Informed Consent for Potential Recipients of Pig Kidney Xenotransplantation in the United States

Clinical trials of kidney xenotransplantation are being considered in the United States. Before this novel procedure can take place, investigators will have to obtain approval from the institutional review board. The consent form that will be used for such a trial and that will receive approval from the institutional review board will be complex. Informed consent-the process by which a research participant provides his/her permission to participate in a clinical trial-is a staple of the research process and most commonly is in the form of a physical document. In the case of a novel procedure with uncertain benefits and risks and a participant population in acute need of a transplant, the consent process is crucial. These complexities may raise several ethical considerations for the initial pig kidney xenotransplantation recipients in the United States that will require adaptations of the required elements of the informed consent process by the US Department of Human and Health Services. The ethical issues include (1) a subject's ability to withdraw from the trial, (2) restrictions on their reproductive rights, and (3) the possibility of the need for quarantine if there is a perceived risk of xenozoonosis. This article aims to discuss ethical considerations that may challenge the general required elements of the informed consent form stipulated by the 45 Code of Federal Regulations 46 of the US Department of Health and Human Services and to suggest recommendations for deliberation.

Using the Default Nudge to Increase Plant-based Meal Consumption on College Campuses

Objectives

Climate, environmental, and nutrition scientists have recommended reduced meat and dairy consumption as key to reducing adverse planetary and human health impacts. We conducted this study to (1) investigate the effect of a default plant-based nudge on participant meal choices at a higher education institution and (2) to project the footprints of these choices: greenhouse gas (GHG) emissions (g CO2-eq), blue water (m3), land use (m2), nitrogen (g N), and phosphorus (g P) usage.

Methods

Data collection was performed at two student events where catering was provided. We used a randomized controlled trial (RCT) design to determine if students presented with a plant-based meal as the default option were less likely to choose a meat option. At each event, students were randomly assigned to two groups. The control group received a RSVP form that presented a meal with meat as the default option. The intervention group received a form that presented a plant-based meal as the default. To project and compare the environmental impacts of each group, we modeled two plant-based and two meals with meat. Using these meals we calculated the footprints of two 100-person events based on the RCT meal selections.

Results

We observed a large effect size (p < 0.0001) across both experiments. In the first event (n = 108) the intervention decreased the selection of meat meals by 43 percentage points (85% to 42%). In the second event (n = 81) the intervention decreased meat meal selection by 56 percentage points (83% to 27%). When comparing the projected 100-person events based on the RCT meal selections, we found reductions in GHG emissions (28–59%), land use (24–59%), nitrogen (40–57%), and phosphorus (37–61%) footprints. However, we also found an increase in blue water usage (41–77%).

Conclusions

This intervention is a low-effort, high impact way to decrease the share of meals containing meat in institutional settings. Adopting a default plant-based policy may be an effective way to reduce environmental impact and encourage healthier options while maintaining choice.

Funding Sources

Better Food Foundation, National Science Foundation.

Jammed Micro-Flake Hydrogel for Four-Dimensional Living Cell Bioprinting

4D bioprinting is promising to build cell-laden constructs (bioconstructs) with complex geometries and functions for tissue/organ regeneration applications. The development of hydrogel-based 4D bioinks, especially those allowing living cell printing, with easy preparation, defined composition, and controlled physical properties is critically important for 4D bioprinting. Here, a single-component jammed micro-flake hydrogel (MFH) system with heterogeneous size distribution, which differs from the conventional granular microgel, has been developed as a new cell-laden bioink for 4D bioprinting. This jammed cytocompatible MFH features scalable production and straightforward composition with shear-thinning, shear-yielding, and rapid self-healing properties. As such, it can be smoothly printed into stable 3D bioconstructs, which can be further cross-linked to form a gradient in cross-linking density when a photoinitiator and a UV absorber are incorporated. After being subject to shape morphing, a variety of complex bioconstructs with well-defined configurations and high cell viability are obtained. Based on this system, 4D cartilage-like tissue formation is demonstrated as a proof-of-concept. The establishment of this versatile new 4D bioink system may open up a number of applications in tissue engineering.

