LETTERS TO THE EDITOR
A ‘‘Smarter’’ Way to Recruit Organ Donors? y 2015, 500 million people are projected to own a smartphone (mobile devices with advanced operating system software) (1). Healthcare-related downloadable software applications (apps) are one of the fastest growing markets within the app sector, driven by patient demand for health information (2, 3). With respect to transplantation, apps have demonstrated usefulness for organ transplant coordinators (4), and renal transplant recipients were eager to engage in mobile health strategies to improve disease monitoring (5). However, little is known about the available apps with respect to transplantation. Arguably, the greatest limitation within the field of transplantation remains shortage of organs for donation; in the UK, three people die daily awaiting a transplant (6). There are multiple factors preventing donation of potentially viable organs (6). One factor is familyconsent rate: if the potential donor’s previous wishes regardingorgan donationwere known,family consented in 93% of cases of donation after brain death versus 43% if not known (6). This study aimed to review contemporary smartphone apps with respect to transplantation and to report potential opportunities to increase organ donation and awareness. Five smartphone app online stores (Google Play, Apple, Blackberry, Samsung, and Windows) were searched for the terms ‘‘transplant, transplantation, organ donor and organ donation’’ on May 23, 2013. Those with little or no reference to solidorgan transplantation were excluded. Content was examined from information provided on overview pages by developers as described previously (7). Seventy-one apps met search criteria. These were aimed at either the public (n=33) or medical health professionals (MHP) (n=38). MHP apps had high levels of stated MHP involvement in their design (n=34; 89%) and 28 (74%) were free to download.
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Eighteen apps principally addressed organ donation; 11 apps allowed the user to declare their organ donor status, while seven apps promoted organ donation publicity. Of the latter, three allowed access to register for organ donation and two apps (29%) had stated MHP development in their design. Of the 11 donor status apps, five apps were principally designed as organ donation ‘‘ecards’’ while six included donor status as part of an ‘‘In Case of Emergency (ICE)’’ apps. Four (36%) of these 11 apps had stated MHP involvement in their design and seven apps (64%) were free. Most apps raised awareness of organ donor status by placing a ‘‘recognizable’’ app symbol on the smartphone opening lock screen (n=6) or home screen of the phone (n=5), which could be easily identified in the case of an unconscious patient. Some apps also increased awareness by sending a text to next of kin (NOK) to stimulate discussion about organ donation or by integrating into their online profile via social media (Facebook, Twitter). Nine apps (91%) included NOK details available on accessing the app, in some cases permitting easy access via the lock screen. Of the five ‘‘ecard’’ apps, just two were affiliated with recognized medical bodies (Irish Kidney Association; The Mohan Foundation in India) and only the ‘‘Mohan app’’ clearly connected to a national transplant registry. The ICE apps additionally (n=6) included the opportunity to store detailed information including organ donor status, NOK, past medical history, medications along with other patient-identifiable factors. One app allowed unprotected access to personal information from the lock screen of the phone, creating a risk of confidentiality breach outside an emergency situation particularly as mobiles may be easily misplaced. This study identifies potential opportunities for smartphone apps to aid Transplantation
organ donor recruitment. There are advantages in disseminating organ donor status by this approach because of the frequency of smartphone app ownership and their ability to seamlessly integrate with social media (1, 3). Indeed the power of social media was recently demonstrated when Facebook enabled users to share their organ donor status online, generating 13,054 new registrations on the first day (8). However, the increased functionality of apps including NOK details and personal information must also be balanced to protect confidentiality while still permitting timely access to relevant information. Unlike MHP transplant apps, only 36% of general public apps were designed by recognized medical body and few provided links to a recognized organ donor registry. Such concerns are compounded by the paucity of healthcare app regulation (9). Many phones are sold with manufacturer apps already included, and inclusion of an organ donation app may translate into increased organ donation awareness. Apps must address confidentiality issues, integrate with the national organ registry database, and have an app symbol which is universally recognizable. NHS England has recently developed a health app library for patients that may establish baseline standards relevant to transplantation apps (10). The use of new technologies such as apps and social media could indeed harness a powerful new level of general public awareness (11), but the translation of this effect into donation numbers will require further evaluation.
