Tesis sobre el tema "Organ Transplant Recipient"

Positive health-related behaviour is particularly important for liver transplant recipients’ (LTRs) recovery. However, non-adherence in adolescents post-transplant is thought to be greater than, or equal to, 50%. Literature searches have found limited research into the area of young adults’ experiences of having a donated liver. Knowing more of their experience seems important to help inform practice to improve adherence and ultimately save lives. The present study aimed to construct a grounded theory of young adults’ experiences of having a liver transplant, in order to better understand how young adults may adjust following such experiences. Semi-structured interviews were conducted with twelve liver transplant recipients (LTRs; five female, seven male). Data were analysed using constructivist grounded theory. A model was constructed to capture the dynamic interactions between thirteen categories, resulting in four main themes: Finding Identity Post-Transplant, Carrying Responsibility, Unseen, Unspoken or Misunderstood Challenges and Adjusting to Life After Transplant. The study highlights the importance of the themes in psychological adjustment post-transplant. Understanding this process is imperative in order to improve health-related behaviours in a cohort with traditionally poor adherence. Implications for further research and clinical practice are discussed, including educating LTRs to raise their levels of self-efficacy, which have a positive impact on adherence.

Bakgrund: I Sverige utfördes den första hjärttransplantationen år 1984 i Göteborg. En ökande trend har identifierats genom åren och Sverige är det land som utför flest hjärttransplantationer i Skandinavien. Det är vid svår hjärtsvikt som den drabbade kan bli kandidat för eventuell hjärttransplantation och sjuksköterskan har en nyckelroll i omvårdnaden av dessa patienter. Omvårdnadens syfte är att förbättra patientens chans för överlevnad och livskvalitet. Syfte: Beskriva organmottagares upplevelser av att ha genomgått en hjärttransplantation. Metod: En litteraturbaserad metod för att bidra till evidensbaserad omvårdnad med grund i analys av kvalitativ forskning. Resultat: Fyra kategorier identifierades; En ny livssituation, förändrad syn på livet, ta del av andra erfarenheter och nya tankar inför framtiden, med tio underkategorier. Konklusion: Resultatet visar att patienter som genomgått en hjärttransplantation upplever en förändrad vardag och livssyn. Nya insikter om livet och upplevelse av att fått en ny chans skapas. Detta väcker känsla av tacksamhet och skyldighet gentemot sin donator. Majoriteten av patienterna upplevde att stödet från sjukvården var bristfälligt, både inför och efter operationen och att det är bristen på information som upplevs som central.
Background: The first heart transplant performed in Sweden took place in 1984 in Gothenburg. An increasing trend has been identified over the years and Sweden is the country that performs most heart transplants in Scandinavia. It is in case of severe heart failure that the affected person can become a candidate for any heart transplant and the nurse has a key role in the care of these patients. The purpose of nursing is to improve the patient's chance of survival and quality of life. Aim: The aim was to describe the organ recipient’ experience after having a heart transplant. Method: A literature-based study where the data consisted of qualitative articles. Result: Four categories were identified; A new life situation, changed view of life, influence from others and new thoughts about the future with ten subcategories. Conclusion: The result shows that patients who have undergone a heart transplant experience a changed everyday life and belief. New insights about life and the experience of having a new chance created. This arouses a sense of gratitude and obligation towards their donor. The majority of the patients felt that the support from the health service was inadequate, both before and after the surgery and that it is the lack of information that is perceived as central.

Is well known that physical activity reduces rate of cardiovascular and all-cause mortality in the general population and in transplanted recipients. However, most of those investigations present limits. Few data are available on exercise effectiveness on kidney and liver transplant recipients and the correlation between practising exercise, lipid profile and renal function. Additionally, the knowledge on the amount of safe training for sport competitions for this population is limited. This thesis aims to increase the knowledge on the type of exercise and training adapted for transplant recipients and its relative effects on aerobic capacity, strength and quality of life. Moreover, correlation between exercise and blood pressure parameters in solid organ transplant are considered for safeguard of the graft function. The first part of this thesis focuses on the effects of exercise in kidney and liver transplant recipients by health pathways. The second part focus on the sport in solid organ transplant recipients to break down the prejudice that “transplantation” and “sport” cannot coexist. In detail, we investigate the renal function, metabolic profile, glycemia and the physical fitness after 12 months of supervised aerobic and resistance training in kidney and liver transplant recipients, compared with not supervised home-based physical activity. The results of these studies can provide information on the beneficial effects of combined exercise and identify the type of safe exercise to prescribe for the kidney and liver transplant population. These indications are intended to encourage the healthcare world to refer pre-and post-transplant patients to follow a healthy lifestyle including regular exercise for the prevention of cardiovascular diseases. To obtain more adherence in the prescription of exercise in transplant patients a study promote the network in which transplant centers, sports medicine centers and certified gyms collaborate to encourage the practice of prescribed and controlled exercise in pre- and post-transplant patients.