Accelerating neovascularization and kidney tissue formation with a 3D vascular scaffold capturing native vascular structure

Establishing an adequate vascularization of three-dimensional (3D) bioengineered tissues remains a critical challenge. We previously fabricated a vascular scaffold using the vascular corrosion casting technique, which provides a similar 3D geometry of native kidney vasculature. In this study, we functionalized the collagen vascular scaffold with a controlled release of vascular endothelial growth factor (VEGF vascular scaffold) to further promote vascularization. The VEGF vascular scaffold showed improved angiogenic capability in 2-dimensional (2D) and 3D in vitro settings. Implantation of the VEGF vascular scaffold seeded with human renal cells into a rat kidney demonstrated enhanced implant vascularization and reduced apoptosis of implanted human renal cells. Hybrid renal tubule-like structures composed of implanted human and migrated host renal cells were formed. This work highlights the critical role of early vascularization of the geometrically mimetic vascular scaffold using the VEGF incorporated vascular scaffold in reducing apoptosis of implanted cells as well as the formation of renal tissue structures.

The immune system in infants: Relevance to xenotransplantation

Despite the improvement in surgical interventions in the treatment of congenital heart disease, many life-threatening lesions (eg, hypoplastic left heart syndrome) ultimately require transplantation. However, there is a great limitation in the availability of deceased human cardiac donors of a suitable size. Hearts from genetically engineered pigs may provide an alternative source. The relatively immature immune system in infants (eg, absence of anti-carbohydrate antibodies, reduced complement activation, reduced innate immune cell activity) should minimize the risk of early antibody-mediated rejection of a pig graft. Additionally, recipient thymectomy, performed almost routinely as a preliminary to orthotopic heart transplantation in this age-group, impairs the T-cell response. Because of the increasing availability of genetically engineered pigs (eg, triple-knockout pigs that do not express any of the three known carbohydrate antigens against which humans have natural antibodies) and the ability to diagnose congenital heart disease during fetal life, cardiac xenotransplantation could be preplanned to be carried out soon after birth. Because of these several advantages, prolonged graft survival and even the induction of tolerance, for example, following donor-specific pig thymus transplantation, are more likely to be achieved in infants than in adults. In this review, we summarize the factors in the infant immune system that would be advantageous in the success of cardiac xenotransplantation in this age-group.

Paediatric xenotransplantation clinical trials and the right to withdraw

Clinical trials of xenotransplantation (XTx) may begin early in the next decade, with kidneys from genetically modified pigs transplanted into adult humans. If successful, transplanting pig hearts into children with advanced heart failure may be the next step. Typically, clinical trials have a specified end date, and participants are aware of the amount of time they will be in the study. This is not so with XTx. The current ethical consensus is that XTx recipients must consent to lifelong monitoring. While this presents challenges to the right to withdraw in the adult population, additional and unanswered questions also linger in the paediatric population. In paediatric XTx, parents or guardians consent not only to the initial treatment of the child but also to lifelong monitoring, thus making a decision whose consequences will remain present as the child develops the capacity for assent, and finally the capacity for informed consent or refusal. This article presents and evaluates unanswered paediatric ethical questions in regard to the right to withdraw from XTx follow-up in the paediatric population.

Repair of Rare Vascular Ring: Circumflex Aortic Arch with Associated Hypoplasia and Coarctation

We describe a neonate with an unusual vascular ring formed by a right-sided aortic arch with associated coarctation and distal hypoplasia in the presence of an aberrant left subclavian artery. The descending aorta traveled behind the esophagus to descend on the left side of the spine. A left ductus arteriosus connected to the descending aorta completing the vascular ring, with notable esophageal compression. Surgical correction was accomplished through median sternotomy, resection of the hypoplastic circumflex arch, aortic arch advancement, and end-to-side anastomosis.

The Case for Cardiac Xenotransplantation in Neonates: Is Now the Time to Reconsider Xenotransplantation for Hypoplastic Left Heart Syndrome?

