Infarct Size With Incremental Global Myocardial Ischemia Times: Cyclosporine A in Donation After Circulatory Death Rat Hearts.

BACKGROUND: We quantified the myocardial infarct size with varying global ischemia durations and studied the benefits of Cyclosporine A (CyA) in reducing cardiac injury in ex vivo and transplanted rat hearts. METHODS: Infarct size was measured after 15, 20, 25, 30, and 35 minutes of in vivo global ischemia (n = 34) and compared with control beating-heart donor (CBD) hearts (n = 10). For heart function assessment, donation after circulatory death (DCD) rat hearts (n = 20) were procured after 25 minutes of in vivo ischemia and reanimated ex vivo for 90 minutes. Half of the DCD hearts received CyA (0.5 mM) at reanimation. The CBD hearts (n = 10) served as controls. A separate group of CBD and DCD (with or without CyA treatment) hearts underwent heterotopic heart transplantation; heart function was measured at 48 hours. RESULTS: Infarct size was 25% with 25 minutes of ischemia and increased significantly with 30 and 35 minutes to 32% and 41%, respectively. CyA treatment decreased infarct size in DCD hearts (15% vs 25%). Heart function in the transplanted DCD hearts was significantly better with CyA treatment and was comparable to CBD hearts. CONCLUSIONS: CyA administered at reperfusion limited infarct size in DCD hearts and improved their function in transplanted hearts.

Adapting Compassionate Conversations for Virtual Mediated Communication.

OBJECTIVE: The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. DESIGN: The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. SETTING: Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. PARTICIPANTS: Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. RESULTS: A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. CONCLUSIONS: This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

Electron Transport Chain Inhibition to Decrease Injury in Transplanted Donation After Circulatory Death Rat Hearts.

ABSTRACT: Donation after circulatory death (DCD) donor hearts sustain ischemic damage and are not routinely used for heart transplantation. DCD heart injury, particularly reperfusion injury, is primarily mediated by releasing reactive oxygen species from the damaged mitochondria (complex I of the electron transport chain). Amobarbital (AMO) is a transient inhibitor of complex I and is known to reduce releasing reactive oxygen species generation. We studied the beneficial effects of AMO in transplanted DCD hearts. Sprague-Dawley rats were assigned to 4 groups-DCD or DCD + AMO donors and control beating-heart donors (CBD) or CBD + AMO donors (n = 6-8 each). Anesthetized rats were connected to a ventilator. The right carotid artery was cannulated, heparin and vecuronium were administered. The DCD process started by disconnecting the ventilator. DCD hearts were procured after 25 minutes of in-vivo ischemia, whereas CBD hearts were procured without ischemia. At procurement, all donor hearts received 10 mL of University of Wisconsin cardioplegia solution. The CBD + AMO and DCD + AMO groups received AMO (2 mM) dissolved in cardioplegia. Heterotopic heart transplantation was performed by anastomosing the donor aorta and pulmonary artery to the recipient's abdominal aorta and inferior vena cava. After 14 days, transplanted heart function was measured with a balloon tip catheter placed in the left ventricle. Compared with CBD hearts, DCD hearts had significantly lower developed pressure. AMO treatment significantly improved cardiac function in DCD hearts. Treatment of DCD hearts at the time of reperfusion with AMO resulted in an improvement of transplanted heart function that was comparable with the CBD hearts.

Telehealth Training for Surgeons to Empathetically Deliver Bad News Via Video-Mediated Communication.

BACKGROUND: The COVID-19 pandemic resulted in a sudden increase in the need to effectively use telehealth in all realms of health care communication, including the delivery of bad news. METHODS: A single arm, unblinded, feasibility study was performed at a tertiary care center located in Central Virginia to explore the value and utility of providing a telehealth training program based on SPIKES to teach surgical residents and faculty best practice for disclosing difficult news via video-mediated communication (VMC). Surgical interns (categorical and preliminary), surgical residents, and surgical faculty from General, Neuro, Pediatric, Plastics, Oncology, Urology, and Vascular surgical specialties were recruited via email to voluntarily participate in a telehealth simulation-based workshop, with 33 surgical learners participating in the training and 28 completing evaluation surveys. RESULTS: Only six respondents (22%) indicated they had prior formal training on telehealth communication with patients or families, while 13 (46%) said they had prior experience giving bad news via telehealth. Comments about improving the training focused on providing more scenarios to practice and more time for feedback. Overall, 25 learners (86%) agreed the activity was a valuable learning experience and the majority (61%) of responses were positive for future use of telehealth for breaking bad news. DISCUSSION: Practicing communication skills with VMC was found to be valuable by surgical interns, residents, and faculty. Formal training should be provided for surgeons at every stage of training and practice to improve skill in the delivery of bad news to patients and their families.

