The association between sleep duration and cardiometabolic risk among children and adolescents in the United States (US): A NHANES study.

PURPOSE: This work aims to assess the association of sleep duration with cardiometabolic risk (adiposity, blood pressure, lipids, albuminuria and A1C) and to investigate lifestyle factors (physical activity, light exposure, caffeine consumption and sugar consumption) associated with sleep duration in children. METHODS: A nationally representative sample of 3907 children ages 6-17 years enrolled in NHANES from 2011 to 2014 was included in this cross-sectional study. Sleep duration was defined as the daily average time spent sleeping over 7 days as measured by a physical activity monitor (PAM). Participants without valid sleep data for ≥95% of the study were excluded. Regression models were adjusted for age, sex, race, body mass index (BMI) Z score, physical activity and light exposure. RESULTS: In adjusted regression models, longer sleep duration was associated with lower systolic blood pressure index (ß = -3.63 * 10-5, 95% CI -6.99 * 10-5, -2.78 * 10-6, p = 0.035) and BMI Z score (ß = -0.001, 95% CI -0.001, 0.000, p = 0.002). In logistic regression models, longer sleep duration was associated with lower odds of obesity (OR = 0.998, 95% CI 0.997, 0.999, p < 0.001) and overweight status (OR = 0.998, 95% CI 0.997, 0.999, p = 0.004). Greater light exposure (ß = 6.64 * 10-5, 95% CI 3.50 * 10-5, 9.69 * 10-5, p < 0.001) and physical activity (ß = 0.005, 95% CI 0.004, 0.006, p < 0.001) were associated with longer sleep. CONCLUSION: Longer sleep duration was associated with lower blood pressure and adiposity measures in children. Improving sleep quality by increasing physical activity and light exposure in childhood may decrease the lifetime risk of cardiometabolic disease.

Anterior and posterior ischemic optic neuropathy in a child with focal segmental glomerulosclerosis on hemodialysis.

BACKGROUND: Ischemic optic neuropathy (ION) is exceedingly rare in children on dialysis, resulting from poor perfusion of the optic nerve, and presents as sudden acute painless vision loss. CASE-DIAGNOSIS/TREATMENT: We report the case of a 3-year-old male with stage 5 chronic kidney disease (CKD 5) due to focal segmental glomerulosclerosis (FSGS) status post-bilateral nephrectomy on chronic hemodialysis who had acute loss of vision several hours after a hemodialysis session. Earlier that day, he had a drop in blood pressure intra-dialysis to 89/67 mmHg, with at home blood pressures ranging 90/60 to 150/100 mmHg. The patient was treated with tight blood pressure control to maintain blood flow and prevent blood pressure lability, received high-dose corticosteroids with a corticosteroid taper, and placed on high-dose erythropoietin for neuroprotective effect. He regained partial vision beginning approximately 1 month after presentation. CONCLUSIONS: The exact cause of our patient's simultaneous bilateral anterior and posterior ION, confirmed via MRI and fundoscopic examination, is unclear; however, is likely secondary to a combination of fluctuating blood pressure, anemia, anephric status, and hemodialysis. This highlights the need for close blood pressure monitoring, management of anemia, and more diligent ophthalmologic screening in pediatric patients on chronic hemodialysis.

Association Between Dietary Fiber Intake and Cardiometabolic Risk Factors in Adolescents in the United States.

OBJECTIVE: To determine the association between dietary fiber intake and markers of cardiometabolic risk in adolescents, with blood pressure (BP) as the primary outcome of interest and secondary outcome measures including other established markers of childhood cardiometabolic risk, such as obesity, lipids, albuminuria, estimated glomerular filtration rate (eGFR), and uric acid. STUDY DESIGN: Dietary fiber intake was assessed by two 24-hour dietary recall interviews, which were averaged and corrected for body weight. Logistic and linear regression models were used to analyze the cross-sectional association between dietary fiber and cardiometabolic markers. Participants aged 13-17 years in the National Health and Nutritional Examination Survey 2009-2018 who completed a 24-hour dietary recall survey were included. Exclusion criteria included pregnancy, small for gestational age status, and history of major health comorbidities. RESULTS: In fully adjusted regression models, low dietary fiber intake was significantly associated with greater diastolic blood pressure (ß = -13.29; 95% CI, -20.66 to -5.93), body mass index z-score (ß = -0.91; 95% CI, -1.47 to -0.34), and uric acid (ß = -0.80; 95% CI, -1.44 to -0.16). CONCLUSIONS: The association found between low dietary fiber intake and poor childhood cardiometabolic risk markers indicate a need for prospective studies using fiber intake as a dietary intervention in childhood and as a tool for prevention of many chronic conditions.

