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    "textoCompleto" => "<p class="elsevierStylePara">Lung transplantation was pioneered more than 50 years ago by James Hardy and introduced into clinical practice in 1986&#44; by Joel Cooper and soon after&#44; by Alexander Patterson&#46; Since then&#44; and through constant improvements&#44; lung transplantation was offered to over 30&#160;000 patients worldwide&#44; establishing itself as the standard therapy for end-stage pulmonary disease&#46; Lung transplantation has allowed patients with chronic and terminal respiratory failure&#44; a significant improvement in their quality of life and prolonged survival&#46; Patients that are candidates to receive a new lung&#44; normally have a life expectancy that is inferior to 18 months&#44; and the mean survival after single or double lung transplantation is&#44; at the present&#44; well over 60&#37; at 3 years&#46;<a href="&#35;bib4" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara">Lung transplantation is&#44; without question&#44; a very complex surgical intervention&#46; Not only due to operative technical challenges&#44; but also due to the fact that chronic respiratory failure produces a dramatic impact on global physical condition of the transplant candidates&#44; inducing an extreme frailty&#44; and putting them at the highest surgical risk&#46; This is the reason why great care must be given on the selection of candidates&#44; in order to minimize peri-operative risk&#46;</p><p class="elsevierStylePara">But not only surgery is demanding &#8211; pre operative selection and optimization &#8211; be it for the nutrition status&#44; the physiotherapy&#44; the sterilization of infections and the general care&#44; at large&#44; that must all be pondered&#46; Post-operative care is&#44; equally&#44; challenging&#44; as these patients combine the need for respiratory optimization&#44; cardiac support&#44; renal function tuning&#44; and the most strict fluid balance&#46; Immediate post-operative results do translate this need for expertise&#44; compensating well for complexity&#44; with an early mortality that stays&#44; for us&#44; well below 10&#37;&#46;</p><p class="elsevierStylePara">Ischaemic and reperfusion lesions&#44; early after transplantation&#44; and infection versus rejection&#44; latter&#44; will threaten every post-operative period&#44; requiring constant surveillance&#44; requesting expertise and imposing frequent adjustments&#46; Later on&#44; chronic rejection&#44; leading to silent obliterating bronchiolitis&#44; will compromise functional capacity and ultimately affect late survival&#44; this in conjunction with the risk for neoplasms&#44; as for any chronically immune-depressed patients&#46;</p><p class="elsevierStylePara">Lung transplantation needs a multidisciplinary team that constantly interacts &#8211; that is to say&#44; needs a true interdisciplinary team&#44; comprising surgeons &#8211; thoracic and cardiac&#44; pulmonologists&#44; bronchology interventionists anaesthesiologists&#44; infectious diseases specialists&#44; nutrition and psychology specialists&#44; perfusion technicians&#44; nurses&#44; physiotherapists&#44; image specialists and all other supporting staff&#46; Different from other surgical endeavours&#44; lung transplantation is&#44; by no means&#44; a one man&#39;s show&#44; it is imperative team work&#33; This team requires volume&#44; and volume imposes the minimum of 15&#8211;20 cases&#44; yearly to provide enough expertise&#46;</p><p class="elsevierStylePara">Lung transplantation depends on suitable candidates&#44; operated within what is called the optimal &#8220;transplantation window&#8221;&#44; but also depends on suitable donors&#44; as it is well known that the lungs are&#44; possibly&#44; the most sensitive organs to preserve and keep in good conditions prior to transplant&#46; From all identified donors&#44; not more than 20&#37;&#44; at the very best&#44; will be suitable for lung donation&#46; Several strategies to increase the donor pool are being introduced &#8211; expanding criteria&#44; optimizing donor&#39;s general conditions and&#44; more recently&#44; ex vivo perfusion preservation&#44; non-beating heart donors and lobar donation&#44; are all being considered&#46; We have practiced all&#44; but the last two&#44; and the ex vivo perfusion is being developed for introduction into our practice in a very near future&#46; One thing is clear to all transplant specialists &#8211; there is no good lung transplantation without optimized donation&#44; this being one area that needs further