Telehealth Care in a Pediatric and Adolescent Gynecology Clinic During the COVID-19 Pandemic.

BACKGROUND: Since the onset of the COVID-19 pandemic, health care systems have increased their telehealth services to meet the changing public health needs. Before the pandemic, telehealth was used primarily in surgical specialties for postoperative visits and rural medicine. However, out of necessity, nearly all medical and surgical subspecialties incorporated this virtual technology to improve patient health care access in a short time. Few studies have addressed telehealth in pediatric and adolescent gynecology (PAG) to date. STUDY OBJECTIVE: To describe the large-scale utilization of telehealth visits, assess patient experience, and improve access to care in a large academic ambulatory gynecology PAG clinic METHODS: This retrospective, cross-sectional quality improvement study was performed by administering patient surveys and compiling aggregate data from the EPIC electronic health record in the Division of Pediatric and Adolescent Gynecology clinics at a single children's hospital between March 2020 and March 2021. Patient demographic characteristics, payer characteristics, visit type and purpose, and patient experience were reviewed. INTERVENTIONS: Wider expansion of telehealth in PAG clinics at a single institution RESULTS: A total of 6159 telehealth appointments were performed, involving 6 clinic sites and 9 providers. Telehealth visits constituted 50% of the total ambulatory volume (12,527). Most patients were located within the institution's state (99.5%), and the remaining called into their telehealth visits from a neighboring state. Most patients were 18 years of age or younger (73%). Video visits lasted 15-30 minutes and included routine follow-up (66.3%), new/consult visits (28.4%), postoperative visits (1.6%), and urgent follow-up (0.2%). The patient population was ethnically diverse by self-identification: 61.4% White, 38.4% Hispanic, 16% Black, 4.4% Asian, and 0.4% Native Hawaiian/American Indian/Alaska Native. Payer mix included self-pay (45.5%), private payer (32.2%), and Medicaid/CHIP (22.3%). Conditions seen ranged from menstrual management (71%) and routine preventive or acute gynecologic concerns (21%) to surgical evaluation for congenital anomalies, endometriosis, fertility preservation, and genital concerns or pelvic masses (8%). Telehealth visits met patient expectations for 87.3% of respondents. Patient-reported opportunities for improvement included improving set-up instructions and more consistent audio/video connections. Challenges identified by providers included difficulty utilizing interpreters, technology limitations, and privacy constraints during HEADSS examination. CONCLUSIONS: This study demonstrates how a large, diverse volume of patients with PAG needs received appropriate care through a telehealth format during the COVID-19 pandemic. Patients were satisfied with the services, but opportunities for improvement were elicited to allow for continued refining of this health care delivery tool in the future.

Heralded Generation of Macroscopic Superposition States in a Spinor Bose-Einstein Condensate.

Macroscopic superposition states enable fundamental tests of quantum mechanics and hold a huge potential in metrology, sensing, and other quantum technologies. We propose to generate macroscopic superposition states of a large number of atoms in the ground state of a spin-1 Bose-Einstein condensate. Measuring the number of particles in one mode prepares with large probability highly entangled macroscopic superposition states in the two remaining modes. The macroscopic superposition states are heralded by the measurement outcome. Our protocol is robust under realistic conditions in current experiments, including finite adiabaticity, particle loss, and measurement uncertainty.

Local probe of single phonon dynamics in warm ion crystals.

The detailed characterization of non-trivial coherence properties of composite quantum systems of increasing size is an indispensable prerequisite for scalable quantum computation, as well as for understanding non-equilibrium many-body physics. Here, we show how autocorrelation functions in an interacting system of phonons as well as the quantum discord between distinct degrees of freedoms can be extracted from a small controllable part of the system. As a benchmark, we show this in chains of up to 42 trapped ions, by tracing a single phonon excitation through interferometric measurements of only a single ion in the chain. We observe the spreading and partial refocusing of the excitation in the chain, even on a background of thermal excitations. We further show how this local observable reflects the dynamical evolution of quantum discord between the electronic state and the vibrational degrees of freedom of the probe ion.

