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Objectives: The majority of patients with mild-to-moderate COVID-19 can be managed using virtual care. Dyspnoea is challenging to assess remotely, and the accuracy of subjective dyspnoea measures in capturing hypoxaemia have not been formally evaluated for COVID-19. We explored the accuracy of subjective dyspnoea in diagnosing hypoxaemia in COVID-19 patients., Methods: This is a retrospective cohort study of consecutive outpatients with COVID-19 who met criteria for home oxygen saturation monitoring at a university-affiliated acute care hospital in Toronto, Canada from 3 April 2020 to 13 September 2020. Dyspnoea measures were treated as diagnostic tests, and we determined their sensitivity (SN), specificity (SP), negative/positive predictive value (NPV/PPV) and positive/negative likelihood ratios (+LR/-LR) for detecting hypoxaemia. In the primary analysis, hypoxaemia was defined by oxygen saturation <95%; the diagnostic accuracy of subjective dyspnoea was also assessed across a range of oxygen saturation cutoffs from 92% to 97%., Results: During the study period, 89/501 (17.8%) of patients met criteria for home oxygen saturation monitoring, and of these 17/89 (19.1%) were diagnosed with hypoxaemia. The presence/absence of dyspnoea had limited accuracy for diagnosing hypoxaemia, with SN 47% (95% CI 24% to 72%), SP 80% (95% CI 68% to 88%), NPV 86% (95% CI 75% to 93%), PPV 36% (95% CI 18% to 59%), +LR 2.4 (95% CI 1.2 to 4.7) and -LR 0.7 (95% CI 0.4 to 1.1). The SN of dyspnoea was 50% (95% CI 19% to 81%) when a cut-off of < 92% was used to define hypoxaemia. A modified Medical Research Council dyspnoea score >1 (SP 98%, 95% CI 88% to 100%), Roth maximal count <12 (SP 100%, 95% CI 75% to 100%) and Roth counting time <8 s (SP 93%, 95% CI 66% to 100%) had high SP that could be used to rule in hypoxaemia, but displayed low SN (≤50%)., Conclusions: Subjective dyspnoea measures have inadequate accuracy for ruling out hypoxaemia in high-risk patients with COVID-19. Safe home management of patients with COVID-19 should incorporate home oxygenation saturation monitoring., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The development of new methods for direct viral detection using streamlined and ideally reagent-free assays is a timely and important, but challenging, problem. The challenge of combatting the COVID-19 pandemic has been exacerbated by the lack of rapid and effective methods to identify viral pathogens like SARS-CoV-2 on-demand. Existing gold standard nucleic acid-based approaches require enzymatic amplification to achieve clinically relevant levels of sensitivity and are not typically used outside of a laboratory setting. Here, we report reagent-free viral sensing that directly reads out the presence of viral particles in 5 minutes using only a sensor-modified electrode chip. The approach relies on a class of electrode-tethered sensors bearing an analyte-binding antibody displayed on a negatively charged DNA linker that also features a tethered redox probe. When a positive potential is applied, the sensor is transported to the electrode surface. Using chronoamperometry, the presence of viral particles and proteins can be detected as these species increase the hydrodynamic drag on the sensor. This report is the first virus-detecting assay that uses the kinetic response of a probe/virus complex to analyze the complexation state of the antibody. We demonstrate the performance of this sensing approach as a means to detect, within 5 min, the presence of the SARS-CoV-2 virus and its associated spike protein in test samples and in unprocessed patient saliva.

MicroRNAs (miRNAs) have remarkable stability and are key regulators of mRNA transcripts for several essential proteins required for the survival of cells and replication of the virus. Exosomes are thought to play an essential role in intercellular communications by transporting proteins and miRNAs, making them ideal in the search for biomarkers. Evidence suggests that miRNAs are involved in the regulation of influenza virus replication in many cell types. During the 2016 and 2017 influenza season, we collected blood samples from 54 patients infected with influenza and from 30 healthy volunteers to identify the potential role of circulating serum miRNAs and cytokines in influenza infection. Data comparing the exosomal miRNAs in patients with influenza B to healthy volunteers showed 76 miRNAs that were differentially expressed ( p < 0.05). In contrast, 26 miRNAs were differentially expressed between patients with influenza A ( p < 0.05) and the controls. Of these miRNAs, 11 were commonly expressed in both the influenza A and B patients. Interferon (IFN)-inducing protein 10 (IP-10), which is involved in IFN synthesis during influenza infection, showed the highest level of expression in both influenza A and B patients. Influenza A patients showed increased expression of IFNα, GM-CSF, interleukin (IL)-13, IL-17A, IL-1β, IL-6 and TNFα, while influenza B induced increased levels of EGF, G-CSF, IL-1α, MIP-1α, and TNF-β. In addition, hsa-miR-326, hsa-miR-15b-5p, hsa-miR-885, hsa-miR-122-5p, hsa-miR-133a-3p, and hsa-miR-150-5p showed high correlations to IL-6, IL-15, IL-17A, IL-1β, and monocyte chemoattractant protein-1 (MCP-1) with both strains of influenza. Next-generation sequencing studies of H1N1-infected human lung small airway epithelial cells also showed similar pattern of expression of miR-375-5p, miR-143-3p, 199a-3p, and miR-199a-5p compared to influenza A patients. In summary, this study provides insights into the miRNA profiling in both influenza A and B virus in circulation and a novel approach to identify the early infections through a combination of cytokines and miRNA expression.

