Assessment of fluid removal using ultrasound, bioimpedance and anthropometry in pediatric dialysis: a pilot study.

BACKGROUND: Fluid overload is associated with morbidity and mortality in children receiving dialysis. Accurate clinical assessment is difficult, and using deuterium oxide (D2O) to measure total body water (TBW) is impractical. We investigated the use of ultrasound (US), bioimpedance spectroscopy (BIS), and anthropometry to assess fluid removal in children receiving maintenance hemodialysis (HD). METHODS: Participants completed US, BIS, and anthropometry immediately before and 1-2 h after HD for up to five sessions. US measured inferior vena cava (IVC) diameter, lung B-lines, muscle elastography, and dermal thickness. BIS measured the volume of extracellular (ECF) and intracellular (ICF) fluid. Anthropometry included mid-upper arm, calf and ankle circumferences, and triceps skinfold thickness. D2O was performed once pre-HD. We assessed the change in study measures pre- versus post-HD, and the correlation of change in study measures with percent change in body weight (%∆BW). We also assessed the agreement between TBW measured by BIS and D2O. RESULTS: Eight participants aged 3.4-18.5 years were enrolled. Comparison of pre- and post-HD measures showed significant decrease in IVC diameters, lung B-lines, dermal thickness, BIS %ECF, mid-upper arm circumference, ankle, and calf circumference. Repeated measures correlation showed significant relationships between %∆BW and changes in BIS ECF (rrm =0.51, 95% CI 0.04, 0.80) and calf circumference (rrm=0.80, 95% CI 0.51, 0.92). BIS TBW correlated with D2O TBW but overestimated TBW by 2.2 L (95% LOA, -4.75 to 0.42). CONCLUSION: BIS and calf circumference may be helpful to assess changes in fluid status in children receiving maintenance HD. IVC diameter, lung B-lines and dermal thickness are potential candidates for future studies.

Evaluation of galectin-3 and intestinal fatty acid binding protein as serum biomarkers in autosomal recessive polycystic kidney disease.

BACKGROUND: Autosomal recessive polycystic kidney disease (ARPKD) causes fibrocystic kidney disease, congenital hepatic fibrosis, and portal hypertension. Serum galectin-3 (Gal-3) and intestinal fatty acid binding protein (I-FABP) are potential biomarkers of kidney fibrosis and portal hypertension, respectively. We examined whether serum Gal-3 associates with kidney disease severity and serum I-FABP associates with liver disease severity in ARPKD. METHODS: Cross-sectional study of 29 participants with ARPKD (0.2-21 years old) and presence of native kidneys (Gal-3 analyses, n = 18) and/or native livers (I-FABP analyses, n = 21). Serum Gal-3 and I-FABP were analyzed using enzyme linked immunosorbent assay. Kidney disease severity variables included estimated glomerular filtration rate (eGFR) and height-adjusted total kidney volume (htTKV). Liver disease severity was characterized using ultrasound elastography to measure liver fibrosis, and spleen length and platelet count as markers of portal hypertension. Simple and multivariable linear regression examined associations between Gal-3 and kidney disease severity (adjusted for liver disease severity) and between I-FABP and liver disease severity (adjusted for eGFR). RESULTS: Serum Gal-3 was negatively associated with eGFR; 1 standard deviation (SD) lower eGFR was associated with 0.795 SD higher Gal-3 level (95% CI - 1.116, - 0.473; p < 0.001). This association remained significant when adjusted for liver disease severity. Serum Gal-3 was not associated with htTKV in adjusted analyses. Overall I-FABP levels were elevated, but there were no linear associations between I-FABP and liver disease severity in unadjusted or adjusted models. CONCLUSIONS: Serum Gal-3 is associated with eGFR in ARPKD, suggesting its value as a possible novel biomarker of kidney disease severity. We found no associations between serum I-FABP and ARPKD liver disease severity despite overall elevated I-FABP levels.

Two-dimensional (2D) morphologic measurements can quantify the severity of liver disease in children with autosomal recessive polycystic kidney disease (ARPKD).

