Tandem Therapeutic Plasma Exchange Reduces Continuous Renal Replacement Therapy Downtime.

INTRODUCTION: Continuous renal replacement therapy (CRRT) has become a primary treatment of severe acute kidney injury in children admitted to the intensive care unit. CRRT "downtime" (when the circuit is not active) can represent a significant portion of the prescribed treatment time and adversely affects clearance. The objective of this study was to evaluate factors associated with CRRT "downtime" and to determine whether instituting a tandem therapeutic plasma exchange (TPE) protocol could significantly and robustly decrease circuit downtime in patients receiving both therapies. METHODS: This is a retrospective cohort study of 116 patients undergoing CRRT in the pediatric, neonatal, or cardiac ICU at UPMC Children's Hospital of Pittsburgh from January 2014 to July 2020. We performed multivariable logistic regression to determine factors associated with CRRT downtime. We instituted a tandem TPE protocol whereby TPE and CRRT could run in parallel without pausing CRRT in April 2018. We analyzed the effect of the protocol change by plotting downtime for patients undergoing CRRT and TPE on a run chart. The effect of initiating tandem TPE on downtime was assessed by special cause variation. RESULTS: For 108/139 (77.7%) sessions with downtime data available, the median (IQR) percentage of downtime was 6.2% (1.7-12.7%). Multivariable logistic regression showed that TPE was significantly associated with CRRT downtime (p = 0.003), and that age, sex, race, catheter size, and anticoagulation were not. For patients undergoing TPE, the median (IQR) percentage of downtime was 14.7% (10.5-26%) and 3.4% (1.3-4.9%) before and after initiation of tandem TPE, respectively (p < 0.001). The difference in downtime percentage met criteria for special cause variation. CONCLUSIONS: Interruptions for TPE increase CRRT downtime. Tandem TPE significantly reduces CRRT downtime in patients undergoing both procedures concomitantly.

A detailed exploration of early infant milk feeding in a prospective birth cohort study in Ireland: combination feeding of breast milk and infant formula and early breast-feeding cessation.

Breast-feeding initiation and continuation rates in the UK and Ireland are low relative to many European countries. As a core outcome of the prospective Cork Nutrition and Development Maternal-Infant Cohort (COMBINE) study (Cork, Ireland), we aimed to describe infant milk feeding practices in detail and examine the prevalence and impact of combination feeding of breast milk and infant formula on breast-feeding duration. COMBINE recruited 456 nulliparous mothers (2015-2017) for maternal-infant follow-up via interview at hospital discharge (median 3 (interquartile range (IQR) 2, 4) d (n 453)), 1 (n 418), 2 (n 392), 4 (n 366), 6 (n 362) and 9 (n 345) months of age. Median maternal age was 32 (IQR 29, 34) years, 97 % of mothers were of white ethnicity, 79 % were Irish-born and 75 % were college-educated. Overall, 75 % breastfed to any extent at discharge and 44 % breastfed solely. At 1, 2, 4, 6 and 9 months, respectively, 40, 36, 33, 24 and 19 % breastfed solely. Combination feeding of breast milk and infant formula was common at discharge (31 %) and 1 month (20 %). Reasons for combination feeding at 1 month included perceived/actual hunger (30 %), healthcare professional advice (31 %) and breast-feeding difficulties (13 %). Of mothers who breastfed to any extent at discharge, 45 % stopped within 4 months. Mothers who combination fed were more likely to cease breast-feeding than those who breastfed solely (relative risk 2·3 by 1 month and 12·0 by 2 months). These granular data provide valuable insight to early milk feeding practices and indicate that supporting early breast-feeding without formula use may be key to the successful continuation of breast-feeding.

Intrinsic factors and the embryonic environment influence the formation of extragonadal teratomas during gestation.

