The Pediatric Data Science and Analytics Subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators Network: Use of Supervised Machine Learning Applications in Pediatric Critical Care Medicine Research

OBJECTIVE

Perform a scoping review of supervised machine learning in pediatric critical care to identify published applications, methodologies, and implementation frequency to inform best practices for the development, validation, and reporting of predictive models in pediatric critical care.

DESIGN

Scoping review and expert opinion.

SETTING

We queried CINAHL Plus with Full Text (EBSCO), Cochrane Library (Wiley), Embase (Elsevier), Ovid Medline, and PubMed for articles published between 2000 and 2022 related to machine learning concepts and pediatric critical illness. Articles were excluded if the majority of patients were adults or neonates, if unsupervised machine learning was the primary methodology, or if information related to the development, validation, and/or implementation of the model was not reported. Article selection and data extraction were performed using dual review in the Covidence tool, with discrepancies resolved by consensus.

SUBJECTS

Articles reporting on the development, validation, or implementation of supervised machine learning models in the field of pediatric critical care medicine.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 5075 identified studies, 141 articles were included. Studies were primarily (57%) performed at a single site. The majority took place in the United States (70%). Most were retrospective observational cohort studies. More than three-quarters of the articles were published between 2018 and 2022. The most common algorithms included logistic regression and random forest. Predicted events were most commonly death, transfer to ICU, and sepsis. Only 14% of articles reported external validation, and only a single model was implemented at publication. Reporting of validation methods, performance assessments, and implementation varied widely. Follow-up with authors suggests that implementation remains uncommon after model publication.

CONCLUSIONS

Publication of supervised machine learning models to address clinical challenges in pediatric critical care medicine has increased dramatically in the last 5 years. While these approaches have the potential to benefit children with critical illness, the literature demonstrates incomplete reporting, absence of external validation, and infrequent clinical implementation.

Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock

Importance

The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach.

Objective

To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings.

Design, Setting, and Participants

Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set.

Exposure

Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock.

Main Outcomes and Measures

The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity.

Results

Among the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings.

Conclusions and Relevance

The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.

International Consensus Criteria for Pediatric Sepsis and Septic Shock

Importance

Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children.

Objective

To update and evaluate criteria for sepsis and septic shock in children.

Evidence Review

The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria.

Findings

Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively.

Conclusions and Relevance

The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Bridging Bone Health: Osteoporosis Disparities in the Rio Grande Valley

INTRODUCTION

Osteoporosis is characterized by decreased bone mass and decreased bone quality, leading to increased bone fragility and risk of fractures. The number of fractures due to osteoporosis is projected to increase to over three million by the year 2025 and cost $25.3 billion annually. It ranks highly among diseases that cause patients to become bedridden with serious complications and reduced quality of life. Additionally, osteoporosis disproportionately affects Hispanics, which comprise most of the Rio Grande Valley (RGV) population. Therefore, our primary objective was to determine the prevalence of osteoporosis within the RGV. Additionally, we had secondary objectives to determine the screening rates of osteoporosis in the RGV and identify other potential risk factors associated with osteoporosis. We hypothesize that individuals residing in the RGV have higher rates of osteoporosis and lower rates of osteoporosis screening than the national average.

METHODS

This retrospective observational cross-sectional study utilized Medicare beneficiary data via the "Mapping Medicare Disparities by Population" interactive tool. Osteoporosis data were compared within the RGV (comprising Starr, Hidalgo, Cameron, and Willacy counties) and compared with national averages between the years 2016 and 2021. Statistical analysis included prevalence ratios with 95% confidence intervals and chi-square values when applicable.

RESULTS

Among Medicare beneficiaries residing in the RGV, there are higher rates of osteoporosis compared to the national average (11.5% vs. 7.20%; p < .00001). Screening for osteoporosis within the RGV is above the national average (9.29% vs. 6.67%, p < .00001). Hispanics residing in the RGV have higher overall rates of osteoporosis than Caucasians residing in the RGV (12.3% vs. 8.60%, p < .00001). Females residing in the RGV have nearly twice the rate of osteoporosis compared to the national average (19.1% vs. 11.8%, p < .00001) and 6.58 times the rate of males residing in the RGV (19.1% vs. 2.9%, p < .00001).

CONCLUSION

Individuals residing in the RGV are disproportionately affected by osteoporosis. Despite increased screening rates seen among Medicare beneficiaries, we also suspect many individuals, uninsured or undocumented, have not received any appropriate osteoporosis screening. Risk factors in the RGV associated with higher rates of osteoporosis could include low education levels, socioeconomic status, physical activity, and mineral intake. These results demonstrate a need to address osteoporosis health literacy, promote earlier interventions to treat osteoporosis and increase healthcare accessibility in the RGV.

Ontologizing health systems data at scale: making translational discovery a reality

Common data models solve many challenges of standardizing electronic health record (EHR) data but are unable to semantically integrate all of the resources needed for deep phenotyping. Open Biological and Biomedical Ontology (OBO) Foundry ontologies provide computable representations of biological knowledge and enable the integration of heterogeneous data. However, mapping EHR data to OBO ontologies requires significant manual curation and domain expertise. We introduce OMOP2OBO, an algorithm for mapping Observational Medical Outcomes Partnership (OMOP) vocabularies to OBO ontologies. Using OMOP2OBO, we produced mappings for 92,367 conditions, 8611 drug ingredients, and 10,673 measurement results, which covered 68-99% of concepts used in clinical practice when examined across 24 hospitals. When used to phenotype rare disease patients, the mappings helped systematically identify undiagnosed patients who might benefit from genetic testing. By aligning OMOP vocabularies to OBO ontologies our algorithm presents new opportunities to advance EHR-based deep phenotyping.

Improving PICU Discharge Timeliness of Infants with Bronchiolitis Using Clinical Decision Support

BACKGROUND

Identifying children ready for transfer out of the pediatric ICU (PICU) is an area that may benefit from clinical decision support (CDS). We previously implemented a quality improvement (QI) initiative to accelerate the transfer evaluation of non-medically-complex PICU patients with viral bronchiolitis receiving floor-appropriate respiratory support.

OBJECTIVES

Design a CDS tool adaptation of this QI initiative to further accelerate transfer evaluation of appropriate patients.

METHODS

The original initiative focused on identifying for transfer evaluation otherwise healthy children admitted to the PICU with bronchiolitis who had been receiving floor-appropriate levels of respiratory support for at least 6-hours. However, this initiative required that clinicians manually track the respiratory support of qualifying patients. We designed an electronic health record (EHR)-based CDS tool to automate identification of transfer-ready candidates. The tool parses EHR data to identify children meeting prior QI initiative criteria and alerts clinicians to assess transfer readiness once a child has been receiving floor-appropriate respiratory support for 6-hours. We compared time from reaching floor-appropriate support to placement of the transfer order ("time-to-transfer"), PICU LOS, and hospital LOS between patients admitted prior to our QI initiative (12/1/2018-10/19/2019, "pre-QI-phase"), during the initiative but before CDS tool implementation (10/20/2019-2/7/2022, "QI-phase"), and after CDS implementation (2/8/2022-11/11/2022, "CDS-phase").

