Factors associated with stress and coping at 5 and 10 years after heart transplantation

Biomarkers from subcutaneous engineered tissues predict acute rejection of organ allografts

Invasive graft biopsies assess the efficacy of immunosuppression through lagging indicators of transplant rejection. We report on a microporous scaffold implant as a minimally invasive immunological niche to assay rejection before graft injury. Adoptive transfer of T cells into Rag2-/- mice with mismatched allografts induced acute cellular allograft rejection (ACAR), with subsequent validation in wild-type animals. Following murine heart or skin transplantation, scaffold implants accumulate predominantly innate immune cells. The scaffold enables frequent biopsy, and gene expression analyses identified biomarkers of ACAR before clinical signs of graft injury. This gene signature distinguishes ACAR and immunodeficient respiratory infection before injury onset, indicating the specificity of the biomarkers to differentiate ACAR from other inflammatory insult. Overall, this implantable scaffold enables remote evaluation of the early risk of rejection, which could potentially be used to reduce the frequency of routine graft biopsy, reduce toxicities by personalizing immunosuppression, and prolong transplant life.

Level of Life Quality in Heart and Kidney Transplant Recipients: A Multicenter Study

OBJECTIVE

The main objective of the researchers was to determine the level of life quality among heart and kidney transplant recipients depending on the time and type of the transplant.

METHODS

The study was conducted using standardized questionnaires: the 36-Item Short-Form Health Survey, Life Orientation Test-Revised, and Hospital Anxiety and Depression Scale. The study included 146 recipients (109 heart transplant recipients and 37 kidney transplant recipients) from 1 to 26 years after the transplantation surgery (mean 9 years).

RESULTS

The mean age of the study group was 52 years. The mean time since organ transplantation was 10 years for heart transplantation and 4.3 years for kidney transplantation. The study group obtained a slightly lower score for quality of life compared to the general population. In the Physical Component Summary (PCS), the study participants obtained the highest mean for the domain bodily pain (47.6), while the lowest score was in the domain role physical (41.82). As for the Mental Component Summary (MCS), the highest mean was obtained for the domain vitality (50.57), whereas the lowest one was for the domain role emotional (43.38). In 33% of the participants, risk of depression was identified. Statistically significant differences were observed depending on the type of the transplanted organ in the PCS for the domains general health, physical functioning, and bodily pain and the MCS for role emotional and social functioning. The statistically significant predictors for the PCS domain were the type of transplanted organ, recipients' age, and occurrence of anxiety. In turn, the predictor for the MCS was the occurrence of depression.

CONCLUSIONS

The quality of life (QOL) assessment varies between kidney and heart transplant recipients. The QOL is determined by the recipients' age and the occurrence of anxiety and depression. The obtained QOL assessment results are slightly lower than those in the general population.

Psychopharmacology in transplantation medicine

Organ transplantation has become a well-established treatment option in patients with end-stage organ diseases. Although quality of life has markedly improved, psychiatric disorders before and after transplantation are more frequent compared to the general population. Psychopharmacological treatment is recommended for almost all mental disorders according to current guidelines, but may pose particular problems in organ transplant patients. Changes in the metabolism and elimination of drugs during organ insufficiency, drug interactions, and overlapping side effects between psychopharmacological and immunosuppressive drugs are challenging problems in clinical management. Furthermore, questions frequently arise concerning the use of psychopharmacological treatment options for sleeping and anxiety disorders. This article reviews psychopharmacology in organ transplant patients, with particular attention to frequent psychiatric disorders observed in the disease course of end-stage organ diseases.

COPD patient education and support - Achieving patient-centredness

BACKGROUND

The art of medicine is undergoing a dramatic shift in focus, evolving to focus on patient involvement as partners in care, transforming the traditional, prescriptive, reactive practice of healthcare into a proactive discipline. The personal and societal burden of chronic diseases is burgeoning and unsustainable in current systems, novel approaches are required to address this.

DISCUSSION

Although considerable progress has been made in the development of diagnostics, therapeutics and care guidelines for patients with chronic obstructive pulmonary disease (COPD), questions remain surrounding the implementation of best practice education and support. Current educational programmes, personal limitations and preferences and patient-clinician communication in modification of coping styles and behaviour are discussed. A novel holistic model, the Kaleidoscope Model of Care is proposed to address the barriers to optimal self-care behaviours.

