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Obesity is one of the major contributors to the excess mortality seen in people with severe mental illness (SMI) and in low- and middle-income countries people with SMI may be at an even greater risk. In this study, we aimed to determine the prevalence of obesity and overweight in people with SMI and investigate the association of obesity and overweight with sociodemographic variables, other physical comorbidities, and health-risk behaviours. This was a multi-country cross-sectional survey study where data were collected from 3989 adults with SMI from three specialist mental health institutions in Bangladesh, India, and Pakistan. The prevalence of overweight and obesity was estimated using Asian BMI thresholds. Multinomial regression models were then used to explore associations between overweight and obesity with various potential determinants. There was a high prevalence of overweight (17·3 %) and obesity (46·2 %). The relative risk of having obesity (compared to normal weight) was double in women (RRR = 2·04) compared with men. Participants who met the WHO recommendations for fruit and vegetable intake had 2·53 (95 % CI: 1·65–3·88) times greater risk of having obesity compared to those not meeting them. Also, the relative risk of having obesity in people with hypertension is 69 % higher than in people without hypertension (RRR = 1·69). In conclusion, obesity is highly prevalent in SMI and associated with chronic disease. The complex relationship between diet and risk of obesity was also highlighted. People with SMI and obesity could benefit from screening for non-communicable diseases, better nutritional education, and context-appropriate lifestyle interventions.
Recent evidence from case reports suggests that a ketogenic diet may be effective for bipolar disorder. However, no clinical trials have been conducted to date.
To assess the recruitment and feasibility of a ketogenic diet intervention in bipolar disorder.
Euthymic individuals with bipolar disorder were recruited to a 6–8 week trial of a modified ketogenic diet, and a range of clinical, economic and functional outcome measures were assessed. Study registration number: ISRCTN61613198.
Of 27 recruited participants, 26 commenced and 20 completed the modified ketogenic diet for 6–8 weeks. The outcomes data-set was 95% complete for daily ketone measures, 95% complete for daily glucose measures and 95% complete for daily ecological momentary assessment of symptoms during the intervention period. Mean daily blood ketone readings were 1.3 mmol/L (s.d. = 0.77, median = 1.1) during the intervention period, and 91% of all readings indicated ketosis, suggesting a high degree of adherence to the diet. Over 91% of daily blood glucose readings were within normal range, with 9% indicating mild hypoglycaemia. Eleven minor adverse events were recorded, including fatigue, constipation, drowsiness and hunger. One serious adverse event was reported (euglycemic ketoacidosis in a participant taking SGLT2-inhibitor medication).
The recruitment and retention of euthymic individuals with bipolar disorder to a 6–8 week ketogenic diet intervention was feasible, with high completion rates for outcome measures. The majority of participants reached and maintained ketosis, and adverse events were generally mild and modifiable. A future randomised controlled trial is now warranted.
It is acknowledged that health technology assessment (HTA) is an inherently value-based activity that makes use of normative reasoning alongside empirical evidence. But the language used to conceptualise and articulate HTA's normative aspects is demonstrably unnuanced, imprecise, and inconsistently employed, undermining transparency and preventing proper scrutiny of the rationales on which decisions are based. This paper – developed through a cross-disciplinary collaboration of 24 researchers with expertise in healthcare priority-setting – seeks to address this problem by offering a clear definition of key terms and distinguishing between the types of normative commitment invoked during HTA, thus providing a novel conceptual framework for the articulation of reasoning. Through application to a hypothetical case, it is illustrated how this framework can operate as a practical tool through which HTA practitioners and policymakers can enhance the transparency and coherence of their decision-making, while enabling others to hold them more easily to account. The framework is offered as a starting point for further discussion amongst those with a desire to enhance the legitimacy and fairness of HTA by facilitating practical public reasoning, in which decisions are made on behalf of the public, in public view, through a chain of reasoning that withstands ethical scrutiny.
