High-risk Sources Research Articles

Water source quality testing in Gezira State, Sudan, using the compartment bag test

Although poor water quality is recognized as a public health threat, it has been little investigated in Sudan. In this paper, water sources in Gezira State, Greater Wad Medani locality, have been categorized as safe, intermediate safe and high-risk unsafe sources using the compartment bag test (CBT) to detect E. coli, which is an indicator of fecal contamination of water. The CBT is simple, portable and self-contained, and it can be done in the field environment. A total of 122 samples were collected from different water sources and included rivers, water treatment plant, boreholes/tube wells, hand pumps, public water taps, public water coolers, public elevated water tanks and household elevated water tanks. It was found that 69% (84/122) of investigated water sources were safe to drink. The sources most likely to be contaminated were those close to industrial points and factories or open sources exposed to pollution. The result showed that the highest level of contamination of water sources (high risk and unsafe) was observed in rural area (9.1%) followed by urban (5.7%) and peri-urban (1.6%). Frequent and routine qualitative analysis of water sources using CBT is recommended to improve human health and hence the country’s development.

Wastewater as a Non-conventional Resource: Impact of Trace Metals and Bacteria on Soil, Plants, and Human Health

In many arid and semi-arid regions, farmers are often obligated to informally use raw wastewater for irrigating their crops. The impacts of wastewater irrigation on soil, crops, and human health were investigated, regarding trace metals and bacteria. Cr, Cu, Fe, Ni, and Zn were detected in wastewater. Cr, Cu, and Zn accumulated in soil and crops in the order rocket > clover > cabbage. The Health Risk Index reported risk from Cr and Zn in rocket. Fecal coliforms in wastewater and crops were detected along with Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa. The frequency (%) was 86.7% (cabbage), 66.7% (rocket), and 43.3% (clover). The multiple antibiotic resistance index (0.503) rendered crops high risk source for contamination. The comprehensive pollution index classified wastewater severely polluted (≥2.01). Conclusions deduced crops alternative reservoirs for trace metals and human pathogens. Recommendations included implementation of low cost treatment methods, holding irrigation 5–15 days before harvest, assuming citric and acetic acids reducing solutions for trace metals, and suggested ofloxacin, amoxycillin/clavulanate, and amikacin antibiotics against reported bacteria.

Vancomycin and florfenicol resistant Enterococcus faecalis and Enterococcus faecium isolated from human urine in an Egyptian urban-rural community

Multidrug resistance is one of the top three threats to global public health. Understanding resistance of bacteria is important to help decrease resistance and improve the development of novel antimicrobial agents or other alternative tools to combat public health challenges. Thus, the goal of this study was to investigate the vancomycin and florfenicol resistance genes of five E. faecalis and 15 E. faecium isolated from patients with urinary tract infections. There were 20 Enterococcus obtained from the library collection of randomly selected private hospitals located in the city of El Qanater El Khayreya; these samples were isolated during 2017. Samples were evaluated for their phenotypic characterization of virulence factors, antimicrobial resistance and PCR was conducted to detect the prescence of the vancomycin vanABC and florfenicol resistance genes encoding the catAB, fexAB and cfu. There were six different antibiotic resistance profiles observed. The 20 isolates showed resistance to clindamycin, oxytetracycline and gentamycin. Resistance was evident to ciprofloxacin, norfloxacin and florfenicol in the absence of the cfr gene in all of the 20 Enterococcus isolates. In addition, all isolates produced biofilms and were classified as extensive drug resistant. MARindices of the isolates were >0.6. The MARindex of human isolates of enterococci suggest these pathogens originate from a high-risk source of contamination where antibiotics are often used. This information highlights a possible public health concern to the Egyptian community. The results also suggest the emergence of a linezolid sensitive-vancomycin resistant E. faecium and E. faecalis in the absence of the cfr gene.

