Transition Care in Cystic Fibrosis

Cystic fibrosis (CF) is a chronic childhood illness with gradually improving survival and significant burden of disease during adult life. Transition of CF care from pediatric to an adult based multidisciplinary team is a complex process and careful coordination with a transition key worker is necessary for successful transition without adverse outcome. Transition is associated with a key change in CF management with shift from family-centred care to self-reliance and independence on part of the patient. Readiness and skills of self-managed care play central part in successful transition. Resource materials for transition are available online for different countries for improved readiness and smooth transition. Situation is worse in resource-limited settings as facilities of fully functional adult multidisciplinary care for CF is not readily available.

A randomized controlled trial evaluating the effectiveness of a self-management program for adolescents with a chronic condition: a study protocol

BACKGROUND

Self-management support is increasingly viewed as an integral part of chronic condition management in adolescence. It is well recognized that markers of chronic illness control deteriorate during adolescence. Due to the increasing prevalence of long-term chronic health conditions in childhood and improved survival rates of previously life-limiting conditions in children and adolescents, significant numbers of adolescents are having to manage their chronic condition effectively as they transition to adult health care. Therapy adherence has been identified as a major challenge for young people living with a chronic condition such as cystic fibrosis, diabetes, or asthma requiring long-term pharmacological therapy and/or lifestyle modifications. Most systematic reviews on self-management interventions address adult populations. Very few intervention studies are directed at adolescents with a chronic condition who are transitioning to adult health services. This protocol describes a prospective randomized controlled trial of a standardized self-management intervention program delivered to adolescents aged 15-18 years prior to their transfer to adult care. This study has been designed to provide evidence regarding self-management programs for adolescents and is the first study to use the Flinders Program with this important, under-researched age group.

METHODS

A randomized controlled trial is used to investigate the effectiveness of a modified adolescent-friendly version of an adult self-management program. This program is directed at improving self-management in an adolescent cohort 15-18 years of age with a chronic condition being treated in a specialist pediatric hospital. Participants will be randomized to either usual care or the modified Flinders Program plus usual care. Data collection will include measures of specific illness control, unscheduled hospital admissions, and questionnaires to record self-management competencies, quality of life, self-efficacy, and outcome measures specific to the chronic condition at baseline, 3 months, 6 months, and 12 months after delivery.

DISCUSSION

This study will provide a better understanding of the elements required for effective self-management programs in adolescents with a chronic condition and address some important knowledge gaps in current literature. The study will be carried out in collaboration with the Discipline of Behavioural Health at Flinders University, Adelaide, Australia, in order to inform the development of an adolescent version of the successful and validated Flinders Program™.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12621000390886). Registered on April 8, 2021.

Transition from paediatric to adult care in cystic fibrosis

In the decades since cystic fibrosis (CF) was first clinically defined in the 1930s, there have been many advancements in the treatment and management of this disease. Initially it was considered a disease of childhood where the majority of those affected died before reaching adolescence. Now, through advancements in management and treatment, the vast majority of those affected will live into adulthood. Therefore, paediatric and adult CF services must collaborate to ensure that young people and their families experience a positive and supportive transition into adult services. Key aspects of transition will be discussed, including when to begin the transition process, who should coordinate this and how the transition process should be structured. Challenges of the transition process and potential pitfalls when transition does not run smoothly will also be discussed, as well as tools that may be used to support a positive transition for young people and their families.

Educational aims

To familiarise readers with factors that make the transition process positive.To make suggestions regarding the application of the transition process.To highlight factors which may impact on the success of the transition process and the risks associated with disengagement at the point of transition.To discuss tools which can be used by care teams to ensure a smooth transition process.

