Role of nutrients in modulating microbiota and immunity in COVID-19 disease

COVID-19 is a novel disease with a broad range of clinical patterns. Several patients show dysbiosis in the intestinal tract, with evidence of reduced beneficial bacteria, such as Bifidobacteria and Lactobacilli. It is well established that human gut microbiota dysbiosis is associated with several clinical conditions, including respiratory tract diseases due to the gut-lung axis. This narrative review discusses the role of nutrients in the relationship between the gut microbiota and the immune response in SARS-CoV-2 infection. In particular, we will focus on the benefits offered by vitamins and micronutrients on different aspects of COVID-19 disease while also discussing which diets seem to provide the most advantages.

Asthma Care Quality Measures at Children's Hospitals and Asthma-Related Outcomes

OBJECTIVE

The Joint Commission requires hospitals to report on Children's Asthma Care (CAC) measures, although their relationship to outcomes is not clear. The objective of this study was to (1) characterize metrics hospitals use for asthma, and to (2) determine if the number and type of metrics used is associated with readmission rates.

STUDY DESIGN

Pediatric hospital quality leaders were asked to identify asthma metrics utilized by their respective organizations via an online survey. "Use" of metrics was defined as periodically measuring data regardless of performance. Linear regression was used to determine if the number or domain of metrics grouped by topic used was associated with 7-, 30-, and 90-day same-cause readmission rates obtained from the Pediatric Health Information System (PHIS).

RESULTS

Among respondents (n = 27, 62.7%), the mean number of metrics used was 20.5 (SD = 9.1, range = 4-38). There was no association between the number or domain type of metrics used and 7-, 30-, or 90-day readmission rates.

CONCLUSIONS

Despite using a wide variety of asthma metrics, there was no association between use of any metric or domain of metrics and asthma-related readmission rates. Additional work should identify asthma process measures that are associated with meaningful outcomes.

Etiology and Laboratory Abnormalities in Bacterial Meningitis in Neonates and Young Infants

We conducted a retrospective review of electronic medical records of all cases of bacterial meningitis in neonates and young infants at our institution from 2004 to 2014. Fifty-six cases were identified. The most common causative organism was group B streptococcus, followed by Escherichia coli and then Listeria monocytogenes. Forty-four of the 56 patients in the study had abnormalities of the blood white blood cell (WBC) count. The most common WBC count abnormalities were leukopenia and elevation of the immature to total (I:T) neutrophil ratio. Six patients in the case series lacked cerebrospinal fluid (CSF) pleocytosis. Overall, just 3 of the 56 patients had normal WBC count with differential, CSF WBC count, and urinalysis. Only 1 of the 56 patients was well appearing with all normal lab studies. Our study indicates that bacterial meningitis may occur without CSF pleocytosis but very infrequently occurs with all normal lab studies and well appearance.

Initial characterization of a gel patch dosimeter for in vivo dosimetry

In vivo dosimetry is a greatly underutilized tool for patient safety in clinical external beam radiotherapy treatments, despite being recommended by several national and international organizations (AAPM, ICRU, IAEA, NACP). The reasons for this underutilization mostly relate to the feasibility and cost of in vivo dosimetry methods. Due to the increase in the number of beam angles and dose per fraction in modern treatments, there is a compelling need for a novel dosimeter that is robust and affordable while able to operate properly in these complex conditions. This work presents a gel patch dosimeter as a novel method of in vivo dosimetry. DEFGEL, a 6% T normoxic polyacrylamide gel, was injected into 1 cm thick acrylic molds to create 1 cm thick small cylindrical patch dosimeters. To evaluate the change in optical density due to radiation induced polymerization, dosimeters were scanned before and after irradiation using an in-house developed laser densitometer. The dose-responses of three separate batches of gel were evaluated and compared to check for linearity and repeatability. The response development time was evaluated to ensure that the patch dosimeter could be high throughput. Additionally, the potential of this system to be used as an in vivo dosimeter was tested with a clinically relevant end-to-end in vivo phantom test. All irradiations were performed with a Varian Clinac 21EX at the University of Wisconsin Medical Radiation Research Center (UWMRRC). The dose-response of all three batches of gel was found to be linear within the range of 2-20 Gy. At doses below 0.5 Gy the statistical uncertainties were prohibitively large to make quantitative assessments of the results. The three batches demonstrated good repeatability in the range of 2 Gy to up to 10 Gy, with only slight variations in response at higher doses. For low doses the dosimeter fully developed within an hour while at higher doses they fully developed within four hours. During the in vivo phantom test the predicted patch absorbed dose was 4.23 Gy while the readout dose was evaluated to be 4.37 Gy, which corresponds to a 3.2% discrepancy. The dosimeter and densitometer pairing shows promise as an in vivo dosimetry system, especially for hypofractionated or MRI-guided radiotherapy treatments where higher doses are prescribed.

Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency

BACKGROUND AND OBJECTIVES

Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency.

METHODS

We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed.

RESULTS

In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P < .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P < .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P < .001 and P < .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change.

CONCLUSIONS

Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.

Prognostic and predictable value of COX2 expression in Russian women with stage I breast cancer

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Background: Some previous studies found worse prognosis among cyclooxygenase-2 (COX2)-expressing breast cancers; we study prognostic and predictiable value of COX2 expression in breast cancer stage I. Methods: our study included Russian women with breast cancer stage I (n=315) treated in RCRC, RMAPE (1985-2009). A Tissue Micro Array (TMA) with triplicate 1 mm tumor tissue punches taken from tumor blocks was constructed in LUMC; sections were immunohistochemically stained for ER, PR, HER2-status, Ki67 (by standard morphological criteria); COX2-expression were evaluated as positive (>median; 31/309 cases, 10%) or negative (≤median; 278/209 cases, 90%). Also the histological type, grade, age and adjuvant endocrine therapy were examined. We analyzed the clinic and morphological data of COX2-positive tumors, prognostic value for survival (relapses free- RFS, overall- OS and cancer specific- CSS) and predictable value for endocrine therapy. Results: COX2-positive tumor were associated with ductal histological type (p=0,018), PR-negative status (p=0,027) and high Ki67 (p<0,0001), but not correlated (p>0,05) with age, grade, ER, HER2 status or biological subtype. In women with ER-negative tumors (104 patients, 34,1%) COX2-expression did not associate with worse survival (p>0,05). In contrast to this, in patients with ER-positive tumors (201 women, 65,9%) COX2-expression strongly correlated with worse RFS in univariate (HR 2,829, 95% CI 1,366-5,860, p=0,005) and multivariate analyses (HR=2,972, 95% CI 1,190-7,423, p=0,02). The same value of COX2-expression in women with ER-positive tumors was found for CSS (univariate: HR 3,421, 95% CI 1,436-8,149, p=0,005; multivariate: HR 4,260, 95% CI 1,344-13,504, p=0,014), but not for OS (p>0,05). In women who did not receive adjuvant endocrine therapy (145 patients, 46%) COX2 expression did not have any prognostic value for RFS, OS and CSS (p>0,05) but in patients that used adjuvant endocrine therapy (170 women, 54%) COX2-expression strongly associated with worse cancer-specific survival (HR 5,614 95% CI 1,165-27,059, p=0,032), but not with RFS and OS (p>0,05). Conclusions: COX2 expression plays a role in hormonal pathways and sensitivity for endocrine therapy.

Clinical and laboratory characteristics of disseminated herpes simplex virus infection in neonates

BACKGROUND AND OBJECTIVES

Disseminated herpes simplex virus (HSV) infection is the most fulminant type of neonatal HSV infection and has the highest mortality. Early diagnosis and treatment are essential for patient survival. We describe the clinical presentation, laboratory characteristics, and outcomes of neonates with disseminated HSV infection at our institution.

METHODS

A retrospective review of electronic medical records from 2006 to 2013 was performed. Only neonates with disseminated HSV infection, confirmed by using polymerase chain reaction or viral culture results, were included.

RESULTS

Twenty-two cases were identified; the age range was 1 to 14 days. The majority of patients did not have a maternal history of HSV or a history of maternal fever at delivery. Eleven of the patients were delivered by cesarean delivery, and 3 of these patients did not have prolonged rupture of membranes. Neonatal fever, the most common historical characteristic, was present in only one-half of the patients. Pneumonia and respiratory distress were present in one-half of the patients. Serum aspartate aminotransferase and alanine aminotransferase levels were elevated in most, but not all, patients. The blood HSV polymerase chain reaction was positive in all patients tested. Of the 22 study patients, 16 survived and 6 died. The majority of the patients who died had respiratory disease and a delay in the initiation of acyclovir therapy.

CONCLUSIONS

Disseminated HSV infection in neonates can be challenging to diagnose and is associated with high mortality. Clinicians must strongly consider this diagnosis, test the blood for HSV polymerase chain reaction, and initiate early treatment in the appropriate clinical scenarios.

