Uric acid and cardio-metabolic risk factors : an epidemiological approach

The role of serum uric acid (SUA) in cardio-metabolic conditions has long been contentious. It is still unclear if SUA is an independent risk factor or marker of cardio-metabolic conditions and most observed associations are not necessarily causal. This study aimed to further understand and explore the causal role of SUA in cardio-metabolic conditions using genetic and non-genetic epidemiological methods in population-based data. In the first part of this study, we found moderate to high heritability estimates for SUA and fractional excretion of urate (FEUA) suggesting the role of genetic factors in the etiology of hyperuricemia. With regards to the role of SUA on inflammatory markers (IMs), a strong positive association of SUA with C-reactive protein (CRP) and a weaker positive association with tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) was observed, which was in part mediated by body mass index (BMI). These findings suggest that SUA may have a role in sterile inflammation. In view of the inconsistency surrounding the causal nature and direction of the relation between SUA and adiposity, we applied a bidirectional Mendelian randomization approach using genetic variants to decipher the association. The finding that elevated SUA is a consequence rather than a cause of adiposity was not totally unexpected and is compatible with the hypothesis that hyperinsulinemia, accompanying obesity, enhances renal proximal tubular reabsorption of uric acid. The fourth part of this study examined the relationship between SUA and blood pressure (BP) in young adults. The association between SUA and BP, significant only in females, was strongly attenuated upon adjustment for BMI. The possibility that BMI lies in the causal pathway may explain the attenuation observed in the associations of SUA with BP and IMs. Finally, a significant hockey-stick shaped association of SUA with social phobia in our data suggests a protective effect of SUA only up to a certain concentration. Although our study findings have shed some light on the uncertainty underlying the pathophysiology of SUA, more compelling evidence using longitudinal designs, randomized controlled trials and the use of robust genetic tools is warranted to increase our understanding of the clinical significance of SUA.

Transportation Program Management System, HR-394, 2003

HR-394 was a software and database development project. Via funding provided by the Iowa Highway Research Board, the Iowa County Engineer's Association Service Bureau oversaw the planning and implementation of an Internet based application that supports two major local-government transportation project activities: Project programming and Development tracking. The goals were to reduce errors and inconsistencies, speed up the processes, link people to both project data and each other, and build a framework that could eventually support a 'paperless' work flow. The work started in 1999 and initial development was completed by the fall of 2002. Since going live, several 'piggy back' applications have been required to make the Programming side better fit actual work procedures. This part of the system has proven adequate but will be rewritten in 2004 to make it easier to use. The original development side module was rejected by the users and so had to be rewritten in 2003. The second version has proven much better, is heavily used, and is interconnected with Iowa DOT project data systems. Now that the system is in operation, it will be maintained and operated by the ICEA Service Bureau as an ongoing service function.

Mice with chronic GSH deficit display phenotypical anomalies that resemble key aspects of schizophrenia

