MICB Genomic Variant Is Associated with NKG2D-mediated Acute Lung Injury and Death.

Rationale: Acute lung injury (ALI) carries a high risk of mortality but has no established pharmacologic therapy. We previously found that experimental ALI occurs through natural killer (NK) cell NKG2D receptor activation and that the cognate human ligand, MICB, was associated with ALI after transplantation. Objectives: To investigate the association of a common missense variant, MICBG406A, with ALI. Methods: We assessed MICBG406A genotypes within two multicenter observational study cohorts at risk for ALI: primary graft dysfunction (N = 619) and acute respiratory distress syndrome (N = 1,376). Variant protein functional effects were determined in cultured and ex vivo human samples. Measurements and Main Results: Recipients of MICBG406A-homozygous allografts had an 11.1% absolute risk reduction (95% confidence interval [CI], 3.2-19.4%) for severe primary graft dysfunction after lung transplantation and reduced risk for allograft failure (hazard ratio, 0.36; 95% CI, 0.13-0.98). In participants with sepsis, we observed 39% reduced odds of moderately or severely impaired oxygenation among MICBG406A-homozygous individuals (95% CI, 0.43-0.86). BAL NK cells were less frequent and less mature in participants with MICBG406A. Expression of missense variant protein MICBD136N in cultured cells resulted in reduced surface MICB and reduced NKG2D ligation relative to wild-type MICB. Coculture of variant MICBD136N cells with NK cells resulted in less NKG2D activation and less susceptibility to NK cell killing relative to the wild-type cells. Conclusions: These data support a role for MICB signaling through the NKG2D receptor in mediating ALI, suggesting a novel therapeutic approach.

The Impact of Donor Smoking on Primary Graft Dysfunction and Mortality after Lung Transplantation.

Rationale: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Prior studies implicated proxy-defined donor smoking as a risk factor for PGD and mortality. Objectives: We aimed to more accurately assess the impact of donor smoke exposure on PGD and mortality using quantitative smoke exposure biomarkers. Methods: We performed a multicenter prospective cohort study of lung transplant recipients enrolled in the Lung Transplant Outcomes Group cohort between 2012 and 2018. PGD was defined as grade 3 at 48 or 72 hours after lung reperfusion. Donor smoking was defined using accepted thresholds of urinary biomarkers of nicotine exposure (cotinine) and tobacco-specific nitrosamine (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol [NNAL]) in addition to clinical history. The donor smoking-PGD association was assessed using logistic regression, and survival analysis was performed using inverse probability of exposure weighting according to smoking category. Measurements and Main Results: Active donor smoking prevalence varied by definition, with 34-43% based on urinary cotinine, 28% by urinary NNAL, and 37% by clinical documentation. The standardized risk of PGD associated with active donor smoking was higher across all definitions, with an absolute risk increase of 11.5% (95% confidence interval [CI], 3.8% to 19.2%) by urinary cotinine, 5.7% (95% CI, -3.4% to 14.9%) by urinary NNAL, and 6.5% (95% CI, -2.8% to 15.8%) defined clinically. Donor smoking was not associated with differential post-lung transplant survival using any definition. Conclusions: Donor smoking associates with a modest increase in PGD risk but not with increased recipient mortality. Use of lungs from smokers is likely safe and may increase lung donor availability. Clinical trial registered with www.clinicaltrials.gov (NCT00552357).

CD94+ natural killer cells potentiate pulmonary ischaemia-reperfusion injury.

