Birgit Wulff

Risk factors for donor cornea contamination: retrospective analysis of 4546 procured corneas in a single eye bank.

Purpose: Microbiological contamination is a common cause for elimination of organ-cultured donor corneas. The aims of the present study were to analyze contamination rates and identify risk factors for contamination. Methods: Retrospectively, the contamination rates of 4546 organ-cultured corneas and the causative species were studied. The impact of sex, age, death-to-explantation interval, explantation technique, cause of death, and mean monthly temperature on contamination rate was analyzed. Results: The median annual contamination rate was 5.3% (range: 3%–19%). Most contaminations were of fungal origin (61.9%), with Candida species (45%) being predominant. Bacterial contaminations (34.4%) were dominated by Staphylococcus species (12.8%). Sex, donor age, and mean monthly temperature had no statistically significant influence on the contamination rate. The median death-to-explantation interval of contaminated corneas (44 hours) was longer than that of sterile corneas (39 hours; P < 0.001; n = 4437). Cardiopulmonary failure was associated with the highest contamination rate (13.6%) of all death causes. The switch from whole globe to in situ excision was followed by a temporary increase in contamination rate (12.5%–19.4%). Conclusions: Although the genesis of donor cornea contamination seems to be multifactorial, resident species from physiological skin flora are the main contaminants indicating that the donor corpses could be the main source of microbiological contamination. A change in the explantation technique was followed by an increase in the contamination rate.

A prospective time-course study on serological testing for human immunodeficiency virus, hepatitis B virus and hepatitis C virus with blood samples taken up to 48 h after death

The transmission of viral and non-viral infectious pathogens continues to be the most serious of the potential adverse effects of allogenic tissue transplantations. EU Directive 2006/17/EC stipulates that cadaveric blood specimens for serology testing in the context of post-mortem tissue donation must be taken not later than 24 h post-mortem. An expanded time slot would significantly improve the availability of tissue donations, but there are no significant data on the stability of infectious serology assays for anti-human immunodeficiency virus (HIV), anti-hepatitis C virus (HCV), hepatitis B virus (HBV) surface antigen (HBsAg) and anti-HBC core antigen (HBc) in samples collected more than 24 h post-mortem. In this prospective study, serum samples of 30 deceased persons were taken upon admission to the Institute of Forensic Medicine (University Hospital Hamburg-Eppendorf, Germany) and at 12, 24, 36 and 48 h post-mortem. All samples were measured twice, first using the Abbott AxSYM system, and then after ~9 months of storage at -70 °C using the BEP III System with Siemens and Ortho reagents. For HIV, six deceased persons with a pre-mortem HIV history were included. All samples (at committal and at 12, 24, 36, 48 h) were reactive. Indeterminate or false-negative results did not occur. For HCV, 17 deceased persons with a pre-mortem HCV history were included; 16 samples were reactive up to 48 h and one was reactive at 36 h post-mortem (48 h sample was not available). Indeterminate or false-negative results did not occur. For HBV, nine deceased persons were included: five samples were initially positive for HBsAg and remained positive up to 48 h, and eight of the samples were reactive for anti-HBc up to 48 h and one up to 36 h post-mortem (48 h sample was not available). Indeterminate or false-negative results did not occur. These data suggest that infectious serological testing may be extended for blood samples of potential tissue donors collected up to 48 h post-mortem to detect antibodies or antigens for HIV, HBV and HCV.

Thirty years of cornea cultivation: long‐term experience in a single eye bank

Purpose:  To evaluate donor demographics, trends in donor tissue procurement and tissue storage over a long period.

