Service-learning for graduate students

OBJECTIVES: The European Commission funded EUROTOLD Project sought to examine the legal and ethical implications of living donor organ transplantation within Europe, facilitated by a multi-centre study acquiring data on practices, laws, policies, attitudes and decision-making processes. METHODS: Methods involving primary sources included interviews with clinical staff and past and present organ donors and recipients, and questionnaire surveys of transplant centres, individual clinical staff and legal experts. These strategies were supplemented by an examination of secondary sources such as official reports, transplantation literature, etc. RESULTS: The surveys generated substantial new evidence relating to transplant centre policies and practices, and the attitudes of physicians toward living donation generally and the use of certain specific classes of donor. The latter was facilitated by the use of case scenarios, providing a window upon factors influencing judgments in this sphere. The interview data confirmed earlier findings about donor decision-making. CONCLUSIONS: Responding centres and clinicians displayed a fairly liberal attitude toward living donation but substantial diversity nonetheless exists with regard to living donor transplant volumes between centres and surrounding acceptable waiting times for transplant. Further research is required to identify precisely the reasons underpinning such disparity.     

Impact of the Hospital Coordinator Program on obtaining kidneys for renal transplantation

Limited organ supply is currently the major obstacle to the transplantation programs around the world. As an alternative to increase the organ donation rate, we undertook a preliminary transplant coordinator program study, during a 6 month period, in five public hospitals, as part of the National Transplant Program of the Centro Nacional de Diálisis y Trasplante. The primary objective of the Transplant Coordinator Program was donor detection and organ procurement, along with education of the community. Forty five predonors were detected, with an average age of 25.8 +/- 1.6 years, of these, 36 were men (80%). None of them was a voluntary donor. The most frequent diagnoses were cranial trauma in 57.8% and stroke in 22.2% Forty two percent (42.3%) of the predonors were detected in the emergency room, 33.3% in intensive care units and 24.4% in the surgery recovery room. The conversion rate of predonors to donors were 29%. The main causes for not conversion of predonors into donors were: family refusal 44%, sepsis 13%, cardiac arrest 13%, and reduced renal function 6%. In conclusion, the Transplant Coordinator Program allows to increase the predonor detection and gives good information for adequate management of donor and public educational campaign about the subject.     

Cloning and characterization of plastid ribosomal protein S16 gene from potato (Solanum tuberosum L. cv Désirée)

STUDY OBJECTIVE: To determine whether an intensive educational campaign of emergency department personnel on the organ donor and procurement process would result in both increased organ donor referrals and organs procured. METHODS: A retrospective review of the performance of an urban teaching ED in identifying and referring potential organ donor candidates was performed. Subsequently an intensive educational campaign of all ED staff, in conjunction with the Regional Organ Procurement Agency of Southern California (ROPA), was initiated. Physicians and nurses were educated about the procurement process, and a ROPA representative was on call 24 hours a day to assist in this process. The need for aggressive resuscitation and vital sign maintenance in potential donors as a strategy to promote organ recovery was emphasized. Reeducation by ROPA occurred every 2 to 3 months. The identification and referral rates were then retrospectively reviewed to evaluate any improvement. RESULTS: In 1994 the initial referral rate of potential organ donors from the ED was 30% (3 of 10) resulting in no organs procured. After the intervention the referral rate increased to 100% (25 of 25) in 1995 (P < .0001). The number of actual donors procured was 0 in 1994, 5 in 1995, and 9 in 1996. The increased ED referrals resulted in 14 and 32 organs procured in 1995 and 1996, respectively. CONCLUSION: Emergency physicians are in a unique position as first caregivers to interact with both potential donors and their families. With intensive education of ED staff, proper identification and referral, as well as timely intervention by organ procurement representatives, the consent and donation rate of organs for transplantation can be increased and maintained.     

