Impact of childhood nephrotic syndrome on obesity and growth: a prospective cohort study

BACKGROUND

Children with nephrotic syndrome are at risk of obesity and growth impairment from repeated steroid treatment. However, incidence and risk factors for obesity and short stature remain uncertain, which is a barrier to preventative care. Our aim was to determine risk, timing, and predictors of obesity and short stature among children with nephrotic syndrome.

METHODS

We evaluated obesity and longitudinal growth among children (1-18 years) enrolled in Insight into Nephrotic Syndrome: Investigating Genes, Health, and Therapeutics. We included children with nephrotic syndrome diagnosed between 1996-2019 from the Greater Toronto Area, Canada, excluding congenital or secondary nephrotic syndrome. Primary outcomes were obesity (body mass index Z-score ≥  + 2) and short stature (height Z-score ≤ -2). We evaluated prevalence of obesity and short stature at enrolment (< 1-year from diagnosis) and incidence during follow-up. Cox proportional hazards models determined the association between nephrotic syndrome classification and new-onset obesity and short stature.

RESULTS

We included 531 children with nephrotic syndrome (30% frequently relapsing by 1-year). At enrolment, obesity prevalence was 23.5%, 51.8% were overweight, and 4.9% had short stature. Cumulative incidence of new-onset obesity and short stature over median 4.1-year follow-up was 17.7% and 3.3% respectively. Children with frequently relapsing or steroid dependent nephrotic syndrome within 1-year of diagnosis were at increased risk of new-onset short stature (unadjusted hazard ratio 3.99, 95%CI 1.26-12.62) but not obesity (adjusted hazard ratio 1.56, 95%CI 0.95-2.56). Children with ≥ 7 and ≥ 15 total relapses were more likely to develop obesity and short stature, respectively.

CONCLUSIONS

Obesity is common among children with nephrotic syndrome early after diagnosis. Although short stature was uncommon overall, children with frequently relapsing or steroid dependent disease are at increased risk of developing short stature. Effective relapse prevention may reduce steroid toxicity and the risk of developing obesity or short stature.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

14 Rational Prescribing in the Frail Elderly Population: A Quality Improvement Project to Reduce Inappropriate Prescribing Using STOPP-Frail Criteria

Introduction

2.5 million people in the UK are aged over 80 and up to 50% can be considered frail. Complex co-morbidities and polypharmacy are linked with adverse drug effects and negative outcomes. NICE recommends a medication review yearly, and a hospital admission provides an opportunity for this. STOPP-Frail is a screening tool designed to highlight medications that could be reduced/stopped with a view to improving quality of life. We conducted a quality improvement project to quantify levels of inappropriate prescribing at Croydon University Hospital (CUH), with a view to de-prescribing and reducing adverse drug effects.

Methods

A retrospective analysis was carried out on the Elderly Care wards at CUH. Data was collected from 60 consecutive patients discharged from 1st November 2018, utilising electronic Cerner records. Recorded medication on admission and discharge, noting any amendments in accordance with the STOPP-Frail criteria.

Results

Data collected from 60 patients; one exclusion for not meeting STOPP-Frail criteria (n=59). Median age 86 years (69 to 103 years). Mean number of medications on admission 7.42 (1 to 15). 93.2% patients had polypharmacy (defined as ≥ 4 medications). Mean number of medications on discharge 8.22; an increase of 0.8/patient.

19.4% admission medications met STOPP-Frail criteria for inappropriate prescriptions. Only 18.8% of these were reduced or stopped during admission. Gastrointestinal and cardiovascular medications were most commonly inappropriately prescribed (n=27 and 24 respectively). Most common medications not amended were lipid-lowering therapies (n=21) and proton-pump inhibitors (n= 20).

Conclusions

The opportunity to rationalise medication in the frailest patients admitted to CUH is missed in over 80% of cases. STOPP-Frail provides clear guidance to aid clinicians in reducing inappropriate prescribing. An educational programme is in place to highlight medication rationalisation and guide clinicians in the use of the STOPP-Frail tool. This includes doctors’ induction, departmental teaching, posters and computer flash cards.

