1
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Yang Z, Bai YZ, Yan Y, Hachem RR, Witt CA, Vazquez Guillamet R, Byers DE, Marklin GF, Kreisel D, Nava RG, Meyers BF, Kozower BD, Patterson GA, Hartwig MG, Heiden BT, Puri V. Validation of a novel donor lung scoring system based on the updated lung Composite Allocation Score. Am J Transplant 2024:S1600-6135(24)00242-9. [PMID: 38531429 DOI: 10.1016/j.ajt.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 03/28/2024]
Abstract
Lung transplantation (LTx) continues to have lower rates of long-term graft survival compared with other organs. Additionally, lung utilization rates from brain-dead donors remain substantially lower compared with other solid organs, despite a growing need for LTx and the significant risk of waitlist mortality. This study aims to examine the effects of using a combination of the recently described novel lung donor (LUNDON) acceptability score and the newly adopted recipient lung Composite Allocation Score (CAS) to guide transplantation. We performed a review of nearly 18 000 adult primary lung transplants from 2015-2022 across the US with retroactive calculations of the CAS value. The medium-CAS group (29.6-34.5) had superior 1-year posttransplant survival. Importantly, the combination of high-CAS (> 34.5) recipients with low LUNDON score (≤ 40) donors had the worst survival at 1 year compared with any other combination. Additionally, we constructed a model that predicts 1-year and 3-year survival using the LUNDON acceptability score and CAS values. These results suggest that caution should be exercised when using marginally acceptable donor lungs in high-priority recipients. The use of the LUNDON score with CAS value can potentially guide clinical decision-making for optimal donor-recipient matches for LTx.
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Affiliation(s)
- Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yun Zhu Bai
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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2
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Patterson GA. Book review of Nobility in Small Things: A Surgeon's Path. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00097-7. [PMID: 38309461 DOI: 10.1016/j.jtcvs.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024]
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3
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Chaft JE, Oezkan F, Kris MG, Bunn PA, Wistuba II, Kwiatkowski DJ, Owen DH, Tang Y, Johnson BE, Lee JM, Lozanski G, Pietrzak M, Seweryn M, Byun WY, Schulze K, Nicholas A, Johnson A, Grindheim J, Hilz S, Shames DS, Rivard C, Toloza E, Haura EB, McNamee CJ, Patterson GA, Waqar SN, Rusch VW, Carbone DP. Author Correction: Neoadjuvant atezolizumab for resectable non-small cell lung cancer: an open-label, single-arm phase II trial. Nat Med 2024; 30:303. [PMID: 37816821 PMCID: PMC10803254 DOI: 10.1038/s41591-023-02627-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Affiliation(s)
- Jamie E Chaft
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Filiz Oezkan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- University Medicine Essen, Ruhrlandklinik, Department of Interventional Pulmonology, University Duisburg-Essen, Essen, Germany
- German Cancer Research Center (DKFZ), A420, Heidelberg, Germany
- Fifth Medical Department, Section of Pulmonology, Faculty of the University of Heidelberg, University Medicine Mannheim, Mannheim, Germany
| | - Mark G Kris
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Paul A Bunn
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - David J Kwiatkowski
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Dwight H Owen
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yan Tang
- Brigham and Women's Hospital, Boston, MA, USA
| | - Bruce E Johnson
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Jay M Lee
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gerard Lozanski
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Maciej Pietrzak
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michal Seweryn
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Biobank Lab, Department of Molecular Biophysics, University of Lodz, Lodz, Poland
- Centre for Data Analysis, Modeling and Computational Sciences, University of Lodz, Lodz, Poland
| | - Woo Yul Byun
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Ann Johnson
- Genentech, Inc., South San Francisco, CA, USA
| | | | | | | | - Chris Rivard
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric Toloza
- Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Eric B Haura
- Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ciaran J McNamee
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | | | - Saiama N Waqar
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - David P Carbone
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
- Pelotonia Institute for Immuno-Oncology, Columbus, OH, USA.
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4
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Terada Y, Takahashi T, Hachem RR, Liu J, Witt CA, Byers DE, Guillamet RV, Kulkarni HS, Nava RG, Kozower BD, Meyers BF, Pasque MK, Patterson GA, Marklin GF, Eghtesady P, Kreisel D, Puri V. Characteristics of donor lungs declined on site and impact of lung allocation policy change. J Thorac Cardiovasc Surg 2023; 166:1347-1358.e11. [PMID: 36990425 PMCID: PMC10533747 DOI: 10.1016/j.jtcvs.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 02/25/2023] [Accepted: 03/08/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE National and institutional data suggest an increase in organ discard rate (donor lungs procured but not implanted) after a new lung allocation policy was introduced in 2017. However, this measure does not include on-site decline rate (donor lungs declined intraoperatively). The objective of this study is to examine the impact of the allocation policy change on on-site decline. METHODS We used a Washington University (WU) and our local organ procurement organization (Mid-America Transplant [MTS]) database to abstract data on all accepted lung offers from 2014 to 2021. An on-site decline was defined as an event in which the procuring team declined the organs intraoperatively, and the lungs were not procured. Logistic regression models were used to investigate potentially modifiable reasons for decline. RESULTS The overall study cohort comprised 876 accepted lung offers, of which 471 donors were at MTS with WU or others as the accepting center and 405 at other organ procurement organizations with WU as the accepting center. At MTS, the on-site decline rate increased from 4.6% to 10.8% (P = .01) after the policy change. Given the greater likelihood of non-local organ placement and longer travel distance after policy change, the estimated cost of each on-site decline increased from $5727 to $9700. In the overall group, latest partial pressure of oxygen (odds ratio [OR], 0.993; 95% confidence interval [CI], 0.989-0.997), chest trauma (OR, 2.474; CI, 1.018-6.010), chest radiograph abnormality (OR, 2.902; CI, 1.289-6.532), and bronchoscopy abnormality (OR, 3.654; CI, 1.813-7.365) were associated with on-site decline, although lung allocation policy era was unassociated (P = .22). CONCLUSIONS We found that nearly 8% of accepted lungs are declined on site. Several donor factors were associated with on-site decline, although lung allocation policy change did not have a consistent impact on on-site decline.
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Affiliation(s)
- Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University, Saint Louis, Mo
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Gary F Marklin
- Mid-America Transplant, Washington University, Saint Louis, Mo
| | - Pirooz Eghtesady
- Department of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo; Department of Pathology & Immunology, Washington University, Saint Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo.
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5
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Patterson GA. Author support and a high-quality publishing experience. J Thorac Cardiovasc Surg 2023; 165:787-788. [PMID: 36624013 DOI: 10.1016/j.jtcvs.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
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6
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Chang SH, Chan J, Patterson GA. History of Lung Transplantation. Clin Chest Med 2023; 44:1-13. [PMID: 36774157 DOI: 10.1016/j.ccm.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation remains the only available therapy for many patients with end-stage lung disease. The number of lung transplants performed has increased significantly, but development of the field was slow compared with other solid-organ transplants. This delayed growth was secondary to the increased complexity of transplanting lungs; the continuous needs for surgical, anesthetics, and critical care improvements; changes in immunosuppression and infection prophylaxis; and donor management and patient selection. The future of lung transplant remains promising: expansion of donor after cardiac death donors, improved outcomes, new immunosuppressants targeted to cellular and antibody-mediated rejection, and use of xenotransplantation or artificial lungs.
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Affiliation(s)
- Stephanie H Chang
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York University Langone Health, New York City, NY, USA.
| | - Justin Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York University Langone Health, New York City, NY, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
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Rusch VW, Nicholas A, Patterson GA, Waqar SN, Toloza EM, Haura EB, Raz DJ, Reckamp KL, Merritt RE, Owen DH, Finley DJ, McNamee CJ, Blasberg JD, Garon EB, Mitchell JD, Doebele RC, Baciewicz F, Nagasaka M, Pass HI, Schulze K, Johnson A, Bunn PA, Johnson BE, Kris MG, Kwiatkowski DJ, Wistuba II, Chaft JE, Carbone DP, Lee JM. Surgical results of the Lung Cancer Mutation Consortium 3 trial: A phase II multicenter single-arm study to investigate the efficacy and safety of atezolizumab as neoadjuvant therapy in patients with stages IB-select IIIB resectable non-small cell lung cancer. J Thorac Cardiovasc Surg 2023; 165:828-839.e5. [PMID: 36369159 PMCID: PMC10288861 DOI: 10.1016/j.jtcvs.2022.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/07/2022] [Accepted: 10/01/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Multimodality treatment for resectable non-small cell lung cancer has long remained at a therapeutic plateau. Immune checkpoint inhibitors are highly effective in advanced non-small cell lung cancer and promising preoperatively in small clinical trials for resectable non-small cell lung cancer. This large multicenter trial tested the safety and efficacy of neoadjuvant atezolizumab and surgery. METHODS Patients with stage IB to select IIIB resectable non-small cell lung cancer and Eastern Cooperative Oncology Group performance status 0/1 were eligible. Patients received atezolizumab 1200 mg intravenously every 3 weeks for 2 cycles or less followed by resection. The primary end point was major pathological response in patients without EGFR/ALK+ alterations. Pre- and post-treatment computed tomography, positron emission tomography, pulmonary function tests, and biospecimens were obtained. Adverse events were recorded by Common Terminology Criteria for Adverse Events v.4.0. RESULTS From April 2017 to February 2020, 181 patients were entered in the study. Baseline characteristics were mean age, 65.1 years; female, 93 of 181 (51%); nonsquamous histology, 112 of 181 (62%); and clinical stages IIB to IIIB, 147 of 181 (81%). In patients without EGFR/ALK alterations who underwent surgery, the major pathological response rate was 20% (29/143; 95% confidence interval, 14-28) and the pathological complete response rate was 6% (8/143; 95% confidence interval, 2-11). There were no grade 4/5 treatment-related adverse events preoperatively. Of 159 patients (87.8%) undergoing surgery, 145 (91%) had pathologic complete resection. There were 5 (3%) intraoperative complications, no intraoperative deaths, and 2 postoperative deaths within 90 days, 1 treatment related. Median disease-free and overall survival have not been reached. CONCLUSIONS Neoadjuvant atezolizumab in resectable stage IB to IIIB non-small cell lung cancer was well tolerated, yielded a 20% major pathological response rate, and allowed safe, complete surgical resection. These results strongly support the further development of immune checkpoint inhibitors as preoperative therapy in locally advanced non-small cell lung cancer.
