Public Perception of Ideal Areola Proportions

BACKGROUND

In breast reconstruction, mastopexy, and breast reduction procedures, surgeons make decisions about the resulting areola size, and this significantly impacts the overall aesthetic result. Despite the importance of these decisions, little is known about the general population's preferences for areola size. The objective of this study was to survey the global population to better understand the public's perceptions of ideal areola dimensions.

METHODS

A survey was developed with 9 different composite diagrams of a female torso (every combination of 3 breast widths and 3 waist widths). In each composite diagram, 6 different areola sizes were shown (areola-to-breast diameter ranging from 1:12 to 6:12). The survey was distributed via the Amazon Mechanical Turk digital platform, and respondents' demographics (sex, age, race/ethnicity, country, and state if located in the United States) and preferences for the most aesthetically pleasing size in each composite diagram were recorded.

RESULTS

Among 2259 participants, with 1283 male (56.8%) and 976 female (43.2%), most participants were between 25 and 34 years old (1012, 44.8%), were from the United States (1669, 73.9%), and identified as White (1430, 63.3%). With 9 breast width and waist width combinations, the respondents were most likely to prefer the 2:12 (32.9%) areola-to-breast ratio ( P < 0.0001). The second most commonly preferred ratio was 3:12 (30.6%) ( P < 0.0001). Gender subgroup analysis showed that women preferred middle-range ratios, such as 2:12, 3:12, and 4:12 ( P < 0.0001). Meanwhile, men were more likely to prefer extreme ratios of 1:12 or 6:12 ( P < 0.0001). Across almost all races/ethnicities, 2:12 was significantly the most popular, except among American Indian/Alaskan Native and Middle Eastern where 3:12 was the most preferred ( P < 0.0001). Within the top 6 countries (United States, India, Brazil, Italy, Canada, United Kingdom), the United States, India, and Italy preferred 2:12, and Brazil, Canada, and the United Kingdom preferred 3:12 ( P < 0.0001).

CONCLUSIONS

This study provides the first objective data on public impressions of the ideal areola proportions and can serve as a guide for surgical decision making in breast reconstruction and reshaping procedures.

Out of the Frying-Pan and into the Fire: Transplant Candidate Selection in Acute Lung Failure Due to SARS-CoV-2 Infection

Purpose

The COVID-19 pandemic led to unprecedented rates of acute lung failure (ALF), and a rise in lung transplantation (LTx) referrals. Data on LTx in ALF is limited to LTx outcomes, and the unpredictable course of SARS-CoV-2 makes candidate selection challenging. This study summarizes our experiences, in both patients transplanted and those we declined.

Methods

LTx referrals for ALF due to SARS-CoV-2 between 01Apr20-01Oct21 were reviewed. Set parameters were collected prospectively. Acceptance criteria reflected previous guidance. Cases were discussed at our multi-disciplinary meeting and suitable candidates evaluated at source before transfer for consent and listing. Internal follow-up and external data from declined patients were retrospectively analysed, with survival to discharge and length of hospital stay as end-points.

Results

45 patients were referred (78% male). Median age was 55.8 [IQR 47.6-59.8] years. 36 (80%) required both mechanical ventilation and vvECMO, of median duration 46 [31-82] and 34 [24-72] days respectively. Consolidation was the commonest CT finding (47%). Bacterial colonisation (23/45, 51%), coagulopathy (21/45, 47%) and hepatic dysfunction (11/45, 24%) were common. Twenty-two patients were conscious, of whom 21 were evaluated. Five patients died during evaluation, from either sepsis or bleeding. One failed evaluation, and one withdrew consent. Six patients improved, making urgent LTx unnecessary, with 5 attending our review clinic. Of the 8 patients successfully evaluated, one died unexpectantly awaiting transfer, one improved at listing and a further patient died of sepsis after listing. Three patients underwent LTx, all being discharged home at 3 months post-LTx.

