Organ Offer Review Cards: Improving Transparency on the Kidney Transplant Waitlist.

INTRODUCTION: The 2022 National Academy of Sciences, Engineering, and Medicine report on equity in organ transplantation highlighted limited transparency and accountability for organ offer declines and recommended prioritizing patient engagement in decisions regarding organ offers. Yet, there is no guidance on how to incorporate patients in organ offers. We elected to study the experiences of patients on the waitlist and their perception of a novel Organ Offer Review Card (OORC). METHODS: A prototype OORC was created using Donornet refusal codes. Sixty randomly selected kidney waitlist patients at a single center were asked to participate in a web-based survey focusing on current medical decision-making preferences and perceptions of the prototype OORC. RESULTS: Among the 43 patients reached, 17 (39.5%) completed the survey. Most participants (88.2%) expressed it was important to be involved in the decision-making about organ offers, with 100.0% of respondents wanting to know why an organ was declined. Regarding the prototype OORC, 94.1% thought it helped them understand the factors and priorities considered when selecting an organ, and 88.2% said it increased their belief that their team was acting in their best interest. CONCLUSION: An OORC could increase transparency and communication during the waitlist process while enhancing trust in the transplant team.

Successful living donor liver transplantation in a patient with hemophilia A and factor VIII inhibitor: A case report with perioperative recommendations.

Liver transplantation in patients with end-stage liver disease and coexisting hemophilia A has been described. Controversy exists over perioperative management of patients with factor VIII inhibitor predisposing patients to hemorrhage. We describe the case of a 58-year-old man with a history of hemophilia A and factor VIII inhibitor, eradicated with rituximab prior to living donor liver transplantation without recurrence of inhibitor. We also provide perioperative management recommendations from our successful multidisciplinary approach.

"I Came up Short on the Academic Ladder": A Grounded Theory Study of Careerism in Academic Surgery.

OBJECTIVE: This study aims to explore the definition of career success in academic surgery. BACKGROUND: Career success in academic surgery is frequently defined as the achievement of a specific title, from full professor to department chair. This type of definition is convenient and established but potentially incomplete. The business literature has a more nuanced view of the relationship between titles and success, but this relationship has not been studied in medicine. METHODS: Semi-structured interviews were conducted from May to November 2020. Data were analyzed in an iterative fashion using grounded theory methodology to develop a conceptual model. RESULTS: We conducted 26 semi-structured interviews with practicing surgeons differing in years of experience; 12 (46%) participants were female, mean age of 48. Participants included 5 chairs of surgery, 6 division chiefs, and 7 past or current presidents of national societies. Four themes emerged on the importance of titles: Some study participants reported that (1) titles are a barometer of success; others argued that (2) titles are not a sufficient metric to define success; (3) titles are a means to an end; and (4) there is a desire to achieve the title of a respected mentor. CONCLUSIONS: As the definition of career success in academic surgery changes to encompass a broader range of interests and ambitions, the traditional markers of success must come into review. Academic surgeons see the value of titles as a marker of success and as a means to achieving other goals, but overwhelmingly our interviewees felt that titles were a double-edged sword and that a more inclusive definition of academic success was needed.

Short-term impact of PM2.5 on contemporaneous asthma medication use: Behavior and the value of pollution reductions.

Asthma ranks among the most costly of chronic diseases, accounting for over $50 billion annually in direct medical expenditures in the United States. At the same time, evidence has accumulated that fine particulate matter pollution can exacerbate asthma symptoms and generate substantial economic costs. To measure these costs, we use a unique nationwide panel dataset tracking asthmatic individuals' use of rescue medication and their exposure to PM2.5 (particulate matter with an aerodynamic diameter of <2.5 µm) concentration between 2012 and 2017, to estimate the causal relationship between pollution and inhaler use. Our sample consists of individuals using an asthma digital health platform, which relies on a wireless sensor to track the place and time of inhaler use events, as well as regular nonevent location and time indicators. These data provide an accurate measurement of inhaler use and allow spatially and temporally resolute assignment of pollution exposure. Using a high-frequency research design and individual fixed effects, we find that a 1 µg/m3 (12%) increase in weekly exposure to PM2.5 increases weekly inhaler use by 0.82%. We also show that there is seasonal, regional, and income-based heterogeneity in this response. Using our response prediction, and an estimate from the literature on the willingness to pay to avoid asthma symptoms, we show that a nationwide 1 µg/m3 reduction in particulate matter concentration would generate nearly $350 million annually in economic benefits.

