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Objectives: Children with medical complexity (CMC) have high rates of mortality and morbidity, prolonged lengths of stay, and use a disproportionately high amount of health care expenditures. A subset of children with CMC have chronic critical illness requiring even higher levels of clinical support and resource use. We aimed to describe the point prevalence of children hospitalized in general inpatient care units with pediatric chronic critical illness (PCCI)., Methods: Point prevalence analysis across 6 pediatric tertiary medical centers in the United States on a "snapshot day" (May 17, 2017). On the day of sampling, a number of demographic, historical, and clinical descriptors were collected. A previously published definition of PCCI was used to establish inclusion criteria., Results: The point prevalence of patients with PCCI in general inpatient care units was 41% (232 out of 571). Of these, 91% (212 out of 232) had been admitted more than once in the previous 12 months, 50% (117 out of 232) had a readmission within 30 days of a previous admission, and 20% (46 out of 232) were oncology patients. Only 1 had a designated complex care team, and there were no attending physicians designated primarily for medically complex children., Conclusions: Children with chronic critical illness, a subset of CMC, may make up a substantial proportion of pediatric patients hospitalized in general inpatient care units. There is a critical need to understand how to better care for this medically fragile population. In our data, it is suggested that resources should be allocated for PCCI in nonintensive care clinical areas., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Biondi performs intermittent consultation for McKesson incorporated. The other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

The role of CTLA-4 in tolerance is primarily inferred from knockout and blocking studies. Anti-CD45RB mediates allograft tolerance in mice by inducing CTLA-4 expression on CD4 cells, providing a novel opportunity to determine how therapeutic enhancement of CTLA-4 promotes tolerance. We now show that induced CTLA-4 expression normally resolves by day 17. Although thymectomy prolongs enhanced CTLA-4 expression, long-term engraftment is unaffected. To address the temporal relationship between increased CTLA-4 expression and engraftment, transplantation was delayed for various times after anti-CD45RB treatment. Delaying transplantation for 7 days (when CTLA-4 expression had peaked but treatment mAb was no longer detectable), resulted in long-term engraftment comparable to transplantation with no delay (day 0). Delaying transplantation from 10 to 18 days led to a progressively poorer outcome as CTLA-4 expression returned to baseline. This suggested that Ag exposure while CTLA-4 expression is enhanced is sufficient to induce long-term engraftment. To substantiate this, on day 0, anti-CD45RB-treated mice received BALB/c vs unrelated alloantigen, followed by transplantation of BALB/c islets 10 days later. Whereas recipients exposed to unrelated Ag experienced acute rejection, recipients exposed to donor Ag achieved long-term engraftment. Anti-CD45RB-treated mice exposed to alloantigen exhibited anergic CD4(+)CD25(-) effector cells and regulatory CD4(+)CD25(+) cells. Moreover, CD25 depletion in the peritransplant period prevented anti-CD45RB-mediated engraftment. Thus, exposure of CD4 cells expressing CTLA-4 to donor Ag is necessary and sufficient to induce long-term engraftment which appears to be mediated by both regulation and anergy.

Knockout and blocking studies have shown a critical role for CTLA-4 in peripheral tolerance, however, it is unknown whether augmenting CTLA-4 expression actually promotes tolerance. Here we demonstrate a specific and requisite role for CTLA-4 and its up-regulation in tolerance through anti-CD45RB. First, long-term murine islet allograft survival induced by anti-CD45RB is prevented by CTLA4-Ig, which interferes with B7:CTLA-4 interactions. Second, anti-CD45RB is ineffective in recipients lacking CTLA-4, B7-1, and B7-2. In contrast, CTLA4-Ig, which targets B7 on allogeneic cells, promotes long-term engraftment in these mice. Moreover, anti-CD45RB was effective in B7-deficient controls expressing CTLA-4. Finally, in wild-type mice, CTLA-4 expression returned to baseline 17 days after receiving anti-CD45RB, and was refractory to further increase. Transplantation and anti-CD45RB therapy at this time could neither augment CTLA-4 nor prolong engraftment. These data demonstrate a specific role for CTLA-4 in anti-CD45RB-mediated tolerance and indicate that CTLA-4 up-regulation can directly promote allograft survival.

