Factors associated with regional disparities for registration on the French national liver transplantation waiting list.

AIM: This study compared the gap between supply and need for liver transplantation among the geographic regions of France. METHODS: Supply was estimated by registration rates on the national waiting list and need by cirrhosis-related death rates. Hierarchical ascendant classification and principal component analysis were applied to identify regional patterns in the gap between supply and need. Associations between socio-ecodemographics and regional healthcare factors were investigated. RESULTS: We have found regional disparities between supply and need, mainly in regions with high rates of cirrhosis-related death. Among the 22 regions studied, six regional patterns were identified. The biggest gap between supply and need was found in regions characterized by the lack of a regional transplantation center or a low density of general and specialized practitioners. These regions were mainly rural or without a city with more than 200,000 inhabitants, and had high proportions of young people and lower social classes. The smallest gap between supply and need was found in regions presenting the opposite patterns. CONCLUSION: These results might be considered by health authorities when planning resource allocation for liver transplantation. Transplantation teams and their networks should strive for better geographical access before registration on the waiting list.

Madreporic coral: a new bone graft substitute for cranial surgery.

Since 1985, the authors have been using madreporic coral fragments (genera Porites) as a bone graft substitute. Of the 167 coral grafts implanted, 150 were coral "corks" used to obliterate burr holes (diameter 10 mm), five were large implants (length 20 to 40 mm) to repair skull defects, and 12 were coral blocks to reconstruct the floor of the anterior cranial fossa. Previous experimental studies suggested that coral grafts would be well tolerated and become partially reossified as the calcific skeleton was resorbed. The authors describe their experience and detail the main biological properties of these materials, which appear to be very promising for use in cranial reconstructive surgery.

The progress of cornea donation and transplantation in France.

PURPOSE: To study the progress of cornea donation and transplantation in France. METHODS: A questionnaire was sent, every year since 1994, to all the heads of ophthalmology departments in public and private hospitals. RESULTS: Response rates of almost 100% were obtained each year. In 1997, 153 hospitals carried out cornea harvesting or transplantation. The number of cornea donations decreased sharply between 1991 (3,774) and 1993 (2,383). Donations then increased slowly to reach 3,591 in 1997 [60 per million population (pmp)]. Cornea-transplantation activity followed the same pattern, decreasing from 3,843 transplants in 1991 to 3,210 (54 pmp) in 1997. In 1997, 73% of cornea transplants took place in 90 public hospitals, and only 27% took place in 28 private hospitals. The number of imported corneas has increased, particularly in 1997, in which 764 corneas were imported (24% of the corneas transplanted). Ninety-two percent of imported corneas were grafted in private hospitals. The estimate of the number of patients registered on local waiting lists increased to 8,303 at the end of 1997. There was a weak correlation between the number of corneas transplanted and the number of patients on local waiting lists by hospital (r = 0.65; p < 0.0001). CONCLUSION: The rate of corneal grafts in France is similar to that in other European countries, but the number of patients on waiting lists is high. Careful thought and effort should be applied to increasing the level of corneal donation and harvesting and reducing waiting lists in France to levels similar to those in other European countries.

A quantitative model of post-laminectomy scar formation. Effects of a nonsteroidal anti-inflammatory drug.

STUDY DESIGN: A quantitative model of peridural post-laminectomy fibrosis in rats was designed in this study. Concurrently, the effects of a nonsteroidal anti-inflammatory drug (ketoprofen) were evaluated. OBJECTIVES: To quantify the amount of fibrotic tissue, the extent of adhesion to the dura mater, and the cell nature and density for drug trials requiring large series of animals. SUMMARY OF BACKGROUND DATA: Most of the previous analyses of experimental post-laminectomy fibrosis were qualitative in nature. Only one quantitative analysis was reported in the rabbit, and the rat has seldom been used. The effects of nonsteroidal anti-inflammatory drugs on post-laminectomy scar formation have never been evaluated. METHODS: L5 laminectomies were performed in 32 rats. The treated group (16 rats) received a systemic injection of ketoprofen (5 mg/kg, once daily from the day before the operation to the seventh postoperative day), the other 16 rats constituted a control group. The post-laminectomy scar formation was evaluated on postoperative days 8, 15, 30, and 90 using a semiautomatic image analysis system. RESULTS: The course of post-laminectomy scar formation was similar to that described in larger animals. There was a good correlation among the measurements of fibrous tissue area obtained by 2 independent observers. The mean amount of peridural scar tissue was significantly smaller in the treated group than in the control group. The extent of adherence to the dura mater and the density of fibroblasts and fibrocytes was not different between the two groups. The density of inflammatory cells was significantly less in the treated group than in the control group only at day 8. CONCLUSION: Quantitative evaluation of post-laminectomy fibrosis can easily be performed in rats and is reproducible. This model could allow trials with drugs administered locally or systemically as preventive treatment of post-laminectomy scar formation. Nonsteroidal anti-inflammatory drugs could decrease the amount of fibrotic tissue.

