Impact of the COVID-19 pandemic on esophageal cancer resource allocation: a systematic review.

Background: The coronavirus disease 2019 (COVID-19) pandemic challenged global infrastructure. Healthcare systems were forced to reallocate resources toward the frontlines. In this systematic review, we analyze the impact of resource reallocation during the COVID-19 pandemic on the diagnosis, management, and outcomes of esophageal cancer (EC) patients. Methods: PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on EC patients. Of the 1,722 manuscripts initially screened, 23 met the inclusion criteria. Results: Heterogeneity of data and outcomes reporting prohibited aggregate analysis. Reduced detection of EC and considerable variability in disease stage at presentation were noted during the COVID-19 pandemic. EC patients experienced delays in diagnostic and preoperative staging investigations but surgical resection was not associated with greater short-term morbidity or mortality. Modeling the impact of pandemic-related delays in EC care predicts significant reductions in survival with associated economic losses in the coming years. Conclusions: Amidst resource scarcity during the COVID-19 pandemic, the multidisciplinary management of patients with EC was affected at multiple stages in the care pathway. Although the complete ramifications of reductions in EC diagnosis and delays in care remain unclear, EC surgery was able to safely continue as a result of collaboration between centers, strict adherence to COVID-19 protective measures, and reallocation of healthcare resources towards the same. Ultimately, when healthcare systems are pushed to the brink, the downstream consequences of resource reallocation require judicious analysis to optimize overall patient outcomes.

Resource allocation during the coronavirus disease 2019 pandemic and the impact on patients with lung cancer: a systematic review.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented tolls on both economies and human life. Healthcare resources needed to be reallocated away from the care of patients and towards supporting the pandemic response. In this systematic review, we explore the impact of resource allocation during the COVID-19 pandemic on the screening, diagnosis, management and outcomes of patients with lung cancer during the pandemic. METHODS: PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on patients with lung cancer. Of the 1605 manuscripts originally screened, 47 studies met the inclusion criteria. RESULTS: Patients with lung cancer during the pandemic experienced reduced rates of screening, diagnostic testing and interventions but did not experience worse outcomes. Population-based modelling studies predict significant increases in mortality for patients with lung cancer in the years to come. CONCLUSIONS: Reduced access to resources during the pandemic resulted in reduced rates of screening, diagnosis and treatment for patients with lung cancer. While significant differences in outcomes were not identified in the short term, ultimately the effects of the pandemic and reductions in cancer screening will likely be better delineated in the coming years. Future consideration of the long-term implications of resource allocation away from patients with lung cancer with an attempt to provide equitable access to healthcare and limited interruptions of patient care may help to provide the best care for all patients during times of limited resources.

Clinical Validation of the Canada Lymph Node Score for Endobronchial Ultrasound.

BACKGROUND: The Canada Lymph Node Score (CLNS) uses 4 sonographic criteria to predict the risk of malignancy in lymph nodes during endobronchial ultrasound. The CLNS may play a role in identifying targets for biopsy or rebiopsy during invasive mediastinal staging for lung cancer. However the CLNS has not yet been prospectively validated in routine clinical practice. METHODS: CLNSs for each lymph node biopsied during endobronchial ultrasound were prospectively captured for 1 year (2019). The CLNS and the presence of malignancy in each node were compared. Univariate binary logistic regression was completed for each ultrasonographic feature and multivariate logistic regression model. RESULTS: CLNSs and diagnostic pathology results were available for 367 lymph nodes. Incidence of malignancy increased with higher scores. Scores ≥ 3 were significantly associated with malignancy (specificity, 84.4%; positive likelihood ratio, 4.0). Area under the curve was 0.76, indicating a good ability of the model to predict presence or absence of malignancy. Nodes scoring < 2 and negative on computed tomography and positron emission tomography were malignant in 10.1%. CONCLUSIONS: The CLNS correlates with the presence or absence of malignancy in thoracic lymph nodes and may serve as an adjunct to currently available methods of invasive and noninvasive mediastinal staging. The CLNS may be most helpful in selecting which nondiagnostic lymph nodes require rebiopsy. There is a significant risk of a false-negative result even with a score of 0, and using a combination of low CLNSs and negative conventional radiology to obviate the need for any initial biopsy remains to be studied in prospective trials.

