Validation of a nomogram to predict the risk of cancer in patients with intraductal papillary mucinous neoplasm and main duct dilatation of 10 mm or less.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is premalignant pancreatic lesion. International guidelines offer limited predictors of individual risk. A nomogram to predict individual IPMN malignancy risk was released, with good diagnostic performance based on a large cohort of Asian patients with IPMN. The present study validated a nomogram to predict malignancy risk and invasiveness of IPMN using both Eastern and Western cohorts. METHODS: Clinicopathological and radiological data from patients who underwent pancreatic resection for IPMN at four centres each in Eastern and Western countries were collected. After excluding patients with missing data for at least one malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum carcinoembryonic antigen and carbohydrate antigen (CA) 19-9 levels, and age). RESULTS: In total, data from 393 patients who fit the criteria were analysed, of whom 265 were from Eastern and 128 from Western institutions. Although mean age, sex, log value of serum CA19-9 level, tumour location, main duct diameter, cyst size and presence of mural nodule differed between the Korean/Japanese, Eastern and Western cohorts, rates of malignancy and invasive cancer did not differ significantly. Areas under the receiver operating characteristic (ROC) curve values for the nomogram predicting malignancy were 0·745 for Eastern, 0·856 for Western and 0·776 for combined cohorts; respective values for the nomogram predicting invasiveness were 0·736, 0·891 and 0·788. CONCLUSIONS: External validation of the nomogram showed good performance in predicting cancer in both Eastern and Western patients with IPMN lesions.

ANTECEDENTES: La neoplasia mucinosa papilar intraductal (intraductal papillary mucinous neoplasm, IPMN) es una lesión pancreática premaligna. Las guías internacionales incluyen un número limitado de factores predictivos de riesgo individual. Para predecir el riesgo individual de malignidad del IPMN se ha propuesto un nomograma con un buen rendimiento diagnóstico, basado en una gran cohorte de pacientes asiáticos con IPMN. Este estudio validó el nomograma para predecir el riesgo de cáncer y de invasión de la IPMN utilizando cohortes tanto orientales como occidentales. MÉTODOS: Se recogieron datos clínico-patológicos y radiológicos de pacientes en los que se realizó una resección de páncreas por IPMN en 4 centros en países orientales y en 4 centros de países occidentales. Se excluyeron los pacientes en los que en el nomograma faltaba ≥ 1 factor(es) predictivo(s) de malignidad (diámetro del conducto pancreático principal, tamaño del quiste, presencia de nódulo mural, niveles séricos de CEA y CA19-9, y edad). RESULTADOS: En total, se analizaron datos de 393 pacientes que cumplían con los criterios de inclusión, de los cuales 265 eran de centros orientales y 128 de centros occidentales. Aunque la edad media, el sexo, el valor logarítmico del nivel sérico de CA19-9, la localización del tumor, el diámetro del conducto principal, el tamaño del quiste y la presencia de un nódulo mural difirieron entre las cohortes de Corea/Japón y las cohortes oriental y occidental, las tasas de malignidad y de cáncer invasivo no fueron significativamente diferentes. Las áreas bajo la curva operativa del receptor (area under the receiver operating curve, AUC) que mostró el nomograma para predecir la malignidad fueron: cohorte oriental: 0,745; cohorte occidental: 0,856 y cohortes combinadas: 0,776; y para predecir la invasión tumoral fueron: cohorte oriental: 0,736; cohorte occidental: 0,891, y cohortes combinadas: 0,788. CONCLUSIÓN: La validación externa del nomograma mostró un buen rendimiento en la predicción de cáncer, tanto en pacientes orientales como occidentales con lesiones IPMN.

The influence of Ouabain on human dendritic cells maturation.

