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Tawfik DS, Rovnaghi C, Profit J, Cornell TT, Anand KJ. Prevalence of burnout and its relation to the neuroendocrine system among pediatric residents during the early Covid-19 pandemic: A pilot feasibility study. Compr Psychoneuroendocrinol 2023; 14:100174. [PMID: 36742128 PMCID: PMC9890933 DOI: 10.1016/j.cpnec.2023.100174] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Background Measuring burnout relies on infrequent and subjective surveys, which often do not reflect the underlying factors or biological mechanisms that promote or prevent it. Burnout correlates with cortisol levels and dysregulation of the hypothalamic-pituitary-adrenal axis, but the chronology and strength of this relationship are unknown. Objective To determine the prevalence and feasibility of studying burnout in pediatric residents using hair cortisol and hair oxytocin concentrations. Design /Methods: Longitudinal observational cohort study of pediatric residents. We assessed burnout using the Stanford Professional Fulfillment Index and hair cortisol (HCC), and hair oxytocin concentrations (HOC) at four 3-month intervals from January 2020-January 2021. We evaluated test-retest reliability, sensitivity to change using Pearson product-moment correlations, and relationships between burnout and hair biomarkers using hierarchical mixed-effects linear regression. Results 17 Pediatrics residents provided 78 wellness surveys and 54 hair samples. Burnout symptoms were present in 39 (50%) of the surveys, with 14 (82%) residents reporting burnout in at least one time point. The lowest (41%) and highest (60%) burnout prevalence occurred in 04/2020 and 01/2021, respectively. No significant associations between burnout scores and HCC (β -0.01, 95%CI: 0.14-0.13), HOC (β 0.06, 95%CI: 0.06-0.19), or the HCC:HOC ratio (β -0.04, 95%CI: 0.09-0.02) were noted in separate analyses. Intra-individual changes in hair cortisol concentration were not associated with changes in burnout score. Conclusions Burnout was prevalent among Pediatrics residents, with highest prevalence noted in January 2021. This pilot longitudinal study demonstrates the feasibility of evaluating burnout with stress and resilience biomarkers in Pediatrics residents.
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Affiliation(s)
- Daniel S. Tawfik
- Corresponding author. 770 Welch Road, Suite 435, Palo Alto, CA, 94304, USA.
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2
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Mukherjee R, Tetri LH, Li SJ, Fajardo G, Ostberg NP, Tsegay KB, Gera K, Cornell TT, Bernstein D, Mochly-Rosen D, Haileselassie B. Drp1/p53 interaction mediates p53 mitochondrial localization and dysfunction in septic cardiomyopathy. J Mol Cell Cardiol 2023; 177:28-37. [PMID: 36841153 PMCID: PMC10358757 DOI: 10.1016/j.yjmcc.2023.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Previous studies have implicated p53-dependent mitochondrial dysfunction in sepsis induced end organ injury, including sepsis-induced myocardial dysfunction (SIMD). However, the mechanisms behind p53 localization to the mitochondria have not been well established. Dynamin-related protein 1 (Drp1), a mediator of mitochondrial fission, may play a role in p53 mitochondrial localization. Here we examined the role of Drp1/p53 interaction in SIMD using in vitro and murine models of sepsis. METHODS H9c2 cardiomyoblasts and BALB/c mice were exposed to lipopolysaccharide (LPS) to model sepsis phenotype. Pharmacologic inhibitors of Drp1 activation (ψDrp1) and of p53 mitochondrial binding (pifithrin μ, PFTμ) were utilized to assess interaction between Drp1 and p53, and the subsequent downstream impact on mitochondrial morphology and function, cardiomyocyte function, and sepsis phenotype. RESULTS Both in vitro and murine models demonstrated an increase in physical Drp1/p53 interaction following LPS treatment, which was associated with increased p53 mitochondrial localization, and mitochondrial dysfunction. This Drp1/p53 interaction was inhibited by ΨDrp1, suggesting that this interaction is dependent on Drp1 activation. Treatment of H9c2 cells with either ΨDrp1 or PFTμ inhibited the LPS mediated localization of Drp1/p53 to the mitochondria, decreased oxidative stress, improved cellular respiration and ATP production. Similarly, treatment of BALB/c mice with either ΨDrp1 or PFTμ decreased LPS-mediated mitochondrial localization of p53, mitochondrial ROS in cardiac tissue, and subsequently improved cardiomyocyte contractile function and survival. CONCLUSION Drp1/p53 interaction and mitochondrial localization is a key prodrome to mitochondrial damage in SIMD and inhibiting this interaction may serve as a therapeutic target.
