Triadic signatures of global human mobility networks.

Global refugee and migrant flows form complex networks with serious consequences for both sending and receiving countries as well as those in between. While several basic network properties of these networks have been documented, their finer structural character remains under-studied. One such structure is the triad significance profile (TSP). In this study, the TSPs of global refugee and migrant flow networks are assessed. Results indicate that the migrant flow network's size and TSP remain stable over the years; its TSP shares patterns with social networks such as trade networks. In contrast, the refugee network has been more dynamic and structurally unstable; its TSP shares patterns with networks in the information-processing superfamily, which includes many biological networks. Our findings demonstrate commonality between migrant and social networks as well as between refugee and biological networks, pointing to possible interdisciplinary collaboration-e.g., application of biological network theories to refugee network dynamics-, potentially furthering theoretical development with respect to both network theory and theories on human mobility.

Pelvic Neuroblastoma of the Pediatric Prostate.

Neuroblastoma accounts for a significant portion of childhood tumors and can present in a variety of ways. Pelvic neuroblastoma has been reported but few cases exist of neuroblastoma invading or originating from the bladder or prostate. We present a 4-year-old patient with pelvic neuroblastoma arising from the prostate and describe the medical and surgical management of this challenging case. While pelvic neuroblastoma may have an improved prognosis, this case demonstrates the challenging surgical decisions that accompany these patients to maintain quality of life while balancing oncologic efficacy of treatment.

Bridging the Gap-Building Surgical Subspecialty Telemedicine Clinics in the Rural Setting.

INTRODUCTION: Pediatric urology is a much-needed subspecialty with a breadth of complex disorders that can often prove challenging to diagnose and manage. Exacerbating this need is the minimal exposure medical trainees receive to pediatric urology. Pediatric urology arrived in West Virginia in 1983 but the subspecialty has been inconsistently represented since then. Currently there are 2 fellowship-trained pediatric urologists in the state of West Virginia, which has an area of approximately 24,038 square miles. We review our experience with the use of telemedicine in providing outreach to the wider parts of our medically underserved state and ultimately evaluate its efficacy from a patient-centric cost analysis and diagnosis concordance perspective. We hypothesized that the use of telemedicine would be cost and time-effective for patients in our rural state. METHODS: We retrospectively reviewed our series of patients presenting from outside telemedicine "referral centers" in Martinsburg, Parkersburg and Wheeling for pediatric urological consultation. We evaluated reason for consultation, geographic driving distance, drive time and travel cost saved from telemedicine consultation. RESULTS: A total of 92 patients presented to outside designated telemedicine centers from August 2018 to April 2020. The mean driving time saved utilizing telemedicine consultation was 4 hours and 46 minutes, and mean driving distance saved was 299.8 miles. Travel costs saved in terms of fuel averaged $173.88 per patient. The most common reason for consultation was undescended testis, followed by recurrent urinary tract infection and nocturnal enuresis. Of the 23 patients who required surgery, only 2 (8.7%) had an initial diagnosis that was not concordant with their operating room examination. CONCLUSIONS: While modest, our data indicate a modern solution to a historical need in our state. Our high diagnosis concordance rate (91.3%) shows that a well-trained advanced practice provider can adequately perform an operative evaluation via telemedicine.

Survey of COVID-19 impact on pediatric urology services.