The murine CD8 glycoprotein interacts with both classical MHC class I molecules and some nonclassical molecules, including the thymic leukemia Ag (TL). TL binds preferentially to CD8alphaalpha homodimers with a 10-fold higher affinity than H-2K(b) class I molecules. To understand the molecular basis for this difference, we created a panel of CD8alpha mutants and tested the ability of the CD8alphaalpha homodimers to bind to H-2K(b) tetramers and TL tetramers. Mutations in three CD8 residues located on the complementarity-determining region-like loops contacting the negatively charged loop in the alpha3 domain of MHC class I greatly reduced binding to both tetramers. Because TL and H-2K(b) class I sequences are highly conserved in the alpha3 domain of MHC class I, this suggests that CD8 contacts the alpha3 domain of TL and H-2K(b) in a similar manner. In contrast, mutations in residues on the A and B beta strands of CD8 that are involved in contact with beta(2)-microglobulin affected interaction with the H-2K(b) tetramer, but not the TL tetramer. Therefore, the orientation of interaction of TL with CD8 appears to be different from that of H-2K(b). The unique high affinity binding of TL with CD8alphaalpha is most likely a result of amino acid differences in the alpha3 domain between TL and H-2K(b), particularly at positions 198 (K to D) and 228 (M to T), which are contact residues in the CD8alphaalpha-H-2K(b) cocrystal.

Human T-cell hybrids with helper activity were obtained after fusion of phytohemagglutinin-activated normal human T cells with a 6-thioguanine-resistant, aminopterin-sensitive human T-cell line. This mutant line, designated CEM-T15, was derived from the human T-cell line CEM after mutagenesis with ethyl methanesulfonate. The polyethylene glycol induced fusion and the selection in hypoxanthine- aminopeterin -thymidine medium were performed by modification of standard somatic cell hybridization techniques. After fusion, the strategy for selecting hybrids consisted in screening growing cultures for the presence of cells expressing the OKT3 cell surface differentiation antigen. OKT3 was chosen because it is present in 85-95% of normal human T cells but absent from CEM-T15 cells. Thus, OKT3+ cells growing 5-7 weeks after fusion most likely represented hybrids between normal T cells (OKT3+) and continuously growing CEM-T15 cells (OKT3-). Several of the hybrids were tested for their capacity to promote pokeweed mitogen-induced antibody production by B cells. These experiments demonstrated that many of the hybrids had helper activity. Periodical testing of these uncloned hybrids for helper activity revealed functional instability, with most of the hybrids losing helper activity after 20 weeks of continuous culture. However, early and repeated cloning of the same hybrids resulted in a series of hybrid clones with helper activity still present more than 8 months after fusion. In more recent fusions, we have demonstrated that human helper hybrids producing helper factor(s) can also be obtained. These and similar hybrids with different functions will be of considerable importance in further studies of the immunobiology of human T lymphocytes.

