Dental divisions: exploring racial inequities of dental caries amongst children

DATA SOURCES

The search strategy involved three sequential stages. Initially, MEDLINE/PubMed was explored for relevant articles, identifying pertinent terms for formal searching. Using the terms ethnic, race, minoritised and dental caries, a strategy was formed and nine databases searched. Finally, hand-searching of reference lists of included articles and sourcing grey literature from relevant government reports, national oral health surveys, and registries which had comparative data for dental caries between racial groups, completed the search.

STUDY SELECTION

Studies included were original primary research which reported dental caries and compared racially minoritised children, aged 5-11 years, to similarly aged from national, majority, or privileged populations. Dental caries had to be recorded from a clinical examination which assessed decayed, missing, and filled teeth (dmft) in primary dentitions. Studies were excluded if they used immigration status as a basis of racial status, or they were a case report, case series, in vitro study, or literature review.

DATA EXTRACTION AND SYNTHESIS

After removing duplicates, two independent researchers screened abstracts, prior to extracting critical data following full-text reviews of included articles. Information collected included study and participant characteristics, definitions of race, and dental caries measurement. The authors of studies which had missing data were contacted, whilst those not written in the English language were translated. Methodological quality of each study was independently assessed by two reviewers using a modified version of the Newcastle-Ottawa scale. All studies were included in the review regardless of quality. A narrative overview of all included studies was conducted. Meta-analyses were completed using studies that reported the mean and standard deviation of the caries outcomes in both groups. Caries outcomes included severity (defined as mean dmft) or prevalence (percentage of teeth with untreated dental caries > 0%). Due to anticipated heterogeneity, statistical analyses approaches such as I2 statistics were used to estimate between-study variability. Additional sub-group analyses were conducted based on country of study and world income index. Contour-enhanced funnel plots and trim-and-fill analysis were completed to explore potential publication bias. Sensitivity analyses were performed to ensure robustness of the findings.

RESULTS

Seventy-five studies were included from a variety of countries. A higher mean dmft score of 2.30 (0.45, 4.15) and prevalence of decayed teeth (d > 0) was 23% (95% CI: 16, 31) was noted amongst racially minoritised children compared to privileged children's populations. Notable disparities were reported in high-income countries, with minoritised children burdening the greatest distribution of caries incidence. The study faced challenges in consistent racial classification and encountered high heterogeneity in its findings, leading to varied GRADE assessment scores.

CONCLUSIONS

The study calls for global, social, and political changes to tackle the substantial disparities in dental caries among minoritised children to achieve oral health equity.

Understanding the experience of time for dementia education programme on undergraduate radiography students

INTRODUCTION

Dementia is a global health priority, which requires the healthcare workforce to have the necessary attitudes and skills to deliver person-centred care to people with dementia. Radiographers have frequent contact with people with dementia, and undergraduate training is potentially an optimal time to deliver dementia education. Time for Dementia is an education programme in which undergraduate healthcare students visit a person with dementia and their carer over a two-year period to gain an in-depth understanding of the condition. The aim of this study was to understand undergraduate radiography students' experiences of undertaking the Time for Dementia (TFD) programme.

METHODS

Two focus groups were undertaken with 14 radiography students who were half-way through the TFD programme. Data was analysed using thematic analysis.

RESULTS

Three key themes were constructed from the analysis: A Holistic Learning Experience, Transferring Learning into Practice and Preparedness & Expectations. Participants discussed the value from learning directly from people with dementia and their carers, reporting an increase in their awareness and understanding of dementia as well as the impact of caring for somebody with the condition. Participants were able to identify learning to take into practice such as person-centred care, compassion, and patience. Challenges to learning were also identified.

CONCLUSIONS

This study suggests that a longitudinal, experiential education programme provides radiography students with the opportunity to develop a more holistic understanding of dementia and the impact it may have on the individual and their family members.

IMPLICATIONS FOR PRACTICE

Experiential dementia teaching is of value to radiography students, however preparation and learning support should fit with previous personal and teaching experience.

