Rare liver transplant offers hope
Sun, 02 Dec 2007 17:41:39 GMTBy RASHA MADKOUR, Associated Press Writer
MIAMI - Kimberly Lindsey marvels that her 3-year-old son Merrick doesn't need to take 10 different medicines anymore. He can safely frolic on the playground among the germs that lurk there.
Two years ago, Merrick's liver suddenly shut down. Standard treatment would have meant a full liver transplant and a lifetime on drugs to keep his body from rejecting the new organ. The medication suppressing his immune system would have raised his risk for infection and possibly damaged his kidneys.
Instead, Merrick underwent a rare and once virtually abandoned operation in which a partial donor liver was attached temporarily to his failing liver.
His own liver regenerated, and the transplanted liver is shrinking and may eventually waste away. He has been taken off the anti-rejection medication.
Seven children have had the operation at the University of Miami/Jackson Memorial Hospital — the only U.S. facility believed to be regularly performing the surgery. Four of them are now off anti-rejection drugs and a fifth is close.
The procedure was first tried in the mid-1990s, but U.S. doctors thought the chance of death or complications was too high. One patient who had the surgery at the Miami hospital in 1998 remained hospitalized for three months because of complications. Ultimately, his liver recovered and he too was taken off the anti-rejection drugs.
Surgeons in England, France and Japan continued to do the procedure, and in several cases had favorable results. Jackson's Dr. Tomoaki Kato was encouraged by reports out of Europe. Since 2005, he has performed six partial transplants; all have survived.
It's "time to revisit the procedure," said Kato, the hospital's director of pediatric liver and gastrointestinal transplant program. "There's a great benefit for the children and the technology has developed so much."
Still, some surgeons say they will stick with the traditional transplant until they see more proof that the partial transplant is safe. The operation can take more than 10 hours, twice as long as the standard transplant surgery, and is more complicated, increasing risks to the patient. After surgery, a patient must have multiple biopsies to see if his own liver is regenerating.
Dr. Charles Miller, director of liver transplantation at the Cleveland Clinic, said that what concerns surgeons "is that you're taking a very sick patient and, in most cases, you would rather do the simplest operation."
The liver, which cleans toxins from the blood, is unique among the body's organs in its ability to regenerate, making the procedure possible. In some cases, the liver can recover from acute, or sudden, failure on its own. But if the organ doesn't recover fast enough, patients can suffer brain damage from the toxins if they don't get a transplant.
For Lindsey, choosing the potentially riskier partial transplant for Merrick was easy. Either road was going to be difficult, she said, and at least with the partial transplant, the little boy had a chance to regain the use of his own liver.
Little more than a year after the operation, Merrick's liver had regenerated enough that Kato took him off his anti-rejection drugs. His transplanted liver is shrinking and may eventually disappear.
"I can sit here and say my son is off. He's off everything," Lindsey said. "What they did was a true miracle."
Because the operation is so rare, organizations like the United Network for Organ Sharing and the American Liver Foundation do not track the number of partial transplants performed or have specific guidelines for it.
Kato has created his own rough guidelines. He says children fare better with the operation because their livers have better rejuvenating abilities than adults, and he's only used it for cases of acute liver failure. Chronic liver problems, like hepatitis or cancer, would not be cured with this procedure.
Using this criteria, the number of people who could benefit from this procedure is limited. Fewer than 400 people got transplants for acute liver failure in 2006, about a fifth of them children, according to data from the Organ Procurement and Transplantation Network.
The procedure is covered by insurance companies. Kato said the cost is roughly the same as traditional transplants. He also noted the long-term health care savings: After patients get off anti-rejection drugs, they save thousands of dollars a year.
And while the Miami patients received livers from deceased donors, the surgery could be performed using a live donor, such as a parent if tests showed compatibility.
The University of Chicago's Dr. Donald Jensen said that although the procedure is promising, if his own child were involved, he would still choose a standard liver transplant.
Jensen, director of the university's Center for Liver Disease, said some of the partial transplant's safety and other issues, still need to be worked out.
