Organ donation as an outcome of traumatic cardiopulmonary arrest: A cost evaluation

BACKGROUND

Survival after traumatic cardiopulmonary arrest (TCPA) is rare and requires significant resource expenditure. Organ donation as an outcome of TCPA resuscitation has not yet been included in a cost analysis. The aims of this study were to identify variables associated with survival and organ donation after TCPA, and to estimate the cost of achieving these outcomes. We hypothesized that the inclusion of organ donation as a potential outcome would make TCPA resuscitation more cost-effective.

METHODS

Adult patients who required resuscitation for TCPA at a level I trauma center were retrospectively reviewed over 36 months. Data were obtained from medical records, hospital accounting records, and the local organ procurement agency. Outcomes included survival to discharge, neurologic function, and organ donor eligibility. An individual-level state-transition cost-effectiveness model was used to evaluate the cost of TCPA resuscitation with and without organ donation included as an outcome. Incremental cost-effectiveness ratio was calculated to determine additional cost per life saved when organ donation is included.

RESULTS

Over the study period, 8,932 subjects were evaluated. Traumatic cardiopulmonary arrest occurred in 237 patients (3%). The mortality rate was 97%. Variables associated with survival included emergency department disposition to the operating room (p < 0.01) and reactive pupils (p < 0.001). Of seven survivors, four were discharged neurologically intact. Of the patients with TCPA, 5% were eligible for organ donation with a procurement rate of 2%. Organ donor eligibility was associated with arrest after arrival to the emergency department (p < 0.01) and transfusion of fresh frozen plasma (p = 0.01). The cost of TCPA resuscitation per survivor was $1.8 million; cost per survivor or life saved by donation was $538,000. The incremental cost-effectiveness ratio was $76,816 per additional life saved including donation as an outcome.

CONCLUSION

The decision to pursue resuscitation should continue to be based on the presence of signs of life, especially pupil reactivity and duration of arrest. If the primary objective is survival, organ procurement will be maximized without conflict of interest. Early fresh frozen plasma transfusion may increase successful organ donation. The financial burden of TCPA resuscitation can be mitigated by expanding end points to include organ donation.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III; cost analysis, level V.

Androgens, Bilateral Oophorectomy, and Cardiovascular Disease Mortality in Postmenopausal Women With and Without Diabetes: The Study of Osteoporotic Fractures

OBJECTIVE

Diabetes elevates cardiovascular disease (CVD) risk more markedly in women than in men. Because the high risk of CVD among women with type 2 diabetes (DM2) may be partly due to increased ovarian androgen production, we investigated whether a history of bilateral salpingo oophorectomy (BSO) is inversely associated with CVD mortality among women with DM2.

RESEARCH DESIGN AND METHODS

Data were obtained from 7,977 women (a random subset of 564 had measurements of sex-steroid hormones) enrolled in the Study of Osteoporotic Fractures (SOF), a community-based, multicenter study that monitored women aged ≥65 years for a mean of 15.1 years. Adjusted hazard ratios (HRs) and 95% CIs were calculated using Cox proportional hazards regression.

RESULTS

The average age at baseline was 71.5 years, with 6.3% and 18% of participants reporting a history of diabetes or BSO, respectively. In the subset of the SOF cohort with sex-steroid hormone measurements, those with DM2 had 43.6% significantly higher levels of free testosterone that were partly explained by age and adiposity, whereas total and free testosterone levels were lower in women with BSO than in those with intact ovaries. CVD mortality was elevated in women with DM2 without BSO (HR 1.95, 95% CI 1.62-2.35) as well as in women with DM2 and BSO (HR 2.56, 95% CI 1.79-3.65; P = 0.190 for interaction). Overall, BSO was not associated with CVD mortality (HR 1.05, 95% CI 0.89-1.23).

CONCLUSIONS

The association of diabetes with CVD was not reduced by BSO, suggesting that ovarian hyperandrogenemia may not be a primary mechanism to explain the high risk for CVD among women with DM2.

