"Feed a Cold, Starve a Fever?" A Review of Nutritional Strategies in the Setting of Bacterial Versus Viral Infections

PURPOSE OF REVIEW

Some data, mostly originally derived from animal studies, suggest that low glucose intake is protective in bacterial sepsis but detrimental in overwhelming viral infections. This has been interpreted into a broad belief that different forms of sepsis may potentially require different nutritional management strategies. There are a few mechanistic differences between the host interactions with virus and bacteria which can explain why there may be opposing responses to macronutrient and micronutrient during the infected state. Here, we aim to review relevant evidence on the mechanisms and pathophysiology of nutritional management strategies in various infectious syndromes and summarize their clinical implications.

RECENT FINDINGS

Newer literature - in the context of the SARS-CoV-19 pandemic - offers some insight to viral infections. There is still limited clinically applicable data during infection that clearly delineate the role of nutrition during an active viral vs bacterial infections. Based on contrasting findings in different models of viruses and bacteria, the macronutrient and micronutrient needs may depend more on specific infectious organisms that may not be generalizable as bacterial versus viral. Overall, the metabolic effects of sepsis are context dependent, and various host-specific (e.g., age, baseline nutritional status, immune status, comorbidities) and illness variables (phase, duration, and severity of illness) play a significant role in determining the outcome besides pathogen-specific (virus or bacterial or fungi and combined infections) factors. Microbe therapy (probiotics and prebiotics) seems to have therapeutic potential in both viral and bacterial infected states, and this seems like a promising area for further practical research.

Impact of elexacaftor/tezacaftor/ivacaftor on lipid and fat-soluble vitamin levels and association with body mass index

INTRODUCTION

Cystic fibrosis transmembrane conductance regulator (CFTR) modulators improve gastrointestinal absorption of nutrients and may result in changes in body mass index (BMI), serum lipids, and fat-soluble vitamin levels. We hypothesized that serum lipids and vitamin levels would increase with CFTR modulator therapy and that greater increase in lipids and vitamin levels would be related to greater increase in BMI.

METHODS

A retrospective study was performed to evaluate the impact of elexacaftor/tezacaftor/ivacaftor (ETI) on nutritional parameters, serum lipids, and fat-soluble vitamin levels. Pre-ETI values (<2 years prior) and post-ETI values (>1 month after) were compared. Linear regression was used to evaluate whether change in BMI is associated with the change in lipid and/or vitamin levels and whether modulator duration is associated with the degree of rise in lipid and/or vitamin levels.

RESULTS

Adults and adolescents with CF (n = 137) were evaluated before and 31-300 days after starting ETI. Median BMI (adults 21.9 vs. 23.5 kg/m2 ; adolescents 48 vs. 63 percentile) increased after initiation of ETI. Total cholesterol (126 vs. 154 mg/dL), low-density lipoprotein cholesterol (63 vs. 78 mg/dL), non-high-density lipoprotein cholesterol (84 vs. 102 mg/dL), and high density lipoprotein cholesterol (43 vs. 49 mg/dL) increased after ETI, while triglycerides and very low density lipoprotein did not change. Median values for vitamin D (34.5 vs. 38.0 ng/mL) and vitamin A (40.1 vs. 47.9 µg/dL) increased, while vitamin E did not change significantly. There was no significant correlation between BMI change or duration of modulator therapy with vitamin levels or lipid changes.

CONCLUSION

After initiation of ETI therapy, serum lipids increased in our population, but most values remained within the normal range. Vitamins A and D levels increased post-ETI and no changes were noted in vitamin E. No significant correlation between the degree of BMI change and the magnitude of increase in lipids or vitamin levels was found.

Cannabis use and cyclic vomiting syndrome

None.

Impact of Erythromycin as a Prokinetic on the Gut Microbiome in Children with Feeding Intolerance-A Pilot Study

BACKGROUND

Studies have demonstrated that the gut microbiome changes upon exposure to systemic antibiotics. There is a paucity of literature regarding impact on the gut microbiome by long-term usage of erythromycin ethyl succinate (EES) when utilized as a prokinetic.

METHODS

Stool samples from pediatric patients with feeding intolerance who received EES (N = 8) as a prokinetic were analyzed for both bacteriome and mycobiome. Age-matched children with similar clinical characteristics but without EES therapy were included as controls (N = 20).

RESULTS

In both groups, Proteobacteria, Firmicutes, and Bacteroidetes were the most abundant bacterial phyla. Ascomycota was the most abundant fungal phyla, followed by Basidiomycota. There were no significant differences in richness between the groups for both bacterial and fungal microbiome. Alpha diversity (at genus and species levels) and beta diversity (at the genus level) were not significantly different between the groups for both bacterial and fungal microbiome. At the species level, there was a significant difference between the groups for fungal microbiota, with a p-value of 0.029. We also noted that many fungal microorganisms had significantly higher p-values in the EES group than controls at both genera and species levels.

CONCLUSIONS

In this observational case-control study, the prokinetic use of EES was associated with changes in beta diversity between the groups for mycobiome at the species level. Many fungal microorganisms were significantly higher in the EES group when compared to the controls. Confirmation of these results in larger trials will provide further evidence regarding the impact of EES on gut microbiota when utilized as a prokinetic agent.

Exocrine Pancreatic Insufficiency in Children - Challenges in Management

Cystic fibrosis (CF) is the leading etiology for exocrine pancreatic insufficiency (EPI) in children, followed by chronic pancreatitis, Shwachman-Diamond syndrome, and other genetic disorders. Management of EPI in children poses several unique challenges such as difficulties in early recognition, lack of widespread availability of diagnostic tests and limited number of pediatric-specific pancreatic centers. Pancreatic enzyme replacement therapy is the cornerstone of EPI management and in young children difficulties in administering pancreatic enzymes are frequently encountered. Patients with EPI also should be screened for fat-soluble vitamin deficiencies and receive appropriate supplementation. Among disorders with EPI in children, CF is the relatively well-studied condition, and most management recommendations for EPI in children come from expert consensus and conventional practice guidelines. The impact of EPI can be greater in children given their high metabolic demands and rapid growth. Early diagnosis and aggressive management of EPI prevent consequences of complications such as malnutrition, fat-soluble vitamin deficiencies, and poor bone health and improve outcomes. Management by multi-disciplinary team is the key to success.

Nutritional considerations for a new era: A CF foundation position paper

OBJECTIVE

To provide interim advice and considerations to the CF Community around CF nutrition in the current era.

METHODS

The Cystic Fibrosis (CF) Foundation organized a multidisciplinary committee to develop a Nutrition Position Paper based on the rapidly changing nutrition landscape in CF, due in part to widespread use of cystic fibrosis transmembrane regulator highly effective modulator therapy (HEMT). Four workgroups were formed: Weight Management, Eating Behavior/Food Insecurity, Salt Homeostasis and Pancreatic Enzyme use. Each workgroup conducted their own focused review of the literature.

