European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates.

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.

Preparing European Nephrology for the next pandemic: lessons from the ERACODA collaboration.

Owing to the vulnerability of patients with chronic kidney disease to infectious diseases, the coronavirus disease 2019 (COVID-19) pandemic has been particularly devastating for the nephrology community. Unfortunately, the possibility of future COVID-19 waves or outbreaks of other infectious diseases with pandemic potential cannot be ruled out. The nephrology community made tremendous efforts to contain the consequences of the COVID-19 pandemic. Despite this, the COVID-19 pandemic has highlighted several shortcomings in our response to the pandemic and has taught us important lessons that can be utilized to improve our preparedness for any future health crises of a similar nature. In this article we draw lessons from the European Renal Association COVID-19 Database (ERACODA) project, a pan-European collaboration initiated in March 2020 to understand the prognosis of COVID-19 in patients on kidney function replacement therapy. We discuss the challenges faced in generating timely and robust evidence for informed management of patients with kidney disease and give recommendations for our preparedness for the next pandemic in Europe. Limited collaboration, the absence of common data architecture and the sub-optimal quality of available data posed challenges in our response to COVID-19. Aligning different research initiatives, strengthening electronic health records, and involving experts in study design and data analysis will be important in our response to the next pandemic. The European Renal Association may take a leading role in aligning research initiatives via its engagement with other scientific societies, national registries, administrators and researchers.

The Operation Rainbow Canada Technique for Unilateral Cleft Lip Revision.

BACKGROUND: Purpose of this article is to demonstrate the "Operation Rainbow Canada" cleft lip revision technique. This is a surgical technique used by Operation Rainbow Canada on volunteer surgical missions in developing nations. We show how to convert previous Millard or straight line cleft lip repairs to a Fisher anatomic subunit repair, placing a favourable scar along the philtrum. We show a case series of results and explain how this technique gives satisfying aesthetic results for patients seeking unilateral cleft lip revision. METHODS: This technique combines the principles of the anatomic subunit repair for primary cleft lip repair as described by Fisher and the correction of the cleft nose deformity as described by McComb. We apply these 2 techniques to unilateral cleft lip revision at the same operation. RESULTS: Patients for revision unilateral lip and nose deformities were treated with this technique over the course of several international surgical missions. There were over 90 cases of revisions performed by our group on previous repaired cleft lips. These procedures were done in India, China, and Cambodia. CONCLUSION: Previously repaired cleft lips can be improved by our revision procedure. We show how incorporating 2 triangular flaps to lengthen the cleft side of the repaired lip can be done in a revision setting. During lip revision, McCombs sutures can be placed to improve the aesthetic of the nose and correct the nasal alar dome.

HISTORIQUE: Le présent article vise à enseigner la technique de correction de la fente labiale d'Operation Rainbow Canada. L'organisme utilise cette technique lors des missions chirurgicales de volontaires dans les pays en développement. Les chercheurs démontrent comment convertir la technique de Millard et la technique en ligne droite en une réparation sous-unitaire anatomique de Fisher, pour former une cicatrice favorable le long du sillon sous-nasal. Ils présentent les observations d'une série de cas et expliquent que cette technique donne des résultats esthétiques pour les patients qui veulent faire corriger une fente palatine unilatérale. MÉTHODOLOGIE: La présente technique combine les principes des sous-unités anatomiques pour réparer les fentes palatines primaires décrites par Fisher et la correction de la fente palatine décrite par McComb. Les chercheurs appliquent ces deux techniques à la correction d'une fente labiale unilatérale lors de la même opération. RÉSULTATS: La technique a été utilisée auprès de patients qui devaient faire corriger une fente labiale et palatine unilatérale dans le cadre de plusieurs missions chirurgicales internationales. Le groupe a effectué plus de 90 corrections de fentes palatines déjà réparées en Inde, en Chine et au Cambodge. CONCLUSION: Les fentes labiales déjà réparées peuvent être améliorées grâce à une intervention de correction. Les auteurs démontrent comment intégrer deux lambeaux triangulaires pour allonger le côté réparé de la lèvre. Pendant cette correction de la lèvre, on peut utiliser des sutures de McCombs pour améliorer l'esthétique du nez et corriger les dômes des cartilages alaires nasaux.

