1
|
Clancy MJ, Tevald MA, Adler J, Butler K, Courtwright AM, Diamond JM, Crespo MM, Bermudez CA. Reevaluating Rehabilitation Practice for Patients Who Were Critically Ill After COVID-19 Infection: An Administrative Case Report. Phys Ther 2024; 104:pzad175. [PMID: 38109784 DOI: 10.1093/ptj/pzad175] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/28/2023] [Accepted: 10/24/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The goal of this case report is to describe the process, challenges, and opportunities of implementing rehabilitation for individuals who were critically ill and required both mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO) support following a coronavirus 2019 (COVID-19) infection in an academic medical center. METHODS This administrative case report is set in a heart and vascular intensive care unit, a 35-bed critical care unit that provides services for patients with various complex cardiovascular surgical interventions, including transplantation. Patients were admitted to the heart and vascular intensive care unit with either COVID-19 acute respiratory distress syndrome or pulmonary fibrosis for consideration of bilateral orthotropic lung transplantation. The authors describe the process of establishing rehabilitation criteria for patients who, by previously established guidelines, would be considered too ill to engage in rehabilitation. RESULTS The rehabilitation team, in coordination with an interprofessional team of critical care providers including physicians, respiratory care providers, perfusionists, and registered nurses, collaborated to implement a rehabilitation program for patients with critical COVID-19 being considered for bilateral orthotropic lung transplantation. This was accomplished by (1) reviewing previously published guidelines and practices; (2) developing an interdisciplinary framework for the consideration of rehabilitation treatment; and (3) implementing the framework for patients in our heart and vascular intensive care unit. CONCLUSION In response to the growing volume of patients admitted with critical COVID-19, the team initiated and developed an interprofessional framework and successfully provided rehabilitation services to patients who were critically ill. While resource-intensive, the process demonstrates that rehabilitation can be implemented on a case-by-case basis for select patients receiving extracorporeal membrane oxygenation and MV, who would previously have been considered too critically ill for rehabilitation services. IMPACT Rehabilitating patients with end-stage pulmonary disease on extracorporeal membrane oxygenation and MV support is challenging but feasible with appropriate interprofessional collaboration and knowledge sharing.
Collapse
Affiliation(s)
- Malachy J Clancy
- Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael A Tevald
- Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
| | - Joe Adler
- Good Shepherd Penn Partners, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelly Butler
- Good Shepherd Penn Partners, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew M Courtwright
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria M Crespo
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian A Bermudez
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
2
|
Diamond JM, Cantu E, Calfee CS, Anderson MR, Clausen ES, Shashaty MGS, Courtwright AM, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Todd JL, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Weinacker AB, Lama VN, Patel MG, Singer JP, Hsu J, Localio AR, Christie JD. The Impact of Donor Smoking on Primary Graft Dysfunction and Mortality after Lung Transplantation. Am J Respir Crit Care Med 2024; 209:91-100. [PMID: 37734031 PMCID: PMC10870879 DOI: 10.1164/rccm.202303-0358oc] [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: 03/02/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Prior studies implicated proxy-defined donor smoking as a risk factor for PGD and mortality. Objectives: We aimed to more accurately assess the impact of donor smoke exposure on PGD and mortality using quantitative smoke exposure biomarkers. Methods: We performed a multicenter prospective cohort study of lung transplant recipients enrolled in the Lung Transplant Outcomes Group cohort between 2012 and 2018. PGD was defined as grade 3 at 48 or 72 hours after lung reperfusion. Donor smoking was defined using accepted thresholds of urinary biomarkers of nicotine exposure (cotinine) and tobacco-specific nitrosamine (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol [NNAL]) in addition to clinical history. The donor smoking-PGD association was assessed using logistic regression, and survival analysis was performed using inverse probability of exposure weighting according to smoking category. Measurements and Main Results: Active donor smoking prevalence varied by definition, with 34-43% based on urinary cotinine, 28% by urinary NNAL, and 37% by clinical documentation. The standardized risk of PGD associated with active donor smoking was higher across all definitions, with an absolute risk increase of 11.5% (95% confidence interval [CI], 3.8% to 19.2%) by urinary cotinine, 5.7% (95% CI, -3.4% to 14.9%) by urinary NNAL, and 6.5% (95% CI, -2.8% to 15.8%) defined clinically. Donor smoking was not associated with differential post-lung transplant survival using any definition. Conclusions: Donor smoking associates with a modest increase in PGD risk but not with increased recipient mortality. Use of lungs from smokers is likely safe and may increase lung donor availability. Clinical trial registered with www.clinicaltrials.gov (NCT00552357).
Collapse
Affiliation(s)
- Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Carolyn S. Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Michaela R. Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Emily S. Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | | | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Maria M. Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | | | | | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jamie L. Todd
- Division of Pulmonary and Critical Care Medicine and
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F. McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D. Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B. Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Ann B. Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan; and
| | - Mrunal G. Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P. Singer
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| |
Collapse
|
3
|
Courtwright AM, Doyon JB, Blumberg EA, Cevasco M, Cantu E, Bermudez CA, Crespo MM. Infectious complications associated with bronchial anastomotic dehiscence in lung transplant recipients. Clin Transplant 2023; 37:e15040. [PMID: 37248788 DOI: 10.1111/ctr.15040] [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: 03/29/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Bronchial anastomotic dehiscence (AD) is an uncommon complication following lung transplantation that carries significant morbidity and mortality. The objective of this study was to characterize fungal and bacterial infections in ADs, including whether infections following AD were associated with progression to bronchial stenosis. METHODS This was a single-center study of 615 lung transplant recipients between 6/1/2015 and 12/31/2021. Airway complications were defined according to ISHLT consensus guidelines. RESULTS 22 of the 615 recipients (3.6%) developed an AD. Bronchial ischemia or necrosis was common prior to dehiscence (68.1%). Fourteen (63.6%) recipients had bacterial airway infections, most commonly with Gram-negative rods, prior to dehiscence. Thirteen (59.1%) recipients had an associated pleural infection, most commonly with Candida species (30.8%). Post-dehiscence Aspergillus species were isolated in 4 recipients, 3 of which were de novo infections. Eleven had bacterial infections prior to dehiscence resolution, most commonly with Pseudomonas aeruginosa. Eleven recipients developed airway stenosis requiring dilation and/or stenting. Development of secondary infection prior to AD resolution was not associated with progression to stenosis (OR = .41, 95% CI = .05-3.30, p = .41). CONCLUSIONS Gram-negative bacterial infections are common before and after AD. Pleural infection should be suspected in most cases. Infections prior to healing were not associated with subsequent development of airway stenosis.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonology, Allergy, and Critical Care, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffery B Doyon
- Division of Infectious Diseases, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily A Blumberg
- Division of Infectious Diseases, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ed Cantu
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria M Crespo
- Division of Pulmonology, Allergy, and Critical Care, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Rubin EB, Robinson EM, Cremens MC, McCoy TH, Courtwright AM. Declining to Provide or Continue Requested Life-Sustaining Treatment: Experience With a Hospital Resolving Conflict Policy. Bioethical Inquiry 2023; 20:457-466. [PMID: 37380828 DOI: 10.1007/s11673-023-10270-7] [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] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/31/2022] [Indexed: 06/30/2023]
Abstract
In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness.
Collapse
Affiliation(s)
- Emily B Rubin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, Bullfinch Building, Boston, MA, 02114, USA.
| | - Ellen M Robinson
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Patient Care Services, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry Massachusetts General Hospital, Boston, MA, USA
| | | |
Collapse
|
5
|
Courtwright AM. The Moral Relevance of ECMO Bridge Maintenance. Am J Bioeth 2023; 23:52-54. [PMID: 37220367 DOI: 10.1080/15265161.2023.2201209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
|
6
|
Clancy MJ, Adler J, Tevald MA, Zaleski D, Fluehr L, Wamsley C, Bermudez CA, Crespo MM, Balar P, Oyster ML, Courtwright AM, Diamond JM. Rehabilitation Characteristics and Outcomes for Lung Transplantation for COVID-19: A Case Series. Phys Ther 2023; 103:7069113. [PMID: 37249530 DOI: 10.1093/ptj/pzad026] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/29/2022] [Accepted: 01/02/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Severe coronavirus disease 2019 (COVID-19) can result in irreversible lung damage, with some individuals requiring lung transplantation. The purpose of this case series is to describe the initial experience with the rehabilitation and functional outcomes of 9 patients receiving a lung transplant for COVID-19. METHODS Nine individuals, ranging in age from 37 to 68 years, received bilateral orthotopic lung transplantation (BOLT) for COVID-19 between December 2020 and July 2021. Rehabilitation was provided before and after the transplant, including in-hospital rehabilitation, postacute care inpatient rehabilitation, and outpatient rehabilitation. RESULTS Progress with mobility was limited in the pretransplant phase despite rehabilitation efforts. Following transplantation, 2 individuals expired before resuming rehabilitation, and 2 others had complications that delayed their progress. The remaining 5 experienced clinically important improvements in mobility and walking capacities. CONCLUSION Considerable rehabilitation resources are required to care for individuals both before and after BOLT for COVID-19. Rehabilitation can have a profound impact on both functional and clinical outcomes for this unique patient population. IMPACT There is limited literature on the rehabilitation efforts and outcomes for patients who received BOLT for COVID-19. Occupational therapists and physical therapists play an important role during the pretransplant and posttransplant recovery process for this novel patient population. LAY SUMMARY Patients with a bilateral orthotopic lung transplant due to COVID-19 require a unique rehabilitation process. They have significant difficulties with activities of daily living and functional mobility across the pretransplant and posttransplant continuum of care, but progressive gains in functional performance may be possible with a comprehensive multidisciplinary rehabilitation program.
