Accuracy of Parent-Reported Allergies and Medications in Pediatric Dentistry.

Purpose: To measure the accuracy of parent-reported allergies and medication usage by comparing parental reports during dental con- sultations to medical reports from their child's primary care physician. Methods: A retrospective chart review was performed for 862 eligible patients 17 years and younger seen in the Department of Pediatric Dentistry at Franciscan Children's, Boston, Mass., USA, and who were required to obtain medical clearance prior to initiating dental treatment with sedation or general anesthesia. Allergies were categorized into three groups: food, environmental, and drug allergies. Allergies in each category reported by the parents were compared to the physician-reported allergies to assess for accuracy. Medications reported by the parents were also compared to the total number of medications reported by the physician and categorized as a full, partial, or non-match. Results: The sensitivity of parental identification for drug, food, and environmental allergies was 50.9 percent, 48.1 percent, and 18.8 percent, respectively. Of the 245 patients taking prescription medications, 53.1 percent of parents were unable to identify any of their child's medications, 22.9 percent of parents were partially able to identify their child's medications, and only 24.1 percent of parents were able to identify their child's medications fully. Among parents of children who take one or more medications as reported by their physician, the average reporting accuracy was 34.7 percent. Conclusion: Utilizing interprofessional collaboration is warranted in identifying accurate reports of patient allergies and medication usage in the pediatric population to prevent adverse reactions and improve the overall quality of dental care.

Portable hypothermic oxygenated machine perfusion for organ preservation in liver transplantation: A randomized, open-label, clinical trial.

BACKGROUND AND AIMS: In liver transplantation, cold preservation induces ischemia, resulting in significant reperfusion injury. Hypothermic oxygenated machine perfusion (HMP-O 2 ) has shown benefits compared to static cold storage (SCS) by limiting ischemia-reperfusion injury. This study reports outcomes using a novel portable HMP-O 2 device in the first US randomized control trial. APPROACH AND RESULTS: The PILOT trial (NCT03484455) was a multicenter, randomized, open-label, noninferiority trial, with participants randomized to HMP-O 2 or SCS. HMP-O 2 livers were preserved using the Lifeport Liver Transporter and Vasosol perfusion solution. The primary outcome was early allograft dysfunction. Noninferiority margin was 7.5%. From April 3, 2019, to July 12, 2022, 179 patients were randomized to HMP-O 2 (n=90) or SCS (n=89). The per-protocol cohort included 63 HMP-O 2 and 73 SCS. Early allograft dysfunction occurred in 11.1% HMP-O 2 (N=7) and 16.4% SCS (N=12). The risk difference between HMP-O 2 and SCS was -5.33% (one-sided 95% upper confidence limit of 5.81%), establishing noninferiority. The risk of graft failure as predicted by Liver Graft Assessment Following Transplant score at seven days (L-GrAFT 7 ) was lower with HMP-O 2 [median (IQR) 3.4% (2.4-6.5) vs. 4.5% (2.9-9.4), p =0.024]. Primary nonfunction occurred in 2.2% of all SCS (n=3, p =0.10). Biliary strictures occurred in 16.4% SCS (n=12) and 6.3% (n=4) HMP-O 2 ( p =0.18). Nonanastomotic biliary strictures occurred only in SCS (n=4). CONCLUSIONS: HMP-O 2 demonstrates safety and noninferior efficacy for liver graft preservation in comparison to SCS. Early allograft failure by L-GrAFT 7 was lower in HMP-O 2 , suggesting improved early clinical function. Recipients of HMP-O 2 livers also demonstrated a lower incidence of primary nonfunction and biliary strictures, although this difference did not reach significance.

Neuronal plasticity contributes to postictal death.

Repeated generalized tonic-clonic seizures (GTCSs) are the most critical risk factor for sudden unexpected death in epilepsy (SUDEP). GTCSs can cause fatal apnea. We investigated neuronal plasticity mechanisms that precipitate postictal apnea and seizure-induced death. Repeated seizures worsened behavior, precipitated apnea, and enlarged active neuronal circuits, recruiting more neurons in such brainstem nuclei as periaqueductal gray (PAG) and dorsal raphe, indicative of brainstem plasticity. Seizure-activated neurons are more excitable and have enhanced AMPA-mediated excitatory transmission after a seizure. Global deletion of the GluA1 subunit of AMPA receptors abolishes postictal apnea and seizure-induced death. Treatment with a drug that blocks Ca2+-permeable AMPA receptors also renders mice apnea-free with five-fold better survival than untreated mice. Repeated seizures traffic the GluA1 subunit-containing AMPA receptors to synapses, and blocking this mechanism decreases the probability of postictal apnea and seizure-induced death.

