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The development of a translatable brain death animal model has significant potential to advance not only transplant research, but also the understanding of the pathophysiologic changes that occur in brain death and severe traumatic brain injury. The aim of this paper is to describe a rhesus macaque model of brain death designed to simulate the average time and medical management described in the human literature.
Following approval by the Institutional Animal Care and Use Committee, a brain death model was developed. Non-human primates were monitored and maintained for 20 hours after brain death induction. Vasoactive agents and fluid boluses were administered to maintain hemodynamic stability. Endocrine derangements, particularly diabetes insipidus, were aggressively managed.
A total of 9 rhesus macaque animals were included in the study. The expected hemodynamic instability of brain death in a rostral to caudal fashion was documented in terms of blood pressure and heart rate changes. During the maintenance phase of brain death, the animal’s temperature and hemodynamics were maintained with goals of mean arterial pressure greater than 60mmHg and heart rate within 20 beats per minute of baseline. Resuscitation protocols are described so that future investigators may reproduce this model.
Citation: Zens TJ, Danobeitia JS, Chlebeck PJ, Zitur LJ, Odorico S, Brunner K, et al. (2017) Guidelines for the management of a brain death donor in the rhesus macaque: A translational transplant model. PLoS ONE12(9): e0182552. https://doi.org/10.1371/journal.pone.0182552
Editor: Johannes Boltze, Fraunhofer Research Institution of Marine Biotechnology, GERMANY
Received: November 18, 2016; Accepted: July 20, 2017; Published: September 19, 2017
Copyright: © 2017 Zens et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper.
Funding: This work was supported by National Institutes of Health NIH #1-R01-AI110617-01A1 (PI: Luis Fernandez) and an NIH training grant NIH #T32 AI125231 is funding Dr. Danobeitia's post-doctoral research fellowship in the lab.
Competing interests: The authors have declared that no competing interests exist.
Since 1988, there have been over 669,000 solid organ transplants in the United States and almost 16,500 transplants were performed over the past year . Currently, approximately 120,000 patients are on an organ transplant waiting list and 22 people die in United States daily while waiting for a transplant. The scientific transplant community is constantly working to develop novel strategies to improve the quality of the available organ pool, as well as, extend the half-life of transplanted grafts. In order to accomplish these goals, animal models of transplantation are used to test new transplant drugs and patient treatment strategies.
Ideally, a model which mimics the cascade of events occurring after brain death would facilitate progress in the field of transplantation. Unfortunately animal models previously published have several deficiencies. First, most models described, use small animals (rats or mice) or non-primate large animals (swine or canines). Although scientific discoveries from these animal models had been tremendously valuable to the transplant community, the results gained from a large animal non-human primate model are more directly translatable to human subjects. Rhesus macaques’ DNA have a >90% similarity to humans. Furthermore, primates possess equivalent HLA-A, HLA-B, HLA-E, HLA-F and HLA-G genes which are critical to understanding the immunologic barriers in transplantation in regards to the human histocompatibility complex. Given the biological similarities with regards to shared anatomy, response to physiologic stress, and drug metabolism between humans and non-human primates, this model provides a significant advantage over rodent or porcine models previously characterized in the literature [4–6].
Second, many of the current brain death animal models are not able to replicate a clinical scenario given the typical duration of time from declaration of brain death to organ procurement is too long to be reproduced in a small animal model. Brain death is associated with hemodynamic instability, hormonal changes, a systemic release of pro-inflammatory cytokines, complement activation and derangement in the coagulation system. It has been established that these physiologic changes result in damage to the transplantable organs that unfortunately translate into shorter graft survival [7–9]. With the exception of a single study by Sereinigg et al, most brain death experiments last between 4–10 hours[10–15]. In contrast, the average time from human brain death declaration to organ procurement is 20–30 hours [16, 17]. Therefore, a model that recapitulates a similar time interval is required to elucidate the factors which damage organs during brain death and the degree by which organ damage translates to poorer outcomes when compared to living donors.
The final limitation in traditional brain death animal models is that the standard of care provided by an Intensive Care Unit (ICU) staff to brain dead human donors has been impossible to reproduce in smaller species. It is known that quality ICU care can decrease the deleterious physiologic consequences of brain death on the transplantable organs, improve the percentage of organs accepted for transplant, and improve outcomes of those grafts [18–24]. Thus, a clinically translatable model needs to reproduce this setting, implementing modern treatments in response to the donor’s medical state.
In order to create the optimal brain death animal model to study transplant treatments and medications, one needs to address all of these issues. Over the last year, we have been working on a non-human primate 20-hour brain death transplant model which provides ICU level care to these animals and can be used to test exciting and innovative medical and technical advances in transplantation. In this paper, we will outline our methodology so it can be applied and utilized by other transplantation laboratories and scientists studying the effects of human brain death, the biology of organ donation and severe traumatic brain injury.
Materials and methods
Rhesus macaques used in this study were housed at the Wisconsin National Primate Research Center, University of Wisconsin Madison, in accordance with Institutional Animal Care and Use Committee (IACUC) guidelines. The experiment was conducted under the University of Wisconsin School of Medicine and Public Health IACUC approved protocol. The animals are house either individually or paired in cages meeting the animal welfare guidelines for cage sizing. They are on a 12 hour light/dark cycle, temperature maintained at 64-84F and humidity at 30–70%. The animals for this experiment are part of the specific pathogen free colony and are negative for SRV, STLV, SIV, and Herpes B. They are fed approximately 6–9 biscuits of Teklad Global 20% Protein Primate Diet twice daily. Prior to surgical procedures, animals are food deprived for approximately 4–18 hours. Water is provided continuously via an automatic water with lixit system. The primate enrichment program include a wide variety of produce and foraging items provided once daily. All animals are monitored a minimum of twice daily. Analgesia is provided with narcotics for procedures and until brain death confirmation, they are under general anesthesia. After brain death, the animal is unable to experience pain, so anesthesia is removed for the maintenance period. Although the animal is still unable to detect pain, for the procurement laparotomy, they are placed back on isoflurane general anesthesia as a precautionary measure. For our experiment, while under general anesthesia, the animals are sacrificed by exsanguination. The animals were continuously monitored throughout the experiment. Chlorohexidine or betadine prep was used prior to all invasive and sterile procedures.
Cardiac monitoring was displayed in real time to a portable Advisor (R) Vital Signs Monitor by SurgiVet (Smiths Medical, OH). ECG electrodes on the animals’ hands and feet displayed continuous heart rate and rhythm. Continuous hemodynamic monitoring was obtained with the use of femoral arterial line and femoral central venous pressure (CVP). A femoral cut down was performed to place the arterial and central line. The vein was accessed and a 5.5F, triple lumen, 30cm long pediatric ARROW central line was placed using the Seldinger technique. Next, an arterial line was placed using a 4F, 12 cm long Cook arterial line. Both lines were tested for brisk blood return. The arterial line and brown port of the central line were connected to transducers in order to display continuous arterial and CVP waveforms respectively.
End tidal CO2 (ETCO2) capnography was attached to the endotracheal circuit and displayed continuously throughout the experiment. SpO2 monitoring was achieved by applying SpO2 monitors to the animal’s fingers, toes or buccal mucosa.
Hourly urine output was monitored by inserting an 8F Bard Foley catheter and attaching a urinometer. Continuous temperature monitoring was measured through an esophageal temperature probe. Vital signs were recorded on a spreadsheet every 15 minutes. Net volume status calculations (total volume in-total volume out) were calculated every hour to avoid dehydration or fluid overload.
All laboratory tests were monitored with an Istat (Abbot, Princeton, NJ) device. Chemistry labs were obtained using a Chem8 (sodium, potassium, chloride, ionized calcium, CO2, BUN, creatinine, glucose, hemoglobin and hematocrit) cartridge, Arterial blood gases (ABG) results obtained using a CG4 (pH, CO2, pO2, HCO3, base excess, lactate, and oxygen saturation) cartridge and troponin results obtained using a cTnI (troponin) cartridge. Arterial blood gases and chemistry lab panels were drawn every 2–4 hours as needed and troponin levels checked every 6 hours until they peaked.
Induction of brain death.
After baseline laboratory values were obtained, brain death was induced. Using a 2mm Dremel rotary tool, a Burr hole was made through the skull exposing the animal’s dura mater. The dura mater was then carefully dissected away from the skull without puncturing it and a 14F Foley catheter was then inserted between the skull and the dura mater. The catheter balloon was inflated with 7-9ml of saline solution and the animal was monitored for the expected hemodynamic instability of brain death in a rostral to caudal fashion. First, at the level of the medulla, there was a sympathetic surge in order to maintain cerebral perfusion pressure that results in profound tachycardia and hypertension. Next, spinal cord ischemia and herniation resulted in deactivation of the sympathetic nervous system, decreased catecholamines, and vasodilation causing normalization of heart rate and hypotension. After this hemodynamic instability was documented, the isoflurane anesthetic is turned off and confirmation of brain death followed.
Confirmation of brain death.
Confirmation of brain death was achieved according to the current recommendations by the American Academy of Neurology (AAN) in 1995. For confirmation, the isoflurane must be off for at least 30 minutes and the animal may not have received any narcotics, paralytics or benzodiazepines. The animal body temperature must be normal prior to declaration of brain death and there can be no severe acid/base or electrolyte disturbances.
