Health status and quality of life following cardiac transplantation

Chronic pain 1-5 years after heart transplantation-A nationwide cross-sectional cohort study

Aim

To provide a multidimensional assessment of self-reported chronic pain 1-5 years after heart transplantation and its relationship with self-reported well-being, fatigue, recovery, self-efficacy and socio-economic factors and to explore differences between heart recipients and a cohort of lung recipients.

Design

This multicentre, cross-sectional, cohort study is a part of the Swedish national Self-management after thoracic transplantation study.

Methods

Six questionnaires were distributed at the heart recipients yearly follow-up (1-5 years) at three Swedish university hospitals 2014-2017.

Results

The study group comprised of 79 heart recipients, 25 women and 54 men with a mean age of 52.68 years. Chronic pain among heart recipients was common and those not in paid employment as well as those with low psychological well-being and high general fatigue reported significantly more pain. Female heart recipients were more affected by pain. General health and vitality, general fatigue, physical fatigue and reduced activity were related to the pain intensity score.

Relevance to clinical practice

As it is the duty of the healthcare system to provide adequate pain treatment, screening for pain should be a mandatory part of long-term follow-up.

Symptom burden in heart failure: assessment, impact on outcomes, and management

Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.

Pain, fatigue and well-being one to five years after lung transplantation - a nationwide cross-sectional study

RATIONALE AND AIM

Little is known about persistent pain after lung transplantation. Therefore, the aim was to present a multidimensional assessment of self-reported pain 1-5 years after lung transplantation and its relationship with fatigue and transplant-specific well-being.

METHODS

This nationwide, cross-sectional cohort study is part of the self-management after thoracic transplantation study. A total of 117 lung recipients, all White, who were due for their annual follow-up at one (n = 35), two (n = 28), three (n = 23), four (n = 20) and 5 years (n = 11) after lung transplantation were included. We used three instruments; the Pain-O-Meter (POM), which provides information about pain intensity, sensation, location and duration, the MFI-19 fatigue instrument and the Organ Transplant Symptom and Well-being Instrument (OTSWI). Permission to carry out this study was granted by the Regional Ethical Review Board in southern Sweden (D-nr 2014-124).

RESULTS

The prevalence of pain was 51% after 1 year, 68% after 2 years, 69.5% after 3 years, 75% after 4 years and 54.5% after 5 years. Women experienced more pain than men. Lung recipients with pain reported lower well-being and higher symptom distress but were not more fatigued than those without pain.

STUDY LIMITATIONS

The limitations of this study are due to the cross-sectional design. The recruitment of patients during the study period was probably affected by the different conditions regarding staffing at the outpatient lung transplant clinic in the two thoracic transplant centres in Sweden. The slightly different approach to the care of these patients in the pre, peri and postoperative setting contributes to the heterogeneity of the study population.

CONCLUSION

Chronic bodily pain up to 5 years after lung transplantation reduces perceived well-being. Lung recipients with pain report higher symptom distress than those without pain.

Preoperative Predictors for Postoperative Problems in Heart Transplantation: Psychiatric and Psychosocial Considerations

The psychiatric and psychosocial evaluation of the heart transplant candidate can identify particular predictors for postoperative problems. These factors, as identified during the comprehensive evaluation phase, provide an assessment of the candidate in context of the proposed transplantation protocol. Previous issues with compliance, substance abuse, and psychosis are clear indictors of postoperative problems. The prolonged waiting list time provides an additional period to evaluate and provide support to patients having a terminal disease who need a heart transplant, and are undergoing prolonged hospitalization. Following transplantation, the patient is faced with additional challenges of a new self-image, multiple concerns, anxiety, and depression. Ultimately, the success of the heart transplantation remains dependent upon the recipient's ability to cope psychologically and comply with the medication regimen. The limited resource of donor hearts and the high emotional and financial cost of heart transplantation lead to an exhaustive effort to select those patients who will benefit from the improved physical health the heart transplant confers.

Frequency of musculoskeletal complications among the patients receiving solid organ transplantation in a tertiary health-care center

Solid organ transplantation is an important lifesaving procedure mainly performed in patients with end-stage organ failure such as liver cirrhosis, congestive heart failure, and end-stage renal disease. While these complications are among the most preventable adverse effects of solid organ transplantation, these are generally neglected by physicians. Accordingly, this study was performed to evaluate the frequency of musculoskeletal complications among the patients receiving solid organ transplantation in a tertiary health-care center in a developing country. This cohort study was performed from 2000 to 2009, among fifty patients receiving organ transplantation (liver, heart, and lung) attending to a training hospital in Tehran, Iran. The main variables were musculoskeletal complaints and findings that were measured according to patients' self-report and clinical examination. The mean age of the patients was 40.2 ± 10.9 years ranging from 5 to 58 years. Twenty out of 50 patients (40%) had musculoskeletal complaints that the most common complaint was the arthralgia. Also, the mechanical arthritis was the most common clinical finding in clinical examination (24%). Low serum level of vitamin D (74.4%) and high serum alkaline phosphatase level (27.9%) were the most common biochemical abnormalities in understudy population. Finally, it may be concluded that nearly forty percent of patients receiving solid organ transplantation may develop musculoskeletal findings and/or complaints. These complications may be found and treated with regular examinations to reduce the burden of disease.

Gender and age differences in symptom distress and functional disability one year after heart transplant surgery

OBJECTIVE

Symptoms and functional status are major concerns for heart transplant (HT) recipients. The study objective was to examine gender and age differences in symptom distress and functional disability 1 year after HT surgery.

METHODS

The sample (N = 237) consisted of 44 female and 193 male patients who were divided into younger (n = 66) and older (n = 171) groups with the breakpoint at age 50 years. Data from chart review and 2 questionnaires (Heart Transplant Symptom Checklist and Sickness Impact Profile) were analyzed with chi-square test, t tests, analysis of variance, and multivariate analysis of variance.

