Stepwise development and expansion of an abdominal normothermic regional perfusion program for donation after circulatory determination of death organ procurement.

INTRODUCTION: Normothermic regional perfusion (NRP) represents an innovative technology that improves the outcomes for liver and kidney recipients of donation after circulatory determination of death (DCD) organs but protocols for abdominal-only NRP (A-NRP) DCD are lacking in the US. METHODS: We describe the implementation and expansion strategies of a transplant-center-based A-NRP DCD program that has grown in volume, geographical reach, and donor acceptance parameters, presented as four eras. RESULTS: In the implementation era, two donors were attempted, and one liver graft was transplanted. In the local expansion era, 33% of attempted donors resulted in transplantation and 42% of liver grafts from donors who died within the functional warm ischemic time (fWIT) limit were transplanted. In the Regional Expansion era, 25% of attempted donors resulted in transplantation and 50% of liver grafts from donors who died within the fWIT limit were transplanted. In the Donor Acceptance Expansion era, 46% of attempted donors resulted in transplantation and 72% of liver grafts from donors who died within the fWIT limit were transplanted. Eight discarded grafts demonstrated a potential opportunity for utilization. CONCLUSION: The stepwise approach to building an A-NRP program described here can serve as a model for other transplant centers.

The American Society of Transplant Surgeons Consensus Statement on Normothermic Regional Perfusion.

On June 3, 2023, the American Society of Transplant Surgeons convened a meeting in San Diego, California to (1) develop a consensus statement with supporting data on the ethical tenets of thoracoabdominal normothermic regional perfusion (NRP) and abdominal NRP; (2) provide guidelines for the standards of practice that should govern thoracoabdominal NRP and abdominal NRP; and (3) develop and implement a central database for the collection of NRP donor and recipient data in the United States. National and international leaders in the fields of neuroscience, transplantation, critical care, NRP, Organ Procurement Organizations, transplant centers, and donor families participated. The conference was designed to focus on the controversial issues of neurological flow and function in donation after circulatory death donors during NRP and propose technical standards necessary to ensure that this procedure is performed safely and effectively. This article discusses major topics and conclusions addressed at the meeting.

Radiographic age estimation based on degenerative changes of vertebrae.

Age estimation is an important component of decedent identification. When assessing adult remains, anthropologists frequently use gross examination of skeletal elements, such as clavicles, ribs, and pubic symphyses. For fleshed bodies, this requires the removal of these elements and maceration prior to analysis. A new method was developed using radiographic imaging to estimate age from degenerative changes of the lower thoracic and upper lumbar vertebrae. This technique will complement anthropological age estimation methods in young and middle-aged adults and may serve as a stand-alone method for older individuals. Digital radiographs from 240 medical examiner cases were evaluated. The sample included 120 females and 120 males between the ages of 18 and 101 years. A 3-phased scoring system was used for the target vertebrae. Transition analysis was conducted on binned average scores and a Bayesian approach was used to assign age intervals. At the 90% credible interval, individuals in Bin 1 were under 36 years of age while those in Bin 3 were over 47 years of age. Individuals in Bin 2 showed too much age variation to be informative. No significant differences were found between males and females. These findings will be especially useful in the age estimation of older adults and may eliminate the need for skeletal sampling in medicolegal cases where advanced degenerative changes are radiographically observed in the lower thoracic and/or upper lumbar vertebrae. This method was developed for use on fleshed individuals but may also be applicable to skeletonized remains.

Maximizing the use of potential donors through increased rates of family approach for authorization.