focusing&#44; if the numbers and quality of transplantation are to be increased&#46;</p><p class="elsevierStylePara">There is one single centre performing lung transplantation in Portugal&#44; our centre&#46; This allows for experience concentration&#44; though being negatively considered by some for being an &#8220;orphan centre&#8221;&#46; For the first time this year&#44; and even more importantly than having celebrated the lung transplant number 100&#44; we will reach the magic mark of 20 lung transplants yearly&#44; not far from our estimated national needs&#46; However&#44; this number is arguable&#44; as there is also a great discrepancy for lung transplantation figures in Europe&#44; from 0&#46;2 per million to 6 per million&#8230;</p><p class="elsevierStylePara">At the moment&#44; 30 patients are on our waiting lung transplantation list and&#44; for them&#44; the mean time on the list is&#44; presently&#44; 250 days&#46; Our donor acceptance rate is 18&#37;&#44; a figure that is similar to other international centres&#44; but that hopefully will improve with the introduction of the ex vivo preservation techniques&#46; Having said that the yearly needs in Portugal may well be slightly over 20 cases&#44; we are convinced that&#44; more offer would create more need&#44; however&#44; one limitation would be the size of the pool of donors in Portugal&#44; that is already being utilized in full extent by our lung programme&#46;</p><p class="elsevierStylePara">So far&#44; 106 lung transplantations were performed at our centre&#44; this representing an acceptance rate of 24&#37; and a refusal rate of 57&#37;&#44; these due mainly to the presence of formal transplantation contra-indications&#46;</p><p class="elsevierStylePara">From those transplanted&#44; 45&#37; were double lungs&#44; mainly for infected lung diseases&#44; as cystic fibrosis or bronchiectasis&#44; or for concomitant pulmonary hypertension&#46; The majority of transplants &#40;53&#37;&#41; were performed due to parenchymal disorders&#44; as lung fibrosis&#46; The other diagnosis for lung transplantation was COPD in 22&#37;&#44; Cystic Fibrosis &#40;CF&#41; in 16&#37; and non-CF bronchiectasis in the remaining 9&#37;&#46;</p><p class="elsevierStylePara">Outcomes are remarkedly good&#44; once the learning curve was overcome&#44; showing now great stability of results&#58; At this moment in time&#44; 64&#37; of all patients that underwent a lung transplant at our centre are still alive&#44; with a median survival of 55&#46;5 months&#44; the longest survival in the series reaching 12 years&#46;</p><p class="elsevierStylePara">Lung transplantation survival curves &#40;Kaplan&#8211;Meier&#41; show a 3-month survival of 83&#46;5&#37; &#40;95&#37; CI 75&#8211;90&#41;&#44; a 12 months survival of 71&#46;3&#37; &#40;95&#37; CI 61&#8211;80&#41; and same values at 24&#44; 36 and 60 months are&#44; respectively&#44; 67&#37; &#40;95&#37; CI 56&#8211;76&#41;&#59; 56&#46;8&#37; &#40;95&#37; CI 44&#8211;68&#41; and 48&#46;5&#37; &#40;95&#37; CI 33&#8211;62&#41;&#46; These figures compare&#44; if I may say&#44; even favourably with those regularly published by the voluntary registry of the International Society of Heart &#38; Lung Transplantation&#46;<a href="&#35;bib5" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a></p><p class="elsevierStylePara">Lung transplantation is an expensive activity&#44; providing good&#44; though very expensive returns&#46; The direct cost for any transplanted patient is&#44; for us&#44; 79&#160;316&#46;07 &#8364; with the price of one QALY levelling at approximately three times the normal accepted for other considered as cost-effective medical interventions&#46;<a href="&#35;bib6" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> However&#44; the very favourable impacts on the quality of life of many of those patients&#44; among whom&#44; I might recall the youngsters with cystic fibrosis&#44; a cohort for which our transplantation mortality nearly approaches zero&#44; makes the team value their daily demanding work&#44; at the service of our national centre&#44; and say&#44; like Einstein &#8211; &#8220;<span class="elsevierStyleItalic">not everything that can be measured counts and not everything that counts can be measured&#8221;&#46;</span></p><hr></hr><p class="elsevierStylePara">&#9734; Please cite this article as&#58; Fragata J&#46; Lung transplantation in Portugal&#46; Rev Port Pneumol&#46; 2015&#59;21&#58;1&#8211;2&#46;</p>"
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Lung transplantation in Portugal
J.. Fragataa
