Health care professionals' attitudes about obesity: an integrative review.

Stigma and discrimination against obese people are common and related to individual attitudes about obesity. Despite a robust field of study on attitudes related to obesity, no integrative review of health providers' beliefs exist. Fifteen studies (1990-2007) on various health care providers are examined along with practice implications. Analysis indicates that attitudes toward overweight patients, although primarily still negative, have improved over time. Findings indicate that care dispensed to obese patients is not as likely to be affected by health care providers' attitudes as in the past. Implications include the need for additional research, awareness education, and practice guidelines.

Psychosocial factors and health perceptions in parents and children who are overweight or obese.

This study examined the relationships among weight status (BMI), health perceptions, and psychosocial characteristics in children, parents, and parent-child dyads. A convenient sample of 114 parent-child dyads participated. All children were overweight or obese. Parents and children completed questionnaires by self-report or interview. Questionnaires included the Parenting Stress Index-Short Form (PSI), the Parents' Stage of Change (SOC) Questionnaire, and the Pediatric Quality of Life Inventory (PedsQL). Child's mean age was 10.34 years (s.d. = 1.87), mean BMI was 28.13 kg/m(2) (s.d. = 5.46), and mean BMI z-score was 2.17 (s.d. = 0.38). Parent mean age was 37.28 years (s.d. = 12.66) and mean BMI was 34.07 kg/m(2) (s.d. = 8.18). Most parents (68.5%) reported that they and their children (70.7%) were African American and many (44.3%) reported that they and their children were Hispanic. Significant correlations included: child health perceptions and child BMI (r = 0.309, P < 0.001) and parent perception of weight and parent BMI (r = 0.691, P < 0.001). For parent-child dyads, one correlation approached significance (child health perceptions and parent stage of change (r = -0.269, P < 0.01). Findings suggest that characteristics of parent-child dyads may be important considerations in the management of childhood obesity.

Arterial-venous fistulas following pediatric liver transplant case studies.

AV fistula is a rare but serious complication following pediatric liver transplant and may lead to graft loss. Our aim was to describe two pediatric centers' experience with the diagnosis, treatment and outcomes of children who presented with AV fistulas post-liver transplantation We report five cases of late arterio-portal fistula following liver transplantation. Four children were successfully treated with coil embolization. All of the children in this series had liver biopsies within 2-6 months of their AV fistula diagnosis. All biopsies were performed using a Bard Monopty 18 gauge needle with no ultrasound guidance and only one pass per biopsy. Two children also had PTC 4-8 months prior to their diagnosis of AV fistula. Three of the five children in this series had GI bleeds requiring banding or sclerotherapy. The other two had varices found on CT scan. All five cases in this series had ascites on their initial presentation. Four out of the five children had a history of non-compliance and the other child had a history of malabsorption and chronic diarrhea.

The standardized patient experience in undergraduate nursing education.

Drexel University College of Nursing and Health Professions was the first Undergraduate Nursing Program to incorporate the Standardized Patient Experience as a requirement for the completion of the Undergraduate Nursing Degree. This requirement has resulted in positive student outcomes and increased student satisfaction.

Liver transplantation as definitive treatment for a factor V Leiden mutation.

Liver transplantation (LT) was achieved for factor V Leiden-induced thrombophilia in a neonate with hepatic veno-occlusive disease. Initial LT was performed with a liver segment removed from a child with primary oxalosis. Four months later, a second, definitive LT was performed. The child remains well without recurrent thrombosis.

Improvement in renal function and rejection control in pediatric liver transplant recipients with the introduction of sirolimus.

