With 40 donors and more than 100 transplant procedures per million population in 2015, Spain holds a privileged position worldwide in providing transplant services to its patient population. The ...Spanish success derives from a specific organizational approach to ensure the systematic identification of opportunities for organ donation and their transition to actual donation and to promote public support for the donation of organs after death. The Spanish results are to be highlighted in the context of the dramatic decline in the incidence of brain death and the changes in end‐of‐life care practices in the country since the beginning of the century. This prompted the system to conceive the 40 donors per million population plan, with three specific objectives: (i) promoting the identification and early referral of possible organ donors from outside of the intensive care unit to consider elective non‐therapeutic intensive care and incorporate the option of organ donation into end‐of‐life care; (ii) facilitating the use of organs from expanded criteria and non–standard risk donors; and (iii) developing the framework for the practice of donation after circulatory death. This article describes the actions undertaken and their impact on donation and transplantation activities.
The authors summarize the challenges that the Spanish donation and transplantation system has faced in further developing deceased organ donation, and describe the three strategies that allowed Spain to rise to the highest solid organ transplant activity in the world in 2015. For further discussion, see the letters from Sharif (page 1694) and Matesanz (page 1695).
Feelings are mental experiences of body states. They signify physiological need (for example, hunger), tissue injury (for example, pain), optimal function (for example, well-being), threats to the ...organism (for example, fear or anger) or specific social interactions (for example, compassion, gratitude or love). Feelings constitute a crucial component of the mechanisms of life regulation, from simple to complex. Their neural substrates can be found at all levels of the nervous system, from individual neurons to subcortical nuclei and cortical regions.
Feelings are conscious mental events that represent body states as they undergo homeostatic regulation. Feelings depend on the interoceptive nervous system (INS), a collection of peripheral and ...central pathways, nuclei and cortical regions which continuously sense chemical and anatomical changes in the organism. How such humoral and neural signals come to generate conscious mental states has been a major scientific question. The answer proposed here invokes (1) several distinctive and poorly known physiological features of the INS; and (2) a unique interaction between the body (the ‘object’ of interoception) and the central nervous system (which generates the 'subject' of interoception). The atypical traits of the INS and the direct interactions between neural and non‐neural physiological compartments of the organism, neither of which is present in exteroceptive systems, plausibly explain the qualitative and subjective aspects of feelings, thus accounting for their conscious nature.
Interoception involves continuous bidirectional interactions between the nervous system and non‐neural body components. This ongoing crosstalk is facilitated by abundant unmyelinated neurons, nonsynaptic signaling and gaps in the blood‐brain barrier. These distinguishing features are typical of interoceptive processes.
The use of donation after circulatory death (DCD) has increased significantly during the past decade. However, warm ischemia results in a greater risk for transplantation. Indeed, controlled DCD ...(cDCD) was associated with inferior outcomes compared with donation after brain death. The use of abdominal normothermic regional perfusion (nRP) to restore blood flow before organ recovery in cDCD has been proposed as better than rapid recovery to reverse the effect of ischemia and improve recipients’ outcome. Here, the first Spanish series using abdominal nRP as an in situ conditioning method is reported. A specific methodology to avoid restoring circulation to the brain after death determination is described. Twenty‐seven cDCD donors underwent abdominal nRP during at least 60 min. Thirty‐seven kidneys, 11 livers, six bilateral lungs, and one pancreas were transplanted. The 1‐year death‐censored kidney survival was 91%, and delayed graft function rate was 27%. The 1‐year liver survival rate was 90.1% with no cases of ischemic cholangiopathy. Transplanted lungs and pancreas exhibited primary function. The use of nRP may represent an advance to increase the number and quality of grafts in cDCD. Poor results in cDCD livers could be reversed with nRP. Concerns about restoring brain circulation after death are easily solved.
Abdominal normothermic regional perfusion with premortem interventions represents an advance to increase the number and quality of grafts recovered in controlled donation after circulatory death.
Hexagonal boron nitride is a large band-gap insulating material which complements the electronic and optical properties of graphene and the transition metal dichalcogenides. However, the intrinsic ...optical properties of monolayer boron nitride remain largely unexplored. In particular, the theoretically expected crossover to a direct-gap in the limit of the single monolayer is presently not confirmed experimentally. Here, in contrast to the technique of exfoliating few-layer 2D hexagonal boron nitride, we exploit the scalable approach of high-temperature molecular beam epitaxy to grow high-quality monolayer boron nitride on graphite substrates. We combine deep-ultraviolet photoluminescence and reflectance spectroscopy with atomic force microscopy to reveal the presence of a direct gap of energy 6.1 eV in the single atomic layers, thus confirming a crossover to direct gap in the monolayer limit.