Katie Connor1 Richard Brady2 Lorna Marson1 1
Department of Transplantation Royal Infirmary of Edinburgh Edinburgh, Scotland
& Volume 97, Number 3, February 15, 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
2014 Lippincott Williams & Wilkins
2 Department of Surgery Western General Hospital Edinburgh, Scotland
No external company was involved in the performance, analysis, or writing of this research, and financial support was received to undertake this project. Conflicts of interest: R.B. is the owner of researchactive.com Ltd, a company which provides smartphone apps, and is a medical advisor to Sermo and Ethicon. L.M. has no conflicts of interest to declare. K.C. and R.B. have previously published in the field of medical smartphone apps. R.B. is the founder of www.researchactive.com Ltd, a company which provides smartphone apps, and is a medical advisor to Worldone interactive and has previously received paid consultancy from Johnson and Johnson Medical Ltd. Address correspondence to Ms. Lorna Marson, Department of Transplantation, Royal Infirmary of Edinburgh, 56 Little France Crescent, Edinburgh, Scotland, EH16 4TJ. E-mail: [email protected] K.C. participated in analyzing the data, performing the research, and writing the article. R.B. participated in designing the research and writing the article. L.M. participated in performing the research and writing the article.
Received 16 September 2013. Accepted 22 October 2013. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9703-e16 DOI: 10.1097/01.TP.0000438213.72960.e7
6.
REFERENCES 1. 2.
3.
4.
5.
Research2Guidance. Global smart phone application market report 2012, update 1st half year 2010. Research2Guidance 2010. Fisher J, Clayton M. Who gives a tweet: assessing patients’ interest in the use of social media for health care. Worldviews Evid Based Nurs 2012; 9: 2. L Type. The 41 Million Dollar Market for Mobile Phone Medical Apps: The Worldwide Market for Medical Apps. leaddiscovery.co.uk, 2010. (Pub ID: KLI2831262) Available at: http://www.kaloramainformation.com/ Worldwide-Mobile-Medical-2831262/. Accessed 11 June 2013. Alexander S, Hoy H, Maskey M, et al. Initiating collaboration among organ transplant professionals through web portals and mobile applications Online J Issues Nurs 2013; 18: 7. McGillicuddy JW, Weiland AK, Frenzel RM, et al. Patient attitudes toward mobile phone-based health monitoring: questionnaire
7. 8.
9.
10.
11.
e17
study among kidney transplant recipients. J Med Internet Res 2013; 8: 15. Murphy C, Allen J. NHS Blood and Transplant Potential Donor Audit April 2011YMarch 2012. NHSBT Website, 2012. Available at: http:// www.organdonation.nhs.uk/statistics/potential_ donor_audit/pdf/pda_report_1112.pdf. Accessed 6th August 2013. Connor K, Brady RR, Tulloh B, et al. Smartphone applications (apps) for bariatric surgery. Obes Surg 2013; 23: 1669. Cameron A.M, Massie AB, Alexander CE, et al. Social media and organ donor registration: the Facebook effect. Am J Transplant 2013; 13: 2059. Barton A. The regulation of mobile health applications. BMC 171 Med, 2012;10: 46. Available at: http://www.biomedcentral.com/ 1721741-7015/10/46. Accessed August 2013. Singh I. Introducing the Health Apps Library. NHS England Website, 2013. Available at: http://www.england.nhs.uk/2013/03/13/healthapps-blog/. Accessed August 7, 2013. Schein R, Wilson K, Keelan J. Literature Review on Effectiveness of the Use of Social Media: A Report for Peel Public Health. Brampton, ON: Peel Public Health; 2011. Available at: http:// www.canadianopenlibrary.ca/SwfDocs/226/ 226272.pdf. Accessed August 6, 2013.
