Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report

OBJECTIVES: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. METHODS: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners. RESULTS: We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report. CONCLUSIONS: This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation

Defining Significant Events for Neonatal and Pediatric Transport: Results of a Combined Delphi and Consensus Meeting Process.

Objective To develop standardized definitions for a list of indicators that represent significant events during pediatric transport, which were previously identified by a national Delphi study. Methods We designed a three-phase consensus process that applied Delphi methodology to a combination of electronic questionnaires and a live consensus meeting. Results Thirty-one pediatric transport experts evaluated a total of 59 indicators. Twenty-four indicators represented events or interventions that did not require definition. One indicator was removed from the list. Definitions for the remaining 34 indicators were developed. Conclusion This standardized indicator list is intended for application to quality improvement and clinical research initiatives.

Time to loss of brain function and activity during circulatory arrest.

PURPOSE: Brain function during the dying process and around the time of cardiac arrest is poorly understood. To better inform the clinical physiology of the dying process and organ donation practices, we performed a scoping review of the literature to assess time to loss of brain function and activity after circulatory arrest. MATERIALS AND METHODS: Medline and Embase databases were searched from inception to June 2014 for articles reporting the time interval to loss of brain function or activity after loss of systemic circulation. RESULTS: Thirty-nine studies met selection criteria. Seven human studies and 10 animal studies reported that electroencephalography (EEG) activity is lost less than 30seconds after abrupt circulatory arrest. In the setting of existing brain injury, with progressive loss of oxygenated circulation, loss of EEG may occur before circulatory arrest. Cortical evoked potentials may persist for several minutes after loss of circulation. CONCLUSION: The time required to lose brain function varied according to clinical context and method by which this function is measured. Most studies show that clinical loss of consciousness and loss of EEG activity occur within 30seconds after abrupt circulatory arrest and may occur before circulatory arrest after progressive hypoxia-ischemia. Prospective clinical studies are required to confirm these observations.

Down-regulation of murine fibrosarcoma transforming growth factor-beta 1 expression by interleukin 7.

BACKGROUND: Cytokine genes encode proteins that modulate immune system responses. Modification of tumor cells by the introduction of cytokine genes has been used as a strategy to augment host immunity. Interleukin 7 (IL-7) gene transfer enhances the immune response to tumor cells and can result in tumor regression. Transforming growth factor-beta 1 (TGF-beta 1) is a potent immunosuppressive cytokine produced by many tumors. We have previously reported that recombinant IL-7 decreases the expression of TGF-beta 1 by murine macrophages. PURPOSE: This study investigates the inhibition of tumor-derived TGF-beta 1 production as a possible mechanism for the enhanced antitumor immunity that accompanies IL-7 gene transfer. METHODS: A fibrosarcoma cell line (FSA-JmIL-7) genetically modified to produce IL-7 was used to evaluate the effects of IL-7 on tumor production of TGF-beta 1. The control cell line (FSA-Jneo) originated from the same parental fibrosarcoma cell line (FSA) and was produced by transduction with the same retroviral vector without the IL-7 gene. FSA-Jneo and FSA-JmIL-7 tumor cells were evaluated for the expression of TGF-beta 1 messenger RNA (mRNA). To determine if the observed change in TGF-beta 1 mRNA was associated with an alteration in protein secretion, we compared supernatants from tumor cell cultures for TGF-beta 1 production. Specific anti-TGF-beta 1 monoclonal antibody (MAb) was used to confirm the role of TGF-beta 1 in these assays. RESULTS: Compared with FSA parental and FSA-Jneo cells, FSA-JmIL-7 cells expressed TGF-beta 1 mRNA at a lower level. Compared with supernatants from FSA-Jneo cells, FSA-JmIL-7 supernatants contained consistently lower levels of TGF-beta 1 activity (P < .05). In addition, FSA-Jneo supernatants suppressed lymphocyte proliferation to a significantly greater degree than supernatants from FSA-JmIL-7 cells (P < .05). Studies with anti-TGF-beta 1 MAb added to the supernatants confirmed the role of TGF-beta 1 in inhibition of lymphocyte proliferation. CONCLUSION: These findings suggest that IL-7 gene transfer inhibits the production of TGF-beta 1 by tumor cells and thus may enhance the efficacy of the host's antitumor immune response. IMPLICATION: The regulation of endogenous tumor-derived cytokines in response to cytokine gene transfer may contribute to altered immune responses in the tumor microenvironment and thus may be an important additional parameter to assess in gene therapy.

