Anne Eshelman

Mental health affects the quality of life and recovery after liver transplantation

There has been little research examining the effects of mental health before liver transplantation on quality of life (QOL) and recovery after transplantation. Therefore, the purpose of the current study was to examine how pretransplant depression and anxiety affect mental health, QOL, and recovery after transplantation. Eighty‐two transplant recipients provided data when they were listed for transplantation and 6 months after transplantation. Pretransplant anxiety predicted posttransplant anxiety (P < 0.001), and there was a trend in predicting posttransplant depression (P = 0.06). Pretransplant depression predicted posttransplant depression (P = 0.03), and there was a trend in predicting posttransplant anxiety (P = 0.06). Additionally, pretransplant anxiety predicted posttransplant QOL for several domains, including Body Pain, Role Limitations Due to Emotional Problems, and Mental Health, as well as the Mental Health Composite Score (P < 0.05). However, in comparison with anxiety, pretransplant depression independently predicted outcomes for more QOL domains, which included Physical Functioning, Role Limitations Due to Physical Problems, General Health, Vitality, and Social Functioning, as well as the Physical Composite Score (P < 0.05). Patients with depression at the baseline were more likely to report incomplete recovery 6 months after transplantation (P < 0.001). With respect to baseline anxiety, there was a trend suggesting that these patients were also more likely to report incomplete recovery (P = 0.09). These findings highlight the importance of evaluating transplant candidates both before and after transplantation for anxiety and depressive symptoms. Once patients with these symptoms are identified, they can be referred for treatment, which may lead to better posttransplant outcomes for mental health, QOL, and recovery. Liver Transpl 19:1272–1278, 2013.

Determinants of Burnout Among Transplant Surgeons: A National Survey in the United States

Burnout is a response to chronic strain within the workplace characterized by feelings of inefficacy (reduced personal accomplishment), cynicism (depersonalization) and emotional exhaustion. The purpose of this study was to report prevalence and explore organizational and interpersonal contributors of burnout in transplant surgeons. We performed a national cross‐sectional survey of 218 transplant surgeons on sociodemographics, professional characteristics, frequency of difficult patient interactions and comfort in dealing with difficult patient interactions, decisional authority, psychological job demands, supervisor and coworker support, with burnout as the outcome. 40.1% reported high levels of emotional exhaustion, 17.1% reported high levels of depersonalization and 46.5% reported low personal accomplishment. Greater emotional exhaustion was predicted by lower decisional authority, higher psychological work demands, and lower coworker support. Greater discomfort with difficult patient interactions and lower coworker support predicted depersonalization. Lastly, lower decisional authority, lower coworker support, less frequent difficult patient interactions but greater discomfort with difficult patient interactions predicted lower personal accomplishment. The findings of this study show that unsupportive environments with little decisional control and high work‐related demands contribute to the development of burnout in transplant surgeons. Implications for interventions aimed at prevention of burnout in transplant surgeons are discussed.

Health literacy in patients referred for transplant: do patients have the capacity to understand?

Adequate levels of health literacy are needed for transplant recipients to be able to understand and comply with medical recommendations. However, little is known about health literacy among transplant candidates. Therefore, the purpose of this study was to examine the levels of health literacy and cognitive functioning among patients being evaluated for various types of transplantation. There were 398 patients who completed a required psychological evaluation prior to being listed for transplant. This included a screen for cognitive impairment and limited reading and math ability. The prevalence of limited reading ability was 27.5%, limited math ability was 42.8%, and 30.7% had probable cognitive impairment. Rates of limited reading and math ability and cognitive impairment varied for each type of end‐stage disease. Limited reading ability was related to poorer cognitive functioning. Those with a higher likelihood of limited reading ability included blacks and males. Those more likely to have cognitive impairment included blacks and patients who are older. Results from this study suggest that patients should be regularly screened for health literacy and cognitive impairment. Once patients with difficulties are identified, recommendations can be provided to these patients at a level that they are able to understand.

