Impact of peri-operative frailty and operative stress on post-discharge mortality, readmission and days at home in Medicare beneficiaries.

BACKGROUND: Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress. METHODS: This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure. RESULTS: In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category. CONCLUSIONS: These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty.

Management of rectal neuroendocrine tumours by transanal endoscopic microsurgery.

AIM: The objective of this study was to evaluate the safety and effectiveness of transanal endoscopic microsurgery for rectal neuroendocrine tumours. METHOD: A retrospective cohort study of all pathology-confirmed rectal neuroendocrine tumours treated by transanal endoscopic microsurgery from April 2007 to December 2020 at a tertiary care centre was performed. Demographic, clinical, radiographic and pathological data were collected. Characteristics of patients with recurrence were examined. Descriptive statistics were performed. RESULTS: There were 58 patients treated by transanal endoscopic microsurgery excision. Referrals were for primary excision (15, 25.9%), completion re-excision after incomplete endoscopic removal (38, 65.5%) or locally recurrent rectal neuroendocrine tumours (5, 8.6%). The mean age of patients was 56.4 ± 11.9 years and 26 patients were women (44.8%). Mean tumour size was 7.4 ± 3.8 mm (range 1.0-15.0 mm). Most (86.4%) were Grade 1 tumours. Mean operative time was 37.2 ± 17.2 min and 56 patients (96.6%) were discharged on the same day. All patients had negative margins on final pathology. Of the 38 patients who were referred for completion re-excision after incomplete endoscopic removal, eight (21.1%) had residual tumour on final pathology. Three recurrences were diagnosed at 2.1, 4.5 and 12.5 years after excision. All recurrences were from Grade 1 or 2 primary tumours, less than 2 cm, and diagnosed radiographically. CONCLUSION: To date, this is the largest North American study looking at transanal endoscopic microsurgery for rectal neuroendocrine tumours. This technique is effective in managing primary, incompletely excised and recurrent tumours with good clinical and oncological outcomes.

The influence of preparation and storage time on endothelial cells in Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK) grafts in vitro.

Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK) has been introduced as a modification of the standard DMEK technique to increase the pool of endothelial grafts. In this study, we evaluated in vitro changes in endothelial cell distribution, viability and morphology of Quarter-DMEK grafts when stored in organ-culture medium. Quarter-DMEK grafts were prepared from 5 corneas and stored in organ-culture medium for 4, 7 and 11 days. Endothelial cell re-distribution was investigated by light microscopy, cell viability by a Calcein-AM assay, and expression of endothelial and non-endothelial markers by immunohistochemistry. Three standard DMEK-grafts were used as controls. After preparation, all Quarter-DMEK grafts showed a band with no viable endothelial cells along the radial cut graft edges [average width 190 (± 20) µm]. Endothelial cell density in the central graft area decreased by 12%, 23% and 26% after 4, 7, and 11 days of storage, respectively. At the same time, empty bands along the cut edges were re-populated and some cells migrated to the stromal side of the Descemet membrane (DM). These cells showed an altered phenotype, as indicated by expression of migration marker CD73 and fibroblast marker αSMA. Majority of migration occurred within the first 4 days of storage. Our data suggest that endothelial cells on Quarter-DMEK grafts re-distribute during organ-culture storage to re-populate preparation-induced empty bands and after re-distribution, cells may show further migration to the stromal DM side during storage.

Bowman layer transplantation to reduce and stabilize progressive, advanced keratoconus.

