Enhanced recovery after surgery pathway leads to decreased length of stay for patients undergoing minimally invasive lung resection

Background

Enhanced recovery after surgery (ERAS) protocols in thoracic surgery have been demonstrated to impact length of stay (LOS), complication rates, and postoperative opioid use. However, ERAS protocols for minimally invasive lung resections have not been well described. Given most lung resections are now performed minimally invasively, there is a gap in the literature regarding the efficacy of ERAS protocols in this setting. In this study, we analyzed patient outcomes following implementation of an ERAS protocol for minimally invasive lung resections.

Methods

Outcome data was retrospectively collected for 442 patients undergoing minimally invasive lung resections between January 1st, 2015 and October 26th, 2021. Patients were divided into either a pre-ERAS (n=193) or ERAS (n=249) group. Primary outcomes included LOS, postoperative complications, intensive care unit (ICU) admission status, 30-day hospital readmissions, and 30-day mortality. Secondary outcomes included common postoperative complications required for the Society for Thoracic Surgeons (STS) database.

Results

We observed an overall decrease in median LOS (4.0 vs. 3.0 days, P=0.030) and ICU admission status (15% vs. 7.6%, P=0.020) after implementation of our ERAS protocol. The difference in LOS was significantly lower for anatomic lung resections, but not non-anatomic resections. There was no difference in 30-day readmissions and a 0% mortality rate in both groups. Overall, there was a low complication rate that was similar between groups.

Conclusions

The implementation of an ERAS protocol led to decreased LOS and decreased ICU admission in patients undergoing minimally invasive lung resection. Process standardization optimizes performance by providers by decreasing decision fatigue and improving decision making, which may contribute to the improved outcomes observed in this study.

Vascularized composite allotransplantation combined with costimulation blockade induces mixed chimerism and reveals intrinsic tolerogenic potential

Vascularized composite allotransplantation (VCA) has become a valid therapeutic option to restore form and function after devastating tissue loss. However, the need for high-dose multidrug immunosuppression to maintain allograft survival is still hampering more widespread application of VCA. In this study, we investigated the immunoregulatory potential of costimulation blockade (CoB; CTLA4-Ig and anti-CD154 mAb) combined with nonmyeoablative total body irradiation (TBI) to promote allograft survival of VCA in a fully MHC-mismatched mouse model of orthotopic hind limb transplantation. Compared with untreated controls (median survival time [MST] 8 days) and CTLA4-Ig treatment alone (MST 17 days), CoB treatment increased graft survival (MST 82 days), and the addition of nonmyeloablative TBI led to indefinite graft survival (MST > 210 days). Our analysis suggests that VCA-derived BM induced mixed chimerism in animals treated with CoB and TBI + CoB, promoting gradual deletion of alloreactive T cells as the underlying mechanism of long-term allograft survival. Acceptance of donor-matched secondary skin grafts, decreased ex vivo T cell responsiveness, and increased graft-infiltrating Tregs further indicated donor-specific tolerance induced by TBI + CoB. In summary, our data suggest that vascularized BM-containing VCAs are immunologically favorable grafts promoting chimerism induction and long-term allograft survival in the context of CoB.

Mechanical Circulatory Support for Cardiogenic Shock in the Critically Ill

Patients requiring mechanical circulatory support (MCS) constitute a heterogeneous group whose needs have guided the development of a broad range of MCS devices. Appropriate patient and device selection are important for maximizing the potential benefit of these therapies. Currently available devices can be deployed percutaneously or surgically implanted. They can also be configured for left, right, or biventricular support and remain in place for hours to years, offering varying levels of flow. In the critical care setting, patients with the highest acuity have the worst outcomes when receiving an implantable long-term ventricular assist device (VAD); therefore, shorter-term devices should be considered for stabilization and optimization prior to implantation of a long-term device. In this focused review for the critical care clinician, we discuss important considerations for identifying VAD candidates, identifying the range of devices available to support them, bridging strategies that may improve outcomes for patients who are critically ill, and identifying areas of ongoing research.

MHC class II-peptide complexes displayed on activated T cells guide Treg suppression

Regulatory T cell (Treg) therapy is a promising strategy for extending allograft survival. Treg suppression requires initial T cell receptor (TCR)/peptide-MHC-II (pMHC-II) contacts, the nature of which remains elusive. As inflammation facilitates transfer of pMHC-II from antigen presenting cells (APCs) to activated T cells, we hypothesize that during transplantation associated inflammation, pMHC-II relocate on alloreactive T effector cells and serve as Treg activation signals. To test this, suppression assays were performed using murine CD4+ CD25− (Teff), CD90 depleted APCs, and CD4+ CD25+ Treg cells of different MHC haplotypes. We also used a transplantation model of skin allografts in RAG1 deficient mice injected with Teff and Treg cells from various MHC backgrounds. Data from more than 150 co-culture experiments show that Treg suppression occurs only when Treg and Teff share the same MHC-II, but independently of Treg matching with APC MHC-II. Further experiments demonstrate that pMHC-II complexes, displayed on activated Teff cells, are crucial to the induction of Treg suppression. In vivo results recapitulate the in vitro data: Treg suppression, leading to graft survival, occurs only when Teff and Treg cells are MHC-II matched. Collectively, these findings suggest that suppression of alloreactivity is directed by Treg TCR recognition of pMHC-II complexes exposed on Teff cells. The nature, origin (host vs. donor), and significance of MHC-II loaded peptides have yet to be established. Future studies to improve targeted Treg therapies for transplantation tolerance will focus on mechanisms coupling Treg function with Teff cell activation.

