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When faced with the fear of low-quality tap water, households are motivated to seek out and use alternatives. This study investigated the role of quality perception and aesthetics on choices among three modes of household water usage: unfiltered tap water, filtered tap water, and bottled water. The data were based on a telephone survey of randomly selected households in Jacksonville, FL, conducted during March 2016. As the three modes of water usage were not mutually exclusive, a multivariate probit model was fitted and simultaneous parameter estimates were generated for each of three binary equations. The key results suggest that concerns regarding safety, contamination and sickness linked to unfiltered tap water are associated with increased bottled water usage in the home, but they have no effect on water filter usage. By contrast, complaints about foul-smelling water are associated with increased usage of water filters. In addition, the evidence implies that while water filter usage increases with household income, bottled water usage appears insensitive to changes in income. Finally, African-American households have a higher probability than other racial groups of using bottled water in the home, all else equal.

Kidney Donor Risk Index (KDRI) introduced in 2009 included hepatitis C serologic but not viremic status of the donors. With nucleic acid amplification testing (NAT) now being mandatory, further evaluation of these donors is possible. We conducted a retrospective matched case-control analysis of adult deceased donor kidney transplants performed between December 5, 2014 to December 31, 2016 with the KDRI score and hepatitis C virus antibody (HCV Ab) and NAT testing status obtained from the United Network for Organ Sharing database. The 205 aviremic HCV Ab+ NAT - kidney transplants were compared to KDRI matched control kidneys that were HCV Ab-NAT-. The aviremic HCV kidneys were recovered from donors who were significantly younger, more likely to be white, and less likely to have hypertension and diabetes. The majority of the recipients of the aviremic HCV kidneys when compared to matched controls were HCV positive: 90.2% vs 4.3%. The recipients were significantly older, were on dialysis for a shorter time, and were transplanted sooner. The graft survival of aviremic HCV kidneys was similar (P .08). If the HCV status of the aviremic kidneys was assumed to be negative, 122 more kidneys could have been allocated to patients with estimated posttransplant survival20. Seven kidneys would no longer have Kidney Donor Profile Index85%. Further policies might consider these findings to appropriately allocate these kidneys.

Young adult and adolescent kidney transplant recipients have shorter graft survival than older and younger recipients. Although multifactorial, the tendency toward premature graft loss in young kidney transplant recipients has often been attributed to medication nonadherence and the transition from pediatric to adult care. Multiple interventions for medication nonadherence in kidney transplant recipients have been studied. Potential preventative interventions include pre-transplant screening, transition and young adult clinics, technologies such as reminders or mobile applications, and simplification of the post-transplant medication regimen. There are also recent advances in monitoring interventions for nonadherence in transplant recipients, including electronic monitoring devices such as wireless pill bottles and the Ingestible Sensor System, which incorporates ingestible microsensors into medications. Treatment interventions for medication nonadherence include cognitive behavioral programs, behavioral contracts, and screening and treatment for depression. Several of the interventions reviewed are currently available to providers caring for young kidney transplant recipients, without any complex programmatic changes. Further research in all of these areas would be of great value.

BACKGROUND The number of Public Health Service increased-risk organ donors (PHS IRD) is growing, largely from an increase in intravenous drug use overdoses due to the current opioid epidemic. MATERIAL AND METHODS We conducted a retrospective case series review using our single-center data. We reviewed 82 PHS IRD kidney transplant offers between 2015 and 2017, 20 of which were declined. We reviewed outcomes of patients who declined vs. accepted PHS IRD offers. We studied the effect of education on these patients' willingness to consider another PHS IRD. RESULTS Twenty patients declined PHS IRD over a 2-year period. They waited on average 9 months for another transplant, and tended to be transplanted with a higher-KDPI kidney than the one originally offered. Patients who declined PHS IRD were more likely to be predialysis, women, and Asian American, and to require an interpreter. Ninety-two percent of patients who received education on PHS IRD after declining an offer stated that they would consider another PHS IRD offer in the future. Four of these patients received a PHS IRD transplant. CONCLUSIONS Our results suggest that education of patients may have a positive impact on patient attitudes toward PHS IRD.

