Living donor psychosocial assesment/follow-up practices in the partners' countries of the ELIPSY project.

BACKGROUND: Living donor (LD) transplantation has increased recently, but psychosocial aspects of living donation have not been well characterized, as risk factors for the donors. ELIPSY is a project confunded by EAHC, seeking to develop a common methodology for all EU countries for LD assessment/follow-up in the psychosocial sphere (www.eulivingdonor.eu). OBJECTIVE: To evaluate current psychosocial LD assessment/follow-up practices among European centers for key aspects and differences between kidney and liver programs. METHODS: Within a timeline of 30 months, this phase of the project sought to identify current LD psychosocial assessment/follow-up practices. The final survey concerned two versions focused on the kidney and on liver transplant program. The survey took place in ELIPSY partner centers under their own responsibility. Each of the centers sent the survey to other ones performing LD in their country. Partners in the EULID project includes ones in the United Kingdom, Poland, and Romania. The results were analyzed separately for each program seeking to compare and define differences among them. RESULTS: The survey took place in 10 European countries including 65 centers with LD programs. Positive answers regarding psychosocial assessment/follow-up practices were obtained for 26 (42%) kidney and nine (38%) liver centers. Some centers perform several psychosocial follow-ups but did not explain their tools, whereas the centers that did explain the tools used the same ones for both programs.

Psychological evaluation of living liver donors--a single centre experience.

The psychological evaluation of living liver donors is a substantial part of the preoperative evaluation of donors in many transplantation centres around the globe and aims at securing decision autonomy and informed consent, verifying the psychological stability of the donor and ruling out psychosocial risks. The aims of this paper are to present a short overview of the current state of the psychosocial evaluation of living donors based on the existing literature and to discuss our centre's experience in the psychological evaluation of donors, the lessons we have learned in the past 10 years and an agenda for the future evaluation of donors and research.

A model of risk and protective factors influencing the postoperative course of living liver donors.

Living donor liver transplantation is increasing as an effort to overcome the organ shortage for patients with terminal liver diseases. To maintain high medical and ethical standards, donors are evaluated before and after donation to assess their suitability, monitor their postoperative courses, and minimize risks. A psychological/psychosocial evaluation is included in the assessment at most transplantation centers. Due to the high risk and the challenging process of recovery and integration of the experience into one's life, it is important to identify donors with suitable psychological/psychosocial profiles. The psychosocial evaluation is performed on the basis of medical ethical standards, common sense, professional experience, and only a few systematic observations. Some studies have identified factors, such as complications for the recipient, as a possible influence on the donor's postoperative course, while others have sought to link donor outcomes with scores on psychometric instruments prior to donation. We suggest that it is not one, but the interplay of several factors that affects the donor's postoperative course, including decision autonomy and embedding the donation into a meaningful context, in addition to coping skills and recipient outcome. Based on pilot data, clinical observations, and a study of the literature, we developed a model of risk and protective factors influencing the donors' postoperative courses, which could be used to assess living liver donors psychosocially before and after donation, thus enhancing selection and support.

Living donor liver transplantation and its effect on the donor-recipient relationship--a qualitative interview study with donors.

An important aspect in the preoperative evaluation and a legal precondition for an living donor liver transplantation (LDLT) is a family or emotionally close relationship between donor and recipient. We investigated the development of the donor-recipient relationship after LDLT. We conducted semi-structured clinical interviews with 18 donors as part of a regular postoperative follow-up and analyzed them using the method of Grounded Theory. The donation does not lead to any major changes in the donor-recipient relationship, probably due to careful pre-selection. It does however enhance the existing positive or conflicting character of the relationship. Donors sometimes downplay negative aspects in the relationship and emphasize the improvement as a way of dealing with a major life event. A donation cannot fulfill expectations linked to it and it is unfavorable to be used to improve the relationship. Potential misuse or instrumentalization of the donation by the donor are possible. Postoperative feelings of gratitude are an issue after surgery. A good relationship enhances a better management of the postoperative course. The preoperative donor-recipient relationship should be as free of conflict as possible. A thorough preoperative evaluation of the donor-recipient relationship is particularly important to assess the donors' suitability and clarify conflicts and unrealistic expectations.

