Background: Infection prevention and control (IPC) workflows are often retrospective and manual. New tools, however, have entered the field to facilitate rapid prospective monitoring of infections in hospitals. Although artificial intelligence (AI)–enabled platforms facilitate timely, on-demand integration of clinical data feeds with pathogen whole-genome sequencing (WGS), a standardized workflow to fully harness the power of such tools is lacking. We report a novel, evidence-based workflow that promotes quicker infection surveillance via AI-assisted clinical and WGS data analysis. The algorithm suggests clusters based on a combination of similar minimum inhibitory concentration (MIC) data, timing of sample collection, and shared location stays between patients. It helps to proactively guide IPC professionals during investigation of infectious outbreaks and surveillance of multidrug-resistant organisms and healthcare-acquired infections. Methods: Our team established a 1-year workgroup comprised of IPC practitioners, clinical experts, and scientists in the field. We held weekly roundtables to study lessons learned in an ongoing surveillance effort at a tertiary care hospital—utilizing Philips IntelliSpace Epidemiology (ISEpi), an AI-powered system—to understand how such a tool can enhance practice. Based on real-time case discussions and evidence from the literature, a workflow guidance tool and checklist were codified. Results: In our workflow, data-informed clusters posed by ISEpi underwent triage and expert follow-up analysis to assess: (1) likelihood of transmission(s); (2) potential vector(s) identity; (3) need to request WGS; and (4) intervention(s) to be pursued, if warranted. In a representative sample (spanning October 17, 2019, to November 7, 2019) of 67 total isolates suggested for inclusion in 19 unique cluster investigations, we determined that 9 investigations merited follow-up. Collectively, these 9 investigations involved 21 patients and required 115 minutes to review in ISEpi and an additional 70 minutes of review outside of ISEpi. After review, 6 investigations were deemed unlikely to represent a transmission; the other 3 had potential to represent transmission for which interventions would be performed. Conclusions: This study offers an important framework for adaptation of existing infection control workflow strategies to leverage the utility of rapidly integrated clinical and WGS data. This workflow can also facilitate time-sensitive decisions regarding sequencing of specific pathogens given the preponderance of available clinical data supporting investigations. In this regard, our work sets a new standard of practice: precision infection prevention (PIP). Ongoing effort is aimed at development of AI-powered capabilities for enterprise-level quality and safety improvement initiatives.

Funding: Philips Healthcare provided support for this study.

Disclosures: Alan Doty and Juan Jose Carmona report salary from Philips Healthcare.

Background: Infection prevention surveillance for cross transmission is often performed by manual review of microbiologic culture results to identify geotemporally related clusters. However, the sensitivity and specificity of this approach remains uncertain. Whole-genome sequencing (WGS) analysis can help provide a gold-standard for identifying cross-transmission events. Objective: We employed a published WGS program, the Philips IntelliSpace Epidemiology platform, to compare accuracy of two surveillance methods: (i.) a virtual infection practitioner (VIP) with perfect recall and automated analysis of antibiotic susceptibility testing (AST), sample collection timing, and patient location data and (ii) a novel clinical matching (CM) algorithm that provides cluster suggestions based on a nuanced weighted analysis of AST data, timing of sample collection, and shared location stays between patients. Methods: WGS was performed routinely on inpatient and emergency department isolates of Enterobacter cloacae, Enterococcus faecium, Klebsiella pneumoniae, and Pseudomonas aeruginosa at an academic medical center. Single-nucleotide variants (SNVs) were compared within core genome regions on a per-species basis to determine cross-transmission clusters. Moreover, one unique strain per patient was included within each analysis, and duplicates were excluded from the final results. Results: Between May 2018 and April 2019, clinical data from 121 patients were paired with WGS data from 28 E. cloacae, 21 E. faecium, 61 K. pneumoniae, and 46 P. aeruginosa isolates. Previously published SNV relatedness thresholds were applied to define genomically related isolates. Mapping of genomic relatedness defined clusters as follows: 4 patients in 2 E. faecium clusters and 2 patients in 1 P. aeruginosa cluster. The VIP method identified 12 potential clusters involving 28 patients, all of which were “pseudoclusters.” Importantly, the CM method identified 7 clusters consisting of 27 patients, which included 1 true E. faecium cluster of 2 patients with genomically related isolates. Conclusions: In light of the WGS data, all of the potential clusters identified by the VIP were pseudoclusters, lacking sufficient genomic relatedness. In contrast, the CM method showed increased sensitivity and specificity: it decreased the percentage of pseudoclusters by 14% and it identified a related genomic cluster of E. faecium. These findings suggest that integrating clinical data analytics and WGS is likely to benefit institutions in limiting expenditure of resources on pseudoclusters. Therefore, WGS combined with more sophisticated surveillance approaches, over standard methods as modeled by the VIP, are needed to better identify and address true cross-transmission events.

