Survey of public attitudes towards imminent death donation in the United States.

Imminent death donation (IDD) is described as living organ donation prior to a planned withdrawal of life-sustaining care in an imminently dying patient. Although IDD was ethically justified by United Network for Organ Sharing, the concept remains controversial due to presumed lack of public support. The aim of this study was to evaluate the public's attitudes towards IDD. A cross-sectional survey was conducted of US adults age >18 years (n = 2644). The survey included a case scenario of a patient with a devastating brain injury. Responses were assessed on a 5-point Likert scale. Results showed that 68% - 74% of participants agreed or strongly agreed with IDD when posed as a general question and in relation to the case scenario. Participants were concerned about "recovery after a devastating brain injury" (34%), and that "doctors would not try as hard to save a patient's life" (33%). Only 9% of participants would be less likely to trust the organ donation process. In conclusion, our study demonstrates strong public support for IDD in the case of a patient with a devastating brain injury. Notably, participants were not largely concerned with losing trust in the organ donation process. These results justify policy change towards imminent death donation.

The role of choledochoscopy in the diagnosis and management of biliary tract diseases.

BACKGROUND: The diagnosis and management of biliary tract disorders in certain cases may be incomplete without direct visualization of the bile ducts. METHODS: We report our experience of 61 choledochoscopies (33 women, 27 men, mean age 44.6 years). Twenty patients had previously undergone orthotopic liver transplantation. All except two choledochoscopies were performed via the transpapillary route. Indications included suspected large bile duct stones in 18 patients, anastomotic strictures in 16, abnormal cholangiograms in 5, elevated liver function tests in 7, suspected cholangiocarcinoma in 4, occluded biliary metallic stent in 4, hemobilia in 4, primary sclerosing cholangitis in 2 and ischemic bile duct injury in 1 patient. RESULTS: Choledochoscopy confirmed the anticipated diagnosis in 36 of 61 (59%) patients. Importantly, it provided additional unsuspected diagnostic information in 18 of the 61 (29.5%) patients. In addition, for patients in whom standard cholangiography was deemed abnormal, choledochoscopy demonstrated normal results in 7 (11.4%) patients. Fifty-two choledochoscopies were performed with therapeutic intentions, and the procedure was helpful in providing targeted treatment in 27 (44.2%) patients. CONCLUSIONS: Choledochoscopy is a safe and useful endoscopic modality that can provide specific diagnoses and direct treatment in various biliary tract diseases. The additional information provided by choledochoscopy may change overall patient management and outcome.

An in-house coordinator program to increase organ donation in public trauma hospitals.

A 4-year retrospective study was conducted regarding the donor potential, consent rates, and organ recovery at a large 500-bed public trauma hospital. An independent organ procurement organization hired two in-house coordinators, one white and one black, to work exclusively in the hospital. The duties of the in-house coordinators included the following: working with nurses, physicians, and residents to identify donors; closely managing and coordinating the consent process; and assisting organ procurement coordinators in donor management. Following the program's implementation and the use of race-specific requesters, a 64% increase in consent rate resulted along with an overall increase of 94% in the number of organ donors. The consent rate of blacks increase 115%, whereas the number of black organ donors increased 154%. The Hispanic consent rate increased 48% with a corresponding increase of 83% in the number of Hispanic organ donors. In addition, the white consent rate increased from 55% (the 3-year average from 1993 to 1995) to 75% in 1996, resulting in a 36% increase following the implementation of the program. The investment of dedicated race-sensitive personnel in large urban county trauma facilities can result in a significant increase in donor conversion rates.

Irritant-associated vocal cord dysfunction.

Vocal cord dysfunction (VCD) is a poorly understood entity that is often misdiagnosed as asthma. We report eleven cases of VCD in which there was a temporal association between VCD onset and occupational or environmental exposure. We conducted a case-control study to determine if the characteristics of irritant-exposed VCD (IVCD) cases differed from non-exposed VCD controls. Chart review of VCD patients at the authors' institution produced 11 cases that met IVCD case criteria. Thirty-three control VCD subjects were selected by age matching. There were statistical differences between the groups in ethnicity and chest discomfort. There were no statistical differences between the groups for gender, tobacco, smoking habits, symptoms, or pulmonary function parameters. Varied irritant exposures were associated with IVCD. IVCD should be considered in patients presenting with respiratory symptoms occurring after irritant exposures.

Impact of liver transplantation on quality of life: a longitudinal perspective.

The impact of transplantation on quality of life in liver transplant recipients was studied in a longitudinal sample of 41 subjects. Quality of life was measured during the pretransplantation and posttransplantation phases of the transplant process. Quality of life improved significantly over time, except in the family domain. This study suggests that quality of life improves after a liver transplant despite the number and length of rehospitalizations. Satisfaction and importance of family remained high throughout the transplant phases. Of the demographic variables, only age and income correlated significantly with quality of life.

Quantitation of lipid in biological tissue by chemical shift magnetic resonance imaging.

