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Kumnig M, Kobler C, Zaccardelli A, Brandacher G, Talbot SG. Advancing vascularized composite allotransplantation: essential factors for upper extremity transplant program development. FRONTIERS IN TRANSPLANTATION 2024; 3:1406626. [PMID: 38993746 PMCID: PMC11235377 DOI: 10.3389/frtra.2024.1406626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/27/2024] [Indexed: 07/13/2024]
Abstract
Vascularized Composite Allotransplantation (VCA) offers a unique option to restore form and function after limb loss or facial trauma that cannot be satisfactorily accomplished through traditional prosthetics or reconstructions. Establishing a successful Upper Extremity Transplantation (UET) program requires strong leadership and a structured surgical team, and extensive interdisciplinary collaboration. We conducted a qualitative study among 12 health care professionals and patients. Informed consent was obtained per protocol, and semi-structured interviews were conducted online and recorded. Participants reported their perceptions of factors that either favored or hindered a successful outcome, including functional status before and after surgery, preparation for transplant, shared decision-making, rehabilitation, and psychosocial support. Thematic analysis revealed that it is essential to establish a team comprising various disciplines well before performing VCA procedures. Defining a common goal and choosing a defined leader is a key factor in procedural success and requires open collaboration beyond what is typical. Primary described categories are interdisciplinary collaboration and skills of the VCA team, building and leading a VCA team, pre-transplant procedures, post-transplant course, and factors to consider when establishing a program. The basic roles of team science play an outsized role in establishing a VCA program. Transplantation medicine involves various overlapping scientific and medical categories requiring health professionals to consciously work together to establish complex vertical and horizontal communication webs between teams to obtain positive outcomes. In addition to medical considerations, patient-specific factors such as transparent communication, therapy plan establishment, plan adherence, and continual follow-up are significant factors to overall success.
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Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Caroline Kobler
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Gerald Brandacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Simon G. Talbot
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
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Thys E, Laspro M, Chaya BF, Rodriguez ED, Kimberly LL. Incorporating Trauma-informed Approaches to Care in Vascularized Composite Allotransplantation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5553. [PMID: 38268713 PMCID: PMC10807881 DOI: 10.1097/gox.0000000000005553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/06/2023] [Indexed: 01/26/2024]
Abstract
Since 1998, vascularized composite allotransplantation (VCA) has been a growing area of research in the field of reconstructive surgery. Although conditions treated with VCA often result from a traumatic injury, there has been limited emphasis on incorporating trauma-informed care (TIC) models in VCA. Considering the importance of psychosocial well-being in VCA candidates and recipients, applying best practices in TIC to the face, upper extremity, and penile transplantation may be critical in minimizing retraumatization throughout the perioperative process. There are six main principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment and choice; and cultural, historical, and gender issues, which may be further incorporated in care for VCA patients. Evaluating for PTSD and incorporating TIC may have substantial benefit to postoperative outcomes.
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Affiliation(s)
- Erika Thys
- From the University of Nevada, Reno School of Medicine, Reno, Nev
| | - Matteo Laspro
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, N.Y
| | - Bachar F. Chaya
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, N.Y
| | - Eduardo D. Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, N.Y
| | - Laura L. Kimberly
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, N.Y
- Division of Medical Ethics, Department of Population Health, NYU Grossman School of Medicine, New York, N.Y
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Boehmer KR, Kennedy CC, Hargraves IG, Griffin JM, Garcia-Bautista AE, Sanchez BB, Chokkalingam A, Finnie DM, Miller AR, Moran SL, Smither FC, Amer H, Jowsey-Gregoire S. A Single-Center Retrospective Evaluation of Decision-Making and Factors Motivating Hand Transplant Candidates. Prog Transplant 2023; 33:216-222. [PMID: 37533326 PMCID: PMC11146747 DOI: 10.1177/15269248231189863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Advancements in vascularized composite allotransplantation have made hand transplants possible for persons living with upper limb loss. Hand transplantation is not a life-saving procedure, but rather a quality-of-life enhancing procedure; hence the risk of morbidity and mortality must be weighed against improvements in function and appearance. This study explored the decision-making process of patients evaluated for hand transplantation. METHODS/APPROACH A qualitative case series study using retrospective chart data of evaluations was conducted between January 1, 2011 and February 28, 2020. Notes were extracted and read by three reviewers. Each case was summarized noting similarities and differences. FINDINGS Nine patients underwent evaluation. Eight were no longer under evaluation and did not receive transplant; one was still undergoing evaluation. Patient motivations for evaluation were dissatisfaction with prostheses or self-image, chronic pain, performing activities of daily living, occupation, burden placed on caregivers, and concerns about overuse of non-affected limbs. Patients chose not to pursue transplantation due to rehabilitation time, immunosuppression, alternative treatments, and social and financial challenges. The clinical team discontinued evaluations due to unmet evaluation requirements, medical contraindications, or treatment alternatives. Different modes of shared decision-making were present depending on the party most heavily featured in the charts as driving decisions. DISCUSSION This was an examination of shared decision-making with hand transplant candidates who did not proceed to transplant. Reasons for choosing alternative strategies for management were multifactorial. Lessons learned regarding patient motivations and shared decision-making can inform future interventions to better support patients.
