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Nicholson B, Goodman R, Day J, Worth A, Carpenter B, Sandford K, Morris EC, Burns SO, Ridout D, Titman P, Campbell M. Quality of Life and Social and Psychological Outcomes in Adulthood Following Allogeneic HSCT in Childhood for Inborn Errors of Immunity. J Clin Immunol 2022; 42:1451-1460. [PMID: 35723794 DOI: 10.1007/s10875-022-01286-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplant (HSCT) is well established as a corrective treatment for many inborn errors of immunity (IEIs) presenting in childhood. Due to improved techniques, more transplants are undertaken and patients are living longer. However, long-term complications can significantly affect future health and quality of life. Previous research has focused on short-term medical outcomes and little is known about health or psychosocial outcomes in adulthood. OBJECTIVE This project aimed to ascertain the long-term social and psychological outcomes for adults who underwent HSCT for IEI during childhood. METHODS Adult patients, who had all undergone HSCT for IEI during childhood at two specialist immunology services at least 5 years previously, were invited to participate in the study. Questionnaires and practical tasks assessed their current functioning and circumstances. Information was also gathered from medical notes. Data was compared with population norms and a control group of participant-nominated siblings or friends. RESULTS Eighty-three patients and 46 matched controls participated in the study. Patients reported significantly better physical health-related quality of life than the general population norm, but significantly worse than matched controls. Patient's self-reported physical health status and the perceived impact of their physical health on everyday life were worse than matched controls and patients reported higher levels of anxiety and lower mood than the general population. For those where their IEI diagnosis was not associated with a learning disability, cognitive function was generally within the normal range. CONCLUSIONS Patients who have had a HSCT in childhood report mixed psychosocial outcomes in adulthood. More research is needed to establish screening protocols and targeted interventions to maximize holistic outcomes. CLINICAL IMPLICATIONS Screening for holistic needs and common mental health difficulties should be part of routine follow-up. Information should be provided to patients and families in order to support decision-making regarding progression to transplant and the early identification of any difficulties.
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Affiliation(s)
- Bethany Nicholson
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - Rupert Goodman
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - James Day
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Austen Worth
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ben Carpenter
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Emma C Morris
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Siobhan O Burns
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Deborah Ridout
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Penny Titman
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mari Campbell
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust, London, UK. .,UCL Institute of Immunity & Transplantation, London, UK.
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Day JW, Elfeky R, Nicholson B, Goodman R, Pearce R, Fox TA, Worth A, Booth C, Veys P, Carpenter B, Hough R, Gaspar HB, Titman P, Ridout D, Workman S, Hernandes F, Sandford K, Laurence A, Campbell M, Burns SO, Morris EC. Retrospective, Landmark Analysis of Long-term Adult Morbidity Following Allogeneic HSCT for Inborn Errors of Immunity in Infancy and Childhood. J Clin Immunol 2022; 42:1230-1243. [PMID: 35579633 PMCID: PMC9537214 DOI: 10.1007/s10875-022-01278-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
Purpose
Allogeneic hematopoietic stem cell transplant (HSCT) remains the treatment of choice for patients with inborn errors of immunity (IEI). There is little published medical outcome data assessing late medical complications following transition to adult care. We sought to document event-free survival (EFS) in transplanted IEI patients reaching adulthood and describe common late-onset medical complications and factors influencing EFS. Methods In this landmark analysis, 83 adults surviving 5 years or more following prior HSCT in childhood for IEI were recruited. The primary endpoint was event-free survival, defined as time post-first HSCT to graft failure, graft rejection, chronic infection, life-threatening or recurrent infections, malignancy, significant autoimmune disease, moderate to severe GVHD or major organ dysfunction. All events occurring less than 5 years post-HSCT were excluded. Results EFS was 51% for the whole cohort at a median of 20 years post HSCT. Multivariable analysis identified age at transplant and whole blood chimerism as independent predictors of long-term EFS. Year of HSCT, donor, conditioning intensity and underlying diagnosis had no significant impact on EFS. 59 events occurring beyond 5 years post-HSCT were documented in 37 patients (45% cohort). A total of 25 patients (30% cohort) experienced ongoing significant complications requiring active medical intervention at last follow-up. Conclusion Although most patients achieved excellent, durable immune reconstitution with infrequent transplant-related complications, very late complications are common and associated with mixed chimerism post-HSCT. Early intervention to correct mixed chimerism may improve long-term outcomes and adult health following HSCT for IEI in childhood. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-022-01278-6.
