Concerns Regarding Organ Donation From Prisoners With Death Penalties: Perspectives of Health Professionals in Taiwan and Mainland China

Objective

This study aimed to compare the dilemmas of using organs from prisoners with death penalties (PDP) from the perspectives of organ transplant health professionals (OTHP) from Taiwan (TW) and Mainland China (MC).

Materials and Methods

A purposive sample including TW's OTHP (including transplant surgeons, nurses, researchers, social workers, and medical religious and legal experts), and MC's OTHP (including surgeons and nurses) was obtained in this qualitative research. TW's subjects received face-to-face interviews, and MC's subjects received telephone interviews due to limited communication opportunities. Data were analyzed by content analysis.

Results

A total of 105 subjects participated in this project (TW n = 99, MC n = 6). They were surgeons (n = 18: TW n = 14, MC n = 4), registered nurses (n = 42: TW n = 40, MC n = 2), OT coordinating nurses (n = 10 TW), OT researchers (n = 5 TW), social workers (n = 10 TW), medical religious experts (n = 15 TW), and medical legal experts (n = 5 TW). The following 8 ethical dilemmas were reported: (1) questionable legitimacy of PDP motivation (TW 100%, MC 100%); (2) recipients' worries about public discrimination (TW 89%, MC 50%); (3) difficulties in approaching PDP (TW 100%); (4) hesitation of HP and volunteers in helping PDP (TW 37%); (5) questionable social contribution of PDP as donor sources (TW 32%); (6) complex legal details of PDP issues (TW 26%); (7) potential threat from PDP families (TW 23%); and (8) difficulties in helping PDP families cope with post-organ donation syndrome (TW 11%).

Conclusions

Five suggestions were developed in managing these challenges: (1) TW OTHP may empower their basic social science knowledge and empirical competence; (2) TW government may form a task force wherein OTHP leaders are encouraged to foster interdisciplinary collaborations with the public within short-, mid-, and long-term time frames; (3) TW and MC may establish evidence-based center(s) to provide systematic literature reviews for clinical guidance, policy making, and educational resources; (4) TW and MC may try to improve the quality of PDP organ harvesting and donation practice in jails/health institutes; and (5) TW and MC may develop reliable communication systems to share experiences of quality care for PDP, and to evaluate the appraisals both pro and con from multidisciplinary societies and the public, if available.     

Attitude of Health Professionals Toward Cadaveric Tissue Donation

Introduction

A positive attitude toward organ donation would be expected among health professionals from transplant centers with active donor activities. However, acceptance and knowledge about cadaveric tissue donation has been insufficiently studied.

Objective

The objective of this study was to analyze the knowledge and attitude of health professionals toward cadaveric tissue donation.

Methods

An anonymous survey composed of 23 questions was given to health professionals from 2 university hospitals with donation experience. Sociodemographic and professional characteristics were described to analyze knowledge and acceptance of cadaveric tissue donation.

Results

Among 600 distributed questionnaires we collected 514 completely answered surveys. Gender distribution was 399 females/115 males of ages ranging from 18-65 years, namely 18-28 years, 27%; 29-39 years, 31%; 40-50 years, 32%; and 51-65 years, 10%. Among the sample, 31% of health professionals had never been in contact with a transplant recipient. In this study 99.4% had knowledge about cadaveric organ donation compare with 89.7% about tissue donation. The knowledge about various types of tissue donation was as follows: eye, 96%; musculoskeletal, 87%; skin, 72%, and cardiovascular, 67%. In the sample, 93% and 92% accepted the opportunity to receive an organ or tissue transplantation, respectively. The acceptance of a tissue varied according to the type: cardiovascular, 93%; ocular, 94%; skin, 89%; and musculoskeletal, 87%. Participant acceptance of a relative's tissue donation was 74%, refusal was 22%, and with doubts was 4%.

Conclusions

Insufficient knowledge about cadaveric tissue was demonstrated among health professionals more exposed to the donation process. These results highlighted the importance of health professional's education to facilitate public information about organ and tissue donation.     

Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center

Background

Traumatic injuries are a major cause of morbidity and mortality in children. The purpose of the present study was to determine the incidence of nonaccidental trauma (NAT) and to compare the outcomes of accidental trauma (AT) patients with NAT patients at a large pediatric trauma center.

