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Purposevon Willebrand factors (vWFs), hemostatic factors, are produced as large multimers and are shear stress-dependently cleaved to become the appropriate size. A reduction in vWF large multimers develops in various conditions including the use of extracorporeal life support, which can cause excessive-high shear stress in the blood flow and result in hemostatic disorders. The objective of this prospective study was to investigate the impact of venovenous extracorporeal membrane oxygenation (VV ECMO) use on the status of vWF large multimers and hemostatic disorders during single lung transplantation (SLT).MethodsWe prospectively enrolled 12 patients who underwent SLT at our center. Among them, seven patients were supported by VV ECMO intraoperatively (ECMO group) and the remaining five patients underwent SLT without ECMO support (control group). The vWF large multimer index (%) was defined as the ratio of the large multimer proportion in total vWF (vWF large multimer ratio) derived from a patient’s plasma to that from the standard human plasma.ResultsThe vWF large multimer index at the end of the surgery was significantly lower in the ECMO group than in the control group (112.6% vs. 75.8%, respectively;p< 0.05). The intraoperative blood loss and the amounts of intraoperative transfusion products in the ECMO group tended to be greater than those in the control group; however, the differences were not significant.ConclusionDuring SLT, the intraoperative use of VV ECMO caused a decrease in the vWF large multimer index. However, the vWF large multimer index was maintained at > 75% in average at the end of SLT, which did not affect the bleeding complications.

Background: Indium lung is characterized by interstitial pneumonia and/or emphysema, which occurs in indium-tin oxide (ITO) workers. Indium lung is now known to progress after stopping exposure to ITO, but the long-term influences of ITO remain unclear. Case presentation: A 47-year-old, male never-smoker, who was engaged in an ITO manufacturing process for 8 years. Emphysema was indicated by a medical check-up for ex-ITO workers, and the subject was diagnosed with indium lung. He underwent partial lung resections for pneumothorax twice, and obstructive pulmonary dysfunction progressed over the years. The subject underwent right single lung transplantation 20 years after ITO exposure. Pathologically, his lung showed severe distal acinar emphysema and honeycomb change. Fibrosis and destruction of the lung tissue significantly progressed compared to the previous partial resections. Scanning electron microscopy combined with energy dispersive spectroscopy revealed that the deposited particles contained indium and tin. After transplantation, his respiratory function was improved. Conclusions: In this case, ITO resided in the lung tissue for 20 years, and lung tissue destruction continued to progress. Careful medical follow-up is recommended for ITO workers even if they are asymptomatic.

Background As lung transplantation (LTX) is a valuable treatment procedure for end-stage pulmonary disease, delayed referral to a transplant center should be avoided. We aimed to conduct a single-center analysis of the survival time after listing for LTX and waitlist mortality in each disease category in a Japanese population. Methods We included patients listed for LTX at Tohoku University Hospital from January 2007 to December 2020 who were followed up until March 2021. Pulmonary disease was categorized into the Obstructive, Vascular, Suppurative, Fibrosis, and Allogeneic groups. Risk factors for waitlist mortality were assessed using a Cox proportional hazards model. The Kaplan–Meier method was used to model time to death. Results We included 269 LTX candidates. Of those, 100, 72, and 97 patients were transplanted, waiting, and dead, respectively. The median time to LTX and time to death were 796 days (interquartile range [IQR] 579–1056) and 323 days (IQR 129–528), respectively. The Fibrosis group showed the highest mortality (50.9%; p Conclusions In Japan, the waiting time is extremely long and candidates with Fibrosis have high mortality. There is a need to document outcomes based on the underlying disease for listed LTX candidates to help determine the optimal timing for listing patients based on the estimated local waiting time.

Background Bronchopulmonary dysplasia (BPD) is a chronic respiratory disease that occurs in premature infants and the prognosis is variable depending on the comorbidities including fibrosis, emphysema, or pulmonary hypertension (PH). We present a case of a 9-year-old girl who developed PH associated with severe BPD (BPD-PH) and underwent bilateral lung transplantation (BLTx). Case description A 9-year-old girl was admitted to our department to undergo BLTx. She was born at 23 weeks and 4 days gestation with a weight of 507 g. She received ventilation for the first 2 months and required further respiratory care due to repetitive, severe respiratory infections. She was diagnosed with BPD-PH at 6 months of age and oral administration of pulmonary vasodilators were initiated. She was registered as a lung transplant candidate at 4 years of age after the life-threatening exacerbation. Chest computed tomography (CT) revealed severe lung conditions with ground-glass opacities and emphysematous low-density areas in the upper and lower lobes. BLTx from a brain-dead male donor was performed. The pathological findings of her resected lung revealed saccular, hypoplastic lung with alveolar repair/regeneration, and medial hypertrophy and muscularization of peripheral arteries. The postoperative course was mostly uneventful. She was free from oxygen administration and showed no signs of PH after 6 months of the surgery. Conclusion This is the first case report of BLTx in a pediatric, irreversible BPD-PH patient with detailed pathohistological findings and clinical examination. Lung transplantation is one of the treatment options for severe BPD-PH.

