Machine Learning-Based Prediction of Changes in the Clinical Condition of Patients With Complex Chronic Diseases: 2-Phase Pilot Prospective Single-Center Observational Study.

BACKGROUND: Functional impairment is one of the most decisive prognostic factors in patients with complex chronic diseases. A more significant functional impairment indicates that the disease is progressing, which requires implementing diagnostic and therapeutic actions that stop the exacerbation of the disease. OBJECTIVE: This study aimed to predict alterations in the clinical condition of patients with complex chronic diseases by predicting the Barthel Index (BI), to assess their clinical and functional status using an artificial intelligence model and data collected through an internet of things mobility device. METHODS: A 2-phase pilot prospective single-center observational study was designed. During both phases, patients were recruited, and a wearable activity tracker was allocated to gather physical activity data. Patients were categorized into class A (BI≤20; total dependence), class B (2060; moderate or mild dependence, or independent). Data preprocessing and machine learning techniques were used to analyze mobility data. A decision tree was used to achieve a robust and interpretable model. To assess the quality of the predictions, several metrics including the mean absolute error, median absolute error, and root mean squared error were considered. Statistical analysis was performed using SPSS and Python for the machine learning modeling. RESULTS: Overall, 90 patients with complex chronic diseases were included: 50 during phase 1 (class A: n=10; class B: n=20; and class C: n=20) and 40 during phase 2 (class B: n=20 and class C: n=20). Most patients (n=85, 94%) had a caregiver. The mean value of the BI was 58.31 (SD 24.5). Concerning mobility aids, 60% (n=52) of patients required no aids, whereas the others required walkers (n=18, 20%), wheelchairs (n=15, 17%), canes (n=4, 7%), and crutches (n=1, 1%). Regarding clinical complexity, 85% (n=76) met patient with polypathology criteria with a mean of 2.7 (SD 1.25) categories, 69% (n=61) met the frailty criteria, and 21% (n=19) met the patients with complex chronic diseases criteria. The most characteristic symptoms were dyspnea (n=73, 82%), chronic pain (n=63, 70%), asthenia (n=62, 68%), and anxiety (n=41, 46%). Polypharmacy was presented in 87% (n=78) of patients. The most important variables for predicting the BI were identified as the maximum step count during evening and morning periods and the absence of a mobility device. The model exhibited consistency in the median prediction error with a median absolute error close to 5 in the training, validation, and production-like test sets. The model accuracy for identifying the BI class was 91%, 88%, and 90% in the training, validation, and test sets, respectively. CONCLUSIONS: Using commercially available mobility recording devices makes it possible to identify different mobility patterns and relate them to functional capacity in patients with polypathology according to the BI without using clinical parameters.

A proposal to reduce the amount of permethrin entering wastewater resultant from topical use to treat scabies.

The incidence of scabies is rising in the last years. Subsequently, the use of pharmaceuticals to treat the disease has also increased. Treatment with topical permethrin is usually recommended as a first line agent. This substance is also an aquatic contaminant that is toxic for many non-target organisms, and has been included as a priority substance in the recently published proposal of the European Water Framework Directive. Current guidelines neglect the potential environmental impact of this drug, recommending that the cream should be applied head to toe and "washed off after 8-12 h". Recently, a wiping procedure before hand washing after application of the topical treatment resulted in a 66 % reduction of the amount of diclofenac released in wastewater. The authors suggested that this method could be explored for other topical treatments. In the case of scabiosis, a protocol implicating the whole body needs to be designed. The absorption of topical permethrin is low. Considering the growing incidence of scabies, the amount of the pyrethroid reaching the environment may also be increasing. Therefore, we believe that applying the wiping procedure to the case of topical permethrin deserves consideration. Other measures to minimize the amount of permethrin residues reaching wastewater by washing clothes and bed linen such as wearing single-use pijamas should also be explored. In conclusion, we need to apply a One Health approach in the treatment with scabies, without neglecting the environmental impact of pharmaceuticals. It is not rational to forget drugs once they go down the drain.

ENSO effects on the relationship between aerosols and evapotranspiration in the south of the Amazon biome.

