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Presents a report on a group of SARS cases among health-care workers (HCW) in a Toronto, Ontario hospital that was using infection-control precautions. Details of the medical history, symptoms, care, and outcome for the index patient who was a Canadian family physician; Description of precautions taken by the nine HCW who cared for the patient and later exhibited symptoms themselves; Editorial note from the Centers for Disease Control and Prevention about SARS transmission and intubation; Assertion that HCW need to be properly trained in the correct use of personal protective equipment and hand hygiene.

Objective: Utilizing biological scaffolds for cartilage tissue engineering is a promising tool for improving auricular reconstruction. Decellularized auricular scaffolds provide a means of regenerating cartilage for in vivo implantation, but identifying the ideal regenerative mix remains challenging., Methods: Human cadaver auricular cartilage was decellularized and recellularized with either auricular chondrocytes alone, auricular chondrocytes with adipose-derived stem cells, or both cells with platelet-rich plasma. Confirmation of decellularization and recellularization was done by hematoxylin and eosin staining. Extracellular matrix preservation and production were determined by Masson's trichrome, Alcian blue, and Verhoeff-van Gieson staining. Collagen II assessments were made using immunohistochemistry., Results: Decellularization of cadaver auricular cartilage was confirmed by the absence of cells, reduction in glycosaminoglycans, and the preservation of collagen and elastin. Recellularization was more efficient when chondrocytes were seeded with adipose-derived stem cells, which was enhanced by adding platelet-rich plasma. Coculture with platelet-rich plasma yielded better total collagen (56% increase) and glycosaminoglycan (47% increase) induction. Moreover, when platelet-rich plasma was added, collagen II induction was significantly increased (42%; P < 0.05)., Conclusion: We identified a regenerative protocol that included auricular chondrocytes, adipose-derived stem cells, and platelet-rich plasma, which stimulated chondrogenesis on decellularized auricular cartilage. This finding provides a model to explore cartilage formation and the potential for improving auricular and cartilage-based reconstruction., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Intensity-modulated radiation therapy and other modifiable radiation factors have been associated with decreased radiation toxicity. These factors could allow for improved reconstructive outcomes in patients requiring postmastectomy radiation therapy (PMRT). However, they have not yet been well studied in implant-based breast reconstruction., Methods: The authors performed a retrospective chart review of patients who underwent mastectomy with immediate tissue expander placement followed by PMRT. Radiation characteristics were collected, including radiation technique, bolus regimen, x-ray energy, fractionation, maximum radiation hot spot, and tissue volume receiving more than 105% or more than 107% of the prescription dose. Reconstructive complications occurring after initiation of PMRT were analyzed with respect to these radiation characteristics., Results: Sixty-eight patients (70 breasts) were included in this study. The overall complication rate was 28.6%, with infection being the most common complication (24.3%), requiring removal of the tissue expander or implant in greater than half of infections (15.7%). Maximum radiation hot spot was greater in patients who required explantation after PMRT, and this approached statistical significance (114.5% ± 7.2% versus 111.4% ± 4.4%; P = 0.059). Tissue volume receiving more than 105% and 107% were also greater in patients who required explantation after PMRT (42.1% ± 17.1% versus 33.0% ± 20.9% and 16.4% ± 14.5% versus 11.3% ± 14.6%, respectively); however, this was not statistically significant ( P = 0.176 and P = 0.313, respectively). There were no significant differences in complication rates between patients with respect to radiation technique or other radiation characteristics studied., Conclusion: Minimizing the radiation hot spots and volumes of tissue receiving greater than the prescription dose of radiation may improve reconstructive outcomes in patients undergoing implant-based breast reconstruction followed by PMRT., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose: Chronic inflammation is integral to myeloproliferative neoplasm (MPN) pathogenesis. JAK inhibitors reduce cytokine levels, but not without significant side effects. Nutrition is a low-risk approach to reduce inflammation and ameliorate symptoms in MPN. We performed a randomized, parallel-arm study to determine the feasibility of an education-focused Mediterranean diet intervention among patients with MPN., Experimental Design: We randomly assigned patients with MPN to either a Mediterranean diet or standard U.S. Dietary Guidelines for Americans (USDA). Groups received equal but separate education with registered dietician counseling and written dietary resources. Patients were prospectively followed for feasibility, adherence, and symptom burden assessments. Biological samples were collected at four timepoints during the 15-week study to explore changes in inflammatory biomarkers and gut microbiome., Results: The Mediterranean diet was as easy to follow for patients with MPN as the standard USDA diet. Approximately 80% of the patients in the Mediterranean diet group achieved a Mediterranean Diet Adherence Score of ≥8 throughout the entire active intervention period, whereas less than 50% of the USDA group achieved a score of ≥8 at any timepoint. Improvement in symptom burden was observed in both diet groups. No significant changes were observed in inflammatory cytokines. The diversity and composition of the gut microbiome remained stable throughout the duration of the intervention., Conclusions: With dietician counseling and written education, patients with MPN can adhere to a Mediterranean eating pattern. Diet interventions may be further developed as a component of MPN care, and potentially incorporated into the management of other hematologic conditions., Significance: Diet is a central tenant of management of chronic conditions characterized by subclinical inflammation, such as cardiovascular disease, but has not entered the treatment algorithm for clonal hematologic disorders. Here, we establish that a Mediterranean diet intervention is feasible in the MPN patient population and can improve symptom burden. These findings warrant large dietary interventions in patients with hematologic disorders to test the impact of diet on clinical outcomes., (© 2024 The Authors; Published by the American Association for Cancer Research.)

