Significant infections after hand transplantation in a Polish population.

The study was conducted to assess serious infectious complications in five hand allograft recipients (four males, one female, age 40 ± 10 years), transplanted between 2006 and 2010. All donors and recipients were positive but one for cytomegalovirus (CMV) immunoglobulin G. All recipients received immunosuppressive therapy basiliximab, tacrolimus, mycophenolate mofetil and methylprednisolone. Until May 2013, there were four cases of severe infections requiring hospitalization. One patient developed CMV infection on the 28th postoperative day. Despite therapy with ganciclovir and prophylaxis with valganciclovir, reinfection episodes occurred both 4 weeks and 7 months later. The female recipient developed CMV infection 8 months after hand transplantation. After 3 weeks of ganciclovir treatment, the polymerase chain reaction results remained negative. We found that the CD4/CD8 T lymphocytes ratio differs in those two patients who had developed CMV disease in the past in comparison to the three remaining hand transplant recipients (mean 0.46 versus 1.7, respectively). Moreover, the ratio of patients who were CD4-8 negative to total T lymphocytes in CMV recovered patients was two-fold higher compared to the remaining recipients (10.0 versus 4.4, respectively). The female recipient was also hospitalized because of acute tonsillitis 25 months after hand transplantation, and successfully treated with amoxicillin clavulanate. The third recipient was hospitalized because of severe acute pain involving right lower limb, especially foot, 74 months after hand transplantation. After 48 hours, a painful vesicular rash occurred on the plantar as well as dorsal surface of right foot and herpes zoster was diagnosed. Immunosuppressive therapy after hand transplantation may be complicated by serious infections. CMV disease was associated with persistent alterations in T lymphocyte subsets.

Impact of immunosuppressive treatment on the cardiovascular system in patients after hand transplantation.

BACKGROUND: Cardiovascular disease is a major cause of mortality in solid organ allograft recipients. Hand transplantation is not a lifesaving procedure, thus the effect of long-term immunosuppression on the cardiovascular system in these patients should be monitored. The aim of this study was to evaluate the morphology and function of heart and blood vessels in patients after hand transplantation. METHODS: The study included 5 patients at ages 32 to 58 years, mean 39 years, who underwent hand transplantation between 2006 and 2010. Immunosuppressive treatment included basiliximab in induction and tacrolimus, mycophenolate mofetil, and prednisone. Cardiac status was assessed by echocardiography (according to the American Society of Echocardiography) and cardiac biomarkers. Blood vessels were estimated by carotid intima-media thickness, pulse wave velocity, and brachial artery flow-mediated dilatation (FMD). The examinations were performed at 28 to 79 (mean 43) months after transplantation. RESULTS: Cardiovascular risk factors were observed in all patients after transplantation: 2 had insulin-dependent diabetes, 3 developed dyslipidemia and hypertension, 2 had chronic kidney disease stage 3. Concentric left ventricular hypertrophy was found in 1 and ventricular concentric remodeling in 4 patients. Impaired diastolic function (E/e' > 8) was observed in 2 patients. The index volume of the left atrium was higher in all patients. The cardiac biomarkers N-terminal pro-brain natriuretic peptide, C-reactive protein, and troponins were within normal range. Carotid intima-media thickness was higher in 1 patient and normal in 4 patients. Arterial stiffness measured by pulse wave velocity was not increased in all patients. Native brachial artery FMD response, an index of endothelium-dependent function, was abnormal in 2 patients, but in the transplanted extremity FMD was abnormal in 4 patients. CONCLUSIONS: Pathologic changes in cardiac structures were found in all patients, but the arterial wall changes and endothelial dysfunction were observed in some patients. Patients after hand transplantation are at higher risk for cardiovascular disease.

Unilateral hand transplant-results after 41 months.

