Report of a National Conference on Donation after Cardiac Death

A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.     

Methicillin-resistant Staphylococcus aureus in the UK and Ireland. A questionnaire survey

The results of a questionnaire survey of the distribution of methicillin-resistant Staphylococcus aureus (MRSA) in the UK and Ireland between 1982 and 1983 are reported. Information was obtained about the geographical distribution of MRSA, the units affected, the sites of isolation and the preventive measures employed. Serious clinical problems were confined to a small number of hospitals with high isolation rates of MRSA.     

Electrophoretic typing of Enterobacter cloacae with a limited set of enzyme stains

Hospital isolates of Enterobacter cloacae were analysed by polyacrylamide gel electrophoresis for enzyme polymorphism and the results were compared with established serotyping, phage typing and biotyping techniques. Initially, the diversity of electromorphs of 13 enzymes was determined on a representative set of 62 distinct strains. Two broad clusters of strains were found in the species, and analysis by serotype suggested a limited diversity within the most frequent O serotypes. A subset of three enzymes, lactate dehydrogenase, 6-phosphogluconate dehydrogenase, glutamate dehydrogenase and an unidentified marker, were selected and used to type groups of hospital isolates. There was good general agreement between the two systems, although the enzyme method failed to distinguish between some strains with the same serotype. This method provided useful epidemiological information and, in the absence of established typing systems, it is a practical approach to subdividing the species.     

Benefits of quadruple immunosuppressive therapy in recipients of living related donor kidneys. A review of 855 operations.

Eight hundred fifty-five living related donor transplant recipients were analyzed according to 15 potential risk factors with regard to patient and graft survival according to immunosuppression. Group I, 1968 to 1983, (n = 440 patients) received azathioprine and prednisone; group II, 1984 to 1987, (n = 229 patients) received triple therapy--azathioprine, prednisone, and cyclosporine; and group III, 1988-1991, (n = 186 patients), quadruple therapy--azathioprine, prednisone, cyclosporine, and Minnesota antilymphocyte globulin. Three important risk factors included immunosuppression, tissue typing, and race. Groups II and III had improved allograft survival over group I (p = 0.03). Patients with two haplotype matches had similar survival in all three groups. Kidney survival in one-haplotype-matched recipients improved in group II and was equal to that of the two-haplotype-matched patients in group III. Cyclosporine improved allograft survival in both races when combined with azathioprine and prednisone. Quadruple therapy improved early survival in one-haplotype black patients, even though long-term results remained better in whites. Cyclosporine did not improve graft survival in two-haplotype recipients. The addition of cyclosporine and quadruple therapy did not increase morbidity and mortality rates.     

Impaired cortisol stress response in fish from environments polluted by PAHs,PCBs, and mercury

The cortisol stress response to capture was investigated in two species of fish (Perca flavescens and Esox lucius) from sites polluted by high levels of polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), and mercury, and from reference sites in the St. Lawrence river system. Fish from the reference sites exhibited the normal elevation of serum cortisol in response to the acute stress of capture and had large pituitary corticotropes. In contrast, fish from the most polluted sites were unable to increase their serum cortisol in response to the acute stress of capture and their pituitary corticotropes were atrophied. These results suggest that a life-long exposure to chemical pollutants may lead to an exhaustion of the cortisol-producing endocrine system, possibly as a result of prolonged hyperactivity of the system.     

Spontaneous migration of an inferior vena cava filter resulting in cardiac tamponade and percutaneous filter retrieval.

Thromboembolic disease accounts for thousands of hospitalizations every year in the US. Its primary management consists of anticoagulation. However, in certain instances this may be contraindicated or not sufficient. Mechanic occlusion of the inferior vena cava (IVC) becomes then a viable alternative. In this case a 35-year-old man presented with a saddle pulmonary embolus but was unable to be anticoagulated due to intestinal bleed. A removable IVC filter was then placed. The filter spontaneously migrated into the right atrium causing severe tricuspid regurgitation, perforation of the atrial wall, and cardiac tamponade. The device was successfully retrieved percutaneously and the patient discharged from the hospital in stable condition. This case illustrates the potentially lethal complications associated with the use of IVC filters, as well as the possibility to percutaneously recover them from within the right atrium.     

Peripheral Foot Blockade Versus Popliteal Fossa Nerve Block: A Prospective Randomized Trial in 51 Patients

The majority of foot and ankle operations are performed on an outpatient basis and often under some form of regional anesthesia. In this prospective, randomized study of 51 patients undergoing elective unilateral forefoot procedures, we compared 2 different anesthetic techniques: the peripheral foot blockade and the popliteal sciatic nerve block. Variables assessed included the quality of surgical anesthesia, postoperative analgesia, and the incidence of postoperative complications. The anesthesia was classified as effective if it was the sole anesthetic technique for the forefoot surgery. We found successful results in both groups: 92% in the foot block group and 96% in the popliteal block group. Analysis of time required to perform the anesthetic procedure showed a significant difference between the 2 groups, with foot block being considerably faster (14.3 minutes vs 19.2 minutes for popliteal block) (P = .0078). Foot block patients demonstrated 10.96 hours of analgesia, whereas popliteal block patients exhibited 14.32 hours (P = .132). With a mean follow-up of 5.7 months, we did not find anesthesia-related complications in any of the patients. Both techniques showed a high level of safety and efficacy, with no significant difference detected between them. Our patients showed a high rate of satisfaction with both procedures (96% for foot block patients and 96.1% for popliteal block patients) and reported a good discharge disposition. These data show that both procedures are safe and effective anesthetic techniques and well suited to forefoot ambulatory surgery.     

Giant perimedullary arteriovenous fistulas of the spine: clinical and radiologic features and endovascular treatment.

PURPOSETo present the clinical and radiologic features of giant perimedullary arteriovenous fistulas (GAVFs) in 12 consecutive cases and to evaluate the results of endovascular treatment.METHODSWe retrospectively reviewed the clinical and radiologic data as well as the results of balloon endovascular treatment obtained from 1980 to 1989.RESULTSGAVFs, defined as large intradural perimedullary direct arteriovenous high-flow shunts, are revealed mainly in childhood either by subarachnoid hemorrhage or by progressive neurologic disorders. MR imaging and myelography show major vascular dilatations. The angioarchitecture of GAVFs can only be assessed by selective spinal angiography. Ten patients were treated by balloon occlusion resulting in eight anatomic cures and six good clinical results. One balloon migrated to the venous side, leading to clinical deterioration.CONCLUSIONGAVF is a special subgroup of intradural perimedullary arteriovenous fistula. The endovascular approach should be the first line of treatment, with surgery reserved for special circumstances. Nondetachable balloon occlusion is a safe and efficient method for treating GAVFs.     

Preliminary results on the inventory of therapeutic strategies

The qualities of a new measure of therapists' interventions, the Inventory of Therapeutic Strategies (ITS), were examined in cognitive and brief dynamic psychotherapy. In contrast to other inventories, the ITS focuses on three types of therapist intentions (exploratory, supportive, and work-enhancing), and it also takes into account the content and object of exploratory strategies. In this preliminary study, ITS categories were found 1) to be reliably rated, 2) to be unrelated to the therapist's contribution to the alliance, 3) to differentiate cognitive and dynamic psychotherapy, and 4) to predict outcome, alone or in interaction with the alliance.