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Affiliation(s)
- Valerie W Rusch
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY.
| | | | | | | | | | | | - Dan J Raz
- Cedars Sinai (previously City of Hope Comprehensive Cancer Center), Los Angeles, Calif
| | - Karen L Reckamp
- Cedars Sinai (previously City of Hope Comprehensive Cancer Center), Los Angeles, Calif
| | - Robert E Merritt
- The Ohio State Medical Center and the Pelotonia Institute for Immune Oncology, Columbus, Ohio
| | - Dwight H Owen
- The Ohio State Medical Center and the Pelotonia Institute for Immune Oncology, Columbus, Ohio
| | | | | | | | - Edward B Garon
- David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | | | | | | | | | | | | | | | - Paul A Bunn
- University of Colorado Cancer Center, Aurora, Colo
| | | | - Mark G Kris
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
| | | | | | - Jamie E Chaft
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
| | - David P Carbone
- The Ohio State Medical Center and the Pelotonia Institute for Immune Oncology, Columbus, Ohio
| | - Jay M Lee
- David Geffen School of Medicine at UCLA, Los Angeles, Calif
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8
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Brunelli A, Argyriou A, Batirel H, Colson Y, Darling G, Fernandez F, Gooseman M, Lerut T, Molena D, Novoa N, Opitz I, Papagiannopoulos K, Patterson GA, Petersen RH, Rawlinson J, Rocco G, Stiles BM, Tariq J, Varela G. Sawubona reprise: reflections on the European Society of Thoracic Surgeons Presidential Address 2022. J Thorac Dis 2023; 15:204-213. [PMID: 36794145 PMCID: PMC9922595 DOI: 10.21037/jtd-22-1550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Affiliation(s)
| | - Amerikos Argyriou
- Department of Cardiothoracic Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Hasan Batirel
- Department of Thoracic Surgery, Biruni University School of Medicine, Istanbul, Turkey
| | - Yolonda Colson
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Gail Darling
- Department of Surgery Dalhousie University, Halifax, Canada
| | - Felix Fernandez
- Section of Thoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals and Hull York Medical School, University of Hull, Hull, UK
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Daniela Molena
- Thoracic Service-Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nuria Novoa
- Department of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | | | - Rene H. Petersen
- Department of Thoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Janette Rawlinson
- European Lung Foundation Lung Cancer Patient Advisory Group, Sheffield, UK
| | - Gaetano Rocco
- Thoracic Service-Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brendon M. Stiles
- Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Javeria Tariq
- Leeds School of Medicine, University of Leeds, Leeds, UK
| | - Gonzalo Varela
- Institute for Biomedical Research of Salamanca (IBSAL) Salamanca, Salamanca, Spain
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9
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Takahashi T, Terada Y, Pasque MK, Nava RG, Kozower BD, Meyers BF, Patterson GA, Kreisel D, Puri V, Hachem RR. Outcomes of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation. Ann Thorac Surg 2023; 115:1273-1280. [PMID: 36634836 DOI: 10.1016/j.athoracsur.2022.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of death in the first 30 days after lung transplantation and is also associated with worse long-term outcomes. Outcomes of patients with PGD grade 3 requiring extracorporeal membrane oxygenation (ECMO) support after lung transplantation have yet to be well described. We sought to describe short- and long-term outcomes for patients with PGD grade 3 who required ECMO support. METHODS This is a single-center retrospective cohort study of patients undergoing lung transplantation. We stratified patients with PGD grade 3 into non-ECMO, venoarterial (VA) ECMO, and venovenous (VV) ECMO groups after transplantation. We then compared the outcomes between the groups. RESULTS Of 773 lung transplant recipients, PGD grade 3 developed in 204 (26%) at any time in the first 72 hours after lung transplantation. Of these, 13 (5%) required VA ECMO and 25 (10%) required VV ECMO support. The 30-day, 1-year, and 5-year survival in the VA ECMO group was 62%, 54%, and 43% compared with 96%, 84%, and 65% in the VV ECMO group and 99%, 94%, and 71% in the non-ECMO group. Multivariable Cox regression analysis showed that VA ECMO was associated with increased mortality (hazard ratio, 2.37; 95% CI, 1.06-5.28; P = .04). CONCLUSIONS Patients who required VA ECMO support for PGD grade 3 have significantly worse survival compared with those who did not require ECMO and those who required VV ECMO support. This suggests that VA ECMO treatment of patients with PGD grade 3 after lung transplantation can be a predictable risk factor for mortality.
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Affiliation(s)
- Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri.
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
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10
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Shepherd HM, Farahnak K, Harrison MS, Frye CC, Marklin GF, Bierhals AJ, Hachem RR, Witt CA, Guillamet RV, Byers DE, Kozower BD, Meyers BF, Nava RG, Patterson GA, Kreisel D, Puri V. Utilizing computed tomography volumetry for size matching prior to lung transplantation: a case series. J Thorac Dis 2023; 15:2233-2239. [PMID: 37197524 PMCID: PMC10183521 DOI: 10.21037/jtd-22-1203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 02/10/2023] [Indexed: 03/08/2023]
Abstract
Background Appropriate size matching between donor and recipient is critical for successful pulmonary transplantation. Although surrogate measurements such as height and gender are often utilized to approximate predicted lung volume, these methods provide only a gross estimation with wide variability and poor predictive value. Case Description A single center exploratory study was conducted in which four patients underwent lung transplantation (LT) with pre-operative computed tomography (CT) volumetry obtained in both the donor and recipient to facilitate decision making regarding organ size and suitability. In four cases in which CT volumetry was used, the lung volumes calculated using surrogate measurements significantly overestimated both donor and recipient lung volumes quantified by CT volumetric analysis. All recipients underwent successful LT without necessary graft downsizing. Conclusions This is an initial report of prospectively utilizing CT volumetry as an adjunct to decision-making regarding suitability of donor lungs. In these cases, CT volumetry facilitated the confident acceptance of donor lungs that were initially predicted to be oversized based on other clinical measures.
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11
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Rendina EA, Patterson GA. Tracheal replacement: A never-ending search. Am J Transplant 2022; 22:2721-2722. [PMID: 35986710 DOI: 10.1111/ajt.17179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Erino A Rendina
- Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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12
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Subramanian MP, Yang Z, Chang SH, Willis D, Zhang J, Semenkovich TR, Heiden BT, Kozower BD, Kreisel D, Meyers BF, Patterson GA, Nava RG, Puri V. Minimum Volume Standards for Surgical Care of Early-Stage Lung Cancer: A Cost-Effectiveness Analysis. Ann Thorac Surg 2022; 114:2001-2007. [PMID: 35780816 DOI: 10.1016/j.athoracsur.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/17/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Multiple stakeholders have advocated for minimum volume standards for complex surgical procedures. The Leapfrog Group recommends that patients with non-small cell lung cancer (NSCLC) receive surgical resection at hospitals that perform at least 40 lung resections annually. However, the cost-effectiveness of this paradigm is unknown. METHODS A cost-effectiveness analysis was performed on 90-day and 5-year horizons for patients with clinical stage I NSCLC undergoing surgical resection at hospitals stratified by Leapfrog standard. Model inputs were derived from either the literature or a propensity score-matched cohort using the National Cancer Database. For the 5-year horizon, we simulated using a Markov model with 1-year cycle. Incremental cost-effectiveness ratio (ICER) was calculated to evaluate cost-effectiveness. RESULTS For the 90-day horizon, resection at a Leapfrog hospital was more costly ($25 567 vs $25 530) but had greater utility (0.185 vs 0.181 quality-adjusted life-years), resulting in an ICER of 10 506. Similarly, for the 5-year horizon, resection at a Leapfrog hospital was more costly ($26 600 vs $26 495) but more effective (3.216 vs 3.122 quality-adjusted life-years), resulting in an ICER of 1108. When the costs for long-distance travel, lodging, and loss of productivity for caregivers were factored in, the ICER was 20 499 during the 5-year horizon for resection at Leapfrog hospitals. Using a willingness-to-pay threshold of $50 000, resection at a Leapfrog hospital remained cost-effective. CONCLUSIONS Receiving surgery for clinical stage I NSCLC at hospitals that meet Leapfrog volume standards is cost-effective. Payers and policymakers should consider supporting patient and caregiver travel to higher volume institutions for lung cancer surgery.
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Affiliation(s)
- Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Su-Hsin Chang
- Division of Public Health Sciences, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Willis
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jianrong Zhang
- George Warren Brown School of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Tara R Semenkovich
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Brendan T Heiden
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri.
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13
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Yang Z, Takahashi T, Terada Y, Meyers BF, Kozower BD, Patterson GA, Nava RG, Hachem RR, Witt CA, Byers DE, Kulkarni HS, Guillamet RV, Yan Y, Chang SH, Kreisel D, Puri V. A comparison of outcomes after lung transplantation between European and North American centers. J Heart Lung Transplant 2022; 41:1729-1735. [PMID: 35970646 PMCID: PMC10305841 DOI: 10.1016/j.healun.2022.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/19/2022] [Accepted: 07/14/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With advancements in basic science and clinical medicine, lung transplantation (LT) has evolved rapidly over the last three decades. However, it is unclear if significant regional variations exist in long-term outcomes after LT. METHODS To investigate potential differences, we performed a retrospective, comparative cohort analysis of adult patients undergoing deceased donor single or double LT in North America (NA) or Europe between January 2006 and December 2016. Data up to April 2019 were abstracted from the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Registry. We compared overall survival (OS) between North American and European LT centers in a propensity score matched analysis. RESULTS In 3,115 well-matched pairs, though 30-day survival was similar between groups (NA 96.2% vs Europe 95.4%, p = 0.116), 5-year survival was significantly higher in European patients (NA 60.1% vs Europe 70.3%, p < 0.001). CONCLUSIONS This survival difference persisted in a sensitivity analysis excluding Canadian patients. Prior observations suggest that these disparities are at least partly related to better access to care via universal healthcare models prevalent in Europe. Future studies are warranted to confirm our findings and explore other causal mechanisms. It is likely that potential solutions will require concerted efforts from healthcare providers and policymakers.
