Identifying opportunities to increase organ donation after brain death. An observational study in Sweden 2009-2014.

BACKGROUND: There is a wide gap between the number of organ donors and patients on waiting lists for transplantation. The purpose of this Swedish nationwide study of the critical pathway for organ donation after brain death (DBD) was to identify missed opportunities for organ donation. METHODS: We performed a prospective, observational study of all ICU deaths in Sweden from Jan 1, 2009 to Dec 31, 2014. The protocol structure followed the critical pathway for organ donation, which was developed and tested during 2008. We analysed differences in donation incidences between healthcare providers (counties) and patient characteristics using descriptive statistics and logistic regression. RESULTS: The number of DBD per million population (pmp) was 14.9, varying almost 10-fold from 4.3 to 40.6 DBD pmp between counties. Regional variation in DBD decreased when we assigned the donor to the place of residence (from 6.9 to 27.7 DBD pmp). Women were more likely to become donors compared to men [crude odds ratio (OR) 1.60, 95% confidence interval (CI) 1.38-1.85, P < 0.001]. The increased likelihood remained after adjusting for age, comorbidity, and main diagnostic categories (OR 1.49, 95% CI 1.25-1.77, P < 0.001). An end-of-life decision was found in 50.9% of possible organ donors. CONCLUSIONS: Regional differences in DBD were considerable, and women were more likely to become donors than men. There is a need for increased awareness of the potential for organ donation as an integral part of end-of-life clinical care. In-depth analysis of these differences may reveal opportunities for action that could lead to increased DBD.

Characteristics and long-term outcome of acute exacerbations in chronic obstructive pulmonary disease: an analysis of cases in the Swedish Intensive Care Registry during 2002-2006.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) represents a major and growing health problem. The purpose of this work was to examine characteristics, resource use and long-term survival in patients with an acute exacerbation of COPD that were admitted to Swedish intensive care units (ICU). METHODS: Patient characteristics at admission, length of stay (LOS), resource use and outcome were collected for admissions due to COPD during 2002-2006 in the database of the Swedish Intensive Care Registry. Vital status was secured for 99.6% of the patients. Kaplan-Meier survival estimates were computed for index admissions only. RESULTS: We identified 1009 patients with 1199 admissions due to COPD (1.3% of all intensive care admissions). The mean (SD) age was 70.2 (9.1) years and the proportion of women were 61.5%. Mean (SD) Acute Physiology and Chronic Health Evaluation II probability of hospital death was 0.31 (0.19). Median LOS was 28 (interquartile range 52) h. The number of readmissions was 190 during the 5-year study. Older patients had fewer readmissions (OR 0.96, 95% CI: 0.95-0.98/year increase in age). ICU mortality was 7.3% (87 of 1199 admissions) and 30-day mortality was 26.0% (262 of 1009 index admissions). Median survival was 14.5 months and 31% of patients survived 3 years after the index admission. CONCLUSIONS: Short (30 days) and long-term survival is poor in acute COPD. Readmissions are frequent reflecting the severity of this chronic illness. Patients are less likely to be readmitted with increasing age which may be due to withholding of further intensive care.

Temperature-induced phase partitioning of peptides in water solutions of ethylene oxide and propylene oxide random copolymers.

A thermoseparating random copolymer (Ucon 50-HB-5100) composed of (50%) ethylene oxide and (50%) propylene oxide has been used to form an aqueous two-phase system by heating the polymer-water solution above the cloud point of the copolymer. In the formed two-phase system a water rich top phase is in equilibrium with an aqueous polymer rich bottom phase. The partitioning of amino acids and peptides in this aqueous two-phase system has been studied. Hydrophobic peptides (containing aromatic amino acids) were strongly partitioned to the polymer rich phase, while hydrophilic peptides were enriched in the water rich phase. The effect of temperature on the partitioning was investigated and a decreased partitioning to the polymer rich phase was obtained upon temperature increase. The effect of two salts (NaClO4 and Na2SO4) on the partitioning of a positively charged polypeptide, poly(Lys, Trp), was very strong. With NaClO4 the polypeptide was quantitatively partitioned to the polymer rich phase while with Na2SO4 the polypeptide was partitioned to the water rich phase. Model calculations based on a modified Flory-Huggins theory have been performed to better understand the experimental behavior.

Effects of ions on partitioning of serum albumin and lysozyme in aqueous two-phase systems containing ethylene oxide/propylene oxide co-polymers.

