Severe adult respiratory distress syndrome (ARDS) is associated with failure to maintain adequate gas exchange. There is increasing success using extracorporeal membrane oxygenation (ECMO) for respiratory failure; the longest reported surviving patient has been supported by ECMO for 57 days. At best about 50% wean from ECMO and should weaning fail their course is fatal. ECMO is generally considered to be a contraindication for successful lung transplantation. This report describes a patient maintained on ECMO for 107 days who underwent bilateral lung transplantation and weaned from organ-perfusion support. He survived for 351 days post-transplantation and died from Pseudomonas aeruginosa pneumonia. ECMO can be used for prolonged intervals to support patients with severe ARDS without complications that preclude lung transplantation. As ECMO use becomes more frequent, it becomes critical to determine criteria that would optimise patient selection for transplantation from ECMO.
Background: Chronic rejection, manifesting as bronchiolitis obliterans, is the leading cause of death in lung transplant recipients. In our previously reported double-blinded, placebo-controlled trial comparing inhaled cyclosporine (ACsA) to aerosol placebo, the rate of bronchiolitis-free survival improved. However, an independent analysis of pulmonary function, a secondary endpoint of the trial, was not performed. We sought to determine the effect of ACsA, in addition to systemic immunosuppression, on pulmonary function. Methods: From 1998-2001, 58 patients were randomly assigned to inhale either 300 mg of ACsA (28 patients) or placebo aerosol (30 patients) 3 days a week for the first 2 years after transplantation. Longitudinal changes in pulmonary function of ACsA patients were compared to aerosol placebo patients. In another analysis, the rate of decline from 6-month maximum FEV 1 in randomized patients was compared to the rate of decline in patients receiving conventional immunosuppression from the Novartis transplant database (644 patients, 12 centers worldwide, transplanted from 1990-1995). Results: The average duration of ACsA and aerosol placebo was 400 days AE 306 and 433 AE 256, respectively. The change in FEV 1 of ACsA patients (adjusted for Cytomegalovirus (CMV) mismatch and transplant type, followed for a maximum duration of 4.6 years) was superior to the aerosol placebo controls (9.0 AE 71.4 mL=year vs. À107.9 AE 55.3, p ¼ 0.007). The FEF 25-75 decreased by À220.3 AE 117.7 L=(secondÂyear) vs. À412.2 AE 139.2, p ¼ 0.07, respectively. Similarly, percent FEV 1 decline from maximal values was improved in ACsA patients compared to aerosol placebo and Novartis controls (ACsA À0.43 AE 1.12%=year vs. aerosol placebo À4.08 AE 1.4, p ¼ 0.04; ACsA vs. Novartis À4.7 AE 0.31, p ¼ 0.007). Single-lung recipients receiving ACsA showed improvement in FEV 1 compared to Novartis controls (FEV 1 À0.8 AE 1.8%=year vs. À4.94 AE 0.4, p ¼ 0.03) but double-lung recipients showed improvement compared to aerosol placebo controls only (FEV 1 À0.28 AE 1.22%=year vs. À8.53 AE 5.95, p ¼ 0.048). Conclusions: In this single center trial, ACsA appears to ameliorate important pulmonary function parameters in lung transplant recipients compared to aerosol placebo and historical control patients. Single-and double-lung transplant recipients may not respond uniformly to treatment, and ongoing randomized trials in lung transplant recipients using ACsA may help elucidate our findings.
Immunosuppressive regimens for lung transplantation frequently fail to prevent rejection and are toxic. Alemtuzumab was used as induction to investigate whether oral immunosuppression could be reduced. From November 2006 to March 2008, 20 consecutive lung transplant patients received alemtuzumab induction, with reduced maintenance immunosuppression; tacrolimus (target level 10 ng/ml), mycophenolate mofetil (MMF) 250 mg bid and prednisone 7.5 mg. Twenty control cases transplanted before 2006 were treated with standard immunosuppression; tacrolimus (target level 10 ng/ml), MMF 750 mg bid and prednisone 15 mg qd. End-points included patient and graft survival, acute rejection (AR) and infection rate. There were no significant differences in six-month and 12-month survival (alemtuzumab 90% vs. controls 95%, P=0.52 and 76% vs. 95%, respectively, P=0.19). AR events were similar (alemtuzumab 2/16 vs. controls 5/20, P=0.43) - as were - bacteria positive bronchoalveolar lavage (BAL) cultures (alemtuzumab 4.9+/-7.3 per patient per year vs. controls 2.7+/-3.3, P=0.26) and viral or fungal infections (alemtuzumab 0.4+/-1.4 per patient per year vs. controls 0.1+/-0.3, P=0.87; alemtuzumab 3.9+/-6.6 vs. controls 2.3+/-1.9, P=0.57, respectively). Alemtuzumab induction and reduced immunosuppression appears to offer comparable early survival, rejection and infection rates to high-dose standard immunosuppression.
Background Given the rapid spread of COVID-19 and its associated morbidity and mortality, healthcare providers throughout the world have been forced to constantly update and change their care delivery models. Objective To assess the outcomes of COVID-19 hospitalized patients during the course of the pandemic in a well-integrated health system. Methods The study used data from the electronic health medical records to assess trends in clinical profile and outcomes of hospitalized adult COVID-19 patients hospitalized in our 5-hospital health system from March 2020-May 2021 (n = 6865). Integration of the health system began in February 2020 and was fully actualized by March 30, 2020. Results Mortality decreased from 15% during first peak (March-May 2020; the rate includes 19% in March-April and 10% in May 2020) to 6% in summer-fall 2020, increased to 13% during the second peak (November 2020-January 2021), and dropped to 7% during the decline period (February-May 2021) (p<0.01). Resource utilization followed a similar pattern including a decrease in ICU use from 35% (first peak) to 16% (decline period), mechanical ventilation from 16% (first peak, including 45% in March 2020) to 9–11% in subsequent periods (p<0.01). Independent predictors of inpatient mortality across multiple study periods included older age, male sex, higher multi-morbidity scores, morbid obesity, and indicators of severe illness on admission such as oxygen saturation ≤90% and high qSOFA score (all p<0.05). However, admission during the first peak remained independently associated with increased mortality even after adjustment for patient-related factors: odds ratio = 1.8 (1.4–2.4) (p<0.0001). Conclusions The creation of a fully integrated health system allowed us to dynamically respond to the everchanging COVID-19 landscape. In this context, despite the increasing patient acuity, our mortality and resource utilization rates have improved during the pandemic.
Background. Recent studies of risks in cardiopulmonary arrest (CPA) have been performed using large databases from a broad mix of hospital settings. However, these risks might be different in a large, urban, academic medical center. We attempted to validate factors influencing outcomes from CPA at the University of Maryland Medical Center (UMMC).Methods. Retrospective chart review of all adult patients who underwent CPA between 2000 and 2005 at UMMC. Risk factors and outcomes were analyzed with appropriate statistical analysis and compared with published results.Results. 729 episodes of CPA were examined during the study period. Surgical patients had better survival than medical or cardiac patients. Intensive care unit' (ICU) patients had poor survival, but there was no difference on monitored or unmonitored floors. Respiratory etiologies survived better than cardiac etiologies. CPR duration and obesity were negatively correlated with outcome, while neurologic disease, trauma, and electrolyte imbalances improved survival. Age, gender, race, presence of a witness, presence of a monitor, comorbidities, or time of day of CPA did not influence survival, although age was associated with differences in comorbidities.Conclusions. UMMC risk factors for CPA survival differed from those in more broad-based studies. Care should be used when applying the results of database studies to specific medical institutions.
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