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The research aimed to measure and evaluate the impact of intellectual capital and governance on organizational performance for a sample of universities in Sulaymaniyah. Where intellectual capital is considered one of the most important assets of the organization, it also helps in adding a competitive advantage and investing these assets in light of the mechanisms and principles of governance, which is reflected in achieving high levels of performance and providing services with high quality. In order to achieve the objectives of the research and test its hypotheses, the primary and secondary data were relied upon and a questionnaire was designed. The two researchers used the statistical program (SPSS) to analyze the data. During the research, it was found that there is a significant effect of intellectual capital on improving performance and raising the efficiency of organizations through the application of governance rules and the exploitation of intellectual resources and assets. The two researchers also made a set of recommendations, the most important of which is to help teachers overcome weaknesses in their performance and enhance strengths by urging the research organizations to develop the capabilities of teachers and improve their performance through their participation in conferences, scientific seminars, and efficient and distinguished training programs

Patients with advanced lung disease can develop pulmonary hypertension and succumb to right ventricular failure/cor pulmonale. Patients with pulmonary hypertension owing to chronic lung disease, or World Health Organization group 3 pulmonary hypertension, are more limited and carry a high risk of mortality. Adjunctive therapies remain the cornerstones of treatment. Recent evidence suggests that inhaled pulmonary vasodilator therapy can be helpful in patients with pulmonary hypertension owing to interstitial lung disease. Lung transplantation may be the only life-saving option in select patients, whereas palliative care and hospice should be sought for those who are not candidates as the disease progresses.

Background Aberrations in the coagulation system have been implicated in the pathogenesis of interstitial lung disease (ILD). Anticoagulants have been proposed as a potential therapy in ILD; however, a randomized controlled trial examining warfarin as a treatment for IPF was terminated early due to increased death rates. This has led some to speculate that warfarin specifically may be harmful in ILD, and use of direct oral anticoagulants (DOACs) could result in superior outcomes. Research Question The goal of this study was to delineate the relationship between anticoagulation and outcomes in patients with ILD through an analysis of the Pulmonary Fibrosis Foundation Patient Registry. Study Design and Methods An analysis of all patients in the Pulmonary Fibrosis Foundation Patient Registry was performed. Patients were stratified into three groups: no anticoagulation, DOAC use, or warfarin use. Survival was analyzed by using both Kaplan-Meier curves and Cox proportional hazards models. Results Of 1,911 patients included in the analysis, 174 (9.1%) were given anticoagulants; 93 (4.9%) received DOACs, and 81 (4.2%) received warfarin. There was a twofold increased risk of death or transplant for patients receiving DOACS; for warfarin, the risk was over two and half times greater. DOACs were not associated with an increased risk of mortality following adjustment for confounding variables. However, even after adjustment, patients given the anticoagulant warfarin remained at increased risk of mortality. In patients with IPF, warfarin was associated with reduced transplant-free survival, but DOACs were not. There was no statistically significant difference in survival between those receiving warfarin and those receiving a DOAC. Interpretation The need for anticoagulation is associated with an increased risk for death or transplant in patients with ILD, in both the IPF and non-IPF population. Further research is required to determine if warfarin and DOACs present varying safety profiles in patients with ILD.

It has been suggested pleural effusions may develop in right heart failure in the absence of left heart disease. The incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension is uncertain. Patients with pulmonary arterial hypertension followed at our tertiary care center were reviewed. Survival was examined based on the subsequent development of a pleural effusion. A total of 191 patients with pulmonary arterial hypertension met the inclusion criteria. The prevalence of pleural effusions on initial assessment was 7.3%. Among patients without a pleural effusion on initial imaging and at least one follow-up computerized tomography ( N = 142), pleural effusion developed in 27.5% ( N = 39) of patients. No alternative etiology of the effusion was identified in 19 (48.7%) cases and effusions deemed related to pulmonary arterial hypertension occurred at an incident rate of 38.6 cases per 1000 person-years. Of these, 14 (73.7%) were bilateral, 3 (15.8%) were right-sided, and 2 (10.5%) were left-sided. Effusion size was trace or small in 18 patients (94.7%). Development of a new pleural effusion was associated with attenuated survival in unadjusted survival analysis (HR: 3.80; 95% CI: 1.55–9.31), multivariate analysis (HR: 5.13; 95% CI: 1.86–14.16), and after the multivariate model was adjusted for concomitant pericardial effusion (HR: 4.86; 95% CI: 1.51–15.71). Negative impact on survival remained unchanged when effusions more likely related to an alternative cause were removed from analysis. In conclusion, pleural effusions can complicate pulmonary arterial hypertension in the absence of left heart disease. These effusions are frequently small in size, bilateral in location, and their presence is associated with decreased survival. Attenuated survival appears independent of the risk associated with a new pericardial effusion.

