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Cryptococcus gattii infection is a rare cause of severe pulmonary disease and meningoencephalitis that has only recently been detected in the southeastern United States. We describe an organ transplant-associated outbreak of C. gattii infection involving an HIV-negative immunosuppressed donor in this region who died following new-onset headache and seizure of unknown cause. Retrospective cryptococcal antigen (CrAg) testing of donor serum was positive. Two of the three transplant recipients developed severe C. gattii infection 11 and 12 weeks following transplantation. One recipient died from severe pulmonary infection, identified on autopsy, and the other ill recipient survived following treatment for cryptococcal meningitis. This outbreak underscores the importance of considering cryptococcosis in patients with clinical findings suggestive of subacute meningitis or other central nervous system (CNS) pathology, and the potential benefit of routine pre-transplant donor CrAg screening using lateral flow assay to guide recipient antifungal prophylaxis. The case also adds to emerging evidence that C. gattii is a potential threat in the southeastern United States.

The development of nursing knowledge requires a close relationship between theory, research, and practice. The purpose of the analysis of the concept of "parental decision-making in pediatric critical care" is to facilitate nurses' therapeutic care of critically ill children and their families. To construct, structure, and give meaning to the concept, we use our experience in the field, critical reading of the literature, and careful analysis of data that have emerged about parental decision-making in pediatric intensive care. Several factors affect parent's ability to act as decision-makers: the psychosocial and physical disorders they develop, the subordination of their parental roles by the health care team, and the child's critical state of health. While different disciplines, including nursing, have well described the decision-making concept, parental decision-making in the context of pediatric intensive care has not been as well delineated. Nursing science recognizes the importance of decision-making and has incorporated the concept as an essential domain of its philosophical and disciplinary interests. Following the method proposed by Walker and Avant, the concept was analyzed, attributes, background, and consequences described. A model case was presented and discussed. An operational definition emerges, providing knowledge for professional nursing practice and will be the basis for an essential theoretical development around this phenomenon. Parents' recognition, the promotion of family-centered care, and shared decisions are ideal for encouraging parental participation.

BACKGROUND Failure of the car seat tolerance screen (CSTS) during hospitalization often leads to a recommendation for automobile travel within a car bed at discharge. PURPOSE To describe the parental experience utilizing a car bed for infant automobile transportation. METHODS A descriptive, qualitative study design was undertaken with a purposive sample of parents recruited for a single interview in the pulmonary clinic at the time of the follow-up CSTS, approximately 1 month after hospital discharge. Interviews, guided by a semistructured interview tool, provided a holistic understanding of the parental experience utilizing car bed travel. FINDINGS/RESULTS Data from 15 parental interviews revealed an overarching emotional journey consisting of 5 themes: (1) an adjustment period; (2) decision-making related to the car bed purchase; (3) encounters with varied provider education and knowledge; (4) safety and security of the car bed during transit; and (5) space and mobility restrictions imposed by the car bed. IMPLICATIONS FOR PRACTICE While recommendations exist for infant travel in a car seat, supportive recommendations for parents with an infant who needs to travel in a car bed do not exist. Based on study findings, providing parents supportive guidelines, education, and recommendations for their infant requiring travel in a car bed may be a strategy to ease the stress experienced in this situation. IMPLICATIONS FOR RESEARCH Findings indicated a need to develop policies and standards, as well as comprehensive education, for providers and parents related to car bed travel. Further research is needed to identify strategies to best support parents and infants.

Background The trapezius muscle is often utilized as a muscle or nerve donor for repairing shoulder function in those with brachial plexus birth palsy (BPBP). To evaluate the native role of the trapezius in the affected limb, we demonstrate use of the Motion Browser, a novel visual analytics system to assess an adolescent with BPBP. Method An 18-year-old female with extended upper trunk (C5–6–7) BPBP underwent bilateral upper extremity three-dimensional motion analysis with Motion Browser. Surface electromyography (EMG) from eight muscles in each limb which was recorded during six upper extremity movements, distinguishing between upper trapezius (UT) and lower trapezius (LT). The Motion Browser calculated active range of motion (AROM), compiled the EMG data into measures of muscle activity, and displayed the results in charts. Results All movements, excluding shoulder abduction, had similar AROM in affected and unaffected limbs. In the unaffected limb, LT was more active in proximal movements of shoulder abduction, and shoulder external and internal rotations. In the affected limb, LT was more active in distal movements of forearm pronation and supination; UT was more active in shoulder abduction. Conclusion In this female with BPBP, Motion Browser demonstrated that the native LT in the affected limb contributed to distal movements. Her results suggest that sacrificing her trapezius as a muscle or nerve donor may affect her distal functionality. Clinicians should exercise caution when considering nerve transfers in children with BPBP and consider individualized assessment of functionality before pursuing surgery.

Background Over the past 2 decades, the prevalence of neonatal abstinence syndrome (NAS) has increased almost 5-fold. Skin-to-skin care (SSC), a method of parent-infant holding, is a recommended nonpharmacologic intervention for managing NAS symptoms. SSC has the potential to reduce withdrawal symptoms while positively influencing parent-infant attachment. Yet, little is known about the SSC experiences of mothers of infants with NAS. Purpose The purpose of this study was to explore the SSC experiences of mothers of infants with NAS, including perceived barriers to SSC in the hospital and following discharge home. Methods A qualitative descriptive design was used to obtain new knowledge regarding the experience of SSC of mothers of infants with NAS. Purposive sampling was used to recruit participants eligible for the study. We conducted semistructured individual interviews with postpartum mothers of infants with NAS. Data were analyzed using thematic analysis. Findings/results Thirteen mothers participated in the study. Four themes emerged from the data analysis: "a little nerve racking"; "she needed me, and I needed her"; dealing with the "hard times"; and "a piece of my puzzle is missing." SSC was described as a conduit for healing and bonding; in addition, several barriers to SSC were reported. Implications for practice and research These findings highlight the inherent benefits of SSC for infants with NAS and demonstrate the unique challenges of these mother-infant dyads. Critical changes in hospital practices are needed to create an environment supportive of SSC for this patient population. In addition, research regarding implementation of interventions to increase SSC usage in this population is warranted.

