Scientists find interferon, one of the body's own proteins, induces persistent viral infection

Apr. 9, 2013 ? Scientists at The Scripps Research Institute (TSRI) have made a counterintuitive finding that may lead to new ways to clear persistent infection that is the hallmark of such diseases as AIDS, hepatitis B and hepatitis C.

The study, reported in the April 12, 2013 issue of the journal Science, focused on the activity of the body's type 1 interferon (IFN-I) proteins. Since its discovery over 50 years ago, IFN-I has been believed to be an especially powerful antiviral agent that marshals the immune system's response against the body's foreign invaders. But in the new study, the TSRI scientists document in mice that IFN-I initiates persistent infection and limits the generation of an effective antiviral immune response.

"Our findings illuminate an unexpected role for IFN-I protein(s) in persistent infections, which has major implications for how we treat these infections," said Michael B. A. Oldstone, a professor in the Department of Immunology and Microbial Science at TSRI and senior investigator for the study.

Mystery of Immune Suppression

For decades, Oldstone and other virologists around the world have been trying to understand how some viruses manage to persist in their hosts.

One big clue, discovered only in recent years, is that some of these viruses are especially effective at getting into cells of the immune system known as dendritic cells. These cells serve as key detectors of infection and normally respond to viral infection by producing IFN-I proteins. They also produce both immune-enhancing proteins (cytokines/chemokines) to drive forward a vigorous immune response, as well as immune-suppressing proteins including interleukin-10 (IL-10) and PD-1, which act as a braking system that balances the immune response to keep within healthy (non-autoimmune) limits.

Persistent viruses can use this immune-suppressing effect for their own purposes. In several experimental models of persistent infections and in humans with persistent infections, a rise in IL-10 and PD-L1 is followed by declines in the function and numbers of antiviral T-cells. Many of the surviving T cells are rendered ineffectual -- a phenomenon called "T-cell exhaustion" or "hyporesponsiveness."

A Surprising Observation

To better understand how this immune-suppressing response develops, Oldstone and his team, including first authors John R. Teijaro and Cherie Ng, along with Brian Sullivan, looked in detail at the early events in a persistent viral infection. The team used a now-standard animal model that Oldstone developed almost 30 years ago: laboratory mice infected with lymphocytic choriomeningitis virus (LCMV) Clone (Cl) 13 strain.

One initial observation surprised them. "A day after infection, bloodstream levels of IFN-I were at least several times higher in the persistent infection, compared to a non-persistent LCMV infection," said Teijaro.

The persistent LCMV Cl 13 strain also turned out to be much better at infecting plasmacytoid dendritic cells -- which are considered the principal source of IFN-I proteins during viral infections. By contrast, the LCMV Armstrong (ARM) 53b strain, from which Cl 13 was derived, generated significantly less IFN-I and did not induce a persistent infection but rather generated antiviral effector CD8 T cells; this infection was terminated within 7 to 10 days. Cl 13 differs from ARM by only three amino acids (protein building blocks) of which just two are important; one in the glycoprotein for binding and entry into dendritic cells and the other in the viral polymerase that enhances viral replication.

Earlier Clearance and Fewer Malfunctions

The production of IFN-Is by plasmacytoid dendritic cells has been considered a normal and beneficial part of the immune reaction to a viral infection. "We usually think of IFN-I proteins as antiviral proteins, so that more IFN is better," said Ng. Indeed, when she and Teijaro used a monoclonal antibody to block IFN-I-alpha-beta (-a-b) receptor, activity just prior to or after infection with Cl 13, they observed a sharp drop in the production of IL-10 and PD-L1, loss of excessive cytokine/chemokine expression (cytokine storm) and maintenance of normal secondary lymphoid tissue architecture.

But the scientists found over the longer term a sharp drop in levels of immune-suppressing IL-10, as well as PD-L1, both inducers of T-cell exhaustion, was associated with restoration of antiviral immune response and virus clearance. And although blocking the IFN-I-a-b receptor led to higher bloodstream levels of virus in the first days after infection, it soon brought about a stronger, infection-clearing response.

"Even when we blocked IFN-I-a-b receptor after a persistent infection had been established and T-cell exhaustion had set in, we still saw a significantly earlier clearance of the virus," Ng said.

Blocking IFN-I-a-b receptor also prevented or reversed other immune malfunctions caused by the persistent LCMV strain, including a disruption of the structure of the spleen tissue and diminished T cell entry and maintenance within lymphoid structures in the spleen that contain dendritic cells. The interaction of dendritic cells with T cells is necessary to generate antiviral effector CD8 and CD4 T cells. "We saw a restoration of this lymphoid architecture, as well as an increase in a subset of antiviral T cells, natural killer cells and dendritic cells, and restoration of antiviral CD4 T cell function," said Teijaro.