RESULTS

CDS-phase patients (n=131) had a shorter median time-to-transfer of 5.23 (IQR 3.38-10.0) hours compared to QI-phase patients (n=304) at 5.93 (4.23-12.2) hours (p=0.04). PICU and hospital LOS values decreased from the pre-QI (n=150) to QI-phase. Though LOS reductions were sustained during the CDS-phase, further reductions from QI to CDS-phase were not statistically significant.

CONCLUSIONS

An EHR-based CDS adaptation of a prior QI initiative facilitated timely identification of PICU patients with bronchiolitis ready for transfer evaluation. Such tools might allow PICU clinicians to focus on other high-acuity tasks while accelerating transfer evaluation of appropriate patients.

Energy Expenditure Estimation From Respiratory Magnetometer Plethysmography: A Comparison Study

Physical activity (PA) quantification by estimating energy expenditure (EE) is essential to health. Reference methods for EE estimation often involve expensive and cumbersome systems to wear. To address these problems, light-weighted and cost-effective portable devices are developed. Respiratory magnetometer plethysmography (RMP) is among such devices, based on the measurements of thoraco-abdominal distances. The aim of this study was to conduct a comparative study on EE estimation with low to high PA intensity with portable devices including the RMP. Fifteen healthy subjects aged 23.84±4.36 years were equipped with an accelerometer, a heart rate (HR) monitor, a RMP device and a gas exchange system, while performing 9 sedentary and physical activities: sitting, standing, lying, walking at 4 and 6 km/h, running at 9 and 12 km/h, biking at 90 and 110 W. An artificial neural network (ANN) as well as a support vector regression algorithm were developed using features derived from each sensor separately and jointly. We compared also three validation approaches for the ANN model: leave one out subject, 10 fold cross-validation, and subject-specific. Results showed that 1. for portable devices the RMP provided better EE estimation compared to accelerometer and HR monitor alone; 2. combining the RMP and HR data further improved the EE estimation performances; and 3. the RMP device was also reliable in EE estimation for various PA intensities.

Development of a Pediatric Blood Pressure Percentile Tool for Clinical Decision Support

This diagnostic study assesses the ability of a pediatric blood pressure percentile tool to accelerate identification of children with hypertension and hypotension by clinicians and researchers.

Questionnaire and tools: clinical powerful instrument in acromegaly diagnosis and management

PURPOSE

Acromegaly is a rare chronic disease characterized by systemic comorbidity and reduced quality of life. Although achieving biochemical control has always been the primary goal of acromegaly therapy, recent evidence has shown that the traditional assessment does not adequately capture the complexity of symptoms and patients' perception. These findings result in the need to improve a fast decision-making process of the clinician, who should not only take into account biochemical-instrumental criteria, but also patients' symptoms. With the aim of supporting the clinician in the diagnostic and therapeutic decision-making process several disease-specific tools have been developed. The aim of this review is to provide a description of the acromegaly-specific tools, presenting their main features, their application in daily practice, and their efficacy and utility.

METHODS

A systematic search of Medline/PubMed, ISI-Web of Knowledge, and Google Scholar databases was done.

RESULTS

Specific instruments and questionnaires have recently been developed to assist clinicians in the assessment of acromegaly. These are either Patient-Reported Outcome tools, such as Acromegaly Quality of Life Questionnaire (AcroQoL) and Pain Assessment Acromegaly Symptom Questionnaire (PASQ), or Clinician-Reported Outcome tools, such as ACROSCORE, SAGIT^® and Acromegaly Disease Activity Tool (ACRODAT^®). Such tools are extremely flexible and, therefore, have been widely adopted by endocrinologists and other professionals, so much so that they have also been included as recommendations in the 2018 international guidelines.

CONCLUSION

Questionnaires and tools are useful in the management of acromegaly patients. They help clinicians evaluate patients' symptoms and could assist in the evaluation of disease activity.

Effects of forage quantity and access-time restriction on feeding behaviour, feed efficiency, nutritional status, and dairy performance of dairy cows fed indoors

Optimising feed is a key challenge for dairy livestock systems, as forage stock shortages are increasingly frequent and feed is the biggest operating cost. The aim of this experiment was to evaluate the effects of reducing forage quantity and access time on dairy performance and animal nutritional status during indoor feeding. Twenty-seven Montbéliarde and Holstein cows were randomly allocated to three groups of nine cows balanced by breed, parity, days in milk, and milk yield. The three groups were given 3.9 kg DM/day of second-cut hay and 4.5 kg/day of concentrate and either i) ad libitum access to first-cut hay (Ad Libitum group; AL), ii) 10.5 kg/day of first-cut hay (Quantity-restricted group; QR), or iii) 10.5 kg/day of first-cut hay but with access time restricted to only 2 h in the morning and 2 h in the afternoon (Quantity-and-Time-restricted group; QTR). Milk yield, composition and coagulation properties, cow nutritional status (weight, body condition score, blood metabolites) and cow activities were recorded. The AL group ingested 10 % more feed than the QR group and 16 % more feed than the QTR group. Organic matter digestibility was lower in the AL group than in the QR and QTR groups whereas feed efficiency did not differ. Milk yield was not significantly different among the three groups. Compared to the QR and QTR groups, the AL group had significantly higher milk fat (35.9 vs 32.9 and 32.8 g/kg of milk) and milk protein content (29.5 vs 27.7 and 28.5 g/kg of milk). QR and QTR cows mobilised their body fat, resulting in a lower final body condition score, and tended to have a lower blood non-esterified fatty acid concentration than the AL group. QTR cows showed greater body fat mobilisation, but their final corrected BW was not different from AL cows. Access-time restriction did not impact fat and protein content but led to decreased casein, lactose contents and casein-to-whey protein ratio. The forage savings achieved through this feed management practice could prove economically substantial when forage prices increase. This practice can be of interest in grassland systems to overcome certain climatic hazards without having to resort to purchases or to increase the farm's forage autonomy.

Acute Upper Airway Disease in Children With the Omicron (B.1.1.529) Variant of SARS-CoV-2-A Report From the US National COVID Cohort Collaborative

This cohort study uses data from the US National COVID Cohort Collaborative to evaluate upper airway infections in children during the surge of the Omicron (B.1.1.529) variant of SARS-CoV-2 in the US.

P-632 Evaluation of low AMH levels in young women

Study question

The primary objective was to evaluate impact of a low AMH level on the live birth rate in a population of young women IVF/ICSI .

Summary answer

Low AMH level in young women in FIV/ICSI is not expected to have an impact on the live birth.

What is known already

AMH is an important criterion for defining ovarian reserve. The majority of studies have shown that the AMH level in the general population is not correlated with the chances of spontaneous pregnancy.

The management remains a challenge and must be individualized taking into account the new quantitative and qualitative criteria to be defined (POSEIDON classification). Finally, we know that the pregnancy rate is correlated to the rate of euploid embryos, and that the rate is higher before 35 years of age.

Study design, size, duration

In this single-center retrospective study from January 2015 to December 2020, 1824 IVF/ICSI attempts were analyzed.