RESULTS

Women reported worse symptom distress (overall, plus cardiovascular, gastrointestinal, dermatologic symptoms) and more functional disability (overall, plus disability in ambulation, mobility, self-care, home management). Older patients reported more disability in ambulation and work. Gender by age interactions showed that older men reported worse genitourinary symptoms and younger women reported worse dermatologic symptoms.

CONCLUSION

There were more gender than age differences in symptoms and disability.

Symptom frequency and distress from 5 to 10 years after heart transplantation

BACKGROUND

Patterns of symptom frequency and distress have not been examined long-term after heart transplantation, nor have predictors of long-term symptom frequency and distress. This report identified the most commonly reported and distressful symptoms long-term after transplantation, described patterns of symptom frequency and distress over time, and examined predictors of symptom frequency and distress at 5 and 10 years after heart transplantation.

METHODS

The sample included 555 participants from a prospective, multisite, longitudinal study of quality of life outcomes. Patients were 78% male, 88% white, 79% married, and mean age of 54 years at time of heart transplantation. Data were collected using patient self-report and medical records review. Statistical analyses included descriptive statistics, Pearson correlations, t-tests, and generalized linear models.

RESULTS

Significant predictors of lower symptom frequency after heart transplantation were not having psychological problems and not having cardiac allograft vasculopathy at 5 years, and not having psychological problems and not having infection at 10 years. Significant predictors of less symptom distress were having more than a high school education, having no psychological problems, and having gout at 5 years, and being married at 10 years.

CONCLUSIONS

Symptom frequency is low and symptom distress is moderate long-term after heart transplantation. Significant relationships exist between both demographic and clinical variables and symptom frequency and distress. Identification of the most common and bothersome symptoms after heart transplantation provides clinicians with important information from which to develop a plan of care.

Patterns and predictors of physical functional disability at 5 to 10 years after heart transplantation

BACKGROUND

Researchers have not examined relationships between perception of physical functional disability and demographic, clinical, and psychological variables at 5 to 10 years after heart transplantation. Therefore, the purposes of this study were to describe physical functional disability over time and identify predictors of physical functional disability from 5 to 10 years after heart transplantation.

METHODS

The study enrolled 555 patients who were between 5 and 10 years post-heart transplant (age, 54 +/- 9 years; 78% male, 88% white, 79% married). Patients completed 6 instruments that measure physical functional disability and factors that may impact physical functional disability. Statistical analyses included calculation of frequencies, means +/- standard deviation (plotted over time), Pearson correlation coefficients, and multiple regression coupled with repeated measures.

RESULTS

Between 5 and 10 years after heart transplantation, physical functional disability was low, and 34% to 45% of patients reported having no functional disability. More physical functional disability was associated with having more symptoms, having depression/mood/negative affect and lower use of negative coping strategies, having more comorbidities and more specific comorbidities (e.g., more orthopedic problems and diabetes); higher New York Heart Association functional class; having more acute rejection, infection, or cardiac allograft vasculopathy; being female, older, less educated, and unemployed; higher body mass index; and more hospital readmissions (explaining 46% of variance [F = 84.75, p < 0.0001]).

CONCLUSIONS

Demographic, clinical, and psychological factors were significantly related to physical functional disability. Knowledge of these factors provides the basis for development of therapeutic plans of care.

Patterns and predictors of quality of life at 5 to 10 years after heart transplantation

BACKGROUND

Although studies have provided us with a cross-sectional analysis of long-term quality of life (QOL) after transplantation, relatively few longitudinal studies have been done that allow us to understand changes in QOL over time. The purposes of our study were to describe QOL over time and identify predictors of QOL longitudinally from 5 to 10 years after heart transplantation.

METHODS

All 555 subjects enrolled in this study completed booklets of questionnaires. These patients had a mean age of approximately 54 years (range 21 to 75 years) at time of transplant. Seventy-eight percent were men and 88% were white. Participants completed nine self-report QOL instruments for this study. Statistical analyses included frequencies, means +/- standard deviations (plotted over time), Pearson correlation coefficients and multiple regression coupled with repeated measures.

RESULTS

At 5 to 10 years after heart transplantation, recipients reported high levels of satisfaction with overall QOL and with health-related QOL, which was stable over the 5-year period. Predictors of satisfaction with overall QOL (that individually accounted for 1% variance or more) were primarily psychosocial variables (overall model explaining 71% of variance), whereas predictors of satisfaction with QOL related to health and functioning (that also explained > or =1% variance) included symptom distress and physical function, as well as psychosocial variables (overall model explaining 72% of variance).

CONCLUSIONS

At 5 to 10 years after heart transplantation, QOL remained positive and stable. Bio-psychosocial variables predicted satisfaction with overall QOL and health-related QOL. Understanding of these bio-psychosocial variables provides direction for the development of long-term therapeutic strategies after heart transplantation so that patients can have good post-transplant outcomes.

Functional Status One Year After Heart Transplant

PURPOSE

Although heart transplantation (HT) increases survival of heart failure patients, many patients still experience problems afterward that affect functioning.

PURPOSES

(1) to compare the functional status of HT patients before transplant versus 1 year after transplant, (2) to identify functional problems 1 year post-transplant, and (3) to identify which variables predicted worse functional status 1 year later.

METHODS

The sample was 237 adult HT recipients who completed the 1-year post-transplant study booklet. Functional ability was assessed by the Sickness Impact Profile. Paired t tests compared Sickness Impact Profile scores before and after transplant. Medical and demographic data plus patient questionnaire data on Sickness Impact Profile, symptoms, stressors, and compliance were used in the regression.

