Citations

Abstract Despite increasing legalization and use of marijuana, there is no consensus among pediatric heart transplant institutions or providers regarding users' eligibility for cardiac transplant. We sent a survey to pediatric and ACHD transplant providers (physicians, surgeons, transplant coordinators, and pharmacists) assessing their current institution's policies and their personal opinions about marijuana use in patients being considered for heart transplantation. Of the respondents, 84% practice in the United States and Canada. Most providers (80%) care for both pediatric and ACHD patients. Respondents included cardiologists (77%) and surgeons (11%), with the remaining being coordinators and pharmacists. Most providers (73%) reported their institution had no policy regarding marijuana use in heart transplant candidates. Only 20% of respondents' institutions consider mode of consumption, with 87% and 53% approving of oral and transdermal routes, respectively, and only 7% approving of vaporized or smoked routes. While 73% of providers would consider illegal marijuana use an absolute/relative contraindication to heart transplant listing, the number decreases to 57% for legal recreational users and 21% for legal medical users. Most providers personally believe marijuana to be physically and mentally/emotionally harmful to pediatric patients (67% and 72%, respectively). Many institutions lack a policy regarding marijuana use in pediatric and ACHD heart transplant candidates, and there is considerable disagreement among providers on the best practice. With increasing legalization and use of marijuana, each institution will have to address this issue thoughtfully to continue to provide high‐quality, consistent, and equitable care for pediatric and ACHD heart transplant candidates.

AbstractObjectivesThere is interest in identifying chronic rhinosinusitis (CRS) endotypes that align pathophysiology with clinical observation and outcomes. CRS with polyps (CRSwNP) has classically been studied with reference to tissue eosinophilia, but the role of other cellular infiltrates remains uncharacterized. No particular tissue prognosticators have been described for CRS without nasal polyps (CRSsNP). Predominance of leukocytes seen in surgical tissue may be useful for differentiating CRS subtypes, severity of inflammation, and outcomes.MethodsStructured histopathology reports were examined for 277 patients undergoing endoscopic sinus surgery for CRSwNP (n = 115), CRSsNP (n = 141), and recurrent acute rhinosinusitis (RARS, n = 21). Inflammatory predominance was examined for associations with nasal polyposis, asthma, allergic rhinitis, aspirin exacerbated respiratory disease (AERD), immune deficiency, preoperative Lund‐Mackay score, and outcome (SNOT‐22 score change).ResultsIn order of frequency, the prevalence of predominant inflammatory patterns accounting for 93.5% of CRS patients were: lymphoplasmocytic (n = 111), lymphocytic (n = 74), eosinophilic (n = 50), and lymphoplasmocytic with eosinophilic (n = 24). Eosinophilic predominance was 97.4% specific for nasal polyps (95% confidence interval [CI], 93.4%‐99.3%), although sensitivity was 43.4% (95% CI, 33.8%‐53.4%). The absence of eosinophilic predominance was 100% sensitive for RARS (95% CI, 82.4%‐100%), however specificity was 30.8% (95% CI 25.1%‐37.1%). There were no significant differences in preoperative SNOT‐22 scores or change postoperatively.ConclusionsEosinophilic inflammatory predominance was predictive for nasal polyps and against RARS. Nevertheless, the majority of CRSwNP patients had a different inflammatory predominance, demonstrating heterogeneity in CRS, even among patients with nasal polyps. Symptomatic outcomes were not associated with inflammatory predominance through 12 months follow up.Level of Evidence4.

Purpose: Healthcare spending as a percentage of Gross domestic product (GDP) is at all-time high and continues to rise in the United States. The Centers for Medicare and Medicaid Services estimate that 33% of resources spent on healthcare goes to waste. As part of a ‘high value care’ exercise, we studied if estimating CD4 cell counts and HIV viral load in hospitalized patients with a known diagnosis of HIV led to any meaningful change in HAART regimen and discharge diagnosis. Methods: Retrospective chart review for all patients admitted with a known diagnosis of HIV from January 1, through December 31, 2017. Results: A total of 83 patient encounters were reviewed during the period. The mean age was 54.1 ± 16.4 years, 64.1 % of patients were males. 75 patients (90.3%) were already on highly active antiretroviral therapy (HAART). The median hospital length of stay (LOS) was 3 days (IQR 2.0 - 5.0). The mean turnaround time for CD4 counts and HIV viral load assay was 2.9 days (95% CI 2.1 – 3.7) and 3.9 days (95% CI, 3.2 – 4.6), respectively. A CD4 count estimation led to no change in HAART regimen. HIV viral load assay testing had no impact on a change in treatment or a change in diagnosis. Conclusions: In our study, testing CD4 counts and HIV viral load for inpatients did not confer any benefit in altering the diagnosis or HAART regimen. We believe that our study identifies a systems level opportunity to add to the concept of ‘Choosing Wisely.’