Conclusion

LTx candidate selection in critically ill SARS-CoV2 patients is challenging. Late recovery, particularly in non-fibrotic ALF is not unusual. Decision-making needs to include “acceptable morbidity” as a prelude to delayed evaluation and perhaps listing. More data is needed about declined candidates, particularly unweanable sedated patients with single-organ failure. Even successful awake recipients may experience significant psychological injury, underlining previous arguments in sedated patients. Equity to all candidates needs consideration, given the extraordinary demands on organ availability and care resources.

Mycoplasma decontamination in Chlamydia trachomatis culture: a curative approach

Mycoplasma contamination of cell culture represents a serious problem in research and decontamination from cell-propagated obligate intracellular bacteria has proven challenging. Here, we presented an optimized protocol to remove Mycoplasma from contaminated Chlamydia trachomatis culture. A stepwise procedure of Mycoplasma removal entails (i) incubation in nonionic detergent containing solution, and (ii) separation of viable chlamydial organisms by fluorescence-activated cell sorting (FACS), followed by subcloning using a focus-forming assay. We also adapted a polymerase chain reaction (PCR) assay using paired universal and Mycoplasma-specific primers, which are distinguishable from the C. trachomatis counterparts, in combination with Sanger sequencing to determine the presence of mycoplasmas' 16S rRNA genes. These integrated approaches allow for full removal of Mycoplasma, as verified by the improved PCR assay, without compromising the capacity of viable C. trachomatis to adapt to new infection in epithelial cells. Some pitfalls during the Mycoplasma decontamination process are discussed.

The Impact of Perioperative Blood Pressure on Hematoma Development After Panniculectomy

PURPOSE

Hematoma affects 10% to 13% of patients undergoing panniculectomy. Although elevated perioperative blood pressure has been associated with hematoma after rhytidectomy, this has not been established for panniculectomy. We sought to determine the impact of perioperative blood pressure on hematoma development in patients undergoing panniculectomy.

METHODS

A retrospective review was performed on patients undergoing isolated panniculectomy procedures. Blood pressure parameters recorded included systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial pressure. The mean, peak, and trough blood pressure values were recorded. Preoperative, intraoperative, and postoperative blood pressures were recorded, and differences between phases were calculated. Univariate and multivariate logistic regressions were performed.

RESULTS

One hundred forty-three patients were identified, which included 84% (n = 120) women and 17% (n = 23) men. A history of hypertension was present in 55% (n = 79) of patients, of which 91% (n = 72) were medically controlled. Preoperative antiplatelet or anticoagulation was used in 21% (n = 31) of patients. Seven patients (5%) developed a hematoma, of which 5 required operative drainage. Development of hematoma was not associated with patient, surgical, or postoperative pain variables. There was an association between hematoma and elevated postoperative blood pressures on univariate and multivariate analyses. The mean peak SBP in the hematoma group was 160 mm Hg in comparison to 141 mm Hg in the nonhematoma group. For each 10-mm Hg increase in postoperative peak SBP, the odds of a hematoma increased by 2.8 times. When comparing phases of care, hematoma patients had similar intraoperative and postoperative peak SBP, but their postoperative SBP was 19 mm Hg higher than preoperative baseline. Conversely, nonhematoma patients had a postoperative blood pressure that was similar to their preoperative baseline and 20 mm Hg lower than their intraoperative values.

CONCLUSIONS

Hematoma is associated with elevated postoperative blood pressures. A postoperative mean peak SBP of 160 mm Hg was associated with hematoma, and for each 10 mm Hg, the risk of hematomsa increased by 2.8 times. The risk of hematoma may be reduced by strict postoperative blood pressure control. We recommend a postoperative peak SBP goal of 140 mm Hg or less, with a value equal to or less than their preoperative baseline and 20 mm Hg lower than their intraoperative pressure.

