Relationship between procalcitonin values and infection in brain-dead organ donors.

BACKGROUND AND AIMS: An association between the inflammatory reactions estimated by several biomarkers and organ dysfunction has been reported in brain-dead organ donors (BDOD). Procalcitonin (PCT), a biomarker of inflammation due to bacterial infection, is increased among BDOD. However, is not known whether infection changes PCT values in BDOD. MATERIALS AND METHODS: We retrospectively analyzed 82 BDOD including several demographic and clinical parameters, bacterial culture results, antibiotics prescription, and plasma values of PCT measured before organ harvesting. Infection was diagnosed to be either a positive bacterial culture (restricted definition) and/or prescription of antibiotics (extended definition). RESULTS: The median PCT value was 1.5 (interquartile range [IQR], 0.4 to 6.9; range, 0 to 526 ng/mL; n=82). Thirty-eight (46%) and 24 (29%) patients had PCT values>2 ng/mL and >5 ng/mL, respectively. Median PCT values among infected (1.18; IQR, 0.27 to 6.55 ng/mL) versus noninfected (1.57; IQR, 0.53 to 7.15 ng/mL) BDOD (restricted definition) were not different (P=.36). The area under the receiver operating characteristic curve using PCT to predict infection (restricted definition) was 0.52. Specificity of PCT to predict infection was above 80% at PCT values>9 ng/mL. CONCLUSION: Our results confirmed PCT values are increased in BDOD, suggesting that this was not related to an infectious cause (whatever definition was used) unless PCT values are high.

Transplantation in Waldenstrom's macroglobulinemia--the French experience.

Published data on transplantation in Waldenstrom's macroglobulinemia (WM) are still limited. We present a retrospective multicentric study of 27 WM patients who underwent 19 autologous (median age, 54 years) and 10 allogeneic (median age, 46 years) transplantations. Median time between diagnosis and transplantation was 36 months; 66% of patients had received three or more treatment lines and 72 % had chemosensitive disease. High-dose therapy (HDT) and autologous transplantation induced a 95% response rate (RR), including 10 major responses. With a median follow-up of 18 months, 12 patients are alive at 10 to 81 months and eight are free of disease progression at 10 to 34 months. The toxic mortality rate (TRM) was 6%. Allogeneic transplantation was preceded by HDT in nine patients and by a nonmyeloablative regimen in one patient. The RR was 80%, including seven major responses. With a median follow-up of 20.5 months, six patients are alive and free of progression at 3 to 76 months. Four patients died, all from toxicity, resulting in a TRM of 40%. HDT followed by autologous transplantation is feasible in WM, even in heavily pretreated patients, with some prolonged responses but a high relapse rate. Conversely, allogeneic transplantation is more toxic, but likely induces a graft-versus-WM effect and may, for some patients, result in long-term disease control.

Oscillatory interaction between dorsal root excitability and dorsal root potentials in the spinal cord of the turtle.

The response to dorsal root stimulation, at one to two times threshold, was investigated in the isolated cervical enlargement of the turtle spinal cord. At frequencies near 10 Hz the synaptic response in motoneurons and the cord dorsum potential, after an initial lag time, oscillated in amplitude with a period of more than 1 s. The mono- and polysynaptyic postsynaptic response in motoneurons, the pre- and postsynaptic component of the cord dorsum potential and the dorsal root potential oscillated in synchrony. These oscillations were only observed with stimulus frequencies in the range 9-11 Hz. The oscillating response could only be evoked from stimulus sites to which dorsal root potentials were conducted from the spinal cord (2-3 mm). At more distant stimulus sites cyclic variations in amplitude of the cord dorsum potential and the synaptic response in motoneurons were not observed. During an oscillating spinal response to a stimulus train in one dorsal root filament, the response evoked by a stimulus in another short filament (2-3 mm) from the same root varied in amplitude with the induced oscillation. The spinal response to a stimulus in a longer filament (i.e. more than 3 mm) did not oscillate. It is argued that the oscillating responses described rely on interactions between distributed elements rather than on unit oscillators. We also show that primary afferent transmission is unaffected by the substantial variations in dorsal root potentials during oscillations.

Short-latency synaptic patterns among cat peroneal motoneurons.

