Utilization of older deceased donors for pediatric liver transplant may negatively impact long-term survival.

BACKGROUND: Multiple adult studies have investigated the role of older donors (ODs) in expanding the donor pool. However, the impact of donor age on pediatric liver transplantation (LT) has not been fully elucidated. METHODS: UNOS database was used to identify pediatric (≤18 years) LTs performed in the United States during 2002-22. Donors ≥40 years at donation were classified as older donors (ODs). Propensity analysis was performed with 1:1 matching for potentially confounding variables. RESULTS: A total of 10,024 pediatric liver transplantation (PLT) patients met inclusion criteria; 669 received liver grafts from ODs. Candidates receiving OD liver grafts were more likely to be transplanted for acute liver failure, have higher Model End-Stage Liver Disease/Pediatric End-Stage Liver Disease (MELD/PELD) scores at LT, listed as Status 1/1A at LT, and be in the intensive care unit (ICU) at time of LT (all p < 0.001). Kaplan-Meier (KM) analyses showed that recipients of OD grafts had worse patient and graft survival (p < 0.001) compared to recipients of younger donor (YD) grafts. KM analyses performed on candidates matched for acuity at LT revealed inferior patient and graft survival in recipients of deceased donor grafts (p < 0.001), but not living donor grafts (p > 0.1) from ODs. Cox regression analysis demonstrated that living donor LT, diagnosis of biliary atresia and first liver transplant were favorable predictors of recipient outcomes, whereas ICU stay before LT and transplantation during 2002-12 were unfavorable. CONCLUSION: Livers from ODs were used for candidates with higher acuity. Pediatric recipients of livers from ODs had worse outcome compared to YDs; however, living donor LT from ODs had the least negative impact on recipient outcomes.

Bioresorbable shape-adaptive structures for ultrasonic monitoring of deep-tissue homeostasis.

Monitoring homeostasis is an essential aspect of obtaining pathophysiological insights for treating patients. Accurate, timely assessments of homeostatic dysregulation in deep tissues typically require expensive imaging techniques or invasive biopsies. We introduce a bioresorbable shape-adaptive materials structure that enables real-time monitoring of deep-tissue homeostasis using conventional ultrasound instruments. Collections of small bioresorbable metal disks distributed within thin, pH-responsive hydrogels, deployed by surgical implantation or syringe injection, allow ultrasound-based measurements of spatiotemporal changes in pH for early assessments of anastomotic leaks after gastrointestinal surgeries, and their bioresorption after a recovery period eliminates the need for surgical extraction. Demonstrations in small and large animal models illustrate capabilities in monitoring leakage from the small intestine, the stomach, and the pancreas.

Does gender affect experiences in the operating room for surgeons and anesthesiologists at a large academic center?

BACKGROUND: Although the number of women medical trainees has increased in recent years, they remain a minority of the academic workforce. Gender-based implicit biases may lead to deleterious effects on surgical workforce retention and productivity. METHODS: All 440 attending surgeons and anesthesiologists employed at our institution were invited to complete a survey regarding perceptions of the perioperative work environment and resources. Odds ratios for dichotomous variables were calculated using logistic regressions, and for trichotomous variables, polytomous regressions. RESULTS: 243 participants (55.2%) provided complete survey responses. Relative to men, women faculty reported a greater need to prove themselves to staff; less respect and fewer resources and opportunities; more frequent assumptions about their capabilities; and a greater need to adjust their demeanor to connect with their team (p â€‹< â€‹0.05). CONCLUSION: Perceived gender bias remains present in the perioperative environment. We need greater efforts to address barriers and create an equitable work environment.

Global liver transplantation: emerging trends and ethical challenges.

