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Following an unexpected pediatric death, survivors undergo unique trauma. Medical examiners (MEs) evaluate most of these deaths. We evaluated the bereavement support available to survivors in the Chicagoland area following a pediatric death. We had two goals: to characterize the available bereavement support options and compare the locations (by zip code) of support groups with the locations (by zip code) in which pediatric ME cases occurred. We identified 48 organizations that provided bereavement support services at 74 locations in the summer and fall of 2020. Locations by zip codes in which the largest number of ME cases occurred did not have support groups. Locations in which more ME cases occurred generally had lower-income populations and a greater proportion of Black or Hispanic residents. Bereavement support following pediatric death is inadequate and unevenly distributed across the Chicagoland area. [ABSTRACT FROM AUTHOR]

BACKGROUND Infants younger than 6 months of age are at high risk for complications of coronavirus disease 2019 (Covid-19) and are not eligible for vaccination. Transplacental transfer of .antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after maternal Covid-19 vaccination may confer protection against Covid-19 in infants. METHODS We used a case-control test-negative design to assess the effectiveness of maternal vaccination during pregnancy against hospitalization for Covid-19 among infants younger than 6 months of age. Between July 1 2021 and March 8,2022 we enrolled infants hospitalized for Covid-19 (case infants) and infants hospitalized without Covid-19 (control infants) at 30 hospitals in 22 states. We estimated vaccine effectiveness by comparing the odds of full maternal vaccination (two doses of mRNA vaccine) among case infants and control infants during circulation of the B.1.6172 (delta) variant (July 1 2021 to December 18 2021) and the B.1.1.259 (omicron) variant (December 19, 2021, to March 8, 2022). RESULTS A total of 537 case infants (181 of whom had been admitted to a hospital during the delta period and 356 during the omicron period; median age 2 months) and512 control infants were enrolled and included in the analyses; 16°/0 of the case infants and 29 of the control infants had been born to mothers who had been fully vaccinated against Covid-19 during pregnancy. Among the case infants 113 (21%) received intensive care (64 [1296] received mechanical ventilation or vasoactive infusions). Two case infants died from Covid-19; neither infant's mother had been vaccinated during pregnancy. The effectiveness of maternal vaccination against hospitalization for Covid-19 among infants was 52% (95 confidence interval ICI] 33 to 65) overall 80% (95% CI 60 to 90) during the delta period and 38% (95% CI 8 to 58) during the omicron period. Effectiveness was 6996 (95% CI,50 to 80) when maternal vaccination occurred after 20 weeks of pregnancy and 38% (95% CI 3 to 60) during the first 20 weeks of pregnancy. CONCLUSIONS Maternal vaccination with two doses of mRNA vaccine was associated with a reduced risk of hospitalization for Covid-19 including for critical illness among infants young- er than 6 months of age. (Funded by the Centers for Disease Control and Prevention.) [ABSTRACT FROM AUTHOR]

