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Lau N, Ramos KJ, Aitken ML, Goss CH, Barton KS, Kross EK, Engelberg RA. "We'll deal with it as it comes": A Qualitative Analysis of Romantic Partners' Dyadic Coping in Cystic Fibrosis. J Soc Pers Relat 2024; 41:689-705. [PMID: 38638205 PMCID: PMC11025702 DOI: 10.1177/02654075231190617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Background Although cystic fibrosis (CF) is a progressive, life-limiting, genetic disease, recent advances have extended survival, allowing persons with CF the time and physical and mental health to form romantic relationships. Previous studies have shown the importance of dyadic coping to positive psychosocial functioning and relationship satisfaction for people with serious chronic illness and their romantic partners, but little work has been done with persons with CF and their partners. The present study examines dyadic coping processes in persons with CF and their romantic partners. Methods Sixteen adults with moderate to severe CF (Mage=42.3, 43.8% identified as cisgender male, 56.2% identified as cisgender female) and their romantic partners (Mage=43.8, 56.3% identified as cisgender male, 43.7% identified as cisgender female) participated in individual semi-structured interviews focused on topics related to quality of life, communication, and palliative care. We conducted a directed content analysis utilizing Berg and Upchurch's (2007) developmental-contextual theoretical model to examine dyadic coping processes in persons with CF and their romantic partners. Results Consistent with the developmental-contextual model of dyadic coping, couples described adapting to health and functional declines that occurred over time. Dyads were aligned in their appraisals of illness representation, illness ownership, and perspectives of illness as a shared stressor; they used shared coping mechanisms that included supportive and collaborative actions rather than uninvolved or controlling strategies. Conclusions We recommend family-based approaches to medical decision-making and goals of care conversations with persons with CF and their partners, aligning those approaches with supportive and collaborative coping configurations. This may improve psychosocial outcomes for patients and their partners.
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Affiliation(s)
- Nancy Lau
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Moira L. Aitken
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Christopher H. Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Division of Pulmonary, Department of Pediatrics, University of Washington, Seattle, WA
| | - Krysta S. Barton
- Biostatistics Epidemiology and Analytics for Research (BEAR) Core, Seattle Children’s Research Institute, Seattle, WA
| | - Erin K. Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Ruth A. Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
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Albaiz FA, Ramos KJ, Sykes J, Stanojevic S, Ma X, Quon BS, Marshall BC, Cromwell EA, Ostrenga JS, Faro A, Elbert A, Goss CH, Stephenson AL. Lung function decline is mitigated following liver transplantation in people with cystic fibrosis: A retrospective cohort study. Liver Transpl 2024; 30:302-310. [PMID: 37530842 DOI: 10.1097/lvt.0000000000000232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023]
Abstract
There is paucity of literature on the health outcomes following liver transplantation (LT) in people with cystic fibrosis (pwCF). We aim to evaluate changes in lung function following LT in pwCF. We performed a retrospective cohort study of pwCF who underwent LT between 1987 and 2019 in the United States and Canada. Simultaneous lung-liver transplants and individuals who had lung transplant prior to LT were excluded. We analyzed pre-LT and post-LT percent predicted forced expiratory volume in 1 second, body mass index, rates of pulmonary exacerbation, and post-LT overall survival. A total of 402 LT recipients were included. The median age of transplant was 14.9 years and 69.7% of the transplants were performed in children less than 18 years old. The rate of decline in percent predicted forced expiratory volume in 1 second was attenuated after LT from -2.2% to -0.7% predicted per year with a difference of 1.5% predicted per year (95% CI, 0.8, 2.2; p < 0.001). Following LT, the rate of decline in body mass index was reduced, and there were fewer pulmonary exacerbations (0.6 pre vs. 0.4 post; rate ratio 0.7, p < 0.01). The median survival time post-transplant was 13.9 years and the overall probability of survival at 5 years was 77.6%. Those with higher lung function pre-LT had a lower risk of death post-LT, and those with genotypes other than F508 deletion had worse survival. LT in pwCF occurs most often in children and adolescents and is associated with a slower rate of decline in lung function and nutritional status, and a reduction in pulmonary exacerbations.
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Affiliation(s)
- Faisal A Albaiz
- Department of Medicine, Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Jenna Sykes
- Department of Medicine, Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Xiayi Ma
- Department of Medicine, Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | | | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Anne L Stephenson
- Department of Medicine, Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
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Milinic T, Ramos KJ. Cardiopulmonary Exercise Testing for Prognostication in Advanced Cystic Fibrosis Lung Disease and Beyond. Ann Am Thorac Soc 2024; 21:380-381. [PMID: 38426830 PMCID: PMC10913767 DOI: 10.1513/annalsats.202311-944ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Affiliation(s)
- Tijana Milinic
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Colon Hidalgo D, Ramos KJ, Harlan EA, Holguin F, Forno E, Weiner DJ, Griffith MF. Historic Use of Race-Based Spirometry Values Lowered Transplant Priority for Black Patients. Chest 2024; 165:381-388. [PMID: 37832783 PMCID: PMC11026175 DOI: 10.1016/j.chest.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/20/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The lung allocation score (LAS) is a tool used to prioritize patients for lung transplantation. For patients with interstitial lung diseases (ILDs), spirometry data are used for the LAS calculation. Spirometry values such as a FVC are subjected to race-specific equations that determine expected values. The effect of race-specific equations in LAS score remains unknown. RESEARCH QUESTION Did the use of a race-based spirometry equation lead to longer waitlist times for Black patients? STUDY DESIGN AND METHODS We performed a retrospective analysis of patients listed for lung transplantation from 2005 through 2020 using publicly available data from the United Network for Organ Sharing. We recalculated LAS scores for Black patients using White-specific equations with the available variables. The primary objective was to evaluate the effect of race-specific equations on LAS scores and time on the transplant waitlist. RESULTS A total of 33,845 patients listed for lung transplantation were included in the analysis. White patients were listed at lower LAS scores, a higher proportion of White patients underwent transplantation, and White patients died on the waitlist at lower rates. When recalculating LAS scores using White-specific equations, Black patients with ILD had up to a 1.9-point higher score, which resulted in additional waitlist time. INTERPRETATION Race-specific equations led to longer wait times in Black patients listed for lung transplantation. The use of race-based equations widened already known disparities in pulmonary transplantation.
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Affiliation(s)
- Daniel Colon Hidalgo
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Emily A Harlan
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Erick Forno
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Daniel J Weiner
- Division of Pulmonary Medicine, Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew F Griffith
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Pulmonary and Critical Care Section, VA Eastern Colorado Health Care System Aurora, Aurora, CO
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Bayomy OF, Bradford MC, Milinic T, Kapnadak SG, Morrell ED, Lease ED, Goss CH, Ramos KJ. Lung Allocation Score Exceptions in Persons with Cystic Fibrosis Undergoing Lung Transplant. Ann Am Thorac Soc 2024; 21:271-278. [PMID: 37878995 PMCID: PMC10848912 DOI: 10.1513/annalsats.202306-509oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/25/2023] [Indexed: 10/27/2023] Open
Abstract
Rationale: Lung transplantation can extend the lives of individuals with advanced cystic fibrosis (CF). Until March 2023, the Lung Allocation Score (LAS) was used in the United States to determine transplant priority. Certain clinical events or attributes ("risk events") that are not included in the LAS (e.g., massive hemoptysis) are relatively common and prognostically important in CF and may prompt an exception request to increase priority for donor lungs. The new Lung Composite Allocation Score (CAS) also allows for exceptions based on the same principles. Objectives: To evaluate the frequency of LAS exceptions in persons with CF (PwCFs) listed for lung transplantation and assess whether LAS exceptions are associated with improved waitlist outcomes for PwCFs compared with similarly "at-risk" individuals without LAS exceptions. Methods: A merged dataset combining data from the CF Foundation Patient Registry and the Organ Procurement and Transplantation Network (2005-2019) was used to identify PwCFs listed for lung transplantation. We compared waitlist outcomes between PwCFs with a LAS exception versus those without an exception despite having a risk event. Risk events were defined as an episode of massive hemoptysis, pneumothorax, at least three moderate/severe pulmonary exacerbations, and/or a decrease in forced expiratory volume in 1 second by ⩾30% predicted (absolute) in the prior 12 months. Analyses were performed using competing risk regression with time to transplantation as the primary outcome and death without a transplant as a competing risk. Results: Of 3,538 listings from 3,309 candidates, 2% of listings (n = 81) had at least one exception. Candidates with an exception and those with a risk event but no exception received lung transplants more slowly than people without an exception or risk event (subdistribution hazard ratio [95% confidence interval]: LAS exception cohort, 0.66 [0.52-0.85]; risk event cohort without exceptions, 0.79 [0.72-0.86]). There was no difference between those with LAS exceptions and those at risk without LAS exceptions: subdistribution hazard ratio, 0.84 (0.66-1.08). Conclusions: LAS exceptions are rare in PwCFs listed for lung transplantation. LAS exceptions resulted in a similar time to transplantation for PwCFs compared with similarly at-risk individuals. As we enter the CAS era, these LAS-based results are pertinent to improve risk stratification among PwCFs being considered for lung transplantation.
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Affiliation(s)
- Omar F. Bayomy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
| | - Miranda C. Bradford
- Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Tijana Milinic
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
| | | | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
| | - Erika D. Lease
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
| | - Christopher H. Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
- Division of Pulmonary Medicine, Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and
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Milinic T, Hobler MR, Bartlett LE, Gill E, Burdis N, Engelberg RA, Curtis JR, Hartzler AL, Aitken ML, Kapnadak SG, Goss CH, Smith PJ, Ramos KJ. Qualitative Analysis of Perspectives on Lung Transplant among People with Cystic Fibrosis. Ann Am Thorac Soc 2024. [PMID: 38259137 DOI: 10.1513/annalsats.202307-625oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 01/22/2024] [Indexed: 01/24/2024] Open
Abstract
RATIONALE Lung transplant (LTx) is a potentially life-saving treatment option for individuals with advanced cystic fibrosis (CF), but more people with CF (PwCF) and advanced lung disease die each year than undergo transplant in the United States. Little is known about these individuals' LTx information needs and factors influencing their decision-making process related to transplant. OBJECTIVES To examine PwCF's experiences with, and preferences for, provision of LTx information; to identify transplant information needs that CF clinicians are well-positioned to address. METHODS We performed semi-structured qualitative interviews in two separate cohorts: PwCF without LTx and PwCF with LTx between July 2019 and June 2020. Questions focused on awareness and knowledge about LTx, perspectives related to communication about transplant in CF clinic, and experiences with LTx. Thematic analysis was utilized to organize the qualitative data. Exemplar quotes were chosen to illustrate domains that emerged pertaining to the research objectives. RESULTS Fifty-five PwCF, 35 without LTx and 20 with LTx, participated. One-third of PwCF without LTx had normal or near-normal lung function. Key common domains among PwCF with and without LTx were identified including information needs, connections with LTx recipients, and conversations with CF clinicians. For PwCF with and without transplant, concrete information needs were identified: success or survival, social support, surgery, recovery/pain, and quality of life post-transplant. The importance of connecting with LTx recipients to hear their stories and experiences was emphasized by both PwCF with and without transplant. Important considerations for timing and content of discussions with CF clinicians were identified, including having information presented early (before LTx referral is needed) and in limited detail at first. PwCF without LTx wanted to understand how LTx was relevant to them, with a focus on the unique experience of CF. PwCF with LTx emphasized the need for a centralized resource for LTx information. CONCLUSIONS The findings provide content areas for CF clinicians to focus on as they proactively initiate conversations about LTx and support the development of tools to aid in discussions about LTx for PwCF.