A systematic review and meta-analysis of coronary artery disease and revascularization in lung transplant patients.

Coronary artery disease (CAD) is common in candidates for lung transplantation (LTx) and has historically been considered a relative contraindication to transplantation. We look to review the outcomes of LTx in patients with CAD and determine the optimum revascularization strategy in LTx candidates. PubMed, Medline and Web of Science were systematically searched by three authors for articles comparing the outcomes of LTx in patients with CAD and receiving coronary revascularization. In total 1668 articles were screened and 12 were included in this review.Preexisting CAD in LTx recipients was not associated with significantly increased postoperative morbidity or mortality. The pooled estimates of mortality rate at 1, 3 and 5 years indicated significantly inferior survival in LTx recipients with a prior history of coronary artery bypass grafting (CABG) [odds ratio (OR), 1.84; 95% confidence interval (CI), 1.53-2.22; P < 0.00001; I2 = 0%; OR, 1.52; 95% CI, 1.21-1.91; P = 0.0003; I2 = 0%; OR, 1.62; 95% CI, 1.13-2.33; P = 0.008; I2 = 71%, respectively). However, contemporary literature suggests that survival rates in LTx recipients with CAD that received revascularization either by percutaneous coronary intervention (PCI), previous or concomitant CABG, are similar to patients who did not receive revascularization. Trends in postoperative morbidity favored CABG in the rates of myocardial infarction and repeat revascularization, whereas rates of stroke favored PCI. The composite results of this study support the consideration of patients with CAD or previous coronary revascularization for LTx. Prospective, randomized controlled trials with consistent patient populations and outcomes reporting are required to fully elucidate the optimum revascularization strategy in LTx candidates.

Bilateral Lung Transplant for Treatment of Idiopathic Pulmonary Fibrosis With Undetected Lung Adenocarcinoma: A Case Report.

BACKGROUND: Lung transplant has become a curative therapy for various forms of progressive lung disease refractory to medical management. Idiopathic pulmonary fibrosis (IPF) is a rare condition characterized by accumulation of activated fibroblasts and secretion of extracellular matrices within the lung parenchyma. End-stage IPF is a fatal condition, with limited medical therapies other than lung transplantation. IPF has been demonstrated as a known risk factor for the development of lung cancer, and current lung transplant standards define history of malignancy within the past five years as an absolute exclusion criterion. CASE REPORT: We present the case of a patient with biopsy-confirmed idiopathic pulmonary fibrosis treated with bilateral lung transplant, discovered to have stage four lung adenocarcinoma in the explanted lungs. The patient subsequently received pseudoadjuvant chemotherapy and remained recurrence-free until 23 months post-transplant. CONCLUSION: This case highlights the challenge of ruling out malignancy in patients with end-stage lung disease. There remains a paucity of clinical studies on lung transplantation for lung cancer and more evidence is required before supporting this clinical decision.

The use of fibrinolytic therapy for parapneumonic effusion in pregnancy: a case report and a review.

The use of intrapleural fibrinolytics for complicated parapneumonic effusion has been shown to be an effective and safe alternative to surgery. However, there is limited evidence about its use during pregnancy. We present a case and a review of the literature of pregnant women who had successful treatment of their complicated parapneumonic effusion with intrapleural fibrinolytics. To our knowledge this is the first review of cases of pregnant women with parapneumonic effusion managed with intrapleural fibrinolytic.

Azithromycin prophylaxis after lung transplantation is associated with improved overall survival.

