Criminal and Civil Responsibility of the Donor in a Case of Transmission of Malaria by a Blood Transfusion in a Nonendemic Country.

Introduction: The blood donation process is strictly regulated by law. The process includes the necessity of a medical history taken to determine if a donor is suitable to donate, which shall guarantee both donor and recipient safety. Supplementary screening for a limited number of infections is performed by antibody (HIV, HCV, syphilis) or antigen (HBV) tests or NAT (HIV, HCV, HBV). Case Presentation: With regard to a possible infection due to (sexual) risk behavior or foreign travel, blood donation facilities are predominantly dependent on information provided by the donor. This is especially true for malaria in nonendemic areas such as Europe. Transmission of malaria by a blood transfusion in a nonendemic country that led to fulminant septic shock and death of the patient happened. Discussion: From a legal perspective, the donor thus assumes a high level of responsibility with regard to the accuracy and completeness of the information provided on the donor questionnaire. Incorrect information may, as in this Austrian case reported, result in civil or criminal responsibility of the donor.

Family discussions and demographic factors influence adolescent's knowledge and attitude towards organ donation after brain death: a questionnaire study.

BACKGROUND: Knowledge and attitude towards organ donation are critical factors influencing organ donation rate. We aimed to assess the knowledge and attitude towards organ donation in adolescents in Austria and Switzerland. METHODS: A paper-based survey was performed in two secondary schools (age range 11-20 years) in Austria and Switzerland. 354/400 surveys were sufficiently answered and analyzed. RESULTS: Our study found that knowledge on organ donation is scarce in adolescents. Less than 60% of those surveyed thinks that a person is dead when declared brain dead. 84.6% would authorize organ donation after brain death for themselves, but only 69% would authorize organ donation after brain death for a close relative. 93.7% would accept a donor organ if they needed one. Family discussions, rather than school discussions, influenced knowledge on organ donation, the percentage of respondents who have a firm opinion on organ donation and the rate of declaration of this opinion. Age, gender, nationality and religion also influenced knowledge and attitude towards organ donation. Nearly one third of adolescents are of the opinion that selling non-vital organs should be legalized. CONCLUSION: Since having had family discussions, a potentially modifiable factor, was positively associated with knowledge and attitude towards organ donation, we postulate that educational programs stimulating family discussions on organ donation may be a promising strategy to increase knowledge.

What ICU nurses in different Austrian hospitals know and think about the Austrian organ donation law.

We previously reported a high level of information on the Austrian organ donation law in medical and non-medical students, patients and ICU nurses, whereby ICU nurses at University Hospital in Graz (n = 185) were very well informed and also had the most critical view of the Austrian organ donation law.This letter reports the extension of our previous study to ICU nurses from hospitals with a Christian background (n = 60). We found that ICU nurses in hospitals run by religious congregations considered the Austrian organ donation law to be good more often than did those at the University Hospital in Graz. A positive attitude was also influenced by gender and prior knowledge of the law.Reasons for this could be the Christian orientation of the hospitals or exposure to organ donation and transplantation procedures on the job.

[Definitions, decision-making and documentation in end of life situations in the intensive care unit]. / Therapiezieländerungen auf der Intensivstation - Definitionen, Entscheidungsfindung und Dokumentation.

The present work provides assistance for physicians concerning decision making in clinical borderline situations in the ICU. Based on a structured checklist the two fundamental aspects of any medical decision, the medical indication and the patient's preference are queried in a systematic way. Four possible steps of withholding and/or withdrawing therapy are discussed. Finally, recommendations regarding appropriate documentation of end of life decisions are provided.

A 10min "no-touch" time - is it enough in DCD? A DCD animal study.

Donation after cardiac death (DCD) is under investigation because of the lack of human donor organs. Required times of cardiac arrest vary between 75s and 27min until the declaration of the patients' death worldwide. The aim of this study was to investigate brain death in pigs after different times of cardiac arrest with subsequent cardiopulmonary resuscitation (CPR) as a DCD paradigm. DCD was simulated in 20 pigs after direct electrical induction of ventricular fibrillation. The "no-touch" time varied from 2min up to 10min; then 30min of CPR were performed. Brain death was determined by established clinical and electrophysiological criteria. In all animals with cardiac arrest of at least 6min, a persistent loss of brainstem reflexes and no reappearance of bioelectric brain activity occurred. Reappearance of EEG activity was found until 4.5min of cardiac arrest and subsequent CPR. Brainstem reflexes were detectable until 5min of cardiac arrest and subsequent CPR. According to our experiments, the suggestion of 10min of cardiac arrest being equivalent to brain death exceeds the minimum time after which clinical and electrophysiological criteria of brain death are fulfilled. Therefore shorter "no-touch" times might be ethically acceptable to reduce warm ischemia time.

