Economic Impact of COVID-19 on a Free-Standing Pediatric Ambulatory Center.

Background: Operating safely throughout the coronavirus disease 2019 (COVID-19) pandemic has required surgical centers to adapt and raise their level of readiness. Intuitively, additional expenses related to such adaptation may have resulted in an increase in the cost of surgical care. However, little is known about the magnitude of such an increase, and no study has evaluated the temporal variation in the costs of care throughout the pandemic. The aim of the current study was to evaluate the impact of COVID-19 on the cost of surgical and anesthetic care in a free-standing, pediatric ambulatory care center. Methods: We performed a retrospective review of the electronic medical record (EMR) and financial data for pediatric ambulatory settings between 2019 and 2020 (April - August) from our tertiary care children's hospital. The primary outcomes were the inflation-adjusted surgical cost for elective tonsillectomy, adenoidectomy, and tympanostomy tubes (BTI) placement procedures in children less than 18 years of age. These data were obtained from financial databases and aggregated into categories including anesthesia services, operating room services, recovery room services, and supply and medical devices. Results: Costs per case to provide care were significantly higher following the COVID-19 pandemic in 2020 compared to 2019 across all services: anesthesia ($1,268 versus $1,143; cost ratio (CR): 1.11, 95% confidence interval (CI): 1.08 - 1.14, P-value < 0.001), operating room ($1,221 vs. $1,255; CR: 1.03, 95% CI: 1.02 - 1.04, P-value < 0.001), recovery room ($659 vs. $751; CR: 1.14, 95% CI: 1.10 - 1.18, P-value < 0.001), and supply ($150 vs. $271; CR: 1.81, 95% CI: 1.26 - 2.6, P-value = 0.001). There was an overall increase in healthcare service costs in 2020, with significant fluctuations in the early and mid-year months. Conclusion: Our study identified specific economic impacts of COVID-19 on free-standing pediatric ambulatory centers, thereby highlighting the need for innovative practices with cost containment for sustainability of such specialized centers when dealing with future pandemics related to COVID-19 or other viral pathogens.

Mechanistic In Situ ATR-FTIR Studies on the Adsorption and Desorption of Major Intermediates in CO2 Electrochemical Reduction on CuO Nanoparticles.

Increasing levels of carbon dioxide (CO2) from human activities is affecting the ecosystem and civilization as we know it. CO2 removal from the atmosphere and emission reduction by heavy industries through carbon capture, utilization, and storage (CCUS) technologies to store or convert CO2 to useful products or fuels is a popular approach to meet net zero targets by 2050. One promising process of CO2 removal and conversion is CO2 electrochemical reduction (CO2ER) using metal and metal oxide catalysts, particularly copper-based materials. However, the current limitations of CO2ER stem from the low product selectivity of copper electrocatalysts due to existing knowledge gaps of the reaction mechanisms using surfaces that normally have native oxide layers. Here, we report systematic control studies of the surface interactions of major intermediates in CO2ER, formate, bicarbonate, and acetate, with CuO nanoparticles in situ and in real time using attenuated total reflection Fourier-transform infrared spectroscopy (ATR-FTIR). Spectra were collected as a function of concentration, pH, and time in the dark and the in absence of added electrolytes. Isotopic exchange experiments were also performed to elucidate the type of surface complexes from H/D exchange. Our results show that the organics and bicarbonate form mostly outer-sphere complexes mediated by hydrogen bonding with CuO nanoparticles with Gibbs free energy of adsorption of about -25 kJ mol-1. The desorption kinetics of the surface species indicated relatively fast and slow regions reflective of the heterogeneity of sites that affect the strength of hydrogen bonding. These results suggest that hydrogen bonding, whether intermolecular or with surface sites on CuO nanoparticles, might be playing a more important role in the CO2ER reaction mechanism than previously thought, contributing to the lack of product selectivity.

Metal exposure causes rDNA copy number to fluctuate in mutation accumulation lines of Daphnia pulex.

