivity was not associated with, and did not add to the prediction of submaximal exercise responses or AMS. In conclusion, participants with greater sea-level fitness reported less effort during simulated and actual trekking activities, had better mood (less fatigue), and chose a higher step rate during perceptually regulated exercise, but did not suffer from worse AMS or arterial oxygen desaturation. Simple sea-level fitness tests may be used to aid preparation for high-altitude travel.

Scalable, high-throughput DNA sequencing is a prerequisite for precision medicine and biomedical research. Recently, we presented a nanopore-based sequencing-by-synthesis (Nanopore-SBS) approach, which used a set of nucleotides with polymer tags that allow discrimination of the nucleotides in a biological nanopore. Here, we designed and covalently coupled a DNA polymerase to an α-hemolysin (αHL) heptamer using the SpyCatcher/SpyTag conjugation approach. These porin-polymerase conjugates were inserted into lipid bilayers on a complementary metal oxide semiconductor (CMOS)-based electrode array for high-throughput electrical recording of DNA synthesis. The designed nanopore construct successfully detected the capture of tagged nucleotides complementary to a DNA base on a provided template. We measured over 200 tagged-nucleotide signals for each of the four bases and developed a classification method to uniquely distinguish them from each other and background signals. The probability of falsely identifying a background event as a true capture event was less than 1.2%. In the presence of all four tagged nucleotides, we observed sequential additions in real time during polymerase-catalyzed DNA synthesis. Single-polymerase coupling to a nanopore, in combination with the Nanopore-SBS approach, can provide the foundation for a low-cost, single-molecule, electronic DNA-sequencing platform.

Highlights • Atmospheric geogenic dust comprised of a mineral-metal mixture is a source of exposure in Clark County, Nevada. • Lung exposures over a period of one month to NDRA atmospheric geogenic dust suppressed immune function in a mouse model. • Similar geological desert surfaces emit dust in southern Nevada and elsewhere in the world. • This study is representative of a desert environment; dust composition may vary by source., Desert areas are usually characterized by a continuous deposition of fine airborne particles. Over time, this process results in the accumulation of silt and clay on desert surfaces. We evaluated health effects associated with regional atmospheric dust, or geogenic dust, deposited on surfaces in the Nellis Dunes Recreation Area (NDRA) in Clark County, Nevada, a popular off-road vehicle (ORV) recreational site frequented daily by riders, families, and day campers. Because of atmospheric mixing and the mostly regional origin of the accumulated particles, the re-suspended airborne dust is composed of a complex mixture of minerals and metals including aluminum, vanadium, chromium, manganese, iron, cobalt, copper, zinc, arsenic, strontium, cesium, lead, uranium, and others. Geogenic dust with a median diameter of 4.1 μm was administered via oropharyngeal aspiration to female B6C3F1 mice at doses of 0.01 to 100 mg dust/kg body weight, four times, a week apart, for 28-days. Immuno- and neurotoxicological outcomes 24 h following the last exposure were evaluated. Antigen-specific IgM responses were dose-responsively suppressed at 0.1, 1.0, 10 and 100 mg/kg/day. Splenic and thymic lymphocytic subpopulations and natural killer cell activity also were significantly reduced. Antibodies against MBP, NF-68, and GFAP were not affected, while brain CD3+ T cells were decreased in number. A lowest observed adverse effect level (LOAEL) of 0.1 mg/kg/day and a no observed adverse effect level (NOAEL) of 0.01 mg/kg/day were derived based on the antigen-specific IgM responses.

Objectives Healthcare facilities internationally have grown outpatient parenteral antibiotic administration services for the last few decades. The literature contains publications from dozens of countries describing systematized processes with specialist oversight and their levels of service provision and outcomes. Such descriptions are absent in the majority of Asian countries. We sought to elucidate the extent and nature of outpatient parenteral antibiotic therapy (OPAT) in Asia and to consider the ramifications and opportunities for improvement. Methods Utilizing colleagues and their personal networks, we surveyed healthcare facilities across 17 countries in Asia to ascertain the current means (if any) of providing OPAT. In that survey we also sought to explore the capacity and interest of these facilities in developing systematized OPAT services. Results Responses were received from 171 different healthcare facilities from 17 countries. Most (97/171, 57%) stated that they administer outpatient parenteral antibiotics, but only 5 of 162 facilities (3%) outside of Singapore described comprehensive services with specialist oversight. Conclusions There is very likely a large unrecognized problem of unchecked outpatient parenteral antibiotic administration in Asia. Developing comprehensive and systematized OPAT in Asia is needed as a priority in an environment in which the infectious diseases community is demanding broad stewardship approaches. There are nonetheless challenges in establishing and sustaining OPAT programmes. Local champions and leverage off identified local incentives and needs are key to regional advancement.

