Pediatric Liver Transplant Center Volume and the Likelihood of Transplantation.

BACKGROUND: Low case volume has been associated with poorer surgical outcomes in a multitude of surgical procedures. We studied the association among low case volume, outcomes, and the likelihood of pediatric liver transplantation. METHODS: We studied a cohort of 6628 candidates listed in the Organ Procurement and Transplantation Network for primary pediatric liver transplantation between 2002 and 2012; 4532 of the candidates went on to transplantation. Candidates were divided into groups according to the average volume of yearly transplants performed in the listing center over 10 years: >15, 10 to 15, 5 to 9, and <5. We used univariate and multivariate Cox regression analyses with bootstrapping on transplant recipient data and identified independent recipient and donor risk factors for wait-list and posttransplant mortality. RESULTS: 38.5% of the candidates were listed in low-volume centers, those in which <5 transplants were performed annually. These candidates had severely reduced likelihood of transplantation with only 41% receiving a transplant. For the remaining candidates, listed at higher volume centers, the transplant rate was 85% (P < .001). Being listed at a low-volume center was a significant risk factor in multivariate Cox regression analysis for both wait-list mortality (hazard ratio, 3.27; confidence interval, 2.53-4.23) and posttransplant mortality (hazard ratio, 2.21; confidence interval, 1.43-3.40). CONCLUSIONS: 38.5% of pediatric transplant candidates are listed in low-volume transplant centers and have lower likelihood of transplantation and poorer outcomes. If further studies substantiated these findings, we would advocate consolidating pediatric liver transplantation in higher volume centers.

Contemporary outcomes of open thoracoabdominal aortic aneurysm repair in octogenarians.

OBJECTIVES: We sought to evaluate our contemporary outcomes with open thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians to determine whether open TAAA repair is a viable option, with acceptable risk, in this elderly cohort. METHODS: We analyzed clinical data from 1267 enrolled patients who underwent open TAAA repair between 2003 and 2013. Eighty-eight patients (7%) were octogenarians (median age, 82 years; range, 80-92 years) and 1179 were 79 years of age or less. RESULTS: Aneurysm rupture was more common in octogenarians (14% vs 4.7%, P = .001), whereas aortic dissections predominated in younger patients (43.9% vs 13%, P < .001). Octogenarians had higher rates of visceral-branch endarterectomy/stenting (58% vs 33.5%, P < .001), adverse postoperative outcomes (36% vs 15.3%, P < .001), operative mortality (26% vs 6.9%, P < .001), and prolonged hospital stay (P = .004). Among octogenarians, preoperative aortic dissection was most commonly associated with extent I repair (42% vs <10% for other extents, P < .001). Extent II repairs most frequently necessitated concomitant visceral-branch procedures and carried the highest risk of mortality (62%). Extent I and III repairs carried intermediate operative risk, and extent IV repairs posed the least risk (11%). Multivariate modeling analysis identified extent II TAAA (P = .001; odds ratio, 11.6), presence of concomitant dissection (P = .02; odds ratio, 5.6), and aneurysm rupture (P = .02; odds ratio, 5.7) as independent predictors of operative mortality in octogenarians. CONCLUSIONS: Open extent II TAAA repair carries significant risk for octogenarians; extent I, III, and IV repairs incur more reasonable postoperative risk. Although TAAA repair should not be denied to octogenarians based solely on age, extensive TAAA repair should be performed with caution.

Physical and social environmental characteristics of physical activity for Mexican-origin children: examining differences between school year and summer perceptions.

BACKGROUND: Colonias are substandard residential areas along the U.S.-Mexico border. Families of Mexican-origin living in colonias face health burdens characterized by environmental and socioeconomic hardships. Mexican Americans and low-income families, including colonias children, do not frequently participate in physical activity despite the known link to disease risk reduction. For colonias children, schools are the most commonly reported location for physical activity. School closures and extreme temperatures during summer months create a need to explore seasonal differences in environmental supports and barriers in this population. The purpose of this study was to examine the effect of seasonality on perceived environmental barriers, opportunities, and social support for physical activity among colonias children. As a secondary aim, mother-child discordance for each factor was analyzed. METHODS: Promotora-researchers recruited mother-child dyads (n=101 dyads, n=202 participants) from colonias in Hidalgo County, Texas. Mothers and children were separately administered surveys at two time points to capture perceived barriers, opportunities, and social support for physical activity (school-year: February-May; summertime: July-August). Summative scores for each outcome were calculated and three multilevel longitudinal models for continuous outcomes were examined; children were nested within households. Mother-child discordance was measured using Cohen's Kappa statistic. RESULTS: Physical activity barriers and environmental opportunities (household and neighborhood) increased from school-year to summer by 1.16 and 2.83 points respectively (p≤0.01), after adjusting for covariates. Significant predictors of increased barriers included household income of >$900/month and having more household members. Children of mothers with significant others who were employed part-time or full-time saw significant decreases in barriers. Mother-child agreement of barriers, environmental opportunities, and social support across seasons was slight to fair (range: median κ=0.047 to κ=0.262). CONCLUSIONS: These results suggest a complex relationship between dimensions of economic hardship (employment status, household income, etc…) and perceived opportunities and barriers of children's physical activity engagement during the school-year and summer. In this study, both barriers and opportunities increased from school-year to summer, further demonstrating that interactions among these characteristics need to be better understood and addressed when considering physical activity initiatives for colonias and other Mexican-American children, specifically during summer when school-based physical activity resources are unavailable.