Media supplementation for targeted manipulation of monoclonal antibody galactosylation and fucosylation

Monoclonal antibodies are critically important biologics as the largest class of molecules used to treat cancers, rheumatoid arthritis, and other chronic diseases. Antibody glycosylation is a critical quality attribute that has ramifications for patient safety and physiological efficacy-one that can be modified by such factors as media formulation and process conditions during production. Using a design-of-experiments approach, we examined the effect of 2-F-peracetyl fucose (2FP), uridine, and galactose on cell growth and metabolism, titer, and gene expression of key glycosylation-related proteins, and report how the glycoform distribution changed from Days 4 to 7 in a batch process used for IgG1 production from Chinese hamster ovary cells. We observed major glycosylation changes upon supplement addition, where the addition of 2FP decreased antibody fucosylation by up to 48%, galactose addition increased galactosylation by up to 21%, and uridine addition decreased fucosylation and increased galactosylation by 6% and 2%, respectively. Despite having major effects on glycosylation, neither galactose nor 2FP significantly affected cell culture growth, metabolism, or titer. Uridine improved peak cell densities by 23% but also reduced titer by ∼30%. The supplements caused significant changes in gene expression by Day 4 of the cultures where 2FP addition significantly reduced fucosyltransferase 8 and nucleotide sugar transporter gene expression (by ∼2-fold), and uridine addition significantly increased expression of UDP-GlcNAcT (SLC35A3) and B4GALT1-6 genes (by 1.5-3-fold). These gene expression data alongside glycosylation, metabolic, and growth data improve our understanding of the cellular mechanisms affected by media supplementation and suggest approaches for modifying antibody glycosylation in antibody production processes.

A228 EVOLUTION OF MRE FINDINGS IN PAEDIATRIC PATIENTS WITH SMALL BOWEL CROHN’S DISEASE ON MAINTENANCE METHOTREXATE

Background

Observational data in children and RCT data in adults indicate that methotrexate (MTX) is associated with induction and maintenance of clinical remission in luminal Crohn’s disease, but efficacy in achieving intestinal healing has not been examined.

Aims

To examine the evolution of MRE signs of inflammation in children treated with MTX.

Methods

In this retrospective cohort study, we reviewed paediatric CD patients on maintenance MTX monotherapy for &gt;4 months who underwent serial MREs between July 2010 and October 2015. MREs were reviewed by a radiologist blind to clinical data. Overall inflammatory activity on each MRE was scored as minimal, mild, moderate or severe, informed by the presence of bowel wall thickness, wall enhancement, T2 hyperintensity, comb sign, mesenteric edema, penetrating disease, stricturing, diffusion restriction and motility. The radiologist’s global assessment of change from MRE 1 to MRE 2 was scored as improved, unchanged or worsened. Clinical findings, disease activity (assessed by weighted paediatric CD activity index [wPCDAI]) and surgical history were also extracted from medical records by a clinician blind to MRE results.

Results

Thirty-five patients were included (median age at diagnosis 12 [IQR 11–14] years; 77% male; 60% inflammatory (B1), 17% stricturing (B2), 23% penetrating (B3) disease). Between baseline and follow-up MRE, wPCDAI (median 15 [IQR 7–43] decreased to 8 [IQR 0–18]; p=0.006) and CRP (median 9 [IQR 2–36] decreased to 5 [IQR 5–9]; p=0.013) and 74% (N=26) were in clinical remission (wPCDAI &lt; 12.5) at MRE 2. MRE features that significantly improved from MRE 1 to 2 were comb sign from 63% (N=37) to 38% (N=14) (p=0.02) and penetrating disease from 14% (N=8) to 0 (p=0.03). After a median of 17 months (IQR 13–23), 51% (N=18) of patients improved, 29% (N=10) worsened and 20% (N=7) had no change based on the radiologist’s global assessment. Of the 21 patients with moderate/severe disease at MRE 1, 33% (N=7) had minimal/mild disease by MRE 2. 66% (N=14/21) continued to have moderate/severe disease at MRE 2. Additionally, a further 14% (N=2/14) of those with minimal/mild disease at baseline MRE progressed to moderate/severe disease at MRE 2. Complete details of change between MRE 1 and MRE 2 are displayed in Figure 1.

Conclusions

Despite signs of clinical improvement, many paediatric CD patients on maintenance MTX therapy for &gt;4 months have unchanged or worsened MRE findings. This underscores the need for follow-up imaging in these cases.