There is a pressing need for an in-depth understanding of immunity to SARS-CoV-2. In this study, we investigated human T cell recall responses to fully glycosylated spike trimer, recombinant N protein, as well as to S, N, M, and E peptide pools in the early convalescent phase and compared them with influenza-specific memory responses from the same donors. All subjects showed SARS-CoV-2-specific T cell responses to at least one Ag. Both SARS-CoV-2-specific and influenza-specific CD4 + T cell responses were predominantly of the central memory phenotype; however SARS-CoV-2-specific CD4 + T cells exhibited a lower IFN-γ to TNF ratio compared with influenza-specific memory responses from the same donors, independent of disease severity. SARS-CoV-2-specific T cells were less multifunctional than influenza-specific T cells, particularly in severe cases, potentially suggesting exhaustion. Most SARS-CoV-2-convalescent subjects also produced IFN-γ in response to seasonal OC43 S protein. We observed granzyme B + /IFN-γ + , CD4 + , and CD8 + proliferative responses to peptide pools in most individuals, with CD4 + T cell responses predominating over CD8 + T cell responses. Peripheral T follicular helper (pTfh) responses to S or N strongly correlated with serum neutralization assays as well as receptor binding domain-specific IgA; however, the frequency of pTfh responses to SARS-CoV-2 was lower than the frequency of pTfh responses to influenza virus. Overall, T cell responses to SARS-CoV-2 are robust; however, CD4 + Th1 responses predominate over CD8 + T cell responses, have a more inflammatory profile, and have a weaker pTfh response than the response to influenza virus within the same donors, potentially contributing to COVID-19 disease., (Copyright © 2020 by The American Association of Immunologists, Inc.)

We provide an update to the Association of Medical Microbiology and Infectious Disease Canada foundation guidance for the upcoming 2020-2021 influenza season in Canada. Important issues for this year include the implications of co-circulation of SARS-CoV-2, the role of diagnostic testing, and a restatement of dosing and administration recommendations for neuraminidase inhibitors in various age groups and underlying health conditions. Although peramivir and baloxivir are now licensed in Canada, neither is currently marketed, so this guidance focuses on further optimizing the use of oseltamivir and zanamivir., Competing Interests: Papenburg reports grants and personal fees from BD Diagnostics, Seegene, Janssen Pharmaceutical, and AbbVie and grants from MedImmune and Sanofi Pasteur, outside the submitted work. Hatchette reports grants from GSK and Pfizer, outside the submitted work., (Copyright © 2020, Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada).)

Background: During medical procedures with the potential to produce aerosols such as bronchoscopy, intubation, or CPR, health-care workers (HCWs) may be exposed to infectious bioaerosols. This scenario is of particular concern when high consequence pathogens such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are circulating. Thousands of HCWs have been infected with SARS-CoV-2. However, the determinants of aerosol generation during medical procedures and their relative risk to HCWs remain poorly characterized., Research Question: The goal of this study was to characterize aerosols produced during airway intubation by using an uninfected translational animal model and in human subjects undergoing elective aerosol-generating procedures. The study also determined the particle size distribution of generated particles., Study Design and Methods: Aerosol generation was measured during highly controlled experimental (pig) intubations (N = 16) and elective bronchoscopies in uninfected patients (N = 49) using an optical particle counter. Recovery of normal respiratory flora was used as a surrogate for pathogen dispersion., Results: There was a small but significant (P = .03) decrease in 0.3 μm size particles during highly controlled pig intubations compared with baseline. The concentration of 1.0 μm and 5.0 μm aerosol particles did not significantly change, although oral bacteria were collected from the air. For elective patient bronchoscopies, there was a significant decrease in the generation of larger particles (1.0 μm and 5.0 μm) compared with baseline (P < .01); however, 18 of 39 (46%) patients showed increased aerosol production in 0.3 μm size particles, four of whom exhibited measurable increases., Interpretation: Although the total amount of aerosols produced during intubation and bronchoscopy did not increase significantly relative to preprocedural levels, a small number of participants exhibited a measurable increase in submicron particle emission, meriting further research to delineate determinants of fine particle production during aerosol-generating procedures., (Copyright © 2020. Published by Elsevier Inc.)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) recently emerged to cause widespread infections in humans. SARS-CoV-2 infections have been reported in the Kingdom of Saudi Arabia, where Middle East respiratory syndrome coronavirus (MERS-CoV) causes seasonal outbreaks with a case fatality rate of ~37 %. Here we show that there exists a theoretical possibility of future recombination events between SARS-CoV-2 and MERS-CoV RNA. Through computational analyses, we have identified homologous genomic regions within the ORF1ab and S genes that could facilitate recombination, and have analysed co-expression patterns of the cellular receptors for SARS-CoV-2 and MERS-CoV, ACE2 and DPP4, respectively, to identify human anatomical sites that could facilitate co-infection. Furthermore, we have investigated the likely susceptibility of various animal species to MERS-CoV and SARS-CoV-2 infection by comparing known virus spike protein-receptor interacting residues. In conclusion, we suggest that a recombination between SARS-CoV-2 and MERS-CoV RNA is possible and urge public health laboratories in high-risk areas to develop diagnostic capability for the detection of recombined coronaviruses in patient samples.

The worldwide repercussions of COVID-19 sparked important research efforts, yet the detailed contribution of aerosols in the transmission of SARS-CoV-2 has not been elucidated. In an attempt to quantify viral aerosols in the environment of infected patients, we collected 100 air samples in acute care hospital rooms hosting 22 patients over the course of nearly two months using three different air sampling protocols. Quantification by RT-qPCR (ORF1b) led to 11 positive samples from 6 patient rooms ( C t < 40). Viral cultures were negative. No correlation was observed between particular symptoms, length of hospital stay, clinical parameters, and time since symptom onset and the detection of airborne viral RNA. Low detection rates in the hospital rooms may be attributable to the appropriate application of mitigation methods according to the risk control hierarchy, such as increased ventilation to 4.85 air changes per hour to create negative pressure rooms. Our work estimates the mean emission rate of patients and potential airborne concentration in the absence of ventilation. Additional research is needed understand aerosolization events occur, contributing factors, and how best to prevent them.

Competing Interests: Intérêts concurrents: Deborah O’Connor est présidente du conseil consultatif (non rémunérée) et Sharon Unger est directrice médicale (rémunérée) de la Rogers Hixon Ontario Human Milk Bank. Aucun autre intérêt concurrent déclaré.