OBJECTIVE: To evaluate the clinical outcome of mid-stromal isolated Bowman layer transplantation, a new surgical technique to reduce and stabilize ectasia in eyes with advanced keratoconus, to postpone penetrating keratoplasty or deep anterior lamellar keratoplasty, and to enable continued daily contact lens wear. DESIGN: Prospective, nonrandomized cohort study at a tertiary referral center. PARTICIPANTS: Twenty-two eyes of 19 patients with progressive, advanced keratoconus not eligible for ultraviolet cross-linking. INTERVENTIONS: The mid-stroma was manually dissected and an isolated donor Bowman layer was positioned within the stromal pocket. MAIN OUTCOME MEASURES: Before and up to 36 months after surgery (mean follow-up, 21±7 months), best spectacle-corrected visual acuity (BSCVA), best contact lens-corrected visual acuity (BCLVA), Scheimpflug-based corneal tomography measurements, endothelial cell density, biomicroscopy, refraction, and intraoperative and postoperative complications were recorded. RESULTS: Two surgeries were complicated by an intraoperative perforation of Descemet membrane; no other intraoperative or postoperative complications were observed. Maximum keratometry decreased on average from 77.2±6.2 diopters (D) to 69.2±3.7 D (P < 0.001) at 1 month after surgery and remained stable thereafter (P ≥ 0.072). Mean BSCVA improved from 1.27±0.44 logarithm of the minimum angle of resolution units before surgery to 0.90±0.30 logarithm of the minimum angle of resolution units 12 months after surgery (P < 0.001), whereas BCLVA remained stable (P = 0.105). Mean thinnest-point pachymetry increased from 332±59 µm before surgery to 360±50 µm at the latest follow-up (P = 0.012), and no change in endothelial cell density was found (P = 0.355). CONCLUSIONS: With isolated Bowman layer transplantation, reduction and stabilization of corneal ectasia was achieved in eyes with progressive, advanced keratoconus. Given the low risk for complications, the procedure may be performed to postpone penetrating or deep anterior lamellar keratoplasty.

Dehydration of corneal anterior donor tissue with polyethylene glycol (PEG)-enriched media.

Anterior donor grafts (including scleral rim, without Descemet membrane) increase in thickness and become hazy upon storage in organ culture (OC) medium. Transfer of these grafts to standard dehydration media just before transplantation does not reduce their thickness to normal. Therefore, we assessed the efficacy of different media enriched with polyethylene glycol (PEG) as dehydrating agents for organ-cultured anterior donor grafts. Grafts were harvested and stored in the commercial OC medium 'Max' (without dextran) for 1 week, and subsequently dehydrated in the standard commercial dehydration medium 'Jet' (with dextran) supplemented with 4-20% PEG3350, or 'Max' supplemented with 20% PEG6000 and PEG20.000, or 5-20% PEG35.000. Central corneal thickness (CCT), as assessed by anterior segment-optical coherence tomography, and transparency were evaluated before, and at 1, 4 and 7 days of dehydration. Transfer of grafts after 1 week of OC (average 1,200 µm) to 'Jet' supplemented with PEG3350 revealed a concentration-dependent effect of dehydration; CCT was restored to normal (500-600 µm) when 10% PEG3350 was added. However, transparency was only temporarily restored; after 1 day, the grafts turned hazy. In contrast, grafts transferred to 'Max' supplemented with 20% PEG35.000 were transparent throughout the evaluation period, but were dehydrated to beyond normal levels (average 300 µm). 'Max' supplemented with 5% PEG35.000 dehydrated grafts to normal values and restored transparency throughout. Thus, dehydration of anterior donor grafts prior to surgery in dextran-free OC medium supplemented with 5% PEG35.000 reduces graft thickness to normal and may facilitate anterior keratoplasty procedures.

Psychological Impact of the COVID-19 Pandemic on Canadian Surgical Residents: A Province-Wide Study.

OBJECTIVES: The objective of this study was to evaluate the psychological impact of the COVID-19 pandemic on surgical residents. DESIGN: An online survey was distributed evaluating multiple domains: demographics, health and socioeconomic factors, clinical experience, educational experience, and psychological outcomes. The Mayo Clinic Resident Well-Being Index (RWBI) was used as a validated measure of resident mental health. SETTING AND PARTICIPANTS: Surgical residents from University of British Columbia's surgical residency programs. RESULTS: A total of 31/86 surgical residents responded to the survey. Of which, 57% and 46% reported feeling burned out or depressed, respectively. Residents who were concerned about personal protective equipment supply and who lived with family members with comorbidities had a higher risk of depression (p = 0.03, p = 0.04). The median Mayo Clinic Resident Well-Being Index was 2.5, higher than the median of 2 observed in the United States national survey of residents. CONCLUSIONS: The pandemic had a considerable negative impact on the psychological well-being of surgical residents.

