Ambient Air Pollution and Adverse Waitlist Events Among Lung Transplant Candidates.

BACKGROUND: Air pollution is associated with cardiopulmonary disease and death in the general population. Fine particulate matter (PM2.5) is particularly harmful due to its ability to penetrate into areas of gas exchange within the lungs. Persons with advanced lung disease are believed to be particularly susceptible to PM2.5 exposure, but only a few studies have examined the effect of exposure on this population. Here we investigate the association between PM2.5 exposure and adverse waitlist events among lung transplant (LT) candidates. METHODS: US registry data were used to identify LT candidates listed between January 1, 2010 and December 31, 2016. Annual PM2.5 concentration at year of listing was estimated for each candidate's ZIP Code using National Aeronautics and Space Administration's (NASA) Socioeconomic Data and Applications Center Global Annual PM2.5 Grids. We estimated crude and adjusted hazard ratios for adverse waitlist events, defined as death or removal, using Cox proportional hazards regression. RESULTS: Of the 15 075 included candidates, median age at listing was 60, 43.8% were female individuals, and 81.7% were non-Hispanic White. Median ZIP Code PM2.5 concentration was 9.06 µg/m3. When compared with those living in ZIP Codes with lower PM2.5 exposure (PM2.5 <10.53 µg/m3), candidates in ZIP Codes in the highest quartile of PM2.5 exposure (≥10.53 µg/m3) had 1.14-fold (95% confidence interval, 1.04-1.25) risk of adverse waitlist events. The result remained significant after adjusting for demographics, education, insurance, smoking, lung allocation score, body mass index, and blood type (hazard ratio, 1.17; 95% confidence interval, 1.07-1.29). CONCLUSIONS: Elevated ambient PM2.5 concentration was associated with adverse waitlist events among LT candidates. These findings highlight the impact of air pollution on clinical outcomes in this critically ill population.

Trends in Heart and Lung Transplantation in the United States Across the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has had a variable course across the United States. Understanding its evolving impact on heart and lung transplantation (HT and LT) will help with planning for next phases of this pandemic as well as future ones. METHODS: We used Scientific Registry of Transplant Recipients data from before the pandemic to predict the number of waitlist registrations and transplants expected to occur between March 15, 2020, and December 31, 2020 (if no pandemic had occurred), and compared these expectations to observed rates. The observed era was divided into wave 1 (March 15-May 31), wave 2 (June 1-September 30), and wave 3 (October 1-December 31). We used multilevel Poisson regression to account for center- and state-level COVID-19 incidence. RESULTS: During wave 1, rates of heart registrations and transplants were 28% (incidence rate ratio [IRR]: 0.72 [95% confidence interval (CI), 0.67-0.77]) and 13% (IRR: 0.87 [95% CI, 0.80-0.93]) lower than expected; lung registrations and transplants were 40% (IRR: 0.60 [95% CI, 0.54-0.66]) and 28% (IRR: 0.72 [95% CI, 0.66-0.79]) lower. Decreases were greatest in states with the highest incidence where registrations were 53% (IRR: 0.47 [95% CI, 0.36-0.62]) and 59% (IRR: 0.41 [95% CI, 0.29-0.58]) and transplants were 57% (IRR: 0.43 [95% CI, 0.31-0.60]) and 58% (IRR: 0.42 [95% CI, 0.29-0.62]) lower than expected. Whereas HT largely recovered during waves 2 and 3, LT continued to fall short of expectations through the end of the year. CONCLUSIONS: The COVID-19 pandemic in the US substantially reduced thoracic transplant access. Ongoing evaluation of the risks and benefits of this dramatic practice change is critical to inform clinical decision-making moving forward.

SARS-CoV-2 messenger RNA vaccine antibody response and reactogenicity in heart and lung transplant recipients.