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Affiliation(s)
- Riddhita Mukherjee
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Laura H Tetri
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Anesthesia, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Sin-Jin Li
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Giovanni Fajardo
- Department of Pediatrics, Division of Cardiology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Nicolai P Ostberg
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Kaleb B Tsegay
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Kanika Gera
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Timothy T Cornell
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Daniel Bernstein
- Department of Pediatrics, Division of Cardiology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Daria Mochly-Rosen
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Bereketeab Haileselassie
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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3
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Carlton EF, Gebremariam A, Maddux AB, McNamara N, Barbaro RP, Cornell TT, Iwashyna TJ, Prosser LA, Zimmerman J, Weiss S, Prescott HC. New and Progressive Medical Conditions After Pediatric Sepsis Hospitalization Requiring Critical Care. JAMA Pediatr 2022; 176:e223554. [PMID: 36215045 PMCID: PMC9552050 DOI: 10.1001/jamapediatrics.2022.3554] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/20/2022] [Indexed: 12/15/2022]
Abstract
Importance Children commonly experience physical, cognitive, or emotional sequelae after sepsis. However, little is known about the development or progression of medical conditions after pediatric sepsis. Objective To quantify the development and progression of 4 common conditions in the 6 months after sepsis and to assess whether they differed after hospitalization for sepsis vs nonsepsis among critically ill children. Design, Setting, and Participants This cohort study of 101 511 children (<19 years) with sepsis or nonsepsis hospitalization used a national administrative claims database (January 1, 2010, to June 30, 2018). Data management and analysis were conducted from April 1, 2020, to July 7, 2022. Exposures Intensive care unit hospitalization for sepsis vs all-cause intensive care unit hospitalizations, excluding sepsis. Main Outcomes and Measures Primary outcomes were the development of 4 target conditions (chronic respiratory failure, seizure disorder, supplemental nutritional dependence, and chronic kidney disease) within 6 months of hospital discharge. Secondary outcomes were the progression of the 4 target conditions among children with the condition before hospitalization. Outcomes were identified via diagnostic and procedural codes, durable medical equipment codes, and prescription medications. Differences in the development and the progression of conditions between pediatric patients with sepsis and pediatric patients with nonsepsis who survived intensive care unit hospitalization were assessed using logistic regression with matching weights. Results A total of 5150 survivors of pediatric sepsis and 96 361 survivors of nonsepsis intensive care unit hospitalizations were identified; 2593 (50.3%) were female. The median age was 9.5 years (IQR, 3-15 years) in the sepsis cohort and 7 years (IQR, 2-13 years) in the nonsepsis cohort. Of the 5150 sepsis survivors, 670 (13.0%) developed a new target condition, and 385 of 1834 (21.0%) with a preexisting target condition had disease progression. A total of 998 of the 5150 survivors (19.4%) had development and/or progression of at least 1 condition. New conditions were more common among sepsis vs nonsepsis hospitalizations (new chronic respiratory failure: 4.6% vs 1.9%; odds ratio [OR], 2.54 [95% CI, 2.19-2.94]; new supplemental nutritional dependence: 7.9% vs 2.7%; OR, 3.17 [95% CI, 2.80-3.59]; and new chronic kidney disease: 1.1% vs 0.6%; OR, 1.65 [95% CI, 1.25-2.19]). New seizure disorder was less common (4.6% vs 6.0%; OR, 0.77 [95% CI, 0.66-0.89]). Progressive supplemental nutritional dependence was more common (1.5% vs 0.5%; OR, 2.95 [95% CI, 1.60-5.42]), progressive epilepsy was less common (33.7% vs 40.6%; OR, 0.74 [95% CI, 0.65-0.86]), and progressive respiratory failure (4.4% vs 3.3%; OR, 1.35 [95% CI, 0.89-2.04]) and progressive chronic kidney disease (7.9% vs 9.2%; OR, 0.84 [95% CI, 0.18-3.91]) were similar among survivors of sepsis vs nonsepsis admitted to an intensive care unit. Conclusions and Relevance In this national cohort of critically ill children who survived sepsis, 1 in 5 developed or had progression of a condition of interest after sepsis hospitalization, suggesting survivors of pediatric sepsis may benefit from structured follow-up to identify and treat new or worsening medical comorbid conditions.
