DiversityNursing Blog

By GILLIAN MOHNEY

A Colorado family welcomed a larger-than-expected bundle of joy when their newborn daughter was born weighing almost 14 pounds.

Mia Yasmin Hernandez tipped the scales at 13 pounds, 13 ounces after her delivery Monday at San Luis Valley Hospital in Alamosa, Colorado. The newborn’s father, Francisco Garcia, said doctors had estimated the baby would weigh 8 pounds at birth.

Mia didn't seem especially large when she was born, Gracia said.

“She was swollen and everything” after delivery, he said. “I thought she was going to [weigh] 10 or 11 pounds.”

But after weighing Mia, the nurse told Garcia the infant’s weight.

“I was like, ‘Whoa, she’s the biggest baby I’ve ever seen,’” Garcia told ABC News.

Even hospital personnel agreed. Garcia said the nurse told hi she’d never seen “a baby that big.”

Dr. Robert Barbieri, chief of obstetrics and gynecology at Brigham and Women’s Hospital in Boston, said in a previous interview about one out of 1,000 babies could weigh 11 pounds, and one out of every 100,000 could weigh 14 pounds. A 14-pound baby, he said, is extremely rare, because usually a doctor will induce labor if a baby appears oversize.

While Mia’s delivery via Caesarean section went smoothly, the infant developed breathing problems and was eventually moved to Children’s Hospital of Colorado in Aurora, Colorado, according to Garcia.

Garcia said Mia is on oxygen and doing well, although they’re not sure when she will get home.

Garcia said the couple has another four daughters at home, which might come in handy for new baby clothes.

“We bought her a lot of stuff like a newborn cap and pampers,” Garcia said. “They don't fit her. She’s too big.”

Source: http://abcnews.go.com

By Dennis Thompson

Already-strong public support for right-to-die legislation has grown even stronger in the days since the planned death of 29-year-old brain cancer patient Brittany Maynard, a new HealthDay/Harris Poll has found.

An overwhelming 74 percent of American adults now believe that terminally ill patients who are in great pain should have the right to end their lives, the poll found. Only 14 percent were opposed.

Broad majorities also favor physician-assisted suicide and physician-administered euthanasia.

Only three states -- Oregon, Washington and Vermont -- currently have right-to-die laws that allow physician-assisted suicide.

"Public opinion on these issues seems to be far ahead of political leadership and legislative actions," said Humphrey Taylor, chairman of The Harris Poll. "Only a few states have legalized physician-assisted suicide and none have legalized physician-administered euthanasia."

People responded to the poll in the weeks after Maynard took medication to end her life in early November.

Maynard moved from California to Oregon following her diagnosis with late-stage brain cancer so she could take advantage of the state's "Death With Dignity Act." Her story went viral online, with a video explaining her choice garnering nearly 11.5 million views on YouTube.

A "poster child for the movement," Maynard helped spark conversations that allowed people to put themselves in her shoes, said Frank Kavanaugh, a board member of the Final Exit Network, a right-to-die advocacy group.

"I think it is just a natural evolution over a period of time," Kavanaugh said of the HealthDay/Harris Poll results. "There was a time when people didn't talk about suicide. These days, each time conversations occur, people think it through for themselves, and more and more are saying, 'That's a reasonable thing to me.'"

The poll also found that:

• Support for a person's right to die has increased to 74 percent, up from 70 percent in 2011. Those opposed decreased to 14 percent from 17 percent during the same period.
• Physician-assisted suicide also received increased support, with 72 percent now in favor, compared with 67 percent in 2011. Opposition declined from 19 percent to 15 percent.
• Sixty-six percent of respondents said doctors should be allowed to comply with the wishes of dying patients in severe distress who ask to have their lives ended, up from 58 percent in 2011. Opposition decreased from 20 percent in 2011 to 15 percent now.

"The very large -- more than 4-to-1 and increasing -- majorities in favor of physician-assisted suicide, and the right of terminally ill patients to end their lives are consistent with other liberal social policy trends, such as support for same-sex marriage, gay rights and the decriminalization of marijuana, seen in the results of referendums and initiatives in the recent mid-term elections," Taylor said.

Support for the right-to-die movement cut across all generations and educational groups, both genders, and even political affiliation, the poll found.

Democrats tended to be more supportive of right-to-die legislation, but 56 percent of Republicans said they favor voluntary euthanasia and 63 percent favor physician-assisted suicide.