Effectiveness of non-immersive virtual reality in the management of procedure-related pain in preschool children: a randomized clinical trial.

The objective of this study is to assess the effectiveness of non-immersive virtual reality as a pain-distraction measure in children between the ages of 3 and 5 years undergoing painful injection procedures in an outpatient setting. We carried out a randomized, unmasked clinical trial in children undergoing venipuncture or intramuscular injection procedures. Patients were randomized to a distraction virtual reality video or standard care. After the procedure, three independent observers (parents, researchers, nursing staff) rated pain on the LLANTO pain scale. We recruited 122 subjects, half of which were randomized to virtual reality. The median age was of approximately 60 months (IQR: 15 months), and the sample was balanced with regard to sex. There were significant differences in LLANTO scales scores between the VR subjects and controls of - 3.34 (95% CI - 4.15; - 2.54), - 3.02 (95% CI - 3.90; - 2.14), and - 2.98 (95% CI - 3.87; - 2.09), as rated by parents, researchers, and nursing staff, respectively. Agreement between raters was high for all three types of observers, with Cohen Kappas over 0.79 in all cases. Bivariate analysis showed reductions in the risk of obtaining higher scores in the LLANTO scale. Linear regression models showed a reduction of approximately 3 points in the scale, regardless of the type of observer. These models were adjusted for sex, age, kind of procedure, use of prior analgesia, and recruitment center. CONCLUSIONS: Non-immersive virtual reality is an effective adjunctive therapy for the reduction of pain in children undergoing painful injection procedures in an outpatient setting. This strategy may be used to improve the quality of care in pediatric outpatient services. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03985930 (Registered June 14, 2019). WHAT IS KNOWN: •The use of immersive virtual reality (VR) has been described as an effective adjunctive distraction method during painful procedures in children over 5 years. WHAT IS NEW: •The utility of non-immersive VR in children below that age is not yet clear. This randomized clinical trial comparing non-immersive VR vs. standard care showed an average reduction of three points in the LLANTO pain scale favoring non-immersive VR. Non-immersive VR is an effective and inexpensive non-pharmacological technique that reduces fear and pain in pediatric patients.

Clinical and Demographic Characteristics of Centenarians versus Other Age Groups Over 75 Years with Hip Fractures.

Objective: The primary objective was to describe the clinical characteristics, management, and outcomes of centenarians with fragility hip fracture and compare them to other age groups. The secondary objective was to determine the variables associated with length of stay, in-hospital mortality and 30-day mortality. Materials and Methods: This is a secondary analysis of the Spanish National Hip Fracture Registry. We included patients ≥75 years admitted for fragility hip fractures in 86 Spanish hospitals between 2017 and 2019, dividing the sample into four age groups. The variables studied were baseline characteristics, type of fracture, management, length of stay, in-hospital mortality and 30-day mortality. Results: We included 25,938 patients (2888 were 75-79 years old; 14,762 octogenarians; 8,035 nonagenarians and 253 centenarians). Of the centenarians, 83% were women, 33% had severe dementia, 9% had severe dependency and 36% lived in residential care homes. Six out of ten had intertrochanteric fracture. Length of hospital stay was 8.6 days; in-hospital mortality was 10.3% and 30-day mortality 20.9%. Older age groups had more women, severe functional dependency, severe dementia, intertrochanteric fracture, living in care facilities and being discharged to nursing care. They had less frequent early mobilization, osteoporosis treatment and discharge to rehabilitation units. In-hospital and 30-day mortality were higher with increasing age. In centenarians, time to surgery >48 hours was independently associated with length of stay (correlation coefficient 3.99 [95% CI: 2.35-5.64; p<0.001]) and anaesthetic risk, based on an ASA score of V, was related to 30-day mortality (ASA score II [OR 0.25, 95% CI: 0.09-0.70; p=0.009] and ASA score III [OR 0.43, 95% CI: 0.19-0.96; p=0.039]). Conclusion: Centenarians had different clinical characteristics, management and outcomes. Although centenarians had worse outcomes, nearly 4 out of 5 centenarians were alive one month after surgery.

Perceived family impact and coping mechanisms of caregivers of children with nephrotic syndrome.