Future Approaches and Therapeutic Modalities for Acute-on-Chronic Liver Failure.

Acute-on-chronic liver failure (ACLF) results from an acute decompensation of cirrhosis due to exogenous insult. The condition is characterized by a severe systemic inflammatory response, inappropriate compensatory anti-inflammatory response, multisystem extrahepatic organ failure, and high short-term mortality. Here, the authors evaluate the current status of potential treatments for ACLF and assess their efficacy and therapeutic potential.

Addressing the Burden and Management Strategies for Disparities and Inequities Among Liver Transplant Professionals: The ILTS Experience.

Medical professional environments are becoming increasingly multicultural, international, and diverse in terms of its specialists. Many transplant professionals face challenges related to gender, sexual orientation or racial background in their work environment or experience inequities involving access to leadership positions, professional promotion, and compensation. These circumstances not infrequently become a major source of work-related stress and burnout for these disadvantaged, under-represented transplant professionals. In this review, we aim to 1) discuss the current perceptions regarding disparities among liver transplant providers 2) outline the burden and impact of disparities and inequities in the liver transplant workforce 3) propose potential solutions and role of professional societies to mitigate inequities and maximize inclusion within the transplant community.

Pre-transplant Biomarkers of Immune Dysfunction Improve Risk Assessment of Post-transplant Mortality Compared to Conventional Clinical Risk Scores.

Introduction: There is a critical need to accurately stratify liver transplant (LT) candidates' risk of post-LT mortality prior to LT to optimize patient selection and avoid futility. Here, we compare previously described pre-LT clinical risk scores with the recently developed Liver Immune Frailty Index (LIFI) for prediction of post-LT mortality. LIFI measures immune dysregulation based on pre-LT plasma HCV IgG, MMP3 and Fractalkine. LIFI accurately predicts post-LT mortality, with LIFI-low corresponding to 1.4% 1-year post-LT mortality compared with 58.3% for LIFI-high (C-statistic=0.85). Methods: LIFI was compared to MELD, MELD-Na, MELD 3.0, D-MELD, MELD-GRAIL, MELD-GRAIL-Na, UCLA-FRS, BAR, SOFT, P-SOFT, and LDRI scores on 289 LT recipients based on waitlist data at the time of LT. Survival, hazard of early post-LT death, and discrimination power (C-statistic) were assessed. Results: LIFI showed superior discrimination (highest C-statistic) for post-LT mortality when compared to all other risk scores, irrespective of biologic MELD. On univariate analysis, the LIFI showed a significant correlation with mortality 6-months, as well as 1-, 3-, and 5-years. No other pre-LT scoring system significantly correlated with post-LT mortality. On bivariate adjusted analysis, African American race (p<0.05) and pre-LT cardiovascular disease (p=0.053) were associated with early- and long-term post-LT mortality. Patients who died within 1-yr following LT had a significantly higher incidence of infections, including 30-day and 90-day incidence of any infection, pneumonia, abdominal infections, and UTI (p<0.05). Conclusions: LIFI, which measures pre-LT biomarkers of immune dysfunction, more accurately predicts risk of post-LT futility compared with current clinical predictive models. Pre-LT assessment of immune dysregulation may be critical in predicting mortality after LT and may optimize selection of candidates with lowest risk of futile outcomes.

An alternative generic groundwater-to-indoor air attenuation factor for application in commercial, industrial, and other nonresidential settings.

