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PubMed1998

Effects of changes in the criteria for nationally shared kidney transplants for HLA-matched patients.

BACKGROUND: Nine years ago, a prospective trial began in all U.S. transplant centers to determine whether the results of renal transplantation would improve with the nationwide shipment of kidneys from cadaveric donors to HLA-matched patients. Since then, the stringency of criteria for HLA matching have been liberalized twice, from sharing only those kidneys that matched at all six HLA-A, -B, -DR antigens, to sharing phenotypically HLA-matched kidneys, and most recently to sharing zero HLA-mismatched kidneys. METHODS: Data reported to the United Network for Organ Sharing Scientific Renal Transplant Registry from October 1987 to December 1996 were analyzed to examine the transplant results of nationally shared HLA-matched kidneys and the effects of changes to the HLA matching criteria on graft survival and the distribution of HLA-matched kidneys. RESULTS: The overall 1-year graft survival rate of 5102 HLA-matched transplants was 88% compared with 81% for 58,207 recipients of kidneys with at least one HLA mismatch (P < 0.001). HLA-matched kidneys had a projected 12-year graft half-life, 50% higher than the 8-year half-life of mismatched grafts (P < 0.01). After the first change in the match criteria in August 1990, 1365 phenotypically matched kidneys with fewer than six HLA antigens identified had an 89% 1-year graft survival rate compared with 84% for 466 six antigen-matched kidneys transplanted before the change. After March 1995, 1067 zero HLA-mismatched kidneys that were not phenotypically identical nor six antigen matched, had a 1-year graft survival rate of 88%. Graft survival has not decreased as a result of these changes in the criteria for national sharing, despite an increase in the percentage of matched transplants from 2.5% during the six antigen-match era to 15.5% during the zero antigen-mismatch era. CONCLUSIONS: Changes to the United Network for Organ Sharing policy for national sharing of HLA-matched kidneys have increased the number of patients, and especially minority patients, who can benefit by receiving a well-matched graft without compromising the high graft survival rates provided by an HLA-matched kidney.

Cadaver↗
PubMed2003

Anterior thoracolumbar instrumentation: stiffness and load sharing characteristics of plate and rod systems.

STUDY DESIGN: An in vitro biomechanical study using a thoracolumbar corpectomy model to compare load sharing capabilities and stiffnesses of six different anterior instrumentation systems (three rod styles and three plate styles) for stabilizing the thoracic and lumbar spine. OBJECTIVES: To evaluate the axial load sharing capabilities of the instrumentation in a thoracolumbar corpectomy model and to measure the bending stiffness of the anterior instrumentation systems for the axes of flexion-extension, lateral bending, and axial rotation with and without an anterior column graft in place. SUMMARY OF BACKGROUND DATA: Prior publications have analyzed biomechanical characteristics of many spinal instrumentation systems. These reports have compared anterior instrumentation systems with posterior instrumentation systems, in situ fusion techniques, intervertebral spacers, structural allograft and instrumentation, and combined anterior and posterior instrumentation. Other reports have published data on the biomechanical characteristics of typical anterior and posterior spinal instrumentation systems. However, there are no published reports that specifically compare the characteristics of anterior plate-style with anterior rod-style systems, or examining load sharing capabilities. METHODS: Six constructs of each of six instrumentation systems were mounted on simulated vertebral bodies. A custom four-axis spine simulator was used to apply independent flexion-extension, lateral bending, and axial rotation moments as well as axial compressive loads. Axial load sharing was measured through a range of applied axial loads from 50 N to 500 N with rotational moments maintained at 0 Nm. The bending stiffness of each construct was calculated in response to +/-5.0 Nm moments about each axis of rotation with a 50 N compressive axial load with a full-length corpectomy graft in place, simulating reconstruction of the anterior column, and with no graft in place, simulating catastrophic graft failure. Statistical significance was determined using an analysis of variance and Fisher PLSD post hoc test with an alpha <or= 0.05. RESULTS: Load sharing results ranged from 63% to 89%. There was an inverse relationship between load sharing and stiffness. No correlation was found between load sharing and implant style (rod vs. plate). With the graft in place, stiffness result varied by instrumentation system rather than by plate/rod style. Without the graft, the stiffness of the constructs decreased approximately one-third in flexion-extension, two-thirds in lateral bending, and one-fifth in axial rotation, underlying the importance of the graft in overall construct stiffness. CONCLUSIONS: For both load sharing and stiffness, there is more influence from the design of the instrumentation system, than whether it is a plate or rod style system. The graft contributed to overall construct stiffness, particularly in lateral bending.

