736–3 Costs and Complications of Non-thoracotomy Defibrillator Systems: Impact of Health Care Financing Administration Guidelines

Non-thoracotomy implantable defibrillator (ICD) systems have been shown to have lower costs and fewer complications than thoracotomy systems. Recent interpretation of Health Care Financing Administration regulations has challenged reimbursement for investigational devices or combinations of components not approved by the Food and Drug Administration (“off-label”). We compared the costs and complications associated with approved pulse generator/lead systems (CPI 1600/Endotak, CPl 1705/Endotak and Medtronic 7217/Transvene, n=136) with investigational and “off-label” systems (CPI 1625/Endotak, CPI 1715/Endotak, Medtronic 7219/Transvene and Ventritex V100 or V110/TVL and Vl00/Endotak, n=79). Age [63±12 years versus 63±11 years (mean±SD)] and ejection fraction (31±15% versus 31±11%) were similar for patients with approved and investigational systems, respectively. However, total hospital charges including preoperative care and evaluation, implant procedure and hardware, postoperative testing and revisions were $64±19,000 for approved devices versus$57±16,000 for non-approved devices (p=0.02) despite higher overall costs of newer pulse generators and leads. Total length of stay was 17±10 days versus 14±8 days (p=0.03) and complications including lead dislodgement, increased defibrillation threshold, hematoma and infection were 25/136 versus 4/77 (p<0.005) for approved and investigational or “off-label” systems, respectively. Based on data provided by the manufacturers, anticipated average battery longevity is 3.8 years for approved systems and 5.5 years for investigational or “off-label” systems.ConclusionsThe prudent use of current investigational or “off-label” nonthoracotomy ICD systems is more cost-effective and is associated with fewer complications than approved ICD systems. When increased battery longevity is considered, long term costs of non-thoracotomy ICD therapy may be improved dramatically with the use of investigational or “off-label” systems. Review of reimbursement regulations may be warranted

Ventricular septal defect associated with aneurysm of the membranous septum

The most common variety of ventricular septal defect, a perimembranous defect, is frequently associated with a so-called aneurysm of the membranous septum. Previous studies have suggested that ventricular septal defects associated with an aneurysm of the membranous septum tend to spontaneously decrease in size or close more than defects without such an aneurysm. To better define the natural history of this entity, clinical and catheterization data from 87 patients with ventricular septal defect and aneurysm of the membranous septum were reviewed. The initial evaluation was made at a median age of 0.3 years (range 0.1 to 11), with the final evaluation at a median age of 10 years (range 1.5 to 20) and a median duration of follow-up of 8.6 years (range 1.2 to 18.8).Approximately 75% of the ventricular septal defects had a small or no left to right shunt at last evaluation. Overall, 48 patients (55%) had no significant change in the size of the defect, and 39 (45%) showed improvement during the period of observation. Only four patients (5%) had spontaneous closure of the defect. Of the 49 patients who presented with a large left to right shunt, with or without congestive heart failure, 23 (47%) had persistence of a shunt large enough to warrant surgery. When spontaneous improvement occurred, it did so by 6 years of age in all but one patient. Therefore, a continued tendency for a ventricular septal defect associated with an aneurysm of the membranous septum to spontaneously decrease in size or close after this age may be less likely than previously suggested. The actual morphologic substrate of this entity usually consists of tricuspid valve tissue adherent to the edges of the ventricular septal defect

New life sciences innovation and distributive justice: rawlsian goods versus senian capabilities

The successful decoding of human genome and subsequent advances in new life sciences innovation create technological presuppositions of a new possibility of justice i.e. the just distribution of both social (income, wealth, etc.) and natural (rationality, intelligence, etc.) goods. Although Rawlsians attempt to expand their theory to include this new possibility, they fail to provide plausible metrics of social justice in the genomics and post-genomics era. By contrast, Senians seem to succeed to do so through their index of basic capabilities. This paper explores what might be regarded as a Senian perspective of distributive justice in new life sciences innovation. The argument is that, by comparing freedoms (different functionings) instead of primary goods, the capability theory allows not only for the identification of injustices linked to natural lottery but also for their elimination through the use of new genomic technologies, including gene-based diagnostics, gene therapy, somatic cell engineering (SCE) and germ-line engineering (GLE). These innovative technologies seem to have the potential to reduce variability in natural goods and therefore enable individuals to convert social goods into well-being or welfare