The opioid epidemic has resulted in increasing the incidence of hepatitis C virus in the general population and more deceased organ donors with hepatitis C in the United States. We aim to describe how the changing donor landscape affects patterns of liver and kidney transplantation among donors, waitlist candidates, and transplanted recipients.Using data supplied by the United Network for Organ Sharing, we examined donor hepatitis C virus antibody (Ab) and nucleic acid testing (NAT) status, center waitlist patterns, and liver and kidney transplants and discards between 2015 and 2017 by 6-month periods.We observed an increase in donors with any marker of the hepatitis C virus (n = 283 [6.2%] in period 1 to n = 384 [7.4%] in period 5, P = .008) and antibody positive nucleic acid testing negative donors (n = 81 [1.8%] in period 1 to n = 131 [2.5%] in period 5, P.001). We observed a significant increase in aviremic recipients of liver transplants from antibody positive nucleic acid testing negative donors (n = 1 [1.7%] in period 1, to n = 27 [31.0%] in period 5, P = .005) and a significant decrease in the antibody positive nucleic acid testing positive liver discard rate (P = .01). By the end of the study, 75.8% (n = 97) of recipients of antibody positive nucleic acid testing negative kidneys were hepatitis C virus negative, an increase from 10.6% (n = 5) in period 1.The number of donors with the hepatitis C virus is increasing. We observed a concomitant increase in the transplantation of kidneys and livers from aviremic donors, and the recipient population of these organs is increasingly hepatitis C virus negative.

Background: The Centers for Medicare and Medicaid services (CMS) have implemented initiatives to improve postdischarge care and reduce unnecessary readmissions. Readmissions within 30 days are frequent and represent an economic burden on both patients and the healthcare system. The aim of this study was to evaluate the frequency and causes for urgent care visits within 30 days of discharge after ankle open reduction and internal fixation (ORIF) and determine factors correlated with such visits. Methods: This was a retrospective analysis of prospectively collected data. All patients who underwent ankle ORIF at our institution between July 1, 2016, and June 30, 2017, were included. Patients were identified using Current Procedural Terminology (CPT) codes for ankle ORIF. Patients’ demographics including age, sex, race, body mass index, occupation, insurance payer, and comorbidities were documented. Results: Thirty-five patients (10.51%) had urgent care visits within 30 days of discharge. Patients presented at a mean of 11.8 days after the day of surgery. Sixteen patients (45.71%) had cast/splint-related issues, 7 (20%) presented with pain, and 7 (20%) with increased operative site drainage. Univariate analysis demonstrated a statistically significant association between postoperative urgent care visits and patients with diabetes ( P = .03) or underlying psychiatric disorders ( P = .03). Conclusion: In this population study of patients undergoing ankle fracture surgery, we found that the rate of urgent care visits within 30 days of discharge exceeded the rate of inpatient readmission. Additionally, patients with diabetes and psychiatric disorders were significantly more likely to present to an urgent care facility postoperatively, potentially accounting for increased expenditures of the healthcare system. Level of Evidence: Level III, comparative series.

Under the new kidney allocation system (KAS), implemented in 2014, the distribution of the best quality donor kidney grafts shifted between age groups, but it is unclear whether this change translates to meaningful differences in post-transplant outcomes. We conducted a retrospective cohort study of 20,345 deceased donor kidney transplant recipients before and 4,605 recipients after implementation of the KAS using data from the United Network of Organ Sharing. Overall, two-year mortality was greater among recipients in the post-KAS era compared with the pre-KAS era (6.31% vs 5.91% respectively, [p = 0.01]), and two-year graft loss was not significantly different between eras (9.95% and 9.65%, respectively [p = 0.13]). In analysis stratified by age group (18-45, 46-55, 56-65, and ≥66 years), relative risk of mortality was 1.48 (95% confidence interval [CI] 1.09-1.98) among recipients 46-55 years old and 1.47 (95% CI 1.18-1.81) among recipients 56-65 years old. Relative risk of all-cause graft loss was 1.43 (95% CI 1.20-1.70) among recipients 56-65 years old. There were no significant differences in relative risk of mortality or graft loss associated with the KAS era among other age groups. After adjustment for recipient characteristics and characteristics of the changing donor pool, relative risk of two-year mortality and graft loss associated with the post-KAS era was attenuated for recipients aged 46-55 and 56-65 years, but remained statistically significant. In this early analysis after implementation of the KAS, there is suggestion that increased risk of mortality and graft loss may be disproportionately borne by middle-aged recipients, which is only partially accounted for by changes in recipient and donor characteristics. These findings signal a need to continue to monitor the effects of the KAS to ensure that allocation practices both maximize utility of the kidney graft pool and respect fairness between age groups.

