The Clinical and Economic Benefit of CMV Matching in Kidney Transplant: A Decision Analysis.

BACKGROUND: The development of cytomegalovirus (CMV) infection after kidney transplant remains a significant cause of posttransplant morbidity, graft loss, and mortality. Despite appropriate antiviral therapy, recipients without previous CMV exposure can currently be allocated a kidney from a donor with previous CMV infection (D+R-) that carries the greatest risk of posttransplant CMV infection and associated complications. Preferential placement of CMV D- organs in negative recipients (R-) has been shown to reduce the risk of viral infection and associated complications. METHODS: To assess the long-term survival and economic benefits of allocation policy reforms, a decision-analytic model was constructed to compare receipt of CMV D- with CMV D+ organ in CMV R- recipients using data from transplant registry, Medicare claims, and pharmaceutical costs. RESULTS: For CMV R- patients, receipt of a CMV D- organ was associated with greater average survival (14.3 versus 12.6 y), superior quality-adjusted life years (12.6 versus 9.8), and lower costs ($529 512 versus $542 963). One-way sensitivity analysis demonstrated a survival advantage for patients waiting as long as 30 mo for a CMV D- kidney. CONCLUSIONS: Altering national allocation policy to preferentially offer CMV D- organs to CMV R- recipients could improve survival and lower costs after transplant if appropriately implemented.

Evaluation of give kids a boost: A school-based program to increase booster seat use among urban children in economically disadvantaged areas.

OBJECTIVE: This study evaluated the effectiveness of a series of 1-year multifaceted school-based programs aimed at increasing booster seat use among urban children 4-7 years of age in economically disadvantaged areas. METHODS: During 4 consecutive school years, 2011-2015, the Give Kids a Boost (GKB) program was implemented in a total of 8 schools with similar demographics in Dallas County. Observational surveys were conducted at project schools before project implementation (P0), 1-4 weeks after the completion of project implementation (P1), and 4-5 months later (P2). Changes in booster seat use for the 3 time periods were compared for the 8 project and 14 comparison schools that received no intervention using a nonrandomized trial process. The intervention included (1) train-the-trainer sessions with teachers and parents; (2) presentations about booster seat safety; (3) tailored communication to parents; (4) distribution of fact sheets/resources; (5) walk-around education; and (6) booster seat inspections. The association between the GKB intervention and proper booster seat use was determined initially using univariate analysis. The association was also estimated using a generalized linear mixed model predicting a binomial outcome (booster seat use) for those aged 4 to 7 years, adjusted for child-level variables (age, sex, race/ethnicity) and car-level variables (vehicle type). The model incorporated the effects of clustering by site and by collection date to account for the possibility of repeated sampling. RESULTS: In the 8 project schools, booster seat use for children 4-7 years of age increased an average of 20.9 percentage points between P0 and P1 (P0 = 4.8%, P1 = 25.7%; odds ratio [OR] = 6.9; 95% confidence interval [CI], 5.5, 8.7; P < .001) and remained at that level in the P2 time period (P2 = 25.7%; P < .001, for P0 vs. P2) in the univariate analysis. The 14 comparison schools had minimal change in booster seat use. The multivariable model showed that children at the project schools were significantly more likely to be properly restrained in a booster seat after the intervention (OR = 2.7; 95% CI, 2.2, 3.3) compared to the P0 time period and compared to the comparison schools. CONCLUSION: Despite study limitations, the GKB program was positively associated with an increase in proper booster seat use for children 4-7 years of age in school settings among diverse populations in economically disadvantaged areas. These increases persisted into the following school year in a majority of the project schools. The GKB model may be a replicable strategy to increase booster seat use among school-age children in similar urban settings.

Preventing deaths and injuries from house fires: a cost-benefit analysis of a community-based smoke alarm installation programme.

BACKGROUND: Operation Installation (OI), a community-based smoke alarm installation programme in Dallas, Texas, targets houses in high-risk urban census tracts. Residents of houses that received OI installation (or programme houses) had 68% fewer medically treated house fire injuries (non-fatal and fatal) compared with residents of non-programme houses over an average of 5.2 years of follow-up during an effectiveness evaluation conducted from 2001 to 2011. OBJECTIVE: To estimate the cost-benefit of OI. METHODS: A mathematical model incorporated programme cost and effectiveness data as directly observed in OI. The estimated cost per smoke alarm installed was based on a retrospective analysis of OI expenditures from administrative records, 2006-2011. Injury incidence assumptions for a population that had the OI programme compared with the same population without the OI programme was based on the previous OI effectiveness study, 2001-2011. Unit costs for medical care and lost productivity associated with fire injuries were from a national public database. RESULTS: From a combined payers' perspective limited to direct programme and medical costs, the estimated incremental cost per fire injury averted through the OI installation programme was $128,800 (2013 US$). When a conservative estimate of lost productivity among victims was included, the incremental cost per fire injury averted was negative, suggesting long-term cost savings from the programme. The OI programme from 2001 to 2011 resulted in an estimated net savings of $3.8 million, or a $3.21 return on investment for every dollar spent on the programme using a societal cost perspective. CONCLUSIONS: Community smoke alarm installation programmes could be cost-beneficial in high-fire-risk neighbourhoods.

