Pain expectancy, prevalence, severity, and patterns following donor nephrectomy: Findings from the KDOC Study

Postoperative pain is an outcome of importance to potential living kidney donors (LKDs). We prospectively characterized the prevalence, severity, and patterns of acute or chronic postoperative pain in 193 LKDs at six transplant programs. Three pain measurements were obtained from donors on postoperative Day (POD) 1, 3, 7, 14, 21, 28, 35, 41, 49, and 56. The median pain rating total was highest on POD1 and declined from each assessment to the next until reaching a median pain-free score of 0 on POD49. In generalized linear mixed-model analysis, the mean pain score decreased at each pain assessment compared to the POD3 assessment. Pre-donation history of mood disorder (adjusted ratio of means [95% confidence interval (CI)]: 1.40 [0.99, 1.98]), reporting "severe" on any POD1 pain descriptors (adjusted ratio of means [95% CI]: 1.47 [1.12, 1.93]) and open nephrectomy (adjusted ratio of means [95% CI]: 2.61 [1.03, 6.62]) were associated with higher pain scores across time. Of the 179 LKDs who completed the final pain assessment, 74 (41%) met criteria for chronic postsurgical pain (CPSP), that is, any donation-related pain on POD56. Study findings have potential implications for LKD education, surgical consent, postdonation care, and outcome measurements.

Mood, body image, fear of kidney failure, life satisfaction, and decisional stability following living kidney donation: Findings from the KDOC study

Prior studies demonstrate that most living kidney donors (LKDs) report no adverse psychosocial outcomes; however, changes in psychosocial functioning at the individual donor level have not been routinely captured. We studied psychosocial outcomes predonation and at 1, 6, 12, and 24 months postdonation in 193 LKDs and 20 healthy controls (HCs). There was minimal to no mood disturbance, body image concerns, fear of kidney failure, or life dissatisfaction, indicating no incremental changes in these outcomes over time and no significant differences between LKDs and HCs. The incidence of any new-onset adverse outcomes postdonation was as follows: mood disturbance (16%), fear of kidney failure (21%), body image concerns (13%), and life dissatisfaction (10%). Multivariable analyses demonstrated that LKDs with more mood disturbance symptoms, higher anxiety about future kidney health, low body image, and low life satisfaction prior to surgery were at highest risk of these same outcomes postdonation. It is important to note that some LKDs showed improvement in psychosocial functioning from pre- to postdonation. Findings support the balanced presentation of psychosocial risks to potential donors as well as the development of a donor registry to capture psychosocial outcomes beyond the mandatory 2-year follow-up period in the United States.

Vascularized Composite Allograft Donation and Transplantation: A Survey of Public Attitudes in the United States

Vascularized composite allograft (VCA) transplantation has emerged as a groundbreaking surgical intervention to return identity and function following traumatic injury, congenital deformity, or disfigurement. While public attitudes toward traditional organ/tissue donation are favorable, little is known about attitudes toward VCA donation and transplantation. A survey was conducted of 1485 U.S. residents in August 2016 to assess VCA donation attitudes. Participants also completed the Revised Health Care System Distrust Scale. Most respondents were willing to donate hands/forearms (67.4%) and legs (66.8%), and almost half (48.0%) were willing to donate the face. Three-quarters (74.4%) of women were willing to donate the uterus; 54.4% of men were willing to donate the penis. VCA donation willingness was more likely among whites and Hispanics (p < 0.001), registered organ/tissue donors (p < 0.001), and those with less health care system distrust (p < 0.001) and media exposure to VCA transplantation (p = 0.003). Many who opposed VCA donation expressed concerns about psychological discomfort, mutilation, identity loss, and the reaction of others to seeing familiar body parts on a stranger. Attitudes toward VCA donation are favorable overall, despite limited exposure to VCA messaging and confusion about how VCA donation occurs. These findings may help guide the development and implementation of VCA public education campaigns.

Financial Neutrality for Living Organ Donors: Reasoning, Rationale, Definitions, and Implementation Strategies

In the United States, live organ donation can be a costly and burdensome undertaking for donors. While most donation-related medical expenses are covered, many donors still face lost wages, travel expenses, incidentals, and potential for future insurability problems. Despite widespread consensus that live donors (LD) should not be responsible for the costs associated with donation, little has changed to alleviate financial burdens for LDs in the last decade. To achieve this goal, the transplant community must actively pursue strategies and policies to eliminate unreimbursed out-of-pocket costs to LDs. Costs should be more appropriately distributed across all stakeholders; this will also make live donation possible for people who, in the current system, cannot afford to proceed. We propose the goal of LD "financial neutrality," offer an operational definition to include the coverage/reimbursement of all medical, travel, and lodging costs, along with lost wages, related to the act of donating an organ, and guidance for consideration of medical care coverage, and wage and other expense reimbursement. The intent of this report is to provide a foundation to inform discussion within the transplant community and to advance initiatives for policy and resource allocation.

Direct and Indirect Costs Following Living Kidney Donation: Findings From the KDOC Study

Some living kidney donors (LKDs) incur costs associated with donation, although these costs are not well characterized in the United States. We collected cost data in the 12 mo following donation from 182 LKDs participating in the multicenter prospective Kidney Donor Outcomes Cohort (KDOC) Study. Most LKDs (n = 167, 92%) had one direct cost or more following donation, including ground transportation (86%), health care (41%), meals (53%), medications (36%), lodging (23%), and air transportation (12%). LKDs missed 33 072 total work hours, 40% of which were unpaid and led to $302 175 in lost wages (mean $1660). Caregivers lost $68 655 in wages (mean $377). Although some donors received financial assistance, 89% had a net financial loss in the 12-mo period, with one-third (33%) reporting a loss exceeding $2500. Financial burden was higher for those with greater travel distance to the transplant center (Spearman's ρ = 0.26, p < 0.001), lower household income (Spearman's ρ = -0.25, p < 0.001), and more unpaid work hours missed (Spearman's ρ = 0.52, p < 0.001). Achieving financial neutrality for LKDs must be an immediate priority for the transplant community, governmental agencies, insurance companies, nonprofit organizations, and society at large.