Prediction of Short- and Long-Term Outcomes in Childhood Nephrotic Syndrome

Introduction

It is unknown whether steroid sensitivity and other putative risk factors collected at baseline can predict the disease course of idiopathic nephrotic syndrome in childhood. We determined whether demographic, clinical, and family reported factors at presentation can predict outcomes in idiopathic nephrotic syndrome.

Methods

An observational cohort of 631 children aged 1 to 18 years diagnosed with idiopathic nephrotic syndrome between 1993 and 2016 were followed up until clinic discharge, 18 years of age, end-stage kidney disease (ESKD), or the last clinic visit. Baseline characteristics were age, sex, ethnicity, and initial steroid sensitivity. Of these, 287 (38%) children also reported any family history of kidney disease, preceding infection, microscopic hematuria, and history of asthma/allergies. The outcomes were complete remission after initial steroid course, need for a second-line agent, frequently relapsing disease, and long-term remission. The discriminatory power of the models was described using the c-statistic.

Results

Overall, 25.7% of children had no further disease after their initial steroid course. In addition, 31.2% developed frequently relapsing disease; however, 77.7% were disease-free at 18 years of age. Furthermore, 1% of children progressed to ESKD. Logistic regression modeling using the different baseline exposures did not significantly improve the prediction of outcomes relative to the observed frequencies (maximum c-statistic, 0.63; 95% confidence interval [CI], 0.59–0.67). The addition of steroid sensitivity did not improve outcome prediction of long-term outcomes (c-statistic, 0.63; 95% CI, 0.54–0.70).

Conclusions

Demographic, clinical, and family reported characteristics, specifically steroid sensitivity, are not useful in predicting relapse rates or long-term remission in idiopathic nephrotic syndrome. Further studies are needed to address factors that contribute to long-term health.

Parental Health Literacy and Outcomes of Childhood Nephrotic Syndrome

OBJECTIVE

Determine the association of parental health literacy with treatment response among children with nephrotic syndrome.

METHODS

This was a cohort study of children aged 1-18 with nephrotic syndrome and their parent. Health literacy was measured using the validated Short Test of Functional Health Literacy in Adults assessing reading comprehension and numeracy. Outcomes included initial relapse-free period, frequently relapsing disease, relapse rate, second-line medication use, and complete remission after therapy.

RESULTS

Of 190 parents, 80% had adequate health literacy (score >67 of 100), and higher scores were not correlated with higher education. Almost all achieved perfect numeracy scores (>86%); numeracy was not associated with outcomes. After adjusting for immigration, education, and income, higher reading comprehension scores (tertile 3) compared with lower scores (tertile 1) were significantly associated with lower risk of first relapse (hazard ratio 0.67, 95% confidence interval [CI] 0.48-0.94, P trend = .02), lower odds of frequently relapsing disease (odds ratio [OR] 0.38, 95% CI 0.21-0.70, P trend = .002), lower relapse rate (rate ratio 0.77, 95% CI 0.73-0.80, P trend < .001), and higher odds of complete remission after both initial steroids and cyclophosphamide (OR 2.07, 95% CI 1.36-3.16, P trend = .003; OR 5.97, 95% CI 2.42-14.7, P trend < .001).

CONCLUSIONS

Lower parental health literacy, specifically reading comprehension, is associated with higher relapse rates among children with nephrotic syndrome and fewer achieving complete remission. This underscores the importance of assessing and targeting health literacy for chronic management of childhood-onset diseases.

Ethnic Differences in Incidence and Outcomes of Childhood Nephrotic Syndrome

BACKGROUND AND OBJECTIVES

Ethnic differences in outcomes among children with nephrotic syndrome are unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a longitudinal study at a single regional pediatric center comparing ethnic differences in incidence from 2001 to 2011 census data and longitudinal outcomes, including relapse rates, time to first relapse, frequently relapsing disease, and use of cyclophosphamide. Among 711 children, 24% were European, 33% were South Asian, 10% were East/Southeast Asian, and 33% were of other origins.