Objectives One of the serious problems after lung transplantation is chronic lung allograft dysfunction (CLAD). Most CLAD patients pathologically characterized by obliterative bronchiolitis (OB). Cytotoxic T-lymphocyte-associated antigen 4 (CTLA4)-Ig is a combination protein of the Fc fragment of human IgG1 linked to the extracellular domain of CTLA4. The aim of the study was to examine the effect of CTLA4-Ig therapy on OB using a mouse intrapulmonary tracheal transplantation (IPTT) model. Methods IPTT was performed between BALB/c (donor) and C57BL/6 (recipient) mice. Abatacept, which is a commercially available form of CTLA4-Ig, was intraperitoneally injected in recipient mice immediately after surgery, on days 7, 14, and 21. The mice in the control group received human IgG. Results We performed semi-quantitative analysis of graft luminal obliteration at post-transplant day 28. We calculated the obliteration ratio of the lumen of the transplanted trachea in each case. The obliteration ratio was significantly lower in the CTLA4-Ig group than that in the control group (91.2 ± 2.1% vs. 47.8 ± 7.9%, p = 0.0008). Immunofluorescent staining revealed significantly decreased lymphoid neogenesis in the lung. Conclusions CTLA4-Ig therapy attenuated tracheal obliteration with fibrous tissue in the mouse IPTT model. The attenuation of fibrous obliteration was correlated with the inhibition of lymphoid neogenesis.

OBJECTIVES The objective of the present study was to examine the effect of venovenous (VV) extracorporeal membrane oxygenation (ECMO) use on the haemodynamics during single lung transplantation (SLT) and postoperative course. METHODS Forty-seven patients who underwent SLT for end-stage lung diseases in our lung transplant centre between January 2010 and December 2019 were included in this study. The recipients were divided into 3 groups according to the type of intraoperative ECMO. No type of ECMO was intra-operatively used in the patients of the no use of ECMO (NO ECMO) group. The patients in the venoarterial (VA) and VV ECMO groups were put on VA and VV ECMO during the surgery, respectively. The data were compared among the 3 groups. RESULTS There were 13 SLT cases in the NO ECMO group, 23 SLT cases in the VA ECMO group and 11 SLT cases in the VV ECMO group. Re-exploration for bleeding was performed in 3 (13.0%) recipients in the VA ECMO group. No recipients required re-exploration in the other groups. In the NO ECMO group, systolic pulmonary arterial pressure (PAP) was significantly elevated during the main pulmonary artery clamp on the SLT side and it was decreased in the VA ECMO group because of the bypass flow. Interestingly, systolic PAP was significantly decreased in the VV ECMO group as well. CONCLUSIONS VV ECMO decreases the PAP during SLT, which could be a choice for extracorporeal life support during lung transplant surgery for patients, even those with pulmonary hypertension.

To date, reports addressing the antibody response following mRNA SARS-CoV-2 vaccination in lung transplant (LTX) recipients are limited. Thus, the aim of this clinical study was to investigate the efficacy and safety of the vaccines in LTX recipients compared to controls.An open-label, nonrandomized prospective study was conducted at Tohoku University Hospital. LTX recipients and controls who received either the BNT162b2 vaccine or the mRNA-1273 vaccine were recruited, and SARS-CoV-2 IgG was measured before and after vaccination. The adverse events were reviewed. Predictors of negative serology after vaccination were evaluated with logistic regression.Forty-one LTX recipients and 24 controls were analyzed. Although all controls had a positive antibody response to a SARS-CoV-2 mRNA vaccine, antibody response was found in 24.4% of LTX recipients (p .0001). The amount of SARS-CoV-2 IgG following the 2nd dose significantly climbed to 6557 AU/mL in controls, whereas the increase in IgG in LTX recipients was 8.3 AU/mL (p .0001). Fewer LTX recipients developed systemic fever than controls (p .0001) despite equivalent overall adverse event percentages in both groups. A higher plasma concentration of mycophenolate was a significant predictor of negative serology (p = .032).An impaired antibody response to mRNA vaccines was significantly found in LTX recipients compared to controls and was associated with the plasma concentration of mycophenolate. While repeating mRNA vaccination may be one of the strategies to improve antibody response given the safety of the vaccines, emerging data on humoral immune responses based on immunosuppression regimens in LTX recipients should be studied (jRCT1021210009).

