Quality improvement review of O positive blood in emergency transfusion.

BACKGROUND: We recently introduced a policy to use O positive red cells in emergency transfusions for males >16 years of age and females >50 years of age. Here, we investigate changes in emergency transfusion practice and rates of red cell alloimmunization with the use of O positive blood for emergency transfusion. STUDY DESIGN AND METHODS: State-wide retrospective review of emergency transfusions between June 2020 and June 2021. The laboratory information system and patient medical records were used to collect demographic details, indications for transfusion, usage of O positive and O negative blood and rates of alloimmunization. RESULTS: There were 2354 red cell units transfused to 1013 patients (male = 59%, average age = 53 years) during the 12-month period. O positive units accounted for 46.9% (1103 units) of emergency transfusions. However, 726 (30.8%) O negative units were transfused to patients without a mandatory indication for O negative blood. Twenty-eight patients (2.9%) had a red cell alloantibody prior to transfusion including anti-E (n = 10), anti-D (n = 4), and anti-K (n = 4). One patient with prior anti-D had mild delayed hemolysis. There were 19 patients (4.3%, median follow-up 22 days) who developed a red cell alloantibody after emergency transfusion and include anti-E (n = 10), anti-D (n = 7), and anti-C (n = 5). DISCUSSION: The use of O positive blood for emergency transfusion has saved 1103 O negative red cell units with no detriment to patient outcome. There remains potential to optimize use of O positive blood in emergency transfusion and to understand red cell alloimmunization rates in a prospective fashion.

A recovery network leads to the natural recolonization of an archipelago and a potential trailing edge refuge.

Rapid environmental change is reshaping ecosystems and driving species loss globally. Carnivore populations have declined and retracted rapidly and have been the target of numerous translocation projects. Success, however, is complicated when these efforts occur in novel ecosystems. Identifying refuges, locations that are resistant to environmental change, within a translocation framework should improve population recovery and persistence. American martens (Martes americana) are the most frequently translocated carnivore in North America. As elsewhere, martens were extirpated across much of the Great Lakes region by the 1930s and, despite multiple translocations beginning in the 1950s, martens remain of regional conservation concern. Surprisingly, martens were rediscovered in 2014 on the Apostle Islands of Lake Superior after a putative absence of >40 yr. To identify the source of martens to the islands and understand connectivity of the reintroduction network, we collected genetic data on martens from the archipelago and from all regional reintroduction sites. In total, we genotyped 483 individual martens, 43 of which inhabited the Apostle Islands (densities 0.42-1.46 km-2 ). Coalescent analyses supported the contemporary recolonization of the Apostle Islands with progenitors likely originating from Michigan, which were sourced from Ontario. We also identified movements by a first-order relative between the Apostle Islands and the recovery network. We detected some regional gene flow, but in an unexpected direction: individuals moving from the islands to the mainland. Our findings suggest that the Apostle Islands were naturally recolonized by progeny of translocated individuals and now act as a source back to the reintroduction sites on the mainland. We suggest that the Apostle Islands, given its protection from disturbance, complex forest structure, and reduced carnivore competition, will act as a potential refuge for marten along their trailing range boundary and a central node for regional recovery. Our work reveals that translocations, even those occurring along southern range boundaries, can create recovery networks that function like natural metapopulations. Identifying refuges, locations that are resistant to environmental change, within these recovery networks can further improve species recovery, even within novel environments. Future translocation planning should a priori identify potential refuges and sources to improve short-term recovery and long-term persistence.

ALK-Positive Histiocytosis with Peripheral Blood Histiocytes: A Case Report.

Histiocytoses are a diverse group of rare, clinically heterogeneous disorders characterised by tissue infiltration of histiocytes, which may result in organ dysfunction and failure. Over 100 different subtypes of histiocytoses have been recognised, including rare cases of ALK-positive histiocytosis. We report a case of histiocytosis in a neonate who presented with refractory thrombocytopenia, anaemia, and intermittent neutropenia. Histiocytes were present in both peripheral blood smears and bone marrow; ALK positivity was demonstrated by immunohistochemistry. Given the scarce reports of this condition, the variable organ involvement, and the different approaches to management in the cases described, we seek to expand the literature by providing a report of our patient whose condition improved without chemotherapy. The presence of histiocytes in peripheral blood smears of patients with this condition has not previously been reported, and it underscores the importance of routine careful evaluation of blood smears.

