Real-World Biomarkers for Pediatric Takayasu Arteritis.

Childhood-onset Takayasu arteritis (TA) is a rare, heterogeneous disease with limited diagnostic markers. Our objective was to identify and classify all candidates for biomarkers of TA diagnosis in children reported in the literature. A systematic literature review (PRISMA) of MEDLINE, EMBASE, Wiley Cochrane Library, ClinicalTrias.gov, and WHO ICTRP for articles related to TA in the pediatric age group between January 2000 and August 2023 was performed. Data on demographics, clinical features, laboratory measurements, diagnostic imaging, and genetic analysis were extracted. We identified 2026 potential articles, of which 52 studies (81% case series) met inclusion criteria. A total of 1067 TA patients were included with a peak onset between 10 and 15 years. Childhood-onset TA predominantly presented with cardiovascular, constitutional, and neurological symptoms. Laboratory parameters exhibited a low sensitivity and specificity. Imaging predominantly revealed involvement of the abdominal aorta and renal arteries, with magnetic resonance angiography (MRA) being the preferred imaging modality. Our review confirms the heterogeneous presentation of childhood-onset TA, posing significant challenges to recognition and timely diagnosis. Collaborative, multinational efforts are essential to better understand the natural course of childhood-onset TA and to identify accurate biomarkers to enhance diagnosis and disease management, ultimately improving patient outcomes.

Patterns of WISC-V Performance in Children with Congenital Heart Disease.

Congenital heart disease (CHD) is one of the most common congenital birth defects. As surgical and interventional techniques have improved, the mortality has been greatly reduced and the focus has shifted to quality of life and long-term outcomes. The impact of CHD on development and cognition is becoming increasingly recognized. However, more research is needed to understand how children with CHD perform across various cognitive and intellectual domains. This study explored the performance of children with CHD on the newest version of the Wechsler Intelligence Scale for Children compared to normative controls. Children with CHD performed more poorly than normal controls across all indices and most subtests with large effect sizes. Additionally, we explored the patterns of impairment across indices and subtests, as well as the relationships between heard disease variables and WISC-V performance. Block design, Digit Span, and Similarities were the most commonly impaired scores in children with CHD, while Symbol Search, Picture Span, Figure Weights, and Vocabulary were least likely to be impaired.

Evaporative silicification in floating microbial mats: patterns of oxygen production and preservation potential in silica-undersaturated streams, El Tatio, Chile.

Microbial mats floating within multiple hydrothermally sourced streams in El Tatio, Chile, frequently exhibit brittle siliceous crusts (~1 mm thick) above the air-water interface. The partially silicified mats contain a diverse assemblage of microbial clades and metabolisms, including cyanobacteria performing oxygenic photosynthesis. Surficial crusts are composed of several amorphous silica layers containing well-preserved filaments (most likely cyanobacteria) and other cellular textures overlying EPS-rich unsilicified mats. Environmental logs, silica crust distribution, and microbial preservation patterns provide evidence for crust formation via repeated cycles of evaporation and silica precipitation. Within the mats, in situ microelectrode profiling reveals that daytime oxygen concentrations and pH values are diminished beneath silica crusts compared with adjacent unencrusted communities, indicating localized inhibition of oxygenic photosynthesis due to light attenuation. As a result, aqueous conditions under encrusted mats have a higher saturation state with regard to amorphous silica compared with adjacent, more active mats where high pH increases silica solubility, likely forming a modest feedback loop between diminished photosynthesis and crust precipitation. However, no fully lithified sinters are associated with floating encrusted mats in El Tatio streams, as both subaqueous and subaerial silica precipitation are limited by undersaturated, low-SiO2 (<150 ppm) stream waters. By contrast, well-cemented sinters can form by evaporation in silica-undersaturated solutions above 200 ppm SiO2 . Floating mats in El Tatio therefore represent a specific sinter preservation window, where evaporation in silica-undersaturated microbial mats produces crusts, which preserve cells and affect mat chemistry, but low-silica concentrations prevent the formation of lasting sinter deposits. Patterns of silica precipitation in El Tatio microbial communities show that the preservation potential of silicifying mats in the rock record is strongly dependent on aqueous silica concentrations.

Morphogenesis of digitate structures in hot spring silica sinters of the El Tatio geothermal field, Chile.

