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Published on 19.12.2019 in Vol 8, No 12 (2019): December
Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/14574, first published May 02, 2019 .
Quantification of Airborne Resistant Organisms With Temporal and Spatial Diversity in Bangladesh: Protocol for a Cross-Sectional Study
Muhammad Asaduzzaman 1, 2, 3 ; Muhammed Iqbal Hossain 1 ; Sumita Rani Saha 1 ; Md Rayhanul Islam 1 ; Niyaz Ahmed 1, 4 ; Mohammad Aminul Islam 1, 5
Article Authors Cited by (2) Tweetations (6) Metrics
Muhammad Asaduzzaman1,2,3, MBBS, MPH, MPhil ;
Muhammed Iqbal Hossain1, MSc ;
Sumita Rani Saha1, MSc ;
Md Rayhanul Islam1, MSc ;
Niyaz Ahmed1,4, PhD ;
Mohammad Aminul Islam1,5, PhD
1Laboratory Sciences and Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
2School of Public Health, University of California, Berkeley, CA, United States
3Centre for Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
4Pathogen Biology Laboratory, Department of Biotechnology and Bioinformatics, School of Life Sciences, University of Hyderabad, Hyderabad, India
5Paul G Allen School for Global Animal Health, College of Veterinary Medicine, Washington State University, Pullman, WA, United States
Corresponding Author:
Muhammad Asaduzzaman, MBBS, MPH, MPhil
Laboratory Sciences and Services Division
International Centre for Diarrhoeal Disease Research, Bangladesh
68 Shaheed Tajuddin Sarani, Mohakhali
Dhaka, 1212
Phone: 880 1712564702
Email: asaduzzaman@icddrb.org
Background: Antimicrobial resistance is a widespread, alarming issue in global health and a significant contributor to human death and illness, especially in low and middle-income countries like Bangladesh. Despite extensive work conducted in environmental settings, there is a scarcity of knowledge about the presence of resistant organisms in the air.
Objective: The objective of this protocol is to quantify and characterize the airborne resistomes in Bangladesh, which will be a guide to identify high-risk environments for multidrug-resistant pathogens with their spatiotemporal diversity.
Methods: This is a cross-sectional study with an environmental, systematic, and grid sampling strategy focused on collecting air samples from different outdoor environments during the dry and wet seasons. The four environmental compartments are the frequent human exposure sites in both urban and rural settings: urban residential areas (n=20), live bird markets (n=20), rural households (n=20), and poultry farms (n=20). We obtained air samples from 80 locations in two seasons by using an active microbial air sampler. From each location, five air samples were collected in different media to yield the total bacterial count of 3rd generation cephalosporin (3GC) resistant Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, vancomycin-resistant Enterococci and methicillin-resistant Staphylococcus aureus.
Results: The study started in January 2018, and the collection of air samples was completed in November 2018. We have received 800 air samples from 80 study locations in both dry and wet seasons. Currently, the laboratory analysis is ongoing, and we expect to receive the preliminary results by October 2019. We will publish the complete result as soon as we clean and analyze the data and draft the manuscript.
Conclusions: The existence of resistant bacteria in the air like those producing extended-spectrum beta-lactamases, carbapenem-resistant Enterobacteriaceae, vancomycin-resistant Enterococci, and methicillin-resistant Staphylococcus aureus will justify our hypothesis that the outdoor environment (air) in Bangladesh acts as a reservoir for bacteria that carry genes conferring resistance to antibiotics. To our knowledge, this is the first study to explore the presence of superbugs in the air in commonly exposed areas in Bangladesh.
International Registered Report Identifier (IRRID): DERR1-10.2196/14574
JMIR Res Protoc 2019;8(12):e14574
doi:10.2196/14574
antimicrobial resistance; airborne resistomes; air quality; global health; planetary health; environmental risk assessment
Antimicrobial resistance is considered a rapidly progressive global public health issue with the potential of environmental transmission to a larger extent. However, very little information is available on the transmission of antimicrobial resistance through the air. Additionally, the capacity to carry and propagate resistance of these resistomes is poorly studied worldwide. There is a recognized need to examine the existence of such bacteria that have the ability to confer resistance through atmospheric air. Bangladesh is an important location to study this pathway. This study can provide critical insight into antimicrobial resistance transmission and help determine where efforts could be implemented to reduce environmental transmission.
Antimicrobial resistance is a widespread and alarming issue in global health, causing more than 700,000 deaths every year [1]. In Bangladesh, the insufficient and poor guidelines for the disposal of antibiotic residues into the environment from pharmaceuticals or clinical settings and the high population density have made its environment favorable for the wide dissemination of antimicrobial resistance. In addition to use in human therapy, antibiotics are used extensively in animal farming and eventually, a large amount of antibiotics and their residues are disseminated into the environment through both air and water [2]. Again, environmental contamination with human and animal-originated bacteria contributes significantly to the mechanism of development of extensive antimicrobial resistance [3]. This occurs when the unlimited genes contained in the bacteria circulating in air invade other pathogenic bacteria through mobile genetic elements and may be transformed to antibiotic resistance genes like integrons, transposons, and plasmids [4,5].
Based on few studies conducted on the presence of antimicrobial resistance in the environment, the spatial and seasonal diversity of antibiotic resistant bacteria are well established [6-11], but the diversity in air is not well studied. In case of detection of airborne resistomes, most of the studies have been conducted in clinical settings, pharmaceutical industries, animal farms, laboratory settings, or highly polluted sites [12-27]. However, there is a gap in the quantification of airborne resistomes in both high-risk and low-risk areas like urban versus rural areas and poultry/industry versus nonpoultry/residential areas in the same study area as well as their transmission dynamics with seasonal differences.
Additionally, several anthropogenic events also enhance the ability of antibiotic resistance genes to be transferred horizontally and pose a further risk for the environment to act as a reservoir for resistant bacteria [28,29]. Unfortunately, we are not quite aware of the presence of resistant genes in the air or their capability of transmission to humans. This needs to be explored, especially the transmission potential of pathogenic resistant bacteria [30]. Another less-exposed area of research is the climatic and seasonal variability (eg, humidity, rainfall, temperature) in the environmental transmission of antimicrobial resistance. Therefore, the quantity of organisms and diversity of antibiotic resistance genes will vary depending on the air in different environments and seasons. The alarming situation is the presence of the same genes in clinically ill patients, which is supported by different studies [31-33]. A study [34] conducted on the hospital air environment yielded 25% multidrug-resistant organisms. This study will address not only the presence of resistant organisms in the air, but also the clonal distribution of those organisms based on seasonal variation. Therefore, we will be able to identify the risky environments effectively.
