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Siddiqui MR, Reddy NM, Faridi HM, Shahid M, Shanley TP. Metformin alleviates lung-endothelial hyperpermeability by regulating cofilin-1/PP2AC pathway. Front Pharmacol 2023; 14:1211460. [PMID: 37361221 PMCID: PMC10285707 DOI: 10.3389/fphar.2023.1211460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Background: Microvascular endothelial hyperpermeability is an earliest pathological hallmark in Acute Lung Injury (ALI), which progressively leads to Acute Respiratory Distress Syndrome (ARDS). Recently, vascular protective and anti-inflammatory effect of metformin, irrespective of glycemic control, has garnered significant interest. However, the underlying molecular mechanism(s) of metformin's barrier protective benefits in lung-endothelial cells (ECs) has not been clearly elucidated. Many vascular permeability-increasing agents weakened adherens junctions (AJ) integrity by inducing the reorganization of the actin cytoskeleton and stress fibers formation. Here, we hypothesized that metformin abrogated endothelial hyperpermeability and strengthen AJ integrity via inhibiting stress fibers formation through cofilin-1-PP2AC pathway. Methods: We pretreated human lung microvascular ECs (human-lung-ECs) with metformin and then challenged with thrombin. To investigate the vascular protective effects of metformin, we studied changes in ECs barrier function using electric cell-substrate impedance sensing, levels of actin stress fibers formation and inflammatory cytokines IL-1β and IL-6 expression. To explore the downstream mechanism, we studied the Ser3-phosphorylation-cofilin-1 levels in scramble and PP2AC-siRNA depleted ECs in response to thrombin with and without metformin pretreatment. Results: In-vitro analyses showed that metformin pretreatment attenuated thrombin-induced hyperpermeability, stress fibers formation, and the levels of inflammatory cytokines IL-6 and IL-β in human-lung-ECs. We found that metformin mitigated Ser3-phosphorylation mediated inhibition of cofilin-1 in response to thrombin. Furthermore, genetic deletion of PP2AC subunit significantly inhibited metformin efficacy to mitigate thrombin-induced Ser3-phosphorylation cofilin-1, AJ disruption and stress fibers formation. We further demonstrated that metformin increases PP2AC activity by upregulating PP2AC-Leu309 methylation in human-lung-ECs. We also found that the ectopic expression of PP2AC dampened thrombin-induced Ser3-phosphorylation-mediated inhibition of cofilin-1, stress fibers formation and endothelial hyperpermeability. Conclusion: Together, these data reveal the unprecedented endothelial cofilin-1/PP2AC signaling axis downstream of metformin in protecting against lung vascular endothelial injury and inflammation. Therefore, pharmacologically enhancing endothelial PP2AC activity may lead to the development of novel therapeutic approaches for prevention of deleterious effects of ALI on vascular ECs.
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Affiliation(s)
- M. Rizwan Siddiqui
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Narsa M. Reddy
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Hafeez M. Faridi
- Drug Discovery Center, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Mohd Shahid
- Department of Pharmaceutical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States
| | - Thomas P. Shanley
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Dahmer MK, Yang G, Zhang M, Quasney MW, Sapru A, Weeks HM, Sinha P, Curley MAQ, Delucchi KL, Calfee CS, Flori H, Matthay MA, Bateman ST, Berg MD, Borasino S, Bysani GK, Cowl AS, Bowens CD, Faustino VS, Fineman LD, Godshall AJ, Hirshberg EL, Kirby AL, McLaughlin GE, Medar SS, Oren PP, Schneider JB, Schwarz AJ, Shanley TP, Source LR, Truemper EJ, Vender Heyden MA, Wittmayer K, Zuppa AF, Wypij D. Identification of phenotypes in paediatric patients with acute respiratory distress syndrome: a latent class analysis. Lancet Respir Med 2022; 10:289-297. [PMID: 34883088 PMCID: PMC8897230 DOI: 10.1016/s2213-2600(21)00382-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous latent class analysis of adults with acute respiratory distress syndrome (ARDS) identified two phenotypes, distinguished by the degree of inflammation. We aimed to identify phenotypes in children with ARDS in whom developmental differences might be important, using a latent class analysis approach similar to that used in adults. METHODS This study was a secondary analysis of data aggregated from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial and the Genetic Variation and Biomarkers in Children with Acute Lung Injury (BALI) ancillary study. We used latent class analysis, which included demographic, clinical, and plasma biomarker variables, to identify paediatric ARDS (PARDS) phenotypes within a cohort of children included in the RESTORE and BALI studies. The association of phenotypes with clinically relevant outcomes and the performance of paediatric data in adult ARDS classification algorithms were also assessed. FINDINGS 304 children with PARDS were included in this secondary analysis. Using latent class analysis, a two-class model was a better fit for the cohort than a one-class model (p<0·001). Latent class analysis identified two classes: class 1 (181 [60%] of 304 patients with PARDS) and class 2 (123 [40%] of 304 patients with PARDS), referred to as phenotype 1 and 2 hereafter. Phenotype 2 was characterised by higher concentrations of inflammatory biomarkers, a higher incidence of vasopressor use, and more frequent diagnosis of sepsis, consistent with the adult hyperinflammatory phenotype. All levels of severity of PARDS were observed across both phenotypes. Children with the hyperinflammatory phenotype (phenotype 2) had worse clinical outcomes than those with the hypoinflammatory phenotype (phenotype 1), with a longer duration of mechanical ventilation (median 10·0 days [IQR 6·3-21·0] for phenotype 2 vs 6·6 days [4·1-10·8] for phenotype 1, p<0·0001), and higher incidence of mortality (17 [13·8%] of 123 patients vs four [2·2%] of 181 patients, p=0·0001). When using adult phenotype classification algorithms in children, the soluble tumour necrosis factor receptor-1 (sTNFr1), vasopressor use, and interleukin (IL)-6 variables gave an area under the curve (AUC) of 0·956, and the sTNFr1, vasopressor use, and IL-8 variables gave an AUC of 0·954, compared with the gold standard of latent class analysis. INTERPRETATION Latent class analysis identified two phenotypes in children with ARDS with characteristics similar to those in adults, including worse outcomes among patients with the hyperinflammatory phenotype. PARDS phenotypes should be considered in design and analysis of future clinical trials in children. FUNDING US National Institutes of Health.
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Affiliation(s)
- Mary K Dahmer
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Michael W Quasney
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Heidi M. Weeks
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Pratik Sinha
- Department of Anesthesia, Washington University, St. Louis, MO
| | - Martha AQ Curley
- Department of Family and Community Health (School of Nursing), Division of Anesthesia and Critical Care Medicine (Perelman School of Medicine) University of Pennsylvania, Philadelphia, PA; Research Institute; Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kevin L Delucchi
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA
| | - Heidi Flori
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
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Zhang X, Jin H, Huang X, Chaurasiya B, Dong D, Shanley TP, Zhao YY. Robust genome editing in adult vascular endothelium by nanoparticle delivery of CRISPR-Cas9 plasmid DNA. Cell Rep 2022; 38:110196. [PMID: 34986352 PMCID: PMC8769807 DOI: 10.1016/j.celrep.2021.110196] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 07/16/2021] [Accepted: 12/10/2021] [Indexed: 12/25/2022] Open
Abstract
Vascular endothelium plays a crucial role in vascular homeostasis and tissue fluid balance. To target endothelium for robust genome editing, we developed poly(ethylene glycol) methyl ether-block-poly(lactide-co-glycolide) (PEG-b-PLGA) copolymer-based nanoparticle formulated with polyethyleneimine. A single i.v. administration of mixture of nanoparticles and plasmid DNA expressing Cas9 controlled by CDH5 promoter and guide RNA (U6 promoter) induced highly efficient genome editing in endothelial cells (ECs) of the vasculatures, including lung, heart, aorta, and peripheral vessels in adult mice. Western blotting and immunofluorescent staining demonstrated an ∼80% decrease of protein expression selectively in ECs, resulting in a phenotype similar to that of genetic knockout mice. Nanoparticle delivery of plasmid DNA could induce genome editing of two genes or genome editing and transgene expression in ECs simultaneously. Thus, nanoparticle delivery of plasmid DNA is a powerful tool to rapidly and efficiently alter expression of gene(s) in ECs for cardiovascular research and potential gene therapy.
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Affiliation(s)
- Xianming Zhang
- Program for Lung and Vascular Biology, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Division of Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Hua Jin
- Program for Lung and Vascular Biology, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Division of Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Xiaojia Huang
- Program for Lung and Vascular Biology, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Division of Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Birendra Chaurasiya
- Program for Lung and Vascular Biology, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Division of Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Daoyin Dong
- Program for Lung and Vascular Biology, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Division of Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Thomas P Shanley
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - You-Yang Zhao
- Program for Lung and Vascular Biology, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA; Department of Pediatrics, Division of Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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4
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Muszynski JA, Banks R, Reeder RW, Hall MW, Berg RA, Zuppa A, Shanley TP, Cornell TT, Newth CJL, Pollack MM, Wessel D, Doctor A, Lin JC, Harrison RE, Meert KL, Dean JM, Holubkov R, Carcillo JA. Outcomes Associated With Early RBC Transfusion in Pediatric Severe Sepsis: A Propensity-Adjusted Multicenter Cohort Study. Shock 2022; 57:88-94. [PMID: 34628452 PMCID: PMC8678199 DOI: 10.1097/shk.0000000000001863] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about the epidemiology of and outcomes related to red blood cell (RBC) transfusion in septic children across multiple centers. We performed propensity-adjusted secondary analyses of the Biomarker Phenotyping of Pediatric Sepsis and Multiple Organ Failure (PHENOMS) study to test the hypothesis that early RBC transfusion is associated with fewer organ failure-free days in pediatric severe sepsis. METHODS Four hundred one children were enrolled in the parent study. Children were excluded from these analyses if they received extracorporeal membrane oxygenation (n = 22) or died (n = 1) before sepsis day 2. Propensity-adjusted analyses compared children who received RBC transfusion on or before sepsis day 2 (early RBC transfusion) with those who did not. Logistic regression was used to model the propensity to receive early RBC transfusion. A weighted cohort was constructed using stabilized inverse probability of treatment weights. Variables in the weighted cohort with absolute standardized differences >0.15 were added to final multivariable models. RESULTS Fifty percent of children received at least one RBC transfusion. The majority (68%) of first transfusions were on or before sepsis day 2. Early RBC transfusion was not independently associated with organ failure-free (-0.34 [95%CI: -2, 1.3] days) or PICU-free days (-0.63 [-2.3, 1.1]), but was associated with the secondary outcome of higher mortality (aOR 2.9 [1.1, 7.9]). CONCLUSIONS RBC transfusion is common in pediatric severe sepsis and may be associated with adverse outcomes. Future studies are needed to clarify these associations, to understand patient-specific transfusion risks, and to develop more precise transfusion strategies.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P Shanley
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Timothy T Cornell
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - David Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Allan Doctor
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - John C Lin
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - Rick E Harrison
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California
| | - Kathleen L Meert
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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5
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Workman JK, Bailly DK, Reeder RW, Dalton HJ, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Dean JM, Meert KL. Risk Factors for Mortality in Refractory Pediatric Septic Shock Supported with Extracorporeal Life Support. ASAIO J 2021; 66:1152-1160. [PMID: 33136603 PMCID: PMC7773130 DOI: 10.1097/mat.0000000000001147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Risk factors for mortality in children with refractory pediatric septic shock who are supported with extracorporeal life support (ECLS) are largely unknown. Therefore, we performed univariable and multivariable analyses to determine risk factors for mortality among children (<19 years) who underwent an ECLS run between January 2012 and September 2014 at eight tertiary pediatric hospitals, and who had septic shock based on 2005 International Consensus Criteria. Of the 514 children treated with ECLS during the study period, 70 were identified with septic shock. The mortality rate was similar between those with (54.3%) and without septic shock (43.7%). Among those with septic shock, significant risk factors for mortality included cardiac failure or extracorporeal cardiopulmonary resuscitation (ECPR) as indication for ECLS cannulation compared with respiratory failure (P = 0.003), having a new neurologic event following cannulation (P = 0.032), acquiring a new infection following cannulation (P = 0.005), inability to normalize pH in the 48 hours following ECLS cannulation (P = 0.010), and requiring higher daily volume of platelet transfusions (P = 0.005). These findings can be used to help guide clinical decision making for children with septic shock that is refractory to medical management.
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Affiliation(s)
- Jennifer K. Workman
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - David K. Bailly
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Ron W. Reeder
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Heidi J. Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, Virginia
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P. Shanley
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago/Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher J. L. Newth
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rick Harrison
- Department of Pediatrics, University of Califronia, Mattel Children’s Hospital, Los Angeles, California
| | - J. Michael Dean
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Kathleen L. Meert
- Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan/Wayne State University, Detroit, Michigan
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Siddiqui MR, Akhtar S, Shahid M, Tauseef M, McDonough K, Shanley TP. miR-144-mediated Inhibition of ROCK1 Protects against LPS-induced Lung Endothelial Hyperpermeability. Am J Respir Cell Mol Biol 2020; 61:257-265. [PMID: 30811958 DOI: 10.1165/rcmb.2018-0235oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Dysfunctional endothelial cell (EC) barrier and increased lung vascular permeability is a cardinal feature of acute lung injury and sepsis that may result in a pathophysiological condition characterized by alveolar flooding, pulmonary edema, and subsequent hypoxemia. In lung ECs, activation of Rho-associated kinase-1 (ROCK1) phosphorylates myosin light chain (MLC)-associated phosphatase at its inhibitory site, which favors phosphorylation of MLC, stress fiber formation, and hyperpermeability during acute lung injury. The role of microRNA-144 (miR-144) has been well investigated in many human diseases, including cardiac ischemia/reperfusion-induced injury, lung cancer, and lung viral infection; however, its role in pulmonary EC barrier regulation remains obscure. Here, we investigated the miR-144-mediated mechanism in the protection of endothelial barrier function in an LPS-induced lung injury model. By using transendothelial electrical resistance and transwell permeability assay to examine in vitro permeability and immunofluorescence microscopy to determine barrier integrity, we showed that ectopic expression of miR-144 effectively blocked lung EC barrier disruption and hyperpermeability in response to proinflammatory agents. Furthermore, using a gain-and-loss-of-function strategy, overexpression of miR-144 significantly decreased ROCK1 expression. Concomitantly, miR-144 inhibits ROCK1-mediated phosphorylation of MLC phosphataseThr853 and thus phosphorylation of MLCThr18/Ser19 to counteract stress fiber formation in LPS-activated EC. Finally, in LPS-challenged mice, intranasal delivery of miR-144 mimic via liposomes attenuated endotoxemia-induced increases in lung wet/dry ratio, vascular permeability, and inflammation. In conclusion, these data suggest that miR-144-attenuated activation of inflammatory ROCK1/MLC pathway in vascular ECs is a promising therapeutic strategy to counter inflammatory lung injury.
