Search

Increased complications following failed hypospadias repairs suggest that impaired wound healing is a contributing factor. We used perioperative hyperbaric oxygen therapy to promote wound healing determined by graft take in staged tubularized autograft reoperations using oral graft.Hyperbaric oxygen therapy was recommended for patients with 3 or more failed hypospadias repairs, comprising 20 preoperative and 10 postoperative sessions. All patients underwent reoperative staged tubularized autograft repair using oral mucosa. Graft lengths and widths were measured at grafting and again at the second stage, from which graft area was calculated. The primary outcomes were percent graft contracture and graft failure, defined as contracture 50% or greater. Patients who received hyperbaric oxygen therapy were compared to other patients who underwent reoperative staged tubularized autograft who did not receive therapy.Among 57 patients 32 received hyperbaric oxygen therapy and 25 did not as they had fewer than 3 prior repairs, or were not able to receive treatment due to insurance issues or lack of local availability. Grafts were healthier in those receiving hyperbaric oxygen therapy, with significantly less percent area contracture (9% vs 26%, p=0.04) and graft failure (6% vs 28%, p=0.03) compared to those not receiving therapy, although treated patients had significantly more prior failed hypospadias repairs.Hyperbaric oxygen therapy improved graft take in hypospadias reoperations. This observation also calls attention to wound healing as another variable to consider in hypospadias surgery.

Objective We examined predictors of clinically significant levels of psychological distress among individuals with upper limb loss (ULL). Design A multisite, cross-sectional study completed at six prosthetic rehabilitation centres throughout the United States. Methods Oral administration of a brief assessment battery to 307 participants with ULL including demographic variables, injury information, screening instruments for PTSD and depression, pain interference, and activity restriction measures. Hierarchical multinomial logit models were conducted. Outcome groups were created using recommended cut-off scores on brief screening measures of depression and PTSD. Final models were assessed including relative risk ratios and marginal effects. Results Over half of the sample screened positive for depression, PTSD, or both. Eight individuals exceeded the recommended cut-off score indicative of PTSD only (2.6%), and 106 participants (34.5%) screened positive for depression only. Moreover, 64 participants (20.8%) reported co-occurring PTSD and depression. Subsequent models revealed women and ethnic minority participants were more likely to have clinically significant levels of depression and PTSD. Greater restriction in activity and increased pain interference also predicted psychological distress. Conclusions These findings indicate a significant number of individuals with ULL experience clinically significant levels of psychological distress, and routine clinical assessment of depression and PTSD is warranted. Women and individuals from ethnic minorities may be particularly at risk, regardless of the severity and cause of ULL. Restrictions in preferred and goal-directed activities and persistent pain are also contributing factors. Psychological interventions that address these issues are indicated. Statement of contribution What is already known on this subject? Research investigating psychological reactions and adjustment after limb loss has primarily focused on lower limb loss. Little research has investigated psychological adjustment or distress following upper extremity loss. Lower extremity limb loss is more likely to be from a disease process while upper extremity limb loss is more likely to be due to traumatic injuries. Upper extremity limb loss possesses a qualitatively different experience as upper limb amputation is more readily apparent to others, impacts activities of daily living, and limits instrumental function in social and non-verbal communication. What does this study add? A significant percentage of individuals with upper limb loss report significant levels of depression, PTSD, and mixed depression and PTSD. Moreover, women and minority clients were more likely to report clinically significant levels of depression and mixed PTSD and depression. Activity restriction and pain interference's contributions in the final model helped to elucidate the clinical picture of psychological distress for persons with upper extremity limb loss. Greater activity restriction and limitations from pain interference increased the likelihood of reporting clinically significant levels of psychological distress.

The hypothalamus is a brain region critical for the homeostatic regulation of appetite and energy expenditure. Hypothalamic neuronal activity that is altered during development can produce permanent physiological changes later in life. For example, circulating hormones such as insulin have been shown to influence hypothalamic neuronal projections, leading to altered metabolism in adult rodents. While insulin signaling in the post-hatch chicken has been shown to mirror that of mammals, the developmental role of insulin in the avian embryonic hypothalamus remains largely unexplored. Here we present the earliest known evidence for insulin receptor (InsR) expression in embryonic avian hypothalamic nuclei governing energy homeostasis. RT-PCR analysis reveals InsR mRNA in E8, E10, and E12 neurons while western blot data demonstrate protein expression in E12 avian whole brain and hypothalamic lysates. Immunohistochemical analysis of avian hypothalamic brain slices demonstrates a shift in InsR localization from paraventricular expression in E8 to a more defined concentration of InsR in developmental regions resembling the ventromedial hypothalamus (VMH) and arcuate nucleus (ARC) in E12 time points. In addition, InsR expression appears in a heterogeneous pattern, suggesting receptor localization to subpopulations of avian hypothalamic neurons as early as E8. With increasing evidence suggesting energy homeostasis pathways may be altered via the gestational environment, it is important to understand how insulin signaling may affect embryogenesis. Our research provides evidence for the earliest known embryonic expression of InsR protein in the avian hypothalamus and may suggest a developmental role for insulin signaling in the early patterning of metabolic pathways in the central nervous system.