A comparison of the i-gel(™) and the PRO-Breathe(®) laryngeal mask during pressure support ventilation in children.

Many studies comparing the i-gel(™) with laryngeal masks include patients in whom laryngeal mask cuff inflation pressures are higher than recommended, or involve the use of neuromuscular blocking drugs and positive pressure ventilation. We compared the i-gel with the PRO-Breathe(®) laryngeal mask in anaesthetised, spontaneously breathing children. Two hundred patients aged up to 16 years were randomly allocated to either the i-gel or the PRO-Breathe laryngeal mask. The PRO-Breathe was inflated to an intracuff pressure of 40 cmH2 O. All patients received pressure support of 10 cmH2 O and positive end-expiratory pressure of 5 cmH2 O. Successful insertion at the first attempt was 82% for the i-gel compared with 93% for the PRO-Breathe (p = 0.019). Leakage volume was significantly higher with i-gel sizes 1.5 (p = 0.015), 2 (p = 0.375), 2.5 (p = 0.021) and 3 (p = 0.003) compared with the equivalent-sized PRO-Breathe device. Device dislodgement following successful initial placement was more frequent with the i-gel (5%) compared with the PRO-Breathe laryngeal mask (0%). We conclude that the PRO-Breathe laryngeal mask is superior to the i-gel in terms of leakage volume and device dislodgement.

[Clinical relevance and indications for cardiac magnetic resonance imaging 2013: an interdisciplinary expert statement]. / Klinischer Stellenwert und Indikationen zur Magnetresonanztomografie des Herzens 2013: Ein interdisziplinäres Expertenstatement.

During the last years the indications of Cardiac Magnetic Resonance Imaging (CMRI) have been continuously expanded. However, the acceptance of the method by cardiologists and radiologists does not correlate with respect to the diagnostic potential. Several factors, such as expensive equipment, relatively long examination times, high technical know how and lack of remuneration, limit the application of CMRI in everyday clinical practice. Furthermore, doctors tend to apply more conventional, well established diagnostic procedures, the access to the method is still limited and there exist difficulties in the interdisciplinary collaboration. The interdisciplinary Austrian approach to Cardiac Imaging is aimed to improve the aforementioned problems and to support the implementation of CMRI in the diagnostic tree of cardiac diseases thus enabling a cost efficient management of patients in cardiology.

Experimental generation of quantum discord via noisy processes.

Quantum systems in mixed states can be unentangled and yet still nonclassically correlated. These correlations can be quantified by the quantum discord and might provide a resource for quantum information processing tasks. By precisely controlling the interaction of two ionic qubits with their environment, we investigate the capability of noise to generate discord. Firstly, we show that noise acting on only one quantum system can generate discord between two. States generated in this way are restricted in terms of the rank of their correlation matrix. Secondly, we show that classically correlated noise processes are capable of generating a much broader range of discordant states with correlation matrices of any rank. Our results show that noise processes prevalent in many physical systems can automatically generate nonclassical correlations and highlight fundamental differences between discord and entanglement.

Silicon supply modifies C:N:P stoichiometry and growth of Phragmites australis.

Silicon is a non-essential element for plant growth. Nevertheless, it affects plant stress resistance and in some plants, such as grasses, it may substitute carbon (C) compounds in cell walls, thereby influencing C allocation patterns and biomass production. How variation in silicon supply over a narrow range affects nitrogen (N) and phosphorus (P) uptake by plants has also been investigated in some detail. However, little is known about effects on the stoichiometric relationships between C, N and P when silicon supply varies over a broader range. Here, we assessed the effect of silicon on aboveground biomass production and C:N:P stoichiometry of common reed, Phragmites australis, in a pot experiment in which three widely differing levels of silicon were supplied. Scanning electron microscopy (SEM) showed that elevated silicon supply promoted silica deposition in the epidermis of Phragmites leaves. This resulted in altered N:P ratios, whereas C:N ratios changed only slightly. Plant growth was slightly (but not significantly) enhanced at intermediate silicon supply levels but significantly decreased at high levels. These findings point to the potential of silicon to impact plant growth and elemental stoichiometry and, by extension, to affect biogeochemical cycles in ecosystems dominated by Phragmites and other grasses and sedges.

