Role of the afferent lymph as an immunological conduit to analyze tissue antigenic and inflammatory load.

The lymphatic fluid is the conduit by which part of the tissue "omics" is transported to the draining lymph node for immunosurveillance. Following cannulation of the pre-nodal cervical and mesenteric afferent lymphatics, herein we investigate the lymph proteomic composition, uncovering that its composition varies according to the tissue of origin. Tissue specificity is also reflected in the dendritic cell-major histocompatibility complex class II-eluted immunopeptidome harvested from the cervical and mesenteric nodes. Following inflammatory disruption of the gut barrier, the lymph antigenic and inflammatory loads are analyzed in both mice and subjects with inflammatory bowel diseases. Gastrointestinal tissue damage reflects the lymph inflammatory and damage-associated molecular pattern signatures, microbiome-derived by-products, and immunomodulatory molecules, including metabolites of the gut-brain axis, mapped in the afferent mesenteric lymph. Our data point to the relevance of the lymphatic fluid to probe the tissue-specific antigenic and inflammatory load transported to the draining lymph node for immunosurveillance.

A knowledge-aware deep learning model for landslide susceptibility assessment in Hong Kong.

Despite the success of the growing data-driven landslide susceptibility prediction, the model training heavily relies on the quality of the data (involving topography, geology, hydrology, land cover, climate, and human activity), the structure of the model, and the fine-tuning of the model parameters. Few data-driven methods have considered incorporating 'landslide priors', as in this article the prior knowledge or statistics related to landslide occurrence, to enhance the model's perception in landslide mechanism. The main objective and contribution of this study is the coupling of landslide priors and a deep learning model to improve the model's transferability and stability. This is accomplished by selecting non-landslide sample grounded on landslide statistics, disentangling input landslide features using a variational autoencoder, and crafting a loss function with physical constraints. This study utilizes the SHAP method to interpret the deep learning model, aiding in the acquisition of feature permutation results to identify underlying landslide causes. The interpretation result indicates that 'slope' is the most influential factor. Considering the extreme rainfall impact on landslide occurrences in Hong Kong, we combine this prior into the deep learning model and find feature ranking for 'rainfall' improved, in comparison to the ranking result interpreted from a pure MLP. Further, the potency of MT-InSAR is utilized to augment the landslide susceptibility map and promote efficient cross-validation. A comparison of InSAR results with historical images reveals that detectable movement before their occurrence is evident in only a minority of landslides. Most landslides occur spontaneously, exhibiting no precursor motion. Comparing with other data-driven methods, the proposed methods outperform in accuracy (by 2 %-5 %), precision (by 2 %-7 %), recall (by 1 %-3 %), F1-score (by 8 %-10 %), and AuROC (by 2 %-4 %). Especially, the Cohen Kappa performance surpasses nearly 20 %, indicating that the knowledge-aware methodology enhances model generalization and mitigates training bias induced by unbalanced positive and negative samples.

Computable phenotype for diagnostic error: developing the data schema for application of symptom-disease pair analysis of diagnostic error (SPADE).

OBJECTIVES: Diagnostic errors are the leading cause of preventable harm in clinical practice. Implementable tools to quantify and target this problem are needed. To address this gap, we aimed to generalize the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) framework by developing its computable phenotype and then demonstrated how that schema could be applied in multiple clinical contexts. METHODS: We created an information model for the SPADE processes, then mapped data fields from electronic health records (EHR) and claims data in use to that model to create the SPADE information model (intention) and the SPADE computable phenotype (extension). Later we validated the computable phenotype and tested it in four case studies in three different health systems to demonstrate its utility. RESULTS: We mapped and tested the SPADE computable phenotype in three different sites using four different case studies. We showed that data fields to compute an SPADE base measure are fully available in the EHR Data Warehouse for extraction and can operationalize the SPADE framework from provider and/or insurer perspective, and they could be implemented on numerous health systems for future work in monitor misdiagnosis-related harms. CONCLUSIONS: Data for the SPADE base measure is readily available in EHR and administrative claims. The method of data extraction is potentially universally applicable, and the data extracted is conveniently available within a network system. Further study is needed to validate the computable phenotype across different settings with different data infrastructures.