RESULTS

The committee summarized current understanding of issues pertaining to the four workgroup topics and provided 6 key take-aways around CF Nutrition in the new era.

CONCLUSION

People with CF (pwCF) are living longer, particularly with the advent of HEMT. The traditional high fat, high calorie CF diet may have negative nutritional and cardiovascular consequences as pwCF age. Individuals with CF may have poor diet quality, food insecurity, distorted body image, and an higher incidence of eating disorders. An increase in overweight and obesity may lead to new considerations for nutritional management, given potential effects of overnutrition on pulmonary and cardiometabolic parameters.

Prevalence and impact of psychiatric disorders on hospitalized pediatric patients with chronic pancreatitis

BACKGROUND

Patients with chronic pancreatitis (CP) often have a debilitating clinical course characterized by high disease burden, and poor quality of life and these factors adversely affect mental health. However, there is paucity of literature on the prevalence and impact of psychiatric disorders on hospitalized pediatric patients with CP.

METHOD

ology: We analyzed the Kids Inpatient Database, and National Inpatient Sample, between 2003 and 2019 and included patients up to 21 years of age. Pediatric CP patients with psychiatric disorders were compared with patients without any of the psychiatric disorders using the ICD diagnostic codes. Various demographic and clinical factors were compared between the groups. Length of hospitalization and total hospital charges were used as surrogates to compare the hospital resource utilization between the groups.

RESULTS

We analyzed a total of 9,808 hospitalizations with CP and the overall prevalence rate of psychiatric disorders was 19.8%. The prevalence rate increased from 19.1% in 2003 to 23.4% in 2019, p = 0.006. The peak prevalence rate of 37.2% was noted at 20 years of age. Depression was noted at 7.6% of the total hospitalizations followed by substance abuse (6.5%), and anxiety (4.4%). Multivariate linear regression analysis showed that among CP patients, psychiatric disorders were independently associated with 1.3 additional days of stay and incurred $15,965 higher charges.

CONCLUSIONS

The prevalence of psychiatric disorders is increasing in pediatric CP. The concomitant presence of psychiatric disorders was found to be associated with prolonged hospital stay and incurred higher healthcare charges than those CP patients without psychiatric disorders.

Association of Anxiety and Gastrointestinal Comorbidities in Repeat Hospital Admissions in Pediatric Cyclic Vomiting Syndrome

INTRODUCTION

Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder with recurrent episodes of intense nausea and vomiting and thus may require frequent hospitalizations. There is paucity of data exploring the association of psychiatric and gastrointestinal comorbidities in repeat hospitalizations among pediatric patients with CVS.

METHODS

We analyzed the Pediatric Health Information System database and included all patients up to 18 years of age with a diagnosis of CVS between 2016 and 2020. We excluded patients with chronic conditions, which mimic CVS. The primary outcome variable was 90-day admission rate, which was defined as a visit to emergency department or admission to observation/inpatient unit with a primary diagnosis of CVS within 90 days after an index CVS hospitalization.

RESULTS

We evaluated a total of 2,604 hospitalizations represented by 1,370 unique individuals. The overall 90-day admission rate was 28.5%, which steadily decreased from 35.7% in 2016 to 23% in 2019 ( P < 0.001). Patients in the repeat hospitalization cohort were slightly older and more often men. Patients with repeat admissions had an increased proportion of anxiety and other gastrointestinal disorders. Multivariable logistic regression showed that anxiety, gastroesophageal reflux disease, functional dyspepsia, and abdominal migraine were associated with increased odds of repeat admissions.

DISCUSSION

Ninety-day admission rates in pediatric CVS are decreasing overall, although still contributing to significant healthcare expenditure. Anxiety and gastrointestinal comorbidities were associated with increased risk of repeat admissions. Further prospective studies are needed to better understand the complex interactions of these comorbidities and their management affecting the natural course of CVS.

Cytomegalovirus Infection Is Associated With Adverse Outcomes Among Hospitalized Pediatric Patients With Inflammatory Bowel Disease

Background

Adults with inflammatory bowel disease (IBD) are at increased risk of developing cytomegalovirus (CMV) colitis, which is associated with adverse outcomes. Similar studies in pediatric IBD patients are lacking.

Methods

We analyzed non-overlapping years of National Inpatient Sample (NIS) and Kids Inpatient Database (KID) between 2003 and 2016. We included all patients < 21 years with a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC). Patients with coexisting CMV infection during that admission were compared with patients without CMV infection for outcome measures such as in-hospital mortality, disease severity, and healthcare resource utilization.

Results

We analyzed a total of 254,839 IBD-related hospitalizations. The overall prevalence rate of CMV infection was 0.3% with an overall increasing prevalence trend, P < 0.001. Approximately two-thirds of patients with CMV infection had UC, which was associated with almost 3.6 times increased risk of CMV infection (confidence interval (CI): 3.11 to 4.31, P < 0.001). IBD patients with CMV had more comorbid conditions. CMV infection was significantly associated with increased odds of in-hospital mortality (odds ratio (OR): 3.58; CI: 1.85 to 6.93, P < 0.001) and severe IBD (OR: 3.31; CI: 2.54 to 4.32, P < 0.001). CMV-related IBD hospitalizations had increased length of stay by 9 days while incurring almost $65,000 higher hospitalization charges, P < 0.001.

Conclusions

The prevalence of CMV infection is increasing in pediatric IBD patients. CMV infections significantly corelated with increased risk of mortality and severity of IBD leading to prolonged hospital stay and higher hospitalization charges. Further prospective studies are needed to better understand the factors leading to this increasing CMV infection.

Increasing incidence of acute kidney injury in pediatric severe sepsis and related adverse hospital outcomes

BACKGROUND

Pediatric severe sepsis (PSS) is associated with increased mortality, and acute kidney injury (AKI) is an independent risk factor of mortality in PSS. However, there is little data on impact of AKI on hospital outcomes in PSS.

METHODS

We analyzed non-overlapping years of the Kids' Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2019 of all pediatric patients with severe sepsis between 1 and 18 years of age. Using ICD diagnosis codes, patients were divided into two groups based on AKI status and compared for outcomes measures including in-hospital mortality and healthcare resource utilization using length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analyzed 192,712 hospitalizations due to PSS during the 17-year period. Prevalence of AKI was 23.6% with overall increasing trend, P<0.001. Prevalence of AKI was significantly increased in patients with diabetes mellitus, organ transplantation, HIV, urinary tract anomalies, and malnutrition, P<0.001. Mortality rate was significantly higher among patients with AKI (19.8% vs. 8.1%, P<0.001). PSS with AKI had significantly higher median length of stay (14 vs. 11 days) and total hospitalization charges ($168,106 vs. 100,906), P<0.001. Multivariate logistic regression analysis showed that AKI without kidney replacement therapy (KRT) was associated with 3.02 times increased odds of mortality (95% CI 2.99-3.17, P<0.001) and those requiring KRT had 6.4 times increased odds of mortality (95%CI 6.1-6.7, P<0.001). AKI without KRT was associated with 7.7 (95% CI 7.3-8.05) additional days of hospitalization and 154,536 (95% CI 149,500-159,572) additional US dollars in hospitalization charges.

