Cost Benefit Analysis of Two Oral health Improvement Programmes.

INTRODUCTION: Oral health is frequently given a low priority when healthcare funds are allocated to new initiatives. One method to highlight the health and social benefits of new oral health initiatives is to use cost benefit analysis to show their value. AIM: To demonstrate how Cost Benefit Analysis (CBA) has been applied to two recent oral health initiatives to evaluate their ability to reduce costs and improve the quality of life. METHODS: CBA was applied to the Mouth Care Matters project in Kent, Surrey and Sussex, and the Senior Smiles project - improving oral health in residential homes in Australia. RESULTS: Over a five-year period, the Mouth Care Matters project would generate £2.66 in cost savings, within the healthcare system, for every £1 spent. Over a three year period the Senior Smiles project would generate a cost saving for the healthcare system of $3.14 for every $1 spent. These evaluations were instrumental to enable a national rollout for Mouth Care Matters and a public endorsement of the programme for Senior Smiles. CONCLUSIONS: Health economics can be a useful tool in aiding care organisations to assess the implications of decisions to spend limited resources in particular areas of healthcare over others.

Familial Hypomagnesemia, Hypercalciuria and Nephrocalcinosis with Novel Mutation.

Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC) is a rare autosomal recessive disorder that is caused by mutation in genes coding for tight junction proteins claudin-16 and claudin-19. It is characterized by renal wasting of magnesium and calcium associated with the development of nephrocalcinosis and renal stones by early childhood. Most of them progress to end-stage renal failure by the second or third decade. Here, we report two siblings with FHHNC, who presented with nephrocalcinosis without any extrarenal manifestations, one of them having novel homozygous nonsense mutation in claudin-16 (CLDN16) (c.620G>A, p. Trp207Ter). Both were treated with dietary changes, hydrochlorothiazide, potassium citrate, and magnesium supplementation. FHHNC is a rare cause of nephrocalcinosis, and we believe that it should be considered in the presence of nephrocalcinosis with hypercalciuria and hypomagnesemia.

An investigation into denture loss in hospitals in Kent, Surrey and Sussex.

Background The loss of dentures for inpatients can have a detrimental effect on their well-being. Self-respect and dignity become compromised along with their ability to eat meals and communicate clearly, and long-term recovery.Aim This investigation aimed to identify the reported number of dentures lost in hospitals and the financial reimbursements given by trusts to replace them.Method Information on reported denture loss and reimbursement was collected in 12 trusts throughout Kent, Surrey and Sussex.Results Eleven out of 12 trusts returned data about how many dentures were lost in their hospitals, between them 695 dentures were reported lost over five years (2011-16). Seven trusts reported financial reimbursements for dentures losses; results showed £357,672 was reimbursed over six years (2010-16), the highest amount reimbursed for a single denture was £2,200.Conclusion The results indicate that denture loss is a problem in hospitals that contributes to the financial burden for the NHS. Consideration needs to be given by hospitals to find ways to reduce the number of dentures lost every year.

Associations between Deceased-Donor Urine MCP-1 and Kidney Transplant Outcomes.

INTRODUCTION: Existing methods to predict recipient allograft function during deceased-donor kidney procurement are imprecise. Understanding the potential renal reparative role for monocyte chemoattractant protein-1 (MCP-1), a cytokine involved in macrophage recruitment after injury, might help predict allograft outcomes. METHODS: We conducted a sub-study of the multicenter prospective Deceased Donor Study cohort, which evaluated deceased kidney donors from five organ procurement organizations from May 2010 to December 2013. We measured urine MCP-1 (uMCP-1) concentrations from donor samples collected at nephrectomy to determine associations with donor acute kidney injury (AKI), recipient delayed graft function (DGF), 6-month estimated GFR (eGFR), and graft failure. We also assessed perfusate MCP-1 concentrations from pumped kidneys for associations with DGF and 6-month eGFR. RESULTS: AKI occurred in 111 (9%) donors. Median (interquartile range) uMCP-1 concentration was higher in donors with AKI compared to donors without AKI (1.35 [0.41-3.93] ng/ml vs. 0.32 [0.11-0.80] ng/ml, p<0.001). DGF occurred in 756 (31%) recipients, but uMCP-1 was not independently associated with DGF. Higher donor uMCP-1 concentrations were independently associated with higher 6-month eGFR in those without DGF [0.77 (0.10, 1.45) ml/min/1.73m2 per doubling of uMCP1]. However, there were no independent associations between uMCP-1 and graft failure over a median follow-up of about 2 years. Lastly, perfusate MCP-1 concentrations significantly increased during pump perfusion but were not associated with DGF or 6-month eGFR. CONCLUSION: Donor uMCP-1 concentrations were modestly associated with higher recipient 6-month eGFR in those without DGF. However, the results suggest that donor uMCP-1 has minimal clinical utility given no associations with graft failure.