Funding Agencies

None

Detection of chronic lung allograft dysfunction using ventilation-weighted Fourier decomposition MRI

Chronic lung allograft dysfunction (CLAD) remains the leading cause of morbidity and mortality after lung transplantation. Diagnosis requires spirometric change, which becomes increasingly difficult with advancing CLAD. Fourier decomposition magnetic resonance imaging (FD-MRI) permits acquisition of ventilated-weighted images during free-breathing. This study evaluates FD-MRI in detecting CLAD in selected patients after bilateral lung transplantation (DLTx). DLTx recipients demonstrating CLAD at various stages participated. Radiologists remained blinded to clinical status until completion of image analysis. Image acquisition used a 1.5-T MR scanner using a spoiled gradient echo sequence. After FD processing and regional fractional ventilation (RFV) quantification, the volume defect percentage at 2 thresholds (VDP_1,2 ), median lung RFV and quartile coefficient of dispersion (QCD) were calculated. Sixty-two patients participated. CLAD was present in 29/62 (47%) patients, of whom 17/62 (27%) had forced expiratory volume in 1 second ≤65% at image acquisition. VDP₁ was higher among these participants compared to other groups (P < .001). Increased VDP₁ was associated with subsequent graft loss, with values >2% showing reduced survival, independent of degree of graft dysfunction (P = .005). VDP₂ discriminated between presence or absence of CLAD (area under the curve = 0.71; P = .03). QCD increased significantly with advancing disease (P < .001). In conclusion, FD-MRI-derived parameters demonstrate potential in quantitative CLAD diagnosis and assessment after DLTx.

Abstract 3789: Role of NOS2-COX2 crosstalk in tumor microenvironment of estrogen receptor-negative breast cancer and its therapeutic implications

Tumor is often described as a wound that never heals. This leads to a chronic inflammatory tumor microenvironment characterized by infiltration of M2 macrophages and Th2 cells causing dysregulated release of multiple cytokines, chemokines and growth factors, thus creating a conducive environment for tumor growth and metastasis. In spite of significant progress in breast cancer treatment, metastatic breast cancer still remains a major health hazard with a high mortality rate among women. Moreover, there is cellular heterogeneity within and among different breast tumors, which poses a significant challenge in developing effective therapeutics, thus making it important to understand subtype-specific mechanisms. Our laboratory and other groups have previously shown that inducible nitric oxide synthase (NOS2), an enzyme involved in production and regulation of endogenous nitric oxide (NO), is a predictor of poor survival among highly metastatic ER-negative (ER-) breast cancer patients. Another proinflammatory enzyme, cyclooxygenase-2 (COX2,) responsible for conversion of arachidonic acid to prostaglandin E2 (PGE2), is also highly expressed in breast cancer and is detectable in ductal carcinoma in situ, invasive breast carcinoma, and metastatic lesions. We investigated the role of inflammation associated enzymes, NOS2 and COX2, and established that their simultaneous elevated expression significantly reduced patient survival (33%) when compared to greater than 95% survival of ER- patients with low NOS2/COX2 tumor expression. We further investigated their tumor subtype specific novel signaling mechanism in vitro and showed TNFα and/or endoplasmic reticulum stress as key players. Proinflammatory cytokines present in tumor microenvironment play a key role in regulation of this pathway and effectiveness of chemotherapeutics. Moreover, the ability of NOS2 and COX2 to regulate different cytokines in the tumor microenvironment further emphasizes the importance of their crosstalk in tumor progression, metastasis and ability of cancer cells to escape immune surveillance. Last, we demonstrated that simultaneous inhibition of COX2 and NOS2 using commercially available inhibitors significantly reduced tumor growth in murine models of ER- breast cancer, thus suggesting the beneficial effects of dual NOS2/COX2 therapy.

