Miami Transplant Institute

Mesenchymal stem cells (MSCs) residing in bone marrow (BM) are the progenitors for osteoblasts and for several other cell types. In humans, the age-related decrease in bone mass could reflect decreased osteoblasts secondary to an age-related loss of osteoprogenitors. To test this hypothesis, BM cells were isolated from vertebral bodies of thoracic and lumbar spine (T1-L5) from 41 donors (16 women and 25 men) of various ages (3-70 years old) after death from traumatic injury. Primary cultures were grown in alpha modified essential medium with fetal bovine serum for 13 days until adherent cells formed colonies (CFU-Fs). Colonies that stained positive for alkaline phosphatase activity (CFU-F/ALP+) were considered to have osteogenic potential. BM nucleated cells were plated (0.5, 1, 2.5, 5, or 10 x 106 cells/10-cm dish) and grown in dexamethasone (Dex), which promotes osteoblastic differentiation. The optimal plating efficiency using BM-derived cells from donors of various ages was 5 x 106 cells/10-cm dish. BM-derived cells were also grown in the absence of Dex at this plating density. At the optimal plating density, in the presence of Dex, the number of CFU-F/ALP+ present in the BM of the younger donors (3-36 years old) was 66.2 +/- 9.6 per 106 cells (mean +/- SEM), but only 14.7 +/- 2.6 per 106 cells in the older donors (41-70 years old). With longer-term culture (4-5 weeks) of these BM cells in medium containing 10 mM beta-glycerophosphate and 100 microg/ml ascorbic acid, the extracellular matrix mineralized, a result consistent with mature osteoblastic function. These results demonstrate that the number of MSCs with osteogenic potential (CFU-F/ALP+) decreases early during aging in humans and may be responsible for the age-related reduction in osteoblast number. Our results are particularly important in that the vertebrae are a site of high turnover osteoporosis and, possibly, the earliest site of bone loss in age-related osteoporosis.

BACKGROUND: Xenografts from genetically modified pigs have become one of the most promising solutions to the dearth of human organs available for transplantation. The challenge in this model has been hyperacute rejection. To avoid this, pigs have been bred with a knockout of the alpha-1,3-galactosyltransferase gene and with subcapsular autologous thymic tissue. METHODS: We transplanted kidneys from these genetically modified pigs into two brain-dead human recipients whose circulatory and respiratory activity was maintained on ventilators for the duration of the study. We performed serial biopsies and monitored the urine output and kinetic estimated glomerular filtration rate (eGFR) to assess renal function and xenograft rejection. RESULTS: in Recipient 2. In both recipients, the creatinine level, which had been at a steady state, decreased after implantation of the xenograft, from 1.97 to 0.82 mg per deciliter in Recipient 1 and from 1.10 to 0.57 mg per deciliter in Recipient 2. The transplanted kidneys remained pink and well-perfused, continuing to make urine throughout the study. Biopsies that were performed at 6, 24, 48, and 54 hours revealed no signs of hyperacute or antibody-mediated rejection. Hourly urine output with the xenograft was more than double the output with the native kidneys. CONCLUSIONS: Genetically modified kidney xenografts from pigs remained viable and functioning in brain-dead human recipients for 54 hours, without signs of hyperacute rejection. (Funded by Lung Biotechnology.).

Abstract Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with high mortality. Mesenchymal stem cells are known to exert immunomodulatory and anti-inflammatory effects and could yield beneficial effects in COVID-19 ARDS. The objective of this study was to determine safety and explore efficacy of umbilical cord mesenchymal stem cell (UC-MSC) infusions in subjects with COVID-19 ARDS. A double-blind, phase 1/2a, randomized, controlled trial was performed. Randomization and stratification by ARDS severity was used to foster balance among groups. All subjects were analyzed under intention to treat design. Twenty-four subjects were randomized 1:1 to either UC-MSC treatment (n = 12) or the control group (n = 12). Subjects in the UC-MSC treatment group received two intravenous infusions (at day 0 and 3) of 100 ± 20 × 106 UC-MSCs; controls received two infusions of vehicle solution. Both groups received best standard of care. Primary endpoint was safety (adverse events [AEs]) within 6 hours; cardiac arrest or death within 24 hours postinfusion). Secondary endpoints included patient survival at 31 days after the first infusion and time to recovery. No difference was observed between groups in infusion-associated AEs. No serious adverse events (SAEs) were observed related to UC-MSC infusions. UC-MSC infusions in COVID-19 ARDS were found to be safe. Inflammatory cytokines were significantly decreased in UC-MSC-treated subjects at day 6. Treatment was associated with significantly improved patient survival (91% vs 42%, P = .015), SAE-free survival (P = .008), and time to recovery (P = .03). UC-MSC infusions are safe and could be beneficial in treating subjects with COVID-19 ARDS.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to significant reductions in transplantation, motivated in part by concerns of disproportionately more severe disease among solid organ transplant (SOT) recipients. However, clinical features, outcomes, and predictors of mortality in SOT recipients are not well described. METHODS: We performed a multicenter cohort study of SOT recipients with laboratory-confirmed COVID-19. Data were collected using standardized intake and 28-day follow-up electronic case report forms. Multivariable logistic regression was used to identify risk factors for the primary endpoint, 28-day mortality, among hospitalized patients. RESULTS: Four hundred eighty-two SOT recipients from >50 transplant centers were included: 318 (66%) kidney or kidney/pancreas, 73 (15.1%) liver, 57 (11.8%) heart, and 30 (6.2%) lung. Median age was 58 (interquartile range [IQR] 46-57), median time post-transplant was 5 years (IQR 2-10), 61% were male, and 92% had ≥1 underlying comorbidity. Among those hospitalized (376 [78%]), 117 (31%) required mechanical ventilation, and 77 (20.5%) died by 28 days after diagnosis. Specific underlying comorbidities (age >65 [adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 1.7-5.5, P < .001], congestive heart failure [aOR 3.2, 95% CI 1.4-7.0, P = .004], chronic lung disease [aOR 2.5, 95% CI 1.2-5.2, P = .018], obesity [aOR 1.9, 95% CI 1.0-3.4, P = .039]) and presenting findings (lymphopenia [aOR 1.9, 95% CI 1.1-3.5, P = .033], abnormal chest imaging [aOR 2.9, 95% CI 1.1-7.5, P = .027]) were independently associated with mortality. Multiple measures of immunosuppression intensity were not associated with mortality. CONCLUSIONS: Mortality among SOT recipients hospitalized for COVID-19 was 20.5%. Age and underlying comorbidities rather than immunosuppression intensity-related measures were major drivers of mortality.