Occurrence of multiple antibiotic resistance and genotypic characterization inEdwardsiella tardaisolated from cage‐cultured hybrid red tilapia (Oreochromissp.) in the Ping River, Northern Thailand

Edwardsiella tarda is a pathogen that causes edwardsiellosis in aquatic animals. The emergence of multiple antibiotic-resistant strains makes antibiotic treatment difficult. This study aimed to investigate the antibiotic susceptibility patterns and the genotypic characterization of E. tarda isolated from cage-cultured red tilapia in Thailand. A total of 30 isolates were identified as E. tarda using biochemical and molecular analysis. The disc diffusion method for testing antibiotic susceptibility showed all the isolates were resistant to colistin sulphate and oxolinic acid. High levels of resistance to amoxicillin, ampicillin, ceftazidime, oxytetracycline and sulphamethoxazole/trimethoprim were observed as well. The multiple antibiotic resistance index ranged from 0.25 to 0.92, indicating that these isolates had been exposed to high risk sources of contamination where antibiotics were commonly used. All the isolates carried the blaTEM gene based on polymerase chain reaction (PCR). The tetA and sul3 genes were detected in 90% (27/30) and 26.7% (8/30) of the isolates respectively. Nine different genetic groups of isolates were obtained using enterobacterial repetitive intergenic consensus polymerase chain reaction (ERIC-PCR). A correlation between genetic types and multiple antibiotic-resistant patterns was found. These results highlight the potential risks of multiple antibiotic-resistant isolates for humans and the environment.

Incorporating bioaccessibility into health risk assessment of heavy metals in particulate matter originated from different sources of atmospheric pollution

Rapid industrialization and urbanization have resulted in widespread pollution of airborne particulate matter (PM) containing various heavy metals with adverse human-health effects. Health risk assessment of PM calls for accurate evaluation of the bioaccessibility, instead of the total content, of heavy metals in PM. Here, we demonstrated that the leachable fraction of particle-bound As, Pb, Cr, Mn, Cd, Cu, Ni and Zn in lung fluid within the typical retention duration of particles in human lungs varied drastically among particles originated from different air pollution sources, including coal combustion, biomass combustion, fugitive dust, road dust, construction dust, cement and soil. Moreover, bioaccessibility of heavy metals, particularly in biomass combustion, cement and soil particles, was strongly dependent on pollution sources, and the particulate Cu, Ni, Pb and Cd appeared to be the primary indicators of the source dependence of heavy metal bioaccessibility. Using total rather than bioaccessible concentrations of particle-bound heavy metals not only led to overestimation of the health risk of source particles, but more importantly, inaccurate identification of the high-risk pollution sources and the priority metal pollutants in the source particles. When considering bioaccessibility of particle-bound heavy metals examined in this study, coal combustion products exhibited the highest carcinogenic and noncarcinogenic risks among all source particles, whereas cement particles would be the source with highest risk based on total metal content. As and Mn appeared to be the main drivers for the noncarcinogenic risks of source particles, while As, Ni and Cr were the major contributors to the carcinogenic risks of source particles, significantly different from those based on total contents. This research underlines the importance of incorporating bioaccessibility into health risk indexes of frequently occurring particle-bound heavy metals from specific air pollution sources, which will facilitate risk-based assessment of source contribution and hence effective source regulation of airborne PM.