Association of blood lead concentrations with mortality in older women: a prospective cohort study

BACKGROUND

Blood lead concentrations have been associated with increased risk of cardiovascular, cancer, and all-cause mortality in adults in general population and occupational cohorts. We aimed to determine the association between blood lead, all cause and cause specific mortality in elderly, community residing women.

METHODS

Prospective cohort study of 533 women aged 65-87 years enrolled in the Study of Osteoporotic Fractures at 2 US research centers (Baltimore, MD; Monongahela Valley, PA) from 1986-1988. Blood lead concentrations were determined by atomic absorption spectrometry. Using blood lead concentration categorized as < 8 microg/dL (0.384 micromol/L), and > or = 8 microg/dL (0.384 micromol/L), we determined the relative risk of mortality from all cause, and cause-specific mortality, through Cox proportional hazards regression analysis.

RESULTS

Mean blood lead concentration was 5.3 +/- 2.3 microg/dL (range 1-21) [0.25 +/- 0.11 micromol/L (range 0.05-1.008)]. After 12.0 +/- 3 years of > 95% complete follow-up, 123 (23%) women who died had slightly higher mean (+/- SD) blood lead 5.56 (+/- 3) microg/dL [0.27(+/- 0.14) micromol/L] than survivors: 5.17(+/- 2.0) [0.25(+/- 0.1) micromol/L] (p = 0.09). Women with blood lead concentrations > or = 8 microg/dL (0.384 micromol/L), had 59% increased risk of multivariate adjusted all cause mortality (Hazard Ratio [HR], 1.59; 95% confidence interval [CI], 1.02-2.49) (p = 0.041) especially coronary heart disease (CHD) mortality (HR = 3.08 [CI], (1.23-7.70)(p = 0.016), compared to women with blood lead concentrations < 8 microg/dL(< 0.384 mumol/L). There was no association of blood lead with stroke, cancer, or non cardiovascular deaths.

CONCLUSION

Women with blood lead concentrations of > or = 8 microg/dL (0.384 micromol/L), experienced increased mortality, in particular from CHD as compared to those with lower blood lead concentrations.

Ladybug hypersensitivity among residents of homes infested with ladybugs in Kentucky

BACKGROUND

There have been isolated case reports of hypersensitivity to the ladybug species Harmonia axyridis. Entomologists now report a rapid increase in ladybug numbers, giving rise to increasing complaints of residential infestations.

OBJECTIVES

To determine whether ladybug infestation of homes causes hypersensitivity among residents and to estimate the prevalence of self-reported ladybug allergy in this population.

METHODS

This pilot observational study was conducted using an anonymous survey.

RESULTS

The participation rate was 59% (99/167). The incidence of self-reported allergy symptoms in this population was 77% (95% confidence interval [CI], 67%-85%). The prevalence of self-reported ladybug allergy was 50% (95% CI, 39%-60%). Of all the respondents, 19% (95% CI, 12%-28%) reported allergy symptoms on direct contact with ladybugs and 31% (95% CI, 22%-41%) reported the use of extra allergy medications during times of infestation. The correlation between worsening of allergy symptoms and time of infestation was significant for spring, fall, and winter infestations (P = .02, P = .001, and P < .001, respectively).

CONCLUSIONS

To our knowledge, this is the first study to estimate the prevalence of ladybug hypersensitivity, which was found to be 50% by self-report among people with home infestations. These results suggest that the ladybug could be a significant cause of respiratory allergy in heavily infested homes. Further studies using diagnostic testing to confirm allergy are now indicated. We recommend that patients with spring, fall, and winter allergies be asked about ladybug infestation and that ladybug reagents be made available for diagnostic testing.

Underestimation of mortality due to chronic obstructive pulmonary disease (COPD) in Kentucky

BACKGROUND

Chronic obstructive pulmonary disease (COPD) mortality may be underestimated because it is frequently listed as a contributory cause of death, rather then the underlying cause of death, on state death certificates. Contributory causes of death are not counted in mortality statistics. This may underestimate the true burden of disease.

OBJECTIVE

Determine the frequency in which COPD is listed as a contributory cause of death, rather than the underlying cause of death, per state mortality records for a one-year period, year 2000.

