NIMH » Therapy Reduces Risk in Suicidal Youth

 

Preventing suicide has proven to be a difficult public health challenge. The suicide rate has climbed in recent years across age groups. In adolescents, suicide is the second leading cause of death. For every young person who dies by suicide, many more have suicidal thoughts, attempt suicide, or deliberately injure themselves without intending suicide.

To date, there have not been any research-validated treatments for preventing suicide among youth. And research has found that it’s hard to get adolescents with suicidal thoughts to start and stay with existing treatments.

Researchers at the University of Washington, Seattle Children’s Research Institute, and collaborators at the Los Angeles Biomedical Research Institute at Harbor- University of California, Los Angeles (UCLA) Medical Center, and the David Geffen School of Medicine at UCLA are addressing the treatment void for adolescents. A recent clinical trial of a psychotherapy called dialectical behavior therapy (DBT)—which has been shown to be effective in reducing suicide-related behavior in adults—showed that DBT can also reduce suicide attempts and suicidal behavior in adolescents.

“We have a real need for more evidence-based interventions to help suicidal youth,” said Jane Pearson, Ph.D., chair of the Suicide Research Consortium in NIMH’s Division of Services and Intervention Research. “This study is significant because it reinforces previous DBT studies with adolescents. DBT shows clear promise for helping at-risk youth develop skills that will set them on a “life preserving” path.”

For this study, Elizabeth McCauley, Ph.D., and colleagues enrolled youth ages 12-18 who were at risk for suicide. The adolescents entering the study had attempted suicide at least once, had a history of repeated self-injury, and had trouble with emotional control—for example, unstable, intense, and often negative moods. Youth entering the trial were randomly assigned to either DBT or a comparison treatment, individual and group-supported therapy (IGST).

By the end of the first six months of the trial, suicide attempts and non-suicidal self-injury (NSSI) were significantly less likely in youth receiving DBT than those receiving IGST. Self-harm, which combines both suicide attempts and NSSI, was about a third as likely in DBT recipients compared with those in IGST. Of 65 youth randomly assigned to IGST who completed the end of treatment assessment, 9 had one suicide attempt and 5 had two or more; out of 72 assigned to DBT, 6 had one suicide attempt and 1 had two or more.

Twelve months after the trial began, rates of self-harm had declined in both groups; the rate was still lower in the DBT group, but the difference was not great enough—given the number of participants in the trial—to be statistically significant. Nonetheless, the benefit seen in the first months potentially saved lives; the authors point out that clinical trials of greater size or length may demonstrate a more sustained advantage to DBT and may assess whether altering components of the therapy could increase its effectiveness.

Another finding of the study was that youth receiving DBT attended more treatment sessions and were more likely to complete DBT treatment (attend at least 24 individual sessions) than youth receiving IGST. The greater success in this respect of DBT may have been an element in the difference in treatment effectiveness relative to IGST.

DBT was developed by Marsha Linehan, Ph.D., senior author on this report, for treatment of people who are suicidal and have symptoms of borderline personality disorder, which is marked by a pattern of unstable moods, self-image, and behavior. The risk of suicide among those with borderline personality disorder is high; recurrent suicidal behavior is among the diagnostic criteria for the disorder. Among the essential elements of DBT are skills training aimed at helping a person regulate emotions, for example, their reactions to stresses; and developing coping strategies to deal with life challenges, including social interactions and relationships with friends and family. The therapy includes individual psychotherapy, multi-family group skills training, youth and parent telephone coaching, and weekly therapist team coaching.

Comparing DBT with another therapy that has some of the general elements common to psychotherapy provides an opportunity to evaluate the effectiveness of the specific components that set DBT apart from other therapies. Comparing DBT with no treatment or treatment as usual would not offer the same insight into the elements that contribute to effectiveness.

The paper reporting this study is online June 20 in JAMA Psychiatry.

Grants

MH090159; MH093898

Clinical Trial

NCT01528020

Reference

McCauley E et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. JAMA Psychiatry. 2018 June 20. doi: 10.1001/jamapsychiatry.2018.1109. [Epub ahead of print]

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UV Exposure: Why Do We Ignore the Health Risks?

 

Published Thursday 17 July 2014

By Honor Whiteman

The sun is shining, so what are your plans? For many of us, the answer will be to hit the beach and soak up the rays. But while you are busy packing beachwear and towels, are you considering the dangers of sun exposure?

