Robotic-assisted laparoscopic colposuspension for female stress urinary incontinence: a prospective series.

The suspension of use of sub-urethral mesh in the UK in 2018 has seen the resurgence of colposuspension in female SUI surgery. Open and laparoscopic colposuspension techniques are well recognised. We present data from 28 robotic-assisted laparoscopic colposuspension (RALCp) procedures, reporting on technique, safety and efficacy. Approval was obtained from the hospital New and Novel Procedures Committee. All patients had urodynamic assessment prior to surgery. Data was prospectively gathered and 24-h pad usage and Urinary Incontinence Short Form Questionnaire (ICIQ-UI-SF) scores were used to assess symptom severity and quality of life. PGII scores were used to assess patient satisfaction after the procedure. Paired T test analysis was conducted. Since May 2019, robotic colposuspension has been performed in 28 patients. The mean age and BMI were 49 and 27 (kg/m2), respectively, with a mean follow-up period of 12 months. 67.9% of patients had pure urodynamic SUI and 32.1% of patients had previous anti-SUI surgery. Average operating time was 127 min, blood loss 20 ml and length of stay 2 days. There was a significant 73% improvement in mean 24-h pad usage (p = 0.001) and an improvement in mean ICIQ-UI-SF scores from 18.1 to 9.4 (p = 0.0001). Day 1 mean pain score was 5/10. This is the largest series of its kind. Robotic colposuspension is safe and feasible with significant improvements seen in quality of life scores and number of pads used per day. It presents a minimally invasive treatment option in female SUI, however needs larger volume evaluation and longer follow-up for further evaluation.

Pulmonary Metastasectomy in Colorectal Cancer: updated analysis of 93 randomized patients - control survival is much better than previously assumed.

AIM: Lung metastases from colorectal cancer are resected in selected patients in the belief that this confers a significant survival advantage. It is generally assumed that the 5-year survival of these patients would be near zero without metastasectomy. We tested the clinical effectiveness of this practice in Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC), a randomized, controlled noninferiority trial. METHOD: Multidisciplinary teams in 14 hospitals recruited patients with resectable lung metastases into a two-arm trial. Randomization was remote and stratified according to site, with minimization for age, sex, primary cancer stage, interval since primary resection, prior liver involvement, number of metastases and carcinoembryonic antigen level. The trial management group was blind to patient allocation until after intention-to-treat analysis. RESULTS: From 2010 to 2016, 93 participants were randomized. These patients were 35-86 years of age and had between one and six lung metastases at a median of 2.7 years after colorectal cancer resection; 29% had prior liver metastasectomy. The patient groups were well matched and the characteristics of these groups were similar to those of observational studies. The median survival after metastasectomy was 3.5 (95% CI: 3.1-6.6) years compared with 3.8 (95% CI: 3.1-4.6) years for controls. The estimated unadjusted hazard ratio for death within 5 years, comparing the metastasectomy group with the control group, was 0.93 (95% CI: 0.56-1.56). Use of chemotherapy or local ablation was infrequent and similar in each group. CONCLUSION: Patients in the control group (who did not undergo lung metastasectomy) have better survival than is assumed. Survival in the metastasectomy group is comparable with the many single-arm follow-up studies. The groups were well matched with features similar to those reported in case series.

Emulsified polycolloid substrate biobarrier for benzene and petroleum-hydrocarbon plume containment and migration control - A field-scale study.

The objective of this field-scale study was to assess the effectiveness of applying an emulsified polycolloid substrate (EPS; containing cane molasses, soybean oil, and surfactants) biobarrier in the control and remediation of a petroleum-hydrocarbon plume in natural waters. An abandoned petrochemical manufacturing facility site was contaminated by benzene and other petroleum products due to a leakage from a storage tank. Because benzene is a petroleum hydrocarbon with a high migration ability, it was used as the target compound in the field-scale study. Batch partition and sorption experiment results indicated that the EPS to water partition coefficient for benzene was 232 mg/mg at 25 °C. This suggests that benzene had a higher sorption affinity to EPS, which decreased the benzene concentrations in groundwater. The EPS solution was pressure-injected into three remediation wells (RWs; 150 L EPS in 800 L groundwater). Groundwater samples were collected from an upgradient background well, two downgradient monitor wells (MWs), and the three RWs for analyses. EPS injection increased total organic carbon (TOC) concentrations (up to 786 mg/L) in groundwater, which also resulted in the formation of anaerobic conditions. An abrupt drop in benzene concentration (from 6.9 to below 0.04 mg/L) was observed after EPS supplementation in the RWs due to both sorption and biodegradation mechanisms. Results show that the EPS supplement increased total viable bacteria and enhanced bioremediation efficiency, which accounted for the observed decrease in benzene concentration. The first-order decay rate in RW1 increased from 0.003 to 0.023 d-1 after EPS application. Injection of EPS resulted in significant growth of indigenous bacteria, and 23 petroleum-hydrocarbon-degrading bacterial species were detected, which enhanced the in situ benzene biodegradation efficiency. Results demonstrate that the EPS biobarrier can effectively contain a petroleum-hydrocarbon plume and prevent its migration to downgradient areas, which reduces the immediate risk presented to downgradient receptors.