BACKGROUND: Pediatric chronic disease impacts the affected child and their family structure. There is limited literature investigating the psychosocial impact of nephrotic syndrome on families. METHODS: Caregivers of children with nephrotic syndrome completed two validated surveys: (1) Impact on Family (IOF) that evaluates the family impact (degree to which family is affected by a pediatric chronic illness) and (2) Coping Health Inventory for Parents (CHIP) that examines the coping patterns used by caregivers. Linear regression models were utilized to determine predictors of perceived family impact and coping patterns. RESULTS: Seventy-five caregivers of a child with nephrotic syndrome completed the surveys. On a scale from low impact to significant impact to very serious impact, results indicated that nephrotic syndrome had a significant impact on families (mean revised IOF total score 33.04 ± 9.38). Families in the steroid-resistant nephrotic syndrome (SRNS) group reported a higher financial impact compared to the steroid-sensitive nephrotic syndrome (SSNS) group (p = 0.03). Families in the frequently relapsing group (FRNS) reported a higher impact on the caregiver's ability to cope with the child's condition compared to the SRNS group (p = 0.02). Tacrolimus use was associated with increasing the perceived family impact (ß = 4.76, p = 0.046). CHIP scores indicated that caregivers did not cope well with family integration (component I) but coped well with social support (component II) and communication (component III). CONCLUSIONS: Childhood nephrotic syndrome has a significant overall perceived impact on the family, and caregivers did not cope well regarding strengthening their family life. These findings can be used as outcome measures for future intervention studies to find solutions that would decrease the perceived family burden. A higher resolution version of the Graphical abstract is available as Supplementary information.

COL4A4 variant recently identified: lessons learned in variant interpretation-a case report.

BACKGROUND: Alport syndrome is a hereditary kidney disease characterized by hematuria and proteinuria. Although there have been reports of autosomal dominant COL4A4 variants, this is likely an underdiagnosed condition. Improved access to affordable genetic testing has increased the diagnosis of Alport syndrome. As genetic testing becomes ubiquitous, it is imperative that clinical nephrologists understand the benefits and challenges associated with clinical genetic testing. CASE PRESENTATION: We present a family of Mexican descent with a heterozygous COL4A4 variant (c.5007delC, ClinVar accession numbers: SCV001580980.2, SCV001993731.1) not previously discussed in detail in the literature. The proband received a biopsy diagnosis suggestive of Fabry disease 18 years after she first developed hematuria and progressed to chronic kidney disease stage III. One year later, the proband was provisionally diagnosed with Alport syndrome after a variant of uncertain significance in the COL4A4 gene was identified following targeted family variant testing of her daughter. Upon review of the medical histories of the proband's children and niece, all but one had the same variant. Of the four with the variant, three display clinical symptoms of hematuria, and/or proteinuria. The youngest of the four, only months old, has yet to exhibit clinical symptoms. Despite these findings there was a considerable delay in synthesizing this data, as patients were tested in different commercial genetic testing laboratories. Subsequently, understanding this family's inheritance pattern, family history, and clinical symptoms, as well as the location of the COL4A4 variant resulted in the upgrade of the variant's classification. Although the classification of this variant varied among different clinical genetic testing laboratories, the consensus was that this variant is likely pathogenic. CONCLUSIONS: This COL4A4 variant (c.5007delC) not yet discussed in detail in the literature is associated with Alport syndrome. The inheritance pattern is suggestive of autosomal dominant inheritance. This report highlights the intricacies of variant interpretation and classification, the siloed nature of commercial genetic testing laboratories, and the importance of a thorough family history for proper variant interpretation. Additionally, the cases demonstrate the varied clinical presentations of Alport syndrome and suggest the utility of early screening, diagnosis, monitoring, and treatment.

Influence of Donor Race and Donor-recipient Race-matching on Pediatric Kidney Transplant Outcomes.

Existing literature has demonstrated the significant relationship between race and kidney transplant outcomes; however, there are conflicting and limited data on the influence of donor race or donor-recipient race-matching on pediatric kidney transplant outcomes. Methods: Analysis included kidney-only transplant recipients between ages 2 and 17 from 2000 to 2017 enrolled in the Organ Procurement and Transplantation Network and their associated donors. Multivariable regression models were used to compare outcomes by donor race and donor-recipient race-matched status. Results: Of the total 7343 recipients, 4458 (60.7%) recipients received a kidney from a White donor, 1009 (13.7%) from a Black donor, 1594 (21.7%) from Hispanic donor, and 169 (4.1%) from an Asian donor; 4089 (55.7%) were race-matched. No donor races were significantly associated with transplant outcomes (all P > 0.05). Race-matched status was not associated with graft failure (hazard ratio, 1.03; 95% confidence interval [CI] = 0.89-1.2; P = 0.68), mortality (hazard ratio, 1.1; 95% CI, 0.79-1.53; P = 0.56), acute rejection at 1 y (odds ratio, 0.94; 95% CI, 0.77-1.15; P = 0.53), or delayed graft function (odds ratio, 1.02; 95% CI, 0.80-1.29; P = 0.91). Conclusions: Neither donor race nor race-matched status is associated with better transplant outcomes. Further studies are necessary to confirm the impact of donor race and race-matching more fully on pediatric kidney transplant outcomes.

