Managing finances of shipping living donor kidneys for donor exchanges

Kidney donor exchanges enable recipients with immunologically incompatible donors to receive compatible living donor grafts; however, the financial management of these exchanges, especially when an organ is shipped, is complex and thus has the potential to impede the broader implementation of donor exchange programs. Representatives from transplant centers that utilize the National Kidney Registry database to facilitate donor exchange transplants developed a financial model applicable to paired donor exchanges and donor chain transplants. The first tenet of the model is to eliminate financial liability to the donor. Thereafter, it accounts for the donor evaluation, donor nephrectomy hospital costs, donor nephrectomy physician fees, organ transport, donor complications and recipient inpatient services. Billing between hospitals is based on Medicare cost report defined costs rather than charges. We believe that this model complies with current federal regulations and effectively captures costs of the donor and recipient services. It could be considered as a financial paradigm for the United Network for Organ Sharing managed donor exchange program.

Melioration, matching, and maximization

Pigeons were studied in an experiment involving two concurrently available response keys. Conditions were such that in the first condition the predictions of melioration (Herrnstein & Vaughan, 1980), minimization of deviation from matching, and maximization were identical: relative time on the right key should have fallen between .125 and .25, which in fact occurred. In the second condition, melioration predicted a shift in relative time on the right to between .75 and .875, which would involve a transient deviation from matching as well as a substantial drop in rate of reinforcement. All three birds eventually shifted their distribution of behavior to within the range predicted by melioration.

Choice: A local analysis

Analyses of free-operant choice usually employ one of two general procedures: the simple concurrent procedure (i.e., a concurrent variable-interval variable-interval schedule) or the concurrent-chains procedure (i.e., concurrently available initial links, each leading to an exclusively available terminal link). Theories about choice usually focus on only one of the two procedures. For example, maximization theories, which assert that behavior is distributed between two alternatives in such a way that overall rate of reinforcement is maximized, have been applied only to the simple concurrent procedure. In the present paper, a form of the pairing hypothesis (according to which pairings between one stimulus and another affect the value of the first, and pairings between responses and reinforcers affect the value of the former) is developed in a way that allows it to make qualitative predictions with regard to choice in a variety of simple concurrent and concurrent-chains procedures. The predictions include matching on concurrent variable-interval variable-interval schedules, preference reversal in the self-control paradigm, and preference for tandem over chained terminal links.

Dissociation of value and response strength

Four pigeons were exposed to multiple schedules and later to concurrent-chains schedules, with terminal links that had previously been multiple-schedule components. For 2 birds, the terminal-link schedules arranged an inverse relationship between response rate and reinforcement rate; for the other 2 birds a direct corresponding relationship was arranged. Those response rates were further modified by differentially reinforcing either longer or shorter interresponse times, relative to the current means. Although the birds' initial-link responses indicated preferences for terminal links with higher rates of reinforcement, in half the cases the birds responded during the terminal links in such a way as to produce lower rates of reinforcement, rates their initial-link behavior indicated they did not prefer. That outcome is inconsistent with maximization theory, but consistent with a strengthening analysis of behavior on single-key schedules.

Choosing among natural stimuli

Pigeons worked on concurrent variable-interval, variable-interval schedules with the alternatives signaled by slides either containing trees or not. The schedules were designed to hold both overall and relative rates of reinforcement within narrowly constrained limits, and slides were quasi-randomly ordered each day. Responding to the two alternatives was well described by the generalized matching equation with substantial undermatching. Using an adaptation of the matching law, we estimated that the subjects were correctly classifying 82% to 95% of exemplars. The matching performance transferred to new exemplars of trees and nontrees with only slight generalization decrement. The pigeons appeared to be discriminating among exemplars even when the alternatives provided equal rates of reinforcement and the average relative performances were close to 50%.

Reply to silberberg and ziriax

Silberberg and Ziriax (1985) report that a modification of Vaughan's (1981) procedure produces results inconsistent with melioration (the position advocated by Vaughan) but consistent with a process they term molecular maximizing. Here it is argued that the theory of molecular maximization is not sufficiently unambiguous that researchers other than the developers can test its predictions, and that in any case none of the data presented by Silberberg and Ziriax are both clearly consistent with molecular maximization and inconsistent with melioration.

Plasmablastic lymphoma presenting in a human immunodeficiency virus-negative patient: a case report

Plasmablastic lymphoma (PBL), an aggressive non-Hodgkin's lymphoma that carries a poor prognosis, previously has been identified almost exclusively in patients infected with the human immunodeficiency virus (HIV). We present a case of a 42-year-old HIV-negative patient presenting with an isolated nasal cavity mass, the typical presentation for PBL. The patient was given systemic chemotherapy, central nervous system prophylaxis, and consolidative locoregional radiotherapy and achieved a complete clinical response. This case suggests PBL should be considered in HIV-negative patients with characteristic findings.

