Incidence and risk factors for inappropriate use of non-culture based fungal assays: Implication for diagnostic stewardship

Background Non-culture-based fungal assays (NCBFAs) have been used increasingly to help diagnose invasive fungal diseases. However, little is known about inappropriate use of NCBFAs. We aimed to investigate inappropriate use of NCBFAs in a tertiary academic hospital. Methods This retrospective cohort study included patients who underwent testing with beta-D glucan (BDG) between Jan and Mar 2018, or galactomannan antigen (GMA) or cryptococcal antigen (CRAG) between Jan and Jun 2018. Testing was deemed appropriate if the clinical presentation was compatible with a fungal infection and there was a predisposing host factor at the time of ordering. We compared patients with appropriate and inappropriate use of NCBFAs using the multivariate logistic regression analysis. Results 470 patients (BDG, 394; GMA, 138; CRAG, 164) met inclusion criteria and were evaluated. About 80% of NCBFAs were deemed inappropriate. Ordering by transplant medicine physicians, repetitions of the test, the absence of predisposing factors for fungal infections, and the absence of recommendations from infectious diseases consultants were associated with an increased risk of inappropriate NCBFA use. Conclusions We found a large proportion of NCBFAs were deemed inappropriate. There is an opportunity for diagnostic stewardship to reduce avoidable fungal testing among patients at low risk for fungal infection.

Transplant Oncology: An Evolving Field in Cancer Care

Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The application of oncology, transplant medicine, and surgery to improve patients’ survival and quality of life is the core of transplant oncology. Hepatobiliary malignancies have been treated by liver transplantation (LT) with significant improved outcome. In addition, as the liver is the most common site of metastasis for colorectal cancer (CRC), patients with CRC who have stable unresectable liver metastases are good candidates for LT, and initial studies have shown improved survival compared to palliative systemic therapy. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years in a stepwise manner; however, they have only been shown to improve patient survival in the setting of limited systemic therapy options. This review illustrates the concept and history of transplant oncology as an evolving field for the management of hepatocellular carcinoma, intrahepatic biliary cancer, and liver-only metastasis of non-hepatobiliary carcinoma. The utility of immunotherapy in the transplant setting is discussed as well as the feasibility of using circulating tumor DNA for surveillance post-transplantation.

Lists in Flux, Lives on Hold? Technologies of Waiting in Liver Transplant Medicine

This chapter examines waiting in liver transplant medicine, a field characterized by immediacy, urgency and delay. By taking a close look at waiting lists, allocating algorithms and mobile phones, it engages with the technological and material features that generate, shape and mediate waiting and hope when livers fail. Based on ethnographic research in Germany, I analyse the powerful workings of ephemeral waiting lists and discuss how these lists in flux put the lives of those looking for an organ on hold. By doing so, I contribute to understandings of how immobilities are produced and their affective dimensions. I approach waiting lists for liver transplants as part of transplant medicine’s invisible digital infrastructure and contend that the mobile phone becomes a critical feature therein, significantly affecting those waiting for a transplant. Firstly, I discuss the wait list as bureaucratic technology, marker of eligibility and symbol for patients’ chances to receive live-saving treatment. I then show, secondly, how complex algorithms create these ephemeral lists. Thirdly, I turn in more detail to the experiences of a patient listed for a transplant. I demonstrate how, in this time of waiting-in-uncertainty, the mobile phone becomes an extension and tangible manifestation of this ephemeral list as well as a reminder of one’s dependency on medical care. I show how the mobile phone transforms from a mere communication tool to an ambivalent marker of people’s simultaneous mobility and immobility during their wait.

Targeted Urine Metabolomics for Monitoring Renal Allograft Injury and Immunosuppression in Pediatric Patients

Despite new advancements in surgical tools and therapies, exposure to immunosuppressive drugs related to non-immune and immune injuries can cause slow deterioration and premature failure of organ transplants. Diagnosis of these injuries by non-invasive urine monitoring would be a significant clinical advancement for patient management, especially in pediatric cohorts. We investigated the metabolomic profiles of biopsy matched urine samples from 310 unique kidney transplant recipients using gas chromatography–mass spectrometry (GC-MS). Focused metabolite panels were identified that could detect biopsy confirmed acute rejection with 92.9% sensitivity and 96.3% specificity (11 metabolites) and could differentiate BK viral nephritis (BKVN) from acute rejection with 88.9% sensitivity and 94.8% specificity (4 metabolites). Overall, targeted metabolomic analyses of biopsy-matched urine samples enabled the generation of refined metabolite panels that non-invasively detect graft injury phenotypes with high confidence. These urine biomarkers can be rapidly assessed for non-invasive diagnosis of specific transplant injuries, opening the window for precision transplant medicine.

Challenging Concepts in Congenital and Acquired Heart Disease in the Young

Challenging Concepts in Congenital and Acquired Heart Disease in the Young contains a series of challenging concepts in paediatric cardiology covering all subspecialty areas, including general paediatric cardiology, intervention, cardiac imaging, electrophysiology, heart failure and cardiomyopathies, cardiac devices, transplant medicine, epidemiology, and fetal cardiology. Each case provides an in-depth review of current practice, the application of national and international guidelines, and a summary of evidence from the medical literature. Data sets, investigation results, and cardiac imaging give the reader a ‘real-life’ sense of being in the outpatient clinic, emergency room, cardiac intensive care unit, or cardiac catheterization laboratory.