Abatacept (cytotoxic T-lymphocyte-associated antigen 4-immunoglobulin fusion protein [CTLA-4-Ig]) is a costimulatory inhibitor that targets B7-1 (CD80). The present report describes five patients who had focal segmental glomerulosclerosis (FSGS) (four with recurrent FSGS after transplantation and one with primary FSGS) and proteinuria with B7-1 immunostaining of podocytes in kidney-biopsy specimens. Abatacept induced partial or complete remissions of proteinuria in these patients, suggesting that B7-1 may be a useful biomarker for the treatment of some glomerulopathies. Our data indicate that abatacept may stabilize β1-integrin activation in podocytes and reduce proteinuria in patients with B7-1-positive glomerular disease.

Twenty Haitian patients, hospitalized from 1 April 1980 to 20 June 1982, had Pneumocystis carinii pneumonia, central nervous system toxoplasmosis, esophageal candidiasis, cryptococcosis, disseminated cytomegalovirus, progressive herpes simplex virus, chronic enteric coccidiosis, or invasive Kaposi's sarcoma. Ten patients died. Opportunistic infections were frequently multiple and were recurrent in three patients. In seven patients disseminated tuberculosis preceded the other infections by 2 to 15 months. There was no evidence of an underlying immunosuppressive disease, and no history of homosexuality or intravenous drug abuse. At least three patients probably acquired the syndrome in Haiti. Lymphadenopathy was common. Seventeen patients tested had anergy, and 18 had lymphopenia. Monoclonal antibody analysis of peripheral-blood T-cell subsets done on 11 patients showed a marked decrease in T-helper cells and an inversion of the normal ratio of T-helper cells to T-suppressor cells. This syndrome among heterosexual Haitians is strikingly similar to the syndrome of immunodeficiency described recently among American homosexuals.

BACKGROUND: For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. METHODS: The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. FINDINGS: Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). INTERPRETATION: Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. FUNDING: Gates Foundation and Bloomberg Philanthropies.

With the development of modern solid-phase assays to detect anti-HLA antibodies and a more precise histological classification, the diagnosis of antibody-mediated rejection (AMR) has become more common and is a major cause of kidney graft loss. Currently, there are no approved therapies and treatment guidelines are based on low-level evidence. The number of prospective randomized trials for the treatment of AMR is small, and the lack of an accepted common standard for care has been an impediment to the development of new therapies. To help alleviate this, The Transplantation Society convened a meeting of international experts to develop a consensus as to what is appropriate treatment for active and chronic active AMR. The aim was to reach a consensus for standard of care treatment against which new therapies could be evaluated. At the meeting, the underlying biology of AMR, the criteria for diagnosis, the clinical phenotypes, and outcomes were discussed. The evidence for different treatments was reviewed, and a consensus for what is acceptable standard of care for the treatment of active and chronic active AMR was presented. While it was agreed that the aims of treatment are to preserve renal function, reduce histological injury, and reduce the titer of donor-specific antibody, there was no conclusive evidence to support any specific therapy. As a result, the treatment recommendations are largely based on expert opinion. It is acknowledged that properly conducted and powered clinical trials of biologically plausible agents are urgently needed to improve patient outcomes.

Retinopathy of prematurity is a disease affecting the blood vessels of the retina in premature infants that may result in scarring, retinal detachment, and loss of vision. An association between this condition and the exposure of premature infants to supplemental oxygen has been postulated, but the relation between retinopathy of prematurity and blood oxygen levels has not been defined. The purpose of this study of a cohort of preterm infants was to correlate the incidence and severity of retinopathy of prematurity with the duration of exposure to different ranges of oxygen tension as measured by transcutaneous monitoring (tcPO2).