The EU Bioeconomy Strategy, updated in 2018, in its Action Plan pledges an EU-wide, internationally coherent monitoring system to track economic, environmental and social progress towards a sustainable bioeconomy. This paper presents the approach taken by the European Commission's (EC) Joint Research Centre (JRC) to develop such a system. To accomplish this, we capitalise on (1) the experiences of existing indicator frameworks; (2) stakeholder knowledge and expectations; and (3) national experiences and expertise. This approach is taken to ensure coherence with other bioeconomy-related European monitoring frameworks, the usefulness for decision-making and consistency with national and international initiatives to monitor the bioeconomy. We develop a conceptual framework, based on the definition of a sustainable bioeconomy as stated in the Strategy, for a holistic analysis of the trends in the bioeconomy sectors, following the three pillars of sustainability (economy, society and environment). From this conceptual framework, we derive an implementation framework that aims to highlight the synergies and trade-offs across the five objectives of the Bioeconomy Strategy in a coherent way. The EU Bioeconomy Monitoring System will be publicly available on the web platform of the EC Knowledge Centre for Bioeconomy., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

We report diagnosis and management of the first laboratory-confirmed case of coronavirus disease 2019 (COVID-19) hospitalized in Toronto, Canada. No healthcare-associated transmission occurred. In the face of a potential pandemic of COVID-19, we suggest sustainable and scalable control measures developed based on lessons learned from severe acute respiratory syndrome., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

While the antibody response to SARS-CoV-2 has been extensively studied in blood, relatively little is known about the antibody response in saliva and its relationship to systemic antibody levels. Here, we profiled by enzyme-linked immunosorbent assays (ELISAs) IgG, IgA and IgM responses to the SARS-CoV-2 spike protein (full length trimer) and its receptor-binding domain (RBD) in serum and saliva of acute and convalescent patients with laboratory-diagnosed COVID-19 ranging from 3-115 days post-symptom onset (PSO), compared to negative controls. Anti-SARS-CoV-2 antibody responses were readily detected in serum and saliva, with peak IgG levels attained by 16-30 days PSO. Longitudinal analysis revealed that anti-SARS-CoV-2 IgA and IgM antibodies rapidly decayed, while IgG antibodies remained relatively stable up to 105 days PSO in both biofluids. Lastly, IgG, IgM and to a lesser extent IgA responses to spike and RBD in the serum positively correlated with matched saliva samples. This study confirms that serum and saliva IgG antibodies to SARS-CoV-2 are maintained in the majority of COVID-19 patients for at least 3 months PSO. IgG responses in saliva may serve as a surrogate measure of systemic immunity to SARS-CoV-2 based on their correlation with serum IgG responses., (Copyright © 2020, American Association for the Advancement of Science.)

Most of the patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mount a humoral immune response to the virus within a few weeks of infection, but the duration of this response and how it correlates with clinical outcomes has not been completely characterized. Of particular importance is the identification of immune correlates of infection that would support public health decision-making on treatment approaches, vaccination strategies, and convalescent plasma therapy. While ELISA-based assays to detect and quantitate antibodies to SARS-CoV-2 in patient samples have been developed, the detection of neutralizing antibodies typically requires more demanding cell-based viral assays. Here, we present a safe and efficient protein-based assay for the detection of serum and plasma antibodies that block the interaction of the SARS-CoV-2 spike protein receptor binding domain (RBD) with its receptor, angiotensin-converting enzyme 2 (ACE2). The assay serves as a surrogate neutralization assay and is performed on the same platform and in parallel with an ELISA for the detection of antibodies against the RBD, enabling a direct comparison. The results obtained with our assay correlate with those of 2 viral-based assays, a plaque reduction neutralization test (PRNT) that uses live SARS-CoV-2 virus and a spike pseudotyped viral vector-based assay.

Seasonal influenza epidemics have been responsible for causing increased economic expenditures and many deaths worldwide. Evidence exists to support the claim that the virus can be spread through the air, but the relative significance of airborne transmission has not been well defined. Particle image velocimetry (PIV) and hot-wire anemometry (HWA) measurements were conducted at 1 m away from the mouth of human subjects to develop a model for cough flow behavior at greater distances from the mouth than were studied previously. Biological aerosol sampling was conducted to assess the risk of exposure to airborne viruses. Throughout the investigation, 77 experiments were conducted from 58 different subjects. From these subjects, 21 presented with influenza-like illness. Of these, 12 subjects had laboratory-confirmed respiratory infections. A model was developed for the cough centerline velocity magnitude time history. The experimental results were also used to validate computational fluid dynamics (CFD) models. The peak velocity observed at the cough jet center, averaged across all trials, was 1.2 m/s, and an average jet spread angle of θ = 24° was measured, similar to that of a steady free jet. No differences were observed in the velocity or turbulence characteristics between coughs from sick, convalescent, or healthy participants., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Purpose: We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products., Source: Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology., Principal Findings: No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density., Conclusions: High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.

Since its emergence in Wuhan, China, in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected ≈6 million persons worldwide. As SARS-CoV-2 spreads across the planet, we explored the range of human cells that can be infected by this virus. We isolated SARS-CoV-2 from 2 infected patients in Toronto, Canada; determined the genomic sequences; and identified single-nucleotide changes in representative populations of our virus stocks. We also tested a wide range of human immune cells for productive infection with SARS-CoV-2. We confirm that human primary peripheral blood mononuclear cells are not permissive for SARS-CoV-2. As SARS-CoV-2 continues to spread globally, it is essential to monitor single-nucleotide polymorphisms in the virus and to continue to isolate circulating viruses to determine viral genotype and phenotype by using in vitro and in vivo infection models.

Genome sequencing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is increasingly important to monitor the transmission and adaptive evolution of the virus. The accessibility of high-throughput methods and polymerase chain reaction (PCR) has facilitated a growing ecosystem of protocols. Two differing protocols are tiling multiplex PCR and bait capture enrichment. Each method has advantages and disadvantages but a direct comparison with different viral RNA concentrations has not been performed to assess the performance of these approaches. Here we compare Liverpool amplification, ARTIC amplification, and bait capture using clinical diagnostics samples. All libraries were sequenced using an Illumina MiniSeq with data analyzed using a standardized bioinformatics workflow (SARS-CoV-2 Illumina GeNome Assembly Line; SIGNAL). One sample showed poor SARS-CoV-2 genome coverage and consensus, reflective of low viral RNA concentration. In contrast, the second sample had a higher viral RNA concentration, which yielded good genome coverage and consensus. ARTIC amplification showed the highest depth of coverage results for both samples, suggesting this protocol is effective for low concentrations. Liverpool amplification provided a more even read coverage of the SARS-CoV-2 genome, but at a lower depth of coverage. Bait capture enrichment of SARS-CoV-2 cDNA provided results on par with amplification. While only two clinical samples were examined in this comparative analysis, both the Liverpool and ARTIC amplification methods showed differing efficacy for high and low concentration samples. In addition, amplification-free bait capture enriched sequencing of cDNA is a viable method for generating a SARS-CoV-2 genome sequence and for identification of amplification artifacts.