Motoneurons innervating peroneal muscles in the cat leg (PB, PT and PL, respectively, for peroneus brevis, tertius and longus) were examined for their connections with afferents from these and other leg muscles and with cutaneous afferents. The aim was to investigate (1) whether inputs from nearby muscles and cutaneous areas are likely to assist or oppose the excitation elicited in peroneal motoneurons by PB contractions, and (2) whether reflex connectivity might allow distinction of alpha (i.e. motoneurons innervating skeletal muscle fibres) and beta (i.e. motoneurons innervating both skeletal and intrafusal muscle fibres) subgroups among PB and PT motoneurons. In the three peroneal pools, every motoneuron had excitatory monosynaptic connections with Ia afferents from each of the three peroneal muscles, and nearly every motoneuron received di- or trisynaptic excitation from low-threshold cutaneous afferents in sural or superficial peroneal nerves. Inputs from these sources might facilitate the contraction-induced positive feedback. In contrast, the patterns of short-latency synaptic connections with group I afferents from pretibial flexor and post-tibial extensor muscles were heterogeneous among peroneal motoneurons but did not point to any specific beta pattern.

Development and regulation of response properties in spinal cord motoneurons.

The intrinsic response properties of spinal motoneurons determine how converging premotor neuronal input is translated into the final motor command transmitted to muscles. From the patchy data available it seems that these properties and their underlying currents are highly conserved in terrestrial vertebrates in terms of both phylogeny and ontogeny. Spinal motoneurons in adults are remarkably similar in many respects ranging from the resting membrane potential to pacemaker properties. Apart from the axolotls, spinal motoneurons from all species investigated have latent intrinsic response properties mediated by L-type Ca2+ channels. This mature phenotype is reached gradually during development through phases in which A-type potassium channels and T-type calcium channels are transiently expressed. The intrinsic response properties of mature spinal motoneurons are subject to short-term adjustments via metabotropic synaptic regulation of the properties of voltage-sensitive ion channels. Recent findings also suggest that regulation of channel expression may contribute to long-term changes in intrinsic response properties of motoneurons.

Evaluation of donor cardiac function for heart transplantation: experience of a French academic hospital.

OBJECTIVES: The diagnostic and therapeutic approaches for evaluation and management of cardiac function in brain-dead patients vary from country to country. The aim of the present study was to describe the results of the evaluation of brain-dead patients as potential cardiac donors in a French teaching hospital that manages the largest number of brain-dead patients in France. METHODS: Demographic parameters, the causes of brain death, clinical evolution, hemodynamic parameters, doses of inotropic and/or vasopressive drugs, the results of echocardiographic examination, and several biochemical markers of myocardial cell injury were retrospectively collected. RESULTS: Seventy-one consecutive brain-dead patients admitted to the intensive care unit of the Academic Hospital of Nancy from October 1st, 1998 to September 30, 1999 were analyzed. Twenty-nine patients were considered as potential heart donors: 22 males and 7 females aged 33 +/- 3 years (Mean + SEM). The cause of brain death was head trauma in 17 cases (59%), cerebrovascular disease in 10 cases (34%), and cerebral anoxia related to cardiac arrest in 2 cases (7%). Eighteen hearts (18/29 or 66%) were harvested and transplanted with a favorable outcome at one month in 17 cases. In 11 cases, the heart was not harvested, nine (9/29 or 31%) because of myocardial dysfunction upon subsequent echocardiographic examination and 2 because of the lack of matched recipients. CONCLUSION: Comparison of these results with those of other groups suggests that hormonal substitution with insulin and triiodothyronine in the presence of myocardial dysfunction could be of potential interest to correct myocardial dysfunction and increase the number of donor hearts.

[Can the quality of renal grafts be judged on basis of the organ donors?]. / Peut-on juger de la qualité du greffon rénal à partir du donneur d'organes?

The aim of this study is to find brain dead organ donor parameters able to predict the functional value of a kidney graft after transplantation. It is a retrospective, multicenter study, set in the east of France (Besançon, Nancy, Reims, Strasbourg). All donors harvested over an 18 month period (n = 169), and kidney grafts transplanted in a recipient in the same region (n = 298) are studied. Recipients from another region receiving a kidney graft as well as kidney grafts transplanted in other regions are not studied. Parameters studied in the donor are: age, sex, etiology of brain death, vascular disease, hemodynamic stability, use of epinephrine, diuresis, creatinine level, graft preservation solution. Parameters studied in the recipient are: age, sex, first transplantation or not, cold ischemia duration, warm ischemia duration, early post-transplantation diuresis and creatinine level evolution, dialysis requirement, immunosuppression, creatinine level at 1, 6 and 12 month. During the early post transplantation period, 264 recipients recovered diuresis, and the creatinine level felt in 246 cases. 31 patients required dialysis. 12 months after transplantation, 128 patients had a normal graft function (creatinine level < 15 mg/l). No parameter in the donor was found able to predict kidney graft function after transplantation. In fact, it is the amount of several risk factors due to donor data, organ retrieval and preservation, and kidney transplantation which is responsible for the early graft function. This points out the importance of being very careful when there is already a risk factor due to old age or vascular disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemorrhagic delivery in a full-term abdominal pregnancy with a live infant]. / Délivrance hémorragique lors d'une grossesse abdominale à terme avec enfant vivant.