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Affiliation(s)
- Kasey R Boehmer
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
| | - Cassie C Kennedy
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Ian G Hargraves
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
| | - Joan M Griffin
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | - Brianna B Sanchez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA
| | - Avudaiappan Chokkalingam
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Dawn M Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Adam R Miller
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Steven L Moran
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
- The Essam and Dalal Obaid Center for Reconstructive Transplantation, Mayo Clinic, Rochester, MN, USA
| | - Fantley C Smither
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Hatem Amer
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
- The Essam and Dalal Obaid Center for Reconstructive Transplantation, Mayo Clinic, Rochester, MN, USA
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Sheila Jowsey-Gregoire
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
- The Essam and Dalal Obaid Center for Reconstructive Transplantation, Mayo Clinic, Rochester, MN, USA
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Gordon EJ, Gacki-Smith J, Kuramitsu BR, Downey M, Vanterpool KB, Nordstrom MJ, Riggleman T, Cooney CM, Jensen S, Dumanian G, Tintle S, Levan M, Brandacher G. Ethical and Psychosocial Factors in the Decision-Making and Informed Consent Process for Upper Extremity Vascularized Composite Allotransplantation: A Mixed-Methods Study. Transplant Direct 2023; 9:e1515. [PMID: 37492079 PMCID: PMC10365204 DOI: 10.1097/txd.0000000000001515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 07/27/2023] Open
Abstract
Although upper extremity (UE) vascularized composite allotransplantation (VCA) aims to improve quality of life, relatively few have been performed worldwide to support evidence-based treatment and informed decision-making. Methods We qualitatively examined factors contributing to anticipated and actual decision-making about UE VCA and perceptions of the elements of informed consent among people with UE amputations, and UE VCA candidates, participants, and recipients through in-depth interviews. Thematic analysis was used to analyze qualitative data. Results Fifty individuals participated; most were male (78%) and had a mean age of 45 y and a unilateral amputation (84%). One-third (35%) were "a lot" or "completely" willing to pursue UE VCA. UE VCA decision-making themes included the utility of UE VCA, psychosocial impact of UE VCA and amputation on individuals' lives, altruism, and anticipated burden of UE VCA on lifestyle. Most respondents who underwent UE VCA evaluation (n = 8/10) perceived having no reasonable treatment alternatives. Generally, respondents (n = 50) recognized the potential for familial, societal, cultural, medical, and self-driven pressures to pursue UE VCA among individuals with amputations. Some (n = 9/50, 18%) reported personally feeling "a little," "somewhat," "a lot," or "completely" pressured to pursue UE VCA. Respondents recommended that individuals be informed about the option of UE VCA near the amputation date. Conclusions Our study identified psychosocial and other factors affecting decision-making about UE VCA, which should be addressed to enhance informed consent. Study participants' perceptions and preferences about UE VCA suggest re-examination of assumptions guiding the UE VCA clinical evaluation process.
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Affiliation(s)
- Elisa J. Gordon
- Department of Surgery, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL
| | - Brianna R. Kuramitsu
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL
| | - Max Downey
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Karen B. Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Michelle J. Nordstrom
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Tiffany Riggleman
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Carisa M. Cooney
- Department of Plastic and Reconstructive Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Sally Jensen
- Department of Medical Social Sciences and Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gregory Dumanian
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Scott Tintle
- Department of Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Macey Levan
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
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Downey MC, Gacki-Smith J, Kuramitsu B, Vanterpool KB, Nordstrom M, Luken M, Langlee W, Riggleman T, Fichter S, Altema W, Jensen SE, Dumanian GA, Cooney CM, Levan ML, Tintle S, Brandacher G, Gordon EJ. Patient definitions of transplant success in upper extremity vascularized composite allotransplantation: A mixed-methods study. SAGE Open Med 2023; 11:20503121231184677. [PMID: 37465724 PMCID: PMC10350745 DOI: 10.1177/20503121231184677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
Objective Upper extremity vascularized composite allotransplantation is an innovative treatment option for people with upper extremity amputations. Limited patient-relevant long-term outcomes data about transplant success may impede patients' informed treatment decision-making. We assessed perceptions of what constitutes upper extremity vascularized composite allotransplantation success among individuals with upper extremity amputations. Methods This multisite study entailed interviews and focus groups with individuals with upper extremity amputations and upper extremity vascularized composite allotransplantation candidates, participants, and recipients. We examined perceptions of transplant success and preferences for five upper extremity vascularized composite allotransplantation outcomes. Qualitative data were analyzed using thematic analysis; and quantitative data were analyzed using descriptive statistics. Results In all, 50 individuals participated in interviews (61.7% participation rate), and 37 participated in nine focus groups (75.5% participation rate). Most were White (72%, 73%), had a mean age of 45 and 48 years, and had a unilateral amputation (84%, 59%), respectively. Participants conceptualized upper extremity vascularized composite allotransplantation success as transplant outcomes: (1) restoring function and sensation to enable new activities; (2) accepting the transplanted limb into one's identity and appearance; (3) not having transplant rejection; (4) attaining greater quality of life compared to prosthetics; and (5) ensuring benefits outweigh risks. Participants rated their most important upper extremity vascularized composite allotransplantation outcomes as follows: not having transplant rejection, not developing health complications, grasping objects, feeling touch and temperature, and accepting the upper extremity vascularized composite allotransplantation into your identity. Conclusion Individuals with upper extremity amputations maintain several conceptions of vascularized composite allotransplantation success, spanning functional, psychosocial, clinical, and quality of life outcomes. Providers should address patients' conceptions of success to improve informed consent discussions and outcomes reporting for upper extremity vascularized composite allotransplantation.