Kavanaugh was not surprised. "People think of this as a liberal issue. But I find that as I talk to [conservatives], you can appeal to them on the basis of 'get the government the hell out of my life,'" he said.

But the public is split over how such policies should be enacted, with 35 percent saying that the states should decide on their own while 33 percent believe the decision should be made by the federal government, the poll found.

"Most of the people I know in the field whose opinion I put stock in don't feel there's ever going to be federal movement on it," Kavanaugh said. "You're just going to have to suffer through a state-by-state process."

Kavanaugh does believe this overwhelming public support will result in steady adoption of right-to-die laws.

"I think this will become the ultimate human right of the 21st century, the right to die with dignity," he said. "There are good deaths and bad deaths, and it is possible to have a good death."

Despite increasing public support for assisted suicide, stiff opposition remains in some quarters.

"Assisted suicide sows confusion about the purpose of life and death. It suggests that a life can lose its purpose and that death has no meaning," Rev. Alexander Sample, archbishop of the Archdiocese of Portland in Oregon, said in a pastoral statement issued during Maynard's final days.

"Cutting life short is not the answer to death," he said. "Instead of hastening death, we encourage all to embrace the sometimes difficult but precious moments at the end of life, for it is often in these moments that we come to understand what is most important about life. Our final days help us to prepare for our eternal destiny."

Todd Cooper, a spokesman for the Portland archdiocese, said the debate over assisted suicide touches him on a very deep level because of his wife, Kathie.

About 10 years ago, she also was diagnosed with terminal brain cancer. She endured two brain surgeries, two years of chemotherapy and six weeks of radiation therapy, and remains alive to this day.

"If she'd given up the fight for life, she wouldn't be here," Cooper said. "That doesn't necessarily happen in every case, but it gives hope for those who struggle to the very end."

source: www.medicinenet.com

Nursing students with previous caring experience are less likely to perform better academically and clinically than those who have none, research shows.

A study assessing the criteria for selecting nursing students found that high emotional intelligence did not mean students performed better on their courses.

Researchers also found that of the students who have withdrawn from their studies, nearly 60 per cent had previous caring experience.

The ongoing study, led by the University of Edinburgh, is tracking performance and emotional intelligence - the ability to recognise your own and other people's feelings and act accordingly - of nearly 900 nursing and midwifery students from the University of the West of Scotland and Edinburgh Napier University.

Researchers found, however, that performance improved with age and that female trainees scored significantly better than male counterparts.

The findings come after the 2013 Frances Report - which highlighted care failings at the Mid Staffordhire NHS Foundation Trust - recommended an emphasis on creating a more compassionate end empathetic culture in nursing.

As a result, aspiring nurses in England could potentially be required to spend a placement year as a carer before undertaking their training.

Lead researcher Rosie Stenhouse, lecturer in Nursing Studies at the University of Edinburgh, said: "The research should sound a note of caution to such pilot schemes. They are potentially expensive, politically motivated and not backed up by evidence."

Source: www.medicalnewstoday.com

By  Kimberly Yam

This young girl is truly benevolent beyond her years.

Three-year-old Ariana Smith from Winterport, Maine watched a video from Extra Life, a charity that raises money for Children’s Miracle Network Hospitals through video gaming, that featured a girl who didn't have any hair. The curious kid then decided to ask her parents about what she saw, Josh Smith, Ariana's father, told the Huffington Post in an e-mail.

"She asked why the little girl had no hair. We explained that she was sick and that the medicine they were using made her hair fall out," Smith said.

The chat left a strong impression on Ariana. 

“Without a second thought, Ariana said ‘Oh, well she can have some of my hair,’” Smith told ABC News.

So, on November 21st, the toddler received her first cut, and with the help of her parents, donated her hair to Locks Of Love. The pictures from the milestone, which were posted on Imgur, have since gone viral with over 500,000 views -- an ode to the 3-year-old's generosity. 

"She could be so selfless like that," Smith told ABC News. "Her first reaction is ‘How about I give up something that I have so a little girl can feel pretty'."

While Ariana's act of kindness is a noble one, her father says that he wasn't surprised when she expressed her desire to donate her hair. He told HuffPost that she loves helping others -- even when she's playing.

"I think she’s just a caring person," he wrote. "She has a little play set of medical devices which she uses often. I’ve had my blood pressure and heart rate 'checked' hundreds of times this year."

