<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_459"
                     title="Murtha Dead at 77"
                     score="0.012"
                     href="http://www.medpagetoday.com/Washington-Watch/Washington-Watch/tb/18388?impressionId=1265752282337"
                     
      &lt;p&gt;Representative John P. Murtha (D-Pa.), 77, long-time chairman of the House Appropriations Subcommittee on Defense, died yesterday afternoon from complications following a planned laparoscopic cholecystectomy, according to a statement from the congressman&apos;s office.&lt;/p&gt;
&lt;p&gt;He had been admitted to the intensive care unit at Virginia Hospital Center in Arlington on Jan. 31, days after surgeons at the National Naval Medical Center in Bethesda, Md., accidentally nicked his intestine during the operation, according to a report in &lt;em&gt;The Washington Post&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;In that same report, Rep. Bob Brady (D-Pa.), a close friend of Murtha&apos;s, said the congressman developed an infection and fever.&lt;/p&gt;
&lt;p&gt;Citing a request for privacy from the Murtha family and patient privacy laws, a spokesperson for the National Naval Medical Center declined to provide information on the operation.&lt;/p&gt;
&lt;p&gt;In a statement, Virginia Hospital Center said Murtha died &quot;despite aggressive critical care interventions.&quot;&lt;/p&gt;
&lt;p&gt;According to the American College of Surgeons, risks of laparoscopic cholecystectomy include bleeding, infection, injury to the bile duct, liver injury, numbness, hernia at the incision site, anesthesia complications, and puncture of the intestine.&lt;/p&gt;
&lt;p&gt;Death is extremely rare in healthy individuals, occurring in no more than one per 1,000 patients, according to the college.&lt;/p&gt;
&lt;p&gt;A 2009 Cochrane Review comparing laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis found no difference in mortality in 38 trials. No patients died in the laparoscopic group and only 0.09% died in the open group.&lt;/p&gt;
&lt;p&gt;Severe complications were reported in 2.2% of the laparoscopic patients and 6.8% of the open patients.&lt;/p&gt;
&lt;p&gt;Murtha had recently become the longest serving member of Congress in Pennsylvania state history.&lt;/p&gt;
&lt;p&gt;First elected in 1974, Murtha, a former Marine, was the first Vietnam War combat veteran to serve in Congress, and he served as an advocate for the military throughout his career. He was also a prominent critic of the Iraq War.&lt;/p&gt;
&lt;p&gt;Murtha is survived by his wife, Joyce, and three children.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_331"
                     title="Physicians Must Treat Transplant Tourists"
                     score="0.008"
                     href="http://www.medpagetoday.com/Gastroenterology/LiverTransplantation/tb/18203?impressionId=1265752282337"
                     
      &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="0.006"
                     href="http://www.medpagetoday.com/Nephrology/KidneyTransplantation/tb/18200?impressionId=1265752282337"
                     
      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_277"
                     title="Liver Cell Culture System Might Test New HCV Drugs (CME/CE)"
                     score="0.002"
                     href="http://www.medpagetoday.com/InfectiousDisease/Hepatitis/tb/18133?impressionId=1265752282337"
                     
      &lt;p&gt;Researchers say they can now grow liver cells that maintain their functions long enough to test potential treatments for hepatitis C.&lt;/p&gt;
&lt;p&gt;The method uses so-called &quot;micropatterned co-cultures&quot; of primary human hepatocytes and supportive stroma, according to Sangeeta N. Bhatia, MD, PhD, of MIT, and colleagues.&lt;/p&gt;
&lt;p&gt;The co-cultures were able to support the entire life cycle of hepatitis C, including infection and replication, Bhatia and colleagues reported online in the &lt;em&gt;Proceedings of the National Academy of Sciences&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Coupled with reporter systems, the co-cultures have &quot;potential as a high-throughput platform for simultaneous assessment of in vitro efficacy and toxicity&quot; of antiviral drugs, the researchers said.&lt;/p&gt;
&lt;p&gt;The lack of such a system has been a roadblock to testing potential treatments for the virus, which affects 130 million people around the world, the researchers noted in the journal.&lt;/p&gt;
&lt;p&gt;Recently, they added, researchers have been able to propagate the virus in human hepatoma cells, but those cells, among other issues, proliferate abnormally and have disturbed gene expression.&lt;/p&gt;
&lt;p&gt;To overcome those obstacles, the researchers turned to primary hepatocytes, which would make a better test system, except that they are notoriously hard to maintain in culture.&lt;/p&gt;
&lt;p&gt;To form the co-cultures, Bhatia and colleagues seeded multi-well plates with human hepatocytes, followed several hours later by murine fibroblasts.&lt;/p&gt;
&lt;p&gt;&quot;If you just put cells on a surface in an unorganized way, they lose their function very quickly,&quot; Bhatia said in a statement. &quot;If you specify which cells sit next to each other, you can extend the lifetime of the cells and help them maintain their function.&quot;&lt;/p&gt;
&lt;p&gt;In a series of experiments, Bhatia and colleagues found:&lt;ul&gt; &lt;li&gt;Pseudoparticles bearing the hepatitis C glycoproteins E1 and E2 were able to infect between 1% and 3% of the hepatocytes, but did not infect the fibroblasts.&lt;/li&gt; &lt;li&gt;A hepatitis C virus modified to express a fluorescent protein persistently replicated over a two-week period.&lt;/li&gt; &lt;li&gt;Infectious virus was found in the co-culture supernatant from four through 12 days after initial infection.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The researchers also tested some possible therapeutics, including antibodies against viral entry factors and viral protease inhibitors, and were able to show effects on replication of hepatitis C.&lt;/p&gt;
&lt;p&gt;They were also able to test two or more drugs simultaneously to show the feasibility of combination drug studies using the system.&lt;/p&gt;
&lt;p&gt;Although the system is &quot;an important step forward,&quot; Bhatia and colleagues said, the co-cultures have some limitations, including the relatively inefficient uptake of virus.&lt;/p&gt;
&lt;p&gt;But they concluded that the co-cultures have the potential to be a &quot;highly valuable system for studies of (hepatitis C) biology.&quot;&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;This study had support from the Greenberg Medical Research Institute, the Ellison Medical Foundation, the Starr Foundation, the Ronald A. Shellow Memorial Fund, the Richard Salomon Family Foundation, and the NIH. The researchers said they had no conflicts.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_201"
                     title="Viral Cause of Appendicitis Called Unlikely (CME/CE)"
                     score="-0.004"
                     href="http://www.medpagetoday.com/Surgery/GeneralSurgery/tb/18048?impressionId=1265752282337"
                     