County-Level Socioeconomic Status Adjustment of Acute Myocardial Infarction Mortality Hospital Performance Measure in the U.S

The U.S. Centers for Medicare and Medicaid Services’ (CMS’s) Hospital Compare (HC) data provides a collection of risk-adjusted hospital performance metrics intended to allow comparison of hospital-provided care. However, CMS does not adjust for socioeconomic status (SES) factors, which have been found to be associated with disparate health outcomes. Associations between county-level SES factors and CMS’s risk-adjusted 30-day acute myocardial infarction (AMI) mortality rates are explored for n = 2462 hospitals using a variety of sources for county-level SES information. Upon performing multiple imputation, a stepwise backward elimination model selection approach using Akaike’s information criteria was used to identify the optimal model. The resulting model, comprised of 14 predictors mostly at the county level, provides an additional 8% explanatory power to capture the variability in 30-day risk-standardized AMI mortality rates, which already account for patient-level clinical differences. SES factors may be an important feature for inclusion in future risk-adjustment models, which will have system and policy implications for distributing resources to hospitals, such as reimbursements. It also serves as a stepping stone to identify and address long-standing SES-related inequities.

IMAGING OF LYMPHATIC DYSPLASIA IN NOONAN SYNDROME: CASE STUDIES AND HISTORICAL ATLAS

To determine the historical use and utility of various lymphatic imaging modalities in Noonan syndrome (NS) patients, we performed a comprehensive literature review by collecting the published medical imaging of NS lymphatic dysplasias. We correlated imaging findings with clinical phenotypes and treatment. Our analysis of lymphatic imaging modalities provides an algorithmic approach to imaging and patient care across the spectrum of NS developmental defects. A total of 54 NS cases have been published since 1975. Using the observations reported in 15 reviewed publications, an association was made between disruptions in central lymphatic flow and poor clinical presentations/outcomes in NS patients.

What Oncologists Want: Identifying Challenges and Preferences on Diagnosis Data Entry to Reduce EHR-Induced Burden and Improve Clinical Data Quality

PURPOSE

Accurate recording of diagnosis (DX) data in electronic health records (EHRs) is important for clinical practice and learning health care. Previous studies show statistically stable patterns of data entry in EHRs that contribute to inaccurate DX, likely because of a lack of data entry support. We conducted qualitative research to characterize the preferences of oncological care providers on cancer DX data entry in EHRs during clinical practice.

METHODS

We conducted semistructured interviews and focus groups to uncover common themes on DX data entry preferences and barriers to accurate DX recording. Then, we developed a survey questionnaire sent to a cohort of oncologists to verify the generalizability of our initial findings. We constrained our participants to a single specialty and institution to ensure similar clinical backgrounds and clinical experience with a single EHR system.

RESULTS

A total of 12 neuro-oncologists and thoracic oncologists were involved in the interviews and focus groups. The survey developed from these two initial thrusts was distributed to 19 participants yielding a 94.7% survey response rate. Clinicians reported similar user interface experiences, barriers, and dissatisfaction with current DX entry systems including repetitive entry operations, difficulty in finding specific DX options, time-consuming interactions, and the need for workarounds to maintain efficiency. The survey revealed inefficient DX search interfaces and challenging entry processes as core barriers.

CONCLUSION

Oncologists seem to be divided between specific DX data entry and time efficiency because of current interfaces and feel hindered by the burdensome and repetitive nature of EHR data entry. Oncologists' top concern for adopting data entry support interventions is ensuring that it provides significant time-saving benefits and increasing workflow efficiency. Future interventions should account for time efficiency, beyond ensuring data entry effectiveness.

Imaging of lymphatic dysplasia in Noonan syndrome: Case studies and historical atlas

To determine the historical use and utility of various lymphatic imaging modalities in Noonan syndrome (NS) patients, we performed a comprehensive literature review by collecting the published medical imaging of NS lymphatic dysplasias. We correlated imaging findings with clinical phenotypes and treatment. Our analysis of lymphatic imaging modalities provides an algorithmic approach to imaging and patient care across the spectrum of NS developmental defects. A total of 54 NS cases have been published since 1975. Using the observations reported in 15 reviewed publications, an association was made between disruptions in central lymphatic flow and poor clinical presentations/outcomes in NS patients.

