Cryoablation in lung transplantation: Its impact on pain, opioid use, and outcomes.

Objective: To assess the effect of intraoperative cryoablation on postoperative patient-reported pain, opioid use, and clinical outcomes in lung transplantation. Methods: We performed a single-center retrospective cohort study of adult lung transplant recipients from August 2017 to September 2018. We compared outcomes of patients who received intraoperative cryoablation of the intercostal nerves with those who did not. Primary outcomes were postoperative patient-reported pain scores and opioid use. Secondary outcomes included postoperative sedation and agitation levels and perioperative outcomes. Data were abstracted from patients' electronic health records. Results: Of the 102 patients transplanted, 45 received intraoperative cryoablation (intervention group) and 57 received the standard of care, which did not include intercostal or serratus blocks or immediate postoperative epidural placement (control group). The intervention group had significantly lower median and maximum postoperative pain scores at days 3 and 7 and significantly lower oral opioid use at days 3, 7, and 14 compared with the control group. Chronic opioid use at 3 and 6 months' posttransplant was lower in the intervention group. Differences in perioperative outcomes, including length of mechanical ventilation, sedation and agitation levels, and hospital stay, were not clinically meaningful. Survival at 30 days and 1 year was superior in the intervention compared with the control group. Conclusions: Findings suggest that use of intraoperative cryoablation is an effective approach for treating pain and reducing opioid use in patients who undergo lung transplant, but a randomized study across multiple institutions is needed to confirm these findings.

Reliability and validity of Japanese version of Fugl-Meyer assessment for the lower extremities.

BACKGROUND: Understanding the degree of motor paralysis in stroke patients is important for assessing the severity of functional impairment and predicting functional prognosis. Fugl-MeyerAssessment for the lower extremities (FMA-LE)is a commonly used measure with high reliability and validity, but there is no official translated Japanese version of FMA-LE. OBJECTIVES: This study aimed to develop Japanese FMA-LE and verify its reliability and validity in patients with acute stroke. METHODS: The Japanese FMA-LE was developed following a standardized translation process. The reliability and validity were evaluated in 50 stroke patients at an acute care hospital. Validity was examined by determining the correlation between FMA-LEand Brunnstrom Recovery Stage (BRS), as well as Short Physical Performance Battery (SPPB). Intra-raterand inter-raterrelative reliabilities were evaluated by calculating intra-classcorrelation coefficients (ICCs). Absolute reliability was assessed by determining the standard error of the measurement and minimum detectible change (MDC). Systematic error was also assessed. RESULTS: FMA-LEtotal score was high correlated with BRS (ρ = 0.73,p < .01) and moderately correlated with SPPB (ρ = 0.69,p < .01). For intra-raterreliability, ICC was 0.98 (p < .01), only fixed systematic error was observed (p < .01), and MDC of the FMA-LEtotal score was 1.24. For inter-raterreliability, ICC was 0.98 (p < .01), no systematic error was observed, and MDC of the FMA-LEtotal score was 3.23. CONCLUSIONS: The Japanese FMA-LE was reliable, valid, and useful for evaluating lower extremity function of acute stroke patients.

Effective silicon production from SiCl4 source using hydrogen radicals generated and transported at atmospheric pressure.

In the Siemens method, high-purity Si is produced by reducing SiHCl3 source gas with H2 ambient under atmospheric pressure. Since the pyrolysis of SiHCl3, which produces SiCl4 as a byproduct, occurs dominantly in the practical Siemens process, the Si yield is low (~30%). In the present study, we generated hydrogen radicals (H-radicals) at pressures greater than 1 atm using tungsten filaments and transported the H-radicals into a reactor. On the basis of the absorbance at 600 nm of WO3-glass exposed to H-radicals in the reactor, we observed that H-radicals with a density of ~1.1 × 1012 cm-3 were transported approximately 30 cm under 1 atm. When SiCl4 was supplied as a source into the reactor containing H-radicals and allowed to react at 850°C or 900°C, Si was produced more efficiently than in reactions conducted under H2 ambient. Because the H-radicals can effectively reduce SiCl4, which is a byproduct in the Siemens method, their use is expected to increase the Si yield for this method.