There is limited research on music therapy for transplant recipients, yet board-certified music therapists working in medical settings often encounter individuals from the transplant population. The purpose of this study was to examine the current practices of music therapists working with bone marrow and organ transplant recipients. A total of 68 board-certified music therapists completed an online survey, providing information related to goal areas addressed in music therapy sessions and interventions frequently used with bone marrow and organ transplant patients. The most frequently reported goal areas included: coping skills, mood, and self-expression. The most frequently reported interventions included: singing, songwriting, and improvisation. Survey respondents also shared opinions related to the need for additional resources for music therapists working with transplant recipients, as well as the most rewarding and challenging aspects of working with transplant patients. Study limitations, suggestions for future research, and implications for clinical practice are included.

IMPORTANCE Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States. OBJECTIVE To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. MAIN OUTCOMES AND MEASURES Incident skin cancerwas determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). RESULTS Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). CONCLUSIONS AND RELEVANCE Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Transplantation requires complex self-management regimens and life-long follow-up care to maintain graft survival and well-being. “eHealth”, defined as the use of the Internet and related digital technology to provide health services, can be utilised to promote self-management, facilitate patient-clinician communication, and improve clinical outcomes in chronic disease. However, there is insufficient evidence to support the routine adaption of eHealth use in kidney transplant recipients. This program of work will address uncertainties in the literature surrounding the effectiveness of eHealth in transplant care. Chapter 2 of this thesis provides a systematic review and meta-analysis of the benefits and harms of eHealth in post-transplant care. Medication taking remains the cornerstone of graft preservation and is a critical part of the self-management regime in transplant care. Chapter 3 of this thesis provides a systematic qualitative review of transplant recipients’ medication-taking perspectives. Chapter 4 addresses the uncertainties of transplant recipients’ perspectives on digital health technology. Therefore, we conducted semi-structured interviews among kidney transplant recipients to understand the perspectives and experiences of eHealth. Understanding the acceptance patterns and preferences for eHealth use in kidney transplant recipients will facilitate digital technology in transplant care. Chapters 5 and 6 of this thesis investigate the determinants and preferences of eHealth uptake in kidney transplant care. This thesis contains published or submitted studies that collectively assess the value of eHealth in transplantation, better understand medication-taking as part of self-management, describe recipients beliefs and experience for eHealth, and understand the determinants and preferences associated with eHealth uptake.

Case reports describe significant norovirus gastroenteritis morbidity in immunocompromised patients. We evaluated norovirus pathogenesis in prospectively enrolled solid organ (SOT) and hematopoietic stem cell transplant (HSCT) patients with diarrhea who presented to Texas Children's Hospital and submitted stool for enteric testing. Noroviruses were detected by real-time reverse transcription polymerase chain reaction. Clinical outcomes of norovirus diarrhea and non-norovirus diarrhea patients, matched by transplanted organ type, were compared. Norovirus infection was identified in 25 (22%) of 116 patients, more frequently than other enteropathogens. Fifty percent of norovirus patients experienced diarrhea lasting ≥14 days, with median duration of 12.5 days (range 1–324 days); 29% developed diarrhea recurrence. Fifty-five percent of norovirus patients were hospitalized for diarrhea, with 27% requiring intensive care unit (ICU) admission. One HSCT recipient developed pneumatosis intestinalis. Three HSCT patients expired ≤6 months of norovirus diarrhea onset. Compared to non-norovirus diarrhea patients, norovirus patients experienced significantly more frequent ICU admission (27% vs. 0%, p = 0.02), greater serum creatinine rise (median 0.3 vs. 0.2 mg/dL, p = 0.01), and more weight loss (median 1.6 vs. 0.6 kg, p < 0.01). Noroviruses are an important cause of diarrhea in pediatric transplant patients and are associated with significant clinical complications.