In order to confirm brain death, we first performed a physical exam. Brain dead animals manifested fixed and dilated pupils, absent corneal, gag, and cough reflexes, and no movement of the limbs to painful stimuli. Next, an apnea test was conducted. The ventilator was turned off for between 8–10 minutes. The animals were monitored for any spontaneous breaths. If no breaths were documented, an arterial blood gas was drawn and the ventilator turned back on. If a PCO2 was documented as 60mmHg or 20mmHg above the baseline, brain death was confirmed. If the animal’s SpO2 dropped below 85% during the apnea challenge with no spontaneous breaths, an ABG was drawn and the animal placed back on the ventilator. In concordance with the AAN, no ancillary testing (cerebral angiogram, electroencephalogram (EEG), transcranial Doppler) was needed in the presence of a positive apnea test and physical exam consistent with brain death.
Hemodynamic maintenance: IV fluid therapy and vasoactive agents.
Over the 20-hour maintenance period of brain death, the hemodynamic goals were to maintain a mean arterial pressure (MAP) greater than 60mmHg and heart rate (HR) within 20 beats per minute (bpm) of baseline HR. In order to accomplish, this we utilized a variety of cardiac medications in accordance with current human critical care guidelines (Table 1)[18–20, 25, 26].
Maintenance IV fluids (MIVF) were administered to each animal to replace insensible losses. MIVF were calculated using the “4-2-1” rule with 4ml/kg/hour for the first 10kg + 2ml/kg/hour for the second 10 kg + 1ml/kg/hour for the remainder. Initially, isotonic fluids of 0.9% normal saline (0.9NS) are used for MIVF. If sodium (Na) was greater than 145, 0.45% normal saline (0.45NS) was used given these animals are prone to hypernatremia. Intravenous (IV) fluid replacement was primarily driven by central venous pressure (CVP) and hourly net total volume calculations. Our goal was to have a net even volume status for the experiment with a CVP< 6mmHg.
An algorithm for vasoactive infusions and isotonic IV fluid boluses needed to augment the animal’s blood pressure is outlined in Fig 1. The choice of first line vasoactive medication was dependent on whether the animal showed evidence of diabetes insipidus (DI). If the animal had polyuria or hypernatremia, vasopressin was used as a first line drug and titrated to max dose of 0.001units/kg/min before adding dopamine as a second agent. Dopamine can be used as the first line drug in animals without evidence of DI. In these cases, if the dopamine infusion exceeded 10mcg/kg/min, consider adding vasopressin as a second agent [25, 26]. Epinephrine infusion or norepinephrine infusion can be used as a third line option for profound hypotension if there is no evidence of cardiac compromise. In animals with evidence of significant myocardial infarction (MI) or ischemia on electrocardiogram (ECG) or elevated troponin values, dobutamine should be used as the third line drug and epinephrine/norepinephrine used as a fourth line last resort medication.
An algorithm for vasoactive infusions and isotonic IV fluid boluses needed to augment the animal’s blood pressure is outlined above.
In instances in which the animal exhibited persistent (>1 hour) tachycardia (>20 bpm over baseline) and hypertension (SBP>145mmHg), low dose labetalol IV push was administered in order to minimize the deleterious cardiac consequences of the increased myocardial oxygen consumption. In cases of persistent bradycardia (HR<70bpm) atropine was administered. In addition, electrolytes (particularly potassium and calcium) were monitored and replaced during brain death.
Anesthesia induction and mechanical ventilator management.
Animals were pre-medicated prior to intubation with 15mg/kg of ketamine, 0.4mg/kg of atropine and 0.01–0.02 mg/kg of buprenorphine. Using a laryngoscope with a Macintosh blade, the animals were intubated with the appropriate size endotracheal tube (usually 4.0 or 4.5). The tube was secured in place and verified via end tidal CO2 (ETCO2) and bilateral breath sounds.
Animals were mechanically ventilated using a pressure controlled ADS2000 ventilator (Engler, Hialeah, Florida). Standard starting ventilator settings were FiO2 = 100%, respiratory rate 8–10 breaths/min, flow rate 6L/min, peak inspiratory pressure = 10–12. Arterial blood gases (ABGs) were measured every 4 hours to determine if changes were needed in the ventilator settings (Table 2).
Diabetes insipidus (DI): Inadequate secretion of an anti-diuretic hormone as a result of brain death.
Diabetes insipidus characterized by a urine output >4 ml/kg/hr with a high serum sodium >145 mEq/L, and increased serum osmolality >300 mosmol kg−1, and a low urine osmolality <200 mosmol kg−1. DI management included early use of vasopressin and fluid replacement with solutions containing minimal sodium.
Continuous vasopressin infusions at a dose of 0.0003un/kg/min-0.005un/kg/min provided a synthetic replacement for the lost endogenous hormone. In addition, isotonic fluid boluses guided by CVP and hourly net fluid volume calculations were used to prevent dehydration and contraction alkalosis. Even with appropriate use of vasopressin infusions and volume resuscitation, some animals developed hypernatremia from their DI. In cases in which sodium (Na) levels exceed 150mEq/L, 5% dextrose in water (D5W) infusions were necessary to prevent severe hypernatremia, which has been associated with worse transplant outcomes[19, 25]. The infusion rate for D5W infusions was calculated using the Adrogue formula for sodium correction.
Pro-inflammatory conditions and physiologic stress is often associated with hyperglycemia. Hyperglycemia can cause osmotic polyuria and worse pre-recovery renal function[17, 25]. Hypoglycemia should also be avoided. As a result, a target glucose of <200mg/dl and >60mg/dl was implemented for this experiment.
After 20 hours, the animal’s abdomen was prepped and draped for organ procurement. A midline laparotomy was performed and the colon mobilized to expose the retroperitoneum. The left and right kidneys and the ureter were dissected free from the neighboring structures with the adrenals left in place. The infra-renal aorta was mobilized and 2.0 silk sutures looped circumferentially at the proximal and distal segments of the inferior mesenteric artery which often was ligated and divided to gain larger lengths. The inferior vena cava (IVC) was mobilized and dissected free to visualize both renal veins and the infra-hepatic inferior vena cava. The proximal supraceliac aorta was dissected an vessel loop placed around the artery in order to facilitate its clamping After making an arteriotomy in the infra-renal aorta, an angiocath of appropriate size (typically 14G-18g) was placed into the lumen of the abdominal aorta and secured in place. 10,000 units of heparin was administered intravenously. The supreceliac aorta was then clamped. Next, 1 liter of UW solution was infused into the abdominal organs via the aortic cannula and the distal IVC was incised, allowing the animal to exsanguinate. The abdomen was packed with sterile ice. Organs for transplantation and research were retrieved using conventional surgical techniques.
Following organ procurement, 20G core needle biopsies were taken from the kidneys and wedge biopsies taken from the liver and pancreas. H&E histological analysis was performed on these specimens by board certified pathologists to determine any damage sustained to the organ during brain death. Given these organs were from elderly animals, naïve elderly renal, pancreatic, and hepatic tissue was obtained for comparison to determine the baseline level of organ damage in a geriatric animal. Additionally, the Remuzzi score was used to determine the transplant eligibility for each kidney biopsy. The Remuzzi score is used by pathologists and transplant surgeons to determine if expanded criteria kidneys should be considered for single organ transplant, dual kidney transplant or discarded. A score of 0–3 indicates an organ is amenable for single kidney transplant, a score of 4–6 indicates dual kidney transplant should be considered and a score of 7–12 indicates the organ should not be transplanted.
A total of nine rhesus macaque animals were used in this model. The mean age of the animals was 17.9±1.41years and the mean weight was 8.07±1.61kg.
Confirmation of brain death.
Prior to performing the apnea challenge and clinical exam to confirm brain death, the animals had baseline labs and vital signs to ensure they were normothermic and without any significant acid/base or electrolyte abnormalities in compliance with the AAN guidelines (summarized in Table 3). Physical exams performed off anesthesia were consistent with brain death (absence of reflexes and no response to pain) in all animals. Eight of the nine animals were stable enough from a respiratory standpoint to undergo an apnea challenge. The remaining animal (#2) continued to desaturate to SPO2<80% when taken off the ventilator. The apnea challenge results are summarized in Fig 2. All animals experienced respiratory acidosis and a rise in pCO2 >20mmHg without a spontaneous breath, consistent with brain death. Other than a single animal (#2) who became extremely hypoxic, the remaining animals were able to maintain pO2>70 during the challenge with pre-oxygenation techniques.
All but one animal (#2) were stable enough from a respiratory standpoint to undergo a successful apnea challenge. All animal experienced respiratory acidosis and a rise in pCO2 of greater than 20mmHg without a spontaneous breath, consistent with brain death. Other than the single animal who became extremely hypoxic, the remaining animals were able to maintain pO2>70 during the challenge with pre-oxygenation techniques.
Initial hemodynamic instability.
We encountered no major bleeding problems or surgical complications while completing the femoral cut down or burr hole with brain death induction. The hemodynamics of brain death (time 0) are outlined in Figs 3 and 4. We noted that although all animals started with slightly different systolic blood pressures, there was a predicable hypertension, followed by hypotension before return to baseline (Fig 3B). A mean SBP of 231.3±29.4mmHg was identified immediately at herniation, then a slow drop in SBP until a nadir at 69.0±23.27mmHg approximately 45 minutes post-brain death (Fig 3A). Finally, we documented a return to baseline by 1-hour post-brain death. The animals exhibited variability in terms of heart rate (HR) response to brain death (Fig 3D). Although most animals became tachycardic and remained tachycardic above their initial baseline, one animal (#9) became bradycardic to 60 bpm and then experienced rebound tachycardia. This animal subsequently developed acute pulmonary edema. When all animals HRs were averaged (Fig 3C), the trend was a slightly delayed tachycardia to 184.4±24.5 bpm 15 minutes after brain death, followed by slow return to a HR approximately 10–15 bpm above the animal’s original baseline by 1 hour post brain death.
When examining the change is systolic blood pressure (SBP), there was a predicable hypertension, followed by hypotension before return to baseline. Fig 3B shows the individual SBP response to brain death and Fig 3A shows the average response for all animals. When change in HRs with BD there was a trend of slightly delayed tachycardia at 15 minutes after brain death, followed by slow return to a HR approximately 10–15 bpm above the animal’s original baseline by 1 hour post brain death. Fig 3C shows the individual HR response to brain death and Fig 3D shows the average response for all animals.
Maintenance of hemodynamic stability.
Utilizing the methods outlined above, we were able to maintain hemodynamic stability throughout brain death with MAP>60 and HR within 20 bpm of the animal’s baseline (Fig 4). In order to accomplish these goals, multiple vasoactive infusions and fluid boluses were administered (Table 4). While three animals required only vasopressin and fluid boluses, three animals required a total of three or more vasoactive agents. The pressor requirements for all animals increased with duration of brain death. The largest vasopressor requirement was noted in the last 1–3 hours of the 20 hour experiment. The average CVP for all animals was 2.7±1.37mmHg and average total volume status at hour 20 was +311.52ml.