BACKGROUND: Pulmonary ischaemia-reperfusion injury (IRI) is a major contributor to poor lung transplant outcomes. We recently demonstrated a central role of airway-centred natural killer (NK) cells in mediating IRI; however, there are no existing effective therapies for directly targeting NK cells in humans. METHODS: We hypothesised that a depleting anti-CD94 monoclonal antibody (mAb) would provide therapeutic benefit in mouse and human models of IRI based on high levels of KLRD1 (CD94) transcripts in bronchoalveolar lavage samples from lung transplant patients. RESULTS: We found that CD94 is highly expressed on mouse and human NK cells, with increased expression during IRI. Anti-mouse and anti-human mAbs against CD94 showed effective NK cell depletion in mouse and human models and blunted lung damage and airway epithelial killing, respectively. In two different allogeneic orthotopic lung transplant mouse models, anti-CD94 treatment during induction reduced early lung injury and chronic inflammation relative to control therapies. Anti-CD94 did not increase donor antigen-presenting cells that could alter long-term graft acceptance. CONCLUSIONS: Lung transplant induction regimens incorporating anti-CD94 treatment may safely improve early clinical outcomes.

Prolonged Grief Disorder: Addressing Misconceptions With Evidence.

There are many misconceptions about Prolonged Grief Disorder (PGD). We show with data that PGD is a diagnosis that applies to a rare few of mourners who are at risk of significant distress and dysfunction. Those mourners who meet criteria for PGD have been shown to benefit from specialized, targeted treatment for it. The case against PGD is empirically unsubstantiated, and the need for scientific examination of effective treatments is warranted.

The Lung Allocation Score Remains Inequitable for Patients with Pulmonary Arterial Hypertension, Even after the 2015 Revision.

Rationale: The lung allocation score (LAS) was revised in 2015 to improve waiting list mortality and rate of transplant for patients with pulmonary arterial hypertension (PAH). Objectives: We sought to determine if the 2015 revision achieved its intended goals. Methods: Using the Standard Transplant Analysis and Research file, we assessed the impact of the 2015 LAS revision by comparing the pre- and postrevision eras. Registrants were divided into the LAS diagnostic categories: group A-chronic obstructive pulmonary disease; group B-pulmonary arterial hypertension; group C-cystic fibrosis; and group D-interstitial lung disease. Competing risk regressions were used to assess the two mutually exclusive competing risks of waiting list death and transplant. Cumulative incidence plots were created to visually inspect risks. Measurements and Main Results: The LAS at organ matching increased by 14.2 points for registrants with PAH after the 2015 LAS revision, the greatest increase among diagnostic categories (other LAS categories: Δ, -0.9 to +2.8 points). Before the revision, registrants with PAH had the highest risk of death and lowest likelihood of transplant. After the 2015 revision, registrants with PAH still had the highest risk of death, now similar to those with interstitial lung disease, and the lowest rate of transplant, now similar to those with chronic obstructive pulmonary disease. Conclusions: Although the 2015 LAS revision improved access to transplant and reduced the risk of waitlist death for patients with PAH, it did not go far enough. Significant differences in waitlist mortality and likelihood of transplant persist.

Public stigma toward prolonged grief and COVID-19 bereavement: A vignette-based experiment.

We investigated the effects of cause of death and the presence of prolonged grief disorder (PGD) on eliciting public stigma toward the bereaved. Participants (N = 328, 76% female; Mage = 27.55 years) were randomly assigned to read one of four vignettes describing a bereaved man. Each vignette differed by his PGD status (PGD diagnosis or no PGD diagnosis) and his wife's cause of death (COVID-19 or brain hemorrhage). Participants completed public stigma measures assessing negative attributions, desired social distance, and emotional reactions. Bereavement with PGD (versus without PGD) elicited large and significantly stronger responses across all stigma measures. Both causes of death elicited public stigma. There was no interaction between cause of death and PGD on stigma. With increased PGD rates expected during the pandemic, the potential for public stigma and reduced social support for people bereaved via traumatic deaths and people with PGD requires mitigation.

Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft.

PURPOSE: To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up. METHODS: Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score. RESULTS: The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal. CONCLUSIONS: Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Feelings of Empowerment Scale for Family Caregivers: Development, Exploratory, and Confirmative Analysis.