Although known as a Na,K-ATPase inhibitor, several other cellular and systemic actions have been ascribed to the steroid Ouabain (Oua). Particularly in the immune system, our group showed that Ouabain acts on decreasing lymphocyte proliferation, synergizing with glucocorticoids in spontaneous thymocyte apoptosis, and also lessening CD14 expression and blocking CD16 upregulation on human monocytes. However, Ouabain effects on dendritic cells (DCs) were not explored so far. Considering the peculiar plasticity and the importance of DCs in immune responses, the aim of our study was to investigate DC maturation under Ouabain influence. To generate immature DCs, human monocytes were cultured with IL-4 and GM-CSF (5 days). To investigate Ouabain role on DC activation, DCs were stimulated with TNF-α for 48 h in the presence or absence of Ouabain. TNF-induced CD83 expression and IL-12 production were abolished in DCs incubated with 100 nM Ouabain, though DC functional capacity concerning lymphocyte activation remained unaltered. Nevertheless, TNF-α-induced antigen capture downregulation, another maturation marker, occurred even in the presence of Ouabain. Besides, Ouabain increased HLA-DR and CD86 expression, whereas CD80 expression was maintained. Collectively, our results suggest that DCs respond to Ouabain maturating into a distinct category, possibly contributing to the balance between immunity and tolerance.

Subcutaneous abatacept versus intravenous abatacept: a phase IIIb noninferiority study in patients with an inadequate response to methotrexate.

OBJECTIVE: To compare the efficacy and safety of subcutaneous (SC) and intravenous (IV) abatacept. METHODS: In this phase IIIb double-blind, double-dummy, 6-month study, patients with rheumatoid arthritis (RA) and inadequate responses to methotrexate were randomized to receive 125 mg SC abatacept on days 1 and 8 and weekly thereafter (plus an IV loading dose [∼10 mg/kg] on day 1) or IV abatacept (∼10 mg/kg) on days 1, 15, and 29 and every 4 weeks thereafter. The primary end point for determining the noninferiority of SC abatacept to IV abatacept was the proportion of patients in each group meeting the American College of Rheumatology 20% improvement criteria (achieving an ACR20 response) at month 6. Other efficacy end points, immunogenicity, and safety were also assessed. RESULTS: Of 1,457 patients, 693 of 736 (94.2%) treated with SC abatacept and 676 of 721 (93.8%) treated with IV abatacept completed 6 months. At month 6, 76.0% (95% confidence interval 72.9, 79.2) of SC abatacept-treated patients versus 75.8% (95% confidence interval 72.6, 79.0) of IV abatacept-treated patients achieved an ACR20 response (estimated difference between groups 0.3% [95% confidence interval -4.2, 4.8]), confirming noninferiority of SC abatacept to IV abatacept. Onset and magnitude of ACR responses and disease activity and physical function improvements were comparable between the SC and IV abatacept-treated groups. The proportions of adverse events (AEs) and serious AEs over 6 months were 67.0% and 4.2%, respectively, in the SC abatacept-treated group and 65.2% and 4.9%, respectively, in the IV abatacept-treated group, with comparable frequencies of serious infections, malignancies, and autoimmune events between groups. SC injection site reactions (mostly mild) occurred in 19 SC abatacept (IV placebo)-treated patients (2.6%) and 18 IV abatacept (SC placebo)-treated patients (2.5%). Abatacept-induced antibodies occurred in 1.1% of SC abatacept-treated patients and 2.3% of IV abatacept-treated patients. CONCLUSION: SC abatacept provides efficacy and safety comparable with that of IV abatacept, with low immunogenicity and high retention rates, consistent with the established IV abatacept profile. Rates of injection site reactions were low. SC abatacept will provide additional treatment options, such as an alternative route of administration, for patients with RA.

Proteomic analysis of rat skeletal muscle submitted to one bout of incremental exercise.