Spatial linear stability analysis is used to study the axisymmetric screech tones generated by twin converging round nozzles at low supersonic Mach numbers. Vortex-sheet and finite-thickness models allow for identification of the different waves supported by the flow at different conditions. Regions of the frequency–wavenumber domain for which the upstream-propagating guided jet modes are observed to be neutrally stable are observed to vary as a function of solution symmetry, jet separation, $S$, and the velocity profile used. Screech-frequency predictions performed using wavenumbers obtained from both models agree well with experimental data. Predictions obtained from the finite-thickness model better align with the screech tones measured experimentally and so are seen to be an improvement on predictions made with the vortex sheet. Additionally, results from the finite-thickness model predict both symmetric and antisymmetric screech tones for low $S$ that are found in the vortex-sheet model only at greater $S$. The present results indicate that the feedback loop generating these screech tones is similar to that observed for single-jet resonance, with equivalent upstream and downstream modes.
We investigate the intermittency of the coupling behaviour in screeching twin round supersonic jets at low Mach numbers across a range of nozzle spacings. Application of proper orthogonal decomposition combined with time-frequency wavelet analysis and spectral proper orthogonal decomposition shows that intermittency can manifest in twin jets as either a competition between the two symmetries, or the jets uncoupling and recoupling. The time scales on which symmetry switching occurs can vary strongly, ranging from $O(10^2)$ to $O(10^3)$ screech cycles. A transition from one symmetry to another is accompanied by a slight change in the screech frequency ranging from 0.30 % to 0.63 %. It was observed that complete uncoupling occurred only at the largest nozzle spacing of $s/D=6$ and at Mach numbers close to modal staging. When the jets are uncoupled they screech at slightly different frequencies, with a disparity of approximately 0.6 %. The coupling is particularly intermittent in the transition from the A1 to A2 branch, where the A2 mode is first observed, and tends toward steady coupling with increasing Mach number.
OBJECTIVES/GOALS: Glioblastomas (GBMs) are heterogeneous, treatment-resistant tumors that are driven by populations of cancer stem cells (CSCs). In this study, we perform an epigenetic-focused functional genomics screen in GBM organoids and identify WDR5 as an essential epigenetic regulator in the SOX2-enriched, therapy resistant cancer stem cell niche. METHODS/STUDY POPULATION: Despite their importance for tumor growth, few molecular mechanisms critical for CSC population maintenance have been exploited for therapeutic development. We developed a spatially resolved loss-of-function screen in GBM patient-derived organoids to identify essential epigenetic regulators in the SOX2-enriched, therapy resistant niche. Our niche-specific screens identified WDR5, an H3K4 histone methyltransferase responsible for activating specific gene expression, as indispensable for GBM CSC growth and survival. RESULTS/ANTICIPATED RESULTS: In GBM CSC models, WDR5 inhibitors blocked WRAD complex assembly and reduced H3K4 trimethylation and expression of genes involved in CSC-relevant oncogenic pathways. H3K4me3 peaks lost with WDR5 inhibitor treatment occurred disproportionally on POU transcription factor motifs, required for stem cell maintenance and including the POU5F1(OCT4)::SOX2 motif. We incorporated a SOX2/OCT4 motif driven GFP reporter system into our CSC cell models and found that WDR5 inhibitor treatment resulted in dose-dependent silencing of stem cell reporter activity. Further, WDR5 inhibitor treatment altered the stem cell state, disrupting CSC in vitro growth and self-renewal as well as in vivo tumor growth. DISCUSSION/SIGNIFICANCE: Our results unveiled the role of WDR5 in maintaining the CSC state in GBM and provide a rationale for therapeutic development of WDR5 inhibitors for GBM and other advanced cancers. This conceptual and experimental framework can be applied to many cancers, and can unmask unique microenvironmental biology and rationally designed combination therapies.
To provide comprehensive population-level estimates of the burden of healthcare-associated influenza.
Retrospective cross-sectional study.
US Influenza Hospitalization Surveillance Network (FluSurv-NET) during 2012–2013 through 2018–2019 influenza seasons.
Laboratory-confirmed influenza-related hospitalizations in an 8-county catchment area in Tennessee.
The incidence of healthcare-associated influenza was determined using the traditional definition (ie, positive influenza test after hospital day 3) in addition to often underrecognized cases associated with recent post-acute care facility admission or a recent acute care hospitalization for a noninfluenza illness in the preceding 7 days.