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Affiliation(s)
- Tijana Milinic
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States;
| | - Mara R Hobler
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
| | - Lauren E Bartlett
- University of Washington School of Medicine, 12353, Division of Pulmonary, Critical Care, and Sleep Medicine, Seattle, Washington, United States
| | - Eliana Gill
- University of Washington, 7284, Division of Biobehavioral and Health informatics, Department of Nursing, Seattle, Washington, United States
| | - Nora Burdis
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
| | - Ruth A Engelberg
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
- University of Washington, 7284, Cambia Palliative Care Center of Excellence, Seattle, Washington, United States
| | - J Randall Curtis
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
- University of Washington, 7284, Cambia Palliative Care Center of Excellence, Seattle, Washington, United States
| | - Andrea L Hartzler
- University of Washington, 7284, Division of Biomedical and Health Informatics, Seattle, Washington, United States
| | - Moira L Aitken
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
| | - Siddhartha G Kapnadak
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
| | - Christopher H Goss
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
- Seattle Children's Research Institute, 145793, Seattle, Washington, United States
- University of Washington Department of Pediatrics, 271845, Seattle, Washington, United States
| | - Patrick J Smith
- The University of North Carolina at Chapel Hill, 2331, Psychiatry, Chapel Hill, North Carolina, United States
| | - Kathleen J Ramos
- University of Washington School of Medicine, 12353, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
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Gill ER, Bartlett LE, Milinic T, Burdis N, Pilewski JM, Dunitz JM, Kapnadak SG, Goss CH, Ramos KJ. A longitudinal analysis of respiratory symptoms in people with cystic fibrosis with advanced lung disease on and off ETI. J Cyst Fibros 2024; 23:161-164. [PMID: 38008684 PMCID: PMC10948304 DOI: 10.1016/j.jcf.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/13/2023] [Accepted: 11/13/2023] [Indexed: 11/28/2023]
Abstract
People with CF (PwCF), particularly those with advanced lung disease (ALD), experience frequent respiratory symptoms. A major CF breakthrough was the approval of elexacaftor/tezacaftor/ivacaftor (ETI) in 2019, which has been shown to improve symptoms and lung function in the CF population, and decrease pulmonary exacerbations. The purpose of this study was to analyze longitudinal changes in respiratory symptoms over 24 months in ETI-treated and untreated PwCF with ALD Symptoms were measured among CF adults with ppFEV1 < 40% (N = 48, 24 ETI-treated, 24 untreated) using the CFRSD-CRISS and the CFQ-R [respiratory]. Two multilevel growth models assessed the rate of change in symptoms overall and within the ETI-treated and untreated groups. PwCF on ETI had significantly lower symptom severity over 24 months than those not on ETI as measured by the CRISS and CFQ-R. The ETI-treated group maintained an -11.7 and +19.3 point difference(p<0.01) in CRISS and CFQ-R scores over the study compared to the non-ETI group, achieving minimal clinically important differences on average between groups on both instruments. No change in the symptom burden trajectory between groups was observed (p = 0.58). Even with ALD, ETI-treated PwCF have a lower respiratory burden than those not on ETI. This may be confounded by survivorship bias in the non-ETI group. Of note, in this ALD cohort, neither instrument demonstrated ceiling effects. Our results suggest that, while ETI has significantly improved the lived experience, PwCF with ALD are still plagued by respiratory symptoms.
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Affiliation(s)
- Eliana R Gill
- Division of Biobehavioral Nursing and Health Informatics, Dept of Nursing, University of Washington, Seattle WA, USA
| | - Lauren E Bartlett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle WA, USA
| | - Tijana Milinic
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle WA, USA
| | - Nora Burdis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle WA, USA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Dept of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jordan M Dunitz
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Dept. of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle WA, USA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle WA, USA; Division of Pulmonary and Sleep Medicine, Dept of Pediatrics, University of Washington, Seattle WA, USA; Seattle Children's Research Institute, Seattle WA, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle WA, USA
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Nomitch JT, Downey L, Pollack LR, Bayomy OF, Ramos KJ, Kross EK, Jennerich AL. Palliative Care Consultation and Family-Centered Outcomes in Patients With Unplanned Intensive Care Unit Admissions. J Palliat Med 2023. [PMID: 38150304 DOI: 10.1089/jpm.2023.0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Context: Hospitalized patients who experience unplanned intensive care unit (ICU) admissions face significant challenges, and their family members have unique palliative care needs. Objectives: To identify predictors of palliative care consultation among hospitalized patients with unplanned ICU admissions and to examine the association between palliative care consultation and family outcomes. Methods: We conducted a prospective cohort study of patients with unplanned ICU admissions at two medical centers in Seattle, WA. This study was approved by the institutional review board at the University of Washington (STUDY00008182). Using multivariable logistic regression, we examined associations between patient characteristics and palliative care consultation. Family members completed surveys assessing psychological distress within 90 days of patient discharge. Adjusted ordinal probit or binary logistic regression models were used to identify associations between palliative care consultation and family symptoms of psychological distress. Results: In our cohort (n = 413 patients and 272 family members), palliative care was consulted for 24% of patients during hospitalization (n = 100), with the majority (93%) of these consultations occurring after ICU admission. Factors associated with palliative care consultation after ICU transfer included enrollment site (OR, 2.29; 95% CI: 1.17-4.50), Sequential Organ Failure Assessment score at ICU admission (OR, 1.12; 95% CI: 1.05-1.19), and reason for hospital admission (kidney dysfunction [OR, 7.02; 95% CI: 1.08-45.69]). There was no significant difference in family symptoms of depression or posttraumatic stress based on palliative care consultation status. Conclusions: For patients experiencing unplanned ICU admission, palliative care consultation often happened after transfer and was associated with illness severity, comorbid illness, and hospital site. Patient death was associated with family symptoms of psychological distress.
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Affiliation(s)
- Jamie T Nomitch
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Lauren R Pollack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Omar F Bayomy
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
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Alshehri M, Ramos KJ, Sykes J, Ma X, Stanojevic S, Quon BS, Marshall BC, Cromwell E, Ostrenga JS, Faro A, Elbert A, Todd J, Chaparro C, Goss CH, Stephenson AL. Cystic fibrosis survival outcomes following second lung transplant: The north American experience. Clin Transplant 2023; 37:e15097. [PMID: 37563332 PMCID: PMC10840857 DOI: 10.1111/ctr.15097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Re-transplant is an option for those who develop end-stage lung disease due to rejection; however, little data exist following re-transplantation in cystic fibrosis (CF). METHODS Data from the Canadian CF Registry and US CF Foundation Patient Registry supplemented with data from United Network for Organ Sharing were used. Individuals who underwent a 2nd lung transplant between 2005 and 2019 were included. The Kaplan-Meier method was used to estimate the probability of survival post-second transplant at 1, 3, and 5-years. RESULTS Of those people who were waitlisted for a second transplant (N = 818), a total of 254 (31%) died waiting, 395 (48%) were transplanted and 169 (21%) people were alive on the waitlist. Median survival time after 2nd lung transplant was 3.3 years (95% CI: 2.8-4.1). The 1-, 3- and 5-year survival rates were 77.4% (95% CI: 73.1-82%), 52% (95% CI: 46.7-58%) and 39.4% (95% CI: 34.1-45.6%). CONCLUSIONS Survival following second lung transplant in CF patients is lower than estimates following the first transplant. Over half of subjects who are potentially eligible for a second transplant die without receiving a second organ. This warrants further investigation.
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Affiliation(s)
- Moayad Alshehri
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
- Unit of Pulmonology, Internal Medicine Department, King Saud University, Riyadh, Saudi Arabia
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Jenna Sykes
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Xiayi Ma
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | | | | | - Cecilia Chaparro
- Toronto Lung Transplant Program, University Health Network, Toronto, Canada
| | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
- Division of Pediatric Pulmonary, Department of Pediatrics, University of Washington Medical Center, Seattle, Washington, USA
| | - Anne L Stephenson
- Department of Respirology, St. Michael's Hospital, Toronto, Ontario, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Hergenroeder GE, Faino A, Bridges G, Bartlett LE, Cogen JD, Green N, McNamara S, Nichols DP, Ramos KJ. The impact of elexacaftor/tezacaftor/ivacaftor on fat-soluble vitamin levels in people with cystic fibrosis. J Cyst Fibros 2023; 22:1048-1053. [PMID: 37563007 PMCID: PMC10843772 DOI: 10.1016/j.jcf.2023.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND While elexacaftor/tezacaftor/ivacaftor (ETI) has improved the pulmonary health of many people with cystic fibrosis (PwCF), less is known about ETI effectiveness for extra-pulmonary manifestations, including fat-soluble vitamin malabsorption. This study aims to evaluate ETI's impact on vitamin A, D, E, and international normalized ratio (INR, an indirect marker for Vitamin K) serum levels. METHODS Retrospective cohort study of PwCF ≥12 years receiving ETI. Vitamin levels up to four years preceding and up to two years following ETI initiation were collected. Pairwise comparisons of vitamin levels pre/post-ETI initiation were made using Wilcoxon signed rank and McNemar's tests. Linear mixed effect models were used to regress vitamin levels on time since starting ETI, ETI use (yes/no), the interaction between time and ETI use, and age. RESULTS Two hundred and sixty-four participants met study inclusion, and 169 (64%) had post-ETI initiation vitamin levels. Median vitamin A levels increased from 422.0 to 471.0 mcg/L (p < 0.001), median vitamin D levels increased from 28.5 to 30.8 ng/mL (p = 0.003), and there were no significant changes in median vitamin E or INR. Vitamin A levels rose at a rate of 40.7 mcg/L/year (CI 11.3, 70.2) after ETI start. CONCLUSIONS ETI initiation is associated with increased median vitamin A and vitamin D levels, but no change in median vitamin E or INR levels. Ongoing monitoring of vitamin levels after ETI initiation is needed to screen for potential deficiencies and toxicities, particularly in light of case reports of hypervitaminosis A following ETI initiation.
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Affiliation(s)
- Georgene E Hergenroeder
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital; Department of Pediatrics, University of Washington.
| | - Anna Faino
- Core for Biostatistics, Epidemiology, and Analytics in Research, Seattle Children's Research Institute
| | - Gracia Bridges
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital
| | - Lauren E Bartlett
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital; Department of Pediatrics, University of Washington
| | - Nicole Green
- Department of Pediatrics, University of Washington; Division of Gastroenterology and Hepatology, Seattle Children's Hospital
| | - Sharon McNamara
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital
| | | | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington
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11
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Young D, Bartlett LE, Guimbellot J, Milinic T, Burdis N, Gill ER, Lease ED, Goss CH, Kapnadak SG, Ramos KJ. Patient perspectives on elexacaftor/tezacaftor/ivacaftor after lung transplant. J Cyst Fibros 2023:S1569-1993(23)00921-9. [PMID: 37798159 PMCID: PMC10987391 DOI: 10.1016/j.jcf.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) modulators, including elexacaftor/tezacaftor/ivacaftor (ETI), significantly improve outcomes and quality of life for people with cystic fibrosis (CF). However, little is known about how lung transplant recipients (LTRs) perceive the use of ETI. We conducted a survey to assess perspectives on ETI among LTRs with CF at our lung transplant program. Of 81 CF LTRs, 46 participants (58 %) responded. The majority of respondents (88 %) were aware of ETI. Over 80 % considered treating non-lung symptoms of CF to be very important. Concerns regarding ETI included potential drug interactions with transplant medications (77 %), side effects (53 %), cost of medication (49 %), and lack of clinical trial data for LTRs (43 %). Half reported they would only consider taking ETI if their CF or transplant doctor recommended it. The findings suggest that CF LTRs seek informational support and shared decision-making about ETI from their clinicians.