The purpose of this research was to develop, standardize, and test the reliability of a short neuropsychological test battery in the Spanish language. This neuropsychological battery was named "NEUROPSI," and was developed to assess briefly a wide spectrum of cognitive functions, including orientation, attention, memory, language, visuoperceptual abilities, and executive functions. The NEUROPSI includes items that are relevant for Spanish-speaking communities. It can be applied to illiterates and low educational groups. Administration time is 25 to 30 min. Normative data were collected from 800 monolingual Spanish-speaking individuals, ages 16 to 85 years. Four age groups were used: (1) 16 to 30 years, (2) 31 to 50 years, (3) 51 to 65 years, and (4) 66 to 85 years. Data also are analyzed and presented within 4 different educational levels that were represented in this sample; (1) illiterates (zero years of school); (2) 1 to 4 years of school; (2) 5 to 9 years of school; and (3) 10 or more years of formal education. The effects of age and education, as well as the factor structure of the NEUROPSI are analyzed. The NEUROPSI may fulfill the need for brief, reliable, and objective evaluation of a broad range of cognitive functions in Spanish-speaking populations.

Extracellular nucleotides are pleiotropic regulators of mammalian cell function. Adenosine triphosphate (ATP) released from CD4(+) helper T cells upon stimulation of the T cell receptor (TCR) contributes in an autocrine manner to the activation of mitogen-activated protein kinase (MAPK) signaling through purinergic P2X receptors. Increased expression of p2rx7, which encodes the purinergic receptor P2X7, is part of the transcriptional signature of immunosuppressive CD4(+)CD25(+) regulatory T cells (T(regs)). Here, we show that the activation of P2X7 by ATP inhibits the suppressive potential and stability of T(regs). The inflammatory cytokine interleukin-6 (IL-6) increased ATP synthesis and P2X7-mediated signaling in T(regs), which induced their conversion to IL-17-secreting T helper 17 (T(H)17) effector cells in vivo. Moreover, pharmacological antagonism of P2X receptors promoted the cell-autonomous conversion of naïve CD4(+) T cells into T(regs) after TCR stimulation. Thus, ATP acts as an autocrine factor that integrates stimuli from the microenvironment and cellular energetics to tune the developmental and immunosuppressive program of the T cell in adaptive immune responses.