Stratification Risk Analysis in Bridging Patients to Lung Transplant on ECMO: The STABLE Risk Score.

BACKGROUND: No clinically validated tool exists to predict in-hospital mortality in patients requiring extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. We generated a quantitative risk assessment tool for these patients. METHODS: Of 822 patients in the United Network for Organ Sharing (UNOS) database who required ECMO as bridge to lung transplant between 2004 and 2018, 630 were included in the analysis after exclusion for age <18 years, prior transplant, or treatment before 2004. Recipient-specific variables associated with posttransplant in-hospital mortality were incorporated into a multivariable logistic regression model in an automated stepwise fashion. Linear prediction was used to construct the Recipient Stratification Risk Analysis in Bridging Patients to Lung Transplant on ECMO (STABLE) score. K-fold cross-validation provided an unbiased estimate of out-of-sample performance. After further exclusion for University of Pennsylvania patients, the remaining cohort was used for external score validation. An iOS application was developed to aid clinical use. RESULTS: Six recipient-specific, pretransplant variables were translated into a 24-point score. STABLE scores in the United Network for Organ Sharing (UNOS) database ranged from 0 to 21, and each point increased the odds of in-hospital mortality by 22.0% (95% confidence interval, 1.14-1.29, P < .001). K-fold cross-validation yielded a receiver operating characteristic area under the curve of 86.2%. Validation of the STABLE score using our institutional database yielded an area under the curve of 89%. CONCLUSIONS: The STABLE score is a novel, internally cross-validated tool for risk stratification of patients on ECMO as a bridge to transplant. Its predictive power and accuracy may aid clinical decision-making and improve posttransplant outcomes.

Multiorgan procurement is associated with a survival benefit after heart transplantation.

We assessed the impact of donor multiorgan procurement on survival following orthotopic heart transplantation (OHT). From the UNOS STAR database, we included all adult (≥18 Y) heart transplants (OHT) performed since 2000 and used donor IDs to determine how many other organs were procured from the same donor as the recipient's heart allograft (regardless of recipient). The Kaplan-Meier survival functions and risk-adjusted Cox proportional hazards regression models were computed to assess the association of multiorgan procurement with post-heart transplantation mortality. We included 40 336 OHT patients. Including the heart, the median number of donor organs procured was 3 (IQR, 3-4). Heart donors underwent liver procurement in 89.7%; kidney(s) in 98.1% (single 95%, bilateral 5%); lung(s) in 38.0% (single 28%, bilateral 72%); pancreas in 10.4%; and intestine in 1.6%. Following risk adjustment across 16 recipient- and donor-specific variables, an increasing number of organs procured were independently associated with reduced post-OHT mortality (HR 0.98, 95% CI 0.96-0.99, P = .025). Though no significant associations were found examining specific organ types, double lung procurement trended toward a protective effect (HR 0.96, 0.92-1.01, P = .086), with counts of non-lung organs procured still bordering on significance (HR 0.97, 95% CI 0.95-1.00, P = .067). These results likely reflect improved multiorgan donor quality.

Simultaneous Recovery of Display Panel Waste Glass and Wastewater Boron by Chemical Oxo-precipitation with Fluidized-Bed Heterogeneous Crystallization.

