The field of psychoneuroimmunology has made significant advances in understanding mechanisms underlying signaling between the immune system and central nervous system since the initial coinage of the term in 1975 and especially in the past 25 years. The current review explores the research supporting the premise that the immune system impacts behavior, including risk of developing stress-related psychiatric disorders (e.g., anxiety disorders, affective disorders, and trauma- and stressor-related disorders such as posttraumatic stress disorder). Beginning with the recent call to examination of interoception as a mental health-relevant signal, inflammation is explored as an important interoceptive signal. Inflammation is viewed through the lens of sickness behavior, before broadening to include the impact of the immune system on a collection of mental-health-related symptoms. This is explored mechanistically through the direct effects of cytokine signaling on the brain, the impact of afferent vagus nerve signaling, and through examination of the role of bone-marrow-derived monocytes in relaying peripheral immune signals to the brain. Immature bone-marrow-derived monocytes contribute to increased peripheral inflammation, but also have the capacity to traffic to brain regions relevant to stress-related psychiatric disorders. This trafficking can increase neuroinflammation causing anxiety-like defensive behavioral responses in mouse models and has been linked to symptoms of stress-related psychiatric disorders in humans. Additionally, the commensal bacteria inhabiting the gut (gut microbiota) exert a modulating effect on inflammation and behavior through several mechanisms, including signaling in the systemic circulation, shifting the body's stress dynamics, and altering inflammatory balance in the gut and the rest of the body. These mechanisms are discussed in the context of mental health conditions, including mood disorders, anxiety disorders, and trauma- and stressor-related disorders. There is a preponderance of evidence supporting the fact that peripheral immune activity and neuroinflammation impact behavior and mental health. Further research will continue to elucidate the mechanisms involved.
Background: Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS). Methods: Retrospective analysis of a prospective observational international cohort study. Results: There were 306 children from 55 pediatric intensive care units included. High mechanical power was associated with younger age, higher oxygenation index, a comorbid condition of bronchopulmonary dysplasia, higher tidal volume, higher delta pressure (peak inspiratory pressure-positive end-expiratory pressure), and higher respiratory rate. Higher mechanical power was associated with fewer 28-day VFD after controlling for confounding variables (per 0.1 J·min-1·Kg-1 Subdistribution Hazard Ratio (SHR) 0.93 (0.87, 0.98), p = 0.013). Higher mechanical power was not associated with higher intensive care unit mortality in multivariable analysis in the entire cohort (per 0.1 J·min-1·Kg-1 OR 1.12 [0.94, 1.32], p = 0.20). But was associated with higher mortality when excluding children who died due to neurologic reasons (per 0.1 J·min-1·Kg-1 OR 1.22 [1.01, 1.46], p = 0.036). In subgroup analyses by age, the association between higher mechanical power and fewer 28-day VFD remained only in children < 2-years-old (per 0.1 J·min-1·Kg-1 SHR 0.89 (0.82, 0.96), p = 0.005). Younger children were managed with lower tidal volume, higher delta pressure, higher respiratory rate, lower positive end-expiratory pressure, and higher PCO2 than older children. No individual ventilator management component mediated the effect of mechanical power on 28-day VFD. Conclusions: Higher mechanical power is associated with fewer 28-day VFDs in children with PARDS. This association is strongest in children < 2-years-old in whom there are notable differences in mechanical ventilation management. While further validation is needed, these data highlight that ventilator management is associated with outcome in children with PARDS, and there may be subgroups of children with higher potential benefit from strategies to improve lung-protective ventilation. Take home message: Higher mechanical power is associated with fewer 28-day ventilator-free days in children with pediatric acute respiratory distress syndrome. This association is strongest in children <2-years-old in whom there are notable differences in mechanical ventilation management.
In this conceptual paper, we describe the approach in storylines that builds on principles of project-based learning and focuses on supports for making science learning coherent from the students’ perspective. In storylines, students see their science work as addressing questions and problems their class has identified. We present design principles that guide the teaching and enactment of storyline units and explore the connections of these principles to ideas of project-based science. We illustrate how these design strategies are reflected in a high school biology unit co-developed by teachers and researchers. We present student artifacts that document the agency students take on in this work. We then summarize results from earlier studies examining students’ learning and perceptions of coherence of their learning experiences.