Neonatal cardiac transplantation for hypoplastic left heart syndrome (HLHS) is associated with excellent long-term survival compared to older recipients. However, heart transplantation for neonates is greatly limited by the critical shortage of donor hearts, and by the associated mortality of the long pre-transplant waiting period. This led to the development of staged surgical palliation as the first-line surgical therapy for HLHS. Recent advances in genetic engineering and xenotransplantation have provided the potential to replicate the excellent results of neonatal cardiac allotransplantation while eliminating wait-list-associated mortality through genetically modified pig-to-human neonatal cardiac xenotransplantation. The elimination of the major pig antigens in addition to the immature B-cell response in neonates allows for the potential to induce B-cell tolerance. Additionally, the relatively mature neonatal T-cell response could be reduced by thymectomy at the time of operation combined with donor-specific pig thymus transplantation to "reprogram" the host's T-cells to recognize the xenograft as host tissue. In light of the recent significantly increased graft survival of genetically-engineered pig-to-baboon cardiac xenotransplantation, we propose that now is the time to consider devoting research to advance the potential clinical application of cardiac xenotransplantation as a treatment option for patients with HLHS. Employing cardiac xenotransplantation could revolutionize therapy for complex congenital heart defects and open a new chapter in the field of pediatric cardiac transplantation.

Analysis of the results of implementation of a pregnancy screening policy at a comprehensive cancer center

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Background: Institutional implementation of a standard pregnancy screening policy for women will enhance the safe and timely delivery of treatment throughout the care continuum. In 2012, we developed and implemented an initial policy on pregnancy screening test (PST). The policy indicated that all providers should fully discuss with their female patients of child bearing potential regarding the potential risks of cancer treatment on fertility and the adverse effects on the fetus. The providers should also discuss the contraceptive options with female patients and their partners prior to diagnostic studies and/or treatment. In 2015, we revised the initial policy to further clarify timeframe for PST and clinical indicators and also developed an algorithm to support this best practice. We assessed practice changes as a result of the policy changes regarding PST at our institution. Methods: A retrospective data review was conducted to assess the number of PST over a 5 year period at The University of Texas MD Anderson Cancer Center. The timeframe includes both baseline and post-implementation policy and reflects annual changes from fiscal year (FY) 2010 to 2015. The pregnancy test was defined as measuring human chorionic gonadotropin (hCG) level in a urine sample. Results: We observed a significant increase in PSTs over time among female patients between ages 10 to 55 years. Over 5 years, there were 23,793 urine pregnancy tests performed. The number of urine pregnancy tests performed per FY were as shown on table below (trend test, p< 0.01). The percentage of PST performed among age groups (years): 1.8% of 10 to 15, 11.6% of 16 to 25, 22.3% of 26 to 35, 34.7% of 36 to 45, and 29.5% of 46-55 years old. Conclusions: Wedemonstrated that developing a standard institutional policy on pregnancy screening tests with further enhancements contributed to a significant increase in the number of PSTs performed over 5 years at our comprehensive cancer center. The majority of PSTs were conducted among female patient between the ages of 26 and 55. [Table: see text]

Leveraging web-based interface systems with institutional databases to improve compliance with survivorship care plans

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Background: ASCO’s Clinical Oncology Clinical Expert Statement on Cancer Survivorship Planning addressed the importance of using survivorship care plans (SCPs) to improve survivors’ care. Evolving information technology strategies, such as web-based systems, offer real-time reporting tools to track providers’ adherence for completion of SCPs. Our abstract reports on the creation of a web-based system to monitor survivors’ care. Methods: Ongoing audits of SCPs indicated broad variation in compliance rates with SCPs. The institutional benchmark for compliance was set at 90%. Yet, FY 2014 rates ranged from 7-97%, X= 84%. To address low or non-compliance rates, our institution selected a commercially available system as the IT intervention to improve compliance with SCPs. Core metrics identified were arrived appointments, missed appointments, completed SCPs, and transitions to survivorship status. To collect data, we used existing institutional databases with information on medical health, scheduled appointments, and other clinical documentation tools were used to collect data. Descriptive statistics were used to analyze and present data. Results: The current design of the Survivorship Performance Scorecard provided a centralized system for reporting data from 11 survivorship clinics. An exploratory review found 18 Passport templates across the 11 clinics, 188 OrderSets, and 986 scheduling codes were used in planning survivorship clinical services. Procedures for patient transition to survivorship clinics were defined in OrderSets, which were reviewed to identify appropriate fields for inclusion in the report. To ascertain compliance, procedures were developed to link arrived appointments with completed SCPs. Final reports will display all metrics by clinic, provider, and other patient level data. After the system goes live in late 2015, the systems benefits and shortfalls will be analyzed. Conclusions: This evolving tool offers a practice-based method for collecting data elements to monitor compliance with SCPs’ completion standards. Future work will focus on designing an alert system to inform providers when compliance rates are below the 90% compliance benchmark.

