Psychiatric evaluation of the face transplant candidate.

PURPOSE OF REVIEW: There have now been a total of 32 face transplants done in the world since the first in Amien, France, in 2005. This procedure is moving from being considered experimental to being considered an accepted option for reconstruction in cases of severe facial disfigurement. RECENT FINDINGS: There have been three published reports of prospective quantitative assessments of facial transplant candidates related to psychological outcomes with face transplant recipients. Various instruments have been used in assessment, including the Beck Depression Inventory, Patient Health Questionnaire-9 (PHQ-9), and Center for Epidemiologic Studies Depression Scale for rating depressive symptoms. Quality-of-life instruments used have included the Short Form-12, the Short Form-36, the Euro-QOL-5D (EQ-5D), the WHO Quality of Life rating scale (WHO-BREF), and the Psychosocial Adjustment to Illness Scale-Self-Report. SUMMARY: There have been three deaths in the first 32 cases of facial transplantation (9.4%), two cases of post-transplant lymphoproliferative disorder in the first 20 face transplant recipients (10%). This rate of post-transplant lymphoproliferative disorder is about 10 times the rate seen in solid-organ transplant recipients. Collaborative assessment protocols are needed to determine whether the improvement in quality of life with facial transplantation is justified in the face of the risk of lifelong immunosuppression.

Ethics of facial transplantation revisited.

PURPOSE OF REVIEW: There have been 26 cases of facial transplantation reported, and three deaths, 11.5%. Mortality raises the issue of risk versus benefit for face transplantation, a procedure intended to improve quality of life, rather than saving life. Thus, one of the most innovative surgical procedures has opened the debate on the ethical, legal, and philosophical aspects of face transplantation. RECENT FINDINGS: Morbidity in face transplant recipients includes infections and metabolic consequences. No graft loss caused by technical failure, hyperacute, or chronic graft rejection or graft-versus-host disease has been reported. One case of posttransplant lymphoproliferative disorder, 3.45% and one case of lymphoma in an HIV-positive recipient were reported. Psychological issues in candidates can include chronic pain, mood disorders, preexisting psychotic disorders, post-traumatic stress disorder (PTSD), and substance abuse. SUMMARY: Early publications on ethical aspects of face transplantation focused mainly on informed consent. Many other ethical issues have been identified, including lack of coercion, donor family consent and confidentiality, respect for the integrity of the donor's body, and financial promotion of the recipient and transplant team, as well as the cost to society for such a highly technical procedure, requiring lifelong immunosuppression.

Face transplantation: psychological outcomes at three-year follow-up.

BACKGROUND: The advent of face transplantation has raised both ethical and psychological issues. Mortality of 18 existing face transplant recipients is 11.1% (2/18) through 2011. OBJECTIVE: Psychological outcomes are as important in face transplantation as is restoring the face physically. Little quantitative information has been published this area. METHODS: Data was systematically collected over 3 years with a face transplant recipient, including appearance self-rating, body image, mood changes, pain rating, perception of teasing, quality of life, self-esteem, and social reintegration. We identified a significant gap in rating instruments for use in the field, so we developed the Perception of Teasing-FACES, Facial Anxiety Scale-State, and the Cleveland Clinic FACES score, analogous to the model for end-stage liver disease (MELD) score for prioritizing patients for a face transplant registry. RESULTS: Appearance self-rating rose from 3/10 prior to transplantation to 7/10 now. Anxiety about body image and the Facial Anxiety score were halved by the end of the third year. Beck Depression Inventory fell from 16 (prior to transplant) to 8. Chronic daily pain was 6-7/10 prior to transplant and 0/10 by day 50. Perception of Teasing-FACES scores fell from 25 to 9 by the end of year 3. Quality of life improved on the Social Environment Domain of the psychological adjustment to illness scale-self-rated (PAIS-SR), where the score dropped from 15 to 1 by the end of year 3, indicating marked improvement in social reintegration. CONCLUSIONS: Standardized data collection may help quantify psychological outcomes with facial transplantation to determine whether the risks of immunosuppression over time are offset by improved quality of life for recipients.

Renal autotransplantation and modified pyelovesicostomy for intractable metabolic stone disease.