We present the final results achieved by a young male hand transplant (HTx) recipient. Harvested from a woman. The limb was grafted at the wrist level 7 years postaccident. There were three HLA-A, -B, -DR mismatches and negative T- and B-cell crossmatches. The maintenance immunosuppression consisted of tacrolimus (trough level 10 ng/mL), steroids (5 mg/d), and mycophenolate mofetil (2 g/d). At the 41-months posttransplant follow-up the Semmens-Weinstein's monofilament tests gave positive results for both main hand nerves: ulnar nerve-blue, median-purple, which rated at S3- and S3+, respectively. The grip strength was 5.4 kg. HTx-specific evaluation systems showed the following results: Hand Transplant Score System (HTSS) 93.5; Chen grade I; Tamai score modified by Ipsen 86; DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire 65. Overall, the patient is able to perform with his transplanted hand practically all daily activities, even those requiring a combination of mobility, motor function, and sensation. He works full-time as a cart driver.

Upper gastrointestinal bleeding in a young female with AIDS: a case report.

Upper gastrointestinal haemorrhage (UGIH) is a surprisingly common condition in patients with AIDS (PWAs), affecting at least 6%. With the growing number of PWAs and their increasing life span, UGIH will certainly gain importance as a diagnostic and therapeutic challenge to health-care professionals, especially in central and eastern Europe because of the AIDS epidemics rapidly developing in that region. With the scarcity of reported cases, lack of management guidelines of UGIH in PWAs, and limited therapeutic possibilities in developing countries, important therapeutic problems should be anticipated. We present a case of UGIH in a female PWA due to ketoprofen overuse, successfully managed with conservative treatment.

Unilateral arm transplant 28 years after amputation: fourteen-month result.

Hand transplantation now represents a therapeutic alternative for amputees. Arm transplantation poses a serious challenge regarding many respects of the reconstructive procedure. To the end of 2010, only seven such procedures had been performed in four patients. The goal of this article was to present the preliminary results of an arm transplant in a 30-year-old male patient at 14 months. The patient sustained an amputation at the elbow-joint level as a 2-year-old child. The procedure was performed in October 2010. His postoperative course was complicated by one rejection episode (BANFF grade II), and a de novo cytomegalovirus infection. At this early stage, the patient is doing well regaining function. He can flex at the elbow joint, move his fingers, and experience protective sensitivity reaching the palm. The patient is satisfied with his transplantation.

Insidious course of cytomegalovirus infection in hand transplant recipient: case report, diagnostics, and treatment.

Cytomegalovirus (CMV) infection is common in solid organ and composite tissue transplant recipients and so becomes an ever more important issue for clinicians of every specialty. In this article we describe a case of CMV infection in a hand transplant recipient, which led to an episode of acute rejection early posttransplantation that was unresponsive to antiviral therapy. Our observations support the guidelines of matching CMV-positive donors with CMV-positive recipients only; however, the possible consequences related to CMV disease make a strong point to advocate the use of CMV prophylaxis in all hand transplant recipients.

Transplanted fingerprints: a preliminary case report 40 months posttransplant.

For the past century, fingerprints have been considered permanent and specific for each individual. However, with the advances in transplantology, fingerprints have lost their permanence. Because no study has yet been described, we examined possible changes in the fingerprint pattern of a transplanted hand. In 2006, we performed a hand transplantation on a 32-year-old man. The donor was revealed to have had a criminal record; his fingerprints were stored in the Polish automated fingerprint identification system. A forensic technician fingerprinted the transplanted hand nine times between June 2006 and September 2009. The appearance of minutiae and white lines and the change in the distance between papillary ridges were assessed in the thumbprints of the transplanted hand. The appearance of white lines was only temporary; at no point did they impair fingerprint identification. No significant changes occurred in the distance between the friction ridges. The observed small differences were ascribed to the two techniques used to collect the prints (spoon vs rolling). The number of minutiae ranged from 1 to 3, reaching a maximum in the third posttransplant month. A 40-month observation showed no significant changes in the fingerprints of the transplanted hand. Nevertheless, a long-term study is needed because of the risk of chronic rejection. The noninvasiveness of dactylography argues for inspecting its application to diagnose acute rejection. Finally, lawmakers should be made aware of the personal-protection issues related to the growing number of hand-transplant recipients.

Hand transplantation--Polish program.

