Telemedicine conferencing is expected to become commonly used internationally. However, national reports on internationally related telemedicine are limited, and related activities and challenges in each country are unclear. In this study, we aimed to clarify the current status and barriers to international telemedicine conferencing in Japan.The questionnaire was sent to the Internationalization Project Team (I-PT) representatives in all 43 Japanese National University Hospitals. The total of 167 assigned staff comprised 86 medical staff in charge of internationalization (MI) and 81 technical staff in telemedicine (TT).The response rate was 93% (40/43 universities) from 88 staff (44 MI and 44 TT). Most respondents (75%) stated that they had not been active in international telemedicine conferencing during the past 3 years, although a videoconferencing system was installed in 93% of universities. A total of 65% respondents felt that barriers to promoting telemedicine and conferencing existed. Most (43%) respondents reported staff shortage as the most serious barrier overall. Five TT (19%) felt that the most serious barrier was difficulty with English communication, although no MI selected this as a barrier. More MI than TT felt that technical issues were the most serious barrier .International telemedicine conferencing was found to be insufficiently active in I-PT of Japan, although the installed equipment and technical expertise of TT seemed adequate. This indicates that merely assigning MI and TT to an I-PT is not enough and that improved cooperation between both MI and TT at each university hospital is needed. Establishment of a structured international telemedicine center in each university hospital is to be suggested to accelerate the activities in Japan. At the same time, the coronavirus disease 2019 (COVID-19) pandemic has greatly influenced human activities with substantial, speedy changes in the style of local and international conferences, from face-to-face meetings to videoconferencing (VC).7 Telemedicine conferencing, which connects international hospitals via VC, enables health care professionals to consult with other health experts around the world, with no travel costs and greatly reduced time requirements.With a view toward the Tokyo Olympic Games, which have been postponed until 2021, Japan is now in a crucial stage of internationalization.8 reported the contribution of tele-educational programs in rebuilding the medical system in Kosovo after a decade of war had destroyed the region's health and education systems. Those authors reported activities, including hosting remote lectures and telesurgeries, from 20 countries. Ho et al.9 reported the usefulness of case teleconferences among leading hospitals in the Asia Pacific region for upgrading treatment with gastrointestinal endoscopy. Shimizu et al.10 reported the effectiveness of live demonstrations given by worldwide experts from their own hospitals, which avoided the time and costs of travel to the transmitting hospitals, and the risks of performing in an unfamiliar environment, such as with unfamiliar medical equipment and staff. National surveys have also been conducted of telemedicine in domestic telehealth expansion12 and medical school curricula.14 However, there are a limited number of research reports specifically regarding internationally related telemedicine activities. Therefore, the level of such activities, as well as the challenges in each country, has been unclear.For example, by attending international case conferences, knowledge and skills, such as how to manage rare diseases and how to control emerging infectious diseases such as COVID-19, can be immediately and safely acquired. In addition, live demonstrations make it possible to view advanced surgical techniques conducted by world-leading experts. Therefore, these telecommunication tools are expected to continue to be more commonly used by health care professionals in the settings of medical education and internationalization. Hoxha et al.15 One aim of the I-PT was to strengthen cooperation with overseas medical institutions through the development and use of information and communications technology (ICT), to establish a world-leading remote medical educational network. Toward this aim, all 43 Japanese national university hospitals assigned staff to one of two roles: (1) medical staff in charge of internationalization (MI) and (2) technical staff in telemedicine (TT).Under the leadership of the National University Hospital Council of Japan, an Internationalization Project Team (I-PT) was established in 2012.17 few reports exist that summarize activities in Japan overall. Therefore, the activities and challenges in international telemedicine conferencing for Japanese hospitals remain unclear. In this study, we aimed to clarify the current status and barriers to international telemedicine conferencing in the National University Hospital Council of Japan, on the basis of past I-PT activities.Although there have been reports on the adoption of international telemedicine conferencing in Japan,Participants in this study were I-PT members in all 43 Japanese national university hospitals. In total, 167 staff were included: 86 MI and 81 TT. We developed a questionnaire regarding characteristics, activities, technical resources, and barriers to international telemedicine conferencing at the hospitals. The questionnaire was created using Google Forms  and was sent via e-mail separately to MI and TT in September 2019. Each university hospital was requested to provide at least one completed questionnaire from both an MI and a TT. The MI questionnaire consisted of 28 questions and the TT questionnaire comprised 43 questions in total. Excerpted questions are shown in The survey response rate was 93% . A total of 88 staff (44 MI and 44 TT) completed the questionnaire. Nearly all  MI were faculty professors and medical doctors (MDs). TT included faculty professors (not MDs) , information technology (IT) staff , faculty professors (MDs) , and administrative staff . Nearly all respondents  reported that less than 20% of their time was dedicated to telemedicine  stated they had not implemented any international programs or did not know whether a program had been implemented in their institution during the past 3 years. The remaining 25% of respondents (22/88), representing 13 university hospitals , had implemented programs in a variety of medical subspecialties such as surgery, neurology, ophthalmology, infectious diseases, and public health. Regarding counterpart countries, most university hospitals  had conducted telemedicine conferencing activities with other Asian countries.VC systems were installed in 93% (37/40) of university hospitals. As for technical skills, 93% of respondents (41/44) had experience in computer operations, audiovisual equipment operation , and VC system operation ; more than half  had experience with network device settings. However, only 30% (13/44) reported a high level of experience with communication in English  stated that barriers existed to promoting international telemedicine conferencing at their university hospitals. The most serious barrier was a shortage of staff such as doctors and engineers , followed by not being sure how to begin , technical issues , and communication in English . No respondents reported policy issues as the most serious barrier . Here, activities (+) and (−) were grouped based on if they had carried out international telemedicine conferencing in the past 3 years, respectively. However, no one in the activity (+) group selected “not sure how to start,” which was the second leading barrier in the activity (−) group . The response “technical issues” was the second-most commonly selected  in the activity (+) group; only one (1/37) respondent in the activity (−) group selected this as the most serious barrier ; however, more MI reported not being sure how to begin  and technical issues  as the barriers. In contrast, 19% (5/27) of TT stated that English communication was the most serious problem, whereas no MI reported this. Difficulty working after hours and on holidays was the third-most common barrier selected by TT (3/27), but only one MI selected this response  in 68% (27/40) of universities were not actively engaged in international telemedicine conferencing, despite this being set as an important goal by the National University Hospital Council of Japan. The results demonstrated the efficiency of technical resources, such as VC systems installed in nearly all institutions. Most TT only had experience in basic skills required to implement telemedicine conferencing, which most (65%) felt was a barrier to promoting international telemedicine conferencing at their hospitals, and which seemed to be the cause of the low level of related activities.The shortage of staff, such as doctors and engineers, was selected as the most serious barrier to international telemedicine conferencing by most survey respondents. MI and TT are in charge of such activities at university hospitals; however, the average reported percentage of time dedicated to telemedicine and telecommunication was less than 20%. MI and TT mainly work in other roles, such as in clinical care and medical research among MI, and management of electronic health record systems and administrative procedures among TT. As a result, there are few human resources available for telemedicine activities.19 Although these training programs are recommended to be included in medical school curricula, this remains uncommon. A 2016 national survey of all 19 medical schools in Australia revealed that the curricula do not include e-health programs.13 In France, telemedicine education and training are limited in medical schools, even though 90% of deans agree with its importance.14Although not selected by any respondents in the activity (+) group, being unsure how to begin was the second-most common response selected by the activity (−) group. Therefore, this barrier must be resolved to engage in telemedicine activities. Conducting seminars for beginners and inviting them to participate in pilot programs may be one solution. Inviting beginners to participate in existing training programs will be also effective, such as Project Echo, which provides a variety of training programs in telemedicine.20 Therefore, many users are now able to set up and control VC on their own.22 However, technical issues can easily occur in international telemedicine conferencing, depending on the available networks and equipment.24 This issue can be resolved with appropriate technical support. Tomimatsu et al.25 reported that the presence of technical staff prevented technical issues in large multiparty medical videoconferences. The responses of TT indicated no problems with respect to equipment and technical experience; this must be the reason why only one (4%) TT selected this item as the most serious barrier. However, more MI  chose this item as the most serious barrier, which shows that there is a distinction between MI and TT in terms of technical issues.Technical issues were the second-most commonly reported barrier in the activity (+) group. Recently, the usability of VC has improved and it has become relatively easier than in the past.English communication was the second-most commonly reported barrier in the TT group, although no MI considered this a problem. Many physicians who belong to university hospitals often partake in conversations in English, for example, at an international congress; however, most IT and administrative staff have no such experience. When establishing VC connections, technical communication between technical staff and overseas partners is mainly conducted in English. Therefore, if TT can receive support with translation, technical setup and implementation of VC should work more smoothly. English communication skills have become an important evaluation criterion for technical personnel. If needed, providing language support from other staff in the hospital is also recommended.26Working after hours or on weekends was the third-most serious barrier in the TT group. When working