Psychiatric morbidity in patients undergoing heart, heart and lung, or lung transplantation

OBJECTIVES: To determine the rate of psychiatric disorder in people undergoing heart and/or lung transplantation; to identify the associations of psychiatric disorder in this group. METHOD: Preoperative assessments were carried out on an 18-month sample of consecutive admissions to a regional unit for heart and lung transplantation in the UK. Assessment included psychiatric morbidity, sexual dysfunction, quality of life, and demographic and clinical characteristics. RESULTS: Seventy-six of 79 eligible subjects took part in the assessment. Thirty (39%) were suffering from a psychiatric disorder, the most common being major depressive disorder. Forty-four (58%) reported sexual dysfunction. Clinically significant psychiatric morbidity was associated with a history of treatment for mental disorder, unemployment, and length of physical illness. Patients with psychiatric disorder reported poorer quality of life on the SF-36, with lower scores on subscales for general health perception, social functioning, and energy/vitality. CONCLUSION: There is a substantial rate of psychiatric disorder in people undergoing heart and/or lung transplantation. Risk is higher in people with a history of psychiatric vulnerability and current illness-related factors. Preoperative psychiatric assessment and intervention in some patients may be a valuable part of their clinical care.     

夫妻活体供肾移植与血缘亲属供肾移植

背景：夫妻间活体肾移植尽管在组织配型方面差于血缘关系供肾移植,但在临床实践观察中夫妻肾移植与血缘关系肾移植间近期疗效并无明显差异。 目的：对比同期实施的夫妻活体供肾移植和血缘亲属供肾移植的临床疗效,总结夫妻活体供肾移植的临床经验。 方法：回顾性分析郑州人民医院实施的夫妻活体供肾移植18例及血缘亲属供肾移植100例的临床资料,通过对两组移植前组织配型情况和移植后(1,3,6个月)肾功能恢复情况,移植肾功能延迟恢及半年内急性排斥反应发生率、感染发生率等指标的分析,对夫妻活体供肾移植和血缘亲属供肾移植的临床疗效进行比较。 结果与结论：同期进行的18例夫妻活体供肾移植组织配型情况较血缘关属供肾移植患者情况差。在移植方案及免疫抑制治疗方案相同的情况下,夫妻活体供肾移植后6个月内血肌酐恢复情况、术后移植肾功能延迟恢、急性排斥反应发生率、感染发生率,均与同期进行的血缘亲属活体供肾移植差异无显著性意义(P > 0.05)。结果表明,无血缘关系的夫妻间供肾移植与血缘亲属供肾移植治疗效果相近。     

Neuropsychological and psychiatric functioning pre- and posthematopoietic stem cell transplantation in adult cancer patients: a preliminary study.

The current study characterizes cognitive and psychiatric status in hematopoietic stem cell transplantation (HSCT) patients shortly before and after transplant. Thirty adult patients were assessed prospectively 1-2 weeks before transplantation and 100 days posttransplantation on neuropsychological and psychiatric measures. Before transplant, participants showed mild impairments on several neuropsychological measures, with the poorest performances occurring on learning and attention. Psychiatric functioning was significantly elevated compared with normative data. Significant improvements, however, were observed on neuropsychological measures by 100 days after transplant. Depression and anxiety scores also improved. Candidates for HSCT experienced mild diffuse cognitive dysfunction and psychiatric morbidity before the procedure, but these symptoms significantly improved by 3 months following their transplant in this small sample. Education about these possible pretransplant sequelae and the potential for rebound may be helpful to patients and families as they prepare for this treatment and the recovery period.     

