Should a Refluxing Internal Diversion Be Considered a Temporizing Procedure? Extended Follow-Up and Outcomes After Side-to-side Ureterovesicostomy for Primary Obstructive Megaureter in Young Children

PURPOSE

To describe long-term outcomes, including urinary tract infections (UTIs) and need for reimplantation, after ureterovesicostomy (UV) as a lasting surgical procedure for children with primary obstructed megaureter (POM).

METHODS

Children referred to our institution between 2016 and 2023 who underwent refluxing UV were analyzed. POM was defined as hydroureteronephrosis with distal ureteral dilatation > 7 mm and a negative workup for other aetiologies of hydronephrosis. We assessed for surgical outcomes, complications, rate of UTI, and improvement in upper tract dilatation. Statistical analyses assessed for change in hydronephrosis metrics over follow-up.

RESULTS

Among 183 patients diagnosed with POM, 47 (24%) underwent UV. Median age of presentation, surgery, and follow-up was 2, 9, and 43 months, respectively. A total of 7 patients developed 30-day complications: Clavien-Dindo grade 1: 2 (transient urinary retention), and grade 2: 5 (UTIs). During monitoring 14 (30%) developed UTIs and 7 (15%) required ureteral reimplant or UV takedown. After surgery there was a significant decrease in the proportion of patients with high-grade hydronephrosis, anteroposterior renal pelvis diameter and maximum ureteral dilatation.

CONCLUSION

Refluxing UV is a safe alternative to cutaneous diversion in POM. Most patients had improvement in upper tract dilatation with an acceptable short-term complication rate and need for re-operation (in comparison to routine later reimplantation). Our experience suggests that monitoring alone after UV is feasible, and that selective subsequent reconstruction is a reasonable strategy.

Efficacy of sodium glucose cotransporter 2 inhibitors for heart failure with preserved and mildly reduced ejection fraction: a systematic review and meta-analysis

Background

SGLT2 inhibition has been a breakthrough approach in the treatment for heart failure. A recent guideline has recommended SGLT2i for the treatment of patients with HFrEF to reduce the risk of HF hospitalization and death, regardless of presence of type 2 diabetes (1). However, its benefit in HFpEF and HFmrEF have yet to be established.

Purpose

We evaluated the cardiovascular outcomes of SGLT2i for HFpEF and HFmrEF.

Methods

Randomized controlled trials on SGLT2i versus placebo in patients with left ventricular ejection fraction of more than 40% reporting CV outcomes were searched using Pubmed, CENTRAL, and ScienceDirect. Primary outcome was the composite of hospitalization for heart failure or CV death. Secondary outcomes were the individual HHF, CV death, as well as all-cause mortality. Pooled hazard ratios with 95% confidence intervals were used as effect estimates using fixed-effects model.

Results

Six studies were included with a total of 10,450 patients. In the combined HFmrEF and HFpEF population, there was a significant reduction in composite of cardiovascular death and heart failure hospitalization in the SGLT2i group (HR 0.79, 95% CI 0.71–0.88, p<0.0001) compared to placebo, driven by a significant reduction in heart failure hospitalization (HR 0.73, 95% CI 0.63–0.84, p<0.00001). In the distinct HFpEF population, there was a significant reduction in composite of cardiovascular death and heart failure hospitalization in the SGLT2i group (HR 0.75, 95% CI 0.63–0.88, p=0.0007) compared to placebo.

Conclusion

SGLT2i provides significant risk reduction in HF hospitalization or CV death among patients with HFpEF compared to placebo.

Funding Acknowledgement

Type of funding sources: None.

Effects of sodium glucose cotransporter 2 inhibitors on the risk of hyperkalemia in patients on mineralocorticoid receptor antagonist: a systematic review and meta-analysis

Background

Occurrence of hyperkalemia has been a great limitation in the full implementation of a guideline-directed medical therapy especially in patients with heart failure. Recent developments have exhibited the positive role of SGLT2 inhibitors, not only on the cardiovascular outcomes but also conferred renal protection.