The main study objective is to detect the existence of resistomes in the air samples from outdoor environments of Bangladesh, which carry genes that confer resistance to antibiotics with temporal and spatial diversity. We hypothesize that the outdoor environment (air) in Bangladesh acts as a reservoir for bacteria carrying genes that confer resistance to antibiotics with temporal and spatial diversity. The specific objectives of the study are as follows:
To determine the prevalence of antibiotic-resistant bacteria in the air samples of outdoor environments (both poultry and residential) in Bangladesh that carry genes conferring resistance to antibiotics.
To characterize antibiotic-resistant organisms using different phenotypic and genotypic methods.
To explore the clonal relationship between antimicrobial resistant organisms isolated from high- and low-risk areas.
To identify the temporal and spatial distribution of resistant bacteria in outdoor environments of Bangladesh.
This is a cross-sectional pilot study designed to collect air samples from high-risk and low-risk environments in urban and periurban settings of Bangladesh, mainly the Dhaka metropolitan area and Mirzapur Upazilla (subdistrict) of Tangail District. Environmental systematic and grid sampling will be followed according to approaches described by Keith [35]. This is suitable for finding hotspots for target organisms/genes over a specific period of time, as samples are taken at regularly spaced intervals. Data collection started in January 2018, and the laboratory analysis is currently ongoing. The live bird markets and commercial poultry farms are considered to be high-risk areas, while the urban residential areas and the periurban households are low-risk areas (Figure 1).
Figure 1. Sampling strategy and framework.
View this figure
Geospatial Mapping
Mapping with GIS software (ArcGIS, Esri, Redlands, California) will plot concentrations of resistant genes and antimicrobial-resistant bacteria in environmental compartments (high- and low-risk areas) in each location using GPS coordinates. Temporal variation will be observed by comparing the magnitude of resistant bacteria and genes in the dry season with those in the wet season.
Collection of Air Samples From Study Sites
Air samples from commercial poultry farms, live bird markets, rural households, and urban residential areas will be collected. All active sampling will be performed using the same Surface Air System Sampler (SAS Super 180 Microbial Air Sampler, Bioscience International, Rockville; Figure 2), with a flow rate of 180 L/min. The following media will be used for collection of samples: standard plate count (SPC) agar (Oxoid, Hampshire, United Kingdom) for aerobic plate count, MacConkey agar (BD Difco, Becton Dickinson, New Jersey) supplemented with cefotaxime (1 mg/L) and MacConkey agar supplemented with meropenem (0.5 mg/L) to obtain gram-negative resistant organisms, Mannitol Salt agar (MSA) (Oxoid) supplemented with oxacillin (8 mg/L), and Slanetz and Bartley (SB) agar (Oxoid) medium supplemented with vancomycin (6 mg/L) to obtain gram-positive resistant organisms. During sampling, the aspirating head will be removed from the air sampler. An identified, closed, and prepared plate will be inserted, and the plate lid will be removed. The aspirating head will be replaced again to cover the plate. The required volume and air flow rate will be adjusted, and the air sampler will be started. Subsequently, the airflow will be directed into the agar surface of the plate and at the end of a cycle, the aspirating head will be removed. The plate will be closed with the lid and removed from the air sampler. An identical method will be followed for different types of agar plates in each location, although the air volume will be different (ie, 1000 L for MacConkey, MSA, and SB agar and 100 L for SPC agar). After sampling, the plates will be carried in a carrying case and transported to the laboratory.
Figure 2. Active microbial air sampler.
Processing and Laboratory Analysis of Air Samples
Analysis of Antibiotic Resistance Genes in the Air Metagenome
According to the manufacturers' instruction and using QIAamp DNA Mini Kit (QIAGEN, Germany), total DNA from the culture sweeps will be extracted after counting colonies on SPC agar plates. The colonies will then be incubated for 44 hours at 37°C. High-throughput sequencing will be performed using an Illumina MiSeq sequencing system (Illumina, San Diego, CA). The downstream analysis quality will be ensured by removing raw reads, with an average quality score below 20 or with length less than 100 bp (101 bp in length) or having three or more ambiguous nucleotides. The high-throughput sequencing will be carried out by the "Index 101 PE" (paired-end sequencing; 101-bp reads and 8-bp index sequence) sequencing strategy. There will be almost the same quantity of clean reads in this manner for each sample. The processing of the call sequences as well as raw fluorescent images will be carried out through a base-calling pipeline (Sequencing Control Software, Illumina). Metagenomic analyses will be carried out with the filtered clean reads (almost 1.6 GB per sample) after removal of the raw reads contaminated by an adapter (>15 bp overlap) or having three or more "N" [36,37]. The antibiotic resistance genes in the samples will be identified through alignment of the Illumina sequencing reads via offline BLAST (Basic Local Alignment Search Tool) against a self-established database. Similarity above 90% and alignments ≥25 amino acids are the identification criteria of a read to be confirmed as an antimicrobial resistance gene based on its best BLAST hit (blastx) [36].
Culture of Samples to Identify Antibiotic-Resistant Gram-Positive and Gram-Negative Organisms
All the culture plates (except SPC) exposed to air during air sampling will be incubated at 37°C, with 44 hours for SB agar and 18-24 hours for MacConkey agar and MSA. After incubation, each plate will be counted for both types of colonies (typical and atypical). To achieve clean/pure cultures, 3-4 phenotypically different isolated colonies will be subcultured from each plate on corresponding antibiotic-supplemented agar media. Following incubation (mentioned earlier), culture sweeps from each plate will be dissolved in tryptic soy broth cryovials containing 30% glycerol. These will be preserved at –80°C for future usage.
Antimicrobial Susceptibility Testing
By using different antibiotic discs, the agar diffusion test will determine the antimicrobial susceptibility as per the Clinical and Laboratory Standards Institute (CLSI 2016) guidelines [38]. Third-generation cephalosporin-resistant isolates will be tested for extended spectrum beta-lactamase (ESBL) production by performing combination disc tests. Vancomycin-resistant Enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), and methicillin-resistant Staphylococcus aureus (MRSA) will be confirmed by reviewing the susceptibility test results.
Detection of Antibiotic Resistance Genes
Polymerase chain reaction for genes specific for each of the resistance phenotypes (for ESBL: CTX-M, TEM, SHV; for carbapenem: NDM; for VRE: vanA; for MRSA: mecA) will be carried out according to the procedures described previously [39-42].
Genetic Fingerprinting of Isolates
Phenotypically same isolates (with or without similar resistance pattern) obtained from different locations or time periods will be further tested by pulsed-filed gel electrophoresis to determine their clonal diversity and dispersion.
Test for Antibiotic Resistance Plasmid