BACKGROUND Implementation of the Kidney Allocation System (KAS) changed how kidneys are allocated and the information on which organ utilization decisions are based. We aimed to evaluate how KAS implementation changed kidney utilization and recipient outcomes. MATERIAL AND METHODS Using the United Network for Organ Sharing database, we identified recipients of kidney transplants from donors with kidney donor profile index (KDPI) of 61-90% in the 5-years pre- and 18-months post-KAS implementation and examined patient and graft survival and donor kidney discard rates based on standard criteria donor (SCD) or expanded criteria donor (ECD) status. RESULTS The proportion of ECD kidneys was unchanged pre- versus post-KAS. Post-KAS, SCD kidneys were less likely to be transplanted into young recipients while ECD kidneys were more likely to be transplanted. SCD kidneys in the post-KAS period conferred a 1.42 (95% CI: 1.18-1.73) times higher adjusted mortality and 2% lower 1-year survival (94.2% vs. 96.2%, P

Eculizumab suppresses the effector functions of the complement system and represents a therapeutic breakthrough for patients with paroxysmal nocturnal hemoglobinuria or atypical hemolytic uremic syndrome (aHUS). Safety monitoring is ongoing; so far, most notable is the expected increase in infection risk with encapsulated organisms. Despite potential applicability in multiple complement-mediated disorders, the off-label use of eculizumab has been limited, mainly by its prohibitive cost. The purpose of this review is to summarize the current data relevant to the use of eculizumab in kidney transplantation.In aHUS, prone to high rates of recurrence and allograft loss, eculizumab has made the most notable therapeutic impact. Further clarification of complement defects may help predict therapeutic responses and hopefully guide treatment duration. In C3 glomerulopathies, the clinical response to eculizumab appears more heterogeneous and less effective in processes mediated by upstream to C5 complement deregulation. A large clinical trial of eculizumab for prevention of delayed graft function is ongoing. In antibody-mediated rejection, the role of eculizumab is unclear as its use has been limited to very complex, mostly presensitized, patients in mixed combinations of therapeutic modalities.Overall, eculizumab has raised awareness of complement-mediated disorders as an exciting, new therapeutic option with multiple potential applications in kidney transplantation. Further research is needed to develop a better understanding of eculizumab applicability, efficacy, and treatment monitoring and beyond, to future therapeutic tools targeting the complement.

OBJECTIVES Recent studies have demonstrated the superiority of bilateral internal mammary arteries (BIMAs) as conduit material for coronary artery bypass grafting (CABG) surgery. However, there is limited research on the effects of other graft conduits used in patients who require additional bypasses. The goal of this study was to evaluate the impact of the radial artery (RA) when used in conjunction with the BIMAs. METHODS From the beginning of 2000 to the end of 2013, 4370 patients underwent CABG for three or more vessels at our institution. There were 568 and 183 patients who received BIMA + saphenous vein graft (SVG) and BIMA + radial ± SVG, respectively. Propensity matching was used to create a balanced cohort from these patients, which resulted in two groups of 183 patients. Thirty-day outcomes and long-term survival were compared between the two groups. Long-term follow-up was generated using the Social Security Death Index. RESULTS There were no significant differences in preoperative characteristics. For 30-day outcomes, the BIMA + radial ± SVG group had more postoperative atrial fibrillation (24.6 vs 12.0%; P = 0.001) and a longer median postoperative length of stay (6 vs 5 days; interquartile range = 2; P = 0.016) than BIMA + SVG patients. There was no significant difference in long-term survival between the two groups over the 14-year period. However, before year 10, the BIMA + SVG group had a trend towards higher survival, whereas on follow-up after 10 years, there was a trend that favoured the BIMA + radial ± SVG patients. Cox regression analysis using a time-dependent covariate demonstrated that when the groups were split at 10 years, there was a statistically significant improvement in survival of the BIMA + radial ± SVG group [adjusted hazard ratio 0.254 95% confidence interval (CI) 0.062-0.977; P = 0.048] over BIMA + SVG patients between 10 and 14 years. CONCLUSIONS Overall, there were no statistically significant differences in survival between the BIMA + SVG and BIMA + radial ± SVG groups over the 14 years. However, further analysis demonstrated that while the BIMA + radial ± SVG group had a trend towards decreased survival before 10 years, use of the RA in conjunction with BIMAs was associated with significantly increased survival in the later years. A larger cohort of patients with longer follow-up is needed to assess the outcomes of CABG using BIMA + radial ± SVG.

Plasma cell diseases are a class of hematologic diseases that are sometimes present as preexisting diagnoses prior to organ transplantation, causative factors leading to a need for organ transplantation, or may occur posttransplant as part of the spectrum of posttransplant lymphoproliferative disorders. Herein, we review the most common plasma cell diseases, both as coexisting with other causes of organ failure, but also as a primary underlying cause for organ failure. In many cases, treatment of the underlying clonal disease may be indicated before proceeding with organ transplant. This review aims to provide current and relevant data regarding the management of these conditions in the organ transplant patient, for transplant providers, and those who take care of these patients.

