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Koo DC, Scalise PN, Chiu MZ, Staffa SJ, Demehri FR, Cuenca AG, Kim HB, Lee EJ. Effect of citizenship status on access to pediatric liver and kidney transplantation. Am J Transplant 2024; 24:1868-1880. [PMID: 38908484 DOI: 10.1016/j.ajt.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/09/2024] [Accepted: 06/11/2024] [Indexed: 06/24/2024]
Abstract
Transplantation of non-US citizen residents remains controversial. We evaluate national trends in transplant activity among pediatric noncitizen residents (PNCR). Pediatric liver and kidney transplant data were obtained from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. Data on transplanted organs, region, waitlist additions, procedures, and citizenship status were analyzed from 2012-2022. Rates of PNCR transplantation activity were compared with population rates from the US Census Bureau. On average, 713 ± 47 pediatric liver and 1039 ± 51 kidney patients were added to the waitlist, with 544 ± 32 liver and 742 ± 33 kidney transplants performed annually. Of these, PNCR comprised 1.5% and 3.3% of liver and kidney waitlist additions and 1.5% and 2.9% of liver and kidney transplant procedures, respectively. There were no significant changes in waitlist or transplant activity nationwide over the study period. There was a significant geographic variation in the percentage of waitlist additions and transplants across the United Network for Organ Sharing regions among the PNCR for liver and kidney transplantation. This is the first study to evaluate national trends in transplantation activity among PNCRs. The significant regional variation in transplantation activity for PNCR may suggest multilevel structural and systemic barriers to transplant accessibility.
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Affiliation(s)
- Donna C Koo
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - P Nina Scalise
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Megan Z Chiu
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alex G Cuenca
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eliza J Lee
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA.
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2
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Vittorio J, Kosmach-Park B, Wadhwani S, Jackson W, Kerkar N, Corbo H, Vekaria P, Gupta N, Yeh H, King LY. Adult provider role in transition of care for young adult pediatric recipients of liver transplant: An expert position statement. Hepatol Commun 2024; 8:e0486. [PMID: 39023314 PMCID: PMC11262821 DOI: 10.1097/hc9.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 07/20/2024] Open
Abstract
Health care transition (HCT) is the process of changing from a pediatric to an adult model of care. Young adult pediatric recipients of liver transplant transferring from pediatric to adult health care services are highly vulnerable and subject to poor long-term outcomes. Barriers to successful transition are multifaceted. A comprehensive HCT program should be initiated early in pediatrics and continued throughout young adulthood, even after transfer of care has been completed. It is critical that pediatric and adult liver transplant providers establish a partnership to optimize care for these patients. Adult providers must recognize the importance of HCT and the need to continue the transition process following transfer. While this continued focus on HCT is essential, current literature has primarily offered guidance for pediatric providers. This position paper outlines a framework with a sample set of tools for the implementation of a standardized, multidisciplinary approach to HCT for adult transplant providers utilizing "The Six Core Elements of HCT." To implement more effective strategies and work to improve long-term outcomes for young adult patients undergoing liver transplant, HCT must be mandated as a routine part of posttransplant care. Increased advocacy efforts with the additional backing and support of governing organizations are required to help facilitate these practices.
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Affiliation(s)
- Jennifer Vittorio
- Department of Pediatrics, New York University (NYU) Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Beverly Kosmach-Park
- Department of Transplant Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sharad Wadhwani
- Department of Pediatrics, University of California-San Francisco, San Francisco, California, USA
| | - Whitney Jackson
- Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nanda Kerkar
- Department of Pediatrics, University of Rochester Medical Center, New York, New York, USA
| | - Heather Corbo
- Department of Pharmacy, New York-Presbyterian Hospital, New York, New York, USA
| | - Pooja Vekaria
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Nitika Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Heidi Yeh
- Division of Transplant Surgery, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lindsay Y King
- Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, North Carolina, USA
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3
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Gutierrez SA, Chiou SH, Rhee S, Lai JC, Wadhwani SI. The influence of neighborhood income on healthcare utilization in pediatric liver transplant. J Pediatr Gastroenterol Nutr 2024; 79:100-109. [PMID: 38693791 PMCID: PMC11216888 DOI: 10.1002/jpn3.12234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/08/2024] [Accepted: 04/13/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Neighborhood contextual factors are associated with liver transplant outcomes. We analyzed associations between neighborhood-level socioeconomic status and healthcare utilization for pediatric liver transplant recipients. METHODS We merged the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases and included liver transplant recipients ≤21 years hospitalized between January 2004 and May 2022. Outcomes were annual inpatient bed-days, risk of hospitalizations, and risk of liver biopsies. The primary exposure was zip code-based neighborhood income at transplant. We applied causal inference for variable selection in multivariable analysis. We modeled annual inpatient bed-days with mixed-effect zero-inflated Poisson regression, and rates of hospitalization and liver biopsy with a Cox-type proportional rate model. RESULTS We included 1006 participants from 29 institutions. Children from low-income neighborhoods were more likely to be publicly insured (67% vs. 46%), Black (20% vs. 12%), Hispanic (30% vs. 17%), and have higher model for end-stage liver disease/pediatric end-stage liver disease model scores at transplant (17 vs. 13) than the remaining cohort. We found no differences in inpatient bed-days or rates of hospitalization across neighborhood groups. In univariable analysis, low-income neighborhoods were associated with increased rates of liver biopsy (rate ratio [RR]: 1.57, 95% confidence interval [CI]: 1.04-2.34, p = 0.03). These findings persisted after adjusting for insurance, race, and ethnicity (RR: 1.86, 95% CI: 1.23-2.83, p < 0.01). CONCLUSIONS Children from low-income neighborhoods undergo more liver biopsies than other children. These procedures are invasive and potentially preventable. In addition to improving outcomes, interventions to mitigate health inequities among liver transplant recipients may reduce resource utilization.
