In this methodologic study (Part 2 of 2), we examined the overlap in sources of evidence and the corresponding results for harms in systematic reviews for gabapentin.>50%) as determined by corrected covered area (CCA).We extracted all citations referenced as sources of evidence for harms of gabapentin from 70 systematic reviews, as well as the harms assessed and numerical results. We assessed consistency of harms between pairs of reviews with a high degree of overlap in sources of evidence  were not cited in more than one review. Among 18 pairs of reviews, we found reviews had differences in which harms were assessed and their choice to meta-analyze estimates or present descriptive summaries. When a specific harm was meta-analyzed in a pair of reviews, we found similar effect estimates.Differences in harms results across reviews can occur because the choice of harms is driven by reviewer preferences, rather than standardized approaches to selecting harms for assessment. A paradigm shift is needed in the current approach to synthesizing harms. SimilIn both primary studies and systematic reviews, hundreds of harms may be observed, especially non-systematically collected harms –5. Consepre-specify their interest and search the literature for relevant data to assess those harms  for included studies because different reports might present different and complementary information ,7,10,11.Across a set of reviews for an intervention, we would hope to see similar results for harms, especially if those reviews include the same sources of evidence. Our objective in this paper is to evaluate whether there are differences in results for harms across reviews that include similar sources of evidence in the choices of harms to assess and the methods that lead to different effect estimates for the same harms.2.The detailed methods can be found in Paper 2 of this series . In brieFor this paper, we extracted the health condition studied; whether reviews pre-specified harms for assessment; the included sources of evidence; the types of harms assessed; and the corresponding results for all reported gabapentin harms. The “results” included whether harms were assessed descriptively  or quantitatively, with meta-analysis , and any2.1.We extracted all citations that were referenced as sources of evidence for harms of gabapentin. Primary studies cited in our sample of reviews can have multiple reports. Our analyses of overlap across reviews is based on the cited reports, not the cited studies. We focused on cited reports because, for the purpose of this investigation, we considered reports for a study to be the best representation of the evidence being used across reviews. Reports from a given study often contain different information, so if two reviews include different reports from the same study, then it would not be surprising if they include different harms and associated results ,7.We used corrected covered area (CCA) as a tool to assess the overlap in the sources among reviews and to guide our assessment of review results for harms . CAA is 2.2.In regulatory sciences, non-systematically assessed harms are mapped to standardized terminology before they are analyzed. That is, harms are collected as many variations of what could be considered a single type of event  . For exabioportal.bioontology.org/ontologies/MEDDRA?p=summary) dictionary and assigning the corresponding preferred term. All mapping of harms was performed by one investigator (RQ).To standardize harms for comparison, we mapped the various ways the same event was described across reviews to the preferred terms of MedDRA. We performed our mapping by searching for each unique harm that we extracted from our reviews in the BioPortal MedDRA “Classes” .We considered differences firstly in terms of the types of harms that were reported in each review and secondly in terms of effect estimates. We considered reviews to have different results for harms if they reported different types of harms or if they reported meaningfully different effect estimates for harms that were common between reviews. If reviews used different measures , we did not consider these as different results if the converted estimates were similar  of 6 (3 to 16). Most of the reports were cited in only a single review . The proportions cited in 2, 3, 4, or 5 reviews were 21% (107/514), 7% (38/514), 8% (39/514), and 5% (26/514), respectively. Fifty-eight (11%) reports were cited between 6 to 9 times. Two reports describing the pivotal trials submitted to the US Food and Drug Administration (US FDA) to extend marketing approval to include pain were cited in 11 and 12 reviews. Overall, the CCA was low at 2%. The CCA varied widely when calculated by condition, with epilepsy having the lowest of 3% (12 reviews with 84 citations of 63 unique reports) and alcohol dependence having the highest at 21% (3 reviews with 20 citations of 14 unique reports) . APPENDI3.2.Across the 70 reviews, we identified 167 reported gabapentin harms before mapping to MedDRA preferred terms. After we mapped the terms, we found reviewers assessed 97 specific harms . Reviewers also used three general methods of assessing harms—“any non-specific harm”, “serious adverse events”, and “grouped specific harms” . Reviewers also assessed a proxy for harm, “loss to follow up or drop out due to harms”. Most reviews used a general or proxy method in addition to assessing specific harms. No reviews assessed harms at a higher order category such as mid-level Nervous system harms; however, the general “grouped specific harms” sometimes assessed harms under a single higher order category . Of the 97 specific harms, 78 (80%) were only ever descriptively assessed and 19 (20%) were quantitatively assessed in one or more reviews–Of 2415 pairwise comparisons between reviews, we found 18 pairs of reviews with more than 50% overlap in the reports cited for gabapentin . As expe4.Systematic reviewers already face many challenges in synthesizing harms, including: multiple types of evidence required in addition to randomized controlled trials; the collection of harms in primary studies is not standardized; harms are often underreported in primary studies; and analysis of harms is difficult, even when given full participant data . While gWhen we examined the overlapping reports and results for harms across systematic reviews of gabapentin, we discovered that reviews often differed in the choice of harms to assess and the approach for analyzing harms. We did not find evidence of prespecified rationales, or of consistent patterns, for choosing which harms to assess, which suggests that harms may be selected based on reviewers’ preferences. For example, we found that even when two reviews cited the exact same included reports as sources of evidence, the types of harms and the approach taken to assess them could be very different. When pairs of reviews with high overlap reported the same harms with meta-analytic effect estimates, the estimates were often similar when considering direction and magnitude. However, when the same harms appeared in multiple reviews, there were discrepancies when considering the decision to pool estimates into a summary effect or to present a descriptive summary. Additionally, across meta-analyses from the broader sample of reviews  there weOur expectation that reviews would have similar results for harms if they included similar sources of evidence was met only when the same harms were assessed using the same approach . In the absence of core outcome sets for harms, and lacking any strong community norms, reviewers have considerable freedom to choose their approach to assessing harms  and to apply their own selection criteria in deciding which harms to assess and report. This freedom can lead to important differences across reviews, even when they cite the same evidence: authors of one review may decide to assess harm using a single proxy such as “drop out due to harms”, whereas authors of another review may choose to assess and report all specific harms identified in the included studies. It is a common practice to limit the number of outcomes assessed in a review and to include “harms” as a single outcome by trying to summarize and create a composite for harm, particularly in when following the Grading of Recommendations Assessment, Development and Evaluation approach and creating a Summary of findings table . The chaad hoc composites created by reviewers.Although standardized systems for describing harms such as MedDRA have existed for decades and are used in regulatory research, systematic reviewers often use common, non-standardized, language to refer to harms. This use of non-standardized language means that the same harms are described to using different terms between reviews; for example, multiple reviews assessing the risks of “Drowsiness,” “Lethargy,” “Sedation,” or “Somnolence” when these all describe the standardized preferred term “Somnolence”. This creates a major challenge for evidence users. When primary studies use common terminology to refer to harms, reviewers could standardize language and terms . Standardized systems are also hierarchical in nature, which provides appropriate ways to aggregate harms using higher order terms. For example, if reviewers mapped specific harms of interest—pre-specified or otherwise—to corresponding mid-level systems  and conducted analyses at the mid-level, then they could draw broader conclusions about the types of harms that patient might expect. Combining related harms using these systems increases statistical power to detect effects, and existing systems might be more appropriate and more easily comparable than Lastly, systematic reviewers should state their rationales for pre-specifying harms to include, or for not prespecifying harms to include, and their reasons for choosing harms for reporting. If reviewers explain their choice of approach and selection criteria, then readers will be better able to contextualize the results. Better reporting of reviewer decisions and review limitations could reduce the likelihood that conclusions are overinterpreted.5.We found that among systematic reviews of gabapentin, reviews that took the same approach to assessing the same harms found similar effect estimates; however, reviews often assessed different harms, and reviews often used different methods to assess harms . Trialists and systematic reviewers should use standardized language when referring to harms so that harms will be more consistently described across reviews. Reviewers should explain the rationale for selecting harms to assess and report. Readers should be aware that conclusions about harms may be unreliable; the types of harms and conclusions about harms in a systematic review might differ from other reviews of the same drug and health condition, even when both reviews include the same sources of evidence.1234