Deterioration of long-term results following high tibial osteotomy in patients under 60 years of age.

We have investigated, in a prospective study, the outcome of a valgus osteotomy of the tibia in patients less than 60 years of age with arthrosis of the medial compartment and a varus angle of no more than 177.7 degrees . Included in the study were 44 high tibial osteotomies (HTO) performed in 42 patients from 1981 until 1996. There were 35 females (2 bilateral) and 7 males, with an average age of 51 years (range: 30-60 years). Only patients in the first three grades, according to Ahlback's classification, were included. During a mean follow-up period of 10 years (range: 5-17 years), all but 2 patients experienced pain relief. The average loss of postoperative correction at 10 years was 2.4 degrees . The average postoperative Hospital for Special Surgery Knee Rating System score (HSSK) for patients with excellent or good results was 83.5 points. Survivorship analysis showed a success rate of 80% and 66% at 10 and 15 years respectively, and over 52.8% at 17 years of follow-up. HTO results in redistribution of the main stresses towards normal levels, although normal values are never attained. This is probably the reason why patients experienced good results only in the medium term.

[Psychological and somatic aspects of living liver donors: preoperative assessment and postoperative course]. / Psychische und somatische Aspekte der Leberlebendspende: Präoperative Evaluation und postoperativer Verlauf.

BACKGROUND AND OBJECTIVE: Living donor liver transplantation (LDLT) has been gaining importance in the treatment of end-stage liver disease in adults as a partial solution to the growing organ shortage. Thus far, only few empirical studies have been published on the situation of donors who are faced with the risk of medical complications after resection of the right hepatic lobe. PATIENTS AND METHODS: 87 potential donors were preoperatively assessed in the years 2000 and 2001 at the Charité Berlin. 41 potential donors were excluded, 46 donors (31 women, 15 men, mean age 41 [19 - 67] years) underwent liver surgery and were re-assessed 6 months after the operation. The frequency of postoperative complications and the course of psychosocial parameters were investigated. Donors' moods were analysed with the Berlin Mood Questionnaire, the physical complaints were assessed with the Giessen Complaint Questionnaire. The preoperative interviews of 20 potential donors were analysed according the current social qualitative research methods. RESULTS: In 11 % (n = 10) of potential donors transplantation was not recommended for psychosocial reasons because they showed a marked ambivalence towards the operation. After operation, 22 % (n = 12) of donors had postoperative complications. Most relevant single causes of severe impairment were temporary and reversible biliary leakages from the cutting edge. There were no long- term complications. 26 % (n = 10) of donors showed postoperative high values for anxious depression and physical complaints. CONCLUSIONS: The resection of the right hepatic lobe holds promise of a good psychosocial outcome for most donors, irrespective of donation-related complications. The psychosocial impairment and physical complaints of some donors after transplantation are yet not clearly understood. Further psychosocial studies will be necessary to develop criteria for an evidence based medical care of living donors.

Willingness to donate: an interview study before liver transplantation.

OBJECTIVES: The introduction of the living donation in organ transplantation introduces important new psychological conflicts and ethical questions in the transplantation process. Operation related risks, as well as dependencies in the family structure, generate considerable pressure on potential donors. The aim of the study was to reconstruct the determinants of willingness to donate before transplantation. METHODS: Evaluation of 20 taped and transcribed interviews oriented to current approaches in qualitative interview research. The approach used is based on grounded theory, qualitative content analysis, and the concept of the ideal type. RESULTS: Before surgery, "openly motivated" donors push for an operation, leaving no room for ambivalence in the evaluation process. They idealise the relationship with the recipient, and link their donation with the individual-partly in subconscious expectations and wishes. In contrast, "openly ambivalent" donors formulate their anxieties and express arguments against donation. CONCLUSIONS: Statements that claim ambivalence towards donation or utterance of arguments against donation indicate earlier coercion. Before transplantation, potential donors should have the opportunity to discuss their emotional situation to help their decision making process.

Quality of life of living donors before and after living donor liver transplantation.