The OKT4 monoclonal antibody reacts with a 62 KD cell surface glycoprotein present on a subset of human T cells with the capacity to help or induce B-cell differentiation. The OKT8 monoclonal antibody reacts with a 76 KD cell surface glycoprotein present on a subset of human T cells with the capacity to suppress B-cell differentiation. The current studies were undertaken to determine whether the T4 and/or T8 antigens themselves play any role in the helper or suppressor function mediated by OKT4+ or OKT8+ cells. Specifically, we asked if monoclonal antibodies that react with noncompeting epitopes on the T4 or T8 molecules could block helper or suppressor function. Isolated human B cells were triggered in vitro to differentiate into antibody-forming cells (AFC) by autologous OKT4+ cells and macrophages in the presence or absence of OKT4 antibodies. By means of a reverse hemolytic plaque assay, AFC were detected as plaque-forming cells (PFC). We found that OKT4A, but not OKT4, antibody inhibited the PFC response over a wide range of concentrations. The antibodies OKT4B, OKT4C, OKT4D, OKT4E inhibited the PFC response to varying degrees. Importantly, inhibition by OKT4A occurred only if the antibody was present during the first 24 hours of cell culture. In the second set of experiments, OKT8+ cells were added to cultures containing B cells, and OKT4+ cells in the presence or absence of OKT8 antibodies, PFC activity was measured 7 days later. We found that the addition of OKT8E or OKT8G, but not OKT8B, OKT8C, OKT8D, OKT8F, or OKT8H, antibodies significantly inhibits the suppressor function mediated by OKT8+ cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Our knowledge of human T cell differentiation and function has expotentially increased during recent years. With this growth in knowledge there has been an increase in our appreciation of the complexity of the T-T interactions which initiate and control immune responses. A great deal remains to be learned concerning the mechanisms of these complex cellular interactions. In particular, it will be important to precisely understand the clear heterogeneity of functions within isolated subsets of OKT4+ and OKT8+ T cells. Perhaps, as importantly, it will be necessary to define more clearly the functions of the T4 and T8 molecules as well as the precise function of the other defined glycoproteins on the T cell surface. The evidence is clearly emerging that many of those molecules are not solely markers of unique functional subsets and are intimately involved in the functions of T cells.

In the present study, we investigated the immunoregulatory potential of OKT8+ cells after in vitro activation. Initial studies had demonstrated that the T cell marker OKT4 identifies T cell sets containing helper cells, whereas OKT8 reacts with the suppressor and cytotoxic T cell effectors. More detailed analysis of the OKT4+ subset, however, demonstrated that there is functional heterogeneity in the OKT4+ population. The evidence for this heterogeneity arose from studies on (1) the relative radiosensitivities of the distinct immunoregulatory functions of cells contained within this set, and, (2) the effects of the state of activation of this population on immune function. For example, OKT4+ cells included radiosensitive helper cells, radioresistant helper cells, and radiosensitive inducers of suppressor cells. Furthermore, after activation, the OKT4+ population also contained cells capable of suppressing B cell differentiation. Since activation of the OKT4+ population results in the emergence of cells with counterbalancing immunoregulatory properties, it was of interest to determine whether the state of activation of the OKT8+ population influences the immunoregulatory potential of this subset. In the experiments reported here E+ cells were cultured with pokeweed mitogen (PWM) for 60-70 h and then thoroughly depleted of OKT4+ cells, leaving OKT8+ cells. The ability of the PWM-activated OKT8+ cells (first culture) to exert suppressive activity was determined by adding graded numbers of these cells to fresh autologous OKT4+ cells and B cells. The cell mixtures were cultured in the presence of PWM for 5 days and then assayed for plaque-forming-cell (PFC) activity by the reverse hemolytic plaque assay. Our studies demonstrate that activation of OKT8+ cells results in the emergence of cells with apparently counterbalancing immunoregulatory properties. Activated nonirradiated OKT8+ cells consistently suppressed B cell immunoglobulin production. However, the immunoregulatory function mediated by irradiated activated OKT8+ cells is highly dependent on the magnitude of the helper activity obtained with fresh OKT4+ cells. Thus, irradiated activated OKT8+ cells suppressed the generation of PFC only when the level of helper activity was optimal. However, when the level of help was not optimal, no suppressor activity was observed; rather, under these conditions, irradiated activated OKT8+ cells amplify the PFC response. We would emphasize that the amplification function of irradiated OKT8+ cells depends strictly on the presence of fresh OKT4+ cells. Irradiated activated OKT8+ cells alone are not helper cells, since addition of these cells to B cells thoroughly dep