Among the 5,904 laboratory-confirmed influenza-related hospitalizations, 147 (2.5%) had traditionally defined healthcare-associated influenza. When we included patients with a positive influenza test obtained in the first 3 days of hospitalization and who were either transferred to the hospital directly from a post-acute care facility or who were recently discharged from an acute care facility for a noninfluenza illness in the preceding 7 days, we identified an additional 1,031 cases (17.5% of all influenza-related hospitalizations).
Including influenza cases associated with preadmission healthcare exposures with traditionally defined cases resulted in an 8-fold higher incidence of healthcare-associated influenza. These results emphasize the importance of capturing other healthcare exposures that may serve as the initial site of viral transmission to provide more comprehensive estimates of the burden of healthcare-associated influenza and to inform improved infection prevention strategies.
Shock-containing supersonic jets undergoing resonance processes are challenging from both a measurement and simulation perspective. These jets are host to a broad range of complex fluid phenomena: intense acoustic waves, turbulence, wavepackets and strong shock waves. Strong shocks present a challenge to both the experimental and numerical researcher. In the paper of Léon et al. (J. Fluid Mech., vol. 947, 2022, A36), a novel optical technique based on multi-axis digital holographic interferometry is applied to the study of a highly underexpanded screeching jet, producing density measurements of unprecedented clarity and resolution. Where prior studies have been restricted to extrapolating the three-dimensional field from two-dimensional slices or projections, in this work the authors directly measure the three-dimensional helical structure of the wavepacket associated with jet screech.
The 2020 presidential election brought expanded vote-by-mail opportunities, a rise in attacks on this process’s integrity, and the implementation of novel programs such as California’s Where’s My Ballot? system to ensure confidence in mail balloting. Can heightening awareness of this ballot-tracking system and other election protections alleviate fraud concerns and raise turnout? We assess whether messages reinforcing election integrity increased participation in the 2020 election through a large-scale voter mobilization field experiment. California registrants were mailed a letter that described either existing safeguards to prevent vote-by-mail fraud or the ability to track one’s ballot and ensure that it was counted. Analysis of state voter records reveals that neither message increased turnout over a simple election reminder or even no contact, even among subgroups where larger effects might be expected. In the context of a high-profile, high-turnout presidential election, assurances about ballot and electoral integrity did not increase turnout.
The shame system appears to be natural selection's solution to the adaptive problem of information-triggered reputational damage. Over evolutionary time, this problem would have led to a coordinated set of adaptations – the shame system – designed to minimise the spread of negative information about the self and the likelihood and costs of being socially devalued by others. This information threat theory of shame can account for much of what we know about shame and generate precise predictions. Here, we analyse the behavioural configuration that people adopt stereotypically when ashamed – slumped posture, downward head tilt, gaze avoidance, inhibition of speech – in light of shame's hypothesised function. This behavioural configuration may have differentially favoured its own replication by (a) hampering the transfer of information (e.g. diminishing audiences’ tendency to attend to or encode identifying information – shame camouflage) and/or (b) evoking less severe devaluative responses from audiences (shame display). The shame display hypothesis has received considerable attention and empirical support, whereas the shame camouflage hypothesis has to our knowledge not been advanced or tested. We elaborate on this hypothesis and suggest directions for future research on the shame pose.
A higher proportion of people in prison have a history of traumatic brain injury (TBI) than the general population. However, little is known about potentially related persistent symptoms in this population.
To compare symptom reporting in men with and without a history of TBI following admission to a correctional facility.
All men transferred to the South Auckland Correctional Facility in New Zealand complete a lifetime TBI history and the Rivermead Post-Concussion Symptom Questionnaire (RPQ) as part of their routine health screen. Data collected between June 2020 and March 2021 were extracted and anonymised. Participants were classified as reporting at least one TBI in their lifetime or no TBI history. The underlying factor structure of the RPQ was determined using principal components analysis. Symptom scores between those with and without a TBI history were compared using Mann Whitney U tests.
Of the N = 363 adult male participants, 240 (66%) reported experiencing at least one TBI in their lifetime. The RPQ was found to have a two-factor structure (Factor 1: cognitive, emotional, behavioural; Factor 2: visual-ocular) explaining 61% of the variance. Men reporting a TBI history had significantly higher cognitive, emotional and behavioural (U = 50.4, p < 0.001) and visuo-ocular symptoms (U = 68.5, p < 0.001) in comparison to men reporting no TBI history.
