Attitude of health care professionals to organ donation: two surveys among the staff of a German university hospital

The persistent shortage of organs for transplantation could be minimized by increasing the number of potential donors. The opinion of the staff of a university hospital toward organ donation is of special interest because they are directly involved in solid organ transplantation. In 2007, we conducted a first voluntary survey concerning organ donation among the staff of the university hospital of Essen. A short information campaign and further opinion poll among staff as well as visitors was performed in 2009 to compare professional and public attitudes toward organ donation. The first poll comprised 242 questionnaires showing 55% of the hospital staff carrying organ donor cards, particularly more women (60%) than men (46%). After this survey, an additional 19% of the hospital staff imagined they might carrying an organ donor card in the future. In the second survey, we analyzed 151 questionnaires, showing 66% of staff members carrying an organ donor card, an incidence significantly greater than among visitors (48%). The need for information regarding organ donation was greater among visitors (35%). However, 21% of the hospital staff still also need education concerning organ donation. More education and increased transparency of transplantation practice are necessary for hospital staff to act successfully as initiators. Hospital staff with positive attitudes toward organ donation may have a positive impact on the attitudes of the general public toward organ donation.

Use of marginal organs in kidney transplantation for marginal recipients: too close to the margins of safety?

Objective

Due to organ shortage, average waiting time for a kidney in Germany is about 4 years after start of dialysis. Number of kidney grafts recovered can only be maintained by accepting older and expanded criteria donors. The aim of this study was to analyse the impact of donor and recipient risk on kidney long-term function.

Methods

All deceased kidney transplantations were considered. We retrospectively studied 332 patients between 2002 and 2006; divided in 4 groups reflecting donor and recipient risk.

Results

Non-marginal recipients were less likely to receive a marginal organ (69 of 207, 33%) as compared to marginal recipients, of whom two-thirds received a marginal organ (p < 0.0001). Graft function significantly differed between the groups, but detrimental effect of marginal recipient status on eGFR after 12 months (-6 ml/min/1.73 qm, 95% CI -2 to -9) was clearly smaller than the effect of marginal donor status (-10 ml/min/1.73 qm, 95% CI -7 to -14).

Conclusions

As we were able to show expanded criteria donor has a far bigger effect on long-term graft function than the "extra risk" recipient. Although there have been attempts to define groups of recipients who should be offered ECD kidneys primarily the discussion is still ongoing.

Evaluation of organ donor card holders among public officials of a major German city

INTRODUCTION

Each year in Germany, the lack of donor organs results in more than 1000 patients dying while on the transplant waiting list. At the same time, there is an organ donor potential that is not being exploited. The objective of this study was to collect the rate of holders of organ donor cards among public officials in a major German city.

METHODS

In 2007, a survey was conducted among public officials in Essen, North Rhine-Westphalia, Germany, regarding the topic of organ donation. Gender, age, and the "indicator for organ donation willingness" were stratified and analyzed according to the holding of organ donor cards.

RESULTS

A total of 1582 completely answered questionnaires were evaluated; 20.92% of the respondents had an organ donor card. No statistically significant association between gender (P = .0691), age (P = .8513), or possession of a donor card could be determined. We observed a significant correlation (P < .0001) between the indicator for organ donation willingness and possession of an organ donor card.

DISCUSSION

Based on current research, we consider an up-to-date, broader-reaching, representative inquiry necessary for our society. Should this present similar results, then a special education campaign is necessary, which considers sociocultural backgrounds and responds to the indicator for organ donation willingness that we analyzed. In so doing, one individual goal is the promotion of health and body awareness and thus an increase in the associated potential organ donor willingness.