Plasmid DNA extraction and analysis from resistant isolates will be executed through the rapid alkaline lysis method and horizontal gel electrophoresis in 0.8% agarose gels, respectively [43]. The unknown plasmid size will be assumed by using known standard plasmid marker following gel electrophoresis for which the plasmids Escherichia coli V517 (1.4, 1.8, 2.0, 2.6, 3.4, 3.7, 4.8 and 35.8 MDa), pDK9 (140 MDa), R1 (62 MDa), RP4 (36 MDa), and Sa (23 MDa) will be considered as standards. Both filter mating and broth mating assays will be performed for conjugation at 30°C for 18 hours. The donor will be the resistant bacterial isolates when E. coli J53 (AziR, F−) and E. coli MC1061 (SmR, F−, nonlactose fermenting) will be recipients. MacConkey agar will be used for the selection of both E. coli J53 and E. coli MC1061 transconjugants. However, MacConkey agar will contain sodium azide (100 mg/L) and cefotaxime (20 mg/L)/cefoxitin (16 mg/L) for E. coli J53 and ampicillin (50 mg/L) for E. coli MC1061 transconjugants. The antibiotic susceptibility test will be performed to confirm transconjugant colonies. Using the alkaline lysis method described above, plasmid DNA will be extracted from transconjugants [43].
Estimation of Sample Size
The primary objective of this study is to determine the prevalence of antibiotic resistant organisms with resistance gene characterization in air samples from different locations and during different seasons. However, there are no baseline data available about measuring antimicrobial resistance in air samples. No prior assumptions were possible to show the anticipated variation in different exposures or seasonal contexts, although some prior knowledge has been utilized [29]. In this exploratory study, we have estimated 5% probability and 95% confidence, which requires a sample size of 59, as per the formula for sample size calculation of pilot studies published by Rik Crutzen et al [44]. Owing to the large number of study settings, we have included 80 sampling units for each season, which includes 20 live bird markets, 20 rural poultry farms, 20 periurban households, and 20 urban residential areas. The sampling bias is expected to be reduced through this strategy and will provide robust findings based on repeating the sampling in wet and dry season conditions.
Outcome Variables
The outcome variables that will be assessed are as follows:
The prevalence of antibiotic-resistant organisms and resistance genes (positive occurrence of resistant bacteria/genes as a proportion of the number of samples) from each environmental location
The geospatial distribution of antibiotic resistant organisms and antibiotic resistance genes in study areas
The temporal prevalence of resistant bacteria and concentration of resistant genes in dry and wet season to assess seasonal variation in antimicrobial resistance
The identification of high-risk environments for air borne pollution with antimicrobial resistance
Data Analysis Plan
In this study, we will determine the presence of resistant organisms in air samples by total counting (colony-forming units per liter) at different study sites in Bangladesh. Significant differences in carriage rates of antibiotic-resistant organisms (and concentrations of resistant genes) in high- and low-risk environments will be determined by Chi-square and independent t tests. Hence, significant predictors will be identified. For identification of significant risk factors, logistic regression analysis will be used. Repeated measures analyses will be applied to examine whether there is significant seasonal variation in the prevalence of antimicrobial resistant bacteria and concentrations of antimicrobial resistance genes (paired t test or repeated measures analysis of variance). Count regression models like Poisson, negative binomial, and zero inflated count will be used, where appropriate, for antibiotic resistance count data.
The Research Review Committee and Ethical Review Committee of International Centre for Diarrhoeal Disease Research, Bangladesh, have approved this research protocol (protocol number: PR-17048). A unique study identification number was assigned to all air samples to ensure anonymity of the study sites. The study started in January 2018, and the collection of air samples was completed in November 2018. We have received 800 air samples from 80 study locations in both dry and wet seasons. Currently, the laboratory analysis is ongoing, and we expect to receive the microbiological results by October 2019. After completion of data cleaning and analysis, the manuscript submission is anticipated to be submitted before fall 2020. In addition to publication in a high-impact, peer-reviewed journal and as per the dissemination plan, the study results will be shared with the study participants, with scientific communities, with relevant government authorities, and in related conferences or workshops.
The rise and spread of superbugs have become a key public health and planetary health concern worldwide. Infections caused by multidrug-resistant bacteria are linked to greater mortality rates than antimicrobial-susceptible bacteria [45]. For therapeutic purposes, medically important antimicrobials are used extensively in agricultural and farming industries for disease prevention (eg, prophylaxis and metaphylaxis), treatments, and growth promotions. More than two-thirds of antimicrobials are consumed in the livestock sector each year. It is projected that by 2030, there may be a massive increase (up to 67%) in global antimicrobial use in food-producing animals, especially in Brazil, Russia, India, China, and South Africa (BRICS) [46]. The antimicrobial resistance problem is severe, not only in developed countries but also in nonindustrialized countries. Scarcity of antimicrobial usage policies and substandard hygiene situations are the precipitating factors that drive antimicrobial resistance issue to be more challenging [47].
The burden of the antimicrobial resistance rate depends on the population of a country and its environment. Bangladesh is a highly populated country; therefore, the rate of antimicrobial resistance is extensive due to rapid spread of antimicrobial-resistant organisms. Antimicrobial resistance genes are conferring their resistance value to a wider community including both animals and humans, through close interactions with the environment and the wastes that are disposed in the environment, directly affecting the food chain [48]. Due to the extensive use of antibiotics as therapeutic and prophylactic in farming, bacterial resistance may be developed by either chromosomal gene mutation or gene acquisition through different mechanisms like transformation, transduction, or conjugation [49]. Continuous accumulation of multiple mutations have caused the genome to become resistant to antibiotics. To screen the antimicrobial resistance genes, whole genome sequencing is an important tool for understanding the antimicrobial resistance mechanisms. Whole genome sequencing helps evaluate the number of mutations and particular mechanisms of the mutated gene that drive antimicrobial resistance to develop new drugs (antibiotic) and diagnose the disease state and treatment process [47]. Primary biological aerosol particles such as bacteria, viruses, pollens, and mold spores are important components of airborne particulate matter (PM), and abundant pathogenic bacteria have been identified from PM2.5 and PM10 samples [50]. However, these compounds from pollution and other sources are not prioritized during analysis. Our study will also focus on the resistant bacteria as an integral part of air pollution.