with people in other countries, working outside of normal hours may be required owing to time differences. However, most MI did not report this as the most serious barrier. One reason is that technical staff must work longer than participants during teleconferences as they perform activities such as setup and connectivity testing before a conference, and dismantlement of equipment after a conference. Another reason is that working hours among Japanese physicians are longer than those in other occupations, so overtime may not be regarded as a barrier for MI.This was the third-most commonly reported barrier in the activity (−) group, even though no one selected this in the activity (+) group. To implement international telemedicine conferencing, collaboration between many different staff participants is needed, such as physicians, nurses, technical staff, administrators, and international coordinators. Therefore, it is important to decide the roles of each of these diverse staff members, which might become a barrier. Furthermore, it is difficult to start something new, especially in a large organization such as a university hospital.Our results concerning barriers to international telemedicine conferencing showed that the current system, which only assigns MI and TT to the I-PT, is inadequate to promote international telemedicine conferencing in Japanese university hospitals. The differences in barriers considered most problematic among MI and TT indicated a lack of collaboration between MI and TT. Therefore, strengthening cooperation between both groups is needed, not by establishing two different roles but rather by establishing an “international telemedicine center” at each university hospital and assigning both MI and TT to be involved in the related activities. In this way, many of the reported barriers could be resolved. For example, the barrier of technical issues among MI could be resolved by providing technical support from TT, and the English language and working hour barriers could be addressed by obtaining translation and incentives from MI and university hospitals, respectively. Collaboration within each university hospital can be improved if the international telemedicine center plays a central role in coordinating the activities of a variety of hospital staff.27 Although their telemedicine center was not intended for international remote educational purposes and not exactly the same as ours, the current situation is similar in many Japanese national university hospitals as there are no dedicated departments and staff for international telemedicine conferencing. Therefore, such projects may be carried out in isolation and not made transparent to all departments and staff.As an example, researchers at the Mayo Clinic in the United States reported difficulties in sharing information among telemedicine projects, as these projects had been developed within individual departments. The Mayo Clinic established a center for telemedicine as a dedicated department, and provider satisfaction was increased with fewer technical issues.29This study has some limitations. Although the study was conducted regarding the I-PT, the responsibility of the representatives differed by institution. Furthermore, respondents' dedication to telemedicine was less than 20% in nearly all cases; therefore, this study was based on limited information. However, the I-PT plays a unique role in promoting international telemedicine conferencing at national university hospitals, so summarizing the current status among I-PT members should be the first step in understanding the situation of international telemedicine conferences in Japan. At least one person from each university hospital was requested to complete the survey, so the results may include individual bias of respondents. Another limitation is that the questionnaire only provided simple response options. More thorough analysis should be performed using qualitative study methods. Moreover, statistical analysis is needed. The status regarding international telemedicine conferencing before the COVID-19 pandemic has been summarized in this article. However, the situation post-COVID-19 would be different as staff in medical institutions have been forced to shift to greater use of online communication.30 analyzed the current status of internationalization in Japanese medical education and pointed out the extremely limited output toward foreign countries, although input, such as “translationalism” with an open mindset for international trends, has been developing in Japan. Hence, greater mutual collaboration with foreign countries is suggested for Japanese medical staff and students. Health care professionals worldwide are now in serious need of communication with other countries to exchange information on controlling COVID-19. ICT allows us to communicate locally and globally with no risk of infection. In the future, more medical institutions will communicate using ICT, nationally and internationally, which will contribute to internationalization of health care and medical professionals in Japan.Japan has been said to be one of the slowest countries to adopt internationalization. Saiki et al.In this study, we clarified the current status and barriers to international telemedicine conferencing in Japan, using questionnaires administered to MI and TT of the I-PT, National University Hospital Council of Japan. International telemedicine conferencing is not sufficiently active in Japan, even though the installed equipment and technical expertise of TT are adequate. Barriers to promoting such activities were clarified, such as staff shortages, being unsure how to begin, technical issues, and difficulty with communication in English. Furthermore, a lack of collaboration between MI and TT was revealed. Establishment of an international telemedicine center is suggested, to address insufficient collaboration between these groups and to promote international telemedicine conferencing activities at national university hospitals in Japan.


In the 10 years since its founding, the Israel Journal of Health Policy Research has established itself as an important voice in Israeli and international health policy. The Journal’s ability to combine national and international perspectives on key issues in health services delivery and health systems analysis has developed a valuable new arena for academic research about the increasingly complex post-COVID future of health care systems. Journals sit at the very heart of the entire academic enterprise. They are essential not just for individual academics to demonstrate their intellectual acumen, but also, and more importantly, to document and transmit core intellectual knowledge among contemporary and future researchers and practitioners. Successful journals help define our understanding of what is true, and help shape academe’s continually emerging assessment of what further knowledge we require to understand the policy phenomena we confront.This essential function is particularly important in the complex multi-disciplinary arena that is health policy. Composed of widely varying academic disciplines , with different, and often divergent, structural environments in different national sometimes within-country regional health delivery arrangements, subject to the complexities of varying national political systems and political cultures, health policy is even more dependent on strong, well-edited, and well-managed journals. Every academic knows the rare pleasure of discovering a smart new journal that publishes important new thinking in the field and that, perhaps, they can publish in themselves.The arrival of the Israel Journal of Health Policy Research was such an event. The Journal has grown in breadth, depth, and, consequently, stature throughout its 10 year history, resulting in what is now an important international as well as national voice in the increasingly complex COVID-driven policy environment that developed country health systems now confront. Faced with the necessity of re-assessing and re-evaluating their core regulatory and operational arrangements, countries from Sweden , 3 and SAcademic journals are not easy enterprises to develop, however. They are notoriously difficult to start, to staff, and to steer in an effective and successful manner. That developmental process takes enormous organizational, intellectual, and sometimes physical fortitude, much of it long before the outcome can be known. The Israel Journal wisely positioned itself strategically astride both the rapidly developing Israeli health policy world, and the broader policy debates across Europe and North America.Initial international discussions about the proposed journal’s focus were held at a meeting of the International Advisory Committee of the Israel National Health Policy Institute, held during its widely attended Global Conference on Health Policy. Suggestions from senior academics from organizations like the European Observatory on Health Systems and Policies, the World Bank, University College London, London School of Hygiene and Tropical Medicine, and other major research institutions in Europe and the United States helped shape the international component of the new journal. Many of these individuals later contributed commentaries or articles as the Journal took form, strengthening its scope and reach, and confirming the wisdom of the founding editors’ combined domestic and international vision.It is to the great credit of the Journal’s editors and sponsors that it has come so far so fast. Those of us in the international community who have worked with them look forward to continuing this wonderful interaction in the coming years.


This research examines the moderating role of gender on the adoption of online payment systems (OPS). It also explores the impact of using OPS on the performance of SMEs in an emerging economy, using the Technology Acceptance Model (TAM) and Resource-Based View (RBV). The results indicate that male SME owners (entrepreneurs) are more likely to focus on perceived usefulness, whereas female SME entrepreneurs are more likely to focus on perceived ease of use while adopting OPS, according to data obtained from 302 SMEs in Bangladesh through face-to-face surveys. The results also report that the use of OPS has a considerable positive effect on SMEs' performance. The study's findings will add to the scarce research on the impact of using OPS on business performance in the context of SMEs in emerging economies, in addition to enhancing the OPS adoption literature from a gendered lens. In the last few years, the rapid diffusion of the internet has played a major role in individual and business practises , let alone the implications of such adoption. Using this as a backdrop, this study examines the adoption of OPS and its impact on company performance in Bangladeshi SMEs.Majority of the existing literature focuses on the factors that impact the adoption of OPS  in emerging economies? Second, does the use of OPS impact SME performance in emerging economies?The remainder of the paper is organised as follows. In the section “Literature Review and Research Framework,” I review existing literature to aggregate different independent, dependent, and moderator variables used in different papers to build my research model. The research strategy, data collection, measurements, and analysis method used for the study are explained in the section “Research Methodology.” The results are presented in the section “Results.” My research findings, implications for future research, and limitations of my study are provided in the section “Discussion and Conclusion.”The TAM's central idea is that a person's attitude toward technology is influenced by both perceived usefulness (PU) and perceived ease of use (PEU). Technology usage is determined by a person's behavioural intention (BI) to use it, which differs from the notion of reasoned action in that it is considered as being mediated by the person's attitudes toward utilising it  Davis, . To get H1: Entrepreneurs' perceived ease of use (PEU) positively influences their behavioural intention (BI) of