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Hill JA, Lee YJ, Vande Vusse LK, Xie H, Chung EL, Waghmare A, Cheng GS, Zhu H, Huang ML, Hill GR, Jerome KR, Leisenring WM, Zerr DM, Gharib SA, Dadwal S, Boeckh M. HHV-6B detection and host gene expression implicate HHV-6B as pulmonary pathogen after hematopoietic cell transplant. Nat Commun 2024; 15:542. [PMID: 38228644 PMCID: PMC10791683 DOI: 10.1038/s41467-024-44828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024] Open
Abstract
Limited understanding of the immunopathogenesis of human herpesvirus 6B (HHV-6B) has prevented its acceptance as a pulmonary pathogen after hematopoietic cell transplant (HCT). In this prospective multicenter study of patients undergoing bronchoalveolar lavage (BAL) for pneumonia after allogeneic HCT, we test blood and BAL fluid (BALF) for HHV-6B DNA and mRNA transcripts associated with lytic infection and perform RNA-seq on paired blood. Among 116 participants, HHV-6B DNA is detected in 37% of BALs, 49% of which also have HHV-6B mRNA detection. We establish HHV-6B DNA viral load thresholds in BALF that are highly predictive of HHV-6B mRNA detection and associated with increased risk for overall mortality and death from respiratory failure. Participants with HHV-6B DNA in BALF exhibit distinct host gene expression signatures, notable for enriched interferon signaling pathways in participants clinically diagnosed with idiopathic pneumonia. These data implicate HHV-6B as a pulmonary pathogen after allogeneic HCT.
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Affiliation(s)
- Joshua A Hill
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA.
| | - Yeon Joo Lee
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
- Weill Cornell Medical College, 400 E 67th St, New York, NY, 10065, USA
| | - Lisa K Vande Vusse
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - E Lisa Chung
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Alpana Waghmare
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Guang-Shing Cheng
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Haiying Zhu
- Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Meei-Li Huang
- Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Geoffrey R Hill
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Danielle M Zerr
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Sina A Gharib
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Sanjeet Dadwal
- City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA, 91010, USA
| | - Michael Boeckh
- Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
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Lynch Y, Vande Vusse LK. Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation. J Intensive Care Med 2023:8850666231207331. [PMID: 37872657 DOI: 10.1177/08850666231207331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.
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Affiliation(s)
- Ylinne Lynch
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Vusse LKV. White Hair Ritual. J Gen Intern Med 2023; 38:2414-2415. [PMID: 37095332 PMCID: PMC10406783 DOI: 10.1007/s11606-023-08210-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/06/2023] [Indexed: 04/26/2023]
Affiliation(s)
- Lisa K Vande Vusse
- Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, University of Washington, Seattle, WA, USA.
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Chen A, Kwendakwema N, Vande Vusse LK, Narayanan M, Strizich L, Albert T, Wu C. Outcomes in quality improvement and patient safety training: moving from in-person to synchronous distance education. BMJ Open Qual 2023; 12:bmjoq-2022-002176. [PMID: 36927629 PMCID: PMC10030926 DOI: 10.1136/bmjoq-2022-002176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/08/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic necessitated increased synchronous distance education (SDE) in graduate medical education, presenting challenges for Quality Improvement and Patient Safety (QIPS) best practices, which call for integration with daily clinical care and investigation of real patient safety events. OBJECTIVE To evaluate educational outcomes for QIPS training after conversion of a mature, in-person curriculum to SDE. METHODS 68 postgraduate year (PGY)-1 residents were surveyed before and after the SDE Culture of Patient Safety training in June 2020, and 59 PGY-2s were administered the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) before and after the SDE QIPS seminar series in July-August 2020. Values before and after training were compared using sign tests for matched pairs (PGY-1) and Wilcoxon signed-rank tests (PGY-2). RESULTS 100% (68 of 68) of PGY-1s and 46% (27 of 59) of PGY-2s completed precourse and postcourse surveys. Before the course, 55 PGY-1s (81%) strongly agreed that submitting patient safety event reports are a physician's responsibility, and 63 (93%) did so after (15% increase, p=0.004). For PGY-2s, the median composite QIKAT-R score was 17 (IQR 14.5-20) before and 22.5 (IQR 20-24.5) after the seminars, with a median difference of 4.5 (IQR 1.5-7), a 32% increase in QIPS competency (p=0.001). CONCLUSIONS Patient safety attitudes and quality improvement knowledge increased after SDE QIPS training at comparable levels to previously published results for in-person training, supporting SDE use in future hybrid curricula to optimise educational value and reach.
