A transplanted organ is rarely a complete replacement for the original, if only because it is denervated\p=m-\a fact often ignored by "sci-fi" writers who will transplant a brain with blatant nonchalance at the bat of an eyelash. Still, incomplete as it is, the grafted organ often functions satisfactorily. This is the case with the renal transplant in which the absence of modulation by the autonomic nervous system does not interfere seriously with performance. Such may also be the case with the cardiac transplant that can function, albeit not optimally, without this modulation. Success or failure of an engraftment depends less on the integrity of the transplant than on histocompatibility, immunosuppression, infection, and persistence of the original disease\p=m-\factorsthat present obstacles that are challenging, but not necessarily unsurmountable. those of An added factor in some transplants\p=m-\notably the bone marrow\p=m-\isthe graft-vs-host reaction. This immunologic assault, mounted by the grafted tissue against its new-found host, has been largely responsible for the dismal results of allogeneic marrow transplants. Perhaps this obstacle will also prove surmountable. Com¬ menting on the outlook for marrow transplants an edi¬ torial in the British Medical Journal1 states:
Recently, however, there has been geneic grafting with the advent of
enthusiasm for allo¬ of human systems, better methods of immunosup¬ a new
pression, and improved supportive care. There has also been a new enthusiasm recently for the grafting of the pancreas or its component islets or beta cells to cure diabetes. How justified is this enthusiasm?
An authoritative answer to these questions is given in the "Position Paper on Pancreatic Islet and Beta Cell Transplantation In Man" released by the National Institute of Arthritis and Metabolic Disease and endorsed by the American Diabetes Association.2 The communication cau¬ tions that such transplantations are still highly experimental procedures to be carried out only by qualified research teams after review by a review board on human research. Pancreatic transplantations have been attempted experi¬ mentally only in patients who had undergone immunosup¬ pression for previous kidney transplants. Even then, the success of these procedures has been exceedingly limited. Even more experimental are the transplantations of pan¬ creatic islets or beta cells, which have been limited so far to diabetic animals with a high degree of tissue com¬ patibility. In man, such grafts would pose serious tech¬ nological, immunological, and possibly oncologic problems. The logistics of separating and preserving the requisite
number of islets or cells, the hazards of immunosup¬ pression, the uncertainties of mitogenesis and mutagenesis of seeded cells, the specter of graft-vs-host reaction, the questionable homeostatic capabilities of denervated islets —all formidable problems—must await resolution before the diabetic whose life is not immediately threatened ex¬ changes his diet and needle for a highly problematic cure. Samuel Vaisrub, MD Senior Editor
1. Bone marrow transplants in leukaemia, editorial. Br Med J 2:676\x=req-\ 1974. 2. The status of transplantation of the pancreas and pancreatic tissues as a cure for diabetes, editorial. Diabetes 23:987-988, 1974.
Medicine in the Bible Items of medical interest abound in the Bible. ning the Proverbs provides a substantial yield.1 Learning and Teaching.\p=m-\The first thing is
to acquire wisdom; gain understanding though it cost you all you have. Do not forsake her, and she will keep you safe; love her, and she will guard you; cherish her, and she will lift you high; if only you embrace her, she will bring you to honour. She will set a garland of grace on your head and bestow on you a crown of glory (Proverbs 4:7-9). My son, if you take my words to heart and lay up my commands in your mind, giving your attention to wisdom and your mind to understanding, if you seek her out like silver and dig for her like buried treasure, then you will understand the fear of the Lord and attain to the knowledge of God; for the Lord bestows wisdom and teaches knowledge and understanding (Proverbs 2:1-6). Happy he who has found wisdom, and the man who has acquired understanding; for wisdom is more profitable than silver, and the gain she brings is better than gold. She is more
precious than red coral, and all your jewels are no match for her. Long life is in her right hand, in her left hand are riches and honour. Her ways are pleasant ways and all her paths lead to prosperity. She is a staff of life to all who grasp her, and those who hold her fast are safe (Proverbs 3:13-18). Insolent men delight in their insolence; stupid men hate
knowledge ( Proverbs 1:18).
