A social perspective on perceived distances reveals deep community structure.

Community structure, including relationships between and within groups, is foundational to our understanding of the world around us. For dissimilarity-based data, leveraging social concepts of conflict and alignment, we provide an approach for capturing meaningful structural information resulting from induced local comparisons. In particular, a measure of local (community) depth is introduced that leads directly to a probabilistic partitioning conveying locally interpreted closeness (or cohesion). A universal choice of threshold for distinguishing strongly and weakly cohesive pairs permits consideration of both local and global structure. Cases in which one might benefit from use of the approach include data with varying density such as that arising as snapshots of complex processes in which differing mechanisms drive evolution locally. The inherent recalibrating in response to density allows one to sidestep the need for localizing parameters, common to many existing methods. Mathematical results together with applications in linguistics, cultural psychology, and genetics, as well as to benchmark clustering data have been included. Together, these demonstrate how meaningful community structure can be identified without additional inputs (e.g., number of clusters or neighborhood size), optimization criteria, iterative procedures, or distributional assumptions.

Real-World Clinical Practice Among Patients With Bipolar Disorder and Chronic Kidney Disease on Long-term Lithium Therapy.

PURPOSE: Long-term lithium therapy (LTLT) has been associated with chronic kidney disease (CKD). We investigated changes in clinical characteristics, pharmacotherapeutic treatments for medical/psychiatric disorders, and outcomes among patients with bipolar disorder (BD) and CKD on LTLT in a 2-year mirror-image study design. METHODS: Adult BD patients on LTLT for ≥1 year who enrolled in the Mayo Clinic Bipolar Disorder Biobank and developed CKD (stage 3) were included, and our study was approved by the Mayo Clinic Institutional Review Board. The primary outcome was the time to the first mood episode after CKD diagnosis among the lithium (Li) continuers and discontinuers. Cox proportional hazards models were used to estimate the time to the first mood episode. We tested for differences in other medication changes between the Li continuers and discontinuers group using Mantel-Haenszel χ2 tests (linear associations). RESULTS: Of 38 BD patients who developed CKD, 18 (47%) discontinued Li, and the remainder continued (n = 20). The median age of the cohort was 56 years (interquartile range [IQR], 48-67 years), 63.2% were female, and 97.4% were White. As compared with continuers, discontinuers had more psychotropic medication trials (6 [IQR, 4-6] vs 3 [IQR, 2-5], P = 0.02), a higher rate of 1 or more mood episodes (61% vs 10%, P = 0.002), and a higher risk of a mood episode after CKD diagnoses (Hazard Ratio, 8.38; 95% confidence interval, 1.85-38.0 [log-rank P = 0.001]]. CONCLUSIONS: Bipolar disorder patients on LTLT who discontinued Li had a higher risk for relapse and a shorter time to the first mood episode, suggesting a need for more thorough discussion before Li discontinuation after the CKD diagnosis.

Long-term lithium therapy and risk of chronic kidney disease in bipolar disorder: A historical cohort study.

AIMS: Long-term lithium therapy (LTLT) has been associated with kidney insufficiency in bipolar disorder (BD). We aimed to investigate the risk factors of chronic kidney disease (CKD) development and progression among BD patients receiving LTLT. METHODS: We included adult patients with BD on LTLT (≥1 year) who were enrolled in the Mayo Clinic Bipolar Biobank, Rochester, Minnesota. We reviewed electronic medical records to extract information related to lithium therapy and kidney-related data to assess changes in the estimated glomerular filtration rate (eGFR). CKD severity was assessed based on eGFR. RESULTS: Among 154 patients who received LTLT, 41 patients (27%) developed CKD, of whom 20 (49%) patients continued lithium (continuers) and 19 (46%) discontinued it (discontinuers). The median time to stage 3 CKD development was 21.7 years from the start of Li treatment. Type-2 diabetes mellitus and benzodiazepine use were independent predictors for CKD development in the survival analysis, after controlling for age. The subsequent CKD progression rate did not differ between continuers and discontinuers (mean GFR 48.6 vs. 44.1, p = 0.13) at the end of follow-up duration (mean duration: 3.5 ± 4.4 years for continuers and 4.9 ± 5.3 years for discontinuers). CONCLUSION: CKD was observed in one fourth of patients with BD receiving LTLT. There was no significant difference in the progression of CKD among Li continuers versus discontinuers, at the mean follow-up duration of 4.2 years, after the CKD diagnosis. Progression of CKD could be influenced by existing comorbidities and may not necessarily be due to lithium alone.