Funding: This study was supported by Philips Healthcare.

Disclosures: None

Introduction: Epidemiologic and modeling studies suggest that between 45 and 70% of individuals with chronic hepatitis C virus (HCV) infection in Canada remain undiagnosed. The Canadian Association for the Study of the Liver (CASL) recommends one-time screening of baby boomers (1945-1975). Screening programs in the US have shown a very high prevalence of previously undiagnosed HCV among patients seen in the emergency department (ED). We sought to assess the feasibility of implementing a targeted birth-cohort HCV screening program in a Canadian ED setting. Methods: Patients born from 1945 to 1975 presenting to the ED of a downtown Toronto hospital were offered HCV testing. Patients with life-threatening conditions, unable to provide verbal consent in English or intoxication were excluded. Blood samples were collected by finger prick on Dried Blood Spot (DBS) collection cards and tested for anti-HCV antibody with reflex to HCV RNA. Patients with positive HCV RNA were referred to a liver specialist. Results: During a 27-month period (July 2017 - Sept 2019), 8363 patients in the birth cohort presented to the ED during daytime hours. 80% (6714) met eligibility criteria, and 48.4% (3247) were offered testing. Screening was performed by non-medical staff (mean 8/day, median spots on DBS 4). 345 (10.6%) had been previously tested, and 639 (19.7%) declined. 2136 (65.8%) patients underwent testing: median age 58.4 years (40-82), 1117 male (52.3%). Of these, 45 patients (2.1%; 95% CI 1.5%-2.7%) were anti-HCV positive: 32 (76.2%) were HCV RNA positive, 10 (23.8%) negative and 3 not done due to inadequate DBS sample. 26 patients (81.3%) were linked to care and 3 (9.4%) lost to follow-up. HCV prevalence in the ED was significantly higher than the general Canadian population (2.1% vs 0.7%; p < 0.0001) but much lower than reported rates in American EDs (2.1% vs 10.3%; p < 0.0001). Conclusion: Acceptance of HCV screening in the ED birth cohort was high and easily performed using DBS to ensure the majority of positive samples were tested for HCV RNA. Challenges included implementation that limited number of people tested, and linkage to care for HCV positive patients. HCV prevalence among this ED birth cohort was higher than the general population but lower than seen in the ED in the US. This may in part be due to exclusion of individuals with more severe medical issues, refusal by higher risk subgroups, or population and healthcare system differences between countries.

On 30 September 2017, an Air France Airbus A380-800 suffered a failure of its fourth engine while over Greenland. This failure resulted in the loss of the engine fan hub, fan blades and surrounding structure. An initial search recovered 30 pieces of light debris, but the primary part of interest, a ~220 kg titanium fan hub, was not recovered because it had a different fall trajectory than the light debris, impacted into the ice-sheet's snow surface, and was quickly covered by drifting snow. Here we describe the methods used for the detection of the fan hub and details of the field campaigns. The search area included two crevasse fields of at least 50 snow-covered crevasses 1 to ~30 m wide with similar snow bridge thicknesses. After 21 months and six campaigns, using airborne synthetic aperture radar, ground-penetrating radar, transient electromagnetics and an autonomous vehicle to survey the crevasse fields, the fan hub was found within ~1 m of a crevasse at a depth of ~3.3 to 4 m and was excavated with shovels, chain saws, an electric winch, sleds and a gasoline heater, by workers using fall-arrest systems.