Improving hip fracture care in Spain: evolution of quality indicators in the Spanish National Hip Fracture Registry.

This study was carried out to analyze the evolution of the quality indicators in the Spanish National Hip Fracture Registry, after disseminating a series of recommendations based on available clinical practice guidelines to the participating hospitals. Six of the seven proposed quality indicators showed a significant improvement. PURPOSE: The Spanish National Hip Fracture Registry (RNFC) arises from the need to know the process and improve the quality of care. Our goal was to analyze the changes in the RNFC's quality indicators after an intervention based on disseminating specific recommendations among the participating hospitals, following available clinical practice guidelines. METHODS: Study comparing before and after performing an intervention in hospitals participating in the RNFC. Data from the hospitals that registered cases in 2017, and that kept registering cases in 2019. Seven quality indicators were chosen, and a standard to be achieved for each indicator was proposed. The intervention consisted in the dissemination of 25 recommendations with practical measures to improve each quality indicator, based on available clinical practice guidelines, by drafting and publishing a scientific paper and sending it via email and printed cards. Fulfilment of each quality indicator was measured after carrying out the intervention. RESULTS: Forty-three hospitals registered 2674 cases between January and May, 2017, and 8037 during 2019. The quality indicators chosen and the degree of compliance were (all with p<0.05): (1) surgery ≤48 h increased from 38.9 to 45.8%; (2) patients mobilised on the first postoperative day increased from 58.9 to 70.3%; (3) patients with anti-osteoporotic medication at discharge increased from 34.5 to 49.8%; (4) patients with calcium supplements at discharge increased from 48.7 to 62.8%; (5) patients with vitamin D supplements at discharge increased from 71.5 to 84.7%; (6) patients developing a grade >2 pressure ulcer during admission decreased from 6.5 to 5.0%; (7) patients able to move on their own at 1 month fell from 58.8 to 56.4%. More than 48% of hospitals improved the proposed indicators. CONCLUSION: Establishing quality indicators and standards and intervening through the dissemination of specific recommendations to improve these indicators achieved an improvement in hospital performance results on a national level.

Differently Regulated Gene-Specific Activity of Enhancers Located at the Boundary of Subtopologically Associated Domains: TCRα Enhancer.

Enhancers activate transcription through long-distance interactions with their cognate promoters within a particular subtopologically associated domain (sub-TAD). The TCRα enhancer (Eα) is located at the sub-TAD boundary between the TCRα and DAD1 genes and regulates transcription toward both sides in an ∼1-Mb region. Analysis of Eα activity in transcribing the unrearranged TCRα gene at the 5'-sub-TAD has defined Eα as inactive in CD4-CD8- thymocytes, active in CD4+CD8+ thymocytes, and strongly downregulated in CD4+ and CD8+ thymocytes and αß T lymphocytes. Despite its strongly reduced activity, Eα is still required for high TCRα transcription and expression of TCRαß in mouse and human T lymphocytes, requiring collaboration with distant sequences for such functions. Because VαJα rearrangements in T lymphocytes do not induce novel long-range interactions between Eα and other genomic regions that remain in cis after recombination, strong Eα connectivity with the 3'-sub-TAD might prevent reduced transcription of the rearranged TCRα gene. Our analyses of transcriptional enhancer dependence during T cell development and non-T lineage tissues at the 3'-sub-TAD revealed that Eα can activate the transcription of specific genes, even when it is inactive to transcribe the TCRα gene at the 5'-sub-TAD. Hence distinct requirements for Eα function are necessary at specific genes at both sub-TADs, implying that enhancers do not merely function as chromatin loop anchors that nucleate the formation of factor condensates to increase gene transcription initiated at their cognate promoters. The observed different regulated Eα activity for activating specific genes at its flanking sub-TADs may be a general feature for enhancers located at sub-TAD boundaries.

Kidney transplant outcomes in children and adolescents with systemic lupus erythematosus.