Invention and Validation of an Automated Camera System That Uses Optical Character Recognition to Identify Patient Name Mislabeled Samples

BACKGROUND

Mislabeled samples are a serious problem in most clinical laboratories. Published error rates range from 0.39/1000 to as high as 1.12%. Standardization of bar codes and label formats has not yet achieved the needed improvement. The mislabel rate in our laboratory, although low compared with published rates, prompted us to seek a solution to achieve zero errors.

METHODS

To reduce or eliminate our mislabeled samples, we invented an automated device using 4 cameras to photograph the outside of a sample tube. The system uses optical character recognition (OCR) to look for discrepancies between the patient name in our laboratory information system (LIS) vs the patient name on the customer label. All discrepancies detected by the system's software then require human inspection. The system was installed on our automated track and validated with production samples.

RESULTS

We obtained 1 009 830 images during the validation period, and every image was reviewed. OCR passed approximately 75% of the samples, and no mislabeled samples were passed. The 25% failed by the system included 121 samples actually mislabeled by patient name and 148 samples with spelling discrepancies between the patient name on the customer label and the patient name in our LIS. Only 71 of the 121 mislabeled samples detected by OCR were found through our normal quality assurance process.

CONCLUSIONS

We have invented an automated camera system that uses OCR technology to identify potential mislabeled samples. We have validated this system using samples transported on our automated track. Full implementation of this technology offers the possibility of zero mislabeled samples in the preanalytic stage.

P53 and Ki-67 antigen expression in small oral biopsy specimens of salivary gland tumors

OBJECTIVE

To investigate the possibility that various salivary gland tumors that look histologically similar could express p53 oncoprotein and Ki-67 proliferation antigen differentially and possibly aid in distinguishing benign from malignant lesions.

STUDY DESIGN

Intraoral paraffin-embedded biopsy specimens of salivary gland tumors were used. Thirty-eight pleomorphic adenomas, 17 adenoid cystic carcinomas, 23 monomorphic adenomas, and 17 polymorphous low-grade adenocarcinomas were stained with p53 and Ki-67 antibodies by using an immunoperoxidase detection system. Each case was evaluated in terms of staining intensity and percentage of cells staining.

RESULTS

Ki-67 and p53 antigens are expressed in generally low levels in the histologically well-differentiated salivary tumors that were studied here, both benign and malignant. Only 1 solid-type adenoid cystic carcinoma showed a high percentage of cells expressing p53.

CONCLUSIONS

The histologically well-differentiated salivary tumors studied do not show differential expression of p53 and Ki-67, in spite of their differing courses of biologic behavior. These antibodies should not be relied on to distinguish benign from malignant lesions of the salivary glands; however, they might be markers for those lesions that are dedifferentiating histologically and, therefore, might be displaying more aggressive behavior.

Antimicrobial and toxic effects of established and potential root canal irrigants

Three dilutions of the commonly used irrigant sodium hypochlorite (0.5%, 2.5%, and 5.25%) and the potential irrigants Peridex, chlorhexidine gluconate (0.12%), and Therasol were tested. Alcohol and saline served as controls also. The in vitro portion of this study used four different microorganisms (Streptococcus mutans, Peptostreptococcus micros, Prevotella intermedius, and Porphyromonas gingivalis) to determine antimicrobial effect. Presterilized 7-mm diameter Whatman paper disks soaked with the test solution were prepared, and disks were placed onto the previously seeded agar petri dishes. Each dish was incubated aerobically or anaerobically according to the microorganisms used. An in vivo animal model (guinea pig) was used to examine subcutaneous local tissue reactions using the same materials; 0.1 ml of each test solution was injected subcutaneously into predetermined locations on the animal dorsum. Test site histological examination was done 2 h, 2 days, and 2 wk after the injections. The results of this comparative study indicate Peridex (chlorhexidine gluconate) and Therasol may have good potential for endodontic usage.