Animals↗
PubMed1991

Probabilistic assessment of the HLA sharing of recurrent spontaneous abortion couples in the Japanese population.

In spite of a number of investigations, the concept of human leukocyte antigen (HLA) sharing in recurrent spontaneous abortion (RSA) couples remains controversial. We introduced the basal antigen sharing rate (BSR) by the original mathematical approach using the gene frequency of all HLA specificities derived from our regional control population and applied this parameter for the comparison with RSA couples. RSA couples were classified into three subgroups; primary (3 or more consecutive abortions), secondary (3 or more consecutive abortions after 1 live birth), and potential (2 consecutive abortions) aborters. No significant differences between the HLA class I sharing rates (one or more antigens shared on a single locus) of the all RSA subgroups and the calculated BSRs were observed. In the HLA-DR and DQ loci, on the other hand, the antigen sharing rates of primary aborters were significantly higher than BSRs (p less than 0.01/DR, p less than 0.05/DQ). While potential aborters showed a result similar to that of the primary aborters, no significant antigen sharing of HLA class II was observed in secondary aborters. Our data suggest that BSR is a useful parameter for detection of significant HLA sharing in regional populations and the consecutive abortions that occurred primarily are certainly relevant to HLA class II sharing.

Abortion, Spontaneous↗
PubMed2006

Anterior cervical fixation: analysis of load-sharing and stability with use of static and dynamic plates.

BACKGROUND: Anterior plates provide stability following decompression and fusion of the cervical spine. Various plate designs have emerged, and they include static plates with fixed-angle screws, rotationally dynamic plates that allow the screws to toggle in the plate, and translationally dynamic plates that allow the screws to both toggle and translate vertically. The goal of this study was to document the effects of plate design following a single-level corpectomy and placement of a full-length strut graft and the effects following 10% subsidence of the graft. METHODS: A total of twenty-one cadaveric cervical spines (C2-T1) were randomized into three treatment groups and were tested for initial range of motion. A C5 corpectomy was performed, reconstruction was done with a full-length interbody spacer containing a load-cell, and an anterior cervical plate was applied. Load-sharing data were recorded with incremental axial loads. The range of motion was measured with +/- 2.5 Nm of torque in flexion-extension, lateral bending, and axial rotation. Then, the total length of the interbody spacer was reduced by 10% to simulate subsidence, and load-sharing and the range of motion were retested. RESULTS: With the full-length interbody spacer, there were no significant differences in the abilities of the constructs to share load or limit motion. Following shortening of the interbody spacer, the static plate construct lost nearly 70% of its load-sharing capability, while neither of the dynamic plate constructs lost load-sharing capabilities. Also, the static plate construct allowed significantly more motion in flexion-extension following simulated subsidence than did either of the dynamic plate constructs (p < 0.05). CONCLUSIONS: Although all of the tested anterior cervical plating systems provide similar load-sharing and stiffness following initial placement of the interbody spacer, the static plate system lost its ability to share load and limit motion following simulated subsidence of the interbody spacer. Both dynamic plate systems maintained load-sharing and stiffness despite simulated subsidence. CLINICAL RELEVANCE: This study provides an improved understanding of the immediate performance of anterior cervical fusion surgery with plate fixation.

Aged↗
PubMed2002

Infant bed-sharing among Pacific families in New Zealand.

AIM: To describe infant bed-sharing among Pacific families in New Zealand. METHODS: The data were gathered as part of the Pacific Island Families: First Two Years of Life (PIF) Study in which 1376 mothers were interviewed when their infants were six-weeks-old. Maternal reports of infant bed-sharing practices were assessed by questions about infant sleep location and the number of people who usually shared a mattress with the infant. RESULTS: Over half of the mothers (54.9%) reported that their infants shared a mattress with other people, 44.2% sharing with one other person, the remainder sharing with two or more people. Of the bed-sharing infants, 4.7% slept on a mattress on top of the bed, and 4.7% only slept part of the night in the shared bed. CONCLUSIONS: Together with effective information delivery, the educational and housing issues that many Pacific families in New Zealand face need to be addressed so that parents can make informed decisions about infant care practices.