438 REPEATED ULTRASOUND-GUIDED FOLLICULAR ASPIRATION IN PREGNANT SUCKLED BEEF COWS PRETREATED WITH OR WITHOUT eCG

In vivo oocyte recovery during the first trimester of pregnancy may be an alternative method of obtaining gametes for IVM/IVF/IVC from genetically valuable females. This study was conducted to evaluate i) the influence of the day of gestation on the follicular growth and number and quality of oocytes recovered by ovum pick-up (OPU) in pregnant suckled beef cows with or without eCG pre-stimulation, and ii) the possible effects on pregnancy outcome. Twelve pregnant suckled Angus cows (40 days after FTAI) were randomly assigned to 2 groups (n = 6/group). Group 1 treatment included: Day 0 = dominant follicle ablation (DFA) to synchronize the emergence of a new follicular wave, Day 1 = eCG treatment (2,000 IU, i.m. Syntex, Argentina) and Day 5 = OPU (follicles >3 mm were aspirated). Group 2: as for Group 1 with no eCG treatment. In both groups, OPU was repeated 5 times (Days 45, 59, 73, 87, and 101 of gestation) and ovarian follicles were classified into 3classes according to diameter (class I, <5 mm; class II, 5-9 mm; and class III, ≥10 mm). The collected COCs were categorized in 4 categories (I to IV) on the basis of both cumulus cells and appearance of oocyte cytoplasm. Categories I + II were considered as viable. Data were analyzed by PROC MIXED (SAS Institute, Cary, NC, USA). There was a significant treatment by follicular class interaction (P < 0.001). The numbers (mean ± SEM) of class II (4.3 ± 0.9) and III (2.5 ± 0.4) follicles/cow/session observed in eCG-treated cows were greater than for nontreated cows (0.9 ± 0.1 and 0.9 ± 0.1, respectively). In contrast, the number (mean ± SEM) of class I follicles/cow/session was lower for cows with eCG treatment (2.8 ± 0.4) than for nontreated cows (5.7 ± 0.5). A significant treatment by day of gestation interaction for aspirated follicles was observed (P = 0.03). The numbers (mean ± SEM) of recovered oocytes and viable oocytes/cow/session were greater (P < 0.05) for eCG-treated cows (2.2 ± 0.2 and 1.6 ± 0.4 respectively) than for nontreated cows (1.0 ± 0.2 and 0.9 ± 0.2, respectively). No donor pregnancies were lost either during or following OPU procedure. The overall efficiency of OPU procedure is shown in Table 1. We can conclude that (1) eCG-treated pregnant suckled cows can be a source of oocytes for IVF to at least 100 days of gestation and (2) repeated DFA/eCG treatment/OPU procedures did not affect the pregnancy outcome. Table 1.Overall efficiency of repeated DFA/eCG treatment/OPU procedures in pregnant suckled cows

Cyclo-oxygenase-2 overexpression is a feature of early and well-differentiated hepatocellular carcinoma with a favourable prognosis

AIMS

To determine the prognostic relevance of cyclo-oxygenase-2 (COX-2) expression in hepatocellular carcinoma (HCC) and its relationship to important clinicopathological parameters.

METHODS

A series of 196 patients with HCCs treated either by surgical resection (n = 106) or liver transplantation (n = 90) was investigated. Immunohistochemically confirmed COX-2 expression was correlated with a series of clinicopathologically relevant parameters as well as proliferative activity and apoptosis.

RESULTS

Overexpression of COX-2 correlated statistically with high histological tumour differentiation (p<0.001) and early TNM stage (p = 0.003). COX-2 overexpression was associated with lower apoptotic rates (p = 0.001), whereas proliferation activity did not differ significantly. In addition, COX-2 overexpression showed a significant correlation with favourable overall survival (p<0.001). In multivariate survival analysis, COX-2 expression qualified as an independent prognostic parameter (p = 0.030).

CONCLUSIONS

Overexpression of COX-2 in HCC indicates early-stage cancer with less aggressive tumour behaviour and constitutes an independent prognostic factor.

Liver transplantation for hilar cholangiocarcinoma: a German survey

BACKGROUND

The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL).

PATIENTS AND METHODS

We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate.

RESULTS

Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014).

CONCLUSIONS

The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.

Liver transplantation for hilar cholangiocarcinoma: a German survey

BACKGROUND

The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL).

PATIENTS AND METHODS

We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate.

RESULTS

Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014).

CONCLUSIONS

The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.

Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration.