Renal Arteries Revisited: Anatomy, Pathologic Entities, and Implications for Endovascular Management.

The renal arteries (RAs) are important vessels that usually arise from the abdominal aorta and supply the kidneys; thus, these arteries play a vital role in physiologic functions such as hemofiltration and blood pressure regulation. An understanding of the basis for embryologic development and the frequently variable anatomy of the RAs is necessary to fully appreciate the range of diseases and the implications for procedural planning. Hemorrhage from an RA is relatively common and is typically traumatic or spontaneous, with the latter form often seen in association with underlying tumors or arteriopathy. Accurate diagnostic evaluation of RA disease due to conditions such as atherosclerosis, fibromuscular dysplasia, vasculitis, aneurysm, arteriovenous shunt, embolic disease, and dissection is dependent on the use of multimodality imaging and is essential for selecting appropriate clinical management, with endovascular therapy having a key role in treatment. Surgical considerations include extra-anatomic renal bypass, which remains an important treatment option even in this era of endovascular therapy, and RA embolization as an adjunct to tumor surgery. A novel area of research interest is the potential role of RA denervation in the management of refractory hypertension. ©RSNA, 2021.

Assessing the Impact of 3% Hypertonic Saline Hyperosmolar Therapy on Intubated Children With Isolated Traumatic Brain Injury by Cerebral Oximetry in a Pediatric Emergency Setting.