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Affiliation(s)
- Anders Chen
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Medicine, Veterans Affairs Puget Sound Heathcare System, Seattle, Washington, USA
| | - Natasha Kwendakwema
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lisa K Vande Vusse
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Maya Narayanan
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lindee Strizich
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Tyler Albert
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Medicine, Veterans Affairs Puget Sound Heathcare System, Seattle, Washington, USA
| | - Chenwei Wu
- Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Medicine, Veterans Affairs Puget Sound Heathcare System, Seattle, Washington, USA
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Hill JA, Lee YJ, Vande Vusse LK, Xie H, Lisa Chung E, Keane-Candib J, Waghmare A, Cheng GS, Zhu H, Huang ML, Hill G, Jerome KR, Gharib SA, Leisenring WM, Zerr DM, Dadwal SS, Boeckh MJ. 2094. A prospective multicenter study of HHV-6B genomic DNA and gene transcription in paired bronchoalveolar lavage fluid and blood from HCT recipients. Open Forum Infect Dis 2022. [PMCID: PMC9752744 DOI: 10.1093/ofid/ofac492.1716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background We previously demonstrated frequent detection of HHV-6B DNA in bronchoalveolar lavage fluid (BALF) and its positive association with mortality in HCT recipients from 1992-2015 with lower respiratory tract disease (LRTD). Whether these findings remain pertinent in contemporary patients, the additive value of testing for viral gene transcription, and the correlation of HHV-6 detection in blood and BALF, are unknown. Methods We conducted a prospective study of allogeneic HCT recipients undergoing BAL for LRTD within 120 days of HCT at three cancer centers from 2015-2019. We collected and tested paired blood and BALF for HHV-6B DNA by qPCR and HHV-6B mRNA (U38 and U90 gene transcripts) among DNA positive samples using RT-qPCR. We described the detection of HHV-6B DNA and mRNA in blood and BALF, generated receiver operating characteristic (ROC) curves to determine the ability of BALF HHV-6B DNA detection to predict HHV-6B mRNA detection, and analyzed the association of HHV-6B DNA detection with mortality. Results We enrolled 116 allogeneic HCT recipients who underwent 125 BALs. HHV-6B DNA was detected in 45 of 122 BALF (37%) compared to 19 of 124 (15%) plasma samples. Among the 45 BALF samples with HHV-6B DNA detected, either HHV-6B mRNA transcript was detected in 22 (49%) (Figure 1). BALF HHV-6B DNA ≥ 218 copies/ml had an area under the curve of 0.93 for predicting detection of BALF viral mRNA (Figure 2). In turn, patients with BALF HHV-6B DNA ≥ 218 copies/mL had increased risk for mortality and death due to LRTD within 60 days after the BAL (Figure 3). This association remained after adjustment for age, oxygen use, and steroid use at the time of BAL in a multivariable Cox model (Figure 3).
