Current status of in-hospital donation coordinators in Japan: nationwide survey.

OBJECTIVES: When the Japanese Organ Transplantation Act was issued, the Japanese Organ Transplantation Network (JOT) was established in 1997. JOT lists recipients, assesses and manages organ donors, and educates publics and headquarters for organ donations. JOT procurement transplant coordinators (PTC) play roles in obtaining consent from relatives for organ donation, donor evaluation and management, organ recovery management, organ transport, and care of donor families during and after donation. Every prefecture has at least one PTC who is mainly working in public education and hospital development. They also help the JOT PTC at the time of organ procurement. Most prefectures commission hospital staff in the procurement hospital to be an in-hospital PTC (In-Hp PTC), who make their hospital staff aware of organ donation and support organ procurement. Although the Act was revised in 2010 with brain-dead organ donation increased from 13 to 44 cases yearly, the number was still extremely smaller than other developed countries. In these circumstances, In-Hp PTC may play greater roles to increase donation and smooth procurement procedures Our primary aim was to describe the current status of In-Hp PTC in Japan. MATERIALS AND METHODS: Between December 15, 2011, and January 31, 2012, we invited 1889 In-Hp PTC to complete a letter survey using a self-designed questionnaire. In all, 56 In-Hp PTC (40%) completed and returned it. RESULTS: The occupation of the respondents was nurse (66%), physician (18%), or other (16%). Although 52% of respondents belonged to the hospital, which was designated for brain-death organ donation by the government, only 46% had any experience with a cadaveric donor. Only 2% were full-time In-Hp PTC. They mainly played a role in preparing their own manual for organ procurement (57%), providing in-hospital lectures (44%) or their own simulation exercise (29%), as well as coordinating donation cases. Although 77% had attended seminar about organ donation provided by JOT or the prefecture PTC, 93% wanted more professional education. However, it was difficult for them to attend these activities, to manage a rare and sudden donation case, and to find time to learn about organ donation because they had another post. The topics that they wanted to learn were donor family care (72%), overall organ/tissue donation procedures (65%), the role of In-Hp PTC (67%), simulations of donation (65%), legislation and social system of organ donation (61%), medical indications for donation (61%), current status of donation and transplantation in Japan (57%), donor management (56%), and case studies (49%). There were significant variations in the topics of interest among the occupations. As they had another post, they could find only a short period (1 or 2 days) to take professional education, such as lectures. Therefore, it was difficult for them to attend practical on-the-job training. CONCLUSIONS: To establish an organ procurement system and increase organ donation, In-Hp PTC have important roles in Japan. However, none is a full-time In-Hp PTC. Most In-Hp PTC require more professional education. A systematic education program for each occupation must be established soon.

Professional education and hospital development for organ donation.

Because of the strict Organ Transplantation Act, only 81 brain dead (BD) organ donations had been performed in Japan for 13 years since 1997. The Act was revised on July 17, 2010, allowing, organs to be donated after BD with consent from the family, if the subject had not denied organ donation previously. This act has lead to an expectation of a 6-7-fold increase in BD donation. The 82 organ procurement coordinators (OPC) in Japan include 32 belonging to the Japanese Organ Network (JOT) and the others to each administrative division. JOT has guideline manuals of standard roles and procedures of OPC during organ procurement from BD and cardiac death donors. To manage the increased organ donations after the revision of the act, we have modified the education system. First, we modified the guideline manuals for OPC to correspond to the revised Transplant Act and governmental guidelines. Second, all OPC gathered in a meeting room to learn the new organ procurement system to deal with the revised Transplant Act and guidelines. Third, a special education program for 2 months was provided for the 10 newcomers. Last, the practical training in each donor case for newcomers was performed by older OPC. Topics of the education program were the revised transplant act and guidelines, family approach to organ donation, BD diagnosis, donor evaluation and management, organ procurement and preservation, allocation system, hospital development and family care. In the future, each OPC will be divided into special categories, such as the donor family OPC, the donor management OPC, and the operating room OPC. Therefore, we need to construct separate special education programs for each category.

