Geometric phase predicts locomotion performance in undulating living systems across scales.

Self-propelling organisms locomote via generation of patterns of self-deformation. Despite the diversity of body plans, internal actuation schemes and environments in limbless vertebrates and invertebrates, such organisms often use similar traveling waves of axial body bending for movement. Delineating how self-deformation parameters lead to locomotor performance (e.g. speed, energy, turning capabilities) remains challenging. We show that a geometric framework, replacing laborious calculation with a diagrammatic scheme, is well-suited to discovery and comparison of effective patterns of wave dynamics in diverse living systems. We focus on a regime of undulatory locomotion, that of highly damped environments, which is applicable not only to small organisms in viscous fluids, but also larger animals in frictional fluids (sand) and on frictional ground. We find that the traveling wave dynamics used by mm-scale nematode worms and cm-scale desert dwelling snakes and lizards can be described by time series of weights associated with two principal modes. The approximately circular closed path trajectories of mode weights in a self-deformation space enclose near-maximal surface integral (geometric phase) for organisms spanning two decades in body length. We hypothesize that such trajectories are targets of control (which we refer to as "serpenoid templates"). Further, the geometric approach reveals how seemingly complex behaviors such as turning in worms and sidewinding snakes can be described as modulations of templates. Thus, the use of differential geometry in the locomotion of living systems generates a common description of locomotion across taxa and provides hypotheses for neuromechanical control schemes at lower levels of organization.

Age- and sex-dependent clinical equations to estimate glomerular filtration rates in children and young adults with chronic kidney disease.

Using data (2655 observations from 928 participants) from the Chronic Kidney Disease in Children Study, we developed and internally validated new glomerular filtration rate estimating equations for clinical use in children and young adults: two forms of K × [heigh(ht) / serum creatinine(sCr)] and two forms of K × [1 / cystatin C(cysC)]. For each marker, one equation used a sex-dependent K; in the other, K is sex-and age-dependent. Glomerular filtration rate (GFR) was measured directly by plasma iohexol disappearance. The equations using ht/sCr had sex-specific constants of 41.8 for males and 37.6 for females. In the age- dependent models, K increased monotonically for children 1-18 years old and was constant for young adults 18-25 years. For males, K ranged from 35.7 for one-year-olds to 50.8 for those 18 and older. For females, the values of K ranged from 33.1 to 41.4. Constant K values for cystatin-C equations were 81.9 for males and 74.9 for females. With age-dependency, K varied non-monotonically with the highest values at age 15 for males (K of 87.2) and 12 years for females (K of 79.9). Use of an age-dependent K with ht/sCr models reduced average bias, notably in young children and young adults; age-dependent cystatin-C models produced similar agreement to using a constant K in children under 18 years, but reduced bias in young adults. These age-dependent proposed equations were evaluated alongside estimated GFRs from 11 other published equations for pediatrics and young adults. Only our proposed equations yielded non- significant bias and within 30% accuracy values greater than 85% in both the pediatric and young adult subpopulations.

Novel two-lead cardiac resynchronization therapy system provides equivalent CRT responses with less complications than a conventional three-lead system: Results from the QP ExCELs lead registry.

INTRODUCTION: The novel two-lead cardiac resynchronization therapy (CRT)-DX system utilizes a floating atrial dipole on the implantable cardioverter-defibrillator lead, and when implanted with a left ventricular (LV) lead, offers a two-lead CRT system with AV synchrony. This study compared complication rates and CRT response among subjects implanted with a two-lead CRT-DX system to those subjects implanted with a standard three-lead CRT-D system. METHODS AND RESULTS: A total of 240 subjects from the Sentus QP-Extended CRT Evaluation with Quadripolar Left Ventricular Leads postapproval study were selected to identify 120 matched pairs based on similar demographic characteristics using a Greedy algorithm. The complication-free rate was evaluated as the primary endpoint. All-cause mortality, heart failure hospitalizations, device diagnostic data, New York Heart Association (NYHA) class improvement, and defibrillator therapy were evaluated from clinical data, in-office interrogations, and remote monitoring throughout the follow-up period. Complication-free survival favored the CRT-DX group with 92.5% without a major complication compared to 85.0% in the CRT-D cohort (P = .0495; 95% confidence interval: 0.1%-14.9%) over a mean follow-up of 1.3 and 1.4 years, respectively. Incidence of all-cause mortality, heart failure hospitalizations, NYHA changes at 6 months postimplant, and percent of LV pacing during CRT therapy were similar in both device cohorts. Inappropriate shocks were more frequent in the CRT-D cohort with 5.8% of subjects receiving an inappropriate shock vs 0.8% in the CRT-DX cohort. CONCLUSION: The results of this subanalysis demonstrate that the CRT-DX system can provide similar CRT responses and significantly fewer complications when compared to a similar cohort with a conventional three-lead CRT-D system.

