Faculty Bibliography

Patient and graft survival are similar following whole versus split liver transplants (SLT) among pediatric and adult recipients, yet SLTs are rarely used. We sought to determine the survival benefit associated with accepting a splittable offer for SLT versus declining and waiting for a subsequent offer using 2010-2018 SRTR data on 928 pediatric and 1814 adult LT candidates who were ever offered a splittable graft. We compared eventual mortality, regardless of subsequent transplants, between those who accepted versus declined a splittable liver offer with adjustment for PELD/MELD, diagnosis, and weight among pediatric candidates, and matching for MELD, height, and offer among adult candidates. Among pediatric candidates ≤7kg, splittable offer acceptance versus decline was associated with a 63% reduction in mortality (aHR _0.17 0.37_0.80 , p=0.01; 93.1% versus 84.0% one-year survival post-decision). Within one year of decline for those ≤7kg, 6.4% died and 31.1% received a whole liver transplant. Among pediatric candidates >7kg, there was no significant difference associated with acceptance of a splittable offer (aHR _0.63 1.07_1.82 , p=0.81; 91.7% vs 94.4% one-year survival post-decision). Within one year of decline for those >7kg, 1.8% died and 45.8% received a whole liver. Among adult candidates, splittable offer acceptance was associated with a 43% reduction in mortality (aHR _0.39 0.57_0.83, p=0.005; 92.2% vs 84.4% one-year survival post-decision). Within one year of decline for adult candidates, 7.9% died and 39.3% received a whole liver. Conclusion: Accepting splittable offers for SLT could significantly improve survival for small children and adults on the waitlist.

BACKGROUND:The association between exposure to air pollution and papillary thyroid carcinoma is unknown. We sought to estimate the relationship between long-term exposure to the fine (diameter ≤ 2.5 μm) particulate matter component of air pollution and the risk of papillary thyroid cancer. METHODS:Adult (age ≥18) patients with newly diagnosed papillary thyroid carcinoma between January 1, 2013 and December 31, 2016 across a single health system were identified using electronic medical records. Data from 1,990 patients with papillary thyroid carcinoma were compared with 3,980 age- and sex-matched control subjects without any evidence of thyroid disease. Cumulative fine (diameter <2.5 μm) particulate matter exposure was estimated by incorporating patients' residential zip codes into a deep learning neural networks model, which uses both meteorological and satellite-based measurements. Conditional logistic regression was performed to assess for association between papillary thyroid carcinoma and increasing fine (diameter ≤2.5 μm) particulate matter concentrations over 1, 2, and 3 years of cumulative exposure preceding papillary thyroid carcinoma diagnosis. RESULTS:n = 0.04). Among current smokers (n = 623), the risk of developing papillary thyroid carcinoma was highest (adjusted odds ratio = 1.35, 95% confidence interval: 1.12-1.63). CONCLUSION/CONCLUSIONS:Increasing concentration of fine (diameter ≤2.5 μm) particulate matter in air pollution is significantly associated with the incidence of papillary thyroid carcinoma with 2 and 3 years of exposure. Our novel findings provide additional insight into the potential associations between risk factors and papillary thyroid carcinoma and warrant further investigation, specifically in areas with high levels of air pollution both nationally and internationally.

BACKGROUND:In older adults (≥65) access to and outcomes following kidney transplantation (KT) have improved over the past three decades. It is unknown if there were parallel trends in re-KT. We characterized the trends, changing landscape, and outcomes of re-KT in older adults. METHODS:Among the 44,149 older kidney-only recipients (1995-2016) in the Scientific Registry of Transplant Recipients, we identified 1,743 who underwent re-KT. We analyzed trends and outcomes (mortality, death-censored graft failure [DCGF]) by eras (1995-2002, 2003-2014 and 2015-2016) that were defined by changes to the ECD and KDPI policies. RESULTS:Among all older kidney-only recipients during 1995-2002, 2003-2014, 2015-2016 the proportion that were re-KTs increased from 2.7%-4.2%-5.7% p<0.001, respectively. Median age at re-KT (67-68-68, p=0.04), years on dialysis after graft failure (1.4-1.5-2.2, p=0.003), donor age (40.0-43.0-43.5, p=0.04), proportion with PRA 80-100 (22.0%-32.7%-48.7%, p<0.001) and donations after circulatory death (1.1%-13.4%-19.5%, p<0.001) have increased. Despite this, the 3-year cumulative incidence for mortality (22.3%-19.1%-11.5%, p=0.002) and DCGF (13.3%-10.0%-5.1%, p=0.01) decreased over time. Compared with deceased donor re-transplant recipients during 1995-2002, those during 2003-2014 and 2015-2016 had lower mortality hazard (aHR=0.78, 95%CI:0.63-0.86 and aHR=0.55, 95%CI:0.35-0.86, respectively). These declines were noted but not significant for DCGF and in living donor re-KTs. CONCLUSIONS:In older re-transplant recipients, outcomes have improved significantly over time despite higher risk profiles; yet they represent a fraction of the KTs performed. Our results support increasing access to re-KT in older adults; however, approaches to guide the selection and management in those with graft failure need to be explored.

BACKGROUND:Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) occurs in critically ill patients with COVID-19. Risks and outcomes remain poorly understood. METHODS:A retrospective cohort study of mechanically ventilated adult patients with COVID-19 admitted to 5 Johns Hopkins hospitals was conducted between March and August 2020. CAPA was defined using composite clinical criteria. Fine and Gray competing risks regression was used to analyze clinical outcomes and, multilevel mixed-effects ordinal logistic regression was used to compare longitudinal disease severity scores. RESULTS:In the cohort of 396 people, 39 met criteria for CAPA. Patients with CAPA were more likely than those without CAPA to have underlying pulmonary vascular disease (41% vs 21.6%, respectively; P = .01), liver disease (35.9% vs 18.2%; P = .02), coagulopathy (51.3% vs 33.1%; P = .03), solid tumors (25.6% vs 10.9%; P = .02), multiple myeloma (5.1% vs 0.3%; P = .03), and corticosteroid exposure during the index admission (66.7% vs 42.6%; P = .005), and had lower body mass indexes (median, 26.6 vs 29.9 [calculated as weight in kilograms divided by height in meters squared]; P = .04). Patients with CAPA had worse outcomes, as measured by ordinal severity of disease scores, requiring longer time to improvement (adjusted odds ratio, 1.081.091.1; P < .001), and advancing in severity almost twice as quickly (subhazard ratio, 1.31.82.5; P < .001). They were intubated twice as long as those without CAPA (subhazard ratio, 0.40.50.6; P < .001) and had longer hospital stays (median [interquartile range], 41.1 [20.5-72.4) vs 18.5 [10.7-31.8] days; P < .001). CONCLUSION:CAPA is associated with poor outcomes. Attention to preventive measures (screening and/or prophylaxis) is warranted in people with high risk of CAPA.