End-stage Chronic Obstructive Pulmonary Disease Research Articles

Compartment-specific remodeling patterns in end-stage chronic obstructive pulmonary disease with and without severe pulmonary hypertension

RationaleIn end-stage COPD patients, severe pulmonary hypertension (PH) is frequently associated with less severe airway obstruction as compared to mild or no PH. However, the histologic correlate of this finding is not clear. ObjectiveTo quantify remodeling of pulmonary arteries, airways and parenchyma in random samples of explanted end-stage COPD lungs. MethodsWe quantified thickening of small pulmonary arteries, remodeling of small airways and the degree of emphysema (mean interseptal distance, MID) with dedicated software. As primary objective, we compared COPD patients with severe PH (SevPH-COPD) with age- and sex matched MildPH-COPD. For comparison, we also investigated COPD lungs with no PH (NoPH-COPD), idiopathic PAH (IPAH), and healthy donors. ResultsWe included n=17 SevPH-COPD (mPAP=43 [39–45]mmHg), n=17 MildPH-COPD (mPAP=28 [24–31]mmHg), n=5 NoPH-COPD (mPAP=18 [16–19]mmHg), n=10 IPAH (mPAP=72 [65–91]mmHg) and n=10 healthy donor lungs. SevPH-COPD vs. MildPH-COPD was characterized by better preserved forced vital capacity (51%vs.40%predicted,p<0.05), less emphysema (MID 169µmvs.279µm,p<0.001), and less PAS-positive and CD45-positive mucosa cells (15%vs.22%,p=0.063 and 5%vs.7%,p=0.058) suggesting less airway inflammation. Over the full range of COPD, intimal and medial thickening were strongly correlated with mPAP (r=0.676,p<0.001 and r=0.595,p<0.001). MID was negatively correlated with mPAP (r=-0.556,p<0.001) and was highest in NoPH-COPD (mean 281µm), suggesting that emphysema per se is not associated with PH. ConclusionEnd-stage COPD with severe PH is characterized by pronounced pulmonary vascular remodeling, less inflammation of small airways and less emphysema as compared to COPD with mild PH or no PH, suggesting that COPD with severe PH may represent a unique phenotype of COPD.

COPD basal cells are primed towards secretory to multiciliated cell imbalance driving increased resilience to environmental stressors

IntroductionEnvironmental pollutants injure the mucociliary elevator, thereby provoking disease progression in chronic obstructive pulmonary disease (COPD). Epithelial resilience mechanisms to environmental nanoparticles in health and disease are poorly characterised.MethodsWe delineated...

Single vs Bilateral Lung Transplant in the Management of Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Lung transplantation is recommended for select patients with end-stage chronic obstructive pulmonary disease (COPD). However, a consensus has not been reached regarding the optimal choice of lung transplantation: single lung transplants (SLTs) vs bilateral lung transplants (BLTs). This meta-analysis aimed to evaluate the safety and efficacy of SLT compared with BLT in managing end-stage COPD. Cochrane, Embase, PubMed, and Scopus were searched for articles by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022343408). Seven studies of 311 screened met the eligibility criteria, with a total of 10,652 patients with end-stage COPD, SLT (n=6233), or BLT (n=4419). Overall survival rates of BLT group were more favorable than SLT group at 1 (odds ratio [OR]=1.29, 95% CI: 1.16, 1.43, I2=0%), 5 (OR=1.46, 95% CI: 1.35, 1.58, I2=23%), and 10 years (OR=1.71, 95% CI: 1.57, 1.87, I2=12%) as well as the hazard ratio (HR=0.73, 95% CI: 0.70, 0.76, I2=40%). Subgroup analysis on survival rates of alpha-1 antitrypsin deficiency also displayed a trend favoring BLT compared with SLT at 1 (OR=1.60, 95% CI: 1.24, 2.08, I2=28%), 5 (OR=1.84, 95% CI: 1.50, 2.26, I2=42%), and 10 years (OR=1.98, 95% CI: 1.59, 2.48, I2=47%) as well as the HR (HR=0.67, 95% CI: 0.35, 1.28, I2=82%). Compared with SLT, BLT seems to demonstrate more favorable trends in survival rates for the management of end-stage COPD. Despite the promising results, the groups have significant heterogeneity in baseline characteristics. Further prospective studies with extended follow-up periods are needed to ascertain the efficacy of treatment.