Aqueous two-phase systems composed of ethylene oxide/propylene oxide random co-polymers, EO30/PO70 or Ucon (EO50/PO50), in the top phase and dextran T500 in the bottom phase, have been studied. The cloud point diagram for EO30/PO70 in water solution was determined. EO30/PO70 has a cloud point of 32 degrees C at a concentration of 10% (w/w). The phase diagram for the system EO30/PO70-dextran T500-water was determined. Salt effects have been studied on the partitioning of two model proteins, bovine serum albumin and hen egg white lysozyme, in EO30/PO70-dextran and Ucon-dextran systems. Ions with different hydrophobicity, i.e., with different position in the Hofmeister or lyotropic series, were investigated with reference to their effect on protein partition. The counterion hydrophobicity was shown to have a strong influence on the partitioning of BSA and lysozyme. Most extreme partitioning was obtained with hydrophobic (chaotropic) ions like CIO4- and I-. A comparison of protein partitioning between PEG-dextran and EO30/PO70-dextran has been done. A more extreme protein partitioning was obtained in the EO30/PO70-dextran containing system. Temperature-induced phase separation was studied with EO30/PO70 at 45 degrees C. Both BSA and lysozyme were completely partitioned to the water phase formed above the cloud point of EO30/PO70. Model calculations, based on Flory-Huggins theory of polymer solutions, have been done which could reproduce the salt effect on the protein partitioning in aqueous-two phase system.

Phase equilibria in the phosphatidylcholine-cholesterol system.

A thermodynamic and a microscopic interaction model are proposed to describe the phase equilibria in the phosphatidylcholine-cholesterol system. The model calculations allow for a solid phase with conformationally ordered acyl chains and liquid phases with conformationally ordered as well as disordered chains. The resulting phase diagram is in excellent agreement with the experimental phase diagram for dipalmitoylphosphatidylcholine bilayers with cholesterol as determined by a recent NMR and calorimetry study. It is thus demonstrated that the phase behaviour of phosphatidylcholine-cholesterol mixtures can be rationalized using only a few basic assumptions: (i) Cholesterol interacts favourably with phosphatidylcholine chains in an extended conformation, (ii) the main transition of pure phosphatidylcholine bilayers takes place in terms of translational variables as well acyl-chain conformational variables, and (iii) cholesterol disturbs the translational order in the crystalline (gel) state of phosphatidylcholine. These results suggest that the occurrence of specific phosphatidylcholine-cholesterol complexes is not implied by the experimental thermodynamic data.

Activation of the humoral antihypertensive system of the kidney increases diuresis.

Isolated kidneys taken from normotensive Wistar-Kyoto rats were cross-perfused extracorporeally by normotensive strain-matched donor rats. The extracorporeal perfusion circuit was arranged so that the perfusion pressure to the normotensive recipient kidney could be varied from 90 to 200 mm Hg without any change in total flow through this circuit. This setup avoided hemodynamic or mechanical interferences with reflexogenic circulatory control in the normotensive donor rat when the recipient kidney was manipulated. Diuresis and natriuresis were measured in the normotensive donor rat and the normotensive recipient kidney. A few minutes after normotensive recipient kidney perfusion pressure had been raised, mean arterial pressure (MAP) and heart rate started to decline rapidly in the normotensive donor rat, and circulatory collapse ensued within 15 to 100 minutes. During the control period at 90 mm Hg normotensive recipient kidney perfusion pressure, urinary flow, MAP and heart rate were stable in the normotensive donor rat and the normotensive recipient kidney. When perfusion pressure was raised to 200 mm Hg in the recipient kidney, the urinary flow in the donor rat increased 62% on average in the first 10 minutes over values recorded before the pressure rise (p less than 0.05) while MAP simultaneously fell by 16% and HR remained unchanged. During the subsequent period, the urinary flow of the donor rat declined together with MAP and heart rate. In the extracorporeally high-pressure perfused recipient kidneys, an eightfold to ninefold increase in diuresis and natriuresis occurred during the first 45 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Do angiotensin converting enzyme inhibitors lower blood pressure in the rat partly via the humorally mediated antihypertensive system of the renal medulla?

