Regional variability in liver waiting list removals causes false ascertainment of waiting list deaths.

Inconsistent identification of reasons for removal from the liver transplant waiting list by Organ Procurement and Transplantation Network (OPTN) regions may contribute to regional variability in wait-list death rates. We analyzed OPTN and Social Security Administration (SSA) reported deaths of 103 364 liver transplant candidates listed May 8, 2003-April 17, 2011, and determined regional variability in risk of death attributable to differences in use of OPTN removal codes. Only 26% of candidates removed as "too sick" died within 90 days of delisting; 6335 deaths after delisting were not reported to OPTN. The ratio of number of candidates removed as "too sick" to number who died on the waiting list varied by region from 0.23 to 0.94, indicating substantial variability in use of removal codes. Including SSA-reported deaths within 90 days of delisting reduced regional variability in risk of death by 48% compared with deaths on the list alone, and by 35% compared with deaths plus the "too sick" designation. Codes for delisting liver transplant candidates are inconsistently applied among OPTN regions, spuriously elevating estimated regional variability in risk of wait-list death. This variability is ameliorated by including SSA- reported deaths within 90 days of delisting.

OPTN policy regarding prioritization of patients with hepatopulmonary syndrome: does it provide equitable organ allocation?

United Network for Organ Transplantation (UNOS) policy 3.6.4.5.1 provides exception points to patients diagnosed with hepatopulmonary syndrome (HPS) to compensate for their reported increased mortality risk. We compared pre- and posttransplant and overall outcomes in 255 patients receiving exception points under this policy (HPS policy patients) with 32 358 nonexception control patients listed in the model for end-stage liver disease (MELD) era to determine whether the intent of the policy is being met. Overall, 92.5% of HPS policy patients versus 45.5% of controls had been transplanted, 5.1% versus 31.2% remained on waiting list and 1.5% versus 14.1% had died while awaiting transplant (p < 0.0001 for each comparison). Relative risk (RR) of death for HPS policy patients compared to controls was 0.158 (confidence interval [CI]: 0.059-0.420, p = 0.0002) pretransplant, and 0.827 (CI: 0.587-1.170, p = 0.28) posttransplant. Overall (combined waitlist and posttransplant) RR of death was 0.514 (CI: 0.374-0.707, p = 0.00004) compared with controls. After adjustment for laboratory MELD, overall RR was 0.807 (CI: 0.587-1.110, p = 0.19), indicating that HPS policy patients' mortality risk would be similar to that of controls had they been listed with their laboratory MELD score. HPS policy patients have a significant pretransplant survival advantage over standard liver transplant candidates because of the exception points awarded, and have similar posttransplant survival. Better criteria for diagnosing and grading of HPS are required.

[The shortening of the duration of pregnancy due to smoking and associated costs for perinatal health care in Germany]. / Erhöhung der Frühgeborenenrate durch Rauchen in der Schwangerschaft und daraus resultierende Kosten für die Perinatalmedizin in Deutschland.

BACKGROUND: As about 20 % of pregnant women smoke, 137,000 of the 685,795 neonates delivered in Germany in 2005 have been affected by smoking during pregnancy. Caring for neonates born prematurely because of smoking results in additional costs. We have attempted to estimate these costs. MATERIAL AND METHODS: Data of 1,815,318 pregnancies were collected from the German perinatal statistics of 1995-1997. In 876,645 cases there was information regarding smoking. Of these, 699,134 pregnant women were non-smokers and 177,511 were smokers. To determine the number of preterm births due to smoking, we compared the distribution of the duration of pregnancy of the non-smoking cohort to that of the smoking cohort. From the difference between this and the actual distribution of the duration of pregnancy among smokers we determined the number of additional preterm births caused by smoking. For the analysis of the associated costs we used the actual costs of care and daily rates used in neonatology. RESULTS: For 2002 we estimate 43 million Euros of additional costs due to neonates born prematurely because of smoking. CONCLUSIONS: We present a rough estimate of the additional health care costs for neonates because of smoking. Costs were estimated only with regard to premature deliveries. Other effects of smoking during pregnancy on neonatal health were not considered. More detailed cost analyses will likely reveal even higher costs.

[Reasons for the delayed realisation of pregnancy. Results of a questionnaire among women in childbed in the new (east) and old (west) federal states of Germany in 1998-2000]. / Gründe für eine spätere Realisierung des Kinderwunsches. Ergebnisse einer Wöchnerinnen-Befragung in den neuen und alten Bundesländern in den Jahren 1998-2000.

BACKGROUND: The number of live births in Germany has decreased by 46.7 % from 1 261 614 in 1960 to 672 675 in 2006. The causes for this are manifold. This study attempts to address the possible causes for the delay of birth in Germany in an east-west comparison. METHOD: Within the "Kinderwunschstudie" (survey of desired/intended fertility) 5 143 women in childbed have been interviewed between 1998 and 2000. They were asked questions concerning the delay of this particular birth. Only women and their spouses who were born in Germany, respectively, were included into the analysis. Berlin women in childbed were excluded from the analysis due to the problematic east-west classification. The number of analysable cases finally added up to 2 020 cases in East Germany and 2 193 cases in West Germany. RESULTS: 24.4 % of the interviewed women in the East admitted a delay of the last birth compared to 21.2 % of those in the West. There are clear differences concerning the reasons for this delay between the old (west) and the new (east) federal states. 34 % of the east German women agreed that an insecure income situation was the reason for the delayed realisation of the desired pregnancy / birth, whereas it was only 16 % in the west. CONCLUSION: This survey ("Kinderwunschstudie") in fact indicates differences regarding the reasons for a delay of birth between east and west German women (in childbed). However, it also highlights the generally negative influence of the given social and economic conditions on the number of births and underlines the prospects for an ongoing decrease. As a result, society will in future have to face problems of unknown dimensions.