亲属活体供肾移植40例临床分析

总结40例亲属活体肾移植的临床观察要点，以及供者选择、配型结果与移植疗效的关系。选择解放军总医院第二附属医院2007-01/2008-07亲属活体肾移植40例进行回顾性分析，其中夫妻间供肾2例，血缘亲属供肾38例；ABO血型相同38例，相容2例；人类白细胞抗原无错配1例，4位点错配者4例，2位点错配者20例,1 位点错配者16例；37例取供者左肾，3例取供者右肾。移植后采用环孢素A或他克莫司、霉酚酸酯及醋酸泼尼松预防排斥反应。39例受者移植肾功能恢复正常时间为(6.17±1.91)d，1例发生移植肾功能延迟恢复，2例移植后发生巨细胞病毒感染，更昔洛韦治疗后痊愈，2例发生肺部感染，减少免疫抑制剂用量及抗感染治疗后痊愈，2例术后3个月内发生急性排斥反应，激素冲击治疗后逆转。全部供者术后恢复顺利，于7~10 d内出院，复查肝、肾功能均正常。提示移植前对供、受者双方进行全面评估，对供、受者手术前后特殊情况及时观察、及时处理是亲属活体肾移植预后的关键，对提高生存率，降低感染率有重要意义。     

Psychiatric morbidity, quality of life, and disability in mesial temporal lobe epilepsy patients before and after anterior temporal lobectomy

Considerable interest has been focused on the psychiatric complications of medically refractory temporal lobe epilepsy (TLE) before and after epilepsy surgery. The aim of the present study was to evaluate the psychiatric status, quality of life, and level of disability in medically refractory mesial temporal lobe epilepsy (MTLE) patients, a homogenous subgroup of patients with TLE, before and after anterior temporal lobectomy (ATL). The study population consisted of 22 patients with medically refractory MTLE who were candidates for ATL. Patients were examined before surgery as well as in the third and sixth months of the postoperative period. Psychiatric diagnosis was determined by using SCID-I. To rate the severity of psychiatric disorders, BPRS, HDRS, and HARS were employed on each visit. WHO-DAS-II and WHOQOL-BREF were used to determine the level of disability and quality of life. Preoperatively, six patients had a psychiatric diagnosis. Three months after surgery, six of the patients had psychiatric diagnoses. Five of these six patients had not been previously diagnosed. There was no significant difference between preoperative and postoperative follow-up evaluations in terms of HDRS, HARS, and BPRS ratings. With respect to the total scores and domains of WHO-DAS-II, the change in pre- and postoperative evaluations was statistically significant only for the social life attendance domain. There was no significant difference in the mean scores on the WHOQOL-BREF domains or on the first question about general evaluation of quality of life. For the second question on the level of satisfaction with health, the difference between the three ratings was statistically significant. Preoperative and postoperative rates of psychiatric disorders in our sample were low. While social phobia was frequently seen preoperatively, the postoperative period was spearheaded by major depressive disorder. The decrease in disability in attendance to social life and improvement in the quality of health were in concordance with the literature, indicating the positive results of surgical treatment of epilepsy on quality of life. This study suggests that surgical intervention might be one of the causes of postoperative psychiatric disorders in patients with MTLE.     

Posttraumatic stress disorder and depression in heart transplantation recipients: the relationship with outcome and adherence to medical treatment

Objective

There is growing evidence of the importance of psychiatric risk factors for predicting the outcome of heart transplantation (HT) recipients. The aim of our study was to investigate the role of major depression and posttraumatic stress disorder (PTSD) in the prediction of the outcome of HT in a consecutive sample of 107 recipients.

Method

All subjects of the study underwent a structured diagnostic interview for assessing the presence of pretransplant and posttransplant major depression and transplantation-related PTSD 1 to 5 years after HT. The adherence to medical treatment was assessed some months after the structured interview. The medical outcome (acute rejections, cancer, mortality) was followed up for 8 years on average after the interview, using a prospective design.

Results

Estimated frequency of psychiatric diagnoses after HT was 12% for transplantation-related PTSD and 41% for major depression. The presence of an episode of major depression prior to HT is a significant independent risk factor for posttransplant malignancies. Age, posttransplant malignancies and poor adherence are significant predictors of mortality in the survival analyses.

Conclusions

The present study highlights the importance of the assessment of psychosocial variables and psychiatric diagnoses before and after transplantation in HT recipients. Our findings have important clinical implications and require replication with larger samples.     

