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155 Insurance and Education Predict Long-Term Survival after Orthotopic Heart Transplantation
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The Journal of Heart and Lung Transplantation, Vol 30, No 4S, April 2011
153
155
Transbronchial Lung Biopsy after Lung Transplantation: Different A and B Scores in Different Lobes P. Jaksch,1 A. Scheed,1 G. Dekan,2 S. Geleff,2 W. klepetko.1 1Thoraic Surgery, Medical University Vienna, Vienna, Austria; 2Division of Pathology, Medical University Vienna, Vienna, Austria.
Insurance and Education Predict Long-Term Survival after Orthotopic Heart Transplantation J.G. Allen,1 G.J. Arnaoutakis,1 E.S. Weiss,1 S.D. Russell,2 W.A. Baumgartner,1 A.S. Shah,1 J.V. Conte.1 1Surgery, Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; 2 Medicine, Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD.
Purpose: The use of transbronchial lung biopsy to monitor and diagnose acute cellular rejection in the lung allograft is a routine procedure in most TX centres. There is consensus in the minimum number of specimens being obtained and mostly biopsies are taken from more than one lobe. Are there differences in histological rejection grading at different anatomic sites? We examined our lung biopsy data from the last 10 years to investigate the distribution of rejection grading of the lung allograft monitored by TBLB. Methods and Materials: A retrospective study was done reviewing pathology files and slides of TBLBs performed on lung allograft recipients. In 99 patients 298 transbronchial biopsies were taken from more than one lobe and were histologically graded following ISHLT 1996 guidelines. Corresponding B scores were available in 207 investigated cases. Results: A-scores with identical grades were seen in 252 of 298 (85%) specimens, a single-grade difference was noted in 43 of 298 (14%) probes. Three cases demonstrated two grade differences on biopsies taken from two separate lobes (higher grade in the lower lobe). B-scores were identical in 160 of 207 (77%) specimens, a single-grade difference was noted in 45 of 207 (21%) cases. Two cases demonstrated 2 grade difference (higher grade in the lower lobe). Among cases with different grades of A and B scores, the “lower” lobes had a higher A grade in 55% (24/46) and a higher B grade in 59% (28/47). Type of TX or underlying disease had no influence on the distribution of histological grading. Conclusions: If limitations on the site for transbronchial biopsy exist, biopsies of the lower lobes appear more informative.
Purpose: Socioeconomic(SE) factors such as education and insurance are known to affect health outcomes. However, the importance of these factors for orthotopic heart transplant(OHT) recipients is unknown. The United Network for Organ Sharing(UNOS) database provides a large cohort to assess insurance and education in post-OHT survival. Methods and Materials: UNOS data were reviewed to identify adult primary OHT patients(pts)(1997-2008). Pts were stratified by insurance(Private/self pay, Medicare, Medicaid, other) and college education. All-cause mortality was examined in a multivariable Cox proportional hazard model using 15 variables. Survival was modeled via the Kaplan-Meier method.
154 Is Your Patient’s Sex Life Dysfunctional? Check the Prolactin Level! M.A. Malouf, R.F. Pearson, A. Fienes, A. Havryk, M. Plit, A.R. Glanville. The Lung Transplant Unit, St Vincents Hospital, Sydney, NSW, Australia. Purpose: Abnormal libido and erectile dysfunction are well recognised after lung transplantation, however galactorrhea is reported rarely. We assessed the incidence and mechanisms involved in the development of hyperprolactinemia as a cause of these symptoms. Methods and Materials: Prospective analysis of all prolactin levels performed at St.Vincent’s Hospital January 1989-October 2010, to determine specific treatable causes in our lung (n⫽ 613) and heart lung (n⫽ 79) transplant population. Results: Hyperprolactinemia was demonstrated on 55/99 (55.6%) prolactin levels obtained from 70 patients. High prolactin levels occurred in 14 females and 17 males, mean age 31⫾11 (17-54) and 42⫾16 (13-62) years respectively at 905⫾1247 (26-3968) days post transplant. Transplant indication was: cystic fibrosis n⫽12, emphysema n⫽ 8, idiopathic pulmonary fibrosis n⫽4, bronchiectasis n⫽2, others n⫽5. 10/14 females and 14/17 males were on domperidone 10mg QID. Other drugs implicated were respiridone n⫽1, citalopram n⫽1, and methyldopa n⫽1. 5/14 females developed galactorrhea and 8/14 amenorrhoea while 7/17 males developed gynecomastia and 6/17 erectile dysfunction. Investigations performed to exclude pituitary tumours were negative (CT head n⫽6, MRI: n⫽3). 8/10 females and 11/13 males ceased domperidone with significant resolution of symptoms. 2 patients were unable to tolerate cessation of domperidone and required concomitant treatment with bromocriptine. Conclusions: Domperidone was the dominant cause of hyperprolactinemia, mediated via antagonism of central dopamine receptors in the chemoreceptor trigger zone. Antihypertensive agents and some antidepressants also increase plasma prolactin, via the prolactin stimulating role of serotonin. Hyperprolactinemia results in significant impairment of quality of life after lung transplantation by causing reduced libido, erectile dysfunction and galactorrhea. Due to the nature of these symptoms the incidence is likely underestimated. Most cases respond to cessation of the causative agent.