RESULTS

Sickness Impact Profile functional scores improved significantly from pre-transplant (23.0%) to post-transplant (13.4%); however, many HT recipients still reported problems in 12 functional areas 1 year after surgery. Major problem areas were the following: work (90% of patients), eating (due to dietary restrictions, 87%), social interaction (70%), recreation (63%), home management (62%), and ambulation (54%). Only 26% were working 1 year after transplant; 59% of those working reported health-related problems performing their job. Predictors of worse functional status were greater symptom distress, more stressors, more neurologic problems, depression, female sex, older age, and lower left ventricular ejection fraction (worse cardiac function).

CONCLUSIONS

Many HT recipients were still having functional problems and had not reached their full rehabilitation potential by the 1-year anniversary after transplant.

Predictors of quality of life at 5 to 6 years after heart transplantation

BACKGROUND

Only a few researchers have examined quality of life (QOL) outcomes more than 5 years after heart transplantation. Therefore, the purpose of this study was to describe QOL (overall, satisfaction with, and perceived importance); identify differences in QOL by age, sex, and race; and identify predictors of QOL at 5 to 6 years after heart transplantation.

METHODS

A nonrandom sample of 231 patients (60 years of age, 76% men, 90% white, 79% married, and fairly well educated) who were 5 to 6 years after heart transplantation were investigated. Patients completed 12 QOL instruments via self-report. Data analyses included descriptive statistics, chi2, independent t-tests, correlations, and stepwise multiple regression. Level of significance was set at 0.05.

RESULTS

Patient satisfaction with all areas of life was high at 5 to 6 years after heart transplantation. Similarly, patients believed that these same areas of life were very important. Yet areas of QOL with lower levels of satisfaction were identified. Patients who were > or =60 years were more satisfied with their QOL than patients <60 years. At 5 to 6 years after heart transplantation, almost 80% of variance in QOL was explained by psychological, physical, social, clinical, and demographic variables.

CONCLUSIONS

At 5 to 6 years after heart transplantation, patients were very satisfied with their QOL, although differences in level of satisfaction were identified by demographic variables, and areas of QOL with lower levels of satisfaction were identified. Understanding those variables that contribute to QOL in the long term after heart transplantation provides direction for assisting patients to improve their QOL.

Who Returns to Work After Heart Transplantation?

BACKGROUND

Detailed information regarding the work history of heart transplant patients is limited. Therefore, the work history and factors associated with return to work at 1 year after heart transplantation were examined in 237 heart transplant patients as part of a longitudinal quality-of-life study at two university medical centers. Patient characteristics were as follows: 81% male; 89% white; mean age 54 years (range 24 to 71); mean level of education 13 years; and 84% were married.

METHODS

Data were collected using the following instruments: Work History tool; Rating Question Form; Heart Transplant Stressor Scale; Quality of Life Index; Sickness Impact Profile; Jalowiec Coping Scale; Social Support Index; Heart Transplant Symptom Checklist; and Chart Review Form. Frequency distributions, chi-square, t-tests and stepwise regression were used to examine the work history of patients.

RESULTS

Pre-transplant, only 17% of patients were working as compared with 26% (61 of 237) working by 1 year after transplant (p = 0.003). Pre-transplant non-working patients (n = 197) were hospitalized more frequently, were more physically disabled, had more symptom distress, and rated their health as poorer. After heart transplant non-working patients (n = 176) had more rejection, infection and medical complications and more hospital days. Patients who were working either pre- or post-transplant were more likely to hold jobs that were less physically demanding. Factors significantly associated with return to work by 1 year after heart transplant were better functional ability, higher education, fewer endocrine problems, fewer acute rejection episodes and shorter heart transplant waiting time.

CONCLUSIONS

Clinical and demographic variables influence return to work after heart transplantation. Knowledge of these variables provides the health-care team with information to assist patients in securing gainful employment.

Predictors of Physical Functional Disability at 5 to 6 Years after Heart Transplantation

BACKGROUND

Few reports were found in the literature that examined predictors of physical functional disability after heart transplantation. Therefore, the purpose of this study was to (1) describe physical functional disability, (2) identify differences in physical functional disability by demographic and clinical variables, and (3) identify predictors of physical functional disability at 5 to 6 years after heart transplantation.

METHODS

A nonrandom sample of 311 patients (approximately 60 years of age, 78% male, and 90% Caucasian) who were 5 to 6 years post-heart transplantation were investigated. Patients completed 8 reliable and valid quality-of-life instruments via self-report. Data analyses included descriptive statistics, chi-square, independent t-tests, correlations, and stepwise multiple regression. Level of significance was set at p = 0.05.

RESULTS

The level of physical functional disability was low at 5 to 6 years after heart transplantation, yet 59% of patients reported having physical disability. Women experienced more functional disability than men, and patients with comorbidities (i.e., diabetes mellitus and orthopedic problems) experienced more functional disability than patients without these comorbidities. At 5 to 6 years after heart transplantation, 70% of variance in physical functional disability was explained by activities of daily living, symptoms, comorbidities, psychologic status, and resource utilization variables.

CONCLUSIONS

At 5 to 6 years after heart transplantation, most patients experienced low levels of physical functional disability. Differences in physical functional disability were identified by both demographic characteristics and clinical variables. Predictors of physical functional disability included activities of daily living and symptoms, and clinical, psychologic, and resource utilization variables. Knowledge of factors related to physical disability long-term after heart transplantation provides direction for the development of strategies to assist patients to reduce their level of disability or function adequately despite their disability.