The effects of the El Nino-Southern Oscillation (ENSO) events have local, regional, and global consequences for water regimes, causing floods or extreme drought events. Tropical forests are strongly affected by ENSO, and in the case of the Amazon, its territorial extension allows for a wide variation of these effects. The prolongation of drought events in the Amazon basin contributes to an increase in gas and aerosol particle emissions mainly caused by biomass burning, which in turn alter radiative fluxes and evapotranspiration rates, cyclically interfering with the hydrological regime. The ENSO effects on the interactions between aerosol particles and evapotranspiration is a critical aspect to be systematically investigated. Therefore, this study aimed to evaluate the ENSO effect on a site located on the southern portion of the Amazonian region. In addition to quantifying and testing possible differences between aerosols and evapotranspiration under different ENSO classes (El Niño, La Niña and Neutrality), this study also evaluated possible variations in evapotranspiration as a function of the aerosol load. A highly significant difference was found for air temperature, relative humidity and aerosol load between the El Niño and La Niña classes. For evapotranspiration, significant differences were found for the El Niño and La Niña classes and for El Niño and Neutrality classes. Under the Neutrality class, the aerosol load correlated significantly with evapotranspiration, explaining 20% of the phenomenon. Under the El Niño and La Niña classes, no significant linear correlation was found between aerosol load and evapotranspiration. However, the results showed that for the total data set, there is a positive and significant correlation between aerosol and evapotranspiration. It increases with a quadratic fit, i.e., the aerosol favors evapotranspiration rates up to a certain concentration threshold. The results obtained in this study can help to understand the effects of ENSO events on atmospheric conditions in the southern Amazon basin, in addition to elucidating the role of aerosols in feedback to the water cycle in the region.

Perfect Match Genomic Landscape strategy: Refinement and customization of reference genomes.

When addressing a genomic question, having a reliable and adequate reference genome is of utmost importance. This drives the necessity to refine and customize reference genomes (RGs). Our laboratory has recently developed a strategy, the Perfect Match Genomic Landscape (PMGL), to detect variation between genomes [K. Palacios-Flores et al.Genetics 208, 1631-1641 (2018)]. The PMGL is precise and sensitive and, in contrast to most currently used algorithms, is nonstatistical in nature. Here we demonstrate the power of PMGL to refine and customize RGs. As a proof-of-concept, we refined different versions of the Saccharomyces cerevisiae RG. We applied the automatic PMGL pipeline to refine the genomes of microorganisms belonging to the three domains of life: the archaea Methanococcus maripaludis and Pyrococcus furiosus; the bacteria Escherichia coli, Staphylococcus aureus, and Bacillus subtilis; and the eukarya Schizosaccharomyces pombe, Aspergillus oryzae, and several strains of Saccharomyces paradoxus. We analyzed the reference genome of the virus SARS-CoV-2 and previously published viral genomes from patients' samples with COVID-19. We performed a mutation-accumulation experiment in E. coli and show that the PMGL strategy can detect specific mutations generated at any desired step of the whole procedure. We propose that PMGL can be used as a final step for the refinement and customization of any haploid genome, independently of the strategies and algorithms used in its assembly.

Teleneurology-Enabled Determination of Death by Neurologic Criteria After Cardiac Arrest or Severe Neurologic Injury.

OBJECTIVE: To determine whether providing teleneurology (TN) consultations aiding in determination of death by neurologic criteria (DNC) to a bedside intensivist is feasible and whether timely access and expert input increase the quality of the DNC examination and identification of potential organ donors, we reviewed retrospective data related to outcomes of such consultations. METHODS: Between November 2017 and March 2019, TN consults were requested for sequential comatose patients in the intensive care unit (ICU). We recorded patients' demographic information, causes leading to coma or suspected DNC, and the results of TN consultations. We obtained data on the number of referrals to the organ bank and number of organ donors. RESULTS: Ninety-nine consults were performed with a median time from request to start of the consult of 20.2 minutes (interquartile range 5.4-65.3 minutes). Eighty consults were requested for determination of prognosis, whereas 19 consults were requested for supervision of the DNC examination. In 1 of 80 (1.2%) prognostication consults, the patient was determined by the neurologist to require assessment of DNC and was found to meet DNC criteria; determination of DNC occurred in 11 of the 19 (57.9%) consultations for a supervised DNC examination. In a comparison of the pre-TN (94 months) and post-TN (17 months) periods, there was 2.56-fold increase in the proportion of patients meeting DNC criteria who were medically suitable for donation (pre-TN 8.9% vs post-TN 21.1%, p = 0.02) and a 2.12-fold increase in the proportion of donors (pre-TN 6.14% vs post-TN 13.1%, p = 0.14). CONCLUSIONS: It is feasible to perform TN consultations for patients with severe neurologic damage and to allow expert supervision for DNC examination. Having a teleneurologist as part of the ICU assessment team helped differentiate severe neurologic deficits from DNC and was associated with increase in organ donation.

Teleneurology Consultations for Prognostication and Brain Death Diagnosis.