Silica-based carrier is a promising material for recovery of metal and nonmetal contaminants in chemical oxo-precipitation-fluidized bed crystallization (COP-FBC) system. Boron species are an essential element for plant growth and can cause health concerns in human beings at high concentrations in water environments. The composition of thin-film transistor liquid crystal display (TFT-LCD) contains a wide variety of metal oxides and can be tailored as promising functional mesoporous carriers for boron crystallization recovery in the presence of barium ions and hydrogen peroxide. In this study, waste-derived mesoporous aluminosilicate (MAS) nanomaterial in the presence of barium ions and hydrogen peroxide was used as a carrier for sustainable recovery of crystallized boron, a priority wastewaters pollutant. The MAS shows the hierarchically homogeneous distribution of nanostructured aluminosilicate particles with an average size of 12.8 ± 3.6 nm on the surface after the activation with Na2CO3 at 1000 °C. Moreover, the negatively charged surface and the mesoporous structure of MAS enhance the adsorption of Ba2+ onto MAS, and the Langmuir adsorption capacity of 105 mg/g is achieved, which is conducive to the enhancement of the recovery of boron species. Moreover, the recovery efficiency and crystallization ratio of boron by MAS can be up to 84.5 and 93.4%, respectively. The cross-sectional scanning electron microscopy images and the high-temperature X-ray diffraction results confirm the boron recovery mechanism that the negatively charged functional group as well as the mesoporosity of MAS triggers the rapid formation of needle-shaped precipitates of barium peroxoborate, and then converted to barium borate after calcination at 1050 °C. Results obtained in this study clearly demonstrate the possibility of fabricating environmentally benign mesoporous aluminosilicate adsorbents from TFT-LCD waste to sustainably recover and crystallize boron species from water and wastewater in COP-FBC.

Shape-Controlled Syntheses of Magnetite Microparticles and Their Magnetorheology.

Magnetic microspheres in a concentrated suspension can be self-assembled to form chain structures under a magnetic field, resulting in an enhanced viscosity and elasticity of the suspension (i.e., the magnetorheological (MR) effect). Recently, interest has been raised about the relationship between nonspherical particles, such as octahedral particles and the MR effect. However, experimental studies have not made much progress toward clarifying this issue due to the difficulty associated with synthesizing microparticles with well-defined shapes and sizes. Here, we presented a method for the shape-controlled synthesis of magnetite (Fe3O4) microparticles and investigated the MR effects of two suspensions prepared from the two shape-controlled samples of Fe3O4 microparticles. Our method, which was based on the polyol method, enabled the preparation of spherical and octahedral Fe3O4 microparticles with similar sizes and magnetic properties, through a reduction of α-FeOOH in a mixed solvent of ethylene glycol (a polyol) and water. The water played an important role in both the phase transition (α-FeOOH to Fe3O4) and the shape control. No substantial difference in the MR effect was observed between an octahedral-particle-based suspension and a spherical-particle-based one. Therefore, in this study, the shape of the microparticles did not strongly influence the MR effect, i.e., the properties of the chain structures.

Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy.

PURPOSE: Blunt aortic injuries (BAI) have historically been considered an indication for emergent surgical intervention. Nevertheless, the observation that the outcome of the concomitant traumatic injuries has a major impact on prognosis and the rise of thoracic endovascular aortic repair (TEVAR) as an effective therapy for BAI have significantly changed in recent years the treatment algorithm of this condition. Our objective was to identify findings associated with the aortic injury which would be the best predictor of prognosis, with the objective of guiding the decision-making process for selecting the optimal timing of aortic repair. METHODS: We reviewed blunt aortic injuries from 3 Level I Trauma Centers from July 2008 to December 2016. We analyzed overall and BAI-related 30-day mortality in relation to: hemodynamics, timing of treatment, TEVAR vs open repair, and aortic injury grade as defined by the Society for Vascular Surgery. Based on computed tomographic angiography (CT scan) imaging, we selected the radiologic aortic findings most indicative of high mortality risk, which we defined as "Radiographic Severe Injury" (RSI): (1) total/partial aortic transection, (2) active contrast extravasation, or (3) the association of 2 of more of the following: contained contrast extravasation > 10 mm, periaortic hematoma, and/or mediastinal hematoma with thickness > 10 mm, or significant left pleural effusion. RESULTS: Of a total of 76 consecutive patients, 50 (66%) underwent immediate repair, 24 (31%) delayed aortic repair, and 2 (3%) died prior to repair. 58 patients (76%) had TEVAR, while 16 (24%) had open repair. Overall mortality was 18% and BAI-related mortality was 13%. In BAI-related mortalities, 70% of patients had RSI. Patients with high risk of overall mortality had hypotension and tachycardia (SBP < 100, HR ≥ 100), high ISS, and required vasopressors. Factors only associated with BAI-related mortality included RSI. CONCLUSION: CT scan findings suggestive of RSI are predictive of mortality associated with BAI. Radiologic assessment of the severity of the aortic injury with characterization for the presence of RSI may represent the key factors to determine the optimal timing of treatment of the aortic injury and guide the overall treatment strategy. LEVEL OF EVIDENCE: IV.

