Clinical judgement in primary care is more often decisive than in the hospital. Clinical decision rules (CDRs) can help general practitioners facilitating the work-through of differentials that follows an initial suspicion, resulting in a concrete ‘course of action’: a ‘rule-out’ without further testing, a need for further testing, or a specific treatment. However, in daily primary care, the use of CDRs is limited to only a few isolated rules. In this paper, we aimed to provide insight into the laborious path required to implement a viable CDR. At the same time, we noted that the limited use of CDRs in primary care cannot be explained by implementation barriers alone. Through the case study of the Oudega rule for the exclusion of deep vein thrombosis, we concluded that primary care CDRs come out best if they are tailor-made, taking into consideration the specific context of primary health care. Current CDRs should be evaluated frequently, and future decision rules should anticipate the latest developments such as the use of point-of-care (POC) tests. Hence, such new powerful diagnostic CDRs could improve and expand the possibilities for patient-oriented primary care.

Background: In the Erasmus MC University Medical Center, Rotterdam, the Netherlands, patients considered at risk for carrying highly resistant microorganisms (HRMO) are placed in isolation on admission, until tested negative for HRMO (ie, targeted screening). Patients without risk factors are not routinely screened (ie, nontargeted screening). However, nontargeted screening could identify patients colonized with HRMO missed by targeted screening. To determine the additional value of nontargeted screening, we compared the outcomes of the nontargeted screening approach with all available clinical cultures. Objective: We aim to identify patients colonized with HRMO, but missed by targeted screening, and to determine whether non-targeted screening has additional value. Methods: For the MOVE study, nontargeted admission and discharge cultures (nose and perianal) were obtained from randomly selected patients admitted to specific wards, regardless of HRMO risk factors. This study was part of a research initiative to identify the relation of a contaminated environment with the risk of becoming infected or colonized on a patient level. All bacteriological clinical samples positive for at least 1 HRMO from January 1, 2018, until August 31, 2019, were compared with the nontargeted screening samples. Samples were screened for methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) as well as highly resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus faecium, and Enterobacteriales. Broth enrichment was used for all cultures. Results: During the study period, 50,653 patients were admitted. 706 patients (1%) had a clinical sample positive for at least 1 HRMO during their hospital stay. 936 (1.8%) patients were included in the nontargeted screening for the MOVE study, and 40 patients were found to have at least 1 culture positive for HRMO (4.3%). Among these 40 patients, 28 were positive at admission and 12 were positive at discharge. Extended-spectrum β-lactamase (ESBL)–producing Enterobacteriales were most prevalent (n = 36, 90.0%) both at admission and discharge (n = 26 and n = 10, respectively). At admission, 1 patient was identified with MRSA and 1 patient was positive for vancomycin-resistant E. faecium (VRE). At discharge, 1 patient was identified with VRE and 1 had Verona Integron-encoded Metallo-β-lactamase (VIM)–positive P. aeruginosa. Conclusions: Our results show that the current targeted screening does not identify all HRMO carriers. Furthermore, patients who acquire an HRMO during admission are missed. The nontargeted screening identified 40 unknown carriers (4.3%). The limitations of the study are the restricted number of sample sites and the fact that we were unable to culture all patients. Therefore, it is likely that our study shows an underestimation of the true number of patients with HRMO.

Funding: None

Disclosures: None

Background: Studies have shown that patients colonized with highly resistant microorganisms (HRMO) contaminate the hospital environment, and that transmission from contaminated environments to patients occurs. In May 2018, the Erasmus MC University Medical Center, Rotterdam, moved from a hospital with mostly multiple-occupancy rooms to a new hospital with 100% single-patient rooms with private bathrooms. This move provided the unique opportunity to determine environmental contamination before the new hospital was open for admissions and thereafter and to compare the environmental contamination to the number of patients colonized with HRMO. Method: Environmental sampling took place twice in the old building and 12 times in the new building, from 2 weeks before to 15 months after relocating patients. At each moment, ~306 samples were taken from 13 locations (eg, nightstands, sinks) in 40 patient rooms. Samples were screened for Staphylococcus aureus (methicillin-susceptible [MSSA] and methicillin resistant [MRSA]) and highly resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus faecium, and Enterobacteriales. During the study period, January 1, 2018, until August 31, 2019, all clinical samples positive for HRMO were included. Results: Environmental sampling revealed that 29 of 724 (4.0%) locations were positive for HRMO in the old building, whereas 4 of 3,358 (0.1%) samples in the new building were positive for HRMO (P < .001). In the old building, 14 of 29 locations were positive for extended-spectrum β-lactamase (ESBL)–producing bacteria and 15 were positive for carbapenemase-producing bacteria. In the new building, 3 of 4 positive samples were positive for vancomycin-resistant E. faecium (VRE), 1 was positive for ESBL-producing K. pneumoniae. For both HRMO, no carriers were detected. In the old building, 145 of 12,256 adult patients (1.2%) had clinical samples positive for HRMO, compared to 561 of 38,397 (1.5%) in the new building, a small but significant increase (P = .02). Conclusions: The transition from mainly 2- and 4-person rooms to 100% single-patient rooms resulted in a significant decrease in environmental contamination, even though the number of patients colonized with HRMO slightly increased. No molecular typing to determine transfer from environment to patients and vice versa has yet been performed. Future sampling is needed to determine whether the low environmental contamination is a long-term effect of the transition to single rooms.