Purpose

We explored the effects of SGLT2i and MRA combination on the risk of developing hyperkalemia.

Methods

Randomized controlled trials on SGLT2i versus placebo in patients already on MRA regardless of heart failure status reporting outcomes of potassium homeostasis were searched using Pubmed, CENTRAL, and ScienceDirect. Outcome of interest was the effects on the risk of hyperkalemia. Pooled hazard ratios with 95% confidence intervals were used as effect estimates using fixed-effects model.

Results

Four studies were included with a total of 8,996 patients. There was a significant reduction on the risk of hyperkalemia in the MRA with SGLT2i group (HR 0.53, 95% CI 0.39–0.73, p<0.0001) compared to MRA without SGLT2i group.

Conclusion

SGLT2i provides significant risk reduction on the development of hyperkalemia in patients already on a mineralocorticoid receptor antagonist.

Funding Acknowledgement

Type of funding sources: None.

Cardiorenal effects of SGLT2i in combination with ARNI for HFrEF: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Recent recommendations suggest a combination of Angiotensin receptor neprilysin inhibitor (ARNI) and beta blocker with other classes of medications in heart failure with reduced ejection fraction (HFrEF) (1). Despite currently available treatment options, mortality remains high (2). From the recent robust clinical trials, both SGLT2 inhibitor (SGLT2i) and ARNI have been found to decrease HF hospitalizations and CV death (3-5). This paper aims to determine the efficacy of SGLT2i and ARNI combination versus ARNI alone in the management of HFrEF.

Methods

Randomized controlled, prospective or retrospective cohort trials on ARNI with SGLT2i versus ARNI without SGLT2i in patients with left ventricular ejection fraction of 40% or less were included. A search using Pubmed, CENTRAL, and ScienceDirect was conducted on April 29, 2021.  Risk of bias was assessed using Cochrane’s Collaboration tool for RCTs and STROBE checklist for cohort, case-control and cross-sectional studies. Review Manager version 5.4 software was used for data synthesis and analysis. Outcomes were measured as mean differences and risk ratio for continuous data and dichotomous data with 95% confidence interval.

Results

Three studies were screened with a total of 1,742 patients; 759 received a combination of SGLT2i and ARNI while 983 received standard care plus ARNI. There was a significant reduction in composite of cardiovascular death and heart failure hospitalization in the combination SGLT2i/ARNI group (HR 0.69, 95% CI 0.56-0.85, and p value of 0.0005). There was significant reduction in heart failure hospitalization in the treatment group with SGLT2i (HR of 0.61, a 95% CI 0.49-0.78) compared to the group without treatment of a SGLT2 inhibitor (< 0.0001). Composite renal event favors combination of ARNI and SGLT2i in some studies (HR of 0.73, with a 95% CI 0.39-1.38), however was not statistically significant (p value = 0.34).

Conclusion

Addition of SGLT2i with ARNI provides significant decrease in mortality and hospitalization among patients with HFrEF compared to control as well as improvement in renal function.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Previous Exposure to Anesthesia and Autism Spectrum Disorder (ASD): A Puerto Rican Population-Based Sibling Cohort Study

BACKGROUND

Autism Spectrum Disorder (ASD) is characterized by impaired social interaction and communication, and by restricted and repetitive behavior, that begins usually before a child is three years old.(1) Researchers have shown that prevalence rates in the U.S. may be as high as 1 in 68.(52) A number of studies have examined the effects of early exposure to anesthesia on brain development and subsequent impairment in neurocognitive function; yet, little is known about the possible effects of anesthetic agents on social-behavioral functioning. The association between exposure to anesthesia either in uterus, during the first years of life, or later and development of Autistic Spectrum Disorder (ASD) or its severity was determined in a retrospective population based cohort study.

OBJECTIVES

Identify if children who had previous exposure to anesthesia either in uterus, first years of life during their developing brain years, or later, are at risk of developing ASD and its severe form of the disease.

