The North American Heritage at Risk (NAHAR) collaborative, which formed during the COVID-19 pandemic, allowed for heritage-at-risk partners to shift from reactive to proactive strategies. The result was the creation of the NAHAR research pipeline to respond to landscapes at risk. The pipeline includes modeling of environmental changes to the landscape; monitoring sites to verify location and assess condition; meeting with the public, descendant community, land managers, and transdisciplinary experts in their field to discuss climate change impacts to their heritage in the next 10 years; methodizing by means of a workflow organizer using data from the modeling, monitoring, and meeting; and when appropriate, mitigating areas identified during the methodizing process. In 2020, the Florida Public Archaeology Network—along with partners in Georgia, South Carolina, Washington, Texas, and Louisiana—began the Science Collaborative People of Guana project at the Guana Tolomato Matanzas Estuarine Research Reserve (GTM NERR) north of St. Augustine, Florida. Using a collaborative science mindset, the project team applied the NAHAR pipeline to gain a better sense of how resources were used in the past and how they currently are being used by communities to ensure responsive resource management and relationship building with visitors, descendants, and other community stakeholders, such as the Gullah/Geechee Nation. This article will provide the building blocks for other collaborative teams to follow the NAHAR pipeline and share lessons learned from the two-year project.

We evaluated the feasibility and acceptability of frailty screening using handgrip strength with gait speed measures within four primary care-based memory clinics in Ontario. This mixed methods quality improvement initiative examined the reach, effectiveness, adoption, implementation, and maintenance of frailty screening from the perspective of patients (N = 216), care partners (N = 142), and healthcare providers (N = 9). Frailty screening was well-received by patients and care partners and perceived as quick and easy to administer and integrate into assessment processes by healthcare providers at all four memory clinics. The ease of integrating frailty screening into clinic processes was a key factor facilitating implementation; few challenges or suggestions for improvement were identified. All four clinics plan to continue frailty screening, three using the methods adopted in this study. Integrating frailty screening into memory assessments is feasible and acceptable and, given the interactional relationship between frailty and dementia, provides a significant opportunity to improve health outcomes for older adults.

Background: Detecting healthcare-associated transmission and outbreaks often relies on reactive whole-genome sequencing (WGS), which occurs after the suspected transmission has occurred. Additionally, reactive WGS frequently misidentifies transmission and misses transmission when it has occurred. We initiated weekly real-time WGS to detect bacterial transmission and direct infection prevention interventions. We describe our experience after 1 year of real-time WGS surveillance at the University of Pittsburgh Medical Center–Presbyterian Hospital, a large, tertiary-care facility. Methods: Weekly WGS surveillance was performed from November 1, 2021, to October 31, 2022. Cultured isolates of select bacterial pathogens from patients who were hospitalized for ≥3 days or had a recent healthcare exposure in the prior 30 days were collected and sequenced. Isolates that were ≤15 single-nucleotide polymorphisms (SNPs) were considered genetically related clusters except for Clostridioides difficile (≤2 SNPs). Genetically related clusters were investigated for epidemiological links and interventions to interrupt transmission were implemented at the discretion of the infection prevention team. We analyzed subsequent infections that occurred within an outbreak after an intervention was in place. Results: In total, 1,909 isolates were sequenced. Of 1,633 unique patient isolates clustered by sequence type, 74 clusters were identified comprising 210 (12.9%) patient isolates (Table 1). The median time from culture date to sequencing was 14 days (IQR, 5.25). The median cluster size was 2 (IQR, 1) (Table 2). Overall, 118 patient isolates (56.2%) had an epidemiological link to a prior isolate, indicating potential transmission. Of 74 clusters, 66 (89.2%) received infection prevention interventions after notification based upon epidemiological data. The infection prevention team performed 69 total interventions, which included unit education (n = 28), hand hygiene observations (n = 16), enhanced cleaning (n = 16), environmental cultures or removal of endoscope (n = 7), and enhanced microbiology surveillance (n = 2). The 59 subsequent infections after infection prevention notification included 17 (28.8%) with no clear epidemiological link, and 41 (69.5%) with an epidemiological link either to a new transmission route (n = 37) or the same route prior to infection prevention intervention (n = 4). Only 1 (1.7%) subsequent infection within a cluster occurred after an infection prevention intervention from the same potential route, which was a suspected unit-based transmission of vancomycin-resistant Enterococcus faecium. Conclusions: Real-time WGS was effective at detecting genetically related clusters, finding potential sources, and halting further transmission after interventions by the infection prevention team. Quick turnaround times from patient culture to sequencing and analysis were vital for successful WGS surveillance. Real-time WGS surveillance has the potential to substantially shift the infection prevention paradigm for outbreak detection.