BACKGROUND: Intubated pediatric patients with isolated traumatic brain injury (TBI) are a diagnostic challenge for early detection of altered cerebral physiology instigated by trauma-induced increased intracranial pressure (ICP) while preventing secondary neuronal damage (secondary insult detection) and assessing the effects of increased ICP therapeutic interventions (3% hypertonic saline [HTS]). Invasive brain tissue oxygen monitoring is guiding new intensive care unit TBI management but is not pediatric emergency department (PED) readily accessible. Objective measurements on pediatric isolated TBI-altered bihemispheric cerebral physiology and treatment effects of 3% HTS are currently lacking. Cerebral oximetry can assess increased ICP-induced abnormal bihemispheric cerebral physiology by measuring regional tissue oxygenation (rcSO2) and cerebral blood volume index (CBVI) and the mechanical cerebrospinal fluid removal effects on the increased ICP-induced abnormal bihemispheric cerebral physiology.In the PED intubated patients with isolated TBI, assessing the 3% HTS therapeutic response is solely by vital signs and limited clinical assessment skills. Objective measurements of the 3% HTS hyperosmolar effects on the PED isolated TBI patients' altered bihemispheric cerebral physiology are lacking. We believe that bihemispheric rcSO2 and CBVI could elucidate similar data on 3% HTS impact and influence in the intubated isolated TBI patients. OBJECTIVE: This study aimed to analyze the effects of 3% HTS on bihemispheric rcSO2 and CBVI in intubated patients with isolated TBI. METHODS: An observational, retrospective analysis of bihemispheric rcSO2 and CBVI readings in intubated pediatric patients with isolated TBI receiving 3% HTS infusions, was performed. RESULTS: From 2010 to 2017, 207 intubated patients with isolated TBI received 3% HTS infusions (median age, 2.9 [1.1-6.9 years]; preintubation Glasgow Coma Scale score, 7 [6-8]). The results were as follows: initial pre-3% HTS, 43% (39.5% to 47.5%; left) and 38% (35% to 42%; right) for rcSO2 < 60%, and 8 (-28 to 21; left) and -15 (-34 to 22; right) for CBVI; post-3% HTS, 68.5% (59.3% to 76%, P < 0.0001; left) and 62.5% (56.0% to 74.8%, P < 0.0001; right) for rcSO2 < 60%, and 12 (-7 to 24, P = 0.04; left) and 14 (-21 to 22, P < 0.0001; right) for CBVI; initial pre-3% HTS, 90% (83% to 91%; left) and 87% (82% to 92%; right) for rcSO2 > 80%, and 16.5 (6 to 33, P < 0.0001; left) and 16.8 (-2.5 to 27.5, P = 0.005; right) for CBVI; and post-3% HTS, 69% (62% to 72.5%, P < 0.0001; left) and 63% (59% to 72%, P < 0.0001; right) for rcSO2 > 80%, and 16.5 (6 to 33, P < 0.0001; left) and 16.8 (-2.5 to 27.5, P = 0.005; right) for CBVI. The following results for cerebral pathology pre-3% HTS were as follows: epidural: 85% (58% to 88.5%) for left rcSO2 and -9.25 (-34 to 19) for left CBVI, and 85.5% (57.5% to 89%) for right rcSO2 and -12.5 (-21 to 27) for CBVI; subdural: 45% (38% to 54%) for left rcSO2 and -9.5 (-25 to 19) for left CBVI, and 40% (33% to 49%) for right rcSO2 and -15 (-30.5 to 5) for CBVI. The following results for cerebral pathology post-3% HTS were as follows: epidural: 66% (58% to 69%, P = 0.03) for left rcSO2 and 15 (-1 to 21, P = 0.0004) for left CBVI, and 63% (52% to 72%, P = 0.009) for right rcSO2, and 15.5 (-22 to 24, P = 0.02) for CBVI; subdural: 63% (56% to 72%, P < 0.0001) for left rcSO2 and 9 (-20 to 22, P < 0.0001) for left CBVI, and 62.5% (48% to 73%, P < 0.0001) for right rcSO2, and 3 (-26 to 22, P < 0.0001) for CBVI. Overall, heart rate showed no significant change. Three percent HTS effect on interhemispheric rcSO2 difference >10 showed rcSO2 < 60%, and subdural hematomas had the greatest reduction (P < 0.001). The greatest positive changes occurred in bihemispheric or one-hemispheric rcSO2 < 60% with an interhemispheric discordance rcSO2 > 10 and required the greatest number of 3% HTS infusions. For 3% HTS 15% rcSO2 change time effect, all patients achieved positive change with subdural hematomas and hemispheric rcSO2 readings <60% with the shortest achievement time of 1.2 minutes (0.59-1.75; P < 0.001). CONCLUSIONS: In intubated pediatric patients with isolated TBI who received 3% HTS infusions, bihemispheric rcSO2 and CBVI readings immediately detected and trended the 3% HTS effects on the trauma-induced cerebral pathophysiology. The 3% HTS infusion produced a significant improvement in rcSO2 and CBVI readings and a reduction in interhemispheric rcSO2 discordance differences. In patients with bihemispheric or one-hemispheric rcSO2 readings <60% with or without an interhemispheric discordance, rcSO2 > 10 demonstrated the greatest significant positive delta change and required the greatest numbers of 3% HTS infusions. Overall, 3% HTS produced a significant positive 15% change within 2.1 minutes of infusion, whereas heart rate showed no significant change. During trauma neuroresuscitation, especially in intubated isolated TBI patients requiring 3% HTS, cerebral oximetry has shown its functionality as a rapid adjunct neurological, therapeutic assessment tool and should be considered in the initial emergency department pediatric trauma neurological assessment and neuroresuscitation regimen.

Clinician Satisfaction with Rapid Adoption and Implementation of Telehealth Services During the COVID-19 Pandemic.

