Wednesday, November 05, 2008

Why heart pumps could kill off the transplant

There are no rejection problems, and they cost a lot less than transplants. The new, smaller heart pumps could save thousands of lives. So why are they still treated as the poor relation?

When the South African surgeon Christiaan Barnard carried out the first heart transplant in December 1967, the world held its breath. His patient, 53-year-old Lewis Washkansky, lived for only another 18 days. The drugs he needed to stop his body rejecting the new organ compromised his immune system to such an extent he couldn't fight off other illnesses, and he died of pneumonia. But the precedent had been set: the most powerful and emotionally iconic of human organs could be taken from the body of a dead person to give the chance of an extended life to another. It was a transforming, era-defining moment that reinforced our faith in medical science and ensured Barnard's place in history. But how successful would heart transplantation be in the long term?

Just over 40 years later, the very same question is still being asked. The procedure, and the drugs needed to maintain a newly donated heart, may be much more sophisticated, and heart transplants may be regarded by the public as one of the most glamorous of surgical career paths, but surgeons themselves are carrying out significantly fewer of the operations. This is partly because a range of other treatments is available to patients, and partly because of the low number of suitable donor hearts.

When surgeons do operate, the outcome is often poor. Of the 100-plus people who receive a new heart each year, 10 are likely to die within 12 months as a result of donor-organ rejection and other complications; and of the remainder, a significant proportion will develop cancer within five years from the toxic anti-rejection drugs they must take for the rest of their lives. Specialists argue that the number of long-term survivors has increased, with some living for decades; but they admit that most transplant patients die within 10 years of receiving a new organ.

In the past year and a half, the deaths of 11 patients who had just received new hearts has raised more serious questions about our cardiac-transplant programme. In that time, both Papworth hospital in Cambridgeshire and Harefield, on the outskirts of London - the most prestigious centres in the UK for heart transplants - have had to suspend these operations because of a run of unexplained deaths: seven patients at Papworth from January to September 2007, and four at Harefield who died one after the other between July and October this year. None of the victims survived to leave hospital, each one dying within a month of their operation. An inquiry at Papworth, where the deaths represented more than one-third of the 20 transplants carried out there last year, was inconclusive. At Harefield, an inquiry is ongoing.

Meanwhile, the number of organ donations has plummeted to an all-time low: only 135 patients received new hearts in the year to April 2008; more than 500 hearts were offered for transplant, but many were not considered a suitable match or of sufficient quality for their intended recipients. At the procedure's peak, in 1989/90, there were over 400 heart transplants. Today there are simply fewer good hearts to choose from, because seat-belt legislation has dramatically cut the number of deaths in road accidents, and thus the number of hearts available for transplantation, and because families are often unwilling to offer up their newly deceased loved ones for organ harvesting. There are now so few heart-transplant surgeons in the country - 50 at most - that it's easy to imagine a time when they outnumber the available donors; not a state of affairs Barnard could have imagined all those years ago.

Against this background, some heart surgeons are arguing that we need to think again and turn our attention to electric heart pumps, an apparently riskier medical solution, but one that offers a cheaper, off-the-shelf opportunity to save a life without someone having to die first; and one that has been proved to have therapeutic potential for those who merely need to rest their heart, not replace it.

Paul Maidment, an army chef, is a case in point. At the time that the unlucky patients at Papworth and Harefield were preparing themselves for transplant surgery last year, Maidment was larking about with his mates in the catering corps in Iraq, fronting a band called the Basra City Rollers. By May this year he was fighting for his life, his heart stopping every few minutes even as doctors struggled to keep it going. It was not a stray bullet that had caused the lethal damage, but a rare adrenalin-secreting tumour that was pouring toxic quantities of the fight-or-flight hormone into his bloodstream, sending his blood pressure soaring and putting a fatal strain on his heart. At the age of 28, Maidment appeared to have metamorphosed from a muscle-bound model for army recruitment into a near-corpse, wracked by repeated heart attacks.

Nobody at the Royal Devon and Exeter hospital knew what to do. David Smith, the cardiologist treating Maidment, was aware of implantable electric heart pumps that could take the strain off exhausted hearts like his, giving the muscle vital time to recover. Smith had read a paper produced by a team in Oxford - one of a small number of groups lobbying for the use of such devices - which had achieved remarkable results with the handful of patients who had received charitable funding for the devices (each unit costs between 40,000 and 60,000 pounds).

The problem in this case wasn't funding but logistics: how to get Maidment to Oxford's John Radcliffe hospital, where a pump could be fitted while he was still attached to the roomful of equipment that might or might not keep him going for the journey. A Sea King helicopter was scrambled by the army for the 40-minute trip. His parents, Steve and Sandy, followed by car. "We'd been told he would probably die on the journey," says his mother. "He was cold and sweaty, and his skin was like candle wax, the most awful colour I have ever seen." By the time the couple reached the hospital, the pump was already in. Stephen Westaby, a cardiac surgeon turned professor of biomedical sciences, who has led the world in the use of the technology, assured them their son would live.

Four days later Maidment's heart was sufficiently rested from its trauma for the pump to be removed. Two weeks after that, he was off the drugs that had kept him unconscious while he recovered. Coincidentally, a letter announcing his promotion from corporal to sergeant had arrived at his home during his suspension from existence. Life, for him, goes on.

For many sufferers of heart problems, that is not the case. Britain has one of the highest heart-disease rates in the developed world: 700 people a day have a heart attack, which usually leaves the muscle damaged and weakened. Every year 100,000 people die of heart failure, either as a result of this damage or as a consequence of infection, high blood pressure or inherited heart weakness. At the moment only 105 of these patients have made it onto the heart-transplant waiting list because the number of available organs is so small. But could many more benefit from a pump?

