The impact of proposed changes in liver allocation policy on cold ischemia times and organ transportation costs.

Changes to the liver allocation system have been proposed to decrease regional variation in access to liver transplant. It is unclear what impact these changes will have on cold ischemia times (CITs) and donor transportation costs. Therefore, we performed a retrospective single center study (2008-2012) measuring liver procurement CIT and transportation costs. Four groups were defined: Local-within driving distance (Local-D, n = 262), Local-flight (Local-F, n = 105), Regional-flight <3 h (Regional <3 h, n = 61) and Regional-Flight >3 h (Regional >3 h, n = 53). The median travel distance increased in each group, varying from zero miles (Local-D), 196 miles (Local-F), 384 miles (Regional <3 h), to 1647 miles (Regional >3 h). Increasing travel distances did not significantly increase CIT until the flight time was >3 h. The average CIT ranged from 5.0 to 6.0 h for Local-D, Local-F and Regional <3 h, but increased to 10 h for Regional >3 h (p < 0.0001). Transportation costs increased with greater distance traveled: Local-D $101, Local-F $1993, Regional <3 h $8324 and Regional >3 h $27 810 (p < 0.0001). With proposed redistricting, local financial modeling suggests that the average liver donor procurement transportation variable direct costs will increase from $2415 to $7547/liver donor, an increase of 313%. These findings suggest that further discussion among transplant centers and insurance providers is needed prior to policy implementation.

Brief report: reduction of inappropriate vocalizations for a child with autism using a self-management treatment program.

Self-management procedures that incorporate elements of self-assessment, self-recording, and self-reinforcement have reduced stereotypic (i.e., repetitive) behaviors in children with autism in clinical settings. This study examined the effects of a self-management program used to reduce high rates of inappropriate vocalizations (e.g., humming, tongue clucking, perseverative and echolalic words/phrases) in a 12-year-old girl having autism served in a public school classroom. When self-management was applied to inappropriate vocalizations in a multiple-baseline design during leisure, prevocational, and reading tasks, the occurrence of vocalizations decreased. Implications for teaching these procedures in classroom settings are discussed.

MMPI-2 items which correctly identified women with histories of childhood sexual abuse.

This study examined whether MMPI-2 items could be used to discriminate between 58 women who experienced childhood sexual abuse and 57 women who did not. A set of 48 items were identified which correctly classified 95% of the subjects.

Clinical documentation of end-stage renal disease due to hypertension.

Hypertensive end-stage renal disease (ESRD) purportedly accounts for 25% of new ESRD patients each year in the United States, but remains poorly understood. Clinical features include normal renal function at diagnosis of hypertension, family history of hypertension, left ventricular hypertrophy, and minimal proteinuria. We evaluated clinical and historic data documenting the diagnosis of hypertensive ESRD in 43 patients with ESRD attributed to hypertension who were referred to our center for renal transplantation. Hypertensive ESRD patients were more likely to be black patients with left ventricular hypertrophy compared with our overall population. Few of the hypertensive ESRD patients had undergone kidney biopsy, none of whom had classic features of benign nephrosclerosis. Less than 5% of patients had hypertension documented at any time with normal renal function. Based on our review, it is clearly possible that the number of patients reaching dialysis and transplantation with renal failure attributed to hypertensive ESRD may be overestimated.

MMPI-2 profiles of women differing in sexual abuse history and sexual orientation.

Four groups of women (N = 115) self-identified as having histories of childhood sexual abuse or no such histories and self-identified as either heterosexual or lesbian were compared using a questionnaire and the MMPI-2. Subjects ranged in age from 21-60 years with 60% between ages 30-50 years. Results of a Three-Way MANOVA for abuse history and sexual orientation repeated across MMPI-2 clinical scales showed a between-subjects effect for abuse, and within-subjects effects for orientation and abuse. T scores of women with abuse histories were significantly higher than those of women without abuse histories on Hs, D, Pd, Pa, Pt, Sc, and Ma scales of the MMPI-2. Profiles indicated an 8-4 codetype and a Scarlett O'Hara V configuration for the group with abuse history. Heterosexual women obtained significantly higher t scores than did lesbians on the Depression scale. Results show that the MMPI-2 can be used to help detect lesbian as well as heterosexual adults who were sexually molested as children.

Local reactions during allergen immunotherapy do not require dose adjustment.

BACKGROUND: The recent World Health Organization position paper on allergen immunotherapy states that local reactions to immunotherapy are not predictive of subsequent systemic reactions. Nevertheless, in clinical practice dose adjustment after local reactions continues to be recommended, presumably in an effort to prevent future systemic reactions. OBJECTIVE: We sought to determine whether dose adjustment versus no adjustment for local reactions during allergen immunotherapy influences the occurrence of subsequent systemic reactions. METHODS: In a single-site allergy clinic before October 1, 1997, local reactions after allergen vaccine injection resulted in adjustment of the subsequent dose. After October 1, 1997, no dose adjustments were made for immediate and late local reactions. For the same 9-month period before and after the change in local reaction dose-adjustment policy, systemic reaction rates were compared retrospectively. For individuals experiencing a systemic reaction, local reaction rates and local reactions immediately preceding a systemic reaction were also compared before and after the policy change. RESULTS: Comparing the 9-month period (October 1996-June 1997) preceding the policy change and the 9 months (October 1997-June 1998) after the change in policy, the systemic reaction rates (0.80% and 1.01%, respectively) were not statistically different (P =.24). Among those experiencing a systemic reaction, the rate of local reactions was unchanged (7.3% and 4.7%, respectively; P =.07), and the rate of local reactions immediately preceding a systemic reaction did not increase (18.8% and 10.5%, respectively; P =.37). The sensitivity of a local reaction predicting a systemic reaction at the next immunotherapy dose was 15%. CONCLUSIONS: A local reaction is a very insensitive predictor for a subsequent systemic reaction at the next allergen vaccine dose. Dose adjustment for most local reactions is unnecessary and may delay therapy, increase costs, and put the patient at increased risk of dose administration errors.

The impact of renal transplantation on survival in hepatitis C-positive end-stage renal disease patients.

Hepatitis C virus (HCV) infection is common in end-stage renal failure patients. It is not known whether the prognosis of HCV-positive patients differs depending on whether they remain on dialysis or receive a kidney transplant. To address this question, we compared the outcomes of HCV-positive renal transplant recipients and HCV-positive patients who were acceptable candidates but had not yet received transplants. We reviewed all patients referred to our institution for renal transplantation evaluation between January 1992 and December 1995. Anti-HCV antibody was detected in 151 of 2,053 (7.4%) patients. HCV-positive patients were more often male (74% v 56%; P < 0.0001), black (68% v 49%; P = 0.001), unemployed (87% v 74%; P = 0.0004), on dialysis (88% v 78%; P = 0.0026), and on dialysis longer (30 +/- 44 months v 13 +/- 23 months; P = 0.0001) than HCV-negative patients. We determined the outcomes of HCV-positive patients who had at least 2 years' follow-up. Thirty-three HCV-positive patients received kidney transplants (group I); 25 HCV-positive patients were acceptable transplant candidates but had not yet received an allograft (group II). Group I and II HCV-positive patients were similar with respect to age, race, duration of dialysis, cause of renal failure, prevalence of heart disease, and results of liver function tests. Survival was significantly decreased in group II versus group I (P = 0.043). Our study showed that HCV-positive renal transplant recipients had a better survival than similar HCV-positive patients awaiting transplantation.