Oriented to Thoracic Transplant Recipients -- February 2000

Physicians and the Pharmaceutical Industry


There are few issues in medicine that bring clinicians into heated discussion as rapidly as the interaction between the pharmaceutical industry and the medical profession. More than $11 billion is spent each year by pharmaceutical companies in promotion and marketing, $5 billion of which goes to sales representatives. ' It has been estimated that $8000 to $13,000 is spent per year on each physician. The attitudes about this expensive interaction are divided and contradictory. One study found that 85% of medical students believe it is improper for politicians to accept a gift, whereas only 46%o found it improper for themselves to accept a gift of similar value from a pharmaceutical company. Most medical associations have published guidelines to address this controversy. Perhaps the intensity of the discussion is related to the potential consequences were it confirmed that gifts influence prescription of medication that results in increasing cost or negative health outcomes.

Is a Gift Ever Just a Gift?

Ashley Wazana, MD

Context: Controversy exists over the fact that physicians have regular contact with the pharmaceutical industry and its sales representatives, who spend a large sum of money each year promoting to them by way of gifts, free meals, travel subsidies, sponsored teachings and symposia.

Objective: To identify the extent of and attitudes toward the relationship between physicians and the pharmaceutical industry and its representatives and its impact on the knowledge, attitudes, and behavior of physicians.

Data Source: A MEDLINE search was conducted for English-language articles published from 1994 to present, with review of reference lists from retrieved article; in addition, an Internet database was searched and 5 key informants were interviewed.

Study Selection: A total of 538 studies that provided data on any of the study questions were targeted for retrieval, 29 of which were included in the analysis.

Data Extraction: Data were extracted by 1 author. Articles using an analytic design were considered to be of higher methodological quality.

Data Synthesis: Physician interactions with pharmaceutical representatives were generally endorsed, began in medical school, and continued at a rate of about 4 times per month. Meetings with pharmaceutical representatives were associated with request by physicians for adding the drags to the hospital formulary and changes in prescribing practice. Drug company-sponsored continuing medical education (CME) preferentially highlighted the sponsor's drug(s) compared with other CME programs. Amending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsors medication. Attending presentations given by pharmaceutical representatives speakers was also associated with non-rational prescribing.

Conclusion: The present extent of physician-industry interactions appears to affect prescribing and professional behavior and should be further addressed at the level of policy and education. Emphasis Ed.

JAMA 2/12/99

An Analysis of the Effect of Age on Survival After Heart Transplant

Michael Borkon, MD, et al

Background: Advances in immuno-suppression and reports of improved survival after cardiac transplantation have led to a liberalization of traditional recipient eligibility criteria, especially age. While age alone is not a contraindication to transplantation, conflicting data exists regarding long-term survival of the older transplant recipient.

Methods: One hundred-fifty three patients undergoing consecutive first time cardiac transplantation from June 7, 1985 through February 1, 1997 were studied. For purposes of analysis, patients were stratified according to age (<55 years vs >55 years) and hospital and late outcomes determined.

Results: The incidence of early and late acute cellular rejection was not different based upon age. The freedom from infection at 12 months was 54 + 5% for patients -<55 compared to 32 + 8% for patients >55 years old. Five year estimated survival for patients >55 years old was only 56 + 9% compared to 78 + 5% for patients <55 years old. The hazard for death was highest within the first post-transplant year for older patients and was most commonly due to infection. Both advanced age and pre-transplant diagnosis of ischemic cardiomyopathy were found to be independently and additively predictive of reduced late survival.

Conclusions: In the present study, late survival was adversely influenced by advanced age. Older patients (>55 years) with pre-transplant diagnosis of ischemic cardiomyopathy were particularly at high risk (risk ratio 4.6:1) for death. Given little prospect of expanding the number of donor hearts, careful selection of patients over the age of 55 with pre-transplant ischemic cardiomyopathy is warranted.
J Heart Lung Transplant 1999; 18:668474.

Heart Transplant Raises Questions

By TOM COHEN - Associated Press Writer

TORONTO (AP 1/8/00) -- A 79-year-old Canadian's new heart isn't really that new, and his operation has kindled debate on transplant surgery ethics.