Cystic fibrosis-related diabetes: The patient perspective

Cystic fibrosis-related diabetes (CFRD) affects nearly 20% of adolescents and 40-50% of adults. However, the impact on patients and their families is poorly understood. Here, we examine how patients perceive CFRD and identify gaps in our understanding of the patient experience. Despite its relatively high prevalence, data suggest that many individuals are not aware of the possibility of developing CFRD or compare it to other types of diabetes. Annual oral glucose tolerance testing (OGTT) may serve as an opportunity to provide education and prepare individuals for the possibility of developing abnormalities in glucose tolerance. Many cite lack of awareness of CFRD as the most difficult part of the diagnosis. While factors such as older age and a strong support system promote acceptance, most individuals view the diagnosis negatively and struggle to balance the demands of diabetes with other obligations, including airway clearance, nebulizer therapies, supplementation nutrition, and administration of vitamins and medications. Relatively few people with CFRD monitor their blood glucoses consistently, which is attributed to time constraints or an attempt to avoid pain. In addition, many feel that they are not prone to hypoglycemia and are not concerned with long-term complications, anticipating that they will succumb to their pulmonary disease before these become problematic. The adolescent period presents unique challenges for adherence as children work to develop autonomy. Factors that promote CFRD adherence include incorporating management into daily CF routines and the support of knowledgeable providers to help develop an individualized approach to management. Diabetes technology has the potential to reduce treatment burden and improve glycemic control, but data in CFRD are limited, and additional study is needed. Given that CFRD is associated with a decline in health-related quality of life, it is critical that providers understand patients' perspectives and address gaps in understanding and barriers to management.

Data driven decision making to characterize clinical personas of parents of children with cystic fibrosis: a mixed methods study

BACKGROUND

Beginning at a young age, children with cystic fibrosis (CF) embark on demanding care regimens that pose challenges to parents. We examined the extent to which clinical, demographic and psychosocial features inform patterns of adherence to pulmonary therapies and how these patterns can be used to develop clinical personas, defined as aspects of adherence barriers that are presented by parents and/or perceived by clinicians, in order to enhance personalized CF care delivery.

METHODS

We undertook an explanatory sequential mixed-methods study consisting of i) multivariate clustering to create clusters corresponding to parental adherence patterns (quantitative phase); ii) parental participant interviews to create clinical personas interpreted from clustering (qualitative phase). Clinical, demographic and psychosocial features were used in supervised clustering against clinical endpoints, which included adherence to airway clearance and aerosolized medications and self-efficacy score, which was used as a feature for modeling adherence. Clinical implications were developed for each persona by combing quantitative and qualitative data (integration phase).

RESULTS

The quantitative phase showed that the 87 parent participants were segmented into three distinct patterns of adherence based on use of aerosolized medication and practice of airway clearance. Patterns were primarily influenced by self-efficacy, distance to CF care center and child BMI percentile. The two key patterns that emerged for the self-efficacy model were most heavily influenced by distance to CF care center and child BMI percentile. Eight clinical personas were developed in the qualitative phase from parent and clinician participant feedback of latent components from these models. Findings from the integration phase include recommendations to overcome specific challenges with maintaining treatment regimens and increasing support from social networks.

CONCLUSIONS

Adherence patterns from multivariate models and resulting parent personas with their corresponding clinical implications have utility as clinical decision support tools and capabilities for tailoring intervention study designs that promote adherence.

Clinical communication preferences in cystic fibrosis and strategies to optimize care

BACKGROUND

The importance of optimizing communication between clinicians and individuals and families living with cystic fibrosis (CF) about daily care, adherence, and related psychosocial concerns is well documented. The purpose of this study was to gain an understanding of interpersonal communication experiences and preferences among individuals and families living with CF as they engage with the clinical team. The study also aimed to reveal opportunities for enhancing future interpersonal communication practices.

METHODS

Five U.S. CF care centers participated in the following activities: (a) On-site observation of clinic interactions during outpatient visits; (b) On-site 1:1 interviews with individuals living with CF, their family members, and CF clinicians; (d) Focus groups conducted in person with CF care team members; (d) Focus groups conducted virtually with adults and family members with CF. Content analysis of transcripts and constant comparative methods were used to identify emergent themes.

RESULTS

Four themes related to participants' needs and preferences for clinic interactions emerged during analysis: (a) eliciting psychosocial concerns, (b) addressing childhood development and transitions, (c) negotiating agendas and sharing decisions, and (d) educating to enhance CF conversations.

CONCLUSION

CF clinicians and individuals and families living with CF expressed the need for resources and training to engage in better conversations with each other. Participants identified areas of high priority, including working together around social, psychological, and economic challenges, preparation for transition to adulthood, and sustaining daily care. Findings point to the value of developing advanced communication skills that foster trust-building, negotiating agendas, active listening, and collaborative goal-setting.

