Chalmers, Sarah

Abstract Effective communication during handoffs and transitions of care is crucial, as over 50% of sentinel patient events are due to communication gaps, according to the Joint Commission. In our open multi-specialty Intensive Care Unit (ICU) at a tertiary care center, we noticed variability in handoff practices leading to provider dissatisfaction, delays in care and increased potential for errors. To address this, we developed and implemented a standardized handoff procedure. METHODS: A multi-disciplinary team comprised of fellow physicians, nursing and advanced practice provider (APP) leadership conducted an online anonymized baseline survey (B) in December 2023 in our open mixed ICU assessing multidisciplinary provider satisfaction in the process of transitioning patients out of the ICU. Based on this, we identified areas for improvement in the ICU transfer-out process, focusing on communication methods and handoff standardization. Between February and June 2024, we designed and posted signage near provider work areas to clearly designate the primary team based on the level of care and co-managing specialties. We also developed electronic record-based template dot phrases based on the I-PASS format to help standardize information provided during handoff, and ICU team members were educated on the use of the same. Post-implementation (PI) surveys were anonymously conducted in June 2024 to assess the impact of changes, with data analysis comparing pre- and post-implementation metrics, and regular feedback meetings facilitated iterative improvements. RESULTS: We received 40 survey responses (B =20 and PI=20). In the baseline survey, 65% identified room for improvement, particularly with the timing of provider handoffs, inconsistencies in transfer documentation, and clarity on the responsible medical team. Post-implementation survey results showed a 15% improvement with 80% reported no problems during the process, and 85% rated the clarity of the process as “very clear” and “clear,” with 15% neutral. Regarding staff communication, 90% rated it as “good” to “very good,” with 5% neutral. Dot phrase utilization was deemed “very helpful” to “helpful” by 54%, while 46% were neutral. The majority (95%) reported no challenges during the transfer-out process, and 80% were satisfied with the initiative's implementation. CONCLUSION: Our study highlights the impact of a multimodal approach in improving the process of ICU transitioning patients. We were able to improve the primary team identification with posted signage in the ICU.Using computer template-based dot phrases, we were also able to successfully improve satisfaction with the sign out process at time of transition out of the ICU level of care.

Abstract RATIONALE: Understanding co-isolation patterns between fungi and other potentially pathogenic microorganisms in the airways of bronchiectasis patients is important for uncovering possible microbial interactions and informing treatment. Although numerous organisms have been identified in respiratory cultures, the specific patterns of their co-isolation are underexplored. OBJECTIVES: To examine the patterns of co-isolation between fungi and bacteria or mycobacteria in respiratory samples from patients with bronchiectasis across a large national health system. METHODS: We reviewed 58,170 respiratory culture tests from 8,194 patients with bronchiectasis (identified using ICD-10-CM codes J47.0, J47.1, and J47.9) across Mayo Clinic. These tests were analyzed for fungal, bacterial, and mycobacterial growth, focusing on co-isolation from the same sample. Chi-square statistics were used to compute p-values. RESULTS: Of all 18,983 samples cultured for fungi, 59% were positive. Of these, 72% yielded yeasts and 40% molds. Among the 11,372 samples cultured for both fungi and bacteria, 681 (6%) showed co-isolation, representing 54% of positive bacterial cultures. The odds of bacterial co-isolation with fungi were 1.4 (95% CI: 1.3-1.6; p < 0.01), driven by yeasts (OR: 1.5, 95% CI: 1.3-1.7; p < 0.01), rather than molds (OR: 1.0, 95% CI: 0.9-1.2; p = 0.8). Pseudomonas species, the most common bacterial isolate, had a higher likelihood of co-isolation with fungi (OR: 1.6, 95% CI: 1.3-1.9; p < 0.01), particularly yeasts (OR: 1.6, 95% CI: 1.4-2.0; p < 0.01). Molds, including those from genera such as aspergillus and penicillium, did not show a significant association with the isolation of pseudomonas. On the other hand, among the 15,859 samples cultured for both fungi and mycobacteria, 1352 (9%) showed co-isolation, representing 62% of positive mycobacterial cultures. Odds of co-isolation were 1.7 (95% CI: 1.5-1.8; p < 0.01). Molds showed a stronger association with isolation of mycobacteria (OR: 1.7, 95% CI: 1.5-1.9; p < 0.01) compared to bacteria, while yeasts also had elevated odds (OR: 1.4, 95% CI: 1.2-1.5). CONCLUSIONS: Distinct patterns of fungal co-isolation with bacteria and mycobacteria have been observed in bronchiectasis, which may influence key aspects of the disease, such as inflammation and mucociliary dysfunction. Advanced metagenomic and immunoprofiling techniques could provide deeper insights into these co-isolation patterns while considering other factors like clinical demographics, previous antibiotic exposure, and disease severity. Understanding whether altering the mycobiome could modify these aspects and improve outcomes remains an important avenue for research.

