A Provider Perspective of Psychosocial Predictors of Upper-Extremity Vascularized Composite Allotransplantation Success.

PURPOSE: We performed a qualitative study to understand the psychosocial factors associated with success in upper-extremity vascularized composite allotransplantation from the perspective of transplant providers. METHODS: We recruited 13 providers actively involved in upper-extremity vascularized composite allotransplantation. Participants included physicians, nurses, social workers, occupational therapists, and research administrators. We conducted semistructured face-to-face focus group interviews using a guide that explored providers' perceptions of qualities contributing to transplant outcome. Topics included social support networks and their influence on recovery, barriers to treatment compliance and successful posttransplant rehabilitation, and the process of setting patients' expectations. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study's guiding questions. RESULTS: The analysis identified numerous factors that contribute to transplant success: (1) recipients' prior experiences modify their ability to cope and adapt after transplantation, (2) behaviors and characteristics such as positivity influence candidacy and may be predictive of successful outcomes, and (3) social support is essential for improved function and compliance. The provider care team cited difficulty in predicting recipient compliance and in setting realistic expectations. CONCLUSIONS: Motivated recipients with developed coping and resiliency, a positive attitude, and stable, physically-able caregivers are perceived by providers to have greater success after transplantation. CLINICAL RELEVANCE: Findings from this work may help providers determine optimal candidates for upper-extremity vascularized composite allotransplantation.

Perceived Success in Upper-Extremity Vascularized Composite Allotransplantation: A Qualitative Study.

PURPOSE: We performed a qualitative study to understand psychosocial factors associated with perceived success of upper-extremity vascularized composite allotransplantation (VCA). We interviewed transplant recipients and their primary caregivers. METHODS: We recruited 4 upper-extremity VCA recipients and primary caregivers for 3 of them. We conducted semistructured face-to-face interviews using a guide that explored participants' transplantation experiences. Topics included comparison of pretransplant and posttransplant expectations, reflections on factors contributing to the success of the transplant experience, and posttransplant rehabilitation and functioning. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study's guiding questions. RESULTS: Participants described several factors as contributing to the success of the transplant experience, including developing realistic expectations about posttransplant function and lifelong immunosuppression, support from one's community and particularly the primary caregiver, and framing the experience in a positive light. Social, aesthetic, and other values unique to the hands, as opposed to prosthetics, motivated recipients to undergo VCA despite its inherent risk and uncertainties. CONCLUSIONS: Despite inherent challenges, undergoing VCA was viewed as worthwhile to regain benefits unique to hands. Participants met the challenges of the transplant process through setting realistic expectations, strong social support, and a positive perspective. CLINICAL RELEVANCE: Findings from this work may help clinicians and prospective patients to prepare for and set appropriate expectations of VCA.

Psychosocial Risk Stratification in Upper Extremity Transplantation Candidates.

BACKGROUND: Candidate selection for upper extremity transplantation remains an inherently subjective process. This work evaluated the effect that psychosocial factors have on outcomes, both to standardize evaluation of potential candidates and in optimizing these factors prior to transplantation. Our goal was to measure and quantify the risk that various psychosocial factors have on transplant outcomes. METHODS: Given that we do not have sufficient post-transplant patients to examine specific factors, we chose to have experts in the field evaluate hypothetical patients based on their experience. We used a Generalized Estimating Equation to estimate and compare surgical candidacy scores using patient scenario vignettes based on the presence or absence of permutations of the following: (1) depression; (2) participation in occupational therapy (OT); (3) expectation of post-transplant function; (4) punctuality; and (5) family support were given to experts in the field. RESULTS: This work suggests there is a decrease in predicted success with increasing numbers of negative factors with participation in OT and realistic expectations of outcomes being most important. An increase in the summarizing risk score from 0 to 1.7 was associated with a decrease in the outcome surgical candidacy score from 8.6 to 5.3, meaning candidates with 2 risk factors would often observe a large drop in surgical candidacy score. CONCLUSIONS: Focusing on optimizing psychosocial variables in transplant candidates may help improve hand transplant success.

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.

A Yorkshire swine (Sus scrofa domesticus) model for nerve regeneration and ischemia based on the sciatic nerve and femoral artery.

Animal studies are essential to biomedical research and the cornerstone is a reproducible animal model. While there are many reports on rodent peripheral nerve injury models, a large animal model is essential to confirm the effects of nerve regeneration over the longer distances of regeneration required in humans. Swine have long been used as a large animal model for other surgical and biomedical studies. This paper represents a novel neurovascular injury model in the Sus scrofa domesticus swine (American Yorkshire pig). This paper will describe our experience and recommendations with pre-operative, operative and post-operative protocols and our refinements to produce an effective model.

Psychosocial Predictors of Upper Extremity Transplantation Outcomes: A Review of the International Registry 1998-2016.

BACKGROUND: Upper extremity transplantation (UET) is becoming increasingly common. This article attempts to collate data from cases contributing to the International Registry on Hand and Composite Tissue Transplantation (IRHCTT), define psychosocial themes perceived as predictors of success using statistical methods, and provide an objective measure for optimization and selection of candidates. METHODS: The IRHCTT provided anonymous data on UET recipients. A supplementary psychosocial survey was developed focusing on themes of depression, posttraumatic stress disorder (PTSD), anxiety, interpersonal functioning and dependence, compliance, chronic pain, social support, quality of life, and patient expectations. We determined the risk of transplant loss and psychological factors associated with higher risk of transplant loss. RESULTS: Sixty-two UET recipients reported to the IRHCTT. Forty-three psychosocial surveys (68%) were received, with 38 (88%) having intact transplants and 5 (12%) being amputated. Among recipients with a diagnosis of anxiety (N = 29, 67%), 5 (17%) reported transplant loss (P = 0.03). Among those with depression (N = 14, 33%), 2 recipients (14%) has transplant loss (P = 0.17); while 4 recipients (22%) with PTSD (N = 18, 42%) had transplant loss (P = 0.01). Of participants active in occupational therapy (N = 28, 65%), 2 (7%) reported transplant loss (P = 0.09). Of recipients with realistic functional expectations (N = 34, 79%), 2 (6%) had transplant loss versus 3 (34%) who were felt to not have realistic expectations (N = 9, 21%, P = 0.05). Recipients with strong family support (N = 33, 77%) had a lower risk of transplant loss compared with poor or fair family support (N = 10, 23%), but did not reach statistical significance (6% versus 30%, P = 0.14). CONCLUSION: Anxiety, depression, PTSD, participation in occupational therapy, expectations for posttransplant function, and family support are associated with postsurgical transplant status.