The diagnosis of brain death and the determination of neurologic prognosis following cardiac arrest are important reasons for neurology consultation in the intensive care unit. In hospitals without access to neurology consultation, it may be challenging to address these important questions with high reliability in a timely manner. The American Academy of Neurology has established consensus criteria for diagnosis of brain death, which include (i) comatose state; (ii) presence of apnea; and (iii) absence of brainstem reflexes in the setting of a diagnosis of underlying brain injury compatible with brain death. It has recently been shown that virtual assessment of coma using standardized scales is feasible with good inter-rater reliability. The supervision of apnea testing and the neurologic examination of the brainstem by a remote neurologist are possible if conducted in conjunction with a well-trained and experienced bedside team. In this communication, we explore the essential clinical and legal framework that can support using virtual teleconsultations to address this complex topic.

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Prediction and identification of recurrent genomic rearrangements that generate chimeric chromosomes in Saccharomyces cerevisiae.

Genomes are dynamic structures. Different mechanisms participate in the generation of genomic rearrangements. One of them is nonallelic homologous recombination (NAHR). This rearrangement is generated by recombination between pairs of repeated sequences with high identity. We analyzed rearrangements mediated by repeated sequences located in different chromosomes. Such rearrangements generate chimeric chromosomes. Potential rearrangements were predicted by localizing interchromosomal identical repeated sequences along the nuclear genome of the Saccharomyces cerevisiae S288C strain. Rearrangements were identified by a PCR-based experimental strategy. PCR primers are located in the unique regions bordering each repeated region of interest. When the PCR is performed using forward primers from one chromosome and reverse primers from another chromosome, the break point of the chimeric chromosome structure is revealed. In all cases analyzed, the corresponding chimeric structures were found. Furthermore, the nucleotide sequence of chimeric structures was obtained, and the origin of the unique regions bordering the repeated sequence was located in the expected chromosomes, using the perfect-match genomic landscape strategy (PMGL). Several chimeric structures were searched in colonies derived from single cells. All of the structures were found in DNA isolated from each of the colonies. Our findings indicate that interchromosomal rearrangements that generate chimeric chromosomes are recurrent and occur, at a relatively high frequency, in cell populations of S. cerevisiae.

Impact of Telemedicine in Pediatric Postoperative Care.

Background: A shortage of pediatricians and long wait times in the hospitals render more efficient follow-up visits increasingly important. Virtual visits between physician and patient offer a solution to this problem. Increased awareness, improved technology, and efficient scheduling methods will contribute to the quality and adoption of telemedicine programs. Introduction: The aim of this study was to analyze the impact of pediatric telemedicine on wait times and visit durations, as compared with in-person visits. A secondary goal was to assess the efficiency of different scheduling methods for virtual visits. Materials and Methods: The study included >800 postoperative virtual visits from urology, cardiovascular surgery, and ophthalmology, comprising data on wait times, visit duration, and postvisit satisfaction collected through SBR Health and Redcap. In-person visit data were collected on 14 patients in urology, and satisfaction scores were obtained through Press Ganey for urology and ophthalmology. Results: Patients reported very high satisfaction with virtual visits and benefitted from reduced wait times, while receiving care of comparable duration and quality. Longer blocks of time scheduled exclusively for virtual visits correlated with shorter wait times. Discussion: Supplementing health care with telemedicine is a viable way to provide patient-centered care. Implemented effectively, a telemedicine program can contribute greatly to the value a hospital provides to its patients. Conclusions: Virtual visits provide an efficient way to conduct postoperative visits, reducing wait times and increasing physician efficiency while retaining high satisfaction and quality of care.

Precise detection of de novo single nucleotide variants in human genomes.

The precise determination of de novo genetic variants has enormous implications across different fields of biology and medicine, particularly personalized medicine. Currently, de novo variations are identified by mapping sample reads from a parent-offspring trio to a reference genome, allowing for a certain degree of differences. While widely used, this approach often introduces false-positive (FP) results due to misaligned reads and mischaracterized sequencing errors. In a previous study, we developed an alternative approach to accurately identify single nucleotide variants (SNVs) using only perfect matches. However, this approach could be applied only to haploid regions of the genome and was computationally intensive. In this study, we present a unique approach, coverage-based single nucleotide variant identification (COBASI), which allows the exploration of the entire genome using second-generation short sequence reads without extensive computing requirements. COBASI identifies SNVs using changes in coverage of exactly matching unique substrings, and is particularly suited for pinpointing de novo SNVs. Unlike other approaches that require population frequencies across hundreds of samples to filter out any methodological biases, COBASI can be applied to detect de novo SNVs within isolated families. We demonstrate this capability through extensive simulation studies and by studying a parent-offspring trio we sequenced using short reads. Experimental validation of all 58 candidate de novo SNVs and a selection of non-de novo SNVs found in the trio confirmed zero FP calls. COBASI is available as open source at https://github.com/Laura-Gomez/COBASI for any researcher to use.