The relationship between immunoregulatory T-cell function and the expression of T-cell subset-specific differentiation antigens was examined using a phenotypically anomalous human T-cell line (TCL), termed H-1. H-1 cells were found to express T11, extremely high levels of T3, but no T4 nor T8 antigen. Despite their lack of T4 antigen expression, H-1 cells could be activated by coculture with pokeweed mitogen (PWM), anti-T3 antibody, or autologous B cells to provide potent help for B-cell differentiation into plaque-forming cells (PFC). In contrast, H-1 cells did not suppress the PFC response triggered by PWM-activated T4+ cells. These results demonstrate that the expression of the T-cell subclass-specific differentiation antigen, T4, is not required for a T cell to become activated and to implement the program for helper function. In addition, enhanced expression of T3 on the T4-, T8-, H-1 cell surface may reflect a compensatory upregulation of the T3/Ti receptor complex on T cells which are deficient in these nonpolymorphic associative recognition structures.

Previous studies have suggested functional heterogeneity within the OKT4+ and the OKT8+ populations. For example, after activation the OKT4+ population contains not only helper cells but also cells capable of suppressing B cell differentiation. Previous studies also indicate that the reciprocal T cell population, OKT8+, does not provide helper activity but contains cytotoxic effector cells and radiosensitive cells important in the suppression of B cell differentiation. Using a new differentiation antigen, OKT17, which recognizes a surface antigen present on the majority of resting normal peripheral T lymphocytes but is present only on a subset of OKT4+ cells after activation, evidence was obtained that two functionally mature subsets can be distinguished within the OKT4+ population itself: OKT4+17+ radiosensitive suppressor cells and OKT4+17- radiosensitive helper cells. Recently, another monoclonal antibody, OKT20, has been described which is present on a small percentage of resting lymphocytes but is expressed in varying proportions on activated T cells. Functional analysis of normal resting human T lymphocytes demonstrated that the OKT20-depleted T cell subset was able to generate cytotoxic cells and to suppress antibody production to the same extent as did OKT8+ cells. On the other hand, when unselected T lymphocytes were cultured for six days in a mixed lymphocyte reaction and then depleted of OKT20 reactive cells, the cytotoxic effector T cells were eliminated. In contrast, OKT20-depleted T cells after identical activation were still able to suppress antibody production. These data provide evidence that following activation of OKT8+ cells, the OKT20 differentiation antigen becomes selectively expressed on cytotoxic effectors but not on suppressor cells.

Two hybridoma-derived monoclonal antibodies have been developed that react with an antigen of molecular weight 92,000 daltons on the surface of human endothelial cells. Cultured human umbilical vein endothelial cells were used for immunization, but the antigen is present on arterial, venous and capillary endothelium, as determined by biotin-avidin immunoperoxidase staining of tissue sections. With this technique, other cell types in the tissues which were examined were not reactive, except for scattered fibroblasts and histiomonocytic cells, trophoblastic cells of the placenta, and benign immature mesenchymal cells in a renal cystadenocarcinoma. By cytofluorography, the antibodies were found to be unreactive with granulocytes, T lymphocytes, B lymphocytes, and the majority of monocytes. Fibroblasts were reactive with the antibodies, but the fluorescence tracings indicated a lower density of antigen on these cells than on endothelial cells. Immunoreactivity of fibroblasts could be decreased by treatment of the cells with thrombin, trypsin, or neuraminidase, whereas these enzymes did not affect the immunoreactivity of endothelial cells. The reactive antigen (E92) does not appear to be any of several previously described endothelial cell proteins, because of its molecular weight and its absence on other cell types. The presence of E92 on trophoblastic cells of the placenta and immature mesenchymal cells, as well as fibroblasts and endothelial cells, may indicate that it is a primitive antigen of mesodermal tissue that is lost by most cell types during differentiation.