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Background: In January 2014, states expanded Medicaid access under the Affordable Care Act. We studied the financial implications of this policy on lung transplantation, a costly procedure. Methods: Lung transplant (LT) hospitalizations were identified within the National Inpatient Sample (2005–2020). Recipients were categorized as "pre‐expansion" (1/2005–12/2013) versus "post‐expansion" (1/2014–12/2020) of Medicaid and as being in "expander" versus "non‐expander" regions. We calculated difference‐in‐differences estimates comparing pre‐ and post‐expansion eras in expander versus non‐expander regions for inflation‐adjusted hospitalization costs and for discharge disposition. We evaluated total hospitalization costs using multivariable generalized linear regression, adjusting for recipient demographics, Charlson Comorbidity Index, single versus double‐lung transplant, and extracorporeal membrane oxygenation (ECMO), ex‐vivo lung perfusion (EVLP), and mechanical ventilation usage. Results: Of the 29 225 LT recipients identified, 14 085 were pre‐expansion and 15 140 were post‐expansion. More recipients were insured by Medicaid in expander n = 735 (9%) versus non‐expander n = 220, (3%) regions (p = 0.01) post‐expansion. Hospitalization costs increased post‐ versus pre‐expansion by $20 948 (95% CI = $8713–$33 183, p < 0.001) more in expander versus non‐expander regions even after adjustment for risk factors associated with increased costs. Within expander regions, recipients post‐ versus pre‐expansion were less likely to be discharged routinely (n = 2625, 28% vs. n = 3959, 44%) and more likely to be discharged to care facilities (n = 2045, 22% vs. n = 1045, 12%, p < 0.001). Conclusions: Although Medicaid expansion resulted in greater access to care, it was associated with increased hospitalization costs and fewer routine discharges for LT recipients. Further research is warranted to identify the reasons that underpin the financial sequelae of Medicaid expansion, including changes in access to care for sicker patients. [ABSTRACT FROM AUTHOR]

Stroke is a well‐characterized complication of isolated heart and lung transplantation, but has not been described in combined heart‐lung transplantation (HLTx). We retrospectively reviewed national U.S. data to describe the incidence, risk factors, and impact of postoperative stroke in HLTx recipients. Of 871 heart‐lung recipients between 1994–2022, 35 (4.0%) experienced stroke, and the incidence increased over time, trending toward significance (p‐trend =.07). After adjustment, extracorporeal membrane oxygenation (ECMO) (Adjusted odds ratio [aOR] = 2.63, 95%CI = [1.13–6.11]) and pre‐transplant implantable defibrillator (aOR = 2.86, 95%CI = [1.20–6.81]) were independent risk factors for stroke. Postoperative stroke is common and is increasing in an era where organ allocation is driven by mechanical circulatory support (MCS) bridging. [ABSTRACT FROM AUTHOR]

Lung transplantation is accepted as a well‐established and effective treatment for patients with end‐stage lung disease. While the number of candidates added to the waitlist continues to rise, the number of transplants performed remains limited by the number of suitable organ donors. Ex vivo lung perfusion (EVLP) emerged as a method of addressing the organ shortage by allowing the evaluation and potential reconditioning of marginal donor lungs or minimizing risks of prolonged ischemic time due to logistical challenges. The currently available FDA‐approved EVLP systems have demonstrated excellent outcomes in clinical trials, and retrospective studies have demonstrated similar post‐transplant survival between recipients who received marginal donor lungs perfused using EVLP and recipients who received standard criteria lungs stored using conventional methods. Despite this, widespread utilization has plateaued in the last few years, likely due to the significant costs associated with initiating EVLP programs. Centralized, dedicated EVLP perfusion centers are currently being investigated as a potential method of further expanding utilization of this technology. In the preclinical setting, potential applications of EVLP that are currently being studied include prolongation of organ preservation, reconditioning of unsuitable lungs, and further enhancement of already suitable lungs. As adoption of EVLP technology becomes more widespread, we may begin to see future implementation of these potential applications into the clinical setting. [ABSTRACT FROM AUTHOR]

Alveolar hypoxia (AH) induces widespread systemic inflammation. Previous studies have shown dissociation between microvascular P[O.sub.2] and inflammation. Furthermore, plasma from AH rats (PAHR) induces mast cell (MC) activation, inflammation, and vasoconstriction in normoxic cremasters, while plasma from normoxic rats does not produce these responses. These results suggest that inflammation of AH is triggered by a blood-carried agent. This study investigated the involvement of the renin-angiotensin system (RAS) in the inflammation of AH. Both an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin II (ANG II) receptor blocker (ANG II RB) inhibited the leukocyte-endothelial adherence produced by AH, as well as the inflammation produced by PAHR in normoxic rat cremasters. MC stabilization with cromolyn blocked the effects of PAHR but not those of topical ANG II on normoxic cremasters, suggesting ANG II generation via MC activation by PAHR. This was supported by the observation that ACE inhibition and ANG II RB blocked the leukocyte-endothelial adherence produced by the MC secretagogue compound 48/80. These results suggest that the intermediary agent contained in PAHR activates MC and stimulates the RAS, leading to inflammation, and imply an RAS role in AH-induced inflammation. microcirculation; mast cells doi:10.1152/ajpheart.00981.2006