Activation of CD8+ T Cells in Chronic Obstructive Pulmonary Disease Lung.

Rationale: Despite the importance of inflammation in chronic obstructive pulmonary disease (COPD), the immune cell landscape in the lung tissue of patients with mild-moderate disease has not been well characterized at the single-cell and molecular level. Objectives: To define the immune cell landscape in lung tissue from patients with mild-moderate COPD at single-cell resolution. Methods: We performed single-cell transcriptomic, proteomic, and T-cell receptor repertoire analyses on lung tissue from patients with mild-moderate COPD (n = 5, Global Initiative for Chronic Obstructive Lung Disease I or II), emphysema without airflow obstruction (n = 5), end-stage COPD (n = 2), control (n = 6), or donors (n = 4). We validated in an independent patient cohort (N = 929) and integrated with the Hhip+/- murine model of COPD. Measurements and Main Results: Mild-moderate COPD lungs have increased abundance of two CD8+ T cell subpopulations: cytotoxic KLRG1+TIGIT+CX3CR1+ TEMRA (T effector memory CD45RA+) cells, and DNAM-1+CCR5+ T resident memory (TRM) cells. These CD8+ T cells interact with myeloid and alveolar type II cells via IFNG and have hyperexpanded T-cell receptor clonotypes. In an independent cohort, the CD8+KLRG1+ TEMRA cells are increased in mild-moderate COPD lung compared with control or end-stage COPD lung. Human CD8+KLRG1+ TEMRA cells are similar to CD8+ T cells driving inflammation in an aging-related murine model of COPD. Conclusions: CD8+ TEMRA cells are increased in mild-moderate COPD lung and may contribute to inflammation that precedes severe disease. Further study of these CD8+ T cells may have therapeutic implications for preventing severe COPD.

Effectiveness of the integration of a palliative care team in the follow-up of patients with advanced chronic obstructive pulmonary disease: The home obstructive lung disease study

BackgroundAccess to palliative care for patients with end-stage chronic obstructive pulmonary disease (COPD) is still very poor. ObjectivesEvaluate our palliative care program for patients with advanced COPD by assessing whether the referral criteria for advanced COPD patients were adequate in identifying patients in end-of-life care and determine the results of the palliative care team's intervention MethodsThis was a prospective observational study of patients admitted to a multidisciplinary unit for advanced COPD. Data on sociodemographic variables, survival, symptomatology, quality of life, ACP, and health resource utilization were analyzed. ResultsEighty-three patients were included in this study. By the end of the follow-up period, 69 (83%) patients had died, mainly due to respiratory failure (96%). The median duration of survival from the start of follow-up was 4.27 months (95% confidence interval, 1.97–16.07). Most patients (94%) had a dyspnea level of 4. Sixty (72%) patients required opioids for dyspnea control. There were no significant differences in the quality of life of the patients during follow-up. Thirty (43%) patients died at home, 26 (38%) in a palliative care unit, and 13 (19%) in an acute care hospital. ACP was performed for 50 (72%) patients. Forty (57%) patients required palliative sedation during follow-up. Dyspnea was the reason for sedation in 34 (85%) patients. Hospital admissions and emergency room visits decreased significantly (p = 0.01) during follow-up. ConclusionsOur integrated model allows for adequate selection of patients, facilitates symptom control and ACP, reduces resource utilization, and favors death at home.

A Real-Life Study of Combined Treatment with Long-Term Non-Invasive Ventilation and High Flow Nasal Cannula in Patients with End-Stage Chronic Obstructive Lung Disease.