Background Anti-human leukocyte antigen (HLA) antibody testing was approved by the Japanese government in 2018. As such, there was no longitudinal data regarding the HLA-sensitization of lung transplant (LTX) patients in Japan. We therefore set out to measure anti-HLA antibodies from all our LTX patients during their annual follow-up to characterize the sensitization status in the Japanese population. Methods The cross-sectional study was conducted for consecutive LTX recipients who underwent transplantation from January 2000 to January 2020 at Tohoku University Hospital (TUH). The serum from the recipients was screened for anti-HLA antibody with the panel-reactive assay (PRA) and the donor-specific antibodies (DSA). Results Sensitization was reviewed in 93 LTX recipients, showing 23 positive (24.7%) and 70 negative (75.3%) PRA. More sensitized recipients were found in recent transplantations (60.9% (14/23), ≤5 years post LTX) than in older transplantations (17.4% (4/23), 5–10 years or 21.7% (5/23), ≥10 years post LTX) (p = 0.04). Even fewer recipients had DSA (5.4%, 5/93), among whom 4/5 (80%) were recently transplanted. Conclusion The rate of PRA positive LTX recipients in our population was lower compared with those in previous reports from US and Europe. More sensitized LTRs were found in recent transplantations than the older cohort, and DSA was identified primarily in the recent recipients. Due to several limitations, it is still unclear whether the sensitization would be related the development of CLAD or survival, yet this study would be fundamental to the future anti-HLA body study in Japanese population.

Owing to advanced respiratory disease among lung transplant (LTX) candidates, some could develop nontuberculous mycobacteria-pulmonary disease (NTM-PD). However, the appropriate management of NTM-PD found at the time of LTX is not clear. We, therefore, established a management protocol for peri-transplant NTM-PD, defined by the presence of granulomas and mycobacteriologic evidence of NTM in the explant. Between 2013 and 2014, 230 LTX recipients (LTRs) who survived >30 days post LTX were followed up to 2017. Of these, 7.8% (18/230) LTRs were diagnosed with peri-transplant NTM-PD and treated with Azithromycin 250mg/day, Ethambutol 15mg/kg/day and Moxifloxacin 400mg/day for 12 months according to the protocol. There was no significant difference in the incidence of post-transplant NTM-PD (p=0.362), chronic lung allograft dysfunction (p=0.530) and mortality (p=0.152) between LTRs with/without peri-transplant NTM-PD as long as being managed with anti-mycobacterial drugs during the early phase of post-transplantation. Patients with NTM-PD other than Mycobacterium abscessus diagnosed at the time of LTX were safely managed and did not experience significantly higher rates of post-transplant NTM-PD.

Lung transplant recipients are at risk of developing many kinds of lung infection, such as community-acquired, nosocomial, opportunistic, and endemic. Here, we report a young lung transplant recipient who developed blastomycosis, which had most likely occurred following eculizumab treatment for atypical hemolytic uremia syndrome. We hypothesize that the agent interfering with C5 would influence the immune response against Blastomyces species. Although eculizumab has opened a new era for treatment of atypical hemolytic uremia syndrome and has led to the understanding that complementmediated pathology is needed, the risk of potentially fatal infections by blocking the complement pathway has not been fully elucidated. Careful follow-up and frequent tests to look for infections are needed after using this monoclonal antibody.

BACKGROUND: Drug-resistant tuberculosis (TB) poses a major public health concern worldwide. However, no studies have addressed risk factors for drug resistance in Ontario, which has its own unique profile of immigrants. We evaluated demographic and clinical risk factors for drug-resistant TB among patients treated at West Park Healthcare Centre, located in Toronto, Ontario (Canada). METHODS: All patients who were diagnosed with TB and treated at West Park Healthcare Centre between January 2010 and December 2016 were included in this retrospective cohort study. Characteristics of patients with isoniazid mono-resistant (INH-R) TB and multidrug resistant (MDR) TB were compared to patients with drug-susceptible TB with bivariate and multivariable logistic regression. RESULTS: Risk factors for INH-R TB included younger age (younger than 35 years), prior TB treatment, non-diabetic and birth in a non-South-East Asian country, but only the latter two factors were significant in multivariable analysis. On the other hand, we found younger generation (younger than 65 years), birth in European region, recent arrival to Canada (fewer than 120 months), prior treatment and human immunodeficiency virus (HIV) infection were associated with MDR-TB, among which younger age (younger than 35 years), more recent immigration (fewer than 24 months), prior treatment and HIV infection were significant in multivariable analysis. CONCLUSION: These findings may be of use to TB clinicians in the province by informing the initial empiric antibiotic regimen prescribed while awaiting phenotypic drug susceptibility testing and assisting in decisions regarding whether to request rapid molecular drug susceptibility testing.