Living donor liver transplantation (LDLT) is becoming an established method for treatment of terminal liver disease in adults. After resection of the right hepatic lobe, postoperative complications can arise in healthy donors, and even individual cases of death have been recorded. There remains, however, little research on the psychosocial aspects in living donors before and after LDLT. Using the WHOQOL questionnaire, this prospective study investigates the quality of life (QoL) in a sample of 28 living donors, including the relationship between postoperative complications and QoL before and 6 months after donation. Before LDLT, the donor QoL is high, above that of the general healthy population. After LDLT, a significant reduction in the QoL appears in the areas of "physical health" and "living conditions." Nevertheless, the QoL remains above the level of the general population. Only two donors showed general QoL values below those of the general population. The postoperative complications had no significant influence on the QoL after transplantation. The high QoL of donors following LDLT indicates a positive psychosocial outcome for the majority of donors, irrespective of donation-related complications. Additional psychosocial studies will be necessary to disclose predictors for an unfavorable psychosocial outcome following LDLT.

A case of hypersensitivity to thyroid hormones with normally functioning thyroid gland and increased nuclear triiodothyronine receptors.

A 52-year-old male presented himself with tachycardia crises which appeared first during childhood, increased in frequency without goiter or exophthalmos. Cardiac and adrenergic diseases were excluded. The thyroid function was normal regarding T4, free T4 and T3, TBG, radioiodine uptake, TSH and T3 suppressibility; however the TSH response to TRH was decreased. The lymphocyte nuclear T3 receptor was found with an affinity close to that of normal volunteers (Ka: 1.42 x 10(10) M-1 vs 1.95 +/- 0.35 x 10(10) M-1) and a binding capacity markedly increased (9.9 vs 3.7 +/- 0.4 fmol T3/100 micrograms DNA). Pindolol was inefficient on the dysrhythmia which disappeared with carbimazole and relapsed after withdrawal of the antithyroid drug. Under carbimazole, the plasma T4 markedly decreased (27.7 +/- 3.6 nmol/l) but the patient remained euthyroid. The clinical course and the laboratory data suggest that the tachycardia crises are the consequence of a hypersensitivity of the heart to thyroid hormones, associated with an increased number of T3 nuclear receptor sites in lymphocytes.

Aqueous humor penetration of ciprofloxacin in the human eye.

Two doses of ciprofloxacin were administered intravenously, 200 mg every 12 hours, to 25 patients undergoing cataract surgery. Plasma and aqueous humor were obtained at 1, 3, 5, 7, and 9 hours after the administration of the second dose of the drug. Peak intraocular concentrations (mean +/- SD), 0.21 +/- 0.1 mg/L, were detected at one hour following ciprofloxacin administration. A time-dependent decrease of the penetration was observed, and by nine hours after the administration, ciprofloxacin levels were 0.05 mg/L. These results illustrate that ciprofloxacin may be an effective antimicrobial agent for prophylactic use in ophthalmologic surgery and also for the treatment of intraocular infections due to susceptible organisms.

[Value of triiodothyroacetic acid as suppressive treatment of the thyrotropin secretion in thyroid pathology]. / Intérêt de l'acide triiodothyroacétique comme traitement freinateur de la sécrétion thyréotrope en pathologie thyroïdienne.

Fifty-six patients were treated with triiodothyroacetic acid (TRIAC) for its suppressive effect on the pituitary-thyroid function. Thirty of these patients had undergone partial thyroidectomy for benign goitre, and among these 14 had developed hyperplasia of the remaining thyroid tissue (group I); 18 presented with homogeneous or nodular goitre (group II); 8 had been thyroidectomized for carcinoma (group III). Before TRIAC was prescribed, thyroid hormones had been used in 33 patients, exerting a suppressive effect on the thyrotropic hormone in 4 patients of group III and producing signs of intolerance in 24 cases. TRIAC was administered in doses of 700-1,750 micrograms/day to all patients of group I and II, and combined with LT4 100 micrograms/day to group III patients. Suppression of the thyrotropic secretion was obtained in all group III patients and in 88 p. 100 of groups I and II patients. Thyroid gland hypertrophy regressed or disappeared in 21 patients of groups I and II, and no relapse or metastasis was observed in group III. TRIAC was well tolerated in all but one patients.

