Ethnicity, length of time on the register and sex predict donor availability at the confirmatory typing stage.

Despite over 20 million unrelated donors being listed worldwide, donor attrition at the confirmatory typing (CT) stage of donor acquisition is a key source of delay. Anthony Nolan undertook a study of CT requests from 2010 to 2011 to identify factors associated with attrition. Of 7541 CT requests, 38.2% were cancelled for donor reasons. Of these, 19.4% were personal, 34.1% medical, 36% no contact, 7.9% emigrated and 2.6% others. African (odds ratio (OR) 2.78, P<0.001), African-Caribbean (OR 3.07, P<0.001), Asian (OR 2.65, P<0.001), Jewish (OR 1.54, P=0.009) and Mediterranean (OR=2.38, P<0.001) donors were more likely not to be available compared to Caucasian donors. Female donors were also more likely not to be available (OR=1.32, P<0.001): primarily due to pregnancy. Older donors were less likely to be available in univariate analysis, but this association was not significant after controlling for other factors. Blood donors and those recruited within the past five years had lower rates of attrition. Accumulation of additional attrition-associated characteristics for a given donor was associated with progressively greater odds of attrition (OR 1.99, 2.52, 3.4 and 5.53, respectively, for 1, 2, 3 and 4 risk factors, P<0.001). Donor registries must develop evidence-driven strategies to recruit and retain the most reliable donors.

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.

Immediate and long-term somatic effects, and health-related quality of life of BM donation during early childhood. A single-center report in 210 pediatric donors.

Since 1968, when Leiden undertook the first successful European pediatric BM transplantation with a 7-year-old sibling donor, more than 300 young children have donated BM in our unit. We first retrospectively studied a cohort of 210 donors, younger than 13 years at donation, to survey procedures of donor eligibility and study immediate effects of BM donation. We then performed a long-term follow-up (FU) and health-related quality of life (HRQoL) study. Despite documentation of previous medical conditions, no child was declared unfit to donate. We found that iron deficiency anemia or low-iron stores in BM did not result in treatment or extended FU. Harvest volumes exceeded 15 mL/kg in 65% of donors, with more than half requiring allogeneic blood transfusions. Donors had no structured FU after their first post-donation control. In this study, 25% of donors reported at least one somatic complaint at long-term FU. Finally long-term HRQoL revealed high scores in most subdomains (representing a higher QoL), compared to norm groups. These results indicate the need for development of (inter)national guidelines for pediatric stem cell donor care management.

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 member's 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.

Managing a dual role--experiences and coping strategies of parents donating haploidentical G-CSF mobilized peripheral blood stem cells to their children.

UNLABELLED: Hematopoietic stem cell transplantation is an effective therapy for life-threatening hematological diseases. Parents may be asked to donate hematopoietic stem cells for their child when no compatible related or unrelated donor is available. OBJECTIVE: Parents donating G-CSF mobilized peripheral blood stem cells simultaneously and uniquely fulfill the dual role of donor and caregiver for their ill child. The experiences of both sibling and unrelated stem cell donors have been extensively reported but not those of parental donors. METHODS: We therefore undertook a study specifically to investigate the experiences and coping strategies of parental stem cell donors. In-depth qualitative interviews were conducted with 13 parental donors, which were subsequently transcribed and subjected to thematic analysis. In addition, parental coping was assessed utilizing the Utrecht Coping List. RESULTS: Qualitative analyses revealed four main thematic categories describing the way parental stem cell donation was experienced, namely 'Hope and Fear', 'Need for Information', 'Do Anything for your Child' and 'Transplant Outcome' In addition parents noted similar difficulties which were unrelated to their specific role as a donor, for example they felt socially isolated. CONCLUSIONS: Individual information for the parents needs to address not only the transplantation procedure but particularly those aspects related to the donation process. We feel there is a need for a protocol specifically designed to support and coach parental donors.

Obstetric health care workers' attitudes and beliefs regarding influenza vaccination in pregnancy.