No correlation between inflammatory serum patterns and Qalb was observed. Correlation analysis of serum expression levels of these sixteen proteins with clinical and MRI parameters pinpointed a subset of five molecules  negatively correlating with spinal cord lesion volume. However, following FDR correction, only the correlation of CXCL9 remained significant. Our data support the hypothesis that the intrathecal inflammation in MS only partially associates with the peripheral one, except for the expression of some immunomodulators that might have a key role in the initial MS immune response.Intrathecal inflammation plays a key role in the pathogenesis of multiple sclerosis (MS). To better elucidate its relationship with peripheral inflammation, we investigated the correlation between cerebrospinal fluid (CSF) and serum levels of 61 inflammatory proteins. Paired CSF and serum samples were collected from 143 treatment-naïve MS patients at diagnosis. A customized panel of 61 inflammatory molecules was analyzed by a multiplex immunoassay. Correlations between serum and CSF expression levels for each molecule were performed by Spearman’s method. The expression of sixteen CSF proteins correlated with their serum expression ( The early and exact diagnosis of neurological diseases is challenging, particularly for multiple sclerosis (MS), due to its pathological and clinical heterogeneity among patients. The need for advanced and specific diagnostic procedures allowed the proposal of several new MS biomarkers, including fluid, imaging, genetic, and immunogenetic biomarkers ,2. In paSeveral experimental and clinical studies demonstrated that the assessment of CSF profiling could specifically reflect intrathecal inflammatory events characterizing MS since early disease phases ,4,5.However, as obtaining CSF from MS patients remains difficult and not always adopted in clinical practice, it is important to compare the results obtained by CSF studies with a paired serum analysis . In addiRecent optimization of advanced techniques for quantitative protein measurements demonstrated that CSF and serum neurofilament light chain (sNfL) concentrations in MS patients are highly correlated, thus sNfL measurements are rapidly gaining traction as a potential biomarker for MS in numerous studies and clinical trials ,8.Our recent studies showed that a specific CSF molecular pattern is associated with an increased intrathecal (meninges and CSF) inflammatory milieu, with cortical gray matter lesion load and more severe progression either at diagnosis or at the time of death ,10. In aTo clarify whether these specific CSF patterns, mainly reflecting intrathecal inflammatory changes , correlap < 0.0001). Five molecules  exhibited a Rho value higher than 0.40, indicating a moderate correlation between serum and liquor expression, whereas the remaining molecules showed a Rho < 0.40  and peripheral (serum) expression levels in MS patients A. The mao < 0.40 B. No sigp-value < 0.001; Rho = −0.20, p-value = 0.03; Rho = −0.25, p-value < 0.01; Rho = −0.28, p-value < 0.01; and Rho = −0.23, p-value < 0.05, respectively); IFNα2 and TSLP also negatively correlated with Gad+ lesions . In the CSF, only the expression of APRIL positively correlated with spinal cord lesions . The CSF expression levels of the other ten molecules  showed positive correlations with the number and the volume of cortical lesions, and T2 white matter lesions (T2WML). However, after FDR correction, most of the reported correlations became not significant. Only two molecules, serum CXCL9 and CSF IFNβ, showed a significant correlation with spinal cord lesions (Rho = −0.35 p < 0.001) and with T2MLV (Rho = 0.33 p < 0.001), respectively  and healthy subjects (HS). Compared to both OND and HS groups, in MS patients the expression of three proteins  was found to increase, whereas only the sIL-6Rα expression was decreased . FurtherFollowing stratification of patients according to the clinical phenotype at the time of diagnosis  we found that the serum expression levels of CXCL9, IFNα2, TSLP, CCL24, and CCL22 were increased in CIS patients compared to RRMS patients . Only CCSeveral clinical and experimental studies have extensively indicated that intrathecal inflammation, possibly compartmentalized in central nervous system (CNS) niches, such as meninges, CSF, choroid plexus, and perivenular spaces, may represent one of the main drivers of progression in MS pathology ,4. This In this cross-sectional study, the evaluation of 61 inflammatory proteins in paired CSF and serum in a large cohort of naïve-treatment MS patients at the time of diagnosis revealed a poor correlation between the inflammatory proteomic profile of CSF and the corresponding serum. Only sixteen molecules showed a significant correlation between the two compartments, and only five of these molecules  showed mild correlations (Rho > 0.40), whereas for the remaining eleven molecules the correlations were not substantial (Rho < 0.40). These data provide further evidence that the CSF inflammatory profile may reflect different disease mechanisms that are not clearly reflected in the serum, probably mainly related to the intrathecal expression of immunomodulators expressed and produced either by cells infiltrating the CNS or resident-activated glial cells.If confirmed, such a hypothesis strongly suggests the relevant role of the assessment of the CSF inflammatory profile at the disease’s onset, reflecting ongoing intrathecal inflammation. CSF molecular profiling may therefore improve the accuracy of diagnosis and help in treatment tailoring .We identified CSF-serum correlation for the expression of 16 molecules that, however, were scarcely correlated with the clinical and MRI parameters evaluated at the diagnosis. Furthermore, none of the serum molecules, such as CXCL9, sTNFR2, IFNα2, IFNβ, and TSLP, which were associated with spinal cord lesions and Gad+ lesions, were correlated with the same parameters considering their CSF expression. It is challenging to explain the potential biological/pathological reason for the negative correlation between serum expression of some inflammatory proteins and the number of spinal cord lesions or Gad+ lesions. Our finding highlights the possibility of early identification of MS patients with a high risk of disease activity and disability accumulation by measuring the serum levels of this inflammatory pattern, together with the use of appropriate imaging tools. In particular, at the time of diagnosis, MS patients are probably characterized by a specific immune-pathogenic profile that may contribute to the prevalence of correspondent disease phenotype. It would be, therefore, interesting to either validate our findings in larger and independent MS cohorts or further analyze the clinical-imaging follow-up of the examined MS patients.Among the five identified molecules, TSLP and INFβ were the only two molecules whose serum expression was increased in MS patients compared to OND and HS. Moreover, the expression of TSLP in serum was able to discriminate between RR and CIS patients. It may, therefore, be suggested that in the initial stage of the disease, these two molecules in the serum may play a key role in regulating the potential resolution and/or activation of the inflammatory processes, including, in particular, the T cell-mediated immune response. A longitudinal follow-up study of the predictive role of these molecules, as well as the validation in an independent MS group, should clarify whether their highest levels at the time of diagnosis may be potentially linked to better disease outcomes.Even if INFβ and IFNα2 showed an opposite expression in the serum of MS patients compared to healthy controls , their serum levels would correlate with the number of spinal cord lesions. On the contrary, the same biomarkers in the CSF were associated with T2WMLV. It would be interesting to understand better why these type I IFNs may reflect different imaging correlates according to the intrathecal (CSF) or peripheral (blood) expression. However, these data strongly support that these molecules play a key role at the beginning of MS inflammatory response. Several studies have previously proposed the importance of type I IFNs in multifunctional immunomodulatory, antiviral, antiproliferative, and anti-inflammatory functions in MS and other chronic inflammatory diseases such as chronic viral hepatitis, experimental colitis, experimental allergic encephalomyelitis, experimental arthritis, and neonatal inflammation ,16.Among the identified molecules present both in CSF and serum samples of examined MS patients, four  were previously described as part of a CSF inflammatory pattern predictive of disease progression and severe cortical damage in MS patients after four years of clinical and imaging follow-up from the diagnosis . TherefoHowever, most of these identified correlations were not strong and became not significant after the FDR correlation. Further validation and functional studies are therefore mandatory to better understand this issue. However, following FDR correction, only the correlation of CXCL9 remained significant, suggesting a key role of this molecule in the spinal cord tissue damage. It is known that CXCL9, particularly overexpressed by stromal cells under inflammatory conditions, is involved, together with other lymphoid chemokines such as CXCL10, CXCL11, CCL2, CCL3, CCL5, and CCL5, in the initial local recruitment of peripherally primed lymphocytes into the target tissues . It woulalb; the majority of MS patients in our cohort showed, in fact, a Qalb below the threshold of 7  serum analysis may be influenced by several other factors even from other peripheral tissues, which may confound the analysis ; (ii) thIn conclusion, this study indicates that the CSF protein profile better reflects intrathecal inflammation and only partially may be associated with the peripheral one. However, serum inflammatory profile seems to correlate with specific MS features such as spinal cord damage and could therefore be helpful for disease diagnosis and prognosis, but also to monitoring therapeutic efficacy. Thus, it deserves further investigation that will help to identify useful blood biomarkers for diagnosis and monitoring.alb .Paired CSF and serum samples were collected from 143 naïve patients at first neurological and radiological assessment, at the time of the clinical onset,  acquired before and after intravenous gadolinium injection; 3D fluid attenuated inversion recovery ; 3D double inversion recovery ; sagittal short-TI inversion recovery ; sagittal T2-weighted ; and axial T2*weighted  images acquired at the locations of the lesions identified on the sagittal images.Brain and spinal cord MRI was carried out for each MS patient using a 3T Philips Achieva scanner . The protocol was: 3D T1-weighted .White and gray matter lesions were identified using FLAIR and DIR images, respectively, following the recommendations for MS lesions assessment ,23. WM lPaired CSF and serum samples were collected at least 2 months after the onset of clinical symptoms(s) and immediately processed according to consensus guidelines for CSF and blood biobanking . After cMolecules that were not detected in at least 50% of CSF and serum samples of the entire cohort  were excluded from the analysis : for thep-value < 0.05 was considered statistically significant. Correlations between serum and CSF expression levels for each molecule were evaluated by using the nonparametric Spearman rank correlation. A pairwise univariate Spearman rank correlation index was also used to measure the association between clinical and MRI variables at diagnosis and both serum and CSF protein levels. A false discovery rate (FDR) correction method with a significance level of 0.05 was adopted to correct the multiple-testing problem. In addition, the results from all the multivariate analyses have been adjusted either for the age at the lumbar puncture or for sex.The R software was used to perform statistical analysis. A Differences between serum expression levels among MS patients stratified according to the clinical form at the time of diagnosis  were assessed using a nonparametric Kruskal–Wallis test followed by pairwise post hoc comparison using Benjamini and Hocberg (BH) approach. The Kruskal–Wallis test, followed by the BH method, was applied to compare serum expression levels between MS, OND, and HS.


Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT.KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America.KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor. Kidney Transplantation (KT) is the best treatment for patients with end stage kidney disease, offering better life expectancy and quality of life to patientsThe number of KT performed in Brazil is increasing, although it is still less than half of the annual need estimated by the Brazilian Association of Organ Transplantation. Thus, the number of patients on the waitlist grows annually, having surpassed 26 thousand in 2020The likelihood to receive a KT becomes even smaller for highly sensitized patients. Before the new allocation policy in the US, the rate of KT with a deceased donor decreased drastically in patients with panel-reactive antibody (PRA) higher than 80% (72% reduction for every 10 points added to the PRA),,,-Living donor KT (LDKT), regardless of kinship, offers better patient and graft survival, presenting an alternative to increase the number of organs offered,Kidney Paired Donation (KPD) offers incompatible donor-recipient pairs the possibility to exchange with another pair in the same situation and performing the transplants, benefiting both recipients-Since the 2000s, KPD programs have been expanding globally, and exist in different types and sizes, and as local, regional or national programs,,,The first description involved only a simple swap between two incompatible pairs. With experience, different ways to perform the exchanges were developed to optimize the benefits for the recipients enrolled for KPD"Closed chains", involving 3 or more pairs, carried out in a way similar to what was described by Rapaport;"Endless chains", started by a deceased or non-direct donor and the last living donor donates to a recipient on the waitlist or becomes a link to begin a new chain in the future;Exchanges involving a deceased donor, in which the incompatible living donor donates to a listed recipient and, in exchange, the incompatible recipient is prioritized on the waitlist;Unbalanced exchanges, when a compatible pair chooses KPD seeking a benefit ;Advanced donation, when there is a chronological incompatibility between donor and recipient, the donation is conducted to a recipient on the waitlist or to start of a new chain. The recipient is given a "voucher" to be prioritized when necessary.,The transplantation capacity of a KPD program depends on the number of pairs registered, on the rate between pairs with ABO incompatibility and positive crossmatch, on the sensitization level of recipients, on the algorithm used for allocation , on the accepted performance models, and on the frequency of match runs for pair allocation,With that in mind, in many countries, the programs are performed on a regional or national level, mainly favoring highly sensitized recipients who tend to accumulate on the waitlistIn 1999, a South Korean study presented their KPD results: patient and graft survival in 5 years were similar to that of haploidentical LDKT and there was no difference in acute rejectionThe first kidney exchange in Europe was conducted in Switzerland in 1999, and 5 years later, the national KPD programs from the Netherlands, the United Kingdom, and Canada had facilitated more than 200 LDKT in each country (29-44% of those registered)In 2016, there were 10 KPD programs in Europe, with different sizes and criteria for acceptance and allocation. Until that year, more than 1300 transplants had been performed in the programs, representing 8% of the LDKT in the continentIn 2020, 20 years after the first transplant with KPD in the US, the outcomes in up to 7 years of the transplanted recipients were analyzed through the National Kidney Registry (NKR), compared to other LDKT recipientsKPD programs are no longer limited to developed countries: in 2017, more than 300 LDKT had been facilitated through KPD in IndiaIn 2010, during the Transplantation Bioethics Forum supported by the Latin American and Caribbean Transplantation Society (STALYC), the "Aguascalientes Document'' was drafted recognizing the legitimacy of KPD( 35).One of the main concerns of programs dedicated to creating longer chains is the possibility of withdrawal by the donor after the start of exchanges, as it is difficult to conduct the procedures simultaneously. In 2017, a study assessing such "break" in the chains of KPD was published. In the analysis performed by the NKR on transplantations carried out in the USA between 2008 and 2016, it became evident that the rate of chain breaks was low and mostly due to a medical contraindication on the part of donorsTo be ethically justified, the KPD program must consider the 4 principles of biomedical ethics: beneficence, nonmaleficence, justice, and autonomy. Living kidney donation (related or unrelated) is justified when beneficence outweighs nonmaleficence and donor autonomy is preserved. These principles are universal and can be extrapolated to KPDBrazilian legislation does not contemplate the possibility of KPD. Law no. 9.434 from February 4, 1997 states that the removal of tissues, organs and body parts of a person in exchancge for payment or promise of reward, as well as for frivolous motives, constitutes a criminal offenceIn 2018, the Brazilian Federal Council of Medicine issued a statement opposing the implementation of KPD in BrazilGlobally, KPD ceased being merely an idea over 20 years ago. Programs with different dimensions, rules of acceptance, and criteria for allocation are being developed and expanded, aiming to meet the demands of patients. The rise in transplantability brought about by KPD meets, especially, the needs of highly sensitized patients, with a possibility of combining KPD with desensitization protocols, seeking the best possible result for that currently vulnerable group(39 )but robust programs that are used almost everywhere in the world and show excellent results, comparable to other LDKT, despite focusing on a population with higher risk and a possible increase in CIT. Another critical issue relates to the main part of the affected population, the highly sensitized people who are sometimes referred to as non-transplantable. A national study in a single center estimated an increase of 7% in the total number of transplants with KPD (which is consistent with the results in the aforementioned countries), and an increase of more than 70% in the number of transplanted recipients with PRA > 80%We believe we have clarified in this review that, contrary to what has been said, KPD programs are no longer "controversial concepts in programs under development"Thus, there seems to be no reason for Brazil not to join KPD, even if initially only locally and then implemented regionally/nationally according to the acceptance of the centers and the necessary logistical adaptation.At the HCFMUSP, KPD research seeks to determine the percentage of living donors rejected due to incompatibility and are eligible for KPD and to determine how many recipients would benefit from such a strategy. As part of this program, the first kidney exchange was carried out in Brazil in March 2020 and 28 additional pairs are currently under evaluation.Nowadays, all the leading countries in world are practicing this procedure and continue to develop it to include more recipients thanks to their excellent results. The importance of this procedure is so great and recognized that in 2012 Alvin Roth and Lloyd Shapley received the Nobel Prize in Economics for their worldwide contribution to the development of algorithms necessary to match a large number of donors and recipients through KDPFinally, it is essential to emphasize that KPD also benefits those on the waitlist who do not have a donor, as it reduces the number of recipients waiting for an organ from a deceased donor. We believe that the Brazilian transplant program is mature enough to take up the challenge of starting a KPD program, primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.


