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Urine serotonin (5-HT)/creatinine was lower at day of life 3 in newborns with pulmonary hypertension compared with controls, while the percent change in the 5-HT metabolite, 5-hydroxyindoleacetic acid (5-HIAA)/creatinine increased. We speculate that the changes in 5-HT and 5-HIAA reflect enhanced pulmonary 5-HT uptake and/or metabolism., Competing Interests: Declaration of Competing Interest Financial support was provided by the National Organization for Rare Disorders193996 (to C.G.). The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Placental phospholipid synthesis is critical for the expansion of the placental exchange surface area and for production of signaling molecules. Despite their importance, it is not yet established which enzymes involved in the de novo synthesis and remodeling of placental phospholipids are expressed and active in the human placenta., Methods: We identified phospholipid synthesis enzymes by immunoblotting in placental homogenates and immunofluorescence in placenta tissue sections. Primary human trophoblast (PHT) cells from term healthy placentas (n = 10) were cultured and exposed to 13 C labeled fatty acids (16:0, 18:1 and 18:2 n-6, 22:6 n-3) for 2 and 24 h. Three phospholipid classes; phosphatidic acid, phosphatidylcholine, and lysophosphatidylcholine containing 13 C fatty acids were quantified by Liquid Chromatography with tandem mass spectrometry (LC/MS-MS)., Results: Acyl transferase and phospholipase enzymes were detected in human placenta homogenate and primarily expressed in the syncytiotrophoblast. Three representative 13 C fatty acids (16:0, 18:1 and 18:2 n-6) were incorporated rapidly into phosphatidic acid in trophoblasts, but 13 C labeled docosahexaenoic acid (DHA; 22:6 n-3) incorporation was not detected. 13 C DHA was incorporated into phosphatidylcholine. Lysophosphatidylcholine containing all four 13 C labeled fatty acids were found in high abundance., Conclusions: Phospholipid synthesis and remodeling enzymes are present in the syncytiotrophoblast. 13 C labeled fatty acids were rapidly incorporated into cellular phospholipids. 13 C DHA was incorporated into phospholipids through the remodeling pathway rather than by de novo synthesis. These understudied pathways are highly active and critical for structure and function of the placenta., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Aim: To explore the usefulness of a co-designed wordless book showing processes of receiving COVID-19 vaccines designed by, and for, adults with intellectual disabilities., Methods: A qualitative evaluation of the resource using mixed methods. Semi-structured interviews were conducted with people with intellectual disabilities, carers and health professionals about resource content, and use. This was analysed thematically. A survey was circulated to intellectual disabilities networks to understand resource need, use, sharing and content., Results: Understanding the COVID-19 vaccine was a process, not a single event using one resource. A visual resource had a place in facilitating conversations about vaccines between people with intellectual disabilities and carers. Differing perspectives were expressed regarding personal needs, existing awareness of vaccine programmes and communication preferences. Changes were suggested to improve the suggested storyline and relevance around COVID-19 restrictions changing., Conclusion: A visual resource may help conversations about the COVID-19 vaccine for people with intellectual disabilities., (© 2024 The Authors. Journal of Applied Research in Intellectual Disabilities published by John Wiley & Sons Ltd.)

The COVID-19 pandemic resulted in changes in all areas of clinical practice, including clinical research and within the intellectual disability population. While there have been some benefits from this rapid adoption of change, those involved in research have had to overcome a number of additional challenges. These adaptive changes, which have included the use of technology, closure of social spaces, working with specific groups who are more vulnerable to COVID-19, and mask use impairing communication, have had both positive and negative impacts on research. As the pandemic and related restrictions evolve, it is important to examine the changes that have occurred. In the future, the adoption of a hybrid model in research is likely to be a common approach, establishing a balance between technology and in-person interaction., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To describe current treatment practices of preterm infants with early hypoxemic respiratory failure (HRF) and pulmonary hypertension (PH) and their association with patient outcomes., Study Design: We developed a prospective, observational, multicenter clinical registry of preterm newborns <34 weeks' gestation with HRF and PH, based on either clinical or echocardiographic evidence during the first 72 hours of life, from 28 neonatal intensive care units in the US from 2017 through 2022. The primary end point was mortality among those who did or did not receive PH-targeted treatment, and the secondary end points included comparisons of major morbidities. Variables were compared using t tests, Wilcoxon rank-sum tests, Fisher exact tests, and χ² tests., Results: We analyzed the results of 224 preterm infants enrolled in the registry. Of which, 84% (188/224) received PH-targeted treatment, most commonly inhaled nitric oxide (iNO). Early mortality in this cohort was high, as 33% (71/224) of this sample died in the first month of life, and 77% of survivors (105/137) developed bronchopulmonary dysplasia. Infants who received PH-targeted treatment had higher oxygenation indices at the time of enrollment (28.16 [IQR: 13.94, 42.5] vs 15.46 [IQR: 11.94, 26.15]; P = .0064). Patient outcomes did not differ between those who did or did not receive PH-targeted therapy., Conclusions: Early-onset HRF with PH in preterm infants is associated with a high early mortality and a high risk of developing bronchopulmonary dysplasia. iNO is commonly used to treat early-onset PH in preterm infants with HRF. In comparison with untreated infants with lower oxygenation indices, iNO treatment in severe PH may prevent poorer outcomes., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest. This study was sponsored by an investigator-initiated research grant from Mallinckrodt Pharmaceuticals (grant number IIR-USA-003947 to J.P.K.). The study was also supported by NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. The manuscript's contents are the authors' sole responsibility and do not necessarily represent the sponsors' views. The sponsors had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Emerging research demonstrates telehealth disparities for patients who communicate in languages other than English. A better understanding of pediatric telehealth use with families who communicate in languages other than English is needed to inform interventions to promote telehealth equity., Methods: We conducted a mixed methods study of telehealth care in a children's hospital health system using electronic health record data for outpatient video telehealth encounters from April 2020 to July 2021 and qualitative interviews with clinical staff and Spanish-speaking parents of telehealth patients., Results: The 16-month study period included 102,387 telehealth encounters; 5% of which were encounters in languages other than English. 83% of languages other than English encounters were with patients/families with a preferred healthcare language of Spanish. 11% of providers conducted ≥10 languages other than English telehealth encounters. This subset of providers conducted 71% of all languages other than English encounters. We conducted 25 interviews with clinical staff (n=13) and parents (n=12). Common themes identified across interviews were: (I) technology barriers affect access to and quality of telehealth; (II) clinical staff and parents are uncertain about the future role of telehealth for patients/families who communicate in languages other than English; (III) the well-known impact of language barriers on in-person healthcare access and quality for patients who communicate in languages other than English is also evident in telehealth., Conclusions: Patients who communicate in languages other than English were underrepresented among telehealth encounters and encounters were concentrated among few providers. Promoting equitable telehealth care requires investment to address technology barriers, increase the readiness of providers and clinics to provide telehealth care in languages other than English, and continued attention to reducing the healthcare impact of language barriers., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-22-43/coif). This project was funded by the Children’s Hospital Colorado Clinical and Operational Effectiveness and Patient Safety Small Grants Program (Principal Investigators: LRD/DAT). This funding provided salary support for CG and CP to fulfill their role in the proposed work. CO was supported to complete this work by the work by the NIH/ NCATS SPROUT-CTSA Collaborative Telehealth Network Grant, #U01TR002626. Effort on this project was provided in-kind by LRD, DAT, LW. DAT reports receiving an honoraria and reimbursement of travel costs in 2022 by Johns Hopkins All Children’s Hospital to teach pediatric residents as part of a curriculum on health equity in which she discussed the care of patients/families whose healthcare communication is in a language other than English. DAT also serves as the Associate Medical Director of the Children’s Hospital Colorado Research Institute and as part of her duties co-chairs the Diversity, Health Equity, and Inclusion in Research Committee for the Research Institute. The authors have no other conflicts of interest to declare., (2023 mHealth. All rights reserved.)