Rationale: Video-assisted thoracoscopic surgery (VATS) remains the gold standard for interstitial lung disease (ILD) characterization when histology is deemed necessary. There is diminishing utiliz...

The global need for energy has grown in tandem with mankind’s development and spread. This has resulted in an increase in the use of fossil energy sources, a decline in these sources and an increase in pollution, necessitating the search for renewable energy sources. One of the important ways to reduce pollution resulting from the increasing consumption of fossil energy is to enhance the sources of solar energy, of which photovoltaic cells (PV) are one of its most important tools. Therefore, it was necessary to pay attention to improving its efficiency for it to become a promising source of clean energy. PVs turn solar energy into electricity; however, the amount of electricity generated decreases as the temperature of the cells rises in response to the sun’s heat. Cooling of the optical surfaces is one of the most important elements to consider while running solar PV systems to obtain maximum efficiency. The electrical efficiency of PVs is enhanced when suitable cooling technology is used, and the rate of cell breakdown is reduced over time, extending the life of the PV panels. There are many materials used to remove unwanted heat in PV cells, and in recent years, the focus has been on integrating nanomaterials in specific proportions with traditional cooling materials such as water to improve their thermal properties. As a bio-material that is environmentally friendly, renewable, sustainable, inexpensive and has high mechanical properties, cellulose nanocrystals (CNCs) are one of the most promising materials for improving the properties of cooling materials for cooling PV cells and improving their performance.

Case Presentation We present the case of a 48-year-old South African woman with no smoking history, and seropositive rheumatoid arthritis diagnosed in 2001. She was treated with chloroquine (150 mg, 4 times per week) and methotrexate (30 mg weekly) with well-controlled symptoms until 2015, when she developed a disease flare. Her treatment regimen was changed to leflunomide (20 mg daily) monotherapy with subsequent symptom control. Biologic agents were not accessible because of cost constraints.

Group 3 pulmonary hypertension (PH) is a broad category of PH caused by chronic lung diseases (CLD) including chronic obstructive pulmonary disease (COPD), diffuse parenchymal lung diseases (DPLD), sleep disordered breathing, chronic exposure to high altitudes and developmental abnormalities. It is the second most common type after group 2 PH which is secondary to left heart disease or pulmonary venous hypertension. Clinical features of group 3 PH are often difficult to discern from the signs and symptoms of the primary lung disease and most of the time, symptoms out of proportion to the severity of lung disease prompts evaluation for group 3 PH. In most patients with group 3 PH, the mean pulmonary artery pressure (mPAP) is usually mildly elevated. However, it is invariably associated with reduced functional ability, impaired quality of life, greater oxygen requirements and an increased risk of mortality. Transthoracic echocardiography is the best screening test to evaluate for underlying PH. Right heart catheterization (RHC) is the gold standard test for confirmation and is performed when significant PH is suspected and the patient's management will likely be influenced by the RHC results. Treatment of group 3 PH can be divided into four major categories- primary, adjunctive, PH-specific and treatment of refractory disease. Treatment of the primary lung disease is the most important aspect but supportive therapy including supplemental oxygen and pulmonary rehabilitation are also very essential. The role of pulmonary vasodilators in group 3 PH is still unclear and large, randomized controlled trials are in dire need.