I takt med att behovet av organ ökar utförs det fler organtransplantationer varje år. För att kunna få ett nytt organ innebär det för många att någon annan avlider under de omständigheterna så att organen kan doneras, och framförallt att viljan att donera sina organ finns från den avlidne eller dess anhöriga. Ett beslut som kan ge flera andra livet tillbaka. Transplantationsprocessen är lång och slutar inte när det nya organet är transplanterat, förutom livslång medicinering kan många tankar och frågor uppstå. Syftet med studien var att beskriva patienters upplevelser att leva med ett organ från en avliden donator. Studien genomfördes som en allmän litteraturstudie där tio resultatartiklar som svarade till studiens syfte granskades och sammanställdes, vilket resulterade i fem teman; Upplevelser av tacksamhet, Upplevelser av ansvar inför donator, Upplevelser av ett förändrat själv, Upplevelser av skuld samt Upplevelser av sorg. Huvudfynden i resultatet var att mottagarna upplevde en förändring av sig själva efter transplantationen samt upplevelser av tacksamhet över att ha fått en andra chans i livet. För att hantera förändringen krävs det hjälp och förståelse från sjukvården. Större förståelse kring mottagares upplevelser efter transplantationen med organ från en avliden donator behövs för att bättre kunna bemöta deras behov.
The need for organ transplants has risen considerably, that is why there are more organ transplants carried out each year. To acquire a new organ means for many that somebody has to die during circumstances that an organ can be donated and the donor or their relatives must have a will to donate their organ. The transplant process is long and doesn't end when the new organ is transplanted, in addition to lifelong medication there can be many thoughts and questions that can arise. The purpose of this study was to describe the patients experience to live with an organ from a deceased donor. The study was carried out like a general literature study. The ten resulting articles were assessed, compiled and resulted in the following five themes: Experience of gratefulness, Experience of responsibility to the donator, Experience of a changed self, Experience of guilt and Experience of grief. The main findings from the study is that the recipient experiences a change in their self and experience of gratefulness. A wider understanding around the recipient experiences after a transplant with an organ from a deceased donor, where personal treatment is needed to support the requirements.

The use of quality-of-life as an outcome measure provides detailed information about the effectiveness of medical treatments than morbidity or mortality rates alone. The use of quality-of-life data in the clinical setting can inform patients regarding treatment options, treatment benefits and costs. In competing health care markets, outcome measurement is regarded as important as it is concerned with the impact of health care practice and affects health policy decisions. Doessel (1978) conducted the first Australian study on the cost-effectiveness analysis of renal replacement therapies. The study was based on Klarman, Francis & Rosenthal's (1968) the study, where the output was measured in terms of the number of life years gained from kidney transplantation, and a twenty-five percent weight was allocated in an attempt to capture quality-of-life from kidney transplantation. Doessel (1978) used two sources of data: Australian data (Disney 1974) and European data (Gurland et al. 1973; Shiel et al. 1974). The study measured life years gained, and agreed with the Klarman et al. (1974) findings that transplantation is the most effective way to increase life expectancy of persons with chronic renal disease (Butler & Doessel 1989). The outputs of the alternative treatments were not reported in monetary terms; the study focused on life years gained as the output measure. Hence the importance of this current study, which includes a cost-effectiveness analysis for cadaver liver, and living kidney transplantation for end-stage liver and kidney disease patients. Calls to respect patient autonomy and to produce patient-centered outcomes have recently brought the patient’s point of view back into the center of clinical medicine (Sullivan 2003). Survival rates indicate one measure of outcome however they do not reflect patients’ perceptions of health benefit or experiences. Noting that patients’ psychosocial effect on functioning is of more concern to them than their physical Thesis Preamble iii ability, that more accurate knowledge of patients’ conditions be measured prior to transplantation (Tarter et al. 1991). Recently researchers advocated investigating transplant patients' states of health to assess the social benefit of these expensive health care services from their perspective (Joralemon & Fujinaga 1997). The current study's mixed method, bridges the gaps in treatment outcome measurements, as the mixed method applied (Creswell 1994; Sim & Sharp 1998) prospectively measured quality-oflife, determined health utility, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). The study reported the living donors experience of the donation process, described their needs; expressed using a new psychosocial model supporting future living kidney donor's during the donation process.

