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Hospital surfaces are known to contribute to the spread of healthcare-associated antimicrobial pathogens. Environmental sampling can help locate reservoirs and determine intervention strategies, although sampling and detection can be labor intensive. Composite approaches may help reduce time and costs associated with sampling and detection. We investigated optimum surface areas for sampling antimicrobial-resistant organisms (AROs) with a single side of cellulose sponge, created theoretical composites (TC) by adding recovery results from multiple optimum areas, then compared the TC to the standard Centers for Disease Control and Prevention sampling method (one sponge using all sides, whole tool; (WT)). Five AROs were evaluated: carbapenemase-producing KPC+ Klebsiella pneumoniae (KPC), Acinetobacter baumannii (AB), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis (VRE) and Clostridioides difficile spores (CD). Steel coupons comprising four surface areas (323; 645; 1,290 and 2,258 cm2) were inoculated, dried, and sampled with one sampling pass using the larger side (face) or the smaller side (edge) of a pre-moistened cellulose sponge tool. Based on the optimum areas determined for each organism, composite areas were 1,290 cm2 for MRSA and VRE, 1,936 cm2 for AB, 2,580 cm2 for CD spores and 3,870 cm2 for KPC. Total colony forming units (CFU) recovered using a composite approach was greater or comparable than using multiple WT samplings (over the same area as the composite) for MRSA, VRE and AB (130%; 144% and 95%) yet less than if using multiple WT samplings for KP and CD (47% and 66%). We propose a conservative composite sampling strategy if the target organism is unknown; 323 cm2 sampling area for each of the four sides of the sponge, (1290 cm2 total). The conservative composite sampling strategy improved the recovery of KP (from 47% to 85% of multiple WT samplings), while MRSA, VRE, AB and CD (131%; 144%; 97% and 66%) remained within 5% to that of the optimum area TC.

Complex enzymes with multiple catalytic activities are hypothesized to have evolved from more primitive precursors. Global analysis of the Phytophthora sojae genome using conservative criteria for evaluation of complex proteins identified 273 novel multifunctional proteins that were also conserved in P. ramorum. Each of these proteins contains combinations of protein motifs that are not present in bacterial, plant, animal, or fungal genomes. A subset of these proteins were also identified in the two diatom genomes, but the majority of these proteins have formed after the split between diatoms and oomycetes. Documentation of multiple cases of domain fusions that are common to both oomycetes and diatom genomes lends additional support for the hypothesis that oomycetes and diatoms are monophyletic. Bifunctional proteins that catalyze two steps in a metabolic pathway can be used to infer the interaction of orthologous proteins that exist as separate entities in other genomes. We postulated that the novel multifunctional proteins of oomycetes could function as potential Rosetta Stones to identify interacting proteins of conserved metabolic and regulatory networks in other eukaryotic genomes. However ortholog analysis of each domain within our set of 273 multifunctional proteins against 39 sequenced bacterial and eukaryotic genomes, identified only 18 candidate Rosetta Stone proteins. Thus the majority of multifunctional proteins are not Rosetta Stones, but they may nonetheless be useful in identifying novel metabolic and regulatory networks in oomycetes. Phylogenetic analysis of all the enzymes in three pathways with one or more novel multifunctional proteins was conducted to determine the probable origins of individual enzymes. These analyses revealed multiple examples of horizontal transfer from both bacterial genomes and the photosynthetic endosymbiont in the ancestral genome of Stramenopiles. The complexity of the phylogenetic origins of these metabolic pathways and the paucity of Rosetta Stones relative to the total number of multifunctional proteins suggests that the proteome of oomycetes has few features in common with other Kingdoms.

IntroductionDelayed hospital discharge is a persistent care quality issue experienced across health systems worldwide and remains a priority area to be addressed in Canada. Often associated with a decrease in services while waiting to leave the hospital, delayed discharge from hospital can lead to increased frailty, physical and cognitive decline, and caregiver burnout. Optimizing availability of and timely access to community-based health and social care are avenues that could reduce initial admissions to the hospital and length of hospital stay, and facilitate hospital discharges.MethodsThis research will explore the ways in which community resources could be leveraged to potentially avoid hospitalization and delayed hospital discharge for older adults using sequential mixed-methods including co-design. To better understand the characteristics and needs of older adults, the research team will first identify sub-populations of older adults (65 years old or older) at risk of hospitalization and delayed discharge using comprehensive, longitudinal administrative health data. From these health data, risk profiles and personas will be created and then shared with key partners (e.g., older adults, caregivers, healthcare providers, healthcare decision-makers), who will be engaged to identify, leverage, and create targeted care solutions. The barriers and facilitators to the implementation of these care solutions will then be explored.DiscussionDelayed hospital discharge has been a critical care quality issue across Canada for decades. The current research will provide health system leaders with an approach to better allocate services to older adults in order to avoid delayed hospital discharge and identify gaps in health and social care resources based on the characteristics, needs, and preferences of older adults, their caregivers, and providers.

