Inferior pedicle breast reduction and long nipple-to-inframammary fold distance: How long is safe?

BACKGROUND

Free nipple grafting indications in breast reduction surgery are outdated. Safety of inferior pedicle technique for large resections and long pedicles has not been clearly defined. We evaluated patients who underwent inferior pedicle reduction mammoplasty to define the safety constraints of the inferior pedicle.

METHODS

A retrospective review of patients who underwent inferior pedicle reduction mammoplasty due to symptomatic macromastia at Mayo Clinic over a six-year period was conducted. Patients with prior breast surgeries were excluded. Demographics, breast measurements, and surgical outcomes were collected. Univariate and multivariate analyses were performed to assess for predictors of necrosis.

RESULTS

Overall, 288 patients (576 breasts) underwent inferior pedicle breast reduction from 2014 to 2019. The mean sternal notch-to-nipple (SNN) distance was 31.5 cm (standard deviation[SD]:4.2; range[r]:16-48), and the mean nipple-to-inframammary fold (N-IMF) distance was 14.8 cm (SD:4.0; r:7.5-27). The mean resection weight was 699.6 g (SD:310.4; r:125-2,385). The median follow-up was 3.9 months (interquartile range[IQR]:2.8-9.0). The overall skin or nipple areolar complex necrosis rate was 2.1%; the overall complication rate was 14.8%. On multivariate analysis, overall necrosis was not found to be associated with the N-IMF distance (adjusted odds ratio[aOR]:1.05, 95%-CI 0.88-1.16). Resection weight was statistically associated with an increased risk of overall necrosis (aOR:1.003, 95%-CI 1.001-1.005), adjusting for N-IMF and SNN distances.

CONCLUSION

Inferior pedicle breast reduction offers low risk of necrosis and can be safely performed in patients regardless of the N-IMF distance. No association was found between N-IMF distance and overall necrosis in our cohort, including lengths >15 cm. However, large resections could increase the risk of necrosis.

Fat Grafting for Improved Ileostomy Ostomy Device Fit: A Case Report

For patients with an ostomy, a poor fitting appliance may cause leakage, peristomal dermatitis, and frequent appliance changes.

PURPOSE

The purpose of this case study was to report the outcome of fat grafting to augment peristomal soft tissue and improve appliance fit.

CASE STUDY

A 57-year-old woman with a history of Crohn's disease presented with soft-tissue deficiency and uneven contour around her ileostomy site. She was unable to properly fit an ostomy appliance, which resulted in leakage, chronic skin irritation, and frequent appliance changes. The patient underwent 2 rounds of fat grafting using fat harvested from her medial thighs and knees infused with dilute lidocaine with epinephrine. The patient noted immediate improvement after 34 cc of processed fat was injected in the first round. Appliance change frequency decreased from daily to every 3 to 4 days. A second graft of 32 cc provided 3 months later further improved appliance fit, reducing appliance change frequency to every 5 to 7 days and obviating the need to use adjustment rings and glue. Pre- and postoperative computed tomography showed increased thickness of abdominal wall subcutaneous tissues.

CONCLUSION

Fat grafting around an ostomy site presents a viable option to improve contour and appliance fit with reduced skin irritation and leakage.

Infectious Disease Transmission through Cell, Tissue, and Organ Transplantation: Reducing the Risk through Donor Selection

The incidence of cell transplant-transmitted infection is unknown and can only be inferred from prospective studies–that have not yet been performed and reported. The possibility of donor-to-recipient disease transmission through cell transplant therapy can be considered by reviewing the risk associated with other transplanted tissues and organs. Viral, bacterial, and fungal infections have been transmitted via transplantation of organs, tissue allografts such as bone, skin, cornea, and heart valves, and cells such as islets, hematopoietic stem cells, and semen. Several types of protozoan and worm parasites have been transferred via organ transplants. Bone allografts have transmitted hepatitis, tuberculosis, and human immunodeficiency virus (HIV-1). Corneas have transmitted rabies, Creutzfeldt-Jakob disease (CJD), hepatitis B (HBV), cytomegalovirus (CMV), herpes simplex virus (HSV), bacteria, and fungi. Heart valves have been implicated in transmitting tuberculosis and hepatitis B. HIV-1 and CMV seroconversion has been reported in patients receiving skin from seropositive donors. CJD has been transmitted by dura and pericardium transplants. Over the past several years, improvements in donor screening criteria, such as excluding potential donors with infection and those with behaviors risky for HIV-1 and hepatitis infection, and introduction of new donor blood tests have greatly reduced the risk of HIV-1 and hepatitis and may have nearly eliminated the risk of tuberculosis and CJD. Prior to use, many tissues are exposed to antibiotics, disinfectants, and sterilants, which further reduce or remove the risk of transmitted disease. Because organs, cells, and some tissue grafts cannot be subjected to sterilization steps, the risk of infectious disease transmission remains and thorough donor screening and testing is especially important.