Troponin values were drawn every 6 hours until they peaked. The average peak troponin value was 8.15± 9.83μg/L, with a maximum peak troponin in animal #8 of 27.4 μg/L and minimum peak troponin in animal#5 of only 0.2 μg/L. In addition to troponin elevations, we were able to document ECG changes consistent with myocardial strain/infarction. During the brain death procedure for animal #8, we noted classic ST elevation, followed by T wave inversion characteristic of myocardial ischemia. No significant prolonged arrhythmias were noted in our animals. Five of the nine animals developed sustained tachycardia>20bpm above baseline during the maintenance phase of brain death. To treat this and reduce myocardial oxygen consumption, the animals were administered labetalol at 0.25mg/kg with an average of 1.6±1.9 doses in the 20-hour period. No animals experienced complications or refractory hypotension/bradycardia from this medication.
Using the respiratory trouble shooting techniques and ventilator adjustments outlined above, we were able to maintain adequate oxygenation and ventilation throughout the 20-hour maintenance brain death period (Fig 5). We did have four animals with significant secretions requiring inline suctioning, three animals with atelectasis requiring breath holds with the Ambu-bag and one animal that went into pulmonary edema following an episode of bradycardia after induction of brain death. This animal (#9) required inline suction, breath holds, and 2mg/kg IV Lasix, but recovered after approximately 90 minutes with no pO2 level<63mmHg.
We documented no evidence of acute renal injury, with average creatinine of 0.59±0.13mg/dL and blood urea nitrogen (BUN) of 14.7±3.84 mg/dL. There was no statistically significant difference between the initial mean creatinine of 0.54±0.22 mg/dL and end mean creatinine of 0.61±0.20 mg/dL (p = 0.141).
Management of DI.
The management of DI in our animals is outlined in Table 5. All of the animals experienced some hypernatremia with and average sodium for all animals across all time points of 151.6±5.6 mEq/L and average maximum sodium of 156.6±5.61 mEq/L. All animals except one (#5) required a D5W infusion to treat hypernatremia with an average infusion time of 11.5±5.5 hours.
The urinary output (UO) values for all animals and trend is summarized in Fig 6. Although there was wide variability among animals (Fig 6B), the average peak UO occurred 5–8 hour after BD induction (Fig 6A). All but one animal exceeded 4ml/kg/hr of urine output at some time point in the experiment. The average hourly urine output for all animals across all time points was 4.87±2.82 ml/kg/hr with an average maximum urine output of 14.2±10.6 ml/kg/hr. Vasopressin infusions were utilized in all animals with an average infusion time of 13.08± 3.25 hours and average maximum dose of 0.003±0.001 units/kg/min.
Maintenance of normoglycemia.
We did not experience significant difficulty with glucose control even in animals on D5W infusions. The mean glucose for all animals across all time points was 111.2 ± 21.18 mg/dL. We documented only one episode of glucose>200 with average maximum glucose of 157.7±39.4 mg/dL. No animal required insulin to meet our goals of glucose<200 mg/dL.
Following organ procurement, core needle biopsies were taken from 17 of the 18 kidneys and wedge biopsies taken from all 9 of the animal’s liver and pancreas. There was no difference (p = 0.23) between the mean age of the brain dead animals (17.9±1.41 years) and naïve control animals (17.7±2.29 years). A full histological summary of the findings are summarized in Table 6. We noted no statistically significant differences (p>0.20) in damage to the renal glomeruli, intersitium, or vasculature. We did note our control naïve animals had more extensive age related renal tubular damage (p<0.01), After applying the Remuzzi score, all the naïve animals had organs suitable for single kidney transplant and all brain dead animals had organs suitable for single organ transplant. When evaluating the liver and pancreas wedge biopsies, there were no differences noted in the histological characteristics between naïve and brain dead animals (p>0.06). Representative histological slides from the naïve and brain dead animals are shown in Figs 7–9.
Biopsy A shows Kidney H&E of naïve rhesus, age 18 years, diagnosed as normal. Biopsy B shows Kidney H&E of naïve rhesus, age 15 years, diagnosed with mild acute tubular injury, focal mild arteriosclerosis. Biospy C shows Kidney H&E of brain dead rhesus, age 16 years, diagnosed normal. Biopsy D shows Kidney H&E of naïve rhesus, age 19 years, diagnosed with mild acute tubular injury, focal mild arteriosclerosis.
Biopsy A shows Liver H&E of naïve rhesus, age 15 years, diagnosed 5–10% macrovesicular fatty infiltrates, moderate/marked vacuolization. Biopsy B shows Liver H&E of brain dead rhesus, age 18 years, diagnosed 5–10% macrovesicular fatty infiltrates, moderate vacuolization.
Significant damage can occur to transplantable organs during the brain death process and, in fact, the conversion rate in United States from potential to actual donors is only 60%[19, 20]. By utilizing our translational model, pharmacological interventions (such as evaluation of new drugs) can be tested in nonhuman primates to understand potential clinical significance and evaluate safety prior to human testing. This manuscript describes in detail the successful development of a rhesus macaque brain death model that mimics clinical practice. Histological analysis of our organs following a 20 hour brain death period demonstrates no significant difference when compared to naïve controls and Remuzzi scores in all brain dead animal’s kidneys demonstrated the quality was sufficient for single organ transplant.
With the exception of one animal, we were able to confirm brain death based on physical exam and apnea challenge in concordance with the recommendations of the American Academy of Neurology. Given that there was one animal too unstable from a respiratory standpoint to undergo brain death confirmation by these means, ancillary testing (cerebral angiogram, EEG, transcranial Doppler) may be necessary for future studies with this model.
We were able to demonstrate reproducible trends of hemodynamic instability immediately after brain death with regards to systolic blood pressure and heart rate. During the initial stage of hypertension and tachycardia, little intervention was needed (lasting<15 minutes in most cases) and this was followed by significant hypotension in most cases. The initial sympathetic surge is caused by release of catecholamines from postganglionic sympathetic nerve endings and can precipitate left ventricular dysfunction, arrhythmias and cardiac stunning. The second stage of brain death is caused from herniation and loss of sympathetic tone causing hypotension. This can be exacerbated if the animal was hypovolemic from being fasted the night before for the surgery. As a result, it is our protocol to pre-hydrate the animals with 20ml/kg subcutaneous 0.9NS twelve hours before brain death. The post-brain death hypotension was initially treated with isotonic intravenous boluses of 10ml/kg to increase preload for the animal. If after two consecutive 10mg/kg boluses (given every 10–15 min), the animal had a mean arterial pressure (MAP<60), a vasoactive agent was started (dopamine or vasopressin) and up to 2 additional bolus were given if needed (total of 40ml/kg). It is well documented that adequate volume expansion and resuscitation is associated with decreased IL-6 and TNF, leading to increased transplant utilization and graft survival.
During the maintenance phase of brain death, we were more restrictive with our use of IV fluid boluses in order to prevent complications of fluid overload and hemodilution of research samples. Our goals were a net volume status of less than +250ml and CVP<6 as studies show restrictive fluid management helps avoid volume overload and lung neurogenic edema without compromising kidney graft survival or rates of delayed graft function (DGF) . Fluid resuscitation with colloids (albumin and hydroxyethyl starch) should not be used as they can cause acute kidney injury, coagulopathies and compromised graft function. Packed red blood cells are not indicated in donor management unless hemoglobin drops below 7 g/dL, which was not the case in any of our experiments.
During the maintenance phase of brain death, we were able to maintain MAP>60mmHg and HR within 20bpm of the animal’s baseline with use of vasoactive drugs and volume replacement. Approximately 80% of human organ donors require some vasopressor support, so it is not surprising that we documented need for these medications in our animal model.
In our model, vasopressin infusion was our first line choice in most cases, given its ability to augment blood pressure by improving the vasodilatory shock associated with brain death and treat DI. The benefit of vasopressin is that it is both a potent vasoconstrictor of vascular smooth muscle via V1 receptors, and it also works in the renal collecting system to counteract the profound diuresis found in DI secondary to the lack of endogenous anti-diuretic hormone. Studies have found the use of vasopressin in donor treatment can decrease use of other vasoactive agents and increase rates of successful organ recovery in patients with DI. In fact, the clinical use of vasopressin decreases the need for more harmful catecholamines, such as epinephrine or norepinephrine, and improves cardiac performance. Dopamine should be a second line drug given its ability to be immunomodulatory and attenuate the inflammatory response. Furthermore, it can protect against ischemia/reperfusion injury by induction of heme oxygenase-1 enzyme[26, 30].
Third line and forth line drugs in our model included dobutamine and epinephrine and were only needed in three of the nine animals. Epinephrine was chosen over norepinephrine, but either could be used. Admittedly, norepinephrine is more studied in the human literature. It is important to note that either of these alpha agonists can lead to increased pulmonary capillary permeability and coronary and mesenteric vasoconstriction and should be used in the lowest dose possible for the shortest duration possible[25, 26]. Dobutamine is traditionally only shown to have value in patients with impaired cardiac function. In humans, this is measure by ejection fraction less than 45% on echocardiography. Given that echocardiograms are unavailable to us, we used surrogates in terms of troponin and ECG changes indicative of ischemia. We documented a wide range of troponin changes in our animals with peaks from 0.22–27.4 μg/L. Animals with higher troponin levels were, on average, more hemodynamically unstable. It is important to note that fluid overload in these animals can precipitate heart failure and pulmonary edema. In addition, the judicious use of nonselective beta blockade in animals with evidence of significant cardiac injury can reduce the myocardial oxygen consumption and be cardioprotective. All the animals in our model were over the age of 16 years, so the impact of brain death on the myocardial function of younger animals has not been assessed in this experiment.
