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Background Coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccines were authorized in the United States in December 2020. Although vaccine effectiveness (VE) against mild infection declines markedly after several months, limited understanding exists on the long-term durability of protection against COVID-19–associated hospitalization. Methods Case-control analysis of adults (≥18 years) hospitalized at 21 hospitals in 18 states 11 March–15 December 2021, including COVID-19 case patients and reverse transcriptase-polymerase chain reaction–negative controls. We included adults who were unvaccinated or vaccinated with 2 doses of a mRNA vaccine before the date of illness onset. VE over time was assessed using logistic regression comparing odds of vaccination in cases versus controls, adjusting for confounders. Models included dichotomous time ( Results A total of 10 078 patients were included, 4906 cases (23% vaccinated) and 5172 controls (62% vaccinated). Median age was 60 years (interquartile range, 46–70), 56% were non-Hispanic White, and 81% had ≥1 medical condition. Among immunocompetent adults, VE Conclusions In a period largely predating Omicron variant circulation, effectiveness of 2 mRNA doses against COVID-19–associated hospitalization was largely sustained through 9 months.

With the increased incidence and survival of lung transplant (LTx) recipients, the risk for chronic sequelae such as chronic kidney disease (CKD) is on the rise. Data on the long-term renal outcome are scarce. We performed a retrospective chart review of 171 adults with LTx from January 1, 2014, to January 1, 2019. Primary outcomes were prevalence of CKD/end-stage renal disease, acute kidney injury (AKI) as a risk factor for future CKD, and all-cause mortality in recipients with CKD compared with the non-CKD group. Secondary outcomes were frequency of utilization of modalities for CKD (urinalysis, imaging, biopsy, nephrology consultations). Baseline median creatinine and estimated glomerular filtration rate (eGFR) were 0.8 mg/dL and 90 mL/min/1.73 m2, respectively. Of the participants, 60% (96 of 161), 67% (102 of 153), 79% (37 of 47), 86% (10 of 12) had CKD at the end of 6, 12, 36, and 60 months, respectively, and 16% were on dialysis at the end of the study period; 3% received a subsequent renal transplant, and 27% mortality was noted over a 5-year follow-up period. The odds of CKD development in patients with an AKI during index hospitalization vs no AKI was 6.22 (2.87 to 13.06, P

Background The study objective was to evaluate 2- and 3-dose coronavirus disease 2019 (COVID-19) mRNA vaccine effectiveness (VE) in preventing COVID-19 hospitalization among adult solid organ transplant (SOT) recipients. Methods We conducted a 21-site case-control analysis of 10 425 adults hospitalized in March to December 2021. Cases were hospitalized with COVID-19; controls were hospitalized for an alternative diagnosis (severe acute respiratory syndrome coronavirus 2-negative). Participants were classified as follows: SOT recipient (n = 440), other immunocompromising condition (n = 1684), or immunocompetent (n = 8301). The VE against COVID-19-associated hospitalization was calculated as 1-adjusted odds ratio of prior vaccination among cases compared with controls. Results Among SOT recipients, VE was 29% (95% confidence interval [CI], −19% to 58%) for 2 doses and 77% (95% CI, 48% to 90%) for 3 doses. Among patients with other immunocompromising conditions, VE was 72% (95% CI, 64% to 79%) for 2 doses and 92% (95% CI, 85% to 95%) for 3 doses. Among immunocompetent patients, VE was 88% (95% CI, 87% to 90%) for 2 doses and 96% (95% CI, 83% to 99%) for 3 doses. Conclusions Effectiveness of COVID-19 mRNA vaccines was lower for SOT recipients than immunocompetent adults and those with other immunocompromising conditions. Among SOT recipients, vaccination with 3 doses of an mRNA vaccine led to substantially greater protection than 2 doses.

Lung transplant patients are vulnerable to various forms of allograft injury, whether from acute rejection (AR) (encompassing acute cellular rejection [ACR] and antibody-mediated rejection [AMR]), chronic lung allograft dysfunction (CLAD), or infection (INFXN). Previous research indicates that donor-derived cell-free DNA (dd-cfDNA) is a promising noninvasive biomarker for the detection of AR and allograft injury. Our aim was to validate a clinical plasma dd-cfDNA assay for detection of AR and other allograft injury and to confirm and expand on dd-cfDNA and allograft injury associations observed in previous studies.We measured dd-cfDNA fraction using a novel single-nucleotide polymorphism-based assay in prospectively collected plasma samples paired with clinical-pathologic diagnoses. dd-cfDNA fraction was compared across clinical-pathologic cohorts: stable, ACR, AMR, isolated lymphocytic bronchiolitis, CLAD/neutrophilic-responsive allograft dysfunction (NRAD), and INFXN. Performance characteristics were calculated for AR and combined allograft injury (AR + CLAD/NRAD + INFXN) versus the stable cohort.The study included 195 samples from 103 patients. Median dd-cfDNA fraction was significantly higher for ACR (1.43%, interquartile range [IQR]: 0.67%-2.32%,These results indicate that our dd-cfDNA assay detects AR and other allograft injury. dd-cfDNA monitoring, accompanied by standard clinical assessments, represents a valuable precision tool to support lung transplant health and is appropriate for further assessment in a prospective randomized-controlled study.