Intrinsic genetic determinants of resistance factors are harbored by bacteria with macromolecules in the environment. Robust evidence suggests that such macromolecules developing "environmental resistomes" are a source from which clinically relevant bacteria acquire antibiotic resistance genes [51]. Poultry, the most common rural domestic species, is considered a major driver for selection of antimicrobial resistance from the environment to human/animal due to fecal shedding of resistant bacteria. As poultry feces are used as fertilizers and household members share sleeping spaces with poultry animals, antibiotic use in poultry in the last 6 months has been reported by more than 50% poultry owners [37]. Commercial poultry farm areas harbor the antimicrobial-resistant isolates in the air, and humans are easily exposed to these antimicrobial-resistant isolates during inhalation of dust and particles. Consequently, antimicrobial-resistant organisms can build up a strong biofilm in the intestinal tract of humans. Through excretion of stool and other body fluids, these can be spread in the environment. Urban live bird markets are the largest site of bird slaughtering, with no proper waste management setting, and the huge amounts of wastes are directly passed into environment through dust and direct wash out [14].
The importance of environmental compartments as the transmission hub of antimicrobial resistance is well established. However, airborne resistomes and their transmission pathway are poorly studied. Without containment of environmental reservoirs, antimicrobial resistance prevention policy will fail [52]. The occurrence of pathogenic resistant organisms and resistance genes in atmospheric air of different locations will guide researchers and policy makers to adopt new strategies for the containment of this alarming issue. However, further large-scale studies need to be carried out to link the clinically important organisms and airborne resistomes. To achieve this, One Health surveillance needs to be carried out in humans (both healthy and clinical patients), animals, and environments at the national level.
Regarding the strengths, our study will focus on the air resistomes, which is a less explored environmental dimension of antimicrobial resistance transmission dynamics. To our knowledge, this is the first study to explore the presence of superbugs in the air in commonly exposed areas in Bangladesh. The limitation exists in the small sample size and lack of baseline data from the atmospheric environment of Bangladesh. Therefore, the findings may not be generalizable for all areas in the country.
This research protocol was funded by The Swedish International Development Cooperation Agency (SIDA; contribution no. 54100089). The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) acknowledges with gratitude the commitment of SIDA to its research efforts. The icddr,b is also grateful to the Governments of Bangladesh, Canada, Sweden, and the UK for providing core/unrestricted support. MA is supported by National Institutes of Health Fogarty International Centre Global Health Equity Scholars program (D43TW010540).
MA and MAI conceptualized the idea and developed the study protocol and field methods with study supervision; MA, MAI, MIH, SRS, and NA formulated the laboratory protocols; MA, MAI, and MRI worked on the sample size estimation and analysis plan; MIH and SRS are responsible for the sample processing and laboratory experiments; MA wrote the original draft; and all authors reviewed, edited, and contributed substantially to writing the manuscript.
Multimedia Appendix 1
Peer-reviewer report from the International Centre for Diarrhoeal Disease Research, Bangladesh.
PDF File (Adobe PDF File), 501 KB
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Talukdar PK, Rahman M, Rahman M, Nabi A, Islam Z, Hoque MM, et al. Antimicrobial resistance, virulence factors and genetic diversity of Escherichia coli isolates from household water supply in Dhaka, Bangladesh. PLoS One 2013 Apr 3;8(4):e61090 [FREE Full text] [CrossRef] [Medline]
Islam MA, Talukdar PK, Hoque A, Huq M, Nabi A, Ahmed D, et al. Emergence of multidrug-resistant NDM-1-producing Gram-negative bacteria in Bangladesh. Eur J Clin Microbiol Infect Dis 2012 Oct 17;31(10):2593-2600. [CrossRef] [Medline]
Kim M, Cha M, Ryu J, Woo G. Characterization of Vancomycin-Resistant Enterococcus faecalis and Enterococcus faecium Isolated from Fresh Produces and Human Fecal Samples. Foodborne Pathog Dis 2017 Apr;14(4):195-201. [CrossRef] [Medline]
Sharma NK, Rees CED, Dodd CER. Development of a single-reaction multiplex PCR toxin typing assay for Staphylococcus aureus strains. Appl Environ Microbiol 2000 Apr 01;66(4):1347-1353 [FREE Full text] [CrossRef] [Medline]
Kado CI, Liu ST. Rapid procedure for detection and isolation of large and small plasmids. J Bacteriol 1981 Mar;145(3):1365-1373 [FREE Full text] [Medline]
Viechtbauer W, Smits L, Kotz D, Budé L, Spigt M, Serroyen J, et al. A simple formula for the calculation of sample size in pilot studies. J Clin Epidemiol 2015 Nov;68(11):1375-1379. [CrossRef] [Medline]
Araos R, Tai AK, Snyder GM, Blaser MJ, D'Agata EMC. Predominance of Lactobacillus spp. Among Patients Who Do Not Acquire Multidrug-Resistant Organisms. Clin Infect Dis 2016 Oct 01;63(7):937-943 [FREE Full text] [CrossRef] [Medline]
Brower CH, Mandal S, Hayer S, Sran M, Zehra A, Patel SJ, et al. The Prevalence of Extended-Spectrum Beta-Lactamase-Producing Multidrug-Resistant Escherichia Coli in Poultry Chickens and Variation According to Farming Practices in Punjab, India. Environ Health Perspect 2017 Jul 24;125(7):077015. [CrossRef]
Abdelgader SA, Shi D, Chen M, Zhang L, Hejair HMA, Muhammad U, et al. Antibiotics Resistance Genes Screening and Comparative Genomics Analysis of Commensal Isolated from Poultry Farms between China and Sudan. Biomed Res Int 2018 Aug 26;2018:5327450-5327459 [FREE Full text] [CrossRef] [Medline]
Holvoet K, Sampers I, Callens B, Dewulf J, Uyttendaele M. Moderate Prevalence of Antimicrobial Resistance in Escherichia coli Isolates from Lettuce, Irrigation Water, and Soil. Appl Environ Microbiol 2013 Aug 23;79(21):6677-6683. [CrossRef]
da Costa P, Loureiro L, Matos A. Transfer of multidrug-resistant bacteria between intermingled ecological niches: the interface between humans, animals and the environment. Int J Environ Res Public Health 2013 Jan 14;10(1):278-294 [FREE Full text] [CrossRef] [Medline]
Liu H, Zhang X, Zhang H, Yao X, Zhou M, Wang J, et al. Effect of air pollution on the total bacteria and pathogenic bacteria in different sizes of particulate matter. Environ Pollut 2018 Feb;233:483-493. [CrossRef] [Medline]
Munita JM, Arias CA. Mechanisms of Antibiotic Resistance. Microbiol Spectr 2016 Apr;4(2) [FREE Full text] [CrossRef] [Medline]
Asaduzzaman M. Antimicrobial resistance: an urgent need for a planetary and ecosystem approach. Lancet Planet Health 2018 Mar;2(3):e99-e100 [FREE Full text] [CrossRef] [Medline]
BLAST: Basic Local Alignment Search Tool
CRE: Carbapenem-resistant Enterobacteriaceae
CLSI: Clinical and Laboratory Standards Institute
ESBL: Extended-Spectrum Beta-Lactamase
MRSA: Methicillin-resistant Staphylococcus aureus
VRE: Vancomycin-resistant Enterococci
Edited by G Eysenbach; submitted 02.05.19; peer-reviewed by E Boriani, L Sheets; comments to author 09.08.19; revised version received 28.09.19; accepted 22.10.19; published 19.12.19
©Muhammad Asaduzzaman, Muhammed Iqbal Hossain, Sumita Rani Saha, Md Rayhanul Islam, Niyaz Ahmed, Mohammad Aminul Islam. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 19.12.2019.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.
Asaduzzaman M, Hossain MI, Saha SR, Islam MR, Ahmed N, Islam MA
doi: 10.2196/14574 PMID: 31855188 PMCID: 6940864
JMIR Research Protocols ISSN 1929-0748