Supplemental Digital Content is available in the text., Background. For liver transplant candidates on the waiting list, deciding to accept a donor organ with known or potential risk factors can be stressful and can lead to declined offers. Current education for patients and family often takes place during transplant evaluations and can be overwhelming and result in low retention and poor understanding of donor quality. Methods. In the first phase, we sought to understand provider experiences when counseling patients about donor risks and donor offers. We conducted interviews and focus groups with liver transplant providers at 1 local center and at a national clinician conference. Twenty providers participated: 15 hepatologists and 5 surgeons. The provider feedback was used to create an initial outline of content that is consistent with decision support frameworks. In a second phase, graphic design collaborators created mockups of a patient-friendly tool. We reviewed mockups with 4 transplant coordinators and 9 liver transplant candidates for feedback on clarity and utility to prepare for an organ offer. Patient responses allowed a comparison of perceived readiness to receive an offer call before and after viewing mockups. Results. We identified themes relating to the offer process, repetition and timing of education, and standardization and tailoring of content. The results indicated a gap in available education after the evaluation session, and information specific to offer decisions is needed. Patient feedback emphasized the need to review the offer process before a real offer. Conclusions. Patients and providers responded favorably to a patient tool addressing existing gaps in education while waiting for a donor offer. Additional patient, family, and provider feedback will guide the development of an interactive tool to prepare patients and families for an offer decision.

Phillip Snodgrass,1 Warren Snodgrass,2 Nicol Bush2 1Dartmouth Medical Center, Lebanon, NH, USA; 2Hypospadias Specialty Center, The Colony, TX, USACorrespondence: Nicol Bush Email bush@hypospadias.comIntroduction: Reports indicate many parents are negatively impacted by their child’s birth defect, experiencing feelings of anxiety, shame, and blame. These reactions have been documented for several conditions, but not hypospadias. We surveyed parents of boys with hypospadias to determine their concerns.Materials: The validated Impact of a Child with Congenital Anomalies on Parents (ICCAP) questionnaire was administered to parents recruited through social media.Results: There were 260 respondents (80% female, average age 35 years): 86% said they had never heard of hypospadias before their son’s diagnosis; 57% of mothers and 38% of fathers wondered if they were to blame for the hypospadias. This increased to 78% among women given progesterone during pregnancy. Sixty-four percent reported they worry “a great deal” about their son’s health, despite successful repair, which increased to 88% when surgery was not successful. Twenty percent responded that the surgeon did not spend enough time with them.Conclusion: Most parents of newborns with hypospadias have never previously heard of the condition. Many wondered if they are to blame for the birth defect, and most reported that they worry “a great deal” about their son’s future health, whether or not repair was successful. One in five said surgeons did not spend enough time to discuss these concerns, and one in four said their explanations were unclear. Awareness of these concerns is important for urologists since they are the primary caregivers for patients with hypospadias.Keywords: birth defect, hypospadias, parent blame, parent anxiety

Patients in the US in need of a life-saving organ transplant must complete a long process of medical decisions, and a first step is to identify a transplant center to complete an evaluation. This study describes a patient-centered process of testing and refinement of a new website (www.transplantcentersearch.org) that was developed to provide data to patients who are seeking a transplant center. Mixed methods, including online surveys and structured usability testing, were conducted to inform changes in an iterative process. Survey data from 684 participants indicated the effects of different icon styles on user decisions. Qualitative feedback from 38 usability testing participants informed improvements to the website interface. The mixed methods approach was feasible and well suited to the need to address multiple development steps of a patient-facing tool. The combined methods allowed for large survey sample sizes and also allowed interaction with a functioning website and in-depth qualitative discussions. The approach is applicable for a broad range of target user groups who are faced with challenging decisions and a need for information tailored to individual users. The survey and usability testing concluded with a functioning website that is positively received by users and meets the objective to support patient decisions when seeking an organ transplant.

We demonstrate a novel way to introduce a so-called Hg reference gas, produced by a gas generator, into an elemental detector, such as ICP-MS, and to directly measure gaseous oxidized mercury (GOM as HgCl2) at a wide range of concentrations, covering 4 orders of magnitude. The approach was tested using two types of generators based on the dilution of a gas saturated with mercury chloride vapours (from dry HgCl2 salt) and on the evaporation of aqueous HgCl2 standards. The former generator provided reference gas at μg m−3 concentrations, while the latter was applicable from low ng m−3 to μg m−3. The generation and measurement of gaseous Hg was achieved in real time without significant memory effects, and with a response time shorter than 5 min. This unique approach of direct measurement (without thermal conversion) of both gaseous elemental mercury (GEM) and GOM from environmentally relevant to industrial concentrations has been shown to offer the potential to significantly improve the reliability of Hg determination from gas generators. This, in the longer term, will be invaluable to improve accuracy of in-field Hg measurements.

BACKGROUND: The Scientific Registry of Transplant Recipients provides transplant program-specific information, but it is unclear what patients and stakeholders need to know. Acceptance criteria for the candidate waitlist and donor organs vary by program and region, but there is no means to search for programs by the clinical profiles of recipients and donors. METHODS: We examined variability in program-specific characteristics that could influence access to transplantation. We also conducted three interviews and three focus groups with heart transplant candidates and recipients. Participants evaluated prototypes of a patient-specific search tool and its capacity to identify programs tailored to specific patient needs. Patient experiences and feedback influenced the development of tools. RESULTS: The distribution of recipient and donor characteristics influenced access to transplantation, as age and body mass index varied across programs (all with p < .01). Several themes emerged related to decision-making and the perceived usability of the patient-specific search. Perceptions of the prototypes varied, but were positive overall and support making the patient-specific search publicly available. Participants revealed barriers to evaluating transplant programs and suggest that patient-specific search results may optimize the process. CONCLUSIONS: The patient-specific tool (http://transplantcentersearch.org/) is valued by heart transplant patients and is important to maximizing access to transplant.

