Trajectories of self-care agency and associated factors in lung transplant recipients over the first 12 months following transplantation.

Self-care agency (SCA), defined as one's ability and willingness to engage in self-care behaviors, can influence actual performance of self-care behaviors in lung transplant recipients (LTRs). Understanding patterns of SCA over time may inform the design of interventions to promote self-care in LTRs. Using group-based trajectory modeling, we sought to identify patterns and correlates of SCA among 94 LTRs over the first 12 months post-transplant. Baseline measures of sociodemographic, clinical, and psychosocial factors, and longitudinally assessed psychological distress were examined for their associations with predicted trajectory group membership. Three distinct stable (ie, zero slope) SCA trajectories were identified as follows: persistently low, persistently moderate, and persistently high. Based on the final multivariate model, requiring a re-intubation after transplant (P=.043), discharged to a facility rather than home (P=.048), and reporting a higher level of baseline anxiety (P=.001) were significantly associated with lower SCA. Linear mixed models revealed that higher levels of anxiety and depression were associated with lower SCA in the persistently moderate and low SCA groups over the 12-month time period (Ps<.05). LTRs who require a re-intubation after transplant and are discharged to a facility other than home, and report high psychological distress, may need additional assistance to engage in post-transplant self-care behaviors.

Long-Term Follow-up of a Randomized Controlled Trial Evaluating a Mobile Health Intervention for Self-Management in Lung Transplant Recipients.

Mobile health interventions may help transplant recipients follow their complex medical regimens. Pocket Personal Assistant for Tracking Health (Pocket PATH) is one such intervention tailored for lung transplant recipients. A randomized controlled trial showed Pocket PATH's superiority to usual care for promoting the self-management behaviors of adherence, self-monitoring and communication with clinicians during posttransplant year 1. Its long-term impact was unknown. In this study, we examined associations between Pocket PATH exposure during year 1 and longer term clinical outcomes-mortality and bronchiolitis obliterans syndrome (BOS)-among 182 recipients who survived the original trial. Cox regression assessed whether (a) original group assignment and (b) performance of self-management behaviors during year 1 predicted time to outcomes. Median follow-up was 5.7 years after transplant (range 4.2-7.2 years). Pocket PATH exposure had no direct effect on outcomes (p-values >0.05). Self-monitoring was associated with reduced mortality risk (hazard ratio [HR] 0.45; 95% confidence interval [CI] 0.22-0.91; p = 0.027), and reporting abnormal health indicators to clinicians was associated with reduced risks of mortality (HR 0.15; 95% CI 0.04-0.65; p = 0.011) and BOS (HR 0.27; 95% CI 0.08-0.86; p = 0.026), regardless of intervention group assignment. Although Pocket PATH did not have a direct impact on long-term outcomes, early improvements in self-management facilitated by Pocket PATH may be associated with long-term clinical benefit.

Pattern and Predictors of Hospital Readmission During the First Year After Lung Transplantation.

Hospital readmission after lung transplantation negatively affects quality of life and resource utilization. A secondary analysis of data collected prospectively was conducted to identify the pattern of (incidence, count, cumulative duration), reasons for and predictors of readmission for 201 lung transplant recipients (LTRs) assessed at 2, 6, and 12 mo after discharge. The majority of LTRs (83.6%) were readmitted, and 64.2% had multiple readmissions. The median cumulative readmission duration was 19 days. The main reasons for readmission were other than infection or rejection (55.5%), infection only (25.4%), rejection only (9.9%), and infection and rejection (0.7%). LTRs who required reintubation (odds ratio [OR] 1.92; p = 0.008) or were discharged to care facilities (OR 2.78; p = 0.008) were at higher risk for readmission, with a 95.7% cumulative incidence of readmission at 12 mo. Thirty-day readmission (40.8%) was not significantly predicted by baseline characteristics. Predictors of higher readmission count were lower capacity to engage in self-care (incidence rate ratio [IRR] 0.99; p = 0.03) and discharge to care facilities (IRR 1.45; p = 0.01). Predictors of longer cumulative readmission duration were older age (arithmetic mean ratio [AMR] 1.02; p = 0.009), return to the intensive care unit (AMR 2.00; p = 0.01) and lower capacity to engage in self-care (AMR 0.99; p = 0.03). Identifying LTRs at risk may assist in optimizing predischarge care, discharge planning and long-term follow-up.