Methods

A retrospective chart review of 6186 trauma patients younger than 18 years evaluated during the period of 1996 to 2004.

Results

During the period of study, NAT accounted for 7.3% (n = 453) of trauma evaluations (n = 6186). Compared to AT, the NAT patient was younger, 12 vs 76 months (P < .05); were more severely injured, injury severity score 18 vs 9 (P < .05); and required both longer intensive care unit stay, 2 vs 1 day (P < .05), and overall hospital stay, 6 vs 3 days (P < .05). Craniotomy was required in 4.4% of NAT patients compared with 2.7 % of AT patients (P < .05). Abdominal exploration was necessary in 3.5% of NAT patients compared to 1.6% of AT patients. The mortality rate for NAT was 9.7% compared to 2.2% for AT (P < .05).

Conclusions

The surgeon caring for children must appreciate the high incidence of NAT with its increased morbidity and mortality relative to AT patients. A surgical evaluation should be performed promptly in NAT patients because of their frequent need for emergent intervention.     

Difficulties in organ procurement and transplantation in the aboriginal minority people in Taiwan

Background

Aboriginal people (AP) are a minority group in Taiwan. Little information on their perspectives on organ transplantation (OT) is available. Their rights for organ donation (OD) and as OT recipients (OTR) are constrained as a vulnerable population in society. This research sought to explore various Highland Aborigine Tribes beliefs systems and concepts related to OT.

Methods

We employed a qualitative design on a purposive sample including seven categories of Taiwanese AP. Data collected by face-to-face interviews were evaluated by content analysis.

Results

Seventy-five informants (45 female and 30 males) of 18 to 82 years from seven tribes completed interviews: Bunun (n = 20), Shao (n = 18), Tsou (n = 15), Amis (n = 12), Truku (n = 4), Rukai (n = 3), and Puyuma (n = 3). Of there, 33% had no idea of OT. All informants reported lack of knowledge of OD, organ procurement, and OTR. Eighty percent (45-82 years) had no willingness for OD or OTR; others might consult family members and health professionals (HP) to learn about OT. Seven hindering factors were identified: (1) having no background of OT; (2) limited impressions obtained from television news reports; (3) negative concepts of donating one's organs to others; (4) OT concepts contrast with cultural meanings of death; (5) possibility of being stigmatized; (6) fear of being rejected by others; and (7) HP had never mentioned OT.

Conclusions

Taiwan APs' perspectives of OT concepts showed the majority to be unfamiliar with the concept and benefits of OT. Future research is necessary to explore the possible avenues to facilitate communications between HP and AP leaders, as well as elders in each AP category in Taiwan.     

Etiology and one-year follow-up results of hearing loss identified by screening of newborn hearing in Japan

Objective

To evaluate the incidence of newborn hearing loss in a Japanese population and to elucidate etiological factors and one-year prognosis.

Study Design

Screening of newborn hearing.

Setting

Children's tertiary referral center.

Subjects and Methods

Between 1999 and 2008, 101,912 newborn infants were screened, with 693 infants (0.68%) referred. Etiology investigation included CT, detection of cytomegalovirus (CMV) DNA, and connexin 26 mutation.

Results

Abnormal results (auditory brainstem response [ABR] threshold ≥ 35 normal hearing level [dB nHL] in either side) were observed in 312 infants (0.31%), and 133 subjects (0.13%) with ABR thresholds ≥ 50 dB nHL on both sides were classified into the habilitation group. In this group, inner ear/internal auditory meatus anomalies were detected in 20 of 121 subjects (17%) tested, middle/external ear anomalies in 14 of 121 subjects (12%), CMV DNA in 13 of 77 subjects (17%), and connexin 26 mutation in 28 of 89 subjects (31%). In 68 subjects undergoing all three investigations (CT, CMV, and connexin 26), 41 (60%) had positive results in at least one test. With inclusion of otitis media with effusion and perinatal problems, this rate amounted to 78% (53 subjects). Of the 97 infants in the habilitation group successfully followed up to one year, 36 (37%) showed a threshold change of 20 dB or more in either ear: 11 (11%) progression and 25 (26%) improvement, and 15 infants (15%) were reclassified into a less severe classification.