PURPOSE: Liver transplant (LT) is the only definitive treatment for end-stage liver disease (ESLD). This review aims to explore current global LT practices, with an emphasis on challenges and disparities that limit access to LT in different regions of the world. METHODS: A detailed analysis was performed of present-day liver transplant practices throughout the world, including the etiology of liver disease, patient access to transplantation, surgical costs, and ongoing ethical concerns. RESULTS: Annually, only 10% of the patients needing a liver transplant receive an organ. Currently, the USA performs the highest volume of liver transplants worldwide, followed by China and Brazil. In both North America and Europe, nonalcoholic fatty liver disease is becoming the most common indication for LT, compared to hepatitis B and C in most Asian, South American, and African countries. While deceased donor liver transplant remains the most performed type of LT, living donor liver transplant is becoming increasingly popular in some parts of the world where it is often the only option due to a lack of well-developed infrastructure for deceased organ donation. Ethical concerns in liver transplantation fundamentally revolve around the definition of a deceased donor and the exploitation of living donor liver donation systems. CONCLUSION: Globally, liver transplant practices and outcomes are varied, with differences driven by healthcare policies, inequities in healthcare access, and ethical concerns.

Factors leading to disparity in lung cancer diagnosis among black/African American communities in the USA: a qualitative study.

OBJECTIVE: This study has two objectives: first, to explore the diagnostic experiences of black/African American (BAA) patients with lung cancer to pinpoint pitfalls, suboptimal experiences and instances of discrimination leading to disparities in outcomes compared with patients of other ethnic backgrounds, especially white patients. The second objective is to identify the underlying causes contributing to health disparities in the diagnosis of lung cancer among BAA patients. METHODS: We employed a phenomenological research approach, guiding in-depth interviews with patients self-identifying as BAA diagnosed with lung cancer, as well as caregivers, healthcare professionals and community advocates knowledgeable about BAA experiences with lung cancer. We performed thematic analysis to identify experiences at patient, primary care and specialist levels. Contributing factors were identified using the National Institute of Minority Health and Health Disparities (NIMHD) health disparity model. RESULTS: From March to November 2021, we conducted individual interviews with 19 participants, including 9 patients/caregivers and 10 providers/advocates. Participants reported recurring and increased pain before seeking treatment, treatment for non-cancer illnesses, delays in diagnostic tests and referrals, poor communication and bias when dealing with specialists and primary care providers. Factors contributing to suboptimal experiences included reluctance by insurers to cover costs, provider unwillingness to conduct comprehensive testing, provider bias in recommending treatment, high healthcare costs, and lack of healthcare facilities and qualified staff to provide necessary support. However, some participants reported positive experiences due to their insurance, availability of services and having an empowered support structure. CONCLUSIONS: BAA patients and caregivers encountered suboptimal experiences during their care. The NIMHD model is a useful framework to organise factors contributing to these experiences that may be leading to health disparities. Additional research is needed to fully capture the extent of these experiences and identify ways to improve BAA patient experiences in the lung cancer diagnosis pathway.

The impact of a dedicated operating room team on robotic transplant program growth and fellowship training.

INTRODUCTION: Despite considerable interest in robotic surgery, successful incorporation of robotics into transplant programs has been challenging. Lack of a dedicated OR team with expertise in both robotics and transplant is felt to be a major barrier. This paper assesses the impact of a dedicated robotic transplant team (DART) on program growth and fellowship training at one of the largest robotic transplant programs in North America. METHODS: This is a single center, retrospective review of all robotic operations performed on the transplant surgery service from October 2017 to October 2022. DART was incorporated in February 2020 and included transplant first assists (RFAs), scrub technologists and circulating nurses who received robotic training. Robotic experience before and after DART was compared to assess its impact on program growth and training. RESULTS: Four hundred and two robotic cases were performed by five transplant surgeons: 63 pre-DART and 339 post-DART. 40% of cases were transplant-related and 59.5%, HPB. There was a significant increase in case volume (2.5-10.6 cases/month, p < .0001) and complexity (36.5% vs. 70.3% high complexity cases, p < .0001) post-DART. RFA case coverage increased from 17% to 95%, and participation of transplant fellows as primary surgeons increased from 17% to 95% post-DART period (both p < .05). Conversion rates (9.5% vs. 4.1%) and room turn-around-times (TAT) (58.4 vs. 40.3 min) were lower post-DART (p < .05). There were no emergent conversions, conversions in transplant patients, or robot-related complications in either group. CONCLUSION: OR teams with expertise in robotics and transplant surgery can accelerate growth of robotic transplant programs while maintaining patient safety.