OBJECTIVES: This study aimed to validate a measure of feelings of empowerment among family caregivers of persons with life limiting illnesses. METHODS: Family caregivers (N = 295) completed a survey on their feelings of empowerment and psychosocial constructs. RESULTS: Utilizing exploratory and confirmatory factor analyses, the study validated the Empowerment in the Context of Caregiving scale, revealing a two-factor structure related to influencing the care recipient and controlling personal outcomes, with high reliability and validity. Convergent validity was supported by a strong association with an established measure of power. Discriminant validity was demonstrated through weak associations with theoretically less relevant constructs, confirming the scale's validity. CONCLUSIONS: This scale provides a reliable tool to identify feelings of disempowerment among caregivers, with implications for theory and practice. Future research should explore predictive validity and consider cultural factors to enhance its applicability in diverse caregiving contexts. CLINICAL IMPLICATIONS: This study provides a reliable tool to identify feelings of empowerment among family caregivers of persons with life limiting illnesses for clinicians. It also allows future studies to reliably investigate a theory-driven intervention target, feelings of power, and allows clinicians to tailor this into theory-driven intervention for family caregivers of persons with life limiting illnesses.

Comparing Public Perceptions of Child and Adult Grief Responses to Familial Incarceration.

Children of incarcerated parents may grieve this loss, yet perceptions of their grief are understudied. Using vignettes varying by age (adult/child) and grief response (prolonged/resilient), we examined differences between perceptions of adults and children grieving parental incarceration. Participants rated grief response appropriateness, comfort providing support, and grief therapy recommendations for the grieving person in the vignette. Participants perceived resilience as more appropriate than prolonged grief [F (1, 224) = 9.02, p = .003, η2 = .04]. Age did not predict outcomes. Recommending grief therapy was higher for prolonged grief, yet 53% of participants with resilient vignettes recommended the person should seek grief therapy, which is concerning given possible iatrogenic effects. Thus, laypeople may have stigma toward individuals grieving parental incarceration, regardless of age.

Prolonged Grief Disorder, but Not Death From COVID-19, Elicits Public Stigma: A Vignette-Based Experiment.

We investigated the effects of cause of death (COVID-19 with an underlying medical condition vs. without) and prolonged grief disorder status (PGD present or absent) on participants' reported public stigma towards the bereaved. Participants (N = 304, 66% women; Mage = 39.39 years) were randomly assigned to read one of four vignettes describing a bereaved man. Participants completed stigma measures assessing negative attributions, desired social distance, and emotional reactions. Participants reported significantly stronger stigmatizing responses towards an individual with PGD (vs. without PGD) across all stigma measures. There was no significant difference in stigma based on cause of death; however, stigma was reported regardless of cause of death. There was no significant interaction between cause of death and PGD on stigma. This study supports the robust finding of public stigma being reported toward an individual with PGD, suggesting these individuals are at risk of public stigma and not receiving adequate bereavement support.

CD16+ natural killer cells in bronchoalveolar lavage are associated with antibody-mediated rejection and chronic lung allograft dysfunction.

Acute and chronic rejections limit the long-term survival after lung transplant. Pulmonary antibody-mediated rejection (AMR) is an incompletely understood driver of long-term outcomes characterized by donor-specific antibodies (DSAs), innate immune infiltration, and evidence of complement activation. Natural killer (NK) cells may recognize DSAs via the CD16 receptor, but this complement-independent mechanism of injury has not been explored in pulmonary AMR. CD16+ NK cells were quantified in 508 prospectively collected bronchoalveolar lavage fluid samples from 195 lung transplant recipients. Associations between CD16+ NK cells and human leukocyte antigen mismatches, DSAs, and AMR grade were assessed by linear models adjusted for participant characteristics and repeat measures. Cox proportional hazards models were used to assess CD16+ NK cell association with chronic lung allograft dysfunction and survival. Bronchoalveolar lavage fluid CD16+ NK cell frequency was associated with increasing human leukocyte antigens mismatches and increased AMR grade. Although NK frequencies were similar between DSA+ and DSA- recipients, CD16+ NK cell frequencies were greater in recipients with AMR and those with concomitant allograft dysfunction. CD16+ NK cells were associated with long-term graft dysfunction after AMR and decreased chronic lung allograft dysfunction-free survival. These data support the role of CD16+ NK cells in pulmonary AMR.