Calcineurin inhibitors have dramatically improved the outcomes of pediatric liver transplantation. However, calcineurin inhibitor use is associated with a 50% reduction in glomerular filtration rate in the first year post-transplant. Nephrotoxicity can be difficult to manage, especially in the pediatric population. We hypothesized that the addition of an mTOR inhibitor with decreased calcineurin inhibitor levels might improve or prevent renal insufficiency and improve control of rejection. A retrospective chart review was performed on the patients treated with sirolimus who had undergone an orthotopic liver transplant between January 2000 and February 2003. Thirty-eight patients were identified. Mean age was 8.6 yr. Fourteen patients were male and 24 were female. Mean weight was 30.3 kg. The most common indications for starting sirolimus were rejection (42%) and renal impairment (29%). Seventy-three percent of patients begun on sirolimus remain on the medication. Those with renal impairment (11 patients) showed improvement in their creatinine levels from a mean baseline of 1.3 to 0.8 mg/dL. Their calculated creatinine clearance (Schwartz formula) improved from 63.7 to 84.8 mL/min (p = 0.03). Patients started on sirolimus for rejection showed significant improvement in hepatocellular enzymes despite a reduction in the tacrolimus level from 12.2 to 7.5 ng/mL. The mean alanine aminotransferase level improved from 221 to 100 units/L (p = 0.02), and the mean aspartate aminotransferase improved from 121 to 99 units/L (p = 0.59). Addition of sirolimus to a tacrolimus-based regimen with lower target tacrolimus levels improved liver function in patients with rejection. Addition of sirolimus significantly improved renal function as shown by creatinine level and calculated creatinine clearance in those children with renal impairment. The effect of combined immunosuppressant treatment with tacrolimus and sirolimus on long-term renal function needs to be evaluated.

Non-compliance in children post-liver transplant. Who are the culprits?

Although non-compliance in pediatric liver transplants is known to be a major cause of late graft loss and patient mortality, follow-up seems inconsistent. As liver transplant becomes a luxury because of the shortage of organs, the need to maximize graft and patient survival by intense monitoring becomes a necessity. When evaluating children with elevated liver enzymes post-transplant, early or late non-compliance should always be suspected. The risk of non-compliance in children with chronic illness varies from 10 to 89%. In a study by Sudan et al. non-compliance was one of the leading causes of late mortality in children age 10-17 yr. Although it is well documented that teenagers have a high rate of non-compliance, the rate in the younger children has not been documented. In our series, we found that parental non-compliance comprises the majority of our problems with liver dysfunction, hospitalization, and graft loss. The purpose of this study was to evaluate the incidence of non-compliance in children post-liver transplant. A retrospective chart review of patient records from admissions and outpatient records was performed for documentation of elevated enzymes and low immunosuppressive levels. From July 1987 to December 2002, our program performed 266 liver transplants in 234 children, with 1-yr graft survival of 84% and 1-yr patient survival of 90%. Our overall patient survival was 85% with 77% graft survival. There were 40 children with documented non-compliance with mild to severe liver dysfunction in this study. Twenty-eight of these children were younger than 10 yr [28 of 40 (46%) <5 yr], and 12 (30%) were older than 10 yr at the time of rejection. In 10 of 40 children, there was one documented incident of non-compliance, while 26 of 40 had two to four incidents, and four had five or more documented events. Our children (50%) came from two-parent households. The remaining 50% were from single households. In 27 of 40 (68%) children, rejection was confirmed by liver biopsy. In children on cyclosporine (Neoral; Novartis, East Hanover, NJ, USA) with a known history of non-compliance and low immunosuppressive levels, C2 monitoring was performed to verify absorption. Admission for drug monitoring and verification of non-compliance was accomplished in 32 of 40 (80%). Four of the 40 children (10%) were retransplanted, and one child had died. In conclusion, non-adherence to medications remains a major source of graft loss and morbidity post-transplant. We found that non-compliance crosses all socio-economic and cultural groups and that flexibility of clinic hours, shortened time between visits, and decreased numbers and times of medication will increase adherence.

Domino as a bridge to definitive liver transplantation in a neonate.

An interim liver transplant was used to extend survival in a neonate. This was accomplished by the initial transplant of a left-lateral segment of a metabolically abnormal liver obtained from a 7-yr-old patient with primary oxalosis. This bridging strategy was required because our neonatal patient was dying of fulminant hepatic failure caused by hepatic vein thrombosis and a small liver or liver segment could not be found. Although problems with hyperoxaluria were encountered in the neonate post-transplant, the interim liver transplant enabled the baby to survive and grow until the age of 4 months. At that time, a definitive transplant was performed using the left-lateral segment of his mother's liver. This case represents the first reported use of a pediatric domino transplant where a metabolically abnormal liver was used to allow sufficient growth to permit a definitive liver transplantation.