The default groundwater-to-indoor air attenuation factor (AF) of 10-3 (0.001) to assess the vapor intrusion (VI) pathway and generate VI screening levels for groundwater was developed by the United States Environmental Protection Agency (EPA) based on chlorinated volatile organic compound (VOC) indoor air and groundwater data collected in residential buildings and compiled in EPA's 2012 VI database. In their VI guidance published in 2015, EPA recognized that this default AF may be overly conservative for nonresidential buildings. In 2015, the Department of Defense (DoD) began developing a first-of-its-kind VI database to assess AFs at commercial and industrial buildings at DoD installations and support the development of alternative generic AF values. This database was expanded in 2019 to include 76 buildings at 22 DoD installations across the United States and is comparable in size to the EPA VI database. The DoD database includes chlorinated VOC data from groundwater and indoor air samples collected from multiple sampling zones within these buildings. Empirical groundwater-to-indoor air AFs were calculated using similar screening methods employed by EPA, including a source strength screen, to filter out potential background source contributions unrelated to VI. Analysis of indoor air-groundwater data pairs found that there is more attenuation occurring from groundwater to indoor air in DoD commercial and industrial buildings relative to residential buildings and that the DoD buildings' AFs are one to four orders of magnitude lower than EPA's residential-based default of 10-3. The results support the use of a generic groundwater AF of 10-4 (0.0001) to support VI assessment and develop groundwater screening levels specific to large commercial and industrial buildings as an alternative to the residential default AF.Implications: The use of groundwater-to-indoor air attenuation factors (AFs) is a key component of vapor intrusion (VI) pathway assessments and VI screening-level development for groundwater. Currently, the United States Environmental Protection Agency (EPA) and many state regulatory agencies use a default groundwater AF of 10-3 (0.001) based on chlorinated volatile organic compound (VOC) data collected in residential buildings. VI assessment data collected at Department of Defense (DoD) installations indicate that there is significantly more groundwater-to-indoor air attenuation occurring at DoD commercial and industrial buildings. For that reason, the default AF of 10-3 results in groundwater screening levels that are overestimating VI-related risks in these types of building. The DoD data support the use of a generic groundwater AF of 10-4 (0.0001) for conducting VI assessment and developing groundwater screening levels at large commercial and industrial buildings.

Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma: Analysis of the National Inpatient Sample From 2007 to 2014.

BACKGROUND: Hepatocellular carcinoma (HCC) remains a deadly disease, with patients' best hope for a cure being liver transplantation; however, access to health care resources, such as donor organs, between ethnic groups has historically been unbalanced. Ensuring equitable access to donor livers is crucial to minimize disparities in HCC outcomes. As a result, we sought to better elucidate the differences in transplantation rates among various ethnic groups. MATERIALS AND METHODS: The National Inpatient Sample (NIS) was utilized to evaluate for disparities in liver transplantation in patients whose primary or secondary diagnosis was recorded as HCC or hepatoma. The study included admissions between 2007 and 2014 to centers with at least 1 documented liver transplant. RESULTS: A total of 7244 transplants were performed over 70,406 weighted admissions. Black race was associated with lower transplantation rates, with an adjusted odds ratio of 0.46 (95% confidence interval: 0.42-0.51, P <0.01) when accounting for a number of possible confounders including socioeconomic and geographic factors. CONCLUSIONS: Our study observed decreased rates of liver transplant in blacks compared with whites for HCC. Furthermore, improved economic status and private insurance had a significantly higher odds ratio for transplantation. Hospital-level studies are needed to clarify confounding factors not apparent in large administrative datasets and help better investigate factors that lead to less optimal transplant rates among blacks. Interventions may include more optimal screening policies and procedures, improved interdisciplinary management, and earlier referrals.

Gender and Racial Disparity Among Liver Transplantation Professionals: Report of a Global Survey.

Equality, diversity, and inclusion (EDI) are fundamental principles. Little is known about the pattern of practice and perceptions of EDI among liver transplant (LT) providers. International Liver Transplant Society (ILTS) EDI Committee survey around topics related to discrimination, mentorship, and gender. Answers were collected and analyzed anonymously. Worldwide female leadership was also queried via publicly available data. The survey was e-mailed to 1312 ILTS members, 199 responses (40.7% female) were collected from 38 countries (15.2% response rate). Almost half were surgeons (45.7%), 27.6% hepatologists and 26.6% anesthetists. Among 856 LT programs worldwide, 8.2% of leadership positions were held by females, and 22% of division chiefs were female across all specialties. Sixty-eight of respondents (34.7%) reported some form of discrimination during training or at their current position, presumably related to gender/sexual orientation (20.6%), race/country of origin (25.2%) and others (7.1%). Less than half (43.7%) received mentorship when discrimination occurred. An association between female responses and discrimination, differences in compensation, and job promotion was observed. This survey reveals alarmingly high rate of experience with racial and gender disparity, lack of mentorship, and very low rates of female leadership in the LT field and calls to action to equity and inclusion.