Background: Increasing body mass index (BMI) is a known risk factor for autologous microsurgical breast reconstruction. No prior studies have stratified outcomes across BMI ranges or defined the BMI at which complication rates dramatically increase., Methods: The authors performed a retrospective chart review of all patients who underwent abdominally based autologous free flap breast reconstruction at their institution between 2004 and 2021. Clinical, surgical, and outcomes data were collected. Patients were stratified into five BMI categories: 25, 25.01 to 30, 30.01 to 35, 35.01 to 40, and greater than 40 kg/m 2 . Complication rates were analyzed across these groups, and a receiver-operating characteristic analysis was used to determine an optimal BMI cutoff point., Results: A total of 365 patients (545 breasts) were included in this study. The rates of several breast complications significantly increased with increasing BMI at distinct levels, including any breast complication (BMI >30 kg/m 2 ), unplanned reoperation (BMI >35 kg/m 2 ), fat necrosis (BMI >40 kg/m 2 ), wound breakdown requiring re-operation (BMI >35 kg/m 2 ), any infection (BMI >30 kg/m 2 ), infection requiring oral antibiotics (BMI >25 kg/m 2 ), infection requiring intravenous antibiotics (BMI >35 kg/m 2 ), and mastectomy flap necrosis (BMI >35 kg/m 2 ). The rates of many abdominal complications significantly increased with increasing BMI at distinct levels as well, including delayed wound healing (BMI >30 kg/m 2 ), wound breakdown requiring re-operation (BMI >40 kg/m 2 ), any infection (BMI >25 kg/m 2 ), and infection requiring oral antibiotics (BMI >25 kg/m 2 ). Optimal BMI cutoffs of 32.7 and 30.0 kg/m 2 were determined to minimize the occurrence of any breast complication and any abdomen complication, respectively., Conclusions: Preoperative weight loss has great potential to alleviate surgical risk in overweight and obese patients pursuing autologous breast reconstruction. The authors' results quantify the risk reduction based on a patient's preoperative BMI., Clinical Question/level of Evidence: Risk, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The impact of concurrent chemotherapy and immunotherapy has been well characterized in patients with recurrent and metastatic head and neck squamous cell carcinoma (RM-SCCHN). Here, we report outcomes in patients treated sequentially with immune checkpoint inhibition (ICI) followed by carboplatin and paclitaxel., Methods: Patients with RM-SCCHN treated with ICI followed by carboplatin/paclitaxel at a single institution were identified retrospectively. ICI therapy history, p16, and PD-L1 status were collected. The best overall response was assessed by RECIST v1.1., Results: Twelve patients met inclusion criteria. Eight patients received pembrolizumab, three durvalumab, and one nivolumab. The median duration of ICI was 3.44 months, median PFS was 5.8 months, and median OS was 15.2 months. 66.7% of patients had an objective response on carboplatin/paclitaxel., Conclusions: Carboplatin/paclitaxel can induce objective responses in patients with prior treatment with ICI and clinical outcomes in this small series compare favorably to those seen in ICI naïve patients., (© 2023 The Authors. Head & Neck published by Wiley Periodicals LLC.)

