Derivation of paediatric blood pressure percentiles from electronic health records

BACKGROUND

Identification of abnormal blood pressure (BP) in children requires normative data. We sought to examine the feasibility of using "real-world" office BP data obtained from electronic health records (EHR) to generate age-, sex- and height-specific BP percentiles for children.

METHODS

Using data collected 01/01/2009-8/31/2021 from eight large children's healthcare organisations in PEDSnet, we applied a mixed-effects polynomial regression model with random slopes to generate Z-scores and BP percentiles and compared them with currently used normative BP distributions published in the 2017 American Academy of Paediatrics (AAP) Clinical Practise Guidelines (CPG).

FINDINGS

We identified a study sample of 292,412 children (1,085,083 BP measurements), ages 3-17 years (53% female), with no chronic medical conditions, who were not overweight/obese and who were primarily seen for general paediatric care in outpatient settings. Approximately 45,000-75,000 children contributed data to each age category. The PEDSnet systolic BP percentile values were 1-4 mmHg higher than AAP CPG BP values across age-sex-height groups, with larger differences observed in younger children. Diastolic BP values were also higher in younger children; starting with age 7 years, diastolic BP percentile values were 1-3 mmHg lower than AAP CPG values. Cohen's Kappa was 0.90 for systolic BP, 0.66 for diastolic BP, and 0.80 overall indicating excellent agreement between PEDSnet and 2017 AAP CPG data for systolic BP and substantial agreement for diastolic BP.

INTERPRETATION

Our analysis indicates that real-word EHR data can be used to generate BP percentiles consistent with current clinical practise on BP management in children.

FUNDING

Funding for this work was provided by the Preserving Kidney Function in Children with Chronic Kidney Disease (PRESERVE) study; Patient-Centred Outcomes Research Institute (PCORI) RD-2020C2020338 (Principal Investigator: Dr. Forrest; Co-Principal Investigator: Dr. Denburg).

An exploration of testicular cancer survivors' experience of ejaculatory dysfunction following retroperitoneal lymph node dissection-a sub-study of the PREPARE clinical trial

PURPOSE

Ejaculatory dysfunction secondary to retrograde ejaculation or anejaculation is a complication of retroperitoneal lymph node dissection (RPLND) for survivors of testicular cancer. We explored survivors' experiences of ejaculatory dysfunction following RPLND.

METHODS

In a sub-study of a single-arm phase 2 clinical trial (ACTRN12622000537752/12622000542796), participants reporting ejaculatory dysfunction ≥ 6 months following RPLND were invited to complete semi-structured interviews. Purposive sampling was used. Interviews continued until thematic saturation occurred, and codebook thematic analysis of interviews was performed.

RESULTS

Of 58 individuals recruited to the trial, 33 (57%) reported ejaculatory dysfunction. Of these, 32 (97%) agreed to interview and 15 participated. Participants interviewed had median age 34 years (range 24-66), 12 (80%) in a long-term relationship with median time from surgery 36 months (range 11-112). Three overarching themes were identified. The first reflected the value of RPLND despite ejaculatory dysfunction. The second illuminated the impact(s) of ejaculatory dysfunction closely mapped to life stage, with flow-on impacts to fertility, sex, psychological wellbeing and communication. The third reflected information needs. Fertility was a substantial source of concern for some participants. Ejaculatory dysfunction had no effect on sex for some, whilst for others, sex was less pleasurable. Some reported benefits. Few reported ejaculatory dysfunction challenged masculinity, confidence, or self-esteem.

CONCLUSIONS

Future research should examine interventions to reduce distress related to fertility, challenged masculinity and body image.

IMPLICATIONS FOR CANCER SURVIVORS

Whilst most participants considered ejaculatory dysfunction to have little impact on their sexual function and relationships, some reported significant difficulties varying by life stage and relationship status.

Design and rationale of re-energize fontan: Randomized exercise intervention designed to maximize fitness in fontan patients

In this manuscript, we describe the design and rationale of a randomized controlled trial in pediatric Fontan patients to test the hypothesis that a live-video-supervised exercise (aerobic+resistance) intervention will improve cardiac and physical capacity; muscle mass, strength, and function; and endothelial function. Survival of children with single ventricles beyond the neonatal period has increased dramatically with the staged Fontan palliation. Yet, long-term morbidity remains high. By age 40, 50% of Fontan patients will have died or undergone heart transplantation. Factors that contribute to onset and progression of heart failure in Fontan patients remain incompletely understood. However, it is established that Fontan patients have poor exercise capacity which is associated with a greater risk of morbidity and mortality. Furthermore, decreased muscle mass, abnormal muscle function, and endothelial dysfunction in this patient population is known to contribute to disease progression. In adult patients with 2 ventricles and heart failure, reduced exercise capacity, muscle mass, and muscle strength are powerful predictors of poor outcomes, and exercise interventions can not only improve exercise capacity and muscle mass, but also reverse endothelial dysfunction. Despite these known benefits of exercise, pediatric Fontan patients do not exercise routinely due to their chronic condition, perceived restrictions to exercise, and parental overprotection. Limited exercise interventions in children with congenital heart disease have demonstrated that exercise is safe and effective; however, these studies have been conducted in small, heterogeneous groups, and most had few Fontan patients. Critically, adherence is a major limitation in pediatric exercise interventions delivered on-site, with adherence rates as low as 10%, due to distance from site, transportation difficulties, and missed school or workdays. To overcome these challenges, we utilize live-video conferencing to deliver the supervised exercise sessions. Our multidisciplinary team of experts will assess the effectiveness of a live-video-supervised exercise intervention, rigorously designed to maximize adherence, and improve key and novel measures of health in pediatric Fontan patients associated with poor long-term outcomes. Our ultimate goal is the translation of this model to clinical application as an "exercise prescription" to intervene early in pediatric Fontan patients and decrease long-term morbidity and mortality.

Establishing a Data Science Unit in an Academic Medical Center: An Illustrative Model

The field of data science has great potential to address critical questions relevant for academic medical centers. Data science initiatives are consequently being established within academic medicine. At the cornerstone of such initiatives are scientists who practice data science. These scientists include biostatisticians, clinical informaticians, database and software developers, computational scientists, and computational biologists. Too often, however, those involved in the practice of data science are viewed by academic leadership as providing a noncomplex service to facilitate research and further the careers of other academic faculty. The authors contend that the success of data science initiatives relies heavily on the understanding that the practice of data science is a critical intellectual contribution to the overall science conducted at an academic medical center. Further, careful thought by academic leadership is needed for allocation of resources devoted to the practice of data science. At the Stanford University School of Medicine, the authors have developed an innovative model for a data science collaboratory based on 4 fundamental elements: an emphasis on collaboration over consultation, a subscription-based funding mechanism that reflects commitment by key partners, an investment in the career development of faculty who practice data science, and a strong educational component for data science members in team science and for clinical and translational investigators in data science. As data science becomes increasingly essential to learning health systems, centers that specialize in the practice of data science are a critical component of the research infrastructure and intellectual environment of academic medical centers.

