Evaluating Acute Pulmonary Changes in Coronavirus Disease 2019: A Comparative Analysis of Computed Tomography, Chest Radiography, Lung Ultrasound, Magnetic Resonance Imaging, and Positron Emission Tomography with Fluorodeoxyglucose Modalities.

This review explores imaging's crucial role in acute Coronavirus Disease 2019 (COVID-19) assessment. High Resolution Computer Tomography is especially effective in detection of lung abnormalities. Chest radiography has limited utility in the initial stages of COVID-19 infection. Lung Ultrasound has emerged as a valuable, radiation-free tool in critical care, and Magnetic Resonance Imaging shows promise as a Computed Tomography alternative. Typical and atypical findings of COVID-19 by each of these modalities are discussed with emphasis on their prognostic value. Considerations for pediatric and immunocompromised cases are outlined. A comprehensive diagnostic approach is recommended, as radiological diagnosis remains challenging in the acute phase.

Enhancing Radiology Education With a Case-Based Intro to Radiology on the UF WIDI e-Learning Platform.

RATIONALE AND OBJECTIVES: This study explores the implementation and efficacy of an online, interactive, case-based radiology education tool, Wisdom in Diagnostic Imaging (WIDI) Case-Based Intro to Radiology (CBIR). We hypothesize that the WIDI CBIR platform would enhance radiology teaching, foster critical thinking, and provide a comprehensive curriculum in imaging interpretation and utilization. MATERIALS AND METHODS: A focus group consisting of 1 undergraduate, 7 medical students, 9 physician assistant students, and 3 PhD students participated in this study. We tested 3 different teaching methods: a didactic approach without WIDI, a proctored didactic approach using WIDI, and a flipped classroom approach using WIDI. An online survey was conducted to assess student preference and feedback on these methods and the use of WIDI in their curriculum. RESULTS: Most students preferred the proctored didactic approach with WIDI. They reported that the platform complemented their curriculum and encouraged critical thinking. The modules covered adequate clinical and imaging details and enhanced their skills in imaging interpretation. Despite the limitations of a small sample size and reliance on self-reported outcomes, this study indicates that the WIDI platform could be integrated into PA and medical school curricula throughout the US, offering a standardized radiology curriculum. CONCLUSION: The UF WIDI appears to be a promising tool for modernizing radiology education, improving imaging interpretation skills, and enhancing appropriate imaging selection among nonradiologist medical learners. WIDI offers case-based education in imaging use, workflow, search-pattern selection, and interpretation of common radiological findings, potentially bridging the gap in radiology education. Further research and larger studies are required to assess the long-term impact on performance and clinical practice.

Mapping the Glymphatic Pathway Using Imaging Advances.

The glymphatic system is a newly discovered waste-clearing system that is analogous to the lymphatic system in our central nervous system. Furthermore, disruption in the glymphatic system has also been associated with many neurodegenerative disorders (e.g., Alzheimer's disease), traumatic brain injury, and subarachnoid hemorrhage. Thus, understanding the function and structure of this system can play a key role in researching the progression and prognoses of these diseases. In this review article, we discuss the current ways to map the glymphatic system and address the advances being made in preclinical mapping. As mentioned, the concept of the glymphatic system is relatively new, and thus, more research needs to be conducted in order to therapeutically intervene via this system.

Development of an Electronic Medical Tool to Facilitate Allocation of Limited Resources in Times of Crisis.

The COVID-19 pandemic has made decisions about resource allocation and reallocation real possibilities even in high-resource settings. In April 2020, in preparation for such an eventuality, Atlantic Health System began to develop a real-time instrument built into the EMR to assist with such decisions. The instrument calculated the modified Sequential Organ Failure Assessment for all patients admitted, in real time, to assist triage teams make decisions if crisis standards of care were declared. A pilot assessment of the instrument was performed using retrospective data by nine members of the triage teams, who were asked to identify the six patients at highest risk of reallocation. Agreement about which patients were at highest risk of resource reallocation was good, but not perfect. All raters agreed on five of the six patients, but only seven of nine agreed on the final patient. Among the six consensus selections for reallocation, five died prior to hospital discharge. All patients at highest risk of reallocation had a predicted life expectancy of less than 1 year. In conclusion, the instrument was easy to use, and the concordance among raters was good but not perfect. Predicted life expectance was a major determinant of the triage score.