In the United States, a small proportion of potential deceased organ donor referrals lead to donation and recovery. Understanding variation in the processes involved between organ procurement organizations (OPOs) may help increase deceased donation and reduce the organ shortage. We studied 103 923 referrals from 10 OPOs from 2018 to 2019, of which 14.4% led to approach for authorization, 8.2% led to authorization, 5.1% led to organ recovery, and 4.8% led to transplantation. First-person authorization (FPA) was associated with threefold higher odds of donation (OR = 2.83 3.02 3.22 , p < .001). Female referrals had 11% lower odds of approach; when approached, Black and Hispanic referrals had 46% and 35% lower odds of authorization, respectively (all p < .001). There was substantial OPO-level variation in rates of approach, authorization, and organ recovery, which persisted after adjusting for age, sex, race, and FPA status. An OPO's relative rate of approach correlated strongly with its relative rate of donation among all referrals (ρ = 0.43). Correlation between an individual OPO's authorization rate among approached families, and overall rate of donation, was negative, suggesting that high authorization rates may be the result of selective approach practices. Therefore, approaching a higher proportion of families for authorization may lead to higher donation rates.

Victim identification from the September 11, 2001 attack on the World Trade Center: Past trends and future projections.

Victim identification following mass fatality events is critically important. Extensive traumatic injuries and body fragmentation add complexity to this process. World Trade Center (WTC) identification efforts have been ongoing for over 20 years and this study tracks identification trends from the 2753 known WTC victims and the 21,905 recovered remains. For identified victims, data include the number of remains identified, date(s) of the identification(s), and identification modalities. Results show a heavy reliance on DNA due to body fragmentation. Other modalities played an important role initially, but DNA eventually became the singular identification modality. For large-scale disasters involving significant body fragmentation, aggressive DNA testing strategies are critical for victim identification. Over time, the number of linked remains (portions of previously identified individuals) will greatly outnumber the new identifications (first-time identifications). A novel approach using statistical modeling from ecology studies was applied to estimate future WTC identification rates using Identification Accumulation Curve extrapolation with the Good-Toulmin estimator. Projections indicate there will be 76 first-time identifications (95% CI: 49-117) through the successful DNA testing of 3404 unidentified, fragmentary remains. The remainder of the identifications would be additional portions of previously identified victims. These results may be instructional for management of other large-scale, protracted victim identification efforts.

Victim identification and body completeness based on last known location at the World Trade Center.

This analysis focuses on the identification efforts conducted by the New York City Office of Chief Medical Examiner (NYC OCME) over a 20-year period from September 11, 2001 to September 11, 2021. Due to this unprecedented level of commitment to victim identification, a wealth of data has been collected over the two-decade period and is still being collected as identification efforts are ongoing. The results of this data analysis are not only informative for the World Trade Center (WTC) victims, but may also be instructional for other large-scale, protracted victim identification efforts. Based on available data, most victims are associated with the impact zones and higher in both towers. No correlation was observed in the overall identification rates based on last known location in the buildings, suggesting that location in the towers does not affect the likelihood of a successful identification. There was, however, a significant difference in the body completeness values observed for victims from the upper floors compared to those below the impact zones. The identification rates and body completeness values for victims onboard the two airplanes are significantly different from each other, possibly related to the varying aircraft speeds at the time of impact.

cDCDD-NRP is consistent with US legal standards for determining death.

Donation after circulatory determination of death (DCDD) has increased organ donation rates in the US over the past decade within an established legal framework, which is consistent with and supports individual and family decisions regarding organ donation in the context of end-of-life care. A new application, controlled DCDD donation utilizing thoracoabdominal normothermic regional perfusion (NRP) protocols (cDCDD-NRP), provides the opportunity to maximize a donation decision by recovering additional organs for transplant, including the heart, and to limit the detrimental impact of warm ischemic time by perfusing organs in situ following the declaration of circulatory death. In this viewpoint, we narrate our rationale for why cDCDD-NRP is consistent within the existing legal framework for organ donation in the United States and recommend no changes to the Uniform Determination of Death Act.

Short Report: Evaluating the Effects of Automated Donor Referral Technology on Deceased Donor Referrals.