text:
Q: Choose between a and the article in a question without context Why we say

How to cross the road?

meanwhile, we also say

How to read a book?

As far as I know, we use "the" when there's some context. For example, I have a car, and I want to paint it, then I say "I want to paint the car". But without context about which car I want to paint, I say "How to paint a car?"
Could you explain why we use the in some sentences instead of a?

A: (A) These are "conventions" used by various communities , where common usage makes it acceptable , even though it is inconsistent (or even wrong , according to other communities) , becoming idiomatic over time.
In you Case , there is some Ambiguity.

How to cross the road?

(A1) I would use this when there is a specific road which I want to cross , but it has Dividers. Hence I may ask the a Passser-by "How to cross the [this] road?" who may reply that there is a subway or there is a bridge or there are Divider openings every kilometer , where the reply will be specific to this road.
(A2) When using this to refer to all general roads sounds odd , but is acceptable in some communities. When asking this , the reply should ideally be about all roads in general.
This usage occurs when we are talking about either all roads (Eg rule of the road or rules of the road) or about some hypothetical Idealized road (Eg one for the road , one for the road , rules of the road or hit the road jack).
There may be no Idealized or Hypothetical book , hence it is generally "a book" , not "the book".
When there is indeed such a book (eg in religious contexts or constitutional books or law books or a compendium) then we may use "the book" when talking in that context.
(B) It is easy to avoid that by using Plurals which is correct in every community or other contexts.

How to cross roads?
How to read books?

Usage trends via google ngrams :

redpajama_set_name: RedPajamaStackExchange


text:
Firstsource celebrates Investors in People accreditation
Categorized: awards | IIP | Investors In People | people management
Firstsource Solutions, was among the 69 organisations celebrating Investors in People (IIP) accreditation at a presentation ceremony held at Belfast Castle on 20 September. Since 1991, Investors in People has set the standard for better people management. The Standard defines what it takes to lead, support and manage people well. Successful accreditation against the Investors in People Standard is the sign of a great employer who understands that it is people that make the difference. Organisations are judged to have achieved IIP standards based on a tried and tested methodology of leading practice and a rigorous process of assessment.
Pictured are Laura Hourican (SVP HR UK), Grainne O'Kane (GM HR UK) and Theresa McDermott from IIP
IIP Board Advisor Mark Huddleston, said: "The commitment to the Investors in People Standard by an organisation is demonstration to not only grow the business but more importantly grow the people also. The opportunity today to recognise what has been achieved by these organisations in Northern Ireland highlights the hard work and effort made to rise above the crowd and become a benchmark for people management and development excellence. The event today allows those businesses being recognised to celebrate the achievement of the IIP Standard and again recognise the benefits to be gained through the continued investment in the skills and effectiveness of the people within an organisation, whether large or small."
Commenting on the award, Laura Hourican, SVP HR UK at Firstsource Solutions, said: "We are exceptionally proud to be awarded the Investors in People gold accreditation and it is a strong testament to the work of the leadership team in Firstsource. The assessment findings demonstrate that people are at the heart of what we do for clients and that our business success depends on attracting the best people and enabling them to reach their potential."
About Investors in People
Investors in People makes people management excellence count. Through the respected standard, business insight and the IIP bank of tools and resources, organisations of all shapes and sizes can put their people first. Over the last 20 years, 100,000 businesses around the world improve, have used the Standard to boost working culture, increase engagement and encourage game-changing leadership.
Investors in People Northern Ireland is managed and delivered by the Investors in People Head Office. The Investors in People trademark is owned and managed by the UK Commission for Employment and Skills.
For more information about Investors in People please visit www.investorsinpeople.com

redpajama_set_name: RedPajamaCommonCrawl


Old Salem Visitors' Center, Winston-Salem, NC.
Or is it the Voluntary in G that we hear on the right ? This one is played by Einer von Weitem, on the 18th century organ in Krezszow Abbey, Silesia. This, like the St Magnus the Martyr organ, has three manuals, but Einer has set aside the stops an English organ would not have had at the time.
Here is a short Cornet Voluntary for which YouTube shows no composer.
Might this be the same Anon as the one we will hear from in the concert ?
Do organists see what we do in this section and make programme choices it will be impossible to match ?
I could not find a decent recording of the John Bennett Adagio. There are two on You Tube which I will let you explore separately.
William Walond Jr was Organist of Chichester Cathedral, but we are interested here in his father.