Suppression of Bile Acid Synthesis in a Preterm Infant Receiving Prolonged Parenteral Nutrition.

Bile acid metabolism is altered in neonates on parenteral nutrition (PN), predisposing them to parenteral nutrition-associated liver disease. Cholesterol 7α-hydroxylase (CYP7A1), the rate-limiting enzyme in the bile acid synthesis pathway, is repressed by fibroblast growth factor 19 (FGF19) and phytosterols (PS). We describe a case of a preterm infant who developed necrotizing enterocolitis (NEC) and received exclusive PN for over 2 months. Our objective was to serially assess CYP7A1 activity and plasma FGF19 and PS concentrations in this infant case compared to five healthy preterm infants. We found that CYP7A1 activity increased during the first 2 weeks of life in control infants but was undetectable in the infant case. FGF19 concentrations were high at birth in all infants and subsequently declined and did not differ between the case and control infants. As expected, PS concentrations were elevated in the infant case and continued to increase despite lipid minimization. In conclusion, CYP7A1 activity was gradually upregulated in healthy preterm infants but remained suppressed in the infant requiring prolonged PN. Preterm infants also had elevated FGF19 concentrations at birth, which decreased with advancing postnatal age.

Iron Balance and Iron Nutritional Status in Preterm Infants During the First Four Months of Life.

OBJECTIVES: To determine whether iron absorption occurs in a dose-dependent fashion and/or is a function of iron nutritional status (INS) in preterm infants during the first 4 months of life. METHODS: Preterm very-low-birth-weight infants (VLBWI) were fed an iron-fortified (0.7 mg/dL) infant formula. Three 48 h balance studies were performed on each infant. INS was determined by serially measuring hemoglobin, mean corpuscular volume (MCV), hematocrit, ferritin, transferrin and transferrin saturation levels. The data were analyzed using ANOVA and stepwise regression. RESULTS: Fifty-four balance studies were performed in 18 infants (birth weight, 1347 ± 201 g; gestation, 30 ±â€Š1.3 weeks; mean ±â€Šstandard deviation) at 33 ±â€Š1.3, 34 ±â€Š1.2, and 48 ±â€Š0.5 weeks corrected age and weights of 1768 ±â€Š260, 2298 ±â€Š314, 5127 ±â€Š939 g. No relationship was detected between iron intake and absorption. Intake decreased during the study (1.17 ±â€Š.08, 1.24 ±â€Š0.11 > 1.1 ±â€Š0.15 mg ·â€Škg-1 ·â€Šday-1) but net (0.32 ±â€Š0.26, 0.36 ±â€Š31 < 0.49 ±â€Š.23 mg ·â€Škg-1 ·â€Šday-1) and % (27 ±â€Š22, 29 ±â€Š23 < 46 ±â€Š21) absorption increased (P < 0.01). Serum ferritin, transferrin saturation and MCV fell, while hematocrit and hemoglobin remained stable. No relationship was noted between serum ferritin and iron absorption but transferrin saturation (54%), MCV (7%), and hematocrit (6%) accounted for 67% of the variation in iron absorption (P < 0.001). CONCLUSIONS: At intakes of 0.8-1.4  mg ·â€Škg-1 ·â€Šday-1, iron absorption is not dose-dependent nor affected by iron stores. Only when iron delivery to the tissues decreases does absorption increase to meet needs in these otherwise normal and rapidly growing infants.