Frailty and genetic risk predict fracture after lung transplantation.

Fractures negatively impact quality of life and survival. We hypothesized that recipient frailty score and genetic profile measured before transplant would predict risk of fracture after lung transplant. We conducted a retrospective cohort study of bone mineral density (BMD) and fracture among lung transplant recipients at a single center. The association between predictors and outcomes were assessed by multivariable time-dependent Cox models or regression analysis. Among the 284 participants, osteoporosis and fracture were highly prevalent. Approximately 59% of participants had posttransplant osteopenia, and 35% of participants developed at least 1 fracture. Low BMD was associated with a polygenic osteoporosis risk score, and the interaction between genetic score and BMD predicted fracture. Pretransplant frailty was associated with risk for spine and hip fracture, which were not associated with chronic lung allograft dysfunction or death. Chest fractures were the most frequent type of fracture and conferred a 2.2-fold increased risk of chronic lung allograft dysfunction or death (time-dependent P < .001). Pneumonia, pleural effusions, and acute rejection frequently occurred surrounding chest fracture. Pretransplant frailty and recipient genotype may aid clinical risk stratification for fracture after transplant. Fracture carries significant morbidity, underscoring the importance of surveillance and osteoporosis prevention.

Subphenotypes of frailty in lung transplant candidates.

Heterogeneous frailty pathobiology might explain the inconsistent associations observed between frailty and lung transplant outcomes. A Subphenotype analysis could refine frailty measurement. In a 3-center pilot cohort study, we measured frailty by the Short Physical Performance Battery, body composition, and serum biomarkers reflecting causes of frailty. We applied latent class modeling for these baseline data. Next, we tested class construct validity with disability, waitlist delisting/death, and early postoperative complications. Among 422 lung transplant candidates, 2 class model fit the best (P = .01). Compared with Subphenotype 1 (n = 333), Subphenotype 2 (n = 89) was characterized by systemic and innate inflammation (higher IL-6, CRP, PTX3, TNF-R1, and IL-1RA); mitochondrial stress (higher GDF-15 and FGF-21); sarcopenia; malnutrition; and lower hemoglobin and walk distance. Subphenotype 2 had a worse disability and higher risk of waitlist delisting or death (hazards ratio: 4.0; 95% confidence interval: 1.8-9.1). Of the total cohort, 257 underwent transplant (Subphenotype 1: 196; Subphenotype 2: 61). Subphenotype 2 had a higher need for take back to the operating room (48% vs 28%; P = .005) and longer posttransplant hospital length of stay (21 days [interquartile range: 14-33] vs 18 days [14-28]; P = .04). Subphenotype 2 trended toward fewer ventilator-free days, needing more postoperative extracorporeal membrane oxygenation and dialysis, and higher need for discharge to rehabilitation facilities (P ≤ .20). In this early phase study, we identified biological frailty Subphenotypes in lung transplant candidates. A hyperinflammatory, sarcopenic Subphenotype seems to be associated with worse clinical outcomes.

European Respiratory Society statement on frailty in adults with chronic lung disease.

