Optimising patients with long-term spinal cord injury for nephrectomy: A review of pre-, peri- and post-operative factors to safeguard outcomes

Objectives:

To review the potential challenges a urologist may encounter when embarking on simple/partial/radical nephrectomy in patients with long-term spinal cord injury and propose strategies to pre-empt and manage these.

Materials and methods:

Comprehensive literature review via PubMed, MEDLINE® and Google™ Scholar searching for relevant scientific articles published to date in English. Recommendations for strategies to safeguard surgical outcomes discussed with a panel of experienced upper-tract urologists.

Results:

Pre-operative considerations:  - urethral assessment via flexible cystoscopy due to higher incidence of urethral pathology in spinal cord injury;  - assessing for chronic constipation and distended bowel; and  - considering glomerular filtration rate assessment by radio-isotope techniques, such as 51chromium-EDTA Peri-operative considerations:  - adequate theatre staffing for safe patient transfer; and  - planned choice of incision, due to higher incidence of previous abdominal surgery, stoma bags and/or foreign body devices. Post-operative considerations:  - ensuring attending medical staff are trained to recognise autonomic dysreflexia;  - early re-mobilisation with physiotherapists experienced in treating spinal cord injury; and  - attentive antibiotic stewardship due to higher risk of hospital-acquired or urinary infections

Conclusions:

Patients with long-term spinal cord injury pose significant potential challenges in the pre-, peri- and post-operative stages of nephrectomy. Familiarisation and optimisation of such factors is recommended to safeguard outcomes.

Level of evidence:

Not applicable for this multicentre audit.

Screening Pediatric Patients for Food Insecurity: A Retrospective Cross-Sectional Study of Comorbidities and Demographic Characteristics

BACKGROUND

Food insecurity is a household-level economic and social condition of limited or uncertain access to adequate and nutritional food that is associated with diabetes, obesity, anxiety, depression, and behavioral disorders. The presence of these comorbidities motivated the UW Health Pediatrics Department to start screening for food insecurity.

METHODS

Our study describes demographic characteristics of screened patients, comparing risk factors and health status between food insecure patients and food secure patients. We extracted variables on all screened patients: sex, age, race, ethnicity, insurance type, height, weight (to calculate body mass index [BMI] and BMI percentile), and any diagnosis of diabetes, hypertension, sleeping problems, restless leg syndrome, anemia, elevated blood lead levels, depression, anxiety, or attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD).

RESULTS

Over the 8-month screening period, 1,330 patients were screened for food insecurity, and 30 screened positive. Insurance type was a significant predictor for food insecurity; patients on public or with no insurance had 6.39 times greater odds of being food insecure than those on private insurance (CI 3.81, 13.29). Also, diagnoses of anemia and ADD/ADHD were both significantly higher in the food insecure group. The odds of having anemia was 8.47 times greater for food insecure patients (CI 3.03, 23.63), and the odds for having ADD/ADHD was 5.89 times greater for food insecure patients than food secure patients (CI 1.48, 23.55).

DISCUSSION

These results provide useful information to clinicians as the screening process moves toward widespread adoption. These results also provide a baseline for expanded research once screening is implemented throughout all pediatric clinics within our health care organization.

Prevalence and Predictors of Unhealthy Weight Gain in Pregnancy

IMPORTANCE

Weight gain during pregnancy affects obesity risk in offspring.

OBJECTIVE

To assess weight gain among UW Health prenatal patients and to identify predictors of unhealthy gestational weight gain.

METHODS

Retrospective cohort study of women delivering at UW Health during 2007-2012. Data are from the UW eHealth Public Health Information Exchange (PHINEX) project. The proportion of women with excess and insufficient (ie, unhealthy) gestational weight gain was computed based on 2009 Institute of Medicine guidelines. Multivariable logistic regression was used to identify risk factors associated with excess and insufficient gestational weight gain.

