Vascularized composite allotransplantation: emerging psychosocial issues in hand, face, and uterine transplant.

PURPOSE OF REVIEW: Currently, several research approaches warrant further attention, given the influence of psychosocial and bioethical issues on the success of upper extremity (UETx), face (FTx), and uterine transplantation (UTx). This review will highlight recent results of psychosocial and bioethical research in the field of vascularized composite allotransplantation (VCA), discuss most recent findings, provide information to guide future research approaches, and address the importance of a multicenter research approach to develop international standards. RECENT FINDINGS: Previously published reports have tried to identify psychosocial factors that are essential to predict psychosocial outcomes and guide posttransplant treatment after VCA procedures. These issues in VCA are receiving more attention but we are still at the beginning of a systematic investigation of these domains. This review article summarizes the emerging psychosocial issues in UeTx, FTx, and UTx by including recent literature and current clinical practice. SUMMARY: Even though different VCA procedures address different domains leading to specific psychosocial issues, common aspects impacting all forms of VCA would benefit of further coordination. These domains include clinical resources, public attitude and perception, bioethical considerations, adherence and rehabilitation, motives for VCA, information needs and multidisciplinary communication, body image, domains of quality of life, coping strategies, and follow-up care.

Long-term outcome after hand and forearm transplantation - a retrospective study.

Between 2000 and 2014, five patients received bilateral hand (n = 3), bilateral forearm (n = 1), and unilateral hand (n = 1) transplants at the Innsbruck Medical University Hospital. We provide a comprehensive report of the long-term results at 20 years. During the 6-20 years follow-up, 43 rejection episodes were recorded in total. Of these, 27.9% were antibody-related with serum donor-specific alloantibodies (DSA) and skin-infiltrating B-cells. The cell phenotype in rejecting skin biopsies changed and C4d-staining increased with time post-transplantation. In the long-term, a change in hand appearance was observed. The functional outcome was highly depending on the level of amputation. The number and severity of rejections did not correlate with hand function, but negatively impacted on the patients´ well-being and quality of life. Patient satisfaction significantly correlated with upper limb function. One hand allograft eventually developed severe allograft vasculopathy and was amputated at 7 years. The patient later died due to progressive gastric cancer. The other four patients are currently rejection-free with moderate levels of immunosuppression. Hand transplantation remains a therapeutic option for carefully selected patients. A stable immunologic situation with optimized and individually adopted immunosuppression favors good compliance and patient satisfaction and may prevent development of DSA.

Standardizing psychosocial assessment for vascularized composite allotransplantation.

PURPOSE OF REVIEW: Vascularized composite allotransplantation (VCA) encompasses hand, face, uterus, penile and lower extremity transplantation. Psychosocial factors are recognized as important, but no standard approach to the evaluation, selection or posttransplant care has been described and thus, the development of a standardized approach is needed. RECENT FINDINGS: Various psychosocial assessment tools have been reported. Body image and the functional impact of hand versus face transplantation are notable issues. Patients with psychiatric, chemical dependence histories and suicide attempts have been transplanted. Loss of graft or decreased function because of nonadherence has occurred. Screening for depression, social adaptation, coping styles and quality of life (QOL) is common. SUMMARY: Although VCA is not a lifesaving procedure, as in solid organ transplantation, the following areas require assessment: psychiatric stability, history of chemical dependence, family support, adherence and understanding of transplantation. VCA requires the incorporation of a visible allograft, lengthy rehabilitation, occupational considerations, prosthetic use, possible screening for posttraumatic stress disorder related to injuries and phantom limb pain. Intense media interest may lead to distress. Development of an instrument to address these areas initially and over time to monitor for changes in QOL and training the psychosocial team is a priority.

Is There a Link Between Physical Activity and Alcohol use?

