Factors influencing the family consent rate for organ donation in the UK.

The refusal rate for organ donation in the UK is 42%, among the highest in Europe. We extracted data on every family approach for donation in UK ICUs or Emergency Departments between 1st April 2012 and 30th September 2013, and performed multiple logistic regression to identify modifiable factors associated with consent. Complete data were available for 4703 of 4899 approaches during the study period. Consent for donation after brain death was 68.9%, and for donation after circulatory death 56.5% (p < 0.0001). Patient ethnicity, knowledge of a patient's wishes and involvement of a specialist nurse in organ donation in the approach were strongly associated with consent (p < 0.0001). The impact of the specialist nurse was stronger for donation after circulatory death than for donation after brain death, even after accounting for the impact of prior knowledge of patients' wishes. Involvement of the specialist nurse in the approach, encouraging family discussions about donation wishes and promotion of the organ donor register are key strategies to increase UK consent rates, and are supported by this study.

Donation after circulatory death.

Donation after circulatory death (DCD) describes the retrieval of organs for the purposes of transplantation that follows death confirmed using circulatory criteria. The persisting shortfall in the availability of organs for transplantation has prompted many countries to re-introduce DCD schemes not only for kidney retrieval but increasingly for other organs with a lower tolerance for warm ischaemia such as the liver, pancreas, and lungs. DCD contrasts in many important respects to the current standard model for deceased donation, namely donation after brain death. The challenge in the practice of DCD includes how to identify patients as suitable potential DCD donors, how to support and maintain the trust of bereaved families, and how to manage the consequences of warm ischaemia in a fashion that is professionally, ethically, and legally acceptable. Many of the concerns about the practice of both controlled and uncontrolled DCD are being addressed by increasing professional consensus on the ethical and legal justification for many of the interventions necessary to facilitate DCD. In some countries, DCD after the withdrawal of active treatment accounts for a substantial proportion of deceased organ donors overall. Where this occurs, there is an increased acceptance that organ and tissue donation should be considered a routine part of end-of-life care in both intensive care unit and emergency department.

Towards a framework for organ donation in the UK.

Implementation of the recommendations from the Organ Donation Taskforce has introduced for the first time into the UK a nationwide framework for deceased donation. This framework is based, in principle, upon a conviction that donation should be viewed as part of end-of-life care and that the actions often necessary to facilitate it become justified when donation is recognized to be consistent with the wishes and interests of a dying patient. The implementation of the Taskforce recommendations across the complex landscape of acute hospital care in the UK represents a challenging programme of change management that has three more or less distinct phases. This programme has involved first creating and communicating the Taskforce's vision for donation in the UK, secondly introducing the structural elements of this new framework into hospital practice, and finally creating the environment in which these new elements can deliver the overall programme goals. Implementation has focused heavily upon areas of practice where significant opportunities to increase donor numbers exist. It is recognized that the greatest challenge is to overcome the societal and clinical behaviours and beliefs that currently create barriers to donation. Although national audit data may point to some of these areas of practice, international comparisons suggest that differences in approach to the care of patients with catastrophic brain injury may have a profound influence on the size of the potential donor pool.

Screening for Corynebacterium diphtheriae and Corynebacterium ulcerans in patients with upper respiratory tract infections 2007-2008: a multicentre European study.