Virus NAT for HIV, HBV, and HCV in Post-Mortal Blood Specimens over 48 h after Death of Infected Patients – First Results

Objective: According to EU regulations (EU directive 2006/17/EC), blood specimens for virologic testing in the context of post-mortal tissue donation must be taken not later than 24 h post mortem. Methods: To verify validity of NAT in blood specimens collected later, viral nucleic acid concentrations were monitored in blood samples of deceased persons infected with HIV (n = 7), HBV (n = 5), and HCV (n = 17) taken upon admission and at 12 h, 24 h, 36 h and 48 h post mortem. HIV and HCV RNA were quantified using Cobas TaqMan (Roche), HBV DNA was measured by in-house PCR. Results: A more than 10-fold decrease of viral load in samples taken 36 h or 48 h post mortem was seen in one HIV-infected patient only. For all other patients tested the decrease of viral load in 36hour or 48-hour post-mortal samples was less pronounced. Specimens of 3 HIV- and 2 HBV-infected patients taken 24 h post mortem or later were even found to have increased concentrations (>10-fold), possibly due to post-mortem liberation of virus from particular cells or tissues. Conclusion: Our preliminary data indicate that the time point of blood collection for HIV, HBV and HCV testing by PCR may be extended to 36 h or even 48 h post mortem and thus improve availability of tissue donations.

Report of the clinical donor case workshop of the European Association of Tissue Banks Annual Congress 2013

The European Association of Tissue Banks (EATB) Donor Case Workshop is a forum held within the program of the EATB Annual Congress. The workshop offers an opportunity to discuss and evaluate approaches taken to challenging donor selection and donation ethics, and it strengthens networking between tissue banking professionals. The workshops actively engage participants from a wide array of international expertise, in an informal, secure and enjoyable setting in which learning from peers and finding potential solutions for submitted cases are facilitated. This report reflects some of the discussion at the Donor Case Workshop during the EATB Annual Congress in Brussels in 2013. The presented cases demonstrate that the findings, their interpretation, the resulting actions and preventive measures in the different tissue facilities are not always predictable. The varied responses from participants and lack of consensus corroborate this and clearly indicate that operating procedures do not comprehensively cover or prepare for all eventualities. For many of the issues raised there is no relevant information in the published literature. By publication of a summary of the discussions we hope to reach a wider audience, to provide information gathered at the workshop and to stimulate individuals and institutions to undertake further literature reviews or to undertake research in order to gather evidence concerning the discussed topics.

