Procuring organs from a non-heart-beating cadaver: commentary on a case report

Procurement of organs from non-heart-beating cadaver donors raises concerns. Standards for optimal patient care during withdrawal of life-sustaining therapy are evolving and continue to be debated and studied. Consensus on specific procedures and methods has not been attained, however, and protocols for the procurement of organs from patients following the withdrawal of life-sustaining therapies may compromise the evolving standards and harm the patient and the attendant family. In addition, there is little evidence to suggest that such protocols will significantly increase the number of organs procured. "Non-heart-beating cadaver" protocols that do not give comprehensive attention to optimal patient/family care at the time of withdrawal of life-sustaining therapy ought not to be endorsed.     

Beyond Pittsburgh: protocols for controlled non-heart-beating cadaver organ recovery

Much of the ethical debate about controlled non-heart-beating cadaver (NHBC) organ recovery has focused on the University of Pittsburgh Medical Center (UPMC) protocol. Some commentators have voiced serious reservations about the ethical acceptability of that protocol; others have argued that the protocol contains sufficiently stringent ethical safeguards to warrant a limited and carefully monitored trial at UPMC. UPMC is not the only organization pursuing controlled NHBC organ procurement, however. The study of organ procurement organizations described in this article suggests that controlled NHBC organ procurement is a practice that, if not yet widespread, is certainly no longer isolated to a few organizations in which it is carefully monitored. Rather, it is being carried out under a variety of circumstances, many of which are less carefully constrained ethically than at the University of Pittsburgh Medical Center. The next stage of the ethical debate should focus on issues that are arising in a variety of settings as the practice spreads.     

"An ignoble form of cannibalism": reflections on the Pittsburgh protocol for procuring organs from non-heart-beating cadavers

The author discusses the ways in which she finds the University of Pittsburgh Medical Center protocol for procuring organs from "non-heart-beating cadaver donors" medically and morally questionable and irreverent. She also identifies some of the factors that contributed to the composition of this troubling protocol, and to its institutional approval.     

The Institute of Medicine's report on non-heart-beating organ transplantation

In December 1997, the Institute of Medicine (IOM) released a report on medical and ethical issues in the procurement of non-heart-beating organ donors. This report had been requested in May 1997 by the Department of Health and Human Services (DHHS). We will here describe the genesis of the IOM report, the medical and moral concerns that led the DHHS to sponsor it, the process of producing it, and its conclusions. The analyses, findings, and recommendations of the report are also reviewed, in particular the central issues that led to suggestions for policy changes.     

Crossed Wernicke's aphasia: a case report

Crossed aphasia is a phenomenon in which an individual sustains a lesion in the right hemisphere (typically non-language dominant), but who exhibits an aphasic syndrome. The authors present a case study of an individual with crossed aphasia (CA) in an attempt to provide anecdotal information for four questions posed by : (a). Is CA a reversal of the normal cerebral hemisphere pattern of language function? (b). Does the presence of aphasia following a right cerebral hemisphere lesion indicate that typical right hemisphere functions (e.g., visual perception) are intact? (c). How may the aphasia's presentation differ from typical left hemisphere aphasias? And (d). is the pattern of improvement following CA similar to that of typical left hemisphere aphasias? We longitudinally examined the communicative-cognitive performance of an adult man with crossed aphasia of the Wernicke's type following a cerebrovascular accident. A 21-week follow-up evaluation indicated improvements in his language functioning from our initial evaluation, but he continued to exhibit a classic, moderately severe Wernicke's aphasia.     

Subcortical anarthria: a case report.

A 56-year-old right-handed male with a history of hypertension and diabetes presented two episodes of stroke: The first affected territory was the left anterior coroidal artery (capsular and paracapsular infarcts at the level of the genu and posterior arm of the internal capsule) and the second was the right thalamus, due to a hematoma. Following the first stroke, the patient developed severe dysarthria and after the second stroke remained anarthric. The pathophysiology of the disorder is discussed, and the role of the left and right thalamus as far as speech is concerned is reviewed.     

Persistent autobiographical amnesia: a case report

We describe a 47-year-old man who referred to the Emergency Department for sudden global amnesia and left mild motor impairment in the setting of increased arterial blood pressure. The acute episode resolved within 24 hours. Despite general recovery and the apparent transitory nature of the event, a persistent selective impairment in recollecting events from some specific topics of his personal life became apparent. Complete neuropsychological tests one week after the acute onset and 2 months later demonstrated a clear retrograde memory deficit contrasting with the preservation of anterograde memory and learning abilities. One year later, the autobiographical memory deficit was unmodified, except for what had been re-learnt. Brain MRI was normal while H20 brain PET scans demonstrated hypometabolism in the right globus pallidus and putamen after 2 weeks from onset, which was no longer present one year later. The absence of a clear pathomechanism underlying focal amnesia lead us to consider this case as an example of functional retrograde amnesia.     

