BackgroundRace influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies.Methods and ResultsMembers of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation.ConclusionsBlack race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.

IMPORTANCE Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. OBJECTIVE To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. EXPOSURE Randomization to clinical vignettes. MAIN OUTCOMES AND MEASURES Thematic differences in allocation of advanced therapies by patient race and gender. RESULTS Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. (continued) Key Points Question Is bias against a patient's gender and race associated with the allocation of advanced heart failure therapies? Findings In a qualitative study of 46 health care professionals, there was more bias against women compared with men when evaluating appearance and social support, particularly among African American women. Fina...

INTRODUCTION: The prevalence of cirrhosis is increasing despite advances in therapeutics, and it remains an expensive medical condition. Studies examining the healthcare burden of inpatient cirrhosis-related care regardless of etiology, stage, or severity are lacking. This study aims to describe the current drivers of cost, length of stay (LOS), and mortality in hospitalized patients with cirrhosis. METHODS: Using the National Inpatient Sample (NIS) data from 2008 to 2014, we categorized admissions into decompensated cirrhosis (DC), compensated cirrhosis (CC), and NIS without cirrhosis. Descriptive statistics and regression analysis were used to analyze the association between patient characteristics, comorbidities, complications, and procedures with costs, LOS, and mortality in each group. RESULTS: The hospitalization costs for patients with cirrhosis increased 30.2% from 2008 to 2014 to $7.37 billion. Cirrhosis admissions increased by 36% and 24% in the DC and CC groups, respectively, compared with 7.7% decrease in the NIS without cirrhosis group. DC admissions contributed to 58.6% of total cirrhotic admissions by 2014. Procedures increased costs in both DC and CC groups by 15%–152%, with mechanical ventilation being associated with high cost increase and mortality increase. Complications are also key drivers of costs and LOS, with renal and infectious complications being associated with the highest increases in the DC group and infections and nonportal hypertensive gastrointestinal bleeding for the CC group. DISCUSSION: Economic burden of hospitalized patients with cirrhosis is increasing with more admissions and longer LOS in DC and CC groups. Important drivers include procedures and portal hypertensive and nonportal hypertensive complications.

Several studies have demonstrated the negative effects of clearcutting on terrestrial plethodontid salamander populations. However, none has experimentally compared clearcutting with multiple alternative timber-harvest methods. Using a randomized, replicated design, we compared the short-term effects (1-4 years after harvest) of clearcutting to effects of leavetree, group selection, and two shelterwood cuts on terrestrial salamanders in the southern Appalachian Mountains of Virginia and West Virginia (U.S.A.). Treatment plots were 2 ha each. We also compared salamander age class (percent juvenile), fecundity (percentage of females carrying eggs and average number of eggs per gravid female), size of gravid females, and species composition and diversity between treatments with canopy removal ( cut ) and those without canopy removal ( uncut). All treatments with canopy removal had significantly fewer salamanders than the control treatment, but salamander abundances on alternative treatments with canopy removal did not differ significantly from salamander abundances on the clearcuts. There were no significant differences between cut and uncut treatments in the proportion of females that were gravid or in the average number of eggs in gravid females; however, gravid Plethodon cinereus females weighed more on the cut treatments and gravid Desmognathus ochrophaeus females weighed more on uncut treatments. There were no significant differences between cut and uncut treatments in the proportion of the sample that was juvenile, except in the largest species tested, P. glutinosus , which had a significantly higher proportion of juveniles in the uncut treatments. We conclude that initial declines in terrestrial plethodontid abundance caused by timber harvesting may be minimized across the landscape by concentrating high-intensity timber harvesting ( clearcutting ) in small areas ( a few hectares in size ). Efectos Iniciales de la Tala Rasa y de Prácticas Silvícolas Alternativas sobre la Abundancia de Salamandras TerrestresResumen: Varios estudios han demostrado los impactos negativos de la tala rasa sobre poblaciones de salamandras pletodóntidas terrestres. Sin embargo, ninguno ha comparado experimentalmente la tala rasa con múltiples métodos alternativos de cosecha de madera. Utilizando un diseño aleatorio, replicado, comparamos los efectos a corto plazo (1-4 años postcosecha) de la tala rasa con los efectos de prácticas silvícolas alternativas sobre salamandras terrestres en el sur de las montañas Apalaches en Virginia y Virginia del Oeste (E.U.A.). Las parcelas de tratamiento eran de 2 ha cada una. También comparamos la clase de edad de salamandras (porcentaje de juveniles), fecundidad (porcentaje de hembras con huevos y promedio de huevos por hembra grávida), tamaño de hembras grávidas y composición de especies y diversidad entre tratamientos con remoción de dosel (corte) y sin remoción de dosel (sin corte). Todos los tratamientos con remoción de dosel tuvieron un número significativamente menor de salamandras que el con...