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Affiliation(s)
- Zhizhou Yang
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | | | - Ruben G Nava
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonology and Critical Care, Washington University, St. Louis, Missouri
| | - Chad A Witt
- Division of Pulmonology and Critical Care, Washington University, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonology and Critical Care, Washington University, St. Louis, Missouri
| | - Hrishikesh S Kulkarni
- Division of Pulmonology and Critical Care, Washington University, St. Louis, Missouri
| | | | - Yan Yan
- Division of Public Health Sciences, Washington University, St. Louis, Missouri
| | - Su-Hsin Chang
- Division of Public Health Sciences, Washington University, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
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14
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Chaft JE, Oezkan F, Kris MG, Bunn PA, Wistuba II, Kwiatkowski DJ, Owen DH, Tang Y, Johnson BE, Lee JM, Lozanski G, Pietrzak M, Seweryn M, Byun WY, Schulze K, Nicholas A, Johnson A, Grindheim J, Hilz S, Shames DS, Rivard C, Toloza E, Haura EB, McNamee CJ, Patterson GA, Waqar SN, Rusch VW, Carbone DP. Neoadjuvant atezolizumab for resectable non-small cell lung cancer: an open-label, single-arm phase II trial. Nat Med 2022; 28:2155-2161. [PMID: 36097216 PMCID: PMC9556329 DOI: 10.1038/s41591-022-01962-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/21/2022] [Indexed: 12/14/2022]
Abstract
In an ongoing, open-label, single-arm phase II study ( NCT02927301 ), 181 patients with untreated, resectable, stage IB-IIIB non-small cell lung cancer received two doses of neoadjuvant atezolizumab monotherapy. The primary end point was major pathological response (MPR; ≤10% viable malignant cells) in resected tumors without EGFR or ALK alterations. Of the 143 patients in the primary end point analysis, the MPR was 20% (95% confidence interval, 14-28%). With a minimum duration of follow-up of 3 years, the 3-year survival rate of 80% was encouraging. The most common adverse events during the neoadjuvant phase were fatigue (39%, 71 of 181) and procedural pain (29%, 53 of 181), along with expected immune-related toxicities; there were no unexpected safety signals. In exploratory analyses, MPR was predicted using the pre-treatment peripheral blood immunophenotype based on 14 immune cell subsets. Immune cell subsets predictive of MPR in the peripheral blood were also identified in the tumor microenvironment and were associated with MPR. This study of neoadjuvant atezolizumab in a large cohort of patients with resectable non-small cell lung cancer was safe and met its primary end point of MPR ≥ 15%. Data from this single-arm, non-randomized trial suggest that profiles of innate immune cells in pre-treatment peripheral blood may predict pathological response after neoadjuvant atezolizumab, but additional studies are needed to determine whether these profiles can inform patient selection and new therapeutic approaches.
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Affiliation(s)
- Jamie E Chaft
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Filiz Oezkan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- University Medicine Essen, Ruhrlandklinik, Department of Interventional Pulmonology, University Duisburg-Essen, Essen, Germany
- German Cancer Research Center (DKFZ), A420, Heidelberg, Germany
- Fifth Medical Department, Section of Pulmonology, Faculty of the University of Heidelberg, University Medicine Mannheim, Mannheim, Germany
| | - Mark G Kris
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Paul A Bunn
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - David J Kwiatkowski
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Dwight H Owen
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yan Tang
- Brigham and Women's Hospital, Boston, MA, USA
| | - Bruce E Johnson
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Jay M Lee
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gerard Lozanski
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Maciej Pietrzak
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michal Seweryn
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Biobank Lab, Department of Molecular Biophysics, University of Lodz, Lodz, Poland
- Centre for Data Analysis, Modeling and Computational Sciences, University of Lodz, Lodz, Poland
| | - Woo Yul Byun
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Ann Johnson
- Genentech, Inc., South San Francisco, CA, USA
| | | | | | | | - Chris Rivard
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric Toloza
- Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Eric B Haura
- Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ciaran J McNamee
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | | | - Saiama N Waqar
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - David P Carbone
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
- Pelotonia Institute for Immuno-Oncology, Columbus, OH, USA.
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15
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Patterson GA. Bistability in orbital trajectories of a chiral self-propelled particle interacting with an external field. Phys Rev E 2022; 106:014615. [PMID: 35974547 DOI: 10.1103/physreve.106.014615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Abstract
In this paper, the dynamics of a self-propelled stochastic particle under the influence of an axisymmetric light field is experimentally studied. The particle under consideration has the main characteristic of carrying a light sensor in an eccentric location. For the chosen experimental conditions, the emerging trajectories are orbital, and, more interestingly, they suggest the existence of bistability. A mathematical model incorporating the key experimental components is introduced. By means of numerical simulations and theoretical analysis, it is found that, in addition to the orbiting behavior, the sensor location could produce trapped or diffusive behaviors. Furthermore, the study reveals that stochastic perturbation and the eccentric location of the sensor are responsible for inducing bistability in the orbital trajectories, supporting experimental observations.
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Affiliation(s)
- G A Patterson
- Instituto Tecnológico de Buenos Aires, CONICET, Lavardén 315, 1437 Ciudad Autónoma de Buenos Aires, Argentina
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16
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Terada Y, Takahashi T, Hachem RR, Liu J, Witt CA, Byers DE, Guillamet RV, Kulkarni HS, Nava RG, Kozower BD, Meyers BF, Pasque MK, Patterson GA, Kreisel D, Puri V. Clinical Features and Outcomes of Unplanned Single Lung Transplants. J Thorac Cardiovasc Surg 2022; 164:1650-1659.e3. [DOI: 10.1016/j.jtcvs.2022.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 01/01/2022] [Accepted: 01/20/2022] [Indexed: 11/16/2022]
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17
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Patterson GA. Discussion. J Thorac Cardiovasc Surg 2022; 164:1667-1668. [DOI: 10.1016/j.jtcvs.2021.11.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Yokoyama Y, Terada Y, Nava RG, Puri V, Kreisel D, Patterson GA, Hachem RR, Takahashi T. Coronavirus disease 2019 positivity immediately after lung transplantation: A case report. Transplant Proc 2022; 54:1572-1574. [PMID: 35581013 PMCID: PMC9023318 DOI: 10.1016/j.transproceed.2022.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/19/2022] [Accepted: 03/25/2022] [Indexed: 01/08/2023]
Abstract
Management of COVID-19 in lung transplant recipients is challenging. We report a case of a 71-year-old male who underwent bilateral lung transplantation with an unexpected case of COVID-19. The patient had been fully vaccinated. The patient and donor tested negative for pretransplant COVID-19. On routine bronchoscopy on day 1 after transplant, the COVID-19 test was positive. Mycophenolic mofetil and the second dose of basiliximab were skipped, but tacrolimus and prednisone were continued. He was treated with casirivimab/imdevimab and remdesivir. He was discharged on day 14 and has had no episodes of acute rejection during the 3 months.
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Affiliation(s)
- Yuhei Yokoyama
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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19
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Yang Z, Subramanian MP, Yan Y, Meyers BF, Kozower BD, Patterson GA, Nava RG, Hachem RR, Witt CA, Pasque MK, Byers DE, Kulkarni HS, Kreisel D, Itoh A, Puri V. The Impact of Center Volume on Outcomes in Lung Transplantation. Ann Thorac Surg 2022; 113:911-917. [PMID: 33857492 PMCID: PMC8505551 DOI: 10.1016/j.athoracsur.2021.03.092] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/13/2021] [Accepted: 03/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies in lung transplantation have shown variable association between hospital volume and clinical outcomes. We aimed to identify the pattern of effect of hospital volume on individual patient survival after lung transplantation. METHODS We performed a retrospective analysis using the United Network for Organ Sharing national thoracic organ transplantation database. Adult patients who underwent lung transplantation between January 2013 and December 2017 were included. The association between mean annual center volume and 1-year overall survival was examined using restricted cubic splines in a random effects multivariable Cox model. The volume threshold for optimal 1-year overall survival was subsequently approximated by the maximum likelihood approach using segmented linear splines in the same model. RESULTS The study included 10,007 patients at 71 transplant centers. Median annual center volume was 22 cases (interquartile range, 10.6 to 38). A center volume threshold was identified at 33 cases per year (95% confidence interval, 28 to 37). Higher center volume, to 33 cases per year, was associated with better 1-year survival (hazard ratio 0.989, 95% confidence interval, 0.980 to 0.999 every additional case). Further increase in center volume above 33 cases per year showed no additional benefit (hazard ratio 1.000, 95% confidence interval, 0.996 to 1.003 every additional case). Twenty-three centers (32.4%) reached the volume threshold of 33 cases per year. CONCLUSIONS One-year survival after lung transplantation improved with increasing center volume to as many as 33 cases per year. Low volume centers below the 33 cases per year threshold had large variations in their outcomes and had a higher risk of performing poorly, although many of them maintained good performance.
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Affiliation(s)
- Zhizhou Yang
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | | | - Yan Yan
- Washington University School of Medicine, Division of Public Health Sciences
| | - Bryan F. Meyers
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Benjamin D. Kozower
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | | | - Ruben G. Nava
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Ramsey R. Hachem
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Chad A. Witt
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Michael K. Pasque
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Derek E. Byers
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Hrishikesh S. Kulkarni
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Daniel Kreisel
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Akinobu Itoh
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri.
