An accumulation of distress: Grief, loss, and isolation among healthcare providers during the COVID-19 pandemic.

This article draws on the journal entries of 62 healthcare professionals (HCP) in the United States and Canada who participated in the Pandemic Journaling Project (PJP) during 2020-2021. The HCP in this article represented healthcare fields including medicine, nursing, physical therapy, social work, and clinical psychology. In their journal entries, HCP provided accounts of witnessing the death and bereavement of their patients and loved ones; experiencing their own loss of loved ones and important milestones; facing isolation from their networks and places of meaning; and juggling increasing workloads and caregiving activities. I illustrate how these four areas were impacted by guilt, duty, ethical deliberations, and gender disparities. I argue that HCP face an accumulation of distress when they witness grief and face loss without space to process these experiences.

Casting and scripting: Visibility, responsibility, and legitimacy in transcultural psychiatry apprenticeships in Paris.

Transcultural psychiatry was developed in France to promote cultural and linguistic diversity and address the mental health needs of immigrants who were excluded from accessing other public mental health services. Professionals in health and social services refer patients to transcultural psychiatry consultations when miscommunications arise or when professionals determine that patients need culturally sensitive therapy. In transcultural psychiatry consultations, a group of therapists, composed primarily of psychologists and psychiatrists, as well as other health and social service professionals, receives a patient, the patient's family, and referring professionals. Previous research on transcultural psychiatry has emphasized the importance of culturally diverse therapy teams and the ways that therapists' diversity could permit patients to open up in consultation sessions. This study draws on ethnographic research in two transcultural psychiatry consultations in Île-de-France, and pays particular attention to the experiences of apprentice therapists, who were often graduate students in clinical psychology. Apprentice therapists reported being introduced to patients in ways that they would not choose themselves. As a result, therapists felt that they had to overemphasize their cultures or countries of origin and French therapists questioned their place in the group. This article describes how transcultural therapy groups are a theater in which belonging, identity, and Frenchness are contested and performed. Apprentice therapists proposed more intersectional and inclusive ways of portraying diversity in the transcultural groups.

Induction immunosuppression strategies and long-term outcomes after heart transplantation.

Although the use of induction therapy has reduced the risk of acute rejection after heart transplantation, its use may be associated with other adverse outcomes. We aimed to examine the effect of no induction (NoInd), induction with basiliximab (BAS), or induction with antithymocyte globulin (ATG) on outcome after heart transplantation. We analyzed data from the International Society for Heart and Lung Transplantation (ISHLT) registry for adult heart transplants performed between 2000 and 2013. The primary outcome was cumulative all-cause mortality, and the secondary outcome was cause-specific death. We identified 27 369 transplants whose recipients received NoInd (n = 15 688), ATG (n = 6830), or BAS (n = 4851). Over a median follow-up of 1497 days, overall 30-day mortality was 5% and 1-year mortality was 11%. Survival after transplant was similar in patients treated with NoInd compared with ATG. The survival was improved using NoInd compared with BAS (log-rank P = .040), adjustment HR = 1.11 (95% CI, 1.04-1.19). Compared to NoInd, BAS was associated with higher risk of graft failure-related deaths, HR = 1.27 (95% CI, 1.02-1.58), and ATG was associated with higher risk of malignancy-related deaths, HR = 1.18 (95% CI, 1.01-1.39). Survival of patients who received NoInd was similar to ATG and better compared with BAS. Further, the use of ATG may be associated with increased malignancy-related mortality, compared with NoInd.

Human Leukocyte Antigen-Based Risk Stratification in Heart Transplant Recipients-Implications for Targeted Surveillance.

Background Human leukocyte antigen (HLA) matching isn't routinely performed in heart transplantation. Novel allograft perfusion methods may make HLA matching feasible. The purpose of this study is to reexamine whether HLA mismatch may be used in risk stratification to improve outcomes in heart transplantation. Methods and Results We analyzed 34 681 recipients undergoing heart transplantation between 1987 and 2013. We used HLAMatchmaker to quantify HLA eplet mismatches and Cox regression for analysis of time to graft loss. Recipients with 4 mismatched HLA-DR/DQ alleles and >40 eplets reached an adjusted hazard ratio (HR) for graft loss of 1.17 (95% CI 1.07-1.28) and 1.11 (95% CI 1.03-1.21), respectively. We found significant interaction between recipient age and numbers of HLA-DR/DQ allele and eplet mismatches resulting in an adjusted HR of 1.78 (95% 1.13-2.80) and 1.82 (95% CI, 1.23-2.70), respectively. HR for both interaction terms was 0.99 (95% CI, 0.98-1.00). Risk of graft loss was more pronounced after 1 year, where recipient <40 years with 4 mismatched HLA-DR/DQ alleles and >40 eplets had an adjusted HR of 1.51 (95% CI 1.12-2.03) and 1.32 (95% CI 1.02-1.70), respectively. Pre-sensitized recipients with panel reactive antibodies >10% had an adjusted HR=1.27 (95% CI 1.16-1.40) for graft loss within 1 year but not thereafter. HLA eplet mismatch was independent of panel reactive antibodies on reduction of graft loss within and after 1 year, P (interaction)=0.888 and 0.389. Conclusions HLA mismatch may be used in risk stratification for intensified post-transplant surveillance and therapy.