Associations of Perfusate Biomarkers and Pump Parameters With Delayed Graft Function and Deceased Donor Kidney Allograft Function.

Hypothermic machine perfusion (HMP) is increasingly used in deceased donor kidney transplantation, but controversy exists regarding the value of perfusion biomarkers and pump parameters for assessing organ quality. We prospectively determined associations between perfusate biomarkers (neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule 1, IL-18 and liver-type fatty acid-binding protein [L-FABP]) and pump parameters (resistance and flow) with outcomes of delayed graft function (DGF) and 6-mo estimated GFR (eGFR). DGF occurred in 230 of 671 (34%) recipients. Only 1-h flow was inversely associated with DGF. Higher NGAL or L-FABP concentrations and increased resistance were inversely associated with 6-mo eGFR, whereas higher flow was associated with higher adjusted 6-mo eGFR. Discarded kidneys had consistently higher median resistance and lower median flow than transplanted kidneys, but median perfusate biomarker concentrations were either lower or not significantly different in discarded compared with transplanted kidneys. Notably, most recipients of transplanted kidneys with isolated "undesirable" biomarker levels or HMP parameters experienced acceptable 6-mo allograft function, suggesting these characteristics should not be used in isolation for discard decisions. Additional studies must confirm the utility of combining HMP measurements with other characteristics to assess kidney quality.

Associations of deceased donor kidney injury with kidney discard and function after transplantation.

Deceased donor kidneys with acute kidney injury (AKI) are often discarded due to fear of poor outcomes. We performed a multicenter study to determine associations of AKI (increasing admission-to-terminal serum creatinine by AKI Network stages) with kidney discard, delayed graft function (DGF) and 6-month estimated glomerular filtration rate (eGFR). In 1632 donors, kidney discard risk increased for AKI stages 1, 2 and 3 (compared to no AKI) with adjusted relative risks of 1.28 (1.08-1.52), 1.82 (1.45-2.30) and 2.74 (2.0-3.75), respectively. Adjusted relative risk for DGF also increased by donor AKI stage: 1.27 (1.09-1.49), 1.70 (1.37-2.12) and 2.25 (1.74-2.91), respectively. Six-month eGFR, however, was similar across AKI categories but was lower for recipients with DGF (48 [interquartile range: 31-61] vs. 58 [45-75] ml/min/1.73m(2) for no DGF, p < 0.001). There was significant favorable interaction between donor AKI and DGF such that 6-month eGFR was progressively better for DGF kidneys with increasing donor AKI (46 [29-60], 49 [32-64], 52 [36-59] and 58 [39-71] ml/min/1.73m(2) for no AKI, stage 1, 2 and 3, respectively; interaction p = 0.05). Donor AKI is associated with kidney discard and DGF, but given acceptable 6-month allograft function, clinicians should consider cautious expansion into this donor pool.

Glutathione S-transferase iso-enzymes in perfusate from pumped kidneys are associated with delayed graft function.