Assessing asthma control: comparison of electronic-recorded short-acting beta-agonist rescue use and self-reported use utilizing the asthma control test.

Background: Question 4 (Q4) of the Asthma Control Test (ACT) asks patients to report their SABA use over the prior 4 weeks, a criterion for evaluating the impairment domain of asthma control. Biases in recall may lead to a misclassification of asthma control and has implications for asthma control determination and management strategies.Objective: To correlate objective electronic-recorded short-acting beta-agonist (SABA) use with self-reported use via Q4 of the ACT.Methods: Patients ≥18 years of age with a self-reported diagnosis of asthma were enrolled in a digital health electronic medication monitoring (EMM) platform, which recorded the date and time of SABA actuations and prompted the completion of the ACT. The correlations between ACT Q4 responses and EMM-recorded SABA use were evaluated using Spearman's rank correlation coefficients.Results: 1,062 patients (mean age: 35.4 years, mean ACT: 16.3) were included in analyses. Higher Q4 scores, indicating lower SABA use, were moderately and negatively correlated with EMM-recorded SABA use (ρ = -0.59 [95% CI: -0.63, -0.54]). Thirty-five percent of patients underreported SABA use when comparing Q4 to EMM-recorded SABA use.Conclusions: While ACT Q4 and EMM-recorded use were moderately correlated, underreported SABA use on the ACT highlights the need for objective measures of SABA use in asthma control assessments. The use of EMM-recorded SABA data has the potential for clinicians to more accurately determine asthma control, guide changes to controller therapy, and estimate imminent exacerbation risk.

Variable Benefits of Antibody Induction by Kidney Allograft Type.

BACKGROUND: Kidneys from acute renal failure (ARF), expanded criteria donors (ECD), and donation after cardiac death (DCD) donors are often discarded due to concerns for delayed graft function (DGF) and graft failure. Induction immunosuppression may be used to minimize these risks, but practices vary widely. Furthermore, little is known regarding national outcomes of transplant recipients receiving induction immunosuppression for receipt of high-risk kidneys. MATERIALS AND METHODS: Using a center-level retrospective study, deceased donor transplants (115,485) from the Scientific Registry of Transplant Recipients from January 2003 to June 2016 were evaluated. Patients who received induction immunosuppression, including lymphocyte immune globulin, muromonab CD-3, IL-1 receptor antagonist, anti-thymocyte globulin, daclizumab, basiliximab, alemtuzumab, and rituximab, were included. Associations of center-level induction use with acute rejection in the first post-transplant year, graft failure, and patient mortality were evaluated using multivariable Cox and logistic regression. RESULTS: Among all kidneys, increasing percentage of center-level induction was associated with lower risk of graft failure, acute rejection, and patient mortality. In recipients of ARF kidneys, the beneficial association of induction on graft failure and acute rejection was greater than in those that received non-ARF kidneys. Marginally greater benefit of induction was seen for acute rejection in ECD compared to standard criteria donor (SCD) recipients and for graft failure in DCD compared to donors after brain death (DBD). No benefit of induction was detected for patient and graft survival in ECD recipients, acute rejection in DCD recipients, and patient survival in DGF recipients. No difference in the benefit of induction was detected in any other comparisons. CONCLUSIONS: While seemingly beneficial for recipients of all kidneys, induction has more robust associations with lower graft failure and acute rejection probability for recipients of ARF kidneys. Given the lack of observed benefit for ECD recipients, induction policies should be carefully considered in these patients.

Risk of peritoneal dialysis catheter-associated peritonitis following kidney transplant.