Objective: As pediatric COVID-19 vaccine eligibility expands, understanding predictors of vaccine intent is critical to effectively address parental concerns. Objectives included: (1) Evaluate maternal COVID-19 vaccine intent for child(ren) and associated predictors of stated intent; (2) Describe attitudes related to hypothetical vaccination policies; (3) Summarize themes associated with intention to vaccinate child(ren) for COVID-19., Study Design: Mothers enrolled in Heath eMoms, a longitudinal survey project, were recruited for this electronic COVID-19 survey. Chi-square analysis was used to compare proportions of respondent characteristics based on vaccination intent. Population survey logistic regression was used for multivariable modeling to assess the independent association between vaccine intent and demographics., Results: The response rate was 65.3% ( n  = 1884); 44.2% would choose vaccination, 20.3% would not choose vaccination, and 35.5% are unsure whether to have their child(ren) vaccinated for COVID-19. Black mothers (AOR 0.26, 95% CI 0.13, 0.54), respondents with less than high school education (AOR 0.26, 95% 0.12, 0.56) and those in rural areas (AOR 0.28, 95% CI 0.16, 0.48) were less likely to choose vaccination. Commonly cited reasons for vaccine hesitancy include the belief that the vaccine was not tested enough, is not safe, and there are concerns regarding its side effects., Conclusion: Over 50% of respondents do not intend or are unsure about their intent to vaccinate their child(ren) for COVID-19 with variability noted by demographics. Opportunities exist for perinatal and pediatric providers to educate pregnant people, parents, and caregivers with a focus on addressing concerns regarding vaccine safety and efficacy., Key Points: · COVID-19 vaccination rates remain suboptimal, especially in the pediatric population, with variation across states.. · We found that the prevalence of vaccine acceptance for young children is low.. · We highlight opportunities for providers to educate parents, focusing on addressing vaccine safety and efficacy.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Emerging evidence from animal experiments indicate that factors secreted by the placenta are critical for normal fetal organ development. Our objective was to characterize the umbilical vein and artery proteome in preterm infants and identify proteins that decrease in the neonatal circulation following delivery., Methods: Cord blood at delivery and neonatal blood at 48-72 h of life was collected in 25 preterm infants. Plasma protein abundance was determined using the SomaLogic platform., Results: When comparing protein levels of umbilical venous to arterial cord blood, 434 proteins were significantly higher indicating placental secretion into the fetal circulation. Moreover, when comparing neonatal blood to umbilical vein levels, 142 proteins were significantly lower. These proteins included Endoplasmic reticulum resident protein 29, CD59, Fibroblast growth factor 2 and Dynactin subunit 2, which are involved in brain development and prevention of brain damage as well as Fibroblast growth factor 1 which prevents lung fibrosis., Conclusions: The late second trimester human placenta secretes proteins into the fetal circulation which decrease following delivery. Many of these proteins are predicted to be important in the development of fetal organs. Further studies are needed to directly link placental proteins to organ development and poor outcomes in preterm infants., Impact: Prematurity remains a leading cause of morbidity and mortality requiring the development of novel treatments. Emerging evidence from animal studies suggest that factors secreted from the placenta may be critical in the development of the fetus. We report that the preterm human placenta secretes an array of proteins into the fetal circulation. Some of these proteins are predicted to be involved in the development of the brain and the lung. When born prematurely, infants are deprived of these placental proteins, which may contribute to their poor outcomes., (© 2022. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Changes in placental lipid metabolism influence the delivery of lipids critical for fetal development and fetal requirements for lipids change across gestation. We hypothesized that placental lipid content and metabolic enzyme protein levels increase across gestation and are elevated in obesity. Placentas (4-40 weeks' gestation) were collected from control (body mass index, BMI = 18.5-24.9, n=37) and obese (BMI > 30, n=19) pregnant women. Trophoblast villous tissue was homogenized and subjected to liquid chromatography tandem mass spectrometry (LC-MS/MS) for phospholipid and triacylglycerol (TAG) analysis and western blot for protein quantification. The placental content of TAG species and nine of 35 identified phosphatidylcholines (PC) were significantly higher (P<0.05) in first trimester (28-79%, 10-47%, respectively). Furthermore, two TAG and three PC differed by maternal BMI and were significantly increased (P<0.05) in the obese group in first trimester (72-87%, 88-119%, respectively). Placental protein abundance of glycerol-2-phosphate (GPAT3) and 1-acyl-sn-glycerol-3-phosphate acyltransferase 2 (AGPAT2), involved in de novo synthesis of PC and TAG, were higher (P<0.05) in the first trimester (66 and 74%, respectively). The protein abundance of the PC-remodeling enzyme PLA2G4c was also higher (63%) in first trimester (P<0.05). In conclusion, the placental content of many phospholipid and TAG species and the protein level of associated synthesis enzymes are higher in first-trimester human placenta. The high PC content may be related to the rapid membrane expansion in early pregnancy and the low placental oxygen tension may promote the accumulation of tissue TAGs in first trimester. Maternal obesity had only limited impact on placental lipid content and metabolic enzyme protein abundance., (© 2022 The Author(s). Published by Portland Press Limited on behalf of the Biochemical Society.)

Objectives: Fetal 2D and 3D fractional limb volume (FLV) measurements by ultrasound can detect fetal lean and subcutaneous mass and possibly percent body fat. Our objectives were to 1) compare FLV measurements in fetuses with fetal growth restriction (FGR) versus small for gestational age (SGA) defined by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)-supported international Delphi consensus and 2) correlate FLV findings with birth metrics. We hypothesize that FLV measurements will be significantly smaller in FGR versus SGA fetuses and will correlate closer with Ponderal index (PIx) in the neonate than abdominal circumference (AC)., Methods: Patients were categorized as FGR or SGA as defined by ISUOG. Total thigh volume (TTV), volumes of lean mass (LMV), and fat mass volume (FMV) were calculated from 3D acquisitions. Measurements were compared between groups and correlated with birthweight (BW) and PIx (BW/crown-heal length)., Results: The FGR group (n = 37) delivered earlier (37/2 versus 38/0; P = .0847), were lighter (2.2 kg versus 2.6 kg; P = .0003) and had lower PIx (0.023 versus 0.025; P = .0013) than SGAs (n = 22). FGRs had reduced TTV (40.6 versus 48.4 cm 3 ; P = .0164), FMV (20.8 versus 25.3 cm 3 ; P = .0413), and LMV (19.8 versus 23.1 cm 3 ; P = .0387). AC had the highest area under the curve (0.69) for FGR. FMV was more strongly associated with PIx than the AC (P = .0032)., Conclusions: The AC and FLV measurements were significantly reduced in FGR fetuses compared to SGAs. While the AC outperformed FLV in predicting FGR, the FLV correlated best with PIx, which holds investigative promise., (© 2021 American Institute of Ultrasound in Medicine.)

Pregnant sheep have been used to model complications of human pregnancies including placental insufficiency and intrauterine growth restriction. Some of the hallmarks of placental insufficiency are slower uterine and umbilical blood flow rates, impaired placental transport of oxygen and amino acids, and lower fetal arterial concentrations of anabolic growth factors. An impact of fetal sex on these outcomes has not been identified in either human or sheep pregnancies. This is likely because most studies measuring these outcomes have used small numbers of subjects or animals. We undertook a secondary analysis of previously published data generated by our laboratory in late-gestation (gestational age of 133 ± 0 days gestational age) control sheep (n = 29 male fetuses; n = 26 female fetuses; n = 3 sex not recorded) and sheep exposed to elevated ambient temperatures to cause experimental placental insufficiency (n = 23 male fetuses; n = 17 female fetuses; n = 1 sex not recorded). The primary goal was to determine how fetal sex modifies the effect of the experimental insult on outcomes related to placental blood flow, amino acid and oxygen transport, and fetal hormones. Of the 112 outcomes measured, we only found an interaction between fetal sex and experimental insult for the uterine uptake rates of isoleucine, phenylalanine, and arginine. Additionally, most outcomes measured did not show a difference based on fetal sex when adjusting for the impact of placental insufficiency. Exceptions included fetal norepinephrine and cortisol concentrations, which were higher in female compared to male fetuses. For the parameters measured in the current analysis, the impact of fetal sex was not widespread., (© 2021. Society for Reproductive Investigation.)

