Utility of the Stanford Integrated Psychosocial Assessment for Transplant in predicting outcomes before and after lung transplantation.

BACKGROUND: Optimizing donor use and achieving maximal survival following lung transplantation (LTx) require a pretransplant assessment that identifies clinical, physiological, and psychosocial patient factors associated with both poor and optimal post-LTx survival. We examined the utility of a psychosocial tool, the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), to identify patient suitability for LTx, as well as its association with clinical outcomes before and after LTx. METHODS: This was a retrospective single-center study analyzing LTx assessment clinical variables (age, gender, diagnosis, functional capacity, nutrition, renal function), with a particular focus on the utility of the SIPAT score, to predict patient suitability for LTx. The same variables were analyzed against LTx waitlist mortality, as well as post-LTx survival. RESULTS: Over an 8-year period dating from December 2012, 914 patients (male 54.4%, mean age 55.2 years) underwent LTx assessment. Patients declined for LTx (n = 152, 16.6%) were older and had reduced functional capacity, nutritional markers, and renal function but had a higher SIPAT score. Once listed for LTx, a higher SIPAT score was not associated with waitlist mortality or reduced post-LTx survival. CONCLUSIONS: The SIPAT tool measures psychosocial suitability for transplantation that can be incorporated into a standardized assessment of LTx suitability. While patients with higher SIPAT score were more likely to be declined for LTx, the SIPAT score did not predict outcome in transplanted patients. A subgroup of patients with high SIPAT scores were successfully transplanted, suggesting that unfavorable psychosocial variables are potentially modifiable with a well-resourced multidisciplinary LTx team.

Reproductive health after thoracic transplantation: An ISHLT expert consensus statement.

Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.

Utility of a thin bronchoscope in facilitating bronchial thermoplasty.

BACKGROUND: A significant correlation has been previously demonstrated between the quantum of radiofrequency treatment delivered at bronchial thermoplasty and the degree of improvement in an asthmatic patient's symptoms. The standard bronchoscope used for bronchial thermoplasty has an outer diameter of 4.8 mm at the distal tip. Thinner bronchoscopes are now available with the same internal channel size (2.0 mm). This study assesses whether using a thinner bronchoscope facilitates bronchial thermoplasty by increasing the radiofrequency activations delivered. PATIENTS AND METHODS: This was a sequential study in a single center, conducted in 27 patients with very severe asthma. The first 12 patients (Group 1) underwent bronchial thermoplasty using the standard bronchoscope, Olympus BF-Q190. In the next group of eight patients (Group 2), the standard bronchoscope was used for all procedures except the left upper lobe, while the left upper lobe was treated with a smaller bronchoscope, Olympus BF-P190, with an outer diameter of 4.2 mm. In the last group of seven patients (Group 3), the smaller bronchoscope was used for every lobe. The quantum of radiofrequency treatment was measured by activations delivered to each lung lobe in each patient, and patient groups were compared by ANOVA. RESULTS: In this group of 27 patients, the mean age was 56.5±12.9 years, the mean Asthma Control Questionnaire-5 item version score was 3.2±1.0 and the mean FEV1% predicted was 55.2±15.7. Bronchial thermoplasty treatment resulted in significant improvements in predicted Asthma Control Questionnaire-5 item version score (to 1.8±1.3, P<0.005), salbutamol rescue usage and oral corticosteroid requiring exacerbations, with no significant change in lung function. Use of the smaller bronchoscope resulted in greater radiofrequency treatment (total activations Group 1: 155±21, Group 2: 176±46, Group 3: 213±37; P<0.01). There were no significant differences in efficacy or safety outcomes among groups. CONCLUSION: Using a thinner bronchoscope facilitates access to the bronchial tree and increases the radiofrequency treatment delivered at bronchial thermoplasty.

Junior doctors' attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease.

BACKGROUND: Refractory breathlessness is a common, distressing symptom in patients with advanced chronic obstructive pulmonary disease (COPD). The judicious, off-licence prescription of opioids, together with other management strategies, can improve breathlessness, however, internationally there is profound reluctance to prescribe opioids for breathlessness in COPD. AIMS: To understand Australian junior doctors' knowledge and attitudes regarding the management of refractory breathlessness and the role of opioids in COPD. METHODS: All junior doctors undertaking basic training in internal medicine in Victoria were invited to complete an online survey. Knowledge, willingness, and experience prescribing opioids to COPD patients with refractory breathlessness, were examined. RESULTS: Of the 243 responses received, most trainees (193, 86.5%) believed opioids have a role in treating refractory breathlessness in stable COPD outpatients, with 143 (64.1%) recommending morphine as first-line treatment for refractory breathlessness. One quarter (55, 24.7%) reported having themselves initiated an opioid and 102 (45.7%) had prescribed an opioid under senior supervision for management of breathlessness in COPD. Concern regarding adverse opioid effects was low, with 58 (26.0%) having no concerns prescribing an opioid to COPD patients. CONCLUSION: This is the first study of doctors to demonstrate high awareness, confidence, willingness and experience in prescribing opioids for the off-licence indication of refractory breathlessness in COPD. These findings differ significantly from attitudes reported overseas and are unexpected given the doctors surveyed were recently qualified. The low awareness of possible adverse events and limited insight regarding knowledge gaps is concerning and highlights the significant need for greater education in palliative care.