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The critical pathway of deceased donation provides a systematic approach to the organ donation process, considering both donation after cardiac death than donation after brain death. The pathway provides a tool for assessing the potential of deceased donation and for the prospective identification and referral of possible deceased donors.

Background The world health report 2008 emphasizes "that putting people at the centre of service delivery" is not only about service delivery models from a short-term perspective, but rather about long-term commitment to health care. (1) Given the critical shortage of the health workforce, investments in training, retaining and sustaining them are necessary. Sub-Saharan Africa is a prime example of uneven distribution of health-care personnel. The subcontinent carries 24% of the global burden of disease in 11% of the world's population, but has as little as 3% of the world's health workers. (2) The concern for countries in sub-Saharan Africa and other nations was recognized by the World Health Assembly resolution WHA59.23 that urged for rapid scaling up of health workforce production. (3) Addressing the situation should take into account the four reforms (universal coverage, people-centred service delivery, leadership and public policies) towards refocusing health systems through primary health care. Importance of anaesthesia workforce The contribution of surgical conditions to the global burden of disease and the potential impact of the provision of basic surgical services at the first referral level facility is widely under appreciated. It is estimated that 11% of the world's disability-adjusted life years (or years lost from healthy lives) are from conditions that are very likely to require surgery. (2) Adequate surgical care as a primary care strategy can address and greatly alleviate this burden. (4) Increasing evidence is beginning to emerge that maternal and infant survival is proportionately correlated to the number of health workers providing obstetric care that includes anaesthesia. (5,6) The delivery of surgical (including obstetrics and trauma) care is highly dependent on the availability and retention of a trained anaesthesia healh workforce. The United Kingdom Confidential Enquiry for Perioperative Death in 1987 reported one death per 185 000 anaesthetic procedures; whereas in Zambia (University teaching hospital), it was one death per 1925. The avoidable anaesthesia-mortality rate in Malawi (central hospital) was one death per 504; in Nigeria (teaching hospital) for Caesarean sections, one death per 387 anaesthetic procedures; in Togo (teaching hospital), one death per 133; and in Zimbabwe (district hospital), one death per 482. (7) Many of these unnecessary deaths were a result of airway problems and hypovolaemia in healthy young patients. (7) Though the common perception is that anaesthesia services are only required at the level of secondary and tertiary health-care facilities, the availability of basic services at the first referral level facility can contribute significantly to a reduction in death and disability. At the district and sub-district level, health personnel are expected to provide a range of anaesthesia services (local, intravenous ketamine, spinal and general anaesthesia) for the management of pregnancy-related complications, unsafe abortion, injuries (road traffic accidents, domestic violence, burns, falls, rape), complications of female genital mutilation, congenital anomalies as well as other surgical conditions. To safely deliver anaesthesia in emergency and surgical procedures, investments for appropriate training are required. The role of anaesthesia extends beyond the operating room, and is necessary in postoperative monitoring, intensive care units, for co-existing medical conditions, as well as providing pain relief (particularly in children and women in labour). A workforce trained in basic anaesthetic techniques at the primary health care level can also resuscitate critically ill patients or those with severe trauma and stabilize their condition, before transfer to a more specialized facility. The anaesthesia services required at the first referral level facilities can mostly be delivered by trained nonphysician anaesthetists. Current situation Physician anaesthetists are scarce in many developing countries and not available at first referral level health facilities. …

Objective: A high mortality rate is associated with anesthesia in low and middle income countries. The provision of basic and emergency surgical services in developing countries includes safe anesthetic care. We sought to determine the resources available to deliver anesthesia care in low and middle income countries. Methods: A standard World Health Organization tool was used to collect data from 34 Low and Middle-Income Countries (LMICs) regarding infrastructure and capacity of facilities. We then performed a database query to extract information on anesthesia-related capacity. Findings: Twelve countries were excluded for providing data on less than four facilities, leaving 22 countries in our results, with a total of 590 facilities surveyed. Thirty five percent of hospitals had no access to oxygen and 40% had no anaesthesia machines; despite this, 58.5% of hospitals offered general inhalational anesthesia. All facilities reported presence of an anaesthesia provider: a nurse or clinical assistant was present in all 590 facilities. Hospitals with > 200 beds reported a range of 2-10 providers; the average number of anesthesia physicians increased from one to four as the hospital size increased from less than to greater than 300 beds. The majority of facilities were district/rural/community hospitals (34.7%), followed by health centres (23.2%), private/NGO/missions hospitals (16.6%), provincial hospitals (11.7%), and general hospitals (13.1%). Conclusion: The delivery of anesthesia is limited by deficiencies in human resources, equipment availability and system capacity in many low and middle income countries.