Patients with end-stage chronic obstructive pulmonary disease (COPD) often develop persistent hypoxic or hypercapnic respiratory failure, or a combination of both. Ventilatory support, in terms of a long-term high-flow nasal cannula (LT-HFNC) and long-term non-invasive ventilation (LT-NIV), may be indicated. Often, clinicians choose either one or the other. This paper explores combined treatment with LT-HFNC and LT-NIV in a real-life setting. In total, 33 patients with COPD and persistent respiratory failure were included in this study. Of those, 17 were initiated on LT-HFNC and used it for 595 (374) days and 16 were initiated on LT-NIV and used it for 558 (479) days. On average, patients used respiratory support continuously for 908 (586) days. Baseline characteristics were comparable, apart from PaCO2 at first ventilatory support initiation (LT-HFNC/LT-NIV 7.1 (1.1) kPa/8.8 (0.9) kPa respectively (p = 0.002)). Both groups experienced a reduction in hospitalizations in the first twelve months after treatment initiation, compared to the twelve months before (LT-HFNC p = 0.022 and LT-NIV p = 0.014). In total, 25% of LT-NIV patients stopped treatment after HFNC initiation due to intolerance and 59% stopped LT-HFNC treatment 126 (36) days after LT-NIV initiation as monotherapy was sufficient. In 44% of these patients, LT-HFNC was re-initiated at the end of life. At the time of analysis, 70% of patients had died. In the last three months of life, patients stopped using LT-NIV, whereas 91% used LT-HFNC. In conclusion, the combined use of LT-NIV and LT-HFNC reduced hospitalizations in patients with COPD and persistent respiratory failure. The study indicates that LT-HFNC is well tolerated, and better tolerated than LT-NIV at the very end stages of COPD.

Child-Pugh Class B or C Liver Disease Increases the Risk of Early Mortality in Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty Regardless of Treatment Status.

Patients with hepatitis C virus (HCV) undergoing primary elective total joint arthroplasty (TJA) are at increased risk of postoperative complications. Patients with chronic liver disease and cirrhosis, specifically Child-Pugh Class B and C, who are undergoing general surgery have high 2-year mortality risks, approaching 60% to 80%. However, the role of Child-Pugh and Model for End-Stage Liver Disease classifications of liver status in predicting survivorship among patients with HCV undergoing elective arthroplasty has not been elucidated. What factors are independently associated with early mortality (< 2 years) in patients with HCV undergoing arthroplasty? We performed a retrospective study at three tertiary academic medical centers and identified patients with HCV undergoing primary elective TJA between January 2005 and December 2019. Patients who underwent revision TJA and simultaneous primary TJA were excluded. A total of 226 patients were eligible for inclusion in the study. A further 25% (57) were excluded because they were lost to follow-up before the minimum study requirement of 2 years of follow-up or had incomplete datasets. After the inclusion and exclusion criteria were applied, the final cohort consisted of 75% (169 of 226) of the initial patient population eligible for analysis. The mean follow-up duration was 53 ± 29 months. We compared confounding variables for mortality between patients with early mortality (16 patients) and surviving patients (153 patients), including comorbidities, HCV and liver characteristics, HCV treatment, and postoperative medical and surgical complications. Patients with early postoperative mortality were more likely to have an associated advanced Child-Pugh classification and comorbidities including peripheral vascular disease, end-stage renal disease, heart failure, and chronic obstructive pulmonary disease. However, both groups had similar 90-day and 1-year medical complication risks including myocardial infarction, stroke, pulmonary embolism, and reoperations for periprosthetic joint infection and mechanical failure. A multivariable regression analysis was performed to identify independent factors associated with early mortality, incorporating all significant variables with p < 0.05 present in the univariate analysis. After accounting for significant variables in the univariate analysis such as peripheral vascular disease, end-stage renal disease, heart failure, chronic obstructive pulmonary disease, and liver fibrosis staging, Child-Pugh Class B or C classification was found to be the sole factor independently associated with increased odds of early (within 2 years) mortality in patients with HCV undergoing elective TJA (adjusted odds ratio 29 [95% confidence interval 5 to 174]; p < 0.001). The risk of early mortality in patients with Child-Pugh Class B or C was 64% (seven of 11) compared with 6% (nine of 158) in patients with Child-Pugh Class A (p < 0.001). Patients with HCV and a Child-Pugh Class B or C at the time of elective TJA had substantially increased odds of death, regardless of liver function, cirrhosis, age, Model for End-Stage Liver Disease level, HCV treatment, and viral load status. This is similar to the risk of early mortality observed in patients with chronic liver disease undergoing abdominal and cardiac surgery. Surgeons should avoid these major elective procedures in patients with Child-Pugh Class B or C whenever possible. For patients who feel their arthritic symptoms and pain are unbearable, surgeons need to be clear that the risk of death is considerably elevated. Level III, therapeutic study.