The purpose of this study is to identify and explore issues and challenges that impact on transplant coordinators and their practice. Such identification enhances understanding of their role, provides evidence for decision-makers to facilitate the positive aspects of the coordinators' practice, highlights their professional needs and contributions and provides baseline data for future research, education and policy development. The study used both qualitative and quantitative data. Data collection methods involved focus group interviews and Delphi surveys. Participants were coordinators who were employed on a full-time, part-time or relieving basis. Recruitment of participants was done by purposive and snowball sampling. There were 112 coordinators in the study and each was randomly assigned to the focus groups or Delphi survey phases of the research. The analysis of the focus group data together with the literature, informed the development of the first Delphi survey. The second Delphi survey was developed using the data from the focus groups, literature and the first survey. Four categories emerged from the data. The first involved 'knowledge and experience', which explored the education needs of coordinators and the issue of nursing qualification requirements. The work environment, demands and conditions, together with role attributes were discussed in the next category - 'the role'. Recipient, donor family and transplant coordinator outcomes were addressed in the 'outcomes’ category. The basic social process – building relationships - explored the relationships that coordinators have with the health team and their client groups. Four types of relationships emerged which were supportive, non-supportive, aggressive and virtual relationships. The emergent theory of the challenges that transplant coordinators face relates to the building of relationships. The theory also discovers how knowledge and experience, the role and outcomes impact on the building of these relationships in an interdependent manner. This study also emphasises that the transplant coordinators' role is complex, demanding and distinctly unique in terms of the context within which coordinators practice.
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Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 2008

The purpose of this study is to identify and explore issues and challenges that impact on transplant coordinators and their practice. Such identification enhances understanding of their role, provides evidence for decision-makers to facilitate the positive aspects of the coordinators' practice, highlights their professional needs and contributions and provides baseline data for future research, education and policy development. The study used both qualitative and quantitative data. Data collection methods involved focus group interviews and Delphi surveys. Participants were coordinators who were employed on a full-time, part-time or relieving basis. Recruitment of participants was done by purposive and snowball sampling. There were 112 coordinators in the study and each was randomly assigned to the focus groups or Delphi survey phases of the research. The analysis of the focus group data together with the literature, informed the development of the first Delphi survey. The second Delphi survey was developed using the data from the focus groups, literature and the first survey. Four categories emerged from the data. The first involved 'knowledge and experience', which explored the education needs of coordinators and the issue of nursing qualification requirements. The work environment, demands and conditions, together with role attributes were discussed in the next category - 'the role'. Recipient, donor family and transplant coordinator outcomes were addressed in the 'outcomes’ category. The basic social process – building relationships - explored the relationships that coordinators have with the health team and their client groups. Four types of relationships emerged which were supportive, non-supportive, aggressive and virtual relationships. The emergent theory of the challenges that transplant coordinators face relates to the building of relationships. The theory also discovers how knowledge and experience, the role and outcomes impact on the building of these relationships in an interdependent manner. This study also emphasises that the transplant coordinators' role is complex, demanding and distinctly unique in terms of the context within which coordinators practice.
Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 2008

碩士
臺北醫學大學
醫學人文研究所
94
In Taiwan, organ transplantation has become a choice of treatments for end-stage organ diseases. After the success of transplantation surgery, the patients must face mental and physical pressure, challenge of social adjustment, personal economic problems and even the near-death experience. Besides, the receivers have to encounter the death of the donators while getting the surviving organs. The process of receiving a new organ is deeply mentally and socially influenced. As a result, the purpose of this study is trying to understand the mental and physical changes of the receivers, and also, to realize how they recognize, through the new organs, the relationship between themselves and the donators. How do they think about their donators? What are the factors that influence the images and conception of their donators? The study used qualitative method to interview 11 receivers of different organs, and, in the viewpoint of the patients, inspected their physical and mental changes in the hope of trying to get more true thoughts and feelings of the patients themselves. The result of the study showed that the patients’ short-term appearance changes caused by steroid taken after surgery have recovered to normal in about 6 months. In addition, the “recovery of the physical power” was the prominent physical improvement confirmed by all organ receivers. Receivers of liver transplantation even reached the functional level of common healthy people. “Fear” was the major feeling of heart and lung receivers in the initial period when new organs began to work in their bodies. They affirmed that the organs they had received are the most important organ among all. Good doctor-patient relationship and the transplantation patient groups both enhanced medical compliance. Interaction between patients helps provide mental support. Regarding patients’ interaction, the sequence of transplantation surgery plays an important role. The factors influencing the patients’ mental and physical status after the transplantation surgery are as the followings: health condition (which may cause change in life style), traumatic experiences during operation, reconsideration about life meaning, attributing the whole process to religious implication, thoughts about donators. Most receivers avoided talking about their donators .Which might be caused by medical concepts imposed during medical treatment process in the hospital system.