Carpal and MCP/MTP joint injuries are an important cause of morbidity in Thoroughbred racehorses. Identification of modifiable risk factors for these injuries may reduce their incidence.

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Use of non‐invasive sources of DNA, such as hair or scat, to obtain a genetic mark for population estimates is becoming commonplace. Unfortunately, with such marks, potentials for genotyping errors and for the shadow effect have resulted in use of many loci and amplification of each specimen many times at each locus, drastically increasing time and cost of obtaining a population estimate. We proposed a method, the Genotyping Uncertainty Added Variance Adjustment (GUAVA), which statistically adjusts for genotyping errors and the shadow effect, thereby allowing use of fewer loci and one amplification of each specimen per locus. Using allele frequencies and estimates of genotyping error rates, we determined, for each pair of specimens, the probability that the pair was obtained from the same individual, whether or not their observed genotypes match. Using these probabilities, we reconstructed possible capture history matrices and used this distribution to obtain a population estimate. With simulated data, we consistently found our estimates had lower bias and smaller variance than estimates based on single amplifications in which genotyping error was ignored and that were comparable to estimates based on data free of genotyping errors. We also demonstrated the method on a fecal DNA data set from a population of red wolves (Canis rufus). The GUAVA estimate based on only one amplification genotypes compares favorably to the estimate based on consensus genotypes. A program to conduct the analysis is available from the first author for UNIX or Windows platforms. Application of GUAVA may allow for increased accuracy in population estimates at reduced cost.

The North Cascades (Nooksack) elk (Cervus elaphus) population declined during the 1980s, prompting a closure to state and tribal hunting in 1997 and an effort to restore the herd to former abundance. In 2005, we began a study to assess the size of the elk population, judge the effectiveness of restoration efforts, and develop a practical monitoring strategy. We concurrently evaluated 2 monitoring approaches: sightability correction modeling and mark-resight modeling. We collected data during February-April helicopter surveys and fit logistic regression models to predict the sightability of elk groups based on group and environmental variables. We used an information-theoretic criterion to compare 9 models of varying complexity; the best model predicted sightability of elk groups based on 1) transformed (log 2 ) group size, 2) forest canopy cover (%), and 3) a categorical activity variable (active vs. bedded). The sightability model indicated relatively steady and modest herd growth during 2006-2011, but estimates were less than minimum-known-alive counts. We also used the logit-normal mixed effects (LNME) mark-resight model to generate estimates of total elk population size and the sizes of the adult female and branch-antlered male subpopulations. We explored 15 LNME models to predict total population size and 12 models to predict subpopulations. Our results indicated individual heterogeneity in resighting probabilities and variation in resighting probabilities across sexes and some years. Model-averaged estimates of total population size increased from 639 (95% CI ¼ 570-706) in spring 2006 to 1,248 (95% CI ¼ 1,094-1,401) in 2011. We estimated the adult female subpopulation increased from 381 (95% CI ¼ 338-424) in spring 2006 to 573 (95% CI ¼ 507-639) by 2011. The branch-antlered male subpopulation estimates increased from 87 (95% CI ¼ 54-119) to 180 (95% CI ¼ 118-241) from spring 2006 to spring 2011. The LNME model estimates were greater than sightability model estimates and minimum-known-alive counts. We concluded that mark-resight performed better and was a viable approach for monitoring this small elk population and possibly others with similar characteristics (i.e., small population and landscape scales), but this approach requires periodic marking of elk; we estimated mark-resight costs would be about 40% greater than sightability model application costs. The utility of sightability-correction modeling was limited by a high proportion of groups with low detectability on our densely forested landscape. ß 2012 The Wildlife Society.