Successful multiple organ donation after donor brain death due to Actinomyces israelii meningitis

The increasing gap between availability of solid organs for transplantation and the demand has led to the inclusion of donor organs that, according to current guidelines, may be discarded, some of them because of the possibility for transmission of infection to the recipients. We present the first report, to the best of our knowledge, of a case of a brain‐dead donor with a localized and treated Actinomyces israelii central nervous system infection who, after a thorough evaluation, provided organs for successful transplant procedures in four recipients. There was no evidence of transmission of infection within a 6‐month follow‐up. Relative contraindications must be individualized in order to expand the number of real organ donors, emphasizing caution in rare causes for brain death in which patients should be thoroughly evaluated for possible donation.     

老年多脏器功能衰竭死亡相关因素分析

目的 通过分析老年多脏器功能衰竭（MOFE）死亡患者住院基本情况，探讨MOFE死亡的相关因素，为MOFE的预防和治疗提供参考。方法 对269例MOFE死亡患者的基础疾病、衰竭器官数目及死亡率、诱因等统计分析。结果 MOFE死亡患者基础疾病中心血管疾病占首位（29．4％）；衰竭脏器数以2或3个为主；MOFE死亡患者衰竭脏器的频率分布以肺部最多；MOFE患者死亡的主要诱因为肺部感染。结论 基础疾病、年龄、肺部感染等是MOFE患者死亡的主要因素。强化对器官功能的保护及治疗有助于降低MOFE患者的死亡率。     

长期照护医养结合的老年多器官功能不全综合征患者死亡危险因素分析

目的探讨长期照护医养结合的老年多器官功能不全综合征(MODSE)患者临床特点及死亡危险因素。方法回顾性分析2012年1月至2018年7月在长江大学附属江汉油田总医院老年医学科以医养结合形式住院的MODSE患者107例,根据发病后第28天转归分为存活组34例,死亡组73例。比较2组患者一般临床资料、急性生理与慢性健康状况评估Ⅱ(APACHEⅡ)评分、肺部感染评分、脑功能Glasgow昏迷量表评分、吞咽功能评分等。采用SPSS 17.0统计软件进行分析。根据数据类型,组间比较采用t检验或χ~2检验。将单因素分析中有统计学意义的指标纳入多因素Cox回归模型分析影响MODSE患者死亡的因素。结果 (1)2组患者一般资料比较,年龄、器官功能不全数、收缩压、舒张压、平均动脉压、二氧化碳分压、氧分压、氧合指数、血红蛋白、白蛋白、空腹血糖、血尿素氮差异有统计学意义(P0.01)。(2)2组患者基础疾病≥4种、慢性阻塞性肺疾病(COPD)、慢性心力衰竭、脑血管病、糖尿病、痴呆与认知功能障碍、肺部感染评估量表≥6分、Glasgow昏迷量表评分、APACHEⅡ≥25分、吞咽困难分级量表≤4分以及肺、心、肾、脑、胃肠功能不全占比比较,差异有统计学意义(P0.05)。(3)多因素Cox回归分析显示,年龄、器官功能不全数、APACHEⅡ评分、Glasgow昏迷量表评分、肺部感染评分及COPD、慢性心力衰竭、脑血管病、血清白蛋白是引起长期照护医养结合的MODSE患者死亡的独立危险因素。结论患多种基础疾病的医养结合的MODSE高龄患者,合并有COPD、慢性心力衰竭、脑血管病、肺部感染、低血清白蛋白更易导致死亡,要加强早期监测和预防。     

Plasma endotoxin as a predictor of multiple organ failure and death in systemic meningococcal disease

We studied prospectively the quantitative relation of circulating endotoxin (lipooligosaccharides [LOSs]) and the development of multiple organ failure and death in 45 consecutively admitted patients with bacteriologically verified systemic meningococcal disease (SMD). A plasma LOS level of greater than 700 ng/L correlated with development of severe septic shock (P less than .0001), adult respiratory distress syndrome (P = .0035), a pathologically elevated serum creatinine level (P less than .0001), or death as a consequence of multiple organ failure (P = .0002). Initial plasma LOS levels of less than 25, 25-700, 700-10,000, and greater than 10,000 ng/L were associated with 0%, 14%, 27%, and 86% fatality, respectively. The LOS half-life after initiation of antibiotic therapy was 1-3 h. Increasing plasma LOS levels were never seen. These observations suggest that LOS quantitation using the limulus amebocyte lysate assay with a chromogenic substrate gives important progsnotic information and may provide new insight concerning pathophysiological aspects of SMD.     

