Apnea Testing on Conventional Mechanical Ventilation During Brain Death Evaluation.

INTRODUCTION: The use of continuous positive airway pressure has been shown to improve the tolerance of the apnea test, a critical component of brain death evaluation. The ability to deactivate the apnea backup setting has made apnea testing possible using several conventional mechanical ventilators. Our goal was to evaluate the safety and efficacy of apnea testing performed on mechanical ventilation, compared with the oxygen insufflation technique, for the determination of brain death. METHODS: This was a retrospective study. In 2016, our institution approved a change in policy to permit apnea testing on conventional mechanical ventilation. We examined the records of consecutive adults who underwent apnea testing as part of the brain death evaluation process between 2016 and 2022. Using an apnea test technique was decided at the discretion of the attending physician. Outcomes were successful apnea test and the occurrence of patient instability during the test. This included oxygen desaturation (SpO2) < 90%, hypotension (mean arterial pressure < 65 mm Hg despite titration of vasopressor), cardiac arrhythmia, pneumothorax, and cardiac arrest. RESULTS: Ninety-two adult patients underwent apnea testing during the study period: 58 (63%) with mechanical ventilation, 32 (35%) with oxygen insufflation, and 2 (2%) lacked documentation of technique. Apnea tests could not be completed successfully in 3 of 92 (3%) patients-two patients undergoing the oxygen insufflation technique (one patient with hypoxemia and one patient with hypotension) and one patient on mechanical ventilation (aborted for hemodynamic instability). Hypoxemia occurred in 4 of 32 (12.5%) patients with oxygen insufflation and in zero patients on mechanical ventilation (p = 0.01). Hypotension occurred during 3 of 58 (5%) tests with mechanical ventilation and 4 of 32 (12.5%) tests with oxygen insufflation (p = 0.24). In multivariate analysis, the use of oxygen insufflation was an independent predictor of patient instability during the apnea test (odds ratio 37.74, 95% confidence interval 2.74-520.14). CONCLUSIONS: Apnea testing on conventional mechanical ventilation is feasible and offers several potential advantages over other techniques.

Blockade of TGF-ß and PD-L1 by bintrafusp alfa promotes survival in preclinical ovarian cancer models by promoting T effector and NK cell responses.

BACKGROUND: Failure of immunotherapy in high-grade serous ovarian cancer (HGSC) may be due to high levels of transforming growth factor-ß (TGF-ß) in ascites or tumour immune microenvironment (TIME). Here, we test whether coordinated blockade of TGF-ß and PD-L1 with bintrafusp alfa (BA) can provoke anti-tumour immune responses in preclinical HGSC models. METHODS: BA is a first-in-class bifunctional inhibitor of TGF-ß and PD-L1, and was tested for effects on overall survival and altered TIME in syngeneic HGSC models. RESULTS: Using a mouse ID8-derived HGSC syngeneic model with IFNγ-inducible PD-L1 expression, BA treatments significantly reduced ascites development and tumour burden. BA treatments depleted TGF-ß and VEGF in ascites, and skewed the TIME towards cytotoxicity compared to control. In the BR5 HGSC syngeneic model, BA treatments increased tumour-infiltrating CD8 T cells with effector memory and cytotoxic markers, as well as cytolytic NK cells. Extended BA treatments in the BR5 model produced ∼50% BA-cured mice that were protected from re-challenge. These BA-cured mice had increased peritoneal T-effector memory and NK cells compared to controls. CONCLUSIONS: Our preclinical studies of BA in advanced ovarian cancer models support further testing of BA as an improved immunotherapy option for patients with advanced ovarian cancer.

Clinical outcomes of 20 brachycephalic dogs with thoracolumbar spinal deformities causing neurological signs treated with spinal stabilization using 3D-printed patient-specific drill guides.