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20
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Terada Y, Puri V, Meyers BF, Kreisel D, Patterson GA, Hachem RR, Takahashi T. Lung transplant for pulmonary fibrosis with dendriform ossification. Ann Thorac Surg 2022; 114:e403-e405. [PMID: 35218702 DOI: 10.1016/j.athoracsur.2022.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/18/2022] [Accepted: 01/23/2022] [Indexed: 11/19/2022]
Abstract
Dendriform pulmonary ossification (DPO) is a rare condition defined as disseminated, widespread heterotopic bone formation within the lungs. This condition is associated with restrictive pulmonary disease, such as interstitial pneumonia or fibrosis. The clinical features and pathophysiology of DPO, however, remain unclear. We report a case of a 66-year-old male with idiopathic pulmonary fibrosis accompanied by DPO who was treated with a double lung transplant. His postoperative course was uneventful without recurrence of DPO.
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Affiliation(s)
- Yuriko Terada
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Ramsey R Hachem
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Tsuyoshi Takahashi
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri.
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21
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Shepherd HM, Bierhals AJ, Hachem RR, Takahashi T, Pasque MK, Patterson GA, Puri V, Kreisel D, Nava RG. Transplantation of Donor Lung with Partial Anomalous Pulmonary Venous Return Using a Carrel Patch. Ann Thorac Surg 2022; 114:e249-e251. [PMID: 34998737 DOI: 10.1016/j.athoracsur.2021.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
Partial anomalous pulmonary venous return is a rare congenital aberrancy which involves oxygen-rich pulmonary venous drainage into the right atrium instead of systemic circulation. Here, we report a case of isolated partial anomalous pulmonary venous return of the right upper lobe in a donor lung. Successful transplantation was performed with a Carrel patch technique for left atrial cuff reconstruction using a segment of donor vena cava. This is the third report of partial anomalous pulmonary venous return in a right donor lung, but the first to describe this reconstructive approach to restore physiologic venous drainage.
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Affiliation(s)
| | | | - Ramsey R Hachem
- Department of Medicine, Washington University School of Medicine
| | | | | | | | - Varun Puri
- Department of Surgery, Washington University School of Medicine
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine; Department of Pathology and Immunology, Washington University School of Medicine
| | - Ruben G Nava
- Department of Surgery, Washington University School of Medicine
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22
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Engelhardt KE, Patterson GA. The more we learn, the more there is to know: the clinical management of stage I non-small cell lung cancer. J Thorac Dis 2022; 14:3654-3659. [DOI: 10.21037/jtd-22-1145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
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23
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Shepherd HM, Hachem RR, Witt CA, Guillamet RV, Byers DE, Kozower BD, Meyers BF, Takahashi T, Patterson GA, Puri V, Kreisel D, Nava RG. Bleeding and thrombotic complications associated with anticoagulation prior to lung transplantation: a case series. J Thorac Dis 2022; 14:2917-2926. [PMID: 36071776 PMCID: PMC9442523 DOI: 10.21037/jtd-22-300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/11/2022] [Indexed: 12/02/2022]
Abstract
Background Scarce data is available on therapeutic anticoagulation (AC) in patients undergoing pulmonary transplantation. We describe our institutional experience with AC-induced coagulopathy in recipients at the time of transplantation and evaluate its impact on posttransplant outcomes. Methods Records of adult patients on therapeutic AC at the time of lung transplantation from January 2014 to July 2021 were reviewed. Administration of preoperative pharmacologic reversal was assessed, with adequate reversal defined as international normalized ratio (INR) ≤1.5. We evaluated the incidence of major bleeding complications [delayed sternal closure, reoperation due to bleeding, chest tube output ≥1,500 cc, ≥4 units of packed red blood cells, ≥4 units of platelets, or ≥5 units of fresh frozen plasma (FFP)], major thrombotic complications [venous thromboembolism (VTE) or other major thrombosis on imaging], and inpatient mortality. Results Of 602 lung transplant recipients, 10 patients taking preoperative warfarin were included in the study. While most patients received pharmacologic reversal preoperatively (n=9, 90%), successful reversal was rarely achieved (n=3, 30%). Inadequate INR reversal was associated with major bleeding events (n=6, 60%). Major thrombotic complications were more frequent (n=7, 70%) than bleeding events. Notably, all fatalities within the cohort (n=2, 20%) were associated with thrombotic, but not bleeding, complications. Conclusions This is the first known report on the incidence and impact of AC-induced coagulopathy in patients undergoing lung transplantation. Major thrombotic events are frequent and associated with high mortality. Routine surveillance and treatment may be warranted.
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Affiliation(s)
- Hailey M. Shepherd
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ramsey R. Hachem
- Departments of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Chad A. Witt
- Departments of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Rodrigo V. Guillamet
- Departments of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Derek E. Byers
- Departments of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D. Kozower
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bryan F. Meyers
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Tsuyoshi Takahashi
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Varun Puri
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Kreisel
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ruben G. Nava
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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24
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Abstract
Pulmonary neuroendocrine tumors (NETs) are relatively rare; however, their incidence is steadily increasing. They now comprise 1% to 2% of all lung cancers. Lung NETs are classified based on the World Health Organization classification into low-, intermediate-, and high-grade tumors. Most patients present with nonspecific symptoms that can result in delayed diagnosis. Bronchoscopy and biopsy are essential to diagnose and classify pulmonary NETs. Surgery is the mainstay of therapy and R0 resection is key. Lung preservation surgery, whenever possible, is preferred. There is little role of systemic therapy in NETs. Survival after R0 resection is reasonably good especially in low-grade tumors.
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Affiliation(s)
- Simran Randhawa
- Division of Thoracic Surgery, Department of Surgery, Washington University School of Medicine, 1 Barnes Jewish Hospital, St Louis, MO 63110, USA.
| | - Nikolaos Trikalinos
- Division of Medical Oncology, Department of Internal Medicine, Washington University School of Medicine, 1 Barnes Jewish Hospital, St Louis, MO 63110, USA
| | - G Alexander Patterson
- Division of Thoracic Surgery, Department of Surgery, Washington University School of Medicine, 1 Barnes Jewish Hospital, St Louis, MO 63110, USA
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Randhawa SK, Patterson GA. Single-stage tracheal transplantation-From bench to bedside. Am J Transplant 2021; 21:3223-3224. [PMID: 34331841 DOI: 10.1111/ajt.16776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Simran K Randhawa
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Yang Z, Gerull WD, Shepherd HM, Marklin GF, Takahashi T, Meyers BF, Kozower BD, Patterson GA, Nava RG, Hachem RR, Witt CA, Byers DE, Guillamet RV, Pasque MK, Yan Y, Kreisel D, Puri V. Different-team procurements: A potential solution for the unintended consequences of change in lung allocation policy. Am J Transplant 2021; 21:3101-3111. [PMID: 33638937 PMCID: PMC8390571 DOI: 10.1111/ajt.16553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/07/2021] [Accepted: 02/23/2021] [Indexed: 01/25/2023]
Abstract
The new lung allocation policy has led to an increase in distant donors and consequently enhanced logistical burden of procuring organs. Though early single-center studies noted similar outcomes between same-team transplantation (ST, procuring team from transplanting center) and different-team transplantation (DT, procuring team from different center), the efficacy of DT in the contemporary era remains unclear. In this study, we evaluated the trend of DT, rate of transplanting both donor lungs, 1-year graft survival, and risk of Grade 3 primary graft dysfunction (PGD) using the Scientific Registry of Transplant Recipient (SRTR) database from 2006 to 2018. A total of 21619 patients (DT 2085, 9.7%) with 19837 donors were included. Utilization of DT decreased from 15.9% in 2006 to 8.5% in 2018. Proportions of two-lung donors were similar between the groups, and DT had similar 1-year graft survival as ST for both double (DT, HR 1.108, 95% CI 0.894-1.374) and single lung transplants (DT, HR 1.094, 95% CI 0.931-1.286). Risk of Grade 3 PGD was also similar between ST and DT. Given our results, expanding DT may be a feasible option for improving lung procurement efficiency in the current era, particularly in light of the COVID-19 pandemic.
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Affiliation(s)
- Zhizhou Yang
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - William D. Gerull
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - Hailey M. Shepherd
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | | | - Tsuyoshi Takahashi
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - Bryan F. Meyers
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - Benjamin D. Kozower
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - G. Alexander Patterson
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - Ruben G. Nava
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - Ramsey R. Hachem
- Division of Pulmonology and Critical Care, Washington University, St. Louis, MO, USA
| | - Chad A. Witt
- Division of Pulmonology and Critical Care, Washington University, St. Louis, MO, USA
| | - Derek E. Byers
- Division of Pulmonology and Critical Care, Washington University, St. Louis, MO, USA
| | | | - Michael K. Pasque
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - Yan Yan
- Division of Public Health Sciences, Washington University, St. Louis, MO, USA
| | - Daniel Kreisel
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
| | - Varun Puri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO, USA
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Terada Y, Harrison MS, Nava RG, Witt CA, Byers DE, Guillamet RV, Meyers BF, Pasque MK, Patterson GA, Kreisel D, Puri V, Hachem RR, Takahashi T. Incidentally Detected Chronic Lymphocytic Leukemia in Hilar Lymph Nodes at the Time of Lung Transplantation: A Case Report. Transplant Proc 2021; 53:2619-2621. [PMID: 34253378 DOI: 10.1016/j.transproceed.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/01/2021] [Indexed: 11/17/2022]
Abstract
A 68-year-old man with interstitial pulmonary fibrosis underwent bilateral lung transplantation. Histopathologic examination of hilar lymph nodes in the explanted lungs showed effacement of normal nodal architecture by the proliferation of small lymphocytes, consistent with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL). Unexpectedly discovered malignancies at the time of lung transplantation is uncommon, especially in the lymph nodes. The clinical management was challenging because of attempts to balance treatment of CLL and immunosuppressive treatment to prevent graft rejection. Here, we report a case of incidentally detected CLL in hilar lymph nodes with explanted lungs and review the relevant literature.
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Affiliation(s)
- Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri
| | - M Shea Harrison
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri; Department of Pathology & Immunology, Washington University, Saint Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Missouri.