Citation Format: Debashree Basudhar, Sharon Glynn, Madison Greer, Veena Somasundaram, Jae H. No, David A. Scheiblin, Pablo Garrido, William F. Heinz, Aideen E. Ryan, Jonathan M. Weiss, Robert Y. Cheng, Lisa A. Ridnour, Stephen J. Lockett, Daniel W. McVicar, Stefan Ambs, David A. Wink. Role of NOS2-COX2 crosstalk in tumor microenvironment of estrogen receptor-negative breast cancer and its therapeutic implications [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3789.

Breath volatile organic compounds of lung transplant recipients with and without chronic lung allograft dysfunction

INTRODUCTION

Chronic lung allograft dysfunction with its clinical correlative of bronchiolitis obliterans syndrome (BOS) remains the major limiting factor for long-term graft survival. Currently there are no established methods for the early diagnosis or prediction of BOS. To assess the feasibility of breath collection as a non-invasive tool and the potential of breath volatile organic compounds (VOC) for the early detection of BOS, we compared the breath VOC composition between transplant patients without and different stages of BOS.

METHODS

75 outpatients (25 BOS stage 0, 25 BOS stage 1 + 2, 25 BOS stage 3) after bilateral lung transplantation were included. Exclusion criteria were active smoking, oxygen therapy and acute infection. Patients inhaled room air through a VOC and sterile filter and exhaled into an aluminum reservoir tube. Breath was loaded directly onto Tenax^® TA adsorption tubes and was subsequently analyzed by gas-chromatography/mass-spectrometry.

RESULTS

The three groups were age and gender matched, but differed with respect to time since transplantation, the spectrum of underlying disease, and treatment regimes. Relative to patients without BOS, BOS stage 3 patients showed a larger number of different VOCs, and more pronounced differences in the level of VOCs as compared to BOS stage 1 + 2 patients. Logistic regression analysis found no differences between controls and BOS 1 + 2, but four VOCs (heptane, isopropyl-myristate, ethyl-acetate, ionone) with a significant contribution to the discrimination between controls and BOS stage 3. A combination of these four VOCs separated these groups with an area under the curve of 0.87.

CONCLUSION

Breath sample collection using our reservoir sampler in the clinical environment was feasible. Our results suggest that breath VOCs can discriminate severe BOS. However, convincing evidence for VOCs with a potential to detect early onset BOS is lacking.

"White-Out" After Lung Transplantation: A Multicenter Cohort Description of Late Acute Graft Failure

Graft failure represents a leading cause of mortality after organ transplantation. Acute late-onset graft failure has not been widely reported. The authors describe the demographics, CT imaging-pathology findings, and treatment of patients presenting with the latter. A retrospective review was performed of lung transplant recipients at two large-volume centers. Acute late-onset graft failure was defined as sudden onset of bilateral infiltrates with an oxygenation index <200 without identifiable cause or concurrent extrapulmonary organ failure. Laboratory, bronchoalveolar lavage (BAL), radiology, and histology results were assessed. Between 2005 and 2016, 21 patients were identified. Median survival was 19 (IQR 13-36) days post onset. Twelve patients (57%) required intensive care support at onset, 12 (57%) required mechanical ventilation, and 6 (29%) were placed on extracorporeal life support. Blood and BAL analysis revealed elevated neutrophilia, with CT demonstrating diffuse ground-glass opacities. Transbronchial biopsy samples revealed acute fibrinoid organizing pneumonia (AFOP), organizing pneumonia, and diffuse alveolar damage (DAD). Assessment of explanted lungs confirmed AFOP and DAD but also identified obliterative bronchiolitis. Patients surviving to discharge without redo transplantation (n = 2) subsequently developed restrictive allograft syndrome. This study describes acute late-onset graft failure in lung allograft recipients, without known cause, which is associated with a dismal prognosis.