Accurate and reliable assessment tools are needed in transplantation. The objective of this prospective, multi-center study was to determine the associations of the alpha and pi iso-enzymes of glutathione S-transferase (GST), measured from perfusate solution at the start and end (base and post) of kidney allograft machine perfusion, with subsequent delayed graft function (DGF). We also compared GST iso-enzyme perfusate levels from discarded versus transplanted kidneys. A total of 428 kidneys were linked to outcomes as recorded by the United Network of Organ Sharing. DGF, defined as any dialysis in the first week of transplant, occurred in 141 recipients (32%). Alpha- and pi-GST levels significantly increased during machine perfusion. The adjusted relative risks (95% confidence interval) of DGF with each log-unit increase in base and post pi-GST were 1.14 (1.0-1.3) and 1.36 (1.1-1.8), respectively. Alpha-GST was not independently associated with DGF. There were no significant differences in GST values between discarded and transplanted kidneys, though renal resistance was significantly higher in discarded kidneys. We found pi-GST at the end of machine perfusion to be independently associated with DGF. Further studies should elucidate the utility of GST for identifying injured kidneys with regard to organ allocation, discard and recipient management decisions.

Medical outcomes in African American live kidney donors: a matched cohort study.

It is uncertain if live kidney donation increases future risk of hypertension and kidney disease in African Americans. We conducted a cohort study across two transplant centers enrolling African Americans who donated between 1993 and 2006. A comparison group of African American nondonors were selected from healthy participants in the Coronary Artery Risk Development in Young Adults (CARDIA) prospective cohort study. A total of 103 donors and 235 matched nondonors were assessed at mean ( ± SD) of 6.8 ± 2.3 and 6.4 ± 2.2 years after donation or cohort entry, respectively. The primary outcome was risk of hypertension in donors at follow-up. The secondary outcomes were proportion of donors with eGFR <60 mL/min/1.73 m2 and microalbuminuria. Hypertension risk was higher in donors compared to nondonors (42/103 [40.8%] vs. 42/235 [17.9%]), absolute risk difference 22.9% (95% confidence interval 12.2-33.6%) and relative risk 2.4 (95% confidence interval 1.7-3.4). Of the 42 donors with hypertension, 22 (52.4%) were untreated. Sixteen donors (15.5%) had an eGFR <60 mL/min/1.73 m(2) , 6 (5.8%) had microalbuminuria and none were on dialysis. Our retrospective study shows that live kidney donation is associated with increased risk of hypertension in African Americans and emphasizes the importance of donor follow-up.

Rates and determinants of HIV-attributable mortality among rural female sex workers in Northern Karnataka, India.

Female sex workers (FSWs) have among the highest rates of HIV infection in India. However, little is known about their HIV-specific mortality rates. In total, 1561 FSWs participated in a cohort study in Karnataka. Outcome data (mortality) were available on 1559 women after 15 months of follow-up. To gather details on deaths, verbal autopsy (VA) questionnaires were administered to key informants. Two physicians reviewed the VA reports and assigned underlying causes of death. Forty-seven deaths were reported during the follow-up (overall mortality rate was 2.44 per 100 person-years), with VA data available on 45 women. Thirty-five (75.6%) of these women were known to be HIV-positive, but only 42.5% were on antiretroviral therapy (ART). Forty deaths were assessed to be HIV-related, for an HIV-attributable mortality rate of 2.11 deaths per 100 person-years. Absence of a current regular partner (incidence rate ratio: 2.79; 95% confidence interval [CI]: 1.39-5.60) and older age (1.06; 1.01-1.11) were associated with increased HIV-attributable mortality. Reported duration in sex work was not related to HIV-attributable mortality. We found a high HIV-related mortality rate among this cohort of FSWs; nearly 10 times that of national mortality rates among women of a similar age group. Older age, but not reported duration in sex work, was associated with increased mortality, and suggests HIV acquisition prior to self-reported initiation into sex work. Despite significant efforts, there remain considerable gaps in HIV prevention near or before entry into sex work, as well as access and uptake of HIV treatment among FSWs.

Short- and long-term outcomes with the use of kidneys and livers donated after cardiac death.