Truancy and injury-related mortality.

Truancy has well-documented short-term and long-term consequences, but there are few studies that look at its impact on injury-related mortality. This study evaluated the rate of injury-related mortality for 2006-2010 among youth (11-17 years old) with a history of severe truancy compared with youth without such history. There were 168 injury-related deaths (51 homicide, 29 suicide and 88 unintentional injury deaths) among youth in Dallas County. Fifteen of these deaths were among youth with a history of severe truancy. Injury-related mortality was more than five times higher among youth with history of severe truancy compared with youth without such history. Youth with a history of severe truancy have an increased risk of injury-related death. Further research may be warranted to evaluate the part of less severe levels of truancy on mortality and to study the effectiveness of truancy intervention programmes on the risk of death from injuries.

How long do smoke alarms function? A cross-sectional follow-up survey of a smoke alarm installation programme.

OBJECTIVE: To assess the functionality of lithium-powered smoke alarms that had been installed through a community-based programme called Operation Installation (OI). METHODS: A random sample was chosen of homes that had received smoke alarms through OI, 2, 4, 6, 8 and 10 years previously. Sampled homes were visited, and information collected included functional status of smoke alarms. For homes in the 6-, 8- and 10-year sample, smoke alarms were removed and tested for battery and alarm function. RESULTS: 800 homes were included in the survey results; 1884 smoke alarms had been installed through OI. The proportion of homes that had at least one functioning OI smoke alarm ranged from 91.8% for year 2 sample to 19.8% for year 10. Of the originally installed smoke alarms in year 10 sample, 45.5% had been removed and 59% (64/108) of those that were still installed were not functioning. Multivariate analysis showed that the presence of at least one working alarm in the home was associated positively with the number of smoke alarms that were originally installed and whether the original occupant was still living in the home, and negatively with the length of time since the smoke alarm was installed, and whether there was a smoker in the home. Testing of the smoke alarms revealed that most non-functioning alarms had missing or dead batteries. CONCLUSIONS: Less than a quarter of the originally installed smoke alarms were still present and functioning by year 10. These findings have important implications for smoke alarm installation programmes.

Preventing deaths and injuries from house fires: an outcome evaluation of a community-based smoke alarm installation programme.

BACKGROUND: Few studies have examined the impact of community-based smoke alarm (SA) distribution programmes on the occurrence of house fire-related deaths and injuries (HF-D/I). OBJECTIVE: To determine whether the rate of HF-D/I differed for programme houses that had a SA installed through a community-based programme called Operation Installation, versus non-programme houses in the same census tracts that had not received such a SA. METHODS: Teams of volunteers and firefighters canvassed houses in 36 high-risk target census tracts in Dallas, TX, between April 2001 and April 2011, and installed lithium-powered SAs in houses where residents were present and gave permission. We then followed incidence of HF-D/I among residents of the 8134 programme houses versus the 24 346 non-programme houses. RESULTS: After a mean of 5.2 years of follow-up, the unadjusted HF-D/I rate was 68% lower among residents of programme houses versus non-programme houses (3.1 vs 9.6 per 100 000 population, respectively; rate ratio, 0.32; 95% CI 0.10 to 0.84). Multivariate analysis including several demographic variables showed that the adjusted HF-D/I rate in programme houses was 63% lower than non-programme houses. The programme was most effective in the first 5 years after SA installation, with declining difference in rates after the 6th year, probably due to SAs becoming non-functional during that time. CONCLUSIONS: This collaborative, community-based SA installation programme was effective at preventing deaths and injuries from house fires, but the duration of effectiveness was less than 10 years.

Impact of errors in age estimates on the classification of proper child occupant restraint use: an observational survey.

BACKGROUND: Proper classification of child occupant restraint use is dependent on the age of the child occupant. Observations of vehicle restraint use involve estimating child age. If estimates of age are incorrect, then a potential for misclassification of restraint use exists. OBJECTIVE: To compare estimated and confirmed child occupant age and calculate the impact of errors in age estimates on the proportion of children classified as properly restrained. METHODS: Observations of restraint use were completed for occupants 0-8 years of age at two health clinics. After initial observation, we approached the driver to confirm the child's age. Each child's restraint use was classified as either compliant or not compliant with state law, based on type of restraint used and based on the child's estimated and confirmed ages. RESULTS: Classification of age categories for child occupants (n=218) was correct in 86.3% of observations. For 48.6%, the confirmed and estimated age matched exactly, and for 98.1%, age matched within ±1 year. Overall, compliant restraint use based on estimated age was 39.4%, and based on confirmed age was 38.5%. In paired comparisons, restraint use based on estimated age versus confirmed age was concordant for more than 95% of children. CONCLUSIONS: The level of accuracy for age estimates was sufficient for making estimates of compliant restraint use. Errors in estimated age resulted in a less than 1 percentage point difference in overall proper restraint use calculations. The results suggest that such observations can be a reliable measure of proper child occupant restraint use.