Autotransplants in men with breast cancer. ABMTR Breast Cancer Working Committee. Autologous Blood and Marrow Transplant Registry

The purpose of this study was to determine the outcome of high-dose therapy with autologous hematopoietic stem cell support (autotransplants) in men with breast cancer. We studied 13 men receiving autotransplants for breast cancer and reported to the Autologous Blood and Marrow Transplant Registry (ABMTR) by 10 centers. Six men had stage 2 breast cancer, four had stage 3, and three had metastatic breast cancer. Of twelve tumors tested, all were estrogen receptor positive. Median age at transplant was 50 years. The most common conditioning regimen was cyclophosphamide, thiotepa and carboplatin (n = 5); the remaining eight men received other alkylator-based regimens. Three men received bone marrow, eight received blood stem cells, and two received both for hematopoietic support. All patients had hematopoietic recovery. There were no unexpected regimen-related toxicities. Of 10 men receiving autotransplants as adjuvant therapy, three relapsed 3, 5 and 50 months post-transplant and died 16, 19 and 67 months post-transplant. Seven of 10 are disease-free with median follow-up of 23 months (range 6-50 months). Of three men treated for metastatic breast cancer, one had progressive disease and two recurrent disease at 6, 7 and 16 months post-transplant. In conclusion, results of autotransplants for male breast cancer appear similar to those reported for women receiving autotransplants for breast cancer.

A multicenter study of platelet recovery and utilization in patients after myeloablative therapy and hematopoietic stem cell transplantation

An observational study was conducted at 18 transplant centers in the United States and Canada to characterize the platelet recovery of patients receiving myeloablative therapy and stem cell transplantation and to determine the clinical variables influencing recovery, determine platelet utilization and cost, and incidence of hemorrhagic events. The study included 789 evaluable patients transplanted in 1995. Clinical, laboratory, and outcome data were obtained from the medical records. Variables associated with accelerated recovery in multivariate models included (1) higher CD34 count; (2) higher platelet count at the start of myeloablative therapy; (3) graft from an HLA-identical sibling donor; and (4) prior stem cell transplant. Variables associated with delayed recovery were (1) prior radiation therapy; (2) posttransplant fever; (3) hepatic veno-occlusive disease; and (4) use of posttransplant growth factors. Disease type also influenced recovery. Recipients of peripheral blood stem cells (PBSC) had faster recovery and fewer platelet transfusion days than recipients of bone marrow (BM). The estimated average 60-day platelet transfusion cost per patient was $4,000 for autologous PBSC and $11,000 for allogeneic BM transplants. It was found that 11% of all patients had a significant hemorrhagic event during the first 60 days posttransplant, contributing to death in 2% of patients. In conclusion, clinical variables influencing platelet recovery should be considered in the design and interpretation of clinical strategies to accelerate recovery. Enhancing platelet recovery is not likely to have a significant impact on 60-day mortality but could significantly decrease health care costs and potentially improve patient quality of life.

Fractional processing of sequential bronchoalveolar lavage to separate bronchial and alveolar samples

Bronchoalveolar lavage has been widely used to sample the lower respiratory tract. Most of the material recovered with this technique represents alveolar contents. A number of modifications have been suggested in order to obtain samples relatively enriched for bronchial material. In order to be able to use a standard technique for bronchoalveolar lavage to sample both airways and "routine" alveolar material, a simple modification of the technique as described by Reynolds and Newball was used: five sequential 20-ml aliquots were infused into the lower respiratory tract, and each aliquot was immediately aspirated. The return from the first aliquot was processed separately from the return from the subsequent four aliquots. These last four aliquots were pooled. Analysis of the first aliquot revealed it to be enriched for ciliated epithelial cells when compared with the subsequent aliquots. There were also differences in inflammatory cell composition with the bronchial sample containing relatively more neutrophils and relatively less lymphocytes. Aspiration during transoral bronchoscopy was documented by quantifying salivary amylase in the bronchial and alveolar lavage fluids. It was estimated, however, that the aspiration was not of quantitative significance in the vast majority of subjects studied. Finally, with the technique of fractional processing of bronchoalveolar lavage samples, it was possible to compare the protein concentrations in bronchial and alveolar lavages. Most prominent among the differences was a marked relative enrichment in the bronchial samples for immunoglobulin A. The technique of fractional processing of bronchoalveolar lavage samples provides a simple means to obtain samples enriched for bronchial and alveolar components. This should facilitate analysis of lower respiratory tract specimens in airway disease.

Teaching pigeons an abstract relational rule: insideness

In 49 sessions, pigeons failed to learn to sort a collection of 80 stimuli composed of a closed curve and a dot, divided into two categories, according to whether the dot was or was not inside the curve. Next, the pigeons were successfully trained, first with the insides of the curves shown in bright red, then with a darker red, and finally with a black matching the background outside the curve. After this stepwise procedure, the pigeons displayed a limited ability to sort novel curves and dot locations according to whether the dot was or was not inside the curve.