Transmembrane domain-driven PD-1 dimers mediate T cell inhibition.

Programmed cell death-1 (PD-1) is a potent immune checkpoint receptor on T lymphocytes. Upon engagement by its ligands, PD-L1 or PD-L2, PD-1 inhibits T cell activation and can promote immune tolerance. Antagonism of PD-1 signaling has proven effective in cancer immunotherapy, and conversely, agonists of the receptor may have a role in treating autoimmune disease. Some immune receptors function as dimers, but PD-1 has been considered monomeric. Here, we show that PD-1 and its ligands form dimers as a consequence of transmembrane domain interactions and that propensity for dimerization correlates with the ability of PD-1 to inhibit immune responses, antitumor immunity, cytotoxic T cell function, and autoimmune tissue destruction. These observations contribute to our understanding of the PD-1 axis and how it can potentially be manipulated for improved treatment of cancer and autoimmune diseases.

A comparative life cycle assessment of recycling waste concrete powder into CO2-Capture products.

Waste concrete powder (WCP), a byproduct of construction and demolition (C&D), currently has a low degree of recycling despite its potential for environmentally friendly applications. WCP can serve as a valuable substitute for cement, offering advantages for resource conservation and carbon sequestration. However, there are very few studies that quantitatively assess the environmental impact of incorporating WCP into the circular economy as a secondary material instead of disposing of it. The energy-intensive processing of WCP raises questions about the optimal carbonation time using available equipment. This study aims to fill this knowledge gap by employing carbon footprint and life cycle assessments (LCA) to optimize WCP recycling. Three recycling WCP scenarios are analyzed. The first scenario involved the conversion of WCP into compacts that absorb CO2 during the carbonation process. The results of the first scenario revealed that the optimal carbonation time for WCP compacts was 8 h, during which 42.7 kg CO2-e per tonne of WCP compacts was sequestered. The total global warming potential (GWP) was -4.22 kgCO2-e, indicating a carbon-negative recycling process. In the second and third scenarios, LCA was conducted to compare the use of carbonated and uncarbonated WCP as a partial replacement for cement in concrete. In these scenarios, it was found that uncarbonated WCP is a more effective solution for reducing the carbon footprint of traditional concrete mixes, achieving a significant 16% reduction of GWP when 20% of cement is replaced. Conversely, using carbonated WCP as a partial cement replacement in concrete mixtures shows limited potential for CO2 uptake. The sensitivity analysis reveals that the carbon footprint of the WCP compacts production process is strongly influenced by the electricity supplier used.

Life cycle analysis of common landfill final cover systems focusing on carbon neutrality.

Carbon emissions from landfill construction and management have become a global concern. Life cycle analysis (LCA) has been widely used to assess the environmental impacts of engineered infrastructures over their lifetimes. LCA has also been applied to landfill leachate and gas management, but rarely to landfill final cover systems. This paper reports the results of an LCA of the following landfill final cover systems: compacted clay cover, geomembrane cover, cover with capillary effects (CCBE), dual capillary barrier cover, three-layer landfill cover system using natural soils, three-layer cover using recycled concrete aggregate (RCA) and biochar-amended three-layer landfill cover system using RCA. The LCA assessment of landfill cover considers the cost, carbon emissions and carbon sequestration during the production, construction and operation phases. The effects of landfill cover on global warming, freshwater eutrophication, terrestrial ecotoxicity, freshwater ecotoxicity, marine ecotoxicity and fossil resource scarcity are also evaluated. In addition, the sensitivities of cost and carbon emission to the use of electric-powered machines and transportation distance are analysed. It is revealed that the three-layer cover system using RCA and biochar has the lowest unit cost and carbon emission of all of the covers, up to 88 % and 66 % lower, respectively, than those of the other six covers. In addition, this cover system has the highest carbon sequestration rate, with a value of 47.9 kg CO2/(y·m2), four times higher than that of the compacted clay cover. Finally, this sustainable cover mitigates global warming and reduces adverse environmental impacts by up to 82 %. Therefore, the biochar amended three-layer cover system using RCA without geomembrane offers the greatest economic benefits, performs effectively in terms of the pursuit of carbon neutrality and promotes sustainable development.