Collapse
Affiliation(s)
- Malachy J Clancy
- Department of Occupational & Physical Therapy, Good Shepherd Penn Partners, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joe Adler
- Department of Occupational & Physical Therapy, Good Shepherd Penn Partners, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael A Tevald
- Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
| | - Derek Zaleski
- Department of Occupational & Physical Therapy, Good Shepherd Penn Partners, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lindsay Fluehr
- Department of Occupational & Physical Therapy, Good Shepherd Penn Partners, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carol Wamsley
- Penn Institute for Rehabilitation Medicine, Good Shepherd Penn Partners, Philadelphia, Pennsylvania, USA
| | - Christian A Bermudez
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria M Crespo
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Priya Balar
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle L Oyster
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew M Courtwright
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
7
|
|
8
|
Courtwright AM, Devarajan J, Fritz AV, Martin AK, Wilkey B, Subramani S, Cassara CM, Tawil JN, Miltiades AN, Boisen ML, Bottiger BA, Pollak A, Gelzinis TA. Cardiothoracic Transplant Anesthesia: Selected Highlights: Part I-Lung Transplantation. J Cardiothorac Vasc Anesth 2023; 37:884-903. [PMID: 36868904 DOI: 10.1053/j.jvca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
| | | | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Jacksonville, FL
| | | | - Barbara Wilkey
- Department of Anesthesiology, University of Colorado, Aurora, CO
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Christopher M Cassara
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin N Tawil
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Andrea N Miltiades
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brandi A Bottiger
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Angela Pollak
- Department of Anesthesiology, Duke University, Durham, NC
| | | |
Collapse
|
9
|
Federico LE, Courtwright AM, Diamond JM, Crespo MM, Bermudez CA. Change in Panel Reactive Antibodies in Patients Bridged to Lung Transplantation With Extracorporeal Membrane Oxygenation. Semin Thorac Cardiovasc Surg 2022; 36:54-56. [PMID: 36182094 DOI: 10.1053/j.semtcvs.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Lydia E Federico
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew M Courtwright
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Joshua M Diamond
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria M Crespo
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
10
|
Murakami N, Baggett ND, Schwarze ML, Ladin K, Courtwright AM, Goldberg HJ, Nolley EP, Jain N, Landzberg M, Wentlandt K, Lai JC, Shinall MC, Ufere NN, Jones CA, Lakin JR. Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation. J Palliat Med 2022; 25:1136-1142. [PMID: 35275707 PMCID: PMC9467633 DOI: 10.1089/jpm.2022.0013] [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: 11/12/2022] Open
Abstract
Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.
Collapse
Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nathan D Baggett
- Division of Emergency Medicine, Health Partners Institute/Regions Hospital, St. Paul, Minnesota, USA
| | | | - Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, Massachusetts, USA.,Department of Community Health, Tufts University, Medford, Massachusetts, USA
| | - Andrew M Courtwright
- Department of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eric P Nolley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael Landzberg
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kirsten Wentlandt
- Division of Palliative Care, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, California, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Section of Palliative Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| |
Collapse
|
11
|
M Courtwright A, Patel N, Chandraker A, J Goldberg H. Human leukocyte antigen antibody sensitization, lung transplantation, and health equity. Am J Transplant 2022; 22:698-704. [PMID: 34379882 DOI: 10.1111/ajt.16795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/18/2021] [Accepted: 08/05/2021] [Indexed: 01/25/2023]
Abstract
Women with advanced lung disease, particularly Black and Hispanic women, are more likely than other patients to have anti-human leukocyte (HLA) antibodies against potential donors. Sensitized patients, especially those who are highly sensitized, are less likely to be listed for lung transplant or to be considered candidates for mechanical circulatory support. They are also at higher risk for waitlist death. Institutional variability in approach to HLA antibody screening and pre-transplant management creates barriers to transplant that disproportionately impact Black and Hispanic women. At the same time, our understanding of the clinical significance of pre-transplant antibodies lags behind the sophistication of our screening assays. The lack of national data on pre- and post-transplant HLA antibody characteristics hinders research into strategies to mitigate concerns about these antibodies and to improve access to lung transplant among sensitized patients. Ongoing work should be done to identify clinically higher risk antibodies, to develop better strategies for safely crossing antibodies at the time of transplant, and to model changes in lung allocation to give priority to sensitized patients for a HLA antibody-antigen compatible donors. These priorities mandate a commitment to collaborative, multicenter research and to real time translation of results to clinical practice and allocation policy.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Namrata Patel
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anil Chandraker
- Renal Transplant Program, Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
12
|
Courtwright AM, Longworth S, Chojnowski D, Lee I, Hunt S. Treatment of a Pulmonary Aspergilloma in a Lung Transplant Recipient Using Catheter-directed Intracavitary Instillation of Liposomal Amphotericin B. Transplant Direct 2022; 8:e1270. [PMID: 34966841 PMCID: PMC8710325 DOI: 10.1097/txd.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/25/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Andrew M. Courtwright
- Advanced Lung Disease and Lung Transplantation, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sarah Longworth
- Division of Infectious Disease, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Donna Chojnowski
- Advanced Lung Disease and Lung Transplantation, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ingi Lee
- Division of Infectious Disease, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Stephen Hunt
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia PA
| |
Collapse
|
13
|
Courtwright AM, Wilkey B, Devarajan J, Subramani S, Martin AK, Fritz AV, Cassara CM, Boisen ML, Bottiger BA, Pollak A, Maisonave Y, Gelzinis TA. The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation. J Cardiothorac Vasc Anesth 2021; 36:33-44. [PMID: 34670721 DOI: 10.1053/j.jvca.2021.09.013] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/11/2022]
Abstract
This special article focuses on the highlights in cardiothoracic transplantation literature in the year 2020. Part I encompasses the recent literature on lung transplantation, including the advances in preoperative assessment and optimization, donor management, including the use of ex-vivo lung perfusion, recipient management, including those who have been infected with coronavirus disease 2019, updates on the perioperative management, including the use of extracorporeal membrane oxygenation, and long-term outcomes.
Collapse
Affiliation(s)
| | - Barbara Wilkey
- Department of Anesthesiology, University of Colorado, Boulder, CO
| | | | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic Florida, Jacksonville, FL
| | - Christopher M Cassara
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Angela Pollak
- Department of Anesthesiology, Duke University, Durham, NC
| | | | - Theresa A Gelzinis
- University of Pittsburgh, Corresponding Author, UPMC Presbyterian Hospital, Pittsburgh, PA.