We analyzed the live birth rate according to 2 categories of young women matched by AMH level.

Participants/materials, setting, methods

We analyzed the live birth rate according to 2 categories of young women managed in IVF/ICSI protocol.

A first group was ≤30 years old and a second group was between 31 and 35 years old.

Then, we matched each of these groups to an AMH level, AMH&lt;1ng/mL and AMH ≥1ng/mL.

We analyzed the live birth rate of 4 groups of young women.

Main results and the role of chance

1824 IVF/ICSI attempts were analyzed in this study. We have 539 women under 30 years of age and 1285 women between 31 and 35 years of age.

For women aged ≤30 years, the group with AMH&lt;1ng/mL had a non-statistically significant live birth rate compared to those with AMH≥1ng/mL (31% vs 32.7% p = 1).

For women aged 31-35 years, the group with AMH&lt;1ng/mL, has a statistically significant lower live birth rate compared to those with AMH≥1ng/mL (14.5% vs 29.3% p = 0.001).

Limitations, reasons for caution

The main limitation of our study is the few number of patients.

Wider implications of the findings

This study tries to demonstrate that low AMH levels in young women do not predict a poor IVF/ICSI success rate. Conclusions should not be drawn too quickly for low AMH in this population. However, the threshold AMH level is still debated in the studies and should be further adjusted.

Trial registration number

not applicable

Machine Learning Approach to Predicting Absence of Serious Bacterial Infection at PICU Admission

BACKGROUND AND OBJECTIVES

Serious bacterial infection (SBI) is common in the PICU. Antibiotics can mitigate associated morbidity and mortality but have associated adverse effects. Our objective is to develop machine learning models able to identify SBI-negative children and reduce unnecessary antibiotics.

METHODS

We developed models to predict SBI-negative status at PICU admission using vital sign, laboratory, and demographic variables. Children 3-months to 18-years-old admitted to our PICU, between 2011 and 2020, were included if evaluated for infection within 24-hours, stratified by documented antibiotic exposure in the 48-hours prior. Area under the receiver operating characteristic curve (AUROC) was the primary model accuracy measure; secondarily, we calculated the number of SBI-negative children subsequently provided antibiotics in the PICU identified as low-risk by each model.

RESULTS

A total of 15 074 children met inclusion criteria; 4788 (32%) received antibiotics before PICU admission. Of these antibiotic-exposed patients, 2325 of 4788 (49%) had an SBI. Of the 10 286 antibiotic-unexposed patients, 2356 of 10 286 (23%) had an SBI. In antibiotic-exposed children, a radial support vector machine model had the highest AUROC (0.80) for evaluating SBI, identifying 48 of 442 (11%) SBI-negative children provided antibiotics in the PICU who could have been spared a median 3.7 (interquartile range 0.9-9.0) antibiotic-days per patient. In antibiotic-unexposed children, a random forest model performed best, but was less accurate overall (AUROC 0.76), identifying 33 of 469 (7%) SBI-negative children provided antibiotics in the PICU who could have been spared 1.1 (interquartile range 0.9-3.7) antibiotic-days per patient.

CONCLUSIONS

Among children who received antibiotics before PICU admission, machine learning models can identify children at low risk of SBI and potentially reduce antibiotic exposure.

Animal performance and stress at weaning when dairy cows suckle their calves for short versus long daily durations

Calves in most dairy farms are separated from their dams either immediately or within a few hours after birth, prompting increasing concern of the society for reasons of animal welfare. The aim of this study was to identify systems to maintain cow-calf contact (CCC) that balance the benefits for calf growth and health against the negative impacts on sellable milk and stress at weaning. We tested reuniting cows and calves for 20 min before (Before-group) or 2.5 h after (After-group) morning milking (in Trial 1) or for a 9 h period between the morning and evening milkings (Half-day-group, in Trial 2). In Control-groups, calves were separated from their dam at birth and fed with artificial nipple with tank milk provided daily at 13% (Trial 1) and 14% (Trial 2) of their BW. In both trials, each practice was applied on a group of 14 dam-calf pairs (7 Holstein [Ho] and 7 Montbéliarde [Mo]). All calves were weaned at a BW of at least 100 kg. In Trial 1, the After-group was prematurely stopped when the calves were eight weeks of age as calf growth became limited (340 g/d) due to low milk intakes (2.97 kg/d). During the first eight weeks of lactation, milk yield at the parlour was 29%, 51% and 42% lower in After-, Before- and Half-day-cows respectively compared to Controls. From week 14 to 16 when all calves were separated from their dam, Before-cows still produced 25% less milk than Control-cows while Half-day-cows reached the milk yield of Control-cows within a week. There were no significant differences in milk somatic cell count and in frequency of health disorders (cows and calves) between suckling and Control-groups. Compared to Control-calves, calf growth until weaning was higher in the suckling calves in Trial 1 (861 vs 699 g/d) and similar in Trial 2 (943 vs 929 g/d). At weaning, Before- and Half-day-calves started to vocalise earlier and continued to vocalise longer than Controls. In conclusion, the best compromise between cow milk yield and calf growth is a long period of CCC (9 h) between the morning and evening milkings. Still abrupt weaning stresses both cows and calves even if CCC has been restricted before separation.

Characteristics, Outcomes, and Severity Risk Factors Associated With SARS-CoV-2 Infection Among Children in the US National COVID Cohort Collaborative

Importance

Understanding of SARS-CoV-2 infection in US children has been limited by the lack of large, multicenter studies with granular data.

Objective

To examine the characteristics, changes over time, outcomes, and severity risk factors of children with SARS-CoV-2 within the National COVID Cohort Collaborative (N3C).

Design, Setting, and Participants

A prospective cohort study of encounters with end dates before September 24, 2021, was conducted at 56 N3C facilities throughout the US. Participants included children younger than 19 years at initial SARS-CoV-2 testing.

Main Outcomes and Measures

Case incidence and severity over time, demographic and comorbidity severity risk factors, vital sign and laboratory trajectories, clinical outcomes, and acute COVID-19 vs multisystem inflammatory syndrome in children (MIS-C), and Delta vs pre-Delta variant differences for children with SARS-CoV-2.

Results

A total of 1 068 410 children were tested for SARS-CoV-2 and 167 262 test results (15.6%) were positive (82 882 [49.6%] girls; median age, 11.9 [IQR, 6.0-16.1] years). Among the 10 245 children (6.1%) who were hospitalized, 1423 (13.9%) met the criteria for severe disease: mechanical ventilation (796 [7.8%]), vasopressor-inotropic support (868 [8.5%]), extracorporeal membrane oxygenation (42 [0.4%]), or death (131 [1.3%]). Male sex (odds ratio [OR], 1.37; 95% CI, 1.21-1.56), Black/African American race (OR, 1.25; 95% CI, 1.06-1.47), obesity (OR, 1.19; 95% CI, 1.01-1.41), and several pediatric complex chronic condition (PCCC) subcategories were associated with higher severity disease. Vital signs and many laboratory test values from the day of admission were predictive of peak disease severity. Variables associated with increased odds for MIS-C vs acute COVID-19 included male sex (OR, 1.59; 95% CI, 1.33-1.90), Black/African American race (OR, 1.44; 95% CI, 1.17-1.77), younger than 12 years (OR, 1.81; 95% CI, 1.51-2.18), obesity (OR, 1.76; 95% CI, 1.40-2.22), and not having a pediatric complex chronic condition (OR, 0.72; 95% CI, 0.65-0.80). The children with MIS-C had a more inflammatory laboratory profile and severe clinical phenotype, with higher rates of invasive ventilation (117 of 707 [16.5%] vs 514 of 8241 [6.2%]; P < .001) and need for vasoactive-inotropic support (191 of 707 [27.0%] vs 426 of 8241 [5.2%]; P < .001) compared with those who had acute COVID-19. Comparing children during the Delta vs pre-Delta eras, there was no significant change in hospitalization rate (1738 [6.0%] vs 8507 [6.2%]; P = .18) and lower odds for severe disease (179 [10.3%] vs 1242 [14.6%]) (decreased by a factor of 0.67; 95% CI, 0.57-0.79; P < .001).