adopting the online payment systems in their SMEs.Men are thought to adopt and use technology more extensively than women, who are considered passive consumers; yet, the number of women customers using e-payment systems has increased dramatically recently  toward entrepreneurs' adoption of the online payment systems in their SMEs.The degree to which a person believes that employing a certain technology would improve their performance is described as perceived usefulness  positively influences their behavioural intention (BI) of adopting the online payment systems in their SMEs.H4: Gender moderates perceived usefulness (PU) toward entrepreneurs' adoption of the online payment systems in their SMEs.Ong and Lai  note varAs per the above discoveries, I suggest the following hypothesis:H5: Entrepreneurs' behavioural intention (BI) of adopting the online payment systems positively influences their use of the online payment systems in their SMEs.This paper is grounded in the Resource-based View (RBV hereafter) because RBV has emerged as a very popular theory for explaining firm performance over the last three decades Newbert, . As per Because competitive advantages are difficult to quantify   and the other 50% from Khulna city . The surveyed SMEs were chosen randomly from the databases of relevant Chambers of Commerce and Industries of two different cities of Bangladesh. These cities have major socio-economic and infrastructure contrasts, and they exhibit rural-urban dynamism, which is relevant to Bangladesh's entrepreneurial eco-system. Agriculture, retailing, crafts, readymade garments, knitwear, infrastructure, healthcare, media, etc., are among the industries represented. I also took around 50% of the samples of female-owned firms and the other 50% male-owned firms. Three hundred and two face-to-face surveys with the key informant person (founder of the SMEs) in each SME were conducted from August to October 2018.A semi-structured questionnaire containing both closed and open-ended questions was used to collect data. In June of 2018, 350 SMEs were contacted, and the foundersIndustry/Sector Categorisation of the collected data is provided in The associated graphs related to Industry/Sector Categorisation are given in The list of variables used in this research is given in It is mentionable here that the female was coded as 0 and the male as 1 for the measurement of gender (moderator).Data has been analysed by applying STATA using Bivariate Analysis (Pearson Correlation Coefficient) and Multiple Hierarchical Regression Analyses. This research is divided into two sections. While the first section examines online payment system adoption via the perspective of TAM, the second part uses RBV to investigate the impact of such adoption (use) on performance. Thus, utilising structural equation modelling (for TAM-related hypotheses) and hierarchical regression analysis, the following hypotheses are investigated in the context of SMEs in Bangladesh in order to serve the research's goals (for RBV related hypothesis). Please see The results of hypotheses testing are provided below see .The above table shows that Gender moderated relationships of PEU and PU to behavioural intention lead to the use of the online payment system (OPS) at the SMEs in Bangladesh see . In PEU According to the findings of the hierarchical regression, there is a significant positive association between the use of online payment systems and the performance of SMEs. Moreover, hierarchical regression has been used in analysing the moderating impact of gender on OPS use and SME performance relationship see .All control and independent variables are significantly correlated with the dependent variable, with the exception of location, and there is no multicollinearity (checked by Pearson correlation coefficient and VIF tests).This study was meant to explore the moderating role of gender on the relationship between the online payment system and SME performance in Bangladesh. The research findings support that both Perceived ease of use and Perceived usefulness of OPS has a positive influence on the adoption of OPS in SMEs in Bangladesh. It was also found that the adoption of OPS has a positive influence on the use of OPS in SMEs in Bangladesh. Moreover, it was found that the use of OPS impacts SME performance positively in Bangladesh. Prior research findings  to achieve economic growth. Bangladesh is an emerging economy with a large number of SMEs. Bangladesh's government is devoted to utilising ICT's capacity to aid the country's economic growth and to establishing “Digital Bangladesh.” To this end, Bangladesh's government should revise its ICT policy and continue and enhance measures such as eliminating all taxes on computer hardware, providing interest-free loans to ICT (software) companies, and launching pro-ICT initiatives, grants, incentives, and motivational programmes to encourage the use of ICT in various sectors of the economy.The development of human resources, particularly women inside SMEs, is a critical component in achieving the goal of a “Digital Bangladesh.” This can be done through lowering training costs, which can be done through a variety of policy instruments. To develop internal knowledge and skills at the firm level, public policies should provide incentives for businesses to invest in their employees' training and specialisation.Acknowledging certain limitations, the study suggests numerous directions for future research. First and foremost, the research was quantitative. As a result, future researchers may choose to use qualitative research methodologies to uncover more in-depth discoveries that will add to the body of knowledge.Though OPS is important to conduct transactions in this pandemic-ridden world, this paper did not relate the implication of the study to the pandemic. This paper looks at the research question in a pre-pandemic period as the data has been collected at that time. OPS in the pandemic ridden world can definitely be the area of research in some future papers.The data for this study was collected from Bangladeshi SMEs. To obtain more robust research results, future researchers may utilise a cross-country sample technique.These studies have explored the impact of Perceived ease of use and Perceived usefulness of TAM. However, other elements of the TAM model were not considered in the study. For instance, technology affordability, trust, privacy, and security are associated with technology adoption. The reason for this is this study was conducted in the context of Bangladesh, and a few studies  in the different business sectors. In this way, more light can be shed on which business sectors the OPS has more positive impacts on firms' performances and which sectors gender plays a more important role.The raw data supporting the conclusions of this article will be made available by the authors upon request.The studies involving human participants were reviewed and approved by Essex University. The patients/participants provided their written informed consent to participate in this study.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Interlocking of intramedullary nails is a challenging procedure in orthopedic trauma surgery. Numerous methods have been described to facilitate this process. But they are exposed patient and surgical team to X-rays or involves trial and error. An accurate and non-invasive method has been provided to easily interlocking intramedullary nails. By transferring a safe visible light inside the nail, a drilling position appears which use to drilling bone toward the nail hole. The wavelength of this light was obtained from ex-vivo spectroscopy on biological tissues which has optimal transmission, reflectance, and absorption properties. Moreover, animal and human experiments were performed to evaluate performance of the proposed system. Ex-vivo performance experiments were performed successfully on two groups of cow and sheep samples. Output parameters were procedure time and drilling quality which there were significant differences between the two groups in procedure time (P < 0.05). But no significant differences were observed in drilling quality (P > 0.05). Moreover, an In-vivo performance experiment was performed successfully on a middle-aged man. To compare the provided method, targeting-arm, and free-hand techniques, two human experiments were performed on a middle-aged and a young man. The results indicate the advantage of the proposed technique in the procedure time (P < 0.05), while the drilling quality is equal to the free-hand technique (P = 0.05). Intramedullary nail holes laser indicator is a safe and accurate method that reduced surgical time and simplifies the process. This new technology makes it easier to interlocking the intramedullary nail which can have good clinical applications. Moreover, holes locations of the intramedullary nail are unknown which adds to the deformation problem9. Numerous techniques for interlocking screw insertion have been proposed to optimize number of drilling and operation time and avoid ionizing radiation exposure11. However, these techniques have not gained widespread clinical application. Other methods are based on fluoroscopy that called free-hand technique (FH) or based on a special device designed for this purpose, knows as targeting-arm devices (TAD)15. Fluoroscopy is a high-cost operation in which patients and the surgical team are exposed to X-ray. Targeting device is a time-consuming process that involves trial and error17.Intramedullary nailing is one of the most common surgical operations for fixation of long bone fractures. Nail deformation affects the accuracy of distal interlocking of the intramedullary nails (IMN) which is a common procedure in tibia and femoral fractures18. In addition to the risk of X-ray exposure, there is still the possibility of error due to the slipping and flag and grid displacement. Computer‐aided IMN localization techniques were also introduced which representing a significant reduction in fluoroscopic process time for interlocking screw insertion in a high-cost procedure22. Robotic techniques were also proposed in which a robotic system is utilized to drilling and installing fixation screws, requiring a large robot in the operating room representing a high cost, cumbersome, and X-ray-based method25. Naked‐eye 3D AR enables observation of the surgical path by costly and cumbersome equipment29. Electro-Magnetic (EM) and laser navigation systems can increase surgical accuracy without any X-ray exposure, but with excessive electrical noise causing large magnetic‐field distortion resulting in unstable tracking paths38. Moreover, the tracking accuracy is degraded with increasing distance of sensor and EM transmitter. This method is time-consuming and requires installation of various equipment39. Augmented fluoroscopy can decrease radiation exposure, surgical time, and simplify the distal interlocking process. But the patient and the surgical team are exposed to X-ray and it is a high-cost procedure42.To reduce the high risk of X‐ray exposure, increases surgical accuracy, and accelerate the interlocking procedure, significant progress has been developed. The flag and grid technique increases the accuracy of intramedullary nailing by displaying the position of nail holes relative to the flag and grid in fluoroscopic imagesIn this work, have been developed a non-invasive optical method for easy determining IMN holes position inside the bone canal utilizing a safe laser system with a safe visible wavelength that possesses proper transmittance, reflectance, and absorbance properties in human tissues. In order to find the optimized wavelength, Ex-Vivo spectroscopy experiments were performed on animal tissues i.e. on two groups of cow and sheep in the visible range of electromagnetic spectrum. Two parameters which are procedure time and drilling quality, are selected as the merit criteria which proves the acceptable performance of our proposed method. Then an In-Vivo performance experiment performed on a middle-aged man with a desired outcomes. To compare the provided method, targeting-arm, and