Exercise can alter gene transcriptional and protein translational rates leading to changes in protein abundance toward adaptation to exercise. We investigated the alterations in protein abundance in skeletal muscle after one bout of an exhaustive exercise through proteomic analysis. Gastrocnemius muscles were sampled from non-exercised control rats and from rats exercised on a treadmill with incremental increases in speed until exhaustion (approximately 30 min). Rats were sacrificed 3 and 24 h after exercise cessation. Two-dimensional gel electrophoresis was performed and spots with a significant alteration in relative volume were identified by mass spectrometry. Six spots presented statistically significant altered abundances after exercise. The spots identified as the metabolic related proteins triosephosphate isomerase 1, glyceraldehyde-3-phosphate dehydrogenase, the ß subunit of pyruvate dehydrogenase E(1) and carnitine palmitoyltransferase 2 were all more abundant after exercise. One spot identified as heat shock cognate 70 was also more abundant after exercise. One spot demonstrated a decreased abundance after exercise and was identified as α-actin. These results suggest that a single session of exhaustive incremental exercise in untrained muscle can alter thin filaments synthesis/degradation rate and enhance cytosolic and mitochondrial proteins synthesis. The identified proteins may be important to a general preconditioning of skeletal muscle for subsequent exercise sessions.

Conservative Treatment of Chronic Pancreatitis: A Practical Approach.

BACKGROUND: Chronic pancreatitis is a long-standing, inflammatory condition of the pancreas that leads to the progressive damage and loss of function of pancreatic parenchyma and to the development of possible locoregional and systemic medical complications. MATERIALS AND METHODS: In this review, we tried to summarize the current evidence on non-surgical treatment trying to suggest a practical approach to the management of chronic pancreatitis. RESULTS: Besides the unclear pathophysiological mechanism and a poorly unknown epidemiology, chronic pancreatitis is a complex syndrome that displays different possible challenges for physicians. Despite being traditionally considered as a benign disease, chronic pancreatitis encompasses 10-year mortality rates which are superior to the ones reported for some of the most common cancers. CONCLUSIONS: Chronic pancreatitis encompasses the management of multiple and complex medical co-morbidities that needs to be understood and addressed in a multidisciplinary specialist context.

Ecophysiological traits of highly mobile large marine predators inferred from nucleic acid derived indices.

Nucleic acid-derived indices such as RNA/DNA ratios have been successfully applied as ecophysiological indicators to assess growth, nutritional condition and health status in marine organisms given that they provide a measure of tissue protein reserves, which is known to vary depending on changes in the environment. Yet, the use of these biochemical indices on highly mobile large predators is scarce. In this study, we tested the applicability of using nucleic acids to provide insights on the ecophysiological traits of two marine mammal species (common bottlenose dolphins and short-finned pilot whales) and explored potential related factors (species, sex, season, and residency pattern), using skin tissue (obtained from biopsy darts) of apparently healthy and adult free-ranging animals. Significantly higher RNA/DNA ratios were obtained for bottlenose dolphins (p < 0.001), and for visitor pilot whales when compared with resident pilot whales (p = 0.001). No significant changes were found between the sexes. Based on the percentile approach, the samples contain individuals in a general good condition (as the 10th percentile is not closer to the mean than the 75th percentile), suggesting that the studied region of Macaronesia may be considered an adequate habitat. The combination of this effective tool with genetic sexing and photographic-identification provided an overall picture of ecosystem health, and although with some limitations and still being a first approach, it has the applicability to be used in other top predators and ecosystems.

mCD14 expression in human monocytes is downregulated by ouabain via transactivation of epithelial growth factor receptor and activation of p38 mitogen-activated protein kinase.

