Egg-sharing in assisted conception: ethical and practical considerations

The present acute shortage of eggs for donation cannot be overcomeunless adequate guidelines are set to alleviate the anxietiesregarding payments, in cash or kind, to donors. The currentHuman Fertilisation and Embryology Authority (HFEA) guidelinesdo not allow direct payment to donors but accept the provisionof lower cost or free in-vitro fertilization (IVF) treatmentto women in recognition of oocyte donation to anonymous recipients.Egg-sharing achieved in this way enables two infertile couplesto benefit from a single surgical procedure. However, the practicalguidelines related to this approach are ill-defined at the presenttime leading to some justifiable uncertainty. A pilot studywas therefore undertaken in order to establish the place ofegg-sharing in an assisted conception programme. The currentHFEA guidelines on medical screening of patients, counselling,age and rigid anonymity between the donor and recipient werefollowed. The study involved 55 women (25 donors and 30 recipients)in 73 treatment cycles involving fresh and frozen-thawed embryos.Donors were previous IVF patients who, regardless of their abilityto pay, shared their eggs equally with matched anonymous recipients.They paid only for their consultations and tests right up tothe point of being matched with a recipient The sole recipientpaid the cost applicable in egg donation of a single egg collection,although both received embryo transfers. The results indicatethat although the recipients were older than the donors (41.4± 0.9 versus 31.6 ± 0.5 years), and there wasno difference in the mean number of eggs allocated, the percentagefertilization rates, or the mean number of embryos transferred,there were more births per patient amongst recipients than amongstdonors (30 versus 20%). We conclude that providing the donorsare selected carefully, this scheme whereby a sub-fertile donorhelps a sub-fertile recipient is a very constructive way ofsolving the problem of the shortage of eggs for donation. Thereare also the advantages of including a group of women who wouldotherwise be denied treatment Problems related to ‘patientcoercion’ can, in our view, be fully overcome by the applicationof strict common-sense safeguards. The ideal of pure altruismis not without its medical and moral risk. The success of egg-sharingdepends on shared interests and a degree of altruism betweenthe donor, the recipient and the centre. The current HFEA guidelinesshould be applauded for enabling a highly effective conceptof mutual help to develop.     

Analysis of depressed cell-mediated immunity in asbestos workers

To explore the mechanisms of asbestos-related perturbations of the immune system, we evaluated the in vitro cell-mediated immunity of five asymptomatic asbestos workers with hypergammaglobulinemia and decreased T-cell numbers. These results were compared with those in 10 matched controls. Analysis of T-lymphocyte populations revealed decreased absolute numbers of OKT4+ (helper/inducer) T cells in the peripheral blood and phytohemagglutinin (PHA)-stimulated mononuclear cell cultures of the workers. When chrysotile asbestos was added to PHA cultures, expansion of OKT4+ cell populations was disproportionately inhibited in workers' cultures. Furthermore, control proliferative responses to PHA became indistinguishable from initial worker responses. These effects were incompletely explained by the cytotoxic effects of asbestos on cultured lymphocytes. We conclude that both in vivo and in vitro exposure of mononuclear cell populations to asbestos may lead to a diminution of helper-inducer T-cell numbers. In asbestos-exposed individuals, this latter lymphocyte subpopulation appears to be especially sensitive to in vitro asbestos exposure. Although the clinical implications of these findings are unclear, we hypothesize that many of the immunologic abnormalities that occur in asbestos workers could be explained by direct asbestos effects on the OKT4+ immunoregulatory population.     

A method for the accurate determination of anti-hapten cytotoxic T lymphocyte precursors: correction for apparent 'anti-self' reactivity

A method is described for accurately determining the frequency of precursors of hapten specific cytotoxic T cells. The method is based on a standard Poisson analysis of limit dilution cultures, but makes a correction of 'anti-self' reacting clones and for spontaneously arising clones that recognise modified self. These corrections are shown to be especially important when low hapten densities are used, where there may be more than a 10-fold difference between the corrected and uncorrected frequency estimates. Determined levels of antigen specificity and of H-2 restriction are significantly enhanced by application of this method.     