INTRODUCTION: To better understand how the COVID-19 pandemic has forced rapid operational changes in the global healthcare industry, changes implemented on an individual, institutional basis must be considered. There currently is not adequate literature about the overall impact COVID-19 has had on pediatric urology services worldwide. We believe that they have dramatically decreased during the COVID-19 crisis, but have adapted to accommodate changes. We hypothesize that patient care was widely variant due to inadequate standardized recommendations or crisis planning. MATERIALS AND METHODS: A web-based survey was deployed to 377 pediatric urologists globally via email to analyze COVID-19's impact on various types of pediatric urology practices. Key categories included impacts on elective services, telemedicine use, finances, and recovery operations. A total of 114 responses were collected between April 29th - May 22nd, 2020. RESULTS: The widespread cancellation of elective surgical procedures caused significant disturbances in the field. There was a uniform, significant increase (75%) in telemedicine use across practices. The pandemic has created many changes in care provision for physicians, institutions, and patients themselves. Furthermore, the sudden economic burden on healthcare facilities could lead to cost-cutting measures, creating further strain within institutions. Though telemedicine has its limitations, it is a very viable option when traditional services are unavailable. CONCLUSIONS: Immediate steps should be taken to ensure that the recovery phases of pediatric urology practices are as efficient as possible. Institutions should develop task forces to develop critical workflow processes in the event of health crises, while still maintaining patient-centered care. This will be essential in maximizing appropriate care allocation.

Prenatally Diagnosed Testicular Torsion: A Rare Condition That Causes Dilemma in Management.

BACKGROUND: Prenatal testicular torsion (PTT) is exceedingly rare in intrauterine development, often diagnosed at the time of birth and very rarely diagnosed in utero during routine gestational ultrasound. As a result, incidence is unknown, and there exists no consensus regarding the pathophysiology of this phenomenon nor universally recognized algorithms and guidelines regarding its diagnosis and management. Case Presentation. We present the case of an antenatally diagnosed torsion and our subsequent management which included ipsilateral orchiectomy and prophylactic contralateral orchiopexy via a scrotal approach. CONCLUSION: While controversy regarding surgical intervention in patients with unilateral PTT exists due to poor salvage rates-estimated to be less than 1%-the risk of anorchia is higher in affected patients due to limitations in the accuracy of detecting bilateral testicular involvement. Risk of misdiagnosis of bilaterality may lead to lasting sequelae such as infertility and devastating psychological consequences for affected patients, supporting the need for surgical exploration, as was performed in our case.

Efficacy, Safety And Feasibility Of Antiemetic Prophylaxis With Fosaprepitant, Granisetron And Dexamethasone In Pediatric Patients With Hemato-Oncological Malignancies.

BACKGROUND: Chemotherapy-induced nausea and vomiting (CINV) are a major burden for patients undergoing emetogenic chemotherapy. International guidelines recommend an antiemetic prophylaxis with corticosteroids, 5-HT3R-antagonists and NK1R-antagonists. The NK1R-antagonist fosaprepitant has shown favorable results in pediatric and adult patients. There is little pediatric experience with fosaprepitant. METHODS: This non-interventional observation study analyzed 303 chemotherapy courses administered to 83 pediatric patients with a median age of 9 years (2-17 years), who received antiemetic prophylaxis either with fosaprepitant and granisetron with or without dexamethasone (fosaprepitant group/FG; n=41), or granisetron with or without dexamethasone (control group/CG; n=42), during moderately (CINV risk 30-90%) or highly (CINV risk>90%) emetogenic chemotherapy. The two groups' results were compared with respect to the safety and efficacy of the antiemetic prophylaxis during the acute (0-24hrs after chemotherapy), delayed (>24-120hrs after chemotherapy) and both CINV phases. Laboratory and clinical adverse events were compared between the two cohorts. RESULTS: Adverse events were not significantly different in the two groups (p>0.05). Significantly fewer vomiting events occurred during antiemetic prophylaxis with fosaprepitant in the acute (23 vs 142 events; p<0.0001) and the delayed (71 vs 255 events; p<0.0001) CINV phase. In the control group, the percentage of chemotherapy courses with vomiting was significantly higher during the acute (24%/FG vs 45%/CG; p<0.0001) and delayed CINV phase (28%/FG vs 47%/CG; p=0.0004). Dimenhydrinate (rescue medication) was administered significantly more often in the CG, compared to the FG (114/FG vs 320/CG doses; p<0.0001). Likewise, in the control group, dimenhydrinate was administered in significantly more (p<0.0001) chemotherapy courses during the acute and delayed CINV phases (79 of 150; 52.7%), compared to the fosaprepitant group (45 of 153; 29.4%). CONCLUSION: Antiemetic prophylaxis with fosaprepitant and granisetron with or without dexamethasone was well tolerated, safe and effective in pediatric patients. However, larger prospective trials are needed to evaluate these findings.

