The impact of pandemic influenza A H1N1 2009 on Australian lung transplant recipients.

Influenza A H1N1 2009 led to 189 deaths during the Australian pandemic. Community-acquired respiratory viruses not only can cause prolonged allograft dysfunction in lung transplant recipients but have also been linked to bronchiolitis obliterans syndrome (BOS). We report the impact of the 2009 H1N1 pandemic on Australian lung transplant recipients. An observational study of confirmed H1N1 cases was conducted across five Australian lung transplant programs during the pandemic. An electronic database collected patient demographics, clinical presentation, management and outcomes up to a year follow-up. Twenty-four H1N1 cases (mean age 43 ± 14 years, eight females) were identified, incidence of 3%. Illness severity varied from upper respiratory tract symptoms only in 29% to lung allograft dysfunction (≥10% decline FEV1) in 75% to death in 5 (21%) cases (pre-existing BOS grade 3, n = 4). Treatment with oseltamivir occurred in all but one case confirmed after death, reduced immunosuppression, n = 1, augmented corticosteroid therapy, n = 16, and mechanical/noninvasive ventilation, n = 4. There was BOS grade decline within a year in six cases (32%). In conclusion, Australian lung transplant recipients were variably affected by the H1N1 pandemic mirroring the broader community with significant morbidity and mortality. After initial recovery, a considerable proportion of survivors have demonstrated BOS progression.

Study of compliance with a clinical pathway for suspected pulmonary embolism.

BACKGROUND/AIMS: Clinical pathways to guide the investigation of suspected pulmonary embolism have been increasingly adopted by emergency departments worldwide. This study evaluated the compliance with a clinical pathway that combines risk assessment (Wells score) with d-dimer, ventilation-perfusion scanning or computed tomographic pulmonary angiography (CTPA). The aims of this study were to identify factors that contribute to compliance and to assess patient outcomes and resource utilization. METHODS: Repeated retrospective chart reviews of 239 patients who underwent investigation for pulmonary embolism through our emergency department extracted patient demographics, pathway parameters and patient outcomes. A phone interview at 3-month follow up was carried out. RESULTS: Incidence of pulmonary embolism was 8.4% (n= 20). Compliance to the clinical pathway occurred in 120 subjects (50.2%). Non-compliance occurred in 71 subjects (29.7%). Forty-eight subjects (20.1%) underwent risk assessments, but subsequent diagnostic tests did not conform to the stated pathway (partial compliance). Compliance was poor in subjects assessed by non-emergency department doctors (χ(2) = 27.95, P≤ 0.001). Compliance occurred less in pregnant subjects (χ(2) = 7.27, P= 0.007) and those with chronic respiratory disease (χ(2) = 5.31, P= 0.021). Subjects in the compliant group were less likely to undergo CTPA (odds ratio 2.07 (1.16-3.70), P= 0.012). CONCLUSIONS: Compliance with this clinical pathway allowed emergency department doctors in an Australian university teaching hospital to complete diagnostic testing for suspected pulmonary embolism appropriately unless non-emergency department doctors became involved. Compliance with this pathway altered the distribution of diagnostic tests performed with less reliance on CTPA, but was not associated with better patient outcomes.