BACKGROUND AND AIMS: The steroid ouabain is found in plasma and in many mammalian tissues, and is now considered as a hormone. In the immune system, ouabain regulates a number of lymphocyte functions, but little is known about its effects on monocyte function. Monocytes are important for adequate immune responses. The aim of this work was to analyze the effect of ouabain on mCD14 expression, a surface molecule involved in the response against Gram-negative bacteria and phagocytosis. METHODS: Human peripheral blood mononuclear cells obtained from healthy donors were separated by density gradient centrifugation. Monocytes were separated by adherence and treated for 24 h with 100 nM ouabain. mCD14, CD1a and P-p38 expression was analyzed by flow cytometry. Inhibitors of cell-signaling pathways, i.e. SB202190, reduced glutathione, rottlerin, tyrphostin A23, genistein, chelerythrine chloride, PD98059, PP1 and Ly 294002, were used concomitantly with ouabain to observe their effect on mCD14 expression. RESULTS: Ouabain induced a significant decrease in mCD14 expression. This feature was not related to receptor endocytosis or cell death. Furthermore, mCD14 downregulation did not reflect a shift in differentiation into dendritic cells because this hormone failed to induce CD1a expression. Amongst several inhibitors of cell-signaling pathways triggered by ouabain, only epidermal growth factor receptor (EGFR) and p38 mitogen-activated protein kinase (MAPK) inhibitors (tyrphostin A23 and SB202109) significantly reverted the effect of ouabain on mCD14 expression. Accordingly, the levels of P-p38 were increased on monocytes after ouabain treatment. However, incubation with epidermal growth factor did not alter mCD14 expression. CONCLUSION: These findings suggest that ouabain downregulates mCD14 expression on monocytes through EGFR transactivation and p38 MAPK activation.

BnP1, a novel P-I metalloproteinase from Bothrops neuwiedi venom: biological effects benchmarking relatively to jararhagin, a P-III SVMP.

Snake venom metalloproteinases (SVMPs) have been extensively studied and their effects associated with the local bleeding observed in human accidents by viper snakes. Representatives of P-I and P-III classes of SVMPs similarly hydrolyze extracellular matrix proteins or coagulation factors while only P-III SVMPs induce significant hemorrhage in experimental models. In this work, the effects of P-I and P-III SVMPs on plasma proteins and cultures of muscle and endothelial cells were compared in order to enlighten the mechanisms involved in venom-induced hemorrhage. To reach this comparison, BnP1 was isolated from B. neuwiedi venom and used as a weakly hemorrhagic P-I SVMPs and jararhagin was used as a model of potently hemorrhagic P-III SVMP. BnP1 was isolated by size exclusion and anion-exchange chromatographies, showing apparent molecular mass of approximately 24kDa and sequence similarity with other members of SVMPs, which allowed its classification as a group P-I SVMP. The comparison of local effects induced by SVMPs showed that BnP1 was devoid of significant myotoxic and hemorrhagic activities and jararhagin presented only hemorrhagic activity. BnP1 and jararhagin were able to hydrolyze fibrinogen and fibrin, although the latter displayed higher activity in both systems. Using HUVEC primary cultures, we observed that BnP1 induced cell detachment and a decrease in the number of viable endothelial cells in levels comparable to those observed by treatment with jararhagin. Moreover, both BnP1 and jararhagin induced apoptosis in HUVECs while only a small increase in LDH supernatant levels was observed after treatment with jararhagin, suggesting that the major mechanism involved in endothelial cell death is apoptosis. Jararhagin and BnP1 induced little effects on C2C12 muscle cell cultures, characterized by a partial detachment 24h after treatment and a mild necrotic effect as evidenced by a small increase in the supernatants LDH levels. Taken together, our data show that P-I and P-III SVMPs presented comparable effects except for the hemorrhagic activity, suggesting that hydrolysis of coagulation factors or damage to endothelial cells are not sufficient for induction of local bleeding.

Evaluation of research products released during a national project funded by the Italian Ministry of Health.