| |
Collapse
|
14
|
Courtwright AM, Kamoun M, Diamond JM, Kearns J, Ahya VN, Christie JD, Clausen E, Hadjiliadis D, Patel N, Salgado JC, Cevasco M, Cantu EE, Crespo MM, Bermudez CA. Lung Transplantation Outcomes after Crossing Low-Level Donor Specific Antibodies Without Planned Augmented Immunosuppression. Clin Transplant 2021; 35:e14447. [PMID: 34365656 DOI: 10.1111/ctr.14447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
It is unknown whether some donor specific antibodies (DSA) can be crossed at the time of lung transplant without desensitization or augmented induction immunosuppression. This study assessed whether crossing low-level pre-transplant DSA (defined as mean fluorescence intensity (MFI) 1000-6000) without augmented immunosuppression is associated with worse retransplant-free or chronic lung allograft dysfunction (CLAD)-free survival. Of the 458 included recipients, low-level pre-transplant DSA was crossed in 39 (8.6%) patients. The median follow-up time was 2.2 years. There were 15 (38.5%) patients with Class I DSA and 24 (61.5%) with Class II DSA. There was no difference in adjusted overall retransplant-free survival between recipients where pre-transplant DSA was and was not crossed (HR: 0.98 (95% CI = 0.49-1.99), p = 0.96). There was also no difference in CLAD-free survival (HR: 0.71 (95% CI = 0.38-1.33), p = 0.28). There was no difference in Grade 3 PGD at 72 hours (OR: 1.13 (95% CI = 0.52-2.48), p = 0.75) or definite or probable AMR (HR: 2.22 (95% CI = 0.64-7.61), p = 0.21). Lung transplantation in the presence of low-level DSA without planned augmented immunosuppression is not associated with worse overall or CLAD-free survival among recipients with intermediate-term follow-up. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Malek Kamoun
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jane Kearns
- Pathology and Laboratory Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Vivek N Ahya
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jason D Christie
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Emily Clausen
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Denis Hadjiliadis
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Namrata Patel
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Juan C Salgado
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Edward E Cantu
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Maria M Crespo
- Division of Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Christian A Bermudez
- Cardiothoracic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
15
|
Courtwright AM, Erler KS, Bandini JI, Zwirner M, Cremens MC, McCoy TH, Robinson EM, Rubin E. Ethics Consultation for Adult Solid Organ Transplantation Candidates and Recipients: A Single Centre Experience. J Bioeth Inq 2021; 18:291-303. [PMID: 33638124 PMCID: PMC7908944 DOI: 10.1007/s11673-021-10092-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/03/2021] [Indexed: 06/12/2023]
Abstract
Systematic study of the intersection of ethics consultation services and solid organ transplants and recipients can identify and illustrate ethical issues that arise in the clinical care of these patients, including challenges beyond resource allocation. This was a single-centre, retrospective cohort study of all adult ethics consultations between January 1, 2007, and December 31, 2017, at a large academic medical centre in the north-eastern United States. Of the 880 ethics consultations, sixty (6.8 per cent ) involved solid organ transplant, thirty-nine (65.0 per cent) for candidates and twenty-one (35.0 per cent ) for recipients. Ethics consultations were requested for 4.3 per cent of heart, 4.9 per cent of lung, 0.3 per cent of liver, and 0.3 per cent of kidney transplant recipients over the study period. Nurses were more likely to request ethics consultations for recipients than physicians (80.0 per cent vs 20.0 per cent , p = 0.006). The most common reason for consultation among transplant candidates was discussion about intensity of treatment or goals of care after the patient was not or was no longer a transplant candidate. The most common reason for ethics consultation among transplant recipients was disagreement between transplant providers and patients/families/non-transplant healthcare professionals over the appropriate intensity of treatment for recipients. Very few consultations involved questions about appropriate resource allocation. Ethics consultants involved in these cases most often navigated communication challenges between transplant and non-transplant healthcare professionals and patients and families.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Department of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Gates 940, Philadelphia, PA, 19102, USA.
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.
| | - Kim S Erler
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Occupational Therapy, MGH Institute of Health Professions, Boston, MA, USA
| | | | - Mary Zwirner
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Social Service, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Ellen M Robinson
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Patient Care Services, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Rubin
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
16
|
Diamond JM, Courtwright AM, Balar P, Oyster M, Zaleski D, Adler J, Brown M, Hays SR, Sutter N, Garvey C, Kukreja J, Gao Y, Bruun A, Smith PJ, Singer JP. Mobile health technology to improve emergent frailty after lung transplantation. Clin Transplant 2021; 35:e14236. [PMID: 33527520 DOI: 10.1111/ctr.14236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/18/2022]
Abstract
We evaluated the feasibility, safety, and efficacy of a mHealth-supported physical rehabilitation intervention to treat frailty in a pilot study of 18 lung transplant recipients. Frail recipients were defined by a short physical performance battery (SPPB score ≤7). The primary intervention modality was Aidcube, a customizable rehabilitation mHealth platform. Our primary aims included tolerability, feasibility, and acceptability of use of the platform, and secondary outcomes were changes in SPPB and in scores of physical activity, and disability measured using the Duke Activity Status Index (DASI) and Lung Transplant-Value Life Activities (LT-VLA). Notably, no adverse events were reported. Subjects reported the app was easy to use, usability improved over time, and the app enhanced motivation to engage in rehabilitation. Comments highlighted the complexities of immediate post-transplant rehabilitation, including functional decline, pain, tremor, and fatigue. At the end of the intervention, SPPB scores improved a median of 5 points from a baseline of 4. Physical activity and patient-reported disability also improved. The DASI improved from 4.5 to 19.8 and LT-VLA score improved from 2 to 0.59 at closeout. Overall, utilization of a mHealth rehabilitation platform was safe and well received. Remote rehabilitation was associated with improvements in frailty, physical activity and disability. Future studies should evaluate mHealth treatment modalities in larger-scale randomized trials of lung transplant recipients.
Collapse
Affiliation(s)
- Joshua M Diamond
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew M Courtwright
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Priya Balar
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Oyster
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Derek Zaleski
- Good Shepherd Penn Partners at the University of Pennsylvania, Philadelphia, USA
| | - Joe Adler
- Good Shepherd Penn Partners at the University of Pennsylvania, Philadelphia, USA
| | - Melanie Brown
- Pulmonary Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven R Hays
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nicole Sutter
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chris Garvey
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jasleen Kukreja
- Division of Adult Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ying Gao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Jonathan P Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
17
|
Courtwright AM, Rubin E, Erler KS, Bandini JI, Zwirner M, Cremens MC, McCoy TH, Robinson EM. Experience with a Revised Hospital Policy on Not Offering Cardiopulmonary Resuscitation. HEC Forum 2020; 34:73-88. [PMID: 33136221 DOI: 10.1007/s10730-020-09429-1] [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] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate (DNR) status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation (CPR) despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics consult outcomes were analyzed. In 42 of the 116 cases (36.2%), the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 (97.3%) of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 (79.2%) of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying (p = 0.007). The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants' recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Department of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Rubin
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kimberly S Erler
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA
| | | | - Mary Zwirner
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Social Services, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Departments of Psychiatry and Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Ellen M Robinson
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA. .,Patient Care Services, Massachusetts General Hospital, Boston, MA, 02114, USA.
| |
Collapse
|
18
|
Courtwright AM, Kamoun M, Kearns J, Diamond JM, Golberg HJ. The impact of HLA-DR mismatch status on retransplant-free survival and bronchiolitis obliterans syndrome‒free survival among sensitized lung transplant recipients. J Heart Lung Transplant 2020; 39:1455-1462. [PMID: 33071182 DOI: 10.1016/j.healun.2020.09.016] [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] [Received: 07/21/2020] [Revised: 09/16/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Donor‒recipient HLA-DR locus matching may be protective against bronchiolitis obliterans syndrome (BOS) in lung transplant recipients. It is unknown whether this benefit is more significant among sensitized (calculated panel reactive antibodies (CPRAs) of >0%) and highly sensitized (CPRAs of ≥80%) recipients who may be at a higher risk for BOS. METHODS This was a retrospective cohort study of adults in the Scientific Registry of Transplant Recipients who underwent lung transplantation between May 5, 2005 and May 31, 2019. Retransplant-free survival and BOS-free survival were compared among recipients with 0 vs ≥1 DR mismatches, grouped according to sensitization. RESULTS Among all 20,355 included recipients, 0 DR mismatch status was associated with improved retransplant-free survival (hazard ratio [HR] = 0.83, 95% CI = 0.74-0.93, p = 0.002) and BOS-free survival (HR = 0.86, 95% CI = 0.77-0.96, p = 0.007). Among sensitized recipients, 0 DR mismatch status was also associated with improved retransplant-free survival (HR = 0.79, 95% CI = 0.65-0.97, p = 0.02) and BOS-free survival (HR = 0.82, 95% CI = 0.67-1.00, p = 0.04). There was however no difference in retransplant-free or BOS-free survival between sensitized and non-sensitized recipients with 0 DR mismatches. Among highly sensitized recipients, 0 DR mismatch status was not associated with retransplant-free or BOS-free survival. Among sensitized and highly sensitized recipients, 0 DR mismatch status was not associated with reduced use of plasmapheresis or reduced biopsy-proven, treated acute cellular rejection compared with non-sensitized recipients. CONCLUSIONS HLA-DR matching is associated with a similar improvement in retransplant-free and BOS-free survival among non-sensitized and sensitized lung transplant recipients. DR matching does not confer a more substantial retransplant-free or BOS-free survival benefit to highly sensitized recipients than to non-sensitized recipients.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane Kearns