Study Objective: Existing screening tools for sepsis in children are limited by suboptimal sensitivity. Our objective was to develop a new, more sensitive screening tool for pediatric septic shock by enhancing 2 aspects of the 4-point Liverpool quick Sequential Organ Failure Assessment (LqSOFA) tool., Methods: We performed a secondary analysis of a cohort of children (1 month to 18 years) who presented to a pediatric emergency department (ED) with suspected infection over a 10-year period. Septic shock was defined as intravenous vasoactive infusion within 24-hours of arrival for children with suspected infection and intravenous antibiotics administered. We developed the 4-point quick Pediatric Septic Shock Screening Score (qPS4) by making 2 changes to the 4-point LqSOFA: (1) the pulse rate parameter was replaced with the recently derived Temperature and Age-adjusted Mean Shock Index and (2) standard respiratory rate cutoffs for tachypnea were replaced by cutoffs derived empirically from the study cohort. The other 2 LqSOFA criteria were unchanged (abnormal mentation and capillary refill ≥3 seconds). We defined a positive qPS4 as ≥2 criteria (consistent with LqSOFA). We used the training cohort from the parent study to derive cutoffs for respiratory rate and the validation cohort to compare the qPS4 with LqSOFA and qSOFA., Results: Among the 47,231 encounters in the validation cohort from the parent study, with median age of 4.5 years, qPS4 had an area under the receiver operating characteristic curve for septic shock of 0.94 (95% confidence interval [CI] 0.92 to 0.96). qPS4 ≥2 had a sensitivity of 89.7% (95% CI 84.9% to 94.5%), and a specificity of 92.2% (95% CI 92.0% to 92.5%) for septic shock. In comparison, the LqSOFA achieved an area under the receiver operating characteristic curve of 0.86 (95% CI 0.82 to 0.89), a sensitivity of 56.1% (95% CI 48.3% to 63.9%), and a specificity of 96.8% (95% CI 96.6% to 96.9%). The median time from first positive qPS4 to initiation of an intravenous vasoactive infusion was 2.5 hours (IQR 0.9 to 6.1) compared to 0.7 hours (IQR 0.0 to 4.5) for LqSOFA., Conclusion: The qPS4, with 2 enhancements to the LqSOFA, demonstrated overall improved sensitivity and specificity for pediatric septic shock., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: To empirically derive a novel temperature- and age-adjusted mean shock index (TAMSI) for early identification of sepsis and septic shock in children with suspected infection., Methods: We performed a retrospective cohort study of children aged 1 month to <18 years presenting to a single emergency department with suspected infection over a 10-year period. TAMSI was defined as (pulse rate - 10 × [temperature - 37])/(mean arterial pressure). The primary outcome was sepsis, and the secondary outcome was septic shock. In the two-thirds training set, we determined TAMSI cutoffs for each age group using a minimum sensitivity of 85% and Youden Index. In the one-third validation data set, we calculated test characteristics for the TAMSI cutoffs and compared them with those for the Pediatric Advanced Life Support (PALS) tachycardia or systolic hypotension cutoffs., Results: In the sepsis validation data set, the sensitivity-targeting TAMSI cutoff yielded a sensitivity of 83.5% (95% confidence interval [CI] 81.7% to 85.4%) and specificity of 42.8% (95% CI 42.4% to 43.3%) versus a sensitivity of 77.7% (95% CI 75.7% to 79.8%) and specificity of 60.0% (95% CI 59.5% to 60.4%) for PALS. For septic shock, the sensitivity-targeting TAMSI cutoff achieved a sensitivity of 81.3% (95% CI 75.2% to 87.4%) and a specificity of 83.5% (95% CI 83.2% to 83.8%) versus a sensitivity of 91.0% (95% CI 86.5% to 95.5%) and a specificity of 58.8% (95% CI 58.4% to 59.3%) for PALS. TAMSI yielded an increased positive likelihood ratio and similar negative likelihood ratio versus PALS., Conclusions: TAMSI achieved a similar negative likelihood ratio and improved positive likelihood ratio compared with PALS vital sign cutoffs for the prediction of septic shock, but it did not improve on PALS for sepsis prediction, among children with suspected infection., (Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Time to positivity (TTP) is the delay of time from incubation to blood culture positivity. Short TTP can predict mortality and source of infection. The aim of this study was to investigate the value of TTP of patients with bloodstream infections with enterococci (E-BSI).In a single centre retrospective cohort study in Germany, the data of 244 patients with monomicrobial E-BSI were analyzed with hospital mortality as the primary outcome of interest from January 1 2014 to December 31 2016. Mortality rate of patients with bloodstream infections (BSI) with E. faecalis was 16.7%, Vancomycin sensitive E. faecium (VSEfm) 26.7% and Vancomycin resistant E. faecium (VREfm) 38.2%. Cut-offs showed a significantly higher mortality rate when compared to longer TTP (E. faecalis: P=0.047; VSEfm: P=0.02), but were not risk factors in survival analysis (E.faecalis: HR (hazard ratio): 2.73; P=0.17; VSEfm: HR: 1.63; P=0.15; VREfm: HR: 1.24; P=0.63). TTP≤10.5 hours with E. faecalis BSI was a discriminator for cardiovascular source of infection (AUC: 0.75). A short TTP could predict mortality rates and source of infection but was not an independent parameter for risk of death in survival analysis., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Scarce resource allocation policies vary across the United States. Little is known about regional variation in resource allocation protocols and variation in their application. We sought to evaluate how Covid-19 scarce resource allocation policies vary throughout the Chicago metropolitan area and whether there are differences in policy application within hospitals when prioritizing hypothetical patients who need critical care resources., Methods: Two cross-sectional surveys were distributed to Chicago metropolitan area hospital representatives and triage officers. Survey responses and categorical variables are described by frequency of occurrence. Intra- and interhospital variation in ranking of hypothetical patients was assessed using Fleiss's Kappa coefficients., Results: Eight Chicago-area hospitals responded to the survey assessing scarce resource allocation protocols (N = 8/18, response rate 44%). For hospitals willing to describe their ventilator allocation protocol (N = 7), most used the sequential organ failure assessment (SOFA) score (N = 6/7, 86%) and medical comorbidities (N = 4/7, 57%) for initial scoring of patients. A majority gave priority in initial scoring to pre-defined groups (N = 5/7, 71%), all discussed withdrawal of mechanical ventilation for adult patients (N = 7/7, 100%), and a minority had exclusion criteria (N = 3/7, 43%). Forty-nine triage officers from nine hospitals responded to the second survey (N = 9/10 hospitals, response rate 90%). Their rankings of hypothetical patients showed only slight agreement amongst all hospitals (Kappa 0.158) and fair agreement within two hospitals with the most respondents (Kappa 0.21 and 0.25). Almost half used tiebreakers to rank patients (N = 23/49, 47%)., Conclusions: Although most respondents from Chicago-area hospitals described policies for resource allocation during the COVID-19 pandemic, the substance and application of these protocols varied. There was little agreement when prioritizing hypothetical patients to receive scarce resources, even among people from the same hospital. Variations in resource allocation protocols and their application could lead to inequitable distribution of resources, further exacerbating community distrust and disparities in health., Supplemental data for this article is available online at https://doi.org/10.1080/23294515.2021.1983667.

