A. DeVito Dabbs

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.

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

Shellmer DA, DeVito Dabbs A, Dew MA, Noll RB, Feldman H, Strauss KA, Morton DH, Vockley J, Mazariegos GV. Cognitive and adaptive functioning after liver transplantation for maple syrup urine disease: A case series.
Pediatr Transplantation 2011: 15:58–64.

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.

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 members 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.

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 PATHs 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.

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 ones 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.

Psychosocial factors, physical symptoms and physical function after lung transplantation

Relationships between psychosocial factors, physical symptoms, and physical function were explored in 50 lung transplant recipients (LTR) to determine whether psychosocial factors rendered LTR vulnerable to increased physical symptoms or functional impairment. Structured assessments were conducted to evaluate personal and family psychiatric history, post-transplant psychiatric distress (SCL-90 anxiety and depression symptoms), selfesteem, sense of mastery, and coping strategies, as well as current physical symptoms and physical functional impairment. Psychological distress, symptoms, and physical impairment were common. The percentage of cohort with each characteristic was: family (31%) and personal psychiatric histories (47%); high anxiety (39%), high depression (36%), low self-esteem (46%), low mastery (52%); low active cognitive (39%), low active behavioral (28%) and high avoidance coping (26%). Pre-transplant psychiatric history increased risk for post-transplant anxiety (r .38) and depression (r .38) and these correlated with physical symptoms (r .54-.65) and impairment (r .49-.51). Anxiety and depression exceeded non-patient norms, and lung recipients had higher depression, symptoms and impairment (p .05) than heart/lung. Low mastery correlated with high physical impairment (r .36). Mean physical impairment scores (16. 23.8) were comparable to other pulmonary populations, including transplant candidates, but were higher than other samples of LTR 3 months post-transplant. Mean physical symptom scores (16.8 5) were higher, but endorsed items were comparable to other LTR samples. Anxiety and depression correlated with symptoms and impairment and symptoms correlated with impairment (r .60). Psychosocial factors explained variance in physical symptoms (R .646) and impairment (R .545). Directions of influence between correlates need to be examined. Interventions to reduce psychological distress need to be developed.