Cardiac surgery in patients with end-stage renal failure

End-stage renal failure is commonly considered a significant factor for an increased risk after coronary artery bypass grafting. This holds true for patients who have received a kidney transplant (NTX group) as well as for patients who require chronic hemodialysis (HD group). To assess the risk in our population we performed a retrospective analysis of 22 patients with end-stage renal failure (HD group: 17, NTX group: 5) who underwent cardiac surgery. The perioperative course was compared to a normal population. In addition to standard data we assessed the following factors: renal failure etiology, risk factors, concurrent diseases, duration of renal failure, function of renal graft, ECG (paying special attention to signs of previous myocardial infarctions and rhythm disorders), results of cardiac catheterization and coronary angiography, NYHA class and urgency of operative intervention. Complications and mortality were the main measures of the perioperative course. We analyzed the hospital charts retrospectively and requested the patients' physicians to complete a questionnaire about the patient's present condition. All HD group patients were dialyzed on the day before surgery. The first postoperative HD was performed for hyperkalemia or signs of volume overload (pulmonary capillary wedge pressure > 20 mmHg) when signs of pulmonary function deterioration were seen. HD was successful in treating these conditions. 3 of the 17 patients on HD expired postoperatively, 4 died within 3 years, all of unrelated diseases. Mortality and morbidity was 0% in the NTX group. In one NTX patient who required intermittent HD preoperatively because of poor renal graft function, renal function improved postoperatively, presumably secondary to better renal perfusion, and he did not require HD after his cardiac surgery. By surgical intervention the NYHA class of all patients improved (by 1.6 on the average) as well as their quality of life. Because of these good short- and long-term results and relatively low operative risk we support an approach of prompt work-up and surgical intervention when necessary in HD and NTX patients.     

Sleep apnea surgery versus tracheostomy in children: an exploratory study of the comparative effects on quality of life

Successful surgery for medically refractory obstructive sleep apnea in children has prevented tracheostomy in many cases. However, sleep apnea surgery requires postoperative ventilatory support and intensive care, and the magnitude of the surgery may be substantial. Tracheostomy, in contrast, is a simple procedure that is considered the standard of care for relief of upper airway obstruction. To determine their relative benefits, the posttreatment quality of life in children with airway obstruction who underwent either sleep apnea surgery or tracheostomy was evaluated and compared in this exploratory study. A 76-item questionnaire was developed to assess the quality of life in this population, including an investigation of physical symptoms, psychosocial function, and costs. Forty-four parent questionnaires were returned; 16 of these parents had children who had had clinically successful sleep apnea surgery and 6 had children who had had tracheostomies placed for obstructive sleep apnea. Results revealed that the parents of children in the tracheostomy group ranked 95 percent of all items on the questionnaire as worse than the parents of children in the surgery group. These rankings included statistically significant group differences (p < 0.05) on number of hospital, emergency room, and physician visits, and hours per day spent on their child's respiratory care. In addition, parents of the successful sleep apnea surgery group reported significant improvement (p < 0.05) in 100 percent of symptom variables (i.e., choking, snoring, and daytime sleepiness), 75 percent of parental care variables (i.e., assisting with their child's breathing, suctioning), 67 percent of medical visit items, and 75 percent of the stress and coping variables (i.e., perception of child's distress, worrying about their child's breathing, level of family stress), indicating substantial gains in quality of life. Despite initially higher costs, successful surgery for obstructive sleep apnea was associated with substantial benefits in quality of life, health, and psychosocial outcomes when compared with tracheostomy.     

Status and after-care of young adults with congenital heart defects

INTRODUCTION: We studied patients with congenital heart defects born in 1975 and followed by our institution. We were interested in the outcome of these patients at the age of 20 years with regard to professional status, physical activity and psychosocial aspects. Furthermore, we investigated the handover from the paediatric to the adult cardiologist as well as the information level concerning antibiotic prophylaxis against bacterial endocarditis. METHODS: From a previous follow-up study to the age of 16 years, we knew 224 patients with congenital heart disease born in 1975, 119 were considered to need further cardiological follow-up. In 112 (94%) we have a complete follow-up to the age of 20 years with a structured interview by phone. RESULTS: Mortality and medical care during the period between 16 and 20 years of age were at a lower level than in the previous periods. Except in patients suffering from complex or surgically treated cyanotic heart disease, the results, compared to the standard population at the age of 20 years, are better with regard to professional status, and equal for physical activity and psychosocial integration. Only 60% of the patients were followed by an adult cardiologist and only 45% of the patients needing antibiotic prophylaxis against bacterial endocarditis are aware of this. CONCLUSION: Except in patients with complex congenital or surgically treated cyanotic heart diseases, the outcome at the age of 20 years with regard to professional status, physical activity and psychosocial integration is very good compared with the standard population at the age of 20 years. The handover to the adult cardiologist is inadequate and knowledge and awareness of antibiotic prophylaxis against bacterial endocarditis is also insufficient-both aspects need improvement.     

