Purpose Sleep quality after lung transplant is important for recovery and participation in the performance of healthy behaviors, including exercise. A better understanding of the relationships between sleep quality and influencing factors is critical for promoting healthy behaviors. The purpose of this study is to describe the relationships between sleep quality and factors likely to influence and/or be influenced by sleep. Methods Correlational study of adult lung transplant recipients (LTRs) in an ongoing telerehab exercise RCT. Baseline data (pre-randomization) were collected for sex, age, length of hospital stay (LOS), days post-transplant (DPT), and clinical characteristics; self-reported sleep quality (Pittsburgh Sleep Quality Index); frequency of exercise ≥ 3 times per week, and physical symptom burden (Questionnaire for Lung Transplant Patients); and psychological distress (SCL-90 Anxiety and Depression subscales). Bivariate correlations were examined between the outcome of poor sleep quality and candidate predictors using Chi-square/Fisher's exact or Wilcoxon rank sum tests. A multiple logistic regression model was used to identify factors associated with poor sleep quality after controlling for age and sex. Results Participants (N=53) were aged 54.6±14.2 years and male (55%). The assessments were conducted 242 ±123 DPT after a 26 ±13 day LOS. PSQI total score was 7.1±3.7, with 76% of the patients reporting poor sleep quality (score > 5). LTRs reported 21.9±8.1 physical symptoms, anxiety (23%), depression (38%), and exercised > 3 times/week (57%). Patients reporting any psychological distress (23%) had increased odds of experiencing poor sleep [OR:15.5; 95%CI (1.73, 140.1); p=0.014]). Clinically significant distress and physical symptom burden was significantly correlated. χ2(1,53) = .283, p=.039. Conclusion LTRs are at risk of experiencing psychological distress which may contribute significant barriers to recovery. More research is needed to determine if sleep quality and its associated factors affect transplant outcomes, including compounding physical and psychological burdens. Longitudinal studies may provide insight into the long-term effects of sleep quality on lung transplant recovery.

Purpose: Patients with COVID-19 show variable clinical course; transplant patients often show worse outcomes.The effect of COVID-19 on the allograft and the sources of tissue injury that contribute to such poor outcomes are poorly defined.This study leverages cell-free DNA (cfDNA) to measure allograft injury as donor-derived cfDNA (ddcfDNA) and injury from different tissue types using tissue-specific DNA methylomic signatures.Methods: 14 consecutive COVID-19 transplant patients (8 Kidney, 3 Lung, 1 Heart, 1 Liver, and one multi-organ transplant patients) and 30 healthy controls were included.Plasma nuclear cfDNA (ncfDNA) and mitochondrial cfDNA (mtcfDNA) level were measured via digital droplet PCR, and ddcfDNA using AlloSure (CareDx).cfDNA whole-genome bisulfite sequencing was performed to identify cfDNA tissues of origin leveraging tissue specific DNA methylomes and deconvolution algorithm.Results: 75% of the COVID-19 transplant patients showed high ddcfDNA level compared to published quiescent values, including all lung, 50% of the kidney, liver and multi-organ transplant patients (8.5, 4.4, 30 and 16-X fold change, respectively).Total ncfDNA and mtcfDNA were 15X and 310X higher in COVID-19 transplant patients compared to controls, respectively; < 0.0001.The predominant tissues contributing to cfDNA were hematopoietic cells (80%) (Figure).More importantly, COVID-19 transplant patients showed 10 to 100 fold higher tissue specific cfDNA derived from monocyte, neutrophil, erythroblast, vascular endothelium, adipocyte, hepatocyte, kidney, heart and lung compared to controls.Analysis comparing cfDNA in transplant and non-transplant COVID-19 patients is on-going. Conclusion:The allograft undergoes significant injury following COVID-19.Further, cfDNA from multiple tissue types is significantly higher in COVID-19 transplant patients.Future studies in a larger cohorts of transplant and non-transplant patients are needed to elucidate why transplant patients show worse COVID-19 outcomes.