Criminal Liability and Artificial Intelligence: Theoretical and Applied Aspects

The humanity is now at the threshold of a new era when a widening use of artificial intelligence (AI) will start a new industrial revolution. Its use inevitably leads to the problem of ethical choice, it gives rise to new legal issues that require urgent actions. The authors analyze the criminal law assessment of the actions of AI. Primarily, the still open issue of liability for the actions of AI that is capable of self-learning and makes a decision to act / not to act, which is qualified as a crime. As a result, there is a necessity to form a system of criminal law measures of counteracting crimes committed with the use of AI. It is shown that the application of AI could lead to four scenarios requiring criminal law regulation. It is stressed that there is a need for a clear, strict and effective definition of the ethical boundaries in the design, development, production, use and modification of AI. The authors argue that it should be recognized as a source of high risk. They specifically state that although the Criminal Code of the Russian Fe­deration contains norms that determine liability for cybercrimes, it does not eliminate the possibility of prosecution for infringements committed with the use of AI under the general norms of punishment for various crimes. The authors also consider it possible to establish a system to standardize and certify the activities of designing AI and putting it into operation. Meanwhile, an autonomous AI that is capable of self-learning is considerably different from other phenomena and objects, and the situation with the liability of AI which independently decides to undertake an action qualified as a crime is much more complicated. The authors analyze the resolution of the European Parliament on the possibility of granting AI legal status and discuss its key principles and meaning. They pay special attention to the issue of recognizing AI as a legal personality. It is suggested that a legal fiction should be used as a technique, when a special legal personality of AI can be perceived as an unusual legal situation that is different from reality. It is believed that such a solution can eliminate a number of existing legal limitations which prevent active involvement of AI into the legal space.

Characterization and source identification of tetracycline antibiotics in the drinking water sources of the lower Yangtze River

The occurrence and spatio-temporal patterns of five tetracyclines (TCs) and six of their degradation products were investigated in twenty-eight drinking water sources along the lower Yangtze River (LYR) over dry, normal and flood seasons. Tetracycline (TC), oxytetracycline (OTC) and doxytetracycline (DXC) were the dominant antibiotics detected with the highest occurrence. The maximum concentrations of TC, OTC and DXC were found in dry season as 11.16, 18.98, and 56.09 ng/L, respectively, because of the low dilution, low degradation, and high consumption in this season. Cluster analysis indicated distinct variations in the TCs’ compositional profiles in both space and time. OTC and its metabolites contributed 18.5–59.6% of the TC load in dry season, possibly due to the seasonally increased release of pharmaceutical OTCs from sewage effluents, but they were seldom detected in other seasons. Pollution load index analysis showed that tributaries carrying large amounts of veterinary TCs derived from breeding wastewater and untreated rural sewage contributed larger proportions of the TC load for most drinking water sources than sewage outlets. The contribution ratio of the TC load from tributaries (74.5%) was approximately three times higher than that from sewage discharges (25.5%). The study demonstrated that the control of load from tributaries is the key to mitigating TC pollution of the drinking water sources in the LYR. An effective source tracking method for evaluating the contribution of antibiotic load from multiple diffuse pollution origins and identifying the high-risk contamination sources was established for antibiotic management and control.

Antimicrobial Profiling of Bacteria Isolated from Fish Sold at Informal Market in Mufakose, Zimbabwe.

The number of infections caused by antibiotic resistant bacteria is rising worldwide. Fish from multisource pollution waters can harbour multidrug-resistant bacteria that can be disseminated to humans through eating or contact of contaminated fish. A cross-sectional study was carried out to (i) isolate and phenotypically identify bacteria from 36 fish samples from informal market in Mufakose, Harare, and (ii) determine the antibiotic sensitivity pattern of the isolated bacteria against ten available antibiotics (ampicillin 10 μg, gentamycin 30 μg, penicillin G 10 μg, erythromycin 15 μg, tetracycline 30 μg, kanamycin 30 μg, neomycin 10 μg, cloxacillin 5 μg, lincomycin 15 μg, and sulfamethoxazole 25 μg) using the Kirby–Bauer disk agar diffusion method. Eight bacterial genera were isolated and identified, and they were Escherichia, Aeromonas, Staphylococcus, Pseudomonas, Citrobacter, Klebsiella, Enterobacter, and Proteus. Among the isolates, Escherichia coli was isolated most frequently (44%) followed by Staphylococcus aureus (19%), Enterobacter aerogenes (7%), Aeromonas spp. (5%), Proteus mirabilis (5%), Citrobacter (5%), and coagulase-negative Staphylococci (5%) and the least frequent were Klebsiella (3%) and Pseudomonas (3%). All isolates were susceptible to gentamycin. Varying antibiotic resistance rates were observed to lincomycin (100%), ampicillin (81%), penicillin (67%), erythromycin (65%), tetracycline (63%), neomycin (61%), cloxacillin (43%), kanamycin (24%), and sulphamethoxazole (13%). All the isolates were multidrug-resistant (resistant to at 3 or more drugs tested) except Proteus mirabilis. Proteus mirabilis has multiple antibiotic resistance (MAR) index of 0.2, and the other isolated bacteria had MAR indexes greater than 0.2 ranging from 0.3 to 0.7. Those MAR indexes above 0.2 showed that the bacteria isolates are from a high risk source where antibiotics were frequently used, possibly from sewage effluents. Isolation of enteric bacteria such as Escherichia coli is an indication of faecal contamination, and this poses a high risk to animal and human health. These significant findings call for effective risk assessment models and management plans that protect human, animal, and environmental health.

