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HICNet Medical News Digest      Sat, 24 Sep 1994        Volume 07 :
Issue 46

Today's Topics:

   [MMWR 16 Sept 94] Inadequately Filtered Drinking Water
   [MMWR] Salmonella enteritidis associated with Home Made Ice Cream
   Reflections on First International Symposium on Brain Death

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----------------------------------------------------------------------

Date: Sat, 24 Sep 94 16:07:45 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR 16 Sept 94] Inadequately Filtered Drinking Water
Message-ID: <[e-mail]>

                Assessment of Inadequately Filtered
             Public Drinking Water -- Washington, D.C.,
                        December 1993

      The risk for waterborne infectious diseases increases when
filtration and other standard water-treatment measures fail. On
December 6, 1993, water-treatment plant operators in the District of
Columbia (DC) began to have difficulty maintaining optimal filter
effectiveness. On December 7, filter performance worsened, and levels
of turbidity (i.e., small suspended particles) exceeded those
permitted by U.S. Environmental Protection Agency (EPA) standards. On
December 8, DC residents were advised to boil water intended for
drinking because of high municipal water turbidity that may have
included microbial contaminants. Although adequate chlorination of the
DC municipal water was maintained throughout the period of increased
turbidity, the parasite Cryptosporidium parvum is highly resistant to
chlorination. Because of the increased risk for infection with this
organism and other enteric pathogens, the DC Commission of Public
Health and CDC conducted four investigations to determine whether
excess cases of diarrheal illness occurred because residents drank
inadequately filtered water. This report describes the results of
these investigations.
      The investigations included a random-digit-dialed telephone
survey of DC residents and retrospective reviews of records from two
emergency departments, two nursing homes, and seven hospital
microbiology laboratories. The occurrence of diarrheal illness or
presence of organisms in stool during the 2 weeks before the turbidity
violation (period 1: November 22-December 5) was compared with that
during the 2-3 weeks after the violation was first noted (period 2:
December 6-December 21 or 26). The incubation period for
cryptosporidiosis typically ranges from 2 to 14 days.

      Telephone survey. The telephone survey sampled 1197 household
members (0.2% of DC's 600,000 residents) from 462 households in all
22 DC residential ZIP code areas. The percentage of persons who
reported having diarrhea (i.e., three or more loose or watery stools
in a 24-hour period) were similar for period 1 (the reference period)
and period 2 (2.8% versus 3.5%, respectively; relative risk [RR]=1.2;
95% confidence interval [CI]=0.8-1.9). A total of 37% of persons
reported that bottled water was their principal source of drinking
water at home, and 30% reported that bottled water was their primary
source of drinking water both at home and at work. For both periods,
reported use of bottled water was similar for persons with and without
diarrhea.

      Hospital emergency department survey. During the two periods,
totals of 2140 (period 1) and 3315 (period 2) persons were evaluated
at two DC hospital emergency departments. Medical records were
reviewed for all persons with diagnoses suggestive of gastrointestinal
illness* (104 and 211 persons for periods 1 and 2, respectively). The
percentage of all persons who had diarrhea recorded in their emergency
department charts was similar for periods 1 and 2 (1.5% versus 2.0%;
RR=1.3; 95% CI=0.9-2.0). For both periods, approximately 70% of
patients with diarrheal illness were DC residents. The percentages of
stool specimens that were positive for enteric pathogens (i.e.,
bacteria, parasites, or rotavirus antigen) were similar for the two
periods. During each period, two stool specimens were examined for
Cryptosporidium: none were positive during period 1, and one was
positive during period 2.

      Nursing home survey. Medical records were reviewed for all 443
residents from two selected nursing homes (14% of the 3156 nursing
home beds in DC). During both periods, the mean numbers of bowel
movements per person per day were 1.3. In addition, the daily mean
number of residents with loose or large-volume bowel movements were
similar (27.1 and 27.8 persons for periods 1 and 2), and antidiarrheal
medications were given at the same rate (0.002 doses per person per
day) during both periods.

      Microbiology laboratory survey. Data were obtained from
microbiology laboratories of seven (64%) of the 11 DC hospitals.
Although the total number of stool specimens examined for
Cryptosporidium increased from period 1 (32 specimens) to period 2 (54
specimens), the percentage positive was lower--but not statistically
different--for period 2 (12.5% versus 7.4%; RR=0.6; 95% CI=0.2-2.2).
The percentages of stools positive for other pathogens (i.e.,
bacteria, Giardia lamblia, and rotavirus antigen) were similar for
both periods.

Reported by: MN Akhter, MD, Commissioner, ME Levy, MD, District
Epidemiologist, C Mitchell, R Boddie, District of Columbia Commission
of Public Health. N Donegan, B Griffith, M Jones, Washington Hospital
Center; TO Stair, MD, Georgetown Univ Medical Center, Washington, DC.
Epidemiology Br, Div of Parasitic Diseases, National Center for
Infectious Diseases, CDC.

Editorial Note: To ensure safe municipal drinking water supplies,
water-treatment programs employ multiple barriers to prevent
contaminants from reaching the consumer. These barriers include
protection of the watershed, chemical disinfection, and filtration of
surface water supplies such as lakes and rivers. When one of these
barriers is absent or fails, the risk for waterborne disease may
increase. The failure of the filtration process in DC prompted
particular concerns about contamination with and exposure to
Cryptosporidium.
      Outbreaks of cryptosporidiosis resulting from surface water
contamination have occurred when turbidity was 0.9-2.0 nephelometric
turbidity units (NTU)**. For example, in a waterborne outbreak in
Milwaukee in 1993, a peak turbidity of 1.7 NTU was associated with
illness in approximately 400,000 persons (1). In DC, the turbidity
levels reached 9.0 NTU.
      Because Cryptosporidium is highly resistant to chlorination,
disinfection of water is not a reliable method for preventing exposure
to it. The failure to detect increased rates of illness among
residents of DC probably reflects the absence of, or presence of only
a small number of, oocysts in the water that supplied the municipal
water-treatment plant at the time the filtration failure occurred. In
addition, the investigations in DC did not detect any increase in
diarrheal illness associated with the elevated water turbidity;
however, the sample sizes in these investigations were too small to
rule out low-level transmission of waterborne agents. For example, the
telephone survey probably would not have detected an outbreak
affecting fewer than 12,000 persons.
      Cryptosporidium is present in 65%-87% of surface water samples
tested throughout the United States (2,3). However, because current
techniques to detect Cryptosporidium in water are cumbersome, costly,
and insensitive, tests to detect it are not routinely performed by
water utilities. During 1995, EPA plans to collect additional
information about Cryptosporidium and other microorganisms in surface
water used by municipal water-treatment facilities in the United
States and to assess the effectiveness of water-treatment methods for
removing them.***
      The early detection of waterborne outbreaks of cryptosporidiosis
is difficult for at least four reasons: 1) many physicians are unaware
that Cryptosporidium can cause watery diarrhea; 2) the symptom complex
often resembles a viral syndrome; 3) clinical laboratories often do
not routinely test for Cryptosporidium when a physician requests a
stool examination for ova and parasites; and 4) few states include
cryptosporidiosis as a reportable disease.
      Variations in recommendations regarding the duration of boiling
during boil-water advisories have reflected uncertainty about how long
some organisms can survive. On the basis of a recent literature
review, CDC and EPA recommend that water be rendered microbiologically
safe for drinking by bringing it to a rolling boil for 1 minute; this
will inactivate all major waterborne bacterial pathogens (i.e., Vibrio
cholerae, enterotoxigenic Escherichia coli, Salmonella, Shigella
sonnei, Campylobacter jejuni, Yersinia enterocolitica, and Legionella
pneumophila) and waterborne protozoa (e.g., Cryptosporidium parvum,
Giardia lamblia, and Entamoeba histolytica [4-7]). Although
information about thermal inactivation is incomplete for waterborne
viral pathogens, hepatitis A virus--considered one of the more
heat-resistant waterborne viruses (8)--also is rendered noninfectious
by boiling for 1 minute (9). If viral pathogens are suspected in
drinking water in communities at elevations above 6562 ft (2 km), the
boiling time should be extended to 3 minutes.

