Do Incentives Matter? Providing Benefits to Families of Organ Donors

Whether the number of organs available for transplant would be positively or negatively affected by providing benefits to families of organ donors has been debated by policymakers, ethicists and the transplant community at large. We designed a telephone survey to measure public opinion regarding the use of benefits in general and of five types in particular: funeral benefits, charitable contributions, travel/lodging expenses, direct payments and medical expenses. Of the 971 adults who completed the survey (response rate = 69%), all were from Pennsylvania households, 45.6% were registered organ donors, and 51.7% were nonwhite. Although 59% of respondents favored the general idea of incentives, support for specific incentives ranged from 53% (direct payment) to 84% (medical expenses). Among those registered as donors, more nonwhites than whites supported funeral benefits (88% vs. 81%; p = 0.038), direct payment (63% vs. 41%; p < 0.001) and medical expenses (92% vs. 84%; p = 0.013). Among those not registered as donors, more nonwhites supported direct payment (64% vs. 46%; p = 0.001). Most respondents believed that benefits would not influence their own behavior concerning donation but would influence the behavior of others. While benefits appear to be favored, their true impact can only be assessed through pilot programs.     

Hydrocephalus following aneurysmal subarachnoid haemorrhage

Ninety-four patients with hydrocephalus following subarachnoid haemorrhage were investigated. Fourteen of these patients had temporary ventricular drains inserted, 19 had drains that were later converted to ventricular-peritoneal shunts, and 61 patients had shunts only. All patients were analysed with respect to their grade on admission, the distribution of blood on CT scan, their Glasgow Coma Score, their intracranial pressure, and the presence or absence of vasospasm on angiography. Outcome was analysed by shunt procedure and time of shunt insertion. The higher the grade on admission, the more likely it was the patient would require a shunt. Fewer patients with a good outcome required shunting as compared to those whose outcome was poor. Patients having more subarachnoid blood on CT scan tended to present with a lower Glasgow Coma Score. The outcome of patients with intraventricular haemorrhage was not obviously influenced by the insertion of a ventriculostomy. Vasospasm was not more common in patients requiring a ventriculo-peritoneal shunt, nor did early shunting in patients with hydrocephalus affect the incidence of vasospasm. The majority of patients were either shunted in the first three days or after 30 days post-SAH. The outcome was better in those patients shunted at a later date.     

Combined Endovenous Laser Therapy and Ambulatory Phlebectomy: Refinement of a New Technique

OBJECTIVE: Sclerotherapy (IS) or ambulatory phlebectomy (AP) are required as subsequent interventions in majority of cases following endovenous laser therapy (EVLT). We assessed whether AP performed concomitantly with EVLT (EVLTAP), is effective, acceptable, and reduces subsequent requirement for interventions. METHOD: 67 patients (70 limbs) with great saphenous varicosities underwent EVLTAP. Pain was assessed on days 1, 4 and 7 using a visual analogue scale (VAS) of 0 to 10. Clinical and ultrasound assessments were done at 1, 6 and 12 weeks (no ultrasound at 6 weeks). Residual varicosities underwent further AP or IS. Patients' satisfaction with the cosmetic outcome and overall treatment was assessed at 12 weeks using a VAS rating. RESULTS: 49 patients (70%) completed follow-up. Median pain scores were 1.6 (IQR 0.2-4.8), 0.3 (0-1.4) and 0.2 (0-1.1) on days 1, 4 and 7 respectively. Ultrasound demonstrated 69 (99%) and 47 (96%) occluded long saphenous veins at 1 and 12 weeks respectively. Subsequent IS or AP was performed on 3 (4%) or 1 (1%) limbs respectively. Cosmetic satisfaction was 9.6 (IQR 8.9-10) and overall satisfaction 9.8 (IQR 9.3-10). CONCLUSION: EVLTAP produces excellent results, is feasible and acceptable, and obviates need for subsequent procedures in the short-term.     