Background: Despite improvement in abdominal morbidity with deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to prior abdominally-based free flap breast reconstruction, abdominal bulge, and hernia rates have been cited anywhere from 2% to 33%. As a result, some surgeons utilize mesh or other reinforcement upon donor-site closure, but its benefit in preventing abdominal wall morbidity has not been well-defined for DIEP flaps. The purpose of this systematic review is to evaluate DIEP donor-site closure techniques and the impact of mesh type and plane on abdominal-wall morbidity including hernia and bulge, relative to primary fascial closure., Methods: MEDLINE, PubMED, Cochrane Library, and SCOPUS were systematically reviewed for studies evaluating DIEP flap breast reconstruction abdominal-donor site closure, where any mesh reinforcement or primary fascial closure was specified, and postoperative outcomes of hernia and/or abdominal bulge were reported. Analysis was performed in Review Manager (RevMan) evaluating mesh use, type, and plane relative to primary fascial closure, using the Mantel-Haenszel method to calculate odds ratios (ORs) of significance level p < .05, and a random effects model to account for inter-study heterogeneity., Results: Of the 2791 DIEP patients across 11 studies, 1901 patients underwent primary closure and 890 were repaired with mesh. When hernia and/or bulge were combined into a single complication, the use of any mesh did not significantly reduce its odds compared to primary closure (OR = 0.69, p = .20). Similarly, the use of any mesh did not significantly reduce the odds of bulge alone compared to primary closure (OR = 0.62, p = .43). However, the odds of hernia alone were significantly reduced by 72% with any mesh use (OR = 0.28, p = .03)., Conclusion: Mesh use was significantly associated with decreased odds of hernia alone with DIEP flap surgery, but there was no difference in bulge or combined hernia/bulge rates. As bulge is the more common abdominal morbidity after DIEP flap harvest in a patient with no prior abdominal surgery or risk factor for hernia, mesh use is not indicated in abdominal closure of all DIEP patients. Future prospective studies are warranted to characterize the specific indications for mesh use in the setting of DIEP flap surgery., (© 2023 Wiley Periodicals LLC.)

Background: Historically, men have been shamed if they cared seemingly too much about their appearance and especially, if they pursued aesthetic surgery. However, due to the changing landscape of the culture, this stigma has seemed to decrease. Men have diverse and quickly changing interests in particular procedures that have not been readily explored in the currently available reports. To examine this, we analyzed interest in specific plastic surgery procedures in men over the last two decades using the Google Trends tool., Methods: The most common cosmetic procedures were chosen from the American Society of Plastic Surgeons website and served as the search terms for the Google Trends tool from 2004 to 2021. All 19 procedures were examined for overall trends and for changes in the last decade through comparing the data in bisected time periods., Results: Interest in all plastic surgery procedures in men increased since 2004 except for breast reduction. Most notably, jawline filler, Botox, microneedling, lip filler, chemical peel, CoolSculpting, and butt lift had the largest trend increases. In the last decade, all procedures showed a significant increase in interest., Conclusions: While surgical volume data are valuable, our study shows that Google Trends is a beneficial tool to predict quickly changing and specific trends, especially as the patient population of plastic surgery grows with increased diversity and generational changes. Our study shows that there is an increase in male-centered plastic surgery procedures, especially nonsurgical facial procedures. Male interest in plastic surgery will continue to increase with time., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 ., (© 2023. The Author(s).)