As for Ariana's new hairstyle, the toddler seems to be adjusting quite nicely to her fashion statement. 

"She loves it," Smith says of her daughter's new hairdo. "She can eat her breakfast without worrying about her hair drooping into it."

Source: www.huffingtonpost.com

Researchers have developed a new device that may result in more comfortable mammography for women. According to a study being presented next week at the annual meeting of the Radiological Society of North America (RSNA), standardizing the pressure applied in mammography would reduce pain associated with breast compression without sacrificing image quality.

Compression of the breast is necessary in mammography to optimize image quality and minimize absorbed radiation dose. However, mechanical compression of the breast in mammography often causes discomfort and pain and deters some women from mammography screening.

An additional problem associated with compression is the variation that occurs when the technologist adjusts compression force to breast size, composition, skin tautness and pain tolerance. Over-compression, or unnecessarily high pressures during compression, is common in certain European countries, especially for women with small breasts. Over-compression occurs less frequently in the United States, where under-compression, or extremely low applied pressure, is more common.

"This means that the breast may be almost not compressed at all, which increases the risks of image quality degradation and extra radiation dose," said Woutjan Branderhorst, Ph.D., researcher in the Department of Biomedical Engineering and Physics at the Academic Medical Center in Amsterdam.

Overall, adjustments in force can lead to substantial variation in the amount of pressure applied to the breast, ranging from less than 3 kilopascals (kPa) to greater than 30 kPa.

Dr. Branderhorst and colleagues theorized that a compression protocol based on pressure rather than force would reduce the pain and variability associated with the current force-based compression protocol. Force is the total impact of one object on another, whereas pressure is the ratio of force to the area over which it is applied.

The researchers developed a device that displays the average pressure during compression and studied its effects in a double-blinded, randomized control trial on 433 asymptomatic women scheduled for screening mammography.

Three of the four compressions for each participant were standardized to a target force of 14 dekanewtons (daN). One randomly assigned compression was standardized to a target pressure of 10 kPa.

Participants scored pain on a numerical rating scale, and three experienced breast screening radiologists indicated which images required a retake. The 10 kPa pressure did not compromise radiation dose or image quality, and, on average, the women reported it to be less painful than the 14 daN force.

The study's implications are potentially significant, Dr. Branderhorst said. There are an estimated 39 million mammography exams performed every year in the U.S. alone, which translates into more than 156 million compressions. Pressure standardization could help avoid a large amount of unnecessary pain and optimize radiation dose without adversely affecting image quality or the proportion of required retakes.

"Standardizing the applied pressure would reduce both over- and under-compression and lead to a more reproducible imaging procedure with less pain," Dr. Branderhorst said.

The device that displays average pressure is easily added to existing mammography systems, according to Dr. Branderhorst.

"Essentially, what is needed is the measurement of the contact area with the breast, which then is combined with the measured applied force to determine the average pressure in the breast," he said. "A relatively small upgrade of the compression paddle is sufficient."

Further research will be needed to determine if the 10 kPa pressure is the optimal target.

The researchers are also working on new methods to help mammography technologists improve compression through better positioning of the breast.

Source: www.sciencedaily.com

U.S. health officials are poised to endorse circumcision as a means of preventing HIV and other sexually transmitted diseases.

The U.S. Centers for Disease Control and Prevention on Tuesday released its first-ever draft guidelines on circumcision that recommend that doctors counsel parents and uncircumcised males on the health benefits of the procedure.

The guidelines do not outright call for circumcision of all male newborns, since that is a personal decision that may involve religious or cultural preferences, Dr. Jonathan Mermin, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, told the Associated Press.

Discussion board is open for inputs on this subject.

But "the scientific evidence is clear that the benefits outweigh the risks," Mermin said.

Circumcision involves the surgical removal of the foreskin covering the tip of the penis. Germs can collect and multiply under the foreskin, creating issues of hygiene.

Clinical trials, many done in sub-Saharan Africa, have demonstrated that circumcision reduces HIV infection risk by 50 percent to 60 percent, the CDC guidelines note. The procedure also reduces by 30 percent the risk of contracting herpes and human papilloma virus (HPV), two pathogens believed to cause cancer of the penis.

The guidelines do point out that circumcision has only been proven to prevent HIV and sexually transmitted diseases in men during vaginal sex. The procedure has not been proven to reduce the risk of infection through oral or anal sex, or to reduce the risk of HIV transmission to female partners.

