OPTN/SRTR 2016 Annual Data Report: Pancreas.

The number of pancreas transplants performed in the United States increased by 7.0% in 2016 over the previous year, the first such increase in more than a decade, largely attributable to an increase in simultaneous kidney pancreas transplants. Transplant rates increased in 2016, and mortality on the waiting list decreased. The declining enthusiasm for pancreas after kidney (PAK) transplants persisted. The uniform definition of graft failure was approved by the OPTN Board of Directors in 2015 and will be implemented in early 2018. Meanwhile, SRTR continues to refrain from reporting pancreas graft failure data. The OPTN/UNOS Pancreas Transplantation Committee is seeking to broaden allocation of pancreata across compatible ABO blood types in a proposal out for public comment July 31 to October 2, 2017. A new initiative to provide guidance on the benefits of PAK transplants is also out for public comment.

Broadened Allocation of Pancreas Transplants Across Compatible ABO Blood Types.

BACKGROUND: Current Organ Procurement and Transplantation Network (OPTN) policy restricts certain blood type-compatible simultaneous pancreas and kidney (SPK) transplants. Using the Kidney Pancreas Simulated Allocation Model, we examined the effects of 5 alternative allocation sequences that allowed all clinically compatible ABO transplants. METHODS: The study cohort included kidney (KI), SPK, and pancreas alone (PA) candidates waiting for transplant for at least 1 day between January 1, 2010, and December 31, 2010 (full cohort), and kidneys and pancreata recovered for transplant during the same period. Additionally, because the waiting list has shrunk since 2010, the study population was reduced by random sampling to match the volume of the 2015 waiting list (reduced cohort). RESULTS: Compared with the current allocation sequence, R4 and R5 both showed an increase in SPK transplants, a nearly corresponding decrease in KI transplants, and virtually no change in PA transplants. Life-years from transplant and median years of benefit also increased. The distribution of transplants by blood type changed, with more ABO:A, B, and AB transplants performed, and fewer ABO:O across all transplant types (KI, SPK, PA), with the relative percent changes largest for SPK. DISCUSSION: Broadened ABO compatibility allowances primarily benefitted SPK ABO:A and AB candidates. ABO:O candidates saw potentially reduced access to transplant. The simulation results suggest that modifying the current allocation sequence to incorporate broadened ABO compatibility can result in an increase in annual SPK transplants.

OPTN/SRTR 2015 Annual Data Report: Pancreas.

The number of pancreas transplants performed in the United States stabilized over the last 3 years after nearly a decade of steady decline. Numbers of new additions to the list also stabilized during the same period. Notably, the persistent decline in pancreas after kidney transplants also seems to have abated, at least for now. The first full year of data after implementation of the new pancreas allocation system revealed no change in the distribution of organs between simultaneous pancreas-kidney (SPK) transplant and pancreas transplant alone. The percentage of kidneys used in SPK transplants was also unchanged. While a uniform definition of pancreas graft failure was approved in June 2015, it is awaiting implementation. Meanwhile, SRTR will refrain from publishing pancreas graft failure data in the program-specific reports. Therefore, it is difficult to track trends in outcomes after pancreas transplant over the past 2 years. New initiatives by the OPTN/UNOS Pancreas Transplantation Committee include facilitated pancreas allocation and broadened allocation of pancreata across compatible ABO blood types to increase organ utilization.

Thiazolo[4,5-d]pyrimidine thiones and -ones as corticotropin-releasing hormone (CRH-R1) receptor antagonists.

A series of thiazolo[4,5-d]pyrimidine thiones and -ones was prepared and discovered to have good binding affinity to the CRH-R1 receptor, thus showing promise as a new class of potential anxiolytics and/or antidepressants.

Purin-8-ones as corticotropin-releasing hormone (CRH-R1) receptor antagonists.

A series of purin-8-ones was prepared and discovered to have excellent binding affinity to the CRH-R1 receptor. Structure-activity studies focused on amine side-chain optimization, urea substitution and pyridyl isostere incorporation. Thus, the highly potent purin-8-ones show promise as a new class of potential anxiolytics and/or antidepressants.

