Feeding volume advancement in preterm neonates: A level 4 neonatal intensive care unit quality improvement initiative.

INTRODUCTION: Because of provider variability in feeding guideline application, a quality improvement (QI) initiative was begun to better standardize feeding initiation and advancement for preterm infants. Our specific, measurable, achievable, relevant, and timely aims included decreasing the time to reach full feeds by 35% and reducing the duration of central lines by 30% over 12 months in infants born between 25 and 30 weeks' gestation or with birth weight between 600 and 1250 g. METHODS: Registered dietitians tracked central line days, parenteral nutrition (PN), enteral nutrition, fortification, guideline adherence, anthropometrics, necrotizing enterocolitis (NEC) cases, and central line-associated bloodstream infections (CLABSIs). QI progress charts were reviewed monthly. RESULTS: Mean central line days decreased from 7.3 to 5.8. Days of PN decreased from 6.7 to 5.1. The day of life that enteral feeds were started decreased from 1.1 to 0.5. The number of days between starting enteral feeds and adding fortification decreased from 3.4 to 2.3 days. Full enteral feeds were achieved on average 2 days earlier. Birth weight was regained at around 10.2 days of life before the guideline was implemented and at a mean of 9.6 days after the guideline. There was no increase in cases of CLABSI or diagnoses of NEC. CONCLUSION: After implementation of this feeding QI initiative at a level 4 neonatal intensive care unit, central line duration and PN use were decreased and infants reached full enteral feeds earlier without changes in cases of NEC, CLABSI, or time to regain birth weight.

Engineering, expression, purification, and characterization of stable clade A/B recombinant soluble heterotrimeric gp140 proteins.

The envelope glycoprotein (Env) of human immunodeficiency virus type 1 (HIV-1) is composed of two noncovalently associated subunits: an extracellular subunit (gp120) and a transmembrane subunit (gp41). The functional unit of Env on the surface of infectious virions is a trimer of gp120/gp41 heterodimers. Env is the target of anti-HIV neutralizing antibodies. A considerable effort has been invested in the engineering of recombinant soluble forms of the virion-associated Env trimer as vaccine candidates to elicit anti-HIV neutralizing antibody responses. These soluble constructs contain three gp120 subunits and the extracellular segments of the corresponding gp41 subunits. The individual gp120/gp41 protomers on these soluble trimers are identical in amino acid sequence (homotrimers). Here, we engineered novel soluble trimeric gp140 proteins that are formed by the association of gp140 protomers that differ in amino acid sequence and glycosylation patterns (heterotrimers). Specifically, we engineered soluble heterotrimeric proteins composed of clade A and clade B Env protomers. The clade A gp140 protomers were derived from viruses isolated during acute infection (Q168a2, Q259d2.17, and Q461e2), whereas the clade B gp140 protomers were derived from a virus isolated during chronic infection (SF162). The amino acid sequence divergence between the clade A and the clade B Envs is approximately 24%. Neutralization epitopes in the CD4 binding sites and coreceptor binding sites, as well as the membrane-proximal external region (MPER), were differentially expressed on the heterotrimeric and homotrimeric proteins. The heterotrimeric gp140s elicited broader anti-tier 1 isolate neutralizing antibody responses than did the homotrimeric gp140s.