Surgery News - October 2008 - (Page 6)

OPINION EDITORIAL SURGERY NEWS • O C T O B E R 2 0 0 8 Salamander Secrets ee Spievack is a 69-year-old hobby University of Leeds, (England), suggested shop worker in Ohio who loves mod- that this injury most likely had little or no el airplanes. Three years ago, he got bone loss and sufficient nail bed to allow a little too close to the propeller of one of for normal regrowth (BBC News, May 2, them, and lost the end of his middle fin- 2008). But if a fingertip can regrow after injury, why can’t we regenerate ger. The amputated tissue more proximal amputations? could not be found and in such We know that frogs can recases, a flap or graft typically is place developing limbs in the used for wound cover. Instead, tadpole stage, but among verhis brother, Dr. Alan Spievack, tebrates, only the salamander sent him a powdered extract of retains the ability as an adult to pig bladder containing extraregenerate limbs over and over cellular matrix with instrucagain (Sci. Am. 2008;298:56tions to apply it to the wound. 63). Dr. Spievack was working at The salamander response to the University of Pittsburgh’s BY LAZAR J. regenerative medicine labora- GREENFIELD, M.D., FACS limb amputation differs significantly from that of mammals. tory with Dr. Stephen F. Badylak, a research veterinarian who has re- After vascular constriction to limit blood ported successful tissue regeneration using loss, the layer of wound epidermis transthis matrix in a variety of animal wound forms into a layer of signaling cells called models ( J. Surg. Res. 2008;147:61-7). Sure the apical epithelial cap (AEC). Instead of enough, the fingertip grew back in about forming scar tissue, the fibroblasts that migrate into the wound collect in the center 4 weeks. Prof. Simon Kay, a hand surgeon at the of the AEC to form a blastema, an aggre- L gation of cells that are progenitors for the new limb. These blastema cells recapitulate embryonic limb development by running the same genetic program (Nature 1982;298:369-71). Since we humans can make limbs as embryos, we also should carry the necessary programming to regenerate limbs as adults. We just have to figure out how to form a blastema. To learn about blastemas, researchers made a wound on the side of the limb, where simple healing would be expected to form a scar (Semin. Cell Dev. Biol. 1999;10:385-93). Since it was known that innervation was necessary for regeneration, they also deviated a nerve to the wound and found that wound fibroblasts did indeed convert into a blastema. Only, it didn’t progress to form a limb until they grafted some skin from the opposite side of the limb. These essential elements of wound epidermis, nerves, and fibroblasts from the opposite side of the limb then required a lot of cellular crosstalk and signaling by growth factors to complete the regeneration. In this process, the family of fibroblast growth factors (FGFs) is critical as well as the Hox gene family, which provides positional information about how much limb needs to be constructed. Research that might be more applicable to man is taking place in a mouse model in which an amputation blastema also can be demonstrated. These proliferating cells express bone morphogenetic protein 4 (Bmp4) and appear to come from fibroblasts in connective tissue and bone marrow (Dev. Biol. 2008;315:125-35). Since so many wartime injuries result in amputation, the U.S. Department of Defense is funding these efforts at a level of about $8 million as investigators strive to learn the secrets of regeneration. So if primitive behavior leads to amputation, perhaps a more primitive ancestor can teach us how to improve the outcome. ■ DR. GREENFIELD is editor in chief of SURGERY NEWS. POINT/COUNTERPOINT Is the Joint Commission’s MS 1.20 a step in the right direction? It would let medical staff partner with the hospital. act in accordance with the medical staff bylaws, rules, and regulations, and with the policies adopted by the medical staff to a medical staff would be listed in MS and approved by the governing body. The 1.20. This states that a medical staff should bylaws of the governing body should not be self-governing, and that the bylaws conflict with those of the medical staff. Being on a medical staff is a privilege should include a means for initiating, dewith responsibilities. Some of veloping, and approving medthe controversy surrounding ical staff bylaws, rules, and regMS 1.20 stems from a belief ulations; for selecting and among some hospital leaders removing medical staff offithat certain medical staff memcers; for determining mechabers are obstructing quality nisms used for establishing and care improvement and using maintaining patient care stantheir executive committees to dards; for credentialing and despeak and act on behalf of all lineating clinical privileges; and the members. This becomes for engaging in performance improvement activities. J. JAMES ROHACK, M.D., more challenging if the executive committee members on Medical staff play a crucial FACC, FACP the medical staff are employees role in ensuring the quality and safety of the