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Affiliation(s)
- Dave Young
- Department of Biology, University of Washington, Seattle, WA 98195, United States
| | - Lauren E Bartlett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Jennifer Guimbellot
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Tijana Milinic
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Nora Burdis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Eliana R Gill
- Division of Biobehavioral Nursing and Health Informatics, Department of Nursing, University of Washington, Seattle, WA 98195, United States
| | - Erika D Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA 98195, United States; Seattle Children's Research Institute, Seattle, WA 98195, United States
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA 98195, United States.
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12
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Somayaji R, Wessels ME, Milinic T, Ramos KJ, Mayer-Hamblett N, Ramsey BW, Heltshe S, Khan U, Goss CH. Potential implicit bias in attribution of adverse events in randomized controlled trials in cystic fibrosis. J Cyst Fibros 2023; 22:669-673. [PMID: 37286384 PMCID: PMC10529796 DOI: 10.1016/j.jcf.2023.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Although work to date in cystic fibrosis (CF) has elucidated frequencies and characteristics of adverse events, the accuracy of attribution of relatedness to study drug by investigators has not been assessed. We aimed to determine whether there was an association of attribution by group allocation in CF clinical trials. METHODS We conducted a secondary analysis from 4 CF trials of all persons who experienced an AE. Our primary outcome was the odds of an AE related to active study drug and predictor of interest was the treatment allocation. We constructed a multivariable generalized estimating equation model allowing for repeated measures. RESULTS A total of 785 subjects (47.5% female, mean age 12 years) had 11,974 AEs, of which 430 were serious. AE attribution was greater with receipt of active study drug as compared to placebo but did not reach statistical significance (OR 1.38, 95% CI 0.98-1.82). Significantly associated factors included female sex (OR 0.58, 95% 0.39-0.87), age (OR 1.24, 95% CI 1.06-1.46) and baseline lung function (per 10%, OR 1.16, 95% CI 1.05-1.28). CONCLUSION In our large study, there was a non-significant but greater odds of AE attribution (a key element of clinical trial reporting) to active study drug based on assigned treatment to study drug or control which suggests that there is a trend in physicians to attribute blinded safety data to the active drug. Interestingly, females were less likely to have AE attribution to study drug and warrants further work in development and validation of monitoring guidelines and processes.
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Affiliation(s)
| | | | - Tijana Milinic
- Department of Medicine, University of Washington, Seattle, WA USA
| | - Kathleen J Ramos
- Department of Medicine, University of Washington, Seattle, WA USA
| | - Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA
| | - Bonnie W Ramsey
- Seattle Children's Research Institute, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA
| | - Sonya Heltshe
- Seattle Children's Research Institute, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA
| | - Umer Khan
- Seattle Children's Research Institute, Seattle, WA USA
| | - Christopher H Goss
- Seattle Children's Research Institute, Seattle, WA USA; Department of Medicine, University of Washington, Seattle, WA USA; Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA USA.
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13
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McKone E, Ramos KJ, Chaparro C, Blatter J, Hachem R, Anstead M, Vlahos F, Thaxton A, Hempstead S, Daniels T, Murray M, Sole A, Vos R, Tallarico E, Faro A, Pilewski JM. Position paper: Models of post-transplant care for individuals with cystic fibrosis. J Cyst Fibros 2023; 22:374-380. [PMID: 36882349 DOI: 10.1016/j.jcf.2023.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/07/2023]
Abstract
There is no consensus on the best model of care for individuals with CF to manage the non-pulmonary complications that persist after lung transplant. The CF Foundation virtually convened a group of international experts in CF and lung-transplant care. The committee reviewed literature and shared the post-lung transplant model of care practiced by their programs. The committee then developed a survey that was distributed internationally to both the clinical and individual with CF/family audiences to determine the strengths, weaknesses, and preferences for various models of transplant care. Discussion generated two models to accomplish optimal CF care after transplant. The first model incorporates the CF team into care and proposes delineation of responsibilities for the CF and transplant teams. This model is reliant on outstanding communication between the teams, while leveraging the expertise of the CF team for management of the non-pulmonary manifestations of CF. The transplant team manages all aspects of the transplant, including pulmonary concerns and management of immunosuppression. The second model consolidates care in one center and may be more practical for transplant programs that have expertise managing CF and have access to CF multidisciplinary care team members (e.g., located in the same institution). The best model for each program is influenced by several factors and model selection needs to be decided between the transplant and the CF center and may vary from center to center. In either model, CF lung transplant recipients require a clear delineation of the roles and responsibilities of their providers and mechanisms for effective communication.
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Affiliation(s)
- Edward McKone
- St. Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Cecilia Chaparro
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Joshua Blatter
- Washington University in St. Louis, Department of Pediatrics, St. Louis, MO, USA
| | - Ramsey Hachem
- Washington University in St. Louis, Division of Pulmonary & Critical Care, St. Louis, MO, USA
| | - Michael Anstead
- Division of Pulmonary, Critical Care, and Sleep Medicine, Departments of Medicine and Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Fanny Vlahos
- Community Advisor to the Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | | | - Thomas Daniels
- Adult Cystic Fibrosis Physician, University Hospital Southampton, Tremona Road, Southampton, UK
| | - Michelle Murray
- National Lung Transplant Programme, Mater Misericordiae Hospital, University College Dublin, Ireland
| | - Amparo Sole
- Lung Transplant and Adult Cystic Fibrosis Unit, Hospital Universitario La Fe, Universitat de Valencia, Valencia, Spain
| | - Robin Vos
- Division of Respiratory Diseases, Univ. Hospitals Leuven, Belgium and BREATHE, Dept. of CHROMETA, KU Leuven, Leuven, Belgium
| | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 MUH, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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14
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Clausen ES, Weber JM, Neely ML, Ramos KJ, Snyder LD. Erratum to Survival difference between high-risk and low-risk CFTR genotypes after lung transplant. J Heart Lung Transpl 2022;41(10):1511-19. https://doi.org/10.1016/j.healun.2022.04.009. J Heart Lung Transplant 2023; 42:688. [PMID: 37080657 DOI: 10.1016/j.healun.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Affiliation(s)
- Emily S Clausen
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Megan L Neely
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Laurie D Snyder
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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15
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Alkhateeb AA, Mancl LA, Ramos KJ, Rothen ML, Kotsakis GA, Trence DL, Chi DL. Periodontitis Risk Factors in Adults with Cystic Fibrosis: A pilot study. J Dent Hyg 2023; 97:7-21. [PMID: 37068884 PMCID: PMC10694797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/16/2022] [Indexed: 04/19/2023]
Abstract
Purpose Individuals with cystic fibrosis (CF) present with multiple condition-specific risk factors for periodontitis including CF-related diabetes, chronic inhaled treatments that induce xerostomia, and increased systemic inflammation because of frequent lung infections. General factors like age, oral hygiene, and diet may also contribute to the risk of periodontitis. However the relative importance of these specific risk factors and periodontitis in individuals with CF has not yet been evaluated. The purpose of this pilot study was to assess the associations between CF condition-specific and general risk factors and the prevalence of periodontitis in adults with CF.Methods This cross-sectional pilot study was designed to assess a multifactorial model of periodontitis risk factors in a population in adults with CF who were recruited from the University of Washington Adult CF center. Periodontitis was defined using the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC/AAP) case definition. Risk factors included condition-specific and general factors. Differences between participants with moderate/severe periodontitis and those with no/mild periodontitis was assessed using the Mann-Whitney test, the Fisher's exact test, and the exact chi-square test (α=0.05).Results Thirty-two participants were enrolled. Twenty-eight percent of the participants had moderate periodontitis, 72% had no/mild periodontitis; none of the participants had severe periodontitis. There were no significant differences in condition-specific factors between between the two study groups. Participants with moderate periodontitis were older (p=0.028) and reported daily flossing in higher proportions than those with no/mild periodontitis (p=0.023).Conclusions The findings from this pilot study suggest that future research is needed to determine whether sociodemographic and other general risk factors are more important contributors to periodontitis risk than CF-specific factors.
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Affiliation(s)
- Alaa A Alkhateeb
- Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, WA, USA.
- Department of Dental Health Sciences, School of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Lloyd A Mancl
- Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, WA, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Marilynn L Rothen
- Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, WA, USA
| | - Georgios A Kotsakis
- Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, WA, USA
| | - Dace L Trence
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Donald L Chi
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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16
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Jennerich AL, Downey L, Goss CH, Kapnadak SG, Pryor JB, Ramos KJ. Computed tomography body composition and clinical outcomes following lung transplantation in cystic fibrosis. BMC Pulm Med 2023; 23:105. [PMID: 36997883 PMCID: PMC10062009 DOI: 10.1186/s12890-023-02398-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Low muscle mass is common in patients approaching lung transplantation and may be linked to worse post-transplant outcomes. Existing studies assessing muscle mass and post-transplant outcomes include few patients with cystic fibrosis (CF). METHODS Between May 1993 and December 2018, 152 adults with CF received lung transplants at our institution. Of these, 83 met inclusion criteria and had usable computed tomography (CT) scans. Using Cox proportional hazards regression, we evaluated the association between pre-transplant thoracic skeletal muscle index (SMI) and our primary outcome of death after lung transplantation. Secondary outcomes, including days to post-transplant extubation and post-transplant hospital and intensive care unit (ICU) length of stay, were assessed using linear regression. We also examined associations between thoracic SMI and pre-transplant pulmonary function and 6-min walk distance. RESULTS Median thoracic SMI was 26.95 cm2/m2 (IQR 23.97, 31.32) for men and 22.83 cm2/m2 (IQR 21.27, 26.92) for women. There was no association between pre-transplant thoracic SMI and death after transplant (HR 1.03; 95% CI 0.95, 1.11), days to post-transplant extubation, or post-transplant hospital or ICU length of stay. There was an association between pre-transplant thoracic SMI and pre-transplant FEV1% predicted (b = 0.39; 95% CI 0.14, 0.63), with higher SMI associated with higher FEV1% predicted. CONCLUSIONS Skeletal muscle index was low for men and women. We did not identify a significant relationship between pre-transplant thoracic SMI and post-transplant outcomes. There was an association between thoracic SMI and pre-transplant pulmonary function, confirming the potential value of sarcopenia as a marker of disease severity.
