Measuring Physical Function in the PICU: Development and Testing of a Children's Version (Age 2-18 yr) of the Chelsea Critical Care Physical Assessment Tool.

OBJECTIVES: To adapt and develop a reliable and easily administered outcome measure of physical and respiratory function in critically ill children in the PICU. DESIGN: Modified Delphi study to adapt the Chelsea Critical Care Physical Assessment (CPAx) tool for use in children 2-18 years old, with subsequent prospective testing in a single-center cohort. SETTING: Single-center tertiary PICU. SUBJECTS: Delphi process in 27 panelists (including physiotherapists, occupational therapists, and pediatric intensivists from seven countries from January 2018 to March 2018). Cohort study in 54 patients admitted to PICU for greater than 24 hours over a 3-month period (April 2018 to June 2018), with median age 5.5 years (interquartile range [IQR], 3-12.75 yr), 33 of 54 male, and 38 of 54 invasively ventilated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three Delphi iterations were required to reach greater than or equal to 80% consensus in all the children's CPAx (cCPAx) items. In the subsequent cohort study, six physiotherapists used the cCPAx tool and scored 54 participants, with a total 106 observations. The median cCPAx tool score was 14.50 (IQR, 3-25) out of a possible total of 50. Inter-rater reliability for 30 randomly selected participants was excellent (intraclass correlation coefficient, 0.998). Completion rate of cCPAx in the 54 patients occurred in 78 of 106 occasions (74%). CONCLUSIONS: The cCPAx tool content that was developed using Delphi methodology provided a feasible and clinically relevant tool for use in assessing physical morbidity in PICU patients 2-18 years old. Overall, the cCPAx scores were low, demonstrating low levels of physical function and high levels of immobility during PICU care.

Crystal size, shape, and conformational changes drive both the disappearance and reappearance of ritonavir polymorphs in the mill.

Organic compounds can crystallize in different forms known as polymorphs. Discovery and control of polymorphism is crucial to the pharmaceutical industry since different polymorphs can have significantly different physical properties which impacts their utilization in drug delivery. Certain polymorphs have been reported to 'disappear' from the physical world, irreversibly converting to new ones. These unwanted polymorph conversions, initially prevented by slow nucleation kinetics, are eventually observed driven by significant gains in thermodynamic stabilities. The most infamous of these cases is that of the HIV drug ritonavir (RVR): Once its reluctant form was unwillingly nucleated for the first time, its desired form could no longer be produced with the same manufacturing process. Here we show that RVR's extraordinary disappearing polymorph as well as its reluctant form can be consistently produced by ball-milling under different environmental conditions. We demonstrate that the significant difference in stability between its polymorphs can be changed and reversed in the mill-a process we show is driven by crystal size as well as crystal shape and conformational effects. We also show that those effects can be controlled through careful design of milling conditions since they dictate the kinetics of crystal breakage, dissolution, and growth processes that eventually lead to steady-state crystal sizes and shapes in the mill. This work highlights the huge potential of mechanochemistry in polymorph discovery of forms initially difficult to nucleate, recovery of disappearing polymorphs, and polymorph control of complex flexible drug compounds such as RVR.

Review of neoplasia in fish at a large display aquarium, 2005-2021.

Fish maintained in managed care may have longer lifespans as a result of advances in veterinary medicine and husbandry and reduced risk of predation. Neoplasia is of increasing interest in managed aquarium populations. However, few studies have systematically evaluated neoplasia in managed fish populations. Our objective in this retrospective study was to review and describe neoplasia diagnosed in fish at a large public display aquarium between 2005 and 2021. Any fish diagnosed with neoplasia on either antemortem or postmortem evaluation during the study period was included, and all medical records, biopsy, and autopsy reports were reviewed. Sixty-two fish met the inclusion criteria; 37 species were included in the study population, most of which were tropical freshwater fish (n = 34 fish). Thirty-two types of neoplasia were identified. Ten fish had benign neoplasms, and 53 fish had malignant neoplasms. The most common neoplasms were of epithelial and neuroectodermal origin. The most common site of tumor origin was the skin. Our data suggest that mesenchymal neoplasms may be more common in cold saltwater fish than in tropical freshwater and saltwater fish. Malignant neoplasms were most commonly diagnosed in the study population and should be a top differential when neoplasms are identified in fish managed under human care. Our study contributes to the overall knowledge of the health of aquarium fish and may aid clinicians in characterizing neoplasia that may be present in fish under human care.

A game of raids: Expanding on a game theoretical approach utilising the prisoner's dilemma and ethnography in situ.

In this commentary, we set out the specifics of how Glowacki's game theoretical framework for the evolution of peace could be incorporated within broader cultural evolutionary approaches. We outline a formal proposal for prisoner's dilemma games investigating raid-based conflict. We also centre an ethnographic lens to understand the norms surrounding war and peace in intergroup interactions in small-scale communities.

Agreement Study between Total Leukocyte Count Methodologies in South American Sea Lions (Otaria byronia) and Peruvian Fur Seals (Arctocephalus australis).