Organ transplants of the future: planning for innovations including xenotransplantation.

The future clinical application of animal-to-human transplantation (xenotransplantation) is of importance to society as a whole. Favourable preclinical data relevant to cell, tissue and solid organ xenotransplants have been obtained from many animal models utilizing genetic engineering and protocols of pathogen-free husbandry. Findings have reached a tipping point, and xenotransplantation of solid organs is approaching clinical evaluation, the process of which now requires close deliberation. Such discussions include considering when there is sufficient evidence from preclinical animal studies to start first-in-human xenotransplantation trials. The present article is based on evidence and opinions formulated by members of the European Society for Organ Transplantation who are involved in the Transplantation Learning Journey project. The article includes a brief overview of preclinical concepts and biology of solid organ xenotransplantation, discusses the selection of candidates for first-in-human studies and considers requirements for study design and conduct. In addition, the paper emphasizes the need for a regulatory framework for xenotransplantation of solid organs and the essential requirement for input from public and patient stakeholders.

Temporal response of an injectable calcium phosphate material in a critical size defect.

BACKGROUND: Calcium phosphate-based bone graft substitutes are used to facilitate healing in bony defects caused by trauma or created during surgery. Here, we present an injectable calcium phosphate-based bone void filler that has been purposefully formulated with hyaluronic acid to offer a longer working time for ease of injection into bony defects that are difficult to access during minimally invasive surgery. METHODS: The bone substitute material deliverability and physical properties were characterized, and in vivo response was evaluated in a critical size distal femur defect in skeletally mature rabbits to 26 weeks. The interface with the host bone, implant degradation, and resorption were assessed with time. RESULTS: The calcium phosphate bone substitute material could be injected as a paste within the working time window of 7-18 min, and then self-cured at body temperature within 10 min. The material reached a maximum ultimate compressive strength of 8.20 ± 0.95 MPa, similar to trabecular bone. The material was found to be biocompatible and osteoconductive in vivo out to 26 weeks, with new bone formation and normal bone architecture observed at 6 weeks, as demonstrated by histological evaluation, microcomputed tomography, and radiographic evaluation. CONCLUSIONS: These findings show that the material properties and performance are well suited for minimally invasive percutaneous delivery applications.

WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management.

BACKGROUND: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Renin-Angiotensin System Blockers and the Risk of COVID-19-Related Mortality in Patients with Kidney Failure.

BACKGROUND AND OBJECTIVES: There is concern about potential deleterious effects of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) in patients with coronavirus disease 2019 (COVID-19). Patients with kidney failure, who often use ACEis/ARBs, are at higher risk of more severe COVID-19. However, there are no data available on the association of ACEi/ARB use with COVID-19 severity in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: From the European Renal Association COVID-19 database (ERACODA), we retrieved data on kidney transplant recipients and patients on dialysis who were affected by COVID-19, between February 1 and October 1, 2020, and had information on 28-day mortality. We used Cox proportional-hazards regression to calculate hazard ratios for the association between ACEi/ARB use and 28-day mortality risk. Additionally, we studied the association of discontinuation of these agents with 28-day mortality. RESULTS: We evaluated 1511 patients: 459 kidney transplant recipients and 1052 patients on dialysis. At diagnosis of COVID-19, 189 (41%) of the transplant recipients and 288 (27%) of the patients on dialysis were on ACEis/ARBs. A total of 88 (19%) transplant recipients and 244 (23%) patients on dialysis died within 28 days of initial presentation. In both groups of patients, there was no association between ACEi/ARB use and 28-day mortality in both crude and adjusted models (in transplant recipients, adjusted hazard ratio, 1.12; 95% confidence interval [95% CI], 0.69 to 1.83; in patients on dialysis, adjusted hazard ratio, 1.04; 95% CI, 0.73 to 1.47). Among transplant recipients, ACEi/ARB discontinuation was associated with a higher mortality risk after adjustment for demographics and comorbidities, but the association was no longer statistically significant after adjustment for severity of COVID-19 (adjusted hazard ratio, 1.36; 95% CI, 0.40 to 4.58). Among patients on dialysis, ACEi/ARB discontinuation was not associated with mortality in any model. We obtained similar results across subgroups when ACEis and ARBs were studied separately, and when other outcomes for severity of COVID-19 were studied, e.g., hospital admission, admission to the intensive care unit, or need for ventilator support. CONCLUSIONS: Among kidney transplant recipients and patients on dialysis with COVID-19, there was no significant association of ACEi/ARB use or discontinuation with mortality.