Development of the Adult ECMO Specialist Certification Examination.

The American Society of Extracorporeal Technology Board of Directors, consistent with the American Society of Extracorporeal Technology's safe patient care improvement mission, charged the International Board of Blood Management to write a knowledge and skill certification examination for healthcare personnel employed as adult extracorporeal membrane oxygenation (ECMO) specialists. Nineteen nationally recognized ECMO subject-matter experts were selected to complete the examination development. A job analysis was performed, yielding a job description and examination plan focused on 16 job categories. Multiple-choice test items were created and validated. Qualified ECMO specialists were identified to complete a pilot examination and both pre- and post-examination surveys. The examination item difficulty and candidate performance were ranked and matched using Rasch methodology. Candidates' examination scores were compared with their profession, training, and experience as ECMO specialists. The 120-item pilot examination form ranked 76 ECMO specialist candidates consistent with their licensure, ECMO training, and clinical experience. Forty-three registered nurses, 28 registered respiratory therapists, four certified clinical perfusionists, and one physician assistant completed the pilot examination process. Rasch statistics revealed examination reliability coefficients of .83 for candidates and .88 for test items. Candidates ranked the appropriateness for examination items consistent with the item content, difficulty, and their personal examination score. The pilot examination pass rate was 80%. The completed examination product scheduled for enrollment in March 2020 includes 100 verified test items with an expected pass rate of 84% at a cut score of 67%. The online certification examination based on a verified job analysis provides an extramural assessment that ranks minimally prepared ECMO specialists' knowledge, skills, and abilities (KSA) consistent with safe ECMO patient care and circuit management. It is anticipated that ECMO facilities and ECMO service providers will incorporate the certification examination as part of their process improvement, safety, and quality assurance plans.

Cardiac Emergencies in Patients with Left Ventricular Assist Devices.

Continuous-flow left ventricular assist devices are frequently used for management of patients with advanced heart failure with reduced ejection fraction. Although technologic advancements have contributed to improved outcomes, several complications arise over time. These complications result from several factors, including medication effects, physiologic responses to chronic exposure to circulatory support that is minimally/entirely nonpulsatile, and dysfunction of the device itself. Clinical presentation can range from chronic and indolent to acute, life-threatening emergencies. Several areas of uncertainty exist regarding best practices for managing complications; however, growing awareness has led to development of new guidelines to reduce risk and improve outcomes.

Thrust and Power Output of the Bacterial Flagellar Motor: A Micromagnetic Tweezers Approach.

One of the most common swimming strategies employed by microorganisms is based on the use of rotating helical filaments, called flagella, that are powered by molecular motors. Determining the physical properties of this propulsive system is crucial to understanding the behavior of these organisms. Furthermore, the ability to dynamically monitor the activity of the flagellar motor is a valuable indicator of the overall energetics of the cell. In this work, inherently magnetic bacteria confined in micromagnetic CoFe traps are used to directly and noninvasively determine the flagellar thrust force and swimming speed of motile cells. The technique permits determination of the ratio of propulsive force/swimming speed (the hydrodynamic resistance) and the power output of the flagellar motor for individual cells over extended time periods. Cells subjected to ultraviolet radiation are observed to experience exponential decays in power output as a function of exposure time. By noninvasively measuring thrust, velocity, and power output over time at a single-cell level, this technique can serve as the foundation for fundamental studies of bacterial hydrodynamics and also provides a novel, to our knowledge, tether-free probe of single-cell energetics over time.

Contribution of symmetric dimethylarginine to GFR decline in pediatric chronic kidney disease.