Purpose: Currently, no treatment corrects the contractile nature of Dupuytren myofibroblasts (DMFs) or prevents recurrence following surgery. Antifibrotic and proadipogenic growth factors are released when adipose-derived stem cells (ASCs) are cultured with platelet-rich plasma (PRP), a platelet concentration from whole blood. Reprograming myofibroblasts into adipocytes via growth factors is proposed as a powerful potential tool to target fibrosis. We aimed to assess whether the combination of ASCs and PRP reprograms DMFs into adipocytes in vitro and alters their contractile nature in vivo., Methods: Normal human dermal fibroblasts (NHDFs) and DMFs from Dupuytren patients were isolated and cocultured with ASCs and PRP either alone or together. Adipocytes were detected by Oil Red O and perilipin staining. DMFs and NHDFs were transplanted into the forepaws of rats (Rowett Nude [rnu/rnu]) and treated with saline, PRP+ASCs, or collagenase Clostridium histolyticum (clinical comparison) 2 months later. After 2 weeks, the tissue was harvested and subjected to Masson trichrome staining, and collagen I and III and alpha-smooth muscle actin detection by immunohistochemistry., Results: Myofibroblasts transform into adipocytes upon coculture with PRP+ASCs. DMFs show increased alpha-smooth muscle actin expression in vivo compared with NHDFs, which is significantly decreased after PRP+ASCs and collagenase Clostridium histolyticum treatments. DMFs induce collagen I and III expressions in rat paws compared with NHDFs, with a type III to I ratio increase. Treatment with PRP+ASC reduced the ratio, but collagenase Clostridium histolyticum did not., Conclusions: Treating DMFs with PRP+ASCs provides factors that induce myofibroblast to adipocyte transformation. This treatment reduces the contractile phenotype and fibrosis markers in vivo. Future studies should detail the mechanism of this conversion., Clinical Relevance: The combination of PRP and ASCs to induce the differentiation of DMFs into adipocytes may serve to limit surgery to a percutaneous contracture release and biological injection, rather than a moderate or radical fasciectomy, and reduce the recurrence of Dupuytren contracture., (Copyright © 2023. Published by Elsevier Inc.)

Approximately 20% of retained foreign bodies are surgical needles. Retained macro-needles may become symptomatic, but the effect of microsurgical needles is uncertain. We present the first animal model to simulate microsurgical needle retention. Given a lack of reported adverse outcomes associated with macro-needles and a smaller cutting area of microsurgical needles, we hypothesized that microsurgical needles in rats would not cause changes in health or neurovascular compromise., Methods: Male Sprague-Dawley rats (x̄ weight: 288.9 g) were implanted with a single, 9.0 needle (n = 8) or 8.0 needle (n = 8) orthogonal to the right femoral vessels and sutured in place. A control group (n = 8) underwent sham surgery. Weekly, a cumulative health score evaluating body weight, body condition score, physical appearance, and behavior for each rat was determined. Infrared thermography (°C, FLIR one) of each hindlimb and the difference was obtained on postoperative days 15, 30, 60, and 90. On day 90, animals were euthanatized, hindlimbs were imaged via fluoroscopy, and needles were explanted., Results: The mean, cumulative health score for all cohorts at each weekly timepoint was 0. The mean temperature difference was not significantly different on postoperative days 15 ( P = 0.54), 30 ( P = 0.97), 60 ( P = 0.29), or 90 ( P = 0.09). In seven of eight rats, 8.0 needles were recovered and visualized on fluoroscopy. In six of eight rats, 9.0 needles were recovered, but 0/8 needles were visualized on fluoroscopy., Conclusions: Microsurgical needle retention near neurovascular structures may be benign, and imaging for needles smaller than 8.0 may be futile. Further studies should explore microsurgical needle retention potentially through larger animal models., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: While free-flap breast reconstruction becomes more common, it is still approached with caution in older patients. Outcomes in the elderly population have not been well characterized, especially with regard to donor-site sequalae. This study compares microvascular autologous breast reconstruction outcomes in patients older and younger 60 years., Methods: A single-institution retrospective review was performed for microvascular autologous breast reconstruction from January 2004 through January 2021. Demographic, intraoperative, and postoperative variables, including breast flap and donor-site complications, were evaluated., Results: Five hundred forty-five breast free flaps were identified, of which 478 (87.8%) were performed on patients younger than 60 years (mean, 46.2 years) and 67 (12.2%) older than 60 years (mean, 64.8 years; P = 0.000). Hyperlipidemia was significantly higher in older patients (19.4% vs 9.6%, P = 0.016). Mean operative time was 46.3 minutes faster in the older cohort ( P = 0.030). There were no significant differences in free-flap loss, venous congestion, takeback, hematoma, seroma, wound healing, or infection. Interestingly, there were significantly more total breast flap complications (28.5% vs 16.4%, P = 0.038) and higher rates of fat necrosis (9.6% vs 1.5%, P = 0.026) in the younger cohort. Significantly more abdominal donor-site complications (43.3% vs 21.3%, P = 0.000) were seen in the older people, with increased wound breakdown ( P = 0.000) and any return to the operating room (20.9% vs 9.8%, P = 0.007). Older patients were also significantly more likely to require surgical correction of an abdominal bulge or hernia (10.4% vs 4%, P = 0.020). The mean follow-up was 1.8 years., Conclusions: Our data showed no worsening of individual breast flap outcomes in the older people. However, there were significantly more abdominal complications including surgical correction of abdominal bulge and hernia. This may be related to the inherent qualities of tissue aging and should be taken into consideration for flap selection. These results support autologous breast reconstruction in patients older than 60 years, but patients should be counseled regarding potentially increased abdominal donor-site sequelae., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Due to the SARS-CoV-2 (COVID-19) pandemic, many elective surgeries were canceled, including most aesthetic plastic surgery procedures. Although studies have shown COVID-19's effect on plastic surgery in the United States, no study to date has examined the international interest in plastic surgery procedures after the start of the COVID-19 pandemic. Thus, we sought to find this effect using the Google Trends tool., Material and Methods: The most common cosmetic procedures and top countries with the highest plastic surgery volume were selected from the International Society of Plastic Surgeons report and used as the search terms for Google Trends. Weekly search data from each procedure and country were collected from March 18, 2018 to March 13, 2022, split into 2 periods according to the start of the US COVID-19 lockdown, and compared., Results: Among the countries, the United States had the most plastic surgery interest after the COVID-19 pandemic, with India and Mexico closely following. On the other hand, Russia and Japan had the fewest changes in procedure interest. Regarding specific procedures, interest in breast augmentation, forehead lift, injectable filler, laser hair removal, liposuction, microdermabrasion, and rhytidectomy increased in all countries after the COVID-19 pandemic., Conclusions: After COVID-19, there has been increasing interest in almost all plastic surgery procedures globally, especially nonsurgical procedures and facial plastic surgery, with the greatest increases in the United States, India, and Mexico. These results can help inform plastic surgeons which procedures to focus on and which devices or technologies to invest in that are specific to their country., (© 2023 The Author(s).)

