National decline in donor heart utilization with regional variability: 1995-2010.

The severe shortage of donor hearts limits the availability of transplantation for the growing population of patients with end-stage heart disease. We examined national trends in donor heart acceptance for transplant. OPTN data were analyzed for all potential adult cardiac organ donors between 1995 and 2010. Donor heart disposition was categorized as transplanted, declined for transplant or other. We studied changes in the probability of donor heart acceptance according to demographic and clinical characteristics, nationwide and by UNOS region. Of 82 053 potential donor hearts, 34% were accepted and 48% were declined (18% used for other purposes). There was a significant decrease in donor heart acceptance from 44% in 1995 to 29% in 2006, and subsequent increase to 32% in 2010. Older donor age, female sex and medical co-morbidities predicted non-acceptance. Donor age and co-morbidities increased during the study period, with a concomitant decrease in acceptance of hearts from donors with undesirable characteristics. Overall, predictors of heart non-use were similar across UNOS regions, although utilization varied between regions. Regional variation suggests a potential to improve heart acceptance rates in under-performing regions, and supports research and policy efforts aimed at establishing evidence-based criteria for donor heart evaluation and acceptance for transplantation.

Regional variation in antenatal corticosteroid use: a network-level quality improvement study.

BACKGROUND AND OBJECTIVES: Examination of regional care patterns in antenatal corticosteroid use (ACU) rates may be salient for the development of targeted interventions. Our objective was to assess network-level variation using California perinatal care regions as a proxy. We hypothesized that (1) significant variation in ACU exists within and between California perinatal care regions, and (2) lower performing regions exhibit greater NICU-level variability in ACU than higher performing regions. METHODS: We undertook cross-sectional analysis of 33,610 very low birth weight infants cared for at 120 hospitals in 11 California perinatal care regions from 2005 to 2011. We computed risk-adjusted median ACU rates and interquartile ranges (IQR) for each perinatal care region. The degree of variation was assessed using hierarchical multivariate regression analysis with NICU as a random effect and region as a fixed effect. RESULTS: From 2005 to 2011, mean ACU rates across California increased from 82% to 87.9%. Regional median (IQR) ACU rates ranged from 68.4% (24.3) to 92.9% (4.8). We found significant variation in ACU rates among regions (P < .0001). Compared with Level IV NICUs, care in a lower level of care was a strongly significant predictor of lower odds of receiving antenatal corticosteroids in a multilevel model (Level III, 0.65 [0.45-0.95]; Level II, 0.39 [0.24-0.64]; P < .001). Regions with lower performance in ACU exhibited greater variability in performance. CONCLUSIONS: We found significant variation in ACU rates among California perinatal regions. Regional quality improvement approaches may offer a new avenue to spread best practice.

Impact of the lung allocation score on survival beyond 1 year.

Implementation of the lung allocation score (LAS) in 2005 led to transplantation of older and sicker patients without altering 1-year survival. However, long-term survival has not been assessed and emphasizing the 1-year survival metric may actually sustain 1-year survival while not reflecting worsening longer-term survival. Therefore, we assessed overall and conditional 1-year survival; and the effect of crossing the 1-year threshold on hazard of death in three temporal cohorts: historical (1995-2000), pre-LAS (2001-2005) and post-LAS (2005-2010). One-year survival post-LAS remained similar to pre-LAS (83.1% vs. 82.1%) and better than historical controls (75%). Overall survival in the pre- and post-LAS cohorts was also similar. However, long-term survival among patients surviving beyond 1 year was worse than pre-LAS and similar to historical controls. Also, the hazard of death increased significantly in months 13 (1.44, 95% CI 1.10-1.87) and 14 (1.43, 95% CI 1.09-1.87) post-LAS but not in the other cohorts. While implementation of the LAS has not reduced overall survival, decreased survival among patients surviving beyond 1 year in the post-LAS cohort and the increased mortality occurring immediately after 1 year suggest a potential negative long-term effect of the LAS and an unintended consequence of increased emphasis on the 1-year survival metric.

