Yield of diagnostic testing in evaluating etiology and end organ effects of pediatric hypertension.

BACKGROUND: Current recommendations regarding the utility of diagnostic investigations for pediatric hypertension are based on limited evidence, leading to wide practice variation. The objective of this study was to characterize the cohort of children that may benefit from secondary hypertension workup, and determine the diagnostic yield of investigations. METHODS: This was a single-center, retrospective cohort study of 169 children aged 1-18 years referred between 2000 and 2015, to a tertiary pediatric nephrology center in Canada, for evaluation of hypertension. The number of investigations completed, abnormal findings, and diagnostic findings that helped establish hypertension etiology was determined. RESULTS: 56 children were diagnosed with primary and 72 children with secondary hypertension in the outpatient setting. Secondary hypertension was predominant at all ages except for obese adolescents ≥ 12 years. Half of children with traditional risk factors for primary hypertension, including obesity, were diagnosed with secondary hypertension. Kidney ultrasound had the highest yield of diagnostic results (19.8%), with no difference in yield between age groups (P = 0.19). Lipid profile had a high yield of abnormal results (25.4%) as part of cardiovascular risk assessment but was only abnormal in overweight/obese children. Echocardiogram had a high yield for identification of target-organ effects in hypertensive children (33.3%). CONCLUSION: A simplified secondary hypertension workup should be considered for all hypertensive children and adolescents. High yield investigations include a kidney ultrasound, lipid profile for overweight/obese children, and echocardiograms for assessment of target-organ damage. Further testing could be considered based on results of initial investigations for the most cost-effective management. A higher resolution version of the Graphical abstract is available as Supplementary information.

Risk factors associated with short- and long-term kidney injury in children with post infectious glomerulonephritis.

BACKGROUND: Post infectious glomerulonephritis (PIGN) is the most common form of acute glomerulonephritis in children. The objective of this study was to evaluate the risk factors for kidney injury in children with PIGN referred to a tertiary care center. METHODS: This was a retrospective cohort study. The primary outcome was acute kidney injury (AKI) at initial presentation; secondary outcome was composite kidney injury, defined as reduced estimated glomerular filtration rate (eGFR), proteinuria, or hypertension at last follow-up. Binary logistic regression defined risk factors associated with the primary and secondary outcomes. RESULTS: We identified 125 PIGN cases with a mean age of 8.3±3.5 years at presentation and 252 ± 501 days of follow-up. Sixty-six percent (79/119) presented with AKI and 57% (71/125) were admitted to hospital. Shorter time to seeing a nephrologist (OR 6.7, 95%CI 1.8-24.6), nadir C3 < 0.12 g/L (OR 10.2, 95%CI 1.9-53.7), starting an antihypertensive medication (OR 7.6, 95%CI 1.8-31.3), and nephrotic range proteinuria (OR 3.8, 95%CI 1.2-12.4) were independent risk factors for AKI when adjusted for each other. At last follow-up 35% (44/125) of the cohort had the composite outcome, with older age at presentation (OR 1.2, 95%CI 1.04-1.4) and nadir C3 < 0.17 g/L (OR 2.6, 95%CI 1.04-6.7) being independent risk factors when adjusted for AKI. CONCLUSION: PIGN is an important cause of AKI in children and adolescents. The severity of initial illness is associated with the extent of kidney injury in both the short- and longer-term. Findings will help identify cases requiring lengthier surveillance. A higher resolution version of the Graphical abstract is available as Supplementary information.

Kidney length standardized to body length predicts outcome in infants with a solitary functioning kidney.

