<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_331"
                     title="Physicians Must Treat Transplant Tourists"
                     score="0.008"
                     href="http://www.medpagetoday.com/Gastroenterology/LiverTransplantation/tb/18203?impressionId=1265791041300"
                     
      &lt;p&gt;Patients who travel to foreign countries for organ transplants may return with more problems than they left with  --  and physicians here have a moral responsibility to treat them, researchers asserted in a transplant journal.&lt;/p&gt;
&lt;p&gt;&quot;Medical tourism&quot; has been on the rise as demand for organs outpaces supply and U.S. healthcare costs skyrocket, Thomas D. Schiano, MD, and Rosamond Rhodes, PhD, of Mount Sinai School of Medicine, reported in &lt;em&gt;Liver Transplantation&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Researchers have estimated that 300 medical tourism transplants occurred between 2004 and 2006, with more than 40% of transplant tourists residing in New York or California, which have only 18% of the total U.S. population. (See &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/12564&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/12564&quot; target=&quot;_blank&quot;&gt;International Medical Trade Turns Big Business&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Yet physicians have had little guidance on delivering care to these patients, and some transplant centers may turn them away, based on their actions, Schiano and Rhodes wrote.&lt;/p&gt;
&lt;p&gt;Their questions about treatment arose with a 46-year-old Chinese patient who had been put on a waiting list for a liver transplant here because of end-stage liver disease.&lt;/p&gt;
&lt;p&gt;The patient waited on the list for a year as his disease progressed from 18 points to 21 points on a 40-point severity scale.&lt;/p&gt;
&lt;p&gt;Rather than wait any longer, the patient flew to China and had a liver transplant there.&lt;/p&gt;
&lt;p&gt;Many transplanted organs in China come from executed prisoners, raising concerns about disease. Also, foreign transplants may be compromised by poor organ matching, unhealthy donors, and post-transplant infections, while some transplant centers abroad may use substandard surgical techniques, the researchers said.&lt;/p&gt;
&lt;p&gt;Foreign centers are also less likely to send patients home with adequate records and education than centers here, they asserted.&lt;/p&gt;
&lt;p&gt;Three months after his transplant in China, the patient came back to the clinic at Mount Sinai for follow-up care because he was about to run out of imunosuppressive medication.&lt;/p&gt;
&lt;p&gt;Two months after that, the patient developed sepsis due to diffuse intrahepatic biliary stricturing related to hepatic artery thrombosis.&lt;/p&gt;
&lt;p&gt;He required three additional hospitalizations for biliary sepsis, and at that point, retransplantation was the only viable option, Schiano said.&lt;/p&gt;
&lt;p&gt;However, members of the medical team had conflicting views about giving the patient another new liver.&lt;/p&gt;
&lt;p&gt;&quot;He was a medically suitable candidate,&quot; Schiano and Rhodes wrote, &quot;but there was disagreement about whether it was morally right to provide him with a transplant.&quot;&lt;/p&gt;
&lt;p&gt;The clinicians had few ethical guidelines to refer to in making their decision because many deal solely with moral issues related to donors and foreign medical standards.&lt;/p&gt;
&lt;p&gt;For example, the International Society for Heart and Lung Transplantation issued a statement against accepting organs from prisoners in April 2007, and the American Association for the Study of Liver Diseases and the International Liver Transplant Society endorsed similar policies.&lt;/p&gt;
&lt;p&gt;The American Medical Association&apos;s guidelines on medical tourism focus on best practices  --  for example, the procedure must be voluntary, it can&apos;t limit the alternatives offered to patients, and patients should only be referred to accredited institutions.&lt;/p&gt;
&lt;p&gt;While the United Network for Organ Sharing (UNOS)&apos;s statement on medical tourism does maintain that the medical community has an obligation to provide care for these patients, it stops short of offering further direction to transplant programs.&lt;/p&gt;
&lt;p&gt;&quot;Little guidance is provided for dealing with the specific problems of patients who choose to become transplant tourists,&quot; Schiano and Rhodes wrote.&lt;/p&gt;
&lt;p&gt;Instead, they created some ethical guidance for the &quot;moral quandary.&quot;&lt;/p&gt;