Re-irradiation for Paediatric Tumours.

Despite best available therapy, many children with cancer develop recurrence after multimodal treatment, including initial radiation therapy. Re-irradiation is defined as the use of a second course of radiation therapy with a retreatment volume that overlaps substantially with that of a previously delivered course of radiation therapy. Re-irradiation is an important part of salvage treatment for patients with recurrent ependymoma, diffuse intrinsic pontine glioma, medulloblastoma and germinoma. In patients with ependymoma, conventionally fractionated re-irradiation (1.8 Gy/day) can provide long-term disease control with low rates of high-grade toxicity. For children with progressive diffuse intrinsic pontine glioma, re-irradiation provides effective palliation of symptoms and a survival gain as compared with those treated without re-irradiation. Repeat radiation therapy that includes craniospinal irradiation, if safe to deliver, may provide long-term tumour control in patients with medulloblastoma. Patients with recurrent intracranial germinoma can be effectively salvaged with re-irradiation that includes craniospinal irradiation. Finally, the emerging role of re-irradiation in non-brainstem high-grade glioma and extracranial solid tumours requires further study regarding its efficacy and safety. When given, re-irradiation should be delivered with care so that doses to organs at risk are minimised. In all cases, re-irradiation should be considered as an option alongside, or concurrently with, other salvage treatments, including surgery or systemic therapy, to maximise the likelihood of durable disease control.

Application of an emulsified polycolloid substrate biobarrier to remediate petroleum-hydrocarbon contaminated groundwater.

Emulsified polycolloid substrate (EPS) was developed and applied in situ to form a biobarrier for the containment and enhanced bioremediation of a petroleum-hydrocarbon plume. EPS had a negative zeta potential (-35.7 mv), which promoted its even distribution after injection. Batch and column experiments were performed to evaluate the effectiveness of EPS on toluene containment and biodegradation. The EPS-to-water partition coefficient for toluene (target compound) was 943. Thus, toluene had a significant sorption affinity to EPS, which caused reduced toluene concentration in water phase in the EPS/water system. Groundwater containing toluene (18 mg/L) was pumped into the three-column system at a flow rate of 0.28 mL/min, while EPS was injected into the second column to form a biobarrier. A significant reduction of toluene concentration to 0.1 mg/L was observed immediately after EPS injection. This indicates that EPS could effectively contain toluene plume and prevent its further migration to farther downgradient zone. Approximately 99% of toluene was removed after 296 PVs of operation via sorption, natural attenuation, and EPS-enhanced biodegradation. Increase in total organic carbon and bacteria were also observed after EPS supplement. Supplement of EPS resulted in a growth of petroleum-hydrocarbon degrading bacteria, which enhanced the toluene biodegradation.

Development of a two-stage biotransformation system for mercury-contaminated soil remediation.

Utilization of bacterial volatilization can be problematic to remediate mercury (Hg)-contaminated soils because most of the Hg in soils is bound to soil particles. The objective of this study was to develop a two-stage system (chemical extraction followed by microbial reduction) for Hg-contaminated soil remediation. The tasks were to (1) select the extraction reagents for Hg extraction, (2) assess the effects of extraction reagents on the growth of Hg-reducing bacterial strains, and (3) evaluate the effectiveness of Ca2+ and Mg2+ addition on merA gene (Hg reductase) induction. Bacterial inhibition was observed with the addition of 0.1 M ethylenediaminetetraacetic acid or citric acid. Up to 65% of Hg was biotransformed (Hg concentration = 69 mg/kg) from the soils after a 24 h extraction using 0.5 M ammonium thiosulfate. Ca2+ and Mg2+ were selected because they have the same electric charge as Hg and the studied groundwater contained high concentrations of Ca2+ and Mg2+. Results showed that the addition of 200 mg/L Ca2+ or 650 mg/L Mg2+ could reach effective merA induction. In the two-stage experiment, 120 mg/kg Hg-contaminated soils were extracted with 2 rounds of extraction processes for 10 h using 0.5 M ammonium thiosulfate. Approximately 77% of Hg was extracted from the soils after the first-step extraction process. Up to 81% of Hg2+ was transformed from the washing solution via the biotransformation processes with Enterobacter cloacae addition and Ca2+ and Mg2+ supplementation. The two-stage remedial system has the potential to be developed into a practical technology to remediate Hg-contaminated sites.