Background For infants with severe congenital diaphragmatic hernia (CDH) stabilized with extracorporeal membrane oxygenation (ECMO), early repair on ECMO improves outcome; however when compared to operative repair after ECMO, repair on ECMO is associated with increase bleeding risk and need for blood product transfusions. Methods A retrospective review of 54 patients with CDH placed on ECMO prior to CDH repair was performed. For the subset of patients repaired on ECMO, analysis comparing those repaired early (within 48 h of cannulation) and late (beyond 48 h) on ECMO was performed. Outcomes of interest included survival to discharge, days on ECMO, and postoperative blood product utilization. Results When compared to those patients repaired prior to 48 h of ECMO initiation, 57.7% of patients survived versus 40.9% of late repair patients. For those repaired early, blood product utilization was significantly less. Early repair patients received a median of 72 mL/kg packed red blood cells (PRBC) and 75 mL/kg platelets compared to 151.9 mL/kg and 98.7 mL/kg, respectively ( p < 0.05 respectively). There was no difference in median days on ECMO ( p = 0.38). Conclusion Our data supports prior reports of improved outcome with repair with 48 h of ECMO initiation and suggests early repair on ECMO is associated with less bleeding and decreased blood product requirement in the postoperative period.
Background This implementation feasibility study was conducted to determine whether an evidence-based parent-implemented distance-learning intervention model for young children at high likelihood of having ASD could be implemented at fidelity by Part C community providers and by parents in low-resource communities. Methods The study used a community-academic partnership model to adapt an evidence-based intervention tested in the current pilot trial involving randomization by agency in four states and enrollment of 35 coaches and 34 parent-family dyads. After baseline data were gathered, providers in the experimental group received 12–15 h of training while control providers received six webinars on early development. Providers delivered 6 months of intervention with children-families, concluding with data collection. Regression analyses were used to model outcomes of the coach behaviors, the parent fidelity ratings, and child outcomes. Results A block design model-building approach was used to test the null model followed by the inclusion of group as a predictor, and finally the inclusion of the planned covariates. Model fit was examined using changes in R ² and F -statistic. As hypothesized, results demonstrated significant gains in (1) experimental provider fidelity of coaching implementation compared to the control group; and (2) experimental parent fidelity of implementation compared to the control group. There were no significant differences between groups on child developmental scores. Conclusions Even though the experimental parent group averaged less than 30 min of intervention weekly with providers in the 6 months, both providers and parents demonstrated statistically significant gains on the fidelity of implementation scores with moderate effect sizes compared to control groups. Since child changes in parent-mediated models are dependent upon the parents’ ability to deliver the intervention, and since parent delivery is dependent upon providers who are coaching the parents, these results demonstrated that two of these three links of the chain were positively affected by the experimental implementation model. However, a lack of significant differences in child group gains suggests that further work is needed on this model. Factors to consider include the amount of contact with the provider, the amount of practice children experience, the amount of contact both providers and parents spend on training materials, and motivational strategies for parents, among others. Trial registration Registry of Efficacy and Effectiveness Studies: #4360, registered 1xx, October, 2020 – Retrospectively registered, https://sreereg.icpsr.umich.edu/sreereg/
A spectrogram of Power Line Harmonic Radiation (PLHR) consists of a set of lines with frequency spacing corresponding exactly to 50 or 60 Hz. It is distinct from a spectrogram of Magnetospheric Line Radiation (MLR) where the lines are not equidistant and drift in frequency. PLHR and MLR propagate in the ionosphere and the magnetosphere and are recorded by ground experiments and satellites. If the source of PLHR is evident, the origin of the MLR is still under debate and the purpose of this paper is to understand how MLR lines are formed. The ELF waves triggered by High-frequency Active Auroral Research Program (HAARP) in the ionosphere are used to simulate lines (pulses of different lengths and different frequencies). Several receivers are utilized to survey the propagation of these pulses. The resulting waves are simultaneously recorded by ground-based experiments close to HAARP in Alaska, and by the low-altitude satellite DEMETER either above HAARP or its magnetically conjugate point. Six cases are presented which show that 2-hop echoes (pulses going back and forth in the magnetosphere) are very often observed. The pulses emitted by HAARP return in the Northern hemisphere with a time delay. A detailed spectral analysis shows that sidebands can be triggered and create elements with superposed frequency lines which drift in frequency during the propagation. These elements acting like quasi-periodic emissions are subjected to equatorial amplification and can trigger hooks and falling tones. At the end all these known physical processes lead to the formation of the observed MLR by HAARP pulses. It is shown that there is a tendency for the MLR frequencies of occurrence to be around 2 kHz although the exciting waves have been emitted at lower and higher frequencies. Graphical Abstract