Pediatric surgeons play an essential role in prenatal consultation for congenital anomalies likely to require surgery in the newborn period. The involvement of pediatric surgeons during multi-disciplinary prenatal meetings has been an important part of the evolution of comprehensive fetal care, characterized by detailed prenatal evaluation, diagnosis, prognosis, and planned perinatal and post-natal care. Advances in fetal diagnostics and treatments, as well as complex postnatal medical care and decision-making create a broad range of care options for pregnant women with fetal surgical anomalies. Ethical challenges involve the availability and risks/benefits of maternal-fetal surgery, and diagnostic and prognostic uncertainty for the newborn. Clinical scenarios illustrate cases that pediatric surgeons may encounter in practice, with discussions highlighting the ethical principles involved as well as considerations for management., (Copyright © 2021. Published by Elsevier Inc.)

Objective: Children with congenital heart disease (CHD) have complex unique post-operative care needs. Limited data assess parents' hospital discharge preparedness and education quality following cardiac surgery. The goals were to identify knowledge gaps in discharge preparedness after congenital heart surgery and to assess the acceptability of an educational mobile application to improve discharge preparedness., Methods: Telephonic interviews with parents of children with two-ventricle physiology who underwent cardiac surgery 5-7 days post-discharge and in-person interviews with clinicians were conducted. We collected parent and clinician demographics, parent health literacy information and patient clinical data. We analysed interview transcripts using summative content analysis., Results: We interviewed 26 parents and 6 clinicians. Twenty-two of the 26 (85%) parents felt ready for discharge; 4 of the 6 (67%) clinicians did not feel most parents were ready for discharge. Fifteen of the 26 parents (58%) reported receiving the majority of discharge teaching on the day of discharge. Eight parents did not feel like all of their questions were answered. Most parents (14/26, 54%) preferred visual educational learning aids and could accurately describe important aspects of care. Most parents (23/26, 88%) and all 6 clinicians felt a mobile application for post-operative care education would be helpful., Conclusions: Most parents received education on the day of discharge and could describe the information they received prior to discharge, although there were some preparedness gaps identified after discharge. Clinicians and parents varied in their perceptions of the readiness for discharge. Most responses suggest that a mobile application for discharge education may be helpful for transition to home.