From chaos to creativity: Designing collaborative communication training for the delivery of bad news.

BACKGROUND: Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines. METHODS: The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields. RESULTS: Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session. CONCLUSION: We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

A Heterotopic Rat Heart Transplantation Model using Circulatory Death Donor Hearts.

The objective of this protocol is to set up a rat heterotopic heart transplantation model with donation after circulatory death (DCD) donor hearts. There are two setups for this protocol: heart donor setup and recipient setup. In the heart donor setup, Sprague Dawley rats are anesthetized, endotracheally intubated, and ventilated. The right carotid artery is cannulated to deliver heparin and the paralytic agent vecuronium-bromide. The DCD process is initiated by terminating the ventilation. After 20 min, the heart is exposed and the aorta distal to the brachiocephalic branch is clamped. At 25 min from terminating the ventilator, ice-cold University of Wisconsin (UW) solution is perfused through the carotid catheter to flush the heart. The heart is procured by dividing the aorta, pulmonary artery, venae cavae, and pulmonary veins and stored in UW solution for implantation. In the recipient setup, the Lewis rat is anesthetized with isoflurane. Slow-release buprenorphine is administered subcutaneously to facilitate a smooth postoperative recovery. Through a midline abdominal incision, the infra-renal aorta and the inferior vena cava are isolated and clamped with an atraumatic vascular clamp. The donor heart aorta and pulmonary artery are sutured to the recipient abdominal aorta and vena cava, respectively, with a running 8-0 Prolene. The vascular clamp is removed to reperfuse the heart. The abdominal wall is closed and the rat is recovered. After a set interval (24 h to 2 weeks), the recipient rat is anesthetized, the transplanted heart is exposed, and a balloon-tip-catheter is inserted into the left ventricle via the apex to record developed pressure and dP/dt using a data acquisition system. The heart tissue is collected for histology, immunology, or molecular analysis. A successful DCD donor rat heart transplantation model will allow further studies on the cardioprotective approaches to improve heart transplantation outcomes from DCD donors.

Modulation of Mitochondrial Respiration During Early Reperfusion Reduces Cardiac Injury in Donation After Circulatory Death Hearts.

ABSTRACT: Donation after circulatory death (DCD) donors are a potential source for heart transplantation. The DCD process has unavoidable ischemia and reperfusion (I/R) injury, primarily mediated through mitochondria, which limits routine utilization of hearts for transplantation. Amobarbital (AMO), a transient inhibitor of the electron transport chain, is known to decrease cardiac injury following ex vivo I/R. We studied whether AMO treatment during reperfusion can decrease injury in DCD hearts. Sprague Dawley rat hearts subjected to 25 minutes of in vivo ischemia (DCD hearts), or control beating donor hearts, were treated with AMO or vehicle for the first 5 minutes of reperfusion, followed by Krebs-Henseleit buffer reperfusion for 55 minutes (for mitochondrial isolation) or 85 minutes (for infarct size determination). Compared with vehicle, AMO treatment led to decreased infarct size (25.2% ± 1.5% vs. 31.5% ± 1.5%; P ≤ 0.05) and troponin I release (4.5 ± 0.05 ng/mL vs. 9.3 ± 0.24 ng/mL, P ≤ 0.05). AMO treatment decreased H 2 O 2 generation with glutamate as complex I substrate in both subsarcolemmal mitochondria (SSM) (37 ± 3.7 pmol·mg -1 ·min -1 vs. 56.9 ± 4.1 pmol·mg -1 ·min -1 ; P ≤ 0.05), and interfibrillar mitochondria (IFM) (31.8 ± 2.8 pmol·mg -1 ·min -1 vs. 46 ± 4.8 pmol·mg -1 ·min -1 ; P ≤ 0.05) and improved calcium retention capacity in SSM (360 ±17.2 nmol/mg vs. 277 ± 13 nmol/mg; P ≤ 0.05), and IFM (483 ± 20 nmol/mg vs. 377± 19 nmol/mg; P ≤ 0.05) compared with vehicle treatment. SSM and IFM retained more cytochrome c with AMO treatment compared with vehicle. In conclusion, brief inhibition of mitochondrial respiration during reperfusion using amobarbital is a promising approach to decrease injury in DCD hearts.

