H. Jefferson Powell on the American Constitutional Tradition: A Conversation

Jefferson Powell\u27s recent book, The Moral Tradition of American Constitutionalism, was the point of departure for a series of short papers and conversations held in March of 1996 at the Notre Dame Law School. The conversation began with a presentation by Professor Joseph Vining. His remarks were followed by a free-flowing conversation, loosely orchestrated by Professor Robinson, among the participants. After a break, the conversation was restarted with a presentation by Professor Maura Ryan, followed once again by a loosely orchestrated conversation. We turn first to Joseph Vining

H. Jefferson Powell on the American Constitutional Tradition: A Conversation

Jefferson Powell\u27s recent book, The Moral Tradition of American Constitutionalism, was the point of departure for a series of short papers and conversations held in March of 1996 at the Notre Dame Law School. The conversation began with a presentation by Professor Joseph Vining. His remarks were followed by a free-flowing conversation, loosely orchestrated by Professor Robinson, among the participants. After a break, the conversation was restarted with a presentation by Professor Maura Ryan, followed once again by a loosely orchestrated conversation. We turn first to Joseph Vining

Lung Rest During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure-Practice Variations and Outcomes.

OBJECTIVE: Describe practice variations in ventilator strategies used for lung rest during extracorporeal membrane oxygenation for respiratory failure in neonates, and assess the potential impact of various lung rest strategies on the duration of extracorporeal membrane oxygenation and the duration of mechanical ventilation after decannulation. DATA SOURCES: Retrospective cohort analysis from the Extracorporeal Life Support Organization registry database during the years 2008-2013. STUDY SELECTION: All extracorporeal membrane oxygenation runs for infants less than or equal to 30 days of life for pulmonary reasons were included. DATA EXTRACTION: Ventilator type and ventilator settings used for lung rest at 24 hours after extracorporeal membrane oxygenation initiation were obtained. DATA SYNTHESIS: A total of 3,040 cases met inclusion criteria. Conventional mechanical ventilation was used for lung rest in 88% of cases and high frequency ventilation was used in 12%. In the conventional mechanical ventilation group, 32% used positive end-expiratory pressure strategy of 4-6 cm H2O (low), 22% used 7-9 cm H2O (mid), and 43% used 10-12 cm H2O (high). High frequency ventilation was associated with an increased mean (SEM) hours of extracorporeal membrane oxygenation (150.2 [0.05] vs 125 [0.02]; p \u3c 0.001) and an increased mean (SEM) hours of mechanical ventilation after decannulation (135 [0.09] vs 100.2 [0.03]; p = 0.002), compared with conventional mechanical ventilation among survivors. Within the conventional mechanical ventilation group, use of higher positive end-expiratory pressure was associated with a decreased mean (SEM) hours of extracorporeal membrane oxygenation (high vs low: 136 [1.06] vs 156 [1.06], p = 0.001; mid vs low: 141 [1.06] vs 156 [1.06]; p = 0.04) but increased duration of mechanical ventilation after decannulation in the high positive end-expiratory pressure group compared with low positive end-expiratory pressure (p = 0.04) among survivors. CONCLUSIONS: Wide practice variation exists with regard to ventilator settings used for lung rest during neonatal respiratory extracorporeal membrane oxygenation. Use of high frequency ventilation when compared with conventional mechanical ventilation and use of low positive end-expiratory pressure strategy when compared with mid positive end-expiratory pressure and high positive end-expiratory pressure strategy is associated with longer duration of extracorporeal membrane oxygenation. Further research to provide evidence to drive optimization of pulmonary management during neonatal respiratory extracorporeal membrane oxygenation is warranted

Cultured Human Airway Epithelial Cells (Calu-3): A Model of Human Respiratory Function, Structure, and Inflammatory Responses

This article reviews the application of the human airway Calu-3 cell line as a respiratory model for studying the effects of gas concentrations, exposure time, biophysical stress, and biological agents on human airway epithelial cells. Calu-3 cells are grown to confluence at an air-liquid interface on permeable supports. To model human respiratory conditions and treatment modalities, monolayers are placed in an environmental chamber, and exposed to specific levels of oxygen or other therapeutic modalities such as positive pressure and medications to assess the effect of interventions on inflammatory mediators, immunologic proteins, and antibacterial outcomes. Monolayer integrity and permeability and cell histology and viability also measure cellular response to therapeutic interventions. Calu-3 cells exposed to graded oxygen concentrations demonstrate cell dysfunction and inflammation in a dose-dependent manner. Modeling positive airway pressure reveals that pressure may exert a greater injurious effect and cytokine response than oxygen. In experiments with pharmacological agents, Lucinactant is protective of Calu-3 cells compared with Beractant and control, and perfluorocarbons also protect against hyperoxia-induced airway epithelial cell injury. The Calu-3 cell preparation is a sensitive and efficient preclinical model to study human respiratory processes and diseases related to oxygen- and ventilator-induced lung injury