South American sea lions (Otaria byronia) and Peruvian fur seals (Arctocephalus australis) are sympatric species inhabiting the coastal Peruvian marine ecosystem. Declining abundance has prompted population health monitoring programs, including temporal monitoring of blood parameters. Several methods exist to determine total leukocyte count, yet no studies have evaluated agreement between methods in pinnipeds. We assessed agreement between total leukocyte counts determined by blood film estimate, Leuko-TIC, HemoCue, and UNOPETTE methods by using archival results from pinnipeds at Punta San Juan, Peru. Blood film estimates were prospectively performed, and resulting data were compared with retrospective leukocyte counts obtained from both species between 2009 and 2019 by using the other methodologies. Agreement in hematologic counts between methods was evaluated using Passing-Bablok regression and Bland-Altman plots (α=0.05). In total, 295 individuals (201 A. australis and 94 O. byronia) were included in the analysis. The blood film estimate method resulted in the highest leukocyte values (P<0.0001). Leuko-TIC counts were significantly higher than HemoCue counts (P<0.0001). Constant and proportional error was present in the agreement between the blood film estimate method and the other methods. Given the variation demonstrated between the different methodologies, additional research is needed to further evaluate agreement between these methodologies. The results underscore the importance of maintaining consistency in leukocyte count methodology for monitoring trends in population health over time. Method consistency may be the more important clinical consideration for assessing changes in leucocyte count over time and avoiding apparent changes depending on the methodology used.

RETROSPECTIVE REVIEW OF NEUROLOGIC DISEASE IN STRANDED ATLANTIC HARBOR SEALS (PHOCA VITULINA CONCOLOR) ALONG THE NEW ENGLAND COAST.

Harbor seals (Phoca vitulina) are a common species admitted to marine mammal rehabilitation facilities. As important indicators of marine ecosystem health, monitoring trends of disease in harbor seal populations is critical. However, few studies have evaluated neurologic disease in this species. The general objective of this study was to retrospectively review and delineate neurologic disease in free-ranging Atlantic harbor seals (P. vitulina concolor) that stranded along the New England (United States) coast and entered a rehabilitation facility between 2006 and 2019. Any Atlantic harbor seal that stranded live along the New England coast during the study period and was diagnosed with neurologic disease on either antemortem or postmortem evaluation was included; medical records and pathologic reports were reviewed. From 211 records, 24 animals met the inclusion criteria. Prevalence of neurologic disease was 11% in the study population and six major categories of neurologic disease were identified including: inflammatory (54%), idiopathic (33%), trauma (4%), congenital (4%), and degenerative (4%). Of the seals diagnosed with neurologic disease, 13 (54%) seals died during rehabilitation, 10 (42%) seals were euthanized, and 1 (4%) seal survived to release. Unique cases seen included a seal with Dandy-Walker-like malformation and another seal with histopathologic findings compatible with neuroaxonal dystrophy, a degenerative process that has not been previously reported in marine mammals. This study contributes to the overall knowledge of the health of free-ranging Atlantic harbor seals and may aid clinicians in characterizing neurologic conditions that may be present in seals undergoing rehabilitation.

The interplay of intra- and intermolecular errors in modeling conformational polymorphs.

Conformational polymorphs of organic molecular crystals represent a challenging test for quantum chemistry because they require careful balancing of the intra- and intermolecular interactions. This study examines 54 molecular conformations from 20 sets of conformational polymorphs, along with the relative lattice energies and 173 dimer interactions taken from six of the polymorph sets. These systems are studied with a variety of van der Waals-inclusive density functionals theory models; dispersion-corrected spin-component-scaled second-order Møller-Plesset perturbation theory (SCS-MP2D); and domain local pair natural orbital coupled cluster singles, doubles, and perturbative triples [DLPNO-CCSD(T)]. We investigate how delocalization error in conventional density functionals impacts monomer conformational energies, systematic errors in the intermolecular interactions, and the nature of error cancellation that occurs in the overall crystal. The density functionals B86bPBE-XDM, PBE-D4, PBE-MBD, PBE0-D4, and PBE0-MBD are found to exhibit sizable one-body and two-body errors vs DLPNO-CCSD(T) benchmarks, and the level of success in predicting the relative polymorph energies relies heavily on error cancellation between different types of intermolecular interactions or between intra- and intermolecular interactions. The SCS-MP2D and, to a lesser extent, ωB97M-V models exhibit smaller errors and rely less on error cancellation. Implications for crystal structure prediction of flexible compounds are discussed. Finally, the one-body and two-body DLPNO-CCSD(T) energies taken from these conformational polymorphs establish the CP1b and CP2b benchmark datasets that could be useful for testing quantum chemistry models in challenging real-world systems with complex interplay between intra- and intermolecular interactions, a number of which are significantly impacted by delocalization error.

Hematology and Biochemistry Panel Reference Intervals for Captive Saddleback Clownfish Amphiprion polymnus and Tomato Clownfish A. frenatus.