Robotic donor nephrectomy: optimizing outcomes beyond the limitations of laparoscopy.

BACKGROUND: Robotic donor nephrectomy (RDN) has emerged as a safe alternate to laparoscopic donor nephrectomy (LDN), offering improved visualization, instrument dexterity and ergonomics. There is still concern about how to safely transition from LDN to RDN. METHODS: We performed a retrospective review of 150 consecutive living donor operations (75 LDN and 75 RDN) at our center, comparing the first 75 RDN's with the last 75 LDN's performed prior to the initiation of the robotic transplant program. Operative times and complications were used as surrogates of efficiency and safety, respectively, to estimate the learning curve with RDN. RESULTS: RDN was associated with a longer total operative time (RDN 182 vs LDN 144 min; P < 0.0001) but a significantly shorter post-operative length of stay (RDN 1.8 vs LDN 2.1 days; P = 0.0213). Donor complications and recipient outcomes were the same between both groups. Learning curve of RDN was estimated to be about 30 cases. CONCLUSIONS: RDN is a safe alternate to LDN with acceptable donor morbidity and no negative impact on recipient outcomes even during the early part of the RDN learning curve. Surgeon preferences for the robotic approach compared to traditional laparoscopy will require further scrutiny to improve ergonomics and operative efficiency.

Liver Transplantation After Hepatic Artery Infusion Pump Therapy: Single-Center Experience and Technical Considerations.

BACKGROUND: Hepatic artery infusion pump (HAIP) therapy has become increasingly commonplace in the treatment of intrahepatic tumors. When combined with standard chemotherapy, HAIP therapy demonstrates a higher response rate than chemotherapy alone. Biliary sclerosis is observed in up to 22 % of patients, for whom no treatment has been standardized. This report describes orthotopic liver transplantation (OLT) both as a treatment for HAIP-induced cholangiopathy and as a possible definitive oncologic treatment after HAIP-bridging therapy. METHODS: A retrospective study reviewed patients who had undergone HAIP placement followed by OLT at the authors' institution. Patient demographics, neoadjuvant treatment, and postoperative outcomes were reviewed. RESULTS: Seven OLTs were performed for patients with prior HAIP placement. The majority were women (n = 6), and the median age was 61 years (range, 44.5-65.5 years). Transplantation was performed for five patients due to biliary complications secondary to HAIP and two patients because of residual tumor after HAIP therapy. All the OLTs had difficult dissections due to adhesions. Because of HAIP-induced damage, atypical arterial anastomoses were required in six patients (2 patients used a recipient common hepatic artery below the gastroduodenal artery takeoff; 2 patients used recipient splenic arterial inflow; 1 patient used the junction of the celiac and splenic arteries; and 1 patient used the celiac cuff). The one patient with standard arterial reconstruction experienced an arterial thrombosis. The graft was salvaged with thrombolysis. Biliary reconstruction was duct-to-duct in five cases and Roux-en-Y in two cases. CONCLUSIONS: The OLT procedure is a feasible treatment option for end-stage liver disease after HAIP therapy. Technical considerations include a more challenging dissection and an atypical arterial anastomosis.

The Impact of a Culturally Meaningful Storytelling Intervention on Stigma and Attitudes About Mental Health Treatment.

ABSTRACT: The fear of being devalued or discriminated against is a salient deterrent to seeking mental health care, especially in communities of color where racial stigma also impacts mental health and perceptions of service utilization. To address this issue, our research team partnered with This Is My Brave Inc to develop and evaluate a virtual storytelling intervention to highlight and amplify the voices of Black and Brown Americans living with mental illness and/or addiction. We utilized a pretest-posttest survey design administered electronically to viewers of the series ( n = 100 Black, indigenous, people of color and n = 144 non-Hispanic White). Results indicated that postintervention, scores on public stigma and perceived discrimination measures were significantly reduced. We identified significant interaction effects, such that Black, indigenous, people of color viewers showed a greater rate of improvement on outcomes. This study provides strong preliminary evidence of the impact of a culturally meaningful virtual approach to addressing stigma and improving attitudes about mental health treatment.

Circadian regulation of dentate gyrus excitability mediated by G-protein signaling.