BACKGROUND: Azithromycin prophylaxis (AP) in lung transplant recipients has been shown to reduce the composite end-point of death or chronic lung allograft dysfunction (CLAD) onset but without a clear effect on overall survival. Our program began using AP in 2010. We sought to evaluate the association between AP and survival and the risk of CLAD and baseline lung allograft dysfunction (BLAD). METHODS: We studied double lung recipients transplanted between 2004 and 2016. We defined AP as chronic use of azithromycin initiated before CLAD onset. We analyzed the association between AP and death or retransplant using Cox regression with adjustment for potential confounders. We further used Cox and logistic models to assess the relationship between AP and post-transplant CLAD onset and BLAD, respectively. RESULTS: A total of 445 patients were included, and 344 (77%) received AP (median time from transplant: 51 days). Patients receiving AP were more likely to receive induction with interleukin-2 receptor antagonists (57% vs 35%; p < 0.001). AP was associated with improved survival (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.42-0.82; p = 0.0020) in our fully adjusted model, with a reduced adjusted risk of BLAD (odds ratio: 0.53; 95% CI: 0.33-0.85; p = 0.0460) but no clear reduction in the adjusted risk of CLAD (HR: 0.69; 95% CI: 0.47-1.03; p = 0.0697). CONCLUSIONS: AP is associated with improved survival after lung transplantation, potentially through improved baseline function. These findings build on prior trial results and suggest that AP is beneficial for lung transplant recipients.

Pretransplant Opioid Use and Survival After Lung Transplantation.

BACKGROUND: The impact of opioid use in lung transplant candidates on posttransplant outcomes is unknown. Studies on opioid therapy in kidney and liver transplant candidates have suggested increased risk of graft failure or death. We sought to analyze the relationship between pretransplant opioid use in lung transplant candidates and retransplant-free survival. METHODS: We retrospectively reviewed adult patients transplanted consecutively between November 2004 and August 2015. The exposure was any opioid use at time of transplant listing and primary outcome was retransplant-free survival, analyzed via Cox regression model adjusted for recipient age, gender, ethnicity, diagnosis, and bridging status. Secondary outcomes included duration of ventilation, intensive care unit and hospital length of stay, 3-month and 1-year survival, continuing opioid use at 1 year, and time to onset of chronic lung allograft dysfunction. RESULTS: The prevalence of opioid use at time of listing was 14% (61/425). Median daily oral morphine equivalent dose was 31 mg (18-54). Recipient ethnicity was associated with pretransplant opioid use. Opioid use at time of listing did not increase risk of death or retransplantation in an adjusted model (hazard ratio 1.12 [95% confidence interval 0.65-1.83], P = 0.6570). Secondary outcomes were similar between groups except hospital length of stay (opioid users 35 versus nonusers 27 d, P = 0.014). Continued opioid use at 1-year posttransplant was common (27/56, 48%). CONCLUSIONS: Pretransplant opioid use was not associated with retransplant-free survival in our cohort and should not necessarily preclude listing. Further work stratifying opioid use by indication and the association with opioid use disorder would be worthwhile.

Disease recurrence after lung transplantation for idiopathic pulmonary hemosiderosis.

Idiopathic pulmonary hemosiderosis is characterized by the triad of hemoptysis, iron deficiency anemia and pulmonary infiltrates. Though idiopathic pulmonary hemosiderosis has classically been described as a childhood disease, survival into adulthood is possible. Treatment options for advanced and/or refractory disease is limited, and in our unique case of idiopathic pulmonary hemosiderosis with precapillary pulmonary hypertension, lung transplantation has had a favorable short-term outcome. We also demonstrate that disease recurrence of idiopathic pulmonary hemosiderosis following lung transplantation is possible.

Automatic Referral for Potential Thoracic Malignant Diseases Detected on Computed Tomographic Scan.