Systematic review on potential brain dead donor estimations and conversion rates to actually realized organ donations.

INTRODUCTION: Accurate estimations of potential organ donors (POTDs) are required to improve transplant systems. This systematic review analyses current studies on national estimations of potential donors for transplantation as well as the practical and policy implications of detected differences. METHOD: A systematic review of literature published between 01.01.2010 and 01.04.2020 in PubMed was conducted. Data was extracted into a self-developed matrix, and further data retrieved on national population sizes, waiting lists and transplant activities. RESULTS: Six studies were included. Investigated populations, underlying data collections and eligibility criteria for POTDs varied widely. Estimated POTDs per million population (p.m.p.) ranged from 25.8 to 333.6, conversion rates from 3.2% to 47.5% leading to 41.2 to 86.4 transplanted organs p.m.p.. Patients on the waiting lists varied from 66.7 to 338.9 p.m.p., defining gaps between organ supply and demand in countries. Not all studies adhered to the definitions and processes of the critical pathway for deceased donation which is the latest international consensus statement on deceased organ donation. CONCLUSION: Differences in estimated POTDs and differences in supply and demand of donor organs between countries cannot be satisfactorily explained yet due to an obvious lack of evidence, consistent methodology, international consensus and robust underlying datasets. Future studies should be based on robust underlying data sets and aim for potential donor estimations that allow national comparisons due to the adherence to the international consensus on definitions, processes and methodology.

Optimizing Organ Donation: Expert Opinion from Austria, Germany, Spain and the U.K.

BACKGROUND Organ donation-rates using deceased donors and organizational approaches to organ donation differ drastically between countries at a similar level of health care as measured by the Euro Health Consumer Index (EHCI). MATERIAL AND METHODS Expert opinions from intensive care nurses, physicians, transplant coordinators and transplant surgeons from Austria, Germany, Spain, and the U.K. were obtained in semi-structured interviews followed by qualitative content analysis. Results were reported back to all interview partners to identify potential controversies and consensus recommendations. RESULTS No controversies could be detected. On a variety of beneficial factors an interprofessional consensus between interview partners could be reached: A) The relevance of standardization of the screening for potential donors, the family approach and training; B) standards and best-practice procedures should be regulated and supervised by state authorities; C) full transparency and the prevention of scandals is essential; D) overburdened intensive care unit (ICU) doctors need to be supported by full-time in-house special nurses who organize donor evaluation, transport logistics and pastoral care, if required; E) public awareness campaigns are helpful; F) a broad public consensus on the concept of donation after brain and cardiac death is essential; G) incentives for the reporting of potential organ donors are inappropriate; H) an opt-out system alone is not sufficient. CONCLUSIONS Expert opinions from different professional backgrounds from different European health care systems reach a broad consensus on the most relevant issues for the improvement of organ donation.

Gastrointestinal Complications After Pancreatoduodenectomy With Epidural vs Patient-Controlled Intravenous Analgesia: A Randomized Clinical Trial.