medical care that is provided of the hospital and they do not address the in a hospital or other health care facility. concerns of all of their colleagues. To improve quality and ensure patient Having a mechanism for agreement from all participants in an organization is key to safety, the whole medical staff, the hospiits success, and medical staff can obtain tal administration, and the governing body need to be aligned. I believe MS 1.20, such agreement through its bylaws. Some procedural details may be dele- along with the leadership standards, will gated to a medical staff executive com- provide the framework for that alignment. To quote Dr. Arther C. Scott Sr., a genmittee, but that committee cannot be charged with determining a medical staff ’s eral surgeon, “What a patient desires most responsibilities and privileges. If that were when they enter a hospital is safety, and it to happen, the medical staff might not buy is the duty of every hospital board and sciinto all decisions regarding quality and pa- entific staff to see that no stone be left unturned to secure the greatest degree of tient safety. The partnership between a hospital’s safety known to the science and art of governing body and its medical staff is cru- medicine.” ■ cial for forming a system committed to quality patient care and safety. To that end, DR. ROHACK is a member of the Joint the Joint Commission leadership standards Commission Board of Commissioners and and the medical staff standard must be tak- the American Medical Association Board of en as a whole. The governing body should Trustees. process of modernizing and streamlining the Joint Commission stanIn the was decided that those pertaining dards, it It would be disruptive and slow decision making. the Joint Commission has supported of Historically, the principlesvitalcontinuous quality improvement as a part of an on the medical staff executive committee would be even tougher. MS 1.20 also has the potential to stifle accredited organization’s culture. How- creativity. A hospital that is planning to reever, the revisions as originally proposed organize its medical staff by disease status, for MS 1.20 work against continuous qual- such as cancer and diabetes, instead of the ity improvement. The overly prescriptive traditional delineation of surgery, obstetrics, and medicine, would likenature of the revised hospital ly not be allowed to implemedical staff standard MS 1.20 ment this type of change discourages innovation and under the revised standard. slows down administrative deThese changes seem to be cision making. aimed at preventing abuses by Continuous quality imthe medical staff executive provement suggests that stancommittee or the hospital dards should describe the demanagement. While that is a sired result, and those who are worthy goal, this policy is a doing the work should come poor way to deal with a small up with the process needed to JAMES R. number of misdeeds. The Joint achieve the desired result. CASTLE Commission should develop a Accredited organizations had expected the review of MS 1.20 to pro- process that deals with those exceptional duce greater flexibility around the rela- circumstances, not punish all accredited tionship of the hospital board, hospital organizations by imposing the kind of rigphysicians, and the medical staff. Instead, or suggested in this standard. The revised standard should focus on the draft of the new MS 1.20 moved back to being more prescriptive. In fact, some the desired outcome—providing highphysicians suggest it is more akin to the quality care—not on how to achieve that goal. It should specify the need for acstandards from the 1980s. As proposed, the revised MS 1.20 dic- credited organizations to credential the tates a process that would force hospitals professional working in the organization; and health systems to make changes at the a method to assess the credentialed propace of the slowest part of the organiza- fessional’s performance; and a plan for tion, even as today’s environment requires corrective action, if the expected levels of successful organizations to move quickly. performance fall short. At the same time, For example, if the medical staff executive accredited organizations need the flexibilcommittee adopted an on-call policy for ity to design these processes in a way that neurosurgeons, which would promote pa- meets their unique needs and those of tient safety and benefit the majority of the their employees. ■ medical staff, a small group could challenge the decision. In addition, the difficult MR. CASTLE is president and CEO of the task of recruiting staff members to serve Ohio Hospital Association in Columbus.

Table of Contents Feed for the Digital Edition of Surgery News - October 2008

Surgery News - October 2008 Contents Call to Action Issued to Support DVT, PE Prevention Protocol Changes May Increase Donor Organs CMS Targets 2011 for Switch to ICD-10 Opinion: Election 2008 The 20/20 Vision: Children's Health News From the College: Survival Strategy General Surgery: Innovations

Surgery News - October 2008

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