Conclusions and Relevance

In this cohort study of US children with SARS-CoV-2, there were observed differences in demographic characteristics, preexisting comorbidities, and initial vital sign and laboratory values between severity subgroups. Taken together, these results suggest that early identification of children likely to progress to severe disease could be achieved using readily available data elements from the day of admission. Further work is needed to translate this knowledge into improved outcomes.

Review: Quality and authentication of organic animal products in Europe

The 'organic' label guarantees a production process that avoids the use of synthetic fertilisers, pesticides and hormones and minimises the use of veterinary drugs; however, consumers are demanding guarantees regarding food quality. This article reviews the current state of knowledge on the quality of organic animal products, including the authentication of their organic origin. Quality has been considered as an integrative combination of six core attributes: commercial value, and nutritional, sensory, technological, convenience and safety attributes. The comparison of these attributes between organic and conventional animal products shows high heterogeneity due to variability in farming pratices in both organic and conventional systems. To overcome this, we pinpoint the farming practices underlying the differences observed. This enables light to be shed on the consequences of possible trajectories of organic farming, if specifications are relaxed or tightened up on commitments concerning farming practices that impact product quality. Two recent meta-analyses showed better nutritional attributes in organic milk and meat linked to their higher poly-unsaturated fatty acid (PUFA) content, particularly n-3 PUFAs. Regarding safety, we point to a lack of integrated studies quantifying the balance between positive and negative effects. Organic farming reduces the risk of drug residues and antibiotic resistance, but both outdoor rearing and a frequently longer rearing period increase the animals' exposition to environmental contaminants and the risk of their bioaccumulation in milk, eggs, meat and fish flesh. We highlight antagonisms between quality attributes for certain animal products (lamb, pork). In general, attributes are more variable for organic products, which can be explained by lower genetic selection (poultry), lower inputs and/or greater variability in farming conditions. However, the literature does not address the implications of this greater variability for the consumers' acceptability and the necessary adaptation of manufacturing processes. Further research is needed to document the impacts on human nutritional biomarkers and health. Methods used to authenticate organic origin are based on differences in animal diet composition between organic and conventional systems, but their reliability is hampered by the variability in farming practices.

A quantitative review of on-farm feeding practices to enhance the quality of grassland-based ruminant dairy and meat products

In the last decades, a large body of evidence has highlighted the major role of feeding management practices in improving specific nutritional, technological and sensory quality traits of ruminant products. However, results have been mostly obtained under controlled conditions, and have been rarely validated on-farm. Therefore, a quantitative review was conducted to quantify the effects of on-farm feeding management practices on carotenoids, fat-soluble vitamins, colour, fatty acids (FAs), terpenes and sensory properties in the main animal product categories (PCs): dairy products from cattle (DC), sheep (DS) and goat (DG), and meat from cattle (MC) and sheep (MS). Four feeding scenarios were selected according to the consistency of on-farm studies in the literature: (a) feeding "Fresh herbage" instead of conserved forages; (b) ban any form of silage ("Silage-free"); (c) ban maize silage ("Maize silage-free"); (d) feeding forages from permanent grasslands rich in species or plant secondary metabolites (PSMs) ("PSM-rich permanent grassland"). Feeding fresh herbage increased the concentration of carotenoids, fat-soluble vitamin, n-3 FA, rumenic acid, and branched chain FA (BCFA), and reduced the concentration of saturated FA, for all PC, with overall stronger effect for dairy products than for meat. The texture of meat and dairy products was marginally affected, whereas feeding fresh herbage decreased lactic and increased vegetal notes in DC. The "Silage-free" feeding scenario resulted in increased vaccenic acid, rumenic acid, BCFA, and C18:3n-3 in DC. The "Maize silage-free" feeding scenario lowered n-6 FA whereas increased n-3, rumenic acid and BCFA concentrations in DC. Feeding ruminants with forages from "PSM-rich permanent grasslands" increased monounsaturated FA, n-3 FA and rumenic acid and decreased n-6 FA in dairy products, and only marginally affected meat FA composition. The DC from "PSM-rich permanent grasslands" showed higher intense, spicy and animal notes. Overall, the differences between feeding management practices observed on farm were smaller than those observed under controlled trials. Several confounding factors, not controlled when operating under on-farm conditions, could be at the origin of these divergences (i.e. mixed diets, forage characteristics, animal-related factors). This review confirmed that farming practices may differently affect several quality traits of ruminant products. It also highlighted the uneven knowledge on the effect of feeding management depending on the PC: larger for milk than for meat and decreasing when moving from cattle to sheep and from sheep to goat.

O-200 Frozen embryo transfer: Miscarriage rates depending on the starting day of intramuscular progesterone

Study question

Objective was to assess whether adjusting starting day of intramuscular progesterone the day of vaginal supplementation versus day of embryo transfer or later, might affect the outcome of the cycle.

Summary answer

additional injection of intramuscular progesterone the day of progesterone initiation or later, is not likely to be more effective on live birth and miscarriage rates.

What is known already

There is no consensus on the most effective method of endometrium preparation prior to FET. However, many studies report that high serum progesterone concentration during the implantation period is associated with optimal live birth rates. Adjusting progesterone treatment the day of embryo transfer seems to be too late and ineffective for rescuing low progesterone levels and should be done before.

Study design, size, duration

In this single center prospective study from October 2019 to november 2020, 239 patients undergoing hormonal replacement therapy protocol for frozen embryo transfer were randomly divided into two groups: additional injection of intramuscular progesterone the day of progesterone initiation or intramuscular progesterone the day of embryo transfer. We compare these results to our previous protocol beginning intramuscular progesterone day 22 of the treatment.

Participants/materials, setting, methods

Our frozen embryo transfer protocol consists to initiate GnRH agonist the day 1 of the cycle. After 14 days of estrogens, we introduce vaginal progesterone, prior to embryo transfer. Patients in group A received an additional injection of intramuscular progesterone the day of progesterone initiation. The group B received intramuscular progesterone the day of embryo transfer. For both, intramuscular injection of progesterone was followed every 3 days.