Automation of deceased donor referrals with standardized clinical triggers allows organ procurement organizations to be rapidly aware of medically eligible potential donors without the need for manual reporting and subjective decision-making of otherwise very busy hospital staff. In October 2018, 3 Texas hospitals (pilot hospitals) began using an automated referral system; our goal was to evaluate the impact of this system on eligible donor referral. Methods: We studied ventilated referrals (n = 28 034) in a single organ procurement organization from January 2015 to March 2021. We estimated the change in referral rate in the 3 pilot hospitals due to the automated referral system using a difference-in-differences analysis with Poisson regression. Results: Ventilated referrals from the pilot hospitals increased from mean 11.7 per month pre-October 2018 to 26.7 per month post-October 2018. The difference-in-differences analysis estimated that automated referral was associated with a 45% increase in referrals (adjusted incidence rate ratio [aIRR] = 1.30 1.45 1.62), an 83% increase in approaches for authorization (aIRR = 1.34 1.83 2.48), a 73% increase in authorizations (aIRR = 1.18 1.73 2.55), and a 92% increase in organ donors (aIRR = 1.13 1.92 3.09). Conclusions: Following deployment of an automated referral system that did not require any actions by the referring hospital, referrals, authorizations, and organ donors increased substantially in the 3 pilot hospitals. Broader deployment of automated referral systems may lead to increases in the deceased donor pool.

Evidence for nonlinear reflections in shock-containing noise near high-performance military aircraft.

Skewness values for the pressure time derivative are greater at ground-based measurements near a tactical aircraft than they are at nearby off-ground locations. A possible explanation for this phenomenon is the occurrence of nonlinear, irregular shock reflections at the ground. Propagation angle, source location, and corresponding angle of incidence relative to the ground are estimated using a two-point cross correlation of windowed shock events. Nonlinear reflections are likely to occur based on the combination of angles of incidence and measured shock strengths and cause a pressure increase at the shock that is greater than twice the free-field pressure. The associated pressure increase at the shocks appears to enhance shock-related metrics at the ground compared to off-ground locations.

Fascia lata attachment at the iliac crest: refining our diagnostic criteria of injury on magnetic resonance imaging.

OBJECTIVE: The objective of this study was to determine the prevalence and spectrum of pathology of the fascia lata attachment at the iliac crest (FLAIC) on MRI in asymptomatic patients in order to refine our diagnostic criteria for clinically relevant FLAIC injury. METHODS AND MATERIAL: Two readers retrospectively evaluated the FLAIC on each side on coronal large field-of-view short tau inversion recovery images on 100 musculoskeletal pelvic MRI exams performed in patients without hip pain (total n = 200). Pathology of the FLAIC was graded using a 3-point Likert scale and discrepancies were resolved by consensus. RESULTS: Of the 200 FLAIC included in the study, 72.5% demonstrated normal size and signal intensity. Low to moderate grade pathology of the FLAIC was identified in 27% and high-grade partial thickness pathology was seen in 0.5%. No cases of complete FLAIC rupture were identified. Inter rater agreement between the two readers was good (k=0.660, p < 0.001). There was no statistical difference in FLAIC scores according to gender or age. FLAIC score was positively correlated with higher body mass index. CONCLUSION: Incidental low to moderate grade FLAIC pathology is commonly seen on MRI in asymptomatic patients. Abnormal MRI findings of the FLAIC should hence be correlated with explicit clinical symptoms and physical exam findings. ADVANCES IN KNOWLEDGE: The Fascia lata is a complex anatomic structure. Its attachment to the iliac crest is an under recognized pathology and sometimes overlooked during evaluation for pelvis and lateral hip pain. Evaluation of the FLAIC is easily done with MRI and abnormality should be correlated to the clinical symptomatology as low grade abnormality is frequently seen in asymptomatic population.

A Retrospective Study of Intentional Body Dismemberment in New York City: 1996-2017.