Background The current US opioid crisis has resulted in a significant increase in opioid use disorder among pregnant and parenting women. Substance use disorders, in general, are highly stigmatized conditions. Stigma serves as a well-documented global barrier to health-seeking behaviors and engagement in healthcare. While extensive research exists on the stigma of mental illness, few studies have explored the stigma experienced by families impacted by neonatal abstinence syndrome (NAS). Purpose Therefore, the purpose of this article is to explore the role of stigma in the care of families impacted by NAS. Methods In this article, we present a discussion about the effects of stigma on this patient population and provide exemplars of stigma experiences from our previous research and the existing literature. Findings/results Mothers of infants with NAS faced the challenges of overcoming stigma as they were often ostracized, excluded, and shamed. Nurses who provide care for these women and their infants have reported experiencing ethical distress, moral distress, and compassion fatigue. Implications for practice Greater awareness of the impact of opioid use on the maternal-child population has resulted in numerous educational offerings for healthcare providers; however, this alone is not adequate to end stigma. Fortunately, promising tools and methods have been developed for assisting nurses with addressing stigma in a manner that can be both nonconfrontational and highly effective. Implications for research Future research is needed to explore and evaluate the efficacy of various existing strategies for counteracting harmful stigma in this patient population.

PurposeThis article proposes a model for benchmarking tourism quality of life (QoL) that is practical and affordable to implement by communities of all sizes. The model is tested on a group of 30 mountain towns in the Appalachian region of the United States.Design/methodology/approachAn existing model measuring resident QoL from Roanoke, Virginia, is discussed and a new model for tourist QoL is proposed. Both models employ secondary data from free sources to calculate a practical, affordable and quantifiable QoL index.FindingsAnalysis of the data indicates the Appalachian mountain town with the highest tourist QoL score is Lynchburg, Virginia, with a composite QoL index value of 128, followed closely by Charlottesville, Virginia, with an index of 126 (where an index of 100 = the US national average).Practical implicationsA tourist QoL model has practical value because it can be used by local policymakers to benchmark their region's QoL, make comparisons with other destinations, and ultimately, as a tool to help market their community – all using free and readily available data.Originality/valueThis case study adds value to the hospitality and tourism literature by sharing the Roanoke QoL model for the first time with the academic and practitioner community and extends its methods to propose how a tourist QoL model would work. It also addresses the research gap noted by Uysal et al. (2016) who observed a dearth of tourism research studies that utilize objective measures.

Background: In patients with heart failure, chronic kidney disease is common and associated with a higher risk of renal events than in patients without chronic kidney disease. We assessed the renal effects of angiotensin/neprilysin inhibition in patients who have heart failure with preserved ejection fraction enrolled in the PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction). Methods: In this randomized, double-blind, event-driven trial, we assigned 4822 patients who had heart failure with preserved ejection fraction to receive sacubitril/valsartan (n=2419) or valsartan (n=2403). Herein, we present the results of the prespecified renal composite outcome (time to first occurrence of either: ≥50% reduction in estimated glomerular filtration rate (eGFR), end-stage renal disease, or death from renal causes), the individual components of this composite, and the influence of therapy on eGFR slope. Results: At randomization, eGFR was 63±19 mL·min –1 ·1.73 m – 2. At study closure, the composite renal outcome occurred in 33 patients (1.4%) assigned to sacubitril/valsartan and 64 patients (2.7%) assigned to valsartan (hazard ratio, 0.50 [95% CI, 0.33–0.77]; P =0.001). The treatment effect on the composite renal end point did not differ according to the baseline eGFR (–1 ·1.73 m –2 ( P -interaction=0.92). The decline in eGFR was less for sacubitril/valsartan than for valsartan (–2.0 [95% CI, –2.2 to –1.9] versus –2.7 [95% CI, –2.8 to –2.5] mL·min –1 ·1.73 m –2 per year). Conclusions: In patients with heart failure with preserved ejection fraction, sacubitril/valsartan reduced the risk of renal events, and slowed decline in eGFR, in comparison with valsartan. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01920711.

We conducted a phase 1 dose escalation study (ACTRN12618000140257 registered on 30/01/2018) to evaluate the safety, tolerability and immunogenicity of a therapeutic human papillomavirus (HPV) DNA vaccine (AMV002) in subjects previously treated for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Eligible subjects had to have no evidence of recurrent and/or metastatic disease at least 12 weeks following the completion of treatment. Three dosing cohorts each consisted of four subjects: group 1: 0.25 mg/dose, group 2: 1 mg/dose, group 3: 4 mg/dose. AMV002 was delivered intradermally on days 0, 28 and 56. Incidence and severity of treatment-emergent adverse events (TEAE) including local reaction at the injection site, and vaccination compliance were recorded. T cell and antibody responses to HPV16 E6 and E7 were measured by interferon gamma (IFN-γ) enzyme-linked immunosorbent spot (ELISpot) assay and enzyme-linked immunosorbent assay (ELISA). All subjects completed the vaccination programme and experienced mild discomfort at the injection site(s). Pre-immunisation, cell-mediated responses to HPV16 E6 and E7 were evident in all subjects, and E7-specific antibodies were detected in 11 (91.7%), reflecting previous exposure to HPV. Post-vaccination, 10 of 12 (83.3%) subjects responded to one or more of the E6 and/or E7 peptide pools, while 2 (16.7%) did not show additional vaccine-induced cell-mediated responses. Vaccination resulted in a ≥ 4-fold increase in anti-HPV16 E7 antibody titre in one subject in group 3. AMV002 was well tolerated at all dose levels and resulted in enhanced specific immunity to virus-derived tumour-associated antigens in subjects previously treated for HPV-associated OPSCC.

BACKGROUND Smaller preterm infants often receive extra attention with implementation of additional thermoregulation interventions in the delivery room. Yet, these bundles of interventions have largely remained understudied in larger infants. PURPOSE The purpose of this study was to evaluate initial (or admission) temperatures of infants born weighing 1500 g or more with diagnoses requiring admission to the neonatal intensive care unit (NICU). METHODS Retrospective medical record review of 388 infants weighing 1500 g or more admitted to the NICU between January 2016 and June 2017. RESULT In total, 42.5% of infants weighing 1500 g or more were admitted hypothermic (

A 19-year-old female college undergraduate developed an intensely swollen, erythematous and pruritic rash on the face and hands while working in an optical fabrication lab producing photosensitive polymers. She had no respiratory symptoms. The rash was consistent with contact dermatitis and there was no clinical evidence of respiratory involvement with normal spirometry. A review of the safety data sheets of chemicals used in the laboratory revealed several known sensitizers, including 6-hexamethylene diisocyanate (HDI), dibutyl phthalate, and 2,4,6-tribromophenyl acrylate. Patch testing confirmed the patient's sensitization to HDI. A subsequent worksite visit identified several hazardous chemicals that were used without appropriate hazard communication, training, standard operating procedures, or personal protective equipment. Simple exposure controls were recommended and instituted, and the patient was able to return to work in the laboratory without the recurrence of symptoms. This case demonstrates the importance of hazard identification, communication, and safety training in academic laboratories, for students and workers. A medical evaluation can identify hazards as well as lead to improvements in exposure controls and safe return to research.

