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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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McMenimen JD, Gauthier JM, Puri V, Vazquez Guillamet R. "Horses for courses" computed tomography or predicted total lung capacity for size matching in lung transplantation. Am J Transplant 2024:S1600-6135(24)00130-8. [PMID: 38346500 DOI: 10.1016/j.ajt.2024.02.004] [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] [Received: 10/31/2023] [Revised: 01/23/2024] [Accepted: 02/02/2024] [Indexed: 02/27/2024]
Abstract
Size-matching donors to recipients in lung transplantation continues to be a clinical challenge. Predicted total lung capacity equations, or more simply, donor and recipient heights, while widely used, are imprecise and may not be representative of the pool of donors and recipients. These inherent limitations may result in size discrepancies. The advent of easily accessible software and the widespread availability of computed tomography (CT) imaging in donor assessments have made it possible to directly measure lung volumes in donors and recipients. As a result, there is a growing interest in adopting personalized CT volumetry as an alternative. This article explores both methods and underscores the potential benefits and precision offered by CT.
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Affiliation(s)
- James D McMenimen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University, St. Louis, Missouri, USA
| | - Jason M Gauthier
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University, St. Louis, Missouri, USA.
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3
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January SE, Hubbard J, Fester KA, Dubrawka CA, Vazquez Guillamet R, Kulkarni HS, Hachem RR. Impact of Angiotensin Blockade on Development of Chronic Lung Allograft Dysfunction. J Pharm Pract 2023:8971900231213699. [PMID: 37923307 DOI: 10.1177/08971900231213699] [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: 11/07/2023]
Abstract
Background: The renin-angiotensin-aldosterone system (RAAS) is responsible for a multitude of physiological functions, including immunological effects such as promotion of TGF-β and upregulation of IL-6 and IL-8 which are also implicated in the development of chronic lung allograft dysfunction (CLAD). Blockade of the RAAS pathway in pre-clinical models has demonstrated a decrease in these cytokines and pulmonary neutrophil recruitment. Objective: This study sought to evaluate whether use of RAAS inhibitor (RAASi) in lung transplant recipients impacted CLAD-free survival. Methods: In this retrospective, single-center study, 35 lung transplant recipients who received a RAASi post-transplant were compared to 70 lung transplant recipients not exposed to a RAASi and were followed for up to 5 years post-transplant. Results: The incidence of CLAD did not differ based on RAASi treatment (34.3% in RAASi vs 38.6%, P-value .668). This was confirmed with a multivariable Cox proportional hazards model with RAASi initiation as a time-varying covariate (RAASi hazard ratio of 1.01, P-value .986). Incidence of hyperkalemia and acute kidney injury were low in the RAASi group. Conclusions: This study demonstrated no association between post-transplant RAASi use and decreased risk of CLAD development. RAASi were also well tolerated in this patient population.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Julie Hubbard
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Keith A Fester
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Casey A Dubrawka
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hrishikesh S Kulkarni
- 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
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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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Escamilla JE, January SE, Vazquez Guillamet R. Diagnosis and Treatment of Fungal Infections in Lung Transplant Recipients. Pathogens 2023; 12:pathogens12050694. [PMID: 37242364 DOI: 10.3390/pathogens12050694] [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: 03/25/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Fungal infections are a significant source of morbidity in the lung transplant population via direct allograft damage and predisposing patients to the development of chronic lung allograft dysfunction. Prompt diagnosis and treatment are imperative to limit allograft damage. This review article discusses incidence, risk factors, and symptoms with a specific focus on diagnostic and treatment strategies in the lung transplant population for fungal infections caused by Aspergillus, Candida, Coccidioides, Histoplasma, Blastomyces, Scedosporium/Lomentospora, Fusarium, and Pneumocystis jirovecii. Evidence for the use of newer triazole and inhaled antifungals to treat isolated pulmonary fungal infections in lung transplant recipients is also discussed.