Lactate activates the mitochondrial electron transport chain independently of its metabolism.

Lactate has long been considered a cellular waste product. However, we found that as extracellular lactate accumulates, it also enters the mitochondrial matrix and stimulates mitochondrial electron transport chain (ETC) activity. The resulting increase in mitochondrial ATP synthesis suppresses glycolysis and increases the utilization of pyruvate and/or alternative respiratory substrates. The ability of lactate to increase oxidative phosphorylation does not depend on its metabolism. Both L- and D-lactate are effective at enhancing ETC activity and suppressing glycolysis. Furthermore, the selective induction of mitochondrial oxidative phosphorylation by unmetabolized D-lactate reversibly suppressed aerobic glycolysis in both cancer cell lines and proliferating primary cells in an ATP-dependent manner and enabled cell growth on respiratory-dependent bioenergetic substrates. In primary T cells, D-lactate enhanced cell proliferation and effector function. Together, these findings demonstrate that lactate is a critical regulator of the ability of mitochondrial oxidative phosphorylation to suppress glucose fermentation.

Niche-specific macrophage loss promotes skin capillary aging.

All mammalian organs depend upon resident macrophage populations to coordinate repair processes and facilitate tissue-specific functions1-3. Recent work has established that functionally distinct macrophage populations reside in discrete tissue niches and are replenished through some combination of local proliferation and monocyte recruitment4,5. Moreover, decline in macrophage abundance and function in tissues has been shown to contribute to many age-associated pathologies, such as atherosclerosis, cancer, and neurodegeneration6-8. Despite these advances, the cellular mechanisms that coordinate macrophage organization and replenishment within an aging tissue niche remain largely unknown. Here we show that capillary-associated macrophages (CAMs) are selectively lost over time, which contributes to impaired vascular repair and tissue perfusion in older mice. To investigate resident macrophage behavior in vivo, we have employed intravital two-photon microscopy to non-invasively image in live mice the skin capillary plexus, a spatially well-defined model of niche aging that undergoes rarefication and functional decline with age. We find that CAMs are lost with age at a rate that outpaces that of capillary loss, leading to the progressive accumulation of capillary niches without an associated macrophage in both mice and humans. Phagocytic activity of CAMs was locally required to repair obstructed capillary blood flow, leaving macrophage-less niches selectively vulnerable to both homeostatic and injury-induced loss in blood flow. Our work demonstrates that homeostatic renewal of resident macrophages is not as finely tuned as has been previously suggested9-11. Specifically, we found that neighboring macrophages do not proliferate or reorganize sufficiently to maintain an optimal population across the skin capillary niche in the absence of additional cues from acute tissue damage or increased abundance of growth factors, such as colony stimulating factor 1 (CSF1). Such limitations in homeostatic renewal and organization of various niche-resident cell types are potentially early contributors to tissue aging, which may provide novel opportunities for future therapeutic interventions.

Lactate activates the mitochondrial electron transport chain independent of its metabolism.

