SUMMARYObjectives: To determine if the activity-dependent trafficking of c2 subunit-containing c-aminobutyric acid type A receptors (GABA A Rs) that has been observed in older animals and posited to contribute to benzodiazepine pharmacoresistance during status epilepticus (SE) is age-dependent, and to evaluate whether blockade of protein phosphatases can inhibit or reverse the activity-dependent plasticity of these receptors. Methods: The efficacy and potency of diazepam 0.2-10 mg/kg administered 3 or 60 min after the onset of a lithium/pilocarpine-induced seizure in postnatal day 15-16 rats was evaluated using video-electroencephalography (EEG) recordings. The surface expression of c2 subunit-containing GABA A Rs was assessed using a biotinylation assay, and GABA A R-mediated miniature inhibitory postsynaptic currents (mIPSCs) were recorded using whole-cell patch-clamp recording techniques from dentate granule cells in hippocampal slices acutely obtained 60 min after seizure onset (SE-treated). The effect of the protein phosphatase inhibitors FK506 and okadaic acid (OA) on the surface expression of these receptors was determined in organotypic slice cultures exposed to high potassium and N-methyl-D-aspartate (NMDA) or in SE-treated slices. Results: Diazepam terminated seizures of 3 min but not 60 min duration, even at the highest dose. In the SE-treated slices, the surface expression of c2 subunit-containing GABA A Rs was reduced and the amplitude of the mIPSCs was diminished. Inhibition of protein phosphatases prevented the activity-induced reduction of the c2 subunit-containing GABA A Rs in organotypic slice cultures. Furthermore, treatment of SE-treated slices with FK506 or OA restored the surface expression of the c2 subunit-containing GABA A Rs and the mIPSC amplitude. Significance: This study demonstrates that the plasticity of c2 subunit-containing GABA A Rs associated with the development of benzodiazepine resistance in young and adult animals is similar. The findings of this study suggest that the mechanisms regulating the activity-dependent trafficking of GABA A Rs during SE can be targeted to develop novel adjunctive therapy for the treatment of benzodiazepine-refractory SE.

BACKGROUND: Early recognition of patients at risk for sepsis is paramount to improve clinical outcomes. We hypothesized that subtle signatures of illness are present in physiological and biochemical time series of pediatric-intensive care unit (PICU) patients in the early stages of sepsis. METHODS: We developed multivariate models in a retrospective observational cohort to predict the clinical diagnosis of sepsis in children. We focused on age as a predictor and asked whether random forest models, with their potential for multiple cut points, had better performance than logistic regression. RESULTS: One thousand seven hundred and eleven admissions for 1425 patients admitted to a mixed cardiac and medical/surgical PICU were included. We identified, through individual chart review, 187 sepsis diagnoses that were not within 14 days of a prior sepsis diagnosis. Multivariate models predicted sepsis in the next 24 h: cross-validated C-statistic for logistic regression and random forest were 0.74 (95% confidence interval (CI): 0.71-0.77) and 0.76 (95% CI: 0.73-0.79), respectively. CONCLUSIONS: Statistical models based on physiological and biochemical data already available in the PICU identify high-risk patients up to 24 h prior to the clinical diagnosis of sepsis. The random forest model was superior to logistic regression in capturing the context of age.

A CNS-led initiative to achieve better patient outcomes-at a significantly lower cost.U rinary tract infections (UTIs) are one of the most common types of health careassociated infections and account for more than 30% of infections in acute care hospitals. 1 Most health care-associated UTIs are caused by indwelling urinary catheters. Also known as a Foley catheter, an indwelling urinary catheter is a drainage tube inserted into the urinary bladder through the urethra; the other end of the tube is connected to a drainage bag. 2 According to the National Healthcare Safety Network, about 12% to 16% of adult inpatients will have an indwelling urinary catheter inserted at some point during hospitalization and each day the catheter remains, there is a 3% to 7% increased risk of acquiring a catheter-associated UTI (CAUTI). 2 CAUTIs are diagnosed in hospitalized patients when a UTI occurs after an indwelling urinary catheter has been in place for two or more consecutive days. 2 The day of catheter insertion is considered day 1. 2 CAUTIs can lead to complications such as pyelonephritis and gram-negative bacteremia. 2 CAUTI-related complications can also prolong hospital stays by two to four days and result in patient discomfort and increased health care costs and mortality. 3 According to the most recent estimates available from the Agency for Healthcare Research and Quality, the approximate total cost of CAUTIs per year in the United States is $340 million to $450 million, but it's likely those costs have grown. 3 As of October 2008, the Centers for Medicare and Medicaid Services no longer reimburses costs associated with hospital-acquired CAUTIs. This makes it a priority to find ways to address factors that increase the risk of CAUTIs and find ways to decrease their incidence.According to the Centers for Disease Control and Prevention (CDC), "An estimated 17% to 69% of CAUTIs may be preventable with recommended infection control measures, which means that up to 380,000 infections and 9,000 deaths related to CAUTI per year could be prevented." 1 A significant number of indwelling urinary catheters are inserted for inappropriate indications, such as routine urine output monitoring, incontinence, confusion, or dementia. 3 According to professional guidelines

BackgroundImmune-mediated melanoma regression relies on melanoma-reactive T cells infiltrating tumor. Cancer vaccines increase circulating melanoma-reactive T cells, but little is known about vaccine-induced circulating lymphocytes (viCLs) homing to tumor or whether interventions are needed to enhance infiltration. We hypothesized that viCLs infiltrate melanoma metastases, and intratumoral interferon (IFN)-γ or Toll-like receptor 7 (TLR7) agonism enhances infiltration.MethodsPatients on two clinical trials (Mel51 (NCT00977145), Mel53 (NCT01264731)) received vaccines containing 12 class I major histocompatibility complex-restricted melanoma peptides (12MP). In Mel51, tumor was injected with IFN-γ on day 22, and biopsied on days 1, 22, and 24. In Mel53, dermal metastases were treated with topical imiquimod, a TLR7 agonist, for 12 weeks, and biopsied on days 1, 22, and 43. For patients with circulating T-cell responses to 12MP by IFN-γ ELISpot assays, DNA was extracted from peripheral blood mononuclear cells (PBMCs) pre-vaccination and at peak T-cell response, and from tumor biopsies, which underwent T-cell receptor sequencing. This enabled identification of clonotypes induced in PBMCs post-vaccination (viCLs) and present in tumor post-vaccination, but not pre-vaccination.ResultsSix patients with T-cell responses post-vaccination (Mel51 n = 4, Mel53 n = 2) were evaluated for viCLs and vaccine-induced tumor infiltrating lymphocytes (viTILs). All six patients had viCLs, five of whom were evaluable for viTILs in tumor post-vaccination alone. Mel51 patients had viTILs identified in day 22 tumors, post-vaccination and before IFN-γ (median = 2, range = 0–24). This increased in day 24 tumors after IFN-γ (median = 30, range = 4–74). Mel53 patients had viTILs identified in day 22 tumors, post-vaccination plus imiquimod (median = 33, range = 2–64). Three of five evaluable patients across both trials had viTILs with vaccination alone. All five had enhancement of viTILs with tumor-directed therapy. viTILs represented 0.0–2.9% of total T cells after vaccination alone, which increased to 0.6–8.7% after tumor-directed therapy.ConclusionCancer vaccines induce expansion of new viCLs, which infiltrate melanoma metastases in some patients. Our findings identify opportunities to combine vaccines with tumor-directed therapies to enhance T-cell infiltration and T cell-mediated tumor control. These combinations hold promise in improving the therapeutic efficacy of antigen-specific therapies for solid malignancies.

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