Heart donation: the New Zealand experience, 1987-1996

AIMS: To audit all donor hearts offered to our unit, assess the outcome, identify factors which might enhance the acceptance rate and provide data on which to base and modify acceptance criteria. METHODS: Demographic, clinical and outcome data were collected retrospectively and analysed for all patients in whom brain death had been established and permission for organ donation obtained from the family prior to referral to the transplant donor coordinator. RESULTS: Over a nine year period (1987-96) 267 hearts were offered for transplantation. The mean donor age was 31.2 years (2-72), 163 being male and 104 female. The cause of death was secondary to trauma in 52%, neurological in 44% and due to hypoxia in 4%. The mean donor weight was 68 kg and the distribution of ABO blood group similar to the New Zealand population. Seventy-six hearts (28%) were implanted. Of the 191 not implanted no suitable recipient was available for 98 (51%) according to blood group and body weight criteria, 38 donors (20%) were medically unsuitable, 37 (19%) were declined because of donor age, 16 (8%) because of a markedly abnormal echocardiogram and 2 (1%) for logistical reasons. CONCLUSIONS: Enhanced efforts are needed to increase public awareness of the benefits of organ donation. However, a greater number of heart transplants may be achieved by increasing the recipient pool.     

Blood donation and patterns of use in southeastern Nigeria

A retrospective study of donor blood availability and patterns of use from 1984 through 1988 was conducted in a 400-bed university teaching hospital in Nigeria by extraction of data from the master registers for blood donors and recipients. Blood transfusion requests, number of persons who underwent phlebotomy, number of crossmatches performed, and blood use increased each year during the period of study. Average wastage rate and crossmatch-to-transfusion ratio were 3.5 percent and 1.61, respectively. Replacement blood donation constituted 98 percent of available donor blood. Obstetrics and gynecology and surgery patients used 70.4 percent of the donor blood. The donor blood units were used as whole blood (81%) because of a lack of infrastructure such as a refrigerated centrifuge. Less than 5 percent of the donors were females. It is concluded that the levels of voluntary blood donation and general blood supply are unacceptably low. The need for a functional National Blood Transfusion Service is highlighted.     

Multiorgan donation in The Netherlands: limited by consent and policy

The percentage of multiorgan donors (MOD) versus single organ donors of kidneys only (SOD-K) has remained markedly low in the Netherlands compared to the other countries in the Eurotransplant region. This suggests a possible loss of donor organs. We investigated the causes of this persisting low percentage of MOD by studying the reasons for kidney donation only. All kidney donors in the Eurotransplant region in 1992 were studied retrospectively. In order to be able to make a comparison between all countries investigated, non heart-beating donors and donors older than 55 years were excluded. Medical reasons were the most frequent cause for kidney donation only in the Netherlands, but this was not significantly different from the other countries in the Eurotransplant region. Multiorgan donation in the Netherlands was restricted by upper age limits for heart and liver transplantation and by the consent system.     

Understanding donors' motivations: a study of unrelated bone marrow donors

Medical advances in bone marrow transplantation techniques and immunosuppressive medications have dramatically increased the number of such transplants performed each year, and consequently, the demand for bone marrow from unrelated donors. Although physiological aspects of bone marrow donation have been thoroughly investigated, very few studies have examined psychosocial factors that may impact individuals' donation decisions and outcomes. To examine one particular set of donor psychosocial issues, this study investigated motives for bone marrow donation among 343 unrelated bone marrow donors who donated through the National Marrow Donor Program. Six distinct types of donor motives were identified from open-ended questionnaire responses. Donors most frequently reported motives reflecting some awareness of both the costs (to themselves) and potential benefits (to themselves and the recipient) of donation. A desire to act in accordance with social or religious precepts, expected positive feelings about donating, empathy for the recipient, and the simple desire to help another person were also commonly cited reasons for donating. Among a series of donor background characteristics, donors' gender was the variable most strongly associated with motive type; women were most likely to cite expected positive feelings, empathy, and the desire to help someone. Central study findings indicated that donor motives predicted donors reactions to donation even after the effects of donor background characteristics (including gender) were controlled. Donors who reported exchange motives (weighing costs and benefits) and donors who reported simple (or idealized) helping motives experienced the donation as less positive in terms of higher predonation ambivalence and negative postdonation psychological reactions than did remaining donors. Donors who reported positive feeling and empathy motives had the most positive donation reactions in terms of lower ambivalence, and feeling like better persons postdonation. These finding add substantially to the body of work concerning medical volunteerism generally, and also have important practical implications for the recruitment and education of potential bone marrow donors.     