The interrelationships between abuse, substance use, and psychosocial stress during pregnancy.

OBJECTIVE: To describe the association between abuse during pregnancy and substance use and psychosocial stress. DESIGN: Prospective study of pregnant women. SETTING: Urban prenatal clinics. PARTICIPANTS: 1,937 predominately low-income, ethnically diverse women. MAIN OUTCOME MEASURES(S): Three questions from the Abuse Assessment Screen were used to measure abuse. For the total sample, 25.7% reported physical abuse in the past year, 10.5% physical abuse since pregnancy, and 4.5% sexual abuse in the past year. Adolescents were significantly more likely to report any abuse (37.6%) than were adults (22.6%) (chi-square = 44.94; df = 1; p < 0.001). White abused women were significantly more likely to report use of tobacco (chi-square = 17.34; df = 1; p < 0.001) and alcohol (chi-square = 5.65; df = 1, p < 0.01). Abused Asian women were more likely to smoke (chi-square = 12.13; df = 1, p < 0.001), as were women ethnically described as "other" (chi-square = 8.39; df = 1, p < 0.001). There was a higher, but not statistically significant, rate of substance use between abused and nonabused African-American, Native-American, and Hispanic women. Abused women of all races reported higher stress, less support from partners, less support from others, and lower self-esteem. CONCLUSIONS: Abuse during pregnancy is associated with an increased incidence of substance use and psychosocial stress. These relationships must be incorporated into the clinical care of abused pregnant women.

Effects of abuse on maternal complications and birth weight in adult and adolescent women.

OBJECTIVE: To estimate the incidence of physical and sexual abuse in a sample of adult and adolescent pregnant women and to determine the relationship between abuse and maternal complications and infant birth weight. METHODS: One thousand eight hundred ninety-seven women were screened for abuse during pregnancy. Maternal complications and infant birth weight were obtained by record review. RESULTS: Physical abuse in the past year and/or during pregnancy was reported by 37.6% of the adolescent and 22.6% of the adult women (P < .001). Abused adult women were more likely to have unplanned pregnancies (P < .001) and to begin care after 20 weeks (P < .01) than nonabused women. For the aggregate sample of 1597 for whom birth weights were available, abuse was a significant risk factor for low birth weight (LBW) (P < .05) as was poor obstetric history (P < .05). Using Institute of Medicine risk factors for LBW, abused adults were more likely to have poorer past obstetric histories and to use tobacco, alcohol, and drugs (P < .05). Abused adolescents were at greater risk for smoking and first- or second-trimester bleeding (P < .05). For the aggregate, abused women were at greater risk for poor obstetric history, vaginal/cervical infection during pregnancy, smoking, and alcohol and drug use. CONCLUSION: More than one-third of the adolescent and nearly one-fourth of the adult women reported abuse in the past year and/or during pregnancy. Abuse is related to poor obstetric history, substance use, and LBW. The short abuse assessment screen detects potential abuse in order that interventions can be implemented.

The Prenatal Psychosocial Profile: a research and clinical tool.

This report summarizes five studies of culturally diverse women who were administered the Prenatal Psychosocial Profile (PPP). These data from 3,444 rural and urban women of all childbearing ages support the validity and reliability of the PPP as a measure of stress, support from partner, and support from others. The self-esteem scale is a valid and reliable measure for Caucasian and African American women. However, the cultural appropriateness of the self-esteem scale for Native American women is questionable, and it is neither valid nor culturally appropriate for traditional Hispanic women. The mean scores for stress, partner support, and other support were similar for all groups except for scales expected to differ by sample groups. Thus, suggested cutoff scores should be useful for screening purposes. The PPP provides a brief, yet comprehensive profile that is accepted by participants and useful to researchers and clinicians.

Abuse among pregnant adolescents: differences by developmental age.