OBJECTIVE: To describe the clinical outcomes for pugs and French bulldogs with congenital vertebral malformations, undergoing thoracolumbar spinal stabilization surgery using 3D-printed patient-specific drill guides. To evaluate the accuracy of pedicle screw placement in this group of dogs. STUDY DESIGN: Retrospective descriptive study. ANIMALS: Twenty dogs (12 pugs and eight French bulldogs). METHODS: Medical records searched between August 2018 and March 2021 for pugs and French bulldogs diagnosed with congenital vertebral abnormalities via magnetic resonance imaging (MRI) scan and computed tomography (CT) scan causing T3-L3 myelopathy signs that underwent spinal stabilization surgery using 3D-printed patient-specific drill guides followed by a postoperative CT scan. The short-term outcome was based on the neurological grade (modified Frankel score-MFS) on the day after surgery, day of discharge, and at the follow-up examination at 4 to 6 weeks after surgery. The mid-term outcome was obtained via an online questionnaire (or direct examination in one case). RESULTS: Twenty dogs met the inclusion criteria (19/20 grade 2 MFS, 1/20 grade 4 MFS). No complications were reported in the immediate postoperative period and optimal pedicle screw placement was obtained in 169/201 of screws. Twenty-four hours after surgery 16/20 dogs displayed an unchanged neurological grade. Short-term outcomes revealed a static (17/20) or improved (2/20) neurological grade. Ten owners participated in the online questionnaire. All patients were reported to be ambulatory; however, 7/10 dogs displayed abnormal gait. Neurological signs had remained static (6/10) or improved (3/10) in comparison with the dogs' preoperative status at a median of 883.5 days from the surgery. CONCLUSION: Dogs in this study had a favorable short-term outcome and mid-term outcome evaluation revealed a static/improved neurological status. CLINICAL SIGNIFICANCE: Thoracolumbar spinal stabilization surgery using 3D-printed patient-specific drill guides showed a favorable outcome in brachycephalic breeds affected by vertebral deformities.

Resurgence of ethanol seeking following voluntary abstinence produced by nondrug differential reinforcement of other behavior.

Resurgence refers to the relapse of a target behavior following the worsening of a source of alternative reinforcement that was made available during response elimination. Most laboratory analyses of resurgence have used a combination of extinction and alternative reinforcement to reduce target behavior. In contingency-management treatments for alcohol use disorder, however, alcohol use is not placed on extinction. Instead, participants voluntarily abstain from alcohol use to access nondrug alternative reinforcers. Inasmuch, additional laboratory research on resurgence following voluntary abstinence is warranted. The present experiment evaluated resurgence of rats' ethanol seeking following voluntary abstinence produced by differential reinforcement of other behavior (DRO). Lever pressing produced ethanol reinforcers during baseline phases. During DRO phases, lever pressing continued to produce ethanol and food reinforcers were delivered according to resetting DRO schedules. Ethanol and food reinforcers were suspended during resurgence test phases to evaluate resurgence following voluntary abstinence. Lever pressing was elevated during baseline phases and occurred at near-zero rates during DRO phases. During the resurgence test phases, lever pressing increased, despite that it no longer produced ethanol. The procedure introduced here may help researchers better understand the variables that affect voluntary abstinence from ethanol seeking and resurgence following voluntary abstinence.

Toward a Template for Synthetic Actin-Targeting Macrolide Analogues That Inhibit Cancer Cell Invasiveness.

Actin barbed end-binding macrolides have been shown to inhibit cancer cell motility and invasion of extracellular matrix (ECM), evoking their potential utility as therapies for metastatic cancers. Unfortunately, the direct use of these compounds in clinical settings is impeded by their limited natural abundance, challenging total synthesis, and detrimental effects on normal tissues. To develop potent analogues of these compounds that are simpler to synthesize and compatible with cell-specific targeting systems, such as antibodies, we designed over 20 analogues of the acyclic side chain (tail) of the macrolide Mycalolide B. These analogues probed the contributions of four distinct regions of the tail towards the inhibition of actin polymerization and ECM invasion by human lung cancer A549 cells. We observed that two of these regions tolerate considerable substituent variability, and we identified a specific combination of substituents that leads to the optimal inhibition of the ECM invasion activity of A549 cells.

Resistance to change, of behavior and of theory.

The persistence of operant behavior when disrupted tends to be positively related to how often reinforcers were delivered in the past. Behavioral momentum theory describes this finding as the outcome of Pavlovian processes. That is, the relation between discriminative stimuli and reinforcers that were delivered in their presence strengthens behavior, thereby making it more likely to persist. If only the story were that simple. A growing number of findings challenge the basic tenets of behavioral momentum theory. Some even call into question whether Pavlovian relations contribute to persistence in the first place. In this paper, I will review behavioral momentum theory and some of the data that have been problematic for the theory. I will argue that despite these very real challenges, the theory provides important utility not only to basic analyses of response persistence but also to clinical interventions directed at long-term reductions in problem behavior. It, for example, has set the stage for the development of alternative conceptual analyses of resistance to change, two of which will be highlighted for readers. Moreover, behavioral momentum theory may tell us something important about the reasons it continues to have an influence on the field, despite the challenging data that deter it.

