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.

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.

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.

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.

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.

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.

Functional and Psychosocial Outcomes of Hand Transplantation Compared with Prosthetic Fitting in Below-Elbow Amputees: A Multicenter Cohort Study.

BACKGROUND: Hand-transplantation and improvements in the field of prostheses opened new frontiers in restoring hand function in below-elbow amputees. Both concepts aim at restoring reliable hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing hand function and quality-of-life of people with transplanted versus prosthetic hands. METHODS: Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36). RESULTS: Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in "role-physical" (p = 0.006), "vitality" (p = 0.008), "role-emotional" (p = 0.035) and "mental-health" (p = 0.003). CONCLUSIONS: The indications for hand transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient's best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for allotransplantation must still be restrictive, the best being bilateral amputees.

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.

Key psychosocial challenges in vascularized composite allotransplantation.

Psychosocial factors are important elements in the assessment and follow-up care for vascularized composite allotransplantation (VCA) and require multidisciplinary evaluation protocols. This review will highlight differences between VCA with solid organ transplantation (SOT), provide information on the psychosocial selection of VCA candidates, ethical issues, psychological outcomes, and on the need for multicenter research. VCA is primarily a life-enhancing procedure to improve recipients' quality of life and psychological well-being and it represents a potential option to provide reproduction in case of penile or uterine transplantation. The risk benefit ratio is distinctly different than SOT with candidates desiring life enhancing outcomes including improved body image, return to occupations, restored touch, and for uterine transplant, pregnancy. The Chauvet Workgroup has been convened with membership from a number of transplant centers to address these issues and to call for multicenter research. A multicenter research network would share similar evaluation approaches so that meaningful research on psychosocial variables could inform the transplant community and patients about factors that increase risk of non-adherence and other adverse psychosocial and medical outcomes.

The Chauvet 2014 Meeting Report: Psychiatric and Psychosocial Evaluation and Outcomes of Upper Extremity Grafted Patients.

Under the auspices for the International Society on Hand and Composite Tissue Allotransplantation, a section of The Transplantation Society (IHCTAS), a meeting was convened on March 21-22, 2014 in Paris to review the following areas that were deemed significant in the understanding of the psychosocial evaluation and outcomes of upper extremity transplant recipients: required domains of the evaluation, screening instruments, clinical monitoring pretransplant, clinical monitoring posttransplant, patient and team expectations, body image, psychiatric complications, functional goals and quality of life, ethics and media relations. Experts in the fields of psychiatry and psychology, transplantation, social work, ethics, and transplant administration met and reviewed center experiences and literature. The attendees highlighted the importance and the complexity of the psychiatric assessment in this field of transplantation. Moreover, the necessity to develop common instruments and evaluation protocols to predict psychosocial outcomes as well as to understand whether we are transplanting the right patients and how the transplantation is affecting the patients were pointed out. Psychiatric complications in upper extremity transplanted patients have been reported by the majority of teams. Preexisting psychiatric difficulties, the initial trauma of amputation, or adjusting to the transplantation process itself (especially the medical follow-up and rehabilitation process) appeared to be important factors. Monitoring during the whole follow-up was recommended to detect psychiatric issues and to facilitate and ensure long-term adherence. The participants proposed an annual meeting format to build upon the findings of this inaugural meeting to be called the Chauvet Workgroup meeting.

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.

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.

Case series on defense mechanisms in patients for reconstructive hand transplantation: consideration on transplant defense concept.

BACKGROUND: The technical demands of reconstructive hand transplantation (RHT) and need for complex multidisciplinary care have led to intense research efforts to improve patient care and outcomes. However, RHT is an extraordinary life event which carries the potential for long-term consequences including psychological distress, which invokes coping and defense mechanisms. MATERIAL/METHODS: Little is known about the relationship between psychological defense mechanisms and health outcomes in RHT patients. In an effort to elucidate this relationship, we studied seven RHT patients who underwent standardized psychological assessment either pre- or post transplantation. RESULTS: No single defense concept was identified as common to all patients, which we suspect was due in part to the varied mechanisms of hand loss. All seven patients demonstrated diverse psychological reactions to RHT. The self-reported defense styles were associated with psychological adjustment. The patients who reported defenses that distorted reality described less adaptive functioning and psychological well-being. CONCLUSIONS: These preliminary findings reveal the varied psychological mechanisms invoked in RHT patients. An assessment of defense mechanisms should be part of multicenter evaluation protocols that address unique psychosocial aspects of RHT in large samples, in order to better guide psychological management.

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.

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.

Patient-reported outcome reference values for patients after kidney transplantation.

BACKGROUND: Patient-reported outcomes (PROs) are important in managing kidney transplant patients. Although, there are many instruments available to assess PROs, such as health-related quality of life (HRQOL), they are rarely collected in routine nephrology practices. Therefore, the aim of this study was the determination of reference values for physical and psychosocial symptom burden in kidney transplant patients. METHODS: Patients with a history of kidney transplantation being in aftercare at a nephrological outpatient unit (n = 120) were consecutively recruited, and a computer-based PRO assessment was used to assess their HRQOL reference values. It covered a broad range of clinically relevant physical and psychological symptoms, adherence to immunosuppressants, and disease-specific quality of life. On an average, PROs were assessed 2.9 times per patient, 351 times in total. RESULTS: For PRO monitoring in kidney transplant patients, we consider the 10th/90th percentile as being of particular clinical relevance, as patients exceeding these scores are likely to be in need of additional care. CONCLUSIONS: With continuously rising survival rates after kidney transplantation, HRQOL of long-term transplant patients becomes increasingly important, and it is generally accepted that HRQOL improves after successful kidney transplantation. We used a computerized PRO monitoring to determine HRQOL reference values for outpatient kidney transplant patients. Routine PRO monitoring may facilitate the identification of patient issues relevant to treatment, and may contribute to improved symptom and side-effect management. Future studies providing detailed PRO values for stratified patient samples are needed.

[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.