Outcomes Following Lung Transplant for COVID-19-Related Complications in the US

IMPORTANCE: The COVID-19 pandemic led to the use of lung transplant as a lifesaving therapy for patients with irreversible lung injury. Limited information is currently available regarding the outcomes associated with this treatment modality. OBJECTIVE: To describe the outcomes following lung transplant for COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, lung transplant recipient and donor characteristics and outcomes following lung transplant for COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis were extracted from the US United Network for Organ Sharing database from March 2020 to August 2022 with a median (IQR) follow-up period of 186 (64-359) days in the acute respiratory distress syndrome group and 181 (40-350) days in the pulmonary fibrosis group. Overall survival was calculated using the Kaplan-Meier method. Cox proportional regression models were used to examine the association of certain variables with overall survival. EXPOSURES: Lung transplant following COVID-19-related acute respiratory distress syndrome or pulmonary fibrosis. MAIN OUTCOMES AND MEASURES: Overall survival and graft failure rates. RESULTS: Among 385 included patients undergoing lung transplant, 195 had COVID-19-related acute respiratory distress syndrome (142 male [72.8%]; median [IQR] age, 46 [38-54] years; median [IQR] allocation score, 88.3 [80.5-91.1]) and 190 had COVID-19-related pulmonary fibrosis (150 male [78.9%]; median [IQR] age, 54 [45-62]; median [IQR] allocation score, 78.5 [47.7-88.3]). There were 16 instances of acute rejection (8.7%) in the acute respiratory distress syndrome group and 15 (8.6%) in the pulmonary fibrosis group. The 1-, 6-, and 12- month overall survival rates were 0.99 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.91-0.98), and 0.88 (95% CI, 0.80-0.94) for the acute respiratory distress syndrome cohort and 0.96 (95% CI, 0.92-0.98), 0.92 (95% CI, 0.86-0.96), and 0.84 (95% CI, 0.74-0.90) for the pulmonary fibrosis cohort. Freedom from graft failure rates were 0.98 (95% CI, 0.96-0.99), 0.95 (95% CI, 0.90-0.97), and 0.88 (95% CI, 0.79-0.93) in the 1-, 6-, and 12-month follow-up periods in the acute respiratory distress cohort and 0.96 (95% CI, 0.92-0.98), 0.93 (95% CI, 0.87-0.96), and 0.85 (95% CI, 0.74-0.91) in the pulmonary fibrosis cohort, respectively. Receiving a graft from a donor with a heavy and prolonged history of smoking was associated with worse overall survival in the acute respiratory distress syndrome cohort, whereas the characteristics associated with worse overall survival in the pulmonary fibrosis cohort included female recipient, male donor, and high recipient body mass index. CONCLUSIONS AND RELEVANCE: In this study, outcomes following lung transplant were similar in patients with irreversible respiratory failure due to COVID-19 and those with other pretransplant etiologies

Simplified Negative Pressure Wound Therapy Device for Application in Low-Resource Settings

Negative pressure wound therapy (NPWT) provides proven wound healing benefits and is often a desirable wound treatment methodology. Unfortunately, NPWT devices are not widely available in low-resource settings. To overcome the identified NPWT barriers, a simplified NPWT (sNPWT) system was designed and iteratively improved during field-based testing. The sNPWT technology, our device design iterations, and the design-based results of our field tests are described in this article. The sNPWT system includes a bellows hand pump, an occlusive drape, and a tube with tube connectors, connecting the drape to the pump. The most critical property of an sNPWT system is that it must be airtight. The details of the design iterations, which are needed to achieve an occlusive system, are explained. During the design process, the sNPWT system was tested during the earthquake relief in Haiti. This testing found that a liquid sealant was necessary to seal the drape to the periwound skin. A study conducted in Rwanda verified that a liquid latex sealant was safe to use, and that the tube connector must be connected to the drape with an airtight method during the manufacturing process. This work has shown that sNPWT is feasible in low-resource settings. Since the completion of the clinical testing, the design has been further evolved, and the developers are working with contract manufacturers to produce the final design and preparing for regulatory approval applications.Legatum Center for Development & Entrepreneurship (Massachusetts Institute of Technology)Massachusetts Institute of Technology (Hugh Hampton Young Memorial Fund Fellowship)Fogarty International Center (Clinical Research Fellowship)National Institutes of Health (U.S.) (Fogarty International Center. R24 TW007988

