Ethical considerations in xenotransplantation of thoracic organs - a call for a debate on value based decisions.

Xenotransplant covers a broad ethical territory and there are several ethical questions that have arisen in parallel with the technological advances that have allowed the first porcine transplants to occur. This brief communication highlights ethical considerations regarding heart and lung xenotransplantation, with an emphasis on unresolved value-based concerns in the field. The aim of this text is therefore to encourage the readers to consider the vast potential of this emerging technique to do good, but also the risk of doing harm, and to participate in a discussion. The list of questions presented here is not exhaustive but hopefully represents some of the questions that appear to be most pressing as the field advances. The focus is on the value-based, or ethical questions, not the questions related to the practical medical procedures.

Factors associated with a positive phosphatidylethanol test during liver transplantation evaluation.

BACKGROUND: Early identification of alcohol use is crucial for informing recommendations of appropriate follow-up treatment pre-liver transplant and optimizing post-liver transplant outcomes. The purpose of the study was to investigate whether there are psychosocial factors associated with a positive PEth test. METHODS: All patients who underwent a routine pre-surgical psychological evaluation for liver transplant listing (all etiologies, including acute liver failure, dual organ, and re-transplantation) at a single health care system in 2020 were included in a retrospective chart review. Data extraction included results from PEth testing and information from the psychological evaluation (i.e., demographic, psychiatric symptoms, and cognitive functioning). RESULTS: There were 158 patients (73.8%) who had a PEth test, of whom 21.5% had a positive result (n = 34). Younger age was associated with a positive PEth (p < .001). ALD status and type of ALD (hepatitis vs. cirrhosis) were also associated with a positive PEth test. Other demographic characteristics and psychiatric symptoms were not associated with a positive PEth result (p > .05). CONCLUSION: Younger age was the only significant demographic variable associated with a positive PEth test. Given the difficulty of predicting who may be using alcohol, it may be useful to use PEth testing for all patients during the pre-liver transplant evaluation and while patients are listed for liver transplant. Early identification of alcohol use through routine PEth testing will help identify patients who are using alcohol and need further treatment for alcohol use to optimize health and post-transplant outcomes.

A center experience with lung transplantation for COVID-19 ARDS.

COVID-19 can cause irreversible lung damage from acute respiratory distress syndrome (ARDS), chronic respiratory failure associated with post COVID-19 de novo fibrosis or worsening of an underlying fibrotic lung disease. Pregnant women are at increased risk for invasive mechanical ventilation, extracorporeal membrane oxygenation, and death. The Centers for Disease Control and Prevention reported more than 22,000 hospitalizations and 161 deaths for COVID-19 in pregnant women. Between August 2020 and September 2021, five patients underwent bilateral lung transplant (LT) for COVID-19 ARDS at the Henry Ford Hospital in Detroit, Michigan. De-identified demographics data, clinical characteristics, perioperative challenges, explanted lung pathology, and post-transplant outcomes are described. In post-hospitalization follow-up (median survival 273 days), we see improving endurance and excellent lung function. One patient did not survive to hospital discharge and succumbed to complications 5 months after LT. We report the first cases of bilateral LT in two postpartum women.

Acceptance of Illness Among Patients Pursuing Transplantation or Left Ventricular Assist Device.

Acceptance of illness is related to better mental health among patients with chronic illness; however, this construct has not been evaluated as part of routine transplantation evaluations. The purpose of this study was to create a brief measure of acceptance of illness for patients pursuing organ transplantation and examine how acceptance is related to distress. Retrospective medical record reviews were conducted for 290 patients who completed a routine psychosocial evaluation prior to transplant listing which included the Illness Acceptance Scale (IAS). Internal consistency for the IAS was excellent (Cronbach's alpha = .92). Illness acceptance was negatively correlated with depression, anxiety, and catastrophizing and was not related to health literacy or health numeracy. The IAS is a reliable and valid measure for patients who are pursuing thoracic transplant or left ventricular assist device. Clinicians may want to screen transplant candidates for illness acceptance and refer those with lower levels to psychological interventions.

A New Measure of Health Numeracy: Brief Medical Numbers Test (BMNT).

BACKGROUND: Approximately half of Americans have inadequate health literacy, which leads to poorer health outcomes. Health numeracy is an important component of literacy, which reflects one's ability to understand and manipulate numbers. This is especially important for transplant candidates, as adherence to medical recommendations is essential for posttransplant care. Although validated measures of numeracy exist, they can be inconvenient and time consuming to administer. OBJECTIVE: The Brief Medical Numbers Test (BMNT) was created in 2011 to quickly assess the health numeracy of a patient during presurgical psychiatric transplant evaluations. The purpose of this study was to evaluate the reliability and validity of the BMNT for this use via retrospective chart review. METHODS: There were 293 patients referred over a 2-year period for a presurgical psychiatric evaluation. The evaluation consisted of a semistructured interview and completion of several measures, including the BMNT, a measure of health literacy, and a brief test of cognitive functioning. RESULTS: The BMNT had acceptable internal consistency (α = .71), convergent validity with health literacy and cognitive functioning, and predictive validity with surgical outcomes. CONCLUSIONS: Preliminary data suggests the BMNT is a reliable and valid measure of health numeracy in patients being evaluated for transplant.

