Face Value

Face transplant patient can smile, blink again



By MARIA CHENG, AP Medical Writer
Fri Aug 22, 7:37 AM ET

LONDON - Transplanting faces may seem like science fiction, but doctors say the experimental surgeries could one day become routine. Two of the world's three teams that have done partial face transplants reported Friday that their techniques were surprisingly effective, though complications exist and more work is still needed.

"There is no reason to think these face transplants would not be as common as kidney or liver transplants one day," said Dr. Laurent Lantieri, one of the French doctors who operated on a man severely disfigured by a genetic disease.

In Friday's issue of the British medical journal Lancet, Lantieri and colleagues reported on their patient's status one year after the transplant. Chinese doctors also reported on their patient, two years after his surgery.

Last year, the French team operated on a 29-year-old man with tumors that blurred his features in a face that looked almost monstrous. They transplanted a new lower face from a donor, giving the patient new cheeks, a nose and mouth. Six months later, he could smile and blink.

The Chinese patient had part of his face ripped off by a bear. Surgeons in Xian gave him a new nose, upper lip and cheek from a donor. After a few months, he could eat, drink and talk normally, and returned home to Yunnan province in southwest China.

The patients were not identified although photos were included in the reports.

As is the case with all transplants, doctors use immune-suppressing drugs to prevent the recipient's body from attacking the donated tissue. In both face transplants, the patients started rejecting the transplanted tissue more than once. Their doctors solved the problem by juggling their medications.

The French patient now takes three pills a day to prevent rejection.

"That's less than most people with diabetes," said Lantieri, a plastic surgeon at the Henri Mondor-Albert Chenevier Hospital in suburban Paris.

Other doctors were reassured by the results.

"To be able to wean down the dosage of the medication in small amounts and relatively quickly, that is encouraging," said Dr. Bohdan Pomahac, a plastic surgeon at the Brigham and Women's Hospital in Boston.

Pomahac has permission to do a face transplant in the U.S., as do doctors at the Cleveland Clinic.

Experts have worried that if patients take lifelong anti-rejection drugs after a transplant, their cancer risk will jump. Some also predicted that rejection would destroy the face within a few years. Those fears seem to have been allayed, Pomahac said.

With three successful partial face transplants so far — including the world's first on a woman whose face was bitten off by a dog in France — doctors say that some of the surgery's initial uncertainties, like how functional the new face would be, are being answered.

For example, Lantieri's patient's face was paralyzed by tumors for more than a decade. The French team wasn't sure if nerves could grow after the transplant. But they discovered later their patient could blink, proving the brain was able to restore long-forgotten facial nerve connections.

Not everyone is convinced that face transplants are so revolutionary.

Dr. Patrick Warnke, a plastic surgeon at the University of Kiel in Germany, calls them a "dead-end road," because he doesn't think the rejection problem can be solved. Instead, he hopes to re-grow tissue from patients' own stem cells.

Still, the biggest obstacle to more face transplants may not be scientific, but social.

"When kidney transplants first began, people were reluctant to donate because there were a lot of cultural, social and religious issues," Pomahac said. "This is exactly the same scenario now."

Doctors plan to do more face transplants, but are having a hard time finding donors.

"Everyone says they would accept a face transplant if they were disfigured," Lantieri said. "The real question is, would you be a donor, or would you allow your family member to donate their face? That is the answer we need to change."

___

On the Net:

http://www.lancet.com

Philippine Physician Examination Results

TOP TEN PHYSICIANS Board Examinees

1. Marlon Diaz Garcia, Far Eastern University-Nicanor Reyes Medical Foundation -- 88.75%

2. Dave Anthony Pasetes Diomampo, Saint Louis University -- 88.17%

3. Gentry George Teng King, University of Santo Tomas -- 87.42%
Janice Jill Keng Lao, University of the Philippines-Manila -- 87.42%

4. Nemencio Jr Reyes Ronquillo, University of the Philippines-Manila -- 87.17%
Paolo Potato Villanueva, University of Santo Tomas -- 87.17%

5. Allan Louie Espino Cruz, University of Santo Tomas -- 86.92%

6. Philip Blanco Antiporta, University of Santo Tomas -- 86.58%

7. Ma Cristina Dela Cruz Briones, University of Santo Tomas -- 86.42%

8. Lemuel Benedict Robleza Non, University of the Philippines- Manila -- 86.17%
Sheila Jane Tan Zanoria, Cebu Institute of Medicine -- 86.17%