A review of New York City dismemberment cases occurring between 1996 and 2017 was conducted, which resulted in a total of 55 dismembered decedents in a 22-year period. Annual trends indicate an average of 2.5 dismembered decedents. Additional results show that 53% of cases involved transection only, 35% involved disarticulation only, and 13% involved a combination of both. When the entire body could be accounted for, the average number of body portions per case was 5.5. Frequent locations for dismemberment were the neck, shoulders, hips, and knees. Dismemberment locations showed a general trend of anatomical symmetry. Seventy-eight percent of the dismemberments involve disposal of body parts in an outside location. Eighty-four percent were concealed from view with some type of covering. The findings from New York City are compared with other studies.

Umbilical Cord Tissue and Meconium May Not Be Equivalent for Confirming in Utero Substance Exposure.

In a retrospective study of 501 neonates with potential in utero substance exposure, the drug detection performance of a commercially available umbilical cord tissue toxicology test was evaluated against a commercially available gold standard meconium toxicology test. Drugs detected in paired meconium and umbilical cord tissue samples were often discordant.

Trends in United States Mass Fatality Incidents and Recommendations for Medical Examiners and Coroners.

It is imperative that medicolegal jurisdictions prepare for the occurrence of a mass fatality incident. Despite the trend to plan for catastrophic and complicated incidents, this analysis of recent mass fatality events seeks to better inform authorities regarding the scale and types of incidents that could potentially impact their jurisdiction. The guidance provided by this study serves as a tool to guide the development of plans, acquisition of appropriate resources, and training of staff. To perform this analysis, data were collected from mass fatality incidents occurring in the United States from January 1, 2000 to December 31, 2016 that resulted in ten or more fatalities. Specific data points were collected for each incident including the date, location, number of fatalities, incident type (e.g., man-made or natural), incident subtype, and description (e.g., mass shooting, hurricane, aviation). A total of 137 incidents fit the criteria for inclusion in the analysis, resulting in a total of 8462 fatalities. The average number of incidents was eight per year during the study period. The analysis demonstrates that most mass fatality incidents (88.8%) result in between ten and 50 fatalities and are variable based on incident type and geographic location. This study includes several large-scale incidents, which as outliers have influenced fatality management operations and preparedness efforts on a national level. In particular, the World Trade Center attack of September 11, 2001 and subsequent remains recovery and identification operations have served to inform the New York City Office of Chief Medical Examiner of the capabilities required to manage a complex, protracted victim identification process involving extensive body fragmentation and commingling. While the World Trade Center attack has been shown to be outside the normal trends of mass fatality incidents, it has nonetheless offered the medicolegal community several invaluable lessons.

The Utility of Forensic Anthropology in the Medical Examiner's Office.

Over the past few decades, the field of forensic anthropology has seen major advancements and experienced a considerable growth of professionals in medical examiner/coroner offices. Despite this expansion, misconceptions regarding the role and utility of the anthropologist in the medicolegal setting still exist. This article brings together practitioners employed full-time in four medical examiner's offices, with each practitioner providing a unique perspective and emphasis regarding their role as an anthropologist. Discussed is the history of the anthropology division in each office as well as the types of casework and ancillary duties completed by the anthropologists. Consistently, the anthropologists are involved in the search and recovery of human remains, managing long-term unidentified cases, facilitating disposition of unclaimed decedents, and developing mass disaster protocols for their respective agency. Also consistent across the four offices is the fact that the anthropologists receive far more consult requests for trauma evaluation of nonskeletonized cases than any other type of case.

Computerized Dental Comparison: A Critical Review of Dental Coding and Ranking Algorithms Used in Victim Identification.

Comparison of antemortem and postmortem dental records is a leading method of victim identification, especially for incidents involving a large number of decedents. This process may be expedited with computer software that provides a ranked list of best possible matches. This study provides a comparison of the most commonly used conventional coding and sorting algorithms used in the United States (WinID3) with a simplified coding format that utilizes an optimized sorting algorithm. The simplified system consists of seven basic codes and utilizes an optimized algorithm based largely on the percentage of matches. To perform this research, a large reference database of approximately 50,000 antemortem and postmortem records was created. For most disaster scenarios, the proposed simplified codes, paired with the optimized algorithm, performed better than WinID3 which uses more complex codes. The detailed coding system does show better performance with extremely large numbers of records and/or significant body fragmentation.