Comorbidity in compulsive hoarding: a case report

A 56-year-old male presented with compulsive hoarding along with attention-deficit/hyperactivity disorder and schizotypal personality disorder. Hoarding has been described as difficult to treat both pharmacologically and behaviorally, and this patient's comorbid conditions also contributed to his overall impairment. The patient's treatment regimen of fluvoxamine, amphetamine salts, and risperidone, along with behavioral therapy, has helped with hoarding behaviors, motivation, procrastination, and increased socialization. Hoarding may be a unique subtype of obsessive-compulsive disorder with poorer prognosis and distinct neuroanatomic dysfunction. Augmentation with stimulants may provide benefits in aspects of hoarding such as procrastination, especially in patients with comorbid attention-deficit hyperactivity disorder.     

Crossed apraxia of speech: a case report

The present study reports on the first case of crossed apraxia of speech (CAS) in a 69-year-old right-handed female (SE). The possibility of occurrence of apraxia of speech (AOS) following right hemisphere lesion is discussed in the context of known occurrences of ideomotor apraxias and acquired neurogenic stuttering in several cases with right hemisphere lesion. A current hypothesis on AOS-the dual route speech encoding (DRSE) hypothesis-and predictions based on DRSE were utilized to explore the nature of CAS in SE. One prediction based on the DRSE hypothesis is that there should be no difference in the frequency of occurrence of apraxic errors on words and non-words. This prediction was tested using a repetition task. The experimental stimuli included a list of minimal pairs that signaled voice-voiceless contrasts in words and non-words. Minimal-pair stimuli were presented orally, one at a time. SE's responses were recorded using audio and videotapes. Results indicate that SE's responses were characterized by numerous voicing errors. Most importantly, production of real word minimal pairs was superior to that of non-word minimal pairs. Implications of these results for the DRSE hypothesis are discussed with regard to currently developing perspectives on AOS.     

Suicidal ideation versus suicidal obsession: a case report

This case report illustrates the relationship between stress and obsessive-compulsive disorder (OCD) by describing an unusual case of OCD sequelae following a suicide attempt. The patient is a 29-year-old married woman who suffered a major depressive episode without OCD and tried to commit suicide by drinking household cleaner. Following the attempt, violent obsessive thoughts of harming herself and others emerged along with avoidance behavior. After exposure therapy, there was a decrease in her obsessive thoughts, less anxiety, and no avoidance behavior. This report highlights not only the existence of "posttraumatic obsession" but also the importance of accurate interpretation of suicidal preoccupation, leading to the diagnosis of OCD rather then suicidal ideation secondary to depression.     

Acquired surface alexia in Spanish: a case report

This paper reports a case study of acquired surface alexia in Spanish and discusses the most suitable tests to detect this syndrome in a writing system that is very regular for reading at the segmental and supra-segmental levels. Patient MM has surface alexia characterized by quantitatively good performance in reading words and pseudowords; accurate but slow and syllabic reading of words, nonwords and sentences; good performance in lexical decision tasks including words and nonwords; errors in lexical decision with pseudohomophones; and homophone confusions. This pattern of reading can be interpreted as a disorder in the lexical reading route and overdependence on the non-lexical route. We discuss nonlexical impairments and the interpretation of alexia and suggest tasks to identify surface alexia in a shallow orthography.     

Policy issues in a non-heart-beating donor protocol

The Pittsburgh protocol is ethically and legally acceptable as written, but more research is needed to determine if it can be implemented in ways that will observe the procedures that make it ethically acceptable. If so, its desirability as public policy will depend on the number of organs it is likely to generate and its effects on public attitudes toward organ donation generally. In the final analysis, the controversial aspects of this protocol concern symbolic issues about respect for the dead and near dead, rather than substantive concerns that real patient interests will be harmed.     

Truthfulness in transplantation: non-heart-beating organ donation

The current practice of organ transplantation has been criticized on several fronts. The philosophical and scientific foundations for brain death criteria have been crumbling. In addition, donation after cardiac death, or non-heartbeating-organ donation (NHBD) has been attacked on grounds that it mistreats the dying patient and uses that patient only as a means to an end for someone else's benefit.     

Repetitive transcranial magnetic stimulation improves depersonalization: a case report

Depersonalization disorder is a poorly understood and treatment-resistant condition. This report describes a patient with depersonalization disorder who underwent six sessions of repetitive transcranial magnetic stimulation on the left dorsolateral prefrontal cortex. Repetitive transcranial magnetic stimulation produced a 28% reduction on depersonalization scores.