Ribosomal (r)DNA is a highly dynamic, conserved, multigene family whose sequence homogeneity is thought to be maintained by intra- and interchromosomal recombination, which are capable of changing rDNA copy number. It is generally not known how environmental stress such as sublethal exposure to environmentally relevant concentrations of metals impacts rDNA copy number. To determine how chronic metal exposure affects rDNA, we measured copy number of the 18S rRNA gene in 355 copper and nickel-exposed samples and 132 metal-free samples derived from 325 mutation accumulation (MA) lines of two genetically distinct Daphnia pulex lineages. The MA lines were sampled at four time points over 100+ generations of clonal propagation. The copy number of rDNA was also measured in 15 individuals sampled from a metal-free non-MA control population established from the same progenitor as one of the MA lineages. We found that mean rDNA copy number fluctuated across lines exposed to metals with a tendency to decrease over time. In contrast, mean rDNA copy number in the metal-free control lines and the non-MA population remained stable over time. It is generally accepted that extreme rDNA loss results in the loss of organism fitness. Thus, fluctuations in rDNA copy number, including losses, could affect the long-term viability of natural populations of Daphnia in metal-contaminated habitats.

In vitro validation of in silico identified inhibitory interactions.

BACKGROUND: Understanding how neuronal signals propagate in local network is an important step in understanding information processing. As a result, spike trains recorded with multi-electrode arrays (MEAs) have been widely used to study the function of neural networks. Studying the dynamics of neuronal networks requires the identification of both excitatory and inhibitory connections. The detection of excitatory relationships can robustly be inferred by characterizing the statistical relationships of neural spike trains. However, the identification of inhibitory relationships is more difficult: distinguishing endogenous low firing rates from active inhibition is not obvious. NEW METHOD: In this paper, we propose an in silico interventional procedure that makes predictions about the effect of stimulating or inhibiting single neurons on other neurons, and thereby gives the ability to accurately identify inhibitory effects. COMPARISON: To experimentally test these predictions, we have developed a Neural Circuit Probe (NCP) that delivers drugs transiently and reversibly on individually identified neurons to assess their contributions to the neural circuit behavior. RESULTS: Using the NCP, putative inhibitory connections identified by the in silico procedure were validated through in vitro interventional experiments. CONCLUSIONS: Together, these results demonstrate how detailed microcircuitry can be inferred from statistical models derived from neurophysiology data.

Action potential propagation recorded from single axonal arbors using multielectrode arrays.

We report the presence of co-occurring extracellular action potentials (eAPs) from cultured mouse hippocampal neurons among groups of planar electrodes on multielectrode arrays (MEAs). The invariant sequences of eAPs among coactive electrode groups, repeated co-occurrences, and short interelectrode latencies are consistent with action potential propagation in unmyelinated axons. Repeated eAP codetection by multiple electrodes was widespread in all our data records. Codetection of eAPs confirms they result from the same neuron and allows these eAPs to be isolated from all other spikes independently of spike sorting algorithms. We averaged co-occurring events and revealed additional electrodes with eAPs that would otherwise be below detection threshold. We used these eAP cohorts to explore the temperature sensitivity of action potential propagation and the relationship between voltage-gated sodium channel density and propagation velocity. The sequence of eAPs among coactive electrodes "fingerprints" neurons giving rise to these events and identifies them within neuronal ensembles. We used this property and the noninvasive nature of extracellular recording to monitor changes in excitability at multiple points in single axonal arbors simultaneously over several hours, demonstrating independence of axonal segments. Over several weeks, we recorded changes in interelectrode propagation latencies and ongoing changes in excitability in different regions of single axonal arbors. Our work illustrates how repeated eAP co-occurrences can be used to extract physiological data from single axons with low-density MEAs. However, repeated eAP co-occurrences lead to oversampling spikes from single neurons and thus can confound traditional spike-train analysis. NEW & NOTEWORTHY We studied action potential propagation in single axons using low-density multielectrode arrays. We unambiguously identified the neuronal sources of propagating action potentials and recorded extracellular action potentials from several positions within single axonal arbors. We found a surprisingly high density of axonal voltage-gated sodium channels responsible for a high propagation safety factor. Our experiments also demonstrate that excitability in different segments of single axons is regulated independently on timescales from hours to weeks.

Analyzing the effect of hydration on the wedge indentation fracture behavior of cortical bone.