Funding: None

Disclosures: None

The Kempen system is a dairy feeding system in which diet is provided in the form of a compound feed (CF) and hay offered ad libitum. Ad libitum access to CF and hay allows cows in this system to achieve a high DM intake (DMI). Out of physiological concerns, the voluntary hay intake could be increased and the consumption pattern of CF could be manipulated to maintain proper rumen functioning and health. This study investigated the effects of an artificial hay aroma and CF formulation on feed intake pattern, rumen function and milk production in mid- to late-lactating dairy cows. Twenty Holstein–Friesian cows were assigned to four treatments in a 4 × 4 Latin square design. Diet consisted of CF and grass hay (GH), fed separately, and both offered ad libitum, although CF supply was restricted in maximum meal size and speed of supply by an electronic system. Treatments were the combination of two CF formulations – high in starch (CHS) and fibre (CHF); and two GH – untreated (UGH) and the same hay treated with an artificial aroma (TGH). Meal criteria were determined using three-population Gaussian–Gaussian–Weibull density functions. No GH × CF interaction effects on feed intake pattern characteristics were found. Total DMI and CF intake, but not GH intake, were greater (P < 0.01) in TGH treatment, and feed intake was not affected by type of CF. Total visits to feeders per day, visits to the GH feeder, visits to the CF feeder and CF eating time (all P < 0.01) were significantly greater in cows fed with TGH. Meal frequency, meal size and meal duration were unaffected by treatments. Cows fed CHF had a greater milk fat (P = 0.02), milk urea content (P < 0.01) and a greater milk fat yield (P < 0.01). Cows fed TGH had a greater milk lactose content and lactose yield (P < 0.05), and milk urea content (P < 0.01). Cows fed TGH had smaller molar proportions of acetic acid and greater molar proportions of propionic acid compared with UGH. In conclusion, treatment of GH with an artificial aroma increased CF intake and total DMI, but did not affect hay intake. Additionally, GH treatment increased the frequency of visits to both feeders, and affected rumen volatile fatty acid profile. Type of CF did not affect meal patterns, ruminal pH, nor fermentation profiles.

When supplementing lamb diets with vitamin E, an equivalence factor of 1.36 is used to discriminate between RRR-α-tocopheryl acetate and all-rac-α-tocopheryl acetate. However, more recent studies suggest a need for new equivalence factors for livestock animals. The current study aimed to determine the effect of RRR- and all-rac-α-tocopheryl acetate supplementation on α-tocopherol deposition in lamb tissues. A total of 108 Rasa Aragonesa breed lambs were fed increasing amounts of all-rac-α-tocopheryl acetate (0.25, 0.5, 1.0 and 2.0 g/kg compound feed) or RRR-α-tocopheryl acetate (0.125, 0.25, 0.5 and 1.0 g/kg compound feed) by adding them to a basal diet that contained 0.025 g/kg feed of all-rac-α-tocopheryl acetate as part of the standard vitamin and mineral mixture. The diets were fed for the last 14 days before slaughtering at 25.8±1.67 kg BW. Within 20 min after slaughter samples of muscle, heart, liver, brain and spleen were frozen at −20°C until α-tocopherol analysis. Increased supplementation of either vitamin E sources led to a significant increase (P < 0.001) in α-tocopherol concentration in all tissues studied. The tissue with the highest α-tocopherol concentration was the liver followed by spleen, heart and muscle. At similar supplementation levels (0.25, 0.50 and 1.0 g/kg compound feed), α-tocopherol content in the selected tissues was not affected by α-tocopherol source. However, the ratios between RRR- and all-rac-α-tocopheryl acetate increased with the increasing α-tocopherol supplementation (at 0.25 and 1.0 g/kg compound feed), from 1.06 to 1.16 in muscle, 1.07 to 1.15 in heart, 0.91 to 0.94 in liver and 0.98 to 1.10 in spleen. The highest relative proportion of Ʃ2S (sum of SSS-, SSR-, SRS- and SRR-α-tocopherol)-configured stereoisomers was found in the liver of lambs supplemented with all-rac-α-tocopheryl acetate accounting for up to 35 to 39% of the total α-tocopherol retained, whereas the proportion of Ʃ2S-configured stereoisomers in the other tissues accounted for <14%. Increasing all-rac-α-tocopheryl acetate supplementation was also found to affect the 2R-configured stereoisomer profile in muscle, heart and spleen with increasing proportions of RRS-, RSR- and RSS- at the cost of RRR-α-tocopherol. In all tissues, the relative proportion of all non-RRR-stereoisomers in lambs receiving RRR-α-tocopheryl acetate was lower than RRR-α-tocopherol. These results confirm that the relative bioavailability of RRR- and all-rac-α-tocopheryl acetate is dose- and tissue-dependent and that a single ratio to discriminate the two sources cannot be used.