This is a new case report of a primary abdominal pregnancy with a full-term live baby in a 26 yr old women. The diagnosis was only made at laparotomy. The premature placental separation was followed by massive haemorrhage. Over a period of five days, the patient required a transfusion of 139 blood units and nine surgical explorations before control of the bleeding site could be obtained. Control of the haemorrhage could only be obtained with massive transfusions of fresh platelets and biological monitoring of coagulation by specialized laboratories. This case confirmed the diagnostic difficulties and the need to leave the placenta in situ until control of bleeding sites can be obtained.

[Value of hormonal treatment with triiodothyronine and cortisone in brain dead patients]. / Intérêt de l'hormonothérapie associant triiodothyronine et cortisone chez le patient en état de mort cérébrale.

Brain death leads to substantial falls in the plasma levels of cortisol and tri-iodothyronine (T3). These alterations may be responsible for physiological instability in these patients, and impairment in donor organ function. A double-blind study was therefore designed to assess the possible improvement in metabolism and haemodynamic stability in brain-dead organ donors treated with T3 and cortisone. Forty adult brain-dead patients were randomly assigned to two groups, the patients of the treated group were given every hour, or half hour, 2 or 4 micrograms T3 and 100 mg hydrocortisone intravenously, and those of the placebo group normal saline. Both groups of patients received conventional management for brain-dead donors. The main assessment criterion was the haemodynamic course, appreciated by the Pasys, the CVP and the needs in dobutamine; the secondary criterion was the start, or worsening, of a metabolic acidosis, as judged by the pH, the level of arterial bicarbonate, and the needs in sodium bicarbonate. The two groups were comparable for age, sex, aetiology of brain death, the delay between brain death and the start of the experimental protocol, and the duration of this protocol. There were differences between the two groups, which were not statistically significant: improvement in haemodynamic profile (hormone group 9/20 versus placebo group 10/20); worsening in haemodynamic profile (2/20 vs 4/20); increased requirements in dobutamine (2/20 vs 4/20); decreased requirements in inotropic support (15/20 vs 13/20); mean dose of dobutamine (3.1 +/- 4.2 micrograms.kg-1 vs 2.5 +/- 3.8 micrograms.kg-1); metabolic acidosis (5/20 vs 5/20); mean bicarbonate dose (30.0 +/- 67.7 mmol vs 45.0 +/- 74.2 mmol); donors harvested (20/20 vs 18/20).(ABSTRACT TRUNCATED AT 250 WORDS)

[Measurement of cardiac output by thoracic electrical bioimpedance or thermodilution]. / Mesure du débit cardiaque par bioimpédance électrique thoracique ou par thermodilution.

The present study was designed to assess a new non invasive method for measuring cardiac output. The thoracic electrical bioimpedance method was compared with the reference one, thermodilution. The measurements were made simultaneously with NCCOM3 (bioimpedance) using the freeze data mode, and with a Swan-Ganz catheter and a haemodynamic computer (thermodilution). The study involved 11 spontaneously breathing patients in a steady haemodynamic state. Ten measurements were carried out with both methods for each patient. Statistical analysis of the 110 paired values was carried out by computer. The various statistical tests applied confirmed that there was a highly significant correlation between values for cardiac output obtained by each of these two methods (r = 0.818; p less than 0.005); they also showed a significantly more important dispersion of the measures for each patient with thermodilution. The mean value of the thermodilution "standard deviation" (0.64 l.min-1) was significantly more important (p less than 0.005) than the one with NCCOM3 (0.24 l.min-1). Thoracic electrical bioimpedance appeared a safe method for measuring cardiac output, providing the limits of the method are kept. The objective is not to replace the Swan-Ganz catheter, but to propose an alternative method for measuring cardiac output. This method is very interesting in many circumstances, particularly for intensive care patients: it is a non invasive technique, continual measurement is not time-limited, and its use is very easy.

[Development of antifactor VIII circulating anticoagulant after surgery of the biliary tract]. / Apparition d'un anticoagulant circulant antifacteur VIII après chirurgie de la voie biliare.

In a 25-year-old woman, admitted with a haemorrhagic syndrome following biliary surgery, an inhibitor of factor VIII was detected. As bleeding was major, she was re-operated on under perioperative administration of the anti-inhibitory coagulant complex Autoplex-T, associated with polyvalent i.v. immunoglobulins. The other therapeutic agents are also considered and their indications discussed, after a review of the circumstances of the diagnosis of this disease.