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Affiliation(s)
- M Rizwan Siddiqui
- 1Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,2Stanley Manne Children's Research Institute, Chicago, Illinois; and
| | - Suhail Akhtar
- 1Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mohd Shahid
- 3College of Pharmacy, Chicago State University, Chicago, Illinois
| | - Mohammad Tauseef
- 3College of Pharmacy, Chicago State University, Chicago, Illinois
| | - Kelli McDonough
- 1Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,2Stanley Manne Children's Research Institute, Chicago, Illinois; and
| | - Thomas P Shanley
- 1Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,2Stanley Manne Children's Research Institute, Chicago, Illinois; and
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7
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Topjian AA, Sutton RM, Reeder RW, Telford R, Meert KL, Yates AR, Morgan RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA, Zuppa AF, Graham K, Twelves C, Diliberto MA, Landis WP, Tomanio E, Kwok J, Bell MJ, Abraham A, Sapru A, Alkhouli MF, Heidemann S, Pawluszka A, Hall MW, Steele L, Shanley TP, Weber M, Dalton HJ, Bell AL, Mourani PM, Malone K, Locandro C, Coleman W, Peterson A, Thelen J, Doctor A. The association of immediate post cardiac arrest diastolic hypertension and survival following pediatric cardiac arrest. Resuscitation 2019; 141:88-95. [PMID: 31176666 DOI: 10.1016/j.resuscitation.2019.05.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/20/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
AIM In-hospital cardiac arrest occurs in >5000 children each year in the US and almost half will not survive to discharge. Animal data demonstrate that an immediate post-resuscitation burst of hypertension is associated with improved survival. We aimed to determine if systolic and diastolic invasive arterial blood pressures immediately (0-20 min) after return of spontaneous circulation (ROSC) are associated with survival and neurologic outcomes at hospital discharge. METHODS This is a secondary analysis of the Pediatric Intensive Care Quality of CPR (PICqCPR) study of invasively measured blood pressures during intensive care unit CPR. Patients were eligible if they achieved ROSC and had at least one invasively measured blood pressure within the first 20 min following ROSC. Post-ROSC blood pressures were normalized for age, sex and height. "Immediate hypertension" was defined as at least one systolic or diastolic blood pressure >90th percentile. The primary outcome was survival to hospital discharge. RESULTS Of 102 children, 70 (68.6%) had at least one episode of immediate post-CPR diastolic hypertension. After controlling for pre-existing hypotension, duration of CPR, calcium administration, and first documented rhythm, patients with immediate post-CPR diastolic hypertension were more likely to survive to hospital discharge (79.3% vs. 54.5%; adjusted OR = 2.93; 95%CI, 1.16-7.69). CONCLUSIONS In this post hoc secondary analysis of the PICqCPR study, 68.6% of subjects had diastolic hypertension within 20 min of ROSC. Immediate post-ROSC hypertension was associated with increased odds of survival to discharge, even after adjusting for covariates of interest.
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Affiliation(s)
- Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States.
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Russell Telford
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - John T Berger
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States
| | - Christopher J Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
| | - Rick E Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, United States
| | - Frank W Moler
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, MI, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States; Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Todd C Carpenter
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, United States
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Katherine Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Carolann Twelves
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Mary Ann Diliberto
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Elyse Tomanio
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States
| | - Jeni Kwok
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Michael J Bell
- Department of Pediatrics, Children's National Medical Center, Washington D.C., United States; Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Alan Abraham
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anil Sapru
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, United States; Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
| | - Mustafa F Alkhouli
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
| | - Sabrina Heidemann
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Ann Pawluszka
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Mark W Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Lisa Steele
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Thomas P Shanley
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, MI, United States; Department of Pediatrics, Lurie Children's Hospital, Northwestern University, Chicago, IL, United States
| | - Monica Weber
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, MI, United States
| | - Heidi J Dalton
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Aimee La Bell
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Peter M Mourani
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, United States
| | - Kathryn Malone
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, United States
| | - Christopher Locandro
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Whitney Coleman
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Alecia Peterson
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Julie Thelen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Allan Doctor
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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Sun L, Hult EM, Cornell TT, Kim KK, Shanley TP, Wilke CA, Agarwal M, Gurczynski SJ, Moore BB, Dahmer MK. Loss of myeloid-specific protein phosphatase 2A enhances lung injury and fibrosis and results in IL-10-dependent sensitization of epithelial cell apoptosis. Am J Physiol Lung Cell Mol Physiol 2019; 316:L1035-L1048. [PMID: 30838865 DOI: 10.1152/ajplung.00299.2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Protein phosphatase 2A (PP2A), a ubiquitously expressed Ser/Thr phosphatase is an important regulator of cytokine signaling and cell function. We previously showed that myeloid-specific deletion of PP2A (LysMcrePP2A-/-) increased mortality in a murine peritoneal sepsis model. In the current study, we assessed the role of myeloid PP2A in regulation of lung injury induced by lipopolysaccharide (LPS) or bleomycin delivered intratracheally. LysMcrePP2A-/- mice experienced increased lung injury in response to both LPS and bleomycin. LysMcrePP2A-/- mice developed more exuberant fibrosis in response to bleomycin, elevated cytokine responses, and chronic myeloid inflammation. Bone marrow-derived macrophages (BMDMs) from LysMcrePP2A-/- mice showed exaggerated inflammatory cytokine release under conditions of both M1 and M2 activation. Notably, secretion of IL-10 was elevated under all stimulation conditions, including activation of BMDMs by multiple Toll-like receptor ligands. Supernatants collected from LPS-stimulated LysMcrePP2A-/- BMDMs induced epithelial cell apoptosis in vitro but this effect was mitigated when IL-10 was also depleted from the BMDMs by crossing LysMcrePP2A-/- mice with systemic IL-10-/- mice (LysMcrePP2A-/- × IL-10-/-) or when IL-10 was neutralized. Despite these findings, IL-10 did not directly induce epithelial cell apoptosis but sensitized epithelial cells to other mediators from the BMDMs. Taken together our results demonstrate that myeloid PP2A regulates production of multiple cytokines but that its effect is most pronounced on IL-10 production. Furthermore, IL-10 sensitizes epithelial cells to apoptosis in response to myeloid-derived mediators, which likely contributes to the pathogenesis of lung injury and fibrosis in this model.
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Affiliation(s)
- Lei Sun
- Department of Pediatrics and Critical Care, University of Michigan , Ann Arbor, Michigan
| | - Elissa M Hult
- Molecular and Integrative Physiology Graduate Program, University of Michigan , Ann Arbor, Michigan
| | - Timothy T Cornell
- Department of Pediatrics and Critical Care, University of Michigan , Ann Arbor, Michigan
| | - Kevin K Kim
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan , Ann Arbor, Michigan
| | - Thomas P Shanley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Stanley Manne Children's Research Institute at Lurie Children's Hospital , Chicago, Illinois
| | - Carol A Wilke
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan , Ann Arbor, Michigan
| | - Manisha Agarwal
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan , Ann Arbor, Michigan
| | - Stephen J Gurczynski
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan , Ann Arbor, Michigan
| | - Bethany B Moore
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan , Ann Arbor, Michigan.,Department of Microbiology and Immunology, University of Michigan , Ann Arbor, Michigan
| | - Mary K Dahmer
- Department of Pediatrics and Critical Care, University of Michigan , Ann Arbor, Michigan
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9
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Muszynski JA, Reeder RW, Hall MW, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Meert KL, Dean JM, Jenkins T, Tamburro RF, Dalton HJ. RBC Transfusion Practice in Pediatric Extracorporeal Membrane Oxygenation Support. Crit Care Med 2018; 46:e552-e559. [PMID: 29517551 PMCID: PMC6085106 DOI: 10.1097/ccm.0000000000003086] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To determine RBC transfusion practice and relationships between RBC transfusion volume and mortality in infants and children treated with extracorporeal membrane oxygenation. DESIGN Secondary analysis of a multicenter prospective observational study. SETTING Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network. PATIENTS Patients age less than 19 years old treated with extracorporeal membrane oxygenation at a participating center. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical data and target hemoglobin or hematocrit values (if set) were recorded daily by trained bedside extracorporeal membrane oxygenation specialists and research coordinators. Laboratory values, including hemoglobin and hematocrit, were recorded daily using the value obtained closest to 8:00 AM. RBC transfusion was recorded as total daily volume in mL/kg. Multivariable logistic regression was used to determine the relationship between RBC transfusion volume and hospital mortality, accounting for potential confounders. Average goal hematocrits varied across the cohort with a range of 27.5-41.3%. Overall, actual average daily hematocrit was 36.8%, and average RBC transfusion volume was 29.4 mL/kg/d (17.4-49.7 mL/kg/d) on extracorporeal membrane oxygenation. On multivariable analysis, each additional 10 mL/kg/d of RBC transfusion volume was independently associated with a 9% increase in odds of hospital mortality (adjusted odds ratio, 1.09 [1.02-1.16]; p = 0.009). CONCLUSIONS In this multicenter cohort of pediatric extracorporeal membrane oxygenation patients, daily hematocrit levels were maintained at normal or near-normal values and RBC transfusion burden was high. RBC transfusion volume was independently associated with odds of mortality. Future clinical studies to identify optimum RBC transfusion thresholds for pediatric extracorporeal membrane oxygenation are urgently needed.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Thomas P Shanley
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - David Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Rick Harrison
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, CA
| | - Kathleen L Meert
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University, Detroit, MI
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tammara Jenkins
- Trauma and Critical Illness Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Robert F Tamburro
- Trauma and Critical Illness Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Cashen K, Reeder R, Dalton HJ, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Dean JM, Tamburro R, Meert KL. Acquired infection during neonatal and pediatric extracorporeal membrane oxygenation. Perfusion 2018; 33:472-482. [PMID: 29638203 DOI: 10.1177/0267659118766436] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Our objectives are to (1) describe the pathogens, site, timing and risk factors for acquired infection during neonatal and pediatric ECMO and (2) explore the association between acquired infection and mortality. METHODS Secondary analysis of prospective data collected by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014. Clinical factors associated with acquired infection were assessed with multivariable Cox regression. Factors associated with mortality were assessed with logistic regression. RESULTS Of 481 patients, 247 (51.3%) were neonates and 400 (83.2%) received venoarterial ECMO. Eighty (16.6%) patients acquired one or more infections during ECMO; 60 (12.5%) patients had bacterial, 21 (4.4%) had fungal and 11 (2.3%) had viral infections. The site of infection included respiratory for 53 (11.0%) patients, bloodstream for 21 (4.4%), urine for 20 (4.2%) and other for 7 (1.5%). Candida species were most common. Median time to infection was 5.2 days (IQR 2.3, 9.6). On multivariable analysis, a greater number of procedures for ECMO cannula placement was independently associated with increased risk of acquired infection during ECMO (Hazard Ratio 2.13 (95% CI 1.22, 3.72), p<0.01) and receiving ECMO in a neonatal ICU compared to a pediatric or cardiac ICU was associated with decreased risk (Hazard Ratio pediatric ICU 4.25 (95% CI 2.20, 8.20), cardiac ICU 2.91 (95% CI 1.48, 5.71), neonatal ICU as reference, p<0.001). Acquired infection was not independently associated with mortality. CONCLUSION ECMO procedures and location may contribute to acquired infection risk; however, acquired infection did not predict mortality in this study.
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Affiliation(s)
- Katherine Cashen
- 1 Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University, Detroit, MI, USA
| | - Ron Reeder
- 2 Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Heidi J Dalton
- 3 Department of Pediatrics, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Robert A Berg
- 4 Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas P Shanley
- 5 Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago/Northwestern University Feinberg School of Medicine; Chicago, IL, USA
| | - Christopher J L Newth
- 6 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- 7 Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - David Wessel
- 7 Department of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Joseph Carcillo
- 8 Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Rick Harrison
- 9 Department of Pediatrics, Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - J Michael Dean
- 2 Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert Tamburro
- 10 Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Kathleen L Meert
- 1 Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University, Detroit, MI, USA
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11
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Berger JT, Villalobos ME, Clark AE, Holubkov R, Pollack MM, Berg RA, Carcillo JA, Dalton H, Harrison R, Meert KL, Newth CJ, Shanley TP, Wessel DL, Anand KJS, Zimmerman JJ, Sanders RC, Liu T, Burr JS, Willson DF, Doctor A, Dean JM, Jenkins TL, Nicholson CE. Cognitive Development One Year After Infantile Critical Pertussis. Pediatr Crit Care Med 2018; 19:89-97. [PMID: 29117060 PMCID: PMC5796844 DOI: 10.1097/pcc.0000000000001367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Pertussis can cause life-threatening illness in infants. Data regarding neurodevelopment after pertussis remain scant. The aim of this study was to assess cognitive development of infants with critical pertussis 1 year after PICU discharge. DESIGN Prospective cohort study. SETTING Eight hospitals comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development Collaborative Pediatric Critical Care Research Network and 18 additional sites across the United States. PATIENTS Eligible patients had laboratory confirmation of pertussis infection, were less than 1 year old, and were admitted to the PICU for at least 24 hours. INTERVENTIONS The Mullen Scales of Early Learning was administered at a 1-year follow-up visit. Functional status was determined by examination and parental interview. MEASUREMENTS AND MAIN RESULTS Of 196 eligible patients, 111 (57%) completed the Mullen Scales of Early Learning. The mean scores for visual reception, receptive language, and expressive language domains were significantly lower than the norms (p < 0.001), but not fine and gross motor domains. Forty-one patients (37%) had abnormal scores in at least one domain and 10 (9%) had an Early Learning Composite score 2 or more SDs below the population norms. Older age (p < 0.003) and Hispanic ethnicity (p < 0.008) were associated with lower mean Early Learning Composite score, but presenting symptoms and PICU course were not. CONCLUSIONS Infants who survive critical pertussis often have neurodevelopmental deficits. These infants may benefit from routine neurodevelopmental screening.