Evaluation of research products released during activities that have received public funds should be a mandatory practice. In this study, we evaluated the research products released during the research program "Innovative Strategies to Expand Cadaveric Donor Pool for Liver Transplantation" (SITF Project), funded by the Italian Ministry of Health. The SITF Project prefigured the participation of Italian transplantation centers with more advanced experience in the field of liver transplantation. The research products released during the SITF Project were evaluated according to Guidelines for Research Evaluation of the Committee for Evaluation of Research (CIVR) from the Italian Ministry of Education, University and Research. Thus, we considered as the research products released during the SITF Project the number of articles published in English language in peer-reviewed scientific journals by each operative unit (OU), as returned by PubMed. The articles were included on the basis of relationship with the research lines of the SITF Project and availability of the impact factor (IF) calculated by Thomson Scientific for each journal. Following these criteria, 62 research products were released during the executive phase of the SITF Project (January 1, 2004-December 31, 2005). All research products were original articles, with no reviews or letters. The articles were published in 10 different scientific journals (mean IF, 2.64+/-1.74). Spearman's rank test found a weak negative correlation between journal IF and number of published articles (r= -.2919; P= .413). Although the OU involved in the coordination of the SITF Project released a relatively high number of articles (n=8; IF, 0.923+/-0.352), several other OUs obtained better results for number of articles (9-11) and/or IF (3.071+/-2.248 or 2.959+/-1.779). In projects that benefit from public funds, the potential negative impact of coordination activities to scientific production should be adequately considered.

Evaluation of an information system for kidney transplantation in adult and pediatric recipients using the RAND/UCLA Appropriateness Method.

In the mid-1980s, RAND Corporation and University of California Los Angeles (UCLA) developed the RAND/UCLA Appropriateness Method (RAM) to evaluate the correctness of medical and surgical procedures. In this study, the RAND/UCLA Appropriateness Method was used to evaluate the appropriateness of a dataset concerning kidney transplantation in adult and pediatric recipients for an information system funded by the Italian Ministry of Health. The original dataset was obtained using an interdisciplinary pool of regional experts (n=60). This dataset held 514 items about kidney transplantation in adult (n=268) and pediatric (n=246) recipients. The items were stratified as 3 main groups: pretransplantation items (adult, n=141; pediatric, n=122), transplantation items (adult, n=49; pediatric, n=45), and early posttransplantation and follow-up items (adult, n=78; pediatric, n=79). In the second round, the dataset was subjected to an extraregional panel of independent experts (n=9) to assess each item using a score ranging from 1 to 9 based on increasing appropriateness. The expert-opinion process returned for adult and pediatric kidney recipient items whole mean scores of 8.52+/-0.32 and 8.65+/-0.32, respectively. Overall agreement, uncertainty, and disagreement between experts about item appropriateness concerning adult kidney recipients were 94.6%, 5.4%, and 0%, respectively. For pediatric kidney recipients, overall agreement, uncertainty, and disagreement between experts about item appropriateness were 96.9%, 2.35%, and 0.07%, respectively. This study supported the use of a structured expert-opinion process as an effective strategy to evaluate the appropriateness of large datasets for kidney transplantation in both adult and pediatric recipients.

Application of the RAND/UCLA Appropriateness Method to evaluate an information system for kidney/pancreas transplantation in adult recipients.

With the aim to evaluate the correctness of medical and surgical procedures, RAND Corporation and University of California Los Angeles (UCLA) developed the RAND/UCLA Appropriateness Method (RAM). In this study, the RAM was applied to evaluate the appropriateness of a dataset concerning kidney/pancreas transplantation in adult recipients for an information system funded by the Italian Ministry of Health. The original dataset was obtained using an interdisciplinary pool of experts (n=60) involved in kidney/pancreas transplantation activity in the Liguria Region. This dataset held 291 items, stratified as pretransplantation items (n=158), transplantation items (n=49), and early posttransplantation and follow-up items (n=84). In the second round, the dataset was subjected to an extraregional panel of independent experts (n=9) to assess each item using a score ranging from 1 to 9 based on increasing appropriateness. The expert-opinion process returned a whole mean score of 8.47+/-0.43 (95% confidence interval [CI] 8.30-8.63). Overall agreement, uncertainty, and disagreement between experts about item appropriateness were 98.5%, 1.49%, and 0%, respectively. Agreement/uncertainty for pretransplantation, transplantation, and posttransplantation items were 99.87%/0.12%, 100%/0%, and 96.37%/3.62%, respectively. This study supported the utility of a structured expert-opinion process as an effective strategy to evaluate the appropriateness of large datasets for kidney/pancreas transplantation in adult recipients.

