Goswami, Umesh

Vaccination remains a cornerstone of infection prevention in adult solid organ transplant (SOT) recipients, a population at heightened risk for vaccine-preventable diseases due to chronic immunosuppression and comorbidities. Updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice (AST IDCOP) and other international bodies emphasize the need for timely and comprehensive vaccination strategies before and after transplantation. This review synthesizes current literature and practice guidelines on vaccination in adult solid organ transplant (SOT) candidates and recipients. Published peer-reviewed studies, clinical trials, and consensus guidelines were evaluated, with emphasis on vaccination timing, safety, immunogenicity, dosing strategies, and serologic response monitoring in the SOT population. Comprehensive vaccination planning before transplantation, combined with appropriate post-transplant booster strategies, remains vital to improving long-term outcomes in SOT recipients. This review provides clinicians with an updated, evidence-based framework for integrating evolving vaccination guidelines into the care of adult transplant patients.

Abstract Introduction A previously published case report suggested that alcohol might cause false-negative results in home sleep apnea testing (HSAT) utilizing Peripheral Arterial Tonometry (PAT). Alcohol is consumed by nearly a third of people globally. Based on this, along with rapid growth in PAT HSAT utilization, we aimed to prospectively study the interaction between alcohol consumption and PAT HSAT technology. We hypothesized that alcohol use would significantly attenuate sleep disordered breathing metrics in contrast to existing literature suggesting alcohol may exacerbate sleep apnea. Methods We planned to recruit subjects (N=100) from Mayo Clinic Arizona sleep clinic who were being evaluated for sleep-disordered breathing and elected to undergo home sleep apnea testing (WatchPAT ONE). Participants were required to report social alcohol use (no more than 1-3 drinks per day). The first and second home sleep apnea test were conducted on separate nights (night 1: without alcohol; night 2: with alcohol). Patients also completed a questionnaire, detailing their normal alcohol intake as well as intake during the respective sleep tests. Statistical analysis included paired sample t-test as well as a descriptive analysis. Results A total of 75 subjects were recruited (mean age [± SD] 56.8 ± 11.9; 90.7% male; mean BMI 29.8 ± 5.8) and 56 patients completed both sleep tests. The mean apnea hypopnea index (AHI) was not statistically different (p=0.784) between night 1 and night 2 (without alcohol: 19.6/hour ± 21.0; with alcohol: 19.3 ± 21.5, respectively). Similarly, no statistically significant difference was found in the AHI during REM and NREM sleep. Conclusion Preliminary data does not suggest a statistically significant difference in AHI without or with alcohol. While no significant change in AHI was observed, this study highlights the need for further investigation into the impact alcohol may have on PAT technology. Further analyses and data enrichment are underway. Support (if any) Mayo Foundation

Abstract Introduction Central sleep apnea (CSA) is associated with several medical conditions (e.g., heart failure, atrial fibrillation) and medications (e.g., opioids, ticagrelor, sodium oxybate and valproic acid). We report a case of a 31-year-old female with bipolar disorder treated with valproic acid diagnosed with central sleep apnea on polysomnography, which revealed an apnea-hypopnea index of 150/hour, central apnea index of 112/hour, nadir oxygen saturation of 78%, and 38.6 minutes with oxygen saturation ≤ 88%. Echocardiogram, electrocardiogram, brain magnetic resonance imaging, serum acylcarnitine and serum ammonia levels were unremarkable. Total and free serum valproic acid level was 33 and < 3 mcg/mL, respectively. Two cases of central sleep apnea associated with valproic acid use, both of which improved upon discontinuation of valproic acid, have been reported in the literature. We started the patient on positive airway pressure and suggested she taper off valproic acid and then repeat polysomnography. Given the possible association between central sleep apnea and valproic acid use, we retrospectively analyzed patients receiving valproic acid at time of polysomnography. Methods We retrospectively identified patients between 2005-2017 who were prescribed valproic acid (n=6,169), and of these 72 received valproic acid within 90 days of polysomnography. After chart review, we were able to confirm that 29 received valproic acid at time of polysomnography via blood levels or clear chart documentation. Results Four patients (13.8 %) demonstrated a central apnea index ≥ 5 per hour (mean apnea-hypopnea index 39.2/hour +/- 32.2/ hour including a central apnea index 11.7 +/- 6.6/hour) during polysomnography. Although one patient (3.4 %), a 2-year-old child with Dravet syndrome and refractory/drug resistant generalized epilepsy, was diagnosed clinically with central sleep apnea, the other three patients were diagnosed with obstructive sleep apnea and had other potential reason(s) for the elevated central apnea index (e.g., opioid use as needed for migraines). Conclusion Our case describes a third report of central sleep apnea possibly associated with valproic acid, and our retrospective study indicates that this association is rare. Prospective sleep studies on patients before and after receiving valproic acid are warranted to determine if valproic acid causes central sleep apnea. Support (if any)

