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A DAY IN THE LIFE OF A LIVER TRANSPLANT TEAM


Most of us have little contact with our transplant teams.  We meet the surgeon and perhaps a coordinator but very few others and once the transplant surgery is over, we are generally turned over to other specialists to follow our recovery.

Transplant teams are in the life saving business and while it is a hectic life it can be intensely rewarding.  You might have wondered exactly what a transplant team does.  Well, there’s not enough space or time here to go into great detail but I found this account of one day in the life of a transplant team fascinating.  I hope you do, too.

A DAY IN THE LIFE OF A LIVER TRANSPLANT TEAM

BY MARY ANN LITTELL

http://www.umdnj.edu/umcweb/marketing_and_communications/publications/umdnj_magazine/spring-2012/034.html

At age 57, Morristown resident Dagoberto Alvarado looked much older, a result of the devastating illness he’d been battling. It left him pale and weak, vomiting and losing weight. In February he was diagnosed with advanced cirrhosis. His physician advised him to go straight to the liver transplant center at University Hospital (UH): “They will save your life.”

At UH, Alvarado was evaluated and put on the liver transplant list. On March 10, he received a new liver in a grueling 12-hour operation. The next morning, his wife was amazed to find him sitting up in his hospital bed, eating a light breakfast. “I couldn’t believe the transformation in my husband — in less than a day,” she said.

“There are only two liver transplant programs in New Jersey. We are the first and the largest,” says Baburao Koneru, MD, chief of liver transplant and hepatobiliary surgery at UH and professor of surgery at New Jersey Medical School (NJMS). He launched the program in 1989 and that year, 15 transplants were performed. Since then, Koneru and his team have transplanted more than 1,000 livers, currently averaging 45 to 50 transplants a year. One-quarter of these patients have liver cancer. Other major reasons for liver transplantation include hepatitis C, alcoholic cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis, primary biliary cirrhosis, Wilson’s disease and other serious disorders. The team also performs approximately 150 major liver operations annually.

The program is organized around a multidisciplinary team that includes surgeons, hepatologists, physician assistants, social workers, a psychiatrist with expertise in transplant issues, and financial coordinators to help navigate the maze of payment and reimbursement. Nurse coordinators (pre- and post-op) serve as the liaison between the transplant team and patients, overseeing the logistics of surgery and recovery.

A typical day with the medical/surgical team includes much more than surgery. This group is all about sharing knowledge and technical skills with residents, fellows, medical students, nurses, physical therapists, nutritionists, pharmacists and other hospital colleagues, on rounds and at weekly meetings and conferences. “There are many key players,” says Koneru. “Teamwork is what makes this program so successful.”

8:00 am

The day begins early with a radiology conference where the team evaluates the X-rays of many patients, identifying those who might benefit from a clinical trial or liver transplant. Patients are referred to the UH program from throughout the state. “We’re known for our excellent outcomes,” says Koneru.

9:45 am

Above left: Samanta and Koneru on rounds, which are attended by residents, medical students, social workers, nurses, pharmacists, physical therapists, dietitians and others. Above right: Koneru discusses patient histories with Michelle Wilkins, MD (left), NJMS’09, an intern at Robert Wood Johnson Medical School; and UH hepatology fellow Eleazer Yousefzaden, MD.

11:45

The team checks on Dagoberto Alvarado, now three days post-transplant. Dramatically improved, he’ll soon be heading home. Patients can wait for months on the transplant list — or in the case of Alvarado, be fortunate enough to secure a liver within a few weeks. “He might not have made it otherwise,” says his wife. The length of time a patient spends on the waiting list depends on many factors, among them the severity of their illness and the availability of donated organs.

1:30 pm

NJMS students may take clinical electives in a variety of specialty areas, including hepatology. This offers opportunities for collaborative learning from those in other health professions. It’s also a chance for students to ‘try out’ a specialty and experience first-hand what it’s like to be an active member of a medical team. Left: Cynthia Quainoo, MD, transplant hepatology fellow, discusses patient management with Samanta.

2:05 pm

Above Left: Patient Jamie Feireria was admitted to UH with cirrhosis of the liver and a severe rash (a common complication of liver disease). “I gained 30 pounds in one month,” she says. The physicians order tests to find out why. Above Right: Arun Samanta, MD, is professor of medicine at NJMS and chief of hepatology and transplant medicine at UH. The UH liver unit accommodates patients who are potential transplant candidates; those who are listed for transplant and await a donor organ; and those with severe liver disease — for example, acute liver failure, metabolic liver disease, advanced liver disease complicated with acute kidney failure, or drug-induced liver injury — who require care but do not need a transplant.