Bat-inspired integrally actuated membrane wings with leading-edge sensing.

This paper presents a numerical investigation on the closed-loop performance of a two-dimensional actuated membrane wing with fixed supports. The proposed concept mimics aerodynamic sensing and actuation mechanisms found in bat wings to achieve robust outdoor flight: firstly, variable membrane tension, which is obtained in bats through skeleton articulation, is introduced through a dielectric-elastomer construction; secondly, leading-edge airflow sensing is achieved with bioinspired hair-like sensors. Numerical results from a coupled aero-electromechanical model show that this configuration can allow for the tracking of prescribed lift coefficient signals in the presence of disturbances from atmospheric gusts. In particular, disturbance measurements through the hair sensor (a feedforward control strategy) are seen to provide substantial advantage with respect to a reactive (feedback) control strategy determining a reduction of the oscillations of the lift coefficient.

Acute modulation of the cholinergic system in the mouse brain detected by pharmacological resting-state functional MRI.

INTRODUCTION: The cholinergic system is involved in learning and memory and is affected in neurodegenerative disorders such as Alzheimer's disease. The possibility of non-invasively detecting alterations of neurotransmitter systems in the mouse brain would greatly improve early diagnosis and treatment strategies. The hypothesis of this study is that acute modulation of the cholinergic system might be reflected as altered functional connectivity (FC) and can be measured using pharmacological resting-state functional MRI (rsfMRI). MATERIAL AND METHODS: Pharmacological rsfMRI was performed on a 9.4T MRI scanner (Bruker BioSpec, Germany) using a gradient echo EPI sequence. All mice were sedated with medetomidine. C57BL/6 mice (N = 15/group) were injected with either saline, the cholinergic antagonist scopolamine, or methyl-scopolamine, after which rsfMRI was acquired. For an additional group (N = 8), rsfMRI scans of the same mouse were acquired first at baseline, then after the administration of scopolamine and finally after the additional injection of the cholinergic agonist milameline. Contextual memory was evaluated with the same setup as the pharmacological rsfMRI using the passive avoidance behavior test. RESULTS: Scopolamine induced a dose-dependent decrease of FC between brain regions involved in memory. Scopolamine-induced FC deficits could be recovered completely by milameline for FC between the hippocampus-thalamus, cingulate-retrosplenial, and visual-retrosplenial cortex. FC between the cingulate-rhinal, cingulate-visual and visual-rhinal cortex could not be completely recovered by milameline. This is consistent with the behavioral outcome, where milameline only partially recovered scopolamine-induced contextual memory deficits. Methyl-scopolamine administered at the same dose as scopolamine did not affect FC in the brain. CONCLUSION: The results of the current study are important for future studies in mouse models of neurodegenerative disorders, where pharmacological rsfMRI may possibly be used as a non-invasive read-out tool to detect alterations of neurotransmitter systems induced by pathology or treatment.

Diffusion kurtosis imaging and high-resolution MRI demonstrate structural aberrations of caudate putamen and amygdala after chronic mild stress.

The pathophysiology of major depressive disorder (MDD) and other stress related disorders has been associated with aberrations in the hippocampus and the frontal brain areas. More recently, other brain regions, such as the caudate nucleus, the putamen and the amygdala have also been suggested to play a role in the development of mood disorders. By exposing rats to a variety of stressors over a period of eight weeks, different phenotypes, i.e. stress susceptible (anhedonic-like) and stress resilient animals, can be discriminated based on the sucrose consumption test. The anhedonic-like animals are a well validated model for MDD. Previously, we reported that in vivo diffusion kurtosis imaging (DKI) of the hippocampus shows altered diffusion properties in chronically stressed rats independent of the hedonic state and that the shape of the right hippocampus is differing among the three groups, including unchallenged controls. In this study we evaluated diffusion properties in the prefrontal cortex, caudate putamen (CPu) and amygdala of anhedonic-like and resilient phenotypes and found that mean kurtosis in the CPu was significantly different between the anhedonic-like and resilient animals. In addition, axial diffusion and radial diffusion were increased in the stressed animal groups in the CPu and the amygdala, respectively. Furthermore, we found that the CPu/brain volume ratio was increased significantly in anhedonic-like animals as compared with control animals. Concurrently, our results indicate that the effects of chronic stress on the brain are not lateralized in these regions. These findings confirm the involvement of the CPu and the amygdala in stress related disorders and MDD. Additionally, we also show that DKI is a potentially important tool to promote the objective assessment of psychiatric disorders.

