What Is the Role of Developmental Disability in Patient Selection for Pediatric Solid Organ Transplantation?

The National Organ Transplant Act stipulates that deceased donor organs should be justly and wisely allocated based on sound medical criteria. Allocation schemes are consistent across the country, and specific policies are publicly vetted. Patient selection criteria are largely in the hands of individual organ transplant programs, and consistent standards are less evident. This has been particularly apparent for patients with developmental disabilities (DDs). In response to concerns regarding the fairness of transplant evaluations for patients with DDs, we developed a transplant centerwide policy using a multidisciplinary, community-based approach. This publication details the particular policy of our center. All patients should receive individualized assessments using consistent standards; disability should be neither a relative nor an absolute contraindication to transplantation. External review can increase trust in the selection process. Patients in persistent vegetative states should not be listed for transplantation.

Multivisceral transplantation using a 2.9 kg neonatal donor.

Prematurity and very low birthweight have often been considered relative contraindications to neonatal organ donation. Organ procurement from neonatal donors is further complicated by unclear guidelines regarding neonatal brain death. We report a successful case of multivisceral transplantation using a graft from a 10-day-old, 2.9 kg, neonatal donor born at 36 6/7 wk in a 3.2 kg, three month old with intestinal and liver failure secondary to midgut volvulus. There was immediate liver graft function with correction of recipient coagulopathy, but delayed normalization of laboratory values and delayed return of bowel function. At six-yr post-transplant follow-up, the patient has normal intestine and liver function. Her last histologically confirmed rejection episode was 30 months prior to last follow-up. This case suggests that multivisceral grafts from very young or small neonatal donors may be transplanted successfully in selected cases. We propose a re-examination of the brain death guidelines for premature and young infants to potentially increase the availability of organs for infant recipients.

Depot-specific regulation of glucose uptake and insulin sensitivity in HIV-lipodystrophy.

Altered fat distribution is associated with insulin resistance in HIV, but little is known about regional glucose metabolism in fat and muscle depots in this patient population. The aim of the present study was to quantify regional fat, muscle, and whole body glucose disposal in HIV-infected men with lipoatrophy. Whole body glucose disposal was determined by hyperinsulinemic clamp technique (80 mU x m(-2) x min(-1)) in 6 HIV-infected men and 5 age/weight-matched healthy volunteers. Regional glucose uptake in muscle and subcutaneous (SAT) and visceral adipose tissue (VAT) was quantified in fasting and insulin-stimulated states using 2-deoxy-[18F]fluoro-D-glucose positron emission tomography. HIV-infected subjects with lipoatrophy had significantly increased glucose uptake into SAT (3.8 +/- 0.4 vs. 2.3 +/- 0.5 micromol x kg tissue(-1) x min(-1), P < 0.05) in the fasted state. Glucose uptake into VAT did not differ between groups. VAT area was inversely related with whole body glucose disposal, insulin sensitivity, and muscle glucose uptake during insulin stimulation. VAT area was highly predictive of whole body glucose disposal (r2 = 0.94, P < 0.0001). This may be mediated by adiponectin, which was significantly associated with VAT area (r = -0.75, P = 0.008), and whole body glucose disposal (r = 0.80, P = 0.003). This is the first study to directly demonstrate increased glucose uptake in subcutaneous fat of lipoatrophic patients, which may partially compensate for loss of SAT. Furthermore, we demonstrate a clear relationship between VAT and glucose metabolism in multiple fat and muscle depots, suggesting the critical importance of this depot in the regulation of glucose and highlighting the significant potential role of adiponectin in this process.

Relative attractiveness of diagnostic radiology: assessment with data from the National Residency Matching Program and comparison with the strength of the job market.

PURPOSE: To quantify medical students' preferences for various specialties and to compare shifts in specialty preference with overall employment market prospects. MATERIALS AND METHODS: By using National Residency Matching Program data, a previously validated help-wanted index (HWI), and American Medical Association (AMA) salary data, the authors quantified medical students' preferences for various specialties and examined the association of shifts in specialty preference with overall trends as seen in the strength of the diagnostic radiology match and its relationship with the job market. The authors established a proxy for the relative attractiveness (RA) of diagnostic radiology (relative to all specialties) in the match, which was calculated by subtracting the percentage fill rate for all specialties from that for radiology. The RA values were plotted for 1990-2000 and compared with trends in the HWI, American College of Radiology data, and AMA salary data. RESULTS: The RA of diagnostic radiology varied greatly during the past 10 years, with a low in 1996 and a return to its high in recent years. There is a relationship between the RA and economic vitality of diagnostic radiology, with the RA lagging behind the HWI and AMA salary data by 2 years. CONCLUSION: Medical students appear to have an in-depth understanding of the economic forces at play in the health care job market and incorporate this information into their choice of a specialty.

Pediatric radiology at the millennium.

PURPOSE: To evaluate the current practice of and job market for pediatric radiologists in the United States and Canada with a 1998 survey and compare findings with those of surveys from 1980 and 1989. MATERIALS AND METHODS: Surveys were mailed to the 728 active members of the Society for Pediatric Radiology. Questions covered professional practice, subspecialization, and involvement in evolving technologies. A pediatric radiology help-wanted index was generated from a diagnostic radiology help-wanted index. RESULTS: Increasing involvement in the interpretation of computed tomographic, ultrasonographic, and magnetic resonance images was found among the 57% (411 of 728) of the members who responded. The attainment of a certificate of added qualification in pediatric radiology was found in nearly three-fourths of the membership, and 85% (348 of 408) had completed a fellowship. More than half of the respondents were involved in interventional procedures amid a continued increase in volume; 24% (100 of 409) of the membership, as compared with 7% in the 1980 survey, was practicing in a community or "other" setting. Subspecialization within pediatric radiology had diminished, and there was a larger percentage of female pediatric radiologists, particularly among the newest members. The job market was robust, having recovered substantially since the middle 1990s. CONCLUSION: The practice of pediatric radiology has evolved, with increasing involvement in advanced techniques and modalities, as well as a greater presence in community settings. The help-wanted index supports the recent discussions of a personnel shortfall.

