Knowledge, beliefs and attitudes of kidney transplant recipients regarding their risk of cancer

Aim: Despite an increased risk of cancer post transplant, little is known about the knowledge, beliefs of and attitudes to cancer and its prevention among kidney transplant recipients. This study aims to explore these beliefs and attitudes, to better understand patient motives and potential barriers to early detection of cancer. Methods: Semi‐structured interviews were conducted with 14 kidney and eight kidney–pancreas transplant recipients based at a single transplant centre in Sydney, Australia, between October 2009 and February 2010. Results: Thematic data analysis identified four major themes: (1) skin cancer‐focused: participants were generally only aware about their increased risk of skin cancer and available prevention strategies for that cancer alone; (2) limited awareness: participants knew little about their excess risk for non‐skin cancers and possible preventative and screening strategies; (3) fear of cancer: cancer fears were heightened by prior experiences; some felt vulnerable to cancer and perceived that cancer outcomes were worse than kidney disease; and (4) prioritizing present health issues: participants believed cancer was not imminent and had limited capacity to absorb information about long‐term risks, particularly as current health concerns appeared pressing and important. Conclusion: Awareness of increased cancer risk and cancer screening among kidney transplant recipients is focused narrowly on skin cancer, with limited awareness for other cancers. Recipients prioritized current health issues rather than future risks to health such as cancer. Transplant care providers should provide evidence‐based information on cancer risk and screening, being sensitive to the timing and needs of the patient. Improved knowledge may empower patients to minimize their risk of cancer by participating in screening and cancer prevention programmes.     

‘Suspended in a paradox’—patient attitudes to wait‐listing for kidney transplantation: systematic review and thematic synthesis of qualitative studies

Patients on waiting lists for kidney transplantation have higher mortality rates and have specific anxieties about their eligibility, process, and outcomes of wait‐listing. We aimed to describe patient experiences and attitudes to wait‐listing for kidney transplantation. Electronic databases were searched to September 2014. Thematic synthesis was used to analyze the findings. From 22 studies (n = 795 patients), we identified six themes: accepting the only option (chance to regain normality, avoiding guilt, impulsive decision‐making); maintaining hope (determined optimism, appreciating a fortuitous gift, enduring for optimal outcomes, trust in clinical judgment); burden of testing (strenuous commitment, losing the battle, medical mistrust); permeating vulnerability (eligibility enigma, being threatened, angst of timing uncertainty, desperate urgency, living in limbo, spiraling doubt and disappointment, residual ambivalence); deprived of opportunity (unfairly dismissed, unexpected disqualification, self‐resignation and acceptance, jealousy, suspicious of inequity); and moral guilt (awaiting someone's death, questioning deservingness). The waiting list offered hope of restored normality. However, the demands of workup, uncertainty about eligibility, and waiting times that exceeded expectations impelled patients to disillusionment, despair, and suspicion of inequity. Managing patient expectations and ensuring transparency of wait‐listing and allocation decisions may allay patient disappointment and skepticism, to improve patient satisfaction and treatment outcomes.     

ICU临床护理专家培训项目课程设置的质性研究

目的了解拟参加ICU临床护理专家培养项目的学员对该项目课程设置的期望,为合理地设置课程提供依据。方法根据课程设置的理论和原则、相关文献及ICU护理实践状况,形成课程设置访谈框架,对拟参加ICU临床护理专家培训项目的 12名ICU护士进行焦点团体访谈。结果培养ICU临床护理专家有必要性和可行性;培养内容应包括临床护理、教育、科研、管理领导和咨询等多方面内容,并体现护理最新理念;教学方法应根据成人学习的特点采用案例讲授法、研讨法、情景模拟教学和自学等多种方法;评价方式以综合评价为主。结论 ICU临床护理专家培养应全面加强基础理论,强调发展学员的综合能力,培养高层次的护理人才。     

Excluding patients from transplant due to social support: Results from a national survey of transplant providers

