Pediatric Living Lung Donor Transplant Candidates: Psychiatric Status of Utilized and Non-Utilized Donors.

Living donor lung (lobar) transplantation has greatly decreased in the past decade due to the success of the lung allocation score (LAS) system, instituted in 2005 by the Organ Procurement and Transplantation Network (OPTN). Between 1993 and 2006, 460 living lung donor transplants were performed in the United States with 369 donations occurring at the University of Southern California and Washington University in St. Louis. These two centers accounted for over 80% of all living donor lung transplants between 1994 and 2006. All potential donors received a psychological/psychiatric evaluation as part of the donor selection process, which is standard practice in the United States, Europe, and Asia. Utilized and non-utilized lung donors were compared in terms of their psychiatric history and present status. Results indicated that 31% (N = 54) of the total sample had a lifetime prevalence of a psychiatric disorder, which is less than that the 46% lifetime rate for the general population (Kessler in Arch Gen Psychiatry 62:593-602, 2005). This study did find that psychiatric history or status was not exclusion factor for transplant surgery in either group. This observation about psychiatric issues in potential living lung donors should be useful to transplant centers who utilize adult live donors of any solid organ type for pediatric recipients and in Japan where live donor lung transplants still represent a significant proportion of lung transplants (Date in J Thorac Dis 8: S631-S636, 2016).

Hyperbaric oxygen: a useful adjunct for purpura fulminans: case report and review of the literature.

INTRODUCTION: We report a case of a previously healthy adult with flulike symptoms who precipitously declined due to pneumococcal sepsis complicated by disseminated intravascular coagulation (DIC) and purpura fulminans (PF). After one week of care, including ventilation support and hemodialysis, the patient was stable enough for hyperbaric oxygen (HBO2) in an attempt to salvage his threatened extremities. HBO2 resulted in reduction of ischemic tissue and demarcation of blackened tissue to the distal digits. We feel that much at-risk tissue has been spared by HBO2 as an adjunctive therapy. METHODS: Literature on the use of hyperbaric oxygen for purpura fulminans was reviewed for precipitating issues, time to treatment, protocol, other adjuncts and outcomes. RESULTS: Fifteen papers were identified representing 19 cases of PF treated with HBO2. No controlled studies exist. HBO2 was believed to be of value in most cases; the improvement was associated with timeliness and aggressiveness of initiating HBO2. CONCLUSIONS: PF is a fulminant disorder with high mortality and morbidity. Hyperbaric oxygen appears to be useful for the management of PF complications, imposing minimal side effects or complications. Aggressive therapy should be started as soon as it is safe to transfer the patient to a facility for HBO2 treatments.

Hypoxemic Respiratory Failure Due to Alveolar Pulmonary Sarcoidosis Following COVID-19 Infection.

Pulmonary sarcoidosis is typically recognized as an interstitial lung disease with an infrequent occurrence of alveolar filling or acinar pattern. This rare form of alveolar sarcoidosis is known to have a rapid progression. Several case reports showed the development/worsening of sarcoidosis after COVID-19 infection. We present a case of a 60-year-old male with chronic hypoxic respiratory failure since having COVID-19 disease followed by gradual progression in symptoms, who had atypical sarcoid-like alveolar opacities on radiography, two prior negative bronchoscopies, transbronchial biopsy and BAL, and third bronchoscopic transbronchial biopsy suggestive of findings of poorly formed granulomas with high suspicion of alveolar sarcoidosis after ruling out other comparative possibilities, and later having a drastic improvement with sarcoidosis management. Our patient's worsening symptoms after COVID-19 infection suggest impaired immunoregulation role of the infection in developing the disease process.

Paraneoplastic Hypereosinophilia in Poorly Differentiated Adenocarcinoma of the Lung.