Beta-adrenergic receptor polymorphisms and cardiac graft function in potential organ donors.

Prior studies have demonstrated associations between beta-adrenergic receptor (ßAR) polymorphisms and left ventricular dysfunction-an important cause of allograft nonutilization for transplantation. We hypothesized that ßAR polymorphisms predispose donor hearts to LV dysfunction after brain death. A total of 1043 organ donors managed from 2001-2006 were initially studied. The following ßAR single nucleotide polymorphisms were genotyped: ß1AR 1165C/G (Arg389Gly), ß1AR 145A/G (Ser49Gly), ß2AR 46G/A (Gly16Arg) and ß2AR 79C/G (Gln27Glu). In multivariable regression analyses, the ß2AR46 SNP was significantly associated with LV systolic dysfunction, with each minor allele additively decreasing the odds for LV ejection fraction <50%. The ß1AR1165 and ß2AR46 SNPs were associated with higher dopamine requirement during the donor management period: donors with the GG and AA genotypes had ORs of 2.64 (95% CI 1.52-4.57) and 2.70 (1.07-2.74) respectively for requiring >10 µg/kg/min of dopamine compared to those with the CC and GG genotypes. However, no significant associations were found between ßAR SNPs and cardiac dysfunction in 364 donors managed from 2007-2008, perhaps due to changes in donor management, lack of power in this validation cohort, or the absence of a true association. ßAR polymorphisms may be associated with cardiac dysfunction after brain death, but these relationships require further study in independent donor cohorts.

The rs4774 CIITA missense variant is associated with risk of systemic lupus erythematosus.

The major histocompatibility complex (MHC) class II transactivator gene (CIITA) encodes an important transcription factor required for human leukocyte antigens (HLA) class II MHC-restricted antigen presentation. MHC genes, including the HLA class II DRB1*03:01 allele, are strongly associated with systemic lupus erythematosus (SLE). Recently the rs4774 CIITA missense variant (+1632G/C) was reported to be associated with susceptibility to multiple sclerosis. In the current study, we investigated CIITA, DRB1*03:01 and risk of SLE using a multi-stage analysis. In stage 1, 9 CIITA variants were tested in 658 cases and 1363 controls (N=2021). In stage 2, rs4774 was tested in 684 cases and 2938 controls (N=3622). We also performed a meta-analysis of the pooled 1342 cases and 4301 controls (N=5643). In stage 1, rs4774(*)C was associated with SLE (odds ratio (OR)=1.24, 95% confidence interval (95% CI)=1.07-1.44, P=4.2 × 10(-3)). Similar results were observed in stage 2 (OR=1.16, 95% CI=1.02-1.33, P=8.5 × 10(-3)) and the meta-analysis of the combined data set (OR=1.20, 95% CI=1.09-1.33, P(meta)=2.5 × 10(-4)). In all three analyses, the strongest evidence for association between rs4774(*)C and SLE was present in individuals who carried at least one copy of DRB1*03:01 (P(meta)=1.9 × 10(-3)). Results support a role for CIITA in SLE, which appears to be stronger in the presence of DRB1*03:01.

Assessing phonological skills in Hispanic/Latino children.

Phonological assessment of Hispanic/Latino children (many of whom are bilingual) is often difficult because of the limited information on appropriate assessment techniques. Without information on appropriate assessment strategies for these children, there may be a delay in their receiving diagnostic (and intervention) services and an inappropriate characterization of phonological skills in both typically developing children and children with phonological disorders. In order to assess the phonological skills of Hispanic/Latino children appropriately, speech-language pathologists (SLPs) must make modifications to the standard assessment protocol. To that end, SLPs must determine language of assessment, choose assessment tools, complete phonological analyses, and consider dialect in their assessment. The purpose of this article is to delineate the procedures for completing a thorough phonological assessment for Hispanic/Latino children.

Long-term inhibition of tinnitus by UltraQuiet therapy: preliminary report.