Adult↗
PubMed2005

Sharing patient data: competing demands of privacy, trust and research in primary care.

BACKGROUND: Patient privacy may conflict with the advancement of knowledge through data sharing. The data contained in primary care records are uniquely comprehensive. AIM: To explore the knowledge and attitudes of patients and members of the primary healthcare team regarding the sharing of data held in primary care records, with particular reference to data sharing for research and the impact that this may have on trust between patients and health professionals. DESIGN OF STUDY: Qualitative study using quota sampled, semi-structured interviews. SETTING: Five general practices in Leicestershire, UK. METHOD: Grounded theory and framework methodology were used. Interviews were transcribed and analysed thematically. RESULTS: Twenty patients and 15 healthcare professionals and managers were interviewed. Patients had limited knowledge of the type of information held in their general practice records and the ways in which these data are shared, but appeared ready to form preliminary views on issues such as data sharing for audit and disease registration. In this climate of limited awareness, there was no suggestion that concern about data sharing for research adversely affects patient trust or leads patients to withhold relevant information from health professionals in primary care. Interviews carried out with staff suggested a lack of clear practice policies regarding data sharing. CONCLUSIONS: General practices may need to develop policies on data sharing, bring these to the attention of their patient population and improve patient awareness about the nature of the data contained in their records. Researchers should ensure that patients are adequately informed about the nature of data contained in patient records when seeking consent for data extraction.

Confidentiality↗
PubMed1990

A mathematical model to describe the risk of infection from sharing injection equipment.

A mathematical model is presented that describes the probability of a subject becoming infected as a result of sharing equipment used for percutaneous injections. This risk is a function of (a) the number of syringes shared by the subject, (b) the probability of a syringe becoming contaminated after being used once by an infective person, (c) the probability of a person becoming infected after using a contaminated syringe once, (d) the number of persons who have previously used each syringe shared by the subject, (e) the prevalence of infectivity in the group from which these previous users are drawn, (f) the number of times each syringe has been used by each previous user, and (g) the number of times the subject uses it. Simulations with the model suggest mainly that (i) when each shared syringe has been used previously by only one person, the number of persons with whom syringes are shared is more important than the number of syringes; (ii) the reverse is true when each shared syringe has previously been used by many persons; and (iii) for an equal number of injections, the "shooting gallery" type of sharing can be much more risky than other kinds of sharing, but this difference decreases as the infections becomes more prevalent.

Humans↗
PubMed1989

Shared governance: what it means to those involved.

Nurses saw shared governance as both a management philosophy and an organizational structure that changes the organizational culture and belief system. Because of these two aspects of shared governance, its implementation is an evolutionary process in which former roles are examined and new roles are learned. Power shifts during the implementation of shared governance create role conflicts and confusion in the decision domains of staff and managerial nurses. Shared governance is highly valued by participants as a mechanism to enhance commitment to the organization, accountability for nursing practice, and the professionalism of both the clinical and managerial staff. The participants valued the opportunities for growth and development of leadership skills that shared governance provided. While negative perspective were shared, they seemed to be secondary to the overall satisfaction with shared governance. Some of the negative perspectives seemed to relate to the length of experience with shared governance, whereas others seemed to be essential elements of the experience.

Decision Making, Organizational↗
PubMed1989

The role of HLA class I antigens in recognition of melanoma cells by tumor-specific cytotoxic T lymphocytes. Evidence for shared tumor antigens.