Each year in the United States, approximately 3.3 million Pap tests are interpreted as having some degree of cytological abnormality [1]. Identifying which of these women are at risk for having a clinically significant cervical abnormality, performing a diagnostic evaluation, and treating clinically significant abnormalities once identified presents a serious clinical and public health problem that has been estimated to cost billions of dollars [2]. This challenge is amplified by the fact that Pap tests are obtained in a variety of clinical settings, including school-based health clinics, sexually transmitted disease clinics, family planning clinics and private physician offices, as well as hospitals and emergency rooms. A spectrum of health care providers is responsible for cervical cancer screening in these various settings, and many of these clinicians have little expertise in managing cervical cytological abnormalities. Because of the magnitude of the clinical problem, there is a clear need for comprehensive, evidence-based guidelines for the management of cervical cytological abnormalities and cervical cancer precursors. There are a number of other reasons why new management guidelines are needed. In May 2001, the National Cancer Institute held a consensus workshop to revise the cervical cytological classification system used in the United States, which is now referred to as the 2001 Bethesda System. The 2001 Bethesda System changes the criteria used by cytologists to render an interpretation of atypical squamous cells (ASC), provides new subcategories of ASC, and changes the subcategories of atypical glandular cells (AGC) [3]. The ASC category is the most common cervical cytological abnormality in the United States, and management guidelines need to be revised to incorporate these changes in terminology. Other reasons for developing new management guidelines are a better understanding of the pathogenesis and natural history of human papillomavirus (HPV) and cervical cancer precursors and the availability of data from the large National Cancer Institute's Atypical Squamous Cells of Undetermined Significance/Low-grade Squamous Intraepithelial Lesion Study (ALTS) clinical trial [3a]. This $25 million, multisite, randomized clinical trial was designed specifically to address the best management approaches for women with a cytological result of ASC and low-grade squamous intraepithelial lesions (LSIL). The results of this trial need to be incorporated into clinical care of women in the United States. It is also important to recognize that current guidelines were developed before sensitive molecular methods for detecting high-risk types of HPV and liquid-based cytology methods became widely available. There is now compelling data that combining these two new technologies provides an attractive alternative to the more traditional management approaches for certain types of cytological abnormalities [4–6]. As a result, the use of these new technologies is increasing, and clinicians need clear, unbiased guidelines delineating the strengths and weakness of different management approaches and the best use of the new technologies. To develop comprehensive management strategies for women with cytological abnormalities and cervical cancer precursors, the American Society of Colposcopy and Cervical Pathology (ASCCP) sponsored a National Consensus Conference in Bethesda, MD, on September 6–8, 2001. This meeting had representatives from 29 national and international health organizations, professional societies, and federal agencies. Throughout the development of the guidelines, input was obtained from the professional community at large through a novel approach that incorporated Internet-based discussion groups. This report provides a summary of the key recommendations and algorithms for managing women with cytological abnormalities. A description of the evidence supporting the guidelines and the guidelines themselves have previously been published [7]. Comprehensive literature reviews of the evidence base supporting the recommendations will be published by each of the four Consensus Conference working groups [atypical squamous cells (ASC); atypical glandular cells (AGC); low-grade squamous intraepithelial lesion (LSIL); and high-grade squamous intraepithelial lesion (HSIL)] at a later date in the Journal of Lower Genital Tract Disease. In addition, separate 2001 Consensus Guidelines for the Management of Women with Cervical Histological Abnormalities will also be published at a later date. OVERVIEW OF GUIDELINE DEVELOPMENT PROCEDURES ASCCP began developing the 2001 Consensus Guidelines in the fall of 2000. To ensure that the guidelines reflect the needs of the diverse array of health care providers, federal agencies and national and international health organizations involved in the health care of women were invited to participate in the guideline development process. Twenty-nine different agencies and organizations agreed to formally participate, or in some instances to formally observe, the Consensus Conference and to send 2 to 4 representatives (seeAppendix 1). In total, 121 representatives attended the Consensus Conference. These included cytopathologists, cytotechnologists, epidemiologists, family physicians, gynecologists, gynecological oncologists, health policy experts, lawyers, nurse clinicians, social scientists, and pathologists. All are recognized experts in various aspects of the diagnosis and management of cervical cancer precursors. Approximately 6 months before the conference, four working groups composed of 10 to 11 participants each began developing draft guidelines through a multistep process. First, a list of key questions that needed to be addressed by literature reviews and comment from the professional community was prepared. These questions were posted on an open Internet bulletin board (http://www.asccp.org) for public discussion. Working groups also conducted MEDLINE searches of English-language, peer-reviewed articles published between at least 1988 and 2001 to identify articles pertaining to the key questions. Abstracts of articles were reviewed by members of the working group to determine their relevancy, and the relevant articles were reviewed to determine whether they fulfilled a minimum scientific standard. Data from articles that fulfilled this standard was extracted using data extraction forms, and summary data tables were prepared for many of the specific topics. Based on the literature review, draft management guidelines were developed. In instances in which published data pertaining to a key issue was either conflicting, scant, or simply missing, information provided by participants of the Internet bulletin boards or expert opinions of members of the working group were used to help formulate the guidelines. Draft guidelines were posted on the open Internet bulletin board for public comment and discussion. Once the discussion period was closed, the draft guidelines were revised by the working groups in light of the public comments and distributed to each of the Consensus Conference participants for review. At the conference, each participant was provided with an electronic numeric keypad that allowed “real-time” voting. Review and adoption of the guidelines took place in three stages. Initially, the draft guidelines and supporting evidence were presented by the working group to the entire Consensus Conference for discussion and voting. Any recommendation that was approved by 66% of the conference participants was accepted. Recommendations that were not approved underwent revision in open working sessions, and the revised recommendations were again discussed and voted on. If the revised recommendation was not accepted, it underwent a second round of revision and was again presented to the Consensus Conference for a third vote. All guidelines were accepted by a two-thirds majority vote. All recommendations are graded using a grading system based on one that has been successfully used for a number of years by the Infectious Disease Society of America (IDSA) for evidence-based practice guidelines [8,9]. More than 30 practice guidelines have been produced by the IDSA using this grading system (with or without minor modifications). Recent important guidelines that have used this grading system include the 1999 Guidelines for the Prevention of Opportunistic Infections in Persons with HIV (and the as yet unreleased 2001 update), produced by a joint panel of the National Institute of Allergy and Infectious Disease, the Centers for Disease Control and Prevention, and the IDSA. The two-part grading system is also almost identical to the one utilized by the US Preventative Services Task Force in its Guide to Clinical Preventative Services. The grading system that was used for the 2001 Consensus Guidelines is a two-part grading system [10]. In this system, the letters A–E reflect the “strength of the recommendation” for or against the use of a particular option (i.e., good, moderate, or insufficient) (Table 1). Roman numerals I–III were used to indicate the “quality of evidence” supporting the recommendation (Table 1). In addition, the terms “recommended,” “preferred,” “acceptable,” and “unacceptable” were specifically defined at the Consensus Conference (Table 1). It was felt that providing an indication of the strength of the evidence supporting each guideline was particularly important in a field in which clinical opinion or small case studies are frequently all that's available to guide a recommendation. Giving the strength of the evidence for a given guideline also provides the additional benefit of highlighting areas in which research is needed. It is expected that the 2001 Consensus Guidelines will be updated on a regular basis; and it is hoped that, with each revision, the data in support of a given practice guideline will become stronger as a result of the grading system.Table 1: Rating the Recommendations2001 CONSENSUS GUIDELINES FOR MANAGING WOMEN WITH CYTOLOGICAL ABNORMALITIES General Comments Although the 2001 Consensus Guidelines are “evidenced-based,” in many instances the evidence that was available to inform the development of a particular guideline was quite limited. This resulted in instances in which the guidelines had to be based on either relatively small studies or simply on expert opinion. It is also important to recognize that, although the 2001 Consensus Guidelines are designed to provide guidance to clinicians caring for women with cytological abnormalities and cervical cancer precursors in the United States, management approaches will frequently need to be individualized to take into account individual patients' clinical findings and preferences. There is a general consensus that guidelines should never be considered a substitute for clinical judgment and that it is impossible to develop guidelines comprehensive enough to apply to all clinical situations. Finally, both clinicians and patients need to realize that, although cervical cancer can often be prevented through a program of screening and treatment of cervical cancer precursor lesions, no screening or treatment modality is perfect and, unfortunately, invasive cervical cancer can develop in women who participate in such programs. The 2001 Bethesda System for cytological classification, which uses the terms low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) to refer to cervical cancer precursors, is used for the guidelines. The 2001 Consensus Guidelines have utilized a two-tiered terminology for the histopathological classification that uses the terms cervical intraepithelial neoplasia–grade 1 (CIN 1) and CIN 2,3 to refer to low-grade and high-grade precursors, respectively [11]. Several terms are used throughout the guidelines, and these have been clarified in Appendix 2. Atypical Squamous Cells General