Pediatric lung transplantation: an emerging program.

Success has many measures, and team members each have personal criteria, but the success of our program is measured in the lives of our patients. To this end, every person associated with the program had a sense of ownership in it. It was imperative, in overcoming resistances, to treat people as individuals with valuable input, involve those affected in the planning, and provide complete and accurate information. Every person understood the process as a team effort. No one person acted alone, although key persons orchestrated the efforts of many. The instruments used were team building, communication, commitment, and collaboration. Problems and resultant pressures were viewed as challenges and opportunities for growth. When mistakes were made, we tried to learn from them, support each other, and move forward. Emphasis was on accomplishments, strengths, and unrealized potential. We learned from each other and from our patients. A close-knit team is an essential component of a successful program. The team is composed of professionals as active participants with mutual goals and a common purpose. Each member brings unique expertise, insights, personality, and experience in a cooperative venture to exchange information, identify problems, and reach a consensus. Time acts as a catalyst for members to learn to respect and appreciate each other. Cohesiveness evolves in a climate of acceptance, flexibility, and understanding. Members support and help each other. Consumers are involved with team members to participate in planning for care. In the space of 1 year, in spite of initial chaos from the Ready! Fire! Aim! approach, we have developed a sophisticated, comprehensive program for children with end-stage lung disease that can grow from a solid foundation. As we approach the second year and gain experience, we continue to evaluate our results and refine our aim.

Macrophage activation decreases macrophage prostaglandin E2 release in experimental trauma.

Prostaglandin E2 (PGE2) derived from macrophages following trauma may contribute to trauma-induced immunosuppression. This study evaluated the effect of glucan, a macrophage-activating agent, on macrophage PGE2 release in a murine trauma model. ICR/HSD mice were administered D5W, glucan pre-trauma, or glucan post-trauma, and subjected to hindlimb crush and amputation injury. Splenic macrophages were isolated 24 hours following trauma, cultured (24 hrs), and macrophage PGE2 levels were determined. In-vitro marrow proliferation was assessed as a measure of immune function. Crush-amputation injury increased (184%) macrophage PGE2 release. In contrast, glucan administration (pre or post) reduced PGE2 levels in macrophage supernatants (71% and 85%, respectively). A 52% decrease in in-vitro bone marrow proliferation was observed following trauma. Glucan pre- or post-trauma eliminated the suppression of bone marrow proliferation. In conclusion, macrophage-activating immunomodulators may exert beneficial effects following trauma by: 1) reducing macrophage PGE2 synthesis and release; and 2) reducing traumatic suppression of bone marrow proliferation.

Effect of enhanced macrophage function on early wound healing.

Although the macrophage is important to wound healing, research has focused on its relationship to fibroblast and collagen synthesis. This study was designed to assess effects of enhanced macrophage function on early wound healing, before established collagen synthesis. Sprague-Dawley rats had dorsal incisions after one of three treatment regimens: (1) saline solution, 0.5 ml administered intravenously, (2) intravenous glucan, a macrophage stimulant, 20 mg; (3) topical glucan, 20 mg. Intravenous therapy was administered 24 hours before and after incision. Breaking strength was significantly increased (p less than 0.01) by both intravenous glucan (49.8 +/- 5.5 gm) and topical glucan (59.7 +/- 5.6 gm) on the fourth day after incision, compared with controls (22.0 +/- 2.6 gm). Similar results occurred on the seventh day after incision. Although formalin fixation significantly enhanced breaking strength in fresh control wounds (22.0 +/- 2.6 vs 39.5 +/- 2.2 gm), no increase occurred in wounds treated with intravenous glucan (49.8 +/- 5.0 vs 55.3 +/- 6.4 gm), indicating maximal cross-linking of collagen. Collagen synthesis, reflected by tritiated proline uptake, was no different in control versus glucan groups. Supernatants from control or glucan-activated macrophages were injected intraperitoneally or applied topically in the rat model. Activated supernatant, both intraperitoneal and topical, resulted in increased breaking strength on the fourth day after incision. Formalin fixation did not increase breaking strength in the activated supernatant groups. We conclude that enhanced macrophage function increases early wound breaking strength. This effect appears unrelated to collagen synthesis but may be related to increased cross-linking of collagen. Similar effects are seen with activated macrophage secretory products administered intraperitoneally or topically.

Incompetency and insanity: feasibility of community evaluation and treatment.

In order to examine the feasibility of doing more sanity and competency evaluations and treatment on an outpatient basis rather than at a state hospital, we gave a feasibility questionnaire to 288 CMHC and state hospital administrators and treatment staff members. The respondents indicated that, given enhanced community evaluation and treatment programs for forensic clients, (a) 41 percent of the sanity evaluations and 45 percent of the competency evaluations done at the hospital could be done in local communities, (b) 35 percent to 38 percent of the clients found incompetent could be treated in local communities, and (c) 39 percent to 50 percent of the clients found insane could be released to outpatient treatment six months earlier than presently. Other findings indicated several specific improvements needed in the community mental health system before it can properly handle more forensic clients.