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients

INTRODUCTION

The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients.

METHODS

A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05.

RESULTS

449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05).

CONCLUSION

In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

Pelvic and acetabular trauma in amateur equestrian enthusiasts - A retrospective review

INTRODUCTION

Horse riding related accidents can present with devastating pelvic and acetabular fractures. This study examines the nature, management and treatment outcomes of severe pelvic and acetabular trauma in amateur horse riders presenting to a national tertiary referral centre. We also aim to define certain at-risk groups.

METHODS

This was a retrospective descriptive cohort of all patients who were referred to the National Centre for Pelvic and Acetabular trauma resulting from horse riding accidents. All patients who were referred to the National Centre for Pelvic and Acetabular Trauma between January 2018 and July 2020 were included. Professional horse riders were excluded. Clinical and treatment outcome measures were stratified to four different mechanisms of injury: fall from horse (FFH), horse crush (HC), Horse Kick (HK) and Saddle Injury (SI).

RESULTS

There were 31 equestrian related injuries referred to our centre between January 2018 and July 2020. One patient was a professional jockey and was thus excluded from the study. Eighteen were female and the mean age at referral was 37 years old. The majority of these were pelvic ring injuries (73%). Fifty per cent of patients required surgical intervention and the majority of these were male.

CONCLUSION

Horse riding is a potentially dangerous recreational pursuit with significant risk of devastating injury. Pelvic and acetabular fractures secondary to horse riding are frequently associated with other injuries and the need operative intervention is common in this group. Young women and older men are higher risk groups.

Assessment of the Association of Leadership Behaviors of Supervising Physicians With Personal-Organizational Values Alignment Among Staff Physicians

IMPORTANCE

Although misalignment of values between physicians and their organization is associated with increased risk of burnout, actionable organizational factors that contribute to perceived values alignment are poorly understood.

OBJECTIVE

To evaluate the association between the leadership behaviors of immediate supervisors and physicians' perception of personal-organizational values alignment.

DESIGN, SETTING, AND PARTICIPANTS

This survey study of faculty physicians and physician leaders at Stanford University School of Medicine was conducted from April 1 to May 13, 2019. The survey included assessments of perceived personal-organizational values alignment, professional fulfillment, and burnout. Physicians also evaluated the leadership behaviors of their immediate supervisor (eg, division chief) using a standardized assessment. Data analysis was performed from May to December 2020.

MAIN OUTCOMES AND MEASURES

Association between mean leadership behavior score (range, 0-10) of each supervisor and the mean personal-organizational values alignment scores (range, 0-12) for the physicians in their work unit.

RESULTS

Of 1924 physicians eligible to participate, 1285 (67%) returned surveys. Among these, 651 (51%) were women and 729 (57%) were aged 40 years or older. Among the 117 physician leaders evaluated, 66 (56%) had their leadership behavior independently evaluated by at least 5 physicians and were included in analyses. The mean (SD) personal-organizational values alignment score on the 0 to 12 scale was 6.19 (3.21). As the proportion of work effort devoted to clinical care increased, values alignment scores decreased. Personal-organizational values alignment scores demonstrated an inverse correlation with burnout (r = -0.39; P < .001) and a positive correlation with professional fulfillment (r = 0.52; P < .001). The aggregate leader behavior score of the 66 leaders evaluated correlated with the mean values alignment score for physicians in their work unit (r = 0.53; P < .001). Aggregate leader behavior score was associated with 21.6% of the variation in personal-organizational values alignment scores between work units. After adjusting for age, gender, academic rank, work hours, physician-leader gender concordance, and time devoted to clinical care, each 1-point increase in leadership score of immediate supervisor was associated with a 0.56-point (95% CI, 0.46-0.66; P < .001) increase in personal-organizational values alignment score.

CONCLUSIONS AND RELEVANCE

This survey study's results suggest that physicians experience their organization through the prism of their work unit leader. Organizational efforts to improve values alignment should attend to the development of first-line physician leaders.

A Big HIIT: A Fracture Dislocation of the Hip in a Young Man Participating in Extreme Conditioning Exercise: A Case Report

CASE

Hip dislocations with associated acetabular fracture are rare events usually associated with high-energy trauma. We describe an unusual case of low-energy acetabular fracture dislocation sustained by a 30-year-old athletic male athlete during a high-intensity training program.

CONCLUSION

Correct execution of training programs is important. Healthcare professionals as well as participants and instructors of extreme conditioning programs should be aware of this serious complication. Avoidance of this injury may be possible with increased interval recovery and improved technique.

Metastasis Suppressor NME1 Modulates Choice of Double-Strand Break Repair Pathways in Melanoma Cells by Enhancing Alternative NHEJ while Inhibiting NHEJ and HR

Reduced NME1 expression in melanoma cell lines, mouse models of melanoma, and melanoma specimens in human patients is associated with increased metastatic activity. Herein, we investigate the role of NME1 in repair of double-stranded breaks (DSBs) and choice of double-strand break repair (DSBR) pathways in melanoma cells. Using chromatin immunoprecipitation, NME1 was shown to be recruited rapidly and directly to DSBs generated by the homing endonuclease I-PpoI. NME1 was recruited to DSBs within 30 min, in concert with recruitment of ataxia-telangiectasia mutated (ATM) protein, an early step in DSBR complex formation, as well as loss of histone 2B. NME1 was detected up to 5 kb from the break site after DSB induction, suggesting a role in extending chromatin reorganization away from the repair site. shRNA-mediated silencing of NME1 expression led to increases in the homologous recombination (HR) and non-homologous end-joining (NHEJ) pathways of double-strand break repair (DSBR), and reduction in the low fidelity, alternative-NHEJ (A-NHEJ) pathway. These findings suggest low expression of NME1 drives DSBR towards higher fidelity pathways, conferring enhanced genomic stability necessary for rapid and error-free proliferation in invasive and metastatic cells. The novel mechanism highlighted in the current study appears likely to impact metastatic potential and therapy-resistance in advanced melanoma and other cancers.

Association of Burnout, Professional Fulfillment, and Self-care Practices of Physician Leaders With Their Independently Rated Leadership Effectiveness

IMPORTANCE

Although leadership behavior of physician supervisors is associated with the occupational well-being of the physicians they supervise, the factors associated with leadership behaviors are poorly understood.