BACKGROUND: While several studies have observed that solid organ transplant recipients experience diminished antibody responses to SARS-CoV-2 mRNA vaccination, data specific to heart and lung transplant (HT/LT) recipients remains sparse. METHODS: US adult HT and LT recipients completed their vaccine series between January 7 and April 10, 2021. Reactogencity and SARS-CoV-2 anti-spike antibody were assessed after a priming dose (D1) and booster dose (D2). Modified Poisson regression with robust variance estimator was used to evaluate associations between participant characteristics and antibody development. RESULTS: Of 134 heart recipients, there were 38% non-responders (D1-/D2-), 48% booster responders (D1-/D2+), and 14% priming dose responders (D1+/D2+). Of 103 lung recipients, 64% were non-responders, 27% were booster responders, and 9% were priming dose responders. Lung recipients were less likely to develop antibodies (p < .001). Priming dose antibody response was associated with younger recipient age (p = .04), transplant-to-vaccination time ≥6 years (p < .01), and lack of anti-metabolite maintenance immunosuppression (p < .001). Pain at injection site was the most commonly reported reaction (85% after D1, 76% after D2). Serious reactions were rare, the most common being fatigue (2% after D1 and 3% after D2). No serious adverse events were reported. CONCLUSIONS: HT and LT recipients experienced diminished antibody response following vaccination; reactogenicity was comparable to that of the general population. LT recipients may exhibit a more impaired antibody response than HT recipients. While current recommendations are to vaccinate eligible candidates and recipients, further studies characterizing the cell-mediated immune response and clinical efficacy of these vaccines in this population are needed.

Characteristics and outcomes of gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices: A systematic review.

Gastrointestinal bleeding (GIB) is a common adverse event after continuous-flow left ventricular assist device (CF-LVAD) implantation. We sought to evaluate patterns of GIB development and related outcomes in CF-LVAD recipients. An electronic search was performed to identify all articles related to GIB in the setting of CF-LVAD implantation. A total of 34 studies involving 1087 patients were pooled for analysis. Mean patient age was 60 years (95% CI 57-64) and 24% (95% CI 21-28%) were female. The mean time from CF-LVAD implantation to the first GIB was 54 days (95% CI 24-84) with 40% (95% CI 34-45%) of patients having multiple episodes of GIB. Anemia was present in 75% (95% CI 41-93%) and the most common etiology of bleeding was arteriovenous malformations (36% [95% CI 24-50%]). The mean duration of follow-up was 14.6 months (95% CI 6.9-22.3) during which the all-cause mortality rate was 21% (95% CI 12-36%) and the mortality rate from GIB was 4% (95% CI 2-9%). Thromboembolic events occurred in 32% (95% CI 22-44%) of patients with an ischemic stroke rate of 16% (95% CI 3-51%) and a pump thrombosis rate of 8% (95%CI 3-22%). Heart transplantation was performed in 31% (95% CI 18-47%) of patients, after which 0% (95% CI 0-10%) experienced recurrent GIB. GIB is a major source of morbidity among CF-LVAD recipients. While death due to GIB is rare, cessation of anticoagulation during treatment increases the risk of subsequent thrombotic events. Heart transplant in these patients appears to reliably resolve the risk of future GIB.

Exploring the cellular uptake and localisation of phosphorescent rhenium fac-tricarbonyl metallosurfactants as a function of lipophilicity.