Objective: To investigate the optimal implementation and clinical and financial impacts of the FilmArray Meningitis Encephalitis Panel (MEP) multiplex polymerase chain reaction testing of cerebrospinal fluid (CSF) in children with suspected central nervous system infection., Study Design: A pre-post quasiexperimental cohort study to investigate the impact of implementing MEP using a rapid CSF diagnostic stewardship program was conducted at Children's Hospital Colorado (CHCO). MEP was implemented with electronic medical record indication selection to guide testing to children meeting approved use criteria: infants <2 months, immunocompromised, encephalitis, and ≥5 white blood cells/μL of CSF. Positive results were communicated with antimicrobial stewardship real-time decision support. All cases with CSF obtained by lumbar puncture sent to the CHCO microbiology laboratory meeting any of the 4 aforementioned criteria were included with preimplementation controls (2015-2016) compared with postimplementation cases (2017-2018). Primary outcome was time-to-optimal antimicrobials compared using log-rank test with Kaplan-Meier analysis., Results: Time-to-optimal antimicrobials decreased from 28 hours among 1124 preimplementation controls to 18 hours (P < .0001) among 1127 postimplementation cases (72% with MEP testing conducted). Postimplementation, time-to-positive CSF results was faster (4.8 vs 9.6 hours, P < .0001), intravenous antimicrobial duration was shorter (24 vs 36 hours, P = .004), with infectious neurologic diagnoses more frequently identified (15% vs 10%, P = .03). There were no differences in time-to-effective antimicrobials, hospital admissions, antimicrobial starts, or length of stay. Costs of microbiologic testing increased, but total hospital costs were unchanged., Conclusions: Implementation of MEP with a rapid central nervous system diagnostic stewardship program improved antimicrobial use with faster results shortening empiric therapy. Routine MEP testing for high-yield indications enables antimicrobial optimization with unchanged overall costs., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Objective: To assess the racial and ethnic disparity in the prevalence of complex chronic conditions (CCC) and/or in-hospital death among US-born very low birth weight (VLBW, <1500 g) infants., Methods: This retrospective, cross-sectional analysis of discharge data from the Kids' Inpatient Database, included VLBW infants born in US hospitals in 2009 and 2012 (n = 554825, weighted n = 573693) exlcuding those with missing demographics. The main outcome was CCC or death. Multiple logistic regression modeling estimated the association of various characteristics with CCC or death, considering race and ethnicity., Results: There was heterogeneity in the association of insurance status and hospital region and experiencing CCC or death when compared across races and ethnicities. Infants of all races and ethnicities had higher odds of CCC or death if they had an operative procedure, were outborn, or had a birth weight of <500 g or 500 g to 999 g compared with 1000 g to 1499 g. Non-Hispanic Black infants <500 g, however, had the highest odds of CCC or death compared with those 1000 g to 1499 g (adjusted odds ratio 67.2, 95% confidence interval, 48.6-93.0), 2.3 times higher than the odds for non-Hispanic White infants (AOR 2.32, 95% confidence interval, 1.57-3.42)., Conclusions: Insurance and region were associated with increased prevalence of CCC or death in certain racial and ethnic groups. Additionally, non-Hispanic Black infants <500 g had >2.3 times the odds of CCC or death compared with non-Hispanic White infants, relative to infants 1000 g to 1499 g. Additional investigation is needed to understand the drivers of these disparities., (Copyright © 2022 by the American Academy of Pediatrics.)

Microbial fermentation offers a sustainable source of fuels, commodity chemicals, and pharmaceuticals, yet strain performance is influenced greatly by the growth media selected. Specifically, trace metals (e.g., iron, copper, manganese, zinc, and others) are critical for proper growth and enzymatic function within microorganisms yet are non-standardized across media formulation. In this work, the effect of trace metal supplementation on the lipid production profile of Yarrowia lipolytica was explored using tube scale fermentation followed by biomass and lipid characterization. Addition of iron (II) to the chemically defined Yeast Synthetic Complete (YSC) medium increased final optical density nearly twofold and lipid production threefold, while addition of copper (II) had no impact. Additionally, dose-responsive changes in lipid distribution were observed, with the percent of oleic acid increasing and stearic acid decreasing as initial iron concentration increased. These changes were reversible with subsequent iron-selective chelation. Use of rich Yeast Peptone Dextrose (YPD) medium enabled further increases in the production of two specialty oleochemicals ultimately reaching 63 and 47% of the lipid pool as α-linolenic acid and cyclopropane fatty acid, respectively, compared to YSC medium. Selective removal of iron (II) natively present in YPD medium decreased this oleochemical production, ultimately aligning the lipid profile with that of non-supplemented YSC medium. These results provide further insight into the proposed mechanisms for iron regulation in yeasts especially as these productions strains contain a mutant allele of the iron regulator, mga2. The work presented here also suggests a non-genetic method for control of the lipid profile in Y. lipolytica for use in diverse applications. KEY POINTS: • Iron supplementation increases cell density and lipid titer in Yarrowia lipolytica. • Iron addition reversibly alters lipid portfolio increasing linolenic acid. • Removal of iron from YPD media provides a link to enhanced oleochemical production., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Fetal growth restriction (FGR) is most commonly diagnosed in pregnancy if the estimated fetal weight (EFW) is < 10th%. Those with abnormal Doppler velocimetry, indicating placental insufficiency and pathological FGR, demonstrate reduced fat and lean mass compared to both normally growing fetuses and FGR fetuses with normal Dopplers. The aim of this study was to determine how severity of FGR and abnormal Doppler velocimetry impacts neonatal body composition. Among a cohort of fetuses with an EFW < 10th%, we hypothesized that those with abnormal Dopplers and/or EFW < 3rd% would have persistent reductions in lean body mass and fat mass extending into the neonatal period compared to fetuses not meeting those criteria., Methods: A prospective cohort of FGR fetuses with an estimated fetal weight (EFW) < 10th% was categorized as severe (EFW < 3rd% and/or abnormal Dopplers; FGR-S) versus mild (EFW 3-10th%; FGR-M). Air Displacement Plethysmography and anthropometrics were performed at birth and/or within the first 6-8 weeks of life., Results: FGR-S versus FGR-M were born one week earlier (P = 0.0024), were shorter (P = 0.0033), lighter (P = 0.0001) with smaller weight-for-age Z-scores (P = 0.0004), had smaller head circumference (P = 0.0004) and lower fat mass (P = 0.01) at birth. At approximately 6-8 weeks postmenstrual age, weight, head circumference, and fat mass were similar but FGR-S neonates were shorter (P = 0.0049) with lower lean mass (P = 0.0258)., Conclusion: Doppler velocimetry abnormalities in fetuses with an EFW < 10th% identified neonates who were smaller at birth and demonstrated catch-up growth by 6-8 weeks of life that favored fat mass accretion over lean mass and linear growth.

Vitamin K content of foods is known to vary substantially by geographical location. In Australia, no Vitamin K database of food exists, thereby creating ambiguity when trying to develop national dietary intake guidelines. This investigation aimed to develop a Vitamin K database for commonly consumed foods that are commercially available in Australian supermarkets. The Vitamin K1 (phylloquinone; PK) and K2 (menaquinone; MK4, MK7) content of 60 foods known to contain Vitamin K were assessed (e.g., vegetables fruits, oils, animal products, dairy and fermented foods). A liquid chromatography with tandem mass spectrometry (LCMS/MS) method was developed and used to measure PK and MKs in different foods with an improved chromatographic separation and detection of Vitamin K's and their analogs. The LOD and LOQ for PK and MK4 was 0.1, 0.5 ng/ml and 0.5, 1.0 ng/ml, respectively. The majority foods contained detectable PK (53/60), about half contained MK4 (31/60), and few contained MK7 (3/60). PK was highest in green leafy vegetables, with moderate amounts in oils. Highest MK4 content was in chicken eggs and meat products such as ham and chicken. This database enables nutritional epidemiologist to estimate dietary Vitamin K intake, especially in Australian cohorts, for a range of health outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Palmer, Koch, Shinde, Blekkenhorst, Lewis, Croft, Hodgson and Sim.)

Enzymes are represented across a vast space of protein sequences and structural forms and have activities that far exceed the best chemical catalysts; however, engineering them to have novel or enhanced activity is limited by technologies for sensing product formation. Here, we describe a general and scalable approach for characterizing enzyme activity that uses the metabolism of the host cell as a biosensor by which to infer product formation. Since different products consume different molecules in their synthesis, they perturb host metabolism in unique ways that can be measured by mass spectrometry. This provides a general way by which to sense product formation, to discover unexpected products and map the effects of mutagenesis., (© 2021. The Author(s).)

Objective: To identify factors associated with gastrostomy tube (GT) placement in infants with congenital diaphragmatic hernia (CDH)., Methods: Retrospective cohort study of 114 surviving infants with CDH at a single tertiary care neonatal intensive care unit from 2010-2019. Prenatal, perinatal and postnatal characteristics were compared between patients who were discharged home with and without a GT. Prenatal imaging was available for 50.9% of the cohort. Logistic regression was used to assess the association between GT placement and pertinent clinical factors. ROC curves were generated, and Youden's J statistic was used to determine optimal predictive cutoffs for continuous variables. Elastic net regularized regression was used to identify variables associated with GT placement in multivariable analysis., Results: GT was placed in 43.9% of surviving infants with CDH. Prenatal variables predictive of GT placement were percent predicted lung volume (PPLV) <21%, total lung volume (TLV) <30 ml, lung-head ratio (LHR) <1.2 or observed to expected LHR (O/E LHR) <55%. Infants who required a GT were diagnosed earlier prenatally (23.6 ± 3.4 vs. 26.4 ± 5.6 weeks). Patients whose stomach was above the diaphragm on prenatal ultrasound (up) had a higher odds of GT placement compared to those with stomachs below the diaphragm (down) position by a factor of 2.9 (95% CI: 1.25, 7.1); p = 0.0154. Postnatally, infants with GT had lower Apgar scores at 1 and 5 min, longer lengths of stay and higher proportion of flap closures. Infants with a type C or D defect and extracorporeal membrane oxygenation (ECMO) were associated with increased odds of needing a GT. Postnatal association included being NPO for >12 days, need for transpyloric (TP) feeds for >10 days, >14 days to transition to a 30 min bolus feed, presence of gastro-esophageal reflux (GER), chronic lung disease and pulmonary hypertension. In multivariable analysis, duration of NPO, time to TP feeds, transition to 30 min bolus feeds remained significantly associated with GT placement after adjusting for severity of pulmonary hypertension (PH), GER diagnosis and sildenafil treatment., Conclusion: Identification of risk factors associated with need for long-term feeding access may improve timing of GT placement and prevent prolonged hospitalization related to feeding issues., Level of Evidence Rating: Level II (Retrospective Study)., (Copyright © 2021. Published by Elsevier Inc.)

