Best practices to optimize utilization of the National Living Donor Assistance Center for the financial assistance of living organ donors

Living organ donors face direct costs when donating an organ, including transportation, lodging, meals, and lost wages. For those most in need, the National Living Donor Assistance Center (NLDAC) provides reimbursement to defray travel and subsistence costs associated with living donor evaluation, surgery, and follow‐up. While this program currently supports 9% of all US living donors, there is tremendous variability in its utilization across US transplant centers, which may limit patient access to living donor transplantation. Based on feedback from the transplant community, NLDAC convened a Best Practices Workshop on August 2, 2018, in Arlington, VA, to identify strategies to optimize transplant program utilization of this valuable resource. Attendees included team members from transplant centers that are high NLDAC users; the NLDAC program team; and Advisory Group members. After a robust review of NLDAC data and engagement in group discussions, the workgroup identified concrete best practices for administrative and transplant center leadership involvement; for individuals filing NLDAC applications at transplant centers; and to improve patient education about potential financial barriers to living organ donation. Multiple opportunities were identified for intervention to increase transplant programs’ NLDAC utilization and reduce financial burdens inhibiting expansion of living donor transplantation in the United States.     

Stafne bone cavities: systematic algorithm for diagnosis derived from retrospective data over a 5-year period

Stafne bone cavities are usually found in men 50–70 years old. Typically they appear as lingual, open, ovoid lesions of the molar region of the lower jaw, and most contain parts of the submandibular gland. We have retrospectively examined panoramic radiographs acquired over a 5-year period. All lesions suspected of being Stafne bone cavities were included and analysed further to retrieve statistical information and derive a systematic diagnostic algorithm. We identified 21 Stafne bone cavities among 2928 patients (0.7%). Four of these were confirmed on cone-beam computed tomography (CT). One patient had magnetic resonance imaging (MRI) to confirm the diagnosis. The M:F ratio was 14:7 and the mean age 53 years (range 22–82). All cavities were located in the posterior mandible, 9 on the right and 12 on the left. The mean length was 10.9 (range 4.5–23) mm and height 5.7 (range 3.3–17.3) mm. All cavities were located in the posterior mandible. Sixteen panoramic radiographs (0.6%) were classified as possibly having a Stafne bone cavity but did not fulfil enough criteria to confirm the diagnosis. These 16 were not further analysed. It is rare to diagnose a Stafne bone cavity on a panoramic radiograph. Thorough investigation is essential to exclude differential diagnoses such as keratocystic odontogenic tumour, ameloblastoma, or a metastasis.     

Validity of the 3D VECTRA photogrammetric surface imaging system for cranio-maxillofacial anthropometric measurements

Purpose

The use of three-dimensional (3D) photography for anthropometric measurements is of increasing interest, especially in the cranio-maxillofacial field. Before standard implementation, accurate determination of the precision and accuracy of each system is mandatory.

Methods

A mannequin head was labelled with 52 landmarks, and 28 three-dimensional images were taken using a commercially available five-pod 3D photosystem (3D VECTRA; Canfield, Fairfield, NJ) in different head positions. Distances between the landmarks were measured manually using a conventional calliper and compared with the digitally calculated distances acquired from labelling by two independent observers. The experimental set-up accounted for clinical circumstances by varying the positioning (vertical, horizontal, sagittal) of the phantom.

Results

In the entire calliper measurement data set (n?=?410), a significant difference (p?=?0.02) between the directly measured and corresponding virtually calculated distances was found. The mean aberration between both modalities covering all data was 7.96 mm. No differences (p?=?0.94) between the two groups were found using a cut-off of 10 % (leaving n?=?369 distances) due to considerable errors in direct measurements and the necessary manual data translation. The mean diversity of both measurement modalities after cut-off was 1.33 mm (maximum, 6.70 mm). Inter-observer analysis of all 1,326 distances showed no difference (p?=?0.99; maximal difference, 0.58 mm) in the digital measurements.