CONCLUSION

Almost 1 in 4 hospitalizations with PSS had AKI and was associated with >3 times increased risk of mortality and need for KRT further adversely impacts mortality and healthcare utilization. A higher resolution version of the Graphical abstract is available as Supplementary information.

Increasing incidence of acute kidney injury in pediatric severe sepsis and related adverse hospital outcomes

BACKGROUND

Pediatric severe sepsis (PSS) is associated with increased mortality, and acute kidney injury (AKI) is an independent risk factor of mortality in PSS. However, there is little data on impact of AKI on hospital outcomes in PSS.

METHODS

We analyzed non-overlapping years of the Kids' Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2019 of all pediatric patients with severe sepsis between 1 and 18 years of age. Using ICD diagnosis codes, patients were divided into two groups based on AKI status and compared for outcomes measures including in-hospital mortality and healthcare resource utilization using length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analyzed 192,712 hospitalizations due to PSS during the 17-year period. Prevalence of AKI was 23.6% with overall increasing trend, P<0.001. Prevalence of AKI was significantly increased in patients with diabetes mellitus, organ transplantation, HIV, urinary tract anomalies, and malnutrition, P<0.001. Mortality rate was significantly higher among patients with AKI (19.8% vs. 8.1%, P<0.001). PSS with AKI had significantly higher median length of stay (14 vs. 11 days) and total hospitalization charges ($168,106 vs. 100,906), P<0.001. Multivariate logistic regression analysis showed that AKI without kidney replacement therapy (KRT) was associated with 3.02 times increased odds of mortality (95% CI 2.99-3.17, P<0.001) and those requiring KRT had 6.4 times increased odds of mortality (95%CI 6.1-6.7, P<0.001). AKI without KRT was associated with 7.7 (95% CI 7.3-8.05) additional days of hospitalization and 154,536 (95% CI 149,500-159,572) additional US dollars in hospitalization charges.

CONCLUSION

Almost 1 in 4 hospitalizations with PSS had AKI and was associated with >3 times increased risk of mortality and need for KRT further adversely impacts mortality and healthcare utilization. A higher resolution version of the Graphical abstract is available as Supplementary information.

Rising Burden of Psychiatric and Behavioral Disorders and Their Adverse Impact on Health Care Expenditure in Hospitalized Pediatric Patients with Inflammatory Bowel Disease

PURPOSE

The incidence and prevalence of inflammatory bowel disease (IBD) are increasing along with an increasing number of patients with comorbid conditions like psychiatric and behavioral disorders, which are independent predictors of quality of life.

METHODS

Non-overlapping years (2003-2016) of National Inpatient Sample and Kids Inpatient Database were analyzed to include all IBD-related hospitalizations of patients less than 21 years of age. Patients were analyzed for a concomitant diagnosis of psychiatric/behavioral disorders and were compared with IBD patients without psychiatric/behavioral disorder diagnoses for outcome variables: IBD severity, length of stay and inflation-adjusted hospitalization charges.

RESULTS

Total of 161,294 IBD-related hospitalizations were analyzed and the overall prevalence rate of any psychiatric and behavioral disorders was 15.7%. Prevalence rate increased from 11.3% (2003) to 20.6% (2016), p<0.001. Depression, substance use, and anxiety were the predominant psychiatric disorders. Regression analysis showed patients with severe IBD (odds ratio [OR], 1.57; confidence interval [CI], 1.47-1.67; p<0.001) and intermediate IBD (OR, 1.14; CI, 1.10-1.28, p<0.001) had increased risk of associated psychiatric and behavioral disorders than patients with a low severity IBD. Multivariate analysis showed that psychiatric and behavioral disorders had 1.17 (CI, 1.07-1.28; p<0.001) mean additional days of hospitalization and incurred additional $8473 (CI, 7,520-9,425; p<0.001) of mean hospitalization charges, independent of IBD severity.

CONCLUSION

Prevalence of psychiatric and behavioral disorders in hospitalized pediatric IBD patients has been significantly increasing over the last two decades, and these disorders were independently associated with prolonged hospital stay, and higher total hospitalization charges.

Update on the management of vitamins and minerals in cystic fibrosis

Advancements in respiratory and nutrition management have significantly improved the survival of patients with cystic fibrosis (CF). With the availability of several nutrition interventions such as oral/enteral nutrition supplements, enteric‐coated pancreatic enzymes, and water‐miscible CF‐specific vitamin supplements, frank vitamin deficiencies—with the exception of vitamin D—are rarely encountered in current clinical practice. Whereas they were previously considered as micronutrients, our current understanding of fat‐soluble vitamins and minerals as antioxidants, immunomodulators, and disease biomarkers has been evolving. The impact of highly effective modulators on the micronutrient status of patients with CF remains elusive. This narrative review focuses on the updates on the management of fat‐soluble vitamins and other micronutrients in CF in the current era and identifies the gaps in our knowledge.

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally.

METHODS

The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented.

FINDINGS

Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]).

INTERPRETATION

The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden.

FUNDING

Bill & Melinda Gates Foundation.

Acute Pancreatitis Is Associated with Increased Risk of In-Hospital Mortality and Health Care Utilization Among Pediatric Patients with Hematopoietic Stem Cell Transplantation

OBJECTIVE

To analyze the impact of acute pancreatitis on mortality and hospital outcomes among the pediatric population following hematopoietic stem cell transplantation (HSCT).

STUDY DESIGN

We analyzed nationally representative, nonoverlapping years of the National Inpatient Sample and Kids Inpatient Database between 2003 and 2016, including all pediatric patients who had HSCT. Patients were divided into those with and without a diagnosis of acute pancreatitis and compared for demographics, clinical characteristics, comorbid conditions related to both HSCT and acute pancreatitis, and outcome measures such as in-hospital mortality and health care resource use (length of hospital stay and total hospitalization charges).

RESULTS

We analyzed a total of 128 772 hospitalizations of children and adolescents with HSCT. The overall incidence rate of acute pancreatitis was approximately 1%, with an overall increasing trend between 2003 and 2016, P < .001. The overall mortality rate was significantly greater among patients with acute pancreatitis (14.9% vs 3.6%, P < .001). Multivariate regression analysis showed that acute pancreatitis was independently associated with 3.4 times (95% CI 2.86-4.02, P < .001) increased risk of in-hospital mortality. Patients with acute pancreatitis who underwent HSCT had a greater incidence of end-organ damage and thrombotic events. Pediatric acute pancreatitis was associated with 24.3 additional days of hospitalization (95% CI 22.9-25.7, P < .001) and incurred additional $213 496 in hospitalization charges (95% CI 193 768-233 063, P < .001).