free-hand techniques, two human experiments were performed on a middle-aged and a young man. The results indicate the advantage of the proposed technique. Intramedullary nail holes laser indicator is introduced here as a simple, non-invasive, and safe tool that reduces surgical time and simplifies the process. The presented Ex-Vivo and In-Vivo results pave the way for development of an effective and safe intramedullary nailing process in clinical applications.In this study have been proposed a novel radiation-free technique, using laser light to target the cross lock of the IMN. To achieve optimal wavelength, transmittance and reflectance spectroscopy of biological tissues were performed. Then, IMN holes laser indicator was made based on spectroscopy results. Animal and human tests were performed to evaluate the performance of the proposed technique. Figure We performed Ex-Vivo spectroscopy of biological tissues including bone, fat, tendon, muscle, and skin. Samples were prepared in dimensions of 30 × 30 ± 2 mm and 2–4 mm thickness from cow and sheep legs which were supplied from the Zarrinshahr slaughterhouse, Iran. Two homemade spectroscopy setups were utilized: one for obtaining the reflectance spectrum  was performed inside the tibia bone, and distal locking was done three times using the laser intramedullary nail holes indicator. Figure Output parameters were procedure time and drilling quality. The procedure time as one of the performance parameters is defined as the total time needed between determining the position of the IMN hole and checking the screw insertion. Another performance parameter is the drilling quality which is evaluated as follows: 3 points for successful operation and if the drill does not hit the nail, 2 points for successful operation but with a slight collision with the nail,1 point for severe interference of the drill with nail , 0 point in case of failure. Mean value, standard deviation, and p-value were calculated for both the procedure time, and drilling quality. Paired t-tests were used to compare these performance parameters for cows' and sheep`s samples considering α = 0.05.The evaluation was performed on a middle-aged man with an acute tibia and fibula fracture of the distal area of the right leg. The study was approved by the ethics committee of the Shohada Lenjan Hospital, Iran, in January 2020. Also, informed consent was obtained from participants and the study was performed under relevant guidelines and regulations. Figure Intramedullary nailing was performed using a tibia nail and three locking screws . By utilizing the IMN holes laser indicator, finding drilling position, incisions skin, and drilling toward the IMN hole performed in a dark surgery room. Then, fastening the locking screw was performed in the natural light of the surgery room. Distal and proximal interlocking performed successfully for one hole in the distal area and two holes in the proximal area with no errors. Figure Interlocking was performed for the tibia bone of a middle-aged man with the left leg fracture using a TAD . The study was approved by the ethics committee of the Shohada Lenjan Hospital, Iran, in September 2021. Also, informed consent was obtained from participants and the study was performed under relevant guidelines and regulations.The IMN was fixed by three fixation screws. The distal interlocking process was performed by two locking screws which encountered errors while the proximal interlocking performed successfully. Figure . The patient was a young man with an acute tibia and fibula fracture of the distal area of the left leg. The surgery team was used X-ray protective lead clothes with a thyroid shield collar. The study was approved by the ethics committee of the Shohada Lenjan Hospital, Iran, in October 2021. Also, informed consent was obtained from participants and the study was performed under relevant guidelines and regulations.Interlocking of the IMN was done by a c-arm device Three fixation screws were used for the interlocking of the IMN. By controlling the movement direction of the drill under X-ray emission, no severe interference occurred between the drill and IMN. Figure Ex-Vivo spectroscopy was performed on biological tissues in the visible range of electromagnetic spectrum. The optical properties of animal tissues of bone, tendon, muscle, skin, and fat were investigated. The transmitted and reflected spectra are shown in Fig. Animal experiments were performed on 10 samples in two group, including 5 sheep legs and 5 cow legs. For each sample, intramedullary nailing performed inside the tibia bone, and distal locking was done three times using laser intramedullary nail holes detector. The output parameters were procedure time and drilling quality shows in Tables Intramedullary nailing was performed for the tibia bone on a middle-aged man. The IMN holes laser indicator used in the dark conditions of the surgery room to interlocking IMN. First, one hole was interlocked in the distal area, and then two holes were interlocked in the proximal area. The interlocking process was successful and there were no errors. The output parameters, the procedure time and the drilling quality are shown in Tables Four fixation screws were inserted in the IMN using the TAD. The distal interlocking process encountered errors while the proximal interlocking performed successfully. For the first and second holes at the distal area of the nail, the drilling position was changed 4 and 3 times, respectively. While for two holes in the proximal area of the nail, the drilling process was performed while the drill did not hit the nail. The output parameters are shown in Tables Interlocking of the IMN was done by four fixation screws using a c-arm device. The movement direction of the drill was controlled under X-ray emission. So, no severe interference occurred between the drill and IMN. But the procedure time was increased comparing using the IMN holes laser indicator device and TAD. Although the surgery team was used X-ray protective lead clothes with a thyroid shield collar, the X-ray emission isn`t ineffective on their health especially the patient. The output parameters, the procedure time and the drilling quality are shown in Tables 43. Changes amount of blood in the tendon vessels can affect the fluorescence spectra45. It may result from α and β attenuation signals due to the absorption capacity of the hemoglobin concentration47. Moreover, different amounts of fluorescent coenzyme concentration in cow and sheep samples have a great effect on the transmitted intensity. The muscle transmitted and reflected spectra are clearly related to its dark red color. The sample of sheep`s skin has a lighter brown color than cows according to its reflectance diagrams. Fat also illustrates an almost flat reflectance, like the bone spectrum regards to its white color.According to the results of spectroscopy of biological tissues, for higher wavelength, higher transmittance is obtained. Due to the white colour of bone, a uniform reflectance is observed on the visible spectral range. Regards to the denser bone of cow, it illustrates lower transmittance. Two dips in wavelengths of 540 nm and 576 nm with a distance of 36 nm in the reflectance spectrum of sheep tendon and two dips in wavelengths of 490 nm and 536 nm, with a distance of 46 nm in the reflectance spectrum of cow samples are observed. These dips can be related to the effect of blood absorption on the endogenous fluorescence signal intensity of biological tissuesTherefore, the optimized wavelength of 680 nm is selected for the IMN holes laser indicator. In addition to low transmittance in lower wavelengths and thus a mitigated performance of the device, the highest absorbance makes these wavelengths unsafe for tissues and organs.There is a significant difference in the overall procedure time  between the two groups. But there isn`t a significant difference in drilling quality  between the two groups. The overall procedure time obtained for sheep samples compared to the cow samples is less. It`s due to the larger dimensions of the cow's leg than the sheep's. Cow's leg has larger dimensions and thicker, denser tissues than sheep's leg. So cutting tissues and drilling the bone procedures takes more time. If we compare the sheep's leg to an immature human's leg being, and the cow's leg to an adult human's leg being. It can be said that the nailing procedure for an adult compared to an immature human takes more time.41. The overall procedure time on cow samples obtained 120.333 ± 33.047 s using the IMN holes laser indicator. The time obtained is about 260.047 s less than the video-augmented fluoroscopy, and about 258.427 s less than the conventional fluoroscopy. Using the IMN holes laser indicator, the procedure time can be reduced compared to fluoroscopy techniques. It`s an X-ray-free technique. While in free hand technique, the patient and the surgical team are exposed to X-ray radiation. However, the fluoroscopy technique can evaluate the reliability and validation of the fracture healing methods50.Weidert et al., during an intramedullary nailing study performed on cow legs, reported 378.76 ± 101.10 s for conventional fluoroscopy (free hand technique), and 380.38 ± 165.11 s for video-augmented fluoroscopyThere aren`t any significant differences in drilling quality between sheep and cow samples (p > 0.05). For sheep samples, 11 holes interlocked successfully without drill impact with the nail, and 4 holes interlocked successfully with a slight collision with the nail. Moreover, in cow samples, 10 holes interlocked successfully without drill impact with the nail, and 5 holes interlocked successfully with a slight collision with the nail. This small difference may be due to human error due to experimenter fatigue of multiple tests. Slight collision with the nail is normal and does not interfere with the process.By comparing the overall procedure times of the IMN holes laser indicator, and the TAD techniques in the human tests, it is clear the IMN holes laser indicator significantly takes less time to interlock the IMN . Also, there is a significant difference between the IMN holes laser indicator, and the FH techniques . There is significant difference in drilling quality between the IMN holes laser indicator, and the TAD techniques . Moreover, the drilling quality between the IMN holes laser indicator, and FH techniques is equal .62. Also, Windolf et al., have reported less procedure time for the FH technique (246 ± 126)39. Comparing the reported times with the obtained time for the IMN holes laser indicator, it is obvious that the IMN holes laser indicator technique takes less procedure time (115.333 ± 8.993).As shown in Table 63. Therefore, the transmitted beam through the patient's foot in the center is more intense, which makes it easier to detect the center of the circle created by the laser beam on the patient's foot. This prevents errors in determining the center position of the IMN hole placed in the patient's foot. Also, the shape of the soft tissue layers on the bone is almost identical, which has no effect on the accuracy of the system.Transmitted light intensity through soft tissues such as fat is more than hard tissues like bone (as shown in Fig. During evaluating the IMN holes laser indicator in a human test, by inserting the probe inside the IMN, the light passing through the nail holes in the proximal region was more intense than in the distal region as shown in schematic image Fig. IMN holes laser indicator is a non-invasive accurate method that reduced surgical time and simplifies the process. This is an X-ray-free technique and prevents patient and surgical team from being exposed to X-ray. This new technology makes it easier to determine the drilling position and interlocking IMN especially distal interlocking which is a big problem for orthopedic surgeons. This new technology uses 680 nm visible light which has optimal transmission, reflectance, and absorption properties that can be seen with the naked eye. This instrument paves the way for development of effective and safe intramedullary nailing in clinical applications.