Adding abiraterone or docetaxel to long-term hormone therapy for prostate cancer: directly randomised data from the STAMPEDE multi-arm, multi-stage platform protocol.

Background: Adding abiraterone acetate with prednisolone (AAP) or docetaxel with prednisolone (DocP) to standard-of-care (SOC) each improved survival in systemic therapy for advanced or metastatic prostate cancer: evaluation of drug efficacy: a multi-arm multi-stage platform randomised controlled protocol recruiting patients with high-risk locally advanced or metastatic PCa starting long-term androgen deprivation therapy (ADT). The protocol provides the only direct, randomised comparative data of SOC + AAP versus SOC + DocP. Method: Recruitment to SOC + DocP and SOC + AAP overlapped November 2011 to March 2013. SOC was long-term ADT or, for most non-metastatic cases, ADT for ≥2 years and RT to the primary tumour. Stratified randomisation allocated pts 2 : 1 : 2 to SOC; SOC + docetaxel 75 mg/m2 3-weekly×6 + prednisolone 10 mg daily; or SOC + abiraterone acetate 1000 mg + prednisolone 5 mg daily. AAP duration depended on stage and intent to give radical RT. The primary outcome measure was death from any cause. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. This was not a formally powered comparison. A hazard ratio (HR) <1 favours SOC + AAP, and HR > 1 favours SOC + DocP. Results: A total of 566 consenting patients were contemporaneously randomised: 189 SOC + DocP and 377 SOC + AAP. The patients, balanced by allocated treatment were: 342 (60%) M1; 429 (76%) Gleason 8-10; 449 (79%) WHO performance status 0; median age 66 years and median PSA 56 ng/ml. With median follow-up 4 years, 149 deaths were reported. For overall survival, HR = 1.16 (95% CI 0.82-1.65); failure-free survival HR = 0.51 (95% CI 0.39-0.67); progression-free survival HR = 0.65 (95% CI 0.48-0.88); metastasis-free survival HR = 0.77 (95% CI 0.57-1.03); prostate cancer-specific survival HR = 1.02 (0.70-1.49); and symptomatic skeletal events HR = 0.83 (95% CI 0.55-1.25). In the safety population, the proportion reporting ≥1 grade 3, 4 or 5 adverse events ever was 36%, 13% and 1% SOC + DocP, and 40%, 7% and 1% SOC + AAP; prevalence 11% at 1 and 2 years on both arms. Relapse treatment patterns varied by arm. Conclusions: This direct, randomised comparative analysis of two new treatment standards for hormone-naïve prostate cancer showed no evidence of a difference in overall or prostate cancer-specific survival, nor in other important outcomes such as symptomatic skeletal events. Worst toxicity grade over entire time on trial was similar but comprised different toxicities in line with the known properties of the drugs. Trial registration: Clinicaltrials.gov: NCT00268476.

Source identification and ecological impact evaluation of PAHs in urban river sediments: A case study in Taiwan.

The Love River and Ho-Jin River, two major urban rivers in Kaohsiung City, Taiwan, are moderately to heavily polluted because different types of improperly treated wastewaters are discharged into the rivers. In this study, sediment and river water samples were collected from two rivers to investigate the river water quality and accumulation of polycyclic aromatic hydrocarbons (PAHs) in sediments. The spatial distribution, composition, and source appointment of PAHs of the sediments were examined. The impacts of PAHs on ecological system were assessed using toxic equivalence quotient (TEQ) of potentially carcinogenic PAHs (TEQcarc) and sediment quality guidelines. The average PAHs concentrations ranged from 2161 ng/g in Love River sediment to 160 ng/g in Ho-Jin River sediment. This could be due to the fact that Love River Basin had much higher population density and pyrolytic activities. High-ring PAHs (4-6 rings) contributed to 59-90% of the total PAHs concentrations. Benzo(a)pyrene (BaP) had the highest toxic equivalence quotient (up to 188 ng TEQ/g). Moreover, the downstream sediments contained higher TEQ of total TPHs than midstream and upstream sediment samples. The PAHs were adsorbed onto the fine particles with high organic content. Results from diagnostic ratio analyses indicate that the PAHs in two urban river sediments might originate from oil/coal combustion, traffic-related emissions, and waste combustion (pyrogenic activities). Future pollution prevention and management should target the various industries, incinerators, and transportation emission in this region to reduce the PAHs pollution.