Background: To examine clinician perspectives on the acceptability, appropriateness/suitability, and feasibility of video telehealth as a way to deliver mental health services during the COVID-19 pandemic. Materials and Methods: Mental health clinicians were surveyed with 27 Likert questions, using previously validated measures, on satisfaction and implementation experience with video telehealth visits between March and June 2020. Results: A total of 112 of 193 clinicians completed the survey (58.0%), including psychiatrists, psychologists, trainees (i.e., residents and fellows), advanced practice providers, and licensed mental health counselors. Clinicians reported high levels of acceptability, feasibility, and appropriateness of video telehealth; they also reported high levels of satisfaction with video telehealth visits. Seventy-nine and a half (79.5%) reported that their patients seemed highly satisfied with video telehealth visits, and 107 (95.5%) of clinicians responded that they would like video telehealth visits to represent at least 25% of their practice in the future. Discussion: Mental health clinicians showed positive attitudes toward the implementation of video telehealth visits, high levels of satisfaction with this care, and indicated strong interest in continuing this modality as a significant portion of clinical practice. Conclusions: This study demonstrates the ability of mental health clinicians to embrace new technology to expand access to care during the COVID-19 pandemic. Results indicate that telemental health is likely to be an integral part of clinic practice in the future.

Degree of Risk of Bias in Randomized Controlled Trials: Does It Have an Impact on Root Coverage Outcomes?

OBJECTIVE: Improvement over time in mean (MRC) and complete root coverage (CRC) reported in randomized controlled trials (RCTs) has been documented. Our objective was to assess the effect that the ROB has on relevant outcomes reported in RCTs evaluating the efficacy of a commonly performed root coverage procedure. METHODS: RCTs that involved the use of a bilaminar technique of coronally advanced flap with connective tissue graft were selected. The following data were extracted: MRC, CRC, whether conflict of interest was addressed (yes/no), adequacy of random sequence generation, allocation concealment, and blinding of outcome assessment. Trials were categorized into four groups as per different time periods: before Consolidated Standards of Reporting Trials (CONSORT) (before 1996), CONSORT (1997 to 2001), CONSORT 2001 (2002 to 2010), and CONSORT 2010 (2011 to 2019). Differences between group means were assessed using statistical analyses. RESULTS: The search yielded a total of 47 RCTs published between 1993 and 2019 that met the inclusion criteria. A trend toward lower ROB over time in the selected RCTs was observed. However, differences in MRC and CRC with respect to the degree ROB of included trials were not significant. CONCLUSIONS: Degree of ROB did not influence MRC and CRC reported in the RCTs included in this investigation. This finding suggests that the observed improvement of clinical outcomes over time should be attributed to other factors, such as refinement of surgical techniques.

Efficacy and tolerability of adjunctive modafinil/armodafinil in bipolar depression: A meta-analysis of randomized controlled trials.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of the dopaminergic-enhancing agent modafinil/armodafinil (MoArm) as adjunctive treatment for bipolar depression. METHODS: A comprehensive search of major electronic databases was conducted to identify randomized controlled trials (RCTs) of adjunctive MoArm that included patients with bipolar I (BP-I) or bipolar II (BP-II) depression. Data for response/remission and all-cause discontinuation were analyzed. Effect size was summarized by relative risk (RR) using a random effect model. RESULTS: Of 58 studies, five RCTs (N = 795 drug, N = 792 placebo) met inclusion criteria. Four armodafinil studies included only BP-I patients and one modafinil study included both bipolar subtypes with limited heterogeneity (I2  = 34%, P = .19; I2  = 18%, P = .30). Compared to placebo, augmentation with MoArm was associated with significantly greater rates of treatment response (RR, 1.18; 95% CI, 1.01-1.37; P = .03) and remission (RR, 1.38; 95% CI, 1.10-1.73; P = .005). All-cause discontinuation was not different than placebo (RR, 1.08; 95% CI, 0.89-1.30; P = .45) with no evidence of increased risk of mood switch or suicide attempts with MoArm (RR, 0.99; 95% CI, 0.39-2.5; P = .98; RR, 1.02; 95% CI, 0.37-2.85; P = .97). CONCLUSION: This narrower scope meta-analysis of one drug for one disease suggests that adjunctive MoArm may represent a novel therapeutic intervention. Further studies delineating the subtypes of bipolar depression responsive to these novel dopaminergic-enhancing agents are encouraged.