Some of Kato's patients have needed a second surgery to remove the transplanted partial liver because it became inflamed after anti-rejection drugs were halted. And a few have yet to get off those drugs.
Yailin Nunez's 2-year-old son Jonathan was the sixth patient to have the partial liver transplant at Miami. Of all the patients, his liver has shown the least recovery more than 20 months later, even compared to a boy who had the operation this summer.
"I still have faith my son's liver's going to regenerate.... It's just taking a little longer," Nunez said through tears. "And if it doesn't, it's OK.... We're given the chance and I've met other moms who weren't given the chance."
Brenner Logan's parents are praying the toss-up goes in their favor. In August, the 2-year-old became the most recent to have the surgery.
His liver is already showing signs of recovery.
Brenner's mother, Kristen Logan, is cautiously optimistic. After her son's surgery, she met one of the patients whose transplant was a success.
"You think, 'Wow. This could be my son,'" Logan said. "You begin to have so much more hope for the future."
Study Immaturity may spark teen crime
Sun, 02 Dec 2007 17:24:53 GMTBy MALCOLM RITTER, AP Science Writer
NEW YORK - The teenage brain, Laurence Steinberg says, is like a car with a good accelerator but a weak brake. With powerful impulses under poor control, the likely result is a crash.
And, perhaps, a crime.
Steinberg, a Temple University psychology professor, helped draft an American Psychological Association brief for a 2005 case in which the U.S. Supreme Court outlawed the death penalty for crimes committed before age 18.
That ruling relies on the most recent research on the adolescent brain, which indicates the juvenile brain is still maturing in the teen years and reasoning and judgment are developing well into the early to mid 20s. It is often cited as state lawmakers consider scaling back punitive juvenile justice laws passed during the 1990s.
"As any parent knows," wrote Justice Anthony Kennedy for the 5-4 majority, youths are more likely to show "a lack of maturity and an underdeveloped sense of responsibility" than adults. "These qualities often result in impetuous and ill-considered actions and decisions."
He also noted that "juveniles are more vulnerable or susceptible to negative influences and outside pressures, including peer pressure," causing them to have less control over their environment.
Some child advocates have pointed to the Supreme Court decision and the research as evidence that teens — even those accused of serious crimes — should not be regarded in the same way as adults in the criminal justice system.
Dr. David Fassler, a psychiatry professor at the University of Vermont College of Medicine who has testified before legislative committees on brain development, says the research doesn't absolve teens but offers some explanation for their behavior.
"It doesn't mean adolescents can't make a rational decision or appreciate the difference between right and wrong," he said. "It does mean, particularly when confronted with stressful or emotional decisions, they are more likely to act impulsively, on instinct, without fully understanding or analyzing the consequences of their actions."
Experts say that even at ages 16 and 17, when compared to adults, juveniles on average are more:
_impulsive.
_aggressive.
_emotionally volatile.
_likely to take risks.
_reactive to stress.
_vulnerable to peer pressure.
_prone to focus on and overestimate short-term payoffs and underplay longer-term consequences of what they do.
_likely to overlook alternative courses of action.
Violence toward others also tends to peak in adolescent years, says psychiatrist Dr. Peter Ash of Emory University. It's mostly likely to start around age 16, and people who haven't committed a violent crime by age 19 only rarely start doing it later, he said.
The good news here, he said, is that a violent adolescent doesn't necessarily become a violent adult. Some two-thirds to three-quarters of violent youth grow out of it, he said. "They get more self-controlled."
Some of the changes found in behavioral studies are paralleled by changes in the brain itself as youths become adults.
In fact, in just the past few years, Steinberg said, brain scans have given biological backing to commonsense notions about teen behavior, like their impulsiveness and vulnerability to peer pressure.
It's one thing to say teens don't control their impulses as well as adults, but another to show that they can't, he said. As for peer pressure, the new brain research "gives credence to the idea that this isn't a choice that kids are making to give in to their friends, that biologically, they're more vulnerable to that," he said.
Consider the lobes at the front of the brain. The nerve circuitry here ties together inputs from other parts of the brain, said Dr. Jay Giedd of the National Institute of Mental Health.