Sequential Split Liver Followed by Isolated Intestinal Transplant: The ‘‘Liver-First’’ Approach atients in need of a liver-containing multiorgan graft continue to experience high mortality rates in the waiting list. Several strategies have been implemented to decrease the mortality of these patients, including organ allocation policy changes, the use of reduced grafts (1, 2), and sequential organ transplantation (3). The latter approach, where the liver is transplanted first, is based on the observation that patients with combined liver and intestinal failure almost always die from liver failure (4). We report a case of adult sequential split liver and intestinal transplant in a patient with short bowel syndrome and intestinal failureY associated liver disease (IFALD), the first to our knowledge. A 47-year-old woman (49 kg) was referred to our Institution for a combined liver-intestine transplant evaluation. Her medical history was significant
P
for fistulizing Crohn disease requiring multiple small bowel resections resulting in total parenteral nutritionYdependent short bowel syndrome. A liver biopsy showed cirrhosis secondary to IFALD. At the time of presentation, the patient had multiple intra-abdominal abscesses along with active Crohn disease involving only the gastrointestinal tract. At that time, her MELD score was 21 and she was listed for a combined liver-intestinal transplantation. Given her active intraabdominal infection, we decided to perform a near-total enterectomy first, with the intent to make her free from infection. An end jejunostomy was created 40 cm distal to the ligament of Treitz with preservation of the rectum and sigmoid colon and her abdomen was closed primarily. Because of her increasing waiting time, decision was made (about 9 mo after listing for the combined graft) to
perform a ‘‘liver first’’ sequential transplant. On waiting list day, 310 and 35 days after the enterectomy, a liver became available for a pediatric recipient from a brain-dead donor (a 15-year-old, 67-kg gil). The liver was split in situ, and a right trisegment graft (segments 1, 4, 5, 6, 7, and 8) was offered to our patient (Fig. 1). The graft included the retrohepatic vena cava, the main and right portal veins, the common and right bile ducts, and the right hepatic artery. The bile duct was reconstructed using an end-to-side choledoco-duodenostomy. Induction therapy consisted of two doses of 20 mg of basiliximab (postoperative day [POD] 1 and 4). Maintenance therapy consisted of tacrolimus and low-dose prednisone. The patient was discharged home on POD 18 with normal liver function test results. Thirty-nine days after the liver transplant (349 d after listing and 74 d after the enterectomy), our patient received an
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A ‘‘Smarter’’ Way to Recruit Organ Donors? y 2015, 500 million people are projected to own a smartphone (mobile devices with advanced operating system software) (1). Healthcare-related downloadable software applications (apps) are one of the fastest growing markets within the app sector, driven by patient demand for health information (2, 3). With respect to transplantation, apps have demonstrated usefulness for organ transplant coordinators (4), and renal transplant recipients were eager to engage in mobile health strategies to improve disease monitoring (5). However, little is known about the available apps with respect to transplantation. Arguably, the greatest limitation within the field of transplantation remains shortage of organs for donation; in the UK, three people die daily awaiting a transplant (6). There are multiple factors preventing donation of potentially viable organs (6). One factor is familyconsent rate: if the potential donor’s previous wishes regardingorgan donationwere known,family consented in 93% of cases of donation after brain death versus 43% if not known (6). This study aimed to review contemporary smartphone apps with respect to transplantation and to report potential opportunities to increase organ donation and awareness. Five smartphone app online stores (Google Play, Apple, Blackberry, Samsung, and Windows) were searched for the terms ‘‘transplant, transplantation, organ donor and organ donation’’ on May 23, 2013. Those with little or no reference to solidorgan transplantation were excluded. Content was examined from information provided on overview pages by developers as described previously (7). Seventy-one apps met search criteria. These were aimed at either the public (n=33) or medical health professionals (MHP) (n=38). MHP apps had high levels of stated MHP involvement in their design (n=34; 89%) and 28 (74%) were free to download.