Outcomes of open distal aortic aneurysm repair in patients with chronic DeBakey type I dissection.

OBJECTIVES: In patients with acute DeBakey type I dissection, endovascular repair of the descending thoracic aorta during proximal aortic repair is an increasingly popular approach to preventing distal aortic sequelae and subsequent repair. To better define the risks and outcomes associated with these secondary operations, we examined our contemporary experience with open distal aortic repair in patients with chronic type I aortic dissection. METHODS: Data were collected between January 2005 and June 2013 regarding 198 consecutive open descending thoracic (n = 27) or thoracoabdominal (n = 171) aortic repairs performed in patients with chronic type I dissection. The median interval between the dissection onset and the subsequent distal operation was 5.0 years (interquartile range, 2.4-10.5 years). A total of 110 repairs (56%) were performed in patients with genetic disorders. RESULTS: There were 14 early deaths (7%). Permanent paraplegia developed in 2 patients (1%), 5 patients (3%) had permanent stroke, and 9 patients (5%) had permanent renal failure. Factors associated with early death included greater age (P = .01), chronic obstructive pulmonary disease (P = .01), clamping proximal to the left subclavian artery (P = .004), and use of hypothermic circulatory arrest (P = .002). The use of cold renal perfusion (P < .001) was associated with early survival. Early death was not associated with genetic disorders, emergency surgery, or extent of aortic repair. There were 36 late deaths, yielding an actuarial 8-year survival of 65.6% ± 5.9%. At 7 years, freedom from repair failure was 95.7% ± 1.7%, and freedom from subsequent repair for disease progression was 84.8% ± 4.6%. CONCLUSIONS: In survivors of DeBakey type I aortic dissection with distal aneurysm, open repair of the descending thoracic or thoracoabdominal aorta can be performed with excellent early survival, acceptable morbidity, and relatively few late aortic events.

Child hunger and the protective effects of Supplemental Nutrition Assistance Program (SNAP) and alternative food sources among Mexican-origin families in Texas border colonias.

BACKGROUND: Nutritional health is essential for children's growth and development. Many Mexican-origin children who reside in limited-resource colonias along the Texas-Mexico border are at increased risk for poor nutrition as a result of household food insecurity. However, little is known about the prevalence of child hunger or its associated factors among children of Mexican immigrants. This study determines the prevalence of child hunger and identifies protective and risk factors associated with it in two Texas border areas. METHODS: This study uses 2009 Colonia Household and Community Food Resource Assessment (C-HCFRA) data from 470 mothers who were randomly recruited by promotora-researchers. Participants from colonias near two small towns in two South Texas counties participated in an in-home community and household assessment. Interviewer-administered surveys collected data in Spanish on sociodemographics, federal food assistance program participation, and food security status. Frequencies and bivariate correlations were examined while a random-effects logistic regression model with backward elimination was used to determine correlates of childhood hunger. RESULTS: Hunger among children was reported in 51% (n = 239) of households in this C-HCFRA sample. Bivariate analyses revealed that hunger status was associated with select maternal characteristics, such as lower educational attainment and Mexican nativity, and household characteristics, including household composition, reliance on friend or neighbor for transportation, food purchase at dollar stores and from neighbors, and participation in school-based nutrition programs. A smaller percentage of households with child hunger participated in school-based nutrition programs (51%) or used alternative food sources, while 131 households were unable to give their child or children a balanced meal during the school year and 145 households during summer months. In the random effects model (RE = small town), increased household composition, full-time unemployment, and participation in the National School Lunch Program were significantly associated with increased odds for child hunger, while participation in Supplemental Nutrition Assistance Program (SNAP) and purchasing food from a neighbor were significantly associated with decreased odds for child hunger. CONCLUSIONS: This study not only emphasizes the alarming rates of child hunger among this sample of Mexican-origin families, but also identifies economic and family factors that increased the odds for child hunger as well as community strategies that reduced the odds. It is unsettling that so many children did not participate in school-based nutrition programs, and that many who participated in federal nutrition assistance programs remained hungry. This study underscores the importance of identifying the presence of child hunger among low-income Mexican-origin children in Texas border colonias and increasing access to nutrition-related resources. Hunger-associated health inequities at younger ages among colonia residents are likely to persist across the life span and into old age.

School-based nutrition programs are associated with reduced child food insecurity over time among Mexican-origin mother-child dyads in Texas Border Colonias.