BACKGROUND: Literature supports equivalent kidney transplant outcomes in adults with systemic lupus erythematosus (SLE) compared with those without SLE. However, there are conflicting and scant data on kidney transplant outcomes, as well as controversy over optimal timing of transplantation, in children and adolescents with SLE. METHODS: Analysis included kidney-only transplant recipients aged 2-21 years from 2000 to 2017 enrolled in the Organ Procurement and Transplant Network (OPTN). The relationship between diagnosis (SLE n = 457, non-SLE glomerular disease n = 4492, and non-SLE non-glomerular disease n = 5605) and transplant outcomes was evaluated. The association between dialysis time and outcomes was analyzed in the SLE group only. RESULTS: In adjusted models, SLE had higher mortality compared with non-SLE glomerular recipients (HR 1.24 CI 1.07-1.44) and non-glomerular recipients (HR 1.42 CI 1.20-1.70). SLE was associated with higher graft failure compared with non-SLE glomerular (HR 1.42 CI 1.20-1.69) and non-glomerular disease (HR 1.67 CI 1.22-2.28). SLE had a higher risk of acute rejection at 1 year compared with non-glomerular disease (HR 1.39 CI 1.03-1.88). There was a decreased risk of delayed graft function compared with non-SLE glomerular disease (HR 0.54, CI 0.36-0.82). There were no significant associations between dialysis time and transplant outcomes in the SLE group. CONCLUSION: SLE in children and adolescents is associated with worse patient and graft survival compared with non-SLE diagnoses. Outcomes in children and adolescents with SLE are not associated with dialysis time. Further studies are needed to assess implications of potential earlier transplantation and shorter time on dialysis prior to transplantation.

Differences in the baseline characteristics, management and outcomes of patients with hip fractures depending on their pre-fracture place of residence: the Spanish National Hip Fracture Registry (RNFC) cohort.

PURPOSE: One in four hip fracture patients comes from an aged care facility. This study aimed to compare the characteristics of these subjects with their community-dwelling counterparts at baseline, during hospitalization and 1-month post-fracture. METHODS: We analyzed data from a cohort of older adults admitted with hip fractures to 75 Spanish hospitals, collected prospectively in the Spanish National Hip Fracture Registry between 2016 and 2018. We classified participants according to pre-fracture residence: community dwellers vs. aged care facilities residents. We collected demographic records at baseline, along with variables relating to in-hospital evolution and discharge to geriatric rehabilitation units. Patients or relatives were interviewed at 1-month follow-up. RESULTS: Out of 18,262 patients, 4,422 (24.2%) lived in aged care facilities. Aged care facilities residents were older (median age: 89 vs. 86 years), less mobile (inability to walk independently: 20.8% vs. 9.4%) and had more cognitive impairment (Pfeiffer's SPMSQ > 3, 75.3% vs. 34.8%). They were more likely to receive conservative treatment (5.4% vs. 2.0%) and less likely to be mobilized early (58.2% vs. 63.0%). At discharge, they received less vitamin D supplements (68.5% vs. 72.4%), less anti-osteoporotic medication (29.3% vs. 44.3%), and were referred to geriatric rehabilitation units less frequently (5.4% vs. 27.5%). One-month post-fracture, 45% of aged care facilities residents compared to 28% of community dwellers experienced a severe gait decline. Aged care facilities residents had a higher one-month mortality (10.6% vs. 6.8%). CONCLUSION: Hip fracture patients from aged care facilities are more vulnerable than their community-dwelling peers and are managed differently both during hospitalization and at discharge. Gait decline is disproportionately higher among those admitted from aged care.

Comparison of Pediatric and Adult Ambulatory Blood Pressure Monitoring Criteria for the Diagnosis of Hypertension and Detection of Left Ventricular Hypertrophy in Adolescents.

OBJECTIVE: To compare pediatric ambulatory blood pressure monitoring (ABPM) criteria with adult ABPM criteria for the diagnosis of hypertension and detection of left ventricular hypertrophy (LVH) in adolescents. STUDY DESIGN: ABPM and echocardiography reports from adolescents age 13-21 years from 2015 to 2019 were analyzed. The concordance of hypertension based on pediatric criteria (American Heart Association 2014) was compared with adult criteria from American College of Cardiology/American Heart Association 2017 (overall BP ≥125/75 mm Hg, wake BP ≥130/80 mm Hg, sleep BP ≥110/65 mm Hg) using the Cohen kappa statistic. Logistic regression, adjusted for body mass index z score, and receiver operating characteristic curves (ROCs) compared pediatric criteria vs adult criteria in predicting LVH (left ventricular mass index >95th percentile reference values and left ventricular mass index >51 g/m2.7). RESULTS: Of 306 adolescents, 140 (45.8%) had hypertension based on pediatric criteria vs 228 (74.5%) based on adult criteria; the agreement was poor (59.3%, n = 137, kappa = 0.41). A higher prevalence of LVH was captured by adult criteria only (n = 91) compared with pediatric criteria only (n = 3). Logistic regression found no significant differences between pediatric and adult criteria in the detection of LVH >95th percentile (OR 1.24, CI 0.66, 2.31, P = .51) or >51 g/m2.7 (OR 1.06, CI 0.47, 2.40, P = .89). ROCs for pediatric criteria were not significant for detecting LVH >95th percentile (0.50, P = .91) or >51 g/m2.7 (0.55, P = .45), whereas the ROC for adult criteria was significant for detecting LVH >95th percentile (0.59, P = .045) but not >51 g/m2.7 (0.63, P = .07). Although all individuals with LVH >51 g/m2.7 were hypertensive by adult criteria, 8 of these individuals were missed by pediatric criteria. CONCLUSIONS: Adult criteria captured a higher prevalence of LVH and appeared to predict better LVH than pediatric criteria. A consideration to align ABPM criteria for diagnosing hypertension in adolescents with adult guidelines is warranted.