Communication skills of doctors in German forensic medicine institutes

ObjectiveThe aim of this questionnaire-based study was to assess the communication skills of German forensic pathologists in respect to talks with the next of kin of the deceased and victims of violence (clinical forensic medicine). The study investigated self-confidence in these challenging situations.MethodsAll 28 German forensic medicine institutes were asked to participate. After consent had been granted a local investigator was appointed who contributed information about the organizational structure and delivered the local questionnaires to the colleagues.ResultsA total of 25 German forensic institutes participated and146 out of 192 questionnaires were retrieved (response rate 76 %: 72 female, 70 male and 4 unknown). The results of the whole sample are shown and the distribution of female/male doctors in respect to the professional status, the amount and topics of next of kin contact and contact to victims of violence and the estimated need for further training. Of the responders 52 % have on average 1–5 contacts with the next of kin of the deceased per month and12 % have more contact. Of the whole sample 30 % but nearly half of the female responders have experienced themselves as not being well-prepared in the past and 38 % reported these conversations to be more challenging than those with victims of violence. Further communication training for the next of kin contact was judged as necessary to very necessary by 64 % of the participating doctors, especially highlighted by those in leading positions. Of the participants 57 % conduct 1–5 examinations per month, 32 % carry out more, 80 % assessed these contacts as difficult and for 7 % even more than next of kin contacts. Further education for the care of victims of violence was evaluated as necessary to very necessary by 74 %, mainly by interns. Both kinds of contact are equally difficult for 36 %.ConclusionMany forensic pathologists, especially the younger ones, do not feel adequately prepared for the communication challenges in legal medicine by their specialty training although these skills are required for forensic specialists in Germany. Therefore, the German Association of Forensic Pathologists is called upon to put the further education rules (Weiterbildungsordnung) into practice and enable the requested achievement of competences. According to the data obtained in this survey even a voluntary offer for communication training would be attended by more than 70 % of the responders.ZusammenfassungHintergrundDas Ziel dieser fragebogengestützten postalischen Umfrage unter den in Deutschland rechtsmedizinisch tätigen Ärzten zum Umgang mit Angehörigen von Verstorbenen und mit Opfern von Gewalt war es, eine erste Einschätzung zu gewinnen, welche Bedeutung diese kommunikativ schwierigen Begegnungen in ihrer Alltagstätigkeit haben, inwieweit sie im Rahmen ihrer Weiterbildung auf entsprechende Situationen vorbereitet wurden und ob zu dieser Thematik aktuell ein Fortbildungsbedarf besteht.MethodenEin telefonisches Vorab-Interview mit jeweils einem Mitarbeiter klärte Fragen zur Organisation der Institute im Hinblick auf die o.g. Fragestellungen. Im Anschluss wurde ein für diese Umfrage erstellter anonymisierter Fragebogen an alle ärztlichen Mitarbeiter der teilnehmenden Institute versendet.ErgebnisseVon insgesamt 28 angeschriebenen universitären Instituten für Rechtsmedizin nahmen 25 teil. Von den 192 ausgegebenen Fragebogen wurden 146 ausgefüllt zurückgesendet (Rücklaufquote von 76 %, 72 Ärztinnen, 70 Ärzte, 4 ohne Angabe zu Geschlecht). Die Ergebnisse der gesamten Stichprobe werden dargestellt in Bezug auf beruflichen Status, auf das Ausmaß und die Themen der Kontakte mit Angehörigen und Gewaltopfern sowie den abgeschätzten Fortbildungsbedarf.Die Auswertung ergab, dass die meisten befragten Ärzte (52 %) etwa 1–5 und 12 % mehr als 5 Gespräche mit Angehörigen pro Monat führen. In Bezug auf Untersuchungen im Rahmen der klinischen Rechtsmedizin sagten 57 % aus, monatlich etwa 1–5 Untersuchungen durchzuführen und 32 % gaben an, es seien mehr als 5 Untersuchungen pro Monat. Etwa 80 % aller Befragten bewerteten diese Gespräche als schwierig; 38 % gaben an, dass Gespräche mit Hinterbliebenen im Vergleich zu denen mit Opfern von Gewalt eine größere Herausforderung seien. Ein Fortbildungsangebot zur Betreuung von Angehörigen wurde von 64 % aller teilnehmenden Ärzte als „notwendig“ bis „sehr notwendig“ eingeschätzt, insbesondere auch von den Institutsleitungen. Fortbildungen zum Umgang mit Opfern von Gewalt wurden von 74 % als „notwendig“ bis „sehr notwendig“ bewertet, und hier wünschten sich vor allem die befragten Assistenzärzte Möglichkeiten der Fortbildung. Von 36% wurde angeben, dass der Umgang mit beiden Gruppen für sie gleich schwierig sei.SchlussfolgerungDiese erstmalige Umfrage zur kommunikativen Kompetenz in der Rechtsmedizin in Deutschland zeigt, dass sich viele rechtsmedizinisch tätige Ärzte, vor allem jüngere, derzeit im Rahmen ihrer Weiterbildung nicht ausreichend auf die beschriebenen kommunikativen Herausforderungen vorbereitet fühlen. Ein freiwilliges Fortbildungsangebot würde von über 70 % der Befragten wahrgenommen werden. Hier ist die rechtsmedizinische Fachgesellschaft aufgerufen, den in der Weiterbildungsordnung geforderten Kompetenzerwerb zu ermöglichen.

Regional experiences of tissue donation and forensic medicine in hamburg - results of a 5-year period.