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Affiliation(s)
- Jesus E Escamilla
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63110, USA
- Rodrigo Vazquez Guillamet, 4921 Parkview Place, Saint Louis, MO 63110, USA
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Heiden BT, Yang Z, Bai YZ, Yan Y, Chang SH, Park Y, Colditz GA, Dart H, Hachem RR, Witt CA, Vazquez Guillamet R, Byers DE, Marklin GF, Pasque MK, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Development and validation of the lung donor (LUNDON) acceptability score for pulmonary transplantation. Am J Transplant 2023; 23:540-548. [PMID: 36764887 PMCID: PMC10234600 DOI: 10.1016/j.ajt.2022.12.014] [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] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
There is a chronic shortage of donor lungs for pulmonary transplantation due, in part, to low lung utilization rates in the United States. We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients database (2006-2019) and developed the lung donor (LUNDON) acceptability score. A total of 83 219 brain-dead donors were included and were randomly divided into derivation (n = 58 314, 70%) and validation (n = 24 905, 30%) cohorts. The overall lung acceptance was 27.3% (n = 22 767). Donor factors associated with the lung acceptance were age, maximum creatinine, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, mechanism of death by asphyxiation or drowning, history of cigarette use (≥20 pack-years), history of myocardial infarction, chest x-ray appearance, bloodstream infection, and the occurrence of cardiac arrest after brain death. The prediction model had high discriminatory power (C statistic, 0.891; 95% confidence interval, 0.886-0.895) in the validation cohort. We developed a web-based, user-friendly tool (available at https://sites.wustl.edu/lundon) that provides the predicted probability of donor lung acceptance. LUNDON score was also associated with recipient survival in patients with high lung allocation scores. In conclusion, the multivariable LUNDON score uses readily available donor characteristics to reliably predict lung acceptability. Widespread adoption of this model may standardize lung donor evaluation and improve lung utilization rates.
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Affiliation(s)
- 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
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, 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
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hank Dart
- 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, St. Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | | | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. 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
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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Vazquez Guillamet R, Rjob A, Bierhals A, Tague L, Marklin G, Halverson L, Witt C, Byers D, Hachem R, Gierada D, Brody SL, Takahashi T, Nava R, Kreisel D, Puri V, Trulock EP. Potential Role of Computed Tomography Volumetry in Size Matching in Lung Transplantation. Transplant Proc 2023; 55:432-439. [PMID: 36914438 PMCID: PMC10225152 DOI: 10.1016/j.transproceed.2023.02.016] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Accumulated knowledge on the outcomes related to size mismatch in lung transplantation derives from predicted total lung capacity equations rather than individualized measurements of donors and recipients. The increasing availability of computed tomography (CT) makes it possible to measure the lung volumes of donors and recipients before transplantation. We hypothesize that CT-derived lung volumes predict a need for surgical graft reduction and primary graft dysfunction. METHODS Donors from the local organ procurement organization and recipients from our hospital from 2012 to 2018 were included if their CT exams were available. The CT lung volumes and plethysmography total lung capacity were measured and compared with predicted total lung capacity using Bland Altman methods. We used logistic regression to predict the need for surgical graft reduction and ordinal logistic regression to stratify the risk for primary graft dysfunction. RESULTS A total of 315 transplant candidates with 575 CT scans and 379 donors with 379 CT scans were included. The CT lung volumes closely approximated plethysmography lung volumes and differed from the predicted total lung capacity in transplant candidates. In donors, CT lung volumes systematically underestimated predicted total lung capacity. Ninety-four donors and recipients were matched and transplanted locally. Larger donor and smaller recipient lung volumes estimated by CT predicted a need for surgical graft reduction and were associated with higher primary graft dysfunction grade. CONCLUSION The CT lung volumes predicted the need for surgical graft reduction and primary graft dysfunction grade. Adding CT-derived lung volumes to the donor-recipient matching process may improve recipients' outcomes.
