Quality of life and performance status before and after small intestinal transplantation.

INTRODUCTION: Intestinal transplantation (IT) is considered for patients with irreversible intestinal failure who develop life-threatening complications of parenteral nutrition or have extensive intra-abdominal disease requiring evisceration. Developing indications may include quality of life (QOL) considerations and therefore assessment of QOL and performance status (PS) after IT is important. We report QOL and PS before and after IT in our cohort. METHODS: Consecutive patients undergoing IT were included. QOL was assessed using the generic 36-item short form survey (SF 36) tool at assessment and 6-month intervals post-transplantation. Performance was assessed using a visual analogue scale (VAS), Karnofsky scale (KS), and the Eastern Cooperative Oncology Group scale at three time points: premorbidly, at listing, and after transplantation. RESULTS: Data were available for 21 patients. There were 11 complete SF 36 datasets and 15 performance scores. Data were not available from 3 patients, and the overall response rate was 62%. Overall, there was a trend for improved SF 36 scores post-transplantation in approximately half of the patients with scores remaining stable in approximately one third. The results of the SF 36 significantly improved in 1 patient (P < .01). After IT, 66% of patients had better VAS scores than at listing and >75% of patients scored better or the same in KS compared to status at listing. However, PS after IT did not improve to premorbid levels. CONCLUSION: We found a trend for QOL scores to improve in approximately half of the patients compared to their status at listing, remain static in approximately one third, and a minority experience a decline. For the majority, differences were not statistically significant. PS of patients after transplantation is equal or better than that at listing in 75%, but rarely reaches that of the premorbid status. Longer-term studies are needed and may reveal progressive improvement.

Adult small intestinal and multivisceral transplantation: lessons through the "retrospecto-scope" at a single UK centre from 1991 to 2013.

The first intestinal transplantation in the United Kingdom was performed in Cambridge in 1991. Thirty-eight intestinal transplantations have since been performed in 35 patients. All deaths in the first postoperative month related to hemorrhage, in 2 cases to severe portal hypertension (SPH) and poor venous access in 2. We have modified our practice to reduce the bleeding risk with SPH. Loss of venous access can be avoided by timely referral. Rejection was implicated in 3/14 deaths all dying of sepsis. Cytomegalovirus disease resulted in 2 deaths; we try to avoid CMV-positive donors giving to CMV-negative recipients. Three deaths were related to psychiatric illness, which led to loss of graft in 2 others. Three patients were retransplanted (2 rejections and 1 infarction) and all remain alive. Most patients (10/13) experienced a fall in body weight in the first postoperative year after SB/MV transplantation. Body weight fell by as much as 25%. As transplantation resulted in a net gain in small bowel in most cases, the postoperative loss of native body weight may be underestimated. Interestingly this was not associated with a significant fall in midarm circumference or handgrip strength. Long-term nutrition can be maintained with oral intake in the majority of patients post-SBT. There is improvement in handgrip strength post-transplant. Transplantation does not significantly alter weight, albumin, or other common anthropometric markers. Despite these problems, our 5-year survival results remain relatively good at 73% in the cohort from 1991, 79% from 2003, and 80% from 2008. We consider that deployment of strategies learned from our experiences has improved outcomes.

Prothrombotic disorders in a cohort of 25 patients undergoing transplantation: investigation and management implications.