Augmentation Mastopexy with Surgical Excision of the Lower Pole to Avoid Waterfall Deformity: A Surgical Technique and Nipple Areolar Complex Case Series.

Purpose of this article is to demonstrate a way of avoiding the waterfall deformity in augmentation mastopexy patients. We will show a case series of results and explain how this technique gives satisfying aesthetic results for patients seeking breast augmentation who also require mastopexy. We will show how addressing the breast parenchyma on the lower pole via direct excision can give reliable results and avoids the waterfall deformity. The surgical technique used by the senior author combines the principles of breast augmentation, mastopexy, and breast reduction. We apply these principles during the initial single operation. Our goal is to achieve the best anatomical results for the patient. We describe 1538 consecutive patients whom underwent single-stage breast augmentation with mastopexy. All implants were submuscular with 12% being saline and 88% were silicone implants. Vertical mastopexies were performed in 8% and wise pattern incisions were used in 92%. There were no life-threatening complications such as deep vein thrombosis, pulmonary embolism, and so on. Tissue-related complications included wound infection (1%) and hematomas (1%). Implant-related complications included malposition or implant displacement 9% and capsular contracture 1%. Aesthetic complications included dystopia of NAC (4%) and volume asymmetries (10%). Revision surgery was tissue related (2%), implant related (3%), and aesthetic related (10%). There were no cases of waterfall deformity seen in the cohort. In conclusion, we believe that the technique detailed here is easy to do, uses principles already known of breast augmentation and reduction and gives consistent results with low reoperation rates.

Le présent article vise à établir un moyen d'éviter les malformations en cascades chez les patientes ayant subi une mastopexie d'augmentation. Les auteurs présentent une série de cas et expliquent en quoi leur technique donne des résultats esthétiques satisfaisants pour les patientes qui veulent une augmentation mammaire et ont également besoin d'une mastopexie. Ils démontrent en quoi le traitement d'un parenchyme mammaire du pôle inférieur par excision directe peut donner des résultats fiables et éviter une malformation en cascades. La technique chirurgicale utilisée par l'auteur principal combine les principes d'augmentation mammaire, de mastopexie et de réduction mammaire. Les auteurs appliquent ces principes pendant l'opération initiale unique. Ils avaient l'objectif de réaliser les meilleurs résultats anatomiques pour les patients. Les auteurs ont décrit 1 538 patients consécutifs qui avaient subi une augmentation mammaire en une étape accompagnée d'une mastopexie. Tous les implants étaient sous-musculaires, 12 % étaient remplis de solution saline et 88 % étaient en silicone. Des mastopexies verticales ont été effectuées dans 8 % des cas, et des incisions en motifs prudents, dans 92 % des cas. Il n'y a pas eu de complications au potentiel mortel comme des thromboses veineuses profondes, des embolies pulmonaires, etc. Les complications tissulaires incluaient les infections des plaies (1 %) et les hématomes (1 %). Les complications liées aux implants incluaient une malposition ou un déplacement des implants dans 9 % des cas, et une contracture capsulaire dans 1% des cas. Les complications esthétiques incluaient la dystopie N-acétylcystéine (4 %) et l'asymétrie des volumes (10 %). Les opérations de révision étaient liées aux tissus (2 %), aux implants (3 %) et aux anesthésiques (10 %). Il n'y a pas eu de malformation en cascades dans la cohorte. Pour terminer, les auteurs sont d'avis que la technique est facile à effectuer, fait appel à des principes d'augmentation et de réduction mammaires déjà connus et donne des résultats uniformes liés à un faible taux de réopération.

A comprehensive evaluation of monochloramine disinfection on water quality, Legionella and other important microorganisms in a hospital.