Complement component 3 protects human bronchial epithelial cells from cigarette smoke-induced oxidative stress and prevents incessant apoptosis.

The complement component 3 (C3) is a pivotal element of the complement system and plays an important role in innate immunity. A previous study showed that intracellular C3 was upregulated in airway epithelial cells (AECs) from individuals with end-stage chronic obstructive pulmonary disease (COPD). Accumulating evidence has shown that cigarette smoke extract (CSE) induces oxidative stress and apoptosis in AECs. Therefore, we investigated whether C3 modulated cigarette smoke-induced oxidative stress and apoptosis in AECs and participated in the pathogenesis of COPD. We found increased C3 expression, together with increased oxidative stress and apoptosis, in a cigarette smoke-induced mouse model of COPD and in AECs from patients with COPD. Different concentrations of CSEinduced C3 expression in 16HBE cells in vitro. Interestingly, C3 knockdown (KD) exacerbated oxidative stress and apoptosis in 16HBE cells exposed to CSE. Furthermore, C3 exerted its pro-survival effects through JNK inhibition, while exogenous C3 partially rescued CSE-induced cell death and oxidative stress in C3 KD cells. These data indicate that locally produced C3 is an important pro-survival molecule in AECs under cigarette smoke exposure, revealing a potentially novel mechanism in the pathogenesis of COPD.

A think-aloud study of the feasibility of patients with end-stage organ failure completing the ICECAP-SCM

Background: The ICECAP-Supportive Care Measure (SCM) is a self-complete measure developed to inform economic decision making at the end-of-life. Previous research has demonstrated its feasibility in hospice and nursing home settings. This is the first study of its use with patients on the organ failure trajectory. Aim: To determine the feasibility of using the ICECAP-SCM with patients experiencing end-stage organ failure in a hospital setting. Design: Participants were asked to ‘think aloud’ when completing the ICECAP-SCM, ICECAP-A and EQ-5D-5L measures. The interviews were transcribed verbatim and examined for errors in comprehension, retrieval, judgement, and response by five raters. Qualitative data were collected to explore reasons for errors in completing the measures and participants’ views about the measures. Setting/participants: Sixty patients (with end-stage renal failure n = 18; end-stage heart failure n = 21; end-stage chronic obstructive pulmonary disease n = 21) participated. Senior clinicians applied prognostic criteria to determine eligibility. Results: Participants reported that the measures were acceptable, clear, and easy to complete. Error rates in completing the measures were low (ICECAP-A = 3%,and ICECAP-SCM = 5.7% and EQ-5D-5L = 6.3%). There was some variation in responses between patients with different end-stage conditions, particularly those with symptom fluctuation. Some patients had not considered their end-of-life (i.e. advance care planning) and reported finding questions about this difficult to answer. Conclusion: It is feasible to use the ICECAP-SCM with patients with end-stage organ failure receiving care in hospital settings. This study provides evidence for researchers and policy makers involved in measuring end-of-life care globally. The ICECAP-SCM can be recommended for research with patients in end-stage organ failure to appropriately capture the broader benefits of end-of-life care.

NADPH Oxidase Isoforms in COPD Patients and Acute Cigarette Smoke-Exposed Mice: Induction of Oxidative Stress and Lung Inflammation.

