Martin Kumnig

World Experience After More Than a Decade of Clinical Hand Transplantation: Update on the Innsbruck Program

Patients who have lost a hand or upper extremity face many challenges in everyday life. For some patients, reconstructive hand transplantation represents a reasonable option for anatomic reconstruction, restoring prehensile function with sensation and allowing them to regain daily living independence. The first clinical case of bilateral hand transplantation at University Hospital Innsbruck was realized on March 17th, 2000. A decade later, a total of 7 hands and forearms were transplanted in 4 patients. This article review the clinical courses of 3 bilateral hand transplant recipients and highlights psychological aspects on reconstructive hand transplantation with special regard to unilateral/bilateral transplantation.

The psychological assessment of candidates for reconstructive hand transplantation

Standardized psychological assessment of candidates for reconstructive hand transplantation (RHT) is a new approach in transplantation medicine. Currently, international guidelines and standardized criteria for the evaluation are not established. Patients suffering from the loss of a hand or an upper extremity have to cope with multiple challenges. For a selected group of patients, RHT represents an option for restoring natural function and for regaining daily living independence. The identification of at‐risk patients and those requiring ongoing counseling due to poor coping or limited psychological resources are the primary focus of the psychological assessment. We have developed the ‘Innsbruck Psychological Screening Program for Reconstructive Transplantation (iRT‐PSP)’ which utilizes a semi‐structured interview and standardized psychological screening procedures and continuous follow‐up ratings. Between January 2011 and October 2011, four candidates were evaluated using the iRT‐PSP. Psychological impairments including social withdrawal, embarrassment, reduced self‐esteem, and a depressive coping style were identified and poor quality of life was reported. The motivation for transplantation was diverse, depending on many factors such as bi‐ or unilateral impairment, native or accidental loss of hand, and social integration.

Poor health behaviour and reduced quality of life of people treated with psychotropic drugs

Recent literature reports a reduced l\ife expectancy in patients with severe mental illness. We have investigated health behaviour, quality of life, and sociodemographic variables of people with psychopharmacological treatment using data from the most recent Austrian Health Survey.

Psychological aspects of hand transplantation.

Purpose of reviewPsychosocial aspects are important indicators for reconstructive hand transplantation (RHT). They warrant further research attention given the influence of psychosocial factors on the success of RHT. This review will contrast RHT with solid organ transplantation, provide information to guide selection of RHT candidates and ethical implications, share information on psychological outcomes, and address the importance of a multicenter research approach. Recent findingsPreviously published RHT reports have tried to identify psychosocial factors that are essential to guide selection of RHT candidates and that predict psychosocial outcomes. These issues in RHT are receiving increased attention, but standardized psychosocial evaluation and follow-up protocols are still needed. Recent study highlights the potential for a multicenter research approach that uses standardized assessment strategies and also emphasizes the need for a shared assessment approach to understand psychosocial outcomes. SummaryRHT combines the technical rigors of hand surgery and microsurgery with the complex multidisciplinary care that defines modern transplantation medicine. As recent work has provided a more complete picture of the complexities of the psychosocial factors in RHT, a psychosocial assessment protocol developed with input across the centers currently performing this procedure would capitalize on the collective diverse clinical experiences and standardize the assessment and follow-up protocol. With such standardized procedures in place, psychosocial risk factors for both poor psychosocial and medical/surgical outcomes can be identified which can inform the selection or preparation of future candidates.

An overview of psychosocial assessment procedures in reconstructive hand transplantation.

There have been more than 90 hand and upper extremity transplants performed worldwide. Functional and sensory outcomes have been reported in several studies, but little is known about the psychosocial outcomes. A comprehensive systematic literature review was performed, addressing the psychosocial impact of reconstructive hand transplantation. This review provides an overview of psychosocial evaluation protocols and identifies standards in this novel and exciting field. Essentials of the psychosocial assessment are discussed and a new protocol, the ‘Chauvet Protocol’, representing a standardized assessment protocol for future multicenter psychosocial trials is being introduced.