Ray Nelson was 14 years older than what previously was considered the maximum age for undergoing a transplant. And the heart he received from a 55-year-old donor normally would have gone unused because of its advanced age.

Unlike Canada, the United States has no age limit for potential transplant patients or organ donors. Cases are based on whether the individual is healthy enough for the operation, and the condition of the organ to be donated.

But Nelson's Dec. 27 operation led to questions in Canada, where fewer than 200 heart transplants are performed each year.

"One has to wonder whether or not the process was being manipulated to provide some advantage to someone who otherwise might not be eligible," said Dr. Douglas Kinsella, a lecturer on medical ethics at the University of Calgary.

Nelson, a director of the Alberta Treasury Branches, a government-owned financial institution, is well-known in provincial business and political circles. He is also a friend of Dr. Dennis Modry, an Edmonton heart transplant specialist.

Complications after a bypass operation last year forced Nelson, an active man who used to swim at least 50 laps a day, to be hospitalized in September. Ten days after his transplant at the University of Alberta Hospital in Edmonton, he was sitting up and talking.

Dr. Arvind Koshal, regional director of the hospital's cardiac science program, acknowledged the committee of cardiologists, social workers and others that approved the transplant took unusual steps.

While 65 had been considered the maximum age for a transplant, that was never "carved in stone," Koshal said.

He said the transplant committee asked the hospital's ethics board for guidance in Nelson's case. The ethics board said that while age alone should not be the determining factor, it also noted that patients needing hearts far exceed the number of donor organs available. As many as 6,000 Canadians are considered possible candidates for a heart transplant.

After "rigorous debate," Koshal said, the transplant committee voted in a secret ballot to permit a transplant, but only if Nelson received a heart that would otherwise go unused.

Hearts from donors older than 50 normally get used only for "status four" patients, meaning emergency cases in which "somebody is going to die otherwise," Koshal said.

When the heart of a 55-year-old brain dead patient became available, he said, no emergency cases were pending. Two independent cardiologists on the transplant committee decided the heart was not appropriate for others on the eligibility list, so Nelson got it, Koshal said.

Glenn Griener of the University of Alberta's John Dossetor Health Ethics Center questioned whether giving Nelson the heart "amounts to substandard medical care."

"I haven't seen a coherent rationale for using this organ," he said.

Kinsella said the transplant committee's lengthy review was unusual and seemed intended to counter any accusations that Nelson "jumped the queue" for a transplant.

To Koshal, the decision hinged on whether cardiac patients younger than Nelson could wait for "a better heart."

"It's not that we're giving him (Nelson) a bad heart," Koshal said. "It's that we're giving him one better than what he had and would give him a better quality of life."


Over the years TX Victor Tenken of Santa Ana has made numerous contributions to UpBeat. Fortunate[y, I just ran across an overlooked envelope containing a few of Vic's gems. No, I'm not sure where he does all his reading, but there's no denying he comes up with some interesting stuff. DM

Bedside manner bad: Physicians like to think of themselves as caring, kind people, but a fair percentage of them must be mean, according to a study published in the Journal of the American Medical Association.

A survey of 1,200 medical residents taken by researchers at Chicago's Rush Medical College found that more than 90 percent of second year medical residents reported at least one incident of mistreatment by their superiors, mainly public humiliation or belittlement. But more than 10 percent of the young doctors said that on three or more occasions they were subjected to things such as being "slapped, pushed, kicked or hit" and having older doctors threaten their reputations or careers. Orange County Register 6/15/99

Wine in a pill? Flavonoids - antioxidants in red wine and many vegetables - are now available as pills. Scientists at the University of Wisconsin in Madison showed that one such product, ProVex CV, inhibits the activity of blood platelets, possibly cutting heart disease risk. Health April 1999 Oh man, last year they gave me the "sugarbusters" diet and took away my dinner time pasta, now my glass of wine!? No way! DM

CAN a donated heart bring with it a deadly curse? Renowned psychic researcher Silvia Brown, author of Adventures Of a Psychic (New American Library/Dutton), has studied hundreds of unusual organ transplant cases involving the phenomenon known as "trait transfer." This is what happens when an organ recipient suddenly takes on the characteristics of the donor!