Assessment of machine perfusion conditions for the donation after circulatory death heart preservation.

BACKGROUND: Donation after circulatory death (DCD) hearts requires machine perfusion preservation, the conditions of which are not well defined. METHODS: To achieve this, rat hearts were procured following a DCD or control beating-heart donation (CBD) model, and perfused for 60 min with one of three machine perfusion solutions-St. Thomas (ST), University of Wisconsin (UW), or Polyethylene Glycol-20k (PEG)-at one of two temperatures, 4°C or 15°C. At 15-min intervals, perfusion pressure was measured as a marker of vascular resistance. Colored microspheres were added to capture the distribution of perfusate into the metabolically active sub-endocardium, and the eluate was collected for troponin assays. Analyses compared groups using Wilcoxon rank-sum and ANOVA. RESULTS: Perfusion pressure was significantly higher for DCD than CBD hearts at 15°C regardless of solutions. The lowest rise in perfusion pressure over time was observed with PEG at 15°C. Except for PEG at 15°C, ST and UW solutions at 4 or 15°C had decreased sub-endocardial perfusion in DCD hearts. Troponin release from DCD hearts with UW and PEG solutions was comparable to CBD hearts but was significantly higher with ST solution at 15°C. CONCLUSIONS: Optimal preservation conditions for DCD hearts were observed with PEG machine perfusion solution at 15°C.

Teaching Toolbox: Breaking Bad News with Virtual Technology in the Time of COVID.

Breaking bad news is a key component of the physicians' work. Traditionally, breaking bad news has been encouraged to be performed in person whenever possible (Monden et al. Proc (Bayl Univ Med Cent) 29(1):101-102, 2016; Nickson 2019). The common practice prior to the pandemic can be summarized by "The first rule of breaking bad news is: do not do it over the phone." It is important to be present with the family and provide support through compassion and empathy. Until recently, virtual communication technology for serious medical discussions was rare and primarily used when compelled by circumstances such as distance. The COVID-19 pandemic has transformed our ability to deliver news in person and has required the medical community to increase the utilization of telephone and video conferencing to communicate with patients and their family members. Breaking bad news through virtual media is a new skill in need of further guidance and education regarding how to set up the conversation, provide empathy, and lend support (Wolf et al., Oncologist 25(6):e879-e880, 2020). Therefore, we have created a teaching toolbox to help educate healthcare providers on how to deliver bad news by phone or video.

Refining murine heterotopic heart transplantation: A model to study ischemia and reperfusion injury in donation after circulatory death hearts.

Heart transplantation is a lifesaving procedure, which is limited by the availability of donor hearts. Using hearts from donors after circulatory death, which have sustained global ischemia, requires thorough studies on reliable and reproducible models that developing researchers may not have mastered. By combining the most recent literature and our recommendations based on observations and trials and errors, the methods here detail a sound in vivo heterotopic heart transplantation model for rats in which protective interventions on the ischemic heart can be studied, and thus allowing the scientific community to advance organ preservation research. Knowledge gathered from reproducible animal models allow for successful translation to clinical studies.

Video-mediated breaking bad news simulation.

BACKGROUND: Communication between clinicians, patients, and families is a core component of medical care that requires deliberate practice and feedback to improve. In March 2020, the COVID-19 pandemic caused a sudden transformation in communication practices because of new physical distancing requirements, necessitating physicians to communicate bad news via telephone and video-mediated communication (VMC). This study investigated students' experience with a simulation-based communications training for having difficult conversations using VMC. METHODS: Thirty-eight fourth-year medical students preparing for their surgical residency participated in a simulated scenario where students discussed a new COVID-19 diagnosis with a standardised family member (SFM) of a sick patient via VMC. Learners were introduced to an established communications model (SPIKES) by an educational video. After the simulation, SFM and course facilitators guided a debrief and provided feedback. Learners completed surveys evaluating reactions to the training, preparedness to deliver bad news, and attitudes about telehealth. RESULTS: Twenty-three students completed evaluation surveys (response rate=61%). Few students had prior formal training (17%) or experience communicating bad news using telehealth (13%). Most respondents rated the session beneficial (96%) and felt they could express empathy using the VMC format (83%). However, only 57% felt ready to deliver bad news independently after the training and 52% reported it was more difficult to communicate without physical presence. Comments highlighted the need for additional practice. CONCLUSION: This pilot study demonstrated the value and feasibility of teaching medical students to break bad news using VMC as well as demonstrating the need for additional training.