Surgical resection of hepatic and pulmonary metastases from colorectal carcinoma

BACKGROUND: Patients with hepatic and pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. We examined the longterm outcomes of patients who underwent both lung and liver resections for colorectal metastases over a 10-year period. STUDY DESIGN: Four hundred twenty-three hepatectomies were performed for metastatic CRC between 1992 and 2002 at two university-affiliated hospitals. Patients who underwent both lung and liver resections for metastatic CRC were studied. Demographic, perioperative, and survival data were evaluated by retrospective chart review. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis and survival curves were compared using the log-rank test. RESULTS: Thirty-nine patients underwent both lung and liver resections for metastatic CRC. Eleven patients (28%) underwent staged liver and lung metastasectomy from synchronously identified metastases. Twenty-eight patients (72%) underwent sequential metastasectomy because of recurrent disease. The median disease-free and overall survivals after initial metastasectomy were 19.8 and 87 months, respectively. Serial metastasectomy was common in this patient population. The mean number of metastasectomies performed was 2.6 per patient (range 1 to 4). There was no difference in overall survival for patients with synchronous versus metachronous presentation of liver and lung metastases (p=0.45). The site of first recurrence after initial metastasectomy was, most commonly, the lung (n=19, 49%), followed by the liver (n=8, 21%). Nineteen patients (49%) underwent subsequent resections for recurrences. Seven patients (18%) underwent 2 or more liver resections for recurrent disease, and 12 (31%) underwent multiple lung resections. CONCLUSIONS: An aggressive multidisciplinary surgical approach should be undertaken for recurrent CRC metastases. In selected patients, serial metastasectomy for recurrent metastatic disease is safe and results in excellent longterm survival after CRC resection.     

Impact of tobacco use on perioperative complications and readmission rates following primary anatomic and reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to investigate the relationship between tobacco use and outcomes following both aTSA and rTSA, with the hypothesis being that tobacco users will have inferior postsurgical outcomes compared to nontobacco users.MethodsThe Nationwide Readmission Database (NRD) was queried from 2016 to 2018 to identify qualifying cases of aTSA (n = 16,241) and rTSA (n = 23,975). These groups were further subdivided based on tobacco use status. Demographic and hospital characteristics were first compared between groups. The unadjusted incidence of postoperative medical and shoulder-specific complications, mortality, revisions, and readmissions were then compared. Finally, the groups were assessed for the same variables after controlling for demographic factors and comorbidities.ResultsFor both aTSA and rTSA, statistically significant differences exist in regard to age, sex, primary expected payer, median household income, hospital region, hospital teaching status, and total number of comorbidities between tobacco users and nonusers (all P < .05). Tobacco users undergoing aTSA experienced higher rates of gastrointestinal complications (0.07% vs. 0.01%, P = .021) and readmissions (15.3% vs. 13.6%, P = .007), while tobacco users undergoing rTSA experienced higher rates of acute renal failure (2.5% vs. 1.9%, P = .005), acute respiratory distress (1.3% vs. 0.9%, P = .002), and the need for ventilator assistance (1.2% vs. 0.7%, P < .001). Adjusted analysis showed that tobacco users were more likely to develop acute respiratory distress syndrome (OR = 1.292, P = .036) and require ventilator assistance (OR = 1.376, P = .008), and are more likely to have at least one readmission (P = .026).ConclusionThe results of this study demonstrate that tobacco users undergoing primary aTSA and rTSA are at an increased risk for several perioperative complications and are more likely to be readmitted following surgery compared to nontobacco users. These findings highlight the importance of determining a patient's tobacco use status as consideration should be given to not performing a TSA until tobacco use has stopped.Level of evidenceLevel III; Retrospective Cohort Treatment Study     

Pain after spinal cord injury: an evidence-based review for clinical practice and research. Report of the National Institute on Disability and Rehabilitation Research Spinal Cord Injury Measures meeting