CT depiction of pulmonary emboli: display window settings

PURPOSE: To compare computed tomographic (CT) window settings selected by radiologists with those determined by using two alternative approaches for depiction of pulmonary emboli (PE). MATERIALS AND METHODS: Institutional review board approval was obtained; informed consent was not required. This study was compliant with the Health Insurance Portability and Accountability Act. Twenty-five clinical chest CT studies were obtained with a standardized PE protocol and retrospectively evaluated by five chest and two body CT radiologists. Of these studies, 13 were positive for PE, and 12 were negative. At the main pulmonary artery (PA), mean attenuations (MPA) and standard deviations (SDPA) were measured. Initially, images were displayed with a standard mediastinal window setting (window width, W = 400 HU; window center, C = 30 HU), and each observer adjusted the setting to a personally preferred setting (eg, "personal") for PE detection. Images displayed at this setting were compared in a side-by-side fashion with the "modified" (W = MPA + 2 . SDPA, C = W/2) and "double-half" (W = 2 . MPA, C = MPA/2) window setting. Each observer rated images from 1 (ie, most preferred) to 3 (ie, least preferred). For quantitative analysis, window width and center value of each setting were divided by corresponding MPA to compute a width ratio and a center ratio. Window settings and ratings were compared with repeated-measures analysis of variance, paired t tests, and Wilcoxon signed-rank tests. RESULTS: Ratings for all three types of window settings were significantly different (P < .001). Observers preferred their personal settings the most and the modified settings the least. Mean ratios for the seven observers were 1.68 +/- 0.20 for window width and 0.47 +/- 0.08 for window center. Window width ratios for all settings were significantly different from each other (P < .001). Window center ratios were significantly higher for the modified setting than for the double-half setting (P = .013). Values for mean PA attenuation were correlated with window width ratios for six (86%) observers (mean r2 value = 0.29 +/- 0.19, P < or = .03) and with window center ratios for four (57%) observers (mean r2 value = 0.16 +/- 0.14, P < or = .02), thus indicating a trend of setting window width and window center higher when contrast enhancement is lower and vice versa. CONCLUSION: On average, observers selected CT window settings for PE detection at a window width of slightly less than twice the mean PA attenuation and at a window center of about half the mean PA attenuation. Observers tended to use larger window widths and centers as the degree of PA enhancement was lower

Pre-COVID-19 National Mortality Trends in Open and Video-Assisted Lobectomy for Non-Small Cell Lung Cancer

Introduction In the current era of episode-based hospital reimbursements, it is important to determine the impact of hospital size on contemporary national trends in surgical technique and outcomes of lobectomy. Methods Patients aged >18 y undergoing open and video-assisted thoracoscopic surgery (VATS) lobectomy from 2008 to 2014 were identified using insurance claims data from the National Inpatient Sample. The impact of hospital size on surgical approach and outcomes for both open and VATS lobectomy were analyzed. Results Over the 7-y period, 202,668 lobectomies were performed nationally, including 71,638 VATS and 131,030 open. Although the overall number of lobectomies decreased (30,058 in 2008 versus 27,340 in 2014, P 0.05) but did decrease among small hospitals (4.1%-1.3% and 5.1%-1.1% for VATS and open, respectively; both P < 0.05). After adjusting for confounders, hospital bed size was not a predictor of in-hospital mortality. Conclusions Utilization of VATS lobectomies has increased over time, more so among small hospitals. Mortality rates for open lobectomy remain consistently higher than VATS lobectomy (range 0.4%-1.4%) but did not significantly differ over time. This data can help benchmark hospital performance in the future

Left ventricle unloading strategies in ECMO: A single‐center experience

ECMO is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n=30) versus immediate (Group 2, n=33) LV unloading and then compared patients unloaded with an Impella CP (n=19) versus an intra-aortic balloon pump (IABP, n=16), analyzing survival and ECMO-related complications. Survival was similar between Groups 1 and 2 (33 vs 42%, p=0.426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, p=0.034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design

Shared learning in an interconnected world: innovations to advance global health equity

The notion of "reverse innovation";--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study.

BackgroundEsophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined.MethodsThis prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach.DiscussionThis study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research.Trial registrationThis study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021,&nbsp; NCT05177393