An evaluation of demographic factors affecting performance in a paediatric membership multiple-choice examination.

OBJECTIVE: To determine if demographic factors are associated with outcome in a multiple-choice, electronically marked paediatric postgraduate examination. METHOD: Retrospective analysis of pass rates of UK trainees sitting Membership of the Royal College of Paediatrics and Child Health (MRCPCH) part 1B from 2007 to 2011. Data collected by the RCPCH from examination candidates were analysed to assess the effects of gender, age, and country and university of medical qualification on examination outcome. RESULTS: At first attempt at MRCPCH part 1B, the overall pass rate from 2007 to 2011 was 843/2056 (41.0%). In univariate analysis, passing the examination was associated with being a UK graduate (649/1376 (47.2%)) compared with being an international medical graduate (130/520 (25.0%)) (OR 2.68 (95% CI 2.14 to 3.36), p<0.001). There was strong evidence that the proportion of candidates passing the examination differed for graduates of the 19 different UK medical schools (Fisher's exact test p<0.001). In multivariate logistic regression analysis, after adjustment for age, sex and whether the part 1A examination was taken concurrently, being a UK graduate was still strongly associated with passing the examination (OR 3.17 (95% CI 2.41 to 4.17), p<0.001). UK graduates performed best at 26-27 years of age (52.4% pass rate), whereas overseas graduates performed best at ≥38 years of age (50.8% pass rate). CONCLUSIONS: MRCPCH part 1B outcome was related to place of primary medical qualification, with a significantly lower pass rate for international medical graduates compared with UK graduates, as well as significant variation in examination outcome between graduates from different UK medical schools. These data may be used to guide new initiatives to improve support and education for these trainees and to inform development of undergraduate curricula and help trainees prepare more successfully for postgraduate examinations.

Nephrectomy for the failed renal allograft in children: predictors and outcomes.

BACKGROUND: There are no guidelines for the removal of a failed renal allograft, and its impact on subsequent dialysis and retransplantation has not yet been described. METHODS: We performed a 10-year review of allograft failure to study the factors that determined an outcome of transplant nephrectomy and choice of subsequent renal replacement therapy in children with or without nephrectomy. RESULTS: A total of 34 children developed graft failure over the 10-year study period, of whom 18 (53 %) required transplant nephrectomy. The median graft survival was 1.1 (range 0.2-10.6) versus 7.5 (1.5-15.0) years in the nephrectomy and non-nephrectomy groups, respectively (p = 0.011). Children with graft failure within 1 year of transplantation were four-fold more likely to require transplant nephrectomy than those with graft failure after 1 year (p = 0.04). Renal biopsy performed at ≤ 8 weeks prior to graft loss showed Banff grade II acute rejection in 13 of the 18 children who required subsequent nephrectomy versus three of the 13 children who did not need nephrectomy (p = 0.01). Inflammation (fever, graft tenderness and raised C-reactive protein (CRP) in the 2 weeks preceding graft failure) was seen in 66 % of nephrectomized children, but not in any in the non-nephrectomy group (p = 0.0003 for CRP between groups). Banff II rejection, an inflammatory response and the time post-transplantation significantly and independently predicted the outcome of nephrectomy (p = 0.008, R (2) = 67 %). Human leukocyte antigen (HLA) antibody levels after graft failure were higher in the nephrectomy group (p = 0.0003), but there was no difference between groups in terms of the presence or class of donor-specific antibodies. Of the children with graft failure, 82 % required dialysis (61 % hemodialysis) and 35 % have to date been successfully retransplanted. CONCLUSIONS: Children with Banff II rejection, an inflammatory response and early graft loss are more likely to require transplant nephrectomy. Nephrectomy may be associated with higher circulating HLA antibody levels.

Infantile midaortic syndrome with aortic occlusion.

Mid aortic syndrome (MAS) is a rare condition often presenting with severe hypertension. It is characterized by narrowing of the abdominal aorta. We here describe a case of complete occlusion of the abdominal aorta presenting in infancy. This child presented at four months of age with heart failure and hypertension. CT angiogram showed total narrowing of the abdominal aorta. This was initially felt to be too severe for surgical treatment and he was planned for palliative care. We were however able to improve his blood pressure with antihypertensive agents and he underwent succesful angioplasty at five and a half months of age. He has required three further angioplasty procedures and still needs two antihypertensive agents to control his blood pressure. His renal function remains normal and at age six years he has excellent quality of life with normal growth and development. This case illustrates that the combination of medical treatment and angioplasty can give an excellent long-term treatment response even in children with extremely severe MAS. This boy now has normal blood pressure and has experienced normal growth, development and quality of life.

IL-4 expression delays eosinophil-independent vasculopathy and fibrosis during allograft rejection in the mouse.

Transplant vasculopathy in the mouse is thought to be dependent on IL-4 and mediated by IL-5 and eosinophils, whereas in the rat and human systems, IL-4 is associated with the absence of transplant vasculopathy and down-regulation of a Th1-type response. In this study we tested the possibility that the apparent difference in the role of IL-4 in transplant vasculopathy is related to protocol differences rather than to the species being studied. Using a protocol that closely resembles that used in rat and human studies, we developed a model of transplant vasculopathy in the mouse that is associated with Th1-type cytokines and independent of IL-5 and eosinophil infiltration. In this model IL-4 promotes a significant delay in vasculopathy in the graft (P = 0.04) and a decrease in the incidence of allograft rejection (P = 0.02). The data suggest that the role of IL-4 in transplant vasculopathy can be controlled by the protocol used to treat the transplant recipient.