Trajectories of positive affect in autistic individuals during the transition to adulthood.

LAY ABSTRACT: Recent research has revealed informative patterns about health, mental health, self-help skills, autism symptoms, and social skills during the transition to adulthood for autistic individuals. This study expands on these findings by examining how positive affect (e.g. excited) changes from age 15 to 30 years using a group of individuals first referred for autism at an early age. We also examined the agreement between caregiver-report and self-report on positive affect. We found different patterns of stability and change in positive affect across the transition to adulthood that related to differences in autism severity, cognitive abilities, self-help skills, as well as social and work participation in adulthood. The agreement between caregiver-report and self-report was strong in adolescence but became much weaker after the individuals were 23 years. These results have implications for how we measure happiness, positive emotions, or other internal experiences of autistic individuals.

Toward a functional classification for autism in adulthood.

Autism spectrum disorder (ASD) is a heterogeneous condition that affects development and functioning from infancy through adulthood. Efforts to parse the heterogeneity of the autism spectrum through subgroups such as Asperger's and Profound Autism have been controversial, and have consistently struggled with issues of reliability, validity, and interpretability. Nonetheless, methods for successfully identifying clinically meaningful subgroups within autism are needed to ensure that research, interventions, and services address the range of needs experienced by autistic individuals. The purpose of this study was to generate and test whether a simple set of questions, organized in a flowchart, could be used in clinical practice and research to differentiate meaningful subgroups based on individuals' level of functioning. Once generated, subgroups could also be compared to the recently proposed administrative category of Profound Autism and to groupings based on standardized adaptive measures. Ninety-seven adults with autism or related neurodevelopmental disorders participating in a longstanding longitudinal study, or their caregivers if they could not answer for themselves, completed phone interviews when the participants were ~30 years old. Information from these phone interviews was used to generate vignettes summarizing characteristics and aspects of the daily lives of each participant (e.g., language level, vocational activities, and social relationships). Three expert clinicians then used these vignettes to classify each participant based on their level of support needs. Meaningfully distinct subgroups within the sample were identified which could be reliably distinguished from one another. Implications of such categorizations and future directions are discussed.

Corrigendum: Understanding profound autism: implications for stigma and supports.

[This corrects the article DOI: 10.3389/fpsyt.2024.1287096.].

Development of Restricted and Repetitive Behaviors from 2-19: Stability and Change in Repetitive Sensorimotor, Insistence on Sameness, and Verbal Behaviors in a Longitudinal Study of Autism.

This study examined trajectories of repetitive sensorimotor (RSM), insistence on sameness (IS), and verbal RRBs from ages 2-19 in a well-characterized longitudinal cohort. We also tested the factor structure of the ADI-R restricted and repetitive behavior (RRB) domain at age 19 and the inclusion of a verbal RRBs factor, in addition to previously identified RSM and IS factors, at ages 9 and 19. The ADI-R was administered to 193 participants at five timepoints from 2 to 19. Confirmatory factor analysis (CFA) was used to examine the factor structure of ADI-R RRB data. Change in RRB subtypes was examined using group-based trajectory modeling and multilevel modeling. RSM and IS behaviors generally decreased from 2 to 19, with some participants experiencing increases from ages 2-9. 46.46% of participants experienced increasing verbal RRBs from 2 to 9, followed by a plateau from 9 to 19. The remaining participants had few to no verbal RRBs throughout development. Multilevel modeling indicated ADOS CSS scores were associated with change in RSM trajectories only. Child IQ was not associated with change in any RRB trajectories. CFA indicated previously-derived RSM and IS factors fit age 19 ADI-R data well. The inclusion of a third factor, verbal RRBs, worsened goodness-of-fit statistics and was ultimately omitted. Our findings suggest the RRB factor structure of the ADI remains consistent into early adulthood and illustrate developmental continuity and change in RRBs. For autistic individuals with fluent speech, RRB presentation may be influenced by verbal ability in ways that are highly variable, but clinically meaningful.

Online compassion-based self-help for depression in people with skin conditions: a feasibility study.