The patient was a 41-year-old man. He was diagnosed with pleurisy and came to our hospital. The pleural effusion and pleurisy remained even after administration of sufficient doses of antibiotics. A thorough examination revealed an anterior mediastinal tumor. Six months later, pericarditis also developed. Autoimmune diseases, infections, and malignant diseases were suspected, but a definitive diagnosis could not be made. In order to confirm the diagnosis, anterior mediastinal tumor resection and pleural biopsy were performed. The anterior mediastinal tumor was diagnosed as cholesterin granuloma pathollogically. Cholesterin granuloma is a granuloma formed by deposition of cholesterin crystals and cholesterin granuloma occurring in the mediastinum is extremely rare.

BackgroundWhile lung transplant (LTX) can be an effective therapy to provide the survival benefit in selected populations, post-transplant outcome in LTX recipients with bronchiectasis other than cystic fibrosis (CF) has been less studied.Pseudomonas aeruginosa, often associated with exacerbations in bronchiectasis, is the most common micro-organism isolated from LTX recipients. We aimed to see the outcomes of patients with bronchiectasis other than CF after LTX and seek the risk factors associated with pre- and post-transplantPseudomonasstatus.MethodsPatients who underwent LTX at Tohoku University Hospital between January 2000 and December 2020 were consecutively included into the retrospective cohort study. Pre- and post-transplant prevalence ofPseudomonascolonization between bronchiectasis and other diseases was reviewed. Post-transplant outcomes (mortality and the development of chronic lung allograft dysfunction (CLAD)) were assessed using a Cox proportional hazards and time-to-event outcomes were estimated using the Kaplan–Meier method.ResultsLTX recipients with bronchiectasis experienced a high rate of pre- and post-transplantPseudomonascolonization compared to other diseases with statistical significance (p p p = 0.522), and the bronchiectasis was not a trigger for death (HR 1.62, 95% CI 0.63–4.19). On the other hand, the chance of CLAD onset in bronchiectasis was comparable to non-bronchiectasis (Log-rankp = 0.221), and bronchiectasis was not a predictor of the development of CLAD (HR 1.88, 95% CI 0.65–5.40).ConclusionsDespite high prevalence of pre- and post-transplantPseudomonascolonization, the outcome in LTX recipients with bronchiectasis other than CF was comparable to those without bronchiectasis.

Mycobacterium xenopi pulmonary disease (Mxe-PD) is common among nontuberculous mycobacterial infections in Europe and Canada. Associations between radiological pattern and clinical features and outcomes are inadequately studied in Mxe-PD. We sought to investigate clinical characteristics and outcomes according to the dominant radiological pattern among patients with Mxe-PD. We retrospectively studied patients with Mxe-PD seen in our clinic, categorizing their predominant CT pattern as nodular bronchiectasis, fibrocavitary, or unclassifiable, and compared clinical characteristics, treatment, and outcomes between radiologic groups. Of 94 patients with Mxe-PD, CT patterns comprised nodular bronchiectasis (40/94, 42.6%), fibrocavitary (37/94, 39.4%), and unclassifiable (17/94, 18.1%). Compared with fibrocavitation, patients with nodular bronchiectasis were female dominant, less often had COPD, less often had AFB smear-positive sputum, and more frequently had co-isolation of Pseudomonas. Patients with nodular bronchiectasis were less often treated (65% versus 91.9%) and when treated, they received fewer anti-mycobacterial drugs (on average 3 versus 4). Outcomes did not differ significantly by radiological pattern. Nodular bronchiectasis was common among Mxe-PD patients in our clinic. Compared with fibrocavitary disease, patients with nodular bronchiectasis had features suggestive of milder disease and were less often treated. Among treated patients, outcomes did not differ by radiologic pattern.