The scientific evidence is mixed regarding homosexual sex, the guidelines say, with some studies having shown that circumcision provides partial protection while other studies have not.

Circumcision does reduce the risk of urinary tract infections in infants, according to the CDC guidelines.

The most common risks associated with the procedure include bleeding and infection.

Male circumcision rates in the United States declined between 1979 and 2010, dropping from almost 65 percent to slightly more than 58 percent, according to a CDC report issued last year.

The new draft guidelines mirror an updated policy on circumcision released by the American Academy of Pediatrics in 2012.

"The American public should take confidence that these are pretty much converging guidelines. There is no doubt that it [circumcision] does confer health benefits and there is no doubt it can be performed safely, with a less than 1 percent risk of complications," Dr. Susan Blank, chair of the task force that authored the AAP policy statement, said Tuesday. "This is one thing a parent can do to protect the future health of their children."

In its policy statement, the AAP declared that the health benefits are great enough that infant male circumcision should be covered by insurance, which would increase access to the procedure for families who choose it, said Blank, who is also assistant commissioner of STD Control and Prevention at the New York City Department of Health and Mental Hygiene.

"The push from the academy's point of view is to really have providers lay out for parents what are the risks, what are the benefits, and give the parents the information they need to make a decision," Blank said. "And the academy feels strongly that since there are proven health benefits, the procedure should be covered by insurance."

The guidelines are expected to spur a response from anti-circumcision groups.

"There are certainly groups that are troubled by circumcision of an individual who is not in a position to provide their own consent," Blank said.

The public can comment on the draft guidelines through Jan. 16, according to the CDC.

Source: www.nlm.nih.gov

By Honor Whiteman

Cancer is one of the leading causes of morbidity and mortality worldwide. In 2012, there were around 14 million new cases of cancer and around 8.2 million deaths from the disease. But despite such alarming numbers, a new study by researchers from the UK finds that most people ignore cancer warning signs, attributing them instead to symptoms of less serious illnesses.

Lead study author Dr. Katriina Whitaker, senior research fellow at University College London in the UK, analyzed the responses of 1,724 people aged 50 and over to a health questionnaire that was sent to them in April 2012.

The questionnaire asked participants whether they had experienced any of 17 symptoms, 10 of which are defined as cancer "alarm" symptoms by Cancer Research UK. These symptoms include unexplained cough, changes in mole appearance, unexplained bleeding, persistent change in bowel habits, unexplained weight loss, difficulty swallowing and unexplained lumps. 

Participants were not told which symptoms are cancer warning signs.

The respondents were also asked what they thought was the cause of any symptoms they experienced, whether they deemed the symptoms to be serious and whether they visited their doctor as a result of their symptoms.

Only 2% of respondents considered warning symptoms to be cancer-related

Results of study - published in the journal PLOS ONE - revealed that 53% of participants reported that they had experienced at least one cancer warning sign over the past 3 months.

The most common cancer warning symptoms reported were persistent cough and persistent change in bowel habits, while unexplained weight loss and problems swallowing were the least common.

However, the researchers were surprised to find that of the respondents who reported cancer warning symptoms, only 2% considered cancer to be a potential cause.

What is more, Dr. Whitaker says that of participants who reported the most obvious signs of cancer - such as unexplained lumps or changes in mole appearance - most did not consider them to be cancer-related.

"Even when people thought warning symptoms might be serious, cancer didn't tend to spring to mind," adds Dr. Whitaker. "This might be because people were frightened and reluctant to mention cancer, thought cancer wouldn't happen to them or believed other causes were more likely."

On a positive note, respondents did deem the cancer warning signs to be more serious than symptoms not linked to cancer - such as shortness of breath, fatigue and sore throat- and 59% of those who experienced cancer warning signs visited their doctor.

But the researchers say their findings show that the majority of people are dismissing potential warning signs of cancer, which could be putting their health at serious risk. Dr. Whitaker says:

"Most people with potential warning symptoms don't have cancer, but some will and others may have other diseases that would benefit from early attention. That's why it's important that these symptoms are checked out, especially if they don't go away. But people could delay seeing a doctor if they don't acknowledge cancer as a possible cause."