[German Environmental Survey for Children (GerES IV). Environmental module of KiGGS. Part 2: The first year of field work]. / Kinder-Umwelt-Survey-das Umweltmodul im KiGGSTeil 2: Das erste Jahr Feldarbeit.

The field work of the German Environmental Survey for Children (GerES IV) was started nationwide in May 2003. The survey is a module of the National Health Interview and Examination Survey for Children and Adolescents (KiGGS). This environmental survey includes a representative subsample of 1800 children from the 18,000 participants of the KiGGS who are being examined regarding health-relevant environmental exposure. The investigational programme of the survey was tested successfully in a pilot study (pretest) the results of which contributed to the optimisation of the main study. The field work is essentially done by the environmental interviewer of the three teams of the KiGGS. Preparation, organization and accompaniment of the work is done by the coordination centre of the Robert Koch Institute on Federal Environmental Agency (UBA) instructions. Funding agencies are the Federal Ministry of Education and Research (BMBF) and the Federal Ministry for the Environment, Nature Conservation and Nuclear Safety (BMU). Both the KiGGS and the environmental module are evaluated by internal and external quality assurance during the whole study period (May 2003-May 2006). Up to now the established teams have done their field work very well and the coordination of the overall project by the Robert Koch Institute works well, too. A total of 722 subjects had taken part in the GerES IV by July 2004.

Helicopters as part of a regional EMS system--a cost-effectiveness analysis for three EMS regions in Germany.

With increasing health care costs the use of rescue helicopters is being questioned on the grounds of expense. No data exist on the cost-effectiveness of the use of rescue helicopters as part of a regional EMS. The end-point of this study was to analyse the cost-effectiveness of a 15 min response time (state regulation) of advanced life support (ALS) equipment provided by helicopter (1,575,000 DM annual costs) versus a ground-based ambulance (1,004,000 DM annual costs) in three EMS systems (50 km radius) with differing demographic and geographic features in Germany. The effect of varying the ratio of helicopters to ground-based vehicles (ALSC) has also been considered using two additional models. In model 1 each region was allocated one additional helicopter and had six ALS cars removed (daytime only). This improved the response times and saved nearly 1,500,000 DM per year. In model 2 each region had its existing helicopter withdrawn and replaced with six ALS cars. This made response times longer and increased expenditure. In conclusion, the additional use of rescue helicopters in EMS regions (50 km radius) remains cost-effective up to an ALSC:helicopter cost ratio of 1:6.

[New aspects of assessment of physical development of children and adolescents by preventive examinations]. / Neue Aspekte der Beurteilung körperlicher Entwicklung von Kindern und Jugendlichen bei Vorsorgeuntersuchungen.

The results of the examinations of a representative cross-section were used as the basis for bringing up to date the standard values and ranges of variability of the body measurements of newborns according to gestational age, of head circumference up to the 3rd year and of body height and weight from 0-18 years. Tables and somatograms were also drawn up for the evaluation of body weight in relation to specific types of build, and standard values for skinfold thickness and total body fat were worked out in order to permit a biologically meaningful assessment of the physical development and nutritional status of children and adolescents. Alongside the description of the individual stages in the development of selected characteristics of maturation used in assessing sexual maturity, percentiles for the average age on reaching each of these stages of development will be available, together with a new series of photographs of breast, pubes and genital development.

[The effect of various parameters on the incidence of premature births]. / Uber den Einfluss verschiedener Merkmalsgrössen auf die Häufigkeit von preterm infants.

In a retrospective study among about 17,000 newborns the preterm infants were registered. Newborns delivered in the District Hospital of Schwerin between 1969 and 1977 are included in the above figure. The influence of different parameters on the deliveries of preterm infants was proved. In order to exclude the influence of age and parity on the results of the examinations s standardization of age and parity was done. The frequency of the delivery of preterm infants was dependent on age, parity, occupation and case histories of abortion, interruption of pregnancy and delivery of under-weight.

[Predisposing factors of pregnancy in adolescents]. / Prädisponierende Faktoren einer Schwangerschaft bei Jugendlichen.

PIP: Results of a study of social characteristics and sexual development of 107 pregnant and 228 nonpregnant adolescents aged 14-19 are presented and compared to earlier findings. The pregnant girls were interviewed after applying for abortions. Fathers of the pregnant girls were found to have had significnatly less education. The pregnant girls had an average of 2.4 siblings compared to 1.7 in the control group, and 32.6% came from families with 3 or more children compared to 20.4% in the control group. 24.2% of the pregnant adolescents lived in incomplete homes compared to 11.8% of controls. 82.2% of pregnant and 88.6% of control subjects reported their family life to be good or very good. A significantly higher proportion in the control group had good or very good school performance and behavior. No significant difference was noted in age at menarche or 1st heterosexual contact. The pregnant girls engaged in genital stimulation and intercourse at significantly earlier ages than the controls, had less knowledge and use of contraceptives, and had fewer female friends. Results of the study are summarized and compared with previous work in the broad areas of social situation and sexual development. 2 concepts of predisposing factors to adolescent pregnancy, 1 using physical precocity as a starting point and the other, environmental risks such as disturbed family life, early sexual contact and frequent changes of partners, are contrasted and questioned. Adequate sex education and better instruction on contraception and contraceptive behavior, particularly for male adolescents, are seen as the best strategies for reducing unwanted pregnancies in adolescents.^ieng