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Affiliation(s)
- Susan A Gutierrez
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Sy Han Chiou
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Statistics and Data Science, Southern Methodist University, Dallas, Texas, USA
| | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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4
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Wadhwani SI, Alvarado A, Shifman HP, Bautista B, Yalung J, Squires JE, Campbell K, Ebel NH, Hsu E, Vittorio J, Zielsdorf S, Desai DM, Bucuvalas JC, Gottlieb L, Kotagal U, Lyles CR, Ackerman SL, Lai JC. Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study. Liver Transpl 2024; 30:717-727. [PMID: 38166123 PMCID: PMC11176037 DOI: 10.1097/lvt.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/12/2023] [Indexed: 01/04/2024]
Abstract
Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.
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Affiliation(s)
| | | | | | | | - Jared Yalung
- University of California, San Francisco, San Francisco, CA
| | | | | | | | - Evelyn Hsu
- Seattle Children’s Hospital, Seattle, WA
| | - Jennifer Vittorio
- Columbia University Medical Center, New York, NY
- New York University Langone Health, New York, NY
| | | | | | | | - Laura Gottlieb
- University of California, San Francisco, San Francisco, CA
| | - Uma Kotagal
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Wadhwani SI, Kruse G, Squires J, Ebel N, Gupta N, Campbell K, Hsu E, Zielsdorf S, Vittorio J, Desai DM, Bucuvalas JC, Gottlieb LM, Lai JC. Caregiver Perceptions of Social Risk Screening in Pediatric Liver Transplantation: From the Multicenter SOCIAL-Tx Study. Transplantation 2024; 108:940-946. [PMID: 37831642 PMCID: PMC10963151 DOI: 10.1097/tp.0000000000004835] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND The social determinants of health contribute to adverse post-liver transplant outcomes. Identifying unmet social risks may enable transplant teams to improve long-term outcomes for at-risk children. However, providers may feel uncomfortable asking about household-level social risks in the posttransplant period because they might make their patients/families uncomfortable. METHODS We conducted a mixed-methods analysis of caregiver participants (ie, parents/guardians of pediatric liver transplant recipients) in the Social and Contextual Impact on Children Undergoing Liver Transplantation study to assess their perceptions of provider-based social risk screening. Participants (N = 109) completed a 20-min social determinants of health questionnaire that included questions on the acceptability of being asked intimate social risk questions. A subset of participants (N = 37) engaged in an in-depth qualitative interview to share their perceptions of social risk screening. RESULTS Of 109 participants across 9 US transplant centers, 60% reported financial strain and 30% reported at least 1 material economic hardship (eg, food insecurity, housing instability). Overall, 65% of respondents reported it very or somewhat appropriate and 25% reported being neutral to being screened for social risks in a liver transplant setting. In qualitative analyses, participants reported trust in the providers and a clear understanding of the intention of the screening as prerequisites for liver transplant teams to perform social risk screening. CONCLUSIONS Only a small minority of caregivers found social risk screening unacceptable. Pediatric liver transplant programs should implement routine social risk screening and prioritize the patient and family voices when establishing a screening program to ensure successful implementation.