CONCLUSIONS

Pediatric recipients of HSCT who develop acute pancreatitis have adverse outcomes with increased in-hospital mortality, end-organ damage, prolonged hospital stay, and greater hospitalization charges.

Epidemiology of Eosinophilic Esophagitis in Patients with Cystic Fibrosis: A Population-Based 5-Year Study

PURPOSE

The prevalence of eosinophilic esophagitis (EoE) has been on the rise since it was first described in the 1990s. Several diseases and exogenous factors have been associated with EoE. Our aim was to investigate the epidemiology of EoE in cystic fibrosis (CF) patients.

METHODS

We identified individuals with CF from September 2014 to September 2019 within a database (IBM Explorys Solutions, Inc.). The prevalence of EoE in patients with CF was compared to the general population.

RESULTS

The database included 36,111,860 patients during the 5-year study period: 12,950 with CF (0.036%) and 28,090 with EoE (0.078%). EoE prevalence was higher in CF patients than the general population (46 in 10,000 vs. 7.8 in 10,000, p<0.001). Patients with CF and EoE were more likely to be male (50% vs. 33.5%, p<0.008), children (33.3% vs. 16.5%, p<0.001), and non-Hispanic (100% vs. 88.7%, p<0.001) than CF patients without EoE. CF with EoE patients were more likely to be children than EoE only (33.3% vs. 10.5%, p<0.001). Allergic conditions were generally more prevalent in CF with EoE than CF only (83.3% vs. 68.3%, p=0.01) and EoE only (83.3% vs. 69.3%, p=0.014).

CONCLUSION

EoE is nearly 6-times more prevalent in CF patients. Those patients had higher incidence of other atopic conditions. EoE must be considered in the differential diagnosis of patients with CF presenting with dysphagia, refractory gastroesophageal reflux, vomiting, and other esophagus-related symptoms.

Cystic fibrosis-related liver disease is an independent risk factor for mortality and increased health care resource utilization in hospitalized pediatric patients with cystic fibrosis

BACKGROUND

Cystic fibrosis-related liver disease (CFLD) is more prevalent in recent decades due to the increasing life expectancy of patients with cystic fibrosis (CF). There is paucity of population-level data on the impact of CFLD on hospital outcomes.

METHODS

We interrogated nonoverlapping years (2003-2016) of the National Inpatient Sample and Kids' Inpatient Database to include all hospitalized patients <21 years of age with a primary diagnosis of CF within the United States. A concomitant diagnosis of cirrhosis, liver fibrosis, chronic liver disease, portal hypertension, hepatomegaly, splenomegaly, hypersplenism, and liver transplant status was considered as surrogates for the diagnosis of CFLD and was compared with CF-related hospitalizations without these diagnoses (controls) for demographics, comorbid conditions, in-hospital mortality, length-of-stay, and hospital charges.

RESULTS

We evaluated 94,374 CF-related hospitalizations. The prevalence of CFLD was 5.8%. The prevalence increased from 3.1% (2003) to a peak of 7.3% (2014) with an overall increasing trend, p < 0.001. Hospitalizations with CFLD had an increased prevalence of significant comorbidities: respiratory failure,lung transplant, pulmonary hypertension, diabetes mellitus, malnutrition, Clostridioides difficile infection, cholelithiasis, anemia, and need for parenteral nutrition, p < 0.001. Multivariate regression models showed CFLD as independently associated with 2.1 (95% confidence interval [CI]: 1.5 to 2.8) times increased risk of inpatient mortality, contributed to 1.1 (95% CI: 0.89 to 1.37) additional days of hospitalization, and incurring $14,852 (95% CI: 12,204 to 17,501) excess hospital charges, p < 0.001.

CONCLUSION

CFLD is associated with multiple comorbidities and is independently associated with increased risk of mortality and increased health care resource utilization in pediatric CF-related hospitalizations.

Eosinophilic esophagitis in cystic fibrosis: A case series with long-term follow-up

Challenging mealtime behaviors in young children and difficulties in meeting their dietary intake recommendations are sources of parenting stress and associated with negative quality of life. The gastrointestinal (GI) manifestations of cystic fibrosis (CF) can often present similarly to a GI pathology unrelated to CF. Specifically, this case series focuses on three toddlers with CF who presented with oral aversion and challenging mealtime behaviors and later were diagnosed with eosinophilic esophagitis (EoE). Though EoE often presents with dysphagia, younger patients commonly present with nonspecific GI symptoms such as regurgitation, emesis, abdominal pain, failure to thrive, food intolerance, and oral aversion. Given the overlap of GI manifestations in CF and EoE, it can be challenging for clinicians to diagnose the coexistent EoE in patients with CF. We describe the presenting symptoms, treatment, and successful outcomes of three pediatric patients with CF and EoE. To our knowledge, this is the second case series with a detailed description of EoE in CF.

Role of Traditional Chinese Herbal Medicines in Functional Gastrointestinal and Motility Disorders

PURPOSE OF REVIEW

Traditional Chinese medicine (TCM) has been in use for thousands of years in Asian countries and is rapidly gaining popularity in the Western world. Among different forms of TCM, the traditional Chinese herbal therapy and acupuncture are the most popular modalities. Here, we review the fundamentals of TCMs for clinicians practicing in the West and will also detail the evidence-based utility of Chinese herbal medicine in the management of functional gastrointestinal disorders (FGIDs).

RECENT FINDINGS

In the recent decades, the popularity and usage of traditional Chinese herbal medicine in FGIDs is increasing in the West. TCMs are commonly utilized by many patients with FGIDs as the conventional therapies do have limitations such as cost, inadequate symptom control and adverse effects. The unfamiliarity of TCM philosophy among clinicians in the West, and shortage of traditional Chinese herbalists remain. The philosophy of TCM is complex and entirely different from the Western medical concepts and is difficult to understand for a clinician trained in the West. Further traditional Chinese herbal therapies are often viewed skeptically by the clinicians in the West for various reasons such as lack of scientific rigor, inconsistencies in the constituents of herbal products, and also concerns due to adverse herb effects. Future clinical trials in FGIDs should focus on herb product quality, herb-drug interactions, and standardized criteria for diagnosis and management outcomes.