OBJECTIVE

To evaluate the associations between burnout, professional fulfillment, and self-care practices of physician leaders and their independently assessed leadership behavior scores.

DESIGN, SETTING, AND PARTICIPANTS

This survey study of physicians and physician leaders at Stanford University School of Medicine (n = 1924) was conducted from April 1 to May 13, 2019. The survey included assessments of professional fulfillment, self-valuation, sleep-related impairment, and burnout. Physicians also rated the leadership behaviors of their immediate physician supervisors using a standardized assessment. Leaders' personal well-being metrics were paired with their leadership behavior scores as rated by the physicians they supervised. All assessment scores were converted to a standardized scale (range, 0-10). Data were analyzed from October 20, 2019, to March 10, 2020.

MAIN OUTCOMES AND MEASURES

Association between leaders' own well-being scores and their independently assessed leadership behavior.

RESULTS

Of 1924 physicians invited to participate, 1285 (66.8%) returned surveys, including 67 of 117 physician leaders (57.3%). Among these respondents, 651 (50.7%) were women and 729 (56.7%) were 40 years or older. Among the 67 leaders, 57 (85.1%) had their leadership behaviors evaluated by at least 5 physicians (median, 11 [interquartile range, 9-15]) they supervised. Overall, 9.8% of the variation in leaders' aggregate leadership behavior scores was associated with their own degree of burnout. In models adjusted for age and sex, each 1-point increase in burnout score of the leaders was associated with a 0.19-point decrement in leadership behavior score (β = -0.19; 95% CI, -0.35 to -0.03; P = .02), whereas each 1-point increase in their professional fulfillment and self-valuation scores was associated with a 0.13-point (β = 0.13; 95% CI, 0.01-0.26; P = .03) and 0.15-point (β = 0.15; 95% CI, 0.02-0.29; P = .03) increase in leadership behavior score, respectively. Each 1-point increase in leaders' sleep-related impairment was associated with a 0.15-point increment in sleep-related impairment among those they supervised (β = 0.15; 95% CI, 0.02-0.29; P = .03). The associations between leaders' well-being scores in other dimensions and the corresponding well-being measures of those they supervised were not significant.

CONCLUSIONS AND RELEVANCE

In this survey study, burnout, professional fulfillment, and self-care practices of physician leaders were associated with their independently assessed leadership effectiveness. Training, skill building, and support to improve leader well-being should be considered a dimension of leadership development rather than simply a dimension of self-care.

Serial Fibroblast Growth Factor 23 Measurements and Risk of Requirement for Kidney Replacement Therapy: The CRIC (Chronic Renal Insufficiency Cohort) Study

RATIONALE & OBJECTIVE

Studies using a single measurement of fibroblast growth factor 23 (FGF-23) suggest that elevated FGF-23 levels are associated with increased risk for requirement for kidney replacement therapy (KRT) in patients with chronic kidney disease. However, the data do not account for changes in FGF-23 levels as kidney disease progresses.

STUDY DESIGN

Case-cohort study.

SETTING & PARTICIPANTS

To evaluate the association between serial FGF-23 levels and risk for requiring KRT, our primary analysis included 1,597 individuals in the Chronic Renal Insufficiency Cohort Study who had up to 5 annual measurements of carboxy-terminal FGF-23. There were 1,135 randomly selected individuals, of whom 266 initiated KRT, and 462 individuals who initiated KRT outside the random subcohort.

EXPOSURE

Serial FGF-23 measurements and FGF-23 trajectory group membership.

OUTCOMES

Incident KRT.

ANALYTICAL APPROACH

To handle time-dependent confounding, our primary analysis of time-updated FGF-23 levels used time-varying inverse probability weighting in a discrete time failure model. To compare our results with prior data, we used baseline and time-updated FGF-23 values in weighted Cox regression models. To examine the association of FGF-23 trajectory subgroups with risk for incident KRT, we used weighted Cox models with FGF-23 trajectory groups derived from group-based trajectory modeling as the exposure.

RESULTS

In our primary analysis, the HR for the KRT outcome per 1 SD increase in the mean of natural log-transformed (ln)FGF-23 in the past was 1.94 (95% CI, 1.51-2.49). In weighted Cox models using baseline and time-updated values, elevated FGF-23 level was associated with increased risk for incident KRT (HRs per 1 SD ln[FGF-23] of 1.18 [95% CI, 1.02-1.37] for baseline and 1.66 [95% CI, 1.49-1.86] for time-updated). Membership in the slowly and rapidly increasing FGF-23 trajectory groups was associated with ∼3- and ∼21-fold higher risk for incident KRT compared to membership in the stable FGF-23 trajectory group.

LIMITATIONS

Residual confounding and lack of intact FGF-23 values.

CONCLUSIONS

Increasing FGF-23 levels are independently associated with increased risk for incident KRT.

Nutritional status of neurologically impaired children: Impact on comorbidity

BACKGROUND AND AIMS

Malnutrition is common in neurologically impaired (NI) children. It is, however, ill-defined and under-diagnosed. If not recognized and treated, it increases the burden of comorbidities and affects the quality of life of these children. The aim of this study was to characterize the nutritional status of a cohort of children followed up at a reference center for cerebral palsy (CP) in Brussels, Belgium, and to investigate possible links with the occurrence of comorbidities.

MATERIAL AND METHODS

We conducted a single-center retrospective study including all the children followed up at the Inter-university Reference Center for Cerebral Palsy ULB-VUB-ULg. The data were obtained by reviewing medical files. Anthropometric measurements as well as the etiology of neurological impairment, comorbidities, feeding patterns, and laboratory test results were collected. The children were assigned a nutritional diagnosis according to the World Health Organization and Waterlow definitions.

RESULTS

A total of 260 children with cerebral palsy were included, 148 males and 112 females. Their mean age was 10.9±4.3 years. The gross motor function classification system (GMFCS) level was I for 79 children, II for 63 children, III for 35 children, IV for 33 children, and V for 50 children. Of the children, 54% had a normal nutritional status, 34% showed malnutrition, and 8% were obese; 38% had oropharyngeal dysphagia. The sensitivity of mean upper arm circumference of<p10 to detect severe malnutrition was 95%. Specific growth charts for CP were neither sensitive nor specific for predicting the risk of comorbidities. Malnutrition was associated with an increased risk of comorbidities (relative risk of 2.4 [1.7; 3.4]). It was also associated with the occurrence of pneumonia, pressure ulcers, and pathological bone fracture.

