Psychiatric aspects of lung transplant. The Toronto Lung Transplant Group

Characterization of the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) in Lung Transplant Candidates

The SIPAT is a standardized measure for pre-transplant psychosocial evaluation. Previous SIPAT studies utilized a relatively small lung transplant sample and only included listed patients. This study characterized the SIPAT in 147 lung transplant candidates to better elucidate its utility. The average score corresponded to a minimally acceptable rating and nearly half of the patients had relative or absolute contraindications. Interstitial Lung Disease (ILD) patients scored more favorably than non-ILD patients (U = 7.69, p < .05). The Total (β = - .05, SE = .018, p < .01), Social Support Subscale (β = - .133, SE = .058, p < .05), and Psychosocial Stability and Psychopathology Subscale (β = - .103, SE = .040, p < .05) significantly predicted listing status. The SIPAT has a unique profile in lung transplant candidates and demonstrated utility for guiding transplant decisions. Future research should examine which lung transplant outcomes are significantly associated with SIPAT scores.

Patterns and predictors of pain following lung transplantation

OBJECTIVE

Our objective was to examine variability in pain levels following lung transplantation, and examine individual biopsychosocial factors influencing changes in pain.

METHOD

We performed a retrospective study of a cohort of 150 patients transplanted and discharged from Duke University Hospital between January 2015 and September 2016. During hospitalization and at clinic visits up to two months after discharge, subjective pain ratings were obtained using a 0-10 Numeric Rating Scale. Psychiatric diagnoses of anxiety and depression and Center for Epidemiological Studies - Depression (CES-D) scores collected after hospital discharge were examined as predictors of post-surgery pain. Medical and surgical variables were examined as covariates.

RESULTS

During hospitalization, pain ratings decreased over time (p<0.001). Predictors of higher pain levels included pre-transplant history of depression (p=0.001) and anxiety (p=0.04), bilateral lung transplant (p=0.03), and lower six-minute walk distance (p=0.02). Two months after discharge, 18% of patients reported continued pain and 34% remained on opioid pain medications. Two months after discharge, more frequent post-operative complications predicted higher pain levels in a univariate analysis (p=0.02) although this relationship was attenuated after adjustment for depression. In a multivariate analysis, elevated CES-D scores (p=0.002), and greater opioid use (p=0.031) predicted higher pain levels 2-months post-discharge.

CONCLUSION

We conclude that patients with psychiatric comorbidities may be at risk for greater pain, and may require additional strategies for more effective pain management.

Health Locus of Control Predicts Survival after Lung Transplant

The purpose of this study was to assess whether health locus of control beliefs measured pre-transplant predicted survival after lung transplant. Participants were 100 patients who completed the Multidimensional Health Locus of Control scale before and after transplant. Cox proportional hazards regressions were used to investigate the relationship between each of the three subscales (IHLC, PHLC, CHLC) and survival time after transplant. After adjusting for age and medical diagnosis, participants with medium and high levels of IHLC had lower hazard ratios than those with low IHLC. Neither PHLC nor CHLC exhibited statistical differences in survival. Compared to patients with low IHLC, patients with medium and high levels of IHLC lived longer after lung transplant.

Psychological criteria for contraindication in lung transplant candidates: a five-year study

Lung transplantation presents a wide range of challenges for multidisciplinary teams that manage the care of the recipients. Transplant teams should perform a thorough evaluation of transplant candidates, in order to ensure the best possible post-transplant outcomes. That is especially true for the psychologist, because psychological issues can arise at any point during the perioperative period. The objective of our study was to evaluate the psychological causes of contraindication to waiting list inclusion in a referral program for lung transplantation. We retrospectively analyzed data on psychological issues presented by lung transplant candidates, in order to understand these matters in our population and to reflect upon ways to improve the selection process.

