Long-range air dispersion of Candida auris in a cardiothoracic unit outbreak in Hong Kong.

BACKGROUND: Nosocomial outbreaks of Candida auris, a multidrug-resistant fungus, are increasingly reported worldwide; the mode of transmission has usually been reported to be via direct contact. Some studies previously suggested potential short-distance air dispersal during high-turbulence activities, but evidence on long-range air dispersal remains scarce. AIM: To describe a C. auris nosocomial outbreak involving two wards (H7, 5E) in two local hospitals. METHODS: Samples were taken from patients, ward surfaces (frequently touched items and non-reachable surfaces) while settle plates were used for passive air sampling to investigate possible contributions by direct contact and air dispersal. Epidemiological and phylogenetic analyses were also performed on the C. auris isolates from this outbreak. FINDINGS: Eighteen patients were confirmed to have asymptomatic C. auris skin colonization. C. auris was expectedly identified in samplings from frequently touched ward items but was also isolated in two samples from ceiling supply air grilles which were 2.4 m high and inaccessible by patients. Moreover, one sample from a corridor return air grille as far as 9.8 m away from the C. auris cohort area was also positive. Two passive air samplings were positive, including one from a cubicle with no confirmed cases for four days, suggesting possible air dispersal of C. auris. Whole-genome sequencing confirmed clonality of air, environment, and patients' isolates. CONCLUSION: This is the first study to demonstrate potential long-range air dispersal of C. auris in an open-cubicle ward setting. Ventilation precautions and decontamination of out-of-reach high-level surfaces should be considered in C. auris outbreak management.

Search for the Pair Production of Dark Particles X with K_{L}

We present the first search for the pair production of dark particles X via K_{L}^{0}→XX with X decaying into two photons using the data collected by the KOTO experiment. No signal was observed in the mass range of 40-110 MeV/c^{2} and 210-240 MeV/c^{2}. This sets upper limits on the branching fractions as B(K_{L}^{0}→XX)<(1-4)×10^{-7} and B(K_{L}^{0}→XX)<(1-2)×10^{-6} at the 90% confidence level for the two mass regions, respectively.

Impact of replacing or adding pregnancy-associated plasma protein-A at 11-13 weeks on screening for preterm pre-eclampsia.

OBJECTIVE: To assess whether pregnancy-associated plasma protein-A (PAPP-A) alters or provides equivalent screening performance as placental growth factor (PlGF) when screening for preterm pre-eclampsia (PE) at 11-13 weeks of gestation. METHODS: This was a secondary analysis of a non-intervention screening study of 6546 singleton pregnancies that were screened prospectively for preterm PE in the first trimester between December 2016 and June 2018. Patient-specific risks for preterm PE were estimated by maternal history, mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), PlGF and PAPP-A. A competing-risks model with biomarkers expressed as multiples of the median was used. All women and clinicians were blinded to the risk for preterm PE. The performance of screening for preterm PE using PlGF vs PAPP-A vs both PAPP-A and PlGF was assessed by comparing areas under the receiver-operating-characteristics (AUC) curves. McNemar's test was used to compare detection rate at a fixed false-positive rate (FPR) of 10%. RESULTS: PlGF and PAPP-A were measured in 6546 women, of whom 37 developed preterm PE. The AUC and detection rate at 10% FPR using PlGF in combination with maternal history, MAP and UtA-PI were 0.854 and 59.46%, respectively. The respective values were 0.813 and 51.35% when replacing PlGF with PAPP-A and 0.855 and 59.46% when using both PAPP-A and PlGF. Statistically non-significant differences were noted in AUC when replacing PlGF with PAPP-A (ΔAUC, 0.04; P = 0.095) and when using both PAPP-A and PlGF (ΔAUC, 0.002; P = 0.423). However, on an individual case basis, screening using PlGF in conjunction with maternal history, MAP and UtA-PI identified three (8.1%) additional pregnancies that developed preterm PE and that were not identified when replacing PlGF with PAPP-A. Screening using PAPP-A in addition to maternal history and other biomarkers did not identify any additional pregnancies. CONCLUSION: On an individual case basis, adoption of a screening strategy that uses PAPP-A instead of PlGF results in reduced detection of preterm PE, consistent with previous literature. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Challenges in the Ethical Review of Clinical and Biomedical Research in Malaysia: A Mixed Methods Study.