Background: Provision of pasteurized donor human milk, as a bridge to mother's own milk, is the standard of care for very low-birth-weight infants in hospital. The aim of this research was to confirm that Holder pasteurization (62.5°C for 30 min) would be sufficient to inactivate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in donated human milk samples., Methods: We spiked frozen milk samples from 10 donors to the Rogers Hixon Ontario Human Milk Bank with SARS-CoV-2 to achieve a final concentration of 1 × 10 7 TCID 50 /mL (50% of the tissue culture infectivity dose per mL). We pasteurized samples using the Holder method or held them at room temperature for 30 minutes and plated serial dilutions on Vero E6 cells for 5 days. We included comparative controls in the study using milk samples from the same donors without addition of virus (pasteurized and unpasteurized) as well as replicates of Vero E6 cells directly inoculated with SARS-CoV-2. We reported cytopathic effects as TCID 50 /mL., Results: We detected no cytopathic activity in any of the SARS-CoV-2-spiked milk samples that had been pasteurized using the Holder method. In the SARS-CoV-2-spiked milk samples that were not pasteurized but were kept at room temperature for 30 minutes, we observed a reduction in infectious viral titre of about 1 log., Interpretation: Pasteurization of human milk by the Holder method (62.5°C for 30 min) inactivates SARS-CoV-2. Thus, in the event that donated human milk contains SARS-CoV-2 by transmission through the mammary gland or by contamination, this method of pasteurization renders milk safe for consumption and handling by care providers., Competing Interests: Competing interests: Deborah O’Connor serves as the Chair of the Advisory Board (unpaid) and Sharon Unger serves as the Medical Director (paid) of the Rogers Hixon Ontario Human Milk Bank. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)

With emergence of pandemic COVID-19, rapid and accurate diagnostic testing is essential. This study compared laboratory-developed tests (LDTs) used for the detection of SARS-CoV-2 in Canadian hospital and public health laboratories, and some commercially available real-time RT-PCR assays. Overall, analytical sensitivities were equivalent between LDTs and most commercially available methods., Competing Interests: Declaration of Competing Interest The authors have no conflicts to declare, (Crown Copyright © 2020. Published by Elsevier B.V. All rights reserved.)

Background: Outpatient parenteral antimicrobial therapy (OPAT) is a safe and effective alternative to hospitalization for many patients with infectious disease. The objective of this study was to describe the experience with a newly established formal OPAT program at a Canadian academic centre., Methods: We conducted a retrospective cohort study including all patients referred to the OPAT clinic between July 2016 and June 2017 and a contemporary cohort of patients who received home parenteral therapy without clinic referral. A quasi-experimental design was used to assess the impact of the clinic on patient outcomes compared with a pre-intervention cohort of patients from 2012 to 2013., Results: Between July 2016 and June 2017, 334 patients were referred to the OPAT clinic; 33% of the patients visited the emergency department (ED), and 21% required readmission within 60 days. Compared with the clinic patients, urinary tract infection diagnoses were more common among the 39 contemporary patients who were treated with home parenteral antibiotics without OPAT clinic referral (51% versus 4%, respectively; p < 0.001) and treatment durations were shorter (median 10 days versus 42 days; p < 0.001). Compared with a pre-intervention cohort, OPAT clinic implementation was associated with a trend toward decreased ED visits (33% versus 43%; p = 0.07). On multivariable analysis, this translated to an overall adjusted odds ratio of 0.64 (95% CI 0.40 to 1.04, p = 0.07) for readmission and ED visits., Conclusions: The OPAT clinic served a high volume of patients in its first year of operation and may be helpful in reducing unfavourable patient outcomes., Competing Interests: The authors have nothing to disclose., (Copyright © 2020, Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada).)

Background: In patients who are discharged home to self-isolate while coronavirus disease 2019 (COVID-19) test results are pending, there is no formal method for physician assessments or counselling to occur if the result returns positive. Our aim was to develop and test the feasibility of a virtual care program for self-isolating outpatients diagnosed with COVID-19., Methods: In preparation for this gap in health care, the COVID-19 Expansion to Outpatients (COVIDEO) program was developed at the Sunnybrook Health Sciences Centre, Toronto, Ontario, to provide ongoing care for outpatients diagnosed with COVID-19. As part of a feasibility study, we describe our experiences with the first 50 patients managed using this program from its inception (Mar. 1, 2020) until Mar. 27, 2020., Results: All 50 people who tested positive for COVID-19 at the Sunnybrook Health Sciences Centre and were discharged home to self-isolation during the study period were assessed through the COVIDEO program. Thirty-two patients (64%) were assessed via the Ontario Telemedicine Network virtual care platform, and the remainder by telephone. The median time from viral swab collection to first COVIDEO program assessment was 2 (interquartile range [IQR] 1-2) days. Among the 26 patients for whom further follow-up care through the COVIDEO program was discontinued by the end of March 2020, the median duration of virtual care was 12.5 (IQR 8.75-16) days. During the study period, 6 patients required transfer to hospital for assessment, of whom 4 required admission., Interpretation: We have shown that a virtual care program can be used in the management of outpatients diagnosed with COVID-19. Further studies evaluating its sustainability and impact on health outcomes are underway., Competing Interests: Competing interests: None declared., (Copyright 2020, Joule Inc. or its licensors.)