[The role of the respiratory and relaxation training in the treatment of the patients after the surgical treatment of non-specific pulmonary diseases]

The present study included 62 patients who had undergone the surgical intervention for the treatment of non-specific pulmonary diseases. All the patients were subjected to the psychological and spirometric examination. The study has demonstrated the relationship between the characteristics of the external respiration function on the one hand and the ability to handle stress, the levels of anxiety, tension, emotional instability and hypochondriacal mood on the other hand. It was shown that the respiratory and relaxation training improves the effectiveness of the treatment of the patients presenting with such symptoms due to the correction of their psychological status and optimization of the external respiration function. The highest effectiveness of the respiratory and relaxation training was documented in the patients suffering moderate neurotic disorders.

Cognitive function, mental health, and health-related quality of life after lung transplantation

RATIONALE

Cognitive and psychiatric impairments are threats to functional independence, general health, and quality of life. Evidence regarding these outcomes after lung transplantation is limited.

OBJECTIVES

Determine the frequency of cognitive and psychiatric impairment after lung transplantation and identify potential factors associated with cognitive impairment after lung transplantation.

METHODS

In a retrospective cohort study, we assessed cognitive function, mental health, and health-related quality of life using a validated battery of standardized tests in 42 subjects post-transplantation. The battery assessed cognition, depression, anxiety, resilience, and post-traumatic stress disorder (PTSD). Cognitive function was assessed using the Montreal Cognitive Assessment, a validated screening test with a range of 0 to 30. We hypothesized that cognitive function post-transplantation would be associated with type of transplant, cardiopulmonary bypass, primary graft dysfunction, allograft ischemic time, and physical therapy post-transplantation. We used multivariable linear regression to examine the relationship between candidate risk factors and cognitive function post-transplantation.

MEASUREMENTS AND MAIN RESULTS

Mild cognitive impairment (score, 18-25) was observed in 67% of post-transplant subjects (95% confidence interval [CI]: 50-80%) and moderate cognitive impairment (score, 10-17) was observed in 5% (95% CI, 1-16%) of post-transplant subjects. Symptoms of moderate to severe anxiety and depression were observed in 21 and 3% of post-transplant subjects, respectively. No transplant recipients reported symptoms of PTSD. Higher resilience correlated with less psychological distress in the domains of depression (P < 0.001) and PTSD (P = 0.02). Prolonged graft ischemic time was independently associated with worse cognitive performance after lung transplantation (P = 0.001). The functional gain in 6-minute-walk distance achieved at the end of post-transplant physical rehabilitation (P = 0.04) was independently associated with improved cognitive performance post-transplantation.

CONCLUSIONS

Mild cognitive impairment was present in the majority of patients after lung transplantation. Prolonged allograft ischemic time may be associated with cognitive impairment. Poor physical performance and cognitive impairment are linked, and physical rehabilitation post-transplant and psychological resilience may be protective against the development of long-term impairment. Further study is warranted to confirm these potential associations and to examine the trajectory of cognitive function after lung transplantation.

Coping and quality of life in patients awaiting lung transplantation

OBJECTIVE

Patients with end-stage lung disease (ESLD) experience significant decrements in quality of life (QOL). Although coping strategies are related to QOL in patients with ESLD, the extent to which specific native lung disease moderates this relationship is unknown.

METHODS

We investigated the relationship between coping, native lung disease, and QOL among 187 patients awaiting lung transplantation, including 139 patients with chronic obstructive pulmonary disease (COPD) and 48 with cystic fibrosis (CF). Participants completed a psychosocial battery assessing psychological QOL, physical QOL, and coping strategies.

RESULTS

For both COPD and CF patients, higher levels of Active Coping (P< .0001) and lower levels of Disengagement (P< .0001) were associated with better psychological QOL. For physical QOL, we observed a Native Disease x Coping interaction (P=.01) such that Active Coping was associated with better physical QOL in patients with COPD but not in patients with CF.

CONCLUSIONS

The relationship between coping and QOL may vary as a function of native lung disease. Patients' native disease may need to be considered in order to develop effective interventions to help patients cope successfully with ESLD.