The main purpose of this study was to assess outcomes (i.e., inpatient mortality, transplant failure or rejection, colectomy, and hospital length of stay) of clostridium difficile infection (CDI) and the association of expenditures (i.e., charges and costs) and CDI in pediatric solid organ transplant (SOT) recipients. Data from the 2000, 2003, 2006, and 2009 Kids’ Inpatient Database (KID) files were used to identify events with SOT- related ICD-9-CM diagnosis codes. Logistic regression was used to assess the association of CDI and dichotomous outcome variables, while log-linked gamma regression models were used to assess the association of CDI and continuous outcome variables. Methods accounting for the complex survey sample design of the KID were used when performing all statistical analyses. The total number of pediatric SOT hospital events was 48,286. The overall prevalence of CDI for pediatric SOT hospitalizations was 1.76%. For SOT hospitalizations with CDI, inpatient mortality was 1.63%; the prevalence of transplant failure or rejection events was 27.71%; the prevalence of a colectomy was 4.86%. The median hospital length of stay was seven days; the median charge and cost for each hospitalization was $48,409 and $17,412, respectively. The results showed that CDI was not significantly associated with inpatient mortality or transplant failure/ rejection in pediatric SOT hospitalizations. SOT patients with CDI were 2.6 times more likely to have a colectomy than SOT patient without CDI. The mean hospital length of stay (LOS) for a SOT admission with CDI was approximately 2 times the mean LOS for a SOT admission without CDI. The mean charges and the mean costs for a SOT admission with CDI was approximately 2 times that for a SOT admission without CDI. In conclusion, CDI diagnoses were not significantly associated with higher inpatient mortality or transplant failure/ rejection for pediatric SOT hospitalizations. But CDI was significantly associated with a higher prevalence of a colectomy, longer hospital LOS, higher charges, and higher costs (all p<0.05). To avoid substantially higher expenditures and health care utilization, CDI in pediatric SOT recipients should be prevented when possible and promptly diagnosed and treated when it occurs.
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Study Purpose and Rationale The United States is witnessing growth in its aging population and an increase in the prevalence of end-stage renal disease, resulting in a substantial rise in kidney transplantation among adults age 65 and over. While older adult recipients fare better clinically than their counterparts on dialysis, far less is known about their psychosocial wellbeing following transplantation. A small body of qualitative work in organ transplantation suggests that there is an important period of adaptation following transplantation during which a recipient must incorporate the new organ into his or her sense of identity and bodily integrity. Difficulty navigating the adaptation process can have significant adverse effects on psychosocial and clinical outcomes, in extreme cases resulting in graft loss and even death. Employing a phenomenological approach, this study sought to better understand the lived experience of older adult kidney transplant recipients and the impact of kidney transplantation on their sense of identity and bodily integrity, with implications for the design of effective supports and interventions to optimize post-transplant mental health and wellbeing. Methods Applying the hermeneutic phenomenology of philosopher Paul Ricoeur, this study explored the lived experience of 10 kidney transplant recipients age 65 and over. Participants completed one to two in-depth phenomenological interviews lasting approximately one hour each. Interview transcripts and field notes were analyzed using an inductive approach, beginning with an epoché (bracketing) phase and followed by the processes of phenomenological reduction (textured description), imaginative variation (structured description) and synthesis to arrive at an understanding or approximation of the universal essence of the phenomenon of adapting to a kidney transplant. Findings Participants reported experiencing the “strangeness” of incorporating the organ of another person into their own body and concern over specific corporeal changes associated with dialysis and transplantation, expressing a disruption of their ‘idem’ sense of identity that ranged from mildly unsettling to deeply distressing. However, participants also articulated powerful narratives of resilience and coping, describing their ability to overcome adversity as an anchor of their ‘ipse’ sense of identity that allowed them to navigate idem corporeal changes over time. The continuity and strength of participants’ ipse sense of self over the life course enabled them to adjust to profound corporeal change, and for some participants kidney transplantation represented a form of liberation from ‘machine life’ (dialysis) and restoration of their idem sense of self. Conclusions/Implications Findings from this study have significant implications for ensuring the provision of optimal support to older adult kidney transplant recipients. A more nuanced understanding of the post-transplant experience of adapting to a new organ will enhance the informed consent process, providing the opportunity for transplant teams, potential recipients and their caregivers to engage in meaningful dialogue about the risks and benefits of the procedure and helping to establish expectations for post-transplant recovery. By shedding light on older adult recipients’ perspectives, findings also will help to inform the design of future research studies addressing candidacy for transplantation and post-transplant quality of life. Furthermore, study results will assist transplant teams in determining how to optimize post-transplant care and support for older adult recipients, thereby improving outcomes and contributing to the overall wellbeing of this population. Finally, the findings have implications for ongoing policy discussions in the field, including how to ensure equitable patient selection by establishing appropriate age-related criteria for kidney transplant recipients.