Mantle cell lymphoma (MCL) is a subtype of non-Hodgkin’s lymphoma characterized by poor prognosis. The complexity of MCL pathogenesis arises from aberrant activities of diverse signaling pathways, including BTK, PI3K–AKT–mTOR and MYC-BRD4. Here, we report that MCL-related signaling pathways can be altered by a single small molecule inhibitor, SRX3305. Binding and kinase activities along with resonance changes in NMR experiments reveal that SRX3305 targets both bromodomains of BRD4 and is highly potent in inhibition of the PI3K isoforms α, γ and δ, as well as BTK and the drug-resistant BTK mutant. Preclinical investigations herein reveal that SRX3305 perturbs the cell cycle, promotes apoptosis in MCL cell lines and shows dose dependent anti-proliferative activity in both MCL and drug-resistant MCL cells. Our findings underscore the effectiveness of novel multi-action small molecule inhibitors for potential treatment of MCL.
Delays in denosumab dosing for osteoporosis treatment may lead to rapid bone loss or increased fractures. We assessed the frequency of delayed denosumab dosing before and after the implementation of a structured ordering plan with automated reminders and found that the rate of delayed denosumab dosing was cut in half. Purpose: The purpose of our study was to assess the frequency of delayed denosumab dosing before and after the implementation of a structured ordering plan with automated reminders. Methods: We conducted a retrospective chart review of 720 adults with osteoporosis who received at least two denosumab doses within the UCHealth system before and after the plan went into effect. Results: There was a significant reduction in delayed dosing from 24.0% (PRE) to 12.6% (POST) (p < 0.001) after implementation of the automated reminder. The fraction of delayed denosumab doses due to scheduling issues decreased significantly between PRE and POST time periods (16.4% vs. 3.3%, p = 0.011), while patient-related issues increased from 31.2% to 46.7% (p = 0.041). The rate of provider, medical, and other/unknown issues did not differ between the two time periods. When normalized to patient-years of follow-up, the number of fractures was the same for both groups at 0.016 fractures per patient-year. Fractures in both the PRE and POST groups were related to dosing delays, but the study was not powered to detect the differences in fracture rates between the groups. Conclusion: Electronic records with automatic reminders can reduce delayed dosing of denosumab and may lead to reductions in fractures associated with delays.
Background Calcific aortic valve disease (CAVD) is the most prevalent heart valve disorder in the elderly. Valvular fibrocalcification is a characteristic pathological change. In diseased valves, monocyte accumulation is evident, and aortic valve interstitial cells (AVICs) display greater fibrogenic and osteogenic activities. However, the impact of activated monocytes on valular fibrocalcification remains unclear. We tested the hypothesis that pro-inflammatory mediators from activated monocytes elevate AVIC fibrogenic and osteogenic activities. Methods and results Picro-sirius red staining and Alizarin red staining revealed collagen and calcium depositions in cultured human AVICs exposed to conditioned media derived from Pam3CSK4-stimulated monocytes (Pam3 CM). Pam3 CM up-regulated alkaline phosphatase (ALP), an osteogenic biomarker, and extracellular matrix proteins collagen I and matrix metalloproteinase-2 (MMP-2). ELISA analysis identified high levels of RANTES and TNF-α in Pam3 CM. Neutralizing RANTES in the Pam3 CM reduced its effect on collagen I and MMP-2 production in AVICs while neutralizing TNF-α attenuated the effect on AVIC ALP production. In addition, Pam3 CM induced NF-κB and JNK activation. While JNK mediated the effect of Pam3 CM on collagen I and MMP-2 production, NF-κB was critical for the effect of Pam3 CM on ALP production in AVICs. Conclusions This study demonstrates that activated monocytes elevate the fibrogenic and osteogenic activities in human AVICs through a paracrine mechanism. TNF-α and RANTES mediate the pro-fibrogenic effect of activated monocytes on AVICs through activation of JNK, and TNF-α also activates NF-κB to elevate AVIC osteogenic activity. The results suggest that infiltrated monocytes elevate AVIC fibrocalcific activity to promote CAVD progression.