BACKGROUND: Hand transplantations (HTs) are performed in specialized centers proceeding within a board-accepted transplantation program. In Poland such requirements are met by the Subdepartment or Replantation of Limbs of St. Jadwiga Hospital in Trzebnica. The goal of this study was to present the experience of the Center after 3 years of activity. MATERIAL AND METHODS: On creating the "waiting list of would-be hand recipients," we adhered to the inclusion criteria commonly used by other centers. Among 52 potential candidates seen over a 4-year period, the selection process and inclusion criteria yielded 13 patients who were preliminary candidates for an HT. They proceeded to a formal hospital admission to obtain a detailed evaluation including invasive diagnostic tests. The group consisted of 12 men of age 21-42 years with single dominant hand amputations and 1 woman of 23 years with amputations of both hands. Within this group we performed 3 HTs in 3 men of 32, 42, and 30 years old: 2006 and in 2007 at mid-forearm level and in 2008 at the distal forearm level. The times elapsed from amputation to HT were 14, 6, and 7 years, respectively. RESULTS: The first patient achieved total motion of fingers equal to 63% of that of his unaffected hand. Evaluation using the SF-36 protocol gave a result of 50; by DASH, 95; by CFSS (according to Lanzetta and Petruzzo), 84 (excellent). He had only 1 mild rejection episode. Our second HT failed. The third patient has a good hand function, namely, 80% of the finger motion of the unaffected hand and sensitivity reaching his finger tips. No rejection episodes were observed. CONCLUSION: On the basis of these results, we plan to proceed with the hand transplantation program.

A detailed comparison of the functional outcome after midforearm replantations versus midforearm transplantation.

OBJECTIVES: The functional outcome after midforearm transplantation (HT) is believed to be similar to the outcome after replantation. However, the few existing reports comparing functional outcomes are based on amputations at the level of the distal forearm. This report provides a comparative analysis of the functional results after midforearm replantation (HR) versus HT. MATERIALS AND METHODS: Transplantation of a dominant right forearm performed in a 32-year-old man was compared to the outcomes after five dominant (right) forearm replantations (four men and one woman) in patients ranging from 22 to 38 years of age. Cold ischemia time ranged from 6 to 12.5 hours in all cases. We used similar operative technique and rehabilitation protocol. At 26 (+/-2) months after replantation/transplantation, we recorded, bony union (x-ray), arterial flow (ultrasonography), range of motion, grip strength, sensation (2 PD Weisensten's filaments), quality of life (DASH, 30-150 points), general evaluation of function according to Chen's or the IRHCTT scoring system. RESULTS: A complication of wound infection was observed in one HR patient; Marginal skin necrosis accompanied by prolonged wound healing, in one HT patient. Unification of bones was achieved faster after forearm replantation when compared with transplantation. Grip strength was 17% greater after replantation, but ranges of motion were comparable in both groups. Sensitivity was superior after forearm transplantation (2 PD 15 mm) and overall patient satisfaction was comparable (90 points of DASH questionnaire for HR versus 108 points for HT patients). None of the patients returned to their previous occupations. CONCLUSION: The functional outcome after HT was comparable, and in some respects superior, to the outcome after replantation performed at the midforearm level.

First Polish forearm transplantation: report after 17 months.

INTRODUCTION: The number of hand transplantations is increasing every year prompted by promising results. Still, the number of transplantations performed at the level of midforearm/elbow is relatively small. The aim of the study was to evaluate after 17 months postoperatively the result of the first Polish upper limb transplantation performed at midforearm level. MATERIALS AND METHODS: The transplant recipient was a 32-year-old man, who lost his right, dominant upper limb at the level of midforearm in an accident 14 years prior. After a comprehensive pretransplantation evaluation and informed consent process we transplanted a right forearm matched for size and skin tone from a 47-year-old brain-dead man. The donor's limb amputated at the elbow was irrigated with University of Wisconsin solution. We dissected donor and recipient limbs simultaneously. The cold ischemia time was 10.5 hours. Immunosuppression included Simulect, tacrolimus, mycophenolic acid, and prednisone. Maintenance therapy included tacrolimus, mycophenolic acid, and Encorton. RESULTS: There were no intraoperative or early postoperative complications, except for delayed wound healing. No episodes of rejection were observed. Immunosuppression was well tolerated. In the process of physiotherapy, a continuous passive motions device was applied, as well as special tests to stimulate tactile sensation. After 11 months, Tinel's sign reached the finger pulps innervated by the ulnar nerve and after 12 months, by the median nerve. The monofilament test/Semmens-Weinstein was positive after 17 months: blue for ulnar nerve and purple for median nerve. The sensations proved grade 3+ and grade 3, respectively. The activity of intrinsic muscles was not detectable by electromyography; active range of motion included 63% of the unaffected hand. The extremity excellently matched the contralateral hand for size, color, and skin texture. The patient uses his hand for writing, riding his bike, and a mobile phone. The total Lanzetta' score was excellent (82 points).