Frailty is a complex, multidimensional syndrome characterised by a loss of physiological reserves that increases a person's susceptibility to adverse health outcomes. Most knowledge regarding frailty originates from geriatric medicine; however, awareness of its importance as a treatable trait for people with chronic respiratory disease (including asthma, COPD and interstitial lung disease) is emerging. A clearer understanding of frailty and its impact in chronic respiratory disease is a prerequisite to optimise clinical management in the future. This unmet need underpins the rationale for undertaking the present work. This European Respiratory Society statement synthesises current evidence and clinical insights from international experts and people affected by chronic respiratory conditions regarding frailty in adults with chronic respiratory disease. The scope includes coverage of frailty within international respiratory guidelines, prevalence and risk factors, review of clinical management options (including comprehensive geriatric care, rehabilitation, nutrition, pharmacological and psychological therapies) and identification of evidence gaps to inform future priority areas of research. Frailty is underrepresented in international respiratory guidelines, despite being common and related to increased hospitalisation and mortality. Validated screening instruments can detect frailty to prompt comprehensive assessment and personalised clinical management. Clinical trials targeting people with chronic respiratory disease and frailty are needed.

Ultra-dense, 1152-core, broadband multicore fiber link deployed in a metro network.

We have designed, developed, and deployed the world's first ultra-dense space division-multiplexing multicore fiber link in a conduit of a metro network. In a 10-mm-diameter fiber optic-cable, 288 4-core multicore fibers are arranged in 24 200-µm spiderweb collapsible ribbons. The multicore fibers are fusion-spliced to 576 fanout devices which provide conventional single-core interfaces at patch panels at both ends of the link.

Biofire pneumonia panel in lung donors: faster detection but limited pathogens.

BACKGROUND: Culture of bronchoalveolar lavage (BAL) specimens takes time to report. We tested whether a molecular diagnostic test could accelerate donor lung assessment and treatment. METHODS: We compared BioFire Film Array Pneumonia Panel (BFPP) with standard of care (SOC) tests on lung allograft samples at three time points: (1) donor BAL at organ recovery, (2) donor bronchial tissue and airway swab at implantation, and (3) first recipient BAL following lung implantation. Primary outcomes were the difference in time to result (Wilcoxon signed-ranked tests) and the agreement in results between BFPP and SOC assays (Gwet's agreement coefficient). RESULTS: We enrolled 50 subjects. In donor lung BAL specimens, BFPP detected 52 infections (14 out of 26 pathogens in the panel). Viral and bacterial BFPP results were reported 2.4 h (interquartile range, IQR 2.0-6.4) following BAL versus 4.6 h (IQR 1.9-6.0, p = 0.625) for OPO BAL viral SOC results and 66 h (IQR 47-87, p < .0001) for OPO BAL bacterial SOC results. Although there was high overall agreement of results between BAL-BFPP versus OPO BAL-SOC tests (Gwet's AC p < .001 for all), the level of agreement differed among 26 pathogens designed in BFPP and differed by types of specimens. BFPP could not detect many infections identified by SOC assays. CONCLUSIONS: BFPP decreased time to detection of lung pathogens among donated lungs, but it cannot replace SOC tests due to the limited number of pathogens in the panel.

An examination and proposed theoretical model of risk and protective factors for bereavement outcomes for family members of individuals who engaged in medical aid in dying: A systematic review.

BACKGROUND: Medical Aid in Dying is an end-of-life option that allows a physician to provide a patient with a prescription to end their life. Though Medical Aid in Dying intends to reduce suffering for a patient, opponents argue Medical Aid in Dying may increase suffering for the family members during bereavement. To better understand the bereavement outcomes for family members/friends following Medical Aid in Dying, an exhaustive review of the risk and protective factors for bereavement outcomes is warranted. AIM: This systemic review aimed to identify studies that examined bereavement outcomes of family members of individuals who engage in Medial Aid in Dying, identify risk and protective factors for bereavement outcomes, and propose a theoretical model to enhance conceptual clarity. DESIGN: A mixed-method systematic review. DATA SOURCES: Ten databases were searched on June 16, 2021 and later conducted two updates (latest April 25, 2022). RESULTS: Thirteen articles met inclusion criteria. Risk and protective factors were identified pre-Medical Aid in Dying and risk factors post-Medical Aid in Dying. Few studies compared bereavement outcomes for family members of individuals utilizing Medical Aid in Dying to family members who lost someone to natural loss. CONCLUSIONS: This study provides equivocal results about the effects of Medical Aid in Dying on family members following the loss. The theoretical model outlines potential risk and protective factors. This model provides a greater understanding of possible universal risk and protective factors for family members of individuals who engaged in Medical Aid in Dying.