Evaluation of the impact of backscatter intensity variations on ultrasound attenuation estimation

PURPOSE

Quantitative ultrasound based approaches such as attenuation slope estimation can be used to determine underlying tissue properties and eventually used as a supplemental diagnostic technique to B-mode imaging. The authors investigate the impact of backscatter intensity and frequency dependence variations on the attenuation slope estimation accuracy.

METHODS

The authors compare three frequency domain based attenuation slope estimation algorithms, namely, a spectral difference method, the reference phantom method, and two spectral shift methods: a hybrid method and centroid downshift method. Both the reference phantom and hybrid method use a tissue-mimicking phantom with well-defined acoustic properties to reduce system dependencies and diffraction effects. The normalized power spectral ratio obtained is then filtered by a Gaussian filter centered at the transmit center frequency in the hybrid method. A spectral shift method is then used to estimate the attenuation coefficient from the normalized and filtered spectrum. The centroid downshift method utilizes the shift in power spectrum toward lower frequencies with depth. Numerical phantoms that incorporate variations in the backscatter intensity from -3 to 3 dB, by varying the scatterer number density and variations in the scatterer diameters ranging from 10 to 100 μm are simulated. Experimental tissue mimicking phantoms with three different scatterer diameter ranges (5-40, 75-90, and 125-150 μm) are also used to evaluate the accuracy of the estimation methods.

RESULTS

The reference phantom method provided accurate results when the acoustical properties of the reference and the sample are well matched. Underestimation occurs when the reference phantom possessed a higher sound speed than the sample, and overestimation occurs when the reference phantom had a lower sound speed than the sample. The centroid downshift method depends significantly on the bandwidth of the power spectrum, which in turn depends on the frequency dependence of the backscattering. The hybrid method was the least susceptible to changes in the sample's acoustic properties and provided the lowest standard deviation in the numerical simulations and experimental evaluations.

CONCLUSIONS

No significant variations in the estimation accuracy of the attenuation coefficient were observed with an increase in the scatterer number density in the simulated numerical phantoms for the three methods. Changes in the scatterer diameters, which result in different frequency dependence of backscatter, do not significantly affect attenuation slope estimation with the reference phantom and hybrid approaches. The centroid method is sensitive to variations in the scatterer diameter due to the frequency shift introduced in the power spectrum.

Community household income and resource utilization for common inpatient pediatric conditions

BACKGROUND AND OBJECTIVE

Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI).

METHODS

Retrospective national cohort from 32 freestanding children's hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups.

RESULTS

From 116,636 hospitalizations, 4 of 5 conditions had differences at the hospitalization and at the patient level, with lowest-income groups having higher costs. The individual hospitalization level cost differences ranged from $187 (4.1%) to $404 (6.4%). Patient-level cost differences ranged from $310 to $1087 or 6.5% to 15% higher for the lowest-income patients. Higher costs were typically not for laboratory, imaging, or pharmacy costs. In total, patients from lowest income zip codes had $8.4 million more in hospitalization-level costs and $13.6 million more in patient-level costs.

CONCLUSIONS

Lower community-level HHI is associated with higher inpatient costs of care for 4 of 5 common pediatric conditions. These findings highlight the need to consider socioeconomic status in health care system design, delivery, and reimbursement calculations.

Children's hospitals with shorter lengths of stay do not have higher readmission rates

OBJECTIVE

To test the hypothesis that children's hospitals with shorter length of stay (LOS) for hospitalized patients have higher all-cause readmission rates.

STUDY DESIGN

Longitudinal, retrospective cohort study of the Pediatric Health Information System of 183616 admissions within 43 US children's hospitals for appendectomy, asthma, gastroenteritis, and seizure between July 2009 and June 2011. Admissions were stratified by medical complexity, based on whether patients had a complex chronic health condition, were neurologically impaired, or were assisted with medical technology. Outcome measures include LOS; all-cause readmission rates within 3, 7, 15, and 30 days; and the association between hospital-specific mean LOS and all-cause readmission rates as determined by linear regression.

RESULTS

Mean LOS was <3 days for all patients across all conditions, except for appendectomy in complex patients (mean LOS 3.7 days, 95% CI 3.47-4.01). Condition-specific 3-, 7-, 15-, and 30-day all-cause readmission rates for noncomplex patients were all <5%. Condition-specific readmission rates for complex patients ranged from <1% at 3 days for seizures to 16% at 30 days for gastroenteritis. There was no linear association between hospital-specific, condition-specific mean LOS, stratified by medical complexity, and all-cause readmission rates at any time interval within 30 days (all P values ≥.10).

