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Kay SPJ, Leonard DA. Hand transplantation: can we balance the risks and benefits? J Hand Surg Eur Vol 2023; 48:208-213. [PMID: 36638129 PMCID: PMC9996778 DOI: 10.1177/17531934221132665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Asking 'can we balance the risks and benefits?' implies that a quantification of both risk and benefit in hand transplantation (here the terms hand transplant and hand transplantation refer to allotransplantation of the human hand or hand and part or all of the upper limb or limbs) is possible. Despite all we have learned in recent years about hand transplantation, much remains unknown. Even if reliable methods for quantification of risk and benefit were available, fundamental issues relating to effective communication across the gulf of lived experience between the (presumably) handed surgeon and the handless patient remain. Inherent complexities mean some consider hand transplantation an unsolved problem, but we believe the medical and technical considerations fall within the ambit of a competent multidisciplinary team, and that psychosocial and ethical challenges are open to management through robust frameworks for assessment and decision making, underpinned by an extended period of assessment and dialogue, with candid acknowledgement where uncertainty remains. This respects the patient's autonomy while addressing the need for a prolonged period of informing consent.Level of evidence: V.
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Affiliation(s)
- Simon P J Kay
- Hand Transplant UK, Leeds Teaching Hospitals Trust, Leeds, UK
| | - David A Leonard
- Hand Transplant UK, Leeds Teaching Hospitals Trust, Leeds, UK.,School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
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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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Kumnig M, Järvholm S. Vascularized composite allotransplantation: emerging psychosocial issues in hand, face, and uterine transplant. Curr Opin Organ Transplant 2022; 27:501-507. [PMID: 36227757 DOI: 10.1097/mot.0000000000001028] [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: 01/27/2023]
Abstract
PURPOSE OF REVIEW Currently, several research approaches warrant further attention, given the influence of psychosocial and bioethical issues on the success of upper extremity (UETx), face (FTx), and uterine transplantation (UTx). This review will highlight recent results of psychosocial and bioethical research in the field of vascularized composite allotransplantation (VCA), discuss most recent findings, provide information to guide future research approaches, and address the importance of a multicenter research approach to develop international standards. RECENT FINDINGS Previously published reports have tried to identify psychosocial factors that are essential to predict psychosocial outcomes and guide posttransplant treatment after VCA procedures. These issues in VCA are receiving more attention but we are still at the beginning of a systematic investigation of these domains. This review article summarizes the emerging psychosocial issues in UeTx, FTx, and UTx by including recent literature and current clinical practice. SUMMARY Even though different VCA procedures address different domains leading to specific psychosocial issues, common aspects impacting all forms of VCA would benefit of further coordination. These domains include clinical resources, public attitude and perception, bioethical considerations, adherence and rehabilitation, motives for VCA, information needs and multidisciplinary communication, body image, domains of quality of life, coping strategies, and follow-up care.
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Affiliation(s)
- Martin Kumnig
- Medical University of Innsbruck, Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Innsbruck, Austria
| | - Stina Järvholm
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
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