Na+ /K+ -ATPase gene duplications in clitellate annelids are associated with freshwater colonization.

Major habitat transitions, such as those from marine to freshwater habitats or from aquatic to terrestrial habitats, have occurred infrequently in animal evolution and may represent a barrier to diversification. Identifying genomic events associated with these transitions can help us better understand mechanisms that allow animals to cross these barriers and diversify in new habitats. Study of the Capitella telata and Helobdella robusta genomes allows examination of one such habitat transition (marine to freshwater) in Annelida. Initial examination of these genomes indicated that the freshwater leech H. robusta contains many more copies (12) of the sodium-potassium pump alpha-subunit (Na+ /K+ -ATPase) gene than does the marine polychaete C. telata (2). The sodium-potassium pump plays a key role in maintenance of cellular ionic balance and osmoregulation, and Na+ /K+ -ATPase duplications may have helped annelids invade and diversify in freshwater habitats. To assess whether the timing of Na+ /K+ -ATPase duplications coincided with the marine-to-freshwater transition in Clitellata, we used transcriptomic data from 18 annelid taxa, along with the two genomes, to infer a species phylogeny and identified Na+ /K+ -ATPase gene transcripts in order to infer the timing of gene duplication events using tree-based methods. The inferred timing of Na+ /K+ -ATPase duplication events is consistent with the timing of the initial marine-to-freshwater transition early in the history of clitellate annelids, supporting the hypothesis that gene duplications may have played a role in the annelid diversification into freshwater habitats.

Phylogenomic analyses of Crassiclitellata support major Northern and Southern Hemisphere clades and a Pangaean origin for earthworms.

BACKGROUND: Earthworms (Crassiclitellata) are a diverse group of annelids of substantial ecological and economic importance. Earthworms are primarily terrestrial infaunal animals, and as such are probably rather poor natural dispersers. Therefore, the near global distribution of earthworms reflects an old and likely complex evolutionary history. Despite a long-standing interest in Crassiclitellata, relationships among and within major clades remain unresolved. METHODS: In this study, we evaluate crassiclitellate phylogenetic relationships using 38 new transcriptomes in combination with publicly available transcriptome data. Our data include representatives of nearly all extant earthworm families and a representative of Moniligastridae, another terrestrial annelid group thought to be closely related to Crassiclitellata. We use a series of differentially filtered data matrices and analyses to examine the effects of data partitioning, missing data, compositional and branch-length heterogeneity, and outgroup inclusion. RESULTS AND DISCUSSION: We recover a consistent, strongly supported ingroup topology irrespective of differences in methodology. The topology supports two major earthworm clades, each of which consists of a Northern Hemisphere subclade and a Southern Hemisphere subclade. Divergence time analysis results are concordant with the hypothesis that these north-south splits are the result of the breakup of the supercontinent Pangaea. CONCLUSIONS: These results support several recently proposed revisions to the classical understanding of earthworm phylogeny, reveal two major clades that seem to reflect Pangaean distributions, and raise new questions about earthworm evolutionary relationships.

Romiplostim in children with immune thrombocytopenia: a phase 3, randomised, double-blind, placebo-controlled study.