a Serviço de Cirurgia Cardiotorácica, Hospital de Santa Marta, Cadeira de Cirurgia, Nova Medical School, Lisboa, Portugal
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    "textoCompleto" => "<p class="elsevierStylePara">Lung transplantation was pioneered more than 50 years ago by James Hardy and introduced into clinical practice in 1986&#44; by Joel Cooper and soon after&#44; by Alexander Patterson&#46; Since then&#44; and through constant improvements&#44; lung transplantation was offered to over 30&#160;000 patients worldwide&#44; establishing itself as the standard therapy for end-stage pulmonary disease&#46; Lung transplantation has allowed patients with chronic and terminal respiratory failure&#44; a significant improvement in their quality of life and prolonged survival&#46; Patients that are candidates to receive a new lung&#44; normally have a life expectancy that is inferior to 18 months&#44; and the mean survival after single or double lung transplantation is&#44; at the present&#44; well over 60&#37; at 3 years&#46;<a href="&#35;bib4" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara">Lung transplantation is&#44; without question&#44; a very complex surgical intervention&#46; Not only due to operative technical challenges&#44; but also due to the fact that chronic respiratory failure produces a dramatic impact on global physical condition of the transplant candidates&#44; inducing an extreme frailty&#44; and putting them at the highest surgical risk&#46; This is the reason why great care must be given on the selection of candidates&#44; in order to minimize peri-operative risk&#46;</p><p class="elsevierStylePara">But not only surgery is demanding &#8211; pre operative selection and optimization &#8211; be it for the nutrition status&#44; the physiotherapy&#44; the sterilization of infections and the general care&#44; at large&#44; that must all be pondered&#46; Post-operative care is&#44; equally&#44; challenging&#44; as these patients combine the need for respiratory optimization&#44; cardiac support&#44; renal function tuning&#44; and the most strict fluid balance&#46; Immediate post-operative results do translate this need for expertise&#44; compensating well for complexity&#44; with an early mortality that stays&#44; for us&#44; well below 10&#37;&#46;</p><p class="elsevierStylePara">Ischaemic and reperfusion lesions&#44; early after transplantation&#44; and infection versus rejection&#44; latter&#44; will threaten every post-operative period&#44; requiring constant surveillance&#44; requesting expertise and imposing frequent adjustments&#46; Later on&#44; chronic rejection&#44; leading to silent obliterating bronchiolitis&#44; will compromise functional capacity and ultimately affect late survival&#44; this in conjunction with the risk for neoplasms&#44; as for any chronically immune-depressed patients&#46;</p><p class="elsevierStylePara">Lung transplantation needs a multidisciplinary team that constantly interacts &#8211; that is to say&#44; needs a true interdisciplinary team&#44; comprising surgeons &#8211; thoracic and cardiac&#44; pulmonologists&#44; bronchology interventionists anaesthesiologists&#44; infectious diseases specialists&#44; nutrition and psychology specialists&#44; perfusion technicians&#44; nurses&#44; physiotherapists&#44; image specialists and all other supporting staff&#46; Different from other surgical endeavours&#44; lung transplantation is&#44; by no means&#44; a one man&#39;s show&#44; it is imperative team work&#33; This team requires volume&#44; and volume imposes the minimum of 15&#8211;20 cases&#44; yearly to provide enough expertise&#46;</p><p class="elsevierStylePara">Lung transplantation depends on suitable candidates&#44; operated within what is called the optimal &#8220;transplantation window&#8221;&#44; but also depends on suitable donors&#44; as it is well known that the lungs are&#44; possibly&#44; the most sensitive organs to preserve and keep in good conditions prior to transplant&#46; From all identified donors&#44; not more than 20&#37;&#44; at the very best&#44; will be suitable for lung donation&#46; Several strategies to increase the donor pool are being introduced &#8211; expanding criteria&#44; optimizing donor&#39;s general conditions and&#44; more recently&#44; ex vivo perfusion preservation&#44; non-beating heart donors and lobar donation&#44; are all being considered&#46; We have practiced all&#44; but the last two&#44; and the ex vivo perfusion is being developed for introduction into our practice in a very near future&#46; One thing is clear to all transplant specialists &#8211; there is no good lung