METHODS

15,036 mortality records from Kentucky death certificates were examined for year 2000 for all deaths due to diseases most often associated with COPD; notably, heart disease, pneumonia/influenza, and asthma.

RESULTS

Cases in which COPD was listed as a contributory cause of death for asthma, pneumonia and influenza was small (less than 1%). Cases in which COPD was listed as a contributory cause of death for heart disease was much higher at 6.8% (824 out of 12,084). Counting these cases increases the COPD age-adjusted mortality rate 39%, from 52.4 to 72.7/ 100,000 people.

CONCLUSION

This study provided evidence to generate and support the hypothesis that COPD mortality is underestimated in Kentucky when the underlying cause of death is heart disease, thus underestimating the true burden of disease. COPD is a chronic, often severe disease commonly associated with comorbid conditions such as heart disease that ultimately lead to death, but which may not be accurately reflected in mortality statistics. Accurate reporting is essential for health planning, education, research, and treatment options.

Lay referral patterns involved in cardiac treatment decision making among middle-aged and older adults

PURPOSE

This study examined age and contextually related factors that are influential in lay referral patterns during cardiac treatment decision making.

DESIGN AND METHODS

A complementary design was used. The Myocardial Infarction (MI) Onset Study identified demographic correlates of who sought medical care for 1,388 MI (heart attack) survivors. Thirty-five in-depth MI illness narratives explicated lay referral patterns.

RESULTS

Data revealed a linear association between older age and reliance on another person to seek medical attention for cardiac symptoms, with gender also shaping lay referral patterns. Although spouses and children were the most frequently cited decision makers for older respondents, friends and other family members also influenced care-seeking decisions. Qualitative results substantiated and provided explanations for such patterns.

IMPLICATIONS

Our results highlight the need for researchers to attend to the complex social processes of lay consultation and for health education messages to extend to venues where lay cardiac decisions are made, including the worksite and social gathering places such as religious institutions. Enhanced outreach includes tailoring health messages to elders and their significant others and casting a broader net to include nontraditional significant others.

Effects of blood lead levels on cognitive function of older women

Elevated blood lead concentrations are known to have detrimental effects on neuropsychological function in both children and occupational cohorts of men and women. Although it is generally accepted that lead exposure at low levels is more dangerous for infants and children than for adults, the issue of the lowest level of exposure at which lead causes deleterious health effects in adults is yet to be solved. There is no available data on the role of lead exposure in cognitive dysfunction in nonoccupational cohorts of older persons. In the current study, we examined the cross-sectional relationship between blood lead levels and a variety of measures of neuropsychological function in a large cohort of elderly women recruited at both urban and rural sites. This study of elderly women demonstrates that blood lead levels as low as 8 micrograms/dl were significantly associated with poorer cognitive function as measured by certain neuropsychological tests. Even a slight decrement in cognition would have a large public health impact due to the large number of elderly at risk.

Lifestyle and sociodemographic factors as determinants of blood lead levels in elderly women

This report presents descriptive data on blood lead levels in 530 white women aged 65-87 years and examines the association of blood lead level in this population with specific variables, including age, diet, reproductive and lifestyle factors, and place of residence. Women were recruited from an urban (Baltimore, n = 205) and a rural site (the Monongahela Valley, Pennsylvania, n = 325) during the period 1990-1991. Information on lifestyle, medical history, and demographics was obtained by questionnaire and interview. Blood lead concentrations were measured by atomic absorption spectrophotometry. The mean blood lead level of this cohort (5.3 micrograms/dl) was nearly 60% lower than that reported by a national survey in 1976-1980 for white women aged 65-74 years (12.8 micrograms/dl). Urban women had significantly higher blood lead levels than rural women (p < 0.0001). Urban residence, smoking, alcohol consumption, and years since menopause were positively associated with blood lead level, while body mass index, breast feeding, current estrogen replacement therapy, moderate physical activity, and calcium intake were inversely associated. These data suggest that mean blood lead levels have declined dramatically since 1980. Because it is not known at what level of lead exposure adverse health effects occur, other factors that modify lead levels, metabolism, or susceptibility, such as nutrition and consumption of tobacco and alcohol, become important.