"Every single cell in the human body retains its memory," she explains.

"Whether it's the heart, lung, kidney, liver or blood, it keeps its cellular memory when transplanted to a new body. So, when an individual receives and organ transplant, his or her personality is likely to be altered."

In 1990, nine-year-old Stephanie Breeding of Seattle, Washington received a heart transplant from an accident victim known only as D.J. She learned her donor had drowned in a ditch as the result of an auto crash. (Hummmm. A Tx donor candidate yet? Ed.)

Then, on September 12, 1998, tragedy struck.

Stephanie, now 17 years old, was riding with two pals on Seattle's Evergreen Point floating bridge when their vehicle crashed through a guardrail and plunged into the water. While her companions managed to swim to safety, Stephanie drowned....just as D.J. had eight years earlier!

There are dozens of intriguing cases where transplanted organs have changed their new owner's personalities. For instance:

  • Heart-lung recipient Claire Sylvia never exhibited any interest in motorcycles. Then suddenly, she found herself obsessed with them, even dreaming about revving up 22 at once! Her donor, a teenage boy, had been an avid motorcycle enthusiast, and her dream occurred on what would have been his 22nd birthday! (Claire wrote a book and was on TV several times -- 22 motorcycles, at once! Oh my.)

  • A kidney transplant recipient who never had any arm problems developed a chronic, shooting pain in his right arm after his surgery. It was later learned that the donor had suffered similar pain due to an accident several years before his death.

The Sun, June 8, 1999

What can we say? Maybe "Please don't tell anyone you read it here! DM

In the interest of furthering culture we did just a bit of quick research and found that Claire's "amazing story" is still very much available. It's called A Change of Heart: A Memoir. It's available in paperback for $5.53, or hardcover, $23.95, both from Amazon.com. Or if you'd rather you can listen, the audio tape set (2 cassettes (3 hrs.) is $14.45 from the same firm. The book had an original printing of 250,000. Claire is probably having a complete and utter ball somewhere.

Gene Therapy May Reverse Heart Disease - Study

WASHINGTON (Reuters 12/7/99) - Gene therapy may be able to reverse heart failure, a chronic condition that kills half its victims after 5 years, researchers said on Monday.

Experiments in test tubes show that a gene known as SERCA2 may be used to bolster failing heart muscles, a team at Massachusetts General Hospital found.

They said their experiment must be shown to work in living animals and then in human beings, but offers hope to treat a condition whose only real cure is a heart transplant.

In heart failure the heart muscle is weakened and cannot pump effectively. This allows fluids to back up in the circulatory system and sometimes into the lungs.

More than 400,000 people in the U.S. alone are diagnosed with heart failure every year. Drugs such as ACE inhibitors and beta-blockers can help but do not cure the condition.

Dr. Roger Hajjar and colleagues knew that in heart failure, cells do not handle calcium properly. And they knew that the SERCA2a protein affects this.

Writing in the journal Circulation, they described how they took muscle cells from 10 hearts taken from heart-failure patients who got new hearts.

They used a virus to carry extra copies of the SERCA2a gene to these heart muscle cells.

Within 24 hours, the cells started to beat like normal, healthy heart cells, they reported.

"These results in isolated cardiac cells need to be validated in the whole human heart, but we're optimistic that this goal will be accomplished," Hajjar said in a statement.

Novartis Fails to Derail FDA- Mandated Neoral Cyclosporine Labeling Change

FREMONT, Calif.--BW HealthWire 12/ 7/99 SangStat, The Transplant Company(R) (Nasdaq:SANG), announced today that the court rejected an attempt by Novartis to have the FDA delay its decision requiring Novartis to change the labeling of its Neoral product line effective December 10, 1999 to make it consistent with the established name and descriptor for the product class, which includes SangStat's SangCya(R) (Cyclosporine Oral Solution, USP (MODIFIED)) 100 mg/mL, the AB rated generic bioequivalent product to Neoral Oral Solution.