Background. Patients face obstacles in finding a transplant program that meets their healthcare needs. Acceptance criteria and waiting times vary by region and program. The Scientific Registry of Transplant Recipients provides program-specific information, but it is unclear what patients and referring physicians need to know. Methods. We examined variability in program-specific characteristics that could influence access to transplantation. We also conducted 20 interviews and 16 focus groups with transplant candidates, recipients, and their family members. Participants were shown prototypes of a patient-specific search tool and evaluated its capacity to identify programs tailored to the needs of individual patients. Results. The distribution of recipient and donor characteristics that may impact access to transplantation, such as recipients on Medicaid, varied across programs (all with P < 0.01). Several themes emerged related to impressions of access to transplantation and the usability of patient-specific search functions. Perceptions of the prototypes and results varied, but were positive overall and support providing an individualized search of program level data. Participants revealed significant barriers to identifying and evaluating transplant programs and suggest that patient-specific search results reduce the anxiety associated with selecting a program. Conclusions. Providing patient-specific tools is valued by patients and important to maximizing access to transplant.

Summary Introduction Hypospadias cripple patients pose a major surgical challenge with high complication rates attributed mainly to graft contraction. Hyperbaric oxygen therapy (HBOT) is an established treatment for compromised grafts and used extensively as a salvage therapy for compromised grafts and ischemic non-healing wounds. Objective We evaluated the graft-take rates in hypospadias cripple cases undergoing a staged tubularized autograft repair (STAG) and compared between patients treated with or without preemptive HBOT. Materials and methods All patients underwent a STAG. Patients receiving preemptive HBOT were compared with patients receiving the standard surgical procedure without HBOT. The HBOT protocol included a daily session, 5 days per week for four weeks before the surgery and 10 additional daily sessions immediately after first-stage surgery. Each HBOT session included 90 min exposure to 100% O2 at 2 atmospheres absolute with 5 min air breaks every 20 min. The primary endpoint was graft take. Sequential tubularization without tension at second stage was defined as success. Results Seven boys received HBOT and 14 boys comprised the control group. All patients in the HBOT group had good graft take with no graft contraction. In the control group, 57% had good graft take and could proceed to the second-stage surgery and 43% had graft contraction (Table). Except for one patient who had claustrophobia while entering the chamber, no significant side-effects developed during the HBOT. Discussion The basic pathophysiology of compromised flaps includes both ischemia and reperfusion injury, which can be attenuated by HBOT. The beneficial effects of HBOT relates to several mechanisms, including hyperoxygenation, fibroblast proliferation, collagen deposition, angiogenesis, and vasculogenesis. Graft contraction is a well-known complication in hypospadias cripple population with reported failure rate of 39–63%. The HBOT procedure was found to be very effective and the entire HBOT group had a good graft take. Accordingly, all patients in the HBOT group proceeded to a successful second-stage tubularization. In addition, HBOT was found to be safe and generally well tolerated by this pediatric population. Study limitations were a relative small, non-homogenous sample size and lack of prospective randomization. Success was defined as sufficient graft elasticity sufficing for tubularization of the neourethra, and exact graft measurements are lacking in this study. Conclusions Preemptive HBOT can be used safely in the hypospadias cripple pediatric population and can potentially reduce the expected high surgical failure secondary to graft contraction. Summary Table . Surgical data and outcome. Surgical parameters Hyperbaric oxygen therapy (n = 7) Control (n = 14) Type of graft Prepuce (%) – 5 (36) Cheek (%) 3 (43) 4 (28) Lower lip (%) 2 (28) 2 (14) Groin skin flap (%) 2 (28) 3 (21) Good graft take (%) 7 (100) 8 (57) Corporoplasty Dorsal plication 2 2 Deep horizontal ventral corporal incisions – 5

SRTR uses data collected by OPTN to calculate metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2018, there were 10,721 deceased donors, and this number has been increasing since 2010. The number of deceased donor transplants increased to 29,676 in 2018 from 28,582 in 2017, and this number has been increasing since 2012. The recent increase may be due in part to the rising number of deaths of young people due to the opioid epidemic. In 2018, 4994 organs were discarded, slightly more than 4813 in 2017. In 2018, 3755 kidneys, 278 pancreata, 707 livers, 3 intestines, 23 hearts, and 317 lungs were discarded. These numbers suggest an opportunity to increase numbers of transplants by reducing discards.

Rajnandgaon district (Chhattisgarh, India) faces serious arsenic pollution problems. Tree bark could be a valuable indicator of As and heavy metals air contamination. In this study, road du...

Purpose: Examining the relationship between posttraumatic stress disorder and posttraumatic stress disorder symptom clusters (re-experiencing, avoidance, hyperarousal, emotional numbing) on three s...

Objectives (1) To develop a performance-based measure for adult upper limb (UL) prosthetic functioning through broad (ie, overall performance) and functional domain-specific (eg, control skills) assessment of commonplace activities; (2) to conduct initial psychometric evaluation of the Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL). Design Internal consistency of CAPPFUL and interrater reliability for task, functional domain, and full-scale (sub)scores among 3 independent raters were estimated. Known-group validity was examined comparing scores by amputation level. Convergent validity was assessed between CAPPFUL and 2 hand dexterity or function tests; discriminant validity was assessed against self-reported disability. Setting Six prosthetic rehabilitation centers across the United States. Participants Subjects (N=60) with UL amputation using a prosthesis. Interventions Not applicable. Main Outcome Measures Not applicable. Results Interrater reliability was excellent for scoring on the task, domain, and full-scale scores (intraclass correlation coefficients=.88-.99). Internal consistency was good (α=.79-.82). Generally, subjects with higher UL amputation levels scored lower (worse) than subjects with lower UL amputation levels. CAPPFUL demonstrated strong correlations with measures of hand dexterity or functioning (rs=−.58 to .72) and moderate correlation with self-reported disability (r=−.35). Conclusions CAPPFUL was designed as a versatile, low-burden measure of prosthesis performance for any UL functional prosthetic device type and any UL amputation level. CAPPFUL assesses overall performance and 5 functional performance domains during completion of 11 tasks that require movement in all planes while manipulating everyday objects requiring multiple grasp patterns. Psychometric evaluation indicates good interrater reliability, internal consistency, known-group validity, and convergent and discriminant validity.