BACKGROUND: Many patients referred for intestinal transplantation have a history of thrombosis. We undertook an analysis of transplanted patients to describe the history and frequency of thrombosis, clinical course, and management strategies used. RESULTS: Twenty-five patients underwent transplantation of intestine containing blocks between 2007 and 2012; 20 of 25 are still alive. Five of 25 patients were transplanted with history of portomesenteric thrombosis, 6 of 25 had experienced loss of venous access due to thrombosis, and 6 of 25 had history of mesenteric ischemia. Pretransplantation, 16 of 25 patients were anticoagulated. Thrombophilia screens identified 3 of 16 patients who were JAK2 positive, 1 of 25 who had antithrombin deficiency, and 1 of 25 who had a factor V Leiden heterozygote. Post-transplantation, of all 16 patients who were anticoagulated pretransplantation and continued postoperatively, 1 of 16 infarcted their small bowel graft and 4 of 16 developed a further venous thrombosis despite anticoagulation. Of the 9 without a previous history of thrombosis, 1 had a pulmonary embolus more than a decade after transplantation and another had an upper limb deep vein thrombosis associated with a line. Both were then anticoagulated. Seven of 25 are not anticoagulated, although they are administered antiplatelet prophylaxis. Postoperative bleeding complications of anticoagulation occurred in 3 patients. After a subarachnoid hemorrhage in 1 of those 3 patients, anticoagulation was stopped. The other 2 patients bled during ileal biopsy, and both remain on low molecular weight heparin treatment. CONCLUSION: Those with identifiable thrombophilic tendency and a history of venous or arterial thrombosis are considered to be at high risk for recurrent thrombosis. Those without such a history could be considered low risk. Our practice is to anticoagulate all high-risk individuals before and after transplantation and offer antiplatelet prophylaxis to low-risk patients as the risk of anticoagulation probably outweighs the risk of thrombosis for them. Early input from hematologists is vital in the management of high-risk patients, particularly those who thrombose when anticoagulated.

Psychiatric disorders in patients undergoing intestinal transplantation.

BACKGROUND: Psychiatric disorders are common in chronic disease states; intestinal transplantation recipients may therefore be at high risk for psychiatric disorder (PD). We sought to investigate the frequency and type of PD in our cohort of patients undergoing transplantation between 2007 and 2012. RESULTS: The notes of 25 patients who had undergone transplantations since 2007 were available for analysis. Five of 25 patients had died at the time of data collection. Pretransplantation, 14 of 25 patients had a history of a single psychiatric disorder (SPD) (depression). Two of 25 had double psychiatric diagnoses (DPD; depression with anxiety), and 1 had three PDs. Three of 25 patients suffered from chronic pain syndrome and 1 patient had this as an isolated diagnosis without any other PD. Post-transplantation, 10 of 14 patients still had an SPD; however, 3 of 14 had acquired a second diagnosis (DPD; anxiety with depression) with suicidal ideation in 2 cases. Those with DPD preoperatively did not improve. Depression resolved in 1 of 14 after transplantation. One patient without a history of psychiatric issues developed DPD during the postoperative course. Only 3 of 25 surviving patients are free of any psychological diagnosis post-transplantation. The presence of other problems in the cohort such as chronic pain syndrome in 4 of 25, medical noncompliance in 3 of 25, cyclizine dependency in 2 of 25, and recreational drug use suspected in 1 were also identified. Problems with body image relating to the stoma were experienced by 2 of 25 patients. CONCLUSION: The incidence of psychiatric disorder in patients embarking on transplantation is high and relates to their history of chronic illness. The additional stress of the transplantation operation and the long in-hospital rehabilitation period takes its toll on patients' emotional health and many acquire further psychiatric diagnoses. Managing the psychiatric health of patients is important for successful rehabilitation and their long-term health and wellbeing.

Occult invasive aspergillosis infection following multivisceral transplantation.

Patients undergoing multivisceral transplantation are particularly susceptible to post-operative infections due to immunosuppression and the inclusion of bowel in the transplanted graft. These patients typically receive broad-spectrum antimicrobial and antifungal agents as prophylaxis and treatment. However, evidence for this is limited due to the small number of patients undergoing the procedure. We present a case of occult disseminated invasive aspergillosis infection in a patient who underwent multivisceral transplantation.

The 'not so short-bowel syndrome': potential health problems in patients with an ileostomy.

