RESUMEN
OBJECTIVE: To evaluate the prevalence of atypical antipsychotic use in privately insured children and the diagnoses associated with treatment. STUDY DESIGN: Claims were used to conduct a retrospective cohort study of children aged 2 through 18 years in the Midwest, covered by private insurance between 2002 and 2005 (n = 172,766). The 1-year prevalence of children receiving atypical antipsychotics was determined along with associated diagnoses. RESULTS: The 1-year prevalence of atypical antipsychotics ranged from 7.9 per 1000 in 2002 to 9.0 in 2005. The leading diagnoses were disruptive behavior disorders (67%), mood disorders (65%), and anxiety disorders (43%).The authors found that 75% of children on atypical antipsychotics had more than one psychiatric diagnosis. CONCLUSIONS: Atypical antipsychotic use is primarily seen in children who have multiple psychiatric diagnoses. Studies are needed to assess the long-term safety and effectiveness in such patients with multiple diagnoses.
Asunto(s)
Seguro Psiquiátrico/estadística & datos numéricos , Trastornos Mentales/epidemiología , Sector Privado/estadística & datos numéricos , Adolescente , Distribución por Edad , Antipsicóticos/administración & dosificación , Antipsicóticos/economía , Trastornos de Ansiedad/diagnóstico , Trastornos de Ansiedad/tratamiento farmacológico , Trastornos de Ansiedad/epidemiología , Niño , Preescolar , Estudios de Cohortes , Intervalos de Confianza , Análisis Costo-Beneficio , Utilización de Medicamentos/economía , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Seguro Psiquiátrico/economía , Clasificación Internacional de Enfermedades , Masculino , Trastornos Mentales/diagnóstico , Trastornos Mentales/tratamiento farmacológico , Trastornos Mentales/economía , Trastornos del Humor/diagnóstico , Trastornos del Humor/tratamiento farmacológico , Trastornos del Humor/epidemiología , Oportunidad Relativa , Prevalencia , Sector Privado/economía , Estudios Retrospectivos , Medición de Riesgo , Distribución por Sexo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The organ shortage has resulted in more use of older deceased donor kidneys. Data are limited on the impact of donor aged 70 years and older on transplant outcomes. We examined patient and graft outcomes of renal transplant from expanded criteria donors (ECDs) aged 70 years and older, using the Organ Procurement Transplant Network/United Network of Organ Sharing database. METHODS: We identified 601 deceased donor transplants from donors older than 70 years from 2000 to 2005. The follow-up time was until May 2007. Allograft and patient survival were compared between recipients of transplants from older ECDs (age > or =70) and younger ECDs (age 50-69). The relative risk of graft loss and patient death were determined using multivariate models. RESULTS: The adjusted relative risks of overall graft loss (hazards ratio [HR] 1.37; 95% confidence interval [CI] 1.19-1.58), death-censored graft loss (HR 1.32; 95% CI 1.09-1.61), and patient death (HR 1.37; 95% CI 1.15-1.64) were greater among recipients of transplants from older ECD kidneys. The relative risk of patient death was lower when older ECD kidneys were transplanted into recipients older than 60 compared with recipients aged 41 to 60. In contrast, the relative risk of death-censored graft loss was not increased when older ECD kidneys were transplanted into recipients older than 60. CONCLUSIONS: Transplants from older ECD kidneys are associated with a higher risk of graft loss and patient death. The risk was highest when older ECD kidneys were transplanted into recipients younger than 60 years.