Background Oral feeding is one of the most complex maturational skills of infancy. Difficulties with feeding require specialized attention, and if not well managed, may prolong the newborn's hospital length of stay. This is particularly true for prenatally opioid exposed (POE) infants. A paucity of literature exists characterizing feeding behaviors of POE infants, yet feeding problems are common. Purpose The purpose of this integrative review was to synthesize and critically analyze the evidence that characterizes feeding behaviors in full-term, POE infants. Methods/search strategy The electronic databases of CINAHL, PubMed, Scopus, and PsycINFO were used. Inclusion criteria were studies in English, conducted from 1970 to 2019, with participant samples consisting of infants with prenatal opioid exposure, born full-term, and between 38 and 40 weeks of gestation. Based on the inclusion criteria, our search yielded 557 articles. After further screening, only 4 studies met our full inclusion/exclusion criteria. These studies were analyzed for evidence of infant feeding behaviors, including characterization of problematic feeding behavior for POE infants. Findings/results Our findings revealed inconsistencies in characterization of feeding behaviors among POE infants. A synthesis of the most common evidence-based behaviors was constructed. Infant feeding behaviors were identified and grouped into 2 major behavior domains: (1) typical feeding behavior and (2) problematic feeding behavior. Implications for practice and research Feeding behaviors related to sucking and behavioral states may be different in POE infants. Further examination of effective assessment methods and the categorization of infant feeding behaviors are warranted for use in the development of evidence-based, targeted intervention.

Hydrogen sulfide (H2 S), a high-threat chemical agent, occurs naturally in a variety of settings. Despite multiple incidents of exposures and deaths, no FDA-approved antidote exists. A rapid-acting, easy to administer antidote is needed. We conducted a randomized control trial in swine comparing intramuscular administration of aminotetrazole cobinamide (2.9 mL, 18 mg/kg) to no treatment following inhalation of H2 S gas. We found that aminotetrazole cobinamide administered 2 min after the onset of respiratory depression-defined as a tidal volume of less than 3 mL/kg for 2 consecutive minutes-yielded 100% survival, while all control animals died. Respiratory depression resolved in the treatment group within 3.6 ± 1.5 min (mean ± SD) of cobinamide administration, whereas control animals had intermittent gasping until death. Blood pressure and arterial oxygen saturation (SO2 ) returned to baseline values within 5 and 10 min, respectively, of cobinamide treatment, and plasma lactate concentration decreased to less than 50% of the highest value by the end of the experiment. In control animals, plasma lactate rose continuously until death. We conclude that intramuscular aminotetrazole cobinamide is effective in a large animal, inhalational model of acute, severe H2 S poisoning.

OBJECTIVE: To determine incidence and risk factors of post-sterilization hyphema in shelter cats. ANIMALS STUDIED: Retrospective medical record review of 1,204 cats and prospective screening of 195 cats. PROCEDURES: The study consisted of 3 parts: (1) Survey responses were collected from 20 veterinarians, who perform high-quality high-volume spay-neuter (HQHVSN) in both shelter and public clinic settings. (2) Medical records of 1,204 cats were analyzed retrospectively over a 14-month time period. (3) Ophthalmic examinations, including tonometry, were performed prospectively on 195 cats before and after sterilization surgery over 8 weeks. RESULTS: Nine of 20 surveyed veterinarians reported having witnessed hyphema in cats following sterilization surgery. Retrospective review of 1,204 medical record and prospective screening of 195 cats showed that 3 juvenile (1 year of age) cats, respectively. CONCLUSIONS: Survey responses and 3 observed cases confirm the existence of feline post-sterilization hyphema with an estimated incidence of 0.2%. The underlying mechanism for this occurrence remains unknown.

The Midwestern “Corn‐Belt” in the United States is the most productive agricultural region on the planet despite being predominantly rainfed. In this region, global climate change is driving precipitation patterns toward wetter springs and drier mid‐ to late‐summers, a trend that is likely to intensify in the future. The lack of precipitation can lead to crop water limitations that ultimately impact growth and yields. Young plants exposed to water stress will often invest more resources into their root systems, possibly priming the crop for any subsequent mid‐ or late‐season drought. The trend toward wetter springs, however, suggests that opportunities for crop priming may lessen in the future. Here, we test the hypothesis that early season dry conditions lead to drought priming in field‐grown crops and this response will protect crops against growth and yield losses from late‐season droughts. This hypothesis was tested for the two major Midwestern crop, maize and soybean, using high‐resolution daily weather data, satellite‐derived phenological metrics, field yield data, and ecosystem‐scale model (Agricultural Production System Simulator) simulations. The results from this study showed that priming mitigated yield losses from a late season drought of up to 4.0% and 7.0% for maize and soybean compared with unprimed crops experiencing a late season drought. These results suggest that if the trend toward wet springs with drier summers continues, the relative impact of droughts on crop productivity is likely to worsen. Alternatively, identifying opportunities to breed or genetically modify pre‐primed crop species may provide improved resilience to future climate change.

Supplemental digital content is available in the text., Background Neonatal abstinence syndrome (NAS) rates have dramatically increased. Breastfeeding is a nonpharmacological intervention that may be beneficial, reducing NAS symptom severity and thus the need for and duration of pharmacological treatment and length of hospital stay. Objectives Conduct meta-analysis to determine whether breastfeeding results in better outcomes for NAS infants. Variables included symptom severity, need for and duration of pharmacological treatment, and length of hospital stay. Methods PubMed, Scopus, Embase, and Cochrane Library were searched from 2000 to 2020, and comparative studies examining breastfeeding for NAS infants were extracted. Randomized trials and cohort studies were included. Data were extracted and evaluated with Review Manager Version 5.3. A random-effects model was used to pool discontinuous outcomes using risk ratio and 95% confidence intervals. Continuous outcomes were evaluated by mean differences and 95% confidence intervals. Results Across 11 studies, 6,375 neonates were included in the meta-analysis. Using a random-effects analysis, breastfeeding reduced initiation of pharmacological treatment, reduced duration of pharmacological treatment, and reduced length of stay. No differences were detected for severity of NAS symptoms. Most studies only reported one to two variables of interest. For most studies, these variables were not the primary study outcomes. All studies were found to be of low risk and good quality based on the Cochrane Risk Assessment Tools. Varying breastfeeding definitions limit generalizability. Discussion Breastfeeding is associated with decreased initiation and duration of pharmacological treatment and length of stay.