Pulmonary transplantation

OBJECTIVE: More than 2700 lung transplants have been performed since the initial clinical success in 1983. The evolution in the techniques of lung transplantation and patient management and the effects on results are reviewed. SUMMARY BACKGROUND DATA: Improvements in donor management, lung preservation, operative techniques, immunosuppression management, infection prophylaxis and treatment, rejection surveillance, and long-term follow-up have occurred in the decade following the first clinically successful lung transplant. A wider spectrum of diseases and patients treated with lung transplant have accentuated the shortage of suitable lung donors. The organ shortage has led to the use of marginal donors and a limited experience using living, related donors. METHODS: Changes in techniques and patient selection and management are reviewed and controversial issues and problems are highlighted. RESULTS: One-year survival of greater than 90% for single-lung transplant recipients and greater than 85% for bilateral lung transplant recipients have been achieved. Complications caused by airway complications has been reduced greatly. Obliterative bronchiolitis develops in 20% to 50% of long-term survivors and is the leading cause of morbidity and mortality after the first year after transplant. CONCLUSIONS: Lung transplantation has evolved into an effective therapy for a wide variety of causes of end-stage lung disease. Wider applicability requires solutions to the problems of donor shortage and development of obliterative bronchiolitis.     

Transcranial Doppler for early identification of potential organ transplant donors

BACKGROUND: Encouraging results in transplant medicine create a growing demand for organ transplant donors. Transcranial Doppler (TCD) has been used by several investigators to assess arrest of the cerebral circulation in brain dead patients. We report on TCD as a monitoring tool for early identification of potential organ transplant donors. DESIGN: A prospective clinical study. SETTING: Intensive care unit (ICU) of a 900-bed community hospital (primary and tertiary care center) in Vienna, Austria. SUBJECTS AND METHODS: All patients with acute intracranial lesions admitted to our intensive care unit underwent TCD examination at least once daily. In patients with Glasgow Coma Scores < 7, TCD waveforms with high resistance profiles unchanged by therapeutic attempts to lower intracranial pressure indicated the need for repeated TCD up to four times a day. TCD waveform abnormality consisting of absent or reversed diastolic flow or small early systolic spikes in at least two intracranial arteries was considered to constitute intracranial circulatory arrest. Brain death was confirmed by clinical criteria, an isoelectric electroencephalography (EEG) or non filling of the intracerebral arteries on arteriography. RESULTS: From January 1994 to July 1996 we identified 11 comatose patients as potential organ transplant donors with typical TCD findings indicating intracranial circulatory arrest. Diagnosis was subarachnoid hemorrhage in 7 and intracerebral hemorrhage in 4 patients. Brain death diagnosis according to the criteria of Austrian law was initiated immediately after the TCD findings suggested intracranial circulatory arrest. Confirmation of brain death was obtained by clinical criteria and either EEG (6 patients) or cerebral angiography (5 patients). CONCLUSION: TCD examinations on a daily routine basis offer a noninvasive monitoring method for early assessment of intracranial circulatory arrest. TCD enables quick identification and further diagnosis of candidates for organ transplant donation.     