We developed an epitope selection method for the design of MHC targeting peptide vaccines. The method utilizes predictions for several clinical checkpoint filters, including binding affinity, immunogenicity, antigenicity, half-life, toxicity, IFNγ release, and instability. The accuracy of the prediction tools for these filter variables was confirmed using experimental data obtained from the Immune Epitope Database (IEDB). We also developed a graphical user interface computational tool called ‘PCOptim’ to assess the success of an epitope filtration method. To validate the filtration methods, we used a large data set of experimentally determined, immunogenic SARS-CoV-2 epitopes, which were obtained from a meta-analysis. The validation process proved that placing filters on individual parameters was the most effective method to select top epitopes. For a proof-of-concept, we designed epitope-based vaccine candidates for squamous cell carcinoma, selected from the top mutated epitopes of the HRAS gene. By comparing the filtered epitopes to PCOptim’s output, we assessed the success of the epitope selection method. The top 15 mutations in squamous cell carcinoma resulted in 16 CD8 epitopes which passed the clinical checkpoints filters. Notably, the identified HRAS epitopes are the same as the clinical immunogenic HRAS epitope-based vaccine candidates identified by the previous studies. This indicates further validation of our filtration method. We expect a similar turn-around for the other designed HRAS epitopes as a vaccine candidate for squamous cell carcinoma. Furthermore, we obtained a world population coverage of 89.45% for the top MHC Class I epitopes and 98.55% population coverage in the absence of the IFNγ release clinical checkpoint filter. We also identified some of the predicted human epitopes to be strong binders to murine MHC molecules, which provides insight into studying their immunogenicity in preclinical models. Further investigation in murine models could warrant the application of these epitopes for treatment or prevention of squamous cell carcinoma. Squamous cell carcinoma (SCC) is a form of non-melanoma skin cancer. It begins in squamous epithelial cells that form the surface of the skin, the surface of organs, and the lining of the respiratory and digestive tract. It is the second most common form of nonmelanocytic skin cancer after basal cell carcinoma, accounting for 20% of cutaneous malignancies and 75% of all non-melanoma skin cancer deaths . UV radiThe HRAS gene is a proto-oncogene and encodes for the H-Ras protein  which biPrevious studies have been conducted on the immune response in the presence of mutated HRAS peptides . Mice whIn this study, we considered several important clinically relevant factors when designing an epitope-based vaccine  to increase the vaccine’s chances of success in pre-clinical and clinical trials . An intrWe assessed the accuracy of several tools to predict these clinically-relevant variables and optimized the top epitope determination process through a new epitope selection method. We then predicted these clinically relevant variables for the most common mutated epitopes of the HRAS gene. These variables allowed us to determine the most prevalent and relevant epitopes in designing an epitope-based vaccine against SCC. Previously, several studies have been conducted using a combination of most of these variables ,9,10,11.We obtained the unmutated HRAS peptide sequence from the National Library of Medicine . We thenEpitopes for each of the mutations were obtained through IEDB NetMHCpan EL 4.1 . NetMHCpNext, we computed several epitope specific clinical checkpoint parameters listed in Antigenicity was determined using VaxiJen v2.0 . VaxiJenToxicity was determined with ToxinPred . It is bIFNγ release was predicted with IFNepitope . IFNepitAllergenicity scores were collected using the AllerTop v2.0 tool . The inaHalf-life, isoelectric point, instability index, aliphatic index, and GRAVY score were all predicted with ProtParam . We alsoThe finalized thresholds for the epitope selection process were decided based on previous studies ,7. ThresThe binding affinity of top epitopes for murine MHC molecules was predicted to determine immunogenicity of the vaccine in pre-clinical murine models. Murine MHC binding affinity was predicted using NetH2pan . AdditioEpitopes for the 44 mutated sequences of the HRAS gene were obtained using IEDB NetMHCpan EL 4.1. Epitopes of length 9 and 10 were obtained from the mutated sequences, and binding affinity was determined to the top 27 HLA alleles present in the human population. These alleles are: HLA-A*01:01, HLA-A*02:01, HLA-A*02:03, HLA-A*02:06, HLA-A*03:01, HLA-A*11:01, HLA-A*23:01, HLA-A*24:02, HLA-A*26:01, HLA-A*30:01, HLA-A*30:02, HLA-A*31:01, HLA-A*32:01, HLA-A*33:01, HLA-A*68:01, HLA-A*68:02, HLA-B*07:02, HLA-B*08:01, HLA-B*15:01, HLA-B*35:01, HLA-B*40:01, HLA-B*44:02, HLA-B*44:03, HLA-B*51:01, HLA-B*53:01, HLA-B*57:01, and HLA-B*58:01. The binding affinity data obtained from IEDB is available in Allergenicity scores were computed using the AllerTop v2.0 tool, which was compared directly against AllerCatPro  using exWe initially considered cell permeability as one of the parameters in the process of determining top epitopes. Cell permeability is an important factor to consider in peptide vaccine design as it directly relates to the vaccine’s ability to be delivered in cells. We initially predicted an epitope’s cell permeability using the tool CellPPD . CellPPDTo select the top epitopes that are most likely to elicit the desired long-term immune response and maximize efficacy, epitopes were selected based on a series of thresholds and filters. A two variable equation is described by Equation (1):In Equation (1), the immunogenicity score and percentile rank are normalized . The α vAfter applying Equation (1) to all epitopes for the top four HRAS mutations, the top 100 epitopes based on highest score were selected. Before using Equation (1) to select top epitopes, the epitopes were not filtered based on percentile rank. Using this filtration method resulted in epitopes with high, undesirable percentile rank scores with values greater than ten. Starting with a percentile rank filtration step and following it by sorting epitopes based on total formula score will result in epitopes with more favorable rank scores. An α value of 0.4, which places a greater emphasis on percentile rank, resulted in a greater number of unique epitopes. Importantly, the higher number of unique epitopes are not guaranteed and, therefore, it is necessary to repeat the same procedure using a greater abundance of experimental data. Additionally, placing greater emphasis on rank resulted in a greater number of non-immunogenic epitopes (immunogenicity less than 0). Fleri et al. showed that the variables of rank and immunogenicity are independent of each other, so formulaic determination of top epitopes using both variables does not provide “vastly improved predictions” . Fleri’sWe developed a program called ‘PopCoverageOptimization’, that collects all epitopes and their associated HLA alleles as input, and returns the lowest number of epitopes required to obtain maximum possible population coverage as output .By utilizing this program, we can determine the minimum number of epitopes needed to be returned from the filtration method. This will help in determining the optimal filtration method. Specificity should be prioritized over sensitivity so that the likelihood of selecting successful epitopes is maximized. Hence, if a filtration method results in fewer epitopes than other filtration methods, but still returns the maximum possible population coverage, that method is considered the most successful.We also designed a graphical user interface using JavaFX for ‘PopCoverageOptimization’, named as ‘PCOptim’, to allow for greater user access to the optimization algorithm. Users can enter their data into the text box labelled 1 in Adding to the previous methods of determination of top epitopes , resulted in a three-variable equation (Equation (2)).Ultimately, four filtration methods were compared. The first three methods all used a variation of the three variable equation using different values for x, y, and z . The fourth method was an individual filtration step that selects top epitopes using the thresholds outlined in Only epitopes with a length of 9 or 10 amino acids long were obtained from the filtration of the overall epitope data. This resulted in a total of 640 epitopes. These epitopes were associated with specific HLA alleles. We then determined the MHC binding affinity of the epitopes using IEDB NetMHCpan EL 4.1. Epitopes with both matching amino acid sequences and MHC alleles were selected, resulting in 97 epitopes. Immunogenicity and antigenicity data were predicted for the remaining epitopes, and percentile rank, immunogenicity, and antigenicity were all normalized. Percentile rank was normalized using Equation (3), while immunogenicity and antigenicity were normalized using Equation (4).Full data for the immunogenic SAR-CoV-2 epitope study can be found in The overall finding of the procedure using experimental SARS-CoV-2 epitopes was that the optimal filtration method is the one which utilizes individual filters on parameters. The half-life of the epitopes was still not a parameter considered. We solved this issue by using ‘ProtParam’ to find the half-life of the peptides . After cWe selected top epitopes of the 15 HRAS mutations by placing individual thresholds on each clinically relevant parameter as our filtration method  by filtering for linear peptides associated with cancer. These epitopes have positive T-cell assays for IFNγ release and result in positive cytokine activity. Using these parameters, querying the IEDB database resulted in 589 epitopes which can be found in Prior to human clinical trials, murine preclinical studies should be performed to measure the immune response to the vaccine in murine models. Therefore, we used a tool called NetH2pan to predict the binding affinity of the top epitopes to murine MHC molecules. The NetH2pan prediction tool was designed using over 8500 peptides eluted from FVB mice, and returns the binding affinity of the peptide to the MHC allele, as well as a qualitative prediction of strong binders and weak binders. Using this prediction tool, two epitopes were predicted to be weak binders to murine MHC molecules: LVVGADSV as a weak binder to H-2-Db and AGLGEYSAM as a weak binder to H-2-Dd and H-2-Kb. LVVVGADRV is predicted to be a strong binder to H-2-Db. Complete data for murine MHC binding prediction can be found in Three-dimensional analysis of the epitope VVVGACDVGK is displayed below, demonstrating the potential structure of the epitope when docking to an HLA allele (HLA-A*68:01 in this case). Information on the HLA allele structure was obtained from the RCSB protein data bank, while the structure of the epitope was determined using PEPstrMOD. The docking was conducted using PyMOL and the FlexPepDoc docking tool . An imagMany studies have been conducted on the HRAS, P13K, PDK1 pathway  were compared to determine the optimal prediction tools for CD4 and CD8 epitopes. The tool ‘PCOptim’ is crucial in determining the success of the new filtration method, as it verified that placing individual filters on each parameter did not eliminate too many epitopes. Additionally, the PCOptim tool would provide guidance for future in silico peptide/epitope-based vaccine design, as it provides a dataset of comparison for any post-filtration epitope data.Using the finalized filtration method, top mutated HRAS epitopes were selected. The final filtered epitopes, totaling 16 unique peptide sequences which potentially protect against nine unique HRAS mutations, are predicted to be immunogenic, antigenic, IFNγ releasing, non-toxic, non-allergenic, and