&lt;p&gt;Physicians have a &quot;professional obligation to promote the good of patients&quot; as well as a &quot;professional responsibility to adhere to medicine&apos;s commitment to nonjudgmental regard,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;Taken together, the moral principles of beneficence and nonjudgmental regard direct us to treat potential or returning transplant tourists as we would treat other patients under our care by focusing on providing the medical treatment and support they need,&quot; they continued.&lt;/p&gt;
&lt;p&gt;Physicians shouldn&apos;t deny patients post-transplantation care, and they ought to provide emergent care at the very least. They may refer the patient to another transplant center for long-term follow-up if they regard it as unethical to continue treatment.&lt;/p&gt;
&lt;p&gt;Patients should also be informed about the possibility of transplant tourism when they are not eligible for a transplant in the U.S. or when they are likely to die before reaching the top of the transplant list, Schiano and Rhodes wrote.&lt;/p&gt;
&lt;p&gt;&quot;Patients should not be threatened with abandonment by a center&apos;s refusal to provide care upon their return,&quot; they added.&lt;/p&gt;
&lt;p&gt;As for the 46-year-old patient who was transplanted in China, the Mount Sinai team decided a transplant program must treat all patients on the basis of their need &quot;regardless of what they might have done or how they secured their transplant organ.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Although [the patient] had a long, complicated transplantation course,&quot; they wrote, &quot;he is currently doing well.&quot;&lt;/p&gt;
&lt;p&gt;Mount Sinai has seen a total of nine patients who pursued transplants in China. Three of those had post-transplant problems but had been turned away elsewhere &quot;because several transplant centers in our region do not render care to transplant tourists,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Seven of those nine patients have hepatitis B. Another three had had a renal transplant in India, and subsequently developed liver failure, the authors reported.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_330"
                     title="Immune Cells Point to Skin Cancer Risk after Transplants (CME/CE)"
                     score="0.008"
                     href="http://www.medpagetoday.com/Nephrology/KidneyTransplantation/tb/18200?impressionId=1265791041300"
                     
      Monitoring two types of immune cells in kidney transplant recipients might identify patients with an increased risk of skin cancer, British investigators reported.&lt;br&gt;
&lt;br&gt;Increased levels of T-regulatory cells (Tregs) more than doubled the risk of squamous cell cancer of the skin. Decreased levels of natural killer (NK) cells were associated with more than a five-fold increased risk of skin cancer.&lt;br&gt;
&lt;br&gt;Both immune parameters had substantially greater predictive power than a history of squamous-cell skin cancer, according to an online report in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt; by a team of Oxford University investigators.&lt;/p&gt;
&lt;p&gt;&quot;Squamous cell cancer of the skin affects about 30% of kidney transplant patients after 10 years of immunosuppression,&quot; Robert Carroll, MD, currently of Queen Elizabeth Hospital in Woodville, Australia, observed in a statement.&lt;/p&gt;
&lt;p&gt;&quot;A small number of patients develop multiple skin cancers per year, but there is no laboratory test to determine which transplant recipients will develop multiple skin cancers in the future.&quot;&lt;/p&gt;
&lt;p&gt;&quot;If a test can confirm high risk of skin cancer development, this may help clinicians to tailor immunosuppressive regimens for individual patients,&quot; he added.&lt;/p&gt;
&lt;p&gt;Long-term immunosuppression, such as that required for transplant recipients, confers an increased risk of squamous-cell skin cancer.&lt;/p&gt;
&lt;p&gt;Estimates of the magnitude have ranged as high as 200 times greater than the general population, the authors wrote. Additionally, 3% of organ transplant recipients require extensive plastic surgery each year as a result of skin cancer lesions.&lt;/p&gt;
&lt;p&gt;Age at transplantation and the immunosuppression dosage are the principal determinants of skin-cancer risk, and the dosage of immunosuppression also influences the risk of metastasis from squamous-cell cancer of the skin.&lt;/p&gt;