Tumor necrosis factor-alpha plays a central role in interleukin-2-induced pulmonary vascular leak and lymphocyte accumulation.

Administration of interleukin-2 (IL-2) leads to pulmonary vascular leak. This form of pulmonary edema has previously been postulated to be due to the in vivo induction of tumor necrosis factor-alpha (TNF-alpha). To determine whether TNF-alpha plays a role in IL-2-induced pulmonary vascular leak, we performed in situ hybridization of lung sections and reverse transcriptase-polymerase chain reaction of bronchoalveolar lavage macrophages from IL-2-challenged mice. The results confirm an in situ upregulation of TNF-alpha mRNA expression in the lungs associated with vascular leak. In addition, a significant increase in TNF-alpha protein production was found in the lung following IL-2 administration, as measured by TNF-alpha-specific ELISA of lung supernatants (P = 0.028). Intravenous administration of a soluble TNF receptor significantly diminished IL-2-induced pulmonary vascular leak (P = 0.006). These findings confirm a central role for TNF-alpha in mediating the pulmonary vascular leak associated with IL-2 toxicity.

Interferon-alpha inhibits murine macrophage transforming growth factor-beta mRNA expression.

Transforming growth factor-beta (TGF-beta), a multifunctional polypeptide is produced by a wide variety of cells and regulates a broad array of physiological and pathological functions. TGF-beta appears to play a central role in pulmonary fibrosis and may contribute to tumor-associated immunosuppression. Alveolar macrophages are a rich source of TGF-beta and are intimately involved in lung inflammation. We therefore chose to study TGF-beta regulation in murine alveolar macrophages as well as an immortalized peritoneal macrophage cell line (IC-21). Murine macrophages were incubated with cytokines to evaluate their role in regulating TGF-beta mRNA expression. We conclude that IFN-alpha downregulates TGF-beta mRNA expression in murine macrophages.

Down-regulation of macrophage transforming growth factor-beta messenger RNA expression by IL-7.

Transforming growth factor-beta (TGF-beta) is a potent inhibitor of immune responses. Macrophage-derived products, including TGF-beta, have been suggested as inhibitors of the antitumor immune response. We hypothesized that IL-7, a cytokine with antitumor properties, may exert its immunoregulatory effects in part through the down-regulation of TGF-beta. To test this hypothesis we analyzed IL-2-stimulated murine macrophage TGF-beta mRNA expression following exposure to IL-7 both in vitro and in vivo. IL-7 down-regulated IL-2-induced TGF-beta expression by macrophages in vitro, as well as after i.p. injections of IL-2 and IL-7 in vivo. The IL-7-mediated inhibition of TGF-beta mRNA expression did not require new protein synthesis and therefore appears to be a direct effect of IL-7. IL-7 had no significant effect on the stability of TGF-beta mRNA. Nuclear run-on assays revealed that the suppression of IL-2-induced TGF-beta gene expression by IL-7 is mediated at the level of transcription. Also, IL-7 decreased TGF-beta secretion as measured by bioassay. We conclude that IL-7 down-regulates TGF-beta and suggest that some of the proliferative and cytolytic activities mediated by cells exposed to IL-7 may be caused by a decrement in macrophage-derived TGF-beta.

Diagnosis and management of the hypothyroid patient with chest pain.

A retrospective analysis of 38 patients undergoing cardiac catheterization with the diagnoses of hypothyroidism and chest pain revealed 23 to be euthyroid while receiving replacement therapy and 15 to be hypothyroid. Cardiac index was significantly reduced (p less than 0.01) in hypothyroid and euthyroid patients with thyroxine values between 4 and 7 micrograms/dl (2.8 +/- 0.7 and 3.0 +/- 0.9 L/min/m2, respectively), compared to euthyroid patients with thyroxine values greater than 7 micrograms/dl with or without coronary artery disease (4.0 +/- 1.2 and 4.0 +/- 0.7 L/min/m2, respectively). Ten hypothyroid patients underwent coronary artery bypass. There were no deaths, and only one patient required prolonged postoperative intubation. With a mean follow-up of 36 months, there have been no myocardial infarctions and one late death, which occurred at 7 years secondary to stroke. We conclude that preoperative thyroid replacement therapy is theoretically dangerous and may not significantly improve hemodynamics until full replacement is achieved. Coronary bypass grafting can be performed safely despite hypothyroidism with excellent early results.