Physical activity (PA) is discussed as a protective factor as well as a risk factor for alcohol consumption. Therefore, this study aimed at exploring a potential relationship between these behaviors. In a population-based cross-sectional study of 15,474 people living in Austria physical activity, alcohol consumption and demographic variables were assessed. Regression analysis including age and gender revealed no significant relationship between PA and alcohol consumption for the total sample. More alcohol consumption was found in men with low PA-levels. Focusing on a part of the population who consumed alcohol the weekend before, men with high PA-levels reported more alcohol consumption in comparison to men with moderate PA-levels. This study does not support a common alcohol-physical activity relationship. Prevention programs to increase PA levels from low to moderate combined with a reduction of alcohol intake in men who regularly drink alcohol should be considered.

The Development of Acceptance of Chronic Tinnitus in the Course of a Cognitive-Behavioral Group Therapy.

OBJECTIVE: Cognitive-behavioral treatment (CBT) is an effective treatment for tinnitus distress. Recently, acceptance-based approaches have received growing attention within the treatment of chronic tinnitus. The development of tinnitus acceptance within CB treatment remains unclear. This study investigates the efficacy of a CBT group therapy and the corresponding change in tinnitus acceptance. METHODS: 68 outpatients took part in a CBT group therapy over a 3-month period. Effect sizes and paired t-tests were used to evaluate the effectiveness of the CBT treatment and to investigate the development of acceptance. RESULTS: Results showed a significant decrease in tinnitus distress and an increase in tinnitus acceptance. Improvements were maintained over a 6-month follow-up period in which large effect sizes were observed. CONCLUSIONS: CBT is considered an effective treatment for tinnitus distress in patients with chronic tinnitus. Acceptance of chronic tinnitus clearly improved within a CBT group therapy.

An overview of psychosocial assessment procedures in reconstructive hand transplantation.

There have been more than 90 hand and upper extremity transplants performed worldwide. Functional and sensory outcomes have been reported in several studies, but little is known about the psychosocial outcomes. A comprehensive systematic literature review was performed, addressing the psychosocial impact of reconstructive hand transplantation. This review provides an overview of psychosocial evaluation protocols and identifies standards in this novel and exciting field. Essentials of the psychosocial assessment are discussed and a new protocol, the 'Chauvet Protocol', representing a standardized assessment protocol for future multicenter psychosocial trials is being introduced.

Psychological aspects of hand transplantation.

PURPOSE OF REVIEW: Psychosocial aspects are important indicators for reconstructive hand transplantation (RHT). They warrant further research attention given the influence of psychosocial factors on the success of RHT. This review will contrast RHT with solid organ transplantation, provide information to guide selection of RHT candidates and ethical implications, share information on psychological outcomes, and address the importance of a multicenter research approach. RECENT FINDINGS: Previously published RHT reports have tried to identify psychosocial factors that are essential to guide selection of RHT candidates and that predict psychosocial outcomes. These issues in RHT are receiving increased attention, but standardized psychosocial evaluation and follow-up protocols are still needed. Recent study highlights the potential for a multicenter research approach that uses standardized assessment strategies and also emphasizes the need for a shared assessment approach to understand psychosocial outcomes. SUMMARY: RHT combines the technical rigors of hand surgery and microsurgery with the complex multidisciplinary care that defines modern transplantation medicine. As recent work has provided a more complete picture of the complexities of the psychosocial factors in RHT, a psychosocial assessment protocol developed with input across the centers currently performing this procedure would capitalize on the collective diverse clinical experiences and standardize the assessment and follow-up protocol. With such standardized procedures in place, psychosocial risk factors for both poor psychosocial and medical/surgical outcomes can be identified which can inform the selection or preparation of future candidates.

[Depressives have the better view - the influence of mood on the recognition of emotional expression]. / Depressive sehen besser-der Einfluss der Stimmung auf das Erkennen emotionaler Gesichter.

OBJECTIVES: There are different approaches to whether depressed people perceive their environment differently than nondepressed.We analyzed whether depressed patients show greater deficits in decoding emotional expressions than nondepressives. METHODS: A sample of 52 depressed patients and a sample of 72 nondepressed persons were investigated as to their ability to identify emotionally laden facial expressions (computer-assisted presentation of photos). RESULTS: Our results demonstrate significant differences between depressive patients and nondepressive persons in the ability to decode the emotional states of others. In four out of six tests the depressive persons achieved significantly better results. CONCLUSIONS: We suggest that these results can be interpreted as further evidence for the concept of depressive emotional realism.