Exposure to ultraviolet (UV) radiation – from the sun, tanning beds, lamps or booths – is the main cause of skin cancer, accounting for around 86% of non-melanoma and 90% of melanoma skin cancers. In addition, excessive UV exposure can increase the risk of eye diseases, such as cataract and eye cancers.

The health risks associated with exposure to UV radiation have certainly been well documented, so much so that the World Health Organization (WHO) have now officially classed UV radiation as a human carcinogen.

This year alone, Medical News Today reported on an array of studies warning of UV exposure risks. One study, published in the journal Pediatrics, revealed that tanning bed use among youths can increase the risk of early skin cancer, while other research found that multiple sunburns as an adolescent can increase melanoma risk by 80%.

Furthermore, in response to reported health risks, the Food and Drug Administration (FDA) recently changed their regulation of tanning beds, lamps and booths. Such products must now carry a visible, black-box warning stating that they should not be used by anyone under the age of 18.

How does UV radiation cause damage?

UV radiation consists of three different wavebands: UVA, UVB and UVC. The UVC waveband is the highest-energy UV but has the shortest wavelength, meaning it does not reach the earth’s surface and does not cause skin damage to humans.

However, UVA has a long wavelength and accounts for 95% of solar UV radiation that reaches the earth’s surface, while UVB – with a middle-range wavelength – accounts for the remainder. Tanning beds and tanning lamps primarily emit UVA radiation, sometimes at doses up to 12 times higher than that of the sun.

Both UVA and UVB radiation can damage the skin by penetrating its layers and destroying cellular DNA. UVA radiation tends to penetrate deeper layers of skin, known as the dermis, aging the skin cells and causing wrinkles. UVB radiation is the main cause of skin reddening or sunburn, as it damages the outer layers of the skin, known as the epidermis.

Excessive UV exposure can cause genetic mutations that can lead to the development of skin cancer. The browning of the skin, or a tan, is the skin’s way of trying to stop further DNA damage from occurring.

Of course, it is not only the skin that can be subject to damage from UV radiation. Bright sunlight can penetrate the eye’s surfaces tissues, as well as the cornea and the lens.

Ignoring the risks of UV exposure

But regardless of the numerous studies and health warnings associated with UV exposure, it seems many of us refuse to take note.

A 2012 survey from the Centers for Disease Control and Prevention (CDC) found that 50.1% of all adults and 65.6% of white adults ages 18-29 reported suffering sunburn in the past 12 months, indicating that sun protection measures are not followed correctly, if at all.

A more recent study from the University of California-San Francisco stated that the popularity of indoor tanning is “alarming” – particularly among young people.

The study revealed that 35% of adults had been exposed to indoor tanning, with 14% reporting tanning bed use in the past year. Even more of a concern was that 43% of university students and 18% of adolescents reported using tanning beds in the past year.

Overall rates of tanning bed use, the researchers estimate, may lead to an additional 450,000 non-melanoma and 10,000 melanoma skin cancer cases every year.

It seems unbelievable that so many of us are willing to put our health at risk to soak up some sunshine. So why do we do it?

The desire for a ‘healthy tan’

A recent study published in the journal Cell suggested that UV radiation causes the body to release endorphins – “feel-good” hormones – which makes sun exposure addictive.

But Tim Turnham, executive director of the Melanoma Research Foundation, told Medical News Today that many people simply favor a tanned body over health:

“Despite elevated awareness of the dangers of UV radiation, people still choose to ignore the dangers in the pursuit of what they consider to be a ‘healthy tan.’ This is particularly an issue among young people who tend to ignore health risks in favor of enhancing their social status and popularity. We know that tanning appeals to people who are interested in being included, and this is a primary driver for teens – being part of the ‘in’ crowd.”

Anita Blankenship, health communication specialist at the CDC, told us that the desire for a tan is particularly common among young women.

“In the US, nearly 1 in 3 young white women ages 16-25 years engages in indoor tanning each year,” she said. “These young women may experience pressure to conform to beauty standards, and young people may not be as concerned about health risks.”

Turnham agreed, telling us that the indoor tanning industry specifically targets this population. “Aggressive marketing, deep discount and package deals are used routinely by tanning salons, who market their services preferentially to young women,” he said.

Blankenship added that the public are also presented with “conflicting messages” when it comes to the safety of excess UV exposure. She pointed out that a recent US report found that only 7% of tanning salons reported any harmful effects from tanning beds, booths or lamps, while 78% reported health benefits.

