Assessing the relative performance of fast molecular dating methods for phylogenomic data.

Advances in genome sequencing techniques produced a significant growth of phylogenomic datasets. This massive amount of data represents a computational challenge for molecular dating with Bayesian approaches. Rapid molecular dating methods have been proposed over the last few decades to overcome these issues. However, a comparative evaluation of their relative performance on empirical data sets is lacking. We analyzed 23 empirical phylogenomic datasets to investigate the performance of two commonly employed fast dating methodologies: penalized likelihood (PL), implemented in treePL, and the relative rate framework (RRF), implemented in RelTime. They were compared to Bayesian analyses using the closest possible substitution models and calibration settings. We found that RRF was computationally faster and generally provided node age estimates statistically equivalent to Bayesian divergence times. PL time estimates consistently exhibited low levels of uncertainty. Overall, to approximate Bayesian approaches, RelTime is an efficient method with significantly lower computational demand, being more than 100 times faster than treePL. Thus, to alleviate the computational burden of Bayesian divergence time inference in the era of massive genomic data, molecular dating can be facilitated using the RRF, allowing evolutionary hypotheses to be tested more quickly and efficiently.

A clinical predictive model of renal injury in children with isolated antenatal hydronephrosis.

BACKGROUND: Antenatal hydronephrosis (ANH) affects ∼1-5% of pregnancies. The aim of this study was to develop a clinical prediction model of renal injury in a large cohort of infants with isolated ANH. METHODS: This is a longitudinal cohort study of 447 infants with ANH admitted since birth between 1989 and 2015 at a tertiary care center. The primary endpoint was time until the occurrence of a composite event of renal injury, which includes proteinuria, hypertension and chronic kidney disease (CKD). A predictive model was developed using a Cox proportional hazards model and evaluated by C-statistics. RESULTS: Renal pelvic dilatation (RPD) was classified into two groups [Grades 1-2 (n = 255) versus Grades 3-4 (n = 192)]. The median follow-up time was 6.4 years (interquartile range 2.8-12.5). Thirteen patients (2.9%) developed proteinuria, 6 (1.3%) hypertension and 14 (3.1%) CKD Stage 2. All events occurred in patients with RPD Grades 3-4. After adjustment, three covariables remained as predictors of the composite event: creatinine {hazard ratio [HR] 1.27, [95% confidence interval (CI) 1.05-1.56]}, renal parenchyma thickness at birth [HR 0.78(95% CI 0.625-0.991)] and recurrent urinary tract infections [HR 4.52 (95% CI 1.49-13.6)]. The probability of renal injury at 15 years of age was estimated as 0, 15 and 24% for patients assigned to the low-risk, medium-risk and high-risk groups, respectively (P < 0.001). CONCLUSION: Our findings indicate an uneventful clinical course for patients with Society for Fetal Urology (SFU) Grades 1-2 ANH. Conversely, for infants with SFU Grades 3-4 ANH, our prediction model enabled the identification of a subgroup of patients with increased risk of renal injury over time.

The Quality of End-of-Life Care after Limitations of Medical Treatment as Defined by a Rapid Response Team: A Retrospective Cohort Study.

BACKGROUND: Despite the increase in the identification of patients at the end of life after the introduction of rapid response team (RRT), there is doubt as to whether there has been an improvement in the quality of care offered to these patients. Proper end-of-life care is the next expected step after identifying patients who are dying. OBJECTIVE: To evaluate the end-of-life care after limitations of medical treatment (LOMTs) as defined by an RRT. DESIGN: This is a single-center retrospective cohort study at a tertiary teaching hospital in Porto Alegre, Brazil, from July 2014 to July 2016. SETTING/SUBJECTS: We included 242 patients with an LOMT as defined by the RRT. MEASUREMENTS: Outcomes of interest included symptoms and palliative measures after RRT review. RESULTS: During the study period, there were 5396 calls to 2937 patients, representing 126 calls per 1000 hospital discharges. Of these calls, 4.9% (n = 242) resulted in an LOMT. The primary care team agreed with the LOMT decision proposed by the RRT in 91.7% of cases. Regarding end-of-life symptoms, 7.4% and 5.8% of patients presented with intense or moderate pain, respectively, and 62.4% of patients presented dyspnea in the last 48 hours of hospitalization. Less than 15% of patients received attention for their spiritual needs and/or received psychological support. CONCLUSIONS: Our data reinforce the important role of RRTs in the identification of end-of-life patients with clinical deterioration. Despite the increase in the identification of these patients, the quality of end-of-life care needs to be improved.