Background Solid-organ transplant (SOT) recipients with COVID-19 have higher risk of adverse outcomes compared to the general population. Whether hospitalized SOT recipients with COVID-19 are at higher risk of mortality than SOT recipients hospitalized for other causes, including non-COVID-19 pneumonia, remains unclear. Methods We used logistic regression to compare outcomes of SOT recipients hospitalized with COVID-19 to non-COVID-19 related admissions and with non-COVID-19 pneumonia. Results Of 17,012 hospitalized SOT recipients, 1,682 had COVID-19. Those with COVID-19 had higher odds of ICU admission (adjusted odds ratio [aOR] 2.12 [95%CI: 1.88-2.39]) and mechanical ventilation (aOR 3.75 [95%CI: 3.24-4.33]). COVID-19 was associated with higher odds of in-hospital death, which was more pronounced earlier in the pandemic (aOR 9.74 [95%CI: 7.08-13.39] for April/May versus aOR 7.08 [95%CI: 5.62-8.93] for June through November 2020; p-interaction = 0.03). Compared to SOT recipients hospitalized with non-COVID-19 pneumonia, odds of in-hospital death were higher in SOT recipients with COVID-19 (aOR 2.44 [95% CI: 1.90-3.13]), regardless of time of hospitalization (p-interaction >0.40). Conclusions In this large cohort of SOT recipients, hospitalization with COVID-19 was associated with higher odds of complications and in-hospital mortality than non-COVID-19 related admissions, and 2.5-fold higher odds of in-hospital mortality, compared to SOT recipients with non-COVID-19 pneumonia. This article is protected by copyright. All rights reserved.

Now is an exciting era of development in immunotherapy checkpoint inhibitors and their effect on the treatment of NPC. While the general prognosis of R/M disease is poor, immunotherapy offers some promise in a malignancy associated with EBV and characterized by a peritumoural immune infiltrate. Our study aims to review past and on-going clinical trials of monoclonal antibody therapies against the checkpoint inhibitors (e.g. PD1 and CTLA-4), in R/M NPC. All randomized and nonrandomized controlled trials involving immune checkpoint inhibitor interventions for treatment of NPC were included in the study. We utilized a validated "risk of bias" tool to assess study quality. Four separate Phase I-II trials report the potential of PD1 inhibitor treatment for patients with NPC. Within the observed groups, camrelizumab combined with chemotherapy achieved an objective response in 91% of patients as first-line treatment for metastatic NPC (PFS 68% at 1-year) but this was associated with a high rate of grade >3 adverse events (87%; CTCAE version 4.03). The remaining three studies focused on recurrent NPC disease in patients who had received at least one line of prior chemotherapy. Within this group, camrelizumab monotherapy achieved an objective response in 34% of patients (PFS 27% at 1-year; range across all three studies 20.5-34%). No NPC trial has yet reported on specific outcomes for non-PD1 checkpoint inhibitors but 11 on-going studies include alternative targets (e.g. PD-L1/CTLA-4) as combination or monotherapy treatments. In considering checkpoint immunotherapies for NPC, initial results show promise for anti-PD1 interventions. Further phase I-III trials are in progress to clarify clinical outcomes, fully determine safety profiles, and optimize drug combinations and administration schedules.

Benefits of exclusive human milk diets for preterm and low birth-weight infants are well established. Despite known benefits, supporting mothers in the provision of mother's own milk for high-risk infants is challenging. Lactation support in the neonatal intensive care unit (NICU) is highly variable. Lactations consultants (LCs) are often shared between postpartum units and the NICU, potentially increasing LC workload with less time spent with high-risk mothers. Furthermore, less than half of NICUs in the United States staff an international board-certified lactation consultant. Limited understanding exists regarding impacts of NICU-specific lactation support on breastfeeding outcomes.The purpose of this evidence-based practice brief is to synthesize the literature on the impact of NICU-specific lactation support, LCs who work exclusively in the NICU, and provide guidance about how NICU staffing with LCs solely focused on supporting mothers of high-risk infants impacts breastfeeding outcomes for low birth-weight infants.CINAHL PLUS, PubMed, Cochrane Library, and OVID databases were searched using key words and restricted to English language.During hospitalization, NICUs staffed with dedicated board-certified LCs have increased potential to yield improved breastfeeding rates through hospital discharge, increased proportion of infants who receive mother's own milk, and increased duration of breastfeeding or human milk expression through hospital discharge.Human milk nutrition is related to improved outcomes for high-risk infants. Neonatal intensive care unit-specific lactation support can potentially optimize maternal breastfeeding practices and improve outcomes for high-risk infants.There is a need for further studies pertaining to NICU-specific lactation consultants and influences on breastfeeding outcomes.

Inflammation occurring within the transplanted organ from the time of harvest is an important stimulus of early alloimmune reactivity, and promotes chronic allograft rejection. Chronic immune-mediated injury remains the primary obstacle to the long-term success of organ transplantation. However, organ transplantation represents a rare clinical setting in which the organ is accessible ex vivo, providing a unique opportunity to use nanotechnology to directly deliver therapeutics to the graft. This approach facilitates the directed delivery of immunosuppressive agents (ISA) to locally target pathogenic immune responses prior to the transplantation. Here, we have developed a system of direct delivery and sustained release of mycophenolate mofetil (MMF), to treat the donor organ prior to transplantation. Perfusion of a donor mouse heart with MMF-loaded PEG-PLGA nanoparticles (MMF-NP) prior to transplantation abrogated chronic allograft rejection by suppressing intra-graft pro-inflammatory cytokines and chemokines. Our findings demonstrate that ex vivo delivery of an ISA to donor organs using a nanocarrier can serve as a clinically feasible approach to reduce chronic allograft rejection.

BACKGROUND The morning period which is recognized as the highest risk for cardiovascular events is associated with a surge in blood pressure (BP). However, it is unclear what aspect of this rise is important. AIM To determine whether the rate of rise (RoR), the magnitude (day night difference) or the product [BP power (BPPower)] is associated with increased cardiovascular risk. METHODS We developed a logistic equation method to fit individual 24-h patterns of BP to determine RoR, amplitude and BPPower using the ambulatory recordings from the Ohasama study including 564 men and 971 women (16.6 years follow-up). RESULTS Men had a higher risk of cardiovascular events than women (24, 16%, P

Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.