Pancreatic cancer and thromboembolic disease, 150 years after Trousseau.

The connection between pancreatic cancer and venous thrombosis has been discussed for almost 150 years. The exact pathophysiological mechanisms are still partly understood, but it is known that pancreatic cancer induces a prothrombotic and hypercoagulable state and genetic events involved in neoplastic transformation (e.g., KRAS, c-MET, p53), procoagulant factors [e.g., tissue factor (TF), platelet factor 4 (PF4), plasminogen activator inhibitor type 1 (PAI-1)], mucin production (e.g., through activation of P- and L-selectin) and pro-inflammatory factors [e.g., cytokines, cyclooxygenase-2 (COX-2)] may be implicated. Also pancreatitis, both acute and chronic, is associated with increased risk of venous thrombosis, but in this circumstance a direct inflammatory process may be more important. This article discusses the incidence, treatment and outcome of venous thromboembolism (VTE) complicating pancreatic disease, with special emphasis on new knowledge obtained during the last fifteen years.

Induction with anti-thymocyte globulin in heart transplantation is associated with better long-term survival compared with basiliximab.

BACKGROUND: The use of induction therapy may reduce the risk of acute rejection after heart transplantation. This study assessed the association between basiliximab (BAS) vs anti-thymocyte globulin (ATG) induction and long-term survival after heart transplantation. METHODS: We used data from the International Society for Heart and Lung Transplantation Registry to examine outcomes of all adult heart transplant recipients treated with ATG or BAS as induction therapy. RESULTS: We identified 9,324 transplantations performed between 2000 and 2011 whose recipients received ATG (n = 6,144) or BAS (n = 3,180). The ATG group had a higher panel reactive antibody class 1 (7.5% vs 6.1%; p < 0.018) and class 2 (6.6% vs 3.7%; p < 0.001), respectively, whereas the BAS group was less likely to have non-ischemic cardiomyopathy but more likely to be in the intensive care unit pre-transplant. One-year survival was similar for both groups, 90% vs 91% (p = 0.858). However, use of BAS was associated with poorer long-term survival compared with ATG at 5 years (77% vs 82%, p = 0.005) and at 10 years (64% vs 67%, p = 0.007). In multivariable Cox model, use of BAS remained associated with increased mortality over a median follow-up of 3.0 years (range, 0-12 years), with a hazard ratio of 1.22 (95% confidence interval, 1.09-1.37; p < 0.001). Sub-group analyses showed BAS was not independently associated with increased risk in those who received a previous transplant or in those who underwent re-transplantation due to graft failure. CONCLUSIONS: In the International Society for Heart and Lung Transplantation Registry experience, use of ATG rather than BAS as induction therapy appears to be associated with better long-term survival. A prospective study is necessary to confirm these findings.

Comparison of Basiliximab and Anti-Thymocyte Globulin as Induction Therapy in Pediatric Heart Transplantation: A Survival Analysis.

BACKGROUND: Basiliximab and anti-thymocyte globulin are widely used drugs for induction therapy after pediatric heart transplantation. The aim of this study was to determine whether any differences could be observed between basiliximab and anti-thymocyte globulin, with respect to long-term mortality, in a population of pediatric cardiac transplant recipients. METHODS AND RESULTS: An analysis of pediatric heart transplant patients (aged <18 years) from the United Network for Organ Sharing database was conducted that compared patients receiving basiliximab with those that received anti-thymocyte globulin for the risk of all-cause mortality. Secondary endpoints included death attributable to graft failure, cardiovascular causes, infection, or malignancy. Of the 2275 patients, 685 received basiliximab and 1590 anti-thymocyte globulin. One-year survival was similar for both groups; however, at 5 and 10 years, basiliximab was associated with poorer long-term survival (68% versus 76% at 5 years [P<0.001] and 49% versus 65% at 10 years [P<0.001], respectively). Basiliximab was associated with higher risk of death attributable to graft failure (P=0.013), but not death attributable to cardiovascular causes (P=0.444), infection (P=0.095), or malignancy (P=0.392). After multivariate analysis, use of basiliximab (versus use of anti-thymocyte globulin) remained significantly associated with all-cause mortality (hazard ratio, 1.27; 95% confidence interval, 1.02-1.57; P=0.030). CONCLUSIONS: In pediatric heart transplant patients, use of basiliximab for induction therapy was associated with an increased risk of mortality, when compared with those receiving anti-thymocyte globulin.