[The French national waiting list for keratoplasty created in 1999: patient registration, indications, characteristics, and turnover]. / Bilan de la liste nationale d'attente de greffe de cornée française créée en 1999: taux d'inscription, flux, indications et caractéristiques des malades.

PURPOSE: To evaluate the French waiting list and the indications of registered patients, to compare the rates of registration, graft, and procurement between French regions. METHODS: In France, each patient with an indication for penetrating keratoplasty should be registered on the waiting list with his or her clinical characteristics. Those registered during 2000 and 2001 were included in the study. Data on transplantation activity from the waiting list were compared to data collected by a questionnaire on graft and procurement activities completed each year by medical teams. RESULTS: In 2000 and 2001, 6093 and 5505 waiting patients, respectively, were registered. For the same years, 3984 and 3457 keratoplasties were declared for the patients registered, but the questionnaires reported 4514 and 4388 grafts, respectively. The national registration rate was 96 per million population (pmp). The extreme values between regions ranged from 53 to 143 pmp. There was a significant correlation between regional procurement and transplantation rates (r=0.75, p=0.001) but not for registration and procurement rates, and not for registration and transplantation rates. The national registration rate was 27 pmp for pseudophakic and aphakic corneal edema, with extreme values of 12-64 pmp. The national registration rate was 24 pmp for keratoconus (11-37 pmp). A high patient turnover was observed between regions. Among the 11,598 patients registered, the most common indications were pseudophakic and aphakic corneal edema (27.7%), keratoconus (25.3%), and Fuchs'endothelial dystrophy (9.1%). Mean recipient age was 57+/-22 years (0-103 years). Among these patients, 14.1% had already received transplants at least once for the same eye (7.8% for keratoconus, 14.3% for pseudophakic and aphakic corneal edema, and 6.1% for Fuchs'dystrophy). DISCUSSION: Ophthalmologists will be able to register their patients directly on the waiting list, which will improve data quality for transplantation notification. Regional policies should be developed to decrease the inequalities of graft shortages between regions.

[Trends and estimates of regional differences of cornea donation and transplantation in France (1991-1998)]. / Evolution et estimation des disparités régionales des activités de prélèvement et de greffe de cornée en France (1991-1998).

PURPOSE: To evaluate national trends of corneal procurement and transplantation, and to estimate regional disparities between the rates of transplantation and patients registered on local waiting lists. METHODS: A questionnaire was sent, every year since 1994, to all the heads of ophthalmology departments in public and private hospitals. RESULTS: After a dramatic decrease in 1992, donations and transplantations then increased to reach 4549 and 4053 in 1998. This increase was mainly observed for cornea retrieval from non heart beating donors in public hospitals. Since 1997, the number of imported corneas has increased, 1016 corneas were imported in 1998 (25% of the corneas transplanted). The estimate of the number of patients registered on local waiting lists decreased to 7400 at the end of 1998. Regional agreement, using the ratio of the number of patients registered on waiting list at the end of 1998 and the number of cornea harvested in 1998 was low for several French regions: Aquitaine, Champagne-Ardenne, Nord-Pas-de-Calais, Picardie, Ile-de-France, Rhône-Alpes, Antilles. CONCLUSION: Careful thought and regional efforts pointed at non-heart beating donors should be applied to increase the level of corneal harvesting, and to reduce waiting lists in France to levels similar to those in other European countries. Recent issue of legal authorization of cornea banking and creation in october 1999 of a national waiting list should facilitate these efforts.

