Assessing Utility of 24-Hour Ambulatory Blood Pressure Monitoring to Distinguish Pediatric Populations Presenting with Elevated Blood Pressure in Rhode Island

This retrospective study aimed to assess the value of 24-hour ambulatory blood pressure monitoring (ABPM) in distinguishing primary from secondary hypertension in pediatric patients. Our study was conducted on 293 patients referred to a pediatric nephrology clinic over 11 years. Various ABPM parameters were analyzed, including daytime and nighttime systolic and diastolic blood pressures, heart rate, and blood pressure load. Among the participants, 74% were normotensive (white-coat hypertension), 21.5% had primary hypertension, and 4.4% had secondary hypertension. There were no significant differences in the analyzed variables between primary and secondary hypertension groups. Our findings suggest that ABPM might not reliably differentiate between the two in this cohort. As white-coat hypertension becomes more prevalent, ABPM remains a valuable tool in preventing unnecessary workups in children without sustained hypertension. However, our study did not identify specific endpoints for distinguishing primary from secondary hypertension.

Isolated benign persistent proteinuria with novel association of CUBN (cubilin) variants

We present two siblings with persistent proteinuria and normal kidney function, each carrying the same compound heterozygous variants in the CUBN gene. The CUBN-related phenotype appears to be dependent upon both variant type and the domain site within the gene. Knowledge of CUBN status may allow for avoidance of invasive testing.

Pediatric Mineral and Bone Disorder of Chronic Kidney Disease and Cardiovascular Disease

Chronic kidney disease is common and causes significant morbidity including shortened lifespans and decrease in quality of life for patients. The major cause of mortality in chronic kidney disease is cardiovascular disease. Cardiovascular disease within the chronic kidney disease population is closely tied with disordered calcium and phosphorus metabolism and driven in part by renal bone disease. The complex nature of renal, bone, and cardiovascular diseases was renamed as mineral and bone disorder of chronic kidney disease to encompass how bone disease drives vascular calcification and contributes to the development of long-term cardiovascular disease, and recent data suggest that managing bone disease well can augment and improve cardiovascular disease status. Pediatric nephrologists have additional obstacles in optimal mineral and bone disorder of chronic kidney disease management such as linear growth and skeletal maturation. In this article, we will discuss cardiovascular and bone diseases in chronic kidney disease and end-stage kidney disease patients with a focus on pediatric issues and concerns.

Nephrolithiasis: A complication of pediatric diabetic ketoacidosis

OBJECTIVE

To determine the frequency of nephrolithiasis as a complication of diabetic ketoacidosis (DKA) in pediatrics.

METHODS

We performed a retrospective chart review of patients with DKA admitted to a pediatric hospital between January 2009 and July 2016. We identified patients with nephrolithiasis during admission for DKA.

RESULTS

We identified 395 episodes of DKA over 7.5 years. Nephrolithiasis developed as a complication of DKA in 3 of those admissions (0.8%). All three patients with nephrolithiasis were males with new onset type 1 diabetes, aged 11 to 16.5 years. They all developed symptoms of nephrolithiasis after transition to subcutaneous insulin. One patient had subsequent worsening acidosis that required an additional 24 hours of IV insulin administration.

CONCLUSIONS

Nephrolithiasis is a rare complication of pediatric DKA, and should be considered in children with DKA who develop hematuria, flank pain, or suprapubic pain. Nephrolithiasis can increase insulin resistance due to increased pain and inflammation, so these patients should be monitored closely for recurrence of DKA. As patients with diabetes have increased risk of chronic kidney disease and nephrolithiasis can cause kidney injury, risk factors for nephrolithiasis should be identified and addressed to avoid subsequent kidney damage.

Two cases of humoral hypercalcemia of malignancy complicating infantile fibrosarcoma

We report two infants with infantile fibrosarcoma (IFS) complicated by severe hypercalcemia. Assessment demonstrated suppressed parathyroid hormone and 1,25-dihydroxyvitamin D levels with elevated circulating levels of parathyroid hormone related protein, indicating the diagnosis of humoral hypercalcemia of malignancy (HHM). HHM is a paraneoplastic syndrome rarely associated with pediatric malignancies. Hypercalcemia manifested clinically with neurologic symptoms and soft tissue calcium deposition and required aggressive management with intravenous fluids, diuretics, and supplemental electrolytes. Following treatment with neoadjuvant chemotherapy, serum calcium levels precipitously declined requiring calcium repletion. These cases highlight the improvement of hypercalcemia secondary to HHM following chemotherapy.

A Mutation in the gene-encoding bacteriophage T7 DNA polymerase that renders the phage temperature-sensitive

Gene 5 of bacteriophage T7 encodes a DNA polymerase essential for phage replication. A single point mutation in gene 5 confers temperature sensitivity for phage growth. The mutation results in an alanine to valine substitution at residue 73 in the exonuclease domain. Upon infection of Escherichia coli by the temperature-sensitive phage at 42 degrees C, there is no detectable T7 DNA synthesis in vivo. DNA polymerase activity in these phage-infected cell extracts is undetectable at assay temperatures of 30 degrees C or 42 degrees C. Upon infection at 30 degrees C, both DNA synthesis in vivo and DNA polymerase activity in cell extracts assayed at 30 degrees C or 42 degrees C approach levels observed using wild-type T7 phage. The amount of soluble gene 5 protein produced at 42 degrees C is comparable to that produced at 30 degrees C, indicating that the temperature-sensitive phenotype is not due to reduced expression, stability, or solubility. Thus the polymerase induced at elevated temperatures by the temperature-sensitive phage is functionally inactive. Consistent with this observation, biochemical properties and heat inactivation profiles of the genetically altered enzyme over-produced at 30 degrees C closely resemble that of wild-type T7 DNA polymerase. It is likely that the polymerase produced at elevated temperatures is a misfolded intermediate in its folding pathway.

Clinical information systems--developing a systematic planning process

CHW is a large and diverse hospital system that developed a systematic planning process to define, prioritize, and assess the current status of those functionalities needed by caregivers to assist them in providing optimal care. In order to develop a durable consensus, a bottom-up approach was used. The details of the process including the structure of the meetings and many of the methodologies employed are presented.

Is computerization keeping up with patient-focused care?

It is essential to improve patient care in both quality and efficiency. Lessons gleaned from implementing bedside computing in a patient-focused care environment are presented. Although selective application of computer-based solutions can be effective, such efforts can also be risky and expensive.

Sensitivity, specificity, and risk of diagnostic procedures in a canine model of Streptococcus pneumoniae pneumonia

A canine model in which unilateral Streptococcus pneumoniae pneumonia was induced was used to evaluate the sensitivity, specificity, and risk of various technics proposed for the diagnosis of pulmonary infection. Control and infected animals were studied during spontaneous and mechanical ventilation. We found that three procedures provided a reasonable degree of combined specificity and sensitivity: transthoracic needle aspiration (TTN), catheter-brush biopsy (CBB), and transbronchial biopsy (TBB). Transtracheal aspiration, although sensitive, was consistently low in specificity, whereas TTN provided the highest sensitivity/specificity. Both CBB and TBB provided almost the same results in intubated animals, but specificity was lower in nonintubated animals. Gram-stained smears obtained by TTN, CBB, and TBB were highly specific, but often negative. The only risk encountered was pneumothorax. The TTN was associated with a 20 to 30% risk of pneumothorax; CBB and TBB did not appear to induce pneumothorax. These studies provide the first animal data regarding the comparative yield/risk of these diagnostic approaches. As such, they may prove useful in the design of future human investigations.