Geogenic dust from arid environments is a possible inhalation hazard for humans, especially when using off-road vehicles that generate significant dust. This study focused on immunotoxicological and neurotoxicological effects following subacute exposure to geogenic dust generated from sediments in the Nellis Dunes Recreation Area near Las Vegas, Nevada that are particularly high in arsenic; the naturally-occurring arsenic concentrations in these surficial sediments ranged from 4.8 to 346μg/g. Dust samples from sediments used in this study had a median diameter of 4.5μm and also were a complex mixture of naturally-occurring metals, including aluminum, vanadium, chromium, manganese, iron, cobalt, copper, zinc, strontium, cesium, lead, uranium, and arsenic. Adult female B6C3F1 mice exposed via oropharyngeal aspiration to 0.01 to 100mg dust/kg body weight, four times, a week apart, for 28days, were evaluated 24h after the last exposure. Peripheral eosinophils were increased at all concentrations, serum creatinine was dose responsively increased beginning at 1.0mg/kg/day, and blood urea nitrogen was decreased at 10 and 100mg/kg/day. Antigen-specific IgM responses and natural killer cell activity were dose-responsively suppressed at 0.1mg/kg/day and above. Splenic CD4+CD25+ T cells were decreased at 0.01, 0.1, 10, and 100mg/kg/day. Antibodies against MBP, NF-68, and GFAP were selectively reduced. A no observed adverse effect level of 0.01mg/kg/day and a lowest observed adverse effect level of 0.1mg/kg/day were determined from IgM responses and natural killer cell activity, indicating that exposure to this dust, under conditions similar to our design, could affect these responses.

This article describes the contours of the residential care placement experience for social service staff, health care providers, and their client families of patients with Huntington’s disease. The purpose of this study was to determine the factors, conditions, and barriers encountered by outpatient clinical staff and families in the transition to skilled nursing care. A Long-Term Care Contact Survey was developed to (a) gather information about long-term care referral sites; (b) determine the factors considered in choosing a facility; (c) describe the factors that hindered the transition to long-term care; (d) describe conditions prior to institutionalization; and (e) determine research interest. The study found that large cohorts of patients with Huntington’s disease in residential care are scarce. A lack of confidence in the available options suggests the need for increased support for educational and social services to facility staff. Speech/swallowing therapy and physical therapy as placement facilitators reflect salient issues of latter stages of the disease, implicating funding support needs. Families facing this transition require long-term guidance for financial, caregiving, and psychosocial issues.

There is concern that elevated levels of selenium found in the source water of a newly formed wetland park in Las Vegas, Nevada, may have detrimental effects on local wildlife. In this study, we collected and analyzed water samples monthly for a three year period from the inflow and outflow of the system. We also gathered dominant aquatic plants and selected terrestrial plants and analyzed the water and plant tissues (root, shoot, leaf and flower) for selenium by high resolution Inductively Coupled Plasma Mass Spectrometer. Except for storm events and the introduction of an alternative low selenium content source water during summer low-flow conditions, selenium in the water was relatively stable. The concentration in the outflow tended to be slightly lower than the inflow. Concentrations of selenium in the dominant plant taxa in this wetlands were typical of ecosystems in the western United States and varied by taxa, tissue type, localized conditions (e.g., contact with selenium-laden water), and to a lesser extent, seasons. Selenium in the aquatic plant spiny naiad (Najas marina) was relatively high and may pose an ecological risk to wildlife during the late spring and summer. Additional work is underway investigating aquatic food chain accumulations of selenium as well as mass balance of selenium in the system.