Effect of Enteral Protein Amount on Growth and Health Outcomes in Very-Low-Birth-Weight Preterm Infants: Phase II of the Pre-B Project and an Evidence Analysis Center Systematic Review.

Adequate protein intake by very-low-birth-weight preterm infants (≤1,500 g at birth) is essential to optimize growth and development. The estimated needs for this population are the highest of all humans, however, the recommended intake has varied greatly over the past several years. A literature search was conducted in PubMed, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central databases to identify randomized controlled trials evaluating the effect of prescribed protein intake and identified outcomes. Articles were screened by 2 reviewers, risk of bias was assessed, data were synthesized quantitatively and narratively, and each outcome was separately graded for certainty of evidence. The literature search retrieved 25,384 articles and 2 trials were included in final analysis. No trials were identified that evaluated effect of protein amount on morbidities or mortality. Moderate certainty evidence found a significant difference in weight gain when protein intake of greater than 3.5 g/kg/day from preterm infant formula was compared with lower intakes. Low-certainty evidence found no evidence of effect of protein intake of 2.6 vs 3.1 vs 3.8 g/kg/day on length, head circumference, skinfold measurements, or mid-arm circumference. Low-certainty evidence found some improvement in development measures when higher protein intake of 3.8 vs 3.1 vs 2.6 g/kg/day were compared. Low-certainty evidence found no significant difference in bone mineral content when these protein intakes were compared. No studies were identified that compared protein intake greater than 4.0 g/kg/day. This systematic review found that protein intake between 3.5 and 4.0 g/kg/day promotes weight gain and improved development.

Exclusive Maternal Milk Compared With Exclusive Formula on Growth and Health Outcomes in Very-Low-Birthweight Preterm Infants: Phase II of the Pre-B Project and an Evidence Analysis Center Systematic Review.

As part of the Pre-B Project, a systematic review was conducted to evaluate associations between exclusive maternal milk (≥75%) intake and exclusive formula intake and growth and health outcomes in very-low-birthweight (VLBW) preterm infants. The protocols from the Academy of Nutrition and Dietetics' Evidence Analysis Center and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist were followed. Thirteen observational studies were included; 11 studies reported data that could be synthesized in a pooled analysis. The evidence is very uncertain (very low quality) about the effect of exclusive maternal milk on all outcomes due to observational study designs and risk of selection, performance, detection, and reporting bias in most of the included studies. Very-low-quality evidence suggested that providing VLBW preterm infants with exclusive maternal milk was not associated with mortality, risk of necrotizing enterocolitis, sepsis, or developing bronchopulmonary dysplasia, as compared with exclusive preterm formula, but exclusive maternal milk was associated with a lower risk of retinopathy of prematurity (very low certainty). Results may change when additional studies are conducted. There was no difference in weight, length, and head circumference gain between infants fed fortified exclusive maternal milk and infants receiving exclusive preterm formula; however, weight and length gain were lower in infants fed non-fortified exclusive maternal milk. Given the observational nature of human milk research, cause-and-effect evidence was lacking for VLBW preterm infants. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=86829, PROSPERO ID: CRD42018086829.

The Impact of COVID-19 Infection on Labor and Delivery, Newborn Nursery, and Neonatal Intensive Care Unit: Prospective Observational Data from a Single Hospital System.