Impact of age and telomere length on circulating T cells and rejection risk after lung transplantation for idiopathic pulmonary fibrosis.

BACKGROUND: Most idiopathic pulmonary fibrosis (IPF) lung transplant recipients (IPF-LTRs) have short telomere (ST) length. Inherited mutations in telomere-related genes are associated with the development of T cell immunodeficiency. Despite this, IPF-LTRs with telomere-related rare variants are not protected from acute cellular rejection (ACR). We set out to determine the impact of both age and telomere length on the circulating T cell compartment and ACR burden of IPF-LTRs. METHODS: We identified 106 IPF-LTRs who had telomere length testing using flowFISH (57 with short telomeres and 49 with long telomeres) as well as a subset from both cohorts who had cryopreserved PBMC at least 1 time point, 6 months posttransplantation. Circulating T cells from before transplantation and at 6 and 12 months posttransplantation were analyzed using multiparameter flow cytometry to study phenotype and functional capacity, and bulk T cell receptor sequencing was performed to study repertoire diversity. Linear regression was used to study the relationship of age and telomere length on early (within 1 year) and late (between 1 and 2 years) ACR. RESULTS: IPF-LTRs with ST were found to have premature "aging" of their circulating T cell compartment, with age-agnostic elevations in posttransplant terminal differentiation of CD8+ T cells, increased granzyme B positivity of both CD8+ and CD4+ T cells, upregulation of the exhaustion marker, CD57, and chemotactic protein CCR5, and enhanced T cell receptor clonal expansion. Additionally, we found a significant decline in early ACR burden with increasing age, but only in the ST cohort. CONCLUSIONS: IPF-LTRs with ST have premature "aging" of their circulating T cell compartment posttransplantation and a clear age-related decline in ACR burden.

Accurate X-ray diffraction data required for proper evaluation of bond valence sums and global instability indexes: redetermination of the crystal structures of diamond-like Cu2CdSiS4 and Cu2HgSnS4 as a case study.

Our calculations of the global instability index (G) values for some diamond-like materials with the general formula I2-II-IV-VI4 have indicated that the structures may be unstable or incorrectly determined. To compute the G value of a given compound, the bond valence sums (BVSs) must first be calculated using a crystal structure. Two examples of compounds with high G values, based on data from the literature, are the wurtz-stannite-type dicopper cadmium silicon tetrasulfide (Cu2CdSiS4) and the stannite-type dicopper mercury tin tetrasulfide (Cu2HgSnS4), which were first reported in 1967 and 1965, respectively. In the present study, Cu2CdSiS4 and Cu2HgSnS4 were prepared by solid-state synthesis at 1000 and 900 °C, respectively. The phase purity was assessed by powder X-ray diffraction. Optical diffuse reflectance UV/Vis/NIR spectroscopy was used to estimate the optical bandgaps of 2.52 and 0.83 eV for Cu2CdSiS4 and Cu2HgSnS4, respectively. The structures were solved and refined using single-crystal X-ray diffraction data. The structure type of Cu2CdSiS4 was confirmed, where Cd2+, Si4+ and two of the three crystallographically unique S2- ions lie on a mirror plane. The structure type of Cu2HgSnS4 was also verified, where all ions lie on special positions. The S2- ion resides on a mirror plane, the Cu+ ion is situated on a fourfold rotary inversion axis and both the Hg2+ and the Sn4+ ions are located on the intersection of a fourfold rotary inversion axis, a mirror plane and a twofold rotation axis. Using the crystal structures solved and refined here, the G values were reassessed and found to be in the range that indicates reasonable strain for a stable crystal structure. This work, together with some examples gathered from the literature, shows that accurate data collected on modern instrumentation should be used to reliably calculate BVSs and G values.

Impact of enzymatic digestion on single cell suspension yield from peripheral human lung tissue.

