Jane L. Holl

The Prevalence, Severity, and Distribution of Childhood Food Allergy in the United States

OBJECTIVE: The goal of this study was to better estimate the prevalence and severity of childhood food allergy in the United States. METHODS: A randomized, cross-sectional survey was administered electronically to a representative sample of US households with children from June 2009 to February 2010. Eligible participants included adults (aged 18 years or older) able to complete the survey in Spanish or English who resided in a household with at least 1 child younger than 18 years. Data were adjusted using both base and poststratification weights to account for potential biases from sampling design and nonresponse. Data were analyzed as weighted proportions to estimate prevalence and severity of food allergy. Multiple logistic regression models were constructed to identify characteristics significantly associated with outcomes. RESULTS: Data were collected for 40 104 children; incomplete responses for 1624 children were excluded, which yielded a final sample of 38 480. Food allergy prevalence was 8.0% (95% confidence interval [CI]: 7.6–8.3). Among children with food allergy, 38.7% had a history of severe reactions, and 30.4% had multiple food allergies. Prevalence according to allergen among food-allergic children was highest for peanut (25.2% [95% CI: 23.3–27.1]), followed by milk (21.1% [95% CI: 19.4–22.8]) and shellfish (17.2% [95% CI: 15.6–18.9]). Odds of food allergy were significantly associated with race, age, income, and geographic region. Disparities in food allergy diagnosis according to race and income were observed. CONCLUSIONS: Findings suggest that the prevalence and severity of childhood food allergy is greater than previously reported. Data suggest that disparities exist in the clinical diagnosis of disease.

Understanding the risks of child neglect: an exploration of poverty and parenting characteristics

A strong association between poverty and child neglect has been established, but the mechanisms that explain this relationship have not been clearly articulated. This research takes advantage of survey and child maltreatment administrative data about families with young children and assesses the influence of poverty and parenting characteristics on subsequent child neglect. The authors find that indicators of poverty, such as perceived material hardship and infrequent employment, and parenting characteristics, such as low parental warmth, use of physical discipline, and allowing a child to engage in frequent television viewing, are predictive of child neglect. Parenting characteristics do not appear to mediate the link between perceived hardship and neglect, although they suppress the link between employment and neglect. Results from this study provide information that is highly relevant to the approach and design of child maltreatment prevention and intervention strategies.

Adverse Events and Preventable Adverse Events in Children

Context. Patient safety has been recognized as an important problem in health care. However, knowledge about adverse events and preventable adverse events in children is relatively limited. Objective. To describe the incidence and types of adverse events and preventable adverse events in children. Design. Analysis of pediatric hospitalizations in the Colorado and Utah Medical Practice Study, which involved a retrospective, 2-level (nurse and physician) medical record review of a population-based, representative sample of all pediatric hospital discharges. Main Measures. Adverse events were defined as an injury caused by medical management rather than disease processes that resulted in either prolonged hospitalization or disability at discharge. A preventable adverse event was defined as an avoidable adverse event based on currently available knowledge and accepted practices. Patients. 3719 discharged hospital patients, 0–20 years old, and 7528 nonelderly (21–65 years old) discharged adult patients in Colorado and Utah. Setting. All hospitals in Colorado and Utah. Results. Adverse events occurred in 1% of pediatric hospitalizations in Colorado and Utah; 0.6% were preventable. Preventable adverse events rates were 0.53% in neonates and infants (0–0.99 years), 0.22% in children 1–12 years of age, and 0.95% in adolescents 13–20 years of age, compared with a rate of 1.50% in nonelderly adults. Of preventable adverse event types, birth related (32.2%) and diagnostic related (30.4%) events were the most common and were significantly more common than surgically related preventable adverse events (3.5%). Conclusions. These data suggest that ∼70 000 children hospitalized in the United States experience an adverse event each year; 60% of these events may be preventable. The epidemiology of adverse events and preventable adverse events in children is different than in adults. To reduce the adverse events that occur in hospitalized children, research should focus on adolescent hospitalized patients, birth-related medical care, and diagnostics in pediatric medicine.