Costimulation is a critical step in T-cell activation, and costimulatory blockade at the time of T cell activation leads to T-cell anergy and allograft tolerance in animal models of transplantation. CD28:B7 is the most important costimulatory pathway and the balance of signals between CD28 and cytotoxic T-lymphocyte associated protein 4 (CTLA-4) is a central determinant of transplant outcome. Form a clinical standpoint, CTLA-4 Ig is the only approved agent for costimulation blockade in transplantation. Advantages and disadvantages of its use are discussed. Progress in developing novel agents to target other pathways, including the promising CD40:CD154 pathway, is also discussed.

BACKGROUND Hispanic mothers are one of the largest groups to give birth. They also experience high rates of morbidity and mortality; however, there is limited data related to their health inequities. PURPOSE The purpose of this study was to evaluate systemic inequities associated with discrimination using the Reproductive Justice Framework to observe factors that influenced depressive symptomology in Hispanic women. METHODS A path analysis was conducted to evaluate systemic inequities that influenced postpartum depression using the public database, Listening to Mothers III (LMIII). The sub-sample consisted of n = 406 Hispanic mothers. Data was initially collected between the years 2011 and 2013. RESULTS Hispanic mothers were more likely to experience occurrences of perceived discrimination while seeking perinatal healthcare. These occurrences of discrimination led to lower trust in their healthcare providers, lower satisfaction with care, more instances of unwanted medical procedures, the need to feel to hold back comments about their health which ultimately resulted in higher rates of self-reported postpartum depression. The model fit indices supported the model's plausibility (χ2 /df ratio = 3.16, Comparative Fit Index = 0.91, Root Mean Square Error of Approximation = 0.06). CONCLUSIONS This data supported our hypothesis that the pathway of discriminatory barriers Hispanic mothers experience during pregnancy influence postpartum depression.

Renal transplantation is the preferred therapy for patients with end-stage kidney disease, leading to increased life expectancy, improved quality of life, and reduced health care resource use. Owing to their preexisting burden of disease, caring for renal transplant recipients is complex. Patient management following successful renal transplantation involves a multifactorial approach to cardiovascular risk factor management, along with titration of immunosuppression, management of complications related to immunosuppression, and active monitoring of allograft function. Recent advances in immunosuppressive management hold promise for improved long-term allograft survival. Finally, immune monitoring of transplant recipients is an area of considerable research, with the ultimate aim of individualized management of immunosuppression and the ability to induce transplant-specific tolerance. This review contains 7 figures, 11 tables, and 119 references. Key words: cardiovascular disease, drug interactions, immunosuppression, infection, interstitial fibrosis and tubular atrophy, malignancy, rejection, tolerance

Background Mother's own milk (MOM) is the gold standard of nutrition for premature infants. Yet, Hispanic and Black preterm infants are less likely than their White counterparts to receive MOM feedings. Evidence is lacking concerning potential modifiable factors and evidence-based strategies that predict provision of MOM among minority mothers of premature infants. Purpose A review of the literature was conducted to answer the clinical question: "What evidence-based strategies encourage and improve mother's own milk expression in Black and Hispanic mothers of premature infants?" Methods/search strategy Multiple databases including PubMed, Cochrane, and CINAHL were searched for articles published in the past 10 years (2010 through May 2020), reporting original research and available in English. Initial search yielded zero articles specifically addressing the impact of lactation interventions on MOM provision in minority mothers. Additional studies were included and reviewed if addressed breastfeeding facilitators and barriers (n = 3) and neonatal intensive care unit breastfeeding support practices (n = 7). Findings/results Current strategies used to encourage and improve MOM expression in minority mothers are based on or extrapolated from successful strategies developed and tested in predominantly White mothers. However, limited evidence suggests that variation in neonatal intensive care unit breastfeeding support practices may explain (in part) variation in disparities and supports further research in this area. Implications for practice Neonatal intensive care unit staff should consider implementing scaled up or bundled strategies showing promise in improving MOM milk expression among minorities while taking into consideration the cultural and racial norms influencing breastfeeding decisions and practice. Implications for research Experimental studies are needed to evaluate the effectiveness of targeted and culturally sensitive lactation support interventions in Hispanic and Black mothers.

BACKGROUND Neonatal intensive care unit (NICU) is a multifaceted, technology-driven high stress environment for professionals, infants and families. PURPOSE Examine healthcare professionals' beliefs and perceptions regarding providing FCC within the context of NICU. METHODS This exploratory descriptive study used an online-survey format. The survey comprised several instruments including the Perceived Stress Scale, symptoms of burnout subscale from the Professional Quality of Life scale, and the Family Nurse Caring Belief Scale (FNCBS). Demographic and open-ended items were also included. RESULTS Sample consisted of 115 multidisciplinary participants working in a level IV neonatal intensive care unit. Participants report strong levels of FCC beliefs. Participants strongly agreed (82%) or agreed (18%) that no matter how sick the infant is, he or she needs to be treated as an individual. A significant correlation (r = -0.343, P < .001) exists between participant's stress composite score and FNCBS composite score. There were significant relationships between participant's years of experience (F = 5.35, P < .002) and education levels (F = 2.60, P < .05) and higher FNCBS composite scores. There were also significant relationships between participant's years of experience (F = 4.77, P < .004) and education (F = 2.89, P < .039) with higher Perceived Stress Scale composite scores. IMPLICATIONS FOR PRACTICE Results suggest that while participants agreed that FCC is important, they also believed that inadequate staffing and inappropriate assignments may lead to rationing of care. IMPLICATIONS FOR RESEARCH Further research is needed to explore factors that lead to rationing of FCC.

BACKGROUND: Methyl mercaptan occurs naturally in the environment, and is found in a variety of occupational settings, including the oil, paper, plastics, and pesticides industries. It is a toxic gas, and deaths from methyl mercaptan exposure have occurred. The Department of Homeland Security considers it a high threat chemical agent that could be used by terrorists. Unfortunately, no specific treatment exists for methyl mercaptan poisoning. METHODS: We conducted a randomized trial in 12 swine comparing no treatment to intramuscular injection of the vitamin B(12) analog cobinamide (2.0 ml, 12.5 mg/kg) following acute inhalation of methyl mercaptan gas. Physiological and laboratory parameters were similar in the control and cobinamide-treated groups at baseline and at the time of treatment. RESULTS: All six cobinamide-treated animals survived, whereas only one of six control animals lived (17% survival) (p=0.0043). The cobinamide-treated animals returned to a normal breathing pattern by 3.8 ±1.1 min after treatment (mean ± SD), while all but one animal in the control group had intermittent gasping, never regaining a normal breathing pattern. Blood pressure and arterial oxygen saturation returned to baseline values within 15 minutes of cobinamide-treatment. Plasma lactate concentration increased progressively until death (10.93±6.02 mmol [mean±SD]) in control animals, and decreased towards baseline (3.79±2.93 mmol [mean±SD]) by the end of the experiment in cobinamide-treated animals. CONCLUSION: We conclude that intramuscular administration of cobinamide improves survival and clinical outcomes in a large animal model of acute, high dose methyl mercaptan poisoning.

