Corticosteroid-free immunosuppression (IS) may be potentially beneficial for transplanted patients, particularly children. The purpose of this study was to evaluate the efficacy and cost of such strategy in primary pediatric liver transplantation (LT). Fifty pediatric LT recipients were prospectively treated with a steroid-free, tacrolimus-basiliximab-based IS (group TB). A group of 34 children transplanted under a conventional tacrolimus-steroids regimen served as control series (group TS). Groups TB and TS were compared regarding patient and graft survival, rejection incidence, infectious complications, and growth, as well as cost of the transplant procedure. Patient and graft survivals at 3 years were 96% and 94% in group TB, versus 91% and 88% in group TS (P ϭ 0.380 and P ϭ 0.370, respectively). Rejection-free graft survival at 3 years was 72% in group TB, versus 41% in group TS (P ϭ 0.007). Patients in group TB had significantly less viral infections than patients in group TS (P ϭ 0.045). Height standard deviation score was significantly enhanced in children from group TB, when compared to group TS. Medical care costs were similar in both groups. Steroid avoidance together with basiliximab immunoprophylaxis was not harmful in terms of allograft acceptance, and even seemed to be beneficial in the long term. Liver Transpl 14: [469][470][471][472][473][474][475][476][477] 2008. Corticosteroids have invariably been part of induction and maintenance immunosuppression (IS) since the early days of clinical liver transplantation (LT). 1,2 Despite the potential benefits to be expected from early withdrawal or even avoidance of steroid administration, steroid therapy is still combined with cyclosporine or tacrolimus in the vast majority of adult and pediatric LT recipients worldwide. 3,4 The putative advantages of a steroid-free IS protocol are of particular interest in children, and include the reduction of infectious complications, decrease of arterial blood pressure and blood cholesterol with reduced atherogenesis in the longterm, better glucose tolerance, reduced risk of cataracts, reduced incidence of osteopenia, and improved linear growth. [3][4][5] Moreover, as suggested in rodent models, the administration of steroids may interfere with the process of hepatic regeneration as well as with the development of immunologic tolerance. 6,7 In 2003, we published a proof-of-concept study evaluating the safety of a steroid-free, tacrolimus-basiliximab-based IS protocol in 20 pediatric LT recipients. 8 The benefits of tacrolimus and basiliximab-based IS at 1-year follow-up have been confirmed in a randomized study. 9 The aim of the present work was to evaluate the longterm (3 years) benefit of this protocol with respect to patient and graft survivals, rejection and infection

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The study shows that the results of the quality assessment of economic evaluations are not so much influenced by the instrument used but more by the assessor. Therefore, quality assessments should be performed by at least two independent experts and final scoring based on consensus.

Sudden cardiac death of young athletes needs to be avoided but does screening really help? Hans Van Brabandt and colleagues look at the evidence

The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders' consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers' support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.