OBJECTIVE: To explore obstetric health care workers' attitudes and beliefs regarding influenza vaccination in pregnancy. METHODS: A survey consisting of 16 multiple-choice questions was administered to nurses, medical and nursing assistants, receptionists, and clinical administrators in obstetric settings. Survey questions addressed general knowledge of influenza and recommendations for vaccination during pregnancy, as well as personal beliefs about the acceptability of the vaccine in the pregnant population. The study was conducted at two sites, Women & Infants Hospital in Providence, RI, and Magee-Women's Hospital in Pittsburgh, PA. Variables were compared by Fisher exact test. RESULTS: Two hundred sixty-seven completed surveys were available for analysis, with a completion rate of 85%. Almost one third of health care workers surveyed do not believe that vaccines are a safe and effective way to decrease infections (31%) and a minority believe that vaccines are safe in pregnancy (36%). Just over half of health care workers know that pregnant women are at increased risk of complications from the flu (56.6%). Only 46% were able to correctly identify influenza symptoms, and only 65% would recommend influenza vaccination to a pregnant woman if indicated. A small percentage would be willing to give an avian influenza vaccine to pregnant women during a pandemic if it had not been tested in pregnancy (12.3%). CONCLUSION: Many obstetric health care workers lack knowledge regarding the safety and importance of influenza vaccination during pregnancy. Misinformed or inadequately informed health care workers may represent a barrier to influenza vaccine coverage of pregnant women. This lack of knowledge among the health care workforce takes on added importance in the setting of the H1N1 2009 swine-origin influenza pandemic. LEVEL OF EVIDENCE: III.

Trajectories of change in quality of life in 12-month survivors of lung or heart transplant.

Survival and functional outcomes for lung transplant recipients continue to lag behind those for heart recipients. Whether these poorer physical outcomes translate into poorer quality of life (QOL) for lung recipients relative to heart recipients is unknown. Lung versus heart transplant recipients' perceptions of QOL were longitudinally compared at three time-points across the first year posttransplant. Additionally, potentially important predictors of patient QOL were examined. Adult transplant recipients (N = 199) participated in semi-structured interviews that included measures of QOL, optimism, mastery, social support, religiosity and coping. Temporal patterns of QOL change were compared between lung and heart recipients who survived until 1 year posttransplant using mixed-model, hierarchical analysis of variance (ANOVA). Demographic and psychosocial predictors were examined with multiple regression analysis to identify the unique effects of each variable on QOL 1 year posttransplant. While heart recipients' QOL across several domains was higher shortly after transplant, lung patients' QOL improved and was equivalent to that of heart recipients by 1 year posttransplant. Greater optimism and support from friends predicted better QOL in physical, psychological and social domains. Conversely, avoidant coping strategies predicted poorer physical functioning. Thus, while clinical interventions designed to improve QOL posttransplant should be tailored to transplant recipients' initial psychosocial assets and liabilities, they need not be distinguished by transplant type.

Patient satisfaction in resident and attending ambulatory care clinics.

OBJECTIVE: To measure and compare patient satisfaction with care in resident and attending physician internal medicine ambulatory care clinics. DESIGN: A cross-sectional survey using a questionnaire derived from the Visit-Specific Satisfaction Questionnaire (VSQ) and Patient Satisfaction Index (PSI) distributed from March 1998 to May 1998. SETTING: Four clinics based at a university teaching hospital and the associated Veterans' Affairs (VA) hospital. PARTICIPANTS: Two hundred eighty-eight patients of 76 resident and 25 attending physicians. RESULTS: Patients of resident physicians at the university site were more likely to be African American, male, have lower socioeconomic status and have lower physical and mental health scores on the Short Form-12 than patients of university attendings. Patients of resident and attending physicians at the VA site were similar. In multivariate analyses, patients of university attending physicians were more likely to be highly satisfied than patients of university residents on the VSQ-Physician (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.8) and the PSI-Physician (OR, 10.1; 95% CI, 3.7 to 27.4) summary scores. Differences were not seen on the summary scores at the VA site. Two individual items displayed significant differences between residents and attendings at both sites: "personal manner (courtesy, respect, sensitivity, friendliness) of the doctor" (P

What factors influence physicians' decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia?