Conclusion

Considering that 26 percent of infants with bilateral moderate to severe hearing loss showed improvement in one year, habilitation protocols, especially very early cochlear implantation within one year of birth, should be reconsidered.     

Addition of epinephrine to epidural bupivacaine infusions following initiation of labor analgesia with epidural fentanyl

Study Objective

To evaluate the analgesic effects of the addition of epinephrine to a bupivacaine epidural infusion in early labor after a fentanyl bolus, following a lidocaine-epinephrine test dose.

Design

Randomized, double-blinded study.

Setting

Labor suite of a tertiary care hospital.

Patients

60 ASA physical status 1 and 2, laboring, nulliparous women.

Interventions

All laboring women received a 3 mL epidural test dose of 1.5% lidocaine with 1:200,000 epinephrine, followed by a fentanyl 100 μg bolus in 10 mL of diluent volume. Patients were randomized to receive one of two continuous epidural infusions: bupivacaine 0.625 mg/mL at 10 mL/hr (control group) or bupivacaine 0.625 mg/mL with epinephrine 5 μg/mL at 10 mL/hr (epinephrine group).

Measurements

Time to re-dose, pain scores, and side effects were recorded.

Main Results

The mean duration of satisfactory analgesia prior to re-dose was 159 ± 62 min for the control group and 221 ± 111 min for the epinephrine group (P < 0.02). Pain scores were significantly higher in the control group than the epinephrine group at two time periods: 2.5 hours and 4.5 hours (P < 0.04).

Conclusions

The administration of 0.625 mg/mL bupivacaine with epinephrine 5 μg/mL at 10 mL/hr, compared with plain 0.625 mg/mL bupivacaine at 10 mL/hr, provided a longer time to re-dose, decreased pain scores at two time intervals, and had no significant difference in duration of labor or side effects.     

Treatment and outcomes of patients with primary breast sarcoma

Background

Surgery is the main treatment for primary breast sarcoma (PBS). Here we characterize this disease and determine factors associated with use of adjuvant therapy.

Methods

Records of patients with PBS from 1986 to 2006 were reviewed. Overall survival (OS) was estimated by Kaplan-Meier. Relationships between patient variables and OS were determined using univariate Cox proportional hazard models.

Results

Thirteen patients with PBS were identified; 10 patients underwent mastectomy, and 3 underwent partial mastectomy. Six patients underwent axillary staging; none were positive. Patients with tumors >5 cm were more likely to undergo radiation therapy (P <.05). Local recurrence occurred in 7 patients. Metastatic disease was present in 2 patients at diagnosis, and 6 patients developed metastatic disease; all 8 patients died from their disease. Five patients remained disease free. Five-year OS was 67% (83% for tumors <5 cm and 42% for tumors >5 cm). Tumor size was significantly associated with OS (relative risk = 1.1/1 cm increase in size > 5 cm).

Conclusions

Treatment for PBS is excision to clear margins. Axillary staging is not indicated. Tumor size >5 cm is the only significant prognostic indicator of overall survival.     

Comparison of outcomes after laparoscopic and open pyloromyotomy at a high-volume pediatric teaching hospital

Background/Purpose

Laparoscopic pyloromyotomy (LP) is used widely for treatment of hypertrophic pyloric stenosis. We examined the results of pyloromyotomy at a high-volume pediatric teaching hospital to compare outcomes of laparoscopic and open pyloromyotomy (OP).

Methods

We reviewed the records of all patients who underwent pyloromyotomy at our institution over a 5-year period. Data were collected regarding operative time, time to full feeds, length of hospital stay, complications, and frequency of postoperative emesis.

Results

There were 335 pyloromyotomies: 212 laparoscopic and 123 open. Five patients in the laparoscopic group required conversion to an open procedure. There were no significant differences in operative time (LP, 30.5 minutes; OP, 32.0 minutes), time to full feeds (LP, 22.4 hours; OP, 23.5 hours), frequency of postoperative emesis (LP, 1.8; OP, 2.2), or length of hospital stay (LP, 49.3 hours; OP, 50.5 hours). There were 5 mucosal perforations in the laparoscopic group and 2 in the open group (LP, 2.3%; OP, 1.6%). There were 3 incomplete pyloromyotomies in the laparoscopic group and none in the open group. Four perforations and all incomplete myotomies occurred in the first 2 years after the laparoscopic technique was introduced at our institution. The overall complication rate was similar (LP, 3.7%; OP, 3.2%).