Acute kidney injury (AKI) is a common complication after lung transplantation (LT) and is associated with higher cost and mortality. We sought to evaluate the incidence of postoperative AKI, defined as AKI within 14 days of transplant, and identify associated perioperative factors.We conducted a single-center, retrospective review of 153 lung transplant recipients. Postoperative AKI was determined using the RIFLE (Risk, Injury, Failure, Loss, End Stage) criteria. Perioperative covariates and their association with postoperative AKI were analyzed using Cox proportional hazards. Kaplan-Meier survival curves were constructed to evaluate patient survival at 1 year and data finalization. A sub-analysis was performed evaluating factors associated with early AKI (within 48 h of transplant) and late AKI.Postoperative AKI occurred in 36.6% of patients with 51.8% of cases occurring within 48 h of LT. Recipient race, transplant type, cardiopulmonary support, and red blood cell administration were associated with postoperative AKI. Survival was significantly lower in patients with postoperative AKI following LT.Postoperative AKI within 2 weeks of lung transplant is associated with lower short- and long-term survival. Perioperative factors associated with postoperative AKI may be potential points of intervention to minimize AKI development in the future.

TOPIC: Transplantation TYPE: Fellow Case Reports INTRODUCTION: SARS-CoV2, commonly known as COVID-19, has been noted to manifest severe illness in certain patient populations. The clinical manifestations of this coronavirus in solid organ transplant recipients is just beginning to be described, and is not well understood. SARS-CoV2 and associated illness have been described in multiple patient populations, so far limited data has been published on the course of illness in lung transplant recipients. Here we present a case series of 26 patients who were unfortunately infected with SARS-CoV2. CASE PRESENTATION: We conducted a single-center, retrospective review of 26 lung transplant recipients infected with SARS-CoV2. Data collection and patient consent were covered by OSU IRB protocol. DISCUSSION: 15 of these patients (55.5%) required admission for hypoxemia, and 4 required intubation and mechanical ventilation. 1 patient required extracorporeal membrane oxygenation (ECMO). 46% (12/26) patients received dexamethasone and remdesivir, 27% (7/26) received convalescent plasma, 1 received hydroxychloroquine, and 2 received azithromycin as part of their treatments. Prior to COVID-19 infection all patients but 1 were on a standard triple immune suppression regimen with calcineurin inhibitors, steroids, and cell cycle inhibitors. Calcineurin dosing was decreased in 2 patients with severe COVID-19 and cell cycle inhibitors were reduced by 50% or held for 2 weeks 50% patients. 1 patient succumbed to COVID-19 ARDS despite ECLS support and a second 3 months after initial diagnosis due to a massive CVA. Mortality 3 months after initial diagnosis was 7.6% which is lower than other reported series. The average change in FEV1 was a loss of 0.52 liters. An average loss of 0.69 liters of FVC was noted in survivors. CONCLUSIONS: To our knowledge this is one of the largest currently reported case series of lung transplant recipients with SARS-CoV2. Overall, mortality was higher in this group than in the general population but at 7.6% 3 months after diagnosis is lowest of the single center reports published. As expected, a decrease in lung function was noted in survivors. Three was no general difference in lung function in patients who received certain treatments over others. REFERENCE #1: Tsuang WM, Budev MM. COVID-19 and lung transplant patients. Cleve Clin J Med. 2020. REFERENCE #2: Aigner C, Dittmer U, Kamler M, Collaud S, Taube C. COVID-19 in a lung transplant recipient. J Heart Lung Transplant. 2020;39(6):610-611. REFERENCE #3: Keller BC, Le A, Sobhanie M, et al. Early COVID-19 infection after lung transplantation. Am J Transplant. 2020;20(10):2923-2927. DISCLOSURES: No relevant relationships by Mena Botros, source=Web Response No relevant relationships by Molly Howsare, source=Web Response

Serotonin syndrome is a life-threatening condition caused by iatrogenic overactivation of 5HT1a and 5HT2a receptors characterized by the triad of encephalopathy, dysautonomia, and neuromuscular abnormalities. Although certain narcotics have been implicated, case reports related to fentanyl are scarce and the entire drug class is likely under-recognized as a potential precipitant in the clinical setting. We describe a postoperative patient who developed moderately severe serotonin syndrome while receiving a high-dose fentanyl infusion in the context of outpatient paroxetine therapy. The case was successfully managed by the withdrawal of the offending agents and treatment with cyproheptadine. We present a summary of the pathophysiology, diagnosis, and management of the serotonin syndrome.

Lung transplantation is a therapeutic option for patients with advanced lung diseases. Lung transplant outcomes have improved over time with improvements in the management of these complex patients. Cytomegalovirus is a common opportunistic organism affecting all solid organ transplant recipients. Characteristics unique to lung transplantation can make this virus difficult to manage, with myriad complications including graft failure and death. Ongoing research into and understanding of cytomegalovirus has opened exciting new avenues of management. We discuss the various manifestations of CMV related pathologies in the lung transplant recipient. We discuss current mainstays of risk stratification, diagnosis, and treatment, as well as present new and evolving concepts. Current medications are highly effective at preventing and treating CMV manifestations, but may be poorly tolerated. A new generation of therapies carry the promise of efficacy, with a greater safety profile and improved tolerance of adverse effects. We discuss host-virus immune interactions, specifically how these can be utilized in clinical practice to individualize the cytomegalovirus related care of lung transplant recipients. Finally, we turn our attention to the near horizon as we continue to evolve the care of this unique population.

Electronic learning, as the name implies, is a non-traditional form of teaching where the student is not always physically present in the same time or place as the educator. Today, this largely means using the Internet to provide students with educational materials, while attempting to deliver a more personal experience that is more suited to the student’s schedule and learning style. From the institution’s perspective, e-learning has allowed for increased access and capacity, diversified the student population, and thereby increased market share in the educational market. With the inherent importance of a high quality medical education, both undergraduate and graduate, many have advocated against e-learning citing lack of appropriate technology, discrepancy in instructional methodology, and lack of consistency in paradigmatic institutionalization of e-learning. The focus of this review is to assess such attitudes toward e-learning, and the efficacy and benefits of e-learning in anesthesiology resident education at present.