Deceased Donor Intervention Research: A Survey of Transplant Surgeons, Organ Procurement Professionals, and Institutional Review Board Members

Innovative deceased donor intervention strategies have the potential to increase the number and quality of transplantable organs. Yet there is confusion over regulatory and legal requirements, as well as ethical considerations. We surveyed transplant surgeons (n = 294), organ procurement organization (OPO) professionals (n = 83), and institutional review board (IRB) members (n = 317) and found wide variations in their perceptions about research classification, risk assessment for donors and organ transplant recipients, regulatory oversight requirements, and informed consent in the context of deceased donor intervention research. For instance, when presented with different research scenarios, IRB members were more likely than transplant surgeons and OPO professionals to feel that study review and oversight were necessary by the IRBs at the investigator, donor, and transplant center hospitals. Survey findings underscore the need to clarify ethical, legal, and regulatory requirements and their application to deceased donor intervention research to accelerate the pace of scientific discovery and facilitate more transplants.

Critical Factors Associated With Missing Follow-Up Data for Living Kidney Donors in the United States

Follow-up care for living kidney donors is an important responsibility of the transplant community. Prior reports indicate incomplete donor follow-up information, which may reflect both donor and transplant center factors. New UNOS regulations require reporting of donor follow-up information by centers for 2 years. We utilized national SRTR data to evaluate donor and center-level factors associated with completed follow-up for donors 2008-2012 (n = 30 026) using multivariable hierarchical logistic models. We compared center follow-up compliance based on current UNOS standards using adjusted and unadjusted models. Complete follow-up at 6, 12, and 24 months was 67%, 60%, and 50% for clinical and 51%, 40%, and 30% for laboratory data, respectively, but have improved over time. Donor risk factors for missing laboratory data included younger age 18-34 (adjusted odds ratio [AOR] = 2.03, 1.58-2.60), black race (AOR = 1.17, 1.05-1.30), lack of insurance (AOR = 1.25, 1.15-1.36), lower educational attainment (AOR = 1.19, 1.06-1.34), >500 miles to center (AOR = 1.78, 1.60-1.98), and centers performing >40 living donor transplants/year (AOR = 2.20, 1.21-3.98). Risk-adjustment moderately shifted classification of center compliance with UNOS standards. There is substantial missing donor follow-up with marked variation by donor characteristics and centers. Although follow-up has improved over time, targeted efforts are needed for donors with selected characteristics and at centers with higher living donor volume. Adding adjustment for donor factors to policies regulating follow-up may function to provide more balanced evaluation of center efforts.

Introduction to the special issue on "psychological research and practice in organ transplantation"

This paper provides a brief overview of articles in this Special Issue on "Psychological Research and Practice in Organ Transplantation." The articles provide empirical information on the psychological adaptation of transplant candidates and recipients, as well as addressing the myriad ethical and clinical issues evident in the field of organ transplantation. Heart, liver, lung, kidney, and bone marrow transplantation for children and adults has increased in frequency in recent years, and the articles address the need for more sophisticated and comprehensive assessment of psychological concomitants. The Guest Editor's "Top Ten" list of research needs which transplantation psychologists might further address is discussed in this article.

Evaluating pediatric psychology consultation services in a medical setting: An example

We examined the nature of referrals to a health center-based pediatric psychology service from 1990 to 1993 and assessed the satisfaction of health professionals with these services. Archival evaluation of 1467 records showed that over half of the consultation requests came from general pediatrics, pediatric neurology, and surgical services and that 70% of the psychological services were delivered on an outpatient basis. The most frequent referrals were for cognitive/neuropsychological evaluation and externalizing behavior problems. Pediatric psychology trainees were involved in 94% of the consultations. Survey of health professionals (n = 143) indicated very high overall satisfaction with the quality of services delivered. Presenting problems yielding the greatest likelihood for future consultation requests were behavior problems, child abuse, coping with illness, and depression/suicide. Results are discussed in the context of previous evaluations of pediatric psychology services and recommendations for future evaluation research.

Prominent impact of community risk factors on kidney transplant candidate processes and outcomes

Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0-40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self-reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk-adjusted models to evaluate effects of community risk for adult candidates listed 2004-2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16-1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85-0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22-1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81-0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43-1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15-1.24). Associations persisted with adjustment for rural-urban location; furthermore the independent effects of rural-urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5-37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.

Challenges to research and innovation to optimize deceased donor organ quality and quantity

Solid organ transplantation is encumbered by an increasing number of waitlisted patients unrequited by the current organ supply. Preclinical models suggest that advances in deceased donor management and treatment can increase the quantity and quality of organs available for transplantation. However, the science of donor intervention and the execution of high quality, prospective, multi-center, randomized-controlled trials are restricted by a myriad of logistical challenges mired in regulatory and ethical ambiguity. By highlighting the obstacles to conducting research in deceased donors, this report endeavors to stimulate the creation of a multi-disciplinary framework to facilitate the design, implementation and supervision of innovative trials that increase the quantity and/or quality of deceased donor organs.

Dynamic challenges inhibiting optimal adoption of kidney paired donation: findings of a consensus conference

While kidney paired donation (KPD) enables the utilization of living donor kidneys from healthy and willing donors incompatible with their intended recipients, the strategy poses complex challenges that have limited its adoption in United States and Canada. A consensus conference was convened March 29-30, 2012 to address the dynamic challenges and complexities of KPD that inhibit optimal implementation. Stakeholders considered donor evaluation and care, histocompatibility testing, allocation algorithms, financing, geographic challenges and implementation strategies with the goal to safely maximize KPD at every transplant center. Best practices, knowledge gaps and research goals were identified and summarized in this document.

