Parasite burden and red blood cell exchange transfusion for babesiosis.

BACKGROUND: The association between parasite burden and end-organ dysfunction in subjects with Babesia microti infection has not been extensively studied, nor has the optimal role of red blood cell exchange (RCE) transfusion in babesiosis treatment. This retrospective chart review evaluates the associations between parasitemia, end-organ dysfunction, and outcomes in babesiosis patients treated with antimicrobial agents and RCE compared to those treated with antimicrobial agents alone. MATERIALS AND METHODS: We evaluated adults (≥18 years of age) with laboratory-confirmed babesiosis who were admitted between 2011 and 2017 to Yale New Haven Hospital, located in a Babesia-endemic region of the Northeastern United States. Patient demographics, parasitemia levels, clinical and laboratory indicators of end-organ dysfunction, and outcomes were examined. RESULTS: Ninety-one subjects (mean age 65.1 years, 69.2% male) were studied. Subjects were stratified according to peak parasitemia: <1% (n = 34), 1-5% (n = 24), 5-10% (n = 15), and >10% (n = 18). Laboratory measures indicating degrees of hemolysis, coagulopathy, and pulmonary, renal and hepatic dysfunction differed significantly across peak parasitemia levels. Median length of hospital stay increased with each successive peak parasitemia level (P < .001). These results indicate a strong association between peak parasitemia level and disease severity. Nineteen subjects underwent RCE, all with peak parasitemia ≥9% and some degree of end-organ dysfunction. CONCLUSIONS: Babesia microti parasitemia is closely associated with disease severity, though not all subjects with end-organ dysfunction had high-grade parasitemia. Our data suggest that the use of parasitemia >10%, coupled with clinical status, is a reasonable indicator for RCE in babesiosis patients.

Cost savings to hospital of rituximab use in severe autoimmune acquired thrombotic thrombocytopenic purpura.

Patients with severe autoimmune thrombotic thrombocytopenic purpura (TTP) experience acute hematologic emergencies during disease flares and a lifelong threat for relapse. Rituximab, in addition to steroids and therapeutic plasma exchange (TPE), has been shown to mitigate relapse risk. A barrier to care in initiating rituximab in the inpatient setting has been the presumed excessive cost of medication to the hospital. Retrospectively reviewing TTP admissions from 2004 to 2018 at our academic center, we calculated the actual inpatient cost of care. We then calculated the theoretical cost to the hospital of initiating rituximab in the inpatient setting for both initial TTP and relapse TTP cohorts, with the hypothesis that preventing sufficient future TTP admissions offsets the cost of initiating rituximab in all patients with TTP. At a median follow-up of 55 months in the initial TTP cohort, rituximab use produced a projected cost savings of $905 906 and would have prevented 185 inpatient admission days and saved 137 TPE procedures. In the relapse TTP setting, rituximab use produced a projected cost savings of $425 736 and would have prevented 86 inpatient admission days and saved 64 TPE procedures. From a hospital cost standpoint, cost of rituximab should no longer be a barrier to initiating inpatient rituximab in both initial and relapse TTP settings.

Blood utilisation and transfusion reactions in adult patients transfused with conventional or pathogen-reduced platelets.

Pathogen-reduced (PR) platelets are routinely used in many countries. Some studies reported changes in platelet and red blood cell (RBC) transfusion requirements in patients who received PR platelets when compared to conventional (CONV) platelets. Over a 28-month period we retrospectively analysed platelet utilisation, RBC transfusion trends, and transfusion reaction rates data from all transfused adult patients transfused at the Yale-New Haven Hospital, New Haven, CT, USA. We determined the number of RBC and platelet components administered between 2 and 24, 48, 72 or 96 h. A total of 3767 patients received 21 907 platelet components (CONV = 8912; PR = 12 995); 1,087 patients received only CONV platelets (1578 components) and 1,466 patients received only PR platelets (2604 components). The number of subsequently transfused platelet components was slightly higher following PR platelet components (P < 0·05); however, fewer RBCs were transfused following PR platelet administration (P < 0·05). The mean time-to-next platelet component transfusion was slightly shorter following PR platelet transfusion (P = 0·002). The rate of non-septic transfusion reactions did not differ (all P > 0·05). Septic transfusion reactions (N = 5) were seen only after CONV platelet transfusions (P = 0·011). These results provide evidence for comparable clinical efficacy of PR and CONV platelets. PR platelets eliminated septic transfusion reactions without increased risk of other types of transfusions with only slight increase in platelet utilisation.

Therapeutic plasma exchange for neuromyelitis optica spectrum disorder: A multicenter retrospective study by the ASFA neurologic diseases subcommittee.