Objective: We present the operational organization and daily workflow of our Hamburg model and the results of the years 2007–2011 concerning donation of corneas, musculoskeletal and, since 2010, cardiovascular tissues. Methods: Each of the about 3,600 deceased every year undergoes an evaluation process by two coordinators on duty, the tissue coordinator and the family coordinator. All donation connected issues are carried out within the standardized protocols of a quality management system and documented in a special data base. Two catamnestic surveys evaluated the satisfaction of donor families retrospectively. The inclusion rate for cornea donation was 23% and for musculoskeletal donation 10%, with a decrease after the 75 years age restriction of musculoskeletal donors in 2011 defined by the contracting tissue bank German Institute for Cell and Tissue Replacement gGmbH (DIZG), Berlin. Results: Since 2007 1,268 corneas were explanted altogether, reflecting an increasing explantation rate from 156 (University Medical Center Hamburg-Eppendorf (UMC: 9) in 2007 up to 304 (UMC: 52) in 2011. Overall 173 musculoskeletal donors (5 years) and 11 cardiovascular donors (2 years) spent tissues. The consent rate was much higher. The evaluation of the families reflected a positive feedback for the guiding of the donation process. Conclusion: Forensic institutes can act as an interface between donors and recipients without neglecting forensic investigations. They are uniquely positioned to recognize potential donors. In addition, the contact with a physician of the forensic institute may help families during the mourning phase.

Die Gewebespende in der Rechtsmedizin am Beispiel Hamburg

Humane Gewebetransplantate haben fur die Patientenversorgung in Deutschland eine von der Offentlichkeit kaum wahrgenommene zunehmende Bedeutung. Verbreitet prasent im offentlichen Bewusstsein sind die lebensrettenden Moglichkeiten der Organspende, wahrend die postmortale Gewebespende als Chance zur Verbesserung der Lebensqualitat z. B. sehbehinderter Patienten weniger bekannt ist. Zur Forderung der postmortalen Gewebespende tragen neben der Diskussion in Medien und Fachkreisen vor allem konkrete Realisierungsprojekte wie am Hamburger Institut fur Rechtsmedizin bei.

Endothelial Cell Count in Eye Bank Corneal Grafts: Impact of Death Cause and Donor Diseases

ABSTRACT Purpose: The purpose of this study is to analyze the impact of death causes and documented donor diseases on initial endothelial cell counts (after retrieval) and the development of corneal graft endothelia during organ culture. Methods: The retrospective statistic analyses was conducted on a data set of 10,185 human corneas prepared at the Hamburg Eye Bank. Results: Although we observed that death by gunshot trauma or alcoholism seems to be associated with marginally higher endothelium cell counts (independently from donor age), we could prove that only donor age is a relevant predictive parameter for the initial cell-density of the endothelium and its development in vitro. Conclusion: We conclude that an extension of prospective quality parameters for donor selection additional to donor age (such as individual causes of death) is not necessary.

Bone microarchitecture of the tibial plateau in skeletal health and osteoporosis

BACKGROUND Impaired bone structure poses a challenge for the treatment of osteoporotic tibial plateau fractures. As knowledge of region-specific structural bone alterations is a prerequisite to achieving successful long-term fixation, the aim of the current study was to characterize tibial plateau bone structure in patients with osteoporosis and the elderly. METHODS Histomorphometric parameters were assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) in 21 proximal tibiae from females with postmenopausal osteoporosis (mean age: 84.3 ± 4.9 years) and eight female healthy controls (45.5 ± 6.9 years). To visualize region-specific structural bony alterations with age, the bone mineral density (Hounsfield units) was additionally analyzed in 168 human proximal tibiae. Statistical analysis was based on evolutionary learning using globally optimal regression trees. RESULTS Bone structure deterioration of the tibial plateau due to osteoporosis was region-specific. Compared to healthy controls (20.5 ± 4.7%) the greatest decrease in bone volume fraction was found in the medio-medial segments (9.2 ± 3.5%, p < 0.001). The lowest bone volume was found in central segments (tibial spine). Trabecular connectivity was severely reduced. Importantly, in the anterior and posterior 25% of the lateral and medial tibial plateaux, trabecular support and subchondral cortical bone thickness itself were also reduced. CONCLUSION Thinning of subchondral cortical bone and marked bone loss in the anterior and posterior 25% of the tibial plateau should require special attention when osteoporotic patients require fracture fixation of the posterior segments. This knowledge may help to improve the long-term, fracture-specific fixation of complex tibial plateau fractures in osteoporosis.