As the outcomes of liver transplantation (LT) continue to improve, liver transplant recipients (L... more As the outcomes of liver transplantation (LT) continue to improve, liver transplant recipients (LTRs) are beginning to resemble other aging, chronic disease populations.1 This improvement in outcomes requires a shift in the focus of post-LT care from that of short-term survival to long-term chronic disease management.2.
The year 2020 was an unprecedented year for all of us, including for the academic surgery researc... more The year 2020 was an unprecedented year for all of us, including for the academic surgery research community. Both stay-at-home and social distancing restrictions posed challenges to our personal and professional lives. The Association for Academic Surgery held its inaugural webinar-based panel discussion titled Association for Academic Surgery Town Hall with its topic on how to optimize research during a pandemic. This article summarizes the highlights from that discussion and lessons learned from the academic surgery research community in 2020.
Purpose of review Uterus transplantation (UTx) is transitioning from an experimental procedure to... more Purpose of review Uterus transplantation (UTx) is transitioning from an experimental procedure to a clinical treatment for absolute uterine factor infertility (AUFI). Standardized protocols for the evaluation and selection of donors and recipients that maximize chances of success – a healthy live birth – are needed. Recent findings To date, recipient eligibility has been limited to otherwise healthy women with AUFI who are of childbearing age and are good candidates for in-vitro fertilization (IVF). For donors (living or deceased), selection criteria vary, apart from basic requirements of blood-type compatibility and freedom from critical infectious diseases, but generally require a term birth and a uterus free from uterine pathologies. The stepwise evaluation process for candidate recipients and living donors moves through health screening (medical and psychosocial); initial selection committee review; IVF (recipients only); and final selection committee review. This eliminates candidates with poor chances of success before exposure to unnecessary risks. Summary The currently stringent selection criteria for prospective recipients and donors will likely broaden, as UTx becomes more widely available. Continued research is needed to define the donor, recipient and uterine graft factors associated with successful outcomes, and to support the development of standardized selection criteria.
Purpose of review Policy development for uterus transplantation (UTx) is in its infancy. Understa... more Purpose of review Policy development for uterus transplantation (UTx) is in its infancy. Understanding current oversight of UTx programmes can inform further development. Recent findings Currently, the United States has the most comprehensive regulations for UTx. Much of the policy outside the USA is focused on candidate selection. In the USA, UTx is categorized as, and follows policies of, a vascular composite allograft. Some considerations for UTx have not yet been addressed in policy, including the need for candidates to have a viable embryo before listing and transplantation, additional factors that may be warranted in organ allocation and the need to report data on the infant as well as the recipient. Summary Oversight of UTx falls within the governance of solid organ transplantation with unique aspects to be considered. Guidelines for multidisciplinary care, transplant-focused infrastructure and defined outcome metrics found in other solid organ transplant programmes provide a useful framework for UTx programmes.
Solid organ transplantation is now an accepted therapeutic modality for children and teenagers su... more Solid organ transplantation is now an accepted therapeutic modality for children and teenagers suffering from a wide variety of complex medical conditions. Unfortunately, patients continue to die while on the organ waiting list as there remains an imbalance between the number of recipients listed for transplantation and the number of donors available. The organ allocation process continues to generate ethical questions and debates. In this publication, we discuss some of the most frequently reported ethical matters in the field of pediatric solid organ transplantation.
The parallel emergence of uterus transplantation (UTx) and other transplantation innovations incl... more The parallel emergence of uterus transplantation (UTx) and other transplantation innovations including face and hand transplantation led to the categorization of the uterus as a vascular composite allograft (VCA). With >60 transplants and >20 births worldwide, UTx is transitioning rapidly from a research endeavor to an effective treatment option for women with uterine factor infertility. While it originally made sense to group the innovations under one umbrella, it is time to revisit the designation of UTx as a VCA. We describe how UTx needs unique policy, procedural codes, insurance contracts, and educational initiatives. We contend that separating UTx from VCAs may become necessary in the future to avoid hindering the growth and regulation of this field.