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Affiliation(s)
- John T. Berger
- Children’s National Medical Center, Washington, District of Columbia
| | | | | | | | - Murray M. Pollack
- Children’s National Medical Center, Washington, District of Columbia
| | - Robert A. Berg
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Rick Harrison
- Mattel Children’s Hospital UCLA, Los Angeles, California
| | | | | | | | - David L. Wessel
- Children’s National Medical Center, Washington, District of Columbia
| | | | | | | | | | | | | | - Allan Doctor
- St. Louis Children’s Hospital, St. Louis, Missouri
| | | | - Tammara L. Jenkins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Carol E. Nicholson
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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12
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Carcillo JA, Dean JM, Holubkov R, Berger J, Meert KL, Anand KJS, Zimmerman JJ, Newth CJL, Harrison R, Burr J, Willson DF, Nicholson C, Bell MJ, Berg RA, Shanley TP, Heidemann SM, Dalton H, Jenkins TL, Doctor A, Webster A, Tamburro RF. Interaction Between 2 Nutraceutical Treatments and Host Immune Status in the Pediatric Critical Illness Stress-Induced Immune Suppression Comparative Effectiveness Trial. JPEN J Parenter Enteral Nutr 2017; 41:1325-1335. [PMID: 27660289 PMCID: PMC6103642 DOI: 10.1177/0148607116670377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS The pediatric Critical Illness Stress-induced Immune Suppression (CRISIS) trial compared the effectiveness of 2 nutraceutical supplementation strategies and found no difference in the development of nosocomial infection and sepsis in the overall population. We performed an exploratory post hoc analysis of interaction between nutraceutical treatments and host immune status related to the development of nosocomial infection/sepsis. METHODS Children from the CRISIS trial were analyzed according to 3 admission immune status categories marked by decreasing immune competence: immune competent without lymphopenia, immune competent with lymphopenia, and previously immunocompromised. The comparative effectiveness of the 2 treatments was analyzed for interaction with immune status category. RESULTS There were 134 immune-competent children without lymphopenia, 79 previously immune-competent children with lymphopenia, and 27 immunocompromised children who received 1 of the 2 treatments. A significant interaction was found between treatment arms and immune status on the time to development of nosocomial infection and sepsis ( P < .05) and on the rate of nosocomial infection and sepsis per 100 patient days ( P < .05). Whey protein treatment protected immune-competent patients without lymphopenia from infection and sepsis, both nutraceutical strategies were equivalent in immune-competent patients with lymphopenia, and zinc, selenium, glutamine, and metoclopramide treatment protected immunocompromised patients from infection and sepsis. CONCLUSIONS The science of immune nutrition is more complex than previously thought. Future trial design should consider immune status at the time of trial entry because differential effects of nutraceuticals may be related to this patient characteristic.
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Affiliation(s)
| | | | | | - John Berger
- 3 Children's National Medical Center, Washington, DC, USA
| | | | | | | | | | - Rick Harrison
- 8 Mattel Children's Hospital at University of California, Los Angeles, California, USA
| | - Jeri Burr
- 2 University of Utah, Salt Lake City, Utah, USA
| | | | - Carol Nicholson
- 10 Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Michael J Bell
- 1 Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert A Berg
- 11 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Heidi Dalton
- 13 Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Tammara L Jenkins
- 10 Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Allan Doctor
- 14 St Louis Children's Hospital, St Louis, Missouri, USA
| | | | - Robert F Tamburro
- 10 Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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13
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Natale JE, Lebet R, Joseph JG, Ulysse C, Ascenzi J, Wypij D, Curley MAQ, Wypij D, Allen GL, Angus DC, Asaro LA, Ascenzi JA, Bateman ST, Borasino S, Bowens CD, Bysani GK, Cheifetz IM, Cowl AS, Dodson BL, Faustino EVS, Fineman LD, Flori HR, Franck LS, Gedeit RG, Grant MJC, Harabin AL, Haskins-Kiefer C, Hertzog JH, Hutchins L, Kirby AL, Lebet RM, Matthay MA, McLaughlin GE, Natale JE, Oren PP, Polavarapu N, Schneider JB, Schwarz AJ, Shanley TP, Simone S, Singer LP, Sorce LR, Truemper EJ, Vander Heyden MA, Watson RS, Wells CR. Racial and Ethnic Disparities in Parental Refusal of Consent in a Large, Multisite Pediatric Critical Care Clinical Trial. J Pediatr 2017; 184:204-208.e1. [PMID: 28410087 DOI: 10.1016/j.jpeds.2017.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/05/2017] [Accepted: 02/02/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their child's participation in a multisite pediatric critical care clinical trial. STUDY DESIGN We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a 31-center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent. RESULT Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non-Hispanic White (White), non-Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56-2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10-1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37-3.36, P < .001). CONCLUSIONS Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their child's participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings. TRIAL REGISTRATION ClinicalTrials.gov: NCT00814099.
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Affiliation(s)
- Joanne E Natale
- Department of Pediatrics, University of California, Davis, CA.
| | - Ruth Lebet
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jill G Joseph
- Betty Irene Moore School of Nursing, University of California, Davis, CA
| | - Christine Ulysse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Judith Ascenzi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children's Hospital, Baltimore, MD
| | - David Wypij
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA; Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Critical Care and Cardiovascular Nursing, Boston Children's Hospital, Boston, MA
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14
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Davis MM, Shanley TP. The Missing -Omes: Proposing Social and Environmental Nomenclature in Precision Medicine. Clin Transl Sci 2017; 10:64-66. [PMID: 28105795 PMCID: PMC5355967 DOI: 10.1111/cts.12453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 01/18/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- M M Davis
- Division of Academic General Pediatrics and Primary Care, Mary Ann and J. Milburn Smith Child Health Research Program, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - T P Shanley
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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15
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Sun L, Pham TT, Cornell TT, McDonough KL, McHugh WM, Blatt NB, Dahmer MK, Shanley TP. Myeloid-Specific Gene Deletion of Protein Phosphatase 2A Magnifies MyD88- and TRIF-Dependent Inflammation following Endotoxin Challenge. J Immunol 2016; 198:404-416. [PMID: 27872207 DOI: 10.4049/jimmunol.1600221] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 10/21/2016] [Indexed: 12/23/2022]
Abstract
Protein phosphatase 2A (PP2A) is a member of the intracellular serine/threonine phosphatases. Innate immune cell activation triggered by pathogen-associated molecular patterns is mediated by various protein kinases, and PP2A plays a counter-regulatory role by deactivating these kinases. In this study, we generated a conditional knockout of the α isoform of the catalytic subunit of PP2A (PP2ACα). After crossing with myeloid-specific cre-expressing mice, effective gene knockout was achieved in various myeloid cells. The myeloid-specific knockout mice (lyM-PP2Afl/fl) showed higher mortality in response to endotoxin challenge and bacterial infection. Upon LPS challenge, serum levels of TNF-α, KC, IL-6, and IL-10 were significantly increased in lyM-PP2Afl/fl mice, and increased phosphorylation was observed in MAPK pathways (p38, ERK, JNK) and the NF-κB pathway (IKKα/β, NF-κB p65) in bone marrow-derived macrophages (BMDMs) from knockout mice. Heightened NF-κB activation was not associated with degradation of IκBα; instead, enhanced phosphorylation of the NF-κB p65 subunit and p38 phosphorylation-mediated TNF-α mRNA stabilization appear to contribute to the increased TNF-α expression. In addition, increased IL-10 expression appears to be due to PP2ACα-knockout-induced IKKα/β hyperactivation. Microarray experiments indicated that the Toll/IL-1R domain-containing adaptor inducing IFN-β/ TNFR-associated factor 3 pathway was highly upregulated in LPS-treated PP2ACα-knockout BMDMs, and knockout BMDMs had elevated IFN-α/β production compared with control BMDMs. Serum IFN-β levels from PP2ACα-knockout mice treated with LPS were also greater than those in controls. Thus, we demonstrate that PP2A plays an important role in regulating inflammation and survival in the setting of septic insult by targeting MyD88- and Toll/IL-1R domain-containing adaptor inducing IFN-β-dependent pathways.
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Affiliation(s)
- Lei Sun
- Division of Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109;
| | - Tiffany T Pham
- Division of Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Timothy T Cornell
- Division of Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Kelli L McDonough
- Division of Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Walker M McHugh
- Division of Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Neal B Blatt
- Division of Pediatric Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI 48109; and
| | - Mary K Dahmer
- Division of Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Thomas P Shanley
- Department of Pediatrics, Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Evanston, IL 60611
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16
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McHugh WM, Russell WW, Fleszar AJ, Rodenhouse PE, Rietberg SP, Sun L, Shanley TP, Cornell TT. Protein phosphatase 2A activation attenuates inflammation in murine models of acute lung injury. Am J Physiol Lung Cell Mol Physiol 2016; 311:L903-L912. [PMID: 27638902 DOI: 10.1152/ajplung.00007.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 09/11/2016] [Indexed: 12/27/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) remains a leading cause of morbidity and mortality in both adult and pediatric intensive care units. A key event in the development of ARDS is neutrophil recruitment into the lungs leading to tissue damage and destruction. Interleukin-8 (IL-8) is the major human chemokine responsible for neutrophil recruitment into the lungs. Protein phosphatase 2A (PP2A) has been shown to be a key regulator of the mitogen-activated protein kinase (MAPK) cascades, which control the production of IL-8. Previously, our laboratory employed an in vitro model to show that inhibition of PP2A results in an increase in IL-8 production in human alveolar epithelial cells. The objective of this study was to determine whether PP2A regulated this response in vivo by investigating the impact of pharmacologic activation of PP2A on chemokine production and activation of the MAPK cascade and lung injury using endotoxin- and bacterial-challenge models of ARDS in mice. N6-cyclopentyladenosine (N6-CPA) increased PP2A activity and inhibited endotoxin-induced cytokine production in a murine alveolar macrophage cell line. N6-CPA pretreatment in mice challenged with intratracheal endotoxin decreased chemokine production, reduced neutrophil infiltration, and attenuated lung injury. Following initiation of lung injury with live Pseudomonas aeruginosa, mice that received N6-CPA 4 h following bacterial challenge showed attenuated chemokine production and reduced neutrophil infiltration compared with control mice. Pharmacologic PP2A activation both limited and prevented inflammation and tissue injury in two direct injury models of ARDS. These results suggest modulation of PP2A activity as a therapeutic target in ARDS.
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Affiliation(s)
- Walker M McHugh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - William W Russell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Andrew J Fleszar
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Paul E Rodenhouse
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Skyler P Rietberg
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Lei Sun
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Thomas P Shanley
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Timothy T Cornell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, and C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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17
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Oh BR, Chen P, Nidetz R, McHugh W, Fu J, Shanley TP, Cornell TT, Kurabayashi K. Multiplexed Nanoplasmonic Temporal Profiling of T-Cell Response under Immunomodulatory Agent Exposure. ACS Sens 2016; 1:941-948. [PMID: 27478873 PMCID: PMC4960639 DOI: 10.1021/acssensors.6b00240] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 06/22/2016] [Indexed: 12/23/2022]
Abstract
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Immunomodulatory drugs—agents
regulating the immune response—are
commonly used for treating immune system disorders and minimizing
graft versus host disease in persons receiving organ transplants.
At the cellular level, immunosuppressant drugs are used to inhibit
pro-inflammatory or tissue-damaging responses of cells. However, few
studies have so far precisely characterized the cellular-level effect
of immunomodulatory treatment. The primary challenge arises due to
the rapid and transient nature of T-cell immune responses to such
treatment. T-cell responses involve a highly interactive network of
different types of cytokines, which makes precise monitoring of drug-modulated
T-cell response difficult. Here, we present a nanoplasmonic biosensing
approach to quantitatively characterize cytokine secretion behaviors
of T cells with a fine time-resolution (every 10 min) that are altered
by an immunosuppressive drug used in the treatment of T-cell-mediated
diseases. With a microfluidic platform integrating antibody-conjugated
gold nanorod (AuNR) arrays, the technique enables simultaneous multi-time-point
measurements of pro-inflammatory (IL-2, IFN-γ, and TNF-α)
and anti-inflammatory (IL-10) cytokines secreted by T cells. The integrated
nanoplasmonic biosensors achieve precise measurements with low operating
sample volume (1 μL), short assay time (∼30 min), heightened
sensitivity (∼20–30 pg/mL), and negligible sensor crosstalk.
Data obtained from the multicytokine secretion profiles with high
practicality resulting from all of these sensing capabilities provide
a comprehensive picture of the time-varying cellular functional state
during pharmacologic immunosuppression. The capability to monitor
cellular functional response demonstrated in this study has great
potential to ultimately permit personalized immunomodulatory treatment.
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Affiliation(s)
| | | | | | | | | | - Thomas P. Shanley
- Department
of Pediatrics, Northwestern University, Evanston, Illinois 60611, United States
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18
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Meert KL, Eggly S, Kavanaugh K, Berg RA, Wessel DL, Newth CJL, Shanley TP, Harrison R, Dalton H, Dean JM, Doctor A, Jenkins T, Park CL. Meaning making during parent-physician bereavement meetings after a child's death. Health Psychol 2015; 34:453-61. [PMID: 25822059 DOI: 10.1037/hea0000153] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Our goal was to identify and describe types of meaning-making processes that occur among parents during bereavement meetings with their child's intensive care physician after their child's death in a pediatric intensive care unit. METHODS Fifty-three parents of 35 deceased children participated in a bereavement meeting with their child's physician 14.5 ± 6.3 weeks after the child's death. One meeting was conducted per family. Meetings were video recorded and transcribed verbatim. Using a directed content analysis, an interdisciplinary team analyzed the transcripts to identify and describe meaning-making processes that support and extend extant meaning-making theory. RESULTS Four major meaning-making processes were identified: (1) sense making, (2) benefit finding, (3) continuing bonds, and (4) identity reconstruction. Sense making refers to seeking biomedical explanations for the death, revisiting parents' prior decisions and roles, and assigning blame. Benefit finding refers to exploring positive consequences of the death, including ways to help others, such as giving feedback to the hospital, making donations, participating in research, volunteering, and contributing to new medical knowledge. Continuing bonds refers to parents' ongoing connection with the deceased child manifested by reminiscing about the child, sharing photographs and discussing personal rituals, linking objects, and community events to honor the child. Identity reconstruction refers to changes in parents' sense of self, including changes in relationships, work, home, and leisure. CONCLUSIONS Parent-physician bereavement meetings facilitate several types of meaning-making processes among bereaved parents. Further research should evaluate the extent to which meaning making during bereavement meetings affects parents' health outcomes.