It is well-documented that lung and bronchus cancers are the leading cause of cancer death in the United States in both male and female patients, with lung adenocarcinoma accounting for the highest prevalence of lung cancers. Significant eosinophilia in the setting of lung adenocarcinoma has been documented in a few reports, being described as a rare paraneoplastic syndrome. We report on an 81-year-old female with hypereosinophilia-associated lung adenocarcinoma. A chest film showed a right lung mass, which was not apparent on a chest film 1 year prior, in the setting of significant leukocytosis of 27.90 x 103/mm3 with eosinophilia of 6.40 x 103/mm3. A computed tomography (CT) chest, obtained during admission, demonstrated significant right lower lobe mass enlargement since the previous study completed 5 months prior, with new occlusion of bronchi and pulmonary vessels to the region of the mass. Our observations are consistent with prior reports showing that the presence of eosinophilia in lung cancers may indicate rapid disease progression.

Prognosis in Hispanic patient population with pulmonary arterial hypertension: An application of common risk stratification models.

Pulmonary arterial hypertension (PAH) is a cardiovascular disease with high mortality rate. Current guidelines propose initiation and escalation of PAH-targeted treatment based on a goal-directed approach targeting hemodynamic, functional, and biochemical variables. This approach has been successfully validated in large Caucasian cohorts. However, given the low number of Hispanic patients enrolled in large PAH trials and registries, it is unknown if the same prognostic tools can be applied to this patient population. We analyzed a single-center outpatient cohort that consisted of 135 Hispanic patients diagnosed with PAH. Baseline characteristics were calculated based on COMPERA, COMPERA 2.0 and REVEAL 2.0 risk scores before the initiation of PAH-targeted therapies. The survival rate at 1 year after diagnosis was 88% for the entire cohort. The three established risk scores to predict PAH outcomes yielded similar results with reasonable discrimination of mortality in the different risk strata (all p < 0.001). Hispanic patients with PAH have a high mortality rate. Our analysis suggests that guideline proposed risk assessment at baseline yields important prognostic information in this patient population.

Bilateral pneumatoceles resulting in spontaneous bilateral pneumothoraces and secondary infection in a previously healthy man with COVID-19.

An acute COVID-19 infection can result in cystic lung changes that have a unique presentation and are inherently difficult to manage with or without preexisting conditions. Even though reportedly very few COVID-19 patients develop secondary bacterial infections due to unclear mechanisms, a postviral sequela with typical and atypical organisms can prolong the course of lung damage. The long-term effects of COVID-19 lung damage are still unclear, as the morbidity of the disease process is yet to be fully understood. This report presents a rare complication of COVID pneumonia with bilateral necrotizing pneumatoceles presenting with hemoptysis and bilateral pneumothoraces with positive sputum cultures for Enterobacter aerogenes and Pseudomonas aeruginosa. It highlights rare complications of COVID-19 requiring multiple hospital admissions and ongoing home oxygen therapy.

Predictors and outcomes of acute respiratory failure in hospitalised patients with acute pancreatitis.

BACKGROUND AND AIM: Acute pancreatitis (AP) is associated with organ failures and systemic complications, most commonly acute respiratory failure (ARF) and acute kidney injury. So far, no studies have analysed the predictors and hospitalisation outcomes, of patients with AP who developed ARF. The aim of this study was to measure the prevalence of ARF in AP and to determine the clinical predictors for ARF and mortality in AP. METHODS: This is a retrospective cohort study using the Nationwide Inpatient Sample database from the year 2005-2014. The study population consisted of all hospitalisations with a primary or secondary discharge diagnosis of AP, which is further stratified based on the presence of ARF. The outcome measures include in-hospital mortality, hospital length of stay and hospitalisation cost. RESULTS: In our study, about 5.4% of patients with AP had a codiagnosis of ARF, with a mortality rate of 26.5%. The significant predictors for ARF include sepsis, pleural effusion, pneumonia and cardiogenic shock. Key variables that were associated with a higher risk of mortality include mechanical ventilation, age more than 65 years, sepsis and cancer (excluding pancreatic cancer). The presence of ARF increased hospital stay by 8.3 days and hospitalisation charges by US$103 460. CONCLUSION: In this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalisation charges in patients with AP. This underlines significantly higher resource utilisation in patients with a dual diagnosis of AP-ARF.

Anti-glomerular basement membrane (Goodpasture) disease exacerbated by invasive pulmonary aspergillosis.

