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This article highlights trends and changes in lung and heart-lung transplantation in the United States from 1999 to 2008. While adult lung transplantation grew significantly over the past decade, rates of heart-lung and pediatric lung transplantation have remained low. Since implementation of the lung allocation score (LAS) donor allocation system in 2005, decreases in the number of active waiting list patients, waiting times for lung transplantation and death rates on the waiting list have occurred. However, characteristics of recipients transplanted in the LAS era differed from those transplanted earlier. The proportion of candidates undergoing lung transplantation for chronic obstructive pulmonary disease decreased, while increasing for those with pulmonary fibrosis. In the LAS era, older, sicker and previously transplanted candidates underwent transplantation more frequently compared with the previous era. Despite these changes, when compared with the pre-LAS era, 1-year survival after lung transplantation did not significantly change after LAS inception. The long-term effects of the change in the characteristics of lung transplant recipients on overall outcomes for lung transplantation remain unknown. Continued surveillance and refinements to the LAS system will affect the distribution and types of candidates transplanted and hopefully lead to improved system efficiency and outcomes.

This article highlights trends in heart transplantation from 1998 to 2007, using data from the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR). The number of candidates actively awaiting heart transplantation has declined steadily, from 2525 in 1998 to 1408 in 2007, a 44% decrease. Despite this decline, a larger proportion of patients are listed as either Status 1A or 1B, likely secondary to increased use of mechanical circulatory support. During this time, the overall death rate among patients awaiting heart transplantation fell from 220 to 142 patients per 1000 patient-years at risk; this likely reflects better medical and surgical options for those with end-stage heart failure. This trend was noted across all racial groups, both sexes, all disease etiologies (retransplantation excepted) and all status groups. Recipient numbers were relatively stable over the past decade. In 2007, 2207 transplants were performed, although the proportion of patients transplanted as Status 1A shifted from 34% to 50%. A trend toward transplanting more patients above 65 years of age was seen. Adjusted patient (and graft) survival at 3 months, 1, 5 and 10 years after transplantation has gradually, but significantly, improved during the same period; current patient survival estimates are 93%, 88%, 74% and 55%, respectively.

This article highlights trends and changes in lung and heart-lung transplantation in the United States from 1998 to 2007. The most significant change over the last decade was implementation of the Lung Allocation Score (LAS) allocation system in May 2005. Subsequently, the number of active wait-listed lung candidates declined 54% from pre-LAS (2004) levels to the end of 2007; there was also a reduction in median waiting time, from 792 days in 2004 to 141 days in 2007. The number of lung transplants performed yearly increased through the decade to a peak of 1 465 in 2007; the greatest single year increase occurred in 2005. Despite candidates with increasingly higher LAS scores being transplanted in the LAS era, recipient death rates have remained relatively stable since 2003 and better than in previous years. Idiopathic pulmonary fibrosis became the most common diagnosis group to receive a lung transplant in 2007 while emphysema was the most common diagnosis in previous years. The number of retransplants and transplants in those aged > or =65 performed yearly have increased significantly since 1998, up 295% and 643%, respectively. A decreasing percentage of lung transplant recipients are children (3.5% in 2007, n = 51). With LAS refinement ongoing, monitoring of future impact is warranted.

The Organ Procurement and Transplantation Network (OPTN) Kidney Committee is considering a proposal for a new deceased donor kidney allocation system. Among the components under consideration is a strategy to rank candidates in part by the estimated incremental years of life that are expected to be achieved with a transplant from a specific available deceased donor, computed as the difference in expected median lifespan with that transplant compared with remaining on dialysis. This concept has been termed life years from transplant or LYFT. Median lifespans could be calculated, based on objective medical criteria, for each candidate when a deceased donor kidney becomes available, based on Cox regression models using current candidate and donor medical information. The distribution of the calculated LYFT scores for an average nonexpanded criteria donor kidney is similar across candidate sex, race/ethnicity, insurance status and, with the exception of diabetes, diagnosis. LYFT scores tend to be higher for younger candidates and lower for diabetics receiving a kidney-alone rather than a simultaneous kidney-pancreas transplant. Prioritizing candidates with higher LYFT scores for each available kidney could substantially increase total years of life among both transplant candidates and recipients. LYFT is also a powerful metric for assessing trends in allocation outcomes and for comparing alternative allocation systems.

