Trends in kidney transplantation rates and disparities

OBJECTIVE: To examine the likelihood of transplantation and trends over time among persons with end-stage renal disease (ESRD) in Wisconsin. METHODS: We examined the influence of patient- and community-level characteristics on the rate of kidney transplantation in Wisconsin among 22,387 patients diagnosed with ESRD between January 1, 1982 and October 30, 2005. We grouped patients by the year of ESRD onset in order to model the change in transplantation rates over time. RESULTS: After multivariate adjustment, all other racial groups were significantly less likely to be transplanted compared with whites, and the racial disparity increased over calendar time. Older patients were less likely to be transplanted in all periods. Higher community income and education level and a greater distance from patients' residence to the nearest dialysis center significantly increased the likelihood of transplantation. Males also had a significantly higher rate of transplantation than females. CONCLUSION: These results demonstrate a growing disparity in transplantation rates by demographic characteristics and a consistent disparity in transplantation by socioeconomic characteristics. Future studies should focus on identifying specific barriers to transplantation among different subpopulations in order to target effective interventions.     

The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS): Rationale,objectives, and design

BackgroundInfluenza viruses pose significant disease burdens through seasonal outbreaks and unpredictable pandemics. Existing surveillance programs rely heavily on reporting of medically attended influenza (MAI). Continuously monitoring cause‐specific school absenteeism may identify local acceleration of seasonal influenza activity. The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS; Oregon, WI) implements daily school‐based monitoring of influenza‐like illness‐specific student absenteeism (a‐ILI) in kindergarten through Grade 12 schools and assesses this approach for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.MethodsStarting in September 2014, ORCHARDS combines automated reporting of daily absenteeism within six schools and home visits to school children with acute respiratory infection (ARI). Demographic, epidemiological, and symptom data are collected along with respiratory specimens. Specimens are tested for influenza and other respiratory viruses. Household members can opt into a supplementary household transmission study. Community comparisons are possible using a pre‐existing and highly effective influenza surveillance program, based on MAI at five family medicine clinics in the same geographical area.ResultsOver the first 5 years, a‐ILI occurred on 6634 (0.20%) of 3,260,461 student school days. Viral pathogens were detected in 64.5% of 1728 children with ARI who received a home visit. Influenza was the most commonly detected virus, noted in 23.3% of ill students.ConclusionORCHARDS uses a community‐based design to detect influenza trends over multiple seasons and to evaluate the utility of absenteeism for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.     

玻璃体内注射曲安奈德治疗视网膜中央静脉阻塞引起的黄斑水肿

目的：探讨玻璃体内注射丙酮化曲安奈德用于治疗视网膜中央静脉阻塞（CRVO）引起黄斑水肿的安全性和有效性。方法：在Wisconsin大学和Bascom Palmer眼科研究所．对13例（13只眼）连续的CRVO引起黄斑水肿的患者应用玻璃体内注射丙酮化曲安奈德（4mg）治疗．回顾研究其病历记录。每次玻璃体内注射时应用27G或30G针头通过睫状体平坦部注射。主要结果测量：Snellen视力的变化、黄斑水肿的临床表现、应用光学相干断层扫描仪（OCT）测量中心凹的增厚以及并发症的出现频率。结果：13例患者的平均年龄为67岁（四分位数间距为57—77岁）．注射前症状的平均持续时间为8个月（四分位数间距为4—9个月）。患眼在初诊时的平均视力为20／500．在6个月随诊检查时的平均视力为20／1踟。所有13例患者都完成了6个月的随诊检查。非缺血型CRVO患眼（n=5）的视力有显著的提高．而缺血型CRVO患眼（n=8）没有显著的视力提高。患者没有出现视力下降。初诊时OCT测量的平均中心凹厚度为590μm（视网膜增厚=416μm）。12例患者在1个月随诊检查时OCT测量的平均中心凹厚度为212pm（视网膜增厚=38μm）。13例患者在3个月随诊检查时OCT测量的平均中心凹厚度为193μm（视网膜增厚=19μm）。在3和6个月随诊检查之间．4例患者的黄斑水肿复发．其中3例患者再次接受了曲安奈德的注射。这3例患者中的2例经过再次治疗视力提高。在6个月随诊检查时．13例患者OCT测量的平均中心凹厚度为281μm（视网膜增厚=107μm）。没有发生视网膜脱离或眼内炎等并发症。1例患者出现了眼压的升高．应用2种房水生成抑制剂治疗得以控制。结论：在部分CRVO引起黄斑水肿的患者中．玻璃体内注射曲安奈德可能是一种有效的治疗方法。与缺血型CRVO患者相比．非缺血型CRVO患者可以获得更令人满意的效果。部分患者可能需要重复治疗。在本组患者中未发现严重的并发症。     