丙型肝炎病毒阳性受者肾移植后的安全性分析

背景：对于丙肝病毒阳性患者接受肾移植后安全性的问题是目前大家关注的热点。 目的：丙型肝炎病毒感染者接受肾移植后临床观察及处理对策。 方法：纳入22例患者,肾移植前肝炎病毒RNA均为阳性,其中14例患者肝功能轻度升高。移植后定期检测患者的肝、肾功能,积极防治可能的排斥反应。主要观察患者一般情况、肝、肾功能、肝炎病毒基因学情况及死亡率。 结果与结论：移植后随访6~36个月,20例患者移植后4周~6个月内出现不同程度的肝功能异常,予护肝治疗后肝功能均恢复正常,1例移植后HCV-RNA 阳性患者,因自行改变抗排斥方案于移植后1.5年出现严重的肝功能衰竭而死亡;4例患者移植后应用干扰素和利巴韦林治疗,HCV-RNA转阴,其余18例患者HCV-RNA均呈阳性,需长期护肝治疗。表明,对丙肝病毒阳性受者,移植后应进行严格的随访,出现肝功能异常时,及时采取相应处理和护肝治疗。     

Occurrence of neuropathies in patients with severe heart failure before and after heart transplantation

Neuropathies may affect heart reinnervation and functional outcome after heart transplantation (HT). In this study, neurological evaluations, standard nerve conduction studies, and electromyography were performed in 32 HT candidates without a previous history of neuromuscular disorder. Ten patients underwent HT and were revaluated 3 months later. We found that before HT 10 (31.3 %) patients had sensorimotor polyneuropathy (18.8 %) or sensory polyneuropathy (12.5 %). After HT, the percentage of patients with a neuromuscular disorder increased to 70 %, most of them showing new or worsening neuropathies or neuromyopathies. The most sensitive abnormality that indicated neuromuscular involvement after HT was a reduction of the compound muscle action potential (CMAP) of the deep peroneal nerve. In conclusion, neuromuscular disorders are common in HT candidates, and they further increase in occurrence after HT. A reduction of the deep peroneal nerve CMAP amplitude after HT may help to identify patients who need a more detailed neurophysiological evaluation. The diagnosis of neuromuscular disorders before and after HT may contribute to the development of more accurate therapeutic and rehabilitative strategies for these patients.     

Psychopathology in children before and after surgery for extratemporal lobe epilepsy

Aim To establish the rates and types of psychiatric disorder in children before and after surgery for extratemporal epilepsy. Relationships between psychiatric morbidity and demographic/clinical variables were examined. Method A retrospective case note review of 71 children undergoing extratemporal focal resection for drug resistant epilepsy in a specialist epilepsy surgery programme between 1997 and 2008. Psychiatric diagnoses were derived from pre‐ and postoperative assessments according to DSM‐IV criteria. Results Seventy‐one children (38 males, 33 females) were eligible for this study. Mean age (SD) at surgery was 9 (5) years. Frontal resections were performed in 73% of the children, parietal in 17%, and occipital in 10%. Mental health problems were present in 37 of 71 (52%) children pre‐ and/or postoperatively. A similar proportion of children had psychiatric diagnoses pre‐ and postoperatively: 31 of 71 (44%) and 32 of 71 (45%) respectively. Interpretation Psychopathology is common in children with extratemporal epilepsy. In this sample, the impact of surgery on psychiatric symptoms was not predictable: some children were unchanged, others improved, and others acquired new psychiatric diagnoses postoperatively. Given the high rates of psychiatric disorder in this group of patients, detection and treatment of mental health needs may be important.     

肝移植后早期胸腔积液的病因

背景：胸腔积液是终末期肝病及肝移植后患者常见并发症,如果采取措施不当,可能会增加移植后死亡率。 目的：探讨肝移植后患者胸腔积液的发病原因。 方法：回顾解放军第309医院全军器官移植中心2009-05/2010-05收治的36例行原位肝移植病例资料,分析移植后早期胸腔积液发生率、危险因素,对左右胸腔积液采用t 检验,对有意义的统计学指标进行Logistic回归分析。 结果与结论：肝移植后早期胸腔积液的发生率为72%(26/36),单纯右侧胸腔积液26例(26/36,72%),双侧胸腔积液13例(13/36,1%)。Logistic回归分析结果显示,是否二次手术、是否肺部感染、移植后机械通气时间、移植后3 d出入量、基础疾病是移植后发生胸腔积液的易感因素。     