BACKGROUND: The thrombopoietin receptor agonist romiplostim could be an effective treatment in symptomatic children with persistent or chronic immune thrombocytopenia. We aimed to assess whether romiplostim is safe and effective in children with immune thrombocytopenia of more than 6 months' duration. METHODS: In this phase 3 double-blind study, eligible participants were children with immune thrombocytopenia aged 1 year to 17 years and mean platelet counts 30 × 10(9)/L or less (mean of two measurements during the screening period) with no single count greater than 35 × 10(9)/L, and were recruited from 27 sites in the USA, Canada, and Australia. Participants were randomly assigned (2:1) through the interactive voice response system to receive weekly romiplostim or placebo for 24 weeks stratified by age (1 year to <6 years, 6 years to <12 years, 12 years to <18 years), adjusting the dose weekly from 1 µg/kg to 10 µg/kg to target platelet counts of 50-200 × 10(9)/L. Patients and investigators were blinded to the treatment assignment. The primary analysis included all randomised patients and the safety analysis included all randomised patients who received at least one dose of investigational product. The primary endpoint, durable platelet response, was defined as achievement of weekly platelet responses (platelet counts ≥50 × 10(9)/L without rescue drug use in the preceding 4 weeks) in 6 or more of the final 8 weeks (weeks 18-25). This study is registered with ClinicalTrials.gov, NCT 01444417. FINDINGS: Between Jan 24, 2012, and Sept 3, 2014, 62 patients were randomly assigned; 42 to romiplostim and 20 to placebo. Durable platelet response was seen in 22 (52%) patients in the romiplostim group and two (10%) in the placebo group (p=0·002, odds ratio 9·1 [95% CI 1·9-43·2]). Durable platelet response rates with romiplostim by age were 38% (3/8) for 1 year to younger than 6 years, 56% (10/18) for 6 years to younger than 12 years, and 56% (9/16) for 12 years to younger than 18 years. One (5%) of 19 patients in the placebo group had serious adverse events compared with 10 (24%) of 42 patients in the romiplostim group. Of these serious adverse events, headache and thrombocytosis, in one (2%) of 42 patients in the romiplostim group, were considered treatment related. No patients withdrew due to adverse events. INTERPRETATION: In children with chronic immune thrombocytopenia, romiplostim induced a high rate of platelet response with no new safety signals. Ongoing romiplostim studies will provide further information as to long-term efficacy, safety, and remission in children with immune thrombocytopenia. FUNDING: Amgen Inc.

KLF1-null neonates display hydrops fetalis and a deranged erythroid transcriptome.

We describe a case of severe neonatal anemia with kernicterus caused by compound heterozygosity for null mutations in KLF1, each inherited from asymptomatic parents. One of the mutations is novel. This is the first described case of a KLF1-null human. The phenotype of severe nonspherocytic hemolytic anemia, jaundice, hepatosplenomegaly, and marked erythroblastosis is more severe than that present in congenital dyserythropoietic anemia type IV as a result of dominant mutations in the second zinc-finger of KLF1. There was a very high level of HbF expression into childhood (>70%), consistent with a key role for KLF1 in human hemoglobin switching. We performed RNA-seq on circulating erythroblasts and found that human KLF1 acts like mouse Klf1 to coordinate expression of many genes required to build a red cell including those encoding globins, cytoskeletal components, AHSP, heme synthesis enzymes, cell-cycle regulators, and blood group antigens. We identify novel KLF1 target genes including KIF23 and KIF11 which are required for proper cytokinesis. We also identify new roles for KLF1 in autophagy, global transcriptional control, and RNA splicing. We suggest loss of KLF1 should be considered in otherwise unexplained cases of severe neonatal NSHA or hydrops fetalis.

The Impact of a Brief Embedded Mindfulness-Based Program for Veterinary Students.

Veterinary medical students, like other university students, are likely to experience elevated levels of stress, anxiety, and depression over the course of their studies. Mindfulness-based interventions have previously been effective for university students in reducing stress, depression, and anxiety. In this study, a mindfulness-based intervention was embedded in a core (compulsory) unit of a veterinary science course, in part with the aim of improving student well-being. Preliminary results suggest that, despite the mindfulness intervention, overall symptoms of stress, depression, and anxiety among participants (n=64) increased between the start and end of the semester. However, further analysis showed that most of this longitudinal increase was attributable to individuals who scored above the normal range (i.e., at least mild level of symptoms) in one or more measures at the beginning of the semester. Within this subset, individuals who regularly engaged in mindfulness practice once a week or more throughout the semester reported significantly lower depression and anxiety symptoms than those who practiced less than once a week (i.e., who had long periods without practice). Results suggest that engaging regularly in mindfulness practice potentially acted as a protective factor for students already experiencing at least a mild range of symptoms of anxiety and depression at the beginning of the semester. While not all veterinary students may derive significant benefit immediately, providing access to an embedded mindfulness program early in their program may facilitate the development of adaptive coping mechanisms, which may be engaged to increase resilience across their academic and professional life.