Potentially Broad Applications

Oldstone and his team now plan to study IFN-I signaling pathways in further detail. In particular, they hope to determine whether the IFN-I-a-b receptor blocking strategy can work against chronic viral infections in humans. The scientists will also seek small pharmacologic molecules with the same function.

"Most of our findings in the LCMV model mirror what has been observed in human persistent infections, namely the upregulation of IL-10 and PD-L1, and the disruption of lymphoid architecture," said Oldstone.

Conceivably, the IFN-I-a-b receptor-blocking strategy could have broad clinical applications. In terms of viruses alone, chronic HIV, hepatitis B and hepatitis C infections collectively are found in hundreds of millions of people worldwide. Other common persistent viruses include Epstein-Barr virus, cytomegalovirus and cancer-causing human papilloma virus. Researchers have estimated that the average person at any one time carries at least several persistent, often silent viral infections.

Other contributors to the study, "Persistent LCMV infection is controlled by blockade of type 1 interferon signaling," were Kathleen C. F. Sheehan and Robert D. Schreiber of Washington School of Medicine at St. Louis; and Megan J. Welch, Andrew M. Lee, and Juan Carlos de la Torre of TSRI.

The study was supported by the National Institutes of Health grants AI009484, AI057160 and AI077719, as well as an American Heart Association Fellowship (11POST7430106).

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The above story is reprinted from materials provided by The Scripps Research Institute.

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Journal Reference:

1. J. R. Teijaro, C. Ng, A. M. Lee, B. M. Sullivan, K. C. F. Sheehan, M. Welch, R. D. Schreiber, J. Carlos de la Torre, M. B. A. Oldstone. Persistent LCMV Infection Is Controlled by Blockade of Type I Interferon Signaling. Science, 2013; 340 (6129): 207 DOI: 10.1126/science.1235214

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

Source: http://feeds.sciencedaily.com/~r/sciencedaily/top_news/top_science/~3/jq2JIzicfHA/130411142815.htm

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One in five seniors on risky meds; more in US South

Apr. 10, 2013 ? A study of more than 6 million seniors in Medicare Advantage plans in 2009 found that 21 percent received a prescription for at least one potentially harmful "high-risk medication." Nearly 5 percent received at least two. Questionable prescriptions are more common in the South and among people who live in poor areas.

More than one in five seniors with Medicare Advantage plans received a prescription for a potentially harmful "high-risk medication" in 2009, according to a newly published analysis by Brown University public health researchers. The questionable prescriptions were significantly more common in the Southeast United States, as well as among women and people living in relatively poor areas.

The demographic trends in the analysis, based on Medicare data from more than 6 million patients, suggest that differences in the rates of prescription of about 110 medications deemed risky for the elderly cannot be explained merely by the individual circumstances of patients, said lead author Danya Qato, a pharmacist and doctoral candidate in health services research at Brown.

"At the population level it is clear that there is a unique phenomenon occurring," said Qato, lead author of the paper published in this month's edition of the Journal of General Internal Medicine. "While one can reason that it might be appropriate for a particular patient to be on a particular medication, with such a preponderance of use of high-risk medications in some locations versus others, our results suggest that we cannot attribute this variation wholly to patient characteristics."

In the analysis, Qato and co-author Dr. Amal Trivedi, assistant professor of health services, policy and practice at Brown and a hospitalist at the Providence VA Medical Center, found that 21.4 percent of the patients, or more than 1.3 million people, received at least one high-risk medication, for which there is often a safer substitute, and that 4.8 percent received at least two.

'Geography is destiny'

Residents of the South Atlantic, East South Central and West South Central regions of the country -- an area stretching from parts of Texas to South Carolina -- had a 10 to 12 percentage point higher risk of receiving potentially harmful prescriptions than people in New England, who had the lowest chance, the analysis found.

The trend persists at the finer resolution of "hospital-referral regions" or HRRs, the authors note. "The 20 lowest performing HRRs were all in the Southern region of the United States. In contrast," they wrote in the journal, "only one of the 20 highest performing HRRs was in the South."

Albany, Ga., had the highest rate of receipt of single high-risk prescriptions: 38.2 percent. Seniors in Alexandria, La., led the nation in receiving at least two high-risk prescriptions, with a rate of 13.5 percent. Mason City, Iowa (9.6%) and Worcester, Mass. (0.7%), had the best rate of single and multiple high-risk prescription use, respectively.