Hydration directly affects the mechanical properties of bone. An initial and basic procedure shows both wedge indentation fracture experiments under plane strain conditions in cortical bone and numerical simulation with finite elements agree that dry bone fractures much more easily than fully hydrated bone submerged in an aqueous environment, such as in the body of an animal. The wedge indentation experiments were performed with high speed video microscopy, under dry and fully hydrated (submerged) conditions. The numerical simulation, specifically finite element analysis using cohesive elements to simulate fracture, was utilized to capture plasticity, fracture initiation and propagation, and to study the applicability of brittle material based indentation fracture theory. Experiment and theory give similar results for the dependence of depth of fracture initiation, and size of plastic zone, on hydration state. Comparison of fracture propagation characteristics between wet and dry bone are examined and discussed. This research demonstrates the ability to quantitatively assess the effect of hydration on the fracture initiation, propagation, and plastic zone size of cortical bone, through an approach using simple wedge indentation, with important implications for efforts in developing methods to understand clinical diagnostic testing and general fracture behavior of living bone in the ultimate interest of health care purposes.

Bone Tissue Properties Measurement by Reference Point Indentation in Glucocorticoid-Induced Osteoporosis.

Glucocorticoids, widely used in inflammatory disorders, rapidly increase bone fragility and, therefore, fracture risk. However, common bone densitometry measurements are not sensitive enough to detect these changes. Moreover, densitometry only partially recognizes treatment-induced fracture reductions in osteoporosis. Here, we tested whether the reference point indentation technique could detect bone tissue property changes early after glucocorticoid treatment initiation. After initial laboratory and bone density measurements, patients were allocated into groups receiving calcium + vitamin D (Ca+D) supplements or anti-osteoporotic drugs (risedronate, denosumab, teriparatide). Reference point indentation was performed on the cortical bone layer of the tibia by a handheld device measuring bone material strength index (BMSi). Bone mineral density was measured by dual-energy X-ray absorptiometry (DXA). Although Ca+D-treated patients exhibited substantial and significant deterioration, risedronate-treated patients exhibited no significant change, and both denosumab- and teriparatide-treated participants exhibited significantly improved BMSi 7 weeks after initial treatment compared with baseline; these trends remained stable for 20 weeks. In contrast, no densitometry changes were observed during this study period. In conclusion, our study is the first to our knowledge to demonstrate that reference point indentation is sensitive enough to reflect changes in cortical bone indentation after treatment with osteoporosis therapies in patients newly exposed to glucocorticoids.

Study of indentation of a sample equine bone using finite element simulation and single cycle reference point indentation.

In an attempt to study the mechanical behavior of bone under indentation, methods of analyses and experimental validations have been developed, with a selected test material. The test material chosen is from an equine cortical bone. Stress-strain relationships are first obtained from conventional mechanical property tests. A finite element simulation procedure is developed for indentation analyses. The simulation results are experimentally validated by determining (1) the maximum depth of indentation with a single cycle type of reference point indentation, and (2) the profile and depth of the unloaded, permanent indentation with atomic force microscopy. The advantage of incorporating in the simulation a yield criterion calibrated by tested mechanical properties, with different values in tension and compression, is demonstrated. In addition, the benefit of including damage through a reduction in Young's modulus is shown in predicting the permanent indentation after unloading and recovery. The expected differences in response between two indenter tips with different sharpness are predicted and experimentally observed. Results show predicted indentation depths agree with experimental data. Thus, finite element simulation methods with experimental validation, and with damage approximation by a reduction of Young's modulus, may provide a good approach for analysis of indentation of cortical bone. These methods reveal that multiple factors affect measured indentation depth and that the shape of the permanent indentation contains useful information about bone material properties. Only further work can determine if these methods or extensions to these methods can give useful insights into bone pathology, for example the bone fragility of thoroughbred racehorses.

A new ion sensing deep atomic force microscope.

Here we describe a new deep atomic force microscope (AFM) capable of ion sensing. A novel probe assembly incorporates a micropipette that can be used both for sensing ion currents and as the tip for AFM imaging. The key advance of this instrument over previous ion sensing AFMs is that it uses conventional micropipettes in a novel suspension system. This paper focuses on sensing the ion current passively while using force feedback for the operation of the AFM in contact mode. Two images are obtained simultaneously: (1) an AFM topography image and (2) an ion current image. As an example, two images of a MEMS device with a microchannel show peaks in the ion current as the pipette tip goes over the edges of the channel. This ion sensing AFM can also be used in other modes including tapping mode with force feedback as well as in non-contact mode by utilizing the ion current for feedback, as in scanning ion conductance microscopy. The instrument is gentle enough to be used on some biological samples such as plant leaves.

Applications of a New Handheld Reference Point Indentation Instrument Measuring Bone Material Strength.