Respiratory diseases remain a significant cause of global morbidity and mortality and primary care plays a central role in their prevention, diagnosis and management. An e-Delphi process was employed to identify and prioritise the current respiratory research needs of primary care health professionals worldwide. One hundred and twelve community-based physicians, nurses and other healthcare professionals from 27 high-, middle- and low-income countries suggested 608 initial research questions, reduced after evidence review by 27 academic experts to 176 questions covering diagnosis, management, monitoring, self-management and prognosis of asthma, COPD and other respiratory conditions (including infections, lung cancer, tobacco control, sleep apnoea). Forty-nine questions reached 80% consensus for importance. Cross-cutting themes identified were: a need for more effective training of primary care clinicians; evidence and guidelines specifically relevant to primary care, adaption for local and low-resource settings; empowerment of patients to improve self-management; and the role of the multidisciplinary healthcare team.
Hepatobiliary cystadenocarcinoma is a rare malignancy associated with ovarian-like stroma and overtly malignant glands that has a favorable prognosis if completely resected, analogous to minimally invasive adenocarcinoma arising in mucinous cystic neoplasms of the pancreas. Ovarian mucinous neoplasms may have a similar histologic appearance and are known to occasionally contain mural nodules of anaplastic carcinoma. We report a case of hepatobiliary cystadenocarcinoma that subsequently presented as metastatic disease mimicking a primary gynecological malignancy. The 30-year-old patient had a history of a completely resected hepatobiliary cystadenocarcinoma 2 years prior to presentation, without adjuvant therapy. She presented to her gynecologist with pelvic pain and vaginal bleeding. Physical examination revealed diffuse nodularity along the anterior vaginal wall, and imaging showed a 5.8 × 4.1 cm pelvic mass with diffuse metastatic disease. Biopsies of the vaginal wall and an inguinal lymph node showed nests of pleomorphic cells with squamoid and glandular features concerning for metastatic ovarian carcinoma; however, immunohistochemistry was negative for PAX8 and ER, but positive for CDX2. Subsequent review of the patient's prior resection revealed a cystic mucinous neoplasm with mural nodules of adenosquamous and anaplastic carcinoma, the latter previously reported only rarely in hepatobiliary cystadenocarcinoma. This case highlights the histologic overlap between hepatobiliary and ovarian neoplasms, which may present a diagnostic challenge, particularly in the setting of incomplete history. In addition, the unusual presence of an anaplastic component in the patient's original tumor portends a worse prognosis; therefore, additional therapy should be considered in these patients.
Background Studies have consistently found high rates of unintended pregnancy among women with opioid use disorder (OUD). Few interventions have been developed to specifically engage and address the family planning (FP) needs of women in substance use disorder treatment. Objectives: Our goal was to collect formative qualitative data to identify the FP experiences, needs and service preferences of women receiving medications for OUD and to use these data to develop a FP education and navigation intervention that could be tested in diverse, resource-limited treatment settings. Methods: From August 2016 to April 2017, we conducted 21 guided qualitative interviews with women from two outpatient treatment clinics in Denver, Colorado. We recorded, transcribed, and coded all interviews. We then facilitated three focus groups (n = 16) from May to July 2017 to verify or challenge interview themes and to further inform the development of the FP intervention. Results: Most participants expressed ambivalence or low perceived risk regarding unintended pregnancy and desired more information about contraceptive methods. Many participants described mistrust or lack of engagement in the medical system and histories of trauma were a common barrier to seeking services. Focus group participants endorsed a peer-led FP navigation intervention and provided feedback to tailor existing FP educational materials to fit the specific needs of women in recovery. Conclusions/Importance: Results from this qualitative study suggest that women in recovery from OUD have unique, unmet FP education and service needs. These findings provide important information for the development of feasible and acceptable FP service delivery within diverse, resource-limited treatment settings and informed the development of a trauma-informed, peer-led FP education and navigation intervention that would be implemented in a subsequent phase of the study.