“It is important to monitor deceptive health and safety claims about UV exposure, as they may make it difficult for consumers to adequately assess risk,” she told us. “It is important for people to understand that tanned skin is damaged skin, and that damage can lead to wrinkles and early aging of the skin, as well as skin cancer including melanoma – the kind of skin cancer that leads to the most deaths.”

Progress has been made, but more needs to be done

This month is UV Safety Month – an annual campaign that aims to increase public awareness of the health implications caused by UV exposure.

With the help of such campaigns and an increase in studies detailing UV risks, many health care professionals believe there has been a change for the better in attitudes toward UV exposure.

Many health care professionals believe much progress has been made in increasing awareness of UV exposure risks in recent years, but more needs to be done.

“Certainly the scientific community, a number of federal agencies, and possibly the general public are more aware of the risk of UV exposure,” a spokesperson from the National Cancer Institute (NCI) told Medical News Today.

“Action and more coordinated efforts increased markedly about 4 years ago, when a number of epidemiological studies documented the harms of indoor tanning, the FDA held their scientific advisory committee meeting to discuss need for changing indoor tanning device regulations, and they also acted on their previous proposals to change sunscreen regulations.”

The spokesperson continued:

“We think these summaries acted as a catalyst for efforts to make the public and policy makers aware of the risks of indoor tanning, and also they gave a boost to efforts to increase awareness of outdoor sun exposure risks and encourage sun safe protective behaviors.”

In addition, some studies have indicated that many youngsters may even be moving away from the use of tanning beds. A recent Youth Risk Behavior Survey found that among high school students, indoor tanning activity decreased from 15.6% in 2009 to 12.8% in 2013.

Turnham told us that since sunless tanning – such as the use of spray tans – is on the increase, it may be that youngsters are using this as an alternative to tanning salons. But the NCI spokesperson said such an association needs to be investigated before any conclusions can be reached:

“We do not know if changes in indoor tanning are related to increases in use of spray-on and sunless tanning products and services,” they told us. “Some studies indicate that sunless products and services are used by people who continue to engage in indoor tanning, but it is an area we continue to research. We are hopeful that we will be able to measure this in an upcoming national survey supplement that is being developed by NCI and CDC.”

But despite widespread efforts to increase UV safety awareness, Turnham believes there is still a lot more that can be done to protect public health:

“Regulators could and should do much more to fight the ravages of UV exposure. We need federal legislation banning the use of tanning beds by minors. We need more funding for awareness and prevention efforts.”

He added that doctors can also play a role in increasing UV exposure awareness by warning patients of associated risks – something the US Preventive Services Task Force (USPSTF) recommend. They state that health care providers should counsel fair-skinned youths between the ages of 10 and 24 about the risks of indoor tanning and how to protect themselves against UV radiation from the sun.

However, Turnham noted that doctors do not have much time with each patient and proposes that signage in waiting areas warning of the risks of UV exposure may also be effective.

Protecting against UV radiation

Whether there will be further regulation for indoor tanning or an increase in awareness efforts is unclear. But one thing is certain: we can help ourselves to avoid the negative health implications associated with UV exposure.

The American Cancer Society notes young children need extra protection from the sun, as they spend more time outside and can burn easily.

The CDC recommend the following for protecting against UV radiation:

  • Stay in the shade if possible, particularly when the sun is at its strongest – usually around midday
  • Wear clothing that covers your arms and legs
  • Wear a wide-brimmed hat that provides shade for your head, face, ears and neck
  • Wear wrap-around sunglasses that protect against both UVA and UVB radiation
  • Use sunscreen with a minimum sun protection factor (SPF) of 15 that protects against UVA and UVB radiation, and reapply every 2 hours
  • Avoid indoor tanning.

In addition, the American Cancer Society notes young children need extra protection from the sun as they spend more time outside and can burn easily. They add that babies younger than 6 months should be kept out of direct sunlight and be covered with protective clothing. Sunscreen should never be used on an infants skin.

As  we embark on the glorious, sunny days of the summer season and enter into the Fourth of July Celebration, let’s do all we can to protect ourselves and our little ones from UV rays’ potential threats to our skin. Remember, UV rays are the major causes of several deadly skin cancers and sunscreen is one of the most easy and accessible ways to protect against them. So, get out those sunscreen tubes and cover your head with a hat and your eyes with some shades because sun protection is trending today and everyday!