AIM: The study aimed to determine whether an ileostomy compromises nutritional, hydration and electrolyte status and bone mineral density. METHOD: Body weight, body mass index (BMI) and fat and lean body mass (LBM) were measured in 60 patients with an ileostomy [14 small-bowel resection (SBR); 46 non-small-bowel resection (NSBR)] and in 60 age- and sex-matched normal controls. Measurement of plasma sodium, potassium, calcium, magnesium, urea and creatinine and 24-h urinary output of water, Na, K, Ca and Mg was made in 45 NSBR and 14 SBR ileostomists and in all the controls. Forty-six NSBR and 13 SBR ileostomists had bone mineral density (BMD) measurements of lumbar spine (LS) and femoral neck (FN). RESULTS: The body weight of ileostomists was less than controls [median 67.8 (36.4-115.1) vs 77.7 (48.0-103.3) kg; P < 0.05]. BMI was also less [25.0 (14.3-43.0) vs 27.3 (20.2-32.2) kg/m(2) ; P < 0.05] with a lower LBM [47.8 (19.3-73.0) vs 52.9 (34.0-73.8) kg; P < 0.05]. The 24-h urinary output of the ileostomists was lower than for controls [1380 (430-4690) vs 2000 (840-4440) ml/24 h; P < 0.05] suggesting some degree of dehydration. In 62.7% of ileostomists 24-h urinary Na excretion was < 100 mmol/day vs 16.7% of controls, and ileostomists with lower urinary Na were more likely than ileostomists with normal Na excretion to have a low BMI [23.9 (14.3-33.0) vs 28.4 (16.6-43.0) kg/m(2) ; P < 0.001] and LBM [44.1 (19.3-73.0) vs 59.5 (36.6-67.9) kg; P < 0.001]. The respective 24-h output of Ca was [2.2 (0-6.1) vs 4.7 (0-13) mmol; P < 0.001] and Mg was [2.0 (0-13.7) vs 3.9 (1.2-5.4) mmol; P < 0.001], and BMD Z-score LS was -0.15 (-2.0 to 5.2) vs 0.3 (-2.5 to 2.1), Z-score FN -0.5 (-1.9 to 3.1) vs 0.2 (-1.2 to 1.4), both P < 0.05. CONCLUSION: Patients with an ileostomy tend to have low body weight, BMI, LBM and BMD. They also tend to have low urine volumes, and some are depleted of Na, Ca and Mg. Abnormalities are greater in those with a lower urinary Na and measuring this will identify ileostomists at risk of Na depletion who will be benefitted by Na supplements.

Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management.

Patients accepting randomization in a randomized controlled trial (RCT) may not be representative of the clinical population from which they are drawn, calling into question the generalizability of study findings. Comparison of randomized and non-randomized inpatient and outpatient samples at baseline and in treatment outcomes up to one year was made to determine whether the findings of the RCT generalized to non-randomized patients in the same treatment program. One hundred and twenty one patients with intractable pain, randomized between inpatient, outpatient and waiting list control, were compared with 128 who elected for either inpatient or outpatient treatment. Treatment was a group-based multidisciplinary cognitive-behavioral treatment program aimed at enabling patients to return to more normal function despite persistent pain, delivered to mixed groups of randomized and elective patients, and outcome was measured by physical performance, pain impact on function, mood, and drug use. Agreement to randomization was a function of travelling distance from home to hospital. Non-randomized patients largely resembled their randomized counterparts before and after treatment. In order to indicate the clinical significance of results, analyses were conducted using numbers needed to treat (NNTs). NNTs estimate the number of patients required in the treatment condition for one of them to achieve the specified outcome who would not have achieved it in the comparison condition. Across a range of measures at one month follow-up, comparison of inpatients with outpatients gave NNTs between 2.3 and 7.5, and comparison of inpatients with waiting list controls gave NNTs between 2.3 and 3.6. At one year inpatients showed greater likelihood than outpatients of maintaining these treatment gains.

Medication misuse, abuse and dependence in chronic pain patients.

We report the prevalence of drug use, misuse, abuse, and dependence in 125 chronic pain patients attending specialist pain clinics in South London. A total of 110 patients (88%) were taking medications for their pain problem. Opioid analgesics (69.6%), nonopioids (48%), antidepressants (25%), and benzodiazepines (17.6%) were the drugs most frequently used. Psychoactive substance abuse or dependence (DSM-III-R) was diagnosed in 12%. A total of 9.6% of the patients met the DSM-III-R criteria for substance abuse or dependence in remission. Data are also presented on the misuse and abuse of nonpsychoactive drugs, qualitative information on how patients use drugs, and the information they have received about medication.

Iatrogenic factors and chronic pain.

OBJECTIVE: Although it is accepted that the etiology of chronic pain is multifactorial, little attention has been given to the possible role of iatrogenesis. The aim of the present study is to identify possible iatrogenic factors in chronic pain patients. METHODS: We report a cross-sectional study of 125 patients attending specialist pain clinics in South London. Data were collected using semistructured checklists. Patients were interviewed with a structured psychiatric interview and were given a questionnaire booklet to complete. RESULTS: We found that possible iatrogenic factors, such as over-investigation, inappropriate information and advice given to patients as well as misdiagnosis, over-treatment, and inappropriate prescription of medication were common in this sample. CONCLUSIONS: We suggest that future studies should take account of the role of the doctors, as well as that of the patients, in the etiology, and hence prevention of chronic pain.