碩士
國立陽明大學
臨床暨社區護理研究所
97
Background In caring for the organ transplant (OT) donors and recipients, critical care nurses (CCN) are always challenged to effectively manage complex caring situations related to organ donors, recipients, their families, nursing and interdisciplinary health team members. It is important to learn their perspectives of caring dilemmas, needed helps, coping strategies between young and senior nurses. Purpose The purposes of this study were to explore CCN’s perspective of their caring dilemma for organ transplant donors and recipients, their needed help, and coping strategies between young and senior nurses. Method A qualitative exploratory study was used. A purposive sample of CCN with experiences of OT was obtained from a leading medical center in Central Taiwan. With semi-structured interview guide, data were collected by in-depth face-to-face interviews, and analyzed by qualitative content analysis mode. Results A total of 30 CCN (29 females, 1 male) participated in this peoject. They were aged between 26 ~ 44 (M ± SD = 36.3 ± 4.5) years old. Twenty-one of them were married, and 9 were single. The majority graduated from university or college. Fourteen of them reported a belief of combination of Confucianism and Buddhism, 9 were Buddhists, 5 were non-believers, and others were Taoist or Christian. In terms of nursing professional status, 21 were occupational nurses, 5 were registered nurses, 2 were nurse practitioners, and others were head nurse or assistant head nurse. The years of nursing profession ranged between 3 ~ 22 (M = 13.8) years; the years of organ transplant nursing care ranged between 0.5 ~ 15 (M = 4.10) years. Finally, 26 received OT training programs, and the rest reported having no related training. Five caring dilemmas were reported as: (a) limitations in medical resources; (b) lacking of sound mental preparations; (c) insufficient OT professional care competence; (d) workload of caring; and (e) inefficient coordination and communication between OT team members. Several explicit needed help were identified as: (a) a functional OT center and long-term OT caring team; (b) improvement in medical equipments and materials; (c) holding periodical single/multiple OT case conference and forum; (d) bereavement care for the donors’ and recipient’s family; (e) OT nursing care standard operating procedure (SOP); (f) comprehensive humanistic training program; (g) comprehensive OT in-service training programs; (h) opportunities of national and/or overseas advanced OT training for senior CCN; (I) encouragement from peers, superiors, and medical team members; (j) stress-managing protocols for CCN; (k) sufficient nursing manpower in multi-organ transplant ICUs; (l) recruiting more young RNs to learn OT care; (m) reasonable work shifts; (n) reimbursement for overtime-work; (o) consensus among physician, CCN and other OT team members; (p) precise caring guidance and decision-making; and (q) coordination efforts from social workers. The coping strategies for needed help were: (a) arousing hospital administrators’ attentions to update OT policies; (b) asking hospitals to provide safe caring environment; (c) holding case conference for successful and failed cases; (d) developing clinical paths for multiple OT cases; (e) establishing long-term team for multiple OT cases; (f) implementing humanistic caring training program; (g) hosting systematical OT in-service training program; (h) offering professional certification for OT CCN; (i) asking hospital to offer reasonable payment systems for OT CCN; (j) asking hospital to offer reasonable manpower systems for OT CCN; (k) establishing coaching systems for OT CCN; (l) searching for available resources; and (m) inviting assistance from social workers. Finally, the perspectives between the young and senior CCN were further compared and discussed. Conclusions The project explored and compared Taiwan’s OT CCN’s perspectives of their caring dilemmas for OT clients, their needed help, and coping strategies for the difficulties. The findings between young and senior CCN’s groups are not identical. The nurse educators and administrators are suggested to develop related programs and administrative support to meet this particular group’s multiple needs. With the reasonable direct and indirect caring systems, and tangible as well as psychological support, OT CCN will be encouraged to devote them to OT care; the functional interdisciplinary OT team will also be established. Finally, the quality of OT care will then be ensured. Keywords: critical care nurses, young and senior nurse, organ transplant caring dilemmas, needed help, coping strategies, explorative qualitative study

