Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation.

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.

Discrete improvement in racial disparity in survival among patients with stage IV colorectal cancer: a 21-year population-based analysis.

PURPOSE: Recently, multiple clinical trials have demonstrated improved outcomes in patients with metastatic colorectal cancer. This study investigated if the improved survival is race dependent. PATIENTS AND METHODS: Overall and cancer-specific survival of 77,490 White and Black patients with metastatic colorectal cancer from the 1988-2008 Surveillance Epidemiology and End Results registry were compared using unadjusted and multivariable adjusted Cox proportional hazard regression as well as competing risk analyses. RESULTS: Median age was 69 years, 47.4 % were female and 86.0 % White. Median survival was 11 months overall, with an overall increase from 8 to 14 months between 1988 and 2008. Overall survival increased from 8 to 14 months for White, and from 6 to 13 months for Black patients. After multivariable adjustment, the following parameters were associated with better survival: White, female, younger, better educated and married patients, patients with higher income and living in urban areas, patients with rectosigmoid junction and rectal cancer, undergoing cancer-directed surgery, having well/moderately differentiated, and N0 tumors (p < 0.05 for all covariates). Discrepancies in overall survival based on race did not change significantly over time; however, there was a significant decrease of cancer-specific survival discrepancies over time between White and Black patients with a hazard ratio of 0.995 (95 % confidence interval 0.991-1.000) per year (p = 0.03). CONCLUSION: A clinically relevant overall survival increase was found from 1988 to 2008 in this population-based analysis for both White and Black patients with metastatic colorectal cancer. Although both White and Black patients benefitted from this improvement, a slight discrepancy between the two groups remained.

Inequity aversion in relation to effort and relationship quality in long-tailed Macaques (Macaca fascicularis).

Social animals may employ evolved implicit rules to maintain a balance between cooperation and competition. Inequity aversion (IA), the aversive reaction to an unequal distribution of resources, is considered such a rule to avoid exploitation between cooperating individuals. Recent studies have revealed the presence of IA in several nonhuman species. In addition, it has been shown that an effort is crucial for this behavior to occur in animals. Moreover, IA may well depend on the partner's identity. Although dominant individuals typically monopolize food, subordinate individuals obtain less preferred food and usually do not protest. Furthermore, "friends" may pay less attention to equity than "nonfriends." We tested whether long-tailed macaques show IA with different cost-benefit ratios. In addition, we determined whether IA depends on relationship quality (RQ). Dominant subjects expressed IA only when a small effort was required. At a very large effort, however, long-tailed macaques did not show IA, possibly owing to bottom effects on the number of rewards they aim to receive. Moreover, and contrary to our predictions, an individual's inequity response was similar when tested with a "friend" or a "nonfriend." Therefore, we conclude that long-tailed macaques show IA only in conditions of moderate effort, yet that IA seems independent of RQ. Furthermore, IA may not be domain specific. Altogether, IA may be a trait present in all species that habitually cooperate, independent of their social organization.

[Controlling and reporting in operating room management: analysis of the state of development]. / Controlling und Berichtswesen im OP-Management: Analyse des Entwicklungsstands.

The operating room (OR) is one of the most expensive facilities in most hospitals. The demands on a professional and process-oriented controlling and reporting in the OR are increased due to the increasingly more limited financial margins at the end of the diagnosis related groups (DRG) convergence phase. This study gives an overview of the current situation for cost calculation, controlling and reporting in OR management in German hospitals in 2007. The data from 69 hospitals were evaluated and this represents the largest currently available data pool on this topic.

Futile cycles revisited: a markov chain model of simultaneous glycolysis and gluconeogenesis.

We have used a random walk model of glycolysis and gluconeogenesis to investigate the bioenergetic implications of considering the cell cytoplasm to be a uniform well-mixed compartment. Radiotracer studies conducted on hepatocytes harvested from fasted rats and incubated with 40 mM glucose and 10 mM lactate demonstrated simultaneous glycolysis and gluconeogenesis, with net glycolysis. Tracer introduced as glycerol was incorporated both into glucose (via gluconeogenesis) and into pyruvate (via glycolysis). The data allow us to place a lower bound on the energetic cost of futile cycles involving adenosine triphosphate (ATP) hydrolysis in the early phosphorylation steps of glycolysis. Applying the Markov Chain model for glucose undergoing metabolism to pyruvate, the expected number of ATP molecules hydrolysed is not less than 15 ATP molecules per glucose molecule. The data suggest that, in hepatocytes under the circumstances of this experiment, either glycolysis is a net consumer of ATP, or glycolysis and gluconeogenesis are compartmentalized to a greater extent than is generally supposed.

Intentional injury treated in community hospitals.