Patients who receive earlier treatment for acute exacerbations of chronic obstructive pulmonary disease (COPD) have a better prognosis, including earlier symptom resolution and reduced risk of future emergency-department visits (ED) or hospitalizations. However, many patients delay seeking care or do not report worsening symptoms to their healthcare provider. In this study, we aimed to understand how patients perceived their breathing symptoms and identify factors that led to seeking or delaying care for an acute exacerbation of COPD. We conducted semistructured interviews with 60 individuals following a recent COPD exacerbation. Participants were identified from a larger study of outpatients with COPD by purposive sampling by exacerbation type: 15 untreated, 15 treated with prednisone and/or antibiotics in the outpatient setting, 16 treated in an urgent care or ED setting, and 14 hospitalized. Data were analyzed using inductive content analysis. Participants were primarily male (97%) with a mean age of 69.1 ± 6.9 years, mean FEV 1 1.42 (±0.63), and mean mMRC dyspnea of 2.7 (±1.1). We identified 4 primary themes: (i) access and attitudinal barriers contribute to reluctance to seek care, (ii) waiting is a typical response to new exacerbations, (iii) transitioning from waiting to care-seeking: the tipping point, and (iv) learning from and avoiding worse outcomes. Interventions to encourage earlier care-seeking for COPD exacerbations should consider individuals’ existing self-management approaches, address attitudinal barriers to seeking care, and consider health-system changes to increase access to non-emergent outpatient treatment for exacerbations. Clinical Trial Registration NCT02725294
Background Hospital systems have rapidly adapted to manage the influx of patients with COVID-19 and hospitalists, specialists in inpatient care, have been at the forefront of this response, rapidly adapting to serve the ever-changing needs of the community and hospital system. Institutional leaders, including clinical care team members and administrators, deployed many different strategies (i.e. adaptations) to manage the influx of patients. While many different strategies were utilized in hospitals across the United States, it is unclear how frontline care teams experienced these strategies and multifaceted changes. As these surge adaptations likely directly impact clinical care teams, we aimed to understand the perceptions and impact of these clinical care and staffing adaptations on hospitalists and care team members in order to optimize future surge plans. Methods Qualitative, semi-structured interviews and focus groups with hospitalist physicians, advanced practice providers (APPs), and hospital nursing and care management staff at a quaternary academic medical center. Interviews focused on the impact of COVID-19 surge practices on the following areas: (1) the experience of clinical care teams with the adaptations used to manage the surge (2) the perception and experience with the communication strategies utilized (3) the personal experience with the adaptations (i.e. how they impacted the individual) and (4) if participants had recommendations on strategies for future surges. We utilized rapid qualitative analysis methods to explore themes and subthemes. Results We conducted five focus groups and 21 interviews. Three themes emerged from the work including (1) dynamic clinical experience with a lot of uncertainty, (2) the importance of visible leadership with a focus on sense-making, and (3) the significant emotional toll on care team members. Subthemes included sufficient workforce, role delineation and training, information sharing, the unique dichotomy between the need for flexibility and the need for structure, the importance of communication, and the emotional toll not only on the provider but their families. Several recommendations came from this work. Conclusions COVID-19 surge practices have had direct impact on hospitalists and care team members. Several tactics were identified to help mitigate the many negative effects of COVID-19 on frontline hospitalist providers and care teams.