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Affiliation(s)
- Max C Downey
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brianna Kuramitsu
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen B Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Michelle Luken
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Whitney Langlee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tiffany Riggleman
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Shannon Fichter
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Withney Altema
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Sally E Jensen
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Macey L Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Scott Tintle
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Vanterpool KB, Gacki-Smith J, Downey MC, Nordstrom M, Luken M, Riggleman T, Fichter S, Altema W, Jensen SE, Dumanian GA, Cooney CM, Levan ML, Tintle S, Brandacher G, Gordon EJ. Patient preferences of patient selection criteria for upper extremity vascularized composite allotransplantation: A qualitative study. SAGE Open Med 2023; 11:20503121231181236. [PMID: 37342616 PMCID: PMC10278401 DOI: 10.1177/20503121231181236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/23/2023] Open
Abstract
Background Upper extremity vascularized composite allotransplantation is a life-enhancing reconstructive treatment option that aims to improve recipients' quality of life and maximize function. This study assessed upper extremity vascularized composite allotransplantation patient selection criteria perceptions among individuals with upper extremity limb loss. The perceptions of individuals with upper extremity limb loss on patient selection criteria may enable vascularized composite allotransplantation centers to improve criteria to avoid mismatched expectations about the posttransplant vascularized composite allotransplantation experience and outcomes. Realistic patient expectations may increase patient adherence, improve outcomes, and reduce vascularized composite allotransplantation graft loss. Methods We conducted in-depth interviews with civilian and military service members with upper extremity limb loss and upper extremity vascularized composite allotransplantation candidates, participants, and recipients from three US institutions. Interviews assessed perceptions of patient selection criteria for suitability as a candidate for upper extremity vascularized composite allotransplantation. Thematic analysis was used to analyze qualitative data. Results A total of 50 individuals participated (66% participation rate). Most participants were male (78%), White (72%), with a unilateral limb loss (84%), and a mean age of 45 years. Six themes emerged regarding upper extremity vascularized composite allotransplantation patient selection criteria, including support for candidates who: (1) are of younger age, (2) are in good physical health, (3) have mental stability, (4) are willing to "put in the work," (5) have specific amputation characteristics, and (6) have sufficient social support. Patients had preferences about selecting candidates with unilateral versus bilateral limb loss. Conclusions Our findings suggest that numerous factors, including medical, social, and psychological characteristics, inform patients' perceptions of patient selection criteria for upper extremity vascularized composite allotransplantation. Patient perceptions of patient selection criteria should inform the development of validated screening measures that optimize patient outcomes.
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Affiliation(s)
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Max C. Downey
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Michelle Luken
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD, USA
| | | | - Shannon Fichter
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD, USA
| | - Withney Altema
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD, USA
| | - Sally E. Jensen
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Carisa M. Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Macey L. Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Scott Tintle
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elisa J. Gordon
- Department of Surgery and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Hummel NR, Zuo KJ, Talbot S, Zimmerman ZE, Katz JN, Kinsley SE, Kumnig M. Psychosocial predictors in upper-extremity vascularized composite allotransplantation: A qualitative study of multidimensional experiences including patients, healthcare professionals, and close relatives. Front Psychol 2023; 14:1092725. [PMID: 36844321 PMCID: PMC9948017 DOI: 10.3389/fpsyg.2023.1092725] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
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.
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Affiliation(s)
- Nikolas R. Hummel
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin J. Zuo
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Simon Talbot
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Zoe E. Zimmerman
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Jeffrey N. Katz
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Sarah E. Kinsley
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria,*Correspondence: Martin Kumnig, ✉
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Kumnig M, Hummel NR, Jowsey-Gregoire SG, Zuo KJ, Gordon EJ, Talbot SG. Editorial: Psychosocial and bioethical challenges and developments for the future of vascularized composite allotransplantations. Front Psychol 2023; 14:1186113. [PMID: 37151323 PMCID: PMC10157283 DOI: 10.3389/fpsyg.2023.1186113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology Transplantation Medicine (CAPTM), Medical University of Innsbruck, Innsbruck, Austria
- *Correspondence: Martin Kumnig
| | - Nikolas R. Hummel
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology Transplantation Medicine (CAPTM), Medical University of Innsbruck, Innsbruck, Austria
| | - Sheila G. Jowsey-Gregoire
- Department of Psychiatry and Psychology, Mayo Graduate School of Medicine, Mayo Clinic Rochester, Rochester, MN, United States
| | - Kevin J. Zuo
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Elisa J. Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Simon G. Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Kumnig M, Jowsey-Gregoire SG, Gordon EJ, Werner-Felmayer G. 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. Front Psychol 2022; 13:1045144. [PMID: 36591015 PMCID: PMC9800026 DOI: 10.3389/fpsyg.2022.1045144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology Transplantation Medicine (CAPTM), Medical University of Innsbruck, Innsbruck, Austria,*Correspondence: Martin Kumnig,
| | - Sheila G. Jowsey-Gregoire
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, Mayo Graduate School of Medicine, Rochester, MN, United States
| | - Elisa J. Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Gabriele Werner-Felmayer
- Institute of Biological Chemistry and Bioethics Network Ethucation, Medical University of Innsbruck, Innsbruck, Austria
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Sarwer DB, Siminoff LA, Gardiner HM, Spitzer JC. The psychosocial burden of visible disfigurement following traumatic injury. Front Psychol 2022; 13:979574. [PMID: 36110275 PMCID: PMC9468754 DOI: 10.3389/fpsyg.2022.979574] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/21/2022] [Indexed: 12/15/2022] Open
Abstract
Hundreds of thousands of individuals experience traumatic injuries each year. Some are mild to moderate in nature and patients experience full functional recovery and little change to their physical appearance. Others result in enduring, if not permanent, changes in physical functioning and appearance. Reconstructive plastic surgical procedures are viable treatments options for many patients who have experienced the spectrum of traumatic injuries. The goal of these procedures is to restore physical functioning and reduce the psychosocial burden of living with an appearance that may be viewed negatively by the patient or by others. Even after receipt of reconstructive procedures, many patients are left with residual disfigurement. In some, disability and disfigurement may be so profound that individuals are candidates for vascularized composite allotransplantation (VCA) procedures, i.e., the transplantation of a vascularized human body part containing multiple tissue types (skin, muscle, bone, nerves, and blood vessels) as an anatomical and/or structural unit. This narrative review paper summarizes the literature on the psychosocial burden experienced by those who have visible disfigurement. While many of these individuals experience stigma and discrimination, relatively few studies have employed a stigma framework to understand the psychosocial sequelea. This paper briefly addresses this framework. Last, particular focus is given to the psychosocial issues of individuals with particularly severe injuries who are potential candidates for VCA procedures.