This circuitry weighs how much priority to give incoming messages like "Do this now" versus "Wait! What about the consequences?" In short, the frontal lobes are key for making good decisions and controlling impulses.
Brain scans show that the frontal lobes don't mature until age 25, and their connections to other parts of the brain continue to improve to at least that age, Giedd said.
The inexplicable behavior and poor judgments teens are known for almost always happen when teens are feeling high emotion or intense peer pressure, conditions that overwhelm the still-maturing circuitry in the front part of brain, Giedd said.
As Steinberg sees it, a teenager's brain has a well-developed accelerator but only a partly developed brake.
By around 15 or 16, the parts of the brain that arouse a teen emotionally and make him pay attention to peer pressure and the rewards of action — the gas pedal — are probably all set. But the parts related to controlling impulses, long-term thinking, resistance to peer pressure and planning — the brake, mostly in the frontal lobes — are still developing.
"It's not like we go from becoming all accelerator to all brake," Steinberg said. "It's that we go from being heavy-foot-on-the-accelerator to being better able to manage the whole car."
Giedd emphasized that scientists can't yet scan an individual's brain and draw conclusions about how mature he is, or his degree of responsibility for his actions.
Brain scans do show group differences between adult and teen brains, he said, "but whether or not that should matter is the part that needs to be decided more by the judicial system than the neuroscientist."
Steinberg, who frequently testifies on juvenile justice policy and consults with state legislators on the topic, said it's not clear to him how much the research on teen brains affects lawmakers. They seem more swayed by pragmatic issues like the cost of treating teens as adults, he said. But he noted that he has been asked to testify more in the past few years than before.
In any case, experts say, there's nothing particularly magic about the age 18 as a standard dividing line between juveniles and adults in the courtroom.
Different mental capabilities mature at different rates, Steinberg notes. Teens as young as 15 or 16 can generally balance short-term rewards and possible costs as well as adults, but their ability to consider what might happen later on is still developing, he said.
A dividing line of age 18 is better than 15 and not necessarily superior to 19 or 17, but it appears good enough to be justified scientifically, he said.
Steinberg said he thinks courts should be able to punish some 16- or 17- year olds as adults. That would be reserved for repeat violent offenders who've resisted rehabilitation by the juvenile justice system, and who could endanger other youth in the juvenile system if they returned. "I don't think there are a lot of these kids," Steinberg said.
For the rest, he thinks it makes sense to try rehabilitating young offenders in the juvenile justice system. That's better than sending them through the adult system, which can disrupt their development so severely that "they're never going be able to be a productive member of society," Steinberg said. "You're not doing society any favor at all."
Ash said that to decide whom to treat as an adult, courts need some kind of guideline that combines the defendant's age with the crime he's accused of. That should leave room for individual assessments, he said.
But "we don't have very good measuring sticks" for important traits like how impulsive a juvenile is, he said.
In any case, the decision for each defendant should balance a number of reasons for punishment, like retribution, protecting society, deterring future crime, and rehabilitation, said Ash, who's a member of the American Psychiatric Association's Committee on Judicial Action.
Even if a 14-year-old murderer is held morally responsible for the crime, he will have matured by the time he's 18, and in the meantime he may be more amenable to rehabilitation than an adult murderer is, Ash said.
In fact, most experts conclude that rehabilitation works better for juveniles than for adult offenders, he said.
And just as parents know how irrational juveniles can be, Ash said, they also know that rehabilitation is a key goal in punishing them.
"What we really want," he said, "is to turn delinquent kids into good adults."
___
On the Net:
American Psychiatric Association statement on youth sentencing: http://www.abanet.org/crimjust/juvjus/simmons/ama.pdf
American Psychological Association brief: http://www.apa.org/psyclaw/roper-v-simmons.html
____
AP National Writer Sharon Cohen contributed to this story.
Mandela Halting new HIV infections key
Sun, 02 Dec 2007 10:12:47 GMTBy CELEAN JACOBSON, Associated Press Writer
JOHANNESBURG, South Africa - The world must not grow complacent about AIDS because the number of new HIV infections still outpaces the number of those being treated for the disease, former South African President Nelson Mandela said at a benefit concert Saturday.