Can the standard treatment of acute spinal cord injury be improved? Perhaps the time has come

OBJECTIVES

To present additional surgical maneuvers that might lead to improved results in the treatment of acute spinal cord injuries (SCI).

METHODS

Techniques are presented that allow the dura mater to be widely opened over a traumatized spinal cord, thus limiting the opportunity for extrusion of edematous spinal cord material. Additionally, placement of an intact omental pedicle over a traumatized SCI allows absorption of spinal cord edematous fluid.

RESULTS

Widely opening the dura mater and placing an intact omental pedicle over an SCI site results in a dynamic equilibrium between the production of spinal cord injury edema fluid and its absorption by the omentum. This absorption of edema fluid allows for the associated absorption of fibrinogen. A decreased fibrinogen level lessens its activation to fibrin, thus resulting in the decreased production of scar tissue which is readily observed in patients with a chronic SCI.

CONCLUSION

A proposal is presented that may have the potential to improve the neurological results following the surgical treatment of an acute SCI.

Coding and traceability for cells, tissues and organs for transplantation

Modern transplantation of cells, tissues and organs has been practiced within the last century achieving both life saving and enhancing results. Associated risks have been recognized including infectious disease transmission, malignancy, immune mediated disease and graft failure. This has resulted in establishment of government regulation, professional standard setting and establishment of vigilance and surveillance systems for early detection and prevention and to improve patient safety. The increased transportation of grafts across national boundaries has made traceability difficult and sometimes impossible. Experience during the first Gulf War with mis-identification of blood units coming from multiple countries without standardized coding and labeling has led international organizations to develop standardized nomenclature and coding for blood. Following this example, cell therapy and tissue transplant practitioners have also moved to standardization of coding systems. Establishment of an international coding system has progressed rapidly and implementation for blood has demonstrated multiple advantages. WHO has held two global consultations on human cells and tissues for transplantation, which recognized the global circulation of cells and tissues and growing commercialization and the need for means of coding to identify tissues and cells used in transplantation, are essential for full traceability. There is currently a wide diversity in the identification and coding of tissue and cell products. For tissues, with a few exceptions, product terminology has not been standardized even at the national level. Progress has been made in blood and cell therapies with a slow and steady trend towards implementation of the international code ISBT 128. Across all fields, there are now 3,700 licensed facilities in 66 countries. Efforts are necessary to encourage the introduction of a standardized international coding system for donation identification numbers, such as ISBT 128, for all donated biologic products.

Logistical aspects of human surgical tissue management in a hospital setting

Many hospital transfusion services have assumed responsibility for the coordinated management of human allograft tissue. This overview summarizes logistical aspects of tissue management based on the experience of a centralized tissue service at a large academic hospital, in which tissue is stored in a location remote from patient care areas. Operational aspects include determination of which personnel classifications will perform the necessary functions, establishment and maintenance of the standing tissue inventory (including pros and cons of alternative approaches to inventory acquisition), and necessary considerations for making tissue available for surgical cases in the hospital. The nature of communications regarding tissue orders for individual surgical cases is discussed, as well as mechanisms for storage of tissue and transportation and delivery of tissue to the surgical suites. Finally, options for the disposition of tissue that has been dispensed from the tissue service but was not used during the surgical procedure are summarized. With attention to these details, a tissue service can provide reliable, high-quality tissue in a timely fashion.

Managing a tissue recall in a large academic hospital

BACKGROUND

In October 2005, a recall of human tissue for implantation was initiated because one recovery center obtained tissues from donors who were not screened properly for infectious diseases. The Food and Drug Administration (FDA) and Centers for Disease Control (CDC) recommended notifying affected patients and offering access to infectious disease testing.