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Affiliation(s)
- Erin F. Carlton
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Aline B. Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora
| | - Nancy McNamara
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Ryan P. Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Timothy T. Cornell
- Lucille Packard Children’s Hospital, Stanford University, Palo Alto, California
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Lisa A. Prosser
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Jerry Zimmerman
- Seattle Children’s Hospital, Harborview Medical Center, University of Washington School of Medicine, Seattle
| | - Scott Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Children’s Hospital of Philadelphia, Pediatric Sepsis Program, Philadelphia, Pennsylvania
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
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4
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Majzner RG, Ramakrishna S, Yeom KW, Patel S, Chinnasamy H, Schultz LM, Richards RM, Jiang L, Barsan V, Mancusi R, Geraghty AC, Good Z, Mochizuki AY, Gillespie SM, Toland AMS, Mahdi J, Reschke A, Nie EH, Chau IJ, Rotiroti MC, Mount CW, Baggott C, Mavroukakis S, Egeler E, Moon J, Erickson C, Green S, Kunicki M, Fujimoto M, Ehlinger Z, Reynolds W, Kurra S, Warren KE, Prabhu S, Vogel H, Rasmussen L, Cornell TT, Partap S, Fisher PG, Campen CJ, Filbin MG, Grant G, Sahaf B, Davis KL, Feldman SA, Mackall CL, Monje M. GD2-CAR T cell therapy for H3K27M-mutated diffuse midline gliomas. Nature 2022; 603:934-941. [PMID: 35130560 PMCID: PMC8967714 DOI: 10.1038/s41586-022-04489-4] [Citation(s) in RCA: 330] [Impact Index Per Article: 165.0] [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: 08/02/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022]
Abstract
Diffuse intrinsic pontine glioma (DIPG) and other H3K27M-mutated diffuse midline gliomas (DMGs) are universally lethal paediatric tumours of the central nervous system1. We have previously shown that the disialoganglioside GD2 is highly expressed on H3K27M-mutated glioma cells and have demonstrated promising preclinical efficacy of GD2-directed chimeric antigen receptor (CAR) T cells2, providing the rationale for a first-in-human phase I clinical trial (NCT04196413). Because CAR T cell-induced brainstem inflammation can result in obstructive hydrocephalus, increased intracranial pressure and dangerous tissue shifts, neurocritical care precautions were incorporated. Here we present the clinical experience from the first four patients with H3K27M-mutated DIPG or spinal cord DMG treated with GD2-CAR T cells at dose level 1 (1 × 106 GD2-CAR T cells per kg administered intravenously). Patients who exhibited clinical benefit were eligible for subsequent GD2-CAR T cell infusions administered intracerebroventricularly3. Toxicity was largely related to the location of the tumour and was reversible with intensive supportive care. On-target, off-tumour toxicity was not observed. Three of four patients exhibited clinical and radiographic improvement. Pro-inflammatory cytokine levels were increased in the plasma and cerebrospinal fluid. Transcriptomic analyses of 65,598 single cells from CAR T cell products and cerebrospinal fluid elucidate heterogeneity in response between participants and administration routes. These early results underscore the promise of this therapeutic approach for patients with H3K27M-mutated DIPG or spinal cord DMG.
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Affiliation(s)
- Robbie G Majzner
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA.,Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA
| | - Sneha Ramakrishna
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Kristen W Yeom
- Division of Neuroradiology, Department of Radiology, Stanford University, Stanford, CA, USA
| | - Shabnum Patel
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Harshini Chinnasamy
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Liora M Schultz
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Rebecca M Richards
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Li Jiang
- Division of Pediatric Neuro-Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Valentin Barsan
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Rebecca Mancusi
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Anna C Geraghty
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Zinaida Good
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA.,Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Aaron Y Mochizuki
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Shawn M Gillespie
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | | | - Jasia Mahdi
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Agnes Reschke
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Esther H Nie
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Isabelle J Chau
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Maria Caterina Rotiroti
- Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Christopher W Mount
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Christina Baggott
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Sharon Mavroukakis
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Emily Egeler
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Jennifer Moon
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Courtney Erickson
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Sean Green
- Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Michael Kunicki
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Michelle Fujimoto
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Zach Ehlinger
- Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Warren Reynolds
- Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Sreevidya Kurra
- Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Katherine E Warren
- Division of Pediatric Neuro-Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Snehit Prabhu
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Hannes Vogel
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Lindsey Rasmussen
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Timothy T Cornell
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Sonia Partap
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Paul G Fisher
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Cynthia J Campen
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Mariella G Filbin
- Division of Pediatric Neuro-Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Gerald Grant
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Bita Sahaf
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Kara L Davis
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Steven A Feldman
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Crystal L Mackall
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA. .,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA. .,Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA. .,Division of Stem Cell Transplantation and Cell Therapy, Department of Medicine, Stanford University, Stanford, CA, USA.
| | - Michelle Monje
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA, USA. .,Division of Pediatric Hematology, Oncology, Stem Cell Transplantation & Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA. .,Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA. .,Department of Pathology, Stanford University, Stanford, CA, USA. .,Department of Neurosurgery, Stanford University, Stanford, CA, USA. .,Howard Hughes Medical Institute, Stanford University, Stanford, CA, USA.
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5
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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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6
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Ostberg N, Ling J, Winter SG, Som S, Vasilakis C, Shin AY, Cornell TT, Scheinker D. Quantifying paediatric intensive care unit staffing levels at a paediatric academic medical centre: A mixed-methods approach. J Nurs Manag 2021; 29:2278-2287. [PMID: 33894027 DOI: 10.1111/jonm.13346] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/08/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
AIM To identify, simulate and evaluate the formal and informal patient-level and unit-level factors that nurse managers use to determine the number of nurses for each shift. BACKGROUND Nurse staffing schedules are commonly set based on metrics such as midnight census that do not account for seasonality or midday turnover, resulting in last-minute adjustments or inappropriate staffing levels. METHODS Staffing schedules at a paediatric intensive care unit (PICU) were simulated based on nurse-to-patient assignment rules from interviews with nursing management. Multivariate regression modelled the discrepancies between scheduled and historical staffing levels and constructed rules to reduce these discrepancies. The primary outcome was the median difference between simulated and historical staffing levels. RESULTS Nurse-to-patient ratios underestimated staffing by a median of 1.5 nurses per shift. Multivariate regression identified patient turnover as the primary factor accounting for this difference and subgroup analysis revealed that patient age and weight were also important. New rules reduced the difference to a median of 0.07 nurses per shift. CONCLUSION Measurable, predictable indicators of patient acuity and historical trends may allow for schedules that better match demand. IMPLICATIONS FOR NURSING MANAGEMENT Data-driven methods can quantify what drives unit demand and generate nurse schedules that require fewer last-minute adjustments.