References
1. Mac Kenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in
Milwaukee of Cryptosporidium infection transmitted through the public
water supply. N Engl J Med 1994;331:161-7.
2. Rose JB, Gerba CP, Jakubowski W. Survey of potable water supplies
for Cryptosporidium and Giardia. Environmental Science and Technology
1991;25:1393-400.
3. LeChevallier MW, Norton WD, Lee RG. Occurrence of Giardia and
Cryptosporidium spp. in surface water supplies. Appl Environ Microbiol
1991;57:2610-6.
4. Bandres JC, Mathewson JJ, Dupont HL. Heat susceptibility of
bacterial enteropathogens. Arch Intern Med 1988;148:2261-3.
5. Anderson BC. Moist heat inactivation of Cryptosporidium sp. Am J
Public Health 1985;75: 1433-4.
6. Bingham AK, Jarroll EL, Meyer EA. Giardia sp.: physical factors of
excystation in vitro, and excystation vs eosin exclusion as
determinants of viability. Exp Parasitol 1979;47:284-91.
7. Boeck WC. The thermal-death point of the human intestinal protozoan
cysts. Am J Hygiene 1921;1:365-87.
8. Larkin EP. Viruses of vertebrates: thermal resistance. In: Rechcigl
M Jr, ed. CRC handbook of foodborne diseases of biological origin.
Boca Raton, Florida: CRC Press, Inc, 1983:3-24.
9. Krugman S, Giles JP, Hammond J. Hepatitis virus: effect of heat on
the infectivity and anti-genicity of the MS-1 and MS-2 strains. J
Infect Dis 1970;122:432-6.

*Gastroenteritis, diarrhea, nausea, vomiting, gastritis, viral
syndrome, dehydration, and hyperemesis gravidarum.
**The American Waterworks Association encourages water utilities to
maintain turbidity measurements of water as it leaves the treatment
plant at or below 0.1 NTU.
***59 FR 6332.





------------------------------

Date: Sat, 24 Sep 94 16:09:00 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: [MMWR] Salmonella enteritidis associated with Home Made Ice
Cream
Message-ID: <[e-mail]>

             Outbreak of Salmonella enteritidis Associated
                with Homemade Ice Cream -- Florida, 1993

      On September 7, 1993, the Epidemiology Program of the Duval
County (Florida) Public Health Unit was notified about an outbreak of
acute febrile gastroenteritis among persons who attended a cookout at
a psychiatric treatment hospital in Jacksonville, Florida. This report
summarizes the outbreak investigation.
      On September 6, seven children (age range: 7-9 years) and seven
adults (age range: 29-51 years) attended the cookout at the hospital.
A case of gastroenteritis was defined as onset of diarrhea, nausea or
vomiting, abdominal pain, or fever within 72 hours of attending the
cookout. Among the 14 attendees, 12 cases (in five of the children and
all seven adults) were identified. The median incubation period was
14 hours (range: 7-21 hours); the mean duration of illness was 18
hours (range: 8-40 hours). Predominant symptoms were diarrhea (93%),
nausea or vomiting (86%), abdominal pain (86%), and fever (86%). All
ill persons were examined by a physician. Salmonella enteritidis (SE)
(phage type 13a) was isolated from stool of three of the seven
patients from whom specimens were obtained.
      Eleven of the 12 ill persons had eaten homemade ice cream served
at the cookout. No other food item was associated with illness.
Testing of a sample of ice cream revealed contamination with SE (phage
type 13a).
      The ice cream was prepared at the hospital on September 6 using
a recipe that included six grade A raw eggs. An electric ice cream
churn was used to make the ice cream approximately 3 hours before the
noon meal. The ice cream had been properly cooled, and no
food-handling errors were identified. The person who prepared the ice
cream was not ill before preparation; however, she became ill 13 hours
after eating the ice cream. Her stool specimen was one of the three
stools positive for SE (phage type 13a).
      The U.S. Department of Agriculture's (USDA) Animal and Plant
Health Inspection Service attempted to trace the implicated eggs back
to the farm of origin. The hospital purchased eggs from a distributor
in Florida. However, the traceback was terminated because the
implicated eggs from the distributor had been purchased from two
suppliers--one of whom bought and mixed eggs from many different
sources. Current USDA Salmonella regulations limit testing of flocks
to one clearly implicated flock.

Reported by: P Buckner, MPH, D Ferguson, HRS Duval County Public
Health Unit, F Anzalone, MD, D Anzalone, DrPH, College of Health, Univ
of North Florida, Jacksonville; J Taylor, Office of Lab Svcs, WG
Hlady, MD, RS Hopkins, MD, State Epidemiologist, State Health Office,
Florida Dept of Health and Rehabilitative Svcs. Foodborne and
Diarrheal Diseases Br, Div of Bacterial and Mycotic Diseases, National
Center for Infectious Diseases, CDC.

Editorial Note: The outbreak described in this report represents the
fourth SE outbreak in Florida since 1985; this outbreak is the first
in the state to implicate eggs. In the United States, the number of
sporadic and outbreak-associated cases of SE infection has increased
substantially since 1985; much of the increase can be attributed to
consumption of raw or undercooked eggs (1-3). During 1983-1992, the
proportion of reported Salmonella isolates that were SE increased from
8% to 19%. During 1985-1993, a total of 504 SE outbreaks were reported
to CDC and resulted in 18,195 cases, 1978 hospitalizations, and 62
deaths (Table 1). Of the 233 outbreaks for which epidemiologic
evidence was sufficient to implicate a food vehicle, 193 (83%) were
associated with eggs. Of these 193 outbreaks, 14 (7%) were associated
with consumption of homemade ice cream. No outbreaks have been
associated with pasteurized egg products.
      After eggs are identified by public health officials as the
cause
of an SE outbreak, USDA attempts to trace the implicated eggs back to
the farm of origin to conduct serologic and microbiologic assessments
of the farm. If SE is detected on the source farm, the eggs are
diverted to pasteurization, or the flocks are destroyed. Under current
regulations, USDA can pursue the traceback only if one farm is
identified as the source. During 1990-1993, the success rate of USDA
tracebacks to the source farm declined from 86% (19/22 outbreaks) in
1990 to 17% (3/21 outbreaks) in 1993. The rate declined primarily
because eggs increasingly have been marketed in shipments containing
eggs from multiple sources.
      Although 0.01% of all eggs contain SE and, therefore, pose a
risk
for infection with SE (4), raw or undercooked eggs are consumed
frequently. Based on the Food and Drug Administration (FDA) Food
Safety Survey conducted in 1993, 53% of a nationally representative
sample of 1620 respondents reported ever eating foods containing raw
eggs; of these, 50% had eaten cookie batter, and 36% had eaten ice
cream containing raw eggs (S. Fein, FDA, personal communication,
September 9, 1994). Many persons may eat raw or undercooked eggs
because they are unaware that eggs are a potential source of
Salmonella (3) and that certain foods (e.g., homemade ice cream,
cookie batter, Caesar salad, and hollandaise sauce) contain raw eggs.
      Consumers should be informed that eating undercooked eggs may
result in Salmonella infection. In addition, eggs should be
refrigerated to prevent proliferation of Salmonella if present and
should be cooked thoroughly to kill Salmonella. Because most serious
------------------------------------------------------------------------

References
1. St. Louis ME, Morse DL, Potter ME, et al. The emergence of grade
A eggs as a major source of Salmonella enteritidis infections: new
implications for the control of salmonellosis. JAMA 1988;259:2103-7.
2. Mishu B, Koehler J, Lee LA, et al. Outbreaks of Salmonella
enteritidis infections in the United States, 1985-1991. J Infect Dis
1994;169:547-52.
3. Hedberg CW, David MJ, White KE, MacDonald KL, Osterholm MT. Role
of egg consumption in sporadic Salmonella enteritidis and Salmonella
typhimurium infections in Minnesota. J Infect Dis 1993;167:107-11.
4. Mason J, Ebel E. APHIS Salmonella enteritidis Control Program
[Abstract]. In: Snoeyenbos GH, ed. Proceedings of the Symposium on the
Diagnosis and Control of Salmonella. Richmond, Virginia: US Animal
ealth Association, 1992:78.



------------------------------

Date: Sat, 24 Sep 94 16:13:51 MST
From: [e-mail] (HICNet Medical News)
To: hicnews
Subject: Reflections on First International Symposium on Brain Death
Message-ID: <[e-mail]>

REFLECTIONS ON THE FIRST  INTERNATIONAL  SYMPOSIUM  ON BRAIN
DEATH. (Havana, September 22-25, 1992).