A Randomized Controlled Trial of a Mobile Health Intervention to Promote Self-Management After Lung Transplantation.

Lung transplant recipients are encouraged to perform self-management behaviors, including (i) monitoring health indicators, (ii) adhering to their regimen, and (iii) reporting abnormal health indicators to the transplant coordinator, yet performance is suboptimal. When hospital discharge was imminent, this two-group trial randomized 201 recipients to use either the mobile health (mHealth) intervention (n = 99) or usual care (n = 102), to compare efficacy for promoting self-management behaviors (primary outcomes) and self-care agency, rehospitalization, and mortality (secondary outcomes) at home during the first year after transplantation. The mHealth intervention group performed self-monitoring (odds ratio [OR] 5.11, 95% confidence interval [CI] 2.95-8.87, p < 0.001), adhered to medical regimen (OR 1.64, 95% CI 1.01-2.66, p = 0.046), and reported abnormal health indicators (OR 8.9, 95% CI 3.60-21.99, p < 0.001) more frequently than the usual care group. However, the two groups did not differ in rehospitalization (OR 0.78, 95% CI 0.36-1.66, p = 0.51) or mortality (hazard ratio 1.71, 0.68-4.28, p = 0.25). The positive impact of the mHealth intervention on self-management behaviors suggests that the intervention holds promise and warrants further testing.

Preventive intervention for living donor psychosocial outcomes: feasibility and efficacy in a randomized controlled trial.

There are no evidence-based interventions to prevent adverse psychosocial consequences after living donation. We conducted a single-site randomized controlled trial to examine the postdonation impact of a preventive intervention utilizing motivational interviewing (MI) to target a major risk factor for poor psychosocial outcomes, residual ambivalence (i.e. lingering hesitation and uncertainty) about donating. Of 184 prospective kidney or liver donors, 131 screened positive for ambivalence; 113 were randomized to (a) the MI intervention, (b) an active comparison condition (health education) or (c) standard care only before donation. Ambivalence was reassessed postintervention (before donation). Primary trial outcomes-psychosocial variables in somatic, psychological and family interpersonal relationship domains-were assessed at 6 weeks and 3 months postdonation. MI subjects showed the greatest decline in ambivalence (p = 0.050). On somatic outcomes, by 3 months postdonation MI subjects reported fewer physical symptoms (p = 0.038), lower rates of fatigue (p = 0.021) and pain (p = 0.016), shorter recovery times (p = 0.041) and fewer unexpected medical problems (p = 0.023). Among psychological and interpersonal outcomes, they had a lower rate of anxiety symptoms (p = 0.046) and fewer unexpected family-related problems (p = 0.045). They did not differ on depression, feelings about donation or family relationship quality. The findings suggest that the intervention merits testing in a larger, multisite trial.

Predictors and outcomes of health-related quality of life in caregivers of cardiothoracic transplant recipients.

Cardiothoracic transplant programs generally require that transplant recipients have family caregivers to assist them posttransplant. The burden of caregiving on the family members remains poorly understood. If caregivers' well-being is compromised by caregiving, it may bode poorly for transplant recipients' own health in the long-term posttransplant. We examined caregiver health-related quality of life (HRQOL) during the first year after their family member's transplant, its predictors and its relationship to subsequent patient survival. Adult (aged 18+) caregivers of 242 cardiothoracic transplant recipients (lung = 134; heart = 108) completed assessments of demographics, psychosocial characteristics and caregiver burden at 2 months posttransplant, and HRQOL at 2, 7 and 12 months posttransplant. Recipients' survival time was obtained from medical records. Caregiver HRQOL was generally high across the first-year posttransplant in emotional and social functioning; caregiver physical functioning significantly worsened. There were no differences by type of recipient transplant. Greater caregiver burden predicted poorer caregiver HRQOL in several physical domains at 12 months posttransplant. Transplant recipients whose caregivers had lower perceived general health at 12 months posttransplant showed poorer survival rates during the subsequent 7 years of follow up. Transplant teams should identify those caregivers at risk for poorer general health posttransplant to maximize positive outcomes for the entire family.

Cognitive and adaptive functioning after liver transplantation for maple syrup urine disease: a case series.