Modification of the education system for organ procurement coordinators in Japan after the revision of the Japanese Organ Transplantation Act.

BACKGROUND: From October 1997 to July 2010, only 86 brain-dead (BD) organ donations were obtained and no organs were retrieved from children under 15 years of age because of the strict Japan Organ Transplantation Act. The Act was revised on July 17, 2010, allowing organs to be donated after BD with family consent. OBJECTIVE: To manage the increased donations after the revision, the Japan Organ Transplant Network (JOT) employed 10 organ procurement coordinators (OPCs) and modified its education systems. We retrospectively reviewed the modified education programs to evaluate whether they were effective and whether the processes of organ donation were promptly performed after the revision of the Act. METHODS: The modifications of education program were: changing OPC to guideline manuals to correspond to the revised Transplant Act; OPCs were taught the new organ procurement system; and a special education program was provided for the 10 newcomers for 2 months. RESULTS: After 12 months of the revision, 58 BD organ donations were accomplished, whereas they had averaged 6.6 in a year before the revision. Two pediatric BD organ donations were accomplished without problem. One priority organ donation to a relative was performed uneventfully. After applying the modified education program, skilled JOT OPCs and leader JOT OPCs increased. CONCLUSIONS: To manage increased organ donations after the revision of the Act, the educational system was modified and 58 brain dead organ donations were performed safely.

Cytodiagnosis through use of a z-axis video by volunteer observers: a promising tool for external quality assessment.

OBJECTIVE: This study examined whether cytological diagnosis through the use of a video, which shows the changing depth of focus in the microscopic field, described as a z-axis video, is useful compared with a still image. METHODS: From 17 cytology preparations of fine needle aspiration of the breast, we made six z-axis videos per case. A frame exhibiting the characteristic features was then extracted from each video and saved as a representative still image. One hundred and twenty-eight volunteer cytotechnologists were randomly divided into two groups of video observers and still image observers. The participants were asked to make a diagnosis of benign, indeterminate, suspicious or malignant without having any clinical information other than the age of the patient. Diagnoses were categorized as 'recommended' or 'unacceptable' according to degree of correlation with histology. RESULTS: The number of definitive diagnoses of 'benign' or 'malignant' were increased in video observers, and indeterminate or suspicious categories were decreased (P = 0.013). The distribution of diagnostic categories in three of the 17 cases was significantly different; the distribution in the remaining cases was similar between the two groups. The z-axis video observers may have selected the definite diagnoses with confidence because they observed valuable microscopic findings by 'focusing through observation'. The average number of 'recommended' diagnoses by individual observers was significantly higher in the video observer group than in the still image observer group (P = 0.016). In contrast, the average number of 'unacceptable' diagnoses was significantly lower (P = 0.019). CONCLUSIONS: A z-axis video is easy to obtain and is therefore expected to become a powerful diagnostic modality for the external quality assessment of clinical cytology and even in the field of primary cytodiagnosis.

Radiographic observation of a case of gastrointestinal stromal tumor in stomach.

A case of gastrointestinal stromal tumor (GIST) in stomach was presented. Serial barium meal x-ray examinations revealed an enlarging elevated lesion on the fornix of the stomach. Tumor volume doubling time was found to be 299 days. Microscopic and immunohistochemical studies of the resected tumor disclosed GIST, uncommitted type, low grade malignant/potentially malignant. A radiographic feature of this rare type of gastric submucosal tumor was demonstrated in this report.

A crossover study of oral administration of UFT in chronic liver disease: comparison of continuous and intermittent schedules.