BACKGROUND Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions. PURPOSE Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age. METHODS Sucking performance of 88 preterm infants born between 24 and 34 weeks of post-menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant's quartile location from baseline to term. RESULTS A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000). IMPLICATION FOR PRACTICE Infants with the weakest sucking pressures at 34 weeks of post-menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post-menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems. IMPLICATIONS FOR RESEARCH Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency.

At present, both the neuropathophysiology of bipolar disorder as well as the mechanism(s) through which current mood-stabilizing agents provide symptom relief are unknown. Through the recent utilization of magnetic resonance spectroscopy (MRS), progress has been made; with optimistic interest being focused on the phosphatidylinositol (PI) cycle as a likely neuropathophysiological factor in bipolar disorder. The present manuscript reviews this interesting and promising area, placing emphasis on the magnetic resonance spectroscopy investigations of PI- cycle function in bipolar disorder reported to date. While relatively few well-designed MRS studies have investigated PI-cycle function in bipolar disorder, current evidence does lend support to PI-cycle involvement in bipolar neuropathophysiology as a means through which mood-stabilizing agents act; pointing to PI-cycle dysfunction as an important neuropathophysiological factor in bipolar disorder. However, there still remains a dearth of information about this interesting hypothesis. In addition to lithium, more data is needed regarding the effects on PI-cycle function of the other commonly prescribed mood-stabilizing agents. As well, studies investigating the temporal relationship between medication effect on PI-cycle functioning and symptom improvement are warranted. In tandem with clinical MRS investigation of bipolar disorder, further preclinical study of the neurochemical effects of mood-stabilizing agents is needed. Finally, greater methodological rigor needs to be implemented during the design phase of any future MRS investigation into bipolar disorder, with particular attention aimed at recruiting a large homogenous sample of bipolar patients.

Background: In patients with heart failure, chronic kidney disease (CKD) is associated with a higher risk of renal events than in patients without CKD, irrespective of the ejection fraction. We assessed the renal effects of angiotensin/neprilysin inhibition in patients with heart failure in a pooled analysis of 13,195 patients with reduced and preserved ejection fraction. Methods: We combined data from PARADIGM-HF (LVEF eligibility≤40%; n=8,399) and PARAGON-HF (LVEF eligibility≥45%; n=4,796) in a prespecified pooled analysis. We assessed the effect of treatment (sacubitril/valsartan compared with enalapril or valsartan) on the renal composite outcome, defined as the time to first occurrence of either: ≥50% reduction in eGFR, end-stage renal disease, or death from renal causes. We also assessed the influence of therapy on eGFR slope. Results: At randomization, eGFR was 68±20 ml/min/1.73m 2 in PARADIGM-HF and 63±19 ml/min/1.73m 2 in PARAGON-HF. The composite renal outcome occurred in 70 of the 6594 patients (1.1%) in the sacubitril/valsartan group and 123 of the 6601 patients (1.9%) in the valsartan or enalapril group, with a risk reduction of 44% (HR 0.56, 95%CI 0.42-0.75; P2 ; P-interaction=0.46) or baseline ejection fraction (P-interaction=0.35). From randomization, the mean decline in eGFR was -1.8 (95%CI -1.9 to -1.7) ml/min/1.73 m 2 per year for the sacubitril/valsartan group, compared with -2.4 (95%CI -2.5 to -2.2) ml/min/1.73 m 2 per year for the valsartan or enalapril group, with an adjusted mean difference of 0.6 (95%CI 0.4 to 0.7; P2 per year. Conclusions: In patients with heart failure, sacubitril/valsartan reduced the risk of renal events, and slowed decline in eGFR, compared with valsartan or enalapril, across the spectrum of ejection fraction.

Aims: This study aimed to determine the prognostic value of serum uric acid (SUA) on outcomes in heart failure (HF) with preserved ejection fraction (HFpEF), and whether sacubitril–valsartan reduces SUA and use of SUA-related therapies. Methods and results: We analysed 4795 participants from the Prospective Comparison of ARNI [angiotensin receptor–neprilysin inhibitor] with ARB [angiotensin-receptor blockers] Global Outcomes in HF with Preserved Ejection Fraction (PARAGON-HF) trial. We related baseline hyperuricaemia (using age and gender adjusted assay definitions) to the primary outcome [cardiovascular (CV) death and total HF hospitalizations]. We assessed the associations between changes in SUA and Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS) and other cardiac biomarkers from baseline to 4 months. We simultaneously adjusted for baseline and time-updated SUA to determine whether lowering SUA was associated with clinical benefit. The mean (± standard deviation) age of patients was 73 ± 8 years and 52% were women. After multivariable adjustment, hyperuricaemia was associated with increased risk for the primary outcome [rate ratio 1.61, 95% confidence interval (CI) 1.37–1.90]. The treatment effect of sacubitril–valsartan for the primary endpoint was not significantly modified by hyperuricaemia (P-value for interaction = 0.14). Sacubitril–valsartan reduced SUA by 0.38 mg/dL (95% CI 0.31−0.45) compared with valsartan at 4 months, with greater effect in those with elevated SUA vs. normal SUA (−0.51 mg/dL vs. −0.32 mg/dL) (P-value for interaction = 0.031). Sacubitril–valsartan reduced the odds of initiating SUA-related treatments by 32% during follow-up (P < 0.001). After multivariable adjustment, change in SUA was inversely associated with change in KCCQ-OSS and directly associated with high-sensitivity troponin T (P < 0.05). Time-updated SUA was a stronger predictor of adverse outcomes than baseline SUA. Conclusions: Serum uric acid independently predicted adverse outcomes in HFpEF. Sacubitril–valsartan reduced SUA and the initiation of related therapy compared with valsartan. Reductions in SUA were associated with improved outcomes.