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Takahashi T, Terada Y, Pasque MK, Liu J, Byers DE, Witt CA, Nava RG, Puri V, Kozower BD, Meyers BF, Kreisel D, Patterson GA, Hachem RR. Clinical features and outcomes of combined pulmonary fibrosis and emphysema after lung transplantation. Chest 2021; 160:1743-1750. [PMID: 34186034 DOI: 10.1016/j.chest.2021.06.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 06/09/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Combined pulmonary fibrosis and emphysema (CPFE) is recognized as a characteristic syndrome of smoking-related interstitial lung disease that has a worse prognosis than idiopathic pulmonary fibrosis (IPF). However, outcomes after lung transplantation for CPFE have not been reported. The aim of this study is to describe the clinical features and outcomes of CPFE after lung transplantation. RESEARCH QUESTION What are the clinical features and outcomes of CPFE after lung transplantation? STUDY DESIGN AND METHODS This is a single-center retrospective cohort study of patients with CPFE and IPF who underwent lung transplantation at our center between January 2011 and December 2016. We defined CPFE as ≥ 10% emphysema in the upper lung fields combined with fibrosis on high-resolution computed tomography scan. We characterized the clinical features of patients with CPFE and compared their outcomes after lung transplantation to those with IPF. RESULTS 27 of 172 (16%) patients with IPF met criteria for CPFE. Severe pulmonary hypertension was present in 16 of 27 (59%) patients with CPFE. On logistic regression analysis, CPFE was significantly associated with primary graft dysfunction (PGD) grade 3 (odds ratio: 3.14, 95% confidence interval [CI]: 1.18-8.37, p=0.02). On competing risk regression analysis, CPFE was associated with acute cellular rejection (ACR) grade ≥ A2, and chronic lung allograft dysfunction (CLAD) (hazard ratio [HR]: 1.89, 95% CI: 1.10-3.25, p=0.02, HR: 1.96, 95% CI: 1.02-3.77, p=0.04, respectively). 5-year survival was 79.0% for the CPFE group and 75.4% for the IPF group, respectively (log rank p = 0.684). INTERPRETATION After transplant, patients with CPFE were more likely to develop PGD, ACR, and CLAD compared to those with IPF. However, survival was not significantly different between the 2 groups.
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Affiliation(s)
- Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Derek E Byers
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Chad A Witt
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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Semenkovich TR, Yan Y, Subramanian M, Meyers BF, Kozower BD, Nava R, Patterson GA, Kreisel D, Puri V. A Clinical Nomogram for Predicting Node-positive Disease in Esophageal Cancer. Ann Surg 2021; 273:e214-e221. [PMID: 31274650 PMCID: PMC6940556 DOI: 10.1097/sla.0000000000003450] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We developed and validated a nomogram predicting the likelihood of occult lymph node metastases in surgically resectable esophageal cancers. BACKGROUND Patients with esophageal cancer with positive lymph nodes benefit from neoadjuvant therapy, but limitations in current clinical staging techniques mean nodal metastases often go undetected preoperatively. METHODS The National Cancer Database was queried for patients with clinical T1-3N0M0 cancer undergoing upfront esophagectomy from 2004 to 2014. Multivariable logistic regression was used to develop the risk model using both statistical significance and clinical importance criteria for variable selection. Predictive accuracy was assessed and bootstrapping was used for validation. A nomogram was constructed for presentation of the final model. RESULTS Of 3186 patients, 688 (22%) had pathologic lymph node involvement (pN+) and 2498 (78%) had pN0 status. Variables associated with pN+ status included histology [adenocarcinoma vs squamous: odds ratio (OR) 1.75], tumor stage (T1: reference, T2: OR 1.90, T3: OR 2.17), tumor size (<1 cm: reference, 1-2 cm: OR 2.25, 2-3 cm: OR 3.82, 3-4 cm: OR 5.40, 4-5 cm: OR 5.66, ≥5 cm: OR 6.02), grade (1: reference, 2: OR 2.62, 3: OR 4.39, 4: OR 4.15, X: OR 1.87), and presence of lymphovascular invasion (absent: reference, present: OR 4.70, missing: OR 1.87), all P < 0.001. A nomogram with these variables had good predictive accuracy (Brier score: 0.14, calibration slope: 0.97, c-index: 0.77). CONCLUSIONS We created a nomogram predicting the likelihood of pathologic lymph node involvement in patients with esophageal cancer who are clinically node negative using a generalizable dataset. Risk stratification with this nomogram could improve delivery of appropriate perioperative care.
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Affiliation(s)
- Tara R Semenkovich
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, and Division of Biostatistics, Washington University, St Louis, MO
| | - Melanie Subramanian
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO
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Randhawa SK, Yang Z, Morkan DB, Yan Y, Chang SH, Hachem RR, Witt CA, Byers DE, Kulkarni HS, Guillamet RV, Kozower BD, Nava RG, Meyers BF, Patterson GA, Kreisel D, Puri V. One year survival worse for lung retransplants relative to primary lung transplants. Ann Thorac Surg 2021; 113:1265-1273. [PMID: 33964255 DOI: 10.1016/j.athoracsur.2021.03.112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/18/2021] [Accepted: 03/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Outcomes after lung re-transplantation (LRT) remain inferior compared to primary lung transplantation (PLT). We examined the impact of center volume on one-year survival after LRT. METHODS Using the UNOS database, we abstracted patients undergoing PLT and LRT between January 2006 and December 2017, excluding combined heart-lung transplants and multiple re-transplants. One-year survival after PLT and LRT were compared using propensity score matching. In the LRT cohort, multivariable Cox models with and without time-dependent coefficients were fitted to examine association between transplant center volume and 1-year survival. Center volume was categorized based on inspection of restricted cubic splines. RESULTS A total of 20,675 recipients (PLT 19853 [96.0%] vs. LRT 822 [4.0%]) were included. One-year survival was lower for LRT recipients in the matched cohort (PLT 84.8% vs LRT 76.7%). There was steady improvement in one-year survival after LRT (2006-2009 72.1% vs. 2010-2013 76.6% vs. 2014-2017 80.1%). Higher center volume was associated with better 1-year survival after LRT. This survival difference was noted in the initial 30 days after transplantation (Intermediate vs. Low volume, HR 0.282 [0.151-0.526]; High vs. Low volume HR 0.406 [0.224-0.737]) but became insignificant after 30 days. CONCLUSIONS Superior 1-year survival after LRT at higher volume centers is predominantly due to better 30-day outcomes. This finding suggests that LRT candidates may be referred to higher volume centers for surgery.
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Affiliation(s)
- Simran K Randhawa
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Deniz B Morkan
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Rodrigo Vasquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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Ridley CH, Al-Hammadi N, Maniar HS, Ben Abdallah A, Steinberg A, Bollini ML, Patterson GA, Henn MC, Moon MR, Dahl AB, Avidan MS. Building a Collaborative Culture: Focus on Psychological Safety and Error Reporting. Ann Thorac Surg 2021; 111:683-689. [DOI: 10.1016/j.athoracsur.2020.05.152] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/06/2020] [Accepted: 05/22/2020] [Indexed: 10/23/2022]
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Bery A, Marklin G, Itoh A, Kreisel D, Takahashi T, Meyers BF, Nava R, Kozower BD, Shepherd H, Patterson GA, Puri V. Specialized Donor Care Facility Model and Advances in Management of Thoracic Organ Donors. Ann Thorac Surg 2021; 113:1778-1786. [PMID: 33421385 DOI: 10.1016/j.athoracsur.2020.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Donor hearts and lungs are more susceptible to the inflammatory physiologic changes that occur after brain death. Prior investigations have shown that protocolized management of potential organ donors can rehabilitate donor organs that are initially deemed unacceptable. In this review we discuss advances in donor management models with particular attention to the specialized donor care facility model. In addition we review specific strategies to optimize donor thoracic organs and improve organ yield in thoracic transplantation. METHODS We performed a literature review by searching the PubMed database for medical subject heading terms associated with organ donor management models. We also communicated with our local organ procurement organization to gather published and unpublished information first-hand. RESULTS The specialized donor care facility model has been shown to improve the efficiency of organ donor management and procurement while reducing costs and minimizing travel and its associated risks. Lung protective ventilation, recruitment of atelectatic lung, and hormone therapy (eg, glucocorticoids and triiodothyronine/thyroxine) are associated with improved lung utilization rates. Stroke volume-based resuscitation is associated with improved heart utilization rates, whereas studies evaluating hormone therapy (eg, glucocorticoids and triiodothyronine/thyroxine) have shown variable results. CONCLUSIONS Lack of high-quality prospective evidence results in conflicting practices across organ procurement organizations, and best practices remain controversial. Future studies should focus on prospective, randomized investigations to evaluate donor management strategies. The specialized donor care facility model fosters a collaborative environment that encourages academic inquiry and is an ideal setting for these investigations.
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Affiliation(s)
- Amit Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.
| | | | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Hailey Shepherd
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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Yang Z, Takahashi T, Gerull WD, Hamilton C, Subramanian MP, Liu J, Meyers BF, Kozower BD, Patterson GA, Nava RG, Hachem RR, Witt CA, Aguilar PR, Pasque MK, Byers DE, Kulkarni HS, Kreisel D, Puri V. Impact of Nighttime Lung Transplantation on Outcomes and Costs. Ann Thorac Surg 2020; 112:206-213. [PMID: 33065051 DOI: 10.1016/j.athoracsur.2020.07.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 06/10/2020] [Accepted: 07/06/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Previous studies in the field of organ transplantation have shown a possible association between nighttime surgery and adverse outcomes. We aim to determine the impact of nighttime lung transplantation on postoperative outcomes, long-term survival, and overall cost. METHODS We performed a single-center retrospective cohort analysis of adult lung transplant recipients who underwent transplantation between January 2006 and December 2017. Data were extracted from our institutional Lung Transplant Registry and Mid-America Transplant services database. Patients were classified into 2 strata, daytime (5 AM to 6 PM) and nighttime (6 PM to 5 AM), based on time of incision. Major postoperative adverse events, 5-year overall survival, and 5-year bronchiolitis obliterans syndrome-free survival were examined after propensity score matching. Additionally we compared overall cost of transplantation between nighttime and daytime groups. RESULTS Of the 740 patients included in this study, 549 (74.2%) underwent daytime transplantation and 191 (25.8%) underwent nighttime transplantation (NT). Propensity score matching yielded 187 matched pairs. NT was associated with a higher risk of having any major postoperative adverse event (adjusted odds ratio, 1.731; 95% confidence interval, 1.093-2.741; P = .019), decreased 5-year overall survival (adjusted hazard ratio, 1.798; 95% confidence interval, 1.079-2.995; P = .024), and decreased 5-year bronchiolitis obliterans syndrome-free survival (adjusted hazard ratio, 1.556; 95% confidence interval, 1.098-2.205; P = .013) in doubly robust multivariable analyses after propensity score matching. Overall cost for NT and daytime transplantation was similar. CONCLUSIONS NT was associated with a higher risk of major postoperative adverse events, decreased 5-year overall survival, and decreased 5-year bronchiolitis obliterans syndrome-free survival. Our findings suggest potential benefits of delaying NT to daytime transplantation.