BACKGROUND: Delays in care negatively affect patients with potentially resectable thoracic malignant diseases. The Alberta Thoracic Oncology Program established an automatic referral process for patients with chest computed tomographic (CT) scans suggestive of malignant disease. The objective of this study was to determine whether automatic referral was associated with decreased time to referral or differences in the quality of referral information received. METHODS: A single-center retrospective review of patients referred to a Canadian tertiary thoracic surgical center was performed. The time between the CT scan and the date of referral was calculated, and the type of information provided with the referral was tabulated. Automatic and traditional referral groups were compared using the Student t test, the Mann-Whitney U test, and multivariable analysis. RESULTS: A total of 689 patients met inclusion criteria, and 405 of these patients were automatic referrals. Average time to referral was shorter in the automatic referral group (4.7 days vs 23.6 days; P < .001). Only 2 automatic referrals took longer than 30 days, compared with more than 25% of traditional referrals. Automatic referrals were always associated with a shorter time for referral on subgroup analysis of lung nodules, different referring physician types, and patient location. There was no difference between referral types in the number of referral data provided to the center. CONCLUSIONS: Automatic referrals for patients with potential thoracic malignant disease have a significant beneficial impact on delays in care, and this could result in improved outcomes, such as decreased upstaging and improved survival. This was not associated with a decrease in the amount of information provided with the referral. Thus, automatic referrals may streamline patient care without compromising quality.

Esophagectomy in a patient with double aortic arch and right descending aorta.

We herein report the case of a 57-year-old man with esophageal cancer who was found to have a double aortic arch and right-sided descending aorta. Traditional approaches such as the Ivor Lewis and McKeown were excluded because the descending aorta would obscure the surgical field, and a neck anastomosis with the conduit through the ring could result in compression. We therefore opted for a left thoracoabdominal incision, allowing excellent exposure while reserving the possibility of placing the conduit substernally.

Pneumatosis Intestinalis and Its Association With Lung Transplant: Alberta Experience.

OBJECTIVES: We evaluated the incidence, clinical presentation, laboratory findings, possible causes, and outcomes associated with pneumatosis intestinalis in the setting of lung transplant. MATERIALS AND METHODS: A departmental database showed that, between October 2002 and August 2013, our institution performed 373 lung transplants. The database was queried for all patients who had pneumatosis intestinalis and/or pneumoperitoneum after lung transplant at our institution. For this retrospective chart review, information collected included demographics, baseline variables, symptoms, signs, laboratory parameters, radiologic work-up, medications, including immunosuppressants at presentation, progress and time to resolution, length of hospital stay, and postoperative complications, as well as short-term and midterm outcomes (up to 1 year). RESULTS: The incidence of pneumatosis intestinalis was 2.68% (10/373 patients). Mean age of patients was 52.2 years (range, 34.9-67.9 y). Mean time for development of pneumatosis intestinalis after transplant was 352.8 days (range, 5-2495 d). Abdominal symptoms and signs were present in 6 patients (60%). The large bowel was the site of involvement in all but 1 patient, with predilection for ascending colon (80%) and transverse colon (90%) in most patients. High serum lactate levels were found in 2 patients, and both underwent bowel resection, with surgical specimens revealing evidence of ischemic changes in the gut. Mean dose of prednisone was 22 mg at the time of presentation (range, 0-60 mg). Mean hospital length of stay was 16.9 days (range, 0-40 d). Short-term survival was 100%. Midterm survival at the end of 1 year was 80%. Mean time for pneumatosis to resolve was 18 days (range, 14-35 d). CONCLUSIONS: Pneumatosis intestinalis in bilateral lung transplant recipients can be treated with a minimal amount of imaging, and most patients can be treated conservatively. Survival outcomes are quite good, with 100% during the short term and 80% at 1 year in our series.

Massive gas under diaphragm after lung transplantation: pneumatosis intestinalis simulating bowel perforation.

The management of pneumatosis intestinalis (PI) can vary from urgent surgical procedure to conservative treatment. Uncommonly, it has been reported in association with organ transplantation, and very few cases have been reported after lung transplantation. The transplant physicians should be well versed in differentiating the fatal form of PI from a benign one. Here, we describe a case of PI with pneumoperitoneum mimicking intestinal perforation after bilateral lung transplantation; this case posed a therapeutic dilemma. After discussion with the multidisciplinary teams, conservative management was chosen to which the patient responded successfully. Clinical signs and imaging features in these situations can mimic true bowel perforation. Hence, a correct diagnosis and proper assessment is imperative.