Importance: Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are frequently used for pain control after pancreatic surgery. Evidence from a post hoc analysis suggests that PCIA is associated with fewer gastrointestinal complications. Objective: To determine whether postoperative PCIA decreases the occurrence of gastrointestinal complications after pancreatic surgery compared with EDA. Design, Setting, and Participants: In this adaptive, pragmatic, international, multicenter, superiority randomized clinical trial conducted from June 30, 2015, to October 1, 2017, 371 patients at 9 European pancreatic surgery centers who were scheduled for elective pancreatoduodenectomy were randomized to receive PCIA (n = 185) or EDA (n = 186); 248 patients (124 in each group) were analyzed. Data were analyzed from February 22 to April 25, 2019, using modified intention to treat and per protocol. Interventions: Patients in the PCIA group received general anesthesia and postoperative PCIA with intravenous opioids with the help of a patient-controlled analgesia device. In the EDA group, patients received general anesthesia and intraoperative and postoperative EDA. Main Outcomes and Measures: The primary end point was a composite of pancreatic fistula, bile leakage, delayed gastric emptying, gastrointestinal bleeding, or postoperative ileus within 30 days after surgery. Secondary end points included 30-day mortality, other complications, postoperative pain levels, intraoperative or postoperative use of vasopressor therapy, and fluid substitution. Results: Among the 248 patients analyzed (147 men; mean [SD] age, 64.9 [10.7] years), the primary composite end point did not differ between the PCIA group (61 [49.2%]) and EDA group (57 [46.0%]) (odds ratio, 1.17; 95% CI, 0.71-1.95 P = .54). Neither individual components of the primary end point nor 30-day mortality, postoperative pain levels, or intraoperative and postoperative substitution of fluids differed significantly between groups. Patients receiving EDA gained more weight by postoperative day 4 than patients receiving PCIA (mean [SD], 4.6 [3.8] vs 3.4 [3.6] kg; P = .03) and received more vasopressors (46 [37.1%] vs 31 [25.0%]; P = .04). Failure of EDA occurred in 23 patients (18.5%). Conclusions and Relevance: This study found that the choice between PCIA and EDA for pain control after pancreatic surgery should not be based on concerns regarding gastrointestinal complications because the 2 procedures are comparable with regard to effectiveness and safety. However, EDA was associated with several shortcomings. Trial Registration: German Clinical Trials Register: DRKS00007784.

Prevalence of palliative care patients in emergency departments.

BACKGROUND: Emergency departments (ED) serve as a contact point for critically ill patients. According to experience, a fraction of patients visiting ED present with palliative symptoms and require palliative care; however, the prevalence of these patients has not been determined in Austria so far. METHODS: In the ED of a tertiary care medical centre in Carinthia all adult patients presenting between 8 January 2018 and 17 January 2018 were classified on arrival with the Manchester triage system (MTS) and were afterwards assessed with a validated 2­tier screening tool for palliative care. Patient records were screened in April 2018 to find out whether they received palliative care. RESULTS: In total 1277 patients visited the ED during the investigation period. Of these patients 1096 were screened and 145 of these patients (13.2%) showed palliative symptoms and needed a goal-oriented therapy. Of these 145 patients 10.9% were assessed by MTS as emergency, 2.7% as very urgent, 34.7% as urgent, 51% as normal, and 0.7% as not urgent. Only 8 (5.5%) of the patients with palliative medical symptoms actually received palliative care consultation. CONCLUSIONS: More than 1 in 10 patients attending an ED suffered from palliative symptoms. Hence it is to be expected that healthcare providers in an ED in Austria will frequently encounter patients with palliative symptoms in emergency admissions. Therefore, it is necessary to develop suitable structures to provide these patients with the best possible care.

Influence of a tilting prosthetic mitral valve orientation on the left ventricular flow - an experimental in vivo magnetic resonance imaging study.

OBJECTIVE: Orientation-related monoleaflet mechanical valve flow and velocity studies in the downstream are limited in mitral valve replacement studies. METHODS: In five sheep, ventricular blood flow was visualized prior to the implantation of a Medtronic Hall tilting valve model. In six sheep, the implant orientation was either anatomical (disc aligned with the anterior leaflet) or anti-anatomical. The mitral subvalvular apparatus was preserved. Sheep were positioned within an 1.5 T field strength MR scanner (Magnetom Sonata; Siemens) to assess time-dependent three dimensional blood flow. RESULTS: The preoperative ventricular velocity profiles presented negligible individual variances. Streamlines passed homogeneously without any spatial differences in flow velocities into the left ventricle. Starting from the anatomical position, blood entered mainly through the major orifice of the mechanical valve. The single artificial leaflet mimicked the rudder effect of the natural anterior mitral leaflet, preventing blood streaming directly towards the septum. The area with inhomogeneous blood velocities in the ventricle increased but not significantly from the preoperative status. The non-axial inflow not directed directly to the apex converted to a similar helix as observed in the preoperative cases. Anti-anatomical orientation of the prosthesis caused a significant increase in turbulence immediately after passing the mitral prosthesis. The main stream was changed so significantly that the blood flow shifted towards the septum and caused higher velocities of the stream profiles and turbulence apically. CONCLUSIONS: To achieve optimal hemodynamics, orientation of the mitral tilting valve has to be considered carefully, as has been long known from aortic valve replacement studies.