Patients' willingness to accept expanded criteria donor liver transplantation

Utilization of livers from expanded criteria donors (ECD) is one strategy to overcome the severe organ shortage. The decision to utilize an ECD liver is complex and fraught with uncertainty for both providers and patients. We assessed patients' willingness to accept ECD liver transplantation (LTx) and acceptable 1-year mortality risk. One hundred eight patients listed for LTx were asked to rate their willingness to accept ECD LTx and the associated 1-year mortality risk they were willing to accept. Also, patients completed the SF-36v2 and sociodemographic and health information was gathered from their medical records. Patients reported significantly higher willingness to accept standard criteria donor (SCD) versus ECD LTx (t = 13.8, p < 0.001), with more than one-third of patients reporting low willingness to accept ECD LTx. Relative to our center's 10% SCD LTx 1-year mortality rate, most patients (71%) were willing to accept moderately or substantially higher 1-year mortality risk for ECD LTx. In multivariable analyses, higher lab MELD score and white race were significant independent predictors of both ECD willingness and ECD increased mortality risk acceptability. Findings highlight the importance of assessing patients' willingness to pursue ECD LTx and the relative mortality risks they are willing to accept.

Disclosing recipient information to potential living donors: preferences of donors and recipients, before and after surgery

Consensus guidelines, while recommending that potential living donors should be given information that could impact their donation decision, are nonspecific about the types of information that should be disclosed. We surveyed potential (n = 36) and past (n = 45) living donors and transplant candidates (n = 45) and recipients (n = 45) about their preferences for sharing or knowing specific information about the recipient, how this information would impact decision-making, and who should be responsible for disclosing information. Potential donors were less likely than all others to feel that recipient information should be disclosed to potential donors. Donors and recipients felt most strongly about disclosing if the recipient lost a previously transplanted kidney due to medication nonadherence as well as the likelihood of 1- and 5-year graft survival. Most donors would be less likely to pursue donation if the recipient lost a previously transplanted kidney due to medication nonadherence or generally had problems with taking medications as prescribed. Transplant programs should consider how to best balance the potential donor's right to receive information that could reasonably be expected to affect their decision-making process with the recipient's right to privacy and confidentiality.

Stimulus for organ donation: a survey of the American Society of Transplant Surgeons membership

Federal legislation has been proposed to modify the National Organ Transplant Act in a way that would permit government-regulated strategies, including financial incentives, to be implemented and evaluated. The Council and Ethics Committee of the American Society of Transplant Surgeons conducted a brief web-based survey of its members' (n = 449, 41.6% response rate) views on acceptable or unacceptable strategies to increase organ donation. The majority of the membership supports reimbursement for funeral expenses, an income tax credit on the final return of a deceased donor and an income tax credit for registering as an organ donor as strategies for increasing deceased donation. Payment for lost wages, guaranteed health insurance and an income tax credit are strategies most strongly supported by the membership to increase living donation. For both deceased and living donation, the membership is mostly opposed to cash payments to donors, their estates or to next-of-kin. There is strong support for a government-regulated trial to evaluate the potential benefits and harms of financial incentives for both deceased and living donation. Overall, there is strong support within the ASTS membership for changes to NOTA that would permit the implementation and careful evaluation of indirect, government-regulated strategies to increase organ donation.

Framing disparities along the continuum of care from chronic kidney disease to transplantation: barriers and interventions

Research in renal transplantation continues to document scores of disparities affecting vulnerable populations at various stages along the transplantation process. Given that both biological and environmental determinants contribute significantly to variation, identifying factors underlying an unfairly biased distribution of the disease burden is crucial. Confounded definitions and gaps in understanding causal pathways impede effectiveness of interventions aimed at alleviating disparities. This article offers an operational definition of disparities in the context of a framework aimed at facilitating interventional research. Utilizing an original framework describing the entire continuum of the transplant process from diagnosis of chronic kidney disease through successful transplant, this article explores the case of racial disparities, illustrating key factors predicting and perpetuating disparities. Though gaps in current research leave us unable to identify which stages of the transplant pathway adversely affect most people, by identifying key risk factors across the continuum of care, this article highlights areas suited for targeted interventions and presents recommendations for improvement and future research.

Relationships among mercury, selenium, and neurochemical parameters in common loons (Gavia immer) and bald eagles (Haliaeetus leucocephalus)

Fish-eating birds can be exposed to levels of dietary methylmercury (MeHg) known or suspected to adversely affect normal behavior and reproduction, but little is known regarding Hg's subtle effects on the avian brain. In the current study, we explored relationships among Hg, Se, and neurochemical receptors and enzymes in two fish-eating birds--common loons (Gavia immer) and bald eagles (Haliaeetus leucocephalus). In liver, both species demonstrated a wide range of total Hg (THg) concentrations, substantial demethylation of MeHg, and a co-accumulation of Hg and Se. In liver, there were molar excesses of Se over Hg up to about 50-60 microg/g THg, above which there was an approximate 1:1 molar ratio of Hg:Se in both species. However, in brain, bald eagles displayed a greater apparent ability to demethylate MeHg than common loons. There were molar excesses of Se over Hg in brains of bald eagles across the full range of THg concentrations, whereas common loons often had extreme molar excesses of Hg in their brains, with a higher proportion of THg remaining as MeHg compared with eagles. There were significant positive correlations between brain THg and muscarinic cholinergic receptor concentrations in both species studied; whereas significant negative correlations were observed between N-methyl-D-aspartic acid (NMDA) receptor levels and brain Hg concentration. There were no significant correlations between brain Se and neurochemical receptors or enzymes (cholinesterase and monoamine oxidase) in either species. Our findings suggest that there are significant differences between common loons and bald eagles with respect to cerebral metabolism and toxicodynamics of MeHg and Se. These interspecies differences may influence relative susceptibility to MeHg toxicity; however, neurochemical responses to Hg in both species were similar.

The medical evaluation of living kidney donors: a survey of US transplant centers

The use of living donors for kidney transplantation in the United States is common, and long-term studies have demonstrated the safety of donation by young, healthy individuals. However, transplant programs have little data to guide them in deciding which donors are unacceptable, and which characteristics are associated with kidney disease or poor psychosocial outcomes after donation. To document current practices in evaluating potential donors, we surveyed all US kidney transplant programs. Compared to a survey 12 years ago, medical criteria for donation are more inclusive in several areas. All responding programs now accept living unrelated donors. Most programs no longer have an upper age limit to be eligible. Programs are now more likely to accept donors with treated hypertension, or a history of kidney stones, provided that certain additional criteria are met. In contrast, medical criteria for donation are more restrictive in other areas, such as younger donor age and low creatinine clearance. Overall, significant variability remains among transplant programs in the criteria used to evaluate donors. These findings highlight the need for more data on long-term outcomes in various types of donors with potential morbidities related to donation.