BACKGROUND: Infants with a solitary functioning kidney (SFK) are at risk for chronic kidney injury (CKI). Lack of compensatory kidney growth (CKG) is associated with CKI, but measuring CKG is challenging since it is typically reported relative to normal kidneys. This study aims to (1) standardize SFK growth in infants, (2) investigate the relationship between standardized kidney length and clinical outcomes, and (3) use these results to develop a risk-based prediction model and local clinical pathway for SFK care. METHODS: This was a quality improvement study of 166 infants with an SFK. Linear regression was used to assess kidney growth from 0 to 180 days of life. Univariate binary regression analysis was used to identify kidney length to body length thresholds associated with the development of CKI, defined as the composite outcome of chronic kidney disease (eGFR < 60 mL/min/1.73 m2), hypertension, or proteinuria. RESULTS: Kidneys grew in length from 0 to 180 days, and growth was constant when standardized to body length. Over follow-up, infants with a baseline kidney length to body length ≤ 0.088 were more likely to experience CKI than the rest of the cohort (27 vs. 8%, p = 0.04). Kidney length to body length ≤ 0.088 was also significantly associated with CKI development (OR 4.17, 95% CI 1.14-15.28, p = 0.04). CONCLUSIONS: In this study, kidney length to body length ratio was a stable CKG metric over 0-180 days, and a baseline ratio ≤ 0.088 was a risk factor for CKI. Results will aid in developing a practical, point-of-care risk assessment tool, and overarching risk-stratified clinical pathway for infants with an SFK. A higher resolution version of the Graphical abstract is available as Supplementary information.

Outcomes of solitary functioning kidneys-renal agenesis is different than multicystic dysplastic kidney disease.

BACKGROUND: Multicystic dysplastic kidney (MCDK) disease and unilateral renal agenesis (URA) are well-known causes of a solitary functioning kidney (SFK) and are associated with long-term kidney injury. The aims of this study were to characterize the natural history of SFK at our center, define the risk factors associated with chronic kidney injury, and identify distinguishing features between URA and MCDK that predict outcome. METHODS: This was a retrospective cohort study of 230 SFK patients. We compared MCDK (n=160) and URA (n=70) according to clinical features at diagnosis and kidney outcomes over follow-up. Univariate and multivariate binary regression analysis was used to determine independent risk factors for chronic kidney injury, defined as the composite outcome of hypertension, proteinuria, or chronic kidney disease (eGFR <60 mL/min/1.73m2). RESULTS: URA had a higher prevalence of comorbid genetic syndromes (15 vs. 6%, p=0.04), non-renal anomalies (39 vs. 11%, p<0.001), and congenital anomalies of the kidney and urinary tract (CAKUT) (51 vs. 26%, p<0.001) than MCDK. Over follow-up, URA experienced more hypertension (19 vs. 3%, p=0.002), proteinuria (12 vs. 3%, p=0.03), and the composite outcome (19 vs. 6%, p=0.003) than MCDK. Independent risk factors for chronic kidney injury included CAKUT (OR 5.01, p=0.002) and URA (OR 2.71, p=0.04). CONCLUSIONS: In our population, URA was more likely to have associated syndromes or anomalies, and to have worse outcomes over time than MCDK. URA diagnosis was an independent risk factor for chronic kidney injury. Our results will be used to develop a standardized clinical pathway for SFK management. A higher resolution version of the Graphical abstract is available as Supplementary information.

The impact of small kidneys.

BACKGROUND: Small kidneys due to renal hypodysplasia (RHD) result from a decrease in nephron number. The objectives of this study were to identify clinical variables that determine long-term renal outcome in children with RHD and to define the role of kidney size as a predictor of developing end-stage renal disease (ESRD). METHODS: This was a single-center retrospective cohort analysis. The primary outcome was development of ESRD. We identified 202 RHD cases, with 25 (12%) reaching ESRD at mean age of 8.9 (±6.6) years. RESULTS: Children with RHD with a known genetic syndrome had the smallest kidneys while those with posterior urethral valves (PUV) had the largest kidneys at diagnosis. Cases with bilateral RHD were most likely to develop ESRD. Younger gestational age (OR 0.8, CI 0.69-0.99, p = 0.05), smaller kidney size at diagnosis (OR 0.13, CI 0.03-0.47, p = 0.002), lower best-estimated glomerular filtration rate (eGFR) (OR 0.74, CI 0.58-0.93, p = 0.01), proteinuria (OR 1.03, CI 1.01-1.05, p < 0.001) and high blood pressure (OR 1.02, CI 1.01-1.04, p = 0.01) were associated with development of ESRD, while kidney size at diagnosis was independently associated with ESRD (HR 0.03, CI 0.01-0.72, p = 0.043). CONCLUSIONS: In children with RHD, kidney size at diagnosis predicts the likelihood of developing ESRD.