The number of waitlisted lung transplant candidates exceeds the availability of donor organs. Barriers to utilization of donor lungs include suboptimal lung allograft function, long ischemic times due to geographical distance between donor and recipient, and a wide array of other logistical and medical challenges. Ex vivo lung perfusion (EVLP) is a modality that allows donor lungs to be evaluated in a closed circuit outside of the body and extends lung donor assessment prior to final acceptance for transplantation. EVLP was first utilized successfully in 2001 in Lund, Sweden. Since its initial use, EVLP has facilitated hundreds of lung transplants that would not have otherwise happened. EVLP technology continues to evolve and improve, and currently there are multiple commercially available systems, and more under investigation worldwide. Although barriers to universal utilization of EVLP exist, the possibility for more widespread adaptation of this technology abounds. Not only does EVLP have diagnostic capabilities as an organ monitoring device but also the therapeutic potential to improve lung allograft quality when specific issues are encountered. Expanded treatment potential includes the use of immunomodulatory treatment to reduce primary graft dysfunction, as well as targeted antimicrobial therapy to treat infection. In this review, we will highlight the historical development, the current state of utilization/capability, and the future promise of this technology.

Background Coronavirus disease 2019 (COVID-19) requiring hospitalization is characterized by robust antibody production, dysregulated immune response, and immunothrombosis. Fostamatinib is a novel spleen tyrosine kinase inhibitor that we hypothesize will ameliorate Fc activation and attenuate harmful effects of the anti-COVID-19 immune response. Methods We conducted a double-blind, randomized, placebo-controlled trial in hospitalized adults requiring oxygen with COVID-19 where patients receiving standard of care were randomized to receive fostamatinib or placebo. The primary outcome was serious adverse events by day 29. Results A total of 59 patients underwent randomization (30 to fostamatinib and 29 to placebo). Serious adverse events occurred in 10.5% of patients in the fostamatinib group compared with 22% in placebo (P = .2). Three deaths occurred by day 29, all receiving placebo. The mean change in ordinal score at day 15 was greater in the fostamatinib group (-3.6 ± 0.3 vs -2.6 ± 0.4, P = .035) and the median length in the intensive care unit was 3 days in the fostamatinib group vs 7 days in placebo (P = .07). Differences in clinical improvement were most evident in patients with severe or critical disease (median days on oxygen, 10 vs 28, P = .027). There were trends toward more rapid reductions in C-reactive protein, D-dimer, fibrinogen, and ferritin levels in the fostamatinib group. Conclusion For COVID-19 requiring hospitalization, the addition of fostamatinib to standard of care was safe and patients were observed to have improved clinical outcomes compared with placebo. These results warrant further validation in larger confirmatory trials. Clinical Trials Registration Clinicaltrials.gov, NCT04579393.

The impact of hospitalization on patient outcomes is increasingly recognized and considered in the prognostication of many pulmonary disorders. We sought to evaluate the impact of hospitalization on survival in connective tissue disease-interstitial lung disease (CTD-ILD) patients.A chart review of patients with CTD-ILD followed at a tertiary care center was performed. Patients were stratified into two groups based on hospitalization status. Outcomes of the groups were compared using Kaplan-Meier survival analyses as well as multivariate competing risk analysis.There were 137 patients identified with confirmed CTD-ILD. Patients who underwent hospitalization for any reason had a significant decrease in transplant-free survival compared to the never hospitalized cohort (3-year survival 60% vs. 94%; p = 0.0001). Hospitalization for ≥7 days was associated with worse outcomes than those hospitalized for7 days (median survival 1.59 years vs. 7.17 years, p = 0.0012). Based on multivariate competing risk analysis, factors associated with death, with lung transplantation as a competing risk, were age (HR = 1.05 [95% 1.01-1.09]; P = 0.0443), male gender (HR = 4.94 [95% CI: 1.58-15.41]; P = 0.006), and all cause hospitalization (HR = 11.97 [95% CI: 1.36-105.49]; P = 0.0253).This study highlights the impact of hospitalization on subsequent outcomes in the CTD-ILD population with a significantly reduced transplant-free survival demonstrated, especially after cardiopulmonary hospitalization events.