Background: Accidental ingestions (AI) of food allergens in children compared with adolescents with food allergies are poorly characterized. It is suggested that AIs are higher in adolescents than children and that their reactions may be more severe, presumptively due, at least in part, to increased risk-taking behavior. We compared reported AIs in children versus adolescents., Methods: An online cross-sectional survey was distributed to parents of children with food allergies via Twitter, food allergy advocacy groups in the UK, South Africa, and Australia, and locally at Children's Hospital Colorado., Results: Of 558 respondents, 105 were parents of adolescents, and 453 had children <12 years. 73% (341) reported an AI since diagnosis, with 85% of adolescents having had an AI versus 70% of children (p = 0.0058). The annualized rate of AI was significantly lower in the adolescent population at 0.21 versus 0.53 in children (p = <0.0001). Although adolescents reported fewer severe reactions (2% vs. 16%, p = 0.0283), more adolescents required epinephrine administered by a medical professional for their most severe AI, (48% vs. 24%, p = 0.0378). Comparison of the two age groups is limited by the fact that many AIs in the adolescent group occurred prior to age 12. There was no significant difference between the groups as to where the food was consumed or the type of food. There was a significant difference in accidental ingestions in patients in all age groups with more than one reported food allergy; 78% of those with more than one food allergy reported a prior history of at least one accidental ingestion, compared with 59% in those with a single food allergy (p < 0.0001). Regional differences were also noted with respondents in the United States reporting 0.3 accidental ingestions a year, 0.4 in the UK, and 0.5 in other countries (p = 0.0455). The number of reactions was, on average, 27% lower (95% CI: 40, 11%) in the United States compared with the UK (p = 0.0019)., Conclusion: The number of severe reactions, and epinephrine need, differs in children compared with adolescents, although many of the reported reactions in both groups occurred before the age of 12. There were also regional differences with the United States reporting a lower number of AIs and less AIs per year than the other participating regions, as well as increased rates of AI in participants with more than one food allergy. Further characterization of the differences in AIs between children and adolescents, as well as between regions, is needed to assist with more patient-centered anticipatory guidance., (© 2021 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Objective: To compare adverse events and outcomes between stereoelectroencephalography (SEEG) and subdural electrode (SDE) implantation in children., Methods: This was a retrospective analysis of 108 patients who underwent intracranial monitoring with SEEG or SDE implantation at Children's Hospital Colorado between January 2011 and June 2019., Results: There were 47 patients who underwent 53 SEEG implantations and 61 patients who underwent 64 SDE implantations, with an average age of 12.45 years (range: 1.22-19.96 years). Post-implantation imaging was performed in all SEEG implantations and 42 SDE implantations. 38 % and 88 % of SEEG and SDE implantations, respectively, had a hemorrhage of any kind (p < 0.01). Clinically significant hemorrhages did not differ between the two groups, though one death was reported in the SEEG group. No patient undergoing SEEG implantation received blood products compared to 20 % of SDE patients (p < 0.01). The rate of infection in SEEG patients was 4% compared to 33 % for SDE patients (p = 0.01). Resection was completed in 60 % of SEEG patients versus 93 % for SDE patients (p < 0.01). Rate of seizure response was not significantly different between the two groups, with 81 % and 71 % of SEEG and SDE patients, respectively, reaching Engel class I or II at 12 months (p = 0.76)., Significance: In pediatric patients at a single institution, SEEG is associated with less adverse effects overall yet similar rates of seizure freedom compared to SDE implantation. This includes significantly lower rates of asymptomatic hemorrhage, infection and need for blood transfusion associated with SEEG monitoring. There was no statistical difference in clinically significant hemorrhages between the two groups, although rare in both., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Reported associations between vitamin K 1 and both all-cause and cause-specific mortality are conflicting. The 56,048 participants from the Danish Diet, Cancer, and Health prospective cohort study, with a median [IQR] age of 56 [52-60] years at entry and of whom 47.6% male, were followed for 23 years, with 14,083 reported deaths. Of these, 5015 deaths were CVD-related, and 6342 deaths were cancer-related. Intake of vitamin K 1 (phylloquinone) was estimated from a food-frequency questionnaire (FFQ), and its relationship with mortality outcomes was investigated using Cox proportional hazards models. A moderate to high (87-192 µg/d) intake of vitamin K 1 was associated with a lower risk of all-cause [HR (95%CI) for quintile 5 vs quintile 1: 0.76 (0.72, 0.79)], cardiovascular disease (CVD)-related [quintile 5 vs quintile 1: 0.72 (0.66, 0.79)], and cancer-related mortality [quintile 5 vs quintile 1: 0.80 (0.75, 0.86)], after adjusting for demographic and lifestyle confounders. The association between vitamin K 1 intake and cardiovascular disease-related mortality was present in all subpopulations (categorised according to sex, smoking status, diabetes status, and hypertension status), while the association with cancer-related mortality was only present in current/former smokers (p for interaction = 0.002). These findings suggest that promoting adequate intakes of foods rich in vitamin K 1 may help to reduce all-cause, CVD-related, and cancer-related mortality at the population level., (© 2021. The Author(s).)

Sorting large libraries of cells for improved small molecule secretion is throughput limited. Here, we combine producer/secretor cell libraries with whole-cell biosensors using a microfluidic-based screening workflow. This approach enables a mix-and-match capability using off-the-shelf biosensors through either coencapsulation or pico-injection. We demonstrate the cell type and library agnostic nature of this workflow by utilizing single-guide RNA, transposon, and ethyl-methyl sulfonate mutagenesis libraries across three distinct microbes ( Escherichia coli , Saccharomyces cerevisiae , and Yarrowia lipolytica ), biosensors from two organisms ( E. coli and S. cerevisiae ), and three products (triacetic acid lactone, naringenin, and L-DOPA) to identify targets improving production/secretion., Competing Interests: Competing interest statement: X.L. and F.F.C. are employees of Sphere Fluidics Limited.

The BioFire blood culture identification (BCID) panel decreases time to pathogen identification and time to optimal antimicrobial therapy. The BioFire blood culture identification 2 (BCID2) panel is an expanded panel with 17 additional targets and resistance genes; however, there are limited data on its impact in pediatric patients. We compared the BioFire BCID2 panel and the BCID panel by assaying BCID2 simultaneously with the current standard of care on 191 consecutive blood culture specimens at Children's Hospital Colorado. The primary outcome was equivalence, measured as percent agreement between the two panels and standard culture. The theoretical reduction in time to optimal therapy was calculated overall, with subanalyses performed on Enterococcus species and Gram-negative resistance genes. The percent agreement was equivalent between the two panels, with BCID at 98% (95% confidence interval [CI], 95 to 100%) and BCID2 at 97% (95% CI, 93 to 99%); the difference was 1.2% (95% CI, -0.8, 3.1%; P  < 0.0001). There was not a significant reduction in time to theoretical optimal therapy with BCID2 compared to BCID for all cultures (reduction of 9 h, P  = 0.3). Notably, 13 Enterococcus faecalis isolates were detected on BCID2, which would have resulted in a theoretical reduction in time to optimal antimicrobial therapy of 34 h ( P  = 0.0046). Five CTX-M genes were detected for enteric bacteria. The BioFire BCID2 panel had equal rates of detection compared to the BioFire BCID panel in pediatric patients. It had the advantage of detecting more organisms at the species level, and significantly reducing time to theoretical optimal antimicrobial therapy for Enterococcus faecalis. With the additional resistance genes, it also has the potential to impact care with earlier identification of resistant enteric pathogens. IMPORTANCE The BioFire BCID2 panel is an accurate panel that is equivalent to the BioFire BCID panel compared to standard culture. The BioFire BCID2 panel offers several advantages over the BioFire BCID panel, including enterococcal species identification, Gram-negative resistance gene detection, Salmonella identification, and the added mec A/ mec C and SCCmec right extremity junction (MREJ) target for better Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) differentiation. Most importantly, it provides additional clinical impact with the potential to decrease the time to optimal antimicrobial therapy compared to the BioFire BCID panel, with likely further impact at institutions with a higher prevalence of Gram-negative resistance.