CTL lines were established in vitro by stimulating patient lymphocytes with autologous melanoma cells in the presence of IL-2. Resulting CTL lines lysed autologous melanoma and failed to lyse several allogeneic melanomas or K562. The mechanism of target cell recognition by autologous tumor-specific CTL was evaluated in this system, using several CTL lines: DT6, DT105, DT141, DT166, DT169, and DT179. Autologous melanoma lysis was inhibited by W6/32, mAb directed against HLA class I Ag, but not by L243, mAb directed against HLA class II Ag. CTL from DT6, DT141, DT166, DT169, and DT179 lysed fresh and cultured allogeneic melanomas, which shared the HLA-A2 Ag, but failed to lyse allogeneic melanomas, which shared B-region or C-region Ag, or shared no HLA class I Ag. CTL from DM141 lysed DM93, which shared A2 and Bw6, but failed to lyse DM105, which shared only Bw6. DM105 CTL failed to lyse allogeneic melanomas that shared HLA-A1, or that shared B or C region Ag, but they did lyse allogeneic melanoma DM49, which expressed an A region Ag that either was A10 or was serologically cross-reactive with A10. A T cell leukemia line, three EBV transformed B cell lines, and a pancreatic cancer line, all of which expressed HLA-A2, were not lysed by DM6 or DM179 CTL. Furthermore, HLA-matched nonmelanomas failed to inhibit autologous tumor lysis in cold target inhibition assays, whereas an HLA-A2+ allogeneic melanoma, DM93, inhibited autologous tumor lysis as effectively as the autologous tumor itself. HLA-A2, and possibly other HLA-A-region Ag, appear to function in HLA-restricted recognition of shared melanoma associated Ag by CTL.

Antibodies, Monoclonal↗
PubMed1988

Insulin-gene sharing in sib pairs with insulin-dependent diabetes mellitus: no evidence for linkage.

An association between insulin-dependent diabetes mellitus (IDDM) and an RFLP adjacent to the insulin gene has been consistently observed, but its etiological significance is unclear. We studied unrelated IDDM patients (N = 45) and controls (N = 65) to confirm the association--and assessed evidence for linkage in 22 families with at least two affected (IDDM) sibs--to determine whether the insulin-gene region actually contributes to susceptibility to IDDM. All individuals were typed for the RFLP in the 5'-flanking region of the insulin gene (5'FP) used in the previous studies, and the 12 families not fully informative for linkage with the 5'FP were typed for additional closely linked RFLPs. We found a higher frequency of class 1 alleles of the 5'FP in IDDM patients (.83) than in controls (.75), which is consistent with the reported association, but the difference was not statistically significant in our sample. Among the 33 affected sib pairs (ASPs) in 22 families, if maximum possible sharing is assumed when sharing is ambiguous, 10 pairs share both parental insulin genes, 17 pairs share one, and six share neither. This distribution is incompatible with close linkage. In contrast, for the HLA region, for which all 22 families are fully informative, 19 of the 33 ASPs share two haplotypes and the remaining 14 share one. There are no pairs that share neither HLA haplotype. Thus, although these data clearly illustrate the contribution of HLA-linked susceptibility to IDDM, they argue strongly against a contribution of similar magnitude by the insulin-gene region.

Diabetes Mellitus, Type 1↗
PubMed1985

Adverse effects of human leukocyte antigen-DR sharing on fertility: a cohort study in a human isolate.

To elucidate further the reproductive effects of human leukocyte antigen (HLA) sharing among spouses, we have been investigating prospectively the relationship between HLA-A, -B, and -DR sharing and reproductive outcome in the Hutterites, a religious isolate that proscribes contraception. For the first time the reproductive effects of HLA-DR sharing in a fertile population is reported in this article. Median intervals from marriage to first through fifth births were longer among couples who shared more than one HLA-A, -B, or -DR antigen. Longer intervals were associated with increased spontaneous abortion rates among couples who shared HLA-DR antigens (27%), compared with couples who shared only HLA-A or -B antigens (9%) and couples who shared no antigens (12%). Median completed family sizes were 5.0, 8.5, and 8.0 among the groups, respectively. However, some couples who shared HLA-DR antigens experienced no spontaneous abortions, despite ten or more pregnancies. Therefore, although HLA-DR compatibility, per se, is not deleterious, our data suggest a potentially important role for undefined HLA-linked genes in normal pregnancy.

Abortion, Spontaneous↗
PubMed2000

All rights reserved, or can we just copy? Cost sharing arrangements and characteristics of health care systems.