BACKGROUND: The impact of intentional injury in major metropolitan trauma centers has been established. Nonaccidental injury has become an increasingly important component of trauma care in mid-sized urban areas. To determine the medical and economic impact of personal violence in the Spokane, Washington, community we undertook a 5-year retrospective review. PATIENTS AND METHODS: Trauma registries were used to identify all victims of intentional injury admitted between May 1, 1994, and April 31, 1999. Demographic data, blood alcohol, mechanism, injury severity, hospital course, and outcome were abstracted from the registries. Financial data were obtained from hospital financial offices. SETTING: Spokane, Washington, has a population of 200,000 with 400,000 in the metropolitan area. Trauma patients are triaged to hospitals according to Washington Administrative Code guidelines, supervised by central medical control. The two level II and two level III facilities are staffed by private practice surgeons and serve a referral area of 650,000. RESULTS: Five hundred eighty-one intentional injury patients were admitted. This represented 15% of all significant injuries. Males accounted for 80% of the patients and 84%were Caucasian. The mean patient age was 30 years, only one quarter were listed as employed. Sixteen percent of the injuries were self-inflicted, gunshot was the most common mechanism (39%). Alcohol was involved in one half of the injuries. Sixty-three patients died, 39 died prior to intensive care unit admission. Hospital stay averaged 6.4 days, with a mean hospital charge of $18,000. Hospitals were reimbursed at 67%. Surgeons collected 31% of billed fees. Fewer than one third of patients had any form of private insurance. CONCLUSIONS: Intentional injury is a significant component of trauma care in our community. Patients are seriously injured and the fatality rate is high. Care is expensive and poorly funded.

Children's exposure assessment: a review of factors influencing Children's exposure, and the data available to characterize and assess that exposure.

We review the factors influencing children's exposure to environmental contaminants and the data available to characterize and assess that exposure. Children's activity pattern data requirements are demonstrated in the context of the algorithms used to estimate exposure by inhalation, dermal contact, and ingestion. Currently, data on children's exposures and activities are insufficient to adequately assess multimedia exposures to environmental contaminants. As a result, regulators use a series of default assumptions and exposure factors when conducting exposure assessments. Data to reduce uncertainty in the assumptions and exposure estimates are needed to ensure chemicals are regulated appropriately to protect children's health. To improve the database, advancement in the following general areas of research is required: identification of appropriate age/developmental benchmarks for categorizing children in exposure assessment; development and improvement of methods for monitoring children's exposures and activities; collection of activity pattern data for children (especially young children) required to assess exposure by all routes; collection of data on concentrations of environmental contaminants, biomarkers, and transfer coefficients that can be used as inputs to aggregate exposure models.

Cost-effectiveness analysis methods for the REACT Study.

The Reconditioning Exercise and Chronic Obstructive Pulmonary Disease Trial (REACT) is a two-arm randomized clinical trial designed to compare short-term versus long-term exercise intervention in terms of physical function, acute exacerbation of chronic obstructive pulmonary disease, health-related quality of life, and cost-effectiveness. Clinical trials such as REACT are now routinely paired with economic analyses, and nurses can expect to play a growing role in the conduct of these studies. This article describes a model that is useful for structuring economic evaluations of health care interventions, and illustrates a cost-effectiveness analysis that is being conducted in conjunction with the REACT study. An in-depth description of collection methods and procedures is provided, as well as a summary of recruitment and retention experience to date.

Population-based dietary intakes and tap water concentrations for selected elements in the EPA region V National Human Exposure Assessment Survey (NHEXAS).

A National Human Exposure Assessment Survey (NHEXAS) field study was performed in U.S. Environmental Protection Agency (EPA) Region V, providing population-based exposure distribution data for selected elements in several personal, environmental, and biological media. Population distributions are reported for the 11 elements that were measured in water and dietary samples. Dietary intakes and home tap water concentrations of lead, arsenic, and cadmium were further examined for intermedia associations, for differences between dietary exposure for adults and children, and to estimate the proportion of the population above health-based reference values (dietary) or regulatory action levels or maximum contaminant levels (water). Water lead and arsenic concentrations were significantly associated with dietary intake. Intake of all elements was higher from solid foods than from liquid foods (including drinking water). Dietary intakes of Pb, As, and Cd were greater than those calculated for intake from home tap water or inhalation on a microg/day basis. Median dietary intakes for the Region V population for Pb, As, and Cd were 0.10, 0.13, and 0.19 microg/kg bw/day, respectively. While Pb, As, and Cd concentrations in the foods consumed by 0 to 6-year-old children were similar to or lower than those for adults, dietary intakes calculated on a body weight basis were 1.5 to 2.5 times higher for young children. Intrapersonal intake differences accounted for most of the variance in short-term (daily) dietary intakes for Pb and As, while interpersonal differences accounted for more of the intake variance for Cd. Only small percentages of the population exceeded health-based intake reference values or concentrations equal to regulatory levels in water for Pb, As, and Cd.