Thyroid stimulating antibody: an index of thyroid stimulation in Graves' disease?

Early (20 min) thyroid radio-iodine uptake (ERU) and thyroid-stimulating antibodies (TSab) were determined in 27 untreated unselected patients with Graves' disease at the time of diagnosis. In 21 subjects the same tests were further performed in parallel during combined carbimazole-L-T3 therapy (mean duration of follow-up: 10.8 +/- 5.8 months; mean +/- SD). TSab was determined by a cAMP-human thyrocyte culture stimulation assay and expressed in microliter-equivalent of a TSab standard/ml (microliter-eq/ml). Before treatment, ERU, ranging from 15 to 54% of the injected dose (normal less than or equal to 8% dose) correlated with serum T3 (r: 0.54; P less than 0.01); TSab, ranging from 6 to 85 microliter-eq/ml was detected in 21/27 patients. There was a significant correlation between ERU and TSab (Spearman rank test: r: 0.57; P less than 0.01). During the first months of treatment, 5 of the 21 patients sequentially studied had undetectable TSab levels throughout the study and in these patients ERU decreased by 57% of its initial value; the remaining 16 subjects were divided into two groups according to ERU changes: in group A (9 patients), initial ERU decreased by 50% or more or the absolute value became less than 20% of the dose and TSab decreased from 10.9 +/- 4.8 microliter-eq/ml to 5.3 +/- 1.6 microliter-eq/ml (P less than 0.01); in group B (7 patients), the fall of ERU was less than 50% or the absolute value remained greater than 20% of the dose and TSab values remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Are pituitary and thyroid function tests useful for the monitoring of antithyroid drug treatment and the post therapeutic control of Graves' disease?

The control of Graves' disease patients treated with antithyroid drugs (ATD) involves monitoring the dose of ATD, the duration of therapy and the prediction of the long-term outcome of the disease. The sequential follow-up of free thyroid hormones and ultrasensitive TSH (USTSH) helps in monitoring of ATD therapy, except in patients complemented with thyroid hormones. The normalization of early thyroid uptake of radioiodine or pertechnetate, which seems to be closely related to circulating thyroid-stimulating immunoglobulins, confirms the remission that leads to stopping ATD therapy. The raise of plasma USTSH in a normal range within the six months following ATD withdrawal is another indicator of remission. However, the post therapeutic course of Graves' patients remains unpredictable: late relapses and hypothyroidism may occur despite the normalization of the pituitary-thyroid axis, leading to a yearly clinical control with USTSH evaluation.

T3 kinetics in euthyroid Graves' disease patients who exhibit hyper-responsiveness to TRH after radioiodine treatment.

A major reduction in T3 turnover has been demonstrated previously in clinically hypothyroid patients. We have used non-compartmental (NC) and monocompartmental (MC) analysis to study ten patients with Graves' disease who, following treatment with radioactive iodine (RAI), are now clinically euthyroid but who showed hyper-responsiveness to TRH although serum T3 and T4 concentrations are within the normal range. T3 production rate (PR), metabolic clearance rate (MRC) and fractional-turnover (K) were all significantly reduced in patients compared with seven controls (P less than 0.01). T3, MCR and PR were consistently higher, and T3 K lower, when calculated by MC, than values calculated by NC analysis. The difference in T3 production rates between patients (mean 16.6 nmol/day) and controls (mean 38.9 nmol/day) raises the question of replacement therapy in patients who are apparently euthyroid but TRH hyper-responsive.

[The treatment of Graves' disease with antithyroid drugs and small doses of radioiodine (author's transl)]. / Traitement de la maladie de Basedow par l'association de faibles doses d'iode radioactif et d'antithyroïdiens de synthèse. A propose de 330 cas aven un recul de 20 ans.