Absolute reliability of measurements of muscle strength and physical performance measures in older people with high functional capacities.

PURPOSE: The purpose of this study was to clarify the absolute reliability of muscle strength and physical performance measures in older people. METHODS: The participants were 718 community-dwelling older people who were living independently. Muscle strength and physical performance tests were administered twice for all participants by the same rater. Grip and knee extension strength during isometric contractions were used as muscle strength tests, and the five-times chair stand test (FCST), 5-m walking time at comfortable pace, and the timed up and go test (TUG) as physical performance tests. Bland-Altman analysis was performed to determine the systematic errors for each muscle strength and physical performance test, and the amount of errors was estimated using the minimum detectable change (MDC). Further, %MDC was calculated by dividing the MDC with the mean of two measurement values for each test. RESULTS: No systematic errors were found in any of the muscle strength or physical performance tests, except for the FCST, for which MDC and %MDC could not be calculated. The %MDC of grip strength, 5-m walking time, and the TUG were estimated at < 10%, whereas that of knee extension strength was 12%. Age and gender were not found to affect any systematic errors or MDC and %MDC. CONCLUSION: Grip strength, 5-m walking time, and the TUG, which all have excellent reliability, were suggested to be appropriate indexes as outcome measures of muscle strength and physical performance in community-dwelling older people.

Applications of Out of Body Lung Perfusion.

RATIONALE AND OBJECTIVES: Out of body organ perfusion is a concept that has been around for a long time. As technology has evolved, so have the systems available for out of body perfusion making whole organ preservation for extended evaluation, resuscitation, and discovery routine. MATERIALS AND METHODS: Clinical use of ex vivo lung perfusion (EVLP) systems has continued to expand as evidence has accumulated to suggest EVLP transplants experience similar mortality, ICU length of stay, length of mechanical ventilation, hospital length of stay, and rates of primary graft dysfunction as conventional lung transplants. In 2017, more lung transplants were performed than any previous year in the US history. RESULTS: Early success of EVLP has motivated groups to evaluate additional donor types and methods for expanding the donor pool. The ability to keep a lung alive in a physiologically neutral environment opens the ability to better understand organ quality, define pathophysiology in certain disease conditions, and provides a platform for interventions to prevent or repair injury. CONCLUSION: The next several years will usher in significant changes in understanding and interventions focused on lung injury. This manuscript highlights applications of EVLP to clarify how this system can be used for basic and translational research.

Protein kinase R-like endoplasmatic reticulum kinase is a mediator of stretch in ventilator-induced lung injury.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a severe form of lung injury characterized by damage to the epithelial barrier with subsequent pulmonary edema and hypoxic respiratory failure. ARDS is a significant medical problem in intensive care units with associated high care costs. There are many potential causes of ARDS; however, alveolar injury associated with mechanical ventilation, termed ventilator-induced lung injury (VILI), remains a well-recognized contributor. It is thus critical to understand the mechanism of VILI. Based on our published preliminary data, we hypothesized that the endoplasmic reticulum (ER) stress response molecule Protein Kinase R-like Endoplasmic Reticulum Kinase (PERK) plays a role in transmitting mechanosensory signals the alveolar epithelium. METHODS: ER stress signal responses to mechanical stretch were studied in ex-vivo ventilated pig lungs. To explore the effect of PERK inhibition on VILI, we ventilated live rats and compared lung injury parameters to non-ventilated controls. The effect of stretch-induced epithelial ER Ca2+ signaling on PERK was studied in stretched alveolar epithelial monolayers. To confirm the activation of PERK in human disease, ER stress signaling was compared between ARDS and non-ARDS lungs. RESULTS: Our studies revealed increased PERK-specific ER stress signaling in response to overstretch. PERK inhibition resulted in dose-dependent improvement of alveolar inflammation and permeability. Our data indicate that stretch-induced epithelial ER Ca2+ release is an activator of PERK. Experiments with human lung tissue confirmed PERK activation by ARDS. CONCLUSION: Our study provides evidences that PERK is a mediator stretch signals in the alveolar epithelium.