insolent man, and be sneered at for your pains; and you will put yourself in the wrong. insolent or they will hate you; correct a wise man, and he will be your friend. Lecture a wise man, and he will grow wiser; teach a righteous man, and his learning will increase ( Proverbs 9:7-9 ) Promiscuity.—I glanced out of the window of my house, I looked down through the lattice, and I saw among simple youths; there amongst the boys I noticed a lad, a foolish lad, passing along the street, at the corner, stepping out in the direction of her house at twilight, as the day faded, at dusk as the night grew dark; suddenly a woman came to meet him, dressed like a prostitute, full of wiles, flighty and inconstant, a woman never content to stay at home, lying in wait at every corner, now in the street, now in the public squares. She Correct
correct a bad man, Do not correct the
Address editorial communications to the Editor, 535 N Dearborn St, Chicago, IL 60610
Downloaded From: http://jama.jamanetwork.com/ by a University of Auckland User on 05/17/2015
caught hold of him and kissed him; brazenly she accosted him and said, "I have had a sacrifice, an offering, to make and I have paid my vows today; that is why I have come out to meet you, to watch for you and find you. I have spread coverings on my bed of coloured linen from Egypt. I have sprinkled my bed with myrrh, my clothes with aloes and cassia. Come! Let us drown ourselves in pleasure, let us spend a whole night of love; for the man of the house is away, he has gone on a long journey, he has taken a bag of silver with him; until the moon is full he will not be home." Persuasively she led him on, she pressed him with seductive words. Like a simple fool he followed her, like an ox on its way to the slaughter-house, like an antelope bounding into the noose, like a bird hurrying into the trap; he did not know that he was risking his life until the arrow pierced his vitals. But now, my son, listen to me, attend to what I say. Do not let your heart entice you into her ways, do not stray down her paths; many has she pierced and laid low, and her victims are without number. Her house is the entrance to Sheol, which leads down to the halls of death (Proverbs 7:6-27 ). Quackery.—Then you will understand what is right and just and keep only to the good man's path; for wisdom will sink into your mind, and knowledge will be your heart's delight. Prudence will keep watch over you, it will save you from evil ways and from men whose talk is subversive, who forsake the honest course to walk in ways of darkness, who rejoice in doing evil and exult in evil and subversive acts, whose own ways are crooked, whose tracks are devious (Proverbs 2:9-15 ). Research.—A simple man believes every word he hears; a clever man understands the need for proof (Proverbs 14:15). Schemes lightly made come to nothing, but with long plan¬ ning they succeed ( Proverbs 15:22). Ecology.—Go to the ant, you sluggard, watch her ways and get wisdom. She has no overseer, no governor or ruler; but in summer she prepares her store of food and lays in her sup¬ plies at harvest. How long, you sluggard, will you lie abed? When will you rouse yourself from sleep? A little sleep, a little slumber, a little folding of the hands in rest, and poverty will come upon you like a robber, want like a ruffian (Proverbs 6:6-11).
Hugh H. Hussey, MD
1. The New English Bible (A New English Translation). New Oxford University Press, 1970.
Cooperation and Educational
Lead to Better Service
Anesthesiology is a rapidly developing specialty of medicine. Its role has become more and more important with the advent of the complicated surgical procedures involved in open heart surgery, organ transplantation, and some neurosurgical procedures. Shortage of anesthestists has been reported from many countries around the world. In Europe, France and West Germany suffer a great manpower short\x=req-\ age in that field. The United States is in a much better position with regard to the quality and academic excellence of anesthesiologists and to the number of anesthetists in the country.
At present, there are almost 12,000 anesthesiologists in the United States. Their postgraduate specialty training and accreditation are regulated by the American Board of Anesthesiology. The annual increase in the number of anesthe-
siologists is slightly less than necessary to meet the demand, but there is no shortage of anesthetists. If one could complain, it would be only about the unequal distribution of anesthesiologists throughout the country. But this is a uni¬ versal problem among physicians, depending on economic, social, and geographic factors.
To supplement the anesthesiologists' work, the United States has nearly 17,000 qualified nurse-anesthetists. Most of these are members of the American Association of Nurse Anesthetists (AANA). The association insists on strict training. To qualify, a nurse-anesthetist must be graduated from a nursing school and, in addition, must have 18 months of training as a nurse-anesthetist. As presently planned, the course in the nurse-anesthetist schools will be extended to 24 months beginning Jan 1, 1976. Before the nurse-anesthetist is certified, he or she must be registered as a nurse and pass qualifying examinations as an anes¬ thetist. At least 55% of the anesthesiologic procedures in this country are done by nurse-anesthetists. In the opinion of the American Society of Anesthesiologists, these specialists will always be needed. However, in an ideal situation, they should work under the supervision of an anesthesiologist. Anesthesiologists welcome the efforts of the AANA to stimulate better training, to plan continuous education, and to supervise the practice of the nurse-anesthetist. The AANA has recently created an Advisory Committee on Education and Accreditation to coordinate the nurse-anes¬ thetists' training and continuous education programs. Dis¬ tinguished representatives of related health professions, anesthesiologists included, have been invited to serve on this committee. Additionally, a Council on Accredition was also created. Another new institution of the AANA is the Council on Practice. Specifically, it will review and revise the standards of practice by nurse-anesthetists; supervise ongoing evalua¬ tion of procedures; act as an investigating and disciplinary
body; develop advisory joint-practice
anesthesia, in consultation with the American Society of Anesthesiologists, the American Hospital Association, and the American Nurses' Association; and will act as the ap¬
peal body in matters of accreditation and training. In ad¬ dition to representatives of nurse-anesthetists, individuals from anesthesiology, hospital administration, nursing, law, and community interest groups will serve on the Council
of Practice. Two most important factors helping to provide the best possible anesthetic services in the United States are cordial cooperation between the anesthesiologists and the nurseanesthetists, and the sincere effort to improve education and scientific sophistication of the nurse-anesthetist. Thus, through cooperation and educational effort, the anesthe¬ siologists and the nurse-anesthetists will be better able to serve their patients.
Downloaded From: http://jama.jamanetwork.com/ by a University of Auckland User on 05/17/2015
Z. Danilevicius, MD Senior Editor