9. Angela Sacayan Apostol, University of the East Ramon Magsaysay Mem. Medical Ctr.-- 86.08%
Karel Ann Alipasa Espejo, University of the Philippines- Manila -- 86.08%

10. Grace Ann Mariano Nicolas, University of Santo Tomas -- 86.00%






Lists of New Physicians--

Dr. A

Dr. B

Dr. C

Dr. D

Dr. E

Dr. F

Dr. G

Dr. H

Dr. I

Dr. J

Dr. K

Dr. L

Dr. M

Dr. N

Dr. O

Dr. P

Dr. Q

Dr. R

Dr. S

Dr. T

Dr. U

Dr. V

Dr. W

Dr. Y

Dr. Z

The Nurse Notes: Old & New

A new nurse throws up when the patient does. An experienced nurse calls housekeeping when the patient throws up.

A new nurse wears so many pins on their name badge you can't read it. An experienced doesn't wear a name badge for liability reasons.

A new nurse charts too much. An experienced nurse doesn't chart enough.

A new nurse loves to run codes. An experienced nurse makes graduate nurses run to codes.

A new nurse wants everyone to know they are a nurse. An experienced nurse doesn't want anyone to know they are a nurse.

A new nurse keeps details and notes on a notepad. An experienced nurse writes on the back of their hands, paper scraps, napkins, etc.

A new nurse will spend all day trying to re-orient a paient. An experienced nurse will chart the patient is dis-orientated and restrain them.

A new nurse can hear any alarm at 50 yards. An experienced nurse can't hear any alarms at any distance.

A new nurse loves to hear abnormal heart and breath sounds. An experienced nurse doesn't even want to hear about them unless the pt is symptomatic.

A new nurse spends 2 hours giving a patient a bath. An experienced nurse lets the nurse's aide give the patient a bath.

A new nurse thinks people respect nurses. An experienced nurse knows everybody blames everything on the nurse.

A new nurse looks for blood on a bandage hoping they will get to change it. An experienced nurse knows a little blood never hurt anybody.

A new nurse looks for a chance "to work with the family". An experienced nurse AVOIDS the family.

A new nurse expects medications and supplies to be delivered on time. An experienced nurse expects them to be never delivered at all.

A new nurse will spend days bladder training an incontinent patient. An experienced nurse will insert a Foley catheter.

A new nurse always answer their phone. An experienced nurse checks their caller ID before answering their phone.

A new nurse thinks psychiatric patients are interesting. An experienced nurse thinks psychiatric patients are crazy.

A new nurse carries reference books in their bag. An experienced nurse carries magazines, lunch and something else in their bag.

A new nurse doesn't find this funny. An experienced nurse does.......


So, what are you?

On Organ Transplants and Medical Ethics

The issue of when to declare a person dead in order to harvest his/ her vital organs so that another person may live is a very delicate one no matter from which angle you look at it. An issue that's hard to ignore and poses a lot of questions and quite a dilemma to all the parties involved.

There’s an on- going debate as to when to declare potential organ donors dead. The old criterion of brain death as the sole determining factor is now being challenged by a lot of people in the medical field. Many of them are now advocating on a new protocol called Cardiocirculatory death as the new basis to declare a person dead.

The New England Journal of Medicine tackle this issue in its August edition and the Associated Press pick up the story. I copied the said article as the link to the NEJM website and posted them here.

So, read on…



Doctors debate when to declare organ donors dead

By STEPHANIE NANO, Associated Press Writer Thu Aug 14, 3:56 PM ET

NEW YORK - A report on three heart transplants involving babies is focusing attention on a touchy issue in the organ donation field: When and how can someone be declared dead?

For decades, organs have typically been removed only after doctors determine that a donor's brain has completely stopped working. In the case of the infants, all three were on life support and showed little brain function, but they didn't meet the criteria for brain death.

With their families' consent, the newborns were taken off ventilators and surgeons in Denver removed their hearts minutes after they stopped beating. The hearts were successfully transplanted, and the babies who got the hearts survived.

"It seemed like there was an unmet need in two situations," said Dr. Mark Boucek, who led the study at Children's Hospital in Denver. "Recipients were dying while awaiting donor organs. And we had children dying whose family wanted to donate, and we weren't able to do it."