Purpose Greater physical activity (PA) and less time in sedentary behavior are associated with better recovery post lung transplantation and reduced all-cause mortality. The aim of this analysis was to describe and examine associations between participant characteristics and objectively measured activity among recent lung transplant recipients (LTRs). Methods In this descriptive study, actigraph accelerometers were used to measure baseline PA for 20 LTRs enrolled in an ongoing telerehabilitation intervention study. Participants were instructed to wear the accelerometer during waking hours for 7 days. Average time spent in sedentary and moderate-to-vigorous PA (MVPA) were calculated in minutes per day. Spearman correlations were used to examine the relationships between activity measures and baseline characteristics (age, sex, body mass index (BMI), underlying lung condition, length of stay (LOS) of transplant hospitalization, hypertension stage, Charlson Comorbidity Index Scores (CCI), and days post-transplantation). Results Baseline PA data were collected at a mean of 252±131 days post-transplantation. LTRs were mostly white (95%) and female (60%) with a mean age of 55.6±13.4 years. Most participants had a double lung transplant (90%), non-obstructive lung disease (60%), elevated blood pressure (55%), normal BMI (50%), and scored ≤3 on the CCI (80%). The mean LOS for transplant hospitalization was 25.8±11.4 days. Participants wore the actigraph accelerometers for an average of 6.8±0.6 days. Time spent in sedentary behavior and MVPA were 700±97 and 15±14 min/day, respectively. Time spent in sedentary behavior was significantly higher among males (757±112 vs. 662±67 p=.045). CCI (r=.482, p=.031), days post-transplantation (r=.597, p=.005), and sex (r=.460, p=.041) were significantly positively correlated with time spent in sedentary behavior. No other significant correlations were found between PA measures and baseline characteristics. Conclusion Participants spend the majority of the day in sedentary behavior and had less than desirable levels of MVPA. Comorbidity index, days post-transplantation, and sex were found to be moderately correlated with sedentary time. Further studies are planned to evaluate physical activity patterns of LTRs over time and examine the influence on lung transplantation recovery.

Despite physical functional HRQOL impairments in the late years after CTx, mental and social HRQOL is strikingly high and other HRQOL benefits are prominent. Because patients with more dyspnea and poorer psychosocial resources appear at risk for more HRQOL impairment and less HRQOL benefit, interventions targeting such individuals may help to maximize their HRQOL.

Purpose TH interventions deliver healthcare using telecommunication technologies alone or in combination with other modes of patient contact. TH exercise interventions for lung transplant recipients (LTRs) have shown promise for overcoming the under-utilization of pulmonary rehabilitation (PR). Yet, these exercise interventions are typically delivered exclusively via TH. LTRs report barriers such as internet access and a desire for more direct interaction with the exercise trainers. The aim of this study was to assess barriers to participation in an RCT evaluating Lung Transplant Go (LTGo), a multi-component TH exercise intervention comprised of a home visit, 12-weekly supervised TH exercise sessions, followed by 3-monthly phone sessions. Methods LTRs transplanted since May 2018 were screened for LTGo. Eligibility included survival at 4 weeks following discharge from index transplant hospitalization, difficulty walking (quarter-mile) or climbing10 steps without rest, physician approval, absence of conditions that could impair participation, residing within 3 hour drive from the transplant center, not currently in a PR program (LTRs could defer the start of LTGo until PR was completed), reliable internet access, adequate bandwidth speed. Results 85 (74%) of LTRs were screened. Of those screened, 38 (45%) were eligible, including 23 enrolled, 5 refused and 10 pending consent. 47(55%) of those screened were ineligible, including 12 who died and 34 who reported barriers that precluded participation, including: driving distance (18); fitness limitations (4); outside the 12-month eligibility period (3); no medical approval (3); in PR for the duration of the study (3); no internet (2); inadequate bandwidth (1). Of the 30 (26%) who were not screened, 12 declined to hear about the study and 18 screenings are pending. Conclusion Technology-related barriers were rare. The primary barrier was driving distance. This was expected due to the wide-catchment region of transplant programs. While TH is designed to deliver interventions remotely to overcome gaps in distance, relying on TH alone precludes the benefits of other points of patient contact, such as home visits to set-up, orient and provide more direct interactions with LTRs. Patient preferences for delivery mode should be considered to maximize efficacy of multi-component TH-interventions. Funding: 1R01NR017196-01A1 TH interventions deliver healthcare using telecommunication technologies alone or in combination with other modes of patient contact. TH exercise interventions for lung transplant recipients (LTRs) have shown promise for overcoming the under-utilization of pulmonary rehabilitation (PR). Yet, these exercise interventions are typically delivered exclusively via TH. LTRs report barriers such as internet access and a desire for more direct interaction with the exercise trainers. The aim of this study was to assess barriers to participation in an RCT evaluating Lung Transplant Go (LTGo), a multi-component TH exercise intervention comprised of a home visit, 12-weekly supervised TH exercise sessions, followed by 3-monthly phone sessions. LTRs transplanted since May 2018 were screened for LTGo. Eligibility included survival at 4 weeks following discharge from index transplant hospitalization, difficulty walking (quarter-mile) or climbing10 steps without rest, physician approval, absence of conditions that could impair participation, residing within 3 hour drive from the transplant center, not currently in a PR program (LTRs could defer the start of LTGo until PR was completed), reliable internet access, adequate bandwidth speed. 85 (74%) of LTRs were screened. Of those screened, 38 (45%) were eligible, including 23 enrolled, 5 refused and 10 pending consent. 47(55%) of those screened were ineligible, including 12 who died and 34 who reported barriers that precluded participation, including: driving distance (18); fitness limitations (4); outside the 12-month eligibility period (3); no medical approval (3); in PR for the duration of the study (3); no internet (2); inadequate bandwidth (1). Of the 30 (26%) who were not screened, 12 declined to hear about the study and 18 screenings are pending. Technology-related barriers were rare. The primary barrier was driving distance. This was expected due to the wide-catchment region of transplant programs. While TH is designed to deliver interventions remotely to overcome gaps in distance, relying on TH alone precludes the benefits of other points of patient contact, such as home visits to set-up, orient and provide more direct interactions with LTRs. Patient preferences for delivery mode should be considered to maximize efficacy of multi-component TH-interventions. Funding: 1R01NR017196-01A1

