The effect of physician education on the rates of donation request and tissue donation.

Our objective was to evaluate physician response to an educational program to increase referral of potential organ or tissue donors in an emergency department (ED). This study was a nonrandomized, controlled, before-after intervention trial at a nonuniversity teaching hospital with 45,000 annual patient visits to the ED. Two one-hour educational sessions reviewed with EMP (but not CON) the physician's role in requesting donation, donor criteria, required-request legislation, and services available from organ procurement professionals. Rates of consideration for donation, discussion with family, consent for donation, recovery of tissues or organs for donation and completion of a donor request form were evaluated before and after the intervention by a blinded chart reviewer. Prior to the intervention, tissue recovery was 0% of EMP and 4% for CON. After intervention, the EMP rate increased to 48% (p < 0.001) but CON remained unchanged (5%, p = 1.0). Similar increases limited to the EMP group were seen for mentioning donation in the narrative chart (1% to 68%, p < 0.001), discussion with family (1% to 65%, p < 0.001), and consent for donation (0% to 32%, p < 0.001). The effect of the intervention was not sustained, with decreased rates of mentioning donation (p = 0.004) and discussion with family (p = 0.02) over six months. Physician education increases request for donation, consent for donation, and recovery of tissue. The duration of this effect is short-lived; repeated interventions may be necessary.

Screening for psychiatric symptoms and illness behaviour in a pain clinic.

Evolution of a multidisciplinary pain clinic in a rehabilitation hospital is described. The assessment process was facilitated, particularly with respect to psychiatric and psychological evaluation, by the preliminary administration of two well established but simple self-administered questionnaire instruments, the Illness Behaviour Questionnaire (IBQ) and the Crown-Crisp Experiential Index (CCEI). The characteristics of our pain clinic population are described. They demonstrate questionnaire profiles which are typical of pain patients. Attention is drawn to the CCEI profile now shown in three studies of pain patients, predominance of the somatic anxiety (S) scale occurring in all. Correlations between the IBQ and CCEI showed, inter alia, that the S scale is a measure of somatisation in pain patients. This paper aims to describe the changes in the clinic since previously published descriptions, to note the characteristics of our patient on the questionnaire instruments and to comment on the value of these questionnaires in the assessment of psychiatric symptoms and somatisation in pain clinic patients.

Organ and tissue donation from the emergency department.

Despite mandatory request legislation, the lack of available donor organs and tissues continues to limit transplant efforts. The potential contribution from emergency department (ED) patients remains undefined. We reviewed the charts of patients dying in our ED for organs and tissues potentially suitable for transplantation, age, cause of death, and physician documentation of donation inquiry. Of 155 charts reviewed, potential donors were identified for corneas (99), bones (61), heart valves (42), and kidneys (3). Of the 155 charts, 130 (84%) made no mention of donation, and of 37 charts containing a donor request form, 34 (92%) were incorrectly filled out or left blank. Four charts (2.6%) mentioned donation in the narrative section, two (1.3%) documented discussion with family, and one patient was referred to our Organ Procurement Organization, with recovery of one kidney and heart valves. We conclude that physicians rarely document consideration of donation for patients dying in the ED; the number of potential donors far exceeds the number referred or recovered. Future efforts should focus on methods to increase recognition and referral of organ and tissue donors from the ED.

The flow cytometric crossmatch and early renal transplant loss.

Data from this retrospective study indicate that a positive two-color T and/or B cell flow cytometric crossmatch (FCXM) is predictive of early renal allograft loss (less than 2 months) in cadaveric kidney donor recipients who had a negative crossmatch by the antihuman globulin complement-dependent cytotoxicity technique. Among 90 cadaveric kidney donor recipients (67 primary, 23 regrafts), 14 (8 primary, 6 regrafts) lost their renal allografts within 2 months, and 10 of the 14 were FCXM positive and HLA sensitized. The remaining 76 allografts survived beyond 2 months, 12 of which were FCXM-positive. Thus, the FCXM sensitivity rate for detecting early graft loss was 71%, and the specificity rate was 84%. Cadaveric graft-loss rates at 2 months were 33% for primary and 60% for FCXM-positive regrafts in contrast to 7% for primary and 0% for FCXM-negative regrafts. The difference in early graft loss between FCXM-positive and FCXM-negative recipients was statistically significant (P less than 0.0001). Subset analyses of FCXM-positive graft recipients indicate: (1) previous early graft loss contraindicates transplantation of an FXCM-positive regraft (P = 0.03); and (2) panel reactive antibody (PRA) less than or equal to 10% at crossmatch is not associated with early graft loss (P = 0.04). There was no significant difference in 1-year graft survival between primary and regrafts in either FCXM-negative recipients (85% vs. 77%, respectively) or FCXM-positive recipients (67% vs. 40%). All 12 of the FCXM-positive primary and regrafts that survived 2 months continued to function at 2 years. Stepwise logistic regression analysis of 5 independent predictor variables (FCXM status, gender, primary vs. regraft status, PRA level, and HLA mismatched antigens) indicated that the FCXM test was the best predictor of early graft loss. When FCXM results of the 90 cadaveric graft recipients were ranked in three groups, an FCXM channel shift of 29 or greater (third tertile) on a 1024 channel log scale was associated with a 7.0-fold (95% confidence interval 1.9-25.5) increased risk of early graft failure when compared to the first two tertiles. These data indicate that the FCXM offers an additional approach for identifying sensitized patients at risk of early renal allograft loss.

A multidisciplinary approach to chronic low-back pain in Western Australia.

Fifty patients with chronic low-back pain were subjected to extensive medical, psychiatric, and psychosocial assessment by a comprehensive Low Back Pain Clinic. Most patients were found to have easily identifiable environment factors which influenced the persistence of the symptomatology. All patients were significantly functionally impaired, and whilst neurologic findings were uncovered in only 12 patients, most had restricted movement of the lumbar spine. The initiating cause of the low-back pain was usually from a minor injury or no injury at all. Thirty-two patients were given psychiatric diagnoses, but only one patient was thought to warrant psychiatric treatment. Whilst some were considered to be candidates for limited further conservative treatment, only two were subjected to further surgery (one fusion, one posterior facet rhizotomy). Only nine were admitted to an inpatient behavior modification program, and the results of this effort were modest. The major benefit was seen to be the definitive diagnosis, prognosis, and medical and social planning which was given to all 50 patients upon conclusion of the assessment. The assessment proved to be of benefit to the patient, the referring doctor, the team itself, as well as all other interested parties, such as his family, insurance company, and lawyer.