Cannabis is the most commonly used drug of abuse in pregnancy and after delivery. However, little is known regarding the disposition of cannabinoids in breast milk, although delta-9-tetrahydrocannabinol (THC), the main psychoactive component, is highly lipophilic. Quantification of cannabinoids in breastmilk is essential for clinical monitoring and research studies and breastmilk banks mainly rely on enzyme-linked immunosorbent assay (ELISA) in terms of screening for cannabinoids. To support clinical studies on disposition of cannabinoids in breastmilk, we validated a high-performance liquid chromatography-tandem mass spectrometry (LC-MS-MS) assay for the simultaneous quantification of 12 cannabinoids and their metabolites in human breast milk. Said assay was based upon a simple one-step protein precipitation, online column extraction and detection in the positive multiple reaction monitoring mode. After successful validation, the assay was used to analyze 30 samples from a clinical research study that had tested negative using an ELISA kit that is commonly used by breastmilk banks. In human breast milk, depending on the analyte, the lower limits of quantification of the LC-MS-MS assay ranged from 0.39 to 7.81 ng/mL. Acceptance criteria for intra- and inter-batch accuracy (85-115%) and imprecision (<15%) were met for all compounds. Mean extraction efficiencies were above 60% for all analytes. Mean matrix effect ranged from -12.5% to 44.5% except of THC-glucuronide for which significant matrix effects were noted. No carry-over was detected. Although cannabinoid-negative based on the ELISA, all 30 samples tested positive for THC using LC-MS-MS (0.8-130 ng/mL) and several also for 11-hydroxy-THC (11-OH-THC), 11-nor-9-carboxy-THC (THCCOOH), cannabidiol (CBD) and cannabigerol (CBG). We validated a sensitive and specific assay for the quantification of 12 cannabinoids in human breastmilk that outperformed an ELISA commonly used by breastmilk banks., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objectives: Very low birth weight (VLBW) infants are at high risk for morbidities beyond the neonatal period and ongoing use of health care. Specific morbidities have been studied; however, a comprehensive landscape of medical complexity in VLBW infants has not been fully described. We sought to (1) describe the prevalence of complex chronic conditions (CCCs) and (2) determine the association of demographic, hospital, and clinical factors with CCCs and CCCs or death., Methods: This retrospective cross-sectional analysis of discharge data from the Kids' Inpatient Database (2009-2012) included infants with a birth weight <1500 g and complete demographics. Outcomes included having CCCs or having either CCCs or dying. Analyses were weighted; univariate and multiple logistic regression models were used to estimate unadjusted and adjusted odds ratios. A dominance analysis with Cox-Snell R 2 determined the relative contribution of demographic, hospital, and clinical factors to the outcomes., Results: Among our weighted cohort of >78 000 VLBW infants, >50% had CCCs or died. After adjustments, the prevalence of CCCs or CCCs or death differed by sex, race and ethnicity, hospital location, US region, receipt of surgery, transfer status, and birth weight. Clinical factors accounted for the highest proportion of the model's ability to predict CCCs and CCCs or death at 93.3% and 96.3%, respectively, whereas demographic factors were 11.5% and 2.3% and hospital factors were 5.2% and 1.4%, respectively., Conclusions: In this nationally representative analysis, medical complexity is high among VLBW infants. Varying contributions of demographic, hospital, and clinical factors in predicting medical complexity offer opportunities to investigate future interventions to improve care delivery and patient outcomes., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

A mutant excision + /integration - piggyBac transposase can be used to seamlessly excise a chromosomally integrated, piggyBac-compatible selection marker cassette from the Yarrowia lipolytica genome. This piggyBac transposase-based genome engineering process allows for both positive selection of targeted homologous recombination events and scarless or footprint-free genome modifications after precise marker recovery. Residual non-native sequences left in the genome after marker excision can be minimized (0-4 nucleotides) or customized (user-defined except for a TTAA tetranucleotide). Both of these options reduce the risk of unintended homologous recombination events in strains with multiple genomic edits. A suite of dual positive/negative selection marker pairs flanked by piggyBac inverted terminal repeats (ITRs) have been constructed and are available for precise genome engineering in Y. lipolytica using this method. This protocol specifically describes the split marker homologous recombination-based disruption of Y. lipolytica ADE2 with a piggyBac ITR-flanked URA3 cassette, followed by piggyBac transposase-mediated excision of the URA3 marker to leave a 50 nucleotide synthetic barcode at the ADE2 locus. The resulting ade2 strain is auxotrophic for adenine, which enables the use of ADE2 as a selectable marker for further strain engineering.

Background: People of minority ethnic backgrounds may be disproportionately affected by severe COVID-19. Whether this relates to increased infection risk, more severe disease progression, or worse in-hospital survival is unknown. The contribution of comorbidities or socioeconomic deprivation to ethnic patterning of outcomes is also unclear., Methods: We conducted a case-control and a cohort study in an inner city primary and secondary care setting to examine whether ethnic background affects the risk of hospital admission with severe COVID-19 and/or in-hospital mortality. Inner city adult residents admitted to hospital with confirmed COVID-19 ( n  = 872 cases) were compared with 3,488 matched controls randomly sampled from a primary healthcare database comprising 344,083 people residing in the same region. For the cohort study, we studied 1827 adults consecutively admitted with COVID-19. The primary exposure variable was self-defined ethnicity. Analyses were adjusted for socio-demographic and clinical variables., Findings: The 872 cases comprised 48.1% Black, 33.7% White, 12.6% Mixed/Other and 5.6% Asian patients. In conditional logistic regression analyses, Black and Mixed/Other ethnicity were associated with higher admission risk than white (OR 3.12 [95% CI 2.63-3.71] and 2.97 [2.30-3.85] respectively). Adjustment for comorbidities and deprivation modestly attenuated the association (OR 2.24 [1.83-2.74] for Black, 2.70 [2.03-3.59] for Mixed/Other). Asian ethnicity was not associated with higher admission risk (adjusted OR 1.01 [0.70-1.46]). In the cohort study of 1827 patients, 455 (28.9%) died over a median (IQR) of 8 (4-16) days. Age and male sex, but not Black (adjusted HR 1.06 [0.82-1.37]) or Mixed/Other ethnicity (adjusted HR 0.72 [0.47-1.10]), were associated with in-hospital mortality. Asian ethnicity was associated with higher in-hospital mortality but with a large confidence interval (adjusted HR 1.71 [1.15-2.56])., Interpretation: Black and Mixed ethnicity are independently associated with greater admission risk with COVID-19 and may be risk factors for development of severe disease, but do not affect in-hospital mortality risk. Comorbidities and socioeconomic factors only partly account for this and additional ethnicity-related factors may play a large role. The impact of COVID-19 may be different in Asians., Funding: British Heart Foundation; the National Institute for Health Research; Health Data Research UK., Competing Interests: JTHT received research funding from Innovate UK & Office of Life Sciences, and iRhythm Technologies, and holds shares <£5000 in Glaxo Smithkline and Biogen. The other authors declare no competing interests., (© 2020 The Author(s).)

Following implementation of the FilmArray meningitis and encephalitis panel, which enables rapid syndromic cerebrospinal fluid testing, HSV testing doubled in children >60 days with suspected central nervous system infection at Children's Hospital Colorado. Acyclovir initiation was unchanged, but duration decreased. Diagnostic and antimicrobial stewardship is needed for MEP optimization., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Key Points: Intrauterine growth restriction (IUGR) is associated with perinatal morbidity and increased risk of lifelong disease, including neurodevelopmental impairment. Fatty acids (FA) are critical for normal brain development, although their transport across the placenta in IUGR pregnancies is poorly understood. The present study used a baboon model of IUGR (maternal nutrient restriction, MNR) to investigate placental expression of FA transport and binding proteins, and to determine gestational age-related changes in maternal and fetal plasma FA concentrations. We found MNR to be associated with increased placental expression of FA binding and transport proteins in late gestation, with fetal plasma FA concentrations that were similar to those of control animals. The present study is the first to report a profile of fetal and maternal plasma FA concentrations in a baboon model of growth restriction with data that suggest adaptation of placental transport to maintain delivery of critically needed FA., Abstract: Intrauterine growth restriction (IUGR) is associated with specific changes in placental transport of amino acids, folate and ions. However, little is known about placental fatty acid (FA) transport in IUGR. We hypothesized that placental FA transport proteins (FATP) and FA binding proteins (FABP) are up-regulated and fetal plasma FA concentrations are decreased at term in a baboon model of IUGR. Pregnant baboons were fed control or maternal nutrient restricted (MNR) diet (70% of control calories) from gestation day (GD) 30 (term 184 days). Plasma and placental samples were collected at GD120 (control n = 8, MNR n = 9), GD140 (control n = 6, MNR n = 7) and GD170 (control n = 6, MNR n = 6). Placentas were homogenized, and syncytiotrophoblast microvillous plasma membrane (MVM) and basal plasma membranes (BM) were isolated. Protein expression of FABP1, 3, 4 and 5 (homogenate) and FATP2, 4, and 6 (MVM, BM) was determined by Western blotting. FA content in maternal and umbilical vein plasma was measured by gas chromatography-mass spectrometry. Placental FABP1 and FABP5 expression was increased in MNR compared to controls at GD170, as was MVM FATP2 and FATP6 expression at GD140 and FATP2 expression at GD170. BM FATP4 and FATP6 expression was increased in MNR at GD140. Fetal plasma FA concentrations were similar in controls and MNR. These data suggest the adaptation of placental transport when aiming to maintain delivery of critically needed FAs for fetal growth and brain development., (© 2020 The Authors. The Journal of Physiology © 2020 The Physiological Society.)