Total mercury (Hg) concentrations were determined in the skeletal muscle of 339 fish collected during the fall of 1998 and spring of 1999 from Lake Mead, USA, the nation's largest human-made reservoir. Five species of fish representing a range of trophic levels and the lake's principal game fishes were studied. Hg generally increased with trophic level and fish size. Median Hg concentrations (ng/g wet mass) were 277 in striped bass, 168 in channel catfish, 160 in largemouth bass, 75 in bluegill, and 8 in blue tilapia. Overall, fish from Las Vegas Bay and Boulder Basin had the lowest Hg concentrations, possibly a result of biodilution in this biologically productive area. In general, fish-mercury advisories might include a warning about consuming fillet from emaciated fish, based on the finding that Hg concentrations in 59 striped bass (captured during a scarce-food season) correlated inversely ( r = -0.89, p < 0.001) with a fish nutritional-status factor. This is consistent with starvation-concentration, whereby Hg in fish muscle is lost at a slower rate than the muscle mass. The median concentration found for 139 striped bass corresponds to a recommended risk-based consumption limit of three 8-oz. (227-g) meals per month for a 70-kg adult. Finally, this paper serves as a useful archive for future research and long-term studies of Hg in Lake Mead fish.

Background Clostridium difficile infection (CDI) has increased to epidemic proportions in recent years. The carriage of C. difficile among healthy adults and hospital inpatients has been established. We sought to determine whether C. difficile colonization exists among healthcare workers (HCWs) in our setting. Methods A point prevalence study of stool colonization with C. difficile among doctors, nurses and allied health staff at a large regional teaching hospital in Geelong, Victoria. All participants completed a short questionnaire and all stool specimens were tested by Techlab® C.diff Quik Check enzyme immunoassay followed by enrichment culture. Results Among 128 healthcare workers, 77% were female, of mean age 43 years, and the majority were nursing staff (73%). Nineteen HCWs (15%) reported diarrhoea, and 12 (9%) had taken antibiotics in the previous six weeks. Over 40% of participants reported having contact with a patient with known or suspected CDI in the 6 weeks before the stool was collected. C. difficile was not isolated from the stool of any participants. Conclusion Although HCWs are at risk of asymptomatic carriage and could act as a reservoir for transmission in the hospital environment, with the use of a screening test and culture we were unable to identify C. difficile in the stool of our participants in a non-outbreak setting. This may reflect potential colonization resistance of the gut microbiota, or the success of infection prevention strategies at our institution.

A retrospective study of 35 case reports of Aspergillus endocarditis published between 2003 and 2009 was carried out. Fifteen percent of cases presented with a new cardiac murmur, 38% with an embolus. Eighty percent of cases involved the aortic or mitral valves. Seventy-four percent of cases involved patients with a history of prior surgery, 48% of these involved a heart valve, 20% had other cardiac surgery and 32% had non-cardiac surgery. Galactomannan testing was helpful diagnostically in four out of nine cases, but PCR testing was positive in six out of six cases. Overall mortality was 68%, all eight survivors had heart valve surgery apart from one - an 8-month-old child. Seven out of eight survivors received liposomal amphotericin B, three of these in combination with other antifungals. We need to think more about the possibility of Aspergillus endocarditis, particularly in immunocompromised patients with recent surgery. Galactomannan and PCR testing may be used more vigorously. Valve replacement, or at least vegetectomy, should be carried out in all patients. Liposomal amphotericin B, 3-5mg/kg/day, for at least 4 weeks is the treatment of choice. Oral voriconazole should be used for at least 2 years. Posaconazole may be an alternative, however there have been no prior cases reported to suggest its efficacy. The value of combination antifungal therapy is uncertain, but consideration should be given to the use of a second agent in addition to liposomal amphotericin. While further case reports on this condition will be helpful, more definitive management guidelines will depend on a prospective study.

