The Journal of Thoracic and Cardiovascular Surgery

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1 Accepted Manuscript Commentary: Failing Grades Jacob A. Klapper, MD PII: S (19) DOI: Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 2 March 2019 Accepted Date: 4 March 2019 Please cite this article as: Klapper JA, Commentary: Failing Grades, The Journal of Thoracic and Cardiovascular Surgery (2019), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 Commentary: Failing Grades Jacob A. Klapper MD 1 1 Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina Dr. Klapper has no potential conflict of interest Word Count: 365 Address correspondence to Dr. Jacob Klapper, Division of Cardiothoracic Surgery, DUMC 3954, Durham NC 27710, Jacob.klapper@duke.edu Central Message: Flawed methods of judgement have significant downstream implications.

3 1 2 The Innocence Project is a network of lawyers and volunteers who over the last 25 years have dedicated themselves to the exoneration of the wrongfully accused and convicted. Through diligent work, these individuals have shown how prosecutorial misdeeds, unreliable witnesses, and even pseudo-science have led many men to spend decades of their lives in prison. One such client, Timothy Bridges, spent 25 years in jail for a crime that he did not commit and whose original conviction was based largely on the imperfect science of hair analysis. Now free, due DNA evidence, Mr. Bridges case is a prime example of how our reliance on flawed instruments for measuring and deciding outcomes can have dire consequences. The manuscript by Schwarz, et al presents a compelling analysis of how our current criteria for measuring primary graft dysfunction is just as flawed as say hair analysis. 1 Not only do the authors demonstrate how infrequently experienced chest radiologists agree on film interpretation when they don t know relevant clinical data, but they also show how consensus does not improve when they do have more insight. In addition, they further show how in cases of patients with low P/F ratios (<200 mmhg), the variability in chest film interpretation can yield significant fluctuations in PGD scoring. In the end, while the inadequacy of this scoring system may not rise to the level of deciding a single man s fate, the current method for measuring PGD forms the foundation for a large body of literature that assesses risk factors for graft dysfunction and its long term implications (i.e. survival). 2 What s more, its use as a primary study endpoint has led to the recent FDA approval of an expensive portable ex vivo lung perfusion device. 3 In any field of science, whether it be forensics or medical science, there is as much value in work that questions perceived wisdom as there is in the discovery of new knowledge. This is particularly 23 true when conclusions are being drawn and crimes adjudicated based on methodology that is

4 24 25 dependent on a human being s subjective analysis. When light is shined upon these errors in judgement, as the authors do here, we bend a bit closer to the ultimate goal truth

5 Schwarz S, Muckenhuber M, Benazzo A, et al. Inter-Observer Variability Impairs Radiological Grading of Primary Graft Dysfunction after Lung Transplantation. JTCVS Diamond J, Lee J, Kawut S, et al. Clinical Risk Factors for Primary Graft Dysfunction after Lung Transplantation. AJRCC 2013;187: Warneck G, Raemdonck D, Smith M, et al. Normothermic ex-vivo preservation with the portable Organ Care System Lung device for bilateral lung transplantation (INSPIRE): a randomised, openlabel, non-inferiority phase 3 study. Lancet Respir Med 2018;6:

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