Hypothesis Surgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs. Design Survey. Setting District-level health facilities in multiple LMICs Main Outcome Measures A standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons. Results Data from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of Sao Tome and Principe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus. Conclusion Enormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

The federal shariat court of Pakistan recently upheld the country’s 2007 Transplantation of human organs and tissue ordinance.1 A courageous campaign had originally established this legislation in Pakistan,2 a country in which poor people once received a pittance for selling their organs, while some organ brokers, doctors and hospitals became rich. The ordinance prohibits commercial organ donation, legalizes deceased donation, excludes donations to foreigners from unrelated Pakistani donors and establishes a human organ transplant authority to monitor transplantation activities and ensure transparency. The transplant authority – at the Ministry of Health – must implement and enforce ethical practices and combat the resurgence of clandestine organ trafficking. Advocates of commercial transplantation and transplant tourism have openly sought to challenge the law. A society of transplant professionals interested in the sale of kidneys and the provision of transplantation services to tourists from abroad petitioned the federal shariat court on various grounds, including a claim that the prohibition against payment constituted a hurdle to the saving of human lives. This petition exemplifies the persistent threats to ethical transplantation practice globally, highlighting the commercial appeal of paying vulnerable organ vendors to provide organs for distant elites. For example, patients from Saudi Arabia were regularly reported as clients of kidney transplantation clinics in Pakistan before the introduction of the 2007 ordinance. Saudi Arabia has since mirrored the Pakistani response to this threat, with both governments demonstrating that the pursuit of national self-sufficiency in human organs is the only way to progress towards equitable transplantation practice on a global level. The number of Saudi patients transplanted abroad has steadily decreased and donations from deceased donors increased to unprecedented levels in 2008.3 The Saudi authorities are clearly taking responsibility for meeting transplantation needs in the Kingdom, thereby minimizing the harmful effects of transplant tourism. Other countries once recognized as transplant tourism destinations – such as Egypt and the Philippines – have recently adopted or are now considering draft laws banning commercial transplants.4,5 Countries that have previously resorted to transplant tourism have established – or are pursuing – self-sufficiency at the national or sub-regional level, for example in Israel, Japan and the Republic of Korea.6–8 Meeting transplantation needs at the national level avoids predatory behaviour at the expense of underprivileged populations in other countries. However, this goal can only be achieved by increasing deceased donations through efficient organ procurement organizations, as well as safely developing live-related kidney donation. The Member States of the World Health Organization were urged to do so in Resolution 57.18 of the 2004 World Health Assembly.9 Advocates of payment for living donation claim that altruism has been shown to be inefficient and insufficient, yet some countries, provinces and states have shown that self-sufficiency is within reach. Some countries have achieved success in the absence of paid donation, thus avoiding exploitative practices that shift the burden of organ donation to the poor. The pursuit of national self-sufficiency in human material for transplantation is the collective responsibility of all citizens, inasmuch as they are necessary participants in the prevention and management of all diseases leading to the need for transplantation. The shariat court judgment was a victory for the federal government and dedicated medical professionals in Pakistan seeking to establish and maintain ethical standards in organ procurement and transplantation. It was also a powerful affirmation of Islamic bioethics in harmony with the universal values expressed in the WHO guiding principles on human cell, tissue and organ transplantation and the Declaration of Istanbul.10,11 By putting a stop to the exploitation of vulnerable human beings and equipping the country with the legislation necessary to establish donation and transplantation services using organs from deceased donors, Pakistan has adopted the path to national self-sufficiency by which the health authorities invite citizens to donate organs after death. Potential donors are also reminded that they themselves may be potential beneficiaries of organs from deceased donors. In the pursuit of self-sufficiency, altruism, reciprocity and civic consciousness are the main motivations for donation. ■

