Rapid Modification of Workflows and Fellow Staffing at a Single Transplant Center to Address the COVID-19 Crisis.

BACKGROUND: Although hospital systems have largely halted elective surgical practices in preparing their response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, transplantation remains an essential and lifesaving surgical practice. To continue transplantation while protecting immunocompromised patients and health care workers, significant restructuring of normal patient care practice habits is required. METHODS: This is a nonrandomized, descriptive study of the abdominal transplant program at 1 academic center (University of California, San Francisco) and the programmatic changes undertaken to safely continue transplantations. Patient transfers, fellow use, and patient discharge education were identified as key areas requiring significant reorganization. RESULTS: The University of California, San Francisco abdominal transplant program took an early and aggressive approach to restructuring inpatient workflows and health care worker staffing. The authors formalized a coronavirus disease 2019 (COVID-19) transfer system to address patients in need of services at their institution while minimizing the risk of SARS-CoV-2 in their transplant ward and used technological approaches to provide virtual telehealth where possible. They also modified their transplant fellow staffing and responsibilities to develop an adequate backup system in case of potential exposures. CONCLUSION: Every transplant program is unique, and an individualized plan to adapt and modify standard clinical practices will be required to continue providing essential transplantation services. The authors' experience highlights areas of attention specific to transplant programs and may provide generalizable solutions to support continued transplantation in the COVID-19 era.

Hematologist and transplant physicians: How and where to meet for the best of sickle cell disease patients?

Despite huge progress in the fields of newborn screening, encapsulated bacterial infection prophylaxis, immunization, and supportive care in general, people suffering from sickle cell anemia still continue to have a shorter life expectancy and a poorer quality of life due to painful vaso-occlusive events and strokes during childhood, and later, cardiac, pulmonary, and renal injuries, including in Western and high-income countries. From the 2000s, allogeneic stem cell transplantation for severe sickle cell disease from a sibling donor provided the best results-overall as well as disease-free survival-never obtained for any other disease. Nevertheless, this only curative option is proposed to few patient numbers, including in Western countries with high-level medical equipment development, with discrepancies between (i) patients and family, (ii) physicians and care centers dedicated to sickle cell disease, and (iii) hematopoietic stem cell transplant teams. Due to these discrepancies and in order to provide the same quality of discussion and treatment choice for every sickle cell disease patient, we developed a National French multidisciplinary pluri-annual meeting dedicated to sickle cell disease patients and transplantation. We report here our experience of such a meeting.

From Experimental Technique to Clinical Practice: Which Pathway in Transplant Surgery?

The question of whether a medical procedure is to be considered experimental or routine practice has enormous practical implications. In transplant surgery, as compared with pharmacologic clinical trials, the transition from experimental procedure to normal care is far from clear cut. Clinical trials comprise 4 well-established phases of evaluation going from phase I, aimed at assessing safety and identifying side effects in a few healthy volunteers, to phase IV, which involves entire populations and is aimed at long-term postmarketing surveillance. In transplant surgery, technical progress and experimentation follow more atypical and individual routes. As compared with pharmacologic research, the decision about "routine practice readiness" of a surgical procedure does not rely on a standardized formal act but rather on experts' capacity to find a consensus based on best practices and on ad-hoc criteria as well. Independent assessment by a panel of experts and oversight by an institutional review board are key to facilitating meaningful protection of transplant recipients and allowing the research to go forward. The framework of the human subjects protection regulations should also consider the transplant of organs that have previously been part of a research project.

Reported effects of the Scientific Registry of Transplant Recipients 5-tier rating system on US transplant centers: results of a national survey.

In the United States, the Scientific Registry of Transplant Recipients (SRTR) provides publicly available quality report cards. These reports have historically rated transplant programs using a 3-tier system. In 2016, the SRTR temporarily transitioned to a 5-tier system, which classified more programs as under-performing. As part of a larger survey about transplant quality metrics, we surveyed members of the American Society of Transplant Surgeons and American Society of Transplantation (N = 280 respondents) on transplant center experiences with patient and payer responses to the 5-tier SRTR ratings. Over half of respondents (n = 137, 52.1%) reported ≥1 negative effect of the new 5-tier ranking system, including losing patients, losing insurers, increased concern among patients, and increased concern among referring providers. Few respondents (n = 35, 13.7%) reported any positive effects of the 5-tier ranking system. Lower SRTR-reported scores on the 5-tier scale were associated with increased risk of reporting at least one negative effect in a logistic model (P < 0.01). The change to a more granular rating system provoked an immediate response in the transplant community that may have long-term implications for transplant hospital finances and patient options for transplantation.

Transplanting the Body: Preliminary Ethical Considerations.

A dissociated area of medical research warrants bioethical consideration: a proposed transplantation of a donor's entire body, except head, to a patient with a fatal degenerative disease. The seeming improbability of such an operation can only underscore the need for thorough bioethical assessment: Not assessing a case of such potential ethical import, by showing neglect instead of facing the issue, can only compound the ethical predicament, perhaps eroding public trust in ethical medicine. This article discusses the historical background of full-body transplantation, documents the seriousness of its current pursuit, and builds an argument for why prima facie this type of transplant is bioethically distinct. Certainly, this examination can only be preliminary, indicating what should be a wide and vigorous discussion among practitioners and ethicists. It concludes with practical suggestions for how the medical and bioethics community may proceed with ethical assessment.