The first step is the hardest - emotion recognition in patients with somatoform disorders.

OBJECTIVES: The aetiology of somatoform disorders is assumed to consist of several factors, as alexithymia, dysfunctional cognitions and emotion regulation. As a consequence of somatoform disorders social withdrawal is discussed. Several studies prove connections between mental problems, emotion recognition, and functioning social relationships. METHODS: A sample of 35 patients suffering from a somatoform disorder and a sample of 73 persons without any somatoform symptoms were investigated according to their ability to identify emotional facial expressions (computer-assisted presentation of photos). RESULTS: Our results demonstrate significant differences in the ability to decode others' emotional states between people with or without somatoform disorders. In all six tests the patients achieved significantly worse results. CONCLUSIONS: Our results suggest that psychotherapeutic treatment of patients with somatoform disorders should also focus on the recognition of emotions and deal with them.

[Officer in charge, that unknown being - an explorative, qualitative study of unconscious fears, wishes, and defense mechanisms]. / Das Unbekannte Wesen Einsatzleiter - Eine Explorative Qualitative Studies zur Erfassung Unbewusster Ängste, Wünsche und Abwehrmechanismen.

OBJECTIVES: The stress and coping strategies found among emergency relief personnel have been studied in detail but without considering their function in the team. However, specifically officers in charge have to be addressed and investigated separately. This study focuses on the unconscious desires, fears, and defense mechanisms present in order to improve our understanding of the stress experienced during operations. METHODS: Four officers in charge were interviewed concerning their stressful experiences during operations. These interviews were then coded and analysed using the JAKOB Narrative Analysis ("Klinische Erzählanalyse JAKOB", Boothe et al. 2002). RESULTS: The recorded unconscious desires included solidarity, phallic integrity, generativity, unconscious fears destruction, loss of power/influence, and social hostility, and as defense strategies rationalism, repression/denial, and idealization. CONCLUSIONS: The analysis of the interviews shows a high reliability between the raters (0.74-0.79). The greatest burden for officers in charge is a loss of safety. Especially being confronted with strains in their own team leads to stress, which shows that the methods used for stress management following critical incidents is not sufficient.

[Preoperative evaluation of the body concept of donors and recipients of living kidney donations]. / Präoperative Evaluation des Körperkonzepts von Nierenlebendspendern und -empfängern.

OBJECTIVES: The psychosocial evaluation of the body concept of living kidney donors and recipients is part of a general psychosocial assessment as well as the early detection of organ integration disorders. METHODS: From 2010 to 2011 we investigated the eligibility for living kidney donation in 36 living kidney donors and 36 recipients using a semistructured clinical interview and the German version of the Transplant Evaluation Rating Scale (TERS). In addition, we used the Fragebogen zum Körperbild (FKB-20) to evaluate body concept. RESULTS: Living kidney donors and recipients differed in their body concept. Living kidney recipients described a body-centered disturbance stemming from a reduction of body-intensive activities including destabilization of body concept. CONCLUSION: The psychological coping process involved in living kidney donation demands a reconstitution of the body self. The coping/health behavior and the affective state of living kidney recipients are protective factors that influence successful organ integration.

[Patterns of dysfunctional parenting styles and psychological disturbances in offspring]. / Muster dysfunktionaler Erziehungsstile und psychische Storungen im Erwachsenenalter.

OBJECTIVES: Dysfunctional parenting styles represent a risk factor for the development of psychological disturbances. The present study investigated the differential validity of the German language Fragebogen zur Erfassung dysfunktionaler Erziehungsstile (FDEB; Measurement of Parental Styles, MOPS) and determined whether different forms of psychological disorders are associated with specific patterns of parenting styles. METHODS: 145 inpatients, 108 outpatients and a control group of 633 representative individuals from the general population were investigated by adapting the FDEB. RESULTS: A comparison of dysfunctional parenting styles showed different distress levels within the diagnostic groups: Patients suffering from depression reported high levels of maternal indifference and over protectiveness together with an abusive rearing behavior on the part of both parents. Patients with anxiety disorders reported having overprotective mothers. Bulimic patients as well as those with personality disorders significantly exhibited stress in almost all areas. However, anorexic patients did not differ significantly from the control group, which appeared to be the least affected of all. CONCLUSION: The FDEB showed a satisfactory differential validity. There was evidence that specific patterns of dysfunctional parenting styles were associated with different diagnostic groups.