A novel, hand-held Reference Point Indentation (RPI) instrument, measures how well the bone of living patients and large animals resists indentation. The results presented here are reported in terms of Bone Material Strength, which is a normalized measure of how well the bone resists indentation, and is inversely related to the indentation distance into the bone. We present examples of the instrument's use in: (1) laboratory experiments on bone, including experiments through a layer of soft tissue, (2) three human clinical trials, two ongoing in Barcelona and at the Mayo Clinic, and one completed in Portland, OR, and (3) two ongoing horse clinical trials, one at Purdue University and another at Alamo Pintado Stables in California. The instrument is capable of measuring consistent values when testing through soft tissue such as skin and periosteum, and does so handheld, an improvement over previous Reference Point Indentation instruments. Measurements conducted on horses showed reproducible results when testing the horse through tissue or on bare bone. In the human clinical trials, reasonable and consistent values were obtained, suggesting the Osteoprobe® is capable of measuring Bone Material Strength in vivo, but larger studies are needed to determine the efficacy of the instrument's use in medical diagnosis.

A new device for performing reference point indentation without a reference probe.

Here we describe a novel, hand-held reference point indentation (RPI), instrument that is designed for clinical measurements of bone material properties in living patients. This instrument differs from previous RPI instruments in that it requires neither a reference probe nor removal of the periosteum that covers the bone, thus significantly simplifying its use in patient testing. After describing the instrument, we discuss five guidelines for optimal and reproducible results. These are: (1) the angle between the normal to the surface and the axis of the instrument should be less than 10°, (2) the compression of the main spring to trigger the device must be performed slowly (>1 s), (3) the probe tip should be sharper than 10 µm; however, a normalized parameter with a calibration phantom can correct for dull tips up to a 100 µm radius, (4) the ambient room temperature should be between 4 °C and 37 °C, and (5) the effective mass of the bone or material under test must exceed 1 kg, or if under 1 kg, the specimen should be securely anchored in a fixation device with sufficient mass (which is not a requirement of previous RPI instruments). Our experience is that a person can be trained with these guidelines in about 5 min and thereafter obtain accurate and reproducible results. The portability, ease of use, and minimal training make this instrument suitable to measure bone material properties in a clinical setting.

In situ Materials Characterization using the Tissue Diagnostic Instrument.

An understanding of the mechanical behavior of polymers is critical towards the design, implementation, and quality control of such materials. Yet experiments and method for the characterization of material properties of polymers remain challenging due the need to reconcile constitutive assumptions with experimental conditions. Well-established modes of mechanical testing, such as unconfined compression or uniaxial tension, require samples with specific geometries and carefully controlled orientations. Moreover, producing specimens that conform to such specifications often requires a considerable amount of sample material. In this study we validate a micromechanical indentation device, the Tissue Diagnostic Instrument (TDI), which implements a cyclic indentation method to determine the material properties of polymers and elastomeric materials. Measurements using the TDI require little or no sample preparation, and they allow the testing of sample materials in situ. In order to validate the use of the TDI, we compared measurements of modulus determined by the TDI to those obtained by unconfined compression tests and by uniaxial tension tests within the limit of small stresses and strains. The results show that the TDI measurements were significantly correlated with both unconfined compression (p<0.001; r(2) = 0.92) and uniaxial tension tests (p<0.001; r(2)=0.87). Moreover, the measurements across all three modes of testing were statistically indistinguishable from each other (p=0.92; ANOVA) and demonstrate that TDI measurements can provide a surrogate for the conventional methods of mechanical characterization.

Microindentation for in vivo measurement of bone tissue mechanical properties in humans.

Bone tissue mechanical properties are deemed a key component of bone strength, but their assessment requires invasive procedures. Here we validate a new instrument, a reference point indentation (RPI) instrument, for measuring these tissue properties in vivo. The RPI instrument performs bone microindentation testing (BMT) by inserting a probe assembly through the skin covering the tibia and, after displacing periosteum, applying 20 indentation cycles at 2 Hz each with a maximum force of 11 N. We assessed 27 women with osteoporosis-related fractures and 8 controls of comparable ages. Measured total indentation distance (46.0 +/- 14 versus 31.7 +/- 3.3 microm, p = .008) and indentation distance increase (18.1 +/- 5.6 versus 12.3 +/- 2.9 microm, p = .008) were significantly greater in fracture patients than in controls. Areas under the receiver operating characteristic (ROC) curve for the two measurements were 93.1% (95% confidence interval [CI] 83.1-100) and 90.3% (95% CI 73.2-100), respectively. Interobserver coefficient of variation ranged from 8.7% to 15.5%, and the procedure was well tolerated. In a separate study of cadaveric human bone samples (n = 5), crack growth toughness and indentation distance increase correlated (r = -0.9036, p = .018), and scanning electron microscope images of cracks induced by indentation and by experimental fractures were similar. We conclude that BMT, by inducing microscopic fractures, directly measures bone mechanical properties at the tissue level. The technique is feasible for use in clinics with good reproducibility. It discriminates precisely between patients with and without fragility fracture and may provide clinicians and researchers with a direct in vivo measurement of bone tissue resistance to fracture.