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hilary J Golberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boson, Massachusetts
| |
Collapse
|
19
|
|
20
|
Courtwright AM, Lamattina AM, Takahashi M, Trindade AJ, Hunninghake GM, Rosas IO, Agarwal S, Raby BA, Goldberg HJ, El-Chemaly S. Shorter telomere length following lung transplantation is associated with clinically significant leukopenia and decreased chronic lung allograft dysfunction-free survival. ERJ Open Res 2020; 6:00003-2020. [PMID: 32577419 PMCID: PMC7293991 DOI: 10.1183/23120541.00003-2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 03/26/2020] [Indexed: 01/11/2023] Open
Abstract
Patients with short telomeres and interstitial lung disease may have decreased chronic lung allograft dysfunction (CLAD)-free survival following lung transplantation. The relationship between post-transplant telomere length and outcomes following lung transplantation has not been characterised among all recipients, regardless of native lung disease. This was a single-centre prospective cohort study. Consenting transplant recipients had their telomere length measured using quantitative real-time PCR assays on peripheral blood collected at the time of surveillance bronchoscopy. We assessed the association between early post-transplant telomere length (as measured in the first 100 days) and CLAD-free survival, time to clinically significant leukopenia, cytomegalovirus (CMV) viraemia, chronic kidney disease, and acute cellular rejection. We also assessed the association between rate of telomere shortening and CLAD-free survival. Telomere lengths were available for 98 out of 215 (45.6%) recipients who underwent lung transplant during the study period (median measurement per patient=2 (interquartile range, 1–3)). Shorter telomere length was associated with decreased CLAD-free survival (hazard ratio (HR)=1.24; 95% CI=1.03–1.48; p=0.02), leukopenia requiring granulocyte colony-stimulating factor (HR=1.17, 95% CI=1.01–1.35, p=0.03), and CMV viraemia among CMV-mismatch recipients (HR=4.04, 95% CI=1.05–15.5, p=0.04). Telomere length was not associated with acute cellular rejection or chronic kidney disease. Recipients with more rapid loss in telomere length (defined as the highest tertile of telomere shortening) did not have worse subsequent CLAD-free survival than those without rapid loss (HR=1.38, 95% CI=0.27–7.01, p=0.70). Shorter early post-transplant telomere length is associated with decreased CLAD-free survival and clinically significant leukopenia in lung transplant recipients, regardless of native lung disease. Shorter recipient telomere length following lung transplantation is associated with clinically significant leukopenia and decreased chronic lung allograft dysfunction-free survivalhttps://bit.ly/2ytymXc
Collapse
Affiliation(s)
- Andrew M Courtwright
- Dept of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony M Lamattina
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Mai Takahashi
- Harvard T.H. Chen School of Public Health, Boston, MA, USA
| | - Anil J Trindade
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Gary M Hunninghake
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Ivan O Rosas
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Suneet Agarwal
- Division of Hematology/Oncology, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Boston Children's Hospital, Boston, MA, USA
| | - Benjamin A Raby
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA.,Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA.,Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
21
|
Nathan AS, Blebea C, Chatterjee P, Thomasson A, Diamond JM, Groeneveld PW, Giri J, Goldberg HJ, Courtwright AM. Mortality trends around the one‐year survival mark after heart, liver, and lung transplantation in the United States. Clin Transplant 2020; 34:e13852. [DOI: 10.1111/ctr.13852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/19/2020] [Accepted: 03/03/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Ashwin S. Nathan
- Cardiovascular Division Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Penn Cardiovascular Outcomes Quality, and Evaluative Research Center Cardiovascular Institute University of Pennsylvania Philadelphia Pennsylvania USA
| | - Catherine Blebea
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Division of General Internal Medicine Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Arwin Thomasson
- Pulmonary Division Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Joshua M. Diamond
- Pulmonary Division Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Peter W. Groeneveld
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Penn Cardiovascular Outcomes Quality, and Evaluative Research Center Cardiovascular Institute University of Pennsylvania Philadelphia Pennsylvania USA
- Division of General Internal Medicine Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Corporal Michael J. Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Jay Giri
- Cardiovascular Division Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Penn Cardiovascular Outcomes Quality, and Evaluative Research Center Cardiovascular Institute University of Pennsylvania Philadelphia Pennsylvania USA
- Corporal Michael J. Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Hilary J. Goldberg
- Pulmonary Division Brigham and Women's Hospital Boston Massachusetts USA
| | - Andrew M. Courtwright
- Pulmonary Division Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| |
Collapse
|
22
|
Krymskaya VP, Courtwright AM, Fleck V, Dorgan D, Kotloff R, McCormack FX, Kreider M. A phase II clinical trial of the Safety Of Simvastatin (SOS) in patients with pulmonary lymphangioleiomyomatosis and with tuberous sclerosis complex. Respir Med 2020; 163:105898. [PMID: 32125970 DOI: 10.1016/j.rmed.2020.105898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 01/20/2023]
Abstract
INRODUCTION The mechanistic target of rapamycin inhibitors (mTORi) sirolimus and everolimus stabilize lung function in patients with pulmonary lymphangioleiomyomatosis (LAM) but do not induce remission. Pre-clinical studies suggest that simvastatin in combination with sirolimus induces LAM cell death. The objective of this study was to assess the safety of simvastatin with either sirolimus or everolimus in LAM patients. METHODS This was a phase II single arm trial evaluating the safety of escalating daily simvastatin (20-40 mg) in LAM patients already treated with sirolimus or everolimus. Adverse events and changes in lipid panel profile, pulmonary function tests, and VEGF-D were assessed. RESULTS Ten LAM patients on a stable dose of mTORi for >3 months were treated with 20 mg simvastatin for two months followed by 40 mg for two months. The most common adverse events were peripheral edema (30%), cough (30%), and diarrhea (30%). No patients withdrew or had a reduction in simvastatin dose because of adverse events. Two patients required sirolumus dose reduction for supratherapeutic trough levels following simvastatin initiation. Total cholesterol and low density lipoproteins declined over the study period (-46.0 mg/dL±20.8, p = 0.008; -41.9 mg/dL±22.0, p = 0.01, respectively). There was also a decline in FEV1 (-82.0 mL±86.4, p = 0.02) but no significant change in FVC, DLCO, or VEGF-D. CONCLUSIONS The combination of simvastatin with mTORi in LAM patients is safe and well-tolerated from an adverse events perspective. The addition of simvastatin, however, was associated with decline in FEV1 and the efficacy of this combination should be explored in larger trials.
Collapse
Affiliation(s)
- Vera P Krymskaya
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew M Courtwright
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Victoria Fleck
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Daniel Dorgan
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert Kotloff
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Maryl Kreider
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
23
|
Bandini JI, Courtwright AM, Rubin E, Erler KS, Zwirner M, Cremens MC, McCoy TH, Robinson EM. Ethics Consultations Related to Opioid Use Disorder. Psychosomatics 2019; 61:161-170. [PMID: 31812218 DOI: 10.1016/j.psym.2019.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The opioid epidemic has resulted in an increased number of patients with opioid use disorder (OUD) hospitalized for serious medical conditions. The intersection between hospital ethics consultations and the opioid crisis has not received significant attention. OBJECTIVE The aim of this study was to characterize ethics consult questions among inpatients with OUD at our institution, Massachusetts General Hospital. METHODS We conducted a single-center retrospective cohort study of ethics consultations from January 1, 1993 to December 31, 2017 at Massachusetts General Hospital. RESULTS Between 1993 and 2017, OUD played a central role in ethics consultations in 43 of 1061 (4.0%) cases. There was an increase in these requests beginning in 2009, rising from 1.4% to 6.8% of consults by 2017. Compared with other ethics cases, individuals with OUD were significantly younger (P < 0.001), more likely to be uninsured or underinsured (P < 0.001), and more likely to have a comorbid mental health diagnosis (P = 0.001). The most common reason for consultation involved continuation of life-sustaining treatment in the setting of overdose with neurological injury or severe infection. Additional reasons included discharge planning, challenges with pain management and behavior, and the appropriateness of surgical intervention, such as repeat valve replacement or organ transplant. Health care professionals struggled with their ethical obligations to patients with OUD, including when to treat pain with narcotics and how to provide longitudinal care for patients with limited resources outside of the hospital. CONCLUSION The growing opioid epidemic corresponds with a rise in ethics consultations for patients with OUD. Similar factors associated with OUD itself, including comorbid mental health diagnoses and concerns about relapse, contributed to the ethical complexities of these consults.