Cigarette smoke (CS) is a major risk factor for chronic obstructive pulmonary disease (COPD), which represents the third leading cause of death worldwide. CS induces reactive oxygen species (ROS) production, leading to pulmonary inflammation and remodeling. NADPH oxidases (NOXs) represent essential sources of ROS production in the cardiovascular system. Whether and how NOX isoforms are activated in COPD patients and in response to acute cigarette smoke (ACS) remains incompletely understood. In the present study, the expression of NOX isoforms was examined in the lungs of end-stage COPD patients. In addition, mice silenced of NOX1 or NOX4 expression using in vivo RNA interference (RNAi), and NOX2-deficient (NOX2−/y) mice, were exposed to ACS for 1 h using a standard TE-10B smoking machine. In lung sections isolated from COPD patients undergoing lung transplantation, protein expression of NOX1, NOX2, NOX4, or NOX5 was markedly upregulated compared to non-smoking donor controls. Likewise, ACS upregulated protein expression of NOX1, NOX2, and NOX4, production of ROS, inflammatory cell infiltration, and mRNA expression of proinflammatory cytokines TNF-α and KC in the mouse lung. In vivo RNAi knockdown of NOX1 or NOX4 decreased ACS induced ROS production, inflammatory cell influx, and the expression of TNF-α and KC, which were accompanied by inhibition of the NF-κB-COX-2 axis. Although ACS induced ROS production was reduced in the lungs of NOX2−/y mice, inflammatory cell influx and expression of NF-κB/COX-2 were increased. Taken together, our results demonstrate for the first time that NOX isoforms 1, 2, 4 and 5 all remain activated in end-stage COPD patients, while NOX1 and NOX4 mediate oxidative stress and inflammatory responses in response to acute cigarette smoke. Therefore, targeting different isoforms of NOX might be necessary to treat COPD at different stages of the disease, which represents novel mechanistic insights enabling improved management of the devastating disease.

Comparing Outcomes of Single versus Double Lung Transplantation for COPD Patients in a Single-Center Setting

<h3>Purpose</h3> There is conflicting data whether single (SLT) or double (DLT) lung transplant is preferred for end-stage chronic obstructive pulmonary disease (COPD) patients. While national data shows that DLT is the method of choice, it is important re-assess this stance considering the current national organ shortage. The purpose of this study is to investigate whether SLT patients perform similarly to DLT patients in a single center setting. <h3>Methods</h3> We retrospectively identified COPD patients who underwent lung transplantation from 02/2012-05/2021 at our center (n=228). Clinical parameters were compared between the patients based on the type of transplant. Survival outcomes between the cohorts were compared using Kaplan Meier, as well as Cox proportional hazard regression. P-value <0.05 was significant. <h3>Results</h3> Of the 228 COPD patients, 81 (35.5%) received DLTs and 147 (64.5%) received SLTs. The difference in survival outcomes between patients receiving SLTs and DLTs was not significant (P = 0.265). The Cox model also did not show a significant difference in survival (P = 0.298). There was no significance in the distribution of transplant type by recipient body mass index, serum creatinine, serum albumin, or forced expiration volume at time of transplant. There was significance in the distribution of transplant type by recipient age (P = 0.017), recipient sex (P<0.001), recipient race (P = 0.049), lung allocation score (P<0.001), recipient height (P<0.001), mean pulmonary artery pressure (P = 0.002), surgical approach (P<0.001), induction (P = 0.043), donor sex (P = 0.030), donor height (P = 0.005), length of stay (P = 0.008), and forced vital capacity at transplant (P = 0.014). Patient age was the only variable to affect survival (HR = 5.60; P = 0.048). <h3>Conclusion</h3> Patients who received SLTs at our center did not show a significant difference in survival outcomes when compared to patients who received DLTs. This could suggest that SLT's may be the preferred method bearing in mind the current organ shortage.

Medical Management of Common Comorbidities in Elderly Patients with Proximal Femur Fractures

Objectives: Provide a framework for the medical treatment of patients with proximal femur fractures. Design: Literature review and evidence based note template. Intervention: Medical management of patient undergoing operative fixation of proximal femur fracture. Main outcome measurement: Perioperative morbidity. Results and conclusions: Proximal femur fractures are common orthopaedic injuries in the geriatric population and present with morbidity and portend mortality. The current evidence suggests that most patients should be surgically managed 24-48 hours from injury in accordance with patient preferences and medical risk stratification. Doing so is likely to improve postoperative outcomes and save both patients and hospital systems financial resources. After proper history and physical examination, imaging with plain radiographs is recommended, with MRI indicated in occult fractures. There are numerous cardiovascular, cognitive, and endocrinologic comorbidities that may delay or impact surgical treatment of hip fracture patients. This review discusses informed consent, cardiovascular implantable electronic devices, anticoagulation, preoperative cardiovascular evaluation, anemia, congenital heart disease, cerebrovascular accident, hyponatremia, diabetes mellitus, end-stage renal disease, osteoporosis, COVID-19 and chronic obstructive pulmonary disease, and history of bariatric surgery. A proper understanding of how these conditions affect hip fracture patients may help orthopaedic surgeons to expedite surgery safely and effectively and may also serve as a framework in the management of other fragility fractures in patients with comorbidities. Level of Evidence: IV, systematic review Keywords: Hip Fracture, Medical co-management, Geriatrics, Fragility fracture, Osteoporosis, Comorbidity, Comorbidity management, Anesthesia, Perioperative morbidity, Cardiovascular, Cerebrovascular, Renal disease, Surgical timing. (J Ortho Business 2022; Volume 2, Issue 2