CONCLUSION AND PRACTICE IMPLICATIONS

Holistic approaches are essential for optimal self-management and improved outcomes. Guidance on personalised goals for patients to help meeting their therapy priorities is needed to aid healthcare professionals (HCPs) and funders to minimise healthcare burden and costs. The novel KALMOD approach may optimise patient empowerment, exploring whole-life factors that impact COPD care and improve interactions between patients and HCPs for optimised outcomes.

Micro RNA-98 suppresses interleukin-10 in peripheral B cells in patient post-cardio transplantation

The immune tolerance to the transplant heart survival is critical. Regulatory B cells are one of the major immune regulatory cell populations in the immune tolerance. Micro RNAs (miR) can regulate the activities of immune cells, such as the expression of interleukin (IL)-10 by B cells. This study tests a hypothesis that micro RNA (miR)-98 plays a role in the regulation of interleukin (IL)-10 expression in B cells (B10 cell) after heart transplantation. In this study, the peripheral blood samples were collected from patients before and after heart transplantation. The expression of miR-98 and IL-10 in B cells was assessed by real time RT-PCR. An allograft heart transplantation mouse model was developed. We observed that after heart transplantation, the frequency of peripheral B10 cell and the IL-10 mRNA levels in peripheral B cells were significantly decreased, the levels of miR-98 were increased in peripheral B cells and the serum levels of cortisol were increased in the patients. Treating naive B cells with cortisol in the culture suppressed the expression of IL-10 in B cells, which was abolished by knocking down the miR-98 gene. Administration with anti-miR-98, or cortisol inhibitor, or adoptive transfer with B10 cells, significantly enhanced the survival rate and time of mice received allograft heart transplantation. In conclusion, the enhancement of serum cortisol affects the immune tolerant feature of B cells, which can be attenuated by anti-miR-98-carrying liposomes.

Appraisal of transplant-related stressors, coping strategies, and psychosocial adjustment following kidney transplantation

This study examined the relations between appraisal of transplant-related stressors, coping, and adjustment dimensions following kidney transplantation (KT). Two models were tested: (1) the main effects model proposing that stress appraisal and coping strategies are directly associated with adjustment dimensions; and (2) the moderating model of stress proposing that each coping strategy interacts with stress appraisal. Importantly, there is a lack of research examining the two models simultaneously among recipients of solid organ transplantation. A total of 174 KT recipients completed the questionnaires. Predictors of post-transplant adjustment included appraisal of transplant-related stressors and coping strategies (task-, emotion-, and avoidance-focused). Adjustment dimensions were psychological distress, worries about the transplant, feelings of guilt, fear of disclosure of transplant, adherence, and responsibility for the functioning of the new organ. The main and moderating effects were tested with regression analyses. Appraisal of transplant-related stressors and emotion-oriented coping were related to all adjustment dimensions, except of adherence and responsibility. Task-oriented coping was positively related to responsibility. Avoidance-oriented coping was negatively correlated with adherence. Only 1 out of 18 hypothesized interactive terms was significant, yielding a synergistic interaction between appraisal of transplant-related stressors and emotion-oriented coping on the sense of guilt. The findings have the potential to inform interventions promoting psychosocial adjustment among KT recipients.

The Relationship Between Stressors and Anxiety Levels After CABG in Sari, Iran

Background

Hospitalization and surgery are crucial adverse life events that lead to considerable anxiety in patients.

Objectives

The present study aimed to investigate stressors after coronary artery bypass graft surgery and identify stressors that predict anxiety.

Patients and Methods

This is a descriptive-analytical study that uses a non-random convenience sampling method on patients undergoing coronary artery bypass graft surgery at the cardiac surgery intensive care unit of Fatemeh Zahra Cardiac center in Sari, Iran. A total of 186 patients completed the post-surgical stressors questionnaire and the Spielberger State-Trait Anxiety Inventory on postoperative days 2 or 3 in the cardiac surgery intensive care unit. Data were analyzed using descriptive statistics including frequencies, means, and standard deviations. The Mann–Whitney U test was used to determine the relationship between the observed variables, and the logistic regression model was used to identify the relationship between stressors and anxiety after-surgery.