OBJECTIVE: One of the major factors influencing length of stay for patients with community-acquired pneumonia is the timing of conversion from intravenous to oral antibiotics. We measured physician attitudes and beliefs about the antibiotic switch decision and assessed physician characteristics associated with practice beliefs. DESIGN: Written survey assessing attitudes about the antibiotic conversion decision. SETTING: Seven teaching and non-teaching hospitals in Pittsburgh, Pa. PARTICIPANTS: Three hundred forty-five generalist and specialist attending physicians who manage pneumonia in 7 hospitals. MEASUREMENTS AND RESULTS: Factors rated as "very important" to the antibiotic conversion decision were: absence of suppurative infection (93%), ability to maintain oral intake (79%), respiratory rate at baseline (64%), no positive blood cultures (63%), normal temperature (62%), oxygenation at baseline (55%), and mental status at baseline (50%). The median thresholds at which physicians believed a typical patient could be converted to oral therapy were: temperature < or =100 degrees F (37.8 degrees C), respiratory rate < or =20 breaths/minute, heart rate < or =100 beats/minute, systolic blood pressure > or =100 mm Hg, and room air oxygen saturation > or =90%. Fifty-eight percent of physicians felt that "patients should be afebrile for 24 hours before conversion to oral antibiotics," and 19% said, "patients should receive a standard duration of intravenous antibiotics." In univariate analyses, pulmonary and infectious diseases physicians were the most predisposed towards early conversion to oral antibiotics, and other medical specialists were the least predisposed, with generalists being intermediate (P <.019). In multivariate analyses, practice beliefs were associated with age, inpatient care activities, attitudes about guidelines, and agreeableness on a personality inventory scale. CONCLUSIONS: Physicians believed that patients could be switched to oral antibiotics once vital signs and mental status had stabilized and oral intake was possible. However, there was considerable variation in several antibiotic practice beliefs. Guidelines and pathways to streamline antibiotic therapy should include educational strategies to address some of these differences in attitudes.

Prevalence and risk of depression and anxiety-related disorders during the first three years after heart transplantation.

Although poor psychological adjustment to organ transplantation appears to be a major contributor to reduced quality of life and increased physical morbidity, the prevalence and risk factors for psychiatric disorder have not been considered beyond the first 12-18 months after transplantation. The authors enrolled a representative sample of 191 heart transplant recipients in a prospective examination of the prevalence, clinical characteristics, and risk factors for DSM-III-R major depressive disorder (MDD), generalized anxiety disorder (GAD), associated adjustment disorders, and posttraumatic stress disorder related to transplant (PTSD-T) during the 3 years postsurgery. Survival analysis indicates that cumulative risks for disorder onset were MDD, 25.5%; adjustment disorders, 20.8% (17.7% with anxious mood); PTSD-T, 17.0%; and any assessed disorder, 38.3%. There was only one case of GAD. PTSD-T onset was limited almost exclusively to the first year posttransplant. Episodes of MDD (but not anxiety disorders) that occurred later posttransplant (8 to 36 months postsurgery) were more likely than early posttransplant episodes to be treated with psychotropic medications. For both MDD and anxiety disorders, later episodes were less likely to be precipitated by transplant-related stressors than other life stressors. Factors increasing cumulative risk for psychiatric disorder posttransplant included pretransplant psychiatric history, female gender, longer hospitalization, more impaired physical functional status, and lower social supports from caregiver and family in the perioperative period. Risk factors' effects were additive; the presence of an increasing number of risk factors bore a dose-response relationship to cumulative risk of disorder.

Donating stimulated peripheral blood stem cells vs bone marrow: do donors experience the procedures differently?

As the demand for undifferentiated stem cells for the treatment of leukemia and other cancers has increased, new methods for their collection have been developed. One of these new methods, allogeneic peripheral blood stem cell (PBSC) donation, involves the administration of a granulocyte colony-stimulating factor (G-CSF, filgrastim), and a 1-2 day apheresis collection procedure. Our goal in the current study was to examine donors' psychosocial and physical experiences of PBSC vs marrow donation. Potential participants included 80 donors from the National Marrow Donor Program (NMDP) who donated a second time between 1991 and 1997. All of these donors had previously donated marrow. A final cohort of 70 donors (25 PBSC and 45 marrow) participated in a retrospective questionnaire study of their donation experiences. In general, all second-time donors reported low levels of concern about the physical consequences of donation. However, PBSC donors were more likely to have postponed the decision to donate a second time. Despite their reservations, PBSC donors reported fewer donation-related side-effects than did marrow donors. Finally, PBSC donors reported that marrow donation was more physically difficult, time-consuming, and inconvenient, and that they preferred PBSC to marrow donation.