Rod-shape theranostic nanoparticles facilitate antiretroviral drug biodistribution and activity in human immunodeficiency virus susceptible cells and tissues.

Human immunodeficiency virus theranostics facilitates the development of long acting (LA) antiretroviral drugs (ARVs) by defining drug-particle cell depots. Optimal drug formulations are made possible based on precise particle composition, structure, shape and size. Through the creation of rod-shaped particles of defined sizes reflective of native LA drugs, theranostic probes can be deployed to measure particle-cell and tissue biodistribution, antiretroviral activities and drug retention. Methods: Herein, we created multimodal rilpivirine (RPV) 177lutetium labeled bismuth sulfide nanorods (177LuBSNRs) then evaluated their structure, morphology, configuration, chemical composition, biological responses and adverse reactions. Particle biodistribution was analyzed by single photon emission computed tomography (SPECT/CT) and laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) imaging. Results: Nanoformulated RPV and BSNRs-RPV particles showed comparable physicochemical and cell biological properties. Drug-particle pharmacokinetics (PK) and biodistribution in lymphoid tissue macrophages proved equivalent, one with the other. Rapid particle uptake and tissue distribution were observed, without adverse reactions, in primary blood-derived and tissue macrophages. The latter was seen within the marginal zones of spleen. Conclusions: These data, taken together, support the use of 177LuBSNRs as theranostic probes as a rapid assessment tool for PK LA ARV measurements.

[Spanish National Hip Fracture Registry (RNFC): First-year results and comparison with other registries and prospective multi-centric studies from Spain]. / Registro Nacional de Fracturas de Cadera (RNFC): resultados del primer año y comparación con otros registros y estudios multicéntricos españoles.

OBJECTIVE: The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi- centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain. METHODS: We included persons 75 years or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies. RESULTS: The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%). CONCLUSIONS: The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differences.

OBJETIVO: El Registro Nacional de Fracturas de Cadera (RNFC) es un registro español multicéntrico, prospectivo y continuo, que comenzó en 2017. El objetivo de este artículo fue presentar los datos del primer informe anual y compararlos con los registros autonómicos y los estudios multicéntricos realizados recientemente en España. METODOS: Se incluyeron las personas de 75 años o más atendidas con el diagnóstico de fractura de cadera por fragilidad en alguno de los hospitales participantes en el RNFC, entre enero y octubre de 2017. En el análisis estadístico se utilizó la media y desviación estándar o mediana y rangos intercuartílicos para las variables numéricas y los porcentajes para las variables categóricas. Se realizó un análisis descriptivo global de la casuística y se comparó con los datos disponibles de los estudios previos mencionados. RESULTADOS: Se registraron 7.208 personas de 54 hospitales, con una edad media de 86,7 años (DE 5,6). El 75,4% fueron mujeres y el 36,4% presentaron deterioro cognitivo previo. La demora quirúrgica media fue de 75,7 horas (DE 63,6) y la estancia media fue de 10,9 días (DE 6,7). De las personas que vivían en un domicilio antes de la fractura (75,4%), menos de la mitad (37,0%) volvieron a él tras el alta hospitalaria. Al mes, había fallecido el 7,1%. La comparación con los otros estudios mostró algunas diferencias importantes, sobre todo en la ubicación previa, en el porcentaje de pacientes institucionalizados de novo (7,7-29,4%) y en el porcentaje con tratamiento antiosteoporótico al alta (14,5-36,7%). CONCLUSIONES: El RNFC es la mayor base de datos prospectiva que aporta datos sobre el perfil de los pacientes hospitalizados por fractura de cadera en España. La comparación con otros estudios recientes muestra algunas diferencias importantes.