Opportunistic pathogens such as Legionella are of significant public health concern in hospitals. Microbiological and water chemistry parameters in hot water throughout an Ohio hospital were monitored monthly before and after the installation of a monochloramine disinfection system over 16 months. Water samples from fifteen hot water sampling sites as well as the municipal water supply entering the hospital were analyzed using both culture and qPCR assays for specific microbial pathogens including Legionella, Pseudomonas spp., nontuberculous Mycobacteria [NTM], as well as for heterotrophic bacteria. Legionella culture assays decreased from 68% of all sites being positive prior to monochloramine addition to 6% positive after monochloramine addition, and these trends were parallel to qPCR results. Considering all samples, NTMs by culture were significantly reduced from 61% to 14% positivity (p<0.001) after monochloramine treatment. Mycobacterium genus-specific qPCR positivity was reduced from 92% to 65%, but the change was not significant. Heterotrophic bacteria (heterotrophic bacteria plate counts [HPCs]) exhibited large variability which skewed statistical results on a per room basis. However, when all samples were considered, a significant decrease in HPCs was observed after monochloramine addition. Lastly, Pseudomonas aeruginosa and Vermamoeba vermiformis demonstrated large and significant decrease of qPCR signals post-chloramination. General water chemistry parameters including monochloramine residual, nitrate, nitrite, pH, temperature, metals and total trihalomethanes (TTHMs) were also measured. Significant monochloramine residuals were consistently observed at all sampling sites with very little free ammonia present and no water quality indications of nitrification (e.g., pH decrease, elevated nitrite or nitrate). The addition of monochloramine had no obvious impact on metals (lead, copper and iron) and disinfection by-products.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

Estimating Time to ESRD in Children With CKD.

RATIONALE & OBJECTIVE: The KDIGO (Kidney Disease: Improving Global Outcomes) guideline for chronic kidney disease (CKD) presented an international classification system that ranks patients' risk for CKD progression. Few data for children informed guideline development. STUDY DESIGN: Observational cohort study. SETTINGS & PARTICIPANTS: Children aged 1 to 18 years enrolled in the North American Chronic Kidney Disease in Children (CKiD) cohort study and the European Effect of Strict Blood Pressure Control and ACE Inhibition on the Progression of CRF in Pediatric Patients (ESCAPE) trial. PREDICTOR: Level of estimated glomerular filtration rate (eGFR) and proteinuria (urine protein-creatinine ratio [UPCR]) at study entry. OUTCOME: A composite event of renal replacement therapy, 50% reduction in eGFR, or eGFR<15mL/min/1.73m2. eGFR was estimated using the CKiD-derived "bedside" equation. ANALYTICAL APPROACH: Accelerated failure time models of the composite outcome using a conventional generalized gamma distribution. Likelihood ratio statistics of nested models were used to amalgamate levels of similar risk. RESULTS: Among 1,232 children, median age was 12 (IQR, 8-15) years, median eGFR was 47 (IQR, 33-62) mL/min/1.73m2, 60% were males, and 13% had UPCRs>2.0mg/mg at study entry. 6 ordered stages with varying combinations of eGFR categories (60-89, 45-59, 30-44, and 15-29mL/min/1.73m2) and UPCR categories (<0.5, 0.5-2.0, and >2.0mg/mg) described the risk continuum. Median times to event ranged from longer than 10 years for eGFRs of 45 to 90mL/min/1.73m2 and UPCRs<0.5mg/mg to 0.8 years for eGFRs of 15 to 30mL/min/1.73m2 and UPCRs>2mg/mg. Children with glomerular disease were estimated to have a 43% shorter time to event than children with nonglomerular disease. Cross-validation demonstrated risk patterns that were consistent across the 10 subsample validation models. LIMITATIONS: Observational study, used cross-validation rather than external validation. CONCLUSIONS: CKD staged by level of eGFR and proteinuria characterizes the timeline of progression and can guide management strategies in children.

The Keystone Flap-A Case Series Demonstrating Practical Design, Use, and Applications.