Evaluating living kidney donors: relationship types, psychosocial criteria, and consent processes at US transplant programs

We conducted a survey of 132 US kidney transplant programs to examine how they evaluate and select potential living kidney donors, focusing on donor-recipient relationships, psychosocial criteria, and consent processes. There is heterogeneity in donor-recipient relationships that are considered acceptable, although most programs (70%) will not consider publicly solicited donors. Most programs (75%) require a psychosocial evaluation for all potential living donors. Most programs agree that knowledge of financial reward (90%), active substance abuse (86%), and active mental health problems (76%) are absolute contraindications to donation. However, there is greater variability in how other psychosocial issues are considered in the selection process. Consent processes are highly variable across programs: donor and recipient consent for the donor evaluation is presumed in 57% and 76% of programs, respectively. The use of 13 different informed consent elements varied from 65% (alternative donation procedures) to 86% (description of evaluation, surgery and recuperative period) of programs. Forty-three percent use a 'cooling off' period. Findings demonstrate high variability in current practice regarding acceptable donor-recipient relationships, psychosocial criteria, and consent processes. Whether greater consensus should be reached on these donor evaluation practices, especially in the context of more expansive use of living donor kidney transplantation, is discussed.

Increasing live donor kidney transplantation: a randomized controlled trial of a home-based educational intervention

With the shortage of deceased donor kidneys and the superior clinical outcomes possible with live donor kidney transplantation (LDKT), more patients should seriously consider LDKT. However, little is known about how best to educate patients and their family members about LDKT. We evaluated the effectiveness of a home-based (HB) educational program in increasing LDKT. Patients were randomized to clinic-based (CB) education alone (CB, n = 69) or CB plus HB education (CB+HB, n = 63). Compared to CB, more patients in the CB+HB group had living donor inquiries (63.8% vs. 82.5%, p = 0.019) and evaluations (34.8% vs. 60.3%, p = 0.005) and LDKTs (30.4% vs. 52.4%, p = 0.013). Assignment to the CB+HB group, White race, more LDKT knowledge, higher willingness to discuss LDKT with others, and fewer LDKT concerns were predictors of having LDKT (p-values < 0.05). Both groups demonstrated an increase in LDKT knowledge after the CB education, but CB+HB led to an additional increase in LDKT knowledge (p < 0.0001) and in willingness to discuss LDKT with others (p < 0.0001), and a decrease in LDKT concerns (p < 0.0001). Results indicate that an HB outreach program is more effective in increasing LDKT rates than CB education alone.

Incompatible kidney donor candidates' willingness to participate in donor-exchange and non-directed donation

Although paired donation, list donation and non-directed donation allow more recipients to receive living donor transplants, policy makers do not know how willing incompatible potential donors are to participate. We surveyed 174 potential donors ruled out for ABO-incompatibility or positive cross-match about their participation willingness. They were more willing to participate in paired donation as compared to list donation where the recipient receives the next deceased donor kidney (63.8% vs. 37.9%, p < 0.001) or non-directed donation (63.8% vs. 12.1%, p < 0.001). Their list donation willingness was greater when their intended recipients moved to the top versus the top 20% of the waiting list (37.9% vs. 19.0%, p < 0.001). Multivariate logistic regression modeling revealed that potential donors' empathy, education level, relationship with their intended recipient and the length of time their intended recipient was on dialysis also affected willingness. For paired donation, close family members of their intended recipient (odds ratio (OR) = 3.01, confidence intervals (CI) = 1.29, 7.02), with high levels of empathy (OR = 2.68, CI = 1.16, 6.21) and less than a college education (OR = 2.67, CI = 1.08, 6.61) were more willing to participate compared to other donors. Extrapolating these levels of willingness nationally, a 1-11% increase in living donation rates yearly (84-711 more transplants) may be possible if donor-exchange programs were available nationwide.

Organ donation decision: comparison of donor and nondonor families

Family members continue to play a prominent role in donation decisions at time of death. This study examined the relative influence of donor and next-of-kin factors, requestor characteristics, communication processes and satisfaction with the health care team on the donation decision. Data were gathered via structured telephone interview with 285 next-of-kin of donor-eligible deceased individuals who had been approached by coordinators from one organ procurement organization (OPO) in the southeastern USA from July 2001 to February 2004. Univariate and multivariate analyses showed that several variables were associated with the donation decision. Subsequent logistic regression analyses revealed that donation was more likely when the deceased was younger, white (OR = 3.20, CI = 1.3, 5.7) and had made his/her donation intentions known (OR = 4.35, CI = 2.6, 7.3), and when the next-of-kin had more favorable organ donation beliefs (OR = 8.72, CI = 5.2, 14.7), was approached about donation by an OPO coordinator (OR = 3.74, CI = 2.2, 6.4), viewed the requestor as sensitive to their needs (OR = 2.70, CI = 1.6, 4.5) and perceived the timing of the request as optimal (OR = 6.63, CI = 3.6, 12.1) (total regression model, chi square = 133.2, p < 0.001, 92.7% of cases correctly predicted). Findings highlight the need for continued public education efforts to maximize positive beliefs about organ donation, to share and document donation decisions and to improve communication processes among the OPO personnel, hospital staff and prospective donor families.

Lead concentrations in ruffed grouse, rock ptarmigan, and willow ptarmigan in Québec

Between 1996 and 1998, ruffed grouse, spruce grouse, willow ptarmigan, and rock ptarmigan harvested by hunters in Québec were examined for lead contamination. On examination of the gizzards of these birds, lead shot was found only in ruffed grouse (1.2%). The probability of ingestion of lead shot by grouse and ptarmigans is low. Analyses of the lead concentrations in the wing bones of grouse and ptarmigans and in the muscle tissue of ptarmigans were conducted. Although differences were observed between individuals based on age and sex, the mean concentrations measured were in the range of those that occur naturally at background levels (<6 microg/g dw). Lead concentrations in muscle tissue were low, often at the limit of detection. However, the few high concentrations detected were probably related to a lead pellet or bullet fragment. Based on an analysis of the health risk associated with consumption of ptarmigan muscle, we conclude that the use of lead ammunition for hunting gallinaceous birds may pose an unnecessary risk of lead poisoning because of the possible ingestion of lead shot, bullets, fragments or embedded shot.