And, if you do find an odd spot on your body’s biggest organ, you can use HealthLynked to find a great physician near you and get the help you need.  Simply go to HealthLynked.com and sign up for free, then Connect and collaborate through HealthLynked to heal your skin!

 

Genes linked with sunburn, skin cancer risk

 

May 8, 2018

Certain genes can determine which people are more at risk of getting sunburn and possibly develop skin cancer as a result..

In a trawl of the genetics of nearly 180,000 people of European ancestry in Britain, Australia, the Netherlands and United States, researchers found 20 sunburn genes.

Eight of the genes had been associated with skin cancer in previous research, according to findings published in the journal Nature Communications.

And in at least one region of the genome, “we have found evidence to suggest that the gene involved in melanoma risk… acts through increasing susceptibility to sunburns,” co-author Mario Falchi of King’s College London told AFP.

Sun exposure is critical for the body’s production of vitamin D, which keeps bones, teeth, and muscles healthy, and which scientists say may help stave off chronic diseases, even cancer.

But too much can be painful in the short-term, and dangerous for your health.

The new study, which claims to be the largest to date into the genetics of sunburn, helps explain why people with the same skin tone can have such different reactions to exposure to sunlight—some burn red while others tan brown.

It may also begin to explain factors in skin cancer risk.
“It is necessary to explore these genes in more detail, to understand the mechanism by which they contribute to propensity to burn,” said Falchi.

In future, the research may help identify people at risk, through genetic testing.

“People tend to ‘forget’ that sunburns are quite dangerous,” said Falchi.

“Given the rise in incidence in skin cancer, we hope that knowing there is a genetic link between sunburn and skin cancer may help in encouraging people to lead a healthy lifestyle.”

More information: Genome-wide association study in 176,678 Europeans reveals genetic loci for tanning response to sun exposure, Nature Communications (2018).
nature.com/articles/doi:10.1038/s41467-018-04086-y
Journal reference: Nature Communications

Millennials aren’t getting the message about sun safety and the dangers of tanning

Many millennials lack knowledge about the importance of sunscreen and continue to tan outdoors in part because of low self-esteem and high rates of narcissism that fuel addictive tanning behavior, a new study from Oregon State University-Cascades has found.

Lead author Amy Watson and her colleagues found that those with higher levels of self-esteem were less likely to tan, while those with lower self-esteem and higher levels of narcissism were more likely to present addictive tanning behavior. The motivation for the addictive tanning behavior was the perception of improved appearance.

“This study gives us a clearer understanding of actual consumer behavior,” said Watson, an assistant professor of marketing at OSU-Cascades. “The number of people still deliberately exposing their skin to the sun for tanning purposes is alarming. We need to find new ways to entice people to protect their skin, including challenging the ideal of tan skin as a standard of beauty.”

The findings were published recently in the Journal of Consumer Affairs. Co-authors are Gail Zank and Anna M. Turri of Texas State University.

Skin cancer is the most common type of cancer worldwide, with more than 3.5 million cases diagnosed annually. Melanoma cases among women rose sharply between 1970 and 2009, with an 800 percent increase among women 18 to 39.

In an effort to improve consumer education about the role of sunscreen in the prevention of skin cancer, the Centers for Disease Control and the Food and Drug Administration developed a new “Drug Facts” panel of information now required on all sunscreen bottles. The panel includes directions for sunscreen use and advice on other sun protection measures, among other information.

The researchers’ goal with the study was to gauge whether the information on this new label is effective at curbing tanning behavior and if new information is helping to increase consumer knowledge about how and when to use sunscreen and how much to use.

The study of 250 college students, most between 18 and 23 years old, measured their sun safety knowledge and included: questions about their beliefs regarding sunscreen effectiveness and ultraviolet light exposure danger; questions about tanning motivation and behavior; an assessment of tanning addiction; and personality questions relating to self-esteem, narcissism, appearance and addictive behavior.

The study participants, 47 percent male and 53 percent female, scored an average of 54 percent on an 11-question sun safety knowledge test, which included true/false statements such as: “On a daily basis I should use at least one ounce of sunscreen on exposed skin” (true); and “When applied correctly, SPF 100 is twice as effective as SPF 50” (false).

