Health-Related Quality of Life Long-Term Study in Lung Transplant Patients: A Single-Center Experience

INTRODUCTION

Health-related quality of life (HRQL) assessment plays a crucial role in the follow-up care of lung transplanted (LTx) patients. Previous reports have indicated that the HRQL achieved by these patients is often poorer compared to that of healthy individuals. However, the factors contributing to this lower HRQL remain unclear. This prospective study aimed to assess the effectiveness of using both a generic and a disease-specific HRQL instrument in evaluating the outcomes of patients who have undergone LTx.

METHODS

A total of 111 LTx patients were enrolled in the study, with 88 survivors completing the 5-year follow-up and 23 nonsurvivors identified within the first 3 y. Among the participants, 84 underwent double LTx, while 27 received a single LTx. Patients were interviewed before LTx, at 6 mo post-transplantation, and annually thereafter. Two validated instruments were utilized: the Euro quality of life five dimensions, a generic measure, and the St. George's Respiratory Questionnaire (SGRQ), a disease-specific questionnaire.

RESULTS

The study showed significant improvements in Euro Quality of Life five Dimensions scores from 6 mo after LTx. Specifically, the percentage of patients without Mobility problems increased from 23% before LTx to 71% at 5 y (P = <0.001), while the ability to self-care improved from 48% to 100% (P = <0.001). The ability to carry out usual activities improved from 13% to 86% (P = <0.001), and the proportion of patients without anxiety and depression increased from 50% to 86% (P > 0.004). However, there was no significant improvement observed in Pain, with only a slight reduction from 57% to 42.8% (P = 0.22). The SGRQ also showed improvements in all dimensions (symptoms, impact, activities) (P < 0.001). However, by the fifth year, the HRQL scores remained below normal reference values. Chronic graft dysfunction was associated with a decline in SGRQ scores. Bilateral LTx patients exhibited better SGRQ scores compared to unilateral LTx patients from the first year post-transplantation. Notably, there were no differences in scores between nonsurvivors and survivors.

CONCLUSIONS

The study highlights the long-term improvement in HRQL among LTx patients, with greater improvements observed in physical dimensions compared to psychological dimensions. Bilateral LTx was associated with better SGRQ scores than unilateral LTx, and chronic graft dysfunction primarily affected SGRQ scores. These findings underscore the importance of utilizing both generic and specific HRQL instruments in assessing LTx outcomes.

Factors Associated with Health-Related Quality of Life in Lung Transplant Candidates and Recipients

OBJECTIVES

Health-related quality of life has been well studied across transplantation fields, but factors associated with lung transplant preoperative and postoperative quality of life remain unknown. Here, we determine factors associated with health-related quality of life in lung transplant candidates and recipients to identify patients at risk of lower health-related quality of life.

MATERIALS AND METHODS

From January 2021 to May 2022, health-related quality of life was measured in candidates and recipients using the RAND 36-Item Short Form Health Survey questionnaire. We reviewed demographic parameters and clinical information and scored frailty according to the modified 5-item frailty index. We performed Fisher exact test and the Pearson chi-square test and used linear regression models to determine covariate associations on physical component summary, mental component summary, and self-reported health scores (α = 0.05).

RESULTS

Eleven candidates and 17 recipients comp-leted the survey. Compared with candidates, transplant recipients reported significantly higher scores in 4 of the 8 health domains and in the physical component summary (P < .01), mental component summary (P = .05), and self-reported health score (P < .01). In candidates, higher body mass index and higher modified 5-item frailty index scores were negatively associated with the physical component summary and mental component summary, respec-tively (P < .05). In recipients, higher body mass index and higher lung allocation scores were associated with lower values for the physical component summary (-2.29; P < .05) and self-reported health score (-0.33; P < .05), respectively.

CONCLUSIONS

Body mass index, the modified 5-item frailty index, and the lung allocation score were significantly associated with health-related quality of life in lung transplant recipients. Future interventions should target these modifiable associations to maximize candidate and recipient health-related quality of life.