"Most cancers are picked up through people going to their general practitioner (GP) about symptoms, and this study indicates that opportunities for early diagnosis are being missed," adds Sara Hiom, director of early diagnosis at Cancer Research UK. "Its results could help us find new ways of encouraging people with worrying symptoms to consider cancer as a possible cause and to get them checked out straight away with a GP."

Source: www.medicalnewstoday.com

By Barry Hoffman

Paul Alexander's most impressive accomplishment is something most people never think about.

He taught himself how to breathe.

Alexander, 67, is a victim of the worst that polio had to offer children in the late 1940s and early 1950s. At the age of 6, he was completely paralyzed by the disease, his lungs stopped working, and he was literally thrown into an iron lung.

Alexander has been in that iron lung for 61 years because he remains almost totally paralyzed, able to move only his head, neck and mouth. He is one of an estimated seven people in the United States who are still living in an iron lung, and yet he has had a long and successful career as a lawyer. 

"Over the years, I've been able to escape this machine for a few hours at a time by teaching myself voluntary breathing," Alexander said recently as he lay in the iron lung at his home in Dallas, Texas. "I have to consciously push air into my lungs, something that's done involuntarily by just about everyone else. It's hard work, but it allows me to escape this infernal device, if only for a little while."

Alexander "escapes" the machine most often when he is litigating a case -- his specialty is family law -- or gives a speech.

While he sometimes condemns the contraption that keeps him alive, Alexander is most grateful for his iron lung, whose machinery is essentially unchanged from the first ones that were put in use in the late 1930s. His machine, in fact, is the same one he entered 61 years ago.

"It is my cage, but it's also my cocoon," he said, as the iron lung issued a noticeable whishing sound, an almost uncanny replication of normal breathing.

But we're getting ahead of the story.

This year marks the 60th anniversary of the nation's first mass polio vaccine inoculations, a time when hundreds of thousands of grade school students -- many of them throughout the South -- lined up in school gymnasiums, stuck out their arm and gritted their teeth as a nurse gave them Dr. Jonas Salk's experimental vaccine.

The shot was literally a game-changer. Most of these children had seen at least one or two classmates come to school on crutches, paralyzed by the ravages of polio. More than a few knew other students and friends who had died from the disease. 

So 1954 signified their liberation during the summer -- they could return to public swimming pools and play in the rain and eat in restaurants and not be afraid that they would wake up the next day with a fever and terrible leg pains, which could rapidly lead to paralysis.

That's what happened to 6-year-old Paul Alexander in 1952, two years too early for the Salk vaccine.

"I remember it was really hot and raining, something that is sort of rare for Dallas in August," he recalled, "and my brother and I had been outside playing, running around and getting wet when the rain started.

"Our mother called for us to come in for dinner, and I remember her taking one look at me -- hot and wet and feverish -- and she cried out, 'Oh my God!' She ripped my clothes off and threw me onto her and my dad's bed and called the doctor.

"She knew right away that I had polio. I don't know how she knew, but she knew. I remember feeling hot and feverish, and for the next few days, I stayed in the bed and didn't move. I remember I had this coloring book, and I felt this compulsion to color as much as I could, sort of like maybe I wouldn't be able to do it in the future."

Why didn't Alexander's parents take him to the hospital? "Our family doctor said that all the kids with polio were at Parkland (Dallas' big municipal hospital), and he didn't want me there with the other kids because maybe I had a better chance to recover at home," Alexander said.

But all of that became moot about six days later when he could no longer move and found it difficult to breathe: "I remember having terrible pains in my legs, and breathing became really laborious. So they finally took me to Parkland."

And that's when the most horrifying event occurred before Alexander's long battle with polio could even begin: "I had become immobile; I don't think I could even talk, so the hospital staff put me on a gurney in a long hallway with all the other hopeless polio kids. Most of them were dead."

That would have been Alexander's fate, too, if not for Dr. Milton Davis, a well-known pediatric cardiologist who was examining all of the children in the hallway. "He took one look at me, gathered me up in his arms, and I think he performed a tracheotomy on me almost immediately so I could breathe," Alexander said. "And the next thing I remember, I was inside an iron lung."

And then he blacked out.

Alexander woke up weeks later still in the iron lung: "The pain was still there, although it seemed much less to me, and the iron lung pumped hot steam through a thick plastic water pump into my chest. This kept the mucuous loose enough so I could breathe." 

He couldn't see through the steam at first, and he couldn't talk. But Alexander said he found some sort of determination within himself as strong as the iron in the device that was keeping him alive. "I decided I was going to fight this," he said. "I was going to have a life."