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Affiliation(s)
- David B. Sarwer
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, United States
- *Correspondence: David B. Sarwer,
| | - Laura A. Siminoff
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, United States
| | - Heather M. Gardiner
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, United States
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Benedict J. Patient Advocacy in Vascularized Composite Allotransplantation. Front Psychol 2022; 13:943393. [PMID: 35923735 PMCID: PMC9340068 DOI: 10.3389/fpsyg.2022.943393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
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12
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Kumnig M, Jowsey-Gregoire SG, Bellew M, Dean W, Järvholm S, Coffman K, Brown C, Moreno E, Talbot SG, Morelon E, Petruzzo P, Amer H. The Chauvet Workgroup: A Resource for the Psychosocial Aspects of Reconstructive Transplantation. Mayo Clin Proc 2022; 97:1050-1053. [PMID: 35662423 DOI: 10.1016/j.mayocp.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 12/24/2021] [Accepted: 02/07/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Martin Kumnig
- Innsbruck Medical University, Department of Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Innsbruck, Austria
| | - Sheila G Jowsey-Gregoire
- Essam and Dalal Obaid Center for Reconstructive Transplant Surgery and the William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Maggie Bellew
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Wendy Dean
- Moral Injury of Healthcare, Carlisle, PA
| | - Stina Järvholm
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Kathy Coffman
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH
| | - Charlotte Brown
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Elisa Moreno
- Departments of Psychiatry and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Simon G Talbot
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Hôpital Édouard Herriot, Lyon, France
| | - Palmina Petruzzo
- Department of Transplantation, Nephrology and Clinical Immunology, Hôpital Édouard Herriot, Lyon, France; Department of Surgery, University of Cagliari, Italy
| | - Hatem Amer
- Essam and Dalal Obaid Center for Reconstructive Transplant Surgery and the William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
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Kinsley SE, Williams EE, Lenhard NK, Shah SB, Edwards RR, Katz JN, Talbot SG. A Provider Perspective of Psychosocial Predictors of Upper-Extremity Vascularized Composite Allotransplantation Success. J Hand Surg Am 2022; 47:387.e1-387.e19. [PMID: 34266683 DOI: 10.1016/j.jhsa.2021.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/14/2021] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Sarah E Kinsley
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Emma E Williams
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Nora K Lenhard
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Sejal B Shah
- Department of Psychiatry; Brigham and Women's Hospital, Boston, MA
| | - Robert R Edwards
- Department of Anesthesiology, Pain Management Center, Brigham and Women's Hospital, Boston, MA
| | - Jeffrey N Katz
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Simon G Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA.
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Shammas RL, Huh J, Huber J, Mithani SK. Evaluating Treatment Preferences and Perceptions of a Prosthetic Versus a Transplanted Hand: A Conjoint Analysis-Based Study. Ann Plast Surg 2022; 88:99-104. [PMID: 34225311 DOI: 10.1097/sap.0000000000002949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study used a conjoint analysis-based survey to assess which factors are most influential when considering treatment with a prosthesis or transplant after a unilateral hand amputation. METHODS Overall, 469 respondents were recruited using Amazon Mechanical Turk and asked to assume that they experienced a hand amputation. To determine preferences for a prosthetic, respondents chose among 11 pairs of alternatives with variations in the following attributes: appearance, function, maintenance, and learning time. Respondents were then presented with descriptions of the risks and outcomes of hand transplantation. The most compelling reasons for and against a transplant were determined and characteristics predictive of support for a transplant were identified. RESULTS The most important attributes for a prosthesis were "lifelike appearance" and "myolectric function." For hand transplantation, respondents were most concerned about immunosuppression side effects (n = 323, 69%) and the intense nature of surgery (n = 275, 59%), whereas the most positive benefit was the concept of the transplant being "natural" (n = 339, 72%). When faced with the choice of a hand transplant or a prosthetic, approximately 50% of respondents chose a transplantation. Younger age, previous medical experiences, a perceived "familiarity with medical issues," and the regular attendance of religious services were associated with strong support for a hand transplantation (P < 0.01). CONCLUSIONS When considering a hand prosthesis, respondents are motivated most by appearance and function. Meanwhile, with hand transplantation, the risks of immunosuppression and the intense nature of surgery and recovery are predominant concerns. These findings may help inform patient-physician discussions when considering treatment after unilateral hand amputation.
