Health-related quality of life following liver transplantation

The objectives of this study were to report on the health-related quality of life (QoL) experienced by patients following liver transplantation and to investigate the factors associated with its variation. A questionnaire comprising the SF-36 and EuroQol EQ-5D instruments was sent by post to 147 patients who had received a liver transplant, indicated by a chronic liver disease, in the previous 8 years. The scores of the respondents were compared to population norm scores. The variation in both the SF-36 and EQ-5D scores was explored. Many liver transplant patients experienced most satisfactory QoL levels post- transplantation although, in general terms, the levels were poorer than those seen in the general population. The variation in the post-transplant health-related QoL scores was found to be associated with a number of pre-transplant factors: disease severity (proxied by Child Pugh class), disease duration at the time of transplantation and liver transplant history (whether the patient had received a single or multiple transplants). In making clinical decisions about the use of transplantation for chronic liver diseases, consideration should be given to the key factors likely to affect subsequent health-related QoL.     

海洛因依赖者美沙酮维持治疗肝肾功能生化指标的变化

目的对海洛因依赖者美沙酮维持治疗前后肝肾功能等生化指标变化进行探讨,进而做好海洛因依赖者肝肾功能损害的防控工作。方法应用奥林巴斯AU2700型全自动生化分析仪分别对88例海洛因依赖者和美沙酮维持治疗1年后海洛因依赖者、91例非药物滥用健康者血样进行谷丙转氨酶(ALT)、谷草转氨酶(AST)、总蛋白(TP)、白蛋白(Alb)、球蛋白(Glb)、尿素氮(BUN)、肌酐(Cr)含量检测。结果海洛海洛因依赖者美沙酮维持治疗1年后与维持治疗前比较,除Cr外,其他各指标差异有统计学意义(P﹤0.01);海洛因依赖者美沙酮维持治疗1年后与非药物滥用健康者比较,除AST、TP、Cr外,各指标差异有统计学意义(P﹤0.01或﹤0.05);海洛因依赖者与非药物滥用健康者比较,除Cr外,各指标差异有统计学意义(P﹤0.01或﹤0.05)。选取ALT、AST、BUN3项指标,比较其异常人数所占比例在3组人群中的不同,发现上述各指标均各组两两不同(P﹤0.01)。结论海洛因依赖者肝肾功能等生化指标有较大变化,美沙酮维持治疗可部分改善肝肾功能及蛋白质代谢。应加强宣教,防止吸毒,对已有吸毒者尽早进行三级预防。     

Immunosuppression for kidney transplant recipients: current strategies

lmmunosuppressive therapy aims to protect transplanted organs from host responses. The success achieved during the last two decades in patient and graft survival is mainly related to the development and clinical use of efficacious immnosuppressive drugs. Nevertheless, the challenge of achieving a balance of adequate graft protection while minimizing the adverse consequences of excessive immunosuppression in the long-term continues. Current maintenance immunosuppression for renal transplant recipients generally consists of a calcineurin inhibitor plus an adjunctive antiproliferative agent, and steroids. The addition of induction therapy with a variety of monoclonal or polyclonal antibodies provides a more potent immunosuppression and its use is more relevant in patients with a high immunological risk. More recently, mammalian target of rapamycin inhibitors have been incorporated in different schemes proven its efficacy in a number of protocols. The incidence of acute rejection is now in its lower historical percentage and excellent results are reported from many transplant centers all over the world due mainly to a judicious combination of these drugs evaluated through many clinical studies. However, long-term use of immunosuppressive drugs convey inherent risks which translate in an increase of cancers and infections, among others. Ongoing investigations and clinical protocols involving new immunosuppressive drugs and biological agents are yielding important information on how to obtain tolerance or the nearest to this goal. Furthermore, there should be a continuous improvement in patient and graft survival, as the use of different immunosuppressive agents for induction and maintenance are individualized (adapted to each patient).     