OBJECTIVES/GOALS: Kidney transplant is superior to dialysis for the treatment of end-stage kidney disease, but accessing transplant requires high patient engagement. We sought to develop a group counseling intervention with patients and their social support members using an evidence-based, stakeholder-engaged approach. METHODS/STUDY POPULATION: We employed an Intervention Mapping approach to incorporate qualitative data from stakeholders on barriers to accessing kidney transplant. Data were collected from 13 focus groups of African American (AA) and white adult kidney transplant candidates and their social support networks in Minnesota and Georgia. We completed this process through (1) qualitative data collection, (2) utilizing data and intervention mapping methods to develop a conceptual framework to describe associations between behavioral determinants and desired outcomes, and (3) using these products to identify evidence-based approaches to modify behavioral determinants through a theory based intervention. RESULTS/ANTICIPATED RESULTS: Participants describe experiences of overwhelm, isolation, helplessness, and difficulty communicating. In addition, AA participants expressed distrust in the medical system. We systematically incorporated these themes into a conceptual model of behavior change that identifies determinants of necessary actions to obtain transplant, including knowledge, self-efficacy, reduced decisional conflict, and perception of social support. Evidence-based methods to modify these determinants, such as modeling, goal-setting, and mobilizing social support, were incorporated into the design of a group education and counseling intervention with an individualized risk calculator. DISCUSSION/SIGNIFICANCE OF IMPACT: Intervention mapping allows for behavior change theories to be incorporated into counseling sessions with patients and their social support networks. This approach translates qualitative data into an evidence-based intervention which will be piloted in a randomized controlled trial (RCT) to determine feasibility for a larger RCT.

Coal-fired power plants cause serious environmental impacts associated with air pollution, particulate matter, and heavy metals (HMs), among others. In this work, the spatial, temporal, and...

Variations in candidate and donor acceptance criteria may influence access and mortality for liver transplantation. We sought to understand how recipient and donor characteristics vary across centers and how patients interpret this information, and we used these data to develop a tool to provide tailored information to candidates seeking a center (www.transplantcentersearch.org). We analyzed liver recipient data from the Scientific Registry of Transplant Recipients to determine how recipient and donor characteristics (eg, age, Medicaid use, and human immunodeficiency virus status) varied across programs. Data included recipients and donors at each US program between January 1, 2015, and December 31, 2017. The variation in characteristics was plotted with centers stratified by total transplant volume and by volume of each characteristic. A subset of characteristics was plotted to show variation over 3 years. We created mockups of potential reports displaying recipient characteristics alongside pretransplant and posttransplant outcomes and solicited feedback at patient and family interviews and focus groups, which included 39 individuals: 10 pilot interviews with candidates seeking liver transplant at the University of Minnesota-Fairview (UMNF) and 5 focus groups with 13 UMNF candidates, 6 UMNF family members, and 10 national recipients. Transcripts were analyzed using a thematic analysis. Several themes emerged: (1) Candidates experience gaps in existing education about center options; (2) patients requested information about how selection criteria might impact access to transplant; and (3) information tailored to a candidate's medical characteristics can inform decisions. Characteristics shown on mockups varied across centers (P

The FAO of the UN convened an Expert Working Group meeting to provide recommendations related to protein quality evaluation of Follow-up Formula for Young Children (FUF-YC) and Ready-to-Use Therapeutic Foods (RUTFs). The protein and amino acid (AA) scoring patterns for the target age groups were defined and recommendations provided on the use of currently available protein and indispensable AA digestibility data. For FUF-YC, an age category of 1-2.9 y was identified, and a matching protein requirement of 0.86 g · kg-1 · d-1 with corresponding AA requirements were recommended. For RUTF, the protein requirement recommended was 2.82 g · kg-1 · d-1, to achieve a catch-up weight gain of 10 g · kg-1 · d-1 in children recovering from severe acute malnutrition. The AA requirements were factorially derived based on the adult protein requirement for maintenance and tissue AA composition. A flowchart was proposed for the best available methods to estimate digestibility coefficients (of either protein or AAs), in the following order: human, growing pig, and rat true ileal AA digestibility values. Where this is not possible, fecal protein digestibility values should be used. The Expert Working Group recommends the use of the Protein Digestibility Corrected Amino Acid Score (PDCAAS), with existing protein digestibility values, or the Digestible Indispensable Amino Acid Score provided that individual AA digestibility values are available for protein quality evaluation using the latter score. The Group also recommends the use of ileal digestibility of protein or of AAs for plant-based protein sources, recognizing the possible effects of antinutritional factors and impaired gut function. A PDCAAS score of ≥90% can be considered adequate for these formulations, whereas with a score

Background: The time dependent benefit of rt-PA in acute stroke patients is established. However, only limited data exist on LVO outcomes post remote telemedicine administered rt-PA. We report the outcomes of such patients. Methods: A retrospective study of the CPMC stroke database was performed. Primary outcome measures were neurologic outcome at discharge, mortality, and TICI reperfusion scores of mechanical thrombectomy (MT) treated patients. The safety outcome measure was symptomatic hemorrhage rate (SICH; NIHSS > 1 at ≤ 36hr). Results: From 1/2014-2/2018, 233 transferred rt-PA patients were identified. Median age was 73, and median NIHSS 6. Risk factors included hypertension (69%), dyslipidemia (43%), AF (27%), prior stroke/TIA (26%), CAD (26%), DM (24%), smoking (16%), and CHF (13%). The post rt-PA SICH rate was 4% and discharge mRS≤2 rate was 43%. Mortality rate was 11%, 43% required help at discharge, and 40% were discharged home. For the 61 patients who received rt-PA + MT, the SICH rate was 2% and mortality rate 12%. Median discharge NIHSS was 2 and mRS ≤2 rate was 19%. Of the 233 transferred patients, 40 had a pre rt-PA CTA with LVO available for review. For these patients, median time to scan was 76 min. Median time to repeat CTA at CPMC was 180 min. LVO was 80% anterior circulation, clot migration was seen in 5%, and >90% of MT patients had AF. Post rt-PA recanalization rate was 12% (0% posterior circulation). MT after rt-PA was performed in 62% (TICI ≥ 2b 88%). Longer time to treatment trended towards poorer result and longer MT time. Average NIHSS dropped from 12 to 5 and average discharge mRS was 3. Conclusions: These data confirm that remote IV rt-PA followed by MT is safe and effective. Of LVO rt-PA patients 17% experienced full or partial recanalization suggesting repeat imaging is appropriate before initiating MT, possibly with the exception of posterior circulation strokes because of poor response to rt-PA. AF is common and may predict need for MT after rt-PA. A trend was observed towards improved TICI score and shorter recanalization time with a shorter latency between rt-PA and MT. These data support the use of stroke systems of care to ensure rapid triage and treatment of LVO patients.