Conclusions

Laparoscopic pyloromyotomy is a safe and effective alternative to OP. There appears to be an institutional learning curve when the laparoscopic technique is introduced as reflected by slightly higher rates of mucosal injury and incomplete pyloromyotomy.     

Strategies for Maximizing Heart and Lung Transplantation Opportunities in Japan

Introduction

Because the donor shortage is extremely severe in Japan because of a strict organ transplantation law, special strategies must be established to maximize heart transplantation (HTx) and lung transplantation (LTx) opportunities. The purpose of this study was to review our strategies to identify and manage heart and lung donors.

Method

Transplantation doctors themselves assessed their own donor heart and lung function before starting the procurement operation; skillful staff surgeons harvested the organs. Since November 2002, a special transplantation consultant doctor assessed donor organ function to identify useful organs and intensively cared for the donor to improve cardiac and lung function.

Results

Only 63 brain-dead donors have been available in Japan. However, 49 HTx (77.7%) and 39 LTx (19 bilateral and 20 single) were performed from 36 donors (57.1%). Thirty-six HTx donors were marginal, requring sustained high doses of inotropes (n = 26), low left ventricular ejection fraction (n = 5), cardiopulmonary resuscitation (n = 15), and age older than 55 years (n = 6). Twenty LTx donors had infected sputa or showed pneumonia using chest X-ray. None of 49 HTx recipients died of primary graft failure (PGF). Patient survival at 3 years after HTx was 98.0%. Although 5/39 LTx died early, including 2 of PGF, patient survival rate at 3 years was 66.9%.

Conclusion

Although the number of cases was still small, the availability of hearts and lungs has been high and the transplantation outcomes were acceptable. These strategies may be useful to maximize HTx/LTx opportunities.     

Normal and abnormal embryonic development of the anorectum in rats

Background

The embryologic and pathologic aspect of anorectal malformation (ARM) remains poorly understood. There is no universally accepted theory to explain anorectal embryology and the abnormal development that produces ARM. The aim of this study was to observe the developmental processes of anorectum in rats and to explore the abnormal embryonic development that leads to ARM.

Methods

Rat embryos with ARM were obtained by treating pregnant rats with administration of ethylenethiourea (ETU). Normal rat embryos and embryos with ARM from gestational days 12.5 to 20 were sectioned serially and sagittally and stained with H & E. The relevant structure including cloaca and urorectal septum (URS) were examined in a temporospatial sequence.

Results

Characteristics of anorectum development in ARM rat embryos treated by ETU were as follows: (1) URS never fused with cloaca membrane. (2) Dorsal cloacal membrane was maldeveloped. (3) Cloacal configuration was abnormal. (4) Tail groove never appeared. All type of ARM was the rectourethal fistula and common cloaca in ETU-treated rat embryos and was discernible on gestation day 16.

Conclusions

Absence of the tail groove and maldevelopment of the dorsal cloacal membrane, cloacal configuration, and urorectal septum are likely to be responsible for the formation of ARM. Failure of fusion of the URS with cloacal membrane is the immediate reason for rectourethral fistula or common cloaca in ETU-treated rats.     

Unplanned Readmission Within 1 Year After Heart Transplantation in Taiwan

Introduction

Survival in patients with refractory heart failure greatly improves after heart transplantation (HTx).

Objective

To evaluate the rate of unplanned readmission within the first year post-HTx and the causes of such readmission.

Patients and Methods

From January 2005 to June 2008, the 112 patients who underwent HTx were regularly followed up at our hospital. A protocol biopsy was performed every week during the first month, then every 3 months during the first year. Any unplanned readmission was discussed in detail in a transplantation meeting. Data were collected from review of medical records.

Results

The rate of unplanned readmission was 19.3% in 2005, 21.5% in 2006, 22.2% in 2007, and 20.3% in 2008. Infection was the primary cause leading to unplanned readmission in 2005 (51.5%), 2006 (42.9%), and 2008 (30.7%). Rejection was the primary cause leading to readmission in 2007 (40%). Other causes included fluid retention, pericardial effusion, anemia, and systemic diseases.