Transition to Adult Care in Children on Long-Term Ventilation

The number of children on long-term ventilation (LTV) has exponentially increased over the past few decades. Improvements in management of ventilation coupled with improvements in standards of medical care are increasingly allowing young people on LTV to survive into adulthood. The process of transition from the pediatric to the adult healthcare system is challenging and requires special attention. This review aims to provide an overview on transition to adult care for children on LTV. Firstly, examining effective models of transition in other childhood onset chronic conditions as a template, whilst highlighting the unique aspects of transition in LTV patients and secondly, summarizing the main relevant findings in the literature on the topic and emphasizing the importance of a multidisciplinary approach to this process.

Where Did They Go? Tracking Young Adult Follow-up During the Transition From Pediatric to Adult-Oriented Care

Continuity of care during health care transition is critical. We sought to evaluate electronic medical record clinic attendance data to examine this outcome. We identified 1623 patients (ages 18-27 years) with 1 of 6 childhood-onset chronic conditions and tracked clinic utilization from January 2002 to July 2016. Patients were classified as active in pediatric care; lost from pediatric care; successfully transferred; or lost from adult care. Using random effects logistic regression, we compared the number of days between last pediatric and first adult visit to each clinic's self-reported transitional care quality score. In this cohort, >44% remained active in care at the end of the study. Clinics with higher proportions of successfully transferred patients had lower median numbers of days between last pediatric and first adult visit and higher transitional care quality scores. Characterizing utilization patterns with electronic medical record data allows health systems to track transitional care outcomes and target improvement efforts.

Masculinity Challenges for Men With Severe Hemophilia

Hemophilia is a congenital bleeding disorder that mainly affects men. Men with severe hemophilia experience stigma because they are unable to live up to various ideals of masculinity. This study involves a qualitative analysis of how nine Danish men aged 40-54 years with severe hemophilia manage life as functionally impaired relative to their masculine identity. The analytical focus is on how the men manage on a daily basis, how they construct their identity as a result of the disorder, and the body's importance in these identity negotiations. The source of their biggest defeat is that the disorder often prevents them from living up to social expectations about men as fathers. This results in a variety of management strategies that they apply to neutralize the stigma, allowing them to (a) distance themselves from the disorder in various practical and verbal ways and to (b) assume primary responsibility for managing the disorder, including internalizing being experts on the disorder. The results identify that men with severe hemophilia are frustrated by the lack of advice provided by the health sector. The article proposes initiatives that can be taken to address the lack of knowledge and to create a broader network of peers for men with hemophilia across varying age groups.

Predictors of uncertainty in parents of children living with chronic conditions

BACKGROUND

Uncertainty in illness implies no meaning has been attributed to an illness event. Although many studies focus on this issue in adults, there is limited research into children with chronic illnesses. Parental uncertainty has been associated with increased risk of post-traumatic stress, which can in turn adversely affect child and parent coping strategies.

AIM

To identify the characteristics of parents who are at greater risk of uncertainty and the associated characteristics of their children's chronic illnesses.

METHOD

An exploratory, cross-sectional study design was adopted across three different sites in the United Arab Emirates. Data were collected from parents who accompanied their children, who were receiving treatment, using a validated, culturally adapted Parent Perception of Uncertainty Scale.

RESULTS

Scores for illness uncertainty ranged from 86.5 to 92.6, on a scale of 31-155, with higher scores indicating greater uncertainty. The highest scores were found in parents of children being cared for in ward settings who had previously been hospitalised, parents of children up to two years of age or those approaching adolescence, fathers, and parents whose first language was Arabic.

CONCLUSION

The groups of parents with the highest illness uncertainty may benefit most from interventions to improve communication and psychological support.

Transition from paediatric to adult healthcare for young people with cystic fibrosis: Parents' information needs

Parents of young people with cystic fibrosis (YPWCF) play an important role during the transition from paediatric to adult health services. There is limited evidence on parental information needs and the extent to which they are met. An online survey was conducted targeting a finite population of 190 parents of YPWCF in Ireland. Fifty-nine parents responded (31% response rate). Parents reported the need for more general preparation and timing of the transfer, more information regarding the differences between adult and child health services and how their child will self-manage his/her illness in the future. Most parents received information on the timing of transfer and new healthcare providers but reported being insufficiently informed about their legal status relating to medical confidentiality for their adult child and community resources available for their child after transition to adult health services. The findings highlight the importance of information and preparation for caregivers as well as young people to promote successful transition to adult healthcare. Providing parents with clear information and anticipatory guidance are simple changes in practice that may lead to improvements in transition experiences.