&lt;p&gt;In the general population, cancer has been associated with increased levels of Tregs, including CDR&lt;sup&gt;+&lt;/sup&gt;CD25&lt;sup&gt;high&lt;/sup&gt;FOXP3&lt;sup&gt;+&lt;/sup&gt; and CD8&lt;sup&gt;+&lt;/sup&gt;CD28&lt;sup&gt;-&lt;/sup&gt; cells. The same types of cells could play a role in the risk of skin cancer among organ transplant recipients, the authors wrote.&lt;/p&gt;
&lt;p&gt;Within the tumor microenvironment, Tregs may impair the antitumor activity of CD8&lt;sup&gt;+&lt;/sup&gt; and NK cell. However, in organ transplant recipients, Tregs help control or prevent rejections and may help improve long-term outcomes.&lt;/p&gt;
&lt;p&gt;Different immunosuppressive drugs affect Tregs differently, the authors continued. Sirolimus (Rapamune), for example, increases the number of FOXP3&lt;sup&gt;+&lt;/sup&gt; cells, whereas cyclosporine decreases Treg numbers.&lt;/p&gt;
&lt;p&gt;&quot;Tregs have not been assessed in relation to cancer after transplantation,&quot; the authors wrote. &quot;We therefore investigated the hypothesis that squamous-cell cancer in kidney transplant recipients would be associated with an increased number of Tregs.&quot;&lt;/p&gt;
&lt;p&gt;To examine the hypothesis, investigators phenotyped peripheral blood from 65 kidney transplant recipients with squamous skin cancer and 51 recipients without skin cancer, matched for age, sex, and duration of immunosuppression.&lt;/p&gt;
&lt;p&gt;They also quantified lymphocyte populations in skin cancer lesions from a subset of 25 patients and matched them with 25 other nontransplant patients with squamous cell cancer of the skin.&lt;/p&gt;
&lt;p&gt;The kidney transplant recipients had a median follow-up of 340 days. The investigators found that a concentration of &amp;gt;35 peripheral FOXP3&lt;sup&gt;+&lt;/sup&gt;CD4&lt;sup&gt;+&lt;/sup&gt;CD127&lt;sup&gt;low&lt;/sup&gt; regulatory T cells/&amp;#181;L was associated with a hazard ratio for squamous cell skin cancer of 2.48 (95% CI 1.04 to 5.98).&lt;/p&gt;
&lt;p&gt;An NK cell count &amp;lt;100 cells/&amp;#181;L was associated with a skin cancer hazard ratio of 5.6 (95% CI 1.31 to 24). A history of squamous cell cancer of the skin increased the risk of skin cancer recurrence by a third (HR 1.33, 95% CI 1.15 to 1.53).&lt;/p&gt;
&lt;p&gt;&quot;If similar immune phenotypes are predictive in other kidney transplant recipient populations, then immune phenotype method has the potential to inform immunosuppressive regimen manipulation in kidney transplant recipients at high risk for developing multiple squamous cell cancers,&quot; the authors concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors had no relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_342"
                     title="Stem Cell Transplant Source Does Not Affect Long-Term Leukemia Outcomes (CME/CE)"
                     score="0.006"
                     href="http://www.medpagetoday.com/HematologyOncology/Leukemia/tb/18220?impressionId=1265791041300"
                     
      Ten-year survival rates after allogeneic stem-cell transplant in leukemia patients were the same whether the cells came from donors&apos; bone marrow or peripheral blood, researchers conducting a randomized trial said.&lt;br&gt;
&lt;br&gt;Among 329 patients participating in the trial, overall survival was 49.1% for those receiving peripheral blood progenitor cell transplants versus 56.5% among those receiving bone marrow transplants (&lt;em&gt;P&lt;/em&gt;=0.27), reported Birte Friedrichs, MD, of Charite-Campus Benjamin Franklin in Berlin, Germany, and colleagues online in &lt;em&gt;Lancet Oncology&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;There was also no significant difference over the long term in performance status, ability to work, hematopoietic function, development of bronchiolitis obliterans, or secondary malignancy rates.&lt;/p&gt;
&lt;p&gt;Ten-year leukemia-free survival rates were somewhat better with bone marrow transplant in patients with acute myeloid and acute lymphoblastic leukemia (AML, ALL) but the differences did not reach statistical significance. There was no apparent difference in disease-free survival for those with chronic myeloid leukemia (CML).&lt;/p&gt;
&lt;p&gt;But significantly more transplants involving peripheral blood progenitor cells led to chronic graft-versus-host disease (GVHD), seen in 73% of patients compared with 56% among those receiving bone marrow transplants (&lt;em&gt;P&lt;/em&gt;=0.021).&lt;/p&gt;
&lt;p&gt;As a result, significantly more patients receiving peripheral blood cell transplants were on immunosuppressant therapy five years postprocedure (26% versus 12%, &lt;em&gt;P&lt;/em&gt;=0.024).&lt;/p&gt;