P < 0.008). The onset and duration of perineal irritation of Groups II, III, and IV were significantly improved compared to Group I (P < 0.001). Dexamethasone-induced perineal irritation can be alleviated by dilution of dexamethasone to 0.5 mg/mL with 5% glucose combined with prolonged injection time of 30 s.Dexamethasone can be used to prevent nausea and vomiting after surgery, but there is concern that it may induced perineal irritation. The aim of this study was to investigate the attenuation effect of dilution and slow injection on dexamethasone-induced perineal irritation. In this prospective, randomized, double-blind study, a total of 400 patients were enrolled and allocated into four groups: Group I, receiving 2 mL dexamethasone (5 mg/mL), Group II, receiving 5 mL dexamethasone (2 mg/mL), Group III, receiving 10 mL dexamethasone (1 mg/mL), and Group IV receiving 20 mL dexamethasone (0.5 mg/mL). Dexamethasone was diluted with 5% glucose. The injection time of dexamethasone was less than 2 s in Group I, while it was 30 s in Groups II, III, and IV. The incidence, onset, duration, and severity of perineal irritation were recorded. The incidence of dexamethasone-induced perineal irritation was 49, 33, 17, and 15% in Groups I, II, III, and IV, respectively. Group IV had less severity than Group I in mild and moderate perineal irritation ( The trial was registered prior to patient enrollment at clinicaltrials.gov  with American Society of Anesthesiologists (ASA) physical status I–III, an age between 18 and 65 years, a body mass index (BMI) of 18–24 kg/ mNo premedication drugs were given, and all the patients were instructed to fast for at least 8 h before the induction of anesthesia. After entering the operation room, all the patients were established with an 18-G cannula in the dorsum vein of the right hand, and Ringer Lactate was infused at a rate of 4–6 mL/min. Electrocardiogram, non-invasive blood pressure, and pulse oximeter were obtained.Patients were randomly assigned into four groups and all received 10 mg dexamethasone : Group I receiving 2 mL dexamethasone (5 mg/mL), the injection time of dexamethasone was less than 2 s; Group II receiving 5 mL dexamethasone (2 mg/mL) diluted with 5% glucose, the injection time of dexamethasone was 30 s; Group III receiving 10 mL dexamethasone (1 mg/mL) diluted with 5% glucose, the injection time of dexamethasone was 30 s; and Group IV receiving 20 mL dexamethasone (0.5 mg/mL) diluted with 5% glucose, the injection time of dexamethasone was 30 s.2.2An anesthesiologist who was unaware of study medication observed and asked immediately if patients felt pain or pruritus during the first 5-min period after the injection of dexamethasone. The primary outcome was the incidence of perineal irritation. The secondary outcomes were onset, duration, and severity  of perineal irritation if the patients felt discomfortable.The day before surgery, all the patients were explained about the use of VAS scale to grade the severity of perineal irritation on the scale marked with 0–10. We defined the range of perineal pruritus including vagina, vulva, anus, scrotum, and penis. The severity of perineal irritation was evaluated based on the VAS as none (VAS 0), mild (VAS 1–3), moderate (VAS 4–6), or severe (VAS 7–10).2.3P < 0.05 was considered statistically significant.Statistical analysis was performed by Statistical Product for Social Sciences (SPSS) software . We tested continuous date for normal distribution using Q–Q plots and Shapiro–Wilk test and equality of variance using variance ratio test and Levene test. The age, weight, onset, and duration of pain are presented as mean with SD and were analyzed using one-way analysis of variance and least significant difference multiple comparisons. The comparison of incidence, severity, and ASA physical status were carried out using Chi-square test with Bonferroni correction. Sample size estimation was performed using NCSSPASS software . It was calculated based on our previous study that the incidence of perineal irritation was 48%. We considered a 10% reduction with the gradual decrease of drug concentration as clinically important. This was based on a contingency table (chi-square tests) using 95% power and a 0.05 two-sided type I error probability. A sample size of 329 in all was required, to account for potential withdrawal or incomplete data, 400 patients were planned in all.3The CONSORT study flow diagram is presented in P < 0.008). Groups IV had a lower incidence than Group II (P < 0.008). There was no significant difference in the incidence between Groups I and II, between Groups II and III, and between Groups III and IV (P > 0.008). The incidence of perineal irritation was significantly higher in females than in males in Groups I and II (P < 0.001), as shown in For primary outcome, the incidence of dexamethasone-induced perineal irritation was 49, 33, 17, and 15% in Groups I, II, III, and IV, respectively. Groups III and IV had a lower incidence than Group I (P < 0.008), and Groups IV had less severity than Group I in moderate perineal irritation (P < 0.008). In the onset and duration of dexamethasone-induced perineal irritation, Group I had shorter time than Groups II, III, and IV in onset (P < 0.001), and Group I had longer time than Groups II, III, and IV in duration (P < 0.001).Secondary outcomes are shown in 4Intravenous dexamethasone-induced perineal irritation has been commonly observed during induction of anesthesia –10. BesiThe results of our study showed that when dexamethasone was diluted ten times with 5% dextrose and given 15 times slower, peritoneal irritation findings were seen 34% less compared to concentrated and rapid administration. In addition, we found that females had higher incidence than males, which was consistent with the previous studies –12. The Several measures have been applied to reduce the incidence of dexamethasone-induced perineal irritation. Rewari et al.  reportedThere are many factors associated with dexamethasone-induced perineal irritation, such as gender, drug dosage, concentration, and intravenous injection rate. Therefore, we chose a 10 mg dose in our study, the usually used clinical dose in operation. We also controlled the injection time of dexamethasone less than 2 s. As the incidence of dexamethasone-induced perineal irritation was higher among females than males, we controlled the sex-ratio in each group as 1:1.There were also some limitations for our study. First, our sample size was limited, just dilute the drug concentration to a minimum of 0.5 mg/mL and prolong the injection time for 30 s, and so we may not find the optimal scheme to reduce the incidence of perineal irritation. Second, we only considered the impact of gender on the results, ignoring other factors such as age and weight.5In summary, dexamethasone administered intravenously appears to cause significant perineal irritation, dilution of dexamethasone to 0.5 mg/mL with 5% glucose combined with prolonged injection time of 30 s is an effective, inexpensive, and feasible method to reduce the incidence, duration, and severity of dexamethasone-induced perineal symptoms.


Despite widespread searches, there are currently no validated biofluid markers for the detection of subclinical neuroinflammation in multiple sclerosis (MS). The dynamic nature of human metabolism in response to changes in homeostasis, as measured by metabolomics, may allow early identification of clinically silent neuroinflammation. Using the delayed-type hypersensitivity (DTH) MS rat model, we investigated the serum and cerebrospinal fluid (CSF) metabolomics profiles and neurofilament-light chain (NfL) levels, as a putative marker of neuroaxonal damage, arising from focal, clinically silent neuroinflammatory brain lesions and their discriminatory abilities to distinguish DTH animals from controls.1H nuclear magnetic resonance (NMR) spectroscopy metabolomics and NfL measurements were performed on serum and CSF at days 12, 28 and 60 after DTH lesion initiation. Supervised multivariate analyses were used to determine metabolomics differences between DTH animals and controls. Immunohistochemistry was used to assess the extent of neuroinflammation and tissue damage.p < 0.0001; CSF: 69.3 [13.5]%, p < 0.0001). The top discriminatory metabolites at day 12  were all reduced in DTH animals compared to controls, and correlated with histological markers of neuroinflammation, particularly astrogliosis . Serum and CSF NfL levels did not distinguish DTH animals from controls at day 12, rather, significant differences were observed at day 28 . Neither serum nor CSF NfL levels correlated with markers of neuroinflammation; serum NfL did, however, correlate strongly with axonal loss , but CSF NfL did not (p = 0.137).Serum and CSF metabolomics perturbations were detectable in DTH animals (vs. controls) at all time points, with the greatest change occurring at the earliest time point (day 12) when the neuroinflammatory response was most intense (mean predictive accuracy [SD]—serum: 80.6 [10.7]%, While NfL levels were elevated later in the pathogenesis of the DTH lesion, serum and CSF metabolomics were able to detect early, clinically silent neuroinflammation and are likely to present sensitive biomarkers for the assessment of subclinical disease activity in patients.The online version contains supplementary material available at 10.1186/s12974-022-02614-8. For control animals, 2 μL of sterile PBS was injected. No stereotaxic surgery was performed for naïve animals.Following isoflurane-induced anaesthesia, the head of the animals were shaved, sterilized and mounted on a stereotaxic frame. Under an operating microscope, a small midline scalp incision was made after bupivacaine injection and a burr hole was created using a dental drill at 1 mm anterior and 3 mm lateral to the bregma. Two microlitres of heat-killed Bacillus Calmette–Guérin (BCG) , shaved, and mounted with neck hyperflexion to allow for maximal access to the cisterna magna, via which ~ 150 μL of clean CSF was drawn using a 25 G needle attached to a 1 mL syringe. CSF obtained was centrifuged , aliquoted, and stored immediately at − 80 °C. Following CSF sampling, blood was collected via cardiac puncture, transferred to a serum tube (BD™ 367837), left to stand for 30 min, and then centrifuged . Serum obtained was aliquoted and stored immediately at − 80 °C.Animals were then transcardially perfused with heparinized saline followed by 4% paraformaldehyde. Brains were harvested, post-fixed in 4% paraformaldehyde overnight and cryoprotected with 30% sucrose, after which they were embedded in OCT compound, frozen in cold isopentane, and stored at − 20 °C.Brains were cryosectioned at 10 μm thickness (Leica Microsystems). Following heat-induced antigen retrieval, quenching and blocking with 10% goat serum, sections were incubated with primary antibodies overnight at 4 °C. The primary antibodies used were: anti-IBA1  for microglia/macrophages; anti-GFAP  for astrocytes; anti-MBP  for myelin, and anti-NfH  for axons.