Diagnostic accuracy of renal pelvic dilatation for detecting surgically managed ureteropelvic junction obstruction.

PURPOSE: In this study we evaluate the diagnostic accuracy of renal pelvic dilatation for detecting infants with prenatal hydronephrosis who will need surgical intervention for ureteropelvic junction obstruction during followup. MATERIALS AND METHODS: Between 1999 and 2010, 371 newborns diagnosed with isolated prenatal hydronephrosis were prospectively followed. The main event of interest was the need for pyeloplasty. Diagnostic odds ratio, sensitivity, specificity and diagnostic accuracy (assessed by AUC) of fetal renal pelvic dilatation and postnatal renal pelvic dilatation were evaluated. RESULTS: A total of 312 patients were included in the analysis and 25 (7.5%) infants underwent pyeloplasty. The diagnostic performance for detecting the need for pyeloplasty was excellent for all ultrasonography measurements. The AUC was 0.96 (95% CI 0.92-0.98) for fetal renal pelvic dilatation, 0.97 (95% CI 0.95-0.98) for postnatal renal pelvic dilatation and 0.95 (95% CI 0.92-0.97) for the Society for Fetal Urology grading system. A cutoff of 18 mm for fetal renal pelvic dilatation and a cutoff of 16 mm for postnatal renal pelvic dilatation had the best diagnostic odds ratio to identify infants who needed pyeloplasty. Considering a diagnosis to be positive only if fetal renal pelvic dilatation was greater than 18 mm and postnatal dilatation was greater than 16 mm, sensitivity was 100% and specificity was 86% (95% CI 80.7-89.9). CONCLUSIONS: Our findings suggest that the combination of fetal and postnatal renal pelvic dilatation is able to increase the diagnostic accuracy for detecting infants who need a more comprehensive postnatal investigation for upper urinary tract obstruction.

Síndrome de Nutcracker: relato de caso / Nutcracker of syndrome: case report

JUSTIFICATIVA E OBJETIVOS: A síndrome do pinçamento aorto-mesentérico da veia renal esquerda - síndrome de Nutcracker - acarreta hipertensão venosa renal e consequentemente o aparecimento de sintomas como dor no baixo ventre, varicocele e hematúria. A dificuldade no diagnóstico nestes casos pode atrasar o tratamento, submeter o paciente a procedimentos desnecessários e resultar em complicações relacionadas à compressão venosa. O objetivo deste estudo foi relatar o caso de um paciente atendido no ambulatório de Nefrologia do Hospital de Clínicas de Porto Alegre. RELATO DO CASO: Paciente do sexo masculino, 22 anos, branco, com queixa de dor no baixo ventre, hematúria e obstrução urinária; com investigação básica etiológica inconclusiva. Investigações futuras, após aproximadamente dois anos de sintomas, revelaram a síndrome de Nutcracker. O manuseio terapêutico inclui tratamento conservador, cirurgia aberta, endovascular ou cauterização química. CONCLUSÃO: A síndrome de Nutcracker é rara, sendo que o conhecimento desta condição é fundamental para suspeita clínica acurada, diagnóstico precoce e manuseio terapêutico adequado.

BACKGROUND AND OBJECTIVES: Mesoaortic compression of the left renal vein, known as Nutcracker syndrome, causes renal venous hypertension and, consequently, the appearance of symptoms such as lower abdominal pain, varicocele and hematuria. The difficulty in the diagnosis may delay treatment, subject the patient to unnecessary procedures and complications of the venous compression. We report a case of a patient with hematuria treated at the Division of Nephrology in the Hospital de Clinicas de Porto Alegre - Universidade Federal do Rio Grande do Sul (Brazil). CASE REPORT: Male patient, 22 years of age, Caucasian, with complaints of pain in the lower abdominal, macroscopic hematuria and urinary obstruction, with basic investigation was inconclusive. Further investigation, after two years, revealed a nutcracker syndrome. Management can be conservative, open surgery, stent placement or intra-pelvic chemical cauterization. CONCLUSION: The Nutcracker syndrome is rare and the knowledge of this condition is the cornerstone to accurate diagnosis and proper management.