A parametric study of an acoustic black hole on a beam

Acoustic black holes (ABHs) are geometric structural features that provide a potential lightweight damping solution for flexural vibrations. In this article, a parametric study of an ABH on a beam has been carried out to assess how practical design constraints affect its behaviour, thus providing detailed insight into design trade-offs. The reflection coefficient of the ABH has been calculated for each taper profile, parameterised via the tip-height, taper-length, and power-law, and it has been shown to exhibit spectral bands of low reflection. These bands have been related to the modes of the ABH cell and become more closely spaced in frequency as the ABH parameters are suitably varied. This suggests that ABH design should maximise the modal density to minimise the broadband reflection coefficient; however, the minimum level of reflection is also dependent on the power-law and tip-height. Consequently, broadband reflection values have been used to show that optimum power-law and tip-height settings exist that achieve a balance between maximum modal density and minimum level of reflection. Additionally, at discrete frequencies, in cases where tip-height and taper-length are practically constrained, the power law can be tuned to maximise performance. Finally, an experimental study is used to validate the results.

Abstract A06: All Nations Breath of Life: A culturally tailored smoking cessation program for heterogeneous urban American Indian communities

Prevalence of cigarette smoking is highest among American Indians, yet few culturally appropriate smoking cessation programs have yet been developed and tested for multi-tribal American Indian adult populations. This study tested for effectiveness the All Nations Breath of Life culturally tailored smoking cessation program in multi-tribal urban and suburban American Indian communities in 7 locations across 5 states (N=312).

This single-arm implementation effectiveness study used community-based participatory research to conduct a 12-week intervention. Participants were followed through month 6 in person and month 12 via telephone. The primary outcome was continuous abstinence from recreational cigarette smoking at 6 months post-baseline, verified through voluntary provision of salivary cotinine levels.

At program completion, 53.3% of program completers remained abstinent; using an intent-to-treat analysis labeling those lost to follow-up as smokers resulted in a 41.4% quit rate. At 6 months post-baseline, 31.1% of retained participants quit smoking (p<0.0001 compared to the highest quit rates among multi-tribal populations reported in the literature, 7%); final quit rate was 22.1% using an intent-to-treat analysis (p=0.002). Retention rate at endpoint was 71.2%. 12-month follow-up was attempted with all participants and had a retention rate of 49.0%. Of those participants reached, 34.0% were smoke-free; using an intent-to-treat analysis, the quit rate at 12 months post-baseline was 16.7%.

All Nations Breath of Life is an effective smoking cessation program for multi-tribal urban American Indian communities. It can be successfully implemented in a variety of urban settings.

Citation Format: Jordyn Gunville, Ryan Goeckenr, Jason Hale, T Edward Smith, Niaman Nazir, Sean Daley, Won Choi, Christine M. Daley. All Nations Breath of Life: A culturally tailored smoking cessation program for heterogeneous urban American Indian communities. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A06.

Hierarchy of alpha fetoprotein (AFP)-specific T cell responses in subjects with AFP-positive hepatocellular cancer

We identified a series of immunodominant and subdominant epitopes from alpha fetoprotein (AFP), restricted by HLA-A*0201, which are recognized by the human T cell repertoire. The four immunodominant epitopes have been tested for immunogenicity in vivo, in HLA-A*0201+AFP+ advanced stage hepatocellular cancer (HCC) patients, and have activated and expanded AFP-specific IFN-gamma-producing T cells in these patients, despite high serum levels of this self Ag. Here, we have examined the frequency, function, and avidity of the T cells specific for subdominant epitopes from AFP. We find that T cells specific for several of these epitopes are of similar or higher avidity than those specific for immunodominant epitopes. We then tested the peripheral blood of subjects ex vivo with different levels of serum AFP for the hierarchy of response to epitopes from this Ag and find that HCC patients have detectable frequencies of circulating IFN-gamma-producing AFP-specific CD8+ T cells to both immunodominant and subdominant epitopes. We find the immunodominant and subdominant peptide-specific T cells to be differentially expanded with different modes of Ag presentation. Whereas spontaneous and AFP protein-stimulated responses show evidence for immunodominance, AdVhAFP-transduced dendritic cell-stimulated responses were broader and not skewed. Importantly, these data identify subdominant epitopes from AFP that can activate high-avidity T cells, and that can be detected and expanded in HCC subjects. These subdominant epitope-specific T cells can also recognize tumor cells and may be important therapeutically.