® Elite ABC-HRP (Vectorlabs) for 1 h. Antibody binding was visualized using 3, 3′ diaminobenzidine (Sigma-Aldrich) as the chromogen. Sections were then counterstained in cresyl violet, dehydrated, cleared, and mounted with DPX mounting media.Sections were then incubated with goat anti-rabbit biotinylated secondary antibody (Vectorlabs) for 2 h, followed by VectastainHistological assessment was performed by an assessor blinded to experimental groups and time points.2 (averaged across the 5 fields).Neuroinflammation was assessed by quantifying the number of IBA1 and GFAP-positive cells in 5 non-overlapping fields at 20X magnification at the medial edge of the outer active border. Images were imported into ImageJ and cells manually counted using the ‘Cell Counter’ function . Final c2.Tissue damage was quantified by the area within the striatum that was devoid of MBP and NfH staining. Images were obtained using a whole slide image scanner connected to a light microscope at 20X magnification and the area calculated using ImageJ , express1H nuclear magnetic resonance (NMR) spectroscopy metabolomics was performed using a 700-MHz Bruker AVIII spectrometer operating at 16.4 T equipped with a 1H [13C/15 N] TCI cryoprobe. After thawing, 245 μL of serum or 80 μL of CSF were buffered with 75 mM sodium phosphate buffer, giving a final volume of 550 μL for each NMR sample, which was then transferred to a 5-mm borosilicate glass tube (Norell™).Serum spectra were acquired using a spin-echo Carr–Purcell–Meiboom–Gill (CPMG) sequence  to suppress broad signals arising from large molecular weight serum components. CSF spectra were acquired using a 1D-nuclear overhauser effect spectroscopy (NOESY) presaturation scheme  for attenuation of the water resonance. Details of NMR spectra processing have been previously published . Followi® assay (Quanterix). Assay methodology has been previously described [CSF and serum NfL levels were determined using the Simoaescribed . Laboratropls package [k-fold external cross-validation with 100 repetitions . This involves repeated cycles of (1) balancing group sizes, (2) random partitioning of the spectral data into a training set and a test set, (3) constructing OPLS-DA models using the training set alone with leave-one-out internal cross-validation, and then (4) determining the predictive accuracy using the independent test set. The metabolomics distinction between animal groups was only valid if the mean predictive accuracy of the ensemble of model accuracies was significantly higher than the mean predictive accuracy of a separate ensemble created by random class assignments (i.e. null distribution) on the same spectral data.Orthogonal partial-least square discriminant analysis (OPLS-DA), using in-house R scripts and the  package , 29, 30,r, was used to determine the strength of correlations. Two-tailed p values of < 0.05 were considered statistically significant.Univariate analysis was performed using GraphPad Prism . Comparative analyses between groups were performed using one-way ANOVA with Tukey post hoc corrections. Two-way ANOVA was used to compare across treatment groups and time points, with Sidak test for multiple comparison corrections. Pearson coefficient, A focal neuroinflammatory lesion centred at the site of BCG implantation was observed in all DTH animals Fig. A. The 5 DTH animals had a higher density of IBA1-positive cells (i.e. microglia/macrophages) compared to control animals at all time points Fig. A, with tThe density of GFAP-positive cells (i.e. astrocytes) was also higher in DTH animals compared to controls at all time points Fig. B. Cell dThe area devoid of MBP staining (i.e. myelin loss) within DTH animals was the lowest at day 12, rose at day 28, and plateaued at day 60 Fig. C. SimilaNo differences in CSF and serum NfL concentrations were noted between control and naïve animals at any time point , which resolved by day 60 , with a weaker correlation for CSF NfL   but not for CSF NfL (p = 0.137).Correlations of CSF and serum NfL with histological markers were performed to determine if NfL can represent a surrogate marker for neuroinflammation and tissue damage throughout the DTH disease course. Normalized data for NfL levels, IBA1 and GFAP-positive cell densities were used for correlation analyses to account for basal levels within controls, thus representing the actual contribution by the DTH lesion. As there was no myelin or axonal loss observed in controls, absolute values in DTH animals were used. A moderate correlation was observed for serum NfL concentration with myelin loss (r range: 0.53–0.89) [It is argued that following axonal injury, NfL is first released into the extracellular space, then into CSF, and finally into blood . Clinica53–0.89) , 33, henr = 0.642, p < 0.0001), as was the case within DTH animals   and 60 (r = 0.654), but not at day 12.Within all animals across all time points, a moderately strong correlation was observed   Fig. B, validap < 0.0001), while this was 72.7 (12.5)% vs. 44.4 (17.7)% (p < 0.0001) at day 60, confirming the presence of serum metabolomics differences at these time points.The predictive accuracy for the ensemble of the OPLS-DA models for DTH vs. control animals at day 28 was significantly higher than that of the random class ensemble  of DTH vs. control animals at each time point are shown in Fig. A similar analytical strategy was employed to explore if CSF metabolomics alterations were also present at different time points. CSF samples with visible blood contamination were excluded from metabolomics analysis as this can introduce aberrant NMR resonances in the CSF spectra   Fig. E, validap < 0.0001), while the mean accuracy at day 60 was 50.6 (12.3)% for the defined-class ensemble against 44.3 (18.4)% for the random ensemble (p = 0.0008). These results suggest that although there were still CSF metabolomics differences between DTH and control animals at these latter time points, they were less pronounced than those observed at day 12 as illustrated in Fig. For day 28, the predictive accuracy for the DTH vs. controls ensemble of OPLS-DA models was higher than that of the random ensemble  scores from the OPLS-DA models were generated. The VIP score summarizes the contribution a variable makes to the model and hence its discriminatory importance—a higher score represents a greater contribution . The topThe VIP ranking plot obtained from the serum OPLS-DA models is shown in Fig. , revealing that allantoin and cytidine levels were lower in DTH compared to control and naive animals, although the difference in cytidine concentration between DTH and naïve animals did not reach statistical significance (p = 0.061).To demonstrate that altered allantoin and cytidine concentrations were specific for the DTH lesion at day 12, one-way ANOVA of both metabolites across all 3 treatment groups were performed Fig. B, D, revTo explore how allantoin and cytidine concentrations change within DTH animals over disease course, data were first normalized to mean levels in controls at each time point. One-way ANOVA was then performed across time points within DTH animals, revealing that allantoin and cytidine concentrations increased with time back to levels seen in controls Fig. C, E.The same approach was used to identify the top discriminatory CSF metabolites at day 12. The VIP ranking plot derived from the CSF OPLS-DA models is shown in Fig. p = 0.110).To determine whether the changes in glutamine and glucose levels were attributable to the DTH lesion, one-way ANOVA of both metabolites at day 12 across all 3 treatment groups were performed Fig. G, I. GluGlutamine and glucose concentrations within DTH animals were then normalized to controls at each time point to explore their fluxes over the time. One-way ANOVA performed across the time points within DTH animals showed that glutamine concentrations increased with time to levels seen in controls, while glucose concentration was the lowest at day 12 and peaked at day 28 Fig. H, J.To investigate if the top serum  and CSF (glutamine and glucose) metabolites can inform on underlying pathological processes, correlations with histological markers were performed. Normalized data  were used for correlation analyses as these represented changes attributable to the DTH lesion.r = − 0.562, p = 0.004)  and positively with markers of tissue damage (r range: 0.426–0.445). CSF glutamine concentration was inversely correlated with astrocyte cell density  and positively correlated with area of myelin and axonal loss, albeit modestly (r range: 0.418–0.430). Glucose concentration was positively correlated with area of axonal loss, with an r of 0.667 (p = 0.0005), indicating moderately strong correlation.Serum allantoin concentration correlated inversely with astrocyte cell density (04) Fig. . Serum cThe results presented here reveal that: (1) serum and CSF metabolic perturbations from a focal DTH lesion were detectable at all experimental time points, with the greatest perturbations occurring at the earliest time point (i.e. day 12) when the lesion area was least, but the inflammatory response was most intense, (2) the top discriminatory serum and CSF metabolites identified at day 12 were specific for the presence of the DTH lesion; the magnitude of their changes decreased with time to return to the levels observed in controls, and (3) the discriminatory metabolites correlated with histological markers of neuroinflammation and tissue damage; in particular, there were robust correlations for astrogliosis with serum allantoin and CSF glutamine, as well as axonal loss with CSF glucose.r range: 0.86–0.94) were noted in diseased animals in which CSF NfL concentrations of > 20,000 pg/mL were observed. However, in wild-type animals, whereby CSF NfL concentrations were mostly < 1000 pg/mL, the correlation was weaker (r = 0.47). These observations suggest that such correlations are present only if the CSF NfL concentration exceeds a high enough threshold, presumably to allow enough to leak into the blood for a corresponding change to be detected.While alteration in the metabolome could be used to distinguish between DTH and control animals at day 12, CSF and serum NfL concentrations could not. Indeed, NfL could only be used to separate the groups at day 28 and this was no longer possible at day 60. It is of note that there were still serum metabolomics differences between DTH and control animals at day 28 and at day 60. Interestingly, CSF and serum NfL levels did not correlate with neuroinflammatory histological markers, but both correlated with