Intolerancia a tornillo interferencial tibial. Una rara complicación en la Cirugía de reconstrucción del ligamento cruzado anterior / Intolerance to tibial fixation devices for ACL repair. A rare complication

Introducción: Se presenta una serie de casos de pacientes que han desarrollado bultoma, secreción y dolor pretibial tras la reconstrucción del LCA fijado con tornillos reabsorbibles (HA-PLLA [Hidroxiapatita- ácido L-poliláctico]). Método: Se revisan de manera retrospectiva todas las reconstrucciones de LCA realizadas entre 2008 y 2014 para identificar las complicaciones relacionadas con el sistema de fijación bioabsorbible. Durante ese periodo de 6 años se realizaron 620 reconstrucciones de LCA usando el tornillo bioabsorbible (HA-PLLA) para la fijación tibial del injerto tetrafascicular de isquiotibiales. Resultados: Nueve pacientes (1,45%) con un rango de edad de 29,8 (19-44 años), presentaron el periodo postoperatorio dolor, tumoración y secreción pretibial en la zona de inserción del tornillo. Todos presentaron marcadores inflamatorios normales. Todos los pacientes requirieron desbridamiento quirúrgico, y retirada de los restos del tornillo y de los tejidos reactivos. Se evidenció infección en 4 cultivos intraoperatorios. La anatomía patológica reveló restos detríticos birrefringentes en el citoplasma de los macrófagos. La retirada de los restos del tornillo y el desbridamiento y curetaje del túnel, supuso la recuperación completa de todos los pacientes de nuestra serie. Conclusiones: La tumoración pre-tibial como respuesta biológica adversa, debe considerarse como una posible complicación en la reconstrucción del LCA. Se aprecia una incidencia de 1,45% de reacción pretibial tras el uso de tornillos reabsorbibles (HA-PLLA) en tibia proximal en la reconstrucción de LCA

Background: We report a series of cases that presented as pre-tibial cyst, swelling and pain following anterior cruciate ligament (ACL) reconstruction using bioabsorble fixation devices (HA-PLLA). Methods: All ACL reconstructions were done between 2008 and 2014 reviewed retrospectively to identify complications related to bioabsorbable fixation devices. During this period of 6 years, 620 ACL reconstructions were performed using the bioabsorbable screw (HA-PLLA) for tibial fixation of the quadrupled hamstring autograft. Results: Nine patients (1,45%) with mean age of 29,8 (19-44) years, presented in the post-operative period, pre-tibial pain, cyst and swelling in tibial screw site. All of them had normal inflammatory markers. All of these patients underwent surgical debridement, which revealed remnants of screw and reactive material. There was evidence of infection in 4 intra-operative specimen cultures. Histopathology revealed detritic birefringent remains in macrophages cytoplasm. Removal of screw debris and curettage of the tunnel resulted in complete recovery of all patients in our series. Conclusions: Pre-tibial cyst as an adverse biological response should be considered as a possible complication in ACL reconstruction. We report a 1,45% of pre-tibial reaction in patients undergoing ACL reconstruction with bio-absorbable (HAPLLA) interference screw fixation for the proximal tibia

Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death

The second edition of the British Transplantation Society Guidelines for Transplantation from Donors after Deceased Circulatory Death was published in June 2013. The guideline has been extensively revised since the previous edition in 2004 and has used the GRADE system to rate the strength of evidence and recommendations. This article summarizes the Statements of Recommendation contained in the guideline, which provide a framework for transplantation after deceased circulatory death in the U.K. and may be of wide international interest. It is recommended that the full guideline document is consulted for details of the relevant references and evidence base. This may be accessed at: http://www.bts.org.uk/MBR/Clinical/Guidelines/Current/Member/Clinical/Current_Guidelines.aspx.

Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death.

The second edition of the British Transplantation Society Guidelines for Transplantation from Donors after Deceased Circulatory Death was published in June 2013. The guideline has been extensively revised since the previous edition in 2004 and has used the GRADE system to rate the strength of evidence and recommendations. This article summarizes the Statements of Recommendation contained in the guideline, which provide a framework for transplantation after deceased circulatory death in the U.K. and may be of wide international interest. It is recommended that the full guideline document is consulted for details of the relevant references and evidence base. This may be accessed at: http://www.bts.org.uk/MBR/Clinical/Guidelines/Current/Member/Clinical/Current_Guidelines.aspx.

Parental refusal of vaccination and transplantation listing decisions: a nationwide survey.

Many professional societies and research studies recommend complete vaccination before pediatric solid organ transplantation. Nevertheless, incompletely vaccinated children often receive transplants. As the number of parents refusing to vaccinate children for nonmedical reasons increases, pediatric transplantation programs face difficult listing decisions. Given the importance of psychosocial criteria in listing decisions, this study explores how parental refusal of vaccination affects those listing decisions. Surveys were emailed to individuals at 195 pediatric solid organ transplantation programs in the United States, with a 71% response rate. Forty-four respondents (39%) reported that their programs have had cases involving parental refusal of vaccination. In response to hypothetical scenarios, 93 respondents (82%) would list a child not vaccinated for medical reasons, whereas only 54 respondents (47%) would list a child whose parents refused vaccination. Only five respondents (4%) reported that their programs had written policies regarding parental refusal of vaccination. These data reveal inconsistencies across pediatric transplantation programs regarding how parental refusal of vaccination affects listing decisions and raise the issue of whether and how the reason for incomplete vaccination should be factored into listing decisions. We recommend further discussion and the development of written guidelines to unify programs' assessments of incompletely vaccinated pediatric transplantation candidates.

Trekking new ground: overcoming medical and social impediments for extended criteria liver transplant recipients.

KEY POINTS: 1. There is an increasing recognition that previously marginal candidates for liver transplantation can receive therapies that allow transplant to take place. 2. Coronary artery disease is an increasing co-morbidity in liver transplant candidates. 3. Physio-social issues require written guidelines and patient advocates. 4. Methadone maintenance therapy per se is not a contra-indication to liver transplantation.