ABSTRACTSchizophrenia is a major psychiatric disorder occurring with a prevalence of 1% in the worldwide population. It develops progressively with psychosis onset in late adolescence or earlyadulthood. The disorder can take many different facets and has a highly diffuse anddistributed neuropathology including deficits in major neurotransmitter systems,myelination, stress regulation, and metabolism. The delayed onset and the heterogeneouspathology suggest that schizophrenia is a developmental disease that arises from interplayof genetic and environmental factors during sensitive periods. Redox dysregulation due to animbalance between pro-oxidants and antioxidant defence mechanisms is among the riskfactors for schizophrenia. Glutathione (GSH) is the major cellular redox regulator andantioxidant. Levels of GSH are decreased in cerebrospinal fluid, prefrontal cortex and postmortemstriatum of schizophrenia patients. Moreover, polymorphisms of the key GSHsynthesizingenzyme, glutamate-cysteine ligase, modifier (GCLM) subunit, are associatedwith the disease, suggesting that GSH deficit is of genetic origin. Here we used miceknockout (KO) for the GCLM gene, which display chronic GSH deficit (~70 to 80% decrease)to investigate the direct link between redox dysregulation and schizophrenia. Accordingly,we evaluated whether GCLM KO compared to normal wildtype mice display behavioralchanges that relate to schizophrenia symptoms and whether their brains showmorphological, functional or metabolic alterations that resemble those in patients.Moreover, we exposed pubertal GCLM mice to repeated mild stress and measured theirhormonal and behavioral stress reactivity. Our data show that chronic GSH deficit isassociated with altered emotion- and stress-related behaviors, deficient prepulse inhibition,pronounced amphetamine-induced hyperlocomotion but normal spatial learning andworking memory. These changes represent important schizophrenia endophenotypes.Moreover, this particular pattern of change indicates impairment of the ventralhippocampus (VH) and related circuitry as opposed to the dorsal hippocampus (DH), which isimplicated in spatial information processing. This is consistent with a selective deficit ofparvalbumin positive interneurons and gamma oscillation in the VH but not DH. Increasedlevels of circulating stress hormones in KO mice following pubertal stress corroborate VHdysfunction as it is involved in negative feedback control of the stress response. VHstructural and functional deficits are frequently found in the schizophrenic brain. Metabolicevaluation of the developing GCLM KO anterior cortex using in vivo magnetic resonancespectroscopy revealed elevated glutamine (Gln), glutamate (Glu), Gln/Glu and N-acetylaspartate(NAA) during the pre-pubertal period. Similar changes are reported in earlyschizophrenia. Overall, we observe phenotypic anomalies in GSH deficient GCLM KO micethat correspond to major schizophrenia endophenotypes. This supports an important rolefor redox dysregulation in schizophrenia and validates the GCLM KO mouse as model for thedisease. Moreover, our results indicate that puberty may be a sensitive period for redoxsensitivechanges highliting the importance of early intervention. Gln, Gln/Glu, Glu and NAAmay qualify as early metabolic biomarkers to identify young at-risk individuals. Since chronictreatment with NAC normalized most metabolic changes in GCLM KO mice, NAC may be oneadjunct treatment of choice for early intervention in patients.RESUMELa schizophrénie est une maladie psychiatrique majeure avec une prévalence de 1% dans lapopulation. Son développement est progressif, les premières psychoses apparaissant àl'adolescence ou au début de l'âge adulte. La maladie a plusieurs présentations et uneneuropathologie étendue, qui inclut des déficits neurochimiques, métaboliques, de lamyélination et de la régulation du stress. L'émergence tardive et l'hétérogénéité de lapathologie suggèrent que la schizophrénie est une maladie développementale, favorisée pardes facteurs génétiques et environnementaux durant des périodes sensibles. La dérégulationrédox, due à un déséquilibre entre facteurs pro-oxidantes et défenses anti-oxidantes,constitue un facteur de risque. Le glutathion (GSH) est le principal régulateur rédox et antioxidantdes cellules, ses taux sont diminués dans le liquide céphalorachidien, le cortexpréfrontal et le striatum de patients. De plus, des variations du gène codant la sous-unitémodulatrice (GCLM) de la glutamate-cystéine ligase, enzyme de synthèse du GSH, sontassociés la maladie, suggérant que le déficit observé chez les patients est d'originegénétique. Nous avons donc utilisé des souris ayant une délétion du gène GCLM (KO), quiont un déficit chronique en GSH (70-80%), afin d'étudier le lien entre une dérégulation rédoxet la schizophrénie. Nous avons évalué si ces souris présentent des altérationscomportementales analogues aux symptômes de la maladie, et des modificationsstructurelles, fonctionnelles et métaboliques au niveau du cerveau, ressemblant à celles despatients. De plus, nous avons soumis les souris à des stresses modérés durant la puberté,puis mesuré les réponses hormonales et comportementales. Les animaux présentent undéficit pré-attentionnel du traitement des informations moto-sensorielles, un déficit pourcertains apprentissages, une réponse accrue à l'amphétamine, mais leurs mémoires spatialeet de travail sont préservées. Ces atteintes comportementales sont analogues à certainsendophénotypes de la schizophrénie. De plus, ces changements comportementaux sontlargement expliqués par une perturbation morphologique et fonctionnelle de l'hippocampeventral (HV). Ainsi, nous avons observé un déficit sélectif des interneurones immunoréactifsà la parvalbumine et une désynchronisation neuronale dans l'HV. L'hippocampe dorsal,impliqué dans l'orientation spatiale, demeure en revanche intact. L'augmentationd'hormones de stress dans le sang des souris KO suite à un stress prépubertal soutien aussil'hypothèse d'une dysfonction de l'HV, connu pour moduler ce type de réponse. Des déficitsstructurels et fonctionnels dans l'hippocampe antérieur (ventral) ont d'ailleurs été rapportéschez des patients schizophrènes. Par de résonance magnétique, nous avons également suivile profil métabolique du le cortex antérieur au cours du développement postnatal des sourisKO. Ces mesures ont révélé des taux élevés de glutamine (Gln), glutamate (Glu), du ratioGln/Glu, et de N-acétyl-aspartate (NAA) durant la période prépubertale. Des altérationssimilaires sont décrites chez les patients durant la phase précoce. Nous avons donc révélédes anomalies phénotypiques chez les souris GCLM KO qui reflètent certainsendophénotypes de la schizophrénie. Nos résultats appuient donc le rôle d'une dérégulationrédox dans l'émergence de la maladie et le potentiel des souris KO comme modèle. De plus,cette étude met en évidence la puberté comme période particulièrement sensible à unedérégulation rédox, renforçant l'importance d'une intervention thérapeutique précoce. Dansce cadre, Gln, Gln/Glu, Glu and NAA seraient des biomarqueurs clés pour identifier de jeunesindividus à risque. De part son efficacité dans notre modèle, NAC pourrait être unesubstance de choix dans le traitement précoce des patients.