Corneal Guttae After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: The aim of this study was to report on the occurrence of corneal guttae after Descemet membrane endothelial keratoplasty (DMEK). METHODS: In this retrospective case series, 13 eyes of 13 patients who underwent DMEK at 2 tertiary referral centers between 2007 and 2021 (average available follow-up 73 ± 52 months, range 18-174 months) and showed corneal guttae during postoperative examinations were included. Eye bank images were retrospectively reviewed. RESULTS: Occurrence of guttae was observed by specular microscopy in 13 eyes. In 11 cases, presence of guttae was confirmed by confocal microscopy and in 1 case by histology. Five eyes showed an increase in guttae density during the postoperative course. Surgery indications were Fuchs endothelial corneal dystrophy (n = 11), pseudophakic bullous keratopathy (n = 1), and DMEK graft failure after allograft rejection (n = 1); the latter eye had shown no signs of guttae after primary DMEK. Two eyes with guttae required a repeat DMEK due to graft failure. At the last available follow-up, all 11 remaining eyes had clear corneas and 10 eyes had a best-corrected visual acuity of ≥0.9 (decimal). During donor cornea processing in the eye bank, no guttae were observed on the donor tissue. CONCLUSIONS: Corneal guttae can occur after DMEK including in eyes operated for indications other than Fuchs endothelial corneal dystrophy and most likely guttae were present on the donor graft but were not detectable by routine slit-lamp and light microscopy evaluation in the eye bank. Postoperative guttae density varies among patients and especially small isolated guttae do not seem to affect clinical outcomes.

In situ open repair of renal artery aneurysm in 43-year-old with solitary kidney: a case report.

Renal artery aneurysms are rare. Indications for management include size > 3 cm, female gender within childbearing age, pain, hematuria, medically refractory hypertension, thromboembolism, dissection, and rupture. Management options include endovascular, open repair, and ex vivo approaches. A 43-year-old female with a history of polycystic kidney disease, solitary kidney, and uncontrolled hypertension was found to have a proximal large renal aneurysm on imaging. The patient underwent an in situ open aneurysm resection, temporary shunt insertion, and patch repair with good postoperative outcomes. Whereas previous studies showed the success of ex vivo repair and autotransplantation in large aneurysms with solitary kidneys, our case demonstrated that in situ open repair and patch with the use of a temporary shunt is a feasible and effective option. In a patient with a solitary kidney and large proximal renal artery aneurysm, an in situ open approach and patch repair with shunt insertion should be considered.

Factors associated with recurrent appendicitis after nonoperative management.

BACKGROUND: The objective of this study is to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively. METHODS: This is a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital. Patient demographics, radiographic information, management, and clinical outcomes were recorded. The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a time-to-event competing-risk analysis was performed. RESULTS: Of the 699 patients presenting with appendicitis, 74 were treated nonoperatively (35 [47%] were women; median [IQR] age, 48 [33,64] years), and 21 patients (29%) had recurrent appendicitis. On univariate and multivariate analysis, presence of an appendicolith on imaging was the only factor associated with a higher risk of recurrent appendicitis (p = 0.02). CONCLUSIONS: The presence of appendicolith was associated with an increased risk of developing recurrent appendicitis within 6 months.

P07-A139†Guttae in corneal donor tissue.