Social support is used to determine transplant eligibility despite lack of an evidence base and vague regulatory guidance. It is unknown how many patients are disqualified from transplantation due to inadequate support, and whether providers feel confident using these subjective criteria to determine eligibility. Transplant providers (n = 551) from 202 centers estimated that, on average, 9.6% (standard deviation = 9.4) of patients evaluated in the prior year were excluded due to inadequate support. This varied significantly by United Network for Organ Sharing region (7.6%‐12.2%), and by center (21.7% among top quartile). Significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs 67.6%). Nearly 25% believed that using social support in listing determinations was unfair or were unsure; 67.3% felt it disproportionately impacted patients of low socioeconomic status. Overall, 42.4% were only somewhat or not at all confident using social support to determine transplant suitability. Compared to surgical/medical transplant providers, psychosocial providers had 2.13 greater odds of supporting the criteria (P = .03). Furthermore, 69.2% supported revised guidelines for use of social support in listing decisions. Social support criteria should be reconsidered in light of the limited evidence, potential for disparities, practice variation, low provider confidence, and desire for revised guidelines.     

A computer program for the storage and retrieval of urodynamic data

The computer is idcally suited for storing and retrieving a large volume of medical data. Described herein is a computer program written for the managemenr of data from patients who have had urodynamic evaluation. The program is highly user-oriented and requires only minimal training of personnel. The required hardware is reliable and relatively inexpensive. Further. the program is flexible and easily modified for use in other subspecialty areas of urology.     

网络支持项目对乳腺癌患者抑郁和疾病知识水平的影响

目的 探讨网络支持项目对乳腺癌术后患者抑郁和疾病知识水平的影响,以提供减轻乳腺癌患者抑郁水平、提高相关知识的有效途径.方法 将110例乳腺癌手术出院患者按照时间顺序分为对照组(59例)和干预组(51例).对照组患者出院后给予乳腺癌术后常规随访,干预组在此基础上给予12周依托网络的干预,提供网络平台的信息资源,邀请专家为...     

腹部外科患者及家属出院准备度自评比较

目的探讨腹部外科患者和家属的出院准备度现状,为提高患者出院准备度评估的准确性,开展个性化出院准备护理服务提供参考。方法纳入腹部外科住院患者及其家属各239例,采用一般资料调查表、中文版患者出院准备度量表和家属出院准备度量表进行问卷调查。结果腹部外科患者及其家属的出院准备度自评得分分别为159.94±37.61和166.49±36.17,两者比较,差异有统计学意义(P0.01),4个维度中3个维度家属得分与患者存在统计学差异(均P0.01)。结论腹部外科患者及其家属的出院准备度均处于中等偏上水平,但两者的出院准备度不同。医护人员应综合多方评价结果,客观、准确地评估患者的出院准备度,结合其特点给予个性化指导,积极开展以患者为中心的出院准备护理服务。     

Implications of worse renal dysfunction and medical comorbidities in patients with NASH undergoing liver transplant evaluation: impact on MELD and more

Increasing numbers of patients with non-alcoholic steatohepatitis (NASH) are referred for liver transplant (LT). Our objective was to characterize patients with NASH among referred LT candidates (from 1998 to 2008), and we compared demographics, etiology of liver disease, diabetes, hypertension, smoking, obesity, cardiac disease, cancer, laboratory data, model for end-stage liver disease (MELD), and outcomes between NASH and non-NASH patients. Patients with NASH (n = 71) were compared to other chronic liver disease (n = 472). Patients with NASH were older (58.7 vs. 52.5 yr, p < 0.0001), Asian (53.5% vs. 34.7%, p = 0.03) and women (50.7% vs. 32.1%, p = 0.003). Patients with NASH had more diabetes, hypertension, obesity, cardiac disease, and smoking history (p < 0.05). Patients with NASH were equally likely to have liver cancer, but more likely to have non-liver cancers (20.8% vs. 4.4%, p = 0.008). There was no difference in MELD, but patients with NASH had lower protime/international normalized ratio (1.14 vs. 1.27, p = 0.04) and higher creatinine (1.26 vs. 0.98 mg/dL, p = 0.0018). Patients with NASH were equally likely to undergo evaluation, listing, and transplantation compared to non-NASH patients. While all patients with chronic liver disease can have renal dysfunction because of hepatorenal syndrome, patients with NASH have more renal dysfunction, perhaps related to diabetes, hypertension, and cardiovascular disease. Transplant centers should consider this carefully in selection of candidates for LT.     