Reference intervals of blood analytes are important diagnostic tools that clinicians use as a basis for making clinical decisions and that have been documented for many fish species. Although the effects of dietary supplementation on hematology and blood biochemistry variables in clownfish have been shown, there are no published reference intervals to date for routine hematology and blood biochemistry panels for these popular cultured marine fish (including Amphiprion spp.). The objective of this study was to establish de novo reference intervals for selected hemogram data and, using whole-blood analysis, commonly utilized chemistry analytes in two species of aquacultured clownfish: the Tomato Clownfish Amphiprion frenatus and Saddleback Clownfish A. polymnus. This study is based on blood samples from 25 clinically normal Tomato Clownfish and 38 clinically normal Saddleback Clownfish from two clownfish production facilities in Florida. Guidelines by the American Society for Veterinary Clinical Pathology were followed to generate robust reference intervals from the data collected. We report descriptive statistics and reference intervals for several hematology (n = 12) and biochemistry (n = 8) analytes using a small sample size and a small amount of blood per sample. The blood analyte data from this study are comparable with hematology and biochemistry data that have been reported in other teleost species. These results provide baseline health data for clownfish species that can be used in various clinical settings while also serving as a springboard for further research studies.

CLINICAL AND MICROBIOLOGICAL CHARACTERIZATION OF LYMPH NODE ABSCESSATION IN PUP AND YEARLING CALIFORNIA SEA LIONS (ZALOPHUS CALIFORNIANUS) UNDERGOING REHABILITATION IN A MARINE MAMMAL CENTER.

Severe focal to multifocal abscessation of the axillary and inguinal lymph nodes is an important cause of morbidity and mortality in stranded pup and yearling California sea lions (Zalophus californianus; CSLs) at The Marine Mammal Center (TMMC). A retrospective case review was conducted of all pup and yearling CSLs with axillary and/or inguinal lymph node abscesses admitted to this California rehabilitation center between January 2015 and December 2019 (n = 162). Clinical data and cultured isolates were evaluated to (1) characterize the clinical syndrome, (2) report isolated pathogens, and (3) investigate factors associated with clinical outcome (survival to release versus death). Of the 162 CSLs admitted with at least one axillary or inguinal lymph node abscess, almost all were in poor body condition, and overall mortality rate was 63% (102 of 165). Mortality rate was lower for animals presenting with a single abscess and abscess(es) in the inguinal location only; odds of death were significantly lower for animals that had their abscesses surgically drained (P = 0.029) and those that received antimicrobials (P = 0.037). Hematology and serum chemistry parameters at the time of abscess diagnosis reflected inflammation and malnutrition. Radiographic findings associated with abscesses from 45 cases included soft tissue swelling (n = 40), intralesional gas (n = 19), and osteomyelitis (n = 3). Ninety bacterial isolates were recovered from aerobic (n = 48) and anaerobic cultures (n = 17), 48.9% of which were gram negative. The most common gram-negative organisms were Escherichia coli (n = 15), Proteus spp. (n = 8), and Bacteroides ureolyticus (n = 7), and the most common gram-positive organisms were Streptococcus phocae (n = 10) and Staphylococcus spp. (n = 9). Management of lymph node abscesses via surgical drainage and multimodal systemic antimicrobial therapy with a broad-spectrum of activity may be considered to improve survival of these cases.

Transforming Computed Energy Landscapes into Experimental Realities: The Role of Structural Rugosity.

We exploit the possible link between structural surface roughness and difficulty of crystallisation. Polymorphs with smooth surfaces may nucleate and crystallise more readily than polymorphs with rough surfaces. The concept is applied to crystal structure prediction landscapes and reveals a promising complementary way of ranking putative crystal structures.

On the entropy cost of making solvates.

We present a simple way of estimating the entropy cost of solvate formation in crystals. The entropy penalty of making solvates can be as low as <1 kJ mol-1 or as high as >9 kJ mol-1 and is entirely dependent on the nature of the liquid component and the temperature of solvate formation. A link is found between a low entropy cost and a higher likelihood for a solvent to make solvates.

Developing clinical skills in paediatric dysphagia management using human patient simulation (HPS).

PURPOSE: The use of simulated learning environments to develop clinical skills is gaining momentum in speech-language pathology training programs. The aim of the current study was to examine the benefits of adding Human Patient Simulation (HPS) into the university curriculum in the area of paediatric dysphagia. METHOD: University students enrolled in a mandatory dysphagia course (n = 29) completed two, 2-hour HPS scenarios: (a) performing a clinical feeding assessment with a medically complex infant; and (b) conducting a clinical swallow examination (CSE) with a child with a tracheostomy. Scenarios covered technical and non-technical skills in paediatric dysphagia management. Surveys relating to students' perceived knowledge, skills, confidence and levels of anxiety were conducted: (a) pre-lectures; (b) post-lectures, but pre-HPS; and (c) post-HPS. A fourth survey was completed following clinical placements with real clients. RESULT: Results demonstrate significant additive value in knowledge, skills and confidence obtained through HPS. Anxiety about working clinically reduced following HPS. Students rated simulation as very useful in preparing for clinical practice. Post-clinic, students indicated that HPS was an important component in their preparation to work as a clinician. CONCLUSION: This trial supports the benefits of incorporating HPS as part of clinical preparation for paediatric dysphagia management.