Diphtheria is now rare in most European countries but, when cases do arise, the case fatality rate is high (5-10%). Because few countries continue to routinely screen for the causative organisms of diphtheria, the extent to which they are circulating amongst different European populations is largely unknown. During 2007-2008, ten European countries each screened between 968 and 8551 throat swabs from patients with upper respiratory tract infections. Six toxigenic strains of Corynebacterium diphtheriae were identified: two from symptomatic patients in Latvia (the country with the highest reported incidence of diphtheria in the European Union) and four from Lithuania (two cases, two carriers); the last reported case of diphtheria in Lithuania was in 2002. Carriage rates of non-toxigenic organisms ranged from 0 (Bulgaria, Finland, Greece, Ireland, Italy) to 4.0 per 1000 (95% CI 2.0-7.1) in Turkey. A total of 28 non-toxigenic strains were identified during the study (26 C. diphtheriae, one Corynebacterium ulcerans, one Corynebacterium pseudotuberculosis). The non-toxigenic C. ulcerans strain was isolated from the UK, the country with the highest reported incidence of cases due to C. ulcerans. Of the eleven ribotypes detected, Cluj was seen most frequently in the non-toxigenic isolates and, amongst toxigenic isolates, the major epidemic clone, Sankt-Petersburg, is still in circulation. Isolation of toxigenic C. diphtheriae and non-toxigenic C. diphtheriae and C. ulcerans in highly-vaccinated populations highlights the need to maintain microbiological surveillance, laboratory expertise and an awareness of these organisms amongst public health specialists, microbiologists and clinicians.

Microbial ecology of the cystic fibrosis lung: does microflora type influence microbial loading?

This study aims to examine the association between the numbers of culturable microbial species forming the microflora of the lung in patients with cystic fibrosis (CF) and microbial loading (i.e., type[s] versus numbers). Additionally, it examines qualitative combinations of the microflora present in a large adult CF centre (n=138) in order to ascertain ecological relationships between the taxa present. The culturable microflora of sputum from 34 adults patients with CF are enumerated using a spread plate technique on non-selective agar, and the microflora identified phenotypically employing the API 20NE scheme. Microbiological examination of the 34 adult patients demonstrated that their sputum contained between one and three taxa, with a mean cell density of 8.25 +/- 0.85 log colony-forming units (cfu)/g sputum and a range of 5.91-9.74 log cfu/g sputum. Most colonising patterns demonstrated only Gram-negative infection (22/34), followed by a mixed Gram-positive/Gram-negative infection pattern (10/34). Only 2/34 patients had a single Gram-positive infection. Most patients (53%) were colonised by only one organism, with 38% of patients colonised by two organisms, and the remainder (4%) colonised with three organisms. There was no statistical difference (P>0.05) between microbial cell density and the number of taxa present (i.e., the greater number of taxa present in sputum did not produce a higher cell density). However, there was a significantly higher cell density (log 0.59 cfu/g sputum) noted for those patients who had only Gram-negative infection, compared to those who had a mixed Gram-negative/Gram-positive infection pattern (P=0.02). Relatively little is known about the ecological interactions that exist between the microflora in the CF lung. Further work is required to explore these interactions in order to aid understanding of the succession and dominance of Gram-negatives in chronic chest infections. Ultimately, a greater understanding of such interactions may allow the opportunity to manipulate the ecology of the lung to control otherwise problematic pathogens

Detection of mycobacterial DNA from sputum of patients with cystic fibrosis.

BACKGROUND: Patients with cystic fibrosis (CF) are at high risk from atypical mycobacterial infections. There have been few attempts to delineate the intensity of mycobacterial infection in CF patients in Ireland. AIMS: To examine the incidence of mycobacterial DNA in an archived collection of genomic DNA extracted from the sputa of CF patients within the Northern Ireland population. METHODS: One hundred and eighty-two CF patients (66 adults and 116 children) were examined for the presence of mycobacterial DNA in their sputum by a genus specific PCR assay based on 16S rRNA, followed by direct automated sequencing of the PCR amplicons. RESULTS: One of 116 (0.9%) children and 2 of 66 adults were positive. Sequence identity revealed Mycobacterium xenopi in the paediatric patient and M. xenopi and M. chelonei in the two adult patients. False-positive results occurred in 11 patients (four adults), mainly due to Corynebacterium spp. CONCLUSIONS: There was a low prevalence of Mycobacterium spp in the CF patient population. All PCR positive results should be confirmed by direct automated sequencing and an alternative specific assay employed. Enhanced molecular screening will contribute in understanding their role as opportunistic pathogens in patients with worsening lung function.