Interaction between posaconazole and flucloxacillin in a lung transplant patient: decrease in plasma exposure of posaconazole and possible undertreatment of invasive aspergillosis: case report

BackgroundVariability in triazole plasma concentrations by drug interactions is well known. An interaction between voriconazole and flucloxacillin has already been described. In our case we observed a similar interaction between posaconazole and flucloxacillin, which in our knowledge has not ever been reported in literature.Case presentationA 60-year-old male who had a double lung transplantation for end-stage chronic obstructive pulmonary disease was being treated with voriconazole for invasive pulmonary aspergillosis (IPA). During this treatment he presented at the emergency room and was diagnosed with endocarditis for which a combination of amoxicillin, flucloxacillin and gentamicin was initiated. A known interaction between voriconazole and flucloxacillin was observed, with a drop of the voriconazole levels, and treatment for IPA was switched to posaconazole. After ending the treatment for endocarditis, the patient had a catheter infection for which flucloxacillin was reinitiated. Unexpectedly we saw a similar immediate drop in posaconazole levels, recovering after ending treatment with flucloxacillin.ConclusionsWe describe a new interaction between posaconazole and flucloxacillin. Presumably the underlying mechanism is activation of the pregnane X receptor by flucloxacillin, which can induce cytochrome P450, uridine glucuronosyl transferase (UGT1A4) and P-glycoprotein. We advise caution when combining flucloxacillin and triazoles, because interactions may lead to undertreatment of invasive aspergillosis.

Early death from COPD related to occupational exposure to gypsum dust:a case report

Chronic obstructive pulmonary disease (COPD) is considered as a fatal but a preventable disease. It occurs rather in the elderly and often after smoking intoxication over many years. However, it may strike younger people particularly, due to a complex interaction between genes and the environment. We report a case of a 34-year-old man, a former smoker with a history of occupational exposure to gypsum dust, who has been diagnosed with end-stage COPD. Tobacco smoke and occupational exposure to gypsum dust were thought to interact in the development and the progression of this early COPD. Thus, physicians must be aware of the potential occupational aetiologies for COPD and should consider them in patients particularly when it occurs at an early age.