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Affiliation(s)
- Rodrigo Vazquez Guillamet
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri.
| | - Ashraf Rjob
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Andrew Bierhals
- Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri
| | - Laneshia Tague
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Gary Marklin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Laura Halverson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Chad Witt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Derek Byers
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - Ramsey Hachem
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
| | - David Gierada
- Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri
| | - Steven L Brody
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri; Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri
| | - Tsuyoshi Takahashi
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Ruben Nava
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Varun Puri
- Department of Surgery, Division of Thoracic Surgery, Washington University, St Louis, Missouri
| | - Elbert P Trulock
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, Missouri
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8
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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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9
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Fortis S, Shannon ZK, Garcia CJ, Guillamet RV, Aloe AM, Schweizer ML, Kim V, Nair R. Association of Nonobstructive Chronic Bronchitis With All-Cause Mortality: A Systematic Literature Review and Meta-analysis. Chest 2022; 162:92-100. [PMID: 35150657 DOI: 10.1016/j.chest.2022.02.003] [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: 08/25/2021] [Revised: 12/13/2021] [Accepted: 02/02/2022] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The effect of nonobstructive chronic bronchitis (CB) on mortality is unclear. RESEARCH QUESTION Is nonobstructive CB associated with increased all-cause mortality? STUDY DESIGN AND METHODS We conducted a systematic literature review and meta-analysis to assess the association of nonobstructive CB and all-cause mortality. We searched for articles that included both CB and mortality in the title, abstract, or both in PubMed and EMBASE. We excluded studies in which participants demonstrated obstructive spirometry findings and studies in which CB and mortality were not defined. We used the Newcastle-Ottawa Quality Assessment Scale to assess study quality. We pooled adjusted hazard ratios (HRs) using the random effects model and inverse variance weighting. We conducted stratified analysis by the definition of CB and smoking status. We used Cochran's Q and I2 to assess for heterogeneity. We assessed publication bias by visual inspection of a funnel plot. RESULTS Of 5,014 titles identified, eight fulfilled the inclusion and exclusion criteria. Overall nonobstructive CB was associated with all-cause mortality (HR, 1.37; 95% CI, 1.26-1.50) with no statistically significant heterogeneity (P = .14; I2 = 29%). Nonobstructive CB was associated with increased mortality in studies that defined CB as any respiratory symptoms (broad definition; HR, 1.28; 95% CI, 1.10-1.48; I2 = 0%) as well as in the rest of the studies (HR, 1.40; 95% CI, 1.26-1.56; I2 = 37%). Nonobstructive CB was associated with increased mortality in ever smokers (HR, 1.49; 95% CI, 1.35-1.64; I2 = 0%), but was not associated with increased mortality in never smokers (HR, 1.22; 95% CI, 0.90-1.66), and moderate heterogeneity was found (P = .10; I2 = 49%). The funnel plot did not indicate evidence of a publication bias because it showed symmetrical distribution of studies. INTERPRETATION Nonobstructive CB is associated with increased all-cause mortality, and this association seems to be present only in current and former smokers. Further research should investigate whether this high-risk population may benefit from early therapeutic intervention. TRIAL REGISTRY PROSPERO; No.: CRD42021253596; URL: www.crd.york.ac.uk/prospero.
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Affiliation(s)
- Spyridon Fortis
- Center for Access & Delivery Research & Evaluation, Iowa City VA Health Care System, Iowa City, IA; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA; Department of Epidemiology, College of Public Health, Iowa City, IA.