B
e16
www.transplantjournal.com
Eighteen apps principally addressed organ donation; 11 apps allowed the user to declare their organ donor status, while seven apps promoted organ donation publicity. Of the latter, three allowed access to register for organ donation and two apps (29%) had stated MHP development in their design. Of the 11 donor status apps, five apps were principally designed as organ donation ‘‘ecards’’ while six included donor status as part of an ‘‘In Case of Emergency (ICE)’’ apps. Four (36%) of these 11 apps had stated MHP involvement in their design and seven apps (64%) were free. Most apps raised awareness of organ donor status by placing a ‘‘recognizable’’ app symbol on the smartphone opening lock screen (n=6) or home screen of the phone (n=5), which could be easily identified in the case of an unconscious patient. Some apps also increased awareness by sending a text to next of kin (NOK) to stimulate discussion about organ donation or by integrating into their online profile via social media (Facebook, Twitter). Nine apps (91%) included NOK details available on accessing the app, in some cases permitting easy access via the lock screen. Of the five ‘‘ecard’’ apps, just two were affiliated with recognized medical bodies (Irish Kidney Association; The Mohan Foundation in India) and only the ‘‘Mohan app’’ clearly connected to a national transplant registry. The ICE apps additionally (n=6) included the opportunity to store detailed information including organ donor status, NOK, past medical history, medications along with other patient-identifiable factors. One app allowed unprotected access to personal information from the lock screen of the phone, creating a risk of confidentiality breach outside an emergency situation particularly as mobiles may be easily misplaced. This study identifies potential opportunities for smartphone apps to aid Transplantation
organ donor recruitment. There are advantages in disseminating organ donor status by this approach because of the frequency of smartphone app ownership and their ability to seamlessly integrate with social media (1, 3). Indeed the power of social media was recently demonstrated when Facebook enabled users to share their organ donor status online, generating 13,054 new registrations on the first day (8). However, the increased functionality of apps including NOK details and personal information must also be balanced to protect confidentiality while still permitting timely access to relevant information. Unlike MHP transplant apps, only 36% of general public apps were designed by recognized medical body and few provided links to a recognized organ donor registry. Such concerns are compounded by the paucity of healthcare app regulation (9). Many phones are sold with manufacturer apps already included, and inclusion of an organ donation app may translate into increased organ donation awareness. Apps must address confidentiality issues, integrate with the national organ registry database, and have an app symbol which is universally recognizable. NHS England has recently developed a health app library for patients that may establish baseline standards relevant to transplantation apps (10). The use of new technologies such as apps and social media could indeed harness a powerful new level of general public awareness (11), but the translation of this effect into donation numbers will require further evaluation.
Katie Connor1 Richard Brady2 Lorna Marson1 1
Department of Transplantation Royal Infirmary of Edinburgh Edinburgh, Scotland
& Volume 97, Number 3, February 15, 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
2014 Lippincott Williams & Wilkins
2 Department of Surgery Western General Hospital Edinburgh, Scotland
No external company was involved in the performance, analysis, or writing of this research, and financial support was received to undertake this project. Conflicts of interest: R.B. is the owner of researchactive.com Ltd, a company which provides smartphone apps, and is a medical advisor to Sermo and Ethicon. L.M. has no conflicts of interest to declare. K.C. and R.B. have previously published in the field of medical smartphone apps. R.B. is the founder of www.researchactive.com Ltd, a company which provides smartphone apps, and is a medical advisor to Worldone interactive and has previously received paid consultancy from Johnson and Johnson Medical Ltd. Address correspondence to Ms. Lorna Marson, Department of Transplantation, Royal Infirmary of Edinburgh, 56 Little France Crescent, Edinburgh, Scotland, EH16 4TJ. E-mail: [email protected] K.C. participated in analyzing the data, performing the research, and writing the article. R.B. participated in designing the research and writing the article. L.M. participated in performing the research and writing the article.
Received 16 September 2013. Accepted 22 October 2013. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9703-e16 DOI: 10.1097/01.TP.0000438213.72960.e7
6.
REFERENCES 1. 2.
3.
4.
5.
Research2Guidance. Global smart phone application market report 2012, update 1st half year 2010. Research2Guidance 2010. Fisher J, Clayton M. Who gives a tweet: assessing patients’ interest in the use of social media for health care. Worldviews Evid Based Nurs 2012; 9: 2. L Type. The 41 Million Dollar Market for Mobile Phone Medical Apps: The Worldwide Market for Medical Apps. leaddiscovery.co.uk, 2010. (Pub ID: KLI2831262) Available at: http://www.kaloramainformation.com/ Worldwide-Mobile-Medical-2831262/. Accessed 11 June 2013. Alexander S, Hoy H, Maskey M, et al. Initiating collaboration among organ transplant professionals through web portals and mobile applications Online J Issues Nurs 2013; 18: 7. McGillicuddy JW, Weiland AK, Frenzel RM, et al. Patient attitudes toward mobile phone-based health monitoring: questionnaire
7. 8.