MRI-guided, open trial of abciximab for ischemic stroke within a 3- to 24-hour window

The authors assessed the effect of IV abciximab on early neurologic improvement and ischemic lesion growth in 29 patients with supratentorial stroke and NIH stroke scale score (NIHSSS) > or = 4 (11.1 +/- 5.9), treated within 3 to 24 (13.6 +/- 5.5) hours of onset. The 48 to 72-hour NIHSSS improvement was 4.4 +/- 3.2 and the 24-hour lesion growth on DWI was +23% (-50%, +103%); 7/26 (27%) patients experienced lesion size decrease. Treatment of sub-24-hour stroke with abciximab improves early post-treatment neurologic status and often attenuates ischemic lesion growth.

Initial clinical experience with IV tissue plasminogen activator for acute ischemic stroke: a multicenter survey. The t-PA Stroke Survey Group

We assessed initial clinical experience with IV tissue plasminogen activator (t-PA) treatment of acute ischemic stroke in a standardized retrospective survey of hospitals with experienced acute stroke treatment systems. The incidence of symptomatic intracerebral hemorrhage (ICH) was 6% (11 of 189 patients; 95% CI 3 to 11%), similar to that in the National Institute of Neurological Disorders and Stroke (NINDS) t-PA Stroke Study. Deviations from the NINDS protocol guidelines were identified in 30% of patients (56 of 189). The incidence of symptomatic ICH was 11% among patients with protocol deviations as compared with 4% in patients who were treated according to the NINDS protocol guidelines, suggesting that strict adherence to protocol guidelines is prudent.

Increased salivary cortisol reliably induced by a protein-rich midday meal

OBJECTIVE

This study was conducted to determine whether an increase in salivary free cortisol would be reliably elicited by a midday meal, thus providing a convenient physiological challenge to the hypothalamic-pituitary-adrenal (HPA) axis, and whether this cortisol release depended on the protein content of the meal.

METHOD

In healthy men, free cortisol was measured in saliva samples taken before and after two identical protein-rich midday meals (39% energy as protein) and compared with a day on which no meal was eaten. Next, in healthy women in a nonclinical setting, salivary cortisol was measured before and after a protein-rich meal (32% energy as protein) on one day and a low-protein meal (5% energy as protein) on another day. Measures of mood, appetite, and psychological well-being were also taken.

RESULTS

An acute meal-dependent increase in salivary cortisol occurred, which was reliable over 2 test days. This increase in cortisol depended on the proportion of protein in the meal, increasing after the high-protein but not the low-protein meal. The extent of this increase in cortisol correlated significantly with poor psychological well-being in women. Some postmeal improvement of mood (positive affect) was associated with the high- but not the low-protein meal.

CONCLUSIONS

The cortisol response to meals may have implications for the effects of meal composition on mood, cognitive function, and food choice. The measurement of free cortisol in saliva provides a psychologically stress-free and reliable technique to assess the cortisol response to a standard protein-rich meal, ie, a physiological challenge to the HPA axis in men and women that could be investigated in naturalistic settings outside the laboratory.

Changes in protein turnover, IGF-I and IGF binding proteins in children with cancer