Prior reports have associated the unusual presentations of anti-glomerular basement membrane (anti-GBM) disease and pulmonary aspergillosis in an immunocompetent host. We present the case of a previously healthy 24-year-old man who presented with symptoms of hemoptysis, cough, and dyspnea. His environmental risk factors included tobacco use (smoking), hydrocarbon exposure, and an unidentified mold present in his home. Laboratory evaluation revealed positive serum anti-GBM autoantibodies and positive detection of galactomannan in the bronchoalveolar lavage fluid. The diagnosis of anti-GBM disease was confirmed with a kidney biopsy. Management included therapy with voriconazole for aspergillosis and prednisone, plasmapheresis, and eventually cyclophosphamide for anti-GBM disease.

Acute isoniazid toxicity and the need for adequate pyridoxine supplies.

A 25-year-old, 54-kg Hispanic man who had recently started multidrug therapy for pulmonary tuberculosis presented in status epilepticus after ingesting 9 g of isoniazid in a suicide attempt. Successful management of this patient required collaboration between several institutions to provide the large amount of necessary intravenous pyridoxine. Ultimately, this single overdose depleted the supply of intravenous pyridoxine for a significant region of the state of Nebraska. Isoniazid is commonly used to treat tuberculosis, but it is encountered relatively infrequently as the cause of an acute overdose. Severe isoniazid overdoses may present as seizure activity that is refractory to conventional antiepileptic therapy. Although intravenous pyridoxine is an effective antidote for isoniazid overdoses in patients presenting with status epilepticus, this agent has few indications and is typically stocked in limited quantities. In regions with large populations of patients who receive antituberculosis therapy, collaborative networks must be created to ensure that adequate supplies of intravenous pyridoxine (> or = 20 g) are available for effective treatment of isoniazid poisonings.

Fatal pulmonary tumor thrombotic microangiopathy caused by undiagnosed metastatic gastric adenocarcinoma.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare cause of rapidly progressive dyspnea in a background of metastatic cancer. Gastric adenocarcinoma is the neoplasm most frequently associated with PTTM. Unfortunately, PTTM is difficult to identify clinically and is most commonly a postmortem diagnosis. We present the case of a woman with no previous diagnosis of cancer who presented with rapidly progressive shortness of breath. She was diagnosed with severe pulmonary arterial hypertension and rapidly succumbed to her illness. A postmortem diagnosis of PTTM was established based on autopsy results.

Impact of COPD on postoperative outcomes: results from a national database.

BACKGROUND: Although COPD affects large sections of the population, its effects on postoperative outcomes have not been rigorously studied. The objectives of this study were to describe the prevalence of COPD in patients undergoing surgery and to analyze the associations between COPD and postoperative morbidity, mortality, and hospital length of stay. METHODS: Patients with COPD who underwent surgery were identified from the National Surgical Quality Improvement Program database (2007-2008). Univariate and multivariate analyses were performed on this multicenter, prospective data set (N = 468,795). RESULTS: COPD was present in 22,576 patients (4.82%). These patients were more likely to be older, men, white, smokers, and taking corticosteroids and had a lower BMI (P < .0001 for each). Median length of stay was 4 days for patients with COPD vs 1 day in those without COPD (P < .0001). Thirty-day morbidity rates were 25.8% and 10.2% for patients with and without COPD, respectively (P < .0001). Thirty-day death rates were 6.7% and 1.4% for patients with and without COPD, respectively (P < .0001). After controlling for > 50 comorbidities through logistic regression modeling, COPD was independently associated with higher postoperative morbidity (OR, 1.35; 95% CI, 1.30-1.40; P < .0001) and mortality (OR, 1.29; 95% CI, 1.19-1.39; P < .0001). Multivariate analyses with each individual postoperative complication as the outcome of interest showed that COPD was associated with increased risk for postoperative pneumonia, respiratory failure, myocardial infarction, cardiac arrest, sepsis, return to the operating room, and renal insufficiency or failure (P < .05 for each). CONCLUSIONS: COPD is common among patients undergoing surgery and is associated with increased morbidity, mortality, and length of stay.

Development and validation of a risk calculator for predicting postoperative pneumonia.