Staged Treatment of Posttraumatic Tibial Osteomyelitis with Rib Graft and Serratus Anterior Muscle Autografts-Case Report.

Osteomyelitis of the tibia is a challenging condition, particularly when it occurs as a result of trauma. This abstract presents a case study detailing the successful staged treatment of posttraumatic tibial osteomyelitis utilizing a unique combination of rib graft and serratus anterior muscle. This medical abstract presents a case study of a 52-year-old male with a history of heavy smoking and obliterating arteriopathy of the lower limbs. The patient sustained a traumatic open fracture classified as Type IIIA Gustilo Anderson involving one-third of the distal right tibia diaphysis, with an associated right fibular malleolus fracture. The treatment approach comprised multiple stages, focusing on wound management, infection control, and limb salvage. The initial stage involved the application of an external fixation device in the emergency setting. Seven days later, an osteosynthesis procedure was performed using a Kuntscher nail and wire cerclage. However, complications emerged, with wound dehiscence and purulent secretion observed at 14 days postsurgery. Subsequently, secondary suturing was carried out at the 20-day mark. The second stage of the treatment involved implant removal, wide excisional debridement, pulse lavage, osteoclasia, and relaxation of the peroneal malleolus. A monoplane external fixation system was applied. As a part of postoperative care, aspiration therapy with a vacuum pump was administered, along with a 10-day course of vancomycin according to the antibiogram. Positive clinical signs of healing were noted, and sterile cultures confirmed the results. The third stage of the intervention focused on grafting the osteo-muscular defect, utilizing autografts from the rib and serratus anterior muscle. The external fixator was maintained in place during this phase. In the fourth and final stage, after an 8-week integration period of the musculocutaneous flap, the external fixator was removed, and internal fixation was accomplished with a blocked Less Invasive Stabilization System (LISS) plate inserted using the Minimally Invasive Plate Osteosynthesis (MIPO) technique. This case underscores the significance of a multistage approach in managing complex limb injuries, emphasizing the importance of timely intervention, infection control, and innovative techniques for limb salvage and restoration of function.

Using a Double Syringe Sterile System for MSK Aspiration/Injection Procedures Eliminates Risk of Iatrogenic Infection.

Introduction: Diverse musculo-skeletal pathology can be treated conservatively by different types of injections and in most cases, results are significantly better if the existing inflammatory fluid is aspirated prior to injection of medication solutions. The present study analyses an original technique which uses infusion therapy accessories to create two types of closed sterile double syringe systems, and compares the benefits of using such a system in aspiration/injection procedures to classic aspiration injection technique that implies changing and connecting multiple syringes to the same needle, thus increasing the risk for septic complications. The aim of the present study is to minimize therapeutic risk of iatrogenic septic complications during aspiration/injection procedures. Methods: 1024 patients underwent aspiration/injection procedures in our clinic using the double syringe system between 2015 and 2020. During the early stages of the study, the second type of assembly was rendered impractical so the study continued with analyzing a single type of double syringe system using a three way infusion therapy device which is readily available, and allows the assembly of a closed sterile system with a single, two-step procedure technique. Iatrogenic local septic complications were followed by means of a six week clinical follow-up evaluation with additional investigations only if necessary. Results: In 1024 procedures we report 0% incidence of iatrogenic septic complications, or other types of complications and recommend this technique in a vast array of rheumatic, orthopedic or traumatic conditions that require aspiration/injection procedures. Discussion: The double syringe system is practical, easy to use, it completely eliminates the risk of iatrogenic infection due to manipulation errors, and significantly simplifies the technique for sonography guided aspiration/injection procedures for musculo-skeletal pathology.

The Teacher-Learner Contract (TLC): An Objectives-Based Checklist for Surgical Shadowing.