Issues in organ procurement: presumed consent,bioethical type II errors,and organ registries

In an effort to alleviate the current imbalance between the many in need of an organ transplant and the limited number of organs procured, a policy of presumed consent has been recently debated. Presumed consent assumes that potential organ donors agree to donate their organs in the absence of known objections to the contrary. The authors examine the bioethical principles and consequences involved in such a policy and apply hypothesis testing, borrowed from clinical epidemiology, to a "bioethical test" of presumed consent in a hypothetical clinical scenario. A possible bioethical alternative to presumed consent, an organ donor registry of advanced directives as has been established in British Columbia, is also discussed.     

Prognostic factors influencing outcome in adult liver transplantation using hypernatremic organ donation after brain death

BackgroundHypernatremic donors was regarded as the expanded criteria donors in liver transplantation. The study was to investigate the effects of donor hypernatremia on the outcomes of liver transplantation and identify the prognostic factors possibly contributing to the poor outcomes.MethodsDonor serum sodium levels before procurement were categorized as normal sodium (< 155 mmol/L), moderate high sodium (155–170 mmol/L), and severe high sodium (≥ 170 mmol/L). Furthermore, we subdivided the 142 hypernatremic donors (≥ 155 mmol/L) into two subgroups: subgroup A, the exposure time of liver grafts from hypernatremia to reperfusion was < 36 h; and subgroup B, the exposure time was ≥ 36 h. The outcomes included initial graft function, survival rates of grafts and recipients, graft loss and early events within the first year following liver transplantation.ResultsThere were no significant differences in the 1-year survival rates of grafts and recipients, 1-year graft loss rates and early events among the normal, moderate high and severe high sodium groups. However, the overall survival rates of grafts and recipients in subgroup A were significantly higher than those in subgroup B. Cox model showed that the exposure time (HR = 1.117; 95% CI: 1.053–1.186; P < 0.001), cold ischemia time (HR = 1.015; 95% CI: 1.006–1.024; P = 0.001) and MELD (HR = 1.061; 95% CI: 1.003–1.121; P = 0.037) were the important prognostic factors contributing to the poor outcomes of recipients with hypernatremic donors.ConclusionsThe level of donor sodium immediately before organ procurement does not have negative effects on the early outcomes following adult liver transplantation. For hypernatremia liver donors, minimization of the exposure time from hypernatremia to reperfusion is critical to prevent graft loss.     

Halofantrine-induced pruritus amongst subjects who itch to chloroquine.

The incidence and nature of pruritus induced by chloroquine and halofantrine were studied in 82 patients with acute malaria and in 40 healthy subjects, using a visual analogue scale for quantitating pruritus. Results showed that the proportion of patients with acute malaria manifesting itch to halofantrine was significantly lower than the proportion manifesting itch to chloroquine. Furthermore, the intensity and duration of halofantrine-induced pruritus were significantly lower than those of chloroquine-induced pruritus. The few patients who itched to halofantrine all had a history of itching to chloroquine. The incidence and intensity of chloroquine-induced pruritus were significantly higher in patients with malaria than in healthy subjects. By contrast, there was no significant difference between malaria patients and healthy subjects as regards halofantrine-induced pruritus. These results suggest that itchers to halofantrine may constitute a small group within the population of itchers to chloroquine. Malaria infection appears to enhance chloroquine-induced pruritus but not halofantrine-induced pruritus and this may be of therapeutic importance.     

Assessment of physicians’ knowledge about brain death and organ donation and associated factors

Precocity and assertiveness when diagnosing brain death are essential for identifying potential donors. To assess the knowledge of physicians about brain death and organ donation, cross-sectional web-based survey was carried out with physicians from different specialties. The knowledge about brain death and organ donation was assessed by a questionnaire with 12 multiple-choice or multiple-answer questions (possible range from 0 to 12). The nonparametric Mann–Whitney and Kruskal–Wallis tests were performed to verify the association between the physicians’ knowledge and others variables. The project was approved by the Research Ethics Committee of the Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, under number 4.022.657, and all patients agreed to participate and provided free prior-informed consent. Three hundred sixty physicians were included in this study, most of them have postgraduate (55%) and 59.2% were intensive care physicians. The median of responses was 5 (obtained range from 0 to 10). The participants were classified in 2 groups: with satisfactory knowledge (scores above 5) or without satisfactory knowledge (scores equal/below 5). There was better performance among participants who: completed graduation between 6 and 10 years (P < .012); were intensive care physicians (P < .002); had participated in training courses (P < .001); and those who had worked in intensive care unit (ICU) from 6 to 10 years (P < .023); had performed over 10 brain death protocols (P < .001), and felt safe to talk to family members about brain death (P < .001). The results showed that the participants had low knowledge about diagnosis of brain death and organ donation protocols despite the majority working in ICUs. Be an intensive care physician, had large time experience in ICU, and had performed brain death protocols were associated with unsatisfactory knowledge concerning the subject.     