Conclusion

To reduce unplanned readmissions and to promote quality of life and long-term survival, health professionals must meticulously monitor the adverse effects of treatments including immunosuppression agents and concomitantly used medications.     

Liver transplantation is an alternative treatment of hepatocellular carcinoma beyond the Milan criteria

Background

The decision to perform liver transplantation (LT) or liver resection (LR) for patients with hepatocellular carcinoma (HCC) who are beyond the Milan criteria remains controversial.

Methods

We retrospectively analyzed outcome data for 179 patients with HCC beyond the Milan criteria who were treated with LR (n = 135) or LT (n = 44). Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and a log-rank test was performed to compare group survival status.

Results

Patients who underwent LR group were significantly older, had a lower TNM stage, and were more likely to have unilateral disease and noncirrhotic liver. Significantly more patients in the LR group had recurrence (53.3% vs 29.5%) or died (61.5% vs 43.2%) than patients in the LT group. Recurrence-free survival rates were 11.9% for the LR group and 61.5% for the LT group. The median overall survival duration showed no statistically difference between the LR group (28.0 months) and the LT group (50.0 months).

Conclusions

LT may be the better choice for patients with HCC beyond the Milan criteria.     

Chronic Kidney Disease After Hematopoietic Cell Transplantation: Frequency, Risk Factors, and Outcomes

Background

Occurrence of chronic kidney disease (CKD) after hematopoietic cell transplantation (HCT) is rare with relatively few reported cases. The aim of this study was to evaluate the frequency of CKD among patients who received HCT for hematologic and nonhematologic disorders.

Objective

We performed a prospective study to evaluate the frequency of CKD and its risk factors. Between 1997 and 2006 there were 1693 patients engrafted at the Bone Marrow Transplant Research Center.

Method

CKD was defined as a doubling of serum creatinine level from the baseline and after 1 year from receiving a transplantation. The risk of CKD in relation to a non-based total body irradiation conditioning regimen, the type of graft (allograft autograft), and the incidences of graft-versus-host disease (GVHD), drug toxicity, and veno occlusive disease (VOD) were examined in 1963 HCT patients.

Results

Kidney involvement developed in 66 patients (4%). By 6-12 months after HCT, approximately 33% of these patients developed CKD (23 patients: 19 allograft and 4 autograft). In most CKD patients, the cause was idiopathic. In 23 patients who developed CKD, 5 patients had acute kidney injury during the transplantation period with GVHD. Other renal involvements were as follows: hypertension (17%), proteinuria (15%), hydronephrosis (2%), hematuria (18%), and diabetes (3%).

Conclusion

The frequency of CKD in this study seems to be high. It is important to know the specific type of kidney damage, to determine when to be aware of the time of occurrence of renal complications and to understand the best methods to treat patients with renal injury secondary to nephrotic syndrome and idiopathic CKD.     

American Board of Surgery examinations: can we identify surgery residency applicants and residents who will pass the examinations on the first attempt?

Background

The Residency Review Committee requires that 65% of general surgery residents pass the American Board of Surgery qualifying and certifying examinations on the first attempt. The aim of this study was to identify predictors of successful first-attempt completion of the examinations.

Methods

Age, sex, Alpha Omega Alpha Honor Medical Society status, class rank, honors in third-year surgery clerkship, interview score, rank list number, National Board of Medical Examiners/United States Medical Licensing Examination scores, American Board of Surgery In-Training Examination scores, resident awards, and faculty evaluations of senior residents were reviewed. Graduates who passed both examinations on the first attempt were compared with those who failed either examination on the first attempt.

Results

No subjective evaluations of performance predicted success other than resident awards. Significant objective predictors of successful first-attempt completion of the examinations were Alpha Omega Alpha status, ranking within the top one third of one's medical student class, National Board of Medical Examiners/United States Medical Licensing Examination Step 1 (>200, top 50%) and Step 2 (>186.5, top 3 quartiles) scores, and American Board of Surgery In-Training Examination scores >50th percentile (postgraduate years 1 and 3) and >33rd percentile (postgraduate years 4 and 5).

Conclusions

Residency programs can use this information in selecting residents and in identifying residents who may need remediation.     