Functional and Psychosocial Outcomes of Hand Transplantation Compared with Prosthetic Fitting in Below-Elbow Amputees: A Multicenter Cohort Study

Background Hand-transplantation and improvements in the field of prostheses opened new frontiers in restoring hand function in below-elbow amputees. Both concepts aim at restoring reliable hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing hand function and quality-of-life of people with transplanted versus prosthetic hands. Methods Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36). Results Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in “role-physical” (p = 0.006), “vitality” (p = 0.008), “role-emotional” (p = 0.035) and “mental-health” (p = 0.003). Conclusions The indications for hand transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient’s best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for allotransplantation must still be restrictive, the best being bilateral amputees.

Hand Transplantation in Its Fourteenth Year: The Innsbruck Experience

Five patients received a bilateral hand (n = 3), a bilateral forearm (n = 1) and a unilateral hand transplant (n = 1) between 03/2000 and 03/2014. We herein describe the long-term outcome with emphasis on function, immunosuppression (IS), histomorphology and graft vascular changes. Induction therapy with antithymocyte globulin or alemtuzumab was followed by tacrolimus, prednisolone ± mycophenolate mofetil (MMF) or tacrolimus and MMF maintenance IS. Later, an mTOR-Inhibitor was added under simultaneous withdrawal or dose reduction of tacrolimus or MMF. Steroids were avoided in one and withdrawn in 2 patients. Range of motion reached up to 70% of normal with a grip strength up to 10kg. Hand function correlated with time after transplantation and amputation level and remained stable after year 5 in all cases. Intrinsic hand muscle function recovery, discriminative sensation and temperature sensation were observed after hand transplantation. Three, 7, 6, 3 and one rejection episodes were successfully treated with steroids, anti-CD25, anti-CD52 and anti-CD20 antibodies and/or intensified maintenance IS. Repetitive events of skin rejection/inflammation late after transplantation were observed in one case. Skin histology at current shows no or mild perivascular lymphocytic infiltrates without signs of progression. Vessels are patent without signs for luminal narrowing or intimal proliferation. The overall functional outcome and patient satisfaction are highly encouraging. All patients are now free of rejection with moderate levels of IS.

The chauvet 2014 meeting report: Psychiatric and psychosocial evaluation and outcomes of upper extremity grafted patients

Abstract Under the auspices for the International Society on Hand and Composite Tissue Allotransplantation, a section of The Transplantation Society (IHCTAS), a meeting was convened on March 21-22, 2014 in Paris to review the following areas that were deemed significant in the understanding of the psychosocial evaluation and outcomes of upper extremity transplant recipients: required domains of the evaluation, screening instruments, clinical monitoring pretransplant, clinical monitoring posttransplant, patient and team expectations, body image, psychiatric complications, functional goals and quality of life, ethics and media relations. Experts in the fields of psychiatry and psychology, transplantation, social work, ethics, and transplant administration met and reviewed center experiences and literature. The attendees highlighted the importance and the complexity of the psychiatric assessment in this field of transplantation. Moreover, the necessity to develop common instruments and evaluation protocols to predict psychosocial outcomes as well as to understand whether we are transplanting the right patients and how the transplantation is affecting the patients were pointed out. Psychiatric complications in upper extremity transplanted patients have been reported by the majority of teams. Preexisting psychiatric difficulties, the initial trauma of amputation, or adjusting to the transplantation process itself (especially the medical follow-up and rehabilitation process) appeared to be important factors. Monitoring during the whole follow-up was recommended to detect psychiatric issues and to facilitate and ensure long-term adherence. The participants proposed an annual meeting format to build upon the findings of this inaugural meeting to be called the Chauvet Workgroup meeting.