Eighteen months later, his parents brought him home. They stayed with him in shifts, fed him, helped him with school work (he was still enrolled in elementary school) and encouraged him to keep up his curiosity and enthusiasm for learning.

"My mother lobbied the school district for home-school learning, something very rare in the 1950s," he said. His dad fashioned a writing implement for him, similar to a T-square, which Alexander would put in his mouth and move around with his neck muscles in order to write.

Through their efforts and his own fierce determination, Alexander graduated high school as the class salutatorian. "I would have been valedictorian but the biology teacher gave me a B because I couldn't take lab," he joked.

Scholarships to Southern Methodist University in Dallas and the University of Texas in Austin allowed Alexander, with the help of a paid health aide, to get an undergraduate degree and then a law degree. He returned to the Dallas area and became associated with an Arlington law firm for a while, but eventually established a private practice that still handles everything from family law to financial cases.

"With help from a medical aide or one of my friends, I can get out of the lung and attend functions in a wheelchair or argue a case for a few hours," he said. "But I always have to remember to tell myself to inhale, exhale, inhale."

Alexander came to the attention this year of the leaders of the Dallas area's Rotary clubs through one of his doctors, Alexander Peralta, Jr., who is a Rotarian from Duncanville, Texas. 

Rotary International has been working with the Bill and Melinda Gates Foundation to eliminate polio worldwide, just as smallpox has been eradicated.

"One of our clubs, which is well-versed in modern technology (the Dallas e-Club) went to Paul's house and made a four-minute video with him," said Bill Dendy, District Governor of District 5810, which has 65 local Rotary clubs in the north Texas area.

"What none of us realized at first is what a compelling story this is, not only Paul's triumphs under difficult circumstances, but also what a terrifying experience it can be, just sitting in the presence of that machine that keeps him alive. The iron lung personalizes the horror all those thousands of kids went through a little more than half a century ago," Dendy said. The video they made has been submitted to the local PBS station in Dallas. 

Since making contact with Alexander, various district Rotary clubs have volunteered to make improvements to his house -- an old ramp leading to the front door was replaced -- and to be available to take him to his appointments. Throughout his life, Alexander has had a combination of help from health aides provided through the government and friends who pitch in.

Alexander said his iron lung is no longer supported by any company on an ongoing basis. The last company to service his machine, Philips Respironics, no longer does so. "So now, we have to strip spare parts from other discarded iron lungs to keep us going," he said. So far, it hasn't been a problem, he added: "There are only seven iron lung users left, so I don't think this is going to be a big problem of supply and demand."

How did he accomplish so much -- and keep his sense of humor -- while being virtually immobile for more than 60 years?

"It all starts with love," Alexander said. "My parents raised me in love. They taught me never to give up. They taught me the importance of relationships. They were always there for me.

"So, naturally, I had to reciprocate. And you know what? They were right. Anything is possible."

Source: www.medicinenet.com

Researchers are using computed tomography (CT) and 3-D printing technology to recreate life-size models of patients' heads to assist in face transplantation surgery, according to a study presented today at the annual meeting of the Radiological Society of North America (RSNA).

Physicians at Brigham and Women's Hospital in Boston performed the country's first full-face transplantation in 2011 and have subsequently completed four additional face transplants. The procedure is performed on patients who have lost some or all of their face as a result of injury or disease.

In the study, a research team led by Frank J. Rybicki, M.D., radiologist and director of the hospital's Applied Imaging Science Laboratory, Bohdan Pomahac, M.D., lead face transplantation surgeon, and Amir Imanzadeh, M.D., research fellow, assessed the clinical impact of using 3-D printed models of the recipient's head in the planning of face transplantation surgery.

"This is a complex surgery and its success is dependent on surgical planning," Dr. Rybicki said. "Our study demonstrated that if you use this model and hold the skull in your hand, there is no better way to plan the procedure."

Each of the transplant recipients underwent preoperative CT with 3-D visualization. To build each life-size skull model, the CT images of the transplant recipient's head were segmented and processed using customized software, creating specialized data files that were input into a 3-D printer.

"In some patients, we need to modify the recipient's facial bones prior to transplantation," Dr. Imanzadeh said. "The 3-D printed model helps us to prepare the facial structures so when the actual transplantation occurs, the surgery goes more smoothly."