2:35 pm

Patient Alita Cruz has hepatitis C and has been on the transplant list for four weeks. She was admitted to UH when a liver became available, but unfortunately, the organ wasn’t in transplantable condition. Her wait for a donor liver continues.
FRONT ROW, LEFT TO RIGHT : GEORGE MAZPULE, MD, SURGICAL RESIDENT; BABURAO KONERU,MD; ARUN SAMANTA, MD.

MIDDLE ROW: ELISABETE DASILVA, PHYSICIAN ASSISTANT; EDITH MENCHAVEZ, RN, NURSE COORDINATOR; MARIA DEALMEIDA, FINANCIAL COORDINATOR; VALERIE BROOKS, SECRETARY; HELEN EDUJARDIN, PROGRAM ADMINISTRATOR; MALIHA AHMAD, MD, ASSISTANT PROFESSOR OF MEDICINE; CONNIE MUNOZ, PATIENT NAVIGATOR/REFERRALS COORDINATOR; ESTHER CALADO-ALIGMAYO, RN, NURSE COORDINATOR; THOMAS LYNCH, MD, SURGICAL RESIDENT; MARLENE ANDRADE, MEDICAL ASSISTANT; FELMA IZAR, FINANCIAL COORDINATOR; ADITI PATEL, PHYSICIAN ASSISTANT; DOROTHY O’HARE, RN, NURSE COORDINATOR; MAUREEN HESTER, RN, NURSE COORDINATOR ;ELOISA LAUDATO-HUFALAR, RN, NURSE COORDINATOR; IONA MONTEIRO, MD, ASSOCIATE PROFESSOR OF PEDIATRIC GASTROENTEROLOGY.

BACK ROW: GEOFFREY KOIZUMI, DATA SYSTEMS MANAGER; JACQUELINE O’BRYANT-TRAVIS, PROGRAM ASSISTANT; FONDA STEWART, MEDICAL ASSISTANT; LATONIA BALDWIN, MEDICAL ASSISTANT ;CARLO OPONT, PHYSICIAN ASSISTANT; ADRIAN FISHER, MD, ASSOCIATE PROFESSOR/TRANSPLANT SURGEON; AND DORIAN WILSON, MD, ASSOCIATE PROFESSOR/TRANSPLANT SURGEON.

3:20 pm

Transplanting an organ is not unlike staging a large, complex opera. There is so much drama — some of it life and death. The starring players — physicians, patients, nurses and myriad support staff — often face obstacles and conflict. There’s the quest for a ‘holy grail’— in this case, a healthy liver.

The group of people pictured above makes it happen at University Hospital. “Most patients are referred by their physicians, but some people find us by themselves,” says UH nurse coordinator Maureen Hester. “When they come here, they’re frightened. They expect to go on the transplant list right away, but it doesn’t work that way.”

Patients are first examined to determine whether they are transplant candidates. The workup includes evaluation by transplant hepatologists and surgeons, cardiologists, social workers and dietitians. A psychiatric workup includes support for patients and evaluation for drug and alcohol abuse – both primary factors in hepatitis C infection. Transplant candidates with alcohol or drug-related illness must agree to give up these substances completely. Their names will not go on the waiting list until they complete six months of sobriety.

Those who are accepted into the program go on a national waiting list until a liver becomes available. Statistical formulas are used to predict which patients’ are in the greatest need of a new liver and they are placed higher on the list. Patients’ placement on the list changes as their health status changes.

The wait for a liver can be days, weeks, or months. It’s part of the drama. When the call finally comes that a liver is available, the patient and the team are ready. And in the best-case scenario, there is a happy ending,

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our video “Thank You From the Bottom of my Donor’s heart” on http://www.organti.org This video was produced to promote organ donation so it is free and no permission is needed for its use.

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to http://www.organti.org and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to bob@baronson.org and usually you will get a copy the same day.

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

Hepatitis C — What You Need to Know


More people in the United States now die from hepatitis C each year than from AIDS, according to a new report from the Centers for Disease Control and Prevention. More than 3.2 million Americans are currently infected with hepatitis C and the really bad news is that most people who have it don’t’ know it.

Let’s start with a definition.

According to the Mayo Clinic Hepatitis C is an infection caused by a virus that attacks the liver and leads to inflammation. Most people infected with the hepatitis C virus (HCV) have no symptoms. In fact, most people don’t know they have the hepatitis C infection until liver damage shows up, decades later, during routine medical tests.

