Despite the establishment of heart transplantation as a life-saving therapy for children and adolescents, little research has focused on the biopsychosocial impact of the transplant process. Few studies have captured the subjective experiences of young heart transplant recipients. This program of research examined how pediatric heart transplant recipients construct their worlds and the meanings they ascribe to their transplant experience. A grounded theory approach was implemented which guided data collection and analysis. A total of twenty-seven adolescents participated in semi-structured qualitative interviews. Findings illuminate pediatric heart transplantation to be a pervasive experience, with consequent impact on physical, psychological and social well-being. Participants described various biopsychosocial processes and experiences that occurred over the course of their transplant journey. Data analysis yielded themes of quality of life reflecting notions of temporality including: 1) the pre-transplant experience – a struggle to survive, 2) the transplant surgery and hospitalization – a difficult transition and 3) the post-transplant experience – an awakening and transformation. This research identifies that heart transplantation, which may contain elements of suffering and loss, may ultimately enhance young recipients’ overall quality of life. Results reveal the possibility that adolescent heart transplant recipients not only adapt to transplantation, but also potentially experience associated growth-enhancing experiences. An emergent theoretical model is presented, with implications for practice and research.

Despite the establishment of heart transplantation as a life-saving therapy for children and adolescents, little research has focused on the biopsychosocial impact of the transplant process. Few studies have captured the subjective experiences of young heart transplant recipients. This program of research examined how pediatric heart transplant recipients construct their worlds and the meanings they ascribe to their transplant experience. A grounded theory approach was implemented which guided data collection and analysis. A total of twenty-seven adolescents participated in semi-structured qualitative interviews. Findings illuminate pediatric heart transplantation to be a pervasive experience, with consequent impact on physical, psychological and social well-being. Participants described various biopsychosocial processes and experiences that occurred over the course of their transplant journey. Data analysis yielded themes of quality of life reflecting notions of temporality including: 1) the pre-transplant experience – a struggle to survive, 2) the transplant surgery and hospitalization – a difficult transition and 3) the post-transplant experience – an awakening and transformation. This research identifies that heart transplantation, which may contain elements of suffering and loss, may ultimately enhance young recipients’ overall quality of life. Results reveal the possibility that adolescent heart transplant recipients not only adapt to transplantation, but also potentially experience associated growth-enhancing experiences. An emergent theoretical model is presented, with implications for practice and research.

Bone marrow transplantation (BMT) is the treatment of choice for many malignancies and other childhood disorders. Acknowledging that the entire family is affected when a child undergoes a BMT, increasing research attention has been given to understanding this experience from the perspectives of recipients, parents and the family as a whole. Yet, minimal attention has been directed at understanding the experience of healthy siblings as they transition through the BMT experience. Before intervention studies can be undertaken that will help healthy siblings transition through the BMT experience, knowledge about the impact of the experience on siblings is needed. Accordingly, a qualitative study guided by the philosophy of hermeneutic phenomenology was conducted to elicit detailed descriptions of the lived experience of siblings. Participants were children, adolescents and young adults with a sibling who had undergone a BMT during childhood. Participants were recruited from a pediatric BMT clinic in Western Canada. Semi-structured, open-ended interviews that explored siblings’ memories about what it is like to be a sibling of a child who has had a BMT were conducted with each participant. Demographic data and field notes were recorded. All interviews and field notes were transcribed. The transcripts were reviewed repeatedly for significant statements in an attempt to find meaning and understanding through themes. The data analysis revealed the essence of siblings’ lived experience of transitioning through the BMT trajectory as an interruption in family life. Four themes communicated the essence of siblings’ lived experience: (1) life goes on, (2) feeling more or less a part of a family, (3) faith in God that things will be okay, and (4) feelings around families. Differences between donor and non-donor siblings are highlighted. Siblings’ recommendations for health care professionals are also provided. Results from this study will help health professionals better anticipate the diverse and shifting needs and demands of siblings of pediatric BMT patients. Recommendations for future research and innovations in nursing interventions are provided. / October 2005