Empirical evidence of the ethical review of clinical and biomedical research in Malaysia is limited. We have conducted a convergent mixed methods research, which comprises an online survey and semistructured interviews to examine the challenges in the ethical review of clinical and biomedical research. Data collected reveal that the ethics review process is inconsistent, duplicate, and inadequate. The results indicate a strong need for a centralized ethical review mechanism and a national system for mutual recognition of ethics reviews to improve the effectiveness and efficiency of the ethics review system in Malaysia. A joint research ethics committee review between Malaysia and sponsoring countries for multinational research should also be encouraged as it could address the concerns of the lack of expertise and training.

Outcome of radiofrequency ablation for selective fetal reduction before vs at or after 16 gestational weeks in complicated monochorionic pregnancy.

OBJECTIVE: To investigate whether gestational age at intervention (< or ≥ 16 weeks) and other factors affect the risk of loss of the cotwin after selective fetal reduction using radiofrequency ablation (RFA) in monochorionic (MC) pregnancy. METHODS: This was a single-center retrospective analysis of 63 consecutive RFA procedures performed at our institution from January 2011 to October 2019 for selective fetal reduction in complicated MC pregnancies. Indications for RFA were twin reversed arterial perfusion sequence (13 cases), twin-to-twin transfusion syndrome (12 cases), twin anemia-polycythemia sequence (two cases), selective fetal growth restriction (10 cases), discordant anomalies (17 cases) and multifetal pregnancy reduction in triplets or quadruplets with a MC pair (nine cases). Twenty-six (41.3%) of these procedures were performed before and 37 (58.7%) after 16 weeks. Potential factors that could affect the risk of loss of the cotwin, including gestational age at RFA, order of multiple pregnancy, amnionicity, indication for RFA and number of ablation cycles, were assessed first by univariate analysis and then by multivariate analysis. RESULTS: There were 17 (27.0%) cotwin losses. Ablation cycles numbering four or more was the only factor among those investigated to be associated with loss of the cotwin after RFA (P = 0.035; odds ratio, 5.21), while the indication for RFA, order of multiple pregnancy, amnionicity and gestational age at RFA had no effect. Comparing RFA performed at < 16 vs ≥ 16 weeks, there was no difference in the rate of cotwin loss (23.1% vs 29.7%; P = 0.558) or preterm prelabor rupture of the membranes before 34 weeks (7.7% vs 5.4%; P = 0.853), or in the median gestational age at delivery (36.2 vs 37.3 weeks; P = 0.706). CONCLUSIONS: RFA is a promising tool for early selective fetal reduction in MC pregnancy before 16 weeks. Four or more ablation cycles is a major risk factor for cotwin loss. Careful assessment pre- and post-RFA, together with proficient operative skills to minimize the number of ablation cycles, are the mainstay to ensure that this procedure is effective and safe. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Transvaginal three-dimensional ultrasound assessment of Sylvian fissures at 18-30 weeks' gestation.

OBJECTIVE: To (1) evaluate the normal development of the Sylvian fissures in the anterior coronal view of the fetal brain at 18-30 weeks' gestation by transvaginal three-dimensional (3D) ultrasound, (2) develop reference ranges of measurements of the right and left Sylvian fissure angles during normal pregnancy at 18-30 weeks' gestation, and (3) examine intra- and interobserver repeatability of measurements of the right and left Sylvian fissure angles. METHODS: This was a prospective cross-sectional study of 422 women with a singleton pregnancy attending an ultrasound-based research clinic between March and December 2017. The entry criteria for the study were appropriately grown live fetus with no suspected structural and/or chromosomal defects between 18 + 0 and 30 + 6 weeks' gestation. Normal development of the Sylvian fissures was assessed in the anterior coronal plane of the fetal brain using transvaginal 3D volume multiplanar imaging. The coronal view was visualized as a single image from the three orthogonal views. Subsequently, the right and left Sylvian fissure angles were measured between a horizontal reference line (0°) and a line drawn along the upper side of the respective Sylvian fissure. Intra- and interobserver repeatability of the Sylvian fissure angle measurements was assessed by Bland-Altman plots. Reference equations were constructed for right and left Sylvian fissure angles for gestational age (GA) and head circumference (HC) using the Generalized Additive Models for Location Scale and Shape package. RESULTS: In the anterior coronal view of the fetal brain, an inward rotation of the upper portion of the Sylvian fissures was observed during the second and third trimesters of pregnancy. There was a significant negative polynomial association between the Sylvian fissure angles and GA and HC. Both Sylvian fissure angles crossed the reference line (zero), going from positive to negative, at around 25 weeks' gestation or at HC of 22 cm. Z-score difference between the smoothed percentiles of the right and left Sylvian fissure angles indicated that median, 10th and 90th smoothed percentiles were closest and almost the same for the GA-based references between 18 and 28 weeks and for the HC-based references between 14 and 24 cm. The intraclass correlation coefficient of the right and left Sylvian fissure angle measurements between the two sonographers was excellent at 0.993 (95% CI, 0.988-0.996) and 0.991 (95% CI, 0.985-0.995), respectively. On Bland-Altman analysis, the mean difference between the two sonographers in right Sylvian fissure angle measurement was 0.4° (95% CI, -10.2 to 10.1°) and in left Sylvian fissure angle it was 1.0° (95% CI, -9.6 to 11.6°). CONCLUSIONS: Assessment of the Sylvian fissure angles is highly reproducible. Sylvian fissure angle reference charts can serve as a screening tool for malformations of cortical development, guiding subsequent follow-up and referral for fetal brain magnetic resonance imaging and/or assessment by an expert neurosonologist. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Search for the rare decays K(L)→π0π0µ+µ- and K(L)→π0π0X0→π0π0µ+µ-.