RESULTS

Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Those who underwent transplantation in the early period had a preoperative diagnosis of inoperable ICC (n = 4) and ICC in the setting of primary sclerosing cholangitis (n = 2). In the latter period the subjects had a diagnosis of HCC in cirrhosis (n = 3) or recurrent ICC after an extended right hepatectomy (n = 1). Median survival was 25.3 months for the whole series and 32.2 months (range, 18-130 months) when hospital mortality was excluded (n = 3). Four patients are currently alive after 30, 35, 42, and 130 months post-OLT, respectively. Two patients died of tumor recurrence at 18 and 21 months post-OLT, respectively. One-, 3-, and 5-year survival rates were 70%, 50%, and 33%, respectively.

CONCLUSIONS

The role of OLT in the setting of ICC may be re-evaluated in the future under strict selection criteria and with prospective multicenter randomized studies. Potential candidates to be included are those with liver cirrhosis and no hilar involvement who meet the Milan criteria for HCC.

[Readiness for organ donation: analysis of a survey for health themes]

BACKGROUND

Currently, organ transplantation is the treatment of choice for patients with chronic or acute organ failure. However, due to a lack of donor organs, every day three patients die on the waiting list for transplantation. At the same time there is a high potential of organ donors that is not utilized. Statements concerning the number of potential donors are possible only to a limited extent at present. Objective of this study was to collect the rate of holders of organ donor cards among the employees of the city of Essen before a targeted awareness raising campaign had been carried out.

PATIENTS AND METHODS

A questionnaire was sent out to the employees of the city of Essen in 2007. Gender, age and the "indicator for readiness for organ donation" were stratified and analyzed according to the holding of organ donor cards. The indicator reflects the evaluation of health awareness in the respondents.

RESULTS

Altogether, 1 814 questionnaires were evaluated. 20 % of the respondents were holding an organ donor card at the time of the survey. No association between gender (p-value 0.17) respectively age (p-value 0.79) and the possession of an organ donor card could be detected. 23 % of the respondents who regularly worked out or donated blood were identified as organ donor card holders. This is significantly more (p-value < 0.0001) than in respondents where this criterion did not apply.

CONCLUSION

In order to optimize the potential of organ donors in the long term, it is necessary to reconsider and advance attitude towards the readiness for organ donation. Further spreading of information and education as well as transparency in the transplantation medicine are essential for this project.

[Kidney procurement and transplantation from a surgical perspective]

Kidney transplantation is the best therapeutic option in many patients with end-stage renal disease, because it significantly increases lifespan over that of patients who remain on dialysis. Because of organ shortage the average waiting time for a suitable kidney in Germany is about four years after the onset of dialysis treatment. Currently about 80% of all transplanted kidneys are obtained from brain-dead patients. The possibility for kidney transplantation after living donation reduces the minimum waiting time to a few weeks. An optimized organizational strategy as well as donor and recipient preparation are possible in living donation, resulting in excellent transplant quality and a short cold-ischemia time. Pre-emptive kidney transplantation after living donation is an attractive treatment option without the need for previous dialysis and is also an option for children. The excellent long-term results after kidney transplantation have been caused by improvement of operative technique, organizational strategy, donor preparation, postoperative care and, in particular, immunosuppression.