Rationale:The outbreak of COVID-19 in March of 2020 led to the emergent search for treatment options. Passive immune therapy with COVID-19 convalescent plasma (CCP) therapy was utilized as an investigational therapy. We designed an open label study and received an investigational new drug (IND) number from the Food and Drug Administration for the study on April 11, 2020. Methods:Patients with severe COVID-19 were enrolled and identical ABO CCP was administered. CCP was collected from recovered COVID-19 patients by our hospital blood donor services in line with FDA guidelines. Patients could receive up to three doses of CCP and each dose came from a different donor to potentiate therapeutic response. Subjects were followed for 28 days after infusion of COVID-19 convalescent plasma (CCP) in hospital or with weekly phone calls if discharged home. Results:45 patients received CCP through the study period of April 24th through August 21st. The median age was 60 (range: 16-87), and two thirds were male (n=30) with Hispanic predominance (58%). Patients also received supplemental therapies such as remdesivir, tocilizumab, dexamethasone, and inhaled nitric oxide. Twenty-six recipients received 1 dose, 12 received 2 doses, and 7 received 3 doses of CCP all of which were collected internally by the hospital blood donor center. 22 recipients were O positive, 17 were A positive, and 6 were B positive. During their hospital course, 18 patients were on mechanical ventilation, 3 of which were on ECMO, 19 were on high-flow nasal cannula, and 8 were on low-flow nasal cannula as the highest level of oxygen therapy. At the 28 day follow up, 14 patients were deceased (31%), 4 (9%) were still hospitalized, and 27 (60%) were discharged home. Two patients had a suspected transfusion related reaction that resolved with supportive care including diphenhydramine and furosemide. Conclusion:We designed and implemented a pragmatic study to provide a treatment option for patients hospitalized with COVID-19. Sixty percent of our very sick study population survived to hospital discharge and there were only two transient infusion reactions. While larger studies with a control group are necessary to more clearly evaluate the benefit of CCP in COVID-19, our study lays the foundation for the rapid implementation of a Convalescent Plasma Program for possible future pandemics as a bridge to vaccine and therapeutic trials.

Rationale: Interpreting the radiologic data in conjunction with an objective clinical score could help to harmonize idiopathic pulmonary fibrosis (IPF) diagnosis and improve accuracy. Objectives: We sought to establish and validate a multivariable objective scoring model based on clinical parameters by stratifying the risk of patients having IPF diagnosed versus having other forms of interstitial lung disease (ILD) diagnosis. Methods: A clinical score was derived from review of patients evaluated at the Inova Fairfax ILD Program and validated in three distinct cohorts. On the basis of known IPF clinical characteristics, a multivariable model was created and assessed by using receiver operating characteristic curves. Results: There were 844 patients with ILD with either IPF (n = 347, 41%) or non-IPF ILD (n = 497, 59%) diagnosis. On the basis of calculated odds ratios, a score was assigned to each of the following clinical parameters: age, sex, smoking history, race or ethnicity, ILD family history, exposures, presence of connective tissue disease signs or symptoms, and velcro crackles. The final Fairfax IPF Clinical Score (FICS) ranged from 1 to 25. The clinical diagnostic score system was accurate in predicting IPF, as measured by the area under the curve (0.88) in the derivation cohort, with similar areas under the curve of 0.91, 0.81, and 0.71 being demonstrated in the respective validation cohorts. Conclusions: The FICS appears to be an accurate tool for estimating the pretest probability of IPF in patients with ILD. How the FICS performs in conjunction with the various high-resolution computed tomographic patterns remains to be determined. This model could ultimately be useful for increasing the degree of confidence in the final diagnosis and could help to obviate the need for lung biopsy in cases with non-usual interstitial pneumonia patterns on high-resolution computed tomographic images., Philippe Foundation; Assistance Publique-Hopitaux de Paris, Supported by Assistance Publique-Hopitaux de Paris and the Philippe Foundation funding (J.P.).