Antibiotic resistance of E. coli isolated from whiteleg shrimp (Litopenaeus vannamei) collected from wet markets and supermarkets in Ho Chi Minh city and their transferability

In this study, a collection of 130 E. coli isolated from white-leg shrimp collected from three wet markets and two supermarkets in Ho Chi Minh City was analysed to examine their antibiotic resistance characteristics and the transferability of resistance markers. High levels of resistance to ampicillin, tetracyclines, trimethoprim/sulfamethoxazole, nalidixic acid and chloramphenicol were observed. The percentage of multiple drug resistance (4 to 10 tested antibiotics) was 73.8%. The multiple antibiotic resistance (MAR) index values of 0.4 to 0.73 (of each sample collection site) indicated that these isolates were exposed to high risk sources of contamination where antibiotics were commonly used. Conjugation experiments demonstrated the successful transfer of all or part of the resistance phenotypes of shrimp isolates to the human recipient strains

Use of Basalt Fiber-Reinforced Tailings for Improving the Stability of Tailings Dam.

As one of the largest artificial geotechnical structures on earth, the tailings dams are classified as one of the high-risk sources in China’s industry. How to improve the stability and safety of tailings dams remains a challenge for mine operators currently. In this paper, an innovative method is presented for improving the stability of tailings dams, in which the basalt fiber is used to reinforce tailings. The mechanical properties of tailings used for dam-construction have a great influence on the stability of tailings dam. In order to investigate the mechanical performance of basalt fiber-reinforced tailings (BFRT), a series of laboratory triaxial tests were conducted. The effects of five parameters (fiber length, fiber content, particle size, dry density and confining pressure) on the mechanical properties of BFRT were studied. The microstructure and the behavior of interfaces between basalt fibers and tailings particles were analyzed by using scanning electron microscopy (SEM). The triaxial experimental test results show that the mechanical properties of BFRT increase with the increases of fiber length and content, particle size, dry density and confining pressure. The SEM results indicate that the interfacial interaction between fibers and tailings particles is mainly affected by particle shape.

Impact of β-Lactam and Daptomycin Combination Therapy on Clinical Outcomes in Methicillin-susceptible Staphylococcus aureus Bacteremia: A Propensity Score-matched Analysis.