OBJECTIVE: Peritoneal dialysis (PD) patients have equivalent or slightly better kidney transplant outcomes when compared to hemodialysis (HD) patients. However, given the risk for postoperative infection, we sought to determine the risk factors for PD catheter-associated infections for patients who do not have the PD catheter removed at the time of engraftment. METHODS: Demographic and outcomes data were collected from 313 sequential PD patients who underwent kidney transplant from 2000 to 2015. Risk factors for postoperative peritonitis were analyzed using logistical regression. RESULTS: Of 329 patients with PD catheters at transplant, 16 PD catheters were removed at engraftment. Of the remaining 313 patients, 8.9% suffered post-transplant peritonitis. On univariate analysis, patients with peritonitis were significantly more likely to have used the PD catheter or HD within 6 weeks after transplant. Multivariate analysis had similar findings, with increased risk for those using the PD catheter after transplant, with a trend for those who underwent HD only within 6 weeks of transplant. CONCLUSION: These results suggest that delayed graft function requiring any type of dialysis is associated with increased post-transplant peritonitis risk.

Bile duct injury and morbidity following cholecystectomy: a need for improvement.

BACKGROUND: Bile duct injury (BDI) remains the most dreaded complication following cholecystectomy with serious repercussions for the surgeon, patient and entire healthcare system. In the absence of registries, the true incidence of BDI in the United States remains unknown. We aim to identify the incidence of BDI requiring operative intervention and overall complications after cholecystectomy. METHODS: Utilizing the Truven Marketscan® research database, 554,806 patients who underwent cholecystectomy in calendar years 2011-2014 were identified using ICD-9 procedure and diagnosis codes. The final study population consisted of 319,184 patients with at least 1 year of continuous enrollment and who met inclusion criteria. Patients were tracked for BDI and other complications. Hospital cost information was obtained from 2015 Premier data. RESULTS: Of the 319,184 patients who were included in the study, there were a total of 741 (0.23%) BDI identified requiring operative intervention. The majority of injuries were identified at the time of the index procedure (n = 533, 72.9%), with 102 (13.8%) identified within 30-days of surgery and the remainder (n = 106, 14.3%) between 31 and 365 days. The operative cumulative complication rate within 30 days of surgery was 9.84%. The most common complications occurring at the index procedure were intestinal disorders (1.2%), infectious (1%), and shock (0.8%). The most common complications identified within 30-days of surgery included infection (1.5%), intestinal disorders (0.7%) and systemic inflammatory response syndrome (SIRS) (0.7%) for cumulative rates of infection, intestinal disorders, shock, and SIRS of 2.0, 1.9, 1.0, and 0.8%, respectively. CONCLUSION: BDI rate requiring operative intervention have plateaued and remains at 0.23% despite increased experience with laparoscopy. Moreover, cholecystectomy is associated with a 9.84% 30-day morbidity rate. A clear opportunity is identified to improve the quality and safety of this operation. Continued attention to educational programs and techniques aimed at reducing patient harm and improving surgeon skill are imperative.

Childhood Asthma Disparities in Chicago: Developing Approaches to Health Inequities.

We conducted a needs assessment to develop an evidence-based, locally tailored asthma care implementation plan for high-risk children with asthma in Chicago. Our team of health policy experts, clinicians, researchers, and designers included extensive stakeholder engagement (N = 162) in a mixed-methods community needs assessment. Results showed the lines of communication and collaboration across sectors were weak; caregivers were the only consistent force and could not always manage this burden. A series of recommendations for interventions and how to implement and measure them were generated. Cooperative, multidisciplinary efforts grounded in the community can target wicked problems such as asthma.

Effect of a mobile health, sensor-driven asthma management platform on asthma control.