The United States District Court for the District of Columbia today rejected Novartis' motion for a preliminary injunction to block the FDA from enforcing its order to change the labeling for Neoral from Cyclosporine Oral Solution for Microemulsion to Cyclosporine Oral Solution, USP (MODIFIED). Significantly, the court stated that Novartis had not shown to date "a substantial likelihood of success on the merits" of its challenge to the FDA on this labeling issue, which is part of Novartis' lawsuit pending against the FDA before the same court. In reaching this decision, the court also noted the public interest in the availability of lower-cost generic drugs.

In October 1998, the FDA approved SangCya as a generic/therapeutically equivalent to Novartis' Neoral with the class name of Cyclosporine Oral Solution, US[' (MODIFIED). At that time the FDA notified Novartis that it must change the labeling of Neoral to reflect the appropriate established name and descriptor for the product class. Novartis' deadline to make the change was June 23, 1999, which was later extended to December 10, 1999. Novartis sued the FDA in February 1999. SangStat has intervened on the side of the FDA.

"We are very pleased with the outcome of this hearing," said Jean-Jacques Bienaime, SangStat's President and CEO. "Novartis has engaged in a number of attempts to stifle competition and block the market entry of generics, including suing the FDA. This decision, allowing the FDA to enforce its labeling change against Novartis, is an important step in the process to ensure fair competition for life-saving therapies which are crucial for hundreds of thousands of transplant recipients.

About SangCya oral solution

On October 31, 1998 the U.S. Food and Drug Administration (FDA) granted marketing clearance and an AB (bioequivalent) rating to SangStat's SangCya oral solution for prevention of rejection in solid organ transplant recipients, as well as autoimmune disease indications. This rating allows pharmacists to substitute SangCya oral solution for the brand drug Neoral oral solution. SangCya oral solution was also approved in the UK on January 28, 1999 for prevention of rejection in solid organ transplant recipients, and autoimmune disease indications.

More than 200,000 recipients of organ transplants in the U.S. and Europe require daily treatment with immunosuppressive medication to prevent graft rejection. Cyclosporine is the most commonly prescribed immunosuppressive drug used to prevent rejection of transplanted organs. Currently, it is marketed by Novartis as Sandimmune(R) and Neoral, and by SangStat as SangCya oral solution; combined worldwide sales for the cyclosporine products were approximately $1.3 billion in 1998. The cost to recipients for cyclosporine therapy currently is estimated at between $5,000 and $7,000 per year. SangCya oral solution is priced approximately 28% less than Neoral oral solution current pricing, which should result in an average annual saving of $1,600 per patient.

Costly Medicines Draw Drugstores Into New Battle

By Laura Johannes - Staff Reporter of The Wall Street Journal

BOSTON (12/22/99) -- The window display features antique, colored bottles and mortar-and-pestle sets. Inside, a druggist chats at leisure with customers, and nearby chairs offer a rest for the weary.

But the shop on a busy street here in Chinatown is no mom-and-pop operation. It's the first of more than a dozen ProCare stores opened nationwide by CVS Corp., whose 4,100 drugstores make it the nation's largest chain.

To appeal to very sick patients, CVS is striving for the personal touch usually associated more with independent drugstores. CVS's goal is to tap the estimated $16 billion annual market for lucrative specialty pharmaceuticals - drugs for everything from AIDS to anemia and organ transplants. CVS estimates sales of specialty drugs will grow about 20% next year.

While the customers require a lot of special attention, the drugs have fat price tags. Biogen Inc.'s Avonex drug for multiple sclerosis, for example, costs about $10,000 a year.

"The specialty-pharmacy business is fragmented, dominated by small mom-and-pops," says CVS Chief Executive Tom Ryan. "There's an enormous opportunity for us to be a consolidator and reduce costs." So far, the small, independent pharmacies - the remnants not wiped out by the chains - have been able to carve out a profitable refuge by serving the consumers of these medicines.

A typical ProCare patient is 60-year-old Stephen Ryder. After a 1997 heart transplant, he left Boston's New England Medical Center with a shopping bag full of medications - one in almost every color. Because Mr. Ryder's medications suppress his immune system, he was under strict instructions to avoid crowds.