                     By: CALIXTO MACHADO
             President of the Organizing Committee

Correspondence: Dr. CALIXTO MACHADO
                 Instituto de Neurologia y Neurocirugia
                 29 y D, Vedado, Habana 4
                 Ciudad de La Habana 10400
                 Apartado Postal 4268
                 CUBA
                   Fax: [phone]
                E.mail: braind@.ceniai.cu

Note: If possible, use E.mail to contact me.


      The "FIRST INTERNATIONAL SYMPOSIUM ON BRAIN DEATH"  was
held at the International Conference Center, Havana, between
September 22 and 25, 1992.
      Delegates from twenty-one countries attended this sunny
and Caribbean city  to  discuss  many  controversial  issues
concerning brain death and other related  states.  Argentina
provided the biggest delegation (22 attenders).
      The Opening Ceremony was highlighted by the performance
of the National Chorus of Cuba.  The  singing  of  beautiful
cuban  songs  prepared   the  delegates  for  the  words  of
welcome given by the Organizing Committee, emphasizing  that
even  in  such  a  scientific  context,   there   would   be
opportunities to discuss human dignity, and life as well  as
death.
      On the morning of September 22, delegates enjoyed  four
striking opening lectures. Like   Olympic  Gold  Medallists,
Earl Walker (U. S. A.), Christopher Pallis (U. K.),  Gaetano
Molinari (U. S. A.) and Daniel Wikler (U. S.  A.)  followed
one another to the rostrum.
      In his address  "Dead or Alive" Earl  Walker  presented
much of the basic material derived  from  the  Collaborative
Study  of  Cerebral  Survival  sponsored  by  the   National
Institute of Neurological  and  Communicative  Diseases  and
Stroke (1). For  ages,  people had considered life to  exist
as long  as  an  individual  was  breathing.  It  was  later
realized that respiration was a means  of   maintaining  the
heart which circulated the blood. Life was  then  attributed
to cardio-respiratory action.   As  long  as  such  activity
maintained  the  nutritional  needs  of   the   brain,   the
individual was alive.  But, in  the middle of this  century,
physicians became aware that the brain  required  much  more
energy than other  organs and, if its needs were not met, it
would cease  to  function, while other  parts  of  the  body
(requiring  less  energy)  might  remain  viable   and  even
regain   their   activity   provided  the  circulation   was
maintained. The result would be a dead brain  in   a  viable
body.   Is  such  a  preparation  alive  or  dead?    Before
answering that question, one had to  establish  the  general
principles upon which the diagnosis of a dead brain could be
made.  The cause of the coma had to be  known,  so  that  it
could be remedied, if possible.  If the  condition  was  not
remediable, the state of the brain (underlying all  sets  of
brain-death  standards) had to be determined.   The clinical
status  could   be  ascertained  by  standard   neurological
examination.  Testing was,  however,  often  complicated  by
factors such as wounds, which could render it  difficult  to
carry   out or difficult to interpret.   Other  confirmatory
examinations then had to be relied upon  to  establish   the
death of  the  brain.   But  these  confirmatory  tests  had
limitations  too,  some  related  to  the  quality  of   the
examination (such  as  electroencephalo-graphy)  and  others
quantitative aspects (such as isotopic  angio-graphy).   But
with the recognition of  these  limitations,  the  available
yardsticks provide a  satisfactory estimate of the state  of
the brain.  In the  rare case  in  which  the  clinical  and
confirmatory test seem  to be at  variance,  observation  of
the  subject  for  a   longer  period  of   time    provided
clarification of the issue.   The validity of these criteria
under   such    circumstances   as   infancy,    concomitant
intoxications  and  impaired   cardiovascular   status   had
been  questioned.   Having established the  clinical  states
of the subject, the physician  usually  had  no  problem  in
certifying  death.  Problem  cases    required   a   careful
consideration of  medical, religious and legal factors.

      The second lecture "Brainstem death. Evolution  of  the
Concept", proved a detonator for future discussions.  Pallis
(2, 3, 4) emphasized that most controversies concerning  the
criteria for diagnosing death had sprung from  a  reluctance
to define death. Discussions about the validity of different
criteria  could   not   meaningfully   take   place   in   a
philosophical vacuum. What we did (or did not or did not do)
in the Intensive Care  Unit  had  to  flow  from  explicitly
formulated philosophical premises. "There was only a kind of
human death: the  irreversible  loss  of  the  capacity  for
consciousness, combined with the irreversible  loss  of  the
capacity to breathe (and  hence  to  sustain  a  spontaneous
beat)". All death, in this perspective, was brainstem death.
But whereas there was only  one  death  there  were  clearly
several  ways  of  dying.  The  commonest,   by   far,   was
circulatory arrest.  But  this  only  proved  lethal  if  it
persisted for long  enough  for  the  brainstem  to  sustain
irreversible anoxic damage. Circulatory  arrest  of  briefer
duration either had no sequelae, or cause  slight,  moderate
or severe neurological damage, the most pronounced  form  of
which was PVS (persistent vegetative state).  The  death  of
the  brainstem  was   nearly   always   the   infratentorial
repercussion of supratentorial events. It implied the  death
of the "brain as a whole". A diagnosis  of  brainstem  death
had two fundamental implications. The first, pragmatic,  was
that the heart  would inevitably  stop,  within  a  relative
short period. This was an empirically validated observation,
to which no exception had as yet been recorded. The  second,
philosophical, was that quite independently of  the  cardiac
prognosis an individual with a dead  brainstem  was  already
dead  (because  irreversible  unconscious  and  irreversible
apnoeic).

      The distinctions between "whole brain death" (death  of
every neuron in the  intracranial  cavity)   and  "brainstem
death"  (death  of  the  "brain  as  a  whole")  were,  both
philosophically and  in  practice,  of  minor  significance.
There were fundamental differences,  however,  between  both
of  these  concepts   and   the   various   "higher   brain"
formulations currently being proposed and  discussed  mainly
by philosophers (5, 6,  7).  Their  views  implied  that  an
individual might be declared dead even if  still  breathing.
We would undoubtedly lose public support for transplantation
(and rightly so) if such a proposition were  ever  seriously
put forward.

      Gaetano Molinari (U. S.  A.)  was  the  third   on  the
scene. He  emphasized  that:  "still  prohibiting  unanimity
among physicians worldwide were  only some  unfortunate  but
persisting choices of words". Terms like brain  death  (BD),
whole brain death, brainstem death, neocortical death served
only to confuse a basic issue, namely, that heartbeat, blood
pressure, and even body temperature had lost significance as
evidence  of  life  in  modern  intensive  care  units.   In
situations in which spontaneous  respirations  had   stopped
but  heartbeat   persisted,   death   must   be   pronounced
"neurologically". Comparing the "whole brain" and "brain  as
a whole" formulations of death,  he  stated  that  the  only
situation in which the British Criteria  (8)  might  declare
persons dead while the cerebrum retained functional capacity
was the possibility and demonstration in three cases in  the
American Study (1),  and  subsequently  by  others  (9),  of
apnoeic coma with absent cephalic reflexes  due  to  primary
brainstem     lesions     (suggesting      death)      while
electroencephalograms   might   indicate    some    residual
biological activity (10).

      The  fourth  speaker   in  this  marathon   was  Daniel
Wikler,  presenting  some  remarks  on  "The   Philosophical
Considerations  on  Death".  Wikler  was   included   as   a
philosopher, on the  professional staff of  the  President's
Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research (11). He  asked:  "Should
we consider a further revision in the definition  of  death,
one  which  would  define  death  as   permanent   loss   of
consciousness?  This  change  would  permit  physicians   to
pronounce dead patients in a PVS. Today we lack the  ability
to diagnose this condition  with  certainty,  so  a  further
change in the law would be unwise.  Nevertheless,  we  might
wish to be prepared for the day when  physicians acquire the
ability to diagnose PVS with certainty, at  least  for  some
types  of patient. Should such patients be  considered  dead
or alive?