A controlled evaluation of the WHO Safe Communities model approach to injury prevention: increasing child restraint use in motor vehicles.

OBJECTIVE: To measure the effect of the WHO Safe Communities model approach to increasing child restraint use in motor vehicles. DESIGN: Pre- and post-intervention observations of restraint use in motor vehicles in several sites in the target area, and in a comparison area community. SETTING: Community; southeast Dallas, Texas, 2003-2005. INTERVENTIONS: A multifaceted approach to increasing use of child safety seats, booster seats and seat belts that included efforts in schools, day care centres, neighbourhoods and a local public clinic, along with child safety seat classes and a low-cost distribution programme. MAIN OUTCOME MEASURES: Prevalence of restraint use among children 0-8 years old riding in motor vehicles. RESULTS: In the target area, the adjusted child restraint use increased by 23.9 percentage points versus 11.8 in the comparison area (difference 12.1; 95% CI 9.9 to 14.3), and adjusted driver seat belt use increased by 16.3 percentage points in the target area versus 4.9 in the comparison area (difference 11.4; 95% CI 11.0 to 11.7). Multivariable multilevel analysis showed that the increase in the target area was significantly greater than in the comparison area for child restraint use (OR 1.6; 95% CI 1.2 to 2.2), as well as for driver seat belt use and proportion of children riding in the back seat. CONCLUSIONS: The Safe Communities approach was successful in promoting the use of child restraints in motor vehicles through a multifaceted intervention that included efforts in various community settings, instructional classes and child safety seat distribution.

The "unintended pedestrian" on expressways.

OBJECTIVE: To explore the epidemiology of pedestrian deaths in Dallas County, Texas, and to compare factors associated with pedestrian deaths on expressways versus those that occurred on other roadways. METHODS: We studied all pedestrian deaths among persons 15 years of age or older in Dallas County, Texas, from 1997 to 2004 by linking data from Medical Examiner's office, the Fatality Analysis Reporting System, and local police records. Univariate and multivariate analysis compared various factors associated with death on an expressway. RESULTS: Among 437 pedestrian deaths who were 15 years of age or older, 197 (45%) occurred on expressways; the proportion that occurred on expressways was highest among 15- to 29-year-olds (65%) and was lower with advancing age group (p < 0.01, chi square for trend). At least 36% of these expressway-related pedestrian deaths were known to have been "unintended pedestrians," who had exited a vehicle after being on the roadway, compared with 11% of pedestrian deaths on surface streets (OR 4.6, 95% CI, 2.7-8.1), and this was also highest among younger age groups. Pedestrian deaths on an expressway, compared with deaths on surface streets, remained strongly associated with having been an "unintended pedestrian" (OR 6.2, 95% CI, 3.1-14.0), after controlling for several other variables, including age, sex, race, nighttime of crash, and alcohol involvement. CONCLUSIONS: Expressways are the predominant site of fatal pedestrian crashes among young adults in this urban area. Since many of these deaths were "unintended pedestrians," procedures for management of occupants of disabled vehicles on expressways could have a large impact on pedestrian deaths in young adults.

Increasing the use of child restraints in motor vehicles in a Hispanic neighborhood.

The use of restraints in motor vehicles is less common in minority and low-income populations than in the general population. A preliminary survey of Hispanic preschool-aged children in west Dallas, Tex, conducted in 1997 showed much lower child restraint use (19% of those surveyed) than among preschool children of all races in the rest of the city (62%). Because there are few reports of successful programs to increase child restraint use among Hispanics, we undertook to implement and evaluate such a program. The program was conducted by bilingual staff and was tailored for this community. It was successful in increasing both child restraint use and driver seat belt use.

Gentamicin and tobramycin in neonates: comparison of a new extended dosing interval regimen with a traditional multiple daily dosing regimen.

Because of a lack of data supporting traditional dosing regimens for aminoglycosides, especially in extremely low-birth-weight infants, the authors developed revised dosing guidelines. The new guidelines increased doses to 5 mg/kg (over traditional doses of 2.5 mg/kg) and lengthened the dosing interval. When results of the two regimens were compared in 120 infants, 26.8% of infants in the traditional dosing group had subtherapeutic levels at <5 microg/mL, whereas only 1.3% of infants in the new practice dosing group were subtherapeutic. With the new dosing practice, serum levels in 1.3% of infants also exceeded the upper therapeutic range of 12 microg/mL. In conclusion, by increasing the dose of aminoglycosides and extending the dosing intervals, therapeutic levels-as defined by a C min <2 microg/mL and a C max of 5 to 12 microg/mL--were obtained significantly more often. In essence the regimen involves once daily dosing for infants <1200 g who are >30 days of age and for infants <1200 g who are >7 days of age. Serum concentrations still need to be monitored where clinically indicated.