| | | | - Crystal J Garcia
- Department of Epidemiology, College of Public Health, Iowa City, IA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary, Critical Care and Occupation Medicine, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO
| | - Ariel M Aloe
- Department of Educational Measurement and Statistics, College of Education, Iowa City, IA
| | - Marin L Schweizer
- Center for Access & Delivery Research & Evaluation, Iowa City VA Health Care System, Iowa City, IA; Department of Epidemiology, College of Public Health, Iowa City, IA; Department of Internal Medicine, Division of General Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Rajeshwari Nair
- Center for Access & Delivery Research & Evaluation, Iowa City VA Health Care System, Iowa City, IA; Department of Epidemiology, College of Public Health, Iowa City, IA; Department of Internal Medicine, Division of General Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA
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10
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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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11
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Vazquez Guillamet R, Vazquez Guillamet MC, Rjob A, Bierhals A, Bello I, Abularach AJ, Tague L, Wallendorf M, Marklin GF, Witt C, Byers DE, Kreisel D, Nava R, Puri V, Hachem R, Trulock EP. Uncertainty analysis of chest X-ray lung height measurements and size matching for lung transplantation. J Thorac Dis 2022; 14:1042-1051. [PMID: 35572863 PMCID: PMC9096316 DOI: 10.21037/jtd-21-1755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
Abstract
Background Errors in measuring chest X-ray (CXR) lung heights could contribute to the occurrence of size-mismatched lung transplant procedures. Methods We first used Bland-Altman analysis for repeated measures to evaluate contributors to measurement error of chest X-ray lung height. We then applied error propagation theory to assess the impact of measurement error on size matching for lung transplantation. Results A total 387 chest X-rays from twenty-five donors and twenty-five recipients were measured by two raters. Individual standard deviation for lung height differences were independent of age, sex, donor vs. recipient, diagnostic group and race/ethnicity and all were pooled for analysis. Bias between raters was 0.27 cm (±0.03) and 0.22 cm (±0.06) for the right and left lung respectively. Within subject variability was the biggest contributor to error in measurement, 2.76 cm (±0.06) and 2.78 cm (±0.2) for the right and left lung height. A height difference of 4.4 cm or more (95% CI: ±4.2, ±4.6 cm) between the donor and the recipient right lung height has to be accepted to ensure matching for at least 95% of patients with the same true lung height. This difference decreases to ±1.1 cm (95% CI: ±0.9, ±1.3 cm) when the average from all available chest X-rays is used. The probability of matching a donor and a recipient decreases with increasing true lung height difference. Conclusions Individual chest X-ray lung heights are imprecise for the purpose of size matching in lung transplantation. Averaging chest X-rays lung heights reduced uncertainty.
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Affiliation(s)
- Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Maria C. Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
- Division of Infectious Diseases at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ashraf Rjob
- Division of Infectious Diseases at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Andrew Bierhals
- Radiology Department at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Irene Bello
- Division of Thoracic Surgery and Lung Transplantation at Vall d’Hebron University Hospital, Barcelona, Spain
| | - Alberto Jauregui Abularach
- Division of Thoracic Surgery and Lung Transplantation at Vall d’Hebron University Hospital, Barcelona, Spain
| | - Laneshia Tague
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael Wallendorf
- Division of Statistics at Washington University School of Medicine, St. Louis, MO, USA
| | | | - Chad Witt
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Derek E. Byers
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Daniel Kreisel
- Division of Thoracic Surgery at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ruben Nava
- Division of Thoracic Surgery at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Varun Puri
- Division of Thoracic Surgery at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
| | - Elbert P. Trulock
- Division of Pulmonary and Critical Care Medicine at Washington University - Barnes Jewish Hospital, St. Louis, MO, USA
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12
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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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13
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Reynolds D, Vazquez Guillamet C, Day A, Borcherding N, Vazquez Guillamet R, Choreño-Parra JA, House SL, O'Halloran JA, Zúñiga J, Ellebedy AH, Byers DE, Mudd PA. Comprehensive Immunologic Evaluation of Bronchoalveolar Lavage Samples from Human Patients with Moderate and Severe Seasonal Influenza and Severe COVID-19. J Immunol 2021; 207:1229-1238. [PMID: 34348975 PMCID: PMC8387368 DOI: 10.4049/jimmunol.2100294] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/01/2021] [Indexed: 12/15/2022]
Abstract
Infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) or seasonal influenza may lead to respiratory failure requiring intubation and mechanical ventilation. The pathophysiology of this respiratory failure is attributed to local immune dysregulation, but how the immune response to viral infection in the lower airways of the human lung differs between individuals with respiratory failure and those without is not well understood. We used quantitative multiparameter flow cytometry and multiplex cytokine assays to evaluate matched blood and bronchoalveolar lavage (BAL) samples from control human subjects, subjects with symptomatic seasonal influenza who did not have respiratory failure, and subjects with severe seasonal influenza or SARS-CoV-2 infection with respiratory failure. We find that severe cases are associated with an influx of nonclassical monocytes, activated T cells, and plasmablast B cells into the lower airways. Cytokine concentrations were not elevated in the lower airways of moderate influenza patients compared with controls; however, 28 of 35 measured cytokines were significantly elevated in severe influenza, severe SARS-CoV-2 infection, or both. We noted the largest elevations in IL-6, IP-10, MCP-1, and IL-8. IL-1 family cytokines and RANTES were higher in severe influenza infection than severe SARS-CoV-2 infection. Interestingly, only the concentration of IP-10-correlated between blood and BAL during severe infection. Our results demonstrate inflammatory immune dysregulation in the lower airways during severe viral pneumonia that is distinct from lower airway responses seen in human patients with symptomatic, but not severe, illness and suggest that measurement of blood IP-10 concentration may predict this unique dysregulation.