A systematic study of the cellular uptake of emissive complexes as a function of their lipophilicity is presented. Here a series of amphiphilic rhenium fac-tricarbonyl bisimine complexes bearing axial substituted imidazole or thiazole ligands, [Re(bpy)(CO)3(ImCnHm)]+ {n = 1 m = 3 (1+), n = 4 m = 9 (2+), n = 8 m = 17 (3+), n = 12 m = 25 (4+), n = 16 m = 33 (5+), n = 2 m = 3 (6+); bpy = 2,2'-bipyridine, Im = imidazole} and [Re(bpy)(CO)3(L)]+ {L = 1-mesitylimidazole, ImMes (7+), 4,5-dimethylthiazole, dmt (8+) and 4-methyl-5-thiazole-ethanol, mte (9+)} is reported. The X-ray crystal structures of 2+, 8+ and 9+ confirm the geometry and expected distribution of ligands and indicated that the plane of the imidazole/thiazole ring is approximately parallel to the long axis of the bipy ligand. Luminescence studies revealed excellent properties for their use in cell imaging with visible excitation and broad emission profiles. Their uptake in two distinct species has been examined by fluorescence imaging of the diplomonad fish parasite Spironucleus vortens (S. vortens) and rod-shaped yeast Schizosaccharomyces pombe (Schiz. pombe) as a function of their lipophilicity. The uptake of the complexes was highest for the more lipophilic 2+-5+ in both S. vortens and Schiz. pombe in which the long alkyl chain aids in crossing bilipid membranes. However, the increased lipophilicity of longer chains also resulted in greater toxicity. Localisation over the whole cell varied with differing alkyl chain lengths with complex 2+ preferentially locating to the nucleus of S. vortens, 3+ showing enhanced nuclear partitioning in Schiz. pombe, and 4+ for the remaining cell wall bound in the case of S. vortens. Interestingly, complexes of intermediate lipophilicity such as 7+ and 8+ showed reasonable uptake, proved to be non-toxic, and were capable of crossing exterior cell walls and localising in the organelles of the cells.

Ligand-Tuneable, Red-Emitting Iridium(III) Complexes for Efficient Triplet-Triplet Annihilation Upconversion Performance.

A series of substituted 2-phenylquinoxaline ligands have been explored to finely tune the visible emission properties of a corresponding set of cationic, cyclometallated iridium(III) complexes. The electronic and redox properties of the complexes were investigated through experimental (including time-resolved luminescence and transient absorption spectroscopy) and theoretical methods. The complexes display absorption and phosphorescent emissions in the visible region that are attributed to metal to ligand charge-transfer transitions. The different substitution patterns of the ligands induce variations in these parameters. Time-dependent DFT studies support these assignments and show that there is likely to be a strong spin-forbidden contribution to the visible absorption bands at λ=500-600 nm. Calculations also reliably predict the magnitude and trends in triplet emitting wavelengths for the series of complexes. The complexes were assessed as potential sensitisers in triplet-triplet annihilation upconversion experiments by using 9,10-diphenylanthracene as the acceptor; the methylated variants performed especially well with impressive upconversion quantum yields of up to 39.3 %.

Long-Term Surgical and Speech Outcomes Following Palatoplasty in Patients With Treacher-Collins Syndrome.

BACKGROUND: Cleft palate is present in one-third of patients with Treacher-Collins syndrome. The authors present long-term speech and surgical outcomes of palatoplasty in this challenging patient population. METHODS: A retrospective review of all patients with Treacher-Collins syndrome and cleft palate was conducted over a 35-year period at a single institution. Demographics, palatal, mandibular, airway, and surgical outcomes were recorded. Speech outcomes were assessed by the same craniofacial speech pathologist. RESULTS: Fifty-eight patients with Treacher-Collins syndrome were identified: 43% (25) had a cleft palate and 16% (9) underwent palatoplasty at our institution. Cleft palate types included 1 Veau I, 5 Veau II, 1 Veau III, and 2 Veau IV. Mean age at the time of palatoplasty was 2.0 years (range, 1.0-6.7 years). Three patients had fistulas (33%) and underwent repairs. Pruzansky classifications included 1 type IIA, 6 type IIB, and 2 type III. Seven patients completed long-term speech evaluations. Mean age at follow-up was 13.9 years (range 2.2-24.3 years). Six patients had articulatory velopharyngeal dysfunction related to Treacher-Collins syndrome. Two patients had structural velopharyngeal dysfunction and required further palatal/pharyngeal surgery. CONCLUSIONS: Cleft palate repair in patients with Treacher-Collins syndrome has a high incidence of velopharyngeal dysfunction. However, the majority of patients are articulatory-based in whom further surgery would not provide benefit. Patients with Treacher-Collins syndrome and cleft palate require close evaluation by a speech pathologist as the incidence of articulatory dysfunction is high.

Cyclometalated cinchophen ligands on iridium(III): towards water-soluble complexes with visible luminescence.