In 2011, an estimated 50.2 million adults and children lived in US households with food insecurity, a condition associated with adverse health effects across the life span. Relying solely on parent proxy may underreport the true prevalence of child food insecurity. The present study sought to understand mothers' and children's (aged 6-11 y) perspectives and experiences of child food insecurity and its seasonal volatility, including the effects of school-based and summertime nutrition programs. Forty-eight Mexican-origin mother-child dyads completed standardized, Spanish-language food-security instruments during 2 in-home visits between July 2010 and March 2011. Multilevel longitudinal logistic regression measured change in food security while accounting for correlation in repeated measurements by using a nested structure. Cohen's κ statistic assessed dyadic discordance in child food insecurity. School-based nutrition programs reduced the odds of child food insecurity by 74% [OR = 0.26 (P < 0.01)], showcasing the programs' impact on the condition. Single head of household was associated with increased odds of child food insecurity [OR = 4.63 (P = 0.03)]. Fair dyadic agreement of child food insecurity was observed [κ = 0.21 (P = 0.02)]. Obtaining accurate prevalence rates and understanding differences of intrahousehold food insecurity necessitate measurement at multiple occasions throughout the year while considering children's perceptions and experiences of food insecurity in addition to parental reports.

Children's reporting of food insecurity in predominately food insecure households in Texas border colonias.

BACKGROUND: Food insecurity is associated with detrimental physical, psychological, behavioral, social, and educational functioning in children and adults. Greater than one-quarter of all Hispanic households in the U.S. are food insecure. Hispanic families in the U.S. comprise 30% of households with food insecurity at the child level, the most severe form of the condition. METHODS: Food security discordance was evaluated among 50 Mexican-origin children ages 6-11 and their mothers living in Texas border colonias from March to June 2010. Mothers and children were interviewed separately using promotora-researcher administered Spanish versions of the Household Food Security Survey Module and the Food Security Survey Module for Youth. Cohen's kappa statistic (κ) was used to analyze dyadic agreement of food security constructs and level of food security. RESULTS: Eighty percent of mothers reported household food insecurity while 64% of children identified food insecurity at the child level. There was slight inter-rater agreement in food security status (κ = 0.13, p = 0.15). Poor agreement was observed on the child hunger construct (κ = -0.06, p = 0.66) with fair agreement in children not eating for a full day (κ = 0.26, p < 0.01) and relying on low-cost foods (κ = 0.23, p = 0.05). CONCLUSIONS: Mother and child-reported household and child-level food insecurity among this sample of limited-resource Mexican-origin colonias residents far surpass national estimates. While the level of dyadic agreement was poor, discordance may be attributable to parental buffering, social desirability in responses, and/or the age of children included in the present analysis. Future research should continue to explore how food security is understood from the perspectives and experiences of children and adolescents.

Convenience stores are the key food environment influence on nutrients available from household food supplies in Texas Border Colonias.

BACKGROUND: Few studies have focused on the relationship between the retail food environment and household food supplies. This study examines spatial access to retail food stores, food shopping habits, and nutrients available in household food supplies among 50 Mexican-origin families residing in Texas border colonias. METHODS: The design was cross-sectional; data were collected in the home March to June 2010 by promotora-researchers. Ground-truthed methods enumerated traditional (supercenters, supermarkets, grocery stores), convenience (convenience stores and food marts), and non-traditional (dollar stores, discount stores) retail food stores. Spatial access was computed using the network distance from each participant's residence to each food store. Data included survey data and two household food inventories (HFI) of the presence and amount of food items in the home. The Spanish language interviewer-administered survey included demographics, transportation access, food purchasing, food and nutrition assistance program participation, and the 18-item Core Food Security Module. Nutrition Data Systems for Research (NDS-R) was used to calculate HFI nutrients. Adult equivalent adjustment constants (AE), based on age and gender calorie needs, were calculated based on the age- and gender composition of each household and used to adjust HFI nutrients for household composition. Data were analyzed using bivariate analysis and linear regression models to determine the association of independent variables with the availability of each AE-adjusted nutrient. RESULTS: Regression models showed that households in which the child independently purchased food from a convenience store at least once a week had foods and beverages with increased amounts of total energy, total fat, and saturated fat. A greater distance to the nearest convenience store was associated with reduced amounts of total energy, vitamin D, total sugar, added sugar, total fat, and saturated fat. Participation in the National School Lunch Program (NSLP) was associated with lower household levels of total energy, calcium, vitamin C, sodium, vitamin D, and saturated fat. Spatial access and utilization of supermarkets and dollar stores were not associated with nutrient availability. CONCLUSIONS: Although household members frequently purchased food items from supermarkets or dollar stores, it was spatial access to and frequent utilization of convenience food stores that influenced the amount of nutrients present in Texas border colonia households. These findings also suggest that households which participate in NSLP have reduced AE-adjusted nutrients available in the home. The next step will target changes within convenience stores to improve in-store marketing of foods and beverages to children and adults.