Comments. The 2001 Bethesda System subcategorizes ASC into two categories: atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells–cannot exclude HSIL (ASC-H) [3]. The prevalence of ASC varies considerably between laboratories and patient populations [1]. In 1997 the median ASC rate of laboratories participating in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology (PAP) was 4.4% [1]. Several points need to be understood to interpret the consensus guidelines for the management of ASC. The first is that even with expert cytologists, the diagnosis of ASC is poorly reproducible [12–14]. For example, in the recent ALTS trial, only 55% of the cytology specimens originally diagnosed as ASC were subsequently given a diagnosis of ASC by the pathology quality control group [5]. Many of the slides initially interpreted as ASC were subsequently classified as normal. Second, a woman with a cytological diagnosis of ASC has a 5% to 17% chance of having biopsy-confirmed CIN 2,3 [5,15–17]. However, the risk that a woman with ASC has invasive cervical cancer is low (approximately 0.1%–0.2%) [18,19]. The prevalence of CIN 2,3 is considerably higher (24%–94%) among women referred for colposcopy (seeAppendix 2) for the evaluation of ASC-H compared with women referred for the evaluation of ASC-US [20–24]. Therefore, a woman with an ASC result requires some form of additional evaluation, but clinicians should attempt to minimize anxiety, cost, inconvenience, and patient discomfort during workup or follow-up. Recommendations for Managing Women with ASC. Management of Women with Atypical Squamous Cells—Undetermined Significance. A program of repeat cervical cytology, or colposcopy, or DNA testing for high-risk types of HPV are all acceptable methods for managing women with ASC-US (AI). When liquid-based cytology is used, or when co-collection for HPV DNA testing can be done, “reflex” HPV DNA testing is the preferred approach (AI). * DNA testing for high-risk types of HPV should be performed using a sensitive molecular test, and all women who are HPV DNA positive should be referred for colposcopic evaluation (AII). Women with ASC-US who are high-risk HPV DNA negative can be followed up with repeat cytology at months management for women who are positive for high-risk types of HPV but who not have biopsy-confirmed CIN include with repeat cytology at 6 and months with to colposcopy a result of ASC-US or is or HPV DNA testing at months with to colposcopy of all HPV DNA positive women Management of Women with Atypical Squamous Cells of Undetermined a program of repeat cervical cytology is used, women with ASC-US should repeat cytological testing or at to two for intraepithelial lesion or results are obtained (AII). Women diagnosed with ASC-US or cytological abnormality on the repeat tests should be referred for colposcopy (AII). two for intraepithelial lesion or repeat cytology tests are women can be to cytological screening (AII). When colposcopy is used to women with women who are referred to colposcopy and not to have CIN should be followed up with repeat cytology at months Women with ASC-US who are referred for colposcopy and to have biopsy-confirmed CIN should be to the 2001 Consensus for the Management of Women with Cervical Histological Abnormalities for Because of the for diagnostic (seeAppendix 2) such as should not be used to women with ASC in the of biopsy-confirmed CIN ASC-US in a of followed by a repeat cervical cytology obtained approximately a the is an acceptable option for women with ASC-US who have clinical or cytological evidence of and no to using If the repeat cervical cytology is for intraepithelial lesion or the cervical cytology should be in 4 to 6 If both repeat cytology tests are for intraepithelial lesion or the patient can to cytological but either repeat cytology is as ASC-US or the patient should be referred for colposcopy Management of Women with Atypical Squamous Cells of Undetermined (ASC-US) In for colposcopy is for all patients with ASC-US This all of HIV or It is that women with ASC-US be in the as women Management of Women with The management of women with ASC-H obtained using either or liquid-based cervical cytology is for colposcopic evaluation Management of Women with Atypical Squamous no lesion is identified colposcopy in women with it is that, when a of the cytology, colposcopy and be performed If the a revised management should guidelines for the revised a cytological interpretation of ASC-H is either cytological at 6 and months or HPV DNA testing at months is acceptable Women who are to have ASC or on their repeat cervical cytology or who are subsequently high-risk HPV DNA positive should be referred for Atypical Cells and In General Comments. abnormalities than are classified into three in the 2001 Bethesda System [3]. These are atypical glandular cells or not atypical glandular cells or and in [3]. In the median rate of laboratories in the United was [1]. most women with not have a significant cervical this category is of risk than the category of ASC or CIN is in of women with biopsy-confirmed is identified in and invasive cervical are identified in The majority of in women the of with are in of into two and women at different for having high-grade or invasive or CIN 2,3 have been in of women with compared with of women with women with a cytological result of will have either biopsy-confirmed or invasive cervical Recommendations for Managing Women with and Colposcopy with (seeAppendix 2) is for women with all subcategories of with the that women with atypical cells should initially be with (seeAppendix should be performed in with colposcopy in women the of with and women with who have Colposcopy with is also for women with a cytological result of Management of women with an result of or using a program of repeat cervical cytology is There is data to an of the use of HPV DNA testing in the management of women with or Management of Women with Atypical Cells and If invasive disease is not identified during the colposcopic it is that women with or a diagnostic (AII). The preferred diagnostic for women with or is If biopsy-confirmed CIN is identified during the workup of a woman with management should be to the 2001 Consensus for the Management of Women with Cervical Histological Abnormalities for If no is identified during the workup of a woman with it is that the woman be followed using a program of repeat cervical cytology at to four for intraepithelial lesion or cytology results are which the woman be to screening If an ASC or result is obtained on of the Pap acceptable include a repeat colposcopic or to a in the management of cytological If an or HSIL result is obtained on of the Pap acceptable include a diagnostic or to a in the management of cytological Squamous Intraepithelial Lesion General Comments. The median rate in the United in was However, as as have been from laboratories high-risk populations There is a relatively between the of lesion identified by cervical cytology and the of lesion that is identified on a CIN 2,3 is identified in approximately of women colposcopy for a cytological result of Recommendations for Managing Women with General Management Colposcopy is the preferred management of women with management on whether a lesion is whether the colposcopic is and whether the patient is or Management of Women with Squamous Intraepithelial is acceptable for women with a colposcopy (seeAppendix 2) and a lesion identified in the but it is preferred for women in no lesions are identified If biopsy-confirmed CIN is not identified and the colposcopy is acceptable management include with repeat cytology at 6 and months with a to colposcopy a result of ASC-US or is or HPV DNA testing at months with to colposcopy of all HPV DNA positive women is preferred for women with an colposcopy (AII). If biopsy-confirmed CIN is not identified and the colposcopy is acceptable management include with repeat cytology at 6 and or HPV DNA testing at months Women with who are to have biopsy-confirmed CIN should be to the 2001 Consensus Management in In without colposcopy using a of with repeat cytology at 6 and months with a to colposcopy of ASC, or HPV DNA testing at months is an acceptable option Management of Women with Squamous Intraepithelial In a of followed by a repeat cervical cytology obtained approximately a the is acceptable for women with ASC-US who have clinical or cytological evidence of with ASC-US and no to using is an acceptable If the repeat cervical cytology is for squamous intraepithelial lesion or the cervical cytology should be in 4 to 6 If both repeat cytology tests are for squamous intraepithelial lesion or the patient can to cytological but either repeat cytology is as ASC or the patient should be referred for In without colposcopy using a of up with repeat cytology at 6 and months with a to colposcopy of ASC, or HPV DNA testing at months is an acceptable option Management of Women with Squamous Intraepithelial In in in Women with The use of diagnostic or is for the management of patients with and either a or colposcopy in the of a biopsy-confirmed Squamous Intraepithelial Lesion to Managing Women with A cytological diagnosis of HSIL is relatively The median rate of HSIL in the United in was only to a College of American Pathologists A cytological result of HSIL is a significant it a of women who are at relatively high-risk for a CIN 2,3 or invasive cervical Approximately of women with HSIL will be at colposcopy to have a biopsy-confirmed CIN and will be to have invasive cervical cancer Recommendations for Managing Women with General Management Colposcopy with (seeAppendix 2) is the management of women with management on whether a lesion is whether the colposcopic is whether the patient is and whether is Management of Women with Squamous Intraepithelial When no lesion or only biopsy-confirmed CIN 1 is identified colposcopy in women with HSIL and a colposcopy, it is that, when a of the cytology, colposcopy and be If the a revised management should guidelines for the revised a cytological interpretation of HSIL is or is not a diagnostic is preferred in A colposcopic with is acceptable in HSIL in When no lesion is identified colposcopy in women with HSIL and an colposcopy, a of the cytology, colposcopy and should be performed when If the a revised management should guidelines for the revised If a cytological interpretation of HSIL is is not or a biopsy-confirmed CIN 1 is a diagnostic is in is of is acceptable when a diagnostic is In women with HSIL and a colposcopic of a high-grade evaluation a diagnostic is also an acceptable either a program of repeat cytology or HPV DNA testing is Women with HSIL who are to have biopsy-confirmed CIN should be the 2001 Consensus for the Management of Women with Cervical Histological Abnormalities for HSIL in It is preferred that the colposcopic evaluation of women with HSIL be conducted by clinicians who are in the evaluation of colposcopic changes by of lesions for high-grade disease or cancer is of other lesions is is in colposcopy become as the it is that women with an colposcopy a repeat colposcopic in 6 to In the of invasive additional colposcopic and cytological are with only the of the lesion or cytology invasive invasive cancer is treatment is A diagnostic is only is with cytology and colposcopy is no than 6 Women of When biopsy-confirmed CIN 2,3 is not identified in a woman with a HSIL cytology, with colposcopy and cytology at to for one year is provided colposcopy is is and the patient the risk of If a lesion to to a colposcopic high-grade lesion or HSIL cytology a diagnostic is The development of the 2001 Consensus Guidelines was by ASCCP and a 1 from the National Cancer The of the guidelines is the of the and not the of the National Cancer The ASCCP to for support for the conference and the development of the guidelines.