Eight cationic heteroleptic iridium(III) complexes, [Ir(epqc)2(N^N)](+), were prepared in high yield from a cyclometalated iridium bridged-chloride dimer bearing two ethyl-2-phenylquinoline-4-carboxylate (epqc) ligands. Two X-ray crystallographic studies were undertaken on selected complexes (where the ancillary ligand N^N = 4,4'-dimethyl-2,2'-bipyridine and 4,7-diphenyl-1,10-phenanthroline) each confirming the proposed formulations, showing an octahedral coordination at Ir(III). In general, the complexes are luminescent (620-630 nm) with moderately long lifetimes indicative of phosphorescence. Hydrolysis of the ethyl ester moieties of the epqc ligands gave the analogous cinchophen-based complexes, which were water-soluble and visibly luminescent (568-631 nm). The spectroscopic and redox characterisation of the complexes was complemented by DFT and TD-DFT calculations, supporting the assignment of dominant (3)MLCT to the emissive character.

Using substituted cyclometalated quinoxaline ligands to finely tune the luminescence properties of iridium(III) complexes.

The syntheses of five new heteroleptic iridium complexes [Ir(L(1-4))(2)(Diobpy)]PF(6) (where Diobpy = 4,4'-dioctylamido-2,2'-bipyridine) and [Ir(L(3))(2)(bpy)]PF(6) (where L = para-substituted 2,3-diphenylquinoxaline cyclometalating ligands; bpy = 2,2'-bipyridine) are described. The structures of [Ir(L(3))(2)(Diobpy)]PF(6) and [Ir(L(3))(2)(bpy)]PF(6) show that the complexes each adopt a distorted octahedral geometry with the expected trans-N, cis-C arrangement of the cyclometalated ligands. Electrochemical studies confirmed subtle perturbation of the Ir(III/IV) redox couple as a function of ligand variation. Luminescence studies showed the significant contribution of (3)MLCT to the phosphorescent character with predictable and modestly tunable emission wavelengths between 618 and 636 nm. DFT studies provided approximate qualitative descriptions of the HOMO {located over the Ir(5d) center (11-42%) and the phenylquinoxaline ligand (54-87%)} and LUMO {located over the ancillary bipyridine ligands (ca. 93%)} energy levels of the five complexes, confirming significant MLCT character. TD-DFT calculations indicate that UV-vis absorption and subsequent emission has substantial MLCT character, mixed with LLCT. Predicted absorption and emission wavelengths are in good general agreement with the UV-vis and luminescence experiments.

Enhanced photooxidation sensitizers: the first examples of cyclometalated pyrene complexes of iridium(III).

The iridium(III) cyclometalation of alkylated pyrene-benzimidazole ligands proceeds in an unprecedented manner. The resultant complexes display remarkably enhanced photooxidation capabilities using 1,5-dihydroxynaphthalene as a substrate.

Luminescent rhenium fac-tricarbonyl-containing complexes of androgenic oxo-steroids.

A new route to luminescent derivatives of androgenic steroids containing a ketone group in the 3- or 17-position has been developed. Reaction with the fac-Re(CO)(3)Cl complex of 3,3'-diamino-2,2'-bipyridine (complex 1) afforded a cyclic aminal product with different steroids. The rate of reaction and yield varies according to the conjugation or steric hindrance around the ketone group.

Water-soluble, luminescent iridium(III)-ytterbium(III) complexes using dipyrido[3,2-a:2',3'-c]phenazine derivatives as bridging units.

Amino-substituted dipyrido[3,2-a:2',3'-c]phenazine (L(1)) and dimethyl-dipyrido[3,2-a:2',3'-c]phenazine (L(2)) have been investigated as: (i) chromophores in cyclen-based ligands for lanthanide(III) ions; (II) ancillary co-ligands in cyclometalated iridium(III) complexes; (III) bridging, linker units in covalently linked, water-soluble bimetallic lanthanide(III) iridium(III) hybrid complexes. The dipyrido[3,2-a:2',3'-c]phenazine (dppz) derivatives can act as sensitising chromophores (λ(ex) 400 nm) for Yb(III), resulting in characteristic near-IR emission at 950-1050 nm. The incorporation of dppz-type ligands into cyclometalated Ir(III) complexes of the general type [Ir(epqc)(2)(L(n))](PF(6)) (where epqc = ethylphenylquinoline carboxylate) gave luminescent species with solvent-sensitive emission properties. Steady state and time-resolved luminescence measurements on the water-soluble d-f hybrid species showed that Yb(III) can be sensitised using visible light.