Psychological factors and heart diseases

We are often faced with patients with increased psychosocial stress, anxiety and depression and various cardiovascular symptoms such as hypertension, tachycardia, arrhythmia and chest pain. Psychological factors are important in particular in ischaemic heart disease and in arterial hypertension. In this respect chronic as well as acute stress plays a part. The problem of stress as a risk factor of these diseases of civilization is investigated. Some psychopathological signs may lead first to cardiological examination but their origin is within the psychic sphere of the patient. In the diagnostic sphere of some diseases which belong primarily into the cardiological or psychiatric sphere collaboration at a scientific as well as practical level is necessary.     

Does psychosocial intervention in cancer patients affect survival and psychological well-being?]

We have critically reviewed the scientific literature examining the effect of psychosocial interventions on survival and well-being among adult cancer patients. Only studies using randomization and including a control-group not receiving psychosocial intervention were reviewed. Six studies examined the effect on prognosis. In four of these studies survival increased significantly in the intervention group as compared to the control group. All of these studies, however, have methodological flaws, leaving a possible prognostic effect to be clarified in larger, well-controlled future studies. The effect of psychosocial intervention on various psychosocial variables (such as anxiety and depression) was evaluated in 20 studies. Differences in patient populations, intervention strategies, and outcomes decrease the comparability of the results, and the majority of these studies suffer from methodological flaws as well. A positive effect on anxiety and depression immediately following the intervention is, however, reported in the majority of these studies. It is thus possible that the level of anxiety and depression may be decreased by integrating psychosocial intervention in the overall treatment of cancer.     

The in vitro effect of vitamin D3 analogue EB-1089 on a human prostate cancer cell line (PC-3)

OBJECTIVES: To assess the impact of augmentation ureterocystoplasty on the success of cadaveric renal transplantation in children with dysfunctional bladders. METHODS: Two patients with end-stage renal failure secondary to dysfunctional bladders (one myelodysplasia and one posterior urethral valves) underwent augmentation ureterocystoplasty prior to renal transplantation in order to increase bladder capacity and improve compliance. RESULTS: Significant improvement of bladder storage function was achieved in both patients. By the use of megaureter for augmentation, untoward sequelae of enteric or gastric augmentation were obviated. Renal transplantation was successful in both patients. Both have normal renal function 4 and 3 years after transplantation. CONCLUSIONS: Renal transplantation into bladders previously augmented with megaureters is successful. The use of urothelial-lined biomaterial for augmentation avoids the potential complications of gastro- or enterocystoplasty, which are especially dangerous in transplant patients.     

Psychosocial adaptation in juvenile rheumatic disease: A controlled evaluation.

Examined the psychosocial functioning of 93 children (aged 1–18 yrs) with severe or mild rheumatic disease and 93 healthy children from demographically matched families. Ss in the severe patient group showed more parent-reported psychological and physical problems than mild patients and healthy controls. Compared with the mild group, the severe group also missed more school due to illness. Older severe patients were more likely to miss school due to illness and to participate in fewer social activities than controls; however, older Ss reported comparable mood and functioning in other areas. A model for examining risk and resistance factors predictive of psychological and social dysfunction among children with severe chronic disease is proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of family drawings by children in pediatric practice

Sleep was actigraphically investigated in 27 Kibbutz children while sleeping in communal sleeping houses, and 1 year after changing to familial sleeping arrangements. Three independent control groups of city-living children were also recorded. Two of them were age-comparable, and the third control group was included in order to examine possible effects of the Gulf War on the communal sleep group. The results showed that the sleep quality of Kibbutz children improved significantly after moving to familial sleep. Comparison with the data from the two control groups revealed a greater resemblance between sleep of the Kibbutz children after moving to live with their families and that of the city-living children. Comparing the sleep of the children in communal sleep to that of the additional group of children examined during the Gulf War strengthened the above results, i.e. the communal sleep group that was investigated before the war slept worse than the control children that were investigated during the war. After discarding developmental and physical condition-related changes, it was concluded that the improvement in sleep quality was due to the children's increased sense of security when sleeping with their families.     

