Introduction: An increased risk of malignancy post-lung transplant (LTx) is established as a complication related to reduced immunosurveillance and patient demographics. Aims: To identify the incidence, risk factors and clinical characteristics of solid-organ malignancy following LTx at The Irish National Lung Transplant Centre. Methods: A retrospective single centre review of all 216 patients transplanted between 2005-2017. Data collected included patient demographics, transplant indication, surgery, smoking status, histological sub-type, TNM staging and outcomes. Results: Nineteen patients were diagnosed with a solid-organ malignancy following LTx during follow-up (8.8%). The median time interval between transplant and cancer diagnosis was 32 months (range 12-133 months). Age at the time of transplant was significantly higher in those who subsequently developed malignancy (p=0.028, mean 58.3 v 49.7 years). Single LTx recipients appear at higher risk compared to double LTx recipients (OR 3.17, 95% CI 1.10-9.14). No single indication for LTx was identified as an independent risk factor. Bronchogenic carcinoma was the most common malignancy (n=11, 5.1%); the majority were identified in the native lung of single transplant recipients (9 of 11). 82% were ex-smokers. Squamous cell carcinoma was the most common subtype (n=5). Five patients were stage IV at diagnosis with an overall 1-year mortality of 82%. Conclusions: Bronchogenic carcinoma is the most common solid organ malignancy post LTx and has a high mortality. Risk factors include older age and single LTx. Despite close prospective monitoring, early detection remains challenging and adequate adequate screening guidelines post-transplant are currently lacking.
In July 2015, the electronic software CATO was introduced for chemotherapy prescribing. Before CATO implementation, chemotherapy prescriptions were handwritten on a designated form.
Purpose
To determine the impact of electronic prescribing by comparing the rate of prescribing errors and omissions using handwritten versus electronic prescriptions, and to compare the clinical significance of errors and omissions for both prescribing methods.
Material and methods
A data collection form was designed based on chemotherapy prescription requirements detailed by the National Cancer Control Programme (NCCP) in Ireland. Omissions and errors were defined as the absence or incorrect recording of these requirements. Data collection was completed by 4 pharmacists. Pharmacists categorised prescription errors/omissions as potentially clinically significant or not. This was not graded for this analysis. A pilot (n=30) was completed by all data collectors to ensure consistent data collection. Only parenteral oncology/haematology prescriptions were included. Data were collected in two phases. Phase 1 was a retrospective review of handwritten chemotherapy prescriptions identified by random systematic sampling. Phase 2 was a prospective analysis of electronic prescriptions. A sample size with 60% population proportion was chosen.
Results
153 handwritten prescriptions and 153 electronic prescriptions were analysed. 53% reduction in prescribing errors was found (p<0.05). At least 1 error was found in 29% of handwritten prescriptions (range 1–4) compared with 14% of electronic prescriptions (range 1–2). The mean number of omissions found per handwritten prescription was 3 (range 1–6) compared with 0 for electronic prescriptions (range 0–1) (p <0.05). Electronic prescribing reduced the incidence of errors/omissions considered potentially clinically significant from 17% to 6% (p <0.05). Examples of these included incorrect doses and chemotherapy or supportive care omissions. Common errors encountered with handwritten prescriptions were incorrect body surface area and cycle number. Common errors associated with electronic prescriptions were incorrect dose reductions and incorrect date of treatment.
Conclusion
Introduction of CATO prescribing has significantly reduced prescribing errors. Potentially clinically significant errors and omissions have also greatly reduced. These data, although subjective, suggest that the quality and safety of chemotherapy prescribing has greatly improved. Continued auditing of prescribing errors and omissions is imperative to further improve these results. No conflict of interest
The COVID-19 pandemic is a public health emergency of international concern. Solid organ transplant recipients have been identified as being at high risk of acquiring the virus SARS-CoV-2 and having a more severe COVID-19 disease. This article describes the experience of the National Lung Transplant Centre in Ireland in changing established care pathways for lung transplant recipients during the pandemic. The innovations which were put in place to protect this clinically vulnerable group are discussed. With the advancement of technology and remote monitoring systems available, patient-focused strategies and community-based interventions were implemented. Additional strategies have been implemented so that the new model of care can be safely maintained.