PURPOSE: To report on the occurrence of guttae in corneal donor tissue. MATERIAL & METHODS: Retrospective database study of discard reasons for corneal donor tissue at Amnitrans EyeBank Rotterdam (AER) for the period from January 2019 to December 2021 and the outcome of an eight-question survey sent to European Eye Bank Association corresponding members addressing the occurrence of corneal guttae and the practice pattern regarding donor tissue with guttae. RESULTS: Between 2019 and 2021 6039 donor corneas were processed at AER. Average discard rate because of guttae in this period was 9 (±4)% (n=552). Most corneas were discarded because of guttae at first evaluation (8%, n=481). Monthly discard rate because of guttae ranged from 3% to 19%. Yearly discard rates related to corneal guttae were 10 (±3)%, 8 (±3)% and 11 (±5)% in 2019, 2020 and 2021, respectively. Average endothelial cell density (ECD) at the first evaluation from 2019-2021 was 2486 (±93) cells/mm2, with average monthly ECD ranging from 2343 to 2642 cells/mm2.Twenty-nine eye banks completed the survey, including 4 located outside Europe. 70% reported a guttae-related discard rate of ≤4. The types of microscope used for the evaluation, the geographical location and the number of guttae permitted do not seem to influence the discard rates. 13 eye banks permitted 0 guttae while 10 banks accepted between 1-10 guttae.The 16 eye banks that responded 'no' to the question whether the contralateral cornea of a guttae-cornea was automatically discarded did report a lower guttae-related discard rate than the other eye banks. CONCLUSION: The high variability of the discard rate due to guttae in donor corneas (ranging from <1% and >12%) is an indication that it is not always easy to detect guttae in donor corneas. Although transplanting corneal grafts with guttae does not necessarily mean that a re-transplantation will be needed on the short term, a vital method to unequivocally determine the presence of guttae in the eye bank seems essential to prevent unnecessary waste of suspect tissue and unnecessary re-surgeries.

Combined chlorhexidine and PVP-I decontamination of human donor eyes prior to corneal preservation.

The aim of this study was to report the efficacy of adding chlorhexidine to the protocol for decontamination of human donor globes prior to excision of corneo-scleral rims for future keratoplasty procedures. In 2005, chlorhexidine was introduced by our eye bank as an additional step in the protocol for decontaminating human donor globes. After 5 years, we prospectively evaluated the number of contaminations. Out of 2,891 globes included in our study, 2,663 globes were processed, of which 36 (1.4%) were considered contaminated. Seventeen contaminations (0.6%) were detected by culturing limbal swabs, directly after decontamination, eight (0.3%) by visible discoloration of the culture medium carrying a corneo-scleral rim, and eleven (0.4%) after inoculation of the culture medium on blood agar plates. Importantly, after 4 weeks of incubation, none of the aerobic and anaerobic cultures taken from the secondary 'transport medium' (dextran containing medium used to transport corneal tissue to the transplantation centre) showed microbiological growth. In conclusion, the combined use of 0.02% chlorhexidine and 0.5% povidone-iodine may allow decontamination of donor globes to a level at which the risk of tissue contamination at the time of transplantation is minimized, while corneal viability is preserved.

Functional status recovery trajectories in hospitalised older adults with pneumonia.

BACKGROUND AND OBJECTIVES: Pneumonia is associated with significant mortality and morbidity in older adults. We investigated changes in functional status over 6 months after pneumonia hospitalisation by frailty status. METHODS AND MEASUREMENTS: This single-centre prospective cohort study enrolled 201 patients (mean age 79.4, 37.3% women) who were hospitalised with pneumonia. A deficit-accumulation frailty index (range: 0-1; robust <0.15, pre-frail 0.15-0.24, mild-to-moderately frail 0.25-0.44, severely frail ≥0.45) was calculated on admission. Functional status, defined as self-reported ability to perform 21 activities and physical tasks independently, was measured by telephone at 1, 3 and 6 months after discharge. Group-based trajectory model was used to identify functional trajectories. We examined the probability of each trajectory based on frailty levels. RESULTS: On admission, 51 (25.4%) were robust, 43 (21.4%) pre-frail, 40 (20.0%) mild-to-moderately frail and 67 (33.3%) severely frail patients. Four trajectories were identified: excellent (14.4%), good (25.4%), poor (28.9%) and very poor (31.3%). The trajectory was more strongly correlated with frailty level on admission than pneumonia severity. The most common trajectory was excellent trajectory (59.9%) in robust patients, good trajectory (74.4%) in pre-frail patients, poor trajectory (85.0%) in mild-to-moderately frail patients and very poor trajectory (89.6%) in severely frail patients. The risk of poor or very poor trajectory from robust to severely frail patients was 11.8%, 25.6%, 92.5% and 100%, respectively. CONCLUSIONS: Frailty was a strong determinant of lack of functional recovery over 6 months after pneumonia hospitalisation in older adults. Our results call for hospital-based and post-acute care interventions for frail patients.