Hypoxia Regulates BMP4 Expression in the Murine Spleen during the Recovery from Acute Anemia

Bone marrow erythropoiesis is primarily homeostatic, producing new erythrocytes at a constant rate. However at times of acute anemia, new erythrocytes must be rapidly produced much faster than bone marrow steady state erythropoiesis. At these times stress erythropoiesis predominates. Stress erythropoiesis occurs in the fetal liver during embryogenesis and in the adult spleen and liver. In adult mice, stress erythropoiesis utilizes a specialized population of stress erythroid progenitors that are resident in the spleen. In response to acute anemia, these progenitors rapidly expand and differentiate in response to three signals, BMP4, SCF and hypoxia. In absence of acute anemic stress, two of these signals, BMP4 and hypoxia, are not present and the pathway is not active. The initiating event in the activation of this pathway is the up-regulation of BMP4 expression in the spleen.In this paper we analyze the regulation of BMP4 expression in the spleen by hypoxia. Using stromal cell lines, we establish a role for hypoxia transcription factor HIFs (Hypoxia Inducible Factors) in the transcription of BMP4. We identified putative Hypoxia Responsive Elements (HREs) in the BMP4 gene using bioinformatics. Analysis of these elements showed that in vivo, Hif2alpha binds two cis regulatory sites in the BMP4 gene, which regulate BMP4 expression during the recovery from acute anemia.These data show that hypoxia plays a key role in initiating the BMP4 dependent stress erythropoiesis pathway by regulating BMP4 expression

Celebrating 20 Years of the ExCEEd Teaching Workshop

In response to the clear need for faculty training, the American Society of Civil Engineers (ASCE) developed and funded Project ExCEEd (Excellence in Civil Engineering Education) which is celebrating its twentieth year of existence. For the past two decades, 38 ExCEEd Teaching Workshops (ETW) have been held at six different universities. The program has 910 graduates from over 267 different U.S. and international colleges and universities. The ExCEEd effort has transformed from one that relied on the grass roots support of its participants to one that is supported and embraced by department heads and deans. This paper summarizes the history of Project ExCEEd, describes the content of the ETW, assesses its effectiveness, highlights changes in the program as a result of the assessment, and outlines the future direction of the program

Usability and digital inclusion: standards and guidelines

This article aims at discussing e-government website usability in relation to concerns about digital inclusion. E-government web design should consider all aspects of usability, including those that make it more accessible to all. Traditional concerns of social exclusion are being superseded by fears that lack of digital competence and information literacy may result in dangerous digital exclusion. Usability is considered as a way to address this exclusion and should therefore incorporate inclusion and accessibility guidelines. This article makes an explicit link between usability guidelines and digital inclusion and reports on a survey of local government web presence in Portugal

Human–agent collaboration for disaster response

In the aftermath of major disasters, first responders are typically overwhelmed with large numbers of, spatially distributed, search and rescue tasks, each with their own requirements. Moreover, responders have to operate in highly uncertain and dynamic environments where new tasks may appear and hazards may be spreading across the disaster space. Hence, rescue missions may need to be re-planned as new information comes in, tasks are completed, or new hazards are discovered. Finding an optimal allocation of resources to complete all the tasks is a major computational challenge. In this paper, we use decision theoretic techniques to solve the task allocation problem posed by emergency response planning and then deploy our solution as part of an agent-based planning tool in real-world field trials. By so doing, we are able to study the interactional issues that arise when humans are guided by an agent. Specifically, we develop an algorithm, based on a multi-agent Markov decision process representation of the task allocation problem and show that it outperforms standard baseline solutions. We then integrate the algorithm into a planning agent that responds to requests for tasks from participants in a mixed-reality location-based game, called AtomicOrchid, that simulates disaster response settings in the real-world. We then run a number of trials of our planning agent and compare it against a purely human driven system. Our analysis of these trials show that human commanders adapt to the planning agent by taking on a more supervisory role and that, by providing humans with the flexibility of requesting plans from the agent, allows them to perform more tasks more efficiently than using purely human interactions to allocate tasks. We also discuss how such flexibility could lead to poor performance if left unchecked