Quantitative Evidence for Revising the Definition of Primary Graft Dysfunction after Lung Transplant.

RATIONALE: Primary graft dysfunction (PGD) is a form of acute lung injury that occurs after lung transplantation. The definition of PGD was standardized in 2005. Since that time, clinical practice has evolved, and this definition is increasingly used as a primary endpoint for clinical trials; therefore, validation is warranted. OBJECTIVES: We sought to determine whether refinements to the 2005 consensus definition could further improve construct validity. METHODS: Data from the Lung Transplant Outcomes Group multicenter cohort were used to compare variations on the PGD definition, including alternate oxygenation thresholds, inclusion of additional severity groups, and effects of procedure type and mechanical ventilation. Convergent and divergent validity were compared for mortality prediction and concurrent lung injury biomarker discrimination. MEASUREMENTS AND MAIN RESULTS: A total of 1,179 subjects from 10 centers were enrolled from 2007 to 2012. Median length of follow-up was 4 years (interquartile range = 2.4-5.9). No mortality differences were noted between no PGD (grade 0) and mild PGD (grade 1). Significantly better mortality discrimination was evident for all definitions using later time points (48, 72, or 48-72 hours; P < 0.001). Biomarker divergent discrimination was superior when collapsing grades 0 and 1. Additional severity grades, use of mechanical ventilation, and transplant procedure type had minimal or no effect on mortality or biomarker discrimination. CONCLUSIONS: The PGD consensus definition can be simplified by combining lower PGD grades. Construct validity of grading was present regardless of transplant procedure type or use of mechanical ventilation. Additional severity categories had minimal impact on mortality or biomarker discrimination.

Combinatorial screening of halide perovskite thin films and solar cells by mask-defined IR laser molecular beam epitaxy.

As an extension of combinatorial molecular layer epitaxy via ablation of perovskite oxides by a pulsed excimer laser, we have developed a laser molecular beam epitaxy (MBE) system for parallel integration of nano-scaled thin films of organic-inorganic hybrid materials. A pulsed infrared (IR) semiconductor laser was adopted for thermal evaporation of organic halide (A-site: CH3NH3I) and inorganic halide (B-site: PbI2) powder targets to deposit repeated A/B bilayer films where the thickness of each layer was controlled on molecular layer scale by programming the evaporation IR laser pulse number, length, or power. The layer thickness was monitored with an in situ quartz crystal microbalance and calibrated against ex situ stylus profilometer measurements. A computer-controlled movable mask system enabled the deposition of combinatorial thin film libraries, where each library contains a vertically homogeneous film with spatially programmable A- and B-layer thicknesses. On the composition gradient film, a hole transport Spiro-OMeTAD layer was spin-coated and dried followed by the vacuum evaporation of Ag electrodes to form the solar cell. The preliminary cell performance was evaluated by measuring I-V characteristics at seven different positions on the 12.5 mm × 12.5 mm combinatorial library sample with seven 2 mm × 4 mm slits under a solar simulator irradiation. The combinatorial solar cell library clearly demonstrated that the energy conversion efficiency sharply changes from nearly zero to 10.2% as a function of the illumination area in the library. The exploration of deposition parameters for obtaining optimum performance could thus be greatly accelerated. Since the thickness ratio of PbI2 and CH3NH3I can be freely chosen along the shadow mask movement, these experiments show the potential of this system for high-throughput screening of optimum chemical composition in the binary film library and application to halide perovskite solar cell.