Lead white is a man-made white pigment commonly used in works of art. In this study, the possibility of radiocarbon dating lead white pigments alone and in oil paints was explored using well-dated lead white pigments and paints. Resulting 14C ages on lead white pigments produced following the traditional stack process, where carbonate groups results from the incorporation of CO2 originating from fermentation, matched the production years, while radiocarbon dating of lead white made using other industrial processes indicate that 14C depleted CO2 was used in their production. The method was applied to two case studies, where lead carbonate samples were dated in two oil paintings, one Baroque and one from the 20th century. We hereby show that the lead white pigment can be dated by 14C and used as proxy for the time of creation of an artwork. Additionally, a two-step method was developed to allow 14C analysis of both the lead white pigment and oil binder from the same sample. A single lead white paint sample can yield two distinct radiocarbon ages, one from the carbonate and one from the natural organic binder. This study thus proposes new strategies for 14C dating of artworks.

The use of accelerator mass spectrometry (AMS) for age determinations of paintings is growing due to decreasing sample size requirements. However, as only the support material is usually dated, the validity of the results may be questioned. This work describes a novel sampling and preparation technique for dating the natural organic binder using radiocarbon (14C) AMS. In the particular case of oil paintings, the natural oil used has a high probability of being representative of the time of creation, hereby circumventing the problem of the originality of the support material. A multi-technique approach was developed for a detailed characterization of all paint components to identify the binder type as well as pigments and additives present in the sample. The technique was showcased on a painting of the 20th century. The results by 14C AMS dating show that both the canvas and binding medium predate the signed date by 4–5 yr. This could be the time span for keeping painting material in the atelier. The method developed provides, especially given the low amounts of material needed for analysis, a superior precision and accuracy in dating and has potential to become a standard method for oil painting dating.

Toasting time (TT) of rapeseed meal (RSM), the diet processing (DP) method and the interaction between both on the apparent CP digestion along the gastrointestinal tract and the apparent ileal digestibility (AID) of amino acids of growing pigs were investigated. The experiment consisted of a 3×3 factorial design of TT of RSM (0, 60 and 120 min) and DP method (mash, pelleting and extrusion). In total, 81 boars with a starting BW of 20 kg were euthanized 4 h after their last feeding. The gastrointestinal tract was dissected and the small intestine divided in three sections of similar length. Samples were collected from the stomach, 1.5 m from the ends of each of the three sections of the small intestine, and the rectum. The apparent digestibility (AD) of CP for each of the small intestine sections was used to calculate the rate of CP digestion. Increasing the TT of RSM resulted in lower protein solubility, lower lysine/reactive lysine contents and higher protein denaturation, indicative of the occurrence of protein aggregation and Maillard reactions. There were significant effects (P⩽0.01) of TT on the AD of CP in the different sections of the gastrointestinal tract. The rate of CP digestion of the 0 min toasted RSM diets was 23% and 35% higher than that of the 60 and 120 min toasted RSM diets, respectively. There was a significant interaction (P=0.04) between TT and DP for the AID of CP. Although pelleting of the 0 and 60 min toasted RSM diets did not change the AID of CP with respect to the mash diets, pelleting of the 120 min toasted RSM diet increased the AID of CP by 9.3% units. Extrusion increased the AID of CP of the 0 and 60 min toasted RSM diets by 3.4% and 4.3% units with respect to the mash diets, whereas extrusion of the 120 min toasted RSM diet increased the AID of CP by 6.9% units. Similar positive effects of pelleting and extrusion were obtained for the AID of lysine and reactive lysine, especially in the diets with higher TT. In conclusion, processing (pelleting and extrusion) of RSM containing diets can ameliorate the negative effects of RSM toasting on protein and amino acid digestibility; these effects were larger for the RSM toasted for longer times.