Background: The World Health Organization has highlighted the need for improved surveillance and understanding of the health burden imposed by non-influenza RNA respiratory viruses. Human coronaviruses (CoVs) are a major cause of respiratory and gastrointestinal tract infections with associated morbidity and mortality., Objectives: The objective of our study was to characterize the epidemiology of CoVs in our tertiary care centre, and identify clinical correlates of disease severity., Study Design: A cross-sectional study was performed of 226 patients admitted with confirmed CoV respiratory tract infection between 2010 and 2016. Variables consistent with a severe disease burden were evaluated including symptoms, length of stay, intensive care unit (ICU) admission and mortality., Results: CoVs represented 11.3% of all positive respiratory virus samples and OC43 was the most commonly identified CoV. The majority of infections were community-associated while 21.6% were considered nosocomial. The average length of stay was 11.8 days with 17.3% of patients requiring ICU admission and an all-cause mortality of 7%. In a multivariate model, female gender and smoking were associated with increased likelihood of admission to ICU or death., Conclusion: This study highlights the significant burden of CoVs and justifies the need for surveillance in the acute care setting., Competing Interests: Declaration of Competing Interest All authors declare no conflicts of interest, (Copyright © 2020. Published by Elsevier B.V.)

COVID-19 has spread globally since its discovery in Hubei province, China in December 2019. A combination of computed tomography imaging, whole genome sequencing, and electron microscopy were initially used to screen and identify SARS-CoV-2, the viral etiology of COVID-19. The aim of this review article is to inform the audience of diagnostic and surveillance technologies for SARS-CoV-2 and their performance characteristics. We describe point-of-care diagnostics that are on the horizon and encourage academics to advance their technologies beyond conception. Developing plug-and-play diagnostics to manage the SARS-CoV-2 outbreak would be useful in preventing future epidemics.

The rising rates of antibiotic resistance increasingly compromise empirical treatment. Knowing the antibiotic susceptibility of a pathogen's close genetic relative(s) may improve empirical antibiotic selection. Using genomic and phenotypic data for Escherichia coli isolates from three separate clinically derived databases, we evaluated multiple genomic methods and statistical models for predicting antibiotic susceptibility, focusing on potentially rapidly available information, such as lineage or genetic distance from archived isolates. We applied these methods to derive and validate the prediction of antibiotic susceptibility to common antibiotics. We evaluated 968 separate episodes of suspected and confirmed infection with Escherichia coli from three geographically and temporally separated databases in Ontario, Canada, from 2010 to 2018. Across all approaches, model performance (area under the curve [AUC]) ranges for predicting antibiotic susceptibility were the greatest for ciprofloxacin (AUC, 0.76 to 0.97) and the lowest for trimethoprim-sulfamethoxazole (AUC, 0.51 to 0.80). When a model predicted that an isolate was susceptible, the resulting (posttest) probabilities of susceptibility were sufficient to warrant empirical therapy for most antibiotics (mean, 92%). An approach combining multiple models could permit the use of narrower-spectrum oral agents in 2 out of every 3 patients while maintaining high treatment adequacy (∼90%). Methods based on genetic relatedness to archived samples of E. coli could be used to predict antibiotic resistance and improve antibiotic selection., (Copyright © 2020 MacFadden et al.)

The quantification of forests available for wood supply (FAWS) is essential for decision-making with regard to the maintenance and enhancement of forest resources and their contribution to the global carbon cycle. The provision of harmonized forest statistics is necessary for the development of forest associated policies and to support decision-making. Based on the National Forest Inventory (NFI) data from 13 European countries, we quantify and compare the areas and aboveground dry biomass (AGB) of FAWS and forest not available for wood supply (FNAWS) according to national and reference definitions by determining the restrictions and associated thresholds considered at country level to classify forests as FAWS or FNAWS. FAWS represent between 75 and 95 % of forest area and AGB for most of the countries in this study. Economic restrictions are the main factor limiting the availability of forests for wood supply, accounting for 67 % of the total FNAWS area and 56 % of the total FNAWS AGB, followed by environmental restrictions. Profitability, slope and accessibility as economic restrictions, and protected areas as environmental restrictions are the factors most frequently considered to distinguish between FAWS and FNAWS. With respect to the area of FNAWS associated with each type of restriction, an overlap among the restrictions of 13.7 % was identified. For most countries, the differences in the FNAWS areas and AGB estimates between national and reference definitions ranged from 0 to 5 %. These results highlight the applicability and reliability of a FAWS reference definition for most of the European countries studied, thereby facilitating a consistent approach to assess forests available for supply for the purpose of international reporting., (© 2019 The Authors.)

Background: Bioaerosol sampling devices are necessary for the characterization of infectious bioaerosols emitted by naturally-infected hosts with acute respiratory virus infections. Assessment of these devices under multiple experimental conditions will provide insight for device use., Objectives: The primary objective of this study was to assess and compare bioaerosol sampling devices using a) an in vitro, environmentally-controlled artificial bioaerosol system at a range of different RH conditions and b) an in vivo bioaerosol system of influenza virus-infected ferrets under controlled environmental conditions. Secondarily, we also sought to examine the impact of NSAIDs on bioaerosol emission in influenza virus-infected ferrets to address its potential as a determinant of bioaerosol emission., Methods: We examined the performance of low and moderate volume bioaerosol samplers for the collection of viral RNA and infectious influenza virus in vitroand in vivo using artificial bioaerosols and the ferret model of influenza virus infection. The following samplers were tested: the polytetrafluoroethylene filter (PTFE filter), the 2-stage National Institute of Occupational Safety and Health cyclone sampler (NIOSH cyclone sampler) and the 6-stage viable Andersen impactor (Andersen impactor)., Results: The PTFE filter and NIOSH cyclone sampler collected similar amounts of viral RNA and infectious virus from artificially-generated aerosols under a range of relative humidities (RH). Using the ferret model, the PTFE filter, NIOSH cyclone sampler and the Andersen impactor collected up to 3.66 log 10 copies of RNA/L air, 3.84 log 10 copies of RNA/L air and 6.09 log 10 copies of RNA/L air respectively at peak recovery. Infectious virus was recovered from the PTFE filter and NIOSH cyclone samplers on the peak day of viral RNA recovery., Conclusion: The PTFE filter and NIOSH cyclone sampler are useful for influenza virus RNA and infectious virus collection and may be considered for clinical and environmental settings., (© 2019 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

This document updates the previous AMMI Canada Foundation Guidance (2013) on the use of antiviral therapy for influenza., (Copyright © 2019, Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada).)