Orthotopic Hind Limb Transplantation in the Mouse

In vivo animal model systems, and in particular mouse models, have evolved into powerful and versatile scientific tools indispensable to basic and translational research in the field of transplantation medicine. A vast array of reagents is available exclusively in this setting, including mono- and polyclonal antibodies for both diagnostic and interventional applications. In addition, a vast number of genotyped, inbred, transgenic, and knock out strains allow detailed investigation of the individual contributions of humoral and cellular components to the complex interplay of an immune response and make the mouse the gold standard for immunological research. Vascularized Composite Allotransplantation (VCA) delineates a novel field of transplantation using allografts to replace "like with like" in patients suffering traumatic or congenital tissue loss. This surgical methodological protocol shows the use of a non-suture cuff technique for super-microvascular anastomosis in an orthotopic mouse hind limb transplantation model. The model specifically allows for comparison between established paradigms in solid organ transplantation with a novel form of transplants consisting of various different tissue components. Uniquely, this model allows for the transplantation of a viable vascularized bone marrow compartment and niche that have the potential to exert a beneficial effect on the balance of immune acceptance and rejection. This technique provides a tool to investigate alloantigen recognition and allograft rejection and acceptance, as well as enables the pursuit of functional nerve regeneration studies to further advance this novel field of transplantation.

A Novel Microsurgical Model for Heterotopic, En Bloc Chest Wall, Thymus, and Heart Transplantation in Mice

Exploration of novel strategies in organ transplantation to prolong allograft survival and minimizing the need for long-term maintenance immunosuppression must be pursued. Employing vascularized bone marrow transplantation and co-transplantation of the thymus have shown promise in this regard in various animal models. Vascularized bone marrow transplantation allows for the uninterrupted transfer of donor bone marrow cells within the preserved donor microenvironment, and the incorporation of thymus tissue with vascularized bone marrow transplantation has shown to increase T-cell chimerism ultimately playing a supportive role in the induction of immune regulation. The combination of solid organ and vascularized composite allotransplantation can uniquely combine these strategies in the form of a novel transplant model. Murine models serve as an excellent paradigm to explore the mechanisms of acute and chronic rejection, chimerism, and tolerance induction, thus providing the foundation to propagate superior allograft survival strategies for larger animal models and future clinical application. Herein, we developed a novel heterotopic en bloc chest wall, thymus, and heart transplant model in mice using a cervical non-suture cuff technique. The experience in syngeneic and allogeneic transplant settings is described for future broader immunological investigations via an instructional manuscript and video supplement.

Health education through interactive radio: a child-to-child project in Bolivia

In developing countries it is common for older children to assume much of the responsibility for care of their younger siblings. Based on this observation, the "child-to-child" approach to health education targets these older children as a means of improving child health. As the initial phase in the development of a radio health curriculum in Bolivia, a module on diarrheal disease was developed and field-tested among fourth- and fifth-grade students in Cochabamba. The module consists of 10 interactive radio lessons in which the students respond orally to drill and practice, sing songs, or write key concepts in their notebooks. Following the 25-minute radio broadcast, the teacher conducts a 20-minute session that focuses on application and practice of the new behaviors. The module includes lessons on personal hygiene, water and oral rehydration, home sanitation, and nutrition. The field evaluation revealed the need for modifications in the teachers' role and greater attention to teacher training. Students responded enthusiastically and achieved significant knowledge gains as a result of the program. Plans are underway to expand the radio health program.

The National Breast Screening Study: pre-recruitment sources of awareness in participants

Data collected by questionnaire from 89,835 women on entry into 15 Canadian National Breast Screening Study (NBSS) centres reveal pre-recruitment sources of awareness: radio and television were reported by 30%; workplace 6%; friends 35%; physician 6%; and other by 23% of respondents. Personalized letters of invitation employed in 5 centres were an important source of awareness. In the age group recruited, 40-59 years, age had no influence on the source reported. However women with post-secondary school education were less likely to report radio and television as a source and more likely to report newspapers compared to women with less education. Women with only public school education were less likely to report the workplace as a source of awareness than women with post-secondary education. Recruitment strategies for screening programs may be more successful if publicity on radio and television is geared to women of lower educational status and if publicity in newspapers is geared to women of higher educational status, supplementing both with personalized letters of invitation.