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Affiliation(s)
| | - Susan Eggly
- Department of Oncology, Karmanos Cancer Institute/Wayne State University
| | | | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
| | - David L Wessel
- Department of Pediatrics, Children's National Medical Center
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles
| | - Thomas P Shanley
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital
| | - Rick Harrison
- Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles
| | - Heidi Dalton
- Department of Pediatrics, Phoenix Children's Hospital
| | | | - Allan Doctor
- Department of Pediatrics, St. Louis Children's Hospital
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19
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Grunwell JR, Weiss SL, Cvijanovich NZ, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Shanley TP, Bigham MT, Fitzgerald J, Howard K, Frank E, Harmon K, Wong HR. Differential expression of the Nrf2-linked genes in pediatric septic shock. Crit Care 2015; 19:327. [PMID: 26376786 PMCID: PMC4574004 DOI: 10.1186/s13054-015-1052-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 08/26/2015] [Indexed: 01/19/2023]
Abstract
Introduction Experimental data from animal models of sepsis support a role for a transcription factor, nuclear erythroid-related factor 2 p45-related factor 2 (Nrf2), as a master regulator of antioxidant and detoxifying genes and intermediary metabolism during stress. Prior analysis of a pediatric septic shock transcriptomic database showed that the Nrf2 response is a top 5 upregulated signaling pathway in early pediatric septic shock. Methods We conducted a focused analysis of 267 Nrf2-linked genes using a multicenter, genome-wide expression database of 180 children with septic shock 10 years of age or younger and 53 healthy controls. The analysis involved RNA isolated from whole blood within 24 h of pediatric intensive care unit admission for septic shock and a false discovery rate of 5 %. We compared differentially expressed genes from (1) patients with septic shock and healthy controls and (2) across validated gene expression–based subclasses of pediatric septic shock (endotypes A and B) using several bioinformatic methods. Results We found upregulation of 123 Nrf2-linked genes in children with septic shock. The top gene network represented by these genes contained primarily enzymes with oxidoreductase activity involved in cellular lipid metabolism that were highly connected to the peroxisome proliferator activated receptor and the retinoic acid receptor families. Endotype A, which had higher organ failure burden and mortality, exhibited a greater downregulation of Nrf2-linked genes than endotype B, with 92 genes differentially regulated between endotypes. Conclusions Our findings indicate that Nrf2-linked genes may contribute to alterations in oxidative signaling and intermediary metabolism in pediatric septic shock. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1052-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jocelyn R Grunwell
- Division of Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta at Egleston, Emory University School of Medicine, 1405 Clifton Road N.E., Atlanta, GA, 30322, USA.
| | - Scott L Weiss
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA. .,Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.
| | - Natalie Z Cvijanovich
- UCSF, Benioff Children's Hospital Oakland, 757 52nd Street, Oakland, CA, 94609, USA.
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Neal J Thomas
- Penn State Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA.
| | - Robert J Freishtat
- Children's National Medical Center, 111 Michigan Avenue N.W., Washington, DC, 20010, USA.
| | - Nick Anas
- Children's Hospital of Orange County, 1201 West La Veta Avenue, Orange, CA, 92868, USA.
| | - Keith Meyer
- Miami Children's Hospital, 3100 S.W. 62nd Avenue, Miami, FL, 33155, USA.
| | - Paul A Checchia
- Texas Children's Hospital, 6621 Fannin Street, Houston, TX, 77030, USA.
| | - Thomas P Shanley
- C.S. Mott Children's Hospital at the University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109, USA.
| | - Michael T Bigham
- Akron Children's Hospital, 1 Perkins Square, Akron, OH, 44302, USA.
| | - Julie Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.
| | - Kelli Howard
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Erin Frank
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA. .,Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
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20
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Yu ZTF, Guan H, Cheung MK, McHugh WM, Cornell TT, Shanley TP, Kurabayashi K, Fu J. Rapid, automated, parallel quantitative immunoassays using highly integrated microfluidics and AlphaLISA. Sci Rep 2015; 5:11339. [PMID: 26074253 PMCID: PMC4466892 DOI: 10.1038/srep11339] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/15/2015] [Indexed: 12/22/2022] Open
Abstract
Immunoassays represent one of the most popular analytical methods for detection and quantification of biomolecules. However, conventional immunoassays such as ELISA and flow cytometry, even though providing high sensitivity and specificity and multiplexing capability, can be labor-intensive and prone to human error, making them unsuitable for standardized clinical diagnoses. Using a commercialized no-wash, homogeneous immunoassay technology ('AlphaLISA') in conjunction with integrated microfluidics, herein we developed a microfluidic immunoassay chip capable of rapid, automated, parallel immunoassays of microliter quantities of samples. Operation of the microfluidic immunoassay chip entailed rapid mixing and conjugation of AlphaLISA components with target analytes before quantitative imaging for analyte detections in up to eight samples simultaneously. Aspects such as fluid handling and operation, surface passivation, imaging uniformity, and detection sensitivity of the microfluidic immunoassay chip using AlphaLISA were investigated. The microfluidic immunoassay chip could detect one target analyte simultaneously for up to eight samples in 45 min with a limit of detection down to 10 pg mL(-1). The microfluidic immunoassay chip was further utilized for functional immunophenotyping to examine cytokine secretion from human immune cells stimulated ex vivo. Together, the microfluidic immunoassay chip provides a promising high-throughput, high-content platform for rapid, automated, parallel quantitative immunosensing applications.
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Affiliation(s)
- Zeta Tak For Yu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Huijiao Guan
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Mei Ki Cheung
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Walker M McHugh
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Timothy T Cornell
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Thomas P Shanley
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Katsuo Kurabayashi
- 1] Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA [2] Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Jianping Fu
- 1] Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA [2] Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109, USA
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21
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Wong HR, Cvijanovich NZ, Anas N, Allen GL, Thomas NJ, Bigham MT, Weiss SL, Fitzgerald J, Checchia PA, Meyer K, Shanley TP, Quasney M, Hall M, Gedeit R, Freishtat RJ, Nowak J, Shekhar RS, Gertz S, Dawson E, Howard K, Harmon K, Beckman E, Frank E, Lindsell CJ. Developing a clinically feasible personalized medicine approach to pediatric septic shock. Am J Respir Crit Care Med 2015; 191:309-15. [PMID: 25489881 DOI: 10.1164/rccm.201410-1864oc] [Citation(s) in RCA: 198] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE Using microarray data, we previously identified gene expression-based subclasses of septic shock with important phenotypic differences. The subclass-defining genes correspond to adaptive immunity and glucocorticoid receptor signaling. Identifying the subclasses in real time has theranostic implications, given the potential for immune-enhancing therapies and controversies surrounding adjunctive corticosteroids for septic shock. OBJECTIVES To develop and validate a real-time subclassification method for septic shock. METHODS Gene expression data for the 100 subclass-defining genes were generated using a multiplex messenger RNA quantification platform (NanoString nCounter) and visualized using gene expression mosaics. Study subjects (n = 168) were allocated to the subclasses using computer-assisted image analysis and microarray-based reference mosaics. A gene expression score was calculated to reduce the gene expression patterns to a single metric. The method was tested prospectively in a separate cohort (n = 132). MEASUREMENTS AND MAIN RESULTS The NanoString-based data reproduced two septic shock subclasses. As previously, one subclass had decreased expression of the subclass-defining genes. The gene expression score identified this subclass with an area under the curve of 0.98 (95% confidence interval [CI95] = 0.96-0.99). Prospective testing of the subclassification method corroborated these findings. Allocation to this subclass was independently associated with mortality (odds ratio = 2.7; CI95 = 1.2-6.0; P = 0.016), and adjunctive corticosteroids prescribed at physician discretion were independently associated with mortality in this subclass (odds ratio = 4.1; CI95 = 1.4-12.0; P = 0.011). CONCLUSIONS We developed and tested a gene expression-based classification method for pediatric septic shock that meets the time constraints of the critical care environment, and can potentially inform therapeutic decisions.
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Affiliation(s)
- Hector R Wong
- 1 Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio
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22
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Ashbrook MJ, McDonough KL, Pituch JJ, Christopherson PL, Cornell TT, Selewski DT, Shanley TP, Blatt NB. Citrate modulates lipopolysaccharide-induced monocyte inflammatory responses. Clin Exp Immunol 2015; 180:520-30. [PMID: 25619261 DOI: 10.1111/cei.12591] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 12/25/2022] Open
Abstract
Citrate, a central component of cellular metabolism, is a widely used anti-coagulant due to its ability to chelate calcium. Adenosine triphosphate (ATP)-citrate lyase, which metabolizes citrate, has been shown to be essential for inflammation, but the ability of exogenous citrate to impact inflammatory signalling cascades remains largely unknown. We hypothesized that citrate would modulate inflammatory responses as both a cellular metabolite and calcium chelator, and tested this hypothesis by determining how clinically relevant levels of citrate modulate monocyte proinflammatory responses to lipopolysaccharide (LPS) in a human acute monocytic leukaemia cell line (THP-1). In normal medium (0.4 mM calcium), citrate inhibited LPS-induced tumour necrosis factor (TNF)-α and interleukin (IL)-8 transcripts, whereas in medium supplemented with calcium (1.4 mM), TNF-α and IL-8 levels increased and appeared independent of calcium chelation. Using an IL-8-luciferase plasmid construct, the same increased response was observed in the activation of the IL-8 promoter region, suggesting transcriptional regulation. Tricarballylic acid, an inhibitor of ATP-citrate lyase, blocked the ability of citrate to augment TNF-α, linking citrate's augmentation effect with its metabolism by ATP-citrate lyase. In the presence of citrate, increased histone acetylation was observed in the TNF-α and IL-8 promoter regions of THP-1 cells. We observed that citrate can both augment and inhibit proinflammatory cytokine production via modulation of inflammatory gene transactivation. These findings suggest that citrate anti-coagulation may alter immune function through complex interactions with the inflammatory response.
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Affiliation(s)
- M J Ashbrook
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - K L McDonough
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - J J Pituch
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - P L Christopherson
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - T T Cornell
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - D T Selewski
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - T P Shanley
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - N B Blatt
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
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23
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Frey LJ, Sward KA, Newth CJL, Khemani RG, Cryer ME, Thelen JL, Enriquez R, Shaoyu S, Pollack MM, Harrison RE, Meert KL, Berg RA, Wessel DL, Shanley TP, Dalton H, Carcillo J, Jenkins TL, Dean JM. Virtualization of open-source secure web services to support data exchange in a pediatric critical care research network. J Am Med Inform Assoc 2015; 22:1271-6. [PMID: 25796596 DOI: 10.1093/jamia/ocv009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/21/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To examine the feasibility of deploying a virtual web service for sharing data within a research network, and to evaluate the impact on data consistency and quality. MATERIAL AND METHODS Virtual machines (VMs) encapsulated an open-source, semantically and syntactically interoperable secure web service infrastructure along with a shadow database. The VMs were deployed to 8 Collaborative Pediatric Critical Care Research Network Clinical Centers. RESULTS Virtual web services could be deployed in hours. The interoperability of the web services reduced format misalignment from 56% to 1% and demonstrated that 99% of the data consistently transferred using the data dictionary and 1% needed human curation. CONCLUSIONS Use of virtualized open-source secure web service technology could enable direct electronic abstraction of data from hospital databases for research purposes.
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Affiliation(s)
- Lewis J Frey
- Biomedical Informatics Center, Department Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Katherine A Sward
- College of Nursing; Department of Biomedical Informatics, University of Utah, Salt Lake City, USA
| | - Christopher J L Newth
- USC Keck School of Medicine; Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Robinder G Khemani
- USC Keck School of Medicine; Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Martin E Cryer
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, USA
| | - Julie L Thelen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Rene Enriquez
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Su Shaoyu
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Murray M Pollack
- Phoenix Children's Hospital, Department of Pediatrics, University of Arizona Phoenix, Phoenix, USA
| | - Rick E Harrison
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - David L Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Thomas P Shanley
- Department of Pediatrics, University of Michigan, Ann Arbor, USA
| | - Heidi Dalton
- Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, USA
| | - Tammara L Jenkins
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, USA
| | - J Michael Dean
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Utah School of Medicine; NICHD Collaborative Pediatric Critical Care Research Network, Salt Lake City, USA
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24
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Eggly S, Manning MA, Slatcher RB, Berg RA, Wessel DL, Newth CJL, Shanley TP, Harrison R, Dalton H, Dean JM, Doctor A, Jenkins T, Meert KL. Language Analysis as a Window to Bereaved Parents' Emotions During a Parent-Physician Bereavement Meeting. J Lang Soc Psychol 2015; 34:181-199. [PMID: 26726278 PMCID: PMC4696603 DOI: 10.1177/0261927x14555549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Parent-physician bereavement meetings may benefit parents by facilitating sense making, which is associated with healthy adjustment after a traumatic event. Prior research suggests a reciprocal relationship between sense making and positive emotions. We analyzed parents' use of emotion words during bereavement meetings to better understand parents' emotional reactions during the meeting and how their emotional reactions related to their appraisals of the meeting. Parents' use of positive emotion words increased, suggesting the meetings help parents make sense of the death. Parents' use of positive emotion words was negatively related to their own and/or their spouse's appraisals of the meeting, suggesting that parents who have a positive emotional experience during the meeting may also have a short-term negative reaction. Language analysis can be an effective tool to understand individuals' ongoing emotions and meaning making processes during interventions to reduce adverse consequences of a traumatic event, such as a child's death.