This report provides our initial experience in islet isolation and intrahepatic allotransplantation in 21 patients. In group 1, 10 patients underwent combined liver-islet allotransplantation following upper-abdominal exenteration for cancer. In group 2, 4 patients received a combined liver-islet allograft for cirrhosis and diabetes. One patients had plasma C-peptide greater than 3 pM and was therefore excluded from analysis. In group 3, 7 patients received 8 combined cadaveric kidney-islet grafts (one retransplant) for end-stage renal disease secondary to type 1 diabetes mellitus. The islets were separated by a modification of the automated method for human islet isolation and the preparation were infused into the portal vein. Immunosuppression was with FK506 (group 1) plus steroids (groups 2 and 3). Six patients in group 1 did not require insulin treatment for 5 to greater than 16 months. In groups 2 and 3 none of the patients became insulin-independent, although decreased insulin requirement and stabilization of diabetes were observed. Our results indicate that rejection is still a major factor limiting the clinical application of islet transplantation in patients with type 1 diabetes mellitus, although other factors such as steroid treatment may contribute to deteriorate islet engraftment and/or function.

OBJECTIVE: To describe intracochlear insertion trauma caused by three perimodiolar cochlear implant electrodes. STUDY DESIGN: Descriptive histological study of 15 human cadaver temporal bones. METHODS: Fifteen cadaver temporal bones underwent surface preparation and were implanted with one of the following perimodiolar electrode arrays: Combi 40+PM (MedEl Corporation), HiFocus II (Advanced Bionics Corporation), or Contour (Cochlear Corporation). A cryosectioning technique was used to study horizontal sections at 200 microm intervals with the electrode in place. Image-enhanced videofluoroscopy and computer-assisted morphometrics were used to assess the mechanism of insertion trauma and to determine electrode position within the modiolus. RESULTS: Histological examination revealed varying degrees of damage to the spiral ligament, basilar membrane, and osseous spiral lamina. Using a novel grading system for electrode trauma, there was no statistically significant difference among the three electrodes. A literature search of histological studies of a commonly used "standard" electrode showed damage equal to or greater than that seen in the current study. CONCLUSIONS: Insertion trauma caused by periomodiolar electrodes occurs to an acceptable degree. Refinement of electrodes based on mechanisms of trauma may be able to further reduce damage.

