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.