Saúde mental nas práticas em saúde: a experiência do PROLIG

O presente trabalho apresenta o relato de experiências do Serviço de Atenção Psicossocial Integrada em Saúde (SAPIS) nos Programas de Ligação (PROLIG). O SAPIS foi implantado em junho de 2002, no Hospital São Paulo (HSP), com o objetivo de promover uma atenção mais ampla às necessidades gerais e específicas do hospital no que diz respeito aos aspectos psicossociais bem como de reorganizar a inclusão de profissionais de saúde mental nas enfermarias e ambulatórios. Esse estudo tem como objetivo descrever a atuação do psicólogo como profissional de ligação em saúde mental no atendimento às demandas específicas de unidades do HSP. A tarefa do profissional de ligação em saúde mental envolve a assistência psicológica ao paciente e seu familiar assim como o desempenho do papel de especialista em saúde mental junto à equipe multiprofissional. Temos encontrado em nossa prática, no entanto, algumas dificuldades para a implementação e a manutenção de algumas propostas. Concluímos que a atuação do psicólogo como profissional de ligação de saúde mental tem promovido mudanças nos cuidados em saúde nessa instituição, porém ainda exige uma profunda reflexão e maior envolvimento da instituição e de políticas de saúde que viabilizem mudanças estruturais para a construção de uma efetiva prática integral e integrada nessa área.

Telephone-based coping skills training for patients awaiting lung transplantation

Impaired quality of life is associated with increased mortality in patients with advanced lung disease. Using a randomized controlled trial with allocation concealment and blinded outcome assessment at 2 tertiary care teaching hospitals, the authors randomly assigned 328 patients with end-stage lung disease awaiting lung transplantation to 12 weeks of telephone-based coping skills training (CST) or to usual medical care (UMC). Patients completed a battery of quality of life instruments and were followed for up to 3.4 years to assess all-cause mortality. Compared with UMC, CST produced lower scores on perceived stress, anxiety, depressive symptoms, and negative affect and improved scores on mental health functioning, optimism, vitality, and perceived social support. There were 29 deaths (9%) over a mean follow-up period of 1.1 year. Survival analyses revealed that there was no difference in survival between the 2 groups. The authors conclude that a telephone-based CST intervention can be effectively delivered to patients awaiting lung transplantation. Despite the severity of pulmonary disease in this patient population, significant improvements in quality of life, but not somatic measures or survival to transplant, were achieved.

Psychosocial Issues in the Assessment and Management of Patients Undergoing Lung Transplantation

This review examines psychosocial issues among lung transplant patients from the time of assessment through the posttransplant period. Although psychological factors are recognized as being important in the transplant evaluation, no standard approach to psychological assessment currently exists. Lung transplant candidates often experience high levels of psychological distress while awaiting transplant, and both pretransplant and posttransplant psychological functioning have been found to predict posttransplant quality of life, adherence to treatment, and, in some cases, medical outcomes. Given the limited long-term survival following transplantation, improving psychosocial functioning is essential for enhancing outcomes among lung transplant recipients. This review summarizes the extant literature on the psychosocial factors in lung transplantation and highlights several innovative efforts to improve psychological outcomes in this challenging patient population.

Cognitive function in adult cardiothoracic transplant candidates and recipients

Innovative surgical and medical techniques have prolonged the life span of cardiothoracic (CT) transplant recipients and made transplantation an option for many older patients. Cognitive function is a key determinant of the CT transplant recipient's ability to manage the complex treatment regimen and experience optimum benefit of the procedure. As the CT population ages, risk of cognitive dysfunction due to normal aging is compounded by the physical and mental changes associated with end-stage organ disease, comorbid conditions, and transplant-related complications. Cognitive abilities consist of (a) receptive functions (ability to select, acquire, classify, and integrate information); (b) memory and learning (ability to store and retrieve information); (c) thinking (ability to mentally organize and reorganize information; and (d) expressive functions (ability to communicate or act upon information). Although each of these functions represents a distinct type of behavior, they are interdependent. The purpose of this article is to (a) discuss the literature regarding cognitive function before and after adult heart, lung, and heart-lung transplantation; (b) identify methodological problems associated with the studies done to date; and (c) make recommendations for future research in this area.