Importance: Opioid-reduction policies have been enacted by US states to address the opioid epidemic. Evidence of an association between policy implementation and decreased rates of pediatric opioid poisoning provides further justification for expanded implementation of these policies., Objective: To examine the association of 3 state-level opioid-reduction policies with the rate of opioid poisoning in children and adolescents., Design, Setting, and Participants: This interrupted time series analysis used data from the National Poison Data System (NPDS), a database of poisoning information reported to poison control centers across the US. Individuals younger than 20 years who experienced poisoning associated with 1 or more prescription opioids from January 1, 2005, to November 30, 2017, were included. The analysis focused on 3 widespread policy interventions: the prescription drug monitoring program (PDMP), pain clinic legislation, and opioid prescribing guidelines. Data analysis was performed from January 30, 2020, to March 30, 2020., Exposures: Any opioid poisoning in individuals younger than 20 years that was reported to the NPDS., Main Outcomes and Measures: Opioid poisoning rates per million person-months before and after implementation of each of the 3 policies, overall and stratified by age (≤4 years, 5-9 years, 10-14 years, and 15-19 years)., Results: A total of 338 476 opioid poisoning incidences in children and young adults were reported to the NPDS within the study period. Of this study population, the mean (SD) age was 9.74 (7.15) years, and 179 011 (52.9%) were female. The implementation of a PDMP was associated with a reduction in the monthly rate of opioid poisoning in children and adolescents (-0.07 per million person-months; 95% CI, -0.09 to -0.04) in the postimplementation period. This reduction was observed for all age groups except for the 10- to 14-year age group (-0.03 per million person-months; 95% CI, -0.05 to 0.00). Pain clinic legislation was associated with an immediate reduction in opioid poisoning (-6.22 per million person-months; 95% CI, -8.98 to -3.47). This association was statistically significant across all ages except for the 4 years or younger group. Analysis of the association of implementation of opioid prescribing guidelines was limited because of insufficient follow-up data and did not show an immediate or monthly change in the rate of opioid poisoning., Conclusions and Relevance: Results of this study suggest that certain state-level opioid-reduction policies were associated with decreases in pediatric opioid exposures across age groups. Further examination of the underlying mechanisms of these associations, including age group-specific outcomes, may expand and strengthen policies that reduce opioid poisoning, misuse, and overdoses in children and adolescents.

We fabricated a microfluidic reactor with a nanoporous barrier to characterize electron transport between Shewanella oneidensis MR-1 and the metal oxide birnessite across a physical separation. Real-time quantification of electron flux across this barrier by strains with different electron transfer capabilities revealed that this bacterium exports flavins to its surroundings when faced with no direct physical access to an electron acceptor, allowing it to reduce metals at distances exceeding 60 μm. An energy balance indicates that flavins must be recycled for S. oneidensis MR-1 to yield energy from lactate oxidation coupled to flavin reduction. In our system, we find that flavins are recycled between 24 and 60 times depending on flow conditions. This energy saving strategy, which until now had not been systematically tested or captured in environmentally relevant systems, suggests that electron shuttling microorganisms have the capacity to access and reduce metals in physically distant or potentially toxic microenvironments (i.e., pores with soluble and transiently sorbed toxins) where direct contact is limited or unfavorable. Our results challenge the prediction that diffusion-based electron shuttling is only effective across short distances and may lead to improved bioremediation strategies or advance biogeochemical models of electron transfer in anaerobic sediments.