Unwrapping the compositional mystery of Eumeninae nest: A laser-induced breakdown spectroscopic study

The nest of Eumeninae wasp is one of nature's creations, revealing the mysterious architectural beauty through its composition and nanostructuring. The present study unveils the compositional mystery of Eumeninae nest through the signal processing of the laser-induced breakdown spectrum (LIBS). The structure, morphological, and optical characterisations of the nest sample shows nanoparticles of oxides of silicon, aluminium, and iron with an optical bandgap of 2.5 eV, giving a fluorescence emission in the blue region upon ultraviolet excitation. Though, the energy dispersive spectroscopic study confirms the major elements present in the sample, the more elements are revealed through LIBS analysis. The intriguing properties of nest is attributed to the elemental compositions - oxygen, silicon, iron, manganese, chromium, cobalt, calcium and carbon - which necessitate deconvolution of peaks in the spectra for estimating the plasma temperature (4300-5045 K) and electron density (1.13 × 10^-19 cm^-3).

Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019

IMPORTANCE

The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden.

OBJECTIVE

To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019.

EVIDENCE REVIEW

The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs).

FINDINGS

In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles.

CONCLUSIONS AND RELEVANCE

The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Clostridioides difficile Infection Is Associated with Adverse Outcomes among Hospitalized Pediatric Patients with Acute Pancreatitis

PURPOSE

Studies in adults have shown an increasing incidence of Clostridioides difficile infection (CDI) in patients hospitalized with acute pancreatitis (AP). There is lack of epidemiological data on CDI and its impact on hospitalized pediatric patients with AP.

METHODS

We analyzed the National Inpatient Sample and Kids' Inpatient Database between the years 2003 and 2016 and included all patients (age <21 years) with a primary diagnosis of AP using specific International Classification of Diseases codes. We compared clinical outcomes between children with CDI and those without CDI. Our primary outcome was severe AP and secondary outcomes included length of stay and hospital charges.

RESULTS

A total of 123,240 hospitalizations related to AP were analyzed and CDI was noted in 0.6% of the hospital. The prevalence rate of CDI doubled from 0.4% (2003) to 0.8% (2016), p=0.03. AP patients with CDI had increased comorbidities, and also underwent more invasive surgical procedures, p<0.05. AP patients with CDI had a higher in-hospital mortality rate and increased prevalence of severe AP, p<0.001. Multivariate regression models showed that CDI was associated with 2.4 times (confidence interval [CI]: 1.91 to 3.01, p<0.001) increased odds of severe AP. CDI patients had 7.24 (CI: 6.81 to 7.67, p<0.001) additional hospital days while incurring $59,032 (CI: 54,050 to 64,014, p<0.001) additional hospitalization charges.

CONCLUSION

CDI in pediatric patients with AP is associated with adverse clinical outcomes and increased healthcare resource utilization. Further studies are needed to elucidate this association to prevent the development of CDI and to improve outcomes.

Acclimatization through thermal diffusivity tuning of coconut oil - A mode mismatched dual-beam thermal lens study

Background

Ayurvedic medicinal oils traditionally prepared by blending herbal extracts in different compositions are commonly used for treatment and improving health. The estimation of the thermal properties of medicinal oils is essential for practical applications.

Objective

The present work aims to expound the ability of medicinal oils for the acclimatization of body temperature by determining its thermal diffusivity and thereby providing a validation to the traditional knowledge.

Materials and methods

The medicinal oils are prepared by incorporating black pepper (Piper nigrum), aloe vera (Aloe barbadensis), hibiscus bud (Hibiscus rosa-sinensis) and Ocimum sanctum in coconut oil base. The samples are subjected to thermal diffusivity study using the mode-mismatched dual-beam thermal lens technique.

Results

The study reveals that the incorporation of black pepper (Piper nigrum), having hot potency (Ushna veerya), to the base fluid lowers the thermal diffusivity value, suggesting its potential in heat-trapping. The addition of aloe vera (Aloe barbadensis), hibiscus bud (Hibiscus rosa-sinensis), and O. sanctum dissipates heat energy quickly, thus increases the thermal diffusivity of coconut oil revealing a cold potency (Sheeta veerya). The study provides a validation for traditional knowledge and delineates the possiblity of thermal diffusivity tuning of the base fluids.

Conclusion

The thermal diffusivity tuning through incorporation of herbal extracts can effectively be used to acclimatize the human body temperature with the surroundings. A higher thermal diffusivity value induces a cooling effect and the lower value causes heating effect. This, opens up the possibility of using thermally tuned oils depending on climate and geographical location.

Graph-based feature extraction and classification of wet and dry cough signals: a machine learning approach

This article proposes a unique approach to bring out the potential of graph-based features to reveal the hidden signatures of wet (WE) and dry (DE) cough signals, which are the suggestive symptoms of various respiratory ailments like COVID 19. The spectral and complex network analyses of 115 cough signals are employed for perceiving the airflow dynamics through the infected respiratory tract while coughing. The different phases of WE and DE are observed from their time-domain signals, indicating the operation of the glottis. The wavelet analysis of WE shows a frequency spread due to the turbulence in the respiratory tract. The complex network features namely degree centrality, eigenvector centrality, transitivity, graph density and graph entropy not only distinguish WE and DE but also reveal the associated airflow dynamics. A better distinguishability between WE and DE is obtained through the supervised machine learning techniques (MLTs)-quadratic support vector machine and neural net pattern recognition (NN), when compared to the unsupervised MLT, principal component analysis. The 93.90% classification accuracy with a precision of 97.00% suggests NN as a better classifier using complex network features. The study opens up the possibility of complex network analysis in remote auscultation.

Impact of COVID-19 on the Intestinal Microbiome

PURPOSE OF REVIEW

This review article aims to explore the GI changes induced by SARS-CoV-2 and how gut microbial homeostasis can influence these changes and affect the lung-gut axis and its relationship with the induction of the cytokine release syndrome in severe COVID-19 patients.

RECENT FINDINGS

Coronavirus disease 2019 (COVID-19) affects not only the respiratory system but can produce multi-systemic damage. The expression of angiotensin-converting enzyme 2 (ACE-2) receptors in the gastrointestinal (GI) tract, the high prevalence of GI symptoms in severely ill COVID-19 patients, and the abnormalities described in the gut microbiome in these patients have raised concerns about the influence of GI tract as a risk factor or as a potential modulator to reduce the severity of COVID-19. Understanding the mechanisms by which gut dysbiosis may influence viral transmission and disease progression in COVID-19 may help in shaping how accessible therapies, like diet modulation, can potentially help beat the devastating consequences of COVID-19.

Prevalence and impact of acute kidney injury in hospitalized pediatric patients with acute pancreatitis

BACKGROUND

The incidence of acute pancreatitis (AP) in pediatric patients is rising with accompanying increased hospitalizations. Acute kidney injury (AKI) is associated with worse clinical outcomes in adults, and similar data in the pediatric age group is limited.

METHODS

We analyzed non-overlapping years of National Inpatient Sample (NIS) and Kids Inpatient Database (KID) to include all patients less than 21 years old with primary diagnosis of AP between 2003 and 2016. Patients with concomitant diagnosis of AKI were compared with patients without AKI for demographics, comorbid/etiologic conditions, procedures, complications, and mortality. Length of stay and inflation-adjusted hospitalization charges were used to compare health care resource utilization.