碩士
國立陽明大學
藥理學研究所
106
Background: Hepatitis C virus (HCV) infection affects millions of individuals worldwide, especially for those who have received organ transplantation. Direct-acting antiviral agents (DAAs) as a combination regimen to treat chronic HCV infection have been proven to be effective. Paritaprevir/ritonavir/ombitasvir/dasabuvir are component of the therapy regimen for HCV genotype (GT) 1 infection. It resulted in a high sustained virologic response (SVR) rate and few side effects though it needed to concern drug interaction if used on organ transplant recipients. Cyclosporine (CsA) is a key immunosuppressant after organ transplantation. Because paritaprevir/ritonavir/ombitasvir/dasabuvir regimen and CsA are both metabolized via cytochrome P450 (CYP) 3A and P-glycoprotein, coadministration of these drugs may result in serious drug interactions. Package insert of paritaprevir/ritonavir/ombitasvir/dasabuvir regimen and recent studies suggest the CsA dose should be reduced to one-fifth of the previous total daily dose and administered once-daily when initiating paritaprevir/ritonavir/ombitasvir/dasabuvir regimen. However, we found this dose recommendation of CsA could not fit Taiwanese organ transplant recipients. Furthermore, there is a paucity of data regarding dose and frequency recommendation for CsA when paritaprevir/ritonavir/ombitasvir/dasabuvir regimen is completed. The research about the safety and efficacy of paritaprevir/ritonavir/ombitasvir/dasabuvir regimen in Taiwanese organ transplant recipients is also absent. Thus, we conducted this study to evaluate the pharmacokinetics change of CsA. Moreover, the safety and efficacy of paritaprevir/ritonavir/ombitasvir/dasabuvir regimen among Taiwanese organ transplant recipients taking CsA were also assessed. Method: We conducted a retrospective study using Taipei Veterans General Hospital electronic medical records. Between January 2017 and September 2017, the patients who are organ transplant recipients under regular CsA regimen, were diagnosed with HCV infection and received paritaprevir/ritonavir/ombitasvir/dasabuvir regimen were enrolled. The non-compartmental method was used to calculate the pharmacokinetics parameters of CsA. Simulated concentration-time profile for paritaprevir/ritonavir/ombitasvir/dasabuvir regimen plus CsA to determine whether the CsA dose regimen as appropriate by using nonparametric super-positioning. The mixed effect model was utilized to assess the effect of paritaprevir/ritonavir/ombitasvir/dasabuvir regimen on CsA and test the difference in laboratory data for the safety evaluation. The data of HCV viral load were collected for the efficacy assessment. Result: Seven patients were enrolled into our study, including 5 kidney transplant recipients and 2 liver transplant recipients. In the presence of paritaprevir/ritonavir/ombitasvir/dasabuvir regimen on the first day, dose-normalized CsA AUC∞ was 5.18-fold when CsA administered alone, respectively. CsA half-life increased from 5.1 to 12.6 hours. When the steady state of paritaprevir/ritonavir/ombitasvir/dasabuvir regimen is reached, CsA dose-normalized AUC∞ were 6.82-fold of the CsA values when administered alone, and CsA half-life increased from 5.1 to 17.1 hours. From simulated concentration-time curve, a reduction in CsA dose and dosing frequency is sevenfold reduction in total daily dose to achieve Ctrough values similar to those observed before paritaprevir/ritonavir/ombitasvir/dasabuvir regimen. The readjustments of CsA for all patients were done within 7 days after the paritaprevir/ritonavir/ombitasvir/dasabuvir regimen is completed. For safety issue, there were no significant deterioration of liver and kidney function. Adverse events for fatigue in one patient, headache in one patient, malaise in one patient and diarrhea in one patient. No episode of graft rejection or patient mortality was observed during the treatment. Six patients achieved rapid virologic response (RVR), and all patients achieved end-of-treatment response (ETR) and sustained virologic response at 12 week (SVR12). Conclusion: When initiating therapy with paritaprevir/ritonavir/ombitasvir/dasabuvir regimen, the CsA dose should be reduced to one-seventh of the previous total daily dose in 70 percentage of Taiwanese organ transplant recipients, with close monitoring of CsA Ctrough to determine subsequent dose modifications. The CsA dose should be resumed within 7 days when the paritaprevir/ritonavir/ombitasvir/dasabuvir regimen completed, followed by frequent therapeutic drug monitoring to maintain appropriate CsA concentration (50-100 ng/ml). The safety and efficacy of paritaprevir/ritonavir/ombitasvir/dasabuvir regimen in Taiwan organ transplant recipients were not inferior to Caucasians. Key words: HCV, paritaprevir/ritonavir/ombitasvir/dasabuvir regimen, organ transplantation, cyclosporine, pharmacokinetics, Asian