We did not have significant problems with oxygenation and ventilation in our animal model. The most frequent complications encountered were secretions, mucus plugs, and atelectasis which could be managed by breath holds with Ambu-bag and PEEP valve or inline suction/lavage. We did encounter one animal (animal #9) who had severe respiratory compromise directly after induction of brain death. The etiology for this was most likely due to either neurogenic pulmonary edema or increased interstitial pressure from profound hypertension without expected tachycardia. Neurogenic pulmonary edema is a phenomenon which occurs in about 20% of severe traumatic brain injuries within minutes to hours. Although the mechanism of neurogenic pulmonary edema is not fully understood, it is thought to be a combination of changes in capillary hydrostatic pressure and pulmonary capillary permeability. Another possible etiology for this animal’s acute pulmonary deterioration was increased pulmonary interstitial pressure and insufficient cardiac output. Unlike all the other animals in our model who exhibited tachycardia and hypertension with brain death, this animal became bradycardic to 60bpm and hypertensive. The etiology of this bradycardia could have been a vagal response from the endotracheal tube or a Cushing response. The increased blood pressure without reflex tachycardia would have increased the pressure within the pulmonary vasculature, leading to leakage of fluid into the interstitum and alveoli.
It is important to not underestimate the profound effect brain death has on the endocrine system. The entire hypothalamic-pituitary system is impacted leading to derangements in thermoregulation, thyroid, adrenal, posterior pituitary hormones, and glucose control. Using a forced air warming blanket (BearHugger) and esophageal temp probe, we were able to maintain normothermia. Mild hypothermia is preferred over hyperthermia given donor hypothermia has been associated with improved transplant outcomes. That being said, profound hypothermia, can exacerbate myocardial depression and arrhythmias.
We documented all but one animal (89%) exhibited evidence of DI (urine output >4ml/kg/hr with hypernatremia). This is consistent with the incidence of this disease in 80% of human donors . DI occurs as a result of damage to the posterior pituitary, which results in decreased or even undetectable levels of arginine vasopressin (also known AVP, or antidiuretic hormone). This hormone stimulates the V1 receptor in vascular smooth muscle causing vasoconstriction, as well as, stimulating V2 receptors which cause increased fluid retention in the renal collecting system. A decrease in plasma AVP levels causes the hallmarks of DI: polyuria (urine outputs>4ml/kg/hour), hypernatremia, dehydration, and hypotension. Continuous vasopressin infusions provide a synthetic replacement for the lost endogenous hormone. These infusions also have the benefit of providing vasoconstriction to improve systemic vascular resistance. Desmopressin was not used given it is only indicated in circumstances of hypernatremia without hypotension[25, 26]. In addition, it is important to replace lost volume with isotonic fluid boluses as guided by your CVP and hourly net fluid volume calculations to prevent dehydration and contraction alkalosis. Even with appropriate use of vasopressin infusions and volume resuscitation, animals may develop hypernatremia from their DI. We found in our first animal that if vasopressin and D5W infusion are delayed until after the urine output is consistently >10ml/kg/hr and sodium is >155, it is difficult to control the hypernatremia. As a result, this animal had our highest sodium of 173 mEq/L and highest UO of 27.5ml/kg/hr. We subsequently started our D5W infusions with Na>150mEq/L. Human literature has shown that donor sodium levels of greater than 155 mEq/L in liver transplant patients and greater than 170 in heart transplant patients are associated with worse outcomes.
The evidence on thyroid replacement in donor treatment is controversial with two recent meta-analyses showing no cardiovascular benefits to thyroid supplementation. The changes in thyroid function in donors are more indicative of a euthyroid sick syndrome than a hypothyroid state [26, 34]. It is for these reasons that we did not supplement thyroid hormone in our model. Adrenal insufficiency in donors has also been documented in 76–87% of cases and can potentially lead to hemodynamic compromise. Unfortunately the literature has not completely supported the benefit of high dose steroids with regards to hemodynamic benefits or anti-inflammatory effects[22, 25]. That being said, there are some observational studies to support this theory and administration of 15mg/kg methylprednisolone is still recommended by many critical care societies and can be added to a donor animal model if so desired[25, 26]. Finally, hyperglycemia is a problem seen in a significant number of human donors, but was not seen in our animal model.
The development of a primate brain death model has significant potential to advance not only transplant research, but also the understanding of the pathophysiologic changes that occur in brain death and severe traumatic brain injury. Our model offers the opportunity for researchers to have translational animal testing prior to human clinical trials of both donor and recipient transplantation drugs and therapies.
This work was supported by National Institutes of Health NIH #1-R01-AI110617-01A1 (PI: LAF) and NIH # T32 AI125231 training grant. We would also like to acknowledge the National Primate Center at the University of Wisconsin for the excellent technical support on the care of our animals and Alpha Genesis for the kind support on providing animals and resources for our research.
- 1. UNOS: National Data 2016 [cited 2016 Aug 1, 2016]. https://www.unos.org/data/.
- 2. Yuan Q, Zhou Z, Lindell SG, Higley JD, Ferguson B, Thompson RC, et al. The rhesus macaque is three times as diverse but more closely equivalent in damaging coding variation as compared to the human. BMC Genet. 2012;13:52. pmid:22747632
- 3. Otting N, Heijmans CM, Noort RC, de Groot NG, Doxiadis GG, van Rood JJ, et al. Unparalleled complexity of the MHC class I region in rhesus macaques. Proc Natl Acad Sci U S A. 2005;102(5):1626–31. pmid:15665097;
- 4. Uno Y, Matsushita A, Murayama N, Yamazaki H. Genetic polymorphism of cynomolgus and rhesus macaque CYP2C9. Drug Metab Pharmacokinet. 2015;30(1):130–2. pmid:25760542.
- 5. Uno Y, Iwasaki K, Yamazaki H, Nelson DR. Macaque cytochromes P450: nomenclature, transcript, gene, genomic structure, and function. Drug Metab Rev. 2011;43(3):346–61. pmid:21303270.
- 6. Hérodin F, Thullier P, Garin D, Drouet M. Nonhuman primates are relevant models for research in hematology, immunology and virology. Eur Cytokine Netw. 2005;16(2):104–16. pmid:15941681.
- 7. Chen L, Feng X, Wang Y, Xu X, Wan C, Wang J, et al. Study of the Role of Transforming Growth Factor β-1 in Organ Damage Protection in Porcine Model of Brain Death. Transplant Proc. 2016;48(1):205–9. pmid:26915869.
- 8. Floerchinger B, Oberhuber R, Tullius SG. Effects of brain death on organ quality and transplant outcome. Transplant Rev (Orlando). 2012;26(2):54–9. pmid:22459036.
- 9. Marasco S, Kras A, Schulberg E, Vale M, Chan P, Lee GA, et al. Donor brain death time and impact on outcomes in heart transplantation. Transplant Proc. 2013;45(1):33–7. pmid:23375272.
- 10. Spindler RS, Schnuelle P, Nickels L, Jarczyk J, Waldherr R, Theisinger S, et al. N-Octanoyl Dopamine for Donor Treatment in a Brain-death Model of Kidney and Heart Transplantation. Transplantation. 2015;99(5):935–41. pmid:25675202.
- 11. Nijboer WN, Ottens PJ, van Dijk A, van Goor H, Ploeg RJ, Leuvenink HG. Donor pretreatment with carbamylated erythropoietin in a brain death model reduces inflammation more effectively than erythropoietin while preserving renal function. Crit Care Med. 2010;38(4):1155–61. pmid:20124889.
- 12. Zhang S, Cao S, Wang T, Yan B, Lu Y, Zhao Y. Modified brain death model for rats. Exp Clin Transplant. 2014;12(5):469–73. pmid:24918972.
- 13. Kolkert JL, 't Hart NA, van Dijk A, Ottens PJ, Ploeg RJ, Leuvenink HG. The gradual onset brain death model: a relevant model to study organ donation and its consequences on the outcome after transplantation. Lab Anim. 2007;41(3):363–71. pmid:17640464.
- 14. Danobeitia JS, Hanson MS, Chlebeck P, Park E, Sperger JM, Schwarznau A, et al. Donor Pretreatment With IL-1 Receptor Antagonist Attenuates Inflammation and Improves Functional Potency in Islets From Brain-Dead Nonhuman Primates. Cell Transplant. 2015;24(9):1863–77. pmid:24759633.
- 15. Valenza F, Coppola S, Froio S, Ruggeri GM, Fumagalli J, Villa AM, et al. A standardized model of brain death, donor treatment, and lung transplantation for studies on organ preservation and reconditioning. Intensive Care Med Exp. 2014;2(1):12. pmid:26266913
- 16. Blasco V, Leone M, Bouvenot J, Geissler A, Albanèse J, Martin C. Impact of intensive care on renal function before graft harvest: results of a monocentric study. Crit Care. 2007;11(5):R103. pmid:17868450
- 17. Blasi-Ibanez A, Hirose R, Feiner J, Freise C, Stock PG, Roberts JP, et al. Predictors associated with terminal renal function in deceased organ donors in the intensive care unit. Anesthesiology. 2009;110(2):333–41. pmid:19194160.
- 18. Youn TS, Greer DM. Brain death and management of a potential organ donor in the intensive care unit. Crit Care Clin. 2014;30(4):813–31. pmid:25257743.
- 19. Wood KE, Becker BN, McCartney JG, D'Alessandro AM, Coursin DB. Care of the potential organ donor. N Engl J Med. 2004;351(26):2730–9. pmid:15616207.
- 20. Wood KE, Coursin DB. Intensivists and organ donor management. Curr Opin Anaesthesiol. 2007;20(2):97–9. pmid:17413390.
- 21. Muller E. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Transplantation. 2015;99(9):1743. pmid:26308408.
- 22. Amatschek S, Wilflingseder J, Pones M, Kainz A, Bodingbauer M, Mühlbacher F, et al. The effect of steroid pretreatment of deceased organ donors on liver allograft function: a blinded randomized placebo-controlled trial. J Hepatol. 2012;56(6):1305–9. pmid:22326464
- 23. Frontera JA, Kalb T. How I manage the adult potential organ donor: donation after neurological death (part 1). Neurocrit Care. 2010;12(1):103–10. pmid:19844809.
- 24. Marques RG, Rogers J, Chavin KD, Baliga PK, Lin A, Emovon O, et al. Does treatment of cadaveric organ donors with desmopressin increase the likelihood of pancreas graft thrombosis? Results of a preliminary study. Transplant Proc. 2004;36(4):1048–9. pmid:15194364.
- 25. Westphal GA. A simple bedside approach to therapeutic goals achievement during the management of deceased organ donors—An adapted version of the "VIP" approach. Clin Transplant. 2016;30(2):138–44. pmid:26588881.
- 26. Kotloff RM, Blosser S, Fulda GJ, Malinoski D, Ahya VN, Angel L, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med. 2015;43(6):1291–325. pmid:25978154.
- 27. Remuzzi G, Grinyò J, Ruggenenti P, Beatini M, Cole EH, Milford EL, et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. Double Kidney Transplant Group (DKG). J Am Soc Nephrol. 1999;10(12):2591–8. pmid:10589699.
- 28. Miñambres E, Rodrigo E, Ballesteros MA, Llorca J, Ruiz JC, Fernandez-Fresnedo G, et al. Impact of restrictive fluid balance focused to increase lung procurement on renal function after kidney transplantation. Nephrol Dial Transplant. 2010;25(7):2352–6. pmid:20154365.
- 29. Plurad DS, Bricker S, Neville A, Bongard F, Putnam B. Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors. Am J Surg. 2012;204(6):856–60; discussion 60–1. pmid:23116641.
- 30. Hoeger S, Gottmann U, Liu Z, Schnuelle P, Birck R, Braun C, et al. Dopamine treatment in brain-dead rats mediates anti-inflammatory effects: the role of hemodynamic stabilization and D-receptor stimulation. Transpl Int. 2007;20(9):790–9. pmid:17596177.
- 31. Bratton SL, Davis RL. Acute lung injury in isolated traumatic brain injury. Neurosurgery. 1997;40(4):707–12; discussion 12. pmid:9092843.
- 32. Mackersie RC, Christensen JM, Pitts LH, Lewis FR. Pulmonary extravascular fluid accumulation following intracranial injury. J Trauma. 1983;23(11):968–75. pmid:6355501.
- 33. Niemann CU, Malinoski D. Therapeutic Hypothermia in Deceased Organ Donors and Kidney-Graft Function. N Engl J Med. 2015;373(27):2687. pmid:26716922.
- 34. Goarin JP, Cohen S, Riou B, Jacquens Y, Guesde R, Le Bret F, et al. The effects of triiodothyronine on hemodynamic status and cardiac function in potential heart donors. Anesth Analg. 1996;83(1):41–7. pmid:8659763.