Hepatitis C is one of several hepatitis viruses and is generally considered to be among the most serious of these viruses. Hepatitis C is passed through contact with contaminated blood. http://www.mayoclinic.com/health/hepatitis-c/DS00097

According to the U.S. Centers For Disease Control (CDC) http://www.cdc.gov/hepatitis/c/cfaq.htm Hepatitis C is most commonly spread through the use of infected needles. Before 1992, when widespread screening of the blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusions and organ transplants. Now we know that people can become infected with the Hepatitis C virus during such activities as

  • Sharing needles, syringes, or other equipment to inject drugs
  • Needlestick injuries in health care settings
  • Being born to a mother who has Hepatitis C

Less commonly, a person can also get Hepatitis C virus infection through

  • Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes
  • Having sexual contact with a person infected with the Hepatitis C virus

***Note, the Executive Director at HCVets.com, Tricia Lupole, indicates that the CDC information may be incorrect. She made this comment on our Facebook page.

“HCV by sex is a risk if both partners experience trauma and exchange blood…. the only cells found is seminal fluids are dead cells…. confirmed by many microbiologist. http://www.ncbi.nlm.nih.gov/pubmed/15128350 There are 100s of studies that show this is the case but it is junk science that reins control of the message to control the funding. Lots of plans to make HCV the fall guy for bad behavior.“

In a second post she went on to say, “Yes, the CDC has quoted the same statement for about 15-20 years now. The study I posted is based on the CDC National Survey. Another sad point, last I checked. Even though we all know better the CDC says that there is not enough evidence to show tattoos are a risk factor.

AMA does not want to regulate tattoo parlors as medical procedures because they are responsible for guidance/ prevention. (The task has been given to OSHA).

Today Ms. Lupole issued this statement:

The Centers for Disease Control federal funding has decreased in recent decades, while there’s been increased demands for vaccination programs; resulting in limited resources for at-risk adults and other mandated priorities. The categorical nature of federal funding for HIV, STD, and viral hepatitis prevention limits the shifting of funds across program lines. In response to these funding woes, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention’s (NCHHSTP) captured HCV disease and redesign public health services to fit HIV programs, instead of critical public health needs. It’s important to note that HCV disease was previously integrated into federal research that included its viral family called Flaviviridae, whose members are Yellow Fever and Dengue viruses and transmit disease through mosquitoes. The HCV genome is almost identical to Dengue virus.


NCHHSTP’s Federal mandate is an integration of existing programs with new programs, like Viral Hepatitis, developed to mirror HIV/AIDS management model based on specific risks and disease pathology. STD and Substance Abuse programs associated with the spread of HIV/AIDS received increased attention and funding, blurring the other components of these programs.

Needless to say, NCHHSTP has meet with resistance from advocates and congressional leaders, because of this effort by public health agencies to narrowly define HCV’s pathology.


Today, NCHHSTP spends half the federal resources acquired for HCV to vaccinate patients with both Hepatitis A & B vaccines. The majority of remaining resources are directed at drug and STD intervention and prevention. The STD division must qualify for its share of funding by defining HCV a sexually transmitted disease.


Despite scientific proof that HCV is not an STD, NCHHSTP promotes HCV as an STD based on a handful of studies that bring about scientific uncertainty, working against broader public health threats. Research excluded several methods by which the virus transmits to insure standard elements comply with CDC corporate agreement requirements. Thus… junk science.
Such actions suggests this poor public health response to the HCV Disease epidemic, may be the direct result of a system in disarray – seemingly captured by special interest with legal and political agendas that have negatively influenced the response. The integration approach has created disparities in access to health care and created “social labels” that have fostered discrimination, responsible for the reduction in quality of life.

The enduring legacy of “junk science” and indifference of governments, nonprofits, advocates, political parties or economic elites, have grave and global consequences given the propensity for viral transmission in provider settings as seen in current headlines.

FY 2012 Hepatitis C transmission and prevention: latest news. Massive increase of hepatitis C incidence in HIV-positive gay men in Switzerland 30 August 2012 …http://www.aidsmap.com/Hepatitis-C-transmission-and-prevention/cat/1628/

• FY 2008- No evidence of a HCV epidemic in HIV negative gay men
Dr Turner et al. Data from attendees at a London GUM clinic suggest that there is no increase in HCV infections amongst HIV negative gay men.

• FY 2007- Injection Behavior, Not Sexual Contact, Accounts for Couples’ HCV Risk NEW YORK (Reuters Health) – Injection behavior, rather than sexual contact, accounts for the clustering of HCV virus (HCV) infection in heterosexual couples, according to a report in the June 1st issue of The Journal of Infectious Diseases.