An increasing number of translational investigations of lung biology rely on analyzing single cell suspensions obtained from human lungs. To obtain these single cell suspensions, human lungs from biopsies or research-consented organ donors must be subjected to mechanical and enzymatic digestion prior to analysis with either flow cytometry or single cell RNA sequencing. A variety of enzymes have been used to perform tissue digestion, each with potential limitations. To better understand the limitations of each enzymatic digestion protocol and to establish a framework for comparing studies across protocols, we performed five commonly published protocols in parallel from identical samples obtained from 6 human lungs. Following mechanical (gentleMACS™) and enzymatic digestion, we quantified cell count and viability using a Nexcelom Cellometer and determined cell phenotype using multiparameter spectral flow cytometry (Cytek™ Aurora). We found that all protocols were superior in cellular yield and viability when compared to mechanical digestion alone. Protocols high in dispase cleaved immune markers CD4, CD8, CD69, and CD103 and contributed to an increased monocyte to macrophage yield. Similarly, dispase led to a differential epithelial cell yield, with increased TSPN8+ and ITGA6+ epithelial cells and reduced CD66e+ cells. When compared to collagenase D, collagenase P protocols yielded increased AT1 and AT2 cells and decreased endothelial cells. These results provide a framework for selecting an enzymatic digestion protocol best suited to the scientific question and allow for comparison of studies using different protocols.

Multifunctional Cu2TSiS4 (T = Mn and Fe): Polar Semiconducting Antiferromagnets with Nonlinear Optical Properties.

Cu2TSiS4 (T = Mn and Fe) polycrystalline and single-crystal materials were prepared with high-temperature solid-state and chemical vapor transport methods, respectively. The polar crystal structure (space group Pmn21) consists of chains of corner-sharing and distorted CuS4, Mn/FeS4, and SiS4 tetrahedra, which is confirmed by Rietveld refinement using neutron powder diffraction data, X-ray single-crystal refinement, electron diffraction, energy-dispersive X-ray spectroscopy, and second harmonic generation (SHG) techniques. Magnetic measurements indicate that both compounds order antiferromagnetically at 8 and 14 K, respectively, which is supported by the temperature-dependent (100-2 K) neutron powder diffraction data. Additional magnetic reflections observed at 2 K can be modeled by magnetic propagation vectors k = (1/2,0,1/2) and k = (1/2,1/2,1/2) for Cu2MnSiS4 and Cu2FeSiS4, respectively. The refined antiferromagnetic structure reveals that the Mn/Fe spins are canted away from the ac plane by about 14°, with the total magnetic moments of Mn and Fe being 4.1(1) and 2.9(1) µB, respectively. Both compounds exhibit an SHG response with relatively modest second-order nonlinear susceptibilities. Density functional theory calculations are used to describe the electronic band structures.

Crystal structure, electronic structure, and optical properties of the novel Li4CdGe2S7, a wide-bandgap quaternary sulfide with a polar structure derived from lonsdaleite.

The novel quaternary thiogermanate Li4CdGe2S7 (tetralithium cadmium digermanium heptasulfide) was discovered from a solid-state reaction at 750 °C. Single-crystal X-ray diffraction data were collected and used to solve and refine the structure. Li4CdGe2S7 is a member of the small, but growing, class of I4-II-IV2-VI7 diamond-like materials. The compound adopts the Cu5Si2S7 structure type, which is a derivative of lonsdaleite. Crystallizing in the polar space group Cc, Li4CdGe2S7 contains 14 crystallographically unique ions, all residing on general positions. Like all diamond-like structures, the compound is built of corner-sharing tetrahedral units that create a relatively dense three-dimensional assembly. The title compound is the major phase of the reaction product, as evidenced by powder X-ray diffraction and optical diffuse reflectance spectroscopy. While the compound exhibits a second-harmonic generation (SHG) response comparable to that of the AgGaS2 (AGS) reference material in the IR region, its laser-induced damage threshold (LIDT) is over an order of magnitude greater than AGS for λ = 1.064 µm and τ = 30 ps. Bond valence sums, global instability index, minimum bounding ellipsoid (MBE) analysis, and electronic structure calculations using density functional theory (DFT) were used to further evaluate the crystal structure and electronic structure of the compound and provide a comparison with the analogous I2-II-IV-VI4 diamond-like compound Li2CdGeS4. Li4CdGe2S7 appears to be a better IR nonlinear optical (NLO) candidate than Li2CdGeS4 and one of the most promising contenders to date. The exceptional LIDT is likely due, at least in part, to the wider optical bandgap of ∼3.6 eV.