A prospective interventional study to examine the effect of a silver alloy and hydrogel-coated catheter on the incidence of catheter-associated urinary tract infection.

INTRODUCTION: Catheter-associated urinary tract infection is a major hospital-acquired infection. This study aimed to analyse the effect of a silver alloy and hydrogel-coated catheter on the occurrence of catheter-associated urinary tract infection. METHODS: This was a 1-year prospective study conducted at a single centre in Hong Kong. Adult patients with an indwelling urinary catheter for longer than 24 hours were recruited. The incidence of catheter-associated urinary tract infection in patients with a conventional latex Foley catheter without hydrogel was compared with that in patients with a silver alloy and hydrogel-coated catheter. The most recent definition of urinary tract infection was based on the latest surveillance definition of the National Healthcare Safety Network managed by Centers for Disease Control and Prevention. RESULTS: A total of 306 patients were recruited with a similar ratio between males and females. The mean (standard deviation) age was 81.1 (10.5) years. The total numbers of catheter-days were 4352 and 7474 in the silver-coated and conventional groups, respectively. The incidences of catheter-associated urinary tract infection per 1000 catheter-days were 6.4 and 9.4, respectively (P=0.095). There was a 31% reduction in the incidence of catheter-associated urinary tract infection per 1000 catheter-days in the silver-coated group. Escherichia coli was the most commonly involved pathogen (36.7%) of all cases. Subgroup analysis revealed that the protective effect of silver-coated catheter was more pronounced in long-term users as well as female patients with a respective 48% (P=0.027) and 42% (P=0.108) reduction in incidence of catheter-associated urinary tract infection. The mean catheterisation time per person was the longest in patients using a silver-coated catheter (17.0 days) compared with those using a conventional (10.8 days) or both types of catheter (13.6 days) [P=0.01]. CONCLUSIONS: Silver alloy and hydrogel-coated catheters appear to be effective in preventing catheter-associated urinary tract infection based on the latest surveillance definition. The effect is perhaps more prominent in long-term users and female patients.

A hospital-wide screening programme to control an outbreak of vancomycin-resistant enterococci in a large tertiary hospital in Hong Kong.

INTRODUCTION: Apart from individual small-scale outbreaks, infections with vancomycin-resistant enterococci are uncommon in Hong Kong. A major outbreak of vancomycin-resistant enterococci, however, occurred at a large tertiary hospital in 2013. We describe the successful control of this outbreak and share the lessons learned. METHODS: In 2013, there was an abnormal increase in the incidence of vancomycin-resistant enterococci carriage compared with baseline in multiple clinical departments at Queen Elizabeth Hospital. A multipronged approach was adopted that included a 10-week hospital-wide active screening programme, which aimed to identify and isolate hidden vancomycin-resistant enterococci carriers among all in-patients. The identified carriers were completely segregated in designated wards where applicable. Other critical infection control measures included directly observed hand hygiene and environmental hygiene. A transparent and open disclosure approach was adopted throughout the outbreak. RESULTS: The infection control measures were successfully implemented. The active screening of vancomycin-resistant enterococci was conducted between 30 September and 10 November 2013. A total of 7053 rectal swabs were collected from patients in 46 hospital wards from 11 departments. The overall carriage rate of vancomycin-resistant enterococci was 2.8% (201/7053). Pulsed-field gel electrophoresis showed a predominant outbreak clone. We curbed the outbreak and kept the colonisation of vancomycin-resistant enterococci among patients at a pre-upsurge low level. CONCLUSIONS: We report the largest cohesive effort to control spread of vancomycin-resistant enterococci in Hong Kong. Coupled with other infection control measures, we successfully controlled vancomycin-resistant enterococci to the pre-outbreak level. We have demonstrated that the monumental tasks can be achieved with meticulous planning, and thorough communication and understanding between all stakeholders.

Treatment and outcomes for primary cutaneous extramedullary plasmacytoma: a case series.