The new kidney allocation system (KAS) intends to allocate the top 20% of kidneys to younger recipients with longer life expectancy. We hypothesized that the new KAS would lead to greater allocation of Public Health Service (PHS) increased-risk donor organs to younger recipients.Analyses of the Organ Procurement and Transplantation Network data of patients who underwent primary deceased kidney transplantation were performed in pre- and post-KAS periods.The allocation of PHS increased-risk kidney allografts in various age groups changed significantly after implementation of the new KAS, with an increased proportion of younger individuals receiving increased-risk kidneys (7% vs 10% in age group 20-29 y and 13% vs 18% in age group 30-39 y before and after KAS, respectively; P .0001). This trend was reversed in recipients 50-59 years old, with 31% in the pre-KAS period compared with 26% after KAS (P .0001).The new KAS resulted in a substantial increase in allocation of PHS increased-risk kidneys to candidates in younger age groups. Because increased-risk kidneys are generally underutilized, future efforts to optimize the utilization of these organs should target younger recipients and their providers.

A surprising number of U.S. cities have drinking water with unhealthy levels of chemicals and contaminants. The city of Jacksonville (Florida), the location for this study, owns the dubious distinction of being ranked among the worst major American cities in water quality according to water quality tests conducted between 2005 and 2009 by the Environmental Working Group (EWG). This report of toxic chemicals in the Jacksonville water supply generated considerable negative publicity and coincides with a frequent and common complaint among residents of foul-smelling water. System revenues from water supply and program subsidies from government are often inadequate in mitigating the problems, perceived or real, with water quality. Therefore, this paper investigates how much residents will be willing to pay for improvements in the quality of tap water. The commonly known economic metric willingness-to-pay (WTP) is applied to estimate any possible rate hikes public utility can assess in any effort to improve real or perceived water quality. The study shows that the estimated weighted average of WTP is $6.22, which can be added to the regular water bill without eliciting much negative reaction from residents. Evidence shows that factors such as trust in authorities, health concerns, family structure, and education significantly impact the WTP.

In coronary artery bypass grafting (CABG), the combined use of left and right internal mammary arteries (LIMA and RIMA) — collectively known as bilateral IMAs (BIMAs) provides a survival advantage over the use of LIMA alone. However, gene expression in RIMA has never been compared to that in LIMA. Here we report a genome-wide transcriptional analysis of BIMA to investigate the expression profiles of these conduits in patients undergoing CABG. As expected, in comparing the BIMAs to the aorta, we found differences in pathways and processes associated with atherosclerosis, inflammation, and cell signaling — pathways which provide biological support for the observation that BIMA grafts deliver long-term benefits to the patients and protect against continued atherosclerosis. These data support the widespread use of BIMAs as the preferred conduits in CABG.

Author(s): Arshad, Aysha; Johnson, Christopher K; Mittal, Suneet; Buch, Eric; Hamam, Ismail; Tran, Thanh; Shaw, Richard E; Musat, Dan; Preminger, Mark; Sichrovsky, Tina; Herweg, Bengt; Shivkumar, Kalyanam; Hummel, John; Steinberg, Jonathan S | Abstract: BackgroundThere are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior.ObjectiveTo compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers.Methods and resultsIn this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16-3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100-3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05-2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01-5.67, P = 0.046) independently predicted total complications.ConclusionsWhen comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

Background Transfusion-related acute lung injury (TRALI) is a serious complication leading to pulmonary edema and respiratory failure. This study's objective was to assess TRALI occurrence and potential risk factors among inpatient US elderly Medicare beneficiaries, ages 65 and older, during 2007 through 2011. Study Design and Methods This retrospective claims-based study utilized large Medicare administrative databases. Transfusions were identified by recorded procedure and revenue center codes. TRALI was ascertained via ICD-9-CM diagnosis code. The study evaluated TRALI rates among the inpatient elderly overall and by calendar year, age, sex, race, blood components, and units transfused. Logistic regression analyses were used to assess potential risk factors. Results Of 11,378,264 inpatient transfusion stays for elderly Medicare beneficiaries, 2556 had a recorded TRALI diagnosis code, an overall rate of 22.46 per 100,000 stays. TRALI rates were higher for platelet (PLT)- and plasma-containing transfusions and increased by year and number of units transfused (p

Background Elderly patients with aortic stenosis are under-referred for aortic valve replacement surgery. This study investigated the perioperative factors associated with midterm outcomes in a consecutive series of patients undergoing aortic valve replacement with or without coronary artery bypass graft surgery. Methods From 2006 to 2010, 509 patients having aortic valve replacement or aortic valve replacement with coronary artery bypass were grouped according to age (Results and conclusions 5-year survival among octogenarians was 59.2% with an observed 30-day mortality of 1% for aortic valve replacement and 3% for aortic valve replacement with coronary artery bypass. Kaplan-Meier survival analysis showed that age ≥80 years, New York Heart Association functional class III/IV, and left ventricular ejection fraction