Although the entire transplant procedure lasts as long as 25 hours, the actual vascular connections from the donor face to the recipient typically takes approximately one hour, during which time the patient's blood flow must be stopped.

"If there are absent or missing bony structures needed for reconstruction, we can make modifications based on the 3-D printed model prior to the actual transplantation, instead of taking the time to do alterations during ischemia time," Dr. Rybicki said. "The 3-D model is important for making the transplant cosmetically appealing."

The researchers said they also used the models in the operating room to increase the surgeons' understanding of the anatomy of the recipient's face during the procedure.

"You can spin, rotate and scroll through as many CT images as you want but there's no substitute for having the real thing in your hand," Dr. Rybicki said. "The ability to work with the model gives you an unprecedented level of reassurance and confidence in the procedure."

Senior surgeons and radiologists involved in the five face transplantations agreed that the 3-D printed models provided superior pre-operative data and allowed complex anatomy and bony defects to be better appreciated, reducing total procedure time.

"Less time spent in the operating room is better for overall patient outcomes," Dr. Pomahac added.

Based on the results of this study, 3-D printing is now routinely used for surgical planning for face transplantation procedures at Brigham and Women's Hospital, and 3-D printed models may be implemented in other complex surgeries.

Source: www.sciencedaily.com

By Meera Senthilingam

"It only takes one virus to get through for a person to be infected," explained Dr. John Mascola. This is true of any viral infection, but in this instance, Mascola is referring to HIV and his ongoing efforts to develop a vaccine against the virus. "It's been so difficult to make an HIV/AIDS vaccine."

Those were the words of many working in HIV vaccine development until the results of a 2009 trial in Thailand surprised everyone. "The field is energized," said Mascola, director of the Vaccine Research Center at the U.S. National Institute of Allergy and Infectious Diseases, describing the change in atmosphere in the vaccine community.

The trial included over 16,000 volunteers and was the largest clinical trial ever conducted for a vaccine against HIV. It was also the first to show any protection at all against infection.

Two previously developed vaccines, known as ALVAC-HIV and AIDSVAX, were used in combination, with the first priming an immune response against HIV and the second used as a booster once the immunity waned. The duo reduced the risk of contracting HIV by 31.2% -- a modest reduction, but it was a start.

To date, only four vaccines have made it as far as testing for efficacy to identify their levels of protection against HIV. Only this one showed any protection.

"That trial was pivotal," Mascola said. "Prior to that, it wasn't known whether a vaccine could be possible."

In recent years, there have been parallel findings of an equally pivotal nature in the field of HIV prevention, including the discovery that people regularly taking their antiretroviral treatment reduce their chances of spreading HIV by 96% and that men who are circumcised reduce their risk of becoming infected heterosexually by approximately 60%.

Both improved access to antiretrovirals and campaigns to increase male circumcision in high-risk populations have taken place since the discoveries, and although numbers of new infections are falling, they're not falling fast enough.

In 2013, there were 35 million people estimated to be living with HIV globally. There were still 2.1 million new infections in 2013, and for every person who began treatment for HIV last year, 1.3 people were newly infected with the lifelong virus, according to UNAIDS. A vaccine remains essential to control the epidemic.

A complex beast

Scientists like Mascola have dedicated their careers to finding a vaccine, and their road has been tough due to the inherently complicated nature of the virus, its aptitude for mutating and changing constantly to evade immune attack, and its ability attack the very immune cells that should block it.

There are nine subtypes of HIV circulating in different populations around the world, according to the World Health Organization, and once inside the body, the virus can change continuously.

"Within an individual, you have millions of variants," explained Dr. Wayne Koff, chief scientific officer for the International AIDS Vaccine Alliance.

HIV invades the body by attaching to, and killing, CD4 cells in the immune system. These cells are needed to send signals for other cells to generate antibodies against viruses such as HIV, and destroying those enables HIV to cause chronic lifelong infections in those affected.

Measles, polio, tetanus, whooping cough -- to name a few -- all have vaccines readily available to protect from their potentially fatal infections. But their biology is seemingly simple in comparison with HIV.

"For the older ones, you identify the virus, either inactivate it or weaken it, and inject it," Koff said. "You trick the body into thinking it is infected with the actual virus, and when you're exposed, you mount a robust immune response."

