Design and implementation of the European-Mediterranean Postgraduate Programme on Organ Donation and Transplantation (EMPODaT) for Middle East/North Africa countries.

This prospective study reports the design and results obtained after the EMPODaT project implementation. This project was funded by the Tempus programme of the European Commission with the objective to implement a common postgraduate programme on organ donation and transplantation (ODT) in six selected universities from Middle East/North Africa (MENA) countries (Egypt, Lebanon and Morocco). The consortium, coordinated by the University of Barcelona, included universities from Spain, Germany, Sweden and France. The first phase of the project was to perform an analysis of the current situation in the beneficiary countries, including existing training programmes on ODT, Internet connection, digital facilities and competences, training needs, and ODT activity and accreditation requirements. A total of 90 healthcare postgraduate students participated in the 1-year training programme (30 ECTS academic credits). The methodology was based on e-learning modules and face-to-face courses in English and French. Training activities were evaluated through pre- and post-tests, self-assessment activities and evaluation charts. Quality was assessed through questionnaires and semi-structured interviews. The project results on a reproducible and innovative international postgraduate programme, improvement of knowledge, satisfaction of the participants and confirms the need on professionalizing the activity as the cornerstone to ensure organ transplantation self-sufficiency in MENA countries.

Quality assessment in intensive care units: proposal for a scoring system in terms of structure and process.

OBJECTIVE: We present a score for assessing the quality of ICU care in terms of structure and process, based on bibliographic review, expert consultations, field test, analysis, and final consensus, and analyze its initial application in the field. DESIGN AND SETTING: This feasibility and observational study was conducted within the framework of a French regional clinical research project (NosoQual); 40 ICUs were visited and assessed between November 2002 and March 2003 according to standardized procedures. MEASUREMENTS AND RESULTS: The grid consisted of 95 variables. The overall score derived from seven independent quality dimensions: human resources, architecture, safety and environment, management of documentation, patient care management, risk management of infections and evaluation, and surveillance. The average level of achievement of the scores varied from 48% to 63% of theoretical maxima. Variability in the individual dimensional subscores was greater than that of the overall score (CV=15). CONCLUSIONS: Evaluation this scoring system encounters the limitation of the absence of a "gold standard." However, this is counterbalanced by the rigorous design methodology, the characteristic strengths of the quality dimensions. The survey also highlights also feasibility and the potential interest for specific tools for the assessment of ICUs.

Confirmation of brain death diagnosis: A study on French practice.

INTRODUCTION: In France, brain death diagnosis is regulated by law and mandates the use of confirmatory tests (electroencephalogram or angiography). No data are available on this practice and the possible influence of medical history. STUDY DESIGN: National survey using an e-mail questionnaire after phone agreement. PATIENTS AND METHODS: A questionnaire was sent to intensive care units allowed to practice organ harvesting. It assessed the use of supplementary tests, the reasons behind the choice of a confirmatory test, as well as the influence of medical history on decision-making. RESULTS: Eighty-two out of 188 intensive care units (ICU) answered the questionnaire. Most of them (80%) performed supplementary tests, mainly transcranial Doppler. Computed tomography (CT) angiography was the only confirmatory test available in all ICUs, and this without interruption for 94% of them. Electroencephalogram (EEG) availability was usually restricted to weekdays. Most ICUs confirmed brain death by a CT-angiography (95%), less frequently by EEG (54%) and rarely by arteriography (12%). These tests were usually performed within 1 to 6 hours after clinical diagnosis. Results from imaging tests were obtained within 15 minutes in the majority of ICUs (59%), whereas the time for EEG results was more frequently between 15 and 60 minutes (62%). The choice of confirmatory test was guided by its availability (43%), or protocol driven (20%), or a combination of both of the latter criteria (35%). Medical history had no influence on this choice for 63% of respondents. DISCUSSION: CT-angiography is currently the privileged confirmatory test for the diagnosis of brain death in France. Availability is the main reason behind this choice. The EEG is the second most commonly used test. Transcranial Doppler helps to determine when to perform confirmatory tests.

Effect of N-acetylcysteine pretreatment of deceased organ donors on renal allograft function: a randomized controlled trial.