Uterus transplantation is a nascent but growing field. To support this growth, the United States ... more Uterus transplantation is a nascent but growing field. To support this growth, the United States Uterus Transplant Consortium proposes guidelines for nomenclature related to operative technique, vascular anatomy, and donor, recipient, and offspring outcomes. In terms of anatomy, the group recommends reporting donor arterial inflow and recipient anastomotic site delivering inflow to the graft and offers standardization of the names for the 4 veins originating from the uterus because of current inconsistency in this particular nomenclature. Seven progressive stages with milestones of success are defined for reporting on uterus transplantation outcomes: (1) technical, (2) menstruation, (3) embryo implantation, (4) pregnancy, (5) delivery, (6) graft removal, and (7) long-term follow-up. The 3 primary metrics for success are recipient survival (as reported for other organ transplant recipients), graft survival, and uterus transplant live birth rate (defined as live birth per transplanted recipient). A number of secondary outcomes should also be reported, most of which capture stage-specific milestones, as well as data on graft failure. Outcome metrics for living donors include patient survival, survival free of operative intervention, and data on complications and hospitalizations. Finally, we make specific recommendations on follow-up for offspring born from uterine grafts, which includes specialty surveillance as well as collection and reporting of routine pediatric outcomes. The goal of standardization in reporting is to create consistency and improve the quality of evidence available on the efficacy and value of the procedure.
This is the author manuscript accepted for publication and has undergone full peer review but has... more This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as
The novel Coronavirus disease 2019 (COVID-19) has upended health care in the United States and ar... more The novel Coronavirus disease 2019 (COVID-19) has upended health care in the United States and around the world. 1 As the first wave of surges hits the coasts of the United States, the rest of the country is likely to follow and most of us will be faced with challenging decisions at personal, professional, and institutional levels. As transplant professionals, we will encounter even more limitations in donor organs, as well as personnel, capacity, and equipment limitations in our hospitals. These limitations will differ among states, cities, and programs, making it exceptionally challenging to come up with national guidance on how to approach transplantation during the COVID-19 pandemic. While transplants have been categorized as Tier 3b by the Centers for Medicare and Medicaid (CMS) recommendations for limiting nonessential surgical procedures, meaning they are of the highest acuity and should not be postponed, we all know that there is nuance to which transplant patients and procedures truly meet this standard. 2 We, therefore, must prepare ourselves to make difficult decisions about which patients to transplant, when to limit transplant capacity, and how to best care for those patients who have undergone transplantation. 3 Transplant capacity is being constrained
The demand for liver transplantation continues to outpace the supply of donor organs in the Unite... more The demand for liver transplantation continues to outpace the supply of donor organs in the United States. 1 In the context of this organ shortage, it is essential to make the best use of all transplantable organs. Previously, donor livers infected with hepatitis C virus (HCV) typically have been either discarded or used in patients already infected with HCV. 2-4 Donor livers infected with HCV are still not widely accepted for non-viremic recipients, due to concerns regarding HCV transmission, the natural history of untreated HCV infection after liver transplantation, and limited evidence in this specific population. 5 Highly effective and well-tolerated direct-acting antiviral (DAA) therapies are now available for the treatment of HCV infection and can eliminate HCV in the allograft in greater than 95% of cases. 6 In the setting of the ongoing organ shortage, the opioid epidemic, and the advent of DAA therapy, more HCV-infected donor organs are being utilized to expand the donor pool, and non-viremic patients are being given the option to accept these grafts in some centers, including ours. 4,7,8 The aim of our study was to summarize the posttransplant outcomes after donor-derived HCV infection in non-viremic liver transplant recipients at our institution.
Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine i... more Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine if operations are possible, are indicated, and have a reasonable risk-to-benefit profile. When an operation is indicated and the patient is amenable to it, the conversation between surgeon and patient is usually straightforward. On the other hand, when a patient's co-morbidities substantially increase the risk of operative intervention, surgeons often question the utility of offering their services. These situations become immensely more difficult when patients have the expectation of being offered surgical treatment. This case describes the clinical encounter between an endocrine surgeon and an 83-year-old woman who has been incidentally found to have adrenal metastasis from melanoma. The patient wants an operation that the surgeon is reluctant to offer because of her frailty and high operative risk. The case focuses on the ethical dilemma that arises when a patient wants an operation that a surgeon does not want to perform. I was the resident in the endocrine surgery clinic the day that Ms. M came in. Given my background in bioethics, the attending physician told me about the patient's history beforehand and asked for advice on how to approach the clinical encounter. I then accompanied him into her room to talk with her and her husband.
These principles are constantly in the background of the stories in the following narrative sympo... more These principles are constantly in the background of the stories in the following narrative symposium even when the authors do not explicitly express them. It is clear from reading these narratives that the surgeons who provided our stories have a strong desire to offer their patients (and patients' families) respect and that they desire to do good and avoid harms. It is also clear that surgeons do not always know how achieve these aims when confronted with unusual patient requests, uncertain prognoses, competing goals, and other challenges regularly presented to them. Response We received many good proposals and invited 15 people to send full stories-13 of whom sent fi nished stories. The 12 stories selected for the print
Encounters between individuals are as an essential part of medicine as they are of life. The case... more Encounters between individuals are as an essential part of medicine as they are of life. The cases in this issue of Virtual Mentor describe challenging encounters in clinical medicine, and their commentaries share an emphasis on the importance of communication between a patient and physician. The articles that fill out the issue explain the importance of the patient-physician relationship and the factors that are shaping it, examine connections between poor communication and risk of litigation, recount an unlikely situation in which a relationship between a "frequent flyer" and physician developed, and introduce a program designed to help medical students build relationships with patients. Patient-physician relationships, as well as encounters between professionals, are often difficult, complicated by both internal and external factors. Yet there are ways that we, as physicians, residents, and medical students, can improve our ability to develop and nurture these relationships.
As the outcomes of liver transplantation (LT) continue to improve, liver transplant recipients (L... more As the outcomes of liver transplantation (LT) continue to improve, liver transplant recipients (LTRs) are beginning to resemble other aging, chronic disease populations.1 This improvement in outcomes requires a shift in the focus of post-LT care from that of short-term survival to long-term chronic disease management.2.
The year 2020 was an unprecedented year for all of us, including for the academic surgery researc... more The year 2020 was an unprecedented year for all of us, including for the academic surgery research community. Both stay-at-home and social distancing restrictions posed challenges to our personal and professional lives. The Association for Academic Surgery held its inaugural webinar-based panel discussion titled Association for Academic Surgery Town Hall with its topic on how to optimize research during a pandemic. This article summarizes the highlights from that discussion and lessons learned from the academic surgery research community in 2020.
Purpose of review Uterus transplantation (UTx) is transitioning from an experimental procedure to... more Purpose of review Uterus transplantation (UTx) is transitioning from an experimental procedure to a clinical treatment for absolute uterine factor infertility (AUFI). Standardized protocols for the evaluation and selection of donors and recipients that maximize chances of success – a healthy live birth – are needed. Recent findings To date, recipient eligibility has been limited to otherwise healthy women with AUFI who are of childbearing age and are good candidates for in-vitro fertilization (IVF). For donors (living or deceased), selection criteria vary, apart from basic requirements of blood-type compatibility and freedom from critical infectious diseases, but generally require a term birth and a uterus free from uterine pathologies. The stepwise evaluation process for candidate recipients and living donors moves through health screening (medical and psychosocial); initial selection committee review; IVF (recipients only); and final selection committee review. This eliminates candidates with poor chances of success before exposure to unnecessary risks. Summary The currently stringent selection criteria for prospective recipients and donors will likely broaden, as UTx becomes more widely available. Continued research is needed to define the donor, recipient and uterine graft factors associated with successful outcomes, and to support the development of standardized selection criteria.