Strongyloides stercoralis infection derived from the donor in solid organ transplant (SOT) places recipients at risk for hyperinfection syndrome and death. We describe the case of a lung transplant recipient who developed strongyloidiasis presenting with GI symptoms and progressing to diffuse alveolar hemorrhage, bacteremia and multi-organ failure. The patient’s clinical course illustrates the life cycle of Strongyloides. For treatment, the patient received ivermectin and albendazole. We advocate that early diagnosis and treatment, prior to hyperinfection, are essential in management in SOT. These rarer donor-derived infections need to remain in the differential, especially given the expanding landscape of the donor population.

PurposeThe outcomes of patients requiring invasive mechanical ventilation for COVID-19 remain poorly defined. We sought to determine clinical characteristics and outcomes of patients with COVID-19 managed with invasive mechanical ventilation in an appropriately resourced US health care system.MethodsOutcomes of COVID-19 infected patients requiring mechanical ventilation treated within the Inova Health System between March 5, 2020 and April 26, 2020 were evaluated through an electronic medical record review.Results1023 COVID-19 positive patients were admitted to the Inova Health System during the study period. Of these, 165 (16.1%) were managed with invasive mechanical ventilation. At the time of data censoring, 63/165 patients (38.1%) had died and 102/165 (61.8%) were still alive. Of the surviving 102 patients, 17 (10.3%) remained on mechanical ventilation, 51 (30.9%) were extubated but remained hospitalized, and 34 (20.6%) had been discharged. Deceased patients were older (median age of 66 vs. 55, p ConclusionMortality of patients with COVID-19 requiring invasive mechanical ventilation is high, with particularly daunting mortality seen in patients of advanced age, even in a well-resourced health care system. A substantial proportion of patients requiring invasive mechanical ventilation were not of advanced age, and this group had a reasonable chance for recovery.

Aberrations in the coagulation system have been implicated in the pathogenesis of interstitial lung disease (ILD). Anticoagulants have been proposed as a potential therapy in ILD; however, a randomized controlled trial examining warfarin as a treatment for IPF was terminated early due to increased death rates. This has led some to speculate that warfarin specifically may be harmful in ILD, and use of direct oral anticoagulants (DOACs) could result in superior outcomes.The goal of this study was to delineate the relationship between anticoagulation and outcomes in patients with ILD through an analysis of the Pulmonary Fibrosis Foundation Patient Registry.An analysis of all patients in the Pulmonary Fibrosis Foundation Patient Registry was performed. Patients were stratified into three groups: no anticoagulation, DOAC use, or warfarin use. Survival was analyzed by using both Kaplan-Meier curves and Cox proportional hazards models.Of 1,911 patients included in the analysis, 174 (9.1%) were given anticoagulants; 93 (4.9%) received DOACs, and 81 (4.2%) received warfarin. There was a twofold increased risk of death or transplant for patients receiving DOACS; for warfarin, the risk was over two and half times greater. DOACs were not associated with an increased risk of mortality following adjustment for confounding variables. However, even after adjustment, patients given the anticoagulant warfarin remained at increased risk of mortality. In patients with IPF, warfarin was associated with reduced transplant-free survival, but DOACs were not. There was no statistically significant difference in survival between those receiving warfarin and those receiving a DOAC.The need for anticoagulation is associated with an increased risk for death or transplant in patients with ILD, in both the IPF and non-IPF population. Further research is required to determine if warfarin and DOACs present varying safety profiles in patients with ILD.