• FY 2004 No Evidence of Sexual Transmission of HCV among Monogamous Couples: Results of a 10-Year Prospective Study The risk of sexual transmission of HCV virus (HCV) infection was evaluated among 895 monogamous heterosexual partners of HCV chronically infected individuals in a long-term prospective study, which provided a follow-up period of 8,060 person-years.

Either way, CDC or not…. junk science remains junk science. Wish the outcry would focus on piercing jewelry or the reuse of razors and personal care items verses a national message about a method that is least as likely as not. This battle over CDC junk science, goes way back and is in memory of many who passed HCV on to family members, while sacrificing pleasures of the mind, body, and soul. As you can imagine, sexual transmission is a constant worry for some. Their partner may catch/transmit this deadly virus through sex, protection or not….. yet… turn right around and share razors and other items as such.  Especially the economically depressed populations.”

Most recently, though, we’ve identified another way people may become infected and through no fault of their own. Recently in a New Hampshire hospital an employee who was a drug addict and who also had Hepatitis C was found to be injecting himself with filled syringes meant for patients, refilling the syringes with a harmless liquid non-pain killer and then replacing the needles and syringes on the tray to be used again. Below is one of the original stories on this 2012 incident.

‘Serial infector’ accused of spreading hepatitis at NH hospital

U.S. Attorney’s Office | ASSOCIATED PRESS

CONCORD, N.H. — Authorities in at least six states are investigating whether a traveling hospital technician accused of infecting 30 people with hepatitis C in New Hampshire also exposed earlier patients to the liver-destroying disease.

David Kwiatkowski, a former technician at Exeter Hospital, was arrested Thursday morning at a Massachusetts hospital where he was receiving treatment. Once he is well enough to be released, he will be transferred to New Hampshire to face federal drug charges, said U.S. Attorney John Kacavas, who called Kwiatkowski, 33, a “serial infector” who worked in at least half a dozen states.

Authorities believe Kwiatkowski stole drugs from a hospital operating room in another state, but they declined to name any of the other states, saying only that they are not clustered in one part of the country. They would not say in what hospital Kwiatkowski was being treated at so he couldn’t be contacted for comment.

This story brought new attention to hospital policies on infection control, narcotics control and patient safety and has had ripple effects across the nation if not around the world.

So…the next question is, how serious is hepatitis C? Chronic Hepatitis C is a serious disease that can result in long-term health problems, including liver damage, liver failure, liver cancer, or even death. It is the leading cause of cirrhosis and liver cancer and the most common reason for liver transplantation in the United States. Approximately 15,000 people die every year from Hepatitis C related liver disease.

What are the long-term effects of Hepatitis C?

Of every 100 people infected with the Hepatitis C virus, about

  • 75–85 people will develop chronic Hepatitis C virus infection; of those,
    • 60–70 people will go on to develop chronic liver disease
    • 5–20 people will go on to develop cirrhosis over a period of 20–30 years
    • 1–5 people will die from cirrhosis or liver cancer

The CDC strongly suggests that all baby boomers born since 1945 should get tested for Hepatitis C. http://tinyurl.com/8tg28x6Baby boomers account for 2 million of the 3.2 million Americans infected with the blood-borne liver-destroying virus. CDC officials believe the new measure could lead 800,000 more boomers to get treatment and could save more than 120,000 lives.

“The CDC views hepatitis C as an unrecognized health crisis for the country, and we believe the time is now for a bold response,” said Dr. John W. Ward, the CDC’s hepatitis chief.

Several developments drove the CDC’s push for wider testing, he said. Recent data has shown that from 1999 and 2007, there was a 50 percent increase in the number of Americans dying from hepatitis C-related diseases. Also, two drugs hit the market last year that promise to cure many more people than was previously possible.

What are the Symptoms of Hepatitis C?

Here’s what WEBMD says. http://www.webmd.com/hepatitis/hepc-guide/hepatitis-c-symptoms

Most people who are infected with hepatitis C-even people who have been infected for a while-usually don’t have symptoms.

If symptoms do develop, they may include:

  • Fatigue.
  • Joint pain.
  • Belly pain.
  • Itchy skin.
  • Sore muscles.
  • Dark urine.
  • Jaundice, a condition in which the skin and the whites of the eyes look yellow.