Real-time X-ray diffraction study at different scan rates of phase transitions for dipalmitoylphosphatidylcholine in KSCN

A questionnaire survey was carried out to examine the attitudes and practices of Australian and New Zealand intensivists with regard to brain death and organ donation. A return rate of 82.5% was achieved. Fifty-eight per cent had written evidence of their own wishes to donate organs and 94% would agree to donation from a dependent. At least one intensivist is involved in certifying brain death on 95% of occasions. Intensivists are involved in the request for organ donation over 90% of the time although one-third do not believe that it is their role to request organ donation. Although two-thirds believe that the family should always be approached for organ donation, another 52 out of 254 indicated that it was their (the intensivist's) role to decide if families should be asked for organ donation. Possible reasons for not requesting are language or other communication problems, perceptions of cultural differences and degrees of family distress. Twenty per cent of respondents do not provide haemodynamic support before brain death confirmation. Australian and New Zealand intensivists overwhelmingly support the concept of brain death, current methods of confirmation of brain death, organ donation and transplantation. Possible reasons behind loss of potential donors include decisions not to resuscitate both before and after brain death is confirmed. Perceptions of family grief and cultural differences clearly inhibit requests for organ donation. A very few units have an effective policy on approaching families about organ donation. Intensivists have almost exclusive control over requests for organ donation and thus bear a full professional responsibility for this element of hospital practice.     

Organ procurement and renal transplants in Spain: the impact of transplant coordination. Spanish National Transplant Organization (ONT)

The growing shortage of cadaveric organ donors remains the major obstacle to achieve satisfactory rates of transplantation. In Spain an integrated transplant organization programme, mainly focusing on organ procurement, has been established, based on a network of well-trained transplant coordinators. In every hospital that was a potential candidate for donor procurement, a transplant coordinating team was founded, including medical doctors and nurses (42% of whom belonged to renal units). The team was put in charge of all steps of transplant procurement, from locating potential donors to the organ grafting or tissue banking. The teams were integrated into a National Organization of Transplants (ONT), i.e. a coordinating structure without executive function. The annual rate of cadaveric organ donors increased from 14.3 per million population (p.m.p.) in 1989 to 21.7 donors p.m.p. in 1992. Total solid organ retrieval rate increased by 81% and renal transplants by 44% during the same period (from 1039 to 1492, i.e. from 26 to 38.8 renal transplants per million population, 99% of which were kidneys from cadaveric donors). This successful approach has overcome obstacles such as untrained or undertrained staff, failure to identify donors, or reluctance to approach grieving families.     

The feasibility of organ salvage from non-heart-beating trauma donors

BACKGROUND: Blunt trauma patients without vital signs on admission are potential non-heart-beating donors. OBJECTIVE: To review the feasibility of postmortem visceral perfusion and organ donation in blunt trauma patients without vital signs. DESIGN: A retrospective case series of blunt trauma victims who were declared dead in the emergency department. SETTING: A level I trauma center. MAIN OUTCOME MEASURES: Factors potentially precluding donation and potential donor yield. RESULTS: The mean trauma-to-death interval was 71 minutes (< 60 minutes in 57% of the cases). Injuries likely to interfere with in situ perfusion were present in 41% of the cases. The tissue donation consent rate was 45%. Assuming a similar organ donation consent rate, the potential donor yield was 9% after excluding victims who were younger than 60 years of age, warm ischemia times that were less than 60 minutes, and patients who had injuries precluding perfusion. CONCLUSIONS: The potential organ yield from non-heart-beating, blunt trauma victims is low, which highlights the ethical and legal problems of this approach.     

The “ick” factor, anticipated regret, and willingness to become an organ donor.