It has been suggested that there is a negative-feedback interaction between the humoral renomedullary antihypertensive system and angiotensin II. If so, the acute blood pressure-lowering effects of angiotensin converting enzyme (ACE) inhibitors might be due, in part, to an increased secretion of renomedullary depressor substances. Groups of anaesthetized Wistar-Kyoto rats (WKY) with an intact or chemically destroyed renal medulla received either saline or the ACE inhibitor enalapril, and mean arterial pressure (MAP), heart rate and renal function were measured. MAP was clearly decreased after enalapril administration in the WKY controls with an intact renal medulla, but was not changed in the medullectomized group. In one WKY control group, where the prostaglandin and kallikrein-kinin systems had also been acutely blocked, the MAP reduction after enalapril was even more marked than in the intact controls. Thus, the acute blood pressure-lowering effect of enalapril is clearly dependent on an intact renal medulla, further suggesting that the renomedullary antihypertensive system is important to normal blood pressure homeostasis.

Influence of the renal medulla and early treatment with enalapril upon the development of hypertension in young spontaneously hypertensive rats.

OBJECTIVE: To investigate the role of the renal medulla in early hypertension in spontaneously hypertensive rats (SHR), and to explore whether the attenuated increase of pressure induced by enalapril treatment is affected by chemical medullectomy. DESIGN: Forty-four male SHR were studied from 5 to 18 weeks of age: 22 remained intact; 22 were medullectomized at 5.5 weeks of age with 2-bromoethylamine hydrobromide; 11 of each of these two groups were treated with enalapril from 6 to 12 weeks of age. Blood pressure, heart rate and body weight were recorded intermittently, and at 18 weeks renal function was also analysed. RESULTS: The results indicate a protective effect of the renal medulla against severe pressure rises in SHR, although even when enalapril also lowered blood pressure in medullectomized SHR, persistent improvements of glomerular filtration rate and renal flow conductance occurred only in intact SHR. Furthermore, after enalapril treatment ended blood pressure rose to higher levels in medullectomized SHR, despite greater sodium-water losses. CONCLUSION: The renal medulla seems to exert a protective role both during and after enalapril treatment.

Physiological effects of the humoral renomedullary antihypertensive system.

In experiments on rats, the physiological effects of the antihypertensive humoral system of the renal medulla were explored. We studied the parameters of blood pressure, heart rate, efferent sympathetic nervous activity to the splanchnic region, diuresis and natriuresis. The experimental situations included studies on normotensive rats, injected with extracted renomedullary lipids (medullipin), and normotensive rats extracorporally cross-perfusing an isolated kidney at increased pressure levels, to explore the release of renomedullary depressor substances. Spontaneously hyperactive rat (SHR) kidneys were also cross-perfused to study whether the renomedullary mechanism was reset upwards in this type of primary hypertension. Finally, the acute pressure reductions caused by angiotensin converting enzyme (ACE)-inhibitors were studied in intact and chemically medullectomized (2-bromo-ethylamine hydrobromide) rats to explore whether they were at least in part dependent on an intact renal medulla. In normal kidneys the renomedullary depressor system was initiated already at physiological pressure levels (at or above 100 mm Hg), causing the following humorally induced response pattern: the blood pressure fall was associated with decreases in both heart rate and sympathetic activity, while diuresis and natriuresis increased. In SHR kidneys, perfusion pressure had to be raised between 200 and 250 mm Hg before this depressor pattern was activated, revealing an "upward renomedullary resetting" well beyond the prevailing SHR blood pressure. The acute blood pressure decrease initiated in normotensive rats by an ACE-inhibitor (enalaprilat) was abolished in medullectomized rats, indicating an interaction between the renin-angiotensin and the renomedullary antihypertensive systems.

Effects on regional renal blood flow when unclipping a two-kidney, one-clip hypertensive Wistar rat during renal nerve stimulation.

Blood pressure (BP) is rapidly normalized when removing the obstruction from the renal artery of a two-kidney, one-clip renovascular hypertensive rat (unclipping). This study tested whether efferent renal nerve stimulation (ERNS) of the unclipped kidney affects this drop in BP or the associated changes in diuresis-natriuresis and regional renal blood flow. Three groups of anesthetized renovascular hypertensive Wistar rats were studied: 1) W(C) (time control); 2) W(UC) (unclipped after 30 min); and 3) W(UC+NS) (unclipped after 30 min, with ERNS at 5 Hz for 2 h). Renal excretion and regional hemodynamics (laser Doppler) were monitored in the unclipped kidney. Medullary and cortical blood perfusion increased by 84% and 95%, respectively, in W(UC) 30 min after unclipping (P < .001) but only with 8% and 9%, respectively, in W(UC+NS) (P = NS). Unclipping induced a marked increase in diuresis-natriuresis that was largely unaffected by ERNS. In W(UC) and W(UC+NS) BP returned to normotensive levels within 4 h. However, during the first 30 min, average BP decreased significantly less in W(UC+NS) (9%, 20 mm Hg) than in W(UC) (16%, 35 mm Hg) (P < .05). ERNS at 5 Hz effectively prevented the increase in medullary blood perfusion but did not affect the fall in blood pressure or the pressure diuretic/natriuretic response seen after unclipping. The results suggest that both the reduction in BP and the pressure-induced increase in diuresis/natriuresis seen when unclipping the 2K,1C renovascular hypertensive rat occurs largely independently of ERNS and an increase in medullary blood perfusion.