      A thought experiment suggested the need for  a  further
redefinition. Suppose that, at  some  future  date,  doctors
became capable of maintaining  function in severed heads and
decapitated bodies. One poor man, careless in his use of  an
electric saw, suffers a complete decapitation. His  head  is
carried in an ambulance to the Head Hospital;  his  body  is
carried to the Body Hospital in the next town. Since no  one
can be in two places at once, we  must  ask:  Where  is  the
patient? Is he in the Body Hospital or  the  Head  Hospital?
All of us would answer, if we had to make a choice, that  he
was in the  Head  Hospital.  Now,  to  continue  the  story,
suppose that the head dies,  but that  the  patient's   body
continues to live. Is he alive or dead? We cannot say he  is
alive, since that would imply that at the time his head died
he magically switched his location  to  the  Body  Hospital.
Therefore we must say: he died. At this point in the  story,
we have his living body,  in  the  Body  Hospital,  but  the
patient is not alive. But  this  is  what  we  have  with  a
patient in PVS; and therefore we ought to say  that  such  a
patient is not alive either. In the future, however, we will
have to  address the problem of those patients who remain in
an  unconscious  state  for  many  years.  As  an  issue  in
bioethics, the definition of death has been put to rest, but
it has not yet expired. In  this remarkable  lecture  Daniel
wikler introduced the Symposium to the concept   of  "higher
brain formulations of death" (5, 6, 7).

      The lunch break was taken  up  in  further  discussion:
three  lunch panels were presented: "Famous Trial Cases" (in
relation  to  BD  and  persistent  vegetative   state)   was
moderated by Gaetano Molinari; "Persistent Vegetative  State
(PVS)" by R. Firshing (Germany)  and   "Do  not  Resuscitate
Orders", by  Daniel Wikler and Stuart Youngner (U. S. A.).

      The afternoon  of  Tuesday,  September  22,  proved  an
interesting  session  in  which  brain  death  criteria   in
different countries were compared. We  presented the  "Cuban
Criteria for Brain Death Diagnosis" (12, 13). These involved
a sequential  approach  for  brain  death  diagnosis,  using
multi-modality     evoked     potentials     (MEPs)      and
electroretinography (ERG) as  a  key  step.  When  reviewing
literature it was clear that most sets of criteria  had  not
presented considering such a sequential approach.  MEPs  and
ERG were not usually included  as  confirmatory  tests.  The
combination of  of  both  a  sequential  approach,  and  the
application of a test  battery  comprising   MEPs  and  ERG,
could  overcome  the  difficulties   posed   by   conditions
traditionally considered as excluding a diagnosis  of  brain
death,  and   could   facilitate   clinical   practice,   in
establishing a precise and early diagnosis of BD, which  was
also fundamental for organ  transplantation (14).

      Christopher Pallis  again  took  the  rostrum  (he  was
always expected by the auditorium) and presented the  U.  K.
code (8). The majority of the delegates thought that he  had
been a  member of the Commission that had drawn  up  the  U.
K.Code, but we  were to learn from him that although the  U.
K.Code  had  a  brainstem  orientation  in  its  concept  of
death, his own contributions in this field had been  due  to
personal interest and commitment. Pallis stressed  that  the
main emphasis of the U. K.   code  was   the  all  important
question  of "context". Unless strict preconditions had been
fulfilled, and certain conditions specifically  excluded,  a
diagnosis of brain  death  could  not  even  considered.  He
likened the picture to a patient having to pass through  two
tight sieved, before been tested for brain death.

      This point had seldom been grasped by those criticizing
the code. The scheme outlined was scientifically  sound  and
clinically easy to  use.  Terminological  problems  remained
however.  The  memorandum  produced  by  the  Conference  of
Medical Royal Colleges and their Faculties was entitled "The
Diagnosis of Brain Death" (8). The document stated, however,
that it was the "permanent functional death of the brainstem
that constituted death". This is unexceptionable,  if  taken
to mean that death of the brainstem prevented  any  kind  of
meaningful functioning of the "brain as a whole". The  title
of the document remained, however, open to misunderstanding.

      A different view concerning the  U.  K.  code  (8)  was
presented by a german delegate, Dr. R.  Firsching,  a  close
collaborator of R. A. Frowein's. In Germany,  death  of  the
entire brain was required and brainstem death alone had  not
in  general  been  accepted  as  death  of  the  individual.
Firsching   emphasized   that   as    recommended   by   the
"Bundersfrztekammer"  in  Germany,  prerequisites  for   the
declaration of brain death were a primary or secondary brain
lesion and the exclusion of  drug  effects,  hypothermia  or
endocrine disorders.

      After the association of apnoeic coma and cranial nerve
arreflexia  had  been  confirmed  (in   cases   of   primary
supratentorial lesions) four options were available:  (1)  a
waiting period of 12 hours; (2) electrocortical  silence  as
revealed by  EEG;  (3)  step  wise  abolition  of  brainstem
auditory evoked potentials in sequential investigations; (4)
the  demonstration  of  intracerebral  circulatory   arrest,
either by angiography or by transcranial Doppler sonography.
In primary infratentorial lesions cortical function might be
preserved  by  hours   or   days.   The   demonstration   of
electrocortical silence by EEG was therefore mandatory.

      An interesting paper was then presented by a  group  of
colleagues from Argentina. A retrospective  analysis of  630
potential donors  showed that  their  average  age  was  31.
There was a net predominance of males (71,4 %). Head  injury
(46,65 %) and cerebrovascular diseases  (44,6  %)  were  the
most common aetiologies among the potential donors.  Consent
for organ donation was obtained in 58 % of the cases.

      Preliminary results from a  prospective  study  on  BD,
were  then  presented  by  neurologists  from  the  National
Institute of Neurology and Neurosurgery, in Mexico.

     A warm evening  proved  a  pleasant  background  to  the
"Welcome Party". There was  plenty of cuban music,  rum  and
friendship.

      The morning of September  23,  began  with  interesting
presentations  on:  "Neurophysiological  Tests   and   other
Confirmatory Techniques in Brain Death and  Related  States"
and  "Legal  Considerations  on  Brain  Death  and   Related
States".

      I presented a paper on the "Early  Diagnosis  of  Brain
Death Using  Multi-modality  Evoked  Potentials  (MEPs)  and
Electroretinography (ERG)" (14, 15, 16, 17).  MEPs  and  ERG
were highly resistant to factors such as: drug intoxication,
barbiturate narcosis, the use of anaesthetics,  hypothermia,
and so on. They  had  been  shown  to  be  reliable  in  the
Intensive Care Unit environment. Considered as single tests,
they had their limitations and they had been  not  routinely
included as confirmatory tests for the diagnosis of BD.   We
applied a  battery of tests  (including  MEPs  and  ERG)  to
thirty   brain-dead patients.  For   brain   stem   auditory
evoked potentials (BAEPs), three   patterns  of  abnormality
were observed: (1)  no identifiable waves (73.34 %); (2)  an
isolated bilateral wave I (16.66  %)  and  (3)  an  isolated
unilateral wave I (10 %).  For short  latency  somatosensory
evoked potentials  (SSEPs)  a  characteristic  pattern   was
found:   absence  of  N20  and  later  responses   in    the
scalp-cephalic record with preservation of  all  or some  of
the so-called subcortical components  in  the  rest  of  the
derivations.  An interesting dissociation  appeared in which
some SSEP components  were  still present  in  neck-cephalic
and spine while absent  in  scalp-non     cephalic    leads.
Our data further suggested that all components after P13-N13
(recorded with restricted filter bandpass)  also  recognized
two  or  multiple  distinct   generator   sources.   Rostral
generators were probably located  in  the  brainstem  and/or
thalamus, but a significant part of  these  SSEP  components
seemed to be generated at the lowest  part  of  the  medulla
oblongata (dorsal column nuclei) and/or at the level of  the
upper cervical spine.

      Visual  evoked  potentials  (VEPs)  and  the  ERG  were
elicited and recorded simultaneously,   using  cephalic  and
non-cephalic   references.    In   all  cases  in  which   a
non-cephalic reference was used  the  ERG   did  not  change
(either in latency or in  morphology)  while the VEP channel
showed no response. In  only   two   cases  (using  the  VEP
derivation  with  a  non-cephalic reference) was it possible
to record waves that indicated  a spread of the ERG  to  the
occipital  area.  These  results   suggested  that  although
contamination of the VEP recordings by the  possible  spread
of the electroretinogram to the occipital area might  occur,
when using a non-cephalic reference it was  easy  to confirm
the  absence  of  a  true  cortical  visual   response    in
brain-dead patients.

