Intrapulmonary administration of recombinant activated factor VII in pediatric, adolescent, and young adult oncology and hematopoietic cell transplant patients with pulmonary hemorrhage

Introduction

Diffuse alveolar hemorrhage (DAH) is a devastating disease process with 50-100% mortality in oncology and hematopoietic cell transplant (HCT) recipients. High concentrations of tissue factors have been demonstrated in the alveolar wall in acute respiratory distress syndrome and DAH, along with elevated levels of tissue factor pathway inhibitors. Activated recombinant factor VII (rFVIIa) activates the tissue factor pathway, successfully overcoming the tissue factor pathway inhibitor (TFPI) inhibition of activation of Factor X. Intrapulmonary administration (IP) of rFVIIa in DAH is described in small case series with successful hemostasis and minimal complications.

Methods

We completed a single center retrospective descriptive study of treatment with rFVIIa and outcomes in pediatric oncology and HCT patients with pulmonary hemorrhage at a quaternary hematology/oncology hospital between 2011 and 2019. We aimed to assess the safety and survival of patients with pulmonary hemorrhage who received of IP rFVIIa.

Results

We identified 31 patients with pulmonary hemorrhage requiring ICU care. Thirteen patients received intrapulmonary rFVIIa, while eighteen patients did not. Overall, 13 of 31 patients (41.9%) survived ICU discharge. ICU survival (n=6) amongst those in the IP rFVIIa group was 46.2% compared to 38.9% (n=7) in those who did not receive IP therapy (p=0.69). Hospital survival was 46.2% in the IP group and 27.8% in the non-IP group (p=0.45). There were no adverse events noted from use of IP FVIIa.

Conclusions

Intrapulmonary rFVIIa can be safely administered in pediatric oncology patients with pulmonary hemorrhage and should be considered a viable treatment option for these patients.

Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit

Introduction

Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population.

Methods

We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission.

Results

Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff.

Conclusions

Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

Alpha 2-adrenoceptors and I1-imidazoline binding sites: relationship with catecholamines in women of reproductive age

A comparison is presented between plasma catecholamine concentrations and platelet [125I]-p-iodoclonidine binding sites in 16 healthy women. Blood samples were obtained at six regularly spaced intervals over two consecutive menstrual cycles from healthy women with regular menstrual periods. Although no cycle-related changes were observed per se, there were significant correlations between the platelet binding sites and plasma norepinephrine and epinephrine concentrations. The densities of platelet alpha 2-adrenoceptors were negatively correlated in an exponential fashion (r2 = 0.694, P = 0.009) with plasma epinephrine concentrations, implying agonist-induced downregulation. On the other hand, platelet I1-imidazoline binding sites were positively correlated with plasma concentrations of norepinephrine in a linear fashion (r2 = 0.326, P = 0.021). This is the first indication that I1 binding sites might be upregulated by a physiological factor. Furthermore, the data suggest that elevations in plasma norepinephrine might explain reports of upregulated I1 binding sites in depressed patients.

Gap junction formation during development of the mouse lens

We have identified a 60 kDa membrane protein (MP60) as a component of the mouse cortical lens fiber gap junction and a monoclonal antibody recognizing this protein has been used to establish the temporal and spatial patterns of gap junction formation during development of the mouse lens. The initial expression of MP60 during embryonic development of the mouse lens correlates with primary fiber elongation and is first seen on the luminal aspect of the extending cells. About 2 days after birth, the relatively large, antibody-positive macular structures characteristic of late embryonic fiber cells begin to disperse into progressively smaller structures within a centrally located region of the lens. This change in the staining pattern with antibody directed against MP60 is consistent with the dispersion of gap junction plaques as confirmed by freeze fracture analysis. Around 5 days after birth, the 60 kDa gap junctional protein in this central region of the lens undergoes a modification resulting in the alteration to the epitope for the monoclonal antibody and a consequent loss of immunorecognition. Our results suggest that gap junctions in the central region of the developing mouse lens undergo sequential changes in immunoreactivity which may reflect potentially distinct functional phases of intercellular communication.

Gap junction assembly in the preimplantation mouse conceptus is independent of microtubules, microfilaments, cell flattening, and cytokinesis

Gap junctions first appear during compaction in the eight-cell stage of mouse development. Their assembly can be initiated in the near absence of transcription and protein synthesis from the four-cell stage, indicating the existence of preformed precursors. We have investigated the temporal control of this event, focusing on the possible involvement of the cytoskeleton, cell flattening, and cytokinesis. Embryos in various cleavage stages were treated with cytochalasins, to disrupt microfilaments and block cell flattening, cytokinesis, or both, or nocodazole, to promote microtubule depolymerization. To assess their capacity to initiate gap junction assembly after such treatments, the embryos were then aggregated with communication-competent, compacted embryos that had been labeled with carboxyfluorescein diacetate. Passage of the fluorescent dye, carboxyfluorescein, from labeled to unlabeled embryo was taken as evidence that interembryonic junction formation had occurred. The capacity to assemble gap junctions was acquired at the normal time by embryos prevented by cytochalasin treatment from undergoing cell flattening or any cytokinesis from fertilization onward. Likewise, treatment with nocodazole beginning in the four-cell or early eight-cell stage did not interfere with gap junction assembly. Neither drug affected the inability of four-cell embryos to assemble gap junctions prematurely. We conclude that intact microfilament or microtubule networks are not required for gap junction assembly in this system, nor do they restrain junctional precursors from assembling prematurely. Furthermore, the timing of gap junction assembly is not linked to cell flattening, cytokinesis, or cell number.