Introduction: Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates., Methods: We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed., Results: One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics., Conclusions: Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: We declare no competing interests. OH is from the Mohawk community of Akwesasne (Haudenosaunee Confederacy).

There is a rapidly closing window of opportunity to stop biodiversity loss and secure the resilience of all life on Earth. In December 2022, Parties to the United Nations (UN) Convention on Biological Diversity (CBD) will meet in Montreal, Canada, to finalize the language and terms of the Post-2020 Global Biodiversity Framework ( Post-2020 GBF ). The Post-2020 GBF aims to address the shortcomings of the previous Strategic Plan on Biodiversity 2011-2020 , by introducing a Theory of Change, that states that biodiversity protection will only be successful if unprecedented, transformative changes are implemented effectively by Parties to the CBD. In this policy perspective, we explore the implications of the Theory of Change chosen to underpin the Post-2020 GBF , specifically that broad social transformation is an outcome that requires actors to be specified. We detail how the health sector is uniquely positioned to be an effective actor and ally in support of the implementation of the Post-2020 GBF . Specifically, we highlight how the core competencies and financial and human resources available in the health sector (including unique knowledge, skill sets, experiences, and established trust) provide a compelling, yet mostly untapped opportunity to help create and sustain the enabling conditions necessary to achieve the goals and targets of the framework. While by no means a panacea for the world's biodiversity problems, we posit that explicitly omitting the health sector from the Post-2020 GBF substantially weakens the global, collective effort to catalyze the transformative changes required to safeguard biodiversity.

Objective: "Nature prescriptions" are increasingly being adopted by health sectors as an adjunct to standard care to attend to health and social needs. We investigated levels of need and interest in nature prescriptions in adults with cardiovascular diseases, psychological distress and concomitants (e.g. physical inactivity, sedentary behaviour, obesity, loneliness, burn-out)., Methods: A nationally-representative survey of 3,319 adults across all states and territories of Australia was completed in February 2021 (response 84.0%). Participants were classified across 15 target groups using validated health indicators and surveyed on (1) time and frequency of visits to green and blue spaces (nature spaces), (2) interest in a nature prescription, and (3) potential confounders (e.g. age, income). Analyses were done using weighted logistic regressions., Results: The sample was 50.5% female, 52.0% were aged ≥45 years, 15.2% were living alone and 19.3% were born overseas in non-English-speaking countries. Two-thirds of the sample spent 2 hours or more a week in nature, but these levels were generally lower in target groups (e.g. 57.7% in adults with type 2 diabetes). Most participants (81.9%) were interested in a nature prescription, even among those spending fewer than 2 hours a week in nature (76.4%). For example, 2 hours a week or more in nature was lowest among sedentary adults (36.9%) yet interest in nature prescriptions in this group was still high (74.0%). Lower levels of nature contact in target groups was not explained by differences in access to or preference for local nature spaces., Conclusions: High levels of interest in nature prescriptions amid low levels of nature contact in many target health groups provides impetus for developing randomised trials of interventions that enable people to spend more time in nature. These findings can inform intervention co-design processes with a wide range of community stakeholders, end-users in target health groups, and the health professionals who support them., (Copyright © 2022. Published by Elsevier B.V.)