RESULTS

Over 10 years, the overall incidence increased from 1.99/100,000 to 4.71/100,000 among children ages 1-18 years old. In 2011, South Asians had a higher incidence rate ratio of 6.61 (95% confidence interval, 3.16 to 15.1) compared with Europeans. East/Southeast Asians had a similar incidence rate ratio (0.76; 95% confidence interval, 0.13 to 2.94) to Europeans. We determined outcomes in 455 children from the three largest ethnic groups with steroid-sensitive disease over a median of 4 years. South Asian and East/Southeast Asian children had significantly lower odds of frequently relapsing disease at 12 months (South Asian: adjusted odds ratio; 0.55; 95% confidence interval, 0.39 to 0.77; East/Southeast Asian: adjusted odds ratio; 0.42; 95% confidence interval, 0.34 to 0.51), fewer subsequent relapses (South Asian: adjusted odds ratio; 0.64; 95% confidence interval, 0.50 to 0.81; East/Southeast Asian: adjusted odds ratio; 0.47; 95% confidence interval, 0.24 to 0.91), lower risk of a first relapse (South Asian: adjusted hazard ratio, 0.74; 95% confidence interval, 0.67 to 0.83; East/Southeast Asian: adjusted hazard ratio, 0.65; 95% CI, 0.63 to 0.68), and lower use of cyclophosphamide (South Asian: adjusted hazard ratio, 0.82; 95% confidence interval, 0.53 to 1.28; East/Southeast Asian: adjusted hazard ratio, 0.54; 95% confidence interval, 0.41 to 0.71) compared with European children.

CONCLUSIONS

Despite the higher incidence among South Asians, South and East/Southeast Asian children have significantly less complicated clinical outcomes compared with Europeans.

A ferromagnet in a continuously tunable random field

Most physical and biological systems are disordered, even though the majority of theoretical models treat disorder as a weak perturbation. One particularly simple system is a ferromagnet approaching its Curie temperature, T(C), where all of the spins associated with partially filled atomic shells acquire parallel orientation. With the addition of disorder by way of chemical substitution, the Curie point is suppressed, but no qualitatively new phenomena appear in bulk measurements as long as the disorder is truly random on the atomic scale and not so large as to eliminate ferromagnetism entirely. Here we report the discovery that a simply measured magnetic response is singular above the Curie temperature of a model, disordered magnet, and that the associated singularity grows to an anomalous divergence at T(C). The origin of the singular response is the random internal field induced by an external magnetic field transverse to the favoured direction for magnetization. The fact that ferromagnets can be studied easily and with high precision using bulk susceptibility and a large variety of imaging tools will not only advance fundamental studies of the random field problem, but also suggests a mechanism for tuning the strength of domain wall pinning, the key to applications.

Quantum phase transition in a common metal

The classical theory of solids, based on the quantum mechanics of single electrons moving in periodic potentials, provides an excellent description of substances ranging from semiconducting silicon to superconducting aluminium. Over the last fifteen years, it has become increasingly clear that there are substances for which the conventional approach fails. Among these are certain rare earth compounds and transition metal oxides, including high-temperature superconductors. A common feature of these materials is complexity, in the sense that they have relatively large unit cells containing heterogeneous mixtures of atoms. Although many explanations have been put forward for their anomalous properties, it is still possible that the classical theory might suffice. Here we show that a very common chromium alloy has some of the same peculiarities as the more exotic materials, including a quantum critical point, a strongly temperature-dependent Hall resistance and evidence for a 'pseudogap'. This implies that complexity is not a prerequisite for unconventional behaviour. Moreover, it should simplify the general task of explaining anomalous properties because chromium is a relatively simple system in which to work out in quantitative detail the consequences of the conventional theory of solids.

Tunable quantum tunnelling of magnetic domain walls

Perhaps the most anticipated, yet experimentally elusive, macroscopic quantum phenomenon is spin tunnelling in a ferromagnet, which may be formulated in terms of domain wall tunnelling. One approach to identifying such a process is to focus on mesoscopic systems where the number of domain walls is finite and the motion of a single wall has measurable consequences. Research of this type includes magnetotransport measurements on thin ferromagnetic wires, and magnetization experiments on single particles, nanomagnet ensembles and rare-earth multilayers. A second method is to investigate macroscopic disordered ferromagnets, whose dynamics are dominated by domain wall motion, and search the associated relaxation-time distribution functions for the signature of quantum effects. But whereas the classical, thermal processes that operate in these experiments are easily regulated via temperature, the quantum processes have so far not been tunable, making difficult a definitive interpretation of the results in terms of tunnelling. Here we describe a disordered magnetic system for which it is possible to adjust the quantum tunnelling probabilities. For this material, we can model both the classical, thermally activated response at high temperatures and the athermal, tunnelling behaviour at low temperatures within a unified framework, where the domain wall is described as a particle with a fixed mass. We show that it is possible to tune the quantum tunnelling processes by adjusting the 'mass' of this particle with an external magnetic field.