32†Corneal guttae after descemet membrane endothelial keratoplasty (DMEK).

PURPOSE: To report on the occurrence of corneal guttae after Descemet membrane endothelial keratoplasty (DMEK) in eyes operated on for Fuchs endothelial corneal dystrophy (FECD). MATERIAL AND METHODS: Case series of 10 eyes of 10 patients operated on for FECD at a tertiary referral center between 2008 and 2019. Average patient age was 61±12 years and 3 patients were female and 6 were male. Five patients were phakic and 4 pseudophakic. Average donor age was 67±9 years. RESULTS: During routine postoperative consultation, specular microscopy images showed suspected recurrence of guttae in 10 eyes after DMEK. Presence of guttae was subsequently confirmed in 9 cases by confocal microscopy and in one case by histology. Six out of 10 patients (60%) had undergone bilateral DMEK, but all only showed recurrence of guttae in one eye. In 9 eyes guttae recurred after primary DMEK, while in one eye recurrence was after a re-DMEK that has been performed 56 months after the first DMEK with no signs of guttae after primary DMEK. Suspected guttae were visible on specular microscopy images already at 1 month after DMEK in most cases.No guttae had been noted during donor cornea processing in the eye bank. Preoperative donor endothelial cell density (ECD) had been 2643±145 cells/mm2 and 1-year postoperative ECD was 1047±458 cells/mm2 (n=8). CONCLUSION: Recurrence of guttae after DMEK is most likely due to guttae on the donor graft that were not detectable by routine slit-lamp and light-microscopy evaluation in the eye bank. Better screening methods for guttae detection need to be developed for eye banks to avoid releasing tissue for transplantation that contains guttae or is prone for postoperative guttae formation.

Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery.

Importance: Gabapentin has been increasingly used as part of a multimodal analgesia regimen to reduce opioid use in perioperative pain management. However, the safety of perioperative gabapentin use among older patients remains uncertain. Objective: To examine in-hospital adverse clinical events associated with perioperative gabapentin use among older patients undergoing major surgery. Design, Setting, and Participants: This retrospective cohort study using data from the Premier Healthcare Database included patients aged 65 years or older who underwent major surgery at US hospitals within 7 days of hospital admission from January 1, 2009, to March 31, 2018, and did not use gabapentin before surgery. Data were analyzed from June 14, 2021, to May 23, 2022. Exposures: Gabapentin use within 2 days after surgery. Main Outcomes and Measures: The primary outcome was delirium, identified using diagnosis codes, and secondary outcomes were new antipsychotic use, pneumonia, and in-hospital death between postoperative day 3 and hospital discharge. To reduce confounding, 1:1 propensity score matching was performed. Risk ratios (RRs) and risk differences (RDs) with 95% CIs were estimated. Results: Among 967 547 patients before propensity score matching (mean [SD] age, 76.2 [7.4] years; 59.6% female), the rate of perioperative gabapentin use was 12.3% (119 087 patients). After propensity score matching, 237 872 (118 936 pairs) gabapentin users and nonusers (mean [SD] age, 74.5 [6.7] years; 62.7% female) were identified. Compared with nonusers, gabapentin users had increased risk of delirium (4040 [3.4%] vs 3148 [2.6%]; RR, 1.28 [95% CI, 1.23-1.34]; RD, 0.75 [95% CI, 0.75 [0.61-0.89] per 100 persons), new antipsychotic use (944 [0.8%] vs 805 [0.7%]; RR, 1.17 [95% CI, 1.07-1.29]; RD, 0.12 [95% CI, 0.05-0.19] per 100 persons), and pneumonia (1521 [1.3%] vs 1368 [1.2%]; RR, 1.11 [95% CI, 1.03-1.20]; RD, 0.13 [95% CI, 0.04-0.22] per 100 persons), but there was no difference in in-hospital death (362 [0.3%] vs 354 [0.2%]; RR, 1.02 [95% CI, 0.88-1.18]; RD, 0.00 [95% CI, -0.04 to 0.05] per 100 persons). Risk of delirium among gabapentin users was greater in subgroups with high comorbidity burden than in those with low comorbidity burden (combined comorbidity index <4 vs ≥4: RR, 1.20 [95% CI, 1.13-1.27] vs 1.40 [95% CI, 1.30-1.51]; RD, 0.41 [95% CI, 0.28-0.53] vs 2.66 [95% CI, 2.08-3.24] per 100 persons) and chronic kidney disease (absence vs presence: RR, 1.26 [95% CI, 1.19-1.33] vs 1.38 [95% CI, 1.27-1.49]; RD, 0.56 [95% CI, 0.42-0.69] vs 1.97 [95% CI, 1.49-2.46] per 100 persons). Conclusion and Relevance: In this cohort study, perioperative gabapentin use was associated with increased risk of delirium, new antipsychotic use, and pneumonia among older patients after major surgery. These results suggest careful risk-benefit assessment before prescribing gabapentin for perioperative pain management.