In another demographic analysis, women across the country had a 10 percentage point greater likelihood of receiving a high-risk prescription. Other differences were less stark. Generally the lower the socioeconomic status of a patient's region, the more likely they were to receive a high-risk medication. Residents of the poorest areas had a 2.7 percentage point higher risk than the residents of the richest areas.

Complex reasons

Qato and Trivedi said the explanation for the gender difference may be straightforward. Some of the high-risk medications treat ailments specific to women or that are more common in women.

People living in poor areas, meanwhile, generally have less access to high-quality health care, Qato said, although the connection between poverty and high-risk prescriptions requires further study.

The higher risk of receiving potentially harmful prescriptions in poor areas does not explain the geographic differences, Qato said. She and Trivedi accounted for the economic statistics in their geographic analysis and for geography in their economic analysis.

Instead the reasons why people in the South are at substantially higher risk than people in the rest of the country could be a combination of many, likely interconnected, factors, Trivedi and Qato said. The factors could include higher patient demand for the drugs, a different prescribing culture, possibly higher prevalence of chronic medical problems in the region, or inadequate medical training with regard to appropriate prescribing among elderly patients.

Trivedi said officials and health care providers should take the study as a cue to improve prescribing.

"Clinicians and policymakers should work to reduce the use of these potentially inappropriate medications in older patients, because their risks outweigh their benefits and safer alternatives exist," he said.

As a pharmacist, Qato said she hopes the research encourages seniors to take greater ownership of their health care and to be more vigilant about their prescription drug use.

"This is one of the many reminders for patients to regularly review the appropriateness and safety of their medications with their pharmacist and physician," Qato said. "Patients are often their own best advocates."

The Agency for Healthcare Research and Quality (grant: 1T32HS019657) and the National Institute of Aging (grant: 5RC1AG036158) supported the study.

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The above story is reprinted from materials provided by Brown University.

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Journal Reference:

1. Danya M. Qato, Amal N. Trivedi. Receipt of High Risk Medications among Elderly Enrollees in Medicare Advantage Plans. Journal of General Internal Medicine, 2012; 28 (4): 546 DOI: 10.1007/s11606-012-2244-9

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

Source: http://feeds.sciencedaily.com/~r/sciencedaily/living_well/~3/Gxvc8u-s14o/130410131333.htm

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Michelle Obama recalls a murdered girl who didn't get to grow up

By Renita D. Young

CHICAGO (Reuters) - First lady Michelle Obama choked up on Wednesday as she recalled the life of a recent teenage murder victim, a girl from Chicago just like her, but who did not get to grow up.

Obama was in her hometown to join Mayor Rahm Emanuel in urging the business community to help raise $50 million for anti-violence youth programs in the city.

The first lady said that as a native of the city, she could relate to Chicago's youth, particularly 15-year-old honor student Hadiya Pendleton.

The girl was shot and killed in a park a week after performing with her high school band as part of President Barack Obama's inauguration festivities on January 21. The shooting took place about a mile from the Obamas' South Side Chicago home.

"Hadiya Pendleton was me, and I was her. But I got to grow up," Obama said, choking up as she talked about the teenager in her address to about 800 business and community leaders at a downtown Chicago hotel. Pendleton's parents, as well as parents of other children who died as a result of Chicago gun violence, attended the event.

Youth violence in Chicago has received national attention - with 506 primarily gun-related homicides in the city last year, an increase of 17 percent over 2011.

The massacre of 20 students and six adults at an elementary school in Newtown, Connecticut, last December prompted the president to push for new gun-control legislation. Michelle Obama's visit to Chicago was seen as part of that campaign.

"Right now, my husband is fighting as hard as he can and engaging as many people as he can to pass common-sense reforms to protect our children from gun violence," Michelle Obama said. "And these reforms deserve a vote in Congress."

The administration is struggling to gain support from lawmakers for proposals to expand background checks for gun buyers and ban assault-style weapons and high-capacity ammunition magazines in the face of opposition by gun rights groups such as the National Rifle Association.

The first lady also met with students at Harper High School, a South Side public school that has seen 29 current and former students shot in the past year. Eight of them died.

"In this world today, if you stay focused you can make it happen," she told students. "The best thing you can do in life is really be serious about education. I'm not going to talk. Ask me whatever you want to know."

Emanuel wants to raise $50 million to create and maintain programs for at-risk youth. Led by Allstate Chief Executive Thomas Wilson and Loop Capital Chief Executive James Reynolds, Jr., the committee is now at $33 million with investments from Allstate, the MacArthur Foundation and other local and national organizations.