MSUD is a complex metabolic disorder that has been associated with central nervous system damage, developmental delays, and neurocognitive deficits. Although liver transplantation provides a metabolic cure for MSUD, changes in cognitive and adaptive functioning following transplantation have not been investigated. In this report, we present data from 14 patients who completed cognitive and adaptive functioning testing pre- and one yr and/or three yr post-liver transplantation. Findings show either no significant change (n=8) or improvement (n=5) in IQ scores pre- to post-liver transplantation. Greater variability was observed in adaptive functioning scores, but the majority of patients evidenced no significant change (n=8) in adaptive scores. In general, findings indicate that liver transplantation minimizes the likelihood of additional central nervous system damage, providing an opportunity for possible stabilization or improvement in neurocognitive functioning.

Rejection after organ transplantation: a historical review.

Progress toward understanding the biochemical basis of human individuality spans centuries, but tissue rejection remains the primary clinical challenge of organ transplantation. This article highlights the chronology of scientific discoveries made in the quest to overcome the rejection associated with transplantation. The purposes of this review are to raise clinicians' awareness of the advances in surgery, genetics, immunology, and immunosuppression that have contributed to the current knowledge of tissue rejection and to indicate potential new directions in this challenging field.

A database to describe the practice component of the CNS role.

The purpose of this paper is to describe the development of the database and its usefulness in describing clinical nurse specialist (CNS) practice, providing the CNS with clinical information about specific patients, and identifying patterns and trends about the care for the specialty patient population during a 3-month pilot period. The pilot revealed that the database, which included elements of clinical encounters between the CNS and patients, was useful in organizing clinical information about patients and the specialty population and in describing the nature of the CNS practice. It provided a quantitative description of the process of CNS functioning that, when combined with data about actions and outcomes, will allow relations to be drawn. The organizing framework of the database may be replicated by CNSs who are interested in describing the nature of their clinical practice.

Selective use of chest tubes in thoracotomies for congenital cardiovascular procedures.

BACKGROUND: Advantages and complications have been reported from the use of chest tubes (CT). To reduce the incidence of complications we have employed a selective use of CT in thoracotomy for congenital cardiovascular procedure; ie, in absence of air leaks and fluid to be drained, no CT was inserted. METHODS: The lung was reexpanded and air evacuated during the chest closure. Early and 6 hours chest roentgenograms were performed on every patient. This study retrospectively reviews the results of this selective approach in 546 patients operated on between 1980 and 1998 mainly for patent ductus arteriosum ligation, pulmonary artery band, aortic coarctation, Blalock-Taussig shunt. Four hundred and eighteen patients did not receive a CT at the initial surgery (group I), and 128 patients received a CT either before or at surgery (group II). RESULTS: 40 patients in group I developed an air or fluid collection large enough to require a CT. Only one patient had complication, from an undetected hemothorax. Nine patients in group II required another CT, and one patient developed a pneumothorax upon pulling out the CT. No death in either group was related to the use or lack of use of the CT. A total of 378 CTs and collecting chambers were saved. CONCLUSIONS: A selective approach to the use of CT in thoracotomies for cardiovascular procedures can be employed with minimal complications, more comfort for the patient, and cost savings.

Nursing assessment of patient readiness for ambulation after cardiac catheterization.

Although nurses routinely perform activities that prevent or detect vascular complications following a cardiac catheterization, determining patient readiness for ambulation has received minimal research attention. Educating nurses to determine patient readiness for ambulation is a safe and effective way to promote patient comfort.

Cognitive dissonance. 1: An overview of the literature and its integration into theory and practice in clinical psychology.

PURPOSE: Clinical psychology may not be making full use of the experimental psychological research available to it. The purpose of this article is to review the literature on cognitive dissonance in order to assess its usefulness in developing and deconstructing clinical psychological therapies and practice. METHODS: Experimental, theoretical and review articles were examined in relation to their possible clinical implications, and included in this review if they related to the arousal, maintenance and reduction of the state termed cognitive dissonance. Well replicated findings based on experimentally sound paradigms were integrated to produce an overall view of the evidence in favour of the existence of these processes, and of the principles behind them. RESULTS: It is concluded that there is an effect on attitudes and behaviour of creating inconsistency in individuals, and that this is not explained away by alternative theories, which in many cases refer to special conditions which maximally arouse dissonance. The dissonant state lasts for a few minutes, but its effects can last for up to two weeks, and might be reinstated by reintroducing the original inconsistency. Individuals can react to dissonance through a variety of cognitive alterations which reinstate consistency. The choice of response is a function of its salience and the difficulty in its execution. CONCLUSIONS: The literature supports the existence of the phenomenon termed cognitive dissonance, and one can distil the principles underlying its production, maintenance and reduction. This body of literature may provide insights into the conduct of therapy generally, as well as into the mechanisms of specific therapies which may guide modifications or development of alternative interventions.