Association of Higher CD4+ CD25high CD127low , FoxP3+ , and IL-2+ T Cell Frequencies Early After Lung Transplantation With Less Chronic Lung Allograft Dysfunction at Two Years

Regulatory T cells (Treg) can regulate alloantigens and may counteract chronic lung allograft dysfunction (CLAD) in lung transplantation. We analyzed Treg in peripheral blood prospectively and correlated percentages of subpopulations with the incidence of CLAD at 2 years. Among lung-transplanted patients between January 2009 and July 2011, only patients with sufficient Treg measurements were included into the study. Tregs were measured immediately before lung transplantation, at 3 weeks and 3, 6, 12, and 24 months after transplantation and were defined as CD4⁺ CD25^high T cells and further analyzed for CTLA4, CD127, FoxP3, and IL-2 expressions. Between January 2009 and July 2011, 264 patients were transplanted at our institution. Among the 138 (52%) patients included into the study, 31 (22%) developed CLAD within 2 years after transplantation. As soon as 3 weeks after lung transplantation, a statistically significant positive association was detected between Treg frequencies and later absence of CLAD. At the multivariate analysis, increasing frequencies of CD4⁺ CD25^high CD127^low , CD4⁺ CD25^high FoxP3⁺ and CD4⁺ CD25^high IL-2⁺ T cells at 3 weeks after lung transplantation emerged as protective factors against development of CLAD at 2 years. In conclusion, higher frequencies of specific Treg subpopulations early after lung transplantation are protective against CLAD development.

Cost-Effectiveness of Caries Prevention in Practice: A Randomized Controlled Trial

A 2-arm parallel-group randomized controlled trial measured the cost-effectiveness of caries prevention in caries-free children aged 2 to 3 y attending general practice. The setting was 22 dental practices in Northern Ireland. Participants were centrally randomized into intervention (22,600 ppm fluoride varnish, toothbrush, a 50-mL tube of 1,450 ppm fluoride toothpaste, and standardized prevention advice) and control (advice only), both provided at 6-monthly intervals during a 3-y follow-up. The primary outcome measure was conversion from caries-free to caries-active states assessed by calibrated and blinded examiners; secondary outcome measures included decayed, missing, or filled teeth surfaces (dmfs); pain; and extraction. Cumulative costs were related to each of the trial’s outcomes in a series of incremental cost effectiveness ratios (ICERs). Sensitivity analyses examined the impact of using dentist’s time as measured by observation rather than that reported by the dentist. The costs of applying topical fluoride were also estimated assuming the work was undertaken by dental nurses or hygienists rather than dentists. A total of 1,248 children (624 randomized to each group) were recruited, and 1,096 (549 in the intervention group and 547 in the control group) were included in the final analyses. The mean difference in direct health care costs between groups was £107.53 (£155.74 intervention, £48.21 control, P < 0.05) per child. When all health care costs were compared, the intervention group’s mean cost was £212.56 more than the control group (£987.53 intervention, £774.97 control, P < 0.05). Statistically significant differences in outcomes were only detected with respect to carious surfaces. The mean cost per carious surface avoided was estimated at £251 (95% confidence interval, £454.39–£79.52). Sensitivity analyses did not materially affect the study’s findings. This trial raises concerns about the cost-effectiveness of a fluoride-based intervention delivered at the practice level in the context of a state-funded dental service (EudraCT No: 2009-010725-39; ISRCTN: ISRCTN36180119).

A Randomized Controlled Trial of Caries Prevention in Dental Practice

We conducted a parallel group randomized controlled trial of children initially aged 2 to 3 y who were caries free, to prevent the children becoming caries active over the subsequent 36 mo. The setting was 22 dental practices in Northern Ireland, and children were randomly assigned by a clinical trials unit (CTU) (using computer-generated random numbers, with allocation concealed from the dental practice until each child was recruited) to the intervention (22,600-ppm fluoride varnish, toothbrush, 50-mL tube of 1,450 ppm fluoride toothpaste, and standardized, evidence-based prevention advice) or advice-only control at 6-monthly intervals. The primary outcome measure was conversion from caries-free to caries-active states. Secondary outcome measures were number of decayed, missing, or filled teeth (dmfs) in caries-active children, number of episodes of pain, and number of extracted teeth. Adverse reactions were recorded. Calibrated external examiners, blinded to the child's study group, assessed the status of the children at baseline and after 3 y. In total, 1,248 children (624 randomized to each group) were recruited, and 1,096 (549 intervention, 547 control) were included in the final analyses. Eighty-seven percent of intervention and 86% of control children attended every 6-mo visit ( P = 0.77). A total of 187 (34%) in the intervention group converted to caries active compared to 213 (39%) in the control group (odds ratio, 0.81; 95% confidence interval, 0.64-1.04; P = 0.11). Mean dmfs of those with caries in the intervention group was 7.2 compared to 9.6 in the control group ( P = 0.007). There was no significant difference in the number of episodes of pain between groups ( P = 0.81) or in the number of teeth extracted in caries-active children ( P = 0.95). Ten children in the intervention group had adverse reactions of a minor nature. This well-conducted trial failed to demonstrate that the intervention kept children caries free, but there was evidence that once children get caries, it slowed down its progression (EudraCT No: 2009-010725-39; ISRCTN: ISRCTN36180119).