In most European countries cost sharing has been introduced in order to reduce the demand for care. Different forms of cost sharing are available, but because of historically grown system characteristics and prevailing values countries differ in the application of specific forms. This review focuses on eighteen European countries, and on the combinations of health system characteristics and present forms of cost sharing. We found that some combinations are more present: different payment systems for primary care physicians go together with different forms of cost sharing, different services have different forms of cost sharing. In countries with a GP as gatekeeper no charges are in use for the GP. No distinct relationship could be found between the financing system (tax-based or insurance-based) and the form of cost sharing or the exclusion of vulnerable populations. It is concluded that there are two ways of filtering 'unnecessary' demand. One is by introducing cost sharing for directly accessible services such as GPs. The second way is by having GPs act as gatekeepers to more specialized, and more costly care.

Cost Sharing↗
PubMed1995

The Health of the Nation target on syringe sharing: a role for routine surveillance in assessing progress and targeting interventions.

The Health of the Nation initiative in the United Kingdom includes a target aimed at reducing the proportion of current injecting drug users who share syringes. The PHLS Collaborative Survey of Salivary Antibodies to HIV and Hepatitis B core in injecting drug users is a comprehensive and national surveillance mechanism which routinely collects data that can be used to monitor progress toward this target. Nineteen per cent of injecting drug users (353/1876) in 1992 and 18% (375/2138) in 1993 shared previously used injecting equipment (difference of -1.3%, 95% Cl -3.7%, 1.1%). Only with further years of data collection will it be possible to tell if this decline represents a real change in behaviour. There was a substantial reduction in the proportion of sharers who received previously used needles and syringes from more than one person, from 45% (138/305) in 1992 to 27% (81/298) in 1993 (fall of 18%, 95% Cl 11%, 26%). This decline could indicate a real reduction in risk behaviour that is not reflected in the target. Monitoring this aspect of sharing could be an important supplementary measure. Women were more likely to have share (adjusted OR = 1.87, 95% Cl 1.53, 2.28) and the likelihood of sharing declined with age (adjusted OR of each 5-year age band = 0.75, 95% Cl 0.72, 0.79). Particular attention should be given to interventions which aim to reduce sharing among women and young people. Clients of agencies at which the main service provided was syringe exchange were less likely to have shared than attenders of other types of agencies (adjusted OR = 0.69, 95% Cl 0.51, 0.93). This suggests that syringe exchange schemes play a role in reducing the transmission of HIV infection.

Adolescent↗
PubMed2000

Needle sharing: a longitudinal study of female injection drug users.

The objective of this study was to examine the psychosocial risk and protective factors related to needle-sharing behavior among female intravenous drug users (IDUs) positive (N = 96) and negative (N = 128) for human immunodeficiency virus (HIV). Participants in this longitudinal study were interviewed individually at two points in time, with a 6-month interval between interviews. The interviewers used a structured questionnaire, which included psychosocial measures and questions about drug and sexual risk behaviors. Data were analyzed using Pearson correlations and hierarchical regression analyses. The findings supported a developmental model in which the psychosocial domains and HIV status predicted T1 (initial) needle-sharing behavior, which in turn was related to T2 (follow-up) needle-sharing behavior. In addition, the relationship between personality and peer risk factors and T2 needle sharing was buffered by family-related protective factors. While HIV-positive status had a direct effect on T1 needle sharing with strangers, its effect was mediated by all of the psychosocial variables in its relation to T1 needle sharing with familiar people. Comparisons of these results were made with a companion study of male IDUs. The results suggest several intervention and treatment approaches that can be implemented at different points in the developmental pathways leading to risky needle-sharing practices among female IDUs.

Adult↗
PubMed2001

Social factors related to syringe sharing among injecting partners: a focus on gender.

The study of social networks has become an increasingly utilized method of examining the relationship between injection drug users' social environment and risk of HIV. This study examined relational aspects of two injection drug users (IDUs) within a single social network as they relate to sharing syringes. Data presented in this study were derived from baseline interviews of 508 IDUs from Baltimore, MD. Analyses were performed separately for male and female participants in an effort to understand gender differences in social aspects of syringe sharing. Among this sample, women shared syringes with a significantly higher percentage of injecting partners compared to men. In separate multilevel logistic regression models, significant variables associated with males' and females' syringe sharing were: sharing drugs daily with female injecting partners, injecting partners' provision of drugs when indexes' were withdrawing, being sexual partners, and injecting partners' injecting speedballs. Factors associated with male injecting dyads sharing of syringes were: being kin, injecting partners' injection of heroin and daily drug use, and drinking alcohol together. Results from this study demonstrate the usefulness of examining relationship characteristics of injecting dyads related to syringe sharing as they differ between men and women.