Initiating transitional care for adolescents with cystic fibrosis at the age of 12 is both feasible and promising

AIM

Adolescence is a vulnerable period in cystic fibrosis, associated with declining lung function. This study described, implemented and evaluated a transition programme for adolescents.

METHODS

We conducted a single centre, nonrandomised and noncontrolled prospective programme at the cystic fibrosis centre at Copenhagen University Hospital Rigshospitalet from 2010 to 2011, assessing patients aged 12-18 at baseline and after 12 months. Changes implemented included staff training on communication, a more youth-friendly feel to the outpatient clinic, the introduction of youth consultations partly alone with the adolescent, and a parents' evening focusing on cystic fibrosis in adolescence. Lung function and body mass index (BMI) were measured monthly and adolescents were assessed for their readiness for transition and quality of life at baseline and 12 months.

RESULTS

We found that 40 (98%) of the eligible patients participated and youth consultations were successfully implemented with no dropouts. The readiness checklist score increased significantly over the one-year study period, indicating increased readiness for transfer and self-care. Overall quality of life, lung function and BMI remained stable during the study period.

CONCLUSION

A well-structured transition programme for cystic fibrosis patients as young as 12 years of age proved to be both feasible and sustainable.

Sputum microbiota is predictive of long-term clinical outcomes in young adults with cystic fibrosis

BACKGROUND

Complex polymicrobial communities infect cystic fibrosis (CF) lower airways. Generally, communities with low diversity, dominated by classical CF pathogens, associate with worsened patient status at sample collection. However, it is not known if the microbiome can predict future outcomes. We sought to determine if the microbiome could be adapted as a biomarker for patient prognostication.

METHODS

We retrospectively assessed prospectively collected sputum from a cohort of 104 individuals aged 18-22 to determine factors associated with progression to early end-stage lung disease (eESLD; death/transplantation <25 years) and rapid pulmonary function decline (>-3%/year FEV₁ over the ensuing 5 years). Illumina MiSeq paired-end sequencing of the V3-V4 region of the 16S rRNA was used to define the airway microbiome.

RESULTS

Based on the primary outcome analysed, 17 individuals (16%) subsequently progressed to eESLD. They were more likely to have sputum with low alpha diversity, dominated by specific pathogens including Pseudomonas. Communities with abundant Streptococcus were observed to be protective. Microbial communities clustered together by baseline lung disease stage and subsequent progression to eESLD. Multivariable analysis identified baseline lung function and alpha diversity as independent predictors of eESLD. For the secondary outcomes, 58 and 47 patients were classified as rapid progressors based on absolute and relative definitions of lung function decline, respectively. Patients with low alpha diversity were similarly more likely to be classified as experiencing rapid lung function decline over the ensuing 5 years when adjusted for baseline lung function.

CONCLUSIONS

We observed that the diversity of microbial communities in CF airways is predictive of progression to eESLD and disproportionate lung function decline and may therefore represent a novel biomarker.

Facilitating transition from children's to adult services for young adults with life-limiting conditions (TASYL): Programme theory developed from a mixed methods realist evaluation

BACKGROUND

Improvements in care and treatment have led to more young adults with life-limiting conditions living beyond childhood, necessitating a transition from children's to adult services. Given the lack of evidence on interventions to promote transition, it is important that those creating and evaluating interventions develop a theoretical understanding of how such complex interventions may work.

OBJECTIVES

To develop theory about the interventions, and organisational and human factors that help or hinder a successful transition from children's to adult services, drawing on the experience, knowledge, and insights of young adults with life-limiting conditions, their parents/carers, and service providers.

DESIGN

A realist evaluation using mixed methods with four phases of data collection in the island of Ireland. Phase one: a questionnaire survey of statutory and non-statutory organisations providing health, social and educational services to young adults making the transition from children's to adult services in Northern Ireland and one Health Services Executive area in the Republic of Ireland. Phase two: interviews with eight young adults. Phase three: two focus groups with a total of ten parents/carers. Phase four: interviews with 17 service providers. Data were analysed seeking to explain the impact of services and interventions, and to identify organisational and human factors thought to influence the quality, safety and continuity of care.