BACKGROUND: There is a need to develop psychological interventions for depression in people with skin conditions. This study aimed to investigate the acceptability, feasibility, and effects of an online compassion-based self-help intervention for depression in people with skin conditions. METHODS: Adult participants (n = 34) with skin conditions and mild-moderate depressive symptoms were invited to undertake a six-week, compassion-based online intervention for depression with email support. Engagement with the intervention was monitored, along with time spent facilitating the intervention, and participant feedback was collected each week and post-intervention. Pre-post changes in depression, self-compassion and dermatological quality of life were also assessed. RESULTS: The intervention was started by 25 participants and completed by 13. Feedback scores indicated that the website was evaluated positively and that the sessions had positive impacts on participants. Participants appreciated the skin-specific aspects of the intervention but varied as to which of the compassion-based exercises they found helpful. The online intervention was feasible to provide and facilitate, and treatment completers showed improvements in depression, quality of life and self-compassion. CONCLUSIONS: The online compassion-based intervention holds promise as a treatment for depression in people with skin conditions. Recommendations are made for future research and further development of the intervention. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov on 21 October 2019, NCT04132973.

Understanding profound autism: implications for stigma and supports.

Introduction: Societal perceptions and lack of understanding of autism spectrum disorder can be stigmatizing for autistic individuals and their families. This may be particularly the case for individuals who meet criteria for profound autism. Despite the considerable service needs of this marginalized group, there is little data on the prevalence of profound autism, nor on the experiences of those with profound autism and their families. Methods: The current study leveraged a mixed-methods approach to address these gaps. First, the prevalence of profound autism was examined in six samples-three from the United States and three from Western Europe. Second, inductive thematic analysis was used to code interviews from 20 caregivers of profoundly autistic adults. Results: The prevalence of profound autism varied widely across the six samples-from 11% to 48%. There were also notable differences between samples in prevalence by gender, race, and ethnicity. Two overarching themes were identified via inductive thematic analysis: Community Perceptions of Autism and Family Support Needs and Advocacy Challenges. Though caregivers were not directly asked about stigmatization during interviews, 85% of caregivers reported at least one instance of perceived stigma. Discussion: Future research should continue to examine the unique needs and stigmatization experiences of profoundly autistic individuals and their families across the life course.

A Longitudinal Mixed-Methods Characterization of Family Support from Adolescence to Young Adulthood in Autism and Other Developmental Disabilities.

Although caregiving responsibilities and need for support persist and evolve across the life course in families with autistic youth or youth with other developmental disabilities (DDs), little is known about support during their child's adulthood years. Therefore, the present study used a mixed-methods approach to examine change and stability in formal and informal family support across the transition to adulthood. Caregivers of 126 individuals with autism or DDs completed a modified version of the Family Support Scale, including open-ended questions, at five time points from adolescence (age 16) into young adulthood (age 22). Caregivers reported that informal support from family members was the most frequently used, helpful, and valued source of support with relative stability across time. In contrast, the reported helpfulness, use, and value of formal support (e.g., professionals, schools) for caregivers declined over time. Qualitative content analyses revealed characteristics of highly valued support included support type (e.g., instrumental or emotional) and features of the support source (e.g., their understanding). There was a shift to valuing emotional support more than instrumental support over time, especially for caregivers of less able adults. Partnership and dependability emerged as highly valued features of the support source. These findings fit within a social convoy perspective and likely reflect the "service cliff" experienced by autistic individuals or people with DDs and their families. As social networks shrink over time and formal services are less readily available in adulthood, remaining sources of support, particularly from family members, become increasingly important.

Social competence as a predictor of adult outcomes in autism spectrum disorder.

There is a wealth of literature characterizing social difficulties in autism spectrum disorder (ASD). However, little work has replicated longitudinal findings from typical development that adolescent social competence predicts positive adult outcomes in ASD. The current study examined social competence trajectories from 2 to 26 and the utility of three social competence measures collected in adolescence in predicting work, residential status, friendship, and romantic outcomes in a longitudinal cohort (n = 253) of ASD. Using group-based trajectory modeling, we identified two patterns of social competence development: a low trajectory characterized by slow linear gains throughout childhood and plateauing in adulthood, and a high trajectory characterized by steeper linear gains in childhood followed by decline in adulthood. Regression models indicated one social competence measure, Vineland Social-AE scores, significantly predicted employment, residential status, and friendships in adulthood. One other social competence measure, SSQ total scores, also significantly predicted friendship in adulthood. Only nonverbal IQ at 9 predicted the likelihood of having ever had a romantic relationship. These findings highlight the role of social competence in both atypical and typical development and suggest the social impairments associated with ASD do not necessarily impact all realms of social functioning equally.

