A Call for a National Transplant Surgical Quality Improvement Program

The severity of illness in transplant patients and the complexity of transplant operations results in significant postoperative morbidity and mortality. Remarkable efforts have been made by transplant physicians to study and improve organ allocation, graft and patient survival, immunosuppression and the long-term management of post-transplant complications. Less effort has been spent studying the actual transplant operation and systems of acute transplant care. The National Surgical Quality Improvement Program (NSQIP) has provided a standardized approach to quality improvement and has demonstrated significant potential for a reduction in postoperative morbidity and mortality in other surgical disciplines. Medical centers are under increasing pressure to measure surgical quality and the nexus of transplant surgical quality improvement should not lie in the hands of CMS or JACHO, but rather it should be created and developed within the transplant community. The time has come for a national transplant surgical quality improvement program based on the NSQIP infrastructure. Such a proactive approach toward quality improvement from the transplant community is an excellent investment for patients, providers and health care payers.     

Associations between soil lead and childhood blood lead in urban New Orleans and rural Lafourche Parish of Louisiana.

This study evaluates associations between soil lead concentrations (SPb), age of housing, and blood lead levels (BPb) of children in metropolitan New Orleans and Lafourche Parish, Louisiana. The database includes over 2,600 SPb and 6,000 BPb samples paired by their median values and pre-1940 housing percentages for 172 census tracts. Associations were evaluated with Fisher's exact test and Spearman's rho test and modeled with the least sum of absolute deviations regression. Census tracts with low SPb are associated with new housing, but census tracts with high SPb are evenly split between old and new housing [Fisher's exact test, p = 8.60 X 10(-13) for the percentage of housing built before 1940 (percent pre-1940 housing) versus SPb]. The p-value for SPb versus BPb is 12 orders of magnitude stronger than the p-value for percent pre-1940 housing versus BPb. Census tracts with low BPb are associated with new housing, but census tracts with high BPb are split evenly between old and new housing (Fisher's exact test, p = 1. 67 X 10(-12) for percent pre-1940 housing versus BPb). Census tracts with high SPb are associated with high BPb and census tracts with low SPb are associated with low BPb (Fisher's exact test, p = 3.18 X 10(-24) for BPb versus SPb). The Spearman's rho test of the association of SPb and BPb in Orleans and Lafourche Parishes yielded a p-value of 6.12 X 10(-24). The least sum of absolute deviations regression model of the data is BPb = 1. 845 + 0.7215 (SPb)0.4. A comparison of the modeled BPb versus observed BPb has an r(2) of 0.552 and a p-value of 2.83 X 10(-23) that this relation was due to chance. If blood lead in children is more closely associated to soil lead than to the age of housing, then primary lead prevention should also include soil lead.     

Bombesin improves survival from methotrexate-induced enterocolitis.

OBJECTIVE: The authors determined whether bombesin could improve survival from methotrexate (MTX)-induced enterocolitis. SUMMARY BACKGROUND DATA: Bombesin prevents gut mucosal atrophy, which is produced by feeding rats an elemental diet. Administration of MTX produces a lethal enterocolitis in rats fed an elemental diet. METHODS: On treatment day 0, 60 rats were divided randomly into three groups and fed an elemental diet (Vivonex TEN, Sandoz, Minneapolis, MN) as the only source of nutrition. Groups were subdivided further to receive either saline or bombesin (10 micrograms/kg, subcutaneously, three times a day) beginning either on day 0 or day 14. Methotrexate (20 mg/kg, intraperitoneally) was given to all rats 14 days after the start of an elemental diet. RESULTS: Bombesin prevented the mucosal atrophy in the ileum produced by the elemental diet and significantly decreased mortality in rats given MTX (whether given as a pretreatment or at the time of MTX administration). CONCLUSION: Bombesin significantly improved survival in a lethal model of MTX-induced enterocolitis, possibly by maintaining gut mucosal structure. Administration of bombesin to patients receiving chemotherapy may be clinically useful in preventing the severe enterocolitis induced by various chemotherapeutic agents.     

The impact of AIDS on state and local health departments: issues and a few answers.

Owing to large differences in the incidence of AIDS (acquired immunodeficiency syndrome) and in public health resources and priorities, the impact of AIDS on state and local health departments has been variable. Nonetheless, health departments everywhere are being held responsible for surveillance and control of the HIV (human immunodeficiency virus) epidemic which we believe requires, at minimum, convenient, free HIV testing and counseling; expanded HIV services in sexually transmitted diseases clinics and substance treatment centers; locally oriented AIDS information/education; notification of persons unknowingly exposed to HIV; restrictive measures for HIV-infected persons who, after counseling, persist in exposing others; regulation or closure of public establishments in which HIV transmission is likely to result; and confidential reporting of all HIV test results to public health departments. In Colorado new legislation was passed to require reporting of HIV test results, to provide the reports with near absolute protections against unauthorized disclosure, and to modify quarantine statues to incorporate rights to due process, appeals, and confidentially. States in which there is a legal basis for discrimination against gay men will need to rectify this problem first. There is no evidence that reporting of HIV infections in Colorado has adversely affected the rate at which persons with HIV risk behaviors volunteer to be tested. For Denver and Colorado Departments of Health, more than 70 per cent of the estimated $2,796,000 expended in AIDS activities during 1987 was federal.     

Two approaches to social support in smoking cessation: Commodity model and nondirective support

The commodity model of social support and features of Nondirective Support may clarify varied results of support interventions for smoking cessation. A commodity model views social support as attractive in and of itself and as an alternative to high-risk choices such as smoking. If such support is easily accessible, a would-be quitter is less likely to choose to smoke. Consistent with the commodity model, social support interventions tend to be effective as long as support remains available, but they lose their effects when support is terminated. From a second approach, Nondirective Support entails accepting recipients' goals, cooperating without taking control, and validating recipients' feelings. In contrast, Directive Support entails taking control and telling recipients what to do and feel. Review of support interventions indicates the value of the continued availability of support suggested by the commodity model and of Nondirective Support's flexibility and responsiveness to the person.