Summary Extended Summary Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened while preserving the urethral plate to use TIP repair. That is usually done by dorsal plication (DP). However, we reported recurrent VC was commonly found after DP in boys with proximal urethroplasty complications, and have diagnosed VC in patients similarly straightened by WS. We reviewed our proximal TIP patients and now report their recurrent VC. Methods We used a prospectively-maintained database to identify all patients with proximal TIP by WS and document recurrent VC. Penile straightening was primarily done by midline DP using 5–0 or 6–0 polypropylene, and/or other maneuvers including combinations of urethral plate elevation off the corpora, mobilization of the urethra to the external sphincter, and ventral corporotomies. Recurrent VC was suspected by a characteristic ‘hunched-over’ appearance and resistance to lifting the glans cephalad (Figure), and confirmed in all cases by artificial erection intraoperatively. Results 58 of the 77 patients with follow up had VC straightened. Recurrent VC was diagnosed in 26%. It was suspected during this review in another 10% who had recurrent urethroplasty complications which we now know often indicate VC, or urethral plate elevation with no treatment for corporal disproportion. This recurrent VC was objectively measured in nearly half those diagnosed, averaging 52 (30–75). It was diagnosed before puberty in all cases. There was no difference in recurrent VC in those managed with DP alone versus those straightened by DP and/or other maneuvers. Discussion The finding that 1 of every 4 patients had recurrent VC after proximal TIP, and that as many as 1 of every 3 might have had that complication, is concerning. During most the study the extent of VC was visually estimated, and most patients were thought to have We reported 70% of patients operated elsewhere for proximal hypospadias and presenting with urethroplasty complications had recurrent VC ≥ 30° following earlier DP. In that series, in the current patients, and in an earlier report by Braga et al., an intact urethral plate correlated with increased risk for recurrent VC. Despite our improved ability to diagnose recurrent VC, we have not found it in boys who underwent STAG repair with urethral plate transection. Conclusions Recurrent VC after proximal TIP repair occurred in at least 1 of every 4 patients despite DP and/or additional maneuvers to straighten the penis while preserving the urethral plate. Accordingly, we now only perform proximal TIP when there is little ( Download : Download high-res image (116KB) Download : Download full-size image Figure 1 . Recurrent ventral curvature > 30 after proximal TIP with dorsal plication. In addition to the ‘hunched over’ appearance, there is resistance to lifting the glans cephalad and the penis snaps back to this position when released.

Background Temporal lobe epilepsy (TLE) with unclear lateralization may require intracranial implantation of electrodes (IIE). We retrospectively assessed the association between the use of IIE and long-term outcomes in patients undergoing anterior temporal lobectomy (ATL). Participants and methods We retrospectively reviewed the records of 1,032 patients undergoing epilepsy surgery at our center from 1977 to 2006. Patients who underwent ATL were included. Seizure outcome was assessed through final follow-up. Those who underwent scalp and IIE (mostly evaluated with temporal subdural strip electrodes) were compared. Results From 497 patients who underwent ATL, 139 did so after IIE placement in the temporal lobes. Mean age at surgery was 32.3±12.3years and median duration of follow-up 24 months (range: 6–36). Fifty-three percent of those evaluated with IIE were seizure-free at their last available visit (vs. 68% evaluated with only scalp EEG, p=0.002). Patients with lesional TLE generally had a better outcome (65.5% seizure free) than those without lesions (56.3%, p=0.093), especially for unilateral TLE diagnosed with IIE. In a multivariate Cox regression analyses adjusted for gender, neuropsychological concordance, pathological findings, and post-operative seizures, bilateral TLE predicted seizure recurrence in IIE patients (HR=2.08, 95% CI: 1.08–4.0, p=0.029). Conclusions More than a half of those who undergo IIE in suspected TLE are seizure free after ATL. IIE allows for the identification of surgical candidates.

Objective To test mediating effects of positive emotion and activity restriction on the associations of resilience and pain interference with distress reported by individuals with traumatic upper limb loss evaluated for prosthetics. Design Cross-sectional correlational study of several demographic and self-report measures of resilience, pain interference, activity restriction, positive emotions, and symptoms of depression and posttraumatic stress. Setting Six regional centers throughout the United States. Participants A total of 263 prospective participants consented to be evaluated for eligibility and need for upper extremity prosthetics; participants (N=202; 57 women [28.2%] and 145 men [71.8%]; mean age, 41.81±14.83y; range, 18.01–72.95y) who sustained traumatic injuries were retained in this study. Most of them were identified as white (70.8%; n=143), followed by black (10.4%; n=21), Hispanic (9.9%; n=20), Asian (3.0%; n=6), other (1.5%; n=3), and missing (4.5%; n=9). Interventions Not applicable. Main Outcome Measures Primary Care Posttraumatic Stress Disorder Screen and depression screen. Results Resilience and pain interference were significantly correlated in predicted directions with positive emotions, activity restriction, and the 2 distress variables. A path model revealed that the associations of resilience and pain interference with both distress variables were completely mediated by positive emotions and activity restriction. There were no significant direct effects of resilience or pain interference on either distress variable. Conclusions Resilience may facilitate adjustment via beneficial and predicted associations with positive emotions and active engagement with the environment. These relations are independent of the significant and inverse associations of pain interference with these same variables. Longitudinal research is needed to understand interactions between positive emotions and activity over time in promoting adjustment after traumatic limb loss. Individuals reporting depression and/or posttraumatic stress disorder symptoms may require interventions that reduce avoidance and promote activities that may increase the likelihood of experiencing positive emotions.