Objective: This research tested the role of traditional rational-cognitive factors and emotional barriers to posthumous organ donation. An example of an emotional barrier is the “ick” factor, a basic disgust reaction to the idea of organ donation. We also tested the potential role of manipulating anticipated regret to increase intention to donate in people who are not yet registered organ donors. Design: In three experiments involving 621 members of the United Kingdom general public, participants were invited to complete questionnaire measures tapping potential emotional affective attitude barriers such as the “ick” factor, the desire to retain bodily integrity after death, and medical mistrust. Registered posthumous organ donors were compared with nondonors. In Experiments 2 and 3, nondonors were then allocated to a simple anticipated regret manipulation versus a control condition, and the impact on intention to donate was tested. Main Outcome Measures: Self-reported emotional barriers and intention to donate in the future. Results: Traditional rational-cognitive factors such as knowledge, attitude, and subjective norm failed to distinguish donors from nondonors. However, in all three experiments, nondonors scored significantly higher than donors on the emotional “ick” factor and bodily integrity scales. A simple anticipated regret manipulation led to a significant increase in intention to register as an organ donor in future. Conclusions: Negative affective attitudes are thus crucial barriers to people registering as organ donors. A simple anticipated regret manipulation has the potential to significantly increase organ donation rates. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A quasi-experimental investigation of message appeal variations on organ donor registration rates.

Objective: Approximately 6,000 Americans die every year awaiting an organ transplant. Health promotion interventions may alleviate the shortage of viable organs by increasing the number of registered organ donors. This study is the first to evaluate the differential effectiveness of various organ donor messages in naturalistic settings. Design: A 4 (Appeal) × 4 (Exemplar) × 4 (Location) counterbalanced quasi-experimental design was implemented. Main Outcome Measure: The behavioral outcome measure was the number of individuals who registered to be organ donors at computer kiosks. Results: A number of significant main effects and interactions emerged. Most notably, of the 4 different appeals (counterargument, emotional, motivating action, dissonance), counterargument was by far the most efficacious, especially in academic-type settings (library, university, community college); the emotional appeal was most successful in hospitals. Conclusions: The findings from this study have implications for both organ donor investigations and health campaign research in general. Statistical interactions highlight the importance of evaluating multiple exemplars in multiple locations for each type of appeal when conducting health campaign research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A method for estimating solid organ donor potential by organ procurement region

OBJECTIVES: This study sought to develop a methodology for estimating potential solid organ donors and measuring donation performance in a geographic region based on readily available data on the hospitals in that region. METHODS: Medical records were reviewed in a stratified random sample of 89 hospitals from 3 regions to attain a baseline of donor potential. Data on a range of hospital characteristics were collected and tested as predictors of donor potential through the use of hierarchical Poisson regression modeling. RESULTS: Five hospital characteristics predicted donor potential: hospital deaths, hospital Medicare case-mix index, total hospital staffed beds, medical school affiliation, and trauma center certification. Regional estimates were attained by aggregating individual hospital estimates. Confidence intervals for these regional estimates indicated that actual donations represented from 28% to 44% of the potential in the regions studied. CONCLUSIONS: This methodology accurately estimates organ donor potential within 3 geographic regions and lays the foundation for evaluating organ donation effectiveness nationwide. Additional research is needed to test the validity of the model in other geographic regions and to further explore organ donor potential in hospitals with fewer than 50 beds.     

Obstacles to donor eye procurement and their solutions at the University of Iowa

Shortages in transplantable corneas are common, yet little appears in the medical literature about patterns of tissue donation and factors affecting procurement. We have analyzed data on eye donations and taken measures to improve procurement rates based on our findings. Fifty consecutive Cardiovascular Intensive Care Unit (CVICU) deaths were reviewed to compare the number of transplant-eligible donors to the amount of tissue received. An anonymous survey of 250 house staff and nurses was undertaken to identify obstacles to donor eye procurement. Although 12 of 50 potential donors in the CVICU met transplant eligibility criteria, only 1 became a donor. A required request policy notwithstanding, the most common reason for nonprocurement was failure to make a request. According to the survey, the most significant impediments to making the request were (a) not thinking to ask, (b) unfamiliarity with eligibility criteria, (c) unfamiliarity with enucleation procedures, (d) feeling that someone else should make the request, and (e) reluctance to impose on a grieving family. Very few cited religious reasons or being too busy. Education based on the specific concerns listed in the survey was undertaken. During the 12 months after this initiative, the number of transplantable corneas donated from our facility doubled, as compared with the same period in 1992. Despite required request laws and regulations, failure to request tissue donation is common in our facility and may be common elsewhere. Systematic analysis of obstacles to donor eye procurement and their solutions may help to improve our country's performance in this area.     