![]() ![]() ![]() Conclusion HHV-6B was detected more frequently in BALF than plasma, suggesting compartment-specific reactivation. BALF HHV-6B DNA ≥ 218 copies/mL had high sensitivity and specificity for detection of viral gene transcription in BALF and was associated with increased mortality; this viral load is strikingly similar to the BALF viral load threshold of 251 copies/mL associated with mortality in our prior retrospective study. Together, these data suggest transcriptionally active HHV-6B is a clinically impactful pulmonary pathogen in contemporary HCT recipients. Disclosures Joshua A. Hill, MD, Allovir: Advisor/Consultant|Allovir: Grant/Research Support|Covance/CSL: Advisor/Consultant|CRISPR: Advisor/Consultant|Deverra: Grant/Research Support|Gilead: Grant/Research Support|Karius: Advisor/Consultant|Karius: Grant/Research Support|Merck: Grant/Research Support|Octapharma: Advisor/Consultant|OptumHealth: Advisor/Consultant|Oxford Immunotec: Grant/Research Support|Pfizer: Advisor/Consultant|Symbio: Advisor/Consultant|Takeda: Advisor/Consultant Alpana waghmare, MD, Allovir: Grant/Research Support|Ansun BioPharma: Grant/Research Support|Kyorin Pharmaceutical: Advisor/Consultant|Pfizer: Grant/Research Support|Vir/GSK: Grant/Research Support Geoffrey Hill, M.D., FRACP, FRCPA, Applied Molecular Transport: Grant/Research Support|Compass Therapeutics: Grant/Research Support|Generon Corporation: Advisor/Consultant|Heat Biologics: Grant/Research Support|iTeos Therapeutics: Advisor/Consultant|iTeos Therapeutics: Grant/Research Support|Laevoroc Oncology: Grant/Research Support|NapaJen Pharma: Advisor/Consultant|Neoleukin Therapeutics: Advisor/Consultant|Serplus Technology: Grant/Research Support|Syndax Pharmaceuticals: Grant/Research Support Danielle M. Zerr, MD MPH, AlloVir: Advisor/Consultant Sanjeet S. Dadwal, MD, FACP, FIDSA, AlloVir: Advisor/Consultant|AlloVir: Grant/Research Support|Ansun Biopharma: Grant/Research Support|Aseptiscope: Advisor/Consultant|Aseptiscope: Stocks/Bonds|Astellas: Speaker's Bureau|Cidara: Advisor/Consultant|Gilead: Grant/Research Support|Karius: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|Merck: Speaker's Bureau|Takeda: Speaker's Bureau Michael J. Boeckh, MD PhD, Allovir: Advisor/Consultant|Amazon: Grant/Research Support|Ansun Biopharma: Grant/Research Support|EvrysBio: Advisor/Consultant|Gates Ventures: Grant/Research Support|Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|GlaxoSmithKline: Advisor/Consultant|GlaxoSmithKline: Grant/Research Support|Helocyte: Advisor/Consultant|Janssen: Advisor/Consultant|Janssen: Grant/Research Support|Kyorin Pharmaceuticals: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support|Moderna: Advisor/Consultant|Moderna: Grant/Research Support|Regeneron: Grant/Research Support|ReViral: Advisor/Consultant|Symbio: Advisor/Consultant|Takeda: Grant/Research Support|Vir Biotechnology: Advisor/Consultant|Vir Biotechnology: Grant/Research Support.
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Affiliation(s)
- Joshua A Hill
- Fred Hutchinson Cancer Center; University of Washington, Seattle, Washington
| | - Yeon Joo Lee
- Memorial Sloan Kettering Cancer Center; Weill Cornell Medical College, New York, New York
| | | | - Hu Xie
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - E Lisa Chung
- Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Alpana Waghmare
- Fred Hutchinson Cancer Center; Seattle Children's Hospital, Seattle, Washington
| | - Guang-Shing Cheng
- University of Washington; Fred Hutchinson Cancer Center, Seattle, Washington
| | - Haiying Zhu
- University of Washington, Seattle, Washington
| | | | | | | | | | | | - Danielle M Zerr
- University of Washington; Seattle Children's Research Institute, Seattle, Washington
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Affiliation(s)
- Lisa K Vande Vusse
- University of Washington School of Medicine, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle
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Vande Vusse LK, Ryder HF, Best JA. Maximizing Career Advancement During the COVID-19 Pandemic: Recommendations for Postgraduate Training Programs. Acad Med 2021; 96:967-973. [PMID: 33480595 DOI: 10.1097/acm.0000000000003938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The ongoing novel Coronavirus disease 2019 (COVID-19) pandemic has created many threats as well as opportunities for the career development of physicians-in-training. Institutional responses to the demand for patient care reduced the time many residents have to pursue clinical electives, scholarship projects, and other experiences meant to clarify and advance their personal and professional goals. Moreover, many academic medical centers experienced profound fiscal losses that require thoughtful revisions to budgets and curricula. In this article, the authors recommend strategies for residency programs to mitigate these losses and capitalize on growth in virtual education, scholarship opportunities, and relationships arising from the pandemic. Drawing from career development guidelines from the National Career Development Association and existing literature about factors associated with positive career outcomes, the authors suggest leadership roles, curricula, and events that training programs can quickly and inexpensively implement to help residents grow as professionals, achieve personal training goals, produce scholarship, and attain future employment. To help trainees manage their careers, the authors recommend structured mentorship and education in career pathways and the preparation of job application materials. To foster attainment of specific knowledge and cultivate lifelong learning, the authors recommend leveraging existing resources to provide time, funding, academic coaching, and skills training for scholarship projects. To promote development of effective work relationships and community, the authors recommend appointment of a faculty champion for career advancement, scholarship showcases, attendance at virtual journal clubs, and networking through social media outlets. These recommendations for supporting career advancement may apply to early career faculty development as well as undergraduate and postgraduate medical education beyond the pandemic era. Outcomes studies will be needed to evaluate the impact of these recommendations.
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Affiliation(s)
- Lisa K Vande Vusse
- L.K. Vande Vusse is assistant professor, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington; ORCID: http://orcid.org/0000-0003-3051-2448
| | - Hilary F Ryder
- H.F. Ryder is associate professor, Department of Medicine, Medical Education and The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jennifer A Best
- J.A. Best is associate professor, Department of Medicine, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
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Chen A, Wolpaw BJ, Vande Vusse LK, Wu C, Meo N, Staub MB, Hicks KG, Carr SA, Schleyer AM, Harrington RD, Klein JW. Creating a Framework to Integrate Residency Program and Medical Center Approaches to Quality Improvement and Patient Safety Training. Acad Med 2021; 96:75-82. [PMID: 32909995 DOI: 10.1097/acm.0000000000003725] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Quality improvement and patient safety (QIPS) are core components of graduate medical education (GME). Training programs and affiliated medical centers must partner to create an environment in which trainees can learn while meaningfully contributing to QIPS efforts, to further the shared goal of improving patient care. Numerous challenges have been identified in the literature, including lack of resources, lack of faculty expertise, and siloed QIPS programs. In this article, the authors describe a framework for integrated QIPS training for residents in the University of Washington Internal Medicine Residency Program, beginning in 2014 with the creation of a dedicated QIPS chief resident position and assistant program director for health systems position, the building of a formal curriculum, and integration with medical center QIPS efforts. The postgraduate year (PGY) 1 curriculum focused on the culture of patient safety and entering traditional patient safety event (PSE) reports. The PGY-2 curriculum highlighted QIPS methodology and how to conduct mentored PSE reviews of cases that were of educational value to trainees and a clinical priority to the medical center. Additional PGY-2/PGY-3 training focused on the active report, presentation, and evaluation of cases during morbidity and mortality conferences while on clinical services, as well as how to lead longitudinal QIPS work. Select residents led mentored QI projects as part of an additional elective. The hallmark feature of this framework was the depth of integration with medical center priorities, which maximized educational and operational value. Evaluation of the program demonstrated improved attitudes, knowledge, and behavior changes in trainees, and significant contributions to medical center QIPS work. This specialty-agnostic framework allowed for training program and medical center integration, as well as horizontal integration across GME specialties, and can be a model for other institutions.