Lactate has long been considered a cellular waste product. However, we found that as extracellular lactate accumulates, it also enters the mitochondrial matrix and stimulates mitochondrial electron transport chain (ETC) activity. The resulting increase in mitochondrial ATP synthesis suppresses glycolysis and increases the utilization of pyruvate and/or alternative respiratory substrates. The ability of lactate to increase oxidative phosphorylation does not depend on its metabolism. Both L- and D-lactate are effective at enhancing ETC activity and suppressing glycolysis. Furthermore, the selective induction of mitochondrial oxidative phosphorylation by unmetabolized D-lactate reversibly suppressed aerobic glycolysis in both cancer cell lines and proliferating primary cells in an ATP-dependent manner and enabled cell growth on respiratory-dependent bioenergetic substrates. In primary T cells, D-lactate enhanced cell proliferation and effector function. Together, these findings demonstrate that lactate is a critical regulator of the ability of mitochondrial oxidative phosphorylation to suppress glucose fermentation.

Dynamics of carbon dioxide emission during cracking in peanut shell biochar-amended soil.

As a primary source of greenhouse gas emissions and a carbon sink, soil plays a key role in climate regulation. The development of cracks in soil strongly influences CO2 emissions, and soil amendment with biochar has been shown to reduce cracking. However, the impact of biochar on CO2 emissions during soil cracking is not well understood. This study investigates the release of CO2 flux during the cracking of peanut shell biochar-amended soil. The biochar-amended soil was incubated at a constant temperature of 35 °C for 160 h with periodic photography and analysis of CO2 concentration and soil moisture. To achieve continuous monitoring of incubation soil, a new coupled sensor was specially designed to measure CO2 concentration and soil moisture, based on the Arduino microcontroller. Measured results reveal that peanut shell biochar reduced the evaporation rate by 29 % compared to unamended soil, resulting in slower soil cracking caused by water loss. The biochar also decreased the shrinkage crack length by 20 % compared to unamended soil. In addition, the crack volume fraction was reduced by 16 % after the peanut shell biochar amendment. Due to the reduction of the soil crack channel openings during drying shrinkage when biochar was applied to the soil, cumulative CO2 fluxes were also reduced by 5 % compared to unamended soil. The presence of biochar induced more stable and larger compounds with the soil particles, which blocked the crack propagation path and inhibited further development of the crack.

Coupled effects of elevated CO2 and biochar on microbial communities of vegetated soil.

Soil microbial communities are important for plant growth and establishing healthy ecosystems. Although biochar is widely adopted as a sustainable fertilizer, its influence on soil ecological functions is still unclear, especially under climate change such as elevated carbon dioxide concentration (eCO2). This study explores the coupled effects between eCO2 and biochar on microbial communities in soil planted with tree seedlings of Schefflera heptaphylla. Root characteristics and soil microbial communities were examined and interpreted with statistical analysis. Results show that biochar application at ambient carbon dioxide concentration (aCO2) always improves plant growth, which is further promoted under eCO2. Similarly, ß-glucosidase, urease and phosphatase activities are enhanced by biochar at aCO2 (p < 0.05). In contrast, only urease activity increases with biochar added at eCO2 (p < 0.05). The beneficial effects of biochar on soil enzyme activities become less significant at eCO2. Depending on biochar type, biochar can increase bacterial diversity and fungal richness at aCO2. However, at eCO2, biochar does not significantly affect microbial richness (p > 0.05) while microbial diversity is reduced by peanut shell biochar (p < 0.05). Owing to better plant growth under biochar application and eCO2, plants are likely to become more dominant in specializing the microbial communities that are favourable to them. In such community, the abundance of Proteobacteria is the greatest and increases after biochar addition at eCO2. The most abundant fungus also shifts from Rozellomycota to Ascomycota and Basidiomycota. These microbes can improve soil fertility. Even though the microbial diversity is reduced, using biochar at eCO2 can further promote plant growth, which in turn enhances carbon sequestration. Thus, biochar application can be an effective strategy to facilitate ecological restoration under climate change and relieve the problem of eCO2.

Hypoxia Potentiates the Inflammatory Fibroblast Phenotype Promoted by Pancreatic Cancer Cell-Derived Cytokines.