Overexpression of the p53 gene in primary and metastatic head and neck carcinomas

The p53 gene has been correlated with disease progression in a number of human malignancies, and p53 abnormalities are found in a high percentage of head and neck squamous cell carcinomas. The objectives of this study were 1. to correlate p53 expression with disease progression in squamous cell carcinoma of the head and neck (SCCHN), and 2. to determine whether there are site-specific differences in p53 expression. Primary lesions and/or lymph node metastases from 147 patients with invasive SCCHN were immunostained for p53 overexpression. Expression of p53 was similar (42% versus 43%) in primary lesions and lymph node metastases. Expression also did not vary significantly by site in the head and neck. In conclusion, increased p53 expression did not correlate with disease progression in our series of patients with invasive SCCHN. The finding of a lack of increased expression with disease spread to lymph nodes supports the belief that p53 alterations occur early in head and neck carcinogenesis.

Summary of hunting injuries in central Wisconsin: a 4-year experience at a rural referral center

Surveillance of hunting-associated injuries was performed over a 4-year period at a rural Emergency Department in central Wisconsin. Over that period of time, 125 individuals sought treatment for hunting-related injuries. The majority of injuries were related to autumn deer hunting and included both gun and bow and arrow hunting. Over half of the persons injured while hunting with a bow and arrow fell from a height. The admission rate for persons in the immediate area was 35.1%, but for those from outside the area, it was 64.8%. The effects of the referral bias result in severe injuries being seen in rural Emergency Departments during hunting seasons, necessitating such departments to be prepared for a wide range of injuries.

p53 is overexpressed in fifty percent of pre-invasive lesions of head and neck epithelium

To identify the stage in head and neck carcinogenesis at which p53 abnormalities become important, we evaluated 512 squamous epithelial tissue samples (201 pre-invasive and 209 invasive lesions, as well as 102 normal epithelia) in specimens from two institutions. Of 311 patients evaluated, 128 did not have an invasive carcinoma. The frequency of p53 overexpression in the pre-invasive lesions was not influenced by an adjacent invasive tumor. There was an increasing frequency of p53 overexpression in specimens from histologically normal epithelium (5%, with only scattered basal layers positive) to mild (28%) and moderate dysplasia (47%). p53 overexpression was also significantly more common in lesions with severe dysplasia (54%) and carcinoma in situ (CIS; 50%) than in those with mild dysplasia. To further evaluate the timing of p53 alterations in the development of head and neck cancer, paired epithelial samples (one pre-invasive and one invasive) from the same patient were evaluated. A discordance in the p53 staining pattern was seen in approximately one-third of the cases. When a discordance was present, the frequency with which the invasive lesion was positive but the non-invasive negative decreased from 97% (invasive versus normal epithelium) to 50% (invasive versus severe dysplasia or CIS). When p53 expression was evaluated by site, buccal lesions appeared to overexpress p53 more frequently than tongue lesions. In conclusion, p53 protein overexpression is an early event in head and neck carcinogenesis and may represent a biomarker for patients with pre-invasive lesions.

Treatment of persistent pulmonary hypertension in the newborn lamb by inhaled nitric oxide

We previously showed that fetal lambs whose ductus arteriosus is ligated prenatally will have persistent pulmonary hypertension at birth. We investigated the effect of inhaled nitric oxide on the pulmonary circulation in this animal model. The ductus arteriosus of six fetal lambs was ligated at 126 days of gestation. The lambs were delivered and studied at 136 days of gestation. Mechanical ventilation was maintained at a fraction of inspired oxygen of 0.80. Nitric oxide gas was administered at five different concentrations (6, 12, 25, 50, and 100 ppm) for 5-minute periods separated by 10-minute periods of ventilation without nitric oxide. Inhaled nitric oxide caused dose-dependent decreases in pulmonary arterial pressure and vascular resistance and dose-dependent increases in pulmonary blood flow without affecting systemic arterial pressure. Thus pulmonary arterial pressure decreased from equal to aortic pressure to less than aortic pressure. At the highest dose, mean pulmonary arterial pressure decreased by 27% +/- 2%, pulmonary blood flow increased by 86% +/- 6%, and pulmonary vascular resistance decreased by 59% +/- 4%. Nitric oxide also caused dose-dependent increases in systemic arterial oxygen tension and in the saturation of hemoglobin with oxygen. Partial pressure of arterial oxygen increased from 43 +/- 16 mm Hg at baseline to 185 +/- 72 mm Hg at the highest dose; saturation increased from 74% +/- 8% to 96% +/- 2%. In our model of persistent pulmonary hypertension of the newborn, inhaled nitric oxide selectively dilates the pulmonary circulation, thereby improving systemic arterial oxygenation. Nitric oxide is a promising new treatment of persistent pulmonary hypertension of the newborn.

