Digitally recorded and remotely classified lung auscultation compared with conventional stethoscope classifications among children aged 1-59 months enrolled in the Pneumonia Etiology Research for Child Health (PERCH) case-control study

BACKGROUND

Diagnosis of pneumonia remains challenging. Digitally recorded and remote human classified lung sounds may offer benefits beyond conventional auscultation, but it is unclear whether classifications differ between the two approaches. We evaluated concordance between digital and conventional auscultation.

METHODS

We collected digitally recorded lung sounds, conventional auscultation classifications and clinical measures and samples from children with pneumonia (cases) in low-income and middle-income countries. Physicians remotely classified recordings as crackles, wheeze or uninterpretable. Conventional and digital auscultation concordance was evaluated among 383 pneumonia cases with concurrently (within 2 hours) collected conventional and digital auscultation classifications using prevalence-adjusted bias-adjusted kappa (PABAK). Using an expanded set of 737 cases that also incorporated the non-concurrently collected assessments, we evaluated whether associations between auscultation classifications and clinical or aetiological findings differed between conventional or digital auscultation using χ² tests and logistic regression adjusted for age, sex and site.

RESULTS

Conventional and digital auscultation concordance was moderate for classifying crackles and/or wheeze versus neither crackles nor wheeze (PABAK=0.50), and fair for crackles-only versus not crackles-only (PABAK=0.30) and any wheeze versus no wheeze (PABAK=0.27). Crackles were more common on conventional auscultation, whereas wheeze was more frequent on digital auscultation. Compared with neither crackles nor wheeze, crackles-only on both conventional and digital auscultation was associated with abnormal chest radiographs (adjusted OR (aOR)=1.53, 95% CI 0.99 to 2.36; aOR=2.09, 95% CI 1.19 to 3.68, respectively); any wheeze was inversely associated with C-reactive protein >40 mg/L using conventional auscultation (aOR=0.50, 95% CI 0.27 to 0.92) and with very severe pneumonia using digital auscultation (aOR=0.67, 95% CI 0.46 to 0.97). Crackles-only on digital auscultation was associated with mortality compared with any wheeze (aOR=2.70, 95% CI 1.12 to 6.25).

CONCLUSIONS

Conventional auscultation and remotely-classified digital auscultation displayed moderate concordance for presence/absence of wheeze and crackles among cases. Conventional and digital auscultation may provide different classification patterns, but wheeze was associated with decreased clinical severity on both.

Urinary arsenic is associated with wasting and underweight status in young children in rural Bangladesh

BACKGROUND

Deficits in child growth are associated with poor cognitive outcomes and an increased risk for infection and mortality globally. One hundred forty million people are chronically exposed to arsenic from contaminated drinking water worldwide. While arsenic exposure has been associated with cognitive developmental delays in children, there is limited research on the association between arsenic exposure and growth deficits in young children.

PURPOSE

The objective of this study was to assess the association between chronic arsenic exposure and deficits in growth among children under 5 years in a rural setting in Bangladesh.

METHODS

Urinary arsenic measurements were collected from 465 children between the ages of 28 days-59 months in rural Matlab, Bangladesh, and analyzed by graphite furnace atomic absorption. Height and weight measurements were collected from children according to World Health Organization child growth standards. A z-score cutoff2 standard deviations below the mean was used to define stunting (height-for-age z-score), underweight (weight-for-age z-score), and wasting (weight-for-height z-score).

RESULTS

Children under 5 years with urinary arsenic concentrations in the third tertile (greater than 31 μg per liter (μg/L)) had a two times higher odds of being underweight after adjustment for age, creatinine, paternal education, breastfeeding, number of individuals using the same sleeping room, and physician-diagnosed pneumonia (Odds Ratio (OR): 2.29 (95% Confidence Interval (CI): 1.16, 4.52)). Children under 2 years of age had a two times higher odds of being wasted after adjustment for age, creatinine, paternal education, breastfeeding, number of individuals using the same sleeping room, and physician-diagnosed pneumonia (OR: 2.85 (95% CI: 1.18, 6.89)).

CONCLUSIONS

These findings suggest that arsenic exposure is associated with an increased odds of being wasted and underweight among young children in rural Bangladesh.

Arsenic exposure is associated with pediatric pneumonia in rural Bangladesh: a case control study

BACKGROUND

Pneumonia is the leading cause of death for children under 5 years of age globally, making research on modifiable risk factors for childhood pneumonia important for reducing this disease burden. Millions of children globally are exposed to elevated levels of arsenic in drinking water. However, there is limited data on the association between arsenic exposure and respiratory infections, particularly among pediatric populations.

METHODS

This case control study of 153 pneumonia cases and 296 controls 28 days to 59 months of age in rural Bangladesh is the first to assess whether arsenic exposure is a risk factor for pneumonia in a pediatric population. Cases had physician diagnosed World Health Organization defined severe or very severe pneumonia. Urine collected during hospitalization (hospital admission time point) and 30 days later (convalescent time point) from cases and a single specimen from community controls was tested for urinary arsenic by graphite furnace atomic absorption.