PURPOSE: The purpose of this study was to describe the incidence of abuse among pregnant teens in the three developmental stages of adolescence and to determine if abuse was related to pregnancy planning, high school participation, substance use during pregnancy, pregnancy complications, and infant birth weight. DESIGN: Prospective survey. METHODS: A total of 559 pregnant adolescents between the ages of 13 and 19 were interviewed. Abuse was measured by the Abuse Assessment Screen. Substance use was measured by self-report. Birth weights were obtained from hospital records. RESULTS: Abuse was reported by 37% of the adolescents. In every age group, the incidence of low birth weight was higher in those who had been abused. CLINICAL IMPLICATIONS: The high rates of abuse reported by both adolescent and adult women in this study emphasize the need for nurses in every setting to incorporate routine screening for abuse into their nursing assessments.

PIP: 72 pregnant female adolescents aged 13-15 years, 166 aged 16-17, and 341 aged 18-19 attending prenatal clinics in the greater metropolitan area of a northwestern city participated in a study to assess the incidence of abuse, including physical and sexual abuse, in that subpopulation and to determine whether such abuse is related to pregnancy planning, high school participation, substance use during pregnancy, pregnancy complications, and infant birth weight. 52% of the subjects were White, 30% were Black, 4% Native American, 4% Hispanic, 3% Asian, and 6% other. They had completed an average of 10.7 years of education, although 47% had dropped out of high school. 8.6% were married and living with their partner, 28% reported being single and cohabiting with a partner, and this was the first pregnancy for 57%. Abuse was measured using the Abuse Assessment Screen, substance abuse was measured by self-report, and birth weights were obtained from hospital records. More than 37% reported abuse, with the middle adolescents reporting the highest incidence and the oldest adolescents the least. In every age group, the incidence of low birth weight was higher among subjects who had been abused, although that difference was not statistically significant. Compared to nonabused subjects, those abused were significantly more likely to be high school dropouts, to smoke, and to have experienced bleeding during the second trimester. No differences were observed between the abused and nonabused subjects in pregnancy planning and reported use of marijuana, alcohol, or other drugs.

Living in two worlds: Native American women and prenatal care.

The purpose of this qualitative study was to explore traditional beliefs and practices related to pregnancy and childbirth among Native American women and examine the relationship of these beliefs and practices to current use of prenatal care. Focus groups of elders and young women were held and the data analyzed with the Ethnograph software. The central theme was the breakdown in transmission of cultural wisdom among Native American women. The major causes described by women were federal assimilation policies and deaths of elders. Major factors influencing young women's nonutilization of prenatal care were this breakdown, the "Western model" of prenatal care, substance abuse, and domestic violence. Recommendations for improving the use of prenatal care are grounded in the reality that Native American women live in two different worlds. Prenatal care should be reconceptualized as traditional cultural wisdom, with the majority of care provided by natural helpers in the Native American community, including tribal elders, grandmothers, and aunts in collaboration with licensed providers.

The effects of nursing case management on the utilization of prenatal care by Mexican-Americans in rural Oregon.

This quasi-experimental, retrospective study used birth certificate and medical record data to evaluate the effectiveness of the Rural Oregon Minority Prenatal Program (ROMPP) in improving patterns of prenatal care utilization by rural-dwelling, low-income, Mexican-American women at risk of poor pregnancy outcomes. The ROMPP intervention provided nursing case management services and peer outreach to pregnant Mexican-American women in a rural Oregon community. The intervention group had more prenatal visits in months 2, 3, 4, 5, 6, and 7 than the comparison group (P < 0.05). The intervention group had a similar number of emergency room (ER) visits, but had more respiratory diagnoses and fewer urinary tract infections. ROMPP women had more inpatient admissions and longer lengths of stay. No differences were found in the initiation of prenatal care or the total number of prenatal care visits, nor in the timing of screening serum glucose tests. The intervention should be expanded to address the persistent attitudinal, financial, transportation and language barriers to adequate prenatal care. Nurses should increase their cultural competency and sharpen their clinical focus on advocacy, marketing, facilitation of relationships between community groups, and community organizing.

Validity and reliability testing of the Prenatal Psychosocial Profile.