Cancer-associated fibroblasts (CAF) are a major cell type in the stroma of solid tumors and can exert both tumor-promoting and tumor-restraining functions. CAF heterogeneity is frequently observed in pancreatic ductal adenocarcinoma (PDAC), a tumor characterized by a dense and hypoxic stroma that features myofibroblastic CAFs (myCAF) and inflammatory CAFs (iCAF) that are thought to have opposing roles in tumor progression. While CAF heterogeneity can be driven in part by tumor cell-produced cytokines, other determinants shaping CAF identity and function are largely unknown. In vivo, we found that iCAFs displayed a hypoxic gene expression and biochemical profile and were enriched in hypoxic regions of PDAC tumors, while myCAFs were excluded from these regions. Hypoxia led fibroblasts to acquire an inflammatory gene expression signature and synergized with cancer cell-derived cytokines to promote an iCAF phenotype in a HIF1α-dependent fashion. Furthermore, HIF1α stabilization was sufficient to induce an iCAF phenotype in stromal cells introduced into PDAC organoid cocultures and to promote PDAC tumor growth. These findings indicate hypoxia-induced HIF1α as a regulator of CAF heterogeneity and promoter of tumor progression in PDAC. SIGNIFICANCE: Hypoxia in the tumor microenvironment of pancreatic cancer potentiates the cytokine-induced inflammatory CAF phenotype and promotes tumor growth. See related commentary by Fuentes and Taniguchi, p. 1560.

Intercropping of Pinellia ternata (herbal plant) with Sedum alfredii (Cd-hyperaccumulator) to reduce soil cadmium (Cd) absorption and improve yield.

Soil contamination by cadmium (Cd) is of global concern, threatening not only crop production, but also supply of herbal medicine. Research studies usually grow crops with Sedum alfredii (a Cd-hyperaccumulator). However, intercropping herbal plants with S. alfredii and their interactions with hydro-chemical properties of soil are rarely considered. This study examines the growth of a herbal plant, Pinellia ternata, intercropped with S. alfredii in Cd-contaminated soil. Plant characteristics were assessed, especially biomass and Cd content of bulbil (yield and quality of P. ternata). Soil hydro-chemical properties including water retention, Cd content and organic matter were determined with statistical analyses. At low soil-Cd contamination (0.6 µg/g), bulbil biomass of intercropped P. ternata (PSL) was almost double compared with monoculture of P. ternata (PL), which is barely significant (p ≈ 0.05). The corm biomass of PSL was also significantly greater than that of PL (p < 0.05). Although soil-Cd contamination became more severe by increasing to 3 µg/g, the bulbil biomass in the intercrop was not significantly different from PL (p > 0.05). That said, it is evidenced that the yield of intercropped P. ternata was improved in Cd-contaminated soil. Such improvement was mainly attributed to reduced soil-Cd content and enhanced soil-water retention which was governed by plant roots and soil organic matters. The soil-water retention was first identified as a critical parameter in promoting plant growth under intercropping. More importantly, the bulbil-Cd content of P. ternata in PSL was significantly reduced (p < 0.05). This study demonstrates that the newly proposed intercrop is feasible to improve yield of herbal plants, and at the same time reduce heavy metal absorption and accumulation in medicinal organs, especially for P. ternata. This is anticipated to reduce the human health risk imposed by ingestion of Chinese herbal plants.

Agr2-associated ER stress promotes adherent-invasive E. coli dysbiosis and triggers CD103+ dendritic cell IL-23-dependent ileocolitis.