User-Centered Mobile Applications for Stroke Survivors (MAPPS): A Mixed-Methods Study of Patient Preferences.

OBJECTIVE: Investigate stroke survivors' (SS) preferences for a hypothetical mHealth app for post-stroke care and to study the influence of demographic variables on these preferences. DESIGN: Mixed-methods, sequential, observational study. SETTING: Focus groups (phase 1) were conducted to identify SS perceptions and knowledge of mHealth applications (apps). Using grounded theory approach, recurring themes were identified. A multiple-choice questionnaire of 5 desired app features was generated using these themes and mailed to SS (national survey, phase 2). SS' demographics and perceived usefulness (yes/no) for each feature were recorded. In-person usability testing (phase 3) was conducted to identify areas of improvement in user interfaces of existing apps. Summative telephone interviews (phase 4) were conducted for final impressions supplementary to national survey. PARTICIPANTS: SS aged >18 years recruited from study hospital, national stroke association database, stroke support and advocacy groups. Non-English speakers and those unable to communicate were excluded. INTERVENTIONS: None. MAIN OUTCOME MEASURES: (1) Percentage of SS (phase 2) identifying proposed app features to be useful. (2) Influence of age, sex, race, education, and time since stroke on perceived usefulness. RESULTS: Ninety-six SS participated in focus groups. High cost, complexity, and lack of technical support were identified as barriers to adoption of mHealth apps. In the national survey (n=1194), ability to track fitness and diet (84%) and communication (70%) were the most and least useful features, respectively. Perceived usefulness was higher among younger SS (P<.001 to .006) and SS of color (African American and Hispanic) (ORs 1.73-4.41). Simple design and accommodation for neurologic deficits were main recommendations from usability testing. CONCLUSIONS: SS are willing to adopt mHealth apps that are free of cost and provide technical support. Apps for SS should perform multiple tasks and be of simple design. Greater interest for the app's features among SS of color may provide opportunities to address health inequities.

Trajectories of cancer-specific stress in cancer patients: a latent growth mixture analysis.

This study aimed to examine trajectories of cancer specific stress (CSS) over the course of a year, starting at the beginning of chemotherapy, and identify psychosocial factors that predicted trajectory class membership. Growth Mixture Modeling was used to identify distinct trajectories of CSS. Multinomial regression examined potential psychosocial predictors of trajectory membership. In the 4-class solution, all four trajectories demonstrated a decrease in CSS over the year but with differing intercepts and magnitudes of slopes. These were characterized as recovery, resilience, chronic, and severely chronic. The recovery group reported significantly higher insomnia scores than the resilient group. The chronic group reported significantly higher insomnia, higher depression, lower social support, and lower optimism than the resilient group. The chronic group reported significantly lower social support and higher depression than the recovery group. The findings provide information about psychosocial risk factors for CSS that can be screened for early intervention following diagnosis.

Perceptions of grief reactions in family members of incarcerated individuals: A vignette-based experiment.

We examined perceptions of individuals grieving the loss of a family member to incarceration. Participants (N = 1095) were randomized to a vignette that varied by race-ethnicity, crime type, and grief trajectory to assess their perceptions. Results indicated: (1) participants perceived prolonged grief as less appropriate than resilience; (2) Black family members grieving someone who committed a violent crime as more appropriate compared to White family members; and (3) women endorsed both grief trajectories as more appropriate and indicated greater comfort supporting the family member. Lastly, participants indicated prolonged, White and Latinx grievers should seek therapy more than resilient or Black individuals.