(Reporting by Renita D. Young; Editing by Mary Wisniewski, Cynthia Johnston and Peter Cooney)

Source: http://news.yahoo.com/michelle-obama-recalls-murdered-girl-didnt-grow-235922742.html

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End-of-Life Discussions: A Talk to Have Before You Get Sick

When James Inman died from complications of Parkinson's disease, his family knew just what to do. The World War II veteran had picked out his coffin and the plaque for his gravesite, and had determined that the U.S. flag would be draped, not folded, over his casket.

Those weren't the only gifts the Massachusetts man gave his family; he had also made his medical wishes very clear.

"He completely unburdened us and took all of that off of our plate," said son-in law-Jim Desrosiers. "It was one of the most unselfish things I ever experienced."

Hallmark Greeting Cards for the 'Final Goodbye'

As Inman lost consciousness during what would be the last two weeks of his life, his family could tell the doctors that he did not want to have his life artificially prolonged.

"That decision, while he was unconscious, was guilt-free," said Desrosiers. "We knew we were just executing his wishes."

All too often, families have the opposite experience. Their loved one may have failed to designate a health care "agent," someone to direct their care if they can't. Or perhaps they never bothered to execute a living will, or talk to family members about their wishes.

You Only Die Once -- Let's Talk About It

Nathan Kottkamp has seen these stressful situations up close. An attorney who specializes in health care, he sits on the ethics boards of four Virginia hospitals. When there's no one designated to make health care decisions, or when families are arguing over what to do for their ill relative, the cases often end up before these ethics boards.

He remembers one instance of a single mom with two young children who was put on a ventilator after suffering complications during surgery. There was no one to make decisions for her, and no indication of what she wanted. Two court cases later, the hospital was finally able to provide appropriate care for her, and a guardian was named for her children.

"It was not just traumatic to the individual involved," he said, "but to everyone in the health care team."

These painful experiences are "so preventable," says Kottkamp, which is why he has launched National Healthcare Decisions Day. Designated as April 16 (right after income tax day because as Kottkamp says, the only things certain in life are death and taxes), it's a day to nudge families to think about "who will stand in your shoes when you can't speak for yourself," said Kottkamp. "I think the single most important thing to do is name somebody. You can name someone the health care team can interact with. You should tell them what is important to you."

Kottkamp started this grassroots effort eight years ago, after the Terri Schiavo case riveted the nation. Schiavo spent 15 years in what doctors said was a persistent vegetative state, while her husband and parents fought a legal battle over whether to prolong her life. Ultimately a court sided with her husband, who wanted to remove Schiavo's feeding tube. She died 13 days later.

National Health Care Decision Day has grown into a nationwide effort supported by hospital, hospice and medical associations.

"We all know that 100 percent of us are going to die, but starting the conversation is often hard," said Ellen Goodman, a Pulitzer Prize-winning columnist and founder of The Conversation Project. The project is designed to help families start a conversation around their wishes if they are ill or incapacitated.

The organization grew out of Goodman's experience when her mother became ill and passed away.

Source: http://abcnews.go.com/Health/end-life-discussion-sick-talk/story?id=18927257

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Robot hot among surgeons but FDA taking fresh look

In this March 22, 2013 photo, Dr. Pier Giulianotti, chief of minimally invasive and robotic surgery at the University of Illinois Hospital & Health Sciences System in Chicago, sits at the control panel of the da Vinci robot system. Surgeons say the advantages of the system include allowing them to operate sitting down, using small robotic hands with no tremor. But critics say a big increase in robot operations nationwide is due to heavy marketing and hype, and the U.S. Food and Drug Administration is looking into problems and deaths that may be linked with robotic surgery. (AP Photo/M. Spencer Green)

In this March 22, 2013 photo, Dr. Pier Giulianotti, chief of minimally invasive and robotic surgery at the University of Illinois Hospital & Health Sciences System in Chicago, sits at the control panel of the da Vinci robot system. Surgeons say the advantages of the system include allowing them to operate sitting down, using small robotic hands with no tremor. But critics say a big increase in robot operations nationwide is due to heavy marketing and hype, and the U.S. Food and Drug Administration is looking into problems and deaths that may be linked with robotic surgery. (AP Photo/M. Spencer Green)

In this March 22, 2013 photo, Dr. Pier Giulianotti, chief of minimally invasive and robotic surgery at the University of Illinois Hospital & Health Sciences System in Chicago, shows off a robotic arm of the da Vinci robot system. Surgeons say the advantages of the system include allowing them to operate sitting down, using small robotic hands with no tremor. But critics say a big increase in robot operations nationwide is due to heavy marketing and hype, and the U.S. Food and Drug Administration is looking into problems and deaths that may be linked with robotic surgery. (AP Photo/M. Spencer Green)

In this photo from video provided by Intuitive?Surgical, Inc. of Sunnyvale, Calif., maker of the da Vinci robotic system, doctors are seen using the device to perform a surgery. Surgeons say the advantages of the system include allowing them to operate sitting down, using small robotic hands with no tremor. But critics say a big increase in robot operations nationwide is due to heavy marketing and hype, and the U.S. Food and Drug Administration is looking into problems and deaths that may be linked with robotic surgery. (AP Photo/Courtesy of Intuitive?Surgical, Inc.)