Nondrug reinforcers contingent on alternative behavior or abstinence increase resistance to extinction and reinstatement of ethanol-maintained behavior.

The effects of delivering nondrug alternative reinforcement on resistance to extinction and reinstatement of rats' ethanol-maintained lever pressing were evaluated in two experiments. In both, rats self-administered ethanol by lever pressing in a two-component multiple schedule during baseline. In the Rich component, alternative food reinforcement was made available for performing an alternative response (Experiment 1) or according to a differential-reinforcement-of-other-behavior schedule for lever pressing (Experiment 2). In the Lean component, only ethanol was available. Moreover, the frequency of alternative reinforcement was manipulated across conditions in Experiment 1. Following baseline, lever pressing was extinguished in both components by suspending ethanol reinforcement, and alternative food reinforcers were discontinued. Finally, to test for reinstatement, ethanol reinforcers were delivered independently of lever pressing in both components. In both experiments, proportion-of-baseline response rates were higher during extinction and reinstatement testing in the Rich component than in the Lean component (although differentiation was not observed at the lowest frequency of alternative reinforcement in Experiment 1). Thus, alternative nondrug reinforcers increased resistance to extinction and reinstatement of rats' ethanol-maintained lever pressing, even when those reinforcers were delivered contingently on an alternative response or on abstinence from lever pressing.

Estrogen mediates inflammatory role of mast cells in endometriosis pathophysiology.

Endometriosis is an estrogen dependent, chronic inflammatory disease characterized by the growth of endometrial lining outside of the uterus. Mast cells have emerged as key players in regulating not only allergic responses but also other mechanisms such as angiogenesis, fibrosis, and pain. The influence of estrogen on mast cell function has also been recognized as a potential factor driving disease pathophysiology in number of allergic and chronic inflammatory conditions. However, precise information is lacking on the cross talk between endocrine and immune factors within the endometriotic lesions and whether that contributes to the involvement of mast cells with disease pathophysiology. In this study, we observed a significant increase in mast cell numbers within endometriotic lesions compared to matched eutopic endometrium from the same patients. Compared to eutopic endometrium, endometriotic lesions had significantly higher levels of stem cell factor (SCF), a potent growth factor critical for mast cell expansion, differentiation, and survival for tissue resident mast cells. Targeted mRNA Q-PCR array revealed that the endometriotic lesions harbour microenvironment (upregulation of CPA3, VCAM1, CCL2, CMA1, CCR1, and KITLG) that is conducive to mast cells recruitment and subsequent differentiation. To examine cross-talk of mast cells within the endometriotic lesion microenvironment, endometriotic epithelial cells (12Z) and endometrial stromal cells (hESC) incubated with mast cell-conditioned media showed significantly increased production of pro-inflammatory and chemokinetic cytokines. To further understand the impact of estrogen on mast cells in endometriosis, we induced endometriosis in C57BL/6 mice. Mature mast cells were significantly higher in peritoneal fluid of estrogen-treated mice compared to untreated mice within the sham operated groups. Mouse endometriotic lesion tissue revealed several genes (qRT-PCR) relevant in mast cell biology significantly upregulated in the estrogen treated, endometriosis-induced group compared to control endometrium. The endometriotic lesions from estrogen treated mice also had significantly higher density of Alcian blue stained mast cells compared to untreated lesions or control endometrium. Collectively, these findings suggest that endometriotic lesions provide a microenvironment necessary for recruitment and differentiation of mast cells. In turn, mast cells potentially release pro-inflammatory mediators that contribute to chronic pelvic pain and endometriosis disease progression.

Development of a clinical prediction model for recurrence and mortality outcomes after Clostridioides difficile infection using a machine learning approach.

OBJECTIVES: Clostridioides difficile infection (CDI) is associated with a large burden of morbidity and mortality worldwide. Previous studies have developed models for predicting recurrence and mortality following CDI, but no machine learning predictive models have been developed specifically using data from Japanese patients. METHODS: Using a database of records from acute care hospitals in Japan, we extracted records from January 2012 to September 2016 (plus a 60-day lookback window). A total of 19,159 patients were included. We used a machine learning approach, XGBoost, and compared it to a traditional unregularized logistic regression model. The first 80% of the dataset (by patient index date) was used to optimize model hyperparameters and train the final models, and evaluation was performed on the remaining 20%. We measured model performance by the area under the receiver operator curve and assessed feature importance using Shapley additive explanations. RESULTS: Performance was similar between the machine learning approach and the classical logistic regression model. Logistic regression performed slightly better than XGBoost for predicting mortality. CONCLUSION: XGBoost performed slightly better than logistic regression for predicting recurrence, but it was not competitive with existing published models. Despite this, a future machine learning-based application provided in a bedside setting at low cost might be a clinically useful tool.