Pseudocyst of Pancreas Transplant Allograft: A Case Report.

BACKGROUND: Pancreatic pseudocysts are rarely reported complications of pancreas transplant. CASE: We present a case of a patient with simultaneous pancreas and kidney transplant with bladder exocrine drainage who developed reflux pancreatitis and symptomatic pancreatic pseudocyst as a result of neuropathic bladder, 15 years after the original transplant. He was initially managed with percutaneous aspiration and drainage along with Foley catheter placement to help with bladder emptying. But the pseudocyst recurred after drains and Foley were removed. Eventually, he underwent an enteric conversion of the pancreas allograft with resolution of his symptoms and the pseudocyst. CONCLUSIONS: Enteric conversion should be considered in cases of bladder-drained pancreas transplants with recurrent reflux pancreatitis and/or pseudocyst formation.

The Commonalities and Differences in Mitochondrial Dysfunction Between ex vivo and in vivo Myocardial Global Ischemia Rat Heart Models: Implications for Donation After Circulatory Death Research.

Heart transplantation is the ultimate treatment option for patients with advanced heart failure. Since hearts from donation after brain death (DBD) donors are limited, donation after circulatory death (DCD) donor hearts could be another source for heart transplantation. DCD process involves ischemia-reperfusion (IR) injury. Mitochondrial dysfunction contributes to IR and is well established in the ex vivo (buffer perfused) ischemia animal model. However, DCD hearts undergo in vivo ischemia with a variable "ischemic period." In addition, the DCD hearts are exposed to an intense catecholamine surge that is not seen with ex vivo perfused hearts. Thus, the severity of mitochondrial damage in in vivo ischemia hearts could differ from the ex vivo ischemia hearts even following the same period of ischemia. The aim of our current study is to identify the mitochondrial dysfunction in DCD hearts and propose strategies to protect mitochondria. Adult Sprague Dawley rat hearts underwent in vivo or ex vivo ischemia for 25 min. Subsarcolemmal mitochondria (SSM) and interfibrillar mitochondria (IFM) were isolated from hearts following ischemia. We found that both ex vivo and in vivo ischemia led to decreased oxidative phosphorylation in SSM and IFM compared to time control or DBD hearts. The proportion of damage to SSM and IFM, including proton leak through the inner membrane, was higher with ex vivo ischemia compare to in vivo ischemia. Time control hearts showed a decrease in SSM and IFM function compared to DBD hearts. The calcium retention capacity (CRC) was also decreased in SSM and IFM with ex vivo and in vivo ischemia, indicating that ischemic damage to mitochondria sensitizes mitochondrial permeability transition pores (MPTP). Our study found differential mitochondrial damage between the in vivo ischemia and the ex vivo ischemia setup. Therefore, consideration should be given to the mode of ischemia while evaluating and testing myocardial protective interventions targeting mitochondria to reduce IR injury in hearts.

Clinical Comparison of 2 Trial-of-Void Methods After Outpatient Midurethral Sling Placement.

OBJECTIVES: This study aimed to assess the efficacy, efficiency, and costs of 2 methods of trial of void (TOV) after midurethral sling (MUS) placement. METHODS: A retrospective chart review was performed on women who underwent outpatient MUS between January 2013 and April 2014 by 3 urologists. Patients were excluded if they had a concomitant prolapse repair, hysterectomy, bladder/urethral injury, or any procedure that may prolong recovery room (RR) stay. Trial of void was performed by either (1) bladder instillation, catheter removal in the operating room (OR) fill with attempted void in RR, or (2) bladder instillation and catheter removal with immediate attempted void in the RR fill. Intraoperative, postoperative, and cost data were analyzed. RESULTS: Ninety-one of 183 women (mean age, 55.9 ± 12 years; mean body mass index, 28.8 ± 5.8 kg/m) met inclusion criteria. Eighty-three had a transobturator sling. Forty-nine (54%) had an OR fill and 42 (46%) had an RR fill; age and body mass index were similar between groups. The OR fill group had shorter median operative time (15 vs 22 minutes; P = 0.003) and median RR time (138 vs 161, P = 0.033). The OR fill and RR fill groups did not differ in TOV failure rate (3/49 vs 6/42; P = 0.29), overall mean LOS (4.96 vs 5.51 hours; P = 0.055), and median RR costs ($627 vs $678; P = 0.065). No patient had urinary retention after successful TOV. CONCLUSIONS: After MUS placement, both OR fill and RR fill TOV methods are effective and efficient with similar TOV failure rates.