RESULTS

In total, 123,185 AP-related hospitalizations were analyzed. Overall prevalence of AKI among AP patients was 1.5% during the study period. The prevalence rate of AKI increased almost five-fold from 0.6% (2003) to a peak rate of 2.9% (2016), P < 0.001. Patients with AKI were older, more often male and had either more systemic diseases or chronic comorbid conditions such as malignancies, systemic lupus erythematosus, solid organ transplantation, hypertriglyceridemia, and hypercalcemia. Multivariate analysis demonstrated AP-related hospitalizations with AKI were 1.97 (CI 1.27-3.08, P < 0.001) times more likely to be associated with in-hospital mortality and contributed to 4.3 additional days of hospitalization (CI 4.02-4.6, P < 0.001), also incurring an additional $51,830 (CI 48571-55088, P < 0.001) in hospital charges.

CONCLUSION

The prevalence of AKI is increasing steadily among pediatric patients with AP and is associated with increased risk of mortality and higher health care resource expenditure.

Complex network analysis of the thermal lens signal: a Markov model approach

The paper reports a novel, to the best of my knowledge, complex network-based Markov model approach to analyze the thermal lens (TL) signal. The complex network is constructed by segmenting the experimental and fitted TL signals into three regions. Here, a new parameter, degree of fluctuation, is introduced to analyze the Markov transition probability matrix (M) and the increase of system enthalpy leading to increased Brownian motion. The spread of data about the diagonal elements of M distinguishes the experimental and fitted data and appears as an increased number of edges in the complex network. Thus, the system's network displays the transient heat flow giving information about the Brownian motion in the medium.

Effect of obesity on mortality among hospitalized paediatric patients with severe sepsis

INTRODUCTION

Severe sepsis is one of the leading causes of mortality among children. Studies in adults have suggested a protective effect of obesity on mortality among patients hospitalized with sepsis. Paediatric studies evaluating similar relationship is lacking.

METHODS

We analysed non-overlapping years of the Kids Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2014 of all paediatric patients with severe sepsis (PSS) up to 20 years of age. PSS was defined using specific International Classification of Diseases (ICD) codes and modified Angus criteria. Using ICD-9 diagnosis codes, patients were divided into three mutually exclusive groups (obesity, morbid obesity and control groups), and these groups were compared for outcomes measures including in-hospital mortality and healthcare resource utilization using the length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analysed 109 026 hospitalizations due to PSS. The prevalence rate of obesity was 1.5% (n = 1643), and morbid obesity was 1.05% (n = 1147). Multivariate regression models showed obesity was associated with 63% (OR 0.37, CI: 0.29-0.47, p < 0.001) and 54% reduction in mortality among PSS patients and patients with septic shock respectively. Contrastingly, morbid obesity was not associated with mortality among PSS patients and but was associated with 1.37 times (CI: 1.06-1.78, p = 0.01) increased risk of mortality among paediatric patients with septic shock.

CONCLUSIONS

Paediatric obesity is associated with reduced mortality among patients with PSS, with the exception of morbid obesity. Further prospective studies are needed to better understand the relationship between obesity and outcomes in PSS.

Nanostructured ZnO and ZnO: Pd with MXene overlayer SPR biosensors

The development of biosensors based on various novel techniques has become highly significant in the context of the outburst of a pandemic like COVID 19. The present work reports the theoretical modeling of two surface plasmon resonance (SPR) based biosensing probe configurations on optical fiber employing Metal/ZnO/MXene and Metal/ZnO: Pd/MXene. Maximum sensitivities of 19,400 nm/RIU and 8350 nm/RIU are calculated with Metal/ZnO/MXene and Metal/ZnO: Pd/MXene, respectively. The sensors are suitable for analytes with refractive index values ranging from 1.354 to 1.422. The refractive index of mucus and serum being in this range, the proposed biosensor, can be a potential tool for COVID-19 detection.

Babao Dan inhibits the migration and invasion of gastric cancer cells by suppressing epithelial-mesenchymal transition through the TGF-β/Smad pathway

OBJECTIVE

To investigate the anti-metastatic effects of Babao Dan (BBD) on gastric cancer (GC) cells (AGS and MGC80-3) and explore the underlying molecular mechanisms by which it inhibits epithelial-mesenchymal transition (EMT).

METHODS

AGS and MGC80-3 cells were treated with BBD. In addition, cells were treated with the EMT inducer transforming growth factor-β1 (TGF-β1). Cell viability was determined using the MTT assay, and the live cell ratio was calculated via cell counting. Cell invasion and migration were evaluated using the Transwell assay. Western blotting was performed to measure the protein expression of EMT biomarkers and related genes.

RESULTS

BBD inhibited the viability, migration, and invasion of AGS and MGC80-3 cells, but it did not reduce the live cell ratio. Furthermore, BBD inhibited the expression of N-cadherin, vimentin, zinc finger E-box binding homeobox (ZEB)1, ZEB2, Twist1, matrix metalloproteinase (MMP)2, MMP9, TGF-β1, and p-Smad2/3, whereas E-cadherin expression was increased in AGS and MGC80-3 cells to different degrees. Using a GC cell model of EMT induced by TGF-β1, we proved that BBD inhibited p-Smad2/3 and N-cadherin expression, cell migration, and cell invasion.

CONCLUSION

BBD suppressed cell migration and invasion by inhibiting TGF-β-induced EMT and inactivating TGF-β/Smad signaling in GC cells.

Impact of Altered Gut Microbiota and Its Metabolites in Cystic Fibrosis

Cystic fibrosis (CF) is the most common lethal, multisystemic genetic disorder in Caucasians. Mutations in the gene encoding the cystic fibrosis transmembrane regulator (CFTR) protein are responsible for impairment of epithelial anionic transport, leading to impaired fluid regulation and pH imbalance across multiple organs. Gastrointestinal (GI) manifestations in CF may begin in utero and continue throughout the life, resulting in a chronic state of an altered intestinal milieu. Inherent dysfunction of CFTR leads to dysbiosis of the gut. This state of dysbiosis is further perpetuated by acquired factors such as use of antibiotics for recurrent pulmonary exacerbations. Since the gastrointestinal microbiome and their metabolites play a vital role in nutrition, metabolic, inflammatory, and immune functions, the gut dysbiosis will in turn impact various manifestations of CF-both GI and extra-GI. This review focuses on the consequences of gut dysbiosis and its metabolic implications on CF disease and possible ways to restore homeostasis.

Effect of Babao Dan on angiogenesis of gastric cancer in vitro by regulating VEGFA/VEGFR2 signaling pathway

Background

To further elucidate the anti-angiogenesis effect of Babao Dan (BBD) in vitro, gastric cancer (GC) cells and human umbilical vein endothelial cells (HUVECs) were used to evaluate the regulation role of BBD by vascular endothelial growth factor A (VEGFA)/vascular endothelial growth factor receptor 2 (VEGFR2) signaling pathway.