61 BOVINE OOPLASM PARTIALLY REMODELS CHIMPANZEE SOMATIC NUCLEI FOLLOWING SOMATIC CELL NUCLEAR TRANSFER

Interspecies somatic cell nuclear transfer (iSCNT) is a tool to address basic questions related to nucleus–cytoplasm interactions between different species. This approach may have practical applications, such as endangered species preservation. To date, live offspring have been obtained only when closely related species were used, such as cow/gaur, cow/buffalo, and domestic cat/wild cat. Several groups have reported preimplantation development of iSCNT embryos using a diverse collection of species; however, further development of these embryos either failed or was not reported. The aim of this study was to investigate developmental events that take place during reprogramming of a somatic nucleus in an enucleated oocyte from a distant species. Our experimental model was cow/chimpanzee iSCNT. We confirmed the donor cell genome origin in SCNT embryos by karyotyping. Embryonic genome activation (EGA) was monitored by Br-UTP incorporation assay and RT-PCR analysis of 6 genes. Chromatin remodeling events such as histone acetylation, histone methylation, and DNA methylation were observed by immunocytochemistry along with examination of Oct4 and Nanog promoter methylation by bisulfite sequencing. As an indicator of embryonic metabolism, ATP levels and apoptotic status of embryonic nuclei were determined by ATP detection and TUNEL assays, respectively. Development of iSCNT embryos did not progress beyond the 8- to 16-cell stage, whereas their cow/cow SCNT counterparts readily developed to the blastocyst stage. Karyotype analysis showed a donor-specific, diploid genomic content in most of the iSCNT nuclei (46 chromosomes). Major EGA takes place at the 16- and 8-cell stages in cow and chimpanzee embryos, respectively. However, our analyses showed a partial EGA pattern in iSCNT embryos at the 8-cell stage, as indicated by lower levels of Br-UTP incorporation and irregular expression of certain embryonic genes compared to that in cow/cow SCNT embryos. GAPDH, Oct4, and Stella transcripts were detected, while Nanog, Glut1, and DSC2 genes failed to be expressed in chimpanzee somatic nuclei, as opposed to robust expression observed for all 6 genes in bovine SCNT embryos. Dynamic chromatin remodeling events as monitored by H3K27 methylation and H4K5 acetylation-specific antibodies were similar in both intra- and interspecies SCNT embryos from 1-cell to 8–16-cell stages. A global demethylation pattern was observed in iSCNT embryos from 1-cell to 8–16-cell stages, which was not significantly different from that of bovine SCNT embryos by immunocytochemistry. However, bisulfite sequencing indicated incomplete demethylaton of Oct4 and Nanog promoters in 8-cell iSCNT embryos, unlike the complete demethylation of the same promoter regions observed in their bovine intraspecific counterparts. ATP levels were significantly higher in bovine SCNT embryos than in iSCNT embryos; TUNEL assay did not reveal any difference in apoptotic status of the nuclei from both types of embryos. Collectively, our results suggest that bovine ooplasm can partially remodel chimpanzee somatic nuclei. However, the remodeling activity was not sufficient to drive embryo development past the 8–16-cell stage.

[Surgical therapy of hilar cholangiocarcinoma]

Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Due to the central anatomic localization within the liver hilum, established guidelines of oncologic surgery are difficult to apply. Resection of the hilar bifurcation alone or in combination with limited hepatic resection can be performed with low morbidity and low mortality but shows a high rate of local tumor recurrence. Usually, extended resection is required to achieve adequate safety margins. Right trisectionectomy complies best with the basic rules of oncologic surgery while allowing the maximum safety margin. The 5-year survival rates reported after right trisectionectomy range between 20% and 40% and reach 59% in selected patients. The increasing experience with living donor transplantation and recent advances in neoadjuvant tumor therapy may lead to renewed discussion of liver transplantation in hilar cholangiocarcinoma.

Biliodigestive anastomosis after intraoperative irradiation in swine

A large animal model was established to investigate the feasibility and suitable dosage of intraoperative radiation therapy (IORT) to the hepatic hilum before biliary-enteric anastomosis is performed. Twenty-two Pietrain Hampshire pigs underwent gallbladder and proximal bile duct resection followed by IORT using 20-40 Gy and performing biliary-enteric anastomosis. In the follow-up period of 56 days, pigs developed dose-dependent complications like stenosis of the biliary-enteric anastomosis. Results demonstrate that IORT of the liver hilum up to 20 Gy is safe with acceptable early complications in the presented animal model. The porcine biliary-enteric anastomosis can tolerate intraoperative irradiation up to a dosage of 40 Gy without disruption.