Endoplasmic reticulum (ER) stress is associated with Crohn's disease (CD), but its impact on host-microbe interaction in disease pathogenesis is not well defined. Functional deficiency in the protein disulfide isomerase anterior gradient 2 (AGR2) has been linked with CD and leads to epithelial cell ER stress and ileocolitis in mice and humans. Here, we show that ileal expression of AGR2 correlates with mucosal Enterobactericeae abundance in human inflammatory bowel disease (IBD) and that Agr2 deletion leads to ER-stress-dependent expansion of mucosal-associated adherent-invasive Escherichia coli (AIEC), which drives Th17 cell ileocolitis in mice. Mechanistically, our data reveal that AIEC-induced epithelial cell ER stress triggers CD103+ dendritic cell production of interleukin-23 (IL-23) and that IL-23R is required for ileocolitis in Agr2-/- mice. Overall, these data reveal a specific and reciprocal interaction of the expansion of the CD pathobiont AIEC with ER-stress-associated ileocolitis and highlight a distinct cellular mechanism for IL-23-dependent ileocolitis.

Effects of Bacillus subtilis and Pseudomonas fluorescens as the soil amendment.

The application of soil beneficial bacteria (SBB) in agriculture is steadily increasing as it provides a promising way to replace chemical fertilisers and other supplements. Although the role of SBB as a biofertiliser is well understood, little is known about the response of soil physiochemical properties via the change in soil enzymatic activities with SBB growth. In this study, sterilised bulk soil was inoculated with Bacillus subtilis (BS) and Pseudomonas fluorescens (PF), which exhibit excellent characteristics in vitro for potentially improving soil quality. It is found that the contents of bioavailable nitrogen and ammonium in soil inoculated with SBB increased significantly, up to 34% and 57% relative to a control. This resulted from the enhancement of soil urease activity with BS and PF treatments by approximately 90% and 70%, respectively. The increased soil urease activity can be explained by the increased microorganism activity evident from the larger population size of BS (0.78-0.97 CFU mL-1/CFU mL-1) than PF (0.55-0.79 CFU mL-1/CFU mL-1) (p < 0.05). Results of principal component analysis also reinforce the interaction apparent in the significant relationship between soil urease activity and microbial biomass carbon (p < 0.05). Therefore, it can be concluded that the enhancement of soil enzymatic activities induced bulk soil fertility upregulation because of bacterial growth. These results demonstrate the application of SBB to be a promising strategy for bulk soil amendment, particularly nutrient restoration.

Microbiota manipulation to increase macrophage IL-10 improves colitis and limits colitis-associated colorectal cancer.

Inflammatory bowel disease (IBD) is a chronic life-long inflammatory disease affecting almost 2 million Americans. Although new biologic therapies have been developed, the standard medical treatment fails to selectively control the dysregulated immune pathways involved in chronic colonic inflammation. Further, IBD patients with uncontrolled colonic inflammation are at a higher risk for developing colorectal cancer (CRC). Intestinal microbes can impact many immune functions, and here we asked if they could be used to improve intestinal inflammation. By utilizing an intestinal adherent E. coli that we find increases IL-10 producing macrophages, we were able to limit intestinal inflammation and restrict tumor formation. Macrophage IL-10 along with IL-10 signaling to the intestinal epithelium were required for protection in both inflammation and tumor development. Our work highlights that administration of immune modulating microbes can improve intestinal outcomes by altering tissue inflammation.

Effects of biochar on shear strength of completely decomposed granite.

Biochar has a great potential to sustainably improve the performance of bio-engineered slope due to its ability to retain water and to supply nutrients. Existing studies mainly focus on hydrological properties of biochar-amended soil. However, the effects of biochar on shear strength of soil are not well studied. This study aims to assess the shearing behaviour of biochar-amended completely decomposed granite (CDG). Soil specimens were prepared by mixing CDG with two types of biochar at a mass ratio of 5% and compacted at 95% of the maximum dry density. Although the peak shear strength of biochar-amended CDG is reduced by up to 20% because of lower initial dry density of the soil and crushing of biochar particles during shearing, both types of biochar have negligible effects on the ultimate shear strength, which is governed by friction between soil particles. This highlights that the ultimate friction angle can be adopted for designing bio-engineered slopes using biochar-amended soils.