Summary Objective We review development and evolution of TIP hypospadias repair, including technical changes made to improve its results. We also discuss general risk factors for hypospadias surgical complications. Methods We describe use of a database with prospective data entry to first identify our most common complications and their frequency, and then to monitor results of technical modifications made to reduce their occurrence. Multiple logistic regression of various factors recorded in the database was done to identify those predicting increased risk for urethroplasty complications. Results Fistula and glans dehiscence are the two most common complications we encountered after TIP repair. Changes in urethral plate tubularization and barrier layers covering the neourethra resulted in a significant reduction in fistulas after proximal TIP. Changes in glansplasty sutures and use of preoperative testosterone to increase glans size did not reduce likelihood for dehiscence, whereas increasing the extent of glans wings dissection did. Logistic regression analysis confirmed proximal meatal location and reoperation predicted increased complications, but also identified glans width ≤14 mm as an independent risk factor for hypospadias urethroplasty complications. Conclusions Systematic, prospective data collection facilitated identification of complications and their risk factors, and provided a means to assess results of modifications made to address them. Limiting the algorithm used for hypospadias repair increases expertise in those techniques used. Reported low surgical volumes for proximal hypospadias repair suggest subspecialization of these cases be carried out so that designated surgeons can achieve sufficient volume to analyze their results and make improvements.

This review summarizes data regarding commonly used surgical techniques to repair distal and proximal hypospadias. We review evidence concerning indications for various procedures used in primary hypospadias repair, and their complications, urinary function and esthetic results. Available evidence suggests TIP is preferable to Mathieu for distal hypospadias correction. Current data do not identify a clear preference between TIP and onlay flap for proximal repair when there is ventral curvature 31°. A review of objective data helps clarify decision-making for distal hypospadias repair. Additional objective evidence is needed to identify preferred options for proximal hypospadias repair. Measuring glansplasty dimensions (meatal size and distance from meatus to corona) may improve urinary function assessments, and provide additional objective data for decision-making between various surgical techniques.

OBJECTIVES/GOALS: AA are over-represented on the waitlist for kidney transplant and are often unaware of how waitlist acceptance practices differ across transplant programs and influence access to transplant. We will develop a culturally sensitive transplant program report card to communicate these variations. METHODS/STUDY POPULATION: Scientific Registry of Transplant Recipients (SRTR) data will be used to identity clinical factors strongly associated with AA access to transplant. Interviews and focus groups with AA kidney transplant candidates and their families will collect feedback on the SRTR report card and inform the development of the culturally sensitive report card. Additional focus groups will evaluate its effect on knowledge and medical decision making. We will collaborate with the stakeholders, including AA transplant candidates and their families, transplant programs, SRTR, and providers, to identify strategies to disseminate the report card in the AA community RESULTS/ANTICIPATED RESULTS: To date, no investigation has systematically collected feedback on the SRTR transplant program report card from AA candidates to ensure that the tool is accessible and effective in the AA community. We hypothesize that a culturally sensitive report card will improve AA candidates’ knowledge of program factors that impact access to transplant and enable informed decisions about where they pursue a transplant evaluation. The results of this study have the potential to change how AA patients are counselled while seeking transplantation. DISCUSSION/SIGNIFICANCE OF IMPACT: A culturally sensitive report card can reach more AA patients and enable more informed decision making by providing education about differences in transplant programs that may impact their access to transplant. In the future, we will design a trial to evaluate the prototype.

Summary Purpose Persistent or recurrent ventral curvature (VC) in patients with complications after proximal hypospadias repair is reported. Methods Records of patients undergoing re-operation for complications after proximal repair performed elsewhere were reviewed, including earlier operative reports when available. Original extent of VC, means used for straightening, and presenting complaints and findings at re-operation were tabulated. Ventral curvature at re-operation was objectively measured by goniometry and classified as due to short ventral skin and/or scarring of skin/dartos, short neourethra, or short ventral corpora (corporal disproportion). The finding of corporal disproportion at re-operation was considered to be failure of initial straightening. Results There were 73 patients with an average of 2.7 [1–5] prior operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50° (30–90). This was due to short skin/scarring in 7% patients, a short neourethra in 23%, and corporal disproportion in 70%. Initial straightening was performed by chordee excision in 18 patients, dorsal plication in 23, and ventral lengthening in 15. Persistent or recurrent corporal disproportion was significantly more likely after chordee excision or dorsal plication than after ventral lengthening (p = 0.005). Of patients with VC, 93% also had urethroplasty complications, including recurrent fistulas and wound dehiscences that appeared related to the curvature. Discussion The VC that was encountered during proximal hypospadias re-operations was important for several reasons. First, all patients with VC who had completed urethroplasty had complications that included recurrent fistulas and wound dehiscences (Figure). Even if they had healed without complications, this VC exceeded 30° in all cases, which is associated with sexual dysfunction in adults. This VC was not reported by 37% of caregivers and sometimes not apparent on pre-operative physical examination. It is possible there is selection bias in this series, although nearly all patients were self-referred for complications, and nearly 40% of them were not aware their son had VC. Furthermore, the finding that most initially had dorsal plication agrees with an earlier survey of pediatric urologists' preferences for straightening penile curvature. Conclusions The most common complication in this series was persistent or recurrent VC, and nearly all these patients also had urethroplasty complications. This VC was more likely when the urethral plate was preserved during straightening and when chordee excision or dorsal plication rather than ventral lengthening was performed. These data suggest that surgeons should objectively measure VC and consider ventral lengthening rather than chordee excision or dorsal plication when it is ≥ 30°. Re-operations for urethroplasty complications should include artificial erection. Download : Download high-res image (304KB) Download : Download full-size image Figure . Recurrent fistulas and VC. Recurrent fistulas after 3 prior fistula closures (left panel). VC 60° found at re-operation (right panel).