OBJECTIVE: Since its emergence in late 2019, severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the novel coronavirus that causes novel coronavirus disease 2019 (COVID-19), has spread globally. Within the United States, some of the most affected regions have been New York, and Northern New Jersey. Our objective is to describe the impact of COVID-19 in a large delivery service in Northern New Jersey, including its effects on labor and delivery (L&D), the newborn nursery, and the neonatal intensive care unit (NICU). MATERIALS AND METHODS: Between April 21, 2020 and May 5, 2020, a total of 78 mothers (3.6% of deliveries) were identified by screening history or examination to either be COVID-19 positive or possible positives (persons under investigation). Of the mothers who were tested after admission to L&D, 28% tested positive for SARS-CoV-2. DISCUSSION: Isolation between mother and infant was recommended in 62 cases, either because the mother was positive for SARS-CoV-2 or because the test was still pending. Fifty-four families (87%) agreed to isolation and separation. The majority of infants, 51 (94%), were initially isolated on the newborn nursery. Six needed NICU admission. No infants had clinical evidence of symptomatic COVID-19 infection. Fourteen infants whose mothers were positive for SARS-CoV-2, and who had been separated from the mother at birth were tested for SARS-CoV-2 postnatally. All were negative. RESULTS: COVID-19 posed a significant burden to mothers, infants, and staff over the 5-week study period. The yield from screening mothers for COVID-19 on L&D was high. Most families accepted the need for postnatal isolation and separation of mother and newborn. CONCLUSION: Our study suggests that the transmission of SARS-CoV-2 from mother to her fetus/newborn seems to be uncommon if appropriate separation measures are performed at birth. KEY POINTS: · The yield of targeted testing for SARS-CoV-2, on mothers on Labor and Delivery is high.. · Agreement to separation of mothers and infants to reduce transmission of SARS-CoV-2 was high.. · The incidence of symptomatic COVID-19 in newborns is low, if appropriate separation occurs at birth..

"Extrauterine growth restriction" and "postnatal growth failure" are misnomers for preterm infants.

Preterm infants are increasingly diagnosed as having "extrauterine growth restriction" (EUGR) or "postnatal growth failure" (PGF). Usually EUGR/PGF is diagnosed when weight is <10th percentile at either discharge or 36-40 weeks postmenstrual age. The reasons why the phrases EUGR/PGF are unhelpful include, they: (i) are not predictive of adverse outcome; (ii) are based only on weight without any consideration of head or length growth, proportionality, body composition, or genetic potential; (iii) ignore normal postnatal weight loss; (iv) are usually assessed prior to growth slowing of the reference fetus, around 36-40 weeks, and (v) are usually based on an arbitrary statistical growth percentile cut-off. Focus on EUGR/PGF prevalence may benefit with better attention to nutrition but may also harm with nutrition delivery above infants' actual needs. In this paper, we highlight challenges associated with such arbitrary cut-offs and opportunities for further refinement of understanding growth and nutritional needs of preterm neonates.

Analysis of Disialyllacto-N-Tetraose (DSLNT) Content in Milk From Mothers of Preterm Infants.

BACKGROUND: Human milk oligosaccharides (HMO) have been recognized for the protective effects they may elicit among high risk infants. One HMO, disialyllacto-N-tetraose (DSLNT), has been shown to reduce the risk for developing necrotizing enterocolitis in preterm infants. RESEARCH AIMS: To measure DSLNT content in the human milk from mothers of preterm infants, and (1) assess variability; (2) establish correlations between maternal factors and/or an infant's risk for developing necrotizing enterocolitis; and (3) determine the effect of pasteurization. METHODS: DSLNT was measured in 84 samples of preterm milk, in human donor milk, and in Holder and flash pasteurized samples. Preterm infant outcomes were assessed by medical record review. RESULTS: DSLNT content of mother's own milk was highly variable and decreased significantly with increasing postnatal age. Four preterm infants (6.7%) developed necrotizing enterocolitis (Bell stage II or greater), 4 (6.7%) developed spontaneous intestinal perforation, and 1 developed both. DSLNT z-score was below the age-specific M within 8 (89%) of the 9 milk samples from mothers whose babies developed necrotizing enterocolitis (p = 0.039), but the DSLNT content did not differ between infants with necrotizing enterocolitis, spontaneous intestinal perforation, or neither condition (p > 0.1). DSLNT levels were significantly reduced in samples of donor milk compared to mothers' own milk (p = 0.0051). Pasteurization did not significantly reduce DSLNT content. CONCLUSIONS: DSLNT content of human milk is variable and may be lower in milk from mothers whose infants developed necrotizing enterocolitis. DSLNT content is unaffected by flash or Holder pasteurization.