In vitro and in vivo activities of HPi1, a selective antimicrobial against Helicobacter pylori.

A high-throughput screen (HTS) was performed to identify molecules specifically active against Helicobacter pylori, the causative agent of peptic ulcer and gastric carcinoma. Currently, treatment of H. pylori infection is suboptimal, with failure rates approaching 25%, despite triple therapy with two broad-spectrum antibiotics and a proton pump inhibitor or quadruple therapy with added bismuth. The HTS was performed in 384-well plates, and reduction of the metabolic indicator resazurin was used as a reporter for cell growth. Diverse molecules from commercial sources were identified as hits, and in vitro validations included measurements of MIC and time-dependent killing as well as anaerobic susceptibility testing against a panel of gut microbes. In vivo validation included testing in the mouse model of H. pylori infection. The small molecule HPi1 (3-hydrazinoquinoxaline-2-thiol) had excellent potency, with an MIC of 0.08 to 0.16 µg/ml and good selectivity for H. pylori compared to a panel of commensal bacteria. HPi1 was also effective in a mouse model of H. pylori infection, reducing colony counts to below the limit of detection after oral dosing of 25 mg/kg/day for 3 days. HPi1 is a promising lead in the search for more effective and specific H. pylori therapeutics.

Fatal immune dysregulation due to a gain of glycosylation mutation in lymphocyte perforin.

Mutations in the perforin gene (PRF1) are a common cause of the fatal immune dysregulation disorder, familial hemophagocytic lymphohistiocytosis (type 2 FHL, FHL2). Here we report a female infant born with biallelic PRF1 mutations: a novel substitution, D49N, and a previously identified in-frame deletion, K285del. We assessed the effects of each mutation on the cytotoxicity of human NK cells in which the expression of endogenous perforin was ablated with miR30-based short hairpin (sh) RNAs. Both mutations were detrimental for function, thereby explaining the clinically severe presentation and rapidly fatal outcome. We demonstrate that D49N exerts its deleterious effect by generating an additional (third) N-linked glycosylation site, resulting in protein misfolding and degradation in the killer cell. Our data provide a rationale for treating some cases of type 2 familial hemophagocytic lymphohistiocytosis, based on the pharmacologic inhibition or modification of glycosylation.

Understanding collaborative and coordinated care in a mental health and well-being context: Essential elements for effective service integration.

Multiple system reforms in Australia, including the National Disability Insurance Scheme (NDIS), are changing mental health (MH) and disability-related service provision, whilst policy drivers continue to require service integration. This has necessitated service providers discovering new ways of working collaboratively to achieve an integrated model of care. This qualitative study examined what does and does not work to support collaborative and coordinated care (CCC), as essential components of service integration. The study sample (n = 59) included four cohorts: health and community service leaders (n = 16), staff (n = 23); MH service consumers with complex needs (n = 10), and MH carers (n = 10). Thematic analysis from interviews was applied to data from each cohort to identify overarching themes that described the lived experience of current CCC delivery. COREQ and EQUATOR guidelines were applied to reporting the findings. Themes emphasized CCC is enabled by the development and sustainability of positive working relationships, and depth of knowledge across health and community services. Unnavigable service systems, stigmatization, perceived power differentials, multiple and rapid service reforms and Fee-For-Service (FFS) models provide significant barriers to CCC. Recommendations include the need for accessible service navigation, consumer-friendly service environments, a stable workforce, standardization of knowledge across sectors, outcome measures and funding attached to CCC as part of a raft of potential changes.

Molecular phylogeny of North American Branchiobdellida (Annelida: Clitellata).