Collapse
Affiliation(s)
- Julia I Bandini
- Department of Sociology, Brandeis University, Waltham, MA; RAND Corporation, Boston, MA
| | - Andrew M Courtwright
- Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA; Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA
| | - Emily Rubin
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Kimberly S Erler
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Occupational Therapy, MGH Institute of Health Professions, Boston, MA
| | - Mary Zwirner
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Social Service, Massachusetts General Hospital, Boston, MA
| | - M Cornelia Cremens
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Department of Psychiatry and Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Thomas H McCoy
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Ellen M Robinson
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA; Patient Care Services, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
24
|
Courtwright AM, Zaleski D, Tevald M, Adler J, Singer JP, Cantu EE, A Bermudez C, Diamond JM. Discharge frailty following lung transplantation. Clin Transplant 2019; 33:e13694. [PMID: 31418935 DOI: 10.1111/ctr.13694] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Frailty at listing for lung transplant has been associated with waitlist and post-transplant mortality. Frailty trajectories following transplant, however, have been less well characterized, including whether recipient frailty improves. The objective of this study was to identify prevalence and risk factors for frailty at discharge and to evaluate changes in frail recipients enrolled in an outpatient physical therapy program. METHODS This was a single-center prospective cohort study of lung transplant recipients. Enrollees completed a short physical performance battery (SPPB) to assess frailty at listing and at initial hospital discharge. RESULTS Of the 111 enrolled recipients, none were frail at listing and 18 (16.2%) were prefrail. At discharge, however, 60 (54.1%) patients were frail. Discharge frailty was associated with prefrailty at listing, acute kidney injury post-transplant, and longer intensive care unit stay. Among the 35 patients who were frail at discharge and who were enrolled in an outpatient PT program, the median improvement in SPPB was 6 points (IQR = 5-7 points), and 85.7% became not frail over a median of 6 weeks. CONCLUSION Discharge frailty is common following lung transplantation. In most frail patients, an intensive outpatient physical therapy program is associated with improvement in frailty, as assessed by the SPPB.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Derek Zaleski
- Good Shepard Penn Partners, Philadelphia, Pennsylvania
| | - Michael Tevald
- School of Health Sciences, Arcadia University, Glenside, Pennsylvania
| | - Joe Adler
- Good Shepard Penn Partners, Philadelphia, Pennsylvania
| | - Jonathan P Singer
- Pulmonary and Critical Care Medicine, University of San Francisco, San Francisco, California
| | - Edward E Cantu
- Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joshua M Diamond
- Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
25
|
Aslam S, Courtwright AM, Koval C, Lehman SM, Morales S, Langlais Furr CL, Rosas F, Brownstein MJ, Fackler JR, Sisson BM, Biswas B, Henry M, Luu T, Bivens BN, Hamilton T, Duplessis C, Logan C, Law N, Yung G, Turowski J, Anesi J, Strathdee SA, Schooley RT. Early clinical experience of bacteriophage therapy in 3 lung transplant recipients. Am J Transplant 2019; 19:2631-2639. [PMID: 31207123 PMCID: PMC6711787 DOI: 10.1111/ajt.15503] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/27/2019] [Accepted: 05/27/2019] [Indexed: 01/25/2023]
Abstract
Bacteriophage therapy (BT) uses bacteriophages to treat pathogenic bacteria and is an emerging strategy against multidrug-resistant (MDR) infections. Experience in solid organ transplant is limited. We describe BT in 3 lung transplant recipients (LTR) with life-threatening MDR infections caused by Pseudomonas aeruginosa (n = 2) and Burkholderia dolosa (n = 1). For each patient, lytic bacteriophages were selected against their bacterial isolates. BT was administered for variable durations under emergency Investigational New Drug applications and with patient informed consent. Safety was assessed using clinical/laboratory parameters and observed clinical improvements described, as appropriate. All patients received concurrent antibiotics. Two ventilator-dependent LTR with large airway complications and refractory MDR P. aeruginosa pneumonia received BT. Both responded clinically and were discharged from the hospital off ventilator support. A third patient had recurrent B. dolosa infection following transplant. Following BT initiation, consolidative opacities improved and ventilator weaning was begun. However, infection relapsed on BT and the patient died. No BT-related adverse events were identified in the 3 cases. BT was well tolerated and associated with clinical improvement in LTRs with MDR bacterial infection not responsive to antibiotics alone. BT may be a viable adjunct to antibiotics for patients with MDR infections.
Collapse
Affiliation(s)
- Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA
| | - Andrew M. Courtwright
- Department of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christine Koval
- Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, OH
| | | | | | | | | | | | | | | | - Biswajit Biswas
- Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, MD
| | - Matthew Henry
- Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, MD
| | - Truong Luu
- Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, MD
| | - Brittany N. Bivens
- Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, MD
| | - Theron Hamilton
- Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, MD
| | - Christopher Duplessis
- Naval Medical Research Center, Biological Defense Research Directorate, Fort Detrick, MD
| | - Cathy Logan
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA
| | - Nancy Law
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA
| | - Gordon Yung
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA
| | - Jason Turowski
- Department of Pulmonary Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Judith Anesi
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia PA
| | - Steffanie A. Strathdee
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA
| | - Robert T. Schooley
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA
| |
Collapse
|
26
|
Courtwright AM, Rubin E, Robinson EM, El-Chemaly S, Lamas D, Diamond JM, Goldberg HJ. An Ethical Framework for the Care of Patients with Prolonged Hospitalization Following Lung Transplantation. HEC Forum 2019; 31:49-62. [PMID: 30232675 DOI: 10.1007/s10730-018-9364-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 01/03/2023]
Abstract
The lung allocation score system in the United States and several European countries gives more weight to risk of death without transplantation than to survival following transplantation. As a result, centers transplant sicker patients, leading to increased length of initial hospitalization. The care of patients who have accumulated functional deficits or additional organ dysfunction during their prolonged stay can be ethically complex. Disagreement occurs between the transplant team, patients and families, and non-transplant health care professionals over the burdens of ongoing intensive intervention. These cases highlight important ethical issues in organ transplantation, including the nature and requirements of transplant informed consent, the limits of physician prognostication, patient autonomy and decision-making capacity following transplant, obligations to organ donors and to other potential recipients, and the impact of program metrics on individualized recipient care. We outline general ethical principles for the care of lung transplant recipients with prolonged hospitalization and give regulatory, research, and patient-centered recommendations for these cases.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA. .,Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Emily Rubin
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ellen M Robinson
- Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA.,Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
| | - Souheil El-Chemaly
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniela Lamas
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua M Diamond
- Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Hilary J Goldberg
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
27
|
Courtwright AM, Lamattina AM, Louis PH, Trindade AJ, Burkett P, Imani J, Shrestha S, Divo M, Keller S, Rosas IO, Goldberg HJ, El-Chemaly S. Hyaluronan and LYVE-1 and allograft function in lung transplantation recipients. Sci Rep 2019; 9:9003. [PMID: 31227795 PMCID: PMC6588572 DOI: 10.1038/s41598-019-45309-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/04/2019] [Indexed: 11/23/2022] Open
Abstract
Hyaluronan (HA) is associated with innate immune response activation and may be a marker of allograft dysfunction in lung transplant recipients. This was a prospective, single center study comparing levels of bronchioalveolar lavage (BAL) and serum HA and the HA immobilizer LYVE-1 in lung transplant recipients with and without acute cellular rejection (ACR). Chronic lung allograft dysfunction (CLAD)-free survival was also evaluated based on HA and LYVE-1 levels. 78 recipients were enrolled with a total of 115 diagnostic biopsies and 1.5 years of median follow-up. Serum HA was correlated with BAL HA (r = 0.25, p = 0.01) and with serum LYVE-1 (r = 0.32, p = 0.002). There was significant variation in HA and LYVE-1 over time, regardless of ACR status. Levels of serum HA (median 74.7 vs 82.7, p = 0.69), BAL HA (median 149.4 vs 134.5, p = 0.39), and LYVE-1 (mean 190.2 vs 183.8, p = 0.72) were not associated with ACR. CLAD-free survival was not different in recipients with any episode of elevated serum HA (HR = 1.5, 95% CI = 0.3–7.7, p = 0.61) or BAL HA (HR = 0.94, 95% CI = 0.2–3.6, p = 0.93). These results did not differ when stratified by bilateral transplant status. In this small cohort, serum HA, BAL HA, and LYVE-1 levels are not associated with ACR or CLAD-free survival in lung transplant recipients.
Collapse
Affiliation(s)
| | | | | | | | | | - Jewel Imani
- Brigham and Women's Hospital, Boston, MA, United States
| | | | - Miguel Divo
- Brigham and Women's Hospital, Boston, MA, United States
| | - Steve Keller
- Brigham and Women's Hospital, Boston, MA, United States
| | - Ivan O Rosas
- Brigham and Women's Hospital, Boston, MA, United States
| | | | | |
Collapse
|
28
|
Courtwright AM, Rubin E, Robinson EM, Thomasson A, El-Chemaly S, Diamond JM, Goldberg HJ. In-hospital and subsequent mortality among lung transplant recipients with a prolonged initial hospitalization. Am J Transplant 2019; 19:532-539. [PMID: 29940091 DOI: 10.1111/ajt.14982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/15/2018] [Accepted: 06/16/2018] [Indexed: 01/25/2023]
Abstract
The care of lung transplant recipients with prolonged index hospitalizations can be ethically complex, with conflicts arising over whether the expected outcomes justify ongoing intensive interventions. There are limited data to guide these conversations. The objective of this study was to evaluate survival to discharge for lung transplant recipients based on length of stay (LOS). This was a retrospective cohort study of adult lung transplant recipients in the Scientific Registry of Transplant Recipients. For each day of the index hospitalization the mortality rate among patients who survived to that length of stay or longer was calculated. Post-discharge survival was compared in those with and without a prolonged hospitalization (defined as the 97th percentile [>90 days]). Among the 19 250 included recipients, the index hospitalization mortality was 5.4%. Posttransplant stroke and need for dialysis were the strongest predictors of index hospitalization mortality. No individual or combination of available risk factors, however, was associated with inpatient mortality consistently above 50%. Recipients with >90 day index hospitalization had a 28.8% subsequent inpatient mortality. Their 1, 3 and 5 year survival following discharge was 53%, 26%, and 16%. These data provide additional context to goals of care conversations for transplant recipients with prolonged index hospitalizations.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Rubin
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ellen M Robinson
- Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA.,Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
| | - Arwin Thomasson
- Penn Transplant Center, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Souheil El-Chemaly
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua M Diamond
- Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hilary J Goldberg
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
29
|
Abstract
Telomeres are repetitive nucleotide sequences that cap linear chromosomes, thereby limiting progressive chromosomal shortening during cell replication. In conjunction with environmental factors, common single-nucleotide polymorphisms and rare and ultra-rare telomere-related mutations are associated with accelerated telomere shortening resulting in organ dysfunction, including interstitial lung disease (ILD). The most common telomere-related mutation-associated ILD is idiopathic pulmonary fibrosis (IPF). Up to one-third of individuals with familial IPF have shortened telomeres and/or carry a telomere-related mutation, and 1 in 10 individuals with sporadic IPF have telomere-related mutations. Regardless of ILD phenotype, individuals with short telomeres and/or known telomere-related mutations have more rapid disease progression and shorter lung transplant-free survival. Management should include initiation of antifibrotic agents for those with an IPF phenotype and early referral to a transplant center. Patients with ILD being considered for transplant should be screened for short telomeres if there is a significant family history of pulmonary fibrosis or evidence of extrapulmonary organ dysfunction associated with a short telomere syndrome. Post-transplant management of recipients with telomere-related mutations should include careful adjustment of immunosuppression regimens on the basis of bone marrow reserve. Data on the impact of shortened telomeres on post-transplant outcomes, however, remain mixed.