How does self-compassion help people adjust to chronic skin conditions? A template analysis study.

Objectives: Skin conditions can greatly impact people's lives, but greater understanding of the processes involved in positive adjustment is required. Self-compassion has strong links to wellbeing and adaptive functioning and therefore may play an important role in adjustment to skin conditions. Design: Template analysis was used to explore how self-compassion operates in people living with skin conditions, with reference to existing theories of self-compassion. Methods: Semi-structured interviews were conducted with highly self-compassionate people with chronic skin conditions (N = 10). Theoretical models of self-compassion were used in the development of the initial template and interview schedule. Participants were purposively selected on the basis of having high scores on a measure of self-compassion. Results: Participants reported a variety of ongoing skin-related difficulties and their ways of managing these. Sensitivity to distress and care for wellbeing were identified as foundation themes: necessary components of a compassionate response to distress. Eleven types of difficulty-management strategies built upon these foundation themes: empathy, non-judgement, distress tolerance, self-kindness, mindful attention, perspective-taking, self-talk, self-care, using social support, concealment, and idiosyncratic coping strategies. Conclusions: Components of self-compassion helped people adjust to chronic skin conditions in a wide variety of ways, indicating that psychological adjustment is not a simple, linear process. Sometimes compassionate responses occurred automatically and sometimes with deliberate effort. Further research on compassion-based interventions for people with skin conditions is warranted.

Adherence to behaviours associated with the test, trace, and isolate system: an analysis using the theoretical domains framework.

BACKGROUND: The UK's test, trace, and isolate system are key measures to reduce the impact and spread of COVID-19. However, engagement with and adherence to guidance on testing, self-isolation, and providing details of contacts can be low and interventions are needed. This qualitative study aimed to identify the key factors affecting adherence to test, trace, and isolate behaviours using the Theoretical Domains Framework (TDF). METHODS: We conducted six online focus groups between October 2020 and February 2021 with people living in Sheffield who came into close contact with others in work or social settings (N = 30). The focus groups explored capability, opportunity, and motivational barriers to adherence to test, trace, and isolate behaviours. Framework analysis was used to code the data into TDF domains. RESULTS: There is a complex relationship between the factors affecting COVID-19 symptom identification, testing, and self-isolation. People who perceived significant barriers to testing and self-isolation were less likely to interpret potential symptoms as COVID-19, and perceiving barriers to self-isolation reduced the likelihood of requesting a test. Concerns about the negative consequences of self-isolation for themselves and others were common and also influenced willingness to pass on details of contacts. There was a lack of trust in the Test and Trace system, with people wanting further evidence of being at risk of infection. CONCLUSIONS: Communications and interventions to increase adherence to test, trace, and isolate strategies need to consider the interplay of these behaviours and their influences and target them collectively. Efforts to promote testing should focus on the range of barriers to self-isolation, especially increasing financial and practical support, and include new messaging to promote symptom identification.

Work and well-being: Vocational activity trajectories in young adults with autism spectrum disorder.

Young adults with autism spectrum disorder (ASD) experience limited social connectedness, difficulty living independently, and other poor outcomes at high rates. Vocational activities, including employment and postsecondary education, are associated with increased positive outcomes and subjective well-being in typical adults. This study identified vocational activity trajectory groups in adults with ASD, examined change in these trajectories from ages 18 to 28, and compared levels of parent- and self-report subjective well-being across trajectory groups. One hundred fifty-one adults with ASD were drawn from an ongoing longitudinal study. Data on psychosocial outcomes and vocational activities were compiled from parent-report demographic forms. Vocational activities were scored using the vocational index (VDI). There was no significant effect of age on the slope of vocational trajectories (p = 0.787). Participants in the Independent Activities group had significantly higher parent-report happiness factor scores than participants in the No Activities group (F [3, 107] = 3.56, p = 0.017) and significantly higher self-report happiness factor scores than participants in the Volunteer Activities group (F [2, 35] = 6.46, p = 0.004). The Independent Activities group was also significantly more likely to have at least one social contact (X2 [3, 118] = 10.54, p = 0.014), however, there was no difference in trajectories groups in the likelihood of living independently (X2 [3, 120] = 1.71, p = 0.634). The results of this study indicate vocational activities in young adults with ASD are stable across time. In the current sample, participation in independent vocational activities was associated with increased levels of subjective well-being.