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Affiliation(s)
- Nicolai Ostberg
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan Ling
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Shira G Winter
- Center for Health Policy, Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA.,VA Palo Alto Health Care System, Center for Innovation to Implementation, Health Services Research & Development, Palo Alto, CA, USA
| | - Sreeroopa Som
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Christos Vasilakis
- Centre for Healthcare Innovation and Improvement, School of Management, University of Bath, Bath, UK
| | - Andrew Y Shin
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy T Cornell
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - David Scheinker
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.,Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
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7
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Carlton EF, Close J, Paice K, Dews A, Gorga SM, Sturza J, Barbaro RP, Cornell TT, Prescott HC. Clinician Accuracy in Identifying and Predicting Organ Dysfunction in Critically Ill Children. Crit Care Med 2020; 48:e1012-e1019. [PMID: 32804793 PMCID: PMC7959260 DOI: 10.1097/ccm.0000000000004555] [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] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To determine clinician accuracy in the identification and prediction of multiple organ dysfunction syndrome. DESIGN Prospective cohort study. SETTING University of Michigan's C.S. Mott Children's Hospital PICU. PATIENTS Patients admitted to the PICU with an anticipated PICU length of stay greater than 48 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For each patient, the clinical team (attending, fellow, resident/nurse practitioner) was surveyed regarding existing and anticipated organ dysfunction. The primary outcomes were clinicians' accuracy at identifying multiple organ dysfunction syndrome and predicting new or progressive multiple organ dysfunction syndrome, compared to the objective assessment of multiple organ dysfunction syndrome using Proulx criteria. We also measured sensitivity, specificity, negative and positive predictive values, and negative and positive likelihood ratios of clinician assessments. We tested for differences in accuracy by clinician type using chi-square tests. Clinicians rated their confidence in prediction on a 5-point Likert scale. There were 476 eligible PICU admissions, for whom 1,218 surveys were completed. Multiple organ dysfunction syndrome was present in 89 patients (18.7%) at enrollment, and new or progressive multiple organ dysfunction syndrome occurred in 39 (8.2%). Clinicians correctly identified multiple organ dysfunction syndrome with 79.9% accuracy and predicted additional organ dysfunction with 82.6% accuracy. However, the positive and negative likelihood ratios for new or progressive multiple organ dysfunction syndrome prediction were 3.0 and 0.7, respectively, indicating a weak relationship between the clinician prediction and development of new or progressive multiple organ dysfunction syndrome. The positive predictive value of new or progressive multiple organ dysfunction syndrome prediction was just 22.1%. We found no differences in accuracy by clinician type for either identification of multiple organ dysfunction syndrome (80.2% vs 78.2% vs 81.0%; p = 0.57) or prediction of new or progressive multiple organ dysfunction syndrome (84.8% vs 82.8% vs 80.3%; p = 0.26) for attendings, fellows, and residents/nurse practitioners, respectively. There was a weak correlation between the confidence and accuracy of prediction (pairwise correlation coefficient, 0.26; p < 0.001). CONCLUSIONS PICU clinicians correctly identified multiple organ dysfunction syndrome and predicted new or progressive multiple organ dysfunction syndrome with 80% accuracy. However, only 8% of patients developed new or progressive multiple organ dysfunction syndrome, so accuracy was largely due to true negative predictions. The positive predictive value for new or progressive multiple organ dysfunction syndrome prediction was just 22%. Accuracy did not differ by clinician type, but was correlated with self-rated confidence and was higher for negative predictions.