Asunto(s)
Sistemas de Administración de Bases de Datos/estadística & datos numéricos , Rechazo de Injerto/epidemiología , Fallo Renal Crónico/cirugía , Trasplante de Riñón/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/métodos , Donantes de Tejidos/estadística & datos numéricos , Obtención de Tejidos y Órganos/estadística & datos numéricos , Adulto , Anciano , Selección de Donante/normas , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Incidencia , Fallo Renal Crónico/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Trasplante Homólogo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Aspirin desensitization is an effective therapy for moderate-to-severe aspirin-exacerbated respiratory disease (AERD). Desensitization also allows the use of aspirin for secondary cardiovascular prevention. OBJECTIVE: We sought to investigate the cost-effectiveness of aspirin desensitization with subsequent aspirin therapy in patients with AERD. METHODS: The Healthcare Cost and Utilization Project was used, together with average reimbursements from a large Midwestern health care plan, to model the costs of aspirin desensitization for therapeutic and prophylactic use in patients with AERD. Event probabilities were based on the published literature. RESULTS: Ambulatory desensitization for AERD cost $6768 per quality-adjusted life year (QALY) saved ($18.54 per additional symptom-free day). Aspirin desensitization for AERD remained cost-effective (<$50,000 per QALY saved) across a wide range of assumptions. When secondary cardiovascular prophylaxis was considered, ambulatory aspirin desensitization was less expensive than an alternative antiplatelet agent, clopidogrel. Clopidogrel cost $106,453 per incremental QALY saved when compared with desensitization. CONCLUSIONS: Aspirin desensitization is a cost-effective therapeutic intervention in patients with moderate-to-severe AERD. Although the incremental cost-effectiveness of clopidogrel in individuals with aspirin allergy is marginal, if available, ambulatory desensitization remains a less-expensive option for secondary cardiovascular prophylaxis.
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Aspirina/efectos adversos , Desensibilización Inmunológica/economía , Hipersensibilidad a las Drogas/terapia , Trastornos Respiratorios/terapia , Adulto , Antiinflamatorios no Esteroideos/efectos adversos , Antiinflamatorios no Esteroideos/economía , Antiinflamatorios no Esteroideos/uso terapéutico , Aspirina/economía , Aspirina/uso terapéutico , Asma/etiología , Asma/terapia , Enfermedades Cardiovasculares/prevención & control , Clopidogrel , Análisis Costo-Beneficio , Desensibilización Inmunológica/métodos , Hipersensibilidad a las Drogas/etiología , Humanos , Cadenas de Markov , Persona de Mediana Edad , Modelos Biológicos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Años de Vida Ajustados por Calidad de Vida , Trastornos Respiratorios/etiología , Ticlopidina/análogos & derivados , Ticlopidina/economía , Ticlopidina/uso terapéuticoRESUMEN
Risk for new-onset diabetes (NOD) after renal transplantation is higher with tacrolimus (Tac) than with cyclosporine (CsA), but the extent to which the diabetogenic effect of Tac is dosage dependent or steroid dependent remains uncertain. Patients who received a transplant between 1995 and 2002 were drawn from the United Network for Organ Sharing registry and prescription records and NOD diagnoses from Medicare claims, both provided by the United States Renal Data System. Patients were divided into six groups of steroid and Tac doses at 30 d after transplantation and referenced against CsA. Relative hazards of NOD with Cox proportional hazards regression were estimated incorporating propensity scores for Tac and nonimmunosuppressive factors related to NOD. A total of 8839 patients with valid immunosuppression records and without pretransplantation evidence of diabetes were included in the study. Unadjusted, cumulative, NOD incidence 1 yr after transplantation was 14.6% with CsA and 22.2% with Tac and at 3 yr after transplantation was 23.4% with CsA and 32.9% with Tac (P < 0.0001). Neither higher CsA nor higher steroid dosages were associated with NOD in CsA-treated patients. However, NOD hazard was significantly higher with Tac than with CsA in all six steroid/Tac dosing groups, including the cohort with the lowest dosages of Tac (dosage thresholds at 30 d after transplantation <0.12 mg/kg per d [mean 0.07 mg/kg per d] and steroids (<0.75 mg/kg per d; hazard ratio 1.28; 95% confidence interval 1.10 to 1.48; P = 0.0012). Whereas the incidence of NOD is greatest with high Tac dosages, the increased risk versus CsA is sustained with lower Tac dosages. Higher steroid dosages increase the early diabetogenic effect of Tac but not of CsA.