CONCLUSION

In children's hospitals, LOS is short and readmission rates are low for asthma, appendectomy, gastroenteritis, and seizure admissions. In the conditions studied, there is no association between shorter hospital-specific LOS and higher readmission rates within the LOS observed.

Capnocytophagaspp. Brain Abscess in an Immunocompetent Host: Problems in Antimicrobial Chemotherapy and Literature Review

The fourth case report of a brain abscess due to the fastidious Gram-negative organism Capnocytophaga spp. is described and discussed on the grounds of clinical, microbiological, and therapeutic evidence. A probable origin from a cat bite and/or an underlying severe mandibulary granuloma is suspected. Due to lack of clinical and neuroradiological response to neurosurgery and a combination of imipenem-amikacin-clindamycin-fluconazole, second-line empiric llnezolid treatment proved rapidly successful, in the absence of further microbial isolations. In vitro antimicrobial susceptibility testing is often unpredictable for Capnocytophaga spp., and agents usually active on Gram-positive organisms may also be effective, both in vitro and in vivo. Due to its favorable brain penetration and its dual mode of administration, linezolid may be an alternative option for patients with multiple risk factors, brain abscess of suspected polymicrobial origin, and lack of response to empiric or culture-driven therapeutic attempts.

Measurement of radionuclides within the Global Atmosphere Watch Programme of WMO

Within the framework of the Global Atmosphere Watch (GAW) Programme of the World Meteorological Organization (WMO), the Deutscher Wetterdienst (DWD) is taking measurements of naturally occurring radionuclides at both the environmental research platform Schneefernerhaus (2650 m a.s.l.) and the summit of Germany's highest mountain Zugspitze (2962 m a.s.l). The radionuclides measured there include 7Be, 210Pb, 212Pb, 214Pb, 214Bi, and 222Rn. This paper especially presents the direct measurement of gaseous 222Rn with a limit of detection of < 0.05 Bq/m3. When combined with meteorological data, these measurements provide a valuable database for characterising air masses and a useful supplementary tool evaluating air transport models and identifying global atmospheric conditions.

Telecardiology on Vancouver Island: imagination to implementation

In 2011, there were more than 97,000 people living with Heart Failure in British Columbia (BC) with a total of 17,592 within VIHA. To increase patient accessibility to specialist care, the Vancouver Island Health Authority (VIHA) implemented a telecardiology program that utilizes digital stethoscopes, telehealth technology and collaboration to deliver cardiac care remotely. The program has successfully completed 20 consultations to date in 6 communities within the VIHA. This article outlines processes and outcomes of enabling the existing VIHA cardiology program with the use of telehealth technologies.

Extended endoscopic transplanum-transtuberculum approach for pituitary adenomas

Few pituitary adenomas require removal through a transcranial route. This may be associated with more significant morbidity and mortality, compared to the transsphenoidal approach. An endoscopic, extended, transplanum-transtuberculum approach (ETTA) in selected pituitary adenomas may offer an alternative to the transcranial route. We describe our technique and experience of ETTA in pituitary adenomas over 10 years. Between 2000 and 2010, we performed 700 endoscopic endonasal procedures for pituitary adenomas. Nineteen patients (13 men; mean age, 48 years; range, 22-76 years) underwent 22 ETTAs. Thirteen patients had non-functioning adenomas. Three tumor groups were identified: (1) tumors developing in or around the pituitary stalk; (2) tumours with sub- frontal extension and (3) tumours with a major extrasellar component. Mean follow-up was 37 months (range 6-72 months). Gross total resection was achieved in 11 procedures (no recurrences), with partial tumour resection in 11 procedures. Of the 12 patients with visual symptoms, ten improved. Of eight patients with hormonal hypersecretion four were cured. Complications included CSF leak (14%), haemorrhage (9%), hemiplegia (5%). There were no mortalities. Experience using the ETTA for pituitary adenomas is limited because it is indicated in highly selected cases (3.1% of our series). An absolute indication is represented by ectopic secreting pituitary stalk/peri-stalk adenomas. ETTA is a useful option in midline frontal adenomas and adenomas with a major extrasellar component, but has a higher morbidity than that seen in the standard transsphenoidal approach. A study comparing ETTA versus transcranial resection is highly desirable.