Background Lung transplant (LTX) recipients are at risk miscellaneous infections, among whom the clinical significance of nontuberculous mycobacteria (NTM) is increasingly recognized. Despite anti-mycobacterial therapy becoming standardized worldwide, there is a lack of data on treatment outcomes in LTX recipients who develop NTM-pulmonary disease (PD). We aimed to review the treatment outcomes of NTM-PD among LTX recipients in our center. Methods Patients who underwent LTX from January 2013 to December 2014 were consecutively enrolled in the retrospective cohort, with follow-up of data retrieved to December 2017. Clinical and radiological improvement and culture conversion after anti-mycobacterial therapy were reviewed in those who developed post-transplant NTM-PD. Results Sixteen out of 230 LTX recipients developed post-transplant NTM-PD. Ten out of 16 patients with post-transplant NTM-PD were treated with macrolide-containing anti-mycobacterial therapy, leading to clinical improvement in 5/10 (50%), radiological improvement in 5/10 (50%), and culture conversion in 6/10 (60%) patients. Conclusion Anti-mycobacterial therapy may relieve pulmonary symptoms and reduce microbial load among individuals with post-transplant NTM-PD.

The incidence of postoperative pulmonary torsion is not frequent but it has a high mortality rate once it occurs, and prompt diagnosis and treatment are required. From past reports, it is considered effective to point out disruption of pulmonary blood flow by contrast-enhanced computed tomography (CT) examination for diagnosis. However, the comparison of pre- and post-operative plain CT images is considered to be useful in diagnosing lung torsion, and postoperative CT lung window setting sagittal images were examined in three cases of postoperative lung torsion. Results indicate that pulmonary torsion of the middle lobe after right lower lobectomy and the middle lobe after right upper lobectomy can be diagnosed by the present method.

Background Lung transplant (LTX) can provide a survival benefit and improve physical function for selected patients with advanced pulmonary disease. Sarcopenia is a systemic muscle-failure that can be found in a variety of life stages and disabilities. In this study, we follow the evolution of each variable defined in sarcopenia and the outcomes in LTX recipients with post-transplant sarcopenia. Methods Patients who underwent LTX at Tohoku University Hospital between 2013 and 2018 were consecutively included in the retrospective cohort study, with follow-up to 2019. Sarcopenia was defined by low muscle mass (the cross-sectional area (CSA) of erector spinae muscle (ESM) in thoracic CT with a threshold 2/m2) and either low muscle strength (hand-grip with a threshold of Results Fifty-five recipients were included into the study, of whom 19 patients were defined as sarcopenic and 36 as non-sarcopenic. The muscle mass improved after transplant in both sarcopenic and non-sarcopenic individuals: the median ESM-CSA enlarged from 17.25 cm2/m2 in 2 months post-LTX to 18.55 cm2/m2 in 12 months (p 2/m2 in 36 months (p 2/m2 in 2 months to 16.31 cm2/m2 in 12 months (p 2/m2 in 36 months (p p p = 0.951 in 36 months). Accordingly, muscle strength and physical performance in both groups improved over time. No difference in survival was seen in both groups (Log-rank p = 0.096), and sarcopenia was not associated with an overall hazard of death (p = 0.147). There was no difference in the cumulative incidence of chronic lung allograft dysfunction between patients with or without sarcopenia (Log-rank p = 0.529). Conclusions Even patients with post-transplant sarcopenia have a chance to recover physical function to levels close to those without sarcopenia several years post LTX.

Caveolins are integral membrane proteins that are the principal structural component of caveolae. Newly synthesized caveolin self-associates into oligomers that further assemble into higher-order structures. Imaging fluorescently labeled caveolin at the plasma membrane with total internal reflection fluorescence (TIRF) microscopy reveals a spatially heterogeneous distribution with aggregates of various sizes. In this chapter, we present a set of image-processing tools to quantify the spatial organization and mobility of caveolin aggregates seen in TIRF images. We apply a spot detection algorithm to identify punctate features on multiple length scales, and computationally estimate the area and integrated fluorescence signal of each detected feature. We then partition the original image into two disjoint sets: one containing pixels within punctae, and the other containing pixels on the rest of the plasma membrane. From these partitions, we estimate the relative fraction of caveolin that is punctate versus diffuse. Finally, we analyze the mobility of caveolin aggregates by tracking them and classify individual trajectories as diffusive or subdiffusive using a moment scaling spectrum analysis. Together, these analyses capture multiple facets of caveolin organization and dynamics. To demonstrate their utility, we quantify the distribution of fluorescent Caveolin 1 stably transfected in HeLa cells. We analyze cells at baseline and after being exposed to the anesthetic Dibucaine that is known to scramble membrane phospholipids. Our analysis shows how this perturbation dramatically alters caveolin aggregation and mobility.