Santeria and Palo Mayombe: skulls, mercury, and artifacts.

Santeria and Palo Mayombe are syncretic religions created in the New World based upon African religious beliefs combined with Christianity. The main worship of Palo Mayombe involves religious receptacles that may contain earth, sticks, varied artifacts, and animal and human remains. Due to the use of human and nonhuman remains, discovery of these items often leads to involvement by the police due to a concern of homicide. We review in detail the medical examiner records of two of these ritualistic cases including the autopsy, anthropology, police, and investigators' reports. For the human remains, careful consideration of the context in which the remains were recovered, their state of preservation, and the associated artifacts (e.g., beads and mercury) are important in determining the appropriate level of forensic significance. Anthropological examination with particular attention to taphonomic characteristics also may help determine the origin and forensic significance.

Estimation of living stature from selected anthropometric (soft tissue) measurements: applications for forensic anthropology.

Estimation of living stature has obvious utility in the identification process. Typically, anthropologists estimate stature from the measurement of long bone length. This type of analysis is traditionally conducted on skeletonized or badly decomposed remains, so collection of the necessary bone measurements is relatively simple. As the role of anthropologists expands into medical examiner offices and mass fatality incidents, the analysis of fleshed bodies and body parts is a more common scenario. For stature estimation in these types of cases (e.g., analysis of body portions recovered from an aircraft crash site or from intentional dismemberment), the presence of soft tissue on the human remains would usually necessitate dissection to expose skeletal elements to derive metric data for stature estimation. In order to circumvent this step, this paper provides various formulae that allow for standard anthropometric (i.e., soft tissue) measurements to be used in place of skeletal measurements. Data were compiled from several anthropometric studies (National Health and Nutrition Examination Survey [NHANES] and U.S. Army Anthropometric Survey [ANSUR]) and numerous regression models are presented. Results are compared between skeletal measurements and the anthropometric measurements from each study. It was found that the ANSUR models are similar to the skeletal models, while the NHANES models exhibit weaker correlation coefficients and higher standard errors. Overall, this study finds that stature estimates derived from anthropometric data provide good results and remove the necessity for dissection when working with fleshed body portions.

Recruitment strategies for a lung cancer chemoprevention trial involving ex-smokers.

The ability to recruit qualified subjects who are willing to adhere to the study protocol in clinical trials is an essential component of translational research. Such tasks can be particularly challenging for chemoprevention studies when the targeted study population is healthy, at risk individuals who do not have signs or symptoms of the disease, and the study participation involves complex scheduling and invasive procedures such as bronchoscopy. In this report, we describe the recruitment process and evaluated the effectiveness of various recruitment strategies utilized in our National Cancer Institute sponsored lung cancer chemoprevention study with celecoxib. Heavy ex-smokers were recruited into the study through various methods such as radio advertisements, print media, mass mailings, flyers, internet postings and others. The number of inquiries, on-site screenees and randomization generated by each method determined the efficacy of that recruitment strategy. We prescreened 4470 individuals, invited 323 people for on-site screening and randomized 137 subjects. Radio advertisements (ads) generated the most inquiries (71.1%), followed by internet posting (11.8%), print media (6.0%), posted and racked flyers (4.4%), mass mailings (2.7%) and other strategies such as referrals from friends or family members or health care providers (2.3%). Radio ads, although costly, yielded the most subjects for on-site screening and randomization. Moreover, among the various types of radio stations, news radio stations were by far the most successful. Our results suggest that advertising on news radio is a highly effective recruitment method for successful accrual of ex-smokers into lung cancer chemoprevention trials.