RESULTS

Gestational weight gain of 7,385 women was analyzed. Fewer than 30% of prenatal patients gained weight in accordance with Institute of Medicine guidelines. Over 50% of women gained excess weight and 20% gained insufficient weight during pregnancy. Pre-pregnancy weight and smoking status predicted excess weight gain. Maternal age, race/ethnicity, smoking status, and having Medicaid insurance predicted insufficient weight gain.

CONCLUSIONS AND RELEVANCE

Unhealthy weight gain during pregnancy is the norm for Wisconsin women. Clinical and community interventions that promote healthy weight gain during pregnancy will not only improve the health of mothers, but also will reduce the risk of obesity in the next generation.

Development of an Obesity Prevention Dashboard for Wisconsin

IMPORTANCE

A comprehensive obesity surveillance system monitors obesity rates along with causes and related health policies, which are valuable for tracking and identifying problems needing intervention.

METHODS

A statewide obesity dashboard was created using the County Health Rankings model. Indicators were obtained through publicly available secondary data sources and used to rank Wisconsin amongst other states on obesity rates, health factors, and policies.

RESULTS

Wisconsin consistently ranks in the middle of states for a majority of indicators and has not implemented any of the evidence-based health policies.

CONCLUSIONS AND RELEVANCE

This state of obesity report shows Wisconsin has marked room for improvement regarding obesity prevention, especially with obesity-related health policies. Physicians and health care systems can play a pivotal role in making progress on obesity prevention.

Inflammatory Papillitis in Uveitis: Response to Treatment and Use of Optic Nerve Optical Coherence Tomography for Monitoring

PURPOSE

To describe the clinical course of uveitis-associated inflammatory papillitis and evaluate the utility and reproducibility of optic nerve spectral domain optical coherence tomography (SD-OCT).

METHODS

Data on 22 eyes of 14 patients with uveitis-related papillitis and optic nerve imaging were reviewed. SD-OCT measure reproducibility was determined and parameters were compared in active vs. inactive uveitis.

RESULTS

Papillitis resolution lagged behind uveitis resolution in three patients. For SD-OCT measures, the intraclass correlation coefficients were 99.1-100% and 86.9-100% for intraobserver and interobserver reproducibility, respectively. All SD-OCT optic nerve measures except inferior and nasal peripapillary retinal thicknesses were significantly higher in active vs. inactive uveitis after correction for multiple hypotheses testing. Mean optic nerve central thickness decreased from 545.1 to 362.9 µm (p = 0.01).

CONCLUSIONS

Resolution of inflammatory papillitis can lag behind resolution of uveitis. SD-OCT assessment of papillitis is reproducible and correlates with presence vs. resolution of uveitis.

Beyond content: leadership development through a journal club

CDC designed its Health Systems Integration Program to prepare leaders to function at the interface of public health and health care. Specific Health Systems Integration Program competencies in the areas of communication, analysis and assessment, and health systems were developed to nurture evidence-based decision-making and leadership skills crucial for future public health leaders. The program therefore designed an innovative journal club as part of its competency-based curriculum not only to meet the standard goals for a journal club-critical reading, interpretation, and acquiring content knowledge-but also to foster leadership development. This report describes the Health Systems Integration Program journal club format, its implementation, challenges, and key elements of success. Other programs using a journal club model as a learning format might consider using the Health Systems Integration Program's innovative approach that focuses on leadership development.

Blau syndrome-associated uveitis and the NOD2 gene

Blau syndrome (BS), a rare autosomal dominant autoinflammatory syndrome, is an example of a monogenic disease. It was first described as a classic triad of uveitis, arthritis, and exanthema, typically seen in patients less than four years of age. Since that time, the phenotype has been expanded to include fever, cranial neuropathies, cardiovascular abnormalities, and granulomas of the liver and kidney. The ocular inflammation is often a panuveitis that occurs later in the disease course and typically carries the greatest morbidity in BS. BS has been mapped to the chromosomal region 16q12-21, also known as the NOD2 gene (formerly CARD15/NOD2). The disease is secondary to a single amino acid mutation NOD2 that leads to peptidoglycan-independent activity of nuclear factor (NF)-κB. Clinical and genetic aspects of BS will be discussed, as well as recent advances in treatment protocols.