The World Magnetic Model (WMM) is a geomagnetic main field model that is widely used for navigation by governments, industry and the general public. In recent years, the model has been derived using high accuracy magnetometer data from the Swarm mission. This study explores the possibility of developing future WMMs in the post-Swarm era using data from the Iridium satellite constellation. Iridium magnetometers are primarily used for attitude control, so they are not designed to produce the same level of accuracy as magnetic data from scientific missions. Iridium magnetometer errors range from 30 nT quantization to hundreds of nT errors due to spacecraft contamination and calibration uncertainty, whereas Swarm measurements are accurate to about 1 nT. The calibration uncertainty in the Iridium measurements is identified as a major error source, and a method is developed to calibrate the spacecraft measurements using data from a subset of the INTERMAGNET observatory network producing quasi-definitive data on a regular basis. After calibration, the Iridium data produced main field models with approximately 20 nT average error and 40 nT maximum error as compared to the CHAOS-7.2 model. For many scientific and precision navigation applications, highly accurate Swarm-like measurements are still necessary, however, the Iridium-based models were shown to meet the WMM error tolerances, indicating that Iridium is a viable data source for future WMMs. Graphical Abstract
Background Although biological males and females are equally likely to become infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), evidence has mounted that males experience higher severity and fatality compared to females. Main The objective of this review is to examine the existing literature on biological mechanisms underlying sex-based differences that could contribute to SARS-CoV-2 infection clinical outcomes. Sex-based differences in immunologic response and hormonal expression help explain the differences in coronavirus disease 2019 (COVID-19) outcomes observed in biological males and females. X inactivation facilitates a robust immune response to COVID-19 in females, who demonstrate a more profound antibody response and faster recovery when compared to males. Low testosterone levels also help explain the dysregulated inflammatory response and poor outcomes observed in some males with COVID-19. Gender differences in health expression and behaviors further compound these observed differences. Conclusion Understanding the biology of sex-based differences in COVID-19 severity and mortality could help inform preventative measures, treatment decisions, and development of personalized, sex-specific therapies.
Background Anthocyanins are major pigments contributing to flower coloration and as such knowledge of molecular architecture underlying the anthocyanin biosynthetic pathway (ABP) is key to understanding flower color diversification. To identify ABP structural genes and associated regulatory networks, we sequenced 16 transcriptomes generated from 10 species of Ruellia and then conducted co-expression analyses among resulting data. Results Complete coding sequences for 12 candidate structural loci representing eight genes plus nine candidate regulatory loci were assembled. Analysis of non-synonymous/synonymous (dn/ds) mutation rates indicated all identified loci are under purifying selection, suggesting overall selection to prevent the accumulation of deleterious mutations. Additionally, upstream enzymes have lower rates of molecular evolution compared to downstream enzymes. However, site-specific tests of selection yielded evidence for positive selection at several sites, including four in F3'H2 and five in DFR3 , and these sites are located in protein binding regions. A species-level phylogenetic tree constructed using a newly implemented hybrid transcriptome–RADseq approach implicates several flower color transitions among the 10 species. We found evidence of both regulatory and structural mutations to F3′5'H in helping to explain the evolution of red flowers from purple-flowered ancestors. Conclusions Sequence comparisons and co-expression analyses of ABP loci revealed that mutations in regulatory loci are likely to play a greater role in flower color transitions in Ruellia compared to mutations in underlying structural genes.
We report a three-dimensional (3D) molecular orientation control of a liquid crystal organic semiconductor (LC-OSC) based on the long-range ordering characteristic of an LC material. To this end, a synthetic LC-OSC molecule, MeOPh-BTBT-C8, with a fluidic nematic (N) phase that is essential for alignment control over a large area and a smectic E (SmE) phase showing high ordering, was prepared. A simple flipping of a sandwich cell made of the LC-OSC material between the top and bottom substrates that have uniaxial–planar degenerated alignment as well as crossed rubbing directions responds to the given surface anchoring condition and temperature gradient. Optical observation of the alignment-controlled LC-OSC was carried out by polarized optical microscopy (POM), and the corresponding charge carrier mobility was also measured by fabricating organic field-effect transistors (OFETs). Our platform offers a facile approach for multidirectional and multifunctional organic electronic devices using the stimulus–response characteristics of LC materials.
Surgical patients with coronavirus disease 2019 (COVID-19) are vulnerable to increased perioperative complications and postoperative mortality, independent of the risk for contracting COVID-19 pneumonia after endotracheal intubation for general anesthesia. The presumed root cause of postoperative infections, microvascular soft tissue injuries and thromboembolic complications is largely attributed to the profound immune dysfunction induced by COVID-19 as a result of complement activation and the “cytokine storm”. The empirical therapy with anti-inflammatory agents has been shown to attenuate some of the adverse effects of systemic hyperinflammation in COVID-19 patients. In addition, the proactive concept of “immunonutrition” may represent a new promising avenue for mitigating the complex immune dysregulation in COVID-19 and thereby reduce the rates of surgical complications and postoperative mortality. This letter provides a narrative summary of the current state-of-the-art in the field of immunonutrition as it pertains to surgical patient safety in COVID-19 patients.
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