Pilot study to evaluate a novel measure of self-perceived competencies among dental students

BACKGROUND

PRISM is a novel approach to support self-reflection and learning appraisal in dental students, based on a visual metaphor. The aim of this study was to evaluate whether PRISM measurments would be reproducible and sensitive to detect learning progress in undergraduate dental students in their clinical years.

METHODS

Voluntarily participating dental students were included. To evaluate reproducibility, a mixed cohort of 10 students each in 3^rd, 4^th and 5^th year (total n = 30) was recruited and received three identically structured PRISM interviews within one week without any other teaching events. To assess perceived learning progress, 29 volunteer 3^rd year students participated in three interviews during their clinical simulation course (beginning, middle, end). Distances between Subject and Objects was measured in millimeter; objects were classified into close or branched clusters depending on their distance from each other on the PRISM board.

RESULTS

Values for perceived competencies within PRISM interviews during one week were comparable between the three time points in the mixed cohort (n = 30; p > 0.05). Comparing the three subgroups (3^rd, 4^th and 5^th year, each n = 10), PRISM indicated that 3^rd year students perceived their competencies are significantly lower than the 4^th and 5^th year students (p < 0.01). 3^rd year students had less often a branched cluster of objects than the other two groups (p < 0.05). PRISM showed that over time, 3^rd year students perceived a gain in their competencies in conservative dentistry and its sub-disciplines (p ≤ 0.01). The PRISM data indicated that by the end of the simulation course, the students appeared to show higher discrimination of their self-perceptions between sub-topics in conservative dentistry than at the start of the course (p = 0.01).

CONCLUSION

PRISM yields a reproducible measure of individual students' learning progress. It is a promising novel approach for appraisal in dental education. Further work is needed to confirm the generalisability of the findings.

Post-operative, inpatient rehabilitation after lung transplant evaluation (PIRATE): A feasibility randomized controlled trial

BACKGROUND

Postoperative rehabilitation is crucial following lung transplantation (LTx); however, it is unclear whether intensive rehabilitation is feasible to deliver in the acute setting. We aimed to establish the feasibility and safety of intensive acute physiotherapy post-LTx.

METHODS

This feasibility trial randomized 40 adults following bilateral sequential LTx to either standard (once-daily) or intensive (twice-daily) physiotherapy. Primary outcomes were feasibility (recruitment and delivery of intensive intervention) and safety. Secondary outcomes included six-minute walk test; 60-second sit-to-stand; grip strength; physical activity; pain; EQ-5D-5L; length of stay; and readmissions. Data were collected at baseline, week 3, and week 10 post-LTx. ClinicalTrials.gov #NCT03095859.

RESULTS

Of 83 LTx completed during the trial, 49% were eligible and 48% provided consent. Median age was 61 years {range 18-70}; waitlist time 85 days [IQR 35-187]. Median time to first mobilization was 2 days [2-3]. Both groups received a median of 10 [7-14] standard interventions post-randomization. A median of 9 [6-18] individual intensive interventions were attempted (86% successful), the most common barrier being medical procedures/investigations (67%). No intervention-related adverse events or between-group differences in secondary outcomes were observed.

CONCLUSIONS

Acute, intensive physiotherapy was feasible and safe post-LTx. This trial provides data to underpin definitive trials to establish efficacy.

COVID-19 pandemic restrictions continuously impact on physical activity in adults with cystic fibrosis

BACKGROUND

We have recently reported reduced physical activity (PA) in people with cystic fibrosis (pwCF) with and without lung transplantation (LTX) during a 6-week stringent lockdown in Switzerland. This follow-up study explores the impact of coronavirus-2019 disease (COVID-19) related pandemic restrictions on individuals' therapy regimens and health-related aspects in pwCF.