METHODS

Data was obtained from structured interviews administered to a sample of 515 parents/guardians distributed in two groups: ASD = 262 children diagnosed with this condition and Non-ASD: 253 children (siblings of ASD group) without diagnosis (95% confidence interval) that freely decided to participate and agreed to a consent form. Variables studied include: demographics, diagnosis and severity of ASD, exposure to anesthesia, method of childbirth, and age of exposure Children less than 2 years of age were considered into have developing brain period. Data was analyzed using Chi-square or Fisher exact test.

RESULTS

In contrast to non-ASD group, most of the children within ASD group were male, 76% (p=0.0001). With regards to methods of childbirth, 64% of the ASD population were vaginal delivery (VD; Non-anesthesia exposure group) and 36% cesarean delivery (CD) compared to non-autistic population with 71% VD and 29% CD, which demonstrates no statistical difference between both groups (p=0.1113). Out of the 36% of ASD population that underwent CD, 7% were performed using general anesthesia and 93% regional anesthesia, while the 29% of the CD of non-ASD, 5% were performed using general anesthesia and 95% regional anesthesia. This reveals no statistical significance (p=0.7569) with the development of ASD and the type of anesthesia used when comparing ASD with non-ASD patients. In view of severity of autism, in VD, 56% of ASD population had mild form of the disorder, 34% moderate, and 10% severe; while CD had a 54% mild form of the disorder, 33% moderate, and 13% severe. This shows no statistical association (p=0.8069) when comparing exposure to anesthesia in uterus to subsequent severe form of ASD. Of the 262 ASD patients, 99 had exposure to anesthetics before their diagnosis, while in Non-ASD population, 110 had exposure to anesthesia, demonstrating no statistically significant association between both groups (p=0.2091). Out of 99 ASD patients exposed to anesthesia prior to their diagnosis, 72 were exposed before age 2. When compared to the 110 Non-ASD patients exposed to anesthesia, 86 had exposure during this developing brain period, which indicates no statistically significant association (p=0.4207). In addition, most of the ASD children exposed to anesthesia during developing brain were diagnosed with mild degree of the disorder when compared to ASD children without any previous exposure to anesthesia (p=0.9700) during the same period. When the exposure occurred after age 2, ASD children developed mild form of the disorder as compared with ASD children without any previous exposure to anesthesia (p=0.1699) in that period.

CONCLUSIONS

Children under early exposure to anesthesia in uterus, first 2 years of life, or later are not more likely to develop neither ASD nor severe form of the disorder.

Previous Exposure to Anesthesia and Autism Spectrum Disorder (ASD): A Puerto Rican Population-Based Sibling Cohort Study

BACKGROUND

Autism Spectrum Disorder (ASD) is characterized by impaired social interaction and communication, and by restricted and repetitive behavior, that begins usually before a child is three years old.1 Researchers have shown that prevalence rates in the U.S. may be as high as 1 in 68.52 A number of studies have examined the effects of early exposure to anesthesia on brain development and subsequent impairment in neurocognitive function; yet, little is known about the possible effects of anesthetic agents on social-behavioral functioning. The association between exposure to anesthesia either in uterus, during the first years of life, or later and development of Autistic Spectrum Disorder (ASD) or its severity was determined in a retrospective population based cohort study.

OBJECTIVES

Identify if children who had previous exposure to anesthesia either in uterus, first years of life during their developing brain years, or later, are at risk of developing ASD and its severe form of the disease.