Early impairment of islet function and graft loss limit the success of allogeneic islet transplantation. Nonspecific inflammatory events occurring at the transplant site immediately after grafting, involving the production of cytokines and free radicals and sinusoidal endothelial cell (SEC) activation, may contribute to islet cell damage. To evaluate whether Kupffer cell inactivation would result in prolonged allograft survival in a model system of intrahepatic islet transplantation in rats, we systemically administered either gadolinium chloride (GdCl3) or dichloromethylene diphosphonate (Cl2MDP) to assess the effects of macrophage inactivation on rejection and on the release of proinflammatory molecules, as well as to assess the functional profile of SEC. The results obtained were compared with those observed in untreated, sham-injected animals and in rats receiving intraportal infusions of microbeads. Transient macrophage inhibition, particularly in hepatic Kupffer cells, is associated with significant prolongation of graft survival after intraportal islet allotransplantation (ITx) in rats: 7.2 days in the control group versus 11.9 days in the GdCl3 group (P < 0.01) and 15.6 days in the Cl2MDP group (P < 0.0006), respectively. Although systemic release of inflammatory mediators was observed only when islet transplantations were performed and it could be inhibited by macrophage-targeting treatments, perturbation of the functional profile of endothelial cells was also observed when microembolization was induced by the use of microbeads and could not be prevented by macrophage inhibition. These experiments provide evidence to support the concept that macrophages play a key role in early inflammatory events known to adversely affect islet engraftment and suggest that manipulation of nonspecific immune activation by inhibition of macrophage function may facilitate hepatic engraftment of islet allografts. The mechanisms mediating this effect are likely to include prevention of release of tumor necrosis factor-alpha, interleukin-1beta, and NO and interference with the rate of immune response to the islets.

The COVID-19 pandemic has rapidly evolved and changed our way of life in an unprecedented manner. The emergence of COVID-19 has impacted transplantation worldwide. The impact has not been just restricted to issues pertaining to donors or recipients, but also health-care resource utilization as the intensity of cases in certain jurisdictions exceeds available capacity. Here we provide a personal viewpoint representing different jurisdictions from around the world in order to outline the impact of the current COVID-19 pandemic on organ transplantation. Based on our collective experience, we discuss mitigation strategies such as donor screening, resource planning, and a staged approach to transplant volume considerations as local resource issues demand. We also discuss issues related to transplant-related research during the pandemic, the role of transplant infectious diseases, and the influence of transplant societies for education and disseminating current information. The COVID-19 pandemic has rapidly evolved and changed our way of life in an unprecedented manner. The emergence of COVID-19 has impacted transplantation worldwide. The impact has not been just restricted to issues pertaining to donors or recipients, but also health-care resource utilization as the intensity of cases in certain jurisdictions exceeds available capacity. Here we provide a personal viewpoint representing different jurisdictions from around the world in order to outline the impact of the current COVID-19 pandemic on organ transplantation. Based on our collective experience, we discuss mitigation strategies such as donor screening, resource planning, and a staged approach to transplant volume considerations as local resource issues demand. We also discuss issues related to transplant-related research during the pandemic, the role of transplant infectious diseases, and the influence of transplant societies for education and disseminating current information.

