Operationalizing Integrated Water Resource Management in Latin America: Insights from Application of the Freshwater Health Index.

Water crises in Latin America are more a consequence of poor management than resource scarcity. Addressing water management issues through better coordination, identification of problems and solutions, and agreement on common objectives to operationalize integrated water resources management (IWRM) could greatly improve water governance in the region. Composite indices have great potential to help overcome capacity and information challenges while supporting better IWRM. We applied one such index, the Freshwater Health Index (FHI) in three river basins in Latin America (Alto Mayo, Perú; Bogotá, Colombia; and Guandu, Brazil) to assess freshwater ecosystem vitality, ecosystem services, and the water governance system in place. The approach included convening management agencies, water utilities, planning authorities, local NGOs and industries, community groups and researchers to co-implement the FHI. The results provide detailed information on the ecological integrity of each basin and the sustainability of the ecosystem services being provided. All three basins show very low scores for governance and stakeholder engagement, thus improving both in the region should be a priority. The results also shed light on how the FHI framework can help inform decision-making to improve IWRM implementation by facilitating stakeholder engagement while contributing to coordination, identification of problems and solutions as well as agreement on common objectives. Because implementation of IWRM is part of the solution for the United Nations Sustainable Development Goal (SDG) 6.5 ("By 2030, implement IWRM at all levels, including through transboundary cooperation as appropriate"), our case studies can serve as examples to other Latin American countries to achieve SDG 6.5.

Imaging for Temporary Mechanical Circulatory Support Devices.

Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device.

First lung and kidney multi-organ transplant following COVID-19 Infection.

As the world responds to the global crisis of the COVID-19 pandemic an increasing number of patients are experiencing increased morbidity as a result of multi-organ involvement. Of these, a small proportion will progress to end-stage lung disease, become dialysis dependent, or both. Herein, we describe the first reported case of a successful combined lung and kidney transplantation in a patient with COVID-19. Lung transplantation, isolated or combined with other organs, is feasible and should be considered for select patients impacted by this deadly disease.

The Penn Classification Predicts Hospital Mortality in Acute Stanford Type A and Type B Aortic Dissections.

OBJECTIVES: Mortality in acute aortic dissection varies depending on anatomic location, extent, and associated complications. The Stanford classification guides surgical versus medical management. The Penn classification stratifies mortality risk in patients with Stanford type A aortic dissections undergoing surgery. The objective of the present study was to determine whether the Penn classification can predict hospital mortality in patients with acute Stanford type A and type B aortic dissections undergoing surgical or medical management. DESIGN: Retrospective, observational study. SETTING: Tertiary care, university hospital. PARTICIPANTS: Patients with acute aortic dissection between January 2008 and December 2017. INTERVENTIONS: Examination of hospital mortality after surgical or medical management. MEASUREMENTS AND MAIN RESULTS: Three hundred fifty-two patients had confirmed dissections (186 type A, 166 type B). The overall mortality was 18.8% for type A and 13.3% for type B. Penn class A patients with type A or type B dissections undergoing surgical repair had the lowest mortality (both 3.1%). Penn class B, C, or B+C patients with type A dissections and Penn class B+C patients with type B dissections undergoing medical management had the greatest incidence of mortality (50.0%-57.1%). All others had intermediate mortality (6.7%-39.3%). Logistic regression analysis demonstrated that Penn class B, C, and B+C patients had a greater odds of mortality and predicted mortality than did Penn class A patients. CONCLUSIONS: The Penn classification predicts hospital mortality in patients with acute Stanford type A or type B aortic dissections undergoing surgical or medical management. Early endovascular repair may confer lower risk of mortality in patients with type B dissections presenting without ischemia.

Managing a surgical exsanguination emergency in the operating room through simulation: an interdisciplinary approach.

OBJECTIVE: Operating room (OR) emergencies, such as fire, anaphylaxis, cardiac arrest, and exsanguination, are infrequent, but high-risk situations that can result in significant morbidity and mortality. An exsanguination scenario involving a pregnant trauma patient in the OR was developed for surgery residents with the objectives of improving overall team performance when activating an emergency response system, identifying a team leader, initiating an exsanguination protocol, following advanced cardiac life support guidelines, and recognizing the mother as the first patient. STUDY DESIGN: During 6 months, 171 OR staff members of the Hospital of the University of Pennsylvania participated in a prospective study in which randomly selected groups of surgery residents, anesthesia residents, and perioperative nurses were trained in a simulated exsanguination and cardiac arrest emergency. Upon arrival to the simulation center, groups of trainees were assigned to a simulated OR equipped with a SimMan 3G (Laerdal, Norway) and a session moderator. The scenario started with a pregnant patient in hemorrhagic shock, bleeding from a carotid injury, ultimately leading to cardiac arrest. Each group did an initial "cold" simulation without any prior training or knowledge of the scenario, followed by a didactic training session, and ending with a "warm" simulation. SETTING: Penn Medicine Clinical Simulation Center at 1800 Lombard Street, Philadelphia, Pennsylvania. RESULTS: Among 156 participants, 50% reported understanding their role in an OR exsanguination emergency pretraining, compared with 98% who understood it posttraining (p < 0.001). For activation of the exsanguination protocol, 50% understood how to do it pretraining, compared with 98% posttraining (p = 0.004). The time needed to complete 8 clinically significant tasks was documented pre- and posttraining, with a statistically significant improvement in all tasks. CONCLUSIONS: The results of this simulated exsanguination emergency demonstrate that team training using a high-fidelity mannequin is an effective way to train OR personnel, on how to manage exsanguinating traumatic patients in a high-risk surgical emergency.

Successful implementation of the american college of surgeons/association of program directors in surgery surgical skills curriculum via a 4-week consecutive simulation rotation.

INTRODUCTION: Increased patient awareness, duty hour restrictions, escalating costs, and time constraints in the operating room have revolutionized surgery education. Although simulation and skills laboratories are emerging as promising alternatives for skills training, their integration into graduate surgical education is inconsistent, erratic, and often on a voluntary basis. We hypothesize that, by implementing the American College of Surgeons/Association of Program Directors in Surgery Surgical Skills Curriculum in a structured, inanimate setting, we can address some of these concerns. METHODS: Sixty junior surgery residents were assigned to the Penn Surgical Simulation and Skills Rotation. The National Surgical Skills Curriculum was implemented using multiple educational tools under faculty supervision. Pretraining and posttraining assessments of technical skills were conducted using validated instruments. Trainee and faculty feedbacks were collected using a structured feedback form. RESULTS: Significant global performance improvement was demonstrated using Objective Structured Assessment of Technical Skills score for basic surgical skills (knot tying, wound closure, enterotomy closure, and vascular anastomosis) and Fundamentals of Laparoscopic Surgery skills, P < 0.001. Six trainees were retested on an average of 13.5 months later (range, 8-16 months) and retained more than 75% of their basic surgical skills. DISCUSSION: The American College of Surgeons/Association of Program Directors in Surgery National Surgical Skills Curriculum can be implemented in its totality as a 4-week consecutive surgical simulation rotation in an inanimate setting, leading to global enhancement of junior surgical residents' technical skills and contributing to attainment of Accreditation Council for Graduate Medical Education core competency.