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Affiliation(s)
- Zhizhou Yang
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Tsuyoshi Takahashi
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - William D Gerull
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Christy Hamilton
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Melanie P Subramanian
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Jingxia Liu
- Department of Surgery, Washington University, St Louis, Missouri
| | - Bryan F Meyers
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Benjamin D Kozower
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - G Alexander Patterson
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Ruben G Nava
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Chad A Witt
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Patrick R Aguilar
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Michael K Pasque
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Derek E Byers
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Hrishikesh S Kulkarni
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri
| | - Varun Puri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St Louis, Missouri.
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34
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Gauthier JM, Doyle MBM, Chapman WC, Marklin G, Witt CA, Trulock EP, Byers DE, Hachem RR, Pasque MK, Meyers BF, Patterson GA, Nava RG, Kozower BD, Kreisel D, Chang SH, Puri V. Economic evaluation of the specialized donor care facility for thoracic organ donor management. J Thorac Dis 2020; 12:5709-5717. [PMID: 33209403 PMCID: PMC7656378 DOI: 10.21037/jtd-20-1575] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Over the last decade two alternative models of donor care have emerged in the United States: the conventional model, whereby donors are managed at the hospital where brain death occurs, and the specialized donor care facility (SDCF), in which brain dead donors are transferred to a SDCF for medical optimization and organ procurement. Despite increasing use of the SDCF model, its cost-effectiveness in comparison to the conventional model remains unknown. Methods We performed an economic evaluation of the SDCF and conventional model of donor care from the perspective of U.S. transplant centers over a 2-year study period. In this analysis, we utilized nationwide data from the Scientific Registry of Transplant Recipients and controlled for donor characteristics and patterns of organ sharing across the nation’s organ procurement organizations (OPOs). Subgroup analysis was performed to determine the impact of the SDCF model on thoracic organ transplants. Results A total of 38,944 organ transplants were performed in the U.S. during the study period from 13,539 donors with an observed total organ cost of $1.36 billion. If every OPO assumed the cost and effectiveness of the SDCF model, a predicted 39,155 organ transplants (+211) would have been performed with a predicted total organ cost of $1.26 billion (−$100 million). Subgroup analysis of thoracic organs revealed that the SDCF model would lead to a predicted 156 additional transplants with a cost saving of $24.6 million. Conclusions The U.S. SDCF model may be a less costly and more effective means of multi-organ donor management, particularly for thoracic organ donors, compared to the conventional hospital-based model.
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Affiliation(s)
- Jason M Gauthier
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Maria B Majella Doyle
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - William C Chapman
- Division of Abdominal Organ Transplantation, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Gary Marklin
- Mid-America Transplant, Washington University School of Medicine, Saint Louis, MO, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Elbert P Trulock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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Subramanian MP, Sahrmann JM, Nickel KB, Olsen MA, Bottros M, Heiden B, Semenkovich TR, Meyers BF, Kozower BD, Patterson GA, Nava RG, Kreisel D, Puri V. Assessment of Preoperative Opioid Use Prevalence and Clinical Outcomes in Pulmonary Resection. Ann Thorac Surg 2020; 111:1849-1857. [PMID: 33011165 DOI: 10.1016/j.athoracsur.2020.07.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/11/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Preoperative opioid use is associated with increased health care use after elective abdominal surgery. However, the scope of preoperative opioid use and its association with outcomes have not been described in elective pulmonary resection. This study aimed to characterize prevalent preoperative opioid use in patients undergoing elective pulmonary resection and compare clinical outcomes between patients with and without preoperative opioid exposure. METHODS The study investigators assembled a retrospective cohort of adult patients undergoing elective pulmonary resection by using the IBM Watson Health MarketScan Database (2007 to 2015). The study compared opioid-naïve patients with patients with a history of preoperative opioid exposure (>0 morphine milligram equivalent prescription filled within 90 days before surgery). Multivariable logistic and linear regressions adjusting for patient sociodemographic, comorbidity, and operative characteristics were used to compare odds of postoperative complication, prolonged length-of-stay (>14 days), 30-day postdischarge emergency department visits, 90-day readmissions, and 90-day costs. RESULTS The study identified 14,373 patients, 4502 (31.3%) of whom had opioid exposure before pulmonary resection. In multivariable regression, patients with preoperative opioid exposure had significantly higher odds of experiencing a prolonged length of stay (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.11 to 1.58), 30-day emergency department visits (OR, 1.24; 95% CI, 1.01 to 1.41), and 90-day readmissions (OR, 1.41; 95% CI, 1.28 to 1.55). Adjusted 90-day costs were approximately 5% higher for patients with preoperative opioid use (P < .001). CONCLUSIONS One-third of patients who underwent pulmonary resection used opioids preoperatively and were at risk of experiencing adverse outcomes and having significantly higher health care use. They represent a unique high-risk population that will require novel, targeted interventions.
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Affiliation(s)
- Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri.
| | - John M Sahrmann
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Katelin B Nickel
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Michael Bottros
- Division of Pain Management, Department of Anesthesia, Washington University School of Medicine, St Louis, Missouri
| | - Brendan Heiden
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Tara R Semenkovich
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
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Gerull WD, Yang Z, Kreisel D, Nava R, Meyers BF, Patterson GA, Kozower BD, Hachem RR, Witt C, Byers D, Kulkarni H, Guillamet RV, Marklin G, Puri V. Local versus distant lung donor procurement does not influence short-term clinical outcomes. J Thorac Cardiovasc Surg 2020; 162:1284-1293.e4. [PMID: 32977961 DOI: 10.1016/j.jtcvs.2020.07.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/22/2020] [Accepted: 07/30/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.
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Affiliation(s)
- William D Gerull
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo.
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Chad Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Derek Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Hrishikesh Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | | | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
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Yang Z, Gerull WD, Gauthier JM, Meyers BF, Kozower BD, Patterson GA, Nava RG, Hachem RR, Witt CA, Byers DE, Marklin GF, Ridolfi G, Liu J, Kreisel D, Puri V. Shipping Lungs Greater Distances Increases Costs Without Cutting Waitlist Mortality. Ann Thorac Surg 2020; 110:1691-1697. [PMID: 32511997 DOI: 10.1016/j.athoracsur.2020.04.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/30/2020] [Accepted: 04/19/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND On November 24, 2017, a change in lung allocation policy was initiated to replace the donor service area with a 250-nautical-mile radius circle around the donor hospital. We aim to analyze the consequences of this change, including organ acquisition cost and transplant outcomes, at the national level. METHODS Data on adult patients undergoing lung transplantation between April 27, 2017, and June 22, 2018 (30 weeks before to 30 weeks after allocation policy change) were extracted from the Scientific Registry of Transplant Recipients database. Patients were classified into pre-change and post-change subgroups. Six-month overall survival was evaluated by Kaplan-Meier analysis. Organ acquisition costs were compared between the pre-change and post-change groups. RESULTS Of the 3317 adult patients removed from the waiting list during the study period (pre-change 1637 vs post-change 1680), 2734 underwent transplantation (pre-change 1371 of 1637 [83.8%] vs post-change 1363 of 1680 [81.1%]), and 382 died or became too sick to be transplanted (pre-change 168 of 1637 [10.3%] vs post-change 214 of 1680 [12.7%], P = .077). Six-month survival rates of transplanted patients were similar between the two groups. However, average organ acquisition costs increased after policy change (pre-change $50,735 ± $10,858 vs post-change $53,440 ± $10,247, P < .001) with an increase in nonlocal donors (pre-change 44.3% vs post-change 68.9%, P < .001). CONCLUSIONS Organ acquisition costs and resource utilization increased with the new lung allocation policy, whereas deaths on the waiting list or after transplantation did not decrease. Further optimization of the allocation policy is necessary to balance access to transplant and proper stewardship of human and financial resources.
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Affiliation(s)
- Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - William D Gerull
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Jason M Gauthier
- Department of Surgery, Washington University, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Chad A Witt
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Derek E Byers
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | | | | | - Jingxia Liu
- Department of Surgery, Washington University, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri.
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Patterson GA, Sornette D, Parisi DR. Properties of balanced flows with bottlenecks: Common stylized facts in finance and vibration-driven vehicles. Phys Rev E 2020; 101:042302. [PMID: 32422803 DOI: 10.1103/physreve.101.042302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 03/16/2020] [Indexed: 11/07/2022]
Abstract
We study experimentally the properties of the flow of mechanical vibration-driven vehicles confined in two chambers connected through a narrow opening. We report that the density of particles around the opening presents critical behavior and scaling properties. By mapping this density to the financial market price, we document that the main stylized facts observed in financial systems have their counterparts in the mechanical system. The experimental model accurately reproduces financial properties such as scaling of the price fluctuation, volatility clustering, and multiscaling.