myelin loss. Serum NfL alone showed a robust correlation with axonal loss as revealed by NfH staining. The absence of a correlation between CSF NfL levels and NfH-determined histological axonal loss may reflect the topological relationship between the position of the lesion and the CSF sampling point; the lesion being present within the forebrain rather than the spinal cord. Thus, the assumption that NfL enter the blood via the CSF may not be true for all lesions along the neuraxis. Our findings also indicate that, in contrast to the metabolome, NfL is a delayed marker of lesion formation/tissue damage as there is already histological evidence of axonal loss and demyelination at day 12 in the model. The turnover rate and half-life of NfL in humans is poorly understood, but, from these studies, it is now clear that the appearance of NfL occurs later in the pathogenesis of an MS-like lesion. Plausible explanations could be the slow release of NfL from damaged axons into the brain interstitial fluid, and/or the slow transport from there into the CSF via the glymphatics/intramural peri-arterial drainage pathways , 35. We The OPLS-DA approach enabled us to construct discriminatory models, and in so doing, identify the principal discriminatory metabolites—serum allantoin and cytidine, and CSF glutamine and glucose. Their correlations with histological markers of neuroinflammation and tissue damage lend support for the interrogation of their metabolic pathways to provide inference to the pathophysiological processes underlying DTH lesion formation.Allantoin is the metabolic end product of purine catabolism in rodents , 38. In 1H NMR spectroscopy, precluding confirmation of this hypothesis in this study.The low allantoin concentrations observed is consistent with other metabolomics studies in MOG-EAE models showing lower plasma and urine allantoin levels as compared to controls , 18. ThiCytidine is a pyrimidine nucleoside required for RNA synthesis and is also a precursor for cytidine triphosphate required for the production of phosphatidylcholine, which is a major component of the neuronal membrane and myelin , 48. A sPerturbations in CSF glucose and glutamine  point towards an energy deficient state within the CNS resulting from metabolic decoupling between neurons and glial cells. Recently, we have demonstrated that the concentrations of these 2 metabolites were lower in the CSF of MS patients compared to non-MS controls , consistDuring neuroinflammation, low CSF glucose could arise from several deranged metabolic pathways including: (1) increased glucose uptake by neurons as the major fuel substrate for adenosine triphosphate (ATP) production caused by reduced lactate shuttling from astrocytes, (2) increased anaerobic glycolysis in neurons from reduced oxidative phosphorylation due to mitochondrial failure, and (3) increased glucose uptake by glial/immune cells to meet energy demands required to mount an inflammatory response , 53. RedIn conclusion, we have shown that serum and CSF metabolomics, and indeed selected metabolites, are able to detect early subclinical lesions and that these perturbations normalize with time. This suggests that metabolomics could be explored as potential biomarkers of subclinical disease activity, and dovetails with our recent findings on its application to differentiate clinical relapses from remission . Indeed,Additional file 1: Fig. S1 Weight of all animals at the 3 experimental time points. No weight differences were observed between the treatment groups at each time point on two-way ANOVA. ANOVA: analysis of variance; DTH: delayed-type hypersensitivityAdditional file 2: Fig. S2 CSF and serum NfL concentrations in control and naïve animals. No differences in NfL concentrations were observed between the 2 groups in both (A) CSF and (B) serum on two-way ANOVA. ANOVA: analysis of variance; NfL: neurofilament-light chainAdditional file 3: Fig. S3 Correlation between CSF and serum NfL concentrations. (A) In all animals at all time points, (B) stratified by treatment groups at all time points, and (C) within DTH animals stratified by time points. DTH: delayed-type hypersensitivity; NfL: neurofilament-light chain; r: Pearson correlation coefficientAdditional file 4: Fig. S4 Comparison of clean vs. blood-contaminated CSF NMR spectra. (A) 1D-NOESY-presat spectra  demonstrating clean CSF (in blue) and blood-contaminated CSF (in red). This revealed aberrant NMR resonances contributed by lipoproteins and macromolecules  in blood, resulting in a broad signal with an elevated baseline . (B) Zoom-in view of this boxed region showed additional resonances arising from the mobile methyl (CH3) and methylene (CH2) groups within lipoproteins, as well as from the branched chain amino acids . NMR: nuclear magnetic resonance; NOESY: nuclear overhauser effect spectroscopy; ppm: parts per millionAdditional file 5: Table S1 The top 2 serum metabolites differentiating DTH and control animals at day 12.Additional file 6: Table S2 The top 2 CSF metabolites differentiating DTH and control animals at day 12. *As multiple ‘bins’ are attributable to glucose, only those with a VIP rank of < 10 are shown.


Multivariate linear regression revealed that there was no association between length of CPR and DAOH . Conclusions: Donor CPR status and length of CPR are not associated with reduced DAOH at one year after HTX.Background: The number of patients waiting for heart transplantation (HTX) is increasing. Optimizing the use of all available donor hearts is crucial. While mortality seems not to be affected by donor cardiopulmonary resuscitation (CPR), the impact of donor CPR on days alive and out of hospital (DAOH) is unclear. Methods: This retrospective study included adults who underwent HTX at the University Hospital Duesseldorf, Germany from 2010–2020. Main exposure was donor-CPR. Secondary exposure was the length of CPR. The primary endpoint was DAOH at one year. Results: A total of 187 patients were screened and 171 patients remained for statistical analysis. One-year mortality was 18.7%. The median DAOH at one year was 295 days (interquartile range 206–322 days). Forty-two patients (24.6%) received donor-CPR hearts. The median length of CPR was 15 (9–21) minutes. There was no significant difference in DAOH between patients with donor-CPR hearts versus patients with no-CPR hearts (CPR: 291 days (211–318 days) vs. no-CPR: 295 days (215–324 days);  The number of patients waiting for heart transplantation (HTX) is constantly increasing due to factors such as demographic shift and improved medical treatment ,5,6,7,8.One criterion to consider in the allocation is a status of cardiopulmonary resuscitation (CPR) of the donor. Recent studies showed that mortality was not altered by the usage of donor CPR hearts after HTX, even when adjusted for longer durations of CPR and no-flow-time ,11,12,13This study was conducted as a retrospective cohort study at the University Hospital Duesseldorf in accordance with the declaration of Helsinki and the guidelines for good clinical practice. The ethical review board of the Heinrich Heine University Duesseldorf approved the study protocol (reference number 4567). As all patients gave their written informed consent to be included in the prospective heart transplantation database of the University Hospital Duesseldorf, the need for additional written informed consent for this retrospective analysis could be waived. The present analysis complements a recent analysis by M’Pembele et al. (under review) which investigated life impact of perioperative variables after HTX. All included variables in this study were based on a meta-analysis . As donoThis report was written according to the “Strengthening the Reporting of Observational studies in Epidemiology” (STROBE) guidelines .Inclusion criteria for this study were defined as HTX from September 2010 to December 2020 at our institution and age ≥18 years. Exclusion criteria were: incomplete medical records and missing data regarding the main exposures and/or the primary endpoint. Patients were then divided into two groups according to their main exposure: patients receiving hearts of donors that underwent cardiopulmonary resuscitation (donor-CPR-group) and patients receiving CPR-naive hearts (no-CPR-group). As a secondary exposure, we analyzed the length of CPR. All data were extracted from the local HTX database, as well as from electronic medical charts and included patient characteristics, medical history, and hospitalizations within one year.The primary endpoint of this study was days alive and out of hospital (DAOH) at one year after HTX. The calculation of DAOH was performed in the same manner as reported previously ,17. Brie© . Continuous variables are reported as mean ± standard deviation (SD) or as median with interquartile ranges (IQR) whenever appropriate, while categorical variables are presented as absolute numbers and percentages.Statistical analysis was performed using GraphPad Prism©  and IBM SPSSTo compare DAOH depending on the donor-CPR status, we performed a Mann–Whitney U test. In order to assess the impact of the CPR length, we stratified the donor-CPR group by quartiles of CPR duration in four groups  of similar size. Group comparison was performed with a Kruskal–Wallis test adjusted for multiple comparisons. Further, we conducted univariable linear regression to quantify the potential correlation between donor-CPR duration and DAOH. This was expanded by a multivariate linear regression model adjusting for donor age, mechanical ventilation, and renal replacement therapy based on M’Pembele et al. 2022 (under review). Finally, univariate survival analysis of donor-CPR- and no-CPR patients was conducted by computing Kaplan–Meier curves.In total, 187 patients underwent HTX at out center from September 2010 to December 2020. After exclusion of 16 (6.4%) patients due to missing data regarding CPR length or DAOH, 171 eligible patients were identified and analyzed, of which 42 (24.6%) received hearts from donors that underwent cardiopulmonary resuscitation see .Mean age for recipients was 54 ± 11 years, 74 out of 171 (43%) patients were female. Mean age for donors was 43 ± 13 years. The median length of CPR was 15 min (IQR: 9–21 min). The inotropic dobutamine was administered to 21% of the donors with CPR status and to 9% of the no-CPR donors. Recipients and donor characteristics are specified in detail in p = 0.619, see There was no significant difference in DAOH after one year between donor-CPR patients: 291 days (IQR: 211–318 days) vs. no-CPR patients: 295 days . According to multivariate linear regression, the association between length of donor-CPR and DAOH was still not significant , whereas significant associations of known risk factors for low DAOH were unaffected   see .The