INTRODUCTION: The keystone design perforator island flap is a trapezoidal-shaped random perforator island flap with many advantages over primary closure, skin grafting, and other local flaps for soft tissue reconstruction commonly encountered with cancer excisions. METHODS: This case series of 39 keystone flaps in 37 patients reviews the practical design, use, and applications of the flap while highlighting certain important considerations. Keystone flaps were designed as in the original description, with a minor modification in the lower extremity where a higher flap to defect width ratio was used. RESULTS: Defects varying in size from 6 to 63 cm2 were reconstructed in 23 males and 14 females ranging in age from 49 to 89. In all 39 cases, there were 2 minor complications of partial flap dehiscence and no major complications such as partial or complete flap loss. CONCLUSION: The keystone flap is a versatile and reliable flap with applications almost anywhere on the body. A higher ratio of flap width to defect width up to 1:3 is more appropriate for the lower extremity where tension is higher.

INTRODUCTION: Le lambeau en clef de voûte perforateur en îlot est un lambeau perforateur trapézoïdal aléatoire qui comporte de nombreux avantages par rapport à la fermeture primaire, à la greffe cutanée et à d'autres lambeaux locaux pour la reconstruction des tissus mous souvent nécessaire après des excisions attribuables au cancer. MÉTHODOLOGIE: Cette série de 39 lambeaux en clef de voûte chez 37 patients vise à analyser la conception, l'utilisation et les applications pratiques du lambeau tout en explorant certains aspects importants. Les lambeaux en clef de voûte ont été conçus comme dans la description originale, à part une légère modification dans les membres inférieurs, où les plasticiens ont privilégié un ratio plus élevé entre la largeur du lambeau et la largeur de l'anomalie. RÉSULTATS: Les plasticiens ont reconstruit des anomalies de 6 cm2 à 63 cm2 chez 23 hommes et 14 femmes de 49 à 89 ans. Dans ces 39 cas, ils ont observé deux complications mineures de déhiscence partielle du lambeau et aucune complication majeure, telle que la perte partielle ou totale du lambeau. CONCLUSIONS: Le lambeau en clef de voûte, polyvalent et fiable, peut être utilisé pratiquement partout sur le corps. Un ratio plus élevé pouvant atteindre 1:3 entre la largeur du lambeau et la largeur de l'anomalie convient mieux aux membres inférieurs, où la tension est plus importante.

Aggressive Combined Medical and Surgical Management of Mucormycosis Results in Disease Eradication in 2 Pediatric Patients.

Rhinocerebral mucormycosis is an acute, rapidly fatal, fungal infection, classically involving the nasal mucosa and paranasal sinuses. It is an aggressive, opportunistic infection that frequently progresses to involve the orbit and cerebrum. Cerebral extension in immunocompromised patients is almost universally fatal. There are limited data on mucormycosis in pediatric immunocompromised patients in the literature, with only few reports on rhinocerebral involvement. The immunocompromised patients described in this report presented with suspected periorbital and nasal cellulitis, progressing rapidly to necrotic changes in nasal tissue and oral palatal mucosa. In these patients, the surgical resection of mucormycosis-infected tissue followed by flap reconstruction combined with medical treatment effectively treated the infection, allowed for the rapid resumption of chemotherapy and dramatically improved the quality of life for both the patient and their family.

La mucormycose rhinocérébrale est une infection fongique aiguë qui devient vite fatale et qui touche généralement les muqueuses nasales et les sinus paranasaux. C'est une infection agressive et opportuniste qui évolue souvent pour toucher l'orbite et le cerveau. Chez les patients immunodéprimés, l'atteinte cérébrale est presque toujours fatale. Les données sur la mucormycose chez les patients immunodéprimés d'âge pédiatrique sont limitées dans les publications, et seulement quelques articles traitent de l'atteinte rhinocérébrale. Les patients immunodéprimés décrits dans le présent rapport ont consulté à cause d'une présomption de cellulite périorbitale et nasale qui a évolué rapidement vers une nécrose des tissus nasaux et de la muqueuse oropalatine. Chez ces patients, la résection chirurgicale des tissus infectés par la mucormycose suivie d'une reconstruction par lambeau combinée à un traitement médical, a favorisé la résolution de l'infection, ce qui a permis une reprise rapide de la chimiothérapie et a considérablement amélioré la qualité de vie du patient et de sa famille.

Peritoneal Dialysis Access Revision in Children: Causes, Interventions, and Outcomes.