Social adaptation after cardiothoracic transplantation: a review of the literature

From the earliest days of transplantation, research has contributed to our knowledge of the psychosocial sequelae associated with the outcomes of the procedure. The purpose of this review is to describe the social adaptation literature for heart, lung, and heart-lung recipients. Social adaptation refers to employment and performance of social roles and responsibilities. Employment research focused on vocational rehabilitation, physical health restoration, and return to work. Social roles and responsibilities research focused on social roles, family relationships, social support, and psychosocial adjustment. Predictors, interventions, and their associations with outcomes are discussed.

Current outcomes following heart transplantation

Survival after cardiac transplantation has improved progressively since its inception over 35 years ago, with current 1 year survival approaching 90% and 7 year survival approaching 75%. In view of continued severe donor shortages, allocation must balance the survival benefit margin for recipients with terminal heart failure (higher risk for death with multiple co-morbidities and refractory low output state) and the charge to maximize graft survival. Continued improvement in short and longer-term survival will depend on an understanding of the early and late risk factors after cardiac transplantation and the development of methods and treatments to neutralize them. Specific risk factors vary for the specific causes of mortality, which include primarily early graft failure, infection, and rejection during the first post transplant year; and allograft vasculopathy and malignancy in later years. Evolving trends in risk profiles and survival indicate that patients undergoing cardiac transplantation have experienced a gradual increase in risk profile over the past decade, and have improved survival. Patient-specific risk profiling will play an increasing role in the allocation of transplantation and other emerging therapies for patients with advanced heart failure.

State of the Science for Cardiovascular Nursing Outcomes

The incidence of heart failure is increasing because of the progressive aging of the population and improved survival from cardiovascular disease. This article synthesizes the state of the science of nurse sensitive outcomes in heart failure treated medically or surgically and provides recommendations for building the science. Outcomes studied include mortality, morbidity, resource use, quality of life, symptoms, physical function, return to work, and self-care and compliance behavior. Gaps in the literature are identified and recommendations for future research are provided.

Change in quality of life from after left ventricular assist device implantation to after heart transplantation

BACKGROUND

No studies have analyzed quality of life (QOL) from before to after heart transplantation in patients with a left ventricular assist device (LVAD). Therefore, the purpose of this longitudinal, multi-site study was to compare QOL outcomes of patients listed for heart transplantation who required a left ventricular assist device (LVAD) at 3 months after implantation of an LVAD vs 3 months after heart transplantation.

METHODS

A non-random sample of 40 patients (predominantly middle-aged, married, white men), who had paired data at both 3 months after LVAD implantation and 3 months after heart transplantation, were investigated. Patients completed self-report questionnaires (with acceptable reliability and validity) at both time periods, including the Quality of Life Index, Rating Question Form, Heart Failure Symptom Checklist, Sickness Impact Profile, LVAD Stressor Scale (completed only after LVAD implant), Heart Transplant Stressor Scale (completed only after heart transplant) and Jalowiec Coping Scale. Descriptive analyses and comparative analyses using paired t-tests were performed with statistical significance set at 0.01.

RESULTS

Patients were significantly more satisfied with their lives overall and with their health and functioning at 3 months after heart transplantation as compared with 3 months after LVAD implantation. Mobility, self-care ability, physical ability and overall functional ability improved from 3 months after LVAD implant to 3 months after heart transplant. There was significantly less symptom distress after LVAD implant as compared with after heart transplant for the neurologic, dermatologic and physical sub-scales. Work/school/financial stress was significantly lower after heart transplant vs after LVAD implant. In contrast, 2 other areas of stress were significantly lower after LVAD implant vs after heart transplant: self-care stress and hospital/clinic-related stress.

CONCLUSIONS

Differences were found in QOL outcomes at 3 months after LVAD implant as compared with 3 months after heart transplant. Our findings point out specific areas of concern with respect to QOL after LVAD implant and post-transplant, some of which are amenable to health-care provider interventions.

Perceived employment barriers and their relation to workforce-entry intent among people with HIV/AIDS

As treatments have improved health and quality of life for people with HIV/AIDS, many have contemplated workforce reentry. Workforce reentry rarely occurs among people with illness-related disability. The authors mailed a survey that included workforce-entry-related concerns to 1,991 HIV/AIDS clients. Factor analysis extracted 6 areas of concern (benefits loss, work-related health, job skills, discrimination, personal health care, workplace accommodation). Levels of concern generally increased with HIV acuity level and time since last worked. Work-related health concerns predicted consideration of workforce entry, and work-related health concerns and benefits-loss concerns predicted estimated time to return to work. Findings provide quantitative validation of intuitive categories of workforce-entry concerns among people with HIV/AIDS and suggest that concerns may shift with progress toward workforce entry.

Lifestyle and quality of life in long-term cardiac transplant recipients

BACKGROUND

The purposes of this study were to describe long-term (>1 year) cardiac transplant recipients' perceptions of barriers to health-promoting behaviors; ability to manage their health, health-promoting lifestyle, health status and quality of life (QOL); and determine predictors of QOL.

METHODS

Data were collected from 93 recipients who completed a self-report questionnaire incorporating: (1). patient characteristics; (2). barriers to health promotion, perceived health competence and health-promoting lifestyle; (3). perceived health status; and (4). QOL. All instruments used had acceptable reliability and validity. Objective measures of health status were retrieved from medical records. Data were analyzed using descriptive and comparative statistics, measures of association and multiple regression.

RESULTS

Recipients were uncertain about their ability to manage their health; felt that barriers sometimes interfered with engaging in health-promoting behaviors; and often included health-promoting behaviors in their lifestyle. They rated their health as good and were moderately satisfied with life. Predictors of better perceptions of QOL included less education, longer time since transplant, ischemic etiology of heart failure, fewer barriers, higher perceived health competence and a health-promoting lifestyle (R(2) = 0.51; F = 14.77; p = 0.001).