Association of Antipsychotic Use With Hospital Events and Mortality Among Medicare Beneficiaries Residing in Long-Term Care Facilities

Objective—Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. Design—Retrospective analysis using sequential multivariate Cox proportional hazards models. Setting—Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. Participants—A total of 2,363 LTC Medicare beneficiaries, 1999–2002. Measurements—Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. Results—AP use rose markedly from 1999 to 2002 (26.4%–35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors, AP use is not related to hospital events (hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.82–1.63 p = 0.7951). AP use is associated with reduced mortality in unadjusted and intermediate models, but loss of significance in the final model (HR = 0.83, 95% CI = 0.69–1.00, p = 0.0537) suggests that disease and drug burden factors may confound the AP-mortality relationship. Conclusion—This study provides no evidence of increased hospital events or mortality in LTC residents who use AP medications. Findings contribute to a growing body of evidence that APs, particularly atypical agents, may be associated with reduced mortality in LTC residents

Racial and ethnic disparities in treatment of dementia among Medicare beneficiaries

Objectives—Numerous studies have documented disparities in health care utilization between non-Hispanic White and minority elders. We investigated differences in anti-dementia medication use between non-Hispanic White and minority community-dwelling Medicare beneficiaries with dementia. Methods—Using multivariate analysis with generalized estimating equations, we estimated prevalence ratios (PRs) for anti-dementia medication use by race/ethnicity for 1,120 beneficiaries with dementia from years 2001 through 2003 of the Medicare Current Beneficiary Survey. Results—After adjusting for demographics, socioeconomics, health care access and utilization, comorbidities, and service year, we found that anti-dementia medication use was approximately 30% higher among non-Hispanic Whites compared to other racial/ethnic groups (PR = 0.73, 95% confidence interval [CI] = 0.59, 0.91). As for individual racial/ethnic groups, prevalence disparities remained significant for non-Hispanic Blacks (PR = 0.75, 95% CI = 0.57, 0.99) and non-Hispanic others (PR = 0.50, 95% CI = 0.26, 0.96) but were attenuated for Hispanics (PR = 0.84, 95% CI = 0.59, 1.20). Discussion—Results provide evidence that racial/ethnic disparities in utilization of drugs used to treat dementia exist and are not accounted for by differences in demographic, economic, health status, or health utilization factors. Findings provide a foundation for further research that should use larger numbers of minority patients and consider dementia type and severity, access to specialty dementia care, and cultural factors

The Effect of Supplemental Medical and Prescription Drug Coverage on Health Care Spending for Medicare Beneficiaries with Cancer

AbstractObjectivesTo examine whether patients with newly diagnosed cancer respond differently to supplemental coverage than the general Medicare population.MethodsA cohort of newly diagnosed cancer patients (n = 1,799) from the 1997-2007 Medicare Current Beneficiary Survey and a noncancer cohort (n = 9,726) were identified and matched by panel year. Two-year total medical care spending was estimated by using generalized linear models with gamma distribution and log link—including endogeneity-corrected models. Interactions between cancer and type of insurance allowed testing for differential effects of a cancer diagnosis.ResultsThe cancer cohort spent an adjusted $15,605 more over 2 years than did the noncancer comparison group. Relative to those without supplemental coverage, beneficiaries with employer-sponsored insurance, other private with prescription drug coverage, and public coverage had significantly higher total spending ($3,510, $2,823, and$4,065, respectively, for main models). For beneficiaries with cancer, supplemental insurance effects were similar in magnitude yet negative, suggesting little net effect of supplemental insurance for cancer patients. The endogeneity-corrected models produced implausibly large main effects of supplemental insurance, but the Cancer × Insurance interactions were similar in both models.ConclusionsMedicare beneficiaries with cancer are less responsive to the presence and type of supplemental insurance than are beneficiaries without cancer. Proposed restrictions on the availability of supplemental insurance intended to reduce Medicare spending would be unlikely to limit expenditures by beneficiaries with cancer, but would shift the financial burden to those beneficiaries. Policymakers should consider welfare effects associated with coverage restrictions

Intestinal transplantation in children under FK 506 immunosuppression

Intestinal transplantation, solitary (n = 3) or in combination with the liver (n = 7), was performed in 10 pediatric patients with intestinal failure. The liver was only replaced if there was liver failure and portal hypertension. Immunosuppression was based on FK 506. Two patients died, one of graft-versus-host disease and one of lymphoproliferative disease. One patient was still in the intensive care unit 1 month posttransplantation due to perioperative complications. The function of the intestinal grafts in the remaining patients is normal. All nutrition and medications including immunosuppression are being administered enterally. This series indicates that small bowel transplantation, alone or in combination with the liver, is feasible in pediatric patients. © 1993