current study aimed to analyze the impact of donor-CPR on DAOH after HTX. Our findings are in line with data on survival and suggest that a status of donor-CPR as well as the length of CPR do not negatively affect DAOH after one year.Mehdiani and colleagues have shown in a retrospective study that postoperative morbidity and one-year mortality are not affected by CPR prior to organ donation in heart transplant patients . From thn = 29,242, n = 1396 with history of CPR), reaching the conclusion that cardiac arrest and subsequent cardiopulmonary resuscitation did not induce poorer outcomes for the recipients [Even earlier than that, the group around Quader and colleagues conducted a retrospective analysis of a large number of cases of HTX in the USA  ,22. HoweSeeing the scarcity of data on patient-centered outcomes, our study could further assist physicians when making choices on donor eligibility and organ allocation. Of course, clinicians primarily have to answer the question if suitable patients for HTX are able to survive when receiving a donor heart with a history of CPR. However, after successful HTX, this focus might change and factors related to functional capacity and QOL might get more and more important. From our point of view, being in hospital is not compatible with good QOL. Consequently, the number of days patients are alive and not hospitalized (=DAOH) after HTX might be an appropriate measure of long-term life impact and QOL to an extent. Referring to our data, the lack of significant difference in DAOH between our study cohorts thus might be interpreted as an additional measure of safety and suitability for CPR-positive donor hearts in regard to patient quality-of-life. Additionally, fewer days in hospital means less financial burden on healthcare systems, and DAOH might be used as a surrogate marker for healthcare costs.Our current study is subject to the usual limitations that incur for retrospective analyses. However, our center’s HTX database is collected prospectively, which can serve to ensure the quality of the data we analyzed. This study also suffers from being limited to a single center and having a modest sample size. Another limitation is the impossibility of including hospitalizations outside of our university hospital into the DAOH calculation. Although patients that underwent HTX at our center are closely connected and normally referred to us for care, we cannot exclude missing data on hospital stays, which might alter the results of our calculations.On the other hand, the usage of DAOH as our endpoint bears the strength of including an objective quantification of QOL and healthcare costs, in addition to the standard assessment of mortality alone. A further strength of this study is the one year follow-up period.With this study, we were able to show that donor CPR status and length of CPR are not associated with a reduction of DAOH at one year after HTX. Our findings emphasize the approach that CPR status might be regarded as a less important factor when deciding on donor eligibility and allocation, even for extended durations of CPR. Importantly, the results of this study should be reproduced in larger cohorts with a prospective design before final conclusions can be drawn.


There was almost no substance that has provided similarly remarkable results in end-stage liver disease as G-CSF, and consequently it was already considered a possible standard therapy for these patients. Published in 2012, Garg et al. showed in a small single-center trial with in total of 47 patients that the administration of G-CSF with a dose of 5 µg/kg s.c. and 12 injections over a period of 26 days improved the 60-day survival of patients with acute-on-chronic liver failure (ACLF) from about 30% to almost 70% [However, the view that G-CSF may be a potential new standard therapy in patients with decompensated cirrhosis with or without ACLF has been questioned by the results of two European multicentre studies that failed to confirm the positive effects previously observed. The REALISITC trial evaluated whether G-CSF as a monotherapy or in combination with hematopoietic stem cell reinfusion acted as a disease-modifying therapy for patients with compensated liver cirrhosis and a MELD score of 11 to 15.5. In total 81 patients were randomly assigned to one of the three treatment arms and G-CSF was given high-dose of 15 µg/kg for 5 days. None of the experimental therapies was able to exhibit a beneficial effect on survival or liver function . The GRAp = 0.053) for those receiving standard medical therapy. None of the patients was transplanted. Patient treated with G-CSF improved their Child–Pugh score, most likely due to an improvement of ascites, whilst the MELD score was unaffected, generally adding to the persistent conflicting results between the single-center trials and recent multicentre trials. In addition, G-CSF treatment reduced the number of SBP infections from 39.4% to 12.1% whilst non-SBP infections were not different. The rational to prolong the treatment with G-CSF in a cohort with lower short-term mortality than patients with ACLF to maximise its pro-regenerative and immune-modulatory capacities seems plausible and indeed, the resolution of ascites and the low number of SBP infections was likely to be the consequence of these effects.The study by PMID: 35322373 presented in the current issue of Hepatology International tried to add more evidence on the safety and efficacy of G-CSF long-term treatment in patients with decompensated cirrhosis. The same group which published the first study with multiple cycles of G-CSF in decompensated cirrhosis  presenteHowever, potential shortcomings of the current study design need to be discussed in the context of the mixed treatment response with an improvement of Child–Pugh score and reduced SBP rate on the one hand and no impact on patients’ outcome in terms of transplant-free mortality on the other hand. It can be argued that this is mainly a consequence of insufficient sample size, which means that consistent results could have been achieved with a larger number of patients. This point highlights a potential general concern not only with the current study but with most of the overall existing body of studies on the use of G-CSF in patients with advanced liver disease, where the study design, particularly the small sample size and lack of external validation due to the single-centre study design, does not allow us to answer questions about subgroups who may or may not benefit from G-CSF therapy. It rather increases the risk of a selection bias and overestimation of the actual effect size. Assuming that G-CSF may have its indication in certain subgroups of patients with end-stage liver disease a collaborative work including individual patient data from all studies performed so far would help identifying markers to predict treatment response for G-CSF and to decipher the heterogeneity of patients among the trials.Among the pleotropic effects of G-CSF, the modification of immune cell function is one of those of particular importance when considering potential beneficial effects in patients with decompensated liver disease and ACLF . These pWhen critically reviewing the current literature it becomes apparent that G-CSF may have several and in part opposing effects on immune cell phenotypes and functionality depending on the cellular microenvironment and disease state. Fostering the recruitment and generation of immunomodulatory cells by G-CSF to reduce inflammation and prevent infections may be desirable in end-stage liver disease and in fact, mobilisation of CD4+ CD25+ CD39+ regulatory T cells was associated with better outcome . It woul+Ly6C+ neutrophils, which enhance tumours growth in models of metastatic tumours [G-CSF, however, not simply induces unidirectional, beneficial effects in individual cell subsets but may also lead to immune cell changes, which can be detrimental. Cell subsets mobilised by G-CSF can exhibit a more pro-tumorigenic phenotype as shown for Ly6G tumours . This so tumours . G-CSF n tumours . Hence,  tumours , 17. And tumours . TherefoIs G-CSF a double-edged sword and does the question of whether patients should be treated with G-CSF or not depend mainly on when in the course of the disease G-CSF is administered? It seems plausible that patients with recent ACLF onset and high-grade systemic inflammation are less likely to benefit from an additional recruitment of neutrophils and monocytes by G-CSF therapy. However, a considerable number of patients remain in a status of persistent organ dysfunction and lack of recovery after the resolution of the first ACLF event , 20. TheFurther studies addressing both, disease-related and treatment-related aspects, will be needed to understand in which clinical scenario G-CSF may act beneficially and to refine the target population accordingly. The art will be to decipher the exact mechanisms by which G-CSF acts in the context of the different stages of liver disease and to identify those who may potentially benefit from its immune-modulatory or pro-regenerative capacities or both. To this end, harmonisation of the current definitions of decompensated liver cirrhosis and ACLF, which are still characterised by relevant clinical heterogeneity, would be a fundamental prerequisite. We also need to better understand whether long-term administration with multiple cycles of G-CSF, as shown in the current study, is preferable to short-term treatment to stabilise neutrophil and monocyte function and reduce the long-term risk of infection in patients with end-stage liver disease. Further clinical trials need to investigate whether, particularly in clinical conditions where there is a risk of endotoxin-induced organ dysfunction, such as ACLF and acute alcoholic hepatitis, both, regeneration and inflammation can be positively influenced synergistically by a combination of G-CSF with an anti-inflammatory drug, which could expand the safety and efficacy as well as the therapeutic window for the use of G-CSF. Other combinatory or sequential treatment approaches where G-CSF was complemented by other stimulatory compounds such as erythropoietin  or growt