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Affiliation(s)
- Erin F. Carlton
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Jeylan Close
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kelli Paice
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Alyssa Dews
- College of Literature, Science and the Arts, University of Michigan, Ann Arbor, MI
| | - Stephen M. Gorga
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Julie Sturza
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Ryan P. Barbaro
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Timothy T. Cornell
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University, Palo Alto, CA
| | - Hallie C. Prescott
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
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8
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Carlton EF, McHugh WM, McDonough K, Sturza J, Desch K, Cornell TT. Markers of Endothelial Dysfunction and Cytokines in High-Risk Pediatric Patients with Severe Sepsis. Am J Respir Crit Care Med 2020; 201:380-384. [PMID: 31597044 PMCID: PMC6999097 DOI: 10.1164/rccm.201904-0910le] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Erin F. Carlton
- University of Michigan School of MedicineAnn Arbor, Michiganand
| | - Walker M. McHugh
- University of Michigan School of MedicineAnn Arbor, Michiganand
- PreDxion Bio, Inc.South San Francisco, California
| | - Kelli McDonough
- University of Michigan School of MedicineAnn Arbor, Michiganand
| | - Julie Sturza
- University of Michigan School of MedicineAnn Arbor, Michiganand
| | - Karl Desch
- University of Michigan School of MedicineAnn Arbor, Michiganand
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9
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Goldstein SA, Beshish AG, Bush LB, Lowery RE, Wong JH, Schumacher KR, Halligan NLN, Cornell TT, Rocchini AP. Analysis of Inflammatory Cytokines in Postoperative Fontan Pleural Drainage. Pediatr Cardiol 2019; 40:744-752. [PMID: 30710164 DOI: 10.1007/s00246-019-02059-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 10/04/2018] [Accepted: 01/16/2019] [Indexed: 10/27/2022]
Abstract
Prolonged pleural drainage is a common complication in patients after Fontan palliation and is associated with short- and long- term morbidities. Among many potential etiologies, prolonged drainage has an inflammatory component, but there are no descriptions of cytokines in Fontan pleural drainage to date. This study aimed to examine the inflammatory make-up of Fontan pleural drainage. This prospective age-range-matched cohort study recruited 25 patients undergoing Fontan procedure and 15 bi-ventricular patients undergoing cardiopulmonary bypass (CPB). Chest tube samples were taken on postoperative day (POD) 1-4, 7, and 10. Cytokines were measured using Bio-Plex Assays. Univariate comparisons were made in patient characteristics and cytokine levels. Median age was 3.7 y (IQR 2.8-3.9) for controls and 2.5 y (IQR 2.1-2.9) in Fontan patients (p = 0.02). Median drainage duration and daily volume was higher in Fontan patients (both p < 0.001). Inflammatory cytokines (IL-17A, IFN-y, MIP-1β, and TNF-α) were higher in Fontan patients than controls (all p < 0.02). There was an increase in pro-inflammatory cytokines (IL-8, MIP-1β, and TNF-α) from POD1 to the last chest tube day (LCD) in Fontan patients (all p < 0.0001) and a decrease in the anti-inflammatory cytokine IL-10 (p = 0.001). There was no difference in cytokine concentration from POD1 to LCD among controls. There was a significant association with the cytokine concentration of TNF-α on POD1 and duration of chest tube drainage (p < 0.05). Inflammatory cytokine levels in the pleural fluid of Fontan patients are higher compared to bi-ventricular controls and rise over time where controls do not. This suggests ongoing localized inflammation that is not a result of CPB alone and may be an important contributor to pleural drainage in patients after the Fontan procedure.
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Affiliation(s)
- Stephanie A Goldstein
- University of Michigan Congenital Heart Center, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA.
| | | | - Lauren B Bush
- University of Michigan Congenital Heart Center, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | - Ray E Lowery
- University of Michigan Congenital Heart Center, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | | | - Kurt R Schumacher
- University of Michigan Congenital Heart Center, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | - Nadine L N Halligan
- University of Michigan Congenital Heart Center, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | | | - Albert P Rocchini
- University of Michigan Congenital Heart Center, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
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10
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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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11
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Cornell TT, Selewski DT, Alten JA, Askenazi D, Fitzgerald JC, Topjian A, Holubkov R, Page K, Slomine BS, Christensen JR, Dean JM, Moler FW. Acute kidney injury after out of hospital pediatric cardiac arrest. Resuscitation 2018; 131:63-68. [PMID: 30075198 DOI: 10.1016/j.resuscitation.2018.07.362] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Many children with return of spontaneous circulation (ROSC) following cardiac arrest (CA) experience acute kidney injury (AKI). The impact of therapeutic hypothermia on the epidemiology of post-CA AKI in children has not been fully investigated. OBJECTIVE The study aims were to: 1) describe the prevalence of severe AKI in comatose children following out-of-hospital CA (OHCA), 2) identify risk factors for severe AKI, 3) evaluate the impact of therapeutic hypothermia on the prevalence of severe AKI, and 4) evaluate the association of severe AKI with survival and functional outcomes. DESIGN A post hoc secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) trial. SETTING Thirty-six pediatric intensive care units in the United States and Canada. PARTICIPANTS Of 282 eligible subjects with an initial creatinine obtained within 24 h of randomization, 148 were randomized to therapeutic hypothermia and 134 were randomized to therapeutic normothermia. MAIN OUTCOMES AND MEASURES Primary outcome was prevalence of severe AKI, as defined by stage 2 and 3 Kidney Disease Improving Global Outcomes (KDIGO) consensus definition; secondary outcome was survival with a favorable neurobehavioral outcome. For this study, risk factors and outcomes were compared between those with/without severe AKI. RESULTS Of the 282 subjects enrolled, 180 (64%) developed AKI of which 117 (41% of all enrolled) developed severe AKI. Multivariable modeling found younger age, longer duration of chest compressions, higher lactate level at time of temperature intervention and higher number of vasoactive agents through day 1 of intervention associated with severe AKI. There was no difference in severe AKI between therapeutic hypothermia (39.9%) and therapeutic normothermia (43.3%) groups (p = 0.629). Survival was lower in those with severe AKI at 28 days (21% vs no severe AKI 49%, p < 0.001) and 12 months (21% vs no severe AKI 42%, p < 0.001). One year survival with favorable functional outcome was lower in those with severe AKI. CONCLUSIONS AND RELEVANCE Severe AKI occurs frequently in children with ROSC after OHCA, especially in younger children and those with higher initial lactates and hemodynamic support. Severe AKI was associated with worse survival and functional outcome. Therapeutic hypothermia did not reduce the incidence of severe AKI.