A method combining several previously used approaches is described for the rapid, accurate quantitation of the fat content of biological tissue based on chemical shift images (CSI) corrected for magnetic field inhomogeneity, and compensated for T1 and T2 effects. The gravimetrically determined lipid content of fatty tissues (pork fat, rabbit and human liver) that had been differentially depleted of lipid by chloroform extraction correlated well (r = 0.99) with the lipid image intensities of the respective tissues. This multi-point CSI method was used to quantitate lipid in fresh fatty human liver tissue (wet and dry) containing varying amounts of lipid. Plots of integrated lipid intensity versus tissue lipid content gave straight parallel lines for hydrated (r = 0.94) and dehydrated (r = 0.98) tissues, permitting determination of a proportionality constant for measuring absolute amounts of lipid present in a specific biological tissue. These results suggest the feasibility of using the method in vivo for absolute quantitation of lipid in tissues of agricultural (e.g. pork, beef) and medical (e.g. human liver) interest.

Surgical complications of liver transplantation.

Surgical complications remain a frequent cause of morbidity after liver transplantation. A high index of suspicion, aggressive diagnostic testing, and a low threshold for re-exploration are necessary to ensure early treatment of these complications.

Liver transplantation. The last ten years.

8960741 10 years have witnessed a number of changes in the liver transplant process. Key among these changes are the longer preservation times allowed with UW solution, the development of the new techniques for the transplantation of pediatric patients, and the reintroduction of xenotransplantation for both permanent and temporary hepatic support. Early referral and prompt transplant of patients are among the most important keys to successful transplantation. However, owing to the present organ allocation system and the lack of suitable organ donors, potential liver transplant recipients will continue to experience a significant mortality rate on the waiting list. In addition, owing to the long waiting times for suitable donor organs, many patients who would have been excellent low-risk candidates will deteriorate as their liver disease progresses and become high-risk patients for liver transplantation. Expanding the donor pool and modifying the present liver allocation system to shift the flow of organs to the better-risk patients will do more to improve the results of liver transplantation than any other change in the management and transplantation of patients with severe liver disease.

Positive pretransplant crossmatches predict early graft loss in liver allograft recipients.

We evaluated the influence of donor-recipient HLA compatibility and recipient pretransplant antidonor sensitization on liver allograft recipient survival. The overall graft survival results for 67 cyclosporine-prednisone treated liver allograft recipients at 3, 6, and 12 months posttransplant were 86%, 83%, and 83%, respectively. No significant differences were observed when comparing the one-year survivals of 81% vs. 85% for men and women or 80% vs. 85% for adult and pediatric patients. Similarly, no differences were observed when comparing one-year graft survivals for well vs. poorly matched recipients of 77% vs. 83% for recipients with < or = 2 HLA A, B vs. > 2 HLA A, B mismatches (MMs) and 82% vs. 82% for recipients with 0-1 HLA-DR MMs vs. 2 HLA-DR MMs, respectively. Pretransplant transfusion history and race also did not influence survival. Standard NIH (long-incubation) and anti-human globulin (AHG) crossmatches were performed. The 12% of recipients (8/67) displaying a positive NIH crossmatch experienced significantly poorer 3-, 6-, and 12-month survivals of 62% vs. 89%, 62% vs. 86%, and 62% vs. 86% (all P < 0.05), respectively, than the 59 NIH-crossmatch negative recipients. Similarly, the 16% (11/67) of recipients displaying a positive AHG crossmatch had significantly poorer 3-, 6-, and 12-month survivals of 63% vs. 91%, 54% vs. 89%, and 54% vs. 89% (all P < 0.05) respectively, than the 56 AHG crossmatch-negative recipients. NIH and AHG crossmatch-positive sera were treated with dithioerythritol (DTE) to establish whether reactivity was due to IgM or IgG immunoglobulin. One-year graft survivals of 65% vs. 30% (P < 0.05) were observed when the crossmatch-positive sera reactivities were due to IgM vs. IgG immunoglobulin. While graft survivals were improved when positive crossmatch serum reactivity was due to IgM, these survivals were still significantly poorer than when the crossmatches were completely negative (86% vs. 60%, P < 0.05 for NIH-negative vs. NIH-positive, but DTE-negative, and 88% vs. 77%, P < 0.05 for AHG-negative vs. AHG-positive, but DTE-negative). Therefore, an NIH- or AHG-positive crossmatch, due either to IgM or IgG reactivity, results in poor early (3- and 6-months) liver allograft survival. Crossmatch-positive recipients experienced significantly (P < 0.05) more rejections and more steroid-resistant rejections (P < 0.05) than crossmatch-negative recipients.(ABSTRACT TRUNCATED AT 400 WORDS)

Pediatric living-related and cadaveric liver transplantation: a single center experience.

Living-related liver transplantation is becoming more commonplace worldwide in the treatment of end-stage liver disease in the pediatric age group. Our LRD experience has resulted in patient and graft survival rates comparable to our cadaveric donor recipients. The incidence and severity of acute rejection episodes were similar. This differs from the clear immunologic advantage of living-related donation in kidney transplantation. It may, however, reflect the relatively small numbers in our LRD group. Overall, however, the technical complications are manageable with early intervention, yielding acceptable results.