Changes in the market for diagnostic radiologists as measured through a help wanted index.

OBJECTIVE: We sought to create and validate a help wanted index for tracking changes in the radiology job market. SUBJECTS AND METHODS: All jobs advertised in Radiology and the American Journal of Roentgenology from January 1991 through December 1998 were tracked according to three separate parameters: academic versus private practice, subspecialty, and region. Statistical comparison was made between the first and second 48-month subperiods to identify changes. RESULTS: Thirteen thousand seven hundred one advertised positions were coded. A dramatic decrease in job advertisements was noted after December 1991, with advertisements falling to one eighth of their late 1991 peak. A recovery has occurred, with advertising now approaching peak levels. Shifts were seen toward more private practice, midwestern location, vascular and interventional, and mammography positions. Declines occurred in the share of positions in California, the Southwest, and several radiology subspecialties. Other trends were noted but were statistically less significant. A strong correlation (R = 0.98) was found between the annual number of positions advertised and radiologists' median incomes relative to those of all physicians. CONCLUSION: The job market in radiology, much as in other fields, can be tracked in a coincident manner with the use of a help wanted index. Changes in the makeup of radiology practice are important and are identified in a well-constructed index. These findings have validity and can be useful as an adjunct to other information for policy and planning purposes.

Stimulus configuration and context effects in perceptual organization in schizophrenia.

Two studies assessed perceptual organization in schizophrenia to determine (a) whether inpatient and outpatient groups with poor premorbid schizophrenia have comparable levels of perceptual organization deficit; and (b) whether the deficit could be eliminated by task manipulations. In Study 1, inpatients demonstrated clear evidence of a perceptual organization deficit, whereas outpatients performed similarly to the control groups. In Study 2, a performance pattern that operationally defined a perceptual organization deficit was eliminated by a task manipulation thought to aid in context processing. The perceptual organization deficit is most pronounced in actively symptomatic patients with poor premorbid schizophrenia, and the deficit reflects, in part, deficient top-down influences to basic perceptual processes.

Effects of explicit time-limits on the initial therapeutic alliance.

This study investigated the hypothesis that the setting of explicit time-limits in individual counseling enhances the formation of the therapeutic alliance. Students at a university-based counseling center were randomly assigned to a 5-session, time-limited therapy condition (n = 16) or a time-unlimited therapy condition (n = 15). Contrary to the hypothesis, statistical analyses showed no differences between audiotaped segments from the second and third therapy sessions rated on the Vanderbilt Therapeutic Alliance Scale.

Property rights and payment to patients for cell lines derived from human tissues: an economic analysis.

The increasing potential for commercial applications in biotechnology has given rise to new legal and ethical questions with regard to ownership of human tissue. As the potential value of human cells and tissue has risen, so have donors' calls for a share in the profits. However, in a recent California ruling (John Moore vs the Regents of the University of California), the court once again held to its traditional position that individuals do not hold property rights in their own tissue and cells. We will show that, in the rare case where tissue value may be determined prospectively, a one-time payment (and, hence granting a property right) is efficient. Moore is such a case. In general, however, the transactions costs of granting full property rights to donors of tissue and cells outweigh the benefits of such a change in policy.

Overcorrections of the Wies procedure.

The Wies procedure may be complicated by an overcorrection, which is in effect a cicatricial ectropion. Four cases of such a complication are presented. The mechanism of an overcorrection is related to the level of the incision in the lid and to the suture placement. Correction of this complication primarily involves lysing cicatricial bands maintaining the overcorrection. Placement of sutures maintains the lid in a normal position.

Correction of upper eyelid retraction.

We used two surgical procedures to treat upper eyelid retraction in ten patients: either a posterior myectomy or the anterior levator muscle recession technique. Our choice was usually based on the amount of retraction. We used the posterior myectomy technique to treat up to 2 mm of retraction or localized retractions (five cases), particularly after blepharoptosis surgery. We used the anterior recession method to treat more than 2mm of retraction (five cases), particularly when associated with dysthyroid ocular disease. Complex eyelid contour abnormalities were treated with a combined recession-resection approach to the aponeurosis of the levator palpebrae superioris muscle (one case).

Overcorrections of the Wies procedure.

The Wies procedure may be complicated by an overcorrection, which is in effect a cicatricial ectropion. Four cases of such a complication are presented. The mechanism of an overcorrection is related to the level of the incision in the lid and to the suture placement. Correction of this complication primarily involves lysing cicatricial bands maintaining the overcorrection. Placement of sutures maintains the lid in a normal position.

Pigmented paravenous retinochorodial atrophy.

Three male patients had paravenous pigmented retinochoroidal atrophy. Extensive retinal function tests showed characteristic retinal pigment epithelial abnormalities on fluorescein angiography, loss of peripheral visual field, diminution of the electroretinographic b-wave, and elevated rod threshold on dark adaptometry. The disease appears to be more progressive than previously indicated, and in late stages, may cause legal blindness through involvement of the posterior pole. No treatment is known.

Slow saccadic eye movements in Wilson's disease.

This is the first reported case of Wilson's disease where a global defect of saccadic eye movements has been documented by electro-oculography. The defect of rapid eye movements is discussed in relation to current anatomical, pathological, and experimental work relating to the descending frontobulbar saccadic eye movement system. It is suggested that the caudate nucleus pathology in Wilson's disease might be responsible for the defect of saccadic movement by interrupting a descending polysynaptic pathway.