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Affiliation(s)
- Ronnie L Shammas
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center
| | - Ji Huh
- Fuqua School of Business, Duke University, Durham, NC
| | - Joel Huber
- Fuqua School of Business, Duke University, Durham, NC
| | - Suhail K Mithani
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center
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15
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Advanced Amputation Techniques in Orthopedic Surgery: Hand Transplantation. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Appreciate the evolution and increasing complexity of transplanted facial allografts over the past two decades. 2. Discuss indications and contraindications for facial transplantation, and donor and recipient selection criteria and considerations. 3. Discuss logistical, immunologic, and cost considerations in facial transplantation, in addition to emerging technologies used. 4. Understand surgical approaches and anatomical and technical nuances of the procedure. 5. Describe aesthetic, functional, and psychosocial outcomes of facial transplantation reported to date. SUMMARY This CME article highlights principles and evolving concepts in facial transplantation. The field has witnessed significant advances over the past two decades, with more than 40 face transplants reported to date. The procedure now occupies the highest rung on the reconstructive ladder for patients with extensive facial disfigurement who are not amenable to autologous reconstructive approaches, in pursuit of optimal functional and aesthetic outcomes. Indications, contraindications, and donor and recipient considerations for the procedure are discussed. The authors also review logistical, immunologic, and cost considerations of facial transplantation. Surgical approaches to allograft procurement and transplantation, in addition to technical and anatomical nuances of the procedure, are provided. Finally, the authors review aesthetic, functional, and psychosocial outcomes that have been reported to date.
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Smith PJ, Potter G, Manson M, Martin M, Cendales LC. Psychosocial considerations in the assessment of hand transplant candidates: A single-center experience and brief literature review. Clin Transplant 2021; 35:e14268. [PMID: 33615558 DOI: 10.1111/ctr.14268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/27/2021] [Accepted: 01/31/2021] [Indexed: 11/27/2022]
Abstract
Vascularized composite allograft, including hand transplantation (HT), has gained wider usage as a reconstructive treatment over the past 30 years. HT recipients face unique psychosocial challenges compared to their solid organ and/or bone marrow transplant counterparts. Accordingly, the psychosocial evaluation among HT candidates continues to evolve, leaving a lack of consensus as to the critical psychosocial domains and psychometric testing instruments to help evaluate individuals considering HT. The present manuscript describes the psychosocial evaluation process within the Duke HT program, which been contacted by 80 potential candidates since 2014. The Duke HT evaluation process incorporates a comprehensive psychosocial assessment within domains including personality, cognitive function, mood, behavioral adherence, social support, and substance use history, among others. Our experience underscores the potential utility of collecting thorough psychosocial evaluations, supplemented by psychometric test data, to comprehensively assess potential HT candidates.
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Affiliation(s)
- Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Guy Potter
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Maria Manson
- Duke Office of Clinical Research, Duke School of Medicine, Durham, NC, USA
| | - Michael Martin
- Atlanta VA Healthcare System, Mental Health Service Line, Decatur, GA, USA.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Linda C Cendales
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Lessons Learned from the Amputation of a Bilateral Hand Grafted Patient due to Psychiatric Disorders. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2905. [PMID: 33173656 PMCID: PMC7647659 DOI: 10.1097/gox.0000000000002905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. The importance of psychosocial aspects in upper extremity transplantation (UET) has been emphasized since the beginning of the vascularized composite allotransplantation era. Herein a long-term UET failure mainly due to psychiatric disorders is reported. A young woman amputated in 2004 (electrocution) underwent bilateral UET in 2007. At the time of transplantation the patient underwent a psychological evaluation, which did not completely consider some traits of her personality. Indeed, she had an anxious personality and a tendency to idealize. The trauma of amputation, the injuries associated with the accident, and the short delay between the accident and the transplantation elicited vindictiveness, entitlement, and impulsivity. Following transplantation, she had a high anxiety level, panic attacks, depression, and hypomanic episodes. She was poorly compliant to the rehabilitation program and the immunosuppressive treatment. She developed 13 acute rejection episodes (reversed by appropriate treatment) but neither clinical signs of chronic rejection nor donor specific antibiodies. She developed many severe complications due to the treatment and the psychiatric disorders. At her request, after many interviews, the allografts were removed in 2018. Pathological examination and an angiography performed post-amputation revealed signs of graft vasculopathy of varying severity, in the absence of clinically overt chronic rejection. This case highlights the need to detect during the initial patients’ assessment even mild traits of personality disorders, which could herald psychiatric complications after the transplantation, compromising UET outcomes. It further confirms that skin and vessels are the main targets of the alloimmune response in the UET setting.
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Psychosocial Predictors of Upper Extremity Transplantation Outcomes: A Review of the International Registry 1998-2016. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3133. [PMID: 33133972 PMCID: PMC7544328 DOI: 10.1097/gox.0000000000003133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/31/2020] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. 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.
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20
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The current outcomes and future challenges in pediatric vascularized composite allotransplantation. Curr Opin Organ Transplant 2020; 25:576-583. [PMID: 33044345 DOI: 10.1097/mot.0000000000000809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We review the outcomes and future challenges associated with pediatric vascularized composite allotransplantation, including follow-up data from our bilateral pediatric hand-forearm transplantation. RECENT FINDINGS In 2015, the first heterologous pediatric upper extremity hand-forearm transplant was performed at the Children's Hospital of Philadelphia, and in 2019, the first pediatric neck reconstructive transplantation was performed in Poland. The 5-year follow-up of the pediatric upper extremity recipient demonstrates similar growth rates bilaterally, an increase in bone age parallel to chronologic age, and perhaps similar overall growth to nontransplant norms. The pediatric upper extremity recipient continues to make gains in functional independence. He excels academically and participates in various extracurricular activities. Future challenges unique to the pediatric population include ethical issues of informed consent, psychosocial implications, limited donor pool, posttransplant compliance issues, and greater life expectancy and therefore time to inherit the many complications of immunosuppression. SUMMARY Currently, we recommend pediatric vascularized composite allotransplantation (VCA) for bilateral upper extremity amputees, preferably on immunosuppression already, and those patients who would have the most potential gain not available through standard reconstructive techniques while being able to comply with postoperative immunosuppression protocols, surveillance, rehabilitation, and follow-up.