Synthesis and Properties of Salicylaldehydes Fine-Tuned by Modular Assembly using "Plug-and-Socket"-Type Extendibility.

A salicylaldehyde derivative bearing four pyridine arms, 3,5-bis(N,N-bis(2-pyridylmethyl)aminomethyl)-2,4-dihydroxybenzaldehyde (Hbpsal) as a "socket", was prepared and used to derive a series of zinc complexes with various extra anions "plugged" into their vacant site. The crystal structure and 1 H NMR spectra were noticeably influenced by the extra anions, allowing fine-tuning of the properties by "plug-and-socket"-type modification. Similar to unsubstituted salicylaldehyde, the zinc complexes reacted with primary amines to afford Schiff-base compounds. Because of the potential chirality around the coordination sphere, reaction with a chiral amine resulted in an equilibrium system between diastereomers, the potential of which as chiral sources tunable by the extra anions is discussed. Some of the complexes were further converted into zinc- or nickel-salphen (=N,N-bis(salicylidene)-1,2-phenylenediamine) complexes. The electrochemical properties of the nickel complex were slightly modified by the extra anions, whereas the photophysical properties of the zinc complex appeared unchanged.

Massive donor transfusion potentially increases recipient mortality after lung transplantation.

OBJECTIVE: Donor blood transfusion has been identified as a potential risk factor for primary graft dysfunction and by extension early mortality. We sought to define the contributing risk of donor transfusion on early mortality for lung transplant. METHODS: Donor and recipient data were abstracted from the Organ Procurement and Transplantation Network database updated through June 30, 2014, which included 86,398 potential donors and 16,255 transplants. Using the United Network for Organ Sharing 4-level designation of transfusion (no blood, 1-5 units, 6-10 units, and >10 units, massive), we analyzed all-cause mortality at 30-days with the use of logistic regression adjusted for confounders (ischemic time, donor age, recipient diagnosis, lung allocation score and recipient age, and recipient body mass index). Secondary analyses assessed 90-day and 1-year mortality and hospital length of stay. RESULTS: Of the 16,255 recipients transplanted, 8835 (54.35%) donors received at least one transfusion. Among those transfused, 1016 (6.25%) received a massive transfusion, defined as >10 units. Those donors with massive transfusion were most commonly young trauma patients. After adjustment for confounding variables, donor massive transfusion was associated significantly with an increased risk in 30-day (P = .03) and 90-day recipient mortality (P = .01) but not 1-year mortality (P = .09). There was no significant difference in recipient length of stay or hospital-free days with respect to donor transfusion. CONCLUSIONS: Massive donor blood transfusion (>10 units) was associated with early recipient mortality after lung transplantation. Conversely, submassive donor transfusion was not associated with increased recipient mortality. The mechanism of increased early mortality in recipients of lungs from massively transfused donors is unclear and needs further study but is consistent with excess mortality seen with primary graft dysfunction in the first 90 days posttransplant.

Adipose Gene Expression Profile Changes With Lung Allograft Reperfusion.

Obesity is a risk factor for primary graft dysfunction (PGD), a form of lung injury resulting from ischemia-reperfusion after lung transplantation, but the impact of ischemia-reperfusion on adipose tissue is unknown. We evaluated differential gene expression in thoracic visceral adipose tissue (VAT) before and after lung reperfusion. Total RNA was isolated from thoracic VAT sampled from six subjects enrolled in the Lung Transplant Body Composition study before and after allograft reperfusion and quantified using the Human Gene 2.0 ST array. Kyoto Encyclopedia of Genes and Genomes pathway analysis revealed enrichment for genes involved in complement and coagulation cascades and Jak-STAT signaling pathways. Overall, 72 genes were upregulated and 56 genes were downregulated in the postreperfusion time compared with baseline. Long pentraxin-3, a gene and plasma protein previously associated with PGD, was the most upregulated gene (19.5-fold increase, p = 0.04). Fibronectin leucine-rich transmembrane protein-3, a gene associated with cell adhesion and receptor signaling, was the most downregulated gene (4.3-fold decrease, p = 0.04). Ischemia-reperfusion has a demonstrable impact on gene expression in visceral adipose tissue in our pilot study of nonobese, non-PGD lung transplant recipients. Future evaluation will focus on differential adipose tissue gene expression and the development of PGD after transplant.