A cluster of dengue cases in American missionaries returning from Haiti, 2010

Dengue is an acute febrile illness caused by four mosquito-borne dengue viruses (DENV-1 to -4) that are endemic throughout the tropics. After returning from a 1-week missionary trip to Haiti in October of 2010, 5 of 28 (18%) travelers were hospitalized for dengue-like illness. All travelers were invited to submit serum specimens and complete questionnaires on pre-travel preparations, mosquito avoidance practices, and activities during travel. DENV infection was confirmed in seven (25%) travelers, including all travelers that were hospitalized. Viral sequencing revealed closest homology to a 2007 DENV-1 isolate from the Dominican Republic. Although most (88%) travelers had a pre-travel healthcare visit, only one-quarter knew that dengue is a risk in Haiti, and one-quarter regularly used insect repellent. This report confirms recent DENV transmission in Haiti. Travelers to DENV-endemic areas should receive dengue education during pre-travel health consultations, follow mosquito avoidance recommendations, and seek medical care for febrile illness during or after travel.

Effect of lead and cadmium co-exposure on testicular steroid metabolism and antioxidant system of adult male rats

The mechanism of testicular toxicity of lead (Pb) and cadmium (Cd) is poorly understood. Previous studies focused on single metal-related changes in testicular toxicity. This study points towards the possible involvement of Pb- and Cd-induced oxidative stress in the suppression of steroidogenesis. The oxidative status of testis of adult male rats exposed to Pb acetate and cadmium acetate either alone or in combination at a dose of 0.025 mg kg(-1) body weight of metal intraperitoneally for 15 days was studied. Pb and Cd caused an increase in reactive oxygen species (ROS) by elevating testicular malondialdehydes (MDA) and decrease in activities of testicular antioxidant enzymes superoxide dismutase (SOD), catalase, glucose 6 phosphate dehydrogenase (G6PDH) and glutathione-S-transferase (GST) in mitochondrial and/or post-mitochondrial fraction. Activities of steroidogenic enzymes 3β and 17β-hydroxysteroid dehydrogenase also decreased significantly leading to altered testosterone production. Metal-exposed groups showed significantly decreased testicular and epididymal sperm count. Epididymal sperm motility and viability was also decreased on Pb and Cd exposure. Cd exposure showed more toxic effect than lead exposure, while combined exposure demonstrated least toxicity. In vitro experiments showed that vitamin C restores steroidogenic enzyme activities, suggesting that Pb- and Cd-induced ROS inhibits the testicular steroidogenesis.

PKC-ι promotes glioblastoma cell survival by phosphorylating and inhibiting BAD through a phosphatidylinositol 3-kinase pathway

The focus of this research was to investigate the role of protein kinase C-iota (PKC-ι) in regulation of Bad, a pro-apoptotic BH3-only molecule of the Bcl-2 family in glioblastoma. Robust expression of PKC-ι is a hallmark of human glioma and benign and malignant meningiomas. The results were obtained from the two human glial tumor derived cell lines, T98G and U87MG. In these cells, PKC-ι co-localized and directly associated with Bad, as shown by immunofluorescence, immunoprecipitation, and Western blotting. Furthermore, in-vitro kinase activity assay showed that PKC-ι directly phosphorylated Bad at phospho specific residues, Ser-112, Ser-136 and Ser-155 which in turn induced inactivation of Bad and disruption of Bad/Bcl-XL dimer. Knockdown of PKC-ι by siRNA exhibited a corresponding reduction in Bad phosphorylation suggesting that PKC-ι may be a Bad kinase. PKC-ι knockdown also induced apoptosis in both the cell lines. Since, PKC-ι is an essential downstream mediator of the PI (3)-kinase, we hypothesize that glioma cell survival is mediated via a PI (3)-kinase/PDK1/PKC-ι/Bad pathway. Treatment with PI (3)-kinase inhibitors Wortmannin and LY294002, as well as PDK1 siRNA, inhibited PKC-ι activity and subsequent phosphorylation of Bad suggesting that PKC-ι regulates the activity of Bad in a PI (3)-kinase dependent manner. Thus, our data suggest that glioma cell survival occurs through a novel PI (3)-kinase/PDK1/PKC-ι/BAD mediated pathway.