BACKGROUND: Antioxidant donor pretreatment is one of the pharmacologic strategy proposed to prevent renal ischemia-reperfusion injuries and delayed graft function (DGF). The aim of the study was to investigate whether a donor pretreatment with N-acetylcysteine (NAC) reduces the incidence of DGF in adult human kidney transplant recipients. METHODS: In this randomized, open-label, monocenter trial, 160 deceased heart-beating donors were allowed to perform 236 renal transplantations from September 2005 to December 2010. Donors were randomized to receive, in a single-blind controlled fashion, 600 mg of intravenous NAC 1 hr before and 2 hr after cerebral angiography performed to confirm brain death. Primary endpoint was DGF defined by the need for at least one dialysis session within the first week or a serum creatinine level greater than 200 µmol/L at day 7 after kidney transplantation. RESULTS: The incidence of DGF was similar between donors pretreated with or without NAC (39/118; 33% vs. 30/118; 25.4%; P = 0.19). Requirement for at least one dialysis session was not different between the NAC and No NAC groups (17/118; 14.4% vs. 14/118; 11.8%, P = 0.56). The two groups had comparable serum creatinine levels, estimated glomerular filtration rates, and daily urine output at days 1, 7, 15, and 30 after kidney transplantation as well as at hospital discharge. No difference in recipient mortality nor in 1-year kidney graft survival was observed. CONCLUSION: Donor pretreatment with NAC does not improve delayed graft function after kidney transplantation.

Transcranial Doppler shortens the time between clinical brain death and angiographic confirmation: a randomized trial.

BACKGROUND: Brain death diagnosis relies on clinical signs, but confirmatory tests are legally mandatory in some countries. In France, transcranial Doppler (TCD) is not recognized as a legal test to confirm brain death. Nevertheless, experts recommend its use to determine the need for a legal confirmatory test. The aim of this study was to test the hypothesis that TCD shortens the time between clinical brain death and computed tomography angiography (CTA) confirmation. METHODS: We conducted a prospective randomized controlled study to evaluate the benefit of a TCD-directed strategy before performing the CTA to confirm brain death. Once the clinical diagnosis of brain death was established, subjects were randomized in a conventional group (CTA 6 hr later as recommended in France) or a TCD group (TCD examination every 2 hr until intracranial brain death flow patterns were found). Forty-four subjects were needed to show a difference of 2 hr between the two strategies. RESULTS: TCD strategy resulted in a shorter time between clinical diagnosis of brain death and CTA confirmation compared with conventional strategy (2.0 [1.3-2.6] vs. 7.2 [6.3-9.5] hr, P<0.0001). The number of brain CTA performed to confirm the diagnosis of brain death was not different between groups. CONCLUSIONS: Our results suggest that TCD-directed strategy allows reducing the time between clinical diagnosis of brain death and CTA confirmation.

Malnutrition is an independent factor associated with nosocomial infections.

The aim of the present prospective study was to determine if malnutrition, measured using a simple validated score, is an independent risk factor for nosocomial infections (NI) in non-selected hospital in-patients. Between 29 and 31 May 2001, a survey on the prevalence of NI was conducted on all 1637 in-patients (61 (SD 25) years old) in a French university hospital as part of a national survey. Actual and usual body weights were recorded in all in-patients, and serum albumin levels were measured on all blood samples taken during the week before the study. Nutritional status was evaluated by using the nutritional risk index (NRI). Albumin values were obtained in 1084 patients, and complete weight information was obtained in 911. Therefore, NRI was calculated in 630 patients (61 (SD 20) years old): 427 (67.8 %) were malnourished. NI prevalence was 8.7 %: 4.4 % in non-malnourished patients, 7.6 % in moderately malnourished patients and 14.6 % in severely malnourished patients. In univariate analysis, the odds ratios for NI were 1.46 (95 % CI 1.2, 2.1) in moderately malnourished patients and 4.98 (95 % CI 4.6, 6.4) in severely malnourished patients. In multivariate analysis, age, immunodeficiency and NRI class influenced NI risk. Vascular and urinary catheters, and surgical intervention, were the extrinsic factors associated with NI, with odds ratios ranging from 2.0 (95 % CI 1.8, 2.6) for vascular catheters to 10.8 (95 % CI 8.8, 12.6) for association of the three factors. In conclusion, in non-selected hospitalized patients, malnutrition assessed with a simple and objective marker is an independent risk factor for NI. An early screening for malnutrition may therefore be helpful to reduce the high prevalence of NI.