Construct validity of posture as a measure of physical function in elderly individuals: Use of a digitalized inclinometer to assess trunk inclination.

AIM: The first aim of the present study was to determine the construct validity of evaluating posture as a measure of physical function in elderly individuals. The second aim was to determine reference values for sternum inclination in elderly individuals when measured using a digitalized inclinometer. METHODS: We included 834 community-dwelling elderly individuals (350 men and 484 women) in this study. We used a digital inclinometer for measuring sternum inclination angle. We evaluated physical functions, including muscle strength, static balance, gait ability and the functional mobility of our study participants. To assess the construct validity of sternum inclination in elderly people, Pearson's correlation coefficient between sternum inclination and participant characteristics was calculated. To determine a reference value of sternum inclination by age, P for trend was calculated. RESULTS: In men, the sternum inclination angle and sternum inclination index were significantly associated with all anthropometric measures, except static balance. In women, the sternum inclination index was significantly associated with all measures, whereas the sternum inclination angle was associated with all measures except for balance and the Timed Up and Go test. Trend of sternum inclination index by age was significant. CONCLUSIONS: Our results show that the sternum inclination as a measure of physical function in elderly men and women has construct validity. We determined reference values for sternum inclination of which trend by age was considered. Geriatr Gerontol Int 2016; 16: 1068-1073.

Mechanical circulatory support as a bridge to definitive surgical repair after post-myocardial infarct ventricular septal defect.

Ventricular septal defect (VSD) after myocardial infarction (MI) is an uncommon but serious complication. Patients refractory to attempts at medical stabilization and requiring emergency surgery have expected mortality rates greater than 50%. We present three cases of extracorporeal membrane oxygenation bridge to surgical repair in patients with multisystem organ failure who would otherwise require emergent cardiac surgery with associated risk and review the literature for mechanical circulatory support for patients with anterior and posterior post-MI VSD.

Oxidant stress regulatory genetic variation in recipients and donors contributes to risk of primary graft dysfunction after lung transplantation.

OBJECTIVE: Oxidant stress pathway activation during ischemia reperfusion injury may contribute to the development of primary graft dysfunction (PGD) after lung transplantation. We hypothesized that oxidant stress gene variation in recipients and donors is associated with PGD. METHODS: Donors and recipients from the Lung Transplant Outcomes Group (LTOG) cohort were genotyped using the Illumina IBC chip filtered for oxidant stress pathway genes. Single nucleotide polymorphisms (SNPs) grouped into SNP sets based on haplotype blocks within 49 oxidant stress genes selected from gene ontology pathways and literature review were tested for PGD association using a sequencing kernel association test. Analyses were adjusted for clinical confounding variables and population stratification. RESULTS: Three hundred ninety-two donors and 1038 recipients met genetic quality control standards. Thirty percent of patients developed grade 3 PGD within 72 hours. Donor NADPH oxidase 3 (NOX3) was associated with PGD (P = .01) with 5 individual significant loci (P values between .006 and .03). In recipients, variation in glutathione peroxidase (GPX1) and NRF-2 (NFE2L2) was significantly associated with PGD (P = .01 for both). The GPX1 association included 3 individual loci (P values between .006 and .049) and the NFE2L2 association included 2 loci (P = .03 and .05). Significant epistatic effects influencing PGD susceptibility were evident between 3 different donor blocks of NOX3 and recipient NFE2L2 (P = .026, P = .017, and P = .031). CONCLUSIONS: Our study has prioritized GPX1, NOX3, and NFE2L2 genes for future research in PGD pathogenesis, and highlights a donor-recipient interaction of NOX3 and NFE2L2 that increases the risk of PGD.