DISCUSSION AND CONCLUSION

Children who are NI should be systematically and thoroughly screened for malnutrition, in the hope of offering early nutritional support and reduce comorbidities.

Where does Pelvic and Acetabular Fracture Treatment fit into the Newly Proposed Major Trauma Model in Ireland?

Aim To provide the most up to date reference of referral patterns for pelvis and acetabular (PA) fractures in Ireland and discuss where services should ideally be located. Methods A retrospective review was conducted of all referrals to the national referral centre for PA fractures in Ireland for 2016 and 2017. Results Over the two-year study period 456 referrals were made. Mean age of patients was 53 years, 62.9% were male. Management was conservative in 60.7%, operative in 38.2% while 1.1% died prior to transfer. Nearly half of fractures (47.8%) were due to falls with 38.6% due to road trauma. Referrals from the proposed central trauma network accounted for 76.1% of referrals. Median length of stay was 7 days. Average cost of operative treatment was €11,774. Conclusions PA trauma is associated with significant morbidity and costs to both patients and society. Consideration needs to be given to where best to place PA services to ensure the highest quality care in this cohort of patients

Major histocompatibility complex class I in the horse (Equus caballus) placenta during pregnancy and parturition

BACKGROUND

Major histocompatibility protein class I (MHC-I) is believed to be expressed in the horse allantochorion only in limited areas at limited times. However, its expression has only been investigated in early pregnancy with non-quantitative techniques that cannot reliably detect small amounts of protein.

OBJECTIVE

To quantify the relative expression of MHC-I in the allantochorion and endometrium during days 90-240 of pregnancy (PREG), parturition with physiological delivery of fetal membranes (PHYS), and parturition with retention of these membranes (FMR). Also, to visualize protein expression and determine whether classical or non-classical MHC-I mRNA is expressed.

ANIMALS

Heavy draft horses.

SETTING

PREG horses (n = 12) were sampled postmortem at a slaughterhouse. PHYS (n = 6) and FMR (n = 5) horses were sampled at farms in the vicinity of Olsztyn, Poland.

METHODS

For relative quantification of MHC-I, western blotting with densitometry was used. To visualize MHC-I, immunohistochemistry was used. For mRNA identification, RT-PCR was performed.

RESULTS

Although the quantity of MHC-I was lower during PREG than parturition, it was present in the allantochorion and endometrium during PREG. During parturition, MHC-I expression was upregulated in the allantochorion (PHYS vs. PREG: 2.7-times higher, 95% confidence interval, 1.3- to 5.7-times higher; FMR vs. PREG: 3.2-times higher, 95% confidence interval, 1.5- to 6.7-times higher). At parturition, staining for MHC-I was detected in the microcotyledons. Classical and non-classical MHC-I were expressed in both tissues during PREG, PHYS, and FMR.

CONCLUSION

MHC-I protein is present in the horse allantochorion and endometrium for at least the first two-thirds of pregnancy and at parturition.

When Environmental Forces Collide

Multiple factors often interact to amplify the effects of severe storms, droughts, and other extreme water-related events.

Hemoglobin Solutions Coupled with Polyethylene Glycol 1900: Preparation, Purification, Quality Control and Pharmacological Trials by Hemorrhagic Shock

The usefulness of hemoglobin solutions as oxygen transporters is limited by their high affinity for oxygen and rapid elimination from the circulation. Various chemical modifications of hemoglobin aimed at overcoming these two handicaps have been suggested. We have developed a conjugate of pyridoxylated human hemoglobin with monomethoxypolyoxyethylene 1900, whose preparation and properties are described. We present comparative results on short-term or definitive survival of Wistar rats which, during hemorrhagic shock due to the loss of 60 or 80% of their blood mass, were given a solution of native or modified hemoglobin, in some cases purified by ion-exchange chromatography to remove non-heme proteins, lipids, and some endotoxins. The more complex the treatment used to improve the properties and the purity of the hemoglobin solutions, the longer the animals survived. The loss of hemoglobin in the urine was greatly reduced after conjugation: after 20 h, less than 6% of the total infused.

Use of an annual art competition to promote Web site traffic and engage children in antimicrobial stewardship in Pennsylvania

We used Google Analytics to assess whether annual kids' art competitions changed traffic to a Web site on appropriate antibiotic use. We found that announcements about kids' art competitions correlated with increased traffic to the Web site, suggesting that this innovation has promise in promoting antimicrobial stewardship efforts.

Fibroblast Growth Factor 23 and Anemia in the Chronic Renal Insufficiency Cohort Study

BACKGROUND AND OBJECTIVES

Anemia is an early complication of CKD that is associated with increased morbidity and mortality. Prior data show associations between abnormal mineral metabolism markers and decreased erythropoiesis. However, few studies have investigated elevated fibroblast growth factor 23 as a risk factor for the development of anemia in patients with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a prospective cohort study of 3869 individuals with mild to severe CKD enrolled in the Chronic Renal Insufficiency Cohort Study between 2003 and 2008 and followed through 2013. We hypothesized that elevated baseline fibroblast growth factor 23 levels are associated with prevalent anemia, decline in hemoglobin over time, and development of incident anemia, defined as serum hemoglobin level <13 g/dl in men, serum hemoglobin level <12 g/dl in women, or use of erythropoietin stimulating agents.

RESULTS

In the 1872 of 3869 individuals who had prevalent anemia at baseline, mean age was 58 (11) years old, and mean eGFR was 39 (13) ml/min per 1.73 m2. Higher levels of fibroblast growth factor 23 were significantly associated with prevalent anemia (odds ratio per 1-SD increase in natural log-transformed fibroblast growth factor 23, 1.39; 95% confidence interval, 1.26 to 1.52), decline in hemoglobin over 4 years, and risk of incident anemia (hazard ratio per 1-SD increase in natural log-transformed fibroblast growth factor 23, 1.13; 95% confidence interval, 1.04 to 1.24; quartile 4 versus quartile 1: hazard ratio, 1.59; 95% confidence interval, 1.19 to 2.11) independent of demographic characteristics, cardiovascular disease risk factors, CKD-specific factors, and other mineral metabolism markers. The results of our prospective analyses remained unchanged after additional adjustment for time-varying eGFR.

CONCLUSIONS

Elevated fibroblast growth factor 23 is associated with prevalent anemia, change in hemoglobin over time, and development of anemia. Future studies are needed to elucidate the mechanisms for these associations.

The effect of social media (#SoMe) on journal impact factor and parental awareness in paediatric urology

BACKGROUND

Social media (SoMe) comprises a number of internet-based applications that have the capability to disseminate multimodal media and allow for unprecedented inter-user connectivity. The role of Twitter has been studied in conferences and education; moreover, there is increasing evidence that patients are more likely to use social media for their own health education.