Purpose/objective The present study examines associations between levels of limb loss (partial hand vs. higher levels of limb loss) and eight clinically relevant measures of functional impairment, psychological well-being, and substance use. Research Method/Design: A cross-sectional, multisite study conducted at seven prosthetic rehabilitation centers across the United States. A total of 305 participants with upper limb loss (Mage = 44.28, SD = 15.45; 68.5% male; 70.5% white) completed orally administered self-assessments of pain interference, perceived activity restrictions, posttraumatic stress disorder (PTSD), depression, emotional reaction to their physical condition, problematic alcohol use, prescription medication overuse, and illicit drug use. Results Results showed individuals with partial hand loss were at significantly greater odds of endorsing pain interference and screening positive for PTSD. Results also showed level of limb loss was significantly associated with emotional reaction to their physical condition, such that participants with partial hand loss scored significantly above those with higher level limb loss. Conclusions/Implication: The current study highlights level of limb loss as an important correlate of several functional impairments and psychological measures among individuals with upper limb loss. These findings may inform clinicians and occupational therapists in their development of treatment and rehabilitation. In particular, practitioners should be cognizant of their patient's level of limb loss, as individuals with partial hand loss may be more susceptible to greater emotional reactions to their physical condition and increased psychological distress due to pain interfering with their work and elevated posttraumatic stress symptoms. (PsycINFO Database Record

Objective: To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries. Methods: The inventory was performed within the framework of the " Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire. Results: Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries. Conclusions: The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

There is widespread belief that hypospadias surgery in adults has a greater urethroplasty complication rate than similar repair in children. We compared outcomes of primary and reoperative hypospadias repair in adults vs children.We evaluated prospectively maintained databases of consecutive boys and adults, defined as Tanner 4 or greater, treated with primary or reoperative hypospadias repair from 2000 to 2013. We searched for urethroplasty complications, including fistula, glans dehiscence, stricture/stenosis and diverticulum. All operations were done with the goal of creating a neomeatus at the normal location at the tip of the glans. Univariate and multivariate analyses were done to determine whether pubertal status impacted urethroplasty complications.A total of 1,140 patients were operated on by a single surgeon, including 69 adults with a mean age of 23 years. Complications developed in 209 cases (18%), including 124 of 883 primary repairs (14%) and 85 of 257 reoperations (33%). There was no difference in outcomes between adults and children. Complications were noted in 1 of 8 men (12.5%) vs 123 of 871 children (14%) with primary repair (p = 0.9) and in 16 of 61 (26%) vs 69 of 196 (35%) with reoperation (p = 0.2). Multivariate analysis showed that a proximal meatus and reoperation were risk factors for complications but not pubertal status.In contrast to popular belief, our data do not indicate a greater risk for urethroplasty complications after hypospadias surgery performed in adulthood. Repair in adults can be done using the same techniques as in children with the same goal of a neomeatus at the tip of the glans.

We report outcomes in consecutive patients with primary proximal hypospadias and ventral curvature 30 degrees or greater after degloving, all repaired with 2-stage tubularized autografts, a variation of the Nicolle-Bracka procedure.Consecutive boys with proximal hypospadias and ventral curvature 30 degrees or greater after degloving underwent transection of the urethral plate. In addition, those with persistent ventral curvature 30 degrees or greater underwent 3 ventral corporotomies without corporal grafting for straightening. Staged graft urethroplasty was performed using prepuce, or labial mucosa, when the family requested preputioplasty. The goal in all cases was a straight penis with a normally positioned neomeatus.A total of 43 boys completed both stages with postoperative followup. Mean ventral curvature was 70 degrees, which necessitated corporotomy in 65%. There was no recurrent ventral curvature. Preputial grafts were used in 88%. A skin graft or scrotal flap was needed for ventral shaft coverage at the second stage in 4 boys (9%). During followup of an average of 22 months urethroplasty complications were diagnosed in 10 (23%), mostly glans dehiscence and fistulas. Of these patients 9 underwent 12 reoperations. Success was achieved in 42 (98%) patients.Staged tubularized autograft resulted in a straight penis with a normally positioned neomeatus in boys with the most severe proximal hypospadias in 77%, increasing to 98% after 1 or 2 distal reoperations for complications. There was no recurrent ventral curvature after 3 corporotomies without corporal grafting. Urethroplasty graft take was reliable.

This article has been withdrawn at the request of the author(s) and/or Editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy of Article Withdrawal can be found at: https://www.elsevier.com/about/our-business/policies/article-withdrawal .