Feline Diaphyseal Fractures: Management and treatment options.

PRACTICAL RELEVANCE: Cats frequently present with diaphyseal fractures, which require treatment in order to achieve a good return to function. These fractures often occur due to significant trauma; for example, as a result of road traffic accidents, high-rise syndrome and dog bite wounds. The first priority is to ensure the patient is systemically well before embarking on any specific surgical treatment of a fracture. CLINICAL CHALLENGES: Surgical management of diaphyseal fractures can be challenging due to the surgical approach for some bones being technically demanding, for example because of the presence of important neurovascular structures, and the small size of feline bones, which limits the choice of implant size and strength. Further, it may be difficult to visualise fracture alignment when using minimally invasive techniques, although the use of intraoperative fluoroscopy can aid with this, and malalignment can be common for some fracture repairs, particularly in cases where anatomical reconstruction is not possible. AIMS: This review focuses on diaphyseal long bone fractures and aims to assist decision-making, with an overview of the management and treatment options available. EVIDENCE BASE: Many textbooks and original articles have been published on aspects of managing fractures in small animals. The authors also provide recommendations based upon their own clinical experience.

Musculoskeletal tuberculosis in Bradford : 12 years of outcomes and observations in a high-incidence region of the UK.

AIMS: Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford. METHODS: An observational study was conducted, using data from the Bradford Teaching Hospitals TB database of patients with a formal diagnosis of MSK TB between January 2005 and July 2017. Patient data included demographic data (including nationality/date of entry to the UK), disease focus, microbiology, and management strategies. Disease incidence was calculated using population data from the Office for National Statistics. Poisson confidence intervals were calculated to demonstrate the extent of statistical error. Disease incidence and nationality were also analyzed, and correlation sought, using the chi-squared test. RESULTS: Between January 2005 and July 2017, 109 cases of MSK TB were diagnosed in Bradford. Mean incidence was 1.65 per 100,000 population, per calendar year (SD 0.75). A total of 38 cases required surgical intervention. Low rates of antimicrobial resistance were encountered. A low rate of loss to follow-up was observed (four patients; 3.7%). Overall, 94.5% of patients (n = 103) were successfully treated. 67% of patients (n = 73) reported their country of origin as either India, Pakistan, or Bangladesh. These ethnicities account for around 25% of the local population. CONCLUSION: Bradford maintains a high prevalence of MSK TB infection relative to national data; the prevalence within the local immigrant population remains grossly disproportionate. Typical associated factors (HIV/hepatitis coinfection, drug resistance), have only modest prevalence in our dataset. However, local socioeconomic factors such as deprivation and poverty appear germane as suggested by global literature. We advocate a high degree of suspicion in treatment of atypical infection in any area with similar population factors to ensure timely diagnosis. Cite this article: Bone Jt Open 2022;3(5):432-440.

Modulation of tissue resident memory T cells by glucocorticoids after acute cellular rejection in lung transplantation.

Acute cellular rejection is common after lung transplantation and is associated with an increased risk of early chronic rejection. We present combined single-cell RNA and TCR sequencing on recipient-derived T cells obtained from the bronchoalveolar lavage of three lung transplant recipients with rejection and compare them with T cells obtained from the same patients after treatment of rejection with high-dose systemic glucocorticoids. At the time of rejection, we found an oligoclonal expansion of cytotoxic CD8+ T cells that all persisted as tissue resident memory T cells after successful treatment. Persisting CD8+ allograft-resident T cells have reduced gene expression for cytotoxic mediators after therapy with glucocorticoids but accumulate around airways. This clonal expansion is discordant with circulating T cell clonal expansion at the time of rejection, suggesting in situ expansion. We thus highlight the accumulation of cytotoxic, recipient-derived tissue resident memory T cells within the lung allograft that persist despite the administration of high-dose systemic glucocorticoids. The long-term clinical consequences of this persistence have yet to be characterized.