Background The therapeutic drug monitoring of mycophenolic acid (MPA) has been investigated for renal and heart transplantations; however, its usefulness in lung transplantation is unclear. Methods The MPA area under the plasma concentration-time curve (AUC) was calculated in 59 adult lung transplant recipients. The MPA AUC0-12 s were compared among the three groups determined by the presence of adverse events (no events, infection, and chronic lung allograft dysfunction [CLAD]). Next, MPA AUC0-12 thresholds for the adverse events were identified by receiver operating characteristic analysis. Cumulative occurrence rate of the adverse events was compared between two groups (adequate and inadequate groups) according to the thresholds. Results The MPA AUC0-12 s in the no event, infection, and CLAD groups were 30.3 ± 6.5, 36.8 ± 10.7, and 20.6 ± 9.6 µg·h/mL, respectively (P = .0027), while the tacrolimus trough levels were similarly controlled in the groups. The thresholds of MPA AUC0-12 for the occurrence of infection and CLAD were 40.5 and 22.8 µg·h/mL, respectively. The cumulative occurrence rate of adverse events of adequate group (15.3%) was significantly lower than that of inadequate group (56.0%) (P = .0050). Conclusions The MPA AUC0-12 may affect the occurrence of adverse events in lung transplant recipients.

Caveolins are integral membrane proteins that are the principal structural component of caveolae. Newly synthesized caveolin self-associates into oligomers that further assemble into higher-order structures. Imaging fluorescently labeled caveolin at the plasma membrane with total internal reflection fluorescence (TIRF) microscopy reveals a spatially heterogeneous distribution with aggregates of various sizes. In this chapter, we present a set of image-processing tools to quantify the spatial organization and mobility of caveolin aggregates seen in TIRF images. We apply a spot detection algorithm to identify punctate features on multiple length scales, and computationally estimate the area and integrated fluorescence signal of each detected feature. We then partition the original image into two disjoint sets: one containing pixels within punctae, and the other containing pixels on the rest of the plasma membrane. From these partitions, we estimate the relative fraction of caveolin that is punctate versus diffuse. Finally, we analyze the mobility of caveolin aggregates by tracking them and classify individual trajectories as diffusive or subdiffusive using a moment scaling spectrum analysis. Together, these analyses capture multiple facets of caveolin organization and dynamics. To demonstrate their utility, we quantify the distribution of fluorescent Caveolin 1 stably transfected in HeLa cells. We analyze cells at baseline and after being exposed to the anesthetic Dibucaine that is known to scramble membrane phospholipids. Our analysis shows how this perturbation dramatically alters caveolin aggregation and mobility.

Membrane curvature is a property of biological membranes essential for organelle morphology and the formation of tubulovesicular carriers. Curvature generation is influenced by the lipid composition of the membrane and protein-mediated processes. Lipids with small headgroups, such as phosphatidic acid, are conical and impose negative curvature on a monolayer. Conversely, lipids with large headgroups relative to the hydrophobic tail(s), such as lysophosphatidylcholine, have an inverted conical shape and impose positive curvature. Due to its abundance and high rates of spontaneous flip-flop between membrane leaflets cholesterol is proposed to buffer the formation of membrane curvature. Recently, we demonstrated that cholesterol is also crucial for maintaining the proper spacing of anionic phospholipids. Upon extraction of cholesterol with cyclodextrin there is a sharp increase in the negative surface charge density of the plasma membrane, which promotes electrostatic repulsion between anionic headgroups, the generation of spontaneous positive curvature and rapid membrane internalization.

Purpose Giant pulmonary arterial aneurysm (PAA) is a rare but serious complication for patients with pulmonary hypertension (PH). Heart-lung transplantation or lung transplantation with a full length of donor pulmonary artery (PA) for pulmonary artery reconstruction (PAR) are options for PH complicated with a giant PAA involving PA trunk to main PAs. We have been using donor aorta for the reconstruction of PA for these lung transplant cases. This study aimed to describe our intermediate-term outcomes of lung transplantation with PAR using donor aorta for PH complicated with a giant PAA. Methods This is a single center retrospective review from March 2000 to May 2020. We reviewed cadaveric lung transplantations for PH and compared the outcomes of lung transplantation with PAR (PAR group) with those without PAR (non-PAR group). Results Twenty-five PH patients underwent cadaveric lung transplantation. Among them, 5 patients with a giant PAA underwent lung transplantation with PAR using donor aorta. Representative 3D-CT images of a giant PAA and the reconstructed PA are shown in Figure A. The diameter of the PA trunk was significantly larger in the PAR group compared to the non-PAR group (Figure B). As expected, operative time was significantly longer in the PAR group compared to the non-PAR group (PAR, 1204 minutes; non-PAR, 965 minutes, p=0.035). On the other hand, primary graft dysfunction grade, 30-day mortality (PAR, 0%; non-PAR, 5.0%), 5-year survival rate (PAR, 100%; non-PAR, 73.9%, Figure C), and 6 minutes walk distance at 1 year after lung transplantation (PAR, 522 m; non-PAR, 526m) were not significantly different between the groups. The donor aortas used for PAR did not show constriction, obstruction, enlargement, or infection during the observation period. Conclusion Our experience supports that lung transplantation with PAR using donor aorta is a feasible surgical option for PH complicated with a giant PAA.