Masking of tinnitus by noise can produce residual inhibition, a persistence in the reduction in tinnitus after the noise is removed. Typically, this relief is very short-lived, on the order of minutes. This report highlights long-term inhibition of tinnitus by UltraQuiet therapy, a new technique that employs patterned sound in the 10- to 20-kHz range, presented through bone conduction. Nine subjects participated in a study of the efficacy of this tinnitus suppression technique. Eight reported improvement in tinnitus symptoms; one did not complete the study. The duration of the improvement ranged from days to weeks. This long-term inhibition may involve a truly plastic change in the brain at the central level.

Phonological patterns in Puerto Rican Spanish-speaking children with phonological disorders.

This study characterizes the phonological patterns in phonologically disordered Spanish-speaking children who speak the Puerto Rican dialect. A single-word assessment was used to describe the mean percentage-of-occurrence and standard deviation of phonological processes and the number and type of nontargeted process errors in 543- and 4-year-olds. Analyses were made in reference to the Puerto Rican dialect of Spanish, yielding a number of specific patterns that characterized the speech of these children.

The role of stimulability in the assessment and treatment of Spanish-speaking children.

Stimulability has been used successfully in planning treatment of phonological disorders in English-speaking children. The effectiveness of stimulability on the treatment of phonological disorders in speakers of languages other than English has not been investigated. Specifically, its role in treatment planning of phonological disorders in Spanish-speaking children has yet to be explored. The purpose of this article is to discuss the role of stimulability in the assessment and treatment of phonological disorders in Spanish-speaking children. Further, a case study applying these principles to a Spanish-speaking child with a phonological disorder is presented.

Selective adaptation to low spatial frequencies does not decrease the Mueller-Lyer illusion.

The idea that low spatial-frequency information in the Mueller-Lyer figure accounts for a major part of the illusion was tested in a series of five studies. In Study 1, subjects were selectively adapted to high or low square-wave spatial-frequency gratings with no difference in the magnitude of illusion they experienced. Similarly, adaptation to sinusoidal grating patterns with either high or low spatial frequency had no effect on the magnitude of illusion experienced (Studies 2 to 5). The failure of adaptation to low spatial-frequency gratings to affect the magnitude of illusion experienced indicates either that the illusion cannot be accounted for by the low spatial-frequency information or that adaptation of the visual system by grating patterns cannot be used to explore any effects of the low spatial frequencies in the figure.

Comparison of Tzanck smear, viral culture, and DNA diagnostic methods in detection of herpes simplex and varicella-zoster infection.

OBJECTIVE: To compare Tzanck smears, viral cultures, and DNA diagnostic methods using the polymerase chain reaction (PCR) in detection of herpes simplex virus (HSV) or varicella-zoster virus (VZV) infection in clinically suspected cases. DESIGN: A 12-month trial comparing PCR with viral cultures and Tzanck smears in patients with clinically suspected HSV or VZV infection. SETTING: Both ambulatory and hospitalized patients were recruited from a tertiary referral center and the Miami (Fla) Veterans Affairs Medical Center. PATIENTS: Convenience samples of patients clinically suspected to have HSV (n = 48) or VZV (n = 35). To be included in the final analysis patients needed to have a positive Tzanck smear, viral culture, or PCR result. Patients who were clinically suspected to have HSV but had VZV by viral culture or PCR were analyzed in the VZV group. Similarly, patients who were clinically suspected to have VZV, but had HSV by viral culture or PCR were analyzed in the HSV group. Seventy-seven patients were available for final analysis: HSV (n = 30), VZV (n = 32), and 15 control cases who did not have evidence of viral infection. RESULTS: For HSV, PCR detected HSV DNA sequences in 73% of stained smears and 83% of unstained smears. For VZV infection, VZV DNA sequences were detected in 88% of stained smears and 97% of unstained smears. Viral DNA sequences were not detected in the 15 control cases. Viral cultures were positive in 83% and 44% of HSV and VZV cases, respectively. The Tzanck smear was positive in 60% and 75% of HSV and VZV cases, respectively. CONCLUSIONS: PCR is a reliable method for detecting HSV and VZV DNA sequences from single stained and unstained Tzanck smears. It is clearly superior to viral culture in identifying VZV infection and is equivalent to conventional culture techniques in identifying cases of HSV.