Abstract Introduction Polysomnography (PSG) requires on-body sensors for respiratory effort measurement, that can adversely affect sleep quality and accuracy of detection of sleep related breathing disorders (SRBD). We developed a non-contact 60 Hz pulsed wave radar system with integrated advanced signal processing to collect respiratory effort, heart rate and gross body movements data using phase differencing to a sub-mm resolution. In this study we tested the performance of this system in detecting SRBD events against standard PSG in human participants. Methods During participants’ clinically indicated PSG, we collected concurrent data from the radar system placed under the bed on a tripod mount. Algorithms were developed to quantify breath amplitude reductions collected by radar and compared to the time-synced signals derived from respiratory impedance plethysmography belts. A Convolutional Neural Network (CNN) was trained on radar in-phase/quadrature (I/Q) data for each 30 second epoch to output probability of apnea and hypopnea events using standard event definitions. Receiver Operating Characteristics (ROC) plot and confusion matrix for the trained network were generated to provide accuracy of event predictions. Results A total of 60 participants completed the study. The participants had a mean age of 65 years (Inter Quartile Range 13.5 years), and 56% subjects were male. The mean AHI for the entire cohort was 12.9 (IQR 14.75) events/hour. ROC plots showed an Area Under the Curve (AUC) of 0.98 for events detection by radar compared to human scored PSGs. The confusion matrix was generated at an operating point of 95% sensitivity and 80% specificity. Conclusion The non-contact high frequency radar system showed excellent performance in respiratory event detection in patients with sleep-related breathing disorders in comparison to the gold standard PSG system. Use of this technology is expected to reduce the number of body contact sensors used during conventional sleep studies and thus improve patient comfort and accuracy of results. Support (if any) Research reported in this abstract was supported by National Institute of Aging of the NIH under award number: R44AG060779

Abstract Introduction OSA is caused by the interaction of impaired upper airway anatomy and dysfunctional upper airway muscle response to airway narrowing during sleep. Oropharyngeal exercises focused on training upper airway muscles are effective in reducing OSA severity and symptoms. However, similar to other physical therapy programs, oropharyngeal exercises require patients to complete multiple therapy sessions which affects patient compliance. To address this, we developed a smartphone application to provide oropharyngeal exercise and tested the effect of adding gamification and habit formation techniques on therapy adherence. Methods The experimental app which included oropharyngeal exercise therapy administered using voice-controlled games, a reward system, a reminder system, and supportive video content was compared to the control app that included text-based exercise therapy instructions and limited video content. Participants with mild to moderate OSA were randomly assigned (1:1) to either group. Demographics, sleep apnea variables, therapy progress, self-reported snoring severity questionnaires were collected for both groups. Appropriate descriptive statistics were used to summarize baseline and outcome data. Results 30 participants (13 male), mean age 60.7 ± 11.1 years were randomized equally to the experimental and control groups. 9 participants (6 in the experimental group and 3 in the control group) were unable to complete the study due to technical challenges with the apps and were excluded from analysis. No statistically significant differences were noted in either group’s baseline demographic and OSA measures. 7/9 (78%) participants in the experimental group vs 7/12 (58%) in the control group met the prespecified compliance thresholds for the 8 weeks therapy period. Self-reported snoring severity mean scores were significantly reduced in the experimental group (from 2.86 to 1.43, p-value 0.04) compared to the control group (from 2.14 to 1.77, p-value 0.21). Conclusion Addition of gamification and therapy monitoring techniques improve compliance to the prescribed oropharyngeal exercises in patients with OSA. Further studies are needed to establish the efficacy of gamified oropharyngeal therapy in the treatment of OSA. Support (if any) Research reported in this abstract was supported by NHLBI of the NIH under award number: R43HL152948-01.