RESULTS

Eight interventions were identified as facilitating transition from children's to adult services. The inter-relationships between these interventions supported two complementary models for successful transition. One focused on fostering a sense of confidence among adult service providers to manage the complex care of the young adult, and empowering providers to make the necessary preparations in terms of facilities and staff training. The other focused on the young adults, with service providers collaborating to develop an autonomous young adult, whilst actively involving parents/carers. These models interact in that a knowledgeable, confident young adult who is growing in decision-making abilities is best placed to take advantage of services - but only if those services are properly resourced and run by staff with appropriate skills. No single intervention or stakeholder group can guarantee a successful transition. Rather, service providers could work with young adults and their parents/carers to consider desired outcomes, and the range of interventions, in light of the organisational and human resources available in their context. This would allow them to supplement the organisational context where necessary and select interventions that are more likely to deliver outcomes in that context.

The Evolving Cystic Fibrosis Microbiome: A Comparative Cohort Study Spanning 16 Years

RATIONALE

The cystic fibrosis (CF) airways are infected with a diverse polymicrobial community.

OBJECTIVES

Understanding how changes in the CF microbiome have occurred over time, similar to the observed changes in the prevalence of cultured pathogens, is key in understanding the microbiome's role in disease.

METHODS

Drawing from a prospectively collected and maintained sputum biobank, we identified 45 patients with sputum samples collected between the ages of 18 and 21 years in three successive cohorts of adults transitioning to our CF clinic: A (1997-2000), B (2004-2007), and C (2010-2013). Patient demographics, clinical status, and medications were collected from detailed chart review. Microbial communities were assessed by Ilumina MiSeq sequencing of the variable 3 (V3) region of the 16S rDNA.

RESULTS

The three cohorts were similar with respect to baseline demographics. There was a trend toward improved health and use of disease-modifying therapies in each successive cohort. Shannon diversity increased in the most recent cohort, suggesting an increase in the diversity of organisms between cohorts. Furthermore, the proportion of samples with Pseudomonas-dominated communities decreased over time, whereas Streptococcus increased. Although β-diversity was associated with transition cohort, the greatest predictor of diversity remained lung function. Furthermore, core microbiome constituents were preserved across cohorts.

CONCLUSIONS

Modest changes in the composition and structure of the microbiome of three successive cohorts of young adults with CF were observed, occurring in parallel with successive improvements in clinical status. Importantly, however, the core microbiome constituents were preserved across cohorts.

Exploring the need for Transition Readiness Scales within cystic fibrosis services: A qualitative descriptive study

AIMS AND OBJECTIVES

To explore healthcare professionals' and patients' perceptions of the potential use of a Transition Readiness Scale in cystic fibrosis care. This included an examination of barriers and facilitators to its implementation along with the identification of key items to include in a Transition Readiness Scale.

BACKGROUND

Due to increasing life expectancy and improved quality of life, more adolescents with cystic fibrosis are transitioning from paediatric to adult health care. To assess and correctly manage this transition, a more structured approach to transition is advocated. This can be achieved using a Transition Readiness Scale to potentially identify or target areas of care in which the adolescent may have poor knowledge. These key items include education, developmental readiness taking into account relationships, reproduction, future plans and self-management skills. Existing tools to gauge readiness concentrate mainly on education and self-care needs assessment as their key items. Currently, there is no specific cystic fibrosis Transition Readiness Scale in use in Ireland or internationally.

DESIGN

The study used a descriptive qualitative design.

METHODS

Data were collected using semi-structured interviews (n = 8) and analysed using a thematic approach.

RESULTS

The findings identified the potential benefits of this tool and second the resources which need to be in place before its development and implementation into cystic fibrosis services.

CONCLUSION

Transition Readiness Scales have substantial relevance with cystic fibrosis services emphasising the importance of establishing the necessary resources prior to its implementation. These were identified as more staff, a dedicated private space and staff training and education.

RELEVANCE TO CLINICAL PRACTICE

Significant resources are needed to fully integrate Transition Readiness Scales in practice. The study findings suggest multidisciplinary collaborations, and patient engagement is pivotal in planning and easing the transition process for adolescents with cystic fibrosis.