The KTeV E799 experiment has conducted a search for the rare decays, K(L)→π(0)π(0)µ(+)µ(-) and K(L)→π(0)π(0)X(0)→π(0)π(0)µ(+)µ(-), where the X(0) is a possible new neutral boson that was reported by the HyperCP experiment with a mass of (214.3 ± 0.5) MeV/c(2). We find no evidence for either decay. We obtain upper limits of Br(K(L)→π(0)π(0)X(0)→π(0)π(0)µ(+)µ(-)) < 1.0 × 10(-10) and Br(K(L)→π(0)π(0)µ(+)µ(-)) < 9.2 × 10(-11) at the 90% confidence level. This result rules out the pseudoscalar X(0) as an explanation of the HyperCP result under the scenario that the dsX(0) coupling is completely real.

Real-time three-dimensional ultrasound with Live xPlane imaging assists first-trimester acquisition of a true midsagittal section.

OBJECTIVE: To determine whether real-time three-dimensional (3D) ultrasound with Live xPlane imaging, which enables the simultaneous display of two real-time high-quality image planes, can assist both operators certified by The Fetal Medicine Foundation (FMF) and non-FMF-certified operators in acquiring a true midsagittal plane in the first trimester. METHODS: Eight operators, four of them FMF certified (FMF group) and the other four not (non-FMF group), were asked to acquire a fetal image that they believed to represent the true midsagittal plane using real-time 3D ultrasound with Live xPlane imaging as guidance. Each operator was asked to obtain such an image five times from each of five patients. A total of 200 images from 40 patients were obtained and stored for subsequent analysis. All pregnancies were between 11 + 0 and 13 + 6 weeks of gestation. The angle between the falx cerebri and vertical axis (angle of deviation) was then measured by a single operator. A true midsagittal section was defined as an angle of deviation equal to 0 degrees. The angle of deviation and the time taken to acquire each image were compared between FMF and non-FMF groups. RESULTS: The median angle of deviation for each operator ranged from 1.2 degrees to 3.4 degrees. There was no significant difference in this angle between those who were FMF certified and those who were not (2.0 degrees vs. 2.2 degrees, P = 0.463). The interquartile range of the angle of deviation was also similar between the FMF- and non-FMF-certified operators. Although the time taken for image acquisition was longer among the non-FMF-certified operators (median, 45.5 s vs. 32.0 s), this difference did not reach statistical significance (P = 0.107). CONCLUSION: Live xPlane imaging can provide a tool to assist the acquisition of a true midsagittal plane and to determine how true a 'midsagittal' plane really is.

Real-time three-dimensional echocardiography using a matrix probe with live xPlane imaging of the interventricular septum.

OBJECTIVE: To describe a technique to rapidly visualize the in-plane view of the fetal interventricular septum (IVS) to enable the identification of a ventricular septal defect (VSD). METHODS: One hundred and fifty-one women were invited to participate after their routine fetal morphology scan, including four suspected to have congenital cardiac defects which were confirmed postnatally. A standard examination protocol using real-time three-dimensional (3D) echocardiography with live xPlane imaging was developed. The ability of this new technology to examine the ventricular septum was investigated. RESULTS: The in-plane view of the fetal IVS was visualized successfully in 150 (99.3%) cases by real-time 3D echocardiography with live xPlane imaging, including 82 (54.3%) cases with the spine posterior and 68 (45.7%) cases with the spine anterior. The in-plane view of the IVS successfully visualized the VSDs in three fetuses with VSD and displayed the intact IVS in one fetus with transposition of the great arteries without VSD. CONCLUSION: We describe live xPlane imaging, a simple method for the real-time assessment of the in-plane view of the IVS that has the potential to enhance the diagnostic accuracy of fetal cardiac examination.