Effects of phosphorus-modified biochar as a soil amendment on the growth and quality of Pseudostellaria heterophylla.

Phosphorus (P) deficiency in agricultural soil is a worldwide concern. P modification of biochar, a common soil conditioner produced by pyrolysis of wastes and residues, can increase P availability and improve soil quality. This study aims to investigate the effects of P-modified biochar as a soil amendment on the growth and quality of a medicinal plant (Pseudostellaria heterophylla). P. heterophylla were grown for 4 months in lateritic soil amended with P-modified and unmodified biochar (peanut shell) at dosages of 0, 3% and 5% (by mass). Compared with unmodified biochar, P-modified biochar reduced available heavy metal Cd in soil by up to 73.0% and osmotic suction in the root zone by up to 49.3%. P-modified biochar application at 3% and 5% promoted the tuber yield of P. heterophylla significantly by 68.6% and 136.0% respectively. This was different from that in unmodified biochar treatment, where tuber yield was stimulated at 3% dosage but inhibited at 5% dosage. The concentrations of active ingredients (i.e., polysaccharides, saponins) in tuber were increased by 2.9-78.8% under P-modified biochar amendment compared with control, indicating the better tuber quality. This study recommended the application of 5% P-modified biochar for promoting the yield and quality of P. heterophylla.

SATB2 preserves colon stem cell identity and mediates ileum-colon conversion via enhancer remodeling.

Adult stem cells maintain regenerative tissue structure and function by producing tissue-specific progeny, but the factors that preserve their tissue identities are not well understood. The small and large intestines differ markedly in cell composition and function, reflecting their distinct stem cell populations. Here we show that SATB2, a colon-restricted chromatin factor, singularly preserves LGR5+ adult colonic stem cell and epithelial identity in mice and humans. Satb2 loss in adult mice leads to stable conversion of colonic stem cells into small intestine ileal-like stem cells and replacement of the colonic mucosa with one that resembles the ileum. Conversely, SATB2 confers colonic properties on the mouse ileum. Human colonic organoids also adopt ileal characteristics upon SATB2 loss. SATB2 regulates colonic identity in part by modulating enhancer binding of the intestinal transcription factors CDX2 and HNF4A. Our study uncovers a conserved core regulator of colonic stem cells able to mediate cross-tissue plasticity in mature intestines.

Clinicians for CARE: A Systematic Review and Meta-Analysis of Interventions to Support Caregivers of Patients With Heart Disease.

Background Caregivers provide critical support for patients with chronic diseases, including heart disease, but often experience caregiver stress that negatively impacts their health, quality of life, and patient outcomes. We aimed to inform health care teams on an evidence-based approach to supporting the caregivers of patients with heart disease. Methods and Results We conducted a systematic review and meta-analysis of randomized controlled trials written in English that evaluated interventions to support caregivers of patients with heart disease. We identified 15,561 articles as of April 2, 2020 from 6 databases; of which 20 unique randomized controlled trials were evaluated, representing a total of 1570 patients and 1776 caregivers. Most interventions focused on improving quality of life, and reducing burden, depression, and anxiety; 85% (17 of 20) of the randomized controlled trials provided psychoeducation for caregivers. Interventions had mixed results, with moderate non-significant effects observed for depression (Hedges' g=-0.64; 95% CI, -1.34 to 0.06) and burden (Hedges' g=-0.51; 95% CI, -2.71 to 1.70) at 2 to 4 months postintervention and small non-significant effects observed for quality of life and anxiety. These results were limited by the heterogeneity of outcome measures and intervention delivery methods. A qualitative synthesis of major themes of the interventions resulted in clinical recommendations represented with the acronym "CARE" (Caregiver-Centered, Active engagement, Reinforcement, Education). Conclusions This systematic review highlights the need for greater understanding of the challenges faced by caregivers and the development of guidelines to help clinicians address those challenges. More research is necessary to develop clinical interventions that consistently improve caregiver outcomes.