Main results and the role of chance

239 patients were enrolled in this study, 125 in the group A and 114 in the group B. The ongoing pregnancy rate in the group A was 26.4 % and miscarriage rate 7.2%, not statistically different from ongoing pregnancy rate and miscarriage rate of women in the group B (22.81 %, p = 0.66/ 6.14%, p = 0.8).

The ongoing pregnancy rate in the group D22 was 24.89 % et miscarriage rate 7.2%, not statistically different from ongoing pregnancy rate of women in the group A and B (p = 0.78 and p = 0.31).

Limitations, reasons for caution

The main limitation of our study is the lack of randomization for the group with additional progesterone IM on day 22. The study is actually followed to enroll more patients in 3 different groups.

Wider implications of the findings

This study tries to determine optimal adaptive management of hormonal replacement treatment for embryo transfer in patients with potential low progesterone values.

Trial registration number

no applicable

Children with SARS-CoV-2 in the National COVID Cohort Collaborative (N3C)

IMPORTANCE

SARS-CoV-2.

OBJECTIVE

To determine the characteristics, changes over time, outcomes, and severity risk factors of SARS-CoV-2 affected children within the National COVID Cohort Collaborative (N3C).

DESIGN

Prospective cohort study of patient encounters with end dates before May 27th, 2021.

SETTING

45 N3C institutions.

PARTICIPANTS

Children <19-years-old at initial SARS-CoV-2 testing.

MAIN OUTCOMES AND MEASURES

Case incidence and severity over time, demographic and comorbidity severity risk factors, vital sign and laboratory trajectories, clinical outcomes, and acute COVID-19 vs MIS-C contrasts for children infected with SARS-CoV-2.

RESULTS

728,047 children in the N3C were tested for SARS-CoV-2; of these, 91,865 (12.6%) were positive. Among the 5,213 (6%) hospitalized children, 685 (13%) met criteria for severe disease: mechanical ventilation (7%), vasopressor/inotropic support (7%), ECMO (0.6%), or death/discharge to hospice (1.1%). Male gender, African American race, older age, and several pediatric complex chronic condition (PCCC) subcategories were associated with higher clinical severity (p ≤ 0.05). Vital signs (all p≤0.002) and many laboratory tests from the first day of hospitalization were predictive of peak disease severity. Children with severe (vs moderate) disease were more likely to receive antimicrobials (71% vs 32%, p<0.001) and immunomodulatory medications (53% vs 16%, p<0.001). Compared to those with acute COVID-19, children with MIS-C were more likely to be male, Black/African American, 1-to-12-years-old, and less likely to have asthma, diabetes, or a PCCC (p < 0.04). MIS-C cases demonstrated a more inflammatory laboratory profile and more severe clinical phenotype with higher rates of invasive ventilation (12% vs 6%) and need for vasoactive-inotropic support (31% vs 6%) compared to acute COVID-19 cases, respectively (p<0.03).

CONCLUSIONS

In the largest U.S. SARS-CoV-2-positive pediatric cohort to date, we observed differences in demographics, pre-existing comorbidities, and initial vital sign and laboratory test values between severity subgroups. Taken together, these results suggest that early identification of children likely to progress to severe disease could be achieved using readily available data elements from the day of admission. Further work is needed to translate this knowledge into improved outcomes.

Co-construction of a method for evaluating the intrinsic quality of bovine milk in relation to its fate

There are time-tested assessments for the environmental and economic aspects of sustainability. Its societal aspect has mainly been approached through the assessment of animal welfare. However, the intrinsic quality of milk is seldom taken into account. We developed a participatory construction method for the overall assessment of intrinsic milk quality in its different dimensions (sensory, technological, nutritional and health), according to the fate of the raw milk. Two assessment models were developed, for semi-skimmed standardized ultra-high temperature (UHT) milk and for pressed uncooked non-standardized raw milk cheese. They were constructed by a participatory approach involving experts in the dairy sector with the aim to obtain a diagnostic tool that could be used in the field to help farmers to manage the quality of their milk (by prioritizing improvements on major problems). They were shaped from prerequisite specifications (limited costs and time of application, desire to obtain a transparent tool with all the steps kept visible) and current technical and scientific knowledge. They were based on indicators obtained from raw bulk tank milk analyses (30 for UHT milk and 50 for cheese assessments), which were then aggregated into criteria, principles, dimensions and overall intrinsic quality at farm level. The assessment models had parts in common, for example, same four dimensions, common indicators for health and nutritional dimensions. They also had process-specific features: units chosen, criteria, indicators and weightings in relation to the final product specifications. For instance, sensory and technological dimensions are more complex and preponderant in the cheese assessment (three principles for cheese vs one for UHT milk in both dimensions). Another example is the lack of microbial pathogens (as potential health risk for consumer) in the UHT milk assessment because of pasteurization. The assessment models then underwent a sensitivity analysis and an application in 30 farms in indoor and grazing periods to finally obtain overall UHT milk and cheese quality scores at a 1-year level. The tool was found to be applicable at farm level. However, we observed low overall quality scores with a narrow dispersion, characteristic of a severe evaluation. Even so, the assessment models showed up seasonal differences of the UHT milk and cheese quality at both overall and dimensional levels. In the light of new scientific knowledge and future quality objectives, these are adaptable to other dairy products allowing for their specific features.

An inverse modelling study on the local volume changes during early morphoelastic growth of the fetal human brain

We take a data-driven approach to deducing the local volume changes accompanying early development of the fetal human brain. Our approach uses fetal brain atlas MRI data for the geometric changes in representative cases. Using a nonlinear continuum mechanics model of morphoelastic growth, we invert the deformation obtained from MRI registration to arrive at a field for the growth deformation gradient tensor. Our field inversion uses a combination of direct and adjoint methods for computing gradients of the objective function while constraining the optimization by the physics of morphoelastic growth. We thus infer a growth deformation gradient field that obeys the laws of morphoelastic growth. The errors between the MRI data and the forward displacement solution driven by the inverted growth deformation gradient field are found to be smaller than the reference displacement by well over an order of magnitude, and can be driven even lower. The results thus reproduce the three-dimensional growth during the early development of the fetal brain with controllable error. Our findings confirm that early growth is dominated by in plane cortical expansion rather than thickness increase.

