RESUMO
Allosensitized children listed with a requirement for a negative prospective crossmatch have high mortality. Previously, we found that listing with the intent to accept the first suitable organ offer, regardless of the possibility of a positive crossmatch (TAKE strategy), results in a survival advantage from the time of listing compared to awaiting transplantation across a negative crossmatch (WAIT). The cost-effectiveness of these strategies is unknown. We used Markov modeling to compare cost-effectiveness between these waitlist strategies for allosensitized children listed urgently for heart transplantation. We used registry data to estimate costs and waitlist/posttransplant outcomes. We assumed patients remained in hospital after listing, no positive crossmatches for WAIT, and a base-case probability of a positive crossmatch of 47% for TAKE. Accepting the first suitable organ offer cost less ($405 904 vs. $534 035) and gained more quality-adjusted life years (3.71 vs. 2.79). In sensitivity analyses, including substitution of waitlist data from children with unacceptable antigens specified during listing, TAKE remained cost-saving or cost-effective. Our findings suggest acceptance of the first suitable organ offer for urgently listed allosensitized pediatric heart transplant candidates is cost-effective and transplantation should not be denied because of allosensitization status alone.
Assuntos
Redução de Custos , Transplante de Coração/economia , Transplante de Coração/métodos , Teste de Histocompatibilidade/economia , Listas de Espera , Criança , Pré-Escolar , Estudos de Coortes , Análise Custo-Benefício , Bases de Dados Factuais , Emergências , Feminino , Rejeição de Enxerto , Sobrevivência de Enxerto , Transplante de Coração/efeitos adversos , Teste de Histocompatibilidade/métodos , Custos Hospitalares , Humanos , Lactente , Masculino , Cadeias de Markov , Seleção de Pacientes , Pediatria , Prognóstico , Sistema de Registros , Medição de Risco , Sensibilidade e Especificidade , Fatores de Tempo , Resultado do TratamentoRESUMO
Allosensitized children who require a negative prospective crossmatch have a high risk of death awaiting heart transplantation. Accepting the first suitable organ offer, regardless of the possibility of a positive crossmatch, would improve waitlist outcomes but it is unclear whether it would result in improved survival at all times after listing, including posttransplant. We created a Markov decision model to compare survival after listing with a requirement for a negative prospective donor cell crossmatch (WAIT) versus acceptance of the first suitable offer (TAKE). Model parameters were derived from registry data on status 1A (highest urgency) pediatric heart transplant listings. We assumed no possibility of a positive crossmatch in the WAIT strategy and a base-case probability of a positive crossmatch in the TAKE strategy of 47%, as estimated from cohort data. Under base-case assumptions, TAKE showed an incremental survival benefit of 1.4 years over WAIT. In multiple sensitivity analyses, including variation of the probability of a positive crossmatch from 10% to 100%, TAKE was consistently favored. While model input data were less well suited to comparing survival when awaiting transplantation across a negative virtual crossmatch, our analysis suggests that taking the first suitable organ offer under these circumstances is also favored.
Assuntos
Técnicas de Apoio para a Decisão , Transplante de Coração , Cadeias de Markov , Transplantados , Listas de Espera , Aloenxertos , Criança , Pré-Escolar , Feminino , Sobrevivência de Enxerto , Transplante de Coração/mortalidade , Teste de Histocompatibilidade , Humanos , Lactente , Masculino , Medição de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , Fatores de Tempo , Listas de Espera/mortalidadeRESUMO
OBJECTIVE: To evaluate granulocyte colony-stimulating factor (G-CSF) as an early marker of bacterial or fungal infection in neonates. STUDY DESIGN: We measured G-CSF levels in infants of varying gestational and postnatal ages. We separated the infants into three groups: group 1, positive bacterial or fungal blood culture result; group 2, negative blood culture result but evidence of clinical sepsis; and group 3, negative blood culture result and no or weak evidence of sepsis. Comparison of mean G-CSF levels by group was accomplished by an analysis of variance. RESULTS: One hundred seventy-six evaluations for sepsis were done for 156 infants with gestational ages ranging from 24 to 43 weeks; 50% of these infants were less than 35 weeks of gestational age. The mean G-CSF levels of groups 1 and 2 were significantly higher than those of group 3. The mean G-CSF level of each group was 2278 pg/ml (group 1), 1873 pg/ml (group 2), and 280 pg/ml (group 3) (p < 0.001). On the basis of a cutoff level of 200 pg/ml, the sensitivity of the test was 95%, specificity 73%, positive predictive value 40%, and negative predictive value 99%. CONCLUSION: G-CSF levels represent a sensitive marker of infection in neonates of all gestational ages.
Assuntos
Infecções Bacterianas/diagnóstico , Fator Estimulador de Colônias de Granulócitos/sangue , Doenças do Prematuro/diagnóstico , Bacteriemia/diagnóstico , Bacteriemia/imunologia , Infecções Bacterianas/imunologia , Fungemia/diagnóstico , Fungemia/imunologia , Idade Gestacional , Humanos , Recém-Nascido , Doenças do Prematuro/imunologia , Micoses/diagnóstico , Micoses/imunologia , Valor Preditivo dos Testes , Valores de ReferênciaRESUMO
Persons with hemophilia who have received therapy since 1978 are at risk for the acquired immunodeficiency syndrome. Plasma and serum specimens collected from 1980 to 1985 from 73 New Mexico residents with hemophilia were tested by enzyme immunoassay for antibody to human T-cell lymphotropic virus type III (HTLV-III), and positive results were confirmed by Western blot. Antibody to HTLV-III was first detected in New Mexico residents with hemophilia in 1981. Among 49 persons tested in 1984-1985, seropositivity was found in 35%. Of these, 17 of 32 (53%) commercial concentrate versus 0 of 17 cryoprecipitate users were seropositive (P = .002). Of the 7 with hemophilia B, 3 (43%) were seropositive versus 14 of 42 (33%) with hemophilia A. Of 17 Albuquerque residents with hemophilia, 2(12%) were seropositive as compared with 15 of 32 (47%) persons with hemophilia who resided outside the city (P = .02). Compared with patients with hemophilia outside of Albuquerque, those living in Albuquerque tended to have milder disease and to use cryoprecipitate rather than commercial concentrate. Less frequent treatment (mild disease) and use of cryoprecipitate were associated with a decreased risk of HTLV-III infection.