Ischemic Cholangiopathy After Controlled Donation After Cardiac Death Liver Transplantation: A Meta-analysis

OBJECTIVE To conduct a meta-analysis to enhance understanding of the risks of biliary complications, particularly ischemic cholangiopathy (IC), after donation after cardiac death (DCD) compared with donation after brain death (DBD) liver transplantation. BACKGROUND Biliary complications after liver transplantation have profound health and economic implications which merit further investigation. METHODS The MEDLINE (1950–2009), EMBASE, and Cochrane Library databases were searched and supplemented by review of conference proceedings and publication bibliographies. All original single institution studies reporting outcomes for DCD and DBD liver transplant recipients were considered. Odds ratios (OR) and 95% confidence intervals (CI) based on random effects models were calculated. RESULTS Eleven publications, all retrospective cohort studies, involving 489 DCD and 4455 DBD recipients, were included. Donation after cardiac death recipients had a 2.4 times increased odds of biliary complications (95% CI= 1.8–3.4) and a 10.8 times increased odds of IC (95% CI = 4.8–24.2).Ischemic cholangiopathy was present in 16% of DCD compared with 3% of DBD recipients. Donation after cardiac death recipients also experienced higher odds of 1-year patient mortality (OR = 1.6, 95% CI = 1.04–2.5) and graft failure (OR = 2.1, 95% CI = 1.5–2.8). CONCLUSIONS Donation after cardiac death liver transplantation is marred by inferior outcomes including higher rates of biliary complications and IC as well as increased mortality and graft failure. Despite current federal mandates to increase DCD donation, these serious complications translate into poor outcomes for individuals and increased healthcare costs. These risks should be considered in decisions regarding the utilization of these grafts.

Chronic stress and low birth weight neonates in a low-income population of women

OBJECTIVE: To estimate whether there is an association between chronic psychosocial stress and low birth weight neonates in low-income women. METHODS: Between 1999 and 2004, a random sample of women receiving welfare in nine Illinois counties was selected. The women were then interviewed annually. Women who delivered during this period were identified. Self-reported stress that occurred in temporal proximity to the delivery was assessed by 1) external stressors, 2) enhancers of stress, 3) buffers against stress, and 4) perceived stress and was compared between women who delivered low birth weight neonates and women who delivered normal birth weight neonates. RESULTS: Of the 1,363 women in the study, 294 women (21.6%) became pregnant and delivered during the study period. Of the 294 deliveries, 39 (13.3%) were low birth weight. The only demographic factor associated with a low birth weight delivery was increasing maternal age. However, multiple psychosocial factors, including food insecurity (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4–7.2), a child with chronic illness in the home (OR 3.4, 95% CI 1.5–7.9), increased crowding in the home (OR 2.7, 95% CI 1.3–5.6), unemployment (OR 3.1, 95% CI 1.2–7.9), and poor coping skills (OR 3.8, 95% CI 1.7–8.7), were significantly associated with low birth weight delivery (P < .01 for all comparisons). These significant associations persisted after adjusting for maternal age in multivariable analysis. CONCLUSION: This study provides evidence that chronic psychosocial stress may be associated with low birth weight neonates in a low-income population of women. LEVEL OF EVIDENCE: II

Laparoscopy-assisted and open living donor right hepatectomy: A comparative study of outcomes

BACKGROUND Minimally invasive liver surgery is a rapidly advancing field with demonstrated applicability to living donation. In this paper, we compare the safety and efficacy of laparoscopy-assisted donor right hepatectomy (LADRH) to open donor right hepatectomy (ODRH). METHODS We performed a retrospective, comparative analysis of 33 LADRH to the most recent 33 ODRH performed at our institution, evaluating donor complications, costs, and recipient outcomes. RESULTS Donor demographics including age, gender, body mass index (BMI), and vascular and biliary anomalies were comparable. Donor complication rates were equivalent for LADRH and ODRH. Donor operative times were shorter for LADRH (LADRH 265 minutes, ODRH 316; P < .001) even after adjusting for BMI. Blood loss and length of stay were comparable. Additionally, total hospitalization costs were equivalent (LADRH

A comprehensive risk assessment of mortality following donation after cardiac death liver transplant – An analysis of the national registry

1.11, ODRH

The increased costs of donation after cardiac death liver transplantation: caveat emptor.