      It was suggested that the   test  battery  we  proposed
would permit the assessment  of  several  sensory  pathways,
in    brain-dead     patients,     thereby      considerably
increasing diagnostic reliability. Taking into account  that
these techniques are highly resistant to  hypothermia,  drug

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intoxication, the use of anesthetics, etc., resort  to  this
battery  as confirmatory tests might  considerably  diminish
the time  of observation  needed to establish  a  definitive
diagnosis  of   BD.  This  was  of  course   a   fundamental
prerequisite to  organ transplantation.  MEPs and  ERG  were
considered as confirmatory tests in the Cuban  Criteria  for
Brain Death Diagnosis (12).

      R.  Firsching  from  Germany  continued  the   session,
presenting an interesting paper about "Evoked Potentials and
Brainstem Reflexes in BD". In Germany registration of  brain
stem  auditory   evoked    potentials   (BAEPs)   had   been
recommended as a confirmatory  test  of  brain  death  under
certain  conditions. The  author's  group  investigated  100
patients  who  exhibited  apnoeic  coma  and  cranial  nerve
arreflexia after  primary brain lesions and who  finally met
all the criteria of brain death. BAEPs, somatosensory  (SEP)
and  visual  evoked  potentials  (VEP)  and,  in   addition,
transcranial  magnetic (TmgMEP) and electric (TelMEP)  motor
evoked potentials  were  registered.  In   no  patient  with
apnoeic coma and cranial  nerve  arreflexia  could  preserve
BAEPs, SEP, VEP or TmgMEP or TelMEP. Brainstem reflexes were
also abolished  with  the  exception of seven cases with   a
preserved  R1 response of the blink reflex immediately after
apnoea  had  been   documented.   Registration   of   evoked
potentials as  a  confirmatory  test  added  safety  to  the
diagnosis   of  brain  death,  as  they  were   particularly
resistant   to  drugs.  They  proved  practicable  for   the
declaration  of brain death in one third of  our   patients.
Brain stem reflexes required further research.

      Hilmar Prange, also from Germany, continued the session
with some remarks  concerning  the  reliability  of  several
technical investigations for the confirmation of  BD.  Fifty
consecutive  patients  with  suspected  brain   death   were
included in his study dedicated to evaluate the  reliability
of different diagnostic techniques.  The techniques employed
comprised clinical examination,    apnoea    testing,   EEG,
extracranial     Doppler  ultrasonography  (ECD),  brainstem
acoustic evoked  potentials   (BAEP)  and  arterial  digital
subtraction  angiography (DSA).  In 39 cases these  were  no
discrepancies in the results of  the  different   techniques
used  to  confirm  brain  death.   With  the  remaining   11
patients  the findings were not exactly  concordant  or,  at
least,  permitted varying interpretations.  For example,  in
six  cases  doubts existed as to whether or  not   the   EEG
was  isoelectric.   In  four  patients  BAEP  findings  were
compatible  with brain  death  two  to  three  days   before
intracranial circulatory arrest was documented.  Finally, in
two   patients  with  isoelectric  EEG  and   absent   BAEP,
arterial   DSA   showed   residual   cerebral   flow.    The
significance of the mentioned  technique   for  brain  death
diagnosis was discussed in the  light  of  their  conceptual
differences implicit in the term brain death.

      A beautiful lady from Chile,  then  proved  that  women
were to be respected in neurophysiology. Nelly Chiofallo had
worked with Professor Earl Walker during the  seventies   in
an International Commission on Brain Death.  She  emphasized
that when  since  clinical  criteria  were  only   partially
realized  and there  was  not   total  certainty  concerning
suspected     brain     death,     certain      non-invasive
electrophysiological tests could provide objective  evidence
as to whether or not the cerebrum was active. Monitoring EEG
and  computer-average  Evoked  Potentials  (EP)  were  among
these confirmatory  methods.   EEG  methodology  was  highly
important in relation  to  both  false  negatives  or  false
positives findings. (The author's  experience  with  corpses
was  reported).  Dr.  Chiofalo  presented   132   brain-dead
patients studied by EEG, in a   three  year  period,  taking
into   consideration:    age-sex    distribution,    primary
diagnosis, consciousness state on  admission,  time  elapsed
until respiratory arrest, time  elapsed from isoelectric EEG
to  asystole,  etc.  She  also  discussed  the  utility   of
topographic brain  mapping  in  a  controversial  paedriatic
case. Minimal EEG activity in few channels were  related  to
artifacts. Mapping-histograms defined the presence of   true
bioelectrical activity.

      Flying thousand of miles, A. Erbengy   came from Turkey
to the Pearl  of  the  Antilles  (Cuba).  He  stressed  that
although   the    determination    of   brain   death    was
fundamentally a clinical diagnosis, conditions   that  might
interfere  with  diagnostic accuracy required assessment  by
at least one ancillary test. In his  institution  (Hacettepe
University Medical School) they had found that  brain   stem
auditory  evoked potentials (BAEPs) was  the  most  reliable
technique.  They    had    also     performed   radionuclide
angiography and brain perfusion studies,  whenever they  had
felt it was necessary. More than 150 brain-dead patients had
been studied by BAEPs and 30   by  radionuclide  angiography
and brain perfusion. A highly  significant  correlation  was
found among  BAEPs and radionuclide study results.  None  of
the  patients  with  absent  BAEPs   had   showed   cerebral
perfusion.  BAEP  records,  with  or  without   radionuclide
studies,  had  been found to be    very  reliable adjunct to
a   clinical  diagnosis  of   brain   death.   Besides   the
determination of brain  death,  radionuclide   studies  also
provided valuable information on the current status of   the
organs  to be used as  grafts   in   organ   transplantation
(kidneys, liver, heart, etc.)

      The chairman of this session, Arnold Starr (U. S.  A.),
had in 1976 reported original data in 1976 about the use  of
auditory brainstem responses in brain  death  (18).  He  now
presented a nice lecture entitled   "Averaged  evoked  brain
potentials and brain death".  The  averaging  of  electrical
events in the brain (time-locked to sensory events) revealed
a sequence of components reflecting  activity  at  different
levels of the pathway from receptor to cerebral cortex.  The
generators of these components varied, and examples that had
been defined included activity in nerve fibers at points  of
an impedance change or activity  in  neuronal  clusters.  In
comatose patients, the pattern of potential  loss  could  be
used to define the level of brain dysfunction.  Brain  death
had been equated with the loss of central brain or brainstem
activity while receptor function could be  preserved.  Among
theoretical problems engendered by these assumptions was the
fact that averaging required  synchrony  of  brain  activity
time-locked to the sensory stimuli.  Pathological  processes
might lead to a loss of this synchrony. Thus even though the
brain  was  viable,  averaged  evoked  potentials  might  be
absent.  A pathological process might result in the loss  of
function of nerve fiber pathways sparing  neurons.  Averaged
evoked potentials would be absent in  this  scenario,  since
the neurons would not be receiving input yet the brain would
be  viable.  Compromised  receptor  function  might   impair
sensory pathway responses in  a  viable  brain.  Alternative
activation of sensory pathways had to be developed for  this
situation as it had to be developed  with  peripheral  nerve
stimulation for somatosensory evoked potentials.

      The lunch break proved  not  only  a  moment  to  enjoy
cuban food. Three equally attractive lunch panels  reported.
As a final game for the World Crown  in  Chess,  Christopher
Pallis (U. K.) and Earl  Walker  (U.  S.  A.)   moderated  a
discussion  on  the  "Brain  as  a  Whole  and  Whole  Brain
formulations  of  death  on  neurological  grounds".  Stuart
Youngner (U. S. A.) chaired a group of discussion   of:  The
"Higher Brain Formulations of Death". Meanwhile R.  Dierkens
(Belgium) was accompanied by enthusiastic delegates  wanting
to discuss "Medical Decisions in Terminal Cases".

      From Oslo,  Marianne  Forsman,  an  interesting  nordic
lady, presented some remarks about the effect of  nimodipine
on cerebral flow  and  cerebrospinal  fluid  pressure  after
cardiac arrest. Fifty-one  patients were included in a blind
randomized  study   to  evaluated  whether  the   Ca-blocker
nimodipine could influence  cerebral  blood  flow  (CBF)  or
cerebrospinal  fluid pressure  (CSFP)  during  the  cerebral
hypoperfusion  period  that  followed   resuscitation   from
cardiac arrest and to  determined  whether  changes  in  CBF
correlated with neurologic outcome.  CBF (measured  1  to  4
hours after arrest with the use of  intravenous  133Xe)  was
significantly greater with nimodipine  than   with  placebo,
There was no clinical evidence of seriously  increased  CSFP
in any patient in either group during the  first  48  hours.
Mean  arterial  pressure  was  significantly   lower,    and
antiarrhythmic drugs were used significantly less frequently
in  the  nimodipine  group  than  in  the   placebo   group.
Twelve  patients   in   each   group   eventually   regained
consciousness.  There  was  no  significant  difference   in
neurologic status between the two groups at  any  point, and
no positive correlation between  CBF  in  the  hypoperfusion
period and neurologic outcome.