[Adolescents with cystic fibrosis: the approach to transition from paediatric to adult care]

Because of early and effective therapies, an increasing numbers of young people with cystic fibrosis (CF) reach adulthood. Preparing for and maintaining high quality CF care in the adult healthcare is critical for prolonged survival. Because adverse health consequences occur when inadequate transition arrangements are in place, safely transferring patients from pediatric to adult care is a priority. Key features include an early preparation, planning and self-management skills, a coordinated approach and a detailed communication between patients, families, pediatric and adult teams. Formal transition protocols and audits can support the process and be helpful for multidisciplinary teams.

Transition from paediatric surgery: how many patients do we need to plan for?

INTRODUCTION Transitional care is an NHS priority with newly published NICE guidance. Many paediatric surgical patients need quality care to continue into adulthood. We undertook an evaluation of our departmental activity to assess the magnitude of this issue. METHODS We identified all outpatients ≥ 15 years (potentially requiring imminent transition) seen over a 12 month period for all five general paediatric surgery consultants in our tertiary centre. Those patients requiring transition were highlighted and the appropriate adult team for referral recorded. RESULTS There were 2989 general paediatric surgery clinic appointments within the year; 289 (9.7%) were for young people aged 15 years or older; 62 patients (28% of those ≥ 15years) were deemed to require transition into adult care. Significantly more patients having colorectal surgery required follow-up (P = 0.0009 Chi-square test) compared with patients in other subspecialties. CONCLUSIONS More patients than expected required transition. This may be the case in other units. Current best practice includes time intensive preclinic planning, careful preparation of patient and family, followed by joint clinics. A joint clinic appointment takes 30 minutes, allowing for comprehensive handover and forging new relationships. In our department, we need at least ten transition clinics across 2 years. Coalition with adult colleagues is vital. These data enable us to plan services to provide quality care for our adolescent patients and highlights colorectal surgery as a priority.

Determinants of Quality of Care for Adolescents and Young Adults With Chronic Illnesses: A Mixed Methods Study

Measuring the quality of service and user experience is an acknowledged priority for healthcare services; however it seems that healthcare systems have to work very hard to achieve this goal as evidenced by reports of gaps and disparities in the quality of care provided to clients, especially within pediatric and adolescent populations.

OBJECTIVES

To identify quality determinants for healthcare services for adolescents and young adults with chronic conditions based on the perceptions and the experiences of adolescents and young adults themselves.

METHODOLOGY

A sequential exploratory mixed method design guided this study. The initial qualitative phase employed semi-structured in-depth interviews to elicit the elements and determinants of quality of care as identified by adolescents and young adults living with chronic conditions. The second phase employed a questionnaire developed from the data gathered during the qualitative phase to survey the target population. This was distributed to a larger sample of adolescents and young adults with chronic conditions to determine and confirm the relevance of the identified care elements and quality determinants.

RESULTS

The study revealed 4 main determinants: the provision of adolescent friendly information relating to all aspects of living with chronic conditions, services that facilitate and encourage independence, services characterized by structure with the capacity to be both dynamic and responsive, and finally health care professionals knowledgeable and skilled in relation to adolescent specific issues.

Concept Analysis of Health Care Transition in Adolescents with Chronic Conditions

Children with chronic conditions are living into adulthood and present with unique needs. One such need is their transition from pediatric to adult health care. This paper examined the literature to analyze and synthesize the concept of transition within two contexts, health care and adolescents with chronic conditions. Fifty multidisciplinary sources were included for analysis. A refined, working definition of the concept of health care transition in adolescents with chronic conditions is presented. Results will enable the scientific community to discuss salient issues using well-defined, uniform terminology. Nursing implications are delineated to ensure that these youths thrive into adulthood.

Men, Masculinities, and Hemophilia

Hemophilia is a congenital bleeding disorder that predominantly affects men. Home intravenous replacement of missing clotting factor is the most effective treatment; however, the uptake of preventative treatment (also known as prophylaxis) varies among men with hemophilia. The purpose of the current qualitative study was to describe the connections between masculinities and men's (n = 11) experiences of hemophilia across varying age groups. The inductively derived findings revealed bleed-related joint pain as the primary prompt for men to treat or seek medical help. Many men reported experiencing a high number of bleed-related injuries in adolescence, particularly in high school, oftentimes as a result of engaging in idealized masculine physical activities. Though the limitations imposed by hemophilia were contested by most men early on in their lives, as men grow older more conservative approaches were employed both in terms of treatment and activity to reduce the potential for residual bleed-related disabilities. Overall, the results indicate that men with hemophilia may benefit from peer and professional education about recognition, prevention, and optimal treatment of bleeds. Furthermore, masculine ideals act as important context in which men navigate hemophilia management practices and may facilitate contesting or conceding behaviors. Masculine ideals of strength and control may be garnered to facilitate optimal hemophilia management practices.