BACKGROUND/SIGNIFICANCE Infants born extremely premature (

The typical evolution of rheumatoid arthritis (RA) is that a person, with genetic risk factors, develops autoantibodies and subclinical inflammation under relevant environmental influences. There are indications that the primary site of the pathology is at mucosal surfaces (e.g. in the gums, lungs, and/or the gut), after which the disease translocates to the joints. Preclinical RA can be defined at the phase during which no clinically apparent features are present (i.e. no symptoms of inflammatory arthritis or clinically apparent joint swelling) but during which RA related biologic derangements such as the presence of autoantibodies are present. This chapter presents an overview of the risk factors, stages, and events occurring during the pre-RA phase. A better understanding of the factors involved will enable more accurate prediction of RA at the individual level and selection of high-risk individuals for inclusion in preventive studies. Several pharmacologic and non-pharmacologic studies aiming to prevent or delay the onset of RA in at-risk individuals are currently underway. It is hoped that such interventions in the pre-RA and indeed in the preclinical-RA phases will allow us to reduce the risk of RA and prevent RA developing in at least a proportion of at-risk patients.

The quantification of metabolites in blood and urine allows nurses to explore new hypotheses about the microbiome. This review summarizes findings from recent studies with a focus on how the state of the science can influence future nursing research initiatives. Metabolomics can advance nursing research by identifying physiologic/pathophysiologic processes underlying patients’ symptoms and can be useful for testing the effects of nursing interventions. To date, metabolomics has been used to study cardiovascular, respiratory, endocrine, autoimmune, and infectious conditions, with research focused on understanding the microbial metabolism of substrates resulting in circulating/excreted biomarkers such as trimethylamine N-oxide. This review provides specific recommendations for the collection of specimens and goals for future studies.

This paper presents a comprehensive review of publicly available online dyslexia learning modules with a particular focus on the extent to which modules address the prevalent myth that dyslexia is caused by “backwards reading.” The authors conducted a systematic internet search to identify publicly available online dyslexia learning modules and coded the content across education, neurocognition, and policy disciplinary domains. We identified 18 topics across a small number (N = 14) of publicly available modules that focused on dyslexia, with only two modules directly addressing this dyslexia myth. While both identified this myth as false, neither provided information about the neurocognitive underpinnings of dyslexia to explain why this myth is false. This review will be useful for guiding further development of online dyslexia learning modules which are urgently needed due to persisting misinformation about this disorder. The coded content reviews of each module will also be beneficial for directing attention to existing resources for professional development on dyslexia.

Plain English summary Patient and public involvement (PPI) improves the quality of health research and ensures that research is relevant to patients’ needs. Though PPI is increasingly evident in clinical and health services research, there are few examples in the research literature of effective PPI in translational and laboratory-based research. In this paper, we describe the development and evaluation of PPI in a multi-centre European project (EuroTEAM – Towards Early biomarkers in Arthritis Management) that included both translational and laboratory-based and psychosocial research. We found that although most PPI in EuroTEAM was centred around the psychosocial research, there were examples of PPI in the laboratory studies. As the project evolved, researchers became better at accommodating PPI and identifying PPI opportunities. It was generally agreed that PPI had a positive impact on the project overall, particularly on public engagement with the research. We concluded that the inclusion of both psychosocial and laboratory-based research in the same project facilitated PPI across all aspects of the research. In future projects, we would try to specify individual PPI activities in more detail at the project-planning stage, and better accommodate patient partners who are not native speakers of English. Abstract Background Patient and public involvement (PPI) enhances research quality and relevance and is central to contemporary health policy. The value of PPI has been recognised in rheumatology research, though there are limited examples of PPI in basic and translational science. The EU FP7 funded ‘EuroTEAM’ (Towards Early biomarkers in Arthritis Management) project was established to develop biomarker-based approaches to predict the future development of rheumatoid arthritis and incorporated psychosocial research to investigate the perceptions of ‘at risk’ individuals about predictive testing, and to develop informational resources about rheumatoid arthritis (RA) risk. Patient involvement was central to EuroTEAM from the inception of the project. The objective of this paper is to describe the development of PPI in EuroTEAM, formatively assess the impact of PPI from the perspectives of researchers and patient research partners (PRPs), reflect on successes and lessons learned, and formulate recommendations to guide future projects. Methods Two mixed-methods surveys (for PRPs and researchers) and a teleconference were undertaken to assess the impact of PPI on individual work packages and on EuroTEAM overall. Results There was consensus about the positive impact of PPI on the research and on the experiences of those involved. In particular, the positive impact of PPI on the personal development of researchers, and on effective public engagement with EuroTEAM research were highlighted. Researchers described adapting their practice in future projects to facilitate PPI. Spin-off projects and ongoing collaborations between PRPs and researchers reflected the value of PPI to participants. PPI was more frequently integrated in psychosocial research, though examples of PPI in laboratory/translational science were also described. PRPs asked for more opportunities to contribute meaningfully to basic scientific research and for more extensive feedback on their contributions. Conclusions The findings were used to formulate recommendations to guide effective involvement of patients in future similar projects, including identifying specific training requirements for PRPs and researchers, the identification of PRP focused tasks/deliverables at the project planning stage, and supporting access to involvement for all PRPs. Importantly, the distinctive multidisciplinary approach of EuroTEAM, incorporating both basic science and psychosocial research, facilitated patient involvement in the project overall.

Although the immune response within draining lymph nodes (DLNs) has been studied for decades, how their stromal compartment contributes to this process remains to be fully explored. Here, we show that donor mast cells were prominent activators of collagen I deposition by fibroblastic reticular cells (FRCs) in DLNs shortly following transplantation. Serial analysis of the DLN indicated that the LN stroma did not return to its baseline microarchitecture following organ rejection and that the DLN contained significant fibrosis following repetitive organ transplants. Using several FRC conditional-knockout mice, we show that induction of senescence in the FRCs of the DLN resulted in massive production of collagen I and a proinflammatory milieu within the DLN. Stimulation of herpes virus entry mediator (HVEM) on FRCs by its ligand LIGHT contributed chiefly to the induction of senescence in FRCs and overproduction of collagen I. Systemic administration of ex vivo-expanded FRCs to mice decreased DLN fibrosis and strengthened the effect of anti-CD40L in prolonging heart allograft survival. These data demonstrate that the transformation of FRCs into proinflammatory myofibroblasts is critically important for the maintenance of a proinflammatory milieu within a fibrotic DLN.

