Continued increase in lung transplantation for coal workers’ pneumoconiosis in the United States

Background

Severe coal workers’ pneumoconiosis (CWP) is increasingly common, and sometimes requires lung transplantation.

Methods

Using Organ Procurement and Transplantation Network data, we updated the trend for CWP‐related lung transplants, described CWP patients who have been waitlisted but not transplanted, and characterized the primary payer of medical costs for CWP‐related and other occupational lung disease transplants.

Results

There have been at least 62 CWP‐related lung transplants; 49 (79%) occurred in the last decade. The rate of these procedures has also increased. Twenty‐seven patients were waitlisted but did not receive a transplant. Compared to other occupational lung diseases, transplants for CWP were more likely to be paid for by public insurance.

Conclusions

The increase in the frequency and rate of lung transplantation for CWP is consistent with the rising prevalence of severe CWP among U.S. coal miners. Effective exposure controls and identification of early stage CWP remain essential for protecting these workers.

     

Measuring and monitoring equity in access to deceased donor kidney transplantation

The Organ Procurement and Transplantation Network monitors progress toward strategic goals such as increasing the number of transplants and improving waitlisted patient, living donor, and transplant recipient outcomes. However, a methodology for assessing system performance in providing equity in access to transplants was lacking. We present a novel approach for quantifying the degree of disparity in access to deceased donor kidney transplants among waitlisted patients and determine which factors are most associated with disparities. A Poisson rate regression model was built for each of 29 quarterly, period‐prevalent cohorts (January 1, 2010‐March 31, 2017; 5 years pre–kidney allocation system [KAS], 2 years post‐KAS) of active kidney waiting list registrations. Inequity was quantified as the outlier‐robust standard deviation (SD_w) of predicted transplant rates (log scale) among registrations, after “discounting” for intentional, policy‐induced disparities (eg, pediatric priority) by holding such factors constant. The overall SD_w declined by 40% after KAS implementation, suggesting substantially increased equity. Risk‐adjusted, factor‐specific disparities were measured with the SD_w after holding all other factors constant. Disparities associated with calculated panel‐reactive antibodies decreased sharply. Donor service area was the factor most associated with access disparities post‐KAS. This methodology will help the transplant community evaluate tradeoffs between equity and utility‐centric goals when considering new policies and help monitor equity in access as policies change.     

Innovation in organ transplantation: A meeting report

This workshop targeted opportunities to stimulate transformative innovation in organ transplantation. Participants reached consensus regarding the following: (1) Mechanisms are needed to improve the coordination of policy and oversight activities, given overlapping responsibilities for transplantation and clinical investigation among federal agencies. Innovative clinical trials span traditional administrative boundaries and include stakeholders with diverse interests. Participants identified the need for a governmental interagency working group to coordinate nationwide transplant‐related activities. (2) Improvements are required in clinical metrics for transplantation, with alignment of performance goals across transplantation organizations and any development of data requirements being consistent with those goals. Database coordination among clinical centers, organ procurement organizations, regulatory agencies, and payers would facilitate research and better inform policy. New data requirements should provide actionable insights into clinical performance. (3) Innovative research seen as potentially adversely affecting Program‐Specific Reports may reduce centers’ participation. Cutting‐edge research requires mitigation of risk‐aversive behaviors created by reporting of clinical outcomes data. Participants proposed a new review process in advance of implementation of clinical trials to guide “carve‐outs” of transplant center outcomes data from Program‐Specific Reports. Clinical transplantation will be advanced by the development of a shared and comprehensive research agenda to facilitate coordination of research and policy.     

Unintended Consequences of the New National Kidney Allocation Policy in the United States

The new national Kidney Allocation System of the Organ Procurement and Transplantation Network (OPTN), effective as of December 4, 2014, was designed to improve the chances of transplanting the most highly sensitized patients on the waitlist, those with calculated panel reactive antibody values of 98%, 99% and 100%. Recently, it was suggested that these highly sensitized patients will experience inequitable access, given the reported high prevalence of antibodies to HLA‐DP, and the fact that only about 1/3 of deceased donors are typed for HLA‐DP antigens. Here we report that 320/2948 flow cytometric crossmatches performed for the Northwestern transplant program over the past 28 months were positive solely due to HLA‐DP donor‐specific antibodies (11%; 16.5% of patients with HLA antibodies—sensitized patients). We further show that 58/207 (12%) HLA‐DR serologically matched donor‐recipient pairs had a positive B cell flow crossmatch due to donor‐specific HLA class II antibodies, and 2/34 (6%) serologic zero‐HLA‐A‐B‐DR mismatch had a positive flow crossmatch due to HLA‐DSA. We therefore provide information regarding the necessity and importance of complete donor HLA typing including both chains of the HLA‐DP antigen (encoded by HLA‐DPA1 and HLA‐DPB1) at the time of organ offer.     