Influenza A virus in swine is of significant importance to human and veterinary public health. Environmental sampling techniques that prove practical would enhance surveillance for influenza viruses in swine. The primary objective of this study was to demonstrate the feasibility of bioaerosol and surface sampling for the detection of influenza virus in swine barns with a secondary objective of piloting a mobile application for data collection. Sampling was conducted at a large swine operation between July 2016 and August 2017. Swine oral fluids and surface swabs were collected from multiple rooms. Room-level air samples were collected using four bioaerosol samplers: a low volume polytetrafluoroethylene (PTFE) filter sampler, the National Institute for Occupational Safety and Health's low volume cyclone sampler, a 2-stage Andersen impactor and/or one high volume cyclonic sampler. Samples were analysed using quantitative RT-PCR. Data and results were reported using a mobile data application. Eighty-nine composite oral fluid samples, 70 surface swabs and 122 bioaerosol samples were analysed. Detection rates for influenza virus RNA in swine barn samples were 71.1% for oral fluids, 70.8% for surface swabs and 71.1% for the PTFE sampler. Analysis revealed a statistically significant relationship between the results of the PTFE sampler and the surface swabs with oral fluid results (p < 0.001 and p < 0.01 respectively). In addition, both the PTFE sampler (p < 0.01) and surface swabs (p = 0.03) significantly correlated with, and predicted oral fluid results. Bioaerosol sampling using PTFE samplers is an effective hands-off approach for detecting influenza virus activity among swine. Further study is required for the implementation of this approach for surveillance and risk assessment of circulating influenza viruses of swine origin. In addition, mobile data collection stands to be an invaluable tool in the field by allowing secure, real-time reporting of sample collection and results., (© 2019 Blackwell Verlag GmbH.)

Transmission in hospital settings of seasonal influenza viruses and novel agents such as the Middle East respiratory syndrome coronavirus (MERS-CoV) is well-described but poorly understood. The characterization of potentially infectious bio-aerosols in the healthcare setting remains an important yet ill-defined factor in the transmission of respiratory viruses. Empiric data describing the distribution of bio-aerosols enable discernment of potential exposure risk to respiratory viruses. We sought to determine the distribution of influenza virus RNA emitted into the air by participants with laboratory-confirmed influenza, and whether these emissions had the potential to reach healthcare workers' breathing zones. Two-stage cyclone bio-aerosol samplers from the Centers for Disease Control and Prevention - National Institute for Occupational Safety and Health were placed 0.5-1.0 m (near field) and 2.1-2.5 m (far field) from infected patient participants, as well as in the corridor immediately outside their rooms. In addition, healthcare worker participants providing care to infected participants were recruited to wear a polytetrafluoroethylene (PTFE) filter cassette in their breathing zones. Viral RNA was detected from the air emitted by 37.5% of the 16 participants infected with influenza virus and distributed both in near and far fields and in all tested particle sizes (<1 µm, 1-4 µm, and >4 µm). Viral RNA was recovered in droplet nuclei and beyond 1 m from naturally-infected participants in the healthcare setting and from the breathing zone of one healthcare worker. There was no correlation between patient participant nasal viral load and recovery of viral RNA from the air, and we did not identify any significant association between RNA detection from the air and patient demographics or clinical presentation. A more substantial study is required to identify patient determinants of virus emission into the air and delineate implications for evidence-based policy for prevention and control.

The occurrence of influenza in different climates has been shown to be associated with multiple meteorological factors. The incidence of influenza has been reported to increase during rainy seasons in tropical climates and during the dry, cold months of winter in temperate climates. This study was designed to explore the role of absolute humidity (AH), relative humidity (RH), temperature, and wind speed (WS) on influenza activity in the Toronto, ON, Canada, area. Environmental data obtained from four meteorological stations in the Toronto area over the period from 1 January 2010 to 31 December 2015 were linked to patient influenza data obtained for the same locality and period. Data were analyzed using correlation, negative binomial regressions with linear predictors, and splines to capture the nonlinear relationship between exposure and outcomes. Our study found a negative association of both AH and temperature with influenza A and B virus infections. The effect of RH on influenza A and B viruses was controversial. Temperature fluctuation was associated with increased numbers of influenza B virus infections. Influenza virus was less likely to be detected from community patients than from patients tested as part of an institutional outbreak investigation. This could be more indicative of nosocomial transmission rather than climactic factors. The nonlinear nature of the relationship of influenza A virus with temperature and of influenza B virus with AH, RH, and temperature could explain the complexity and variation between influenza A and B virus infections. Predicting influenza activity is important for the timing of implementation of disease prevention and control measures as well as for resource allocation. IMPORTANCE This study examined the relationship between environmental factors and the occurrence of influenza in general. Since the seasonality of influenza A and B viruses is different in most temperate climates, we also examined each influenza virus separately. This study reports a negative association of both absolute humidity and temperature with influenza A and B viruses and tries to understand the controversial effect of RH on influenza A and B viruses. This study reports a nonlinear relation between influenza A and B viruses with temperature and influenza B virus with absolute and relative humidity. The nonlinear nature of these relations could explain the complexity and difference in seasonality between influenza A and B viruses, with the latter predominating later in the season. Separating community-based specimens from those obtained during outbreaks was also a novel approach in this research. These findings provide a further understanding of influenza virus transmission in temperate climates., (Copyright © 2019 Peci et al.)

The transmission of infectious microbes via bioaerosols is of significant concern for both human and animal health. However, gaps in our understanding of respiratory pathogen transmission and methodological heterogeneity persist. New developments have enabled progress in this domain, and one of the major turning points has been the recognition that cross-disciplinary collaborations across spheres of human and animal health, microbiology, biophysics, engineering, aerobiology, infection control, public health, occupational health, and industrial hygiene are essential. Collaborative initiatives support advances in topics such as bioaerosol behavior, dispersion models, risk assessment, risk/exposure effects, and mitigation strategies in clinical, experimental, agricultural, and other field settings. There is a need to enhance the knowledge translation for researchers, stakeholders, and private partners to support a growing network of individuals and agencies to achieve common goals to mitigate inter- and intra-species pathogen transmission via bioaerosols.