The bone diagnostic instrument III: testing mouse femora.

Here we describe modifications that allow the bone diagnostic instrument (BDI) [P. Hansma et al., Rev. Sci. Instrum. 79, 064303 (2008); Rev. Sci. Instrum. 77, 075105 (2006)], developed to test human bone, to test the femora of mice. These modifications include reducing the effective weight of the instrument on the bone, designing and fabricating new probe assemblies to minimize damage to the small bone, developing new testing protocols that involve smaller testing forces, and fabricating a jig for securing the smaller bones for testing. With these modifications, the BDI was used to test the hypothesis that short-term running has greater benefit on the mechanical properties of the femur for young growing mice compared to older, skeletally mature mice. We measured elastic modulus, hardness, and indentation distance increase (IDI), which had previously been shown to be the best discriminators in model systems known to exhibit differences in mechanical properties at the whole bone level. In the young exercised murine femora, the IDI was significantly lower than in young control femora. Since IDI has a relation to postyield properties, these results suggest that exercise during bone development increases post yield mechanical competence. We were also able to measure effects of aging on bone properties with the BDI. There was a significant increase in the IDI, and a significant decrease in the elastic modulus and hardness between the young and old groups. Thus, with the modifications described here, the BDI can take measurements on mouse bones and obtain statistically significant results.

The tissue diagnostic instrument.

Tissue mechanical properties reflect extracellular matrix composition and organization, and as such, their changes can be a signature of disease. Examples of such diseases include intervertebral disk degeneration, cancer, atherosclerosis, osteoarthritis, osteoporosis, and tooth decay. Here we introduce the tissue diagnostic instrument (TDI), a device designed to probe the mechanical properties of normal and diseased soft and hard tissues not only in the laboratory but also in patients. The TDI can distinguish between the nucleus and the annulus of spinal disks, between young and degenerated cartilage, and between normal and cancerous mammary glands. It can quantify the elastic modulus and hardness of the wet dentin left in a cavity after excavation. It can perform an indentation test of bone tissue, quantifying the indentation depth increase and other mechanical parameters. With local anesthesia and disposable, sterile, probe assemblies, there has been neither pain nor complications in tests on patients. We anticipate that this unique device will facilitate research on many tissue systems in living organisms, including plants, leading to new insights into disease mechanisms and methods for their early detection.

The bone diagnostic instrument II: indentation distance increase.

The bone diagnostic instrument (BDI) is being developed with the long-term goal of providing a way for researchers and clinicians to measure bone material properties of human bone in vivo. Such measurements could contribute to the overall assessment of bone fragility in the future. Here, we describe an improved BDI, the Osteoprobe IItrade mark. In the Osteoprobe IItrade mark, the probe assembly, which is designed to penetrate soft tissue, consists of a reference probe (a 22 gauge hypodermic needle) and a test probe (a small diameter, sharpened rod) which slides through the inside of the reference probe. The probe assembly is inserted through the skin to rest on the bone. The distance that the test probe is indented into the bone can be measured relative to the position of the reference probe. At this stage of development, the indentation distance increase (IDI) with repeated cycling to a fixed force appears to best distinguish bone that is more easily fractured from bone that is less easily fractured. Specifically, in three model systems, in which previous mechanical testing and/or tests reported here found degraded mechanical properties such as toughness and postyield strain, the BDI found increased IDI. However, it must be emphasized that, at this time, neither the IDI nor any other mechanical measurement by any technique has been shown clinically to correlate with fracture risk. Further, we do not yet understand the mechanism responsible for determining IDI beyond noting that it is a measure of the continuing damage that results from repeated loading. As such, it is more a measure of plasticity than elasticity in the bone.