Chronic dynamic exercise increases apolipoprotein A-I expression in rabbit renal cortex as determined by proteomic technology.

OBJECTIVE: We have shown previously that exercise training enhances endothelium-dependent and endothelium-independent vascular relaxation in rabbit kidney. This study aimed to investigate protein expression changes in the rabbit renal cortex induced by chronic dynamic exercise. DESIGN: Kidneys were obtained from New Zealand rabbits either confined to pens (n = 8) or trained on a treadmill (0% grade) for 5 days/week at a speed of 18 m/min for 60-min periods over 12 weeks (n = 8). Expression of proteins in the renal cortex was determined by colloidal Coomassie blue staining after two-dimensional polyacrylamide gel electrophoresis. Differential protein spots were excised and digested with trypsin, and peptides were sequenced by electrospray ionization-ion trap mass spectrometry. RESULTS: Two pairs of matching differentially stained spots displayed an approximate threefold increase in trained compared with sedentary animals. These four spots presented a molecular mass of 23 kDa but different pI values. Mass spectrometric analyses revealed the pairs of matching spots as being rabbit apolipoprotein A-I. CONCLUSION: Chronic dynamic exercise increases apolipoprotein A-I expression in the rabbit renal cortex. This fact could be involved in the alterations observed in the renal circulation after exercise training.

Cytosolic glutathione peroxidase from liver of pacu (Piaractus mesopotamicus), a hypoxia-tolerant fish of the Pantanal.

Pacu (Piaractus mesopotamicus Holmberg, 1887, Characiformes) dwells in waters of Pantanal, in which it has adapted for alternate concentrations of dissolved oxygen. Intracellular antioxidant protection should be vital for such an adaptation. Accordingly, we found that cytosol from liver of pacu has the highest antioxidant glutathione peroxidase activity so far reported for fish and murine species. To clarify whether this activity was due to a selenium independent glutathione S-transferase or to a glutathione peroxidase, we purified it and studied its kinetics. The substrates cumene hydroperoxide and hydrogen peroxide were promptly reduced by the enzyme, but peroxidized phosphatidylcholine had to undergo previous fatty acid removal with phospholipase A(2). Augmenting concentrations (from 2 to 6 mM) of reduced glutathione activated the pure enzyme. Curves of velocity versus different micromolar concentrations of hydrogen peroxide in the presence of 2, 4 or 8 mM reduced glutathione indicated that at least 2.5 mM reduced glutathione should be available in vivo for an efficient continuous destruction of micromolar concentrations of hydrogen peroxide by this peroxidase. Molecular exclusion HPLC and SDS-polyacrylamide gel electrophoresis indicated that the purified peroxidase is a homotetramer. Data from internal sequences showed selenocysteine in its primary structure and that the enzyme was a homologue of the type-1 glutathione peroxidase found in rat, bull, trout, flounder and zebra fish. Altogether, our data establish that in liver cells of pacu, a hypoxia-tolerant fish from South America, there are high levels of a cytosolic GPX-1 capable of quenching hydrogen peroxide and fatty acid peroxides, providing an effective antioxidant action.

Application of a Bayesian simulation model to a database for split liver transplantation on two adult recipients in the environment of WinBUGS (Bayesian Inference Using Gibbs Sampling).