Combined whole pancreas and liver retrieval: comparison between Y-iliac graft and splenomesenteric anastomosis

With the recent increase in the number of liver and pancreas transplants being performed in Europe, many groups have found it necessary to develop techniques for the combined harvesting of whole pancreaticoduodenal and liver grafts. To date we have carried out a total of 35 multiorgan procurements including liver, heart, pancreas, and kidneys. In ten cases we reconstructed the arterial supply of the pancreas with an end-to-end anastomosis between the proximal splenic artery and the distal end of the superior mesenteric artery (SMA), and in eight patients we used a donor Y-iliac graft. Patients were monitored postoperatively by determination of BUN, serum creatinine, blood glucose, serum and urinary amylase levels, and Doppler assessment of the graft was carried out at regular intervals. Mean ischemia/prservation time in both groups was 6 h. All simultaneous kidney and pancreas transplants functioned well initially with none of the patients requiring dialysis. All patients were insulin-free immediately after surgery. One patient in the splenomesenteric group developed venous thrombosis of the graft, requiring removal of the gland, but has subsequently been successfully retransplanted. All remaining patients have been insulin-free for 1–14 months. One patient in the Y-iliac group also developed venous thrombosis of the graft, but all remaining patients in this group have been insulin-free for 1–12 months after transplantation. Both groups were comparable in terms of serum creatinine (1.4±1.0 vs 1.5±0.9 mg%), blood glucose (105±15 vs 104±12 mg%), serum amylase (400±106 vs 410±100 IU/l), and urinary amylase (130,000±54,000 vs 100,000±42,000 IU/l). Therefore, we now prefer to use this simpler technique of splenomesenteric revascularization as a first choice for reconstruction of pancreatic grafts.     

Effect of procurement cost on the drinking of a saccharin-sucrose solution by non-deprived rats

Four non-deprived female rats were required to run in a wheel to obtain 20 min unconstrained access to a saccharin and sucrose solution. Each was run in a series of conditions in which the requirement was a proportion (0.25, 0.5, 1.0, 1.25 and 1.5) of the amount of running performed in a condition in which the wheel alone was available. A condition in which no running was required to gain access to the solution and one in which the subject was locked in the stationary wheel for the time taken to complete the highest requirement before being allowed access to the solution were also included. The results showed that as the requirement increased the amount of solution consumed also increased, and this relationship did not depend on the time taken to perform the requirement.     

Scientific, legal, and ethical challenges of end-of-life organ procurement in emergency medicine

Aim

We review (1) scientific evidence questioning the validity of declaring death and procuring organs in heart-beating (i.e., neurological standard of death) and non-heart-beating (i.e., circulatory-respiratory standard of death) donation; (2) consequences of collaborative programs realigning hospital policies to maximize access of procurement coordinators to critically and terminally ill patients as potential donors on arrival in emergency departments; and (3) ethical and legal ramifications of current practices of organ procurement on patients and their families.

Data sources

Relevant publications in peer-reviewed journals and government websites.

Results

Scientific evidence undermines the biological criteria of death that underpin the definition of death in heart-beating (i.e., neurological standard) and non-heart-beating (i.e., circulatory-respiratory standard) donation. Philosophical reinterpretation of the neurological and circulatory-respiratory standards in the death statute, to avoid the appearance of organ procurement as an active life-ending intervention, lacks public and medical consensus. Collaborative programs bundle procurement coordinators together with hospital staff for a team-huddle and implement a quality improvement tool for a Rapid Assessment of Hospital Procurement Barriers in Donation. Procurement coordinators have access to critically ill patients during the course of medical treatment with no donation consent and with family or surrogates unaware of their roles. How these programs affect the medical care of these patients has not been studied.

Conclusions

Policies enforcing end-of-life organ procurement can have unintended consequences: (1) erosion of care in the patient's best interests, (2) lack of transparency, and (3) ethical and legal ramifications of flawed standards of declaring death.     

中国与西太平洋地区发展中国家公立药品采购系统基本药物价格比较及启示

目的:为制定和调整我国基本药物价格和采购监管政策提供参考。方法:对我国黑龙江省、马来西亚、蒙古和越南的公立药品采购系统相关政策,及其2009年5～9月31个基本药物的公立采购价格进行国家间和与国际及世界卫生组织西太平洋地区中位数价格的比较、分析。结果与结论:我国黑龙江省公立药品采购系统多数只采购国产通用名药,价格水平与健康管理科学组织(MSH)和世界卫生组织西太平洋地区相当,但与印度通用名药、甚至是品牌通用名药相比偏高。某些同时采购通用名药和原研药的品种价差与他国相比过大,但一些原研药仍能在公立药品采购系统中有一席之地。原研药和通用名药"共生"的品种,价格与印度相比没有优势,国产通用名药的价格甚至高于印度品牌通用名药。     

Providing affordable essential medicines to African households: the missing policies and institutions for price containment

Medicines are integral of any healthcare system, and limited access to medicines undermines health systems' objectives of equity, efficiency and health development. In African countries, where it is estimated that 50-60% of the populace lack "access" to essential medicines, health problems associated with limited drug benefits are more damaging. However, there is no single solution to medicine access problem given its multiple dimensions: availability, acceptability, affordability and accessibility. This paper explores affordability dimension of medicine access and concentrates solely on price regulatory policies and institutional structures that national and international policy makers may consider in making prices of essential drugs compatible to the purchasing power of African households. The main theme is the application of the concept of bilateral dependence in creating price-sensitive purchasers to exert countervailing market power on drug price setting in African healthcare systems.