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Affiliation(s)
- Daniel Reynolds
- Division of Pulmonology and Critical Care, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Cristina Vazquez Guillamet
- Division of Pulmonology and Critical Care, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Aaron Day
- Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Nicholas Borcherding
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonology and Critical Care, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - José Alberto Choreño-Parra
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
- Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, México City, México
| | - Stacey L House
- Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Jane A O'Halloran
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Joaquín Zúñiga
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, México City, México; and
| | - Ali H Ellebedy
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
- Bursky Center for Human Immunology and Immunotherapy Program, Washington University School of Medicine, Saint Louis, MO
| | - Derek E Byers
- Division of Pulmonology and Critical Care, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Philip A Mudd
- Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO;
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14
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Saha A, Browning C, Dandamudi R, Barton K, Graepel K, Cullity M, Abusalah W, Christine D, Rossi C, Drexler N, Basavaraju S, Annambhotia P, Guillamet RV, Eid AJ, Maliakkal J, Miller A, Hugge C, Dharnidharka VR, Kandula P, Moritz MJ. Donor-derived ehrlichiosis: two clusters following solid organ transplantation. Clin Infect Dis 2021; 74:918-923. [PMID: 34329411 DOI: 10.1093/cid/ciab667] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 11/14/2022] Open
Abstract
Ehrlichiosis has been infrequently described as transmissible through organ transplantation. Two donor derived clusters of ehrlichiosis are described here. During the summer of 2020, two cases of ehrlichiosis were reported to the Organ Procurement and Transplantation Network (OPTN) and the Centers for Disease Control and Prevention (CDC) for investigation. Additional transplant centers were contacted to investigate similar illness in other recipients and samples were sent to CDC. Two kidney recipients from a common donor developed fatal ehrlichiosis-induced hemophagocytic lymphocytic histiocytosis (HLH). Two kidney recipients and a liver recipient from another common donor developed ehrlichiosis. All three were successfully treated. Clinicians should consider donor-derived ehrlichiosis when evaluating recipients with fever early after transplantation after more common causes are ruled out, especially if the donor has epidemiological risk factors for infection. Suspected cases should be reported to the organ procurement organization (OPO) and the OPTN for further investigation by public health authorities.
