Delay In Entry Research Articles

Protein Kinase D2 Modulates Cell Cycle By Stabilizing Aurora A Kinase at Centrosomes.

Aurora A kinase (AURKA) is a master cell-cycle regulator that is often dysregulated in human cancers. Its overexpression has been associated with genome instability and oncogenic transformation. The protein kinase D (PKD) family is an emerging therapeutic target of cancer. Aberrant PKD activation has been implicated in tumor growth and survival, yet the underlying mechanisms remain to be elucidated. This study identified, for the first time, a functional crosstalk between PKD2 and Aurora A kinase in cancer cells. The data demonstrate that PKD2 is catalytically active during the G2-M phases of the cell cycle, and inactivation or depletion of PKD2 causes delay in mitotic entry due to downregulation of Aurora A, an effect that can be rescued by overexpression of Aurora A. Moreover, PKD2 localizes in the centrosome with Aurora A by binding to γ-tubulin. Knockdown of PKD2 caused defects in centrosome separation, elongated G2 phase, mitotic catastrophe, and eventually cell death via apoptosis. Mechanistically, PKD2 interferes with Fbxw7 function to protect Aurora A from ubiquitin- and proteasome-dependent degradation. Taken together, these results identify PKD as a cell-cycle checkpoint kinase that positively modulates G2-M transition through Aurora A kinase in mammalian cells.Implications: PKD2 is a novel cell-cycle regulator that promotes G2-M transition by modulating Aurora A kinase stability in cancer cells and suggests the PKD2/Aurora A kinase regulatory axis as new therapeutic targets for cancer treatment. Mol Cancer Res; 16(11); 1785-97. ©2018 AACR.

PMD166 - REVIEW OF NICE MEDICAL TECHNOLOGIES EVALUATION PROGRAMME (MTEP) FOR MEDICAL DEVICES

The NICE medical technologies evaluation programme (MTEP) selects and evaluates new or innovative medical technologies to support the NHS in rapid adoption of efficient and cost effective medical devices and diagnostics. This study aimed to review the MTEP and evaluate factors relevant in the decision process and the likelihood of positive Medical Technology Guidance (MTG). The study was conducted to assess whether MTEP can simplify access to evaluation, speed up the evaluation process, and increase capacity for device reviews within NICE to better support the NHS in this area. All MTGs published from 2010 to 2017 were reviewed with the following data fields extracted: submission date, publication date , submitting company size and submission outcome. Between 2010 and 2017, a total of 34 MTGs were published. On average, four MTGs were published each year (range 1-7). The outcomes were: 25 recommended, three restricted, and six not recommended. Twelve small (<50 employees), 8 medium sized (<250 employees) (SMEs) and 14 large enterprises were represented. For the evaluative process, time for publication varied widely between four to 22 months. Over the period assessed, uptake of MTEP was lower than initially expected due to the cost-saving criterion, which may neglect some beneficial new technologies. The evaluation process timeline varied immensely as certain companies may have better resources required to support a submission. To assist in streamlining NICE evaluations, the MedTech Early Technical Assessment (META) tool was developed to assist companies towards a better understanding of the requirements needed to demonstrate product value to the NHS leading towards a successful application. It helps to identify data gaps that impact product approval or could create delay in market entry This may help to reduce variation in the time to publication and improve innovation by offering vital guidance to SMEs.

Ear transplantations reveal conservation of inner ear afferent pathfinding cues

Vertebrate inner ear neurons project into the correct brainstem nuclei region before target neurons become postmitotic, or even in their absence. Moreover, afferents from transplanted ears in frogs have been shown to navigate to vestibular nuclei, suggesting that ear afferents use molecular cues to find their target. We performed heterochronic, xenoplastic, and heterotopic transplantations in chickens to investigate whether inner ear afferents are guided by conserved guidance molecules. We show that inner ear afferents can navigate to the vestibular nuclei following a delay in afferent entry and when the ear was from a different species, the mouse. These data suggest that guidance molecules are expressed for some time and are conserved across amniotes. In addition, we show that chicken ears transplanted adjacent to the spinal cord project dorsally like in the hindbrain. These results suggest that inner ear afferents navigate to the correct dorsoventral brainstem column using conserved cues.

Loss of Gata6 causes dilation of the hair follicle canal and sebaceous duct.