      From my group, Dr. Orlando Garcia presented the results
of a study dealing with heart rate variability (HRV) in coma
and brain death. Thirty-three comatose patients were studied
serially by HRV and Glasgow Coma Scale  (GCS),  as  were  40
normal subjects to document  our normative data. HRV  values
were considered for different GCS scores. For GCS from 7  to
9, the HRV achieved its maximum values. We considered  these
in relation to a functional  disconnection  of  the  defense
hypothalamic area with a normal functioning brainstem,  such
results apparently  not  been  previously  reported  in  the
literature. HRV showed a significant  tendency  to  decrease
with low GCS values (3-6). For high GCS scores (10-15),  the
HRV also showed a significant  tendency  to  decrease.  With
these results a non-lineal correlation between HRV  and  GCS
was defined. Fourteen brain-dead patients were also  studied
and  were  found  to  present  the  lowest  values  for  HRV
(significantly different from normals). During the  atropine
test no significant  changes  in  the  HRV  were  found  for
brain-dead patients.

      An enthusiastic group of neurologists and neurosurgeons
from the Neurological  Center  of  the  French  Hospital  in
Buenos Aires, (Argentina)  presented  three  papers  dealing
with the application of  neurophysiological   techniques  to
study  brain-dead  patients.  They   described   a   patient
diagnosed as  brain dead who had  preservation of the spinal
(somatosensory) evoked potential  at  L5-S1.  These  results
might be used to explain the finding of the  Lazarus's  Sign
in brain death. In another paper, they described a series of
30 patients, studied by multi-modality evoked potentials and
EEG, finding patterns which confirmed  absence  of  cerebral
function. All cases showed a electrocerebral silence, except
three patients, who showed preservation of  rudimentary  but
recordable EEG. They discussed the  possible  mechanisms  of
EEG preservation  in  such  patients,  in  relation  to  the
intracranial pathology and to the timing of the EEG study in
relation to  the clinical evolution, since  brain death  was
established. The colleagues  from  Argentina  were  in  fact
defending  the  "brain  as  a   whole"   (brainstem   death)
formulation of death.  The  third  paper  consisted  in  the
presentation of a patient who  developed  a  cardiac  arrest
during a study of the brainstem auditory  evoked  potential.
Several  changes  in  evoked  responses  were  noted,   that
confirmed the diagnosis of brain death.

      The   session   devoted   to   discuss    the    "Legal
Considerations  on  Brain  Death  and  Related  States"  was
chaired by Professor R. Dierkens,  President  of  the  World
Association of Medical Law.  Dierkens  emphasized  that  the
wishes  of the patient  had  to  be  considered,  but  in  a
context in which the medical opinion was also important. The
deontological code in  Belgium  proposed  the  cessation  of
treatment when the clinical  diagnosis  was  hopeless.   The
Catholic  Church  in  this  country  had  also  proposed  to
discontinue treatments progressively in  terminal  patients,
but  without  abandoning  nurse  care,   pain   relief   and
psychological support.

      From my  group,  Dr.  Jesus  Parets,  a  young  lawyer,
continued  with  "Legal  Considerations   on   Brain   Death
Diagnosis and the Moment of its Occurrence" . The old  Civil
Code in Cuba (1942) had stated that "death was diagnosed  by
physicians   confirming   an   irreversible   cessation   of
cardio-respiratory functions". In  1985  a  new  Civil  Code
altered  this,  starting  that    "death  is  diagnosed   by
physicians in relation to criteria defined by  the  Ministry
of Public Health". This view defended a  position  in  which
the relevant  criteria were  not included in  any  law.  New
criteria could thus be included at any time. The Ministry of
Public Health had then organized a national commission which
every year reviewed and updated the criteria to  be  applied
in our country. A ministerial resolution had  validated  the
use and application of the "Cuban Criteria for  Brain  Death
Diagnosis" (19).

      DONAR (the Spanish for to donate)  is  an  organization
from Santa Fe, Argentina. Its President,  Dr.  Pedro  Zukas,
emphasized that "Time is too short for  egoism".  Dr.  Zukas
read a paper whose main  author  was  Dr.  Cesar  Rey  Leyes
(Argentina). Article  103  of  the  Argentinean  Civil  Code
emphasized that death made  it   impossible  to  have  human
rights. The diagnosis of death was accepted in  relation  to
medical criteria, but this  had to be done independently  of
any  decision   concerning    organ   transplantation.   The
patient's  relatives  could  give   or   refuse   permission
regarding organ donation. The law had to facilitate  medical
development, and not impede it.

      A controversial session (Bioethical  Considerations  on
Brain Death and Related States)  began  in  the  morning  of
thursday 24. It was chaired  by  Daniel  Wikler  and  Stuart
Youngner (U. S. A.)

      An expected lecture  was  presented  by  the  chairman,
Daniel  Wikler:  "Why  Brain-dead  Patients  are  Dead?  The
President's  Commission  Explanations  After  One   Decade".
Daniel  Wikler's  presentation  was  a  discussion  of   the
definition of death provided by the  President's  Commission
for the study of Ethical Problems in Medicine and Biomedical
and Behavioral  Research  (11).  This  commission  had  been
appointed in 1979, by the President of the United States. It
had  produced eleven reports which had proven influential in
American  and  international  bioethics.   The   President's
Commission report addressed three topics:  (a) What  concept
of death should be used? (b) What legal  statute  should  be
adopted? (c) How should brain death be  diagnosed?  However,
only (a) was the official product  of  the  Commission.  The
statute had been written in collaboration with the  American
Medical Association and the American Bar Association  (among
others). It gave a  legal  definition  of  death  as  either
whole-brain   death   or   cardio-respiratory   death.   The
Commission's report provided (c) as a public service  in  an
Appendix  (not  endorsed  by  the  Commission  itself)   its
recommendations  on  diagnosing  death.   These   had   been
formulated by an expert panel, including Dr. Walker and  Dr.
Molinari. In its comments on the concept of death  (a),  the
Commission had argued that patients who suffered whole-brain
death should be viewed as dead. The primary reason was  that
the  brain  (and  in  particular  the  brainstem)  was   the
integrator of the body's major organ systems.  Without  this
integration,  the Commission reasoned, continued functioning
of the patient's major organ systems (in  an  ICU)  did  not
constitute  organismic  life.  The  Commission  rejected   a
"cortical-death"  definition,  pointing  out  that  such   a
definition of death would seem to endorse the  burial  of  a
patient with a spontaneously beating heart. The Commission's
findings had resulted in a change in the definition of death
in nearly every one of the states in the  U.  S.  A.  (where
defining death is a matter of state,  rather  than  federal,
law). Philosophers, however, had questioned the logic of the
Commission's central argument, pointing out that  the  major
organ  systems  in  a  well-maintained  brain-dead  patient,
interacted so as to sustain the  main  non-cognitive  bodily
functions.

      Dr. Stuart Youngner (Associate Professor  of  Medicine,
Psychiatry and Biomedical Ethics at the Case Western Reserve
University School of Medicine and Director of  the  Clinical
Ethics Program of the  University  Hospitals  of  Cleveland)
presented a paper on "Brain Death and Organ Transplantation:
Confusion and Its Consequences" (20). He argued that despite
the rapid and widespread embrace of so-called "brain  death"
in the  United  States,  confusion  about  its  meaning  and
implications remained a  problem.  He gave several  examples
of evidence of this confusion. First, the criterion of brain
death, i.e the irreversible loss of all brain function,  was
accepted for practical reasons (without a wide agreement  on
exactly why patients who had lost all  brain  function  were
dead).  The practical reasons were: (1) in the  hands  of  a
competent  neurologist,  neurosurgeon,  or   critical   care
physician, brain death was a relatively  easy  diagnosis  to
make; and (2) that once the diagnosis  of  brain  death  had
been made the prognosis was certain that the  patient  would
never regain consciousness and would develop asystole within
a short time,  despite  continued  aggressive  intervention.
The  diagnostic  certainty  and  uniformly  dismal   cardiac
prognosis for brain-dead patients facilitated the acceptance
of  policies  aimed  at  treatment  withdrawal   and   organ
retrieval.