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Affiliation(s)
- Susan Eggly
- Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Mark A. Manning
- Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | | | - Robert A. Berg
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | | | - Rick Harrison
- Mattel Children’s Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Allan Doctor
- St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Tammara Jenkins
- National Institute of Child Health and Human Development, Bethesda, MD, USA
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25
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Chen P, Chung MT, McHugh W, Nidetz R, Li Y, Fu J, Cornell TT, Shanley TP, Kurabayashi K. Multiplex serum cytokine immunoassay using nanoplasmonic biosensor microarrays. ACS Nano 2015; 9:4173-81. [PMID: 25790830 PMCID: PMC4447431 DOI: 10.1021/acsnano.5b00396] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Precise monitoring of the rapidly changing immune status during the course of a disease requires multiplex analysis of cytokines from frequently sampled human blood. However, the current lack of rapid, multiplex, and low volume assays makes immune monitoring for clinical decision-making (e.g., critically ill patients) impractical. Without such assays, immune monitoring is even virtually impossible for infants and neonates with infectious diseases and/or immune mediated disorders as access to their blood in large quantities is prohibited. Localized surface plasmon resonance (LSPR)-based microfluidic optical biosensing is a promising approach to fill this technical gap as it could potentially permit real-time refractometric detection of biomolecular binding on a metallic nanoparticle surface and sensor miniaturization, both leading to rapid and sample-sparing analyte analysis. Despite this promise, practical implementation of such a microfluidic assay for cytokine biomarker detection in serum samples has not been established primarily due to the limited sensitivity of LSPR biosensing. Here, we developed a high-throughput, label-free, multiarrayed LSPR optical biosensor device with 480 nanoplasmonic sensing spots in microfluidic channel arrays and demonstrated parallel multiplex immunoassays of six cytokines in a complex serum matrix on a single device chip while overcoming technical limitations. The device was fabricated using easy-to-implement, one-step microfluidic patterning and antibody conjugation of gold nanorods (AuNRs). When scanning the scattering light intensity across the microarrays of AuNR ensembles with dark-field imaging optics, our LSPR biosensing technique allowed for high-sensitivity quantitative cytokine measurements at concentrations down to 5-20 pg/mL from a 1 μL serum sample. Using the nanoplasmonic biosensor microarray device, we demonstrated the ability to monitor the inflammatory responses of infants following cardiopulmonary bypass (CPB) surgery through tracking the time-course variations of their serum cytokines. The whole parallel on-chip assays, which involved the loading, incubation, and washing of samples and reagents, and 10-fold replicated multianalyte detection for each sample using the entire biosensor arrays, were completed within 40 min.
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Affiliation(s)
- Pengyu Chen
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Meng Ting Chung
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Walker McHugh
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Robert Nidetz
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Yuwei Li
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Jianping Fu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Timothy T. Cornell
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Thomas P. Shanley
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Katsuo Kurabayashi
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan 48109, United States
- Address correspondence to
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Govindan ML, Kuo KW, Mahani MG, Shanley TP. Refractory hypoxemia caused by hepatopulmonary syndrome: a case report. J Med Case Rep 2014; 8:418. [PMID: 25491238 PMCID: PMC4295258 DOI: 10.1186/1752-1947-8-418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/17/2014] [Indexed: 02/06/2023] Open
Abstract
Introduction Hepatopulmonary syndrome is a clinical syndrome that can affect patients of all ages with liver disease and is more common in children with biliary atresia. Contrast echocardiography is the test of choice to diagnose the presence of intrapulmonary vascular dilatation. The established treatment for hepatopulmonary syndrome is liver transplantation. Case presentation We present the case of an 8-month-old Caucasian baby boy with a history of biliary atresia, polysplenia, and interrupted inferior vena cava who presented with hypoxemia and cyanosis that progressed rapidly. A chest computed tomography angiogram revealed significant dilatation of the pulmonary vasculature, prompting further evaluation and diagnosis of hepatopulmonary syndrome with contrast echocardiography. He was maintained on a milrinone infusion while awaiting liver transplantation. His hypoxemia improved slowly following liver transplantation, requiring tracheostomy and prolonged ventilator dependence. Conclusions Hepatopulmonary syndrome should be included in the differential for progressive hypoxemia in children with liver disease, particularly those with biliary atresia. Imaging with chest computed tomography angiogram and contrast echocardiography should be considered in cases of unexplained refractory hypoxemia.
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Affiliation(s)
- Morgen L Govindan
- Department of Pediatrics and Communicable Diseases, C,S, Mott Children's Hospital, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, USA.
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27
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Weiss SL, Cvijanovich NZ, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Shanley TP, Bigham MT, Fitzgerald J, Banschbach S, Beckman E, Howard K, Frank E, Harmon K, Wong HR. Differential expression of the nuclear-encoded mitochondrial transcriptome in pediatric septic shock. Crit Care 2014; 18:623. [PMID: 25410281 PMCID: PMC4247726 DOI: 10.1186/s13054-014-0623-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 10/28/2014] [Indexed: 01/09/2023]
Abstract
Introduction Increasing evidence supports a role for mitochondrial dysfunction in organ injury and immune dysregulation in sepsis. Although differential expression of mitochondrial genes in blood cells has been reported for several diseases in which bioenergetic failure is a postulated mechanism, there are no data about the blood cell mitochondrial transcriptome in pediatric sepsis. Methods We conducted a focused analysis using a multicenter genome-wide expression database of 180 children ≤10 years of age with septic shock and 53 healthy controls. Using total RNA isolated from whole blood within 24 hours of PICU admission for septic shock, we evaluated 296 nuclear-encoded mitochondrial genes using a false discovery rate of 1%. A series of bioinformatic approaches were applied to compare differentially expressed genes across previously validated gene expression-based subclasses (groups A, B, and C) of pediatric septic shock. Results In total, 118 genes were differentially regulated in subjects with septic shock compared to healthy controls, including 48 genes that were upregulated and 70 that were downregulated. The top scoring canonical pathway was oxidative phosphorylation, with general downregulation of the 51 genes corresponding to the electron transport system (ETS). The top two gene networks were composed primarily of mitochondrial ribosomal proteins highly connected to ETS complex I, and genes encoding for ETS complexes I, II, and IV that were highly connected to the peroxisome proliferator activated receptor (PPAR) family. There were 162 mitochondrial genes differentially regulated between groups A, B, and C. Group A, which had the highest maximum number of organ failures and mortality, exhibited a greater downregulation of mitochondrial genes compared to groups B and C. Conclusions Based on a focused analysis of a pediatric septic shock transcriptomic database, nuclear-encoded mitochondrial genes were differentially regulated early in pediatric septic shock compared to healthy controls, as well as across genotypic and phenotypic distinct pediatric septic shock subclasses. The nuclear genome may be an important mechanism contributing to alterations in mitochondrial bioenergetic function and outcomes in pediatric sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0623-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Scott L Weiss
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA. .,Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.
| | - Natalie Z Cvijanovich
- UCSF Benioff Children's Hospital Oakland, 1411 East 31st Street, Oakland, CA, 94602, USA.
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Neal J Thomas
- Penn State Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA.
| | - Robert J Freishtat
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010, USA.
| | - Nick Anas
- Children's Hospital of Orange County, 1201 W La Veta Avenue, Orange, CA, 92868, USA.
| | - Keith Meyer
- Miami Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
| | - Paul A Checchia
- Texas Children's Hospital, 6621 Fannin Street, Houston, TX, 77030, USA.
| | - Thomas P Shanley
- CS Mott Children's Hospital at the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109, USA.
| | - Michael T Bigham
- Akron Children's Hospital, 1 Perkins Square, Akron, OH, 44302, USA.
| | - Julie Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.
| | - Sharon Banschbach
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Eileen Beckman
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Kelli Howard
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Erin Frank
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA.
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Atkinson SJ, Cvijanovich NZ, Thomas NJ, Allen GL, Anas N, Bigham MT, Hall M, Freishtat RJ, Sen A, Meyer K, Checchia PA, Shanley TP, Nowak J, Quasney M, Weiss SL, Banschbach S, Beckman E, Howard K, Frank E, Harmon K, Lahni P, Lindsell CJ, Wong HR. Corticosteroids and pediatric septic shock outcomes: a risk stratified analysis. PLoS One 2014; 9:e112702. [PMID: 25386653 PMCID: PMC4227847 DOI: 10.1371/journal.pone.0112702] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/09/2014] [Indexed: 12/17/2022] Open
Abstract
Background The potential benefits of corticosteroids for septic shock may depend on initial mortality risk. Objective We determined associations between corticosteroids and outcomes in children with septic shock who were stratified by initial mortality risk. Methods We conducted a retrospective analysis of an ongoing, multi-center pediatric septic shock clinical and biological database. Using a validated biomarker-based stratification tool (PERSEVERE), 496 subjects were stratified into three initial mortality risk strata (low, intermediate, and high). Subjects receiving corticosteroids during the initial 7 days of admission (n = 252) were compared to subjects who did not receive corticosteroids (n = 244). Logistic regression was used to model the effects of corticosteroids on 28-day mortality and complicated course, defined as death within 28 days or persistence of two or more organ failures at 7 days. Results Subjects who received corticosteroids had greater organ failure burden, higher illness severity, higher mortality, and a greater requirement for vasoactive medications, compared to subjects who did not receive corticosteroids. PERSEVERE-based mortality risk did not differ between the two groups. For the entire cohort, corticosteroids were associated with increased risk of mortality (OR 2.3, 95% CI 1.3–4.0, p = 0.004) and a complicated course (OR 1.7, 95% CI 1.1–2.5, p = 0.012). Within each PERSEVERE-based stratum, corticosteroid administration was not associated with improved outcomes. Similarly, corticosteroid administration was not associated with improved outcomes among patients with no comorbidities, nor in groups of patients stratified by PRISM. Conclusions Risk stratified analysis failed to demonstrate any benefit from corticosteroids in this pediatric septic shock cohort.
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Affiliation(s)
- Sarah J. Atkinson
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Department of Surgery, University of Cincinnati, Cincinnati, OH, United States of America
| | | | - Neal J. Thomas
- Penn State Hershey Children’s Hospital, Hershey, PA, United States of America
| | - Geoffrey L. Allen
- Children’s Mercy Hospital, Kansas City, MO, United States of America
| | - Nick Anas
- Children’s Hospital of Orange County, Orange, CA, United States of America
| | | | - Mark Hall
- Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Robert J. Freishtat
- Children’s National Medical Center, Washington, DC, United States of America
| | - Anita Sen
- Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY, United States of America
| | - Keith Meyer
- Miami Children’s Hospital, Miami, FL, United States of America
| | - Paul A. Checchia
- Texas Children’s Hospital, Houston, TX, United States of America
| | - Thomas P. Shanley
- C. S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI, United States of America
| | - Jeffrey Nowak
- Children’s Hospital and Clinics of Minnesota, Minneapolis, MN, United States of America
| | - Michael Quasney
- C. S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI, United States of America
| | - Scott L. Weiss
- The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Sharon Banschbach
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Eileen Beckman
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Kelli Howard
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Erin Frank
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Christopher J. Lindsell
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- * E-mail:
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Selewski DT, Cornell TT, Heung M, Troost JP, Ehrmann BJ, Lombel RM, Blatt NB, Luckritz K, Hieber S, Gajarski R, Kershaw DB, Shanley TP, Gipson DS. Validation of the KDIGO acute kidney injury criteria in a pediatric critical care population. Intensive Care Med 2014; 40:1481-8. [DOI: 10.1007/s00134-014-3391-8] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 07/01/2014] [Indexed: 12/16/2022]
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30
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Wong HR, Cvijanovich NZ, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Weiss SL, Shanley TP, Bigham MT, Banschbach S, Beckman E, Harmon K, Zimmerman JJ. Corticosteroids are associated with repression of adaptive immunity gene programs in pediatric septic shock. Am J Respir Crit Care Med 2014; 189:940-6. [PMID: 24650276 DOI: 10.1164/rccm.201401-0171oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Corticosteroids are prescribed commonly for patients with septic shock, but their use remains controversial and concerns remain regarding side effects. OBJECTIVES To determine the effect of adjunctive corticosteroids on the genomic response of pediatric septic shock. METHODS We retrospectively analyzed an existing transcriptomic database of pediatric septic shock. Subjects receiving any formulation of systemic corticosteroids at the time of blood draw for microarray analysis were classified in the septic shock corticosteroid group. We compared normal control subjects (n = 52), a septic shock no corticosteroid group (n = 110), and a septic shock corticosteroid group (n = 70) using analysis of variance. Genes differentially regulated between the no corticosteroid group and the corticosteroid group were analyzed using Ingenuity Pathway Analysis. MEASUREMENTS AND MAIN RESULTS The two study groups did not differ with respect to illness severity, organ failure burden, mortality, or mortality risk. There were 319 gene probes differentially regulated between the no corticosteroid group and the corticosteroid group. These genes corresponded predominately to adaptive immunity-related signaling pathways, and were down-regulated relative to control subjects. Notably, the degree of down-regulation was significantly greater in the corticosteroid group, compared with the no corticosteroid group. A similar pattern was observed for genes corresponding to the glucocorticoid receptor signaling pathway. CONCLUSIONS Administration of corticosteroids in pediatric septic shock is associated with additional repression of genes corresponding to adaptive immunity. These data should be taken into account when considering the benefit to risk ratio of adjunctive corticosteroids for septic shock.
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Affiliation(s)
- Hector R Wong
- 1 Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Oh BR, Huang NT, Chen W, Seo JH, Chen P, Cornell TT, Shanley TP, Fu J, Kurabayashi K. Integrated nanoplasmonic sensing for cellular functional immunoanalysis using human blood. ACS Nano 2014; 8:2667-76. [PMID: 24568576 PMCID: PMC4004291 DOI: 10.1021/nn406370u] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 02/19/2014] [Indexed: 05/18/2023]
Abstract
Localized surface plasmon resonance (LSPR) nanoplasmonic effects allow for label-free, real-time detection of biomolecule binding events on a nanostructured metallic surface with simple optics and sensing tunability. Despite numerous reports on LSPR bionanosensing in the past, no study thus far has applied the technique for a cytokine secretion assay using clinically relevant immune cells from human blood. Cytokine secretion assays, a technique to quantify intercellular-signaling proteins secreted by blood immune cells, allow determination of the functional response of the donor's immune cells, thus providing valuable information about the immune status of the donor. However, implementation of LSPR bionanosensing in cellular functional immunoanalysis based on a cytokine secretion assay poses major challenges primarily owing to its limited sensitivity and a lack of sufficient sample handling capability. In this paper, we have developed a label-free LSPR biosensing technique to detect cell-secreted tumor necrosis factor (TNF)-α cytokines in clinical blood samples. Our approach integrates LSPR bionanosensors in an optofluidic platform that permits trapping and stimulation of target immune cells in a microfluidic chamber with optical access for subsequent cytokine detection. The on-chip spatial confinement of the cells is the key to rapidly increasing a cytokine concentration high enough for detection by the LSPR setup, thereby allowing the assay time and sample volume to be significantly reduced. We have successfully applied this approach first to THP-1 cells and then later to CD45 cells isolated directly from human blood. Our LSPR optofluidics device allows for detection of TNF-α secreted from cells as few as 1000, which translates into a nearly 100 times decrease in sample volume than conventional cytokine secretion assay techniques require. We achieved cellular functional immunoanalysis with a minimal blood sample volume (3 μL) and a total assay time 3 times shorter than that of the conventional enzyme-linked immunosorbent assay (ELISA).