The procedure — called donation after cardiac death — is being encouraged by the federal government, organ banks and others as a way to make more organs available and give more families the option to donate.

But the approach raises legal and ethical issues because it involves children and because, according to critics, it violates laws governing when organs may be removed.

As the method has gained acceptance, the number of cardiac-death donations has steadily increased. Last year, there were 793 cardiac-death donors, about 10 percent of all deceased donors, according to United Network for Organ Sharing. Most of those were adults donating kidneys or livers.

"It is a much more common scenario today that it would have been even five years ago," said Joel Newman, a spokesman for the network.

The heart is rarely removed after cardiac death because of worries it could be damaged from lack of oxygen. In brain-death donations, the donor is kept on a ventilator to keep oxygen-rich blood flowing to the organs until they are removed.

The Denver cases are detailed in Thursday's New England Journal of Medicine. The editors, noting the report is likely to be controversial, said they published it to promote discussion of cardiac-death donation, especially for infant heart transplants.

They also included three commentaries and assembled a panel discussion with doctors and ethicists. Many of the remarks related to the widely accepted "dead donor rule" and the waiting time between when the heart stops and when it is removed to make sure that it doesn't start again on its own.

In two of the Denver cases, doctors waited only 75 seconds; the Institute of Medicine has suggested five minutes, and other surgeons use two minutes.

State laws stipulate that donors must be declared dead before donation, based on either total loss of brain function or heart function that is irreversible. Some commentators contended that the Denver cases didn't meet the rule since it was possible to restart the transplanted hearts in the recipients.

"In my opinion, it's an open-and-shut case. They don't have irreversibility, and they don't have death," said Robert Veatch, a professor of medical ethics at Georgetown University.

But others argue the definition of death is flawed, and that more emphasis should be on informed consent and the chances of survival in cases of severe brain damage.

The Denver transplants were done over three years; one in 2004 and two last year. The three donor infants had all suffered brain damage from lack of oxygen when they were born. On average, they were about four days old when life support was ended.

In the first case, doctors waited for three minutes after the heart stopped before death was declared. Then the waiting time was reduced to 75 seconds on the recommendation of the ethics committee to reduce the chances of damage to the heart.

The authors said 75 seconds was chosen because there had been no known cases of hearts restarting after 60 seconds.

The hearts were given to three babies born with heart defects or heart disease. All three survived, and their outcomes were compared to 17 heart transplants done at the hospital during the same time but from pediatric donors declared brain dead.

"We couldn't tell the difference," said Boucek, who's now at Joe DiMaggio Children's Hospital in Hollywood, Fla.

There were nine other potential cardiac-death donors at the hospital during the same period, but there wasn't a suitable recipient in the area for their hearts, the report said.

The parents of one of the infants in the study, David Grooms and Jill Airington-Grooms, faced the devastating news on New Year's Day 2007 that their first child, Addison, had been born with little brain function and wouldn't survive.

After they decided to remove life support, they were asked about organ donation, and quickly agreed.

"The reality was Addison was not going to live," said Jill Airington-Grooms. "As difficult as that was to hear, this opportunity provided us with a ray of hope."

Three days later, Addison was taken off a ventilator and died. Her heart was given to another Denver-area baby, 2-month-old Zachary Apmann, who was born five weeks premature with an underdeveloped heart.

His parents, Rob and Mary Ann Apmann, said they were given several options and decided to wait for a transplant. They agreed they would accept a cardiac-death donation to increase Zachary's chances.

Mary Ann Apmann said she wasn't worried that the first available heart came from a cardiac-death donor.

"At that point, Zachary was so sick. We did have him at home. But we knew it wasn't much longer," she said.

After the transplant on Jan. 4, his condition quickly improved, and his blue lips disappeared.

Now, at 21 months: "He's just a crazy little kid who loves to play and swim and throw rocks," his mother said.

The two families haven't met yet but have been in touch through letters and calls. Coincidentally, David Grooms said he had an older brother who died three days after he was born in the 1970s with the same heart condition as Zachary's. The Grooms now have an 8-month-old daughter, Harper.

"Addison did only live three days in this world, but because of this, she lives on," her mother said.


Here's the link to--
The New England Journal of Medicine