Subsurface environments often contain mixtures of contaminants in which the microbial degradation of one pollutant may be inhibited by the toxicity of another. Agricultural settings exemplify these complex environments, where antimicrobial leachates may inhibit nitrate bioreduction, and are the motivation to address this fundamental ecological response. In this study, a microfluidic reactor was fabricated to create diffusion-controlled concentration gradients of nitrate and ciprofloxacin under anoxic conditions in order to evaluate the ability of Shewanella oneidenisis MR-1 to reduce the former in the presence of the latter. Results show a surprising ecological response, where swimming motility allow S. oneidensis MR-1 to accumulate and maintain metabolic activity for nitrate reduction in regions with toxic ciprofloxacin concentrations (i.e., 50× minimum inhibitory concentration, MIC), despite the lack of observed antibiotic resistance. Controls with limited nutrient flux and a nonmotile mutant (Δ flag) show that cells cannot colonize antibiotic rich microenvironments, and this results in minimal metabolic activity for nitrate reduction. These results demonstrate that under anoxic, nitrate-reducing conditions, motility can control microbial habitability and metabolic activity in spatially heterogeneous toxic environments.

Ethical issues in pediatric heart transplantation (Htx) include resource allocation, benefit, and burden assessment in high-risk recipients, and informed consent. Practice patterns and decision-making was investigated using an internet survey with 47-multiple choice items and vignette-based questions. Of 43 pediatric Htx cardiologists contacted, 28 (65%) responded. Respondents reported that an overall median 1-month survival of 73% (range 50-100%), 1-year survival of 70% (range 50-85%), 5-year survival of 50% (range 40-85%), and 10-year survival of 50% (range 25-85%) was adequate to offer Htx. Based on vignettes presented, 100% of those surveyed would offer Htx to a straightforward 12-year old with end-stage dilated cardiomyopathy and a 7-year old with hypoplastic left heart syndrome with protein losing enteropathy. Thirty percent of physicians would offer Htx to a patient status post a Fontan procedure with mutliple co-morbidities. Seventy-five percent of physicians would offer Htx despite proven non-adherence. Considerable variability exists in the practice patterns of pediatric heart transplant cardiologists with regards to decision-making while evaluating patients for listing. Disagreements among pediatric Htx cardiologists exist when there are concerns for non-adherence and associated multiple co-morbidities. Further work is needed to understand these variations and develop consensus for pediatric Htx organ allocation.

Background: Little is known about how decision-making conversations occur during pediatric intensive care unit (PICU) family conferences (FCs)., Objective: Describe the decision-making process and implementation of shared decision making (SDM) during PICU FCs., Design: Observational study., Setting/subjects: University-based tertiary care PICU, including 31 parents and 94 PICU healthcare professionals involved in FCs., Measurements: We recorded, transcribed, and analyzed 14 PICU FCs involving decision-making discussions. We used a modified grounded theory and content analysis approach to explore the use of traditionally described stages of decision making (DM) (information exchange, deliberation, and determining a plan). We also identified the presence or absence of predefined SDM elements., Results: DM involved the following modified stages: information exchange; information-oriented deliberation; plan-oriented deliberation; and determining a plan. Conversations progressed through stages in a nonlinear manner. For the main decision discussed, all conferences included a presentation of the clinical issues, treatment alternatives, and uncertainty. A minority of FCs included assessing the family's understanding (21%), assessing the family's need for input from others (28%), exploring the family's desired decision-making role (35%), and eliciting the family's opinion (42%)., Conclusions: In the FCs studied, we found that DM is a nonlinear process. We also found that several SDM elements that could provide information about parents' perspectives and needs did not always occur, identifying areas for process improvement.