Missouri riverfront parkway & scenic highway design study, 1973.

This report concerns a proposed Parkway and Scenic Highway along both sides of the Missouri River in Harrison, Pottawattamie and Mills County in Iowa and Washington, Douglas and Sarpy Counties in Nebraska. This Parkway will make the Missouri River valley accessible to the public, link existing and planned attractions and facilitate planned development while at the same time preserving for posterity the best of the natural attributes of the area.

Common genetic loci influencing plasma homocysteine concentrations and their effect on risk of coronary artery disease.

BACKGROUND: The strong observational association between total homocysteine (tHcy) concentrations and risk of coronary artery disease (CAD) and the null associations in the homocysteine-lowering trials have prompted the need to identify genetic variants associated with homocysteine concentrations and risk of CAD. OBJECTIVE: We tested whether common genetic polymorphisms associated with variation in tHcy are also associated with CAD. DESIGN: We conducted a meta-analysis of genome-wide association studies (GWAS) on tHcy concentrations in 44,147 individuals of European descent. Polymorphisms associated with tHcy (P < 10(-8)) were tested for association with CAD in 31,400 cases and 92,927 controls. RESULTS: Common variants at 13 loci, explaining 5.9% of the variation in tHcy, were associated with tHcy concentrations, including 6 novel loci in or near MMACHC (2.1 Ã- 10(-9)), SLC17A3 (1.0 Ã- 10(-8)), GTPB10 (1.7 Ã- 10(-8)), CUBN (7.5 Ã- 10(-10)), HNF1A (1.2 Ã- 10(-12)), and FUT2 (6.6 Ã- 10(-9)), and variants previously reported at or near the MTHFR, MTR, CPS1, MUT, NOX4, DPEP1, and CBS genes. Individuals within the highest 10% of the genotype risk score (GRS) had 3-μmol/L higher mean tHcy concentrations than did those within the lowest 10% of the GRS (P = 1 Ã- 10(-36)). The GRS was not associated with risk of CAD (OR: 1.01; 95% CI: 0.98, 1.04; P = 0.49). CONCLUSIONS: We identified several novel loci that influence plasma tHcy concentrations. Overall, common genetic variants that influence plasma tHcy concentrations are not associated with risk of CAD in white populations, which further refutes the causal relevance of moderately elevated tHcy concentrations and tHcy-related pathways for CAD.

07042-016 Kettle Creek Watershed Final Report

The urban portion of the Kettle Creek Watershed is experiencing severe bank and bed erosion due to unchecked stormwater runoff and a steep stream slope. The Kettle Creek Urban Watershed Improvement Project will reduce sediment input to the stream by stabilizing the steam bed with rock-riffle stream stabilization structures and stream bank improvements at select locations. Other components of the watershed are being addressed for excess sediment loads including the agricultural portion by constructing sediment detention basins, and the urban stormwater component by separating the existing combined sanitary and stormwater systems. The urban stream erosion factor represents the weak link in the current watershed impairment. The benefits of the all the watershed improvements components will be realized by all the residents of Kettle Creek Watershed as well as the citizens of Ottumwa.