Psychosocial predictors in upper-extremity vascularized composite allotransplantation: A qualitative study of multidimensional experiences including patients, healthcare professionals, and close relatives.

Background: The impact of patient-specific psychosocial factors on functional outcomes after upper-extremity (UE) vascularized composite allotransplantation (VCA) is poorly understood. The objective of this study was to identify relevant psychosocial predictors for success or failure of UE VCA in an Austrian cohort. Methods: A qualitative study was undertaken consisting of semi-structured interviews with UE VCA staff, transplanted patients, and close relatives. Participants were asked about their perceptions of factors that either favored or hindered a successful transplant outcome, including functional status before surgery, preparation for transplant, decision-making, rehabilitation and functional outcome after surgery, and family and social support. Interviews were conducted online and recorded with the consent of interviewees. Results: Four bilateral UE VCA patients, 7 healthcare professionals, and a sister of a patient participated in the study. Thematic analysis revealed the importance of an expert interdisciplinary team with adequate resources for patient selection. Psychosocial aspects of prospective candidates are crucial to evaluate as they contribute to success. Both patients and providers may be impacted by public perceptions of UE VCA. Functional outcomes are optimized with a life-long commitment to rehabilitation as well as close, ongoing provider involvement. Conclusion: Psychosocial factors are important elements in the assessment and follow-up care for UE VCA. To best capture psychosocial elements of care, protocols must be individualized, patient-centered, and interdisciplinary. Investigating psychosocial predictors and collecting outcomes is, thus, critical to justifying UE VCA as a medical intervention and to providing accurate and salient information to prospective candidates.

The psychological assessment of candidates for reconstructive hand transplantation.

Standardized psychological assessment of candidates for reconstructive hand transplantation (RHT) is a new approach in transplantation medicine. Currently, international guidelines and standardized criteria for the evaluation are not established. Patients suffering from the loss of a hand or an upper extremity have to cope with multiple challenges. For a selected group of patients, RHT represents an option for restoring natural function and for regaining daily living independence. The identification of at-risk patients and those requiring ongoing counseling due to poor coping or limited psychological resources are the primary focus of the psychological assessment. We have developed the 'Innsbruck Psychological Screening Program for Reconstructive Transplantation (iRT-PSP)' which utilizes a semi-structured interview and standardized psychological screening procedures and continuous follow-up ratings. Between January 2011 and October 2011, four candidates were evaluated using the iRT-PSP. Psychological impairments including social withdrawal, embarrassment, reduced self-esteem, and a depressive coping style were identified and poor quality of life was reported. The motivation for transplantation was diverse, depending on many factors such as bi- or unilateral impairment, native or accidental loss of hand, and social integration.

[The influence of relationship dynamics on the psychosocial outcome of genetically related and unrelated living kidney donor-recipient pairs]. / Einfluss von beziehungsdynamischen Aspekten auf den psychosozialen Outcome von genetisch verwandten und nicht-verwandten Nierenlebendspendern und-empfangern.

OBJECTIVES: Renal diseases and their treatment can cause distress and psychosocial problems for both patients and relatives. METHODS: Relationship dynamics and parameters of quality of life were assessed in 10 genetically related (brothers) and 14 genetically unrelated donor-recipient pairs (spouses) involved in living kidney donation (LKD). RESULTS: LKDs were described by related donors and recipients as fundamentally positive and in many cases led to an intensification of the relationship between donor and recipient. LKDs between unrelated donors and recipients appeared to achieve the same results as donations between related donors and recipients. Particularly the general desire to help determined the decision-making process of donors. CONCLUSION: In addition to general clinical parameters, especially motivational and relationship dynamics should be evaluated in the pre- and postoperative clinical psychological assessment of potential donors and recipients of LKD.