Ipsilateral fracture of the femur and tibia.

Thirty-two cases of simultaneous ipsilateral femoral and tibial fractures in thirty-one patients were treated by rigid internal or pin fixation of both fractures in fourteen cases, by rigid internal or pin fixation of one fracture in three, and by conservative management or non-rigid internal fixation in fifteen. Rigid internal or pin fixation of both fractures resulted in a lower incidence of complications and shorter duration of hospitalization and time to healing. An initially active surgical approach also produced considerably better functional end results: twelve of fourteen patients so treated resumed their former occupations, compared with four of thirteen patients treated conservatively.

Percutaneous pin fixation of open tibial fractures. Double-frame anchorage using the Vidal-Adrey method.

From 1970 to 1973, twenty-eight severe open tibial fractures in twenty-seven patients were treated with stable external transfixation by the Vidal-Adrey double-frame method. Excluding one patient who had an amputation because of vascular damage at the time of injury, wound healing was satisfactory in all patients with no primary soft-tissue or deep infection. There was one late infection following secondary intramedullary nailing three months after injury. Secondary skin and bone grafts were part of the original plan of treatment and were easily performed. All patients were able to start range-of-motion exercises in the early postoperative period. In the case of a severely comminuted tibial fracture combined with arterial injury, this method made it possible to observe the limb for a few days before amputation for vascular insufficiency. The average time in the frame was 4.9 months, and then a patellar-tendon bearing plaster case or splint was used. The mean time until full weight-bearing without external support was 7.9 months. In the twenty-two patients who could be assessed, the final result was excellent or good in seventeen and acceptable in five.

Cavus deformity of the foot after fracture of the tibial shaft.

Twenty-three cases of claw foot with limited talocrural and subtalar mobility were the result of muscle contracture of the leg after tibial-shaft fracture. A roentgenographic study including arteriography was performed. It was concluded that the typical short cavus foot is due to fibrous contracture of the muscles in the deep posterior compartment caused by vascular damage, swelling in the deep posterior compartment, or severe muscle laceration. On physical examination the distance between the lateral malleolus and the Achilles tendon was shortened in comparison with the sound side in all cases. This was found to be caused by dorsiflexion in the talocrural joint coincident with adduction in the mid-tarsal joint. The angulation of the foot forced the patients to rotate the leg outward in order to get the feet in parallel position for walking. This deformity could be misinterpreted as an inward malrotation of the tibial fracture. In severe cases a derotating three-dimensional wedge osteotomy of the distal part of the tibia was performed with promising results.

Indirect spinal canal decompression in burst fractures treated with pedicle screw instrumentation.

STUDY DESIGN: Prospective evaluation of spinal canal areas in 67 consecutive burst fractures between T12 and L2 treated by reduction and stabilization with a pedicle fixator. OBJECTIVES: Assessment of the efficacy of "indirect" spinal canal decompression in a large series of burst fractures. SUMMARY OF BACKGROUND DATA: Up to 50% of burst fractures cause neurologic impairment. Reduction and posterior instrumentation is the most common surgical treatment. This also reduces spinal canal encroachment by indirect decompression. No consensus exists as to the consistency and adequacy of such indirect decompression. METHODS: Spinal canal areas were measured on preoperative and postoperative computed tomography scans. The degree of encroachment was compared with clinical and radiographic variables for possible correlation. RESULTS: Spinal canal encroachment was more severe among patients with neurologic deficits than among the neurologically intact. Postoperatively, mean encroachment was reduced from 35% to 12% at T12, from 37% to 17% at L1, and from 52% to 35% at L2. Loss (and postoperative restoration) of anterior vertebral height correlated best with the degree of canal encroachment (and its reduction), especially in Denis Type A burst fractures. In Denis Type B fractures, canal compromise usually was less severe and fragment reduction better in patients older than 40 years of age than in younger patients. CONCLUSIONS: Indirect decompression in burst fractures averages about half of the preexisting encroachment. Results are usually better at T12 and L1 than at L2. Additional or secondary decompression is rarely indicated if these fractures are treated early and by experienced surgeons. Burst Type B fractures in patients older versus younger than 40 years of age differ in many respects.