[Isolated traumatic dislocation of the extensor carpi ulnaris tendon]. / Luxation traumatique isolée du tendon cubital postérieur.

The authors describe one case of post-traumatic dislocation of the extensor carpi ulnaris tendon. They found eleven other cases reported in the literature. The type of lesion should be looked for in cases of trauma to the wrist without a bony lesion. The treatment should be surgical when function is impaired, either shortly after the initial trauma or if the dislocation becomes habitual. The aim is to reconstruct a tendon sheath. The results were generally satisfactory.

[Coral: a new procedure for cranio-facial reconstruction]. / Le corail: un nouveau procédé de reconstruction cranio-faciale.

Twenty two cranio-facial reconstructions were performed utilizing madreporic coral graft, genera porites. Long-term tolerance was excellent. Surgical technique is described and coral properties are analyzed. Coral grafts used for anterior skull base reconstruction were partly reossified without any infectious complication.

[Use of Knodt's equipment for spinal osteosynthesis in emergency laminectomy for spinal cord compression]. / Utilisation du matériel de Knodt pour ostéosynthèse rachidienne lors de laminectomies effectuées en urgence pour compression médullaire.

The authors report on spinal posterior synthesis using Knodt 's instrumentation in compression. This technic has been applied in case of spinal instability , when a laminectomy has been achieved in emergency for epidural medullary compression. The technic is reported and qualities are discussed on the bases of the first ten cases.

[Reconstruction of the anterior face of the base of the skull using coral grafts]. / Reconstruction de l'étage antérieur de la base du crâne à l'aide de greffons de corail.

Following experimental investigations on animals, small coral grafts have been utilized on patients since 1985 to fill in burr holes (42 patients). This first clinical experimental step has been satisfactory. Therefore, blocks of corals have since then been used as bone graft substitutes for anterior skull basis reconstruction (12 patients). Cheap and easily sterilized, coral implants have the advantage of being inert (99% of calcium carbonate), biodegradable and well reossified. They shorten surgical procedures by avoiding the use of iliac and/or costal grafts. No infectious complications have been noted.

[Tissue grafts: an activity concerning many patients]. / Les greffes de tissus: une activité concernant de nombreux patients.

Tissue allografts mainly include corneas, bone (and cartilage, tendon, ligament, aponevrosis), skin, vessels and cardiac valves. All these grafts have been widely used for many years and were the subject of a large number of experimental and clinical studies. The different steps allowing the obtention of different tissue allografts have in fact a common organization through tissue procurement and banking activities. Tissue banks have a central situation ensuring security, safety, traceability and distribution of tissues. Appropriate organization of the banks, and respect of high level standards are thus mandatory. Tissue transplantation activity in France has been studied through national surveys: they concern more than 600 hospitals and clinics, and grafts procured in France (excluding imported allografts) are around 15,000 a year. Precise regulation implied by the bioethical law published in 1994 and homogeneous organization of the activity allow the use of stringent and regularly updated standards, allowing the distribution to the patients of safe grafts procured in ethical conditions. The actual shortage of tissue allografts in France implies increasing procurement through a better organization of retrieval in hospitals and clinics and donation promotion.

European quality system for tissue banking.

AIM: The aims of this project were to analyze the factors that influence quality and safety of tissues for transplantation and to develop the method to ensure standards of quality and safety in relation to tissue banking as demanded by European Directive 2004/23/EC and its technical annexes. It is organized in 4 Working Groups, the objectives of each one being focused in a specific area. STANDARDS: The Guide of Recommendations for Tissue Banking is structured into 4 parts: (1) quality systems that apply to tissue banking and general quality system requirements, (2) regulatory framework in Europe, (3) standards available, and (4) recommendations of the fundamental quality and safety keypoints. REGISTRY: This Working Group handled design of a multinational musculoskeletal tissue registry prototype. TRAINING: This Working Group handled design and validation of a specialized training model structured into online and face-to-face courses. The model was improved with suggestions from students, and 100% certification was obtained. AUDIT: The Guide for Auditing Tissue Establishments provides guidance for auditors, a self-assessment questionnaire, and an audit report form. The effectiveness and sustainability of the outputs were assessed. Both guides are useful for experienced tissue establishments and auditors and also for professionals that are starting in the field. The registry prototype proves it is possible to exchange tissues between establishments throughout Europe. The training model has been effective in educating staff and means having professionals with excellent expertise. Member states could adapt/adopt it. The guides should be updated periodically and perhaps a European organization should take responsibility for this and even create a body of auditors.