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21
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A Multisystemic Approach to Psychosocial Evaluations of Vascularized Composite Allotransplantation Candidates. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00293-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Van Pilsum Rasmussen SE, Ferzola A, Cooney CM, Shores JT, Lee WA, Goldman E, Kaufman CL, Brandacher G, Segev DL, Henderson ML. Psychosocial factors and medication adherence among recipients of vascularized composite allografts. SAGE Open Med 2020; 8:2050312120940423. [PMID: 32695395 PMCID: PMC7350038 DOI: 10.1177/2050312120940423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/15/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives Psychosocial factors are important predictors of medication adherence, and subsequently graft survival, in solid organ transplantation. Early experiences suggest this may also be the case in vascularized composite allotransplantation. Methods Using validated tools, we surveyed upper extremity transplant recipients at two centers to assess depression (Patient Health Questionnaire-9), personality (Ten-Item Personality Inventory), anxiety (Generalized Anxiety Disorder 7-Item Scale), post-traumatic stress disorder (Primary Care Post-Traumatic Stress Disorder Screen for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), and social support (Multidimensional Scale of Perceived Social Support). Medication adherence among vascularized composite allotransplantation recipients at two centers was assessed by a member of the clinical research team using the recipients' medical records. Results Medication adherence was reported for 12 vascularized composite allotransplantation recipients, and 9 vascularized composite allotransplantation recipients completed psychosocial assessments. Most recipients were believed to be adherent to their immunosuppression, however, three recipients were believed to be non-adherent and a member of the clinical team had discussed non-adherence at least once with five recipients. Results from the psychosocial assessment (n = 9) indicated that eight participants had high levels of social support, and eight demonstrated high levels of conscientiousness which have been associated with better medication adherence in solid organ transplantation. However, three participants demonstrated mild anxiety, two demonstrated minimal symptoms of depression, and one demonstrated post-traumatic stress disorder which have been associated with worse medication adherence in solid organ transplantation. Conclusion These findings lay the groundwork for future assessments of the role psychosocial factors play in facilitating medication adherence and broader transplant outcomes.
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Affiliation(s)
| | - Alexander Ferzola
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jaime T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wp Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily Goldman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Christina L Kaufman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, USA
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Emerging Ethical Challenges Raised by the Evolution of Vascularized Composite Allotransplantation. Transplantation 2020; 103:1240-1246. [PMID: 30300280 DOI: 10.1097/tp.0000000000002478] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite early skepticism, the field of vascularized composite allotransplantation (VCA) has demonstrated feasibility. The ethics of VCA have moved past doubts about the morality of attempting such transplants to how to conduct them ethically. METHODS Leaders of each program performing and/or evaluating VCA in the United States were invited to participate in a working group to assess the state and future of VCA ethics and policy. Four meetings were held over the course of 1 year to describe key challenges and potential solutions. RESULTS Working group participants concluded that VCA holds great promise as treatment for patients with particular injuries or deficits, but the field faces unique challenges to adoption as standard of care, which can only be overcome by data sharing and standardization of evaluation and outcome metrics. CONCLUSIONS Adequate attention must be given to concerns including managing the uniquely intense physician-patient relationship, ethical patient selection, ensuring patients have adequate representation, informing and earning the trust of the public for donation, standardizing metrics for success, and fostering an environment of data sharing. These steps are critical to transitioning VCA from research to standard of care and to its insurance coverage inclusion.
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24
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Sarwer DB. Body image, cosmetic surgery, and minimally invasive treatments. Body Image 2019; 31:302-308. [PMID: 30704847 DOI: 10.1016/j.bodyim.2019.01.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/20/2022]
Abstract
Over the past 60 years, a growing body of research has investigated the psychological aspects of cosmetic surgery and related minimally-invasive treatments. While the earliest studies were influenced by psychoanalytic thinking, much of the work over the past several decades has been influenced by Thomas Cash's cognitive-behavioral theory of body image and has focused on the appearance concerns of patients who seek these procedures. The majority of individuals interested in the procedures report heightened dissatisfaction typically focused on the feature being considered for treatment. Studies from around the world also have suggested that between 5-15% of patients who present for cosmetic procedures meet diagnostic criteria for body dysmorphic disorder (BDD). While individuals with BDD typically do not report a reduction in their BDD symptoms following a cosmetic procedure, the great majority of patients without the disorder do report improvement in body image. The paper reviews this literature and also discusses the role of body image in three newer areas of plastic surgery-body contouring after massive weight loss, genital procedures (either for cosmetic purposes or as part of gender reassignment), and vascularized composite allotransplantation, including face and hand transplantation.
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Affiliation(s)
- David B Sarwer
- College of Public Health, Temple University, United States.
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25
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Upper extremity and craniofacial vascularized composite allotransplantation: ethics and immunosuppression. Emerg Top Life Sci 2019; 3:681-686. [PMID: 32915212 DOI: 10.1042/etls20190060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/02/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022]
Abstract
Vascularized composite allotransplantation (VCA) is the name most often used to refer to the transplantation of anatomical units composed of multiple tissue types (skin, bone, muscle, tendon, nerves, vessels, etc.) when such transplants do not have the primary purpose of extending life, as is the case in the more familiar field of solid organ transplantation (SOT). A serious interest in VCA developed in the late twentieth century following advances in immunosuppression which had led to significant improvements in short and medium-term survival among SOT recipients. Several ethical concerns have been raised about VCA, with many being connected in one way or another to the limitations, burdens, and risks associated with immunosuppression. This article will focus on upper extremity and craniofacial VCA, beginning with a brief review of the history of VCA including reported outcomes, followed by a discussion of the range of ethical concerns, before exploring in greater detail how immunological issues inform and shape several of the ethical concerns.