STUDY DESIGN AND METHODS

A multidisciplinary team was established to provide a framework for responding to the recall. The plan was designed to meet six goals. Steps included patient identification, surgeon and patient notification, patient education and testing, communication of test results, and information for the public.

RESULTS

The institution received 55 recalled tissues, of which 48 had been implanted into 30 patients undergoing neurosurgical, orthopedic, and general surgical procedures. Patients were identified and sent notification letters within 2 weeks of the FDA and CDC recommendations. Twenty-seven patients underwent testing, which was performed at the convenience of the patients at no cost to them. One patient had evidence of previous (but not current) hepatitis B infection. Overall, patients were appreciative of the processes used. Media coverage was positive.

CONCLUSION

The response plan was generally successful in achieving the established goals. Potential improvements were identified in several areas, including initial patient notification and coordination of test result communication. It is critical to allow flexibility to meet each patient's needs. The plan may serve as a template for use in future tissue recalls by other hospital-based tissue banks.

Einfluss europäischer Regulativa auf Qualität, Sicherheit und Verfügbarkeit allogener Zell- und Gewebetransplantate in Deutschland

The transplantation of allogenic tissue (bone, cartilage, tendon, skin, amnion and special preparations such as demineralised bone matrix and acellular dermis) is an important component of the treatment of bone and soft tissue defects, particularly in traumatology and orthopaedic, reconstructive and plastic surgery. In Germany, the requirement for such tissue transplants is met by supply from local tissue banks (in particular bone banks) and a small number of regional and national tissue banks. These banks operate on the basis of the "Guidelines for Bone Banks" laid down by the German Chamber of Physicians, and of the German Drug Law (AMG). The 2004/23/EG guidelines issued by the European Parliament and ratified on 31/3/2004 define the quality and safety standards for the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells. These guidelines will have a major impact on all aspects of tissue banking and transplantation. In particular, the new guidelines will remove the possibility for local tissue banks to operate outside of national drug laws ( section sign 4 a [4]). The currently in draft law on "Quality and Safety of Human Tissues and Cells" ("Tissue Law") of the Federal Health Ministry seems to be heading in this direction, but it also includes possibilities for the continuation of local banks. An additional European guideline draft "Proposal for the regulation of advanced therapeutic medical products" is currently under discussion. This paper assesses the impact of these new pieces of legislation on the quality, safety and availability of human cell and tissue transplants in terms of the current situation and future prospects in Germany.

Face Transplantation: A Review of the Technical, Immunological, Psychological and Clinical Issues with Recommendations for Good Practice

Three years ago, the Working Party on Facial Transplantation concluded that until there was more information available about risks any potential patient would be exposed to, it would be unwise to proceed with transplantation of the human face. Over the last three years, there has been a deepening understanding of the potential psychological problems of facial transplantation as well as a very considerable debate on the ethical aspects of the procedure. Further data on experimental work in animal models of facial transplantation as well as medium-term follow-up data from 24 hand and forearm transplants in 18 patients has now become available. Furthermore, a partial facial transplantation has been performed in France and a second one in China. In this second edition of the report, the technical, immunological, psychological, and ethical issues are discussed again in the light of this developing knowledge. In particular, there has been a major expansion of the sections on the psychological and societal issues, as well as the ethical and legal problems of facial transplantation. The working party still has considerable reservations about facial transplantation. Although it accepts that on balance the risks cannot be precisely quantified, they remain substantial. Therefore, if patients are allowed to make an informed choice to proceed, they must be very carefully selected and protected in the process, along with the families of both the donors and the recipients. To achieve this, the working party insists that 15 minimum requirements, described at the end of this report, must be fulfilled before it would be appropriate for a research ethics committee/institutional review board to approve of a proposal to undertake facial transplantation.

CHALLENGES IN THE EVALUATION OF SAFETY AND EFFICACY OF HUMAN TISSUE AND CELL BASED PRODUCTS

Human tissue and cell-based therapeutic interventions provide efficacious alternative treatment where traditional drugs or medical devices have proved unsatisfactory. Yet human tissue and cell-based products (HTC/P) still present a series of challenges regarding their safety and efficacy. By reviewing the history of development and current regulatory standards and observing activities related to the manufacture of HTC/P, we have described the common characteristics of HTC/P, including the risk of pathogen transmission, transportation methods of human tissues, quality control in HTC/P manufacturing, and the concern of ancillary materials. The ethical issues of cadaveric donation and clinical trial standards for HTC/P have also been discussed. Overall, we have provided a general standard, which articulates the essential requirements on the safety and efficacy of HTC/P.