      &lt;p&gt;The cause of appendicitis remains a mystery, according to a study that discounts flu and intestinal infection as candidates.&lt;/p&gt;
&lt;p&gt;Influenza&apos;s distinctive seasonal variations don&apos;t match appendicitis hospitalization rates, according to researchers led by Edward H. Livingston, MD, of the University of Texas Southwestern Medical Center in Dallas.&lt;/p&gt;
&lt;p&gt;Enteric infections and rotavirus showed trends that were likewise dissimilar to those of perforating and nonperforating appendicitis, the researchers reported in the January issue of the &lt;em&gt;Archives of Surgery&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Most theories regarding the underlying causes of appendicitis rely on the notion that the appendix becomes obstructed,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;However, a more complex explanation appears necessary, they said, citing studies suggesting that blockage by hard pieces of stool called fecaliths is rare and that intraluminal pressures become elevated only in late-stage disease as inflammation progresses.&lt;/p&gt;
&lt;p&gt;Viral infection has been proposed as one explanation.&lt;/p&gt;
&lt;p&gt;And apparent &quot;outbreaks&quot; of appendicitis have been described in epidemiologic studies, suggesting an infectious etiology, Livingston&apos;s group noted.&lt;/p&gt;
&lt;p&gt;&quot;Viral infection of the appendix could cause mucosal ulceration followed by secondary bacterial infection of the appendix,&quot; they wrote. &quot;Alternatively, viral disease could result in lymphoid hyperplasia of the appendix with resultant obstruction and mucosal injury followed by bacterial infection.&quot;&lt;/p&gt;
&lt;p&gt;To explore the viral etiology scenario, the researchers used the National Hospital Discharge Survey to measure disease incidence trends from 1970 to 2006 based on admissions for appendicitis, flu, rotavirus, and enteric infections.&lt;/p&gt;
&lt;p&gt;They found a decline in overall annual incidence of both nonperforating appendicitis and influenza until 1995, after which the incidence for both rose in parallel.&lt;/p&gt;
&lt;p&gt;Perforating appendicitis, on the other hand, slowly rose in incidence over the years without a U-shaped curve.&lt;/p&gt;
&lt;p&gt;The incidence of perforating appendicitis, in fact, did not correlate with that of nonperforating appendicitis or any infectious disease studied.&lt;/p&gt;
&lt;p&gt;This suggested that &quot;perforated appendicitis has causative factors that are more complex than the simple delay in treating acute appendicitis,&quot; the researchers said.&lt;/p&gt;
&lt;p&gt;Rebecca C. Britt, MD, of Eastern Virginia Medical School in Norfolk, Va., commented that this was perhaps the most important implication of the study  --  that perforating and nonperforating appendicitis may be separate entities.&lt;/p&gt;
&lt;p&gt;Her critique accompanying the &lt;em&gt;Archives&lt;/em&gt; paper cautioned that further investigation is &quot;definitely warranted.&quot;&lt;/p&gt;
&lt;p&gt;But if confirmed, management patterns could shift, the researchers said.&lt;/p&gt;
&lt;p&gt;&quot;This has important clinical ramifications since appendectomy is generally performed as an emergency operation for fear of causing a perforation if treatment is delayed,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;For nonperforating appendicitis, the year-to-year association with influenza was discounted by the lack of within-year correlation.&lt;/p&gt;
&lt;p&gt;Appendicitis occurred throughout the year, with a &quot;slight tendency&quot; to occur more often in summer months whereas the flu was largely limited to winter.&lt;/p&gt;
&lt;p&gt;Furthermore, appendicitis is predominantly a disease of the young, while influenza disproportionately affects the older population, &quot;which goes against influenza as a proximate agent,&quot; Britt added.&lt;/p&gt;
&lt;p&gt;&quot;While perhaps influenza plays a role in the development of appendicitis by sensitizing the immune system to another viral agent, there remains no clear evidence that it is a causative agent for appendicitis,&quot; she wrote.&lt;/p&gt;
&lt;p&gt;Rotavirus infection also peaked in the winter months, without an apparent association with appendicitis incidence.&lt;/p&gt;
&lt;p&gt;Intestinal infection incidence matched the fairly even distribution of appendicitis throughout the year, but had a propensity to be higher in winter months rather than during the summer as was the case with appendicitis.&lt;/p&gt;
&lt;p&gt;Overall and peak hospital admission rates for intestinal infection began a yearly rise in 1989 and have been steadily increasing, which also did not match trends in appendicitis.&lt;/p&gt;
&lt;p&gt;Britt cautioned that the study relied on hospital discharge data, which is not likely to be a complete picture of incidence for viral illness because the vast majority of cases do not require hospitalization and many are not treated at all.&lt;/p&gt;
&lt;p&gt;&quot;Certainly this makes comparison onerous,&quot; she said.&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 researchers reported no conflicts of interest. Britt reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>