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Affiliation(s)
- Ann L Jennerich
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Lois Downey
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Joseph B Pryor
- Department of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
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17
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Hartzler AL, Bartlett LE, Hobler MR, Reid N, Pryor JB, Kapnadak SG, Berry DL, Lober WB, Goss CH, Ramos KJ. Take on transplant: human-centered design of a patient education tool to facilitate informed discussions about lung transplant among people with cystic fibrosis. J Am Med Inform Assoc 2022; 30:26-37. [PMID: 36173364 PMCID: PMC9748576 DOI: 10.1093/jamia/ocac176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/10/2022] [Accepted: 09/23/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Lung transplant (LTx) saves lives in cystic fibrosis (CF). However, many potential candidates express uncertainty about LTx and die before receiving this treatment. CF guidelines recommend LTx education and clinical discussions well before the need for LTx arises, but limited patient resources exist. MATERIALS AND METHODS We engaged people with CF and CF physicians in human-centered design of "Take On Transplant" (TOT), a web-based education tool to prepare patients for LTx discussions. Across 3 phases, needs assessment, design groups, and iterative user testing of TOT, we refined TOT from wireframe prototypes, to an interactive website, to a fully functional intervention ready for clinical trials. RESULTS Fifty-five people with CF and 105 physicians identified information needs to prepare for LTx discussions. Design groups (n = 14 participants) then established core requirements: didactic education ("Resource Library"), patient narratives ("CF Stories"), frequently asked questions ("FAQ"), and self-assessment to tailor content ("My CF Stage"). Iterative usability testing (n = 39) optimized the design of CF Stories and prototype layout. We then developed the TOT website and demonstrated feasibility and preliminary efficacy of use through 2-week field testing (n = 9). DISCUSSION Our human-centered design process provided guidance for educational tools to serve the evolving needs of potential LTx candidates. Our findings support the process of patient deliberation as a foundation for shared decision-making in CF, and inform educational tools that could potentially translate beyond LTx. CONCLUSION TOT fills a critical gap in preparing people with CF for shared decision-making about LTx and may serve as a model for educational tools for other preference-sensitive decisions.
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Affiliation(s)
- Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Lauren E Bartlett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Mara R Hobler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Nick Reid
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Joseph B Pryor
- Department of General Internal Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Donna L Berry
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington, USA
| | - William B Lober
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, Washington, USA
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
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18
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Bayomy OF, Ramos KJ, Hee Wai T, Kapnadak SG, Morrell ED, Nomitch JT, Pollack LR, Lease ED, Aitken ML, Stephenson AL, Goss CH. Hemoptysis and the Risk for Lung Transplant or Death without Transplant in Individuals with Cystic Fibrosis in the United States. Ann Am Thorac Soc 2022; 19:1986-1992. [PMID: 35759341 PMCID: PMC9743473 DOI: 10.1513/annalsats.202202-110oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
Rationale: Hemoptysis is a common and important complication in persons with cystic fibrosis (PwCF). Despite this, there is limited literature on the impact of hemoptysis on contemporary cystic fibrosis (CF) outcomes. Objectives: Evaluate whether hemoptysis increases the risk of lung transplant or death without a transplant in PwCF. Methods: We reviewed a dataset of PwCF ages 12 years or older from the CFFPR (CF Foundation Patient Registry) that included 29,587 individuals. We identified hemoptysis as our predictor of interest and categorized PwCF as either no hemoptysis, any hemoptysis (submassive and/or massive), or massive hemoptysis. We subsequently evaluated whether hemoptysis, as defined above, was associated with death without transplant or receipt of lung transplant via logistic regression. We adjusted for age, sex, body mass index, forced expiratory volume in one second (FEV1), number of exacerbations, supplemental oxygen use, CF-related diabetes, and Pseudomonas aeruginosa colonization status. Subgroup analyses were performed in advanced lung disease, defined as PwCF with an FEV1 <40% predicted. Results: PwCF with any form of hemoptysis were more likely to progress to lung transplant or die without transplant than PwCF who did not have hemoptysis (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.7]). The effect size of these associations was larger when hemoptysis events were classified as "massive" (massive hemoptysis OR, 2.2 [95% CI, 1.2-3.8]) or in PwCF with advanced lung disease (massive hemoptysis in advanced lung disease OR, 3.2 [95% CI 1.3-8.2]). Conclusions: Hemoptysis is associated with an increased risk of lung transplant and death without a transplant in PwCF, especially among those with massive hemoptysis or advanced lung disease. Our results suggest that hemoptysis functions as a useful predictor of serious outcomes in PwCF and may be important to incorporate into risk prediction models and/or transplant decisions in CF.
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Affiliation(s)
- Omar F. Bayomy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Travis Hee Wai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | | | - Eric D. Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Jamie T. Nomitch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Lauren R. Pollack
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Erika D. Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Moira L. Aitken
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Anne L. Stephenson
- Division of Respirology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Christopher H. Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
- Division of Pulmonary Medicine, Department of Pediatrics, University of Washington, Seattle, Washington; and
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Stephenson AL, Swaleh S, Sykes J, Stanojevic S, Ma X, Quon BS, Faro A, Marshall B, Ramos KJ, Ostrenga J, Elbert A, Desai S, Cromwell E, Goss CH. Contemporary cystic fibrosis incidence rates in Canada and the United States. J Cyst Fibros 2022:S1569-1993(22)01390-X. [PMID: 36371312 DOI: 10.1016/j.jcf.2022.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The availability of new diagnostic algorithms for cystic fibrosis (CF), changing population demographics and programs that impact family planning decisions can influence incidence rates. Thus, previously reported incidence rates in Canada and the United States (US) may be outdated. The objectives of this study were to estimate contemporary CF incidence rates in Canada and the US and to determine if the incidence rate has changed over time. METHOD This population-based cohort study utilized data between 1995-2019 from the Canadian CF Registry (CCFR), Statistics Canada, US CF Foundation Patient Registry (CFFPR) data, and US Center for Disease Control (CDC) National Vital Statistics System. Incidence was estimated using the number of live CF births by year, sex, and geographic region using Poisson regression, with the number of live births used as the denominator. To account for delayed diagnoses, we imputed the proportion of diagnoses expected given historical trends, and varying rates of newborn screening (NBS) implementation by region. RESULTS After accounting for implementation of NBS and delayed diagnoses, the estimated incidence rate for CF in 2019 was 1:3848 (95% CI: 1:3574, 1:4143) live births in Canada compared to 1:5130 (95% CI:1:4996, 1:5267) in the US. There was substantial regional variation in incidence rates within both Canada and the US. Since 1995, incidence rates have decreased at a rate of 1.6% per year in both countries (p<0.001). CONCLUSION Contemporary CF incidence rates suggest CF incidence is lower than previously reported and varies widely within North America. This information is important for resource planning and for tracking how programs (e.g., genetic counselling, modulator availability etc.) may impact the incidence of CF moving forward.
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20
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Ramos KJ, Hee Wai T, Stephenson AL, Sykes J, Stanojevic S, Rodriguez PJ, Bansal A, Mayer-Hamblett N, Goss CH, Kapnadak SG. Development and Internal Validation of a Prognostic Model of the Probability of Death or Lung Transplantation Within 2 Years for Patients With Cystic Fibrosis and FEV 1 ≤ 50% Predicted. Chest 2022; 162:757-767. [PMID: 35643116 PMCID: PMC9633811 DOI: 10.1016/j.chest.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 04/19/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Improved methods are needed to risk-stratify patients with cystic fibrosis (CF) and reduced FEV1. RESEARCH QUESTIONS What are the predictors of death or lung transplantation (LTx) within 2 years among patients with CF whose FEV1 ≤ 50% predicted? Do these markers similarly predict outcomes among G551D patients taking ivacaftor since 2012? STUDY DESIGN AND METHODS Patients with CF, age ≥ 6 years with FEV1 ≤ 50% predicted as of December 31, 2014, were identified in a data set that merged Cystic Fibrosis Foundation and United Network for Organ Sharing (UNOS) registries. The least absolute shrinkage and selection operator (LASSO) method was applied to a randomly selected training set to select important prognostic variables. Accuracy and association of the model with death or LTx with 2 years (2-year death or LTx) were validated via logistic regression on an independent test set. Sensitivity analyses explored predictors for patients with UNOS data. RESULTS FEV1 percent predicted (OR, 1.51 for 5% decrease; 95% CI, 1.27-1.81), number of pulmonary exacerbations treated with IV antibiotics (OR, 1.35; 95% CI, 1.11-1.65), and continuous or nocturnal oxygen (OR, 3.71; 95% CI, 1.81-7.59) were significantly associated with 2-year death or LTx. Our model predicted outcomes with greater sensitivity (ratio of sensitivity, 1.26; 95% CI, 1.02-1.54), ratio of positive predictive value (1.25; 95% CI, 1.05-1.51), and ratio of negative predictive value (1.04; 95% CI, 1.01-1.07) than FEV1 < 30% predicted. Among those taking ivacaftor in 2014, only FEV1 remained associated with 2-year death or LTx. For patients with UNOS data, LASSO identified additional covariates of interest, including noninvasive ventilation use, low hemoglobin, pulmonary arterial systolic pressure, supplemental oxygen, mechanical ventilation, FEV1 percent predicted, and cardiac index. INTERPRETATION Among individuals with CF and FEV1 ≤ 50% predicted, FEV1 percent predicted, oxygen therapy, and number of pulmonary exacerbations predicted 2-year death or LTx. Although limited by small sample size, only FEV1 remained predictive in patients receiving highly effective modulator therapy. Additional physiologic variables could improve prognostication in CF.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Travis Hee Wai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Anne L Stephenson
- Department of Respirology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jenna Sykes
- Department of Respirology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Patricia J Rodriguez
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Aasthaa Bansal
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Nicole Mayer-Hamblett
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Research Institute, Seattle, WA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Research Institute, Seattle, WA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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21
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Ramos KJ, Guimbellot JS, Valapour M, Bartlett LE, Wai TH, Goss CH, Pilewski JM, Faro A, Diamond JM. Use of elexacaftor/tezacaftor/ivacaftor among cystic fibrosis lung transplant recipients. J Cyst Fibros 2022; 21:745-752. [PMID: 35474016 PMCID: PMC9509406 DOI: 10.1016/j.jcf.2022.04.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) lung transplant (LT) recipients may warrant treatment with elexacaftor/tezacaftor/ivacaftor (ETI) to improve extrapulmonary manifestations of CF. Our objectives were to identify reasons for prescribing ETI after LT and evaluate changes in body mass index (BMI), hemoglobin A1c, hemoglobin, and liver enzymes. METHODS This was an electronic health record-based cohort study, October 2019-September 2020, at 14 CF LT Consortium sites in North America. The study included CF LT recipients prescribed ETI after transplant. Differences in BMI, A1c, and hemoglobin were assessed with paired t-tests. RESULTS There were 94 patients prescribed ETI; indications included sinus disease (68%), GI symptoms (39%), or low BMI (19%). Prescriptions were written by CF physicians (34%), LT physicians (27%), or physicians who practice both CF and LT (39%). Forty patients (42%) stopped ETI at a median of 56 days [IQR 26, 139] after start/prescription date. ETI was not associated with a significant change in BMI (0.2 kg/m2, 95% CI [-0.1, 0.6], p = 0.150), but was associated with decreased A1c (0.4%, 95% CI 0.2, 0.7, p = 0.003), and increased hemoglobin for patients with anemia (0.6 g/dL, 95% CI 0.2, 1.0, p = 0.007). Three people (3%) stopped ETI due to elevated transaminases. CONCLUSIONS ETI is rarely prescribed for non-pulmonary indications after LT for CF. Further study is needed to determine the risks and benefits of ETI in the CF lung transplant population given the potential for drug interactions, side effects leading to discontinuation of ETI, and the possible mechanisms for ETI to positively impact long-term post-transplant outcomes.