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Affiliation(s)
- Bo-Ram Oh
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Nien-Tsu Huang
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Electrical Engineering, Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Weiqiang Chen
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Jung Hwan Seo
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Mechanical and Design Engineering, Hongik University, Seoul, South Korea
| | - Pengyu Chen
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Timothy T. Cornell
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Thomas P. Shanley
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Jianping Fu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Katsuo Kurabayashi
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan 48109, United States
- Address correspondence to
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Wong HR, Weiss SL, Giuliano JS, Wainwright MS, Cvijanovich NZ, Thomas NJ, Allen GL, Anas N, Bigham MT, Hall M, Freishtat RJ, Sen A, Meyer K, Checchia PA, Shanley TP, Nowak J, Quasney M, Chopra A, Fitzgerald JC, Gedeit R, Banschbach S, Beckman E, Harmon K, Lahni P, Lindsell CJ. The temporal version of the pediatric sepsis biomarker risk model. PLoS One 2014; 9:e92121. [PMID: 24626215 PMCID: PMC3953585 DOI: 10.1371/journal.pone.0092121] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/18/2014] [Indexed: 01/18/2023] Open
Abstract
Background PERSEVERE is a risk model for estimating mortality probability in pediatric septic shock, using five biomarkers measured within 24 hours of clinical presentation. Objective Here, we derive and test a temporal version of PERSEVERE (tPERSEVERE) that considers biomarker values at the first and third day following presentation to estimate the probability of a “complicated course”, defined as persistence of ≥2 organ failures at seven days after meeting criteria for septic shock, or death within 28 days. Methods Biomarkers were measured in the derivation cohort (n = 225) using serum samples obtained during days 1 and 3 of septic shock. Classification and Regression Tree (CART) analysis was used to derive a model to estimate the risk of a complicated course. The derived model was validated in the test cohort (n = 74), and subsequently updated using the combined derivation and test cohorts. Results A complicated course occurred in 23% of the derivation cohort subjects. The derived model had a sensitivity for a complicated course of 90% (95% CI 78–96), specificity was 70% (62–77), positive predictive value was 47% (37–58), and negative predictive value was 96% (91–99). The area under the receiver operating characteristic curve was 0.85 (0.79–0.90). Similar test characteristics were observed in the test cohort. The updated model had a sensitivity of 91% (81–96), a specificity of 70% (64–76), a positive predictive value of 47% (39–56), and a negative predictive value of 96% (92–99). Conclusions tPERSEVERE reasonably estimates the probability of a complicated course in children with septic shock. tPERSEVERE could potentially serve as an adjunct to physiological assessments for monitoring how risk for poor outcomes changes during early interventions in pediatric septic shock.
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Affiliation(s)
- Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Scott L. Weiss
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - John S. Giuliano
- Division of Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Mark S. Wainwright
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States of America
| | - Natalie Z. Cvijanovich
- Children’s Hospital and Research Center Oakland, Oakland, California, United States of America
| | - Neal J. Thomas
- Penn State Hershey Children’s Hospital, Hershey, Pennsylvania, United States of America
| | - Geoffrey L. Allen
- Children’s Mercy Hospital, Kansas City, Missouri, United States of America
| | - Nick Anas
- Children’s Hospital of Orange County, Orange, California, United States of America
| | | | - Mark Hall
- Nationwide Children’s Hospital, Columbus, Ohio, United States of America
| | - Robert J. Freishtat
- Children’s National Medical Center, Washington, DC, United States of America
| | - Anita Sen
- Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York, United States of America
| | - Keith Meyer
- Miami Children’s Hospital, Miami, Florida, United States of America
| | - Paul A. Checchia
- Texas Children’s Hospital, Houston, Texas, United States of America
| | - Thomas P. Shanley
- CS Mott Children’s Hospital at the University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jeffrey Nowak
- Children’s Hospital and Clinics of Minnesota, Minneapolis, Minnesota, United States of America
| | - Michael Quasney
- CS Mott Children’s Hospital at the University of Michigan, Ann Arbor, Michigan, United States of America
| | - Arun Chopra
- St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania, United States of America
| | - Julie C. Fitzgerald
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Rainer Gedeit
- Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Sharon Banschbach
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, Ohio, United States of America
| | - Eileen Beckman
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, Ohio, United States of America
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, Ohio, United States of America
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, Ohio, United States of America
| | - Christopher J. Lindsell
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
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33
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Wong HR, Weiss SL, Giuliano JS, Wainwright MS, Cvijanovich NZ, Thomas NJ, Allen GL, Anas N, Bigham MT, Hall M, Freishtat RJ, Sen A, Meyer K, Checchia PA, Shanley TP, Nowak J, Quasney M, Chopra A, Fitzgerald JC, Gedeit R, Banschbach S, Beckman E, Lahni P, Hart K, Lindsell CJ. Testing the prognostic accuracy of the updated pediatric sepsis biomarker risk model. PLoS One 2014; 9:e86242. [PMID: 24489704 PMCID: PMC3906040 DOI: 10.1371/journal.pone.0086242] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/02/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We previously derived and validated a risk model to estimate mortality probability in children with septic shock (PERSEVERE; PEdiatRic SEpsis biomarkEr Risk modEl). PERSEVERE uses five biomarkers and age to estimate mortality probability. After the initial derivation and validation of PERSEVERE, we combined the derivation and validation cohorts (n = 355) and updated PERSEVERE. An important step in the development of updated risk models is to test their accuracy using an independent test cohort. OBJECTIVE To test the prognostic accuracy of the updated version PERSEVERE in an independent test cohort. METHODS Study subjects were recruited from multiple pediatric intensive care units in the United States. Biomarkers were measured in 182 pediatric subjects with septic shock using serum samples obtained during the first 24 hours of presentation. The accuracy of PERSEVERE 28-day mortality risk estimate was tested using diagnostic test statistics, and the net reclassification improvement (NRI) was used to test whether PERSEVERE adds information to a physiology-based scoring system. RESULTS Mortality in the test cohort was 13.2%. Using a risk cut-off of 2.5%, the sensitivity of PERSEVERE for mortality was 83% (95% CI 62-95), specificity was 75% (68-82), positive predictive value was 34% (22-47), and negative predictive value was 97% (91-99). The area under the receiver operating characteristic curve was 0.81 (0.70-0.92). The false positive subjects had a greater degree of organ failure burden and longer intensive care unit length of stay, compared to the true negative subjects. When adding PERSEVERE to a physiology-based scoring system, the net reclassification improvement was 0.91 (0.47-1.35; p<0.001). CONCLUSIONS The updated version of PERSEVERE estimates mortality probability reliably in a heterogeneous test cohort of children with septic shock and provides information over and above a physiology-based scoring system.
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Affiliation(s)
- Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Scott L. Weiss
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - John S. Giuliano
- Department of Pediatrics, Division of Critical Care Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Mark S. Wainwright
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, United States of America
| | - Natalie Z. Cvijanovich
- Children's Hospital and Research Center Oakland, Oakland, California, United States of America
| | - Neal J. Thomas
- Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States of America
| | - Geoffrey L. Allen
- Children's Mercy Hospital, Kansas City, Missouri, United States of America
| | - Nick Anas
- Children's Hospital of Orange County, Orange, California, United States of America
| | | | - Mark Hall
- Nationwide Children's Hospital, Columbus, Ohio, United States of America
| | - Robert J. Freishtat
- Children's National Medical Center, Washington, DC, United States of America
| | - Anita Sen
- Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, United States of America
| | - Keith Meyer
- Miami Children's Hospital, Miami, Florida, United States of America
| | - Paul A. Checchia
- Texas Children's Hospital, Houston, Texas, United States of America
| | - Thomas P. Shanley
- CS Mott Children's Hospital at the University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota, United States of America
| | - Michael Quasney
- CS Mott Children's Hospital at the University of Michigan, Ann Arbor, Michigan, United States of America
| | - Arun Chopra
- St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States of America
| | - Julie C. Fitzgerald
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Rainer Gedeit
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Sharon Banschbach
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio, United States of America
| | - Eileen Beckman
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio, United States of America
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio, United States of America
| | - Kimberly Hart
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Christopher J. Lindsell
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
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Abstract
Because of its multi-organ involvement, the syndrome of sepsis provides clinical challenges to a wide variety of health care providers. While multi-organ dysfunction triggered by sepsis requires general supportive critical care provided by intensivists, the impact of sepsis on renal function and the ability of renal replacement therapies to modulate its biologic consequences provide a significant opportunity for pediatric nephrologists and related care providers to impact outcomes. In this review, we aim to highlight newer areas of understanding of the pathobiology of sepsis with special emphasis on those aspects of particular interest to pediatric nephrology. As such, we aim to: (1) review the definition of sepsis and discuss advances in our mechanistic understanding of sepsis; (2) review current hypotheses regarding sepsis-induced acute kidney injury (AKI) and describe its epidemiology based on evolving definitions of AKI; (3) review the impact of renal failure on the immune system, highlighting the sepsis risk in this cohort and strategies that might minimize this risk; (4) review how renal replacement therapeutic strategies may impact sepsis-induced AKI outcomes. By focusing the review on these specific areas, we have omitted other important areas of the biology of sepsis and additional interactions with renal function from this discussion; however, we have aimed to provide a comprehensive list of references that provide contemporary reviews of these additional areas.
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Affiliation(s)
- Neal B. Blatt
- Division of Pediatric Nephrology, C.S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI USA
| | - Sushant Srinivasan
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Theresa Mottes
- Division of Pediatric Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Maureen M. Shanley
- Division of Pediatric Nephrology, C.S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI USA
| | - Thomas P. Shanley
- Division of Pediatric Critical Care Medicine, C.S. Mott Children’s Hospital at the University of Michigan, Building 400 2800 Plymouth Road, Ann Arbor, MI 48109 USA
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Chen W, Huang NT, Oh B, Lam RHW, Fan R, Cornell TT, Shanley TP, Kurabayashi K, Fu J. Cell Assays: Surface-Micromachined Microfiltration Membranes for Efficient Isolation and Functional Immunophenotyping of Subpopulations of Immune Cells (Adv. Healthcare Mater. 7/2013). Adv Healthc Mater 2013. [DOI: 10.1002/adhm.201370035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Chen W, Huang NT, Oh B, Lam RHW, Fan R, Cornell TT, Shanley TP, Kurabayashi K, Fu J. Surface-micromachined microfiltration membranes for efficient isolation and functional immunophenotyping of subpopulations of immune cells. Adv Healthc Mater 2013; 2:965-975. [PMID: 23335389 DOI: 10.1002/adhm.201200378] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Indexed: 01/02/2023]
Abstract
An accurate measurement of the immune status in patients with immune system disorders is critical in evaluating the stage of diseases and tailoring drug treatments. The functional cellular immunity test is a promising method to establish the diagnosis of immune dysfunctions. The conventional functional cellular immunity test involves measurements of the capacity of peripheral blood mononuclear cells to produce pro-inflammatory cytokines when stimulated ex vivo. However, this "bulk" assay measures the overall reactivity of a population of lymphocytes and monocytes, making it difficult to pinpoint the phenotype or real identity of the reactive immune cells involved. In this research, we develop a large surface micromachined poly-dimethylsiloxane (PDMS) microfiltration membrane (PMM) with high porosity, which is integrated in a microfluidic microfiltration platform. Using the PMM with functionalized microbeads conjugated with antibodies against specific cell surface proteins, we demonstrated rapid, efficient and high-throughput on-chip isolation, enrichment, and stimulation of subpopulations of immune cells from blood specimens. Furthermore, the PMM-integrated microfiltration platform, coupled with a no-wash homogeneous chemiluminescence assay ("AlphaLISA"), enables us to demonstrate rapid and sensitive on-chip immunophenotyping assays for subpopulations of immune cells isolated directly from minute quantities of blood samples.
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Affiliation(s)
- Weiqiang Chen
- Department of Mechanical Engineering University of Michigan Ann Arbor, MI 48109 USA
| | - Nien-Tsu Huang
- Department of Mechanical Engineering University of Michigan Ann Arbor, MI 48109 USA
| | - Boram Oh
- Department of Mechanical Engineering University of Michigan Ann Arbor, MI 48109 USA
| | - Raymond H W Lam
- Department of Mechanical and Biomedical Engineering City University of Hong Kong, Hong Kong, China
| | - Rong Fan
- Department of Biomedical Engineering Yale University New Haven, CT 06511, USA
| | - Timothy T Cornell
- Department of Pediatrics and Communicable Diseases University of Michigan, Ann Arbor, MI 48109, USA
| | - Thomas P Shanley
- Department of Pediatrics and Communicable Diseases University of Michigan, Ann Arbor, MI 48109, USA
| | - Katsuo Kurabayashi
- Department of Mechanical Engineering University of Michigan Ann Arbor, MI 48109 USA
| | - Jianping Fu
- Department of Mechanical Engineering University of Michigan Ann Arbor, MI 48109 USA
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Sun L, Cornell TT, LeVine A, Berlin AA, Hinkovska-Galcheva V, Fleszar AJ, Lukacs NW, Shanley TP. Dual role of interleukin-10 in the regulation of respiratory syncitial virus (RSV)-induced lung inflammation. Clin Exp Immunol 2013; 172:263-79. [PMID: 23574323 DOI: 10.1111/cei.12059] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 12/23/2022] Open
Abstract
RSV lower respiratory tract infections (LRTI) are among the most common diseases necessitating hospital admission in children. In addition to causing acute respiratory failure, RSV infections are associated with sequelae such as secondary bacterial infections and reactive airway disease. One characteristic host response observed in severe RSV-induced LRTI and/or subsequent development of asthma is increased expression of interleukin (IL)-10. However, contradictory results have been reported regarding whether IL-10 inhibits asthmatic responses or intensifies the disease. We aimed to reconcile these discordant observations by elucidating the role of IL-10 in regulating the host response to RSV LRTI. In this study, we used a lung-specific, inducible IL-10 over-expression (OE) transgenic mouse model to address this question. Our results showed that the presence of IL-10 at the time of RSV infection not only attenuated acute inflammatory process (i.e. 24 h post-infection), but also late inflammatory changes [characterized by T helper type 2 (Th2) cytokine and chemokine expression]. While this result appears contradictory to some clinical observations where elevated IL-10 levels are observed in asthmatic patients, we also found that delaying IL-10 OE until the late immune response to RSV infection, additive effects rather than inhibitory effects were observed. Importantly, in non-infected, IL-10 OE mice, IL-10 OE alone induced up-regulation of Th2 cytokine (IL-13 and IL-5) and Th2-related chemokine [monocyte chemoattractant protein 1 (MCP-1), chemokine (C-C motif) ligand 3 (CCL3) and regulated upon activation normal T cell expressed and secreted (RANTES)] expression. We identified a subset of CD11b(+)CD11c(+)CD49b(+)F4/80(-)Gr-1(-) myeloid cells as a prinicipal source of IL-10-induced IL-13 production. Therefore, the augmented pathological responses observed in our 'delayed' IL-10 over-expression model could be attributed to IL-10 OE alone. Taken together, our study indicated dual roles of IL-10 on RSV-induced lung inflammation which appear to depend upon the timing of when elevated IL-10 is expressed in the lung.