Hospitalizations for cytomegalovirus disease after renal transplantation in the United States

PURPOSE: Risk factors, sites, and mortality of hospitalized cytomegalovirus (CMV) disease in renal transplant recipients have not been studied in a national population. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System from 1 July 1, 1994 to June 30, 1997 were analyzed in an historical cohort study of patients with a primary discharge diagnosis of CMV disease (ICD9 Code 078.5x). RESULTS: Renal transplant recipients had an incidence density of hospitalized CMV disease of 1.26/100 person years, and 79% of hospitalizations for CMV disease occurred in the first six months post transplant. The leading manifestation of hospitalized infection was pneumonia (17%). In logistic regression analysis controlling for transplant era, pre-transplant dialysis > or = 6 months, maintenance mycophenolate mofetil (MMF) therapy, and allograft rejection, but not induction antibody therapy, were significantly associated with hospitalized CMV disease. Compared with recipients with negative CMV serology (R-) who had donor kidneys with negative CMV serology (D-), D+/R- had the highest risk of hospitalization for CMV disease [adjusted odds ratio (AOR) 5.19, 95% confidence interval (CI) 3.89-6.93] followed by D+/R+ recipients, whereas D-/R+ were not at significantly increased risk. In Cox Regression analysis the relative risk of death associated with hospitalized CMV disease was 1.32 (95% CI 1.02-1.71). CONCLUSIONS: Even in modern era, renal transplant recipients were at high risk for hospitalizations for CMV disease, which were associated with decreased patient survival. Current prophylactic measures have apparently not reduced the high risk of D+/R- recipients. Prolonged pre-transplant dialysis and maintenance MMF should also be considered risk factors for hospitalized CMV infection, and prospective trials of prophylactic antiviral therapy should be performed in these subgroups.     

Tuberculosis treatment through directly observed therapy in a large multisite methadone maintenance treatment program: addressing the public health needs of a high-risk population.

The rate of tuberculosis in patients receiving methadone treatment is significantly greater than the general population. The stabilization of former injection drug users occurs within methadone maintenance treatment programs, indicating the suitability of these sites for directly observed therapy (DOT). There are formidable barriers to the success of DOT, some are institutional, others patient-related. Strategies to address these obstacles need to be implemented. The integration of DOT into existing programs required support from the New York State Department of Health, institutional commitment, as well as continued staff and patient education and training.     

Implementing a directly observed therapy program in an urban community hospital.

St. Clare's Health and Hospital Center has implemented a directly observed therapy (DOT) program for a challenging urban population of largely HIV+ patients in response to a need for the prevention of the spread of multidrug-resistant tuberculosis in the population. Identified treatment barriers are needs of patient subgroups within the population. Issues in the implementation include: patient compliance, effectiveness of patient identification and follow-up, and continuity of care. Challenges to continuity of care include patients signing out of the hospital against medical advice and missed clinic appointments. Patient identification and follow-up is enhanced by coordinating DOT treatment with the methadone maintenance treatment program.     

Simultaneous pancreas-kidney transplantation--an alternative option for the treatment of type 1 diabetes mellitus with renal failure

INTRODUCTION: Simultaneous pancreas kidney (SPK) transplantation is the only routinely used therapeutic option which can provide insulin independence, euglycemia and good renal replacement. AIMS: Analysis of the five years' experience of the first Hungarian SPK transplants. MATERIAL: From 29 October 1998. through 31 December 2003. 32 SPK transplants were performed from 53 type 1 diabetes mellitus patients with ESRD on the waiting list. Enteric drainage was performed in all transplanted patients in 20 combined with systemic venous drainage, whereas in 12 patients portal venous drainage was used. In 18 patients only maintenance immunosuppression was administered without ATG induction therapy. Anti IL-2R antibody, daclizumab was given as induction therapy in 14 patients. RESULTS: 24 patients out of 32 transplanted are insulin independent with excellent renal function. 2 patients were lost in the perioperative period due to septic complication. 2 patients died 5 months after transplantation. 1 patient became insulin dependent in 7 month following the SPK transplant, while preserving a marginal renal function. One patient became insulin dependent 2 years after the SPK transplant and was returned to chronic hemodialysis treatment one more year later. 2 patients are insulin independent but lost his renal graft due to therapy resistant rejection. CONCLUSION: SPK transplant is a routinely used therapeutic option with good survival rate and good quality of life for type I diabetes mellitus patients with ESRD.     