Acquisition and transmission of group B Streptococcus during pregnancy

Group B Streptococcus (GBS) is a major cause of neonatal sepsis and meningitis. We followed up 78 pregnant couples for < or =2 months to estimate the risk of GBS transmission. Among couples with discordant GBS status, we observed 1 male-to-female transmission event (1 of 3 couples in which the woman was GBS negative at enrollment), but no female-to-male transmission events (0 of 8 couples in which the man was GBS negative at enrollment).

Distribution of novel and previously investigated virulence genes in colonizing and invasive isolates of Streptococcus agalactiae

Although Streptococcus agalactiae has emerged as an important cause of invasive disease, relatively little is known regarding the genetic basis of virulence of this organism. Three novel genes with characteristics suggesting a role in virulence were identified via comparison of sequenced genomes of S. agalactiae. The presence of these genes and of the previously identified genes bac, bca, rib, and spb1 was determined, and isolates were assigned a binary genetic signature. It was found that isolates containing spb1, previously suggested to be limited to serotype III-3, were represented by 18 different genetic signatures and several serotypes, and that the presence of both sbp1 and rib was more predictive of invasive disease than spb1 alone. Additionally, bac-positive isolates, reported to be genetically homogeneous, were represented by 14 different genetic signatures. Finally, the majority of serotype V isolates examined contained zero or only one of the genes tested, suggesting that much remains undiscovered regarding important virulence factors in isolates of this serotype.

Modelling response time profiles in the absence of drug concentrations: definition and performance evaluation of the K-PD model

The plasma concentration-time profile of a drug is essential to explain the relationship between the administered dose and the kinetics of drug action. However, in some cases such as in pre-clinical pharmacology or phase-III clinical studies where it is not always possible to collect all the required PK information, this relationship can be difficult to establish. In these circumstances several authors have proposed simple models that can analyse and simulate the kinetics of the drug action in the absence of PK data. The present work further develops and evaluates the performance of such an approach. A virtual compartment representing the biophase in which the concentration is in equilibrium with the observed effect is used to extract the (pharmaco)kinetic component from the pharmacodynamic data alone. Parameters of this model are the elimination rate constant from the virtual compartment (KDE), which describes the equilibrium between the rate of dose administration and the observed effect, and the second parameter, named EDK(50) which is the apparent in vivo potency of the drug at steady state, analogous to the product of EC(50), the pharmacodynamic potency, and clearance, the PK "potency" at steady state. Using population simulation and subsequent (blinded) analysis to evaluate this approach, it is demonstrated that the proposed model usually performs well and can be used for predictive simulations in drug development. However, there are several important limitations to this approach. For example, the investigated doses should extend from those producing responses well below the EC(50) to those producing ones close to the maximum response, optimally reach steady state response and followed until the response returns to baseline. It is shown that large inter-individual variability on PK-PD parameters will produce biases as well as large imprecision on parameter estimates. It is also clear that extrapolations to dosage routes or schedules other than those used to estimate the parameters should be undertaken with great caution (e.g., in case of non-linearity or complex drug distribution). Consequently, it is advised to apply this approach only when the underlying structural PD and PK are well understood. In any case, K-PD model should definitively not be substituted for the gold standard PK-PD model when correct full model can and should be identified.

Intra-operative diagnosis of hypopituitarism in a patient undergoing radical nephrectomy

A 43-year-old woman presented for elective radical nephrectomy. After induction of anaesthesia, she developed hypotension that failed to respond to standard treatment measures. Her core temperature decreased to 34 degrees C in spite of active warming. She required very low concentrations of anaesthetic agents to maintain an adequate depth of anaesthesia for abdominal surgery. After excluding the common causes of hypotension, the possibility of subclinical hypopituitarism was considered and subsequently confirmed.