Background: In Sweden the primary reason for heart transplants is severe heart failure. Heart transplants are performed both at Sahlgrenska University hospital and at Skånes University hospital. Patient undergoing several extensive investigations before he or she will be considered for the waiting list. Primary factor for receiving a heart is first of all the patient who is in the greatest need of a new heart and the patient most suited to receive the donated heart. Previous studies show that patients feel the waiting time to be unpredictable. Aim: To describe patients’ experiences of the time before a heart transplant. Method: Qualitative content analysis was used as the analysis method and seven blogs were applied. Results: Life is seen from a new and different perspective. A common factor for patients with heart failure was the physical limitation they felt. Life stopped for a while, and a waiting to regain “life” grew strong. Family and nursing staff was thought to play an important role. To maintain a positive attitude was thought to be a criterion to manage the anticipations. Conclusion: A patient waiting for a heart transplant experiences a change in their life world. To allow proper care it is important that the nurse recognizes this change and acknowledge it.

Background. Although nutritional deficiency is known to be both common and multifactorial in the post-liver transplant population, a global systematic method of assessing nutritional status has not been widely implemented. The Subjective Global Assessment has been validated in many clinical populations, but to this investigator's knowledge there are no reports on its use in the post-acute liver transplant population. The purpose of this Doctorate of Nursing Practice project was to assess nutritional risk using a Nutritional Assessment Tool, consisting of the Subjective Global Assessment plus additional indicators, for use in the post-acute liver transplant population, defined as one week or less after hospital discharge from liver transplant. The additional indicators consist of age, body mass index, Model for End-Stage Liver Disease score, hospital length of stay for liver transplant, and diagnosis of diabetes mellitus. Methods. This was a practicality study in which a Nutritional Assessment Tool was administered by advanced practice nurses to post-acute liver transplant patients in an outpatient clinic. Each advanced practice nurse completed a practicality survey. Dependence of the additional indicators on the Subjective Global Assessment classification was evaluated using ANOVA and Fisher's exact test. Time to administer the tool was also collected. Results. Seventeen participants were enrolled over a period of three months. Among these, 70.5% were ranked as well-nourished, 23.5% as moderately malnourished, and 5.9% as severely malnourished. No statistically significant dependence of the indicators on the Subjective Global Assessment classification was found. The average time to administer the tool was 9.7+/- 2.4 minutes. Based on the survey from advanced practice nurses, the Nutritional Assessment Tool was found to be practical in this outpatient clinic setting. Conclusions. Implementing a Nutritional Assessment Tool, or the Subjective Global Assessment at minimum, in the post-acute liver transplant population in this setting served to be a practical method of evaluating global nutritional risk.

Improved success of paediatric cardiac transplantation has resulted in increased survival of recipients into young adulthood (19 to 29 years of age). Young adults who received a heart transplant during childhood have experienced multiple life sustaining procedures. As survival and longevity increase, it is clear that transplant recipients experience negative physiological, psychological and social sequelae. With heart transplant offering individuals a chance to extend life into young adulthood, recipients need lifelong care and at age 18 they will transition from paediatric to adult healthcare facilities. The study addressed young adults circumstances of existence and their competing interests within various social environments. This research project applied Pierre Bourdieu’s theoretical concepts of habitus, field and capital, to conceptualize and engage with empirical knowledge production about young adults who have received a heart transplant during childhood. Using visual methodology, focused open-ended interviews were conducted with 12 young adults who had a heart transplant during childhood. Bourdieu’s work provided a theoretical framework to investigate transplant recipients’ identities and social repositioning in relation to dominant discourses of organ transplant and shifting relationships with health services providers. This study involved an iterative process to identify recipients’ encounters and new compositions in relation with others, in order to answer the research objective. These findings highlight that young adult transplant recipients struggle with relational dispositions that excludes them from various fields of social engagement; their struggle and exclusion from various fields is symbolic and is embedded in the structure of the dominant social order of the field from where they become excluded; the social order is taken up and embodied, leading young transplant recipients to practices of accommodation and “normalization”. Changes in healthcare practices, attuned to person implications and peer relationships can begin to address young transplant recipients’ contradictory social positions. Such an approach can potentially lead to improvement in ongoing care and services for young adults who require a lifetime of care. At the same time, it will allow nurses to better prepare and counsel young individuals who are preparing for a heart transplant.

