Monday, February 29, 2016

First U.S. Uterine Transplant is History

The first uterine transplant in the U.S. was performed recently by a team of surgeons at the Cleveland Clinic. The 26-year-old recipient was unable to have children of her own because she suffered from uterine factor infertility (UFI), meaning either that she didn't have a uterus or her uterus was non-functional. The donated uterus came from a deceased donor.

This was just the first of ten uterine transplants planned over the next five years as part of a clinical trial funded by the government. The ten patients will be chosen from a pool of volunteers according to strict criteria described in the clinical trial summary document. The donated uteri will come from cadavers. Once the first ten transplants have been completed and fully evaluated, it will be decided whether the procedure should become more widely available.

The possibility that uterine transplants might become routine raises important ethical issues related to safety for the recipient. Substantial counseling and psychological evaluation may be needed. After all, uterine transplant would be an elective procedure undertaken only to allow a woman to experience childbirth, and not to improve her health or prolong her life.

Then there's the thorny issue of who should pay for an elective transplant procedure; the patient, or health insurance? (See this blog Nov. 23, 2015).

Thursday, February 25, 2016

Transplanting HIV-Positive Organs

If all goes according to plan, there will soon be a significant increase in the number of human organs available for transplantation. That's because the United Network for Organ Sharing (UNOS), the system that oversees organ transplants in this country, has given final approval to begin transplanting organs from HIV positive donors into HIV recipients.

Twenty years ago, HIV-positive patients were not considered good candidates for organ transplantation because they were not expected to live very long. But over the years better treatment of HIV has meant that HIV-positive patients can live nearly a normal life. So although HIV-positive people are now eligible for organ transplants, there are not nearly enough HIV-negative organs available to satisfy a rapidly growing demand. (Traditionally, organs from donors who test positive for HIV are rejected because of the fear of transferring HIV to the recipient.)

Prior to 2013 it was illegal to even conduct research using HIV-positive organs. Then in 2013 the government passed the HIV Organ Policy Equity (HOPE) act, allowing such research for the first time. The research showed conclusively that HIV-positive organs could be effectively and safely transplanted into HIV-infected recipients. The first such transplant is likely to occur within months. The availability of HIV-infected organs dramatically increases the pool of organs available to HIV-positive recipients (they will now be eligible for organs that HIV-negative recipients are not). It will also improve the situation for potential recipients who are not HIV-positive, because there will be fewer HIV-positive recipients competing for the available HIV-negative organs.

It's win-win for all potential organ recipients, regardless of HIV status. The government should be congratulated for their vision on this one.

Wednesday, February 17, 2016

Does Lumosity's Brain Training System Work?

Can an online brain training program (i.e. Lumosity) improve memory or help patients with mild cognitive impairment or dementia? That's what the company claimed until the Federal Trade Commission (FTC) made them stop. The FTC says that Lumosity's claims for its product are "unsubstantiated" because they are not backed by scientific proof, and has asked the company to quit making such claims. (The company has done so.) Lumosity will pay a fine of about two million dollars, according to an article in The New York Times.

But don't expect this to be the end of it. The fundamental issue of how to determine whether brain training actually works remains with us. People who have undergone brain training often "feel" that they have improved, but have they really? When people know they've purchased the program and undergone the training, it is quite natural for them to feel that they have improved. It's the well-known placebo effect. But how would one prove any improvement, even if it had occurred? If tests similar to the training games are used for assessment, or if the same types of tests are used for "before" and "after" assessments, then how would one know that any improvement isn't just the result of familiarity with the type of assessment test? In addition, do better speeds or scores on a computer game translate to a delay of memory loss or the development of dementia over many decades? Finally, does brain training improve cognitive ability in any more general way, such as making better decisions or being a more successful student? The experts aren't yet convinced that it does, hence the FTC's action.

Any company that can convince the scientific community and government regulators (such as the FTC) that it actually can train the brain to perform better in the long-term will make a lot of money. I'd be one of the first to buy their product. But we're not there yet.

Friday, February 12, 2016

Sexual Transmission of the Zika Virus

A recent case of Zika virus infection in a man whose sexual partner returned from Venezuela with a Zika virus infection raises the distinct possibility that it may be possible for the virus to be transmitted sexually. How easily it is transmitted via sexual contact, and at what point during an infection it may be transmitted, isn't known. But the finding is cause for concern because it means that an outbreak could spread beyond areas in which the Zika-transmitting mosquito is found. The World Health Organization (WHO) will be following this latest development closely.

In related news, laboratory tests have detected the Zika virus in the saliva and urine of at least two people with Zika virus infections. Most people don't come in direct contact with urine, but person-to-person saliva contact is another matter. At this time it isn't known whether Zika infection via contact with saliva is even possible. Nevertheless, revelers at Brazil's annual street festival known as Carnival are being urged to forego the common practice of kissing total strangers, just as a precaution.

We need to know a lot more about this virus, that's for sure.

Tuesday, February 9, 2016

CDC Recommends No Alcohol Without Birth Control

The U.S. Centers for Disease Control and Prevention (CDC) is now recommending that women of reproductive age (roughly 15-44) who are not on birth control should not drink ANY alcohol, ever. That may be a tough sell. Many women of reproductive age do not have easy access to birth control; in most states it is available only by a doctor's prescription.

The new recommendation is based on the knowledge that no amount of alcohol is safe for the fetus; alcohol can cause several types of permanent damage to the fetus, collectively called fetal alcohol spectrum disorders (FASD). Many pregnancies are unplanned, and the woman may not know she is pregnant for 4-6 weeks. These 4-6 weeks are critical when it comes to the possible damage done by alcohol.

Waiting to stop drinking until you know you are pregnant is just asking for trouble. If you want to drink and don't want to take a chance of damaging your future child, get on birth control until you're ready to give up alcohol for nine months.

For more, review the CDC web page on the subject.

Wednesday, February 3, 2016

An Effective Treatment for Multiple Sclerosis?

Multiple sclerosis is a progressive disease in which the patient's immune cells (specifically, white blood cells) begin attacking the patient's nerve cells in much the same way that they attack foreign pathogens. No one knows quite why they do that, but once they do, their immune memory becomes fixed on continuing the attack. The disease is often intermittent (the symptoms may come and go) and progressive, leading to more permanent symptoms. Immunosuppressive drugs to treat the disease can cost upwards of $60,000 per year.

Now there may be a way to halt the progression of the disease. The basic idea is to reboot the patient's immune system - to wipe out the immune system's memory and start again. In practice here is how it might be done: First, hemopoietic stem cells are harvested from the patient's bone marrow. As you may recall, hemopoietic stem cells have the capacity to develop into all of the various kinds of blood cells. Next, the patient is treated with low-dose chemotherapy to kill the white blood cells that are attacking his/her nerve cells. Finally, the patient's own stem cells are returned to the patient, where they develop into new white blood cells without the previous white cells' memory.

Preliminary data from clinical trials in three countries (Brazil, Sweden, and Britain) have been very encouraging; most patients feel subjectively as if they have been cured. Only about 10% of the patients suffer a relapse within five years of treatment.

It's an awesome advance if it can be proven to work. Even more exciting is that the same type of therapy (rebooting the immune system) might also work against other autoimmune disorders.