Idiopathic pulmonary fibrosis (IPF) is a fatal age-associated disease with no cure. Although IPF is widely regarded as a disease of aging, the cellular mechanisms that contribute to this age-associated predilection remain elusive. In this study, we sought to evaluate the consequences of senescence on myofibroblast cell fate and fibrotic responses to lung injury in the context of aging. We demonstrated that nonsenescent lung myofibroblasts maintained the capacity for dedifferentiation, whereas senescent/IPF myofibroblasts exhibited an impaired capacity for dedifferentiation. We previously demonstrated that the transcription factor MyoD acts as a critical switch in the differentiation and dedifferentiation of myofibroblasts. Here, we demonstrate that decreased levels of MyoD preceded myofibroblast dedifferentiation and apoptosis susceptibility in nonsenescent cells, whereas MyoD expression remained elevated in senescent/IPF myofibroblasts, which failed to undergo dedifferentiation and demonstrated resistance to apoptosis. Genetic strategies to silence MyoD restored the susceptibility of IPF myofibroblasts to undergo apoptosis and led to a partial reversal of age-associated persistent fibrosis in vivo. The capacity for myofibroblast dedifferentiation and subsequent apoptosis may be critical for normal physiologic responses to tissue injury, whereas restricted dedifferentiation and apoptosis resistance in senescent cells may underlie the progressive nature of age-associated human fibrotic disorders. These studies support the concept that senescence may promote profibrotic effects via impaired myofibroblast dedifferentiation and apoptosis resistance, which contributes to myofibroblast accumulation and ultimately persistent fibrosis in aging.

Idiopathic pulmonary fibrosis (IPF) treatment was revolutionized by the advent of two novel antifibrotics, nintedanib and pirfenidone. However, neither is a panacea and other agents are still sorely needed. This review presents on-going efforts to improve outcomes for patients with IPF by targeting novel pharmacologic pathways, improving comorbidity management, and aiming for improved quality of life. Areas covered: We provide an overview of on-going basic and clinical science efforts focused on development of additional drug therapies for patients with IPF. Known and emerging pathogenic pathways such as the microbiome and pulmonary vasculature hold promise as targets for therapy. While the focus remains on pharmacologic intervention, the impact of comorbidities and their management may also impact patient outcomes significantly. Supportive care with pulmonary rehabilitation, oxygen therapy, and palliative care remain integral at various stages of the disease course. Finally, lung transplant is the only lifesaving intervention for patients with end-stage fibrosis. Expert commentary: Future investigation should aim to prevent the initial insult or injury that engages the multiple pathways associated with the development and progression of IPF. Targeted therapies represent just one management aspect with a multidisciplinary approach necessary for the global holistic care of these complex patients.

Introduction L’interpretation des donnees radiologiques en association avec les donnees cliniques pourrait ameliorer la precision diagnostique dans la fibrose pulmonaire idiopathique (FPI). Dans cette hypothese, nous avons souhaite mettre en place un score base sur des parametres cliniques permettant d’evaluer la probabilite de FPI chez des patients se presentant pour le bilan d’une pneumopathie interstitielle diffuse (PID). Methodes Le modele de score clinique etait etabli par analyse des dossiers de patients s’etant presentes entre 2012 et 2019 au Inova Advanced Lung Disease Program (Fairfax, Virginie, USA) pour une PID. Seuls les patients avec un diagnostic etabli avec un haut degre de confiance et en accord avec les recommandations internationales sur la FPI ou les autres PID etaient inclus. 8 parametres cliniques etaient retenus pour la mise en place du modele. Le modele multivarie etait etabli par analyse des caracteristiques de la courbe ROC puis ensuite teste dans trois cohortes de validations internationales differentes. Resultats 844 patients atteints de PID et qui presentaient un diagnostic classable entre FPI (347, 41 %) ou PID non-FPI (497, 59 %) ont ete evalues pendant cette periode. Sur la base de rapports de cote calcules pour 8 parametres cliniques suivants, un index chiffre etait assigne a chaque variable: âge ( 80: +4), sujet masculin (+3), antecedent de tabagisme (+2), Caucasien (+2), antecedent familial de PID (+5), exposition respiratoire (−1), signe de connectivite (−3), crepitants velcro (+4). Le score final etait obtenu par addition des points et variait de −5 a 20. Ce score clinique presentait une precision diagnostique evaluee par l’aire sous la courbe (ASC) de 0,88. Un score de 5 points ou moins etait associe a une probabilite de FPI de 4 %, un score de 6–10: 29 %, 11–15: 75 % et > 15: 97 %. Les caracteristiques de la courbe ROC etaient comparable dans les cohortes internationales de validation (n = 694 patients, ASC: 0,87). Conclusion Ce modele de score clinique apparait comme un outil precis et simple pour estimer la probabilite pretest de FPI parmi les patients avec une PID. Son impact utilise en conjonction avec l’imagerie reste a determiner. Ce modele pourrait in fine etre utile pour augmenter le degre de confiance dans le diagnostic final, homogeneiser les DMD, diminuer le nombre de cas « inclassable » ou eviter le recours a une biopsie pulmonaire si la probabilite pretest de FPI etait elevee.