In the mink industry, feed costs are the largest variable expense and breeding for feed efficient animals is warranted. Implementation of selection for feed efficiency must consider the relationships between feed efficiency and the current selection traits BW and litter size. Often, feed intake (FI) is recorded on a cage with a male and a female and there is sexual dimorphism that needs to be accounted for. Study aims were to (1) model group recorded FI accounting for sexual dimorphism, (2) derive genetic residual feed intake (RFI) as a measure of feed efficiency, (3) examine the relationship between feed efficiency and BW in males (BWM) and females (BWF) and litter size at day 21 after whelping (LS21) in Danish brown mink and (4) investigate direct and correlated response to selection on each trait of interest. Feed intake records from 9574 cages, BW records on 16 782 males and 16 875 females and LS21 records on 6446 yearling females were used for analysis. Genetic parameters for FI, BWM, BWF and LS21 were obtained using a multivariate animal model, yielding sex-specific additive genetic variances for FI and BW to account for sexual dimorphism. The analysis was performed in a Bayesian setting using Gibbs sampling, and genetic RFI was obtained from the conditional distribution of FI given BW using genetic regression coefficients. Responses to single trait selection were defined as the posterior distribution of genetic superiority of the top 10% of animals after conditioning on the genetic trends. The heritabilities ranged from 0.13 for RFI in females and LS21 to 0.59 for BWF. Genetic correlations between BW in both sexes and LS21 and FI in both sexes were unfavorable, and single trait selection on BW in either sex showed increased FI in both sexes and reduced litter size. Due to the definition of RFI and high genetic correlation between BWM and BWF, selection on RFI did not significantly alter BW. In addition, selection on RFI in either sex did not affect LS21. Genetic correlation between sexes for FI and BW was high but significantly lower than unity. The high correlations across sex allowed for selection on standardized averages of animals’ breeding values (BVs) for RFI, FI and BW, which yielded selection responses approximately equal to the responses obtained using the sex-specific BVs. The results illustrate the possibility of selecting against RFI in mink with no negative effects on BW and litter size.

In patients with chronic idiopathic pain disorders we have analysed the construct validity of the Melancholia Scale as compared to the results with the scale in primary depression. The patients (n= 253) were treated in a placebo controlled trial with either clomipramine or mianserin independently of the Melancholia score. The construct validity of the Melancholia Scale was further analysed by the testing of the intensity model of depression versus anxiety using the Beck Depression Inventory, the Hamilton Anxiety Scale, the Spielberger State-Trait Anxiety Scale, and the Melancholia Scale. The construct validity in terms of scale homogeneity was analysed by Loevinger coefficients which can be considered as a latent structure evaluation. The Melancholia Scale showed acceptable homogeneity, while the Hamilton Anxiety Scale lacked sufficient homogeneity. In total, 33% of the patients had a score of 10 or more on the Melancholia Scale (corresponding to 13 or more on the Hamilton Depression Scale). The predictive validity of the Melancholia Scale was evaluated using active treatment versus placebo response after 6 weeks of therapy. It was shown that in patients with a Melancholia Scale score of 10 or more (corresponding to “less than major depression”) 72% had full recovery when treated with clomipramine, while 36% of the placebo treated patients obtained a full recovery (P≤0.05). The patients treated with mianserin obtained a full recovery in 52%. The group of patients with a Melancholia Scale score of 10 or more scored higher also on the anxiety scales indicating that the relation between depression and anxiety is a matter of severity. The depressed patients had significantly lower imipramine binding sites than the non-depressed patients.

Much of the research on ecosystem service values (ESVs) has limited applicability to USDA program benefit analyses, largely because the models/data/results (1) lack spatial breadth and hence cannot be applied in national analyses of USDA programs, and (2) do not link land use changes to the changes in ESs. This article provides an overview of a set of 15 ESVs related to agriculture's impacts on erosion in order to identify (1) weaknesses in methods, data, and assumptions that limit the quality of the ESVs and means of avoiding such weaknesses in future ESV development, and (2) approaches that might improve the reliability and spatial resolution of future ESV estimates.