CONCLUSIONS

The present results provide information regarding factors that contribute to perceptions of quality of life after cardiac transplantation, have implications for identifying patients at risk for poor QOL, and sensitize clinicians to the need for ongoing patient education.

Quality of life after heart transplantation: are things really better?

Studies of quality of life (QOL) in heart transplant recipients have been published during the last 2 decades. More recent studies of QOL outcomes have built on previous research. Relationships between posttransplant complications and QOL, longitudinal studies of intermediate and long-term QOL, QOL in patients awaiting transplant (bridged to transplant with a left ventricular assist device), and intervention studies to improve QOL have been published recently. Is QOL better from before to after heart transplantation? The current body of literature suggests that QOL is better overall. However, change in QOL (both positive and negative) is variable based on demographic characteristics, clinical problems, QOL domain, time posttransplant, and other life events. Moreover, although more recent reports have begun to examine unanswered questions, much work remains to be done. Future studies need to be scientifically rigorous, using definitions of QOL with identification of domains to be studied; prospective, multisite, longitudinal study designs; large sample sizes; reliable and valid instruments; and appropriate statistical techniques. As changes in QOL outcomes and risks for poor QOL outcomes are identified, more intervention studies need to be developed to assist patients toward better QOL.

Heart failure and its impact on older women's lives

AIM OF THE STUDY

This phenomenological study sought to examine and describe the experience of living with heart failure (HF) from the perspective of five women who live with Stage II HF.

BACKGROUND

Research has shown that women are affected by HF differently than men, having different risk factors, a higher increase in mortality per decade, and longer survival after diagnosis. Women have also been greatly under-represented in studies of HF. A search of the literature revealed only one Swedish study examining the overall impact of HF on women's conceptions of their own lives.

RESEARCH METHODS

Four 1-hour semi-structured interviews were held with each participant. Colaizzi's steps were used to analyse the verbatim transcripts of the interviews, drawing meanings from the participants' words.

FINDINGS

Four main themes emerged from the data: 'Acknowledging Losses in Their Lives', 'Accepting the Losses', 'Changing Their Lives' and 'Deepening Relationships'. Additionally, each theme contained several subthemes.

CONCLUSION

Findings from this study indicate that no aspect of women's lives escapes the impact of HF. It causes immense losses in many areas of life, and requires tremendous changes in many aspects of daily living. Yet, drawing on inner resources of great strength and courage, these women learn to find contentment in their lives. They discover ways to create productive lives and deeply meaningful relationships, within the boundaries imposed by HF.

An economic evaluation of lung transplantation

OBJECTIVE

This study was undertaken to determine the cost per quality-adjusted life-year gained with lung transplantation relative to medical treatment for end-stage lung disease in the United Kingdom.

METHODS

Patients on the transplant waiting list were used to represent medical treatment. Four-year national survival data were extrapolated to 15 years by means of parametric techniques. Quality-adjusted life-years were derived by means of utility scores obtained from a cross-section of patients. Resource consumption and costs were based on local and national sources. Costs and benefits were discounted at an annual rate of 6%.

RESULTS

Across a 15-year period lung transplantation yielded mean benefits (relative to medical treatment) of 2.1, 3.3, and 3.6 quality-adjusted life-years for single-lung, double-lung, and heart-lung transplantation, respectively. During the same period the mean cost of medical treatment was estimated at $73,564, compared with $176,640, $180,528, and $178,387 for single-lung, double-lung, and heart-lung transplantation, respectively. The costs per quality-adjusted life-year gained were $48,241 for single-lung, $32,803 for double-lung, and $29,285 for heart-lung transplantation. Sensitivity analysis found the principal determinants of cost-effectiveness to be quality of life and maintenance costs after transplantation.

CONCLUSIONS

Lung transplantation results in survival and quality of life gains but remains expensive, with cost-effectiveness limited by substantial mortality and morbidity and high costs. The cost-effectiveness of lung transplantation can be improved with lowered immunosuppression costs and improvements in quality of life after transplantation.

Preoperative expectations and postoperative quality of life in liver transplant survivors

OBJECTIVE

To assess normalization in the lives of liver transplant patients and the impact of preoperative expectations on postoperative quality of life (QOL).

DESIGN

A semistructured interview, 2 QOL questionnaires, and chart reviews of medical histories.

SETTING

Internal medicine department at Innsbruck university hospital, Austria.

PARTICIPANTS

Fifty-five patients (32 men, 23 women) with liver transplants.

INTERVENTIONS

The Sickness Impact Profile (SIP) and Functional Assessment of Cancer Therapy-General.

RESULTS

Patients' preoperative expectations of a normal life style posttransplantation were predominantly optimistic (60%), but postoperatively only 40% thought that their expectations had been realized. The patients' SIP values showed significant impairments in nearly every area of life when compared with the values of a healthy control group. Only "complications during the hospitalized phase" had a statistically significant impact among the sociodemographic and clinical parameters on postoperative QOL. The lowest QOL scores were found among patients whose expectations of a return to normal life style had not been realized.

CONCLUSION

Unmet life-style expectations after liver transplantation may lead to increased stress, which affects QOL long term. This finding is of clinical relevance; therapeutic measures, particularly professional pretransplant counseling, are indicated.

Determinants of disability after lower extremity fracture

BACKGROUND

Factors influencing the progression of physical impairment to patient-perceived disability are not well known. We sought to better understand this relationship in the setting of injury.

METHODS

We followed a cohort of 302 patients with lower extremity fractures over a 1-year period. Physical impairment was assessed by range of motion, strength, and pain. Range of motion and strength were assessed together as a proportion of normal function of the extremity (impairment score). Pain was assessed using a Visual Analogue Scale (VAS) pain score. Disability was assessed using the Sickness Impact Profile (SIP), a widely used measure of patient-perceived limitations of everyday activities attributable to illness. The SIP was administered during hospitalization to assess preinjury baseline. Impairment assessment and readministration of the SIP were performed at 12 months after injury.

