Traditional Farming Lifestyle in Old Older Mennonites Modulates Human Milk Composition.

Background: In addition to farming exposures in childhood, maternal farming exposures provide strong protection against allergic disease in their children; however, the effect of farming lifestyle on human milk (HM) composition is unknown. Objective: This study aims to characterize the maternal immune effects of Old Order Mennonite (OOM) traditional farming lifestyle when compared with Rochester (ROC) families at higher risk for asthma and allergic diseases using HM as a proxy. Methods: HM samples collected at median 2 months of lactation from 52 OOM and 29 ROC mothers were assayed for IgA1 and IgA2 antibodies, cytokines, endotoxin, HM oligosaccharides (HMOs), and targeted fatty acid (FA) metabolites. Development of early childhood atopic diseases in children by 3 years of age was assessed. In addition to group comparisons, systems level network analysis was performed to identify communities of multiple HM factors in ROC and OOM lifestyle. Results: HM contains IgA1 and IgA2 antibodies broadly recognizing food, inhalant, and bacterial antigens. OOM HM has significantly higher levels of IgA to peanut, ovalbumin, dust mites, and Streptococcus equii as well TGF-ß2, and IFN-λ3. A strong correlation occurred between maternal antibiotic use and levels of several HMOs. Path-based analysis of HMOs shows lower activity in the path involving lactoneohexaose (LNH) in the OOM as well as higher levels of lacto-N-neotetraose (LNnT) and two long-chain FAs C-18OH (stearic acid) and C-23OH (tricosanoic acid) compared with Rochester HM. OOM and Rochester milk formed five different clusters, e.g., butyrate production was associated with Prevotellaceae, Veillonellaceae, and Micrococcaceae cluster. Development of atopic disease in early childhood was more common in Rochester and associated with lower levels of total IgA, IgA2 to dust mite, as well as of TSLP. Conclusion: Traditional, agrarian lifestyle, and antibiotic use are strong regulators of maternally derived immune and metabolic factors, which may have downstream implications for postnatal developmental programming of infant's gut microbiome and immune system.

Infant gut microbiome is enriched with Bifidobacterium longum ssp. infantis in Old Order Mennonites with traditional farming lifestyle.

BACKGROUND: Growing up on traditional, single-family farms is associated with protection against asthma in school age, but the mechanisms against early manifestations of atopic disease are largely unknown. We sought determine the gut microbiome and metabolome composition in rural Old Order Mennonite (OOM) infants at low risk and Rochester, NY urban/suburban infants at high risk for atopic diseases. METHODS: In a cohort of 65 OOM and 39 Rochester mother-infant pairs, 101 infant stool and 61 human milk samples were assessed by 16S rRNA gene sequencing for microbiome composition and qPCR to quantify Bifidobacterium spp. and B. longum ssp. infantis (B. infantis), a consumer of human milk oligosaccharides (HMOs). Fatty acids (FAs) were analyzed in 34 stool and human 24 milk samples. Diagnoses and symptoms of atopic diseases by 3 years of age were assessed by telephone. RESULTS: At a median age of 2 months, stool was enriched with Bifidobacteriaceae, Clostridiaceae, and Aerococcaceae in the OOM compared with Rochester infants. B. infantis was more abundant (p < .001) and prevalent, detected in 70% of OOM compared with 21% of Rochester infants (p < .001). Stool colonized with B. infantis had higher levels of lactate and several medium- to long/odd-chain FAs. In contrast, paired human milk was enriched with a distinct set of FAs including butyrate. Atopic diseases were reported in 6.5% of OOM and 35% of Rochester children (p < .001). CONCLUSION: A high rate of B. infantis colonization, similar to that seen in developing countries, is found in the OOM at low risk for atopic diseases.

Designing and running an online Objective Structured Clinical Examination (OSCE) on Zoom: A peer-led example.

INTRODUCTION: The COVID-19 pandemic threatened medical teaching and progression secondary to the 'lockdown' measures which limit physical interactions. Consequently, there was a necessity to shift medical teaching and assessment online. Our challenge was to logistically organise and conduct an Objective Structured Clinical Examination (OSCE) using a virtual, socially distanced approach. METHODS: We found that Zoom offered the most suitable functionality in mimicking a physical OSCE online and its breakout rooms were used to represent different stations. One organiser manually transferred candidates between stations, allowing for the OSCE to operate punctually. Examiners screen shared to display an automated slideshow with station vignettes, investigation results, and viva questions. RESULTS: Participants found the use of Zoom's features to be extremely beneficial with one candidate describing the experience as 'brilliant, very efficient and smooth'. Numerous aspects of the OSCE from decision making, to verbal communication, to medical knowledge were assessed, equivalent to a physical OSCE. DISCUSSION: As the transformation of medical education is catalysed by the pandemic, it is important to ensure that peer to peer teaching and assessments are revolutionised with a quality similar to that of physical teaching. We have displayed how this may be achieved in an OSCE setting using Zoom teleconferencing.

Asthmatic granulomatosis as a rare variant of uncontrolled severe asthma.

Asthmatic granulomatosis (AG) is a variant of severe asthma, first described in 2012, that consists of small airway changes compatible with asthma as well as interstitial nonnecrotizing granulomas. Treatment of AG requires immunosuppression as opposed to the traditional asthma therapy of inhaled steroids. We describe a 5-year course of a patient with AG that has shown no improvement with immunosuppression or other standards of therapy.

Left upper lobe torsion in pneumothorax.

We report a case of left upper lobe torsion in a patient who had a pneumothorax as a complication of subclavian venous access for an elective neurosurgical operation. Despite appropriate management of the pneumothorax, the patient's chest radiograph did not improve. Computed tomography of the chest was concerning for left upper lobe torsion. Fiberoptic bronchoscopy revealed near complete obstruction of the left upper lobe bronchus. Review of computed tomography imaging before and after bronchoscopy and subsequent thoracotomy confirmed lobar torsion. Consideration of lobar torsion in the differential diagnosis of patients with persistently abnormal chest imaging despite appropriate management after complications of routine procedures is important for early recognition and intervention of a potentially life-threatening problem.