Handwashing with soap and water is an important way to prevent transmission of viruses and bacteria and worldwide it is estimated handwashing can prevent 1 in 5 viral respiratory infections. Frequent handwashing is associated with a decreased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Using a hand sanitizer with at least 60% alcohol when handwashing is not feasible can also help prevent the transmission of viruses and bacteria.Since early 2020, the public has been encouraged to handwash frequently with soap and water and use alcohol-based hand sanitizer when soap and water are not available to reduce COVID-19 transmission. This study’s objectives were to assess U.S. adults’ perceptions of components of the Capability, Opportunity, Motivation and Behavior (COM-B) Model in relation to these two hand hygiene behaviors and to identify relationships between these components and hand hygiene behaviors.FallStyles, a survey completed by 3,625 adults in the fall of 2020 through an online panel representative of the U.S. population. We calculated composite capability, opportunity, and motivation measures and descriptive statistics for all measures. Finally, we conducted multiple logistic regressions to identify predictors of handwashing and hand sanitizer use.Items assessing capability, opportunity, motivation, and hand hygiene behaviors were included in Most respondents reported frequently washing hands with soap and water (89%) and using alcohol-based hand sanitizer (72%) to prevent coronavirus. For capability, over 90% of respondents said that neither behavior takes a lot of effort, but fewer agreed that they knew when, or how, they should engage in handwashing  and hand sanitizer use . For opportunity, over 95% of respondents said lack of time didn’t make it hard to engage in either behavior; fewer said visual cues reminded them to engage in the behaviors . For motivation, the majority believed the two behaviors were good ways to prevent coronavirus illness . Regressions indicated that capability, opportunity, and particularly motivation were positively associated with both hand hygiene behaviors.The COM-B model was a helpful framework for increasing understanding of hand hygiene behavior; it identified capability, opportunity, and motivation as predictors of both handwashing and hand sanitizer use. Handwashing with soap and water is an important way to prevent transmission of viruses and bacteria and worldwide it is estimated handwashing can prevent 1 in 3 diarrheal illnesses and 1 in 5 viral respiratory infections , the virSince the beginning of the COVID-19 pandemic, the U.S. Centers for Disease Control and Prevention (CDC) has included frequent handwashing with soap and water  in its recommendations to prevent the spread of SARS-CoV-2 . Hand hyNumerous studies have described factors associated with hand hygiene behavior during the COVID-19 pandemic. These include demographic factors such as gender, age, income, education, and self-rated health , 16–19 aAn increasing number of studies have used behavioral science theories to guide formative research on hand hygiene behaviors during the COVID-19 pandemic , 27, 28.FallStyles, was conducted from September 24 – October 10, 2020 (prior to the availability of COVID-19 vaccines). The survey was sent to a sample of 4,548 panelists ages 18 or older who answered the spring wave  of the survey. Email reminders were sent to non-responders on day 3, 7 and 13 of the survey period. Respondents completed surveys in a median time of approximately 33 min. Respondents were not required to answer any of the questions and could exit the survey at any time; data from respondents who did not answer at least half of the questions or completed the survey in five minutes or less were removed from the dataset (n = 8). A total of 3,625 adults completed the survey for a response rate of 79.7%. The analyses were weighted to match the U.S. Census 2019 U.S. Current Population Survey proportions by gender, age, annual household income, race/ethnicity, household size, education, census region, metropolitan status, and parental status. See the Porter Novelli website for more information on ConsumerStyles methodology [In 2020, Porter Novelli Public Services conducted several surveys via Ipsos’ KnowledgePanel, an online panel that is representative of the non-institutionalized U.S. population . RespondData on multiple demographic characteristics were collected when respondents agreed to participate in the survey panel. Of those, gender, age, income, education, race/ethnicity, and geographic region (based on U.S. Census regions) were included in our analyses as statistical controls.To assess hand hygiene precautions taken in response to COVID-19, respondents were asked, “What, if any, precautions are you taking to prevent coronavirus?”. They were then provided a list of precautions, presented randomly, and asked to endorse those they engaged in. We present data on the following hygiene-related behaviors from the list of precautions: washing hands often with soap and water and using alcohol-based hand sanitizer (hereafter referred to as handwashing and hand sanitizer use) , two focused on perceived severity , and three focused on perceived behavioral control . Exploratory factor analyses of the items indicated that these items should be treated individually. For interpretability’s sake, several items were reverse scored Table .Table 3PWe calculated weighted frequencies and means for the hand hygiene behaviors Table , as well1Respondent demographic characteristics, weighted to match the U.S. population, are included in Table N = 3,237; weighted N = 3,210) and were using alcohol-based hand sanitizer  to prevent coronavirus  and the majority reporting that they are capable of frequently washing their hands to prevent coronavirus (76%), have the supplies to wash hands frequently (74%), and know how to wash hands to prevent coronavirus (74%) Table . About tFor the composite measures, respondents scored an average of 3.6  on the capability measure, an average of 0.6  on the opportunity measure and an average of 2.5  on the motivation measure.Respondents report high levels of capability to use hand sanitizer, with almost all respondents reporting that it does not take a lot of effort to frequently use hand sanitizer (93%) Table . Two thiFor the composite measures, respondents scored an average of 3.2  on the capability measure, an average of 0.80  on the opportunity measure and an average of 2.0  on the motivation measure.Less than half (49%) of respondents said they were concerned about their own risk of infection with coronavirus Table . Over 80p < 0.05) with respondents reporting that they wash their hands often with soap and water to prevent coronavirus (Table Multiple logistic regressions identified seven variables that were significantly associated (us Table . Those wp < 0.05) with respondents reporting that they were using alcohol-based hand sanitizer to prevent coronavirus , self-reported handwashing appeared to drop four percentage points from 93 to 89%) between spring of 2020 and fall of 2020   were related to hand hygiene behaviors. The COM-B model states that individuals must have both the psychological and physical capability to engage in a specific behavior . This inThe composite measure of capability was associated with both hand hygiene behaviors assessed in this study, although the relationship was stronger for hand sanitizer use than for handwashing. The finding of association between capability and hand hygiene is consistent with studies conducted both before and during the pandemic. In a pre-COVID-19 systematic review, White et al. (2020) found that knowledge of when to wash hands and having access to supplies were positively associated with handwashing . A studynot remind them to engage in hand hygiene behaviors. Indeed, the composite variable for opportunity, which included two items assessing visual cues, had a negative association with handwashing and was not associated with hand sanitizer use. This finding contrasts with work conducted before the COVID-19 pandemic that found that being cued by handwashing facilities tended to be positively associated with handwashing [Opportunity in the COM-B model refers to the physical and social opportunities for individuals to engage in a specific behavior and includes factors such as having time or resources to do the behavior, cues to engage in the behavior, and interpersonal influencers such as social cues and norms . Our datdwashing . It is udwashing , 41. Altdwashing .Overall, however, our results suggest that when designing health communication, education, and behavior change interventions to promote hand hygiene behavior, a focus on the construct of opportunity may not be as useful as focusing on other constructs of the COM-B model.Of the three COM-B constructs evaluated in this study, motivation was most strongly associated with likelihood to report frequent handwashing and hand sanitizer use. The COM-B model posits that an individual must have enough motivation to engage in a particular behavior rather than engage in other behaviors or to not engage in any behaviors at all . Our resOur data on motivation measures suggest that the majority of U.S. adults are motivated to engage in hand hygiene behaviors—they believe that frequent handwashing is a good way to protect themselves from coronavirus, and to a lesser extent feel this way about hand sanitizer. Perceived efficacy of recommended behaviors and outcome expectancies have been found to be associated with increased hand hygiene behavior during the COVID-19 pandemic , 26 and Motivational measures of perceived susceptibility, severity, and behavioral control were associated with one or both of the hand hygiene behaviors. These findings support other research showing significant relationships between these constructs and hand hygiene in the COVID-19 pandemic , 23, 26,This study is subject to several limitations. First, although the data were weighted to be nationally representative and computers and internet access were provided to respondents who needed them, it is possible that results may not be fully representative of the U.S. adult population . Second, the items developed for this study were not piloted prior to use. Correspondingly, composite measures were created post hoc and may lack construct validity. Third, the data might be affected by social desirability bias, which might have resulted in overreporting of agreement with statements assessing COM-B constructs and of socially desirable behaviors, such as hand hygiene behaviors. Indeed, self-reported handwashing rates are consistently higher than observed handwashing rates . FinallyThe COM-B model was a helpful framework for increasing our understanding of hand hygiene behavior; it identified capability and motivation, and to a lesser extent, opportunity, as predictors of both handwashing and hand sanitizer use during the COVID-19 pandemic, prior to the availability of vaccines. We also found that the motivational measures of perceived severity and susceptibility to illness and behavioral control were positively associated with handwashing and hand sanitizer use. These findings highlight the need for health promotion strategies to focus on increasing and maintaining capability, opportunity, and motivation to engage in the targeted hand hygiene behaviors. The Behavior Change Wheel  outlines