Psychosocial and bioethical challenges and developments for the future of vascularized composite allotransplantation: A scoping review and viewpoint of recent developments and clinical experiences in the field of vascularized composite allotransplantation.

Vascularized Composite Allotransplantation (VCA) has evolved in recent years, encompassing hand, face, uterus, penile, and lower extremity transplantation. Accordingly, without centralized oversight by United States Organ Procurement and Transplantation Network (OPTN) or European Programs, centers have developed their own practices and procedures that likely vary, and accordingly, present different levels of rigor to the evaluation process, internationally. The importance of psychosocial factors in the selection process and treatment course has been widely recognized, and therefore, several approaches have been developed to standardize and guide care of VCA candidates and recipients. We propose to develop an international multidisciplinary platform for the exchange of expertise that includes clinical, patient, and research perspectives. Patient perspectives would derive from peer education and the assessment of patient-reported outcomes. To establish a foundation for such a platform, future research should review and combine current VCA protocols, to develop the ethical framework for a standardized psychosocial evaluation and follow-up of VCA candidates and recipients. This review presents a comprehensive overview of recent results in the field of VCA, developments in structural aspects of VCA, and provides viewpoints driven from clinical experience.

Poor health behaviour and reduced quality of life of people treated with psychotropic drugs.

BACKGROUND: Recent literature reports a reduced l\ife expectancy in patients with severe mental illness. We have investigated health behaviour, quality of life, and sociodemographic variables of people with psychopharmacological treatment using data from the most recent Austrian Health Survey. METHODS: Quality of life (the World Health Organization quality of life, abbreviated version) questionnaires and items from the European Health Interview Survey were used in assessing health status and health behaviour of 15,474 people living in Austria. From this sample, 882 individuals (5.7%) under psychopharmacological treatment were compared with respondents without mental illness. RESULTS: We found significant differences in health behaviour (reduced physical activity, more smoking) and sociodemographic data (age, gender, education, income) between people treated for mental illness and respondents without psychopharmacological treatment. Correspondingly, more somatic illness and reduced quality of life were found in the former group. CONCLUSION: These data stress the necessity of health intervention and antipoverty programmes taking social and somatic issues for people with moderate mental health problems into account.

Communicative and social competence in the medical curriculum of the Medical University of Innsbruck: learning objectives, content, and teaching methods.

Aim: The Austrian Competence Level Catalogue for Medical Skills clearly states the importance of teaching communicative and social competence in the different subject areas of undergraduate medical and dental education. This paper aims to present an overview of the academic courses at the Medical University of Innsbruck that explicitly address the promotion of communication and social skills in medical students. Method: This paper focuses on educators' descriptions of how communicating with patients is taught. The Medical University's longitudinal curriculum on medical interviewing is presented in detail. The courses on ethical principles in the dissection course, palliative medicine, and gender medicine are also outlined as examples. In addition, lecturers (n=536) participated in an online survey to determine the teaching and testing content regarding patient communication and to measure the value attached to the associated teaching and learning methods. Results: The examples given by educators to illustrate learning objectives, educational content, and the teaching methods used to impart communicative and social competence provide an overview of the courses which focus on this topic or intentionally address it during the course. The results of the online survey offer a broad overview of the awareness of the topic at the university. Different testing formats are used to assess the skills being taught. Conclusion: Familiarity with the various teaching methods used in the different courses is important for developing communicative and social competence in medical education. Active networking is necessary to anchor communicative and social competency as a major thread throughout an entire medical curriculum.

Dimensions of posttraumatic growth in a German-speaking sample using mixed methods.