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Affiliation(s)
- Anders Chen
- A. Chen was assistant program director, Health Systems and Quality Improvement, Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, Washington, at the time this work was completed. He is curriculum and pathway director, Health Systems and Quality Improvement, Internal Medicine Residency Program, and assistant professor of medicine, University of Washington School of Medicine, Seattle, Washington
| | - Benjamin J Wolpaw
- B.J. Wolpaw was chief resident for quality and safety, Harborview Medical Center, Seattle, Washington, at the time this work was completed. He is clinical instructor of medicine, University of Washington School of Medicine, Seattle, Washington
| | - Lisa K Vande Vusse
- L.K. Vande Vusse is associate program director, Research and Scholarship, Internal Medicine Residency Program, and assistant professor of medicine, University of Washington School of Medicine, Seattle, Washington
| | - Chenwei Wu
- C. Wu was chief resident for quality and safety, Puget Sound VA Medical Center, Seattle, Washington, at the time this work was completed. He is director, Office of Transformation in the Quality, Safety and Values service line, Puget Sound VA Medical Center, and clinical instructor of medicine, University of Washington School of Medicine, Seattle, Washington
| | - Nicholas Meo
- N. Meo was chief resident for quality and safety, Puget Sound VA Medical Center, Seattle, Washington, at the time this work was completed. He is associate director of Graduate Medical Education Quality and Safety and clinical instructor, University of Washington School of Medicine, Seattle, Washington
| | - Milner B Staub
- M.B. Staub was chief resident for quality and safety, Puget Sound VA Medical Center, Seattle, Washington, at the time this work was completed. She is VA quality scholar, VA Tennessee Valley Healthcare System, and clinical instructor, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katherine G Hicks
- K.G. Hicks was chief resident for quality and safety, Harborview Medical Center, Seattle, Washington, at the time this work was completed. She is acting instructor of medicine, University of Washington School of Medicine, Seattle, Washington
| | - Stephanie A Carr
- S.A. Carr was chief resident for quality and safety, Puget Sound VA Medical Center, Seattle, Washington, at the time this work was completed. She is staff physician, Family Care Network, Bellingham, Washington
| | - Anneliese M Schleyer
- A.M. Schleyer is associate medical director, Hospital Quality and Safety, Harborview Medical Center, and associate professor of medicine, University of Washington School of Medicine, Seattle, Washington
| | - Robert D Harrington
- R.D. Harrington is chief of medicine, Harborview Medical Center, and vice chair, Department of Medicine and professor of medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jared W Klein
- J.W. Klein is internal medicine representative, Medical Quality Improvement Committee, Harborview Medical Center, and assistant professor of medicine, University of Washington School of Medicine, Seattle, Washington
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Vail EA, Nadig NR, Sahetya SK, Vande Vusse LK, Walkey AJ, Liu V, Mathews KS. The Role of Professional Organizations in Fostering the Early Career Development of Academic Intensivists. Ann Am Thorac Soc 2020; 17:412-418. [PMID: 31800295 PMCID: PMC8174059 DOI: 10.1513/annalsats.201908-573ps] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/04/2019] [Indexed: 11/20/2022] Open
Affiliation(s)
- Emily A. Vail
- Assembly on Critical Care Early Career Professionals Working Group, and
- Department of Anesthesiology, University of Texas Health San Antonio, San Antonio, Texas
| | - Nandita R. Nadig
- Assembly on Critical Care Early Career Professionals Working Group, and
- Members in Transition and Training Committee, American Thoracic Society, New York, New York
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Sarina K. Sahetya
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lisa K. Vande Vusse
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Allan J. Walkey
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University, Boston, Massachusetts
| | - Vincent Liu
- Assembly on Critical Care Early Career Professionals Working Group, and
- Division of Research, Kaiser Permanente, Oakland, California
| | - Kusum S. Mathews
- Assembly on Critical Care Early Career Professionals Working Group, and
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, and
