Development of the New Lung Allocation System in the United States

This article reviews the development of the new U.S. lung allocation system that took effect in spring 2005. In 1998, the Health Resources and Services Administration of the U.S. Department of Health and Human Services published the Organ Procurement and Transplantation Network (OPTN) Final Rule. Under the rule, which became effective in 2000, the OPTN had to demonstrate that existing allocation policies met certain conditions or change the policies to meet a range of criteria, including broader geographic sharing of organs, reducing the use of waiting time as an allocation criterion and creating equitable organ allocation systems using objective medical criteria and medical urgency to allocate donor organs for transplant. This mandate resulted in reviews of all organ allocation policies, and led to the creation of the Lung Allocation Subcommittee of the OPTN Thoracic Organ Transplantation Committee. This paper reviews the deliberations of the Subcommittee in identifying priorities for a new lung allocation system, the analyses undertaken by the OPTN and the Scientific Registry for Transplant Recipients and the evolution of a new lung allocation system that ranks candidates for lungs based on a Lung Allocation Score, incorporating waiting list and posttransplant survival probabilities.     

Intracranial circulation: pulse-sequence considerations in three- dimensional (volume) MR angiography

The technique and feasibility of magnetic resonance (MR) angiography of intracranial vessels were studied in 35 healthy volunteers. Variations in image orientation, repetition time (TR), and flip angle were evaluated to determine their effects on flow-related enhancement. Gradient modifications--including echo time (TE), motion compensation, bandwidth, and field of view--were also studied in an effort to reduce motion-induced phase shifts. Results indicated that a FISP (fast imaging with steady precession) sequence with a TR of 50 msec, TE of 15 msec, velocity compensation in the read and section-select directions, acceleration compensation in the read direction, anisotropic volume, and a 1.25-mm partition thickness produced three-dimensional angiographic MR images that were accurate and reproducible in the depiction of the major intracranial vessels. Difficulties with field of view, persistent signal void secondary to higher-order motion, and spatial resolution remain major problems requiring additional study.     

Paediatric dacryocystorhinostomy

Of 258 cases of dacryocystorhinostomy performed on children in the period September 1981 to September 1991, 130 were for simple, unresolved congenital nasolacrimal duct obstruction. Other indications for surgery included punctal agenesis, lacrimal fistula, post-traumatic and post-inflammatory canalicular obstruction. Of 177 children without canalicular pathology, 171 (96%) were relieved of symptoms with one operation, without canalicular intubation. Of 81 cases with canalicular disease, 55 of 70 (79%) who underwent DCR plus canalicular intubation, and 10 of 11 who underwent DCR plus Lester-Jones tube, were substantially improved with one operation. No child required peroperative or postoperative blood transfusion. Dacryocystorhinostomy in childhood, in experienced surgical hands, is a safe procedure, achieving relief of symptoms in most cases, particularly in the absence of canalicular disease.     

Orbital exenteration at the Mayo Clinic. 1967-1986

Orbital exenteration was performed in 102 patients at the Mayo Clinic during the 20-year period from 1967 through 1986. The surgical procedure was performed for mucormycosis in one patient and for pain and deformity after a severe facial burn in another; in the remaining 100 patients, exenteration was used to treat a neoplastic disorder. Although 19 different neoplasms were encountered, squamous cell carcinoma, basal cell carcinoma, and melanoma constituted 70% of the total. In 82 patients with no known residual tumor or metastases at operation, the 1-year survival rate was 88.6%, the 5-year rate was 56.8%, and the 5-year rate free of recurrence or metastases was 48.3%. In 18 patients with known residual tumor or metastases at exenteration, 55.0% were alive 1 year postoperatively, and the 5-year survival rate was 25.8%. Unusual findings in this series included two patients with metastatic basal cell carcinoma and one patient with a metastatic thyroid Hürthle cell carcinoma.     

Testing nursing home iatrogenesis

Many nursing home residents, admitted for "temporary" stays, are expected to return to the community. To test the notion of iatrogenesis, this research examined the discharge status of "temporary" residents discharged from a proprietary nursing home during the first six years of its operation. The research noted 1) the extent to which those residents did not return home and 2) reasons for their derailment. The results of the research did not support the notion of iatrogenesis. Of 419 residents, seventy-nine were expected to return to the community. Only 16 percent of those seventy-nine did not. Content analysis of histories, moreover, showed that two chose to remain, four had families who declined to fill caregiver roles, and two quickly deteriorated. Even the histories of the five who generally lost the ability to function independently did not suggest institutional life was to blame.