Hot spots for diversity of Magnaporthe oryzae physiological races in irrigated rice fields in Brazil

The objective of this work was to evaluate the Magnaporthe oryzae pathotype diversity in new commercial irrigated rice fields in the Araguaia River Valley, state of Tocantins, Brazil. The causal agent of rice blast has heavily affected rice production in the region. Despite the efforts of breeding programs, blast resistance breakdown has been recorded shortly after the release of new resistant cultivars developed for the region. Among the causes of resistance breakage is the capacity of the fungus to rapidly develop new pathotypes. A sample of 479 M. oryzae monosporic isolates was obtained and tested using the international rice blast differential set. Isolate collections were made in small areas designed as trap nurseries and in scattered sites in their vicinity. Analysis of 250 M. oryzae isolates from three trap nurseries indicated the presence of 45 international M. oryzae races belonging to seven pathotype groups (IA-IG). In the isolates tested, 61 M. oryzae pathotypes belonging to all but the IH group were detected. The new areas of irrigated rice in the Araguaia River Valley have the highest diversity of M. oryzae pathotypes reported so far in Brazil.

Improved flooding of broadcast messages using extended multipoint relaying

A common operation in wireless ad hoc networks is the flooding of broadcast messages to establish network topologies and routing tables. The flooding of broadcast messages is, however, a resource consuming process. It might require the retransmission of messages by most network nodes. It is, therefore, very important to optimize this operation. In this paper, we first analyze the multipoint relaying (MPR) flooding mechanism used by the Optimized Link State Routing (OLSR) protocol to distribute topology control (TC) messages among all the system nodes. We then propose a new flooding method, based on the fusion of two key concepts: distance-enabled multipoint relaying and connected dominating set (CDS) flooding. We present experimental simulationsthat show that our approach improves the performance of previous existing proposals.

Ydinvoimalaitoksen tuotannon ylläpitoprosessin suorituskyvyn mittaaminen

Kilpailun kiristyminen on pakottanut ydinvoimalaitoksia parantamaan tehokkuuttaan etsimällä uusia toimintatapoja. Heräte työn teettämiseen syntyi tutkimuksen case-kohteen Loviisan voimalaitoksen kiinnostuksesta Balanced Scorecard (BSC) -johtamisjärjestelmää,sen käyttöönoton mahdollisia vaikutuksia sekä BSC:n ja prosessiajattelun yhdistämistä kohtaan. Tutkimuksen tavoitteena on rakentaa Loviisan voima-laitoksen tuotannon ylläpitoprosessille BSC-mittaristo. Tämä edellyttää selvitystä siitä, mitä erityispiirteitä ydinvoimalaitoksiin liittyy strategisen suorituskyvyn mittaamisen kohteena. Lisäksi tavoitteena on selvittää, mikä tulisi prosessikohtaisten tuloskorttien rooli olla Loviisan voimalaitoksen BSC-järjestelmässä. Tavoitteenaon myös muodostaa suositus toimintamallista, jolla BSC voitaisiin ottaa käyttöön Loviisan voimalaitoksella, sekä selvittää, mitä vaikutuksia käyttöönotolla voiolla. Ydinvoimalaitoksen erityispiirteitä ovat muutokset toimintaympäristössä, viranomais-valvonta, toiminnan pitkäjänteisyys, laaja osaamis- ja tietotarve sekä turvallisuuden ja tiettyjen sidosryhmäsuhteiden merkityksen korostuminen. Johtuen erityispiirteistä Kaplanin ja Nortonin alkuperäistä asiakasnäkökulmaa muutetaan kattamaan sidosryhmät laajemmin. Tuotannon ylläpitoprosessin tuloskortissa vähiten painottuva näkö-kulma on henkilöstön ja uudistumisen näkökulma. Osa laitostason kriittisistä menestystekijöistä todetaan prosessin kannalta epäolennaisiksi. Prosessikohtaiset tuloskortit osoittautuvat vaikeasti hyödynnettäviksi linjaorganisaation ohjaamisessa. Strategiakartta todetaan hyväksi työvälineeksi BSC:nlaadinnassa. Toivasen projektimalli arvioidaan sopivaksi välineeksi mahdolliseen BSC:n käyttöönottoon Loviisan voimalaitoksella. Henkilöstön rooli ja erityispiirteiden vaikutukset tulee kuitenkin tarkistaa ennen mallin käyttöä. BSC-järjestelmän käyttöönoton arvioidaan selkeyttävän voimalaitoksen mittaristokokonaisuutta sekä parantavan syy-seuraussuhteiden hahmottamista ja alempien tasojen tavoitteiden kytkentää laitostason tavoitteisiin.