      A study by Youngner and his  colleagues  (20)  at  Case
Western Reserve University   had,  however,  indicated  that
physicians and nurses working in critical care and operating
room settings accepted brain death  for  different  reasons.
Some thought brain-dead  patients  were  dead  because  they
would never wake up again.  Others  accepted  them  as  dead
because they had  lost  the  integrating  functions  of  the
brainstem.  Still others indicated that they did not  really
believe the patients were dead,  saying  that  the  patients
were "going to die very soon despite  aggressive  treatment"
or that their "quality of life was unacceptable."

      Further     evidence  of  confusion  was  the  stubborn
persistence  of  the  term  "brain  death"  itself.   Health
professionals consistently referred to patients who had lost
all brain function as brain-dead (rather than, simply dead).
It is also common to  hear  them  say  that  the  brain-dead
patient "died" after life  support  had  been  removed.   Of
course you  can  not  die  if  you  are  already  dead.  The
persistence  of  term  brain  death   may  well  reflect  an
inevitable conflict  between  reason  (which  told  us  that
brain-dead patients were dead)  and  emotions.   The  latter
were stimulated by the many signs of "life" still shown   in
brain-dead patients. These were  of  particular  concern  to
nurses who took care of brain-dead patients.  Intensive Care
Unit nurses  reported  feelings  of  discomfort  at  calling
patients "dead" who require aggressive treatment  (including

·
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· (Continued from last message)
resuscitative  efforts  if  the  "dead"  patient  develop  a
cardiac arrests) at a time when clearly living and conscious
patients,   in  the  same  unit,  fell  into  the  "do   not
resuscitate" category.   In the  operating  theater,  nurses
sometimes felt that the patient's spirit  was  in  the  room
during organ retrieval surgery, and only departed  when  the
ventilator was turned off and the patient came  to  complete
rest. These examples of confusion were  inevitable  when  we
were willing  to  call  patients  dead  when  so  much  life
persisted.  This confusion pointed not only to the need  for
more ongoing education about brain death, but also for  wide
debate and  consensus  among  various  elements  of  society
(including not only doctors, but  the  legal  and  religious
communities, and especially the lay public) before  policies
are implemented and enforced.  To do otherwise was to foment
distrust  and  suspicion   of   medical   science,   perhaps
undermining the worthwhile goal  of  saving  more  lives  by
getting more persons to donate their organs.

      Dr. E. Bochiardo from  DONAR  (Argentina)  presented  a
paper "Brain Death", in which he emphasized that until  some
time ago the determination of  death  was  relatively  easy:
confirming the irreversible  absence  of  cardio-respiratory
function. In the sixties, the development of reanimation and
other  intensive  care  techniques,  forced  physicians   to
confront the concept  of  brain  death.  A  man  had  to  be
considered dead when his  brain  functions  disappeared.  He
considered that the decision (made by  patient's  relatives)
to donate organs was a transcendental and admirable token.

      The  results  of  an  interesting  survey   were   then
presented by Dr. Eduardo Fermin, a  delegate  of  the  Cuban
group.  The  subject  of  the  survey  was  related  to  the
decisions and feelings of the physician, who had  to  decide
what to do in a brain-dead patient, when transplantation was
not envisaged. The survey described to the attitudes  of  50
specialists in intensive  care  medicine.  This  survey  was
anonymous,  assessing  the  concepts  of  life  and   death,
euthanasia, as well as the methods used in  the  process  of
diagnosing brain death. Many interesting results had arisen:
for example, the confusion about  methods and  criteria  for
diagnosing death, concerns about  the  legal  protection  of
physicians, doubts about when to  turn-off  the  respirator,
mistakes in the concepts of BD  and  euthanasia,  etc.  Many
physicians  had  expressed  religious  opinions    in   this
context.

      Two cuban  specialists  in  psychiatry  (Drs.  Jose  A.
Hernandez  and  Carlos  M.  Notario)  ended   this   session
presenting    a    paper     entitled:     "Attention     to
Near-Death-Patients". They appreciated the classic study  of
Dr. Klubler-Ross and particularly  her  description  of  the
psychological stages in dying persons. They  paid  attention
to the medical  custom  which  sought  to  prolong,  in  all
possible ways,  the life of hopelessly ill  patients,  while
accepting that  medical procedures should   be  directed  to
relieve the pain of the dying and allowing a decorous death.
They stated that their purpose was to stimulate a discussion
about this subject in our country and to  exchange  opinions
with foreign experts, but always keeping their  patients  in
the forefront of their minds.

      Three interesting lunch panels  joined  delegates  with
providing food for  thought.  "Near-death  Experiences"  was
chaired  by  the  Reverend  Douglas  Lynn  (Canada),  "Organ
Marketing"  by  Dr.  Raul  Herrera  (Cuba)  and  "Transplant
Alternatives" by Dr. Noel Gonzalez (Cuba).

      "Brain Death in Children"  is  always  a  controversial
subject. This session was chaired by Dr. Kimio  Sainio  from
Finland. He opened the session with a study of  the patients
with suspected brain death seen in the Children's University
Hospital of Helsinki,  during a ten year period (1983-1992).
The study correlated clinical, neuroradiological   and   EEG
data.  A total of 36 patients were studied, ranging  in  age
from 0 days  to 11 years (mean = 1.9).   Brain   death   was
diagnosed in 21 patients.  The diagnosis was  confirmed   in
three patients by cerebral angiography and in four  patients
by colour flow Doppler ultrasound examinations.  The EEG was
inactive in 19 patients.  Two patients  showed  minimal  EEG
activity two to five days before  brain death was confirmed.
The diagnosis of BD was not confirmed in 15 patients.   Five
of these cases had either flat  or  burst-suppression  EEGs.
Four of them died and one survived with  major  neurological
sequelae.   The  inactivity   of  the   EEG   was   due   to
barbiturate medication in two patients; both  survived  with
major  neurological   sequelae.   Both   EEG   and   Doppler
examinations   were  compatible  with  brain  death,   while
clinically  some  brainstem function persisted in these  two
cases; both developed asystole  within  24  hours.   Of  the
remaining 6 patients, five died and one  survived,  a  child
who  had inactive EEG  at  t7
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½▄█ OδÅLÑq▒=Zε╖╗φ~p°ëΦú≤╖6╛*n«≈|εP╒4╧·╦~┴┘{┼╞íEX╔óδα╠Ç╬O¡∙É≡4═/Å┐·yú┌π┌║y╗₧σy&?┬å∞Γà┤ε·6ú∩u@ƒ₧67≥╙▐╜7╥_c5è╗]│5┘(I¼    ¿╞7læ╨,Uⁿóσ½σWtJ║Vh4A»┌\yè╗ê╛Σ╜╚-íhq╩5¿y╔VΓn$┌╧âö-╚φ:dç²h8EXµ8╧á╠ⁿ$Czoå3Öαδ¥aP\φ[j¡vɼOúáÑòB█└╠MPq(J┴òîJi╟òN┼he  age  of  0  days  and  later
developed  major   neurological  damage.    The   ultrasound
Doppler examination reliably confirmed  the diagnosis of  BD
in  these  patients.   The  inactive   EEG   often  preceded
clinical and Doppler signs of brain death. An  inactive  EEG
in patients that were not brain-dead   was  associated  with
poor prognosis.

      A psychopedagogical view of organ  transplantation  was
presented by Daniel  De  Greef  (DONAR,  Argentina)  in  his
paper: "The Child and his Death and Organ  Transplantation".
The speaker considered that to be prepared for the moment of
death, it was necessary to educate people to achieve  a  new
culture about the need for organ  transplantation.  In  this
context,  people  would  be  psychologically  prepared  when
facing the death of a relative, to  give  their  concern  to
donate organs. This was a message that we should learn since
the child-hood in our schools. Organ transplantation  allows
a dead person  to offer life to another.

      A cultural  night  (on  Thursday  evening)  gave  us  a
marvelous opportunity to listen to cuban music.

      Two important sessions took place on the last day:  "BD
and Organ Transplantation" and "Philosophical,  theological,
cultural, historical and sociological considerations  on  BD
and related issues".