Mild rejection episode evoked by modification of immunosuppressive protocol observed in a patient with forearm transplantation: case report.

Skin is the most immunogenic component of a composite tissue allograft (CTA). Clinicopathologic monitoring of the skin seems to be the most reliable method to detect rejection in CTA patients. The symptoms in cases demonstrating full-blown rejection are clear, contrary to those of just mild rejection. The aim of the study was to present the symptoms of mild rejection observed in a midforearm transplant patient at 20 months postoperative. The 32-year-old man underwent right dominant forearm transplantation at 12 years after a traumatic amputation. During the first 20 months, the course was uneventful, with no signs of impaired function. Immunotherapy at 20 months consisted of: Cellcept (2 g/d), prednisolone (10 mg/d), tacrolimus (7 mg/d; level C(0) of 13 ng/mL), An attempt was made to modify therapy by diminishing the tacrolimus dose to 4 mg/d (C(0)-8 ng/mL). After 10 days postimplementation of the new regimen, are hardly visible macullopapular erythematous rash appeared on the palmar and dorsal sides of the hand as well as the skin of the forearm. There was a slight red swelling of the nail bed margins. No deterioration of hand function was observed. The patient was immediately admitted to the hospital; despite unclear clinical and pathomorphological symptoms, we diagnosed a mild rejection (grade I). The therapy consisted of methylprednisolone (500 mg three times daily for 3 consecutive days) and 5 days of topical application of immunosuppressant ointments (tacrolimus and Protopic) with maintenance of the previously applied oral tacrolimus doses. After 5 days of treatment, the symptoms subsided. This approach utilized the advantage of the unique possibility to treat rejection locally, consistent with current awareness that skin is the primary target of hand rejection. However, topical application of immunosuppressants has not been extensively investigated. The manifestations of rejection in CTA patients may be heterogeneous and difficult to diagnose.

[Intramedullary fixation within bones of the hand: 20 years of experience]. / Szynowanie sródszpikowe kosci reki--20 lat doswiadczen.

Intramedullary fixation within bones of the hand has been used for treatment of 313 fractures in 169 patients after serious trauma or replantation between 1978 and 1998. Kirschner wires or Steinmann pins were introduced at the fracture site and anchored within both metaphyses. The method was used in various types of fractures, comminuted ones and bone defects included. In all cases fracture healed between 4 and 8 weeks. No deep infection occurred, in 2 patients the implants had to be removed because of their migration. The method is technically undemanding and allows for immediate postoperative rehabilitation. Total range of motion exceeded by 15% results achieved in patients treated with temporary immobilization of the hand.

High prevalence of complement component C6 deficiency among African-Americans in the south-eastern USA.

Complement component C6 is a part of the membrane attack complex that forms a pore-like structure in cell membranes following complement activation. Deficiency of terminal complement components including C6 predisposes individuals to infection with Neisseriae. Using polymerase chain reaction/single-strand conformation polymorphism analysis followed by DNA sequencing, we screened genomic DNA from 200 randomly chosen blacks and an equal number from whites for three loss-of-function C6 mutations. Ten blacks and two whites were found to be heterozygous for one of the mutations. Two of the mutations, 1195delC and 1936delG, were found exclusively in black individuals. A third previously undescribed mutation, 878delA, was found at equal frequency among the two groups. The difference between the two groups was significant (P = 0.027), indicating that C6 deficiency due to these three mutations is more common among blacks than whites in the local area, principally Jefferson County, Alabama. In addition, three previously undescribed point mutations, two of which result in amino acid substitutions, were identified within exon 6. A review of the county health department records over the past 6 years revealed a higher incidence of meningococcal meningitis in blacks due to serogroups Y and W-135 which paralleled the difference in the estimated prevalence of C6 deficiency. Among black residents of the county (n = 235 598) there were 15 cases of meningitis due to these two serogroups, compared with two cases in the white population (n = 422 604) (P = 0.002). We conclude that C6 deficiency is more common among blacks than whites in the south-eastern United States, with a frequency approaching 1 in 1600 black individuals.