Purpose PocketPATH Synergy (PPS) is an IHT that combines customized smartphone software (PocketPATH: Personal Assistant for Tracking Health) with PocketPATH Link, a clinician website, to share data collected through the smartphone app between lung transplant recipients (LTR) and the transplant team. The success of PPS depends on clinicians' adoption of the website. Before possible full-scale deployment, our aims were to assess clinicians' intention to use the website, their actual use, and perceptions regarding its usability and acceptability. Methods All 22 members of the lung transplant team (including surgeons, pulmonologists, nurses) were invited to participate. Responders were oriented to the website and asked about their intention to use the website. After the website was deployed, clinicians were followed prospectively as they monitored data from 27 LTRs uploaded in real-time to the website over a 2-month period. Clinicians were instructed to view the website at will. At the end of the 2-months, clinicians were sent an on-line survey including the Perceived Ease of Use and Usefulness scales and open-ended questions related to acceptability of the website (benefits and barriers). Results 18/22 (88%) agreed to use the website (physicians 11, nurses 7). Over the 2 months, 2/11 (18%) of physicians logged in at least once and 4/18 (22%) of professionals (all nurses) met the threshold of weekly log-ins. 15/18 (83%) completed the post-survey regardless of whether they logged-in to the website. Over 85% agreed that the website was useful and easy to use. The most commonly cited benefits were to: monitor patients between visits (92%) and identify potential problems early (83%). The most common barriers were: too busy to use the website (83%), interruption of workflow (75%), forgot log-in (50%), and inconvenient to log-on to another website besides the electronic health record (EHR) (33%). Conclusion Clinicians' intention to use, perceived usability and acceptability of the website were favorable, but actual use was low. Future work should integrate data into the EHR and use of the website into clinicians' workflow. Data suggest that as barriers are resolved, assessment of how PPS impacts clinical management will be a crucial next step. Funding: NR010711

Mobile health interventions may help lung transplant recipients (LTRs) follow their complex medical regimen. We developed one such intervention, Pocket Personal Assistant for Tracking Health (PPATH), and demonstrated its efficacy in a randomized controlled trial (RCT) for improving self-monitoring and adherence during the first year after LT in LTRs transplanted in 2009-2012. Here, we examine whether improved short-term adherence led to less longer-term nonadherence, and we consider other predictors and correlates of long-term nonadherence.

Optimal management of patients with chronic cardiopulmonary illness requires a longitudinal care perspective with an emphasis on self-management. The collaboration between patients and their clinicians through interactive health technologies (IHTs) supports self-management behaviors and thus helps in the prevention and early treatment of complications. However, little is known about the factors that influence clinicians’ intention to use IHTs, an issue that is vital to the success of such technologies.

Lung transplant recipients (LTRs) are expected to measure spirometry after discharge to assess their lung function and detect complications. Monitoring and reporting declines are important for early treatment and better health outcomes. However, adherence to home spirometry is challenging. We examined trajectories of adherence to home spirometry over time and explored predictors of adherence trajectories.