An effective evidence-based cleaning method for the safe reuse of intermittent urinary catheters: In vitro testing.

AIMS: To determine a safe bactericidal cleaning method that does not damage urethral catheters used for intermittent catheterization. In some countries, single-use catheters are the norm; in others, the reuse of catheters is common depending on health insurance, personal preference, or individual concerns about the environment. However, no recent study of cleaning methods has been published to provide evidence for the safe reuse of catheters. METHODS: Using advanced microbiological methods, a laboratory study of eight cleaning methods was conducted. Sections of uncoated polyvinylchloride (PVC) catheters were exposed to bacterial uropathogens in physiologically correct artificial urine media then tested with a range of heat, chemical, and mechanical cleaning methods. Analysis of culturable and viable but nonculturable (VBNC) bacteria was done and direct microscopy was used. Descriptive statistics were used to compare values. RESULTS: Heat treatments, although effective, resulted in catheter surface breakdown and damage. Ultrasonic cleaning and vinegar showed evidence of VBNC populations indicating the methods were bacteriostatic. Detergent and water wash followed by immersion in a commercially available 0.6% sodium hypochlorite solution and 16.5% sodium chloride (diluted Milton) gave consistent bactericidal results and no visible catheter damage. CONCLUSIONS: Combined mechanical and chemical treatment of a detergent and water wash followed by immersion in diluted Milton (the "Milton Method") provided consistent and effective cleaning of uncoated PVC catheters, showing bactericidal action for all uropathogens tested after repeated exposure. If found safe in clinical testing, this method could increase the reuse of catheters, reduce plastic waste in the environment, reduce cost, and increase patient choice.

Complications of cardiac implantable electronic device placement in public and private hospitals.

BACKGROUND: Few safety data exist comparing clinical outcomes in Australian public and private hospitals. We hypothesised that differences could exist between public and private hospitals due to differences in acuity and patient-level co-morbidities. AIMS: To report comparative complications of cardiac implantable electronic device (CIED) placement in public and private hospitals. METHODS: We conducted an observational cohort study of outcomes of patients aged >18 years from 2010 to 2015 undergoing a new permanent pacemaker (PPM), implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy pacemaker or defibrillator (CRT-D/P) implant in NSW and Queensland public and private hospitals. The primary endpoint was major CIED-related complications occurring in-hospital or within 90 days of discharge. The independent effect of hospital sector was determined using multiple logistic regression, adjusting for covariates, including age, sex, co-morbidities and procedural acuity. RESULTS: A total of 32 364 new CIED implants (PPM 23 845, ICD 5361 and CRT-D/P 3158) were included (49% in private hospitals). Overall, 8.0% of private hospital procedures and 9.6% public hospital procedures experienced at least one complication. After adjustment, the overall risk of CIED complications was similar in private and public hospitals (OR: 0.92, 95% CI: 0.84-1.00, P = 0.06). In analysis of individual complications, adjusted all-cause in-hospital mortality was higher in private hospitals, (OR: 1.49, 95% CI: 1.03-2.16, P = 0.036) primarily driven by an excess mortality in acute cases. The adjusted risk of in-hospital generator operation (OR: 0.53, 95% CI: 0.30-0.94, P = 0.03) and post-discharge infection (OR: 0.61, 95% CI: 0.46-0.81, P < 0.001) was lower in private hospitals. CONCLUSIONS: These data identify important similarities and differences in safety outcomes of CIED implantation between Australian public and private hospitals.