Background: Case-based surveillance of antimicrobial resistance (AMR) provides more actionable data than isolate- or sample-based surveillance. We developed A Clinically Oriented antimicrobial Resistance surveillance Network (ACORN) as a lightweight but comprehensive platform, in which we combine clinical data collection with diagnostic stewardship, microbiological data collection and visualisation of the linked clinical-microbiology dataset. Data are compatible with WHO GLASS surveillance and can be stratified by syndrome and other metadata. Summary metrics can be visualised and fed back directly for clinical decision-making and to inform local treatment guidelines and national policy. Methods: An ACORN pilot was implemented in three hospitals in Southeast Asia (1 paediatric, 2 general) to collect clinical and microbiological data from patients with community- or hospital-acquired pneumonia, sepsis, or meningitis. The implementation package included tools to capture site and laboratory capacity information, guidelines on diagnostic stewardship, and a web-based data visualisation and analysis platform. Results: Between December 2019 and October 2020, 2294 patients were enrolled with 2464 discrete infection episodes (1786 community-acquired, 518 healthcare-associated and 160 hospital-acquired). Overall, 28-day mortality was 8.7%. Third generation cephalosporin resistance was identified in 54.2% (39/72) of E. coli and 38.7% (12/31) of K. pneumoniae isolates . Almost a quarter of S. aureus isolates were methicillin resistant (23.0%, 14/61). 290/2464 episodes could be linked to a pathogen, highlighting the level of enrolment required to achieve an acceptable volume of isolate data. However, the combination with clinical metadata allowed for more nuanced interpretation and immediate feedback of results. Conclusions: ACORN was technically feasible to implement and acceptable at site level. With minor changes from lessons learned during the pilot ACORN is now being scaled up and implemented in 15 hospitals in 9 low- and middle-income countries to generate sufficient case-based data to determine incidence, outcomes, and susceptibility of target pathogens among patients with infectious syndromes., Competing Interests: Competing interests: I am a board member of Wellcome SEDRIC, (Copyright: © 2022 van Doorn HR et al.)

Background: The Centers for Disease Control and Prevention reports that catheter-associated urinary tract infections (CAUTIs) are the most common hospital-acquired infection. Female external urinary collection devices (EUCDs) may be an alternative to indwelling urethral catheters (IUCs), thereby decreasing CAUTIs. However, no study has demonstrated that EUCDs can help reduce CAUTIs in female surgical patients. We sought to compare CAUTI rate and the median number of days an IUC was used before and after availability of this female EUCD for surgical patients., Methods: A retrospective analysis of adult female surgical patients admitted to a single academic institution who received an IUC and/or EUCD was performed. Patients who received an IUC three months before (PRE) EUCD availability (08/2017-10/2017) were compared to patients receiving an IUC and/or EUCD 12 months after (POST) (11/2017-11/2018)., Results: From 906 surgical patients receiving an IUC/EUCD, 127 received an EUCD in the POST cohort. Compared to the PRE, the POST had a higher rate of CAUTIs (infections per 1000 catheter days, 11.2 vs. 4.6, p = 0.017) and overall UTI rate (infections per 1000 catheter days, 5.4 vs. 4.8, p = 0.036), whereas IUC days were similar between cohorts (median, two vs. two days, p = 0.18). The POST cohort rate of EUCD UTI was 4.6 infections per 1000 device days., Conclusion: While EUCDs appear to be a promising alternative to IUCs for female surgical patients, this study found increased CAUTIs after introduction of an EUCD. Further research is needed to clarify if female EUCDs are effective in decreasing CAUTI prior to widespread adoption., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Individuals experiencing homelessness face unique barriers to oral health care. In collaboration with local universities in Ottawa, Canada, research was conducted to explore the experiences of Community Veterinary Outreach (CVO) clients in accessing oral health care. CVO utilizes a One Health approach, providing preventive veterinary care alongside human health care services to promote health service uptake among pet owners experiencing homelessness. Based on the results of 4 research projects, this short communication proposes recommendations for promoting accessible oral health care and increasing service uptake at One Health clinics by CVO clients experiencing homelessness. Relevant themes leading to the recommendations were 1) barriers to care, including financial and individual circumstances, and discrimination by service providers; and 2) facilitators of care, including the presence of pets, compassionate care, and care received in community settings. Recommendations to improve accessibility of oral health services for CVO clients are 1) continuation of pet-friendly services; 2) delivery of oral health care in alternative settings; and 3) reduction of discrimination through continuing education for oral health professionals. It is hypothesized that the implementation of these recommendations will improve oral health care service accessibility and uptake among clients at CVO clinics and in the community., Competing Interests: Brianna Jennings was a MSW Practicum student at Community Veterinary Outreach (CVO) and was paid an honorarium by CVO as part of her placement. Michelle Lem and Susan Kilborn supervised the placement and were supported through a “One Health" knowledge translation grant. Amanda Acker served on the board of directors of CVO during the research and writing phases of this project. She resigned from the board in March 2021., (Copyright © 2022 CDHA | ACHD.)