The doctors crusading for their greater use are convinced that the life-saving possibilities of the new battery-operated devices have been under-researched to keep a lid on spiralling healthcare costs, and to ensure that talking up the pumps does not deal a potentially fatal blow to Britain's struggling heart-transplant industry. They are keen that patients should have a range of treatments available and want to widen the debate, not narrow it.

There are also uncomfortable ethical issues that the campaigners would rather not address. The advent of electric heart pumps raises the possibility of thousands of wealthy old people demanding access to a new lease of battery-powered life. In the United States, Westaby's innovation is proving popular with a growing number of over-75s. There are an estimated 1,000 battery-operated elderly Americans going about their business in the US. The record for the oldest patient to be fitted with one has just been set by an 87-year-old from San Diego. Because the research isn't available, nobody knows how long these patients may live.

Back in the more prosaic world of the British NHS, the deaths at Papworth and Harefield have raised inevitable questions. Is the stock of good hearts decreasing? Are surgeons doing enough operations to maintain their skill levels? "There was no common factor to explain the deaths which occurred here," said a Papworth spokesman.

While awaiting the full results of their inquiry, Harefield say they see no obvious pattern emerging: their four deaths involved hearts from three different unidentified retrieval centres, with three different surgeons operating. In addition to Harefield and Papworth, specialist units in Newcastle, Manchester and Birmingham also receive heart-transplant patients. A handful more are occasionally carried out in Glasgow (three in the year to April 2008) and at Great Ormond Street children's hospital in London, which did nine in the same year. Each centre employs up to five highly skilled transplant surgeons to give the requisite 24-hour cover. That means most of them are doing no more than four to six transplants a year - considerably fewer than, for example, liver- or kidney-transplant surgeons. The UK performs between 600 and 700 liver transplants a year and more than 1,300 kidney transplants.

Children currently have better survival rates than adults for heart transplants, and as yet there is no immediate possibility of a paediatric pump being made available to them. For around 30 youngsters a year, transplantation is their best chance of a span of extra life. Mike Burch, a senior cardiologist who is lead transplant consultant at Great Ormond Street, says he has used 16 heart pumps in children to keep them alive while they wait for a donor organ, but in none of these cases did the child's heart stage the miraculous recovery seen in adult hearts relieved of the burden of pumping. He thinks donor- organ transplants will for some time remain the only option for children.

More here

Losing weight with a food diary

Simply writing down your daily food intake can double your weight loss -- for some people anyway

When Bridget Jones slavishly recorded her lists - "Food consumed today: 2 pkts emmenthal cheese slices, 14 cold new potatoes, 2 bloody marys, 12 Milk Tray" - it turns out she was way ahead of medical science. According to the American Journal of Preventive Medicine, dieters who keep a food diary can double their weight loss. The study followed 1,700 overweight people over six months, and revealed that those who wrote down everything they ate lost an average of 13lb.

"Recording what you eat can really help you lose weight, because a lot of the time, you're not conscious of your behaviour," says Azmina Govindji, a consultant nutritionist and author of The Hot Body Plan. "Some eating habits are situational - for example, having tea and a chocolate biscuit while watching your favourite television programme. We do it on autopilot. If you know that you actually have to record every item you eat, it gives a split-second pause for thought. You think, `Do I really want to write this down?' "

It's a trend that is sweeping America, with a plethora of websites, such as, that allow users to log their food sins into a digital confessional that even calculates the calories for you. Julia Cameron, author of the creativity bible The Artist's Way, has gone a step further with The Writing Diet, a self-help book that explores the link between eating mindfully and living a happy life.

"Through the use of a food journal, we often become aware of patterns that are self-destructive," Govindji says. "We become more authentically honest with ourselves, and we start asking the question `What's eating me?' instead of `What can I eat?' " Even people who believe that they are resolutely healthy can get a shock when they see everything written down in black and white. "Mothers who eat the last few chips on a child's plate, or the single woman who reaches for the H„agen-Dazs when she's feeling lonely in front of the TV, start to see where their diets are going wrong," she says.

These emotional triggers can often come as the biggest surprise. To this end, Govindji gets clients to keep a "food and mood" diary, so they write down not only every mouthful they eat, but the time of day and how they were feeling at that moment. "Once someone spots a pattern, then they can do something to change it," she says. The most common patterns she uncovers are in those who eat naughty foods because they are bored, hormonal or depressed.

Which brings us to an obvious flaw in the food diary. Surely mere mortals are tempted to cheat? "Well, yes, we're all human. If someone is going to see an expert, they are obviously going to be concerned to be seen in a good light," she concedes. "But if you're just doing this at home for yourself, what would be the point of lying? You're setting up a dialogue with yourself, so there's no point. It can just be for your eyes only."

In any case, new research from the University of Wisconsin-Madison has revealed a way around the tendency to fib - the photo diary. Taking a digital snap of every meal was shown to be an even more powerful and accurate weight-loss tool. One volunteer told the researchers: "I had to think more carefully about what I was going to eat because I had to take a picture of it. I was less likely to have a jumbo bag of M&M's. It curbed my choices. It didn't alter them completely, but who wants to take a photo of a jumbo bag of M&M's?"

Who, indeed. But the good news, according to Govindji, is that you don't have to keep this up for very long. "Two or three days is enough to get a real understanding of how and why we eat what we do."


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