Purpose Lung transplantation (LTx) is an effective treatment for patients with end-stage pulmonary lymphangioleiomyomatosis (LAM). However, native lung-related complications, such as chylothorax, chylous sputum, and native lung hyperinflation, can develop after a single LTx. LAM lesion recurrence in transplanted lungs and abdominal LAM lesions may also occur post-LTx. Further, while sirolimus therapy can be used to treat these complications, its efficacy and tolerability in patients with LAM after LTx remain unclear. This study aimed to evaluate the effect of sirolimus on post-LTx LAM complications. Methods We retrospectively reviewed the records of LTx recipients who received sirolimus for treating post-LTx LAM complications from March 2000 to December 2019. Results Of the 40 patients who underwent LTx for LAM treatment, eight underwent sirolimus treatment for post-LTx LAM complications. Two patients exhibited chylous sputum; two, chylous ascites; one, chylothorax; one, native lung hyperinflation; one, LAM recurrence in the transplanted lung; and one, angiomyolipoma. Patients’ immunosuppressive regimen consisting of tacrolimus (TAC), mycophenolate mofetil (MMF), and steroids was not changed, but the target trough level of TAC was reduced with the baseline levels of TAC and sirolimus being 5 ng/mL each. Sirolimus was discontinued for one patient because nausea occurred soon after the first dose. LAM lesions improved or were suppressed in six patients (Figure 1). The forced expiratory volume at 1 s post-sirolimus administration was stable (Figure 2). Acute rejection and infection were not observed, but one patient underwent a second LTx on the contralateral side due to chronic lung allograft dysfunction. Conclusion Providing sirolimus immunosuppressive therapy after LTx for LAM treatment can be effective in managing post-LTx LAM complications and may be acceptable when combined with TAC, MMF, and steroids.

Mycobacterium xenopi is associated with the highest mortality among pulmonary nontuberculous mycobacterial (NTM) infections, but whether this is due to the infection or other factors is unclear. There is little information regarding outcomes among patients infected with M. xenopi versus other NTM species. We conducted a retrospective matched cohort study comparing M. xenopi pulmonary disease (Mx-PD) to M. avium complex (MAC)-PD. Patients were matched by sex, age, radiologic subtype, and presence of cavitation. Baseline clinical characteristics, treatment, and outcomes were compared using matched analyses. We identified 70 Mx-PD cases: 29 fibrocavitary-type, 28 nodular-bronchiectatic-type, and 13 unclassifiable-type CT patterns, mean (SD) age 63 (13) years, and 54.3% (n = 38) female. Median follow-up duration was longer in the Mx-PD cohort (1552 days versus 1035 days, p = 0.01). Symptoms, radiologic phenotype, and pulmonary function were similar between groups although the Charlson Comorbidity Index was numerically higher in Mx-PD patients (3.6 versus 3.2, p = 0.08). Rifamycins were used less frequently in Mx-PD (59.5% versus 85.7%, p = 0.02). Although combined clinical and radiologic improvement was similar between the groups, successful treatment was more common with Mx-PD (40.5% versus 16.7%, p = 0.02) owing to superior culture conversion (70.8% versus 33.3%, p = 0.0001). Mortality 24 months after initiation of treatment was numerically but not statistically greater in the Mx-PD cohort (20.4% versus 10.3%, p = 0.32). Among matched Mx-PD and MAC-PD patients, standard anti-mycobacterial treatment was significantly more likely to achieve culture conversion and successful treatment for Mx-PD patients. Mortality among Mx-PD patients was numerically, but not statistically higher, possibly explained by increased comorbidity burden.