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Affiliation(s)
| | | | - Jeffrey A Alten
- The Heart Institute, Cincinnati Children's Hospital Medical Center, United States
| | | | | | - Alexis Topjian
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Kent Page
- University of Utah, Salt Lake City, UT, United States
| | - Beth S Slomine
- Kennedy Krieger Institute and Johns Hopkins University, Baltimore, MD, United States
| | - James R Christensen
- Kennedy Krieger Institute and Johns Hopkins University, Baltimore, MD, United States
| | | | - Frank W Moler
- University of Michigan, Ann Arbor, MI, United States
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12
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Song Y, Chen P, Chung MT, Nidetz R, Park Y, Liu Z, McHugh W, Cornell TT, Fu J, Kurabayashi K. AC Electroosmosis-Enhanced Nanoplasmofluidic Detection of Ultralow-Concentration Cytokine. Nano Lett 2017; 17:2374-2380. [PMID: 28296413 PMCID: PMC5487264 DOI: 10.1021/acs.nanolett.6b05313] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [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: 05/06/2023]
Abstract
Label-free, nanoparticle-based plasmonic optical biosensing, combined with device miniaturization and microarray integration, has emerged as a promising approach for rapid, multiplexed biomolecular analysis. However, limited sensitivity prevents the wide use of such integrated label-free nanoplasmonic biosensors in clinical and life science applications where low-abundance biomolecule detection is needed. Here, we present a nanoplasmofluidic device integrated with microelectrodes for rapid, label-free analysis of a low-abundance cell signaling protein, detected by AC electroosmosis-enhanced localized surface plasmon resonance (ACE-LSPR) biofunctional nanoparticle imaging. The ACE-LSPR device is constructed using both bottom-up and top-down sensor fabrication methods, allowing the seamless integration of antibody-conjugated gold nanorod (AuNR) biosensor arrays with microelectrodes on the same microfluidic platform. Applying an AC voltage to microelectrodes while scanning the scattering light intensity variation of the AuNR biosensors results in significantly enhanced biosensing performance. The AC electroosmosis (ACEO) based enhancement of the biosensor performance enables rapid (5-15 min) quantification of IL-1β, a pro-inflammatory cytokine biomarker, with a sensitivity down to 158.5 fg/mL (9.1 fM) for spiked samples in PBS and 1 pg/mL (58 fM) for diluted human serum. Together with the optimized detection sensitivity and speed, our study presents the first critical step toward the application of nanoplasmonic biosensing technology to immune status monitoring guided by low-abundance cytokine measurement.
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Affiliation(s)
- Yujing Song
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Pengyu Chen
- Materials Research and Education Center, Auburn University, Auburn, Alabama 36849, United States
| | - Meng Ting Chung
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Robert Nidetz
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Younggeun Park
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Zhenhui Liu
- Department of Mechanical Engineering, Tsinghua University, Beijing, 100084, People’s Republic of China
| | - Walker McHugh
- Department of Pediatrics and Communicable Diseases, 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
| | - 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
- Department of Cell and Developmental Biology, University of Michigan Medical School, 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
- Corresponding Author:
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13
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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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14
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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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15
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Affiliation(s)
- Neal B. Blatt
- University of Michigan Department of Pediatrics and Communicable Diseases, Division of Pediatric Nephrology, Ann Arbor, MI
| | - Timothy T. Cornell
- University of Michigan Department of Pediatrics and Communicable Diseases, Division of Pediatric Critical Care, Ann Arbor, MI
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16
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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
![]()
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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17
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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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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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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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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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21
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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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22
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Chang HN, Leroueil PR, Selwa K, Gasper CJ, Tsuchida RE, Wang JJ, McHugh WM, Cornell TT, Baker JR, Goonewardena SN. Profiling inflammatory responses with microfluidic immunoblotting. PLoS One 2013; 8:e81889. [PMID: 24312374 PMCID: PMC3842271 DOI: 10.1371/journal.pone.0081889] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [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: 06/24/2013] [Accepted: 10/17/2013] [Indexed: 11/18/2022] Open
Abstract
Rapid profiling of signaling pathways has been a long sought after goal in biological sciences and clinical medicine. To understand these signaling pathways, their protein components must be profiled. The protein components of signaling pathways are typically profiled with protein immunoblotting. Protein immunoblotting is a powerful technique but has several limitations including the large sample requirements, high amounts of antibody, and limitations in assay throughput. To overcome some of these limitations, we have designed a microfluidic protein immunoblotting device to profile multiple signaling pathways simultaneously. We show the utility of this approach by profiling inflammatory signaling pathways (NFκB, JAK-STAT, and MAPK) in cell models and human samples. The microfluidic immunoblotting device can profile proteins and protein modifications with 5380-fold less antibody compared to traditional protein immunoblotting. Additionally, this microfluidic device interfaces with commonly available immunoblotting equipment, has the ability to multiplex, and is compatible with several protein detection methodologies. We anticipate that this microfluidic device will complement existing techniques and is well suited for life science applications.