Background Studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality during the first year after surgery, but risk appears to decrease after the first year. This study compared 5-year mortality in a propensity-matched cohort of cardiac surgery patients. Study Design and Methods Between July 1, 2004, and June 30, 2011, 3516 patients had cardiac surgery with 1920 (54.6%) requiring blood transfusion. Propensity matching based on 22 baseline characteristics yielded two balanced groups (blood transfusion group [BTG] and nontransfused control group [NCG]) of 857 patients (1714 in total). The type and number of blood products were compared in the BTG. Results Operative mortality was higher in BTG versus NCG (2.3% vs. 0.4%; p

Objective The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our double LAA ligation (LLAA) technique was shown to be 96% successful in a small study. However, the outcomes of these patients have yet to be compared with a set of nonligated patients. Methods From 2005 to 2012, a total of 808 patients received LAA using our double ligation technique using both a polydioxanone (PDS) II endosnare and a running 4-0 Prolene pledgeted suture. The 30-day outcomes of these patients were compared with that of nonligated patients. Fifty-six of the ligated patients had a postoperative transesophageal echocardiography (TEE). An echocardiographer reviewed the follow-up TEEs for LAA remnant and/or residual flow into the LAA using color Doppler imaging. The patients with LAA flow and/or remnant depth of 1 cm or greater were deemed to have an unsuccessful exclusion. Results The ligated group had a trend of less postoperative atrial fibrillation (19.4% vs 22.9%, P = 0.07) and an overall significantly lower in-hospital mortality (0.7% vs 3.0%, P < 0.001) and lower 30-day mortality (0.7% vs 3.4%, P < 0.0001). The LAA was successfully excluded in 53 (94.7%) of the 56 patients with TEE. Conclusions Double LAA ligation correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in perioperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared with LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi perioperatively and in the long-term.

Prior studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality and morbidity following surgery. It is not clear whether this increased risk occurs across all haematocrit (HCT) levels. The goal of this study was to compare operative mortality in propensity-matched cardiac surgery patients based on stratification of the preoperative HCT levels.Between 1 August 2004 and 30 June 2011, 3516 patients had cardiac surgery. One thousand nine hundred and twenty-two (54.5%) required blood transfusion during or after surgery. A propensity score for transfusion was developed based on 22 baseline variables. One thousand seven hundred and fourteen patients were matched: 857 in the transfusion group (TG) and 857 in the non-transfused control group (CG). Univariate analyses demonstrated that, after propensity matching, the groups did not differ on any baseline factors included in the propensity model. Operative mortality was defined as death within 30 days of surgery. Preoperative HCT was stratified into four groups:36, 36-39, 40-42 and ≥ 43.For HCT36%, 30-day mortality was higher in the TG than that in the CG (3.0 vs 0.0%). For HCT 36-39, operative mortality was similar between TG (1.1%, N = 180) and CG (0.8%, N = 361; P = 0.748). For HCT 40-42, operative mortality was significantly higher in the TG compared with that in the CG (1.9 vs 0%, N = 108 and 218, respectively; P = 0.044). For HCT of ≥ 43, there was a trend towards higher operative mortality in the TG vs the CG (2.0 vs 0%, N = 102 and 152, respectively; P = 0.083). Other surgical complications followed the same pattern with higher rates found in the transfused group at higher presurgery HCT levels. HCT at discharge for the eight groups were similar, with an average of 29.1 ± 1.1% (P = 0.117).Our study indicates that a broad application of blood products shows no discernible benefits. Furthermore, patients who receive blood at all HCT levels may be placed at an increased risk of operative mortality and/or other surgical complications. Paradoxically, even though patients with low HCTs theoretically should benefit the most, transfusion was still associated with a higher complication and mortality rate in these patients. Our results indicate that blood transfusion should be used judiciously in cardiac surgery patients.

The Kidney Donor Risk Index (KDRI) and Kidney Donor Profile Index (KDPI) assist clinicians with the selection of deceased donor kidneys. This scoring system is based on 10 donor factors including Hepatitis C virus (HCV) status from serological or NAT testing. The donor HCV status (i.e., having either a positive hepatitis C antibody (Ab) or nucleic acid testing (NAT) result) increases the hazard ratio for graft failure by 1.27 and the KDPI by approximately 20%. Whether this increase in KDPI is a true reflection of graft quality for HCV seropositive but not viremic donors is unknown. Further investigations are needed to maximize the use of these organs.

