Organ and tissue procurement in the acute care setting: principles and practice--Part 2

In this two-part series on organ and tissue procurement in the acute care setting, the procurement problem, cost-benefit analysis, organizational development and framework, approach to surviving relatives, public attitudes, and brain death certification were discussed in part 1 (January 1990). Part 2 examines evaluation, selection, maintenance, and management of the organ-tissue donor. It concludes with a discussion of disease transmission, controversial issues, and financial considerations relevant to the procurement process in the acute care setting.     

Manufacture and in vitro Characterization of a Solvent/Detergent-Treated Human Plasma

We have developed a modified solvent/detergent (S/D) treatment to inactivate viruses in human plasma using 1% w/w final concentration of tri(n-butyl) phosphate (TNBP) and Triton X-100 and an incubation period of 4 h at 30 degrees C. The procedure inactivates > or = 10(6) chimpanzee-infectious doses (CID50) of HBV, > or = 10(5) CID50 of HCV, and > or = 10(6.2) tissue culture infectious doses (TCID50) of HIV. After virus inactivation, eleven plasma batches were lyophilized and 12 batches were deep-frozen until further use. The batches were characterized by extensive laboratory tests including measurement of clotting factors I-XIII, von Willebrand factor, plasminogen, inhibitors of blood coagulation and fibrinolysis, and other clinically important plasma proteins. All parameters were determined before and after S/D treatment. Twelve conventional single donor plasma units served as control. There were no marked losses of activities of clotting factors, antithrombin III, protein C, plasminogen, and C1-esterase inhibitor due to treatment. After the S/D step, the levels of these parameters were within the normal range in all batches. The same holds true for total protein, immunoglobulins, albumin, complement factors C3 and C4, haptoglobin, hemopexin, caeruloplasmin, alpha 1-antitrypsin, and pH. Protein S and alpha 2-antiplasmin activities decreased by about 50% and were frequently found to be slightly below the lower limit of the respective normal range after treatment. The interindividual variations of all proteins analysed were significantly lower than in the single donor plasma units. The S/D procedure did not lead to increases of markers indicating activation of hemostasis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mental rotation strategies reflected in event‐related (de)synchronization of alpha and mu power

During a mental rotation task of hands, participants mentally rotate their hand into the orientation of the shown hand. These mental movements are subject to the body's biomechanical constraints. In this study, we investigated whether the involvement of motor processes during the mental rotation process, as reflected in mu‐power desynchronization, is also influenced by one's movement capabilities. We performed an EEG study and used a delayed response mental rotation task of hands to examine the event‐related desynchronization differences between movements that are biomechanically easy and difficult to perform. Our results show an increase in event‐related desynchronization of the mu power for biomechanically easy compared to difficult‐to‐adopt postures. These findings provide further evidence for the notion that motor simulations can only be performed for movements that can already be performed overtly.     

Influence of MRE11, RAD50 and NIBRIN protein expression on survival in pancreatic carcinoma after curative resection

The MRE11/RAD50/NIBRIN complex, a protein complex that repairs DNA double-strand breaks, could serve as an early marker for new lesions in pancreatic cancer. We determined the expression of MRE11, RAD50 and NIBRIN, and their possible prognostic value regarding survival.     

Changing attitudes towards the care of children in hospital: a new assessment of the influence of the work of Bowlby and Robertson in the UK, 1940–1970

It is generally believed that the work of Bowlby and Robertson was new and decisive in changing the hospital conditions for young children. The fact that parents in the UK and other European countries can now visit their sick child at any time they wish or even room-in is attributed to an acquaintance with Bowlby's findings and Robertson's well-known films about the potentially detrimental effects of hospital stays for young children. In this paper we shall argue that this picture is incomplete and that, historically, things were rather more intricate. Bowlby and Robertson were neither the first nor the only researchers who tried to change hospital policies. Moreover, the older hospital policies were not uniformly bad. Long before Bowlby and Robertson began their plea for reforms, several individuals and hospitals had already introduced conditions that we now still regard as exemplary. The whole change towards more liberal, flexible, and humane practices in children's wards took place over several decades and was fuelled by both worried medical doctors, pressure groups of parents, sympathetic editors of medical journals, and emerging new research findings such as those provided by Bowlby and Robertson. In that societal debate, the voices of Bowlby and Robertson were influential but not necessarily new or decisive.     

Toxicity of Amphotericin B Deoxycholate-Based Induction Therapy in Patients with HIV-Associated Cryptococcal Meningitis

Amphotericin B deoxycholate (AmBd) is the recommended induction treatment for HIV-associated cryptococcal meningitis (CM). Its use is hampered by toxicities that include electrolyte abnormalities, nephrotoxicity, and anemia. Protocols to minimize toxicity are applied inconsistently. In a clinical trial cohort of AmBd-based CM induction treatment, a standardized protocol of preemptive hydration and electrolyte supplementation was applied. Changes in blood counts, electrolyte levels, and creatinine levels over 14 days were analyzed in relation to the AmBd dose, treatment duration (short course of 5 to 7 days or standard course of 14 days), addition of flucytosine (5FC), and outcome. In the 368 patients studied, the hemoglobin levels dropped by a mean of 1.5 g/dl (95% confidence interval [CI], 1.0 to 1.9 g/dl) following 7 days of AmBd and by a mean of 2.3 g/dl (95% CI, 1.1 to 3.6 g/dl) after 14 days. Serum creatinine levels increased by 37 μmol/liter (95% CI, 30 to 45 μmol/liter) by day 7 and by 49 μmol/liter (95% CI, 35 to 64μmol/liter) by day 14 of AmBd treatment. Overall, 33% of patients developed grade III/IV anemia, 5.6% developed grade III hypokalemia, 9.5% had creatinine levels that exceeded 220 μmol, and 6% discontinued AmBd prematurely. The addition of 5FC was associated with a slight increase in anemia but not neutropenia. Laboratory abnormalities stabilized or reversed during the second week in patients on short-course induction. Grade III/IV anemia (adjusted odds ratio [aOR], 2.2; 95% CI, 1.1 to 4.3; P = 0.028) and nephrotoxicity (aOR, 4.5; 95% CI, 1.8 to 11; P = 0.001) were risk factors for 10-week mortality. In summary, routine intravenous saline hydration and preemptive electrolyte replacement during AmBd-based induction regimens for HIV-associated CM minimized the incidence of hypokalemia and nephrotoxicity. Anemia remained a concerning adverse effect. The addition of flucytosine was not associated with increased neutropenia. Shorter AmBd courses were less toxic, with rapid reversibility.     

Current Options and Emerging Biomaterials for Periprosthetic Joint Infection

Purpose of Review

Infection in the setting of total joint arthroplasty, referred to as periprosthetic joint infection (PJI), is a devastating complication requiring prolonged and costly treatment. The unique environment around an artificial joint and ability of surrounding tissues to sequester bacteria collectively make prevention, diagnosis, and treatment of this condition challenging. In light of the unique pathogenesis of PJI, this review explores the limitations of contemporary treatments and discusses novel treatment options.

Recent Findings

Recent advancements in local antibiotic delivery platforms for preventing and treating PJI include titanium nanotube arrays, synthetic polymers, resorbable hydrogels, and cyclodextrin-based drug delivery options. In particular, cyclodextrins have facilitated great advancements in other clinical disorders and have demonstrated early promise as a future option in the arena of PJI.

Summary

Novel treatment modalities for PJI optimize the implant surfaces to prevent bacterial biofilm formation or provide prolonged intra-articular antibiotic dosing to eradicate bacteria.