Clinical assessment of medication adherence among HIV-infected children: examination of the Treatment Interview Protocol (TIP)

This paper presents findings of a multi-site study designed to document: (1) caregivers' regimen knowledge; (2) barriers to adherence; and (3) the relationships between adherence, regimen knowledge and barriers. Fifty-one predominantly female, African American parents and caregivers of HIV-infected children completed the Treatment Interview Protocol (TIP), a brief, structured interview designed to assess regimen knowledge and barriers to adherence. TIP data were compared to information obtained from medical records and pharmacy refill histories. Forty-nine per cent of children were considered adherent, defined as > or = 90% refill rate, which was significantly associated with virologic response. Significant regimen knowledge deficits were observed among caregivers, and inaccurate identification of prescribed medications was significantly associated with adherence. Caregivers identified 21 barriers to adherence, and poor adherence was significantly related to the number of barriers reported. Results indicate that the TIP is a successful tool for identifying regimen knowledge, potential adherence barriers and adherence problems. Results suggest that the TIP could be integrated into clinical practice as a quick, effective tool to identify poor adherers and guide interventions and treatment decision making.

Mismanaging the gift of life: noncompliance in the context of adult stem cell transplantation

In this paper, we address the issue of noncompliance with medical regimens in adult stem cell transplant patients. We review the definition, prevalence, and consequences of noncompliance and address whether or not we should alter our medical decision-making with regard to stem cell transplantation based on patient noncompliance. We discuss how the health care team should handle noncompliance issues and propose clinical guidelines for stem cell transplant programs to consider regarding evaluation and management of medical compliance.

Predicting adherence to recommendations by parents of clinic-referred children

The authors examined predictors of parents' adherence to recommendations made by psychologists after the evaluation of clinic-referred children. Parents or legal guardians of 93 children aged 4 to 12 years participated. The major findings were that (a) child behavior problem severity, parent recall of recommendations, parent satisfaction with the child's psychological evaluation, and locus of control were not significantly associated with adherence; (b) number of perceived barriers was the most salient predictor of adherence to recommendations, regardless of recommendation type; and (c) adherence rates to psychological services recommendations were significantly lower, compared with those for school-based or professional nonpsychological recommendations. Implications for more research on predictors of adherence to recommendations and clinical strategies for overcoming barriers to adherence are discussed.

Brief report: perceptions of young adolescents about a hypothetical new peer with cancer: an analog study

OBJECTIVE

To assess attitudes and behavioral intentions (desire to engage a peer in academic, social, and general activities) of young adolescents toward a hypothetical new peer with cancer and to assess the relationship between attitudes and empathy.

METHODS

Two hundred fifty middle school students viewed videotapes of a hypothetical peer (i.e., actor) with or without cancer. Participants completed a measure of empathy and a measure of social desirability before viewing the videotape. Participants completed a measure of attitudes and a measure of behavioral intentions after viewing the videotape.

RESULTS

Participants gave significantly higher ratings of behavioral intention (e.g., were more accepting) to the peer with cancer than to the healthy peer. Also, participants with high empathy reported more favorable impressions toward the hypothetical new peer than did participants with low or moderate empathy. Female participants had more favorable attitudes and behavioral intentions toward the hypothetical new peer than did male participants.

CONCLUSIONS

The social perceptions of young adolescents about peers with cancer may be less negative than previously hypothesized.

Predicting adherence to recommendations by parents of clinic-referred children

The authors examined predictors of parents' adherence to recommendations made by psychologists after the evaluation of clinic-referred children. Parents or legal guardians of 93 children aged 4 to 12 years participated. The major findings were that (a) child behavior problem severity, parent recall of recommendations, parent satisfaction with the child's psychological evaluation, and locus of control were not significantly associated with adherence; (b) number of perceived barriers was the most salient predictor of adherence to recommendations, regardless of recommendation type; and (c) adherence rates to psychological services recommendations were significantly lower, compared with those for school-based or professional nonpsychological recommendations. Implications for more research on predictors of adherence to recommendations and clinical strategies for overcoming barriers to adherence are discussed.

The Psychosocial Adjustment to Illness Scale--Self-Report: factor structure and item stability

The Psychosocial Adjustment to Illness Scale--Self-Report (PAIS-SR; Derogatis & Derogatis, 1990), a frequently used measure of adjustment in medically ill adults, was subjected to several exploratory factor analyses, with principal-axes factor extractions and varimax rotation procedures. The sample consisted of kidney, heart, liver, lung, and bone marrow transplant candidates (N = 280). The final analysis yielded a six-factor, 26-item instrument accounting for 59% of the variance. Coefficient alpha for the 26-item measure was .87, and internal consistency estimates for the factors ranged from .50 to .86. Strong correlations with other adjustment measures commonly used in the assessment of adults with chronic physical conditions support the validity of the PAIS-SR.

Cognitive behavioral and behavioral interventions help young children cope during a voiding cystourethrogram

OBJECTIVE

To reduce young children's distress and increase coping behavior among children undergoing a voiding cystourethrogram (VCU).

METHODS

Three- to seven-year-old children were stratified based on prior VCU experience and randomly assigned to an intervention (n = 20) or a standard care (n = 20) condition. The intervention included provision of information, coping skills training, and parent coaching. We hypothesized that the intervention would reduce children's distress as assessed by child report, parent and technician ratings, and behavioral observations.

RESULTS

Children in the intervention displayed fewer distress behaviors and greater coping behaviors and were rated as more cooperative than children receiving standard care. Children's fear and pain ratings did not differ significantly between groups.

CONCLUSIONS

A cognitive-behavioral treatment package effectively reduced children's distress, increased coping, and increased cooperation during voiding cystourethrogram procedures. This type of an intervention should be integrated into routine pediatric radiological procedures.