A Systematic Review of Two Different Trimetoprim-Sulfamethoxazole Regimens Used to Prevent Pneumocystis jirovecii and No Prophylaxis at All in Transplant Recipients: Appraising the Evidence

Background

The aim of this study was to clarify the potential advantages of a low-dose regimen of trimethoprim-sulfamethoxazole prophylaxis to prevent Pneumocystis jirovecii pneumonia (PJP) in transplant recipients (80/400 mg/d every day or 160/800 mg/d every other day) with those obtained from the full-dose prophylaxis (160/800 mg/d every day) or no prophylaxis.

Methods

Prospectively randomized and retrospectively case controlled studies were selected.

Results

Four studies matched the inclusion criteria—2 randomized and 2 case controls—for a total of 570 patients. The pneumonia incidence was 0% after full-dose prophylaxis (0/181), 1% after the low-dose regimen (1/105), and 11% with no prophylaxis (31/284). Pneumonia occurrences were significant lower between the full-dose prophylaxis versus the no prophylaxis group (0% vs 11%; P < .001), and between the low-dose and no prophylaxis groups (1% vs 11%; P < .001). There was no difference between patients receiving the full-dose prophylaxis versus the low-dose regimen (0% vs 1%; P = NS).

Conclusions

The low-dose gives similar results as the full-dose regimen for the prevention of PJP and seems a feasible, safe option for transplanted patients.     

Knowledge, attitudes, and behaviors of officials of religion about organ donation in Kahramanmaras, an eastern Mediterranean city of Turkey

Objective

To establish the knowledge, attitudes, and behaviors of the officials of religion, a group with potentially powerful influence on the society, in particular regarding organ donation.

Methods

This study, performed in Kahramanmaras Province, Turkey, included 416 of 641 officials of religion (64.9%): 295 of 492 imams (59.9%) and 121 of 149 Koran course educators (81.2%).

Results

The mean (SD) age of the study group was 37.2 (8.2) years. Only 1.4% had stated that carried organ donation cards. Of participants who had not donated organs asked whether they thought of donation, 14.1% answered yes, 17.1% answered no, and 68.8% were undecided. Of the study group, 88.2% considered organ donation appropriate according to their religion. The imams compared with Koran course educators, and men compared with women demonstrated higher rates of considering organ donation appropriate according to their religion (P < .05). Among participants who stated they had knowledge about organ donation, the 3 leading information sources were television, newspapers or journals, and in- service training by the Directorate of Religious Affairs. The 3 primary organs the study group stated they were aware of being transplanted were kidneys, liver, and heart.

Conclusion

Although 88.2% of religious officials in the present study stated that organ donation was appropriate according to their religion, only 1.4% agreed to donate organs. Officials of religion hold an important place in society, and should be well informed and educated about organ donation via in-service training courses, and encourage organ donation by members of society.     

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool

Aims

The Intercollegiate Surgical Curriculum Project (ISCP) has devised assessment tools for index operations to assess trainee technical skills. In this study we used the Procedural-Based Assessment (PBA) tool to evaluate operations performed by trainees.

Methods

Live and simulated laparoscopic cholecystectomies were performed by trainees. Two experienced surgeons assessed each operation blindly and independently.

Results

Eighty-four live (supervised) and 112 simulated (unsupervised) operations were performed by 28 trainees. Mean inter-rater reliability was kappa = .86 and .84 for live and simulated operations, respectively. Construct validity using Mann-Whitney for generic technical skills was significant for live and simulated operations, P ≤ .05. Assessing specific technical skills showed construct validity for simulated unsupervised operations only, Mann-Whitney P < .05, but not for supervised live operations, Mann-Whitney P > .05.

Conclusions

The PBA showed good inter-rater reliability. Assessing generic technical skills, PBA showed construct validity for both types of operations and for specific technical skills in the unsupervised simulated operations. We conclude that the PBA seems to be a reliable and valid assessment tool for generic technical skills in unsupervised simulated and live supervised laparoscopic cholecystectomies.     

Kasai portoenterostomy: 12-year experience with a novel adjuvant therapy regimen

Aim

The role of adjuvant therapy with corticosteroids and choleretics after Kasai portoenterostomy for biliary atresia (BA) remains uncertain. Experience with a novel postoperative adjuvant therapy regimen is reported.