Analysis of the Influence of HLA-A Matching Relative to HLA-B and -DR Matching on Heart Transplant Outcomes.

BACKGROUND: There are conflicting reports on the effect of donor-recipient HLA matching on outcomes in heart transplantation. The objective of this study was to investigate the effects of HLA-A matching relative to HLA-B and -DR matching on long-term survival in heart transplantation. METHODS: A total of 25 583 patients transplanted between 1988 and 2011 were identified from the International Society for Heart and Lung Transplantation registry. Transplants were divided into 2 donor-recipient matching groups: HLA-A-compatible (no HLA-A mismatches) and HLA-A-incompatible (1-2 HLA-A mismatches). Primary outcome was all-cause mortality. Secondary outcomes were graft failure-, cardiovascular-, infection-, or malignancy-related deaths. RESULTS: The risk of all-cause mortality 15 years after transplantation was higher for HLA-A-compatible (vs HLA-A-incompatible) grafts in patients who had HLA-B-, HLA-DR-, or HLA-B,DR-incompatible grafts (P = 0.027, P = 0.007, and P = 0.002, respectively) but not in HLA-B- and/or HLA-DR-compatible grafts. This was confirmed in multivariable Cox regression analysis where HLA-A compatibility (vs HLA-A incompatibility) was associated with higher mortality in transplants incompatible for HLA-DR or HLA-B and -DR (hazard ratio [HR], 1.59; 95% confidence interval [95% CI], 1.11-2.28; P = 0.012 and HR, 1.69; 95% CI, 1.17-2.43; P = 0.005, respectively). In multivariable analysis, the largest compromise in survival for HLA-A compatibility (vs HLA-incompatibility) was for chronic rejection in HLA-B- and -DR-incompatible grafts (HR, 1.91; 95% CI, 1.22-3.01; P = 0.005). CONCLUSIONS: Decreased long-term survival in heart transplantation was associated with HLA-A compatibility in HLA-B,DR-incompatible grafts.

Enhancing social networks: a qualitative study of health and social care practice in UK mental health services.

People with severe mental health problems such as psychosis have access to less social capital, defined as resources within social networks, than members of the general population. However, a lack of theoretically and empirically informed models hampers the development of social interventions which seek to enhance an individual's social networks. This paper reports the findings of a qualitative study, which used ethnographic field methods in six sites in England to investigate how workers helped people recovering from psychosis to enhance their social networks. This study drew upon practice wisdom and lived experience to provide data for intervention modelling. Data were collected from 73 practitioners and 51 people who used their services in two phases. Data were selected and coded using a grounded theory approach to depict the key themes that appeared to underpin the generation of social capital within networks. Findings are presented in four over-arching themes - worker skills, attitudes and roles; connecting people processes; role of the agency; and barriers to network development. The sub-themes which were identified included worker attitudes; person-centred approach; equality of worker-individual relationship; goal setting; creating new networks and relationships; engagement through activities; practical support; existing relationships; the individual taking responsibility; identifying and overcoming barriers; and moving on. Themes were consistent with recovery models used within mental health services and will provide the basis for the development of an intervention model to enhance individuals' access to social capital within networks.

Human leukocyte antigen matching in heart transplantation: systematic review and meta-analysis.

Allocation of donors with regard to human leukocyte antigen (HLA) is controversial in heart transplantation. This paper is a systematic review and meta-analysis of the available evidence. PubMed, Embase, and the Cochrane Library were searched systematically for studies that addressed the effects of HLA matching on outcome after heart transplantation. Fifty-seven studies met the eligibility criteria. 34 studies had graft rejection as outcome, with 26 of the studies reporting a significant reduction in graft rejection with increasing degree of HLA matching. Thirteen of 18 articles that reported on graft failure found that it decreased significantly with increasing HLA match. Two multicenter studies and nine single-center studies provided sufficient data to provide summary estimates at 12 months. Pooled comparisons showed that graft survival increased with fewer HLA-DR mismatches [0-1 vs. 2 mismatches: risk ratio (RR) = 1.09 (95% confidence interval (CI): 1.01-1.19; P = 0.04)]. Having fewer HLA-DR mismatches (0-1 vs. 2) reduced the incidence of acute rejection [(RR = 0.81 (0.66-0.99; P = 0.04)]. Despite the considerable heterogeneity between studies, the short observation time, and older data, HLA matching improves graft survival in heart transplantation. Prospective HLA-DR matching is clinically feasible and should be considered as a major selection criterion.