IMPORTANCE: Neuromyelitis optica/neuromyelitis optica spectrum disorder patients' response to therapeutic plasma exchange (TPE) is currently incompletely characterized. OBJECTIVE: Our study aims to understand the clinical status improvement of neuromyelitis optica/neuromyelitis optica spectrum disorder patients treated with TPE. DESIGN, SETTING, AND PARTICIPANTS: This is a multicenter retrospective study conducted between 1 January 2003 and 31 July 2017 at 13 US hospitals performing apheresis procedures. Subjects studied were diagnosed with neuromyelitis optica/neuromyelitis optica spectrum disorder who received TPE during presentation with acute disease. MAIN OUTCOMES AND MEASURES: The primary outcome was clinical status improvement in patients treated with TPE. Secondary measures were procedural and patient characteristics associated with response to treatment. RESULTS: We evaluated 114 patients from 13 institutions. There was a female predilection. The largest ethnic group affected was non-Hispanic Caucasian. The average age of diagnosis was 43.1 years. The average time to diagnosis was 3.1 years. On average, five procedures were performed during each treatment series. The most commonly performed plasma volume exchange was 1.0 to 1.25 using 5% albumin as replacement fluid. Most patients (52%) did not require an additional course of TPE and noted "mild" to "moderate" clinical status improvement. Maximal symptom improvement appeared by the fourth or fifth TPE treatment. CONCLUSION AND RELEVANCE: TPE improved the clinical status of patients. Adults responded more favorably than children. Procedural characteristics, including number of TPEs, plasma volume exchanged, and replacement fluid used, were similar between institutions. TPE was well-tolerated and had a low severe adverse event profile.

Blood Utilization and Transfusion Reactions in Pediatric Patients Transfused with Conventional or Pathogen Reduced Platelets.

OBJECTIVES: To assess the safety and efficacy of a Food and Drug Administration-approved pathogen-reduced platelet (PLT) product in children, as ongoing questions regarding their use in this population remain. STUDY DESIGN: We report findings from a quality assurance review of PLT utilization, associated red blood cell transfusion trends, and short-term safety of conventional vs pathogen-reduced PLTs over a 21-month period while transitioning from conventional to pathogen-reduced PLTs at a large, tertiary care hospital. We assessed utilization in neonatal intensive care unit (NICU) patients, infants 0-1 year not in the NICU, and children age 1-18 years (PED). RESULTS: In the 48 hours after an index conventional or pathogen-reduced platelet transfusion, respectively, NICU patients received 1.0 ± 1.4 (n = 91 transfusions) compared with 1.2 ± 1.3 (n = 145) additional platelet doses (P = .29); infants 0-1 year not in the NICU received 2.8 ± 3.0 (n = 125) vs 2.6 ± 2.6 (n = 254) additional platelet doses (P = .57); and PEDs received 0.9 ± 1.6 (n = 644) vs 1.4 ± 2.2 (n = 673) additional doses (P < .001). Time to subsequent transfusion and red cell utilization were similar in every group (P > .05). The number and type of transfusion reactions did not significantly vary based on PLT type and no rashes were reported in NICU patients receiving phototherapy and pathogen-reduced PLTs. CONCLUSIONS: Conventional and pathogen-reduced PLTs had similar utilization patterns in our pediatric populations. A small, but statistically significant, increase in transfusions was noted following pathogen-reduced PLT transfusion in PED patients, but not in other groups. Red cell utilization and transfusion reactions were similar for both products in all age groups.

Novel Strategies for the Production of Fuels, Lubricants, and Chemicals from Biomass.