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Affiliation(s)
- James W Day
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Reem Elfeky
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | - Bethany Nicholson
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | - Rupert Goodman
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | | | - Thomas A Fox
- University College London Hospitals NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Austen Worth
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Claire Booth
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Paul Veys
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Ben Carpenter
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Rachael Hough
- University College London Hospitals NHS Foundation Trust, London, UK
| | - H Bobby Gaspar
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Penny Titman
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Deborah Ridout
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sarita Workman
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | - Fernando Hernandes
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK
| | | | - Arian Laurence
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Mari Campbell
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Siobhan O Burns
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK.,UCL Institute of Immunity & Transplantation, London, UK
| | - Emma C Morris
- Department of Immunology, Royal Free London Hospitals NHS Foundation Trust, London, UK. .,University College London Hospitals NHS Foundation Trust, London, UK. .,UCL Institute of Immunity & Transplantation, London, UK.
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Moore DA, Nunns M, Shaw L, Rogers M, Walker E, Ford T, Garside R, Ukoumunne O, Titman P, Shafran R, Heyman I, Anderson R, Dickens C, Viner R, Bennett S, Logan S, Lockhart F, Thompson Coon J. Interventions to improve the mental health of children and young people with long-term physical conditions: linked evidence syntheses. Health Technol Assess 2020; 23:1-164. [PMID: 31122334 DOI: 10.3310/hta23220] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although mental health difficulties can severely complicate the lives of children and young people (CYP) with long-term physical conditions (LTCs), there is a lack of evidence about the effectiveness of interventions to treat them. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of interventions aiming to improve the mental health of CYP with LTCs (review 1) and explore the factors that may enhance or limit their delivery (review 2). DATA SOURCES For review 1, 13 electronic databases were searched, including MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Science Citation Index. For review 2, MEDLINE, PsycINFO and CINAHL were searched. Supplementary searches, author contact and grey literature searches were also conducted. REVIEW METHODS The first systematic review sought randomised controlled trials (RCTs) and economic evaluations of interventions to improve elevated symptoms of mental ill health in CYP with LTCs. Effect sizes for each outcome were calculated post intervention (Cohen's d). When appropriate, random-effects meta-analyses produced pooled effect sizes (d). Review 2 located primary qualitative studies exploring experiences of CYP with LTCs, their families and/or practitioners, regarding interventions aiming to improve the mental health and well-being of CYP with LTCs. Synthesis followed the principles of metaethnography. An overarching synthesis integrated the findings from review 1 and review 2 using a deductive approach. End-user involvement, including topic experts and CYP with LTCs and their parents, was a feature throughout the project. RESULTS Review 1 synthesised 25 RCTs evaluating 11 types of intervention, sampling 12 different LTCs. Tentative evidence from seven studies suggests that cognitive-behavioural therapy interventions could improve the mental health of CYP with certain LTCs. Intervention-LTC dyads were diverse, with few opportunities to meta-analyse. No economic evaluations were located. Review 2 synthesised 57 studies evaluating 21 types of intervention. Most studies were of individuals with cancer, a human immunodeficiency virus (HIV) infection or mixed LTCs. Interventions often aimed to improve broader mental health and well-being, rather than symptoms of mental health disorder. The metaethnography identified five main constructs, described in an explanatory line of argument model of