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<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=1265738609585"
                     
      &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=1265738609585"
                     
      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="20090101_19_2797"
                     title="FDA Warns of New Risk on Transplant Drug"
                     score="-0.005"
                     href="http://www.medpagetoday.com/ProductAlert/Prescriptions/tb/15845?impressionId=1265738609585"
                     
      &lt;p&gt;WASHINGTON --  The FDA has updated prescribing information for the anti-rejection drug mycophenolic acid (myfortic) to reflect a danger of pure red cell aplasia (PCRA).&lt;/p&gt;
&lt;p&gt;The new label explains that the risk of PCRA increases in patients combining mycophenolic mofetil, the active ingredient in mycophenolic acid, with other immunosuppressive agents.&lt;/p&gt;
&lt;p&gt;Patients who reduced or ceased therapy with mycophenolic acid after developing PCRA reversed their condition in some instances, but the FDA noted that this may put organ grafts at risk.&lt;/p&gt;
&lt;p&gt;Healthcare professionals are asked to conduct blood tests on patients before starting drug treatment to check for signs of infection, unexpected bruising, or bleeding.&lt;/p&gt;
&lt;p&gt;The news comes two months after the FDA released a blanket warning about several immunosuppressant drugs, including mycophenolic acid, citing an increased risk of opportunistic or latent infection. (See &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/15086&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/15086&quot; target=&quot;_blank&quot;&gt;FDA Wants Stronger Warning on Immunoauppressants&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Mycophenolic acid is contraindicateded in patients with hypersensitivity to mycophenolate sodium, mycophenolate mfetil, or any of its exipients.&lt;/p&gt;
&lt;p&gt;Mycophenolic acid is produced by Novartis.&lt;/p&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=1265738609585"
                     
      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>
    <recommendedItem id="20090101_19_2654"
                     title="Kidney Transplants from Very Young Donors Succeed (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Nephrology/KidneyTransplantation/tb/15656?impressionId=1265738609585"
                     
      &lt;p&gt;Adults who receive a single kidney from a very young donor can survive with minimal complications, so that splitting pairs of kidneys from young donors may increase the number of patients who receive transplants, a new study found.&lt;/p&gt;
&lt;p&gt;Patients who received a single kidney from a donor under the age of 5 had no significant difference in long-term survival after five years than patients who received single kidneys from donors between the ages of 5 and 10 (&lt;em&gt;P&lt;/em&gt;=0.73), according to Rubin Zhang, MD, of the Tulane Abdominal Transplant Institute, and colleagues.&lt;/p&gt;
&lt;p&gt;However, compared to transplants from older donors, those from younger donors had slightly higher rejection rates (25% versus 18%; &lt;em&gt;P&lt;/em&gt;=0.67) and required ureteral stents to be inserted more often (73% versus 38%), the researchers reported online in the August 20 &lt;em&gt;Clinical Journal of the American Society of Nephrology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;To our knowledge, this is the first study to compare directly long-term outcomes of using single pediatric kidneys from very young donors with those from older pediatric donors,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;Although there were higher incidences of acute rejection and vascular thrombosis that caused three more graft losses in the younger donor group, there were equivalent patient survival and long-term graft survival in both groups.&quot;&lt;/p&gt;
&lt;p&gt;More than 85,000 people in the U.S. are waiting for kidney transplants, according to the Organ Procurement and Transplantation Network, which maintains the official national waiting list.&lt;/p&gt;
&lt;p&gt;Each year 4,000 people die while waiting for a kidney transplant, and guidelines for who can donate kidneys have gradually broadened to included younger children as demand for transplants has risen.&lt;/p&gt;
&lt;p&gt;Transplants from children under the age of 5 typically involve transferring both kidneys to the donor, a procedure known as &lt;em&gt;en block&lt;/em&gt; transplant, because transferring both small kidneys into an adult&apos;s larger body theoretically provides better kidney function.&lt;/p&gt;
&lt;p&gt;&quot;The minimum donor age or body weight that allows successfully splitting &lt;em&gt;en block&lt;/em&gt; kidneys for adult recipients remains controversial,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;They noted, however, that the pairs of kidneys from very young donors could help address the extraordinary demand for the organs. &quot;Splitting &lt;em&gt;en block&lt;/em&gt; kidneys and transplanting a solitary pediatric kidney into one recipient could double the number of kidney transplants from one donor,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;To explore whether a single kidney from a very young child could provide adequate renal function for an adult, the researchers transplanted kidneys from 50 pediatric donors into 79 adults at the Tulane Abdominal Transplant Institute&lt;strong&gt; &lt;/strong&gt;between January 1996 and June 2007.&lt;/p&gt;
&lt;p&gt;Half of the adults (40 patients, average age 44 &amp;#0177; 16.5 years) received kidneys from children who died before reaching the age of 5, and the other half (39 patients, average age 45.5 &amp;#0177; 16.2 years) received transplants from children who died between the ages of 5 and 10.&lt;/p&gt;
&lt;p&gt;Overall, kidney function improved dramatically in both groups. More patients who received kidneys from the younger donors needed ureteral stents to help drain urine from the kidney, but the numbers of serious complications that required surgical correction were about the same for both groups.&lt;/p&gt;
&lt;p&gt;At the long-term followup (average of five years), 84% of the patients who received a kidney from the youngest donors were still alive, and 87% in the other group were still alive.&lt;/p&gt;
&lt;p&gt;The youngest donor in the study was a deceased 9-month-old girl who weighed 8 kilograms. Both of her transplanted kidneys remained functional in the two adult recipients six years after the transplant.&lt;/p&gt;
&lt;p&gt;While the researchers acknowledged that data collected from organ registries has shown worse outcomes in single pediatric kidney transplants when the donors were younger than 5 years or weighed less than 21 kilograms, they concluded that their study shows otherwise.&lt;/p&gt;
&lt;p&gt;&quot;Single pediatric kidney transplants from donors who are younger than 5 [years] can be used with acceptable complications and good long-term outcomes as those from older pediatric donors,&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 reported no financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>