METHODS

We conducted a cross-sectional web-based national survey in Spring 2021. The survey included questions on daily PA, airway clearance and inhalation therapy, questions on COVID-19-compatible symptoms, diagnostic tests and vaccination status, and enquired health-related aspects covering the pandemic period between March 2020 to April 2021.

RESULTS

193 individuals with CF (53% female; 25% LTX recipients) participated. Among pwCF, 10 reported COVID-19 (n = 2 LTX recipients), two subjects were hospitalized, no invasive ventilation required, no deaths. The clinical course was generally mild. Overall, 46% reported less PA during the pandemic, mostly due to closed fitness facilities (85%), lack of motivation (34%), and changes in daily structures (21%). In contrast, 32/193 (17%) pwCF were able to increase their PA levels: 12 (38%) and 11 (34%) reported undertaking home-based training and outdoor activities more frequently; 6 (19%) reported an increase in routine PA, and another 3 (9%) started new activities. Among pwCF without LTX, 5% and 4% reported to undertake less airway clearance and inhalation therapy, respectively.

CONCLUSIONS

Our study reveals unfavorable consequences of COVID-19 pandemic restrictions on PA of pwCF with unknown long-term consequences for their overall physical fitness and lung health. Strategies to overcome this undesirable situation are needed; increased uptake of telehealth PA programs and virtual exercise classes to promote PA participation might be one promising approach along with vaccination of pwCF and their close contacts.

Organ integration in kidney transplant patients - Results of a KTx360° substudy

OBJECTIVE

Organ transplantation is the treatment of choice for patients with end-stage organ disease. From early on, the psychological perspective on integrating the organ has been of interest. As quantitative studies on organ integration are scarce, we aimed at evaluating this aspect in a large sample of kidney transplant (KTx) recipients.

METHODS

For this cross-sectional study, 684 patients after KTx were recruited within the structured post-transplant care program KTx360°. To measure organ integration and donor relationship, a previously developed and published questionnaire (FOSP), generated explicitly for this purpose, was used. Associations with sociodemographic, medical, donation-specific, and psychological variables were investigated.

RESULTS

Overall, more than 90% of the patients perceived the transplant as part of themselves; however, a small minority reported perceiving it as a foreign object. Frequent thoughts about the donor and the belief of having adopted some of the donor's traits were common (52% and 14%, respectively), specifically in living donor recipients. Higher anxiety and depression scores and reduced kidney functioning were associated with less ideal organ integration, while a more extended period since KTx and more perceived social support correlated with better organ integration. No association between organ integration and adherence, as well as organ integration and cognitive functioning, could be found.

CONCLUSION

Organ integration and donor relationship were unproblematic in most KTx patients. However, offering psychosocial support to those struggling with organ integration and donor relationship is crucial from a clinical perspective.

The Actualization of the Transplantation Complex on the Axis of Psychosomatic Totality-Results of a Qualitative Study

Although transplantation medicine is not new, there is a clinically justified gap in the existing literature with respect to the psychological processing of lung transplants. The present study aims to examine whether lung transplantation leads to an actualization of psychological, e.g., oral-sadistic fantasies. Following a qualitative approach, 38 lung transplant patients were interviewed three times within the first six months after transplantation. Data analysis focused on identifying unconscious and conscious material. The inter-rater reliability for all codes was calculated using Krippendorff’s Alpha (c-α-binary = 0.94). Direct and implicit evidence of a so-called transplantation complex was detected e.g., regarding the “incorporation” of the dead donor and his lungs. These processes occur predominantly at an imaginary level and are related to the body. Our findings emphasize that such psychological aspects should be borne in mind in the psychological treatment of lung-transplant patients in order to improve the processing of lung transplants, and that this might have a positive effect on patient adherence.

Recommended shielding against COVID-19 impacts physical activity levels in adults with cystic fibrosis

BACKGROUND

Severe acute respiratory syndrome - coronavirus-2 (SARS-CoV-2) has caused a pandemic threatening the life of people with chronic respiratory diseases including cystic fibrosis (CF). This study was designed to investigate health-related aspects of individuals with CF, with and without lung transplantation (LTX), their communication with their specialist healthcare providers during the pandemic, potential changes in peoples' individual therapy regimes and daily physical activity levels.