The use of medicinal zinc oxide (ZnO) must be phased out by 2022, thus prompting an urgent need for alternative strategies to prevent diarrhoea in weaner piglets. The objectives of this study were to assess the impact on weaner piglet performance, diarrhoea incidence and gut development, when (1) dietary ZnO supplementation was substituted by alternative commercial products based on macroalgae, specific probiotics or synbiotics, or (2) dietary ZnO inclusion was reduced from 2500 to 1500 ppm. A total of 4680 DLY piglets (DanBred, Herlev, Denmark), weaned around 35 days of age, were randomly assigned according to sex and BW to six different dietary treatment groups. A basal diet was supplemented with no ZnO (NC = negative control), 2500 ppm ZnO (PC = positive control), 1500 ppm ZnO (RDZ = reduced dose of ZnO) or commercial macroalgae (OceanFeed™ Swine = OFS), probiotic Miya-Gold or synbiotic GærPlus products. The piglets entered and exited the weaner unit at ~7.0 and 30 kg BW, respectively. In-feed ZnO was provided the first 10 days post-weaning, while the alternative supplements were fed throughout the weaner period. As expected, the average daily feed intake, average daily weight gain (ADG), feed conversion ratio (FCR) and diarrhoea incidence were improved in the PC compared to NC group (P < 0.05) during phase 1 consistent with improved indices of villi development observed in subgroups of piglets sacrificed 11 days post-weaning. Reduction of ZnO to 1500 ppm lowered ADG (P < 0.05) and slightly increased incidence of diarrhoea during the first 10 days after weaning (but not later) without affecting FCR. None of the three alternative dietary additives, including a 10-fold increased dose of GærPlus than recommended, improved piglet performance, gut health and gut development above that of NC piglets. The OFS piglets sacrificed 11 days after weaning had significantly lower weights of hindgut tissue and contents compared to the PC group, consistent with antimicrobial activity of the product, which was detected from anaerobic in vitro fermentation. In conclusion, dietary ZnO supplementation during the first 10 days post-weaning may be reduced from 2500 to 1500 ppm without major negative implications for weaner piglet performance and health in herds under a high management level. However, none of the alternative dietary supplements were able to improve piglet performance or gut health, when ZnO was omitted from the diet.

Subglacial rock friction is an important control on the sliding dynamics and erosive potential of hard-bedded glaciers, yet it remains largely unconstrained. To explore the relative influence of basal melt rate, effective stress and ice temperature on frictional resistance, we conducted abrasion experiments in which limestone beds were slid beneath a fixed slab of ice laden with granitic rock fragments. Shear stress scales linearly with melt rate and cryostatic stress, confirming that both viscous drag and effective stress are first-order controls on the contact force in drained conditions. Furthermore, temperature gradients in the ice increase the contribution of viscous drag on basal shear stress. In all experiments, the relationship between melt rate and shear stress is best explained by a model that accounts for the effects of regelation and viscous creep on the bed-normal drag force. We interpret this to mean fluid flow around entrained clasts contributed to basal drag even at subfreezing temperatures. Incorporating premelting dynamics into the Watts/Hallet model for subglacial rock friction, we find that the predicted debris-bed drag decreases by approximately an order of magnitude, with a corresponding ~3.5 × increase in the transition radius. This is lower than we observe for ice slightly below the pressure melting point.

The evolution of glaciers and ice sheets depends on processes in the subglacial environment. Shear seismicity along the ice–bed interface provides a window into these processes. Such seismicity requires a rapid loss of strength that is typically ascribed to rate-weakening friction, i.e., decreasing friction with sliding or sliding rate. Many friction experiments have investigated glacial materials at the temperate conditions typical of fast flowing glacier beds. To our knowledge, however, these studies have all found rate-strengthening friction. Here, we investigate the possibility that rate-weakening rock-on-rock friction between sediments frozen to the bottom of the glacier and the underlying water-saturated sediments or bedrock may be responsible for subglacial shear seismicity along temperate glacier beds. We test this ‘entrainment-seismicity hypothesis’ using targeted laboratory experiments and simple models of glacier sliding, seismicity and sediment entrainment. These models suggest that sediment entrainment may be a necessary but not sufficient condition for the occurrence of basal shear seismicity. We propose that stagnation at the Whillans Ice Stream, West Antarctica may be caused by the growth of a frozen fringe of entrained sediment in the ice stream margins. Our results suggest that basal shear seismicity may indicate geomorphic activity.