Collapse
Affiliation(s)
- Andrew M. Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
30
|
Cho JK, Acord M, Goldfarb SB, Reddy SN, Goldberg HJ, Courtwright AM. Complications related to totally implantable venous access devices in children and adults following lung transplantation. Clin Transplant 2019; 33:e13465. [PMID: 30561770 DOI: 10.1111/ctr.13465] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 11/29/2018] [Accepted: 12/13/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Totally implantable venous access devices (TIVADs) are the preferred devices for patients with advanced lung disease who require long-term venous access. The primary purpose of this study was to describe the natural history of TIVADs left in place at the time of transplant. METHODS This multicenter retrospective cohort study evaluated pediatric and adult lung transplant recipients from 5/5/2005 to 12/31/17 with pretransplant TIVAD. Incident rates (IR) for infectious and mechanical complications were calculated. Poisson regression models were used to identify TIVAD characteristics associated with complications. RESULTS Of 1253 transplant recipients, 82 (6.5%) had pretransplant TIVAD. Five (6.1%) TIVADs were removed at transplantation. Fifty-five (67.1%) TIVADs were eventually removed, most commonly because they were no longer required (50.9%) or because of infection (25.5%). Overall incident rates (IR) of infectious or mechanical complications were 0.33 and 0.14, respectively. The IR of infection was highest within one year of transplant, particularly during the index hospitalization (IR = 1.67). Youngest tertile (<22 years) had the lowest incident rate ratio of TIVAD infections (IRR = 0.22). CONCLUSION Although TIVAD complication rates in lung transplant recipients are similar to non-transplant and other immunocompromised patients, TIVAD removal at transplant or within the first post-transplant year may minimize the risk of TIVAD infections.
Collapse
Affiliation(s)
- Joshua K Cho
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acord
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samuel B Goldfarb
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shilpa N Reddy
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew M Courtwright
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
31
|
Courtwright AM, Baldi BG, Kidambi P, Cui Y, Lamattina AM, Villalba JA, Bagwe S, Goldberg HJ, Rosas IO, Henske EP, Carvalho CRR, El-Chemaly S. Characterization of lymphangioleiomyomatosis patients with discordance between spirometric and diffusion measurements of pulmonary function. Sarcoidosis Vasc Diffuse Lung Dis 2018; 35:206-212. [PMID: 32476904 DOI: 10.36141/svdld.v35i3.6321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 08/22/2017] [Indexed: 01/12/2023]
Abstract
Background: A subset of lymphangioleiomyomatosis (LAM) patients present with normal FEV1 and FVC but with reduced DLCO. Patients with an isolated reduction in DLCO in other diseases appear to be at higher risk for pulmonary hypertension and worse survival but this has not been previously described in LAM patients. Objective: To characterize the prevalence and clinical progression of LAM patients who present with discordantly low DLCO. Methods: This was a retrospective cohort study of LAM patients in two centers in the United States and Brazil. Discordant DLCO was defined as FEV1 >80% predicted, FVC >80% predicted, and DLCO<80% predicted. We compared the rate of decline in pulmonary function, pulmonary artery to aorta (PA-A) ratio, and VEGF-D levels in patients with concordant and discordant DLCO. Results: The overall prevalence of discordant DLCO was 26.0%. Patients with discordant DLCO did not have a higher rate of yearly decline in FEV1 (-1.0±0.6 vs -1.0±0.6, p=0.50), FVC (-1.0±0.7 vs -0.3±0.8, p=0.54), or DLCO (-2.2±0.9 vs -1.6±0.6, p=0.79). They did not have higher rates of PA-A ratio>1 (23.3% vs 20.1%, p=1.00). Patients with discordant DLCO did not have higher levels of VEGF-D (1214±1256 pg/mL vs 1706±1214 pg/mL, p=0.07). Conclusions: LAM patients who present with a discordantly low DLCO do not appear to have different rates of decline in pulmonary function. Additional biological and radiographic markers are needed to more fully characterize this population. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 206-212).
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, PA, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | - Bruno G Baldi
- Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Pranav Kidambi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | - Ye Cui
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | - Anthony M Lamattina
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | - Julian A Villalba
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | - Shefali Bagwe
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | - Ivan O Rosas
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| | | | - Carlos R R Carvalho
- Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, MA, USA
| |
Collapse
|
32
|
Abstract
A clinical database is a repository of patient medical and sociodemographic information focused on one or more specific health condition or exposure. Although clinical databases may be used for research purposes, their primary goal is to collect and track patient data for quality improvement, quality assurance, and/or actual clinical management. This article aims to provide an introduction and practical advice on the development of small-scale clinical databases for chest physicians and practice groups. Through example projects, we discuss the pros and cons of available technical platforms, including Microsoft Excel and Access, relational database management systems such as Oracle and PostgreSQL, and Research Electronic Data Capture. We consider approaches to deciding the base unit of data collection, creating consensus around variable definitions, and structuring routine clinical care to complement database aims. We conclude with an overview of regulatory and security considerations for clinical databases.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Peter E Gabriel
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
33
|
Courtwright AM, Burkett P, Divo M, Keller S, Rosas IO, Trindade A, Mody GN, Singh SK, El-Chemaly S, Camp PC, Goldberg HJ, Mallidi HR. Posttransplant Lymphoproliferative Disorders in Epstein-Barr Virus Donor Positive/Recipient Negative Lung Transplant Recipients. Ann Thorac Surg 2017; 105:441-447. [PMID: 29223419 DOI: 10.1016/j.athoracsur.2017.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 08/18/2017] [Accepted: 09/11/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Epstein-Barr virus (EBV) donor positive/recipient negative (D+/R-) status is a significant risk factor for posttransplant lymphoproliferative disorder (PTLD) in lung transplant. There are, however, no studies that identify the risk factors for PTLD in the EBV D+/R- lung transplant population to guide the decision to proceed with an EBV-positive donor. METHODS This was a retrospective cohort study of adults listed in the Scientific Registry of Transplant Recipients between May 5, 2005, and August 31, 2016. Cox proportional hazards models were used to assess the impact of EBV D+/R- status on the development of PTLD, the impact of PTLD on survival, and survival differences between EBV D+/R- and EBV D-/R- recipients. RESULTS The incidence of PTLD was 6.2% (79 of 1,281) versus 1.4% (145 of 10,352) in EBV D+/R- versus all other recipients (adjusted odds ratio 4.0; 95% confidence interval: 2.8 to 5.9, p < 0.001). Among EBV D+/R- recipients, age less than 40 years and white race were associated with PTLD. The EBV D+/R- patients who had PTLD had increased adjusted risk of death (hazard ratio 1.91; 95% confidence interval: 1.35 to 2.71; p < 0.001). Compared with EBV D+/R- recipients, EBV D-/R- recipients did not have improved adjusted survival (hazard ratio 0.82; 95% confidence interval: 0.57 to 1.18; p = 0.30). CONCLUSIONS Despite increased rates of PTLD and associated mortality in the EBV D+/R- population, EBV seronegative patients did not have worse mortality when transplanted with lungs from EBV seropositive donors compared with lungs from EBV seronegative donors. Consideration should be given for close monitoring for PTLD among EBV D+/R- recipients, particularly those who are white and less than 40 years of age.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick Burkett
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Miguel Divo
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven Keller
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ivan O Rosas
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anil Trindade
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gita N Mody
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Steve K Singh
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Phillip C Camp
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hari R Mallidi
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| |
Collapse
|
34
|
Cao S, Courtwright AM, Lamattina AM, Guleria I, Burkett P, El-Chemaly S, Goldberg HJ. The impact of screening method on HLA antibody detection before and after lung transplantation: A prospective pilot study. J Heart Lung Transplant 2017; 37:531-533. [PMID: 29229269 DOI: 10.1016/j.healun.2017.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/13/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Severine Cao
- Harvard Medical School, Boston, Massachusetts, USA; Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital Boston, Massachusetts, USA
| | - Andrew M Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anthony M Lamattina
- Harvard Medical School, Boston, Massachusetts, USA; Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital Boston, Massachusetts, USA
| | - Indira Guleria
- Harvard Medical School, Boston, Massachusetts, USA; Clinical Laboratory Division, Tissue Typing Laboratory, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Patrick Burkett
- Harvard Medical School, Boston, Massachusetts, USA; Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital Boston, Massachusetts, USA
| | - Souheil El-Chemaly
- Harvard Medical School, Boston, Massachusetts, USA; Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital Boston, Massachusetts, USA
| | - Hilary J Goldberg
- Harvard Medical School, Boston, Massachusetts, USA; Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital Boston, Massachusetts, USA.