This study was aimed at evaluating the tolerance to an intermittently administered oral UFT for hepatocellular carcinoma (HCC) with chronic liver disease (CLD). Ten patients who had received curative therapy for HCC with CLD (Child's classification A or B) were randomly assigned either an intermittent schedule (IS), oral administration of UFT (130 mg/m2/b.i.d.) with 2 days rest a week, or a continuous schedule (CS), consecutive administration of UFT with the same dose. On day 12, the serum concentration of 5-fluorouracil (5-FU) was measured. After 2 weeks rest, the patients were switched to the other schedule for 10 weeks and the concentration of 5-FU was measured on day 12. The median values of the area under the curve (AUC) and maximum concentration (Cmax) of 5-FU in IS and CS were 187.7 and 263.2 ng/ml/h, 57.1 and 93.0 ng/ml, respectively. Both the AUC and Cmax for IS were significantly lower than those for CS. One IS patient had tolerable diarrhea, while three of the CS patients had intolerable nausea and one had hemorrhagic gastritis. IS seemed to be a suitable measure for CLD.

Serum DNA polymerase beta as an indicator for fatal liver injury of rat induced by D-galactosamine hydrochloride and lipopolysaccharide.

DNA polymerase beta (pol beta) is a nuclear enzyme that is tightly bound to chromatin. Release of the pol beta activity into serum, therefore, may indicate the occurrence of massive destruction of cell nuclei in organs or tissues. In the present study, we made a liver injury model rat by the intraperitoneal injection of D-galactosamine hydrochloride (GalN, 500 mg/kg) and lipopolysaccharide (LPS, 100 microg/kg). Serum from the GalN/LPS-treated rats showed a high level of pol beta activity up to 118 pmol/0.5 microl serum (4700 cpm) at 12 h after the treatment, while the control rat serum showed the back ground level (3.8 pmol/0. 5 microl, 150+/-70 cpm). The serum pol beta activity was sensitive to inhibition by 2',3'-dideoxyTTP and by an anti-rat pol beta antibody. Among 30 rats treated with GalN/LPS, 10 rats died within 120 h (dead group). Serum pol beta activity in the dead group was as high as 23.0+/-19.5 pmol/0.5 microl (925+/-778 cpm) at 10 h after the treatment, while in alive group (n=20), it was 3.7+/-3.2 pmol. Levels of the serum pol beta activity correlated well with the prognosis of GalN/LPS-treated rats based on an analysis of the receiver-operator characteristic curves.

Carboplatin as an anticancer agent for transcatheter arterial chemoembolization in patients with hepatocellular carcinoma.

Transcatheter arterial chemoembolization (TACE) is a conservative treatment in patients with hepatocellular carcinoma (HCC). In the present study, 30 patients with unresectable HCC underwent TACE using carboplatin (300 mg), and their clinical results were evaluated. After TACE, 18 (60.0%) of 30 patients demonstrated tumor size reduction rates > or = 50%. Of 23 patients with pretreatment serum alpha-fetoprotein (AFP) levels >20 ng/ml (cutoff), 14 (60.9%) showed AFP reduction > or = 75%. The 1-, 2-, 3- and 4-year survival rates were 82.9, 68.1, 45.1 and 37.6%, respectively. The median survival was 2.3 years. The only notable adverse reaction accompanying TACE was a transient myelosuppression. Carboplatin is thought to be a useful anticancer agent in patients with HCC treated with TACE.

[Early detection of primary liver cancer--diagnosis of small liver cancer by needle aspiration biopsy].

Small liver cancer is defined as a solitary hepatocellular carcinoma (HCC) with a diameter less than 2cm. To detect liver cancer as early as possible, patients with liver cirrhosis are screened by ultrasound scanning. Pathological diagnosis in needle aspiration biopsy materials is needed because of low positivity of imaging other than ultrasound scanning. Pathological features are different from those of classical hepatocellular carcinoma. Most of the small HCCs are characterized by the following features: (1) increased cellularity, (2) increased nucleus/cytoplasm ratio, (3) irregular thin trabecular pattern, (4) pseudoglandular or acinar structures, (5) increased staining affinity (eosinophilic/basophilic), (6) frequent fatty change, and (7) residue of the portal tract. Capsules of HCCs, 1-1.5 cm in diameter, are formed. Before the formation of capsules, cancerous cells show a replacing growth pattern. Two cases of small HCC are presented, and these characteristic features are explained.