Disclosure: None

Background: Traditional infection prevention (IP) methods for outbreak detection often rely on geotemporal clustering confined to single locations. We recently developed the Enhanced Detection System for Healthcare-Associated Transmission (EDS-HAT), which combines whole-genome sequencing (WGS) surveillance and machine learning of the electronic health record (EHR). Our retrospective research findings show potential transmissions averted and cost savings using EDS-HAT in real time. Here, we describe the process and initial findings from EDS-HAT real-time implementation. Methods: Real-time whole-genome sequencing surveillance began on November 1, 2021. Patient cultures positive for select bacterial pathogens who were hospitalized for ≥3 days or had a recent healthcare exposure in the prior 30-days were collected. Isolates were deemed genetically related if ≤15 single-nucleotide polymorphisms (SNPs) were identified for all organisms except Clostridioides difficile (≤2 SNPs). Clusters were manually investigated by both research and IP teams, and interventions were performed by the IP team. Data on collection, analysis, notification, and intervention dates were gathered. Results: As of January 11, 2022, 413 isolates had undergone whole-genome sequencing. Among them, 18 unique patient isolates were genetically related to ≥1 other isolate, comprising 7 clusters (range, 2–6 patients). Notable findings include a Pseudomonas aeruginosa cluster possibly related to a shared bronchoscope, a pseudo-outbreak of Serratia marcescens related to autopsy blood culture practice, and a cluster of vancomycin-resistant Enterococcus faecium on a shared transplant unit. Only 1 cluster of 2 isolates of Klebsiella pneumoniae had no known possible transmission routes. The median turnaround time from patient’s culture date to IP notification was 19 days (range, 13–28), with noted delays over the winter holiday. Concusions: Real-time WGS can identify small clusters including potentially interruptible transmission routes. Rapid turnaround time, coordination between clinical and genomic laboratories, and a robust IP team are key factors in implementing a WGS surveillance program. Real-time WGS surveillance has the potential to reduce costs for hospitals, improve patient safety, and save lives.

Funding: None

Disclosures: None

Although twins often participate in medical research, few clinical trials are conducted entirely in twin populations. The purpose of this review is to demonstrate the substantial benefits and address the key challenges of conducting clinical trials in twin populations, or ‘twin-only trials’. We consider the unique design, analysis, recruitment and ethical issues that arise in such trials. In particular, we describe the different approaches available for randomizing twin pairs, highlight the similarity or correlation that exists between outcomes of twins, and discuss the impact of this correlation on sample size calculations and statistical analysis methods for estimating treatment effects. We also consider the role of both monozygotic and dizygotic twins for studying variation in outcomes, the factors that may affect recruitment of twins, and the ethics of conducting trials entirely in twin populations. The advantages and disadvantages of conducting twin-only trials are also discussed. Finally, we recommend that twin-only trials should be considered more often.

COVID-19 has had a devasting impact on older adults in Canada, including persons living with dementia. This intrinsic case study sought to understand the perceptions of persons living with dementia regarding how COVID-19 has impacted their well-being. Ten persons living with dementia participated in in-depth qualitative interviews about their experience with COVID-19. Using thematic analysis, four themes were identified: (1) expressing current and future concerns; (2) social connections and isolation; (3) adapting to change and resilience through engagement and hope; and (4) we’re not all the same: reflecting individual experiences of the pandemic. Results highlight that while COVID-19 contributed to isolation, concerns, and frustrations, persons with dementia also demonstrated adaptation and resilience. This study reinforced that persons with dementia and their responses to challenges are unique. Therefore, interventions to support persons with dementia must also be individualized to each person’s abilities and circumstances.

The systematic review examined the phenomenon of trust during public health emergency events. The literature reviewed was field studies done with people directly affected or likely to be affected by such events and included quantitative, qualitative, mixed-method, and case study primary studies in English (N = 38) as well as Arabic, Chinese, French, Russian, and Spanish (all non-English N = 30). Studies were mostly from high- and middle-income countries, and the event most covered was infectious disease. Findings from individual studies were first synthesized within methods and evaluated for certainty/confidence, and then synthesized across methods. The final set of 11 findings synthesized across methods identified a set of activities for enhancing trust and showed that it is a multi-faceted and dynamic concept.

Frailty prevalence is higher in low- and middle-income countries (LMICs) compared with high-income countries when measured by biomedical frailty models, the most widely used being the frailty phenotype. Frailty in older people is becoming of global public health interest as a means of promoting health in old age in LMICs. As yet, little work has been done to establish to what extent the concept of frailty, as conceived according to ‘western’ biomedicine, has cross-cultural resonance for a low-income rural African setting. This study aimed to investigate the meaning of frailty contextually, using the biomedical concept of the frailty phenotype as a framework. Qualitative interviews were conducted with a purposive sample of older adults, their care-givers and community representatives in rural northern Tanzania. Thirty interview transcripts were transcribed, translated from Kiswahili to English and thematically analysed. Results reveal that despite superficial similarities in the understanding of frailty, to a great extent the physical changes highlighted by the frailty phenotype were naturalised, except when these were felt to be due to a scarcity of resources. Frailty was conceptualised as less of a physical problem of the individual, but rather, as a social problem of the community, suggesting that the frailty construct may be usefully applied cross-culturally when taking a social equity focus to the health of older people in LMICs.