The uppermost aspect of the hair follicle, known as the infundibulum or hair canal, provides a passageway for hair shaft egress and sebum secretion. Recent studies have indicated that the infundibulum and sebaceous ducts are lined by molecularly distinct differentiated cells expressing markers including Keratin 79 and Gata6. Here, we ablated Gata6 from the skin and observed dilation of both the hair canal and sebaceous ducts, independent of gender and hair cycle stage. Constitutive loss of Gata6 yielded only a mild delay in depilation-induced entry into anagen, while unperturbed mutant mice possessed overtly normal skin and hair. Furthermore, we noted that Keratin 79 and Gata6 expression and localization did not depend upon each other. Our findings implicate Gata6 in maintaining the upper hair follicle and suggest that regulation of this transcription factor may be compromised in pathologies such as acne or infundibular cystic diseases that are characterized by abnormal expansion of this follicular domain.

Abstract 4480: Irx1 gene knockout in zebrafish induces to multiorgan tumorigenesis through cell cycle aberration

Abstract The Iroquois homeobox 1 (IRX1) belongs to Iroquois homeobox family and plays an important role during embryonic development. Recent studies have suggested that IRX1 acts as a tumor suppressor in gastric cancer and head and neck carcinoma. The zebrafish allows easy genetic modification at a lower cost, thus being a valuable model for cancer biology. For functional annotation we established homozygous knockout mutants of Irx1a and Irx1b and followed to evaluate long-term phenotypes. Homozygous knockout zebrafish for either Irx1a or Irx1b are vital and survived long enough to see long-term phenotypes. However, majority of the homozygotes for both Irx1a /b were severely malformed, could not survive longer than 6 month, and were not fertile. Surprisingly, hyperplasia and tumorigenesis developed in homozygous Irx1a mutants in multiple organs, including bile duct, intestine, kidney, ovary, and testis where irx1 genes are expressed in adults when evaluated by in situ hybridization. Bile duct hyperplasia or tumor was the most common phenotype, occurring in half and two thirds at 6 and 12 months, respectively. Irx1b mutants also developed similar tumorigenesis but showed less prevalent phenotypes than Irx1a mutants, suggesting functional preservation and redundancy. Analysis of differential genes (Wild type vs. Irx1a/b knockout) by cRNA microarray (Agilent Zebrafish v3 GE 4X44 Microarrays) revealed 687 up- and 963 downregulated genes by Irx1a/b knockout. Significant canonical pathways were cyclins and cell cycle regulation, mitotic roles of polo-like kinase, FXR/RXR activation, estrogen-mediated S-phase entry, and cell cycle control of chromosomal replication, suggesting aberrant cell cycle regulation as an important mechanism of tumorigenesis. Real-time RT PCR validated the differential expression of cell cycle-related genes, especially genes involved in G2/M phase progression. Differential genes included CCND1, ARAF, CDKN2C, and FGFR1 among the upregulated genes, and ANAPC7, CCNA2, CCNB1, 2, HAUS1, 3, 6, CDC7, CDC20, CDCA8, FBXO5, 32, 43 and PLK3 among the downregulated genes. Overexpression by transfection decreased cell proliferation in cholangiocarcinoma cells (SNU-1196 and HuCCT1) without altering sensitivity to H2O2-induced apoptosis on annexin V flow cytometry. Western blot revealed decreased expression of CCND1, CCNE, CCNA1, CCNB1 by IRX1 expression. Flow cytometry using propidium iodide and Alexa647-anti-pHH3 showed decreased mitotic fraction by IRX1 expression. On cell cycle synchronization and release using hydroxyuria and nocodazole showed slight delay in G1-S progression and marked delay in G2-M progression and entry into G1. In conclusion, this study identified Irx1 gene as an important tumor-suppressor gene at various organs, and knockout or Irx1 leads to tumorigenesis by altering cell cycle regulation, especially at G2/M phase. Citation Format: Inhye Jung, Dawoon E. Jung, DoHee Kim, Dong Hee Kim, Yong Yoon Chung, Seung Woo Park. Irx1 gene knockout in zebrafish induces to multiorgan tumorigenesis through cell cycle aberration [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4480.

Cardiac glycoside bufalin blocks cancer cell growth by inhibition of Aurora A and Aurora B activation via PI3K-Akt pathway.