FOR STORY BY LINDSEY TANNER TO MOVE PRIMETIME, TUESDAY, APRIL 9 - In this March 26, 2013 photo, Aidee Diaz, 36, is seen at the Rauner Family YMCA on Chicago's South Side before a workout with a personal trainer. Diaz has lost 100 pounds since a simultaneous robotic kidney transplant and obesity surgery in July 2012 at the University of Illinois Hospital & Health Sciences System in Chicago. Diaz says the YMCA workouts are helping her get in shape. (AP Photo/M. Spencer Green)

In this March 26, 2013 photo, Aidee Diaz, 36, right, exercises with personal trainer Angela Appleton at the Rauner Family YMCA on Chicago's South Side. Diaz has lost 100 pounds since a simultaneous robotic kidney transplant and obesity surgery in July 2012 at the University of Illinois Hospital & Health Sciences System in Chicago. Diaz says the YMCA workouts are helping her get in shape. (AP Photo/M. Spencer Green)

CHICAGO (AP) ? The biggest thing in operating rooms these days is a million-dollar, multi-armed robot named da Vinci, used in nearly 400,000 surgeries nationwide last year ? triple the number just four years earlier.

But now the high-tech helper is under scrutiny over reports of problems, including several deaths that may be linked with it, and the high cost of using the robotic system.

There also have been a few disturbing, freak incidents: a robotic hand that wouldn't let go of tissue grasped during surgery and a robotic arm hitting a patient in the face as she lay on the operating table.

Is it time to curb the robot enthusiasm?

Some doctors say yes, concerned that the "wow" factor and heavy marketing are behind the boost in use. They argue that there is not enough robust research showing that robotic surgery is at least as good or better than conventional surgeries.

Many U.S. hospitals promote robotic surgery in patient brochures, online and even on highway billboards. Their aim is partly to attract business that helps pay for the costly robot.

The da Vinci is used for operations that include removing prostates, gallbladders and wombs, repairing heart valves, shrinking stomachs and transplanting organs. Its use has grown worldwide, but the system is most popular in the United States.

"We are at the tip of the iceberg. What we thought was impossible 10 years ago is now commonplace," said Dr. Michael Stifelman, robotic surgery chief at New York University's Langone Medical Center.

For surgeons, who control the robot while sitting at a computer screen, these operations can be less tiring. Plus robot hands don't shake. Advocates say patients sometimes have less bleeding and often are sent home sooner than with conventional laparoscopic surgeries and operations involving large incisions.

But the Food and Drug Administration is looking into a spike in reported problems. Earlier this year, the FDA began surveying surgeons using the robotic system. The agency conducts such surveys of device use routinely, but FDA spokeswoman Synim Rivers said the reason for it now "is the increase in number of reports received" about da Vinci.

Reports filed since early last year include at least five deaths.

Whether there truly are more problems lately is uncertain. Rivers said she couldn't quantify the increase and that it may simply reflect more awareness among doctors and hospitals. Doctors aren't required to report such things; device makers and hospitals are.

It could also reflect wider use. Last year there were 367,000 robot-assisted surgeries versus 114,000 in 2008, according to da Vinci's maker, Intuitive Surgical Inc. of Sunnyvale, Calif.

Da Vinci is the company's only product, and it's the only robotic system cleared for soft-tissue surgery by the FDA. Other robotic devices are approved for neurosurgery and orthopedics, among other things.

A search for the company's name in an FDA medical device database of reported problems brings up 500 events since Jan. 1, 2012. Many of those came from Intuitive Surgical. The reports include incidents that happened several years ago and some are duplicates. There's also no proof any of the problems were caused by the robot, and many didn't injure patients. Reports filed this year include:

? A woman who died during a 2012 hysterectomy when the surgeon-controlled robot accidentally nicked a blood vessel.

? A Chicago man who died in 2007 after spleen surgery.

? A New York man whose colon was allegedly perforated during prostate surgery. Da Vinci's maker filed that report after seeing a newspaper article about it and said the doctor's office declined to provide additional information.