The central circadian regulator within the suprachiasmatic nucleus transmits time of day information by a diurnal spiking rhythm driven by molecular clock genes controlling membrane excitability. Most brain regions, including the hippocampus, harbor similar intrinsic circadian transcriptional machinery, but whether these molecular programs generate oscillations of membrane properties is unclear. Here, we show that intrinsic excitability of mouse dentate granule neurons exhibits a 24-h oscillation that controls spiking probability. Diurnal changes in excitability are mediated by antiphase G-protein regulation of potassium and sodium currents that reduce excitability during the Light phase. Disruption of the circadian transcriptional machinery by conditional deletion of Bmal1 enhances excitability selectively during the Light phase by removing G-protein regulation. These results reveal that circadian transcriptional machinery regulates intrinsic excitability by coordinated regulation of ion channels by G-protein signaling, highlighting a potential novel mechanism of cell-autonomous oscillations.

Alzheimer disease and the evolving treatment landscape.

Alzheimer disease (AD) is an irreversible, progressive neurodegenerative disorder that destroys memory and the ability to think, slowly over time. AD is the leading type of dementia, accounting for 60% to 80% of cases, and the sixth leading cause of death in the United States. AD, which can range from mild to severe, is thought to occur secondary to the aggregation and accumulation of ß-amyloid peptides, abnormal phosphorylation of tau protein, and neuroinflammation. Current treatment options vary depending on the severity of AD, and emerging treatment options continue to arise. Managed care organizations are in an excellent position to implement viable patient care ecosystems to support patients and caregivers in decreasing AD progression and its consequences. Vigilance in identifying AD and providing early treatment is crucial to improving patient outcomes and burden of disease on patients, caregivers, and health systems.

An Artistic Active-Learning Approach to Teaching a Substance Use Disorder Elective Course.

Objective. To incorporate an artistic, multimedia approach to teaching within a substance use disorder (SUD) elective course to intellectually, visually, physically, and emotionally engage Doctor of Pharmacy (PharmD) students in learning and applying clinical and legal SUD topics. Methods. Faculty members created a two credit-hour SUD elective course that required students to engage in visual, linguistic, and performing art forms, including acting, screenwriting, choreography, dancing, artwork, writing movie reviews, writing book reports, writing journal reflections, create-your-own-adventure storytelling, speech writing, examination writing, policy writing, and creative thinking in an escape room gaming environment to learn about SUD and related topics. Results. Student learning and perception of the activities was evaluated using faculty-created analytic rubrics, pre- and post-intervention tests, student feedback, and student responses on standard course evaluations. Students performed well on the graded assignments. Pre- and post-intervention tests administered for the escape room activity demonstrated an increase in scores from 56.7% to 94.9%. Student feedback and course evaluations revealed student engagement with subject material and enthusiasm for creative applications, critical thinking, and collaborative aspects of the activities. Conclusion. The PharmD students consistently rated the interactive class format highly on course evaluations and reported having the perception of simultaneously learning and having fun. Pharmacy instructors are encouraged to incorporate creative projects and activities in courses to enhance student learning experiences and increase student motivation to engage with the material, their classmates, and other professionals.

Evaluating the quality of red blood cell concentrates irradiated before or after cryopreservation.

BACKGROUND: Cryopreserved red blood cell concentrates (RCCs) are often required for patients with rare blood groups. Although transfusions from blood relatives are irradiated before transfusion, research has yet to make clear if this is necessary in cryopreserved RCCs. Given insufficient evidence to the contrary, irradiation of cryopreserved RCCs has been recommended, but the effect of irradiation timing is unknown. Therefore, this study was performed to assess the effect of RCC irradiation pre- and postcryopreservation on RCC quality. STUDY DESIGN AND METHODS: Nine whole blood units from healthy donors were processed into RCCs using the buffy coat method. ABO- and Rh-matched units were pooled and split into three groups: precryopreservation irradiation (pre-CIG), postcryopreservation irradiation (post-CIG), and nonirradiated controls. Hemoglobin, hematocrit, white blood cell (WBC) count, extracellular potassium, mean cell volume, red blood cell (RBC) morphology, and RBC deformability were measured. RESULTS: Extracellular potassium was greater in the irradiated conditions when compared to the nonirradiated controls and was greater in the post-CIG group when compared to the pre-CIG group (p < 0.05). WBC counts decreased after cryopreservation in all groups to values lower than the sensitivity of the assay. RBC deformability was greater in the post-CIG group when compared to the pre-CIG group and control group. No other significant differences were observed between groups. CONCLUSION: Irradiation of RCCs can be performed pre- or postcryopreservation with little effect on the RCC product, as both irradiated groups resulted in RCCs that were comparable to the nonirradiated cryopreserved RCCs.