Enhanced biological phosphorus removal in the retrofitting from an anoxic selector to an anaerobic selector in a full-scale activated sludge process in Singapore.

This paper presents the investigation results of retrofitting an anoxic selector to an anaerobic selector through stepwise reduction of air supply in a full-scale activated sludge process with a focus on enhanced biological phosphorus removal (EBPR). The process experienced gradual shift from a Ludzack-Ettinger (LE) to an anaerobic-anoxic-oxic (A(2)O) process and subsequently, an anaerobic-oxic (A/O) process. The major findings are: (i) the average influent-based PO(4) (3-)-P release in the anaerobic selector compartment was 16.3 mg P l(-1) and that in the secondary clarifier was 1.7 mg P l(-1). 75% of the SCOD and 93% of the acetic acid in the primary effluent were taken up in the anaerobic selector compartment, respectively; (ii) PO(4) (3-)-P uptake contributed by both aerobic and denitrifying phosphorus accumulating organisms (DPAOs) occurred mainly in the first and second aerobic lanes together with simultaneous nitrification and denitrification (SND) while there was not much contribution from the last aerobic lane; (iii) The average PO(4) (3-)-P concentration of the final effluent was 2.4 mg P l(-1) corresponding to a removal efficiency of 85%; (iv) the SVI was satisfactory after retrofitting; and (v) the increase of NH(4) (+)-N in the final effluent from the commencement to the completion of the retrofitting resulted in an approximate 40-50% reduction in oxygen demand and a significant aeration energy saving was achieved.

How true is a 'true' midsagittal section?

OBJECTIVES: To study the deviation of presumed midsagittal sections of the fetal head from the true image plane, to compare whether certification (by The Fetal Medicine Foundation (FMF), UK) has an effect on the degree of this deviation, and to investigate the impact of imperfect midsagittal sections on nuchal translucency thickness (NT) measurement. METHODS: Eight sonographers, four of them FMF-certified (Group A) and the other four not (Group B), were asked to obtain image sections which they believed to represent true midsagittal sections of the fetal head and neck in five patients each. Three-dimensional volume datasets were acquired for subsequent analysis. The angle between the falx cerebri and the vertical axis was measured and the effect of this angle on NT measurement was assessed. RESULTS: The mean angle of deviation was significantly lower among those who were FMF-certified (5.7 degrees vs. 14.7 degrees, P < 0.001). The 1.8% underestimation of NT by Group A was not statistically significant (P = 0.76), while in Group B the NT could not be measured when the angle of deviation was 14.7 degrees. CONCLUSIONS: FMF-certified operators obtain a better midsagittal section compared with non-certified operators. The minor deviation from the true midsagittal section by certified operators has no significant effect on the value of NT measurement. This study could provide a model for operator training and auditing.

Search for lepton-flavor-violating decays of the neutral kaon.

The Fermilab KTeV experiment has searched for lepton-flavor-violating decays of the K(L) meson in three decay modes. We observe no events in the signal region for any of the modes studied, and we set the following upper limits for their branching ratios at the 90% C.L.: BR(K(L) --> pi(0) micro(+/-) e(-/+)) <7.6 x 10(-11); BR(K(L) --> pi(0)pi(0) micro(+/-) e(-/+)) <1.7 x 10(-10); BR(pi(0) --> micro(+/-) e(-/+)) <3.6 x 10(-10). This result represents a factor of 82 improvement in the branching ratio limit for K(L) --> pi(0) micro(+/-) e(-/+) and is the first reported limit for K(L) --> pi(0)pi(0) micro(+/-) e(-/+).

Determination of the parity of the neutral pion via its four-electron decay.

We present a new determination of the parity of the neutral pion via the double Dalitz decay pi0-->e+e-e+e-. Our sample, which consists of 30,511 candidate decays, was collected from KL-->pi0pi0pi0 decays in flight at the KTeV-E799 experiment at Fermi National Accelerator Laboratory. We confirm the negative pi0 parity and place a limit on scalar contributions to the pi0-->e+e-e+e- decay amplitude of less than 3.3% assuming CPT conservation. The pi0gamma*gamma* form factor is well described by a momentum-dependent model with a slope parameter fit to the final state phase-space distribution. Additionally, we have measured the branching ratio of this mode to be B(pi0-->e+e-e+e-)=(3.26+/-0.18)x10(-5).

Measurements of the decay KL-->e+ e- gamma.