Review: cognitive and psychological outcomes in pediatric heart transplantation

OBJECTIVE

To review empirical literature investigating the cognitive and psychological effects of pediatric heart transplantation.

METHODS

Electronic and library searches were used to identify empirical studies examining the cognitive and psychological effects of pediatric heart transplantation. Only studies investigating cognitive or psychological outcomes, either prospectively or cross-sectionally, were reviewed.

RESULTS

Preliminary findings suggest that children and adolescents generally functioned within the normal range on most measures of cognitive functioning post-transplant. However, a complicated transplant course caused by infections or rejections may place these recipients at increased risk for cognitive difficulties post-transplant. Studies also suggested that approximately 20%-24% of pediatric heart transplant recipients experienced significant symptoms of psychological distress (e.g., anxiety, depression, behavior problems) during the first year post-transplant.

CONCLUSIONS

Research suggests that some recipients are at risk for cognitive and psychological difficulties post-transplant and may require additional academic remediation and/or psychological intervention to address these challenges. Given the limited number of empirical studies available at this time, continued research investigating cognitive and psychological outcomes following pediatric heart transplantation is needed.

Brief report: parents of children undergoing bone marrow transplantation: documenting stress and piloting a psychological intervention program

OBJECTIVE

To document levels of stress in parents of children undergoing bone marrow transplantation (BMT) over the course of hospitalization and to pilot a psychological intervention program designed to teach parents techniques for managing stress associated with their child's illness and hospitalization.

METHODS

Twenty-two mothers of children (ages 2-16) undergoing BMT were followed prospectively from preadmission to three weeks posttransplant. Eleven mothers, randomly assigned to participate in a pilot intervention program, were compared with 11 control mothers receiving standard care preparation of their child's BMT.

RESULTS

Repeated measures ANOVAs detected significant changes in stress over time, with most stress reported preadmission. Mothers in the intervention condition reported using more stress management techniques than mothers in the standard care condition, though the majority of analyses revealed no significant differences in stress between groups.

CONCLUSIONS

Increased levels of parenting distress may occur pretransplant, suggesting the need for additional psychological intervention at that time.

Ichthyophonus-like infection in wild amphibians from Québec, Canada

Myositis associated with infection by Ichthyophonus-like organisms was diagnosed in 35 of 260 (13%) wild amphibians collected in Quebec, Canada, from 1959 to 1964 (n = 30), and 1992 to 1999 (n = 230). Infection was diagnosed in 17 green frogs Rana clamitans, 9 wood frogs R. sylvatica, 4 red-spotted newts Notophthalmus viridescens, 3 bullfrogs R. catesbeiana, 1 spring peeper Pseudacris crucifer, and 1 pickerel frog R. palustris. The spring peeper and one of the bullfrogs were collected in 1964 from the Mont Saint-Hilaire Biosphere Reserve, indicating long-term presence of the organism. Spores of the organisms invaded striated muscle fibers and were associated with variable degrees of granulomatous and eosinophilic inflammation. Infection was considered fatal in 2 green frogs, 1 wood frog, and 1 red-spotted newt. It was considered potentially significant in 3 additional green frogs in which up to 100% of the fibers of some muscles were replaced by spores associated with a severe granulomatous reaction. Ultrastructural features of Ichthyophonus-like spores included a thick trilaminated wall, a paramural cytoplasm, multiple nuclei, oval mitochondria with short tubulo-vesicular cristae and numerous ribosomes. This report represents 4 new host records and shows that ichthyophonosis is enzootic in amphibians from Quebec.

Acquiescence to adjunctive experimental therapies may relate to psychological distress: pilot data from a bone marrow transplant center

Use of alternative therapy for breast cancer outside of the hospital setting has been identified as a marker of psychological distress. Whether acquiescence to experimental therapies within the medical setting might also be a sign of psychological distress is not well known. We therefore evaluated patients with breast cancer undergoing bone marrow transplantation (BMT), an experimental method for treatment, to determine if acquiescence to further adjunctive experimental therapy related to psychological distress. In order to do this, we studied psychological test results of 42 breast cancer patients undergoing BMT at the University of Florida between January and December 1997. These tests included the Medical Outcomes Short Form Health Survey, the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Medical Coping Modes Questionnaire. Women who accepted adjunctive experimental therapy had significantly higher trait anxiety and poorer role functioning compared to women who did not (both P < 0.001). These findings suggest that psychological distress may be a factor in medical decision-making even within the medical setting and that prospective research in this area is warranted.

The role of patients' ability to pay, gender, and smoking history on public attitudes toward cardiac transplant allocation: an experimental investigation

This study assessed public attitudes toward organ allocation through vignettes that were varied by patient's ability to pay (insured or uninsured), gender, and smoking history (current, former, or never). Participants were 681 adults contacted at a state driver's license office who read a vignette about a heart transplant candidate and subsequently rated their likelihood and priority of offering transplantation. Results revealed main effects for patient smoking history exclusively. Post hoc analyses for likelihood of offering transplantation revealed that participants gave higher ratings for never smokers than current smokers. For priority of transplantation, analyses revealed higher ratings for never smokers than for both former smokers and current smokers. Results suggest that public opinion about organ allocation may include the consideration of smoking history but not ability to pay or gender.

A psychometric normative database for pre-liver transplantation evaluations. The Florida cohort 1991-1996

In this study, the authors describe the psychological characteristics of a large sample (N = 407) of adult patients evaluated for liver transplantation, and provide normative data on commonly used measures of cognitive functioning, affective status, psychosocial adjustment, coping, quality of life, and life satisfaction. The normative data suggest that the study's liver transplant candidates have poorer cognitive functioning and health-related quality of life when compared with available normative comparison groups, yet the former group is more comparable to medically ill peers on measures of anxiety, depression, psychosocial adjustment, and coping. Data also suggest a high rate of affective disturbance in liver transplant candidates. Results indicate the utility of normative data, such as the authors', for providing an appropriate comparison group for liver pretransplant candidates.