A Bayesian simulation model has been applied to a database developed for split liver transplantation on two adult recipients (SLT A/A) in the context of a macroregional project funded by the Italian Ministry of Health. The model was entered within Bayesian inference Using Gibbs Sampling (WinBUGS), a free software for Bayesian analysis of complex statistical models using Markov chain Monte Carlo techniques developed by the MRC Biostatistics Unit Cambridge jointly with the Imperial College School of Medicine at St Mary's, London. The model was built by using data entry performed from January 1, 2005 to August 5, 2005. In that period, 20 potential donors suitable for the SLT A/A procedure were entered into the database. We only selected the continuous and dichotomous donor-related variables (DRV, n = 62) for which almost one data entry procedure. The model assumed that a database user learned during data entry procedures for each donor, and that the probability of a successful input may depend on the number of previous errors and corrections. After binary transformation of the DRV (value 0 for each input record, value 1 for each no input record), we calculated an overall value of 0.28 +/- 0.27 (median: 0.3; 95% confidence interval: from 0.18 to 0.629). The transformed DRV were entered within the WinBUGS environment after model specification, assuming as success (y = 1) each procedure of input record, and as failure (y = 0) each procedure of no input record. A unequivocal convergence was obtained after 10,000 iterations, and a simulation run was launched for a further 10,000 updates. We obtained a negligible Monte Carlo error and a fine profile in the kernel density plot. This study supported the application of simulation models to databases concerning liver transplantation as a useful strategy to identify a critical state in the data entry process.

A preliminary data entry analysis on a multicentric informative system for split liver transplantation in two adult recipients.

In the context of the national research program "Innovative Strategies to Expand Cadaveric Donor Pool for Liver Transplantation" (SITF project), funded by the Italian Ministry of Health, an experimental and multicentric Web-based information system was developed to automate theoretical matching between a potential donor and two adult recipients for in situ split liver transplantation (SLT A/A). Data entry in the SITF database was performed in addition to activities formally required for patient and donor management by national legislation and guidelines. Data entry carried out within the SITF database from January 1, 2005 to August 8, 2005 was processed by stratifying original variables as donor- and patient-related. Only records required for donor-recipients matching had a mandatory data entry. The donor subset showed data entry procedures in 62 variables for 20 potential donors, whereas in the patient subset, we found 28 variables for 100 potential liver recipients. In the donor subset, 1004 records were filled, for a raw completeness of 77.08%. After adjustment for appropriateness, there were 935 remaining records with an adjusted completeness of 76.64% (P = .823). In the patient subset, 2653 records were filled, for a raw completeness of 98.69%. No difference in patient subset records was found after rechecking for appropriateness. A significant difference occurred for adjusted completeness between the donor versus the patient subsets (P < .0001). The results of this study suggested that only the presence of mandatory donor records may produce a consistent database suitable for SLT A/A.

Application of the RAND/UCLA appropriateness method to evaluate an informative system for liver transplantation in adult and pediatric recipients.

The Delphi Method (DM) is the most frequently used technique to acquire structured expert-opinion elicitation (EOE). It has been increasingly applied to construct guidelines in medicine and to evaluate the appropriateness of clinical procedures. In this study, the RAND/UCLA appropriateness method was used as a structured EOE process to evaluate the appropriateness of a dataset concerning liver transplantation in adult and pediatric recipients for an information system funded by the Italian Ministry of Health. The original dataset was obtained using an interdisciplinary pool of regional experts (n = 60). This dataset held 280 items stratified into three groups: I. pretransplant items (n = 123); II. transplant items (n = 65); III. early posttransplant and follow-up items (n = 92). In the second DM round, the dataset was subjected to an extraregional panel of independent experts (n = 9) to assess a score ranging from 1 to 9 on each item based on increasing appropriateness, according to the RAND/UCLA Appropriateness Method. Overall agreement, uncertainty, and disagreement between experts was 95.89%, 3.12%, and 0.99%, respectively. For each group, agreement-uncertainty-disagreement were 99.35%/0.65%/0% (group I), 91.53%/5.30%/3.17% (group II), and 96.87%/3.13%/0% (group III), respectively. This study supported the use of a structured EOE process to evaluate the appropriateness of a large dataset for liver transplantation activity.