Abstract Introduction Placing a magnet over a Permanent Pacemaker (PPM) or Implanted Cardioverter-Defibrillator (ICD) may cause the device to pace asynchronously or inhibit tachyarrhythmia detection, respectively, potentially preventing delivery of electrical shocks. Manufacturers for masks used with positive airway pressure devices have started using magnets in place of more traditional headgear clips to connect the headgear to mask. Mask manufactures do not list presence of a PPM/ICD as a contraindication to use of a mask with magnet but do recommend keeping the mask some distance away from PPM/ICD. A published case series describes two patients with magnet response events captured during PPM/ICD interrogation that correlated with nightly use of CPAP. The authors were able to replicate the response by placing the mask with magnet directly over the patient’s pulse generate site. Although we advise all patients with implanted device to avoid use of masks with magnets, select patients refuse to stop using mask with magnets regardless of our policy. We, therefore, started offering these patients referral for PPM/ICD interrogation to evaluate for an interaction between mask with magnet and PPM/ICD as next best alternative. Methods We retrospectively reviewed all patients (n=10) referred for routine PPM/ICD interrogation to test whether the mask with magnet interacted with PPM/ICD when mask on face as during normal use (i.e., simulated normal use) or magnetic area of mask placed directly over the PPM/ICD (i.e., direct contact). Results Although no interaction was detected in any patient (n=10) with simulated normal use (0 %), one interaction was documented with direct contact (10 %). Conclusion Although simulated normal use of masks with magnets did not demonstrate any interactions, it is concerning that one patient (10 % of patients) demonstrated an interaction with direct contact of magnetic area of mask over the PPM/ICD. It is not uncommon for patients to remove a mask during the night while sleeping. This preliminary data along with the published case series calls for further research and increased awareness of this potential interaction for both sleep and cardiac health care providers. Support (If Any) None

Background. Induction choices for kidney-after-heart transplant recipients are variable. We examined the impact of kidney induction types on kidney graft and patient survival in heart transplant recipients. Methods. We analyzed the Scientific Registry of Transplant Recipient database from inception through the end of 2018 to study kidney and patient outcomes in the United States after heart transplantation. We only included recipients who were discharged on tacrolimus and mycophenolate maintenance. We grouped recipients by induction type into 3 groups: depletional (N = 307), nondepletional (n = 253), and no-induction (steroid only) (n = 57). We studied patients and kidney survival using Cox PH regression, with transplant centers included as a random effect. We adjusted the models for heart induction, recipient and donor age, gender, time between heart and kidney transplant, heart transplant indication, HLA mismatches, payor, live-donor kidney, transplant year, dialysis status, and diabetes mellitus at the time of kidney transplant. Results. The 1-y kidney rejection rates and creatinine levels were similar in all groups. The 1-y rehospitalization rate was higher in the depletional group (51.7%) and nondepletional group (50.7%) than in the no-induction group (39.1%) although this was not statistically significant. There were no differences in recipient or kidney survival by kidney induction type. Live-donor kidney was associated with improved patient (hazard ratio, 0.74; 95% confidence interval, 0.54-1.0; P = 0.05) and kidney survival (hazard ratio, 0.45; 95% confidence interval, 0.24-0.84; P = 0.012]. Conclusions. Type of kidney induction did not influence patient or kidney graft survival in heart transplant recipients. No-induction may be the preferred choice due to the lack of clinical benefits associated with induction use.