IL-4–BATF signaling directly modulates IL-9 producing mucosal mast cell (MMC9) function in experimental food allergy

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Evaluation of quantitative aerosol techniques for use in bronchoprovocation studies

To investigate airway physiology by use of inhaled aerosols, it is frequently necessary to measure the actual amount of material deposited on the airway wall as well as the site of particle deposition. To satisfy these needs, radiolabeled aerosols and gamma camera techniques have been used to measure regional deposition of inhaled particles. To make quantitative measurements of the amount deposited, previous investigators have used a "phantom" technique to indirectly calibrate the gamma camera for the attenuation of gamma rays through the lungs and chest wall. For this calibration, the phantom is a simulated lung containing a known amount of radioactivity. Radioactive counts emitted from the phantom are assumed to be attenuated in the same manner as the intact human lung. The present article describes a technique to determine directly the amount of inhaled aerosol deposited in the lung and simultaneously to calibrate the gamma camera for each individual subject. We used right angle light scattering and a gamma camera to measure individual values of the deposition fraction (DF) of inhaled aerosol deposited in the lung and the coefficient of attenuation (AC) of gamma rays in normal and obstructed lungs of human subjects. Radiolabeled monodisperse aerosols 1 and 2 microns in diameter were used. Knowledge of the activity of the inhaled aerosol (microcurie per liter), the volume inhaled, and the measured DF determined each subject's AC (counts per minute per microcurie). DF varied by an order of magnitude in normal (0.04 to 0.48) and obstructed (0.16 to 0.75) of subjects.(ABSTRACT TRUNCATED AT 250 WORDS)     

Direct infant UV light exposure is associated with eczema and immune development

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Cost of Aseptic Revision Total Knee Arthroplasty at a Tertiary Medical Center

BackgroundRevision total knee arthroplasty (TKA) involves varying levels of case complexity and costs depending on the following: (1) number of components revised, (2) duration of operating room time, and (3) length of hospital stay. However, the cost associated with different types of aseptic TKA revisions, based on number and type of components revised, is not well described. We sought to determine differences in cost associated with different revision types, and to correlate this with average national hospital and surgeon reimbursement based on current Centers for Medicare and Medicaid Services data.MethodsThis is a retrospective review of aseptic revision TKAs performed at a single tertiary referral center from 2015 to 2018. Patient demographic data, operating room time, and direct surgery and total hospital costs obtained from an internal accounting database (Enterprise Performance Systems, Inc) were collected. Patients were stratified by the components revised (polyethylene liner only, tibia only, femur only, or both femur and tibia). We hypothesized that direct surgery and total hospital costs would increase as case complexity increased from poly exchange to single-component revisions and both-component revisions.ResultsIn total, 106 patients were included (19 poly exchanges, 10 tibia-only revisions, 13 femur-only revisions, and 64 both-component revisions). Operating room time was significantly lower for poly exchange than all other groups (P < .001). Direct surgery and total hospital costs were significantly lower for poly exchange than all other groups (P < .001), and were significantly lower for tibia-only and femur-only revisions compared to both-component revisions (P < .001). Average national surgeon reimbursement by Medicare decreased as a percentage of direct surgery cost as case complexity increased from poly exchange to tibia-only, femur-only, and both-component revisions. Total hospital cost per average Diagnosis Related Group weight was lowest for single-component revisions and highest for both-component revision.ConclusionThere are significant differences in cost associated with aseptic TKA revisions based on number and type of components revised. These differences may not be accurately reflected in reimbursement, and often represent a burden to those who treat complex revisions.     