In silica-rich hot spring environments, internally laminated, digitate sinter deposits are often interpreted as bio-mediated structures. The organic components of microbial communities (cell surfaces, sheaths and extracellular polymeric substances) can act as templates for silica precipitation, therefore influencing digitate sinter morphogenesis. In addition to biologic surface-templating effects, various microenvironmental factors (hydrodynamics, local pH and fluctuating wind patterns) can also influence silica precipitation, and therefore the morphology of resulting digitate sinters. Digitate sinter morphology thus depends on the dynamic interplay between microenvironmentally driven silica precipitation and microbial growth, but the relative contributions of both factors are a topic of continuing research. Here we present a detailed study of digitate silica sinters in distal, low-temperature regimes of the El Tatio geothermal field, Chile. This high-altitude geothermal field is extremely arid and windy, and has one of the highest silica precipitation rates found in the world. We find that digitate silica sinters at El Tatio always accrete into the prevailing eastward wind direction and exhibit laminar growth patterns coinciding with day-night cycles of wind- and thermally driven evaporation and rewetting. Subaerial parts of digitate sinters lack preserved organics and sinter textures that would indicate past microbial colonization, while filamentous cyanobacteria with resistant, silicified sheaths only inhabit subaqueous cavities that crosscut the primary laminations. We conclude that, although fragile biofilms of extremophile micro-organisms may have initially been present and templated silica precipitation at the tips of these digitate sinters, the saltation of sand grains and precipitation of silica by recurrent wind- and thermally driven environmental forcing at El Tatio are important, if not dominant factors shaping the morphology of these digitate structures. Our study sheds light on the relative contributions of biogenic and abiogenic factors in sinter formation in geothermal systems, with geobiological implications for the cautious interpretation of stromatolite-like features in ancient silica deposits on Earth and Mars.

Formation and Preservation of Microbial Palisade Fabric in Silica Deposits from El Tatio, Chile.

Palisade fabric is a ubiquitous texture of silica sinter found in low temperature (<40°C) regimes of hot spring environments, and it is formed when populations of filamentous microorganisms act as templates for silica polymerization. Although it is known that postdepositional processes such as biological degradation and dewatering can strongly affect preservation of these fabrics, the impact of extreme aridity has so far not been studied in detail. Here, we report a detailed analysis of recently silicified palisade fabrics from a geyser in El Tatio, Chile, tracing the progressive degradation of microorganisms within the silica matrix. This is complemented by heating experiments of natural sinter samples to assess the role of diagenesis. Sheathed cyanobacteria, identified as Leptolyngbya sp., were found to be incorporated into silica sinter by irregular cycles of wetting, evaporation, and mineral precipitation. Transmission electron microscopy analyses revealed that nanometer-sized silica particles are filling the pore space within individual cyanobacterial sheaths, giving rise to their structural rigidity to sustain a palisade fabric framework. Diagenesis experiments further show that the sheaths of the filaments are preferentially preserved relative to the trichomes, and that the amount of water present within the sinter is an important factor for overall preservation during burial. This study confirms that palisade fabrics are efficiently generated in a highly evaporative geothermal field, and that these biosignatures can be most effectively preserved under dry diagenetic conditions.

Use of a Graphic Memoir to Enhance Clinicians' Understanding of and Empathy for Patients with Parkinson Disease.

CONTEXT: Parkinson disease (PD) can be physically, emotionally, and financially burdensome. Understanding its impact from the patient's perspective is an important way to sensitize clinicians to the challenges of living with PD. OBJECTIVE: To evaluate whether a book-length graphic memoir (an illness story in comic form) can help clinicians appreciate PD from the patient's perspective. DESIGN: A convergent mixed-methods study of clinicians working in a multidisciplinary movement disorders clinic. Participants read My Degeneration and completed preintervention and post-intervention questionnaires. They also attended a book group discussion. Quantitative findings were compared before and after the intervention, and qualitative data were analyzed for themes. MAIN OUTCOME MEASURES: Clinicians': 1) confidence in understanding patients' experiences with PD, 2) knowledge about PD, and 3) empathy toward patients and families. RESULTS: After reading the book, participants' confidence in understanding patients' experiences with PD increased significantly in the areas of stigma and disease impact on patients and families. Clinical knowledge was unchanged. Qualitative analysis revealed 3 main themes: 1) the book provides a meaningful way for clinicians to learn about the experience of living with PD; 2) the medium of comics engages clinicians in ways different from other mediums; and 3) benefits of the book may extend beyond the clinical team. CONCLUSION: Clinicians who read My Degeneration gained insight into the psychosocial effects of PD on patients and their loved ones. The book helped facilitate deeper understanding of patients' experiences living with PD and fostered greater empathy and self-reflection.

A Collaborative Response to Provocative Comments in a Medical School.