RESULTS

Impairment in leg function (range of motion and strength) was highly correlated (p < 0.001) with overall SIP score at 12 months, but accounted for only 23% of the variance in overall SIP scores. Likewise, VAS pain score was highly correlated (p < 0.001) with overall SIP score at 12 months, but accounted for only 29% of the variance in overall SIP scores. In a multivariate linear regression analysis, variables that were independently associated with overall SIP score included impairment score, VAS pain score, preinjury SIP, poverty status, education status, social support, having hired a lawyer, and involvement with workers' compensation. These variables accounted for 52% of the variance in overall SIP scores at 12 months.

CONCLUSION

The degree of physical impairment accounts for only a small amount of the variance in disability from lower extremity fracture. Identifiable patient characteristics including age, socioeconomic status, preinjury health, and social support together with impairment account for over half of the variance in long-term disability. Further research is needed to increase understanding of other factors that influence the progression of impairment to disability, especially those factors that may be amenable to intervention.

Pain and health related quality of life after heart, kidney, and liver transplantation

No study has focused particularly on the sensory and affective experience of bodily pain among transplanted patients. The aim of this study was to explore pain and other factors that influence health related quality of life (HRQOL) in heart, kidney, and liver transplant recipients during the first 2 yr after transplantation, and to define similarities and/or differences in the three groups. A total of 76 patients, 18-60 yr old, undergoing heart, kidney, or liver transplantation between 1995 and 1997 with a follow-up of 6-24 months were included. HRQOL and pain were investigated by using the Short-Form-36 items (SF-36), the Hospital Anxiety and Depression Scale (HAD), and the Pain-O-Meter (POM). Overall, the patients show satisfactory HRQOL. There were no differences in experienced HRQOL 6 24 months after transplantation between kidney, liver, and heart transplant recipients except in the area of Role-Physical (RP). Fifty-three percent of all patients reported bodily pain. The most common locations were the hands, feet, and back, and sensory experiences were burning, stabbing, or dull pain. There was a correlation between number of rejections and total score for POM-VAS (p < 0.05) (rho = 0.47). There was also a correlation between the number of rejection episodes and the total pain intensity score for POM-WDS (p < 0.05) (rho = 0.48). Patients with pain scored higher in the area of depression (p < 0.05). Bodily pain is an important problem after organ transplantation, affecting daily living even in patients with good allograft function and it limits physical function. vitality, and general health.

Preoperative psychosocial predictors of hospital length of stay after heart transplantation

The effect of psychosocial factors on hospital length of stay (LOS) after heart transplantation has not been reported. This study examines relationships between preoperative psychosocial variables and LOS and identifies preoperative psychosocial predictors of LOS after transplant. A nonrandom sample of 307 patients at two medical centers completed a self-administered booklet of psychosocial measures. A chart review was also conducted. Psychosocial problems included anxiety, stress, and inadequate coping; questionable understanding of heart failure and treatment; substance abuse; and noncompliance. Self-care disability, a history of noncompliance, and more emotional disability predicted 8% of LOS. This supports the inclusion of psychosocial issues and functional disability in post-heart transplant clinical pathways.

Predictors of quality of life in patients at one year after heart transplantation

BACKGROUND

A multivariate approach to the study of relationships between quality of life and demographic, physical, and psychosocial variables after heart transplantation has not been examined in a large, multi-site sample. The purpose of this study was to describe quality of life, examine relationships between quality of life and demographic, physical, and psychosocial variables, and identify predictors of quality of life in patients who were 1 year post heart transplantation.

METHODS

Data were collected from a nonrandom sample of adult patients (n = 232) who were 1 year post heart transplantation at a Midwestern or Southern medical center. Nine self-administered instruments and chart review were used to gather data from patients. All tools had adequate psychometric support. Descriptive statistics, Pearson correlations, and step-wise multiple regression were used to analyze data. Level of significance was set at 0.05.

RESULTS

Patients were most satisfied with the areas of quality of life regarding social interaction and least satisfied with their psychological state. Patients experienced an average amount of stress, were coping fairly well, reported overall good quality of life, and were very satisfied with the outcome of their transplant surgery. Nine out of 16 variables were significant predictors of quality of life and explained 66% of the variance in quality of life: less stress, more helpfulness of information from health care providers, better health perception, better compliance with the transplant regimen, more effective coping, less functional disability, less symptom distress, older age, and fewer complications.

CONCLUSIONS

Predictors of quality of life at 1 year after heart transplantation were primarily psychological. Additional variance in quality of life was explained by physical, somatic sensation, demographic, and health status variables. Knowledge of these factors provides (1) information to identify patients who are at risk for poor quality of life at 1 year after heart transplantation and (2) direction for the development of interventions to improve quality of life.

Psychological adjustment after cardiac transplantation

Psychosocial function improves after cardiac transplantation but the extent of improvement is not established. Neither are the factors established that account for variability in function between patients following successful transplantation. We therefore compared illness-related dysfunction in patients following orthotopic cardiac transplantation (OCT) with that in angina-free patients following coronary artery bypass graft (CABG) and stable patients in heart failure awaiting transplantation (HF). We also measured two factors that might contribute to variation in function: emotional distress and concern with physical symptoms. Psychosocial function was as good in OCT as in CABG patients and, in both, was better than in HF patients. Differences in emotional distress and in physical symptoms showed a similar pattern and contributed to, but did not completely account for, differences in function. Concern with physical symptoms contributed to variability in functional impairment in HF but not CABG patients; transplantation strengthened this relationship. The results show that successful cardiac transplantation enhances psychosocial function to a level comparable with that after CABG, and suggest targets for psychological or educational intervention to improve quality of life after transplantation in patients whose recovery is inhibited by concern about physical symptoms.