Defining and listing very rare cancers of paediatric age: consensus of the Joint Action on Rare Cancers in cooperation with the European Cooperative Study Group for Pediatric Rare Tumors.

Although all tumours are rare in childhood, there are some particularly rare paediatric cancers which have not benefited from advances made by the international paediatric oncology network. To establish a shared definition and produce a list of these entities, the European Union Joint Action on Rare Cancers (JARC) promoted a consensus effort. The definition was based on the incidence rates estimated using the information network on rare cancers (RARECAREnet) database, pooling data from 94 population-based cancer registries and 27 countries. The RARECAREnet list of cancers was used to estimate the incidence rates. This list groups cancers by combining the International Classification of Diseases for Oncology, third edition, morphology and topography codes. According to the consensus, very rare paediatric cancers were identified as those with an annual incidence <2/1000000 and corresponded to 11% of all cancers in patients aged 0-14 years. Two subgroups were identified: tumour types typical of childhood (i.e. hepatoblastoma, pleuropulmonary blastoma, pancreatoblastoma) and those typical of adult age (i.e. carcinomas, melanoma). The threshold of 2/1000000 could also be adopted in populations aged 0-19 years: in this case, three tumour types had an incidence rate which was >2/1000000 (i.e. thyroid and testicular cancers and skin melanoma), but the consensus experts considered them as 'very rare' according to their clinical needs (e.g. shortage of knowledge and clinical expertise as the other rare paediatric cancers). The JARC consensus produced a definition and a list of very rare paediatric cancers which may represent a starting point for prioritising research on these tumours, based on data and patients' clinical needs.

Ossifying Renal Tumor of Infancy: Laparoscopic Treatment and Literature Review.

We present an unusual case of a rare ossifying renal tumor of infancy. A 6-month-old male initially presented with gross hematuria and without any palpable abdominal mass. Renal ultrasound and MRI showed a right lower pole, calcified, endophytic renal mass. Laparoscopic radical nephrectomy was performed without complications. Pathology demonstrated an ossifying renal tumor of infancy. We report this case, in addition to a review of the literature for similar cases, to highlight a rare renal tumor in infancy that can be managed laparoscopically.

Staphylococcal Enterotoxins Dose-Dependently Modulate the Generation of Myeloid-Derived Suppressor Cells.

Staphylococcus aureus is one of the major human bacterial pathogens causing a broad spectrum of serious infections. Myeloid-derived suppressor cells (MDSC) represent an innate immune cell subset capable of regulating host-pathogen interactions, yet their role in the pathogenesis of S. aureus infections remains incompletely defined. The aim of this study was to determine the influence of different S. aureus strains and associated virulence factors on human MDSC generation. Using an in vitro MDSC generation assay we demonstrate that low concentrations of supernatants of different S. aureus strains led to an induction of functional MDSC, whereas increased concentrations, conversely, reduced MDSC numbers. The concentration-dependent reduction of MDSC correlated with T cell proliferation and cytotoxicity. Several findings supported a role for staphylococcal enterotoxins in modulating MDSC generation. Staphylococcal enterotoxins recapitulated concentration-dependent MDSC induction and inhibition, T cell proliferation and cytotoxicity, while an enterotoxin-deficient S. aureus strain largely failed to alter MDSC. Taken together, we identified staphylococcal enterotoxins as main modulators of MDSC generation. The inhibition of MDSC generation by staphylococcal enterotoxins might represent a novel therapeutic target in S. aureus infections and beyond in non-infectious conditions, such as cancer.

Urologic Phenotype and Patterns of Care in Patients With Megacystis Microcolon Intestinal Hypoperistalsis Syndrome Presenting to a Major Pediatric Transplantation Center.