The influence of vitamin C and e or beta-carotene on peroxidative processes in persons with myocardial ischemia

An increasing body of evidence suggests that beside hypercholesterolemia peroxidative processes and natural antioxidant defence system play important role in the development of atherosclerosis. Our earlier investigation showed the increased intensity of the peroxidative processes in the course of the acute myocardial infarction and unsatisfactory tocopherol, ascorbic acid and retinol status. The purpose of the present study was the evaluation of the effect of antioxidant vitamins supplementation by the period of 21 days on the peroxidative processes in patients after heart attack or after "bypass" admitted to the cardiological rehabilitation centre. Daily oral supplementation with vitamin C, E and beta-carotene decreased significantly plasma lipid peroxide concentration (TBARS). The highest drop in TBARS activity was found in the group after bypass. No significant effect of vitamin supplementation was observed on antioxidant enzymes activity.     

Comparisons of adult children of alcoholic, divorced, and control parents in four outcome domains.

This study evaluated potential differences among 82 adult children of paternal alcoholics, 80 adult children of divorced parents, and 82 controls. Participants completed questionnaires assessing psychosocial functioning, internalizing and externalizing behaviors, alcohol use, and early family environment. After controlling for stressors often associated with alcoholic families, the authors found no group differences on current outcome measures. However, there were group differences on measures of early family environment. Children of alcoholics reported less father warmth than children of divorce or controls, and children of alcoholic and divorced parents reported more parental conflict than did controls. Post hoc analyses revealed that these early family environment variables were associated with participants' current psychosocial functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improved kidney function with intravenous prostaglandin E1 in patients with terminal heart failure

In end stage congestive heart failure activation of a series of compensatory mechanisms increase renal vascular resistance and impair renal function. Prostaglandin E1 is increasingly used in the treatment of severe heart failure for its vasodilating actions. In various experimental settings prostaglandin E analogues are known to improve renal function by modulating renal filtration pressure and redistribution of renal blood flow. However, prostaglandin E1 decreases systemic blood pressure and thus, also renal perfusion pressure, a fact by which renal function might be further compromized in heart failure patients. The aim of the study was to evaluate the effects of prostaglandin E1 on excretory renal function in patients with end stage heart failure and to prove the hypothesis, that the well known local actions of prostaglandins on renal microcirculation might outweigh the negative impact of an expected decrease in perfusion pressure. 25 patients with terminal congestive heart failure were investigated. 13 patients received prostaglandin E1 at a dose of 13.5 +/- 1.9 ng/kg/min in combination with constant rates of dopamine and dobutamine (group A), 12 patients received prostaglandin E1 at a dose of 10.3 +/- 1.7 ng/kg/min without catecholamines (group B). There was no significant difference in prostaglandin dosages between groups. Kidney function was assessed by measuring plasma creatinine and urea nitrogen, urinary output, creatinine clearance, osmotic and free water clearance at baseline and after 72 h of infusion therapy. Hemodynamic parameters were measured by using a balloon tipped pulmonary arterial catheter. Hemodynamic measurements during infusion showed a significant improvement in all patients. At the same time as expected mean arterial pressure decreased in both groups (p < 0.001). Nevertheless, in both groups a significant increase of creatinine clearance during infusion was observed (in group A from 45 ml/min to 78 ml/min., p < 0.05, in group B from 59 ml/min to 105 ml/min., p < 0.001). Creatinine clearance in group B (without catecholamines) reached higher levels than group A (p < 0.05). Urinary volumes did not change during infusion therapy, whereas free water clearance significantly decreased, as an indication of an improvement of renal concentrations ability. We conclude, that in patients with end stage heart failure continuous infusion of prostaglandin E1 improves excretory kidney function. These findings suggest that the local effects of prostaglandin E1 on renal microcirculation can counterregulate the negative impact of prostaglandins on renal perfusion pressure.     

