Cardiac transplantation using extended-donor criteria organs for systemic amyloidosis complicated by heart failure.

BACKGROUND: Systemic amyloidosis complicated by heart failure is associated with high cardiovascular morbidity and mortality. Heart transplantation for patients with systemic amyloidosis is controversial due to recurrence of disease in the transplanted organ or progression of disease in other organs. METHODS: All patients with systemic amyloidosis and heart failure referred for heart transplant evaluation from 1997 to 2004 were included in this retrospective cohort analysis. An interdisciplinary protocol for cardiac transplantation using extended-donor criteria organs, followed in 6 months by either high-dose chemotherapy and stem cell transplantation for patients with primary (AL) or by orthotopic liver transplantation for familial (ATTR) amyloidosis, was developed. Survival of the transplanted amyloid cohort was compared to survival of those amyloid patients not transplanted and to patients transplanted for other indications. RESULTS: A total of 25 patients with systemic amyloidosis and heart failure were included in the study; 12 patients received heart transplants. Amyloid heart transplant recipients were more likely female (58% vs. 8%, P=0.02) and had lower serum creatinine (1.3+/-0.5 vs. 2.0+/-0.7 mg/dL, P=0.01) than nontransplanted amyloid patients. Survival at 1-year after heart transplant evaluation was higher among transplanted patients (75% vs. 23%) compared to patients not transplanted (P=0.001). Short-term survival posttransplant did not differ between transplanted amyloid patients and contemporaneous standard and extended-donor criteria heart transplant patients (P=0.65). CONCLUSIONS: Cardiac transplantation for amyloid patients with extended-donor criteria organs followed by either stem cell or liver transplantation is associated with improved survival compared to patients not transplanted. Short- to intermediate-term survival is similar to patients receiving heart transplantation for other indications. This clinical management strategy provides cardiac amyloid patients a novel therapeutic option.

Finding a Path to Entrustment in Undergraduate Medical Education: A Progress Report From the AAMC Core Entrustable Professional Activities for Entering Residency Entrustment Concept Group.

PROBLEM: To better prepare graduating medical students to transition to the professional responsibilities of residency, 10 medical schools are participating in an Association of American Medical Colleges pilot to evaluate the feasibility of explicitly teaching and assessing 13 Core Entrustable Professional Activities for Entering Residency. The authors focused on operationalizing the concept of entrustment as part of this process. APPROACH: Starting in 2014, the Entrustment Concept Group, with representatives from each of the pilot schools, guided the development of the structures and processes necessary for formal entrustment decisions associated with students' increased responsibilities at the start of residency. OUTCOMES: Guiding principles developed by the group recommend that formal, summative entrustment decisions in undergraduate medical education be made by a trained group, be based on longitudinal performance assessments from multiple assessors, and incorporate day-to-day entrustment judgments by workplace supervisors. Key to entrustment decisions is evidence that students know their limits (discernment), can be relied on to follow through (conscientiousness), and are forthcoming despite potential personal costs (truthfulness), in addition to having the requisite knowledge and skills. The group constructed a developmental framework for discernment, conscientiousness, and truthfulness to pilot a model for transparent entrustment decision making. NEXT STEPS: The pilot schools are studying a number of questions regarding the pathways to and decisions about entrustment. This work seeks to inform meaningful culture change in undergraduate medical education through a shared understanding of the assessment of trust and a shared trust in that assessment.