Results

Post-surgical anxiety predictors included insufficient sleep during hospitalization (Odds ratio [OR]: 5.42; 95% confidence interval [CI]: 1.46 - 20.00; P = 0.010), treatment not explained to the patient by the nurse (OR: 4.83; 95% CI: 1.82 - 12.84; P = 0.002), being away from family members (OR: 3.88; 95% CI: 1.46 - 10.26; P = 0.006), presence of a chest tube (OR: 3.27; 95% CI: 1.83 - 5.84; P = 0.000), and pain in any part of the body (OR: 1.95; 95% CI: 1.06 - 3.58; P = 0.031).

Conclusions

Physical or physiological and psychological stressors impose greater stress and are predictors of anxiety. When preparing their nursing care plan, nurses should consider these stressors that affect anxiety levels in patients undergoing CABG surgery and those hospitalized in intensive care units.

Gender differences in appraisal of stress and coping 5 years after heart transplantation

OBJECTIVES

We examined whether gender differences exist regarding stress, symptom distress, coping, adherence, and social support 5 years after heart transplantation.

BACKGROUND

Differences exist in health-related quality of life outcomes by gender after heart transplantation; women report poorer outcomes.

METHODS

Patients (n = 210, female = 42), were from a prospective, multi-site, study of health-related quality of life long-term after heart transplantation. Patients completed self-report instruments 5 years after heart transplantation (mean = 4.98 ± 0.17 years after transplant). Statistical analyses included two-sample t-tests, Chi-square or Fisher's exact test, and multivariable modeling.

RESULTS

Women did not report more overall stress or symptom distress, but reported more difficulty adhering to the transplant regimen, yet more actual adherence than men. Women reported using more negative coping styles, but reported more satisfaction with social support.

CONCLUSIONS

Gender differences exist regarding appraisal of stress, coping styles, and coping resources long-term after heart transplantation. These differences may guide tailoring therapy regarding stress, poor coping, and lack of resources.

Assessment of psychosocial factors and predictors of psychopathology in a sample of heart transplantation recipients: a prospective 12-month follow-up

BACKGROUND AND OBJECTIVES

In the last decades, researchers of heart transplantation (HT) programs have attempted to identify the existence of psychosocial factors that might influence the clinical outcome before and after the transplantation. The first objective of this study is the prospective description of changes in psychiatric and psychosocial factors in a sample of HT recipients through a 12-month follow-up. The second goal is to identify predictors of psychopathology 1 year after HT.

METHODS

Pretransplant baseline assessment consisted of clinical form; Hospital Anxiety and Depression Scale (HADS); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Structured Clinical Interview; Coping questionnaire (COPE); Five Factors Inventory Revised; Apgar-Family questionnaire and Multidimensional Health Locus of Control (MHLC). The assessment 1 year after HT consisted of HADS, COPE, Apgar-Family and MHLC.

RESULTS

The sample included 78 recipients. During the waiting list period, 32.1% of them had a psychiatric disorder; personality factors profile was similar to the general population, and they showed adaptive coping strategies. Some changes in psychosocial factors were observed at 12 months after the surgery: lower scores of anxiety and depression, less necessity of publicly venting of feelings and a trend to an internal locus of control. Neuroticism and Disengagement pre-HT were predictors of psychopathology in the follow-up assessment.

CONCLUSIONS

Pretransplant psychosocial screening is important and enables to find out markers of emotional distress like Neuroticism or Disengagement coping styles to identify patients who might benefit from psychiatric and psychological interventions. Successful HT involved some positive changes in psychosocial factors 12 months after the surgery beyond physical recovery.

Repercussões no cotidiano dos pacientes pós-transplante cardíaco

Resumo Objetivo Conhecer as repercussões no cotidiano de pacientes submetidos a transplante cardíaco. Métodos Trata-se de estudo descritivo, qualitativo, conduzido em um centro de transplantes do nordeste brasileiro. Nove pacientes submetidos ao transplante cardíaco participaram do estudo, tendo sido utilizada para coleta dos dados a técnica de grupo focal, facilitada em quatro reuniões. Os recortes de suas falas resultaram em duas categorias temáticas: ser transplantado cardíaco - o antes e o depois; e sentimentos e percepções sobre o transplante cardíaco. Resultados A pessoa submetida ao transplante identificou as modificações positivas obtidas após o procedimento, porém ressentiu-se com as inúmeras proibições, com interferência direta em seu cotidiano; as limitações decorrentes do transplante ganharam destaque e não permitiram que os pacientes se sentissem realmente curados. Conclusão Os participantes reconheceram o transplante cardíaco como uma solução para seus sintomas clínicos, contudo, com significativa perda de autonomia, obrigando-os a um intenso esforço adaptativo.