[Pneumonia, disseminated intravascular coagulation and colonic hematoma]. / Pneumopathie, coagulation intravasculaire disséminée et hématome colique.

A case of pneumopathy associated with a colonic haematoma and a disseminated intravascular coagulation is reported. No bacteriological or serological evidence of the infection could be found. The rarity of such a pathological association made this case particularly interesting.

[Analysis of the criteria that contribute to the decision to harvest the heart in brain-dead organ donors]. / Analyse des critères qui participent à la décision de prélèvement cardiaque chez les patients en état de mort encéphalique.

OBJECTIVES: The number of cardiac transplantation procedures does not increase because of the lack of donor hearts despite an increase in the number of brain-dead organ donors. The criteria used to select a donor heart are not formally standardized. The aim of the present study was to analyze the criteria that contribute to the selection of a donor heart. TYPE OF STUDY: Descriptive, retrospective study. PATIENTS AND METHOD: Clinical parameters, the initial causes that lead to brain death, maximum doses of catecholamines, several biochemical markers of myocardial ischaemia/necrosis as well as several echocardiography criteria were extracted from a prospectively collected database. Univariate and multivariate (logistic regression) analyses were performed with the "harvested heart" as dependent variable and the above-cited independent variables. RESULTS: One hundred and eighty consecutive brain-dead patients admitted from 1st October 1998 to 31st December 2000 out of which 112 gave at least one organ were analyzed. Among these 112 patients, 59 (39 males and 20 females) were pre-selected as potential heart donors. Only 44 hearts were harvested. Logistic regression analysis showed that harvesting of the heart was more probable if the donor were a male, had no left ventricle systolic wall motion abnormalities, had low doses of norepinephrine and low serum troponin Ic concentrations. CONCLUSION: After an initial phase of selection, the final decision to harvest a heart is based on several criteria. These results should be an incentive to conceive a score that could allow a more formal decision process for heart harvesting.

Serum troponin Ic values in organ donors are related to donor myocardial dysfunction but not to graft dysfunction or rejection in the recipients.

BACKGROUND: Increased plasma cardiac troponin I (cTnI) values in heart donors are associated with donor myocardial dysfunction and increased risk of rejection in the recipients. We investigated the association between cTnI values and myocardial dysfunction in potential heart donors and the relationship between donors' cTnI values and recipients' early myocardial function and 1 year survival and risk of rejection. METHODS: cTnI was measured in 159 consecutive potential heart donors. Myocardial function was estimated by the left ventricular ejection fraction (LVEF) and segmental wall motion abnormalities (SWMA). Results are mean+/-SD (range) or median (interquartile range). RESULTS: cTnI values in potential donors were 2.1+/-5 ng/ml (0-40.4 ng/ml); cTnI values were significantly (P<0.001) higher: 4.2+/-5.9 ng/ml (0-30.6 ng/ml) for potential donors with LVEF <50% versus LVEF >50%: 1.7+/-4.7 ng/ml (0-40.4 ng/ml). cTnI values were significantly lower for donors without SWMA. cTnI values were significantly (P<0.001) lower for the 90 donors whose hearts were harvested: 1.1+/-2.3 ng/ml (0-15.6 ng/ml) versus the not harvested: 3.6+/-6.9 ng/ml (0-40.4 ng/ml). There were 87 recipients followed for 1 year. Donors' cTnI values were not associated with early alteration of LVEF, incidence of rejection or 1 year recipients' survival. CONCLUSION: Increased cTnI values in potential heart donors are statistically associated with myocardial dysfunction and could be helpful for organ selection. In contrast, cTnI values in heart donors were not associated with graft dysfunction or recipient survival after transplantation.

Sequential measurements of troponin Ic values in brain-dead patients considered as potential heart donors.

It was suggested that a single value of normal or increased plasma cardiac troponin T or I (cTnT or cTnI) concentration could contribute to estimate donor myocardial damage and function in brain-dead patients. In patients with acute coronary syndromes, an initial normal value of troponin must be confirmed several hours later but no such recommendations exist for brain-dead patients. We investigated the relationship between two sequential (6 h interval) measurements of plasma cTnI concentrations in brain-dead patients considered as potential heart donors. The first and the second TnIc values were correlated with an adjusted r2 value of 0.92 (p<0.001). Our results suggest therefore that it is not necessary to repeat the measurements, when the value of plasma cTnI concentration is taken into consideration in the algorithm for cardiac harvesting.