The influence of alcohol abuse history on the differential, longitudinal patterns of mental and physical quality of life following liver transplantation

This prospective, longitudinal study investigated change in physical and mental health quality of life (QoL) in a sample of 65 end-stage liver disease patients before and after liver transplantation. Physical and mental health QoL were assessed using the SF-36 Physical Health Summary and Mental Health Summary, respectively. Baseline data were collected prior to transplant and follow-up data were collected at 1 and 6 months after transplantation. Repeated-measures analysis of variance results indicate that physical QoL did not improve significantly between baseline and 1-month follow-up (F = .031, P = .860) but did between 1- and 6-month follow-up (F = 20.873, P < .001). Significant between-subject effects suggested attenuated improvement for patients with alcohol abuse histories (F = 6.213, P = .017). Physical QoL did not improve between 1- and 6-month follow-up for patients with alcohol abuse history (t((13)) = -1.074, P = .112). By contrast, mental health QoL improved significantly between baseline and 1-month follow-up (F = 13.840, P < .001), but not between 1- and 6-month follow-up (F = .750, P = .391). No significant differences were found on the Mental Health Summary index based on alcohol abuse history for either time period. Post hoc multivariate analysis of variance results suggested worse functioning (F = 2.674, P = .013) for individuals with alcohol abuse history on SF-36 Physical Functioning (F = 5.55, P = .021), Body Pain (F = 13.578, P < .001), Vitality (F = 4.337, P = .040), and Social Functioning (F = 10.50, P = .002) subscales. For liver transplant patients, improvements in psychosocial functioning and QoL precede improvements in physical QoL. Attenuated physical QoL improvements for patients with alcohol abuse histories are related to greater pain and physical deficits.

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.

When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain

Chronic pelvic pain (CPP) is related to psychological distress and interference in daily activities; however, CPP is not as extensively researched as other forms of chronic pain. Therefore, the purpose of this study was to investigate the relationships among pain, psychological distress, and functional impairment in patients with CPP. There were chart reviews conducted of 107 female patients who completed a psychiatric evaluation at a specialty, CPP clinic as a part of a multidisciplinary evaluation. Results suggest that psychological distress and impairment in daily activities are common in CPP patients. Most areas of functional impairment were not associated with pain variables. Rather, several forms of functional impairment were related to higher levels of depression and anxiety. Results from this study suggest the possibility that psychiatric symptoms are contributing to functional impairment in this population. These findings highlight the importance of a multidisciplinary approach in the evaluation and treatment of CPP patients to help decrease functional impairment in these patients.

Burnout in Transplant Nurses

Context— Burnout is a response to chronic strain within the workplace and is common across nursing professions. Little has been published about burnout in organ transplant nurses. Objective— To report the prevalence of the 3 main components of burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) in organ transplant nurses and to examine factors that contribute to the development of burnout in transplant nurses. Design— Cross-sectional survey of transplant nurses (recruited via listservs) on professional and personal demographics, decisional authority, psychological job demands, supervisor and coworker support, frequency and comfort with difficult patient interactions, and burnout. Participants— 369 transplant nurses. Results— About half reported high levels of emotional exhaustion, 15.7% reported high levels of depersonalization, and 51.8% reported low levels of personal accomplishment. Working more hours per week, lower decisional authority, greater psychological job demands, lower perceived supervisor support, and greater frequency and discomfort with difficult patient interactions were significant predictors of emotional exhaustion. Greater frequency and discomfort with difficult patient interactions were significant predictors of depersonalization. Younger age, lower decisional authority, and greater discomfort with difficult patient interactions were predictors of low personal accomplishment. Conclusions— The study provides strong evidence of the presence of burnout in transplant nurses and opportunities for focused and potentially very effective interventions aimed at reducing burnout.

Pursuing bariatric surgery in an urban area: Gender and racial disparities and risk for psychiatric symptoms

BACKGROUND Bariatric surgery is effective for weight loss; however, only a small percentage of those who qualify choose to pursue it. Additionally, although psychiatric symptoms appear to be common among candidates, the risk factors for symptoms are not known. Therefore, the purpose of this study was to examine the characteristics of those who are pursuing bariatric surgery in an urban area, whether demographic disparities continue to exist, and identify characteristics of those who may be at higher risk for experiencing psychiatric symptoms. METHODS There were 424 bariatric candidates who completed a required psychological evaluation prior to bariatric surgery. RESULTS AND CONCLUSIONS Bariatric surgery candidates tended to be middle-aged, Caucasian females, which was unexpected when compared to the rates of obesity among these groups. Therefore, it appears that there are disparities in who chooses to seek out bariatric surgery compared to those who may qualify due to their obesity status. Cultural factors may play a role in why males and African Americans seek out bariatric surgery less frequently. Psychiatric symptoms among candidates are also common, with depression symptoms increasing with age and BMI. Perhaps the compounding effects of medical comorbidities over time are contributing to greater depressive symptoms in the older patients. Findings from this study suggest that we may need to explore ways of encouraging younger patients, males, and ethnic minorities to pursue bariatric surgery to increase weight loss success and decrease medical comorbidities.