One of the major challenges associated with modeling the influence of the cellular microenvironment on cell growth and differentiation is finding suitable substrates for growing the cells in a manner that recapitulates the cell-cell and cell-microenvironmental interactions in vitro. As one approach to address this challenge, we have developed graphene oxide (GO)-3D mesh with tunable hardness and porosity for application in cell culture systems. The synthetic method of GO-3D mesh is simple, easily reproducible, and low cost. The foundation of the method is the combination of poly(ethylene)(glycol) (PEG) and GO together with a salt-leaching approach (NaCl) in addition to a controlled application of heat during the synthetic process to tailor the mechanical properties, porosity, and pore-size distribution of the resulting GO-3D mesh. With this methodology, the hydrogel formed by PEG and GO generates a microporous mesh in the presence of the NaCl, leading to the formation of a stable 3D scaffold after extensive heating and washing. Varying the ratio of NaCl to GO controls porosity, pore size, and pore connectivity for the GO-3D mesh. When the porosity is less than 90%, with an increasing ratio of NaCl to GO, the number of pores increases with good interconnectivity. The 3D-mesh showed excellent biocompatibility with vascular cells which can take on a morphology comparable to that observed in vessels in vivo. Cell proliferation and gene expression can be determined from cells grown on the GO-3D scaffold, providing a valuable tool for investigating cell-microenvironmental changes. The GO-3D mesh described results from the synergy of the combined chemical properties of the PEG and GO with the salt-leaching methodology to generate a unique and flexible mesh that can be modified and optimized for a variety of in vitro applications.

Context: Pediatric palliative care has no evidence-based needs assessment measure. The Parent and Child Needs Survey (PCNeeds) is a new instrument designed to assess the needs of children in palliative care, including children receiving end-of-life care, and their families., Objectives: This study examines the psychometrics of and respondents' perceptions about the PCNeeds., Methods: Parents of children in four outpatient pediatric palliative care programs completed the PCNeeds and the World Health Organization Quality of Life-Brief tool (WHOQOL-BREF). Parents answered questions about demographics and the experience of completing the PCNeeds. Internal scale reliability was measured with Cronbach's alpha. Validity was assessed by correlating the PCNeeds total and subscale scores with the WHOQOL-BREF subscales. Additional respondent perceptions were obtained via written comments and analyzed using content analysis., Results: The 93 respondents were predominantly female (n = 69, 74%); white (n = 79, 85%); college graduates (n = 71, 76%); and married or partnered (n = 75, 81%). Internal reliability was acceptable (Cronbach's α = 0.83), and validity correlations with the WHOQOL-BREF subscales were consistent with theoretical expectations (moderate negative correlations ranging from -0.36 to -0.51). The most frequently cited need not addressed by our survey was sibling impact (n = 17, 18%). Twelve parents (13%) indicated that no content was missing. The least met needs were financial impact, family impact, and the child's physical problems besides pain. Sixty-eight percent of parents (n = 63) rated completion of the survey as "easy" or "very easy.", Conclusion: Initial psychometric analysis of the PCNeeds is encouraging, but further study of reliability and validity with more diverse respondents is needed., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Although medical marijuana (MM) may have utility in the supportive care of children with serious illness, it remains controversial. We investigated interdisciplinary provider perspectives on legal MM use in children with cancer., Methods: We sent a 32-item, cross-sectional survey to 654 pediatric oncology providers in Illinois, Massachusetts, and Washington characterizing MM practices, knowledge, attitudes, and barriers. Forty-eight percent responded; 44% ( n = 288) were included in analyses. Providers were stratified by status as legally eligible to certify (ETC) for MM. We used Fisher's exact and Wilcoxon rank tests and univariate and multivariate logistic regression models for group comparisons., Results: The provider median age was 35 years (range 22-70 years); 33% were ETC (83 physicians; 13 Washington state advance practice providers). Thirty percent of providers received ≥1 request for MM in the previous month. Notably, only 5% of all providers knew state-specific regulations. ETC providers were more likely to know that MM is against federal laws ( P < .0001). Whereas most providers (92%) reported willingness to help children with cancer access MM, in adjusted models, ETC providers were less likely to indicate approval of patient MM use by smoking, oral formulations, as cancer-directed therapy, or to manage symptoms ( P < .005 for all). Forty-six percent of all providers cited the absence of standards around formulations, potency, or dosing to be the greatest barrier to recommending MM., Conclusions: Most pediatric oncology providers are willing to consider MM use in children with cancer and receive frequent inquiries. However, ETC providers endorse less favorable attitudes overall. The absence of standards is an important barrier to recommending MM., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Members of the Geobacteraceae family are ubiquitous metal reducers that utilize conductive "nanowires" to reduce Mn(IV) and Fe(III) oxides in anaerobic sediments. However, it is not currently known if and to what extent the Mn(IV) and Fe(III) oxides in soil grains and low permeability sediments that are sequestered in pore spaces too small for cell passage can be reduced by long-range extracellular electron transport via Geobacter nanowires, and what mechanisms control this reduction. We developed a microfluidic reactor that physically separates Geobacter sulfurreducens from the Mn(IV) mineral birnessite by a 1.4 μm thick wall containing <200 nm pores. Using optical microscopy and Raman spectroscopy, we show that birnessite can be reduced up to 15 μm away from cell bodies, similar to the reported length of Geobacter nanowires. Reduction across the nanoporous wall required reducing conditions, provided by Escherichia coli, and an exogenous supply of riboflavin. Our results discount electron shuttling by dissolved flavins, and instead support their role as bound redox cofactors in electron transport from nanowires to metal oxides. We also show that upon addition of a soluble electron shuttle (i.e., AQDS), reduction extends beyond the reported nanowire length up to 40 μm into a layer of birnessite.