肾移植后并发卡氏肺孢子虫肺炎36例资料回顾

背景：卡氏肺孢子虫肺炎是常见的肾移植后早期并发症,起病隐匿,进展快,若诊治不及时,死亡率高,认识和掌握肾移植后卡氏肺孢子虫肺炎的发生发展规律和干预措施具有重要的临床意义。 目的：回顾性分析肾移植后并发卡氏肺孢子虫肺炎的病因、临床特点、诊疗措施及预后。 方法：回顾分析36例南方医科大学珠江医院器官移植科收治的肾移植后并发卡氏肺孢子虫肺炎患者的临床资料,分析一般状况、临床表现、治疗方案及人、肾预后情况,总结和认识该病诊断干预措施。 结果与结论：36例患者中男22例,女14例,33例痊愈且移植肾功能保持良好,3例患者并发严重急性呼吸窘迫综合征死亡。36例患者卡氏肺孢子虫肺炎发生在肾移植后6个月内31例,7~18个月5例。15例(41.7%)通过纤维支气管镜下支气管灌洗液或肺组织活检检出卡氏肺孢子虫,21例未检出。多数患者经过减少免疫抑制剂、给予复方磺胺甲恶唑及支持治疗后痊愈且移植肾功能良好。提示卡氏肺孢子虫肺炎多发生在肾移植后6个月内,临床症状典型,病原体难以发现,早期诊断主要依据临床病史、症状和影像学检查,尽早、足量给予复方磺胺甲恶唑,减少免疫抑制剂,充分的支持治疗能改善预后。     

肾移植后的真菌和病毒感染

背景：肾移植后感染已成为肾移植患者移植肾失功和死亡的主要原因之一,肾移植后感染目前尚无统一、标准的治疗方案。 目的：探讨肾移植患者后感染临床特点及诊治方法,提高肾移植后感染的治愈率。 设计、时间及地点：回顾性病例分析,于2006-02/2008-02在昆明医学院第一附属医院器官移植中心完成。 对象：84例肾移植患者中18例移植后的感染者。 方法：所有患者入院后均行胸部X射线检查,X射线检查未提示肺部明显病变或肺部感染症状及体征明显者行肺部CT检查。行病原学检测,包括血、尿、痰、鼻拭子、咽拭子培养,痰涂片+培养查真菌,抽血查CMV、EB-DNA及支原体,痰查抗酸杆菌。对所有肺部感染患者均采用综合治疗,即抗菌素+抗病毒药物+抗真菌药物,根据患者病情、血常规淋巴细胞绝对值及CD4+T细胞绝对值计数调整免疫抑制剂用量对患者感染发生时间、临床症状、辅助检查及诊断和治疗策略进行分析。 主要观察指标：①感染发生时间及症状。②影像学表现和病原学检测结果。③抗生素的选用和免疫抑制剂调整。 结果：18例患者中,11例(61.2%)为尸体供肾肾移植患者。12例(66.7%)发生于移植后3月内,15例(83.3%)发生于移植后6月内。14例(77.8%)以发热为主要症状,呼吸道感染15例(83.3%),其中13(72.2%)例为肺部感染。6例病原学检查提示真菌感染,且以念珠菌为主。3例(16.7%)死亡其中2例合并巨细胞病毒感染,均为混合性感染。 结论：肾移植后感染患者病原体呈多样性,但以细菌、真菌和病毒为主。重症肺炎合并CMV感染提示预后不良,真菌和病毒感染在肾移植后感染患者中应引起足够重视。治疗以综合降阶梯治疗为主,及时调整免疫抑制剂治疗方案甚至停用免疫抑制剂是治疗的关键之一。     

肾移植前后PRA抗体变化与排斥反应关系的临床观察

目的　 观察肾移植前后PRA I类、II类抗体的变化,分析不同抗体变化是否与排斥反应有关系。 方法 分别测定肾移植术前、术后PRA I类、II类抗体水平,通过对移植前后两类抗体进行统计学分析,分析其同排斥反应的关系。 结果 100例患者行血清PRA水平测定中,发生变化者18例。18例患者术前PRA I类抗体(14.1+19.6)%,PRA II类抗体(6.01+9.4)%,术后PRA I类(21.1+24.7)%,PRA II类抗体(20.8+13.2)%,其中9例AR患者手术前后PRA II类抗体变化差异有统计学意义。9例无AR者手术前后PRA变化无统计学意义。18例患者中17例肾功能恢复,1例移植肾失功。 结论　 PRA II类抗体变化同移植后排斥反应关系密切,术后PRAII类抗体升高易导致AR, PRAII类抗体降低,AR发生率降低。     