Branchiobdellidans, or crayfish worms, are ectosymbiotic clitellate annelids associated primarily with freshwater crayfishes. The main objectives of our study were to infer a molecular phylogeny for the North American Branchiobdellida, examine its congruence with morphology-based hypotheses of relationships at the subfamily and genus level, and use our dataset to assess consistency of GenBank-archived branchiobdellidan sequences. We used nucleotide sequence data from two mtDNA genes (COI and 16S rDNA) and three nuclear genes (28S rDNA, 18S rDNA, and ITS1) to estimate phylogenetic relationships among 47 described and one undescribed species of Branchiobdellida. We recovered a monophyletic branchiobdellidan clade with generally short branch lengths, suggesting that a large portion of the taxon has likely undergone a recent and rapid radiation in North America. Results from our phylogenetic analyses indicate that current taxonomic groupings are largely unsupported by the molecular data. All four subfamilies are either paraphyletic or polyphyletic, and only three of seven sampled non-monotypic genera were monophyletic. We found a high rate (49%) of inconsistency in GenBank-archived sequences, over 70% of which can be attributed to field- or laboratory-based error.

Integrative taxonomy reveals two new narrowly-endemic crayfish species (Decapoda: Cambaridae) from the Yadkin River Basin in western North Carolina, USA.

Two new species of stream-dwelling crayfish, Cambarus lapidosus, the Stony Fork Crayfish, and Cambarus burchfielae, the Falls Crayfish, are described from the Yadkin River basin in western North Carolina, USA, using an integrative taxonomic approach consisting of morphological, genetic, and biogeographic data. Both species were previously considered to be members of the widely distributed Cambarus species C complex, which occurs throughout mid-Atlantic Slope river basins; however, they are in fact morphologically and genetically more similar to the Cambarus robustus species complex from interior basins in the south-central Appalachians, indicating Atlantic basin stream capture of an Interior basin faunal group has occurred in this region. Both new species described herein can be differentiated from these two complexes, and each other, by several morphological characteristics. Cambarus lapidosus and C. burchfielae are differentiated from C. species C by the absence of cervical spines and the presence of 1-2 subpalmar tubercles on the chelae in most specimens; both species are less-punctate across the areola than C. aff. robustus. Cambarus burchfielae is further differentiated from C. lapidosus, C. species C, and C. aff. robustus by the presence of a narrower and sparsely punctate areola, a single weak row of tubercles on the mesial margin of the palm, and the absence of tubercles on the dorsal surface of the dactyl. The newly described species are genetically sister taxa and together are most similar by genetic distance to undescribed members of the C. robustus species complex from the nearby (~30 km) Watauga River basin and most phylogenetically similar to C. aff. robustus from the adjacent New River basin; both are interior basin drainages. The newly-described species are endemic to the Blue Ridge Mountains of western North Carolina and have restricted distributions (<100 km2-150 km2) in small (<4th order) tributaries to the Yadkin River. Cambarus lapidosus is known only from the upper Stony Fork watershed and C. burchfielae is known only from the upper reaches of the adjacent Lewis Fork watershed; both species likely qualify for conservation status protections under narrow geographic range criteria.

Isoperla riverae, a new stonefly species from the southeast Nearctic, with notes on sympatric species including the larval description of Isoperla lenati Szczytko & Kondratieff, 2015 (Plecoptera: Perlodidae).

Isoperla riverae sp. n. is described from the southeastern USA. The new species is proposed based on details of the adult habitus, male aedeagus, vesicle, female subgenital plate, ovum chorion, and larval habitus. Supporting data includes color images, scanning electron micrographs, genetic analysis of DNA barcodes, and comparative morphology of cognate species. The larva of Isoperla lenati Szczytko & Kondratieff, 2015 is also described supported by color images.

Paediatric B lymphoblastic leukaemia with hyperdiploidy and a false-positive KMT2A fluorescence in situ hybridization result.

