Framing our Expectations: Variability in Entrustable Professional Activity Assessments.

OBJECTIVE: To determine the ability of surgical trainees and faculty to correctly interpret entrustability of a resident learner in a modeled patient care scenario. DESIGN: Prospective study utilizing a web-based survey including 4 previously-recorded short videos of resident learners targeted to specific levels of the American Board of Surgery's (ABS) Entrustment Scale. Respondents were asked to choose the entrustment level that best corresponded to their observations of the learner in the video. Responses were subcategorized by low and high entrustment. SETTING: Online, utilizing the Qualtrics survey platform. PARTICIPANTS: Survey targeting US surgical trainees and surgical faculty via email and social media. We received 31 complete responses and 2 responses which completed > 1 video assessment question without demographic information (n = 33). Respondents included 10 trainees (32%) and 21 attending surgeons (68%). RESULTS: Neither faculty nor trainees readily identified the targeted entrustment level for Question 1 (preoperative care of a patient with acute appendicitis with high entrustment, 36% correct), though evaluations of the remaining questions (2 through 4) demonstrated more accuracy (70, 84, and 75% correct, respectively). Faculty were more readily able than trainees to identify low entrustment (level Limited Participation) in intraoperative inguinal hernia repair (95% vs 60%, p = 0.03). After subcategorization to high and low entrustment, both residents and faculty were able to accurately identify entrustment 95% overall. CONCLUSIONS: Both trainees and attending surgeons were able to identify high- and low-performing residents on short video demonstrations using the ABS EPA entrustment scale. This provides additional evidence in support of the need for frequent observations of EPAs to account for the variability in raters' perceptions in addition to complexity of clinical scenarios. Frame-of-reference training via a video-based platform may also be beneficial for both residents and faculty as an ongoing EPA implementation strategy.

Physiologic homeostasis after pig-to-human kidney xenotransplantation.

Demand for kidney grafts outpaces supply, limiting kidney transplantation as a treatment for kidney failure. Xenotransplantation has the potential to make kidney transplantation available to many more patients with kidney failure, but the ability of xenografts to support human physiologic homeostasis has not been established. A brain-dead adult decedent underwent bilateral native nephrectomies followed by 10 gene-edited (four gene knockouts, six human transgenes) pig-to-human xenotransplantation. Physiologic parameters and laboratory values were measured for seven days in a critical care setting. Data collection aimed to assess homeostasis by measuring components of the renin-angiotensin-aldosterone system, parathyroid hormone signaling, glomerular filtration rate, and markers of salt and water balance. Mean arterial blood pressure was maintained above 60 mmHg throughout. Pig kidneys secreted renin (post-operative day three to seven mean and standard deviation: 47.3 ± 9 pg/mL). Aldosterone and angiotensin II levels were present (post-operative day three to seven, 57.0 ± 8 pg/mL and 5.4 ± 4.3 pg/mL, respectively) despite plasma renin activity under 0.6 ng/mL/hr. Parathyroid hormone levels followed ionized calcium. Urine output down trended from 37 L to 6 L per day with 4.5 L of electrolyte free water loss on post-operative day six. Aquaporin 2 channels were detected in the apical surface of principal cells, supporting pig kidney response to human vasopressin. Serum creatinine down trended to 0.9 mg/dL by day seven. Glomerular filtration rate ranged 90-240 mL/min by creatinine clearance and single-dose inulin clearance. Thus, in a human decedent model, xenotransplantation of 10 gene-edited pig kidneys provided physiologic balance for seven days. Hence, our in-human study paves the way for future clinical study of pig-to-human kidney xenotransplantation in living persons.

A Current View of SARS-CoV-2 Vaccine Policies Amongst Pediatric Renal Transplant Centers and Relationships to State Policy.

Given its mortality benefit, renal transplantation remains the ideal treatment modality for end stage renal disease in children. Despite the recent expansion of use in young children, the novel SARS-CoV-2 vaccine has not been universally accepted. Similarly, vaccine related state regulations are heterogenous. We present a cross-sectional analysis of institutional specific vaccination policies at US pediatric renal transplant centers and relationships to state legislation. We found that 36.1% of institutions require COVID-19 vaccination prior to transplant, while 17 states have current legislation prohibiting proof of vaccination as a means of access to public services. Of the 63.9% of transplant centers without immunization requirement, almost two-thirds are located in states without prohibitory regulations. Despite an unclear primary influence of institutional policy, our study demonstrates a lack of standardization and potential to create unnecessary inequities.