Split liver network: a collaborative internet-based scenario to expand the organ pool.

BACKGROUND: Split liver transplantation (SLT) has become a crucial option to maximize the liver pool, while organ procurement organizations (OPOs) usually allocate whole livers to single centers. In 2003, Italian Ministry of Health funded the Innovative Strategies to Expand Cadaveric Donor Pool for Liver Transplantation project with the goal to establish sharing criteria for SLT for two adults (SLT A/A), involving Italian transplantation centers, the North Italy Transplant OPO, and the Italian National Transplant Center. METHODS: SITF group defined donor/recipient inclusion criteria, setting minimum graft/recipient weight ratio (GRWR) at 1.2%. Donors and recipients on waiting list were shared on an Internet secured Web-based application (Split Liver Network [SLN]). SLN performs real-time matches between the registered donor and all patients on the bases of GRWR, displaying a size-based list of matched donor/patients, figuring hemiliver allocation once the whole organ is referred to a specific center. RESULTS: In the 2005 period, 47 donors and 124 patients were entered by nine centers, and six hemiliver allocations for three SLT A/A procedures were performed. By retrospective simulation of 32 donors and 613 recipients in the Nord Italia Transplant area, matchable recipients were available for all donors, while blood group frequency seemed a determining factor, more than donor body weight. COMMENTS: SLN hemiliver allocation might increase matching possibilities, offering a timely transplant for recipients of rare group, small-size, or in need of short wait. Our experience suggests that such an environment may be helpful to share a macroregional pool of liver recipients and to optimize SLT.

Medical report type in liver transplantation as a quality system document: new prospects for computerization.

The usage of a computerized system to organize data and ease the activity procedures of liver transplantation is useful in clinical transplantation. Preliminary cognitive research on systems of clinical transplantation database concerning medical reports was performed to verify their development level. The survey highlighted that, so far, there has been no experimentation that can be applied to a medical report type devoted to liver transplantation. Regulations in force substantially point out that the medical report ought to contain all items that have to be taken into account in handling the patient from pretransplantation to follow-up. The Department of Transplantation of Genoa chose its medical report model for liver transplantation. The medical report model included the following items: personal data; case history; diagnosis; initial examination for prelisting; fitness for transplantation; assistance context; clinical data including subjective, objective, and instrumental parameters; pharmacological therapies; informed consent, evaluation of fitness; nursing data; counseling and clinical evaluations according to protocols and guidelines of the national transplantation centers. If the computing is well trained, it is supposed to help maintain a whole data view provided it is supplied information in an adequate way. Immediate clinical procedural advantages and useful scientific observations may be obtained from a high-quality database. In fact, all functions have to be applied to specific clinical, administrative needs to be remotely shared and conveniently integrated with each other to make the liver transplantation medical report an easy and handy instrument for inputting and handling data. It must be a precise, complete instrument that may be accessible in real time from any site connected with the intranet network, be unchangeable, and be protected to ensure certification and forensic medicine value.

Reproductive phenology of Mauritia flexuosa L. (Arecaceae) in a coastal restinga environment in northeastern Brazil.

The buriti, Mauritia flexuosa, is the most common palm in Brazil, where it has considerable ecological and economic importance. However, few data are available on the phenology of the species, mainly in coastal restinga ecosystems. The present study monitored the reproductive phenology of M. flexuosa in the restinga of Barreirinhas, in the Brazilian Northeast, and investigated the relationship between phenophases and climatic variables. The presence/absence of flowers and fruits was recorded monthly in 25 individuals of each sex between August, 2009, and October, 2012. There was no difference in the phenology of male and female specimens, with flowering and fruiting occurring exclusively in the dry season. We believe that the specific abiotic characteristics of the study environment, such as the intense sunlight and availability of water in the soil, contribute to the reproductive success of M. flexuosa in the dry season, with consequent germination and establishment of seedlings occurring during the subsequent rainy season.