Increasing transplantability in Brazil: time to discuss Kidney Paired Donation

Introduction: 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. Discussion: 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. Conclusion: 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.

Modelling Kidney Outcomes Based On MELD Eras - Impact of MELD Score In Renal Endpoints After Liver Transplantation

Background: Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain.Methods: This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups. Results: 874 patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p<0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p<0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p<0.01). Conclusion: Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.

Classification of the flood severity of the Guadalquivir River in the Southwest of the Iberian Peninsula during the 13th to 19th centuries

This study estimates the pluviometric evolution between the 13th and 19th centuries on the southwestern Iberian Peninsula based on the historic records of the impacts of the Guadalquivir River flooding on the city of Seville (Spain). The main documentary source was “Critical history of the floods of the Guadalquivir in Seville”, published in 1878, which compiles news from different observers, who were contemporaries of each event. Regarding the methodology, it was necessary to transfer the information from different documentary sources to ordinal indices, which required developing allocation criteria per flood impact. From the annual assigned flood index, an interannual series was generated. Moreover, for the last decades of the 21st century, quantifying the flooding levels in the records allowed us to relate them directly to instrumental records of rainfall and establish a relationship between these two phenomena. Through interannual weighing of the flooding indices, it was possible to deduce the durations and intensities of sequences of rainy periods between 1250 and 1850. This allowed us to reconstruct the pluviometric evolution. Of the ten floods classified as most destructive during the five centuries analysed, i.e., from 1280 to 1880, five occurred during little more than a century (1598-1701). The obtained results contribute to knowledge on regional rainfall, as well as to historical climatology and hydrology, over multiple centuries.

Promoting equity with a multi-principle framework to allocate scarce ICU resources

We wholeheartedly agree with Schmidt and colleagues’ efforts to promote equity in intensive care unit (ICU) triage. We also take issue with their characterisation of the New Jersey (NJ) allocation framework for ICU beds and ventilators, which is modelled after the multi-principle allocation framework we developed early in the pandemic. They characterise it as a two-criterion allocation framework and claim—without evidence—that it will ‘compound disadvantage for black patients’. However, the NJ triage framework—like the model allocation policy we developed—actually contains four allocation criteria: the two criteria that the authors mentioned (chances for survival and near-term prognosis) and two criteria that they failed to mention which we included to promote equity: giving priority to frontline essential workers and giving priority to younger patients. These omissions are problematic both for reasons of factual accuracy and because the two criteria they failed to acknowledge would likely mitigate rather than exacerbate racial disparities during triage.

Diminished autonomy and justice in liver transplantation – The price of scarcity?

Patient autonomy and distributive justice are fundamental ethical principles that may be at risk in liver transplant units where decisions are dictated by the need to maximise the utility of scarce donor organs. The processes of patient selection, organ allocation and prioritisation on the wait list have evolved in a constrained environment, leading to high levels of complexity and low transparency. Regarding paternalism, opaque listing and allocation criteria, patient factors such as passivity, guilt, chronic illness and sub-clinical encephalopathy are cited as factors that may inhibit patient engagement. Regarding justice, established regional, gender and race based inequities are described. The paradox whereby hepatologists both advocate for individual patients and discharge their duty of stewardship to apportion organs according to larger utilitarian principles is explored. Competing subjective factors such as physicians’ perception of moral responsibility, the qualitative nature of expert medical assessment and institutional or personal loyalty to re-transplantation candidates are described. Realistic limits of self-determination and justice are discussed, and possible future directions in terms of patient involvement proposed.

Ethical considerations of age-based allocation of intensive care treatments amid the COVID-19 outbreak