Growing concern with the environmental impact of CO2 emissions produced by combustion of fuels derived from fossil-based carbon resources has stimulated the search for renewable sources of carbon. Much of this focus has been on the development of methods for producing transportation fuels, the major source of CO2 emissions today, and to a lesser extent on the production of lubricants and chemicals. First-generation biofuels such as bioethanol, produced by the fermentation of sugar cane- or corn-based sugars, and biodiesel, produced by the transesterification reaction of triglycerides with alcohols to form a mixture of long-chain fatty esters, can be blended with traditional fuels in limited amounts and also arise in food versus fuel debates. Producing molecules that can be drop-in solutions for fossil-derived products used in the transportation sector allows for efficient use of the existing infrastructure and is therefore particularly interesting. In this context, the most viable source of renewable carbon is abundantly available lignocellulosic biomass, a complex mixture of lignin, hemicellulose, and cellulose. Conversion of the carbohydrate portion of biomass (hemicellulose and cellulose) to fuels requires considerable chemical restructuring of the component sugars in order to achieve the energy density and combustion properties required for transportation fuels-gasoline, diesel, and jet. A different set of constraints must be met for the conversion of biomass-sourced sugars to lubricants and chemicals. This Account describes strategies developed by us to utilize aldehydes, ketones, alcohols, furfurals, and carboxylic acids derived from C5 and C6 sugars, acetone-butanol-ethanol (ABE) fermentation mixtures, and various biomass-derived carboxylic acids and fatty acids to produce fuels, lubricants, and chemicals. Oxygen removal from these synthons is achieved by dehydration, decarboxylation, hydrogenolysis, and hydrodeoxygenation, whereas reactions such as aldol condensation, etherification, alkylation, and ketonization are used to build up the number of carbon atoms in the final product. We show that our strategies lead to high-octane components that can be blended into gasoline, C9-C22 compounds that possess energy densities and properties required for diesel and jet fuels, and lubricants that are equivalent or superior to current synthetic lubricants. Replacing a fraction of the crude-oil-derived products with such renewable sources can mitigate the negative impact of the transportation sector on overall anthropogenic greenhouse gas (GHG) emissions and climate change potential. While ethanol is a well-known fuel additive, there is significant interest in using ethanol as a platform molecule to manufacture a variety of valuable chemicals. We show that bioethanol can be converted with high selectivity to butanol or 1,3-butadiene, providing interesting alternatives to the current production from petroleum. Finally, we report that several of the strategies developed have the potential to reduce GHG emissions by 55-80% relative to those for petroleum-based processes.

Clotting during autologous hematopoietic progenitor cells collection.

Autologous hematopoietic progenitor cell (HPC) transplant through peripheral blood mobilization and leukapheresis is a standard treatment for many patients with hematopoietic malignancies. Although leukapheresis is usually completed with no complications, we present a case in which the hematopoietic progenitor cells clotted during collection. The patient had no history of hypercoagulopathy. It was identified that the anticoagulant infusion line was partially constricted by a blood warmer clamp. The machine did not alarm. Most of the multiple Food and Drug Administration reports of clotting occurring during apheresis procedures were due to the patients' preexisting hypercoagulopathy or insufficient anticoagulant solution being used. The machine alarmed in most of these cases. Our case demonstrates that inadequate anticoagulation can occur during an HPC collection procedure without activation of an alarm.

Production of Biomass-Based Automotive Lubricants by Reductive Etherification.

Growing concern with the effects of CO2 emissions due to the combustion of petroleum-based transportation fuels has motivated the search for means to increase engine efficiency. The discovery of ethers with low viscosity presents an important opportunity to improve engine efficiency and fuel economy. We show here a strategy for the catalytic synthesis of such ethers by reductive etherification/O-alkylation of alcohols using building blocks that can be sourced from biomass. We find that long-chain branched ethers have several properties that make them superior lubricants to the mineral oil and synthetic base oils used today. These ethers provide a class of potentially renewable alternatives to conventional lubricants produced from petroleum and may contribute to the reduction of greenhouse gases associated with vehicle emissions.

Synergistic Effects in Bimetallic Palladium-Copper Catalysts Improve Selectivity in Oxygenate Coupling Reactions.

Condensation reactions such as Guerbet and aldol are important since they allow for C-C bond formation and give higher molecular weight oxygenates. An initial study identified Pd-supported on hydrotalcite as an active catalyst for the transformation, although this catalyst showed extensive undesirable decarbonylation. A catalyst containing Pd and Cu in a 3:1 ratio dramatically decreased decarbonylation, while preserving the high catalytic rates seen with Pd-based catalysts. A combination of XRD, EXAFS, TEM, and CO chemisorption and TPD revealed the formation of CuPd bimetallic nanoparticles with a Cu-enriched surface. Finally, density functional theory studies suggest that the surface segregation of Cu atoms in the bimetallic alloy catalyst produces Cu sites with increased reactivity, while the Pd sites responsible for unselective decarbonylation pathways are selectively poisoned by CO.

From Sugars to Wheels: The Conversion of Ethanol to 1,3-Butadiene over Metal-Promoted Magnesia-Silicate Catalysts.