Approximately 35 000 people experience homelessness in some form each night in Canada, with similar rates (approximately 1/200 individuals) among developed countries. Ten to twenty percent of those individuals are pet owners. Animal companionship provides a variety of mental and physical benefits to people who are living homeless or vulnerably housed, but many in the non-vulnerable sector, including veterinary professionals and animal welfare advocates, express concern for the health and welfare of these animals. We describe the demographics of a population of animals owned by individuals experiencing homelessness and housing vulnerability, and investigate animal and owner factors influencing body condition score and over-conditioning using data collected from Community Veterinary Outreach (CVO). Community Veterinary Outreach is a registered charity focused on improving the health and welfare of people and their pets who are experiencing homelessness and housing vulnerability. The organization provides free services to clients in ten Canadian communities. Data associated with 636 owners and 946 animals were collected during clinics held between April 2018 and March 2020, representing a total of 1124 visits. The population of dogs and cats seen by CVO was demographically similar to populations seen in general companion animal veterinary practice and were in similar health. For both species, the mean body condition score was 5.4/9, where an ideal score is five for cats and four to five for dogs, and 38 % of animals were considered over-conditioned (overweight/obese). Risk factor analysis demonstrated significant associations between being over-conditioned and pet age and the reason for the veterinary visit for cats, and pet age, the number of abnormal findings on physical exam, and a previous CVO visit for dogs. Pet age, sex-neuter status, disease of the oral cavity, and a previous CVO visit were significantly associated with body condition score in cats. Body condition score in dogs was associated with owner age, and with interactions between pet age and breed size group, and between sex-neuter status and owner-reported housing security. These findings suggest that animals owned by those experiencing homeless and housing vulnerability are generally in good health and similar factors influence body condition score and over-conditioning as animals seen in general companion animal veterinary practice. Further efforts to provide support to pet owners within these communities by veterinarians will help support the good health of this population., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

Approximately one in 10 people experiencing homelessness have pets. Despite the psychosocial benefits derived from pet ownership, systemic and structural barriers can prevent this group from meeting their basic needs and exiting homelessness. A multilevel framework is proposed for improving the health and well-being of pet owners experiencing homelessness. Informed by a One Health approach, the framework identifies interventions at the policy, public, and direct service delivery levels. Policy interventions are proposed to increase the supply of pet-friendly emergency shelters, access to market rental housing and veterinary medicine, and the use of a Housing First approach. At the public level, educational interventions are needed to improve knowledge and reduce stigma about the relationship between homelessness and pet ownership. Direct service providers can support pet owners experiencing homelessness by recognizing their strengths, connecting them to community services, being aware of the risks associated with pet loss, providing harm reduction strategies, documenting animals as emotional support animals, and engaging in advocacy. By targeting policies and service approaches that exacerbate the hardships faced by pet owners experiencing homelessness, the framework is a set of deliberate actions to better support a group that is often overlooked or unaccommodated in efforts to end homelessness.