Antitumor effect of k+/h+-antiporter nigericin on human lung-carcinoma grown in in-vivo-like histocultures

Small shifts of intracellular pH (pH(i)) play a crucial role in many cellular functions, in particular progression through the cell cycle. We present results demonstrating that in the majority of cases, nigericin shows cytostatic effect on tumor cells in the in vivo-like 3-dimensional histocultures of human lung tissues while the normal tissue remains morphologically intact.

Anechoic sphere phantoms for estimating 3-D resolution of very-high-frequency ultrasound scanners

Two phantoms have been constructed for assessing performance of high-frequency ultrasound imagers. They also allow for periodic quality assurance tests and training technicians in the use of higher-frequency scanners. The phantoms contain eight blocks of tissue-mimicking material; each block contains a spatially random distribution of suitably small anechoic spheres having a small distribution of diameters. The eight mean sphere diameters are distributed from 0.10 to 1.09 mm. The two phantoms differ primarily in terms of the frequency dependence of the backscatter coefficient of the background material. Because spheres have no preferred orientation, all three (spatial) dimensions of resolution contribute to sphere detection on an equal basis; thus, the resolution is termed 3-D. Two high-frequency scanners are compared. One employs single-element (fixed focus) transducers (25 and 55 MHz), and the other employs variable focus linear arrays (20, 30, and 40 MHz). The depth range for detection of spheres of each size is determined corresponding to determination of 3-D resolution as a function of depth. As expected, the single-element transducers are severely limited in useful imaging depth ranges compared with the linear arrays. In this preliminary report, only one human observer analyzed images.

Thyrotropin-secreting pituitary tumours: significance of “atypical adenomas” in a series of 10 patients and association with Hashimoto thyroiditis as a cause of delay in diagnosis

Background:

Thyrotropin-secreting adenomas (TSH-As) are rare and, according to the World Health Organization criteria (WHO 2004), a significant proportion of them present features of atypical adenomas at the time of diagnosis.

Aims:

To determine the frequency of “atypical adenomas” and the significance of this definition as regards follow-up. To investigate their possible association with Hashimoto thyroiditis, leading to a delay in diagnosis.

Methods:

Case notes for patients who underwent trans-sphenoidal surgery between 1992 and 2006 were retrieved. Follow-up ranged from 6 to 180 months.

Results:

Ten cases of TSH-As out of 908 pituitary adenomas were selected. Before surgery, eight patients had hyperthyroidism, one was euthyroid and another one showed hypothyroidism associated with Hashimoto thyroiditis. All cases were macroadenomas; six of them were invasive. Three cases met the criteria for classification as atypical. In none of the cases, including the three “atypical adenomas”, were clinical or radiological signs of recurrence observed.

Conclusions:

The three cases with features of atypical adenoma did not recur or metastasise, suggesting that, at least in the present series, a strict relationship between the morphological criteria for diagnosing atypical adenomas and biological behaviour may be sometimes lacking. Furthermore, the casual association of TSH-As with Hashimoto thyroiditis may led to an adjunctive delay in diagnosis, because of low thyroid hormone levels.

An accelerator for neural networks with pulse-coded model neurons

The labeling of features by synchronization of spikes seems to be a very efficient encoding scheme for a visual system. Simulation of a vision system with millions of pulse-coded model neurons, however, is almost impossible on the base of available processors including parallel processors and neurocomputers. A "one-to-one" silicon implementation of pulse-coded model neurons suffers from communication problems and low flexibility. On the other hand, acceleration of the simulation algorithm of pulse-coded leaky integrator neurons has proved to be straightforward, flexible, and very efficient. Thus we decided to develop an accelerator for a special version of the French and Stein neurons with modulatory inputs which are advantageous for simulation of synchronization mechanisms. Moreover, our accelerator also provides a Hebbian-like learning rule and supports adaptivity. Up to 128 K neurons with a total number of 16 M freely allocatable synapses are simulated within one system. The size of networks, however, is not at all limited by these numbers as the system may be arbitrarily expanded. Simulation speed obviously depends on the number of interconnections and on the average activity within the network. In the case of locally interconnected networks for simulation of vision mechanisms there is only a very low percentage of simultaneously active neurons: stimuli are not simultaneously presented in all orientations and at all positions of the visual field. In these cases our accelerator provides close to real-time behavior if one second of a biological neuron is simulated by 1000 time slots.