Feeding cows with hay, silage, or fresh herbage on pasture or indoors affects sensory properties and chemical composition of milk and cheese

In European countries, silage-free feeding is an ancient tradition and has a particularly positive reputation among consumers. In the present study, we compared grass-based forages from the same plot conserved as hay or silage or fed fresh either on pasture or indoors, and we evaluated the differences in sensory properties of milk and uncooked pressed cheese. All herbage from the first cut of a grassland dominated by perennial ryegrass was harvested on the same day and preserved either as hay or silage. The first regrowth of the same plot was used for strip grazing or green feeding indoors. Balanced by breed, 24 Montbéliarde and 24 Holstein cows were allocated to the 4 treatments. Apart from the forages, the late-lactation cows received 3 kg/d of dry matter from concentrate. After 2 wk of dietary adaptation, the bulk milk of 3 subgroups, each with 4 cows, was collected. Part of the milk was pasteurized, and part was left raw and partly transformed to small-sized Cantal-type cheese ripened for 9 wk. Milk and cheese underwent descriptive sensory analysis by a trained sensory panel, as well as analyses of physicochemical traits. Volatile organic compounds of the cheeses were also analyzed. Raw and pasteurized milk from hay-fed cows had less intense odors of cooked milk, cream, and barnyard than milk from grazing cows, whereby the effect of pasteurization did not differ between herbage utilization methods. Cheeses obtained from cows fed fresh herbage (grazing and indoors) were clearly yellower than cheeses from silage- and hay-fed cows, which coincided with the color intensity perceived by the panelists. Moreover, cheeses from cows fed fresh herbage had more intense barnyard and dry fruit flavors, were perceived as creamier and having less lactic odor, and exhibited more fat exudation than those from cows fed conserved herbage. Only a few differences were observed in milk and cheeses from hay-fed compared with silage-fed cows, and those differences were far less pronounced than those of milk and cheeses from cows fed fresh herbage. In conclusion, the present study did not substantiate assumptions of clear sensory differences of milk and uncooked pressed cheese from hay-fed compared with silage-fed cows. For the first time, this study reports that the global flavor intensity of cheeses from indoor green-fed cows is similar to that of cheeses derived from cows fed conserved forages, whereas cheeses from grazing cows have the greatest global flavor intensity.

An inverse modelling study on the local volume changes during early morphoelastic growth of the fetal human brain

We take a data-driven approach to deducing the local volume changes accompanying early development of the fetal human brain. Our approach uses fetal brain atlas MRI data for the geometric changes in representative cases. Using a nonlinear continuum mechanics model of morphoelastic growth, we invert the deformation obtained from MRI registration to arrive at a field for the growth deformation gradient tensor. Our field inversion uses a combination of direct and adjoint methods for computing gradients of the objective function while constraining the optimization by the physics of morphoelastic growth. We thus infer a growth deformation gradient field that obeys the laws of morphoelastic growth. The errors between the MRI data and the forward displacement solution driven by the inverted growth deformation gradient field are found to be smaller than the reference displacement by well over an order of magnitude, and can be driven even lower. The results thus reproduce the three-dimensional growth during the early development of the fetal brain with controllable error. Our findings confirm that early growth is dominated by in plane cortical expansion rather than thickness increase.

Topics and trends in Mountain Livestock Farming research: a text mining approach

Pasture-based and small-scale livestock farming systems are the main source of livelihood in the mountain primary sector, ensuring socioeconomic sustainability and biodiversity in rural communities throughout Europe and beyond. Mountain livestock farming (MLF) has attracted substantial research efforts from a wide variety of scientific communities worldwide. In this study, the use of text mining and topic modelling analysis drew a detailed picture of the main research topics dealing with MLF and their trends over the last four decades. The final data corpus used for the analysis counted 2 679 documents, of which 92% were peer-reviewed scientific publications. The number of scientific outputs in MLF doubled every 10 years since 1980. Text mining found that milk, goat and sheep were the terms with the highest weighed frequency in the data corpus. Ten meaningful topics were identified by topic analysis: T1-Livestock management and vegetation dynamics; T2-Animal health and epidemiology; T3-Methodological studies on cattle; T4-Production system and sustainability; T5-Methodological studies; T6-Wildlife and conservation studies; T7-Reproduction and performance; T8-Dairy/meat production and quality; T9-Land use and its change and T10-Genetic/genomic studies. A hierarchical clustering analysis was performed to explore the interrelationships among topics, and three main clusters were identified: the first focused on sustainability, conservation and socioeconomic aspects (T4; T6 and T9), the second was related to food production and quality (T7 and T8) and the last one considered methodological studies on mountain flora and fauna (T1; T2; T3; T5 and T10). The 10 topics identified represent a useful and a starting source of information for further and more detailed analysis (e.g. systematic review) of specific research or geographical areas. A truly holistic and interdisciplinary research approach is needed to identify drivers of change and to understand current and future challenges faced by livestock farming in mountain areas.

Outcome of the glutaric aciduria type 1 (GA1) newborn screening program in Manitoba: 1980–2020

Glutaric aciduria type 1 (GA1) is a severe inherited neurometabolic disorder whose clinical outcome has improved after implementation of newborn screening (NBS) programs and prompt beginning of guideline-directed presymptomatic metabolic treatment. We report the outcome of our 40-year experience with the diagnosis and management of GA1 which has improved but remains suboptimal.

Prediction of indicators of cow diet composition and authentication of feeding specifications of Protected Designation of Origin cheese using mid-infrared spectroscopy on milk

The ability of mid-infrared spectroscopy (MIR) to predict indicators (1) of diet composition in dairy herds and (2) for the authentication of the cow feeding restrictions included in the specification of 2 Protected Designation of Origin (PDO) cheeses (Cantal and Laguiole) was tested on 7,607 bulk milk spectra from 1,355 farms located in the Massif Central area of France. For each milk sample, the corresponding cow diet composition data were obtained through on-farm surveys. The cow diet compositions varied largely (i.e., from full grazing for extensive farming systems to corn silage-based diets, which are typical of more intensive farming systems). Partial least square regression and discriminant analysis were used to predict the proportion of different feedstuffs in the cows' diets and to authenticate the cow feeding restrictions for the PDO cheese specifications, respectively. The groups for the discriminant analysis were created by dividing the data set according to the threshold of a specific feedstuff. They were issued based on the specifications of the restriction of the PDO cheese. The pasture proportion in the cows' diets was predicted by MIR with an coefficient of determination in external validation (R²V) = 0.81 and a standard error of prediction of 11.7% dry matter. Pasture + hay, corn silage, conserved herbage, fermented forage, and total herbage proportion in the cows' diets were predicted with a R²V >0.61 and a standard error of prediction <14.8. The discrimination models for pasture presence, pasture ≥50%, and pasture ≥57% in the cows' diets achieved an accuracy and specificity ≥90%. A sensitivity and precision ≥85% were also observed for the pasture proportion discrimination models, but both of these indexes decreased at increasing thresholds from 0 to 50, and 57% pasture in the cows' diets. An accuracy ≥80% was also observed for pasture + hay ≥72%, herbage ≥50%, pasture + hay ≥25%, absence of fermented herbage, absence of corn silage, and corn silage ≤30% in the cows' diets, but for several models, either the sensitivity or precision was lower than the accuracy. Models built on the simultaneous respect of all the criteria of the feeding restrictions of PDO cheese specifications achieved an accuracy, specificity, sensitivity, and precision >90%. Both the regression and discriminant MIR models for bulk milk can provide useful indicators of cow diet composition and PDO cheese specifications to producers and consumers (farmers, dairy plants).