[Tests for evaluating various methods of bone fixation in digital replantation]. / Próba oceny róznych metod zespolenia kostnego replantowanych palców.

Clinical results comparing different methods of bony fixation in 50 replanted digits in a series of 41 patients over a 13 year period are presented. The analysis was restricted only to replantantions involving sharp amputations of the proximal phalanx in order to restrict this study to a relatively homogenous group of patients. Evaluated techniques included: single and crossed Kirschner wire, intraosseous wire with or without Kirschner wire support, intramedullary splintage and intramedullary screws. Angulation deformities and delayed union were most common in cases treated with Kirschner wire technique. Nonunion was noted in 1 case (2%) stabilized with a single Kirschner wire. Angulation deformities were noted in 6 cases (12%). No such complications were noted in cases treated with intramedullary splintage and intramedullary screws. The best stabilizing effect and the most rapid union was noted in cases treated with intramedullary screws.

Recurrent primary well-differentiated intrascrotal liposarcoma: case report and review of the literature.

Lipoma-like liposarcomas of the scrotal wall are very rarely reported neoplasms in the surgical and histopathological literature. We treated a well-differentiated liposarcoma of the inside wall of the scrotum in a 62-year-old man. Following local excision, the tumor recurred after three months, and a funiculoorchidectomy was performed. Today, 24 months following secondary surgery, the patient is completely asymptomatic and there is no evidence of tumor recurrence either on physical examination, ultrasonography or abdominal and pelvic computed tomography. In this paper we present the case and a review of the relevant literature.

[Rehabilitation after upper extremity replantation at the wrist level -- own experience]. / Wlasne doswiadczenia w zakresie usprawniania konczyn po replantacji na wysokosci nadgarstka.

An amputation at the wrist level (the level with the best prognosis) has been characterized. Rehabilitation protocol after replantation at the wrist level developed on the ground of 328 replantations done in the Center over 25 years has been presented. Its essential quality is an early initiation of active movements (second postoperative day) and resistive movements on 10-14 days after surgery. The differences between currently used protocols have been emphasized. Excellent and good results were achieved in 65% of cases according to Chen's criteria.

[Salvage surgery for severely mutilated hand: report of 2 cases]. / Oszczedzajace operacje w przypadkach rozleglych obrazen reki--opis dwóch przypadków.

Immediate, one stage reconstruction is an optimal mode of treatment for severely mutilated hand. This might be feasible only with the use of tissues destined for amputation. Two cases are reported. The first patient had a thumb reconstruction with transfer of the index finger. The second one had metacarpal reconstruction with little finger structures. Both patients resumed previous occupation.

[Treatment of intraarticular finger fractures with the help of the traction system of "pins and rubbers" according to Y. Suzuki]. / Leczenie zlaman sródstawowych palców reki za pomoca systemu wyciagowego "druty i gumki" wg Y. Suzuki.

The results of treatment of intraarticular finger fractures by means of Y. Suzuki's pins and rubbers traction system are presented. The system consists of 2-3 thin K-wires and 2 rubber bands, is easy to assemble, effective, and less clumsy then the ones applied previously. It also allows for the reduction of palmar displacement of bony fragments. Sixteen intraarticular fractures have been treated. The average total range of motion of the injured PIP joint was 82 degrees at the average follow-up of 8.5 months.

[Treatment of complex fractures within the hand with external fixation]. / Leczenie skomplikowanych zlaman w obrebie reki stabilizacja zewnetrzna.

External fixation with the use of bone cement was employed in treatment for 22 metacarpal and phalangeal fractures in 18 patients. Open fractures prevailed (70%). A frame or "V" construction was used. Metal implants were connected with balls of bone cement. The average hand function loss in cases of metacarpal fractures associated with nerves and tendons lesion was 25%.