BACKGROUND: Asthma inflicts a significant health and economic burden in the United States. Self-management approaches to monitoring and treatment can be burdensome for patients. OBJECTIVE: To assess the effect of a digital health management program on asthma outcomes. METHODS: Residents of Louisville, Kentucky, with asthma were enrolled in a single-arm pilot study. Participants received electronic inhaler sensors that tracked the time, frequency, and location of short-acting ß-agonist (SABA) use. After a 30-day baseline period during which reference medication use was recorded by the sensors, participants received access to a digital health intervention designed to enhance self-management. Changes in outcomes, including mean daily SABA use, symptom-free days, and asthma control status, were compared among the initial 30-day baseline period and all subsequent months of the intervention using mixed-model logistic regressions and χ2 tests. RESULTS: The mean number of SABA events per participant per day was 0.44 during the control period and 0.27 after the first month of the intervention, a 39% reduction. The percentage of symptom-free days was 77% during the baseline period and 86% after the first month, a 12% improvement. Improvement was observed throughout the study; each intervention month demonstrated significantly lower SABA use and higher symptom-free days than the baseline month (P < .001). Sixty-nine percent had well-controlled asthma during the baseline period, 67% during the first month of the intervention. Each intervention month demonstrated significantly higher percentages than the baseline month (P < .001), except for month 1 (P = .80). CONCLUSION: A digital health asthma management intervention demonstrated significant reductions in SABA use, increased number of symptom-free days, and improvements in asthma control. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02162576.

Homeostasis alteration within small intestinal mucosa after acute enteral refeeding in total parenteral nutrition mouse model.

Feeding strategies to care for patients who transition from enteral nutrient deprivation while on total parenteral nutrition (TPN) to enteral feedings generally proceed to full enteral nutrition once the gastrointestinal tract recovers; however, an increasing body of literature suggests that a subgroup of patients may actually develop an increased incidence of adverse events, including death. To examine this further, we studied the effects of acute refeeding in a mouse model of TPN. Interestingly, refeeding led to some beneficial effects, including prevention in the decline in intestinal epithelial cell (IEC) proliferation. However, refeeding led to a significant increase in mucosal expression of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), as well as an upregulation in Toll-like receptor 4 (TLR-4). Refeeding also failed to prevent TPN-associated increases in IEC apoptosis, loss of epithelial barrier function, and failure of the leucine-rich repeat-containing G protein-coupled receptor 5-positive stem cell expression. Transitioning from TPN to enteral feedings led to a partial restoration of the small bowel microbial population. In conclusion, while acute refeeding led to some restoration of normal gastrointestinal physiology, enteral refeeding led to a significant increase in mucosal inflammatory markers and may suggest alternative strategies to enteral refeeding should be considered.

Small Bowel Diameter in Short Bowel Syndrome as a Predictive Factor for Achieving Enteral Autonomy.

Children with short bowel syndrome commonly have dilated small bowel. We found that the extent of dilation was associated with bowel length and that both were related to achieving enteral autonomy.

Species discovery and validation in a cryptic radiation of endangered primates: coalescent-based species delimitation in Madagascar's mouse lemurs.

Implementation of the coalescent model in a Bayesian framework is an emerging strength in genetically based species delimitation studies. By providing an objective measure of species diagnosis, these methods represent a quantitative enhancement to the analysis of multilocus data, and complement more traditional methods based on phenotypic and ecological characteristics. Recognized as two species 20 years ago, mouse lemurs (genus Microcebus) now comprise more than 20 species, largely diagnosed from mtDNA sequence data. With each new species description, enthusiasm has been tempered with scientific scepticism. Here, we present a statistically justified and unbiased Bayesian approach towards mouse lemur species delimitation. We perform validation tests using multilocus sequence data and two methodologies: (i) reverse-jump Markov chain Monte Carlo sampling to assess the likelihood of different models defined a priori by a guide tree, and (ii) a Bayes factor delimitation test that compares different species-tree models without a guide tree. We assess the sensitivity of these methods using randomized individual assignments, which has been used in bpp studies, but not with Bayes factor delimitation tests. Our results validate previously diagnosed taxa, as well as new species hypotheses, resulting in support for three new mouse lemur species. As the challenge of multiple researchers using differing criteria to describe diversity is not unique to Microcebus, the methods used here have significant potential for clarifying diversity in other taxonomic groups. We echo previous studies in advocating that multiple lines of evidence, including use of the coalescent model, should be trusted to delimit new species.

Intestine, immunity, and parenteral nutrition in an era of preferred enteral feeding.