&lt;p&gt;Noting that subgroup analyses did show notable differences in survival in patients with acute leukemias, Friedrichs and colleagues added, &quot;These data alone do not currently support the return to bone marrow transplantation for specific indications, but we believe that long-term data from other randomized trials should be collected.&quot;&lt;/p&gt;
&lt;p&gt;Patients in the study were participating in a parallel-group trial of the two transplant types, with transplants conducted from 1995 to 1999. Participants were adults up to age 55 with CML in second remission or newly diagnosed ALL or AML.&lt;/p&gt;
&lt;p&gt;Specific overall and leukemia-free survival rates for leukemia subtypes after 10 years were: &lt;ul&gt; &lt;li&gt;ALL: 32.9% overall and 28.3% disease-free with bone marrow transplant, 18.2% overall and 13.0% disease free with peripheral blood transplant (&lt;em&gt;P&lt;/em&gt;=0.071 and 0.12, respectively)&lt;/li&gt; &lt;li&gt;AML: 65.3% overall and 62.3% disease-free with bone marrow transplant, 52.3% overall and 47.1% disease-free with peripheral blood transplant (&lt;em&gt;P&lt;/em&gt;=0.24 and 0.16, respectively)&lt;/li&gt; &lt;li&gt;CML: 61.1% overall and 40.2% disease-free with bone marrow transplant, 56.8% overall and 48.5% disease-free with peripheral blood transplant (&lt;em&gt;P&lt;/em&gt;=0.81 and 0.60, respectively)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The failure to find significant differences may have been related to small patient numbers in these subgroups: 64 with AML, 19 with ALL, and 89 with CML.&lt;/p&gt;
&lt;p&gt;Transplant types were performed at equal rates in patients with AML and CML, but the randomization was unbalanced in ALL patients, with 15 of 19 receiving bone marrow transplants.&lt;/p&gt;
&lt;p&gt;Chronic GVHD was the most common cause of death in the study, killing nine patients (of whom six received peripheral blood progenitor cell transplants). Six patients died of recurrent leukemia. The remaining nine deaths were distributed among several causes including hemorrhage, bronchial cancer, suicide, and traffic accident.&lt;/p&gt;
&lt;p&gt;Patients with chronic GVHD after peripheral blood cell transplants were more likely to have skin, liver, and oral mucosal involvement compared with GVHD following bone marrow transplant, with relative risks ranging from 1.49 to 1.85.&lt;/p&gt;
&lt;p&gt;Factors significantly associated with better overall survival included a diagnosis of ALL (HR 2.90 versus other diagnoses, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), age of 40 or more (HR 1.55 versus age under 40, &lt;em&gt;P&lt;/em&gt;=0.009), and use of total body irradiation instead of a chemotherapy-only myeloablative regimen before transplant (HR 1.55, &lt;em&gt;P&lt;/em&gt;=0.014).&lt;/p&gt;
&lt;p&gt;The researchers noted that many of their findings, including the apparent benefit of preparative total body irradiation, were consistent with earlier studies.&lt;/p&gt;
&lt;p&gt;Limitations to the study included loss to follow-up of 26 patients, lack of detailed data on surviving participants&apos; quality of life, and changes in treatment since the study began.&lt;/p&gt;
&lt;p&gt;Friedrichs and colleagues noted that the introduction of tyrosine kinase inhibitors and new approaches to pretransplant conditioning have altered practice significantly.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No external funding for the study was received.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_2210"
                     title="Infant Heart Transplant Need Not Be Permanent"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Surgery/Transplantation/tb/15069?impressionId=1265791041300"
                     
       WHEELING, W.Va., July 14 -- Doctors have found that a baby&apos;s severely damaged heart eventually recovered fully after a donor heart was grafted onto it, allowing the second organ to be removed later.
              &lt;p&gt; 
              &lt;p&gt;The case suggests that this type of &quot;heterotopic&quot; transplant may have significant advantages over replacing the original heart with a donor organ in small children.
              &lt;p&gt; 
              &lt;p&gt;Primarily, it means that immunosuppressive therapy need not last a lifetime.
              &lt;p&gt; 
              &lt;p&gt;In 1995, British surgeons led by Magdi Yacoub, MD, of Imperial College London, fused a donor heart with two-year-old Hannah Clark&apos;s own heart, which was failing because of severe dilated cardiomyopathy.