A December 2006 amendment to the Special Inspector General for Iraq Reconstruction's (SIGIR) enabling legislation and an expanded mandate in the 2008 National Defense Authorization Act, P.L. 110-181, require that SIGIR prepare a final forensic audit report "on all amounts appropriated or otherwise made available for the reconstruction of Iraq." Under this requirement, SIGIR has undertaken a series of focused contract audits to examine major Iraq reconstruction contracts. The objective of these audits is to examine contract outcome, cost, and management oversight, emphasizing issues related to vulnerabilities to fraud, waste, and abuse. This report is the seventh in a series of focused contract audits. It examines reconstruction work contracted by the U.S. government and performed by Parsons Delaware, Inc. (Parsons). In March 2004, the U.S. Army Corps of Engineers, on behalf of the Coalition Provisional Authority, awarded Parsons a cost-plus award-fee contract (W914NS-04-D-0009) to provide design and construction services in Iraq' security and justice sector. This contract was one of twelve design-build construction contracts approved by the Deputy Assistant Secretary of the Army for Policy and Procurement to provide an overarching framework of construction capability to restore the Iraqi infrastructure. The contracts were issued in six defined work sectors, such as water, oil, transportation, and electric. The contracts were competitively awarded and included a two-year base period with three one-year option periods. This contracting approach was intended to allow continuity of operations and facilitate recompetition after the completion of these contracts.

The Forest Inventory and Analysis program (FIA) is the key USDA Forest Service (USFS) program that provides the information needed to assess the status and trends in the environmental quality of the Nation's forests. The goal of the FIA Quality Assurance (QA) program is to provide a framework to assure the production of complete, accurate and unbiased forest information of known quality. Specific Measurement Quality Objectives (MQO) for precision are designed to provide a window of performance that we are striving to achieve for every field measurement. These data quality goals were developed from knowledge of measurement processes in forestry and forest ecology, as well as the program needs of FIA. This report is a national summary and compilation of MQO analyses by regional personnel and the National QA Advisor.The efficacy of the MQO, as well as the measurement uncertainty associated with a given field measurement, can be tested by comparing data from blind check plots where, in addition to the field measurements of the standard FIA crew, a second QA measurement of the plot was taken by a crew without knowledge of the first crew's results. These QA data were collected between 2000 and 2003 and analyzed for measurement precision between FIA crews.The charge of this task team was to use the blind-check data to assess the FIA program's ability to meet data quality goals as stated by the MQO. The results presented indicate that the repeatability was within project goals for a wide range of measurements across a variety of forest and nonforest environments. However, there were some variables that displayed noncompliance with MQO goals. In general, there were two types of noncompliance: the first is where all the regions were below the MQO standard, and the second is where a subset of the regions was below the MQO standards or was substantially different from the other remaining regions. Results for each regional analysis are presented in appendix tables. In the course of the study, the task team discovered that there were difficulties in analyzing seedling species and seedling count variables for MQO compliance, and recommends further study of the issue. Also the task team addresses the issue of trees missed or added and recommends additional study of this issue. Lastly, the team points out that traditional MQO analysis of the disturbance and treatment variables may not be adequate.Some attributes where regional compliance rates are dissimilar suggest that regional characteristics (environmental variables such as forest type, physiographic class, and forest fragmentation) may have an impact on the ability to obtain consistent measurements. Additionally, differences in data collection protocols may cause differences in compliance rates. For example, a particular variable may be measured with a calibrated instrument in one region, while ocularly estimated in another region.

As the working hours of junior doctors decrease, adequate handover of patients becomes more important to maintain continuity of care and avoid errors caused by information gaps. A minimum dataset for surgical handover should include the patient's name, location (ward and bed number), date of admission, diagnosis, procedure (with date), complications and progress, management plan, resuscitation plan, consultant availability (and instructions if not available), expected need for review, and name of doctor completing handover and date to confirm that information is current. An electronic handover system is a potential solution, but our survey shows that free-text entry into such systems may be inadequate; prompts or predefined fields for handover content are possible solutions.

