Report from the 2018 consensus conference on immunomodulating agents in thoracic transplantation: Access, formulations, generics, therapeutic drug monitoring, and special populations.

In 2009, the International Society for Heart and Lung Transplantation recognized the importance and challenges surrounding generic drug immunosuppression. As experience with generics has expanded and comfort has increased, substantial issues have arisen since that time with other aspects of immunomodulation that have not been addressed, such as access to medicines, alternative immunosuppression formulations, additional generics, implications on therapeutic drug monitoring, and implications for special populations such as pediatrics and older adults. The aim of this consensus document is to address critically each of these concerns, expand on the challenges and barriers, and provide therapeutic considerations for practitioners who manage patients who need to undergo or have undergone cardiothoracic transplantation.

Engineered bacteriophages for treatment of a patient with a disseminated drug-resistant Mycobacterium abscessus.

A 15-year-old patient with cystic fibrosis with a disseminated Mycobacterium abscessus infection was treated with a three-phage cocktail following bilateral lung transplantation. Effective lytic phage derivatives that efficiently kill the infectious M. abscessus strain were developed by genome engineering and forward genetics. Intravenous phage treatment was well tolerated and associated with objective clinical improvement, including sternal wound closure, improved liver function, and substantial resolution of infected skin nodules.

Making space work: Staff socio-spatial practices in a paediatric outpatient department.

Studies of the characteristics of therapeutic landscapes have become common in medical geography. However, there is limited analysis of how therapeutic landscapes are produced. Based upon the qualitative theoretical thematic analysis of focus group data, this study examined the spatial work carried out by healthcare practitioners in a paediatric outpatients' department, turning unsatisfactory space into a therapeutic place. The study highlights the spatial strategies employed by staff to mitigate socio-spatial deficiencies in the healthcare environment. Staff perceived the task of making space work as an integral part of their duty of care to patients and an important facet of their professional identity. This study concludes that many of the spatial aspects of health care practice are often taken for granted. However this may hide the crucial role that health professionals have in producing places that heal.

Patient advocacy by nurses - past, present and future.

BACKGROUND: Patient advocacy is central to the nursing profession yet a sense of certainty about the concept, its meaning and its implications for nursing practice remains elusive. AIM: This scholarly paper examines the concept of patient advocacy and its relevance to the nursing profession in Aotearoa/New Zealand. DESIGN: A broad historical overview of the evolution of the role of advocacy in nursing practice is provided including factors that encourage or discourage nurses to practice patient advocacy. CONCLUSIONS: This paper highlights the gap between the ideal of patient advocacy and the realities of everyday nursing practice. The responsibility for enacting advocacy sits with both individual practitioners and the organizations nurses work within.

Initial data on basiliximab in critically ill children undergoing heart transplantation.

BACKGROUND: More children are coming to heart transplantation on extracorporeal membrane oxygenation (ECMO), or inotropic support and/or with renal impairment. The use of basiliximab, a chimeric monoclonal antibody against CD25 (interleukin 2 receptor alfa) has not been previously reported in critically ill pediatric heart transplant recipients. Basiliximab has potential advantages in the treatment of patients with renal impairment. METHODS: Basiliximab was provided to 29 patients (median age 7.8 years; range 0.4-16 years) on ECMO, with renal impairment or receiving intravenous inotropes at transplantation. Children normally received 2 doses on Day 0 and Day 4 after transplantation. Calcineurin inhibitor was provided in low dose or withheld altogether in patients with renal impairment. Flow cytometry was used to monitor CD25. RESULTS: At transplantation, 11 patients were prescribed cyclosporine; the remaining 18 received tacrolimus. All but 4 patients had subtherapeutic levels of calcineurin inhibitor in the first postoperative week. Excluding these 4, there were 19 patients who had more than 4 consecutive doses of calcineurin inhibitor canceled in the first week (median 8 doses; range 3-40 doses). A total of 71 surveillance biopsies were performed, and 4 episodes of severe acute rejection occurred in the first 6 months. In all but one child, the glomerular filtration rate had returned to, or improved on baseline measurement by 1 month after transplantation. Infections rates were low and acceptable. CD25 was undetectable at first assessment, and in all but 1 patient (on ECMO) for at least 2 to 3 weeks thereafter. There were no adverse effects. CONCLUSIONS: Basiliximab was well tolerated in this group of very ill children. In children with pre- or postoperative renal dysfunction, where doses of calcineurin inhibitor were low or canceled, basiliximab was associated with a low incidence of rejection. Posttransplant ECMO may reduce the efficacy of basiliximab. These preliminary results are encouraging and now need confirmation in a large, randomized trial.

Chlorosis-inducing products from Pseudomonas syringae pathovars: new N-coronafacoyl compounds.

Liquid cultures of Pseudomonas syringae pv. tomato strains that also produced the phytotoxin coronatine, were found to have a new chlorosis-inducing activity, not previously described. Bioassay-guided fractionation and HPLC analysis revealed two new peaks that were chlorosis-inducing on leaves of bean plants. Mass spectrometry and NMR analyses of the compounds led to the derivation of their structures as coronafacoyl-L-serine and coronafacoyl-L-threonine, respectively. The amino acid C-2 configurations were determined by GC analysis following hydrolysis with 6M HCl. Both compounds have more polar and more acidic properties than coronatine, norcoronatine, and other known coronafacoyl conjugates with non-polar amino acids. Investigation of Pseudomonas syringae pv. glycinea strains that are known to be prolific producers of the coronatine family of compounds revealed the production of coronafacoylserine and coronafacoylthreonine also.