Acquired Immunodeficiency Syndrome↗
PubMed2007

Modelling the impact on Hepatitis C transmission of reducing syringe sharing: London case study.

BACKGROUND: Hepatitis C virus (HCV) prevalence and incidence among injecting drug users (IDUs) has increased in London and rest of UK. To inform public health action, mathematical modelling is used to explore the possible impact of strategies to decrease syringe sharing. METHODS: A mathematical model was developed to simulate HCV transmission amongst IDUs in London. Because of parameter uncertainty, numerical search algorithms were used to obtain different model fits to HCV seroprevalence data from London for 2002-03. These simulations were used to explore the likely impact of HCV prevention activities that reduce syringe sharing amongst all IDUs, IDUs that have injected for greater than one year, or IDUs with lower or higher frequencies of syringe sharing. RESULTS: Key differences between model fits centred on how they simulated the high HCV incidence amongst new injectors, either through assuming increased HCV infectivity during acute infection, a large sub-group of high frequency syringe sharers, or increased sharing among new IDUs. Despite parameter uncertainty, the model projections suggest that modest reductions in syringe sharing frequency (<25%) will reduce the HCV seroprevalence in newly initiated IDUs (injecting less than four years) but much larger and sustained reductions (>50%) are required to reduce the HCV seroprevalence in long-term IDUs (injecting more than 8 years). Critically the model also suggested that large reductions in HCV seroprevalence will be achieved only if interventions target all IDUs and reach IDUs within 12 months of injecting. DISCUSSION: Public health interventions must reduce syringe sharing amongst all IDUs, including newly initiated IDUs, and be sustained for many years to reduce HCV infection. More accurate data on key behavioural (sharing frequency) and biological (percentage of infected IDUs that clear infection) parameters is required to improve model projections.

Female↗
PubMed1991

A comparison of cost-sharing versus free care in children: effects on the demand for office-based medical care.

Using data from the community based RAND Health Insurance Experiment, the effect of cost-sharing versus free care on the use of office-based medical care in children was examined. Children from families on cost-sharing plans had a 22 percent lower probability (P less than 0.005) of having an episode of care during the study year. Both the number of episodes of care and total charges for outpatient professional services were 30 percent lower (P less than 0.005) with cost-sharing. cost-sharing reduced average charges for medical services by 30 percent (P less than 0.01) and pathology charges by 45 percent (P less than 0.005). cost-sharing reduced medical services received by 26 percent (P less than 0.05) and pathology services received by 43 percent (P less than 0.05) but did not have a significant effect on either the price for medical services or pathology services. It was concluded that there is a large difference between cost-sharing insurance plans and free care in the demand for office-based medical care in children. Cost-sharing results in children receiving fewer services, not lower priced services.

Child↗
PubMed1996

People and places: behavioral settings and personal network characteristics as correlates of needle sharing.

Sharing of contaminated needles constitutes one of the primary modes of HIV transmission in the U.S. This study examined social and environmental factors as possible correlates of needle sharing in a sample of inner-city drug users in Baltimore, Maryland. Drug users' social context was assessed through an analysis of personal networks, and the environmental context of drug use was assessed through a delineation of injection settings. The 330 respondents participating in an HIV prevention study were administered two surveys an average of 5.2 months apart. An examination of the association of network characteristics at baseline and needle sharing at followup revealed that the factors of higher total network density, larger drug network size, and injecting at friends' residences were positively associated with reports of sharing needles that had been cleaned with bleach. Sharing of needles that had not been disinfected with bleach was positively associated with reports of injecting in semipublic areas (streets, rooftops, parks, cars, public bathrooms, and abandoned buildings). These data support ecological and resource models of needle sharing and suggest the potential utility of network-oriented strategies for reducing needle sharing among injecting drug users.

Adult↗