1,3-Butadiene (1,3-BD) is a high-value chemical intermediate used mainly as a monomer for the production of synthetic rubbers. The ability to source 1,3-BD from biomass is of considerable current interest because it offers the potential to reduce the life-cycle greenhouse gas (GHG) impact associated with 1,3-BD production from petroleum-derived naphtha. Herein, we report the development and investigation of a new catalyst and process for the one-step conversion of ethanol to 1,3-BD. The catalyst is prepared by the incipient impregnation of magnesium oxide onto a silica support followed by the deposition of Au nanoparticles by deposition-precipitation. The resulting Au/MgO-SiO2 catalyst exhibits a high activity and selectivity to 1,3-BD and low selectivities to diethyl ether, ethylene, and butenes. Detailed characterization of the catalyst shows that the desirable activity and selectivity of Au/MgO-SiO2 are a consequence of a critical balance between the acidic-basic sites associated with a magnesium silicate hydrate phase and the redox properties of the Au nanoparticles. A process for the conversion of ethanol to 1,3-BD, which uses our catalyst, is proposed and analyzed to determine the life-cycle GHG impact of the production of this product from biomass-derived ethanol. We show that 1,3-BD produced by our process can reduce GHG emissions by as much as 155 % relative to the conventional petroleum-based production of 1,3-BD.

Upgrading Lignocellulosic Products to Drop-In Biofuels via Dehydrogenative Cross-Coupling and Hydrodeoxygenation Sequence.

Life-cycle analysis (LCA) allows the scientific community to identify the sources of greenhouse gas (GHG) emissions of novel routes to produce renewable fuels. Herein, we integrate LCA into our investigations of a new route to produce drop-in diesel/jet fuel by combining furfural, obtained from the catalytic dehydration of lignocellulosic pentose sugars, with alcohols that can be derived from a variety of bio- or petroleum-based feedstocks. As a key innovation, we developed recyclable transition-metal-free hydrotalcite catalysts to promote the dehydrogenative cross-coupling reaction of furfural and alcohols to give high molecular weight adducts via a transfer hydrogenation-aldol condensation pathway. Subsequent hydrodeoxygenation of adducts over Pt/NbOPO4 yields alkanes. Implemented in a Brazilian sugarcane biorefinery such a process could result in a 53-79% reduction in life-cycle GHG emissions relative to conventional petroleum fuels and provide a sustainable source of low carbon diesel/jet fuel.

Novel pathways for fuels and lubricants from biomass optimized using life-cycle greenhouse gas assessment.

Decarbonizing the transportation sector is critical to achieving global climate change mitigation. Although biofuels will play an important role in conventional gasoline and diesel applications, bioderived solutions are particularly important in jet fuels and lubricants, for which no other viable renewable alternatives exist. Producing compounds for jet fuel and lubricant base oil applications often requires upgrading fermentation products, such as alcohols and ketones, to reach the appropriate molecular-weight range. Ketones possess both electrophilic and nucleophilic functionality, which allows them to be used as building blocks similar to alkenes and aromatics in a petroleum refining complex. Here, we develop a method for selectively upgrading biomass-derived alkyl methyl ketones with >95% yields into trimer condensates, which can then be hydrodeoxygenated in near-quantitative yields to give a new class of cycloalkane compounds. The basic chemistry developed here can be tailored for aviation fuels as well as lubricants by changing the production strategy. We also demonstrate that a sugarcane biorefinery could use natural synergies between various routes to produce a mixture of lubricant base oils and jet fuels that achieve net life-cycle greenhouse gas savings of up to 80%.

Global N-acetylaspartate in normal subjects, mild cognitive impairment and Alzheimer's disease patients.

BACKGROUND: Mild cognitive impairment (MCI) is an intermediary state on the way to Alzheimer's disease (AD). Little is known about whole brain concentration of the neuronal marker, N-acetylaspartate (NAA) in MCI patients. OBJECTIVE: To test the hypothesis that since MCI and AD are both neurodegenerative, quantification of the NAA in their whole brain (WBNAA) could differentiate them from cognitively-intact matched controls. METHODS: Proton MR spectroscopy to quantify the WBNAA was applied to 197 subjects (86 females) 72.6 ± 8.4 years old (mean ± standard deviation). Of these, 102 were cognitively intact, 42 diagnosed as MCI, and 53 as probable AD. Their WBNAA amounts were converted into absolute concentration by dividing with the brain volume segmented from the MRI that also yielded the fractional brain volume (fBPV), an atrophy metric. RESULTS: WBNAA concentration of MCI and AD patients (10.5 ± 3.0 and 10.1 ± 2.9 mM) were not significantly different (p = 0.85). They were, however, highly significantly 25-29% lower than the 14.1 ± 2.4 mM of normal matched controls (p < 10-4). The fBPV of MCI and AD patients (72.9 ± 4.9 and 69.9 ± 4.7%) differed significantly from each other (4%, p = 0.02) and both were significantly lower than the 74.6 ± 4.4% of normal elderly (2%, p = 0.003 for MCI; 6%, p < 10-4 for AD). ROC curve analysis has shown WBNAA to have 70.5% sensitivity and 84.3% specificity to differentiate MCI or AD patients from normal elderly versus just 68.4 and 65.7% for fBPV. CONCLUSION: Low WBNAA in MCI patients compared with cognitively normal contemporaries may indicate early neuronal damage accumulation and supports the notion of MCI as an early stage of AD. It also suggests WBNAA as a potential marker of early AD pathology.