OBJECTIVE

The aim of this study was to assess the impact of social media platforms on the impact factor of both urological and paediatric journals that publish on paediatric urology, and to assess parental awareness of social media in paediatric urology.

STUDY DESIGN

A filtered Journal of Citation Reports (JCR) search was performed for the period 2012-16 for journals that published articles on paediatric urology. Journals were ranked according to impact factor, and each individual journal website was accessed to assess for the presence of social media. Parents in paediatric urology clinics and non-paediatric urology patients also filled out a questionnaire to assess for awareness and attitudes to social media. All statistical analysis was performed using Prism 6 software (Prism 6, GraphPad Software, California, USA).

RESULTS

Overall, there were 50 urological journals and 39 paediatric journals with a mean impact factor of 2.303 and 1.766, respectively. There was an overall average increase in impact factor across all urological journals between 2012 and 16. The presence of a Twitter feed was statistically significant for a rise in impact factor over the 4 years (P = 0.017). The cohort of parents was statistically more likely to have completed post-secondary education, to have and access to a social media profile, use it for health education, and use it to access journal/physician/hospital social media accounts.

DISCUSSION

This study examined, for the first time, the role of social media in paediatric urology, and demonstrated that SoMe use is associated with a positive influence in impact factor, but also a parental appetite for it. Limitations included a non-externally validated questionnaire. There may also have been bias in larger journals that generate and maintain social media platforms such as Twitter, which may then in turn have an influence on impact factor.

CONCLUSIONS

Social media use within paediatric urology was associated with a higher impact factor, which remained significant after 4 years of analysis. Parents were more likely to use a wide variety of social media to search for conditions and physicians/healthcare providers; therefore, journals and institutions need to embrace and endorse SoMe as a potential source of important clinical information.

Acid Load and Phosphorus Homeostasis in CKD

BACKGROUND

The kidneys maintain acid-base homeostasis through excretion of acid as either ammonium or as titratable acids that primarily use phosphate as a buffer. In chronic kidney disease (CKD), ammoniagenesis is impaired, promoting metabolic acidosis. Metabolic acidosis stimulates phosphaturic hormones, parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF-23) in vitro, possibly to increase urine titratable acid buffers, but this has not been confirmed in humans. We hypothesized that higher acid load and acidosis would associate with altered phosphorus homeostasis, including higher urinary phosphorus excretion and serum PTH and FGF-23.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

980 participants with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study.

PREDICTORS

Net acid excretion as measured in 24-hour urine, potential renal acid load (PRAL) estimated from food frequency questionnaire responses, and serum bicarbonate concentration < 22 mEq/L.

OUTCOME & MEASUREMENTS

24-hour urine phosphorus and calcium excretion and serum phosphorus, FGF-23, and PTH concentrations.

RESULTS

Using linear and log-linear regression adjusted for demographics, kidney function, comorbid conditions, body mass index, diuretic use, and 24-hour urine creatinine excretion, we found that 24-hour urine phosphorus excretion was higher at higher net acid excretion, higher PRAL, and lower serum bicarbonate concentration (each P<0.05). Serum phosphorus concentration was also higher with higher net acid excretion and lower serum bicarbonate concentration (each P=0.001). Only higher net acid excretion associated with higher 24-hour urine calcium excretion (P<0.001). Neither net acid excretion nor PRAL was associated with FGF-23 or PTH concentrations. PTH, but not FGF-23, concentration (P=0.2) was 26% (95% CI, 13%-40%) higher in participants with a serum bicarbonate concentration <22 versus ≥22 mEq/L (P<0.001). Primary results were similar if stratified by estimated glomerular filtration rate categories or adjusted for iothalamate glomerular filtration rate (n=359), total energy intake, dietary phosphorus, or urine urea nitrogen excretion, when available.

LIMITATIONS

Possible residual confounding by kidney function or nutrition; urine phosphorus excretion was included in calculation of the titratable acid component of net acid excretion.

CONCLUSIONS

In CKD, higher acid load and acidosis associate independently with increased circulating phosphorus concentration and augmented phosphaturia, but not consistently with FGF-23 or PTH concentrations. This may be an adaptation that increases titratable acid excretion and thus helps maintain acid-base homeostasis in CKD. Understanding whether administration of base can lower phosphorus concentrations requires testing in interventional trials.

Assessing quality of life of patients with hypospadias: A systematic review of validated patient-reported outcome instruments

BACKGROUND

Patient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential.

OBJECTIVE

To identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population.

METHODS

A systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains.

RESULTS

A total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae.

CONCLUSIONS

While many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.

Hip Fracture in Patients With Non-Dialysis-Requiring Chronic Kidney Disease

Patients with end-stage renal disease (ESRD) are at a high risk for hip fracture. Little is known about the risk for, and consequences of, hip fracture among patients with non-dialysis-requiring chronic kidney disease (CKD). We examined the incidence of hip fracture, in-hospital mortality, length of stay, and costs among patients with ESRD, non-dialysis-requiring CKD, and normal or near normal kidney function. Using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, a nationally representative database, we identified hospitalizations for hip fracture in 2010. We incorporated data from the United States Renal Data System (USRDS) and the US census to calculate population-specific rates. Age-standardized incidence of hip fracture was highest among patients with ESRD (3.89/1000 person-years), followed by non-dialysis-requiring CKD (1.81/1000 persons) and patients with normal or near normal kidney function (1.18/1000 persons). In-hospital mo rtality (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.46 to 1.96), lengths of stay (median [10th, 90th percentiles] 5 [3 to 11] versus 5 [3 to 10] days) and costs (median $14,807 versus $13,314) were significantly higher in patients with non-dialysis-requiring CKD relative to patients with normal or near normal kidney function. In summary, non-dialysis-requiring CKD is associated with higher age-standardized rates of hip fracture and post-hip fracture mortality and higher resource utilization. © 2016 American Society for Bone and Mineral Research.

Bowel preparation prior to percutaneous ilio-sacral screw insertion: is it necessary?

PURPOSE

The aim of this study was to compare the outcomes of ilio-sacral (IS) screw fixation with and without the use of bowel preparation, in terms of obtaining adequate visualisation, malpositioning of screw requiring revision surgery and neurovascular injury.