Asunto(s)
Inhibidores de la Calcineurina , Diabetes Mellitus/inducido químicamente , Diabetes Mellitus/epidemiología , Glucocorticoides/administración & dosificación , Glucocorticoides/efectos adversos , Trasplante de Riñón , Prednisona/administración & dosificación , Prednisona/efectos adversos , Adulto , Ciclosporina/administración & dosificación , Ciclosporina/efectos adversos , Ciclosporina/uso terapéutico , Relación Dosis-Respuesta a Droga , Glucocorticoides/uso terapéutico , Humanos , Incidencia , Estimación de Kaplan-Meier , Persona de Mediana Edad , Cuidados Posoperatorios , Prednisona/uso terapéutico , Modelos de Riesgos Proporcionales , Medición de Riesgo , Tacrolimus/administración & dosificación , Tacrolimus/efectos adversos , Tacrolimus/uso terapéuticoRESUMEN
BACKGROUND: HLAMatchmaker is a recently developed computer-based algorithm to determine donor-recipient HLA compatibility at the molecular level. Originally designed for highly alloimmunized patients, this algorithm is based on the concept that immunogenic epitopes are represented by amino acid triplets on exposed parts of protein sequences of HLA-A, -B, and -C chains accessible to alloantibodies. Donor HLA compatibility is determined by intralocus and interlocus comparisons of triplets in polymorphic sequence positions. For most patients, HLAMatchmaker can identify certain mismatched HLA antigens that are zero-triplet mismatches to the patient's HLA phenotype and should, therefore, be considered fully histocompatible. The present study was designed to determine how class I HLA matching at the triplet level affects kidney transplant outcome. METHODS: We analyzed two multicenter databases of zero-HLA-DR-mismatched kidneys transplanted from 1987 to 1999. One database consisted of 31,879 primary allografts registered by U.S. transplant centers in the United Network for Organ Sharing database and the other consisted of 15,872 transplants in the Eurotransplant program. RESULTS: HLA-A,B mismatched kidneys that were compatible at the triplet level exhibited almost identical graft survival rates as the zero-HLA-A,B antigen mismatches defined by conventional criteria. This beneficial effect of triplet matching was seen for both nonsensitized and sensitized patients and also for white and nonwhite patients. CONCLUSIONS: These findings suggest that the application of HLAMatchmaker will increase the number of successful transplants, at least in the HLA-DR match combinations.
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Antígenos HLA-A/análisis , Antígenos HLA-B/análisis , Prueba de Histocompatibilidad/métodos , Trasplante de Riñón/inmunología , Trasplante de Riñón/mortalidad , Algoritmos , Secuencia de Aminoácidos , Bases de Datos Factuales , Epítopos/análisis , Epítopos/genética , Supervivencia de Injerto/inmunología , Antígenos HLA-A/química , Antígenos HLA-B/química , HumanosRESUMEN
BACKGROUND: HLAMatchmaker is a computer algorithm that determines human leukocyte antigen (HLA) compatibility at the level of polymorphic amino acid triplets in antibody-accessible sequence positions. Recent studies have shown that HLA-DR-matched kidney transplant recipients with zero to two triplet mismatches had almost identical graft survival rates as those with zero HLA-A,B,DR antigen mismatches. This report describes how HLAMatchmaker can be used to identify more compatible donors for highly sensitized patients. METHODS: The HLAMatchmaker program was used to calculate the probability of finding a donor (PFD) with zero, one, or two triplet mismatches for 54 highly sensitized patients waiting for a kidney transplant and having panel reactive antibody (PRA) values greater than 85% and 50 randomly selected nonsensitized patients with PRA values less than 3%. RESULTS: There was a wide variability for PFD values for the two patient cohorts. If only donors with zero HLA-A,B mismatches were deemed acceptable for recipients, the median PFD of a zero-antigen mismatch was 0.046% for nonsensitized patients and 0.009% for highly sensitized patients (P=0.007). Half of the highly sensitized patients had a PFD below 0.01%, or fewer than 1 in 10,000 donors would have zero antigen mismatches. Application of HLAMatchmaker identified additional HLA antigens with zero-triplet mismatches for 27 patients, resulting in a 1.8-fold increase in PFD. Considering additional antigens with one-triplet or two-triplet mismatches increased the PFD by an additional 3.8-fold and 13.7-fold, respectively. Acceptable antigen mismatches for 37 of the 54 highly sensitized patients were identified by consistently negative reactions in serum screens, and their addition resulted in a 12.7-fold increase of the PFD to a median of 0.141%. Applying these acceptable antigens to the HLAMatchmaker algorithm identified additional antigens with zero or acceptable triplet mismatches and their inclusion increased the PFD by 3.3-fold to 0.347%. CONCLUSIONS: HLAMatchmaker offers a valuable strategy for identifying more suitably HLA-matched donors and has the potential for alleviating the problem of accumulation of highly sensitized patients on the transplant waiting list.