Morbidity and mortality following bone marrow transplantation: Predictive utility of pre-BMT affective functioning, compliance, and social support stability

This study investigated the utility of 3 pretransplant psychological variables (affective functioning, compliance, social support stability) in predicting subsequent bone marrow transplantation (BMT) health outcomes. The pre-BMT psychological evaluations of 92 BMT recipients were coded along the specified psychological dimensions and used to predict post-BMT survival status and health-related quality of life. Data analyses showed that, in addition to medical risk status (low) and quality of the marrow graft (histocompatible), higher levels of pre-BMT affective functioning and social support stability significantly predicted survival status (i.e., alive) and higher levels of quality of life. These findings have important implications for the role of psychological assessment prior to BMT and the need for interventions designed to enhance psychological functioning and subsequent health outcomes following BMT.

Smokeless tobacco and cigarettes: differential attitudes and behavioral intentions of young adolescents toward a hypothetical new peer

Examined adolescents' perceptions of cigarette smokers and smokeless tobacco users. Participants were 562 middle school students in rural Florida who viewed 1 of 6 videotapes of a hypothetical peer (i.e., actor) who would soon be attending their school. The videotapes differed only as a function of sex (boy or girl) and tobacco condition (no tobacco, cigarette, smokeless tobacco). After viewing the videotape, participants completed 2 measures designed to assess attitudes and behavioral intentions toward the peer. Results indicated that (a) the actor in the no-tobacco condition was rated more favorably than actors in the other two conditions, although the actor in the smokeless-tobacco condition was rated more favorably than the actor in the cigarette condition; (b) girls viewed the actor in smokeless-tobacco condition more favorably than did boys; (c) compared to nonsmokers, adolescents with a cigarette use history provided more favorable ratings for the actor in the cigarette condition. Taken together, results suggest that different types of tobacco use may have a different impact on social image within the young adolescent population.

Mercury Accumulation and Biomagnification in Ospreys (Pandion haliaetus) in the James Bay and Hudson Bay Regions of Québec

Mercury exposure was examined in adults and nestlings of ospreys (Pandion haliaetus) from lakes, rivers, and hydroelectric reservoirs in northern Québec between 1989 and 1991 by assessing the amount of mercury transferred from fish to ospreys, which are voracious fish-eaters. The high mercury concentrations detected in adult feathers and tissues (feathers, blood, liver, kidneys, muscles, brain) of nestlings indicate an increase in mercury availability at recently constructed hydroelectric reservoirs (10-12 years for the La Grande-2 Reservoir). With mean total mercury levels of 37.3 mg/kg and 1.9 mg/kg in feathers (dry weight) and in blood (wet weight), respectively, contamination rates were, in both tissues, five times higher for chicks born near the La Grande Reservoirs (western sector) than in those reared in natural habitats. Furthermore, the mean quantity of total mercury in 40-day-old chicks reared near a reservoir was 10.5 mg, compared with to 1.6 mg for those reared in a natural environment. Modeling of mercury transfer from fish to osprey nestlings showed that the mercury level in chicks' blood provides a good estimate of mercury concentrations in ingested food. In addition, the relationship between mercury concentrations in the blood and that in feathers indicates that substantial biomagnification of mercury occurs from the ingested dose to the feathers. The intensity of this biomagnification varies with the age of the chicks and reaches a maximum value as the flight feathers start to form (at 20-25 days of age) declining thereafter until the bird is 45 days old and growth of those feathers is complete. Nevertheless, the mean number of young fledged on reservoirs where mercury exposure is greatest (>40 mg/kg of Hg in chicks' feathers) did not differ (1.6 +/- 0.7) from that observed elsewhere in built-up environments (1.9 +/- 0.7) or in natural habitats (2.0 +/- 0.7) (H = 4.39; p = 0.11). Storage of mercury in growing feathers (86% of all mercury in osprey) prevents accumulation in living tissues, thereby protecting the chick from related toxic effects. However, toxicological problems may arise after fledging. In particular, attention should be paid to postfledging survival before concluding that mercury exposure is insufficiently high in Osprey young reared at reservoirs.

Health-related quality of life and symptom frequency before and after lung transplantation

Health-related quality of life (HRQOL) and symptom frequency and severity were assessed in 17 lung transplant recipients both prior to and following the procedure. Using standardized assessment techniques we found that the following components of QOL significantly improved post-transplantation: physical functioning, general health, vitality and social functioning. Both prior to and following transplantation, lung transplant recipients had significantly lower scores on all health-related quality of life indices when compared with a normative sample. Perhaps as a consequence of immunosuppression medication, recipients reported increased frequency of symptomatology following the procedure; however, considered together the symptoms were not reported as significantly more problematic following transplantation. These findings document improved HRQOL for lung transplant recipients and provide useful information for patients considering this potentially life-saving treatment option.

Transplantation in children. A longitudinal assessment of mothers' stress, coping, and perceptions of family functioning

This study examined the parenting stress, coping resources, and family functioning among 27 mothers of children undergoing bone marrow, liver, kidney, and heart transplantation. The mothers completed a comprehensive battery of psychological instruments at the pretransplant stage and at 1- and 6-month posttransplant stages. Increased parenting stress, financial strain, caregiver burden, and family stress were reported following transplantation and persisted for several months. The mothers reported using coping strategies characterized by attempts to maintain family integration and to understand the child's medical situation. Development and evaluation of intervention programs to enhance parents' ability to cope with stress and maintain family stability are warranted.

Stage II breast cancer: differences between four coping patterns in side effects during adjuvant chemotherapy

Fifty-six women with stage II breast cancer receiving adjuvant chemotherapy were recruited for a study evaluating and comparing coping patterns for differences in physical and psychological side effects during treatment with adjuvant chemotherapy. Cluster analyses were used to split women into confrontive, avoidant-confrontive, avoidant-resigned, and resigned coping clusters. Side-effect measurements were taken on the day of adjuvant chemotherapy infusion and 3 and 7 days later. Repeated measures ANCOVAs indicated that coping clusters predicted significant variance in physical, psychological, and total side effects when variance in covariates was held constant. Confrontive subjects reported significantly fewer psychological and physical symptoms than avoidant-confrontive and avoidant-resigned copers. Confrontive copers also reported fewer side effects than resigned copers, but this difference was not significant when differences in covariate distributions were controlled. Particularly robust differences were noted when confrontive copers were compared with avoidant-confrontive copers. Results suggest that a critical component in optimal coping may be a willingness to discuss and think about illness.