Development of a microsphere-based immunoassay for the serological detection of glanders in equids

Burkholderia mallei is the etiologic agent of glanders, an infectious disease of solipeds, with renewed scientific interest due to its increasing incidence in different parts of the world. More rapid, sensitive and specific assays are required by laboratories for confirmatory testing of this disease. A microsphere-based immunoassay consisting of beads coated with B. mallei recombinant proteins (BimA, GroEL, Hcp1, and TssB) has been developed for the serological diagnosis of glanders. The proteins' performance was compared with the OIE reference complement fixation test (CFT) and an indirect enzyme-linked immunosorbent assay (iELISA) on a large panel of sera comprised of uninfected horses (n=198) and clinically confirmed cases of glanders from India and Pakistan (n=99). Using Receiver Operating Characteristics (ROC) analysis and adjusting the cutoff levels, Hcp1 (Se=100%, Sp=99.5%) and GroEL (Se= 97%, Sp=99.5%) antigens exhibited the best specificity and sensitivity. Neither Hcp1 and GroEL proteins, nor iELISA reacted with doubtful and positive CFT samples from glanders free countries which further confirmed the false positive reactions seen in CFT.

Aneuploïdie 47,XYY et schizophrénie avec troubles du comportement : report de cas et discussion de la littérature

Nous rapportons le cas d’un jeune patient âgé de 22 ans, adressé à notre consultation devant un tableau de schizophrénie atypique, pour recherche d’un diagnostic différentiel. L’histoire neurodéveloppementale révèle des troubles des apprentissages mis en évidence à l’entrée en primaire avec une dyslexie, une dyspraxie, des troubles attentionnels avec comportements oppositionnels. Après une classe de 6e difficile, le patient est orienté vers un apprentissage en alternance et obtient un CAP en mécanique automobile. La première décompensation psychotique a lieu à l’âge de 20 ans dans un contexte de surmenage. Le tableau clinique est dominé par une dissociation psychique avec hermétisme. Le patient est très agressif et mégalomaniaque. Il présente des crises clastiques difficilement contrôlables. Devant la coexistence de troubles importants du comportement, d’une grande taille (202 cm), de doigts courts et d’une dysmorphie faciale (rétraction de l’étage moyen du visage avec prognatisme), un caryotype est effectué avec mise en évidence d’une aneuploïdie de type 47,XYY. La revue de littérature portant sur les liens entre les troubles du comportement avec troubles neurocognitifs et l’aneuploïdie de type XYY sont bien documentés. Les liens avec la schizophrénie sont plus contradictoires. Le repérage des affections gonosomiques est important en population souffrant de troubles mentaux atypiques afin de mieux caractériser les troubles cognitifs qui y sont associés et qui pourraient avoir un rôle dans les manifestations comportementales. Chez ce patient, la remédiation cognitive a eu un impact très positif sur les manifestations comportementales. Une telle prise en charge serait donc à envisager chez les patients porteurs d’aneuploïdie avec troubles cognitifs caractérisés.

Review: Authentication of grass-fed meat and dairy products from cattle and sheep

Meat and dairy products derived from grassland carry premium values and sensory and nutritional qualities that aroused much interest for authentication methods to guarantee grassland origin claims. This article reviews the current state of knowledge on the authentication of meat and dairy of grassland origin from food analysis in both cattle and sheep. A range of methods alone or combined, involving analysis of elemental or molecular constituents of food product and fingerprinting profiling combined with chemometrics, have been developed and proved useful to differentiate contrasted feeding regimes and authenticate grass-fed meat and dairy. Their robustness and discriminatory reliability in more complex feeding conditions, such as in the case of dietary switches or when grass only makes up part of the animal's diet, are under active investigation. Our review highlights the possibilities and limitations of these methods, the latter being chiefly posed by variations in the quantity, characteristics and composition of grassland feedstuffs consumed by animals, which are nevertheless inherent to grassland-based production systems, variations in animal responses within and across breeds, and difficulties in detecting the consumption of non-grass feedstuffs by the animal. It also highlights a number of issues for consideration, points of caution and caveats in applying these methods. Scientists agree that much of the research carried out so far has been a 'proof of concept' type and that efforts should be made in the future to develop more databases to help gain genericity and robustness.

Consequences of walking or transport by truck on milk yield and quality, as well as blood metabolites, in Holstein, Montbéliarde, and Valdostana dairy cows

In the mountains, the traditional practice of transhumance is common in dairy production systems to make use of the high-altitude summer pastures. Although the effects of highland grazing have been intensively studied with respect to cow performance and milk and cheese quality, the actual moving of the animals to the highlands and the consequences of this stressor for performance and milk quality in the days immediately following transhumance has not been investigated in detail. The aim of the present study was to compare the effects of a 6-km walk (lasting 1.5 h) to those of a truck transport of 10.5 km (lasting 1 h), simulating cow movement in transhumance systems, as well as a control treatment in which cows were not moved. The experiment included 12 late-lactating Valdostana Red Pied, 12 Montbéliarde, and 12 Holstein cows (i.e., breeds contrasting in genetic merit for milk production). Each cow was subjected to each treatment in a 3-wk Latin square design. Milk yield was measured, and milk and blood samples were taken around the transhumance simulation events. Cows of the 3 breeds responded similarly to both movement treatments. Walking decreased milk yield by 1 kg/milking, but truck transport did not affect milk yield. Both treatments led to an increase in plasma nonesterified fatty acids and milk somatic cell count compared with controls, and truck transport increased milk fat content. Milk coagulation properties were better for Valdostana Red Pied and Montbéliarde cows than for Holstein cows but were not affected by walking or truck transport. Further studies aiming to compare the 3 breeds should include a wider range of response variables over a longer term, including reproduction performance and repeated transhumance.

Complementary and alternative medicine and musculoskeletal pain in the first year of adjuvant aromatase inhibitor treatment in early breast cancer patients

Background

Patients with breast cancer (BC) show strong interest in complementary and alternative medicine (CAM), particularly for adverse effects of adjuvant endocrine treatment — e.g., with letrozole. Letrozole often induces myalgia/limb pain and arthralgia, with potential noncompliance and treatment termination. This analysis investigated whether CAM before aromatase inhibitor (AI) therapy is associated with pain development and the intensity of AI-induced musculoskeletal syndrome (AIMSS) during the first year of treatment.

Patients and methods

The multicenter phase IV PreFace study evaluated letrozole therapy in postmenopausal, hormone receptor–positive patients with early BC. Patients were asked about CAM use before, 6 months after, and 12 months after treatment started. They recorded pain every month for 1 year in a diary including questions about pain and numeric pain rating scales. Data were analyzed for patients who provided pain information for all time points.

Results

Of 1396 patients included, 901 (64.5%) had used CAM before AI treatment. Throughout the observation period, patients with CAM before AI treatment had higher pain values, for both myalgia/limb pain and arthralgia, than non-users. Pain increased significantly in both groups over time, with the largest increase during the first 6 months. No significant difference of pain increase was noted regarding CAM use.

Conclusions

CAM use does not prevent or improve the development of AIMSS. Pain intensity was generally greater in the CAM group. Therefore, because of the risk of non-compliance and treatment discontinuation due to the development of higher pain levels, special attention must be paid to patient education and aftercare in these patients.

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Pain levels of myalgia/limb pain and arthralgia increase under letrozole intake.

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Within one year pain levels increase in both, CAM users as well as non-CAM users.

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In CAM users pain levels were higher at all time points than in non-CAM users.

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The greatest increase of pain levels was noted in the first six treatment months.

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CAM does not prevent or improve the development of myalgia/limb pain and arthralgia.