Bispecific T cell engagers have demonstrated clinical efficacy; however, their use can be accompanied by severe toxicity. Mechanistic understanding of these toxicities is limited by a lack of suitable immunocompetent preclinical models. In this study, we describe an immunocompetent mouse tumor model that exhibits bispecific T cell engager-induced toxicity and recapitulates key features similar to those in human cytokine release syndrome. In this study, toxicity occurred between the second and fourth injections of an NK Group 2D bispecific T cell engager protein. Symptoms were transient, peaking 3-4 h after treatment and resolving by 8 h. Mice developed weight loss, elevated plasma cytokines, a significant reduction in spleen white pulp, and lymphocyte infiltration in the liver. Systemic cellular immune changes also occurred; notably, an increase in CD8 + T cell activation, an increase in myeloid cells in the blood, and a population of Ly-6C int monocytes (CD11b + Ly-6G - F4/80 - ) emerged in the liver and spleens of bispecific protein-treated mice. IFN-γ was primarily produced by CD8 + T cells in the spleen and was required for the observed changes in both T cell and myeloid populations. Rag deficiency, IFN-γ deficiency, or depletion of either CD4 + or CD8 + T cells prevented toxicity, whereas perforin deficiency, GM-CSF deficiency, or modulation of the myeloid population through clodronate-mediated depletion showed a partial abrogation of toxicity. Together, these findings reveal that T cell activation by a bispecific T cell engager leads to changes in the host myeloid cell population, both of which contribute to treatment induced toxicity in immunocompetent mice., (Copyright © 2020 by The American Association of Immunologists, Inc.)

Cardiovascular disease is the leading cause of death and disability worldwide. Recent work suggests a link between vitamin K insufficiency and deficiency with vascular calcification, a marker of advanced atherosclerosis. Vitamin K refers to a group of fat-soluble vitamins important for blood coagulation, reducing inflammation, regulating blood calcium metabolism, as well as bone metabolism, all of which may play a role in promoting cardiovascular health. Presently, there is a lack of a comprehensive vitamin K database on individual foods, which are required to accurately calculate vitamin K1 and K2 intake for examination in epidemiological studies. This has likely contributed to ambiguity regarding the recommended daily intake of vitamin K, including whether vitamin K1 and K2 may have separate, partly overlapping functions. This review will discuss the presence of: (i) vitamin K1 and K2 in the diet; (ii) the methods of quantitating vitamin K compounds in foods; and (iii) provide an overview of the evidence for the cardiovascular health benefits of vitamin K in observational and clinical trials.

Background: High vegetable intake is associated with beneficial effects on bone. However, the mechanisms remain uncertain. Green leafy vegetables are a rich source of vitamin K1, which is known to have large effects on osteoblasts and osteocalcin (OC) metabolism., Objective: To examine the effects of consumption of two to three extra serves of green leafy vegetables daily on bone metabolism., Methods: Thirty individuals (mean age 61.8 ± 9.9 years, 67% male) completed three experimental phases in a randomised controlled crossover design, each lasting four weeks, with a washout period of four weeks between phases (clinical trial registration: ACTRN12615000194561). The three experimental phases were: (i) increased dietary vitamin K1 by consuming green leafy vegetables (H-K; ~200 g/d containing 164.3 [99.5-384.7] μg/d of vitamin K1); (ii) low vitamin K1 by consuming vitamin K1-poor vegetables (L-K; ~200 g/d containing 9.4 [7.7-11.6] μg/d of vitamin K1); and (iii) control (CON) where participants consumed an energy-matched non-vegetable control. OC forms, total OC (tOC), carboxylated OC (cOC) and undercarboxylated OC (ucOC), were measured in serum pre- and post-intervention for each experimental phase using a sandwich-electrochemiluminescence immunoassay., Results: Pre-intervention tOC, ucOC and ucOC:tOC levels were similar between phases ( P  > .05). Following H-K, but not L-K, tOC, ucOC and ucOC:tOC levels were significantly lower compared to pre-intervention levels ( P  ≤ .001) and compared to CON (~14%, 31% and 19%, respectively, all P  < .05), while cOC remained unchanged., Conclusions: In middle-aged healthy men and women, an easily achieved increase in dietary intake of vitamin K1-rich green leafy vegetables substantially reduces serum tOC and ucOC suggesting increased entry of OC into bone matrix, where it may improve the material property of bone. In conjunction with previous epidemiological and randomised controlled trial data, these findings suggest that interventions to increase vegetable intake over extended periods should include bone end points including fracture risk., (© 2020 The Authors.)

Background: Currently, there is no validated objective rating system to address the acuity of medication orders that pharmacists review., Objective: The objective was to assess the acuity of a given medication through creating and validating an acuity scoring tool., Methods: Phase I included the development of the medication acuity scoring tool (MAST) from national safety standards and clinical experience. A survey was administered to pharmacists nationwide to establish a consensus on the individual components of the tool and their associated weighted scores. Phase II was designed to assess MAST's predictive validity by comparing a medication acuity rating generated by MAST to a rating assigned based upon clinical experience of experts. Additionally, in phase II, interrater and intrarater reliability of MAST was evaluated., Results: In phase I, most of MAST's components and their associated scores achieved >75% agreement for inclusion in the final tool. In phase II, without MAST, approximately 50% of pharmacist-assigned acuity ratings were statistically consistent with tool-generated acuity ratings, and there was fair agreement between respondents (k=0.31). With the use of MAST, agreement in acuity ratings improved to substantial (k=0.69), and intrarater reliability was almost perfect (k=0.88)., Conclusion: MAST is a validated rating system that captures the acuity of medications.

Polyketides are a diverse class of molecules sought after for their valuable properties, including as potential pharmaceuticals. Previously, we demonstrated that the oleaginous yeast Yarrowia lipolytica is an optimal host for production of the simple polyketide, triacetic acid lactone (TAL). We here expand the capacities of this host by overcoming previous media challenges and enabling production of more complex polyketides. Specifically, we employ a β-oxidation related strategy to improve polyketide production directly from defined media. Beyond TAL production, we establish biosynthesis of the 4-coumaroyl-CoA derived polyketides: naringenin, resveratrol, and bisdemethoxycurcumin, as well as the diketide intermediate, (E)-5-(4-hydroxyphenyl)-3-oxopent-4-enoic acid. In this background, we enable high-level de novo production of naringenin through import of both a heterologous pathway and a mutant Y. lipolytica allele. In doing so, we generated an averaged maximum titer of 898 mg/L naringenin, the highest titer reported to date in any host. These results demonstrate that Y. lipolytica is an ideal polyketide production host for more complex 4-coumaroyl-CoA derived products., (Copyright © 2019 International Metabolic Engineering Society. Published by Elsevier Inc. All rights reserved.)

Background: Anterior tibial spine fractures (ATSF) in the skeletally immature parallel anterior cruciate ligament (ACL) tears in adult patients, yet these injuries are generally regarded as mutually exclusive. Biomechanical analysis suggests that intrinsic ACL damage occurs during ATSF, and long-term clinical studies demonstrate residual anteroposterior knee laxity following ATSF. We aim to describe prevalence, demographics, and characteristics of pediatric patients who sustained ATSF with concomitant ACL injury., Methods: We included 129 patients with ATSF over a 16-year period. Age, sex, injury mechanism, ATSF type, magnetic resonance imaging (MRI) evaluation, treatment modality, ACL injury, and concomitant meniscal/chondral injuries were analyzed. Concurrent ACL injury was confirmed either from MRI or intraoperatively., Results: Nineteen percent (n=25) of ATSF patients had concomitant ACL injury, with ACL injury significantly more likely in type II or type III ATSF compared with type I ATSF (P=0.03). Patients with combined ATSF/ACL injury were significantly older (P=0.02) and more likely to be male (P=0.01). Mechanism of ATSF injury was not associated with ACL injury (P=0.83). Preoperative MRI had low sensitivity (0.09) for recognizing ACL injury at the time of ATSF relative to intraoperative assessment. Half of ATSF/ACL-injured patients had additional meniscal or chondral injury, with meniscal repair or debridement required in 37.5% of the type II ATSF/ACL injury., Conclusions: There are demographic characteristics, such as age (older) and sex (male), associated with a higher risk of concomitant ACL injury at the time of ATSF. Type II and type III ATSF patterns had a higher prevalence of ACL injury. MRI failed to correctly identify ACL injury at the time of ATSF. Concomitant ACL injury at the time of ATSF is highly prevalent in the skeletally immature, occurring in 19.4% of patients with ATSF., Level of Evidence: Level IV-case series.