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Affiliation(s)
- Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 1959 NE Pacific Street, Box 356522, Seattle, WA 98195, USA.
| | - Jennifer S Guimbellot
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Lauren E Bartlett
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 1959 NE Pacific Street, Box 356522, Seattle, WA 98195, USA
| | - Travis Hee Wai
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 1959 NE Pacific Street, Box 356522, Seattle, WA 98195, USA
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 1959 NE Pacific Street, Box 356522, Seattle, WA 98195, USA; Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Joseph M Pilewski
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Joshua M Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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22
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Jennerich AL, Pryor JB, Wai TYH, Kapnadak SG, Aitken ML, Goss CH, Ramos KJ. Low body mass index as a barrier to lung transplant in cystic fibrosis. J Cyst Fibros 2022; 21:475-481. [PMID: 34922852 PMCID: PMC9156539 DOI: 10.1016/j.jcf.2021.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/05/2021] [Accepted: 12/05/2021] [Indexed: 11/20/2022]
Abstract
RATIONALE Low body mass index (BMI) may influence lung transplant decisions for patients with advanced cystic fibrosis (CF) lung disease. OBJECTIVE Determine whether patients with advanced CF lung disease and BMI ≤17 kg/m2 are less likely to be listed for lung transplant or have a higher risk of death without listing compared to those with higher BMI. METHODS Using merged United Network for Organ Sharing and CF Foundation Patient Registries, we identified adults with onset of advanced lung disease (FEV1 ≤ 40% predicted) between May-2005 and December-2016. We analyzed survival using competing risks regression with cause-specific risks of listing for lung transplant and death without listing. BMI ≤ 17 kg/m2 was our predictor. MEASUREMENTS AND MAIN RESULTS Among 5,121 CF patients with advanced lung disease, 23% were listed for lung transplant (n = 1,201), 23% died without listing (n = 1,190), and 44% were alive without listing (n = 2,730) as of December-2016. Patients with BMI ≤ 17 kg/m2 were less likely to be listed for transplant (HR 0.69; 95% CI 0.57, 0.83) and more likely to die without listing (HR 1.63; 95% CI 1.41, 1.88). We identified important regional variations in the likelihood of referral and listing, based on BMI. CONCLUSIONS Patients with advanced CF lung disease and BMI ≤ 17 kg/m2 are less likely to be listed for lung transplant and have a higher risk of dying without listing, compared to those with higher BMI. Regional differences suggest access to transplant for malnourished CF patients may be limited by location.
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Affiliation(s)
- Ann L Jennerich
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, United States.
| | - Joseph B Pryor
- Department of General Internal Medicine, University of Washington, Seattle, WA, United States
| | - Travis Y Hee Wai
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, United States
| | - Siddhartha G Kapnadak
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, United States
| | - Moira L Aitken
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, United States
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, United States; Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, United States
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23
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Ramos KJ, Wai TH, Sykes J, Ma X, Stephenson AL, Jennerich AL, Kapnadak SG, Mayer-Hamblett N, Goss CH. Validation of the French 3-year prognostic score for death or lung transplant in the United States cystic fibrosis population. J Cyst Fibros 2022; 21:471-474. [PMID: 34465539 PMCID: PMC8882706 DOI: 10.1016/j.jcf.2021.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/22/2021] [Accepted: 08/11/2021] [Indexed: 11/30/2022]
Abstract
In 2017, Nkam et al. published a prognostic score to predict death or lung transplant within 3 years among adult cystic fibrosis (CF) patients. Their model was developed using French CF registry data and was subsequently validated in the Canadian CF registry. We evaluated this prognostic score using data from adult patients with CF in the United States (US) CF Foundation Patient registry, combined with lung transplant records from the United Network for Organ Sharing (UNOS) Registry (2013 to 2016) (n=11,542). We found that the prognostic score had a very good discriminative index predicting death or lung transplant in the US CF population (AUC 0.88, 95% CI 0.88-0.89) with an odds ratio (OR) of 2.83 (95% CI 2.69 - 2.97) for each unit increase in the score. However, it did not provide significant additional utility over an FEV1 ≤30% of predicted as a predictor of death or lung transplant.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Travis Hee Wai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jenna Sykes
- Department of Respirology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Xiayi Ma
- Department of Respirology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anne L Stephenson
- Department of Respirology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA
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24
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Brahmbhatt JM, Wai TH, Goss CH, Lease ED, Merlo CA, Kapnadak SG, Ramos KJ. The Lung Allocation Score and Other Available Models Lack Predictive Accuracy for Post-Lung Transplant Survival. J Heart Lung Transplant 2022; 41:1063-1074. [PMID: 35690561 PMCID: PMC9329266 DOI: 10.1016/j.healun.2022.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/29/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Improved predictive models are needed in lung transplantation in the setting of a proposed allocation system that incorporates longer-term post-transplant survival in the United States. Allocation systems require accurate mortality predictions to justly allocate organs. METHODS Utilizing the United Network for Organ Sharing database (2005-2017), we fit models to predict 1-year mortality based on the Lung Allocation Score (LAS), the Chan, et al, 2019 model, a novel "clinician" model (a priori clinician selection of pre-transplant covariates), and two machine learning models (Least Absolute Shrinkage and Selection Operator; LASSO and Random Forests) for predicting 1-year and 3-year post-transplant mortality. We compared predictive accuracy among models. We evaluated the calibration of models by comparing average predicted probability vs observed outcome per decile. We repeated analyses fit for 3-year mortality, disease category, including donor covariates, and LAS era. RESULTS The area under the cure for all models was low, ranging from 0.55 to 0.62. All exhibited reasonable negative predictive values (0.87-0.90), but the positive predictive value for was poor (all <0.25). Evaluating LAS calibration found 1-year post-transplant estimates consistently overestimated risk of mortality, with greater differences in higher deciles. LASSO, Random Forests, and clinician models showed no improvement when evaluated by disease category or with the addition of donor covariates and performed worse for 3-year outcomes. CONCLUSIONS The LAS overestimated patients' risk of post-transplant death, thus underestimating transplant benefit in the sickest candidates. Novel models based on pre-transplant recipient covariates failed to improve prediction. There should be wariness in post-transplant survival predictions from available models.
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25
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Morrell ED, Brager C, Ramos KJ, Chai XY, Kapnadak SG, Edelman J, Matute-Bello G, Altemeier WA, Hwang B, Mulligan MS, Bhatraju PK, Wurfel MM, Mikacenic C, Lease ED, Limaye AP, Fisher CE. CXCL10 and Soluble Programmed Death-Ligand 1 during Respiratory Viral Infections Are Associated with Chronic Lung Allograft Dysfunction in Lung Transplant Recipients. Am J Respir Cell Mol Biol 2022; 66:577-579. [PMID: 35486077 PMCID: PMC9116355 DOI: 10.1165/rcmb.2021-0404le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eric D Morrell
- University of Washington Seattle, Washington.,VA Puget Sound Health Care System Seattle, Washington.,University of Washington at South Lake Union Campus Seattle, Washington
| | | | | | - Xin-Ya Chai
- University of Washington Seattle, Washington
| | | | - Jeffrey Edelman
- University of Washington Seattle, Washington.,VA Puget Sound Health Care System Seattle, Washington
| | - Gustavo Matute-Bello
- University of Washington Seattle, Washington.,VA Puget Sound Health Care System Seattle, Washington.,University of Washington at South Lake Union Campus Seattle, Washington
| | - William A Altemeier
- University of Washington Seattle, Washington.,University of Washington at South Lake Union Campus Seattle, Washington
| | - Billanna Hwang
- University of Washington Seattle, Washington.,University of Washington at South Lake Union Campus Seattle, Washington
| | - Michael S Mulligan
- University of Washington Seattle, Washington.,University of Washington at South Lake Union Campus Seattle, Washington
| | | | - Mark M Wurfel
- University of Washington Seattle, Washington.,University of Washington at South Lake Union Campus Seattle, Washington
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26
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Solomon M, Willemse BW, Ramos KJ, Leard LE. Response to Selection of lung transplant candidates: A pediatric perspective on the ISHLT consensus document. J Heart Lung Transplant 2022; 41:1000-1001. [DOI: 10.1016/j.healun.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022] Open
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27
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Rodriguez PJ, Veenstra DL, Heagerty PJ, Goss CH, Ramos KJ, Bansal A. A Framework for Using Real-World Data and Health Outcomes Modeling to Evaluate Machine Learning-Based Risk Prediction Models. Value Health 2022; 25:350-358. [PMID: 35227445 PMCID: PMC9311314 DOI: 10.1016/j.jval.2021.11.1360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/19/2021] [Accepted: 11/16/2021] [Indexed: 05/06/2023]
Abstract
OBJECTIVES We propose a framework of health outcomes modeling with dynamic decision making and real-world data (RWD) to evaluate the potential utility of novel risk prediction models in clinical practice. Lung transplant (LTx) referral decisions in cystic fibrosis offer a complex case study. METHODS We used longitudinal RWD for a cohort of adults (n = 4247) from the Cystic Fibrosis Foundation Patient Registry to compare outcomes of an LTx referral policy based on machine learning (ML) mortality risk predictions to referral based on (1) forced expiratory volume in 1 second (FEV1) alone and (2) heterogenous usual care (UC). We then developed a patient-level simulation model to project number of patients referred for LTx and 5-year survival, accounting for transplant availability, organ allocation policy, and heterogenous treatment effects. RESULTS Only 12% of patients (95% confidence interval 11%-13%) were referred for LTx over 5 years under UC, compared with 19% (18%-20%) under FEV1 and 20% (19%-22%) under ML. Of 309 patients who died before LTx referral under UC, 31% (27%-36%) would have been referred under FEV1 and 40% (35%-45%) would have been referred under ML. Given a fixed supply of organs, differences in referral time did not lead to significant differences in transplants, pretransplant or post-transplant deaths, or overall survival in 5 years. CONCLUSIONS Health outcomes modeling with RWD may help to identify novel ML risk prediction models with high potential real-world clinical utility and rule out further investment in models that are unlikely to offer meaningful real-world benefits.
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Affiliation(s)
- Patricia J Rodriguez
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA.
| | - David L Veenstra
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | | | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA; Division of Pulmonology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Aasthaa Bansal
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA.
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28
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Reid N, Ramos KJ, Hobler MR, Bartlett LE, Pryor JB, Berry DL, Basile M, Kapnadak SG, Hartzler AL. Usability preferences of people living with cystic fibrosis about a lung transplant education website. AMIA Annu Symp Proc 2022; 2022:922-931. [PMID: 37128444 PMCID: PMC10148363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
People living with cystic fibrosis (CF) need educational resources about lung transplant prior to engaging in shared decision making with their medical providers. We conducted a usability study to elicit preferences of people living with CF about how didactic and experiential content could be used in an educational resource to learn about lung transplant. We created two prototypes with different design features that participants used in a scenario-based task and evaluated using the System Usability Scale. We interviewed participants and analyzed the data to understand their preferences for educational content and design. Study participants indicated that didactic resource articles were important to understanding their illness trajectory, while experiential patient stories supported fear reduction and knowledge discovery. When learning about lung transplant participants stated a preference to control the amount of information they receive and preferred a combination of didactic and experiential knowledge.