Hygiene- and food-related behaviors associated with blood lead levels of young children from lead-contaminated homes.

Exposures associated with blood lead levels greater than 40 micrograms/dL in young children who live in lead-contaminated homes have been well documented. As the action level for lead is reduced, activities that contribute to lower levels of lead exposure must be identified. A child's eating habits and related hygiene behaviors are major hand-to-mouth activities that have been largely overlooked in the study of activities contributing to lead ingestion. To examine this subject, a survey questionnaire for caretakers of young children was developed. The objective of the questionnaire was to characterize food-related activities of young children and to identify behavioral indicators of lead exposure. The association between food- and hygiene-related behaviors and blood lead levels among 60 children between 13 and 36 months old with low-to-moderate blood lead levels was examined in homes that had been identified as containing lead in paint and house dust. The participants were enrolled in the Children's Lead Exposure and Reduction Study in Jersey City, New Jersey. Blood lead levels of children 13-24 months old did not differ significantly from those of children 25-36 months of age (10.1 and 11.3 micrograms/dL, respectively). Differences in eating habits and hygiene behaviors were found for the two age groups. Bivariate analyses found that the primary behavioral indicators of blood lead levels were determined by whether the child prepared his/her own food and whether the child ate food that had been on the floor. This factor was dependent on age. Children 13-24 months old had significantly elevated blood lead levels if these behaviors exhibited. No significant differences were found, however, for children 25-36 months old. Several food-related habits were also associated with blood lead levels. Eating hamburgers, doughnuts, peanut butter and jelly sandwiches, and cold cuts were associated with elevated blood lead levels in 13-24-month-old children, while eating vitamins, raw vegetables, and yogurt were associated with lower blood lead levels in this age group. For children 25-36 months old, eating hamburgers and peanut butter and jelly sandwiches was associated with elevated blood lead levels, while yogurt consumption was associated with lower blood lead levels.

Transforming growth factor-beta 1 and basic fibroblast growth factor in the injured CNS.

After injuries that penetrate the mature brain or spinal cord, damaged axons initially show a growth response, but later their regeneration is aborted as a dense permanent scar is laid down within the core of the wound. Functional recovery from such injuries is poor and morbidity is severe, particularly for those patients with spinal cord damage. Clinically, no long term therapeutic treatments have been developed that might inhibit scarring and promote neuronal growth. Consequently, the prevalence of patients permanently disabled from head and spinal cord injury is high, estimated at more than 1:1000 of the population of North America (Office of Technology Assessment USA, 1990). Ann Logan and Martin Berry define the mechanisms that underlie the wound healing response in the CNS and discuss the rationale for the development of novel therapeutic strategies.

Role of exposure databases in risk assessment.

Risk assessments have assumed an increasingly important role in the management of risks in this country. The determination of which pollutants or public health issues are to be regulated, the degree and extent of regulation, and the priority assigned to particular problems are all areas of risk assessment that influence the country's $100 billion annual investment in environmental protection. Recent trends in public policy have brought the practice of risk assessment under greater scrutiny. As policy makers increasingly insist that specific numerical risk levels (so-called bright lines) be incorporated into regulatory decisions, the stakes for good risk assessment practice, already high, are raised even further. Enhancing the scientific basis of risk assessments was a major goal of the Workshop on Exposure Databases. In this article, we present the Risk Assessment Work Group's evaluation of the use of exposurerelated databases in risk assessment and the group's recommendations for improvement. The work group's discussion focused on the availability, suitability, and quality of data that underly exposure assessments, a critical component of risk assessment. The work group established a framework for evaluation, based on exposure scenarios typically used in regulatory decisions. The scenarios included examples from Superfund, the Clean Air Act, the Toxic Substances Control Act, and other regulatory programs. These scenarios were used to illustrate current use of exposure data, to highlight gaps in existing data sources, and to discuss how improved exposure information can improve risk assessments. The work group concluded that many of the databases available are designed for purposes that do not meet exposure and risk assessment needs. Substantial gaps exist in measurements of actual human exposure and in the data necessary to model exposures, to characterize distributions of exposure, to identify high-risk groups, and to identify possible environmental inequities in exposure. The work group, on the basis of its findings, made both short-term and longer-term recommendations for improving the collection of exposure data in the future.

Needs of the family caregivers of frail elderly.

The purpose of the study was to determine the needs of family caregivers of frail elderly. Forty-one caregivers were interviewed. More than two-thirds of the caregivers were spouses and about 85% of them had health problems which affected their caregiving. Ninety-eight percent of the caregivers were living with the care recipients and the cumulative stress from their continual involvement had affected their lifestyle. Also more than 58% felt that the care recipients needed more care than they could provide. More than 68% of the caregivers were seniors. Differential planning based on each of the caregivers' needs can maximize the care they provide.