Mortality rates from Staphylococcus aureus bacteremia are high and have only modestly improved in recent decades. We compared the efficacies of a β-lactam in combination with daptomycin (BL/D-C) and β-lactam monotherapy (BL-M) in improving clinical outcomes in methicillin-susceptible S. aureus (MSSA) bacteremia. A retrospective cohort study of MSSA bacteremia was performed in a tertiary hospital from January 2011 to December 2017. Patients receiving BL/D-C and BL-M were compared to assess 7-, 30-, and 90-day mortality rates. A 1:2 propensity score matching analysis was performed. Differences were assessed using Cox regression models. Of the 514 patients with MSSA bacteremia, 164 were excluded as they had received combination therapies other than BL/D-C, had pneumonia, or died within 48 hours of admission. Of the remaining 350 patients, 136 and 214 received BL/D-C and BL-M, respectively. BL/D-C patients had higher Pitt scores and persistent bacteremia more often than BL-M patients. In the raw analysis, there were no differences in mortality rates between groups. After propensity score matching, there were no significant differences between the BL/D-C (110 patients) and BL-M (168 patients) groups for all-cause mortality rates at 7 days (8.18% vs 7.74%; P = 1.000), 30 days (17.3% vs 16.1%; P = .922), and 90 days (22.7% vs 23.2%; P = 1.000), even in a subanalysis of patients with high-risk source of infection and in a subgroup excluding catheter-related bacteremia. BL/D-C failed to reduce mortality rates in patients with MSSA bacteremia. Treatment strategies to improve survival in MSSA bacteremia are urgently needed.

Cardioembolic Sources in Patients With Small Single Subcortical Infarcts.

Transthoracic echocardiogram (TTE) is widely used as part of the work-up for ischemic stroke. However, the added utility of TTE in the management of small single subcortical infarcts (SSSI) has not been extensively evaluated. Therefore, we aimed to determine the frequency of high-risk and medium-risk cardioembolic sources diagnosed by TTE in SSSI patients, and whether the findings altered clinical management. We performed a retrospective analysis of a prospective cohort of patients with confirmed acute ischemic stroke enrolled in a single-center observational registry between August 2012 and July 2014. We assessed infarct topography on brain magnetic resonance imaging, blinded to final stroke subtype and treatment, to identify patients with SSSI. We defined SSSI as lesions in the corona radiata, basal ganglia, thalamus, or brainstem measuring <1.5 cm in maximal diameter. We excluded patients with atrial fibrillation and large artery stenosis >50%, and assessed the frequency of cardioembolic sources found by TTE in the remaining patients. Among 908 patients, 75 (8.3%) had SSSI, of which 4 (5.3%) had atrial fibrillation and 6 (8%) had symptomatic large artery stenosis. TTE revealed cardiac abnormalities in 46% of the remaining patients (mean age: 65.1 y, 52% female, 58% white). The most common findings were dilated left atrium (29%), patent foramen ovale (14%), and atrial septal aneurysm (7.7%). Anticoagulants were prescribed in 3 (4.6%) patients on the basis of TTE results. TTE identified potential cardioembolic sources in almost half of the patients, but altered antithrombotic management in only 5% of patients with SSSI.

The impact of on-site hospital wastewater treatment on the downstream communal wastewater system in terms of antibiotics and antibiotic resistance genes.

This study quantified antibiotic and antibiotic resistance gene (ARG) concentrations in hospital and communal wastewaters as well as the influents and effluents of the receiving urban wastewater treatment plants (UWWTP) in two Dutch cities. In only one city, hospital wastewater was treated on-site using advanced technologies, including membrane bioreactor treatment (MBR), ozonation, granulated activated carbon (GAC) and UV-treatment. On-site hospital wastewater (HWW) treatment reduced gene presence of hospital-related antibiotic resistance genes and antibiotic concentrations in the receiving urban wastewater treatment plant. These findings support the need for on-site treatment of high-risk point sources of antibiotic resistance genes. 13 antibiotic resistance genes, Integrase Class 1 and 16S rRNA concentrations were quantified using multiplex quantitative real-time PCR (qPCR) assays and the presence and/or concentration of 711 antibiotics were analyzed. Hospital wastewater contained approximately 25% more antibiotics and gene concentrations between 0.4 log to 1.8-fold higher than communal wastewater (CWW). blaKPC and vanA could be identified as hospital-related genes and were reduced to under the limit of detection (LOD) during on-site treatment. Advanced on-site treatment removed between 0.5 and 3.6-fold more genes than conventional biological urban wastewater treatment (activated sludge). Advanced on-site treatment was able to eliminate 12 out of 19 detected antibiotics, while urban waste water treatment eliminated up to 1 (out of 21 detected). Different advanced treatment technologies were able to target different pollutants to varying extents, making sequential alignment more effective. MBR treatment was most efficient in antibiotic resistance gene reduction and ozonation in antibiotic reduction. blaKPC could only be detected in the influent of the urban wastewater treatment plant receiving untreated hospital wastewater. Similarly, vanA was only consistently detected in this treatment plant. These results indicate a positive effect of on-site treatment of hospital wastewater on the communal sewage system.