domain: medical


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The Oireachtas Banking Inquiry began work last December with an abundance of critics and disadvantages. Among other difficulties, the work involves walking a legal tightrope at some speed to meet a November 2015 reporting deadline.
Since its first hearing, the seven TDs and four senators have worked creditably through endless hours, posing many thoughtful questions on behalf of the Irish people.
Much of the focus of its work is around the fateful night of September 29 and 30 in 2008, when the Government decided to guarantee deposits in all major banks up to a maximum of €100,000.
Many of the subsequent decisions taken in response to the bank system collapse were a function of the events of that fateful evening. But we are looking at a very complex set of factors and relations involving the principals in the Irish bank system, the Irish government and administration in Dublin, and their counterparts within the EU system in Brussels, Frankfurt and other centres of European decision-making.
Next Thursday, the inquiry faces a crucial meeting as the former Secretary General of the Finance Department, Kevin Cardiff, will give evidence. And already there are strong signals that Mr Cardiff will raise questions about the versions of events previously given by other key witnesses.
It is at this point that we may get to assess the true worth of the inquiry. It will be the TDs' and senators' difficult task to parse and evaluate all the evidence they are given. Testimony we hear this week may require the recall of some witnesses to hear more fully about their memory of events.
It will be a most testing time for banking inquiry chairman Ciaran Lynch and his colleagues. We trust they will proceed with cautious but steely determination.
We need a productive and decisive fact-finding parliamentary inquiry to help us understand why Ireland had a phoney economic boom followed by an all-too-real bust. An effective banking inquiry is important to help us find out why Ireland came to have a "lost economic decade" from which we are only now emerging.
We need these things to avoid a repeat of that dangerous folly for the coming generations of Irish people.
We are just 15 months away from the 50th anniversary of Donogh O'Malley's announcement on "free" secondary education. But in too many ways we remain far from realising that wonderful ideal.
In fact, even primary education remains a costly strain on many parents. If you doubt that, just tot up the cost of stationery, bus passes and school books. If you like, you can use the back of the envelope your child brings home telling you about the "voluntary" contributions.
The children's charity Barnardos is launching a new campaign to have the taxpayer pick up the tab of €103m per year for the nation's half a million primary school pupils. Surveys the charity has been conducting for 10 years show that parents pay an average of €185 per year, per pupil, to fund these primary school extras.
Let's recall that primary schooling is the bedrock of every citizen's education. The more equality of opportunity we can put into things at this stage, the better the likelihood of more equality across the board in society.
And an effective education system is central to our economic well-being as a nation.