stable. As a result of high allergenicity rates in epitopes with single mutations, many of the top epitopes include two simultaneous mutations. The predicted population coverage for these collective epitopes was adequately high, at 89.24% for the world population. However, the predicted population coverage across different regions of the world differ greatly with the highest being for Europe and North America. Clinically relevant epitope data for CD4 epitopes were collected and filtered following the same procedures used for the CD8 epitopes. However, due to the difficulty of obtaining high prediction accuracy for longer peptides, immunogenicity predictions could not be obtained and conclusions could not be drawn. The unfiltered data is available in Epitopes with single point mutations of G12D, G13C, and E62G do not provide any high-quality epitopes post-filtration. Several epitopes with these mutations are either predicted to be allergenic or do not release IFNγ. Combining mutations that occur on adjacent or nearby codons can provide epitopes that fit the outlined requirements to output a high-quality epitope. The prevalence of simultaneous mutations of the HRAS gene causing SCC is unknown, so further studies should be conducted on SCC patients with mutated HRAS gene.The low post-filtration epitope recovery can be attributed to gene-specific attributes of Ras peptides. Many of the epitopes were eliminated during the filtration process due to the IFNγ predictions resulting in many negative predictions. To remedy this, another dataset selecting top epitopes while disregarding the IFNγ parameter was created following the results of the IFNepitope accuracy assessment using CD8 epitopes. This dataset can be accessed in Due to the high immunogenicity and antigenicity scores of the individual peptides, the epitope-based vaccine is predicted to produce an immune response to both the initial immunization as well as the antigens post-vaccination. Previous studies involving the HRAS gene in designing epitope-based vaccines to target cancer have resulted in T-cell proliferation, but have failed to result in significant tumor size reduction . The pepThe purpose of this study was to develop and implement a new epitopes selection method to predict clinically-viable epitopes for vaccine design. Several clinical checkpoints, such as immunogenicity, antigenicity, toxicity, IFNγ release, allergenicity, half-life, and stability, were predicted. The accuracy of these tools was determined either through literature review, or testing with experimental epitopes. Of the two tools tested for allergenicity predictions, AllerTop v2.0 was determined to be superior over AllerCatPro due to its higher sensitivity. IFNγ predictions using IFNepitope were deemed inaccurate for MHC class I epitopes, which led to the determination of top epitopes without filtering for positive IFNγ release. Previous studies have used IFNγ analysis in conjunction with docking analysis to select viable SARS-CoV-2 epitopes . This epUsing a dataset of SARS-CoV-2 immunogenic epitopes, we determined that the most effective method to select top epitopes was by placing filters on individual parameters. We verified this by filtering a dataset of SARS-CoV-2 non-immunogenic epitopes and comparing the top epitopes to a dataset of immunogenic SARS-CoV-2 epitopes. This method was implemented in the design of an epitope-based vaccine for HRAS mutations, resulting in 16 unique epitopes that account for nine unique mutations. Epitopes predicted to release IFNγ provide a world population coverage of 89.24%. Without considering epitope data for IFNγ release, 64 epitopes were selected resulting in 98.55% world population coverage. Additionally, the epitopes we selected using our filtration method were confirmed by matching them against the epitopes found in previous studies involving HRAS-based epitope vaccines.A challenge in the design of an epitope-based vaccine exists during the stage of murine model development, as only one peptide was predicted to be a strong binder for murine MHC molecules, and two peptides were predicted as weak binders to three H2 alleles. While this study does predict clinically viable epitopes in humans, testing these epitopes using murine models may prove to be a challenge. One potential explanation for these results is that HRAS is not a suitable gene to perform murine model testing on, or that other HRAS mutations would result in better outcomes. Other potential mutations to investigate would include p53 and MUC1. These findings suggest that the newly designed filtration method is successful in accounting for clinically-relevant parameters to design an effective multi-valent epitope-based vaccine.


An increasing number of AB0-incompatible (AB0i) liver transplantations (LT) are being undertaken internationally in recent years due to organ shortages and the need for urgent transplantation. The aim of our study was establish the value of ABOi LT from available retrospective results of AB0i pediatric liver transplantations performed in European reference centers now belonging to the TransplantChild, European Reference Network (ERN). Data from medical records were analyzed, including demographic data, diagnosis, urgency of transplantation, time on the waiting list, PELD/MELD score, desensitization procedures, immunosuppression, selected post-transplant complications, and patient and graft survival. A total of 142 patients (pts) with transplants between 1986 and 2018 in 8 European transplant centers were included in the study. The indications for liver transplantation were: cholestatic diseases in 62 pts, acute liver failure in 42 pts, and other conditions in the remaining 38 pts. Sixty-six patients received grafts from living donors, and seventy-six received grafts from deceased donors. Both patient and graft survival were significantly affected by deceased donor type, urgent transplantation, and the development of vascular complications. In the multivariate analysis, vascular complications had a negative impact on patient and graft survival, while a longer time from the first AB0i LT in the study showed better results, suggesting an international learning experience. In conclusion, we believe that AB0i LT in children is now a safe procedure that may be adopted more readily in children. For more than 30 years, liver transplantation (LT) has been accepted as a major life-saving yet routine treatment for children with end-stage liver disease. This highly successful situation has led to an international situation of organ shortages that is especially critical for patients needing urgent transplantation. Therefore, a number of responses to the shortage have been adopted including marginal donors and donors with recipient-incompatible blood groups (AB0i).Starzl et al. were the first to report 11 cases of AB0i LT in 1979 ,3,4.It has been noted by several authors that the results of AB0i LT were better in the pediatric recipient population, particularly among the youngest children below 2 years of age, attributed to their immature immune system ,6.The aim of our study was to retrospectively review the experience of AB0i transplants in children in leading pediatric liver transplant centers of the TransplantChild, European Reference Network in Europe. We set out to review the indications, practices for pre- and post-transplant treatment, and the results of these transplantations with the inclusion of immunological and other complications to assess patients and graft survival as well as the factors influencing these results. We also wanted to assess if any progress has been made in the outcomes of AB0i LT in children over the study period and to consider the current situation with respect to the use of this organ source.Clinical material: data on 150 pts were collected from eight European transplant centers. Eight patients were excluded from the analysis due to a lack of sufficient data. The contributing centers were Children’s Memorial Health Institute, Warsaw, Poland (72 pts); ASST Hospital Papa Giovanni XXIII, Bergamo, Italy (2 pts); Hannover Medical School Children’s Hospital, Germany (12 pts); Karolinska University Hospital, Stockholm, Sweden (5 pts); King’s College Hospital, London, UK (23 pts); Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal (12 pts); La Paz University Hospital, Madrid, Spain (8 pts); and OspedalePediatrico Bambino Gesu, Roma, Italy (8 pts).Data from medical charts were analyzed, including demographic data, diagnosis, urgency of transplantation, time on the waiting list, PELD/MELD score, desensitization procedures, immunosuppression, vascular, biliary, rejection, CMV, PTLD and related post-transplant complications, and patient and graft survival. We also analyzed the results of AB0i LT according to recipient age (0–1 yr vs. older), and early and later periods of time were chosen on the basis of comparing equal numbers of patients in each period (1986–2010 vs. 2011–2018).t-test and Mann–Whitney U test were used to assess unpaired associations between continuous variables. The Chi-Square test was used to examine the differences between categorical variables. We also created Kaplan–Meier plots to analyze both patient and graft survival and compared them between groups using a log-rank test. A logistic regression analysis was used for the multivariate assessment of the relation between graft loss, recipient death, and the various predictor variables. Risk factors with a known or suspected clinical significance and a p-value less than 0.10 in the univariate analysis were included in the initial multivariable model. A p-value of less than 0.05 was considered statistically significant.The data were analyzed using Statistica 13.3 software, StatSoftinc . The analysis involved the assessment of baseline demographics and clinical data using median and ranges, and distributions for categorical variables. The Student This study was approved by the ethics committee at the Children’s Memorial Health Institute: decision number 30/KBE/2018 issued on 10 October 2018. All participant centers followed the required ethics requisites for transmission of anonymized data to the TransplantChild, European Reference Network.Upon analysis, 142 patients with transplants between 1986 and 2018 were included in this retrospective study. There were 67 boys and 75 girls. Their ages at transplantation ranged from 0.02 to 18 yrs (median 0.93 yrs). The indications for liver transplantation were biliary atresia and other cholestatic diseases in 62 pts (43.6%), acute liver failure in 42 children (29.6%), primary hepatic tumors in 8 pts (5.6%), other diseases in 15 pts (10.6%), and re-transplantation in 15 pts (10.6%).The transplantations were performed with grafts from 66 living and 76 deceased donors. The donor ages ranged between 0.17 and 76 yrs (median 28.2 yrs).Follow-up after transplantation in the entire study group was 1 day to 32 yrs, with a median 4.2 yrs and a mean 5.5 ± 5.4 yrs, and was limited in most cases to transition to adult care. Overall results: patient and graft survival are shown in We also compared the results of AB0i LT in infants up to one year old  and older than one year children . The demographic and clinical data of recipients and donors are presented in After transplantation, the only differences occurred in the rates of intrahepatic biliary stenosis and re-transplantation, both more common in Group 2. There was no significant difference in the rate of rejection, or patient or graft survival between the two groups, but more children survived due to re-transplantation among patients older than one year There was a clear trend towards an increased number of AB0i LT over the study period. Between 1986 and 2003, seven AB0i liver transplants were performed in the eight centers participating in the study; between 1997 and 2007, there were 36 AB0i LTs; and between 2008 