Background Cytomegalovirus (CMV) infection is common in thoracic organ transplant recipients. Valganciclovir and ganciclovir are used for both prophylaxis and treatment of this infection, but intolerance and treatment failure are common. Letermovir has been demonstrated to reduce the risk of CMV infection when used for prophylaxis in allogeneic hematopoietic cell transplantation. However, there are no data on its efficacy in thoracic organ transplantation. Methods We examined the use of letermovir for either CMV prophylaxis (primary and secondary) or treatment in heart and lung transplant recipients at our institution from February 1, 2018, through December 31, 2018. Results Nine total patients received letermovir at our institution (8 lung transplant, 1 heart transplant) during the study period. Letermovir was prescribed for CMV prophylaxis in eight patients (primary prophylaxis in two patients and secondary prophylaxis in 6 patients), and for treatment of CMV DNAemia in two cases. One patient received letermovir for both secondary prophylaxis and treatment on separate occasions. Three out of 8 (37.5%) patients receiving letermovir for prophylaxis developed CMV DNAemia during prophylaxis. One patient treated for CMV disease had clinical failure with a sharp rise in serum CMV DNA PCR. The other patient treated for low-grade CMV DNAemia initially had a slight rise in CMV DNA PCR, but has since had a sustained response. No major side effects were experienced, and 2 patients reported minor side effects. Conclusion Letermovir was well tolerated with only minor side effects reported; however, the rate of development of CMV DNAemia on prophylaxis was considerable. Further study of the dosing and efficacy of letermovir for CMV prophylaxis or treatment in thoracic organ transplant recipients is warranted.

Purpose Tracheostomy (trach) placement after lung transplantation (LTx) may be required in patients with prolonged ventilator dependence. However, little research exists on predictors and outcomes for recipients with post-LTx trachs. We examined baseline data and compared short and intermediate term patient outcomes with and without post-LTx trachs. Methods Baseline data, short/long term outcomes from patients s/p LTx performed between 1/1/12 and 6/31/19 who required trach during the index hospitalization were evaluated and compared with the trach-free cohort. Results Compared to trach-free patients, the trach cohort patients were younger (51.6±13.6 vs. 56.9±10.8, p=0.034) and had a higher mean lung allocation score (LAS) (66.6±22.8 vs. 55.2±20.7, p=0.014). They were more likely to be inpatient at time of LTx (54.2% vs 32.1%, p=0.035), had a bilateral LTx (60.8% vs 35.9%, p=0.001) and require extracorporeal life support (ECLS) pre- (16.7% vs. 1.9%, p=0.0005) and post-LTx (16.7% vs. 0.6%, p=0.001). Trach cohort patients had longer mechanical ventilation (p=0.0001) and hospital length of stay (HLOS) (p=0.0001). More patients in the trach cohort required acute rehab on discharge (p=0.0016). Although index in-hospital mortality of the trach cohort was higher (16.7% vs 2.5%, p=0.013), there was no difference in 1 year mortality (16.7% vs 8.3%, p=0.229) c/w trach-free cohort. There was significantly reduced long-term survival in trach patients (Fig.1) with limited follow up. Conclusion LTx recipients requiring post-op trach appear to be sicker, as evidenced by higher LAS and greater ECLS use pre-LTx. Trach cohort had longer duration of mechanical ventilation, post-op HLOS and discharge to acute rehabilitation. In our study, the need for post-LTx trach was associated with increased short term mortality. Although 1 year post-LTx mortality was similar between the groups, long term survival was worse in trach cohort with larger and longer studies needed.