OBJECTIVE: To identify preoperative factors associated with an increased risk of postoperative pneumonia and subsequently develop and validate a risk calculator. PATIENTS AND METHODS: The American College of Surgeons' National Surgical Quality Improvement Program, a multicenter, prospective data set (2007-2008) was used. Univariate and multivariate logistic regression analyses were performed. The 2007 data set (N=211,410) served as the training set, and the 2008 data set (N=257,385) served as the validation set. RESULTS: In the training set, 3825 patients (1.8%) experienced postoperative pneumonia. Patients who experienced postoperative pneumonia had a significantly higher 30-day mortality (17.0% vs 1.5%; P<.001). On multivariate logistic regression analysis, 7 preoperative predictors of postoperative pneumonia were identified: age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The risk model based on the training data set was subsequently validated on the validation data set, with model performance being very similar (C statistic: 0.860 and 0.855, respectively). The high C statistic indicates excellent predictive performance. The risk model was used to develop an interactive risk calculator. CONCLUSION: Preoperative variables associated with an increased risk of postoperative pneumonia include age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The validated risk calculator provides a risk estimate for postoperative pneumonia and is anticipated to aid in surgical decision making and informed patient consent.

A systematic review of the cardiovascular risk of inhaled anticholinergics in patients with COPD.

The long-term use of inhaled anticholinergic agents has recently been suggested to be associated with an excess risk of adverse cardiovascular (CV) outcomes in patients with COPD. We identified 15 published studies that reported on the association between long-term inhaled anticholinergic use and adverse CV outcomes. Only 3 of the studies were adequately designed randomized controlled trials (RCTs). The first RCT that suggested that anticholinergic agents increased the risk of adverse CV outcomes was the Lung Health Study (LHS). Smokers randomized to inhaled ipratropium had a significantly increased risk of CV death than smokers receiving placebo. The LHS results have been questioned as the statistical tests used in the study were not adjusted for multiple tests and endpoints, a convincing dose-effect relationship between ipratropium use and the adverse CV outcomes was not established, and most of the CV deaths in the ipratropium group occurred in patients who were non-compliant to ipratropium. The Investigating New Standards for Prophylaxis in Reducing Exacerbations (INSPIRE) was a RCT that compared the combination of salmeterol plus fluticasone against tiotropium in patients with COPD. All-cause mortality was significantly lower in the salmeterol plus fluticasone group (3%) compared to the tiotropium group (6%). Fatal CV events occurred in 1% of the salmeterol plus fluticasone group compared to 3% in the tiotropium group. The INSPIRE trial was not designed to be a mortality trial, lacked adequate adjudication of fatal outcomes, and lacked a full intention-to-treat analysis of the data. The Understanding Potential Long-Term Impacts on Function with Tiotropium (UPLIFT) trial was a RCT comparing tiotropium and placebo in patients with COPD. Follow-up in UPLIFT was planned for 1440 days (4 years) plus 30 days (1470 days) of post-treatment follow-up. At 1440 days with 95% of patient outcome accounted for, tiotropium was associated with a significant 13% reduction in all-cause mortality compared to placebo. However, at 1470 days with only 75% of patient outcome accounted for, tiotropium was associated with a non-significant 11% reduction in all-cause mortality compared to placebo. The relative risks for serious CV events, heart failure, and myocardial infarction were all significantly lower with tiotropium than placebo. It is not certain why such a wide disparity in findings exists among the published studies evaluating the CV risks of inhaled anticholinergic agents. Prospective, adequately powered RCTs are needed to provide more evidence for the CV safety of tiotropium.

Differences in treatment and in outcomes between idiopathic and secondary forms of organizing pneumonia.

Organizing pneumonia is a major reparative response of the lung tissue to an acute injury and is a pathological hallmark of an entity called bronchiolitis obliterans organizing pneumonia (BOOP). It can be idiopathic and called cryptogenic organizing pneumonia (COP) or be secondary to various conditions such as infections, drugs, connective tissue disorders, and radiation. Fifty-seven patients with pathologically confirmed BOOP were identified and were classified as having either COP or secondary BOOP on the basis of whether there was an identifiable cause. The two groups were compared for demographic, clinical, laboratory, radiological and treatment variables. Duration of treatment with corticosteroids was longer for patients with COP.