The supply of organs—particularly kidneys—donated by living and deceased donors falls short of the number of patients added annually to transplant waiting lists in the United States. To remedy this ...problem, a number of prominent physicians, ethicists, economists and others have mounted a campaign to suspend the prohibitions in the National Organ Transplant Act of 1984 (NOTA) on the buying and selling of organs. The argument that providing financial benefits would incentivize enough people to part with a kidney (or a portion of a liver) to clear the waiting lists is flawed. This commentary marshals arguments against the claim that the shortage of donor organs would best be overcome by providing financial incentives for donation. We can increase the number of organs available for transplantation by removing all financial disincentives that deter unpaid living or deceased kidney donation. These disincentives include a range of burdens, such as the costs of travel and lodging for medical evaluation and surgery, lost wages, and the expense of dependent care during the period of organ removal and recuperation. Organ donation should remain an act that is financially neutral for donors, neither imposing financial burdens nor enriching them monetarily.
In order to increase organ donation while preserving its core ethical values, organ donation should remain an act that is financially neutral for donors, neither imposing financial burdens nor enriching them monetarily. Also see viewpoint by Fisher et al (page 1180) and meeting report by Salomon et al (page 1173).
•Compulsive Sexual Behavior Disorder (CSBD) co-occurs with psychiatric disorders.•We compared psychiatric comorbidity in individuals with and without CSBD.•91.2% of CSBD participants met the criteria ...for one comorbid Axis I disorder.•CSBD participants were more likely to qualify mainly for substance use disorders.•Results support the use of the addiction paradigm in explaining CSBD as an addictive disorder beyond other competing models.
Compulsive Sexual Behavior Disorder (CSBD) is characterized by a persistent failure to control intense and recurrent sexual impulses, urges, and/or thoughts, resulting in repetitive sexual behavior that causes a marked impairment in important areas of functioning. Data collected from clinical populations suggest that CSBD frequently co-occurs with other Axis I and II psychiatric disorders; however, studies conducted so far suffer from methodological shortcomings that prevent the determination of accurate psychiatric comorbidity rates (e.g., small sample sizes, reliance on non-reliable assessment methods in the estimation of comorbidity or the non-inclusion of healthy individuals to compare prevalence rates). The purpose of this study was to explore psychiatric comorbidity in a sample of individuals with and without CSBD. The study sample comprised 383 participants distributed into two groups through a cluster analyses: 315 participants without CSBD (non-CSBD) and 68 qualifying as sexually compulsives (CSBD). Participants were assessed for co-occurring Axis I and II clinical conditions using structured clinical interviews for the DSM-IV (SCID-I and II). The majority of CSBD participants (91.2%) met the criteria for at least one Axis I disorder, compared to 66% in non-CSBD participants. CSBD participants were more likely to report an increased prevalence of alcohol dependence (16.2%), alcohol abuse (44%), major depressive disorder (39.7%), bulimia nervosa (5.9%), adjustment disorders (20.6%), and other substances –mainly cannabis and cocaine– abuse or dependence (22.1%). Concerning Axis II, prevalence of borderline personality disorder was significantly higher in CSBD participants (5.9%). As expected, prevalence of different psychiatric conditions was significantly increased among sexually compulsive participants, revealing comorbidity patterns with important implications in the conceptualization, assessment, and treatment of patients with CSBD.
Reproduction is one of the requirements for evolution and a defining feature of life. Yet, across the tree of life, organisms reproduce in many different ways. Groups of cells (e.g., multicellular ...organisms, colonial microbes, or multispecies biofilms) divide by releasing propagules that can be single-celled or multicellular. What conditions determine the number and size of reproductive propagules? In multicellular organisms, existing theory suggests that single-cell propagules prevent the accumulation of deleterious mutations (e.g., cheaters). However, groups of cells, such as biofilms, sometimes contain multiple metabolically interdependent species. This creates a reproductive dilemma: small daughter groups, which prevent the accumulation of cheaters, are also unlikely to contain the species diversity that is required for ecological success. Here, we developed an individual-based, multilevel selection model to investigate how such multi-species groups can resolve this dilemma. By tracking the dynamics of groups of cells that reproduce by fragmenting into smaller groups, we identified fragmentation modes that can maintain cooperative interactions. We systematically varied the fragmentation mode and calculated the maximum mutation rate that communities can withstand before being driven to extinction by the accumulation of cheaters. We find that for groups consisting of a single species, the optimal fragmentation mode consists of releasing single-cell propagules. For multi-species groups we find various optimal strategies. With migration between groups, single-cell propagules are favored. Without migration, larger propagules sizes are optimal; in this case, group-size dependent fissioning rates can prevent the accumulation of cheaters. Our work shows that multi-species groups can evolve reproductive strategies that allow them to maintain cooperative interactions.
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