Acute myelogenous leukemia with eosinophilic differentiation and trisomy-1

A 50-year-old woman presented with anemia and eosinophilia. Her bone marrow biopsy, peripheral blood, and clinical features were consistent with a diagnosis of an evolving acute myelogenous leukemia. Striking dysplastic eosinophilic differentiation associated with trisomy-1 was evident, and eosinophil granule major basic protein was detected in involved tissue. Trisomy-1 has not been previously reported in association with acute myelogenous leukemia showing eosinophilic differentiation. Intensive cytotoxic chemotherapy produced a short-lived clinical and cytogenetic remission. At autopsy multiple tumor nodules composed of dysplastic eosinophil precursors and myeloblasts were evident in multiple organs.

Molar optimization versus delayed reinforcement as explanations of choice between fixed-ratio and progressive-ratio schedules

In a discrete-trials procedure, pigeons chose between a fixed-ratio 81 schedule and a progressive-ratio schedule by making a single peck at the key correlated with one or the other of these schedules. The response requirement on the progressive-ratio schedule began at 1 and increased by 10 each time the progressive-ratio schedule was chosen. Each time the fixed-ratio schedule was chosen, the requirement on the progressive-ratio schedule was reset to 1 response. In conditions where there was no intertrial interval, subjects chose the progressive-ratio schedule for an average of about five consecutive trials (during which the response requirement increased to 41), and then chose the fixed-ratio schedule. This ratio was larger than that predicted by an optimality analysis that assumes that subjects respond in a pattern that minimizes the response-reinforcer ratio or one that assumes that subjects respond in a pattern that maximizes the overall rate of reinforcement. In conditions with a 25-s or 50-s intertrial interval, subjects chose the progressive-ratio schedule for an average of about eight consecutive trials before choosing the fixed-ratio schedule. This change in performance with the addition of an intertrial interval was also not predicted by an optimality analysis. On the other hand, the results were consistent with the theory that choice is determined by the delays to the reinforcers delivered on the present trial and on subsequent trials.

Cystic fibrosis complicated by acute leukemia

During a 3-month period, two men ages 20 and 25 years, respectively, with cystic fibrosis developed acute lymphocytic and nonlymphocytic leukemias, respectively. These two patients were among 120 patients who attended our cystic fibrosis clinic during the last 3 years. Thirty-five of the 120 patients have survived beyond the second decade. The authors ask whether acute leukemia will be recognized with increasing frequency in cystic fibrosis patients who achieve prolonged survival.

Inability of caliper measurement to enhance observer agreement in the interpretation of coronary cineangiograms

Important clinical decisions are made on the basis of the interpretation of the degree of stenosis in the coronary cineangiogram. Thus, minimization of observer variation (both intra and inter) is crucial. The purpose of this investigation was to determine if measurement of stenotic lesions by caliper (CM) as compared with the usual eyeball method (EM) would reduce observer variation. Five observers, using the AHA scoring system, estimated maximal luminal narrowing in 14 segments on 10 films providing 2 reports on each film by EM and 2 by CM, thus making observations on 2800 segments. This allowed analysis of intraobserver variation for each reporter for method EM and CM, and for interobserver variation by each method. Since chance agreement is an important component in an observational study, a correction for this was made using the Kappa statistic. The results revealed that the mean Kappa by EM was 0.71 compared to 0.63 by CM (1 being perfect agreement and 0 no agreement). Agreement was much greater in proximal rather than distal segments. Interobserver agreement was consistently higher by EM K = 0.62 than CM K = 0.53 (p = 0.0007). A delineation of the types of disagreement and their clinical significance are important considerations in the evaluation of observer variation. It is concluded that the use of a caliper does not enhance either intra or interobserver agreement.

Differential swelling in compartments of the corneal stroma

When a hypotonic solution is applied to the corneal surface the stroma swells. This well-known osmotic response masks a surprising hydration change in the posterior stroma. This was studied by measuring thickness changes in the anterior, middle, and posterior stroma of the rabbit cornea. Measurements were made continuously for 1 hour following osmotic perturbation of the epithelial surface. The data revealed that following a hypotonic shift on the epithelial surface, the posterior stroma thinned briefly. This unexpected effect is predicted satisfactorily by Klyce and Russell's mathematical model. The method of measuring fluid flow between stromal compartments will allow further development of the model in describing the dynamics of stromal hydration.

Optimization versus response-strength accounts of behavior

Pigeons were run in both single-key and concurrent-key experiments in which, over most of the range of response rates, an increase in response rate gave rise to a continuous decrease in reinforcement rate. In spite of the fact that a low response rate would have produced a high reinforcement rate, all birds responded at relatively high rates, thus keeping reinforcement rates substantially below the maximum possible. In the concurrent-key experiment, in addition to responding at relatively high rates, the birds' ratios of responses approximately matched the corresponding ratios of obtained reinforcers. The results are inconsistent with most theories of optimal performance, which assume that organisms behave in ways that either maximize reinforcement value or minimize deviations from a free-behavior point. On the other hand, the results are consistent with the assumption that reinforcement strengthens the tendency to respond.

High resolution gel electrophoresis of chloroplast membrane polypeptides

In the present study we extend previous work from this laboratory on the polypeptide composition of photosynthetic lamellae. Using a high resolution sodium dodecyl sulfate gel electrophoresis technique, we show that both grana and stroma lamellae have qualitatively very similar polypeptide compositions although some clear quantitative differences are demonstrated.