BACKGROUND: Pluripotent cells are present in early embryos until the levels of the pluripotency regulator Oct4 drop at the beginning of somitogenesis. Elevating Oct4 levels in explanted post-pluripotent cells in vitro restores their pluripotency. Cultured pluripotent cells can participate in normal development when introduced into host embryos up to the end of gastrulation. In contrast, pluripotent cells efficiently seed malignant teratocarcinomas in adult animals. In humans, extragonadal teratomas and teratocarcinomas are most frequently found in the sacrococcygeal region of neonates, suggesting that these tumours originate from cells in the posterior of the embryo that either reactivate or fail to switch off their pluripotent status. However, experimental models for the persistence or reactivation of pluripotency during embryonic development are lacking. METHODS: We manually injected embryonic stem cells into conceptuses at E9.5 to test whether the presence of pluripotent cells at this stage correlates with teratocarcinoma formation. We then examined the effects of reactivating embryonic Oct4 expression ubiquitously or in combination with Nanog within the primitive streak (PS)/tail bud (TB) using a transgenic mouse line and embryo chimeras carrying a PS/TB-specific heterologous gene expression cassette respectively. RESULTS: Here, we show that pluripotent cells seed teratomas in post-gastrulation embryos. However, at these stages, induced ubiquitous expression of Oct4 does not lead to restoration of pluripotency (indicated by Nanog expression) and tumour formation in utero, but instead causes a severe phenotype in the extending anteroposterior axis. Use of a more restricted T(Bra) promoter transgenic system enabling inducible ectopic expression of Oct4 and Nanog specifically in the posteriorly-located primitive streak (PS) and tail bud (TB) led to similar axial malformations to those induced by Oct4 alone. These cells underwent induction of pluripotency marker expression in Epiblast Stem Cell (EpiSC) explants derived from somitogenesis-stage embryos, but no teratocarcinoma formation was observed in vivo. CONCLUSIONS: Our findings show that although pluripotent cells with teratocarcinogenic potential can be produced in vitro by the overexpression of pluripotency regulators in explanted somitogenesis-stage somatic cells, the in vivo induction of these genes does not yield tumours. This suggests a restrictive regulatory role of the embryonic microenvironment in the induction of pluripotency.

Bringing Cultural Competency to the EHR: Lessons Learned Providing Respectful, Quality Care to the LGBTQ Community.

The lesbian, gay, bisexual, transgender, queer (LGBTQ) community is vulnerable to healthcare disparities. Many healthcare organizations are contemplating efforts to collect sexual orientation and gender identity in the electronic health record (EHR), with a goal of providing more respectful, inclusive, high-quality care to their LGBTQ patients. There are significant human and technical barriers that must be overcome to make these efforts successful. Based on our four-year experience at Geisinger (an integrated health system located in a rural, generally conservative area), we provide insights to overcome challenges in two critical areas: 1) enabling the EHR to collect and use information to support the healthcare needs of LGBTQ patients, and 2) building a culture of awareness and caring, empowering members of the healthcare team to break down barriers of misunderstanding and mistrust.

A comparison of rapists and sexual murderers on demographic and selected psychometric measures.

This study compared 58 sexual murderers and 112 rapists who were about to undergo treatment in prison for their sexual offending behavior. The two groups were compared on background, personality, offense, and victim characteristics. The sexual murderer group were less likely to have been involved in a relationship at the time of their index offense, generally attacked older victims, and had higher self-esteem. The rapist sample were found to have more violent previous convictions and scored higher on measures of historical deviance (nonsexual), paranoid suspicion, and resentment. No differences were found on the personality or clinical syndrome scales of the Millon Clinical Multiaxial Inventory-III. However, the rapist sample had significantly higher mean scores on the Paranoid Suspicion, Resentment, and Self-Esteem subscales of the Antisocial Personality Questionnaire. Future research should compare the two groups on dynamic or changeable factors to determine differential treatment needs.

Embryonic stem cell technology: applications and uses in functional genomic studies.

In this postgenomic era, the role of functional genomics is becoming increasingly important and playing a key role in this field are embryonic stem cells. These cells are capable of proliferating indefinitely in a pluripotent state and have the potential to differentiate into all somatic cell types. Through a combination of their ease of genetic manipulation and directed in vitro differentiation they have proved themselves to be an extremely valuable tool in functional genomics. Here, some of their applications in functional genomic studies are discussed.

The identification of sexual and violent motivations in men who assault women: implication for treatment.

A qualitative analysis of interview data with 41 rapists determined that five implicit theories (ITs) underlie rapists' offense supportive beliefs/feelings/motives: (a) dangerous world (DW)-where men have feelings of generalized anger and/or resentment toward others; (b) women are dangerous-where men hold a set of attitudes that are hostile toward women; (c) women as sexual objects (WSO)-where women are seen as primarily sexual objects; (d) male sex drive is uncontrollable-where sexual urges are seen all consuming; (e) entitlement-where men feel that they can do exactly what they want. Consideration of whether DW or WSO ITs were present or absent indicated that three main groups could be identified: Group 1: violently motivated-presence of DW and/or absence of WSO; Group 2: sexually motivated-presence of WSO and/or absence of DW; Group 3: sadistically motivated-presence of DW and WSO. These results are discussed in terms of treatment needs of rapists.

Sexual murderers' implicit theories.