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Affiliation(s)
- Nick Reid
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, WA, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Mara R Hobler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lauren E Bartlett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph B Pryor
- Department of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Donna L Berry
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA
| | | | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, WA, USA
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29
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Kapnadak SG, Morrell ED, Wai TH, Goss CH, Shah PD, Merlo CA, Hachem RR, Ramos KJ. Variability in azithromycin practices among lung transplant providers in the International Society for Heart and Lung Transplantation Community. J Heart Lung Transplant 2022; 41:20-23. [PMID: 34785136 PMCID: PMC8742766 DOI: 10.1016/j.healun.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/09/2021] [Accepted: 10/05/2021] [Indexed: 01/03/2023] Open
Abstract
Chronic lung allograft dysfunction (CLAD) is the most important long-term complication after lung transplant (LTx), and clinical experience suggests significant variability in its management. We sought to capture azithromycin practices among LTx providers internationally. A survey was distributed via the International Society for Heart and Lung Transplantation and completed by 103 respondents (15 countries). Azithromycin indications, timing, and dosing varied significantly, and 37 (36%) reported inconsistency even within their center. Thirty (29%) reported initiating azithromycin prophylactically (during initial transplant hospitalization). Of 73 others, only 10 (14%) reported waiting until CLAD diagnosis (with persistent ≥20% pulmonary function decline). Most initiated azithromycin after a CLAD risk-factor and/or event, including 59 (81%) for a persistent ≥10% decrement in FEV1, 32 (44%) for lymphocytic bronchiolitis, and 27 (37%) for bronchoalveolar lavage neutrophilia. Azithromycin prescribing patterns appear to vary significantly, and further study is needed to elucidate the optimal timing and indications for its initiation after LTx.
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Affiliation(s)
- Siddhartha G. Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA,Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Travis Hee Wai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher H. Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Pali D. Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ramsey R. Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, MO, USA
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Bayomy OF, Ramos KJ, Goss CH. Improving lung transplant outcomes in France: the high emergency lung transplantation programme. Eur Respir J 2022; 59:59/1/2102209. [PMID: 35086845 PMCID: PMC8896388 DOI: 10.1183/13993003.02209-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/22/2021] [Indexed: 01/29/2023]
Affiliation(s)
- Omar F. Bayomy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher H. Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA,Division of Pulmonary Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
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Ramos KJ, Sykes J, Stanojevic S, Ma X, Ostrenga JS, Fink A, Quon BS, Marshall BC, Faro A, Petren K, Elbert A, Goss CH, Stephenson AL. Survival and Lung Transplant Outcomes for Individuals With Advanced Cystic Fibrosis Lung Disease Living in the United States and Canada: An Analysis of National Registries. Chest 2021; 160:843-853. [PMID: 33878343 DOI: 10.1016/j.chest.2021.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Understanding how health outcomes differ for patients with advanced cystic fibrosis (CF) lung disease living in the United States compared with Canada has health policy implications. RESEARCH QUESTION What are rates of lung transplant (LTx) and rates of death without LTx in the United States and Canada among individuals with FEV1 < 40% predicted? STUDY DESIGN AND METHODS This was a retrospective population-based cohort study, 2005 to 2016, using the US CF Foundation, United Network for Organ Sharing, and Canadian CF registries. Individuals with CF and at least two FEV1 measurements < 40% predicted within a 5-year period, age ≥ 6 years, without prior LTx were included. Multivariable competing risk regression for time to death without LTx (LTx as a competing risk) and time to LTx (death as a competing risk) was performed. RESULTS There were 5,899 patients (53% male) and 905 patients (54% male) with CF with FEV1 < 40% predicted living in the United States and Canada, respectively. Multivariable competing risk regression models identified an increased risk of death without LTx (hazard ratio [HR], 1.79; 95% CI, 1.52-2.1) and decreased LTx (HR, 0.66; 95% CI, 0.58-0.74) among individuals in the United States compared with Canada. More pronounced differences were seen in the patients in the United States with Medicaid/Medicare insurance compared with Canadians (multivariable HR for death without LTx, 2.24 [95% CI, 1.89-2.64]; multivariable HR for LTx, 0.54 [95% CI, 0.47-0.61]). Patients of nonwhite race were also disadvantaged (multivariable HR for death without LTx, 1.56 [95% CI, 1.32-1.84]; multivariable HR for LTx, 0.47 [95% CI, 0.36-0.62]). INTERPRETATION There are lower rates of LTx and an increased risk of death without LTx for US patients with CF with FEV1 < 40% predicted compared with Canadian patients. Findings are more striking among US patients with CF with Medicaid/Medicare health insurance, and nonwhite patients in both countries, raising concerns about underuse of LTx among vulnerable populations.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Jenna Sykes
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Xiayi Ma
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Bradley S Quon
- Division of Respirology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Anne L Stephenson
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Stephenson AL, Ramos KJ, Sykes J, Ma X, Stanojevic S, Quon BS, Marshall BC, Petren K, Ostrenga JS, Fink AK, Faro A, Elbert A, Chaparro C, Goss CH. Bridging the survival gap in cystic fibrosis: An investigation of lung transplant outcomes in Canada and the United States. J Heart Lung Transplant 2021; 40:201-209. [PMID: 33386232 PMCID: PMC7925420 DOI: 10.1016/j.healun.2020.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/13/2020] [Accepted: 12/03/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Previous literature in cystic fibrosis (CF) has shown a 10-year survival gap between Canada and the United States (US). We hypothesized that differential access to and survival after lung transplantation may contribute to the observed gap. The objectives of this study were to compare CF transplant outcomes between Canada and the US and estimate the potential contribution of transplantation to the survival gap. METHODS Data from the Canadian CF Registry and the US Cystic Fibrosis Foundation Patient Registry supplemented with data from United Network for Organ Sharing were used. The probability of surviving after transplantation between 2005 and 2016 was calculated using the Kaplan‒Meier method. Survival by insurance status at the time of transplantation and transplant center volume in the US were compared with those in Canada using Cox proportional hazard models. Simulations were used to estimate the contribution of transplantation to the survival gap. RESULTS Between 2005 and 2016, there were 2,653 patients in the US and 470 in Canada who underwent lung transplantation for CF. The 1-, 3-, and 5-year survival rates were 88.3%, 71.8%, and 60.3%, respectively, in the US compared with 90.5%, 79.9%, and 69.7%, respectively, in Canada. Patients in the US were also more likely to die on the waitlist (p < 0.01) than patients in Canada. If the proportion of who underwent transplantation and post-transplant survival in the US were to increase to those observed in Canada, we estimate that the survival gap would decrease from 10.8 years to 7.5 years. CONCLUSIONS Differences in waitlist mortality and post-transplant survival can explain up to a third of the survival gap observed between the US and Canada.
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Affiliation(s)
- Anne L Stephenson
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Jenna Sykes
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Xiayi Ma
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | - Cecilia Chaparro
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington; Division of Pediatric Pulmonary, Department of Pediatrics, University of Washington Medical Center, Seattle, Washington
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Kapnadak SG, Ramos KJ, Dellon EP. Enhancing care for individuals with advanced cystic fibrosis lung disease. Pediatr Pulmonol 2021; 56 Suppl 1:S69-S78. [PMID: 32609949 DOI: 10.1002/ppul.24937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 11/09/2022]
Abstract
While remarkable advances in cystic fibrosis (CF) care have led to improvements in survival and quality of life, many individuals with CF are living with advanced cystic fibrosis lung disease (ACFLD) and others will face continued disease progression and its associated complex treatments and choices. This review will provide a summary of recently published guidelines for ACFLD care and lung transplant referral and highlight ongoing work to enhance the care of those with ACFLD through improvements in medical and psychosocial care, palliative care, and care around lung transplantation.
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Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Department of Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Kathleen J Ramos
- Division of Pulmonary, Department of Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Elisabeth P Dellon
- Division of Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Ramos KJ, Pilewski JM, Taylor-Cousar JL. Challenges in the use of highly effective modulator treatment for cystic fibrosis. J Cyst Fibros 2021; 20:381-387. [PMID: 33531206 DOI: 10.1016/j.jcf.2021.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/12/2021] [Accepted: 01/18/2021] [Indexed: 12/23/2022]
Abstract
The last decade has seen development of oral, small molecule therapies that address the basic cystic fibrosis transmembrane conductance regulator (CFTR) protein defect. Highly effective modulator treatment (HEMT) that is efficacious for a large majority of people living with cystic fibrosis (CF) promises to change the landscape of this chronic life-limiting disease. Some people living with CF have a CFTR genotype that renders them eligible for HEMT, but also have comorbidities that excluded them from the original Phase III clinical trials that led to US Food and Drug Administration approval. The purpose of this review is to address the use of HEMT in challenging situations, including initiation for those with advanced CF lung disease, and use after solid organ transplant, during pregnancy, and for individuals with CFTR-related disorders without a definitive diagnosis of CF.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer L Taylor-Cousar
- Divisions of Pulmonary, Critical Care and Sleep Medicine and Pediatric Pulmonary Medicine, National Jewish Health, Denver, CO, USA
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Smith PJ, Dunitz JM, Lucy A, Hempstead SE, Tallarico E, Faro A, Pilewski JM, Ramos KJ. Incorporating patient and caregiver feedback into lung transplant referral guidelines for individuals with cystic fibrosis-Preliminary findings from a novel paradigm. Clin Transplant 2020; 34:e14038. [PMID: 32654238 DOI: 10.1111/ctr.14038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/27/2020] [Accepted: 06/25/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lung transplantation is a common therapeutic option for individuals with cystic fibrosis (CF) and advanced lung disease, yet many individuals with CF are not appropriately referred for evaluation. The present study sought to enhance CF transplant referral guidelines by integrating patient-centered input to identify possible psychosocial barriers contributing to suboptimal referral for appropriate CF transplant candidates. METHODS As a component of developing the Cystic Fibrosis Foundation (CFF) Lung Transplant Referral Consensus Guidelines, we convened a focus group of lung transplant recipients with CF and two spouses of CF recipients. Each session involved standardized approaches to elicit qualitative, thematic content. RESULTS CF patients and caregivers characterized five areas for improvement, which were integrated into formal CFF referral guidelines. These included (a) timing of transplant discussion with CF providers, (b) accuracy of transplant-related knowledge and expectations, (c) stigma associated with the need for transplantation, (d) treatment team transition issues, and (e) social support and mental health concerns. Earlier introduction of transplant, greater details regarding manageable aspects of treatment, and greater provision of social support were all associated with better psychosocial experiences. CONCLUSIONS Integrating patient-centered input into guideline development yielded important and previously unknown psychosocial barriers contributing to suboptimal transplant referral.
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Affiliation(s)
- Patrick J Smith
- Departments of Psychiatry, Medicine, and Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jordan M Dunitz
- Division of Pulmonary, Allergy, Critical Care Medicine and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Amy Lucy
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Ramos KJ, Kapnadak SG, Collins BF, Pottinger PS, Wall R, Mays JA, Perchetti GA, Jerome KR, Khot S, Limaye AP, Mathias PC, Greninger A. Detection of SARS-CoV-2 by bronchoscopy after negative nasopharyngeal testing: Stay vigilant for COVID-19. Respir Med Case Rep 2020; 30:101120. [PMID: 32566476 PMCID: PMC7298516 DOI: 10.1016/j.rmcr.2020.101120] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/07/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Real-time polymerase chain reaction (RT-PCR) detection of severe acute respiratory syndrome coronavirus (SARS-CoV-2) is required for diagnosis of coronavirus disease 2019 (COVID-19). Sensitivity of RT-PCR nasopharyngeal (NP) testing is presumed to be high, but there is no gold standard against which this has been determined. The objective was to determine whether lower respiratory tract infection (LRTI), detected in bronchoalveolar lavage fluid (BALF), occurs in the absence of upper respiratory tract infection with clinical testing of both specimen types. METHODS Between March 26, 2020 and April 17, 2020 at the University of Washington Medical Center all patients with BALF specimens clinically tested for SARS-CoV-2 were identified. We assessed the proportion of patients with positive RT-PCR for SARS-CoV-2 in BALF after negative NP testing. We describe 3 cases with positive testing in BALF. RESULTS Among 16 patients with BALF samples, 3 cases (19%) had SARS-CoV-2 detected in BALF. In Case 1, negative NP testing occurred early in the infection and respiratory symptoms may have been missed due to neurologic injury. In Case 2, outpatient diagnosis was aspiration pneumonia, but clinical suspicion remained high for COVID-19 at hospitalization based on epidemiological and clinical features. All 3 cases involved older adults (age >65 years), one of whom was immunosuppressed in the setting of lung transplantation (Case 3). CONCLUSIONS These data demonstrate that SARS-CoV-2 LRTI occurs in the presence of negative NP testing. NP testing may underestimate the prevalence of COVID-19 and has implications for spread of SARS-CoV2 in the community and healthcare setting.