Hospital‐acquired pressure ulcer incident rates among hospitals that implement an education program for staff,patients, and family caregivers inclusive of an after discharge follow‐up program in Saudi Arabia

A tertiary public hospital in Saudi Arabia set out in 2015 to establish a team focused on reducing hospital‐acquired pressure ulcers (HAPUs). The pressure ulcer prevention program (PUPP) had a multifaceted approach and data were collected for a period of 5 years. The results showed a definite reduction in the incidences of HAPUs. Many such programs show similar positive results and echo many of the same considerations of risk, prevention strategies, and the need for early intervention. However, none of the other studies either replicate the hospital's PUPP nor the extent of the positive and lasting effect of the program. Eager to determine the contributing factor(s) in order that the project success could be continued and possibly replicated in other quality improvement projects, it was decided that an examination and comparison of other similar programs and their results would be necessary in order to uncover the answer. It was determined that the in‐person in‐home discharge follow‐up portion of the program most likely had the largest effect on the outcomes. Outcomes that were supported by the pre‐work completed during the hospital portion of the PUPP towards reducing HAPUs and readmissions.     

Waitlist characteristics of patients at a single‐center intestinal and multivisceral transplant program

Intestinal transplantation (ITX) can be a successful treatment for patients with irreversible intestinal failure and associated severe complications. Because of long waiting periods and organ shortages, the precise identification of eligible patients and their early referral to centers that perform ITX is important. We retrospectively analyzed all patients who were referred to our center between 2000 and 2011 concerning their referral criteria, waitlist characteristics, and outcome. A total of 87 patients (47 male patients, 40 female patients; median age 39.8 ± 13.4 years) were referred to our center. All patients presented with intestinal failure caused by short bowel syndrome or motility disorders. About 80.5% of patients were evaluated for isolated ITX, modified multivisceral (mMVTX), or multivisceral transplantation (MVTX). About 56.3% were listed at EUROTRANSPLANT, 33.3% suffered from severe secondary organ failure requiring MVTX, and 34.5% were transplanted. 14.3% (all MVTX‐candidates) died on the waitlist as a result of infectious complications. The high proportion of MVTX candidates underlines the need for early referral to specialized centers. MVTX‐candidates have a high waitlist mortality for different reasons. However, the current allocation policy for MVTX does not mirror the severity of disease and may therefore contribute to high waitlist mortality.     

Effect of bisphosphonates on bone mineral density in liver transplant patients: a meta‐analysis and systematic review of randomized controlled trials

Bone mineral density (BMD) loss after liver transplantation (LT) results in considerable morbidity with the increased risk of fractures. Data on the efficacy of bisphosphonate use in post LT patients is scarce. This meta‐analysis aims to summarize the results from published randomized controlled trials (RCTs) on the topic of interest. Electronic databases were searched to identify relevant publications. A total of 157 articles were identified and reviewed. Individual authors were contacted from relevant RCTs to obtain individual patient data where necessary to uniformly quantify BMD values post LT pre‐ and post LT. A total of six RCTs were used for final data extraction. (i) Lumbar Spine: In 364 patients (six studies, 182 in intervention and control groups each), bisphosphonate therapy improved BMD by 0.03 g/cm² (95% C.I. 0.01–0.05 g/cm²; P = 0.02) at 12 months post LT. (ii) Femoral neck: In 268 patients (four studies, 130 bisphosphonate, 138 control), bisphosphonate use did not result in a statistically significant change in BMD at the end of 1 year. None of the studies noted serious adverse effects related to bisphosphonate administration. Data on incident fractures could not be pooled because of heterogeneity. Bisphosphonate therapy during the first year in LT recipients appears to reduce accelerated bone loss and improve bone mineral density at the lumbar spine.     