METHODS

Data was obtained from structured interviews administered to a sample of 515 parents/guardians distributed in two groups: ASD = 262 children diagnosed with this condition and Non-ASD: 253 children (siblings of ASD group) without diagnosis (p = 0.8069) when comparing exposure to anesthesia in uterus to subsequent severe form of ASD. Of the 262 ASD patients, 99 had exposure to anesthetics before their diagnosis, while in Non-ASD population, 110 had exposure to anesthesia, demonstrating no statistically significant association between both groups (p = 0.2091). Out of 99 ASD patients exposed to anesthesia prior to their diagnosis, 72 were exposed before age 2. When compared to the 110 Non-ASD patients exposed to anesthesia, 86 had exposure during this developing brain period, which indicates no statistically significant association (p = 0.4207). In addition, most of the ASD children exposed to anesthesia during developing brain were diagnosed with mild degree of the disorder when compared to ASD children without any previous exposure to anesthesia (p = 0.9700) during the same period. When the exposure occurred after age 2, ASD children developed mild form of the disorder as compared with ASD children without any previous exposure to anesthesia (p = 0.1699) in that period.

CONCLUSIONS

Children under early exposure to anesthesia in uterus, first 2 years of life, or later are not more likely to develop neither ASD nor severe form of the disorder. INDEX WORDS: Anesthesia, Autism Spectrum Disorder, Puerto Rico. (95% confidence interval) that freely decided to participate and agreed to a consent form. Variables studied, include: demographics, diagnosis and severity of ASD, exposure to anesthesia, method of childbirth, and age of exposure. Children less than 2 years of age were considered into have developing brain period. Data was analyzed using Chi-square or Fisher exact test.

RESULTS

In contrast to non-ASD group, most of the children within ASD group were male, 76% (p = 0.0001). With regards to methods of childbirth, 64% of the ASD population were vaginal delivery (VD; Non-anesthesia exposure group) and 36% cesarean delivery (CD) compared to non-autistic population with 71% VD and 29% CD, which demonstrates no statistical difference between both groups (p = 0.1113). Out of the 36% of ASD population that underwent CD, 7% were performed using general anesthesia and 93% regional anesthesia, while the 29% of the CD of non-ASD, 5% were performed using general anesthesia and 95% regional anesthesia. This reveals no statistical significance (p = 0.7569) with the development of ASD and the type of anesthesia used when comparing ASD with non-ASD patients. In view of severity of autism, in VD, 56% of ASD population had mild form of the disorder, 34% moderate, and 10% severe; while CD had a 54% mild form of the disorder, 33% moderate, and 13% severe. This shows no statistical association.

Probing the structure of influenza B hemagglutinin using site-directed mutagenesis

The crystal structure of the hemagglutinin (HA) of influenza virus A/Aichi/68 (H3N2) from the X-31 reassortant virus was reported in 1981, but as yet there are no X-ray diffraction structures for hemagglutinins of other types or even subtypes of influenza virus. We have used site-directed mutagenesis to probe the structure of the hemagglutinin of influenza B/Hong Kong/8/73. We investigated a region in the globular head domain that is helical in the influenza A HA structure, targeting sidechains that in the H3 HA point toward solvent (Thr196) or into the receptor-binding pocket (Gln197). None of the mutations affected hemagglutination activity, but mutations T196P or Q1971 eliminated binding of a monoclonal antibody. The data suggest that this region of the influenza B HA forms a surface structure different from the alpha-helix of the influenza A HA structure and that it accounts for much of the antigenic activity of influenza B HA.

Effect of dietary fiber and starch on fecal composition in preschool children consuming maize, amaranth, or cassava flours

Metabolic balance studies were carried out in young children fed diets based on maize, amaranth, or cassava flours and in corresponding casein controls. Dietary fiber intakes were 22.2, 20.5, and 9.0 g/day for the maize, amaranth, and cassava groups, respectively. Fecal energy losses at least doubled in all test diets when compared with the corresponding controls and could generally be accounted for by recovered fiber in the feces. Fecal starch was also a significant contributor to fecal energy in the cassava group. All cassava fiber was recovered in the feces, whereas only 48.4 and 16.3% were recovered from ingested maize and amaranth. 2,6-Diaminopimelic acid (DAPA), an indicator of bacterial mass, was highest in the cassava group. Expired breath hydrogen was highest for those consuming maize or cassava. Resistant starch may have been responsible for the high DAPA and breath hydrogen values in the cassava group.