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Hill JA, Vande Vusse LK, Xie H, Chung EL, Yeung CC, Seo S, Stevens-Ayers T, Fisher CE, Huang ML, Stewart FM, Jerome KR, Zerr DM, Corey L, Leisenring WM, Boeckh M. Human Herpesvirus 6B and Lower Respiratory Tract Disease After Hematopoietic Cell Transplantation. J Clin Oncol 2019; 37:2670-2681. [PMID: 31449472 PMCID: PMC7351330 DOI: 10.1200/jco.19.00908] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Human herpesvirus 6B (HHV-6B) DNA is frequently detected in bronchoalveolar lavage fluid (BALF) from immunocompromised subjects with lower respiratory tract disease (LRTD). Whether HHV-6B is a pulmonary pathogen is unclear. METHODS We tested BALF for HHV-6B DNA using polymerase chain reaction in allogeneic hematopoietic cell transplantation (HCT) recipients who underwent a BAL for evaluation of LRTD from 1992 to 2015. We used multivariable proportional hazards models to evaluate the association of HHV-6B+ BALF with overall mortality, death from respiratory failure, and the effect of anti-HHV-6B antivirals on these outcomes. We used branched-chain RNA in situ hybridization to detect HHV-6 messenger RNA (U41 and U57 transcripts) in lung tissue. RESULTS We detected HHV-6B+ BALF from 147 of 553 (27%) individuals. Subjects with HHV-6B+ BALF, with or without copathogens, had significantly increased risk of overall mortality (adjusted hazard ratio [aHR], 2.18; 95% CI, 1.41-3.39) and death from respiratory failure (aHR, 2.50; 95% CI, 1.56-4.01) compared with subjects with HHV-6B- BALF. Subjects with HHV-6B+ BALF who received antivirals within 3 days pre-BAL had an approximately 1 log10 lower median HHV-6B BALF viral load, as well as a lower risk of overall mortality (aHR, 0.42; 95% CI, 0.16-1.10), compared with subjects with HHV-6B+ BALF not receiving antivirals. We detected intraparenchymal HHV-6 gene expression by RNA in situ hybridization in lung tissue in all three tested subjects with HHV-6B+ BALF and sufficient tissue RNA preservation. CONCLUSION These data provide evidence that HHV-6B detection in BALF is associated with higher mortality in allogeneic hematopoietic cell transplantation recipients with LRTD. Definitive evidence of causation will require a randomized prevention or treatment trial.
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Affiliation(s)
- Joshua A. Hill
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Lisa K. Vande Vusse
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Hu Xie
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Cecilia C.S. Yeung
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sachiko Seo
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Cynthia E. Fisher
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - F. Marc Stewart
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Keith R. Jerome
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Danielle M. Zerr
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Lawrence Corey
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Michael Boeckh
- University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
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11
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Wenger DS, Triplette M, Crothers K, Cheng GS, Hill JA, Milano F, Shahrir S, Schoch G, Vande Vusse LK. Incidence, Risk Factors, and Outcomes of Idiopathic Pneumonia Syndrome after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:413-420. [PMID: 31605819 PMCID: PMC7035790 DOI: 10.1016/j.bbmt.2019.09.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 11/26/2022]
Abstract
Our current knowledge of idiopathic pneumonia syndrome (IPS) predates improved specificity in the diagnosis of IPS and advances in hematopoietic cell transplantation (HCT) and critical care practices. In this study, we describe and update the incidence, risk factors, and outcomes of IPS. We performed a retrospective cohort study of all adults who underwent allogeneic HCT at the Fred Hutchinson Cancer Research Center between 2006 and 2013 (n = 1829). IPS was defined using the National Heart, Lung, and Blood Institute consensus definition: multilobar airspace opacities on chest imaging, absence of lower respiratory tract infection, and hypoxemia. We described IPS incidence and mortality within 120 and 365 days after HCT. We examined conditioning intensity (nonmyeloablative versus myeloablative with high-dose total body irradiation [TBI] versus myeloablative with low-dose TBI) as an IPS risk factor in a time-to-event analysis using Cox models, controlled for age at transplant, HLA matching, stem cell source, and pretransplant Lung function Score (a combined measure of impairment in Forced Expiratory Volume in the first second (FEV1) and Diffusion capacity for carbon monoxide (DLCO)). Among 1829 HCT recipients, 67 fulfilled IPS criteria within 120 days (3.7%). Individuals who developed IPS were more likely to be black/non-Hispanic versus other racial groups and have severe pulmonary impairment but were otherwise similar to participants without IPS. In adjusted models, myeloablative conditioning with high-dose TBI was associated with increased risk of IPS (hazard ratio, 2.5; 95% confidence interval, 1.2 to 5.2). Thirty-one patients (46.3%) with IPS died within the first 120 days of HCT and 47 patients (70.1%) died within 365 days of HCT. In contrast, among the 1762 patients who did not acquire IPS in the first 120 days, 204 (11.6%) died within 120 days of HCT and 510 (29.9%) died within 365 days of HCT. Our findings suggest that although the incidence of IPS may be declining, it remains associated with post-transplant mortality. Future study should focus on early detection and identifying pathologic mediators of IPS to facilitate timely, targeted therapies for those most susceptible to lung injury post-HCT.