BACKGROUND: In pediatric chronic kidney disease (pCKD), traditional factors (proteinuria, etiology, and race) do not fully explain disease progression. The levels of methylated arginine derivatives (MADs: asymmetric and symmetric dimethylarginine, respectively) rise in CKD and increase with CKD progression. The impact of MADs on glomerular filtration rate (GFR) decline has not been examined in pCKD. The aim of this study was to examine the additive impact of baseline (BL) levels of MADs on directly measured GFR (mGFR) decline per year (ml/min/1.73 m2/year) for a period of up to 4 years. METHODS: Plasma and data, including mGFR by plasma iohexol clearance, were provided by the prospective, observational Chronic Kidney Disease in Children study. BL MADs were analyzed by high-performance liquid chromatography-tandem mass spectrometry. RESULTS: For 352 pCKD subjects, the median [interquartile range] BL mGFR was 45 [35, 57] ml/min/1.73 m2. The levels of BL MADs were inversely related to the initial mGFR and its decline over time (p < 0.0005) but not to the rate of decline. Covariates, non-glomerulopathy and Tanner stage of ≥ 3 demonstrated weaker relationships between BL levels and beginning mGFR (p = 0.004 and p = 0.002, respectively). CONCLUSIONS: In pCKD, higher concentrations of BL MADs were inversely related to BL mGFR. MADs did not affect the CKD progression rate. Quantification of this relationship is novel to the pCKD literature.

Renin-angiotensin II-aldosterone system blockers and time to renal replacement therapy in children with CKD.

BACKGROUND: Clinical care decisions to treat chronic kidney disease (CKD) in a growing child must often be made without the benefit of evidence from clinical trials. We used observational data from the Chronic Kidney Disease in Children cohort to estimate the effectiveness of renin-angiotensin II-aldosterone system blockade (RAAS) to delay renal replacement therapy (RRT) in children with CKD. METHODS: A total of 851 participants (median age: 11 years, median glomerular filtration rate [GFR]: 52 ml/min/1.73 m2, median urine protein to creatinine ratio: 0.35 mg/mg) were included. RAAS use was reported at annual study visits. Both Cox proportional hazards models with time-varying RAAS exposure and Cox marginal structural models (MSM) were used to evaluate the effect of RAAS use on time to RRT. Analyses were adjusted or weighted to control for age, male sex, glomerular diagnosis, GFR, nephrotic range proteinuria, anemia, elevated blood pressure, acidosis, elevated phosphate and elevated potassium. RESULTS: There were 217 RRT events over a 4.1-year median follow-up. At baseline, 472 children (55 %) were prevalent RAAS users, who were more likely to be older, have a glomerular etiology, have higher urine protein, be anemic, have elevated serum phosphate and potassium, take more medications, but less likely to have elevated blood pressure, compared with non-users. RAAS use was found to reduce the risk of RRT by 21 % (hazard ratio: 0.79) to 37 % (hazard ratio: 0.63) from standard regression adjustment and MSM models, respectively. CONCLUSIONS: These results support inferences from adult studies of a substantial benefit of RAAS use in pediatric CKD patients.

Longitudinal changes in overactive bladder and stress incontinence among parous women.

AIMS: To describe longitudinal changes in symptoms of overactive bladder (OAB) and stress urinary incontinence (SUI) among parous women. METHODS: At annual examinations, beginning at least 5 years from first delivery, OAB and SUI were assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. Published thresholds were used to define "bothersome" symptom scores. The prevalence, the incidence of bothersome symptoms, and treatment rates were calculated. In separate analyses for women who delivered by cesarean versus vaginal delivery, odds of SUI or OAB symptoms (score > 0) were modeled as a function of time since childbirth, age, race, and obesity. Among those with persistent symptoms, severity symptom score was modeled as a function of time since childbirth and these same covariates. RESULTS: One thousand four hundred and eighty-one participants completed up to 5 annual assessments (2,722 woman-years). During follow-up, the incidences of bothersome SUI and OAB were 2.5/100 woman-years and 1.7/100 woman-years, respectively. Although SUI and OAB symptoms were more common in the vaginal birth group (P < 0.001), the odds of symptoms increased since increasing time from delivery in the cesarean group. Symptom severity did not change substantially over time in either group. Obesity was strongly associated with symptoms related to SUI and OAB. CONCLUSIONS: Five years from first delivery, symptoms related to SUI and OAB were more common and of greater severity after vaginal than cesarean birth. However, differences between these two groups lessen as time from childbirth increases. Obesity control should be a primary target for reduction of incontinence and incontinence severity among parous women.

