Expert Consensus on Pediatric Urodynamics Reporting Using Modified Delphi Technique.

PURPOSE: Urodynamic testing (UDS) is an important tool in the management of pediatric lower urinary tract conditions. There have been notable efforts to standardize pediatric UDS nomenclature and technique, but no formal guidelines exist on essential elements to include in a clinical report. We sought to identify ideal structure and elements of a pediatric UDS assessment based on expert consensus. MATERIALS AND METHODS: Pediatric urologists regularly performing UDS were queried using a Delphi process. Participants were invited representing varied geographic, experience, and societal involvement. Participants underwent 3 rounds of questionnaires between November 2022 and August 2023 focusing on report organization, elements, definitions, and automated electronic health record clinical decision support. Professional billing requirements were also considered. Consensus was defined as 80% agreeing either in favor of or against a topic. Elements without consensus were discussed in subsequent rounds. RESULTS: A diverse sample of 30 providers, representing 27 institutions across 21 US states; Washington, District of Columbia; and Canada completed the study. Participants reported interpreting an average number of 5 UDS reports per week (range 1-22). The finalized consensus report identifies 93 elements that should be included in a pediatric UDS report based on applicable study conditions and findings. CONCLUSIONS: This consensus report details the key elements and structure agreed upon by an expert panel of pediatric urologists. Further standardization of documentation should aid collaboration and research for patients undergoing UDS. Based on this information, development of a standardized UDS report template using electronic health record implementation principles is underway, which will be openly available for pediatric urologists.

The computational and the representational language-of-thought hypotheses.

There are two versions of the language-of-thought hypothesis (LOT): Representational LOT (roughly, structured representation), introduced by Ockham, and computational LOT (roughly, symbolic computation) introduced by Fodor. Like many others, I oppose the latter but not the former. Quilty-Dunn et al. defend representational LOT, but they do not defend the strong computational LOT thesis central to the classical-connectionist debate.

Antireflux Surgery at National Surgical Quality Improvement Program-Pediatric Hospitals.

PURPOSE: This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data. MATERIALS AND METHODS: Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures). RESULTS: In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections. CONCLUSIONS: Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.

Does defective volume sensation contribute to detrusor underactivity?

AIMS: The urodynamic finding of detrusor underactivity (DU) in neurologically intact unobstructed patients may relate to impaired volume sensations rather than detrusor contractile defects. We hypothesized that DU patients would demonstrate higher volumes but similar wall stress at sensation thresholds, and similar voiding contractility, compared to other groups. METHODS: Chart review of urodynamic studies in neurologically normal, nonobstructed symptomatic patients. Urodynamic studies having the primary findings of DU, stress urinary incontinence (SUI), detrusor overactivity (DO), and increased sensations without detrusor overactivity (IS) were abstracted. Age, gender, and pressure/volume data associated with sensations and voiding parameters were collected. Wall stress at sensations was calculated. Urodynamic variables at standard sensations and progression across standard sensations were compared among the four groups. RESULTS: Fifty-one urodynamic studies were analyzed for comparison. Mean age did not differ between groups. The DU group was predominantly male versus the other groups. DU, SUI, and DO had higher volume thresholds for strong desire than did IS. DU and DO demonstrated higher wall stress at strong desire than did IS and SUI. Watts factor was not significantly different between groups, however, DU had a smaller voided volumes and a higher post-void residuals. CONCLUSION: Increased volume and wall stress at strong desire, and similar contractility but the smaller voided volumes and elevated PVRs in DU suggest that diminished central sensitivity to volume afferent activity contributes to DU in nonobstructed, non-neurogenic symptomatic patients.

Distal hypospadias repair in infants without a postoperative stent.

PURPOSE: To review our experience with infants undergoing distal hypospadias repair without a postoperative stent to determine if an unacceptable complication rate might justify its use. METHODS: Children <1 year of age who underwent distal hypospadias repair by a single surgeon were identified through a prospectively maintained database. The use of a postoperative urethral stent was recorded for each case. Demographics, meatus position, operative technique and complications were also recorded. Patients older than 1 year or with hypospadias proximal to a subcoronal position were excluded. RESULTS: Eighty-nine patients without a stent were identified in addition to 21 patients who had a stent for a minimum of 3 days. At 3 months follow-up, 4/89 (4.49 %) patients in the stentless group required circumcision revision. 1 patient experienced urinary retention. 1/21 (4.76 %) patients with a postoperative stent required reoperation for meatal stenosis. CONCLUSIONS: The complication rate for infants undergoing distal hypospadias repair is low, does not appear to be significantly increased by forgoing a postoperative urethral stent. Avoiding a stent likely reduces a variety of associated adverse events and needs for short-term follow-up.