Nasopharyngeal swabs from 148 adult patients with influenza were analyzed by polymerase chain reaction for Staphylococcus aureus and or Streptococcus pneumoniae. We found that patients colonized with S. pneumoniae were younger, had lower oxygen saturations, and were more likely to require admission to critical care., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: The Canadian Network for Public Health Intelligence (CNPHI) is a secure, web-based scientific informatics and biosurveillance platform that leverages disparate public health information resources and expertise for the direct benefit of local, regional and national decision makers. CNPHI fosters collaboration and consultation through innovation in disease surveillance, intelligence exchange, research and response to protect, promote and support public health. The objective of this article is to present the CNPHI 'on the go' mobile application, and to discuss preliminary evaluation of the technology. The mobile application is intended to enable rapid mobile data collection using both online and offline modes supporting various stages of surveillance and response through the extension of data collection and analysis to the mobile environment., Methods: Two needs assessment meetings were held with stakeholders representing individuals from government, academia and research institutions, to inform the development of the CNPHI "on the go" mobile application. An initial version of the mobile technology (an "app") was developed and piloted by end-users with expertise in the field. Two focused pilots were conducted to test the technology: Pilot 1: 17-7-2017 to 21-11-2017 (6 participants); Pilot 2: 25-7-2017 to 15-9-2017 (2 participants). An initial consultation was held with the project leads to identify data elements for mobile data collection. A custom data collection form was designed using CNPHI's Web Data technology for each pilot, which was then made available through the mobile app. The technology was assessed using feedback received during each pilot as well as through a survey that was conducted at the conclusion of pilots., Results: Pilot participants reported that the mobile technology allowed seamless data collection, data management and rapid information sharing. Participants also reported that the entire process was seamless, simple, efficient, and that fewer steps were required for data collection and management. Further, significant efficiencies were gained by directly entering information using the mobile app without having to transfer handwritten information into an electronic database. An overall positive experience was reported by participants from both pilots., Discussion: Literature suggests that traditional methods of surveillance and data collection using a paper based methodology pose many challenges such as data loss and duplication, difficulty in managing the database, and lack of timely access to the data. Accurate and rapid access is critical for public health professionals in order to effectively make decisions and respond to public health emergencies. Results show that the CNPHI "on the go" app is well poised to address some of the suggested challenges. A limitation of this study was that sample size for pilot participation was small for capturing overall feedback on the readiness of the technology for integration into regular surveillance activities and response procedures., Conclusions: CNPHI "on the go" is a customizable technology developed within an already thriving collaborative CNPHI platform used by public health professionals, and performs well as a tool for rapid data collection and secure information sharing.

Contaminated surfaces serve as an important reservoir for Clostridium difficile transmission. Current strategies to detect environmental contamination of C. difficile rely heavily on culture, and often only indicate presence versus absence of spores. The goal of this study was to compare quantitative PCR (qPCR) to culture for the detection and quantification of C. difficile from inert surfaces. First, we compared the limit of detection (LOD) of a 16S rRNA gene and toxin B gene qPCR assay for detection of C. difficile in solution. Second, we compared the LODs of 16S rRNA gene qPCR versus culture for detection of C. difficile from surfaces. Solution experiments were performed by direct seeding of spores into neutralizing broth, whereas surface experiments involved seeding of spores onto plastic test surfaces, and recovery using sponge swabs. Both experiments were conducted using spores expressing short (NAP1) and long (NAP4) hair lengths. Combining data from both strains, the overall LOD for C. difficile cells in solution was 1.4 cells for 16S rRNA gene and 23.6 cells for toxin B gene qPCR (p<0.001). The overall LOD for C. difficile cells from surfaces was 17.1 cells for 16S rRNA gene qPCR and 54.5 cells for culture (p = 0.05), and was not statistically different between strains for each method (p = 0.52). Overall, the proportion of C. difficile cells recovered from surfaces was good when detected by 16S rRNA gene qPCR and culture (qPCR: 76%, culture: 67%, p = 0.36), but, 16S rRNA gene qPCR was capable of detecting lower levels of surface contamination. Future work attempting to measure the presence of C. difficile on environmental surfaces should consider using qPCR., Competing Interests: The authors have declared that no competing interests exist.

Objective: Clostridium difficile spores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmental C. difficile are unknown. We sought to determine whether increased sample surface area improved detection of C. difficile from environmental samples., Setting: Samples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada., Methods: Samples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficile infected) shedding risk. Presence of C. difficile in samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture., Results: Of the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2-13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9-181) more spores than bedrails, and rooms of C. difficile-positive patients yielded 11 times (95% CI, 0·55-164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings., Conclusions: Clostridium difficile spores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmental C. difficile in transmission should prefer samples with large surface areas.