A history of TBI was associated with higher symptom burden on admission to a correctional facility. Screening for TBI history and current symptoms on admission may assist prisoners experiencing persistent effects of TBI to access rehabilitation.
This paper describes the mechanism underpinning modal staging behaviour in screeching jets. An upstream-propagating subsonic guided-jet mode is shown to be active in all stages of screech. Axial variation of shock-cell spacing manifests in the spectral domain as a series of suboptimal peaks. It is demonstrated that the guided-jet mode may be energized by interactions of the Kelvin–Helmholtz wavepacket with not only the primary shock wavenumber peak, but also suboptimal peaks; interaction with suboptimals is shown to be responsible for closing the resonance loop in multiple stages of jet screech. A consideration of the full spectral representation of the shocks reconciles several of the classical models and results for jet screech that had heretofore been paradoxical. It is demonstrated that there are multiple standing waves present in the near field of screeching jets, corresponding to the superposition of the various waves active in these jets. Multimodal behaviour is explored for jets in a range of conditions, demonstrating that multiple peaks in the frequency spectra can be due to either changes in which peak of the shock spectra the Kelvin–Helmholtz wavepacket is interacting with, or a change in azimuthal mode, or both. The absence of modal staging in high-aspect-ratio non-axisymmetric jets is also explained in the context of the aforementioned mechanism. The paper closes with a new proposed theory for frequency selection in screeching jets, based on the observation that these triadic interactions appear to underpin selection of the guided-jet mode wavelength in all measured cases.
An investigation of shock diffraction through a non-quiescent background medium is presented using both experimental and numerical techniques. Unlike diffracting shocks in quiescent media, a spatial distortion of the shock front occurs, producing a region of constant shock angle. An example of this process arises in the exhaust from a pulse-detonation combustor. As the background velocity is increased, such as through the inclusion of a converging nozzle at the exhaust, the spatial distortion becomes more apparent. Numerical simulations using a compressible Euler solver demonstrate that the distortion is not due to the geometrical influence of the nozzle, but rather is a function of the magnitude of the background flow velocity. The distortion is studied using a modified geometrical shock dynamics formulation which includes the background flow and is validated against experiments. A simple model is presented to predict the shock distortion angle in the weak-shock limit. Finally, the axial decay behaviour of the shock is investigated and it is shown that the advection of the shock by the background flow delays the arrival of the head and tail of the expansion characteristic at the centreline. This leads to an increase in the rate of decay of the shock Mach number as the background flow velocity is increased.
Subthreshold/attenuated syndromes are established precursors of full-threshold mood and psychotic disorders. Less is known about the individual symptoms that may precede the development of subthreshold syndromes and associated social/functional outcomes among emerging adults.
We modeled two dynamic Bayesian networks (DBN) to investigate associations among self-rated phenomenology and personal/lifestyle factors (role impairment, low social support, and alcohol and substance use) across the 19Up and 25Up waves of the Brisbane Longitudinal Twin Study. We examined whether symptoms and personal/lifestyle factors at 19Up were associated with (a) themselves or different items at 25Up, and (b) onset of a depression-like, hypo-manic-like, or psychotic-like subthreshold syndrome (STS) at 25Up.
The first DBN identified 11 items that when endorsed at 19Up were more likely to be reendorsed at 25Up (e.g., hypersomnia, impaired concentration, impaired sleep quality) and seven items that when endorsed at 19Up were associated with different items being endorsed at 25Up (e.g., earlier fatigue and later role impairment; earlier anergia and later somatic pain). In the second DBN, no arcs met our a priori threshold for inclusion. In an exploratory model with no threshold, >20 items at 19Up were associated with progression to an STS at 25Up (with lower statistical confidence); the top five arcs were: feeling threatened by others and a later psychotic-like STS; increased activity and a later hypo-manic-like STS; and anergia, impaired sleep quality, and/or hypersomnia and a later depression-like STS.
These probabilistic models identify symptoms and personal/lifestyle factors that might prove useful targets for indicated preventative strategies.
The Canadian Nosocomial Infection Surveillance Program conducted point-prevalence surveys in acute-care hospitals in 2002, 2009, and 2017 to identify trends in antimicrobial use.