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Affiliation(s)
- Aditi Saha
- Renal and Pancreas Transplant Division and Department of Medicine, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Charles Browning
- Department of Transplant Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Raja Dandamudi
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Kevin Barton
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Kevin Graepel
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Madeline Cullity
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wala Abusalah
- Renal and Pancreas Transplant Division and Department of Medicine, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Du Christine
- Department of Transplant Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Carla Rossi
- Department of Infectious Disease, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Naomi Drexler
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sridhar Basavaraju
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Disease, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pallavi Annambhotia
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Disease, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Albert J Eid
- Division of Infectious Diseases, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joseph Maliakkal
- Division of Pediatric Nephrology, Saint Louis University, Missouri, USA
| | - Aaron Miller
- Division of Pediatric Infectious Disease, Saint Louis University, Missouri, USA
| | - Christopher Hugge
- Division of Pediatric Hematology Oncology, Saint Louis University, Missouri, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Washington University of Medicine St. Louis, Missouri, USA
| | - Praveen Kandula
- Renal and Pancreas Transplant Division and Department of Medicine, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Michael J Moritz
- Department of Transplant Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
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15
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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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16
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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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17
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Vazquez Guillamet R. Chronic Obstructive Pulmonary Disease and the Optimal Timing of Lung Transplantation. Medicina (Kaunas) 2019; 55:medicina55100646. [PMID: 31561607 PMCID: PMC6843760 DOI: 10.3390/medicina55100646] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) accounts for the largest proportion of respiratory deaths worldwide and was historically the leading indication for lung transplantation. The success of lung transplantation procedures is measured as survival benefit, calculated as survival with transplantation minus predicted survival without transplantation. In chronic obstructive pulmonary disease, it is difficult to show a clear and consistent survival benefit. Increasing knowledge of the risk factors, phenotypical heterogeneity, systemic manifestations, and their management helps improve our ability to select candidates and list those that will benefit the most from the procedure.
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Petersen H, Vazquez Guillamet R, Meek P, Sood A, Tesfaigzi Y. Early Endotyping: A Chance for Intervention in Chronic Obstructive Pulmonary Disease. Am J Respir Cell Mol Biol 2019. [PMID: 29522352 DOI: 10.1165/rcmb.2018-0002ps] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 11/24/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a syndrome that comprises several lung pathologies, but subphenotyping the various disease subtypes has been difficult. One reason may be that current efforts focused on studying COPD once it has occurred do not allow tracing back to the different origins of disease. This perspective proposes that emphysema originates when susceptible airway, endothelial, and/or hematopoietic cells are exposed to environmental toxins such as cigarette smoke, biomass fuel, or traffic emissions. These susceptible cell types may initiate distinct pathobiological mechanisms ("COPD endotypes") that ultimately manifest the emphysematous destruction of the lung. On the basis of evidence from the "airway" endotype, we suggest that grading these endotypes by severity may allow better diagnosis of disease at early stages when intervention can be designed on the basis of the mechanisms involved. Therefore, genomic, proteomic, and metabolomic studies on at-risk patients will be important in the identification of biomarkers that help designate each endotype. Together with understanding of the involved molecular pathways that lead to disease manifestation, these efforts may lead to development of intervention strategies.
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Affiliation(s)
- Hans Petersen
- 1 COPD Program, Lovelace Respiratory Research Institute, Albuquerque, New Mexico
| | - Rodrigo Vazquez Guillamet
- 2 Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico; and
| | - Paula Meek
- 3 Adult and Gerontological Health Division, University of Colorado College of Nursing, Colorado
| | - Akshay Sood
- 2 Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico; and
| | - Yohannes Tesfaigzi
- 1 COPD Program, Lovelace Respiratory Research Institute, Albuquerque, New Mexico
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Abukhalaf J, Davidson R, Villalobos N, Meek P, Petersen H, Sood A, Tesfaigzi Y, Vazquez Guillamet R. Chronic obstructive pulmonary disease mortality, a competing risk analysis. Clin Respir J 2018; 12:2598-2605. [DOI: 10.1111/crj.12963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/13/2018] [Accepted: 09/21/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Jawad Abukhalaf
- Department of Internal Medicine; University of New Mexico School of Medicine; Albuquerque New Mexico
| | - Ross Davidson
- Department of Internal Medicine; University of New Mexico School of Medicine; Albuquerque New Mexico
| | - Nicolas Villalobos
- Department of Internal Medicine; University of New Mexico School of Medicine; Albuquerque New Mexico
| | - Paula Meek
- College of Nursing; University of Colorado; Denver Colorado
| | - Hans Petersen
- Lovelace Respiratory Research Institute; Albuquerque New Mexico
| | - Akshay Sood
- Department of Internal Medicine; University of New Mexico School of Medicine; Albuquerque New Mexico
| | | | - Rodrigo Vazquez Guillamet
- Department of Internal Medicine; University of New Mexico School of Medicine; Albuquerque New Mexico
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Abstract
Pulmonary infections in immunocompromised patients remain a significant contributor to mortality, morbidity, and health care-associated costs in such a vulnerable patient population. Their epidemiology is changing, set forth by new trends in immunosuppressive regimens and also prophylaxis. The host characteristics, presenting clinical symptomatology, along with radiographic patterns, have also evolved. The microbiology diagnostics are now enriched with nonculture methods for better identification of the causative pathogens. Chest imaging remains the cornerstone of the initial workup. Our article will examine the new trends in epidemiology, clinical findings, and diagnostics for immunocompromised patients with pulmonary infections (transplant recipients, neutropenic hosts, HIV-infected patients, and patients with autoimmune conditions). We will also review the differential diagnosis that most of the times includes malignancies and drug or radiation-related toxicities.