About 70 percent of the study participants reported purposefully exposing their skin to the sun to achieve a tan. About a third of the participants reported that having a tan is important to them, while about 37 percent said they feel better with a tan, and 41 percent indicated that having a tan makes them more confident in their appearance

The participants’ levels of tanning addiction were measured through questions such as “I get annoyed when people tell me not to tan,” and “I continue to tan knowing that it is bad for me,” and “I feel unattractive or anxious to tan if I do not maintain my tan.”

The researchers found that those with lower self-esteem and higher narcissism rates were also more likely to exhibit addictive tanning behavior. They found no evidence that increased knowledge about sun safety leads to lower levels of addictive tanning.

“What we found is that this knowledge doesn’t matter to the consumers,” Watson said. “That tactic to require sunscreen manufacturers to include this information is not effective.”

Sun safety and sunscreen messaging from the CDC is all statistics-based, emphasizing the likelihood of a skin cancer occurrence or diagnosis, Watson said. But that type of message isn’t resonating with millennials. The next step for Watson and her colleagues is to begin testing other types of messages to identify ways millennials would respond more positively to sun safety measures.

“People are starting to get the message about the dangers of using tanning beds, but a large number of people are still tanning outdoors, deliberately exposing their skin to the sun, because they think it’s attractive,” she said.

“We need to move away from the narrative where tan skin is associated with health and youth. That’s the opposite of reality. Because reality is tan skin is damaged skin.”

More information: Amy Watson et al, I Know, but I Would Rather Be Beautiful: The Impact of Self-Esteem, Narcissism, and Knowledge on Addictive Tanning Behavior in Millennials, Journal of Consumer Affairs (2018). DOI: 10.1111/joca.12179
Provided by: Oregon State University

Here comes the sun, and kid sun safety

(HealthDay)—Summer sun brings childhood fun, but experts warn it also brings skin cancer dangers, even for kids.

“Don’t assume children cannot get skin cancer because of their age,” said Dr. Alberto Pappo, director of the solid tumor division at St. Jude Children’s Research Hospital in Memphis, Tenn. “Unlike other cancers, the conventional melanoma that we see mostly in adolescents behaves the same as it does in adults.”

His advice: “Children are not immune from extreme sun damage, and parents should start sun protection early and make it a habit for life.”

So, this and every summer, parents should take steps to shield kids from the sun’s harmful UV rays.

Those steps include:

* Avoid exposure. Infants and children younger than 6 months old should avoid sun exposure entirely, Pappo advised. If these babies are outside or on the beach this summer, they should be covered up with hats and appropriate clothing. It’s also a good idea to avoid being outside when UV rays are at their peak, between 10 a.m. and 2 p.m.

* Use sunscreen. It’s important to apply a broad-spectrum sunscreen to children’s exposed skin. Choose one with at least SPF15 that protects against both UVA and UVB rays. Pappo cautioned that sunscreen needs to be reapplied every couple of hours and after swimming—even if the label says it is “water-resistant.”

However, sunscreen should not be used on infants younger than 6 months old because their exposure to the chemicals in these products would be too high, he noted.

* Keep kids away from tanning beds. Melanoma rates are rising among teenagers, partly due to their use of indoor tanning beds. Use of tanning beds by people younger than 30 boosts their risk for this deadly form of cancer by 75 percent, according to the International Agency for Research on Cancer.

* Get children screened. Early detection of melanoma is key to increasing patients’ odds of survival. Children with suspicious moles or skin lesions should be seen by a doctor as soon as possible, Pappo advised. Removing melanoma in its early stages also increases the chances of avoiding more invasive surgical procedures later on, he added.

More information: There are more sun-safety tips at the Skin Cancer Foundation.

What is Cholesterol?

This waxy, fat-like substance sounds gross, but your body can’t function without it. What happens when your cholesterol level is too high or low?

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Genetic Testing for Breast Cancer – Mayo Clinic

It could be your mom, sister, aunt or best friend. One out of 8 women will get breast cancer in her lifetime. A small subset of the women who get diagnosed have inherited an abnormal copy of a gene that runs in families and can greatly increase their risk of certain cancers. One question these women and their families face is, “Should I get tested to find out if I have a genetic risk?” The answer is always a very personal one.

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The Beat Goes On | Heart Transplants Still a Marvel of Modern Medicine

On this day in 2001, a petite 44-year-old woman received a successful heart transplant at Ronald Reagan UCLA Medical Center, thanks to an experimental Total Artificial Heart designed for smaller patients.