Psychological disorders and distress after adult cardiothoracic transplantation

This review summarizes and integrates evidence concerning mental health outcomes following heart, lung, and heart-lung transplantation. Drawing on English-language case reports and empirical studies published between January 1980 and December 2004, the goals of the review were to (a) describe the prevalence and clinical characteristics of psychological disorders, as well as the level and pattern of clinically significant distress in the years posttransplant; (b) review the major risk factors for poor posttransplant psychological outcomes; (c) consider evidence suggesting that posttransplant psychological outcomes predict physical morbidity and mortality after transplant; (d) summarize findings from intervention studies designed to improve posttransplant psychological outcomes; and (e) provide patient care recommendations for the practicing clinician and recommendations for continued clinical research. Several major conclusions can be drawn from this literature. First, depressive and anxiety-related disorders and associated distress are common posttransplant. While new onsets of disorder may decline after the first year posttransplant, the development of new medical complications in the late years posttransplant may provoke renewed distress and recurrences of disorder. Second, risk factors for posttransplant psychological disorders and elevated distress include both standard risk factors observed in other populations (eg, younger age, lifetime history of psychiatric disorder) and transplant-specific factors related to physical functional impairments, social supports, and strategies for coping with health problems. Third, while little evidence has been published to date, there is some indication that posttransplant psychological outcomes can predict subsequent physical health outcomes. Fourth, extremely few intervention studies in cardiothoracic transplant recipients have been performed. The few reports indicate that multicomponent psychosocial strategies focused on risk factor reduction and enhancement of personal coping resources may lead to reductions in psychological distress. An important caveat in considering all of the evidence reviewed is that most studies focus on heart rather than lung or heart-lung recipients. Recommendations for practicing clinicians focus on assessment and treatment options, based on the evidence to date. Research recommendations focus on the need for intervention effectiveness studies.

Gas exchange and exercise capacity affect neurocognitive performance in patients with lung disease

OBJECTIVE

This study examined the relationship between cognitive functioning and the severity of underlying lung disease in patients awaiting lung transplantation.

METHODS

Ninety-four patients with end-stage lung disease completed a test battery to assess cognitive performance in two domains: executive functioning/attention (Trails A and B, COWA, Animal Naming, Stroop Color-Word Test, Digit Symbol, and the 2 & 7 Test) and verbal memory (Digit Span-Backward and Forward, WMS-R Logical Memory and Paired Verbal Associates).

RESULTS

Thirty-seven percent of the patients demonstrated moderate to severe cognitive impairment data on two or more tests. Adjusting for age and education, there were no statistically significant differences on executive functioning or verbal memory as a function of specific lung disease diagnosis. Lower PCO2 values were associated with better cognitive performance on latent measures of executive functioning and attention (p = .006) and verbal memory (p = .009), whereas higher PO2 values tended to be associated with better performance on the executive functioning/attention measure (p = .064). Distance walked in 6 minutes was positively related to verbal memory (p < .023).

CONCLUSIONS

Impaired neurocognitive functioning may be relatively common in patients awaiting lung transplantation and is associated with ineffective pulmonary gas exchange and reduced exercise tolerance.

The effect of bronchiolitis obliterans syndrome on health related quality of life