Evaluation of a fluorescent derivative of AMD3100 and its interaction with the CXCR4 chemokine receptor.

AMD3100 is a potent and selective antagonist of the CXCR4 receptor; it has been shown to block the route of entry of HIV into host T-cells. This compound and its analogues have since been found to act as haematopoietic stem cell mobilisation agents and, more recently, as anti-cancer agents. Here, we have examined a fluorescent derivative of AMD3100, L(1), which offered the potential to assess the behaviour of AMD3100 at the cell surface by using optical imaging modalities. The binuclear Zn(II) , Cu(II) and Ni(II) complexes of L(1) have also been investigated as these metals have been previously shown to enhance the binding properties of AMD3100. Furthermore, Zn(II) and Cu(II) are known to enhance and quench, respectively, the fluorescence of similar anthracenyl-based ligands. Whilst L(1) demonstrates an ability to inhibit the binding of the anti-CXCR4 monoclonal antibody 12G5 (IC(50) =0.25-0.9 µM), the incorporation of an anthracenyl moiety resulted in a significantly reduced affinity for CXCR4 compared to AMD3100 (IC(50) =10 nM). We observed no significant increase in fluorescence intensity following incubation with murine pre-B cells overexpressing CXCR4 compared to a control cell line. This limits the usefulness of L(1) as a fluorescent imaging probe. Interestingly, the Zn(II) complex, which carries an overall +4 charge, revealed marginally higher specificity and reduced toxicity in vitro compared to the free ligand, albeit with reduced affinity for CXCR4 (IC(50) =1.8-5 µM). We suggest that the incorporation of an anthracenyl group contributes to the lipophilic character of the free ligand, thereby resulting in transport across the plasma membrane. This effect is seemingly diminished when the ligand is complexed to charged metal ions.

Hypothyroidism in preterm infants following normal screening.

Congenital hypothyroidism is screened for in the UK using blood spot thyroid-stimulating hormone (TSH) screening at 5-8 d of age. Although standards are set by the UK Newborn Screening Programme Centre, there are variations in TSH cut-offs used. The introduction of repeat screening of preterm babies at 36 weeks' gestational age in 2005 was controversial in its utility and timing. Two cases of preterm babies are presented, who had normal blood spot TSH values on the first test and who became screen positive when re-tested at term. The first with Trisomy 21 was born at 29 + 6 weeks with an initial blood spot TSH of 3.3 mU/L rising to 263 mU/L at term-corrected gestational age (plasma TSH 476.5 mU/L). The second was born at 24 + 6 weeks' gestational age and on day 7, the heel prick blood spot TSH was <2 mU/L, rising to 6.4 mU/L at 36 weeks corrected gestational age. After a barium enema, the plasma TSH increased to 66.6 mU/L with a free thyroxine of 7.6 pmol/L at day 101. Both cases were treated with thyroxine until death due to complications of prematurity. These cases illustrate the difficulties in screening for congenital hypothyroidism in preterm infants, due to the immaturity of the hypothalamo-pituitary-thyroid axis, and the effect of intercurrent illness and drugs on thyroid function. Despite a reassuring published review of 2200 preterm infants, these cases suggest that it may be unwise not to re-screen ex-preterm infants for congenital hypothyroidism at term.

The co-ordination chemistry of tris(3,5-dimethylpyrazolyl)methane manganese carbonyl complexes: synthetic, electrochemical and DFT studies.

