[Hand allografts: experience from Lyon team]. / Allogreffe de mains: expérience lyonnaise.

Hand allograft is a method in the stage of clinical experimentation, which is reserved in France for the treatment of bilateral traumatic amputees. This study reports the Lyon team experience, which is pioneer in this domain. Four patients (3 males and 1 female) underwent seven (one unilateral and three bilateral) hand transplantations from September 1998 to February 2007. The level of amputation was at the wrist or at the mid-forearm. Delay since hand loss ranged from 2.5 to 9 years. The surgical protocol was elaborated and planned case by case. All recipients received the same immunosuppressive treatment. Episodes of acute rejection were observed in the first 3 months after transplantation, which were easily managed after a few days increasing oral prednisone doses and applying topical immunosuppressants. Currently the patients receive the doses of immunosuppressants comparable to those in kidney-grafted patients. We have not registered any severe complication of immunosuppressive treatment up till now (7 years follow-up for the earliest graft). We performed analytical and functional clinical, as well as questionnaire evaluation of patients. The first case (unilateral graft) resulted in graft failure at 2 years due to non-compliance of the patient. The three bilateral graftees demonstrate a favorable evolution despite some immunological (hyperglycemia, serum sickness) and surgical (thrombosis, osteomyelitis, skin loss) complications, which could be managed. The middle and long-term follow-up evaluation revealed good to excellent sensorimotor recovery of 4 hands in both male recipients (4 and 7 years) with satisfactory social adaptation, higher or equal to those expected after post-traumatic replantations at the equivalent level and higher to those obtained with currently available myoelectric prosthesis. The last patient, a young female who has been grafted in February 2007, receives ongoing reeducation course and shows normal progress of functional restoration of both hands. The encouraging results of this clinical experimentation make us currently consider hand allografting as reasonable and useful both for the patients and for evolution of research in composite tissues allotransplantation (CTA). Further long-term careful research and worldwide monitoring of all patients with hand allografts is required to, on the one part, state on the authorization of this surgery, and, on the other part, to better elucidate the mechanisms of successful CTA.

Chronic pain and posttraumatic stress disorders.

The paper reports on the role of consultation-liaison psychiatry in a pain clinic, where posttraumatic disorders are prevalent. An original approach to consultation is described.

[Evaluation using DSM-III of the clinical activity of a psychiatry department at a general hospital]. / Evaluation par le DSM-III de l'activité clinique d'un service de psychiatrie à l'hôpital général.

The DSM-III multiaxial classification was used to evaluate the one-year clinical activity of a psychiatry and medical psychology department in a general hospital. Compared to the general population, the patients (n = 1,071) corresponded to a sample of professionally active subjects in which top and middle executives as well as students were over=represented. Fifty-one per cent of the patients suffered from anxiety or affective disorders, while 9 per cent presented somatoform disorders. Histrionic and dependent personalities were more frequent in women. Thirty six per cent of the subjects had a concurrent physical illness. Psychosocial stress and altered adaptation were higher in unemployed people and in patients with physical illness. Specific diagnostic and socioprofessional patterns corresponded to the various types of mental care: psychoanalytically oriented psychotherapy, behaviour therapy, psychopharmacological treatments, consultation-liaison, pain consultation.