Methods

After induced by VEGFA, GC cells (AGS, MGC80-3 and BGC823) were treated by different concentrations of BBD and then were detected cell viability, migration and VEGFA level. And the anti-angiogenesis effect of BBD was evaluated with HUVECs. To furtherly mimic the tumor microenvironment of angiogenesis, VEGFA as an inducer (10 ng/mL) was used to trigger a cascade of angiogenesis of HUVECs in vitro.

Results

The viability and migration of GC cells with VEGFA-induced or non-induced and VEGFA levels in GC cells were significantly inhibited by BBD with concentration-dependent manner (P<0.01). BBD significantly inhibited the HUVECs viability with concentration-dependent manner (P<0.01), which was consistent with the inhibitory action on augmentation of cell viability induced by VEGFA (P<0.01). BBD exhibited the similar inhibitory trend on cyto behavioral variability such as wound repairing (P<0.05), migration (P<0.01) and tube formation (P<0.01) and activation effect on cell apoptosis rate (P<0.01) with VEGFA-induced or non-induced. Moreover, BBD notably regulated the levels of VEGFA, VEGFR2, matrix metalloprotein 2 (MMP2) and matrix metalloprotein 9 (MMP9) of HUVECs on present or absent of VEGFA with dose-dependent manner.

Conclusions

BBD inhibited GC growth against VEGFA-induced angiogenesis of HUVECs by VEGFA/VEGFR2 signaling pathway in vitro.

Effects of Qing Hua Chang Yin on lipopolysaccharide‑induced intestinal epithelial tight junction injury in Caco‑2 cells

Disruption of the intestinal mucosal barrier integrity is a pathogenic process in inflammatory bowel disease (IBD) development, and is therefore considered a drug discovery target for IBD. The well‑known traditional Chinese formulation Qing Hua Chang Yin (QHCY) has been suggested as a potential therapeutic agent for the treatment of ulcerative colitis. However, the possible underlying molecular mechanisms regarding its therapeutic effect remain unclear. Consequently, the present study investigated the effects of QHCY on lipopolysaccharide (LPS)‑induced loss of intestinal epithelial barrier integrity in vitro using the Caco‑2 cell model of intestinal epithelium. QHCY reversed the LPS‑induced decrease in transepithelial electrical resistance and significantly alleviated the increased fluorescently‑labeled dextran 4 flux caused by LPS. Moreover, QHCY upregulated the mRNA and protein expression levels of occludin, zona occludens‑1 and claudin‑1 in LPS‑exposed Caco‑2 cells. In conclusion, QHCY was able to protect intestinal epithelial barrier integrity following an inflammatory insult; the protective effects of QHCY may be mediated by modulation of the expression of tight junction proteins.

Is SARS CoV-2 a Multifractal?—Unveiling the Fractality and Fractal Structure

A first report of unveiling the fractality and fractal nature of severe acute respiratory syndrome coronavirus (SARS CoV-2) responsible for the pandemic disease widely known as coronavirus disease 2019 (COVID 19) is presented. The fractal analysis of the electron microscopic and atomic force microscopic images of 40 coronaviruses (CoV), by the normal and differential box-counting method, reveals its fractal structure. The generalised dimension indicates the multifractal nature of the CoV. The higher value of fractal dimension and lower value of Hurst exponent (H) suggest higher complexity and greater roughness. The statistical analysis of generalised dimension and H is understood through the notched box plot. The study on CoV clusters also confirms its fractal nature. The scale-invariant value of the box-counting fractal dimension of CoV yields a value of 1.820. The study opens the possibility of exploring the potential of fractal analysis in the medical diagnosis of SARS CoV-2.

Undernutrition and Obesity Are Associated with Adverse Clinical Outcomes in Hospitalized Children and Adolescents with Acute Pancreatitis

Background: Adult studies demonstrated that extremes of nutritional status adversely impact clinical outcomes in acute pancreatitis (AP). With rising prevalence of undernutrition/obesity in children, we analyzed the effect of nutritional status on the clinical outcomes in children and adolescents with acute pancreatitis. Methodology: We analyzed the Kids’ Inpatient Database (KID) between 2003 and 2016 to include all patients with a primary diagnosis of AP using specific International Classification of Diseases (ICD) codes. We classified into (1) undernutrition, (2) obesity and (3) control groups, based on ICD codes, and we compared severe acute pancreatitis and healthcare utilization (length of stay and hospitalization costs). Results: Total number of AP admissions was 39,805. The prevalence of severe AP was higher in the undernutrition and obesity groups than the control group (15.7% vs. 5.8% vs. 3.5% respectively, p < 0.001). Multivariate analyses demonstrated that undernutrition and obesity were associated with 2.5 and 1.6 times increased risk of severe AP, p < 0.001. Undernutrition was associated with an additional six days of hospitalization and almost $16,000 in hospitalization costs. Obesity was associated with an additional 0.5 day and almost $2000 in hospitalization costs, p < 0.001. Conclusion: Undernutrition and obesity were associated with greater severity of AP, as well as prolonged hospitalization stay and costs. It is imperative for treating clinicians to be aware of these high-risk groups to tailor management and strive for improved outcomes.

Meet the Meat Alternatives: The Value of Alternative Protein Sources

PURPOSE OF REVIEW

Meat alternatives are non-animal-based proteins with chemical characteristics and aesthetic qualities comparable to meat. The global increase in meat consumption is associated with the adverse environmental impacts such as increased greenhouse gas emissions contributing to global warming and higher water/land use. In this review, we focus on the development, availability, and nutritional value of various meat alternatives and their impact on meat consumption.

RECENT FINDINGS

Changing dietary patterns and drive for environmental conservation contribute to the recent increase in the consumption of environmental friendly sources of proteins such as plant-based and mycoprotein-based meat alternatives. Perceived lack of naturalness and poor cultural acceptance present as roadblocks for widespread societal acceptance for meat alternatives. Continued research and efforts are needed to make the meat alternatives more aesthetically appealing with improved nutritive value.

Phase portrait for high fidelity feature extraction and classification: A surrogate approach

This paper proposes a novel surrogate method of classification of breath sound signals for auscultation through the principal component analysis (PCA), extracting the features of a phase portrait. The nonlinear parameters of the phase portrait like the Lyapunov exponent, the sample entropy, the fractal dimension, and the Hurst exponent help in understanding the degree of complexity arising due to the turbulence of air molecules in the airways of the lungs. Thirty-nine breath sound signals of bronchial breath (BB) and pleural rub (PR) are studied through spectral, fractal, and phase portrait analyses. The fast Fourier transform and wavelet analyses show a lesser number of high-intense, low-frequency components in PR, unlike BB. The fractal dimension and sample entropy values for PR are, respectively, 1.772 and 1.041, while those for BB are 1.801 and 1.331, respectively. This study reveals that the BB signal is more complex and random, as evidenced by the fractal dimension and sample entropy values. The signals are classified by PCA based on the features extracted from the power spectral density (PSD) data and the features of the phase portrait. The PCA based on the features of the phase portrait considers the temporal correlation of the signal amplitudes and that based on the PSD data considers only the signal amplitudes, suggesting that the former method is better than the latter as it reflects the multidimensional aspects of the signal. This appears in the PCA-based classification as 89.6% for BB, a higher variance than the 80.5% for the PR signal, suggesting the higher fidelity of the phase portrait-based classification.