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Affiliation(s)
- L Sun
- Division of Critical Care Medicine, C.S Mott Children's Hospital and Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Kuo KW, Cornell TT, Shanley TP, Odetola FO, Annich GM. The use of extracorporeal membrane oxygenation in pediatric patients with sickle cell disease. Perfusion 2013; 28:424-32. [PMID: 23630196 DOI: 10.1177/0267659113485873] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous reports have described the use of extracorporeal membrane oxygenation (ECMO) for acute chest syndrome of sickle cell disease (SCD). However, there have been no reports of venoarterial (VA) ECMO for cardiac dysfunction in patients with SCD. We describe a patient with SCD and life-threatening cardiogenic shock who was successfully treated with VA ECMO. Furthermore, SCD patients have unique comorbidities that warrant particular consideration when utilizing ECMO. We discuss these considerations and review the documented experience with ECMO for pediatric SCD patients from the Extracorporeal Life Support Organization (ELSO) registry. From 1990 until 2012, 52% of the 65 pediatric patients with SCD placed on ECMO survived, with 85% of those receiving venovenous (VV) ECMO surviving and 43% of those receiving VA ECMO surviving. However, significant complications, such as bleeding, neurological injury and kidney injury, also occurred with both VV and VA ECMO. Ten percent of SCD patients receiving VA ECMO experienced either a cerebral infarct or hemorrhage; our patient suffered a cerebrovascular accident while on ECMO, though she survived with good neurologic outcome. To our knowledge, this is the first report of a pediatric patient with SCD and cardiogenic shock successfully managed with VA ECMO. In conjunction with the ELSO registry review, this case report suggests that, while VA ECMO can be successfully used in patients with SCD and severe cardiovascular dysfunction, clinicians should also be aware of the potential for serious complications in this high-risk population.
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Affiliation(s)
- K W Kuo
- Department of Pediatrics and Communicable Diseases, Division of Critical Care, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI 48109, USA.
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Ray D, Shukla S, Allam US, Helman A, Ramanand SG, Tran L, Bassetti M, Krishnamurthy PM, Rumschlag M, Paulsen M, Sun L, Shanley TP, Ljungman M, Nyati MK, Zhang M, Lawrence TS. Tristetraprolin mediates radiation-induced TNF-α production in lung macrophages. PLoS One 2013; 8:e57290. [PMID: 23468959 PMCID: PMC3585360 DOI: 10.1371/journal.pone.0057290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 01/20/2013] [Indexed: 12/26/2022] Open
Abstract
The efficacy of radiation therapy for lung cancer is limited by radiation-induced lung toxicity (RILT). Although tumor necrosis factor-alpha (TNF-α) signaling plays a critical role in RILT, the molecular regulators of radiation-induced TNF-α production remain unknown. We investigated the role of a major TNF-α regulator, Tristetraprolin (TTP), in radiation-induced TNF-α production by macrophages. For in vitro studies we irradiated (4 Gy) either a mouse lung macrophage cell line, MH-S or macrophages isolated from TTP knockout mice, and studied the effects of radiation on TTP and TNF-α levels. To study the in vivo relevance, mouse lungs were irradiated with a single dose (15 Gy) and assessed at varying times for TTP alterations. Irradiation of MH-S cells caused TTP to undergo an inhibitory phosphorylation at Ser-178 and proteasome-mediated degradation, which resulted in increased TNF-α mRNA stabilization and secretion. Similarly, MH-S cells treated with TTP siRNA or macrophages isolated from ttp (−/−) mice had higher basal levels of TNF-α, which was increased minimally after irradiation. Conversely, cells overexpressing TTP mutants defective in undergoing phosphorylation released significantly lower levels of TNF-α. Inhibition of p38, a known kinase for TTP, by either siRNA or a small molecule inhibitor abrogated radiation-induced TNF-α release by MH-S cells. Lung irradiation induced TTPSer178 phosphorylation and protein degradation and a simultaneous increase in TNF-α production in C57BL/6 mice starting 24 h post-radiation. In conclusion, irradiation of lung macrophages causes TTP inactivation via p38-mediated phosphorylation and proteasome-mediated degradation, leading to TNF-α production. These findings suggest that agents capable of blocking TTP phosphorylation or stabilizing TTP after irradiation could decrease RILT.
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Affiliation(s)
- Dipankar Ray
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States of America.
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Davis MM, Clark SJ, Butchart AT, Singer DC, Shanley TP, Gipson DS. Public participation in, and awareness about, medical research opportunities in the era of clinical and translational research. Clin Transl Sci 2013; 6:88-93. [PMID: 23601336 DOI: 10.1111/cts.12019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
CONTEXT In the United States, levels of public participation in medical research in the era of Clinical and Translational Science Awards (CTSAs) are unknown. METHODS In 2011, a household survey was administered to a sample of U.S. adults, asking whether they (and children <18 years old) had participated, or were aware of opportunities to participate, in medical research. Respondents living within 100 miles of CTSA sites were identified. Regression analyses of participation and awareness (PA) were performed, applying sampling weights to permit nationally representative inferences. RESULTS Overall, 2,150 individuals responded (completion rate = 60%); 65% of adults and 63% of families with children resided within 100 miles of ≥1 CTSA location. Research participation rates were 11% among adults and 5% among children. Among nonparticipants, awareness rates were 64% among adults and 12% among parents of children. PA among adults was associated with higher income and education, older age, presence of chronic conditions, and living within 100 miles of four specific CTSA locations. For children, PA was associated with higher household income and parents' chronic health conditions. CONCLUSIONS PA of medical research opportunities is substantially higher for adults than children. Higher PA levels near specific CTSAs merit investigation to identify their successful approaches.
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Affiliation(s)
- Matthew M Davis
- Division of General Pediatrics, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Wong HR, Cvijanovich NZ, Hall M, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Lin R, Bigham MT, Sen A, Nowak J, Quasney M, Henricksen JW, Chopra A, Banschbach S, Beckman E, Harmon K, Lahni P, Shanley TP. Interleukin-27 is a novel candidate diagnostic biomarker for bacterial infection in critically ill children. Crit Care 2012; 16:R213. [PMID: 23107287 PMCID: PMC3682317 DOI: 10.1186/cc11847] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 10/26/2012] [Indexed: 02/16/2023]
Abstract
Introduction Differentiating between sterile inflammation and bacterial infection in critically ill patients with fever and other signs of the systemic inflammatory response syndrome (SIRS) remains a clinical challenge. The objective of our study was to mine an existing genome-wide expression database for the discovery of candidate diagnostic biomarkers to predict the presence of bacterial infection in critically ill children. Methods Genome-wide expression data were compared between patients with SIRS having negative bacterial cultures (n = 21) and patients with sepsis having positive bacterial cultures (n = 60). Differentially expressed genes were subjected to a leave-one-out cross-validation (LOOCV) procedure to predict SIRS or sepsis classes. Serum concentrations of interleukin-27 (IL-27) and procalcitonin (PCT) were compared between 101 patients with SIRS and 130 patients with sepsis. All data represent the first 24 hours of meeting criteria for either SIRS or sepsis. Results Two hundred twenty one gene probes were differentially regulated between patients with SIRS and patients with sepsis. The LOOCV procedure correctly predicted 86% of the SIRS and sepsis classes, and Epstein-Barr virus-induced gene 3 (EBI3) had the highest predictive strength. Computer-assisted image analyses of gene-expression mosaics were able to predict infection with a specificity of 90% and a positive predictive value of 94%. Because EBI3 is a subunit of the heterodimeric cytokine, IL-27, we tested the ability of serum IL-27 protein concentrations to predict infection. At a cut-point value of ≥5 ng/ml, serum IL-27 protein concentrations predicted infection with a specificity and a positive predictive value of >90%, and the overall performance of IL-27 was generally better than that of PCT. A decision tree combining IL-27 and PCT improved overall predictive capacity compared with that of either biomarker alone. Conclusions Genome-wide expression analysis has provided the foundation for the identification of IL-27 as a novel candidate diagnostic biomarker for predicting bacterial infection in critically ill children. Additional studies will be required to test further the diagnostic performance of IL-27. The microarray data reported in this article have been deposited in the Gene Expression Omnibus under accession number GSE4607.
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Huang NT, Chen W, Oh BR, Cornell TT, Shanley TP, Fu J, Kurabayashi K. An integrated microfluidic platform for in situ cellular cytokine secretion immunophenotyping. Lab Chip 2012; 12:4093-101. [PMID: 22892681 PMCID: PMC3508001 DOI: 10.1039/c2lc40619e] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Rapid, quantitative detection of cell-secreted biomarker proteins with a low sample volume holds great promise to advance cellular immunophenotyping techniques for personalized diagnosis and treatment of infectious diseases. Here we achieved such an assay with the THP-1 human acute moncytic leukemia cell line (a model for human monocyte) using a highly integrated microfluidic platform incorporating a no-wash bead-based chemiluminescence immunodetection scheme. Our microfluidic device allowed us to stimulate cells with lipopolysaccharide (LPS), which is an endotoxin causing septic shock due to severely pronounced immune response of the human body, under a well-controlled on-chip environment. Tumor necrosis factor-alpha (TNF-α) secreted from stimulated THP-1 cells was subsequently measured within the device with no flushing process required. Our study achieved high-sensitivity cellular immunophenotyping with 20-fold fewer cells than current cell-stimulation assay. The total assay time was also 7 times shorter than that of a conventional enzyme-linked immunosorbent assay (ELISA). Our strategy of monitoring immune cell functions in situ using a microfluidic platform could impact future medical treatments of acute infectious diseases and immune disorders by enabling a rapid, sample-efficient cellular immunophenotyping analysis.
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Affiliation(s)
- Nien-Tsu Huang
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | - Weiqiang Chen
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, 48109, USA
- Integrated Biosystems and Biomechanics Laboratory, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | - Bo-Ram Oh
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | - Timothy T. Cornell
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | - Thomas P. Shanley
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | - Jianping Fu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, 48109, USA
- Integrated Biosystems and Biomechanics Laboratory, University of Michigan, Ann Arbor, Michigan, 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | - Katsuo Kurabayashi
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, 48109, USA
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan, 48109, USA
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Wong HR, Salisbury S, Xiao Q, Cvijanovich NZ, Hall M, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Lin R, Shanley TP, Bigham MT, Sen A, Nowak J, Quasney M, Henricksen JW, Chopra A, Banschbach S, Beckman E, Harmon K, Lahni P, Lindsell CJ. The pediatric sepsis biomarker risk model. Crit Care 2012; 16:R174. [PMID: 23025259 PMCID: PMC3682273 DOI: 10.1186/cc11652] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 10/01/2012] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The intrinsic heterogeneity of clinical septic shock is a major challenge. For clinical trials, individual patient management, and quality improvement efforts, it is unclear which patients are least likely to survive and thus benefit from alternative treatment approaches. A robust risk stratification tool would greatly aid decision-making. The objective of our study was to derive and test a multi-biomarker-based risk model to predict outcome in pediatric septic shock. METHODS Twelve candidate serum protein stratification biomarkers were identified from previous genome-wide expression profiling. To derive the risk stratification tool, biomarkers were measured in serum samples from 220 unselected children with septic shock, obtained during the first 24 hours of admission to the intensive care unit. Classification and Regression Tree (CART) analysis was used to generate a decision tree to predict 28-day all-cause mortality based on both biomarkers and clinical variables. The derived tree was subsequently tested in an independent cohort of 135 children with septic shock. RESULTS The derived decision tree included five biomarkers. In the derivation cohort, sensitivity for mortality was 91% (95% CI 70 - 98), specificity was 86% (80 - 90), positive predictive value was 43% (29 - 58), and negative predictive value was 99% (95 - 100). When applied to the test cohort, sensitivity was 89% (64 - 98) and specificity was 64% (55 - 73). In an updated model including all 355 subjects in the combined derivation and test cohorts, sensitivity for mortality was 93% (79 - 98), specificity was 74% (69 - 79), positive predictive value was 32% (24 - 41), and negative predictive value was 99% (96 - 100). False positive subjects in the updated model had greater illness severity compared to the true negative subjects, as measured by persistence of organ failure, length of stay, and intensive care unit free days. CONCLUSIONS The pediatric sepsis biomarker risk model (PERSEVERE; PEdiatRic SEpsis biomarkEr Risk modEl) reliably identifies children at risk of death and greater illness severity from pediatric septic shock. PERSEVERE has the potential to substantially enhance clinical decision making, to adjust for risk in clinical trials, and to serve as a septic shock-specific quality metric.