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Affiliation(s)
| | - Gina Kruse
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James Squires
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | | | - Evelyn Hsu
- Seattle Children’s Hospital, Seattle, WA
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6
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Schaefer SL, Dualeh SHA, Kunnath N, Scott JW, Ibrahim AM. Higher Rates Of Emergency Surgery, Serious Complications, And Readmissions In Primary Care Shortage Areas, 2015-19. Health Aff (Millwood) 2024; 43:363-371. [PMID: 38437607 DOI: 10.1377/hlthaff.2023.00843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
Primary care physicians are often the first to screen and identify patients with access-sensitive surgical conditions that should be treated electively. These conditions require surgery that is preferably planned (elective), but, when access is limited, treatment may be delayed and worsening symptoms lead to emergency surgery (for example, colectomy for cancer, abdominal aortic aneurysm repair, and incisional hernia repair). We evaluated the rates of elective versus emergency surgery for patients with three access-sensitive surgical conditions living in primary care Health Professional Shortage Areas during 2015-19. Medicare beneficiaries in more severe primary care shortage areas had higher rates of emergency surgery compared with rates in the least severe shortage areas (37.8 percent versus 29.9 percent). They were also more likely to have serious complications (14.9 percent versus 11.7 percent) and readmissions (15.7 percent versus 13.5 percent). When we accounted for areas with a shortage of surgeons, the findings were similar. Taken together, these findings suggest that residents of areas with greater primary care workforce shortages may also face challenges in accessing elective surgical care. As policy makers consider investing in Health Professional Shortage Areas, our findings underscore the importance of primary care access to a broader range of services.
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Affiliation(s)
- Sara L Schaefer
- Sara L. Schaefer , University of Michigan, Ann Arbor, Michigan
| | | | | | - John W Scott
- John W. Scott, University of Washington, Seattle, Washington
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7
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Yalung JE, Shifman HP, Manning ER, Beck A, Bucuvalas J, Lai JC, Wadhwani SI. Ambient air pollution is associated with graft failure/death in pediatric liver transplant recipients. Am J Transplant 2024; 24:448-457. [PMID: 37898318 PMCID: PMC10922359 DOI: 10.1016/j.ajt.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/28/2023] [Accepted: 10/12/2023] [Indexed: 10/30/2023]
Abstract
Children exposed to disproportionately higher levels of air pollution experience worse health outcomes. In this population-based, observational registry study, we examine the association between air pollution and graft failure/death in children following liver transplantation (LT) in the US. We modeled the associations between air pollution (PM2.5) levels localized to the patient's ZIP code at the time of transplant and graft failure or death using Cox proportional-hazards models in pediatric LT recipients aged <19 years in the US from 2005-2015. In univariable analysis, high neighborhood PM2.5 was associated with a 56% increased hazard of graft failure/death (HR: 1.56; 95% CI: 1.32, 1.83; P < .001). In multivariable analysis, high neighborhood PM2.5 was associated with a 54% increased risk of graft failure/death (HR: 1.54; 95% CI: 1.29, 1.83; P < .001) after adjusting for race as a proxy for racism, insurance status, rurality, and neighborhood socioeconomic deprivation. Children living in high air pollution neighborhoods have an increased risk of graft failure and death posttransplant, even after controlling for sociodemographic variables. Our findings add further evidence that air pollution contributes to adverse health outcomes for children posttransplant and lay the groundwork for future studies to evaluate underlying mechanisms linking PM2.5 to adverse LT outcomes.
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Affiliation(s)
- Jared E Yalung
- School of Medicine, University of California, San Francisco, San Francisco, California, USA; UC Berkeley-UCSF Joint Medical Program, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Holly P Shifman
- School of Medicine, Oakland University William Beaumont, Rochester, Michigan, USA
| | | | - Andrew Beck
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John Bucuvalas
- Department of Pediatrics, Division of Hepatology, Mount Sinai Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, San Francisco, California, USA.
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8
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Shifman HP, Huang CY, Beck AF, Bucuvalas J, Perito ER, Hsu EK, Ebel NH, Lai JC, Wadhwani SI. Association of state Medicaid expansion policies with pediatric liver transplant outcomes. Am J Transplant 2024; 24:239-249. [PMID: 37776976 PMCID: PMC10843745 DOI: 10.1016/j.ajt.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 08/22/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.
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Affiliation(s)
- Holly Payton Shifman
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Department of Pediatrics Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Hepatology, Department of Pediatrics, Kravis Children's Hospital, New York, New York, USA
| | - Emily R Perito
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Noelle H Ebel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
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Wadhwani SI, Lai JC. The digital determinants of liver disease. Hepatology 2023; 77:13-14. [PMID: 35753068 PMCID: PMC10268049 DOI: 10.1002/hep.32639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Sharad I. Wadhwani
- Department of Pediatrics, University of California, San
Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Department of Medicine, University of California, San
Francisco, San Francisco, California, USA
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10
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Ebel NH, Dike PN, Hsu EK. Addressing Racism in Pediatric Liver Transplantation: A Moral Imperative. J Pediatr 2022; 246:8-10. [PMID: 35504347 DOI: 10.1016/j.jpeds.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Noelle H Ebel
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California.
| | - Peace N Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Evelyn K Hsu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
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