Work in progress: a correction for tissue iodine accumulation in videodensitometric measurements of left ventricular ejection fraction.

Left ventricular ejection fractions were determined following eight intravenous injections in three dogs using area/length and digital videodensitometric techniques. Ejection fractions were measured by both techniques for all beats during left ventricular opacification. Even after noniodinated background corrections, tissue iodine accumulation produced large errors in measured iodine content late in the contrast material curve. By using a model for tissue iodine accumulation, an algorithm was developed that appears to reduce these errors. The measured ejection fraction for ten beats following the peak of the contrast material curve declined an average of 1.8% following correction, compared with 14% prior to correction. Following correction for tissue iodine accumulation, correlation between area/length and video-densitometric ejection fractions was 0.94. By correcting for tissue iodine accumulation, much more of the contrast material curve provides usable data for estimating ejection fractions.

Detection and estimation of rheumatic mitral regurgitation in the presence of mitral stenosis by pulsed Doppler echocardiography.

The sensitivity and specificity of pulsed Doppler echocardiography (PDE) in diagnosis and estimation of the severity of mitral regurgitation in the presence of rheumatic mitral stenosis was studied in 34 patients (18 women and 16 men) ranging in age from 33 to 70 years (mean 55). Definitive diagnosis of mitral regurgitation was confirmed in all patients by angiography and in 20 patients also by indicator dilution technique. Mitral regurgitation was detected by PDE in all patients with angiographically proven severe mitral regurgitation and in 7 of 8 patients with moderate mitral regurgitation. In patients with trace to mild mitral regurgitation, PDE was positive in only 7 of 13 patients. When subdivided for mild, moderate and severe mitral regurgitation, PDE sensitivity for diagnosis was 54, 88, and 100%, respectively; overall accuracy was 79% and specificity was 100%. Average systolic dispersion on time-interval histogram was 59% for mild, 89% for moderate, and 100% for severe mitral regurgitation. Groups of patients with mild mitral regurgitation could be differentiated from those with moderate (p less than 0.05) and severe (p less than 0.01) mitral regurgitation. A significant overlap of individual values, however, occurred. In 7 of 11 patients with moderate to severe mitral regurgitation, systolic turbulence also was detected in the left atrium. PDE was sensitive and specific in diagnosing moderate to severe mitral regurgitation in the presence of mitral stenosis. Assessment of precise severity of mitral regurgitation is still a problem in individual patients.

Computerized fluoroscopy: new technique for the noninvasive evaluation of the aorta, coronary artery bypass grafts, and left ventricular function.

A computerized fluoroscopy system has been developed on the basis of real-time digital processing of x-ray transmission data from traditional image-intensified fluoroscopy equipment. High-quality visualization of any part of the arterial system is obtained following intravenous injection of 0.5 to 0.75 ml/kg of iodinated contrast materials. This report describes the use of this technique to evaluate the aortic arch, left ventricular function, and coronary artery bypass graft patency. Fifty intravenous studies were performed in 25 patients. Among 20 patients with coronary artery bypass grafts, computerized fluoroscopy correctly identified 11 of 15 patent grafts and 11 of 11 occluded grafts as confirmed by standard coronary arteriography in 11 of these patients. Unlike computerized tomography, our technique gives a longitudinal view of the bypass graft much like direct coronary angiography. Aortic arch studies included demonstration of a right aortic arch with a small left subclavian artery, a coarctation, and a normal aortic arch in a trauma patient with a wide mediastinum. Segmental wall motion abnormalities were clearly identified by a modification of the technique which produces a negative outline on the ventriculogram in dyskinetic segments. Ejection fractions may be calculated by determining the amount of iodine in the ventricle in systole and diastole. This technique may also be used to evaluate carotid disease and peripheral vascular disease in patients undergoing coronary artery bypass procedures. Computerized fluoroscopy, therefore, allows evaluation of the entire cardiovascular system by the relatively noninvasive technique of intravenous angiography.