and 2018, the number of AB0i transplants almost tripled, reaching 99 procedures. As the oldest group had few patients and some data are lacking, we divided the patients into two almost equal groups: 72 pts transplanted between 1986 and 2010 (Group 1) and 70 pts transplanted between 2011–2018 (Group 2) to compare if there was any change in patient and graft survival over time. The group characteristics and a comparison of the results are presented in In the multivariable analysis, only vascular complications and year since first AB0i LT were important for graft loss and patient death .The increasing success and utility of liver transplantations has been leading to increasingly more being undertaken internationally while organ donation is unchanged or falling, leading to an increasing discrepancy between the availability of grafts and the number of patients on waiting lists. Various responses have been developed: split liver transplantation, living donation, and wider acceptance of so-called marginal donors and grafts, including, as we described, grafts from AB0i donors. The acceptance of donor-recipient AB0 blood group incompatibility was initially limited largely to the extreme circumstances of patients with an urgent need for LT. The initial results were unsatisfactory, with high rates of rejection, HA thrombosis, biliary complications, sepsis, and other causes of graft and patient loss ,7,8,9,10Therefore, we aimed to consider the achievements of centers in Europe, to review current practices, and to set a benchmark for the use of this source of grafts for liver transplantation in children.During our study period, several protocols of pre-transplant desensitization were developed internationally in an attempt to prevent early or immediate humoral rejection and to improve late results after AB0i LT: splenectomy, plasma exchange, immunoadsorption, high-dose intravenous immunoglobulins (IVIG), and antiCD20 monoclonal antibodies (rituximab) ,16,17,18However, almost 30% of children were treated with IVIG postoperatively. Other methods of desensitization were used only occasionally both pre- and post-transplantation. As reported in the literature, pediatric immunosuppression protocols for AB0i liver transplant differ significantly between centers ,24,25,26When desensitization and immunosuppression between the two age groups were compared, children below 1 year of age received less immunosuppressive drugs after AB0i LT , which wIsoagglutinin levels increase with age from infancy so we expect less acute rejection episodes and severity in children below 1 year of age, particularly of the humoral type ,12,27,28It is recognized that patients receiving AB0i grafts are at increased risk of developing certain complications ,29,30,31Another common complication that may occur usually within the first 3 months after AB0i LT is damage to the intrahepatic bile ducts and development of multiple intrahepatic biliary stenosis. It may be caused by immunological insult by humoral reaction to the donor blood group antigens, which are present on the epithelium of bile ducts for 3–6 months after LT ,32,33. IThe overall patient and graft survival in our series is perhaps not as good as we wish, but our study period included children with transplants from as early as 1986. Comparing these results to those reported by the European Liver Transplant Registry (ELTR), for a similar period, the results in our series of AB0i LT are similar to all contemporaneous pediatric liver transplantations reported to the ELTR  34]..34].Although both patient and graft survival are better in younger children ,6, the dWe used a univariate analysis as a starting point for the creation of a multivariate logistic regression model to assess the relationship between graft loss, recipient death, and the various predictor variables. We showed that graft loss and recipient death were only related to two independent risk factors: vascular complications and time from first transplant, supporting the view that immunological reactions do not have a major influence on the results of AB0i LT in our particular pediatric populations.In summary, our study has shown that the outcome of AB0i liver transplantations in children has improved considerably over the last 20 years. The reasons for this improvement are probably multifactorial, including better perioperative and anesthetic management; better perioperative monitoring; increasing multidisciplinary experience and surgical skills; improved immunosuppression and understanding; and the prevention, diagnosis, and treatment of humoral rejection  ,36,37,38While there is a pressing need for expansion of the pediatric donor pool in response to a critical organ shortage, the improvement in the results of AB0i LT makes it justifiable to use this type of transplantation not only in circumstances of emergency transplantation due to acute liver failure and severe acute decompensation of chronic liver disease and semi-elective transplantation for primary hepatic tumors but also in elective transplantations, particularly from living related donors ,25,39,40


Theoretically, pancreas transplant alone in uremic (PTAU) patients could also be one of the options for those waiting for both pancreas and kidney grafts, but it has never been reported. There were 160 cases of pancreas transplant in this study, including 16% PTAU. The 5-year patient survival was 66.2% after PTAU, 94.5% after SPK, 95.8% after PAK, and 95.4% after PTA. Rejection of pancreas graft was significantly lower in PTAU group (3.8%), followed by 16.7% in pancreas after kidney transplant (PAK), 29.8% in simultaneous pancreas and kidney transplant (SPK) and 37.0% in pancreas transplant alone (PTA). Fasting blood sugar and serum HbA1c levels after PTAU were not significantly different from those by other subgroups. The 5-year death-censored pancreas graft survival was 100% after PTAU and PAK, and 97.0% after SPK and 77.9% after PTA. However, the 5-year death-uncensored pancreas graft survival was 67.0% after PTAU, 100% after PAK, 91.3% after SPK, and 74.0% after PTA. The superior graft survival in the PTAU group was achieved only if deaths with a functioning graft were censored. In conclusion, given the inferior patient survival outcome, PTAU is still not recommended unless SPK and PAK is not available. Although PTAU could be a treatment option for patients with diabetes complicated by end-stage renal disease (ESRD) in terms of surgical risks, endocrine function, and immunological and graft survival outcomes, modification of the organ allocation policies to prioritize SPK transplant in eligible patients should be the prime goal. For patients with labile DM and ESRD, SPK would be a preferred treatment because it can simultaneously provide an insulin-free and dialysis-free life for patients during the same operation9. Nevertheless, SPK has also been claimed to have the best long-term outcome in diabetic cases with renal failure11. However, pancreas and kidney transplants are not necessarily to be accomplished at the same time because both pancreas and kidney are not vital organs. Kidney transplant is the well-known treatment of choice for ESRD patients. However, in diabetic patients, the underlying metabolic disturbance will persist and even may get worse after isolated kidney transplant10. Currently, PAK has also been an acceptable option for those previously receiving a kidney graft in many centers13. According to the updated Scientific Registry of Transplant Recipients (SRTR) reports3, majority of the pancreas transplants are for SPK (81% ~ 84%), followed by PTA (9% ~ 11%) and PAK (7% ~ 8%). Theoretically, pancreas transplant alone in uremic patients (PTAU) could also be one of the options for those waiting for both pancreas and kidney grafts. To our knowledge, PTAU has never been reported in the literature.Pancreas transplant remains the best option of treatment to achieve long-term physiological euglycemia and insulin independence for patients with labile diabetes mellitus (DM) such as type 1 DM (T1DM). Traditionally, pancreas transplant has been reserved for diabetic patients with end-stage renal disease (ESRD), undergoing simultaneous pancreas-kidney transplant (SPK), and previously receiving a kidney graft and pancreas after kidney transplant (PAK), or those with brittle diabetes without uremia, undergoing pancreas transplant alone (PTA)For diabetic patients with uremia, SPK is undoubtedly the preferred option, and kidney transplant first in PAK is also well documented choice, but how about pancreas transplant first in PTAU? Therefore, the aim of this work was to assess the feasibility and justification of pancreas transplant first in the diabetic patients with uremia, PTAU group, by comparing the surgical risks and outcomes of endocrine, immunology, and pancreas graft survival between PTAU and other traditional transplant subgroups. This work would be the first study regarding the PTAU.https://www.torsc.org.tw/about/about_08.jsp). There is always very competition for kidney grafts from deceased donors in our country. A diabetic patient with ESRD might not have pancreas and kidney transplanted at the same time, and some patients who actually needed SPK would even accept pancreas transplant first, so called PTAU, after the procedure is fully explained.Diabetes patients undergoing pancreas transplant from September of 2003 to May of 2020 were included in this study. Perioperative and follow-up data for each patient were prospectively collected and kept in a computer database. This study was approved by our institutional review board, Institutional Review Board (IRB) of Taipei Veterans General Hospital, (IRB-TPEVGH No.: 2020-05-006CC). The study was carried out in accordance with our IRB guidelines and regulations. The informed consent was waived in this retrospective cohort study with anonymity of the data by our institutional review board. The official indications for pancreas transplant in Taiwan include the following: (1) T1DM with diabetic complications such as nephropathy, retinopathy, neuropathy, and cardio-cerebral vasculopathy; (2) T1DM with frequent life-threatening hypoglycemia or hyperglycemia; (3) T1DM with severe disability in school learning, working, and living; and (4) type 2 DM (T2DM) with kidney disease leading to ESRD under insulin control with insulin requirement of less than 1.5 units/kg/day. Based on the patient’s condition, pancreas transplants were classified into 4 subgroups at our institute: PTAU, pancreas transplant alone in uremic patients waiting for both pancreas and kidney transplant; SPK, simultaneous pancreas-kidney transplant; PAK, pancreas after kidney transplant; PTA, pancreas transplant alone. According to the regulations of Taiwan Organ Registry and Sharing Center, the waiting lists for pancreas and kidney grafts are separate, and there are always more than 7,000 uremic patients waiting for a kidney graft, but only about 100 diabetic patients waiting for a pancreas graft  and late (after discharge) complications, surgical mortality, acute and chronic rejections, graft loss, fasting blood sugar, serum hemoglobin A1c (HbA1c), serum C-peptide, and pancreas graft survival were compared between each subgroup of pancreas transplant. In this study, surgical mortality was defined as postoperative death before discharge or within 90 days after operation. Any return to insulin use was counted as pancreas graft failure. Graft loss due to patient death with functioning graft was considered as censor, not event of interest, in graft survival analysis.The primary endpoint was to compare the patient survivals after the pancreas transplant first in PTAU group with other subgroups. The secondary endpoints were comparisons of pancreas transplant first in PTAU group to other subgroups in terms of endocrine function, immunological, surgical outcomes and graft survival outcomes