Determination of Deposition Order of Toners, Inkjet Inks, and Blue Ballpoint Pen Combining MeV-Secondary Ion Mass Spectrometry and Particle Induced X-ray Emission.

Determination of the deposition order of different writing tools is very important for the forensic investigation of questioned documents. Here we present a novel application of two ion beam analysis (IBA) techniques: secondary ion mass spectrometry using MeV ions (MeV-SIMS) and particle induced X-ray emission (PIXE) to determine the deposition order of intersecting lines made of ballpoint pen ink, inkjet printer ink, and laser printer toners. MeV-SIMS is an emerging mass spectrometry technique where incident heavy MeV ions are used to desorb secondary molecular ions from the uppermost layers of an organic sample. In contrast, PIXE provides information about sample elemental composition through characteristic X-ray spectra coming from greater depth. In the case of PIXE, the information depth depends on incident ion energy, sample matrix and self-absorption of X-rays on the way out from the sample to the X-ray detector. The measurements were carried out using a heavy ion microprobe at the Ruder Boskovic Institute. Principal component analysis (PCA) was employed for image processing of the data. We will demonstrate that MeV-SIMS alone was successful to determine the deposition order of all intersections not involving inkjet printer ink. The fact that PIXE yields information from deeper layers was crucial to resolve cases where inkjet printer ink was included due to its adherence and penetration properties. This is the first time the different information depths of PIXE and MeV-SIMS have been exploited for a practical application. The use of both techniques, MeV-SIMS and PIXE, allowed the correct determination of deposition order for four out of six pairs of samples.

Factors affecting continuation of clean intermittent catheterisation in people with multiple sclerosis: Results of the COSMOS mixed-methods study.

BACKGROUND: Clean intermittent catheterisation (CIC) is often recommended for people with multiple sclerosis (MS). OBJECTIVE: To determine the variables that affect continuation or discontinuation of the use of CIC. METHODS: A three-part mixed-method study (prospective longitudinal cohort ( n = 56), longitudinal qualitative interviews ( n = 20) and retrospective survey ( n = 456)) was undertaken, which identified the variables that influenced CIC continuation/discontinuation. The potential explanatory variables investigated in each study were the individual's age, gender, social circumstances, number of urinary tract infections, bladder symptoms, presence of co-morbidity, stage of multiple sclerosis and years since diagnosis, as well as CIC teaching method and intensity. RESULTS: For some people with MS the prospect of undertaking CIC is difficult and may take a period of time to accept before beginning the process of using CIC. Ongoing support from clinicians, support at home and a perceived improvement in symptoms such as nocturia were positive predictors of continuation. In many cases, the development of a urinary tract infection during the early stages of CIC use had a significant detrimental impact on continuation. CONCLUSION: Procedures for reducing the incidence of urinary tract infection during the learning period (i.e. when being taught and becoming competent) should be considered, as well as the development of a tool to aid identification of a person's readiness to try CIC.

Surgical complexity score and role of laparoscopy in women with advanced ovarian cancer treated with neoadjuvant chemotherapy.