OBJECTIVE: A lack of structure and communication in physician shadowing experiences may prevent medical students from accruing its potential benefits. In this study, we evaluated the use of an objectives-based surgical shadowing teacher-learner contract (TLC) on the outcomes of shadowing experiences. DESIGN: Cross-sectional study with 30 unique student-surgeon pairs who participated in a 1-time shadowing experience between December 2016 and May 2017. SETTING: Eight hospitals and clinics in Metro Vancouver, British Columbia, Canada. PARTICIPANTS: A convenience sample of preclinical medical students attending University of British Columbia and local surgeons from a variety of specialties were recruited by email. A random sample of 30 students was selected from a pool of interested students. RESULTS: Twenty-eight students and 18 surgeons completed the study. In general, students and surgeons reported that the TLC focused learning and improved communication between teachers and learners. Students also commented that using the TLC prompted them to reflect on their goals and consider how the shadowing experience might contribute to their overall medical education. Both students and surgeons found benefit in using the checklist (mean 3.5 ± 0.75 and mean 3.8 ± 1.1, respectively, where 1 was not useful and 5 was very useful). All participants rated the TLC as easy to use (mean 1.429 ± 1.271 and mean 1.333 ± 0.686, respectively, where 1 was not difficult and 5 was very difficult), and 80% of respondents said they would use the tool again. Participants who benefited the most were students with limited surgical shadowing experience and surgeons with less experience teaching preclerkship students. CONCLUSIONS: This study demonstrates that an objectives-based learning contract like the TLC can facilitate meaningful shadowing experiences for teachers and learners and may have longitudinal educational benefits. However, widespread implementation will require institutional support of this concept.

Meniscus-shaped cell-free polyglycolic acid scaffold for meniscal repair in a sheep model.

Since loss of meniscus is correlated with an increasing risk for osteoarthritis, meniscal scaffolds are proposed as new strategies. Development of a suitable scaffold has to take into account differing meniscus thickness, exposure to compressive and tensile forces combined with high porosity and biocompatibility of the material. After physical testing of three flat scaffolds composed of different modified polyglycolic acid (PGA) fibers, a three-dimensional meniscus-shaped PGA-hyaluronan implant was generated. Micro-computed tomography showed 90% porosity in the outer area with 50% in the inner area of the implant. Biocompatibility and expression of meniscus typical cartilaginous genes were shown for human meniscus cells cultivated in the implant with 10% human serum or 5% platelet-rich plasma for 14 days in vitro. The proof-of-concept study in sheep demonstrated proteoglycan- and collagen type I-rich repair tissue formation in partial meniscectomy combined with a meniscus-shaped PGA-hyaluronan implant after 6 months. In contrast, the control showed nearly no repair tissue formation. Thus, meniscus-shaped PGA-hyaluronan implants might be a suitable therapeutic approach to support repair tissue formation in partial meniscectomy.

Prevalence and risk factors for near and far visual difficulty in Burkina Faso.

PURPOSE: To determine the prevalence and risk factors for near and far visual difficulty in Burkina Faso. METHODS: Population-based data were used from the World Health Survey done in Burkina Faso in 2002-2003;2003 (n=4,822 adults). Near and far visual difficulty were assessed by questions about difficulty seeing and recognizing an object at arm's length and about difficulty seeing and recognizing a person across the road. Prevalence estimates were adjusted for the multi-stage, stratified, random cluster sampling design. Logistic regression was used to identify independent risk factors. RESULTS: The overall prevalence of any near and far visual difficulty was 10% (standard error [SE] = 0.7%) and 13% (SE=0.9%) respectively. Prevalence estimates were strongly associated with age with 48% (SE=4.2%) and 66% (SE=3.9%) of those >or= 65 years old having near or far visual difficulty (P < 0.001). Only 5% (SE=0.6%) of people wore glasses. We identified two potentially modifiable variables associated with near visual difficulty: a cooking stove in the same room as sleeping area (Odds Ratio [OR]=1.45, 95% Confidence Interval [CI] 1.01, 2.02) and high fruit consumption (OR=0.65, 95% CI 0.50, 0.86). CONCLUSION: The prevalence of visual difficulty was high in Burkina Faso. Efforts to confirm these findings with cooking stove location and fruit consumption should be undertaken in this population.