[Isolation of penicillin-resistant Streptococcus pneumoniae in Saga Medical School Hospital].

A recent nationwide increase in beta-lactams-resistant Streptococcus pneumoniae has attracted a great deal of attention. We studied the drug sensitivity of S. pneumoniae isolated from various clinical specimens in Saga Medical School Hospital between April 1988 and December 1991. To determine the drug sensitivity of the strains, we used a micro-dilution method and determined the MIC. Drug resistance was evaluated using MIC of ampicillin (ABPC) as a reference MIC, and the results were roughly classified into the following three groups: sensitive (< or = 0.1 microgram/ml), moderately resistant (0.2-3.13 micrograms/ml) and highly resistant (> or = 6.25 micrograms/ml). The isolation frequency was calculated on the basis of one strain from one patient. No strain of S. pneumoniae with high resistance against ABPC was found in 1988 (94 strains of S. pneumoniae were isolated) and 1990 (115 strains isolated), but one such strain (0.8%) was found among 129 strains isolated in 1989, and 2 such strains (2.4%) among 84 strains isolated in 1991. Moderately resistant strains were isolated at the frequencies of 12.8%, 15.5%, 22.6%, and 21.4% respectively, in 1988, 1989, 1990, and 1991. A sum of the frequencies of "moderately resistant" and "highly resistant" (2.4%) strains was 23.8% in 1991. The frequency of resistant strains is increasing and the intensity of resistance is also being elevated.

[Hospital infection with methicillin-resistant Staphylococcus aureus (MRSA) in Saga Medical School Hospital, a rapid increase in coagulase type-VIII strains].

Hospital infection with MRSA has increased in Saga Medical School Hospital. The causative MRSA consisted predominantly of coagulase type-II strain before 1989, but after 1990, coagulase type-VII MRSA increased rapidly. This type-VII strain has marked multiple drug-resistance, and the pattern of drug sensitivity of MRSA in this hospital was different from that of MRSA detected in other facilities, which are clinically serious problems, therefore, we conducted an etiological study of the background of the increase in MRSA infection in our hospital. The results of the study are summarized as follows: 1) The proportions of MRSA (on strain from one patient) to all types of S. aureus detected in the hospital were 26% for 1986, 23% for 1988, 37% for 1989, 30% for 1990 and 60% for 1991. The proportion increased greatly in 1991. 2) Coagulase type VII-MRSA was first detected only in 5 patients in 1989, then it tended to spread, and this type (probably derived from the same strain) accounted for 47% of MRSA infection in patients examined in 1991. 3) The study of the drug sensitivity pattern and etiological survey of the infection showed that coagulase type VII-MRSA prevalent in the hospital consisted of two types: CLDM, and EM-sensitive, IPM/CS, and MINO-resistant and TSST-1 non-producing and enterotoxin non-producing type, and CLDM, and EM-sensitive, IPM/CS, and MINO-resistant and TSST-1 non-producing type with enterotoxin serotype A. 4) Coagulase type VII-MRSA (Probably derived from the same strain) was detected in physicians and nurses working in affected wards and also in the patients's room.(ABSTRACT TRUNCATED AT 250 WORDS)

Transvaginal-transmyometrial embryo transfer: the Towako method; experiences of 104 cases.

A new technique of ET based on US-guided transmyometrial puncture has been performed in 104 cases. Thirty-eight patients conceived for a clinical PR of 36.5% per attempt. The use of this technique is proposed to overcome problems of difficult transfers because of cervical abnormalities. No serious complications were observed.

[A case of Wegener's granulomatosis with a giant solitary pulmonary mass].