Nonlinear time series and principal component analyses: Potential diagnostic tools for COVID-19 auscultation

The development of novel digital auscultation techniques has become highly significant in the context of the outburst of the pandemic COVID 19. The present work reports the spectral, nonlinear time series, fractal, and complexity analysis of vesicular (VB) and bronchial (BB) breath signals. The analysis is carried out with 37 breath sound signals. The spectral analysis brings out the signatures of VB and BB through the power spectral density plot and wavelet scalogram. The dynamics of airflow through the respiratory tract during VB and BB are investigated using the nonlinear time series and complexity analyses in terms of the phase portrait, fractal dimension, Hurst exponent, and sample entropy. The higher degree of chaoticity in BB relative to VB is unwrapped through the maximal Lyapunov exponent. The principal component analysis helps in classifying VB and BB sound signals through the feature extraction from the power spectral density data. The method proposed in the present work is simple, cost-effective, and sensitive, with a far-reaching potential of addressing and diagnosing the current issue of COVID 19 through lung auscultation.

Time series and fractal analyses of wheezing: a novel approach

Since the outbreak of the pandemic Coronavirus Disease 2019, the world is in search of novel non-invasive methods for safer and early detection of lung diseases. The pulmonary pathological symptoms reflected through the lung sound opens a possibility of detection through auscultation and of employing spectral, fractal, nonlinear time series and principal component analyses. Thirty-five signals of vesicular and expiratory wheezing breath sound, subjected to spectral analyses shows a clear distinction in terms of time duration, intensity, and the number of frequency components. An investigation of the dynamics of air molecules during respiration using phase portrait, Lyapunov exponent, sample entropy, fractal dimension, and Hurst exponent helps in understanding the degree of complexity arising due to the presence of mucus secretions and constrictions in the respiratory airways. The feature extraction of the power spectral density data and the application of principal component analysis helps in distinguishing vesicular and expiratory wheezing and thereby, giving a ray of hope in accomplishing an early detection of pulmonary diseases through sound signal analysis.

The efflorescent carbon allotropes: fractality preserved blooming through alkali treatment and exfoliation

The work reported in the paper elucidates morphological modification induced nanoart and surface area enhancement of graphite, graphene, and soot containing carbon allotropes through ultrasonication and alkali-treatment. The field emission scanning electron microscopic (FESEM) analysis of the samples before and after exfoliation reveals the formation of brilliant flower-like structures from spindle-like basic units due to Ostwald ripening. The x-ray diffraction analysis of the samples gives information about structural composition. The fractal analysis of the FESEM images indicates a multifractal structure with the dimensions—box-counting dimension D0 (1.72), information dimension D1 (1.66), and correlation dimension D2 (1.63)—preserved upon exfoliation. The process of ultra-sonication assisted liquid phase exfoliation resembles blooming as if the carbon allotropes are efflorescent.

Qingda granule inhibits angiotensin Ⅱ induced VSMCs proliferation through MAPK and PI3K/AKT pathways

ETHNOPHARMACOLOGICAL RELEVANCE

The abnormal increase in vascular smooth muscle cell (VSMC) proliferation is widely accepted as the pivotal process in the vascular remodeling of hypertension. Qingda granule (QDG) is simplified from Qingxuan Jiangya Decoction (QXJYD) which has been in usage for a long time as a traditional Chinese medicine formula to treat hypertension based on the theory of traditional Chinese medicine. However, its underlying molecular mechanisms of action remain largely unknown.

AIM OF STUDY

To investigate the therapeutic efficacy of QDG in the attenuation of elevation of blood pressure and proliferation of VSMCs in vivo and in vitro and explore its possible mechanism of action.

MATERIALS AND METHODS

In vivo, we established an angiotensin Ⅱ (Ang Ⅱ)-mediated hypertension model in C57BL/6 mice and orally administered 1.145 g/kg/day of QDG. The systolic and diastolic blood pressures of all mice were measured at the end of the treatment by using the tail-cuff plethysmograph method and CODA™ noninvasive blood pressure system. VSMC proliferation within the aorta was determined by immunohistochemistry. In vitro, primary rat VSMCs were cultured to further verify the effects of QDG on Ang Ⅱ induced VSMC proliferation. Cell proliferation was investigated using cell counting and MTT assays. The protein expression was determined by western blotting.

RESULTS

We found that oral administration of QDG significantly attenuated the elevation of blood pressure and proliferation of VSMCs in Ang Ⅱ-induced hypertensive mice. Moreover, QDG remarkably inhibited Ang Ⅱ-induced primary rat VSMCs proliferation and decreased mitogen-activated protein kinase (MAPK) and PI3K/AKT activity by attenuating the expression of phospho-extracellular signaling-regulated kinase 1/2, phospho-p38, phospho-c-Jun N-terminal kinase and phospho-protein kinase B.

CONCLUSION

Collectively, our findings suggest that QDG attenuates Ang Ⅱ-induced elevation of blood pressure and proliferation of VSMCs through a decrease in the activation of MAPK and PI3K/AKT pathways. Based on this study, we postulate this could be one of the mechanisms whereby QDG effectively controls hypertension.

Downscaling of sample entropy of nanofluids by carbon allotropes: A thermal lens study

The work reported in this paper is the first attempt to delineate the molecular or particle dynamics from the thermal lens signal of carbon allotropic nanofluids (CANs), employing time series and fractal analyses. The nanofluids of multi-walled carbon nanotubes and graphene are prepared in base fluid, coconut oil, at low volume fraction and are subjected to thermal lens study. We have studied the thermal diffusivity and refractive index variations of the medium by analyzing the thermal lens (TL) signal. By segmenting the TL signal, the complex dynamics involved during its evolution is investigated through the phase portrait, fractal dimension, Hurst exponent, and sample entropy using time series and fractal analyses. The study also explains how the increase of the photothermal energy turns a system into stochastic and anti-persistent. The sample entropy (S) and refractive index analyses of the TL signal by segmenting into five regions reveal the evolution of S with the increase of enthalpy. The lowering of S in CAN along with its thermal diffusivity (50%-57% below) as a result of heat-trapping suggests the technique of downscaling sample entropy of the base fluid using carbon allotropes and thereby opening a novel method of improving the efficiency of thermal systems.