The Hospital Frailty Risk Score is Not an Accurate Predictor of Treatment Costs for Total Joint Replacement Patients in a Medicare Bundled Payment Population

BackgroundMedically complex patients require more resources and experience higher costs within total joint arthroplasty (TJA) bundled payment models. While risk adjustment would be beneficial for such patients, no tool currently exists which can reliably identify these patients preoperatively. The purpose of this study is to determine if the Hospital Frailty Risk Score (HFRS) is a valid predictor of high-TJA treatment costs.MethodsRetrospective analysis was performed on patients who underwent primary TJA between 2015 and 2020 from a single large orthopedic practice. ICD-10 codes from an institutional database were used to calculate HFRS. Cost data including inpatient, postacute, and episode of care (EOC) costs were collected. Charlson comorbidity index, demographics, readmissions, and complications were analyzed.Results4936 patients had a calculable HFRS and those with intermediate and high scores experienced more frequent readmissions/complications after TJA, as well as higher EOC costs. However, HFRS did not reliably predict EOC costs, yielding a sensitivity of 49% and specificity of 66%. Multivariate analysis revealed that both patient age and sex are superior individual cost predictors when compared with HFRS. Secondary analyses indicated that HFRS more effectively predicts TJA complications and readmissions but is still nonideal for clinical applications.ConclusionHFRS has poor sensitivity as a predictor of high-EOC costs for TJA patients but has adequate specificity for predicting postoperative readmissions and complications. Further research is needed to develop a scale that can appropriately predict orthopedic cost outcomes.     

Emergency Department Observation Versus Readmission Following total Joint Arthroplasty: Can We Avoid the Bundle Buster?

BackgroundAs the Center for Medicare and Medicaid (CMS) moves toward bundled payment plans for total joint arthroplasty (TJA), it becomes necessary to reduce factors that increase cost for an episode of care such as readmissions. The goal of this study is to evaluate the payment for observation stay versus readmission for patients who present to the emergency department.MethodsA retrospective review from 2014-2019 was conducted identifying all Medicare patients who had a primary, elective TJA and visited the ED within 90 days postoperatively. If a readmission was one midnight or less or had an equivalent diagnosis to an observation stay patient, it was characterized as a readmission that could have qualified as an observation stay. Using our institution’s average payment for Medicare readmissions and observations, actual and potential savings were calculated.ResultsSixty-nine out of 523 (13.2%) patients were placed under observation, while 454 (86.8%) patients were readmitted. Eighty-six out of 523 (18.9%) patients qualified for observation status. There was an actual savings of 11.8% by placing patients on observation status and readmission rate was decreased by 13.2%. Savings could have increased by a total of 27.7% and readmissions decreased by a total of 29.6% if all patients who qualified had been placed on observation status.ConclusionAt our institution, the implementation of observation stay has led to a savings of 11.8% and a potential total savings of 27.7%. The rate of readmissions was decreased by 13.2% and had the potential to decrease by a total of 29.6%.     

Understanding the financial impact of a diagnosis of young onset dementia on individuals and families in the United Kingdom: Results of an online survey

Although literature on postdiagnostic support for people affected by young onset dementia acknowledges financial concerns, this topic has remained underresearched. The aim of this study was to explore the financial impact of a diagnosis of young onset dementia on individuals and families. An online survey, comprising binary yes/no, multiple-response and open-ended questions, was codesigned with people living with young onset dementia. The survey was promoted via networks and online platforms. Data were collected from August to October 2019. Survey respondents across the United Kingdom (n = 55) who had received a diagnosis of young onset dementia were aged between 45 and 64, were at different stages of dementia and had been diagnosed with thirteen different types of dementia. Of the 55 respondents, 71% (n = 39) had received assistance from family members when completing the survey. The main financial impact of a diagnosis of young onset dementia resulted from premature loss of income and reduced and often deferred pension entitlements. In some cases, care-costs became unaffordable. Lack of clarity of processes and procedures around needs assessments, carers' assessments and financial assessments by different organisations resulted in some families having to ask for legal advice and, in some cases, involved lengthy appeal processes. Future research needs to involve Adult Social Care and Third Sector organisations to help codesign and test financial management interventions to support people affected by this progressive health condition.