But as I said I messaged the Suzuki Ebay folks and they listed it as a one off for me.... and I'm sure PA Lynch would get one too.
BTW if you appear to have found a bargain service kit for around £34 double check as this is usually the pre-2013 one.
Thanks both, very helpful. I'll check the prop when I'm allowed time off sorting out the cruisers bbq for tomorrow! Happy Christmas to all.
The prop is 9 1/4 x 12. What's your view given this please? I'm assuming overpropped means too much grip, ie won't rev?
Yep that's what mine would have come with. As I said above even the 11" I agreed the dealer should substitute felt a little over geared and the 10" is perfect.
We carry 3 folks plus dog and a lot of kit.. also our SIB being a deepish V is a bit draggy compared to a lighter load and flattish bottom outfit.
Just looking back at the posts... being held to 3000rpm and not getting on the plane 2 up is really bogged down. How big is the AB rib?
I agree with fenlander going down to a 10 inch pitch will bring you up to 3400 a 3500 rpm, what is your trim position, it sounds like you may just be in front of the bow wave and need that bit more to get over it.
I guess your boat weight is around £120 kg at 10 ft so your motor should cope easily achieving around 20 knots I would of thought.
Have a look on the Suzuki web site they have boat tests with figures to compare.
If your down to 3000rpm are you sure the tach is reading correctly that's like half what you should be doing, have you tried taking the rpm up with no load to determine the tach is correct?
Ken's suspicions sound right to me. If you are only getting 3000rpm then I am surprised you get on the plane (or certainly quickly) with two on board. How do the revs compare fully loaded and lightly loaded and how does it sound?
If the engine is giving full power lightly loaded, then it's possible that better use of trim and/or load distribution will help you get over the "hump".
In truth for a 20hp on a SIB or light tiller steer RIB up to 4m (I'm guessing the OP's isn't longer than this) with two up the range of props hardly needs calculating. 12" would only do for a light skimmy hulled outfit with minimal load... 9" would only be needed if the SIB/RIB is over large or carrying a greater load like 4 folks and kit. So the choice is 10" or 11" and the 10" that these OBs were mostly supplied with is perfect for 90% of situations.
We do need a bit more info from the OP though... particularly if the 3000rpm is when it's bogged down not planning... or is it 3000rpm showing when flat out on the plane with a light load at WOT??
Re tach settings what does it read at idle? Should be 850rpm.
Thanks again guys, super helpful!
The rib is an AB Lammina 10 al, it is 10'6" and weighs 53kg, plus engine and fuel. I bought the Rev counter / hour timer from ebay after reading the original thread on the 20 I think.
This is all from memory but. With just me in, circa 15 stone, it pops into the plane fine and does about 20kts. With me and my wife in (weight a closely guarded secret!) again no problems. Add a third person and we just can't get onto the plane. the engine is fully trimmed down, ie bow pushed fully down.
I have a feeling that perhaps it's the prop given what I've been reading on here and I do need/want a spare prop anyhow so I can keep 12' As a spare.
One question, our last set up was an Avon rib of similar length and a 15hp two stroke that someone kindly stole. That engine had those fins on it - should I fit some of those as I understand they help one onto the plane?
I won't rev out of gear, seems to be limited? Apart from the vibrations at low revs I'm very happy with the engine. So long as the electronics hold out I much prefer this to a carburettor managed engine.
Re load vs performance. Our SIB as I've said above will be more draggy than yours due to our flexible hull and sharper V profile... they weigh broadly the same. So yours should be capable of greater performance with the same OB for any given load.
Our standard load is a total of 34st in people plus dog, too much kit and a full 25l fuel tank. With the 10" prop we can leap on the plane in any circumstance we choose without waiting to get over the hump. Sometimes we are 42st in people plus dog/kit/fuel and we still pop on the plane OK.
If I put the 11" prop on we can still plane under these circumstances with both loads but it feels much more draggy getting onto the plane... particularly with the greater load.
The difference between 10" and 11" props is far more than any theoretical prop pitch calculation would have you believe hence me being fairly sure your 12" prop is a big factor.
Re trim and weight distribution... Keeping the bow down to get on the plane is important but usually just for that brief period getting over the hump then a standard trim is often best. I always run a mid point OB trim position and shift weight to get the boat's trim right. When getting on the plane is marginal I'd just be inclined to ask one crew to move up forward for those few moments and then back when plane is established. By being trimmed fully in you may be causing drag by having too much of the bow in the water.
Doel fins are a marmite thing... I've had them and didn't like them. In truth they are to attempt to correct a poor setup. Your small RIB and 20hp should be an excellent performing outfit without fins.
Re the OB in general. Yes the just off idle offbeat vibration would be better done without but it's a minor thing. So far these engines seem to be very reliable re elecs and I agree I far prefer the accurate control of injection and an ECU.
BTW your Beneteau looks so elegant and for me in the perfect hull colour. One of my all time memories is as a kid in the late 60s on a family holiday in a sleek hulled 55ft motorsailer cruising France, Brittany and The Channel isles for a couple of weeks.


text:
Q: Difference smart card with same ATR In a Java program I need to difference two identical Javacard and GlobalPlatform smart cards (with same ATR, of course). I need do it before to establish any secure channel, so is there a way to know the aid's of the applets that there are installed in the card without use the GET STATUS command? Can I change the historical bytes of the ATR of one card?

A: You can try out the possible AID's using the SELECT by NAME APDU. Otherwise, no, you cannot request the applet AID's without authenticating to the card manager.
Note that you may shorten the AID to 5 bytes (the RID), the card manager should select an applet with an instance AID that starts with the same RID.


text:
A wide range of arthropod species harbour bacterial endosymbionts in various tissues, many of them playing important roles in the fitness and biology of their hosts. In several cases, many different symbionts have been reported to coexist simultaneously within the same host and synergistic or antagonistic interactions can occur between them. While the associations with endosymbiotic bacteria have been widely studied in many insect species, in ticks such interactions are less investigated. The females and immatures of Ixodes ricinus (Ixodidae), the most common hard tick in Europe, harbour the intracellular endosymbiont "Candidatus Midichloria mitochondrii" with a prevalence up to 100%, suggesting a mutualistic relationship. Considering that the tissue distribution of a symbiont might be indicative of its functional role in the physiology of the host, we investigated M. mitochondrii specific localization pattern and the corresponding abundance in selected organs of I. ricinus females. We paired these experiments with in silico analysis of the metabolic pathways of M. mitochondrii, inferred from the available genome sequence, and additionally compared the presence of these pathways in seven other symbionts commonly harboured by ticks to try to obtain a comparative understanding of their biological effects on the tick hosts. M. mitochondrii was found to be abundant in ovaries and tracheae of unfed I. ricinus, and in ovaries, Malpighian tubules and salivary glands of semi-engorged females. These results, together with the in silico metabolic reconstruction allow to hypothesize that the bacterium could play multiple tissue-specific roles in the host, both enhancing the host fitness (supplying essential nutrients, enhancing the reproductive fitness, helping in the anti-oxidative defence, in the energy production and in the maintenance of homeostasis and water balance) and/or for ensuring its presence in the host population (nutrients acquisition, vertical and horizontal transmission). The ability of M. mitochondrii to colonize different tissues allows to speculate that distinctive sub-populations may display different specializations in accordance with tissue tropism. Our hypotheses should be corroborated with future nutritional and physiological experiments for a better understanding of the mechanisms underlying this symbiotic interaction.
Tissue tropism and metabolic pathways of Midichloria mitochondrii suggest tissue-specific functions in the symbiosis with Ixodes ricinus
OLIVIERI, EMANUELA;Epis S.;Castelli M.;Varotto Boccazzi I.;ROMEO, CLARISSA;Desiro A.;Bazzocchi C.;Bandi C.;Sassera D.


> incompatibility issue, see bottom of this email.
> for any build dependencies that are missing, do a yum install.
> I'll add the binary VIC RPM to the Fedora 8 yum repository later.
Ah thanks Doug, I'd missed this one.  I'll give it a roll.