肾移植后早期监测环孢素A血药浓度峰值的临床意义

背景：近几年有报道,检测环孢素A的峰浓度可以更准确地反映环孢素A在体内的药代动力学变化,指导移植后的临床用药比检测谷浓度更合理,而对大样本临床资料统计的研究报道较少。 目的：探讨肾移植后早期监测环孢素A血药浓度峰值对判定环孢素A抗排异疗效及毒副作用的临床意义。 方法：采用单抗免疫荧光偏振法同步监测环孢素A全血谷浓度和峰浓度,回顾性分析78例肾移植受者,移植后观察6个月,48例未发生任何移植后并发症设为正常组,16例发生急性排异反应设为急性排斥反应组,14例出现药物性损害设为药物损害组,观察各组谷浓度及峰浓度在患者发生急性排斥反应或药物毒性时的变化。 结果与结论：移植后各时间段发生急性排异患者环孢素A谷浓度与未发生的比较,差异无显著性意义(P > 0.05),而各时间段发生急性排斥反应患者环孢素A峰浓度明显低于正常组(P < 0.05)。移植后1个月内,发生药物性肝损害、肾中毒患者谷浓度和峰浓度均明显高于未发生的(P < 0.05)。移植后2~6个月,药物性肝损害、肾中毒组谷浓度与常组比较差异无显著性意义(P > 0.05),而峰浓度明显高于正常组(P < 0.05)。提示,监测环孢素A峰浓度能有效预测肾移植后急性排异反应的发生;移植后2~6个月监测环孢素A峰浓度能有效预测肾移植后药物性肝损害、肾中毒的发生。     

Psychopathology in children with epilepsy before and after temporal lobe resection

The aim of this study was to establish the rate and spectrum of psychiatric disorder among children before and after temporal lobe surgery for epilepsy. Data were examined for associations between psychopathology and seizure outcome following surgery, or association between psychopathology and other variables, such as laterality of lesion, sex, cognitive level, and underlying pathology. Participants were 60 children (35 males, 25 females) who had focal seizures of temporal lobe origin and who had undergone temporal lobe resection between 1992 and 1998; mean age at time of operation 10 y 7 mo, (SD 4 y 11 mo) range 7 mo to 17 y 11 mo. Mean length of follow-up was 5.1 years (SD 2.3, range 2 to 10 y). Twenty-eight (47%) children had undergone right temporal lobectomy. Diagnosis of a psychiatric disorder was present in 50/60 (83%) children at some point, with high rates of psychiatric comorbidity. Common childhood psychiatric disorders of attention-deficit-hyperactivity disorder, oppositional defiant disorder/conduct disorder, and emotional disorders were present in about 25% of children. Disorders rarely seen in the general child population were over-represented: disruptive behaviour disorder--not otherwise specified (30/60 [50%]), and pervasive developmental disorder (autistic spectrum disorder; 23/60 [38%]). there was no significant relationship between pathology, sex, seizure frequency, or postoperative seizure outcome and psychiatric disorder, other than for pervasive developmental disorder. The same proportion of children had psychiatric diagnoses pre- and postoperatively (43/60 [72%] and 41/57 [72%] respectively). Although mental health problems are common in children undergoing temporal lobe resection, there are few predictors of psychiatric outcome following epilepsy surgery. Parents require counselling on these issues in the preoperative work-up.     