That pretty much ruled out chain drugstores, so he went to Chartwell Pharmacy, an independent store where he was greeted by name and sent his rainbow of medications by mail. Late last year, when CVS bought Chartwell, he stayed loyal, particularly to pharmacist Alice Chung, who has cheerfully answered his many questions for years. "I haven't stumped her yet," he says. "When she doesn't know the answer to a question, she looks it up."

Other big chains are looking to the market for high-priced medicines. Walgreen Co., of Deerfield, Ill., Rite Aid Corp., Camp Hill, Pa., and Eckerd Corp., a unit of J.C. [Penney Corp., Dallas, have all recently begun giving pharmacists special training in AIDS. Last year Eckerd opened two Patient Care Centers in Atlanta, which offer comprehensive pharmacist counseling for people on all types of medications.

But so far, among the major chains, only CVS, of Woonsocket, R.I., has made such a concerted effort to woo very sick patients. CVS says it plans to have one or more ProCare stores in each of the nation's 32 largest urban markets by the end of next year. The stores will be only about 2,000 or 3,000 square feet, a fifth the size of its typical stores, but will have 20% to 30% more staff than ordinary CVS stores. That means there will usually be two pharmacists on duty during peak hours to answer questions and help patients solve insurance-reimbursement headaches.

And, like the independents, the ProCare stores seek community ties. In Boston, the ProCare pharmacist volunteers at a local AIDS action group, answering questions. CVS also took out ads in New York and Boston gay publications, promising: "See the difference individual care can make to the way you live with a chronic illness."

Competition will be tough. Next door to CVS's ProCare store in New York's Chelsea neighborhood is American Prescription Providers Inc., a specialty pharmacy with many AIDS customers that opened in 1994. The pharmacist at that store, which has $30 million a year in sales - high for a drugstore - scoffs that CVS is offering too little, too late.

But CVS also faces heightened competition. With four stores nationwide, American Prescription, of Melville, N.Y., plans to open 40 new ones within a few years, says Chief Executive Burt Zweigenhaft. And Statlanders Pharmacy, a Pittsburgh-based unit of Bergen Brunswig Corp., says it has an "aggressive" expansion plan for the next two years.

Statlanders is already a market leader in specialty pharmacy, with four storefront pharmacies and a large mail-order business. While it won't give specifics of its growth plan, it will begin selling oral cancer drugs and certain cardiology products, says Gordon Vanscoy, the company's executive vice president of managed care. He says he believes Statlanders' history of serving AIDS patients and organ-transplant recipients will give it ammunition against CVS. But, he adds, "we never underestimate them."

For its part, CVS is paying particular attention to the personal touch. After buying the pharmacy in Chelsea, CVS converted it into a ProCare store, kept its gregarious former owner on staff and hired away a pharmacist and a technician from a nearby Statlanders. CVS also hired a part-time nutritionist at the Chelsea store. The ProCare store across town in the East Village has a naturopathic doctor on staff to advise patients on alternative therapies.

Pharmacist Gerald D'Averso lavishes attention on an AIDS patient, sitting on a stool in the Chelsea outlet one recent morning. Mr. D'Averso tells him about a new product, made from the sap of trees in the Amazon ram forest, which helps patients suffering from diarrhea caused by the strong protease inhibitors he is taking. "It's far better than anything available now," the pharmacist says.

ProCare heard about the product, made by Shaman Pharmaceuticals Inc., and rushed to order it before competitors, says Molly Murphy, market manager for New York City's two ProCare stores.

Unlike a typical CVS, where records are kept in open bins, prescriptions here are stored in closed drawers, to protect patient confidentiality. A refrigerator in the back is packed with various sizes and strengths of perishable and expensive medicines, such as Epogen, an anemia drug for kidney-dialysis patients. Many other pharmacies would need to special-order them.

CVS is also gearing up to run a major specialty pharmacy mail-order business, and it recently signed a deal with Merck & Co.'s Merck Medco Managed Care. The powerful pharmacy benefits manager has agreed to market CVS's specialty products to its clients, and will acquire up to a 10% equity interest in ProCare. -- (Ed. Note: I think I challenge anyone to call CVS, tell them you're on a barge on the Mississippi and need them to call a small pharmacy in the next town so you can get more cyclosporine. Last summer when I called "Bob", my "pop" local pharmacist, he did, and I got it, no problem.)