There are a total of 4 assisted living facilities in GAFFNEY, South Carolina area. This list includes GAFFNEY senior housing, assisted senior living communities and residential care homes for the elderly. GAFFNEY assisted senior living facilities also provide dementia and Alzheimer's care (also known as memory care in GAFFNEY, SC).
Magnolias Of Gaffney Assisted Living Community is an assisted living facility in Gaffney, South Carolina. It can house a maximum of 90 senior citizens at a time. It is located at 101 Park Ct, 29341 zip code in Cherokee county. Magnolias Of Gaffney Assisted Living Community helps older adults who need assistance with daily living tasks. Magnolias Of Gaffney Assisted Living Community is a state-licensed senior living facility with License # CRC-1281.
Peachtree Centre Community Residential Care Facility provides senior living in Cherokee county, South Carolina. It contains a total of 28 assisted living apartments for 55 and over adults. Peachtree Centre Community Residential Care Facility provides affordable, pet-friendly assisted elderly housing and is located at 1434 N Limestone St, Gaffney, South Carolina 29340.
Blue Ridge In Brookview House is an upscale assisted senior living facility in Gaffney, South Carolina. It supports a total of 132 assisted living units. Blue Ridge In Brookview House is available to all Cherokee county elderly residents in need of assisted living. Blue Ridge In Brookview House is situated at 510 Thompson Street in Gaffney, South Carolina.
Ivy Grove Residential Care Center is a residential care facility in Gaffney, South Carolina, located at 483 Lockhart Ln in 29341 zip code. It provides memory care and assisted living throughout Cherokee county in South Carolina. Ivy Grove Residential Care Center has a total of 62 assisted living apartment units.
Assisted Living Facilities in GAFFNEY, SC. List of all of the best assisted living, senior living and elderly housing options in GAFFNEY for 2019.


text:
Q: Device does not send any content after sending MDM Command I have successfully managed to send a MDM push notification to the device and the device responds with an Idle status. However, when I sent an MDM Command:
<?xml version=\"1.0\" encoding=\"utf-16\"?>
<!DOCTYPE plist PUBLIC \"-//Apple//DTD PLIST 1.0//EN\" \"http://www.apple.com/DTDs/PropertyList-1.0.dtd\">
<plist version=\"1.0\">
  <dict>
    <key>CommandUUID</key>
    <string>4FB2550B-ADFD-425C-BF6C-92CEDE747F23</string>
    <key>Command</key>
    <dict>
      <key>RequestType</key>
      <string>InstalledApplicationList</string>
    </dict>
  </dict>
</plist>

The device does not contain any response. It closes connection somehow. I am writing the XML and then reading the stream to check for a response over the same connection. when i close the connection and then resend a push notification, I get back this empty response:
PUT / HTTP/1.1
Host: 172.18.130.31:1234
User-Agent: MDM/1.0
Content-Length: 0
Accept: */*
Content-Type: application/x-apple-aspen-mdm
Accept-Language: en-us
Accept-Encoding: gzip, deflate
Connection: keep-alive

I also tried deviceinformation but to no avail:
<!DOCTYPE plist PUBLIC "-//Apple//DTD PLIST 1.0//EN" "http://www.apple.com/DTDs/PropertyList-1.0.dtd">
<plist version="1.0">
  <dict>
    <key>CommandUUID</key>
    <string>7C28313A-BFE7-4430-A516-BB16C8F6F750</string>
    <key>Command</key>
    <dict>
      <key>RequestType</key>
      <string>DeviceInformation</string>
      <array>
        <string>DeviceName</string>
        <string>OSVersion</string>
        <string>BuildVersion</string>
        <string>ModelName</string>
        <string>Model</string>
        <string>ProductName</string>
        <string>SerialNumber</string>
        <string>DeviceCapacity</string>
        <string>AvailableDeviceCapacity</string>
        <string>BatteryLevel</string>
        <string>CellularTechnology</string>
        <string>IMEI</string>
        <string>MEID</string>
        <string>ModemFirmwareVersion</string>
      </array>
    </dict>
  </dict>
</plist>

It is supposed to send an Acknowledged state or at least an error. What am I doing wrong please?

A: I solved the problem. I had an encoding of 16 and not 8 in the XML plist I was sending.

A: I had this symptom too, although my problem was different.
You should not sign your XML.


text:
Uncharted STL
Webster Body Art Special
Webster music students performed 'The Human Experience' on March 9
Kate McCracken - April 5, 2022
Seventeen Webster University music students created a concert to perform for peers, family and community members on March 9 titled "The Human Experience." The...
Photo Series: 10 things studying abroad taught me
Vanessa Jones - January 31, 2023
Last fall, I studied abroad at Webster's Geneva, Switzerland campus. After spending four months exploring six countries and 14 cities, here are 10 things...
Fandom businesses thrive in St. Louis
Sean Mullins - December 18, 2022
From conventions to small businesses that celebrate hobbies like games and anime, St. Louis is becoming a hot destination for fandom. St. Louis has always...
The District in Chesterfield wows as new entertainment venue
Rayna Friedman - December 18, 2022
Bringing new life to Chesterfield, The District of St. Louis offers a unique combination of entertainment sure to capture all audiences, including the already-popular...
Brickline Greenway to connect several St. Louis Parks
Kelly Bowen - December 18, 2022
In five to 10 years, St. Louis city's infrastructure will be completely transformed and changed. Forest Park, Tower Grove Park, Fairground Park and Gateway Arch...
Expanding City Foundry STL curates local vendors in Midtown
Alexandria Darmody - December 18, 2022
It all started in Atlanta: Will Smith, managing director of New + Found investment firm, was living there when his father, the company's CEO,...
Saint Louis Zoo WildCare Park expected to open in 2027
Molly Foust - December 18, 2022
In five years, locals and St. Louis visitors will have the opportunity to experience a real-life safari without leaving the city at the new...
Minority- and women-owned businesses support each other at City Foundry
Jordyn Grimes - December 18, 2022
Tiffany Wesley was diagnosed with a hormonal condition called polycystic ovarian syndrome (PCOS) in 2013 that led to severe skin issues such as acne...
St. Louis Union Station modernized for changing city
KP Benton - December 18, 2022
Just five years ago, the downtown St. Louis skyline was just the Gateway Arch and the buildings that surround it. Today, St. Louis Union Station,...
How East Coast pizza infiltrated the Midwest at Racanelli's
Gerald Burton Jr. - December 10, 2022
It has been said St. Louisans love their pizza – those distinctly thin, flaky provel-topped squares. With St. Louis style-pizza being embedded onto the...
Euro Trash: a unique designer for a unique neighborhood
Lauren Brennecke - December 9, 2022
The work of Dutch-American interior designer Annie Brahler has been hailed by the Chicago Tribune, Elle magazine and countless others ranging from celebrity clients...
Dharma + Dwell helps Old Orchard reduce, reuse and recycle
Joshua Wright - December 9, 2022
Owner Jordan Blackhurst founded Dharma + Dwell in early 2020 as a pop-up shop around St. Louis providing eco-friendly home and beauty products. Later that...
Union Studio helps Webster Groves and St. Louis 'come together through art'
Gaby Ocampo - December 6, 2022
Support of local business should be of great importance for communities across the country as it provides economic benefits, as well as economic growth,...
Webster Groves Animal Hospital: an Old Orchard landmark that does it all
Kennedy Moore - December 5, 2022
One wouldn't have to look very far to see that Webster Grovians love their pets. The neighborhood, with its walkable business districts and open,...
Nerinx Hall and Webster University: closer than you might think
Kellen Furmaniak - December 1, 2022
Nerinx Hall and Webster University are undoubtedly two institutions that have anchored the Old Orchard district dating back to the early 1900s. Did you know...
What is Old Orchard?
Noah Robinett - November 30, 2022
The Old Orchard District in Webster Groves has been around for 125 years, but one thing has remained constant throughout its history: It's been...
Ukrainian Webster student adjusts to 'new normal'
Kelly Bowen - November 28, 2022
For Dariia Sidorova, most days are the same. She goes throughout her day with hardly any electricity, no warmth, no fresh meals, sometimes no...