OUTCOMES OF PALLIATIVE CARE HOSPITALIZATIONS DUE TO END STAGE COPD

TOPIC: Palliative Care and End of Life Issues TYPE: Original Investigations PURPOSE: Palliative care is increasingly utilized among terminal comorbid illnesses like end stage Chronic Obstructive Pulmonary Disease (COPD) in the past several years. There is no recent population-based data available regarding outcomes of palliative care among end stage COPD patients and factors associated with it. We aimed to estimate temporal trends of outcomes and predictors of poor outcomes among palliative care hospitalizations due to end stage COPD. METHODS: We identified adult hospitalizations due to end stage COPD by using International Classification of Diseases (9th/10th Editions) Clinical Modification (ICD-9-CM/ICD-10-CM) from the Nationwide Inpatient Sample (NIS) for the years 2007-2018. were identified. Palliative care encounters and other diagnosis of interests were identified by ICD-9/10-CM codes and comorbidities by Elixhauser comorbidity software. Our primary outcome was in-hospital mortality. We then utilized the Cochran Armitage trend test and multivariable survey logistic regression models to analyze temporal trends of outcomes. RESULTS: From 2007 to 2018 a total of 1,544,988 hospitalizations due to end stage COPD occurred, out of which 39,423 (2.6%) received palliative care. Among patients who received palliative care, overall In-hospital mortality was 23.2% and discharge to facilities was 27.1%. In trend analysis, in-hospital mortality has decreased (from 30.2% in 2007 to 18.6% in 2018; ptrend<0.01) and discharge to facilities increased (22.2% in 2007 to 29.2% in 2018; ptrend<0.01) among patients who received palliative care. In multivariable regression analysis after adjusting with confounding factors, rural hospital (OR 1.3; 95%CI 1.2 - 1.4; p<0.01), urban non-teaching (OR 1.2; 95%CI 1.1 - 1.3; p<0.01), uninsured/self-pay (OR 1.7; 95%CI 1.2 - 2.0; p<0.01), elective admission (OR 1.4; 95%CI 1.2 - 1.6; p<0.01) as well as concurrent conditions such as pneumonia, sepsis and other comorbidities were independently associated with higher in-hospital mortality among end stage COPD patients receiving palliative care. However African Americans vs Caucasians (OR 0.7; 95%CI 0.6 - 0.8; p<0.01), Mid-West region vs North-East region (OR 0.5; 95%CI 0.4 - 0.6; p<0.01) were associated with lower in-hospital mortality. CONCLUSIONS: We found that the in-hospital mortality rate among end stage COPD patients receiving palliative care has improved significantly between 2007-2018. Additionally, hospital teaching status, demographics, insurance status and secondary infections were associated with higher odds of mortality. CLINICAL IMPLICATIONS: Although in-hospital mortality in patients receiving palliative care during hospitalization due to end stage COPD has declined during the last decade, there are still several modifiable factors such as sociao demographics and hospital staus are associated with higher mortality. Our study highlights the need for better risk stratification and quality improvement in palliative care management of end stage COPD patients to further improve in-hospital outcomes. DISCLOSURES: No relevant relationships by Nawar Al janabi, source=Web Response No relevant relationships by Madiha Bari, source=Web Response No relevant relationships by Jasveen Kaur, source=Web Response No relevant relationships by Manmeet Kaur, source=Web Response No relevant relationships by Kinjalben Patel, source=Web Response No relevant relationships by Harshil Shah, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response No relevant relationships by Renan Soneghet, source=Web Response No relevant relationships by Astha Upadhyaya, source=Web Response

Diagnostic accuracy, sensitivity, and specificity of CT pulmonary artery to aorta diameter ratio in screening for pulmonary hypertension in end-stage COPD patients

AimTo determine the diagnostic accuracy of pulmonary artery to aorta ratio in screening for pulmonary hypertension in advanced chronic obstructive pulmonary disease (COPD) patients.MethodsA prospective, diagnostic study was conducted in University Hospital Center Zagreb between January 2015 and March 2018. The study enrolled 100 patients who consecutively underwent chest computed tomography (CT), echocardiographic exam, and right heart catheterization. Two independent observers measured pulmonary artery and ascending aorta diameters. The correlation between the ratio and mean pulmonary artery pressure, measured invasively, was assessed. Patients with echocardiographic signs of moderate systolic or diastolic left ventricular dysfunction were excluded (n = 44).ResultsSixty-six patients (55.5% men), with a median age of 61, were identified. Median forced expiratory volume during the first second (FEV1) was 34 ± 12, FEV1/forced vital capacity <0.70. Patients with and without pulmonary hypertension had pulmonary artery diameter of 36 ± 7 mm and 27 ± 4.6 mm, respectively (P < 0.001). Median pulmonary artery/aorta (PA/A) ratios for patients with and without pulmonary hypertension were 1.05 and 0.81, respectively (P < 0.001). PA/A ratio above 0.95 was an independent predictor of pulmonary hypertension with a specificity of 100% and a sensitivity of 74.51% (area under the curve = 0.882; standard error = 0.041; P < 0.001).ConclusionPA/A ratio as measured on chest CT images can be used as a screening tool instead of echocardiography.

Influence of an Acute Exacerbation During Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease Awaiting Lung Transplantation.

