Characterizing Adaptive Changes and Patient Survival After 2018 Donor Allocation Restructuring: A UNOS Database Analysis.

PURPOSE: We sought to characterize adaptive changes to the revised United Network for Organ Sharing donor heart allocation policy and estimate long-term survival trends for heart transplant (HTx) recipients. METHODS: Patients listed for HTx between October 17, 2013 and September 30, 2021 were identified from the United Network for Organ Sharing database, and stratified into pre- and postpolicy revision groups. Subanalyses were performed to examine trends in device utilization for extracorporeal membranous oxygenation (ECMO), durable left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), microaxial support (Impella), and no mechanical circulatory support (non-MCS). Survival data post-HTx were fitted to parametric distributions and extrapolated to 5 years. RESULTS: We identified 27,523 HTx waitlist candidates during the study period, most of whom (n = 16,376) were waitlisted in the prepolicy change period. Overall, 19,554 patients underwent HTx during the study period (pre: 12,037 and post: 7517). Listings increased after the policy change for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients. Listings for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients decreased. HTx increased for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients after the policy change and decreased for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients. Waitlist survival increased for the overall ( P < 0.01), ECMO ( P < 0.01), IABP ( P < 0.01), and non-MCS ( P < 0.01) groups. Waitlist survival did not differ for the LVAD ( P = 0.8) and Impella ( P = 0.1) groups. Post-transplant survival decreased for the overall ( P < 0.01), LVAD ( P < 0.01), and non-MCS ( P < 0.01) populations. CONCLUSIONS: Allocation policy revisions have contributed to greater utilization of ECMO, Impella, and IABP, decreased utilization of LVADs and non-MCS, increased waitlist survival, and decreased post-HTx survival.

Urinary metabolites of 1-nitropyrene in US-Mexico border residents who frequently cross the San Ysidro Port of Entry.

Diesel exhaust presents a community exposure hazard, but methods to measure internal exposure are lacking. We report results from a community-based study using 1-nitropyrene (1-NP) and its urinary metabolites as markers of exposure to traffic-related diesel particulate matter (DPM). The study participants were Tijuana, Mexico residents who commuted on foot into San Diego, California for work or school using the International San Ysidro Port of Entry, placing them within feet of idling traffic (referred to as border commuters). The comparison group (non-border commuters) was comprised of residents of south San Diego who did not commute into Mexico. Air concentration of 1-NP in fine particulate matter (PM2.5) was measured in personal samples from participants. Spot urine samples were analyzed for 1-NP urinary metabolites 8-hydroxy-1-nitropyrene (8-OHNP) and 8-hydroxy-N-acetyl-1-aminopyrene (8-OHNAAP). Compared with non-border commuters, border commuters had two- to threefold higher mean urinary concentrations for unadjusted and creatinine-adjusted 8-OHNP and 8-OHNAAP. Urinary 8-OHNAAP and the sum of 8-OHNP and 8-OHNAAP were both associated with personal exposure to 1-NP in the prior 24 h. These results suggest that 1-NP urinary metabolites reflect recent exposure to DPM-derived 1-NP in community settings and can be useful for exposure analysis.

Learning from the Brazilian community health worker model in North Wales.

Health policymakers in many countries are looking at ways of increasing health care coverage by scaling up the deployment of community health workers. In this commentary, we describe the rationale for the UK to learn from Brazil's scaled-up Community Health Worker primary care strategy, starting with a pilot project in North Wales.