The UCLA patient was the first person in California to receive the smaller Total Artificial Heart, and the first patient in the world with the device to be bridged to a successful heart transplant — that is, to go from needing a transplant to receiving one.

The 50cc SynCardia temporary Total Artificial Heart is a smaller investigational version of the larger 70cc SynCardia heart, which was approved for use in people awaiting a transplant by the Federal Food and Drug Administration in 2004 and has been used by more than 1,440 patients worldwide.

The 50cc device is designed to be used by smaller patients — including most women, some men and many adolescents — with end-stage biventricular heart failure, where both sides of the heart are failing to pump enough blood to sustain the body. The device provides mechanical support until a donor heart can be found

Nemah Kahala, a wife and mother of five, was transferred to UCLA from Kaiser Permanente Los Angeles Medical Center in March.  She was suffering from restrictive heart muscle disease and in critical condition.  Her heart failure was so advanced that repair surgery and other mechanical assist devices could not help.

Kahala was placed on a life support system called extra corporal membrane oxygenation, but this only works for about 10 days before a person’s organs begin to deteriorate.

With the clock ticking, doctors needed to buy time by replacing Kahala’s failing heart with an artificial heart while she waited for a heart transplant.  Her chest cavity was too small for her to receive the larger 70cc artificial heart.  However, under a one-time emergency use permitted under FDA guidelines, her doctors were able to implant the experimental 50cc device.

“Mrs. Kahala’s condition was deteriorating so rapidly that she would have not survived while waiting for a transplant,” said her surgeon, Dr. Abbas Ardehali, a professor of cardiothoracic surgery and director of the UCLA Heart and Lung Transplant Program. “We were grateful to have this experimental technology available to save her life and help bridge her to a donor heart.”

The artificial heart provides an immediate and safe flow of blood to help vital organs recover faster and make patients better transplant candidates.

After the two-hour surgery to implant the artificial heart, Kahala remained hospitalized in the intensive care unit and eventually began daily physical therapy to help make her stronger for transplant surgery.

Two weeks after the total artificial heart surgery, she was strong enough to be placed on the heart transplant list.  After a week of waiting, a donor heart was found.

“In addition to the high-tech medicine that kept her alive, Mrs. Kahala and her family exemplified how a solid support system that includes loved ones and a compassionate medical team practicing what we at UCLA have termed ‘Relational Medicine’ plays an important role in surviving a medical crisis,” said Dr. Mario Deng, professor of medicine and medical director of the Advanced Heart Failure, Mechanical Support and Heart Transplant program at UCLA.

Kahala was discharged from UCLA on April 18.

Since 2012, the UCLA Heart Transplant Program has implanted eight 70cc SynCardia Total Artificial Hearts. UCLA also participated in the clinical study of a 13.5-pound Freedom portable driver — a backpack-sized device that powers the artificial heart, allowing the patient to leave the hospital — that received FDA approval on June 26, 2014.

The FDA cautions that in the United States, the 50cc SynCardia temporary Total Artificial Heart is an investigational device, limited by United States law to investigational use.  The 50cc TAH is in an FDA-approved clinical study.

First Fully Contained Artificial Heart

On the same day, a patient was implanted with the world’s first self-contained mechanical heart after a 7-hour operation, a hospital in Louisville, Kentucky. The procedure was the first major advance in the development of an artificial replacement heart in nearly two decades.

The device, created by Danvers, Massachusetts-based Abiomed Inc., replaces the lower chambers of a patient’s failing heart with a plastic-and-metal motorized hydraulic pump which weighs 2 pounds (1 kg) and is about the size of a grapefruit.

It was the first artificial heart to be free of wires connecting it to the outside.

“This is the first time this has ever been done,” said Kathy Keadle, a spokeswoman at Jewish Hospital where the procedure was performed by University of Louisville surgeons Laman Gray and

Neither Abiomed nor hospital officials would disclose the name, sex or gender of the patients, all of whom are seriously ill.  The long-awaited surgery had been expected by June 30 but was delayed because the company had not completed patient screening.

Abiomed got U.S. Food and Drug Administration approval in February’s 2001 to test the device on as many as 15 patients, all of whom are too ill to be candidates for a heart transplant.  Unlike existing devices, which serve as a temporary solution to extend a patient’s life until a patient can secure a donor heart, the AbioCor heart is designed to be a fully functioning replacement heart.