METHODS

A retrospective case control study was performed. We reviewed 74 consecutive cases of IS screw fixation performed at our institution within the last 5 years. We included all patients who had undergone percutaneous IS screw fixation. Two groups, one consisting of patients who underwent bowel preparation prior to surgery (Group 1) and one consisting of patients who had no bowel preparation (Group 2), were compared in terms of the above outcomes. There were 37 patients in each group. The mean age in Group 1 was 41 years (17-63) and in Group 2 was 47 years (12-89).

RESULTS

In Group 1 there were two procedures abandoned due to poor visualisation. In Group 2 there were no cases abandoned for poor visualisation. There were two nerve injuries in Group 1 and no nerve injuries in Group 2. Revision surgery was performed in four patients in Group 1-for malposition, persistent buttock pain, sciatic nerve palsy and inadequate fixation while one revision performed in Group 2 for persistent buttock pain.

CONCLUSION

Based on these results, we conclude that bowel preparation is not necessary to obtain adequate visualisation for safe and accurate percutaneous IS screw insertion. In fact, in Group 1 two procedures were abandoned and there was higher incidence of complications. Therefore, it would appear that this treatment arm should be abandoned all together. Further studies to prove it conclusively and explain the reasons are required.

The validity of questionnaire measures for assessing depression after stroke

Objective: Depression has been reported to occur frequently after stroke. The aim of the study was to assess the validity of questionnaire measures for screening for depression after stroke.

Design: Cross-sectional correlational study between questionnaire measures of mood and psychiatric interview.

Setting: Hospital and community.

Participants: Stroke patients were recruited from hospital wards and from a randomized controlled trial of cognitive behavioural therapy.

Main measures: Beck Depression Inventory, Wakefield Depression Inventory, General Health Questionnaire 28 and Schedules for Clinical Assessment in Neuropsychiatry.

Results: Poor agreement was found between psychiatric diagnosis and questionnaire measures of mood. The sensitivity of the questionnaire measures was high, but specificity was low. No cut-off points with satisfactory sensitivity and specificity could be identified from ROC curves.

Conclusions: Although questionnaire assessments of depression provide a satisfactory screening method, specificity values are too low to provide a basis for the diagnosis of depression. Measures need to be developed with higher specificity to facilitate screening for depression after stroke.

Prenatal Oxycodone Exposure Alters CNS Endothelin Receptor Expression in Neonatal Rats

Prenatal opioid exposure such as oxycodone is linked to significant adverse effects on the developing brain. Endothelin (ET) and its receptors are involved in normal development of the central nervous system. Opioid tolerance and withdrawal are mediated through ET receptors. It is possible that adverse effect of oxycodone on the developing brain is mediated through ET receptors. We evaluated brain ETA and ETB receptor expression during postnatal development in rats with prenatal oxycodone exposure. Timed pregnant Sprague-Dawley rats received either oxycodone or placebo throughout gestation. After birth, male rat pups were sacrificed on postnatal day (PND) 1, 7, 14 or 28. Brain ETA and ETB receptor expression was determined by Western blot analysis. Oxycodone pups compared to placebo demonstrated congenital malformations of the face, mouth, and vertebrae at the time of birth [4/69 (5.7%) vs. 0/60 (0%); respectively] and intrauterine growth retardation [10/69 (15%) vs. 2/60 (3.3%); respectively]. On PND 28, oxycodone pups compared to placebo had lower body and kidney weight. ETA receptor expression in the oxycodone group was significantly higher compared to placebo on PND 1 (p=0.035), but was similar on PND 7, 14, or 28. ETB receptor expression decreased in oxycodone compared to placebo on PND 1 and 7 (p=0.001); and increased on PND 28 (p=0.002), but was similar on PND 14. Oxycodone-exposed rat pups had lower birth weight and postnatal weight gain and greater congenital malformations. ETB receptor expression is altered in the brain of oxycodone-treated rat pups indicating a possible delay in CNS development.

Is there a role for antifibrinolytics in pelvic and acetabular fracture surgery?

BACKGROUND

Pelvic and acetabular fractures are rare, complex injuries associated with significant morbidity. Fixation of these injuries requires major orthopaedic surgery which in itself is associated with substantial blood loss owing to the extensile operative approach and prolonged operating time required to address the complex fracture anatomy. In order to reduce morbidity, a multifactor approach to blood conservation must be adopted.

CURRENT ROLE OF ANTIFIBRINOLYTICS IN ORTHOPAEDIC SURGERY

The use of antifibrinolytics to reduce operative blood loss is well documented in many surgical specialties, including orthopaedic surgery. Elective spinal surgery and joint arthroplasty have benefited from the introduction of antifibrinolytics; however, their role in trauma and fracture surgery is not fully defined. Pelvic and acetabular fracture surgery would benefit from further investigation on the benefit and safety of these agents.

CONCLUSION

Routine use cannot be recommended at this time but agents may be considered on a case-specific basis.

Differences in extracellular matrix remodeling in the placenta of mares that retain fetal membranes and mares that deliver fetal membranes physiologically

INTRODUCTION

In mammals, placenta separation at term may involve degradation of the extracellular matrix by matrix metalloproteinases (MMPs). The activity of MMPs is modulated by TIMPs. We hypothesized that the placentas of mares that deliver fetal membranes physiologically and those that retain fetal membranes (FMR) differ in terms of histology; mRNA expression of MMP-2 and MMP-9; protein expression of MMP-2, MMP-9, and TIMP-2; and the potential activity of both MMPs.

METHODS

Placenta biopsies were taken from mares (n = 9; 4 FMR, 5 controls) immediately after foal expulsion. Retention was defined as failure to expel all fetal membranes within 3 h of expulsion. All mares were monitored for time of expulsion. The degree of allantochorial/endometrial adhesion was determined in FMR mares, and biopsies from all mares were histologically examined. mRNA expression, protein immunolocalization, protein amount and potential enzyme activity were determined with RT-PCR, immunohistochemistry, Western Blotting and zymography, respectively.

RESULTS

FMR mares had strong to extremely strong allantochorial/endometrial adhesion, and significantly more connective tissue in the allantochorial villi than controls. The range of MMP-2 mRNA expression levels was more than 13 times greater in FMR mares than in controls. Protein content of both MMPs and TIMP-2 differed significantly between groups. The range of potential MMP-2 and MMP-9 activity was larger in FMR mares, and MMP-2 potential activity was 1.4 times higher in controls (P = 0.02).

DISCUSSION

These results indicate differences in extracellular matrix remodeling in FMR mares and controls, and suggest dysregulation of MMP expression and activation in FMR mares.