presenting with and without censoring for death with a functioning graft.Patients with a positive crossmatch against donor cells were excluded for pancreas transplant. The pancreas grafts were procured in a “‘no touch” technique en bloc with the duodenum. The spleen was routinely separated from the pancreas before aorta cross-clamping. The reason to separate the spleen from pancreas tail before vascular cross-clamping is easier to identify the vessels and to avoid injury to pancreas tail, as compared with the back-table work. We have been doing that procedure from the beginning of our first case, and no detrimental effect is observed so far. Histidine-tryptophan-ketoglutarate solution was used for in situ perfusion, with 4,000 to 6,000 c.c. via aorta and 2,000 to 4,000 c.c. via inferior mesenteric vein. Back-table bench preparation included removal of the peripancreatic fat and arterial Y-graft reconstruction. The graft portal vein was anastomosed end-to-side to the recipient’s distal vena cava with head-up position of the pancreas graft. The superior mesenteric and splenic arteries reconstructed by donor iliac arterial Y-graft at the back-table was anastomosed to the recipient’s right common iliac or external iliac artery. Exocrine drainage was achieved by enteric drainage with a hand-sewn side-to-side duodenojejunostomy 30–50 cm beyond the flexure of Treitz ligament using roux-en-y technique and retroperitoneal placement.Immunosuppressive treatment was quadruple therapy for all recipients of pancreas transplantation without any specific protocol for each subgroup. Induction therapy included basiliximab , 20 mg given on postoperative days 0 to 4, or anti-thymocyte globulin  for high risk of rejection such as positive panel-reactive antibody (PRA) and re-transplant, 1 mg/kg daily from postoperative days 1 to 7. Maintenance therapy mainly included administration of tacrolimus , enteric-coated mycophenolic acid , and prednisolone. Prednisolone was tapered and gradually withdrawn 6 months after transplant. The target trough level for tacrolimus was 8–12 ng/mL during the first year and 6–8 ng/mL thereafter.2 test or Fisher’s exact test contingency tables. Actuarial graft survival rates were estimated using the Kaplan–Meier method, excluding the primary graft failure and surgical mortality. The log-rank test was used to compare differences in the survival curves. For all analyses, P < 0.05 was considered to be statistically significant.Statistical analyses were performed using Statistical Product and Service Solutions (SPSS) version 21.0 software . All continuous data were presented as median and mean ± standard deviation (SD), and frequencies were presented when appropriate to the type of data. The mean values of the continuous variables were compared using a two-tailed Student’s t-test. Nonparametric statistical tests were used if the variables did not follow normal distribution. Categorical variables were presented as numbers and percentages. Categorical variables were compared using Pearson’s χP < 0.001  PTAU, 37 (23%) SPK, 24 PAK (15%), and 73 (46%) PTA. Medical reasons for brain death of deceased donors in pancreas transplants  in PTAU and PTA groups, P < 0.001. Majority (9/10) of pancreas graft loss in PTAU group was due to patient death with functioning graft (34.6%) and the remaining one (1/10) was resulted from technical failure with graft hemorrhage (3.8%) after revascularization of graft during operation. Majority (16/28) of pancreas graft loss in PTA group was chronic rejection (21.9%).The surgical and immunological outcomes were listed in Table P = 0.003  values after PTAU were not significantly different from those by other pancreas transplant subgroups Fig. a. There 003 Fig. b. The se003 Fig. c.Figure 14. For diabetic patients with ESRD, SPK has been a standard treatment to provide a healthier lifestyle without the burden of dialysis and insulin therapy10. Pancreas graft allocation system may be different from country to country15. The new pancreas allocation system went into effect on October 30, 2014 in the America, run by Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS)15. All solid‐organ pancreas transplant types  were combined into a single waiting list15. According to OPTN/SRTR 2018 Annual Data Report, 84% of pancreas transplants were SPK, 9% PTA, and 7% PAK1. No PTAU has been reported in the literature to date. In Taiwan, the pancreas and kidney allocation systems are separate and different. Pancreas and kidney waiting lists are not combined together, and the diabetic candidates (about 100 patients) on the pancreas waiting list are always much outnumbered by uremic candidates  on the kidney waiting list . Therefore, there is very competition for a kidney graft from a deceased donor in Taiwan; a diabetic patient with ESRD might not have pancreas and kidney transplanted at the same time, and some patients who actually needed SPK would even undergo PTAU. These PTAU patients after pancreas transplant first in diabetic patient with uremia are still on the regular kidney transplant waiting list according to Taiwan organ allocation system. Nevertheless, the priority of pancreas transplant is SPK, PAK, PTA and PTAU. Therefore, when there is a suitable pancreas graft without an available kidney graft from the same donor, the pancreas graft might go to the patients on the PTA group. That is why the proportion of PTA is so high in our series.Pancreas transplant remains the most effective option of treatment to achieve and maintain physiological euglycemia, and, moreover, to halt or even potentially reverse the secondary complications related to diabetes. Significant improvements in quality of life and better life expectancy make it in the longer term, a lifesaving procedure compared to waiting candidates20.However, patient survival outcome in PTAU group is inferior to other pancreas transplant subgroups. PTAU patients with unresolving uremic condition seem to be more vulnerable to cardiac events, cerebrovascular accidents, infections and malignancies, like seen in our series. These risks could be attributed to the underlying uremia-associated immune deficiency as mentioned earlier1, incidence of a first rejection episode 1 year after pancreas transplant was 12.4% for SPK, 19.2% for PTA and 11.7% for PAK respectively. The higher incidence of rejection after PTA might reflect a trend toward protocol biopsies based on historically higher incidence of rejection and lack of reliable markers for rejection in the absence of a simultaneously transplanted kidney1. This study also showed higher incidence of both acute (26.0%) and chronic (15.1%) rejection in PTA group; however, only 1 case of acute rejection (3.8%) and 0% chronic rejection occurred in PTAU. Although both PTAU and PTA were eventually associated with higher graft loss rate, 38.5% and 38.4% respectively, the causes of graft loss for these two groups were different. Most of graft loss in PTA group resulted from rejection (30.1%), including chronic (21.9%) and acute (8.2%) rejection, whereas the leading cause of graft loss in PTAU group was patient death with functioning graft (34.6%). It has been claimed that uremia-associated immune deficiency is a well-known complication of loss of renal function and contributes significantly to the overall mortality and morbidity of patients with ESRD17. Immunologically, ESRD is associated with functional defects in virtually all cell populations of both the innate and adaptive immune systems. The ESRD-related changes in the immune system resemble immunological aging in the very old healthy individuals, a concept known as premature immunological aging18. Chronic inflammation and increased oxidative stress probably contribute to the underlying the uremia-associated immune deficiency. Although these disorders are complex, yet thoroughly unknown, the uremia-associated immune deficiency would result in a decreased vaccination response, cardiovascular events, more infections and increased susceptibility for malignancies20. Therefore, the low graft rejection in PTAU patients might be a reflection of the underlying uremia-associated immune deficiency/inertia. In the other hand, the uremia-associated immune deficiency might play a substantial role in the clinical implications, and could be the main contributing factor for the higher rate of patient death with functioning graft after a successful PTAU in this study.Technically, PTAU could be performed with similar operation times (cold and warm ischemic times) and without increasing surgical risks in terms of surgical morbidity and mortality, as compared with other pancreas transplant subgroups. Meanwhile, PTAU did not significantly increase the hospital stay and cost. According to OPTN/SRTR 2018 Annual Data Report21. One of the reasons for superior levels of c-peptide in PTAU group is probably biased by persistent uremia, which is known to increase c-peptide level.Endocrine function of the pancreas graft would be the prime concern after pancreas transplant. PTAU could also effectively provide similar endocrine function in terms of fasting blood sugar and HbA1c levels, compared to other pancreas transplant subgroups in this study. Nevertheless, the serum c-peptide levels in PTAU group are even significantly higher than those in other pancreas transplant subgroups. This finding of higher serum c-peptide levels could a reflection of more T2DM patients (50%) in PTAU groups because T2DM patients tend to be associated with hyperinsulinemia Pancreas graft survival outcome after PTAU is essentially similar to SPK and PAK, and superior to PTA by our study. These findings imply that the uremia-associated immune deficiency/inertia in PTAU, SPK and PAK patients might play a role in the lower incidence of rejection, which contribute to the better graft survival outcome, as compared with PTA group. It seems that the uremia-associated immune deficiency/inertia in PTAU patients would trade a superior pancreas graft survival for an inferior patient survival outcome. Therefore, subsequent kidney transplant following a successful pancreas transplant should be encouraged whenever possible.Limitation of this study is no data of kidney grafts to be presented in PTAU group. It has been very competitive for our uremic patients to have a kidney graft for transplant because the pancreas and kidney waiting lists are separate according to our organ allocation policy. Actually, no one in PTAU group undergo subsequent kidney transplant so far during the follow-up period although they had been kept waiting for that. Therefore, the term “pancreas before kidney (PBK)” transplant would be some kind of misnomer without subsequent kidney transplant. Probably, pancreas transplant alone in uremic patients (PTAU) could be more clearly understandable.PTAU could be a treatment option for patients with diabetes complicated by ESRD in terms of surgical risks, endocrine function, and immunological and graft survival outcomes. However, given the inferior patient survival outcome, pancreas transplant alone in uremic patients in PTAU group is still not recommended whenever possible, unless SPK and PAK is not available due to constraints from the kidney allocation policies. Therefore, the rationale for PTAU would be amelioration of short-term diabetic morbidity to allow for patients to remain medically stable to wait for a kidney transplant and also to further avoid the long-term complications associated with DM, and also seen in SPK and PAK patients. Subsequent kidney transplant following successful pancreas transplant should be encouraged whenever possible because PTAU patients might be more vulnerable to cardiac events, cerebrovascular accident, infection, and malignancy. Nevertheless, modification of the organ allocation policies to prioritize SPK transplant in eligible patients should be the prime goal and PTAU should be avoided.