Effect of silver nanoparticles on Candida albicans biofilms: an ultrastructural study.

BACKGROUND: Candida albicans is the most common pathogenic fungus isolated in bloodstream infections in hospitalized patients, and candidiasis represents the fourth most common infection in United States hospitals, mostly due to the increasing numbers of immune- and medically-compromised patients. C. albicans has the ability to form biofilms and morphogenetic conversions between yeast and hyphal morphologies contribute to biofilm development and represent an essential virulence factor. Moreover, these attached communities of cells are surrounded by a protective exopolymeric matrix that effectively shelters Candida against the action of antifungals. Because of dismal outcomes, novel antifungal strategies, and in particular those targeting biofilms are urgently required. As fungi are eukaryotic, research and development of new antifungal agents has been difficult due to the limited number of selective targets, also leading to toxicity. RESULTS: By microwave-assisted techniques we obtained pure 1 nm spherical silver nanoparticles ideal for their potential biological applications without adding contaminants. A phenotypic assay of C. albicans demonstrated a potent dose-dependent inhibitory effect of silver nanoparticles on biofilm formation, with an IC50 of 0.089 ppm. Also silver nanoparticles demonstrated efficacy when tested against pre-formed C. albicans biofilms resulting in an IC50 of 0.48 ppm. The cytotoxicity assay resulted in a CC50 of 7.03 ppm. The ultrastructural differences visualized under SEM with silver nanoparticles treatment were changes in the surface appearance of the yeast from smooth to rough thus indicating outer cell wall damage. On the fungal pre-formed biofilm true hyphae was mostly absent, as filamentation was inhibited. TEM measurement of the cell-wall width of C. albicans after treatment resulted in significant enlargement (206 ± 11 nm) demonstrating membrane permeabilization. CONCLUSIONS: Our results demonstrate that silver nanoparticles are potent inhibitors of C. albicans biofilm formation. SEM observations are consistent with an overall loss of structure of biofilms mostly due to disruption of the outer cell membrane/wall and inhibition of filamentation.TEM indicates the permeabilization of the cell wall and subsequent disruption of the structural layers of the outer fungal cell wall. The anti-biofilm effects are via cell wall disruption.

Long-term cumulative incidence of cervical intraepithelial neoplasia grade 3 or worse after abnormal cytology: impact of HIV infection.

To estimate the long term cumulative risk for cervical intraepithelial neoplasia grade 3 or worse after an abnormal cervical Pap test and to assess the effect of HIV infection on that risk. Participants in the Women's Interagency HIV Study were followed semiannually for up to 10 years. Pap tests were categorized according to the 1991 Bethesda system. Colposcopy was prescribed within 6 months of any abnormality. Risk for biopsy-confirmed CIN3 or worse after abnormal cytology and at least 12 months follow-up was assessed using Kaplan-Meier curves and compared using log-rank tests. Risk for CIN2 or worse was also assessed, since CIN2 is the threshold for treatment. After a median of 3 years of observation, 1,947 (85%) women subsequently presented for colposcopy (1,571 [81%] HIV seropositive, 376 [19%] seronegative). CIN2 or worse was found in 329 (21%) of HIV seropositive and 42 (11%) seronegative women. CIN3 or worse was found in 141 (9%) of seropositive and 22 (6%) seronegative women. In multivariable analysis, after controlling for cytology grade HIV seropositive women had an increased risk for CIN2 or worse (H.R. 1.66, 95% C.I 1.15, 2.45) but higher risk for CIN3 or worse did not reach significance (H.R. 1.33, 95% C.I. 0.79, 2.34). HIV seropositive women with abnormal Paps face a marginally increased and long-term risk for cervical disease compared to HIV seronegative women, but most women with ASCUS and LSIL Pap results do not develop CIN2 or worse despite years of observation.

Nephrotic-range proteinuria is strongly associated with poor blood pressure control in pediatric chronic kidney disease.

