The BAASIS scale was developed with this phenomenon in mind and i

The BAASIS scale was developed with this phenomenon in mind and is therefore intentionally strict in its scoring mechanism: even a small deviation in the regime sellectchem leads to being classified as nonadherent [20]. However, these scores were not associated with intrapatient variability of tacrolimus, a direct and potentially more objective measure for adherence, so that underreporting cannot be dismissed. Secondly, patients who did not have sufficient mastery of the Dutch language were excluded and another group of patients declined to participate. It is possible that these harder-to-reach patients demonstrate yet another attitude, not identified here. Findings therefore cannot be generalised to these patients. Finally, this study was conducted among a limited number of patients in a single centre.

Replication of this study in different centres, with particular attention to inclusion of the harder-to-reach patients as well, is therefore advised. There are a few clinical implications of these findings. We found that Q-methodology was a useful tool for nurses in their interactions with patients, as it helped patients to talk freely about a difficult clinical topic. This approach offered patients the opportunity to (visually) structure their thoughts and nurse researchers the opportunity to investigate such pertinent issues in greater depth and to develop and tailor education programmes for this patient population. In any case, the finding that self-reported nonadherence was related to likelihood of graft failure suggests that a dialog between nurse and patient on medication adherence early in the transplant recovery period could be a useful tool to flag up individuals at risk of graft failure.

Future research is also needed to further explore the (reciprocal) relationship between worry/anxiety and nonadherence and its clinical consequences. Acknowledgments This study was funded from an internal grant ��Evidence Based Care Nurses�� by the Erasmus University Medical Centre Rotterdam, The Netherlands. Conflict of Interests The authors declare that there is no conflict of interests regarding the publication of this paper.
Vascularized Composite Allotransplantation, or VCA, refers to the transfer and integration of multiple tissue components and has generally been used to describe nonorgan transplants such as face and extremity [1].

The goal of such procedures is to AV-951 restore both form and functionality following catastrophic injury. The first such procedure was performed by Peacock in the form of an ��en bloc digital flexor mechanism transplant�� in 1957 [2�C4]. However, the successful investigation into complete extremity transplantation occurred only after the introduction of cyclosporine in 1982, paving the way for the first successful unilateral hand transplant which occurred in Lyon France in September 1998 [4, 5].

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