Self-care agency (SCA), defined as one's ability and willingness to engage in self-care behaviors, can influence actual performance of self-care behaviors in lung transplant recipients (LTRs). Understanding patterns of SCA over time may inform the design of interventions to promote self-care in LTRs. Using group-based trajectory modeling, we sought to identify patterns and correlates of SCA among 94 LTRs over the first 12months post-transplant. Baseline measures of sociodemographic, clinical, and psychosocial factors, and longitudinally assessed psychological distress were examined for their associations with predicted trajectory group membership. Three distinct stable (ie, zero slope) SCA trajectories were identified as follows: persistently low, persistently moderate, and persistently high. Based on the final multivariate model, requiring a re-intubation after transplant (P=.043), discharged to a facility rather than home (P=.048), and reporting a higher level of baseline anxiety (P=.001) were significantly associated with lower SCA. Linear mixed models revealed that higher levels of anxiety and depression were associated with lower SCA in the persistently moderate and low SCA groups over the 12-month time period (Ps<.05). LTRs who require a re-intubation after transplant and are discharged to a facility other than home, and report high psychological distress, may need additional assistance to engage in post-transplant self-care behaviors.

Exercise and maintaining an active lifestyle is recommended to achieve better quality of life and health, however, adherence to exercise after lung transplant may vary. We examined trajectories of adherence to recommended exercise over time and explored the predictors for these trajectories.

Lung transplant (LTX) recipients must follow a complex medical regimen to preserve their health. A growing literature has examined nonadherence and its risk factors in lung recipients during the first few years post-LTX. However, risk for nonadherence in the late-term years post-LTX—when physical morbidities and demands for care increase—has received little attention. We sought to examine a) the prevalence of late-term nonadherence, and b) early-term predictors and late-term correlates of late-term nonadherence. Among 178 patients from a prospective study during the first two yrs post-LTX, we recontacted survivors 6-11 yrs post-LTX. We assessed adherence by a combination of recipient and informant report and examined its relationship to recipient demographic, psychological and personal characteristics, and post-LTX morbidities with multivariable regression analyses. Sixty-four patients (86% of survivors) were assessed (M=8.1 yr post-LTX, SD=1.2, 47% female, 53% bilateral LTX). Fig 1 shows nonadherence rates over the early- and late-term assessment timepoints. Rates worsened over time in several areas (Fig 1). Nonadherence in the first 2 yrs post-LTX increased risk for late-term nonadherence to clinic appointments and substance use restrictions (p's<.01). Recipients were also at risk for late-term nonadherence if they experienced less late-term posttraumatic psychological growth from the LTX experience, lived farther from the LTX center, and had more respiratory symptoms (p's<.05). Other factors (e.g., demographics, psychological distress early posttransplant, acute or chronic graft rejection) did not predict nonadherence. Medical adherence should be monitored well past the early years post-LTX; even recipients adherent early on are at risk for later nonadherence. Because recipients with less psychological benefit from LTX and more respiratory symptoms are at risk for late-term nonadherence, interventions targeting these individuals may foster better late-term adherence.

Hospital readmission after lung transplantation negatively affects quality of life and resource utilization. A secondary analysis of data collected prospectively was conducted to identify the pattern of (incidence, count, cumulative duration), reasons for and predictors of readmission for 201 lung transplant recipients (LTRs) assessed at 2, 6, and 12 mo after discharge. The majority of LTRs (83.6%) were readmitted, and 64.2% had multiple readmissions. The median cumulative readmission duration was 19 days. The main reasons for readmission were other than infection or rejection (55.5%), infection only (25.4%), rejection only (9.9%), and infection and rejection (0.7%). LTRs who required reintubation (odds ratio [OR] 1.92; p = 0.008) or were discharged to care facilities (OR 2.78; p = 0.008) were at higher risk for readmission, with a 95.7% cumulative incidence of readmission at 12 mo. Thirty-day readmission (40.8%) was not significantly predicted by baseline characteristics. Predictors of higher readmission count were lower capacity to engage in self-care (incidence rate ratio [IRR] 0.99; p = 0.03) and discharge to care facilities (IRR 1.45; p = 0.01). Predictors of longer cumulative readmission duration were older age (arithmetic mean ratio [AMR] 1.02; p = 0.009), return to the intensive care unit (AMR 2.00; p = 0.01) and lower capacity to engage in self-care (AMR 0.99; p = 0.03). Identifying LTRs at risk may assist in optimizing predischarge care, discharge planning and long-term follow-up.