OBJECTIVE: To describe the phenotype, referral pattern, and trends of urologic management for children with megacystis microcolon intestinal hypoperistalsis syndrome. MATERIALS AND METHODS: We performed a retrospective review of all patients with megacystis microcolon intestinal hypoperistalsis syndrome treated at a large tertiary children's medical center over a 14-year period. Our primary outcomes included the rate of urology referral, urodynamic characteristics of bladder function, and the proportion of patients managed with clean intermittent catheterization. RESULTS: Twenty-six patients were evaluated at our institution with a median age at presentation of 1.3 years (73% female, 19 of 26). Most patients presented for intestinal transplantation evaluation and were dependent on parenteral nutrition. Megacystis was diagnosed prenatally in 15 patients and postnatally in 11 patients. Twenty patients (77%, 20 of 26) were evaluated by a pediatric urologist. Six patients (23%, 6 of 26) had varying degrees of vesicoureteral reflux. Early bladder management consisted of clean intermittent catheterization in 13 patients and vesicostomy in 8 patients. CONCLUSION: Megacystis microcolon intestinal hypoperistalsis syndrome is a severe form of intestinal failure and bladder atony with substantial urologic morbidity. Parents should be counseled accordingly and prompt urologic consultation should be included in the multidisciplinary approach to these complex patients.

Conservative Management of Staghorn Calculi: When Is It Safe?

BACKGROUND: To describe the clinical characteristics, infectious and kidney function patterns, and overall outcomes in a cohort of patients with staghorn calculi treated conservatively. METHODS: Staghorn calculi treated nonoperatively between January 2009 and January 2017 were identified. A retrospective analysis was completed. RESULTS: Twenty-nine patients were identified with a median age of 74 years (interquartile range [IQR] 61-81). Mean follow-up was 24 months. Fifty-nine percent (17/29) had complete staghorn calculi with 6/29 (21%) bilateral. Mean body mass index was 29.4 (IQR 24.8-31.7). Of the 29 patients, 14 were treated conservatively due to comorbidities, 12 refused treatments, and 3 were due to aberrant anatomy. The age-adjusted Charlson Comorbidity Index (CCI) score demonstrated 8 patients in our cohort with a CCI of <3, 11 patients with a CCI of 4 or 5, 7 patients with a CCI of 6 or 7, and 3 patients with a CCI of >8. Overall, kidney function remained stable for 19/29 patients (66%) and the glomerular filtration rate decreased by <10% for 4/29 (14%), by 10%-29% for 2/29 (7%), and >30% for 4/29 patients (14%) over the study period. None of the study patients required hemodialysis. No patients in the cohort developed an abscess, nor were any patients on daily prophylactic antibiotics. There was only one related admission for a complication during the study; this was for pyelonephritis. There were two deaths during the study period. One death was an unrelated cardiac death and the other was from urosepsis; this patient had been noncompliant with follow-up. CONCLUSIONS: Outcomes for patients treated conservatively were reasonable in this select group. There is a need for future prospective studies to show whether conservative treatment of these patients is safe.

Hydronephrosis From Ureteropelvic Junction Obstruction Discovered on Point-of-Care Ultrasound in Patients With Trauma.

We present 2 cases of patients with abdominal trauma who were found to have hydronephrosis on point-of-care ultrasound secondary to previously undiagnosed ureteropelvic junction obstructions. We review the ultrasound findings, technique, and relevant literature regarding renal point-of-care ultrasound and ureteropelvic junction obstruction.

Pediatric Ureteroscopy.

In recent years, the incidence of nephrolithiasis in the pediatric population appears to be increasing. 1 This has placed a new emphasis on surgical management of stones in children. In the past, extracorporeal shockwave lithotripsy was the preferred management technique for stones in children. 2 More recently, though, advances in endoscopy have allowed ureteroscopy to be adapted to the pediatric population and this approach has become more frequently utilized not just for lower ureteral calculi but also for proximal ureteral and renal stones.