INTRODUCTION Limited evidence exists regarding use of inhaled nitric oxide (iNO) in spontaneously breathing patients. We evaluated the effectiveness of continuous iNO via high-flow nasal cannula (HFNC) in COVID-19 respiratory failure. METHODS We performed a multicenter cohort study of patients with respiratory failure from COVID-19 managed with HFNC. Patients were stratified by administration of iNO via HFNC. Regression analysis was used to compare the need for mechanical ventilation and secondary endpoints including hospital mortality, length of stay, acute kidney injury, need for renal replacement therapy, and need for extracorporeal life support. RESULTS A total of 272 patients were identified and 66 (24.3%) of these patients received iNO via HFNC for a median of 88 h (interquartile range: 44, 135). After 12 h of iNO, supplemental oxygen requirement was unchanged or increased in 52.7% of patients. Twenty-nine (43.9%) patients treated with iNO compared to 79 (38.3%) patients without iNO therapy required endotracheal intubation ( P = .47). After multivariable adjustment, there was no difference in need for mechanical ventilation between groups (odds ratio: 1.53; 95% confidence interval [CI]: 0.74-3.17), however, iNO administration was associated with longer hospital length of stay (incidence rate ratio: 1.41; 95% CI: 1.31-1.51). No difference was found for mortality, acute kidney injury, need for renal replacement therapy, or need for extracorporeal life support. CONCLUSION In patients with COVID-19 respiratory failure, iNO delivered via HFNC did not reduce oxygen requirements in the majority of patients or improve clinical outcomes. Given the observed association with increased length of stay, judicious selection of those likely to benefit from this therapy is warranted.

Introduction Il n’existe pas d’echelle consensuelle pour evaluer la gravite de la maladie dans la fibrose pulmonaire idiopathique (FPI) bien qu’a ce titre, l’alteration fonctionnelle basee sur les epreuves fonctionnelles respiratoires (EFR) soit frequemment utilisee. Le but de cette etude etait de decrire les caracteristiques cliniques, fonctionnelles et evolutives des patients FPI presentant une alteration severe de leur fonction respiratoire. Methodes Tous patients presentant une FPI avec un deficit severe de sa fonction respiratoire, defini par un CVF ≤ 50 % et/ou une DLco ≤ 30 % de la theorique, evalue et pris en charge au Inova Advanced Lung Disease Program (Fairfax, Virginie, USA) entre 2011 et 2019 etaient inclus dans cette etude. Leurs caracteristiques demographiques, fonctionnelles ainsi que leur evolution et traitements etaient recueillis. Resultats 531 patients avec une FPI ont ete evalues durant cette periode parmi lesquels 185 (35 %) presentaient une alteration severe de leur fonction respiratoire a leur premiere visite (CVF ≤ 50 % et/ou DLco ≤ 30 %), tandis que 58 autres (11 %) franchissaient cette limite durant le suivi. L’âge moyen etait de 72 ± 8 ans ; la CVF initiale etait de 53 ± 17 % et la DL CO de 28 ± 9 % de la theorique. La distance moyenne au test de marche de 6 minutes (T6 M) etait de 304 ± 121 metres. 59 % des patients necessitaient une oxygenotherapie (groupe T6 M O2). On observait une faible correlation entre la distance parcourue au T6 M et la CVF % ou la DLco %. Les patients du groupe T6 M AA avaient une meilleure survie sans transplantation que ceux du groupe T6 M O2 (p = 0,002). Les patients pris en charge avant la disponibilite des antifibrosants (et non traites par ces molecules) presentaient un moins bon pronostic (diminution de la survie sans transplantation) que ceux traites par l’une des deux molecules antifibrosantes (n = 113) (log rank p Conclusion Les patients atteints de FPI evoluent frequemment vers une alteration severe de leur fonction respiratoire et celle-ci est faiblement correlee avec leur performance au T6 M. L’evaluation de la severite au cours de la FPI ne devrait pas uniquement se baser sur les capacites fonctionnelles, mais devrait egalement tenir compte du T6 M ainsi que de la necessite d’une oxygenotherapie additionnelle. L’utilisation des traitements antifibrosants dans cette population est associee a une amelioration du pronostic.