the experience of interventions. Nine overarching synthesis categories emerged from the integrated evidence, raising implications for future research. LIMITATIONS Review 1 conclusions were limited by the lack of evidence about intervention effectiveness. No relevant economic evaluations were located. There were no UK studies included in review 1, limiting the applicability of findings. The mental health status of participants in review 2 was usually unknown, limiting comparability with review 1. The different evidence identified by the two systematic reviews challenged the overarching synthesis. CONCLUSIONS There is a relatively small amount of comparable evidence for the effectiveness of interventions for the mental health of CYP with LTCs. Qualitative evidence provided insight into the experiences that intervention deliverers and recipients valued. Future research should evaluate potentially effective intervention components in high-quality RCTs integrating process evaluations. End-user involvement enriched the project. STUDY REGISTRATION This study is registered as PROSPERO CRD42011001716. FUNDING The National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
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Affiliation(s)
- Darren A Moore
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, UK
| | - Michael Nunns
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, UK
| | - Liz Shaw
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, UK
| | - Morwenna Rogers
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter Medical School, Exeter, UK
| | - Erin Walker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tamsin Ford
- Child Mental Health Group, University of Exeter Medical School, Exeter, UK
| | - Ruth Garside
- The European Centre for Environment and Human Health, University of Exeter Medical School, Exeter, UK
| | - Obi Ukoumunne
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter Medical School, Exeter, UK
| | - Penny Titman
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roz Shafran
- University College London Institute of Child Health, London, UK
| | - Isobel Heyman
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rob Anderson
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, UK
| | - Chris Dickens
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter Medical School, Exeter, UK
| | - Russell Viner
- University College London Institute of Child Health, London, UK
| | - Sophie Bennett
- University College London Institute of Child Health, London, UK
| | - Stuart Logan
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter Medical School, Exeter, UK
| | - Fiona Lockhart
- Biomedical Research Centre Patient & Public Involvement Group, University College London Hospitals, London, UK
| | - Jo Thompson Coon
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter Medical School, Exeter, UK
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Towner S, Berger ZE, Titman P, New HV, Theodore K, Brown G, Sibson KR. Fatigue, executive function and psychological effects in children with immune thrombocytopenia: a cross-sectional study. Br J Haematol 2020; 189:534-542. [PMID: 31978938 DOI: 10.1111/bjh.16387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/17/2019] [Indexed: 01/19/2023]
Abstract
Childhood ITP is often considered to be a relatively mild haematological disorder, with only a minority of patients requiring treatment for troublesome bleeding. Over recent years, wider effects of the condition have been identified in some adults, particularly relating to fatigue and cognitive impairment. In this study, we sought to investigate such effects in a group of children with ITP and further our understanding of their psychological profile. Children attending routine haematology outpatient clinics and their parents were asked to complete standardised questionnaires designed to assess a range of psychological and cognitive factors. Although the majority of children had some scores within the normal range, a significantly high proportion had difficulties with fatigue (70·6%), emotional and behavioural symptoms (25·7%) or executive functioning (19·4%). Quality of life and subjective evaluation of the illness (appraisal) correlated significantly with each of these domains, but bleeding severity and platelet count did not. Our findings provide valuable insight into the broader impact of childhood ITP, which could aid in providing holistic care, potentially contribute to decisions regarding medical treatment, and guide future research.