domain: finance


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Organised as a Dutch-German collaboration between Leiden University and the University of Cologne, this workshop on colonial photography and visual culture took place in early July 2021. The workshop focused on European colonial photography and visual culture more broadly between 1850 and 1950, investigating the diverse ways in which photography was used to create a sense of familiarity between the colonies and the metropole. Moreover, the specific functions of colonial photography not only for familiarising the colony, but also with respect to the long-term effects of colonial visualities and the legitimisation and spread of racist stereotypes were addressed during the workshop. While the workshop included researchers from all stages of their academic careers who presented their most recent academic working papers, one panel featured artistic perspectives on colonial visuality. Initially, the workshop aimed to shed light on the ways images from and of the colonial world influenced Europeans that never saw colonialism with their own eyes. Finally, it went well beyond its initial focus on German and Dutch colonial visual culture, both geographically and medially.
In the first panel, Intermedial Perspectives, three presentations set colonial photographs in relation to other forms of media and archives from the colonial era. LORENA RIZZO (Basel) presented her current research project that taps into the vast multimedia archive of the Dammann collection stored at the Basler Afrika Bibliographien. Particularly her investigation of how the Finnish missionaries’ audio archive from the early 1950s relates to textual and visual sources of the collection provided much food for thought about how intermedial approaches enable us to pay respect to the archives’ materiality.
CAROLINE BRÄUER (Cologne) analysed the interplay of textual and visual sources in the German illustrated magazine ‘Kolonie und Heimat’. She showed how depictions of German visual icons, such as scenes of tea time or images of churches, were used to familiarise the colonial world to German audiences and promote colonialism.
While the focus of ANA CAROLINA SCHVEITZER’s (Berlin) work lay exclusively on photographs, her analysis placed these photographs in the broader context of ‘colonial work situations’. Focusing on photographs from German South-West Africa, Schveitzer illustrated the relationship between photographs, physical places, and abstract spaces. The imagery rendered places abstract and portrayed individual workers merely as natural assets to the situation defined by labour. Audiences in Europe would perceive the non-white workers, stripped of their individuality, as naturally fitting into the space defined by hard physical labour.
The second panel, Artistic Interventions, took a leap into current debates on colonial legacies in the US, the Netherlands, Namibia, and Germany. Artist and cultural scientist VITJITUA NDJIHARINE (Windhoek / Stuttgart) presented some of her past projects which critically engage with the archival as well as geopolitical legacies of colonialism. Ndjiharine’s works seek to interlink investigations of her ancestry, the desire to give back dignity to the people portrayed in colonial photographs, and her special eye for the intimacy of photographs. For one of her past projects, she “clothed” photographs of naked female individuals from the colonial era. In directing the viewers’ gaze away from the women’s brutal nakedness, Ndjiharine illustrated how artistic intervention enables us to focus on novel aspects of these visuals. Recently, however, Ndjiharine has grown critical of the ways her clothing style imposes ideas of gender on the individuals portrayed. Accordingly, she worked out the Mirrored Reality Installation in which she replaced the contours of individuals portrayed in colonial photographs with mirrors.
Film-maker TIM VAN DEN HOF (Rotterdam) presented two of his projects which focus on questions of remembrance, preservation, and how we can look at the past from a new perspective. The documentaries Monumental Crossroads (2018) and The Images of Piet Hein (in production) chronicle the legacies of controversial monuments in the South of the United States and The Netherlands and the different reactions they continue to provoke. Van den Hof’s documentaries vividly show the deep societal rifts that spark the dispute over monuments, the need to find a reconciliatory path forward, and ultimately the power monuments possess.
For the third panel the organisers chose to focus on colonial violence; a necessary and important yet very delicate issue. Strikingly, the panel’s first paper, Private Visual Reporting? Representations of the Herero-Nama War in Illustrated Postcards in Imperial Germany, focused on the absence of violence in visual mass media. CEYDA ÜNLÜ (Cologne) argued that most postcards which were sent from German Southwest Africa to Germany between 1904 and 1907 did not include depictions or descriptions of violence. These postcards generally omitted the Herero and Nama war that simultaneously raged in modern-day Namibia. Ünlü argues that the clear absence of violence in German visual mass media testifies to a colonial self-expectation that considered colonial wars trivial and their outcomes predetermined. Her brilliant paper showed what familiarisation meant in practical terms and what aspects of colonialism did not find their way into European mass media. One aspect that future scholarship should focus on, however, is the role mass media played for colonised societies.
LIESBETH OUWEHAND (Amsterdam) delivered the second and final paper in Panel three. Her analysis of the life of a photograph of the Balinese Puputan—a form of collective suicide—touched upon both the use of photographs as historical sources as well as the implications of digitisation. There are intricate ethical and copyright-related problems to making scenes of human suffering available online. But the digitisation of colonial photographs also influences their value as sources. Online, the photographs exist exclusively in their historical context. Digitisation entirely stripps them of their materiality.
The fourth panel focused on long-term effects of colonial photography. In their presentation, JAN BECKER (Leiden) and LEONIE RUPP (Leiden) argued that the time for a transnational conceptualisation of colonial imagery is long overdue. In analysing the transnational and at times global circulation of postcards depicting colonial images, Becker and Rupp showed that the racist, pejorative notions transmitted through these postcards were universally comprehensible, and thus colonial imagery was not restricted to national boundaries. They emphasised the long-term effects colonial imagery had not only for former colonial powers but also for indirectly involved European states and even the EU. The transnational legacies of colonial visuality are severely under-researched.
DIANA NATERMANN (Leiden), finally, took a step back and reflected on the junctures from ego document to archive. Natermann used a German colonial photographic collection from the MARKK (Museum am Rothenbaum: Kulturen und Künste der Welt) in Hamburg, Germany, named the Mecklenburg Collection, as a starting point. The mentioned collection was used to portray a rich, under-exposed yet ‘typical’ Central-African and German colonial photographic collection from the years 1910/11 to then thematically move on to the early twenty-first century by venturing into the question of modern-day museums and their role in preserving but also making available and decolonising colonial photographic archives.
In his concluding remarks, JENS JÄGER (Cologne) emphasised the importance for future research to pay more attention to visual orders and to go beyond the limitations of academic research to explore these orders. One possible way, according to Jäger, is collaboration with artists and artistic interventions. Furthermore, he pointed out the lack of research on mass media in the Global South, which was equally relevant for and part of the development of a certain visual culture. Particularly the question of whom to focus on when researching mass media and visual culture more generally sparked a vivid discussion between the workshop participants. Referencing the presentation by Becker and Rupp, Jäger underlined that “we still think too nationally” and we should take greater account of the fact that colonial and visual culture was and is inevitably transnational.
Whereas the workshop offered an abundance of novel insights into the history and the legacies of colonial visual culture, it ultimately posed even more new questions. There is plenty of work to do for scholars and artists and colonial visuality has rarely been more topical.
Panel I: Intermedial Perspectives
Lorena Rizzo (Basel): “What Else Must I Say or Add?” – (In)audible Northern Namibian Pasts
Caroline Bräuer (Cologne): “In Word and Image?” Visual Culture in the Magazine Kolonie und Heimat
Ana Carolina Schveitzer (Berlin): Framing Colonial Work Situation: Photographs from the Deutsche Kolonialgesellschaft (DKG) Archive
Comments: Ali Shobeiri (Leiden)
Panel II: Artistic Interventions
Vitjitua Ndjiharine (Windhoek / Stuttgart): German Colonialism and Namibian Art
Tim van den Hoff (Rotterdam): The Images of Piet Hein: A Documentary About the History of an (Un)wanted Icon
Comments: Johannes Müller (Leiden)
Panel III: Visualising Violence
Ceyda Ünlü (Cologne): Private Visual Reporting? Representations of the Herero-Nama War in Illustrated Postcards in Imperial Germany
Liesbeth Ouwehand (Amsterdam): The Circulation of Atrocity: the Puputan Bali Case Study
Comments: Diana Natermann (Leiden)
Panel IV: Long-Term Effects
Leonie Rupp and Jan Becker (Leiden): Putting Colonial Imagery in Perspective: Investigating Transnational Visual Legacies
Diana Natermann (Leiden): (Post-)Colonial Images and How Museums Can Address Their Heritages
Comments and Concluding Remarks: Jens Jäger (Cologne)
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domain: artistic


text:
Mission Pie is a corner café, bakery, and neighborhood gathering place in the SF Mission District that brings the flavors of local farms into the city and tells their stories. Mission Pie encourages urban folks toward intimacy with their food through live relationships with the people and places that grow our ingredients. With pie as our ally, we create a warm environment that encourages exploration of our choices and values, and where, as neighbors, we can find support and friendship in our pursuit of healthy and sustainable lives. We celebrate farmers, bakers, chefs, and all who work together toward a healthful food system.
Mission Pie is a business venture in collaboration with the non-profit Pie Ranch, a diversified small-scale educational farm that is just one hour south of San Francisco.Through “hands-on work and collective reflection at Pie Ranch, San Francisco teenagers discover new competencies and insights” that truly benefit them as individuals and in community.
Since opening on January 3, 2007, Mission Pie has provided jobs and training for the youth Pie Ranch works with at the farm.