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Affiliation(s)
| | - Joe Le Hsu
- Stanford University Medical Center, Stanford, CA, USA
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Abstract
The COmorbidity TEst (COTE) is a Chronic Obstructive Pulmonary Disease (COPD)-specific co-morbidity score created to predict mortality. Before its wide application at the University of New Mexico we intended to validate it. The study was conducted at the University of New Mexico Hospital (UNMH) in Albuquerque, NM, USA, a tertiary academic hospital. Consecutive patients with the clinical diagnosis of COPD were identified using the hospital's medical records system and included if they were older than 40 years, had smoked at least 20 pack-years and their post bronchodilator forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) was <0.7 without an alternative diagnosis. The data collected included demographics, co-morbidities as described in the COTE, COPD-specific therapies, spirometry results and mortality. Of 317 patients 51.4% were male, average age was 65.6 ± 9.6 years and the mean post-bronchodilator FEV1 percent predicted (FEV1%) was 52.9 ± 16.9%. 31 (9.8%) patients were on triple long-acting bronchodilator inhaler therapy, 88 (27.8%) on two long-acting bronchodilators and 163 (51.4%) on at least one long-acting bronchodilator. The median follow-up was 3.5 years (IQR = 1.9-6.9). Fifty four patients died by the end of the follow-up period and their median COTE of 4 (IQR = 1-8) was significantly higher than for the survivors with COTE = 1 (IQR = 0-6; p = 0.002). In univariable analyses COTE was positively associated while FEV1%, body mass index (BMI) and gender were negatively associated with all-cause mortality. In multivariable analysis BMI, FEV1% and COTE remained independent predictors for mortality. The COTE is an independent predictor of mortality for COPD patients at UNMH.
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Affiliation(s)
- Nicholas Villalobos
- a Department of Internal Medicine , University of New Mexico School of Medicine , Albuquerque , NM , USA
| | - Ross Davidson
- a Department of Internal Medicine , University of New Mexico School of Medicine , Albuquerque , NM , USA
| | - Uzair K Ghori
- b Department of Internal Medicine , Medical College of Winconsin , Milwaukee , WI , USA
| | - Yara Abdou
- a Department of Internal Medicine , University of New Mexico School of Medicine , Albuquerque , NM , USA
| | - Jawad Abukhalaf
- a Department of Internal Medicine , University of New Mexico School of Medicine , Albuquerque , NM , USA
| | - Rodrigo Vazquez Guillamet
- a Department of Internal Medicine , University of New Mexico School of Medicine , Albuquerque , NM , USA
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Guillamet RV, Petersen H, Meek P, Sood A, Tesfaigzi Y. Grading Severity of Productive Cough Based on Symptoms and Airflow Obstruction. COPD 2018; 15:206-213. [PMID: 29697285 PMCID: PMC6239864 DOI: 10.1080/15412555.2018.1458218] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/20/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
Abstract
The binary approach to the diagnosis of Chronic Bronchitis (CB) is a major barrier to the study of the disease. We investigated whether severity of productive cough can be graded using symptoms and presence of fixed airflow obstruction (FAO), and whether the severity correlates with health status, exposures injurious to the lung, biomarkers of inflammation, and measures of airway wall thickening. Findings from a cross-sectional sample of 1,422 participants from the Lovelace Smokers Cohort (LSC) were validated in 4,488 participants from the COPDGene cohort (COPDGene). Health status was based on the St. George's Respiratory Questionnaire, and Medical Outcomes Study 36-Item Short Form Health Survey. Circulating CC16 levels were quantified by ELISA (LSC), and airway wall thickening was measured using computed tomography (COPDGene). FAO was defined as postbronchodilator FEV1/FVC <0.7. The presence and duration of productive cough and presence of FAO or wheeze were graded into Healthy Smokers, Productive Cough (PC), Chronic PC, PC with Signs of Airflow Obstruction, and Chronic PC with Signs of Airflow Obstruction. In both cohorts, higher grade of severity correlated with lower health status, greater frequency of injurious exposures, greater airway wall thickening, and lower circulating CC16 levels. Further, longitudinal follow-up suggested that disease resolution can occur at every grade of severity but is more common in groups of lower severity and least common once airway remodeling develops. Therefore, severity of productive cough can be graded based on symptoms and FAO and early intervention may benefit patients by changing the natural history of disease.