1.00; P = .19). Higher operative supply costs for LADRH were balanced by higher time-based operative costs for ODRH resulting in no significant differences in total operative costs. Finally, there were no differences in graft size, recipient patient or graft survival, or recipient vascular or biliary complications. CONCLUSION Our experience suggests that LADRH compares favorably with ODRH with equivalent safety, resource utilization, and effectiveness. We believe that LADRH provides potential physical and psychological benefits without an adverse effect on outcomes.

Ambulatory care adverse events and preventable adverse events leading to a hospital admission

BACKGROUND & AIMS Organ scarcity has resulted in increased utilization of donation after cardiac death (DCD) donors. Prior analysis of patient survival following DCD liver transplantation has been restricted to single institution cohorts and a limited national experience. We compared the current national experience with DCD and DBD livers to better understand survival after transplantation. METHODS We compared 1113 DCD and 42,254 DBD recipients from the Scientific Registry of Transplant Recipients database between 1996 and 2007. Patient survival was analyzed using the Kaplan-Meier methodology and Cox regression. RESULTS DCD recipients experienced worse patient survival compared to DBD recipients (p<0.001). One and 3 year survival was 82% and 71% for DCD compared to 86% and 77% for DBD recipients. Moreover, DCD recipients required re-transplantation more frequently (DCD 14.7% vs. DBD 6.8%, p<0.001), and re-transplantation survival was markedly inferior to survival after primary transplant irrespective of graft type. Amplification of mortality risk was observed when DCD was combined with cold ischemia time >12h (HR = 1.81), shared organs (HR = 1.69), recipient hepatocellular carcinoma (HR=1.80), recipient age >60 years (HR = 1.92), and recipient renal insufficiency (HR = 1.82). CONCLUSIONS DCD recipients experience significantly worse patient survival after transplantation. This increased risk of mortality is comparable in magnitude to, but often exacerbated by other well-established risk predictors. Utilization decisions should carefully consider DCD graft risks in combination with these other factors.

Association between rising professional liability insurance premiums and primary cesarean delivery rates.

Objective:To determine the effect of donation after cardiac death (DCD) livers on post-transplantation costs. Background:DCD livers are increasingly being used to expand the donor pool despite higher complication rates. Although complications after liver transplantation have profound financial implications, the effect of DCD livers on post-transplantation costs has not been studied. Methods:We estimated direct medical care costs based on inpatient and outpatient hospital costs for 28 DCD and 198 donation after brain death (DBD) liver recipients. Organ acquisition and physician costs were excluded. Results:Donor and recipient demographics were comparable for DCD and DBD transplants. One-year, post-transplantation costs were higher for DCD recipients (124.9% of DBD costs, P = 0.04). DCD costs remained higher (125.2% of DBD costs, P = 0.009) after adjusting for recipient characteristics. Furthermore, DCD post-transplantation costs were 30% higher than DBD costs after adjusting for pre-transplantation costs (P = 0.02). Biliary complications (DCD 58% vs. DBD 21%; P < 0.001) and, specifically, ischemic cholangiopathy (DCD 44% vs. DBD 1.6%; P < 0.001) occurred more frequently after DCD transplantation. Moreover, DCD recipients underwent retransplantation more often (DCD 21% vs. DBD 7.1%, P = 0.02). One-year costs were increased for recipients with ischemic cholangiopathy or retransplantation by 53% (P = 0.01) and 107% (P < 0.001), respectively. However, DCD costs continued to be higher when retransplanted patients were excluded (120% of DBD costs, P = 0.02). Conclusions:Higher rates of graft failure and biliary complications translate into markedly increased direct medical care costs for DCD recipients. These important financial implications should be considered in decisions regarding the use of DCD livers.