Variation in the use of surveillance endomyocardial biopsy among pediatric heart transplant centers over time

EMB is widely utilized for graft surveillance after HTx; however, there is significant variation in the frequency of surveillance EMB use during the first year post-HTx. The aim of this study was to assess changes in the utilization of surveillance EMB over time among member institutions of PHTS. A survey of PHTS centers assessing the frequency of surveillance EMB use during the first year post-HTx was conducted in 2006. The same survey was repeated in 2014 to assess changes in practice over time. The number of EMB in infants ranged from 0 to 9 and in adolescents 0 to 16. The number of EMB decreased or remained unchanged in the majority of centers. Fewer EMB are performed in infants compared to adolescents and this practice did not change over time. There was a significant decrease in surveillance EMB use in adolescents (p = 0.012). International centers perform significantly fewer EMB in adolescents when compared to centers within the United States (p = 0.006). There continues to be significant variation in the utilization of surveillance EMB, with a shift toward less reliance on EMB for adolescents in the current era. Further research is necessary to determine the optimal frequency of invasive monitoring that reduces costs without compromising outcomes.

Adherence with immunosuppression in heart transplant recipients

PURPOSE OF REVIEW

Nonadherence is a major problem in heart transplantation (htx) and a challenge for clinical practice and research. In heart transplant recipients, nonadherence could cause chronic rejection of the transplanted heart followed by difficult clinical course and/or death of the patient.

RECENT FINDINGS

Main topics are the relationship between psychological aspects and adherence, risk factors and prediction of nonadherence, strategies for improving adherence like single-dose immunosuppressant therapy and follow-up studies.

SUMMARY

There is a lack of behavioral intervention studies. So-called targeted interventions should be defined for clinical practice and research with randomized controlled studies.

Quality of life and metrics of achievement in long-term adult survivors of pediatric heart transplant

Many children who undergo heart transplantation will survive into adulthood. We sought to examine the QOL and capacity for achievement in long-term adult survivors of pediatric heart transplantation. Adults >18 yr of age who received transplants as children (≤18 yr old) and had survived for at least 10 yr post-transplant completed two self-report questionnaires: (i) Ferrans & Powers QLI, in which life satisfaction is reported as an overall score and in four subscale domains and is then indexed from 0 (very dissatisfied) to 1 (very satisfied); and (ii) a "Metrics of Life Achievement" questionnaire regarding income, education, relationships, housing status, and access to health care. A total of 20 subjects completed the survey. The overall mean QLI score was 0.77 ± 0.16. Subjects were most satisfied in the family domain (0.84 ± 0.21) and least satisfied in the psychological/spiritual domain (0.7 ± 0.28). Satisfaction in the domains of health/functioning and socioeconomic were intermediate at 0.78 and 0.76, respectively. Most respondents had graduated from high school, reported a median annual income >$50 000/yr, and lived independently. Adult survivors of pediatric heart transplant report a good QOL and demonstrate the ability to obtain an education, work, and live independently.

Heart transplants: Identity disruption, bodily integrity and interconnectedness

Of heart transplant recipients, 30 per cent report ongoing or episodic emotional issues post-transplant, which are not attributable to medications or pathophysiological changes. To this end, our team theorized that cardiac transplantation introduces pressing new questions about how patients incorporate a transplanted heart into their sense of self and how this impacts their identity. The work of Merleau-Ponty provided the theoretical underpinning for this project as it rationalizes how corporeal changes affect one’s self and offer an innovative framework to access these complex aspects of living with a transplanted heart. We used visual methodology and recorded 25 semi-structured interviews videographically. Both visual and verbal data were analyzed at the same time in an iterative process. The most common theme was that participants expressed a disruption to their own identity and bodily integrity. Additionally, participants reported interconnectedness with the donor, even when the transplanted heart was perceived as an intruder or stranger. Finally, transplant recipients were very vivid in their descriptions and speculation of how they imagined the donor. Receiving an anonymous donor organ from a stranger often leaves the recipient with questions about who they themselves are now. Our study provides a nuanced understanding of heart transplant recipients’ embodied experiences of self and identity. Insights gained are valuable to educate transplant professionals to develop new supportive interventions both pre- and post-transplant, and to improve the process of informed consent. Ultimately, such insights could be used to enable heart transplant recipients to incorporate the graft optimally over time, easing distress and improving recovery.