Feasibility of integrating research data collection into routine clinical practice using the electronic health record.

PURPOSE: The electronic health record is becoming central to routine medical practice and has the potential to facilitate large scale clinical research. We evaluated the completeness and accuracy of data collection using designated research fields integrated into a semistructured clinical note. We hypothesized that prospective research data collection as part of routine clinical charting is feasible, with a high rate of utilization (greater than 80%) and accuracy (kappa greater than 0.80). MATERIALS AND METHODS: Infants with congenital hydronephrosis were followed prospectively at a single institution. Existing functionality in the electronic health record was used for data collection by creation of 28 different data elements captured from a hydronephrosis note or phrase template. Completeness (percent utilization) was calculated and accuracy was assessed by comparing the structured data to manual chart review. Comparisons were conducted using the chi-square test, with 2-tailed p values <0.05 considered statistically significant. RESULTS: A total of 80 patients were eligible for manual chart review. Data were recorded through template use in 64 patients for an overall completeness of 80.0%. Of 28 elements 17 (60%) demonstrated "almost perfect" agreement (kappa greater than 0.80), and all variables reached at least "moderate" agreement (greater than 0.40). CONCLUSIONS: Integrating research fields into routine clinical practice is feasible by using semistructured clinical templates within an electronic health record. High completion and accuracy rates were captured from a variety of fields within a hydronephrosis template.

Analysis of energy flow during playground surface impacts.

The amount of energy dissipated away from or returned to a child falling onto a surface will influence fracture risk but is not considered in current standards for playground impact-attenuating surfaces. A two-mass rheological computer simulation was used to model energy flow within the wrist and surface during hand impact with playground surfaces, and the potential of this approach to provide insights into such impacts and predict injury risk examined. Acceleration data collected on-site from typical playground surfaces and previously obtained data from children performing an exercise involving freefalling with a fully extended arm provided input. The model identified differences in energy flow properties between playground surfaces and two potentially harmful surface characteristics: more energy was absorbed by (work done on) the wrist during both impact and rebound on rubber surfaces than on bark, and rubber surfaces started to rebound (return energy to the wrist) while the upper limb was still moving downward. Energy flow analysis thus provides information on playground surface characteristics and the impact process, and has the potential to identify fracture risks, inform the development of safer impact-attenuating surfaces, and contribute to development of new energy-based arm fracture injury criteria and tests for use in conjunction with current methods.

David J. Chalmers.

David Chalmers is a philosopher who studies consciousness. After sketching his background in mathematics, science, and philosophy, he describes the problems of consciousness and his collaboration with neuroscientists. He also discusses the roles of neuroscience and philosophy in studying consciousness and other topics as well as the future of these fields.

An adversarial collaboration protocol for testing contrasting predictions of global neuronal workspace and integrated information theory.

The relationship between conscious experience and brain activity has intrigued scientists and philosophers for centuries. In the last decades, several theories have suggested different accounts for these relationships. These theories have developed in parallel, with little to no cross-talk among them. To advance research on consciousness, we established an adversarial collaboration between proponents of two of the major theories in the field, Global Neuronal Workspace and Integrated Information Theory. Together, we devised and preregistered two experiments that test contrasting predictions of these theories concerning the location and timing of correlates of visual consciousness, which have been endorsed by the theories' proponents. Predicted outcomes should either support, refute, or challenge these theories. Six theory-impartial laboratories will follow the study protocol specified here, using three complementary methods: Functional Magnetic Resonance Imaging (fMRI), Magneto-Electroencephalography (M-EEG), and intracranial electroencephalography (iEEG). The study protocol will include built-in replications, both between labs and within datasets. Through this ambitious undertaking, we hope to provide decisive evidence in favor or against the two theories and clarify the footprints of conscious visual perception in the human brain, while also providing an innovative model of large-scale, collaborative, and open science practice.

Risk factors for injury in rugby union football in New Zealand: a cohort study.

