The impact of proposed changes in liver allocation policy on cold ischemia times and organ transportation costs.

Changes to the liver allocation system have been proposed to decrease regional variation in access to liver transplant. It is unclear what impact these changes will have on cold ischemia times (CITs) and donor transportation costs. Therefore, we performed a retrospective single center study (2008-2012) measuring liver procurement CIT and transportation costs. Four groups were defined: Local-within driving distance (Local-D, n = 262), Local-flight (Local-F, n = 105), Regional-flight <3 h (Regional <3 h, n = 61) and Regional-Flight >3 h (Regional >3 h, n = 53). The median travel distance increased in each group, varying from zero miles (Local-D), 196 miles (Local-F), 384 miles (Regional <3 h), to 1647 miles (Regional >3 h). Increasing travel distances did not significantly increase CIT until the flight time was >3 h. The average CIT ranged from 5.0 to 6.0 h for Local-D, Local-F and Regional <3 h, but increased to 10 h for Regional >3 h (p < 0.0001). Transportation costs increased with greater distance traveled: Local-D $101, Local-F $1993, Regional <3 h $8324 and Regional >3 h $27 810 (p < 0.0001). With proposed redistricting, local financial modeling suggests that the average liver donor procurement transportation variable direct costs will increase from $2415 to $7547/liver donor, an increase of 313%. These findings suggest that further discussion among transplant centers and insurance providers is needed prior to policy implementation.

What liver transplant outcomes can be expected in the uninsured who become insured via the Affordable Care Act?

Our study objective is to measure the survival impact of insurance status following liver transplantation in a cohort of uninsured "charity care" patients. These patients are analogous to the population who will gain insurance via the Affordable Care Act. We hypothesize there will be reduced survival in charity care compared to other insurance strata. We conducted a retrospective study of 898 liver transplants from 2000 to 2010. Insurance cohorts were classified as private (n = 640), public (n = 233) and charity care (n = 23). The 1, 3 and 5-year survival was 92%, 88% and 83% in private insurance, 89%, 80% and 73% in public insurance and 83%, 72% and 51% in charity care. Compared to private insurance, multivariable regression analyses demonstrated charity care (HR 3.11, CI 1.41-6.86) and public insurance (HR 1.58, CI 1.06-2.34) had a higher 5-year mortality hazard ratio. In contrast, other measures of socioeconomic status were not significantly associated with increased mortality. The charity care cohort demonstrated the highest incidence of acute rejection and missed clinic appointments. These data suggest factors other than demographic and socioeconomic may be associated with increased mortality. Further investigations are necessary to determine causative predictors of increased mortality in liver transplant patients without private insurance.

Patient satisfaction, chronic pain, and quality of life after elective incisional hernia repair: effects of recurrence and repair technique.

PURPOSE: To determine the effects of repair technique and hernia recurrence on patient-reported outcomes after incisional hernia repair. METHODS: This cohort study included patients from sixteen Veteran's Affairs Medical Centers across the United States who underwent elective incisional hernia repair between 1997 and 2002. Technical details and outcomes (repair type and recurrence status) were determined by physician chart review. Patient satisfaction, chronic pain (McGill pain scale and visual analogue scale), and health-related quality of life (Short Form 36) were evaluated with a mailed survey at a median of five years after repair. Multivariable regression modeling was performed to evaluate the effect of repair type and recurrence status on patient-reported outcomes. RESULTS: Of 854 patients alive at the time of survey mailing, 371 responded (43.4%). Patients with active recurrence were more likely to be dissatisfied with their results (odds ratio (OR) 6.2, P < 0.0001), to have chronic sensory hernia site pain (OR 3.2, P = 0.01), to report disturbance from pain (OR 2.1, P = 0.04), and to have significantly worse quality of life on the Physical Function, General Health, and Physical Component Score domains. Repair technique with permanent mesh versus suture had no independent effect on patient satisfaction, chronic pain, or QOL. CONCLUSIONS: Recurrence has a substantial negative effect on patient-reported outcomes after incisional hernia repair, whereas the repair technique has no independent effect.

Evaluation of 3-ethoxy-1,2,4-dithiazoline-5-one (EDITH) as a new sulfurizing reagent in combination with labile exocyclic amino protecting groups for solid-phase oligonucleotide synthesis.

3-ethoxy-1,2,4-dithiazoline-5-one (EDITH) was recently introduced as an efficient sulfurizing reagent for solid-phase oligonucleotide synthesis. The successful syntheses were performed using standard base protecting groups (i.e. benzoyl for A and C, isobutyryl for G), which required deprotection in concentrated ammonium hydroxide at 55 degrees C for 15-18 h. We have explored the possibility of using EDITH in combination with fast deprotection chemistry(e.g. Expedite Chemistry using tert -butylphenoxy acetyl as a base protecting group). Surprisingly, poor synthesis performance was observed when syntheses were conducted with EDITH, Expedite Chemistry and standard synthesis cycle (i.e. Coupling-Thio-Cap). Potential G modification seemed to be the source of incompatibility since sequences containing no G or carrying isobutyryl- protected G residues could be synthesized with high efficiency. However, the deleterious G modification can be readily eliminated by inserting a capping step before the sulfurization reaction. Oligomers prepared with the Coupling-Cap-Thio-Cap cycle contained few phosphodiester contaminants as measured by31P-NMR, anion-exchange HPLC and MALDI-TOF mass spectrometry. In addition to reducing deprotection time, this new combination also provides a mild method for the preparation of certain phosphorothioate oligomers that may be sensitive to prolonged ammonia treatment (e.g. thioated RNAs).

Developing practice guidelines for psychoanalysis.

Consensus-based practice guidelines codify clinical intelligence and the rich oral tradition in medicine. Because they reflect actual practice, they are readily accepted by clinicians as a basis for external review. This article illustrates the development of guidelines for a psychoanalytic approach to the large pool of patients who present with a depression. It suggests an integrated biopsychosocial approach to these individuals that is useful in current practice, and it offers propositions that may be tested in future research undertakings. Eventually, practice guidelines such as these may form the basis of economical systems of health care that avoid arbitrary, clinically untenable limitations on services.

A twenty-four year retrospective study of dependent catheter paracentesis.

Dependent catheter paracentesis has been used on 590 patients over the last 24 years. The complication rate is zero. It is faster, as accurate, cheaper and less hypersensitive than diagnostic peritoneal lavage. Open, semi-open and closed diagnostic peritoneal lavage when used with trocars is unjustified because of a significant complication rate.

Social aspects of body image: perception of normalcy of weight and affect of college undergraduates.

Two aspects of body image, perception of normalcy of weight and affect, were studied by means of a paper-and-pencil test with 62 male and 117 female undergraduates. The relationship of the social characteristics of sex, age, race, and actual body weight (underweight, normal weight, overweight) to body-image distortion was investigated. Individuals who were underweight or overweight were more likely to perceptually distort their weight-related appearance than were normal weight respondents. Among those who misperceived their weight-related appearance, both underweight and overweight persons tended to normalize their appearance. Among those who misperceived their weight-related appearance, sex was also related to the type of perceptual distortion experienced. Females tended to perceive themselves as appearing heavier, whereas males tended to perveive themselves as appearing lighter, than they actually were. There was no relationship between perceptual distortion of body weight and body affect. Age, race, and actual body weight were related to affect. Affect was more negative among young respondents than older respondents. White individuals had poorer affect scores than non-whites. Overweight respondents also had more negative affect scores than other respondents.