The magnetic resonance imaging (MRI) appearance of the brain and spinal cord in humans with neuroangiostrongyliasis (NA) due to Angiostrongylus cantonensis infection has been well reported. Equivalent studies in animals are lacking. This case series describes clinical and MRI findings in 11 dogs with presumptively or definitively diagnosed NA. MRI of the brain and/or spinal cord was performed using high-field (1.5 T) or low-field (0.25 T) scanners using various combinations of transverse, sagittal, dorsal and three-dimensional (3D) T1-weighted (T1W), transverse, sagittal and dorsal T2-weighted (T2W), T2W fluid-attenuated inversion recovery (FLAIR) and T2*-weighted (T2*W) gradient echo (GRE), dorsal T2W short tau inversion recovery (STIR) and post-gadolinium transverse, sagittal, dorsal and 3D T1W and transverse T2W FLAIR sequences. In 4/6 cases where the brain was imaged, changes consistent with diffuse meningoencephalitis were observed. Evidence of meningeal involvement was evident even when not clinically apparent. The spinal cord was imaged in 9 dogs, with evidence of meningitis and myelitis detected in regions consistent with the observed neuroanatomical localization. Pathognomonic changes of neural larva migrans, as described in some human patients with NA, were not detected. NA should be considered in the differential diagnosis of dogs with MRI evidence of focal or diffuse meningitis, myelitis and/or encephalitis, especially in areas where A. cantonensis is endemic. If not precluded by imaging findings suggestive of brain herniation, cerebrospinal fluid (CSF) collection for cytology, fluid analysis, real-time polymerase chain reaction (qPCR) and enzyme-linked immunosorbent assay (ELISA) testing should be considered mandatory in such cases after the MRI studies.

The principal aim of this study was to optimize the diagnosis of canine neuroangiostrongyliasis (NA). In total, 92 cases were seen between 2010 and 2020. Dogs were aged from 7 weeks to 14 years (median 5 months), with 73/90 (81%) less than 6 months and 1.7 times as many males as females. The disease became more common over the study period. Most cases (86%) were seen between March and July. Cerebrospinal fluid (CSF) was obtained from the cisterna magna in 77 dogs, the lumbar cistern in f5, and both sites in 3. Nucleated cell counts for 84 specimens ranged from 1 to 146 150 cells μL−1 (median 4500). Percentage eosinophils varied from 0 to 98% (median 83%). When both cisternal and lumbar CSF were collected, inflammation was more severe caudally. Seventy-three CSF specimens were subjected to enzyme-linked immunosorbent assay (ELISA) testing for antibodies against A. cantonensis; 61 (84%) tested positive, titres ranging from <100 to ⩾12 800 (median 1600). Sixty-one CSF specimens were subjected to real-time quantitative polymerase chain reaction (qPCR) testing using a new protocol targeting a bioinformatically-informed repetitive genetic target; 53/61 samples (87%) tested positive, CT values ranging from 23.4 to 39.5 (median 30.0). For 57 dogs, it was possible to compare CSF ELISA serology and qPCR. ELISA and qPCR were both positive in 40 dogs, in 5 dogs the ELISA was positive while the qPCR was negative, in 9 dogs the qPCR was positive but the ELISA was negative, while in 3 dogs both the ELISA and qPCR were negative. NA is an emerging infectious disease of dogs in Sydney, Australia.

Migration is an important social determinant of health for immigrants in the United States. Increased attention on Latino immigrants in recent years has sparked interest in policies that affect this population. While prior research has assessed the potential health impact of specific immigration policies, there is limited understanding of how the overall sociopolitical context shapes the health of Latino immigrants. This study examines the potential mechanisms that link the sociopolitical context and health among Latino immigrants. Specifically, we explore how perceptions of the sociopolitical context are implicated in this relationship. Qualitative interviews with community gatekeepers (n=13) and Latino immigrants (n=34) in New York City revealed general perceptions about the overall sociopolitical context, which were characterized by discrimination towards immigrants, unpredictable and mercurial circumstances, and confusion and lack of information. These perceptions influenced participants’ psycho-emotional health and health-related behaviors. Findings suggest the importance of integrating immigrants’ perceptions of the sociopolitical context into health promotion efforts. Furthermore, findings demonstrate the need for paradigm shifts in developing policy-related actions to integrate immigrants’ perspectives. We propose an integrated, multi-level framework to guide future research and practice regarding social determinants of immigrant health.