Three hundred and thirty Graves' disease patients (258 F. 72 M. ; mean age = 50 +/- 07 years) were treated by 131I from 1961 to 1979 ; 57 % had a goiter and 32 % had exophthalmos. One or several doses of radioiodine were given to each patient without dosimetry. The mean total dose (+/- SEM) was = 8,51 +/- 0,44 mCi and the mean for the first dose 4,34 +/- 4 ans 54,8 % of the patients received only one dose but 10,3 % of them had more than 3 doses. Data obtained by actuarial methods showed 66 % of the cases to be in remission in less than 2 years ; the frequency of hypothyroidism increased steadily by 3 % every year to give 15 % at 5 years and 30 % at 10 years. Remission was slower to occur in goitrous subjects and hypothyroidism was less frequent in this group despite doses significantly higher of radioiodine (p less than 0,001). Recovery was also slower among exophthalmos patients. Finally, the mean 3-hour radioiodine uptake and plasma T3 level were significantly lower six months after the first therapeutic dose among those who were cured of thier hyperthyroidism within two years.

The TRG Test. Which is the best index of TSH release?.

Prolonged (two hours) TRH tests were performed on 29 controls and 182 thyrotoxicosis patients of varying thyroid status after treatment with radioiodine. The object was to find which of the simple measurements of TSH from the TRH test most faithfully reflected the total amount of TSH (TTSH) released in response to the TRH. The simple indices compared were the absolute levels of TSH (ATSH) achieved at intervals during the test, and the increments in TSH (delta TSH) recorded at the same points in time. TTSH was measured by planimetry of the area beneath the response curve. Patients were classified as normo-responders, hyper-responders or hypo-responders according to normal limits for TTSH deduced from the controls. When each simple index of TSH response was substituted in turn for TTSH, the overall frequency of misclassification was considerably greater for ATSH than for delta TSH. This was largely due to the wide variability of passive or basal TSH secretion, which seriously confused the distinction between normally-responsive and hypo-responsive patients when ATSH was used. The delta TSH measured at 30 minutes gave the best overall results in terms of least classification error and closest correlation with TTSH.

Short and long term effects of radioiodine and antithyroid drugs on T4 binding proteins, free T4 and T3, during Graves' disease therapy.

Ninety five patients with Graves' disease were studied before and at three months intervals after antithyroid drugs (ATD) (31 cases) or radioiodine (64 cases) therapy until recovery. Before treatment, the T4 maxima binding capacity of TBPA was significantly decreased 253.5 +/- 11.4 mug/100 ml)(mean + se) (control values: 287 +/- 10.4 mug/100 ml) (alpha = 0.04), especially in 53.7% of patients (m = 177 +/- 8 mug/100 ml). The mean of TBG (m = 20.7 +/- 0.9 mug/100 ml) was not different from euthyroid subjects (m = 19.7 +/- 1.7 mug/100 ml) except in 51.2% of patients who had a low TBG (m = 14.3 +/- 1.1 mug/100 ml). An inverse linear correlation was found between TBG-DFT4 (alpha = 0.05) and DF T 3 (alpha = 0.002), TBPA-log DF T4 (alpha = 0.05) but not between TBG and TBPA. The physiological relationship between DFT3, DFT4, TT3, TBG and TBPA was studied in vitro; after adding increased quantities of T4 to a pool of sera collected from eu, hypo or hyperthyroid patients, DFT4, DFT3, FT3 index increased in linear positive relationship with TT4 concentrations, the kinetic of this phenomena was inversely correlated with T4 maximal binding capacity of TBG or TBPA for T4. Addition of T3 to the same sera did not show any effect on the previous parameters. DFT3 depended on the level of T4 in serum more than T3 concentration and was in inverse relationship with the maximal binding capacity of TBG. This data might explain the paradoxal normal or slightly increased values of DFT3 found in T3 thyrotoxicosis. In patients treated with ATD or radioiodine, TBPA but not TBG increased significantly on year after. However, in subjects with an initial very low TGB or TBPA, this phenomenon occurred on the third month after radioiodine or ATD. During the same period, DF T4 and DF T3 were inversely correlated to TBG and TBPA. In conclusion, important changes in T4 binding proteins and free fractions of thyroid hormones were observed in Graves' disease but were corrected by antithyroid therapy. All these data were in good agreement with the normalisation of thyroid function.