Purpose of review Policy development for uterus transplantation (UTx) is in its infancy. Understa... more Purpose of review Policy development for uterus transplantation (UTx) is in its infancy. Understanding current oversight of UTx programmes can inform further development. Recent findings Currently, the United States has the most comprehensive regulations for UTx. Much of the policy outside the USA is focused on candidate selection. In the USA, UTx is categorized as, and follows policies of, a vascular composite allograft. Some considerations for UTx have not yet been addressed in policy, including the need for candidates to have a viable embryo before listing and transplantation, additional factors that may be warranted in organ allocation and the need to report data on the infant as well as the recipient. Summary Oversight of UTx falls within the governance of solid organ transplantation with unique aspects to be considered. Guidelines for multidisciplinary care, transplant-focused infrastructure and defined outcome metrics found in other solid organ transplant programmes provide a useful framework for UTx programmes.
Solid organ transplantation is now an accepted therapeutic modality for children and teenagers su... more Solid organ transplantation is now an accepted therapeutic modality for children and teenagers suffering from a wide variety of complex medical conditions. Unfortunately, patients continue to die while on the organ waiting list as there remains an imbalance between the number of recipients listed for transplantation and the number of donors available. The organ allocation process continues to generate ethical questions and debates. In this publication, we discuss some of the most frequently reported ethical matters in the field of pediatric solid organ transplantation.
The parallel emergence of uterus transplantation (UTx) and other transplantation innovations incl... more The parallel emergence of uterus transplantation (UTx) and other transplantation innovations including face and hand transplantation led to the categorization of the uterus as a vascular composite allograft (VCA). With >60 transplants and >20 births worldwide, UTx is transitioning rapidly from a research endeavor to an effective treatment option for women with uterine factor infertility. While it originally made sense to group the innovations under one umbrella, it is time to revisit the designation of UTx as a VCA. We describe how UTx needs unique policy, procedural codes, insurance contracts, and educational initiatives. We contend that separating UTx from VCAs may become necessary in the future to avoid hindering the growth and regulation of this field.
Uterus transplantation is a nascent but growing field. To support this growth, the United States ... more Uterus transplantation is a nascent but growing field. To support this growth, the United States Uterus Transplant Consortium proposes guidelines for nomenclature related to operative technique, vascular anatomy, and donor, recipient, and offspring outcomes. In terms of anatomy, the group recommends reporting donor arterial inflow and recipient anastomotic site delivering inflow to the graft and offers standardization of the names for the 4 veins originating from the uterus because of current inconsistency in this particular nomenclature. Seven progressive stages with milestones of success are defined for reporting on uterus transplantation outcomes: (1) technical, (2) menstruation, (3) embryo implantation, (4) pregnancy, (5) delivery, (6) graft removal, and (7) long-term follow-up. The 3 primary metrics for success are recipient survival (as reported for other organ transplant recipients), graft survival, and uterus transplant live birth rate (defined as live birth per transplanted recipient). A number of secondary outcomes should also be reported, most of which capture stage-specific milestones, as well as data on graft failure. Outcome metrics for living donors include patient survival, survival free of operative intervention, and data on complications and hospitalizations. Finally, we make specific recommendations on follow-up for offspring born from uterine grafts, which includes specialty surveillance as well as collection and reporting of routine pediatric outcomes. The goal of standardization in reporting is to create consistency and improve the quality of evidence available on the efficacy and value of the procedure.