Bronchiolitis obliterans syndrome (BOS) is the most important factor limiting long-term survival after lung transplantation, and has a substantial impact on patients' daily life in terms of disability and morbidity. Aim of our study was to examine the effects of BOS on health related quality of life (HRQL) in lung transplantation patients. Data on HRQL from 29 patients who developed BOS at least 18 months earlier were studied longitudinally. HRQL measures were: the Nottingham Health Profile (NHP), the State Trait Anxiety Inventory (STAI), the Self-rating Depression Scale (ZUNG), and the Index of Well Being (IWB). Furthermore questions concerning activities of daily life and dyspnea were asked. The majority of the patients were male, and the most common diagnosis was emphysema. After the onset of BOS, significantly more restrictions were reported on the dimensions energy and mobility of the NHP. These restrictions appeared to increase over time. After the onset of BOS, STAI scores remained more or less stable and close to the value of the general population. ZUNG scores were significantly higher after the onset of BOS, and patients experienced a lower level of well being than the general population. The percentage of patients that reported to be able to perform activities of daily life without effort declined dramatically after the onset of BOS. Furthermore, the percentage of patients complaining of dyspnea increased after the onset of BOS. In conclusion, our study showed that HRQL was negatively affected by the onset of BOS. However, in spite of these less favorable long-term results, even patients who develop BOS may at least temporarily benefit from a lung transplantation.

Acute postoperative pain in lung transplant recipients

BACKGROUND

This retrospective study was designed to assess the quality of postoperative pain control and the facility of transition from epidural to oral analgesia in lung transplant recipients.

METHODS

After institutional review board approval, data were collected from the charts of all patients who underwent lung transplantation at our institution between 1998 and 2002. The study group consisted of the patients for whom an epidural was the first postoperative pain management modality. To serve as a control group we reviewed the charts of 30 patients, randomly selected over the same period, who underwent a thoracotomy for indications other than transplantation and who received postoperative epidural analgesia.

RESULTS

Eighty-three patients were available for analysis. Unilateral and bilateral lung transplant recipients had equivalent quality of pain control. However, lung transplant recipients had a lower incidence of adequate pain relief than patients undergoing thoracotomy for other indications (73% vs 87%, p < 0.05). Lung transplant recipients also had a higher incidence of epidural to oral analgesia transition failure (47% vs 20%, p < 0.01).

CONCLUSIONS

This is the first study to assess the quality of postoperative pain control and success of transition from epidural to oral analgesia in lung transplant recipients. Prospective studies are needed to assess the impact of our findings on patients' outcome.

Treatment of Anxiety and Depression in Transplant Patients

Depressive and anxiety disorders appear during the transplant process due to psychological stressors, medications and physiological disturbances. Treatment is necessary to prevent impact on patient compliance, morbidity and mortality. Psychotropic medications provide an effective option, although most are only available as oral formulations. Because of this, they are more susceptible to alterations in pharmacokinetic behaviour arising from organ dysfunction in the pretransplant period. Kinetics are also an issue when considering potential drug-drug interactions before and after transplantation. Prior to transplant, organ dysfunction can change the pharmacokinetic behaviour of some psychotropic agents, requiring adjustment of dosage and schedules. Thoracic or abdominal organ failure may reduce drug absorption through disturbances in intestinal motility, perfusion and function. Cirrhotic patients experience increased drug bioavailability due to portosystemic shunting, and thus dosage is adjusted downward. In contrast, dosage needs to be raised when peripheral oedema expands the drug distribution volume for hydrophilic and protein-bound agents. Drug clearance for most psychotropic medications is dependent upon hepatic metabolism, which is often disrupted by endstage organ disease. Selection of drugs or their dosage may need to be adjusted to lower the risk of drug accumulation. Further adjustments in dosage may be called for when renal failure accompanies thoracic or abdominal organ failure, resulting in further impairment of clearance. Studies regarding the treatment of anxiety and depressive disorders in the medically ill are limited in number, but recommendations are possible by review of clinical and pharmacokinetic data. Selective serotonin reuptake inhibitors are well tolerated and efficacious for depression, panic disorder and post-traumatic stress disorder. Adjustments in dosage are required when renal or hepatic impairment is present. Among them, citalopram and escitalopram appear to have the least risk of drug-drug interactions. Paroxetine has demonstrated evidence supporting its use with generalised anxiety disorder. Venlafaxine is an alternative option, beneficial in depression, post-traumatic stress and generalised anxiety disorders. Nefazodone may also be considered, but there is some risk of hepatotoxicity and interactions with immunosuppressant drugs. Mirtazapine still needs to be studied further in anxiety disorders, but can be helpful for depression accompanied by anorexia and insomnia. Bupropion is effective in the treatment of depression, but data are sparse about its use in anxiety disorders. Psychostimulants are a unique approach if rapid onset of antidepressant action is desired. Acute or short-term anxiolysis is obtained with benzodiazepines, and selection of particular agents entails consideration of distribution rate, half-life and metabolic route.