Changes in insulin-like growth factor-I (IGF-I) and insulin-like growth factor binding proteins (IGFBPs) were correlated with protein synthesis and breakdown using [1-13C]leucine before chemotherapy and during subsequent febrile neutropenia (FN) in eight children with cancer, aged 6.3-17.5 y. IGF-I levels were similar to age-matched controls before chemotherapy (mean +/- SEM: 250+/-28 and 228+/-22 microg l(-1), respectively). During FN, IGF-I fell to 156+/-22 microg l(-1) (p = 0.02), and rose to 276+/-27 microg l(-1) with recovery at 6 months (p = 0.004). Similarly, IGFBP-3 decreased from 4.0+/-0.2 mg l(-1) before chemotherapy to 3.0+/-0.3 mg l(-1) during FN (p = 0.01), and returned to 4.1+/-0.2 mg l(-1) at 6 months (p = 0.01). IGF-I correlated with IGFBP-3 (r = +0.7, p < 0.001). Scanning densitometry showed a decrease in IGFBP-3 from 94 to 54% during FN, when the presence of IGFBP-3 protease activity was observed. Compared with normal human serum, IGFBP-2 was elevated throughout the study. IGFBP-1 increased from 14.6+/-3.5 to 30.6+/-2.8 microg l(-1) (p = 0.004), whereas serum insulin decreased from 26.5+/-6.8 to 7.8+/-0.8 mU l(-1) (p = 0.03) before and during FN, respectively. Whilst IGF-I and IGFBP-3 fell, daytime growth hormone increased from 3.3+/-0.6 to 6.7+/-0.8 mU l(-1) (p=0.01), and cortisol from 197+/-48 to 594+/-98 nmol l(-1) (p = 0.005). Albumin decreased from 47+/-2 to 38+/-2 g l(-1) (p = 0.004) and improved to 47+/-2 g l(-1) with recovery (p = 0.003). Protein synthesis increased from 4.5+/-0.4 to 5.0+/-0.6 g kg(-1)d(-1) before chemotherapy and during FN, while protein breakdown rose from 5.4+/-0.4 to 6.3+/-0.4 kg(-1)d(-1). Increasing protein breakdown was related to falling IGF-I and IGFBP-3 levels. Modification of IGFBP-3 by circulating proteolytic activity may alter IGF bioavailability, allowing protein synthesis to increase during periods of severe catabolic stress.

Education to improve stroke awareness and emergent response. The NINDS rt-PA Stroke Study Group

Patients delay in responding to stroke as an emergency in part because they have deficient information about the disease and treatment. Healthcare providers may also have a lack of information about stroke assessment and management, which could attribute to delays in patient care. In order to provide early, rapid stroke treatment in eligible persons, the public and the healthcare community must be informed. Information on stroke risk, symptoms and treatment should be provided to those likely to experience stroke, the general public and the emergency and medical communities who may witness and intervene when stroke occurs. Programs developed at the eight centers of the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA stroke trial provide a sampling of approaches that increase awareness in these groups. Lessons learned include: 1. Program planning should start with a community needs assessment. 2. A variety of strategies can be applied to meet the community needs and resources. 3. Educational principles and models should be utilized in planning effective programs. 4. The message must be simple: "Stroke is an emergency. Time is brain".

Nursing care of acute stroke patients after receiving rt-PA therapy. The NINDS rt-PA Stroke Study Group

Treatment with tissue plasminogen activator (rt-PA) for acute stroke requires intensive care of the patient. The risk of thrombolytic therapy and the need for rapid interventions make it clear that the nursing role during this time is crucial. Nurses should be familiar with safe dosage and administration of rt-PA for stroke, which is clearly different than administration of rt-PA for myocardial infarction. Furthermore, thrombolytic stroke treatment must be accompanied by intensive neurological monitoring to observe for complications. Intracerebral hemorrhage is usually accompanied by an acute change in neurological status and vital sign instability. Intensive monitoring of neurologic condition, vital signs, cardiac status and other standard critical care practices must be initiated immediately to optimize patient outcome.

Code Stroke: rapid transport, triage and treatment using rt-PA therapy. The NINDS rt-PA Stroke Study Group

With the approval of rt-PA therapy for ischemic stroke, stroke care has acutely transitioned from focusing on rehabilitative services to emergency services. This treatment, which must be initiated within the first three hours after the onset of stroke symptoms, requires reorganization of current management approaches. Developing a Code Stroke Team facilitates this process and helps to identify potential thrombolysis candidates. A pathway to deliver rapid care begins with 911 notification and transport, emergency department triage and procedures, and moves through the initiation of thrombolytic therapy. We call this pathway "Code Stroke".

Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group

The stroke patient is acutely ill within minutes of symptom onset. Typically, he or she is awake and thus requires a focal neurologic exam to evaluate vision, movement, sensation and language. With the advent of acute stroke treatments that need to be rapidly implemented, it is critical that the nurse be able to assess patients and relay the information accurately and efficiently to other members of the health care team. Performing and documenting the awake stroke exam in the most efficient and useful manner is key to the nursing care of the stroke patient. The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool designed to measure the neurologic deficits most often seen with acute stroke patients. Originally designed as a research tool, it is a nonlinear ordinal scale, with possible scores ranging form 0-42. Exam performance has been timed to take 5-8 minutes. Use of the NIHSS includes documentation of neurologic status and outcome, data collection for planning safe nursing care and standardization of information exchanges between nurse caregivers and other health care professionals.