Stimulation of endothelin B receptors by IRL-1620 decreases the progression of Alzheimer's disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by severe cognitive impairment that ultimately leads to death. Endothelin (ET) and its receptors have been considered as therapeutic targets for AD. Recent studies in our lab have shown that stimulation of ETB receptors provide significant neuroprotection following Aβ1-40 administration. It is possible that IRL-1620 may be neuroprotective due to angiogenesis. However, the effect of IRL-1620 on neurovascular remodeling following Aβ1-40 administration has not been established. The purpose of this study was to determine the effect of stimulation of ETB receptors by IRL-1620 on vascular and neuronal growth factors after Aβ1-40 administration. Rats were treated with Aβ1-40 (day 1, 7 and 14) in the lateral cerebral ventricles using stereotaxically implanted cannula and received three intravenous injections of IRL-1620 (an ETB agonist), and/or BQ788 (an ETB antagonist) at 2-h interval on day 8; experiments were performed on day 15. Rats were sacrificed for estimation of brain ETB receptors, vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) expression using immunofluorescence and Western blot. In the Morris swim task, amyloid-β (Aβ)-treated rats showed a significant (p<0.0001) impairment in spatial memory. Rats treated with IRL-1620 significantly (p<0.001) reduced the cognitive impairment induced by Aβ. BQ788 treatment completely blocked IRL-1620-induced improvement in cognitive impairment. IRL-1620 treatment enhanced the number of blood vessels labeled with VEGF compared to vehicle treatment. Additionally, cells showed increased (p<0.001) positive staining for NGF in IRL-1620-treated animals. ETB, VEGF and NGF protein expression significantly (p<0.001) increased in the brain of IRL-1620-treated rats as compared to vehicle. Pretreatment with BQ788 blocked the effects of IRL-1620, thus confirming the role of ETB receptors in the neurovascular remodeling actions of IRL-1620. Results of the present study demonstrate that IRL-1620 improves both acquisition (learning) and retention (memory) on the water maze task and enhances angiogenic and neurogenic remodeling. These findings indicate that the ETB receptor may be a novel therapeutic target for AD and other neurovascular degenerative disorders.

Ontogeny of endothelin receptors in the brain, heart, and kidneys of neonatal rats

BACKGROUND

Endothelin (ET) plays an important role in many physiological functions. It has been demonstrated that endogenous ET-1 concentration in the central nervous system (CNS) changes with age; however the ontogeny of ETA and ETB receptors in the brain, heart, and kidneys during postnatal development has not been studied.

METHODS

Brains, hearts and kidneys of rats at postnatal days 1, 7, 14 and 28 were evaluated for the expression of ETA and ETB receptors via Western blot. ETB receptors within the developing brain were further accessed via immunofluorescence.

RESULTS

The mean organ and body weights increased proportionally with advancing age demonstrating normal growth. The expression of ETA receptors in the brain, heart, and kidneys and ETB receptor expression in the heart and kidneys was similar in these rats at postnatal ages 1, 7, 14 and 28days. However, brain ETB receptor expression significantly (P<0.001) decreased by 72% on day 28 compared to the levels on postnatal day 1. Upon immunofluorescent analysis, the intensity of ETB staining in the cerebral cortex and subventricular zones of the developing rat brain decreased significantly from day 1 to day 7 (P<0.001) and from day 7 to day 14 (P<0.0001). There was no further decrease in ETB intensity noted in the cerebral cortex and subventricular zones between day 14 and day 28 of postnatal age. The intensity of ETB receptor staining within the cerebrovasculature, on the other hand, increased significantly (P<0.05) from days 1 and 7 to day 14.

CONCLUSIONS

These results demonstrate that expression of ETA receptors does not change with postnatal development. On the other hand ETB receptors in the cerebral cortex and subventricular zones of the brain decrease with age, while ETB receptors in the cerebrovasculature increase with age, implicating ETB receptor involvement in the structural maturity and development of the CNS.

Frequency of delirium and subsyndromal delirium in an adult acute hospital population

Background The frequency of full syndromal and subsyndromal delirium is understudied. Aims We conducted a point prevalence study in a general hospital. Method Possible delirium identified by testing for inattention was evaluated regarding delirium status (full/subsyndromal delirium) using categorical (Confusion Assessment Method (CAM), DSM-IV) and dimensional (Delirium Rating Scale-Revised-98 (DRS-R98) scores) methods. Results In total 162 of 311 patients (52%) screened positive for inattention. Delirium was diagnosed in 55 patients (17.7%) using DSM-IV, 52 (16.7%) using CAM and 58 (18.6%) using DRS-R98⩾12 with concordance for 38 (12.2%) individuals. Subsyndromal delirium was identified in 24 patients (7.7%) using a DRS-R98 score of 7-11 and 41 (13.2%) using 2/4 CAM criteria. Subsyndromal delirium with inattention (v. without) had greater disturbance of multiple delirium symptoms. Conclusions The point prevalence of delirium and subsyndromal delirium was 25%. There was modest concordance between DRS-R98, DSM-IV and CAM delirium diagnoses. Inattention should be central to subsyndromal delirium definitions.

Should money follow the patient: Financial implication for being the National Centre for the Treatment and Management of Pelvic and Acetabular Fractures in Ireland

BACKGROUND

Pelvic and acetabular fractures are complex injuries requiring specialist treatment. Our institution is the National Centre for Treatment and Management of these injuries.

AIM

To audit all referrals to our institution over a 6-month period and calculate the cost incurred by being the national referral centre.

METHODS

Retrospective review of database, and subsequent allocation of Casemix points to assess total cost of treatment for each patient referred to our institution.

RESULTS

103 patients referred with pelvic or acetabular fracture for operative management. The furthest referral distance was 181miles. Over-all, the length of stay was 15.4 days. The average inclusive cost for a referral to our unit for operative management was €16,302.

CONCLUSION

Pelvic and acetabular fractures are complex injuries that require specialist referral unit management. However for these units to remain sustainable money needs to "follow the patient".

Pelvic and acetabular fractures

Patients that sustain pelvic and/or acetabular trauma in Ireland and require surgical intervention are treated at the Adelaide and Meath National Children's Hospital (AMNCH). For this study an audit was conducted of all pelvic and acetabular fractures referred to the AMNCH over a 12 month period from July 2010 to June 2011. This study was conducted with the purpose of recording the different fracture patterns, methods of injury and surgical procedures performed over this time frame. The results demonstrate that 109 patients were referred to the AMNCH with the majority of these fractures being sustained as the result of an RTA (43) or a fall from a height (45). Seventy one patients suffered an acetabular fracture while 43 patients suffered a fracture of their pelvic ring with some patients suffering both. There were 129 surgical procedures performed with 25 patients having more than one surgical procedure.