First proposal of quality indicators and standards and recommendations to improve the healthcare in the Spanish National Registry of Hip Fracture / Primera propuesta de indicadores y estándares de calidad y recomendaciones de mejora de la atención en el Registro Nacional de Fractura de Cadera

Background: The Spanish National Hip Fracture Registry (or Registro Nacional de Fractura de Cadera, RNFC) is a database of hip fracture patients admitted to Spanish hospitals. Its goals include assessment and continuous improvement of the care process. Objectives: To (1) establish a series of indicators, (2) evaluate their initial fulfillment, (3) propose quality standards, (4) suggest recommendations to facilitate standards compliance, and (5) monitor the indicators. Method: The indicators fulfilled the criteria of (1) evaluating the process or outcome, (2) being clinically relevant for patients, (3) being modifiable through changes in healthcare practice, and (4) being considered important by the RNFC participants. The first quartile obtained by the group of hospitals in each of the respective variables was proposed as the standard. The Indicators Advisory Committee (IAC) elaborated a list of recommendations for each indicator, based on the available evidence. Results: Seven indicators were chosen. These indicators (its baseline compliance vs. the standard to be reached, respectively) were: the proportion of patients receiving surgery within 48h (44% vs. 63%), mobilized the first postoperative day (56% vs. 86%), with antiosteoporotic medication at discharge (32% vs. 61%), with calcium supplements at discharge (46% vs. 77%), with vitamin D supplements at discharge (67% vs. 92%), who developed pressure ulcers during hospitalization (7.2% vs. 2.1%) and with independent mobility at 30 days (58% vs. 70%). The IAC has established 25 recommendations for improving care. Conclusion: The indicators and standards chosen are presented, as well as the list of recommendations. This process completes the first step to improve quality of care. The results will be evaluated 6 months after implementing the recommendations

Antecedentes: El Registro Nacional de Fractura de Cadera (RNFC) es una base de datos de pacientes con fractura de cadera ingresados en hospitales españoles. Entre sus objetivos se encuentran el conocimiento y la mejora continua del proceso asistencial. Objetivos: 1) establecer una serie de indicadores, 2) evaluar su cumplimiento inicial, 3) proponer unos estándares, 4) sugerir recomendaciones para facilitar el cumplimiento de los estándares y 5) realizar una monitorización de los indicadores. Método: Los indicadores cumplían los criterios de: 1) evaluar proceso o resultados, 2) tener relevancia clínica para los pacientes, 3) ser potencialmente modificables mediante cambios en la práctica asistencial y 4) ser considerados importantes por los participantes del RNFC. Se propuso como estándar el primer cuartil obtenido por el grupo de hospitales en cada una de las variables respectivas. El Comité de Indicadores (CI) elaboró una lista de recomendaciones basadas en la evidencia disponible. Resultados: Se eligieron 7 indicadores. Estos indicadores (con su grado de cumplimiento inicial vs. el estándar a alcanzar, respectivamente) fueron la proporción de pacientes intervenidos en menos de 48h (44 vs. 63%), levantados el primer día del postoperatorio (56 vs. 86%), con tratamiento anti-osteoporótico al alta (32 vs. 61%), con tratamiento de calcio al alta (46 vs. 77%), con tratamiento de vitamina D al alta (67 vs. 92%), que desarrollaron úlceras por presión durante la hospitalización (7,2 vs. 2,1%) y con movilidad independiente a los 30 días (58 vs. 70%). El CI ha establecido una serie de 25 recomendaciones para la mejora asistencial. Conclusión: Se presentan los indicadores y estándares elegidos, así como las recomendaciones. Este proceso completa el primer paso de mejora de calidad asistencial, cuyo resultado deberá ser evaluado tras 6 meses de implementación de las recomendaciones elegidas

First proposal of quality indicators and standards and recommendations to improve the healthcare in the Spanish National Registry of Hip Fracture.

BACKGROUND: The Spanish National Hip Fracture Registry (or Registro Nacional de Fractura de Cadera, RNFC) is a database of hip fracture patients admitted to Spanish hospitals. Its goals include assessment and continuous improvement of the care process. OBJECTIVES: To (1) establish a series of indicators, (2) evaluate their initial fulfillment, (3) propose quality standards, (4) suggest recommendations to facilitate standards compliance, and (5) monitor the indicators. METHOD: The indicators fulfilled the criteria of (1) evaluating the process or outcome, (2) being clinically relevant for patients, (3) being modifiable through changes in healthcare practice, and (4) being considered important by the RNFC participants. The first quartile obtained by the group of hospitals in each of the respective variables was proposed as the standard. The Indicators Advisory Committee (IAC) elaborated a list of recommendations for each indicator, based on the available evidence. RESULTS: Seven indicators were chosen. These indicators (its baseline compliance vs. the standard to be reached, respectively) were: the proportion of patients receiving surgery within 48h (44% vs. 63%), mobilized the first postoperative day (56% vs. 86%), with antiosteoporotic medication at discharge (32% vs. 61%), with calcium supplements at discharge (46% vs. 77%), with vitamin D supplements at discharge (67% vs. 92%), who developed pressure ulcers during hospitalization (7.2% vs. 2.1%) and with independent mobility at 30 days (58% vs. 70%). The IAC has established 25 recommendations for improving care. CONCLUSION: The indicators and standards chosen are presented, as well as the list of recommendations. This process completes the first step to improve quality of care. The results will be evaluated 6 months after implementing the recommendations.