Psychiatric Disorder and Quality of Life in Patients Awaiting Lung Transplantation *

STUDY OBJECTIVE

To examine the relationship between psychiatric comorbidity and quality of life in patients awaiting lung transplantation.

SETTING

Duke University Medical Center/Lung Transplantation Program.

PARTICIPANTS

One hundred patients with end-stage pulmonary disease listed for lung transplantation.

MEASUREMENTS AND RESULTS

Twenty-five percent (n = 25) of the sample met diagnostic criteria for at least one current mood or anxiety disorder. Controlling for age, gender, ethnicity, percentage of predicted FEV, and lung disease diagnosis, patients with a current psychiatric diagnosis reported poorer general quality of life (p < 0.0001), poorer disease-specific quality of life (p < 0.0001), greater shortness of breath (p = 0.01), more symptoms of psychological distress (p < 0.0001), lower levels of social support (p < 0.0001), and fewer positive health habits (p < 0.04) than their counterparts without a psychiatric diagnosis.

CONCLUSIONS

Psychiatric comorbidity affects a significant portion of patients awaiting lung transplantation and is associated with decreased health-related quality of life.

Long-term quality of life in patients surviving at least 55 months after lung transplantation

The aim of this study was to examine the long-term effect of lung transplantation on Health Related Quality of Life by studying 28 patients who survived at least 55 months after lung transplantation. Measures included the Nottingham Health Profile, questions concerning lung-specific problems, the State-Trait Anxiety Inventory, the Self-rating Depression Scale, the Index of Well-Being, the Karnofsky performance index, and questions concerning activities of daily life. Furthermore, comorbid conditions were measured. Before transplantation patients reported restrictions on almost all quality of life measures. Until approximately 43 months after transplantation there were significant improvements on most dimensions of the Nottingham Health Profile and more patients could walk without dyspnea. Significant improvements occurred with regard to the levels of anxiety, depression, and well being, and the scores on the Karnofsky performance index improved. Activities of daily life could be performed without help by most patients. After approximately 43 months patients experienced more dyspnea, anxiety, depression, and a lower level of well being. The number of patients suffering from a decrease of kidney function, drug treated hyperlipidemia, insulin dependent diabetes mellitus and bronchiolitis obliterans syndrome increased. It may be concluded that patients experience a stable and better overall quality of life after transplantation. Long-term after lung transplantation patients experience a decline on several dimensions of quality of life, which may be explained by an increase of comorbid conditions and Bronchiolitis Obliterans Syndrome.

Effects of a telephone-based psychosocial intervention for patients awaiting lung transplantation

STUDY OBJECTIVES

To test the efficacy of a tailored telephone-based intervention consisting of supportive counseling and cognitive behavioral techniques for individuals awaiting lung transplantation on measures of quality of life and general well-being.

METHOD

Patients were randomly assigned to either a telephone-based special intervention (SI; n = 36) for 8 weeks (average session length, 16.3 min) or a usual care (UC) control condition (n = 35) in which subjects received usual medical care but no special treatment or phone calls. At baseline, and immediately following the 8-week intervention, patients completed a psychometric test battery.

SETTING

Duke University Medical Center, Pulmonary Transplantation Program.

PATIENTS

Seventy-one patients with end-stage pulmonary disease listed for lung transplantation.

PRIMARY OUTCOME MEASURES

Measures of health-related quality of life (both general and disease-specific), general psychological well-being, and social support.

RESULTS

Multivariate analysis of covariance, adjusting for pretreatment baseline scores, age, gender, and time waiting on the transplant list, revealed that patients in the SI condition compared to the UC reported greater general well-being (p < 0.05), better general quality of life (p < 0.01), better disease-specific quality of life (p < 0.05), and higher levels of social support (p < 0.0001).