BACKGROUND AND OBJECTIVES: Little published information is available about access failure in children undergoing chronic peritoneal dialysis. Our objectives were to evaluate frequency, risk factors, interventions, and outcome of peritoneal dialysis access revision. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were derived from 824 incident and 1629 prevalent patients from 105 pediatric nephrology centers enrolled in the International Pediatric Peritoneal Dialysis Network Registry between 2007 and 2015. RESULTS: In total, 452 access revisions were recorded in 321 (13%) of 2453 patients over 3134 patient-years of follow-up, resulting in an overall access revision rate of 0.14 per treatment year. Among 824 incident patients, 186 (22.6%) underwent 188 access revisions over 1066 patient-years, yielding an access revision rate of 0.17 per treatment year; 83% of access revisions in incident patients were reported within the first year of peritoneal dialysis treatment. Catheter survival rates in incident patients were 84%, 80%, 77%, and 73% at 12, 24, 36, and 48 months, respectively. By multivariate logistic regression analysis, risk of access revision was associated with younger age (odds ratio, 0.93; 95% confidence interval, 0.92 to 0.95; P<0.001), diagnosis of congenital anomalies of the kidney and urinary tract (odds ratio, 1.28; 95% confidence interval, 1.03 to 1.59; P=0.02), coexisting ostomies (odds ratio, 1.42; 95% confidence interval, 1.07 to 1.87; P=0.01), presence of swan neck tunnel with curled intraperitoneal portion (odds ratio, 1.30; 95% confidence interval, 1.04 to 1.63; P=0.02), and high gross national income (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; P=0.01). Main reasons for access revisions included mechanical malfunction (60%), peritonitis (16%), exit site infection (12%), and leakage (6%). Need for access revision increased the risk of peritoneal dialysis technique failure or death (hazard ratio, 1.35; 95% confidence interval, 1.10 to 1.65; P=0.003). Access dysfunction due to mechanical causes doubled the risk of technique failure compared with infectious causes (hazard ratio, 1.95; 95% confidence interval, 1.20 to 2.30; P=0.03). CONCLUSIONS: Peritoneal dialysis catheter revisions are common in pediatric patients on peritoneal dialysis and complicate provision of chronic peritoneal dialysis. Attention to potentially modifiable risk factors by pediatric nephrologists and pediatric surgeons should be encouraged.

Reverse Radial Artery Flap Perforator Anatomy and Clinical Applications.

The pedicled reverse radial forearm flap is a well-known option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and comprehensively document the anatomy of the radial artery perforators. This data provide an anatomic basis for a modification to the reversed radial forearm flap used to decrease venous congestion in the postoperative period. Two case reports are presented to provide clinical demonstration of the importance of this modification.

Peritoneal-pericardial communication in an adolescent on peritoneal dialysis.

BACKGROUND: Dialysate leakage into the pericardium is a rare but potentially life-threatening complication of peritoneal dialysis (PD). There has been one reported pediatric case of spontaneous peritoneo-pericardial fistula in a 2-year-old boy with tissue fragility due to malnutrition and two reported adult cases in PD patients with a history of previous cardiac surgery and/or pericardiocentesis. CASE-DIAGNOSIS/TREATMENT: We describe a 15-year-old girl with end-stage renal disease secondary to granulomatosis with polyangiitis, with recurrent pericardial effusions secondary to a peritoneo-pericardial fistula while on continuous cycling peritoneal dialysis (CCPD). She had previously presented with chylous pericardial effusion that required pericardiocentesis and subsequently developed recurrent pericardial effusions when she was commenced on CCPD 9 months later. Pericardial fluid chemistry revealed a sterile, serous fluid containing 15.1 mmol/L of glucose and <0.11 mmol/L of triglycerides. Peritoneal scintigraphy with Tc-99m labeled sulfur colloid injected intra-peritoneally confirmed the presence of a peritoneo-pericardial fistula. The pericardial effusions resolved upon switching the patient to hemodialysis (HD). CONCLUSIONS: Our case of recurrent pericardial effusions in a child on PD secondary to a peritoneo-pericardial fistula highlights the need for close follow-up in patients with a history of previous pericardiocentesis who are commenced on PD.

Low contribution of PbO2-coated lead service lines to water lead contamination at the tap.

