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Hochstetler E, Taweh O, Mistry AJ, Metz P. Worcester Refugee Assistance Project: An Example of Strengths-Based, Community-Based, Culturally Sensitive Care. Child Adolesc Psychiatr Clin N Am 2024; 33:263-276. [PMID: 38395510 DOI: 10.1016/j.chc.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Refugee populations are diverse and can present with a variety of unique and complex circumstances. The purpose of this article is to examine an organization that provides care to refugee youth, the ways in which this is accomplished, and a few of the challenges that have been faced. Specifically, the work of this organization will be examined using a Systems of Care philosophy to demonstrate how using these concepts can assist in providing sensitive, high-quality care.
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Affiliation(s)
- Emily Hochstetler
- University of Massachusetts, T.H. Chan School of Medicine, 55 Lake Avenue North, Worcester, MA 01655, USA.
| | - Omar Taweh
- University of Massachusetts, T.H. Chan School of Medicine, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Anushay J Mistry
- Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Peter Metz
- University of Massachusetts, T.H. Chan School of Medicine, 55 Lake Avenue North, Worcester, MA 01655, USA
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Novak T, Hall MW, McDonald DR, Newhams MM, Mistry AJ, Panoskaltsis-Mortari A, Mourani PM, Loftis LL, Weiss SL, Tarquinio KM, Markovitz B, Hartman ME, Schwarz A, Junger WG, Randolph AG. RIG-I and TLR4 responses and adverse outcomes in pediatric influenza-related critical illness. J Allergy Clin Immunol 2020; 145:1673-1680.e11. [PMID: 32035159 PMCID: PMC7323584 DOI: 10.1016/j.jaci.2020.01.040] [Citation(s) in RCA: 4] [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] [Received: 09/20/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Decreased TNF-α production in whole blood after ex vivo LPS stimulation indicates suppression of the Toll-like receptor (TLR)4 pathway. This is associated with increased mortality in pediatric influenza critical illness. Whether antiviral immune signaling pathways are also suppressed in these patients is unclear. OBJECTIVES We sought to evaluate suppression of the TLR4 and the antiviral retinoic acid-inducible gene-I (RIG-I) pathways with clinical outcomes in children with severe influenza infection. METHODS In this 24-center, prospective, observational cohort study of children with confirmed influenza infection, blood was collected within 72 hours of intensive care unit admission. Ex vivo whole blood stimulations were performed with matched controls using the viral ligand polyinosinic-polycytidylic acid-low-molecular-weight/LyoVec and LPS to evaluate IFN-α and TNF-α production capacities (RIG-I and TLR4 pathways, respectively). RESULTS Suppression of either IFN-α or TNF-α production capacity was associated with longer duration of mechanical ventilation and hospitalization, and increased organ dysfunction. Children with suppression of both RIG-I and TLR4 pathways (n = 33 of 103 [32%]) were more likely to have prolonged (≥7 days) multiple-organ dysfunction syndrome (30.3% vs 8.6%; P = .004) or prolonged hypoxemic respiratory failure (39.4% vs 11.4%; P = .001) compared with those with single- or no pathway suppression. CONCLUSIONS Suppression of both RIG-I and TLR4 signaling pathways, essential for respective antiviral and antibacterial responses, is common in previously immunocompetent children with influenza-related critical illness and is associated with bacterial coinfection and adverse outcomes. Prospective testing of both pathways may aid in risk-stratification and in immune monitoring.
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Affiliation(s)
- Tanya Novak
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Mass; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Anesthesia, Harvard Medical School, Boston
| | - Mark W Hall
- Nationwide Children's Hospital, Division of Critical Care Medicine, Department of Pediatrics, Columbus, Ohio
| | - Douglas R McDonald
- Boston Children's Hospital, Division of Immunology and Harvard Medical School Department of Pediatrics, Boston, Mass
| | - Margaret M Newhams
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Mass
| | - Anushay J Mistry
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Mass
| | | | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Keiko M Tarquinio
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Barry Markovitz
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Mary E Hartman
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Mo
| | - Adam Schwarz
- Department of Pediatrics, Children's Hospital of Orange County, Orange, Calif
| | - Wolfgang G Junger
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Adrienne G Randolph
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Mass; Department of Anesthesia, Harvard Medical School, Boston.