Backflux of ammonia from brain to blood in human subjects with and without hepatic encephalopathy

In patients with hepatic encephalopathy (HE) the blood concentration of ammonia is usually highly elevated. Ammonia readily enters brain cells from the blood, and toxic effects of ammonia on brain metabolism and neurotransmission are believed to play a key role in the pathogenesis of HE. It has, however, been a matter of great controversy whether backflux of unmetabolized ammonia (NH₃ + NH₄ ⁺) from brain cells to the blood occurs in man. In the present analysis of data from a dynamic PET study of brain ¹³N–ammonia metabolism in healthy subjects and cirrhotic patients with and without HE, we provide the first unambiguous evidence for backflux of ammonia from brain cells to the blood in man. The high temporal and spatial resolution of modern PET technology was employed to distinguish between unidirectional blood-brain transport of ammonia and subsequent metabolism of the ammonia in the brain. In all 16 subjects, clearance of the unidirectional transport of ¹³N–ammonia from the blood to brain cells (K₁) was higher than the metabolic clearance of ¹³N–ammonia from the blood (K_met=K₁ k₃/(k₂+k₃). This can only be explained by backflux (k₂) of ammonia from brain cells to the blood. In conclusion, backflux of ammonia from the brain to the blood does indeed occur in both healthy subjects and cirrhotic patients with and without hepatic encephalopathy.     

Apnea testing in brain death

A standardized protocol was followed in 33 apneic oxygenation tests on 20 patients suspected of being brain dead. Spontaneous respiratory movements developed in just one patient; this patient was the only one who did not show electrocerebral silence on electroencephalography. Significant hypoxemia, hypotension, or cardiac arrhythmias were not encountered despite lung disease in 14 of our 20 patients. The apnea test protocol employed proved to be safe and sensitive. With a starting partial arterial carbon dioxide pressure greater than or equal to 36 mm Hg and a disconnection time from the ventilator of ten minutes in a normothermic patient (greater than or equal to 36.1 degrees C [greater than or equal to 97 degrees F]), the pressure threshold of 60 mm Hg should be reached in all patients.     

Pseudohypoaldosteronism: multiple target organ unresponsiveness to mineralocorticoid hormones.

The first report of a 7-month-old male with pseudohypoaldosteronism in which unresponsiveness to mineralocorticoids has been demonstrated in the kidney, colon, and sweat and salivary glands is presented here. This is documented by urinary, salivary, and sweat sodium wasting in the presence of elevated urinary aldosterone excretion, plasma aldosterone concentration, and PRA. There was no mineralocorticoid response in the kidney or salivary or sweat glands to the administration of high doses of 9 alpha-flurocortisol. Furthermore, in this patient, the colonic mucosal cells failed to respond to exogenous aldosterone administration. Repeat evaluation at 25 months of age showed persistence of the sodium wasting and multiple target organ insensitivity to administered mineralocorticoid. Since this patient has defective mineralocorticoid response in the major sodium-conserving organs, the only therapy possible was administration of sodium to compensate for total sodium loss.     

Sudden death of school children in Japan

The autopsy findings of sudden deaths of school children revealed that the main causes of death were latent myocarditis and arrhythmia, followed by idiopathic cardiomyopathy. The incidence of sudden death of school children in recent years is gradually increasing and 150 cases of sudden death occurred during the 1983 school year. A high incidence of sudden death in senior high school students was found. Sudden cardiac death accounted for approximately 80% of total deaths. The incidence of sudden cardiac death revealed prominent regional differences in Japan. The average for deaths was 0.40/100,000 children/5 years and the highest prefecture revealed 0.70 and the lowest 0.07. The cause of such differences is not clear and requires further analysis.