Review: Tissue Engineering of the Urinary Bladder: Considering Structure-Function Relationships and the Role of Mechanotransduction

A variety of conditions encountered in urology result in bladder dysfunction and the need for bioengineered tissue substitutes. Traditionally, a number of synthetic materials and natural matrices have been used in experimental and clinical settings. However, the production of functional bladder tissue replacements remains elusive. The urinary bladder sustains considerable structural deformation during its normal function and represents an ideal model tissue in which to study the effects of biomechanical simulation on tissue morphogenesis, differentiation, and function. However, the actual role of mechanical forces within the bladder has received little attention. A strategy in which in vitro-generated tissue constructs are conditioned by exposure to the same mechanical forces as they would encounter in vivo could potentially be used both in the development of functional tissue replacements and to further study the role of biomechanical signalling. The purpose of this review is to examine the role and structure-function relationship of the urinary bladder and, through consultation of the literature available on mechanotransduction and tissue engineering of alternative tissues, to determine the factors that need to be considered when biomechanically engineering a functional bladder.

Transmission of hepatitis C virus to several organ and tissue recipients from an antibody-negative donor

BACKGROUND

Although hepatitis C virus (HCV) transmission through tissue transplantation has been rarely reported, a donor with undetected viremia may infect several recipients. A patient developed acute hepatitis C shortly after tissue transplantation. Ninety-one tissues or organs had been recovered from the donor.

OBJECTIVE

To determine whether the donor was the source of infection and the extent of transmission to other organ and tissue recipients.

DESIGN

Descriptive epidemiologic study; serum testing for HCV infection.

SETTING

Recipients were located in 16 states and 2 other countries.

PARTICIPANTS

Donor and graft recipients.

MEASUREMENTS

Hepatitis C virus infection was defined as the presence of anti-HCV or HCV RNA. The authors determined the genetic relatedness of viral isolates from the donor and recipients by genotype comparison and quasi-species analysis.

RESULTS

The donor was anti-HCV-negative but was HCV RNA-positive (genotype 1a). Forty persons received transplants during 22 months. Five persons were HCV-infected before transplantation or had a genotype other than 1a, and 5 persons had no post-transplantation serum specimens available. Of the remaining 30 recipients, HCV infection occurred in 8 recipients: 3 of 3 organ recipients, 1 of 2 saphenous vein recipients, 1 of 3 tendon recipients, and 3 of 3 tendon with bone recipients. These 8 recipients had viral isolates genetically related to those of the donor. No cases occurred in recipients of skin (n = 2), cornea (n = 1), or irradiated bone (n = 16).

LIMITATIONS

Post-transplantation serum specimens were unavailable for 5 recipients.

CONCLUSIONS

An anti-HCV-negative donor was the source of HCV infection for 8 recipients of organs or tissues. Although HCV transmission from anti-HCV-negative donors is probably uncommon, changes in donor screening to include routine testing for HCV RNA merit further consideration to improve the safety of transplantation.

Safety and FDA regulations for musculoskeletal allografts: perspective of an orthopaedic surgeon

The Musculoskeletal Transplant Foundation Symposium held in September 2003, in Edinburgh, Scotland provided the opportunity for an orthopaedic surgeon experienced in tissue banking and musculoskeletal allograft transplantation to summarize to orthopaedic colleagues the past and current efforts made by the Food and Drug Administration to ensure the safety of allograft tissues, aspects of tissue banking, concerns of allograft safety and future Food and Drug Administration proposals. The review allows an orthopaedic surgeon an understanding of allograft safety issues and provides information for better informed consent to be obtained by the orthopaedic surgeon from the recipient patient.

2003 report of the intestine transplant registry: a new era has dawned

SUMMARY BACKGROUND DATA

The intestine has been more difficult to transplant than other solid organs. We analyzed registry data to determine the scope and success of intestine transplantation in the current era.

METHODS

All known intestinal-transplant programs participated. Patient- and graft-survival estimates were obtained using the Kaplan-Meier product limit method and were analyzed with the Wilcoxon statistic.