This is the premise of all vaccines, but the changeability of HIV means the target is constantly changing. A new route is needed, and the true biology of the virus needs to be understood. "In the case of HIV, the old empirical approach isn't going to work," Koff said.

Scientists have identified conserved regions of the virus that don't change as readily, making them prime targets for attack by antibodies. When the success of the Thai trial was studied deep down at the molecular level, the protection seemed to come down to attacking some of these conserved regions. Now it's time to step it up.

In January, the mild success in Thailand will be applied in South Africa, where over 19% of the adult population is living with HIV. The country is second only to bordering Swaziland for having the highest rates of HIV in the world.

"The Thai vaccine was made for strains (of HIV) circulating in Thailand," said Dr. Larry Corey, principal investigator for the HIV Vaccine Trials Network, which is leading the next trial in South Africa. The strain, or subtype, in this case was subtype B. "For South Africa, we've formed a strain with common features to (that) circulating in the population." This region of the world has subtype C.

An additional component, known as an adjuvant, is being added to the mix to stimulate a stronger and hopefully longer-lasting level of immunity. "We know durability in the Thai trial waned," Corey said. If safety trials go well in 2015, larger trials for the protective effect will take place the following year. An ideal vaccine would provide lifelong protection, or at least for a decade, as with the yellow fever vaccine.

A broad attack

The excitement now reinvigorating researchers stems not only from a modestly successful trial but from recent successes in the lab and even from HIV patients themselves.

Some people with HIV naturally produce antibodies that are effective in attacking the HIV virus in many of its forms. Given the great variability of HIV, any means of attacking these conserved parts of the virus will be treasured and the new found gold comes in the form of these antibodies -- known as "broadly neutralizing antibodies." Scientists including Koff set out to identify these antibodies and discover whether they bind to the outer coat of the virus.

The outer envelope, or protein coat, of HIV is what the virus uses to attach to, and enter, cells inside the body. These same coat proteins are what vaccine developers would like our antibodies to attack, in order to prevent the virus from entering our cells. "Broadly neutralizing antibodies" could hold the key because, as their name suggests, they have a broad remit and can attack many subtypes of HIV. "We will have found the Achilles heel of HIV," Koff said.

Out of 1,800 people infected with HIV, Koff and his team found that 10% formed any of these antibodies and just 1% had extremely broad and potent antibodies against HIV. "We called them the elite neutralizers," he said of the latter group. The problem, however, is that these antibodies form too late, when people are already infected. In fact, they usually only form a while after infection. The goal for vaccine teams is to get the body making these ahead of infection.

"We want the antibodies in advance of exposure to HIV," explained Koff. The way to do this goes back to basics: tricking the body into thinking it is infected.

"We can start to make vaccines that are very close mimics of the virus itself," Mascola said.

Teams at his research center have gained detailed insight into the structure of HIV in recent years, particularly the outer coat, where all the action takes place. Synthesizing just the outer coat of a virus in the lab and injecting this into humans as a vaccine could "cause enough of an immune response against a range of types of HIV," Mascola said.

The vaccine would not contain the virus itself, or any of its genetic material, meaning those receiving it have no risk of contracting HIV. But for now, this new area remains just that: new. "We need results in humans," Mascola said.

Rounds of development, safety testing and then formal testing in high-risk populations are needed, but if it goes well, "in 10 years, there could be a first-generation vaccine." If improved protection is seen in South Africa, a first-generation vaccine could be with us sooner.

Making an Impact

When creating vaccines, the desired level of protection is usually 80% to 90%. But the high burden of HIV and potentially beneficial impact of lower levels of protection warrant licensing at a lower percentage.

"Over 50% is worth licensing from a public health perspective," Koff said, meaning that despite less shielding from any contact with the HIV virus, even a partially effective vaccine would save many lives over time.

The next generations will incorporate further advancements, such as inducing neutralizing antibodies, to try to increase protection up to the 80% or 90% desired.

"That's the history of vaccine research; you develop it over time," Corey said. He has worked in the field for over 25 years and has felt the struggle. "I didn't think it would be this long or this hard ... but it's been interesting," he ponders.

But there is light at the end of tunnel. Just.

"There has been no virus controlled without a vaccine," he concluded when explaining why, despite antiretrovirals, circumcision and increased awareness, the need for a one-off intervention like a vaccine remains strong.

"Most people that transmit it don't even know they have it," he said. "To get that epidemic, to say you've controlled it, requires vaccination."

Source: www.cnn.com