Quality-of-life and formal functional testing of survivors of out-of-hospital cardiac arrest correlates poorly with traditional neurologic outcome scales

STUDY HYPOTHESIS

The traditional (and unvalidated) five-point Cerebral Performance Category (CPC) score at hospital discharge does not correlate with the results yielded by a validated functional status instrument and subjective quality-of-life assessment.

METHODS

We compared CPC scores with the results of prospective standardized testing after discharge in survivors of out-of-hospital cardiac arrest. Consenting survivors were tested with the validated Functional Status Questionnaire (FSQ), a subjective quality-of-life assessment, and traditional CPC scoring.

RESULTS

Of the 3,130 arrests during the 52 months of the study, 93 patients survived. Thirty-five patients were tested (71% of those eligible at the time of follow-up). Of these patients, 34% said their quality of life was worse, 38% said it was the same, and 28% said it was better than before the cardiac arrest. Fifty-four percent of patients scored normally on all FSQ subscales, but the remainder had an average 2.1 areas (of 6) with significant impairment. CPC score correlated very poorly with quality-of-life rating and with all scores and subscores on the FSQ. A CPC of 1 on discharge (supposedly normal function) had a sensitivity of 78%, a specificity of 43%, a positive predictive value of 64%, and a negative predictive value of 60% for quality of life the same as or better than that before arrest. With regard to ability to predict the presence of any major areas of impairment on the FSQ, the respective figures were 32%, 43%, 43%, and 32%.

CONCLUSION

The CPC score, relied on as a measure of functional outcome in cardiac arrest, correlates poorly with subsequent subjective quality of life and with validated objective functional testing instruments, and conclusions based on it are suspect. Future researchers should employ standardized testing instruments.

Quality of life following transplantation of the heart, liver, and lungs

The purpose of this study was to describe the quality of life of patients who have received a transplant of the heart, liver, and lungs. We wished to document how the different patient groups fared in relation to each other with respect to physical, psychological, and social functioning, as well as in relation to published normative data. We also wished to identify factors that contribute to better functioning. We sent out a questionnaire by mail and received responses from 55 heart, 149 liver, and 59 lung transplant recipients (82% response rate). Measures included the SF-36, Mental Health Inventory, the State Anxiety Inventory, the UCLA Loneliness Scale-Revised, a quality of life measure that rated degree of improvement since transplantation, a measure of degree of difficulty in following medical and lifestyle regimens, sleep disturbance, and the Illness Intrusiveness Rating Scale. Results indicated that lung transplant patients reported better functioning than heart or liver transplant patients in all three domains of physical, psychological, and social functioning. Lung patients' level of functioning was equivalent to or better than published norms for the SF-36. Heart and liver recipients reported equivalent functioning to published norms in some domains, but reported impairment in the areas of physical and social functioning. Heart patients especially reported greater intrusiveness of their illness on their daily lives and indicated more difficulty complying with their lifestyle regimen. In all three groups, a large majority of patients reported feeling that life had improved since transplant with respect to health, energy level, activity level, and overall quality of life. Fewer patients reported improvements in the areas of sex life, marriage, family relationships, and social relationships. Where there were differences among the three patient groups, again it was the lung patients who reported more improvement in life since transplantation. Patients with better physical functioning tended to have more energy and pep, to be younger, to see themselves as being in better health, to feel less intrusion on their lives of their illness, and to be employed. Those with better psychological functioning tended to report less sleep disturbance, less loneliness, better social functioning, more vitality, and to be older. Better social functioning was associated with better mental health, less illness intrusiveness, and less role impairment as a result of physical or emotional factors. Relatively few patients-roughly a quarter of the total sample-reported that they were working either full or part time. We conclude that transplantation results in improved quality of life overall, but that problems persist for some patients in their physical and social functioning. Interventions aimed at improving rehabilitation in specific targeted areas may enable patients to resume a more fulfilling lifestyle posttransplant.

Sequential assessment of exercise tolerance in heart transplantation compared with coronary artery bypass surgery after phase II cardiac rehabilitation

To investigate the improvement in exercise capacity of transplant patients after an early postoperative (phase II) cardiac rehabilitation program during the first year after surgery, we analyzed retrospectively exercise capacity within 3 months (at the completion of phase II rehabilitation) and 1 year after surgery in 17 orthotopic heart transplantation patients (15 men and 2 women) and 17 age- and gender-matched coronary artery bypass graft (CABG) patients. All patients participated in a phase II cardiac rehabilitation exercise program followed by a home-based exercise program. At the completion of phase II cardiac rehabilitation, mean peak oxygen (VO2) adjusted for body weight in heart transplant patients was not significantly different from that in CABG patients (19.7 +/- 3.7 vs 21.9 +/- 4.1 ml/kg/min), and oxygen pulse at peak exercise did not differ between the 2 groups (11.5 +/- 2.5 vs 12.6 +/- 2.4 ml/beat). Between 3 months and 1 year after surgery, CABG patients had a marked increase in exercise time, increase in heart rate from rest to peak exercise (heart rate reserve), peak VO2, and oxygen pulse. In contrast, heart transplant patients had a significant but only modest increase in peak VO2, and were much more limited in exercise capacity at 1 year than were CABG patients (21.3 +/- 3.9 vs 27.4 +/- 4.7 ml/kg/min, p <0.0001). In our limited patient population, usual phase I rehabilitation with subsequent home-based exercise training was inadequate to improve the exercise capacity of heart transplant patients, and different rehabilitation protocols, such as long-term supervised exercise training, specific to this patient group may be indicated.