A hierarchical model for spatially clustered disease rates

Maps of regional disease rates are potentially useful tools in examining spatial patterns of disease and for identifying clusters. Bayes and empirical Bayes approaches to this problem have proven useful in smoothing crude maps of disease rates. In recent years, models including both spatially correlated random effects and spatially unstructured random effects have been very popular. The spatially correlated random effects have been proposed in an attempt to capture a general clustering in the data. As an alternative, we propose replacing the spatially structured random effect with fixed clustering effects associated with particular areas. A reversible jump Markov chain Monte Carlo (RJMCMC) algorithm for posterior inference is described. We illustrate the model using the well-known New York leukaemia data.     

Deforestation and Malaria in Mancio Lima County, Brazil

Malaria is the most prevalent vector-borne disease in the Amazon. We used malaria reports for health districts collected in 2006 by the Programa Nacional de Controle da Malária to determine whether deforestation is associated with malaria incidence in the county (município) of Mâncio Lima, Acre State, Brazil. Cumulative percent deforestation was calculated for the spatial catchment area of each health district by using 60 × 60–meter, resolution-classified imagery. Statistical associations were identified with univariate and multivariate general additive negative binomial models adjusted for spatial effects. Our cross-sectional study shows malaria incidence across health districts in 2006 is positively associated with greater changes in percentage of cumulative deforestation within respective health districts. After adjusting for access to care, health district size, and spatial trends, we show that a 4.3%, or 1 SD, change in deforestation from August 1997 through August 2000 is associated with a 48% increase of malaria incidence.     

Effect of interhospital transfer on resource utilization and outcomes at a tertiary care referral center

OBJECTIVE: Mortality and length of stay are two outcome variables commonly used as benchmarks in rating the performance of medical centers. Acceptance of transfer patients has been shown to affect both outcomes and the costs of health care. Our objective was to compare observed and predicted lengths of stay, observed and predicted mortality, and resource consumption between patients directly admitted and those transferred to the intensive care unit (ICU) of a large academic medical center. DESIGN: Observational cohort study. SETTING: Mixed medical/surgical ICU of a university hospital. PATIENTS: A total of 4,569 consecutive patients admitted to a tertiary care ICU from April 1, 1997, to March 30, 2000. INTERVENTIONS: None. MEASUREMENTS: Acute Physiology and Chronic Health Evaluation (APACHE) III score, actual and predicted ICU and hospital lengths of stay, actual and predicted ICU and hospital mortality, and costs per admission. MAIN RESULTS: Crude comparison of directly admitted and transfer patients revealed that transfer patients had significantly higher APACHE III scores (mean, 60.5 vs. 49.7, p < .001), ICU mortality (14% vs. 8%, p < .001), and hospital mortality (22% vs. 14%, p < .001). Transfer patients also had longer ICU lengths of stay (mean, 6.0 vs. 3.8 days, p < .001) and hospital lengths of stay (mean, 20 vs. 15.9 days, p < .001). Stratified by disease severity using the APACHE III model, there was no difference in either ICU or hospital mortality between the two populations. However, in the transfer group with the lowest predicted mortality of 0-20%, ICU and hospital lengths of stay were significantly higher. In crude cost analysis, transfer patients' costs were $9,600 higher per ICU admission compared with nontransfer patients (95% confidence interval, $6,000-$13,400). Risk stratification revealed that the higher per-patient cost was entirely confined to the transfer patients with the lowest predicted mortality. CONCLUSIONS: Patients transferred to a tertiary care ICU are generally more severely ill and consume more resources. However, they have similar adjusted mortality outcomes when compared with directly admitted patients. The difference in resource consumption is mainly attributable to the group of patients in the lowest predicted risk bracket.