Dioxin-like compounds in fishing people from the Lower North Shore of the St. Lawrence River, Quebec, Canada

In this study, investigators assessed exposure to dioxin-like compounds in a fishing population that inhabits small coastal communities along the Lower North Shore of the St. Lawrence River, Quebec. This population relies heavily on wildlife foods for sustenance. Investigators analyzed chemically the most popular marine foods (i.e., fish, crustaceans, sea mammals, and sea-bird eggs), and they also obtained 25 human plasma samples from individuals in two villages along the river. The mean level of total polychlorinated biphenyls in this population was approximately twice that found in the entire fishing cohort. Plasma levels of dioxin-like compounds, expressed as tetrachlorodibenzodioxin toxic equivalents, were approximately eight times higher than levels in urban residents. Most of the increase in tetrachlorodibenzodioxin toxic equivalents in the selected fish eaters resulted primarily from an elevation in polychlorinated biphenyls. Concentrations of dioxin-like compounds from the Lower North Shore were low in fish and seals, but concentrations were elevated in the eggs of sea birds. Given that there was also a significant statistical correlation in the entire population between human plasma levels and consumption of birds' eggs-and not other traditional foods-much of the increased human dose appeared to originate from this one food source. Because there appear to be increased, but uncertain, health risks from this elevated body burden, investigators advised the residents of the area to avoid consumption of wild birds' eggs (i.e., a food source of minor nutritional importance).

Promoting healthier behaviors, attitudes, and beliefs toward sun exposure in parents of young children

The present study examined the impact of a conceptually driven intervention designed to increase skin cancer knowledge and promote healthier, "sun-safe" attitudes, beliefs, and behaviors about sun exposure in mothers of children ages 6 months to 10 years old. Participants (N = 55) were assigned to a comprehensive prevention program (CPP), information-only condition (IOC), or a no-information control group (NIC). An assessment battery measuring skin cancer knowledge, sun-safe behaviors, and sun exposure attitudes and beliefs was administered at baseline, 2 weeks postintervention, and 12 weeks postintervention. Consistent with prediction, mothers in the CPP and IOC groups showed significant increases in skin cancer knowledge; however, only those in the CPP condition showed increases in sun-safe behaviors, attitudes, and beliefs that were maintained at the 12-week follow-up. Also, results provide support for the influence of perceived severity, self-efficacy, response-efficacy, and perceived barriers on sun-safe behaviors.

Hindlimb deformities (ectromelia, ectrodactyly) in free-living anurans from agricultural habitats

High prevalences of hindlimb deformities were recorded in wild-caught green frogs (Rana clamitans), northern leopard frogs (Rana pipiens), American toads, (Bufo americanus), and bullfrogs (Rana catesbeiana) from agricultural sites exposed to pesticide runoff in the St. Lawrence River Valley of Québec, Canada, between July and September 1992 and 1993. Of 853 metamorphosing anurans examined in 14 farmland habitats, 106 (12%; range 0 to 69%) had severe degrees of ectromelia and ectrodactyly, compared to only two (0.7%; range 0 to 7.7%) of 271 in 12 control sites. However, the variation in the proportion of deformities among sites was too large to conclude that there was a significant difference between control and pesticide-exposed habitats. Clinical signs varied and were characterized by segmental hypoplasia or agenesis of affected limbs. Conspicuous abnormalities interfered with swimming and hopping, and likely constituted a survival handicap. Because of circumstances and the frequency of these malformations in nine distinct habitats, and in three different species from one of our study sites, we propose a teratogenic action of exogenous factors. Despite the fact that many biotic and abiotic agents are potentially harmful to limb development, agricultural contaminants were suspected as primary aggressors. Thus, clinical examination and frequency of deformities in anurans might be an economical screening tool to assess ecosystem health and the presence of environmental contaminants.

Perceptions of parenting stress and family relations by fathers of children evaluated for organ transplantation

18 fathers of children evaluated for solid organ or bone marrow transplantation completed measures of parenting stress and family functioning. Comparisons with normative data indicated that these fathers reported less parenting stress, less family conflict, more concern about family finances, and more limitations in family activities. These data highlight the need for family-based assessments in pediatric transplantation.

Promoting healthier behaviors, attitudes, and beliefs toward sun exposure in parents of young children

The present study examined the impact of a conceptually driven intervention designed to increase skin cancer knowledge and promote healthier, "sun-safe" attitudes, beliefs, and behaviors about sun exposure in mothers of children ages 6 months to 10 years old. Participants (N = 55) were assigned to a comprehensive prevention program (CPP), information-only condition (IOC), or a no-information control group (NIC). An assessment battery measuring skin cancer knowledge, sun-safe behaviors, and sun exposure attitudes and beliefs was administered at baseline, 2 weeks postintervention, and 12 weeks postintervention. Consistent with prediction, mothers in the CPP and IOC groups showed significant increases in skin cancer knowledge; however, only those in the CPP condition showed increases in sun-safe behaviors, attitudes, and beliefs that were maintained at the 12-week follow-up. Also, results provide support for the influence of perceived severity, self-efficacy, response-efficacy, and perceived barriers on sun-safe behaviors.

Mothers of children evaluated for transplantation: stress, coping resources, and perceptions of family functioning

The stress, coping resources, and family functioning of 36 mothers of children awaiting transplantation were evaluated. Using standardized assessment techniques, we found that, overall, 20% of mothers reported clinically elevated stress responses and that parenting stress was higher for mothers of children evaluated for solid organ transplantation (vs. bone marrow transplantation). Coping strategies characterized by maintenance of personal and family stability were strongly associated with lower levels of parenting stress. Findings also showed significant disruption in family planning and activities, as well as a strong association between lower socioeconomic status and higher parenting stress. There is a need for the longitudinal assessment of parental and family functioning throughout the transplantation process as well as for interventions designed to reduce parenting distress.