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Affiliation(s)
- Kathleen J. Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Siddhartha G. Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Bridget F. Collins
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Paul S. Pottinger
- Division of Allergy & Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Richard Wall
- Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Washington Valley Medical Center, Renton, WA, USA
| | - James A. Mays
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Garrett A. Perchetti
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Keith R. Jerome
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sandeep Khot
- Department of Neurology, University of Washington Medical Center, Seattle, WA, USA
| | - Ajit P. Limaye
- Division of Allergy & Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Patrick C. Mathias
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, WA, USA
| | - Alexander Greninger
- Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Ramos KJ, Pilewski JM, Faro A, Marshall BC. Improved Prognosis in Cystic Fibrosis: Consideration for Intensive Care during the COVID-19 Pandemic. Am J Respir Crit Care Med 2020; 201:1434-1435. [PMID: 32289235 PMCID: PMC7258637 DOI: 10.1164/rccm.202004-0999le] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Albert Faro
- Cystic Fibrosis FoundationBethesda, Maryland
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Ramos KJ, Kapnadak SG, Bradford MC, Somayaji R, Morrell ED, Pilewski JM, Lease ED, Mulligan MS, Aitken ML, Gries CJ, Goss CH. Underweight Patients With Cystic Fibrosis Have Acceptable Survival Following Lung Transplantation: A United Network for Organ Sharing Registry Study. Chest 2020; 157:898-906. [PMID: 31958441 DOI: 10.1016/j.chest.2019.11.043] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 11/13/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Reduced BMI is an absolute contraindication for lung transplantation (LTx) at most centers in the United States. The objective of this study was to quantify post-LTx survival of moderate to severely underweight patients with cystic fibrosis (CF) (BMI < 17 kg/m2) in the United States relative to normal-weight recipients with CF and other frequently transplanted patient cohorts. METHODS Using United Network for Organ Sharing Registry data (undergoing transplant from June 2005-November 2015), Kaplan-Meier estimates of median posttransplant survival were calculated for all patients with CF, COPD, and idiopathic pulmonary fibrosis (IPF), as well as low and normal weight CF subgroups. Cox regression modeling stratified according to transplant center assessed risk of posttransplant mortality in recipients with CF and a BMI < 17 kg/m2 compared with recipients with COPD (reference). RESULTS Median posttransplant survival (95% CI) for CF, COPD, and IPF was 7.9 (7.2-8.6), 5.9 (5.6-6.2), and 5.5 (5.2-5.8) years, respectively. Although an absolute decrease was noted in posttransplant survival for recipients with CF and a BMI < 17 kg/m2, compared with those with CF and a BMI ≥ 17 kg/m2 (7.0 years [4.5-7.9] vs 8.2 years [7.3-9.0]), Cox modeling found no increased mortality risk (adjusted hazard ratio, 1.09; 95% CI, 0.90-1.32; P = .38). There was no difference in posttransplant mortality between patients with CF and a BMI < 17 kg/m2 and recipients with COPD and all BMIs (adjusted hazard ratio, 1.04; 95% CI, 0.86-1.25; P = .71). CONCLUSIONS Transplant recipients with CF and a BMI < 17 kg/m2 had posttransplant survival rates comparable to those of other groups frequently undergoing transplantation. BMI < 17 kg/m2 as a single risk factor in the CF population should not be treated as an absolute contraindication to LTx.
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Affiliation(s)
- Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA.
| | - Siddhartha G Kapnadak
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA
| | - Miranda C Bradford
- Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, WA
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eric D Morrell
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA
| | - Joseph M Pilewski
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Erika D Lease
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA
| | - Michael S Mulligan
- Department of Surgery, Division of Cardiothoracic Surgery, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA
| | - Moira L Aitken
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA
| | - Cynthia J Gries
- Advent Health Transplant Institute, Advent Health Hospital, Orlando, FL
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA; Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA; Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, WA
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Affiliation(s)
- Kathleen J Ramos
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine University of Washington Seattle, Washington
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Parkins MD, Ramos KJ, Goss CH, Somayaji R. Cytomegalovirus: an unrecognised potential contributor to cystic fibrosis disease progression? Eur Respir J 2019; 53:13993003.01727-2018. [PMID: 30956206 DOI: 10.1183/13993003.01727-2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/10/2019] [Indexed: 12/30/2022]
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Ramos KJ, Hobler MR, Engelberg RA, Curtis JR, Zander MI, Howard SS, Goss CH, Aitken ML. Addressing lung transplant with adults with cystic fibrosis: A qualitative analysis of patients' perspectives and experiences. J Cyst Fibros 2019; 18:416-419. [PMID: 31003953 DOI: 10.1016/j.jcf.2019.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 03/29/2019] [Accepted: 04/05/2019] [Indexed: 12/21/2022]
Abstract
Referral for lung transplantation is a complex process that typically begins with a discussion in cystic fibrosis (CF) clinic. We performed a secondary analysis of interviews conducted at the University of Washington CF Clinic as part of a study of unmet palliative care needs, June 2015 - January 2016, among adults with moderate-to-severe CF-related lung disease. Content analysis methods were used to identify themes related to discussion of lung transplant in CF clinic. Thirty-two of 48 interviews (67%) addressed transplant. An individual's willingness to discuss transplant was not necessarily related to the degree of lung function impairment. Patients reported reliance on CF physicians as a source of accurate information about transplant. Individuals with CF sometimes reported feeling too old or not worthy of transplant. Many had apprehensive or ambivalent feelings towards transplant. Patient-identified barriers and facilitators to lung transplant discussions can inform physicians as they discuss transplant in CF clinic.
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Affiliation(s)
- Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Mara R Hobler
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Ruth A Engelberg
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Miriam I Zander
- Department of Internal Medicine, Cooper University Hospital, Camden, NJ, USA
| | - Shacole S Howard
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA, USA; Seattle Children's Hospital, Seattle, WA, USA
| | - Moira L Aitken
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
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Ramos KJ, Smith PJ, McKone EF, Pilewski JM, Lucy A, Hempstead SE, Tallarico E, Faro A, Rosenbluth DB, Gray AL, Dunitz JM. Lung transplant referral for individuals with cystic fibrosis: Cystic Fibrosis Foundation consensus guidelines. J Cyst Fibros 2019; 18:321-333. [PMID: 30926322 DOI: 10.1016/j.jcf.2019.03.002] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Provide recommendations to the cystic fibrosis (CF) community to facilitate timely referral for lung transplantation for individuals with CF. METHODS The CF Foundation organized a multidisciplinary committee to develop CF Lung Transplant Referral Consensus Guidelines. Three workgroups were formed: timing for transplant referral; modifiable barriers to transplant; and transition to transplant care. A focus group of lung transplant recipients with CF and spouses of CF recipients informed guideline development. RESULTS The committee formulated 21 recommendation statements based on literature review, committee member practices, focus group insights, and in response to public comment. Critical approaches to optimizing access to lung transplant include early discussion of this treatment option, assessment for modifiable barriers to transplant, and open communication between the CF and lung transplant centers. CONCLUSIONS These guidelines will help CF providers counsel their patients and may reduce the number of individuals with CF who die without consideration for lung transplant.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA.
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Behavioral Medicine Division, Department of Medicine, Pulmonary Division, Duke University Medical Center, Durham, NC, USA.
| | - Edward F McKone
- National Referral Centre for Adult Cystic Fibrosis, St. Vincent's University Hospital, Dublin, Ireland.
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Amy Lucy
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA.
| | - Daniel B Rosenbluth
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Alice L Gray
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
| | - Jordan M Dunitz
- Division of Pulmonary, Allergy, Critical Care Medicine and Sleep, Dept of Medicine, University of Minnesota, Minneapolis, MN, USA.
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Crull MR, Somayaji R, Ramos KJ, Caldwell E, Mayer-Hamblett N, Aitken ML, Nichols DP, Rowhani-Rahbar A, Goss CH. Changing Rates of Chronic Pseudomonas aeruginosa Infections in Cystic Fibrosis: A Population-Based Cohort Study. Clin Infect Dis 2018; 67:1089-1095. [PMID: 29534149 PMCID: PMC6137120 DOI: 10.1093/cid/ciy215] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 03/08/2018] [Indexed: 12/26/2022] Open
Abstract
Background Chronic Pseudomonas aeruginosa lung infection is associated with significant morbidity and mortality in cystic fibrosis (CF). It is not known whether recent advances in care have affected the rates of chronic infection. We aimed to determine if the rates of developing new chronic P. aeruginosa infection among adolescents and adults with CF significantly changed over time. Methods The cohort consisted of individuals with CF followed in the Cystic Fibrosis Foundation Patient Registry aged ≥13 years without chronic P. aeruginosa at baseline. Multivariable regression models accounting for within-patient correlation were used to assess the change in rate of developing chronic P. aeruginosa infection between 2003 and 2012. Results A total of 15504 individuals were followed for a median of 5 (interquartile range, 2-9) years. The annual rates of developing new chronic P. aeruginosa decreased from 14.3% in 2003 to 6.4% in 2012. After adjusting for potential confounders, relative risk (RR) of developing chronic P. aeruginosa infection decreased significantly over time compared to 2003 (P value test of trend < .001). Compared with 2003, the RR of developing chronic P. aeruginosa infection in 2012 was 0.33 (95% confidence interval, 0.30-0.37). No significant increases in risk of chronic infections with other major CF bacterial pathogens relative to 2003 were identified. Conclusions Among individuals with CF, a significant decrease in the risk and rates of developing chronic P. aeruginosa infection between 2003 and 2012 was observed. Whether this decline results in changes in clinical outcomes warrants further exploration.
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Affiliation(s)
| | - Ranjani Somayaji
- Department of Medicine, University of Washington, Seattle
- Department of Medicine, University of Calgary, Alberta, Canada
| | | | - Ellen Caldwell
- Department of Medicine, University of Washington, Seattle
| | | | - Moira L Aitken
- Department of Medicine, University of Washington, Seattle
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Hobler MR, Engelberg RA, Curtis JR, Ramos KJ, Zander MI, Howard SS, Goss CH, Aitken ML. Exploring Opportunities for Primary Outpatient Palliative Care for Adults with Cystic Fibrosis: A Mixed-Methods Study of Patients' Needs. J Palliat Med 2018; 21:513-521. [PMID: 29298400 DOI: 10.1089/jpm.2017.0259] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Persons with cystic fibrosis (CF) experience high morbidity and mortality, yet little is known about their palliative care needs and how clinicians may address these needs. OBJECTIVES (1) To identify palliative care and advance care planning needs of patients with CF and their families; and (2) to identify clinicians' potential roles in meeting these needs. METHODS A mixed-methods study of adult patients (age ≥18 years) with moderate-to-severe CF [forced expiratory volume in the first second (FEV1) <65% predicted] were recruited from a CF Center. Semi-structured interviews (30-60 minutes) and questionnaires were administered in person or by phone. Grounded theory was used to analyze the interviews. Questionnaires were analyzed descriptively. RESULTS Forty-nine patients (FEV1 % range = 19%-63%) participated; the participation rate was 80% for eligible patients. Three main domains of palliative care needs were identified: (1) to be listened to, feel heard, and be "seen"; (2) understanding the context around CF and its trajectory, with the goal of preparing for the future; and (3) information about, and potential solutions to, practical and current circumstances that cause stress. In questionnaires, few patients (4.3%) reported talking with their clinician about their wishes for care if they were to become sicker, but mixed-methods data demonstrated that more than half of participants were willing to receive palliative care services provided those services were adapted to CF. CONCLUSION Patients expressed a need for and openness to palliative care services, as well as some reluctance. They appreciated clinician communication that was open, forthcoming, and attuned to individualized concerns.
