Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF <15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

Natural history of prostatic lesions on serial multiparametric magnetic resonance imaging.

INTRODUCTION: The natural history of prostatic lesions identified on multiparametric magnetic resonance imaging (mpMRI) is largely unknown. We aimed to describe changes observed over time on serial MRI. METHODS: All patients with ≥2 MRI studies between 2008 and 2015 at our institution were identified. MRI progression was defined as an increase in Prostate Imaging Reporting and Data System (PI-RADS; version 2) or size of existing lesions, or the appearance of a new lesion PIRADS ≥4. Patients on active surveillance (AS) were analyzed for correlation of MRI progression to biopsy reclassification. RESULTS: A total of 83 patients (54 on AS and 29 for diagnostic purposes) underwent serial MRI, with a mean interval of 1.9 years between scans. At baseline, 115 lesions (66 index, 49 non-index) were identified. Index lesions were more likely than non-index lesions to increase in size ≥2 mm (36.2 vs. 7.3 %; p=0.002). Overall progression was more likely to be seen among the index cohort (34.8 vs. 7.6%; p<0.001). New lesions with PIRADS ≥4 were seen on second imaging in 13 (16.5%) men, and became the index lesion in 29 cases (34.9%). Eighteen men on AS showed evidence of MRI progression (five with new lesions, 13 with progression of a previous lesion). Biopsy reclassification was present in three men (16.7%) with and seven men without MRI progression (19.4%). CONCLUSIONS: Overall changes in size and PIRADS scores of index lesions on MRI were small. New lesions were common, but usually did not alter management.

Natural history of prostatic lesions on serial multiparametric magnetic resonance imaging.

INTRODUCTION: The natural history of prostatic lesions identified on multiparametric magnetic resonance imaging (mpMRI) is largely unknown. We aimed to describe changes observed over time on serial MRI. METHODS: All patients with ≥2 MRI studies between 2008 and 2015 at our institution were identified. MRI progression was defined as an increase in Prostate Imaging Reporting and Data System (PI-RADS; version 2) or size of existing lesions, or the appearance of a new lesion PIRADS ≥4. Patients on active surveillance (AS) were analyzed for correlation of MRI progression to biopsy reclassification. RESULTS: A total of 83 patients (54 on AS and 29 for diagnostic purposes) underwent serial MRI, with a mean interval of 1.9 years between scans. At baseline, 115 lesions (66 index, 49 non-index) were identified. Index lesions were more likely than non-index lesions to increase in size ≥2 mm (36.2 vs. 7.3 %; p=0.002). Overall progression was more likely to be seen among the index cohort (34.8 vs. 7.6%; p<0.001). New lesions with PI-RADS ≥4 were seen on second imaging in 13 (16.5%) men, and became the index lesion in 29 cases (34.9%). Eighteen men on AS showed evidence of MRI progression (five with new lesions, 13 with progression of a previous lesion). Biopsy reclassification was present in three men (16.7%) with and seven men without MRI progression (19.4%). CONCLUSIONS: Overall changes in size and PI-RADS scores of index lesions on MRI were small. New lesions were common, but usually did not alter management.

Evaluation of the use of a stabilization device to improve the quality of care in patients with peripherally inserted central catheters.

OBJECTIVES: This project evaluated the implementation of use of the StatLock stabilization device (Bard Access Systems, Inc, Salt Lake City, Utah) for peripherally inserted central catheters (PICCs) in pediatric cardiology patients. The aim was to implement the use of the StatLock device and evaluate its effects on the following 4 outcomes: incidence of dislodgement, infection, catheter dwell time, and the number of catheter replacements. The primary goal was to determine whether the StatLock device offered advantages over tape and sutures. METHODS: A quality improvement design was used to evaluate whether the use of the StatLock stabilization device for PICC securement on 30 pediatric cardiology patients decreased the number of PICC complications compared with 30 historical comparison patients. RESULTS: The comparison group had a significantly higher number of catheter dislodgements (n = 16; 59.3%) than the StatLock group (n = 8; 30.8%; P = .035). The comparison group did not have a significantly higher number of catheter replacements (n = 16; 59.3%) than the StatLock group (n = 10; 34.5%; P = .10). No significant differences were found in the rate of infection or in the catheter dwell time between the 2 groups (StatLock group, mean ± SD = 33.13 ± 22.71 days; comparison group, mean ± SD = 28.10 ± 24.83 days; P > .20). CONCLUSIONS: Use of the StatLock device resulted in better outcomes when compared with the use of sutures, and it provided a more effective way to stabilize and secure PICCs.

The Spn4 gene of Drosophila encodes a potent furin-directed secretory pathway serpin.

Proprotein convertases (PCs) are an important class of host-cell serine endoproteases implicated in many physiological and pathological processes. Owing to their expanding roles in the proteolytic events required for generating infectious microbial pathogens and for tumor growth and invasiveness, there is increasing interest in identifying endogenous PC inhibitors. Here we report the identification of Spn4A, a previously uncharacterized secretory pathway serine protease inhibitor (serpin) from Drosophila melanogaster that contains a consensus furin cleavage site, -Arg(P4)-Arg-Lys-Arg(P1) downsream-, in its reactive site loop (RSL). Our biochemical and kinetics analysis revealed that recombinant Spn4A inhibits human furin (K(i), 13 pM; k(ass), 3.2 x 10(7) M(-1) x s(-1)) and Drosophila PC2 (K(i), 3.5 nM; k(ass), 9.2 x 10(4) M(-1) x s(-1)) by a slow-binding mechanism characteristic of serpin molecules and forms a kinetically trapped SDS-stable complex with each enzyme. For both PCs, the stoichiometry of inhibition by Spn4A is nearly 1, which is characteristic of known physiological serpin-protease interactions. Mass analysis of furin-Spn4A reaction products identified the actual reactive site center of Spn4A to be -Arg(P4)-Arg-Lys-Arg(P1)-downstream-. Moreover, we demonstrate that Spn4A's highly effective PC inhibition properties are critically dependent on the unusual length of its RSL, which is composed of 18 aa instead of the typical 17-residue RSL found in most other inhibitory serpins. The identification of Spn4A, the most potent and effective natural serpin of PCs identified to date, suggests that Spn4A could be a prototype of endogenous serpins involved in the precise regulation of PC-dependent proteolytic cleavage events in the secretory pathway of eukaryotic cells.