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Affiliation(s)
- G A Patterson
- Instituto Tecnológico de Buenos Aires, CONICET, Lavardén 315, 1437 Ciudad Autónoma de Buenos Aires, Argentina
| | - D Sornette
- Department of Management, Technology and Economics, ETH Zürich, 8092 Zürich, Switzerland; Institute of Risk Analysis, Prediction and Management, Academy for Advanced Interdisciplinary Studies, Southern University of Science and Technology, Shenzhen 518055, China; Tokyo Tech World Research Hub Initiative, Institute of Innovative Research, Tokyo Institute of Technology, Tokyo 152-8550, Japan; and Swiss Finance Institute, University of Geneva, 1211 Geneva, Switzerland
| | - D R Parisi
- Instituto Tecnológico de Buenos Aires, CONICET, Lavardén 315, 1437 Ciudad Autónoma de Buenos Aires, Argentina
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Chang SH, Patterson GA. Granulomatous Inflammation Presenting as a Pulmonary Artery Mass. Ann Thorac Surg 2019; 109:e363-e365. [PMID: 31563494 DOI: 10.1016/j.athoracsur.2019.08.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 11/26/2022]
Abstract
Granulomatous fungal infections are common worldwide, and they can result in mediastinal lymphadenopathy. However, infectious pulmonary artery masses are rare and have only been associated with tuberculosis or mucormycosis. Here, we present a case of histoplasmosis resulting in a pulmonary artery mass, which was treated with debulking and reconstruction of pulmonary vasculature.
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Affiliation(s)
- Stephanie H Chang
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York University, New York, New York.
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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Puri V, Hachem RR, Frye CC, Harrison MS, Semenkovich TR, Lynch JP, Ridolfi G, Rowe C, Meyers BF, Patterson GA, Kozower BD, Pasque MK, Nava RG, Marklin GF, Brockmeier D, Sweet SC, Chapman WC, Kreisel D. Unintended consequences of changes to lung allocation policy. Am J Transplant 2019; 19:2164-2167. [PMID: 30758137 PMCID: PMC6658330 DOI: 10.1111/ajt.15307] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/23/2019] [Accepted: 02/01/2019] [Indexed: 01/25/2023]
Abstract
Organ allocation for transplantation aims to balance the principles of justice and medical utility to optimally utilize a scarce resource. To address practical considerations, the United States is divided into 58 donor service areas (DSA), each constituting the first unit of allocation. In November 2017, in response to a lawsuit in New York, an emergency action change to lung allocation policy replaced the DSA level of allocation for donor lungs with a 250 nautical mile circle around the donor hospital. Similar policy changes are being implemented for other organs including heart and liver. Findings from a recent US Department of Health and Human Services report, supplemented with data from our institution, suggest that the emergency policy has not resulted in a change in the type of patients undergoing lung transplantation (LT) or early postoperative outcomes. However, there has been a significant decline in local LT, where donor and recipient are in the same DSA. With procurement teams having to travel greater distances, organ ischemic time has increased and median organ cost has more than doubled. We propose potential solutions for consideration at this critical juncture in the field of transplantation. Policymakers should choose equitable and sustainable access for this lifesaving discipline.
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Affiliation(s)
- Varun Puri
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Ramsey R. Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - C. Corbin Frye
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - M. Shea Harrison
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Tara R. Semenkovich
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | | | | | - Casey Rowe
- Barnes Jewish Hospital, St. Louis, Missouri
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | | | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Michael K. Pasque
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Ruben G. Nava
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | | | | | - Stuart C. Sweet
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - William C. Chapman
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
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Semenkovich TR, Samson PP, Hudson JL, Subramanian M, Meyers BF, Kozower BD, Kreisel D, Patterson GA, Robinson CG, Bradley JD, Puri V. Induction Radiation Therapy for Esophageal Cancer: Does Dose Affect Outcomes? Ann Thorac Surg 2018; 107:903-911. [PMID: 30444988 DOI: 10.1016/j.athoracsur.2018.09.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/26/2018] [Accepted: 09/29/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Wide variation is seen in the dosage of preoperative induction radiation therapy for esophageal cancer. We investigated associations between outcomes after esophagectomy and dosage of induction radiation therapy. METHODS Patients undergoing induction radiation therapy (30 to 70 Gy), followed by esophagectomy, were identified from the National Cancer Database and classified as low (<40 Gy), standard (40 to 50.4 Gy), and high dose (>50.4 Gy). Perioperative outcomes and overall survival were compared. Subgroup analysis compared two common dosages: 45 Gy and 50.4 Gy. RESULTS From 2004 to 2014, 10,738 patients (84.7%) received standard-dose radiation, increasing from 69.7% in 2004 to 93.6% in 2014 (p < 0.001), 1,329 (10.5%) received low-dose radiation, and 608 (4.8%) received high-dose radiation. Higher rates of pathologic complete response (pCR; low: 11.7%, standard: 16.2%, high: 21.0%; p < 0.001) and downstaging (low: 52.0%, standard: 56.4%, high: 63.1%, p = 0.001) were observed as the dosage increased. On multivariable analysis, compared with standard-dose, high-dose radiation was associated with higher 30-day mortality (odds ratio [OR], 2.11; p < 0.001) without a higher likelihood of downstaging or pCR. Low-dose radiation was associated with lower likelihood of downstaging (OR, 0.85; p = 0.04) and pCR (OR, 0.67; p < 0.001) without lowering the risk of 30-day mortality. The dose of 50.4 Gy was associated with higher likelihood of pCR (OR, 1.12; p = 0.04), without affecting 30-day mortality, compared with 45 Gy. CONCLUSIONS High-dose induction radiation (>50.4 Gy) is associated with increased perioperative death after esophagectomy, without a significant improvement in tumor response. Low-dose radiation (<30 Gy) is associated with worse tumor response without a lower risk of perioperative death. Within standard dosages, 50.4 Gy is associated with higher likelihood of pCR without adversely affecting perioperative mortality compared with 45 Gy.
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Affiliation(s)
- Tara R Semenkovich
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Jessica L Hudson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Melanie Subramanian
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri.
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Abstract
Development of postpneumonectomy empyema with bronchopleural fistula is a life-threatening condition that requires prompt action. Although measures should be taken to prevent bronchopleural fistula at time of pneumonectomy, many patients experience this complication. Management focuses on drainage of the pleural space, control of the pleural infection including repair of the bronchopleural fistula, and obliteration of the residual pleural cavity. Multiple techniques and procedures have been developed over time to achieve these goals. Knowledge of the diverse therapeutic options is important to select the optimal treatment for these complex patients.
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Affiliation(s)
- Alejandro Bribriesco
- Department of Thoracic & Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J4-1, Cleveland, OH 44195, USA.
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, 660 South Euclid, Campus Box 8234, St Louis, MO 63110, USA
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Gauthier JM, Takahashi T, Bierhals AJ, Brody SL, Hachem RR, Witt CA, Byers DE, Yusen RD, Trulock EP, Aguilar PR, Nava RG, Kozower BD, Meyers BF, Patterson GA, Kreisel D, Puri V. Technical Considerations for Lung Transplantation in Kartagener's Syndrome. Ann Thorac Surg 2018; 107:e337-e339. [PMID: 30612988 DOI: 10.1016/j.athoracsur.2018.08.095] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 11/25/2022]
Abstract
Kartagener's syndrome is a rare genetic disorder of ciliated epithelial cells associated with recurrent respiratory tract infections, bronchiectasis, and situs inversus. In some patients, the accumulation of airway secretions and recurrent infections lead to end-stage lung disease, for which lung transplantation is the only effective treatment. Anatomical variations, such as dextrocardia and pulmonary situs inversus, make the procedure challenging, yet feasible with certain technical modifications and careful preparation of donor lungs. We report a case of bilateral lung transplantation without the use of cardiopulmonary bypass in a patient with Kartagener's syndrome while describing important technical details of the operation.
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Affiliation(s)
- Jason M Gauthier
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Andrew J Bierhals
- Division of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Steven L Brody
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Elbert P Trulock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Patrick R Aguilar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Department of Pathology & Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
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Takahashi T, Gauthier JM, Albertin EK, Damiano RJ, Patterson GA, Bierhals AJ, Pasque MK, Hachem RR, Puri V, Kreisel D. Transplantation of Lungs Procured From a Donor With an Atrioesophageal Fistula. Ann Thorac Surg 2018; 107:e121-e122. [PMID: 30081029 DOI: 10.1016/j.athoracsur.2018.06.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/29/2018] [Accepted: 06/09/2018] [Indexed: 11/30/2022]
Abstract
Lung transplantation continues to be limited by a shortage of donor organs. We report the case of procurement and transplantation of lungs from a young donor who died from an atrioesophageal fistula, complicating catheter ablation for atrial fibrillation. Our case illustrates that structural damage to the left atrium is not an absolute contraindication to lung donation. As atrioesophageal fistulas are being increasingly recognized as a rare but often lethal complication of catheter ablation, such donors can contribute to the expansion of the donor pool.
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Affiliation(s)
- Tsuyoshi Takahashi
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jason M Gauthier
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Elizabeth K Albertin
- Transplant Center, Washington University in St. Louis School of Medicine and Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ralph J Damiano
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Andrew J Bierhals
- Department of Radiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Michael K Pasque
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Ramsey R Hachem
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Pathology and Immunology, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
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Abstract
Airway emergencies are life-threatening events that face providers of many different backgrounds. In cannot-intubate-cannot-ventilate situations, emergent access to the airway can be obtained through the cricothyroid membrane by cricothyroidotomy. The 3 main techniques are open, percutaneous, and needle cricothyroidotomy. To date, there is no compelling evidence demonstrating superiority of a particular approach. Ultimately, the method used for cricothyroidotomy should be based on the comfort and experience of the provider performing the procedure.
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Affiliation(s)
- Alejandro Bribriesco
- Department of Thoracic & Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J4-1, Cleveland, OH 44195, USA.