The shortage of deceased donor kidneys and livers for transplantation has prompted the use of organs from donors deceased after cardiac death (DCD). We used the UNOS database to examine patient and graft survival following transplantation of DCD organs compared to those following grafts from donors deceased after brain death (DBD; for livers, grafts from donors < 60 years old were labeled '< 60 yrs'). Of 44035 deceased donor kidney transplant recipients, 1177 (3%) received a DCD kidney. There was no difference in patient or graft survival at 5 years (DCD vs. DBD: 81.3% vs. 80.8% and 66.9% vs. 66.5%; p = 0.70 and p = 0.52 respectively). Of 24688-deceased donor liver transplant recipients, 345 (1.4%) were from DCD donors and 20289 (82%) were from '< 60 yrs' DBD donors. Three-year patient and graft survival were inferior in the DCD group (DCD vs. '< 60 yrs' DBD: 77% vs. 80% and 65% vs. 75%; p = 0.016 and p < 0.0001 respectively) but were comparable to current alternatives, '>/= 60 yrs' DBD livers (donor age >/= 60) and split livers. DCD livers are a reasonable option when death is imminent. Our study demonstrates good outcomes using DCD kidneys and livers and encourages their use.

Short-term experience with early steroid withdrawal in African-American renal transplant recipients.

There are limited data on the results of early steroid withdrawal (ESW) in African-American (AA) renal allograft recipients. We examined short-term transplant outcomes in a retrospective, non-concurrent cohort study of 40 AAs who did not (ESW group), and 33 who did [steroid maintenance (SM) group] receive maintenance steroids after day 4 post-transplant. Patients received thymoglobulin (ATG) induction, mycophenolate mofetil, and tacrolimus or sirolimus. Data were analyzed using survival analysis methods and regression models. Patients in the ESW group were older, had lower current panel reactive antibody and fewer re-transplants, and received fewer doses of ATG. One-year graft survival and acute rejection (AR) rates were 100% and 13% in the ESW group and 97% and 15% in the SM group. After controlling for confounders, at 1 year, ESW was not associated with higher risk of graft loss, AR, or worse graft function, but was associated with less weight gain. The SM group had higher cholesterol levels at 3 months and higher risk of post-transplant diabetes mellitus. We did not observe any cases of subclinical rejection. This study suggests that ESW under modern immunosuppression is safe over the short term in at least a subset of AA recipients with risk profiles similar to those studied herein, and could be associated with improved outcomes.

Fulminant liver failure: an indicator of silent myocardial rupture.

A 56 year old man presented with an atypical chest infection. Remote inferoposterior myocardial infarction was noted on electrocardiography and transthoracic echocardiography. Hepatic failure developed with sudden gross elevation of liver aminotransferases and coagulopathy. No primary hepatic cause could be identified. Subsequent right heart failure led to transoesophageal echocardiography that revealed a large inoperable ventricular septal defect. Histopathological data showed ischaemic hepatitis and reinfarction of the inferoposterior myocardial wall. Acute cardiac events may be silent and precipitate misleading severe hepatic dysfunction.

Early diagnosis of skin cancer based on segmentation and measurement of vascularization and pigmentation in Nevoscope images.

This work presents techniques developed for automated image segmentation and classification of skin lesions as malignant or benign based on the ground truth. For each skin lesion two images are obtained, one in each of two different modalities of epiluminescence microscopy (ELM): side-transillumination which highlights the subsurface vasculature and surface pigmentation, and cross polarization, which only highlights the details of skin surface pigmentation. The automated procedure consists of three steps: i) Segmentation of images, using three segmentation methods; ii) Selection of the most accurate segmentation results based on a weighted scoring technique; and iii) classification of the lesion as malignant or benign by verifying the presence of a ring of hypervascularity around the lesion in the side transillumination images. The segmentation results were validated against manual segmentation by an expert and the malignancy results were validated against the result from pathology.

Multiple clinical manifestation of HTLV1 infection in a single patient

HTLV-1 infection is endemic in the Caribbean and several publications have reported the clinical disease entities seen in this population of patients. This case report is an account of a patient admitted to Kingstown General Hospital, St Vincent and the Grenadines, who had severe infective dermatitis, tropical spastic paraparesis (TSP) and Non-Hodgkin's Lymphoma (NHL). As far as we are aware, all three diseases have not been described in a single patient