Total mercury (Hg) concentrations were determined in seven tissues (skeletal muscle, liver, blood, gonad, brain, gill, and heart) of 59 striped bass and four tissues (muscle, liver, blood, and gonad) of 69 largemouth bass, 76 channel catfish, 12 bluegill, and 22 blue tilapia collected from Lake Mead, USA. Mercury levels generally increased according to trophic level and fish length. For striped bass, mean Hg levels (ng g(-1), wet mass) were highest in the liver (531), followed by muscle (309), heart (186), gonad (136), brain (77), gill (52), and blood (36). Similarly, Hg levels in the catfish and tilapia were livermusclegonadblood. In contrast, largemouth bass and bluegill had the highest levels in muscle, followed by liver, gonad, and blood. Generally, Hg levels were strongly correlated among the tissues, especially for blood/muscle and blood/liver. As the body burden of Hg increased, the concentration in blood and organs increased relative to the concentration in muscle. The trend was most pronounced for the liver. These relationships could form the basis of a predictive model and suggest that blood and muscle (plugs) could be useful for a non-lethal measure of Hg concentration and exposure in fish. For the striped bass, elevated Hg levels in the tissues were also correlated with degree of emaciation. Liver-to-muscle ratios were similar to literature values, except for tilapia with an average ratio of approximately 1.7, which is higher than generally reported for non-piscivores. Finally, this study demonstrates the usefulness of a solid sampling approach in trace element monitoring, especially as pertaining to in vivo analysis, analysis of a large number of samples and reduction of contamination risk.

In recent tests the plume current density profile, plume ion energy, and radiated EMI were characterized for Pratt & Whitney’s T -220HT Hall Effect thruster. The T-220HT is a high pow er (6 -20 kW) thruster designed for maximum peak thrust. Tests covered a power range from 8 -10 kW and discharge voltages of 300 and 600 V. Plume measurements at Air Force Research Laboratory (AFRL) facilities demonstrated plume widths narrower than typical Hall thrusters. Half angles containing 90% of the integrated plume flux were in the range of 27 -29 °. Radiated electromagnetic emissions were measured over a frequency range from 200 MHz to 60 GHz at The Aerospace Corporation. For discharge voltages at or below 300 V, EMI was below MIL -STD 461E limits except at a single peak below 1.4 GHz, where the limit was exceeded by only about 5 dB. Increasing the discharge voltage to 600 V noticeably increased emissions in this frequency range, but these were still generally below MIL -STD 461E. Plume ion energy spectra were also characterized at The Aerospace Corporation’s facility. An RPA (Retarding Potential Analyzer) was mounted at a downstream distance of 1 meter and was varied in position from 20 ° to 100 ° fro m the thruster centerline. Measurements generally confirmed the plume profile data taken at AFRL. Energy spectra confirm that the flux at high angles is dominated by low energy charge exchange ions.

A new field washing technique for removal of invertebrates from aquatic vegetation was investigated. This technique, which involved field washing samples in alchohol (ETOH), was developed and tested with aquatic vegetation samples from two undisturbed lotic systems in Southern Nevada. Results indicated that approximately 60% of the animals were removed from watercress and algal mat samples by vigorous water washing in a bucket. Field washing of algal and watercress samples using ETOH removed an additional 20–40% of the total macroinvertebrates, with ETOH wash efficiency being higher in the watercress samples. Generally, tightly clinging organisms such as hydroptilid caddisfly pupae or case building midges were the only invertebrates not effectively removed from aquatic vegetation samples by a cambination of alchohol and water-washing in the field.

Four 2-m columns filled with sandy soil were loaded with six organic chemicals (dicamba, 2,4-dichlorophenoxyacetic acid, atrazine, diazinon, pentachlorophenol, and lindane) and watered for 30 d in a controlled laboratory experiment. Chemical migration was monitored by analyses of daily effluent samples and soil sample cores, the latter collected on day 30 from 5-cm compartments throughout each column. Observed chemical migration patterns were compared with the predictions of three vadose zone fate-and-transport models: SESOIL, PRZM and PESTAN. Two sets of comparisons with the observed data were conducted using input data either obtained from the literature or derived from laboratory measurements using the actual experimental chemicals and soil. Evaluations of model performance revealed substantial variability depending on the chemical type and model tested. PRZM and PESTAN showed greater improvement in prediction of observed chemical migration patterns with the use of measured input data than did SESOIL. The limitations of these models, if used for screening purposes without a priori measurement of chemical- and site-specific model input data or post hoc calibration with existing field data, should be recognized.