text:
Distracted Driving Highlights Major Problems with San Francisco Muni Bus Accidents
GJEL » Archives » Distracted Driving Highlights Major Problems with San Francisco Muni Bus Accidents
What would you do if your bus driver was texting while driving? If you're anything like San Francisco resident Shawn Higgins, who saw a bus driver texting on the 24 Divisadero bus, you'd try to stop it. Though Higgins was backed by other riders, her confrontation did not go over well with the driver, who "took out her iPhone and started recording us. On the bus. And saying 'I'm going to show you. I'll never pick you up again a—hole.'" In past years, San Francisco bus drivers have repeatedly been caught acting irresponsibly, highlighting the importance of reforming the San Francisco Municipal Transit Agency's policy toward its staff.
Of course, Muni was quick to distance itself from this week's incident. "This is absolutely against our rules and regulations. Anytime anything like this happens, we try to take immediate action," said Muni spokesman Paul Rose. But their actions don't quite match the words; the driver was suspended immediately from her job, but was back in rotation only three days later. Muni drivers have also been caught sleeping, speeding, and snacking while operating trains, and are often faced with little or no punishment.
Earlier this year, the San Francisco Examiner reported that while 348 Muni drivers were involved in preventable bus accidents (sometimes multiple), the transit agency only planned to fire seven bus drivers. Noting that most Muni drivers have zero or one accident on their record, Rose said at the time "that's saying that the vast majority of our operators are exceptional at what they do." That may be true, but any bus accident should be considered unacceptable, as they can cause significant injury to passengers and cost the city a fortune. For one recent incident, the city of San Francisco agreed to a $2 million settlement for a passenger injured in a train accident.
Bus accidents aside, San Francisco Muni has recently been cited for some infrastructure problems, and is currently being investigated by the California Public Utilities Commission for consistent safety violations. In late February, the California PUC said the city's transit tracks could "present a public safety risk, and could result in…possible derailments" constituting "a public safety hazard." PUC President Michael Peevey has said the agency is currently in the process of determining "whether SFMTA's behavior violates the law, and if so, whether fines and penalties are appropriate."
Public transportation drivers who break the law by texting behind the wheel put passengers and San Francisco pedestrians in danger, and hold the city hostage to millions in legal fees and settlements. So if you're on a bus and see your driver on the cell phone, follow Higgins' lead and try to stop it before the inevitable bus accident.
Photo credit: randychiu


text:
All the latest news from MEDICAL FAIR THAILAND 2019.
The state of healthtech in Southeast Asia
CIO Asean
The Asian healthtech industry closed 2018 with a record-breaking US$6.3 billion in funding, making it the second-largest digital health ecosystem in the world, surpassed only by the US.
ข้อมูลเพิ่มเติม »
Indian AI-driven online healthcare startup bags $17.2m in series B round
India-based, artificial intelligence-driven online consultation startup Mfine raised US$17.2 million in a series B round led by Japanese VC firm SBI Group subsidiary SBI Investment.
BlueChilli launches healthtech accelerator for South-east Asia
AUSTRALIAN startup accelerator BlueChilli has partnered Enterprise Singapore (ESG) to launch a Singapore-based healthtech accelerator, as part of efforts to scout for and support startups aimed at addressing health challenges and opportunities in South-east Asia.
Innovation In The Pink Of Health: Trends & Tech In Healthcare
Asian Scientist Magazine
Burdened by chronic disease and aging populations, the healthcare sector is looking to technology to prevent, diagnose and treat illnesses more efficiently. But more than just augment physician capabilities, technology is changing our approach to healthcare—it is empowering doctors to advocate for prevention rather than treatment, to deliver personalized medicine and to care for patients beyond the clinics and hospitals.
Managing Merdeka Generation problems with Gen Z solutions
Technology promises to improve patient outcomes and with much greater efficiency. However, these IT systems must be implemented well. In an industry subject to strict regulatory requirements, and marred by incidents such as the SingHealth breach and the HIV leak, it is important that healthcare providers work in close concert with the technology providers and ensure patients such as those in Singapore's Merdeka Generation receive the best care for their spend.
How video analytics is reshaping the healthcare industry
Today, technological advances are transforming the notion of "video surveillance". What was once most commonly used to record empty spaces, or a closed door, can now aid the search for missing children, to assisting doctors in diagnosing patients.
3 Deep Technologies That Will Impact Healthcare in ASEAN
Sg Innovate
Healthcare expenditure per capita in ASEAN is around 4% of GDP, as compared to the OECD average of 9.5%. Growth in average annual healthcare spending between 2014 to 2018 is forecasted to be around 11% of ASEAN's GDP, but in this diverse region where healthcare systems are at varying stages of evolution, the rates among countries are disparate: Vietnam leads at 6.6% while Myanmar falls far behind at 1.8%.
Picture of health
Regional chief of Siemens Healthineers foresees a future of more personalised, accurate and accessible care enabled by digital imaging advances.
Seed Money for Healthcare Startups in Southeast Asia
finews.asia
Singapore-based HealthXCapital wants to fuel healthcare innovation in Asia's emerging economies and help meet the rising healthcare demands.
Grab, Ping An form JV to deliver online healthcare services in South-east Asia
GRAB said on Thursday that it has formed a joint venture (JV) with Ping An Healthcare and Technology Company (or Ping An Good Doctor) to deliver "transformative online healthcare services in South-east Asia."


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