Recognition and sex categorization of adults' and children's faces: examining performance in the absence of sex-stereotyped cues

The ability of children and adults to classify the sex of children's and adults' faces using only the biologically based internal facial structure was investigated. Face images of 7- to 10-year-old children and of adults in their 20s were edited digitally to eliminate hairstyle and clothing cues to sex. Seven-year-olds, nine-year-olds, and adults classified a subset of these faces by sex and were asked, subsequently, to recognize the faces from among the entire set of faces. This recognition task was designed to assess the relationship between categorization and recognition accuracy. Participants categorized the adult faces by sex at levels of accuracy varying from just above chance (7-year-olds) to nearly perfect (adults). All participant groups performed less accurately for children's faces than for adults' faces. The 7-year-olds were unable to classify the children's faces by sex at levels above chance. Finally, the faces of children and adults were equally recognizable--a finding that has theoretical implications for understanding the relationship between categorizing and identifying faces.

Nonlinear electric field effects at a continuous mott-hubbard transition

We characterize the non-Ohmic portion of the conductivity at temperatures T<1 K in the highly correlated transition metal chalcogenide Ni(S,Se)(2). Pressure tuning of the T = 0 metal-insulator transition reveals the influence of the quantum critical point and permits a direct determination of the dynamical critical exponent z = 2.7(+0.3)(-0.4). Within the framework of finite temperature scaling, we find that the spatial correlation length exponent nu and the conductivity exponent &mgr; differ.

Quantum annealing of a disordered magnet

Traditional simulated annealing uses thermal fluctuations for convergence in optimization problems. Quantum tunneling provides a different mechanism for moving between states, with the potential for reduced time scales. Thermal and quantum annealing are compared in a model disordered magnet, where the effects of quantum mechanics can be tuned by varying an applied magnetic field. The results indicate that quantum annealing hastens convergence to the optimum state.

The evaluation of sexual function in men presenting with symptomatic benign prostatic hyperplasia

OBJECTIVE

To evaluate quantitatively and qualitatively the degree of sexual dysfunction in an unselected population of men attending a prostate-assessment clinic using a sexual-function inventory, and to ascertain the degree of correlation between sexual dysfunction, urinary symptoms and age.

PATIENTS AND METHODS

In all, 168 men with symptomatic BPH attending a prostate assessment clinic were investigated prospectively using the International Prostate Symptom Score (IPSS), BPH Impact Index (BPHII), a measurement of urinary flow rate and residual urine volume, and a sexual function questionnaire. The results were assessed using Spearman's rank order correlation to discern any correlations between the measured variables.

RESULTS

The data from 140 patients were available for analysis; of these, low scores were obtained in 59% for sexual drive, in 56% for erections (with 46% of men satisfying the National Institute of Health criterion for impotence) and in 38% for ejaculation. There was a statistically significant rank order correlation between age and the sexual symptom scores for each of the three categories (sexual drive, erection and ejaculation), but no correlation between age and the problem assessment scores for these domains, suggesting that the older patients are just as bothered by their sexual dysfunction as the younger men. Furthermore, the BPHII scores correlated weakly but significantly with all aspects of sexual function, including overall sexual satisfaction, in contrast to the poor correlation seen with the total IPSS and sexual function scores.

CONCLUSION

There is a significant number of patients with symptomatic BPH who have sexual dysfunction, with the proportion increasing with advancing age and with the older men still showing a high degree of bother from their symptoms. Sexual function scores were better correlated with BPHII scores than with the total IPSS, although some of the individual IPSS questions correlated well.

