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The aim of this work was to evaluate the diagnostic performance of grey-scale, color Doppler, and dynamic ultrasound (US) for diagnosing carpal tunnel syndrome (CTS) using the medical diagnostic test called nerve conduction study (NCS) as the reference standard, and to correlate the increase in median nerve (MN) cross-sectional area (CSA) with severity of CTS. Fifty-one patients (95 wrists) with clinical symptoms of idiopathic CTS were recruited. The CSA and flattening ratio of the MN were measured at the distal radio-ulnar joint, pisiform, and hamate levels; bowing of the flexor retinaculum was determined at the hamate level. The hypervascularity of the MN was evaluated. The transverse sliding of the MN was observed dynamically and recorded as being either normal or restricted/absent. Another 15 healthy volunteers (30 wrists) were recruited as controls. Interoperator reliability was established for all criteria. CTS was confirmed in 75 wrists (75/95: 79 %; 14 minimal, 21 mild, 23 moderate, 17 severe). CSA at the pisiform level was found to be the most reliable and accurate grey-scale criterion to diagnose CTS (optimum threshold: 9.8 mm 2 ). There was a good correlation between the severity of NCS and CSA ( r  = 0.78, p  < 0.001). The sensitivity and specificity of color-Doppler and dynamic US in detecting CTS was 69, 95, 58, and 86 %, respectively. Combination of these subjective criteria with CSA increases the sensitivity to 98.3 %. US measurement of CSA provides additional information about the severity of MN involvement. Color-Doppler and dynamic US are useful supporting criteria that may expand the utility of US as a screening tool for CTS.

Sterile surgical instruments are essential for successful surgical outcomes. The Singapore General Hospital’s Theatre Sterile Supplies Unit (TSSU) has faced many challenges, including increasing demand for instruments and the need to maintain instruments of greater complexity. To address these challenges, stakeholders from key departments at Singapore General Hospital formed a multidisciplinary team to transform operations in the TSSU. The team adopted and implemented the TSSU Instrument Management System (TIMS) in three phases over five years. The project included standardizing instrument-naming conventions, implementing electronic integration of instrument tracking in the unit, extending traceability of instruments to the major ORs, initiating integrated web-based instrument ordering, and extending the system management of instruments at ambulatory surgery and specialized OR facilities. The implementation of TIMS has improved inventory, supply, and quality management; reduced instrument repairs; and led to savings through increased productivity and lower expenses.

Aggressive debridement is a cornerstone intervention in necrotizing fasciitis. Our approach consists of 4 steps: (1) confirming the diagnosis and isolate the causative organism; (2) defining the extent of fasciitis; (3) surgical excision; and (4) post-excision wound care. The extent of the infection is defined by probing the wound bluntly. Systematic excision follows. Fascial excision must be complete and uncompromising with the full extent of the involved wound laid open. We classify the infected skin into zones 1, 2, and 3. Zone 1 is necrotic tissue. Zone 2 is infected but potentially salvageable soft tissue, and zone 3 is non-infected skin. Zone 1 is completely excised. Zone 2 is meticulously assessed and cut back as necessary to remove nonviable tissue while maximally preserving salvageable tissue. Zone 3 is left alone. The aim of surgical debridement is to remove all infected tissue in a single operation. This halts the progression of the fasciitis and minimizes unnecessary returns to the operating room.