Background. Acute kidney injury (AKI) is a common complication after lung transplant (LTx), and continuous renal replacement therapy (CRRT) is increasingly of use to critically ill patients who have developed AKI. However, the optimal timing or threshold of kidney impairment for which to commence CRRT after LTx has been uncertain. There has also been limited information on the impact of CRRT among LTx recipients (LTRs) introduced in the early posttransplant period on survival, graft function, and renal function. We aimed to review LTRs who developed AKI requiring CRRT postoperatively and followed their long-term outcomes at Tohoku University Hospital (TUH). Methods. Medical records of consecutive patients who underwent LTx at TUH between 2000 and 2018 were reviewed, with follow-up to 2019 inclusive. Results. Although mortality in those who required CRRT (n = 21) was increased versus those who did not require CRRT (n = 85)(P = 0.024), conditional survival beyond 3-month posttransplant was not affected (P = 0.131). Additionally, the cumulative incidence of chronic lung allograft rejection (P = 0.160) and the development of chronic kidney disease (P = 0.757) were not significant between groups. Conclusions. The initiation of CRRT posttransplant may be a useful strategy to preserve cardiac and optimize volume management among critically ill patients.

Currently molecular techniques are a broadly accepted tool for diagnosis and are able to benefit patients in clinical practice. The polymerase chain reaction (PCR) has been especially incorporated into practical applications that are already in widespread use across the globe. With regard to the initial DNA extraction from clinically relevant samples, a number of commercially available kits are commonly used and are also designed to be easy to handle and less labor-intensive. In this study, the pressure system extracting DNA in column-based kit was developed, and its utility was compared with the centrifuge method using sputum from patients who were diagnosed with pneumonia. Also, due to the compact size and rapid processing time, the practical application of the pressure-based system incorporated into an automated pipetting machine was evaluated through clinical study. Our data suggests that DNA extraction by pressure was capable of serving as a substitute for the centrifuge method, and the compact and automatic nature of the pressure system device provided rapid and valuable information for clinical practice.

Nontuberculous Mycobacterial Pulmonary Disease in Allogeneic Haematopoietic Stem Cell Transplant recipients

The plasma membrane is uniquely enriched in phosphatidylserine (PtdSer). This anionic phospholipid is restricted almost exclusively to the inner leaflet of the plasmalemma. Because of their high density, the headgroups of anionic lipids experience electrostatic repulsion that, being exerted asymmetrically, is predicted to favor membrane curvature. We demonstrate that cholesterol limits this repulsion and tendency to curve. Removal of cholesterol or insertion of excess PtdSer increases the charge density of the inner leaflet, generating foci of enhanced charge and curvature where endophilin and synaptojanin are recruited. From these sites emerge tubules that undergo fragmentation, resulting in marked endocytosis of PtdSer. Shielding or reduction of the surface charge or imposition of outward membrane tension minimized invagination and PtdSer endocytosis. We propose that cholesterol associates with PtdSer to form nanodomains where the headgroups of PtdSer are maintained sufficiently separated to limit spontaneous curvature while sheltering the hydrophobic sterol from the aqueous medium., The plasma membrane is enriched in phosphatidylserine (PtdSer) mostly localized at the inner leaflet, which is predicted to induce membrane curvature. Here the authors show that membrane curvature induced by the proximity of anionic phospholipids can induce endocytosis and that cholesterol limits spontaneous curvature.

Caveolae are bulb-shaped nanodomains of the plasma membrane that are enriched in cholesterol and sphingolipids. They have many physiological functions, including endocytic transport, mechanosensing, and regulation of membrane and lipid transport. Caveola formation relies on integral membrane proteins termed caveolins (Cavs) and the cavin family of peripheral proteins. Both protein families bind anionic phospholipids, but the precise roles of these lipids are unknown. Here, we studied the effects of phosphatidylserine (PtdSer), phosphatidylinositol 4-phosphate (PtdIns4P), and phosphatidylinositol 4,5-bisphosphate (PtdIns(4,5)P2) on caveolar formation and dynamics. Using live-cell, single-particle tracking of GFP-labeled Cav1 and ultrastructural analyses, we compared the effect of PtdSer disruption or phosphoinositide depletion with caveola disassembly caused by cavin1 loss. We found that PtdSer plays a crucial role in both caveola formation and stability. Sequestration or depletion of PtdSer decreased the number of detectable Cav1-GFP puncta and the number of caveolae visualized by electron microscopy. Under PtdSer-limiting conditions, the co-localization of Cav1 and cavin1 was diminished, and cavin1 degradation was increased. Using rapamycin-recruitable phosphatases, we also found that the acute depletion of PtdIns4P and PtdIns(4,5)P2 has minimal impact on caveola assembly but results in decreased lateral confinement. Finally, we show in a model of phospholipid scrambling, a feature of apoptotic cells, that caveola stability is acutely affected by the scrambling. We conclude that the predominant plasmalemmal anionic lipid PtdSer is essential for proper Cav clustering, caveola formation, and caveola dynamics and that membrane scrambling can perturb caveolar stability.