Global threats to human water security and river biodiversity.

Protecting the world's freshwater resources requires diagnosing threats over a broad range of scales, from global to local. Here we present the first worldwide synthesis to jointly consider human and biodiversity perspectives on water security using a spatial framework that quantifies multiple stressors and accounts for downstream impacts. We find that nearly 80% of the world's population is exposed to high levels of threat to water security. Massive investment in water technology enables rich nations to offset high stressor levels without remedying their underlying causes, whereas less wealthy nations remain vulnerable. A similar lack of precautionary investment jeopardizes biodiversity, with habitats associated with 65% of continental discharge classified as moderately to highly threatened. The cumulative threat framework offers a tool for prioritizing policy and management responses to this crisis, and underscores the necessity of limiting threats at their source instead of through costly remediation of symptoms in order to assure global water security for both humans and freshwater biodiversity.

Elevated resource availability sufficient to turn opportunistic into virulent fish pathogens.

There is mounting evidence that organic or inorganic enrichment of aquatic environments increases the risk of infectious diseases, with disease agents ranging from helminth parasites to fungal, bacterial, and viral pathogens. The causal link between microbial resource availability and disease risk is thought to be complex and, in the case of so-called "opportunistic pathogens," to involve additional stressors that weaken host resistance (e.g., temperature shifts or oxygen deficiencies). In contrast to this perception, our experiment shows that the link between resource levels and infection of fish embryos can be very direct: increased resource availability can transform benign microbial communities into virulent ones. We find that embryos can be harmed before further stresses (e.g., oxygen depletion) weaken them, and treatment with antibiotics and fungicides cancels the detrimental effects. The changed characteristics of symbiotic microbial communities could simply reflect density-dependent relationships or be due to a transition in life-history strategy. Our findings demonstrate that simple microhabitat changes can be sufficient to turn "opportunistic" into virulent pathogens.

Fungi on leaf blades of Phragmites australis in a brackish tidal marsh: diversity, succession, and leaf decomposition.

Although fungi are known to colonize and decompose plant tissues in various environments, there is scanty information on fungal communities on wetland plants, their relation to microhabitat conditions, and their link to plant litter decomposition. We examined fungal diversity and succession on Phragmites australis leaves both attached to standing shoots and decaying in the litter layer of a brackish tidal marsh. Additionally, we followed changes in fungal biomass (ergosterol), leaf nitrogen dynamics, and litter mass loss on the sediment surface of the marsh. Thirty-five fungal taxa were recorded by direct observation of sporulation structures. Detrended correspondence analysis and cluster analysis revealed distinct communities of fungi sporulating in the three microhabitats examined (middle canopy, top canopy, and litter layer), and indicator species analysis identified a total of seven taxa characteristic of the identified subcommunities. High fungal biomass developed in decaying leaf blades attached to standing shoots, with a maximum ergosterol concentration of 548 +/- 83 microg g(-1) ash-free dry mass (AFDM; mean +/- SD). When dead leaves were incorporated in the litter layer on the marsh surface, fungi experienced a sharp decline in biomass (to 191 +/- 60 microg ergosterol g(-1) AFDM) and in the number of sporulation structures. Following a lag phase, species not previously detected began to sporulate. Leaves placed in litter bags on the sediment surface lost 50% of their initial AFDM within 7 months (k = -0.0035 day(-1)) and only 21% of the original AFDM was left after 11 months. Fungal biomass accounted for up to 34 +/- 7% of the total N in dead leaf blades on standing shoots, but to only 10 +/- 4% in the litter layer. These data suggest that fungi are instrumental in N retention and leaf mass loss during leaf senescence and early aerial decay. However, during decomposition on the marsh surface, the importance of living fungal mass appears to diminish, particularly in N retention, although a significant fraction of total detrital N may remain associated with dead hyphae.