Background: Wrist-worn activity trackers are popular, and an increasing number of these devices are equipped with heart rate (HR) measurement capabilities. However, the validity of HR data obtained from such trackers has not been thoroughly assessed outside the laboratory setting. Objective: This study aimed to investigate the validity of HR measures of a high-cost consumer-based tracker (Polar A370) and a low-cost tracker (Tempo HR) in the laboratory and free-living settings. Methods: Participants underwent a laboratory-based cycling protocol while wearing the two trackers and the chest-strapped Polar H10, which acted as criterion. Participants also wore the devices throughout the waking hours of the following day during which they were required to conduct at least one 10-min bout of moderate-to-vigorous physical activity (MVPA) to ensure variability in the HR signal. We extracted 10-second values from all devices and time-matched HR data from the trackers with those from the Polar H10. We calculated intraclass correlation coefficients (ICCs), mean absolute errors, and mean absolute percentage errors (MAPEs) between the criterion and the trackers. We constructed decile plots that compared HR data from Tempo HR and Polar A370 with criterion measures across intensity deciles. We investigated how many HR data points within the MVPA zone (≥64% of maximum HR) were detected by the trackers. Results: Of the 57 people screened, 55 joined the study (mean age 30.5 [SD 9.8] years). Tempo HR showed moderate agreement and large errors (laboratory: ICC 0.51 and MAPE 13.00%; free-living: ICC 0.71 and MAPE 10.20%). Polar A370 showed moderate-to-strong agreement and small errors (laboratory: ICC 0.73 and MAPE 6.40%; free-living: ICC 0.83 and MAPE 7.10%). Decile plots indicated increasing differences between Tempo HR and the criterion as HRs increased. Such trend was less pronounced when considering the Polar A370 HR data. Tempo HR identified 62.13% (1872/3013) and 54.27% (5717/10,535) of all MVPA time points in the laboratory phase and free-living phase, respectively. Polar A370 detected 81.09% (2273/2803) and 83.55% (9323/11,158) of all MVPA time points in the laboratory phase and free-living phase, respectively. Conclusions: HR data from the examined wrist-worn trackers were reasonably accurate in both the settings, with the Polar A370 showing stronger agreement with the Polar H10 and smaller errors. Inaccuracies increased with increasing HRs; this was pronounced for Tempo HR.

Background. A large outbreak of hepatitis A affected individuals in several Australian states in 2009, resulting in a 2-fold increase in cases reported to state health departments compared with 2008. Two peaks of infection occurred (April—May and September—November), with surveillance data suggesting locally acquired infections from a widely distributed food product. Methods. Two case-control studies were completed. Intensive product trace-back and food sampling was undertaken. Genotyping was conducted on virus isolates from patient serum and food samples. Control measures included prophylaxis for close contacts, public health warnings, an order by the chief health officer under the Victorian Food Act 1984, and trade-level recalls on implicated batches of semidried tomatoes. Results. A multijurisdictional case-control study in April—May found an association between illness and consumption of semidried tomatoes (odds ratio [OR], 3.0; 95% CI 1.4—6.7). A second case-control study conducted in Victoria in October—November also implicated semidried tomatoes as being associated with illness (OR, 10.3; 95% CI, 4.7—22.7). Hepatitis A RNA was detected in 22 samples of semidried tomatoes. Hepatitis A virus genotype IB was identified in 144 of 153 (94%) patients tested from 2009, and partial sequence analysis showed complete identity with an isolate found in a sample of semidried tomatoes. Conclusions. The results of both case-control studies and food testing implicated the novel vehicle of semidried tomatoes as the cause of this hepatitis A outbreak. The outbreak was extensive and sustained despite public health interventions, the design and implementation of which were complicated by limitations in food testing capability and complex supply chains.

Complexity in food testing arises from the food (matrix), the need to detect low numbers of target microorganisms in the presence of potentially similar background microflora, the potential use of testing to demonstrate compliance and the high cost (not just financial) of getting it wrong. Microbiological criteria for food specify the method of analysis1 because “test results are dependent on the analytical method used”2. Several bodies are involved in the development of standardised methods, and laboratories may have to run several methods for the same target to meet client needs. The current review of Standard 1.6.1 of the Food Standards Code3 and the July 2012 collaboration agreement struck between the International Organization for Standardization (ISO) and the Association of Analytical Chemists (AOAC International)4 should hopefully reduce the workload for food laboratories.