Paperikoneen käyttöönoton onnistumisen riippuvuus valmistelutyöstä

Paperikoneinvestointi toteutetaan projekteina, joista muodostuvaa ketjua kutsutaan projektien elinkaareksi. Toteutusketjun viimeinen lenkki on käynnistykseen huipentuva käyttöönotto. Hyvä käyttöönotto palvelee investointia. Käyttöönotoissa koetaan erilaisia ongelmatilanteita, joista osa on satunnaisesti tai usein toistuvia. Investoinnin onnistumisen ja aikataulun asettama paine luo tilanteiden selvittämiseen erityishaasteita. Aina ei selvitä ilman takaiskuja. Tutkimustavoitteena oli kartoittaa käyttöönoton yleiset ongelmat ja niiden yhteydet projektihistoriaan, sekä ne projektinhallinnan osa-alueet, joita parantamalla varmistetaan käyttöönoton ja investoinnin onnistuminen. Tutkimus pohjautuu erilaisistainvestointiprojekteista ja käyttöönotoista saatuihin kokemuksiin, haastatteluihin (3 kpl) ja kyselypalautteeseen (42 kpl). Investoinnin onnistumisedellytykset luodaan projektihistoriassa, käyttöönotossa ne viimeistellään. Onnistuminen mitataan tuotto-odotusten saavuttamisena aikataulussa, johon vaikuttavia tekijöitä ovat tuotannon hallinta, käyttövarmuus ja markkinat. Käyttöönoton onnistumista tulee arvioida käyttöönottotehtävistäsuoriutumisen pohjalta, ei pelkästään investoinnille asetettujen aikataulu- ja tuotantotavoitteiden (laatu, määrä, hallinta) saavuttamisena, kuten usein tapahtuu. Tulosten perusteella käyttöönoton merkittävimmät ongelmat ovat tiedonkulun puutteet, ohjelmallisten korjausten suuri määrä ja palautumisajan riittämättömyys. Tärkeimmät painotukset ovat laiterikkojen estäminen, ohjelmavirheiden korjaaminen ja henkilöstön osaamisen varmentaminen. Konelinjan vaikeimmin hallittava osa on radan päänvienti. Osapuolten poikkeavat näkökulmat sekä työn laadun merkitys testauksissa, koulutuksissa ja kenttätoiminnoissa nousee tuloksista myös vahvasti esiin. Tutkimus on selvittänyt sille asetetut tavoitteet. Käyttöönoton merkittävimmät ongelmat syntyvät sen lähihistoriassa: testauksissa, koulutuksessa ja kenttätoiminnoissa. Käyttöönoton onnistumiseksi tulee painotusprojektinhallinnassa keskittää käynnistysvaiheen suunnitteluun sekä kenttätoimintojen hallintaan.

Team Effectiveness in Patient Health Management: An Overview of Reviews

Background: The desire to improve the quality of health care for an aging population with multiple chronic diseases is fostering a rapid growth in inter-professional team care, supported by health professionals, governments, businesses and public institutions. However, the weight of evidence measuring the impact of team care on patient and health system outcomes has not, heretofore, been clear. To address this deficiency, we evaluated published evidence for the clinical effectiveness of team care within a chronic disease management context in a systematic overview. Methods: A search strategy was built for Medline using medical subject headings and other relevant keywords. After testing for perform- ance, the search strategy was adapted to other databases (Cinhal, Cochrane, Embase, PsychInfo) using their specific descriptors. The searches were limited to reviews published between 1996 and 2011, in English and French languages. The results were analyzed by the number of studies favouring team intervention, based on the direction of effect and statistical significance for all reported outcomes. Results: Sixteen systematic and 7 narrative reviews were included. Diseases most frequently targeted were depression, followed by heart failure, diabetes and mental disorders. Effective- ness outcome measures most commonly used were clinical endpoints, resource utilization (e.g., emergency room visits, hospital admissions), costs, quality of life and medication adherence. Briefly, while improved clinical and resource utilization endpoints were commonly reported as positive outcomes, mixed directional results were often found among costs, medication adherence, mortality and patient satisfaction outcomes. Conclusions: We conclude that, although suggestive of some specific benefits, the overall weight of evidence for team care efficacy remains equivocal. Further studies that examine the causal interactions between multidisciplinary team care and clinical and economic outcomes of disease management are needed to more accurately assess its net program efficacy and population effectiveness.