The trial involved severely ill patients with less than 30 days to live, said John Thero, vice president and chief financial officer of Abiomed.

“This is not a bridge to transplant. There is a scarcity of donor hearts available,” Thero said in a telephone interview. “We are starting with patients who are at the ends of their lives. They are not candidates for transplant and are near death. Our goal is to provide them with a reasonable quality of life and an extension of life.”

Thero said the current candidates had a life expectancy of two months. “While the device is designed to eventually go much longer, if we were able to double someone’s life expectancy, we would be very pleased,” he said.

The 40,000 patients awaiting heart transplants far outnumber the number of hearts available, and a successful mechanical heart could fill a huge need.

Earlier versions of the artificial heart were bulky and provided limited benefit to patients.  In 1982, Dr. Barney Clark, 61, of Salt Lake City, Utah, received the first permanent artificial heart, known as Jarvik-7. He was bound to his bed by protruding cables, tubes and a noisy box-like air compressor during the 112 days that he survived with the artificial heart.

With the Jarvik-7 and other “bridge devices,” the outside connectors leave patients exposed to infection.  The AbioCor contains a small electric motor attached to an implanted battery and is designed to last for years. Patients could wear a battery pack or plug into an electrical outlet to recharge the heart’s battery.

A Brief History of Heart Transplant

Long before human-to-human transplantation was ever imagined by the public, scientists were conducting pioneering medical and surgical research that would eventually lead to today’s transplantation successes. From the late 1700s until the early 1900s, the field of immunology was slowly evolving through the works of numerous independent scientists. Among the notable breakthroughs were Ehrlich’s discovery of antibodies and antigens, Lansteiner’s blood typing, and Metchnikoff’s theory of host resistance.

Because of advances in suturing techniques at the end of the 19th century, surgeons began to transplant organs in their lab research. At the start of the 20th century, enough experimentation had taken place to know that xenographic (cross species) transplants invariably failed, allogenic transplants (between individuals of same species) usually failed, while autografts (within the same individual, generally skin grafts) were almost always successful. It was also understood that repeat transplants between same donor and recipient experienced accelerated rejection, and that graft success was more likely when the donor and recipient shared a “blood relationship.”

Alexis Carrel was a French surgeon and Nobel laureate whose experiments involved sustaining life in animal organs outside the body. He received the 1912 Nobel Prize in Medicine or Physiology for his technique for suturing blood vessels. In the 1930s, he collaborated with the aviator Charles Lindbergh to invent a mechanical heart that circulated vital fluids through excised organs. Various organs and animal tissues were kept alive for many years in this fashion.

Throughout the 1940s and 50s, small but steady research advances were made. In 1958, Dickinson Richards, MD, chairman of the Columbia University Medical Division, and Andre Cournaud were awarded the same Nobel Prize for their work leading to fuller understanding of the physiology of the human heart using cardiac catheterization.

In that same year, Keith Reemtsma, MD, a member of the faculty of Tulane University who later became chairman of the Department of Surgery at Columbia University Medical Center, showed for the first time that immunosuppressive agents would prolong heart transplant survival in the laboratory setting.

At this time, Norman Shumway, MD, Richard Lower, MD, and their associates at Stanford University Medical Center were embarking on the development of heart-lung machines, solving perfusion issues, and pioneering surgical procedures to correct heart valve defects. Key to their success was experimentation with “topical hypothermia,” the localized hyper-cooling of the heart which allowed the interruption of blood flow and gave the surgeons the proper blood-free environment and adequate time to perform the repairs. Next came “autotransplantation,” where the heart would be excised and resutured in place.

By the mid-1960s, the Shumway group was convinced that immunologic rejection was the only remaining obstacle to successful clinical heart transplantation. In 1967, Michael DeBakey, MD, implanted an artificial left ventricle device of his design in a patient at Baylor College of Medicine in Houston.

In 1967, a human heart from one person was transplanted into the body of another by a South African surgeon named Dr. Christiaan Barnard in Cape Town. In early December, Dr. Barnard’s surgical team removed the heart of a 25-year-old woman who had died following an auto accident and placed it in the chest of Louis Washkansky, a 55-year-old man dying of heart damage. The patient survived for 18 days. Dr. Barnard had learned much of his technique from studying with the Stanford group. This first clinical heart transplantation experience stimulated world-wide notoriety, and many surgeons quickly co-opted the procedure. However, because many patients were dying soon after, the number of heart transplants dropped from 100 in 1968, to just 18 in 1970. It was recognized that the major problem was the body’s natural tendency to reject the new tissues.