In our previous study, cardiac glycosides including bufalin, a group of sodium pump (Na+/K+-ATPase) inhibitors widely used to treat heart failure for many years, have been demonstrated to induce a delay of mitotic entry and mitotic arrest in many cancer cells. However, the underlying mechanism remains poorly understood. Here, we reported for the first time that cardiac glycoside bufalin induced mitotic entry delay and prometaphase arrest by inhibition of activation of Aurora A/B. Furthermore, cardiac glycoside bufalin prevented Aurora A recruitment to mitotic centrosomes and Aurora B recruitment to unattached kinetochores. Mechanistically, bufalin and knockdown of sodium pump inhibited PI3K-Akt pathway, which in turn inhibit the activation of Aurora A/B, followed by a delay in mitotic entry and mitotic arrest. These actions were reversed by overexpression of Akt. In addition, ERK, mTOR, and ROS are not involved in bufalin-mediated downregulation of active form of Aurora A/B. Taken together, cardiac glycoside bufalin induces mitotic entry delay and mitotic arrest in cancer cells through inhibition of Aurora A/B activation via PI3K-Akt pathway. Based on this novel finding we could suggest that targeting PI3K-Akt pathway may have therapeutic value for the treatment of cancers associated with sodium pump overexpression.

The gift of time? School starting age and mental health.

Using linked Danish survey and register data, we estimate the causal effect of age at kindergarten entry on mental health. Danish children are supposed to enter kindergarten in the calendar year in which they turn 6years. In a "fuzzy" regression-discontinuity design based on this rule and exact dates of birth, we find that a 1-year delay in kindergarten entry dramatically reduces inattention/hyperactivity at age 7 (effect size = -0.73), a measure of self-regulation with strong negative links to student achievement. The effect is primarily identified for girls but persists at age 11.

Cell Size Control via an Unstable Accumulating Activator and the Phenomenon of Excess Mitotic Delay

Unstable Accumulating Activator models for cellular size control propose an activator that accumulates in a size-dependent manner and triggers cell cycle progression once it has reached a certain threshold. Having a short half life makes such an activator responsive to changes in cell size and makes specific predictions for how cells respond to perturbation. In particular, it explains the curious phenomenon of excess mitotic delay. Excess mitotic delay, first observed in Tetrahymena in the '50s, is a phenomenon in which a pulse of protein synthesis inhibition causes a delay in mitotic entry that is longer than the pulse and that gets longer the later in the cell cycle the pulse is delivered. The interpretation of this phenomenon championed by Zeuthen and Mitchison in the '60s and '70s is that an unstable activator of mitosis is degraded during the pulse and has to be resynthesized to a threshold level to trigger mitosis; small cells have more time to resynthesize the activator before mitosis and so suffer less excess delay, whereas, large cells have less time thus suffer greater excess delay. Fifty years later, with our detailed understanding of cell cycle biochemistry, we can identify and test candidate Unstable Accumulating Activators. Here I review the field and further develop this concept.

Hair Regenerative Mechanisms of Red Ginseng Oil and Its Major Components in the Testosterone-Induced Delay of Anagen Entry in C57BL/6 Mice.

Hair loss (alopecia) is a universal problem for numerous people in the world. The present study was conducted to investigate the effects of red ginseng oil (RGO) and its major components on hair re-growth using testosterone (TES)-induced delay of anagen entry in C57BL/6 mice and their mechanisms of action. Seven-week-old C57BL/6 mice were daily treated with TES for 1 h prior to topical application of 10% RGO, 1% linoleic acid (LA), 1% β-sitosterol (SITOS), or 1% bicyclo(10.1.0)tridec-1-ene (BICYCLO) once a day for 28 days. Hair regenerative capacity was significantly restored by treatment of RGO and its major compounds in the TES-treated mice. Histological analysis showed that RGO along with LA and SITOS but not BICYCLO promoted hair growth through early inducing anagen phase that was delayed by TES in mice. Treatment of mice with RGO, LA, or SITOS up-regulated Wnt/β-catenin and Shh/Gli pathways-mediated expression of genes such as β-catenin, Lef-1, Sonic hedgehog, Smoothened, Gli-1, Cyclin D1, and Cyclin E in the TES-treated mice. In addition, RGO and its major components reduced the protein level of TGF-β but enhanced the expression of anti-apoptotic protein Bcl-2. These results suggest that RGO is a potent novel therapeutic natural product for treatment of androgenic alopecia possibly through hair re-growth activity of its major components such as LA and SITOS.

Impacts of Late School Entry on Children's Cognitive Development in Rural Northwestern China—Does Preprimary Education Matter?