Predictors of survival after cardiac or respiratory arrest in critical care units.

BACKGROUND: Survival outcomes after cardiac or respiratory arrest occurring outside of intensive care units (ICUs) has been well described. We investigated survival outcomes of adults whose arrest occurred in ICUs and determined predictors of decreased survival. METHODS: We reviewed all records of adults who experienced cardiac or respiratory arrest from Jan. 1, 2000, to Apr. 30, 2005, in ICUs at four hospitals serving Edmonton, Alberta. We evaluated patient and clinical characteristics, as well as survival outcomes during a five-year follow-up period. We determined risk factors for immediate (within 24 hours) and later death. RESULTS: Of the 517 patients included in the study, 59.6% were able to be resuscitated, 30.4% survived to discharge from ICU, 26.9% survived to discharge from hospital, 24.3% survived to one year, and 15.9% survived to five years. Pulseless electrical activity or asystole was the most common rhythm (45.8% of the arrests). Survival was lowest among patients with an arrest due to pulseless electrical activity or asystole: only 10.6% survived to one year, compared with 36.3% who had other arrest rhythms (p < 0.001). Independent predictors of decreased later survival (eight months or more after arrest) were increasing age (adjusted hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.03-1.09) and longer duration of cardiopulmonary resuscitation (CPR) (adjusted HR 1.38, 95% CI 1.03-1.83, per additional logarithm of a minute of CPR). INTERPRETATION: Our study showed no major improvement in survival following cardiac arrest with pulseless electrical activity or asystole as the presenting rhythm in the ICU despite many advances in critical care over the previous two decades. The independent predictors of death within 24 hours after arrest in an ICU were sex, the presenting rhythm and the duration of CPR. Predictors of later death (eight months or more after arrest) were age and duration of CPR.

Glutaraldehyde treatment of allograft tissue decreases allosensitization after the Norwood procedure.

OBJECTIVE: Cryopreserved allograft tissue used in the Norwood procedure for infants with hypoplastic left heart syndrome causes a marked immunologic sensitization that may complicate future heart transplantation. Treatment of the allograft tissue before implantation may prevent this sensitization. The purpose of this study was to assess the anti-human leukocyte antigen antibody response to glutaraldehyde-treated allograft tissue used in the repair of hypoplastic left heart syndrome. METHODS: Since June 2005, the University of Alberta has subjected allograft vascular tissue used in the Norwood procedure to glutaraldehyde treatment. An observational study was designed to assess whether glutaraldehyde treatment of the allograft tissue affected subsequent panel reactive antibody after patch implantation. Panel reactive antibodies for class I (human leukocyte antigen-A, B, C) and class II (human leukocyte antigen-DR, DQ) antibodies were measured 4 months postoperatively using flow cytometry. RESULTS: Fourteen patients underwent a Norwood procedure using glutaraldehyde-treated allograft tissue. Historical controls consisted of 12 patients who underwent a Norwood procedure using untreated allograft tissue. At 4 months, infants who had received glutaraldehyde-treated allograft tissue had lower class I panel reactive antibody (7.3% +/- 17.4% [median, 0%] vs 61.9% [median, 73%] +/- 39.9%; P = .0005) and class II panel reactive antibody (6.1% [median, 0%] +/- 22.7% vs 49.3% [median, 63%] +/- 41.9%, P = .001) compared with the historical controls. CONCLUSION: Intraoperative glutaraldehyde treatment of allograft tissue used in hypoplastic left heart syndrome repair prevents the profound immunologic sensitization that occurs in the majority of infants undergoing surgical palliation. In patients requiring subsequent heart transplantation, this decreases the risk of antibody-mediated rejection and increases the likelihood of finding a suitable donor, thus improving access to transplantation.