Grazing behaviour of dairy cows on biodiverse mountain pastures is more influenced by slope than cow breed

The aim of this study was to determine how cows with different genetic merit behave and perform when grazing biodiverse and heterogeneous mountain pastures with different slopes. Three groups of 12 cows in late lactation, each composed of four Holstein, four Montbéliarde and four Valdostana Red Pied cows, breeds of increasing presumed robustness and decreasing milk yield (MY) potential. Cows grazed without concentrate either on a low-diversity flat pasture or on two species-rich mountainous pastures having slopes of either 7° or 22°. Milk yield, BW and grazing behaviour were monitored two times in the first and once in the second grazing cycle. Cows of different breeds had similar behaviour on all pastures. The Montbéliarde cows performed close to their production potential; Holstein and Valdostana cows produced less milk than anticipated. No breed difference in terms of BW loss was found. The Valdostana cows exhibited the least selective behaviour with respect to plant species and plant growth stage. Still, all cows searched for the most palatable vegetation regardless of pasture diversity. On the steep pasture, cows optimised the trade-off between ingesting and saving energy to obtain feed. They remained longer at the lowest zone and selected forbs, whereas cows on the flatter pasture went to the upper zone to select grasses. The present study gave no evidence for a superior short-term adaptation to harsh grazing conditions through an optimised feeding behaviour of the Valdostana breed compared to Montbéliarde and Holstein cows.

Forage system is the key driver of mountain milk specificity

The aims of this work were to determine the effect of upland origin on milk composition when comparing similar lowland and upland production system and to highlight the factors responsible for the added value of upland milk from commercial farms. Tanker milk from 55 groups of farms (264 farms in total) in France, Slovakia, and Slovenia was collected twice during the indoor season and 3 times during the outdoor season. The tanker rounds were selected in each country to be balanced according to their origin (lowland or upland) and within upland or lowland groups, according to the forage systems: corn-based or grass-based forage system. At each milk sampling, the production conditions were recorded through on-farm surveys. The milk was analyzed for gross composition, carotenoids, minerals, fatty acids, phenolic compound derivatives, volatile organic compound concentrations, and color. The milk from upland and lowland areas differed in their contents of a few constituents. Upland milk was richer in not identified (n.i.) retention time (Rt) 13,59, 4-methylpentylbenzene, 1-methyl-2-n-hexylbenzene, and β-caryophyllene than lowland milk. These differences could be most likely attributable to the utilization of highly diversified and extensively managed semi-natural grasslands. The higher forbs content of upland pastures could be related as well to the richness in C18:3n-3, CLA cis-9,trans-11, MUFA, and PUFA we observed in upland compared with lowland milk during the outdoor season. In contrast, grazing on lowland pastures rich in grasses gave a yellower milk that was richer in β-carotene. Out of the few compounds showing a significant effect of origin or its interaction, most of the milk constituents were unaffected by the origin at all. However, almost all milk constituents differed according to the forage system and the season, and the differences observed between seasons can be attributed to differences in the cow diet composition.

Thrombectomy for acute ischemic stroke in nonagenarians compared with octogenarians

Introduction

Multiple randomized trials have shown that endovascular thrombectomy (EVT) leads to improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Elderly patients were poorly represented in these trials, and the efficacy of EVT in nonagenarian patients remains uncertain.

Methods

We performed a retrospective cohort study at a single center. Inclusion criteria were: age 80–99, LVO, core infarct <70 mL, and salvageable penumbra. Patients were stratified into octogenarian (80–89) and nonagenarian (90–99) cohorts. The primary outcome was the ordinal score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included dichotomized functional outcome (mRS ≤2 vs mRS ≥3), successful revascularization, symptomatic intracranial hemorrhage (ICH), and mortality.

Results

108 patients met the inclusion criteria, including 79 octogenarians (73%) and 29 nonagenarians (27%). Nonagenarians were more likely to be female (86% vs 58%; p<0.01); there were no other differences between groups in terms of demographics, medical comorbidities, or treatment characteristics. Successful revascularization (TICI 2b–3) was achieved in 79% in both cohorts. Median mRS at 90 days was 5 in octogenarians and 6 in nonagenarians (p=0.09). Functional independence (mRS ≤2) at 90 days was achieved in 12.5% and 19.7% of nonagenarians and octogenarians, respectively (p=0.54). Symptomatic ICH occurred in 21.4% and 6.4% (p=0.03), and 90-day mortality rate was 63% and 40.9% (p=0.07) in nonagenarians and octogenarians, respectively.

Conclusions

Nonagenarians may be at higher risk of symptomatic ICH than octogenarians, despite similar stroke- and treatment-related factors. While there was a trend towards higher mortality and worse functional outcomes in nonagenarians, the difference was not statistically significant in this relatively small retrospective study.

Interactions between oral commensal Candida and oral bacterial communities in immunocompromised and healthy children

Candida species are usually found as commensal microorganisms in the oral cavity of healthy people. During chemotherapy, cytostatic drugs lead to depletion of the oral flora with the emergence of a dominant bacterial species. The transition from commensal to pathogenic state, further associated with yeast colonization and oral mucositis implies a replacement of the dominant microorganism by Candida albicans. This process goes plausibly through cooperation between C. albicans and bacteria. This study focused on the first step of cooperation between microorganisms isolated from the same oral flora either of leukemic or healthy children. C. albicans isolated from 8/20 children were cultured to display their noninvasive blastosporic yeast form and mixed with their dominant bacteria to study the capacity of planktonic aggregation and the early state of biofilm formation. None of the dominant bacteria opposed the presence of yeast, on the contrary, an interesting cooperation was observed. This behavior is apparently different from that observed when mixing the type strains. In fact, three mutated C. albicans strains display, by their spontaneous ability to form filament, enhanced risks of virulence for leukemic ill carriers. Despite such risks, neither oral nor systemic pathology were observed in ill patients probably because the study was conducted during the first course of chemotherapy and Candida colonization is related to the number of chemotherapeutic cycles. The presence of C. albicans during the initial cycle represents, by its ability to interact with oral bacteria, an actual threat for further cures.

Semantic integration of clinical laboratory tests from electronic health records for deep phenotyping and biomarker discovery

Electronic Health Record (EHR) systems typically define laboratory test results using the Laboratory Observation Identifier Names and Codes (LOINC) and can transmit them using Fast Healthcare Interoperability Resource (FHIR) standards. LOINC has not yet been semantically integrated with computational resources for phenotype analysis. Here, we provide a method for mapping LOINC-encoded laboratory test results transmitted in FHIR standards to Human Phenotype Ontology (HPO) terms. We annotated the medical implications of 2923 commonly used laboratory tests with HPO terms. Using these annotations, our software assesses laboratory test results and converts each result into an HPO term. We validated our approach with EHR data from 15,681 patients with respiratory complaints and identified known biomarkers for asthma. Finally, we provide a freely available SMART on FHIR application that can be used within EHR systems. Our approach allows readily available laboratory tests in EHR to be reused for deep phenotyping and exploits the hierarchical structure of HPO to integrate distinct tests that have comparable medical interpretations for association studies.