To determine if residential water sampling corroborates the expectation that formation of stable PbO2 coatings on lead service lines (LSLs) provides an effective lead release control strategy, lead profile sampling was evaluated for eight home kitchen taps in three U.S. cities with observed PbO2-coated LSLs (Newport, Rhode Island; Cincinnati and Oakwood, Ohio). After various water standing times, these LSLs typically released similar or lower peak lead levels (1 to 18 µg/L) than the lead levels from the respective kitchen faucets (1 to 130 µg/L), and frequently 50-80% lower than the lead levels typically reported from Pb(II)-coated LSLs in comparable published sampling studies. Prolonged stagnation (10-101 h) at the Cincinnati sites produced varying results. One site showed minimal (0-4 µg/L) increase in lead release from the PbO2-coated LSL, and persistence of free chlorine residual. However, the other site showed up to a 3-fold increase proportional to standing time, with essentially full depletion of the chlorine residual. Overall, lead release was consistently much lower than that reported in studies of Pb(II)-coated LSL scales, suggesting that natural formation of PbO2 in LSLs is an effective lead "corrosion" control strategy.

Hepcidin and risk of anemia in CKD: a cross-sectional and longitudinal analysis in the CKiD cohort.

BACKGROUND: Hepcidin, a key iron regulatory protein, is elevated in patients with chronic kidney disease (CKD). Its role in the development and progression of the anemia of CKD in children remains poorly defined. METHODS: Cross-sectional and longitudinal study in children aged 1-16 years with stage 2-4 CKD in the Chronic Kidney Disease in Children (CKiD) cohort (n = 133) with hepcidin measured at baseline and hemoglobin (HGB) measured annually at follow-up. Anemia was defined as HGB <5th percentile for age/sex OR treatment with an erythropoiesis-stimulating agent (ESA). RESULTS: Hepcidin levels correlated negatively with glomerular filtration rate (GFR; r = -0.22, p = 0.01) and positively with ferritin (r = 0.67, p < 0.001). At the lower end of the GFR spectrum at baseline (10th percentile, 27.5 mL/min/1.73 m(2)), higher hepcidin was associated with a 0.87 g/dL decrease in HGB during follow-up (95 % CI -1.69, -0.05 g/dL, p = 0.038). At higher GFR percentiles there was no significant association between baseline hepcidin and HGB during follow-up. Among 90 non-anemic subjects at baseline, 23.3 % developed incident anemia. In subjects with GFR ≤ the median, a higher hepcidin level was associated with an increased risk of incident anemia (at the 10th percentile GFR, HR 3.471, 95 % CI 1.228, 9.810, p = 0.019; at the 25th percentile GFR, HR 2.641, 95 % CI 1.213, 5.750, p = 0.014; at the 50th percentile GFR, HR 1.953, 95 % CI 1.011, 3.772, p = 0.046). Among subjects with GFR at the 75th percentile or above, incrementally higher baseline hepcidin was not associated with increased anemia risk. CONCLUSIONS: Higher hepcidin levels are associated with a decreased HGB and an increased risk of incident anemia, and this association is most significant among subjects with lower GFR.

Characterization of the cell surface properties of drinking water pathogens by microbial adhesion to hydrocarbon and electrophoretic mobility measurements.

The surface characteristics of microbial cells directly influence their mobility and behavior within aqueous environments. The cell surface hydrophobicity (CSH) and electrophoretic mobility (EPM) of microbial cells impact a number of interactions and processes including aggregation, adhesion to surfaces, and stability of the cells within the aqueous environments. These cell characteristics are unique to the bacterial species and are a reflection of the large diversity of surface structures, proteins, and appendages of microorganisms. CSH and EPM of bacterial cells contribute substantially to the effectiveness of drinking water treatment to remove them, and therefore an investigation of these properties will be useful in predicting their removal through drinking water treatment processes and transport through drinking water distribution systems. EPM and CSH measurements of six microbiological pathogen or surrogate species suspended in phosphate-buffered water are reported in this work. Two strains of Vibrio cholerae were hydrophobic, while three strains of Escherichia coli were hydrophilic. Bacillus cereus was categorized as moderately hydrophobic. The strains of E. coli had the highest (most negative) EPM. Based on the measurements, E. coli species is predicted to be most difficult to remove from water while V. cholerae will be the easiest to remove.