病人专家项目干预对肺动脉高压患者自我效能与生活质量的影响

目的 探讨病人专家项目干预对肺动脉高压患者自我效能与生活质量的影响。 方法 选择60例肺动脉高压住院患者为研究对象,随机分为观察组和对照组各30例。对照组给予常规护理,观察组在常规护理基础上实施病人专家项目干预。干预前后分别测量患者的一般自我效能和生活质量。 结果 观察组和对照组分别有29、27例完成研究。干预后,观察组一般自我效能感得分显著高于干预前和对照组,心力衰竭生活质量得分（除身体领域外）显著低于干预前和对照组（均P＜0.05）。 结论 实施病人专家项目可改善肺动脉高压患者的自我效能,促进其生活质量提升。     

Comparison of two equivalent model for end‐stage liver disease scores for hepatocellular carcinoma patients using data from the United Network for Organ Sharing liver transplant waiting list registry

Patients with hepatocellular carcinoma (HCC) have been advantaged on the liver transplant waiting list within the United States, and a 6‐month delay and exception point cap have recently been implemented to address this disparity. An alternative approach to prioritization is an HCC‐specific scoring model such as the MELD Equivalent (MELD_EQ) and the mixed new deMELD. Using data on adult patients added to the UNOS waitlist between 30 September 2009 and 30 June 2014, we compared projected dropout and transplant probabilities for patients with HCC under these two models. Both scores matched actual non‐HCC dropout in groups with scores <22 and improved equity with non‐HCC transplant probabilities overall. However, neither score matched non‐HCC dropout accurately for scores of 25–40 and projected dropout increased beyond non‐HCC probabilities for scores <16. The main differences between the two scores were as follows: (i) the MELD_EQ assigns 6.85 more points after 6 months on the waitlist and (ii) the deMELD gives greater weight to tumor size and laboratory MELD. Post‐transplant survival was lower for patients with scores in the 22–30 range compared with those with scores <16 (P = 0.007, MELD_EQ; P = 0.015, deMELD). While both scores result in better equity of waitlist outcomes compared with scheduled progression, continued development and calibration is recommended.     

Cultural competency of a mobile,customized patient education tool for improving potential kidney transplant recipients’ knowledge and decision‐making

Patients considering renal transplantation face an increasingly complex array of choices as a result of the revised kidney transplant allocation system. Decision aids have been shown to improve patient decision‐making through the provision of detailed, relevant, individualized clinical data. A mobile iOS‐based application (app) including animated patient education and individualized risk‐adjusted outcomes following kidney transplants with varying donor characteristics and DSA waiting times was piloted in two large US transplant programs with a diverse group of renal transplant candidates (N = 81). The majority (86%) of patients felt that the app improved their knowledge and was culturally appropriate for their race/ethnicity (67%‐85%). Patients scored significantly higher on transplant knowledge testing (9.1/20 to 13.8/20, P < .001) after viewing the app, including patients with low health literacy (8.0 to 13.0, P < .001). Overall knowledge of and interest in living and deceased donor kidney transplantation increased. This pilot project confirmed the benefit and cultural acceptability of this educational tool, and further refinement will explore how to better communicate the risks and benefits of nonstandard donors.     

Occurrence of newly discovered human polyomaviruses in skin of liver transplant recipients and their relation with squamous cell carcinoma in situ and actinic keratosis – a single‐center cohort study

To date 14 human polyomaviruses (HPyVs) have been identified. The newly found HPyVs have not been examined with regard to post‐transplant skin carcinogenesis. To determine the occurrences in skin and possible pathological associations of the HPyVs, we studied their genoprevalences in squamous cell carcinoma (SCC) in situ or actinic keratosis and benign skin in liver transplant recipients (LiTRs); and of healthy skin in immunocompetent adults. We used highly sensitive and specific HPyV PCRs of two types. Overall, Merkel cell polyomavirus (MCPyV), human polyomavirus 6 (HPyV6), human polyomavirus 7 (HPyV7), trichodysplasia spinulosa polyomavirus (TSPyV), and Lyon IARC polyomavirus (LIPyV) were found in 58/221 (26.2%) skin biopsies. MCPyV DNA was detected in 5/14 (35.7%) premalignant vs. 32/127 (25.2%) benign skin of LiTRs, and in 12/80 (15%) healthy skin of immunocompetent adults, with no statistically significant difference in viral DNA prevalence or load. TSPyV DNA was found in a single skin lesion. LIPyV, HPyV6 and HPyV7 DNAs occurred exclusively in benign skin. Overall, the viral findings in premalignant versus benign skin were alike. The occurrences of HPyVs in skin of LiTRs and immunocompetent individuals speak against a role for any of the 14 HPyVs in SCC development.