Abstract Introduction: Cystic fibrosis (CF) is a genetic disorder characterized by defective chloride ion transport, leading to thick mucus production, chronic respiratory infections, and other multisystem involvement. Although CF is often diagnosed in childhood, the condition can be missed or misdiagnosed in adults. Description of Case: We present the case of a 60-year-old male from India who was diagnosed with CF after a prolonged period of sinopulmonary symptoms. He initially presented in 2014. His medical history was pertinent for asthma, and multiple episodes of clinically and radiographically confirmed pneumonia and polypoid sinusitis requiring IV antibiotics and sinus surgery. He carried a prior diagnosis of allergic bronchopulmonary aspergillosis treated with itraconazole and steroids, as well as elevated IgE levels. His CT chest was notable for extensive bronchiectasis, bronchial wall thickening, and mucus plugging of both lungs. He had no known family history of CF. Sweat chloride testing was in the intermediate range (44, 47 mmol/L; normal <30 mmol/L, intermediate 30 to 59 mmol/L, abnormal >59 mmol/L). Given high suspicion for CF, cystic fibrosis transmembrane conductance regulator (CFTR) full gene analysis was pursued. Sequence analysis and multiplex ligation-dependent probe amplification of the CFTR gene detected heterozygous sequence changes c.1717-2A>T, classified as likely deleterious, and c.1367T>C (p.V456A), variant of uncertain significance. He was thus initially diagnosed as a CF carrier. He re-presented in 2024 with decline in pulmonary function testing and continued sinopulmonary infections. Genetic testing results from 2014 were re-analyzed. Between initial presentation and present, his V456A variant was upgraded to pathogenic. He met diagnostic criteria for CF with two pathogenic CFTR variants, a repeated intermediate sweat chloride (47 mmol/L) suggestive of CFTR protein dysfunction, and disease that could be attributed to CFTR dysfunction. He subsequently started TRIKAFTA® (elexacaftor/tezacaftor/ivacaftor and ivacaftor) and airway clearance therapy. Discussion: The diagnosis of CF in adults can be challenging, particularly in individuals without a known family history, intermediate sweat chloride testing, and with inconclusive genetic testing. Our understanding of CF in Asian populations is limited. CF is suspected to be underreported in patients with Southeast Asian ancestry in part due to genetic heterogeneity. The interpretation of certain genetic variants can evolve over time. A variant of unknown significance may later be reclassified as pathogenic, revealing its true role in disease development. This highlights the critical importance of regularly re-evaluating genetic test results.

Abstract RATIONALE: Absolute Blood Eosinophil Counts (BEC) in bronchiectasis patients offer insights into inflammatory patterns and potential treatments. In non-cystic fibrosis bronchiectasis (NCFB), BEC≥300 cells/μL characterizes Eosinophilic Bronchiectasis (EB), a type-2 inflammation endotype estimated in 20% of patients. Guidance on BEC assessment strategy (i.e., number, frequency and timing of BEC≥300 defining this endotype) is unclear. We hypothesize that EB incidence varies by BEC≥300 assessment strategy. We also investigate eosinophilic inflammation in CF for comparison. Objectives: Assess BEC≥300 incidence in NCFB and CF cohorts. METHODS: From January 2023 to October 2024, BEC were measured in 9,953 stable bronchiectasis patients across Mayo Clinic, including 9,806 with NCFB (J47.9; 66,780 CBCs) and 147 with CF (E84.0; 1,405 CBCs). Incidence of BEC≥300 was evaluated in relation to CBC frequency and timing (i.e., BEC≥300 on first, second, last, any, any two, first two simultaneously) and the number of CBCs per patient. RESULTS: In the NCFB cohort, median age was 74 years (IQR:66-82), with 59.5% female. Median CBCs/patient was 3 (IQR:1-7). Incidence of BEC≥300 on the first CBC was 19.8%. Among patients with ≥2 CBCs (n=7,075), incidence was 20.1% on the first, 19.8% on the second, and 20.0% on the last. This incidence rose to 36.3% when considering any CBC/patient. BEC≥300 on at least two CBCs was 29.3%, decreasing to 11.8% when considering consecutive BEC≥300 on both first and second CBCs. The incidence of BEC≥300 increased linearly with the number of CBCs obtained: 24.6% for those with 1-3 CBCs, up to 64.6% for >12 CBCs. In the CF cohort, median age was 36 years (IQR:27-52), with 55.1% female. Median CBCs/patient was 4 (IQR:2-8). BEC≥300 was present in 22.9% of first CBCs, rising to 36.3% when considering any CBC and 29.3% when present on at least two CBCs. Similar to the NCFB cohort, incidence increased with the number of CBCs: 26.5% for 1-3, up to 77.3% for >12. CONCLUSIONS: The incidence of BEC≥300 in our NCFB cohort remained steady at 20% at any specific measurement point, consistent with prospective literature. However, nearly half of those with BEC≥300 on the first or second CBC did not meet this threshold on both. Incidence significantly increased when any CBC was considered, and more CBCs were available. Similar observations were made in the CF cohort. Clearer BEC assessment strategies are needed to define clinically significant eosinophilic inflammation in bronchiectasis, to better identify patients who may most benefit from type 2 inflammation-targeted treatments.