The relationship between poverty and economic growth is reexamined using pooled cross section and time series estimates of state level poverty. Empirical evidence is provided for both cash and comprehensive income headcounts and Sen indexes of poverty. Particular emphasis is placed on the differential impacts of growth on poverty in the long economic expansions of the 1980s and 1990s. Contrary to prior work, we find that the long-term effects of growth did not strengthen and may have actually diminished during the 1990s.

This paper attempts to answer several questions addressing the provision of health care services in the Jacksonville, Florida MSA. Previous literature in the field of medical geography has focused on describing potential accessibility to hospitals and healthcare services, but this study also models actual use of such services by using a hospital patient database. Findings from a GIS-based analysis using ESRI ArcGIS and the Business Analyst extension suggests that distance to the nearest hospital is not the best measure of access to hospital care because of the lack of consideration of hospital capacity. This study demonstrates that health services delivery can be better understood and planned when the potential accessibilities to services and the actual utilization of such services are jointly considered.

Poverty remains a persistent problem in central cities across the US and the government's approach to measuring it is not without shortcomings. This paper applies recently developed innovations in poverty measurement and presents improved estimates of central-city poverty across time. A broader and more comprehensive income concept is employed to measure family resources and important distributional aspects of poverty are incorporated by using the Sen index. In general, Sen indexes for the central city are significantly reduced when comprehensive income is used to evaluate poverty. Motivating these changes are the substantial reductions that occur in the depth of poverty and the relative income inequality among poor central-city residents. Regionally, the results suggest that the elements of comprehensive income have their greatest impact on estimates of poverty in Southern central cities, while the central cities of the West are least affected.

Objective: The Duke Activity Status Index (DASI) questionnaire has become an established measure of cardiac functional capacity and quality of life. However, the relationship between a low DASI score and presence of major adverse cardiac events has not yet been assessed. This study evaluates differences in patient function and occurrence of late cardiac events in patients undergoing coronary artery bypass (CAB). Methods: Patients undergoing CAB between 1994 and 2014 at the Valley Hospital were assessed and propensity matched for surgical approach. The resulting population of 1856 patients was followed for a mean time of 11.2 years ranging from 1 to 20 year. Survival, occurrence of MI, stroke, repeat revascularization and patient function using the DASI questionnaire were assessed. At the latest follow-up, 1363 patients were still alive, of which 776 had completed the DASI questionnaire. Patients who completed the questionnaire (Responders) were compared to those who did not complete the DASI (Non-Responders) on baseline demographic and clinical characteristics. Kaplan-Meier and Cox Proportional Hazards Regression were used to compare late non-fatal events that occurred in patients with a low (52, N=310) DASI score. Results: Responders had a higher rate of prior MI, increased hypertension, and were significantly older at baseline procedure compared to Non-Responders. Both groups had comparable surgical risk and left ventricle ejection fraction at baseline revascularization. Kaplan-Meier analysis of the Responders showed that patients with a low scoring DASI had significantly greater occurrence of all late events. Cox Regression analysis controlling for all baseline factors showed that patients with a low DASI score had a two-fold increase in late non-fatal events compared to medium and high DASI scoring patients (adjusted hazard ratio: 2.076, 95% C.I. 1.309-3.293, p=0.002) (Figure 1). Conclusions: This study demonstrates that in cardiac surgical patients, a low score on DASI is independently associated with a higher occurrence of late non-fatal cardiac events. This provides further evidence supporting the use of the DASI questionnaire in evaluating patient functioning after cardiac surgery.

Increasingly resistant bacteria in sickle cell disease patients indicate need to evaluate extendedspectrum cephalosporin therapy., Few long-term multicenter investigations have evaluated the relationships between aggregate antimicrobial drug use in hospitals and bacterial resistance. We measured fluoroquinolone use from 1999 through 2003 in a network of US hospitals. The percentages of fluoroquinolone-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) were obtained from yearly antibiograms at each hospital. Univariate linear regression showed significant associations between a hospital's volume of fluoroquinolone use and percent resistance in most individual study years (1999–2001 for P. aeruginosa, 1999–2002 for S. aureus). When the method of generalized estimating equations was used, a population-averaged longitudinal model incorporating total fluoroquinolone use and the previous year's resistance (to account for autocorrelation) did not show a significant effect of fluoroquinolone use on percent resistance for most drug-organism combinations, except for the relationship between levofloxacin use and percent MRSA. The ecologic relationship between fluoroquinolone use and resistance is complex and requires further study.