Registro Nacional de Fracturas de Cadera (RNFC): resultados del primer año y comparación con otros registros y estudios multicéntricos españoles / Spanish National Hip Fracture Registry (RNFC):First-year results and comparison with other registries and prospective multi-centric studies from Spain

OBJETIVO: El Registro Nacional de Fracturas de Cadera (RNFC) es un registro español multicéntrico, prospectivo y continuo, que comenzó en 2017. El objetivo de este artículo fue presentar los datos del primer informe anual y compararlos con los registros autonómicos y los estudios multicéntricos realizados recientemente en España. MÉTODOS: Se incluyeron las personas de 75 años o más atendidas con el diagnóstico de fractura de cadera por fragilidad en alguno de los hospitales participantes en el RNFC, entre enero y octubre de 2017. En el análisis estadístico se utilizó la media y desviación estándar o mediana y rangos intercuartílicos para las variables numéricas y los porcentajes para las variables categóricas. Se realizó un análisis descriptivo global de la casuística y se comparó con los datos disponibles de los estudios previos mencionados. RESULTADOS: Se registraron 7.208 personas de 54 hospitales, con una edad media de 86,7 años (DE 5,6). El 75,4% fueron mujeres y el 36,4% presentaron deterioro cognitivo previo. La demora quirúrgica media fue de 75,7 horas (DE 63,6) y la estancia media fue de 10,9 días (DE 6,7). De las personas que vivían en un domicilio antes de la fractura (75,4%), menos de la mitad (37,0%) volvieron a él tras el alta hospitalaria. Al mes, había fallecido el 7,1%. La comparación con los otros estudios mostró algunas diferencias importantes, sobre todo en la ubicación previa, en el porcentaje de pacientes institucionalizados de novo (7,7-29,4%) y en el porcentaje con tratamiento antiosteoporótico al alta (14,5-36,7%). CONCLUSIONES: El RNFC es la mayor base de datos prospectiva que aporta datos sobre el perfil de los pacientes hospitalizados por fractura de cadera en España. La comparación con otros estudios recientes muestra algunas diferencias importantes

OBJECTIVE: The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi-centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain. METHODS: We included persons 75 years or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies. RESULTS: The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%). CONCLUSIONS: The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differences

Outcomes of underweight, overweight, and obese pediatric kidney transplant recipients.

BACKGROUND: Obesity is a risk factor for poor transplant outcomes in the adult population. The effect of pre-transplant weight on pediatric kidney transplantation is conflicting in the existing literature. METHODS: Data was collected from the Organ Procurement and Transplantation Network (OPTN) database on recipients aged 2-21 years who received a kidney-only transplant from 1987 to 2017. Recipients were categorized into underweight, normal, overweight, and obese cohorts. Using adjusted regression models, the relationship between recipient weight and various graft outcomes (delayed graft function [DGF], acute rejection, prolonged hospitalization, graft failure, mortality) was examined. RESULTS: 18,261 transplant recipients (mean age 14.1 ± 5.5 years) were included, of which 8.7% were underweight, 14.8% were overweight, and 15% were obese. Obesity was associated with greater odds of DGF (OR 1.3 95% CI 1.13-1.49, p < 0.001), acute rejection (OR 1.23 95% CI 1.06-1.43, p < 0.01), and prolonged hospitalization (OR 1.35 95% CI 1.17-1.54, p < 0.001) as well as greater hazard of graft failure (HR 1.13 95% CI 1.05-1.22, p = 0.001) and mortality (HR 1.19 95% CI 1.05-1.35, p < 0.01). The overweight cohort had an increased risk of graft failure (HR 1.08 95% CI 1.001-1.16, p = 0.048) and increased odds of DGF (OR 1.2 95% CI 1.04-1.38, p = 0.01) and acute rejection (OR 1.18 95% CI 1.01-1.38, p = 0.04). When stratified by age group, the increased risk was realized among younger and older age groups for obese and overweight. Underweight had lower risk of 1-year graft failure (HR 0.82 95% CI 0.71-0.94, p < 0.01), overall graft failure in the 13-17-yr. age group (HR 0.84 95% CI 0.72-0.99, p = 0.03) and acute rejection in the 2-5-yr. age group (OR 0.24 95% CI 0.09-0.66, p < 0.01). CONCLUSION: Pre-transplant weight status and age impact pediatric kidney transplant outcomes. Recipient underweight status seems to be protective against adverse outcomes while overweight and obesity may lead to poorer graft and patient outcomes.