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Affiliation(s)
- David S Wenger
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington.
| | - Matthew Triplette
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kristina Crothers
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; VA Puget Sound Healthcare System, University of Washington, Seattle, Washington
| | - Guang-Shing Cheng
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joshua A Hill
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington; Vaccine and Infectious Disease Division & Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Hematology and Oncology, Seattle Cancer Care Alliance, Seattle, Washington
| | - Shahida Shahrir
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington
| | - Gary Schoch
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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12
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Vande Vusse LK, Wurfel MM, Madtes DM, Schoch HG, Harju-Baker S, Hill JA, Jerome KR, Boeckh M, Watkins TR. Alveolar levels of immuno-inflammatory mediators in diffuse alveolar hemorrhage after allogeneic transplant. Bone Marrow Transplant 2018; 53:1206-1209. [PMID: 29670209 PMCID: PMC6474338 DOI: 10.1038/s41409-018-0168-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 11/25/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Lisa K Vande Vusse
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA. .,Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.
| | - Mark M Wurfel
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
| | - David M Madtes
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA
| | - H Gary Schoch
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA
| | - Susanna Harju-Baker
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
| | - Joshua A Hill
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Keith R Jerome
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Center Research Center, Seattle, WA, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Timothy R Watkins
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
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13
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Affiliation(s)
- Lisa K Vande Vusse
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Mailstop D5-360, Seattle, WA 98109, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA.
| | - David K Madtes
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Mailstop D5-360, Seattle, WA 98109, USA
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Vande Vusse LK, Madtes DK, Bolgiano D, Watkins TR. The association between platelet transfusion and idiopathic pneumonia syndrome is unaffected by platelet product type. Transfusion 2015; 56:489-96. [PMID: 26435205 DOI: 10.1111/trf.13361] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 08/25/2015] [Accepted: 08/28/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Methods used to produce platelet (PLT) components, pooling of PLT-rich plasma (PRP-PLT) and apheresis (AP-PLT), may variably contribute to the pathogenesis and severity of idiopathic pneumonia syndrome (IPS). STUDY DESIGN AND METHODS We performed a retrospective cohort study of 906 allogeneic hematopoietic cell transplant recipients to examine associations between PLT product type and risks of developing IPS and dying after IPS onset. Proportional hazards models included separate terms for the sum of all PLT transfusions and the sum of PRP-PLT units received in the 3 or 7 days before IPS onset. Similarly constructed models analyzed the outcome of time to death after IPS onset. All analyses were adjusted for known IPS risk factors. RESULTS Patients received a median of three PRP-PLT transfusions (interquartile range [IQR], 0-6) and five AP-PLT transfusions (IQR, 1-13) while at risk for IPS. Seventy-five patients (8%) developed IPS by Posttransplant Day 120. The proportion of PRP-PLT transfusions was not associated with risk of developing IPS (3-day hazard ratio [HR] 0.98, 95% CI 0.74-1.29, p = 0.86; 7-day HR 1.00, 95% CI 0.86-1.15, p = 0.95) or dying after IPS onset (3-day HR 0.99, 95% CI 0.75-1.31, p = 0.97; 7-day HR 0.98, 95% CI 0.78-1.12, p = 0.47). CONCLUSION The association between PLT transfusions and risk of developing IPS or dying after IPS onset does not differ according to PLT product type. Further research is required to identify potentially modifiable steps in PLT component production that contribute to IPS.