| |
Collapse
|
35
|
Robinson EM, Cadge W, Erler K, Brackett S, Bandini J, Cist A, Cornelia Cremens M, Krakauer EL, Courtwright AM. Structure, Operation, and Experience of Clinical Ethics Consultation 2007-2013: A Report from the Massachusetts General Hospital Optimum Care Committee. The Journal of Clinical Ethics 2017. [DOI: 10.1086/jce2017282137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
36
|
Courtwright AM, Abrams J, Robinson EM. The Role of a Hospital Ethics Consultation Service in Decision-Making for Unrepresented Patients. J Bioeth Inq 2017; 14:241-250. [PMID: 28265798 PMCID: PMC5529225 DOI: 10.1007/s11673-017-9773-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 09/01/2016] [Indexed: 05/26/2023]
Abstract
Despite increased calls for hospital ethics committees to serve as default decision-makers about life-sustaining treatment (LST) for unrepresented patients who lack decision-making capacity or a surrogate decision-maker and whose wishes regarding medical care are not known, little is known about how committees currently function in these cases. This was a retrospective cohort study of all ethics committee consultations involving decision-making about LST for unrepresented patients at a large academic hospital from 2007 to 2013. There were 310 ethics committee consultations, twenty-five (8.1 per cent) of which involved unrepresented patients. In thirteen (52.0 per cent) cases, the ethics consultants evaluated a possible substitute decision-maker identified by social workers and/or case managers. In the remaining cases, the ethics consultants worked with the medical team to contact previous healthcare professionals to provide substituted judgement, found prior advance care planning documents, or identified the patient's best interest as the decision-making standard. In the majority of cases, the final decision was to limit or withdraw LST (72 per cent) or to change code status to Do Not Resuscitate/Do Not Intubate (12 per cent). Substitute decision-makers who had been evaluated through the ethics consultation process and who made the final decision alone were more likely to continue LST than cases in which physicians made the final decision (50 per cent vs 6.3 per cent, p = 0.04). In our centre, the primary role of ethics consultants in decision-making for unrepresented patients is to identify appropriate decision-making standards. In the absence of other data suggesting that ethics committees, as currently constituted, are ready to serve as substitute decision-makers for unrepresented patients, caution is necessary before designating these committees as default decision-makers.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA.
- Division of Pulmonary and Critical Care, Center for Chest Disease, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02115, USA.
| | - Joshua Abrams
- Office of General Counsel, Partners HealthCare, Boston, MA, USA
| | - Ellen M Robinson
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
37
|
Courtwright AM, Goldberg HJ, Henske EP, El-Chemaly S. The effect of mTOR inhibitors on respiratory infections in lymphangioleiomyomatosis. Eur Respir Rev 2017; 26:26/143/160004. [PMID: 28096282 DOI: 10.1183/16000617.0004-2016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/25/2016] [Indexed: 11/05/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) is a destructive cystic lung disease. Mammalian target of rapamycin (mTOR) inhibitors are the primary treatment for LAM but it is unknown whether these immunosuppressing medications increase the risk for or the severity of respiratory infections in LAM patients.We searched multiple databases for original articles that reported the rate of respiratory infections in LAM patients treated with mTOR inhibitors or placebo. We calculated incidence rates for respiratory infections in these groups and incidence rate ratios for respiratory infections and severe respiratory infections in mTOR inhibitors treated versus placebo treated patients.11 studies were included. There were 294 patients in the treatment groups and 93 patients in the placebo groups. Among subjects in placebo arms, the incidence rate of respiratory infections was 58.8 per 100 patient-years (95% CI 35.3-82.3 per 100 patient-years). The incidence-rate ratio (IRR) for respiratory infection among treated subjects was 0.71 (95% CI 0.50-1.02; p=0.06 compared to placebo subjects). The IRR for severe respiratory infections among treated subjects was 1.56 (95% CI 0.43-8.55; p=0.52).We found that respiratory infections are common in patients with LAM. Importantly, treatment with mTOR inhibitors does not increase the incidence of these infections and may be protective.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth Petri Henske
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
38
|
Robinson EM, Cadge W, Zollfrank AA, Cremens MC, Courtwright AM. After the DNR:Surrogates Who Persist in Requesting Cardiopulmonary Resuscitation. Hastings Cent Rep 2017; 47:10-19. [DOI: 10.1002/hast.664] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
39
|
Courtwright AM, El-Chemaly S, Dellaripa PF, Goldberg HJ. Survival and outcomes after lung transplantation for non-scleroderma connective tissue-related interstitial lung disease. J Heart Lung Transplant 2016; 36:763-769. [PMID: 28131664 DOI: 10.1016/j.healun.2016.12.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/28/2016] [Accepted: 12/26/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients with non-scleroderma connective tissue-related lung disease (NS-CTLD), including rheumatoid arthritis, idiopathic inflammatory myopathies, Sjögren syndrome, mixed connective tissue disease, and systemic lupus erythematosus, may be at risk for worse outcomes after lung transplantation because of immune dysregulation or extrapulmonary manifestations of their underlying disease. We compared survival, acute and chronic rejection, and extrapulmonary organ dysfunction after transplantation in patients with NS-CTLD and idiopathic pulmonary fibrosis (IPF). METHODS This was a retrospective cohort study of patients with NS-CTLD and IPF who were listed in the Scientific Registry of Transplant Recipients and underwent lung transplantation from May 5, 2005, to March 1, 2016. RESULTS Patients with NS-CTLD (n = 275) were younger, a higher percentage female and non-white than patients with IPF (n = 6,346). NS-CTLD patients did not have worse adjusted survival (hazard ratio, 1.14, 95% confidence interval [CI], 0.92-1.42; p = 0.24). They were not more likely to have an episode of acute cellular rejection (odds ratio, 0.96; 95% CI, 0.72-1.28; p = 0.77) or to develop bronchiolitis obliterans syndrome (odds ratio, 0.82; 95% CI, 0.60-1.12; p = 0.21). Patients with NS-CTLD were not more likely to require plasmapheresis or dialysis or to develop a lymphoproliferative malignancy or liver disease after transplantation. CONCLUSIONS We found no significant differences in survival, acute or chronic rejection, or extrapulmonary organ dysfunction in patients who underwent lung transplantation for NS-CTLD compared with IPF. In appropriately selected candidates, NS-CTLD should not be considered a contraindication to lung transplantation.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul F Dellaripa
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts.
| |
Collapse
|
40
|
Courtwright AM, Salomon S, Fuhlbrigge A, Divo M, Rosas IO, Camp PC, Mallidi HH, Burkett P, El-Chemaly S, Wolfe DJ, Goldberg HJ. Predictors and outcomes of unplanned early rehospitalization in the first year following lung transplantation. Clin Transplant 2016; 30:1053-8. [PMID: 27312895 DOI: 10.1111/ctr.12787] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 12/11/2022]
Abstract
Unplanned early rehospitalization (UER), defined as an unscheduled admission within 30 days of a hospital discharge, is associated with graft loss and recipient mortality in some solid organ transplants but has not been investigated in lung transplant. In this retrospective study, we collected socio-demographic and clinical factors to determine predictors and outcomes of UER in the first year following lung transplantation. There were 193 patients who underwent lung transplantation and survived to discharge during the 7.9-year study period. There were 116 (60.1%) patients with at least one UER. Infections (32.8%) and post-surgical complications (11.8%) were the most common reasons for UER. On multivariate analysis, the strongest predictor of having an UER was discharge to a long-term acute care facility (odds ratio: 3.01, 95% confidence interval [CI] 1.46-6.20; P=.003). Patients with any UER in the first year following transplantation had worse adjusted survival (hazard ratio: 1.89, 95% CI 1.02-3.50; P=.04). It is unclear, however, to what extent UERs reflect preventable outcomes. Further large-scale, prospective research is needed to identify the extent to which certain types of UER are modifiable and to define patients at high-risk for preventable UER.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Stacey Salomon
- Social Work, Care Coordination, Brigham and Women's Hospital, Boston, MA, USA
| | - Anne Fuhlbrigge
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Miguel Divo
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Ivan O Rosas
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Phillip C Camp
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Hari H Mallidi
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Patrick Burkett
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA
| | - David J Wolfe
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA, USA.