CONCLUSION

A brief, relatively inexpensive, telephone-based psychosocial intervention is an effective method for reducing distress and increasing health-related quality of life in patients awaiting lung transplantation.

The psychological impact of end-stage lung disease

STUDY OBJECTIVES

End-stage lung disease is associated with poor quality of life and increased risk for psychological distress. Despite the significant number of individuals with end-stage lung diseases, the emotional health of these patients, as compared with those with other chronic organ diseases, is not well-known. The purpose of this article is to elucidate personality styles and the presence of psychopathology in a clinical sample of patients with end-stage lung disease presenting for possible lung transplantation.

DESIGN

Cross-sectional survey.

SETTING

Two academic medical center transplant programs.

PARTICIPANTS

Two hundred forty-three consecutively referred transplant candidates.

RESULTS

Cluster analysis of the Minnesota Multiphasic Personality Inventory (MMPI)-2 indicated five different personality styles. The majority of patients evidenced mild somatic and depressive symptoms. Approximately one fourth of the sample exhibited marked anxiety and mood disturbances. A small cluster also evidenced features consistent with an antisocial personality style.

CONCLUSIONS

Separate and distinct personality styles that could affect quality of life, the need for adjunct treatments, and medical compliance emerged from this sample of individuals with end-stage lung disease. Results are discussed in light of prior research on other end-stage organ conditions and in relation to personality and coping theories.

Care before and after lung transplant and quality of life research

Lung transplantation is a growing surgical option for patients with end-stage lung and pulmonary vascular diseases. After completing an extensive evaluation and meeting the selection criteria, patients are listed for either single or bilateral-sequential lung transplantation. Immediate postoperative management requires detailed attention to fluid management, monitoring for infection, reperfusion injury, pulmonary hygiene, and pain management. Length of stay depends on the patient's condition before transplant and postoperative complications. Discharge from the hospital can be as early as 7 days after transplantation. Newer immunosuppressive medications offer more options for treating and preventing rejection. Advanced practice nurses, such as coordinators, case managers, nurse practitioners, and clinical nurse specialists, are uniquely positioned to play key roles in coordinating the care of transplant patients across settings and both before and after the transplant procedure. The perioperative needs of lung transplant patients and the impact of this complex procedure on the recipients' and family's quality of life merit further investigation by clinicians and researchers.

Making the transition: pediatric lung transplantation

INTRODUCTION

Little information exists regarding how parents whose children have undergone lung transplantation perceive the meaning of their return home to face the reality of the posttransplant experience.

METHOD

A naturalistic approach was selected to investigate the meaning of the experience from the perspective of the parents. Fifteen parents of 12 children were interviewed. Colaizzi's method of phenomenologic analysis guided the analysis of the interview data.

RESULTS

A theme cluster, "making the transition," emerged from the data. The themes that reflected parents' perceptions of the issues they faced in the posttransplant period included reuniting the family, assuming a new role, returning to school, facing the risk of infection, facing the threat of rejection, and striking a balance.

DISCUSSION

Parents' perceptions of the situation reflected the shifting impact of uncertainty on their daily lives and coping strategies. The need exists to recognize the parents' unique and changing needs and to implement individualized nursing care to meet their needs.

Psychiatric assessment in transplantation

The implementation of the presumptive donor law in Brazil is expected to increase the availability of organs for transplantation. As medical management of end-stage organ dysfunction continues to improve, increasing numbers of potential transplant recipients will be available to meet this supply. There is mounting evidence that supports the involvement of skilled psychiatric practitioners in the selection of transplant candidates. Data supporting the influence of psychosocial factors on compliance and therefore medical outcomes continues to grow. The literature review allows delineating the components and rationale for comprehensive psychosocial evaluations as a component of preoperative transplantation evaluation.