domain: food


Remove the terminals of the battery and take off the distributor cap. If your automobile does not contain a distributor, then turn the cam sensor position to the “Top Dead Centre”. Read the instructions from the user manual on how to achieve this in your car.
Turn the engine such that the crankshaft pulley is aligned with the timing belt at the 'O' position on the belt. Keep rotating the engine till the distributor rotor is in line with the markings on the distributor housing assembly.
Unscrew all the bots with the help of a spanner or a wrench that come in the way of the removal of the timing belt. This differs from car to car, in some vehicles hardly one or two bolt needs to be opened while in some other it is a quite complex procedure.
Loosen the timing belt tension controller and unscrew its bolts but do not remove them completely. Move the tension controller slightly far from the timing belt and now tighten those bolts again. Now the timing belt can be removed from the engine; carefully slide the belt off the engine.
Fit in the new timing belt in the space and follow all the steps in the reverse order. Read the car manual and tighten the timing belt accordingly. Carefully screw all the bolts and fire in the ignition to check if the time belt has perfectly settled or not.


M.C. Taylor of Hiss Golden Messenger wrote a review of Ryan Adams’ latest album Prisoner, and it’s one of the most interesting pieces on the album you’re likely to read.
Rather than detailing his thoughts on the particular album, he recalls the moment that he first heard Heartbreaker and how Adams work plays into his own ideas of life and death.
Via his piece on The Talkhouse:
“I’ve been looking at the way people survive. Mainly because I want to survive but sometimes just have no idea how to do it. Some people get sober, some get drunk or high. Some get jobs, either hard jobs that don’t let them ever see their families or friends or easy jobs where they can just coast. Some people die. Some become wildly successful. And they’re happy. Or they’re sad. Or depressed or lonely. Some people put their heads down and just press on, not thinking about the passage of time, how time passes through us and shapes us. I mean, the way time works on us is not even subtle; it can make us lean and hard, sanding away the inessentials even if we think we need the inessentials and love those things the best. Time is callous, I guess, but there are so many ways to survive. And Ryan Adams seems like a survivor. It’s something that we share.”
His summation of Prisoner is that it’s the sound of a man who has realized he needs to create to survive.. Check it out in full over at The Talkhouse. For another take on Prisoner — one that was confirmed by Adams himself — check out Steven Hyden’s analysis of the new album and how it plays into his trilogy of divorce albums.


New Fiscal Framework
B.C. is committed to co-developing a new fiscal framework with Indigenous Peoples that recognizes Indigenous rights as outlined in the United Nations Declaration on the Rights of Indigenous Peoples.
New Fiscal Framework
Indigenous governments – like all governments – require sources of revenues to deliver service and accountabilities to their citizens. As part of implementing the United Nations Declaration on the Rights of Indigenous Peoples, B.C. is working towards a future where Indigenous governments can fulfil their responsibilities, care for their citizens and First Nations can manage their territories in ways that reflects their values.
The Province is committed to co-developing a new fiscal framework with Indigenous Peoples that supports the operation of Indigenous governments. The provincial government recognizes that there is much work to do. The Declaration Act Action Plan includes a commitment to this work over the next five years and beyond.
As an initial step, the Province finalized a long-term gaming revenue sharing arrangement that, since 2019, shares seven percent of gaming revenues, approximately $100 million annually, with First Nations. Learn more here.
In April 2022, B.C. announced a commitment to continue this work through the co-development of a new forestry revenue-sharing model with First Nations. In the interim, as the co-development work takes place, B.C. is more than doubling forestry revenues that will be shared with First Nations.
Learn more about interim changes to forest revenue sharing here.
In November 2022, the B.C. Government released a discussion paper to First Nations to support the co-development work, with an initial focus on forestry revenue sharing.
The Discussion Paper identifies two simultaneous tracks of work in partnership with First Nations.
- Track 1 is the co-development of a new model of fiscal relations, including the vision, objectives, and principles, and how those will be applied comprehensively.
- Track 2 is the co-development of near-term changes to specific revenue-sharing streams. The initial focus of track 2 will be on forestry revenue sharing.
Read the Discussion Paper here.
‘What We Heard’ report
Following engagement with First Nations across the province, on April 12, 2023, the Province released a ’What We Heard’ report, which summarizes the perspectives shared by First Nations during this first phase of engagement on the co-development of a new fiscal framework.
The What We Heard report includes an overview of the Province’s engagement activities and a summary of the feedback raised by First Nations during government-to-government meetings, conferences, forums, and a virtual information session. The Province has sought to accurately reflect all of the feedback received, without interpreting or filtering the comments beyond summarizing them into key themes.Read the ‘What We Heard’ report here.
The Province is currently developing an options paper, which will contain a series of preliminary options for a new forestry revenue sharing model as well as co-developed principles for a new fiscal framework, based on the feedback summarized in the What We Heard Report.
The Province will undertake further engagement with First Nations, the public and industry on the options paper, as well as make it available for comment by the public and industry. Check back here for more information soon.


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How to send an inquiry?
To contact the owner or contact person of object, you must submit a completed form. Contact form is accessible by clicking on the link send request
for booking private accommodation in Seget Vranjica.
All agreements and terms about the availability (and booking) you arrange with the responsible person. After you send a request, you can expect to be contacted by email or phone/cell phone.
Seget Vranjica is a small tourist place located 5 km north of Trogir and 8km from the international airport "Split". Seget Vranjica contains everything you need for a pleasant and peaceful family holiday in a beautiful Mediterranean setting.
Due to the proximity of several ACI marina and ferry port of Split, which connects you to numerous Dalmatian destinations, is an ideal base for exploring the Adriatic.
Trogir Riviera and surrounding Seget Vranjica marked bays with rocky and sandy beaches, lush Mediterranean vegetation, centuries-old vineyards and...