An opportunistic evaluation of a routine service improvement project to reduce falls in hospital.

BACKGROUND: Preventing falls in hospital is a perennial patient safety issue. The University Hospital Coventry and Warwickshire initiated a programme to train ward staff in accordance with guidelines. The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West Midlands was asked to expedite an independent evaluation of the initiative. We set out to describe the intervention to implement the guidelines and to evaluate it by means of a step-wedge cluster study using routinely collected data. METHODS: The evaluation was set up as a partially randomised, step-wedge cluster study, but roll-out across wards was more rapid than planned. The study was therefore analysed as a time-series. Primary outcome was rate of falls per 1000 Occupied Bed Days (OBDs) collected monthly using routine data. Data was analysed using a mixed-effects Poisson regression model, with a fixed effect for intervention, time and post-intervention time. We allowed for random variations across clusters in initial fall rate, pre-intervention slope and post-intervention slope. RESULTS: There was an average of 6.62 falls per 1000 OBDs in the control phase, decreasing to an average of 5.89 falls per 1000 OBDs in the period after implementation to the study end. Regression models showed no significant step change in fall rates (IRR: 1.02, 95% CI: 0.92-1.14). However, there was a gradual decrease, of approximately 3%, after the intervention was introduced (IRR: 0.97 per month, 95% CI: 0.95-0.99). CONCLUSION: The intervention was associated with a small but statistically significantly improvement in falls rates. Expedited roll-out of an intervention may vitiate a step-wedge cluster design, but the intervention can still be studied using a time-series analysis. Assuming that there is some value in time series analyses, this is better than no evaluation at all. However, care is needed in making causal inferences given the non-experimental nature of the design.

Post-High School Daily Living Skills in Autism Spectrum Disorder.

OBJECTIVE: Daily living skills (DLS) are a predictor of positive outcomes in youths with autism spectrum disorder (ASD), yet little is known about trajectories of DLS in adults with ASD. This study investigated the impact of high school exit on participants' trajectories of daily living skills age equivalent (DLS-AE) scores from ages 2 to 26 and the relationship between DLS-AE trajectories and employment and education outcomes. METHOD: Participants were 98 adults with ASD drawn from an ongoing longitudinal study. The Vineland Adaptive Behavior Scales were administered 8 times from ages 2 to 26. Employment and education data were compiled from parent report demographic forms. RESULTS: DLS-AE trajectories modestly increased with age before exiting school, at which point DLS-AE trajectories plateaued, then declined. A significant (p < .01) decrease occurred in the slope of DLS-AE trajectories following school exit. High DLS-AE scores predicted participation in postsecondary education (χ25 [n = 73] = 27.83, p < .001). Autism symptom severity predicted participation in employment (χ25 [n = 58] = 27.54, p < .001). CONCLUSION: These findings provide evidence that DLS decline in adults with ASD, specifically after school exit, and highlight the importance of DLS in normative adult outcomes. Future work should examine the trajectories of DLS in middle and later adulthood and consider intervention targets for bolstering DLS following school exit.

Depression in people with skin conditions: The effects of disgust and self-compassion.

Objectives Skin conditions can be accompanied by significant levels of depression; there is therefore a need to identify the associated psychological factors to assist with the development of appropriate interventions. This study sought to examine the effects of disgust propensity, disgust sensitivity, self-focused/ruminative disgust, and self-compassion on depression in people with skin conditions. Design A cross-sectional survey with follow-up survey. Methods Dermatology outpatients (N = 147) completed self-report measures of disgust traits, self-compassion, and depression. At three-month follow-up, participants (N = 80) completed the depression measure again. Results Multiple regression analyses revealed that disgust propensity, disgust sensitivity, self-focused/ruminative disgust, and self-compassion each explained significant amounts of variance in baseline depression. Self-compassion also explained a significant amount of variance in depression at follow-up, after accounting for baseline depression. In addition, self-compassion moderated the effect of disgust propensity on depression at baseline, such that at high levels of self-compassion, disgust propensity no longer had a positive relationship with depression. Conclusions Disgust traits contribute to depression in people with skin conditions, while being self-compassionate may be protective against depression. High self-compassion also buffers the effects of disgust propensity on depression in people with skin conditions. The findings indicate the potential of compassion-focused interventions for depression in people with skin conditions. Statement of contribution What is already known on this subject? People with skin conditions can experience depression that is not well explained by condition severity. Skin conditions can elicit disgust reactions that, in turn, may contribute to the development of depression. Self-compassion is negatively associated with depression. What does this study add? Disgust traits explain significant variance in depression in people with skin conditions. Self-compassion may protect against depression through main and moderation effects. Disgust and self-compassion may provide important targets for interventions.