Rates of fluoroquinolone resistance among Pseudomonas aeruginosa in hospitals are increasing, but interhospital variability is great. We sought to determine whether this variability correlated to fluoroquinolone use in hospitals and in the surrounding community. Hospital quinolone use in 1999 (24 hospitals) through 2001 (35 hospitals) was determined from billing records. The number of fluoroquinolone prescriptions within a 10-mile (approximately 16-km) radius of each hospital was determined for 1999 and 2000. Hospital fluoroquinolone use increased from 1999 through 2001, from 137 to 163 defined daily doses (DDD)/1000 patient-days (P=.01). The rate of community fluoroquinolone use also increased, from 2.3 to 2.8 DDD/1000 inhabitant-days (P

OBJECTIVE: To determine whether the cure rate was similar between traditional and newer antibiotics in the treatment of acute exacerbations of chronic bronchitis (AECB), to determine whether antibiotic selection during the first AECB of the season influences the frequency of subsequent AECB, and to identify variables associated with poor short- and long-term treatment outcome. METHODS: A retrospective analysis of subjects seen for management of their first seasonal AECB was conducted. Subjects were stratified into traditional therapies (n = 95) or newer therapies (n = 101) by antibiotic prescription. RESULTS: There was no difference in initial cure rates between older versus newer antibiotics (93% vs. 95%; p = 0.48). There was no difference in the number of subjects that remained AECB-free for 6 months after initial treatment with older versus newer antibiotic regimens (34% vs. 28%; p = 0.37). Oxygen initiation or increased dose (OR 10.9; 95% CI 1.4 to 84.2; p = 0.02) was the only variable independently associated with lack of AECB resolution. Nonsmoking status trended toward an association with remaining AECB-free at 180 days (OR 0.39; 95% CI 0.15 to 1.01; p = 0.053). CONCLUSIONS: The use of older versus newer antibiotics did not independently predict short-term outcome or future AECB.

There are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior.To compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers.In this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16-3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100-3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05-2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01-5.67, P = 0.046) independently predicted total complications.When comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

Juvenile xanthogranuloma is the most frequent type of non-Langerhans cell histiocytosis. It most commonly presents in infancy and early childhood; manifesting as cutaneous lesions on the head, neck, and trunk that suddenly appear and usually undergo spontaneous regression. Extracutaneous involvement, although rare, may occur along with the cutaneous form or in isolation. It most frequently involves the eye, deep subcutaneous tissues, lung, and liver. Involvement of the heart is exceptionally rare, with only seven reports found in the English literature, all affecting infants. We present the first report of an intracardiac juvenile xanthogranuloma in an adult.

Studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality during the first year after surgery, but risk appears to decrease after the first year. This study compared 5-year mortality in a propensity-matched cohort of cardiac surgery patients.Between July 1, 2004, and June 30, 2011, 3516 patients had cardiac surgery with 1920 (54.6%) requiring blood transfusion. Propensity matching based on 22 baseline characteristics yielded two balanced groups (blood transfusion group [BTG] and nontransfused control group [NCG]) of 857 patients (1714 in total). The type and number of blood products were compared in the BTG.Operative mortality was higher in BTG versus NCG (2.3% vs. 0.4%; p 0.0001). Kaplan-Meier analysis of 5-year survival demonstrated no difference between groups in the first 2 years (BTG 96.3% and 93.0% vs. NCG 96.4% and 93.9%, respectively). There was a significant divergence during Years 3 to 5 (BTG 82.0% vs. NCG 89.3% at 5 years; p 0.007). Five-year survival was significantly lower in patients who received at least 2 units of blood (79.6% vs. 88.0%; p 0.0001). In multivariate Cox regression analyses, transfusion was independently associated with increased risk for 5-year mortality. Patients receiving cryoprecipitate products had a twofold mortality risk increase (adjusted hazard ratio, 2.106; p = 0.002).Blood transfusion, specifically cryoprecipitates, was independently associated with increased 5-year mortality. Transfusion during cardiac surgery should be limited to patients who are in critical need of blood products.

Background: The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our technique of doubly ligating the LAA (LLAA) has recently demonstrated a 95% success rate of achieving complete LAA occlusion by follow-up transesophageal echocardiography. However, the outcomes of these patients have yet to be compared to a set of non-ligated patients. Methods: From 2005 to 2012, 814 patients received LLAA using our previously published technique of double ligation with both a PDS II endosnare and a running 4-0 Prolene pledgeted suture. Propensity scores were developed based on 22 observed baseline covariates in a logistic regression model with LLAA as the dependent variable. This produced two patient cohorts of 602 patients balanced for baseline factors. These patients were retrospectively analyzed regarding their incidence of 30-day outcomes. Results: Overall, the ligated group had a higher rate of comorbidities, shorter ICU and post-surgical length of stay, less post-operative bleeding, lower rate of permanent stroke, and an overall significantly lower in-hospital mortality (0.7% vs. 3.0% p Conclusions: Propensity matched analysis demonstrates that LLAA correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in intraoperative or postoperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared to LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi peri-operatively and in the long term.