Introduction: Interest groups have become increasingly popular as students explore potential career paths earlier in their undergraduate experience. Emergency medicine (EM) has grown as a specialty and the match has become quite competitive. Attractive features of EM cited by learners (diversity, procedural skills and flexible schedule) appeal broadly to the undergraduate population. Learners at Memorial University recognized this leadership opportunity and worked with faculty to reach this wide target audience through a streamlined iterative evaluation of their EM Interest Group (EMIG). Methods: The local EMIG was formed in 2010. Yearly, EMIG executive work with outgoing members using prior experiences, contacts and best practices to facilitate handover and progress. From 2015 to present, 305 surveys were collected, giving an 81.9% response rate. 59.7% of respondents were first year students, and 40.3% were second year. The survey consisted of Likert scale and open-response questions. The Likert scale questions yielded favorable responses. 304 students (99.6%) felt presenters were knowledgeable, 301 (98.6%) would recommend the sessions to others and 301 (98.6%) were satisfied they attended. Surprisingly, 133 students (43.6%) said they were not interested in Emergency Medicine, likely attending due to the appeal of session topics and transferrable of EM skills. 232 (76.0%) stated that attendance did increase their interest in EM. Top responses for aspects of EM most interesting to them included: ability to find a work/life balance, ability to work urban or rural, variety of cases seen, and the non-routine shifts. Results: Survey feedback is used to inform refinement of the content, delivery and format of EMIG activities, delivered by EM faculty. Hands-on sessions (eg. suturing & airway management) have been popular. Informational sessions, on specific medical topics (ECG, resuscitation cases) or broader topics (EM streams) have also been very well received. Inclusion of all interested students, particularly large numbers for hands-on sessions, has presented challenges. Beyond current survey results, it will be interesting to consider if EMIG participation translates to learning or behavioral changes relevant to later clinical encounters; a question that will be difficult to quantify. Conclusion: The EM interest group is one of the most active at Memorial University. Survey results indicate that participants enjoy the EMIG session content and the structured iterative approach used by the group has been successful in maintaining an effective student led organization.

Introduction: Despite clear health benefits, and Public Health Agency of Canada recommendations, vaccination rates among Canadian adults are low. Frequent patient contacts, wait times, and the availability of trained staff make the emergency department (ED) a potential location to target specific populations and administer vaccinations. We evaluated the feasibility of two strategies to administer the Tdap vaccine to adult patients presenting to a single referral ED. Methods: Two immunization strategies and a control group were randomly ordered from one to three. Data collection for group one started on study day one with data collection for groups two and three on study days two and three respectively. This sequence was repeated over 15 consecutive weekdays (Monday-Friday, 0730-1530), evenly assigning each group to 5 different days. On intervention days, adult patients were screened during the triage process for eligibility to receive the Tdap vaccine. An ED based (EDB) strategy offered patients vaccination during that visit. The second strategy offered eligible patients a public health referral (PHR) to receive the vaccine at a later date. On all study days, patient triage times (TT), as well as markers of ED efficiency (number of patient registrations, time to physician, length of stay, left without being seen, number of admissions, number of boarded patients) were recorded. Results: The primary outcome, the proportion of eligible adults immunized, was significantly higher at 66% (n=81) for the EDB strategy (228 screened, 122 eligible), compared with 21% (n=20) for the PHR strategy (217 screened, 94 eligible; x2 (2, n=216)=43.41, p<0.00001). In addition, 10 participants in the PHR group received a second vaccine (Pneumococcal (7), Influenza (2), Human Papillomavirus (1)). Reasons for vaccine ineligibility included having an up-to-date Tdap (EDB n=47 (21%), PHR n=46 (21%)) and being considered in too much distress by the triage nurse (EDB n=26 (11%), PHR n=19 (9%)). Triage time was less for the control group (M=5:55 [mins:secs], SD=2:48) than for the EDB (M=6:47, SD=3:12) and PHR (M=7:25, SD=2:45) strategies. Conclusion: An ED based screening and immunization strategy was highly effective in providing eligible adult patients with the Tdap vaccine. A resulting small increase in triage time was not clinically significant. Further studies are required to generalize these results.

Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.