PURPOSE: Some patients with intractable metabolic stone disease experience narcotic dependence, which cannot be managed with standard treatments. We offered these patients renal autotransplantation with a modified pyelovesicostomy as an alternative solution. MATERIALS AND METHODS: Renal autotransplantation with pyelovesicostomy was performed for 15 kidneys in 12 patients (3 bilateral, 2 solitary), 9 female and 3 male, with a mean age of 33.8 years (range 16 to 55). The etiology of metabolic stone disease was calcium oxalate (40%), cystinuria (33%), type 1 renal tubular acidosis (14%), calcium oxalate/urate (7%) and medullary sponge kidney (7%). Patients reported that lifetime stone events ranged from 10 to more than 70, that underwent an average of 3 to 4 surgical interventions per year in the previous 2 years and that they were dependent on daily oral narcotics for stone related pain. RESULTS: All 15 kidneys were successfully autotransplanted with a mean followup of 41.8 months (range 3 to 74). We used a modified pyelovesicostomy with ureteral strip in 13 and standard Boari tube in 2 cases. All patients continued to pass small stone debris per urethra with minimal symptoms. Of 12 patients 11 (92%) were weaned off daily narcotics. There have been 17 stone episodes in 4 patients (3 cystinuria) for which medical intervention and pain medication was required. The number of urological procedures/patients before (155/12 [12.9]) and after (8/12 [0.66]) autotransplantation was dramatically reduced (paired t test p = 0.0001). The preoperative mean estimated glomerular filtration rate was 77.2 cc/minute, and 73.5, 71.9, 79.2 cc/minute at 12, 36 and 60 months, respectively. CONCLUSIONS: Renal autotransplantation and pyelovesicostomy offer patients with intractable metabolic stone disease the opportunity to improve quality of life and to decrease daily narcotic use.

Psychological outcomes with face transplantation: overview and case report.

PURPOSE OF REVIEW: The purpose of this review is to provide guidance in a burgeoning new field of facial composite tissue transplantation. This review will contrast face transplant with solid organ transplantation, provide information to guide selection of face transplant candidates, and share information on psychological outcomes. RECENT FINDINGS: Previously published face transplant reports have not investigated body image, mood changes, perception of teasing, quality of life, self-esteem, or social reintegration quantitatively. Face transplantation appears to decrease depression and verbal abuse, and improve quality of life and social reintegration, though may not alter anxiety or self-esteem. The Psychosocial Adjustment for Illness Scale-Self-Report scale may have advantages over the SF-36 and World Health Organization Quality of Life (WHOQOL)-BREF rating scales for measuring psychological distress and social reintegration. SUMMARY: Face transplantation is currently a technique of last resort after traditional reconstructive techniques have failed, not for cosmesis alone. Mortality among eight existing face transplant patients is 25%, two of eight. Some consider blindness as an absolute contraindication; however, those who are legally blind but retain some vision may be appropriate candidates. Physical goals of transplantation include regaining movement of underlying structures and restoring the appearance of a normal face. However, psychological outcomes and quality of life are also important to the success of face transplantation and ultimately will determine the value of the procedure.

The debate about marijuana usage in transplant candidates: recent medical evidence on marijuana health effects.

PURPOSE OF REVIEW: Cannabis is currently the most widely used illicit substance in the world. The issue of how to handle transplant candidates with active use of cannabis is a commonly encountered one for transplant-selection committees. RECENT FINDINGS: Correlates of marijuana use include increased risk of use of other illicit substances, increased risk of affective disorders and psychosis, as well as impaired cognition and motor skills. Risk of fungal infections and possible effects on cellular immunity that may increase cancer risk have also been reported. Reliability of laboratory testing for cannabis is discussed. False-negatives may occur with stealth peroxidases and false-positives with efavirenz (Sustiva). Photometric immunoassay (EMITS) has a 3% false-positive rate. Using a cutoff point of 20 ng/ml with confirmation via GC/MS will give a 'virtually 100% reliable accuracy' in detecting cannabis abuse. SUMMARY: Guidelines on management of the problem should be based on objective medical evidence on the health effects of marijuana, as well as on the implications in the transplant setting where medical urgency can drive medical decision-making. A recent survey of 16 academic transplant centers showed little consensus on guidelines for length of abstinence prior to listing candidates for transplantation.