[Corneal graft activity in France (1990-2005): decreasing the gap between supply and demand]. / Activité de greffe de cornée en France (1990-2005): vers une stabilisation de la demande et de l'offre.

OBJECTIVE: To evaluate changes in the balance between supply and demand for corneal grafts over the last 15 years in France in the light of the measures implemented and the 2005 national and regional audit. MATERIALS AND METHODS: Corneal transplantation activities were estimated, mainly from a national prospective survey of ophthalmologists (1991-1994), annual surveys of ophthalmologists (1995-2000), tissue banks (1996-2005), and the national waiting list for surgery (since 2000). RESULTS: In 2005, the main indicators available were consistent with a stabilization in the number of candidates added to the waiting list every year (4606 in 2005), accompanied by a large increase in the number of grafts procured (9264 in 2005). There was also a substantial increase in quality testing of these grafts, leading to a high rate of rejection (49.5% of the procured grafts). In addition, the number of grafts exported decreased to a very low level (213 in 2005). The percentage of malades registered on the waiting list who received grafts in the same year also increased (68.5% in 2005). Once the waiting list had been updated, 3016 malades remained on the list at the beginning of July 2006. The gap between supply and demand for corneal transplantation has therefore narrowed. Two actions made particularly large contributions to these changes: the creation in 2000 of 120 full-time staff positions in hospital coordination teams, which has had a major impact on procurement rates; and the organization of the tissue bank sector, making it possible to guarantee the quality and distribution of grafts. CONCLUSION: Corneal procurement and transplantation activities seem to have reached equilibrium in France. A reliable estimation of demand, particularly at the regional level, has led the French agency in charge of tissue transplantation to modify the functioning of the national corneal transplant waiting list, with tissue banks now allowed access to declare transfers and the temporary registration of malades on the list to limit stagnation.

Infection in massive bone allografts sterilised by radiation.

Massive bone allografts sterilised by radiation have been used in our hospital since 1985. The 164 consecutive reconstructions which we carried out before December 1990 were in equal part for tumour resections and revision arthroplasties associated with major bone defects. The allografts were used as intercalary or composite graft-prosthesis reconstructions. Fourteen (8.5%) skin sloughs or infections occurred, all but one after operations for malignant tumours. The grafts never appeared to be responsible. Infection after malignant tumour resection most commonly occurred at the knee when preoperative radiation had been used. Twenty-five reconstructions were performed in the presence of infection, which only recurred in one case. Twelve infections were treated, but 2 other patients died for other reasons within a year. One patient had to have an amputation and one had persistent infection. In the other cases, the infection healed. Only two debridements alone were successful. Removal of the graft and replacement with antibiotic-loaded cement was the most effective treatment.

Bone allografts sterilised by irradiation. Biological properties, procurement and results of 150 massive allografts.

Massive bone allografts from cadavers have been sterilised by gamma-radiation from radioactive cobalt at a dose of 25,000 gray (Gy). The biological effects of radiation are discussed. Human cortical bone showed an acceptable 20% decrease in strength on bending tests after 27,000 Gy irradiation, but higher doses are more damaging and should be avoided. The procurement protocol used at the Cochin Hospital is described, and the importance of dosimetry and record-keeping emphasised. The clinical results of 150 massive bone allografts are reported. The infection rate was low. The evolution of the graft in each type of reconstruction is analysed and appears to be comparable to nonirradiated allografts. Very few complications occurred after composite reconstructions in the lower limb. Pelvic reconstructions had the highest complication rate, but most were not related to the use of the allograft.