Different anesthesia regimes modulate the functional connectivity outcome in mice.

PURPOSE: The use of resting-state functional MRI (rsfMRI) in preclinical research is expanding progressively, with the majority of resting-state imaging performed in anesthetized animals. Since anesthesia may change the physiology and, in particular, the neuronal activity of an animal considerably, it may also affect rsfMRI findings. Therefore, this study compared rsfMRI data from awake mice with rsfMRI results obtained from mice anesthetized with α-chloralose (120 mg/kg), urethane (2.5 g/kg), or isoflurane (1%). METHODS: Functional connectivity (FC) was estimated using both independent component analysis (40 components) and ROI-based analysis to zoom in on the effect of different anesthetics on inter-hemispheric FC. RESULTS: The data revealed an important diminishment of cortical interhemispheric FC in both the α-chloralose and urethane groups in comparison with the isoflurane and awake groups. CONCLUSION: When performing FC analysis in anesthetized mice, the impact of anesthetics must be taken into account. The required doses for stable anesthesia during MRI significantly decrease interhemispheric FC.

Resting state FMRI reveals diminished functional connectivity in a mouse model of amyloidosis.

INTRODUCTION: Functional connectivity (FC) studies have gained immense popularity in the evaluation of several neurological disorders, such as Alzheimer's disease (AD). AD is a complex disorder, characterised by several pathological features. The problem with FC studies in patients is that it is not straightforward to focus on a specific aspect of pathology. In the current study, resting state functional magnetic resonance imaging (rsfMRI) is applied in a mouse model of amyloidosis to assess the effects of amyloid pathology on FC in the mouse brain. METHODS: Nine APP/PS1 transgenic and nine wild-type mice (average age 18.9 months) were imaged on a 7T MRI system. The mice were anesthetized with medetomidine and rsfMRI data were acquired using a gradient echo EPI sequence. The data were analysed using a whole brain seed correlation analysis and interhemispheric FC was evaluated using a pairwise seed analysis. Qualitative histological analyses were performed to assess amyloid pathology, inflammation and synaptic deficits. RESULTS: The whole brain seed analysis revealed an overall decrease in FC in the brains of transgenic mice compared to wild-type mice. The results showed that interhemispheric FC was relatively preserved in the motor cortex of the transgenic mice, but decreased in the somatosensory cortex and the hippocampus when compared to the wild-type mice. The pairwise seed analysis confirmed these results. Histological analyses confirmed the presence of amyloid pathology, inflammation and synaptic deficits in the transgenic mice. CONCLUSIONS: In the current study, rsfMRI demonstrated decreased FC in APP/PS1 transgenic mice compared to wild-type mice in several brain regions. The APP/PS1 transgenic mice had advanced amyloid pathology across the brain, as well as inflammation and synaptic deficits surrounding the amyloid plaques. Future studies should longitudinally evaluate APP/PS1 transgenic mice and correlate the rsfMRI findings to specific stages of amyloid pathology.

Levofloxacin-induced delirium in a patient suffering from schizoaffective disorder and multiple sclerosis.

Levofloxacin induced psychiatric adverse effects are rare, although they can be serious. There are just five cases of fluoroquinolone-induced delirium published in the medical literature. To our best knowledge, none of them occurred in psychotic patients. We report a case of a 38-year-old Caucasian man diagnosed with schizoaffective disorder and multiple sclerosis who developed delirium and visual hallucinations after initiating levofloxacin therapy. In psychiatric patients, suspecting levofloxacin could be responsible for the symptoms can be a diagnostic challenge, since they could be interpreted like worsening of the mental state as well. Although levofloxacin-induced delirium is a rare adverse event, physicians should be aware of the occurrence of this serious, but potentially reversible CNS complication of levofloxacin, even in psychotic patients.

Levofloxacin-Induced Delirium in a Patient Suffering from Schizoaffective Disorder and Multiple Sclerosis.

Levofloxacin induced psychiatric adverse effects are rare, although they can be serious. There are just five cases of fluoroquinolone-induced delirium published in the medical literature. To our best knowledge, none of them occurred in psychotic patients. We report a case of a 38-year-old Caucasian man diagnosed with schizoaffective disorder and multiple sclerosis who developed delirium and visual hallucinations after initiating levofloxacin therapy. In psychiatric patients, suspecting levofloxacin could be responsible for the symptoms can be a diagnostic challenge, since they could be interpreted like worsening of the mental state as well. Although levofloxacin-induced delirium is a rare adverse event, physicians should be aware of the occurrence of this serious, but potentially reversible CNS complication of levofloxacin, even in psychotic patients.