METHODS

A web-based survey was conducted among Swiss adults with CF with and without LTX, study period from March 16th, 2020 - the day the "extraordinary situation" was officially declared in Switzerland introducing stringent measures protecting the public - until May 16th, 2020.

RESULTS

327 individuals (25% LTX recipients) were included, 45 individuals reported coronavirus-2019 disease (COVID-19) like symptoms. Of 28 subjects tested, only three subjects were tested positive, all with mild symptoms, no hospitalization required. Almost half of the survey respondents (45%) reported undertaking less physical activity during the lockdown, while 79% and 91% of participants reported no change in traditional airway clearance and inhalation therapies, respectively. Distress regarding a potential SARS-CoV-2 infection or worsening of lung disease were no major concerns for subjects.

CONCLUSIONS

Our study reveals that the direct impact of SARS-CoV-2 on clinical outcomes of individuals with CF was mild although people with chronic lung diseases like CF are considered a high-risk population; overall, this is reassuring. However, strict lockdown measures substantially affected peoples' physical activity levels, a vital cornerstone of CF therapy; and this is worrisome.

Perceptions towards physical activity in adult lung transplant recipients with cystic fibrosis

Background

Barriers and motives towards physical activity (PA) in lung transplant (LTx) recipients with cystic fibrosis (CF) are largely unknown. We aimed to explore perceptions towards PA in LTx recipients with CF to better understand individuals’ needs and preferences.

Methods

Participants completed an online survey at two Swiss LTx and one follow-up shared care centre between June and December 2018.

Results

One hundred and eleven individuals completed the survey (87.4% response rate). Overall, survey participants perceive PA as important for their daily life and health. Perceived motives of PA were improving muscle strength, endurance and quality of life (QoL), to feel better, fun, to achieve personal goals and having more energy for everyday life. Fatigue was the most common perceived barrier to PA and associated with poorer QoL (r = -0.43, p<0.001) and health status (r = -0.31, p = 0.001). Participants with lung allograft dysfunction (LAD, n = 20) reported lower habitual PA (p = 0.009) and health status (p = 0.011), and rated shortness of breath, bad weather and concerns regarding lung rejection higher than those without LAD (all p<0.05). When we asked how an optimal training programme should look like, the majority would prefer individual, non-supervised (60%), outdoor (77%), endurance training (90%), once or twice a week (47%) for 40–60 minutes (48%). Only a minority of patients (14%) would be willing to use exercise applications for their home-based training.

Conclusions

LTx recipients with CF value PA as important for their health. People with CF should be encouraged individually by their multidisciplinary transplant team to implement PA in their daily life, potential barriers should be identified and addressed. Overall, knowledge on perceived barriers and motives for PA should be considered in the development of future patient-centred PA programmes.

The experience of transplantation as reflected in dream life: A case study illustrating the mental processing of a lung transplant

Although it is well known that a lung transplant enhances the recipient's quality of life, our knowledge of how it is processed mentally is limited. In this study, interviews were conducted with a lung-transplant patient two weeks, three months, and six months after surgery so as to investigate the relevant unconscious processing mechanisms. A dream reported in the first interview was analysed in accordance withapplying the Zurich Dream Process Coding System. A 'transplantation complex' was reconstructed on the basis of various sources of information (the dream and the waking narratives). The principal aspects of the transplantation complex that emerged from both the dream and the waking narratives concerned the oral-sadistic phantasy that the donor had been killed and that his lung, or soul, had been violently incorporated in the patient. The main unconscious themes involved in the processing of the transplant were found to have been already laid down in the dream and to have been presented in it in the form of visual analogues. According to our interpretation of the data analysed, powerful cannibalistic phantasies and death wishes played an important part in the processing of the transplant. These archaic phantasies may have been actualized by the transplant.