Cardiovascular abnormalities in children with autosomal dominant polycystic kidney disease

It is known that adults with autosomal dominant polycystic kidney disease (ADPKD) have an increased incidence of cardiovascular abnormalities, including mitral valve prolapse. The cardiac manifestations of ADPKD in the pediatric population have not been well established. To determine the cardiac manifestations of children with ADPKD, echocardiography was performed in 154 children of 66 families in which one parent has ADPKD. Eighty-six affected children and 68 unaffected children were evaluated in a prospective, single-blinded manner by echocardiography. Affected children were defined as those with any cysts on a concurrent renal ultrasound or those predicted to be gene carriers by gene linkage analysis. A 12% incidence of mitral valve prolapse was found in the affected children compared with only 3% of the unaffected children (P < 0.05). ADPKD children, but not their unaffected siblings, demonstrate a significant correlation between left ventricular mass index and systolic blood pressure. Moreover, hypertensive ADPKD children have significantly larger left ventricular mass index than do normotensive ADPKD children. A 3.5% incidence of congenital heart disease was found in the affected group, whereas 2.9% of the unaffected children had congenital heart disease. It was concluded that systemic manifestations of ADPKD, particularly cardiovascular abnormalities, are present even in childhood and these warrant the clinician's attention.     

Long-term improvement in renal function after cyclosporine reduction in renal transplant recipients with histologically proven chronic cyclosporine nephropathy

BACKGROUND: Chronic cyclosporine (CsA) nephropathy, which has been unequivocally documented in recipients of heart, heart-lung, liver, or bone marrow transplants, as well as in nontransplant situations, usually results in a progressive deterioration of renal function. In this study, we assessed the potential reversibility of chronic CsA nephropathy in renal transplant recipients. PATIENTS AND METHODS: Twenty-three renal transplant patients with biopsy-proven CsA nephropathy associated with long-term CsA administration (27+/-4 months) were followed up for more than 2 years after CsA reduction (18/23 patients) or withdrawal (5/23 patients) and addition of azathioprine. Changes in effective renal plasma flow and glomerular filtration rate were assessed before and 2 years after CsA reduction, whereas serum creatinine, proteinuria, blood pressure, and CsA concentrations were monitored up to 5 years. RESULTS: At 2-year follow-up, glomerular filtration rate increased from 40+/-3 to 47+/-4 (P<0.05) and effective renal plasma flow from 217+/-23 to 244+/-24 ml/min/1.73 m2 (NS). Mean arterial pressure significantly decreased from 98.7+/-2.9 to 93.1+/-2.7 mmHg (P<0.05). There was no significant change in renal vascular resistance, filtration fraction, or albumin excretion. A significant decrease in serum creatinine was also observed during the whole follow-up (73+/-6.5 months). CsA reduction was followed by only one episode of acute reversible rejection; chronic rejection developed in three patients 2 years or later after CsA reduction. CONCLUSIONS: These data suggest that CsA nephropathy participates in graft dysfunction in a small group of renal transplant recipients. In addition, graft dysfunction may be reversible when CsA dosage is reduced early after diagnosis of chronic CsA nephropathy.     

Age and ethnicity affect the risk and outcome of focal segmental glomerulosclerosis

In patients with proteinuria, African-American (AA) ethnicity is reported to be a risk factor for focal segmental glomerulosclereosis (FSGS) and its progression to end-stage renal disease (ESRD). We reviewed our single-center experience to determine the probability of FSGS and its progression to ESRD based on ethnicity and age at presentation in children with proteinuria with or without nephrotic syndrome. Proteinuria without systemic disease or acute glomerulonephritis was the presenting feature in 17% (236/1,403) of children in the renal patient database of Texas Children's Hospital, Baylor College of Medicine. Histopathological diagnoses were established in 107 of 236 patients (45%). FSGS was identified in 65 patients, accounting for 28% of all patients with proteinuria and 61% of patients who underwent renal biopsy. FSGS was more prevalent in AA (45%) than in non-AA patients (22%) (P=0.001), and AA patients with FSGS were older at presentation (12.7+/-4.4 years) than non-AA patients (5.6+/-4.6 years) (P<0.001). Among patients who underwent renal biopsy, increasing age at presentation increased the probability of having FSGS in AA but not non-AA patients (P=0.04). Five-year actuarial renal survival of FSGS was worse in AA (8%) than in non-AA patients (31%) (P=0.01). These data suggest an increased risk and worse outcome of FSGS in AA compared with non-AA children.     