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Levy ER, Yip WK, Super M, Ferdinands JM, Mistry AJ, Newhams MM, Zhang Y, Su HC, McLaughlin GE, Sapru A, Loftis LL, Weiss SL, Hall MW, Cvijanovich N, Schwarz A, Tarquinio KM, Mourani PM, Randolph AG. Evaluation of Mannose Binding Lectin Gene Variants in Pediatric Influenza Virus-Related Critical Illness. Front Immunol 2019; 10:1005. [PMID: 31139182 PMCID: PMC6518443 DOI: 10.3389/fimmu.2019.01005] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 04/18/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Mannose-binding lectin (MBL) is an innate immune protein with strong biologic plausibility for protecting against influenza virus-related sepsis and bacterial co-infection. In an autopsy cohort of 105 influenza-infected young people, carriage of the deleterious MBL gene MBL2_Gly54Asp(“B”) mutation was identified in 5 of 8 individuals that died from influenza-methicillin-resistant Staphylococcus aureus (MRSA) co-infection. We evaluated MBL2 variants known to influence MBL levels with pediatric influenza-related critical illness susceptibility and/or severity including with bacterial co-infections. Methods: We enrolled children and adolescents with laboratory-confirmed influenza infection across 38 pediatric intensive care units from November 2008 to June 2016. We sequenced MBL2 “low-producer” variants rs11003125(“H/L”), rs7096206(“Y/X”), rs1800450Gly54Asp(“B”), rs1800451Gly57Glu(“C”), rs5030737Arg52Cys(“D”) in patients and biologic parents. We measured serum levels and compared complement activity in low-producing homozygotes (“B/B,” “C/C”) to HYA/HYA controls. We used a population control of 1,142 healthy children and also analyzed family trios (PBAT/HBAT) to evaluate disease susceptibility, and nested case-control analyses to evaluate severity. Results: We genotyped 420 patients with confirmed influenza-related sepsis: 159 (38%) had acute lung injury (ALI), 165 (39%) septic shock, and 30 (7%) died. Although bacterial co-infection was diagnosed in 133 patients (32%), only MRSA co-infection (n = 33, 8% overall) was associated with death (p < 0.0001), present in 11 of 30 children that died (37%). MBL2 variants predicted serum levels and complement activation as expected. We found no association between influenza-related critical illness susceptibility and MBL2 variants using family trios (633 biologic parents) or compared to population controls. MBL2 variants were not associated with admission illness severity, septic shock, ALI, or bacterial co-infection diagnosis. Carriage of low-MBL producing MBL2 variants was not a risk factor for mortality, but children that died did have higher carriage of one or more B alleles (OR 2.3; p = 0.007), including 7 of 11 with influenza MRSA-related death (vs. 2 of 22 survivors: OR 14.5, p = 0.0002). Conclusions:MBL2 variants that decrease MBL levels were not associated with susceptibility to pediatric influenza-related critical illness or with multiple measures of critical illness severity. We confirmed a prior report of higher B allele carriage in a relatively small number of young individuals with influenza-MRSA associated death.
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Affiliation(s)
- Emily R Levy
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA, United States.,Divisions of Pediatric Critical Care and Pediatric Infectious Diseases, Department of Pediatrics, Mayo Clinic, Rochester, MN, United States
| | - Wai-Ki Yip
- Foundation Medicine Inc., Cambridge, MA, United States
| | - Michael Super
- Wyss Institute at Harvard University, Boston, MA, United States
| | - Jill M Ferdinands
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Anushay J Mistry
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Margaret M Newhams
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Yu Zhang
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Helen C Su
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Anil Sapru
- Critical Care Medicine Division, Department of Pediatrics, Children's Hospital of Los Angeles, University of California, Los Angeles, Los Angeles, CA, United States
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, United States
| | - Natalie Cvijanovich
- Department of Pediatrics, Benioff Children's Hospital Oakland, University California San Francisco, Oakland, CA, United States
| | - Adam Schwarz
- Department of Pediatrics, Children's Hospital of Orange County, Orange, CA, United States
| | - Keiko M Tarquinio
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta at Egleston, Emory University School of Medicine, Atlanta, GA, United States
| | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | | | - Adrienne G Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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Fiore-Gartland A, Panoskaltsis-Mortari A, Agan AA, Mistry AJ, Thomas PG, Matthay MA, Hertz T, Randolph AG. Cytokine Profiles of Severe Influenza Virus-Related Complications in Children. Front Immunol 2017; 8:1423. [PMID: 29163498 PMCID: PMC5681736 DOI: 10.3389/fimmu.2017.01423] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 08/08/2017] [Accepted: 10/13/2017] [Indexed: 12/25/2022] Open
Abstract
Rationale Effective immunomodulatory therapies for children with life-threatening “cytokine storm” triggered by acute influenza infection are lacking. Understanding the immune profiles of children progressing to severe lung injury and/or septic shock could provide insight into pathogenesis. Objectives To compare the endotracheal and serum cytokine profiles of children with influenza-related critical illness and to identify their associations with severe influenza-associated complications. Methods Children with influenza-related critical illness were enrolled across 32 hospitals in development (N = 171) and validation (N = 73) cohorts (December 2008 through May 2016). Concentrations of 42 cytokines were measured in serum and endotracheal samples and clustered into modules of covarying cytokines. Relative concentrations of cytokines and cytokine modules were tested for associations with acute lung injury (ALI), shock requiring vasopressors, and death/ECMO. Measurements and main results Modules of covarying cytokines were more significantly associated with disease severity than individual cytokines. In the development cohort, increased levels of a serum module containing IL6, IL8, IL10, IP10, GCSF, MCP1, and MIP1α [shock odds ratio (OR) = 3.37, family-wise error rate (FWER) p < 10−4], and decreased levels of a module containing EGF, FGF2, SCD40L, and PAI-1 (shock OR = 0.43, FWER p = 0.002), were both associated with ALI, shock, and death-ECMO independent of age and bacterial coinfection. Both of these associations were confirmed in the validation cohort. Endotracheal and serum cytokine associations differed markedly and were differentially associated with clinical outcomes. Conclusion We identified strong positive and negative associations of cytokine modules with the most severe influenza-related complications in children, providing new insights into the pathogenesis of influenza-related critical illness in children. Effective therapies may need to target mediators of both inflammation and repair.
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Affiliation(s)
- Andrew Fiore-Gartland
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Angela Panoskaltsis-Mortari
- Department of Pediatrics, Bone Marrow Transplantation, Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Anna A Agan
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Anushay J Mistry
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Paul G Thomas
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Michael A Matthay
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | | | - Tomer Hertz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,The Shraga Segal Department of Microbiology, Immunology and Genetics, Ben-Gurion University of the Negev, Be'er-Sheva, Israel.,National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Adrienne G Randolph
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Anaesthesia, Harvard Medical School, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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