Two studies of low-income pregnant women (N = 179) were done to examine the validity and reliability of the Prenatal Psychosocial Profile (PPP). The PPP, a composite of the Rosenberg Self-Esteem Scale, the Support Behaviors Inventory, and a newly developed measure of stress, is a brief, comprehensive clinical assessment of psychosocial risk during pregnancy. Construct validity of the stress scale was supported by theoretically predicted negative correlations with self-esteem, partner support, and support from others (N = 91). Convergent validity of the stress scale was demonstrated by a correlation of .71 with the Difficult Life Circumstances Scale. Adequate levels of internal consistency were found. Interrelationships between the four subscales were consistent with the underlying conceptualization, and there was beginning evidence of the factorial independence of the subscales.

Factors related to the keeping of appointments by indigent clients.

Few recent studies address how situational variables and the characteristics of clients and organizations predict whether indigent clients will keep medical appointments. In this study at a southern urban charity hospital, lack of transportation was a main reason given for not keeping the last appointment at an internal medicine clinic. In contrast, clients who kept their last appointment had higher incomes; had visited the facility for pain, infection, or follow-up after hospitalization; and had been referred to the clinic less than two weeks before their appointment. Overall, whether appointments were kept or broken seemed to depend on the recency of medical attention and the perceived severity of a problem. Implementation of a system-wide discharge-planning system resulted in fewer broken appointments. Perceived communication difficulties with clinic personnel and long waits were important predictors of overall utilization. Decentralizing care through community health clinics and adopting a more holistic approach to care may improve utilization of health care facilities.

Stress, social support, and self-esteem during pregnancy.

The relationship between stress, social support, and self-esteem during pregnancy is explored. The effects of high stress and low social support and low self-esteem on pregnancy outcomes are described and illustrated with a case example. Examples of nursing interventions aimed at reducing stress and enhancing social support and self-esteem during pregnancy are provided.

Nonfinancial barriers to prenatal care.

This article focused on nonfinancial barriers to prenatal care and pointed out that these barriers cannot be ignored if access to care is to be improved. The strategies suggested by the Consensus Conferences for reducing these barriers provide abundant opportunities for all professionals, and the implications for health policy formulated by the Conferences provide direction for eventually eliminating the barriers. It will take a combination of professional, political and public will to make this happen.

PIP: This article focuses on what is currently known about nonfinancial barriers to prenatal care. The primary source of data is the findings from the Consensus Conferences on Access to Prenatal Care and Low Birthweight which were held in 1986 (American Nurses' Association, 1987). Prior to describing these data, the literature regarding nonfinancial barriers will be reviewed and findings from this author's studies on access to care described. Implications for health policy will conclude this article. The landmark study: Preventing Low Birthweight (Institute of Medicine, Committee to Reduce Low Birthweight, 1985) concluded that there were 5 major categories of nonfinancial barriers to care: 1) limited availability of providers of maternity care; 2) insufficient prenatal services in some sites routinely used by high-risk populations; 3) experiences, attitudes and beliefs among women that make them disinclined to received prenatal care services; 4) poor or absent transportation or child care; and 5) inadequate systems to recruit hard-to-reach women into care. These categories will be used to organize this review. 4 regional consensus conferences on access to prenatal care and low birthweight were held in early 1986. The conferences were designed to build upon the Institute of Medicine's study, "Preventing Low Birthweight" and had 3 specific goals: 1) to identify strategies to reduce the nonfinancial barriers to access to prenatal care; 2) to identify the components of prenatal care most effective in reducing the incidence of low birthweight" and had 3) specific goals: 1) to identify strategies to reduce the nonfinancial barriers to access to prenatal care; 2) to identify the components of prenatal care most effective in reducing the incidence of low birthweight; and 3) to develop health policy recommendations aimed at reducing the incidence of low birthweight. The framework that evolved for categorizing the nonfinancial barriers organized the barriers into 1 of 3 categories: 1) policy or system barriers; 2) provider barriers or 3) patient barriers. The article lists 11 recommendations for health policy proposed by the conference participants. (Author's modified).