? A robotic arm that wouldn't let go of tissue grasped during colorectal surgery on Jan. 14. "We had to do a total system shutdown to get the grasper to open its jaws," said the report filed by the hospital. The report said the patient was not injured.

? A robotic arm hit a patient in the face during a hysterectomy. Intuitive Surgical filed the report and said it's not known if the patient was injured but that the surgeon decided to switch to an open, more invasive operation instead.

Intuitive Surgical filed all but one of those reports.

Complications can occur with any type of surgery, and so far it's unclear if they are more common in robotic operations. That's part of what the FDA is trying to find out.

Intuitive Surgical disputes there's been a true increase in problems and says the rise reflects a change it made last year in the way it reports incidents.

The da Vinci system "has an excellent safety record with over 1.5 million surgeries performed globally, and total adverse event rates have remained low and in line with historical trends," said company spokeswoman Angela Wonson.

But an upcoming research paper suggests that problems linked with robotic surgery are underreported. They include cases with "catastrophic complications," said Dr. Martin Makary, a Johns Hopkins surgeon who co-authored the paper.

"The rapid adoption of robotic surgery ... has been done by and large without the proper evaluation," Makary said.

The da Vinci system, on the market since 2000, includes a three- or four-armed robot that surgeons operate with hand controls at a computer system several feet from the patient. They see inside the patient's body through a tiny video camera attached to one of the long robot arms. The other arms are tipped with tiny surgical instruments.

Robotic operations are similar to conventional laparoscopy, or "keyhole" surgery, which involves small incisions and camera-tipped instruments controlled by the surgeon's hands, not a robot.

Almost 1,400 U.S. hospitals ? nearly 1 out of 4 ? have at least one da Vinci system. Each one costs about $1.45 million, plus $100,000 or more a year in service agreements.

The most common robotic operations include prostate removal ? about 85 percent of these in the U.S. are done with the robot. Da Vinci is often used for hysterectomies too, Wonson said.

Makary says there's no justification for the big growth in robotic surgery, which he attributes to aggressive advertising by the manufacturer and hospitals seeking more patients.

He led a study published in 2011 that found 4 in 10 hospitals promoted robotic surgery on their websites, often using wording from the manufacturer. Some of the claims exaggerated the benefits or had misleading, unproven claims, the study said.

Stifelman, the Langone surgeon, said it makes sense for hospitals to promote robotic surgery and other new technology, but that doesn't mean it's the right option for all patients.

"It's going to be the responsibility of the surgeon ... to make sure the patient knows there are lots of options," and to discuss the risks and benefits, he said.

His hospital expects to do more than 1,200 robotic surgeries this year, versus just 175 in 2008.

For a few select procedures that require operating in small, hard-to-reach areas, robotic surgery may offer advantages, Makary said. Those procedures include head and neck cancer surgery and rectal surgery.

Some surgeons say the robotic method also has advantages for weight-loss surgery on extremely obese patients, whose girth can make hands-on surgery challenging.

"At the console, the operation can be performed effectively and precisely, translating to superior quality," said Dr. Subhashini Ayloo, a surgeon at the University of Illinois Hospital & Health Sciences System in Chicago.

Ayloo, who uses the da Vinci robot, last year began a study on the effectiveness of robotic obesity surgery in patients who need a kidney transplant. Some hospitals won't do transplants on obese patients with kidney failure because of the risks. In the study, robotic stomach-shrinking surgery and kidney transplants are done simultaneously. Patients who get both will be compared with a control group getting only robotic kidney transplants.

"We don't know the results, but so far it's looking good," Ayloo said.

Aidee Diaz of Chicago was the first patient and was taken aback when told the dual operation would be done robotically.

"At first you would get scared. Everybody says, 'A robot?' But in the long run that robot does a lot of miracles," said Diaz, 36.

She has had no complications since her operation last July, has lost 100 pounds and says her new kidney is working well.

Lawsuits in cases that didn't turn out so well often cite inadequate surgeon training with the robot. These include a malpractice case that ended last year with a $7.5 million jury award for the family of Juan Fernandez, a Chicago man who died in 2007 after robotic spleen surgery. The lawsuit claimed Fernandez's surgeons accidentally punctured part of his intestines, leading to a fatal infection.

The surgeons argued that Fernandez had a health condition that caused the intestinal damage, but it was the first robot operation for one of the doctors and using the device was overkill for an ordinarily straightforward surgery, said Fernandez's attorney, Ted McNabola.

McNabola said an expert witness told him it was like "using an 18-wheeler to go the market to get a quart of milk."

Company spokesman Geoff Curtis said Intuitive Surgical has physician-educators and other trainers who teach surgeons how to use the robot. But they don't train them how to do specific procedures robotically, he said, and it's up to hospitals and surgeons to decide "if and when a surgeon is ready to perform robotic cases."