This article highlights trends in heart and lung transplantation between 1997 and 2006, drawing on data from the OPTN and SRTR. The total number of candidates actively awaiting heart transplantation declined by 45% over the last decade, dropping from 2414 patients in 1997 to 1327 patients in 2006. The overall death rates among patients awaiting heart transplantation declined over the same period. The distribution of recipients among the different status groups at the time of heart transplantation changed little between the inception of the new classification system in 1999 and 2005. Deaths in the first year after heart transplantation have steadily decreased. At the end of 2006, 2885 candidates were awaiting a lung transplant, up 10% from the 1997 count. The median time-to-transplant for listed patients decreased by 87% over the decade, dropping from 1053 days in 1997 to 132 days in 2006. Selection for listing and transplantation has shifted toward more urgent patients since the May 2005 implementation of a new lung allocation system based on survival benefit and urgency rather than waiting time. Only 31 heart-lung transplants were performed in 2006, down from a high of 62 in 1997.

This article examines the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients data on heart and lung transplantation in the United States from 1996 to 2005. The number of heart transplants performed and the size of the heart waiting list continued to drop, reaching 2126 and 1334, respectively, in 2005. Over the decade, post-transplant graft and patient survival improved, as did the chances for survival while on the heart waiting list. The number of deceased donor lung transplants increased by 78% since 1996, reaching 1407 in 2005 (up 22% from 2004). There were 3170 registrants awaiting lung transplantation at the end of 2005, down 18% from 2004. Death rates for both candidates and recipients have been dropping, as has the time spent waiting for a lung transplant. Other lung topics covered are living donation, recent surgical advances and changes in immunosuppression regimens. Heart-lung transplantation has declined to a small (33 procedures in 2005) but important need in the United States.

This article reviews the development of the new U.S. lung allocation system that took effect in spring 2005. In 1998, the Health Resources and Services Administration of the U.S. Department of Health and Human Services published the Organ Procurement and Transplantation Network (OPTN) Final Rule. Under the rule, which became effective in 2000, the OPTN had to demonstrate that existing allocation policies met certain conditions or change the policies to meet a range of criteria, including broader geographic sharing of organs, reducing the use of waiting time as an allocation criterion and creating equitable organ allocation systems using objective medical criteria and medical urgency to allocate donor organs for transplant. This mandate resulted in reviews of all organ allocation policies, and led to the creation of the Lung Allocation Subcommittee of the OPTN Thoracic Organ Transplantation Committee. This paper reviews the deliberations of the Subcommittee in identifying priorities for a new lung allocation system, the analyses undertaken by the OPTN and the Scientific Registry for Transplant Recipients and the evolution of a new lung allocation system that ranks candidates for lungs based on a Lung Allocation Score, incorporating waiting list and posttransplant survival probabilities.

Murray and Tsiatis (1996) described a weighted survival estimate that incorporates prognostic time-dependent covariate information to increase the efficiency of estimation. We propose a test statistic based on the statistic of Pepe and Fleming (1989, 1991) that incorporates these weighted survival estimates. As in Pepe and Fleming, the test is an integrated weighted difference of two estimated survival curves. This test has been shown to be effective at detecting survival differences in crossing hazards settings where the logrank test performs poorly. This method uses stratified longitudinal covariate information to get more precise estimates of the underlying survival curves when there is censored information and this leads to more powerful tests. Another important feature of the test is that it remains valid when informative censoring is captured by the incorporated covariate. In this case, the Pepe-Fleming statistic is known to be biased and should not be used. These methods could be useful in clinical trials with heavy censoring that include collection over time of covariates, such as laboratory measurements, that are prognostic of subsequent survival or capture information related to censoring.

We address four major issues related to physicians' fear of litigation: What are physicians' attitudes and beliefs toward malpractice? To whom or what do they attribute the "malpractice crisis"? Is fear of litigation associated with demographic and practice variables? What measures do physicians take to reduce risk? Hospital physicians in a southeastern health science center were surveyed (N = 356). Physicians attributed the malpractice crisis to circumstances outside medicine and beyond their control, perceived some patients as suitprone, and reported altering their practice to avoid being sued. Litigation fear was associated with physicians who were female, younger, not board certified, less clinically experienced, more clinically active, defendants in prior lawsuits, and in high-risk specialties. Physicians who were especially fearful of litigation placed less value in risk-management techniques. The findings are important in understanding how the prospect of litigation is perceived by physicians and how that perception may affect medical practice.

The frequency of symptoms of depression and selected health-related practices and events was measured in a sample of 572 students at a large midwestern university. Students reported many symptoms of depression, with women experiencing depression more often and to a greater degree than men. Depression was significantly correlated with 17 of the 22 practices and states of affect examined, but uncorrelated with certain health-related activities commonly identified with poor emotional well-being. Both the determinants and manifestations of depression among university students require further in-depth investigation. Implications for health professionals and other university personnel are discussed.