The tricarbonyl [Mn(CO)(3){HC(pz')(3)}][PF(6)] 1(+)[PF(6)](-) (pz' = 3,5-dimethylpyrazolyl) reacts with a range of P-, N- and C-donor ligands, L, in the presence of trimethylamine oxide to give [Mn(CO)(2)L{HC(pz')(3)}](+) {L = PEt(3)3(+), P(OEt)(3)4(+), P(OCH(2))(3)CEt 5(+), py 6(+), MeCN 7(+), CNBu(t)8(+) and CNXyl 9(+)}. The complex [Mn(CO)(2)(PMe(3)){HC(pz')(3)}](+)2(+) is formed by reaction of 7(+) with PMe(3). Complexes 2(+) and 6(+) were structurally characterised by X-ray diffraction methods. Reaction of 7(+) with half a molar equivalent of 4,4'-bipyridine gives a purple compound assumed to be the bridged dimer [{HC(pz')(3)}Mn(CO)(2)(µ-4,4'-bipy)Mn(CO)(2){HC(pz')(3)}](2+)10(2+). The relative electron donating ability of HC(pz')(3) has been established by comparison with the cyclopentadienyl and tris(pyrazolyl)borate analogues. Cyclic voltammetry shows that each of the complexes undergoes an irreversible oxidation. The correlation between the average carbonyl stretching frequency and the oxidation potential for complexes of P- and C-donor ligands is coincident with the correlation observed for [Mn(CO)(3-m)L(m)(η-C(5)H(5-n)Me(n))]. The data for complexes of N-donor ligands, however, are not coincident due to the presence of a node (and phase change) between the metal and the N-donor in the HOMO of the complex as suggested by preliminary DFT calculations.

New 2,3-disubstituted-5-hydroxyquinoxaline ligands and their coordination chemistry with cyclometallated iridium(III): syntheses, structures and tunable electronic properties.

A new series of para-substituted 2,3-diphenyl-5-hydroxyquinoxaline ligands (LH(n)) were synthesised and characterised. These ligands were prepared in high yield via a two-step synthetic method. Four novel heteroleptic iridium(III) complexes were correspondingly prepared in high yield giving [Ir(ppy)(2)(L(n))]. Two X-ray crystallographic studies were undertaken on LH(3) and [Ir(ppy)(2)(L(2))] with each confirming the proposed formulations, with the complex showing the O,N-coordination mode of the quinoxalinato ligand. Density functional theoretical calculations were performed, firstly to compare the coordinated quinoxalinato system with the related quinolinato analogue, and secondly to probe the influence of the variation in para-substitution on the ancillary ligand. The calculations suggest that for either the quinoline or quinoxaline systems ligand-centred character appears to dominate the HOMO and LUMOs. Experimental electrochemical and spectroscopic characterisation showed that the subtle variations in absorption and emission wavelengths are probably due to ligand-dominated transitions that are influenced by the electronic nature of the para-substituted phenyl units in coordinated L(n).

Rhodium and iridium complexes of an asymmetric bicyclic NHC bearing secondary pyridyl donors.

A tridentate N^C^N ligand, 1, containing a bicyclic central NHC ring and two flanking pyridyl groups has been coordinated to Rh(I) and Ir(I) to give complexes of the type [M(κ(3)-1)(1,5-COD)]PF(6) (2 M = Rh; 3 M = Ir). In contrast to our earlier study with this ligand, the complexes have been shown to approximate to a trigonal bipyramidal geometry in the solid state and exist as an isomeric mixture in solution as determined by (1)H and (13)C NMR spectroscopy. Electrochemical studies revealed that both complexes undergo a 1-electron oxidation with the potential of the Rh complex 0.1 V less than that of the Ir complex in CH(2)Cl(2). Preliminary DFT studies confirm the lowest energy conformations as those seen in the solid state and show the location and energy of the HOMOs to be identical in 2 and 3. Partial charge analysis shows a greater positive charge on the Ir in 3 compared to the Rh in 2. Some preliminary studies of hydrogenation reactivity have shown the complexes to be efficient for both transfer and direct hydrogenation of prochiral ketones and alkenes at moderate temperatures but without any discernible enantioselectivity.