Autism Heterogeneity in a Densely Sampled U.S. Population: Results From the First 1,000 Participants in the RI-CART Study.

The objective of this study was to establish a large, densely sampled, U.S. population-based cohort of people with autism spectrum disorder (ASD). The Rhode Island Consortium for Autism Research and Treatment (RI-CART) represents a unique public-private-academic collaboration involving all major points of service for families in Rhode Island affected by ASD. Diagnosis was based on direct behavioral observation via the Autism Diagnostic Observation Schedule, Second Edition. For the first 1,000 participants, ages ranged from 21 months to 64 years. Using Geographic Information System and published prevalence rates, the overall cohort is estimated to represent between 20% and 49% of pediatric age persons in Rhode Island with ASD, with demographics representative of U.S. Census. We observed a high rate of co-occurring medical and psychiatric conditions in affected individuals. Among the most prominent findings of immediate clinical importance, we found that females received a first diagnosis of ASD at a later age than males, potentially due to more advanced language abilities in females with ASD. In summary, this is the first analysis of a large, population-based U.S. cohort with ASD. Given the depth of sampling, the RI-CART study reflects an important new resource for studying ASD in a representative U.S. population. Psychiatric and medical comorbidities in ASD constitute a substantial burden and warrant adequate attention as part of overall treatment. Our study also suggests that new strategies for earlier diagnosis of ASD in females may be warranted. Autism Res 2020, 13: 474-488. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The Rhode Island Consortium for Autism Research and Treatment (RI-CART) represents a unique public-private-academic collaboration involving all major points of service for families in Rhode Island affected by autism spectrum disorder (ASD). In this article, we provide results from the first 1,000 participants, estimated to represent >20% of affected families in the state. Importantly, we find a later age at first diagnosis of ASD in females, which potentially calls attention to the need for improved early diagnosis in girls. Also, we report a high rate of co-occurring medical and psychiatric conditions in affected individuals.

Molecular dynamics study of CO2 hydrate dissociation: Fluctuation-dissipation and non-equilibrium analysis.

Equilibrium and non-equilibrium molecular dynamics (MD) simulations have been performed to investigate thermal-driven break-up of planar CO2 hydrate interfaces in liquid water at 300-320 K. Different guest compositions, at 85%, 95%, and 100% of maximum theoretical occupation, led to statistically-significant differences in the observed initial dissociation rates. The melting temperatures of each interface were estimated, and dissociation rates were observed to be strongly dependent on temperature, with higher dissociation rates at larger over-temperatures vis-à-vis melting. A simple coupled mass and heat transfer model developed previously was applied to fit the observed dissociation profiles, and this helps to identify clearly two distinct régimes of break-up; a second well-defined region is essentially independent of composition and temperature, in which the remaining nanoscale, de facto two-dimensional system's lattice framework is intrinsically unstable. From equilibrium MD of the two-phase systems at their melting point, the relaxation times of the auto-correlation functions of fluctuations in number of enclathrated guest molecules were used as a basis for comparison of the variation in the underlying, non-equilibrium, thermal-driven dissociation rates via Onsager's hypothesis, and statistically significant differences were found, confirming the value of a fluctuation-dissipation approach in this case.

Inference and sentence comprehension in children with specific or pragmatic language impairments.