四川省美沙酮维持治疗患者脱失现状及其影响因素

目的 了解四川省美沙酮维持治疗患者的脱失现状,分析患者脱失的影响因素,为降低美沙酮维持治疗的脱失率提供理论依据。方法 多阶段整群随机法,通过面对面问卷调查,对四川省5家美沙酮美沙酮维持治疗门诊点的581名海洛因成瘾者的脱失情况进行调查, 使用卡方检验和logistic回归分析,探究美沙酮患者脱失的影响因素。结果 logistic回归分析发现,调查对象过去6个月的脱失情况与其对美沙酮维持治疗的认知有关(P＜0.05)。首次服用美沙酮剂量＞50ml的患者不易发生脱失(OR=0.568,95%CI:0.333~0.969);与家人现阶段关系非常好或较好的患者不易发生脱失(OR=0.509,95%CI:0.264~0.982)。偷吸海洛因的患者容易发生服药脱失(OR=2.542,95%CI=1.879-4.299) 。结论 MMT门诊应对美沙酮患者进行适当的健康教育,普及正确的美沙酮维持治疗知识,帮助恢复其家庭及社会功能、克服毒瘾,减少患者的脱失。     

Effects of Regulation on Methadone and Buprenorphine Provision in the Wake of Hurricane Sandy

Hurricane Sandy led to the closing of many major New York City public hospitals including their substance abuse clinics and methadone programs, and the displacement or relocation of thousands of opioid-dependent patients from treatment. The disaster provided a natural experiment that revealed the relative strengths and weaknesses of methadone treatment in comparison to physician office-based buprenorphine treatment for opioid dependence, two modalities of opioid maintenance with markedly different regulatory requirements and institutional procedures. To assess these two modalities of treatment under emergency conditions, semi-structured interviews about barriers to and facilitators of continuity of care for methadone and buprenorphine patients were conducted with 50 providers of opioid maintenance treatment. Major findings included that methadone programs presented more regulatory barriers for providers, difficulty with dose verification due to impaired communication, and an over reliance on emergency room dosing leading to unsafe or suboptimal dosing. Buprenorphine treatment presented fewer regulatory barriers, but buprenorphine providers had little to no cross-coverage options compared to methadone providers, who could refer to alternate methadone programs. The findings point to the need for well-defined emergency procedures with flexibility around regulations, the need for a central registry with patient dose information, as well as stronger professional networks and cross-coverage procedures. These interventions would improve day-to-day services for opioid-maintained patients as well as services under emergency conditions.     

The nature of methadone diversion in England: a Merseyside case study

Background  

Methadone maintenance treatment (MMT) is a key element in treatment for opiate addiction; however concerns about the diversion of methadone remain. More current empirical data on methadone diversion are required. This research investigated the market for diverted methadone in Merseyside, UK, in order to provide a case study which can be transferred to other areas undertaking methadone maintenance treatment on a large scale.     

云南省德宏州美沙酮维持治疗海洛因依赖者生存质量及影响因素

目的 了解云南省德宏州参加美沙酮维持治疗的海洛因依赖者的生存质量,并分析其影响因素.方法 于2011年1月对云南省德宏州芒市、瑞丽、陇川、盈江和梁河等5个县(市)正在参加美沙酮维持治疗的海洛因依赖者,按照等比例分层抽样法抽取462例进行现场访谈,使用WHO生存质量测定量表简表(QOL-BREF)进行问卷调查,了解调查前4周调查对象在生理领域、心理领域、社会关系领域、环境领域的生存质量,并结合其入组时收集的基线资料,分析生存质量及其影响因素.结果 462例调查对象年龄为(37.80±9.13)岁,男性占97.6％ (451/462),女性占2.4％(11/462).文化程度多为小学(35.93％,166/462)和初中(37.23％,172/462),未婚者占31.39％(145/462),已婚者占58.44％(270/462).参加美沙酮维持治疗的海洛因依赖者总的生存质量与健康状况得分为(54.11±6.74)分,生理领域的生存质量得分为(14.31±2.23)分,心理领域得分为(13.28±1.79)分,社会关系领域得分为(13.90±2.52)分,环境领域得分为(12.63±1.77)分.年龄在30 ～40岁之间、未婚、高中或中专及以上文化程度、接受美沙酮维持治疗前吸毒时间大于10年、美沙酮维持治疗时间小于半年、收入来源不是固定工作的调查对象在各领域的生存质量均较低.首次吸毒年龄在16 ～30岁者生理领域、心理领域的生存质量较低[得分分别为(14.29±2.25)、(13.22±1.84)分],在接受美沙酮维持治疗前单纯注射使用毒品、注射与其他方式混合使用毒品者在生理领域、心理领域、社会关系领域的生存质量较低[前者各领域得分依次为(13.92±2.25)、(13.08±1.67)、(13.25±2.60)分,后者各领域得分依次为(13.67±2.52)、(13.43±1.71)、(13.80±2.56)分].结论 参加并坚持美沙酮维持治疗有利于改善海洛因成瘾者的生存质量.年龄、婚姻状况、文化程度、吸毒年限、维持治疗持续时间等是影响其生存质量的因素.     