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Newth CJL, Meert KL, Clark AE, Moler FW, Zuppa AF, Berg RA, Pollack MM, Sward KA, Berger JT, Wessel DL, Harrison RE, Reardon J, Carcillo JA, Shanley TP, Holubkov R, Dean JM, Doctor A, Nicholson CE. Fatal and near-fatal asthma in children: the critical care perspective. J Pediatr 2012; 161:214-21.e3. [PMID: 22494876 PMCID: PMC3402707 DOI: 10.1016/j.jpeds.2012.02.041] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 01/10/2012] [Accepted: 02/23/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize the clinical course, therapies, and outcomes of children with fatal and near-fatal asthma admitted to pediatric intensive care units (PICUs). STUDY DESIGN This was a retrospective chart abstraction across the 8 tertiary care PICUs of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Inclusion criteria were children (aged 1-18 years) admitted between 2005 and 2009 (inclusive) for asthma who received ventilation (near-fatal) or died (fatal). Data collected included medications, ventilator strategies, concomitant therapies, demographic information, and risk variables. RESULTS Of the 261 eligible children, 33 (13%) had no previous history of asthma, 218 (84%) survived with no known complications, and 32 (12%) had complications. Eleven (4%) died, 10 of whom had experienced cardiac arrest before admission. Patients intubated outside the PICU had a shorter duration of ventilation (median, 25 hours vs 84 hours; P < .001). African-Americans were disproportionately represented among the intubated children and had a shorter duration of intubation. Barotrauma occurred in 15 children (6%) before admission. Pharmacologic therapy was highly variable, with similar outcomes. CONCLUSION Of the children ventilated in the CPCCRN PICUs, 96% survived to hospital discharge. Most of the children who died experienced cardiac arrest before admission. Intubation outside the PICU was correlated with shorter duration of ventilation. Complications of barotrauma and neuromyopathy were uncommon. Practice patterns varied widely among the CPCCRN sites.
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Affiliation(s)
- Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
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Cornell TT, Fleszar A, McHugh W, Blatt NB, Le Vine AM, Shanley TP. Mitogen-activated protein kinase phosphatase 2, MKP-2, regulates early inflammation in acute lung injury. Am J Physiol Lung Cell Mol Physiol 2012; 303:L251-8. [PMID: 22683570 PMCID: PMC3423860 DOI: 10.1152/ajplung.00063.2012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 06/01/2012] [Indexed: 01/11/2023] Open
Abstract
Acute lung injury (ALI) is mediated by an early proinflammatory response resulting from either a direct or indirect insult to the lung mediating neutrophil infiltration and consequent disruption of the alveolar capillary membrane ultimately leading to refractory hypoxemia. The mitogen-activated protein kinase (MAPK) pathways are a key component of the molecular response activated by those insults triggering the proinflammatory response in ALI. The MAPK pathways are counterbalanced by a set of dual-specific phosphatases (DUSP) that deactivate the kinases by removing phosphate groups from tyrosine or threonine residues. We have previously shown that one DUSP, MKP-2, regulates the MAPK pathway in a model of sepsis-induced inflammation; however, the role of MKP-2 in modulating the inflammatory response in ALI has not been previously investigated. We utilized both MKP-2-null (MKP-2(-/-)) mice and MKP-2 knockdown in a murine macrophage cell line to elucidate the role of MKP-2 in regulating inflammation during ALI. Our data demonstrated attenuated proinflammatory cytokine production as well as decreased neutrophil infiltration in the lungs of MKP-2(-/-) mice following direct, intratracheal LPS. Importantly, when challenged with a viable pathogen, this decrease in neutrophil infiltration did not impact the ability of MKP-2(-/-) mice to clear either gram-positive or gram-negative bacteria. Furthermore, MKP-2 knockdown led to an attenuated proinflammatory response and was associated with an increase in phosphorylation of ERK and induction of a related DUSP, MKP-1. These data suggest that altering MKP-2 activity may have therapeutic potential to reduce lung inflammation in ALI without impacting pathogen clearance.
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Affiliation(s)
- Timothy T Cornell
- Division of Pediatric Critical Care Medicine, Dept. of Pediatrics and Communicable Diseases, Univ. of Michigan Medical School, C S Mott Children's Hospital, Ann Arbor, MI 48109-0243, USA.
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Bratton SL, Newth CJL, Zuppa AF, Moler FW, Meert KL, Berg RA, Berger J, Wessel D, Pollack M, Harrison R, Carcillo JA, Shanley TP, Liu T, Holubkov R, Dean JM, Nicholson CE. Critical care for pediatric asthma: wide care variability and challenges for study. Pediatr Crit Care Med 2012; 13:407-14. [PMID: 22067984 PMCID: PMC3298633 DOI: 10.1097/pcc.0b013e318238b428] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe pediatric severe asthma care, complications, and outcomes to plan for future prospective studies by the Collaborative Pediatric Critical Care Research Network. DESIGN Retrospective cohort study. SETTING : Pediatric intensive care units in the United States that submit administrative data to the Pediatric Health Information System. PATIENTS Children 1-18 yrs old treated in a Pediatric Health Information System pediatric intensive care unit for asthma during 2004-2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirteen-thousand five-hundred fifty-two children were studied; 2,812 (21%) were treated in a Collaborative Pediatric Critical Care Research Network and 10,740 (79%) were treated in a non-Collaborative Pediatric Critical Care Research Network pediatric intensive care unit. Medication use in individual Collaborative Pediatric Critical Care Research Network centers differed widely: ipratropium bromide (41%-84%), terbutaline (11%-74%), magnesium sulfate (23%-64%), and methylxanthines (0%-46%). Complications including pneumothorax (0%-0.6%), cardiac arrest (0.2%-2%), and aspiration (0.2%-2%) were rare. Overall use of medical therapies and complications at Collaborative Pediatric Critical Care Research Network centers were representative of pediatric asthma care at non-Collaborative Pediatric Critical Care Research Network pediatric intensive care units. Median length of pediatric intensive care unit stay at Collaborative Pediatric Critical Care Research Network centers was 1 to 2 days and death was rare (0.1%-3%). Ten percent of children treated at Collaborative Pediatric Critical Care Research Network centers received invasive mechanical ventilation compared to 12% at non-Collaborative Pediatric Critical Care Research Network centers. Overall 44% of patients who received invasive mechanical ventilation were intubated in the pediatric intensive care unit. Children intubated outside the pediatric intensive care unit had significantly shorter median ventilation days (1 vs. 3), pediatric intensive care unit days (2 vs. 4), and hospital days (4 vs. 7) compared to those intubated in the pediatric intensive care unit. Among children who received mechanical respiratory support, significantly more (41% vs. 25%) were treated with noninvasive ventilation and significantly fewer (41% vs. 58%) were intubated before pediatric intensive care unit care when treated in a Pediatric Health Information System hospital emergency department. CONCLUSIONS Marked variations in medication therapies and mechanical support exist. Death and other complications were rare. More than half of patients treated with mechanical ventilation were intubated before pediatric intensive care unit care. Site of respiratory mechanical support initiation was associated with length of stay.
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Affiliation(s)
- Susan L Bratton
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
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Huskins WC, Sullivan CD, Wang J, Aitken M, Alexander SR, Epstein L, Hoberman A, Neufeld E, Philipps A, Shanley TP, Szilagyi P, Purucker M, Barkin SL. Tracking the impact of the National Institutes of Health Clinical and Translational Science Awards on child health research: developing and evaluating a measurement strategy. Pediatr Res 2012; 71:619-24. [PMID: 22398699 PMCID: PMC3582389 DOI: 10.1038/pr.2012.5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Since 2006, the National Institutes of Health has provided institutional infrastructure grants, called Clinical and Translational Science Awards (CTSAs), to support adult and pediatric clinical and translational research in United States institutions. A CTSA Consortium Child Health Oversight Committee workgroup developed metrics to measure the impact of CTSAs on child health (CH) research. A cross-sectional survey to collect metric data was distributed to the 46 institutions that received CTSAs during 2006-09. Thirty-seven (80%) institutions responded to the survey. Data regarding 7 metrics were reported by >70% of responding institutions: the proportion of overall funding (median, interquartile range; 0.12, 0.06–0.19) and pilot grants (0.15, 0.11–0.21) supporting CH research; the proportion of active clinical research center studies involving children (0.23, 0.15–0.35); the proportion of IRB-approved (0.24, 0.16–0.30) and funded (0.22, 0.18–0.30) studies involving children; the proportion of mentored research training awards to CH investigators (0.18, 0.11–0.28); and, the proportion of CTSA leadership positions held by pediatricians (0.18, 0.12–0.28). CTSAs provide substantial support for CH research, although additional investment in CH research is needed to improve the health of children. These metrics provide an initial means to track the impact of CTSAs on CH research.
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Affiliation(s)
- W. Charles Huskins
- Corresponding author: Mayo Clinic 200 First Avenue SW Rochester, MN 55905 Tel: 507-255-8464; Fax: 507-255-7767
| | - Clare D. Sullivan
- Vanderbilt Institute for Clinical and Translational Research Nashville, Tennessee 37203
| | - Janey Wang
- Vanderbilt Institute for Clinical and Translational Research Nashville, Tennessee 37203
| | - Mary Aitken
- Arkansas Children’s Hospital Research Institute, Little Rock, Arkansas 72202
| | - Steven R. Alexander
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California 94305
| | - Leon Epstein
- Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15224
| | - Ellis Neufeld
- Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115
| | - Anthony Philipps
- Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California 95817
| | | | - Peter Szilagyi
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry; Rochester, New York 14642
| | - Mary Purucker
- National Center for Research Resources, National Institutes of Health, Bethesda, Maryland 20892
| | - Shari L. Barkin
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee 37232
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Basu RK, Standage SW, Cvijanovich NZ, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Lin R, Shanley TP, Bigham MT, Wheeler DS, Devarajan P, Goldstein SL, Wong HR. Identification of candidate serum biomarkers for severe septic shock-associated kidney injury via microarray. Crit Care 2011; 15:R273. [PMID: 22098946 PMCID: PMC3388679 DOI: 10.1186/cc10554] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 10/10/2011] [Accepted: 11/18/2011] [Indexed: 12/19/2022]
Abstract
Introduction Septic-shock-associated acute kidney injury (SSAKI) carries high morbidity in the pediatric population. Effective treatment strategies are lacking, in part due to poor detection and prediction. There is a need to identify novel candidate biomarkers of SSAKI. The objective of our study was to determine whether microarray data from children with septic shock could be used to derive a panel of candidate biomarkers for predicting SSAKI. Methods A retrospective cohort study compared microarray data representing the first 24 hours of admission for 179 children with septic shock with those of 53 age-matched normal controls. SSAKI was defined as a >200% increase of baseline serum creatinine, persistent to 7 days after admission. Results Patients with SSAKI (n = 31) and patients without SSAKI (n = 148) were clinically similar, but SSAKI carried a higher mortality (45% vs. 10%). Twenty-one unique gene probes were upregulated in SSAKI patients versus patients without SSAKI. Using leave-one-out cross-validation and class prediction modeling, these probes predicted SSAKI with a sensitivity of 98% (95% confidence interval (CI) = 81 to 100) and a specificity of 80% (95% CI = 72 to 86). Serum protein levels of two specific genes showed high sensitivity for predicting SSAKI: matrix metalloproteinase-8 (89%, 95% CI = 64 to 98) and elastase-2 (83%, 95% CI = 58 to 96). Both biomarkers carried a negative predictive value of 95%. When applied to a validation cohort, although both biomarkers carried low specificity (matrix metalloproteinase-8: 41%, 95% CI = 28 to 50; and elastase-2: 49%, 95% CI = 36 to 62), they carried high sensitivity (100%, 95% CI = 68 to 100 for both). Conclusions Gene probes upregulated in critically ill pediatric patients with septic shock may allow for the identification of novel candidate serum biomarkers for SSAKI prediction.
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Affiliation(s)
- Rajit K Basu
- Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH 45223, USA
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Cornell TT, Sun L, Hall MW, Gurney JG, Ashbrook MJ, Ohye RG, Shanley TP. Clinical implications and molecular mechanisms of immunoparalysis after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2011; 143:1160-1166.e1. [PMID: 21996297 DOI: 10.1016/j.jtcvs.2011.09.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 07/14/2011] [Accepted: 09/15/2011] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We used a whole blood assay to characterize the immune system's response after cardiopulmonary bypass (CPB) in children to identify the risk for postoperative infections. We assessed the impact of CPB on histone methylation as a potential mechanism for altering gene expression necessary for the immune system's capacity to defend against infections. METHODS We prospectively enrolled patients less than 18 years old undergoing heart surgery requiring CPB at C.S. Mott Children's Hospital. Blood was obtained from patients before CPB, on CPB, and on postoperative days 1, 3, and 5. Ex vivo lipopolysaccharide-induced tumor necrosis factor-alpha production measured the capacity of the immune system. Serum cytokines were measured using a multiplex assay. Chromatin immunoprecipitation to detect histone modifications at the interleukin (IL) 10 promoter was performed on circulating mononuclear cells from a subgroup of patients. RESULTS We enrolled 92 patients, and postoperative day 1 samples identified a subpopulation of immunocompetent patients at low risk for infections with a specificity of 93% (confidence interval [CI], 83%-98%) and a negative predictive value of 88% (CI, 77%-95%; P = .006). Patients classified as immunoparalyzed had serum IL-10 levels 2.4-fold higher than the immunocompetent group (mean, 14.3 ± 18.3 pg/mL vs 6.0 ± 5.0 pg/mL; P = .01). In a subgroup of patients, we identified a greater percent of the "gene on" epigenetic signature, H3K4me3, associated with the IL-10 promoter after CPB. CONCLUSIONS Our data demonstrate that immunophenotyping patients after CPB can predict their risk for the development of postoperative infections. Novel mechanistic data suggest that CPB affects epigenetic alterations in IL-10 gene regulation.
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Affiliation(s)
- Timothy T Cornell
- Division of Critical Care Medicine, C.S. Mott Children’s Hospital, F-6882, 1500 East Medical Center Dr, Ann Arbor, MI 48109-0243, USA.
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Abstract
Sepsis remains one of the leading causes of morbidity and mortality in children despite improved understanding of the pathophysiology leading to better clinical management and survival. Recent studies have identified several areas that must be addressed by the clinician in order to continue to impact the morbidity and mortality associated with sepsis. In this review, we discuss the evidence in several of these areas including initial resuscitation, pathogen eradication, maintenance of oxygen delivery, and directed modifiers of the inflammatory response. Our overall goal is to provide the bedside clinician with an updated systematic approach to treat sepsis in children.
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Affiliation(s)
- Nidal El-Wiher
- Division of Critical Care Medicine, C.S. Mott Children's Hospital at the University of Michigan, Ann Arbor, MI
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