SANBORN, DAVID

Background Medication nonadherence has been associated with poor outcomes in transplant recipients yet identifying these behaviors pre-transplant remains challenging. The simplified medication adherence questionnaire (SMAQ) is a brief, reliable instrument to assess medication adherence. The aim of this study was to perform SMAQ testing on thoracic organ candidates and examine correlations between these scores and individual patient factors predicting medication nonadherence. Methods Consenting waitlisted lung, heart, and heart-lung transplant candidates from six thoracic transplant centers were mailed a survey that included demographic information and the Simplified Medication Adherence Questionnaire (SMAQ). Univariate logistic regression analysis was performed to assess association between pre-transplant medication adherence and demographic characteristics, psychosocial factors, and mortality. Results Among 298 participants, 60.7% were medication nonadherent. Nonadherence was associated with some college education (OR: 1.73; CI: 1.06, 2.81), lower positive affect (OR: 0.95; CI: 0.92, 0.99), and higher uncertainty (OR: 1.02; CI: 1.01, 1.04). Higher positivity ratio predicted adherence. Conclusion Identifiable patient-specific characteristics associated with medication nonadherence can be screened for during thoracic transplant evaluation. Interventions aimed at improving these factors during the pre-transplant period may improve clinical post-transplant outcomes, however, larger studies are needed to validate these findings.

Abstract Introduction: Prolonged mechanical ventilation can often be complicated with post-intubation tracheal stenosis (PITS). It usually manifests within few weeks following extubation. However, delayed presentations are rare and have disastrous outcomes if not identified. Early recognition of stridor and dyspnea post-extubation is crucial for timely intervention. We report a case of late presentation of PITS in a 67-year-old female patient with new-onset stridor after prolonged intubation. Case: A 67-year-old female with past medical history of coronary artery disease, type 1 diabetes, obstructive sleep apnea presented with a six-week history of progressive dyspnea on exertion and stridor. This occurred in the context of a three-week intubation following a pulseless electrical activity (PEA) arrest over five months prior. Immediately post-extubation, the patient had developed stridor without hypoxia or exertional symptoms and was subsequently discharged home without further investigation. On this presentation, she was afebrile and saturating 95% on room air with audible inspiratory stridor at bedside. Respiratory viral panel and autoimmune work up was negative. Computed tomography (CT) scan noted a significant circumferential narrowing in the proximal portion of the trachea measuring 2.5 cm in length with 0.5 cm in width with associated wall thickening. She was managed with 2.25% racemic epinephrine as needed and prednisone 10 mg daily with rescue continuous positive airway pressure (CPAP) until intervention could be safely performed after clopidogrel washout. On Day 5, she underwent rigid bronchoscopy with extensive CO2 laser vaporization (Fig. B) of scar release and paclitaxel-coated balloon dilation of the 3 mm narrowing (Fig. A) to 12 mm (Fig. C). Her stridor resolved with significant improvement in dyspnea and exercise tolerance. She was subsequently discharged on a steroid taper with outpatient interventional pulmonology follow up for repeat rigid bronchoscopy in 4 weeks to evaluate for restenosis. Discussion: Tracheostomy is often considered when extended period of intubation is anticipated as it can lead to increased risk of complications like PITS. It is important to have a high index of suspicion for tracheal stenosis in patients with a history of prolonged mechanical ventilation presenting with new-onset stridor, even when the symptoms are mild or intermittent. Early recognition and timely intervention can prevent the progression of stenosis and improve morbidity and clinical outcomes. Additionally, these patients tend to have an increased incidence of recurrence which requires close follow up for restenosis.

Background. Invasive fungal infections are associated with high morbidity in solid organ transplant recipients. Risk factor modification may help with preventative efforts. The objective of this study was to identify risk factors for the development of fungal infections within the first year following solid organ transplant. Methods. We searched for eligible articles through February 3, 2023. Studies published after January 1, 2001, that pertained to risk factors for development of invasive fungal infections in solid organ transplant were reviewed for inclusion. Of 3087 articles screened, 58 were included. Meta-analysis was conducted using a random-effects model to evaluate individual risk factors for the primary outcome of any invasive fungal infections and invasive candidiasis or invasive aspergillosis (when possible) within 1 y posttransplant. Results. We found 3 variables with a high certainty of evidence and strong associations (relative effect estimate ≥ 2) to any early invasive fungal infections across all solid organ transplant groups: reoperation (odds ratio [OR], 2.92; confidence interval [CI], 1.79-4.75), posttransplant renal replacement therapy (OR, 2.91; CI, 1.87-4.51), and cytomegalovirus disease (OR, 2.97; CI, 1.78-4.94). Both posttransplant renal replacement therapy (OR, 3.36; CI, 1.78-6.34) and posttransplant cytomegalovirus disease (OR, 2.81; CI, 1.47-5.36) increased the odds of early posttransplant invasive aspergillosis. No individual variables could be pooled across groups for invasive candidiasis. Conclusions. Several common risk factors exist for the development of any invasive fungal infections in solid organ transplant recipients. Additional risk factors for invasive candidiasis and aspergillosis may be unique to the pathogen, transplanted organ, or both.

Colorectal cancer (CRC) is the third-most lethal cancer in the USA, and early detection through screening is crucial for improving outcomes. However, significant disparities in access and utilisation of CRC screening exist among patients with limited English proficiency. Our Quality Improvement (QI) team developed and implemented a video, featuring a Somali-speaking physician, created with input from internal medicine (IM) residents, patient education experts and community leaders to increase the rate of CRC screening uptake within a Somali-speaking population receiving primary care within an IM Residency Clinic. The baseline proportion of average-risk Somali-speaking patients who had successfully been screened for CRC was 46.3% (63/134). The proportion of patients agreeable to undergo CRC screening was assessed monthly from the beginning of video implementation (June 2022 to December 2022). We found that this intervention corresponded with a significant increase in willingness to undergo CRC screening from 36.4% to 100% during the early stages of intervention. At the end of our measurement timeframe, the proportion of the original population fully screened for CRC was 50.7% (68/134). Implementation of the video intervention was also assessed and determined to be minimally disruptive to the clinic flow.

Technology in navigating to peripheral pulmonary nodules has improved in recent years. The recent integration of a robotic platform using shape-sensing technology and mobile cone-beam computed tomography imaging technology has enhanced confidence in sampling lesions with intraprocedural imaging by complimenting the pre-planned navigation to peripheral pulmonary nodules. We present 2 cases using the software integration that improved the robotic catheter positioning to allow for diagnostic specimens to be obtained in the initial biopsies.