World Health Organization collaborative study to establish a replacement WHO international standard for hepatitis C virus RNA nucleic acid amplification technology assays.

BACKGROUND AND OBJECTIVES: A collaborative study was undertaken to establish a replacement for the current (1st) World Health Organization (WHO) hepatitis C virus (HCV) International Standard, 96/790. MATERIALS AND METHODS: Both the 1(st) International Standard and the replacement standard were prepared from the same starting material by diluting a high titre genotype 1a HCV isolate in pooled, human plasma. The only difference was that each standard was lyophilized in two, separate lyophilisation runs but under the same conditions. RESULTS: In the study to establish the 1st International Standard, no significant difference in potency was found between the material eventually designated as the 1st International Standard and that now selected as the 2nd International Standard. The present study also showed no significant differences between the materials stored at -20 degrees C and no evidence of degradation over 5 years. CONCLUSIONS: Material 96/798 was established as the 2nd HCV International Standard and assigned the same unitage as the 1st International Standard, i.e. 10(5) IU/ml (50,000 IU/vial).

Incorporation of radiolabeled leucine into protein to estimate bacterial production in plant litter, sediment, epiphytic biofilms, and water samples.

The present study assessed the application of tritiated leucine incorporation into protein, as a measure of bacterial biomass production, within four benthic habitats of a littoral freshwater wetland dominated by emergent vegetation. Basic assumptions underlying the method, such as linearity of leucine incorporation, saturation level of incorporation rates, and specificity of incorporation for bacterial assemblages, were tested, and two procedures for extracting radiolabeled protein were compared. TCA precipitation followed by ultrasonication, and subsequent alkaline dissolution in 0.5 M NaOH, 25 mM EDTA, and 0.1% w/v SDS, gave best results in terms of both extraction efficiency and signal-to-noise ratio. Incorporation of leucine was linear for all habitats for up to 1 h. Saturation concentrations of leucine incorporation into protein were 150 nM for littoral surface waters, >960 nM for biofilms on plant surfaces, and 50 mM for aerobic sediment and submerged plant litter. An experiment with prokaryotic and eukaryotic inhibitors designed to examine specificity of leucine incorporation into bacterial protein showed no significant leucine incorporation into eukaryotes during short-term incubations. Calculations based on kinetic parameters of fungal leucine uptake suggest, nevertheless, that significant leucine incorporation cannot be ruled out in all situations. Thus, the leucine methodology can be used for estimating bacterial production in benthic aquatic habitats, provided that substrate saturation and isotope dilution are determined and that the active biomass of eukaryotes, such as fungi, does not greatly exceed bacterial biomass.

Tissue-specific expression and cold-induced mRNA levels of uncoupling proteins in the Djungarian hamster.

The uncoupling protein 1 (UCP1), a mitochondrial transmembrane protein, is responsible for adaptive thermogenesis in brown adipose tissue (BAT). Two UCP1 homologues, UCP2 and UCP3, were recently discovered, but it is controversial whether they also play a role in energy homeostasis. Djungarian hamster UCPs were found to exhibit high similarity with homologues known in other species. UCP1 mRNA was restricted to BAT, UCP2 mRNA was expressed in multiple tissues, and UCP3 mRNA was detected mainly in BAT and skeletal muscles. We examined the cold-induced regulation of hamster UCP mRNA levels and tested their correlation with serum free fatty acid (FFA) concentrations. In BAT UCP1, UCP2, and UCP3 expression was upregulated in the cold, but the increase and time course of increase differed. In skeletal muscle, UCP2 and UCP3 mRNA levels were not altered. Cold-induced changes of serum FFA levels correlated with the stimulation of UCP1 mRNA in BAT but not with UCP2 and UCP3.