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26
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Psychosocial dimensions of hand transplantation: lessons learned from solid organ transplantation. Curr Opin Organ Transplant 2019; 24:705-713. [PMID: 31689261 DOI: 10.1097/mot.0000000000000712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The present review examines psychosocial factors emerging as predictive of clinical outcomes among solid organ transplant (SOT) recipients, with possible extensions to vascular composite allograft (VCA) and hand transplantation, in particular. The Chauvet Workgroup report and International Society of Heart and Lung Transplantation consensus guidelines are used to delineate areas of commonality between SOT and VCA, as well as unique features contributing to post-VCA psychosocial risk. RECENT FINDINGS Increasing evidence suggests that depression, cognitive function, and other posttransplant psychosocial factors consistently associate with clinical risk in SOT. However, the mechanisms precipitating these psychosocial risk factors are likely diverse in their cause, with large individual differences across SOT and VCA. Transdiagnostic dimensions may serve as mechanistic factors, increasing the risk of adverse clinical outcomes and suggesting potential treatment strategies for risk mitigation. Psychosocial dimensions including psychological flexibility, self-efficacy, and posttraumatic growth are discussed as potential contributory factors. SUMMARY Psychosocial factors hold importance in predicting posttransplant clinical outcomes. Emerging transdiagnostic factors may provide insight into mechanisms and potential treatments.
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Rose J, Cooney CM, Kaufman C, Talbot SG, Caplan A, Kahn J, Sugarman J, Shores JT, Levin LS, Brandacher G, McDiarmid SV, Lee WPA, Dean W. Evolving ethics, policy and reimbursement issues of vascularized composite allotransplantation: Symposium summary. SAGE Open Med 2019. [PMID: 31384465 PMCID: PMC6661784 DOI: 10.1177/2050312119866944] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In this article, we present a report from a national meeting titled, “Evolving Issues of Vascularized Composite Allotransplantation—A Symposium on Ethics, Policy, and Reimbursement Issues,” which convened in September 2017. We discuss the maturation of vascularized composite allotransplantation from an emerging technology to becoming an extension of clinical practice for select patients with complex reconstructive needs. Viewpoints and action items were presented by and discussed among the 70+ clinicians, researchers, policymakers, ethicists, healthcare administrators, and third-party payers who attended the symposium with the goals of implementing a collaborative roadmap for vascularized composite allotransplantation growth, evaluation, and sustainability by establishing a unified plan to help address concerns of the public, policymakers, and healthcare finance. We review the current status of vascularized composite allotransplantation in clinical practice and summarize symposium discussions regarding ethical considerations, reimbursement, payer strategies, and standardization of data collection.
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Affiliation(s)
- John Rose
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christina Kaufman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Simon G Talbot
- Division of Plastic and Reconstructive Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Arthur Caplan
- Division of Medical Ethics, New York University School of Medicine, New York City, NY, USA
| | - Jeffrey Kahn
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L Scott Levin
- Department of Orthopaedic Surgery, Division of Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sue V McDiarmid
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics and Surgery. David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - WP Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy Dean
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
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Talbot SG, Carty MJ, Jensen SE, Dumanian GA. Adjustment to amputation and interest in upper limb transplantation. SAGE Open Med 2019; 7:2050312119858248. [PMID: 31217973 PMCID: PMC6563387 DOI: 10.1177/2050312119858248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 12/03/2022] Open
Abstract
Objective: Upper limb transplantation provides a new restorative option for individuals with amputations. As true for most operations, patient selection is critical to optimizing transplantation outcomes. To improve on the patient selection process, we used qualitative methods to better understand the issues regarding upper extremity loss as well as upper limb transplantation from the amputee point of view. Methods: Individuals with upper limb amputations (age range = 24–73 years) discussed their adjustment following amputation and their interest toward transplantation in either a focus group (n = 5) or semi-structured interview (n = 17). Transcripts were coded by theme and summarized. Results: Participants described a year-long process typified by adjustment to a new role as an amputee, both psychosocially and functionally. We found that the extent of adjustment was inversely related to an interest in transplantation. Conclusions: These findings could explain the difficulty in identifying “ideal” candidates for upper extremity transplantation and may have implications for patient selection and counseling. Level of Evidence: Prognostic Study, Level V
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Affiliation(s)
- Simon G Talbot
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew J Carty
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Sally E Jensen
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gregory A Dumanian
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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29
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Thuong M, Petruzzo P, Landin L, Mahillo B, Kay S, Testelin S, Jablecki J, Laouabdia-Sellami K, Lopez-Fraga M, Dominguez-Gil B. Vascularized composite allotransplantation - a Council of Europe position paper. Transpl Int 2018; 32:233-240. [DOI: 10.1111/tri.13370] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/19/2018] [Accepted: 10/25/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Marie Thuong
- Intensive Care Unit; Hospital René Dubos; Cergy Pontoise France
| | - Palmina Petruzzo
- Department of Vascular Surgery; Hôpital Edouard Herriot; Lyon France
| | - Luis Landin
- Plastic & Reconstructive Surgery; Hospital Universitario La Paz; Madrid Spain
| | | | - Simon Kay
- Leeds Teaching Hospitals NHS Trust; Leeds UK
| | - Sylvie Testelin
- Department of Maxillofacial Surgery; Centre Hospitalier Universitaire Amiens-Picardie; Amiens France
| | | | | | - Marta Lopez-Fraga
- European Committee on Organ Transplantation (CD-P-TO); Council of Europe; Strasbourg France
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30