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
A transplantação de órgão sólido é, atualmente, uma oportunidade terapêutica para diversas doenças em fase terminal que afetam órgãos como o coração, fígado, rim, pulmão e pâncreas. Apesar dos resultados cada vez mais promissores, existem inúmeras complicações resultantes dos regimes imunossupressores e do aumento da sobrevida. Uma das complicações tardias mais frequentes e também causa de elevada mortalidade é a doença oncológica. Porém, dentro deste grupo a incidência do carcinoma pulmonar em doentes transplantados é controversa.Deste modo, o objetivo desta revisão da literatura, foi explorar a possível relação entre doentes com transplante de órgão sólido e o posterior desenvolvimento de carcinoma pulmonar. Adicionalmente, foram também investigadas possíveis causas para esta associação.Para a elaboração deste trabalho, foi realizada uma pesquisa nas bases de dados PubMed e Web of Science, com restrição para artigos redigidos em inglês, português e espanhol, com data de publicação entre 2008 e 2019, inclusive.Vários estudos demonstraram que doentes com transplante cardíaco, hepático ou pulmonar tiveram uma incidência superior de cancro do pulmão em relação à população geral. Relativamente aos doentes com transplante renal, diversos autores consideraram que a incidência de carcinoma pulmonar nestes doentes foi semelhante à da população geral.O tabagismo permaneceu como principal fator de risco para o desenvolvimento de carcinoma pulmonar em doentes transplantados. Entre outros fatores etiologicamente relacionados destacam-se a idade avançada, o álcool na transplantação hepática e a fibrose pulmonar idiopática ou enfisema em doentes com doença pulmonar obstrutiva crónica na transplantação pulmonar.O seguimento destes doentes é fulcral para que seja realizado um diagnóstico precoce do cancro do pulmão, com consequente aumento da sobrevida. Alguns autores aconselham o uso da tomografia computorizada torácica de baixa dose em doentes com risco superior para o desenvolvimento de cancro do pulmão após transplante de órgão sólido.
Solid organ transplantation is a therapeutic option for patients with end-stage organ disease. Despite the promising results, there are several complications associated with immunosuppressive strategies and patient survival. Post-transplant malignancy is a common late complication and an important cause of mortality. However, the incidence of lung cancer in transplant recipients is controversial.The goal of this literature review was to explore the possible relationship between solid organ transplantation and the later development of lung cancer. Following this association, the possible causes that may support this relationship were also reviewed.The research was done using the PubMed and Web of Science databases, with two restrictions. One was made to insure that only articles written in English, Portuguese and Spanish, would appear. The other was to limit the search results to articles published between, 2008 and 2019, including both years.Several studies have shown that in people which have undergone a cardiac, liver or lung transplant, the incidence of lung cancer was higher than general population. Regarding kidney transplant recipients, several authors have considered that the incidence of lung cancer in these patients was similar to the general population.Smoking remained the main risk factor for the development of post-transplant lung cancer. Other risk factors identified were advanced age, alcohol for liver transplant and idiopathic pulmonary fibrosis or emphysema in patients with chronic obstructive pulmonary disease for lung transplant.The follow-up of these patients is crucial for an early detection of lung cancer, with a significant improvement in patient’s survival rates. Some authors consider that, after solid organ transplantation, patients with high-risk to develop lung cancer should be screened with low-dose chest computed tomography.