Developmental regulation of the gut-liver (FGF19-CYP7A1) axis in neonates.

Introduction: Fibroblast growth factor 19 (FGF19) is a gut-derived hormone that regulates the expression of CYP7A1, the rate-limiting enzyme in bile acid (BA) synthesis pathway. Dysregulation of the FGF19-CYP7A1 (gut-liver) axis is associated with cholestatic liver disease. Infants, especially preterm infants and those with intestinal failure are at high risk for developing cholestatic liver disease. The activity of the gut-liver axis has not been characterized in this population. Our objective was to assess relationships between circulating FGF19 concentrations and CYP7A1 activity in neonates.Materials and methods: Plasma samples were obtained longitudinally from term and preterm infants (22-41-week gestation) hospitalized in a neonatal intensive care unit. Infants with congenital and acquired gastrointestinal disorders were excluded. Plasma levels of 7α-hydroxy-4-cholesten-3-one (C4), a marker of CYP7A1 activity, were quantified using HPLC-MS/MS. Plasma FGF19 concentrations were quantified by ELISA. Data were analyzed using linear regression models and structural equation modeling.Results: One hundred eighty-one plasma samples were analyzed from 62 infants. C4 concentrations were undetectable prior to 30 weeks' gestation and, thereafter, increased with advancing gestational age and with volume of enteral feeds. They did not correlate with serum FGF19 concentrations, which decreased with advancing gestational age and volume of enteral feeds.Discussion: The activity of CYP7A1, the rate-limiting BA synthetic enzyme in adults, is developmentally regulated and undetectable in newborns less than 30 weeks' gestation. FGF19 concentrations do not correlate with CYP7A1 activity, suggesting that the gut-liver axis is not functional in infants. High FGF19 concentrations at birth in infants less than 37 weeks' gestation is a novel finding, and its source and role in preterm infants warrants further investigation.Rationale: The intestinal hormone, fibroblast growth factor 19 (FGF19), is a major regulator of CYP7A1, the rate limiting enzyme in bile acid (BA) synthesis. Recently, dysregulation of the gut-liver (FGF19-CYP7A1) axis has been implicated in adult cholestatic liver disease, and animal studies have shown that exogenous FGF19 protects against liver injury. Given the therapeutic potential related to this signaling pathway, we sought to characterize the association between CYP7A1 and FGF19 in term and preterm infants. We conducted a prospective, observational study that measured in vivo CYP7A1 activity and FGF19 concentrations in 62 term and preterm infants (n = 181 samples). We found that CYP7A1 activity is developmentally regulated; its activity is undetectable prior to 30 weeks' gestation and increases with advancing gestational age and volume of enteral feeds. Contrary to expectation, we demonstrated that FGF19 is expressed at birth in preterm infants and decreases over time, even as enteral feeds increase. Using structural equation modeling, we were able to show that CYP7A1 activity does not correlate with FGF19 concentrations. Our results suggest that the gut-liver axis is not upregulated in preterm and term infants and that neonates with cholestatic liver disease will unlikely benefit from supplemental FGF19. We also report novel findings of elevated FGF19 concentrations in preterm infants at birth and speculate that there may be an extra-intestinal source of FGF19 that is developmentally expressed in these infants.

Macronutrient Digestion and Absorption in the Preterm Infant.

The human fetus receives oral nutrition through swallowed amniotic fluid and this makes a significant nutritional contribution to the fetus. Postnatally, macronutrient absorption and digestion appear to function well in the preterm infant. Although pancreatic function is relatively poor, the newborn infant has several mechanisms to overcome this. These include a range of digestive enzymes in human milk, novel digestive enzymes involved in fat and protein digestion that do not appear to be present in the older child or adult, and the presence of a Bifidobacterium-rich colonic microbiome that may "scavenge" unabsorbed macronutrients and make them available to the infant.