As of April 2022, the Mater Hospital serves 190 patients who have been the recipient of a lung transplant in Ireland. During the COVID-19 pandemic, solid organ transplant was recognised as a risk factor for progression to severe disease. In January 2022, the European Medicines Agency (EMA) approved the use of Sotrovimab for high risk patients. Sotrovimab is a monoclonal antibody which neutralises SARS-CoV-2 with recent data showing efficacy in reducing the risk of progression to severe disease in high risk patients1. We aim to describe our patient cohort and the rates of COVID-19 infection seen before and after the introduction of monoclonal antibody therapy. While likely reflecting emerging variants resulting in less severe disease, we observe variation in morbidity and mortality in this time. From March 2020 to April 2022, 116 post-lung transplant patients tested positive for COVID-19 infection. This represents 61% of our overall population. Since January 2022, coinciding with the surge of the omicron variant, 57 patients contracted COVID-19. 47 were deemed to be suitable for treatment with 10 presenting outside the window for therapeutic intervention. 3.5% (n=2) required ICU admission and 2 died directly as a result of COVID-19. Prior to this, 58 patients contracted COVID-19, 31 of which (53.5%) required hospital admission with 18 (58%) requiring ICU admission. Overall we saw 13 deaths representing 22.4% of this group and 6.8% of the overall population. 1. Gupta A, Gonzalez-Rojas Y, Juarez E, Crespo Casal M, Moya J, Falci DR, Sarkis E, Solis J, Zheng H, Scott N, Cathcart AL. Early treatment for Covid-19 with SARS-CoV-2 neutralizing antibody sotrovimab. New Englad Journal of Medicine. 2021 Nov18;386(21):1941-50
Background: Chronic rejection, more commonly called bronchiolitis obliterans syndrome (BOS), is the leading cause of death beyond the first year post lung transplantation. TLI is an established treatment for the management of post lung transplant BOS. We sought to describe our experience of outcomes in the use of TLI in a single transplant centre. Methods: We identified all patients who had a clinical diagnosis of BOS and were suitable for TLI from 2009-2018. Data collection includes functional baseline of recipients presented with FEV1 pre and post TLI and survival post treatment. Results: 15 patients with BOS underwent TLI treatment. Mean age of patients was 39.26 years (range 20.75 - 57.5), with 53% being male. 13 (86.6%) received a bilateral lung transplant, with 2 (13.3%) receiving a single lung transplant. 60% of patients underwent transplant for cystic fibrosis, with 33% being for interstitial lung disease. Mean time to development of BOS was 64 months (range 14-117). 10 patients (66%) completed scheduled TLI (8 Gy, 10 fractions). The mean decline in lung function leading up to TLI was 1180 ml, with a mean of 1601ml pre treatment. There was a further decrease in lung function of 85ml immediately post treatment. A mean peak increase of 130ml was seen at an average of 3 months post treatment. Mean survival post TLI was 4.2 years (range 0.75-7.5). Conclusions: Of those patients deemed suitable for therapy, TLI was well tolerated with the majority of complications being minor and not leading to cessation of treatment. Therapy is associated with a significant slowing in the rate of decline in lung function impacting overall survival.
Lung transplantation provides a significant survival benefit to patients with advanced idiopathic pulmonary fibrosis (IPF). However, at this time, the transplant community is unable to meet the requirements on it services due to donor organ shortages. This results in an increased length of time spent on the waiting list and an increased risk of death prior to transplantation. Pirfenidone has been reported to reduce the rate of disease progression in patients with IPF. It may therefore prolong the length of time that patients are able to spend on the transplant waiting list. We report the outcomes of three patients with progressive IPF who were successfully bridged to transplantation with Pirfenidone.
Methods
We retrospectively reviewed the medical records of all patients who had undergone lung transplantation for IPF from 2012–14 at our institution. Three patients who had been prescribed Pirfenidone prior to transplantation were identified. Each patient continued Pirfenidone until the day of transplantation. Patient demographics, lung function and post transplant data were collated.
Results
Prior to the commencement of Pirfenidone the mean decline in forced vital capacity (FVC) was 52.2ml per month. Following Pirfenidone therapy, the mean decline in FVC was 29.2ml per month. The mean length of time from commencing Pirfenidone to transplantation was 419 days (range 190–768 days). The mean length of time spent on the transplant waiting list was 144 days (range 35–271 days). With a mean follow up of 1.45 years, no episodes of acute or chronic rejection have occurred. Post-transplant survival is 100%. No adjustment in immunosuppressant induction or post-transplant therapy was necessitated. In the post-transplant period, Pirfenidone therapy was not linked to any adverse events.
Conclusion
Pirfenidone has been reported to reduce disease progression in IPF. However, despite this, lung transplantation remains necessary in the management of this condition. For patients with IPF, in whom the transplant window is short, Pirfenidone may allow for valuable added time on the lung transplant waiting list.
The Health Information and Quality Authority (HIQA) in Ireland are currently promoting and guiding the development of key performance indicators and minimum data sets to monitor health care quality. A third of Irish hospital pharmacies surveyed in 2006 believed that performance indicators were the most effective quality assessment tool. Despite this, performance indicators for clinical pharmacy services in Ireland have not been published.
Purpose
To obtain consensus on whether performance indicators identified from the literature provide a valid and feasible method of measuring the quality of the Mater Misericordiae University Hospital (MMUH) clinical pharmacy service and whether they could be introduced as a regular quality measurement.
Materials and Methods
Review the literature relating to the use of performance indicators in a clinical pharmacy setting and identify performance indicators which have been piloted or used in other institutions. Achieve consensus of a multidisciplinary panel, using a Delphi method of the most valid and feasible performance indicators for the MMUH clinical pharmacy service Implement one of the selected performance indicators Make recommendations on the further use of performance indicators
Results
Performance indictors relating to hospital pharmacy are available (n = 240) in the literature. The Delphi method achieved consensus and rated the following three performance indicators as both valid and feasible: Percentage of reserve antimicrobials checked by a clinical pharmacy for approval by microbiology or infectious diseases Percentage of patients discharged on warfarin who receive warfarin counselling by a clinical pharmacist Percentage of medication orders for intermittent therapy that have been reviewed by a clinical pharmacist for safe prescribing. The indicator chosen for measurement was the percentage of medication orders for intermittent therapy that were reviewed by a clinical pharmacist for safe prescribing. A 79% compliance with this performance indicator was achieved by the clinical pharmacy service.
Conclusions
A multidisciplinary panel achieved consensus that three of the performance indicators identified from the literature provide valid and feasible methods of measuring the quality of the clinical pharmacy service of the MMUH. One of these was successfully implemented and consideration will be given to implementing further performance indicators No conflict of interest.
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