A hepatitis C infection can cause damage to your liver (cirrhosis). If you develop cirrhosis, you may have:

  • Redness on the palms of your hands caused by expanded small blood vessels.
  • Clusters of blood vessels just below the skin that look like tiny red spiders and usually appear on your chest, shoulders, and face.
  • Swelling of your belly, legs, and feet.
  • Shrinking of the muscles.
  • Bleeding from enlarged veins in your digestive tract, which is called variceal bleeding.
  • Damage to your brain and nervous system, which is called encephalopathy. This damage can cause symptoms such as confusion and memory and concentration problems.

What Treatment is Available?

So if you have Hepatitis C, then what? There are a number of options and there might even be a cure before too long. Standard state of the art treatment today for Hepatitis C is with Peginterferon and Ribavirin which achieves a “sustained response” up to 54% of people, which means that the virus has been eliminated from their blood after stopping treatment. People with hepatitis C types 2 and 3 have sustained response rates of about 80%; people with type 1 have rates of up to 50%.

While hepatitis C treatment has come a long way, there are still drawbacks. For a person who’s newly diagnosed, a 54% cure rate may not sound great. After all, it means that about one out of two people won’t respond to treatment.

Also, hepatitis C treatment is less effective in some populations. For reasons that no one understands yet, African-Americans are less likely to benefit from treatment. And the treatments may not be safe for people with other medical conditions — such as kidney failure, heart disease, or pregnancy. Interferon can also be expensive; according to the American Academy of Family Physicians, it can cost $6,000 per year. http://www.medicinenet.com/script/main/art.asp?articlekey=52451

It is important to note again, that while liver transplants can be very helpful to Hepatitis C patients, the procedure is not a cure but rather a delaying action and an effective one. There is some evidence that a transplant from a living donor to a patient who has been receiving the Interferon treatment could represent a cure. http://www.youtube.com/watch?v=3kOElXz0vVg

A Possible Medicinal Cure

Gilead Science is performing multiple studies to test an experimental drug, but the trial that is possibly the most intriguing looks at a combination therapy that rolls two medicines into a single pill. Gilead hopes to advance tests of its lead hepatitis drug GS-7977 in a combination with another company medicine, GS-5885.

Bristol Myers Squibb had a promising drug but clinical trials resulted in some negative results so the company has sent the project back to the drawing board. http://www.nytimes.com/2012/08/24/business/bristol-myers-ends-work-on-hepatitis-c-drug.html?_r=2&

Finally, Gilead Sciences, mentioned earlier, has a drug that combined with another from Bristol Myers Squibb could be a cure, at least clinical trials seem to offer that indication but the two companies, according to Hepatitis C activist Margaret Dudley can’t seem to cooperate. She is circulating a petition to get the “cure” on the market. http://hepc-cured.com/

October is National Liver Awareness month. We hope you have found these blogs helpful and offer these links for further information.

http://www.liverfoundation.org/

http://www.nlfindia.com/index.asp

http://www.mayoclinic.com/health/liver-problems/DS01133

http://tinyurl.com/92bjlup U.S. Government Link

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our video “Thank You From the Bottom of my Donor’s heart” on http://www.organti.org This video was produced to promote organ donation so it is free and no permission is needed for its use.

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to http://www.organti.org and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to bob@baronson.org and usually you will get a copy the same day.

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

Hepatitis C — No One is Immune Everyone is Affected


More people in the United States now die from Hepatitis C each year than from AIDS  according to a new report from the Centers for Disease Control and Prevention.   More than 3.2 million Americans are currently infected with Hepatitis C and the really bad news is that most people who have it don’t’ know it.

In coming days I will publish more information and heart wrenching stories about Hep C and the patients it affects, the lives it wrecks and what it costs our society in both human lives and dollars…it is astounding.

Hep C is a disease of the liver that society likes to keep in the shadows because of some of the ways in which it is contracted, but we cannot begin to deal with a disease if it is kept secret and treated as though it was sinful and dirty.  It isn’t.  The people aren’t and they need our help and our compassion.

Hepatitis C can be treated and there are some exciting possibilities on the horizon but now there is no available cure,  not even a liver transplant is a cure because Hepatitis C is systemic.

To get us started on the road to understanding please view this video.  It says more in a few minutes than anything I can write at this moment.  Please share the video with others and then watch this space for more.  I fully intend to say a lot more on the subject of this disease that affects so many of my friends.

Thank you  http://www.youtube.com/watch?v=J4TCo-qVoKk

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our video “Thank You From the Bottom of my Donor’s heart” on http://www.organti.org This video was produced to promote organ donation so it is free and no permission is needed for its use.

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to http://www.organti.org and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to bob@baronson.org and usually you will get a copy the same day.

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

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