BackgroundInappropriate overuse of antibiotics contributes to antimicrobial resistance (AMR), yet policy implementation to reduce inappropriate antibiotic use is poor in low and middle-income countries.AimsTo determine whether public sector inappropriate antibiotic use is lower in countries reporting implementation of selected essential medicines policies.Materials and methodsResults from independently conducted antibiotic use surveys in countries that did, and did not report implementation of policies to reduce inappropriate antibiotic prescribing, were compared. Survey data on four validated indicators of inappropriate antibiotic use and 16 self-reported policy implementation variables from WHO databases were extracted. The average difference for indicators between countries reporting versus not reporting implementation of specific policies was calculated. For 16 selected policies we regressed the four antibiotic use variables on the numbers of policies the countries reported implementing.ResultsData were available for 55 countries. Of 16 policies studied, four (having a national Ministry of Health unit on promoting rational use of medicines, a national drug information centre and provincial and hospital drugs and therapeutics committees) were associated with statistically significant reductions in antibiotic use of ≥20% in upper respiratory infection (URTI). A national strategy to contain antibiotic resistance was associated with a 30% reduction in use of antibiotics in acute diarrheal illness. Policies seemed to be associated with greater effects in antibiotic use for URTI and diarrhea compared with antibiotic use in all patients. There were negative correlations between the numbers of policies reported implemented and the percentage of acute diarrhoea cases treated with antibiotics (r = -0.484, p = 0.007) and the percentage of URTI cases treated with antibiotics (r = -0.472, p = 0.005). Major study limitations were the reliance on self-reported policy implementation data and antibiotic use data from linited surveys.ConclusionsSelected essential medicines policies were associated with lower antibiotic use in low and middle income countries.

Health behaviours, important factors in cardiovascular disease, are increasingly a focus of prevention. We appraised whether stroke risk can be accurately assessed using self-reported information focused on health behaviours.Behavioural, sociodemographic and other risk factors were assessed in a population-based survey of 82,259 Ontarians who were followed for a median of 8.6 years (688,000 person-years follow-up) starting in 2001. Predictive algorithms for 5-year incident stroke resulting in hospitalization were created and then validated in a similar 2007 survey of 28,605 respondents (median 4.2 years follow-up).We observed 3236 incident stroke events (1551 resulting in hospitalization; 1685 in the community setting without hospital admission). The final algorithms were discriminating (C-stat: 0.85, men; 0.87, women) and well-calibrated (in 65 of 67 subgroups for men; 61 of 65 for women). An index was developed to summarize cumulative relative risk of incident stroke from health behaviours and stress. For men, each point on the index corresponded to a 12% relative risk increase (180% risk difference, lowest (0) to highest (9) scores). For women, each point corresponded to a 14% relative risk increase (340% difference, lowest (0) to highest (11) scores). Algorithms for secondary stroke outcomes (stroke resulting in death; classified as ischemic; excluding transient ischemic attack; and in the community setting) had similar health behaviour risk hazards.Incident stroke can be accurately predicted using self-reported information focused on health behaviours. Risk assessment can be performed with population health surveys to support population health planning or outside of clinical settings to support patient-focused prevention.

We evaluated a cohort of Canadian donors for T cell and antibody responses against influenza A/California/7/2009 (pH1N1) at 8-10 months after the 2nd pandemic wave by flow cytometry and microneutralization assays. Memory CD8 T cell responses to pH1N1 were detectable in 58% (61/105) of donors. These responses were largely due to cross-reactive CD8 T cell epitopes as, for those donors tested, similar recall responses were obtained to A/California 2009 and A/PR8 1934 H1N1 Hviruses. Longitudinal analysis of a single infected individual showed only a small and transient increase in neutralizing antibody levels, but a robust CD8 T cell response that rose rapidly post symptom onset, peaking at 3 weeks, followed by a gradual decline to the baseline levels seen in a seroprevalence cohort post-pandemic. The magnitude of the influenza-specific CD8 T cell memory response at one year post-pandemic was similar in cases and controls as well as in vaccinated and unvaccinated donors, suggesting that any T cell boosting from infection was transient. Pandemic H1-specific antibodies were only detectable in approximately half of vaccinated donors. However, those who were vaccinated within a few months following infection had the highest persisting antibody titers, suggesting that vaccination shortly after influenza infection can boost or sustain antibody levels. For the most part the circulating influenza-specific T cell and serum antibody levels in the population at one year post-pandemic were not different between cases and controls, suggesting that natural infection does not lead to higher long term T cell and antibody responses in donors with pre-existing immunity to influenza. However, based on the responses of one longitudinal donor, it is possible for a small population of pre-existing cross-reactive memory CD8 T cells to expand rapidly following infection and this response may aid in viral clearance and contribute to a lessening of disease severity.

BackgroundWe designed a seroprevalence study using multiple testing assays and population sources to estimate the community seroprevalence of pH1N1/09 and risk factors for infection before the outbreak was recognized and throughout the pandemic to the end of 2009/10 influenza season.MethodsResidual serum specimens from five time points (between 01/2009 and 05/2010) and samples from two time points from a prospectively recruited cohort were included. The distribution of risk factors was explored in multivariate adjusted analyses using logistic regression among the cohort. Antibody levels were measured by hemagglutination inhibition (HAI) and microneutralization (MN) assays.ResultsResidual sera from 3375 patients and 1024 prospectively recruited cohort participants were analyzed. Pre-pandemic seroprevalence ranged from 2%-12% across age groups. Overall seropositivity ranged from 10%-19% post-first wave and 32%-41% by the end of the 2009/10 influenza season. Seroprevalence and risk factors differed between MN and HAI assays, particularly in older age groups and between waves. Following the H1N1 vaccination program, higher GMT were noted among vaccinated individuals. Overall, 20-30% of the population was estimated to be infected.ConclusionsCombining population sources of sera across five time points with prospectively collected epidemiological information yielded a complete description of the evolution of pH1N1 infection.