Patient-reported outcome reference values for patients after kidney transplantation

SummaryBackgroundPatient-reported outcomes (PROs) are important in managing kidney transplant patients. Although, there are many instruments available to assess PROs, such as health-related quality of life (HRQOL), they are rarely collected in routine nephrology practices. Therefore, the aim of this study was the determination of reference values for physical and psychosocial symptom burden in kidney transplant patients.MethodsPatients with a history of kidney transplantation being in aftercare at a nephrological outpatient unit (n = 120) were consecutively recruited, and a computer-based PRO assessment was used to assess their HRQOL reference values. It covered a broad range of clinically relevant physical and psychological symptoms, adherence to immunosuppressants, and disease-specific quality of life. On an average, PROs were assessed 2.9 times per patient, 351 times in total.ResultsFor PRO monitoring in kidney transplant patients, we consider the 10th/90th percentile as being of particular clinical relevance, as patients exceeding these scores are likely to be in need of additional care.ConclusionsWith continuously rising survival rates after kidney transplantation, HRQOL of long-term transplant patients becomes increasingly important, and it is generally accepted that HRQOL improves after successful kidney transplantation. We used a computerized PRO monitoring to determine HRQOL reference values for outpatient kidney transplant patients. Routine PRO monitoring may facilitate the identification of patient issues relevant to treatment, and may contribute to improved symptom and side-effect management. Future studies providing detailed PRO values for stratified patient samples are needed.ZusammenfassungGrundlagenPatientInnenbezogene Ergebnisparameter (‚Patient-Reported Outcomes‘, PROs) sind wichtig im Therapiemanagement von NierentransplantpatientInnen. Obwohl mittlerweile zahlreiche Instrumente zur Beurteilung der gesundheitsbezogenen Lebensqualität (‚Health Related Quality of Life‘, HRQOL) zur Verfügung stehen, werden diese nur selten im Rahmen der klinischen Routine angewendet. Zielsetzung dieser Studie war daher die Entwicklung von Referenzwerten hinsichtlich der physischen und psychosozialen Belastungen von PatientInnen nach erfolgter Nierentransplantation.MethodikNierentransplantpatientInnen (n = 120) wurden im Rahmen ihrer postoperativen Nachsorge an einer nephrologischen Ambulanz konsekutiv rekrutiert und unter Anwendung eines computerunterstützten PRO-Assessments untersucht, um HRQOL-Referenzwerte zu erheben. Dieses Assessment umfasste klinisch relevante physische und psychische Symptome, die Adhärenz hinsichtlich der immunsuppressiven Therapie sowie die krankheitsspezifische Lebensqualität. Durchschnittlich wurde das PRO-Assessment 2,9 Mal pro PatientIn durchgeführt; über alle PatientInnen wurden gesamt 351 Assessments erhoben.ErgebnisseFür das PRO-Monitoring wurden Werte außerhalb des 10. und 90. Perzentils als klinisch relevant beurteilt, da bei diesen PatientInnen die Notwendigkeit einer supportiven Behandlung festgestellt wurde.SchlussfolgerungenMit kontinuierlich steigenden Überlebensraten nach erfolgter Nierentransplantationen gewinnt auch die HRQOL von Langzeit-TransplantationspatientInnen an Bedeutung, und es ist allgemein anerkannt, dass sich die HRQOL nach erfolgreicher Nierentransplantation verbessert. Wir verwendeten ein computerunterstütztes PRO-Monitoring, um Referenzwerte für ambulant behandelte NierentransplantpatientInnen zu entwickeln. Ein routinemäßiges PRO-Monitoring kann die Identifikation von behandlungsrelevanten Fragen der PatientInnen erleichtern und zu einem verbesserten Management behandlungsassoziierter Symptome und Nebenwirkungen beitragen. Zukünftige Studien, die eine Erfassung detaillierter PRO-Referenzwerte für stratifizierte PatientInnengruppen gewährleisten, sind erforderlich.

Is There a Link Between Physical Activity and Alcohol use

Physical activity (PA) is discussed as a protective factor as well as a risk factor for alcohol consumption. Therefore, this study aimed at exploring a potential relationship between these behaviors. In a population-based cross-sectional study of 15,474 people living in Austria physical activity, alcohol consumption and demographic variables were assessed. Regression analysis including age and gender revealed no significant relationship between PA and alcohol consumption for the total sample. More alcohol consumption was found in men with low PA-levels. Focusing on a part of the population who consumed alcohol the weekend before, men with high PA-levels reported more alcohol consumption in comparison to men with moderate PA-levels. This study does not support a common alcohol–physical activity relationship. Prevention programs to increase PA levels from low to moderate combined with a reduction of alcohol intake in men who regularly drink alcohol should be considered