Incorporation of Professionalism Expectations and Evaluative Processes Within a College of Pharmacy.

Objective. To determine professionalism factors of interest to the University of South Florida (USF) College of Pharmacy (COP) and develop a programmatic plan to monitor the professionalization of students, faculty, preceptors and staff. Methods. In 2013, the USF COP began investigating how best to incorporate processes to capture professionalism across all aspects of the program. A Professionalism Task Force was convened to identify key professionalism factors valued by faculty and preceptors to be incorporated in pharmacy practice experiences, didactic courses, faculty, and preceptor performance evaluations. A factor analysis was performed to identify items for inclusion in professional practice experience evaluations, course syllabi, faculty, preceptor and staff evaluations. Results. The analysis identified 11 factors for practice experiences, three for syllabi, and five for performance evaluations. The information from the factor analysis spurred additional discussion that led to the development of a programmatic plan for professionalization. Conclusion. A brief description of the programmatic professionalization plan is provided, including possible assessment processes. The goal of this endeavor was to ensure appropriate support and development of professionalization across the COP community.

Active-learning Strategies for Legal Topics and Substance Abuse in a Pharmacy Curriculum.

Objective. To implement active-learning strategies to engage students in learning, applying, and teaching legal and substance abuse topics. Design. Medication Safety course student groups created films on a National Patient Safety Goal (NPSG) using a movie genre and presented them in film festival format. Pharmacogenomics course student groups taught ethical, legal, and social implications (ELSI) topics through presentation of short stories about comic book characters with genetic mutations. Students in the Drugs of Abuse course composed and performed dances depicting the mechanism of action of a drug in an in-class rave dance format. Assessment. Course evaluations revealed student engagement with subject material and enjoyment of the creative applications, critical thinking, and collaborative aspects of the activities. Students performed well on examination questions and graded assignments. Conclusion. These active-learning strategies facilitated students' abilities to learn, apply, and teach material in medication safety, pharmacogenomics, and substance abuse courses.

Identifying biomarkers of dementia prevalent among amnestic mild cognitively impaired ethnic female patients.

BACKGROUND: There is a need to investigate biomarkers that are indicative of the progression of dementia in ethnic patient populations. The disparity of information in these populations has been the focus of many clinical and academic centers, including ours, to contribute to a higher success rate in clinical trials. In this study, we have investigated plasma biomarkers in amnestic mild cognitively impaired (aMCI) female patient cohorts in the context of ethnicity and cognitive status. METHOD: A panel of 12 biomarkers involved in the progression of brain pathology, inflammation, and cardiovascular disorders were investigated in female cohorts of African American, Hispanic, and White aMCI patients. Both biochemical and algorithmic analyses were applied to correlate biomarker levels measured during the early stages of the disease for each ethnicity. RESULTS: We report elevated plasma Aß40, Aß42, YKL-40, and cystatin C levels in the Hispanic cohort at early aMCI status. In addition, elevated plasma Aß40 levels were associated with the aMCI status in both White and African American patient cohorts by the decision tree algorithm. Eotaxin-1 levels, as determined by the decision tree algorithm and biochemically measured total tau levels, were associated with the aMCI status in the African American cohort. CONCLUSIONS: Overall, our data displayed novel differences in the plasma biomarkers of the aMCI female cohorts where the plasma levels of several biomarkers distinguished between each ethnicity at an early aMCI stage. Identification of these plasma biomarkers encourages new areas of investigation among aMCI ethnic populations, including larger patient cohorts and longitudinal study designs.