The E799-II (KTeV) experiment at Fermilab has collected 83 262 K(L)-->e+ e- gamma(gamma) events above a background of 79 events. We measure a decay width, normalized to the K(L)-->pi0pi0pi(D)0 (pi0-->gammagamma, pi0-->gammagamma, pi(D0-->e+ e- gamma(gamma)) decay width, of Gamma(K(L)-->e+e-gamma(gamma))/Gamma(K(L)-->pi0pi0pi(D)0)=(1.3302+/-0.0046(stat)+/-0.0102(syst)) x 10(-3). We also measure parameters of two K(L)gamma*gamma form factor models. In the Bergström-Massó-Singer parametrization, we find Calpha(K*)= -0.517 +/- 0.030(stat) +/- 0.022(syst). We separately fit for the first parameter of the D'Ambrosio-Isidori-Portolés model and find alpha(DIP)= -1.729 +/- 0.043(stat) +/- 0.028(syst).

First observation of K{L}-->pi{+/-}e{-/+}nue{+}e{-}.

This Letter is the first report of the K{L}-->pi{+/-}e{-/+}nue{+}e{-} decay. Based on 19 208+/-144 events, we determine the branching fraction, B(K{L}-->pi{+/-}e{-/+}nue{+}e{-}M_{e{+}e{-}}>5 MeV/c{2},E{e{+}e{-}}{*}>30 MeV)=(1.285+/-0.041)x10{-5}, and Gamma(K{e3ee}M{e{+}e{-}}>5 MeV/c{2})/Gamma(K{e3})=[4.57+/-0.04(stat)+/-0.14(syst)]x10{-5}. This ratio agrees with a theoretical prediction based on chiral perturbation theory (ChPT) calculated to O(p{4}). The measured kinematical distributions agree with those predicted by just ChPT O(p{4}), but show significant disagreement with ones predicted by leading-order ChPT.

Analysis of phosphorus removal and anaerobic selector performance in a full-scale activated sludge process in Singapore.

This paper analyses the performance of the anaerobic selector (A/O process) in a full-scale activated sludge process receiving mostly industrial sewage discharge (> 60%) in Singapore. In addition to the sludge settleability, enhanced biological phosphorus removal (EBPR) was studied. The sludge volume index (SVI) reduced from 200 to 80 ml g(-1) and foaming was suppressed significantly, indicating the effectiveness of the anaerobic selector in improving sludge settleability. The phosphorus removal efficiency was 66%, and 7.5 mg HAc-COD was consumed per mg PO4(3-) -P removed. In the anaerobic compartment, 31% of the SCOD and 73% of the acetic acid in the settled sewage were removed with PO4(3-) -P release of 14.1 mg PO4(3-)-P l(-1). The linear correlation between PO4(3-) -P release in the anaerobic compartment and PO4(3-) -P uptake in the aerobic compartment indicates that there is about 0.8 mg PO4(3-) -P release in the anaerobic compartment per mg PO34(3-) -P uptake in the aerobic compartment. The fates of volatile fatty acids (VFAs) and its short chain acids (SCAs) in the process were studied and discussed.

Measurement of the K0 charge radius and a CP-violating asymmetry and a search for CP-violating E1 direct photon emission in the rare decay KL--> pi+ pi- e+ e-.

Using the complete KTeV data set of 5,241 candidate K(L)--> pi(+) pi(-) e(+) e(-) decays (including an estimated background of 204 +/- 14 events), we have measured the coupling g(CR)= 0.163 +/- 0.0149(stat) +/- 0.023(syst) of the CP conserving charge radius process and from it determined a K(0) charge radius of = [-0.077 +/- 0.007(stat) +/- 0.011(syst)]fm(2). We have determined a first experimental upper limit of 0.04 (90% C.L.) /g(e1)/ / /g(M1)/ of the couplings for the E1 and M1 direct photon emission processes. We also report the measurement of /g(M1)/ including a vector form factor /g(M1)/(1 + (a(1)/a(2))/((M(2)(p)-(M(2)(k))= 2M(K)E(gamma*)), where vector /g(M1)/= 1.11+/- 0.12(stat) +/- 0.08(syst) and a(1)/a(2) = [-0.744 +/- 0.027(stat) +/- 0.032(syst)] GeV(2)/c(2). Finally, a CP-violating asymmetry of [13.6 +/- 1.4(stat) +/- 1.5(syst)]% in the CP and T odd angle phi between the decay planes of the e(+) e(-) and pi(+) pi(-) pairs in the K(L) center of mass is reported.