Abstract Purpose: Frail and malnourished patients with bronchiectasis have worse outcomes. This study examines frailty and malnutrition as predictors of 30-day readmission after bronchiectasis exacerbation (BE). Methods: We utilized the 2018 Nationwide Readmissions Database to analyze hospitalizations for BE. Patients with BE were identified through principal and secondary ICD-10 diagnosis codes J47.0 and J47.1. Among those who survived the index hospitalization, only individuals discharged to home were included in the analysis. The primary objective was to identify predictors of 30-day readmission, with a specific focus on frailty and malnutrition. Frailty was measured using the validated Hospital Frailty Risk Score, as described by Gilbert et al. (Lancet, 2018), while malnutrition was identified using ICD-10 codes E43, E44.0, E44.1, and E46. Comorbidity burden was categorized using the Charlson Comorbidity Index: mild (score 0-2), moderate (3-5), and severe (≥6). A multivariate logistic regression model was employed to calculate adjusted odds ratios (ORs) for readmission, with statistical significance defined as p < 0.05. Results: Among 20,742 patients discharged home following bronchiectasis exacerbation, 4% (830) were readmitted within 30 days. Patients with readmission were younger (median age 63 vs. 69 years, p<0.01) and more likely to be treated at urban hospitals (84.9% vs. 80.0%, p=0.01). They also had higher rates of frailty (52.6% vs. 46.5%, p=0.01), malnutrition (21.0% vs. 14.7%, p<0.01), and Pseudomonas pneumonia (5.9% vs. 3.9%, p=0.03). The comorbidity burden was not different (p=0.29). After adjusting for age, malnutrition demonstrated a trend toward higher odds of readmission (OR 1.31, 95% CI 0.99-1.73, p=0.059), though this did not reach statistical significance. In contrast, frailty was significantly associated with increased readmission (OR 1.36, 95% CI 1.12-1.66). The presented Table describes the demographic characteristics and outcomes of ALL hospitalized patients with BE (n = 40, 789) stratified by frailty and malnutrition. Conclusions: Frailty is a significant predictor of 30-day readmission following BE. Targeted interventions addressing frailty in hospitalized patients with BE may help reduce readmission rates.

Abstract Rationale Nontuberculous mycobacteria (NTM) are prevalent among patients with bronchiectasis. However, the long-term natural history of patients with NTM and bronchiectasis is not well described. Objectives To assess the impact of NTM on 5-year clinical outcomes and mortality in patients with bronchiectasis. Methods Patients in the Bronchiectasis and NTM Research Registry with ⩾5 years of follow-up were eligible. Data were collected for all-cause mortality, lung function, exacerbations, hospitalizations, and disease severity. Outcomes were compared between patients with and without NTM at baseline. Mortality was assessed using Cox proportional hazards models and the log-rank test. Measurements and Main Results In total, 2,634 patients were included: 1,549 (58.8%) with and 1,085 (41.2%) without NTM at baseline. All-cause mortality (95% confidence interval) at Year 5 was 12.1% (10.5%, 13.7%) overall, 12.6% (10.5%, 14.8%) in patients with NTM, and 11.5% (9.0%, 13.9%) in patients without NTM. Independent predictors of 5-year mortality were baseline FEV1 percent predicted, age, hospitalization within 2 years before baseline, body mass index, and sex (all P < 0.01). The probabilities of acquiring NTM or Pseudomonas aeruginosa were approximately 4% and 3% per year, respectively. Spirometry, exacerbations, and hospitalizations were similar, regardless of NTM status, except that annual exacerbations were lower in patients with NTM (P < 0.05). Conclusions Outcomes, including exacerbations, hospitalizations, rate of loss of lung function, and mortality rate, were similar across 5 years in patients with bronchiectasis with or without NTM.