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Deaton, the Mid-Life Crisis in America and Thoracic Transplantation


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Mandeep Mehra, MD, MBBS, FACC, FACP
Brigham & Women's Hospital
Boston, MA, USA
Mmehra@partners.org



Angus Deaton won the 2015 Nobel memorial prize in economic science for his work on the behavior of consumption and its effect on poverty and social ills [1]. In an incisive analysis of recent data from the Centers for Disease Control, Deaton and his wife, Ann Case, concluded that the gains in life expectancy from advances in the treatment of heart disease, cancer and infectious diseases had somehow eluded a significant sector of the US population - the non-Hispanic middle aged white population (age groups of 25-45 years) [2]. As it turns out, this group is tracking a disturbing increase in death rates from drug overdose, substance abuse and suicides. Naturally, one must ask why this trend is occurring and how its unintended consequences might manifest in our world of transplantation.

There is a drug crisis in America - Whether it relates to the abuse of prescription pain killers or illicit drugs like heroin, we are in the midst of a terrifying new epidemiology where the perils of physical disease have been supplanted by mental ill health in this vulnerable population. The non-college educated non-Hispanic white middle aged man or woman in America finds isolation and exclusion from the larger economy. Poor jobs, low wages, more physically demanding jobs with prospects of injury requiring prescription pain medications, lack of healthcare security and consistent pressures of their physical environment render them vulnerable assets for transitioning into more horrendous addictive states or leading them to contemplate suicides [3].

No wonder then, that Organ Procurement Organizations are reporting a marked increase in the rates of organ donations from decedents of drug overdose, illicit substance toxic effects or suicides [4]. Naturally, this creates an unintended opportunity in organ transplantation where we are offered such organs, often with variable placement rates. Due to the "high risk" nature of such donors, care providers and their patients are reluctant to accept these organs. Furthermore, donations after cardiac death may be more common among this subset of organ donors. So, what must we, as stewards of society, do?

Even as the political establishment, government and federal as well as state legislative authorities debate the solutions to this societal illness, we can at least honor the donor and their families by giving their organs a chance to inhabit a better life. Advances in organ care, recovery and transport systems as well as enhanced algorithms for retrieving thoracic organs from deceased donors represent an important mandate for study and development [5,6]. We are in the pre-maturation cycle for embedding these opportunities into our routine practice paradigm.

This is not a curiosity but an urgent mandate. Clearly, we must redouble our efforts in avoiding loss of organs from otherwise healthy and viable donors, simply on the premise of this defined "high risk", which in fact may be quite an acceptable risk in most situations. It is time that we confront this emerging epidemiology and develop solutions, together, in a scientifically rigorous but expedient manner.

So, I ask you all - What are YOU doing about it? ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2015/deaton-facts.html
  2. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83.
  3. G. Packer, The Unwinding: An Inner History of the New America (New York: Farrar, Straus and Giroux, 2013); and C. Murray, Coming Apart: The State of White America, 1960-2010 (New York: Crown Forum, 2012).
  4. https://www.thefix.com/content/heroin-overdoses-ohio-lead-spike-organ-donors
  5. Ardehali A, Esmailian F, Deng M, Soltesz E, Hsich E, Naka Y, Mancini D, Camacho M, Zucker M, Leprince P, Padera R, Kobashigawa J; PROCEED II trial investigators. Ex-vivo perfusion of donor hearts for human heart transplantation (PROCEED II): a prospective, open-label, multicentre, randomised non-inferiority trial. Lancet. 2015 Jun 27;385(9987):2577-84.
  6. Dhital KK, Iyer A, Connellan M, Chew HC, Gao L, Doyle A, Hicks M, Kumarasinghe G, Soto C, Dinale A, Cartwright B, Nair P, Granger E, Jansz P, Jabbour A, Kotlyar E, Keogh A, Hayward C, Graham R, Spratt P, Macdonald P. Adult heart transplantation with distant procurement and ex-vivo preservation of donor hearts after circulatory death: a case series. Lancet. 2015 Jun 27;385(9987):2585-91.



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