24†Effect of graft preparation techniques on clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK).

PURPOSE: To compare the clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK) for grafts prepared by the manual no-touch peeling technique and grafts prepared by a modified liquid bubble technique. MATERIAL AND METHODS: For this study, 236 DMEK grafts were included that were prepared at Amnitrans EyeBank Rotterdam by experienced eye bank personnel. 132 grafts were prepared by using the 'no-touch' DMEK preparation technique and 104 grafts by using a modified liquid bubble technique. The liquid bubble technique was modified to render it a no-touch technique while maintaining the ability to save the anterior donor button as a potential Deep Anterior lamellar keratoplasty (DALK) or Bowman layer (BL) graft. DMEK surgeries were performed at Melles Cornea Clinic Rotterdam by experienced DMEK surgeons. All patients underwent DMEK for Fuchs endothelial dystrophy. Average patient age was 68 (±10) years and average donor age was 69 (±9) years with no difference between the two groups. Endothelial cell density (ECD) was evaluated after graft preparation by light microscopy in the eye bank and at 6-month postoperatively by specular microscopy. RESULTS: Endothelial cell density (ECD) decreased from 2705 (±146) cells/mm2 (n=132) before to 1570 (±490) cells/mm2 (n=130) at 6 months postoperatively for grafts prepared by the no-touch technique. For grafts prepared by the modifiedliquid bubble technique, ECD decreased from 2627 (±181) cells/mm2 (n=104) before to 1553 (±513) cells/mm2 (n=103) after surgery. Postoperative ECD did not differ for grafts prepared by the two techniques (P=0.79). Central corneal thickness (CCT) decreased from 660 (±124) µm to 513 (±36) µm postoperatively in the no-touch group and from 684 (±116) µm to 515 (±35) µm postoperatively in the modified liquid bubble group, with no postoperative CCT difference between groups (P=0.59). In total 3 eyes underwent re-surgery within the study period (n=2 (1.5%) in the no-touch group, n=1 (1.0%) in the liquid bubble group; P=0.71) and 26 eyes required a re-bubbling procedure for incomplete graft adherence (n=16 (12%) in the no-touch group, n=10 (10%) in the liquid bubble group; P=0.37). CONCLUSION: Clinical outcomes after DMEK are comparable for grafts prepared by either the manual no-touch peeling technique or the modified liquid bubble technique. While both techniques are safe and useful techniques to prepare DMEK grafts, the modified liquid bubble technique offers advantages for corneas with scars.

Optimizing Resident Wellness During a Pandemic: University of British Columbia's General Surgery Program's COVID-19 Experience.