BACKGROUND: Primary cutaneous plasmacytoma (pcp) is a rare disease, with few studies to guide therapy. Our primary study objective was to define treatments used for pcp; a secondary objective was to describe outcomes of patients, including disease recurrence and death. METHODS: An institutional cancer registry was used to identify cases for retrospective chart review. In a systematic review, treatments for, and outcomes of, all known cases of pcp were described. RESULTS: Three eligible cases identified at our institution; each patient had a solitary pcp. The systematic review identified 66 patients. Radiotherapy was the most commonly used primary treatment modality (31% of all patients; 42% for patients with solitary lesions), followed by surgery (28% of all patients; 36% for patients with solitary lesions). Median survival for all patients was 10.4 years [95% ci: 4.3 years to not reached], with a trend toward a decreased risk of death with solitary lesions compared with multiple lesions (hazard ratio: 0.37; 95% ci: 0.13 to 1.08; p = 0.059). For patients with solitary lesions, the median and recurrence-free survivals were, respectively, 17.0 years (95% ci: 1.7 years to not reached) and 11.0 years (95% ci: 2 years to not reached); for patients with multiple lesions, they were 4.3 years (95% ci: 1.3 to not reached) and 1.4 years (95% ci: 0.6 years to not reached). Disease recurrence, including progression to multiple myeloma, was the most common cause of death. CONCLUSIONS: Compared with patients having multiple pcp lesions, those presenting with a single pcp lesion might experience longer overall survival. Local therapy (radiation or surgery) is a reasonable curative treatment for a solitary pcp lesion.

Survival outcomes in elderly patients with glioblastoma.

AIMS: Many elderly glioblastoma patients are excluded from randomised trials due to age, comorbidity or poor functional status. The purpose of this study was to describe the survival outcomes in all elderly patients with glioblastoma managed at a tertiary cancer centre. MATERIALS AND METHODS: A retrospective chart review identified 235 elderly patients (age 65 years or over) with a histological diagnosis of glioblastoma between 1 December 2006 and 31 December 2013. The primary outcome of this study was overall survival by treatment type. Univariate and multivariate Cox proportional hazard models were used to explore significant prognostic variables associated with overall survival. RESULTS: The median survival for all patients was 6.5 months (95% confidence interval 5.3-7.7), with 1 year overall survival of 23.7% (95% confidence interval 18.8-30.0). The median survival for patients treated with radiation and chemotherapy was 11.1 months (95% confidence interval 8.1-13.7). Patients treated with radiation alone had a median survival of 6.8 months (95% confidence interval 5.6-7.9). For patients managed with comfort measures only, the median survival was 1.9 months (95% confidence interval 1.6-2.6). Univariate analysis revealed age, performance status, surgery type (biopsy, subtotal resection, gross total resection) and type of treatment received (comfort measures only, radiotherapy alone, radiotherapy and chemotherapy) to be statistically associated with overall survival. In the multivariate analysis, only two predictive factors (treatment received and surgery type) were significant. CONCLUSIONS: Elderly patients with glioblastoma selected for treatment (surgery followed by radiation alone or radiation and chemotherapy) survive longer than patients managed with comfort measures. Prospective randomised trials will help guide management for patients eligible for therapy. Elderly patients with glioblastoma who are deemed not eligible for active therapy have very short survival.

Importance of early detection of vancomycin-resistant subpopulations in apparently susceptible meticillin-resistant Staphylococcus aureus clinical isolates.

This study aimed to investigate the presence of vancomycin-non-susceptible subpopulations in apparently susceptible meticillin-resistant Staphylococcus aureus (MRSA) and the ability of these isolates to develop into homogeneously resistant strains. Vancomycin MICs of 200 clinical MRSA isolates were determined using agar dilution (AD) and spiral gradient endpoint (SGE) technique. Isolates with an MIC≤2mg/L but displaying subpopulations with an MIC>2mg/L by SGE were re-tested by Etest and PAP-AUC and were incubated with 2mg/L vancomycin for 2 weeks. MIC testing was repeated weekly by AD, Etest and SGE to observe progression to non-susceptibility. A total of 17.5% and 16.0% of isolates were non-susceptible to vancomycin (MIC>2mg/L) by SGE and AD, respectively. Eight isolates (4%) displayed a resistant subpopulation; five met the definition of hVISA by PAP-AUC. The initial Etest MIC for these isolates was 2mg/L, but resistant subpopulations were observed in only three isolates on prolonged incubation. MICs of all eight isolates increased rapidly in the presence of vancomycin, reaching ≥3.0mg/L by Day 7 and ≥4mg/L after 14 days by all three methods. The prevalence of vancomycin-non-susceptible MRSA was high, and non-susceptibility developed rapidly in seemingly susceptible isolates with covert subpopulations. These were effectively detected by SGE. With increasing reports of vancomycin clinical failure, early detection of potentially non-susceptible isolates before or early in vancomycin therapy is essential to avoid further resistance development and poor clinical outcomes. SGE offers a novel and cost-effective technique for detection of potentially non-susceptible strains.