Intercostal thorascopic harvesting of the internal mammary artery for supercharging a pedicled rectus abdominis flap

This review on non-heartbeating donation focusses on three issues: the number of kidneys procured from a non-heartbeating donor programme, the transplant results and the influence of a non-heartbeating programme on public opinion regarding transplantation.     

Anticipated regret and organ donor registration—A pilot study.

Objective: In this pilot study we tested the influence of manipulating anticipated regret on organ donor registration behavior. Method: A simple web-based experimental trial was conducted. Nonorgan donors were allocated to a simple anticipated regret manipulation versus a theory of planned behavior or a control condition. The main outcome measure was registration on the U.K. organ donor register at 1-month follow-up. Results: A simple anticipated regret manipulation led to a significant increase in organ donor registrations. Conclusion: Interventions utilizing anticipated regret may have the potential to significantly increase organ donation rates. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Knowledge, attitude and reservations of medical students about organ transplantation: results of a survey during the first year of study

AIM: Establish a list of first year medical students' attitudes, doubts, and knowledge in the fields of organ transplantation and donation. METHOD: Anonymized questionnaire handed out to students during class lectures. RESULTS: 183 questionnaires were distributed and 117 returned (participation: 64%). The average age of the students was 21.6 +/- 2.7 years (range 18 to 38 years); the sample included 71 women (60.7%) and 48 men (39.3%). Only 2 students (2%) were not interested in the subject of organ donation. The students knew very little of the legal aspects of organ donation and 1/4 of them thought there was even a Federal law regarding organ transplantation. When asked if they knew whether a law existed in the Canton of Berne, 44% replied yes, but only 24 (20%) knew that this is contradictory. There was no gender difference in the answers to these question. From 57 students (48%) 246 individual comments on doubts and concerns were analyzed. In this respect, the students mainly questioned whether the donor was truly dead when donation took place (n = 48), if illegal transplantation could be eliminated (n = 44) and if transplantation was truly necessary (n = 43). Some also mentioned religious/ethical doubts (n = 42). In regard to organ donation by a living individual, 27 students were concerned about the health of this donor. 20 students had doubts regarding the pressure possibly applied by family members and friends and as many voiced doubts in regard to premature diagnosis of brain death of potential donors. Only 2 students were concerned about the post-mortem presentation. 45 students (48%) indicated discomfort with the donation of certain organs. They ranked the kidney as the first organ to donate, followed by the pancreas, heart, cornea, intestine, lung and liver. CONCLUSION: The interest in organ donation and transplantation is already strong in fist year medical students in the pre-clinical stage. However, differences from lay public are not readably detectable at this stage of medical training. Adequate information could influence future physicians in their mediatory role.     

Comparison of human telomerase RNA and telomerase activity in urine for diagnosis of bladder cancer

Currently the demand for transplant organs far outstrips the supply in the UK. This problem is even more severe for the Asian population, who have been shown to be disproportionately over-represented on transplant waiting lists in some regions of the UK. Several commentators have suggested that religious and cultural traditions may be the major determinant preventing Asians from donating organs. An exploratory qualitative study was undertaken with the aim of examining the influence of religious beliefs, amongst other things, on the extent and direction of public attitudes towards organ donation in a cross-section of the Asian population in Luton. This study indicates that, in the population studied, culture and religion play a much less prohibitive part in determining the level of organ donation than previously suggested. However, there is a desire to be aware of the religious stances so that people can make a more informed decision. The emphasis should clearly been a reconsideration of the presently inadequate approaches to organ procurement and on devising and supplementing these with more appropriate ones. An example of the failure to inform effectively the relevant populations about important developments is that only two of the 32 Muslims in the survey had heard of the 'fatwa' by the Muslim Legislative Council permitting organ donation.