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Affiliation(s)
| | - Hans Petersen
- COPD Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
| | - Paula Meek
- Adult and Gerontological Health Division, University of Colorado College of Nursing - Denver, CO, USA
| | - Akshay Sood
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Yohannes Tesfaigzi
- COPD Program, Lovelace Respiratory Research Institute, Albuquerque, NM, USA
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Vazquez Guillamet R, Petersen H, Meek PM, Tesfaigzi Y, Sood A. Normalization of FEV 1/FVC Ratio to Greater Than 0.7 Does Not Equal Resolution of Disease. Am J Respir Crit Care Med 2018; 197:834-835. [PMID: 29106290 DOI: 10.1164/rccm.201708-1693le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Hans Petersen
- 2 Lovelace Respiratory Research Institute Albuquerque, New Mexico and
| | - Paula M Meek
- 3 University of Colorado College of Nursing Denver, Colorado
| | | | - Akshay Sood
- 1 University of New Mexico School of Medicine Albuquerque, New Mexico
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Vazquez Guillamet R, Ursu O, Iwamoto G, Moseley PL, Oprea T. Chronic obstructive pulmonary disease phenotypes using cluster analysis of electronic medical records. Health Informatics J 2016; 24:394-409. [PMID: 27856785 DOI: 10.1177/1460458216675661] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic obstructive pulmonary disease is a heterogeneous disease. In this retrospective study, we hypothesize that it is possible to identify clinically relevant phenotypes by applying clustering methods to electronic medical records. We included all the patients >40 years with a diagnosis of chronic obstructive pulmonary disease admitted to the University of New Mexico Hospital between 1 January 2011 and 1 May 2014. We collected admissions, demographics, comorbidities, severity markers and treatments. A total of 3144 patients met the inclusion criteria: 46 percent were >65 years and 52 percent were males. The median Charlson score was 2 (interquartile range: 1-4) and the most frequent comorbidities were depression (36%), congestive heart failure (25%), obesity (19%), cancer (19%) and mild liver disease (18%). Using the sphere exclusion method, nine clusters were obtained: depression-chronic obstructive pulmonary disease, coronary artery disease-chronic obstructive pulmonary disease, cerebrovascular disease-chronic obstructive pulmonary disease, malignancy-chronic obstructive pulmonary disease, advanced malignancy-chronic obstructive pulmonary disease, diabetes mellitus-chronic kidney disease-chronic obstructive pulmonary disease, young age-few comorbidities-high readmission rates-chronic obstructive pulmonary disease, atopy-chronic obstructive pulmonary disease, and advanced disease-chronic obstructive pulmonary disease. These clusters will need to be validated prospectively.
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Affiliation(s)
| | - Oleg Ursu
- University of New Mexico School of Medicine, USA
| | - Gary Iwamoto
- University of New Mexico School of Medicine, USA
| | | | - Tudor Oprea
- University of New Mexico School of Medicine, USA
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