RESULTS

Sixty-one programs provided data on 989 grafts in 923 patients. Four patients were lost to follow-up. The short-gut syndrome was the most common primary indication for transplantation. Sixty-one percent of the recipients were < or =18 years. Proportionally more combined intestinal and liver transplants were performed in this group. More than 80% of all current survivors had stopped parenteral nutrition and resumed normal daily activities. A multivariate analysis of cases within the last 5 years revealed that transplantation of patients waiting at home, recipient age, antibody induction immune suppression, and center experience with at least 10 cases were associated with improved patient survival. One-year graft survival rates of 81% were achieved in patients who were induced with antithymocyte globulin and maintained on tacrolimus.

CONCLUSIONS

Transplantation is an effective therapy for the treatment of patients with end-stage intestine failure who cannot tolerate parenteral nutrition. With newer immune suppressive protocols, 1-year graft and patient survival rates approach the results of liver transplantation. Further improvement in survival are expected with early referral since suitable donor organs are scarce and survival rates are better when patients are well enough to wait at home for their transplant.

The latest developments in surgical hair restoration

Surgical hair restoration has evolved rapidly over the past 10 years. Patient outcome is paramount. Current developments in hair transplantation focus on using the most appropriate harvesting techniques to use this finite resource effectively and to relocate it quickly and efficiently to achieve the optimum effective aesthetic coverage. To date,follicular unit transplantation has afforded surgeons the greatest efficiency in hair trans-plantation. These units are unlikely to become smaller, so surgeons must look at what other means are available to improve the final result.

The influence of HLA genotyping compatibility on clinical outcome after cord blood transplantation from unrelated donors

We performed retrospective DNA typing of class I (A, B, Cw) and class II (DRB1, DQB1, DPB1) HLA alleles in 27 unrelated cord blood transplantation (CBT) cases donated from a single cord blood bank (Kanagawa Cord Blood Bank). The influence of HLA genotype matching on clinical outcome was evaluated. From Cox's model, we found that incompatibility of two or more HLA alleles between the donor and recipient of an unrelated CBT was suggested to be a risk factor for a worse event-free survival (EFS) (p = 0.04; RR, 4.06; 95% CI, 1.06-15.61). Furthermore, mismatches including HLA-DRB1 alleles had an adverse effect on EFS (p = 0.04; RR, 4.91; 95% CI, 1.01-24.02). For definite conclusions on the role of HLA allele typing in unrelated CBT, more accumulation of data and analysis will be required.

Ex vivo expansion of megakaryocytic cells

The use of platelet transfusion to ensure the recovery of thrombopoiesis in patients constitutes high-cost support. The identification and cloning of recombinant human thrombopoietin (TPO) and the development of efficient methods of purification of hematopoietic stem cells and progenitor cells have ameliorated the development of strategies of ex vivo expansion of megakaryocyte (MK) progenitor cells and mature MKs. Synergistic combinations of cytokines including TPO, interleukin (IL)-1, IL-3, IL-11, stem cell factor, and FLT-3 ligand induce the ex vivo expansion of colony-forming unit-MK progenitors and MKs from cytokine-mobilized peripheral blood cells, bone marrow, and cord blood CD34+ cells. Depending on the various culture conditions, i.e., combinations of growth factors, initial concentration of CD34+, serum or serum-free cultures, and/or oxygen tensions, the expansion-fold of MKs and their progenitor cells vary greatly. The clinical applications of the reinfusion of ex vivo-generated MK cells have been investigated successfully in cancer patients following high-dose chemotherapy. This review reports the latest information concerning ex vivo expansion of MKs and the current status of clinical trials.

Evaluation of the long-term function of cryopreserved ovarian grafts in the mouse, implications for human applications

Ovarian tissue storage has several potentially very valuable clinical applications, including the management of young female patients that are at risk of premature menopause. Ovarian tissue collection, used alone or in combination with oocyte and embryo cryopreservation, may help these patients safeguard their own future fertility. All available evidence from animal studies indicates that grafting of frozen ovarian tissue should be feasible in the human. This study on the mouse shows that frozen thawed ovarian tissue grafts can restore long term fertility to previously ovariectomised recipients. This, and other available evidence, indicates that ovarian tissue collection and storage, used alone or in combination with oocyte or embryo collection, may help safeguard the fertility of patients at risk of premature menopause.