Results: Of 20,676 pts, insurance type distributed as follows: 12,298(59.5%) private/self pay; 5,227(25.3%) Medicare; 2,320(11.2%) Medicaid; and 831(4.0%) other. 15,735 pts had a recorded education level(76.1% of total); 7,738(49.2%) had a college degree. 6,125(29.6%) pts died in 53⫾41 months of follow up(mortality incidence: 6.7 deaths/100 pt-yrs). Survival differed by insurance(Figure). Medicare and Medicaid pts had 8.6% and 10.0% lower 10yr survival, respectively, compared to private/self pay pts. Pts with a college education had 6.6% higher 10yr survival compared to those with a pre-college education. On multivariable analysis, college education decreased the risk of death by 11%; while, Medicare and Medicaid increased the risk of death by 18% and 33%, respectively (pⱕ0.001). Conclusions: Our study represents the largest cohort examining insurance and education in OHT pts. Medicare/Medicaid pts and those without a college education have higher short and long term mortality after OHT. This study points to a potential systems bias in the care of OHT pts with low SE status. 156 Demographic, Quality of Life, and Behavioral Predictors of LongTerm Survival after Heart Transplantation K.L. Grady,1 E. Wang,1 E. McGee,1 W. Cotts,2 P. McCarthy.1 1Surgery/ Cardiac Surgery, Northwestern University, Chicago, IL; 2 Medicine/Cardiology, Northwestern University, Chicago, IL. Purpose: Few studies have reported on non-clinical predictors of mortality after heart transplantation (HT). The purpose of this study was to determine demographic, quality of life (QOL), and behavioral predictors of mortality at 5-10 years after HT. Methods and Materials: The non-random sample of patients (pts), from a prospective, multi-site study of QOL after HT, was transplanted between 7/1/90 and 6/30/99 at 4 U.S. medical centers. Pts completed the QOL
The Journal of Heart and Lung Transplantation, Vol 30, No 4S, April 2011
153
155
Transbronchial Lung Biopsy after Lung Transplantation: Different A and B Scores in Different Lobes P. Jaksch,1 A. Scheed,1 G. Dekan,2 S. Geleff,2 W. klepetko.1 1Thoraic Surgery, Medical University Vienna, Vienna, Austria; 2Division of Pathology, Medical University Vienna, Vienna, Austria.
Insurance and Education Predict Long-Term Survival after Orthotopic Heart Transplantation J.G. Allen,1 G.J. Arnaoutakis,1 E.S. Weiss,1 S.D. Russell,2 W.A. Baumgartner,1 A.S. Shah,1 J.V. Conte.1 1Surgery, Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; 2 Medicine, Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD.
Purpose: The use of transbronchial lung biopsy to monitor and diagnose acute cellular rejection in the lung allograft is a routine procedure in most TX centres. There is consensus in the minimum number of specimens being obtained and mostly biopsies are taken from more than one lobe. Are there differences in histological rejection grading at different anatomic sites? We examined our lung biopsy data from the last 10 years to investigate the distribution of rejection grading of the lung allograft monitored by TBLB. Methods and Materials: A retrospective study was done reviewing pathology files and slides of TBLBs performed on lung allograft recipients. In 99 patients 298 transbronchial biopsies were taken from more than one lobe and were histologically graded following ISHLT 1996 guidelines. Corresponding B scores were available in 207 investigated cases. Results: A-scores with identical grades were seen in 252 of 298 (85%) specimens, a single-grade difference was noted in 43 of 298 (14%) probes. Three cases demonstrated two grade differences on biopsies taken from two separate lobes (higher grade in the lower lobe). B-scores were identical in 160 of 207 (77%) specimens, a single-grade difference was noted in 45 of 207 (21%) cases. Two cases demonstrated 2 grade difference (higher grade in the lower lobe). Among cases with different grades of A and B scores, the “lower” lobes had a higher A grade in 55% (24/46) and a higher B grade in 59% (28/47). Type of TX or underlying disease had no influence on the distribution of histological grading. Conclusions: If limitations on the site for transbronchial biopsy exist, biopsies of the lower lobes appear more informative.