Caducidad de un documento escrito en handoff

El “handoff” o “pase del paciente” se define como el intercambio de información clínica cuando un nuevo médico o equipo médico asume el manejo de un paciente, bien sea de forma oral o escrita. La transmisión de información (handoff) oral, es una fuente de errores de comunicación y debe mejorar para disminuir los errores y los eventos adversos. La naturaleza estática de los documentos escritos hace que rápidamente la información se desactualice aumentando el error. Los documentos de handoff electrónicos, integrados en la historia clínica se han asociado con mejoras. La impresión hace que la actualización de los datos a tiempo real sea prácticamente imposible, incrementando el riesgo de una información inexacta. El objetivo del estudio fue determinar el tiempo en el que los datos clínicos del documento escrito se vuelven imprecisos, caracterizar el tipo de imprecisiones e identificar diferencias entre los turnos de día y de noche, así como entre servicios médicos y quirúrgicos. La hipótesis afirmaba que al final del turno de noche, la mayoría de los documentos de handoff contenían al menos un error, con potencial de producir daño. Se usó el término de “vida media”. Documentando estas imprecisiones, los autores esperaron que existiera la posibilidad de actualizar los datos en la historia clínica electrónica a tiempo real, con el objetivo de mejorar la seguridad del paciente. ABSTRACT Expiry of a handoff printed document The handoff is defined as the change of clinical information about patients for whom physicians are responsible for between doctors and medical teams, both printed and verbal. Medical errors related to poor communication remain unacceptably common. Verbal handoffs are known to be high-risk source of communication errors and it may be improved to reduce adverse events. The static nature of printed documents makes it likely that some of the information will quickly become inaccurate, increasing the potential for medical errors. Computerised handoff documents integrated with electronic health records have been associated with improvements. Printing makes real-time automatic updating impossible, and therefore, increases the potential for inaccurate information. The main goals of this study were to measure the average time to potential inaccuracy of a printed handoff, to determine the types of inaccuracy and to identify differences between day and night shifts, as well as surgical and non-surgical services. They hypothesized that by the end of an overnight call shift, most handoffs documents would contain at least one error, which had the potential to impact patient care. They used the term “half-life”. By documenting the inaccuracies which can be expected on printed handoff documents, the authors hope to achieve a shift toward reliance on the electronic health records on screen real, real-time, with the ultimate desired result of improved patient safety.

Relationship between the Angle of the Posterior Inferior Cerebellar Artery and Cardioembolic Stroke