OBJECTIVE: The University of British Columbia's General Surgery Program delineates a unique and systematic approach to wellness for surgical residents during a pandemic. SUMMARY BACKGROUND DATA: During the COVID-19 pandemic, health care workers are suffering from increased rates of mental health disturbances. Residents' duty obligations put them at increased physical and mental health risk. It is only by prioritizing their well-being that we can better serve the patients and prepare for a surge. Therefore, it is imperative that measures are put in place to protect them. METHODS: Resident wellness was optimized by targeting 3 domains: efficiency of practice, culture of wellness and personal resilience. RESULTS: Efficiency in delivering information and patient care minimizes additional stress to residents that is caused by the pandemic. By having a reserve team, prioritizing the safety of residents and taking burnout seriously, the culture of wellness and sense of community in our program are emphasized. All of the residents' personal resilience was further optimized by the regular and mandatory measures put in place by the program. CONCLUSIONS: The new challenges brought on by a pandemic puts increased pressure on residents. Measures must be put in place to protect resident from the increased physical and mental health stress in order to best serve patients during this difficult time.

Improving Endothelial Explant Tissue Culture by Novel Thermoresponsive Cell Culture System.

AIM: Studying cell migration of corneal endothelial cells in vitro is challenging because the capacity for cell migration needs to be maintained while at the same time the tissue must remain fixed on a rigid substrate. In this study, we report a thermoresponsive culture technique designed to maintain cellular viability, and to reduce tissue handling in order to analyze in vitro endothelial cell migration from corneal grafts. MATERIALS AND METHODS: As a test tissue, fifteen Quarter-Descemet membrane endothelial keratoplasty (Q-DMEK) grafts were used that were embedded in a three-dimensional culture system using a temperature-reversible hydrogel and cultured over 2-3 weeks in a humidified atmosphere at 37°C and 5% CO2. RESULTS: All grafts could be successfully cultured inside the thermoresponsive polymer solution for periods of up to 21 days. Using this system, cell migration could be assessed by light microscopy at fixed time intervals. At the end of the culture period, the gel could be removed from all grafts and immunohistochemistry analysis showed that endothelial cells were able to maintain confluence, viability, and junctional integrity. Some problems were encountered when using the thermoresponsive cell culture system. These were mostly structural inconsistencies during the sol-to-gel transition phase that resulted in the formation of tiny bubbles in the matrix. Additionally, areas with different viscosity resulted in optical distortions showing up as folds throughout the matrix which can persist even after several cycles of culture medium exchange. These effects had impact on the imaging quality but did not affect the viability of the explant tissue. CONCLUSION: This study proves that temperature-reversible hydrogel is a very useful matrix for studying in vitro corneal endothelial cell migration from explant grafts and allows for subsequent biological investigation after gel removal.

Preclinical testing of small diameter Descemet membrane endothelial keratoplasty grafts to increase tissue availability.

In this study, we describe a process of preparing, surgically manipulating, and validating a novel "small diameter" 4mm circular Descemet membrane endothelial keratoplasty (DMEK) graft in vitro. Three small diameter DMEK grafts can be prepared from a single donor endothelium and could, therefore, potentially expand the donor pool. Prior to clinical use, however, we aimed to examine each step of the process to determine the effect on the endothelial cell loss and whether or not cells retained their capacity to migrate uniformly. For this study, circular small diameter grafts, obtained from twelve corneas of ten donors deemed ineligible for transplantation, were included. Small diameter DMEK graft preparation was successful in all cases (n = 36). Endothelial cell density (ECD), determined in the eye bank on seventeen grafts, showed an average decrease from 2413 (±189) cells/mm2 before to 2240 (±413) cells/mm2 after preparation. Twenty-four grafts were used to simulate DMEK-surgery in vitro and were successfully stained with 0.06% trypan blue, loaded into a straight DMEK-injector, unfolded, positioned, and centered within the circular ~ 4mm descemetorhexis. The estimated % area populated by viable cells on the grafts decreased from on average 92 (±3) % before to 78 (±10) % (n = 4) after in vitro surgery. Cells displayed a capacity for uniform cell migration from all edges of the graft (n = 4) when embedded in the 3D hydrogel system. Our data show, that by using an in vitro model of DMEK-surgery it was possible to test the 4mm circular DMEK grafts from eye bank preparation to surgical implantation. The cell loss after in vitro surgery was comparable with the in vivo ECD decline early after DMEK and the capacity of the cells to migrate to potentially cover bare stroma indicates that these small diameter grafts may be a viable clinical option to treat central endothelial disease.