Non-HLA barriers to unrelated donor stem cell transplantation.

A prospective survey involving 544 searches of the US National Marrow Donor Program (NMDP) Registry was conducted to identify reasons why many patients who have apparent HLA-matched donors do not proceed to transplant. Coordinators at NMDP transplant centers, patients and referring physicians were surveyed shortly after the initial search, and follow-up surveys were sent to the coordinators as the search was ongoing. The death of the patient, worsening of the patient's medical condition and length of the search process were the most commonly cited barriers to transplantation. Other times a decision was made not to transplant through the NMDP due to the use of a donor from another source, a preference for chemotherapy or immunotherapy, hesitancy on the part of the transplant physician or patient, or because the patient did not require a transplant. Responses differed between U.S. and international cases. An unrelated donor outside the NMDP was the most common reason cited by international coordinators (46%), whereas the death of the patient was the most common reason among US coordinators (13%). The death of the patient was the second most common reason cited by international coordinators at 9%. Financial problems were listed by 41% of US coordinators as a potential barrier at the time of initial search, but only 5% indicated this as an actual barrier on a follow-up survey. Finances were cited as the most important reason 3% of the time overall, and 6% for African Americans and Asian/Pacific Islanders.

Psychosocial assessments and outcomes in organ transplantation.

A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.

Psychological symptom levels and their correlates in lung and heart-lung transplant recipients.

This study examined depression, anxiety, and anger-hostility symptom levels, as well as overall quality of life, in a cohort of 50 lung and heart-lung transplant recipients. Only the subjects' mean anxiety symptoms were substantially elevated over normative levels. However, nearly half of the sample showed clinically significant distress in one or more of the three symptom areas. Pretransplant psychiatric history, educational level, posttransplant caregiver support, and health concerns were the most important independent correlates of the recipients' psychological outcome. Low sense of mastery and poorer physical functional status also showed some evidence of association with mental health.

Selecting, developing, and evaluating research instruments.

The goal of this paper is to provide researchers who are not experts in psychometric theory with a concise guide to instrument selection, development and evaluation. Issues of context - factors related to the setting or population in which an instrument will be used - and psychometrics - the functioning of an instrument within a given context - are reviewed and discussed. Finally, four categories or types of instruments, and the psychometric analyses that are necessary for establishing the reliability and validity of each type, are described.

Factors associated with attrition from a national bone marrow registry.

During its 10-year existence, the National Marrow Donor Program (NMDP) has been extremely successful at recruiting potential bone marrow donors to join the volunteer registry. Due in part to successful recruitment and the longevity of the registry, the focus of the NMDP has now shifted to decreasing potential attrition when volunteers are recontacted for additional testing to determine whether they would be the optimal donor for a specific patient. Our own interest in the bone marrow donation process led us to examine four domains of variables - demographic characteristics, volunteer history, recruitment-related characteristics and donation-related concerns - that we hypothesized would be associated with increased likelihood of donor attrition at a key donor decision-point (DR-stage blood typing). Questionnaires were mailed to potential donors after they were contacted at the DR-stage, and had made the decision of whether or not to continue with blood typing. Our final sample included 756 volunteers who decided to continue with typing, and 258 individuals who declined further participation in the registry. In the bivariate analyses, factors in three of the four domains (all except demographic characteristics) were found to be substantially correlated with likelihood of attrition. Logistic regression indicated that nine central variables across the three domains produced the majority of increased attrition likelihood. Finally, a dose-response analysis suggested that as the number of attrition-related factors endorsed by an individual increased, his/her likelihood of dropping out of the registry also increased. Implications for future research and interventions to reduce potential donor attrition are discussed.

PTSD in heart transplant recipients and their primary family caregivers.

Posttraumatic stress disorder associated with transplantation (PTSD-T) is a complication for some heart transplant recipients. By using a structured, standardized interview and DSM-III-R criteria, the authors examined whether recipients (n = 158) and their family caregivers (n = 142) showed similar PTSD-T rates and clinical characteristics during the first year posttransplant. Among the recipients, 10.5% met full criteria for the disorder and an additional 5% were probable cases. Among the caregivers, 7.7% met full criteria and an additional 11.0% were probable cases. Severity and duration of disorder were similar across the groups. Being female, having a history of psychiatric illness, and having lower friend support were increased risks for PTSD-T.