Background: Potential lung transplant (LTx) recipients are assigned a donor sequence number (DSN) based on their position on the match list. Since a higher DSN offer has already been declined for other recipients, some providers may assume that a high DSN connotates poorer allograft quality. This study evaluated the association between DSN and outcomes, the correlation between transplant program case volume and the utilization of higher DSN lungs, and whether LTx outcomes differ between lower- and higher-volume programs., Methods: Using the Scientific Registry of Transplant Recipients database, LTx cases from 2015-2021 were retrospectively reviewed. Recipients were categorized into low (<20), medium (21-50), high (51-100), and very high (>100) DSN groups. The primary outcome was LTx survival. For cases involving high or very high DSN donors, a subgroup analysis compared survival among programs with annual transplant volumes in the bottom, middle two, and top quartiles., Results: Median survival was similar among the low (6.9 years), medium (6.1), high (5.9), and very high DSN (6.5) groups (log-rank p=0.09). Higher DSN donors were more commonly accepted by higher-volume lung transplant centers. However, the annual case volume of the transplanting institution did not impact survival when high (log-rank p=0.16) or very high DSN (log-rank p=0.36) donors were used., Conclusions: Higher DSN should not be considered an independent marker of low allograft quality. Additionally, lower-volume centers achieved similar post-transplant outcomes as higher-volume centers for recipients receiving higher DSN lungs. These findings underscore that surgeons must judge each donor offer independent of other programs' assessments., (Copyright © 2024. Published by Elsevier Inc.)

Background: Non-intubated extracorporeal membrane oxygenation (ECMO) has become an increasingly common method of support for patients with severe respiratory failure. Since data on its use as a bridge to lung transplant remain limited to single-center studies, we evaluated its use in a national cohort., Methods: Adult lung-only transplant recipients bridged with ECMO 5/4/2005-3/8/2023 in the United Network for Organ Sharing database were categorized by use of ECMO and mechanical ventilation at transplant (ECMO+MV vs. ECMO-only). We compared post-transplant intubation and ECMO at 72 hours using logistic regression, length of stay using negative binomial regression, and post-transplant survival using Cox regression., Results: The 1,599 transplants identified included 902 (56.4%) bridged with ECMO+MV and 697 (43.6%) bridged with ECMO-only. ECMO-only recipients had higher median age (52 vs. 49 years, p<0.001), shorter ischemic times (5.7 vs. 6.0 hours, p=0.003), and similar lung allocation scores (89.5 vs. 89.6, p=0.11). ECMO-only recipients had lower likelihood of intubation at 72 hours (56.5% vs. 77.5%; aOR 0.33 [95% CI: 0.25, 0.42], p<0.001) and shorter lengths of stay (28 vs. 35 days; coefficient -0.19 [95% CI: -0.27, -0.11], p<0.001). ECMO-only recipients had higher 90-day survival (92.1% vs. 89.1%; aHR 0.69 [95% CI: 0.48, 0.99], p=0.04) but similar 1-year (83.1% vs. 81.5%; aHR 0.87 [95% CI: 0.67, 1.12], p=0.27) and 5-year (54.6% vs. 54.7%; aHR 0.98 [95% CI: 0.82, 1.17], p=0.83) survival., Conclusions: Non-intubated ECMO bridge to lung transplant was associated with improved perioperative outcomes and short-term survival and should be considered for candidates requiring ECMO., (Copyright © 2024. Published by Elsevier Inc.)

Background: Fifteen reports of bowel necrosis in patients receiving jejunal feeding have been reported. Etiology remains unexplained., Methods: A patient with a 60% burn receiving jejunostomy tube feeding developed hypernatremia and was given distilled water in the jejunum, 400 mL every 2 hours. One week later, he developed an acute abdomen with abdominal distention. At operation, he had 4 L of cloudy fluid containing jejunal feeding. Three large duodenal perforations were present. The jejunostomy site was normal. In an animal study, water or normal saline (0.85% NaCl) were infused into the mid small bowel, and sections of bowel were taken 5 minutes later for histologic study., Results: Animal study of the effect of water in the rat intestine revealed disruption of intestinal epithelium. It is suggested that disruption of epithelium by electrolyte-free water may permit digestion of the bowel wall and result in perforation, as was observed in this patient. This mechanism may have been responsible for some of the cases reported in the literature., Conclusions: Tap or distilled water may injure intestinal epithelium and should not be infused directly into the small bowel as jejunal feeding.