A 2010 New England Journal of Medicine essay by a doctor and a health policy analyst said surgeons must do at least 150 procedures to become adept at using the robotic system. But there is no expert consensus on how much training is needed.

New Jersey banker Alexis Grattan did a lot of online research before her gallbladder was removed last month at Hackensack University Medical Center. She said the surgeon's many years of experience with robotic operations was an important factor. She also had heard that the surgeon was among the first to do the robotic operation with just one small incision in the belly button, instead of four cuts in conventional keyhole surgery.

"I'm 33, and for the rest of my life I'm going to be looking at those scars," she said.

The operation went smoothly. Grattan was back at work a week later.

___

Online:

Robotic surgery: http://tinyurl.com/byuljds

___

AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

Associated Press

Source: http://hosted2.ap.org/APDEFAULT/b2f0ca3a594644ee9e50a8ec4ce2d6de/Article_2013-04-09-Robotic%20Surgery/id-f5236df925f84f3db7fb3c8e53de8669

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Obama calls on GOP to help ?finish the job? on budget

President Barack Obama delivers remarks on the budget at the White House, April 10, 2013. (Jason Reed/Reuters)

President Barack Obama declared on Wednesday that his newly unveiled fiscal 2014 budget would ?reignite? sputtering economic growth and pressed skeptical Republicans to help him ?finish the job? of deficit reduction. But while GOP leaders embraced Obama's call for cuts to entitlement spending, they decreed that his appeal for further tax hikes on the rich ensured that the symbolic blueprint would be dead on arrival in Congress.

?Our economy is poised for progress?as long as Washington doesn't get in the way,? Obama said in the White House Rose Garden. "Frankly, the American people deserve better than what we've been seeing: a shortsighted, crisis-driven decision-making."

The president's $3.77 trillion budget?a symbolic, nonbinding spending blueprint?includes many of his 2012 campaign themes: higher taxes on the rich, modest investments in education and infrastructure, cash for scientific endeavors. It also includes elements of his past offer to the GOP as part of a quest for a "grand bargain" that would reduce deficits by at least $4 trillion over 10 years, like adopting "chained CPI." This would reduce cost-of-living increases to Social Security and Medicare, a step loathed by liberal Democrats but heralded by Republicans in the past as a potential trade-off for higher taxes.

"When it comes to deficit reduction, I?ve already met Republicans more than halfway," Obama declared. "So in the coming days and weeks, I hope that Republicans will come forward and demonstrate that they?re really as serious about the deficits and debt as they claim to be."

In his actual budget submission, Obama served notice to liberals that he won't shy from potentially painful entitlement cuts. "I am willing to make tough choices that may not be popular within my own party, because there can be no sacred cows for either party."

Republicans panned the president's budget, but seized on his offer to reduce the growth of mandatory programs like Social Security and Medicare.

Republican House Speaker John Boehner said Obama "does deserve some credit" for those proposals, but said the White House should not "hold hostage these modest reforms" by using them to win GOP support for higher tax revenues. Republican leaders have repeatedly said they aren't interested in discussing boosting tax revenues in the aftermath of the so-called "fiscal cliff" deal adopted in the early hours of 2013. That agreement extended Bush-era tax cuts on income up to $400,000 for individuals and $450,000 for households, while letting rates rise above that level.

?The president got his tax hikes in January. We don?t need to be raising taxes on the American people," Boehner said. "So I?m hopeful in the coming weeks we?ll have an opportunity, through the budget process, to come to some agreement.?

Republican Senate Minority Leader Mitch McConnell was a bit more biting, dismissing Obama's budget as "just another left-wing wish list." Oh, except for the entitlement changes. "Let me clarify: a wish list with an asterisk."

Presidential budgets are symbolic documents that don't directly decide government spending even if they pass Congress (this one won't) and accordingly don't typically do much to create jobs.

But the nonbinding blueprint already has done something that the president himself has only rarely accomplished since taking office: It?s basically united Washington. In opposition.

Boehner had repeatedly attacked the plan, based on carefully calculated disclosures from the White House about what it would include. At the other end of the spectrum, independent Sen. Bernie Sanders of Vermont promised to fight against Obama?s call for adopting a less generous cost-of-living formula for entitlements such as Social Security.

Democrats are perplexed and annoyed by the White House strategy, which they view as a premature compromise.

Despite all that, the document could still matter.

While budgets serve chiefly as political mission statements for presidents, and political punching bags for their opponents, they can still cast a long shadow over public debates. And there's no shortage of urgency for Washington to do something in the face of sluggish economic growth and unsettlingly weak job creation.