Despite the importance of blood pressure (BP) control in chronic kidney disease (CKD), few longitudinal studies on its trends exist for pediatric patients with CKD. Here we longitudinally analyzed casual data in 578 children with CKD and annual BP measurements standardized for age, gender, and height. At baseline, 124 children were normotensive, 211 had elevated BP, and 243 had controlled hypertension. Linear mixed-effects models accounting for informative dropout determined factors associated with BP changes over time and relative sub-hazards (RSH) identified factors associated with the achievement of controlled BP in children with baseline elevated BP. Younger age, black children, higher body mass index, and higher proteinuria at baseline were associated with higher standardized BP levels. Overall average BP decreased during follow-up, but nephrotic-range proteinuria and increased proteinuria and body mass index were risk factors for increasing BP over time. Only 46% of hypertensive patients achieved controlled BP during follow-up; least likely were those with nephrotic-range proteinuria (RSH 0.19), black children (RSH 0.42), and children with baseline glomerular filtration rate under 40 ml/min per 1.73 m(2) (RSH 0.58). Thus, of many coexisting factors, nephrotic-range proteinuria was most strongly associated with poor BP control and worsening BP over time. Future research should focus on strategies to reduce proteinuria, as this may improve BP control and slow the progression of CKD.

In vitro study of sequential fluconazole and caspofungin treatment against Candida albicans biofilms.

Candida albicans biofilms are generally considered to be resistant to azole antifungal agents but susceptible to echinocandins. We demonstrate that in a sequential therapy regimen, treatment with fluconazole first followed by caspofungin leads to a significant decrease of the efficacy of this echinocandin. Cellular stress responses induced by high fluconazole concentrations and mediated by Hsp90 and calcineurin play an important role in this phenomenon.

A case report of long-term effects of Delayed post-hypoxic leukoencephalopathy (DPHL) following benzodiazepine overdose.

Objective: We report a neuropsychological evaluation for a 39-year-old, right-handed, white female who 8 years ago developed delayed post-hypoxic leukoencephalopathy (DPHL), a rare demyelinating syndrome, two-weeks following an anoxic brain injury due to an overdose from benzodiazepines. Methods: An extensive record review documenting her medical timeline and treatment over the last 8 years was conducted using the available EMR system, which also included both EEG and neuroimaging data. Eight years post injury, a comprehensive neuropsychological battery was administered with corrected normative data for age, race, education, and other demographic factors when available. Collected data was compared with other case reports of DPHL. Results: The neuropsychological profile indicated difficulties across multiple cognitive domains that appeared driven by executive dysfunction, likely related to fronto-subcorto-striatal dysfunction. Conclusion: As a rare disease, the process by which DPHL occurs is not fully understood. Our results revealed similar findings in the literature for learning and memory, attention, processing speed, and executive functions. This is discussed in the context of available neuroimaging while highlighting the value of comprehensive neuropsychological assessment in DPHL even years post-injury.

Highly selective quantum sieving of D2 from H2 by a metal-organic framework as determined by gas manometry and infrared spectroscopy.

The quantum sieving effect between D2 and H2 is examined for a series of metal-organic frameworks (MOFs) over the temperature range 77-150 K. Isothermal adsorption measurements demonstrate a consistently larger isosteric heat of adsorption for D2 vs H2, with the largest difference being 1.4 kJ/mol in the case of Ni-MOF-74. This leads to a low-pressure selectivity for this material that increases from 1.5 at 150 K to 5.0 at 77 K. Idealized adsorption solution theory indicates that the selectivity decreases with increasing pressure, but remains well above unity at ambient pressure. Infrared measurements on different MOF materials show a strong correlation between selectivity and the frequency of the adsorbed H2 translational band. This confirms that the separation is predominantly due to the difference in the zero-point energies of the adsorbed isotopologues.

High-throughput screening of a collection of known pharmacologically active small compounds for identification of Candida albicans biofilm inhibitors.