IntroductionThe aetiology and pathogenesis of bacterial vaginosis (BV) are unclear which has impacted greatly on efforts to improve the efficacy of current treatment approaches. We examined the microbial composition of the vaginal microbiota and factors associated with the development of BV, in women-who-have-sex-with-women (WSW) who were participating in a two year cohort study, in order to gain insights into the microbial changes that occur around the development of BV.Methods298 women self-collected high vaginal swabs and completed questionnaires detailing behavioural practices and symptoms three monthly for 24 months or until incident BV, whichever occurred first. BV was diagnosed by the Nugent method and women could only enrol in the cohort if they were BV negative on 3 weekly vaginal samples at screening. Fifty-one cases of incident BV occurred over 24 months (BV incidence rate, 9.75/100 woman-years). Vaginal swabs were stored at - 80°C. Available longitudinal vaginal specimens from the 51 cases who developed BV and 51 age-matched controls who did not, were included in this study to examine the vaginal microbial composition by 16S rRNA gene sequencing; 47 case participants and 50 control participants met the requirements for specimen submission and sequencing quality (353 swabs). Microbial factors associated with the development of BV were determined by multivariable analysis, adjusting for sexual behaviours. Microbial diversity and stability were assessed by the Shannon diversity index and Bray-Curtis dissimilarity scores between consecutive paired longitudinal samples.ResultsFor each 1% increase in Gardnerella vaginalis abundance there was a 2% increased risk of developing BV (Adjusted Hazard Ratio [AHR]=1.02, 95% CI 1.01–1.03, p0.001). Detection of BVAB TM7 (uncharacterised bacterium of candidate division TM7) was associated with a 6 fold increase in risk of developing BV (AHR=6.06, 95% CI: 1.99, 18.43, p=0.002). In contrast for each 1% increase in Lactobacillus crispatus abundance there was a 1% reduction in the risk of developing BV (AHR=0.99 95% CI 0.098–1.00, p=0.038). The vaginal microbiome of women who developed BV was characterised by high microbial diversity and less stability compared to controls (p=0.04).ConclusionIn a cohort that was designed carefully to study incident BV, lower abundance of L. crispatus, increased abundance of G. vaginalis, and detection of BVAB TM7 were significantly associated with development of BV, after adjusting for bacterial species and sexual behaviour. Increased vaginal microbial diversity, decreased stability and exposure to new sexual partners were also associated with the development of BV in WSW. Incident BV may result from sexual exchange of key BV-associated bacteria such as G. vaginalis which could destabilise the microbial ecology through displacement of beneficial bacteria such as L. crispatus.

Listeria monocytogenes surveillance requires robust laboratory support in detection and organism characterisation. Such laboratory support includes ensuring all relevant isolates are secured and uniformly typed to allow detection of clusters and attribution to potential source. Different typing have different strengths. The move toward sequencing of the whole genome and its subsequent analysis although presenting new challenges to laboratories and practitioners receiving the outputs alike is proving of great utility by providing information of genetic distance between isolates. Australia has established surveillance integrating laboratory typing with epidemiological information relating to human cases. Extending this model to include the potential sources of L. monocytogenes does and has led to early detection of sources thus mitigating the risk to all stakeholders and vulnerable consumers.

Heat shock protein gp96 primes class I restricted cytotoxic T cells against antigens present in the cells from which it was isolated. Moreover, gp96 derived from certain tumors functions as an effective vaccine, causing complete tumor regressions in in vivo tumor challange protocols. Because tumor-derived gp96 did not differ from gp96 isolated from normal tissues, a role for gp96 as a peptide carrier has been proposed. To test this hypothesis, we analyzed whether such an association of antigenic peptides with gp96 occurs in a well-defined viral model system. Here we present the full characterization of an antigenic peptide that endogenously associates with the stress protein gp96 in cells infected with vesicular stomatitis virus (VSV). This peptide is identical to the immunodominant peptide of VSV, which is also naturally presented by H-2Kb major histocompatibility complex class I molecules. This peptide associates with gp96 in VSV-infected cells regardless of the major histocompatibility complex haplotype of the cell. Our observations provide a biochemical basis for the vaccine function of gp96.