A bilateral crescent and anterior ring pelvic fracture sustained by inadvertently performing the 'splits'

A case is presented of a healthy 57 year old female who slipped and fell awkwardly into what is known in athletic terms as the front splits. As a result of her fall she sustained bilateral crescent and superior and inferior rami pelvic fractures. Successful operative fixation was undertaken by a combination of open and percutaneous techniques. To our knowledge this is the first reported case of bilateral crescent fractures, and of a pelvic fracture as a result of this mechanism of injury.

Injectable PLA-based in situ forming implants for controlled release of Ivermectin a BCS Class II drug: solvent selection based on physico-chemical characterization

In situ forming implants (ISI) prepared from biodegradable polymers such as poly(D,L-lactide) (PLA) and biocompatible solvents can be used to obtain sustained drug release after parenteral administration. The aim of this work was to study the effect of several biocompatible solvents with different physico-chemical properties on the release of ivermectin (IVM), an antiparasitic BCS II drug, from in situ forming PLA-based implants. The solvents evaluated were N-methyl-2-pyrrolidone (NMP), 2-pyrrolidone (2P), triacetine (TA) and benzyl benzoate (BB). Hansen's solubility parameters of solvents were used to explain polymer/solvent interactions leading to different rheological behaviours. The stability of the polymer and drug in the solvents were also evaluated by size exclusion and high performance liquid chromatography, respectively. The two major factors determining the rate of IVM release from ISI were miscibility of the solvent with water and the viscosity of the polymer solutions. In general, the release rate increased with increasing water miscibility of the solvent and decreasing viscosity in the following order NMP>2P>TA>BB. Scanning electron microscopy revealed a relationship between the rate of IVM release and the surface porosity of the implants, release being higher as implant porosity increased. Finally, drug and polymer stability in the solvents followed the same trends, increasing when polymer-solvent affinities and water content in solvents decreased. IVM degradation was accelerated by the acid environment generated by the degradation of the polymer but the drug did not affect PLA stability.

Fibroblast growth factor 23 and risks of mortality and end-stage renal disease in patients with chronic kidney disease

CONTEXT

A high level of the phosphate-regulating hormone fibroblast growth factor 23 (FGF-23) is associated with mortality in patients with end-stage renal disease, but little is known about its relationship with adverse outcomes in the much larger population of patients with earlier stages of chronic kidney disease.

OBJECTIVE

To evaluate FGF-23 as a risk factor for adverse outcomes in patients with chronic kidney disease.

DESIGN, SETTING, AND PARTICIPANTS

A prospective study of 3879 participants with chronic kidney disease stages 2 through 4 who enrolled in the Chronic Renal Insufficiency Cohort between June 2003 and September 2008.

MAIN OUTCOME MEASURES

All-cause mortality and end-stage renal disease.

RESULTS

At study enrollment, the mean (SD) estimated glomerular filtration rate (GFR) was 42.8 (13.5) mL/min/1.73 m(2), and the median FGF-23 level was 145.5 RU/mL (interquartile range [IQR], 96-239 reference unit [RU]/mL). During a median follow-up of 3.5 years (IQR, 2.5-4.4 years), 266 participants died (20.3/1000 person-years) and 410 reached end-stage renal disease (33.0/1000 person-years). In adjusted analyses, higher levels of FGF-23 were independently associated with a greater risk of death (hazard ratio [HR], per SD of natural log-transformed FGF-23, 1.5; 95% confidence interval [CI], 1.3-1.7). Mortality risk increased by quartile of FGF-23: the HR was 1.3 (95% CI, 0.8-2.2) for the second quartile, 2.0 (95% CI, 1.2-3.3) for the third quartile, and 3.0 (95% CI, 1.8-5.1) for the fourth quartile. Elevated fibroblast growth factor 23 was independently associated with significantly higher risk of end-stage renal disease among participants with an estimated GFR between 30 and 44 mL/min/1.73 m(2) (HR, 1.3 per SD of FGF-23 natural log-transformed FGF-23; 95% CI, 1.04-1.6) and 45 mL/min/1.73 m(2) or higher (HR, 1.7; 95% CI, 1.1-2.4), but not less than 30 mL/min/1.73 m(2).

CONCLUSION

Elevated FGF-23 is an independent risk factor for end-stage renal disease in patients with relatively preserved kidney function and for mortality across the spectrum of chronic kidney disease.

Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review

PURPOSE

Fowler and Stephens showed that by dividing the spermatic vessels a high intra-abdominal testis could be placed in the scrotum. Testicular atrophy is a potential complication of this technique. We conducted a systematic review to determine whether single or 2-stage Fowler-Stephens orchiopexy results in better testicular viability.

MATERIALS AND METHODS

We searched electronic databases, clinical trial registries and gray literature. We included reports describing boys younger than 18 years with a primary outcome of "testicular viability and position." We performed a meta-analysis using random effects models. Heterogeneity was assessed using forest plot and I(2) statistic.

RESULTS

We identified 1,807 citations and included 61 articles. Single stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage procedure in 36 and both approaches in 16. There were no randomized controlled trials, and most studies were cohort or case series. The pooled estimate of success rates was 80% for single stage Fowler-Stephens orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy (95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the 2-stage procedure. There was no difference in the success rate between laparoscopic and open techniques in either single or 2-stage Fowler-Stephens orchiopexy. There was no evidence of asymmetry on the funnel plot. There were no complications reported with single stage, while ileus, hematoma and infection were the most common complications with 2-stage Fowler-Stephens orchiopexy.

CONCLUSIONS

Both techniques have a fairly high success rate but 2-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage). Laparoscopic and open techniques had the same success rate. However, the level of evidence of the studies was low, and a study of a more robust design, such as a randomized controlled trial, should be performed.

A note on the use of unbiased estimating equations to estimate correlation in analysis of longitudinal trials

Longitudinal trials can yield outcomes that are continuous, binary (yes/no), or are realizations of counts. In this setting we compare three approaches that have been proposed for estimation of the correlation in the framework of generalized estimating equations (GEE): quasi-least squares (QLS), pseudo-likelihood (PL), and an approach we refer to as Wang-Carey (WC). We prove that WC and QLS are identical for the first-order autoregressive AR(1) correlation structure. Using simulations, we then develop guidelines for selection of an appropriate method for analysis of data from a longitudinal trial. In particular, we argue that no method is uniformly superior for analysis of unbalanced and unequally spaced data with a Markov correlation structure. Choice of the best approach will depend on the degree of imbalance and variability in the temporal spacing of measurements, value of the correlation, and type of outcome, e.g. binary or continuous. Finally, we contrast the methods in analysis of a longitudinal study of obesity following renal transplantation in children.