Over the next 20 years, important advances in tissue typing and immunosuppressant drugs allowed more transplant operations to take place and increased patients’ survival rates. The most notable development in this area was Jean Borel’s discovery of cyclosporine, an immunosuppressant drug derived from soil fungus, in the mid 1970s.

The cardiac transplant program at Columbia University Medical Center began in 1971 as part of an investigational surgery program initiated by Dr. Keith Reemtsma. At that time, Columbia University Medical Center was one of only a handful of medical centers in the nation actively engaged in cardiac transplant research. Columbia University Medical Center’s first cardiac transplant was performed by Dr. Reemtsma in 1977, when survival rates had begun to improve significantly. That patient survived for 14 months. Two additional transplants were performed that year. Initially Columbia University Medical Center accepted patients deemed too risky for transplantation by Stanford and the Medical College of Virginia, the only other medical centers in the country performing heart transplants.

Thanks to the persistence of pioneers in immunosuppression research, transplant patients have dramatically expanded life expectancies. The first immunosuppressant drugs used in organ transplantation were the corticosteroids. In 1983, Columbia University Medical Center became one of a small group of medical centers to initiate clinical trials of cyclosporine; approved for commercial use in November of that year, it is still the most commonly prescribed immunosuppressant used in organ transplantation. General information on the variety of medications that may be prescribed for you is found in the chapter on Medications in the section Care and Concerns after Your Operation.

In 1984, the world’s first successful pediatric heart transplant was performed at Columbia on a four-year-old boy. He received a second transplant in 1989 and lived until he succumbed to other health issues in 2006.

Also, in 1984, in Loma Linda, California, Leonard Bailey, MD, implanted a baboon heart into a 12-day-old girl who came to be known as “Baby Fae.” The infant survived for twenty days as the most famous recipient of xenographic transplantation. Throughout the decade of the 1980s and into the 90s, physicians continue to refine techniques for balancing dosages of immunosuppressant medications to protect the new heart yet allow the patient sufficient immunologic function to stave off infection. In 1994 a new drug, tacrolimus or FK-506, originally discovered in a fungus sample, was approved for immunosuppression in transplant patients. Newer formulations of cyclosporine now enable efficacy (effectiveness) at lower, less toxic dosages.

While research on transplantation issues continues, other techniques for the management and cure of heart disease are also under development. Some future directions include:

Coronary assist devices and mechanical hearts are being developed or perfected to perform the functions of live tissues. Artificial hearts have been under development since the 1950s. In 1966, Dr. DeBakey first successfully implanted a booster pump as a temporary assist device. Columbia’s cardiac surgeons have been instrumental in the development of a LVAD (left ventricular assist device) to function as a bridge-to-transplantation for those waiting for a new heart to become available. Columbia University Medical Center’s lead role in the REMATCH clinical trial helped to lead to approval for the the LVAD as a permanent, or destination, therapy as well.

In 1969, Dr. Denton Cooley implanted the first completely artificial heart in a human, again on a temporary basis. The first permanent artificial heart, designed by Dr. Robert Jarvik, was implanted in 1982. Numbers of patients have received Jarvik or other artificial hearts since, but surviving recipients have tended to suffer strokes and related problems.

There is a tremendous gap in the number of patients waiting for new hearts and the number of organs that actually become available. In addition to avoiding the immunosuppression and rejection complications of transplantation, success in clinical application of such mechanical devices can help resolve the issue of organ availability and thus, stakes are high to continue research in this arena.

Advances in immunosuppression have most recently involved the development and expanded use of polyclonal and monoclonal antibodies to counteract steroid-resistant rejection. Research continues into the management, reversal and avoidance of accelerated atherosclerosis in the transplanted heart, believed to be caused or aggravated by the required suppression of the body’s normal immunology. From the development of more powerful and specific immunosuppressants to new treatments for accelerated graft atherosclerosis, advances in the science of immunology appear to hold the key to expanding the success of heart transplantation in our treatment of end-stage cardiac disease.

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Sources

UCLAnewsroom.edu

Wired.com

Columbiasurgery.org

Title:  The Beat Goes On | Heart Transplants a Marvel of Modern Medicine

 

#heart,#transplant,#immunosuppression

 

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