Cardiovascular, pulmonary, and cancer rehabilitation. 1. Cardiac rehabilitation

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of cardiac patients and other rehabilitation patients with cardiac diseases. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. New advances covered in this article include the management of patients who have undergone cardiac surgery, including transplantation, and gender differences in evaluation, therapy, and outcome.

The Sickness Impact Profile as a tool to evaluate functional outcome in trauma patients

Because the ultimate goal of trauma care is to restore injured patients to their former functional status, reliable evaluation of functional status is needed to assess fully the effectiveness of trauma care. We hypothesized that the Sickness Impact Profile (SIP), a widely used measure of general health status, would be a useful tool to evaluate the long-term functional outcome of trauma patients and that the SIP would identify unexpected problems in the recovery process and groups of patients at high risk for long-term disability. A prospective cohort of 329 patients with lower extremity fractures admitted to three level I trauma centers were interviewed using SIP at 6 and 12 months postinjury. Patients with major neurologic injuries were excluded. Overall SIP scores and each of the component subscores may range from 0 (no disability) to 100. In this series, the mean overall SIP was 9.5 at 6 months and 6.8 at 12 months, compared with a preinjury baseline of 2.5. At 12 months, 52% of patients had no disability (SIP 0 to 3), 23% mild disability (4 to 9), 16% moderate disability (10 to 19), and 9% severe disability ( > or = 20). Disability was widely distributed across the spectrum of activities of daily living, including physical functioning (mean score of 5.5), psychosocial health (mean score of 5.5), sleeping (mean score of 10.0), and work (mean score of 21.0). The SIP scores did not correlate with Injury Severity Score.(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of patients surviving more than ten years after cardiac transplantation

The clinical status and quality of life of 40 patients who lived or are still alive more than 10 years after transplantation at our institution were reviewed with the use of our transplant database, prospective patient examinations, cardiac catheterization, and exercise testing. Patient-perceived health status was determined with use of the Nottingham Health Profile and General Well Being examinations. Factors associated with longevity were determined by a Cox proportional hazards model. Twenty-six patients are alive and 14 have died. The mean age at transplant was 32.4 +/- 12 years and the current age (or age at death) is 46.1 +/- 12.8 years. Actuarial freedom from rejection was similar to that of patients surviving less than 10 years (p = 0.8), but freedom from all types of infection was less (p = 0.005). Immunosuppressive drugs include cyclosporine (11/26 patients), azathioprine (24/26), and prednisone (26/26, mean dose 12.7 mg/day). Catheterization hemodynamic data show well-preserved graft function at a mean follow-up of 11.7 +/- 3.3 years. Graft coronary artery disease prevalence is 51.0% +/- 8%. Exercise test results are as follows: duration 8.7 +/- 3.5 minutes (range 2 to 16 minutes), maximum heart rate/expected rate 77.3% +/- 11% (50% to 92%), maximum systolic blood pressure 171 +/- 23 mm Hg (140 to 208 mm Hg), and metabolic equivalents 9.2 +/- 2.3 units (5.5 to 12.9 units), or about 84% of predicted. Mean score on the General Well Being examination was 75.3 +/- 21.6 (normal). Nottingham Health Profile scores were nearly normal, except for in the 50- to 64-year-old age group in categories of mobility, pain, sleep quality, and energy level. Causes of death were coronary artery disease in 7 of 14, infection in 4 of 14, lymphoma in 1 of 14, and nonlymphoid cancer in 2 of 14. In the Cox regression, variables most associated with survival (t > 2.0, multivariate p = 0.0005) were age at transplantation (t = 3.26), preoperative duration of illness (t = 3.57), postoperative cytomegalovirus infection (t = 2.16), and ejection fraction at 12 months after operation (t = -2.62). We conclude that cardiac transplantation can provide patients with end-stage cardiac failure an acceptable general medical condition, functional status, and perceived quality of life well into the second decade after operation.

Sex differences in patient acceptance of cardiac transplant candidacy

BACKGROUND

The overwhelming majority of cardiac transplant recipients are men. This can be partially explained by the earlier age at which heart failure develops in men. However, an underrepresentation of women also may reflect physician referral or selection biases or differences in patients' access to or acceptance of heart transplantation.

METHODS AND RESULTS

We investigated whether sex bias occurred in the transplant candidate selection process at a single cardiac transplant center. We prospectively evaluated 386 individuals < 70 years of age (295 men, 91 women) referred for management of moderate to severe heart failure and/or cardiac transplant evaluation. Age, race, sex, heart failure type, New York Heart Association class, left ventricular ejection fraction, peak exercise oxygen consumption, disease duration, resting hemodynamic measurements, comorbidity index score, health insurance coverage, and estimated household income were recorded. For patients not accepted for transplantation, the reason for rejection was also obtained. Univariable and multivariable (logistic regression) analyses were performed comparing men and women and patients accepted and those not accepted for cardiac transplantation. Female sex was independently associated with rejection for cardiac transplantation (odds ratio, 2.57; P = .01). However, the reason for rejection (odds ratio, 2.57; P = .01). However, the reason for rejection was more likely to be patient self-refusal for women than for men (29% versus 9%), and female sex was independently associated with patient self-refusal (odds ratio, 4.68; P = .003). When patients who refused transplant were reclassified as accepted for transplant, female sex was no longer associated with nonacceptance. However, lower patient income was associated with nonacceptance for transplant.

CONCLUSIONS

We found no evidence of sex bias in the selection of cardiac transplant recipients at our center. These findings suggest that the underrepresentation of women among cardiac transplant recipients may result, in part, from a sex difference in treatment preference, with a decreased willingness of women to undergo transplantation. The reasons for the difference in acceptance rates between men and women need to be elucidated.