The humoral renal antihypertensive system: nervous and hemodynamic effects in normotensive and unclipped renal hypertensive rats.

A series of studies of the humoral renal antihypertensive system in normotensive and 2K 1C-renal antihypertensive rats is outlined. The rapid structural upward resetting of the cardiovascular system in renal hypertensive rats was associated with a structural downward resetting in the vasculature of the hypotensive clipped kidney. Unclipping of this kidney caused a pronounced release of renomedullary depressor agents, explaining the rapid normalization of pressure seen after unclipping. This normalization of pressure masks a state of pronounced functional hypotension in a structurally still hypertensive cardiovascular system, characterized by marked splanchnic vasodilatation and a lack of neurogenic counter-regulation. Only when this state has lasted long enough to normalize the structural upward resettings, characteristic of hypertension does the cardiovascular system return to normal. Further, cross-circulation techniques have shown that the humoral antihypertensive agents suppress tonic sympathetic activity, thereby inhibiting normal reflex counter-regulation of their vasodilator effects. Presumably this occurs via both vagal cardiac afferents and central actions. Further, behavior and awareness become depressed during intense and prolonged renomedullary release. Finally, experiments for which a normotensive kidney is cross-circulated from a normotensive rat suggest that the humoral renomedullary antihypertensive system has its threshold of release set so low as to contribute to normal blood pressure regulation, presumably in reciprocal balance with the renocortical renin-angiotensin system. Stepwise pressure elevations increasingly enhance release of the depressor agents from the cross-perfused kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrent dislocation after total hip replacement. Treatment by fixing an additional sector to the acetabular component.

Six patients with recurrent dislocation after total hip replacement have been treated by fixing an additional sector to the acetabular component. Muscle imbalance or unsatisfactory positioning of the prosthetic components (or both) had caused the dislocations in five patients. In the sixth, a schizophrenic, the dislocations were due to the positions in which the patient placed his limb. At operation a sector was cut from another acetabular prosthesis and screwed on to the previously inserted acetabular component in such a position as to prevent further dislocation. This method has been successful and seems a simple alternative to exchange arthroplasty.

Cervical spine fracture caused by high jump.

A case of disabling cervical spine arthrosis after a facet joint fracture sustained during a high jump is described. The condition was successfully treated by posterior fusion.

Direct leg lengthening.

Twenty patients with an average posttraumatic leg length shortening of 4.6 cm (range 2.5-9) underwent direct leg lengthening. The operation time averaged 210 min and the peroperative blood loss was 1,800 ml. Angular and rotational malalignment, when present, were corrected. Lengthening averaged 3 cm. At follow-up, two patients had serious sequelae after vascular injuries. Seven patients had postoperative neurological complications, which in four cases resolved completely. The time required for solid union of the lengthened segment averaged 10 months. Bone grafting two or more times was performed in six patients. Seventeen patients were assessed an average of 7 years (range 3-10) after surgery. Thirteen of these were satisfied with the results of the lengthening. Complications of the procedure and/or a remaining major leg length inequality could explain the dissatisfaction of the others. A majority of the patients complained of low-back pain both preoperatively and at follow-up. Few complaints about the joints in the long leg were expressed. Preoperative pain about the hip and knee in the short leg existed in more than half of the patients, and these complaints were reduced on a weak statistical level at follow-up. Walking ability improved in 12 patients, working ability in 10, and recreational activity level in eight. Direct leg lengthening is generally regarded as major, demanding surgery, entailing potential risks of serious complications, and should be used with great care and only in selected cases.

Transpedicular bone grafts misplaced into the spinal canal.

After open reduction of a burst fracture of L1, transpedicular bone grafting of the fractured vertebral body was performed. Bone grafts accidentally slipped into the spinal canal through the damaged medial wall of the pedicle. No adverse effects were noted clinically, but this case illustrates that transpedicular bone grafting is a potentially dangerous procedure. Computed tomography after 1 year showed complete resorption of the intraspinal bone grafts.