OBJECTIVES: To evaluate surgical complexity scores (SCS) and minimally invasive surgery (MIS) at interval debulking surgery (IDS) in advanced epithelial ovarian cancer (EOC) patients receiving neoadjuvant chemotherapy (NACT). METHODS: A multi-institutional study of NACT with IDS for advanced EOC was conducted. Demographic data were abstracted and SCS assigned based on IDS findings. Disease-specific overall survival (DSS) was defined as the time from completion of adjuvant chemotherapy to death due to disease. Cox proportional hazards regression models were used for univariate and multivariate survival analyses. RESULTS: 282 patients were identified; 80.5% had high-grade serous histology and 54.6% were <75 (median 63.9; range 34.1-84.8). Approximately 84% were optimally cytoreduced (61% R0; 23% <1 cm). In multivariate analyses, age 75+ (p ≤ 0.001), residual disease (>1 cm; p = 0.03), and SCS ≥ 3 (p = 0.04) were significantly predictive of worse DSS when morbidity and ASA score were also in the model. When optimally debulked was defined as R0, only age 75+ (<0.001) was significantly associated with decreased DSS. In the R0 cohort, SCS did not significantly predict DSS. However, subset analysis defining optimal ≤1 cm, revealed higher SCS was associated with a 1.6-fold increased risk of death (p = 0.02). Fifty-one patients underwent laparoscopic IDS. Twenty-four (47%) were converted to laparotomy to achieve optimal debulking in 21 patients (87.5%); while 25 had laparoscopic optimal cytoreduction (19/25 [76%] R0). CONCLUSIONS: In women with advanced EOC treated with NACT, older age, SCS ≥ 3, and residual disease >1 cm at IDS were predictors of worse survival. MIS appears safe and feasible with acceptable optimal cytoreduction rates.

Pharmacologic Approach to Management of Clostridium difficile Infection.

Clostridium difficile is a gram-positive, anaerobic, spore-forming bacterium that is the leading cause of nosocomial infections in hospitals in the United States. Critically ill patients are at high risk for C. difficile infection (CDI) and face potentially detrimental effects, including prolonged hospitalization, risk of recurrent disease, complicated surgery, and death. CDI requires a multidisciplinary approach to decrease hospital transmission and improve treatment outcomes. This article briefly reviews the current literature and guideline recommendations for treatment and prevention of CDI, with a focus on antibiotic treatment considerations including dosing, routes of administration, efficacy data, adverse effects, and monitoring parameters.

The association of exercise during pregnancy with trimester-specific and postpartum quality of life and depressive symptoms in a cohort of healthy pregnant women.

Few published studies have examined the relationship between exercise during pregnancy, quality of life (QOL), and postpartum depressive symptoms in healthy pregnant women. A prospective cohort of 578 healthy pregnant women were followed during their pregnancy through 6 months postpartum. Levels of self-reported exercise and QOL before, during, and following pregnancy were assessed using standardized questionnaires during each trimester of pregnancy and 6 months postpartum. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS) at 28 weeks gestation and 6 weeks postpartum. Participants were classified as having "sufficient exercise" if they achieved at least 150 min of exercise per week. Sufficient exercisers reported significantly higher ratings on most domains of QOL during each trimester of pregnancy and in the postpartum follow-up, compared with insufficient exercisers. There were no significant between-group differences in depressive symptoms. In examining the impact of exercise during each trimester, active women who became sedentary during their third trimester demonstrated a decline in their QOL. Achieving recommended levels of exercise during pregnancy was associated with higher QOL during pregnancy and the postpartum in healthy pregnant women. Decreasing the amount of exercise during pregnancy was associated with reduced QOL. These results suggest that it may be important for health care professionals to counsel healthy pregnant women about both the benefits of being physically active during pregnancy, and to provide guidance on how to remain physically active during a healthy pregnancy.

Climate research priorities for policy-makers, practitioners, and scientists in Georgia, USA.

Climate change has far-reaching effects on human and ecological systems, requiring collaboration across sectors and disciplines to determine effective responses. To inform regional responses to climate change, decision-makers need credible and relevant information representing a wide swath of knowledge and perspectives. The southeastern U. S. State of Georgia is a valuable focal area for study because it contains multiple ecological zones that vary greatly in land use and economic activities, and it is vulnerable to diverse climate change impacts. We identified 40 important research questions that, if answered, could lay the groundwork for effective, science-based climate action in Georgia. Top research priorities were identified through a broad solicitation of candidate research questions (180 were received). A group of experts across sectors and disciplines gathered for a workshop to categorize, prioritize, and filter the candidate questions, identify missing topics, and rewrite questions. Participants then collectively chose the 40 most important questions. This cross-sectoral effort ensured the inclusion of a diversity of topics and questions (e.g., coastal hazards, agricultural production, ecosystem functioning, urban infrastructure, and human health) likely to be important to Georgia policy-makers, practitioners, and scientists. Several cross-cutting themes emerged, including the need for long-term data collection and consideration of at-risk Georgia citizens and communities. Workshop participants defined effective responses as those that take economic cost, environmental impacts, and social justice into consideration. Our research highlights the importance of collaborators across disciplines and sectors, and discussing challenges and opportunities that will require transdisciplinary solutions.

