Ethical considerations in lung re-transplantation.

PURPOSE OF REVIEW: Patients undergoing re-transplantation constitute a growing proportion of annual lung transplants. It is necessary to consider ethical considerations of re-transplantation in parallel with clinical progress. RECENT FINDINGS: Most clinical data demonstrate patients undergoing re-transplantation have worse survival outcomes; however, there is limited discussion of the ethical principles surrounding re-transplantation. Ethical guidance in re-transplantation trails clinical advancement. SUMMARY: The four-box model offers a valuable framework for assessing the ethical considerations in re-transplantation. This includes an analysis of medical indications, patient preferences, quality-of-life and contextual factors to support the ethical use of scarce donor lungs.

Delayed esophagectomy for adenocarcinoma is associated with a negative impact on long-term survival and an increased risk of perioperative morbidity.

OBJECTIVE: Delayed esophagectomy (DE) following chemoradiation therapy (CXRT) for esophageal carcinoma is undertaken in selected patients. This study aimed to assess both short-term outcomes and long-term survival for patients with adenocarcinoma undergoing DE. METHODS: The National Cancer Database was queried for patients with American Joint Committee on Cancer clinical stage II-III esophageal adenocarcinoma undergoing esophagectomy after CXRT. Patients were categorized as (1) DE, ≥90 days between completion of CXRT and surgery or (2) nondelayed esophagectomy (NDE), <90 days. Cox regression was performed to identify factors associated with mortality. RESULTS: A total of 8157 patients met criteria. Age >69, nonwhite race, Medicare/Medicaid insured patients preferentially underwent DE. Five-year overall survival (OS) favored NDE (36% vs. 31%, p = 0.008). Cox regression identified DE, clinical stage >T2, or >N0 as factors associated with mortality. Within the DE group, OS favored early cT-status. DE fared worse than NDE in 30- and 90-day mortality (4.5%/11.1% vs. 2.9%/6.5%, p < 0.01/p < 0.001) and margin positive resection (7.1% vs. 4.2%, p < 0.001). CONCLUSIONS: For esophageal adenocarcinoma, DE is associated with decreased OS compared to NDE. For DE, cT-status is prognostic for OS, while cN-status was not. Increased 30-/90-day mortality and margin positive resection rates for DE question whether patients with locally advanced (cT3/T4) primary esophageal adenocarcinoma should undergo intentional DE.

Pulmonary Function Tests May Better Predict Dyspnea-Severity in Patients with Subglottic Stenosis Compared to Clinician-Reported Stenosis.

OBJECTIVE: Patients with subglottic stenosis (SGS) present with varied degree of breathing complaints. The dyspnea index (DI) is a 10-question patient-reported outcome measure designed to measure the severity of upper airway obstruction. We set out to determine whether pulmonary function tests or clinician-reported degree of stenosis best predicted DI scores. METHODS: Thirty patients with SGS were retrospectively reviewed over a 6-year period. One visit from each patient was included. Data including peak expiratory flow rate (PEFR), body-mass index (BMI), clinician-reported degree of stenosis, and DI scores were reviewed. Multiple linear regression was performed to determine how degree of stenosis and PEFR % predicted the variation in DI score. RESULTS: PEFR % better predicted DI scores compared to degree of stenosis (partial correlation -0.32 vs 0.17). After stepwise elimination, PEFR % remained in the regression and was significantly associated with DI scores (F[1, 29] = 9.38, P = .005). BMI did not demonstrate a linear relationship with DI scores and was not included in the regression (r = -.02). The PEFR % unstandardized coefficient was -0.25 (95% CI: -0.42 to -0.08, P = .005). The model predicts that a 4% increase in the PEFR % results in a 1-point decrease in the DI score (95% CI: -1.68 to -0.32). CONCLUSION: This study suggests that pulmonary function tests may be a better in-office measure to substantiate the severity of symptoms in patients with SGS.

The Utility of Recycled Eyeglasses: A Pilot Study at the Los Angeles County Department of Health Services.

Background: The cost of eyeglasses is variably covered by medical insurance and thus is a significant barrier for patients in lower socioeconomic classes. We evaluated the efficacy of Recycle Vision (RV) at LAC+USC Medical Center, a monthly clinic run by volunteer medical students that provides free donated eyeglasses. Methods: A convenience sample of 30 patients was surveyed from August 1, 2019 to December 31, 2019. Patients' prescriptions were matched with available eyeglasses based on spherical equivalent and axis of astigmatism using Winglasses software algorithm; patients selected glasses from these options based on subjective improvement of vision. All participants consented to a phone follow-up survey 1 month after initial visit to gauge satisfaction with glasses and rate difficulty in completing daily activities pre- and post-RV visit on a scale of 1 to 5 (5 being the greatest), with a 100% response rate. Results: Of the 30 study participants, 90% received eyeglasses from RV, with reported improvement in ease of daily activities of 3.96. 67% of respondents stated that if RV clinic did not exist, they would not have obtained glasses elsewhere; cost was the most commonly (70%) cited barrier. Upon follow-up, average likelihood of patients referring friends/family to RV was 4.07 (SD 1.14). Conclusion: The majority of RV patients received free eyeglasses and had subsequent improvement in their quality of life. This pilot study demonstrates that programs offering free eyeglasses can effectively correct refractive error and can offer a practical public health solution to improve functionality for underserved populations.