This article was migrated. The article was marked as recommended. In 2018, anonymous online provocative comments were submitted to student leaders of a Syrian Refugee Initiative (SRI) at the Penn State College of Medicine. This triggered a series of actions with students and medical school leaders aimed at identifying the person who submitted the comments, trying to understand mutual perspectives, and managing the impact of the event on the student body. We describe the history of our college's commitment to humanism and how the SRI was a direct outgrowth of that culture. Voices of the student leaders who were directly impacted by the provocative comments and educational leaders who worked to resolve the crisis are presented. We also describe a collaborative process that involved engaging cybersecurity experts to identify the perpetrator, and share how the students and educational leaders were able to develop trust despite initial skepticism by students over the leadership's avowed commitment to taking the hate speech seriously. While the perpetrator was never identified and opportunities for improvement were identified along the way, by including student leaders in the process, students and administrators were able to develop trust and reach reasonable closure on this disturbing event. Take home messages are presented to guide other institutions in navigating instances of provocative comments or speech.

Graphic Pathographies and the Ethical Practice of Person-Centered Medicine.

Graphic medicine is a swiftly growing movement that explores, theoretically and practically, the use of comics in medical education and patient care. At the heart of graphic medicine are graphic pathographies, stories of illness conveyed in comic form. These stories are helpful tools for health care professionals who seek new insight into the personal, lived experience of illness and for patients who want to learn more about their disease from others who have actually experienced it. Featuring excerpts from five graphic pathographies, this essay illustrates how the medium can be used to educate patients and enhance empathy in health care professionals, particularly with regard to informed consent and end-of-life issues.

Exercise Effects on Adipose Tissue Postprandial Lipolysis and Blood Flow in Children.

Poor suppression of lipolysis and blunted increase in blood flow after meal ingestion in obese adults may indicate resistance to the antilipolytic action of insulin. Exercise may be used to normalize lipolytic responses to food intake by increasing insulin sensitivity. PURPOSE: To determine if acute bouts of aerobic exercise and/or excise training alter lipolytic and blood flow responses to food intake in lean (LN) and obese (OB) children. METHODS: Sixty-five children (9-11 yr) were randomized into acute exercise (EX: 16 LN and 28 OB) or control (CON: 9 LN and 12 OB) groups that exercised (EX), or rested (CON) between standardized breakfast and lunch. Microdialysis probes were inserted into the subcutaneous abdominal adipose tissue to monitor interstitial glycerol (lipolysis) and blood flow. Changes in interstitial glycerol and nutritive flow were calculated from dialysate samples before and after each meal. A subgroup (OB = 15 and LN = 9) from the acute exercise group underwent 16 wk of aerobic exercise training. RESULTS: Poor suppression of lipolysis and a blunted increase in adipose tissue nutritive blood flow in response to breakfast was associated with BMI percentile (r = 0.3, P < 0.05). These responses were normalized at lunch in the OB in the EX (P < 0.05), but not in OB in the CON. Sixteen weeks of exercise training did not improve meal-induced blood flow and marginally altered the antilipolytic response to the two meals (P = 0.06). CONCLUSIONS: Daily bouts of acute aerobic exercise should be used to improve the antilipolytic and nutritive blood flow response to a subsequent meal in obese children.

Team Investment and Longitudinal Relationships: An Innovative Global Health Education Model.

PROBLEM: Increasing student interest in global health has resulted in medical schools offering more global health opportunities. However, concerns have been raised, particularly about one-time, short-term experiences, including lack of follow-through for students and perpetuation of unintentional messages of global health heroism, neocolonialism, and disregard for existing systems and communities of care. Medical schools must develop global health programs that address these issues. APPROACH: The Global Health Scholars Program (GHSP) was created in 2008-2009 at Penn State College of Medicine. This four-year program is based on values of team investment and longitudinal relationships and uses the service-learning framework of preparation, service, and reflection. Teams of approximately five students, with faculty oversight, participate in two separate monthlong trips abroad to the same host community in years 1 and 4, and in campus- and Web-based activities in years 2 and 3. OUTCOMES: As of December 2016, 191 students have been accepted into the GHSP. Since inception, applications have grown by 475% and program sites have expanded from one to seven sites on four continents. The response from students has been positive, but logistical challenges persist in sustaining team investment and maintaining longitudinal relationships between student teams and host communities. NEXT STEPS: Formal methods of assessment should be used to compare the GHSP model with more traditional approaches to global health education. Other medical schools with similar aims can adapt the GHSP model to expand their global health programming.