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A robust relationship between procedure volume and clinical outcomes has been demonstrated across many surgical fields. This study assessed whether a center volume–outcome relationship exists for contemporary kidney transplantation, specifically for diabetic recipients, older recipients (aged ≥65 years), and recipients of high kidney donor profile index (KDPI ≥ 85) kidneys.

Some United States organ procurement organizations transfer deceased organ donors to donor care units (DCUs) for recovery procedures. We used Organ Procurement and Transplantation Network data, from April 2017 to June 2021, to describe the proximity of adult deceased donors after brain death to DCUs and understand the impact of donor service area (DSA) boundaries on transfer efficiency. Among 19 109 donors (56.1% of the cohort) in 25 DSAs with DCUs, a majority (14 593 [76.4%]) were in hospitals within a 2-hour drive. In areas with DCUs detectable in the study data set, a minority of donors (3582 of 11 532 [31.1%]) were transferred to a DCU; transfer rates varied between DSAs (median, 27.7%, range, 4.0%-96.5%). Median hospital-to-DCU driving times were not meaningfully shorter among transferred donors (50 vs 51 minutes for not transferred, P< .001). When DSA boundaries were ignored, 3241 cohort donors (9.5%) without current DCU access were managed in hospitals within 2 hours of a DCU and thus potentially eligible for transfer. In summary, approximately half of United States deceased donors after brain death are managed in hospitals in DSAs with a DCU. Transfer of donors between DSAs may increase DCU utilization and improve system efficiency.

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To evaluate the teaching dictum “wind, water, wound, walk” in the modern surgical environment.

The virtual patient (VP) is a web-based tool that allows students to test their clinical decision-making skills using simulated patients.

In this essay the author describes the status of the humanities within United States research universities, and notes that there is a place in the research university for clinical analysts with non‐quantitative research interests, who are seen as humanities scholars by other humanities specialists. He discusses the current trend in psychoanalytic research in the United States, which perpetuates an historically well‐known divide between quantitative and non‐quantitative investigators, and causes non‐quantitative clinician–researcher analysts to seek a workplace outside organized analysis, as it exists within the American Psychoanalytic Association. He goes on to describe the way a clinical analyst with a strong non‐quantitative research commitment has found a supportive home for his investigations in a humanities institute in a research university. That analyst has been welcomed as a colleague by university‐based humanities scholars, and has found that those collegial relationships offer creative freedom and interdisciplinary stimulation. The author notes that a cadre of analysts, enriched by such experiences, will be better equipped to bridge the divide which exists between non‐quantitative and quantitative analytic researchers, for the benefit of psychoanalytic research in the future. The author also illustrates the benefits experienced by university‐based humanities scholars when they collaborate with clinical analysts, and suggests this makes stronger ties between psychoanalysis and research universities more likely in the future.

In this contribution, the authors defi ne and discuss the educational boundary in analytic training, which they believe is an often neglected and useful concept in psychoanalytic education. The framework on which their discussion rests includes the recent attention of psychoanalysts to issues of boundaries and ethics. Their understanding of how clinical work affects the mind of the analyst educator, as well as the ways the personalities of various analysts affect their dealings with faculty peers and students, are the other cornerstones of their discussion. The authors contend that many of the institutional problems encountered in the training of analysts can be better understood when viewed through the prism of the educational boundary. They present examples which illustrate several of the ways psychoanalytic educators complicate the training experience of candidates, offer specifi c explanations as to why analysts struggle as they try to manage their educational interventions, and indicate in a discussion of potential remedies that those behaviors might be avoided if the educational boundary is in focus. They also provide an example of how the educational boundary can be more effectively managed.

The prevalence rates of periodontitisand dental caries in 30 Down's syndrome patients and 30 matched, otherwise retarded, controls were compared. The populations were older than those usually studied, with mean (±SE) ages of 27.4 (±2.1) and 28.9 (±2.3) for the Down's syndrome and control groups, respectively. Bone loss was found in 60.0% of sites in the Down's syndrome patients, compared with 9.3% sites in controls. In Down's syndrome, bone loss was first seen at about age 16, with 92% of patients 16 or older having loss; in contrast, only 42% of control patients 16 or older had bone loss, which first appeared at about age 28. There was a considerable difference in caries prevalence in the two groups, with the Down's syndrome patients having a lower overall prevalence which was most noticeable with respect to interproximal lesions. Seven Down's syndrome patients over age 15 were caries‐free, as opposed to only one control patient.

Persons with developmental disabilities living in the community have a greater number and variety of health care needs than the average population of the same age and sex. The erroneous assumption that the generic health care system would be able to provide all necessary services to the large number of individuals recently transferred from state residential facilities to the community has proved to be an unexpected disappointment to human service policymakers. In an effort to remedy this situation, a program of health care services was established by the New Jersey Department of Human Services at a community teaching hospital to supplement the existing generic system of medical care. Within four years, the program had rapidly grown to provide care for 729 patients who had come to rely on the center for primary care, specialty medical and dental services, and medical case management. The demographic characteristics of this program are described as well as data on morbidity, service utilization, and special problems encountered when care was provided to this complex and medically underserved population.(JAMA 1988;260:1439-1444)

In reviewing descriptions of self-analysis in the literature, as part of an ongoing inquiry into the nature and role of self-analysis in the life and work of the psychoanalyst, the author noted a focus on circumscribed self-analytic work, or on a method for self-analysis that did not stress its clinical relevance. Missing were descriptions of the encompassing, multi-sourced, multimotivated, interminable nature of self-analysis in the analyst's work life and personal life. In response to those findings, the author focuses on the conduct of his self-analysis over a period of several months, following an illness experienced by his mother. He attempts to convey certain qualities of his self-analysis: it goes on all the time, it is variously fueled by experiences in and outside his consulting room, and it is practiced self-consciously and with self-discipline. He also describes the ways in which his self-analysis enhances his clinical effectiveness and promotes his personal growth, and notes that all of an analyst's experiences are interconnected opportunities for personal and professional development.

The serious decline in applicants for psychoanalytic training mandates the attention of psychoanalytic educators. If students are to be drawn to psychoanalysis, creative methods must be employed to convey the vigor and excitement of work in the field.

Two patients with severe pre-eclampsia in the third trimester of pregnancy developed sudden blindness. Physical examination and computed tomography indicated a central cause, most likely cerebral edema. Swan-Ganz catheterisation revealed a low cardiac preload and a markedly elevated afterload. Following pharmacologic reduction of the afterload the blindness disappeared completely.On the basis of the two cases presented and a review of the pertinent literature we conclude that temporary cortical blindness in patients with severe pre-eclampsia may usually be attributed to focal cerebral edema. It seems likely that a combination of high cerebral arterial pressure, leading to disruption of capillary tight junctions, with an elevated interstitial cerebral colloid osmotic pressure constitutes the main determinant of fluid leakage into cerebral tissue. Treatment should consist of gradual pharmacologic reduction of mean arterial blood pressure.

Questions concerning the suitability of different forms of vegetarian diets for young children and infants are explored. The basic principles and some practical approaches are outlined, with emphasis given to lacto-ovo-vegetarian diets.