European Cystic Fibrosis Society Standards of Care: Framework for the Cystic Fibrosis Centre

A significant increase in life expectancy in successive birth cohorts of people with cystic fibrosis (CF) is a result of more effective treatment for the disease. It is also now widely recognized that outcomes for patients cared for in specialist CF Centres are better than for those who are not. Key to the effectiveness of the specialist CF Centre is the multidisciplinary team (MDT), which should include consultants, clinical nurse specialist, microbiologist, physiotherapist, dietitian, pharmacist, clinical psychologist, social worker, clinical geneticist and allied healthcare professionals, all of whom should be experienced in CF care. Members of the MDT are also expected to keep up to date with developments in CF through continued professional development, attendance at conferences, auditing and involvement in research. Specialists CF Centres should also network with other Centres both nationally and internationally, and feed Centre data to registries in order to further the understanding of the disease. This paper provides a framework for the specialist CF Centre, including the organisation of the Centre and the individual roles of MDT members, as well as highlighting the value of CF organisations and disease registries.

Evaluation of a multidimensional cystic fibrosis transition program: a quality improvement initiative

The adequate preparation of cystic fibrosis (CF) youth for the transfer from pediatric to adult-based health care services is essential to meet the needs of this changing population. This paper describes the evolution of a transition clinic for patients with CF into a multidimensional quality improvement transition initiative. Three transition interventions (a patient transition clinical pathway; collaboration with the adult clinic; and a tool to measure transfer readiness) were sequentially implemented and evaluated. Each was found to be a valuable addition to a comprehensive transition protocol and today are endorsed as part of transition best practices.

Doenças crônicas em crianças e adolescentes: uma revisão bibliográfica

O artigo analisa artigos publicados entre 2003 e 2011 enfocando discussões sobre condições crônicas ou doenças crônicas de crianças e adolescentes. Metodologicamente conjuga a revisão de literatura a uma análise de conteúdo temática com vistas a identificar quais os elementos que caracterizam doenças crônicas em crianças e adolescentes e as especificidades geradas por essas condições. A revisão resultou na descrição do conjunto dos artigos, caracterizando-os quanto ano de publicação, país, tipo de estudo, população e condição de cronicidade abordada. A análise de conteúdo temática gerou dois temas: Definição de Doença Crônica e Formas de se lidar com as doenças crônicas em crianças e adolescentes. Destaca-se como conclusão que as transições etárias quando uma doença é diagnosticada e tratada desde a infância, vai passar por transformações que incluem a maneira como se dá o seu fluxo entre os serviços e as mudanças que envolvem processos de alta, de tomada de decisão e de construção de rede que inclua família, hospital, escola e sistema de garantia de direitos.

Improving transition from paediatric to adult cystic fibrosis care: programme implementation and evaluation

BACKGROUND

The paradigm of cystic fibrosis (CF) care has changed as effective therapies extend the lives of patients well into adulthood. Preparing for and maintaining high quality CF care into the adult healthcare setting is critical for prolonged survival. Unfortunately, this transfer process from the paediatric to the adult CF centre is met with a variety of challenges.

OBJECTIVE AND METHODS

The objective of this quality improvement (QI) project was to develop, implement and evaluate a theory-based programme for transition from paediatric to adult CF care. In a multi-phase process, the paediatric and adult programmes developed a transition curriculum, addressed care standards and standardised patient transfer protocols. We evaluated the impact of this process through staff surveys, review of field notes from QI meetings, tracking transfers and responses of patients to the Transition Readiness Assessment Questionnaire (TRAQ) at the start of the programme and 18 months after initiation.

RESULTS

The collaboration between the paediatric and adult teams continued through quarterly meetings over the past 4 years. This has provided a forum that sustained our transition programme, harmonised care across CF centres and addressed other needs of our CF centre. Discussion of transition with families in the paediatric centre increased twofold (35% to 73% p<0.001), and resulted in a trend towards improved patient TRAQ self-advocacy scores and decreased in-hospital transfer.