Weightlifting Builds Bone Strength for Transplant Patients

Unlike other transplant patents who develop brittle bones after surgery from anti-rejection drugs, lung patents often acquire the problem long before they reach the operating room. That's because the anti-inflammatory and steroid medications they use to treat their lung conditions often causes their bones to thin.

Long-term studies at the University of Florida have shown that pumping iron can counteract rapid bone loss in patients after an organ transplant. But for the first time, it appears the regimen also can help lung patients who are awaiting surgery.

"It is well known that people who do weight training have strong bones. However, resistance training for people with weak bones usually isn't recommended by doctors because they are afraid patients could get injured," said Randy W. Braith, an associate professor of cardiology and physiology at University of Florida's College of Medicine.

The problem of brittle bones, commonly known as osteoporosis, is sometimes so serious that life or death hangs in the balance for transplant patient. One lung transplant candidate said his concern about being refused a lifesaving lung transplant because of his advanced osteoporosis promoted him to work with Braith.

"Had I not done the weight training, I might not have been considered as highly a candidate for a new lung," patient Mitch Davey said.

At the end of a four-month weight-training program, Davey increased his lower spine and hip bone mass by 3 percent. During the twice-a-week program, he exercised on eight different machines, each time performing one set of lower back exercises that isolates the lumbar spine.

"Gaining density in the lumbar spine is especially important because up to 35 percent of transplant patents have bone fractures there," Braith said. The results mirrored those found with heart transplant patients who followed the same exercise routine post-surgery to restore bone mineral density levels to their pre-surgery- levels. (Emphasis Ed.)

Davey, who has since received a lung transplant, said exercising has the added benefit of helping him feel better about his situation. "When I feel better physically, it helps me emotionally to feel more positive because I can see improvements," he said.

Theseus Imaging Achieves Technical Milestone in Imaging Apoptosis Associated with Cardiac Transplant Rejection

CHATSWORTH, Calif.---(Business Wire 1/13/00)--North American Scientific Inc. (and Theseus Imaging Corp. announced today that Theseus has achieved a significant technical milestone in clinical studies of its Apomate(TM) Kit for use in imaging apoptosis associated with organ transplant rejection.

The technical milestone was the successful correlation of noninvasive imaging of apoptosis with biopsy-proven cardiac transplant rejection using Theseus' Apomate(TM) Kit for the preparation of Technetium Tc-99m recombinant human Annexin V.

Nuclear medicine images obtained using routine instrumentation available in over 3,500 U.S. hospitals clearly demonstrated localization of the imaging agent in patients with transplant rejection. In current clinical practice, obtaining such information requires repeated cardiac catheterization and endomyocardial biopsy.

Each patient receiving a cardiac transplant may undergo up to 15 catheterization procedures in the first year after transplant in order to assess the adequacy of immunosuppression medication required to prevent rejection of the new heart. Apomate(TM) is intended to provide equivalent information through a noninvasive imaging procedure using a new technique involving molecular imaging of the biochemical changes associated with rejection.

The demonstration of imaging of cardiac transplant rejection in patients provides proof of principle for the concept of Apoptosis imaging developed in preclinical studies by Drs. H. William Strauss and Francis Blankenberg of Stanford University, Dr. Jonathan Tait of the University of Washington and their colleagues. Theseus has licensed the apoptosis imaging technology from those institutions.

"The ability to image apoptosis in patients would provide physicians with an important new tool for managing the treatment of disorders involving programmed cell death, such as transplant rejection," said Dr. Allan Green, president of Theseus Imaging.

"The availability of a noninvasive imaging study which could replace multiple catheterization procedures and allow more timely assessment of the adequacy of patient medication would benefit the patients and markedly reduce treatment costs, while maintaining the current good outcomes associated with cardiac transplant." (Just maybe heart Tx patients of the future will avoid the annoying, invasive biopsy "pac-man ". Ed.)