Portal venous system thrombosis after pancreatic resection.

BACKGROUND: Portal venous system thrombosis (PVST) is a rare, potentially fatal complication after pancreatic resection. The aim of this study was to assess the incidence, presenting symptoms, management, and treatment of PVST in a large cohort of patients. METHODS: Prospectively collected data on patients undergoing pancreatic resection between 1997 and 2009 were reviewed retrospectively. Preoperative and postoperative imaging were analyzed for the presence or absence of venous thrombi. All patients received standard thromboprophylaxis with low-molecular-weight heparin (LMWH). RESULTS: Of 516 pancreatic resections performed, 18 (3.5 %) were complicated by PVST. The most common clinical presentations were abdominal pain (n = 9) and ascites (n = 5) but never any alarm symptoms. Other symptoms were vague and nonspecific (e.g., weight loss, fatigue, fever). Total pancreatectomy was a risk factor compared to hemipancreatectomy (p < 0.01), whereas the underlying disease per se did not make any difference. The median interval between surgery and diagnosis of PVST was 105 days (range 1-1,440 days). PVST was at least a contributing factor in the postoperative deaths of two patients. LMWH therapy did not significantly affect survival. CONCLUSIONS: PVST remains a relatively infrequent complication after pancreatic resection. Because accurate diagnosis and timely intervention may reduce morbidity and mortality, the possibility of PVST should be considered in patients presenting with vague symptoms. Whether anticoagulant treatment is needed is still not clear; there were no obvious differences in outcome between treated and untreated patients.

Senegalese religious leaders' perceptions of HIV/AIDS and implications for challenging stigma and discrimination.

Senegal has been heralded as a model country in the fight against HIV/AIDS because of the low prevalence in the general population and concerted prevention efforts since the start of the epidemic. Despite its success, stigma and discrimination remain a reality for people living with HIV/AIDS as HIV transmission remains linked to lifestyle and perceived morality. Because religious teaching and the participation of religious leaders in HIV prevention is reported as partially responsible for Senegal's success, the present study seeks to deepen the understanding of their role in psychosocial aspects of care and support of people living with HIV/AIDS. Interviews were conducted with 87 religious leaders. Muslim, Catholic and Protestant leaders differ in their involvement in HIV/AIDS education, their opinions of condom use and their counselling techniques for people living with HIV/AIDS. Most religious leaders in each group believed that addressing the HIV/AIDS epidemic and the reduction of HIV/AIDS-related stigma and discrimination are priorities, yet some leaders still hold beliefs about HIV/AIDS that may ostracise people living with HIV/AIDS. Organisations working to sensitise religious leaders on HIV/AIDS should focus more on the everyday experience of people living with HIV/AIDS, promote the value of condom use, even if solely among married couples, and reinforce religious leaders' roles as spiritual counsellors.

Heterogeneous interleukin-15 inducibilities in murine B16 melanoma and RM-1 prostate carcinoma by interferon-alpha treatment.

Long-term treatment of mouse cancer cells with interferon-alpha (IFN-alpha) converts parental B16 melanoma cells to B16alpha vaccine cells. Inoculation of syngeneic mice with UV-irradiated B16alpha vaccine cells triggers immunity to the parental B16 tumor that is mediated by host macrophages, T cells, and NK cells. Lymph node cells from mice inoculated with irradiated B16alpha vaccine cells, but not with irradiated parental cells, proliferate when cultured in vitro, suggesting long-term in vivo activation of lymphoid cells. Both IL-15 mRNA and IL-15 protein are highly induced in B16alpha vaccine cells. The bulk of the induced IL-15 is shown to be cell-associated, either cytoplasmic or membranous. The current study investigated the feasibility of applying the B16alpha vaccination protocol to generate a cancer vaccine against murine RM-1 prostate carcinoma. In comparison to B16alpha vaccine cells, long-term IFN-alpha-treated RM-1 cells (RM-1alpha vaccine cells) showed significant IL-15 mRNA induction but relatively low IL-15 protein up-regulation. When UV-irradiated, a 3-fold increase in intracellular IL-15 was observed in RM-1alpha vaccine cells, suggesting UV damage may have negated a possible control mechanism for IL-15 synthesis. Efficacy of in vivo vaccination of syngeneic mice with UV-irradiated RM-1alpha and B16alpha vaccine cells showed correlation between high IL-15 level and high vaccine efficacy in B16alpha cells compared to low IL-15 level and low vaccine efficacy in RM-1alpha cells. This supports the concept that the induction of IL-15 in tumor cells can be useful for creating whole-cell cancer vaccines.