A 44-year-old woman was admitted to hospital with a history of high fever, cough, and weight loss. Her chest X-ray film showed a giant solitary pulmonary mass in the left lower lobe. After admission, she developed bilateral eyeache and left exophthalmos. CT film of the head showed a massive lesion in the sinuses. Biopsy specimens obtained from both massive lesions showed either epithelioid granulomas with Langhans' giant cells or necrotising vasculitis. Antineutrophil cytoplasmic antibodies, which have high sensitivity and specificity for active WG, were found. The diagnosis of WG was thus made.

[Contrast echocardiographic assessments of myocardial blood flow in acute myocardial infarction].

Clinical information on the regional myocardial blood flow in the post-ischemic myocardium has been limited. In the present study, we assessed the influence of early coronary reperfusion and coronary obstruction that remained after reperfusion on regional myocardial perfusion by myocardial contrast echocardiography. The study population consisted of 17 patients with acute myocardial infarction who underwent either successful PTCR or emergent PTCA within 6 hours after the onset of the symptom. Myocardial blood flow was visualized by selective injections of hand-agitated poly-gelin colloid solutions into the right and left coronary arteries before and after coronary reperfusion. Before coronary reperfusion, the area at risk for necrosis was defined as the area of contrast defects by the intracoronary injection of contrast medium. The size (severity) of this defect correlated with the anatomic distribution of the obstructed coronary artery. Immediately after emergent PTCA (mean residual stenosis = 25%), 2 of 10 patients still showed injected contrast medium, however, in the remaining 8 patients (80%), the contrast washout time in the risk area was 1.5 times (mean value) longer than that in the normal region. This indicated impairment of the microcirculation in the post-ischemic myocardium. Immediately after PTCR (mean residual stenosis = 89%, p < 0.01 vs PTCA), contrast enhancement was observed only in the peripheral region of the risk area; contrast defects at the center of this region were observed on contrast echocardiography after reperfusion for all patients. This showed that there was impairment of myocardial blood flow in the risk area, even after successful recanalization in patients undergoing PTCR.(ABSTRACT TRUNCATED AT 250 WORDS)

[Quantification of mitral regurgitation by Doppler color flow mapping: comparison of mitral regurgitant fraction and volume with Doppler measurements].

Color flow imaging of the regurgitant areas has been used to quantitate the severity of valvular regurgitation, however, the exact relationship between color flow areas and regurgitant volumes or fraction has not been clarified. This study was designed to determine whether measurements of jet flow areas and distances using color flow imaging are closely related to the regurgitant volume (MRV:ml/beat) and fraction (MRF: %). Doppler examinations were performed in 29 patients with mitral regurgitation (MR). The MR jet was depicted as the largest clearly definable flow disturbance on the echo images, and the maximal jet area (cm2) and length (cm) were measured. The MRV and MRF were obtained from the Doppler measurements of the transmitral flow (TMF) and the aortic flow (AF) as follows: MRV = TMF-AF, MRF = MRV/TMF x 100. The maximal jet area showed significant correlations with the MRV and MRF (r = 0.75 and 0.75, p < 0.01), and the maximal jet length showed even better correlations with the MRV and MRF (r = 0.82 and 0.80, p < 0.01), irrespective of the etiology of MR. Thus, both the maximal jet area and length obtained from color flow imaging can be simple and useful measurement methods for predicting the MRV and MRF.

Diffuse panbronchiolitis as a pulmonary complication in patients with adult T-cell leukemia.

Forty-three cases of adult T-cell leukemia (ATL) admitted to our hospital between 1982 and 1987 were studied. Three of those were found to be complicated with diffuse panbronchiolitis (DPB). The incidence of DPB is considered to be significantly higher in patients with ATL. The three DPB-complicated cases composed one case each of the smoldering, chronic, and acute type of ATL. In each type, DPB preceded overt ATL and Candida albicans was found in sputa following detection for bacteria. The DPB complication apparently worsened the prognosis of the ATL patients. We have discussed a possible relationship between ATL and DPB.