Neurolysis of the conducting neuroma-in-continuity in perinatal brachial plexus palsy - evaluation of the results of surgical treatment

The aim of the study was to evaluate the surgical treatment results of cases of perinatal brachial plexus palsy with presence of neuroma-in-continuity. Clinical material included 21 children, aged from 3.5 to 36 months, treated surgically between 1996 and 2005. The control examination included 19 children. The shortest postoperative observation period was 4 years. After surgical treatment during clinical evaluation of function dependent on localization of neuroma-in-continuity we observed the following: in upper injury in 1 child good shoulder and elbow function; in upper-middle injuries with neuroma-in-continuity in upper trunk good elbow function in 66.6%, good shoulder function in 83.3% of cases; in upper-middle injuries with neuroma-in-continuity in upper and middle trunk in 1 examined child good function of elbow, shoulder, and wrist; in total injuries with neuroma-in-continuity in upper trunk good elbow function in 75%, and good shoulder function in 50% of cases; in total injuries with neuroma-in-continuity in upper and middle trunk good elbow function in 66.6%, good shoulder function in 33.3%, good wrist function in 66.6% of cases; in total injuries with neuroma-in-continuity in lower trunk grade 2 of motor hand function and return of sensibility to a level of S3+. CONCLUSIONS: The choice of microsurgical technique during surgical treatment of perinatal brachial plexus palsies with neuroma-in-continuity should be based on the whole clinical and intraoperative view. The best results after neurolysis should be expected when neuroma-in-continuity is localized in the upper trunk, the injury corresponds to third degree on Sunderland's scale, and during electric stimulation a normal motor response can be obtained.     

Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy

OBJECTIVES: Psychopathology has been reported to be prevalent both before and after surgical treatment for medically intractable temporal lobe epilepsy. Individual patients were evaluated prospectively to assess the effect of anterior temporal lobectomy (ATL) on prevalence and severity of psychiatric disease. METHODS: Psychiatric status was assessed in a consecutive series of epilepsy patients before and 6 months after ATL using a structured psychiatric interview, psychiatric rating scales, and self report mood measures. RESULTS: A DSM-III-R axis I diagnosis was present in 65% of patients before and after surgery. The most common diagnoses were depression, anxiety, and organic mood/personality disorders. There was a trend for major psychiatric diagnoses to be more common in patients with right compared to left temporal lobe seizure focus, both before and after surgery. The apparent stability in the overall rate of psychiatric dysfunction concealed onset of new psychiatric problems in 31% of patients in the months shortly after surgery, and resolution of psychiatric diagnoses in 15% of patients. In the group as a whole, the severity of psychiatric symptoms was lower at 6 months postsurgery than before temporal lobectomy. CONCLUSIONS: The overall prevalence of psychiatric dysfunction was comparably high before and after ATL, but individual changes in psychiatric status and changes in severity of symptoms occurred in many patients in the 6 months after surgery.     

Panic disorder in later life: results from a national survey of Canadians

BACKGROUND: At present, our understanding of the risk markers associated with panic disorder among older, community dwelling older adults is limited. To address this gap, we examined the prevalence, risk markers, and comorbidity of panic disorder defined using DSM-IV criteria among older adults. METHOD: Using data drawn from a large, nationally representative sample of Canadians, we estimated lifetime and 12-month prevalence of panic disorder, and examined demographic predictors and patterns of comorbidity of current panic disorder in adults aged 55 years and older (n = 12,792). RESULTS: The 12-month and lifetime prevalence estimates of panic disorder in this sample were 0.82% and 2.45% respectively, and one-fifth of these cases reported a first onset after the age of 55 years. In multivariate models, the risk of panic disorder decreased with older age and was significantly lower among widowed respondents. Physical limitations in daily activities as well as the presence of other psychiatric disorders (major depression, and social phobia) were also significantly associated with panic disorder in this sample. CONCLUSIONS: Consistent with previous research on panic disorder, the prevalence of the disorder decreased with age among older adults. Potential explanations for the age effect and the clinical implications of the mental health comorbidities with panic disorder are discussed.     

Suicide rates in the Lundby cohort before and after the introduction of tricyclic antidepressant drugs.

The Lundby cohort consisting of 3563 subjects was investigated in 1947, 1957, 1972, and 1997. It represents a rural, but gradually urbanized Swedish sample without non-Nordic immigrants and offers an opportunity to study suicide rates before and after the introduction of tricyclic antidepressant drugs in Sweden in 1962. Since then, a fall in suicide rate among depressed individuals was observed, while there was an increase in the overall suicide rate. In fact, in 1977-1992 other psychiatric diagnoses, alcohol disorder included, were more often associated with suicide than depression. No psychiatric or alcohol disorder was registered in 7% of the suicides.