9.
10.
11.
e17
study among kidney transplant recipients. J Med Internet Res 2013; 8: 15. Murphy C, Allen J. NHS Blood and Transplant Potential Donor Audit April 2011YMarch 2012. NHSBT Website, 2012. Available at: http:// www.organdonation.nhs.uk/statistics/potential_ donor_audit/pdf/pda_report_1112.pdf. Accessed 6th August 2013. Connor K, Brady RR, Tulloh B, et al. Smartphone applications (apps) for bariatric surgery. Obes Surg 2013; 23: 1669. Cameron A.M, Massie AB, Alexander CE, et al. Social media and organ donor registration: the Facebook effect. Am J Transplant 2013; 13: 2059. Barton A. The regulation of mobile health applications. BMC 171 Med, 2012;10: 46. Available at: http://www.biomedcentral.com/ 1721741-7015/10/46. Accessed August 2013. Singh I. Introducing the Health Apps Library. NHS England Website, 2013. Available at: http://www.england.nhs.uk/2013/03/13/healthapps-blog/. Accessed August 7, 2013. Schein R, Wilson K, Keelan J. Literature Review on Effectiveness of the Use of Social Media: A Report for Peel Public Health. Brampton, ON: Peel Public Health; 2011. Available at: http:// www.canadianopenlibrary.ca/SwfDocs/226/ 226272.pdf. Accessed August 6, 2013.
Sequential Split Liver Followed by Isolated Intestinal Transplant: The ‘‘Liver-First’’ Approach atients in need of a liver-containing multiorgan graft continue to experience high mortality rates in the waiting list. Several strategies have been implemented to decrease the mortality of these patients, including organ allocation policy changes, the use of reduced grafts (1, 2), and sequential organ transplantation (3). The latter approach, where the liver is transplanted first, is based on the observation that patients with combined liver and intestinal failure almost always die from liver failure (4). We report a case of adult sequential split liver and intestinal transplant in a patient with short bowel syndrome and intestinal failureY associated liver disease (IFALD), the first to our knowledge. A 47-year-old woman (49 kg) was referred to our Institution for a combined liver-intestine transplant evaluation. Her medical history was significant
P
for fistulizing Crohn disease requiring multiple small bowel resections resulting in total parenteral nutritionYdependent short bowel syndrome. A liver biopsy showed cirrhosis secondary to IFALD. At the time of presentation, the patient had multiple intra-abdominal abscesses along with active Crohn disease involving only the gastrointestinal tract. At that time, her MELD score was 21 and she was listed for a combined liver-intestinal transplantation. Given her active intraabdominal infection, we decided to perform a near-total enterectomy first, with the intent to make her free from infection. An end jejunostomy was created 40 cm distal to the ligament of Treitz with preservation of the rectum and sigmoid colon and her abdomen was closed primarily. Because of her increasing waiting time, decision was made (about 9 mo after listing for the combined graft) to
perform a ‘‘liver first’’ sequential transplant. On waiting list day, 310 and 35 days after the enterectomy, a liver became available for a pediatric recipient from a brain-dead donor (a 15-year-old, 67-kg gil). The liver was split in situ, and a right trisegment graft (segments 1, 4, 5, 6, 7, and 8) was offered to our patient (Fig. 1). The graft included the retrohepatic vena cava, the main and right portal veins, the common and right bile ducts, and the right hepatic artery. The bile duct was reconstructed using an end-to-side choledoco-duodenostomy. Induction therapy consisted of two doses of 20 mg of basiliximab (postoperative day [POD] 1 and 4). Maintenance therapy consisted of tacrolimus and low-dose prednisone. The patient was discharged home on POD 18 with normal liver function test results. Thirty-nine days after the liver transplant (349 d after listing and 74 d after the enterectomy), our patient received an
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