Using technology to educate deaf and hard of hearing children in rural Alaskan general education settings

Teachers in Alaskan rural schools were surveyed on their use of instructional technology. The surveyed teachers included the entire population of certified elementary and secondary school classroom teachers of deaf and hard of hearing students in these schools. Respondents generally were older, more experienced, elementary level female teachers who were relatively well educated. Almost half of the respondents held special education certification; about 25% had an endorsement in deaf education. Data analysis indicates that educators who use instructional technology, either in curriculum or broad agenda formats, may be older, hold an advanced degree and secondary education certification, benefit from in-service training on site, are connected to the Internet, and actively use the technology available at their schools. Most of the surveyed educators identified lack of training in the use and integration of software as a barrier to increased classroom use of technology. Based on the study findings, recommendations are made concerning the training needs of teachers in rural Alaska.

Assessment of depression in older people

Practitioners working in the field of mental health are becoming increasingly aware that depression and suicide in old age are a major source of concern. Peter Pillai continues the series of articles on aspects of mental health assessment co-ordinated by the RCN Steering Committee for Mental Health and Older People which explores the nurse's role in assessing depression in this particular client group.

High-performance liquid chromatographic resolution of NADP+ after induction of fluorescence and its application to assay for an NADPH-dependent enzyme: application to the determination of glutathione reductase activity in plant leaf extracts

A method is described for the determination of glutathione reductase activity (GR; EC 1.6.4.2) in plant extracts utilizing HPLC quantitation of NADP+ following the reduction of glutathione disulfides. After protein incubation, fluorescence of NADP+ was induced under strongly basic conditions, and the product was directly resolved from the reaction medium by isocratic reversed-phase elution on a silica-coated alumina support which took 2 min. The mobile phase was acetonitrile-water (50:50) delivered at a flow rate of 1.5 ml/min. The adduct (stable for at least 7 days) was detected fluorometrically and quantitated by direct integration of peak area.

Rapid diagnosis of typhoid fever by detection of Barber protein and Vi antigen of Salmonella serotype typhi

Co-agglutination (coagg) and latex agglutination (LA) tests were used for the detection of Salmonella serotype Typhi Vi and Barber protein (BP) antigens in sera from five groups of individuals (A-E). Group A consisted of 30 blood culture-positive cases of typhoid fever and group B consisted of 30 suspected cases of typhoid fever who had sterile blood cultures but positive Widal tests. Thirty cases of pyrexia of unknown origin (PUO) were placed in group C, while group D consisted of 15 cases of septicaemia caused by organisms other than Salmonella serotype Typhi. Group E comprised 50 normal healthy individuals with no history of typhoid fever or TAB vaccination in the previous 5 years. The Vi-LA test performed best with 96.7% of group A sera and 90% of group B sera giving positive results. No false positive results and only 2.58% false negative results were obtained with this test. Considering patients with positive blood culture results or positive Widal tests as true positives, the sensitivities of the Vi-LA, BP-LA, Vi-coagg and BP-coagg tests were 93.3, 91.7, 83.3 and 86.7%, respectively. The specificities of these tests were 100, 98.5, 98.5 and 98.5%, respectively. It is suggested that the Vi-LA test can be used for the rapid and early diagnosis of typhoid fever.

Licorice-derived compounds inhibit linoleic acid (C:18:2 omega 6) desaturation in soybean chloroplasts

Although glycyrrhizic acid, a major constituent of licorice root, has important pharmacological effects in humans, the biological activity of glycyrrhizic acid and its aglycone glycyrrhetinic acid in plants is unknown. Here we report that these licorice-derived compounds and the analog carbenoxolone inhibit desaturation of linoleic acid (C18:2 omega 6) in soybean chloroplasts using monogalactosyldiacylglycerol and phosphatidylcholine substrates in an in vitro assay for desaturase activity. At 10 nM glycyrrhetinic acid, there is significant inhibition of desaturation of linoleic acid suggesting that licorice-derived compounds could prove useful in investigating biochemical pathways of linoleic acid desaturation in plant chloroplasts and plant desaturase regulation, which has application in modification of plant response to environmental stress, as well as optimization of oil seed composition.