PURPOSE: To evaluate the correlation of 2D shape-based features with magnetic resonance elastography (MRE)-derived liver stiffness and portal hypertension (pHTN) in children with ARPKD-associated congenital hepatic fibrosis. METHODS: In a prospective IRB-approved study, 14 children with ARPKD (mean age ± SD = 13.8 ± 5.8 years) and 14 healthy controls (mean age ± SD = 13.7 ± 3.9 years) underwent liver MRE. A 2D region of interest (ROI) outlining the left liver lobe at the level of the abdominal aorta was drawn on sagittal T2-weighted images. Eight shape features (perimeter, major axis length, maximum diameter, perimeter to surface ratio (PSR), elongation, sphericity, minor axis length, and mesh surface) describing the 2D-ROI were calculated. Spearman's correlation was calculated between shape features and MRE-derived liver stiffness (kPa) (n = 28). Shape features were compared between participants with ARPKD with pHTN (splenomegaly and thrombocytopenia), (n = 4) and without pHTN (n = 8) using the Mann Whitney U test. Receiver operating characteristic (ROC) curves were generated to examine the diagnostic accuracy of shape features in identifying cases with liver stiffness > 2.9 kPa. RESULTS: In ARPKD participants and healthy controls, all eight shape features, except elongation, showed moderate to strong correlation with liver stiffness (kPa); the perimeter surface ratio had the strongest correlation (rho = - 0.75, p < 0.001). In ROC analysis, a cut-off of PSR ≤ 0.057 mm-1 gave 100% (95% CI: 59.0-100.0) sensitivity and 100% (95% CI: 83.9-100.0) specificity in identifying ARPKD participants with liver stiffness > 2.9 kPa, with an area under the ROC curve (AUC) of 1.0 (95% CI: 0.88-1.00). Individuals with pHTN had a lower median PSR (mean ± SD = 0.05 ± 0.01) than those without (0.07 ± 0.01; p = 0.027) with an AUC of 0.91 (95% CI: 0.60-0.99) in differentiating the participants with and without pHTN. CONCLUSION: Shape-based features of the left liver lobe show potential as non-invasive biomarkers of liver fibrosis and portal hypertension in children with ARPKD.

Magnetic resonance elastography to quantify liver disease severity in autosomal recessive polycystic kidney disease.

OBJECTIVES: To evaluate whether liver and spleen magnetic resonance elastography (MRE) can measure the severity of congenital hepatic fibrosis (CHF) and portal hypertension (pHTN) in individuals with autosomal recessive polycystic kidney disease (ARPKD), and to examine correlations between liver MRE and ultrasound (US) elastography. METHODS: Cross-sectional study of nine individuals with ARPKD and 14 healthy controls. MRE was performed to measure mean liver and spleen stiffness (kPa); US elastography was performed to measure point shear wave speed (SWS) in both liver lobes. We compared: (1) MRE liver and spleen stiffness between controls vs. ARPKD; and (2) MRE liver stiffness between participants with ARPKD without vs. with pHTN, and examined correlations between MRE liver stiffness, spleen length, platelet counts, and US elastography SWS. Receiver operating characteristic (ROC) analysis was performed to examine diagnostic accuracy of liver MRE. RESULTS: Participants with ARPKD (median age 16.8 [IQR 13.3, 18.9] years) had higher median MRE liver stiffness than controls (median age 14.7 [IQR 9.7, 16.7 years) (2.55 vs. 1.92 kPa, p = 0.008), but MRE spleen stiffness did not differ. ARPKD participants with pHTN had higher median MRE liver stiffness than those without (3.60 kPa vs 2.49 kPa, p = 0.05). Liver MRE and US elastography measurements were strongly correlated. To distinguish ARPKD vs. control groups, liver MRE had 78% sensitivity and 93% specificity at a proposed cut-off of 2.48 kPa [ROC area 0.83 (95% CI 0.63-1.00)]. CONCLUSION: Liver MRE may be a useful quantitative method to measure the severity of CHF and pHTN in individuals with ARPKD.

A usability assessment of riding lawn-mowing equipment with varying levels of design standards compliance.