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Affiliation(s)
- Lisa K Vande Vusse
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington
| | - David K Madtes
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington.,Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Douglas Bolgiano
- Research Institute, Puget Sound Blood Center, Seattle, Washington
| | - Timothy R Watkins
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington.,Research Institute, Puget Sound Blood Center, Seattle, Washington
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15
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Vande Vusse LK, Madtes DK, Guthrie KA, Gernsheimer TB, Curtis JR, Watkins TR. The association between red blood cell and platelet transfusion and subsequently developing idiopathic pneumonia syndrome after hematopoietic stem cell transplantation. Transfusion 2013; 54:1071-80. [PMID: 24033082 DOI: 10.1111/trf.12396] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 07/10/2013] [Accepted: 07/22/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Blood transfusions are common during hematopoietic stem cell transplantation (HSCT) and may contribute to lung injury. STUDY DESIGN AND METHODS This study examined the associations between red blood cell (RBC) and platelet (PLT) transfusions and idiopathic pneumonia syndrome (IPS) among 914 individuals who underwent myeloablative allogeneic HSCT between 1997 and 2001. Patients received allogeneic blood transfusions at their physicians' discretion. RBCs, PLTs, and a composite of "other" transfusions were quantified as the sum of units received each 7-day period from 6 days before transplant until IPS onset, death, or Posttransplant Day 120. RBC and PLT transfusions were modeled as separate time-varying exposures in proportional hazards models adjusted for IPS risk factors (age, baseline disease, irradiation dose) and other transfusions. Timing of PLT transfusion relative to myeloid engraftment and PLT ABO blood group (match vs. mismatch) were included as potential interaction terms. RESULTS Patients received a median of 9 PLT and 10 RBC units. There were 77 IPS cases (8.4%). Each additional PLT unit transfused in the prior week was associated with 16% higher IPS risk (hazard ratio, 1.16; 95% confidence interval, 1.09-1.23; p < 0.001). Recent RBC and PLT transfusions were each significantly associated with greater risk of IPS when examined without the other; only PLT transfusions retained significance when both exposures were included in the model. The PLT association was not modified by engraftment or ABO mismatch. CONCLUSION PLT transfusions are associated with greater risk of IPS after myeloablative HSCT. RBCs may also contribute; however, these findings need confirmation.
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Affiliation(s)
- Lisa K Vande Vusse
- Division of Pulmonary and Critical Care Medicine, University of Washington, Washington
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Vande Vusse LK, Zacharski LR, Dumas MG, McKernan LJ, Cornell CJ, Kinsler EA, Whiteside JL. Prohemostatic therapy: the rise and fall of aprotinin. Semin Thromb Hemost 2010; 36:103-12. [PMID: 20391301 DOI: 10.1055/s-0030-1248729] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Aprotinin has been used clinically to enhance hemostasis for decades and was approved in the United States by the Food and Drug Administration in 1993 to reduce the transfusion requirement during coronary artery bypass surgery. Marketing of aprotinin ceased recently when observational studies and a randomized clinical trial reported increased cardiovascular toxicity in patients receiving this drug. The importance of prohemostatic therapy is reviewed in light of new information on long-term deleterious effects of blood transfusion, including increased risk of cardiovascular disease, malignancy, and infection possibly attributable to delivery of a load of red cell-derived redox-active iron. Weaknesses in design of clinical trials that failed to control adequately for such alternative mechanisms of toxicity complicate interpretation of risks versus benefits in clinical trials of aprotinin given to reduce transfusion requirement in the acute surgical setting. Properties and applications of aprotinin that may not have received sufficient attention in the decision to remove this drug from the therapeutic armamentarium are reviewed. Potential application of prohemostatic drugs, including aprotinin to special populations at risk for operative blood loss requiring transfusion, is illustrated by the description of nine patients with coagulopathies whose operative bleeding was managed effectively with aprotinin. This drug may remain safe and effective in patients at risk of bleeding with surgery. Beneficial effects of aprotinin seemingly unrelated to its prohemostatic properties, especially its apparent striking antineoplastic effects, warrant further study.
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Affiliation(s)
- Lisa K Vande Vusse
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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