Improved success of paediatric cardiac transplantation has resulted in increased survival of recipients into young adulthood (19 to 29 years of age). Young adults who received a heart transplant during childhood have experienced multiple life sustaining procedures. As survival and longevity increase, it is clear that transplant recipients experience negative physiological, psychological and social sequelae. With heart transplant offering individuals a chance to extend life into young adulthood, recipients need lifelong care and at age 18 they will transition from paediatric to adult healthcare facilities. The study addressed young adults circumstances of existence and their competing interests within various social environments. This research project applied Pierre Bourdieu’s theoretical concepts of habitus, field and capital, to conceptualize and engage with empirical knowledge production about young adults who have received a heart transplant during childhood. Using visual methodology, focused open-ended interviews were conducted with 12 young adults who had a heart transplant during childhood. Bourdieu’s work provided a theoretical framework to investigate transplant recipients’ identities and social repositioning in relation to dominant discourses of organ transplant and shifting relationships with health services providers. This study involved an iterative process to identify recipients’ encounters and new compositions in relation with others, in order to answer the research objective. These findings highlight that young adult transplant recipients struggle with relational dispositions that excludes them from various fields of social engagement; their struggle and exclusion from various fields is symbolic and is embedded in the structure of the dominant social order of the field from where they become excluded; the social order is taken up and embodied, leading young transplant recipients to practices of accommodation and “normalization”. Changes in healthcare practices, attuned to person implications and peer relationships can begin to address young transplant recipients’ contradictory social positions. Such an approach can potentially lead to improvement in ongoing care and services for young adults who require a lifetime of care. At the same time, it will allow nurses to better prepare and counsel young individuals who are preparing for a heart transplant.

The active state of plasminogen activator inhibitor type-1 (PAI-1) is prolonged when it forms a complex with vitronectin (VN), a major serum protein. Active PAI-1 in the PAI-1:VN complex serves many functions related to fibrinolysis and cell migration but key to these effects is its extracellular distribution. PAI-1:VN complexes can bind to exposed vimentin (VIM) on activated platelet and platelet microparticles, resulting in the assembly of PAI-1:VN:VIM ternary complexes. However, the manner in which the vimentin cytoskeleton is presented extracellularlyi s not well understood. I hypothesized that PAI-1:VN:VIM ternary complex assembly occurs on cell surfaces when microparticle release leads to exposure of vimentin cytoskeleton which can lead to either assembly of the ternary complex or become involved in an autoimmune response specific for vimentin. To follow the intracellular and extracellular fate of PAI-1, I constructed an expression vector encoding PAI-1-dsRed, a fluorescent form of PAI-1, which would permit live cell tracking of PAI-1 in megakaryocytes and endothelial cells. Secondly, to study how vimentin is expressed on platelets and platelet microparticles, flow cytometry was used to isolate vimentin positive platelets or PMP's and atomic force microscopy was performed to image platelets or PMP's at nanoscale resolution. From these studies, I propose a model of vimentin expression in which the junction of microparticle release results in the exposure of cytoskeletal vimentin on both the cell and the microparticle. This exposed vimentin could potentially induce VN multimerization on the same cell surface leading to incorporation of multiple PAI-1:VN complexes. Finally, I investigated how anti-vimentin antibodies can induce platelet:leukocyte conjugate formation. To achieve this, in vitro tests were performed to determine the binding site of anti-vimentin antibodies (AVA's) and how they induce blood cell activation. Overall, my results suggest that vimentin exposure in our model of microparticle release can lead to ternary complex assembly if suitable quantities of PAI-1 are released during platelet activation. In the setting of transplant vasculopathy with high titres of AVA's, vimentin-positive granulocytes can bind these autoantibodies, which then leads to platelet activation and the formation of platelet:leukocyte conjugates.