Clinical survey of congenital cytomegalovirus infection in Japan

Contrast media-induced nephropathy is one of the leading causes of hospital-acquired renal failure, occurring most frequently in patients with pre-existing renal insufficiency. We prospectively studied 55 patients with chronic renal insufficiency (serum creatinine concentration 1.4 to 3.5 mg/dl) who underwent abdominal aortography and arteriography of the lower extremities. The patients were randomized into two groups. Group 1, 28 patients, received dopamine 2.5 mcg/kg beginning 1 hour before arteriography and continuing for 12 hours. Group 2 received an equal volume of saline for the same period of time. Serum creatinine and 12-hour creatinine clearance were measured before arteriography and for 4 consecutive days afterward. Acute contrast-induced decrease in renal function was defined as increase in the baseline serum creatinine concentration > or = 0.5 mg/dl. On day 1 postarteriography the serum creatinine increased from baseline .193 mg/dl for controls while the dopamine group decreased slightly from baseline .018 mg/dl (p = 0.002). Excepting day 1 postarteriography, there was no statistical difference between groups, and serum levels for both groups increased linearly from baseline across time (dopamine p = 0.028, control p = 0.025). In patients with pre-arteriography baseline serum levels greater than or equal to 2.0 mg/dl, however, the increase in serum creatinine from baseline levels was consistently and significantly greater in the control group through the fourth day (0.012 < or = p < or = 0.049). Creatinine clearance did not change significantly from baseline after arteriography in the dopamine group (baseline versus days 1 through 4, 0.238 < or = p < or = 0.968); however, the control group showed a significant linear decrease in creatinine clearance from baseline through the fourth day after arteriography (p = 0.016). Dopamine infusion prevented a rise in serum creatinine 24 hours after angiography in patients with pre-existing renal insufficiency, and protected against contrast-induced decrease in renal function in patients whose baseline serum creatinine was > or = 2.0 mg/dl.     

Identification of patients with autosomal dominant polycystic kidney disease at highest risk for end-stage renal disease

To identify those potential factors that, early in the course of disease, mark a population of patients with autosomal dominant polycystic kidney disease (ADPKD) who have worse renal survival, survival analysis and risk ratio calculation for 1215 ADPKD patients were performed. Survival times were calculated as time to dialysis, transplantation, or death. Risk ratios were calculated using the Cox proportional hazards model. Three hundred eighty-eight patients entered end-stage renal disease and 205 patients died. ADPKD2 subjects had longer renal survival than ADPKD1 subjects (median survival, 68 versus 53 yr; P < 0.0005; risk ratio, 2.5). Women had significantly better renal survival than men (56 versus 52 yr; P < 0.0001; risk ratio, 1.6). Subjects who were diagnosed before age 30 and those who developed hypertension before age 35 had worse renal survival than those subjects who were diagnosed after age 30 or those who remained normotensive after age 35, respectively (age of diagnosis: 49 versus 59 yr; P < 0.0001; risk ratio, 3.2; hypertension: 51 versus 65 yr; P < 0.0001; risk ratio, 4.4). Similarly, those who had an episode of gross hematuria before age 30 had a worse renal outcome than those who did not (49 versus 59 yr; P < 0.0001; risk ratio, 2.6). We have also calculated risk ratios for a combined model. When therapeutic interventions become available for this disease, these populations with high risk ratios should be considered for such interventions.     

Circulating immune complexes in patients with advanced tuberculosis and their association with autoantibodies and reduced CD4+ lymphocytes

Critically ill patient status and prior sternotomy have separately been associated with increased risk of mortality and morbidity after heart transplantation. Consequently, the justification of assigning urgent priority for transplantation to critically ill patients with prior sternotomy may be arguable. The authors therefore undertook a retrospective analysis to evaluate the outcome of urgent and elective heart transplantation in 64 patients who had undergone one to four previous sternotomies. Patients in group 1 (n = 23) were critically ill and underwent urgent heart transplantation. Group 2 (n = 41) consisted of more stable patients who received heart transplantation as an elective procedure. Intravenous inotropes or mechanical circulatory support were required by all patients in group 1 but by none in group 2. The mortality rate within 30 days post-transplant was higher in group 1 than in group 2 (22% versus 10%), though the difference was not statistically significant. The 1-year actuarial allograft survival was similar between the two groups (72% versus 74%). In addition, there was no significant difference between groups 1 and 2 in the incidence of postoperative coagulopathy (57% versus 42%), re-exploration (13% versus 15%), early infections (57% versus 49%), renal failure (17% versus 10%) or rejection episodes in the first 3 months (65% versus 78%). The authors' findings suggest that despite higher operative mortality in critically ill patients with previous sternotomies, the intermediate-term outcome of heart transplantation in these patients is similar to that in more stable patients. Critically ill patients with prior sternotomies should therefore continue to be considered for urgent heart transplantation.     