Since the first report by Nobel laureate, the late E. Donnall Thomas (NEJM, 1957, 257), HSCT has developed from an experimental to an established curative treatment for many congenital or acquired disorders of the hematopoietic system. The key steps of this success story are linked to progress in tissue typing, donor selection, supportive care and immunosuppression and fostered by intensive collaboration of physicians around the world through outcome and donor registries. The WBMT, a federation and official Non-governmental Organization of the World Health Organization, has collected HSCT activity data from its member societies and from national registries not part of an international HSCT society. Data collection did include the first transplants by ED Thomas and the first global report by M. Bortin (Transplantation 1970, 571). European data were derived from the Med A form of the European Group for Blood and Marrow Transplantation-EBMT for the years 1965-1989 and from the annual activity survey since 1990. Non-European data back to 1969 were provided by the Center for International Blood and Marrow Transplant Research-CIBMTR, with additional recent data provided by the Asia-Pacific Blood and Marrow Transplantation Group (APBMT, since 1974), the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR, since 1980), the Eastern Mediterranean Blood and Marrow Transplantation Group (EMBMT, since 1984), the Canadian Blood and Marrow Transplantation Group (CGBMT, since 2002), the Latin American Blood and Marrow Transplantation Group (LABMT, since 2009) and the African Blood and Marrow Transplant Group (AFBMT, since 2010). Double reporting was minimized by crosschecking registries and unrelated donations. Missing data from a few regions in 2012 were extrapolated from previous years assuming a 5% increase. As of December 2012, the 1450 transplant centers from 72 countries over 5 continents had reported 1.000.000 HSCT (58% autologous, 42% allogeneic). The dramatic recent increase in rate of utilization of HSCT is illustrated by the fact that there were 10.000 HSCTs worldwide by 1985, 50.000 by 1990, 100.000 by 1994, 500.000 by 2004 and 1.000.000 by December 2012. The absolute and relative contribution differed significantly with Europe providing 53%, the Americas 31%, Australasia 14% and Eastern-Mediterranean and Africa 2% to the total HSCT number (allogeneic HSCT: 45%, 32%, 20% and 3%; autologous HSCT: 58%, 31%, 10% and 1%). The increase in activity has been almost linear over the past 55 years with two exceptions, a decrease in autologous HSCT for breast cancer from 1999 especially in the Americas and a decrease in allogeneic HSCT for CML after 2000 seen everywhere except in the Eastern-Mediterranean/African region. The rise in HSCT numbers during the last decade was mainly due to an increase in allogeneic HSCT from unrelated donors; the relative increase being highest in Australasia. Recent growth was primarily due to increases in activity in existing transplant centers, rather than in the number of transplant centers. The main indications for autologous HSCT today are lymphoproliferative disorders 87% (myeloma 46% and lymphoma 41%), solid tumors 8.6% and AML 2.75%; for allogeneic HSCT leukemias 73% (AML 34.6%; ALL 16.8%; CML 4%; myelodysplastic and myeloproliferative disorders 13.3%; CLL 2.9% and other leukemias 1%), lymphoproliferative disorders 14.3% and bone marrow failure syndromes 5.5%. In 2010, cord blood was used as stem cell source in 19% of unrelated HSCT. These data were compiled through collaboration of the global HSCT community. Global collaboration has also been essential for the diffusion of HSCT as a therapy and especially for unrelated HSCT. More than 22 million unrelated donors are available today from a global network (World Marrow Donor Association, WMDA) of donor registries and cord blood banks and about 30% of unrelated HSCT involve a donor and recipient in different countries. The success of HSCT serves as a model for organ repair by the use of healthy stem cells and as a model for global cooperation in meeting the needs of an international patient population. These data also illustrate the challenges for the global medical community in providing state of the art care in regions with constrained resources and the need to find ways to make the therapy more available in order to provide better outcomes for patients with life-threatening but potentially curable diseases. Disclosures: Gluckman: Cord use: Honoraria; gamida: Honoraria.