A quantitative, internally controlled real-time PCR Assay for the detection of parvovirus B19 DNA.

Parvovirus B19 is an erythrovirus causing diverse clinical manifestations ranging from asymptomatic or mild, to more severe outcomes in, for example, immune-compromised patients. B19 is spread primarily via the respiratory route, but it can also be transmitted via blood and blood products. Viral loads in blood or plasma donations amount up to 10(11) genome equivalents/ml. Therefore, screening of plasma for fractionation for the presence of B19 and removal of highly loaded donations is a way to limit considerably the input of B19 into production pools and to improve further the safety of plasma products. An assay for the quantitative detection of B19 DNA, based on real-time PCR using ABI Prism SDS7700 (TaqMan) is described here. This assay allows precise quantitation of viral loads over 7 orders of magnitude. An exogenous internal control (internal quality marker) is included in each individual sample to prevent false negative results. A linearized plasmid is used as an internal quality marker that contains the identical sequence of the B19 target sequence but with an altered probe hybridization site. This allows co-amplification of B19 and internal quality marker and co-detection of FAM (6-carboxyfluorescein) or VIC labeled probes respectively. The assay is validated according to current guidelines (of the International Conference on Harmonization, Paul Ehrlich Institute, and the Council of Europe) and is optimized for high throughput screening.

Functional dissociation between medial and lateral prefrontal cortical spatiotemporal activation in negative and positive emotions: a combined fMRI/MEG study.

The orbitofrontal cortex has been cytoarchitectonically and connectionally subdivided into a medial and a lateral part which are assumed to subserve distinct functions in emotional processing. However the exact spatiotemporal mechanisms of negative and positive emotional processing in medial and lateral orbitofrontal cortex remain unclear. We therefore investigated spatiotemporal orbitofrontal and prefrontal cortical activation patterns during emotional stimulation in a combined fMRI/MEG study. We investigated 10 healthy subjects, 5 women and 5 men. Positive and negative pictures from the International Affective Picture system (IAPS) were used for emotional stimulation, whereas neutral and gray pictures were taken as control conditions. fMRI/MEG measurements covered the whole frontal lobe and a time window between -2000 and +200 ms around motor responses (right index finger extension) associated with each picture. Positively and negatively correlated activities were determined in various prefrontal/frontal cortical regions in fMRI. Isocontour maps and single dipoles in MEG were analyzed in 50 ms time windows ranging from -2000 to +200 ms. Dipoles and fMR images were mapped on three-dimensional anatomical MRI so that anatomical localization of single dipoles and regional fMRI activity could be compared. Both negative and positive emotional conditions differed from non-emotional control conditions by strong orbitofrontal and lateral prefrontal activation as well as by the presence of early magnetic fields (-1700 to +1100 ms). Negative emotional processing was characterized by strong medial orbitofrontal activation and earlier (-1700 ms), stronger and more medially oriented orbitofrontal dipoles. In contrast positive emotional processing showed a rather strong activation in lateral prefrontal cortex with later (-1500 ms), weaker and more laterally oriented orbito and prefrontal dipoles. Negative emotional processing can be characterized by strong and early medial orbitofrontal cortical activation, whereas positive emotional processing showed rather later and weaker activation in lateral orbitofrontal/prefrontal cortex. Such a functional dissociation between medial and lateral orbito-frontal/prefrontal cortex during negative and positive emotional processing lends further support to the assumption of a functional subdivision in the orbitofrontal cortex.

Nutrient addition accelerates leaf breakdown in an alpine springbrook.