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, 660 South Euclid, Campus Box 8234, St Louis, MO 63110, USA
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46
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Samson P, Puri V, Lockhart AC, Robinson C, Broderick S, Patterson GA, Meyers B, Crabtree T. Adjuvant chemotherapy for patients with pathologic node-positive esophageal cancer after induction chemotherapy is associated with improved survival. J Thorac Cardiovasc Surg 2018; 156:1725-1735. [PMID: 30054137 DOI: 10.1016/j.jtcvs.2018.05.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 03/13/2018] [Accepted: 05/07/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The study objectives were to identify variables associated with the use of adjuvant chemotherapy among patients with node-positive esophageal cancer who received induction therapy and to evaluate its relationship with overall survival. METHODS Treatment data for patients with esophageal cancer receiving induction chemotherapy ± radiotherapy and esophagectomy were abstracted from the National Cancer Data Base. Pathologic node-positive patients were dichotomized by whether they received 2 or more cycles of adjuvant chemotherapy or none. Kaplan-Meier survival curves were generated, and a Cox proportional hazards model was done to identify factors associated with overall survival. RESULTS From 2006 to 2012, 3100 patients had pathologic positive nodes after induction therapy and esophagectomy. A total of 2625 patients (84.7%) did not receive adjuvant chemotherapy, and 475 patients (15.3%) did. N3 nodal stage was associated with an increased likelihood of receiving adjuvant chemotherapy (reference: N1, odds ratio, 1.82, 95% confidence interval, 1.15-2.97, P = .01), whereas increasing age (by year, odds ratio, 0.97, confidence interval, 0.96-0.98, P < .001), induction chemoradiation therapy (reference: induction chemotherapy, odds ratio, 0.39, confidence interval, 0.30-0.52, P < .001), and increasing inpatient length of stay after esophagectomy (per day: odds ratio, 0.98, confidence interval, 0.97-0.99, P = .007) were associated with a decreased likelihood. Patients receiving adjuvant chemotherapy had improved overall survival at each pathologic nodal stage: 31.6 months versus 22.7 months for N1 disease (P < .001), 32.4 months versus 19.2 months for N2 disease (P = .035), and 19.5 months versus 10.4 months for N3 disease (P < .001). Adjuvant therapy was independently associated with decreased mortality hazard (hazard ratio, 0.69, 95% confidence interval, 0.57-0.83, P < .001). CONCLUSIONS Patients receiving adjuvant chemotherapy after induction therapy and esophagectomy show a survival benefit at all positive nodal stages. Prospective studies may help further delineate this benefit.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | | | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Mo
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Johns Hopkins University, Baltimore, Md
| | | | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Southern Illinois University, Springfield, Ill.
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47
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Chang SH, Kreisel D, Marklin GF, Cook L, Hachem R, Kozower BD, Balsara KR, Bell JM, Frederiksen C, Meyers BF, Patterson GA, Puri V. Lung Focused Resuscitation at a Specialized Donor Care Facility Improves Lung Procurement Rates. Ann Thorac Surg 2018; 105:1531-1536. [DOI: 10.1016/j.athoracsur.2017.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
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Balsara KR, Krupnick AS, Bell JM, Khiabani A, Scavuzzo M, Hachem R, Trulock E, Witt C, Byers DE, Yusen R, Meyers B, Kozower B, Patterson GA, Puri V, Kreisel D. A single-center experience of 1500 lung transplant patients. J Thorac Cardiovasc Surg 2018; 156:894-905.e3. [PMID: 29891245 DOI: 10.1016/j.jtcvs.2018.03.112] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 02/28/2018] [Accepted: 03/03/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Over the past 30 years, lung transplantation has emerged as the definitive treatment for end-stage lung disease. In 2005, the lung allocation score (LAS) was introduced to allocate organs according to disease severity. The number of transplants performed annually in the United States continues to increase as centers have become more comfortable expanding donor and recipient criteria and have become more facile with the perioperative and long-term management of these patients. We report a single-center experience with lung transplants, looking at patients before and after the introduction of LAS. METHODS We retrospectively reviewed 1500 adult lung transplants at a single center performed between 1988 and 2016. Patients were separated into 2 groups, before and after the introduction of LAS: group 1 (April 1988 to April 2005; 792 patients) and group 2 (May 2005 to September 2016; 708 patients). RESULTS Differences in demographic data were noted over these periods, reflecting changes in allocation of organs. Group 1 patient average age was 48 ± 13 years, and 404 subjects (51%) were male. Disease processes included emphysema (52%; 412), cystic fibrosis (18.2%; 144), pulmonary fibrosis (16.1%; 128) and pulmonary vascular disease (7.2%; 57). Double lung transplant (77.7%; 615) was performed more frequently than single lung transplant (22.3%; 177). Group 2 average age was 50 ± 14 years, and 430 subjects (59%) were male. Disease processes included pulmonary fibrosis (46%; 335), emphysema (25.8%; 188), cystic fibrosis (17.7%; 127) and pulmonary vascular disease (1.6%; 11). Double lung transplant (96.2%; 681) was performed more frequently than single lung transplant (3.8%; 27). Overall incidence of grade 3 primary graft dysfunction (PGD) in group 1 was significantly lower at 22.1% (175) than in group 2 at 31.6% (230) (P < .001). Nonetheless, overall hospital mortality was not statistically different between the 2 groups (4.4% vs 3.5%; P < .4). Most notably, survival at 1 year was statistically different at 646 (81.6%) for group 1 and 665 (91.4%) for group 2 (P < .02). CONCLUSIONS Patient demographics over the study period have changed with an increased number of fibrotic patients transplanted. In addition, more aggressive strategies with donor/recipient selection appear to have resulted in a higher incidence of primary graft dysfunction. This does not, however, appear to affect patient survival on index hospitalization or at 1 year. In fact, we have observed a significant improvement in survival at 1 year in the more recent era. This observation suggests that continued expansion of possible donors and recipients, coupled with a more sophisticated understanding of primary graft dysfunction and long-term chronic rejection, can lead to increased transplant volume and prolonged survival.
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Affiliation(s)
- Keki R Balsara
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo.
| | - Alexander S Krupnick
- Division of Cardiothoracic Surgery, University of Virginia School of Medicine, Charlottesville, Va
| | - Jennifer M Bell
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Ali Khiabani
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Masina Scavuzzo
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Elbert Trulock
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Chad Witt
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Roger Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Benjamin Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
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49
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Patterson GA, Fierens PI, Sangiuliano Jimka F, König PG, Garcimartín A, Zuriguel I, Pugnaloni LA, Parisi DR. Clogging Transition of Vibration-Driven Vehicles Passing through Constrictions. Phys Rev Lett 2017; 119:248301. [PMID: 29286724 DOI: 10.1103/physrevlett.119.248301] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Indexed: 06/07/2023]
Abstract
We report experimental results on the competitive passage of elongated self-propelled vehicles rushing through a constriction. For the chosen experimental conditions, we observe the emergence of intermittencies similar to those reported previously for active matter passing through narrow doors. Noteworthy, we find that, when the number of individuals crowding in front of the bottleneck increases, there is a transition from an unclogged to a clogged state characterized by a lack of convergence of the mean clog duration as the measuring time increases. It is demonstrated that this transition-which was reported previously only for externally vibrated systems such as colloids or granulars-appears also for self-propelled agents. This suggests that the transition should also occur for the flow through constrictions of living agents (e.g., humans and sheep), an issue that has been elusive so far in experiments due to safety risks.
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Affiliation(s)
- G A Patterson
- Instituto Tecnológico de Buenos Aires, CONICET, Lavardén 315, 1437 C. A. de Buenos Aires, Argentina
| | - P I Fierens
- Instituto Tecnológico de Buenos Aires, CONICET, Lavardén 315, 1437 C. A. de Buenos Aires, Argentina
| | - F Sangiuliano Jimka
- Instituto Tecnológico de Buenos Aires, Lavardén 315, 1437 C. A. de Buenos Aires, Argentina
| | - P G König
- Instituto Tecnológico de Buenos Aires, Lavardén 315, 1437 C. A. de Buenos Aires, Argentina
| | - A Garcimartín
- Departamento de Física y Matemática Aplicada, Facultad de Ciencias, Universidad de Navarra, Pamplona 31080, Spain
| | - I Zuriguel
- Departamento de Física y Matemática Aplicada, Facultad de Ciencias, Universidad de Navarra, Pamplona 31080, Spain
| | - L A Pugnaloni
- Departamento de Ingeniería Mecánica, Facultad Regional La Plata, Universidad Tecnológica Nacional, CONICET, Avenida 60 Esq. 124, 1900 La Plata, Argentina
| | - D R Parisi
- Instituto Tecnológico de Buenos Aires, CONICET, Lavardén 315, 1437 C. A. de Buenos Aires, Argentina
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50
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Hudson JL, Bell JM, Crabtree TD, Kreisel D, Patterson GA, Meyers BF, Puri V. Office-Based Spirometry: A New Model of Care in Preoperative Assessment for Low-Risk Lung Resections. Ann Thorac Surg 2017; 105:279-286. [PMID: 29157739 DOI: 10.1016/j.athoracsur.2017.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 07/26/2017] [Accepted: 08/01/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Formal pulmonary function testing with laboratory spirometry (LS) is the standard of care for risk stratification before lung resection. LS and handheld office spirometry (OS) are clinically comparable for forced expiratory volume in 1 second and forced vital capacity. We investigated the safety of preoperative risk stratification based solely on OS. METHODS Patients at low-risk for cardiopulmonary complications were enrolled in a single-center prospective study and underwent preoperative OS. Formal LS was not performed when forced expiratory volume in 1 second was more than 60% by OS. Propensity score matching was used to compare patients in the OS group to low-risk institutional database patients (2008 to 2015) who underwent LS and lung resection. Standardized mean differences determined model covariate balance. The McNemar test and log-rank test were performed, respectively, for categorical and continuous paired outcome data. RESULTS There were 66 prospectively enrolled patients who received OS and underwent pulmonary resection, and 1,290 patients received preoperative LS, resulting in 52 propensity score-matched pairs (83%). There were no deaths and two 30-day readmissions per group. The major morbidity risk was similar in each group (7.7%). All analyses of discordant pair morbidity had p exceeding 0.56. There was no association between length of stay and exposure to OS vs LS (p = 0.31). The estimated annual institutional cost savings from performing OS only and avoiding LS was $38,000. CONCLUSIONS Low-risk patients undergoing lung resection can be adequately and safely assessed using OS without formal LS, with significant cost savings. With upcoming bundled care reimbursement paradigms, such safe and effective strategies are likely to be more widely used.
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Affiliation(s)
- Jessica L Hudson
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jennifer M Bell
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
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