Pulmonary rehabilitation (PR) has been shown to be an effective intervention in patients with very severe chronic obstructive pulmonary disease (COPD) awaiting lung transplantation (LTx). The objective of this study was to characterize the prevalence of acute exacerbations (AEs) during PR and their impact on the outcomes of pre-LTx PR. In this retrospective analysis, 559 patients with COPD awaiting LTx who were referred to a 4-wk inpatient PR program were evaluated. A total of 114 patients (20%) acquired an AE during PR and continued in an adapted fashion. Pulmonary function testing, 6-min walk test (6MWT), and a health-related quality-of-life questionnaire (SF-36) were administered on admission and on discharge of PR. Following PR, both groups, patients with and without AE, increased their 6MWT significantly (P < .001) to a clinically relevant amount (58 ± 72 and 52 ± 64 m, respectively). The sum scores of the SF-36 also improved significantly without any between-group differences. No observed changes were different between the two groups. No relevant predictors for PR outcomes could be detected by logistic regression. Our data show that patients with end-stage COPD listed for LTx can achieve clinically relevant improvements in functional exercise capacity and quality of life even if they develop an AE during PR.

Comparing outcomes in patients with end-stage chronic obstructive pulmonary disease: single versus bilateral lung transplants.

Debate continues on whether a bilateral (BLT) or a single lung transplantation (SLT) is preferred for patients with end-stage chronic obstructive pulmonary disease (COPD). The purpose of this study is to examine the interplay between patient age and transplant type on survival outcomes. We performed a retrospective study of lung transplants for COPD at our centre from February 2012 to March 2020 (n = 186). Demographics and clinical parameters were compared between patients based on their age (≤65 vs >65 years old) and type of transplant (single vs bilateral). Cox proportional hazards regression was also performed. P-values <0.05 were considered significant. Of the 186 patients with COPD who received lung transplants, 71 (38.2%) received BLTs and 115 (61.8%) received SLTs. There was no significant difference in survival outcomes when looking at patients with single versus BLTs (P = 0.870). There was also no difference in survival between the 2 age groups ≤65 versus > 65 years (P = 0.723). The Cox model itself also did not show a statistically significant improvement in survival outcomes (P = 0.126). Lung transplant outcomes in patients with end-stage COPD demonstrated non-inferior results in patients with an SLT compared to patients with a BLT. When we compared the age groups, neither transplant type showed superior survival benefits, suggesting there may be some utility in an SLT in younger recipients.

Impact of Pulmonary Artery Pressure on Survival Outcome of Single- and Double-Lung Transplantation in Chronic Obstructive Pulmonary Disease Patients

<h3>Purpose</h3> It remains unclear whether double lung transplantation (DLT) or single lung transplantation (SLT) is preferred for end-stage chronic obstructive pulmonary disease (COPD) patients. The purpose of this study is to examine the interplay between patient age and pulmonary artery pressure on survival after SLT vs DLT for COPD. <h3>Methods</h3> We performed a single-center retrospective study of lung transplantations for COPD between February 2012 to March 2020 (n=186). Demographics and clinical parameters were compared between patients based on their pulmonary artery pressure (PAP; PAP<25 mmHg vs PAP≥25 mmHg) and type of transplantation (single vs. double). Additionally, survival based on age (≤65 vs. >65 years old) and PAP were analyzed using Kaplan-Meier curves and log-rank tests. Cox proportional-hazards regression was also performed. P-value less 0.05 was considered significant. <h3>Results</h3> Of the 186 COPD patients who received lung transplants, 71 (38.2%) received double-lung transplants and 115 (61.8%) received single-lung transplants. Demographics and clinical parameters between the two PAP groups showed significance in: lung allocation score (p=0.002) and BMI at time of transplant (p<0.001). There was no significant difference in survival outcomes between SLT vs. DLT patients (p=0.870). Patients with elevated pulmonary artery pressures (PAP≥25 mmHg) did not have significantly different survival outcomes from patients with normal pressures (PAP<25 mmHg; p=0.16). There was also no difference in survival between the two age groups, ≤65 vs. >65 years (p=0.723). The Cox model itself, also, did not show a statistically significant improvement in evaluating survival outcomes (p=0.126). <h3>Conclusion</h3> Lung transplantation outcomes in end-stage COPD patients demonstrated non-inferior results with SLT compared to DLT. When patients were differentiated based on PA pressure, adopting SLT or DLT did not show any survival differences.

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?