Association of Primary Care Shortage Areas with Adverse Outcomes after Pediatric Liver Transplant.

OBJECTIVE: To characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation. STUDY DESIGN: This was an observational study of all pediatric patients (aged <19 years) who received a liver transplant between January 1, 2005, and December 31, 2015 in the US, with follow-up through January 2019 (N = 5964). One hundred ninety-five patients whose home ZIP code could not be matched to primary care shortage area status were excluded. The primary outcome was a composite endpoint of graft failure or death. We used Cox proportional hazards to model the associations between health professional shortage area (HPSA) and graft failure/death. RESULTS: Children living in HPSAs had lower estimated graft survival rates at 10 years compared with those not in HPSAs (76% vs 80%; P < .001). In univariable analysis, residence in an HPSA was associated with a 22% higher hazard of graft failure/death than non-residence in an HPSA (hazard ratio [HR], 1.22; 95% CI, 1.09-1.36; P < .001). Black children from HPSAs had a 67% higher hazard of graft failure/death compared with those not in HPSAs (HR, 1.67; 95% CI, 1.29 to 2.16; P = .006); the effect of HPSA status was less pronounced for White children (HR, 1.11; 95% CI, 0.98-1.27; P = .10). CONCLUSIONS: Children living in primary care shortage areas are at increased risk of graft failure and death after liver transplant, and this risk is particularly salient for Black children. Future work to understand how living in these regions contributes to adverse outcomes may enable teams to mitigate this risk for all children with chronic illness.

A global review of past land use, climate, and active vs. passive restoration effects on forest recovery.

Global forest restoration targets have been set, yet policy makers and land managers lack guiding principles on how to invest limited resources to achieve them. We conducted a meta-analysis of 166 studies in naturally regenerating and actively restored forests worldwide to answer: (1) To what extent do floral and faunal abundance and diversity and biogeochemical functions recover? (2) Does recovery vary as a function of past land use, time since restoration, forest region, or precipitation? (3) Does active restoration result in more complete or faster recovery than passive restoration? Overall, forests showed a high level of recovery, but the time to recovery depended on the metric type measured, past land use, and region. Abundance recovered quickly and completely, whereas diversity recovered slower in tropical than in temperate forests. Biogeochemical functions recovered more slowly after agriculture than after logging or mining. Formerly logged sites were mostly passively restored and generally recovered quickly. Mined sites were nearly always actively restored using a combination of planting and either soil amendments or recontouring topography, which resulted in rapid recovery of the metrics evaluated. Actively restoring former agricultural land, primarily by planting trees, did not result in consistently faster or more complete recovery than passively restored sites. Our results suggest that simply ending the land use is sufficient for forests to recover in many cases, but more studies are needed that directly compare the value added of active versus passive restoration strategies in the same system. Investments in active restoration should be evaluated relative to the past land use, the natural resilience of the system, and the specific objectives of each project.

An assessment of the disability trends within the Hansen's disease control programme in Jamaica 1982-1996

Even with the constant decline in the incidence of Hansen's disease in Jamaica and declared elimination status in 1981, there is still a high percentage of patients being registered with multibacillary type of Hansen's disease and with disabilities at the time of diagnosis. This increase is noted, at a time when the global focus is on Hansen's eradication by the year 2000. Young adults are the group most a risk for Hansen's disease and its complications. Delayed diagnoses have resulted in an increase in deformities. Men are more prone to disabilities and the severe type of the disease (RR=1.00). Children have been diagnosed with the multibacillary type of disease. A retrospective study was conducted, over the period 1982 to 1996, in order to anlayse the disability trends and what it means for the Hansen's disease control programme in Jamaica. It was demonstrated that among the 88 patients graded 42 percent had disability, of which the most common was that of the hand (OR=5.33 p=0.03). These findings indicate that there is an urgent need for active case finding of Hansen's disease patients in Jamaica. Early case finding must be seen as the key to an effective "prevention of disability" programme.(AU)