Purpose: Socioeconomic(SE) factors such as education and insurance are known to affect health outcomes. However, the importance of these factors for orthotopic heart transplant(OHT) recipients is unknown. The United Network for Organ Sharing(UNOS) database provides a large cohort to assess insurance and education in post-OHT survival. Methods and Materials: UNOS data were reviewed to identify adult primary OHT patients(pts)(1997-2008). Pts were stratified by insurance(Private/self pay, Medicare, Medicaid, other) and college education. All-cause mortality was examined in a multivariable Cox proportional hazard model using 15 variables. Survival was modeled via the Kaplan-Meier method.
154 Is Your Patient’s Sex Life Dysfunctional? Check the Prolactin Level! M.A. Malouf, R.F. Pearson, A. Fienes, A. Havryk, M. Plit, A.R. Glanville. The Lung Transplant Unit, St Vincents Hospital, Sydney, NSW, Australia. Purpose: Abnormal libido and erectile dysfunction are well recognised after lung transplantation, however galactorrhea is reported rarely. We assessed the incidence and mechanisms involved in the development of hyperprolactinemia as a cause of these symptoms. Methods and Materials: Prospective analysis of all prolactin levels performed at St.Vincent’s Hospital January 1989-October 2010, to determine specific treatable causes in our lung (n⫽ 613) and heart lung (n⫽ 79) transplant population. Results: Hyperprolactinemia was demonstrated on 55/99 (55.6%) prolactin levels obtained from 70 patients. High prolactin levels occurred in 14 females and 17 males, mean age 31⫾11 (17-54) and 42⫾16 (13-62) years respectively at 905⫾1247 (26-3968) days post transplant. Transplant indication was: cystic fibrosis n⫽12, emphysema n⫽ 8, idiopathic pulmonary fibrosis n⫽4, bronchiectasis n⫽2, others n⫽5. 10/14 females and 14/17 males were on domperidone 10mg QID. Other drugs implicated were respiridone n⫽1, citalopram n⫽1, and methyldopa n⫽1. 5/14 females developed galactorrhea and 8/14 amenorrhoea while 7/17 males developed gynecomastia and 6/17 erectile dysfunction. Investigations performed to exclude pituitary tumours were negative (CT head n⫽6, MRI: n⫽3). 8/10 females and 11/13 males ceased domperidone with significant resolution of symptoms. 2 patients were unable to tolerate cessation of domperidone and required concomitant treatment with bromocriptine. Conclusions: Domperidone was the dominant cause of hyperprolactinemia, mediated via antagonism of central dopamine receptors in the chemoreceptor trigger zone. Antihypertensive agents and some antidepressants also increase plasma prolactin, via the prolactin stimulating role of serotonin. Hyperprolactinemia results in significant impairment of quality of life after lung transplantation by causing reduced libido, erectile dysfunction and galactorrhea. Due to the nature of these symptoms the incidence is likely underestimated. Most cases respond to cessation of the causative agent.
Results: Of 20,676 pts, insurance type distributed as follows: 12,298(59.5%) private/self pay; 5,227(25.3%) Medicare; 2,320(11.2%) Medicaid; and 831(4.0%) other. 15,735 pts had a recorded education level(76.1% of total); 7,738(49.2%) had a college degree. 6,125(29.6%) pts died in 53⫾41 months of follow up(mortality incidence: 6.7 deaths/100 pt-yrs). Survival differed by insurance(Figure). Medicare and Medicaid pts had 8.6% and 10.0% lower 10yr survival, respectively, compared to private/self pay pts. Pts with a college education had 6.6% higher 10yr survival compared to those with a pre-college education. On multivariable analysis, college education decreased the risk of death by 11%; while, Medicare and Medicaid increased the risk of death by 18% and 33%, respectively (pⱕ0.001). Conclusions: Our study represents the largest cohort examining insurance and education in OHT pts. Medicare/Medicaid pts and those without a college education have higher short and long term mortality after OHT. This study points to a potential systems bias in the care of OHT pts with low SE status. 156 Demographic, Quality of Life, and Behavioral Predictors of LongTerm Survival after Heart Transplantation K.L. Grady,1 E. Wang,1 E. McGee,1 W. Cotts,2 P. McCarthy.1 1Surgery/ Cardiac Surgery, Northwestern University, Chicago, IL; 2 Medicine/Cardiology, Northwestern University, Chicago, IL. Purpose: Few studies have reported on non-clinical predictors of mortality after heart transplantation (HT). The purpose of this study was to determine demographic, quality of life (QOL), and behavioral predictors of mortality at 5-10 years after HT. Methods and Materials: The non-random sample of patients (pts), from a prospective, multi-site study of QOL after HT, was transplanted between 7/1/90 and 6/30/99 at 4 U.S. medical centers. Pts completed the QOL