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Antígenos HLA-A/análisis , Antígenos HLA-B/análisis , Prueba de Histocompatibilidad/métodos , Obtención de Tejidos y Órganos , Algoritmos , Secuencia de Aminoácidos , Autoanticuerpos/sangre , Bases de Datos Factuales , Supervivencia de Injerto/inmunología , Antígenos HLA-A/química , Antígenos HLA-A/inmunología , Antígenos HLA-B/química , Antígenos HLA-B/inmunología , Humanos , Datos de Secuencia Molecular , Donantes de TejidosRESUMEN
BACKGROUND: Acute cellular rejection is the mechanism of most immune-related injury in cardiac transplant recipients. However, antibody-mediated humoral rejection (HR) has also been implicated as an important clinical entity following orthotopic heart transplantation. Humoral rejection has been reported to play a role in graft dysfunction in the early post-transplant period, and to be a risk factor for the development of transplant coronary artery disease. Some involved in transplantation pathology doubt the existence of clinically significant humoral rejection in cardiac allografts. Those who recognize its existence disagree on its possible role in graft dysfunction or graft coronary artery disease. In this study, we report clinical features of patients with the pathologic diagnosis of HR at our institution since July 1997, when we began systematic surveillance for humoral rejection. METHODS: We reviewed medical records of patients with the pathologic diagnosis of HR without concurrent cellular rejection between July 1997 and January 2001. Diagnosis was based on routine histology ("swollen cells" distending capillaries, interstitial edema and hemorrhage) and immunofluorescence (capillary deposition of immunoglobulin and complement with HLA-DR positivity), or immunoperoxidase staining of paraffin-embedded tissue (numerous CD68-positive macrophages and fewer swollen endothelial cells distending capillaries). RESULTS: A total of 44 patients (4 to 74 years old) showed evidence of HR without concurrent cellular rejection at autopsy or on one or more biopsies. Although females comprised only 26% of our transplant population, 23 patients (52%) with HR were female. A positive peri-operative flow cytometry T-cell crossmatch was observed in 32% of HR patients compared with 12% of controls (p = 0.02). Hemodynamic compromise consisting of shock, hypotension, decreased cardiac output/index and/or a rise in capillary wedge or pulmonary artery pressure was observed in 47% of patients at the time of diagnosis of HR. Six patients (5 females) died (14% mortality) with evidence of HR at or just before autopsy, 6 days to 16 months after transplantation. The incidence of transplant coronary artery disease was 10% greater at 1 year, and 36% greater at 5 years, in patients with HR when compared with non-HR patients. CONCLUSIONS: Humoral rejection was associated with acute hemodynamic compromise in 47% of patients, and was the direct cause of death in 6 patients (13%). Humoral rejection is a clinicopathologic entity with a high incidence in women and is associated with acute hemodynamic compromise, accelerated transplant coronary artery disease and death.