AbstractThis article estimates the causal effect of primary school entry age on children's cognitive development in rural northwestern China, using data on nearly 1,800 primary school aged children from the Gansu Survey of Children and Families. Instrumental variable estimates, exploiting the discontinuity structure in children's school entry age around the enrolment cut‐off date, indicate that a 1‐year delay in school entry reduces children's scores on a cognitive ability test administered when they were aged 9–12 by 0.11–0.16 standard deviations (of the distribution of test scores). The negative late‐school‐entry effect is significantly larger in villages with no preprimary schools. It also persists as children advance to higher grades. These findings suggest that delayed school entry, even if it may be rural parents' rational response to resource constraints, can be harmful for children's cognitive development in developing areas with underdeveloped preprimary school systems.

Identification of Genes Controlled by the Essential YycFG Two-Component System Reveals a Role for Biofilm Modulation in Staphylococcus epidermidis.

Biofilms play a crucial role in the pathogenicity of Staphylococcus epidermidis, while little is known about whether the essential YycFG two-component signal transduction system (TCS) is involved in biofilm formation. We used antisense RNA (asRNA) to silence the yycFG TCS in order to study its regulatory functions in S. epidermidis. Strain 1457 expressing asRNAyycF exhibited a significant delay (~4–5 h) in entry to log phase, which was partially complemented by overexpressing ssaA. The expression of asRNAyycF and asRNAyycG resulted in a 68 and 50% decrease in biofilm formation at 6 h, respectively, while they had no significant inhibitory effect on 12 h biofilm formation. The expression of asRNAyycF led to a ~5-fold increase in polysaccharide intercellular adhesion (PIA) production, but it did not affect the expression of accumulation-associated protein (Aap) or the release of extracellular DNA. Consistently, quantitative real-time PCR showed that silencing yycF resulted in an increased transcription of biofilm-related genes, including icaA, arlR, sarA, sarX, and sbp. An in silico search of the YycF regulon for the conserved YycF recognition pattern and a modified motif in S. epidermidis, along with additional gel shift and DNase I footprinting assays, showed that arlR, sarA, sarX, and icaA are directly regulated by YycF. Our data suggests that YycFG modulates S. epidermidis biofilm formation in an ica-dependent manner.

Optimal Incentives for Patent Challenges in the Pharmaceutical Industry

Since the patent system relies on private litigation for challenging weak patents, and patent settlements might influence the incentives for challenging patents, the question arises whether the antitrust assessment of patent settlements should also consider their impact on the incentives to challenge potentially invalid patents. Patent settlements in the pharmaceutical industry between originator and generic firms have been scrutinized critically by competition authorities for delaying the market entry of generics and therefore harming consumers. In this paper we present a model that analyzes the tradeoff between limiting the delay of generic entry through patent settlements and giving generic firms more incentives for challenging weak patents of the originator firms. We show that allowing patent settlements with a later market entry of generics than the expected market entry under patent litigation can increase consumer welfare under certain conditions. We introduce a policy parameter for determining the optimal additional period for collusion that would maximize consumer welfare and show that the size of this policy parameter depends on the size of the challenging costs, the intensity of competition, and the duration between the generics’ market entry decisions.

Product Differentiation and Entry Timing in a Continuous-Time Spatial Competition Model with Vertical Relations

We study the entry timing and location decisions of two exclusive buyer-supplier relationships in a continuous-time spatial competition model. In each relationship, the firms determine their entry timing and location, and negotiate a wholesale price through Nash bargaining. Then, the downstream firm immediately determines its retail price. Our findings are as follows. Ordinarily, if the supplier of the first entrant (called the leader pair) has strong bargaining power, the equilibrium location of the leader will be closer to the center, inducing a delay in entry by the second entrant (called the follower pair). This delay implies the stronger bargaining power of the supplier in the leader pair can also benefit the buyer of the pair. The location of the leader pair can change non-monotonically with an increase in the supplier's bargaining power, which has a substantial impact on the entry timing of the follower pair. However, the greater the bargaining power of the supplier in the follower pair, the closer the leader pair will be to the edge. This implies that having greater bargaining power will enhance the profitability of the supplier in the follower pair.