Background: A quarter of the population present at least once a year with a musculoskeletal disorder. Primary hip osteoarthritis is a high-volume condition with significant clinical need and population-level costs. There remains much variation in patient outcomes and care delivery costs for this condition., Aims: The study aimed to gauge if pathway redesign based on the principles of value-based healthcare (VBHC) could increase value. The aim was to calculate the value of treatment for primary hip osteoarthritis through measuring outcomes that matter to patients, as well as the costs of delivering them. Additionally it aimed to compare two care pathways to identify which elements may better promote the delivery of high-value clinical care., Methods: Two care models were evaluated: the first being a traditional model with multiple entry points and without pathway standardisation, and the second an intentionally designed standardised multidisciplinary pathway. Mandated National Health Service patient-reported outcomes were assessed but were restructured into a patient-centred format to assess the impact on pain, function and psychological outcomes. Patient-level pathway economic evaluation was performed. Using these data, outcomes were mapped against cost to calculate value., Results: There were no significant differences in clinical outcomes between the two models. The intentionally designed model delivered better value care, having lower pathway costs. This model produced a small but inconsistent positive financial margin., Conclusions: Intentionally designed, integrated elective services offer an opportunity to develop and evaluate VBHC models. Analysis of two care pathways from a VBHC perspective demonstrated that an intentionally designed pathway had higher value. The higher value pathway maximised the benefits of having physiotherapists and orthopaedic surgeons working side by side. Developing and measuring patient-orientated outcomes and performing accurate economic evaluation are the key to understanding and achieving better value care., Competing Interests: Competing interests: None declared.

Background: Historically, bicycle accidents were described as the most common mechanism for pediatric anterior tibial spine fractures (ATSFs). There is a paucity of current literature examining the demographic factors associated with these injuries. The purpose of this cohort study was to characterize the epidemiology of ATSFs presenting to a single tertiary referral pediatric hospital., Methods: A consecutive cohort of 122 pediatric patients with ATSFs between 1996 and 2014 were reviewed. Radiographic variables, classification of fractures (Meyers and McKeever type), age, sex, height, weight, body mass index, and mechanism of injury were retrieved. Categories of mechanism of injury included organized sports (football, soccer, basketball, lacrosse, wrestling, and gymnastics), bicycling, outdoor sports (skiing, skateboarding, and sledding), fall, motor vehicle collision/pedestrian versus motor vehicle, and trampoline., Results: Organized sports-related injuries represented the most common cause of ATSFs (36%). Other common mechanisms of injury included bicycle accidents (25%), outdoor sports (18%), and falls (11%). There was a higher proportion of males (69%) compared with females (31%). Males (mean age, 11.6 y) were significantly older than females (mean age, 9.8 y) (P=0.004). Younger patients (aged 11.5 y and below) were more likely to have displaced fractures (type III), whereas type I and type II were more common in patients above 11.5 years (P=0.02). Patients with fracture type I were significantly taller than patients with fracture type III. No other variables were found to differ significantly according to fracture severity, including sex, weight, and body mass index., Conclusions: To our knowledge, our study represents both the largest (n=122) and most up-to-date epidemiological ATSF study in pediatric patients. A higher rate of ATSF occurs due to organized sports rather than bicycling or motor vehicle collision. This 18-year data collection represents a change in the paradigm, and is likely multifactorial, including increased participation in youth sports and early sport specialization., Level of Evidence: Level IV-retrospective, cohort study.

Triggered electromyography (t-EMG) is a common technique used during spinal instrumentation in surgery for adolescent idiopathic scoliosis. This study tests the validity of t-EMG values obtained with a standard ball-tipped probe after completion of screw placement versus t-EMG values obtained during screw insertion with a powered screwdriver. t-EMG values were collected for screws spanning T7-L5 using both a standard probe and a powered screwdriver. A power analysis determined that a sample size of 300 screws would provide enough precision to estimate limits of agreement within ±2 mA. A monopolar constant current stimulation technique (0.2 ms duration and 3.11 Hz stimulation rate) was used at each level. EMG was acquired with placement of bipolar pairs of subdermal needle electrodes. A Bland-Altman plot was used to assess agreement between threshold readings from the two techniques. Twenty-nine patients were enrolled in this study with 305 screws. t-EMG values measured using a powered screwdriver were on average 1 mA lower than values from a standard probe. When readings less than or equal to 20 mA were considered, the limits of agreement were approximately 4 and 7 mA overall. In total, 28/305 (9%) screws were removed and reinserted, 9/305 (3%) screws were redirected, and 3/305 (1%) screws were aborted based on t-EMG readings. Despite a small overall difference in t-EMG value between the standard probe and screwdriver, there was still large variability in agreement between the two techniques. t-EMG values obtained with a powered screwdriver during screw insertion are not interchangeable with values measured by a probe.

Polyketides are a unique class of molecules with attractive bioactive and chemical properties. As a result, biorenewable production is being explored with these molecules as potential pharmaceutical, fuel, and material precursors. In particular, type III polyketide synthases enable access to a diverse class of chemicals using a relatively simple biochemical synthesis pathway. In this review, the recent advances in the engineering of microbial hosts for the production of type III PKS-derived polyketides are highlighted. In particular, the field has moved beyond simple proof-of-concept and has been exploring engineering efforts that have led to improved production scales. This review details engineering progress for the production of acetyl-CoA- and malonyl-CoA-derived polyketides including the products triacetic acid lactone and phloroglucinol as well as polyphenolic, phenylpropanoid-derived compounds including flavonoids, stilbenoids, and curcuminoids. Specifically, the authors focus on enumerating the metabolic engineering strategies employed and product titers achieved for these molecules. Finally, the authors highlight tools and strategies that can be leveraged to realize the potential of microbial production and diversification of these molecules., (© 2018 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: Axillary implant location is an alternative implant location in patients for cardiac implantable electronic devices (CIEDs) for the purposes of improved cosmetic outcome. The impact from the patient's perspective is unknown. The purpose of this study was to compare scar perception scores and quality of life (QOL) in pediatric patients with axillary CIED implant location versus the standard infraclavicular approach., Methods: This is a multicenter prospective study conducted at eight pediatric centers and it includes patients aged from 8 to 18 years with a CIED. Patients with prior sternotomy were excluded. Scar perception and QOL outcomes were compared between the infraclavicular and axillary implant locations., Results: A total of 141 patients (83 implantable cardioverter defibrillator [ICD]/58 pacemakers) were included, 55 with an axillary device and 86 with an infraclavicular device. Patients with an ICD in the axillary position had better perception of scar appearance and consciousness. Patients in the axillary group reported, on average, a total Pediatric QOL Inventory score that was 6 (1, 11) units higher than the infraclavicular group, after adjusting for sex and race (P = 0.02)., Conclusions: QOL is significantly improved in axillary in comparison to the infraclavicular CIED position, regardless of device type. Scar perception is improved in patients with ICD in the axillary position., (© 2018 Wiley Periodicals, Inc.)

Introduction: The purpose of this study was to compare both bone diaphyseal forearm fractures in adolescent patients treated with plate fixation to patients treated with intramedullary fixation to identify differences in complications and outcomes., Materials & Methods: A retrospective study was performed on all adolescent patients with age between 10 and16 year and treated with intramedullary fixation or plate fixation for a diaphyseal both bone forearm fracture between 2005 and 2014. Demographic information and clinical data was collected. Radiographs were reviewed to evaluate post-operative radial bow magnitude and location, time to union, and residual angulation. Complications were graded using the modified Clavien-Dindo Classification system., Results: A total of 102 patients met the inclusion criteria. Of these, 32 were treated with plate fixation and 70 with intramedullary fixation. The intramedullary nail group had 55% of complications classified as major. There were no major complications in the plate fixation group (P = 0.1). The radial bow was significantly more distal and smaller in magnitude in the intramedullary fixation group (P < 0.01). Of the patients who underwent intramedullary fixation, 76% required an open reduction of at least one forearm bone. There was increased time to radiographic union in patients treated with intramedullary fixation when compared to those treated with plates, 68 days versus 58 days (P = 0.03). A second operation was necessary for 91% of patients treated with intramedullary fixation compared to only 3% of patients treated with a plate (P < 0.01)., Conclusion: Diaphyseal forearm fractures in adolescent patients remain challenging injuries to treat. Forearm bony anatomy is not completely restored with intramedullary fixation. Results suggested an association towards increased complication rates and complication severity with intramedullary fixation., Level of Evidence: Level 3 retrospective comparative study., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The nonconventional, oleaginous yeast, Yarrowia lipolytica is rapidly emerging as a valuable host for the production of a variety of both lipid and nonlipid chemical products. While the unique genetics of this organism pose some challenges, many new metabolic engineering tools have emerged to facilitate improved genetic manipulation in this host. This review establishes a case for Y. lipolytica as a premier metabolic engineering host based on innate metabolic capacity, emerging synthetic tools, and engineering examples. The metabolism underlying the lipid accumulation phenotype of this yeast as well as high flux through acyl-CoA precursors and the TCA cycle provide a favorable metabolic environment for expression of relevant heterologous pathways. These properties allow Y. lipolytica to be successfully engineered for the production of both native and nonnative lipid, organic acid, sugar and acetyl-CoA derived products. Finally, this host has unique metabolic pathways enabling growth on a wide range of carbon sources, including waste products. The expansion of carbon sources, together with the improvement of tools as highlighted here, have allowed this nonconventional organism to act as a cellular factory for valuable chemicals and fuels., (Copyright © 2018 International Metabolic Engineering Society. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors declare no conflict of interest.