Attitudes and practices regarding the use of methadone in US State and federal prisons

In the United States, vigorous enforcement of drug laws and stricter sentencing guidelines over the past 20 years have contributed to an expanded incarcerted population with a high rate of drug use. One in five state prisoners reports a history of injection drug use, and many are opiate dependent. For over 35 years, methadone maintenance therapy has been an effective treatment for opiate dependence; however, its use among opiate-dependent inmates in the United States is limited. In June 2003, we conducted a survey of the medical directors of all 50 US states and the federal prison system to describe their attitudes and practices regarding methadone. Of the 40 respondents, having jurisdiction over 88% (n=1,266,759) of US prisoners, 48% use methadone, predominately for pregnant inmates or for short-term detoxification. Only 8% of respondents refer opiate-dependent inmates to methadone programs upon release. The results highlight the need to destigmatize the use of methadone in the incarcerated setting, expand access to methadone during incarceration, and to improve linkage to methadone treatment for opiate-dependent offenders who return to the community.     

Mobile methadone dispensing in Delhi,India: implementation research

ObjectiveTo assess the implementation of a mobile dispensing service to improve opioid users’ access to methadone maintenance therapy.MethodsIn March 2019, we started mobile methadone dispensing in an urban underprivileged locality in Delhi, India. The doctor was available only at the main community drug treatment clinic for clinical services, while the nurse dispensed methadone from a converted ambulance. We involved patients in identifying community leaders for sensitization and in deciding the location and timings for dispensing. We conducted a retrospective chart review of the programme data collected during delivery of clinical services. We compared the numbers of patients registered for methadone therapy and their retention and adherence to therapy in the 12-month periods before and after implementation of the mobile service.FindingsThe number of patients registered for therapy at the clinic increased from 167 in the year before implementation to 671 in the year after. A significantly higher proportion of patients were retained in therapy at 3, 6 and 9 months after enrolment; 9-month retention rates were 19% (32/167 patients) and 45% (44/97 patients) in the year before and after implementation, respectively. There was no significant difference in patients’ adherence to therapy between the two periods. Challenges included providing suitable dispensing hours for patients in employment and concerns of local community near to the dispensing sites.ConclusionIt is feasible to dispense methadone by a mobile team in an urban setting, with better retention rates in therapy compared with dispensing through a stationary clinic.     

武汉市海洛因依赖患者美沙酮维持治疗剂量的影响因素

目的 分析武汉市海洛因依赖患者美沙酮维持治疗（Methadone Maintenance Treatment, MMT）剂量的影响因素。方法 武汉市3所MMT门诊的549例海洛因依赖患者完成社会人口学特征和临床特征问卷,并收集其MMT剂量、计算BMI指数和用5点口述分级评分法测量患者的疼痛强度。结果 MMT门诊海洛因依赖患者的MMT剂量为（70.4±29.2）mg/d,高MMT剂量（≥60mg/d）患者占比59%。多因素线性回归分析结果显示,年龄20~39岁、BMI正常、BMI超重及肥胖、人际关系一般/差、注射吸毒、吸毒时间>10年、焦虑和疼痛患者的MMT剂量水平较高。结论 武汉市MMT门诊的海洛因依赖患者MMT剂量相对较高。需综合考虑患者的社会人口学、临床和心理因素特征以确定MMT剂量。     

美沙酮维持治疗患者不同时期生命质量研究

目的了解美沙酮维持治疗患者不同治疗时期的生命质量状态，为将来调整治疗方案提供依据。方法对美沙酮维持治疗门诊接受维持治疗的患者面对面现场调查，利用世界卫生组织生命质量测定简表，采用患者自评。结果患者生理、心理、社会三个领域生命质量得分随着治疗的开展，均与刚入组时有显著性差异。治疗第一个月时患者生命质量变化最大，生命质量四个领域之间得分存在着显著性差异。结论美沙酮维持治疗患者生命质量在引入期改善最明显，坚持治疗可以不断地提高患者生命质量。     