Intensive induction chemotherapy with C-BOP/BEP for intermediate- and poor-risk metastatic germ cell tumours (EORTC trial 30948)

New chemotherapy regimens are continuously explored in patients with high-risk malignant germ cell tumours (MGCTs). This multicentre phase II trial assessed the efficacy and toxicity of C-BOP/BEP chemotherapy in intermediate and poor prognosis MGCT (IGCCCG criteria). C-BOP/BEP treatment consisted of cycles of cisplatin, vincristine, bleomycin and carboplatin, followed by one cycle of vincristine and bleomycin and three cycles of BEP (bleomycon, etoposide, cisplatin). The trial was designed to demonstrate a 1-year progression-free survival rate of 80%, that is, to exclude a 1-year rate of 70% or less, with a one-sided significance level of 5%. Secondary end points included toxicity, overall survival and the postchemotherapy complete response rate. In total, 16 European hospitals entered 66 eligible patients (intermediate prognosis group: 37; poor prognosis group: 29). A total of 45 patients (68.2%, 95% confidence interval (95% CI): 56.9–79.4%) achieved a complete response (intermediate prognosis: 30; poor prognosis: 15). After a median observation time of 40.4 months (range: 13.7–66.3), the 1-year progression-free survival rate was 81.8% 95% CI: 72.5–91.1%). The 2-year overall survival was 84.5% (95% CI: 75.6–93.3%). In all, 51 patients experienced at least one episode of WHO grade 3/4 leucopenia, and at least one event of grade 3/4 thrombocytopenia occurred in 30 patients. There was no toxic death. With an 82% 1-year progression-free survival and a lower limit of the 95% CI above 70%, the efficacy of C-BOP/BEP is comparable to that of published alternative chemotherapy schedules in high-risk MGCT patients. The treatment's toxicity is manageable in a multicentre setting. In poor prognosis patients, C-BOP/BEP should be compared to standard chemotherapy of four cycles of BEP.

New surgical technique for portal venous port system in Swine

The need for serial blood sampling and continuous infusion using the portal vein for experimental surgery and pharmacological studies is evident. As suitable animal models are rare, we established a new technique to implant a permanent vascular access device to the portal vein in swine. All operations in study animals (n=8) were technically feasible due to a regularly detected side branch of the portal vein within the inferior pancreatic region; complications did not occur. Mean operation time was 48+/-17 min. This study clearly shows that the portal venous access is feasible and can be achieved safely using the inferior pancreatic vein for a permanent vascular access port system.

[Two cystic retroperitoneal lesions mimicking adrenal cysts]

Adrenal cysts are uncommon lesions and most of them are found incidentally during abdominal imaging. We report on two benign extraadrenal lesions mimicking adrenal tumors in abdominal imaging. The histopathological investigation of the lesions revealed a foregut duplication cyst of the lesser gastric curvature and an epithelial inclusion cyst (epidermoid cyst) in an intrapancreatic accessory spleen respectively.

Staging laparoscopy in gastric cancer

BACKGROUND

As patients with gastric cancer are offered choices between surgical resection, neoadjuvant or palliative chemotherapy, or symptomatic relief alone, the need for accurate preoperative staging becomes apparent. Laparoscopy has been suggested as an appropriate staging modality in a variety of upper gastrointestinal malignancies.

METHODOLOGY

Staging laparoscopy was performed in 45 patients with potentially resectable gastric cancer as determined by physical examination, gastroscopy, endosonography, transcutaneous ultrasonography and current generation computed tomography. Conventional clinic staging and laparoscopic staging according to the Tumor-Node-Metastases classification of the International Union against Cancer were registered separately on a database. Results were then compared to evaluate the agreement of both staging procedures.

RESULTS

Compared to conventional staging, laparoscopy resulted in up staging of 23 patients (51.1%). In 10 patients of them peritoneal seeding was first found during laparoscopy, whereas additional liver metastases were detected in 3 patients and Krukenberg's tumor in one. As a consequence, the therapy planning was changed and laparotomy was avoided in 14 of these patients as the first operative procedure. Sensitivity of clinical staging was especially poor for stage IV tumors (5.3%) and for the majority of stage IIIB tumors (42.9%). Cytologic examination of peritoneal fluid had no additional information in our series.

CONCLUSIONS

The value of laparoscopy in staging patients with gastric carcinoma could be demonstrated in this study. It is a safe and effective staging modality, helping to avoid unnecessary laparotomies and providing new means of directing appropriate treatment strategy.