Dual Therapy for Refractory Overactive Bladder in Children: A Prospective Open-Label Study.

PURPOSE: Mirabegron (ß3 adrenoreceptor agonist) is a new molecule with a mechanism of action distinct from antimuscarinics. Combination therapy with solifenacin was recently studied in an adult population. We evaluated the efficacy and safety of mirabegron as add-on therapy to treat urinary incontinence in children with idiopathic overactive bladder refractory/intolerant to antimuscarinics. MATERIALS AND METHODS: A prospective off-label study using add-on regimens of mirabegron was conducted in pediatric patients presenting with no symptom improvement while undergoing intensive behavioral and medical therapies and/or significant side effects while undergoing antimuscarinic dose escalation. Our primary outcome was better reported efficacy than with the use of prior antimuscarinic monotherapy. Secondary end points were tolerability, safety and satisfaction. Efficacy and tolerability were assessed based on voiding diaries, post-void residuals, urine cultures, electrocardiograms and vital signs. Families were questioned regarding continence, side effects and compliance. Wilcoxon signed-rank test was used for statistical analysis. RESULTS: A total of 35 patients were recruited at a median age of 10.3 years and were administered add-on mirabegron for a median of 16.4 months. Median bladder capacity improved from 50% to 74% expected bladder capacity (p <0.001). Continence improved in all patients, with 12 being completely dry. Post-void residual was increased in 2 patients and 1 urinary tract infection was reported. Seven patients reported mild or moderate side effects, with 2 withdrawals because of side effects (1 patient) and post-void residual (1). CONCLUSIONS: Add-on mirabegron appears to be a safe alternative for children with refractory overactive bladder. Dual therapy is well tolerated and adjusted dose regimen appears safe in this first pediatric study.

Polyacrylamide Hydrogel as a Bulking Agent for the Endoscopic Treatment of Vesicoureteral Reflux: Long-Term Results and Safety.

PURPOSE: Polyacrylamide hydrogel has been shown to offer good short-term success for the endoscopic treatment of vesicoureteral reflux. Our objective was to provide long-term results of its efficacy and safety. MATERIALS AND METHODS: We performed a prospective study using polyacrylamide hydrogel to treat all grades of vesicoureteral reflux. Every patient underwent endoscopic injection of polyacrylamide hydrogel followed by 3-month postoperative renal ultrasound and voiding cystourethrogram. Renal ultrasound was repeated at 12 and 36 months. Treatment success was defined as the absence of de novo or worsening hydronephrosis and the absence of reflux. Safety elements included new or worsening hydronephrosis, calcifications of the injected material and urinary tract infections. RESULTS: A total of 76 patients (123 refluxing renal units) were assessed. Median age at surgery was 45 months and median followup was 36 months. Median injected volume of hydrogel per refluxing renal unit was 1.0 ml. The overall success rate 3 months after a single injection was 71%. During long-term followup 68 of 70 eligible patients underwent 12-month ultrasound and 40 of 46 underwent 36-month ultrasound. No upper tract deterioration or bulking agent calcifications were reported. Nine (12%) and 2 patients (3%) presented with nonfebrile and febrile urinary tract infections, respectively. CONCLUSIONS: The success rate of polyacrylamide hydrogel for endoscopic treatment of vesicoureteral reflux is comparable to published results of dextranomer hyaluronic acid. The long-term safety data and potential lower cost of polyacrylamide hydrogel provide further support for the use of this nonparticulate bulking agent to treat reflux.