Cost of Heart Transplants

According to the UNOS the estimated first year charges for a heart transplant at $209,100, and annual follow-up charges are $15,000. In most cases these costs are paid by private insurance companies. More than 80 percent of commercial insurers and 97 percent of Blue Cross/Blue Shield plans offer coverage for heart transplants. Medicaid programs in 33 states and the District of Columbia also reimburse for transplants. Heart transplants are covered by Medicare for Medicare-eligible patients if the operation is performed at an approved center.

Approximately 70 percent of commercial insurance companies and 92 percent of Blue Cross/Blue Shield plans cover heart-lung transplants. Medicaid coverage for heart-lung transplant is available in 20 states according to the UNOS, estimated first year charges for a heart-lung transplant is $246,000 and annual follow-up charges are $18,400.

National Heart, Lung, and Blood Institute 10/22/99

Surgeons Conduct First Double Hand Transplant

LYON, France (Reuters 1/15/00) - An international team of surgeons has transplanted both hands and forearms onto a former house painter in a world first, the team leaders said on Friday.

The 33-year-old patient, a Frenchman from the Atlantic coast port of Rochefort whose name was not given, was doing as well as could be expected after major surgery, they said.

The 17-hour operation was conducted by France's Jean-Michel Dubernard and Australian Earl Owen, part of the Team that conducted the first single hand graft in 1998.

"I'm feeling much more relaxed than the day after the first transplant," said Dubernard.

The patient lost his forearms in 1996 when an amateur rocket he made with his nephews exploded as he was preparing it for launch.

Dubernard said the key test of the operation would be whether the patient's body accepted the transplant but early signs showed that drugs to prevent the immune system from rejecting the limbs were working.

"We have observed that the immunosuppressors have acted even more efficiently than we hoped," he said. Owen, of the Microsearch Foundation of Australia in Sydney, earlier told Reuters: "The patient just woke up and he's very happy."

The father-of-two asked for the operation after hearing about the world's first hand transplant.

Doctors said they chose the man, an amateur marathon runner, as much for his iron will to face arduous follow-up treatment as for the physical strength needed to cope with the operation.

He has been monitored by a psychiatrist since he came into contact with the surgeons a year ago.

Surgeons in Louisville, Kentucky, Innsbruck, Austria, and Milan, Italy, were ready to conduct similar operations, Dubernard said.

Dubernard's team said it had the authorization to conduct four similar transplants in the next two years.

A team of 50 doctors and medical technicians were involved in preparation phases but only some of them took part in the operation on Thursday at the Edouard Herriot hospital in the central city of Lyon.

Dubernard performed the world's first single hand transplant in September 1998 on Australian Clint Hallam at the same hospital. Owen was also involved then.

Sixteen months later, Hallam's body has not rejected the grafted hand and forearm. However, he has said the transplant did not quite produce the full sensitivity and dexterity of his original hand.

"Clint Hallam regained his nervous sensations around two to three times more quickly than patients who have had their own hand grafted back on," Dubernard said.

French law prevents the donor being named but doctors said the family had given the go-ahead for his arms to be removed.

Hand Transplant Man Can Use Fingers

LOUISVILLE, Ky. (AP 11/29/99) --Everyday tasks -- right down to tying shoelaces -- are becoming easier for Matthew Scott, the nation's first recipient of a hand transplant.

Scott, 38, is using his left hand to open doors without having to tell himself what he needs to do every step of the way, said Anne Hodges, who was his physical therapist during his three-month recovery in Louisville.

And, although it's a struggle, he has been using his new fingers to tie his shoes for about a month.

"He can't do it fast, and he doesn't do it every day because it's not easy for him. But he can do it," Hodges said in a news release Saturday.

Hodges, who talks on the phone and writes to Scott every week or two, added that "his sensation is improving, and he's doing more with his hand that's automatic. He doesn't have to think about it."

Scott couldn't be reached for comment but said in a Thanksgiving news release that he was "most thankful for the courage and generosity of the donor family. It was their compassion that made this unbelievable gift possible."