Background and purpose Retinoblastoma (RB) is a rare malignancy affecting the pediatric population. Intravenous chemotherapy is the longstanding delivery method, although intra-arterial (IA) chemotherapy is gaining popularity given the reduced side effects compared with systemic chemotherapy administration. Given the sensitivity of the target organ, patient age, and secondary tumor susceptibility, a premium has been placed on minimizing procedural related radiation exposure. Materials and methods To reduce patient x-ray dose during the IA infusion procedure, customized surgical methods and fluoroscopic techniques were employed. The routine fluoroscopic settings were changed from the standard 7.5 pulses/s and dose level to the detector of 36 nGy/pulse, to a pulse rate of 4 pulses/s and detector dose to 23 nGy/pulse. The angiographic dose indicators (reference point air kerma (K a ) and fluoroscopy time) for a cohort of 10 consecutive patients (12 eyes, 30 infusions) were analyzed. An additional four cases (five eyes, five infusions) were analyzed using dosimeters placed at anatomic locations to reflect scalp, eye, and thyroid dose. Results The mean K a per treated eye was 20.1±11.9 mGy with a mean fluoroscopic time of 8.5±4.6 min. Dosimetric measurements demonstrated minimal dose to the lens (0.18±0.10 mGy). Measured entrance skin doses varied from 0.7 to 7.0 mGy and were 73.4±19.7% less than the indicated Ka value. Conclusions Ophthalmic arterial melphalan infusion is a safe and effective means to treat RB. Modification to contemporary fluoroscopic systems combined with parsimonious fluoroscopy can minimize radiation exposure.

Little is known about how patients make the critical decision of choosing a transplant center. In the United States, acceptance criteria, waiting times, and mortality vary significantly by geography and center. We sought to understand patients' experiences and perspectives when selecting transplant centers. We included 82 kidney transplant patients in 20 semi-structured interviews, nine focus groups with local candidates, and three focus groups with national recipients. Sites included two local transplant centers in Minneapolis, Minnesota, and national recipients from across the United States. Transcripts were analyzed by two researchers using a thematic analysis. Several themes emerged related to priorities and barriers when choosing a center. Patients were often unfamiliar with options, even with multiple local centers. Patients described being referred to a specific center by a trusted provider. Patients prioritized perceived reputation, comfort, and convenience. Insurance coverage was both a source of information and a barrier to options. Patients underestimated differences across centers and the effects on being waitlisted and receiving a transplant. Barriers in decision making included an overwhelming scope of information and difficulty locating information relevant to patients with unique medical needs. Informed decisions could be improved by the dissemination of understandable information better tailored to individual patient needs.

To determine prevalence and risk factors for renal scar in children referred for urologic assessment of febrile UTI and/or VUR.Pre-determined risk factors for renal scar were prospectively recorded in consecutive patients referred for UTI/VUR. Age, gender, VUR grade, and reported number of febrile and non-febrile UTIs were analyzed with logistic regression to determine risk for focal cortical defects on non-acute DMSA.Of 565 consecutive children, 24 (4%) had congenital renal dysplasia and 84 (15.5%) had focal defect(s). VUR, especially grades IV-V, recurrent febrile UTI, and older age increased risk. For any age child with the same number of UTIs, VUR increased odds of renal defect 5.4-fold (OR = 5.4, 95% CI = 2.7-10.6, AUC = 0.759).Focal DMSA defects were present in 15.5% of 565 consecutive children referred for febrile UTI and/or VUR; 4% had presumed congenital reflux nephropathy without cortical defect. All VUR grades increased risk for these defects, as did recurrent febrile UTIs and older age. However, 43% with grades IV-V VUR and 76% with recurrent UTI had normal DMSA.

Introduction We previously described urethral plate (UP) dissection and urethral mobilization from the corpora cavernosa to achieve or facilitate straightening ventral curvature while preserving the UP for TIP in boys with proximal hypospadias. The original patients had similar complications to those undergoing proximal TIP without UP elevation. Subsequently an increased occurrence of neourethra strictures in those with UP elevation and urethral mobilization was recognized, and is now reported. Materials Information on consecutive patients with proximal TIP repair with and without UP elevation and urethral mobilization by a single surgeon was reviewed in a database with pre-determined data points entered on the day of service. Results There were 76 proximal TIP patients with follow up, 29 with and 47 without UP elevation and urethral mobilization, with strictures developing in 5 (17%) and 0, respectively, p = 0.01. All strictures were symptomatic (UTI, urinary retention), 0.1–1.0 cm long, and diagnosed at ≤1.5 years after surgery. Conclusions UP elevation and urethral mobilization with TIP resulted in focal devascularization of the neourethra with symptomatic stricture development. Although most patients with these straightening maneuvers did not have stricture, we no longer recommend UP elevation and urethral mobilization with proximal TIP repair.

Polyethylene glycol (PEG) is common first-line therapy for urinary symptoms despite minimal evidence-based support. We performed a randomized, double-blind, placebo-controlled study of PEG for initial treatment of overactive bladder (OAB) symptoms in children.Patients aged3 years underwent baseline urinary symptom questionnaire (USQ, scored 0-16), bowel symptom questionnaire (scored 0-20) and abdominal X-ray (KUB). Patients were randomized to placebo/PEG regardless of parent's perception of constipation. After 1 month, patients completed follow-up questionnaires and KUB. Improvement was defined as decrease in USQ (ΔUSQ) ≥ 3 points. Secondary analyses compared urinary and bowel symptoms to KUB.Of 138 enrolled patients, 71 (51.4%) completed 1 month of therapy. Analyses of those randomized to placebo vs. PEG and non-completers demonstrated similar demographics, baseline symptoms, and KUB. Patients treated with placebo and PEG both had significant improvement in USQ scores (p0.0001). Patients treated with placebo and PEG responded similarly to placebo (ΔUSQ 3.7 vs. 3.4, p = 0.773), with improvement in nearly half (48.5% PEG vs. 44.7% placebo). There was no correlation between KUB and urinary or bowel symptoms.Nearly 50% of patients with urinary urge symptoms treated with either placebo or PEG for 1 month had improvement in urinary symptoms. KUB did not correlate with baseline or follow-up urinary or bowel symptoms.