Translation and validation of the Chinese version of the short Warwick-Edinburgh Mental Well-being Scale for patients with mental illness in Hong Kong.

OBJECTIVE: Quality of life outcomes are useful in the assessment of mental and social wellbeing and for informed health care decision-making, especially in the choice of interventions in psychiatric rehabilitation. In its original form, the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) is a proven reliable and valid tool for assessing quality of life in normal adults, but not in adults from Asian countries. A shortened 7-item version of WEMWBS (SWEMWBS) with good internal construct validity was used for this study. The present study describes the translation of WEMWBS from English to Chinese and its validation in a sample of Chinese-speaking patient population. METHODS: Participants included patients admitted to the inpatient units, and those attending the day hospital and outpatient units of the Kowloon Hospital (n = 126). Translation was performed using the multiple forward and backward translation protocol. Patients also completed the 5-item World Health Organization Well-being Index (WHO5) questionnaire. A case therapist completed the Brief Psychiatric Rating Scale within 2 days. A total of 20 patients were selected for test-retest measurements performed after 2 weeks. RESULTS: The sample displayed a normal distribution of the Chinese version of SWEMWBS (C-SWEMWBS) scores (mean ± standard deviation, 23.16 ± 5.39; skewness, -0.068; kurtosis, -0.355). Internal reliability coefficient (Cronbach's alpha) for C-SWEMWBS was 0.89 which was consistent with that of English version. The corrected item-total correlation was high with Spearman's rank correlation coefficients ranging from 0.57 (item 6) to 0.75 (item 5). Good test-retest reliability was observed (r = 0.677; p = 0.001). Principal components factor analysis identified a single component (eigenvalues, 4.28; 61.1% variance), similar to the English version. Scores of C-SWEMWBS were positively correlated with the scores of WHO5 (r = 0.49; p < 0.001), suggesting good concurrent validity. Few item scores including 'feeling useful', 'dealing with problems well', 'able to make decisions', and the total score were significantly correlated with diagnostic groups (p < 0.05). Education and diagnosis of mental illness were valid predictors for C-SWEMWBS (F = 5.41; p = 0.01). There were no effects due to age and gender. CONCLUSION: The C-SWEMWBS showed high levels of internal consistency and reliability against accepted criteria. It is short, acceptable, and culturally meaningful to clients with mental illness. Further large-scale studies in normal subjects and varied patient groups are recommended to generalise the findings.

Antimicrobial susceptibility in hospitals in Hong Kong: The current status 2009-2011.

Hospitals in Hong Kong, like many hospitals in the world, are constantly challenged by the increasing rate of non-susceptible and multidrug-resistant organisms (MDROs). Accurate and timely surveillance is essential for effective control. The Hospital Authority of Hong Kong has developed a comprehensive antimicrobial susceptibility monitoring system that utilises data obtained from all of its 38 hospitals. In this review, the susceptibility pattern of more than 320000 isolates covering the period 2009-2011 will be discussed. Special attention will be paid to MDROs.

An anti-glitch in a magnetar.

Magnetars are neutron stars with X-ray and soft γ-ray outbursts thought to be powered by intense internal magnetic fields. Like conventional neutron stars in the form of radio pulsars, magnetars exhibit 'glitches' during which angular momentum is believed to be transferred between the solid outer crust and the superfluid component of the inner crust. The several hundred observed glitches in radio pulsars and magnetars have involved a sudden spin-up (increase in the angular velocity) of the star, presumably because the interior superfluid was rotating faster than the crust. Here we report X-ray timing observations of the magnetar 1E 2259+586 (ref. 8), which exhibited a clear 'anti-glitch'--a sudden spin-down. We show that this event, like some previous magnetar spin-up glitches, was accompanied by multiple X-ray radiative changes and a significant spin-down rate change. Such behaviour is not predicted by models of neutron star spin-down and, if of internal origin, is suggestive of differential rotation in the magnetar, supporting the need for a rethinking of glitch theory for all neutron stars.