Accuracy of parent-reported health history in a dental setting.

BACKGROUND: Obtaining thorough documentation of a patient's medical history is important for dental care professionals, as oral health is connected intricately to systemic health. The purpose of this study was to assess the accuracy of parent-reported health history for pediatric patients in a dental setting. METHODS: A retrospective chart review was conducted on 863 patients 17 years and younger. Parent-reported health history was compared with subsequent physician-to-dentist consultations. The most common diagnoses were grouped on the basis of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, categories. RESULTS: The sensitivity of parent report of health conditions was highest for reporting mental and behavioral disorders (75.1%; 95% CI, 69.6% to 80.0%), followed by nervous system diseases (63.0%; 95% CI, 47.5% to 76.8%), respiratory conditions (47.9%; 95% CI, 37.6% to 58.4%), congenital conditions (46.3%; 95% CI, 30.7% to 62.6%), and cardiovascular conditions (25.0%; 95% CI, 11.4% to 43.4%) and was lowest for hematologic conditions (12.2%; 95% CI, 4.1% to 26.2%). Parents of children 6 years and older and those with private insurance had higher sensitivity for reporting mental and behavioral conditions than those with children younger than 6 years or having Medicaid (P < .0001). The specificity of parent-reported health conditions ranged from 96.0% for mental and behavioral disorders to 99.8% for hematologic conditions. CONCLUSIONS: Sensitivity varied widely, showing that parents may be unreliable in their report of children's health histories and that dentists cannot rely solely on parents when obtaining health history. PRACTICAL IMPLICATIONS: In advocating for patient safety, especially for those with special needs and complex medical conditions, this study supports the use of medical evaluation before dental treatment and for the integration of dental and electronic health records.

Chilling Effects on Immigrants' Health Insurance Coverage After the 2016 Presidential Election.

BACKGROUND: Depressed enrollment in public benefits among immigrants and their families may occur due to concerns about deportation and obstacles to permanent residency status related to immigration policies. METHODS: Using data from the American Community Survey (ACS) from 2014 to 2019, we conducted an interrupted time series analysis to estimate Medicaid enrollment, private insurance enrollment, and uninsured rates among low-income non-citizen adults and their children, compared to U.S. citizens before and after the Trump administration entered office in January 2017. RESULTS: Compared to U.S. citizen adults, Medicaid enrollment among non-citizen adults decreased and the uninsured rate increased (1.5 percentage points per year, p < 0.05) from 2017 to 2019. Decreases in coverage starting in 2017 were larger among both children with at least one non-citizen parent and non-citizen children. DISCUSSION: These findings suggest that the Trump administration immigration policy climate is associated with decreased health insurance enrollment among this population.

Survival following liver transplantation for locally advanced, unresectable intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (iCCA) has previously been considered a contraindication to liver transplantation (LT). However, recent series showed favorable outcomes for LT after neoadjuvant therapy. Our center developed a protocol for neoadjuvant therapy and LT for patients with locally advanced, unresectable iCCA in 2010. Patients undergoing LT were required to demonstrate disease stability for 6 months on neoadjuvant therapy with no extrahepatic disease. During the study period, 32 patients were listed for LT and 18 patients underwent LT. For transplanted patients, the median number of iCCA tumors was 2, and the median cumulative tumor diameter was 10.4 cm. Patients receiving LT had an overall survival at 1-, 3-, and 5-years of 100%, 71%, and 57%. Recurrences occurred in seven patients and were treated with systemic therapy and resection. The study population had a higher than expected proportion of patients with genetic alterations in fibroblast growth factor receptor (FGFR) and DNA damage repair pathways. These data support LT as a treatment for highly selected patients with locally advanced, unresectable iCCA. Further studies to identify criteria for LT in iCCA and factors predicting survival are warranted.