The effectiveness of non-pharmacological interventions in improving psychological outcomes for heart transplant recipients: a systematic review

BACKGROUND

Post-heart transplant psychological distress may directly hinder physiological health as well as indirectly impact on clinical outcomes by increasing unhealthy behaviors, such as immunosuppression non-adherence. Reducing psychological distress for heart transplant recipients is therefore vitally important in order to improve not only patients' overall health and well-being but also clinical outcomes, such as morbidity and mortality. Evidence from other populations suggests that non-pharmacological interventions may be an effective strategy.

AIM

The purpose of this study was to appraise the efficacy of non-pharmacological interventions on psychological outcomes after heart transplant.

METHOD

A systematic review was conducted using the Joanna Briggs Institute methodology. Experimental and quasi-experimental studies that involved any non-pharmacological intervention for heart transplant recipients were included, provided that data on psychological outcomes were reported. Multiple electronic databases were searched for published and unpublished studies and reference lists of retrieved studies were scrutinized for further primary research. Data were extracted using a standardized data extraction tool. Included studies were assessed by two independent reviewers using standardized critical appraisal instruments.

RESULTS

Three studies fulfilled the inclusion and exclusion criteria, which involved only 125 heart transplant recipients. Two studies reported on exercise programs. One study reported a web-based psychosocial intervention. While psychological outcomes significantly improved from baseline to follow-up for the recipients who received the interventions, between-group comparisons were not reported. The methodological quality of the studies was judged to be poor.

CONCLUSIONS

Further research is required, as we found there is insufficient evidence available to draw conclusions for or against the use of non-pharmacological interventions after heart transplant.

Sweet and sour after renal transplantation: a qualitative study about the positive and negative consequences of renal transplantation

OBJECTIVES

This qualitative study investigated the renal patients' experience of positive and negative consequences of transplantation, as well as the strategies they use to adapt to the transplantation.

DESIGN AND METHODS

A qualitative design (30 participants in total), using individual interviews (18 participants) and two focus groups (12 participants in total), was used.

RESULTS

The results showed that patients experienced a wide range of positive and negative emotions, in particular, guilt, gratefulness, and fear, partly as a result of their normative persuasions. Normative persuasions may transform inherent positive emotions into negative emotions and subsequent maladaptive behaviour. Not only physical limitations but also physical improvements were found to be related to the experience of negative emotions. Finally, the results indicated that patients mainly used adaptive coping strategies to adjust to life after transplantation, such as looking for opportunities, setting different priorities, making own choices, trying to maintain control, taking good care of oneself, and appreciating other things in life.

CONCLUSIONS

This study offers several new insights regarding the range of experiences of renal patients after transplantation. Health professionals are invited to pay more attention to the full range of positive and negative experiences following transplantation, including the existence of normative persuasions. Health professionals may assist renal patients by helping them to recognize and acknowledge both positive and negative emotions and to encourage the use of more beneficial coping strategies.

STATEMENT OF CONTRIBUTION

What is already known on this subject? The quality of life (QoL) of renal patients significantly improves after transplantation but the post-transplant QoL is lower compared with the QoL in healthy populations. Patients on dialysis and those who have received a donor kidney tend to use mainly emotion-focused coping strategies. What does this study add? This study offers several new insights regarding experiences of renal patients after transplantation: Patients experience a range of positive and negative emotions like guilt, gratefulness, and fear. Emotions are partly a result of normative persuasions. Persuasions may transform positive emotions into negative emotions and maladaptive behaviour. Physical limitations and improvements can due to the persuasions lead to negative emotions. Patients mainly use adaptive coping strategies.