Fifteen years later: main lessons from composite tissue allografts

Composite tissue allografts (CTA) are also called "reconstructive transplantation" as they are a valid alternative approach to repairing complex tissue defects. These procedures are still considered "experimental" and their therapeutic value remains to be validated. An immunosuppressive treatment similar to that used in solid organ transplantation allows CTA survival and function despite a high rate of acute rejection (AR) episodes. Clinical experience seems to confirm that skin is the most antigenic tissue and the first target of AR episodes, which are easy to reverse and do not seem to adversely influence graft survival and function when promptly treated. Chronic rejection can also occur in CTA, although its features are still unclear. Upper-extremity or face-transplanted patients show a relevant sensorimotor recovery. Patients are able to perform the majority of daily activities and to lead normal social lives. Global cortical remodeling occurs in the months following transplantation, reversing the functional reorganization induced by the amputation. Appropriation of the graft occurs in parallel with functional recovery. The patients' compliance is essential for the success of CTAs as well as careful recipient selection and patient follow-up to prevent complications of long-term immunosuppression.

Un modèle de qualité de la vie subjective adapté aux essais thérapeutiques : intérêt chez les patients dépressifs

Cet article présente les bases conceptuelles qui ont présidé à l'élaboration d'un questionnaire (« Profil de la Qualité de Vie Subjective » ou « PQVS ») évaluant la qualité de vie subjective des patients en pathologie somatique et psychiatrique. Une description de l'instrument précède les données concernant la validation de ce questionnaire ainsi que les résultats déjà obtenus sur environ 1500 sujets présentant des pathologies différentes. Les premiers résultats montrent qu'à chaque pathologie correspond un profil différent de patients; qu'il est possible, grâce à ce nouvel instrument d'évaluation, de mettre en évidence des changements spécifiques et parfois inattendus chez les patients; et qu'enfin, dans un certain nombre de cas, l'on peut dégager des hypothèses explicatives de ces changements.

[Psychotherapeutic process in a day hospital: results of a survey and importance of qualitative data]

This survey was carried out in a psychiatric day hospital over three years on all patients admitted. The aim was to assess the patients' state at discharge, and to identify the factors to explain the clinical changes, in particular to evaluate the impact of the various types of therapy proposed. The patients were evaluated when they entered the hospital and at discharge using mainly validated translated English-language questionnaires ("Health Sickness Rating Scale" of Luborsky, "Helping Alliance questionnaire" of Luborsky), but also two instruments developed and validated by our team: "Clinical Evaluation Profile", and the "Commitment Scale". The results provide not only a good description of the patients' state at arrival but also of their evolution. The factors found to be important in the evaluation were similar to those identified in most of previous studies, i.e. the initial severity, and quality of the therapeutic relationship, but we also found that the degree of commitment of the patients to the various therapies offered was important. In addition, we found that, when using the commitment scale in homogeneous subgroups of patients (identified using the CIM 9 diagnostic scale) were examined, the favourable outcome of a given psychotherapeutic approach was dependent on the type of the pathology. Thus, patients with personality disorders and high scores at the commitment scale benefited above all from group therapy. The reverse was found for patients with neurotic disorders. For patients suffering from schizophrenia the most important factor was the commitment to the background milieu of the hospital. These observations are in contradiction with some of the main conclusions (known as the equivalence paradox) from english and american studies over the last 40 years of Psychotherapy Research, which state that all psychotherapies are equivalent, and that the reason why some give successful results, and other do not can, only be by non specific factors (i.e. the quality of the therapeutic bond, patients' motivations, etc.). From our results, if homogeneous subgroups of patients are considered and if we use subjective (commitment to the therapy) instead of hard data (as for example having this type of therapy or an other one, or the length of therapy, ect.), we can distinguish the effect of the various psychotherapeutic approaches at least in a psychiatric institution.