?The timeline between the submission of a president?s budget and someone saying the phrase ?dead on arrival? is the shortest measure of time in Washington,? Tony Fratto, a spokesman for George W. Bush?s Treasury Department and later his White House, joked to Yahoo News.

But Fratto still calls himself ?a big believer? in the process. Why?

?They are the aspirational game plans for each party. It?s the way they would like to see the world, lays out markers for the programs they consider priorities,? Fratto said.

And by offering to cut entitlement spending?a key driver of U.S. government deficits and the debt?in exchange for new tax increases that chiefly target the well-off, Obama aims to bridge the gap between Republicans and Democrats and restart so-called "grand bargain" talks aimed at finding $4 trillion in deficit reduction over the next 10 years. Obama aides, though, say any big deal has to include new revenues, something that makes Republicans balk.

"We don't view this budget as a starting point," a senior White House official told reporters on a conference call on Tuesday. "This is an offer where the president came more than halfway toward the Republicans in an attempt to get a fiscal deal."

The budget?s call for the rich to pay more in taxes lined up neatly with Obama?s winning 2012 campaign argument?as did its push to balance deficit reduction goals with modest investments in education and infrastructure. ($100 million in NASA funding to ?lasso? an asteroid, though? A step toward fulfilling Obama?s plan to send an astronaut to an asteroid by 2025? A wee bit more off the beaten path. And awesome.)

The White House says that, if reflected in spending legislation, Obama's new budget would cut $1.8 trillion over 10 years. Republicans say the real figure is $600 billion because the budget replaces existing so-called "sequestration" spending cuts of $1.2 trillion with an equivalent amount.

But both sides agree the budget does not balance over its 10-year horizon. The House-passed GOP budget does so thanks to mostly undetailed spending cuts to mostly unidentified programs.

The White House budget predicts the deficit will run $744 billion in fiscal year 2014 (which starts Oct. 1). That's about 4.4 percent of gross domestic product. And senior administration officials, briefing reporters on condition of anonymity, said Tuesday that it would fall to 2.8 percent of GDP by 2016 and 1.7 percent by 2023. They did not give a dollar figure, which means those estimates could rely on rosy predictions of economic growth that are typical in any president's budget.

Budgets serve as guidelines, sometimes influential ones, but they don't become law. Actual spending levels for individual agencies are supposed to come in a two-step legislative process of authorizing programs and then appropriating funds for them, though this spring it?ll be in the form of a catch-all continuing resolution.

All this is to say that, when you hear a politician compare a government budget with a family budget, that?s true only if your family disregards its budget.

One early test of whether the GOP?anyone in the GOP?is willing to consider Obama's offer will come on Wednesday night, when he is scheduled to host 12 Republican senators for a fence-mending dinner where the budget will surely be discussed. (Sanders, meanwhile, tells ABC/Yahoo that progressives are still waiting for their invitation.)

But Fratto warned there might not be an opportunity for a major budget breakthrough even if both sides want it, thanks to a deal reached during the so-called "fiscal cliff" negotiations in early January when Republicans agreed to raise taxes on higher earners.

A major budget agreement "may be too much to ask, because I don?t know that the components of a grand bargain exists any more since the tax increase deal, tax cut deal, whatever you want to call it," Fratto said.

In that accord, Republicans agreed to extend Bush-era income tax cuts on income up to $400,000 for individuals and $450,000 for households. Since then, GOP leaders have publicly ruled out new tax hikes even as the White House has pushed for raising revenues, notably by closing loopholes and slicing into deductions for wealthier Americans.

"What we?re left with now is a situation where all of the components of a so-called grand bargain cause pain for somebody?except for inside-the-beltway deficit hawks," Fratto said. "It would be some combination of tax increases, entitlements cuts, discretionary spending cuts, so who are the winners?"

One possibility is that Obama views a grand bargain as a way to polish his legacy?he would be The Democratic President Who Reined In Entitlement Spending. He still has the "bully pulpit"?the ability to dominate the national political conversation.

Whether Democrats see it that way and are prepared to run the political risks to help the White House is an open question.

Party strategists say Democrats got clubbed like baby seals in the 2010 midterm elections in large part because of GOP ads accusing the president's party of wanting to cut Medicare. That line of attack was based on Democratic support for Obamacare, which reduced Medicare spending by $716 billion, mostly taken from insurance companies and hospitals rather than beneficiaries.

And the 2014 midterms aren't that far away.

Source: http://news.yahoo.com/blogs/ticket/obama-budget-dead-arrival-may-second-life-095859326--politics.html

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