Role of lignin in reducing life-cycle carbon emissions, water use, and cost for United States cellulosic biofuels.

Cellulosic ethanol can achieve estimated greenhouse gas (GHG) emission reductions greater than 80% relative to gasoline, largely as a result of the combustion of lignin for process heat and electricity in biorefineries. Most studies assume lignin is combusted onsite, but exporting lignin to be cofired at coal power plants has the potential to substantially reduce biorefinery capital costs. We assess the life-cycle GHG emissions, water use, and capital costs associated with four representative biorefinery test cases. Each case is evaluated in the context of a U.S. national scenario in which corn stover, wheat straw, and Miscanthus are converted to 1.4 EJ (60 billion liters) of ethanol annually. Life-cycle GHG emissions range from 4.7 to 61 g CO2e/MJ of ethanol (compared with ∼ 95 g CO2e/MJ of gasoline), depending on biorefinery configurations and marginal electricity sources. Exporting lignin can achieve GHG emission reductions comparable to onsite combustion in some cases, reduce life-cycle water consumption by up to 40%, and reduce combined heat and power-related capital costs by up to 63%. However, nearly 50% of current U.S. coal-fired power generating capacity is expected to be retired by 2050, which will limit the capacity for lignin cofiring and may double transportation distances between biorefineries and coal power plants.

Distinctive microRNA signature of medulloblastomas associated with the WNT signaling pathway.

AIM: Medulloblastoma is a malignant brain tumor that occurs predominantly in children. Current risk stratification based on clinical parameters is inadequate for accurate prognostication. MicroRNA expression is known to be deregulated in various cancers and has been found to be useful in predicting tumor behavior. In order to get a better understanding of medulloblastoma biology, miRNA profiling of medulloblastomas was carried out in parallel with expression profiling of protein-coding genes. MATERIALS AND METHODS: miRNA profiling of medulloblastomas was carried out using Taqman Low Density Array v 1.0 having 365 human microRNAs. In parallel, genome-wide expression profiling of protein-coding genes was carried out using Affymetrix gene 1.0 ST arrays. RESULTS: Both the profiling studies identified four molecular subtypes of medulloblastomas. Expression levels of select protein-coding genes and miRNAs could classify an independent set of medulloblastomas. Twelve of 31 medulloblastomas were found to overexpress genes belonging to the canonical WNT signaling pathway and carry a mutation in CTNNB1 gene. A number of miRNAs like miR-193a, miR-224/miR-452 cluster, miR-182/miR-183/miR-96 cluster, and miR-148a having potential tumor/metastasis suppressive activity were found to be overexpressed in the WNT signaling associated medulloblastomas. Exogenous expression of miR-193a and miR-224, two miRNAs that have the highest WNT pathway specific upregulation, was found to inhibit proliferation, increase radiation sensitivity and reduce anchorage-independent growth of medulloblastoma cells. CONCLUSION: Expression level of tumor/metastasis suppressive miRNAs in the WNT signaling associated medulloblastomas is likely to determine their response to treatment, and thus, these miRNAs would be important biomarkers for risk stratification within the WNT signaling associated medulloblastomas.

On the mechanism of low-temperature water gas shift reaction on copper.

Periodic, self-consistent density functional theory (DFT-GGA) calculations are used to investigate the water gas shift reaction (WGSR) mechanism on Cu(111). The thermochemistry and activation energy barriers for all the elementary steps of the commonly accepted redox mechanism, involving complete water activation to atomic oxygen, are presented. Through our calculations, we identify carboxyl, a new reactive intermediate, which plays a central role in WGSR on Cu(111). The thermochemistry and activation energy barriers of the elementary steps of a new reaction path, involving carboxyl, are studied. A detailed DFT-based microkinetic model of experimental reaction rates, accounting for both the previous and the new WGSR mechanism show that, under relevant experimental conditions, (1) the carboxyl-mediated route is the dominant path, and (2) the initial hydrogen abstraction from water is the rate-limiting step. Formate is a stable "spectator" species, formed predominantly through CO2 hydrogenation. In addition, the microkinetic model allows for predictions of (i) surface coverage of intermediates, (ii) WGSR apparent activation energy, and (iii) reaction orders with respect to CO, H2O, CO2, and H2.