Anthropogenic air pollution is ubiquitous in urban areas worldwide. Microorganisms such as bacteria and fungi in addition to other biological matter like endotoxins and spores comingle with particulate matter (PM) air pollutants but have rarely been considered in air pollution research. Microorganisms may be influenced by interactions with ambient particles in matrices such as soil and dust leading to the inhibition or enhancement of viability and environmental stability (e.g. tolerance to variation in seasonality, temperature, humidity, etc.). Similar effects of airborne particles on microbes are plausible; however, to our knowledge the influence of PM on airborne microbes has remained largely unexamined. In the case of microbial agents of communicable disease, such as viruses, the potential for interactions with pollution may have public health implications. Here we describe an experimental platform to study aerosol-aerosol interactions between PM2.5 particulate from urban air and artificially generated viral bioaerosol. Preliminary studies using this platform have revealed interactions between PM2.5 and the enveloped bacteriophage Φ6 that reduce infectivity of the bacteriophage by 44% compared to a control exposed only to HEPA-filtered air. Co-aerosolization and aging of concentrated PM2.5 with Φ6 in combination with ΦX174 (a non-enveloped bacteriophage) showed a similar trend in reduction of Φ6 infectivity but revealed an antithetical enhancement of ΦX174 infectivity compared to control exposures in HEPA-filtered air. Ongoing investigations are needed to understand the nature of interactions between bioaerosols and PM2.5 particles., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Prosthetic joint infections (PJI) of hip and knee arthroplasties are becoming increasingly common with an aging population and an increasing demand for these procedures. Despite attempts at standardization, medical and surgical approaches vary widely among practitioners., Questions/purposes: We first sought to determine if there were specific factors associated with choice of one- versus two-stage revision. Then we investigated whether the type of revision approach influenced clinical treatment success. Finally, among two-stage revisions, we assessed if an antibiotic holiday prior to the second procedure affected clinical treatment success., Methods: We retrospectively reviewed patients who had revision surgery for infection of a hip or knee arthroplasty between January 1, 2000, and December 31, 2013, at the Sunnybrook Health Sciences Centre and the Holland Orthopedic and Arthritic Centre. PJI cases were identified using the Ontario Joint Replacement Registry. Infection was defined by gross intraoperative evidence of infection, positive intraoperative culture(s), and/or sinus tract prior to operation. The primary outcome was treatment failure at 1 year after revision surgery based on requirement for further surgery, ongoing infection, and/or continuous suppressive antibiotics., Results: Of 110 eligible patients identified, 35 patients had a one-stage and 75 patients had a two-stage revision. Choice of a one-stage approach was most influenced by particular surgeon preference and was more likely for hip revision versus knee revision (OR 3.39 (95%CI 1.85-6.23). There was no statistical difference in clinical treatment success rate between one-stage (33/35; 94.2% success) and two-stage revision (63/75; 84%; p  = 0.13). Enterococcus spp. (21 versus 3%; p  = 0.027) and Peptostreptococcus spp. (14 versus 1%; p  = 0.042) were more common among clinical treatment failures than successes, with a trend towards the same for Staphylococcus aureus (29 versus 9%; p  = 0.06). Additionally, treatment success was not influenced by whether the patient had an antibiotic holiday with a two-stage revision., Conclusion: Our findings confirm the uncertainty of surgical strategy for treatment of PJI in hip and knee arthroplasty. Superiority of one- versus two-stage revision and the value of antibiotic-free periods prior to definitive revision remain unclear. Large prospective studies or randomized controlled trials are needed to inform best practice for treatment of these complex clinical problems.

We describe the current difference in reporting the performance of nanotechnology diagnostic devices between technologists and clinicians. This perspective specifies the "metrics" used to evaluate these devices and describes strategies to bridge the gap between these two communities in order to accelerate the translation from academic bench to the clinic. We use two recently published ACS Nano articles to highlight the evaluation of silicon nanowire and surface-enhanced Raman spectroscopy-breath diagnostic tests for patients afflicted with cancer and asthma. These studies represent some of the earliest studies of emerging nanotechnology devices utilizing clinical parameters to assess performance.

Background: The emergence of novel respiratory viruses such as avian influenza A(H7N9) virus and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) highlights the importance of understanding determinants of transmission to healthcare workers (HCWs) and the public., Objectives: We aim to determine the viral content of the air emitted by symptomatic inpatients or long-term care residents with laboratory-confirmed influenza virus infection (emitters), and in the breathing zones of healthcare workers who attend to them., Design: A prospective pilot study of patients with laboratory-confirmed influenza virus infection was undertaken. Air within 1m of the patient was sampled using a high volume air sampler. In addition, a lower volume air sampler was placed <1 m from the patient, with another >1 m from the patient. Viral RNA was recovered from the samplers and submitted for quantitative real time PCR. In addition, personal button samplers were provided to HCWs., Results: The air emitted by 15 participants with laboratory-confirmed influenza virus infection was sampled. Of the patients infected with influenza A, viral RNA was recovered from the air emitted by 9/12 patients using the low-volume sampler; no viral RNA was detected from air emitted by patients with influenza B (n=3). Influenza virus RNA was recovered from one HCW's sampler., Conclusions: Patients with respiratory virus infection emit virus into the air which disperses to >1 m and may reach the breathing zone of a HCW. This pilot study highlights the feasibility and importance of conducting a larger-scale study to identify determinants of exposure and transmission from patient to HCW., (Copyright © 2015 Elsevier B.V. All rights reserved.)

We analyzed the matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) of smudge plate growth for bacterial identification from 400 blood cultures. Ninety-seven percent of Gram-negative bacilli and 85% of Gram-positive organisms were correctly identified within 4 h; only eight isolates (2.0%) were misidentified. This method provided rapid and accurate microbial identification from positive blood cultures., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

The recent emergence of a severe respiratory disease caused by enterovirus D68 prompted investigation into whether Canadian hospital and provincial laboratories can detect this virus using commercial and laboratory-developed assays. This study demonstrated analytical sensitivity differences between commercial and laboratory-developed assays for the detection of enterovirus D68., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Bacterial pneumonia complicating influenza is well-recognized as a severe manifestation of influenza, accounting for a substantial number of deaths from the 1918 influenza pandemic. Influenza-associated bacterial pneumonia remains a major contributor to the burden of influenza, and poses new challenges as antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus spread. We provide an overview of the current state of knowledge of the epidemiology and co-pathogenesis of influenza-associated bacterial pneumonia, and outline management approaches and their limitations. We review preventative measures and discuss implications for pandemic planning. Knowledge gaps are underscored and future research directions are proposed.

Green infrastructure (GI), a network of nature, semi-natural areas and green space, delivers essential ecosystem services which underpin human well-being and quality of life. Maintaining ecosystem services through the development of GI is therefore increasingly recognized by policies as a strategy to cope with potentially changing conditions in the future. This paper assessed how current trends of land-use change have an impact on the aggregated provision of eight ecosystem services at the regional scale of the European Union, measured by the Total Ecosystem Services Index (TESI8). Moreover, the paper reports how further implementation of GI across Europe can help maintain ecosystem services at baseline levels. Current demographic, economic and agricultural trends, which affect land use, were derived from the so called Reference Scenario. This scenario is established by the European Commission to assess the impact of energy and climate policy up to 2050. Under the Reference Scenario, economic growth, coupled with the total population, stimulates increasing urban and industrial expansion. TESI8 is expected to decrease across Europe between 0 and 5 % by 2020 and between 10 and 15 % by 2050 relative to the base year 2010. Based on regression analysis, we estimated that every additional percent increase of the proportion of artificial land needs to be compensated with an increase of 2.2 % of land that qualifies as green infrastructure in order to maintain ecosystem services at 2010 levels.