BACKGROUND/OBJECTIVES: To examine the reliability, validity, sensitivity, and practicality of various outcome measures for pain after spinal cord injury (SCI), and to provide recommendations for specific measures for use in clinical trials. DATA SOURCES: Relevant articles were obtained through a search of MEDLINE, EMBASE, CINAHL, and PubMed databases from inception through 2006. STUDY SELECTION: The authors performed literature searches to find articles containing data relevant to the reliability and validity of each pain outcome measure in SCI and selected non-SCI populations. DATA EXTRACTION: After reviewing the articles, an investigator extracted information utilizing a standard template. A second investigator reviewed the chosen articles and the extracted pertinent information to confirm the findings of the first investigator. DATA SYNTHESIS: Taking into consideration both the quantity and quality of the studies analyzed, judgments on reliability and validity of the measures were made by the two investigators. Based upon these judgments, recommendations were formulated for use of specific measures in future clinical trials. In addition, for a subset of measures a voting process by a larger group of SCI experts allowed formulation of recommendations including determining which measures should be incorporated into a minimal dataset of measures for clinical trials and which ones need revision and further validity and reliability testing before use. CONCLUSIONS: A 0-10 Point Numerical Rating Scale (NRS) is recommended as the outcome measure for pain intensity after SCI, while the 7-Point Guy/Farrar Patient Global Impression of Change (PGIC) scale is recommended as the outcome measure for global improvement in pain. The SF-36 single pain interference question and the Multidimensional Pain Inventory (MPI) or Brief Pain Inventory (BPI) pain interference items are recommended as the outcome measures for pain interference after SCI. Brush or cotton wool and at least one high-threshold von Frey filament are recommended to test mechanical allodynia/hyperalgesia while a Peltier-type thermotester is recommended to test thermal allodynia/hyperalgesia. The International Association for the Study of Pain (IASP) or Bryce-Ragnarsson pain taxonomies are recommended for classification of pain after SCI, while the Neuropathic Pain Scale (NPS) is recommended for measuring change in neuropathic pain and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) for quantitating neuropathic and nociceptive pain discrimination.     

Stability-preserving decompression in degenerative versus congenital spinal stenosis: demographic patterns and patient outcomes

Background Context

Although lumbar spinal stenosis often presents as a degenerative condition (degenerative stenosis [DS]), some patients present with symptoms from lifelong narrowing of the spinal canal. These patients have congenital stenosis (CS) and present with symptoms of stenosis at a younger age. Patients with CS often have a distinct pathophysiology with fewer degenerative changes but present with multilevel involvement. In the setting of neurologic symptoms, decompression alone while preserving stability has been proposed for both patient populations.

Surgical management of hepatocellular carcinoma: Resection or transplantation?

Liver resection or transplantation offers the best opportunity for cure of hepatocellular carcinoma (HCC). To determine the relative roles for resection and transplantation and to evaluate the patient and tumor characteristics that might predict survival, the records of 125 patients treated for nonfibrolamellar HCC at The Toronto Hospital between 1981 and 1996 were reviewed. No adjuvant chemotherapy or antiviral protocols were used. Resection was the first operation in 67 patients; one underwent re-resection. Sixty patients underwent transplantation including two who had previously had a resection; 40 had known or suspected HCC and 20 had incidental tumors identified in the explanted liver. The incidence of cirrhosis was 49% for resection and 88% for transplantation. The incidence of hepatitis B virus (HBV) was 58% and 33%, respectively. The operative mortality rate for resection was 4.4% (9.4% in cirrhotic and 0 in noncirrhotic patients) and 13.3 % for transplantation. The 5-year cumulative recurrence rate was 55% following resection and 20% following transplantation (P <0.001). The 5-year Kaplan-Meier survival rates were 38% for resection and 45% for transplantation—60% for transplanted HBV-negative and 17% for HBV-positive patients (P <0.001). After resection, recurrent HCC accounted for 86% of deaths, whereas recurrent HBV was responsible for 42 % of deaths after transplantation. By univariate analysis, following resection, vascular invasion, advanced stage, multiple tumors, and lack of a capsule were predictive of survival; cirrhosis, HBV, age, tumor size, number, and grade were not. By multivariate analysis, only vascular invasion was predictive for resection and HBV for transplantation. Resection and transplantation are complementary methods of treating HCC. With the current organ shortage, resection should be considered first-line treatment. HBV-positive patients with HCC should only undergo transplantation in combination with effective antiviral therapy. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.     

Neratinib in Combination With Trastuzumab for the Treatment of Patients With Advanced HER2-positive Breast Cancer: A Phase I/II Study

Background

Despite the availability of several human epidermal growth factor receptor 2 (HER2)-directed treatments, many HER2-positive (HER2⁺) breast cancers eventually progress because of primary or acquired resistance.

Moral attitudes and willingness to enhance and repair cognition with brain stimulation

Background

The availability of technological means to enhance and repair human cognitive function raises questions about the perceived morality of their use. However, we have limited knowledge about the public's intuitive attitudes toward uses of brain stimulation. Studies that enlighten us about the public's willingness to endorse specific uses of brain stimulation on themselves and others could provide a basis to understand the moral psychology guiding intuitions about neuromodulation and opportunities to inform public education and public policy.