OBJECTIVE: To identify risk factors for injury in amateur club rugby. DESIGN: Prospective cohort design; with follow-up over the 2004 season. SETTING: Amateur club rugby in New Zealand. Participants Seven hundred and four male rugby players, aged 13 years and over. Assessment of risk factors The study investigated the independent effect on injury incidence of age, ethnicity, rugby experience, height, weight, body mass index, physical activity, cigarette smoking, previous injury, playing while injured, grade, position, training, time of season, warm-up, foul play, weather conditions, ground conditions and protective equipment. Generalised Poisson regression was used to estimate the effect of each factor after adjusting for all other factors. MAIN OUTCOME MEASURES: Game injury, defined as 'any event that resulted in an injury requiring medical attention or causing a player to miss at least one scheduled game or team practice'. RESULTS: A total of 704 players, representing 6263 player-games, contributed information on injury and exposure. Evidence was obtained of the effect on injury incidence of increasing age, Pacific Island versus Maori ethnicity (injury rate ratio (IRR)=1.48, 1.03-2.13), ≥40 h strenuous physical activity per week (IRR=1.54, 1.11-2.15), playing while injured (IRR=1.46, 1.20-1.79), very hard ground condition (IRR=1.50, 1.13-2.00), foul-play (IRR=1.87, 1.54-2.27) and use of headgear (IRR=1.23, 1.00-1.50). CONCLUSIONS: Opportunities for injury prevention might include promoting injury-prevention measures more vigorously among players of Pacific Island ethnicity, ensuring injured players are fully rehabilitated before returning to play, reducing the effects of ground hardness through ground preparation and stricter enforcement of the laws relating to foul play.

Multicystic Dysplastic Kidney With Mass Effect in a Neonate Treated With Nephrectomy: Case Report.

Multicystic Dysplastic Kidney is a developmental disease that results in a lobulated kidney of noncommunicating cysts and abnormal parenchymal tissue. Dysplastic kidneys are usually benign and often involute over time with conservative management. The second most common cause of palpable abdominal mass in a neonate, Multicystic Dysplastic Kidney can cause respiratory distress secondary to extrinsic compression. However, such cases are sparse. Here we present the case of an otherwise healthy term newborn with an exceptionally large MCDK requiring CPAP support and intubation. His respiratory distress improved immediately after nephrectomy. Communication about cases like this will inform management of future comparable cases.

A Cystic Renal Mass in the Setting of a Pneumothorax: More Than Meets the Eye?

DICER1 syndrome is a rare hereditary cancer predisposition syndrome that has relevance to pediatric urology providers due to its association with many various pediatric genitourinary malignancies. We describe the case of a pediatric patient who was eventually diagnosed with a pathogenic DICER1 germline variant after undergoing resection of a cystic nephroma and pleuropulmonary blastoma.

Posterior Reversible Encephalopathy Syndrome Following Failure of Conservative Management in Renal Trauma: Case Report.

Blunt renal trauma is relatively common in children. Conservative management has become the mainstay of treatment. A 4-year-old boy presented following a fall onto his right abdomen resulting in renal trauma. Initial conservative management was followed by complete embolization of the kidney. The resulting continued hypertension, as well as endothelial disruption, resulted in PRES as manifested by a single instance of generalized seizure. The patient regained normal neurological function following nephrectomy. Better understanding of the potential for acute hypertensive crisis resulting in PRES in the urology community may result in more urgent and effective management in these scenarios.

Examination of interventions to prevent common lower-limb injuries in the New Zealand Defense Force.

The biomechanical mechanisms of lower-limb injuries in the New Zealand Defense Force were identified from the circumstances of the injuries, and injury prevention strategies that addressed these mechanisms examined for their applicability to a military setting. Many of the injuries were the result of rolling or twisting movements and ankle instability was a common causal factor. Ankle bracing and stability training were identified as the strategies that address this factor and are most likely to be effective in preventing the injuries. A successful intervention strategy must also take into account the particular requirements of the user group. Concerns with ankle bracing included ongoing costs, individual fitting requirements, and the inability to remain effective under extremes of physical activity and external conditions. Stability training was considered more appropriate than ankle bracing for the defense force. Stability training is low cost and has the ability to address the biomechanical mechanisms of several lower-limb injuries. However, it requires trialing in a military setting to assess the logistics of implementation and whether the reported sport-specific programs should be adjusted for the varied physical activities undertaken by military forces.

Estimating subject-specific body segment parameters using a 3-dimensional modeller program.