Scott, of Absecon, N.J., received his new hand during 15 hours of surgery performed by doctors from Kleinert, Kutz Hand Care Center and the University of Louisville medical school at Jewish Hospital in January.

Some doctors criticized the surgery, saying the risks posed by the drugs Scott must take for the rest of his life to prevent his body from rejecting the new hand outweigh the benefits.

Scott lost his left hand in a firecracker accident almost 14 years ago. Formerly a paramedic, he now is a manager for an emergency medical service, and he teaches paramedic courses at a college near his home.

Dr. Warren Breidenbach, head of the team of surgeons who performed the transplant, said Scott's recent progress is encouraging.

But Breidenbach cautioned that it's too soon to rule out the possibility that more surgery may be needed to make sure the progress continues.

Scott was scheduled for a checkup in Louisville in January.

Study Tracks Transplant Death Rates

BOSTON (AP 12/30/99) -- A study of all liver transplants performed in the United States found that hospitals performing the operations infrequently have higher death rates.


Whenever I feel like exercising I lie down until the feeling goes away.
Robert Benchley

1. My grandmother started walking five miles a day when she was 60. She's 97 now and we don't know where the hell she is.

2. The only reason I would take up jogging is so that I could hear heavy breathing again.

3. I joined a health club last year, spent about 400 bucks. Haven't lost a pound. Apparently you have to show up.

4. I have to exercise in the morning before my brain figures out what I'm doing.

5. I don't exercise at all. If God meant us to touch our toes, he would have put them further up our body.

6. I like the idea of long walks, especially when people who annoy me take them.

7. I have flabby thighs, but fortunately my stomach covers them up.

8. The advantage of exercising every day is that you die healthier.

9. If you are going to try cross-country skiing, start with a small country.

10. I don't jog. It makes the ice jump right out of my glass.

Contributed by ....... the Staff of Riverside Walter Reed Cardiac Rehab., Gloucester, VA
"We testify to the accuracy of the above, when applied to Ed. UpBeat"

The researchers, who recommended that such data be made widely available to the public, said the findings were no surprise. Studies of other operations and procedures have shown that results are often poorer at inexperienced medical centers.

In this study, Erick Edwards and others from the United Network for Organ Sharing in Richmond, Va., reviewed all 9,623 liver transplants done in the United States from 1987 to 1994. The results were published in today's New England Journal of medicine.

They found that 52 hospitals did more than 20 liver transplants a year, while 47 did fewer. The yearly death rate was 20 percent in the high-volume centers and 26 percent in the ones with low volume.

Thirteen centers, all of them low volume, had annual death rates above 40 percent. At one hospital, the death rate was 100 percent.

The hospitals surveyed were not identified.

A Leftover Tidbit...

One night over dinner in a restaurant in Ciudad Juarez, a businessman was telling me about a Kuwaiti potentate who owns a 747 with a gyroscopically rotating prayer room perpetually oriented toward Mecca. This Kuwaiti has serious heart problems, the businessman continued, so he had converted the plane's upper deck into a cardiac intensive-care unit with all the latest technology. I made suitable murmurings of awe. The businessman smiled patiently, and then got to the part that impressed even him: "The plane is also equipped," he said, "with a living donor." A heart donor, that is. It was a poor man of compatible tissue type whose reward, it seemed, was living well for a little while and the promise that his family would live well afterward.

The story naturally stuck with me. Maybe it was just the usual mix of horror story and envy that we crave when we tell ourselves stories about the rich. Maybe it was just a story, a nice twist on the old Yiddish conundrum: "If the rich could hire other people to die for them, the poor would make a wonderful living." But it left me with a lingering sense that the rules of the natural world, rules by which the rest of us live and die, might not apply to the very rich: They have money enough to buy a man's heart, literally. Enough to buy time.

This is a delusion to which the rich themselves are highly susceptible. "The rules are - - - there are no rules. Aristotle Onassis once said, and you can understand the attitude, given the unreal quality of the lives the rich lead.

Opening paragraphs of the Natural History of the Rich by Richard Conniff Worth Magazine. Jan/Feb 2000. Contributed by Marguerite Supler, Gloucester, VA.

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