The use of riding lawn equipment (RLE) is related to a significant number of accidents every year. To provide basis for product design and enhance user performance and safety, a usability and performance assessment of modern riding lawn-mowing tractor designs and features was conducted in a real-world test environment. Five current commercially available RLEs were tested with response measures including task performance time and accuracy, physiological workload, system usability scores (SUS), and subjective rankings of RLE models. This data was used to identify sensitivity of responses to variations in RLE design features and functionality. The data was also used to assess the validity of new tractor design standard conformance tool, the RLEval methodology. This tool made comprehensive evaluation of RLE models compliance with over 70 specific design standards and was applied by human factors experts. Experiment results revealed sensitivity of all response measures to design differences among the five RLE models, except the objective workload measures. Response measures including task performance, SUSs and subjective rankings showed partial agreement with the RLEval scores. In general, the study results demonstrated a comprehensive experimental methodology for usability and performance evaluations of RLEs as well as merit of using the RLEval as preliminary method to compare design features. Some aspects of the usability experimentation and the RLEval method appear to be complementary.

A biomechanical and subjective comparison of two powered ambulance cots.

This study investigated biomechanical effects of different leg folding/unfolding mechanisms used for loading/unloading two powered cots (Cots A and B) into and from a simulated ambulance. Sixteen experienced emergency medical service (EMS) workers loaded and unloaded cots with weights of 45, 68 and 91 kg placed on the cots to simulate patients. Peak back and shoulder/arm muscle activity was reduced 52-87% when using Cot A in comparison to Cot B. Peak ground reaction force (PGRF) was reduced by 74% with Cot A. Adding weight resulted in increased muscle activity and PGRF when using Cot B, but had little effect when using Cot A. Task time was longer with Cot A, though was not perceived unfavourably by participants. This study confirmed that it is possible to substantially reduce physical stress imposed on EMS workers when loading and unloading a cot to and from an ambulance through improvements in cot design. PRACTITIONER SUMMARY: This study compared two powered ambulance cots, one that lifts/lowers the front and rear wheels independently and one that lifts/lowers the four wheels simultaneously during ambulance loading and unloading. Measured muscle activity, ground reaction forces and operator perceptions support using cot designs that lift/lower the front and rear wheels independently.

A biomechanical and subjective assessment and comparison of three ambulance cot design configurations.

Effects of ambulance cot design features (handle design and leg folding mechanism) were evaluated. Experienced ambulance workers performed tasks simulating loading and unloading a cot to and from an ambulance, and a cot raising task. Muscle activity, ratings of perceived exertion, and performance style were significantly affected by cot condition (p < 0.05). Erector Spinae activity was significantly less when using Cot-2's stretcher-style handles. Shoulder muscle activity was significantly less when using Cot-2's loop handle. During loading and unloading, operators allowed the cot to support its own weight most often with Cot-2's stretcher-style handles. Preference for Cot-2 (either handles) over Cot-1 (with loop handle) was consistent across tasks. Handle effects were influenced by operator stature; taller participants received more benefit from Cot-2's stretcher-style handles; shoulder muscles' demands were greater for shorter participants due to handle location. Providing handle options and automatic leg folding/unfolding operation can reduce cot operator's effort and physical strain. Practitioner Summary: Paramedics frequently incur musculoskeletal injuries associated with patient-handling tasks. A controlled experiment was conducted to assess effects of ambulance cot design features on physical stress of operators, as seen through muscle activity and operator's perceptions. Differences between cots were found, signalling that intentional design can reduce operator's physical stress.

Association between spinal loads and the psychophysical determination of maximum acceptable force during pushing tasks.

The objective of this study was to investigate potential associations between an individual's psychophysical maximum acceptable force (MAF) during pushing tasks and biomechanical tissue loads within the lumbar spine. Ten subjects (eight males, two females) pushed a cart with an unknown weight at one push every two minute for a distance of 3.9 m. Two independent variables were investigated, cart control and handle orientation while evaluating their association with the MAF. Dependent variables of hand force and tissue loads for each MAF determination and preceding push trial were assessed using a validated, electromyography-assisted biomechanical model that calculated spinal load distribution throughout the lumbar spine. Results showed no association between spinal loads and the MAF. Only hand forces were associated with the MAF. Therefore, MAFs may be dependent upon tactile sensations from the hands, not the loads on the spine and thus may be unrelated to risk of low back injury. Practitioner Summary: Pushing tasks have become common in manual materials handling (MMH) and these tasks impose different tissue loads compared to lifting tasks. Industry has commonly used the psychophysical tables for job assent and decision of MMH tasks. However, due to the biomechanical complexity of pushing tasks, psychophysics may be misinterpreting risk.