Candida albicans is the most common etiologic agent of systemic fungal infections with unacceptably high mortality rates. The existing arsenal of antifungal drugs is very limited and is particularly ineffective against C. albicans biofilms. To address the unmet need for novel antifungals, particularly those active against biofilms, we have screened a small molecule library consisting of 1,200 off-patent drugs already approved by the Food and Drug Administration (FDA), the Prestwick Chemical Library, to identify inhibitors of C. albicans biofilm formation. According to their pharmacological applications that are currently known, we classified these bioactive compounds as antifungal drugs, as antimicrobials/antiseptics, or as miscellaneous drugs, which we considered to be drugs with no previously characterized antifungal activity. Using a 96-well microtiter plate-based high-content screening assay, we identified 38 pharmacologically active agents that inhibit C. albicans biofilm formation. These drugs were subsequently tested for their potency and efficacy against preformed biofilms, and we identified three drugs with novel antifungal activity. Thus, repurposing FDA-approved drugs opens up a valuable new avenue for identification and potentially rapid development of antifungal agents, which are urgently needed.

Mechanical intelligence simplifies control in terrestrial limbless locomotion.

Limbless locomotors, from microscopic worms to macroscopic snakes, traverse complex, heterogeneous natural environments typically using undulatory body wave propagation. Theoretical and robophysical models typically emphasize body kinematics and active neural/electronic control. However, we contend that because such approaches often neglect the role of passive, mechanically controlled processes (those involving "mechanical intelligence"), they fail to reproduce the performance of even the simplest organisms. To uncover principles of how mechanical intelligence aids limbless locomotion in heterogeneous terradynamic regimes, here we conduct a comparative study of locomotion in a model of heterogeneous terrain (lattices of rigid posts). We used a model biological system, the highly studied nematode worm Caenorhabditis elegans, and a robophysical device whose bilateral actuator morphology models that of limbless organisms across scales. The robot's kinematics quantitatively reproduced the performance of the nematodes with purely open-loop control; mechanical intelligence simplified control of obstacle navigation and exploitation by reducing the need for active sensing and feedback. An active behavior observed in C. elegans, undulatory wave reversal upon head collisions, robustified locomotion via exploitation of the systems' mechanical intelligence. Our study provides insights into how neurally simple limbless organisms like nematodes can leverage mechanical intelligence via appropriately tuned bilateral actuation to locomote in complex environments. These principles likely apply to neurally more sophisticated organisms and also provide a design and control paradigm for limbless robots for applications like search and rescue and planetary exploration.

The rhizodynamics robot: Automated imaging system for studying long-term dynamic root growth.

The study of plant root growth in real time has been difficult to achieve in an automated, high-throughput, and systematic fashion. Dynamic imaging of plant roots is important in order to discover novel root growth behaviors and to deepen our understanding of how roots interact with their environments. We designed and implemented the Generating Rhizodynamic Observations Over Time (GROOT) robot, an automated, high-throughput imaging system that enables time-lapse imaging of 90 containers of plants and their roots growing in a clear gel medium over the duration of weeks to months. The system uses low-cost, widely available materials. As a proof of concept, we employed GROOT to collect images of root growth of Oryza sativa, Hudsonia montana, and multiple species of orchids including Platanthera integrilabia over six months. Beyond imaging plant roots, our system is highly customizable and can be used to collect time- lapse image data of different container sizes and configurations regardless of what is being imaged, making it applicable to many fields that require longitudinal time-lapse recording.

Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease.

OBJECTIVE: To compare the reliability of blood pressure (BP) readings obtained with an oscillometric device with those obtained by auscultation and assess for differences in BP status classification based on the 2 techniques. STUDY DESIGN: Resting BP was measured by auscultation and with an oscillometric device at the same encounter in 235 subjects enrolled in the Chronic Kidney Disease in Children study. Resting auscultatory BP values were averaged and compared with averaged oscillometric readings. BP agreement by the 2 methods was assessed using Bland-Altman plots, and BP status classification agreement was assessed by calculation of kappa statistics. RESULTS: Oscillometric BP readings were higher than auscultatory readings, with a median paired difference of 9 mm Hg for systolic BP (SBP) and 6 mm Hg for diastolic BP (DBP). Correlation for mean SBP was 0.624 and for mean DBP was 0.491. The bias for oscillometric BP measurement was 8.7 mm Hg for SBP (P < .01) and 5.7 mm Hg for DBP (P < .01). BP status classification agreement was 61% for SBP and 63% for DBP, with Kappa values of .31 for SBP and .20 for DBP. CONCLUSIONS: Compared with auscultation, the oscillometric device significantly overestimated both SBP and DBP, leading to frequent misclassification of BP status.