ACT Processes in Group Intervention for Mothers of Children with Autism Spectrum Disorder.

Few studies have examined interventions or therapeutic processes that may help parents of children with Autism Spectrum Disorder (ASD) manage their stress. This study examines the impact of a brief Acceptance and Commitment Therapy (ACT) group intervention, led by parents, among a cohort of 33 mothers of children with ASD. Changes in ACT process measures (psychological flexibility, cognitive fusion, values) were evaluated at pre, post, and 3 months following the intervention. Mothers reported significant improvement post-intervention in psychological flexibility, cognitive fusion, and value-consistent activities in multiple life domains, including parenting, relationships, and self-care. These improvements were maintained at follow-up. The results provide preliminary evidence that improvements observed in depression and stress may be mediated by cognitive fusion and action-values consistency.

Leadership Perspectives on Integrating Psychologists into Specialty Care Clinics: An Evolving Paradigm.

Integration of health psychologists into specialty care is a shift in the tertiary care construct that addresses all aspects of a patient's presentation, including psychiatric/social history, psychological well-being, and behavioral contributions to the disease process, assuring both optimal health outcomes and cost-effectiveness in a financially challenging healthcare environment. In this paper, we discuss leadership perspectives (physician and psychologists) on the factors involved in integrating a health psychologist into a busy tertiary care environment. Ultimately, we hope that this information provides a primer on how to frame a proposal for an integrated health psychologist emphasizing the elements important to senior medical leadership and administration. First, we briefly discuss the current payer framework, providing support for integration emphasizing costs and other metrics. Second, we introduce organizational structure models and strategies for integration. Lastly, we will discuss the unique skillset psychologists possess, and additional skills necessary, to be effective in the changing landscape of healthcare. We think this information is important both for leaders attempting to integrate a health psychologist into specialty care and for the early career health psychologist embarking on his/her first senior staff position.

Problematic Eating Behaviors Predict Outcomes After Bariatric Surgery.

BACKGROUND: There are no clear psychosocial predictors of weight loss following bariatric surgery. The purpose of this study was to investigate whether preoperative problematic eating behaviors predict weight loss outcomes following bariatric surgery. METHODS: Clinical records were utilized to examine outcomes of 101 patients who completed a pre-surgical psychosocial evaluation and underwent gastric bypass or sleeve gastrectomy. Information analyzed included binge eating history and scores from the Hospital Anxiety and Depression Scale, Yale Food Addiction Scale, and Emotional Eating Scale. Measures of weight loss 1 year post-surgery were compared to pre-surgical assessments. RESULTS: One-year follow-up data were available for 60 patients. Patients with higher levels of eating in response to anger/frustration (p = .02), anxiety (p = .01), or depression (p = .05) were more likely to miss the 1-year follow-up appointment. Eating in response to anger/frustration and depression were related to poorer weight loss outcomes. There was a trend for binge eating to predict greater %EWL (p = .06). A higher number of food addiction symptoms increased the likelihood that patients would experience less weight loss (p = .01). Psychiatric symptoms were not related to weight loss outcomes. CONCLUSIONS: Patients who endorsed higher levels of pre-surgical emotional eating and food addiction symptoms had poorer weight loss 1 year post-surgery. Providers should consider screening patients for these behaviors during the pre-surgical psychosocial evaluation which would allow opportunities for psychotherapy and potential improvement in weight loss outcomes. Future research should examine which interventions are successful at improving problematic eating behaviors.

Health Literacy Status Affects Outcomes for Patients Referred for Transplant.

BACKGROUND: It is hypothesized that limited health literacy affects outcomes for patients referred for transplant; however, research has not examined this for all types of end-stage organ disease. OBJECTIVE: The purpose of this study was to determine whether health literacy and cognitive impairment were related to listing for transplant and posttransplant outcomes. METHODS: Chart reviews were conducted on 398 patients who completed a required psychiatric evaluation before transplant listing. Information gathered from these evaluations included reading ability, math ability, and cognitive functioning. Variables before transplant and 6 months after transplantation were also collected. RESULTS: Patients with limited reading ability were less likely to be listed for transplant (p = .018) and were more likely to be removed from listing (p = .042), to miss appointments prelisting (p = .021), and to experience graft failure (p = .015). Patients with limited math ability were less likely to be listed (p = .010) and receive a transplant (p = 0.031), and more likely to be readmitted posttransplant (p = .029). Patients with cognitive impairment were less likely to be listed (p = .043) and to receive a transplant (p = .010). CONCLUSIONS: To achieve superior transplant access and outcomes, transplant providers should regularly screen patients for limited health literacy and cognitive impairment. Future studies should evaluate whether interventions result in better outcomes for these patients.