Detection with the polymerase chain reaction of human papillomavirus DNA in condylomata acuminata treated in vitro with liquid nitrogen, trichloroacetic acid, and podophyllin.

BACKGROUND: The mechanisms of action for local treatments used against condylomata acuminata are unknown, but most are believed to cause physical destruction of infected tissue. OBJECTIVE: Our purpose was to determine whether liquid nitrogen, trichloroacetic acid (TCA), and podophyllin damage HPV DNA found in condylomata acuminata. METHODS: Fourteen genital warts were excised from 14 patients and divided. One part was treated with liquid nitrogen, the second and third parts were treated with TCA and podophyllin, respectively, and the remainder served as a control. DNA was then extracted from tissue by proteolytic digestion and amplified by the polymerase chain reaction. Dot blots were performed with the use of radiolabeled consensus and HPV type-specific probes. RESULTS: HPV DNA was amplified and detected in 100% of untreated specimens, in 92% of specimens treated with liquid nitrogen, and in 15% and 7% of specimens treated with podophyllin and TCA, respectively. CONCLUSION: TCA and podophyllin damage HPV DNA more effectively than does liquid nitrogen.

Probe-tube measurements of ALDs: uniformity, linearity and frequency response differences.

A Madsen IGO 1000 was used to assess six assistive listening devices (ALDs) (Sound Plus Infrared, Minicon Induction Floor Loop, Phonic Ear Phonear, Radio Shack Realistic Personal Amplifier, Williams Sound PockeTalker with induction neck loop and Williams Sound PockeTalker permanently wired) worn by a single subject. In situ measures determined product uniformity of three samples of each of the same ALDs, volume control linearity, ear coupling effects on canal resonance and frequency response differences. ALDs were generally uniform, although the two PockeTalker models showed gain variability at all frequencies. Frequency response changes controlled by high boost switches in the Realistic were also found not to be uniform. The earbud had almost no effect on canal resonance, while lightweight headphones caused a slight loss of canal resonance. Non-telecoil coupled devices had broader/flatter responses than telecoil coupled devices. Average differences between telecoil and non-telecoil coupling were minimal. Probe-tube measurements were found to be a feasible means of assessing ALDs in situ.

Effect of tinnitus masker noise on speech discrimination in quiet and two noise backgrounds.

Use of masking devices is achieving recognition as a means of providing tinnitus relief. While palliative results have been described, possible disruptive consequences have not yet received attention. The present study examined the effects of tinnitus masker noise on speech intelligibility. Twenty young normals listened to NU-6 word lists presented in sound field in quiet white noise, and cocktail party noise backgrounds (S/N = O dB) with and without a tinnitus masker. Although there was little impairment while wearing the masker in quiet, substantial discrimination loss was observed in the two noise backgrounds. The potential disruption in communication function while wearing a masking device is discussed.

Early identification of hearing impaired infants: Public Law 94-142 falls short.

Public Law (P.L.) 94-142, although greatly increasing the physician's role in delivery of services to handicapped children, falls short in meeting the needs of hearing impaired children from birth to 36 months in that it does not mandate referral services until age three years. The literature has shown that both conductive and sensorineural hearing losses cause delay in the development of normal speech and language. Further, those children identified and treated earlier demonstrate higher skill levels on speech and language tasks than those children identified late. The High Risk Register for hearing loss has been found a reliable means to identify such children. Given that the most critical period for learning language is from birth to three years and that at least two objective and reliable procedures for evaluating the hearing of infants and pre-school children, Impedance Audiometry and Brainstem Evoked Response Audiometry, are becoming more readily available in the United States, it is no longer acceptable to support the "wait and see" approach in referring suspected hearing impaired children for auditory, speech, and language diagnostics and habilitative intervention.