Urapidil reduces elevated pulmonary vascular resistance in patients before heart transplantation.

BACKGROUND: Elevated pulmonary vascular resistance is a major limitation for heart transplantation. Urapidil is a centrally and peripherally acting anti-hypertensive drug, able to decrease elevated pulmonary vascular resistance in patients with either chronic obstructive pulmonary disease or heart failure. Urapidil is available as an oral or intravenous drug. In this study, we evaluated the possible beneficial effects of intravenous urapidil in patients with reversible, elevated pulmonary vascular resistance who were scheduled for heart transplantation. METHODS: After approval by the Ethics Committee and written consent, 22 consecutive patients with end-stage heart failure and history of pulmonary vascular resistance >3 Wood units were enrolled into an open, prospective study. Using a (right ventricular ejection fraction) REF-Swan-Ganz catheter, hemodynamics were determined during administration of nitric oxide, and before and after 3 repeated intravenous applications of 10 mg urapidil. The treatment goal was reduction of pulmonary vascular resistance by at least 30%. RESULTS: Twenty-two patients were included to obtain complete data for 14 patients. Eight patients were not treated with urapidil: 7 patients had normal pulmonary vascular resistance at baseline, and 1 patient experienced moderate pulmonary edema before the study began. Two patients did not reach the treatment goal. In patients who responded to urapidil, the following hemodynamic changes were observed: decreased pulmonary vascular resistance (-48%), decreased transpulmonary gradient (20.0 to 13.7 mm Hg), decreased mean pulmonary arterial pressure (40 to 31 mm Hg), decreased systemic vascular resistance (-27%), mean arterial pressure (80 to 72 mm Hg), and increased right heart ejection fraction (21% to 27%). Heart rate remained unchanged. CONCLUSIONS: Intravenous urapidil lowered elevated pulmonary vascular resistance in patients before heart transplantation. In comparison with other vasodilative drugs, the major benefit of urapidil is its oral formulation.

[Evaluation of the potential organ donor with special regards to heart donation]. / Der potentielle Organspender - Evaluierung unter besonderer Berücksichtigung der Herzentnahme.

Regarding limited availability of organ donors for heart transplantation, it is necessary to discuss optimal donor evaluation and donor management. In this manuscript general donor-related parameters as well as heart-specific parameters are discussed regarding international literature. In addition, "marginal" donors and in contrast "optimal" donors are defined. Donor management including optimal hemodynamic management and additional specific intensive care aspects are presented. Exact donor evaluation allows for matching the organ to the most suitable recipient and is therefore especially in the context of marginal donors a crucial step within transplantation process.

A hyperpolarization activated inward current (If) is present in infant ventricular myocytes.

I(f) was shown to be present in adult human atrial and ventricular myocytes but data obtained from infant myocytes are lacking. We have studied I(f) in isolated ventricular myocytes from children undergoing surgical correction of tetralogy of Fallot (TOF; n = 5; mean age: 15.3 months). All recordings were made with the patch clamp technique in the whole cell mode at a temperature of 36-37 degrees C. A modified Tyrode solution containing 25 mM KCl was used to amplify I(f). Considering I(f) to be present when its current density at -120 mV was greater than 0.5 pA/pF, I(f) could be found in 28 out of 32 myocytes (88%). The mean current density was -2.01 +/- 0.3 pA/pF (mean +/- S.E.M.). First current activation occurred at -70 mV and I(f) could be reversibly inhibited by superfusing the myocytes with CsCl (2 mM). Half maximal activation (V(1/2)) of I(f) was at -80.3 +/- 1.0 mV (n = 28). Beta-adrenergic receptor stimulation with isoproterenol (1 microM) caused an acceleration of current activation and a shift of V(1/2) by 7.88 +/- 1.8 mV (n = 10) to less negative potentials. This study provides first evidence that the hyperpolarization-activated pacemaker current I(f) is present in infant human ventricular myocytes. Our results suggest that I(f) in ventricle of infants suffering from TOF has similar properties as I(f) in adult ventricle.