Pay-for-Delay Agreements in the EU Pharmaceutical Industry

This article analyses the compatibility of pay-for-delay agreements with Article 101 of the Treaty on the Functioning of the European Union, in light of the recent judgment of the General Court in H. Lundbeck A/S and Lundbeck Ltd v European Commission. These commercial agreements, also known as reverse payment settlements, are characterised by a value transfer from the originator to generic companies, which results in a delay in generic market entry. The European Commission first examined pay-for-delay agreements in the Pharmaceutical Sector Inquiry in 2009, instituting an annual patent settlements monitoring exercise and initiating proceedings against a number of pharmaceutical companies, imposing fines totalling over €580 million. In September 2016, the General Court confirmed the decision of the Commission against Lundbeck, holding that the generic undertakings involved in the pay-for-delay agreements were potential competitors of the originator company and that the agreements constituted restrictions of competition by object. The seminal decision of the court adds strength to the arguments used by the Commission in its pay-for-delay investigations, providing an apparently coherent legal framework for the assessment of these agreements. However, significant uncertainty remains in relation to the application of key concepts of competition law in the pay-for-delay context.

Reverse Payments: An EU and US Perspective

In recent years, reverse payment settlements in the pharmaceutical industry have attracted the attention of US and European competition authorities. Originator pharmaceutical companies facing patent challenges from generic companies may be incentivized to reach terms of settlement prior to a ruling at trial. Reverse payment settlements occur when the terms of settlement contain a transfer of value from the originator to the generic company. Competition authorities in particular are interested in reverse payment settlements that potentially delay the entry of the generic company’s competing pharmaceutical product. The chapter reviews and compares the approaches of the US and European competition authorities in investigating reverse payment settlements.It also examines the economic incentives faced by originators and generic companies that result from the patent system and pharmaceutical regulatory framework in which they operate. When combined with originators’ and generic companies’ diverging beliefs as to the validity of the patent in question, these incentives lead to a set of feasible reverse payment settlement outcomes that include both a transfer of value and a specified date of generic entry. Economic theory indicates that, under certain circumstances, a set of reverse payment settlements that result in the delay of generic entry can be beneficial to the health systems and patients that pay for pharmaceutical products. This kind of beneficial settlement allows litigating parties to avoid costly and time consuming litigation and establishes a generic entry date that is earlier than the counterfactual (probability weighted) expected date of entry.Given the potential benefits from certain reverse payment settlements, it is that competition authorities investigating reverse payment settlements should use an effects based approach to ensure that potential benefits of such settlements to health care systems and patients are not overlooked in the analysis.

Breaks in the 45S rDNA Lead to Recombination-Mediated Loss of Repeats.

rDNA repeats constitute the most heavily transcribed region in the human genome. Tumors frequently display elevated levels of recombination in rDNA, indicating that the repeats are a liability to the genomic integrity of a cell. However, little is known about how cells deal with DNA double-stranded breaks in rDNA. Using selective endonucleases, we show that human cells are highly sensitive to breaks in 45S but not the 5S rDNA repeats. We find that homologous recombination inhibits repair of breaks in 45S rDNA, and this results in repeat loss. We identify the structural maintenance of chromosomes protein 5 (SMC5) as contributing to recombination-mediated repair of rDNA breaks. Together, our data demonstrate that SMC5-mediated recombination can lead to error-prone repair of 45S rDNA repeats, resulting in their loss and thereby reducing cellular viability.

Dynamics in car ownership: the role of entry into parenthood

This study investigates the impact of entry into parenthood on changes in car ownership. If entry into parenthood affects changes in car ownership, then delay or offset of entry into parenthood might also be an important explanation of recent car travel trends of young adults. This study analysed the impact of entry into parenthood on changes in the number of cars per household. Also, attention is given to the role of other related life course changes such as a change in urbanisation level, employment or household income. Using a unique data set, in which register data from 2011 and 2013 on the Dutch population, income and vehicle registration were combined, the study revealed that couples are more likely to enter car ownership and less likely to exit car ownership when they enter into parenthood. This implies that the delay of entry into parenthood might lead to later entry into car ownership and an increase in life time childlessness might lead to an overall decline in car ownership.

The Catalytic Subunit of DNA-Dependent Protein Kinase Coordinates with Polo-Like Kinase 1 to Facilitate Mitotic Entry

DNA-dependent protein kinase catalytic subunit (DNA-PKcs) is the key regulator of the non-homologous end joining pathway of DNA double-strand break repair. We have previously reported that DNA-PKcs is required for maintaining chromosomal stability and mitosis progression. Our further investigations reveal that deficiency in DNA-PKcs activity caused a delay in mitotic entry due to dysregulation of cyclin-dependent kinase 1 (Cdk1), the key driving force for cell cycle progression through G2/M transition. Timely activation of Cdk1 requires polo-like kinase 1 (Plk1), which affects modulators of Cdk1. We found that DNA-PKcs physically interacts with Plk1 and could facilitate Plk1 activation both in vitro and in vivo. Further, DNA-PKcs–deficient cells are highly sensitive to Plk1 inhibitor BI2536, suggesting that the coordination between DNA-PKcs and Plk1 is not only crucial to ensure normal cell cycle progression through G2/M phases but also required for cellular resistance to mitotic stress. On the basis of the current study, it is predictable that combined inhibition of DNA-PKcs and Plk1 can be employed in cancer therapy strategy for synthetic lethality.