Lessons from a pre-season influenza outbreak in a day school.

An outbreak of an upper respiratory tract illness at a secondary school, which led to the hospitalisation of 23 cases, occurred in Ireland at the beginning of September 2003. Medical and laboratory examinations, initially for suspected meningitis, were carried out on the hospitalised cases and bacterial meningitis was ruled out. One hundred and seventy-nine students and teachers were interviewed and a retrospective cohort study was conducted among the sixth year students. One hundred and seven respondents met the case definition, but no associations were found between the environmental exposures investigated and illness. As it was before the expected influenza season, initial samples were not tested for influenza, but one month later the new influenza A/Fujian/411/2002 (H3N2)-like strain was confirmed and implicated in the outbreak. It was the first reported outbreak of influenza in Europe in the 2003 'winter' season and it demonstrated the need for vigilance for early and unexpected occurrence of influenza. It also provided valuable lessons for laboratory and epidemiological investigation and management of pre-season influenza.

Brainstem death testing in the UK--time for reappraisal?

BACKGROUND: A diagnosis of brainstem death in the UK is based on clinical assessment rather than technical investigations, but is considered rigorous enough to be legally synonymous with death. METHODS: A questionnaire in five sections concerning clinician details, initiation of support, criteria for testing, conduct of the tests, and the process of organ donation, was sent to all members of the Neuroanaesthesia Society. RESULTS: The survey reveals evidence of failure to apply existing guidelines accurately and a wide variation in practice where the recommendations are not specific. CONCLUSIONS: In an era of scrutiny of medical process, it is timely to consider whether the current guidelines should be revisited. Clarification of the approach to biochemical derangement, and the role of confirmatory tests when the residual effect of sedative agents cannot be excluded, are two areas worthy of debate.

Novel employment of lactate dehydrogenase release from porcine aortic endothelial cells (PAEC) as a quantitative marker of cytotoxic activity in thermophilic Campylobacter spp. from human faecal isolates, poultry and environmental sources.

The aim of this study was to employ a novel cytotoxicity assay based on primary porcine aortic endothelial cells in combination with a lactate dehydrogenase release assay to quantitatively determine differences in cytotoxin production between Campylobacter jejuni, C. coli, C. lari and urease-positive thermophilic campylobacters (UPTC), isolated from human faeces, animals and environmental sources. Campylobacter isolates totalling 34 and comprising of C. jejuni (n = 24) C. coli (n = 5) and UPTC (n = 4) and C. lari (n = 1) were analysed. The cytotoxic response ranged from 32.15 to 64.47% and 33.08 to 59.41%, for C. jejuni from chicken and human isolates, respectively and there was no statistically significant difference (P > 0.05) in cytotoxic response between C. jejuni isolated from humans and chicken isolates (50.78% versus 50.55% cytotoxicity, respectively). However, there was a difference in response between C. jejuni and C. coli isolated from chickens (50.78% versus 33.22% cytotoxicity, respectively). The greatest cytotoxic response was obtained with the UPTC group of organisms examined (n = 4 isolates) (mean cytotoxic response = 57.11% cytotoxicity. Employment of this cytotoxin assay may help identify virulent strains in poultry that could potentially proceed to cause clinical problems for humans and thus intervention measures targeted at the reduction or elimination of such specific strains, may be sought.

Haemophilus segnis: a rare cause of endocarditis.

This report presents a case of endocarditis due to Haemophilus segnis, which represents a speciation difficulty for the routine laboratory. In this study, a molecular approach provided speciation, which was confirmed phenotypically by a reference laboratory. The use of molecular genotypic analysis is an additional strategy in the investigation of endocarditis. It has applications not only in isolate identification but also in primary detection of infection, particularly in patients whose blood is culture negative by conventional methodologies.