This study assessed the effect of nutrient enrichment on organic matter breakdown in an alpine springbrook, using alder leaf packs to which phosphorus and nitrogen were added in the form of slow-release fertilizer briquettes. The breakdown of leaf packs with nutrients added (k=0.0284 day-1) was significantly faster than that of unfertilized packs (k=0.0137 day-1), resulting in a 30% higher mass loss after 42 days. Unfertilized leaves enclosed in fine-mesh bags broke down at an even slower rate (k=0.0062 day-1). Phosphorus and nitrogen concentrations were initially higher in leaf packs with nutrients added, but this difference disappeared within 3 weeks. Fungal biomass developing in decomposing leaves was substantial (c. 55 mg dry mass per 1 g leaf dry mass) although similar between fertilized and unfertilized packs, as was the sporulation activity of aquatic hyphomycetes. There was a significantly greater number and higher biomass of macroinvertebrates (shredding nemourid stoneflies in particular) on the fertilized packs, suggesting that the increased leaf mass loss was brought about by shredder feeding.

Off-flavor compounds in wine and other food products formed by enzymatical, physical, and chemical degradation of tryptophan and its metabolites.

Tryptophan (TRP) and its metabolites are considered as potential precursors of 2-aminoacetophenone (AAP) in different food products causing different off-flavors. AAP is also responsible for the "untypical aging flavor (UTA)" in wine, developing a floor polish-like flavor in white wines within a few months of storage. In this study the formation of AAP was elucidated by GC-MS analysis of volatile components in model systems, grape musts and wines, spiked with TRP and different TRP metabolites like indole-3-acetic acid (IAA) and sulfite. In sulfurized wines and model solutions which were stored at different temperatures (20 degrees C, 45 degrees C) formylaminoacetophenone (FAP) and AAP were formed mainly from IAA with formation rates up to 20 mole%. Minor formation rates of AAP (< 1 mole%) were found in sulfurized solutions of TRP, indole-3-lactic acid, and indole-3-pyruvic acid. The results showed that the formation of AAP in wine can be referred to an oxidative degradation of IAA by superoxide- and hydroxyl-radicals, which can be formed in wine after the sulfuration by cooxidation of sulfite to sulfate. After decarboxylation, pyrrole oxidation, and ring cleavage, FAP was the main volatile compound of the nonenzymatic degradation of IAA by sulfite which was quantitatively hydrolyzed to AAP. The formation of AAP and FAP was significantly lower in white wines than in ethanolic solutions spiked with IAA. However AAP formation rates of up to 5 mole% were still enough for an UTA. Due to the fact that the AAP- and UTA-formation by cooxidation of sulfite and IAA was completely blocked in red wines, it could be deduced that polyphenolic compounds, typical for red wines, have a scavenger effect on the radical oxidation of sulfite. Possibilities for an inhibition of the IAA degradation during winemaking to avoid the UTA in white wines by addition of radical scavengers like grape marc or ascorbic acid are discussed.

Application of pulsed-Doppler tissue imaging in patients with dual chamber pacing: the importance of conduction time and AV delay on regional left ventricular wall dynamics.

UNLABELLED: Pulsed-Doppler tissue imaging (pDTI) is able to measure myocardial wall velocities (systolic: S; early diastolic: E; late diastolic: A) and their timings. Relationships have been demonstrated between the pre-ejection period and indexes of left ventricular systolic function. This study was designed to examine with pDTI the effects of variations in atrioventricular delay (AVD) (100 ms, 150 ms, 200 ms) on myocardial dynamics and on their timings at the basal interventricular septum (IVS) from an apical approach and at the posterior wall (PW) from the parasternal view. These data were compared with stroke volume measurements recorded from the left ventricular outflow tract. Seventeen patients with dual chamber pacemakers (7 because of complete heart block, 10 with sick sinus syndrome and first-degree AV block) were studied; full atrial and ventricular capture was present at any AVD. These data were also compared with those obtained in 10 age-matched healthy volunteers with comparable heart rates. RESULTS: Optimal atrial contribution to left ventricular filling and, consequently, best systolic performance were achieved when AVD was programmed such that a mean interval of 77 ms was allowed between the end of the A wave and the beginning of the S wave, similar to what was measured in the healthy control group by pDTI. CONCLUSION: The noninvasive measurement of timings of the cardiac cycle by pDTI is helpful to determine the optimal AVD in individual patients.