CONCLUSIONS

We successfully created a curriculum and process for transition from paediatric to adult CF care at our centres. This collaboration shapes the communication between our paediatric and adult CF care teams and enables ongoing feedback among patients, families and providers. The impact of our transition programme on long-term patient morbidity will require future evaluation.

Cystic fibrosis adolescent transition care in Canada: A snapshot of current practice

Cystic fibrosis (CF) adolescent transition is not a new health care issue, yet progress in many areas associated with the transition process has been slow. In Canada, the status of CF transition has not been previously reported. The aim of the present study was to describe the transition from paediatric to adult health care for CF patients in Canada, specifically: availability of adult CF clinic services; average age of transfer from paediatric to adult CF health care; and existing CF transition practices. Results show that access to appropriate adult CF health care in Canada is universal; however, the availability, quantity and quality of CF transition care vary among CF clinics. Over a four-year period, the number of CF clinics using formal transition protocols almost doubled, but more work remains to be performed.

Health outcomes associated with transition from pediatric to adult cystic fibrosis care

BACKGROUND

Almost half of individuals who have cystic fibrosis (CF) are over 18 years old, thus safely transferring patients from pediatric to adult care is a priority. The purpose of this study is to compare youth transferred from pediatric to adult CF care versus those remaining in pediatric CF care and quantify the relationship between transfer status and health outcomes.

METHODS

Patients who transferred from pediatric to adult CF care were identified from the CF Foundation Patient Registry from 1997 to 2007. Transferred patients were compared with individuals who have similar baseline characteristics who remained in pediatric care throughout the same time period. The main outcome measures include pulmonary function, nutritional status, care use, and home intravenous antibiotic events per year. A propensity-matched analysis was performed.

RESULTS

Fifty-eight percent of patients remained in pediatric programs throughout the study period. The mean age at transfer to adult care was 21.2 (1.3) years. In the 2 years after transfer there was a less rapid decline in percent predicted forced expiratory volume in 1 second of 0.78 percentage points per year among transfer-positive patients compared with transfer-negative ones (95% confidence interval; 0.06-1.51); there were no other significant health related changes.

CONCLUSIONS

The current study contradicts reports of other chronic childhood conditions, in which transfer between the pediatric and adult health system was associated with adverse health outcomes. Further research is needed to explore the long-term relationship between transition practices and health status outcomes to establish a systematic, evidence-based transition process.

Child to adult: transitional care for young adults with cystic fibrosis

Managing the transitional care needs of young adults with a complex chronic illness such as cystic fibrosis (CF) as they move from a child-orientated to adult setting has been reported in the literature as challenging and stressful, and may impart additional risks to the young person's health. However, in the Republic of Ireland, which has the highest incidence of CF in the world, the current services provided for children during this transitional period are still reported as underdeveloped. The aim of the author's research was to explore and understand the experience of young people before and after their transitional care, and the factors that both contribute to and hinder that experience. A qualitative approach guided by phenomenological tradition, and using in-depth interviews. The findings suggest that there are a range of needs required for patients during this transitional period, including the need for information, interventions that decrease the negative feelings associated with transition (e.g. distress, anxiety, uncertainty), structured service, and an approach to care that focuses on young adults. The author concludes that health professionals in the clinical setting who have responsibility for young adults in transitional care should focus on these needs to provide a more relevant and effective transition service.

[Adults with cystic fibrosis. It's not just about longevity]

Cystic fibrosis (CF) is one example of serious disorders for which medical progress and the integration of chronic treatment into the patients' daily routines have led to markedly better longevity. Formerly known as a 'killer disease' of childhood, CF is now considered a disorder with childhood onset, but is well known in adult medicine. Since 2009, for the first time CF adults have made up the majority of patients in the German CF registry. The drawbacks of improved longevity are long-term complications (e.g., CFRD, osteoporosis) that were rarely seen before. In particular, unwanted effects of treatments that today are performed for decades rather than years are becoming pressing problems. Unwanted effects as well as the ever-increasing treatment burden must be carefully weighed against the expected benefits of treatment. However, CF medicine has always been aware that it is not just about longevity, but that prolonged life has to have meaning. Therefore, the marked increase in longevity is also a psychosocial challenge. So far, empirical data suggest that the majority of people with CF courageously struggle for a normal life.