Norries disease

A 2-month-old male infant was found to have Norrie's disease. The clinical presentation and detailed histological features diagnostic of the disease are discussed. This is the first authentic, histologically proven case of Norrie's disease from India. The absence of hearing loss and mental retardation at the time of presentation at the early stage of infancy and the fact that the case was sporadic do not detract from the diagnosis. However the child at the age of one year developed hearing loss.

Scleral tuberculosis

A rare case of scleral tuberculosis manifesting as an ulcerative scleral nodule is described. Corroborative evidence of systemic tuberculous lesions was detectable. The lesion responded to antituberculous treatment alone.

Bilateral sino-orbital pseudotumour

The authors present a case of histopathologically proved bilateral idiopathic inflammatory pseudotumour of the orbits with involvement of the paranasal sinuses in a child. Clinically, the bilateral proptosis was manifest at the age of 5 years. While extraorbital manifestations are rare, orbital pseudotumour should be considered in such cases.

Cyclic esotropia with central nervous system disease: report of two cases

Two cases of cyclic esotropia with associated central nervous system lesions are presented. One had a 48-hour cycle and the other a 24-hour cycle. In the first child, the condition developed after a third ventricular astrocytoma removal and in the second with the advent of an epileptiform disorder. Both were non-accommodative, non-paralytic in nature, and not associated with fusion disrupting factors. These patterns persisted uninterruptedly in one child for 22 months and in the other for more than 8 months until lost for follow-up.

Congenital cataract: management and results

The visual outcome in cases of congenital cataract, managed both surgically and conservatively, is outlined. Final vision was better in cases with partial cataract, about 40% of whom attained 6/24 or better vision. With total cataracts, none could achieve this level of vision, with the majority (84%) attaining only 6/60 or less acuity. Visual results were also better in patients without nystagmus, 34% of whom attained 6/24 or better vision, while in cases with nystagmus, only 15% could come up to this level. Cataracts necessitating early surgery had a worse prognosis than cataracts necessitating late surgery. Visual results were best in cases with bilateral cataracts, partial cataracts, absence of associated ocular anomalies, the absence of nystagmus and in patients requiring later surgery. The important causes of nonimprovement of vision were amblyopia and after-cataract. Retinal detachment, retinopathy, and degenerative myopia were some of the less frequent causes of poor vision, while mental retardation was another important factor. Full cooperation from the parents is absolutely essential in the proper visual rehabilitation of the handicapped child.

Lipid composition of chloroplast membranes from weed biotypes differentially sensitive to triazine herbicides

Chloroplasts were isolated from triazine-sensitive and triazine-resistant biotypes of common groundsel (Senecio vulgaris L.), common lambsquarter (Chenopodium album L.), and redroot pigweed (Amaranthus retroflexus L.). Chloroplast lipids were extracted and analyzed for differences among sensitive and resistant biotypes. The distribution of lipid between major lipid classes differed in chloroplasts from resistant and susceptible biotypes. Chloroplasts from resistant biotypes contained higher proportions of monogalactosyl diglyceride and phosphatidyl ethanolamine and lower proportions of digalactosyl diglyceride and phosphatidyl choline than did chloroplasts from susceptible biotypes. Monogalactosyl diglyceride and phosphatidyl ethanolamine were also quantitatively higher in membranes of resistant versus susceptible biotypes. The major lipid classes of resistant chloroplast membranes contained lipids comparatively richer in unsaturated fatty acids with the exceptions of digalactosyl diglyceride from all three biotypes and phosphatidyl ethanolamine from common groundsel. Results correlated changes in triazine sensitivity with qualitative and quantitative differences in the lipid composition of chloroplast membranes.