domain: travel


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Building Ethical Futures
This spring, US News and World Report ranked Luther number two in the nation for the percentage of students who study abroad. Our students choose to learn off-campus in such great numbers in part because they adopt the Luther ethos of global citizenship. They also learn off-campus because we offer some incredible study-away courses.
Case-in-point: Building Ethical Futures through Architecture, Design, and Narrative in Norway, a brand-new Paideia 450 course that professors Andy Hageman (English) and Maren Johnson (Nordic studies) offered over J-Term 2023.
The thoughtful, high-impact course asked students to think about how the design of buildings and systems reflects the values and ethics of a place.
Funny enough, this farflung course began hyper-locally, with a world-renowned architecture firm putting down roots in Decorah.
A global presence in Decorah
Snøhetta is responsible for dozens of heavy-hitting projects around the world: opera houses in Shanghai, Oslo, and Busan; libraries in Beijing, Calgary, and Alexandria; the National September 11 Memorial Museum Pavilion and Times Square in New York; and soon the Vesterheim Commons in Decorah, Iowa.
Hageman says, “We’re seeing a globally significant architecture/design firm that started from humble roots, doing things in their own, very innovative way. And they’re going to help change the landscape of Decorah and downtown.”
Plans for the visionary 7,600-square-foot Vesterheim Commons project began in 2018. Johnson, the Luther representative to Vesterheim’s Board of Trustees, remembers being struck by Snøhetta’s inclusive, collaborative, ethics-based approach to design—and the fact that it started with values. “Built spaces can help us shape the way we tell a story and invite more voices into the conversation,” she says. “In this redesign, we started with the value of the immigrant story. Narrative is a value for the museum, and it’s important for Vesterheim to put the immigrant story and the immigrant experience at the forefront.”
The Vesterheim project inspired Hageman to include a unit about it in the first-year Paideia 111 course in the fall of 2020 and 2021. “It’s really where we welcome students to the liberal arts, which I think of more as a welcome to interdisciplinary studies,” he says. “It got students to think about architecture and design as embodied values, as this intersection of fields. With Snøhetta, we thought about how you’ve got people who do physics and engineering and people who have to understand economics and accounting as they look at their budgets, and then aesthetics, art, design. What narrative does a building tell? And issues of diversity, equity and inclusion—how do we design better with those principles in mind?”
He also lifted Snøhetta up as a model of cooperation and teamwork. “Paideia means learning in community. And part of that is starting out at Luther and realizing that what you’re doing here is not just producing individual papers and analyses,” he says.
Learning in parliament
The Paideia 450 course in Norway took three years of planning. When it was offered last J-Term, students jumped at the chance to take their Luther learning full circle—23 out of 24 of them had taken the Snøhetta unit in Paideia 111. “They thought this would be a really interesting way to do their ethics capstone with something that was meaningful to them,” Hageman says.
While the course used Snøhetta as a jumping-off point, Johnson says, “The focus became Scandinavia and design—not just physical spaces, but societal and community design and how alternate models of life and society offer different opportunities and challenges.”
The group’s tour of Norwegian parliament is a powerful example of how design can reflect—and maybe even encourage—societal values. The Norwegian parliament building is surrounded by a waist-high gate, which visitors can open themselves before walking directly to the front door. The Luther group was met by two parliamentarians who represented opposite ends of the spectrum of Norway’s nine political parties. Hageman recalls them saying, “‘We’re going to talk for about half an hour about all the shared values that we have and what we want to accomplish together. Then we’ll take a little time to talk to you about how we disagree on how to get there.’ Then they walked us through things like: how do we together, as opposites, share a sense of health care as a human right, education as a human right, child care as a human right?”
Because Norway has so many political parties, everything has to be done as a parliament, as coalitions, and so its approach to government is a collaborative one.
The parliamentarians took the group down to the main chamber and talked about its design and how it facilitates debate and discussion. They pointed out that if you look out the window where they all sit, you can see up to the palace. They described how that monument to the history of monarchy plays into their ideas of power dynamics, parliament, and democracy.
“There was this openness and this idea that these are sacred spaces where the laws of the country are made, but it’s very possible for everyone to access them,” Johnson says. “There’s this perception there that public institutions like the government are for people.”
Hageman says, “Design and architecture—students understand that, but the narrative part was a little tricky. But that day—that day I think it clicked.”
Taking things full circle
The course took students through a diverse, high-impact itinerary. They toured the Edvard Munch museum, where groups of students started at different points in the space and moved through it in different ways, so they all got different narratives of it. They also toured the Nordic Black Theatre, a small independent theatre that stages shows largely written, directed, and acted by people of color. The recent immigrant stories they staged tied back to Versterheim’s focus on immigrant stories in Decorah.
The group visited Hans Brattskar ’79, special envoy of the Norwegian Foreign Ministry, who is leading a multinational, multibillion-dollar project to combat deforestation of rainforest. They took a few classes at the Oslo School of Architecture and Design. They visited a high school for top athletes in western Oslo. And, of course, they visited the Oslo office of Snøhetta, the architecture and design firm that inspired the entire course.
“Snøhetta was one of my favorite units in Paideia 111,” says Jared Penshorn ’23. “I remember admiring their unique architecture styles and the scale of their buildings. More importantly, I remember being fascinated by their visions. They were attempting to overhaul traditional architecture by being environmentally conscious with materials and reusing as many buildings as possible. They wanted to redesign old places more than design new spaces. As a young environmental science major, these ideas were inspiring to me.”
About his visit to Snøhetta’s Oslo office, Penshorn says, “I was finally able to see all these concepts and visions with my own eyes. Their buildings are grand and impressive, but I kept marveling at ways they incorporated passive solar heat and local sourcing into their designs. I found Snøhetta to be exactly as I had learned: a firm that’s looking toward the future and reimagining what’s possible in the spaces around them.”
Time to reimagine
Principles of design, architecture, and narrative—or DAN, as the group affectionately called it—were the cornerstone of the course. But, as with any Luther study-away course, the lessons students learned extended well beyond academics.
Johnson remembers a trying first day of travel during which the whole group lost its luggage. On the high-speed train from the airport to central Oslo, the announcement came on: The doors are closing. Please sit down. We’re headed to central Oslo. Our trip will take about 20 minutes. Two of the students started crying. When Johnson checked in with them, they explained, “It has absolutely nothing to do with logistics—it has everything to do with the fact that we realize it matters for us to learn language because we understand. We understand.” They’d studied Norwegian at Luther, and now they saw the value of having learned a language, of understanding how to navigate in a foreign city. It was profound.
Anthropology major Sam Liska ’23 left the course with a brand-new outlook. “As a class, we reflected a lot about what it means to be a student and, more importantly, a young adult in this day and age,”
Liska recalls Johnson saying that the trip was meant to show them that the world isn’t a scary place—an idea he took to heart. “Our world doesn’t have to be the overwhelmingly depressing, hopeless, and fearful place it’s often made out to be,” he says. “Rather, it’s time for us to reimagine and create the world we want to see.” He developed a new mantra to remind himself of this: to pivot is to trust. He says, “It’s a phrase to remind us that change is possible so long as there is trust in ourselves and each other.”


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“Near Tellus Science Museum”
The Courtesy Inn White is located .5 miles from Interstate 75 and less than 15 minutes’ drive from Cartersville city centre. This hotel offers free Wi-Fi to all guests. Cable TV is included in every simply decorated guestroom of this White hotel. All rooms feature a seating area and bedding has floral patterns with wood furnishings. A launderette is available to guests of the White Courtesy Inn as well as a 24-hour reception. Fax and photocopying facilities are available for added convenience. This hotel is 30 minutes’ drive from the shopping options of the Premium Outlet Mall. The Tellus Science Museum is located 2 miles away. You must show a valid photo ID and credit card upon check-in. Please note that all special requests cannot be guaranteed and are subject to availability upon check-in. Additional charges may apply.
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Former three-term New York Gov. George Pataki (R) has all but thrown his hat into the ring for president.
“If I were a betting person, I would bet that I would make the decision to go,” Pataki told WABC’s Rita Cosby on Sunday, adding that he is “strongly leaning towards” running.
Pataki, who has flirted with running in previous presidential primaries, added he is “closer to making that decision than I’ve ever been.”
“I know we need to change the direction of this country and in particular, our government,” he said. “I know I have the ability to not just lead a big, complex government, but to change it as I did in New York, so I’m seriously looking at it.”
“If you care about the country,” he added, “it’s very hard to sit on the sideline if you believe you have the ability to run a government, like this country’s government, well.”
Pataki has made frequent trips to pivotal primary states — including six visits to New Hampshire — since September. Earlier this month, he attended a Republican donor event in Florida and joined other potential GOP candidates at an event in Iowa. He is scheduled to speak alongside other potential candidates at the South Carolina Freedom Summit in Greenville on May 9.
Pataki is the chairman of “We The People Not Washington,” a super PAC that, according to its website, is aimed at supporting Pataki’s vision to “dismantle the perpetual growth and overreach of the federal government and begin reducing the size of the federal government to a more appropriate level.”
Yet he told WABC Sunday that now is not the time to formally launch a campaign. “Given the way the federal rules are structured, I am not going to make that announcement, or the decision, at this time,” he said.
Pataki would enter the race slightly to the left of many in the crowded field of GOP presidential hopefuls. He has previously said that he is pro-choice and that he believes decisions on same-sex marriage should be left up to the states. And although he has said he doesn’t see the need for new federal gun laws, as governor of New York signed some of the nation’s tightest gun regulations.
On Sunday he also attacked Hillary Clinton for using her private email while serving as secretary of state, saying the likely Democratic presidential nominee should “be held accountable” for her actions.
“I find it inconceivable that for four years she never on that server said one thing that was classified while serving as secretary of state,” he said.
And he criticized President Barack Obama for not being aggressive enough toward the Islamic State group.
“I was governor on September 11th, and I saw the consequences of government thinking that because this radical Islam was thousands of thousands of miles overseas, it didn’t pose a threat to us,” he said. “It obviously did.”
“We cannot sit back and simply say they are over there,” he added. “They want to attack us here and I believe we have to go in, destroy as many of them as we can, as quickly as we can, destroy their recruiting centers and training facilities and then get out.”
In an interview with The New York Post earlier this month, Pataki positioned himself as a humble, Republican farm boy from a blue state.
“I’m from New York and I probably spent more of my life on a farm than anybody out there,” he said, referring to his GOP primary opponents. Pataki grew up on a farm in Peekskill and currently operates a cherry farm with his wife, where they also own 85 head of cattle.
“I am not unaccustomed to getting my hands dirty on a farm,” he said.
Sen. Ted Cruz (R-Texas) is the only top-tier Republican candidate to have officially launched a campaign. Other likely candidates include former Florida Gov. Jeb Bush, Sen. Rand Paul of Kentucky and former Arkansas Gov. Mike Huckabee.
Source: Huff Post

domain: news


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Bhubaneswar: The BJP on Monday launched a State-wide protest against the State Government for its alleged failure to provide justice to the Kunduli gang-rape victim who committed suicide.
While condoling the death of the minor girl, Union Ministers Jual Oram and Dharmendra Pradhan blamed Chief Minister Naveen Patnaik for the incident. Terming the suicide as a calculated murder, Oram said the State Government is responsible for the unfortunate incident.
In a separate statement, Pradhan said the State Government had shown utter insensitivity in the Kunduli incident and this will not be tolerated.
Perhaps the girl lost her state of mind and preferred to take the extreme step for the manner in which the Government handled the case, he said.

domain: law