Eligible inpatients were identified from a 24-hour period in February of each survey year. Patients were eligible (1) if they were admitted for ≥48 hours or (2) if they had been admitted to the hospital within a month. Chart reviews were conducted. We calculated the prevalence of antimicrobial use as follows: patients receiving ≥1 antimicrobial during survey period per number of patients surveyed × 100%.
In each survey, 28−47 hospitals participated. In 2002, 2,460 (36.5%; 95% CI, 35.3%−37.6%) of 6,747 surveyed patients received ≥1 antimicrobial. In 2009, 3,566 (40.1%, 95% CI, 39.0%−41.1%) of 8,902 patients received ≥1 antimicrobial. In 2017, 3,936 (39.6%, 95% CI, 38.7%−40.6%) of 9,929 patients received ≥1 antimicrobial. Among patients who received ≥1 antimicrobial, penicillin use increased 36.8% between 2002 and 2017, and third-generation cephalosporin use increased from 13.9% to 18.1% (P < .0001). Between 2002 and 2017, fluoroquinolone use decreased from 25.7% to 16.3% (P < .0001) and clindamycin use decreased from 25.7% to 16.3% (P < .0001) among patients who received ≥1 antimicrobial. Aminoglycoside use decreased from 8.8% to 2.4% (P < .0001) and metronidazole use decreased from 18.1% to 9.4% (P < .0001). Carbapenem use increased from 3.9% in 2002 to 6.1% in 2009 (P < .0001) and increased by 4.8% between 2009 and 2017 (P = .60).
The prevalence of antimicrobial use increased between 2002 and 2009 and then stabilized between 2009 and 2017. These data provide important information for antimicrobial stewardship programs.
Many patients with mental health disorders become increasingly isolated at home due to anxiety about going outside. A cognitive perspective on this difficulty is that threat cognitions lead to the safety-seeking behavioural response of agoraphobic avoidance.
We sought to develop a brief questionnaire, suitable for research and clinical practice, to assess a wide range of cognitions likely to lead to agoraphobic avoidance. We also included two additional subscales assessing two types of safety-seeking defensive responses: anxious avoidance and within-situation safety behaviours.
198 patients with psychosis and agoraphobic avoidance and 1947 non-clinical individuals completed the item pool and measures of agoraphobic avoidance, generalised anxiety, social anxiety, depression and paranoia. Factor analyses were used to derive the Oxford Cognitions and Defences Questionnaire (O-CDQ).
The O-CDQ consists of three subscales: threat cognitions (14 items), anxious avoidance (11 items), and within-situation safety behaviours (8 items). Separate confirmatory factor analyses demonstrated a good model fit for all subscales. The cognitions subscale was significantly associated with agoraphobic avoidance (r = .672, p < .001), social anxiety (r = .617, p < .001), generalized anxiety (r = .746, p < .001), depression (r = .619, p < .001) and paranoia (r = .655, p < .001). Additionally, both the O-CDQ avoidance (r = .867, p < .001) and within-situation safety behaviours (r = .757, p < .001) subscales were highly correlated with agoraphobic avoidance. The O-CDQ demonstrated excellent internal consistency (cognitions Cronbach’s alpha = .93, avoidance Cronbach’s alpha = .94, within-situation Cronbach’s alpha = .93) and test–re-test reliability (cognitions ICC = 0.88, avoidance ICC = 0.92, within-situation ICC = 0.89).
The O-CDQ, consisting of three separate scales, has excellent psychometric properties and may prove a helpful tool for understanding agoraphobic avoidance across mental health disorders.
This paper explores the screech closure mechanism for different axisymmetric modes in shock-containing jets. While many of the discontinuities in tonal frequency exhibited by screeching jets can be associated with a change in the azimuthal mode, there has to date been no satisfactory explanation for the existence of multiple axisymmetric modes at different frequencies. This paper provides just such an explanation. As shown in previous works, specific wavenumbers arise from the interaction of waves in the flow with the shocks. This provides new paths for driving upstream-travelling waves that can potentially close the resonance loop. Predictions using locally parallel and spatially periodic linear stability analyses and the wavenumber spectrum of the shock-cell structure suggest that the A1 mode resonance is closed by a wave generated when the Kelvin–Helmholtz mode interacts with the leading wavenumber of the shock-cell structure. The A2 mode is closed by a wave that arises owing to the interaction between the Kelvin–Helmholtz wave and a secondary wavenumber peak, which arises from the spatial variation of the shock-cell wavelength. The predictions are shown to closely match experimental data, and possible justifications for the dominance of each mode are provided based on the growth rates of the absolute instability.