With the COVID-19 outbreak severely overwhelming healthcare systems worldwide, countries must decide on allocation criteria for scarce intensive care resources such as ventilators, leaving some without life-saving treatment. Groups such as the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) have suggested using age as allocation criteria, prioritizing the young over the elderly. In judging the morality of such criteria, different ethical frameworks must be applied. From a utilitarian perspective, age-based allocation ensures “the greatest good” – that those with greater “therapeutic success” or “quality-of-life” get access to intensive treatment. However, age poorly predicts prognostic outcomes, and quality-of-life measures are inherently value-laden. From a contractarian view, a morally justifiable action is one made in ignorance of one’s own stake in the outcome. In this lens, age-based allocation is justified since it maximizes the most life-years for the most people. However, it relies on the same flawed assumptions as utilitarianism. From a prioritarian view, age-based allocation ensures that the rights of the young to live out a “normal life span” are respected. However, such judgements ignore the positive experiences of later life and cannot be made on a patient’s behalf. Through a deontological lens, age-based allocation is discriminatory as it views elderly people as means to an end rather than individual agents. Ultimately, the rationing criteria a society uses reflects its values, with age limitations implicitly devaluating the elderly. Therefore, allocation guidelines should deemphasize age in favor of more predictive and less discriminatory measures like multimorbidity or frailty.

Construction of maintenance staffing model for managing sports venues in comprehensive sports games: A research based on the practice of the 7th military world games

The operation and maintenance of sports venues is the basis of ensuring the orderly organization of various events in large-scale comprehensive sports games. Due to the lack of evaluation methods and an index system, it was difficult to predict the input of operating and managing sports venues in large-scale comprehensive sports games. Excessive manpower is often put to guarantee the smooth operation work, causing the problem of waste on all resources. Based on the practice of the operational work for specified sports fields during the 7th World Army Games, this paper establishes a staffing allocation model for the maintenance and operation of sports venues. On the premise of building up a clear maintenance scope, a clarified organization structure and working procedure, the maintenance index of 15 specified venues is evaluated with analytic hierarchy process (AHP), and a set of allocation criteria of the operation team is put forward. The maintenance coefficients of studied venues range from 0.08 to 0.91, and the venues with highest coefficients are the main stadium, the naval pentathlon venues and the soccer field, etc.

Dairy Farms and Life Cycle Assessment (LCA): The Allocation Criterion Useful to Estimate Undesirable Products

In this study, the life cycle assessment (LCA) principle was performed to estimate the environmental impact of three dairy farms that operate using different farming systems, namely, conventional (CON), organic (ORG), and high-quality (HQ) modes. In Italy, the typical style of high-quality (HQ) farming is commonly included in the conventional system but is more strictly regulated by the Decree of the Italian Ministry of Health N° 185/1991. Although the farms are not fully representative of each conduct, they showed intrinsic peculiarities, e.g., the cow-culling rate of each system. This rate requires a quantification as it may be related to loss of income. Allocation criteria were applied to attribute the quantities of pollutants to the co-products: wheat, involved in the congruence and number of cows culled, the latter being undesirable and therefore necessary to quantify. Analysis of variance (ANOVA) highlighted that the no-dairy products significantly mitigated (p < 0.05) some of the impacts’ categories. The allocation of culled cows decreased the impacts of the CON and particularly those of the ORG farms when the mass mode was adopted. HQ showed values similar to the results without allocation. Overall, the objective of identifying a “marker” of undesirable products, estimated by the culling rate, was partially achieved.

A methodology for evaluating student learning outcomes

Introduction. Currently, there is no uniform methodology for assessing student competencies and learning outcomes in Russia. Educational organizations develop these methodologies independently. There are no uniform grade allocation criteria, and there is confusion about the concepts of “indicators” and “evaluation criteria” that challenges the assessment of the quality of educational activities and triggers complaints about biased assessments. In this regard, there is a need to set reasonable rules for evaluating learning outcomes. Materials and methods. The author made a contribution in the development of a methodology for evaluating learning outcomes at NRU MGSU. A comparative analysis of the assessment methods described in the publications made by different authors was carried out to identify the strengths and weaknesses of this methodology. The proposed methodology is compared with Bloom’s taxonomy. Results. The analysis has shown that currently used assessment methods are far from being perfect, and a number of problems of their development have been identified. Principles of selecting indicators and evaluation criteria are proposed on the basis of the analysis performed by the author. It is advisable to use such learning outcomes, as knowledge and skills, as assessment indicators. A system of knowledge and skills assessment criteria characterizing their amount and quality is proposed. Conclusions. The proposed assessment method has advantages and disadvantages. Its advantages include clarity and flexibility of the criteria that ensure a comprehensive assessment of knowledge and skills. The disadvantages of the methodology are the complexity of the criterial system and disregard for any personal features of a student in the process of evaluation.