              &lt;p&gt; 
              &lt;p&gt;However, the girl suffered recurring bouts of Epstein-Barr-virus-associated post-transplant lymphoproliferative disorder (EBV-PTLD) -- resulting from the immunosuppressive regimen given to all transplant recipients -- as well as rejection of the donor heart despite the immunosuppression.
              &lt;p&gt; 
              &lt;p&gt;These complications, along with evidence that the girl&apos;s own heart had recovered near-normal function, led her physicians to remove the donor organ in February 2006.
              &lt;p&gt; 
              &lt;p&gt;Reporting online today in &lt;em&gt;The Lancet&lt;/em&gt;, Dr. Yacoub and colleagues said Clark, now 16, has made a full and successful recovery, &quot;with normal heart function and evidence of complete clinical and radiological remission from her PTLD 39 months after dividing the heterotopic heart.&quot;
              &lt;p&gt; 
              &lt;p&gt;The physicians said the case could lead to improvements in the management of cardiomyopathy in infants as well as PTLD.
              &lt;p&gt; 
              &lt;p&gt;Clark was first diagnosed with dilated cardiomyopathy when she was eight months old; medical therapies failed to halt deterioration of her condition, which is seen in about 1.2 to 1.4 of every 100,000 infants.
              &lt;p&gt; 
              &lt;p&gt;Shortly after Clark&apos;s second birthday, she received a second heart from a five-month-old child.
              &lt;p&gt; 
              &lt;p&gt;Such a heart would be inadequate for orthotopic transplant because of its small size. Dr. Yacoub and colleagues pointed out that, by using a heterotopic procedure in which the donor organ is fused with the recipient&apos;s own heart, the shortage of size-matched donor hearts for young children can be partly overcome.
              &lt;p&gt; 
              &lt;p&gt;The operation corrected the girl&apos;s heart failure, with the donor heart doing most of the work initially. The native heart slowly gained function, however, reaching an ejection fraction of 70% by the end of 2000.
              &lt;p&gt; 
              &lt;p&gt;But at about that time, Clark developed EBV-PTLD. The episodes continued despite reduced doses of cyclosporine and elimination of azathioprine.
              &lt;p&gt; 
              &lt;p&gt;Different treatments for the PTLD episodes were tried with varying success. Combinations of chemotherapeutic drugs such as cyclophosphamide, vincristine, and doxorubicin were given in combination with prednisolone or biologic drugs such as rituximab (Rituxan) and elsilimomab. Autologous EBV cytotoxic T lymphocyte infusions were given as well.
              &lt;p&gt; 
              &lt;p&gt;Eventually, Dr. Yacoub and colleagues found that the donor heart was failing, with a fractional shortening of 10%, apparently because of rejection.
              &lt;p&gt; 
              &lt;p&gt;Faced with the choice of stepping up immunosuppression -- which could trigger another PTLD relapse -- or allowing the rejection process to continue, the physicians decided to remove the donor heart altogether.
              &lt;p&gt; 
              &lt;p&gt;At last follow-up, they reported, Epstein-Barr loads were minimal and Clark&apos;s cardiac function and daily life appeared normal. No further recurrence of PTLD has been seen.
              &lt;p&gt; 
              &lt;p&gt;In a statement released by &lt;em&gt;The Lancet&lt;/em&gt;, Clark said her life was vastly improved.
              &lt;p&gt; 
              &lt;p&gt;&quot;Thanks to this operation, I&apos;ve now got a normal life just like all of my friends. I&apos;ve just done my [high school exams], and I&apos;ve now got a Saturday job looking after animals, which I couldn&apos;t have done before,&quot; she said.
              &lt;p&gt; 
              &lt;p&gt;Dr. Yacoub and colleagues said the case highlights the potential for heterotopic transplant as a means to facilitate recovery of the recipient&apos;s own heart in pediatric cardiomyopathy.
              &lt;p&gt; 
              &lt;p&gt;&quot;Unloading&quot; the native heart for a period of time may allow for &quot;reverse remodeling,&quot; they said, adding that such effects have been seen in adults receiving left ventricular assist devices.
              &lt;p&gt; 
              &lt;p&gt;&quot;Further application of this strategy in children using biological or newly available mechanical devices is warranted,&quot; they said.