To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution.
Retrospective cohort study.
Two affiliated academic medical centers in Los Angeles, California.
Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards.
We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation.
Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91–4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28–3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34–0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22–0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria.
Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.
We present an analysis of the linear stability characteristics of shock-containing jets. The flow is linearised around a spatially periodic mean, which acts as a surrogate for a mean flow with a shock-cell structure, leading to a set of partial differential equations with periodic coefficients in space. Disturbances are written using the Floquet ansatz and Fourier modes in the streamwise direction, leading to an eigenvalue problem for the Floquet exponent. The characteristics of the solution are directly compared with the locally parallel case, and some of the features are similar. The inclusion of periodicity induces minor changes in the growth rate and phase velocity of the relevant modes for small shock amplitudes. On the other hand, the eigenfunctions are now subject to modulation related to the periodicity of the flow. Analysis of the spatio-temporal growth rates led to the identification of a saddle point between the Kelvin–Helmholtz mode and the guided jet mode, characterising an absolute instability mechanism. Frequencies and mode shapes related to the saddle points for two conditions (associated with axisymmetric and helical modes) are compared with screech frequencies and the most energetic coherent structures of screeching jets, resulting in a good agreement for both. The analysis shows that a periodic shock-cell structure has an impulse response that grows upstream, leading to oscillator behaviour. The results suggest that screech can occur in the absence of a nozzle, and that the upstream reflection condition is not essential for screech frequency selection. Connections to previous models are also discussed.
Background: Despite significant morbidity and mortality, estimates of the burden of healthcare-associated viral respiratory infections (HA-VRI) for noninfluenza infections are limited. Of the studies assessing the burden of respiratory syncytial virus (RSV), cases are typically classified as healthcare associated if a positive test result occurred after the first 3 days following admission, which may miss healthcare exposures prior to admission. Utilizing an expanded definition of healthcare-associated RSV, we assessed the estimates of disease prevalence. Methods: This study included laboratory-confirmed cases of RSV in adult and pediatric patients admitted to acute-care hospitals in a catchment area of 8 counties in Tennessee identified between October 1, 2016, and April 30, 2019. Surveillance information was abstracted from hospital and state laboratory databases, hospital infection control databases, reportable condition databases, and electronic health records as a part of the Influenza Hospitalization Surveillance Network by the Emerging Infections Program. Cases were defined as healthcare-associated RSV if laboratory confirmation of infection occurred (1) on or after hospital day 4 (ie, “traditional definition”) or (2) between hospital day 0 and 3 in patients transferred from a chronic care facility or with a recent discharge from another acute-care facility in the 7 days preceding the current index admission (ie, “enhanced definition”). The proportion of laboratory-confirmed RSV designated as HA-VRI using both the traditional definition as well as with the added enhanced definition were compared. Results: We identified 900 cases of RSV in hospitalized patients over the study period. Using the traditional definition for HA-VRI, only 41 (4.6%) were deemed healthcare associated. Adding the cases identified using the enhanced definition, an additional 12 cases (1.3%) were noted in patients transferred from a chronic care facility for the current acute-care admission and 17 cases (1.9%) were noted in patients with a prior acute-care admission in the preceding 7 days. Using our expanded definition, the total proportion of healthcare-associated RSV in this cohort was 69 (7.7%) of 900 compared to 13.1% of cases for influenza (Figure 1). Although the burden of HA-VRI due to RSV was less than that of influenza, when stratified by age, the rate increased to 11.7% for those aged 50–64 years and to 10.1% for those aged ≥65 years (Figure 2). Conclusions: RSV infections are often not included in estimates of HA-VRI, but the proportion of cases that are healthcare associated are substantial. Typical surveillance methods likely underestimate the burden of disease related to RSV, especially for those aged ≥50 years.