BackgroundIn patients with unilateral posterior inferior cerebellar artery (PICA) territory infarction, the absence of relevant vessel stenosis may make it difficult to determine the etiology of the infarction. The incidence of cardioembolic (CE) infarction and the factors associated with infarction in such patients remains largely unknown. We hypothesized that the PICA angle would affect the flow direction of embolic sources. Thus, we analyzed the association between high-risk CE sources and the PICA angle. MethodsPatients with an isolated unilateral PICA territory infarction without relevant vessel stenosis who were admitted between 2014 and 2017 were included from the Korea University Stroke Registry, which includes data from 3 university hospitals. We classified patients according to the presence of CE sources. For each case, we measured the angle between the vertebral artery (VA) and the proximal PICA. ResultsIn all, 71 patients met the final study entry criteria. Multivariable analysis showed that the PICA angle was independently associated with the risk of a CE source. The optimal cut-off value using Youden's index was 89°. We classified the PICA shape based on the optimal cut-off value. A CE source was identified in 83.3% of cases in which the PICA angle exceeded 89°. ConclusionsThe angle between the PICA and VA was an independent predictor of unilateral PICA stroke with high-risk CE sources without relevant artery stenosis, suggesting that an angle greater than 89° could be a new image marker for determining the stroke subtype.

Return to work after ischemic stroke in young adults: A registry-based follow-up study.

ObjectiveWe aimed to investigate the proportion of young patients not returning to work (NRTW) at 1 year after ischemic stroke (IS) and during follow-up, and clinical factors associated with NRTW.MethodsPatients from the Helsinki Young Stroke Registry with an IS occurring in the years 1994–2007, who were at paid employment within 1 year before IS, and with NIH Stroke Scale score ≤15 points at hospital discharge, were included. Data on periods of payment came from the Finnish Centre for Pensions, and death data from Statistics Finland. Multivariate logistic regression analyses assessed factors associated with NRTW 1 year after IS, and lasagna plots visualized the proportion of patients returning to work over time.ResultsWe included a total of 769 patients, of whom 289 (37.6%) were not working at 1 year, 323 (42.0%) at 2 years, and 361 (46.9%) at 5 years from IS. When adjusted for age, sex, socioeconomic status, and NIH Stroke Scale score at admission, factors associated with NRTW at 1 year after IS were large anterior strokes, strokes caused by large artery atherosclerosis, high-risk sources of cardioembolism, and rare causes other than dissection compared with undetermined cause, moderate to severe aphasia vs no aphasia, mild and moderate to severe limb paresis vs no paresis, and moderate to severe visual field deficit vs no deficit.ConclusionsNRTW is a frequent adverse outcome after IS in young adults with mild to moderate IS. Clinical variables available during acute hospitalization may allow prediction of NRTW.

The implementation of cattle market closure strategies to mitigate the foot-and-mouth disease epidemics: A contact modeling approach

Foot-and-mouth disease (FMD) is one of the most endemic diseases in livestock worldwide. The disease occurrence generally results in a huge economic impact. The virus may distribute across countries or even continents along the contact network of animal movements. The present study, therefore, aimed to explore a cattle movement network originated in Tak, a Thailand-Myanmar bordered province and to demonstrate how FMDV spread among the nodes of market, source and destination. Subsequently, we examined the effectiveness of market closure intervention. The market-market (M-M) network was constructed to highlight the inter-market connections and the FMDV was modeled to spread along the trade chain. Four market closure scenarios based on rapidness and duration of implementation were examined. Our results indicate that two of the three major markets located in the province were highly connected and a strongly connected component was identified. The intra-provincial animal movements, which were currently overlooked, should be moved into sights as most of the high-risk sources for FMD epidemics were recognized in a close proximity to the cattle markets. Simultaneously, remote destinations across the country were identified. The inter-provincial animal movement control must be strengthened once FMD outbreak is notified. Based on our simulations, closing markets with low inter-market connectivity may not prevent the spread of FMDV. A selective market closure strategy targeting highly connected markets together with cattle trader tracking system was an alternative approach. However, socio-economic consequences regarding this intervention must be considered.

Emergency Department (ED) Triage for Transient Ischemic Attack (TIA).