Ability of the c-mos product to associate with and phosphorylate tubulin

The mos proto-oncogene product, pp39mos, is a protein kinase and has been equated with cytostatic factor (CSF), an activity in unfertilized eggs that is thought to be responsible for the arrest of meiosis at metaphase II. The biochemical properties and potential substrates of pp39mos were examined in unfertilized eggs and in transformed cells in order to study how the protein functions both as CSF and in transformation. The pp39mos protein associated with polymers under conditions that favor tubulin oligomerization and was present in an approximately 500-kilodalton "core" complex under conditions that favor depolymerization. beta-Tubulin was preferentially coprecipitated in pp39mos immunoprecipitates and was the major phosphorylated product in a pp39mos-dependent immune complex kinase assay. Immunofluorescence analysis of NIH 3T3 cells transformed with Xenopus c-mos showed that pp39mos colocalizes with tubulin in the spindle during metaphase and in the midbody and asters during telophase. Disruption of microtubules with nocodazole affected tubulin and pp39mos organization in the same way. It therefore appears that pp39mos is a tubulin-associated protein kinase and may thus participate in the modification of microtubules and contribute to the formation of the spindle. This activity expressed during interphase in somatic cells may be responsible for the transforming activity of pp39mos.

Lung abscess secondary to xanthogranulomatous pyelonephritis

In a patient with xanthogranulomatous pyelonephritis the initial clinical and radiological picture suggested a diagnosis of lung abscess.

Solid adenoid cystic carcinoma of the maxilla

Seven cases of solid variant of adenoid cystic carcinoma of the maxilla are reported. Clinical and radiographic characteristics suggest origin within the maxillary alveolar bone. Swelling was minimal and disproportionate to the extensive, diffuse bone destruction universally present. Histologic features were typical of this neoplasm occurring in other sites and consisted of diffusely infiltrating islands of small, closely packed monomorphous cells with sparse cytoplasm, indistinct borders, and small hyperchromatic nuclei. Four of five patients with follow-up data died of their disease. This confirms the lethality of the solid variant. Rationale is presented for considering these malignancies to be of primary intraosseous origin.

Probing the function of the eucaryotic 5' cap structure by using a monoclonal antibody directed against cap-binding proteins

A monoclonal antibody directed against cap-binding proteins was used to elucidate the possible mechanism by which cap-binding proteins function in initiation of eucaryotic translation. The monoclonal antibody preparation employed in this study exhibited a marked differential effect in inhibiting the translation of folded, capped eucaryotic-mRNAs to a far greater extent than naturally uncapped mRNAs or native capped mRNAs that do not possess extensive 5' end secondary structure. These findings were consistent with the effects of the antibody on initiation complex formation with three different types of reovirus mRNA: native reovirus mRNA; inosine-substituted reovirus mRNA, which has a relaxed secondary structure; and bromouridine-substituted reovirus mRNA, in which base pairing is enhanced relative to regular reovirus mRNA. The extent that translation initiation complex formation was inhibited by the monoclonal antibody directly correlated to the degree of secondary structure present in the mRNA. Binding of bromouridine-substituted reovirus mRNA to ribosomes was inhibited to the greatest extent, while binding of inosine-substituted reovirus mRNA was not inhibited at all in the reticulocyte lysate system or was slightly inhibited in a wheat-germ system. These results support the hypothesis that cap-binding proteins are involved in unwinding of the 5' terminal, secondary structure of many eucaryotic mRNAs, thus facilitating the attachment of ribosomes to mRNA.