Effect of ethanol drinking and naltrexone on subsequent drinking in rats

The effects of several days of oral ethanol drinking paired with naltrexone (NTX) on subsequent ethanol drinking were investigated in rats. We hypothesized that repeated pairings of NTX combined with forced oral ethanol intake would extinguish ethanol drinking so that when NTX injections were terminated, voluntary oral ethanol drinking would be suppressed. Thirty-two male. Long-Evans rats were provided with alternate days of either 8% ethanol solution or water as the sole source of fluid. Intraperitoneal injections of 0, 2.5, or 5.0 mg of NTX hydrochloride were administered on the ethanol days. Following the termination of injections, rats were returned to unrestricted access to water and ethanol and 24-h measurements of fluid intake were recorded. NTX decreased ethanol intake 4 h, but not 24 h, after NTX injections. Despite the consumption of significant amounts of ethanol during NTX treatment, there was no change in voluntary oral ethanol intake patterns after NTX injections were terminated (reinstatement of voluntary ethanol drinking). Thus, NTX's reduction in ethanol intake was limited in duration and did not result in long-term extinction of ethanol drinking behavior.     

Erythrocyte superoxide dismutase activity and plasma malondialdehyde levels in children with Henoch Sch?nlein purpura

Reactive oxygen molecules (ROM) have been suggested to contribute to many pathological conditions including vasculitides and renal diseases. In the present study we measured the activity of superoxide dismutase (SOD) as an antioxidant enzyme in red blood cells and the level of malondialdehyde (MDA), which is a product and an indicator of lipid peroxidation, in the plasma of 16 children (7M, 9F) with Henoch Sch?nlein purpura (HSP) at the onset of the disease (SOD 1 and MDA 1) and at the remission period (SOD 2 and MDA 2). The results were compared with the results of 17 healthy children studied as a control group. There was no significant difference for SOD activities between the patients in each period and the control group (p > 0.05). There was a statistically significant difference between MDA 1 and MDA 2 levels (p < 0.01), each of which were also significantly different from the MDA levels of control group (p < 0.001 and p < 0.01, respectively). The effect of ROMs on different clinical conditions of HSP was also examined and lipid peroxidation was found to be increased more in patients with renal involvement. It is concluded that oxidant stress especially lipid peroxidation plays an important role in the pathogenesis of HSP and in development of renal injury.     

Defining and measuring unintended pregnancy: issues and concerns

PURPOSE: The authors describe a proactive model of psychosocial care for patients undergoing blood or marrow transplantation and their families. DESCRIPTION OF PROGRAM: This program for blood or marrow transplantation patients, developed at the Center for Cancer Treatment and Research, Richland Memorial Hospital, and the University of South Carolina School of Medicine in Columbia, South Carolina, involves pretransplant comprehensive psychosocial assessment; development and implementation of an individual psychosocial treatment plan; monitoring and medical management of neuropsychiatric problems; and psychotherapeutic sessions with a psychiatrist. These functions are achieved through the use of a multidisciplinary psychosocial team and ongoing consultation-liaison with the entire blood or marrow transplantation team. CLINICAL IMPLICATIONS: This positive, proactive model demonstrates significant benefit to patients, families, and the blood or marrow transplantation healthcare team. Benefits of this model are derived from psychosocial assessment during work-up, subsequent planning, and communication with the entire team, thus allowing early identification of problems and avoiding escalation and the likelihood of negative outcomes. Less energy is exerted and less resources expended when problems are resolved with early intervention rather than with intensive interventions during transplant. The psychosocial staff members develop strong relationships with patients and families before transplant, increasing the power of interventions and receptivity of the patient. The blood or marrow transplantation team benefits from the ongoing presence of psychosocial staff and the consistency of approaches offered by team members. An integral part of this approach is teaching psychosocial care to all staff members and modeling approaches to problems. Other blood or marrow transplantation centers and centers providing other intensive anticancer therapies may benefit by adapting this model into the day-to-day care of their patients.