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Affiliation(s)
- Sarah Towner
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, UK
| | - Zoe E Berger
- Psychological Services, Great Ormond Street Hospital, London, UK
| | - Penny Titman
- Psychological Services, Great Ormond Street Hospital, London, UK
| | - Helen V New
- Department of Paediatrics, Imperial College Healthcare NHS Trust, NHS Blood and Transplant, London, UK
| | - Kate Theodore
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, UK
| | - Gary Brown
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, UK
| | - Keith R Sibson
- Haematology Department, Great Ormond Street Hospital, London, UK
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Titman P, Allwood Z, Gilmour C, Malcolmson C, Duran-Persson C, Cale C, Davies G, Gaspar H, Jones A. Quality of life in children with primary antibody deficiency. J Clin Immunol 2014; 34:844-52. [PMID: 25005831 PMCID: PMC4165866 DOI: 10.1007/s10875-014-0072-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 06/20/2014] [Indexed: 01/25/2023]
Abstract
Primary antibody deficiency disorders (PADs) can have an excellent outlook if diagnosed early and treated appropriately, but require lifelong treatment with immunoglobulin replacement. Some carry risks of inflammatory complications even with optimal treatment. Quality of life (QoL) and the psychological impact of PADs has been relatively little studied, particularly in children. The purpose of this study was to evaluate QoL and psychological impact in a large group of children affected by a range of PADs, as well as a group with transient hypogammaglobulinemia of infancy (THI). Both parental and, where appropriate, child ratings, were collected using standardised questionnaires (PedsQL and SDQ). Higher rates of psychological difficulties, particularly emotional and peer-relationship difficulties were found in children with PAD when compared with healthy controls. Quality of life was poorer than in healthy controls, and also worse than in children affected by diabetes mellitus. Variations in QoL and the degree of psychological difficulties were found between specific diagnostic groups, with children affected by THI being amongst those with the lowest scores for QoL. Further studies are needed to corroborate and extend these findings, but this study confirms previous findings that primary antibody deficiency has a significant impact on quality of life and psychological well-being, and additionally suggests that the impact varies according to severity of the underlying condition. For those with significant difficulties psychological intervention at an early stage may be beneficial.
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Affiliation(s)
- P Titman
- Immunology Department, Great Ormond Street Hospital, London, WC1N 3JH, United Kingdom
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Cole TS, McKendrick F, Cant AJ, Pearce MS, Cale CM, Goldblatt DR, Gennery AR, Titman P. Cognitive ability in children with chronic granulomatous disease: a comparison of those managed conservatively with those who have undergone hematopoietic stem cell transplant. Neuropediatrics 2013; 44:230-2. [PMID: 23397467 DOI: 10.1055/s-0033-1333875] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Chronic granulomatous disease (CGD) is a primary immunodeficiency managed conservatively or with hematopoietic stem cell transplant. Studies have shown people with CGD and those transplanted for primary immunodeficiencies have lower than average cognitive ability. In this study, IQ in children with CGD and those transplanted for it was within the normal range.
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Affiliation(s)
- Theresa S Cole
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.
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Cole TS, Jones LKR, McGrogan P, Pearce MS, Flood TJ, Cant AJ, Goldblatt D, Thrasher AJ, Gennery AR, McKendrick F, Titman P. Emotional and behavioural difficulties in chronic granulomatous disease. Arch Dis Child 2012; 97:87. [PMID: 21994243 DOI: 10.1136/archdischild-2011-300780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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McDowell E, Titman P, Davidson S. Parents' experiences one year on from their child's hematopoietic stem cell transplant for primary immunodeficiency. J Health Psychol 2010; 15:897-904. [PMID: 20616181 DOI: 10.1177/1359105309359331] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study explored parental experience one year after hematopoietic stem cell transplant for primary immunodeficiency. Eight parents whose child had undergone transplant were interviewed one year after their child's transplant. Transcripts were analysed using interpretative phenomenological analysis. Four themes emerged: parents' paradoxical existence within an 'abnormal normality'; isolation felt by parents; gender differences between mothers and fathers; and the 'positive growth' parents attribute to their experience. As well as describing stressful or traumatic experiences they identified aspects of post-traumatic growth. The methodology used allowed contrasting experiences to emerge and highlights the importance of follow-up for parents as well as children.
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Affiliation(s)
- Elizabeth McDowell
- Department of Psychosocial and Family Services, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Abstract
The impending closure of many large psychiatric hospitals has led to the involvement of clinical psychologists in surveys of whole hospital populations. REHAB is a recent addition to the range of behaviour-rating scales. In a test of the inter-rater reliability of this scale, we have assessed the ratings from an initial sample of 50 patients. We obtained higher correlation co-efficients than expected given the larger number of raters used in our study. Some implications for the general use of rating scales in reprovision are discussed.
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Affiliation(s)
- J Carson
- Psychology Department, Claybury Hospital, Woodford Green, Essex, UK
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