Patients with transient ischemic attacks (TIAs) have a higher risk for stroke and vascular events. Specialized and organized management, if rapidly initiated in the emergency department (ED), reduces the vascular burden of TIA. This review summarizes the rationale for optimal triage of patients suspected with TIA in the ED, focusing on early diagnosis confirmation, individual risk stratification, and management. New evidence is emerging on the yield of integrating clinical scales with advanced neuroimaging of the vessels and brain for improved diagnosis and risk stratification in patients with TIA. The "TIA clinic" model of management is associated with the lowest long-term cardio-cerebrovascular recurrence rate ever reported. TIA are vascular emergencies that require a specialized, systematic evaluation to confirm the diagnosis of an ischemic mechanism, identify high-risk source of brain ischemia and initiate a tailored therapeutic strategy. TIA triage in the ED should organized as part of a "TIA clinic program" that unifies the expedited specialized management of the patient, in collaboration with stroke neurologists.

Evaluation of a CTA-Triage Based Transient Ischemic Attack Service: A Retrospective Single Center Cohort Study

ObjectiveWe designed a computed tomography angiography (CTA)-based algorithm for patients presenting to hospital with a transient ischemic attack (TIA) which identified high-risk patients, as well as inpatient versus semiurgent outpatient management following MRI, and we hypothesised that this would be effective. MethodsPatients seen in the ED at the Royal Adelaide Hospital from March 3, 2012 to November 30, 2016 with TIA-like symptoms were assessed for a cardioembolic source (clinical assessment, electrocardiogram) and underwent intra and extracranial CTA. Patients with a referable >50% stenosis were admitted and given dual antiplatelets. Most high-risk cardiac source patients were also admitted and anticoagulated. Other patients were loaded with aspirin, or changed to clopidogrel if on aspirin, and reviewed as outpatients following semiurgent MRI (3-4 days). We assessed the 90-day recurrent stroke risk in this cohort as a whole, and in those with a final cerebrovascular diagnosis. Results1167 patients were diagnosed in Emergency as TIA and referred via our algorithm. A total of 150 were admitted, 78 had “high-risk” features. A total of 1017 patients were reviewed in the TIA clinic. The average age of the total cohort was 65.8 years old. Final diagnosis was TIA/minor stroke in 69% admitted patients and 30% clinic patients (P value < .0001). The 90-day recurrent stroke risk in these patients was 2.0% (5.8% admitted vs .7% clinic patients, P value < .0001). In those with noncerebrovascular diagnoses, there were no recurrent strokes within 90 days. ConclusionsStroke risk is very low using CTA guided semiurgent clinic review algorithm.

Incidence and Etiology of Microinfarcts in Patients with Ischemic Stroke.

Cerebral microinfarcts (CMI) are associated with intracerebral hemorrhage due to small vessel disease (SVD) in studies not including an ischemic etiologic workup. We aimed to determine their incidence and potential causes in a large ischemic stroke (IS) cohort. Consecutive patients with MRI-confirmed IS within 72 hours of onset were enrolled. Subjects had either single high-risk embolic source (cardioembolic or large vessel disease) or no embolic source. CMIs were classified by their relationship to the primary infarct as within or outside the same vascular territory. White matter hyperintensities (WMH) and microbleeds were markers SVD severity. Multivariable regression tested the association between CMIs and potential etiologies. We analyzed 946 IS patients, mean age 69 ± 15 years, 46% female. We detected CMI (≤5 mm) on diffusion-weighted imaging in 269 (28%) subjects, 190 (71%) within the vascular territory of the primary infarct. Large-vessel atherosclerosis (P <.001), cardioembolic source (P <.001), higher WMH (P = .032) and lower systolic blood pressure (SBP, P = .024) were independently associated with the presence of CMI. While SBP was associated with CMI in any location (P <.05), WMH was only associated with CMI outside the territory of the primary infarct (P = .033), and large vessel atherosclerosis with CMI within the primary infarct territory (P = .004). CMIs occurring within the vascular territory of a larger infarct are more likely embolic, but those occurring outside are probably related to SVD. Our findings suggest a role for SVD in pathogenesis of CMIs and emphasize the importance of etiologic workup to identify alternate etiologies.