While there is a robust literature describing family conferences (FCs) in adult intensive care units (ICUs), less information exists about FCs in pediatric ICUs (PICUs). We conducted a pilot study to describe the focus of discussion, communication patterns of health care team members (HTMs) and parents, and parents' perspectives about clinician communication during PICU FCs. We analyzed data from 22 video- or audiorecorded PICU FCs and post-FC questionnaire responses from 27 parents involved in 18 FCs. We used the Roter Interaction Analysis System (RIAS) to describe FC dialogue content. Our questionnaire included the validated Communication Assessment Tool (CAT). FCs were focused on care planning (n = 5), decision making (n = 6), and updates (n = 11). Most speech came from HTMs (mean 85%; range, 65-94%). Most HTM utterances involved medical information. Most parent utterances involved asking for explanations. The mean overall CAT score was 4.62 (using a 1-5 scale where 5 represents excellent and 1 poor) with a mean of 73.02% "excellent" responses. Update and care-planning FCs had lower CAT scores compared to decision-making FCs. The lowest scoring CAT items were "Involved me in decisions as much as I wanted," "Talked in terms I could understand," and "Gave me as much information as I wanted." These findings suggest that while health care providers spend most of their time during FCs relaying medical information, more attention should be directed at providing information in an understandable manner. More work is needed to improve communication when decision making is not the main focus of the FC.

Objective: Leptin (LEP) deficiency results in major metabolic perturbations, including obesity, dyslipidemia, and diabetes. Although LEP deficiency can be treated with daily injections of a recombinant LEP, generation of an antibody activating the LEP receptor (LEPR) that has both an intrinsically long half-life and low immunogenicity could be useful in the treatment of this condition., Methods: Phage display technology coupled with flow cytometry and cell-based in vitro assays were employed to identify an allosteric agonist of the mouse LEPR. LEP-deficient Lep(ob) /Lep(ob) mice were used to compare in vivo effects of LEP to antibody administration. To evaluate hypothalamic effects of treatment, changes in mRNA levels of neuropeptide Y and proopiomelanocortin were measured., Results: XPA.80.037 is a monoclonal antibody that demonstrates allosteric agonism of the mouse LEPR. Treatment of Lep(ob) /Lep(ob) mice with XPA.80.037 markedly reduced hyperphagia and body weight, normalized blood glucose and plasma insulin levels, and corrected dyslipidemia. These metabolic alterations correlated with changes in mRNA levels of neuropeptide Y and proopiomelanocortin, suggesting that XPA.80.037 had hypothalamic effects., Conclusions: Agonist allosteric monoclonal antibodies to the LEPR can correct metabolic effects associated with LEP deficiency in vivo and thereby have the potential to treat conditions of LEP deficiency., (© 2016 The Obesity Society.)