Embedding a Psychologist Into Primary Care Increases Access to Behavioral Health Services

Background: Patients commonly report psychological issues during primary care visits; however, few patients will follow through with a referral for behavioral health services at an outside facility. Therefore, patients may benefit from having psychologists embedded into primary care clinics. The purpose of this study was to determine who saw a primary care psychologist and to investigate which patient characteristics predicted who was more likely to attend subsequent visits with behavioral health services. Methods: There were 96 patients referred to a primary care psychologist by their primary care physician. Chart reviews were conducted to obtain patient characteristics and to determine whether the patients attended a subsequent visit with behavioral health services after the initial evaluation. Results: There were 84.4% of patients who completed an initial evaluation with a psychologist and 15.6% either cancelled or did not show for this evaluation. Of those who completed the initial evaluation, more than half had never received treatment from a behavioral health specialist. Of the 70.4% patients recommended to attend additional behavioral health treatment, 54.4% of patients attended a subsequent visit. Gender, age, race, years of education, and whether a patient had previous behavioral treatment did not predict who was more likely to attend a subsequent behavioral health visit after the initial evaluation. Conclusions: Embedding a psychologist in a primary care clinic leads to increased access to behavioral health services, especially among patients who may not seek out these services themselves or follow through with a physician’s referral to an outside behavioral health clinic.

Screening for Wilson's disease: which tests are good enough?

Wilson’s disease (WD) is a rare autosomal recessive disease caused by a mutation of the copper-transport gene ATP7B, resulting in copper accumulation and toxicity in various organ systems. Presentation and age of onset vary, but WD is associated predominantly with neuropsychiatric and hepatic symptoms during childhood. Once the diagnosis is confirmed, genetic testing is recommended for siblings of affected individuals. We present the case of a 17-year-old female (II-3, third of four sisters; see Fig. 1) who presented in acute fulminant hepatic failure and died prior to undergoing liver transplantation. Two years before, her eldest sister (II-1, age 19 years at the time) presented in acute fulminant liver failure, was diagnosed with WD, and underwent successful transplantation. At that time, the remaining three siblings were screened at an outside hospital, including liver panels and serum ceruloplasmins. The fourth and youngest sister (II-4) showed elevated liver enzymes (alanine aminotransferase 79 U/L), normal ceruloplasmin (21 mg/dL), and recurrent epistaxis. She was referred to the transplant center (with her laboratory results) for additional testing, underwent 24-hour urine copper (132 mg/24 hours) and liver biopsy (abnormal and elevated hepatic copper content, 938 mg/g hepatic dry weight), was diagnosed with WD, and copper chelation therapy was initiated. The second (II-2) and third (II-3) sisters had normal liver panels and serum ceruloplasmins. They did not have analyses of urine for copper or repeat follow-up testing at that time. In late 2010, the third sister (II-3) presented at our transplant center in acute fulminant hepatic failure. Transplant evaluation was initiated and showed a developmentally normal 17-year-old in acute fulminant hepatic failure resulting from WD (initial urine copper 3400 mg/24 hours and serum ceruloplasmin 19 mg/dL, and ophthalmologic examination showed yellowish-brown discoloration at the level of Descemet’s membrane consistent with but not definitive for Kayser-Fleischer rings). She was placed on the United Network for Organ Sharing waiting list with status 1 (priority), however, her condition deteriorated and she passed away within 10 days, before an appropriate donor organ became available. This case is evidence of the need for thorough and comprehensive testing for WD and supports the current recommendations on the importance of genetic testing for any patient with a “provisional diagnosis” of WD and for screening of siblings of confirmed cases of WD. At the time of the first sister’s presentation, recommendations regarding genetic screening for WD in first-degree relatives were less clear than current recommendations. Had the current genetic testing recommendations been in place at the time of the first sister’s presentation, the outcome for the third sister might not have been so tragic. Even without genetic testing, the third sister (II-3) did not have adequate laboratory testing at the first sister’s presentation (II-1, no evaluation of urine copper or follow-up testing) and such testing might have yielded the diagnosis. However, genetic testing of siblings by mutation analysis requires only a single test and is the only definite solution for differentiating heterozygote carriers from affected asymptomatic patients, especially for young patients in whom laboratory testing is less sensitive. It also overcomes the need for continued testing. Although the costs can be significant, costs decline with testing of siblings once the index mutations are identified. We also note that a growing body of research has shown that, even with genetic counseling, an average of 19.5% of patients continue to underestimate and an average of 25% overestimate their genetic risk. It is critical that patients and families understand each sibling’s individual risk, that genetic testing is essential, and that one-time laboratory testing is not sufficient. If the hepatologist believes that the patient and family would benefit from further education, and