BACKGROUND: The Network for Pancreatic Organ Donors with Diabetes (nPOD) was established to recover and characterize pancreata and related organs from cadaveric organ donors with various risk levels for type 1 diabetes (T1D). These biospecimens are available to investigators for collaborative studies aimed at addressing questions related to T1D natural history and pathogenesis. RESEARCH DESIGN AND METHODS: Organ donors included T1D patients (new onset to long term), non-diabetic autoantibody-positive subjects, non-diabetic controls and individuals with disorders relevant to β-cell function. Pancreas recovery and transport met transplant-grade criteria. Additional samples recovered included serum, whole blood, spleen and pancreatic and non-pancreatic lymph nodes. Biospecimens were processed for cryopreserved cells, fixed paraffin and fresh frozen blocks and snap frozen samples. T1D autoantibodies, C-peptide levels and high-resolution HLA genotyping for risk alleles were also determined. RESULTS: Over 160 donors have been enrolled (ages of 1 day to >90 years). Standard operating procedures were established along with a quality management system. Donor demographics, laboratory assays and histopathological characterizations were shared through an open online informatics system. Biospecimens were distributed to more than 60 investigators. CONCLUSIONS: The nPOD programme provides access to high quality biospecimens without cost to investigators. Collaborations and open data sharing are emphasized to maximize research potential of each donor. On the basis of initial successes, the nPOD programme is expanding to recover additional organs relevant to T1D pathogenesis and complications from European countries (PanFin network).

Comparable cognitive disturbances associated with brain pathology have similar manifestations across members of the human species. However, cognitive abilities measured by neuropsychological tests represent, at least in their contents, culturally learned abilities. Performance is under the influence of a vast array of moderating variables, including: culture, ecological demands, primary language, and educational level. Test scores are associated therefore, not only with the subject's learning opportunities, but also with those variables which a culture dictates are worthy of cognitive amplification. Different cultural environmental contexts will result in the development of different patterns of abilities. The evaluation of an alien cultural group using our current neuropsychological instruments, procedures and norms, results in conceptual errors in assessment. Cross-cultural neuropsychology is in need of addressing several key focal points of neglected research: (1) the normalization of current basic neuropsychological instruments, in different cultural contexts, (2) the development of new neuropsychological instruments, appropriate for different cultural contexts, (3) the analysis of educational factors and subcultural variations in relation to test performance, (4) the analysis of cognitive disturbances in cases of brain pathology in different cultural and educational contexts, (5) the search for commonality in neuropsychological performance among existing human groups, and (6) the analysis of the origins of cognitive activity.

Recurrence of focal segmental glomerulosclerosis (rFSGS) after kidney transplantation is a cause of accelerated graft loss. To evaluate pathogenic antibodies (Abs) in rFSGS, we processed 141 serum samples from 64 patients with and without primary rFSGS and 34 non-FSGS control patients transplanted at four hospitals. We screened about 9000 antigens in pretransplant sera and selected 10 Abs targeting glomerular antigens for enzyme-linked immunosorbent assay (ELISA) validation. A panel of seven Abs (CD40, PTPRO, CGB5, FAS, P2RY11, SNRPB2, and APOL2) could predict posttransplant FSGS recurrence with 92% accuracy. Pretransplant elevation of anti-CD40 Ab alone had the best correlation (78% accuracy) with rFSGS risk after transplantation. Epitope mapping of CD40 with customized peptide arrays and rFSGS sera demonstrated altered immunogenicity of the extracellular CD40 domain in rFSGS. Immunohistochemistry of CD40 demonstrated a differential expression in FSGS compared to non-FSGS controls. Anti-CD40 Abs purified from rFSGS patients were particularly pathogenic in human podocyte cultures. Injection of anti-CD40/rFSGS Ab enhanced suPAR (soluble urokinase receptor)-mediated proteinuria in wild-type mice, yet no sensitizing effect was noted in mice deficient in CD40 or in wild-type mice that received blocking Ab to CD40. In conclusion, a panel of seven Abs can help identify primary FSGS patients at high risk of recurrence before transplantation. Intrarenal CD40 (and possibly other specific glomerular antigens) is an important contributor to FSGS disease pathogenesis. Human trials of anti-CD40 therapies are warranted to evaluate their efficacy for preventing rFSGS and improving graft survival.

BACKGROUND: This exploratory study was the first study of remimazolam in patients to assess the safety and efficacy of different single doses for procedural sedation. METHODS: Patients scheduled to undergo a diagnostic upper gastrointestinal endoscopy were randomized to receive 1 of 3 doses of remimazolam or midazolam (25 per group) in a double-blind manner. After a single dose of study drug to achieve sedation, patients underwent gastroscopy. We assessed the success of the procedure, sedation levels, recovery from sedation, and safety. RESULTS: A single dose of remimazolam resulted in a successful procedure in 32%, 56%, and 64% of patients in the low (0.10), middle (0.15), and high (0.20 mg/kg) dose groups compared with 44% of patients in the midazolam (0.075 mg/kg) dose group. The onset of sedation was 1.5 to 2.5 minutes in the remimazolam dose groups compared with 5 minutes for midazolam. Because this was a single administration study, sedation could be maintained for as long as necessary to complete the procedure, using rescue midazolam or propofol. Recovery from sedation was rapid for all treatment groups but was influenced by the choice of rescue medication. There were no obvious differences in the safety profiles of remimazolam and midazolam. CONCLUSIONS: This exploratory dose-finding study showed that a single administration of remimazolam (0.10-0.20 mg/kg) was capable of inducing rapid sedation with a quick recovery profile in patients undergoing a diagnostic upper gastrointestinal endoscopy. The safety profile was favorable and appeared to be similar to that of midazolam, warranting further development of this short-acting compound.