The adaptation of dairy cows to methane (CH4)-mitigating feed additives was evaluated using the in vitro gas production (GP) technique. Nine rumen-fistulated lactating Holstein cows were grouped into three blocks and within blocks randomly assigned to one of three experimental diets: Control (CON; no feed additive), Agolin Ruminant® (AR; 0.05 g/kg dry matter (DM)) or lauric acid (LA; 30 g/kg DM). Total mixed rations composed of maize silage, grass silage and concentrate were fed in a 40 : 30 : 30 ratio on DM basis. Rumen fluid was collected from each cow at days −4, 1, 4, 8, 15 and 22 relative to the introduction of the additives in the diets. On each of these days, a 48-h GP experiment was performed in which rumen fluid from each individual donor cow was incubated with each of the three substrates that reflected the treatment diets offered to the cows. DM intake was on average 19.8, 20.1 and 16.2 kg/day with an average fat- and protein-corrected milk production of 30.7, 31.7 and 26.2 kg/day with diet CON, AR and LA, respectively. In general, feed additives in the donor cow diet had a larger effect on gas and CH4 production than the same additives in the incubation substrate. Incubation substrate affected asymptotic GP, half-time of asymptotic CH4 production, total volatile fatty acid (VFA) concentration, molar proportions of propionate and butyrate and degradation of organic matter (OMD), but did not affect CH4 production. No substrate×day interactions were observed. A significant diet×day interaction was observed for in vitro gas and CH4 production, total VFA concentration, molar proportions of VFA and OMD. From day 4 onwards, the LA diet persistently reduced gas and CH4 production, total VFA concentration, acetate molar proportion and OMD, and increased propionate molar proportion. In vitro CH4 production was reduced by the AR diet on day 8, but not on days 15 and 22. In line with these findings, the molar proportion of propionate in fermentation fluid was greater, and that of acetate smaller, for the AR diet than for the CON diet on day 8, but not on days 15 and 22. Overall, the data indicate a short-term effect of AR on CH4 production, whereas the CH4-mitigating effect of LA persisted.

Protein structure influences the accessibility of enzymes for digestion. The proportion of intramolecular β-sheets in the secondary structure of native proteins has been related to a decrease in protein digestibility. Changes to proteins that can be considered positive (for example, denaturation and random coil formation) or negative (for example, aggregation and Maillard reactions) for protein digestibility can occur simultaneously during processing. The final result of these changes on digestibility seems to be a counterbalance of the occurrence of each phenomenon. Occurrence of each phenomenon depends on the conditions applied, but also on the source and type of the protein that is processed. The correlation between denaturation enthalpy after processing and protein digestibility seems to be dependent on the protein source. Heat seems to be the processing parameter with the largest influence on changes in the structure of proteins. The effect of moisture is usually limited to the simultaneous application of heat, but increasing level of moisture during processing usually increases structural changes in proteins. The effect of shear on protein structure is commonly studied using extrusion, although the multifactorial essence of this technology does not allow disentanglement of the separate effects of each processing parameter (for example, heat, shear, moisture). Although most of the available literature on the processing of feed ingredients reports effects on protein digestibility, the mechanisms that explain these effects are usually lacking. Clarifying these mechanisms could aid in the prediction of the nutritional consequences of processing conditions.

Windpumping has been identified as a process that could potentially enhance sublimation of surface snow at high forcing frequency and spawn air movement deeper in firn at lower frequencies. We performed an experiment to examine the relationship between high-frequency wind and pressure measurements within the top meter of an alpine snowpack and compared experimental results with two theoretical predictions. We find that both theoretical predictions underestimate high-frequency perturbation pressure attenuation with depth in the near-surface snowpack and the discrepancy between theory and measurement increases with perturbation pressure frequency. The impact of this result for near-surface snow is that potential enhanced sublimation will occur over a shallower snow depth than these two theories predict. Correspondingly, interstitial air mixing at depth in firn will be driven by lower frequencies than these two theories predict. While direct measurement of these energy-rich lower frequencies is beyond the scope of this paper, stationary pressure measurements validate the presence of a pressure field that could drive near-surface circulation.

