Controlled donation after circulatory death lung transplantation: Results of the French protocol including in situ abdominal normothermic regional perfusion and ex vivo lung perfusion

BACKGROUND

The French national protocol for controlled donation after circulatory determination of death (cDCD) includes normothermic regional perfusion (NRP) in case of abdominal organ procurement and additional ex-vivo lung perfusion (EVLP) before considering lung transplantation (LT).

METHODS

We made a retrospective study of a prospective registry that included all donors considered for cDCD LT from the beginning of the program in May 2016 to November 2021.

RESULTS

One hundred grafts from 14 donor hospitals were accepted by 6 LT centers. The median duration of the agonal phase was 20 minutes [2-166]. The median duration from circulatory arrest to pulmonary flush was 62 minutes [20-90]. Ten lung grafts were not retrieved due to prolonged agonal phases (n = 3), failure of NRP insertion (n = 5), or poor in situ evaluation (n = 2). The remaining 90 lung grafts were all evaluated on EVLP, with a conversion rate of 84% and a cDCD transplantation rate of 76%. The median total preservation time was 707 minutes [543-1038]. Seventy-one bilateral LTs and 5 single LTs were performed for chronic obstructive pulmonary disease (n = 29), pulmonary fibrosis (n = 21), cystic fibrosis (n = 15), pulmonary hypertension (n = 8), graft-versus-host disease (n = 2), and adenosquamous carcinoma (n = 1). The rate of PGD3 was 9% (n = 5). The 1-year survival rate was 93.4%.

CONCLUSION

After initial acceptance, cDCD lung grafts led to LT in 76% of cases, with outcomes similar to those already reported in the literature. The relative impacts of NRP and EVLP on the outcome following cDCD LT should be assessed prospectively in the context of comparative studies.

[What place for lung volume reduction surgery for emphysema?]

Lung volume reduction surgery (LVRS) has been part of the management for the treatment of selected emphysematous patients for two decades. In a large randomized American trial (NETT), lung volume reduction surgery was shown to improve overall survival at 5 years as well as exercise capacity and health-related quality of life, especially in cases of upper-lobe-predominant emphysema and low exercise capacity. Inclusion criteria were pretreatment FEV1≤45 %, TLC≥100 %, RV≥150 %, room air resting PaCO₂≤60mmHg and PaO₂≥45mmHg. Patients with FEV1≤20 % and either a DLCO<20 % or homogeneous emphysema were at increased risk of mortality following LVRS and should not be considered for this procedure. Despite this evidence base, lung volume reduction surgery is performed infrequently, competing with lung transplantation and new endoscopic volume reduction techniques.

Clinical significance of Koebner phenomenon in vitiligo

BACKGROUND

The clinical significance of Koebner phenomenon (KP) in vitiligo with respect to disease activity and course is still debatable. Recently, a new classification was introduced for the assessment of KP.

OBJECTIVES

To evaluate the new assessment method for KP in clinical practice and to determine its clinical significance, both with respect to the clinical profile, course of vitiligo and treatment response.

METHODS

Seven hundred patients with generalized vitiligo were included in this observational cohort study. KP was classified according to the new classification system into different subtypes [KP1, by history; KP2A and KP2B, by clinical examination (A, lesions on friction areas; B, linear, artefactual lesions)].

RESULTS

KP1 was positive in 34·1% of the patients, 66·3% were KP2A positive and 15·1% showed KP2B. The body surface area (BSA) was significantly (P < 0·001) higher in the presence of any KP subtype and more disease activity was found in KP1-positive and KP2B-positive patients. An earlier age at onset and elevated risk of further depigmentation despite treatment were observed in all KP-positive groups. In KP2A- and KP2B-positive patients, depigmentation of wrists/ankles was more common. In the KP2A-positive group, a significantly higher prevalence of thyroid disease was found while autoimmune diseases were less prevalent in KP2B-positive patients.

CONCLUSION

The new assessment method for KP, taking into account both history and clinical examination, seems to be a useful and valuable tool for assessing KP in daily practice. Our results support the hypothesis that KP may function as a clinical parameter to assess and predict the clinical profile and course of vitiligo.

Enrichment and properties of a 1,2,4-trichlorobenzene-dechlorinating methanogenic microbial consortium

A methanogenic microbial consortium capable of reductively dechlorinating 1,2,4-trichlorobenzene (1,2,4-TCB) was enriched from a mixture of polluted sediments. 1,2,4-TCB was dechlorinated via 1,4-dichlorobenzene (1,4-DCB) to chlorobenzene (CB). Lactate, which was used as an electron donor during the enrichment, was converted via propionate and acetate to methane. Glucose, ethanol, methanol, propionate, acetate, and hydrogen were also suitable electron donors for dechlorination, whereas formate was not. The addition of 5% (wt/vol) sterile Rhine River sand was necessary to maintain the dechlorinating activity of the consortium. The addition of 2-bromoethanesulfonic acid (BrES) inhibited methanogenesis completely but had no effect on the dechlorination of 1,2,4-TCB. The consortium was also able to dechlorinate other chlorinated benzenes via various simultaneous pathways to 1,3,5-TCB, 1,2-DCB, 1,3-DCB, or CB as an end product. The addition of BrES inhibited several of the simultaneously occurring dechlorination pathways of 1,2,3,4- and 1,2,3,5-tetrachlorobenzene and of pentachlorobenzene, which resulted in the formation of CB as the only final product. Hexachlorobenzene and polychlorinated biphenyls (PCBs) were dechlorinated after a lag phase of ca. 15 days, showing a dechlorination pattern that is different from those observed for lower chlorinated benzenes: only chlorines with two adjacent chlorines were removed. The results show that the consortium possesses at least three distinct dechlorination activities toward chlorinated benzenes and PCBs.

Contingency arrangements do not necessarily equal fraud and abuse

Many healthcare organizations avoid entering contingency-based arrangements with consulting firms that specialize in Medicare revenue optimization because they fear Federal investigation of such an arrangement might lead to a finding of fraud and abuse. A Medicare fraud alert issued by the HHS Office of the Inspector General (OIG) appears to justify that fear, suggesting that contingency arrangements are inherently unethical. Nonetheless, current Federal regulations clearly allow healthcare organizations to enter into contingency-based relationships with consulting firms to seek legitimate optimal payment. Healthcare organizations may do so without fear of Federal legal action if they ensure that the consultant is ethical and competent and that the DRG review process used is both legitimate and retrospective, subjecting all recommended changes to approval by both the healthcare organization and appropriate peer review organization.

[Myxoid schwannoma of the forearm. A case report]

Tumors arising from or located within a peripheral nerve are not common and recognition and treatment are difficult. We report a patient with a myxoid swannoma surrounding the axon of ulnar nerve. This 50-year old woman had pain and tenderness. Careful clinical and technical investigation--including CT and angiography--could not give a definite diagnosis preoperatively. The patient was cured by simple enucleation without damage to the axon bundles. At surgery the appearance of the tumor was typical. An oval, encapsulated mass measuring up to 5.5 by 9 centimeters in diameter was seen. Only biopsy and pathologic examination can exclude malignancy. After follow-up of 48 months no local recurrence of the tumor was found.