Utility of microbiologic testing in surveillance bronchoscopy following lung transplantation: A retrospective cohort study.

BACKGROUND: The utility of surveillance bronchoscopy (SB) for the clinical management of lung transplant recipients (LTRs) is undefined. This study evaluates the role of SB in the monitoring and care of LTRs. METHODS: We retrospectively analyzed all LTRs who had SB at Henry Ford Hospital in Detroit, Michigan between August 2014 and August 2019. Bronchoscopies performed for clinical symptoms, new radiographic abnormalities, and to assess stents or acute rejection were excluded. A total of 107 LTRs and 449 bronchoscopies were analyzed. The primary outcome was the rate of change in clinical care based on microbiologic and pathologic test results. Secondary outcomes were rates of microbiologic and pathologic test positivity and rates of adverse effects. RESULTS: The most common microbiologic tests performed on bronchoalveolar lavage were bacterial (96.9%), fungal (95.3%), and acid-fast bacillus (95.1%) stains and cultures. Of 2560 microbiologic tests, 22.0% were positive and resulted in therapy changes for 2.9%. Positive galactomannan, acid-fast bacillus tests, and Pneumocystis jirovecii antigen/polymerase chain reaction did not result in therapy changes. Of the 370 transbronchial biopsies performed, 82.2% were negative for acute rejection and 13% were positive for A1/A2 rejection. Immunosuppressive therapy changes occurred after 15.8% with reduction in immunosuppression due to positive microbiologic tests in 16.9%. Adverse events occurred in 8.0% of patients. CONCLUSION: Diagnostic stewardship is warranted when performing SB in LTRs.

Clinical characteristics and outcomes of COVID-19 in solid organ transplant recipients: A cohort study.

Solid organ transplant recipients (SOTr) with coronavirus disease 2019 (COVID-19) are expected to have poorer outcomes compared to nontransplant patients because of immunosuppression and comorbidities. The clinical characteristics of 47 SOTr (38 kidneys and 9 nonkidney organs) were compared to 100 consecutive hospitalized nontransplant controls. Twelve of 47 SOTr managed as outpatients were subsequently excluded from the outcome analyses to avoid potential selection bias. Chronic kidney disease (89% vs 57% P = .0007), diabetes (66% vs 33% P = .0007), and hypertension (94% vs 72% P = .006) were more common in the 35 hospitalized SOTr compared to controls. Diarrhea (54% vs 17%, P < .0001) was more frequent in SOTr. Primary composite outcome (escalation to intensive care unit, mechanical ventilation, or in-hospital all-cause mortality) was comparable between SOTr and controls (40% vs 48%, odds ratio [OR] 0.72 confidence interval [CI] [0.33-1.58] P = .42), despite more comorbidities in SOTr. Acute kidney injury requiring renal replacement therapy occurred in 20% of SOTr compared to 4% of controls (OR 6 CI [1.64-22] P = .007). Multivariate analysis demonstrated that increasing age and clinical severity were associated with mortality. Transplant status itself was not associated with mortality.

An Internist's Approach to a Case of Negative Pressure Pulmonary Edema: A Rare Cause of Noncardiogenic Pulmonary Edema.

Negative-pressure pulmonary edema (NPPE) is a rare cause of noncardiogenic pulmonary edema, which usually presents postoperatively. Its pathophysiology is mostly described as a profound negative intrathoracic pressure caused by an airway obstruction such as laryngospasm, which may occur during extubation. But, there are other hypotheses about it, such as catecholamines release causing an elevated hydrostatic pressure in the cardiopulmonary circuit and, consequently, a major capillary leak to the interstitium. Its natural course varies, from prompt recovery to intensive care unit escalation and prolonged mechanical ventilation. Although anesthesiologists often detect this condition, this case's objective is to bring awareness of this condition to internists as a potential differential diagnosis for hypoxia in the postoperative setting.

Cardiac arrest from massive PE in nephrotic syndrome successfully treated with embolectomy and ECMO.

Pulmonary emboli (PE) are commonly encountered events with presentations ranging from benign incidental findings to obstructive shock. We present a case of a 20 year old male with nephrotic syndrome who suffered complete cardiovascular collapse with cardiac arrest in the setting of a massive PE, requiring open surgical embolectomy and ECMO support. We reviewed the literature on massive PE's focusing on the use of ECMO and success of the rarely performed open embolectomy for the treatment of obstructive shock from a massive PE.

Sepsis outcomes in patients receiving statins prior to hospitalization for sepsis: comparison of in-hospital mortality rates between patients who received atorvastatin and those who received simvastatin.

BACKGROUND: The purpose of this study is to compare the in-hospital mortality rates between septic patients receiving statins and those that did not prior to developing sepsis. We compared subgroups receiving atorvastatin and simvastatin because these two drugs differ in their pharmacologic properties. METHODS: This study was a retrospective analysis of patients selected from an institutional data base of patients hospitalized with sepsis. The study patients were drawn from a data base of 1,961 hospitalized patients with sepsis and included patients who met selection criteria and who were studied for HMG-CoA reductase inhibitor (statin) use both prior to and during hospitalization. The in-hospital mortality rates of patients receiving statins and those that did not prior to developing sepsis were compared. In-hospital mortality rates of patient subgroups receiving atorvastatin and simvastatin were also compared. A multivariable analysis was conducted with in-hospital mortality as the outcome variable and with multiple risk factors to include atorvastatin and simvastatin use. RESULTS: The mortality rate for 359 patients receiving statins prior to hospitalization for sepsis was not significantly different than that for 1,302 patients who did not receive pre-hospital statins (26.5% versus 30.4%, p > 0.05). The mortality rate for 92 patients who had received atorvastatin prior to hospitalization was significantly less than that of 253 patients who received simvastatin (18.5% versus 30.0%, p = 0.032). The use of atorvastatin prior to sepsis was independently associated with lower in-hospital mortality in a multivariable analysis of sepsis risk factors (p = 0.021, OR = 0.455). Patients who received atorvastatin prior to hospitalization for sepsis and had statins continued in hospital had a very low mortality rate that was significantly less than that of those patients who never received statins (15.7% versus 30.8%, p = 0.007). CONCLUSIONS: Pre-hospital atorvastatin use was associated with improved in-hospital mortality in septic patients when compared with pre-hospital simvastatin use and was independently associated with an improved outcome when compared to other sepsis risk factors. The effect of statins in patients with sepsis may be different for individual statins.