The dramatic improvement in the event-free survival of paediatric B-lymphoblastic leukaemia (B-ALL) has led to risk-stratified treatment. Through a combination of clinical features, cytogenetic abnormalities and assessment of treatment response, patients are stratified to receive different intensities of therapy. The presence of high hyperdiploidy (>50 chromosomes) is considered a favourable genetic feature. Conversely, KMT2A fusion genes in B-ALL are associated with a poor prognosis, resulting in intensification of treatment. We present a seven-year-old female with B-ALL, a high hyperdiploid karyotype (56 chromosomes) and KMT2A rearrangement detected on FISH, but with no productive fusion identified. Single nucleotide polymorphism (SNP) array suggested the KMT2A rearrangement was due to chromosome 11 chromothripsis. Subsequent targeted RNA fusion panel and whole transcriptomic sequencing (mRNA-seq) did not detect an expressed KMT2A fusion. Differential expression analyses of the mRNA-seq data led to clustering of this case with other hyperdiploid cases, consistent with the hyperdiploid cytogenetic results. Given the additional intensity and potential toxicity of high-risk treatment, unusual findings by chromosome analysis, FISH and/or chromosomal microarray should prompt consideration of testing for a KMT2A fusion by another method to avoid misclassification.

Review of neonatal alloimmune thrombocytopenia.

Neonatal alloimmune thrombocytopenia (NAIT), with an incidence of one in 1000 live births, is the most common cause of severe thrombocytopenia and intra-cerebral haemorrhage in term neonates. NAIT results from trans-placental passage of maternal antibodies against a paternally derived fetal platelet alloantigen. Clinical presentation varies from unexpected thrombocytopenia on a blood film in a well newborn to intracranial haemorrhage (ICH). In contrast to haemolytic disease of the newborn, NAIT can present in a first pregnancy, and subsequent pregnancies are usually more severely affected. The role of antenatal screening for maternal alloantibodies instead of fetal blood sampling to identify at-risk fetuses remains uncertain, but there is a trend towards less invasive maternally directed treatment for at-risk pregnancies. Neonatal management is aimed at preventing or limiting thrombocytopenic bleeding with transfusion of antigen-matched platelets.

Cambarus ectopistes sp. nov., a new stream-dwelling crayfish (Decapoda: Cambaridae) from the French Broad, Pigeon, and Nolichucky River watersheds in the Appalachian Mountain region of North Carolina and Tennessee, USA.

The Cataloochee Crayfish, Cambarus ectopistes sp. nov., is a large, stream-dwelling crayfish that occupies a narrow noncontiguous distribution within the Appalachian Mountain region running through the Upper Tennessee River basin, in the French Broad, Pigeon, and Nolichucky watersheds along the Tennessee and North Carolina border. It is split from the southernmost extent of the C. robustus species complex, and is morphologically and genetically most similar to a second undescribed member of the group endemic to the upper Nolichucky River watershed in North Carolina. Cambarus ectopistes sp. nov. can be distinguished from other members of the C. robustus complex and co-distributed congeners by a combination of characters, including body size, coloration, and morphology of the chela and rostrum. The new species is typically found in channel and edge habitats of moderate to large perennial streams with large cobbles and boulders.

Effects of multiple founder populations on spatial genetic structure of reintroduced American martens.

Reintroductions and translocations are increasingly used to repatriate or increase probabilities of persistence for animal and plant species. Genetic and demographic characteristics of founding individuals and suitability of habitat at release sites are commonly believed to affect the success of these conservation programs. Genetic divergence among multiple source populations of American martens (Martes americana) and well documented introduction histories permitted analyses of post-introduction dispersion from release sites and development of genetic clusters in the Upper Peninsula (UP) of Michigan <50 years following release. Location and size of spatial genetic clusters and measures of individual-based autocorrelation were inferred using 11 microsatellite loci. We identified three genetic clusters in geographic proximity to original release locations. Estimated distances of effective gene flow based on spatial autocorrelation varied greatly among genetic clusters (30-90 km). Spatial contiguity of genetic clusters has been largely maintained with evidence for admixture primarily in localized regions, suggesting recent contact or locally retarded rates of gene flow. Data provide guidance for future studies of the effects of permeabilities of different land-cover and land-use features to dispersal and of other biotic and environmental factors that may contribute to the colonization process and development of spatial genetic associations.