This article begins with an examination of the evidence in support of traditional explanations of poverty: labor market and macroeconomic conditions; family structure; and government policy and programs. It argues that these explanations provide a useful but ultimately incomplete understanding of poverty. It then considers alternative explanations that are under-researched in the United States: social capital and social exclusion. Social capital is defined as “the social and economic spaces in which individuals reside and which provides them with certain group interactions, networks, and resources that help to inform their strategic actions that provide access to public and private resources.” Social exclusion occurs when individuals do not have access to standards of well-being, such as health care, education, and affordable housing.

We administer a basic mathematics exam to over 600 students enrolled in various college economics courses to understand what factors influence a student's ability to use basic math skills in solving simple real world problems. We find that students with strong elementary math skills are better able to use their math background in solving everyday problems. Moreover, our findings suggest that by taking more math classes in college, students significantly improve their ability to apply math in real world settings. Finally, we find that many demographic variables are important determinants, particularly the size of personal and family income. Students with greater personal financial responsibility in funding their education do significantly better in understanding and applying basic math skills.

Objective Previous studies have demonstrated that bilateral internal mammary artery (BIMA) grafts lead to superior outcomes compared with single internal mammary artery grafts. This study examines whether cardiopulmonary bypass affects conduit-dependent outcomes of coronary artery bypass grafting (CABG) surgery. Methods From 1994 to 2013, a total of 6666 patients underwent isolated CABG surgery at our institution. Of these procedures, 3548 (53.2%) were performed off pump. A BIMA–saphenous vein graft (SVG) was used in 1544, and 5122 had left internal mammary artery–SVGs. These 2 conduit groups differed significantly in baseline characteristics. Propensity matching based on 22 preoperative variables and using a nearest-neighbor matching algorithm was used to make balanced cohorts, resulting in 2 groups of 1006. To account for the influence of pump status on conduit selection, a second propensity score was developed for pump use. These cases were matched to create 4 patient cohorts of 353 patients each (a total of 1412), balanced for both conduit use and pump status. Late mortality was determined using the Social Security Death Index. Results No difference was found in survival between patients receiving BIMA-SVGs on or off pump (78.9% vs 79.1%). BIMA-SVGs outperformed the left internal mammary artery–SVGs regardless of whether the procedure was performed off pump (73.9%) or on pump (69.9%). Conclusions This study demonstrates that the use of cardiopulmonary bypass does not significantly affect the long-term outcomes in these patients as long as full revascularization is achieved. In addition, these results are consistent with prior research showing that the use of BIMAs produces better outcomes than use of a single internal mammary artery when performing CABG.

Background. Fluoroquinolones are widely prescribed in hospitals and the community. Previous studies have shown associations between fluoroquinolone use and isolation of fluoroquinolone-resistant Eshcerichia coli and methicillin-resistant Staphylococcus aureus (MRSA). We performed an ecologic-level study to determine whether variability in hospital percentages of fluoroquinolone-resistant E. coli and MRSA were associated with fluoroquinolone use in hospitals and their surrounding communities. Methods. We measured fluoroquinolone use in 17 US hospitals and their surrounding communities in the year 2000. Data on fluoroquinolone use in hospitals was electronically extracted from billing data. Data on fluoroquinolone use in communities was obtained from IMS health data for all prescriptions filled in pharmacies within a 16-km radius of each hospital. We used hospital antibiograms to determine the percentage of isolates that were fluoroquinolone-resistant E. coli and MRSA, and we performed linear regression to determine the relationship between percentage of resistant isolates and fluoroquinolone use in hospitals and their surrounding communities. Results. There was a significant association between total fluoroquinolone use within hospitals and percentage of S. aureus isolates that were MRSA (r = 0.77; P = .0003) and between total fluoroquinolone use in the community and percentage of E. coli isolates that were fluoroquinolone-resistant E. coli (r = 0.68; P = .003). Population density within the 16-km radius also correlated with MRSA percentage (r = 0.57; P = .015) and fluoroquinolone-resistant E. coli percentage (r = 0.85; P = .002), but associations between total fluoroquinolone use and resistance remained significant after adjustment for population density. Conclusions. In this ecologic analysis, we found associations between fluoroquinolone use in hospitals and methicillin resistance in S. aureus and between fluoroquinolone use in communities and fluoroquinolone resistance in E. coli in hospitals. Antimicrobial use in hospitals and communities may have different relative importance with regard to resistance in different pathogens encountered in hospitals.