Methods

Between 1994 and 2006, 71 infants with BA were referred. Four died from uncorrectable congenital heart disease/cardiorespiratory failure without undergoing portoenterostomy, 7 underwent primary liver transplantation (3 referred ≥19 weeks of age), and 60 underwent portoenterostomy at a median of 51 (10-104) days. Of these, 55 (92%) had type 3 BA and 6 had the BA splenic malformation syndrome. Fifty (83%) received the following adjuvant therapy beginning on postoperative day 5: oral dexamethasone 0.3 mg/kg bd for 5 days, 0.2 mg/kg bd for 5 days, and 0.1 mg/kg bd for 5 days together with oral ursodeoxycholic acid 5 mg/kg bd and phenobarbitone 5 mg/kg nocte, both of which were continued for 1 year. All infants received routine perioperative prophylactic antibiotics.

Results

Overall, 42 of 60 (70%) infants cleared their jaundice (bilirubin <20 μmol/L): 38 of 50 (76%) with the dexamethasone/ursodeoxycholic acid regimen compared with 4 of 10 (40%) not receiving this adjuvant treatment. There were 4 late deaths after portoenterostomy: 2 from associated congenital disorders and 2 after liver transplantation. Of the remaining 56 children, 39 (70%) are currently alive with their native liver at a median follow-up of 3.3 years and 17 are alive after liver transplantation. Surgical complications occurred in 3 after portoenterostomy: adhesive bowel obstruction (2) and an anastomotic leak. One infant had gastrointestinal bleeding that may have been related to dexamethasone, but this resolved with ranitidine. There were no perioperative septic complications.

Conclusion

In this series, adjuvant postoperative treatment with a short course of oral dexamethasone and longer-term ursodeoxycholic acid significantly improved the outcome after Kasai portoenterostomy.     

Attitudes of Medical Students About Brain Death and Organ Donation

Introduction

There have been publications on the attitudes of the general Iranian population and health care personnel about brain death and organ donation; however, there is little information about such attitudes of medical students. In 2006, a survey was conducted in Tehran about the attitudes of medical students in a hospital with a transplantation program.

Material and Methods

The general population, health care personnel, and medical students were surveyed, and data were extracted from interviews with 41 medical students. The survey included 35 items about attitudes toward brain death and organ transplantation.

Results

Nine students (22.0%) had ever seen a transplant recipient, and 7 (17.1%) had ever seen a brain-dead patient. Thirty-four students (82.9%) agreed with organ donation after brain death. Six students (14.6%) had received information through university lectures, and 40 (97.5%) perceived a need for further information about organ donation and brain death in the university curriculum. Nine students (22.0%) had an organ donor card.

Conclusion

Most Iranian medical students have neither been exposed to brain death or organ recipients nor received appropriate information about organ donation and transplantation.     

A comparison of the cleft lift procedure vs wide excision and packing for the treatment of pilonidal disease in adolescents

Background/Purpose

The cleft lift for pilonidal disease is a flap procedure designed to counteract suspected causes of closed-technique failure. This study compares cleft lift with wide excision and packing in adolescents with respect to complications, healing, and recurrence.

Methods

Charts of all patients surgically treated for pilonidal disease at our institution from August 2000 to August 2009 were reviewed retrospectively. Wide excision was routinely performed until May 2007 when the cleft lift as described by Bascom was instituted here. Factors examined were postoperative complications, wound healing, and disease recurrence.

Results

Seventy patients (49 males, 21 females; mean age, 16 years; mean weight, 170.5 lb) with pilonidal disease underwent a total of 39 cleft lift procedures and 34 wide excision procedures. All but 1 cleft lift patient (97.4%) healed completely, whereas 25 (73.5%) of 34 patients in the excision group healed (P < .001). The remaining 9 excision patients had chronic wounds, 3 of whom have undergone cleft lift with full healing. One cleft lift patient had recurrent disease (2.5%) compared with 7 (20.6%) of 34 excision patients (P < .02).

Conclusions

The cleft lift procedure is a superior treatment method of pilonidal disease in adolescents, resulting in primary healing, lower likelihood of recurrent disease, and simplified wound care.