transplantation without optimized donation&#44; this being one area that needs further focusing&#44; if the numbers and quality of transplantation are to be increased&#46;</p><p class="elsevierStylePara">There is one single centre performing lung transplantation in Portugal&#44; our centre&#46; This allows for experience concentration&#44; though being negatively considered by some for being an &#8220;orphan centre&#8221;&#46; For the first time this year&#44; and even more importantly than having celebrated the lung transplant number 100&#44; we will reach the magic mark of 20 lung transplants yearly&#44; not far from our estimated national needs&#46; However&#44; this number is arguable&#44; as there is also a great discrepancy for lung transplantation figures in Europe&#44; from 0&#46;2 per million to 6 per million&#8230;</p><p class="elsevierStylePara">At the moment&#44; 30 patients are on our waiting lung transplantation list and&#44; for them&#44; the mean time on the list is&#44; presently&#44; 250 days&#46; Our donor acceptance rate is 18&#37;&#44; a figure that is similar to other international centres&#44; but that hopefully will improve with the introduction of the ex vivo preservation techniques&#46; Having said that the yearly needs in Portugal may well be slightly over 20 cases&#44; we are convinced that&#44; more offer would create more need&#44; however&#44; one limitation would be the size of the pool of donors in Portugal&#44; that is already being utilized in full extent by our lung programme&#46;</p><p class="elsevierStylePara">So far&#44; 106 lung transplantations were performed at our centre&#44; this representing an acceptance rate of 24&#37; and a refusal rate of 57&#37;&#44; these due mainly to the presence of formal transplantation contra-indications&#46;</p><p class="elsevierStylePara">From those transplanted&#44; 45&#37; were double lungs&#44; mainly for infected lung diseases&#44; as cystic fibrosis or bronchiectasis&#44; or for concomitant pulmonary hypertension&#46; The majority of transplants &#40;53&#37;&#41; were performed due to parenchymal disorders&#44; as lung fibrosis&#46; The other diagnosis for lung transplantation was COPD in 22&#37;&#44; Cystic Fibrosis &#40;CF&#41; in 16&#37; and non-CF bronchiectasis in the remaining 9&#37;&#46;</p><p class="elsevierStylePara">Outcomes are remarkedly good&#44; once the learning curve was overcome&#44; showing now great stability of results&#58; At this moment in time&#44; 64&#37; of all patients that underwent a lung transplant at our centre are still alive&#44; with a median survival of 55&#46;5 months&#44; the longest survival in the series reaching 12 years&#46;</p><p class="elsevierStylePara">Lung transplantation survival curves &#40;Kaplan&#8211;Meier&#41; show a 3-month survival of 83&#46;5&#37; &#40;95&#37; CI 75&#8211;90&#41;&#44; a 12 months survival of 71&#46;3&#37; &#40;95&#37; CI 61&#8211;80&#41; and same values at 24&#44; 36 and 60 months are&#44; respectively&#44; 67&#37; &#40;95&#37; CI 56&#8211;76&#41;&#59; 56&#46;8&#37; &#40;95&#37; CI 44&#8211;68&#41; and 48&#46;5&#37; &#40;95&#37; CI 33&#8211;62&#41;&#46; These figures compare&#44; if I may say&#44; even favourably with those regularly published by the voluntary registry of the International Society of Heart &#38; Lung Transplantation&#46;<a href="&#35;bib5" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a></p><p class="elsevierStylePara">Lung transplantation is an expensive activity&#44; providing good&#44; though very expensive returns&#46; The direct cost for any transplanted patient is&#44; for us&#44; 79&#160;316&#46;07 &#8364; with the price of one QALY levelling at approximately three times the normal accepted for other considered as cost-effective medical interventions&#46;<a href="&#35;bib6" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> However&#44; the very favourable impacts on the quality of life of many of those patients&#44; among whom&#44; I might recall the youngsters with cystic fibrosis&#44; a cohort for which our transplantation mortality nearly approaches zero&#44; makes the team value their daily demanding work&#44; at the service of our national centre&#44; and say&#44; like Einstein &#8211; &#8220;<span class="elsevierStyleItalic">not everything that can be measured counts and not everything that counts can be measured&#8221;&#46;</span></p><hr></hr><p class="elsevierStylePara">&#9734; Please cite this article as&#58; Fragata J&#46; Lung transplantation in Portugal&#46; Rev Port Pneumol&#46; 2015&#59;21&#58;1&#8211;2&#46;</p>"
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