Inpatient vs. outpatient pain management: results of a randomised controlled trial.

Inpatient and outpatient cognitive behavioural pain management programmes for mixed chronic pain patients were compared. Patients were randomly allocated to the 4 week inpatient programme or to the 8 half day per week outpatient programme, or to a waiting list control group. Staff, teaching materials, and setting were the same for the two treatment groups. Patients were assessed pre-treatment, and at 1 month after discharge, and treated patients also at 6 months and 1 year after discharge, by assessors blind to treatment group; assessments included physical, functional and psychological measures, and medication use. In total, 121 mixed chronic pain patients (mean age 50 years; mean chronicity 8.1 years) were included in the study, following medical examination to ensure that no further medical treatment was appropriate. There was no change in the control group; inpatients and outpatients, comparable before treatment, both made significant improvements in physical performance and psychological function, and reduced medication use. Inpatients made greater gains, and maintained them better at 1 year; they also used less health care than outpatients. There were no outstanding predictors of improvement other than treatment group.

Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain.

The aim of this prospective longitudinal study was to evaluate an inpatient cognitive behavioural pain management programme for patients with chronic pain. A physical and psychological assessment of patients was carried out before and after treatment, and at one and six months follow up. A total of 212 patients with disabling chronic pain of mean duration 10.5 years, for whom no further medical or psychiatric treatment was appropriate or available, were admitted; their mean age was 50 years and 65% were women. The four week programme was delivered by a multidisciplinary team of two psychologists, a physiotherapist, nurse, occupational therapist and anaesthetist. The main components of therapy included: education, teaching behavioural and cognitive skills, a stretch and exercise programme, medication reduction, goal setting and pacing, and relaxation training. Outcome measures assessed quality of life, physical performance (for example walking speed), pain intensity and distress, depression severity and confidence. Assessment immediately after treatment revealed significant improvements on all measures. Improvements were well maintained at six month follow up. Cognitive behavioural treatment can be of value in improving the day-to-day functioning and quality of life of patients with chronic pain for whom conventional medical treatments have apparently failed.

The effect of a priming epidural injection of adrenaline on epidural blockade with bupivacaine.

Twenty-four patients receiving epidural anaesthesia were studied to test the hypothesis that 1:200,000 adrenaline administered into the epidural space 5 minutes before 20 ml bupivacaine 0.5% would improve nerve block and delay systemic absorption of the local anaesthetic. Group A/B received 20 ml adrenaline 1:200,000 5 minutes before 20 ml bupivacaine 0.5%, group S/BA 20 ml saline followed by 20 ml bupivacaine 0.5% with 100 micrograms adrenaline, and group S/B saline 20 ml followed by 20 ml plain bupivacaine 0.5%. Mean maximum plasma concentrations of bupivacaine tended to be lower in the adrenaline groups. A delay in the time to peak plasma concentration of bupivacaine was noted in the A/B group; this indicated that priming with adrenaline may be effective at delaying early systemic uptake of the local anaesthetic. In both adrenaline groups a more prolonged epidural block and increased efficacy were noted, although this was only significant for the duration of block at T6 (p = 0.023) and duration of motor block at Bromage level 1 (p = 0.016) in group A/B. There seems little clinical advantage in administering adrenaline 5 minutes before bupivacaine.

Psychological approaches in chronic pain management.

Psychological factors are contributory to the genesis and maintenance of many chronic pain syndromes. Treatment can be delivered either as one component of multimodal therapy or as the sole approach in a pain management programme. This distinction is important as it has a bearing on the goals of treatment, which in the latter situation is to improve management of the pain and encourage the patient to take more responsibility for their treatment, rather than cure the illness. Treatment typically comprises elements of operant conditioning, where activity and performance can be substantially improved, and cognitive therapy where the thoughts and emotions associated with the pain are tackled, leading to diminution of distress. Relaxation training is also of benefit. The documented success of these techniques in various settings suggests that psychological treatment should be considered a necessary component of any multidisciplinary clinic offering therapies to chronic pain sufferers.