              &lt;p&gt; 
              &lt;p&gt;&quot;We feel that from the evidence obtained from our case, regression of secondary elevated pulmonary vascular resistance is extremely slow and could take up to a year or more. Continued improvements in pediatric left ventricular assist devices could make mechanical unloading possible in the future.&quot;
              &lt;p&gt; 
              &lt;p&gt;With regard to EBV-PTLD, Dr. Yacoub and colleagues said their findings in the Clark case suggested that autologous cytotoxic T-lymphocyte infusions are not effective in transplant recipients.
              &lt;p&gt; 
              &lt;p&gt;&quot;Even low-dose immunosuppression might prevent the function of EBV-specific T cells in vivo, a finding that has important implications for adoptive immunotherapy for PTLD,&quot; they wrote.
              &lt;p&gt; 
              &lt;p&gt;Other approaches are clearly risky as well. Reduction of immunosuppression can allow rejection to occur and chemotherapy is toxic. The researchers said Clark&apos;s treatment involving both approaches was effective at inducing remissions but failed to prevent relapses.
              &lt;p&gt; 
              &lt;p&gt;On the other hand, they noted, complete cessation of immunosuppression -- made possible by the removal of the donor organ -- &quot;can lead to long-term remission of apparently intractable PTLD.&quot;
              &lt;p&gt; 
              &lt;p&gt; 
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt; No external funding for the work was reported.
              &lt;p&gt; 
              &lt;p&gt;The authors said they had no conflicts of interest.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_2635"
                     title="Hand Transplants Get Good Review"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Surgery/Transplantation/tb/15625?impressionId=1265791041300"
                     
      Hand transplantation has joined the prosthesis and autologous reconstruction as an option for selected amputees, researchers concluded from a small clinical series with long-term follow-up.&lt;br&gt;
&lt;br&gt;Composite tissue allotransplantation has achieved functionality similar to that of replantation, and graft survival and quality of life have exceeded expectations, according to Christina L. Kaufman, PhD, of the Christine M. Kleinert Institute for Hand and Microsurgery in Louisville, Ky.&lt;br&gt;
&lt;br&gt;During follow-up for as long as 10 years, all five patients in the series regained reasonable function, including one patient who had progressive improvement for six years.&lt;/p&gt;
&lt;p&gt;&quot;It is possible to achieve prolonged survival of a transplanted hand using the same kind of drugs that are used in kidney transplant recipients,&quot; the authors wrote the current issue of the &lt;em&gt;Journal of Rehabilitation Research &amp;amp; Development&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Reasonable function does return,&quot; they added. &quot;We were worried that our patients might injure their hands while they were waiting for protective sensation to return, but that has not been the case.&lt;/p&gt;
&lt;p&gt;&quot;None of our patients developed ulcers or chronic injuries at any time during sensory recovery.&quot;&lt;/p&gt;
&lt;p&gt;Since 1964, more than 40 hand transplantations have been performed worldwide, including 12 patients who underwent transplantation of both hands.&lt;/p&gt;
&lt;p&gt;Investigators at the Louisville center initiated the first clinical trial of hand transplantation in the U.S. Their report covered the outcomes of five patients who have undergone composite tissue allotransplantation at the center since 1999.&lt;/p&gt;
&lt;p&gt;The five are white men ages 32 to 54. Two lost hands in fireworks accidents, two had work-related accidents, and the one had a firearm accident. The transplantation procedures occurred from two years to more than 30 years after amputation.&lt;/p&gt;
&lt;p&gt;All patients require lifetime immunosuppression. Two patients received a standard, three-drug regimen (tacrolimus, mycophenolate mofetil, and prednisone). The remaining patients received Campath 1H for induction, followed by maintenance with tacrolimus and mycophenolate mofetil.&lt;/p&gt;
&lt;p&gt;The authors characterized all five surgical procedures as uneventful. Three of the five patients have had one or more severe rejection episodes during long-term follow-up. The remaining two patients have had no severe rejection episodes during follow-up for two and six months.&lt;/p&gt;
&lt;p&gt;&quot;Continual follow-up on our current patients not only maintains their [graft] survival but also builds on our previous research, updating and improving all aspects of the transplantation process, from patient selection to postoperative care,&quot; the authors concluded. &lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors had no relevant financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>