Background Tacrolimus therapy in solid organ transplant (SOT) recipients is challenging due to its narrow therapeutic window and pharmacokinetic variability both between patients and within a single patient. Intrapatient variability (IPV) of tacrolimus trough concentrations has become a novel marker of interest for predicting transplant outcomes. The purpose of this review is to evaluate the association of tacrolimus IPV with graft and patient outcomes and identify interventions to improve IPV in SOT recipients. Methods A systematic review of the literature was performed using PubMed and Embase from database inception to September 20, 2020. Studies were eligible only if they evaluated an association between tacrolimus IPV and transplant outcomes. Both pediatric and adult studies were included. Measures of variability were limited to standard deviation, coefficient of variation, and time in therapeutic range. Results Forty‐four studies met the inclusion criteria. Studies were published between 2008 and 2020 and were observational in nature. Majority of data were published in adult kidney transplant recipients and identified an association with rejection, de novo donor specific antibody (dnDSA) formation, graft loss, and patient survival. Evaluation of IPV‐directed interventions was limited to small preliminary studies. Conclusions High tacrolimus IPV has been associated with poor outcomes including acute rejection, dnDSA formation, graft loss, and patient mortality in SOT recipients. Future research should prospectively explore IPV‐directed interventions to improve transplant outcomes.

ObjectivesEmployment following illness is associated with better physical and psychological functioning. This study aimed to assess the feasibility and acceptability of a theoretically led workbook intervention designed to support patients with cancer returning to work.DesignParallel-group randomised controlled trial with embedded qualitative interviews.SettingOncology clinics within four English National Health Service Trusts.ParticipantsPatients who had received a diagnosis of breast, gynaecological, prostate or colorectal cancer and who had been receiving treatment for a minimum of two weeks.InterventionA self-guided WorkPlan workbook designed to support patients with cancer to return to work with fortnightly telephone support calls to discuss progress. The control group received treatment as usual and was offered the workbook at the end of their 12-month follow-up.Outcome measuresWe assessed aspects of feasibility including eligibility, recruitment, data collection, attrition, feasibility of the methodology, acceptability of the intervention and potential to calculate cost-effectiveness.ResultsThe recruitment rate of eligible patients was 44%; 68 participants consented and 58 (85%) completed baseline measures. Randomisation procedures were acceptable, data collection methods (including cost-effectiveness data) were feasible and the intervention was acceptable to participants. Retention rates at 6-month and 12-month follow-up were 72% and 69%, respectively. At 6-month follow-up, 30% of the usual care group had returned to full-time or part-time work (including phased return to work) compared with 43% of the intervention group. At 12 months, the percentages were 47% (usual care) and 68% (intervention).ConclusionsThe findings confirm the feasibility of a definitive trial, although further consideration needs to be given to increasing the participation rates among men and black and ethnic minority patients diagnosed with cancer.Trial registration number ISRCTN56342476; Pre-results.

Purpose Returning to work is a process that is intertwined with the social aspects of one's life, which can influence the way in which that person manages their return to work and also determines the support available to them. This study aimed to explore cancer patients' perceptions of the role of their social context in relation to returning to work following treatment. Methods Twenty-three patients who had received a diagnosis of either urological, breast, gynaecological, or bowel cancer participated in semi-structured interviews examining general perceptions of cancer, work values and perceptions of the potential impact of their cancer diagnosis and treatment on work. Interviews were analysed using the iterative process of Framework Analysis. Results Two superordinate themes emerged as influential in the return to work process: Social support as a facilitator of return to work (e.g. co-workers' support and support outside of the workplace) and Social comparison as an appraisal of readiness to return to work (e.g. comparisons with other cancer patients, colleagues, and employees in other organisations or professions). Conclusions Two functions of the social context of returning to work after cancer were apparent in the participants' narrative: the importance of social support as a facilitator of returning to work and the utilisation of social comparison information in order to appraise one's readiness to return to work. The role of social context in returning to work has largely been absent from the research literature to date. The findings of this study suggest that social support and social comparison mechanisms may have a significant impact on an individual's successful return to the workplace.

BackgroundReturning to work after cancer is associated with improved physical and psychological functioning, but managing this return can be a challenging process. A workbook based intervention (WorkPlan) was developed to support return-to-work among cancer survivors. The aim of this study was to explore how participants using the workbook engaged with the intervention and utilised the content of the intervention in their plan to return-to-work.MethodsAs part of a feasibility randomised controlled trial, 23 participants from the intervention group were interviewed 4-weeks post intervention. Interviews focussed on intervention delivery and data was analysed using Framework analysis.ResultsParticipants revealed a sense of empowerment and changes in their outlook as they transitioned from patient to employee, citing the act of writing as a medium for creating their own return-to-work narrative. Participants found the generation of a return-to-work plan useful for identifying potential problems and solutions, which also served as a tool for aiding discussion with the employer on return-to-work. Additionally, participants reported feeling less uncertain and anxious about returning to work. Timing of the intervention in coordination with ongoing cancer treatments was crucial to perceived effectiveness; participants identified the sole or final treatment as the ideal time to receive the intervention.ConclusionsThe self-guided workbook supports people diagnosed with cancer to build their communication and planning skills to successfully manage their return-to-work. Further research could examine how writing plays a role in this process.Trial registrationCurrent Controlled Trials ISRCTN56342476. Retrospectively registered 14 October 2015.

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