Psychiatric disorders and survival after lung transplantation

The 30 patients who underwent lung transplantation between 1990 and 1996 were included in this study, and data were analyzed to find predictors of 1-year survival posttransplantation. All patients were followed throughout the posttransplantation period. Fifteen patients had a pretransplantation diagnosis of an anxiety and/or depressive disorders. Of the 30 patients transplanted, 19 survived 12 months or more, and 11 died less than 12 months posttransplantation. The > 12-month survival group had a mean age of 45.2 years at transplantation, compared with a mean age of 43.0 years in the < 12-month group (NS). The mean Psychosocial Assessment of Candidates for Transplant score and premorbid history of smoking did not differ between the groups. The > 12-month survival group had more psychiatric illness pretransplantation than the < 12-month survival group (56% vs. 27%, P < 0.05). The recipients with a psychiatric history (N = 15) were more likely to survive 1 year posttransplantation than the recipients without a psychiatric history (80% vs. 47%, P < 0.05) and were not significantly different from the recipients without a psychiatric history in terms of episodes of rejection, bronchiolitis obliterans, or noncompliance with treatment. Depression and anxiety are treatable disorders that occur frequently in patients with end-stage lung disease, and a premorbid history of either did not predict a worse outcome posttransplantation in this study of lung transplantation recipients.

Technology assessment of the Dutch Lung Transplantation Program

The costs, effects, and cost-effectiveness of the Dutch Lung Transplantation program were assessed. The results show that lung transplantation is a very costly intervention that improves survival and quality of life. Costs per life-year and per QALY gained were, respectively, US $90,000 and US $71,000.

The effect of lung transplantation on health-related quality of life: a longitudinal study

STUDY OBJECTIVES

To assess the change in health-related quality of life (HRQL) among Dutch lung transplant patients before and after transplantation.

DESIGN

Prospective longitudinal study on HRQL among 24 Dutch lung transplant patients who participated first as transplant candidates, and later as recipients in the study. This study design provides an accurate estimate of the change in HRQL as a result of lung transplantation because there is no confounding between change due to differences in composition between groups of patients at the different points of follow-up and the true change as a result of the transplantation. Patients completed self-administered questionnaires before transplantation, and at 1, 4, 7, 13, and 19 months after transplantation. The main HRQL measures were: the Nottingham health profile (NHP), the State-trait Anxiety Inventory, the Self-rating Depression Scale-Zung, the Karnofsky Performance Index, the index of well-being, and activities of daily living (ADL).

SETTING

University Hospital Groningen, the Netherlands.

RESULTS

Before transplantation, patients report major restrictions on the dimensions mobility and energy of the NHP, a low level of experienced well-being, and depressive symptoms. In addition, patients experience difficulties in performing ADL and report a low ability to take care of themselves. About 4 months after transplantation, mobility, energy, sleep, ADL dependency level, and dyspnea were particularly positively affected by the lung transplantation. These improvements were maintained in the following 15 months.

CONCLUSIONS

Lung transplantation contributes positively to the HRQL of surviving patients over time.

Patient selection, evaluation, and preoperative management for lung transplant candidates

The selection process to assess candidacy for transplant is based on medical and psychosocial criteria and surgical considerations. The degree of disease severity requiring transplantation for survival has become more apparent as the disparity in survival outcome widens between patients with and without transplant. The contraindications to transplant surgery have been modified over time. Candidate selection is considered in the context of the risks and benefits of the surgical procedure on a case by case basis. The wait for transplant has increased as the growth in the number of candidates for transplant exceeds available donors. As much as 30% of patients die on the UNOS waiting list.

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

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

Development of an eating disorder in a 40 year-old male lung transplant candidate: a case study

This paper presents the treatment of a lung transplant candidate suffering from an eating disorder who refused communication between the Eating Disorders Clinic and the transplant team. The importance of psychiatric evaluation in transplantation and the need for the free flow of information among all health professionals working with the transplant patient are discussed. Explanations are proposed for the role of dieting in the development of the eating disorder and the patient's continued food restriction, vomiting, and laxative abuse after transplantation.