Musculoskeletal tissue banking in Europe--regulations and quality assurance

This paper is confined to the use of human musculoskeletal tissue in the treatment of patients. Its focus is on the safety and quality dimension of human tissue transplantation, including the ethical and legal aspects, the regulations and standards from the European perspective, quality assurance and quality management in tissue banking and as a special subject, tissue sterilisation and the validation of sterilisation methods.

The current state of bone and tissue banking in Australia

The development of bone and tissue banking in Australia over the last decade is described and details of the administrative structure, donor and recipient testing protocols, allograft segment processing procedures, and internal audit safety arrangements are also provided. Demographic data concerning both the retrieval and dispersal of musculoskeletal allograft materials in Australia are also discussed. Current price schedules for a variety of allograft materials available in Australia are made available for international comparison.

Practical issues in tissue banking

Medical and hospital facilities, including hospital blood banks, may be involved in various aspects of tissue banking. A key issue in running a successful tissue bank is understanding the scope of activity performed. The steps involved in collection, processing, storage, and distribution are reviewed, and potentially applicable rules and regulations and practical issues of tissue banking are discussed. In addition, "industry" standards that focus on storage and distribution of tissue for transplantation are summarized.

Safeguarding human tissue transplants

Transplants of human tissues, such as cornea and bone, can be modern miracles. But they can also transmit disease such as HIV and hepatitis. FDA has tightened controls of transplanted human tissue to minimize risks, and is considering additional action.

Guidelines for preventing transmission of human immunodeficiency virus through transplantation of human tissue and organs. Centers for Disease Control and Prevention

Although previous recommendations for preventing transmission of human immunodeficiency virus (HIV) through transplantation of human tissue and organs have markedly reduced the risk for this type of transmission, a case of HIV transmission from a screened, antibody-negative donor to several recipients raised questions about the need for additional federal oversight of transplantation of organs and tissues. A working group formed by the Public Health Service (PHS) in 1991 to address these issues concluded that further recommendations should be made to reduce the already low risk of HIV transmission by transplantation of organs and tissues. In revising these recommendations, the PHS sought assistance from public and private health professionals and representatives of transplant, public health, and other organizations. The revised guidelines address issues such as donor screening, testing, and exclusionary criteria; quarantine of tissue from living donors; inactivation or elimination of infectious organisms in organs and tissues before transplantation; timely detection, reporting, and tracking of potentially infected tissues, organs, and recipients; and recall of stored tissues from donors found after donation to have been infected. Factors considered in the development of these guidelines include differences between the screening of living and cadaveric donors; time constraints due to organ/tissue viability that may preclude performing certain screening procedures; differences in the risk of HIV transmission from various organs and tissues; differences between systems for procuring and distributing organs and tissues; the effect of screening practices on the limited availability of organs and some tissues; and the benefit of the transplant to the recipient.

Tissue transplantation. Quality assurance in the banking and utilization of musculoskeletal allografts

Tissue allografts are being used more frequently, and, as a consequence, an increasing number of hospitals and physician assistants must face the difficult and perplexing task of evaluating their effectiveness and safety. Quality assurance programs are designed to enhance patient care during the transplantation process and should outline the responsibilities of both the tissue bank and the hospital using the allograft. Recommendations for the establishment of quality assurance programs at hospitals are made based on guidelines established by national certifying agencies. It is of paramount importance to recognize the areas of responsibility and to delineate acceptable standards of practice when developing and implementing quality assurance programs for tissue transplantation.

Tissue transplantation. The PA's role in donation and recovery

The use of musculoskeletal and soft-tissue allografts for reconstructive procedures has become routine. The demand has doubled over the past several years, and will surely continue to rise. However, the availability of allografts has not kept pace with this demand. Physician assistants, by virtue of their position on specialty teams and their commitment to community service, can play a leading role in increasing the availability of allografts through the identification, evaluation, and referral of appropriate donor candidates to local recovery agencies.

Studies try to sidetrack abortion politics with focus on "pre-embryo"

The politics of abortion has completely halted NIH studies on in vitro fertilization and experiments involving transplants of human fetal tissue. The following articles describe some efforts on the part of medical organizations and religious thinkers to break this political barrier.