Study Design: Retrospective cohort study., Objectives: Evaluate the effectiveness of topical vancomycin in reducing surgical site infection (SSI) in pediatric patients undergoing posterior spinal fusion (PSF)., Summary of Background Data: There has been increased interest in use of topical vancomycin to reduce SSI in spine surgery with mixed results reported in the literature. In Summer 2012, our institution implemented the use of topical vancomycin in definitive primary and revision PSF as part of our infection control protocol., Methods: After IRB approval, a consecutive series of 527 patients (538 procedures) undergoing PSF January 2010-December 2014 were retrospectively reviewed to identify the occurrence of SSI. Based on published results from a similar study, an a priori power analysis determined 190 patients were needed per group to achieve 0.90 power. In 228 procedures, topical vancomycin was used (Vanco) and in 310 procedures it was not (No Vanco). Exclusion criteria were <90 days follow-up, >18 years at time of surgery, and combined anterior and posterior fusion. Two-sample t tests, Wilcoxon rank-sum tests, and Fisher exact tests were used to compare the cohorts., Results: Groups were similar in age, sex, implant density, fusion length, risk categorization, and surgical time (p > .05). No Vanco had significantly higher blood loss and incidence and amount of intraoperative allogenic transfusion (p < .001). Incidence of SSI was 3% (7/228) in Vanco and 2% (6/310) in No Vanco (p = .4099). Six of the 7 SSIs occurred in high-risk patients in Vanco and 5 of 6 occurred in high-risk patients in No Vanco (p = 1). Reoperation within 90 days was 6% (13/228) in Vanco and 4% (11/310) in No Vanco (p = .2912). Occurrence of other complications was similar between Vanco, 3% (7/228), and No Vanco, 2% (5/310)., Conclusion: Use of topical vancomycin did not reduce incidence of SSI for pediatric patients undergoing PSF at our institution., Level of Evidence: Level III., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Growth-friendly surgery has high complication rates. The Complication Severity Score for growth-friendly surgery was developed to maintain consistency while reporting complications as part of research in this rapidly evolving field. This study evaluates the interrater and intrarater reliability of this complication classification system., Methods: After Institutional Review Board approval, complications during treatment for early onset scoliosis were identified from a prospectively collected database. Previous validation studies and a 10-case pilot survey determined that 60 cases were needed to represent a minimum of substantial agreement. In total, 63 of 496 cases were selected randomly to evenly represent each severity classification. The cases comprised an internet survey for classification sent to faculty and research coordinators involved in early onset scoliosis research, 3 weeks apart, with questions shuffled between iterations. Fleiss Kappa and Cohen Kappa were used to assess interrater and intrarater agreement, respectively., Results: A total of 20 participants, 12 faculty and 8 research assistants, completed the survey twice. The overall Fleiss Kappa coefficient for interrater agreement from the second round of the survey was 0.86 (95% confidence interval, 0.86-87), which represents substantial agreement. Reviewers agreed almost perfectly on categorizing complications as Device I (0.85), Disease I (0.91), Disease II (0.94), Device IIB (0.92), and Disease IV (0.98). There was substantial agreement for categorizing Device IIA (0.73) and Device III (0.76) complications. Disease III and Device IV were not evaluated in this survey since none of these occurred in the database. There was almost perfect intrarater agreement among faculty (0.87), research coordinators (0.85), and overall (0.86)., Conclusions: There is strong interrater and intrarater agreement for the published complications classification scheme for growing spine surgery. The complication classification system is a reliable tool for standardizing reports of complications with growth-friendly surgery. Adoption of this classification when reporting on growth-friendly surgery is recommended to allow for comparison of complications between treatment modalities., Level of Evidence: Level I-diagnostic study.

Objective: To determine incidence, associated risk factors, and characteristics of delirium in a pediatric cardiac intensive care unit (CICU). Delirium is a frequent and serious complication in adults after cardiac surgery, but there is limited understanding of its impact in children with critical cardiac disease., Study Design: Single-center prospective observational study of CICU patients ≤21 years old. All were screened for delirium using the Cornell Assessment for Pediatric Delirium each 12-hour shift., Results: Ninety-nine patients were included. Incidence of delirium was 57%. Median time to development of delirium was 1 day (95% CI 0, 1 days). Children with delirium were younger (geometric mean age 4 vs 46 months; P < .001), had longer periods of mechanical ventilation (mean 35.9 vs 8.8 hours; P = .002) and had longer cardiopulmonary bypass times (geometric mean 126 vs 81 minutes; P = .001). Delirious patients had longer length of CICU stay than those without delirium (median 3 (IQR 2, 12.5) vs 1 (IQR1, 2) days; P < .0001). A multivariable generalized linear mixed model showed a significant association between delirium and younger age (OR 0.35 for each additional month, 95% CI 0.19, 0.64), need for mechanical ventilation (OR 4.1, 95% CI 1.7, 9.89), and receipt of benzodiazepines (OR 3.78, 95% CI 1.46, 9.79)., Conclusions: Delirium is common in patients in the pediatric CICU and is associated with longer length of stay. There may be opportunities for prevention of delirium by targeting modifiable risk factors, such as use of benzodiazepines., (Published by Elsevier Inc.)

Introduction: Neuroprotection with therapeutic hypothermia (TH) is standard of care for neonatal encephalopathy (NE) and decreases death and neurodevelopmental disability. TH initiated shortly after birth insult results in greater neuroprotection compared with delayed initiation., Methods: Quality improvement methodology was used to improve temperature control during transport to a level IV neonatal intensive care unit. We included neonates with NE transported to a single institution for TH from 2010 to 2016. The quality improvement interventions were 2-fold. Review of the Transport Body Cooling Protocol revealed a suboptimal temperature goal of 34-35°C; this protocol was revised to 33-34°C. The second intervention was the implementation of an active cooling protocol. Clinical characteristics were compared using 2-sample t tests for continuous variables and Fisher's exact tests for categorical variables; statistical process control chart was used to monitor admission temperatures., Results: We obtained baseline data for 78 neonates admitted from 2010 to 2014. These data were compared with postintervention data for 26 patients admitted between 2015 and 2016. Distance transported, NE severity, and seizures were similar between the 2 groups. The use of active cooling increased from 8% preimplementation to 31% postimplementation ( P < 0.01). After implementation of the 2 interventions, more infants were admitted within the goal temperature of 33-34°C, 58% versus 22% ( P < 0.01), and the average neonatal intensive care unit admission temperature improved from 34.4 ± 0.8°C to 33.8 ± 0.8°C ( P < 0.01)., Conclusion: Increased utilization of active cooling during transport for TH improves the percentage of neonates admitted within the target temperature range. However, 42% of neonates remained outside the target temperature range, supporting the need for additional tools to improve admission temperatures.

Polyketides represent an extremely diverse class of secondary metabolites often explored for their bioactive traits. These molecules are also attractive building blocks for chemical catalysis and polymerization. However, the use of polyketides in larger scale chemistry applications is stymied by limited titers and yields from both microbial and chemical production. Here, we demonstrate that an oleaginous organism (specifically, Yarrowia lipolytica ) can overcome such production limitations owing to a natural propensity for high flux through acetyl-CoA. By exploring three distinct metabolic engineering strategies for acetyl-CoA precursor formation, we demonstrate that a previously uncharacterized pyruvate bypass pathway supports increased production of the polyketide triacetic acid lactone (TAL). Ultimately, we establish a strain capable of producing over 35% of the theoretical conversion yield to TAL in an unoptimized tube culture. This strain also obtained an averaged maximum titer of 35.9 ± 3.9 g/L with an achieved maximum specific productivity of 0.21 ± 0.03 g/L/h in bioreactor fermentation. Additionally, we illustrate that a β-oxidation-related overexpression ( PEX10 ) can support high TAL production and is capable of achieving over 43% of the theoretical conversion yield under nitrogen starvation in a test tube. Next, through use of this bioproduct, we demonstrate the utility of polyketides like TAL to modify commodity materials such as poly(epichlorohydrin), resulting in an increased molecular weight and shift in glass transition temperature. Collectively, these findings establish an engineering strategy enabling unprecedented production from a type III polyketide synthase as well as establish a route through O-functionalization for converting polyketides into new materials., Competing Interests: The authors declare no conflict of interest.