Bone marrow-derived progenitor cell populations have been implicated in tissue regeneration and also in human disease pathology. This thesis investigated the hypothesis that Clara Cell Secretory Protein positive (CCSP+) epithelial-like progenitor cells and circulating fibrocyte numbers are altered in human lung disease and injury, and aimed to determine the predictive value of these cell profiles. It was found that cystic fibrosis patients have an increased number of CCSP+ cells in their bone marrow and peripheral blood, while patients with bronchiolitis obliterans syndrome (BOS) have a decreased number. In addition, BOS and pulmonary fibrosis patients have increased circulating fibrocytes. In response to ischemia reperfusion injury, an increase in CCSP+ cells in the peripheral blood was found at 24 hrs following lung transplant. Lastly, in patients studied greater than 1-year from transplant, those diagnosed with BOS had a higher number of fibrocytes and a loss of CCSP+ peripheral blood cells when compared to patients with stable lung function, with increased fibrocytes being associated with time post-transplant. In these patients, the ratio of fibrocytes-to-CCSP+ cells was predictive of lung function. Multiplex protein arrays were used to investigate corresponding patient plasma, aiming to elucidate key mediators of progenitor cell recruitment. While differences in various cytokines were found between end-stage diseases, a specific relationship between Stem Cell Growth Factor- and CCSP+ cells was identified and between Monocyte Chemotactic Protein-1 and fibrocytes. Conversely, response of CCSP+ cells following transplant appears to be mediated by known mobilizing factors SDF-1 and GM-CSF. Interestingly, in patients followed long-term after transplant, MCP-1 was associated with the number of CCSP+ cells, while SDF-1 correlated with fibrocyte numbers. These observations suggest common pathways acting on both populations that may be altered by the microenvironment, and may further suggest a common origin. This work contributes important information regarding changes in lung progenitor cells and their association with human disease and tissue repair, which could ultimately support future directions that directly advance therapy and improve patient care.

Bone marrow-derived progenitor cell populations have been implicated in tissue regeneration and also in human disease pathology. This thesis investigated the hypothesis that Clara Cell Secretory Protein positive (CCSP+) epithelial-like progenitor cells and circulating fibrocyte numbers are altered in human lung disease and injury, and aimed to determine the predictive value of these cell profiles. It was found that cystic fibrosis patients have an increased number of CCSP+ cells in their bone marrow and peripheral blood, while patients with bronchiolitis obliterans syndrome (BOS) have a decreased number. In addition, BOS and pulmonary fibrosis patients have increased circulating fibrocytes. In response to ischemia reperfusion injury, an increase in CCSP+ cells in the peripheral blood was found at 24 hrs following lung transplant. Lastly, in patients studied greater than 1-year from transplant, those diagnosed with BOS had a higher number of fibrocytes and a loss of CCSP+ peripheral blood cells when compared to patients with stable lung function, with increased fibrocytes being associated with time post-transplant. In these patients, the ratio of fibrocytes-to-CCSP+ cells was predictive of lung function. Multiplex protein arrays were used to investigate corresponding patient plasma, aiming to elucidate key mediators of progenitor cell recruitment. While differences in various cytokines were found between end-stage diseases, a specific relationship between Stem Cell Growth Factor- and CCSP+ cells was identified and between Monocyte Chemotactic Protein-1 and fibrocytes. Conversely, response of CCSP+ cells following transplant appears to be mediated by known mobilizing factors SDF-1 and GM-CSF. Interestingly, in patients followed long-term after transplant, MCP-1 was associated with the number of CCSP+ cells, while SDF-1 correlated with fibrocyte numbers. These observations suggest common pathways acting on both populations that may be altered by the microenvironment, and may further suggest a common origin. This work contributes important information regarding changes in lung progenitor cells and their association with human disease and tissue repair, which could ultimately support future directions that directly advance therapy and improve patient care.