Cultural Biases in Public Service Delivery : Evidence from a Regression Discontinuity Approach

What determines the share of public employment, at a given size of the State, in countries of similar levels of economic development? While the theoretical and empirical literature on this issue has mostly considered technical dimensions (efficiency and political considerations), this paper emphasizes the role of culture and quantifies it. We build a representative database for contracting choices of municipalities in Switzerland and exploit the discontinuity at the Swiss language border at identical actual set of policies and institutions to analyze the causal e↵ect of culture on the choice of how public services are provided. We find that French-speaking border municipalities are 50% less likely to contract with the private sector than their German-speaking adjacent municipalities. Technical dimensions are much smaller by comparison. This result points out that culture is a source of a potential bias that distorts the optimal choice for public service delivery. Systematic differences in the level of confidence in public administration and private companies potentially explain this discrepancy in private sector participation in public services provision.

Una interpretación de los cambios de uso del suelo desde el punto de vista del metabolismo social agrario. La comarca catalana del Vallès, 1853-2004

El paisaje puede ser visto como la expresión territorial del metabolismo que cualquier sociedad mantiene con los sistemas naturales que la sustentan. Uno de los caminos para comprender cómo y por qué la intervención humana cambia la configuración del territorio consiste en analizar los flujos energéticos del intercambio metabólico de la economía con su entorno ambiental, y en identificar los impactos ecológicos que se imprimen en él. Este trabajo busca verificar, mediante la contabilidad del metabolismo social, y el empleo diacrónico de diversos índices desarrollados por la ecología del paisaje, que el enorme incremento de energía externa empleada por los sistemas agrarios tras la “revolución verde”, y la drástica reducción de su eficiencia, están estrechamente relacionados con los cambios de uso del suelo que han degradado considerablemente los tradicionales paisajes agrarios en mosaico del Mediterráneo. El recurso a flujos biofísicos externos, y el abandono del manejo integrado del territorio, han comportado una pérdida de la estructura funcional de la matriz territorial y de su conectividad ecológica. Los resultados obtenidos en cinco municipios de la comarca catalana del Vallès corroboran la estrecha relación existente durante los últimos 150 años entre la eficiencia energética y territorial, y el estado ecológico del paisaje.

Quantum black holes: Nonperturbative corrections and no-veil scenario

A common belief is that further quantum corrections near the singularity of a large black hole should not substantially modify the semiclassical picture of black hole evaporation; in particular, the outgoing spectrum of radiation should be very close to the thermal spectrum predicted by Hawking. In this paper we explore a possible counterexample: in the context of dilaton gravity, we find that nonperturbative quantum corrections which are important in strong-coupling regions may completely alter the semiclassical picture, to the extent that the presumptive spacelike boundary becomes timelike, changing in this way the causal structure of the semiclassical geometry. As a result, only a small fraction of the total energy is radiated outside the fake event horizon; most of the energy comes in fact at later retarded times and there is no problem of information loss. This may constitute a general characteristic of quantum black holes, that is, quantum gravity might be such as to prevent the formation of global event horizons.

Key elements for, and indicators of, a successful transition: an international Delphi study.

PURPOSE: The purpose of this study was to reach an international consensus to determine what key elements should be part of a transition program and what indicators could be used to assess its success. METHODS: For this purpose, a Delphi study including an international panel of 37 experts was carried out. The study consisted of three rounds, with response rates ranging from 86.5% to 95%. At each round, experts were asked to assess key elements (defined as the most important elements for the task) and indicators (defined as quantifiable characteristics). At each round, panelists were contacted via e-mail explaining them the tasks to be done and giving them the Web link where to complete the questionnaire. At Round 3, each key element and indicator was assessed as essential, very important, important, accessory, or unnecessary. A 70% agreement was used as cutoff. RESULTS: At Round 3, more than 70% of panelists agreed on six key elements being essential, with one of them (Assuring a good coordination between pediatric and adult professionals) reaching an almost complete consensus (97%). Additionally, 11 more obtained more than 70% agreement when combined with the Very important category. Among indicators, only one (Patient not lost to follow-up) was considered almost unanimously (91%) as essential by the panelists and seven others also reached consensus when the Very important category was included. CONCLUSIONS: Using these results as a framework to develop guidelines at local, national, and international levels would allow better assessing and comparing transition programs.