BACKGROUND: Children with language impairments have difficulty in reporting verbal inferences, but it is unclear whether the source of this problem lies in limitations of language comprehension, an inability to access world knowledge, or the integration of information in discourse. Children with pragmatic language impairments (CwPLI) are often described as having disproportionate difficulty with verbal inference, although there is little empirical support for this view. AIMS: To examine the performance of children with specific language impairment (CwSLI), CwPLI and a control group with typical language development (CwTLD) on a verbal inferential comprehension task; to explore whether CwPLI's verbal inferential comprehension performance are disproportionate to their sentence comprehension difficulties; and to analyse inferential error types made by the three groups. METHODS & PROCEDURES: Sixty-four children with language impairments (CwLI), aged between 6 and 11 years, participated in an inference comprehension task (IC) and a task of sentence comprehension (SC). For the purpose of analysis, the LI group was then split into two subgroups: CwPLI and CwSLI, using a checklist of pragmatic features. A group of CwTLD were matched to LI children on SC ability and gender; a separate group of CwTLD (CA) was matched to CwLI by age and gender. OUTCOMES & RESULTS: CwLI had lower raw scores on the IC task than CA-matched CwTLD, but similar scores to SC-matched CwTLD. CwPLI produced lower raw IC scores than CwSLI, and this was the same when age and SC performance were controlled for. CwSLI performed similarly to their SC-matched and CA-matched control subjects on the IC task. CwPLI scored significantly less on the IC task than both their SC-matched and CA-matched control subjects. A regression analysis showed that age and SC ability account for 36% of the variance on the IC task, but group (SLI versus PLI) status accounts for just 5%. A detailed analysis of error types and item performance on the IC task showed a trend for CwPLI to perform more poorly on developmentally more complex inference items, but there was no evidence for a unique pattern of inference errors in CwPLI. CONCLUSIONS & IMPLICATIONS: Children with language impairments tend to perform like younger children with matched level of sentence comprehension ability on a verbal inference comprehension task. CwPLI have more difficulty with this task than CwSLI, but the distribution of scores shows considerable overlap exists between clinical groups. Sentence comprehension ability, age and, to a lesser extent, group status contribute to verbal inferencing ability in children with language impairments, but other factors may be important. The implications for assessment and intervention are discussed.

Mismatch negativity and frequency representational width in children with specific language impairment.

The aim of this study was to compare the degree of frequency separation that is required between tones to generate mismatch negativity (MMN) in a group of children with specific language impairment (SLI) and a comparison group, who had their temporal processing abilities assessed in a previous experiment. Using a 1000Hz standard (85%) and 1020, 1050, and 1100Hz deviant tones presented at inter-stimulus intervals (ISIs) of 200 and 400ms, MMN was compared in 19 children with SLI (13 males, six females, age range 7y 4mo-11y 10mo, mean age 9y 7mo [SD 1y 2mo]), and 19 comparison children (13 males, six females, age range 7y 3mo-11y 4mo, mean age 9y 5mo [SD 1y 3mo]). Temporal processing ability was assessed by the Auditory Fusion Test-Revised. Children with SLI who had poor temporal processing abilities generated a positive mismatch response (P-MMR) for 2% tone contrasts at 400ms ISI but MMN with larger contrasts. These children also generated stronger MMN than the comparison group at 200ms ISI for 2% contrasts. Children with SLI who had good temporal processing abilities generated only P-MMR in response to contrasts up to 10% for both ISIs. Some children with SLI show an inverse relationship between frequency discrimination and temporal processing. Furthermore, certain stimulus-related and biological criteria may need to be met for P-MMR to switch to MMN.

A novel scheme for graft allocation in non-heart beating donor renal transplantation.

Patients waiting more than 3 years for a renal transplant were ranked according to our novel Bristol and Region Allocation by Non-heart beating Donor Score (BRANDS). One kidney from 40 non-heart beating donors was allocated to the highest BRANDS long-waiter and the other kidney allocated according to the UK National Allocation Scheme (NAS). The scheme reduced the number of patients waiting more than 3 years by 20%. Despite longer dialysis time, greater sensitization and more human leukocyte antigen mismatches, BRANDS patients had equivalent 3-year graft survival (BRANDS 91%, NAS 97%, P=0.264) and patient survival (BRANDS 94%, NAS 92%, P=0.99). Results were similar to 242 synchronous recipients from heart-beating donors. Renal function was significantly lower in BRANDS recipients (40 vs. 62 mL/min/1.73 m2, P<0.0001). Transplanting long-waiting patients with kidneys from non-heart beating donors has reduced waiting times without compromising early outcomes. It is unclear if equivalent survival will be sustained in the long term.