Conclusion

The precision and accuracy of this five-pod 3D photosystem suggests its suitability for clinical applications, particularly anthropometric studies. Three-hundred-and-sixty degree surface-contour mapping of the craniofacial region within milliseconds is particularly useful in paediatric patients. Proper patient positioning is essential for high-quality imaging.     

Dose-Related Hepatic Blood Flow Effects Differentiate Nicorandil, Hydralazine, and Isosorbide Dinitrate in Healthy Subjects

Dose response on hepatic blood flow of nicorandil (2.5, 5, and 10 mg), isosorbide dinitrate (5, 15, and 40 mg), and hydralazine (10, 25, and 50 mg) was assessed in 18 healthy subjects (6 per drug) using a three-period crossover design. Indocyanine green clearance was used to estimate hepatic blood flow before and at two timepoints after dosing. Greater hepatic blood flow changes occurred 90 (than 30) min after nicorandil and isosorbide dinitrate, and 60 (than 150) min after hydralazine. Nicorandil (mixed vasodilator) decreased hepatic blood flow by minus sign13 plus minus 4% (p < 0.05), minus sign15 plus minus 7%, and minus sign21 plus minus 6% (p < 0.05) (mean plus minus standard error of the mean) after 2.5, 5, and 10 mg, respectively; blood pressure was not reduced and heart rate was unchanged. Individual changes correlated poorly with plasma nicorandil concentrations. Isosorbide dinitrate (predominant venodilator) decreased hepatic blood flow by minus sign23 plus minus 9%, minus sign27 plus minus 5% (p < 0.05), and minus sign26 plus minus 7% (p < 0.05) after 5, 15, and 40 mg, respectively; blood pressure decreased (8--12 mm Hg) and heart rate increased (8 beats min(minus sign1)). Hydralazine (arterial dilator) increased hepatic blood flow by 29 plus minus 16%, 32 plus minus 11% (p < 0.05), and 33 plus minus 26% after 10, 25, and 50 mg, respectively; blood pressure was unchanged and heart rate increased (16 beats min(minus sign1)). Hepatic vascular resistance increased after nicorandil and isosorbide dinitrate but decreased after hydralazine. As assessed by hepatic blood flow response, nicorandil behaves more like a predominant venodilator than a direct arterial dilator. Dose and time variables were important to understanding the overall hemodynamic profile of each drug.     

Report of a Consensus Conference on Transplant Program Quality and Surveillance

Public reports of organ transplant program outcomes by the US Scientific Registry of Transplant Recipients have been both groundbreaking and controversial. The reports are used by regulatory agencies, private insurance providers, transplant centers and patients. Failure to adequately adjust outcomes for risk may cause programs to avoid performing transplants involving suitable but high‐risk candidates and donors. At a consensus conference of stakeholders held February 13–15, 2012, the participants recommended that program‐specific reports be better designed to address the needs of all users. Additional comorbidity variables should be collected, but innovation should also be protected by excluding patients who are in approved protocols from statistical models that identify underperforming centers. The potential benefits of hierarchical and mixed‐effects statistical methods should be studied. Transplant centers should be provided with tools to facilitate quality assessment and performance improvement. Additional statistical methods to assess outcomes at small‐volume transplant programs should be developed. More data on waiting list risk and outcomes should be provided. Monitoring and reporting of short‐term living donor outcomes should be enhanced. Overall, there was broad consensus that substantial improvement in reporting outcomes of transplant programs in the United States could and should be made in a cost‐effective manner.     

Self-labelling and stigma as predictors of attitudes towards help-seeking among people at risk of psychosis: 1-year follow-up

Mental health service use is helpful but rare among young people at risk of psychosis. The label and stigma associated with mental illness may affect attitudes towards help-seeking. We examined 67 individuals at risk of psychosis over the course of 1 year. An increase of self-labelling as “mentally ill” predicted more positive attitudes towards psychiatric medication, while increased perceived stigma and the cognitive appraisal of stigma as a stressor predicted poorer attitudes towards psychotherapy after 1 year. Early intervention could improve non-stigmatizing awareness of at-risk mental state and reduce the public stigma associated with at-risk status to facilitate help-seeking.