The estimation of body segment properties is important in the biomechanical analysis of movement. Current subject-specific estimation methods however can be expensive and time-consuming, while other methods do not adequately take into account individual or group variability. We describe a simple procedure for estimating subject-specific geometric properties, independent of joint centres. The method requires only a small number of anthropometric measurements and digital images of the segment or subject, a 3-dimensional modeller program and simple mathematical calculations to estimate segment volumes and centroids. Assuming that the segment is of uniform density, it's mass and moment of inertia can also be derived. Future work should include generating segment density profiles for particular populations, to increase the accuracy of the method, and comparing the accuracy of the results obtained with those produced by other techniques.

Lower limb injuries in New Zealand Defence Force personnel: descriptive epidemiology.

OBJECTIVE: To describe the epidemiology of lower limb injuries in the New Zealand Defence Force (NZDF). METHOD: Data from all NZDF lower limb injury claims from an 11-month period were examined for type, site, and circumstances of injury. Both injury codes and narratives were analysed, allowing each injury event to be classified according to mechanism of injury, object involvement, and activity at the time of injury, as well as type and site. RESULTS: The commonest lower limb musculoskeletal injuries were ankle sprains or strains (35%) and knee sprains or strains (16%). Most commonly, injuries were due to acute over-exertion (37%), involved no other person (50%), and occurred while running (28%) or playing team sports (25%). The injury rate for recruits was more than five times that of trained personnel. CONCLUSIONS: Potential interventions should target ankle sprains primarily, but also knee sprains and fractures. Fractures, while accounting for only 6% of lower limb injuries, should be a priority because of their high medical and time-lost costs. Interventions must also take into account the high incidence of injuries involving individuals alone and sustained during recruit training. The study also demonstrated that analysis of military injury narratives provides valuable extra information on injury causation and the circumstances of injury, and allows more accurate characterisation of the injury process. IMPLICATIONS: This study will provide the basis for development of an injury prevention strategy for lower limb training injuries in the NZDF.

Incidence and risk factors for positive urine culture at the time of pediatric urologic surgery.

PURPOSE: Urinary tract infections are relatively common in pediatric patients. Unrecognized bacteriuria at the time of urologic surgery puts patients at increased risk for perioperative complications. Many pediatric urologists obtain preoperative or intraoperative urine cultures prior to surgery, but data are lacking regarding rates and risk factors for positive intraoperative urine cultures. We conducted a retrospective cohort study of patients undergoing pediatric urologic surgery to examine factors associated with positive intraoperative urine cultures. MATERIALS AND METHODS: Charts of patients of age 0-18 years from a single pediatric urologist with associated intraoperative urine culture results between 2008 and 2013 were retrospectively reviewed. Demographics, prior culture results, and information regarding possible risk factors of interest-history of constipation, hydronephrosis, neurogenic bladder, posterior urethral valves, ureterocele, UPJ obstruction, urolithiasis, vesicoureteral reflux, and circumcision status-were collected and analyzed. RESULTS: Seven hundred and fifty procedure encounters with associated intraoperative urine culture results were reviewed. Overall positive urine culture rate was 13.5%. Factors associated with increased odds of positive intraoperative urine culture included neurogenic bladder (odds ratio 26.3, p < 0.001), prior positive culture (OR 5.4, p < 0.001), female sex (OR 2.1, p 0.007), constipation (OR 2.9, p < 0.001), and urolithiasis (OR 1.58, p = 0.04). Patients without any of these risk factors had no positive intraoperative cultures (p = 0.03). CONCLUSIONS: Patients with neurogenic bladder, prior positive urine culture, constipation, female gender, and urolithiasis were at increased risk for positive intraoperative urine culture. This may aid in decision-making regarding obtaining preoperative or intraoperative urine cultures in pediatric urology patients.

Prediction of distal radius fracture in children, using a biomechanical impact model and case-control data on playground free falls.

OBJECTIVES: To assess the ability of a biomechanical impact model to predict the likelihood of distal radius fracture in children using data gathered for a previous epidemiological case-control study of falls from playground equipment. METHODOLOGY: Factor of Risk (FR) values were generated for each of selected subjects from the case-control study using a biomechanical model. Logistic regression curves were fitted to examine the relationship between the FR values and the probability of radius fracture. RESULTS: Forty-five cases and thirty-one controls were selected. The logistic regression analyses showed a significant association between the probability of fracture and FR. CONCLUSIONS: The biomechanical model distinguished between children who fractured their distal radius and those who did not. The model can be used to test how risk factors, such as fall height and ground surface type, affect physical stresses transmitted through the arm and their relation to the fracture tolerance of the distal radius.