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Affiliation(s)
- Huai-Ning Chang
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Pascale R. Leroueil
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Katherine Selwa
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
| | - C. J. Gasper
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Ryan E. Tsuchida
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jason J. Wang
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Walker M. McHugh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Timothy T. Cornell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, United States of America
| | - James R. Baker
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Sascha N. Goonewardena
- Michigan Nanotechnology Institute for Medicine and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
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23
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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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27
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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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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 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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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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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Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T, Kommareddi M, Kershaw DB, Shanley TP, Heung M. Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med 2011; 37:1166-73. [PMID: 21533569 DOI: 10.1007/s00134-011-2231-3] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 03/08/2011] [Indexed: 01/20/2023]
Abstract
PURPOSE In pediatric intensive care unit (PICU) patients, fluid overload (FO) at initiation of continuous renal replacement therapy (CRRT) has been reported to be an independent risk factor for mortality. Previous studies have calculated FO based on daily fluid balance during ICU admission, which is labor intensive and error prone. We hypothesized that a weight-based definition of FO at CRRT initiation would correlate with the fluid balance method and prove predictive of outcome. METHODS This is a retrospective single-center review of PICU patients requiring CRRT from July 2006 through February 2010 (n = 113). We compared the degree of FO at CRRT initiation using the standard fluid balance method versus methods based on patient weight changes assessed by both univariate and multivariate analyses. RESULTS The degree of fluid overload at CRRT initiation was significantly greater in nonsurvivors, irrespective of which method was used. The univariate odds ratio for PICU mortality per 1% increase in FO was 1.056 [95% confidence interval (CI) 1.025, 1.087] by the fluid balance method, 1.044 (95% CI 1.019, 1.069) by the weight-based method using PICU admission weight, and 1.045 (95% CI 1.022, 1.07) by the weight-based method using hospital admission weight. On multivariate analyses, all three methods approached significance in predicting PICU survival. CONCLUSIONS Our findings suggest that weight-based definitions of FO are useful in defining FO at CRRT initiation and are associated with increased mortality in a broad PICU patient population. This study provides evidence for a more practical weight-based definition of FO that can be used at the bedside.
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Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
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Abstract
Sepsis is defined as the systemic inflammatory response of the human host that is triggered by an invading pathogen. Despite tremendous advances in both our knowledge of and treatment strategies for this syndrome, sepsis remains among the major causes of morbidity and mortality in children worldwide. Thus, we hypothesize that an improved mechanistic understanding obtained via basic and translational science will continue to identify novel therapeutic targets and approaches. As a result, given the central importance of the alterations in gene expression in regulating the human host's physiologic response to a pathogen, we review the complex factors-genetics, transcriptional expression, and epigenetics-that regulate unique gene-expression patterns in pediatric sepsis and septic shock. We anticipate that emerging data from genetic, genomic, and other translation studies in pediatric sepsis will advance our biological understanding of this response and undoubtedly identify targets for newer therapies.
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Affiliation(s)
- Timothy T. Cornell
- Division of Critical Care Medicine, C.S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI
| | - James Wynn
- Division of Neonatology, Duke University Children’s Hospital, Durham, NC
| | - Thomas P. Shanley
- Division of Critical Care Medicine, C.S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI
| | - Derek S. Wheeler
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Abstract
Invasion of the human by a pathogen necessitates an immune response to control and eradicate the microorganism. When this response is inadequately regulated, systemic manifestations can result in physiologic changes described as "sepsis." Recognition, diagnosis, and management of sepsis remain among the greatest challenges shared by the fields of neonatology and pediatric critical care medicine. Sepsis remains among the leading causes of death in both developed and underdeveloped countries and has an incidence that is predicted to increase each year. Despite these sobering statistics, promising therapies derived from preclinical models have universally failed to obviate the substantial mortality and morbidity associated with sepsis. Thus, there remains a need for well-designed epidemiologic and mechanistic studies of neonatal and pediatric sepsis to improve our understanding of the causes (both early and late) of deaths attributed to the syndrome. In reviewing the definitions and epidemiology, developmental influences, and regulation of the host response to sepsis, it is anticipated that an improved understanding of this host response will assist clinician-investigators in identifying improved therapeutic strategies.