      "Brain Death and  Organ  Transplantation"  was  chaired
Professor     Noel    Gonzalez,    pioneer    of     cardiac
transplantation in Cuba, and Raul Herrera, Director  of  the
National Institute of Nephrology.

      Professor Noel Gonzalez presented an  overview  of  the
evolution of  organ  transplantation  in  Cuba,  emphasizing
cardiac transplantation.  Professor Gonzalez had   organized
the Cuban National Program for Transplantation.

      Dr. Raul Herrera  described  the  Cuban  experience  in
relation  to  renal   transplantation.   The   first   renal
transplantation took place on February  24,  1970  in  Cuba.
This initiated the development of transplantation surgery in
our country. The total number amount of  renal  transplants,
up to 1992, had been 1809.

      Dr. Antonio Marrero, a member of  Professor  Gonzalez's
group,  described  the  coordination  of  organ  and  tissue
transplants. He described  the  medical  and   psychological
problems encountered in obtaining adequate number of  donors
and viable organs and tissues. He also described the care of
the donor in the Intensive Care Unit,  the  anaesthetic  and
surgical  techniques  employed,  etc.   Dr.   Marrero   also
commented   on   the   group's   experience    in    cardiac
transplantation.  He  analyzed data relating to 307 possible
donors processed between  1985  and 1991,   emphasizing  the
cause of brain death, age, sex, number of extracted  organs,
blood groups, causes of no  acceptance,  and   the   average
ischaemia time,  among  other  elements.  He  explained  the
selection criteria in donors for cardiac   transplants,  and
summarized the technique used for organ harvesting.

      A cuban lady, Sofia Sanchez, emphasized  the  important
roll of the psychologist in the  Intensive  Care  Unit,   in
managing   patients'   relatives.    She    described    the
medical-psychologic  stages  in  the  comprehension  of  the
patient's relatives. She also described the organization  of
the  Cuban  National  Program  for  Transplantation  at  the
"Hermanos  Ameijeiras"  Hospital,   showing   the   national
statistics for multi-organ donors between December 1985  and
December 1991.

      This session was ended with  a  round  table  involving
specialists from the Intensive Care Unit  of  the  "Hermanos
Ameijeiras" Hospital.

      The session  devoted  to  "Philosophical,  Theological,
Cultural, Historical and Sociological considerations  on  BD
and related issues" was  chaired  by  Douglas  Lynn,  Senior
Pastor   and   President   of   the   Crossroad    Cathedral
International Ministries and Dorita Caballero,  also  Pastor
of the Crossroad Cathedral (Canada). Reverend Lynn began the
session with these remarks: "The Human race had been  caught
up in a unique moment of wold history precipitated by  man's
tremendous advancements in medicine and science.  Technology
had outstripped the development of man himself, so that  the
two were no longer synchronized. What man "can do"  was  out
of step with our  knowledge  of  "who  man  is",  which  had
resulted in an ever increasing tension and  a  multitude  of
unanswered questions. This had been further  complicated  by
the interdisciplinary nature  of  bioethics  which  extended
these  questions  beyond  the  field  of  medicine  to   the
philosopher, the ethicist and the theologian.  He  proposed,
in his paper to delineate the contours of  this  tension  by
examining  fundamental  questions  like,  "What   determines
humanity?", "What are the components of  personhood?,  "What
defines the dignity and value of a human being?", "Is  there
a difference between human life and biological life?", "What
does life  as  defined  by  a  holy  world  View  where  our
judgments are based on deep-seated absolutes  to  which  are
added precepts based upon experience?". Reverend  Lynn  came
to this exchange as a fellow inquirer sharing  some  of  the
uncertainties common to us all. As an Evangelical Christian,
his  aim  was  to   set  forth  what  many  of   the   great
philosophers of the last 300 years had  verbalized,  namely,
that  without  resort  to  a  concept  of   God   (variously
under-stood) and to an understanding of the purpose of  life
which is provided by the great religions of  the  world,  it
was not possible to justify the rules of  living  which  had
been the guiding principles of our  world.  He  believed  we
were more than the  products  of  random  accidents  without
purpose and meaning.

      The Jewish position was defended  by  Rabby  Dr.  Moshe
Tendler,  Chairman  of  the  Bioethics  Committee   of   the
Rabbinical Council  of  America  and  Professor  of  Medical
Ethics and Biology at New York's Yeshiva  University.  Since
decapitation  was  regarded  by   the  Talmud  as  the  only
applicable model for brain death, Tendler  and  Rabbi  Yigai
Shafren had performed an interesting experiment: a  pregnant
ewe, close to delivery, was decapitated and organ  viability
was maintained by a ventilator. The  decapitated  sheep  was
kept in this condition for several hours with  heart  action
and blood pressure remaining within normal  values.  A  live
lamb was them delivered by Caesarean  section.  Dr.  Tendler
emphasized  that  this  experiment  proved  that  neither  a
beating heart nor a live foetus were a signs of life when an
animal was on respiratory support.  The  critical  condition
required by Rabbi Auerbach,  one  of  the  leading  halachic
arbiters in Israel, was a 30 seconds cessation of heart beat
after  the  respirator  had  been    disconnected   from   a
brainstem-dead patient.  Transplant  surgeons  could  accept
this condition when it involved the use of a kidney,  liver,
lung and pancreas, but it considerably reduced  the  success
rate in cardiac transplants. Dr. Tendler considered that the
heart could  be removed from the brainstem-dead donor  while
it it was still beating. Tendler disputed the belief held by
many Jews that they would be denied entrance to Paradise  or
resurrection after death unless they were  buried  with  all
their organs. If a man's leg was  amputated,  should  it  be
buried so that its being above ground  did  not  defile  the
Priestly Tribe?  The  greatest  guarantee  of  Paradise  was
having donated organs to save  another  person's  life.  Dr.
Moshe Tendler had called on all rabbis and  Jews  to  accept
brainstem death and to actively promote organ donation.

      "DONAR" went again to  scene.  Dr.  Zukas  stated  that
death compelled man to face the mystery  of  his  own  life.
Pope Pio XII had stated  that the diagnosis of death  was  a
subject of Medicine and not of the  Church.  Nowadays,  what
characterized death  was  the  irreversible  damage  to  the
brain, with the disappearance of  personhood. A "patient" in
this state was a corpse. But was it not  possible  to  offer
life from these cadavers? Juan Pablo II had emphasized  that
organ transplantation was like the resurrection  of  Christ,
who after his death continued to offer life: "Because I  was
thirsty, you gave me water; because I was hungry,  you  gave
food to eat; because I was blind,  you  gave  your  corneas;
because my heart was  sick,  you  gave  yours,  before  mine
stopped; because I was on a dialysis machine, you gave  your
kidney; because of this I came to share the kingdom of God".

      Dr. Orlando Garcia (from my group) and Dorita Caballero
(Pastor of the Crossroad Cathedral, Canada)  presented  "One
Body, Many Lives". Science and modern  technology  had  made
possible a dream that had caused wonder to humanity from the
oldest times:  organ  transplantation.  Today  the  lack  of
available organs constituted a major problem  for  thousands
of people who remained on waiting  lists.  Medical  activity
could be an areas of deep meaning, and co-creating  activity
in the  relation  between  man  and  God  in  a  context  of
humanized  structures,  but  such  activity  can   also   be
adulterated, for example by the criminal practice  of  organ
marketing.  A theological understanding of the body was (and
by far) more communitarian than individualistic. We belonged
to one  another.  This  derived  from  an  understanding  of
Creation by God, and of a life project in Jesus Christ  open
to humanity. As part of their theological mission,  churches
could  support a donation  system  and  contributed  to  the
public dialogue. "Look for  a  new  heart,  why  should  you
die?...I will give you a new heart and will put a new Spirit
within you, and I will take away from your flesh  the  heart
of stone, and I will give you a heart of flesh". These words
from the prophet Ezequiel had a special  resonance  in  this
context. The cuban hero Jose Marti said: "to die is to close
one's eyes the  better  to  see  ...".  The  vision  he  was
referring to so profoundly  did  not  depend  on  our  sense
organs or the corneas  which  otherwise  could  restore  the
sight to others.

      May be, for the first time,  a group  of  Cuban  Yoruba
Theologians participated in an event like this. Spanish  and
African emigrations had provided  the  main  core  to  cuban
nationality. From a region of Africa, which is now  Nigeria,
had come  numerous groups of slaves, who practiced  wha