The scale-up of the surgical workforce

BackgroundCountries with fewer than 20 specialist surgeons, anaesthetists, and obstetricians (SAO) per 100 000 population have worse health outcomes. To achieve surgical workforce densities of 20 per 100 000 by 2030, a scale up of the surgical workforce is required. No previous study has shown what this will cost, how many providers will be required, or how long it will take to increase the global surgical workforce. We aim to identify these answers for health-care systems that employ SAO alone and for those that use a hybrid model of SAO and task shifting to inform strategic planning. MethodsData for the density of SAO per country were obtained from the WHO Global Surgical Workforce Database. To find the total number of SAO that need to enter the workforce by 2030 to achieve surgical workforce thresholds of 20 per 100 000, the population growth formula (P=0ert) was used and we assumed exponential surgical workforce growth and two potential retirement rates of either 1% or 10%. We did not account for migration. The same calculations were used for associate clinicians needed to enter the workforce in either a 2:1 or 4:1 associate clinicians-to-SAO ratio. The costs to train SAO and associate clinicians were estimated with data for training costs imputed into a regression analysis with health-care expenditure per capita for each country. We assumed training costs will remain constant, and we did not account for inflation. The time needed to train new surgical and anaesthetic providers was estimated with average length of training for SAO and associate clinicians and was measured in person years. Two models (one for a system of SAO only and one for a hybrid of SAO and associate clinicians) were created to show how many providers will need to enter the workforce per year once training is complete to reach targets by 2030. The model did not involve the scale-up of the surgical workforce needed to address unmet needs of essential surgical services. FindingsBy 2030, the world will need 1 272 586 new surgical workforce providers to meet a surgical workforce density of 20 per 100 000 assuming a 1% retirement rate. This will cost US$71–146 billion depending on the model used. Low-income and lower-middle-income countries show the largest required scale-up. An additional 806 352 (median 3412 [IQR 691–6851]) providers are needed in those countries. In the SAO only model, this will cost a median of US$19·66 per 2013 capita (IQR 15·79–25·07) and will take a median of 34 121 person years (IQR 6911–68 509). In the 4:1 associate clinician-to-SAO ratio, it will cost a median of US$7·57 per capita and take 20 472 person years. When accounting for the delay of entry to the workforce due to training in these countries, the median rate of entry to meet the goal density will have to increase 10·9 times after a 10 year delay in an SAO only model as opposed to 4·98 times with a 5 year delay in the hybrid 4:1 associate clinician-to-SAO model. InterpretationAlthough low-income countries, lower-middle-income countries, and upper-middle-income countries will require a surgical workforce scale-up, lower-middle-income countries will require the largest scale-up. In these countries, implementing a system of task shifting can decrease costs and training times by 40%. Meeting densities of 20 per 100 000 will not guarantee quality care or improved access in rural areas, and equal attention must be paid to the provision of safe, affordable, accessible surgical care to all who need it. FundingNone.

Expert opinion of nephrologists about the effectiveness of low-protein diet in different stages of chronic kidney disease (CKD)

No clinical trials have specifically explored the benefits of low-protein diet in patients with different stages of chronic kidney disease (CKD) 3B. In the absence of RCTs, expert opinion may be a valid surrogate to estimate treatment effectiveness. A questionnaire-based survey of a large sample of nephrologists from Southern Italy was conducted to explore benefits of low-protein diet (LPD) in delaying dialysis entry in different CKD stages. For the case vignettes describing eight different patient profiles with various CKD stages, nephrologists reported expected benefits as time delay of dialysis entry. Information was collected through questionnaires filled by 88 nephrologists from different Southern Italian hospitals. On average, nephrologists estimated the highest delay in starting dialysis due to LPD in stages 3B (15 months) and 3A (14 months), and the lowest for 5 stage (3 months). According to opinion of a large sample of Southern Italian nephrologists, low-protein diet may be more efficacious if started in CKD stage 3B than 4 and 5.