In Vitro Evaluation and Transplantation of Human Corneal Endothelial Cells Cultured on Biocompatible Carriers.

Corneal transplantation is currently the only effective treatment option for dysfunctional corneal endothelial cells (CEC). In this study, we test in vitro the surgical potential of cultivated human corneal endothelial cells (hCEC) on human anterior lens capsule (HALC), LinkCell™ bioengineered collagen sheets of 20-µm thickness (LK20), and denuded Descemet membrane (dDM) as tissue-engineered grafts for Descemet membrane (DM) endothelial keratoplasty (DMEK) to bypass the problem of donor tissue availability. Primary hCEC cultured on all carriers formed a monolayer of tightly packed cells with a high cell viability rate (96% ± 4%). hCEC on HALC and LK20 showed unremarkable expression of zonula occludens-1 (ZO-1) and Na+/K+-adenosine triphosphatase (ATPase), while Na+/K+-ATPase expression of cells seeded on dDM was mainly cytoplasmic. All hCEC-carrier constructs were evaluated by simulating DMEK surgery in vitro using a human donor cornea without DM mounted on an artificial anterior chamber (AC) and a regular DMEK-graft used as a surgical reference model. During in vitro surgery, hCEC-HALC constructs behaved most similarly to a DMEK-graft during implantation and unfolding, showing good adhesion to the bare stroma. On the other hand, hCEC-LK20 and hCEC-dDM constructs required some additional handling because of challenges related to the surgical procedure, although they were both successfully unfolded and implanted in the artificial AC. The hCEC-dDM constructs showed similar graft adherence as hCEC-HALC constructs, while adherence of hCEC-LK20 constructs was less effective. After the in vitro surgery, the estimated area populated by viable cells on the hCEC-HALC and hCEC-LK20 constructs was ∼83% and ∼67%, respectively. Overall, hCEC-HALC constructs behaved most similarly to a DMEK-graft during in vitro DMEK surgery, while graft adhesion and surgical handling, respectively, are parameters still requiring optimization for hCEC-LK20 and hCEC-dDM constructs.

In vitro endothelial cell migration from limbal edge-modified Quarter-DMEK grafts.

Endothelial cell migration plays a crucial role in achieving corneal clearance after corneal transplantation when using smaller-sized endothelial grafts to increase the donor pool. In this study we investigated how different strategies of Quarter-Descemet Membrane Endothelial Keratoplasty (Quarter-DMEK) limbal graft edge modification influence peripheral endothelial cell migration in an in vitro culture environment. For this study, 15 Quarter-DMEK grafts, prepared from 7 corneas deemed ineligible for transplantation but with intact and viable endothelial cells, were embedded in a cooled biocompatible, thermoresponsive matrix for culture. The limbal edge of ten Quarter-DMEK grafts were modified, either by using a small diameter punch or by peripheral radial cuts. All Quarter-DMEK grafts showed substantial collective endothelial cell migration from the radial cut graft edges, as observed by light microscopy at standardized time intervals. Grafts were retrieved from the polymer matrix after the two-week culture for immunohistochemistry analyses of the newly formed cell monolayers; this demonstrated the presence of tightly packed and viable cells that showed higher migratory ability at the leading edge. Peripheral endothelial cell migration, however, was not triggered by increasing cell exposure to free space through surgical modifications of the far periphery. Our data suggest that alterations in the far peripheral area of Quarter-DMEK grafts were insufficient to triggering cell migration from the limbal graft edge. This may be due to transient-amplifying cells that reside in the far periphery and which lack cytokinetic directional cues. Understanding the migration capacity of the peripheral endothelium could unlock cells' therapeutic potential which are, at present, routinely discarded from transplantation. Encouraging peripheral cell migration may also improve clinical outcomes from Quarter-DMEK, but a more effective solution is required prior to clinical implementation of modified grafts.