Since stepping down as South Africa's first black president in 1999, Mandela, whose son died from the disease, has championed the cause of people with AIDS. On Saturday, he drew a crowd of about 15,000 to his fifth international awareness concert, held this year to coincide with World AIDS Day.
Recent U.N. figures estimate that the number of AIDS cases fell from almost 40 million last year to 33.2 million in 2007.
"This lower figure suggests that prevention programs have been successful in bringing down infection rates," Mandela said. "That trend is encouraging but it is still alarming that for every person receiving treatment, four others are newly infected."
"If we are to stop the AIDS epidemic from expanding we need to break the cycle of new HIV infections. All of us working together with government, communities and civil society can make the difference that is needed. Together we have the power to change the course of destiny," he said to rapturous applause.
Wearing a sweat shirt emblazoned with 46664 — the number apartheid prison authorities gave him — the 89-year-old statesman beamed and waved at the crowd who chanted his name.
Of South Africa's 48 million people, about 5.5 million are infected with the AIDS virus — the highest number in the world — and about 900 people in the country die every day from the disease.
Sub-Saharan Africa remains the center of the epidemic. AIDS is still the leading cause of death there; it particularly affects women and children.
At the event, the singer Annie Lennox expressed her anger at the number of children who die from AIDS-related diseases.
"Why is this happening?" Lennox asked. "It is an outrage and it needs to be dealt with. It is unacceptable that children die from a preventable disease. Treatment works. Get your government to do something about it."
The reference was to South Africa's often confusing message about antiretroviral drugs, and the slow rollout of the lifesaving medicines.
Star after star appealed to the crowd to heed the slogan of the campaign — "It is in your hands" — calling on them to get tested and practice safe sex.
The musician Peter Gabriel likened the fight against AIDS to the fight against apartheid.
Introducing his song "Biko," about the South African activist who died in detention in 1977, Gabriel paid tribute to the bravery of those who fought the racist regime.
"We must not forget them. We need to focus the same power and intensity in the struggle against AIDS that was in the struggle against apartheid," he said.
Speaking at a World Aids Day event elsewhere in the country, President Thabo Mbeki, who has been criticized for his handling of the AIDS crisis, said that the government's plea to South Africans to be faithful and use condoms was not being heeded.
"What is really of importance is that we must, all of us, take these messages very seriously, particularly our young people," Mbeki said on SABC radio.
"We don't want our people to be suffering from ill health when they could have handled their own lives in a way that makes for healthy lives."
Mandela launched the AIDS awareness campaign in 2003. Funds raised through the concerts are used to increase awareness of the AIDS pandemic, particularly among young people. More than $3 million has been raised through the concerts so far.
Other performers Saturday included Angelique Kidjo, Ludacris, Corinne Bailey Rae and the Goo Goo Dolls. All performed for free.
__
On the Net:
46664 Campaign: http://www.46664.com
Brazil to dispense condoms in schools
Sat, 01 Dec 2007 19:56:37 GMTRIO DE JANEIRO, Brazil - Brazil's government announced plans to put condom-dispensing machines in public schools to help teenagers reduce the spread of AIDS.
The health and education ministries and the United Nations sponsored a nationwide contest for students to design the dispenser. Three potential models were selected on Friday, the government news agency Agencia Brasil said.
Condom machines are to be installed in 100 public schools in 2008, officials said.
The head of the National Program of Sexually Transmitted Diseases, Mariangela Simao, said part of the project is educational and aims not to "banalize" the use of condoms. She said 100,000 schools were involved with the anti-AIDS program.
Health Minister Jose Gomes Temporao this week said young Brazilians between 13 and 24 were the target of Brazil's anti-AIDS campaign this year. Nearly 70,000 cases of AIDS were registered among Brazilians under 24, or about 16 percent of the cases reported in the country, according to the anti-AIDS program.
Brazil provides free AIDS drugs to anyone who needs them and has aggressively pushed drug manufacturers to lower prices.