Cognitive dissonance. 2: A theoretical grounding of motivational interviewing.

PURPOSE: The aim of this article is to demonstrate the utility of the concept of cognitive dissonance in clinical psychology by showing how it may underlie an existing intervention. The technique of motivational interviewing (MI) is taken as an example of an area where the literature on cognitive dissonance can find such an application. The further aim of this exercise is to utilize insights from cognitive dissonance to suggest possible modifications to the intervention as it currently stands. METHODS: A mapping is undertaken of principles of cognitive dissonance as found in Draycott & Dabbs (1998) onto the description of nature, principles and techniques of MI as set out by Miller & Rollnick (1991). Following this, areas where insights from cognitive dissonance are ignored or underutilized are drawn out and used to suggest modifications to MI. RESULTS: The nature, principles and techniques of MI are, without exception, found to relate to one or more of the principles of cognitive dissonance. Criticisms and amendments to the technique of MI can be offered with the aim of making this mapping of cognitive dissonance more exact. Several practical suggestions can be made and a more structured approach offered. CONCLUSIONS: The concept of cognitive dissonance can clearly be seen to be of use in understanding the mechanism of action of MI. It can further be of use in guiding modifications to this existing intervention. This concept, and others available through the experimental psychological literature, can be of use in all branches of clinical psychology.

Complications after placement of an intracoronary stent: nursing implications.

BACKGROUND: Care of patients after stent placement has evolved with the goal of reducing thrombosis and bleeding. Initially, all patients received full antithrombotic therapy; now most receive antiplatelet therapy only. Despite this evolution, no description of the differences in complications and nursing care with these two treatments has been published. OBJECTIVES: To determine the differences in complications and nursing care for patients receiving different pharmacological therapies after placement of an intracoronary stent. METHODS: A nonrandomized, noncontrolled, retrospective, comparative design was used with 176 sequential patients assigned to treatment groups on the basis of the adjunctive pharmacological therapy the patient received after placement of a stent. The equivalency of baseline characteristics and risk of complications, as well as the differences in length of stay, intensity of nursing care, and frequencies of bleeding and ischemic or thrombotic events were determined for the two groups: 65 patients who received anticoagulant therapy and 111 patients who received antiplatelet therapy. RESULTS: The two groups were equivalent with respect to baseline characteristics of sex, concomitant illness, and cardiac condition before stent placement. The two groups differed with respect to predisposing risks for bleeding and ischemic or thrombotic events. Patients receiving antiplatelet therapy alone had significantly shorter lengths of stay, less use of intensive care, fewer requirements for nursing care, and fewer bleeding complications, with no increase in ischemic or thrombotic events. CONCLUSIONS: Patients receiving anticoagulant therapy had more complications and required a higher intensity of nursing care than did patients who received antiplatelet therapy alone.

Pulmonary edema associated with the treatment of preterm labor: what critical care nurses need to know.

Knowledge of the physiologic changes, conditions, and therapies of pregnancy that increase the risk of pulmonary edema enables nurses to influence the outcome of their patients who develop medical complications while undergoing tocolytic therapy. Cooperation between perinatal and critical care nurses ensures optimal care of both the mother and the fetus.

Serial angiographic appearance of healing dissection after balloon angioplasty.

In this report we describe the case of a patient with a significant coronary artery dissection following percutaneous transluminal coronary angioplasty (PTCA) in whom serial coronary arteriograms were obtained over a 6-week period. These demonstrated healing of the dissected vessel and correlated with abatement of the patient's angina.

The relationship between well-being and job satisfaction for staff working on long stay wards for the elderly confused.

The psychological well-being and job satisfaction of nursing staff working on long stay wards for the elderly confused were examined in one health district. Feelings of well-being were not related to job satisfaction. However, feelings of unhappiness were found to be related to job dissatisfaction, this relationship was found in the ward managers (predominantly males) and not other qualified or unqualified staff. The implications of this finding are discussed.

The new alternatives to intubation.

Noninvasive positive-pressure ventilation devices are brightening prospects for a diverse group of patients--and placing new demands on nurses. Here's how to work with them.