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Waldner M, Zhang W, James IB, Allbright K, Havis E, Bliley JM, Almadori A, Schweizer R, Plock JA, Washington KM, Gorantla VS, Solari MG, Marra KG, Rubin JP. Characteristics and Immunomodulating Functions of Adipose-Derived and Bone Marrow-Derived Mesenchymal Stem Cells Across Defined Human Leukocyte Antigen Barriers. Front Immunol 2018; 9:1642. [PMID: 30087676 PMCID: PMC6066508 DOI: 10.3389/fimmu.2018.01642] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Vascularized composite allotransplantation opens new possibilities in reconstructive transplantation such as hand or face transplants. Lifelong immunosuppression and its side-effects are the main drawbacks of this procedure. Mesenchymal stem cells (MSCs) have clinically useful immunomodulatory effects and may be able to reduce the burden of chronic immunosuppression. Herein, we assess and compare characteristics and immunomodulatory capacities of bone marrow- and adipose tissue-derived MSCs isolated from the same human individual across defined human leukocyte antigen (HLA) barriers. Materials and methods Samples of omental (o.) adipose tissue, subcutaneous (s.c.) adipose tissue, and bone marrow aspirate from 10 human organ donors were retrieved and MSCs isolated. Cells were characterized by flow cytometry and differentiated in three lineages: adipogenic, osteogenic, and chondrogenic. In mixed lymphocyte reactions, the ability of adipose-derived mesenchymal stem cells (ASCs) and bone marrow-derived mesenchymal stem cells (BMSCs) to suppress the immune response was assessed and compared within individual donors. HLA mismatched or mitogen stimulations were analyzed in co-culture with different MSC concentrations. Supernatants were analyzed for cytokine contents. Results All cell types, s.c.ASC, o.ASC, and BMSC demonstrated individual differentiation potential and cell surface markers. Immunomodulating effects were dependent on dose and cell passage. Proliferation of responder cells was most effectively suppressed by s.c.ASCs and combination with BMSC resulted in highly efficient immunomodulation. Immunomodulation was not cell contact-dependent and cells demonstrated a specific cytokine secretion. Conclusion When human ASCs and BMSCs are isolated from the same individual, both show effective immunomodulation across defined HLA barriers in vitro. We demonstrate a synergistic effect when cells from the same biologic system were combined. This cell contact-independent function underlines the potential of clinical systemic application of MSCs.
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Affiliation(s)
- Matthias Waldner
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Zurich, Switzerland
| | - Wensheng Zhang
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Isaac B James
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kassandra Allbright
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Emmanuelle Havis
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jacqueline M Bliley
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Aurora Almadori
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Riccardo Schweizer
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Zurich, Switzerland
| | - Jan A Plock
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Zurich, Switzerland
| | - Kia M Washington
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vijay S Gorantla
- Wake Forest Institute for Regenerative Medicine, Wake Forest University, Winston-Salem, NC, United States
| | - Mario G Solari
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kacey G Marra
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - J Peter Rubin
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
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31
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Pediatric Vascular Composite Allograft Transplantation: Medical Considerations. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0189-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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32
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Cooney CM, Siotos C, Aston JW, Bello RJ, Seal SM, Cooney DS, Shores JT, Brandacher G, Lee WPA. The Ethics of Hand Transplantation: A Systematic Review. J Hand Surg Am 2018; 43:84.e1-84.e15. [PMID: 28985978 DOI: 10.1016/j.jhsa.2017.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 07/21/2017] [Accepted: 08/02/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) allotransplantation and how these concerns have changed over time. METHODS We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE allotransplantation. Inclusion criteria were papers that were on the topic of UE allotransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change. RESULTS We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0-7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002. CONCLUSIONS Upper extremity transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies. CLINICAL RELEVANCE Because UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.
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Affiliation(s)
- Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Charalampos Siotos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey W Aston
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ricardo J Bello
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stella M Seal
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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33
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Jowsey-Gregoire S, Kumnig M. Standardizing psychosocial assessment for vascularized composite allotransplantation. Curr Opin Organ Transplant 2016; 21:530-5. [DOI: 10.1097/mot.0000000000000351] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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34
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Uluer MC, Brazio PS, Woodall JD, Nam AJ, Bartlett ST, Barth RN. Vascularized Composite Allotransplantation: Medical Complications. CURRENT TRANSPLANTATION REPORTS 2016; 3:395-403. [PMID: 32288984 PMCID: PMC7101879 DOI: 10.1007/s40472-016-0113-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The objective of this review is to summarize the collective knowledge regarding the risks and complications in vascularized composite tissue allotransplantation (VCA), focusing on upper extremity and facial transplantation. The field of VCA has entered its second decade with an increasing experience in both the impressive good outcomes, as well as defining challenges, risks, and experienced poor results. The limited and selective publishing of negative outcomes in this relatively new field makes it difficult to conclusively evaluate outcomes of graft and patient survival and morbidities. Therefore, published data, conference proceedings, and communications were summarized in an attempt to provide a current outline of complications. These data on the medical complications of VCA should allow for precautions to avoid poor outcomes, data to better provide informed consent to potential recipients, and result in improvements in graft and patient outcomes as VCA finds a place as a therapeutic option for selected patients.
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Affiliation(s)
- Mehmet C. Uluer
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, 29 S Greene Street STE 200, Baltimore, MD 21201 USA
| | - Philip S. Brazio
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, 29 S Greene Street STE 200, Baltimore, MD 21201 USA
| | - Jhade D. Woodall
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, 29 S Greene Street STE 200, Baltimore, MD 21201 USA
| | - Arthur J. Nam
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, 29 S Greene Street STE 200, Baltimore, MD 21201 USA
| | - Stephen T. Bartlett
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, 29 S Greene Street STE 200, Baltimore, MD 21201 USA
| | - Rolf N. Barth
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, 29 S Greene Street STE 200, Baltimore, MD 21201 USA
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