This is the author manuscript accepted for publication and has undergone full peer review but has... more This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as
The novel Coronavirus disease 2019 (COVID-19) has upended health care in the United States and ar... more The novel Coronavirus disease 2019 (COVID-19) has upended health care in the United States and around the world. 1 As the first wave of surges hits the coasts of the United States, the rest of the country is likely to follow and most of us will be faced with challenging decisions at personal, professional, and institutional levels. As transplant professionals, we will encounter even more limitations in donor organs, as well as personnel, capacity, and equipment limitations in our hospitals. These limitations will differ among states, cities, and programs, making it exceptionally challenging to come up with national guidance on how to approach transplantation during the COVID-19 pandemic. While transplants have been categorized as Tier 3b by the Centers for Medicare and Medicaid (CMS) recommendations for limiting nonessential surgical procedures, meaning they are of the highest acuity and should not be postponed, we all know that there is nuance to which transplant patients and procedures truly meet this standard. 2 We, therefore, must prepare ourselves to make difficult decisions about which patients to transplant, when to limit transplant capacity, and how to best care for those patients who have undergone transplantation. 3 Transplant capacity is being constrained
The demand for liver transplantation continues to outpace the supply of donor organs in the Unite... more The demand for liver transplantation continues to outpace the supply of donor organs in the United States. 1 In the context of this organ shortage, it is essential to make the best use of all transplantable organs. Previously, donor livers infected with hepatitis C virus (HCV) typically have been either discarded or used in patients already infected with HCV. 2-4 Donor livers infected with HCV are still not widely accepted for non-viremic recipients, due to concerns regarding HCV transmission, the natural history of untreated HCV infection after liver transplantation, and limited evidence in this specific population. 5 Highly effective and well-tolerated direct-acting antiviral (DAA) therapies are now available for the treatment of HCV infection and can eliminate HCV in the allograft in greater than 95% of cases. 6 In the setting of the ongoing organ shortage, the opioid epidemic, and the advent of DAA therapy, more HCV-infected donor organs are being utilized to expand the donor pool, and non-viremic patients are being given the option to accept these grafts in some centers, including ours. 4,7,8 The aim of our study was to summarize the posttransplant outcomes after donor-derived HCV infection in non-viremic liver transplant recipients at our institution.
Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine i... more Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine if operations are possible, are indicated, and have a reasonable risk-to-benefit profile. When an operation is indicated and the patient is amenable to it, the conversation between surgeon and patient is usually straightforward. On the other hand, when a patient's co-morbidities substantially increase the risk of operative intervention, surgeons often question the utility of offering their services. These situations become immensely more difficult when patients have the expectation of being offered surgical treatment. This case describes the clinical encounter between an endocrine surgeon and an 83-year-old woman who has been incidentally found to have adrenal metastasis from melanoma. The patient wants an operation that the surgeon is reluctant to offer because of her frailty and high operative risk. The case focuses on the ethical dilemma that arises when a patient wants an operation that a surgeon does not want to perform. I was the resident in the endocrine surgery clinic the day that Ms. M came in. Given my background in bioethics, the attending physician told me about the patient's history beforehand and asked for advice on how to approach the clinical encounter. I then accompanied him into her room to talk with her and her husband.
These principles are constantly in the background of the stories in the following narrative sympo... more These principles are constantly in the background of the stories in the following narrative symposium even when the authors do not explicitly express them. It is clear from reading these narratives that the surgeons who provided our stories have a strong desire to offer their patients (and patients' families) respect and that they desire to do good and avoid harms. It is also clear that surgeons do not always know how achieve these aims when confronted with unusual patient requests, uncertain prognoses, competing goals, and other challenges regularly presented to them. Response We received many good proposals and invited 15 people to send full stories-13 of whom sent fi nished stories. The 12 stories selected for the print
Encounters between individuals are as an essential part of medicine as they are of life. The case... more Encounters between individuals are as an essential part of medicine as they are of life. The cases in this issue of Virtual Mentor describe challenging encounters in clinical medicine, and their commentaries share an emphasis on the importance of communication between a patient and physician. The articles that fill out the issue explain the importance of the patient-physician relationship and the factors that are shaping it, examine connections between poor communication and risk of litigation, recount an unlikely situation in which a relationship between a "frequent flyer" and physician developed, and introduce a program designed to help medical students build relationships with patients. Patient-physician relationships, as well as encounters between professionals, are often difficult, complicated by both internal and external factors. Yet there are ways that we, as physicians, residents, and medical students, can improve our ability to develop and nurture these relationships.
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