Phenotyping Chronic Lung Allograft Dysfunction Using Body Plethysmography and Computed Tomography

Restrictive subtype of chronic lung allograft dysfunction (CLAD) was recently described after lung transplantation. This study compares different definitions of a restrictive phenotype in CLAD patients and impact on survival. Eighty-nine CLAD patients out of 1191 screened patients (September 1987 to July 2012) were included as complete longitudinal lung volume measurements and chest computed tomography (CT) after CLAD onset was available. CT findings and lung volumes were quantified and survival was calculated for distinctive groups and predictive factors for worse survival were investigated. Graft survival in patients with total lung capacity (TLC) between 90% and 81% of baseline (BL) (n = 13, 15%) in CLAD course was similar to those with TLC >90% BL (n = 64, 56%; log-rank test p = 0.9). Twelve patients (13%) developed a TLC ≤80% BL and 10 (11%) had significant parenchymal changes on CT, of whom 6 (46%) also had TLC ≤80% BL. CT changes correlated with TLC ≤80% BL (Φ-coefficient = 0.48, p = 0.001). Patients with either TLC ≤80% or significant CT changes (n = 16, 18%) had a significantly reduced survival (log-rank p < 0.001). Forced vital capacity loss at CLAD onset was associated with poorer survival but did not correlate with the TLC or CT changes. A restrictive subtype of CLAD may be defined by either TLC ≤80% BL or severe parenchymal changes on chest CT.

Prolonged Mechanical Ventilation After Lung Transplantation-A Single-Center Study

This single-center study examines the incidence, etiology, and outcomes associated with prolonged mechanical ventilation (PMV), defined as time to definite spontaneous ventilation >21 days after double lung transplantation (LTx). A total of 690 LTx recipients between January 2005 and December 2012 were analyzed. PMV was necessary in 95 (13.8%) patients with decreasing incidence during the observation period (p < 0.001). Independent predictors of PMV were renal replacement therapy (odds ratio [OR] 11.13 [95% CI, 5.82-21.29], p < 0.001), anastomotic dehiscence (OR 8.74 [95% CI 2.42-31.58], p = 0.001), autoimmune comorbidity (OR 5.52 [95% CI 1.86-16.41], p = 0.002), and postoperative neurologic complications (OR 5.03 [95% CI 1.98-12.81], p = 0.001), among others. Overall 1-year survival was 86.0% (90.4% for LTx between 2010 and 2012); it was 60.7% after PMV and 90.0% in controls (p < 0.001). Conditional long-term outcome among hospital survivors, however, did not differ between the groups (p = 0.78). Multivariate analysis identified renal replacement therapy (hazard ratio [HR] 3.55 [95% CI 2.40-5.25], p < 0.001), post-LTx extracorporeal membrane oxygenation (HR 3.47 [95% CI 2.06-5.83], p < 0.001), and prolonged inotropic support (HR 1.95 [95% CI 1.39-2.75], p < 0.001), among others, as independent predictors of mortality. In conclusion, PMV complicated 14% of LTx procedures and, although associated with increased in-hospital mortality, outcomes among patients surviving to hospital discharge were unaffected.