Biosynthesis of corticotrophin-releasing hormone (CRH) in mouse corticotrophic tumour cells expressing the human proCRH gene: intracellular storage and regulated secretion

The mouse corticotrophic tumour cell line AtT-20 naturally synthesizes pro-opiomelanocortin (POMC) which is proteolytically processed to N-POMC(1-76), ACTH, beta-lipotrophin and beta-endorphin. The processed products are stored in secretory vesicles and released upon stimulation with specific secretagogues. AtT-20 cells which have been stably transfected with the human corticotrophin-releasing hormone (CRH) gene store and secrete immunoreactive CRH. The present results demonstrate that the CRH precursor is proteolytically processed in the transfected cells to yield the 41 amino acid neuropeptide CRH(1-41). On stimulation with the secretagogue noradrenaline, CRH(1-41) was released into the medium, while the precursor was not. Whilst treatment of wild-type AtT-20 cells with exogenous CRH(1-41) (1 nM) caused a fourfold stimulation of ACTH release above basal levels, the peptide had no effect on ACTH release from the stably transfected cells R1 and R4. These results suggest that the endogenous CRH produced by the transfected R1 and R4 cells may cause down-regulation of their CRH receptors, and thus exogenous CRH cannot cause further stimulation of ACTH release in these cells. We propose that the CRH precursor is correctly processed in the transfected AtT-20 cells (R1 and R4) and that the foreign prohormone is sorted into the secretory pathway.

Cytotoxic effects of dihydroorotase inhibitors upon human CCRF-CEM leukemia

6-L-Thiodihydroorotate (TDHO) and 2-oxo-1,2,3,6-tetrahydropyrimidine-4,6-dicarboxylate (HDDP) are potent inhibitors of mammalian dihydroorotase in vitro (R. I. Christopherson, K. J. Schmalzl, E. Szabados, R. J. Goodridge, M. C. Harsanyi, M. E. Sant, E. M. Algar, J. E. Anderson, A. Armstrong, S. C. Sharma, W. A. Bubb, and S. D. Lyons, Biochemistry, 28: 463-470, 1989). Using human CCRF-CEM leukemia cells growing in culture, TDHO and HDDP as the free acids have 50% inhibitory concentration (IC50) values of 32 microM and greater than 1000 microM, respectively, whereas for TDHO methyl ester, the IC50 value is 25 microM, and for HDDP dimethyl ester, the IC50 value is 21 microM. These IC50 values were not affected by addition of dihydroorotate, uridine, or deoxycytidine to the culture medium. TDHO methyl ester (25 microM) had only slight inhibitory effects upon the dihydroorotase reaction of de novo pyrimidine biosynthesis in growing leukemia cells, cells arrested in G2 + M phases of the cell cycle. At 250 microM TDHO methyl ester, analysis of cell extracts by high-performance liquid chromatography showed that after 4 h carbamyl aspartate had accumulated from undetectable levels to 760 microM, whereas UTP decreased from 580 to 110 microM and CTP from 350 to 86 microM, indicating inhibition of dihydroorotase in growing leukemia cells. IMP accumulated from 63 to 350 microM, total guanylates increased while adenylates decreased, and the adenylate energy charge decreased from 0.91 to 0.69 after 4 h. The cellular concentration of 5-phosphoribosyl 1-pyrophosphate increased from 180 to 290 microM due to sparing from pyrimidine nucleotide biosynthesis resulting in complementary stimulation of the de novo purine pathway. HDDP dimethyl ester at concentrations of up to 250 microM had no discernable effect upon pyrimidine or purine nucleotide biosynthesis. At 25 microM HDDP-dimethyl ester, cells arrested in G2 + M phases initially, with accumulation of cells in G1/G0 at later times. These data suggest that the primary mechanisms of growth inhibition for TDHO and HDDP involve inhibition of cell cycle progression from late G2 or M phase to G1 phase and that blockade of the pyrimidine pathway by TDHO is a secondary effect found at higher concentrations.

Effects of supine exercise on fetal heart rate in the second and third trimesters

The effects of a brief period of supine exercise on fetal heart rate (FHR) was studied in 25 healthy, regularly exercising women, 12 in the late second trimester and 13 in the mid third trimester. Although statistically significant increases in maternal mean arterial pressure and pulse occurred, the exercise intensity was mild, with the average percent maximal pulse being 46 +/- 5% and 49 +/- 5% in the second and third trimester groups, respectively. Small increases in FHR were seen in both groups, which were insignificant statistically and physiologically. No patient experienced significant FHR abnormalities as a result of the supine exercise sequence. The findings suggest that pregnant women may continue submaximal supine exercise of short duration into the mid to late third trimester.