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Affiliation(s)
- James Wynn
- Division of Neonatology, Duke University Children’s Hospital, Durham, NC
| | - Timothy T. Cornell
- Division of Critical Care Medicine, C.S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Thomas P. Shanley
- Division of Critical Care Medicine, C.S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI
| | - Derek S. Wheeler
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Cornell TT, Hinkovska-Galcheva V, Sun L, Cai Q, Hershenson MB, Vanway S, Shanley TP. Ceramide-dependent PP2A regulation of TNFalpha-induced IL-8 production in respiratory epithelial cells. Am J Physiol Lung Cell Mol Physiol 2009; 296:L849-56. [PMID: 19286927 DOI: 10.1152/ajplung.90516.2008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
IL-8 is a key mediator in the pathophysiology of acute lung injury. TNFalpha stimulates IL-8 production in respiratory epithelial cells by activating both the NF-kappaB and MAP kinase pathways. The precise mechanism by which these pathways are downregulated to terminate IL-8 production remains unclear. We studied the regulatory role of the serine/threonine phosphatase, PP2A, on the signaling pathways involved in IL-8 production from respiratory epithelial cells. Inhibition of PP2A using okadaic acid or gene knockdown using siRNA resulted in an augmentation of TNFalpha-induced IL-8 production. We also found that PP2A inhibition resulted in prolonged activation of JNK, p38, and ERK resulting in both increased transcriptional activation of the IL-8 promoter and posttranscriptional stabilization of IL-8 mRNA. Because TNFalpha had been shown to activate ceramide accumulation, and separate studies had linked ceramide with activation of PP2A, we hypothesized the pathway of TNFalpha-inducing ceramide to activate PP2A comprised an endogenous regulatory pathway. Inhibition of the immediate sphingomyelinase-dependent pathway as well as the de novo synthesis pathway of ceramide production reduced serine/threonine phosphatase activity and augmented IL-8 production. These data suggest that ceramide plays a role in activating PP2A to terminate ongoing IL-8 production. In summary, our data suggest that in respiratory epithelium, TNFalpha induces ceramide accumulation, resulting in subsequent activation of PP2A, which targets those kinases responsible for transcriptional activation of IL-8.
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Affiliation(s)
- Timothy T Cornell
- Division of Pediatric Critical Care Medicine, C. S. Mott Children's Hospital, Ann Arbor, MI 48109-0243, USA.
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Fleming GM, Cornell TT, Welling TH, Magee JC, Annich GM. Hepatopulmonary syndrome: use of extracorporeal life support for life-threatening hypoxia following liver transplantation. Liver Transpl 2008; 14:966-70. [PMID: 18581508 PMCID: PMC4414403 DOI: 10.1002/lt.21477] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [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] [Indexed: 12/26/2022]
Abstract
Hepatopulmonary syndrome is an uncommon complication of nonacute liver failure, and in rare cases, hypoxia may be the presenting sign of liver dysfunction. The condition, once thought to be a contraindication, is improved in most cases by transplantation. There is a significant risk of postoperative, hypoxia-related morbidity and mortality in patients with hepatopulmonary syndrome. We present a case of life-threatening hypoxia following liver transplantation for liver failure and associated hepatopulmonary syndrome, with successful management using extracorporeal membrane oxygenation.
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Mischler M, Fleming GM, Shanley TP, Madden L, Levine J, Castle V, Filipovich AH, Cornell TT. Epstein-Barr virus-induced hemophagocytic lymphohistiocytosis and X-linked lymphoproliferative disease: a mimicker of sepsis in the pediatric intensive care unit. Pediatrics 2007; 119:e1212-8. [PMID: 17403820 DOI: 10.1542/peds.2006-1534] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A rare complication of infection with the Epstein-Barr virus is the development of hemophagocytic lymphohistiocytosis. Although most cases of Epstein-Barr virus-induced hemophagocytic lymphohistiocytosis develop in immunocompetent individuals, the rare immunodeficiency X-linked lymphoproliferative disease is often unmasked by Epstein-Barr virus infection and is clinically indistinguishable from Epstein-Barr virus-induced hemophagocytic lymphohistiocytosis. We describe the clinical course and management of a previously healthy 17-year-old boy who presented with hemodynamic collapse and severe systemic inflammatory response syndrome resulting from overwhelming hemophagocytosis in the setting of X-linked lymphoproliferative disease. A novel therapeutic approach using anti-tumor necrosis factor alpha therapy was instituted, aimed at attenuating the viral-induced hyperinflammatory state. Given the similarity to overwhelming sepsis, yet a substantially different therapeutic approach, this case illustrates the importance of early recognition and prompt treatment that are necessary to reduce the high morbidity and mortality associated with Epstein-Barr virus-induced hemophagocytic lymphohistiocytosis and X-linked lymphoproliferative disease.
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Affiliation(s)
- Matthew Mischler
- Division of Pediatric Critical Care Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan 48109, USA
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Affiliation(s)
- Timothy T Cornell
- Division of Pediatric Critical Care Medicine, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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