| |
Collapse
|
41
|
Courtwright AM, Salomon S, Lehmann LS, Brettler T, Divo M, Camp P, Goldberg HJ, Wolfe DJ. The association between mood, anxiety and adjustment disorders and hospitalization following lung transplantation. Gen Hosp Psychiatry 2016; 41:1-5. [PMID: 27302717 DOI: 10.1016/j.genhosppsych.2016.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/19/2016] [Accepted: 04/21/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Psychiatric comorbidities such as mood, anxiety and adjustment disorders are common among individuals seeking lung transplantation. The objective of this study is to describe the association between these disorders and length of initial hospitalization and number of hospitalizations in the first year following transplantation. METHODS This was a retrospective cohort study of all lung transplantation patients between January 1, 2008 and July 1, 2014 at a large academic center. We evaluated whether pretransplantation mood, anxiety or adjustment disorders were associated with length and number of hospitalizations after transplant, adjusting for age, sex, native disease, forced expiratory volume in 1 s prior to transplantation, wait list time and lung allocation score. RESULTS There were 185 patients who underwent transplantation during the 7.5-year study period of whom 125 (67.6%) had a mood, anxiety or adjustment disorder. Patients with an adjustment disorder had decreased length of initial hospitalization [B coefficient=-5.76; 95% confidence interval (CI)=-11.40 to -0.13; P=.04]. Patients with anxiety disorders had an increased number of hospitalizations in the first year following transplantation (rate ratio=1.41; 95% CI=1.06-1.88; P=.02). There was no association between mood disorders and length or number of hospitalizations. Mood, adjustment and anxiety disorders were not associated with time to initial rehospitalization. CONCLUSIONS Among the three most common pretransplantation psychiatric disorders, only anxiety disorders are associated with increased hospitalization in the first year following lung transplant. Interventions designed to better control pretransplantation and posttransplantation anxiety may be associated with less frequent hospitalization.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Stacey Salomon
- Social Work, Care Coordination, Brigham and Women's Hospital, Boston, MA, USA
| | - Lisa Soleymani Lehmann
- Department of Medicine, Brigham and Women's Hospital; Department of Health Policy and Management, Harvard T. H. Chan School of Public Health; and Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Talya Brettler
- Department of Pediatrics, Kaiser Permanente, Northern California, CA, USA
| | - Miguel Divo
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Phillip Camp
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - David J Wolfe
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
42
|
Courtwright AM, Salomon S, Lehmann LS, Wolfe DJ, Goldberg HJ. The Effect of Pretransplant Depression and Anxiety on Survival Following Lung Transplant: A Meta-analysis. Psychosomatics 2015; 57:238-45. [PMID: 26927623 DOI: 10.1016/j.psym.2015.12.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 12/15/2015] [Accepted: 12/16/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Current lung transplant allocation guidelines recommend considering psychological function when assessing candidacy despite limited data on whether patients with conditions, such as anxiety and depression, have reduced benefit from transplant because of decreased survival after transplant. OBJECTIVE The aim of this article was to determine whether pretransplant depression and anxiety are associated with worse posttransplant survival. METHODS We searched Medline, Journal Storage, and Embase for original articles that assessed the effect of pretransplant depression and anxiety on survival following lung transplant published up to November 2015. We calculated a summary estimate of hazard ratios for death using a random effects model. RESULTS In total, 6 prospective longitudinal cohort studies were included in the meta-analysis, 4 of which used continuous scores on validated instruments to measure anxiety and depression. There were 711 patients of whom 345 (48.5%) died during the available follow-up time (mean = 7.8 years). Pretransplant anxiety and depression were not associated with posttransplant survival (hazard ratio = 1.009; 95% CI: 0.998-1.019). Heterogeneity was not detected (I(2) = 0.00%, Q = 5.87, p = 0.66) and the results did not differ whether anxiety or depression was treated as the exposure of interest. CONCLUSIONS There is sufficient evidence to conclude that scores on indices of depression and anxiety pretransplant are not associated with worse survival following lung transplant.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care Division, Brigham and Women׳s Hospital, Boston, MA
| | - Stacey Salomon
- Social Work, Care Coordination, Brigham and Women׳s Hospital, Boston, MA
| | | | - David J Wolfe
- Department of Medicine, Brigham and Women׳s Hospital, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Division, Brigham and Women׳s Hospital, Boston, MA.
| |
Collapse
|
43
|
Courtwright AM, Brackett S, Cadge W, Krakauer EL, Robinson EM. Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial. J Crit Care 2014; 30:173-7. [PMID: 25457115 DOI: 10.1016/j.jcrc.2014.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/04/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE This study investigated the impact of age, race, and functional status on decisions not to offer cardiopulmonary resuscitation (CPR) despite patient or surrogate requests that CPR be performed. METHODS This was a retrospective cohort study of all ethics committee consultations between 2007 and 2013 at a large academic hospital with a not offering CPR policy. RESULTS There were 134 cases of disagreement over whether to provide CPR. In 45 cases (33.6%), the patient or surrogate agreed to a do-not-resuscitate (DNR) order after initial ethics consultation. In 67 (75.3%) of the remaining 89 cases, the ethics committee recommended not offering CPR. In the other 22 (24.7%) cases, the ethics committee recommended offering CPR. There was no significant relationship between age, race, or functional status and the recommendation not to offer CPR. Patients who were not offered CPR were more likely to be critically ill (61.2% vs 18.2%, P < .001). The 90-day mortality rate among patients who were not offered CPR was 90.2%. CONCLUSIONS There was no association between age, race, or functional status and the decision not to offer CPR made in consultation with an ethics committee. Orders to withhold CPR were more common among critically ill patients.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Sharon Brackett
- Patient Care Services, Ellison 4 Surgical Intensive Care Unit, Massachusetts General Hospital, Boston, MA
| | - Wendy Cadge
- Department of Sociology, Brandeis University, Waltham, MA
| | - Eric L Krakauer
- Division of Palliative Care, Massachusetts General Hospital, Boston, MA; Departments of Medicine and of Global Health & Social Medicine, Harvard Medical School, Boston, MA
| | - Ellen M Robinson
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA; Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
44
|
Sise ME, Courtwright AM, Channick RN. Pulmonary hypertension in patients with chronic and end-stage kidney disease. Kidney Int 2013; 84:682-92. [PMID: 23739239 DOI: 10.1038/ki.2013.186] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 03/09/2013] [Accepted: 03/14/2013] [Indexed: 11/09/2022]
Abstract
Pulmonary hypertension is defined as a mean pulmonary artery pressure ≥25 mm Hg and is a recently recognized complication of chronic kidney disease and end-stage renal disease. There is significant epidemiological overlap with kidney disease and the underlying causes of World Health Organization group 1-4 pulmonary hypertension (pulmonary arteriopathy, left heart disease, chronic pulmonary disease, and chronic thromboembolic disease, respectively). In addition, an entity of 'unexplained pulmonary hypertension,' group 5, in patients with chronic kidney disease and end-stage renal disease has emerged, with prevalence estimates of 30-50%. The pathogenesis of pulmonary hypertension in this population is due to alterations in endothelial function, increased cardiac output, and myocardial dysfunction leading to elevated left heart filling pressure, with recent data suggesting that left heart dysfunction may account for the vast majority of pulmonary hypertension in patients with kidney disease. Pulmonary hypertension is an independent predictor of increased mortality in patients on dialysis and those undergoing kidney transplantation. This review summarizes what is known about the epidemiology, pathogenesis, transplantation outcomes, mortality, and treatment of pulmonary hypertension in patients with chronic kidney disease and end-stage renal disease.
Collapse
Affiliation(s)
- Meghan E Sise
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | | | | |
Collapse
|
45
|
Abstract
Recent research in epidemiology has identified a number of factors beyond access to medical care that contribute to health disparities. Among the so-called socioeconomic determinants of health are income, education, and the distribution of social capital. One factor that has been overlooked in this discussion is the effect that stigmatization can have on health. In this paper, I identify two ways that social stigma can create health disparities: directly by impacting health-care seeking behaviour and indirectly through the internalization of negative interpersonal judgments. I then argue that social arrangements that foster self-respect can reduce the impact of stigmatization on health disparities. I conclude by showing how John Rawls' conception of justice can be used to address the intersection of stigma, health, and self-respect, in contrast to critics of his position, who have seen him as excessively focused on the allocation of material goods.
Collapse
Affiliation(s)
- Andrew M Courtwright
- University of North Carolina School of Medicine, Bondurant Hall, CB# 7000, Box #307, Chapel Hill, NC 27599, USA.
| |
Collapse
|
46
|
Affiliation(s)
- Andrew M Courtwright
- Department of Philosophy at the University of North Carolina Chapel Hill and a fourth-year student in the UNC School of Medicine
| | | |
Collapse
|
47
|
Abstract
Chromosomes have to establish the proper attachment to the spindle before segregation-a process that requires Ipl1p Aurora kinase. Recent work has identified Dam1p, a member of the DASH complex, as the key Ipl1p substrate responsible for kinetochore/microtubule interaction.
Collapse
Affiliation(s)
- Andrew M Courtwright
- Department of Biochemistry and Molecular Biology, Graduate School of Biomedical Sciences, University of Texas Health Science Center at Houston Medical School, 6431 Fannin, 6.200, Houston, TX 77030, USA
| | | |
Collapse
|