Stearoyl-CoA desaturase (SCD) in the bovine mammary gland introduces a cis-double bond at the Δ9 position in a wide range of fatty acids (FA). Several long-chain polyunsaturated fatty acids (PUFA) inhibit expression of SCD, but information on the effect of short-chain fatty acids on mammary SCD expression is scarce. We used a bovine mammary cell line (MAC-T) to assess the effect of acetic acid (Ac) and β-hydroxybutyric acid (BHBA) in comparison with the effect of various long-chain fatty acids on the mRNA expression of the lipogenic enzymes SCD, acetyl-CoA carboxylase (ACACA), fatty acid synthase (FASN) and their associated gene regulatory proteins sterol regulatory element binding transcription factor 1 (SREBF1), insulin-induced gene 1 protein (INSIG1) and peroxisome proliferator-activated receptor alpha (PPARA)and peroxisome proliferator-activated receptor delta (PPARD) by quantitative real-time PCR. MAC-T cells were treated for 12 h without FA additions (CON) or with either 5 mM Ac, 5 mM BHBA, a combination of 5 mM Ac + 5 mM BHBA, 100 μM C16:0, 100 μM C18:0, 100 μM C18:1 cis-9, 100 μM C18:1 trans-11, 100 μM C18:2 cis-9,12 or 100 μM C18:3 cis-9,12,15. Compared with control, mRNA expression of SCD1 was increased by Ac (+61%) and reduced by C18:1 cis-9 (−61%), C18:2 cis-9,12 (−84%) and C18:3 cis-9,12,15 (−88%). In contrast to native bovine mammary gland tissue, MAC-T cells did not express SCD5. Expression of ACACA was increased by Ac (+44%) and reduced by C18:2 cis-9,12 (−48%) and C18:3 cis-9,12,15 (−49%). Compared with control, FASN expression was not significantly affected by the treatments. The mRNA level of SREBF1 was not affected by Ac or BHBA, but was reduced by C18:1 cis-9 (−44%), C18:1 trans-11 (−42%), C18:2 cis-9,12 (−62%) and C18:3 cis-9,12,15 (−68%) compared with control. Expression of INSIG1 was downregulated by C18:0 (−37%), C18:1 cis-9 (−63%), C18:1 trans-11 (−53%), C18:2 cis-9,12 (−81%) and C18:3 cis-9,12,15 (−91%). Both PPARA and PPARD expression were not significantly affected by the treatments. Our results show that Ac upregulated mRNA expression of SCD1 and ACACA in MAC-T cells. The opposite effect of the PUFA C18:2 cis-9,12 and C18:3 cis-9,12,15 on the these genes and the failure of Ac to mimic the PUFA-inhibited SREBF1 and INSIG1 mRNA expression, suggest that Ac can stimulate mammary lipogenesis via a transcriptional regulatory mechanism different from PUFA.

The aim of the current study was to explore the use of the tracer 13C as an internal marker to assess feed fraction-specific digesta passage kinetics through the digestive tract of dairy cows. Knowledge on feed-specific fractional passage rates is essential to improve estimations on the extent of rumen degradation and microbial protein efficiency; however, this information is largely lacking. An in vivo and in vitro experiment was conducted with grass silages (Lolium perenne L.) that were enriched with 13C by growing the grass under elevated 13CO2 conditions. In a crossover design, two dairy cows received pulse doses of two 13C-enriched grass silages and chromium-mordanted neutral detergent fibre (Cr-NDF) into the rumen. The two 13C-enriched grass silages used differed in digestibility and were grown under identical field conditions as the bulk silages fed to the animals. Faecal excretion patterns of 13C-enriched dry matter (13C-DM), neutral detergent fibre (13C-NDF) and Cr-NDF were established, and a nonlinear multicompartmental model was used to determine their rumen passage kinetics. In addition, the 13C-enriched silages were incubated in rumen liquid in an in vitro batch culture system at different time intervals to determine the effect of fermentation on 13C-enrichment in the residue. The in vitro study showed that the 13C : 12C ratios in DM and NDF residues remained stable from 24 h of incubation onwards. In addition, in vitro fractional degradation rates for 12C in the DM and NDF did not differ from those of 13C, indicating that fermentative degradation does not affect the 13C : 12C ratio in the DM nor in the NDF fraction of the residue. Model fits to the faecal excretion curves showed a significant difference in fractional rumen passage rates between Cr-NDF, 13C-DM and 13C-NDF (P ⩽ 0.025). Silage type had no clear effect on rumen passage kinetics (P ⩾ 0.081). Moreover, it showed that peak enrichments for 13C-DM and 13C-NDF in faeces were reached at 30.7 and 41.7 h post dosing, respectively. This is well after the time (24 h) when the 13C : 12C ratios of the in vitro unfermented residues have reached stable enrichment level. Fractional rate constants for particle passage from the rumen are estimated from the descending slope of faecal excretion curves. The present study shows that the decline in 13C : 12C ratio after peak enrichment is not affected by fermentative degradation and therefore can be used to assess feed component-specific fractional passage rates.