Interviews with 28 sexual murderers were subjected to grounded theory analysis. Five implicit theories (ITs) were identified: dangerous world, male sex drive is uncontrollable, entitlement, women as sexual objects, and women as unknowable. These ITs were found to be identical to those identified in the literature as being present in rapists. The presence of dangerous world and male sex drive is uncontrollable were present, or absent, such that three groups could be identified: (a) dangerous world plus male sex drive is uncontrollable; (b) dangerous world, in the absence of male sex drive is uncontrollable; (c) male sex drive is uncontrollable in the absence of dangerous world. These three groups were found to differ in motivation: (a) were motivated by urges to rape and murder; (b) were motivated by grievance, resentment and/or anger toward women; (c) were motivated to sexually offend but were prepared to kill to avoid detection, or secure compliance.

A randomized trial of ex vivo CD40L activation of a dendritic cell vaccine in colorectal cancer patients: tumor-specific immune responses are associated with improved survival.

PURPOSE: To determine whether an autologous dendritic cell (DC) vaccine could induce antitumor immune responses in patients after resection of colorectal cancer metastases and whether these responses could be enhanced by activating DCs with CD40L. EXPERIMENTAL DESIGN: Twenty-six patients who had undergone resection of colorectal metastases were treated with intranodal injections of an autologous tumor lysate- and control protein [keyhole limpet hemocyanin (KLH)]-pulsed DC vaccine. Patients were randomized to receive DCs that had been either activated or not activated with CD40L. All patients were followed for a minimum of 5.5 years. RESULTS: Immunization induced an autologous tumor-specific T-cell proliferative or IFNγ enzyme-linked immunospot response in 15 of 24 assessable patients (63%) and a tumor-specific DTH response in 61%. Patients with evidence of a vaccine-induced, tumor-specific T-cell proliferative or IFNγ response 1 week after vaccination had a markedly better recurrence-free survival (RFS) at 5 years (63% versus 18%, P = 0.037) than nonresponders. In contrast, no association was observed between induction of KLH-specific immune responses and RFS. CD40L maturation induced CD86 and CD83 expression on DCs but had no effect on immune responses or RFS. CONCLUSION: Adjuvant treatment of patients after resection of colorectal metastases with an autologous tumor lysate-pulsed, DC vaccine-induced, tumor-specific immune responses in a high proportion of patients. There was an association between induction of tumor-specific immune responses and RFS. Activation of this DC vaccine with CD40L did not lead to increased immune responses.

Identification of the domains of the influenza A virus M1 matrix protein required for NP binding, oligomerization and incorporation into virions.

The matrix (M1) protein of influenza A virus is a multifunctional protein that plays essential structural and functional roles in the virus life cycle. It drives virus budding and is the major protein component of the virion, where it forms an intermediate layer between the viral envelope and integral membrane proteins and the genomic ribonucleoproteins (RNPs). It also helps to control the intracellular trafficking of RNPs. These roles are mediated primarily via protein-protein interactions with viral and possibly cellular proteins. Here, the regions of M1 involved in binding the viral RNPs and in mediating homo-oligomerization are identified. In vitro, by using recombinant proteins, it was found that the middle domain of M1 was responsible for binding NP and that this interaction did not require RNA. Similarly, only M1 polypeptides containing the middle domain were able to bind to RNP-M1 complexes isolated from purified virus. When M1 self-association was examined, all three domains of the protein participated in homo-oligomerization although, again, the middle domain was dominant and self-associated efficiently in the absence of the N- and C-terminal domains. However, when the individual fragments of M1 were tagged with green fluorescent protein and expressed in virus-infected cells, microscopy of filamentous particles showed that only full-length M1 was incorporated into budding virions. It is concluded that the middle domain of M1 is primarily responsible for binding NP and self-association, but that additional interactions are required for efficient incorporation of M1 into virus particles.

A functional link between the actin cytoskeleton and lipid rafts during budding of filamentous influenza virions.

Morphogenesis of influenza virus is a poorly understood process that produces two types of enveloped virion: approximately 100-nm spheres and similar diameter filaments that reach 20 microm in length. Spherical particles assemble at plasma membrane lipid rafts in a process independent of microfilaments. The budding site of filamentous virions is hitherto uncharacterised but their formation involves the actin cytoskeleton. We confirm microfilament involvement in filamentous budding and show that after disruption of cortical actin by jasplakinolide, HA, NP, and M1 redistributed around beta-actin clusters to form novel annular membrane structures. HA in filamentous virions and jasplakinolide-induced annuli was detergent insoluble at 4 degrees C. Furthermore, in both cases HA partitioned into low buoyant density detergent-insoluble glycolipid domains, indicating that filamentous virions and annuli contain reorganised lipid rafts. We propose that the actin cytoskeleton is required to maintain the correct organisation of lipid rafts for incorporation into budding viral filaments.