PURPOSE OF REVIEW: To review the benefits of enteral nutrition in contrast to the inflammatory consequences of administration of parenteral nutrition and enteral deprivation. To present the most recent evidence for the mechanisms of these immunologic changes and discuss potential areas for modification to decrease infectious complications of its administration. RECENT FINDINGS: There is significant data supporting the early initiation of enteral nutrition in both medical and surgical patients unable to meet their caloric goals via oral intake alone. Despite the preference for enteral nutrition, some patients are unable to utilize their gut for nutritious gain and therefore require parenteral nutrition administration, along with its infectious complications. The mechanisms behind these complications are multifactorial and have yet to be fully elucidated. Recent study utilizing both animal and human models has provided further information regarding parenteral nutrition's deleterious effect on intestinal epithelial barrier function along with the complications associated with enterocyte deprivation. SUMMARY: Changes associated with parenteral nutrition administration and enteral deprivation are complex with multiple potential areas for modification to allow for safer administration. Recent discovery of the mechanisms behind these changes present exciting areas for future study as to make parenteral nutrition administration in the enterally deprived patient safer.

Reducing Health Care Resource Utilization in COPD: A Retrospective Matched Control Analysis of a Digital Quality Improvement Program.

Introduction: COPD is a progressive lung disease that adds significant economic burden to the healthcare system in the United States. Digital platforms integrated into clinical workflows have demonstrated success in improving patient outcomes in COPD, but few studies have explored the impact of an integrated digital and clinical approach on drivers of direct healthcare costs (COPD-related prescriptions, emergency department (ED) visits and hospitalizations) in a real-world setting. Methods: We conducted a six-month retrospective matched control analysis to assess the impact of a digital quality improvement (QI) program delivered by clinical pharmacists on healthcare resource utilization among people living with COPD. Results: Compared to matched controls at six months, participants in the digital QI program had a nearly two-third relative reduction in COPD-related ED visits and hospitalizations (p=0.044), as well as a 47% reduction in all-cause ED visits and hospitalizations (p=0.059). Participants in the digital QI program also had higher rates of COPD-related prescription fills for antibiotics and oral corticosteroids, as well as a greater number of non-acute care visits compared to matched controls. Conclusion: Digital health platforms integrated into a virtual clinical pharmacist workflow can help reduce costly COPD-related emergency department visits and hospitalizations. Care models integrating digital platforms may also offer a scalable approach to managing COPD and should be explored in different clinical settings.

Health effects of air pollution on respiratory symptoms: A longitudinal study using digital health sensors.

Previous studies of air pollution and respiratory disease often relied on aggregated or lagged acute respiratory disease outcome measures, such as emergency department (ED) visits or hospitalizations, which may lack temporal and spatial resolution. This study investigated the association between daily air pollution exposure and respiratory symptoms among participants with asthma and chronic obstructive pulmonary disease (COPD), using a unique dataset passively collected by digital sensors monitoring inhaled medication use. The aggregated dataset comprised 456,779 short-acting beta-agonist (SABA) puffs across 3,386 people with asthma or COPD, between 2012 and 2019, across the state of California. Each rescue use was assigned space-time air pollution values of nitrogen dioxide (NO2), fine particulate matter with diameter ≤ 2.5 µm (PM2.5) and ozone (O3), derived from highly spatially resolved air pollution surfaces generated for the state of California. Statistical analyses were conducted using linear mixed models and random forest machine learning. Results indicate that daily air pollution exposure is positively associated with an increase in daily SABA use, for individual pollutants and simultaneous exposure to multiple pollutants. The advanced linear mixed model found that a 10-ppb increase in NO2, a 10 µg m-3 increase in PM2.5, and a 30-ppb increase in O3 were respectively associated with incidence rate ratios of SABA use of 1.025 (95 % CI: 1.013-1.038), 1.054 (95 % CI: 1.041-1.068), and 1.161 (95 % CI: 1.127-1.233), equivalent to a respective 2.5 %, 5.4 % and 16 % increase in SABA puffs over the mean. The random forest machine learning approach showed similar results. This study highlights the potential of digital health sensors to provide valuable insights into the daily health impacts of environmental exposures, offering a novel approach to epidemiological research that goes beyond residential address. Further investigation is warranted to explore potential causal relationships and to inform public health strategies for respiratory disease management.