RESULTS

The odds for pneumonia was nearly double for children with urinary arsenic concentrations higher than the first quartile (≥6 μg/L) at the hospital admission time point (Odd Ratio (OR):1.88 (95% Confidence Interval (CI): 1.01, 3.53)), after adjustment for urinary creatinine, weight for height, breastfeeding, paternal education, age, and number of people in the household. This was consistent with findings at the convalescent time point where the adjusted OR for children with urinary arsenic concentrations greater than the first quartile (≥6 μg/L) was 2.32 (95% CI: 1.33, 4.02).

CONCLUSION

We observed a nearly two times higher odds of pneumonia for children with creatinine adjusted urinary arsenic concentrations greater than the first quartile (≥6 μg/L) at the hospital admission time point. This novel finding suggests that low to moderate arsenic exposure may be a risk factor for pneumonia in children under 5 years of age.

Coordinating research and practice: challenges testing messages to increase medical reserve corps participation in local health department activities

Local health departments (LHDs) increasingly depend on volunteers, often Medical Reserve Corps (MRC) volunteers, to assist with a variety of functions. While LHDs have extensive lists of volunteers, only about 10 % are actively involved in LHD activities. Psychological literature has shown that well-designed messages can motivate behavior among individuals. Key to this theory is the concept of "framing," defined as the influence the characterization of an issue can have on its understanding. Research has been conducted on how to frame and disseminate both political and public health messages to alter individual behavior. We aimed to design and test appropriate evidence-based messages to increase volunteer participation rates in LHD flu clinics. After inviting over 900 MRC units to participate during the 2011-2012 influenza season, five were able to collect and report data to the research team. Using a randomized trial design, we tested messages among the five participating MRC units consisting of a total of 2,020 volunteers. Chi Square analysis showed no difference in attendance between those who received either of the test messages versus the control message (p = .305). Our small sample size of MRC units likely biased our sample and reduced the external validity of our study. Our experience in conducting research with MRC coordinators and volunteers highlights the challenges of conducting research with practitioners who lack the time, infrastructure and resources necessary to work with researchers. There is a strong need for more supportive infrastructure for conducting research with practitioners.

Evidence for apical sodium proton exchange in macula densa cells

These studies were performed to determine if changes in luminal sodium chloride concentration ([NaCl]) might alter macula densa intracellular pH. Isolated thick ascending limbs with attached glomeruli were bathed in a 150 mM NaCl Ringer's solution and perfused in vitro with a 25 mM NaCl solution; N-methyl-D-glucamine cyclamate was used to substitute for NaCl. Macula densa cells were loaded with BCECF and intracellular pH was monitored using a microscope based-dual excitation photometer system. Control intracellular pH for all experiments in which tubules were initially perfused with 25 mM NaCl averaged 7.22 +/- 0.06; N = 28. Increasing luminal [NaCl] from 25 to 150 mM elevated macula densa pH by 0.15 +/- 0.03 (N = 6; P < 0.05) while increasing just luminal [Na] from 25 to 150 mM alkalinized macula densa cells by 0.17 +/- 0.05 (N = 6; P < 0.05). In addition, there was a highly significant linear relationship between luminal [Na] and intracellular pH between 25 and 150 mM NaCl. Other studies were performed to assess the effects of amiloride, an inhibitor of Na:H exchange, on macula densa intracellular pH. Addition of amiloride, to the 25 mM NaCl perfusate acidified macula densa cells by 0.09 +/- 0.03 (N = 6; P < 0.001) and significantly attenuated the increase in pH obtained when luminal [NaCl] was raised from 25 to 150 mM. Other studies evaluated the effects of inhibition of Na:2Cl:K cotransport on macula densa pH.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of cytosolic Ca in renal tubule damage induced by anoxia

Cytosolic free Ca (Caf) was measured in three different preparations of freshly prepared proximal tubules from the rabbit kidney during energy deprivation using fura-2. Isolated perfused tubules, tubules immobilized on glass cover slips, and tubules in suspension were subjected to inhibitors of oxidative phosphorylation ("chemical hypoxia"); the latter two preparations were also subjected to 40 min of anoxia. During normoxia, Caf ranged from 100 to 180 nM in all three preparations, and chemical hypoxia caused either no change or a small (30-100%) increase in Caf values. Subsequent addition of Ca ionophores increased Caf to 300-500 nM in the first 2 min and to greater than 1 microM after 15 min. In individual experiments, anoxia produced similar responses to those of chemical hypoxia, eliciting no average significant change in Caf, despite clear evidence for impaired respiration and plasma membrane damage after 40 min of anoxia. This lack of change in Caf was unrelated to "Ca buffering" by fura-2 or inactivation of the dye, since Caf increased to 666 +/- 59 nM upon addition of Ca ionophore during anoxia. These data suggest that increased Caf is not a prerequisite for cellular damage during anoxia in proximal renal tubules. Furthermore, no apparent alteration in plasma membrane permeability to Ca occurs before membrane disruption. Decreased ATP seems to initiate a series of Caf-independent events that cause irreversible injury.