Overview: hyperacute rt-PA stroke treatment. The NINDS rt-PA Stroke Study Group

Ischemic stroke remains a significant problem in the United States. Complex intracellular metabolic events occur leading to cell death. A search for treatments to prevent this ischemic process continues. Thrombolytic agents, recently developed and tested, may lessen the disabling effects of stroke.

Nursing management of acute complications following rt-PA in acute ischemic stroke. The NINDS rt-PA Stroke Study Group

In the National Institutes of Neurologic Disorders and Stroke (NINDS) recombinant tissue plasminogen activator (rt-PA) stroke trial, the primary adverse events monitored were intracranial hemorrhage (ICH), systemic bleeding, death and new stroke. Nurses caring for the study patients noted these adverse events and other complications. In addition to what is known about acute ischemic stroke (AIS), the NINDS trial provides further information for optimal care of this specific group of patients. The complications found in this trial require expert nursing care to monitor, prevent and intervene, making clinical decisions relevant to the patients needs. The critical decision-making process must be grounded in knowledge of acute stroke physiology and thrombolysis.

Pathophysiology and mechanisms of acute ischemic stroke. The NINDS rt-PA Stroke Study Group

Stroke is a leading cause of death and disability among Americans. The recent US Food and Drug Administration approval of recombinant tissue plasminogen activator (rt-PA, Activase) for the treatment of acute ischemic stroke offers the first proven therapy to reverse or ameliorate stroke symptoms. rt-PA is thought to restore circulation in the patient with acute ischemic stroke by dissolving an occluding thrombus or embolus. A basic understanding of cerebral circulation and the mechanism by which stroke compromises brain tissue is fundamental to appreciating this new therapy. The importance of prompt stroke diagnosis and treatment cannot be underestimated.

Cocaine blunts human CD4+ cell activation

Cocaine is reported to be immunotoxic. The biochemical mechanisms responsible for the immunopharmacological outcomes of cocaine in vivo and in vitro remain, however, to be fully elucidated. Our experimental data confirm that exposure of normal human T cells to micromolar concentrations of cocaine modulates T-cell responses to stimulation by a variety of stimuli, and indicate that cocaine impairs early activation events during CD4+ but not CD4- T-cell stimulation. Pre-incubation of enriched CD4+ T-cell subpopulations that express the homing receptor CD62L with nanomolar concentrations of the endogenous opioid peptide beta-endorphin leads to a more severe impairment of activation than that noted following pre-incubation with micromolar concentrations of cocaine alone. These findings begin to elucidate the molecular and cellular mechanisms of the immunopathology of cocaine. Our data support the proposition that cocaine abuse may place cocaine-abuser HIV-seropositive individuals at increased risk of opportunistic infections.

The distribution of fibro-fatty atherosclerotic lesions in the aortae of casein- and cholesterol-fed rabbits

Atherosclerotic lesions were induced in the aortas of 50 rabbits by feeding a semi-purified cholesterol-free casein diet or normal rabbit chow with a low level of added cholesterol for 6 or 10 months. Following perfusion fixation, the aortae from these animals were opened along their length, stained with oil red O and photographed en face. Orifice associated lesions were mapped by measuring radial lesion length at 10 degrees intervals circumferentially around ostia. Histology of these lesions revealed abundant smooth muscle cells surrounded by collagen and elastin in the extracellular matrix, typical of fibrous plaques, as well as oil red O staining lipid and some macrophage derived foam cells. These fibro-fatty lesions were found distal and lateral to ostia, at the same locations as fatty streaks seen in rabbits fed a 2% cholesterol diet for 1 week to 2 months in previous studies. The results of this study show that in moderately hypercholesterolemic rabbits fed an atherogenic diet for 6 to 10 months, advanced atherosclerotic plaques develop in the same location as the fatty streaks seen in short term experiments.

Plague in San Diego

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Specialty conference. Staphylococcal pneumonia

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