IMPORTANCE During the coronavirus disease 2019 pandemic, there may be too few ventilators to meet medical demands. It is unknown how many US states have ventilator allocation guidelines and how these state guidelines compare with one another. OBJECTIVE To evaluate the number of publicly available US state guidelines for ventilator allocation and the variation in state recommendations for how ventilator allocation decisions should occur and to assess whether unique criteria exist for pediatric patients. EVIDENCE REVIEW This systematic review evaluated publicly available guidelines about ventilator allocation for all states in the US and in the District of Columbia using department of health websites for each state and internet searches. Documents with any discussion of a process to triage mechanical ventilatory support during a public health emergency were screened for inclusion. Articles were excluded if they did not include specific ventilator allocation recommendations, were in draft status, did not include their state department of health, or were not the most up-to-date guideline. All documents were individually assessed and reassessed by 2 independent reviewers from March 30 to April 2 and May 8 to 10, 2020. FINDINGS As of May 10, 2020, 26 states had publicly available ventilator guidelines, and 14 states had pediatric guidelines. Use of the Sequential Organ Failure Assessment score in the initial rank of adult patients was recommended in 15 state guidelines (58%), and assessment of limited life expectancy from underlying conditions or comorbidities was included in 6 state guidelines (23%). Priority was recommended for specific groups in the initial evaluation of patients in 6 states (23%) (ie, Illinois, Maryland, Massachusetts, Michigan, Pennsylvania, and Utah). Many states recommended exclusion criteria in adult (11 of 26 states [42%]) and pediatric (10 of 14 states [71%]) ventilator allocation. Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%). CONCLUSIONS AND RELEVANCE These findings suggest that although allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur. Guidelines among states, including adjacent states, varied significantly and could cause inequity in the allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.

Background. Biome depletion, or loss of biodiversity from the ecosystem of the human body, is a major "evolutionary mismatch" underlying a variety of inflammatory diseases in Western populations. Enhancing biodiversity via exposure to helminths has effectively treated immune diseases in a variety of experimental animal models and in a few published studies involving human subjects. Purpose. This study probes another untapped resource for helminthic therapy: the methods and outcomes reported by individuals currently self-treating with helminths. Procedures. Helminth providers were interviewed, surveys were collected from self-treaters, and publically available information was compiled. Results. More than 250 anecdotal experiences of self-treatment were assessed, and the total number of individuals worldwide currently self-treating was estimated at between 6,000 and 7,000. A wide range of inflammationrelated diseases, including inflammatory bowel disease, allergies, and autoimmunity, were effectively treated. Conclusions. This study finds that the therapy is being refined through experience and is now expanding to treat widespread neuropsychiatric problems such as depression, anxiety, migraine headaches, bipolar disorder, and perhaps Parkinson's disease.

Living donor liver transplantation (LDLT), originally used in children with left lateral segment grafts, has been expanded to adults who require larger grafts to support liver function. Most adult LDLT procedures have been performed with right lobe grafts, and this means a significant risk of morbidity for the donors. To minimize the donor risk for adults, there is renewed interest in smaller left lobe grafts. The smaller graft size increases the recipient risk in the form of small-for-size syndrome (SFSS) and essentially transfers the risk from the donor to the recipient. We review the donor and recipient risks of LDLT and pay particular attention to the different types of liver grafts and the use of graft inflow modification to ameliorate the risk of SFSS. Finally, a new metric is proposed for quantifying the recipient benefit in exchange for a specific donor risk. Liver Transpl 19:472-481, 2013. V C 2013 AASLD.Received September 27, 2012; accepted January 9, 2013.Early efforts in living donor liver transplantation (LDLT) focused on left lateral segment (LLS) grafts in pediatric recipients because they were initially disadvantaged on the waiting list. 1 The LLS donor operation yields a graft with more than enough liver mass for an infant recipient. The relatively small size of LLS grafts can lead to liver dysfunction in adult recipients, so larger left lobe (LL) and right lobe (RL) grafts are commonly used. These larger grafts are associated with increased donor risk. There is a renewed interest in using smaller grafts to minimize donor risk. The use of smaller grafts, with their potential for lower donor risk but higher recipient risk, can be viewed as shifting risk from the donor back to the recipient. This review examines the tradeoff of donor and recipient risk associated with the donation and transplantation of smaller grafts, attempts to quantify that risk, and discusses ways to ameliorate it through graft inflow modification (GIM). COMPETING RISKSThe recipient benefit from LDLT is well documented, with 83% survival 5 years after transplantation. 2 Recipients with access to living donors have a shorter time to transplantation than patients awaiting cadaveric donors, and they have better outcomes when both the waiting-list mortality and posttransplant mortality are considered. The risk of death for a recipient of LDLT is 56% of the risk for a patient who does not have a living donor and either undergoes deceased donor liver transplantation (DDLT) or remains on the waiting list. For hepatocellular carcinoma (HCC) patients with a Model for End-Stage Liver Disease Abbreviations: DDLT, deceased donor liver transplantation; HCC, hepatocellular carcinoma; GIM, graft inflow modification; GW/ RW, graft weight/recipient weight; GW/SLV, graft weight/standard liver volume; ICU, intensive care unit; LDLT, living donor liver transplantation; LL, left lobe or left lobectomy or left hepatectomy; LLS, left lateral segment or left lateral segmentectomy; MELD, Model for End-Stage Liver Disease; PVF, portal venous flow; PVP...

Industrialized society currently faces a wide range of non-infectious, immune-related pandemics. These pandemics include a variety of autoimmune, inflammatory and allergic diseases that are often associated with common environmental triggers and with genetic predisposition, but that do not occur in developing societies. In this review, we briefly present the idea that these pandemics are due to a limited number of evolutionary mismatches, the most damaging being ‘biome depletion’. This particular mismatch involves the loss of species from the ecosystem of the human body, the human biome, many of which have traditionally been classified as parasites, although some may actually be commensal or even mutualistic. This view, evolved from the ‘hygiene hypothesis’, encompasses a broad ecological and evolutionary perspective that considers host-symbiont relations as plastic, changing through ecological space and evolutionary time. Fortunately, this perspective provides a blueprint, termed ‘biome reconstitution’, for disease treatment and especially for disease prevention. Biome reconstitution includes the controlled and population-wide reintroduction (i.e. domestication) of selected species that have been all but eradicated from the human biome in industrialized society and holds great promise for the elimination of pandemics of allergic, inflammatory and autoimmune diseases.