Pre and Post Operative Occupational Therapy for a Toe to Hand Transplantation

Thumb loss is a significant disability for the hand. This paper describes a traumatic thumb injury and amputation after which the occupational therapist placed an orthotic device to substitute for the thumb. When the patient was undecided about a proposed toe-to-hand transplant, the occupational therapist fabricated a mold of the toe, and attached it to the patient's hand. After training with the mold, the patient was ready to accept the toe-to-hand transplant. The post transplant occupational therapy program and patient's return to work was described.     

美沙酮维持治疗者社会支持现状及其影响因素调查分析

目的 了解美沙酮维持治疗者的社会支持现状及其影响因素,为建立提高治疗依从性的社会支持系统提供科学依据.方法 采用自拟的一般情况问卷和肖水源的《社会支持评定量表》对246名美沙酮受治者的社会支持现状及其影响因素进行调查,对资料进行描述性分析、t检验和多因素回归分析.结果 受治者的社会支持总分为31.97 ±-8.58,主观支持分为19.38±5.67;不同性别、文化程度、婚姻状况、工作现状受治者的社会支持总分组间比较和主观支持度比较差异均有统计学意义(均有P ＜0.05);多因素Logistic回归分析结果显示,婚姻状况和工作现状为受治者社会支持得分的影响因素(均有P ＜0.05).结论 美沙酮受治者社会支持水平较低,影响美沙酮受治者社会支持得分的主要因素为婚姻状况和工作现状.     

DRD2基因多态性与美沙酮维持治疗剂量的关联性研究

目的 探讨DRD2基因的3个单核苷酸多态性位点（rs1800497、rs6275以及rs1799978）与美沙酮维持治疗剂量之间的关联。方法 采用病例对照研究的方法,使用Quanto软件估算样本量至少180人。实际共纳入美沙酮维持治疗者257人,其中低剂量对照组89人,高剂量病例组168人。收集研究对象的一般情况、既往吸毒状况以及服药状况等信息,并对其进行DRD2基因分型,以探讨DRD2基因的多态性与美沙酮维持治疗剂量的关联性。结果 DRD2基因rs6275位点基因型在不同美沙酮维持治疗剂量组间的分布差异有统计学意义,TC基因携带者相比于TT基因携带者（OR=0.338,95% CI：0.115~0.986）,TC+CC基因型携带者相比于TT基因型携带者（OR=0.352,95% CI：0.127~0.975）可能需要更低的美沙酮维持治疗剂量。尚未发现rs6275位点的等位基因,rs1800497位点、rs1799978位点的等位基因以及各遗传模型下的基因型在不同美沙酮治疗剂量组间分布的差异有统计学意义。结论 DRD2基因rs6275位点与美沙酮维持治疗剂量有关联。尚未发现rs1800497位点、rs1799978位点与美沙酮维持治疗剂量有关联。     

Bariatric Surgery Complications Leading to Small Bowel Transplant

Obesity is a major chronic disease affecting the U.S. population. Bariatric surgery has consistently shown greater weight loss and improved outcomes compared with conservative therapy. However, complications after bariatric surgery can be catastrophic, resulting in short bowel syndrome with a potential risk of intestinal failure, ultimately resulting in the need for a small bowel transplant. A total of 6 patients became dependent on home parenteral nutrition (HPN) after undergoing bariatric surgery at an outside facility. Four of the 6 patients required evaluation for small bowel transplant; 2 of the 6 patients were successfully managed with parenteral nutrition and did not require further small bowel transplant evaluation. Catheter‐related bloodstream infection, a serious complication of HPN, occurred in 3 patients despite extensive patient education on catheter care and use of ethanol lock. Two patients underwent successful small bowel transplantation, 1 died before transplant could be performed, and 1 was listed for a multivisceral transplantation. Surgical procedures to treat morbid obesity are common and growing in popularity but are not without risk of serious complications, including intestinal failure and HPN dependency. Despite methods to prevent complications, failure of HPN may lead to the need for transplant evaluation. In selected cases, the best therapeutic treatment may be a small bowel transplant to resolve irreversible, post–bariatric surgery intestinal failure.