Background: Highly adverse events can shatter fundamental assumptions about one's self and the expected course of life actuating a process of adjustment regarding new appraisals. This struggle in the aftermath of adversity might yield posttraumatic growth (PTG), which refers to positive transformation within the person. PTG is a concept that has been established within a Western cultural framework and has both universal and culture-specific characteristics. Although across cultures individuals perceive benefits from their struggles with life crises, the nature of PTG might be coloured by cultural factors. Objective: This study aimed to identify aspects of PTG in a German-speaking sample (Austria and Germany) that are unique to this individualistic culture and not yet covered by the Posttraumatic Growth Inventory (PTGI). Method: We used a convergent parallel mixed methods design. In sum, 188 German-speaking adults were recruited via snowball sampling. They reported on their worst experience ever and completed the PTGI, and 54 participants detailed in open-ended questions possible positive changes additionally to the questionnaire. Results: The existing growth dimensions of the German PTGI were confirmed by participants' qualitative statements. Additionally, qualitative data analysis revealed the elaboration of two PTGI dimensions, and the emergence of two new domains: (1) 'lessons learned', which involves newfound knowledge about oneself and one's life, and (2) 'processing of adversity with potential growth experiences', which illustrates the tightrope walk of growth. Conclusions: The results support Tedeschi and Calhoun's model of the process and outcomes of PTG. By including qualitative methodology this study contributed to (1) revealing culture-specific growth experiences (i.e. different sub-forms of individualism were identified), and (2) underscoring the importance of 'potential growth' so that further promotion of growth is possible at an early stage of processing adversities.

Antecedentes: Los eventos altamente adversos pueden destruir las suposiciones fundamentales sobre uno mismo y el curso de vida esperado, activando un proceso de adaptación con respecto a las nuevas valoraciones. Este conflicto después de la adversidad podría producir un crecimiento postraumático (CPT), que se refiere a la transformación positiva dentro de la persona. CPT es un concepto que se ha establecido dentro de un marco cultural occidental y tiene características tanto universales como específicas de la cultura. Aunque en todas las culturas las personas perciben los beneficios de sus conflictos con las crisis de la vida, la naturaleza del CPT puede verse influida por factores culturales.Objetivo: Este estudio tuvo como objetivo identificar aspectos de CPT en una muestra de habla alemana (Austria y Alemania) que son exclusivos de esta cultura individual y que aún no están cubiertos por el Inventario de crecimiento postraumático (ICPT).Método: Utilizamos un diseño de métodos mixtos paralelos convergentes. En total, 188 adultos de habla alemana fueron reclutados mediante muestreo de bolas de nieve. Informaron sobre su peor experiencia y completaron el ICPT, y 54 participantes detallaron en preguntas abiertas posibles cambios positivos adicionales al cuestionario.Resultados: Las dimensiones de crecimiento existentes del ICPT alemán fueron confirmadas por las declaraciones cualitativas de los participantes. Además, el análisis de datos cualitativos reveló la elaboración de dos dimensiones ICPT y la aparición de dos nuevos dominios: (1) 'lecciones aprendidas', que implica un nuevo conocimiento sobre uno mismo y la propia vida, y (2) 'procesamiento de la adversidad con potenciales experiencias de crecimiento', que ilustra el camino del crecimiento en la cuerda floja.Conclusiones: Los resultados apoyan el modelo de Tedeschi y Calhoun del proceso y los resultados de CPT. Al incluir una metodología cualitativa, este estudio contribuye a (1) revelar experiencias de crecimiento específicas de la cultura (es decir, se identificaron diferentes subformas individualismo) y (2) subrayar la importancia del 'crecimiento potencial', de modo que sea posible una mayor promoción del crecimiento en una etapa temprana de procesamiento de adversidades.

Why Quality-of-Life Data Collection and Use Should Be Standardized When Evaluating Candidates for Hand Transplantation.

This article argues for 3 mutually reinforcing interventions in the field of hand transplantation (HTx): (1) collection of qualitative data about hand transplant recipients' subjective quality of life (QoL) outcomes, (2) multicenter standardization of data collection, and (3) use of data to develop evidence-based, standardized protocols for HTx candidate evaluation and information disclosure. These interventions are needed to improve candidate evaluation and informed consent processes in HTx, wherein the highly personal nature of desired outcomes justifies holding a candidate's consent to a standard approaching authenticity rather than the usual minimal standard of being informed and voluntary.