Xenotransplantation carries the potential risk of the transmission of infection with the cells or tissues of the graft. The degree of risk is unknown in the absence of clinical trials. The clinical application of xenotransplantation has important implications for infectious disease surveillance, both at the national and international levels. Preclinical data indicate that infectious disease events associated with clinical xenotransplantation from swine, should they occur, will be rare; data in human trials are limited but have demonstrated no transmission of porcine microorganisms including porcine endogenous retrovirus. Xenotransplantation will necessitate the development of surveillance programs to detect known infectious agents and, potentially, previously unknown or unexpected pathogens. The development of surveillance and safety programs for clinical trials in xenotransplantation is guided by a “Precautionary Principle,” with the deployment of appropriate screening procedures and assays for source animals and xenograft recipients even in the absence of data suggesting infectious risk. All assays require training, standardization and validation, and sharing of laboratory methods and expertise to optimize the quality of the surveillance and diagnostic testing. Investigation of suspected xenogeneic infection events (xenosis, xenozoonosis) should be performed in collaboration with an expert data safety review panel and the appropriate public health and competent authorities. It should be considered an obligation of performance of xenotransplantation trials to report outcomes, including any infectious disease transmissions, in the scientific literature. Repositories of samples from source animals and from recipients prior to, and following xenograft transplantation are essential to the investigation of possible infectious disease events. Concerns over any potential hazards associated with xenotransplantation may overshadow potential benefits. Careful microbiological screening of source animals used as xenotransplant donors may enhance the safety of transplantation beyond that of allotransplant procedures. Xenogeneic tissues may be relatively resistant to infection by some human pathogens. Moreover, xenotransplantation may be made available at the time when patients require organ replacement on a clinical basis. Insights gained in studies of the microbiology and immunology of xenotransplantation will benefit transplant recipients in the future. This document summarizes approaches to disease surveillance in individual recipients of nonhuman tissues.

Objective To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. Design Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. Setting Sixteen county hospitals in Liberia. Main Outcome Measures Infrastructure, personnel, procedures performed, and supplies and equipment available. Results Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. Conclusions The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

As long as the global supply of tissues, cells and organs for transplant does not meet needs, desperate patients are easy prey for unscrupulous individuals. Yet countries including Spain and the Unit-ed States of America have shown that it is possible to make progress towards self sufficiency in transplants by meeting these needs with altruistic donations. Achieving national self-sufficiency is not easy. It requires a level of commitment from society that very few countries have been able to garner, but building this commitment arguably costs much less in the long term than relying on the payment of “volunteers”– inevitably the poor and vulnerable.In contrast to organs, most human tissues and cells destined for transplan-tation can be processed, preserved and stored, often for long periods. Their transportation can be very easy and ship-ping across national boundaries is some-times necessary to best meet patients’ needs. Risks of ethical breaches arise at all stages; from consent to donation through to the allocation of transplants, and the clinical care of donors and re-ceipients. Recent cases of cadaveric tissue theft have shown how unethical behav-iour in tissue procurement bypasses the safety barriers designed to decrease the risk of transmitting infectious diseases to receipents.

Adsorption and desorption isotherms of nitrogen, obtained by the volumetric (B.E.T.) method, have been used to determine the specific surface and the porosity of a series of chrysotile asbestos fibers, before and after chemical treatments. It was shown that the phosphorus compounds that are formed by the reaction of POCl3 and chrysotile asbestos seal the surface of the fibrils and block the pores between the fibrils. These chemical modifications result in an important diminution of the specific surface and of the porosity of the fibers. Washing the fibers with 0.1 M HCl results in an increase of the specific surface and of the porosity. Solvation of the impurities and leaching of the brucitic surface of the fibers are responsible for this increase. [Journal translation]

Many reports indicate that the carcinogenic (genotoxic) potential of benzo[a]pyrene (B[a]P) may be enhanced several-fold by the promoter (epigenetic) effect of asbestos particles. This promoting effect could be related to the fact that when B[a]P is adsorbed onto the particles, there is a resulting enhanced transport and uptake of the carcinogen into microsomial membranes. These in vitro data bear relevance to the epidemiological studies which indicate an association between exposure to inhaled asbestos dusts and the high incidence of pulmonary cancers in smokers. Using HPLC, it has been observed that B[a]P has great affinity for natural asbestos fibers, and that chemical modification of natural chrysotile with POCl3 results in the complete loss of this adsorption potential of chrysotile for benzo[a]pyrene.