Summary Objective This study aimed to examine the temporal activation of NF-κB and its relationship to the development of pain-related sensitivity and behavioral changes in a non-invasive murine knee loading model of PTOA. Method Following knee injury NF-κB activity was assessed longitudinally via in vivo imaging in FVB. Cg-Tg (HIV-EGFP,luc)8Tsb/J mice. Measures of pain-related sensitivity and behavior were also assessed longitudinally for 16 weeks. Additionally, we antagonized NF-κB signaling via intra-articular delivery of an IκB kinase two antagonist to understand how local NF-κB inhibition might alter disease progression. Results Following joint injury NF-κB signaling within the knee joint was transiently increased and peaked on day 3 with an estimated 1.35 p/s/cm2/sr (95% CI 0.913.1.792 p/s/cm2/sr) fold increase in signaling when compared to control joints. Furthermore, injury resulted in the long-term development of hindpaw allodynia. Hyperalgesia withdrawal thresholds were reduced at injured knee joints, with the largest reduction occurring 2 days following injury (estimate of between group difference 129.1 g with 95% CI 60.9,197.4 g), static weight bearing on injured limbs was also reduced. Local delivery of an NF-κB inhibitor following joint injury reduced chondrocyte death and influenced the development of pain-related sensitivity but did not reduce long-term cartilage degeneration. Conclusion These findings underscore the development of behavioral changes in this non-invasive loading model of PTOA and their relationships to NF-κB activation and pathology. They also highlight the potential chondroprotective effects of NF-κB inhibition shortly following joint injury despite limitations in preventing the long-term development of joint degeneration in this model of PTOA.

The American Academy of Pediatrics recommends donor human milk (DHM) as the preferred feeding strategy for preterm infants when the milk of the mother is unavailable, based on conclusive evidence of lower rates of necrotizing enterocolitis with DHM feedings compared with preterm infant formula. The nutritional composition of DHM may differ from maternal milk for many reasons including differences in maternal characteristics, milk collection methods, and the impact of donor milk banking practices. The purpose of this systematic review is to examine the literature regarding research on the fat, protein, carbohydrate, vitamin, and mineral composition of DHM obtained through nonprofit milk banks or commercial entities. PubMed, CINAHL, and Scopus databases were searched for articles published between 1985 and 30 April, 2019. In total, 164 abstracts were screened independently by 2 investigators, and 14 studies met all inclusion criteria. Studies were predominantly small (

Background The benefits of human milk for the preterm infant are well established. Preterm infants have lower breastfeeding rates and often face breastfeeding challenges. It is important that feeding practices for preterm infants optimize their chances of breastfeeding. Objective The purpose of this integrated review is to synthesize and critically analyze research related to the safety and efficacy of cup feeding as an alternative, supplemental feeding method for breastfed infants. Data Sources The electronic data bases of PubMed, CINAHL and were used to identify studies published in English from 1998- 2017. Design Using inclusion and exclusion criteria, 27 articles were initially assessed. After further screening 19 articles were included in the full review and of these 5 more were excluded. Lastly, an in-depth review of these 14 studies resulted in 2 more exclusions, for a total of 12 studies that met full inclusion and exclusion criteria. Review Methods Studies were examined for information on safety and efficacy of cup feeding as an alternative, supplemental feeding method for preterm breastfed infants. Studies were grouped into categories of outcomes that included (a) safety and physiologic properties; (b) breastfeeding outcomes. Results Use of cup feeding resulted in more stable heart rate and oxygen saturation than bottle feeding with similar weight gain. Additionally, breastfeeding rates were higher at discharge with continued higher rates at 3 and 6 months post-discharge for cup fed infants. Conclusions Premature infants face more breastfeeding obstacles than term infants. The potential for cup feeding as an alternative to bottle-feeding for breast fed preterm infants is positively supported by these results It is fundamentally important for NICU professionals to establish a protocol, education and training for the potential use of this feeding method for this vulnerable population.

Key Clinical Message Spontaneous coronary artery dissection (SCAD) is a common cause of acute coronary syndrome particularly in younger women. Good outcomes with conservative management are generally expected. However, there is uncertainty of how to manage symptomatic or unstable patients. Percutaneous angioplasty may propagate the subintimal hematoma compromising coronary blood flow. Cutting balloon angioplasty can relieve the compressive effects of a propagated subintimal hematoma in SCAD.

Ischemia reperfusion injuries (IRI) are unavoidable in solid organ transplantation. IRI augments alloimmunity but the mechanisms involved are poorly understood. Herein, we examined the effect of IRI on antigen specific alloimmunity. We demonstrate that ischemia promotes alloimmune activation, leading to more severe histological features of rejection, and increased CD4+ and CD8+ T cell graft infiltration, with a predominantly CD8+ IFNγ+ infiltrate. This process is dependent on the presence of alloreactive CD4+ T cells, where depletion prevented infiltration of ischemic grafts by CD8+ IFNγ+ T cells. IL-6 is a known driver of ischemia-induced rejection. Herein, depletion of donor antigen-presenting cells reduced ischemia-induced CD8+ IFNγ+ allograft infiltration, and improved allograft outcomes. Following prolonged ischemia, accelerated rejection was observed despite treatment with CTLA4Ig, indicating that T cell costimulatory blockade failed to overcome the immune activating effect of IRI. However, despite severe ischemic injury, treatment with anti-IL-6 and CTLA4Ig blocked IRI-induced alloimmune injury and markedly improved allograft survival. We describe a novel pathway where IRI activates innate immunity, leading to upregulation of antigen specific alloimmunity, resulting in chronic allograft injury. Based on these findings, we describe a clinically relevant treatment strategy to overcome the deleterious effect of IRI, and provide superior long-term allograft outcomes.

According to the Healthy People 2020 goals, the sustainability of breastfeeding duration rates within the United States has not been achieved. To increase these rates, it is important that women with breastfeeding difficulties receive the support needed to continue breastfeeding. When supplementation occurs, it is essential that the breastfeeding relationship be preserved. Various methods of supplementation are often recommended including use of the supplemental feeding tube device (SFTD).The question guiding this brief is "What evidence exists to support the use of an SFTD as a method of supplementation for breastfed infants?"The PubMed and CINAHL databases were queried for original research published in English from 1990 through July 2016. Search terms included "supplemental feeding tube," "breastfeeding," "term infants," "premature infants," "Supplemental Nursing System," "Lact-aid," and "supply line."Very limited research exists on the use of SFTDs as a method of supplementation for breastfed infants; however, existing research suggests that an SFTD may be useful as a supplementation method for breastfed infants. High-quality research is needed to evaluate the efficacy of using an SFTD for supporting exclusive and all breastfeeding rates.Nurses and providers need to be educated and trained in the use of SFTDs as well as all supplemental feeding methods. Information on efficacy and SFTD use should also be included in policies related to breastfeeding and human milk use.Further research should determine best methods of supplementation for breastfed infants and should examine differences in breastfeeding rates when using the SFTD for supplementation.