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Affiliation(s)
- Mara R Hobler
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle, Washington
| | - J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle, Washington
| | - Kathleen J Ramos
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle, Washington
| | - Miriam I Zander
- 3 Touro College of Osteopathic Medicine , New York, New York
| | - Shacole S Howard
- 4 Sports Medicine Center, University of Washington Medical Center , Seattle, Washington
| | - Christopher H Goss
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle, Washington.,5 Seattle Children's Hospital , Seattle, Washington.,6 Pediatric Pulmonology, Department of Pediatrics, University of Washington , Seattle, Washington
| | - Moira L Aitken
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington , Seattle, Washington
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45
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Affiliation(s)
- Sonya L Heltshe
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and.,2 Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Jonathan Cogen
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and
| | - Kathleen J Ramos
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington; and
| | - Christopher H Goss
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and.,3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington; and.,2 Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
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46
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Kapnadak SG, Kicska GA, Ramos KJ, Marshall DA, Carroll TY, Pipavath SN, Mulligan MS, Goss CH, Aitken ML. Tracheal diverticula in advanced cystic fibrosis: Prevalence, features, and outcomes after lung transplantation. J Cyst Fibros 2017; 16:735-743. [PMID: 28757079 DOI: 10.1016/j.jcf.2017.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tracheal diverticula (TD) are rare anomalies that may harbor infected secretions, posing potential risk to patients with lung disease. In an end-stage cystic fibrosis (CF) cohort, we describe the characteristics and associated post-lung transplant (LTx) outcomes of TD. METHODS Pre-transplant computed tomography (CT)'s were reviewed in CF patients undergoing LTx. TD were characterized radiographically and on autopsy when available. Pre-transplant clinical variables and post-transplant outcomes were compared by TD status. RESULTS Of 93 patients, 35 (37.6%) had TD. 58% of TD had fat-stranding, and post-mortem TD examinations revealed histology carrying intense submucosal inflammation, and purulent contents that cultured identical species to sputum. There was no difference in post-LTx survival [HR 1.77 (0.82-3.82), p=0.147], bacterial re-colonization, or rejection in patients with TD compared to those without. Patients with TD were more likely to die from infection, but the result was not statistically significant [HR 2.02 (0.62-6.63), p=0.245]. CONCLUSIONS We found a high prevalence of TD in end-stage CF, where diverticula may represent a large-airway bacterial reservoir. TD were not associated with differences in post-LTx outcomes, but given the infectious concerns further investigation is necessary.
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Affiliation(s)
- Siddhartha G Kapnadak
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Gregory A Kicska
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Desiree A Marshall
- Department of Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Tamara Y Carroll
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Sudhakar N Pipavath
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States; Department of Pediatrics, Division of Pediatric Pulmonology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
| | - Moira L Aitken
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, United States.
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47
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Somayaji R, Ramos KJ, Kapnadak SG, Aitken ML, Goss CH. Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency). Presse Med 2017; 46:e109-e124. [PMID: 28554722 DOI: 10.1016/j.lpm.2017.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022] Open
Abstract
First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- University of Calgary, Department of Medicine, Calgary, AB, Canada
| | - Kathleen J Ramos
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Moira L Aitken
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Christopher H Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pediatric Pulmonology, Seattle, WA, USA; Seattle Children's Research Institute, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle, WA, USA.
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Ramos KJ, Somayaji R, Lease ED, Goss CH, Aitken ML. Cystic fibrosis physicians' perspectives on the timing of referral for lung transplant evaluation: a survey of physicians in the United States. BMC Pulm Med 2017; 17:21. [PMID: 28103851 PMCID: PMC5248524 DOI: 10.1186/s12890-017-0367-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 01/13/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Prior studies reveal that a significant proportion of patients with cystic fibrosis (CF) and advanced lung disease are not referred for lung transplant (LTx) evaluation. We sought to assess expert CF physician perspectives on the timing of LTx referral and investigate their LTx knowledge. METHODS We developed an online anonymous survey that was distributed by the Cystic Fibrosis Foundation (CFF) to the medical directors of all CFF-accredited care centers in the United States in 2015. The survey addressed only adult patients (≥18 years old) and was sent to 119 adult CF physicians, 86 CFF-affiliated CF physicians (who see adults and children, but have smaller program sizes than adult or pediatric centers), and 127 pediatric CF physicians (who see some adults, but mostly children). The focus of the questions was on CFF-care center characteristics, physician experience and indications/contraindications to referral for LTx evaluation. RESULTS There were 114/332 (34%) total responses to the survey. The response rates were: 57/119 (48%) adult physicians, 12/86 (14%) affiliate physicians and 43/127 (34%) pediatric physicians; 2 physicians did not include their CFF center type. Despite the poor ability of FEV1 < 30% to predict death within 2 years, 94% of responding CF physicians said they would refer an adult patient for LTx evaluation if the patient's lung function fell to FEV1 < 30% predicted. Only 54% of respondents report that pulmonary hypertension would trigger referral. Pulmonary hypertension is an internationally recommended indication to list a patient for LTx (not just for referral for evaluation). Very few physicians (N = 17, 15%) employed components of the lung allocation score (LAS) to determine the timing of referral for LTx evaluation. Interestingly, patient preference not to undergo LTx was "often" or "always" the primary patient-related reason to defer referral for LTx evaluation for 41% (47/114) of respondents. CONCLUSIONS Some potential barriers to timely LTx referral for patients with CF include physician knowledge regarding non-lung function-based recommendations related to timing of referral and listing for LTx, and patient preference not to undergo LTx. Further exploration of physician-level and CF patient-level barriers to timely LTx referral is warranted.
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Affiliation(s)
- Kathleen J Ramos
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Box 356522, Seattle, WA, 98195, USA.
| | - Ranjani Somayaji
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Box 356522, Seattle, WA, 98195, USA.,Department of Medicine, University of Calgary, 3330 Hospital Drive, Calgary, AB, Canada
| | - Erika D Lease
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Box 356522, Seattle, WA, 98195, USA
| | - Christopher H Goss
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Box 356522, Seattle, WA, 98195, USA.,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA.,Department of Pediatrics, University of Washington, 6200 NE 74th St, Ste 110, Seattle, WA, 98115, USA
| | - Moira L Aitken
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, 1959 NE Pacific Street, Box 356522, Seattle, WA, 98195, USA
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Ramos KJ, Sack CS, Mitchell KH, Goss CH, Starr JR. Cystic Fibrosis is Associated with Adverse Neonatal Outcomes in Washington State, 1996-2013. J Pediatr 2017; 180:206-211.e1. [PMID: 27793338 PMCID: PMC5183460 DOI: 10.1016/j.jpeds.2016.09.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/17/2016] [Accepted: 09/29/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether cystic fibrosis (CF) is associated with adverse neonatal outcomes in a recent birth cohort in the US. STUDY DESIGN A retrospective matched cohort study of infants born in Washington State from 1996 to 2013 was identified through birth certificate data and linked to statewide hospital discharge data. Infants with CF were identified by hospitalization (through age 5 years) in which a CF-specific International Classification of Diseases, Ninth Revision code was recorded. "Unexposed" infants lacked CF-related International Classification of Diseases, Ninth Revision codes and were randomly selected among births, frequency-matched to "exposed" infants on birth year. Associations of CF with adverse neonatal outcomes (low birth weight [LBW], small for gestational age [SGA], preterm birth, and infant mortality) were estimated through Poisson regression. We performed extreme value imputation to address possible ascertainment bias. RESULTS We identified 170 infants with CF and 3400 unexposed infants. CF was associated with increased relative risk (95% CI) of 3.5 (2.5-4.9), 1.6 (1.1-2.4), 3.0 (2.2-4.0), and 6.8 (1.7-26.5) for LBW, SGA, preterm birth, and infant death, respectively. The estimated relative risks were similar among infants born from 2006 to 2013, except SGA was no longer associated with CF diagnosis. Results were robust to extreme value imputation and exclusion of infants with meconium ileus. CONCLUSIONS Observed associations of CF with LBW, preterm birth, and infant death are unlikely to be due to ascertainment bias. Further work is needed to determine how to prevent these adverse neonatal outcomes.
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Affiliation(s)
- Kathleen J. Ramos
- University of Washington, School of Public Health, Department of Epidemiology, Seattle, WA, University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle WA
| | - Coralynn S. Sack
- University of Washington, School of Public Health, Department of Epidemiology, Seattle, WA, University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle WA
| | - Kristina H. Mitchell
- University of Washington, School of Public Health, Department of Epidemiology, Seattle, WA, University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle WA
| | - Christopher H. Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle WA, University of Washington, Department of Pediatrics, Seattle, WA, Seattle Children's Hospital, Seattle, WA
| | - Jacqueline R. Starr
- University of Washington, School of Public Health, Department of Epidemiology, Seattle, WA, The Forsyth Institute, Cambridge, MA
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50
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Crull MR, Ramos KJ, Caldwell E, Mayer-Hamblett N, Aitken ML, Goss CH. Change in Pseudomonas aeruginosa prevalence in cystic fibrosis adults over time. BMC Pulm Med 2016; 16:176. [PMID: 27927212 PMCID: PMC5142409 DOI: 10.1186/s12890-016-0333-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/22/2016] [Indexed: 01/16/2023] Open
Abstract
Background Little is known about risk factors for chronic and mucoid Pseudomonas aeruginosa (Pa) infection in cystic fibrosis (CF) adults, and whether the prevalence is changing. Methods We employed a retrospective cohort to analyze data from a single adult CF center (2002 to 2012). Regression models were used to assess independent predictors and change in prevalence of chronic and mucoid Pa infection over time. Results The odds ratio of mucoid Pa infection was significantly less in individuals with better baseline lung function (OR 0.84,95%CI:0.77–0.92) and those diagnosed after the age of 25 (OR 0.21, 95%CI:0.05–0.95). The prevalence of chronic Pa and mucoid Pa decreased during the time interval. After adjusting for confounders, the observed decrease in chronic and mucoid Pa between 2002 and 2012 was no longer significant. Conclusions The prevalence of chronic and mucoid Pa is decreasing. Larger studies are needed to confirm these regional trends and their significance. Electronic supplementary material The online version of this article (doi:10.1186/s12890-016-0333-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathew R Crull
- Department of Medicine, University of Washington, Seattle, WA, USA. .,University of Washington Medical Center, Campus Box 356522, 1959 N.E. Pacific, Seattle, WA, 98195, USA.
| | - Kathleen J Ramos
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ellen Caldwell
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Moira L Aitken
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher H Goss
- Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Pediatrics, Division of Pulmonary, University of Washington, Seattle, WA, USA
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