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Introduction: Data quality is essential for trauma registries, but few tools have been developed to maximize it. The author's center created a new application to automatically identify >500 logic errors in registry data and produce individualized data quality reports for staff. Objective metrics indicated the application is effective, but staff perceptions were unknown. The aim of this project was to assess registry staff satisfaction with and perceived usefulness of the new application., Methods: Anonymous cross-sectional online survey with 5-point Likert scales and free-text responses., Results: Of 10 eligible staff members who use the new application, 8 responded to the survey. Confidence in data accuracy before the new application was generally low but unanimously higher after implementation (8/8; 95% CI, 5/8-8/8). Respondents found the application at least somewhat helpful overall (6/6; 95% CI, 3/6-6/6; 2 nonresponses), with 5/6 finding it very helpful. Respondents were at least somewhat satisfied with the new application (8/8; 95% CI, 5/8-8/8), with 4/8 being very satisfied. There was minimal negative feedback other than the new process being initially overwhelming., Conclusions: Respondents found the new application to be beneficial in several ways, including indirectly. Additional research is needed to be able to generalize these single center findings and determine best practices for data validation, but software-based approaches to augment more common data validation processes may be a beneficial and welcomed job aid for registry staff., (© 2024 National Cancer Registrars Association.)

Background: Project Safe Neighborhoods: Dallas (PSND) is part of a national initiative that partners federal, state, and local stakeholders and law enforcement to reduce violent crime, especially firearm violence, in select communities. The authors' hospital is located centrally in PSND's target areas, and the trauma center's service area fully covers the target areas. This cohort study evaluated PSND's effectiveness by examining if PSND's April 2018 launch was associated with decreases in (1) violent crime or (2) the rate of patients presenting with firearm and assaultive injuries., Methods: Data on violent crime (murder/non-negligent homicide, robbery, and aggravated assault) were obtained from all municipalities in the county for January 2015 - December 2020. Patient volume data were queried from the trauma registry for the same period. Nonlinear spatiotemporal models were used to calculate estimated rates and confidence intervals; derivatives were used to determine periods of significant change. Spatial point pattern tests assessed potential relocation of criminal activity. Given the importance of reducing violent crime, alpha was set at 0.05., Results: The target areas' violent crime rate remained higher than the non-target areas' throughout the study period, and target area violent crime non-significantly increased after PSND's launch. Violent crime in the non-target area increased significantly between February 2018 and February 2019. Part of this increase was attributable to a 7-fold increase (odds ratio [95% confidence interval] = 7.32 [2.58, 30.65], p < 0.001) in one police patrol beat just outside of the target areas. After years of decreases, rates of patients presenting with assaultive injuries or firearm injuries began significantly increasing and nearly doubled within two years of PSND., Conclusions: Results suggest PSND was ineffective. Criminal activity in the target area was not reduced relative to its pre-intervention levels or relative to the non-target areas. Offenders may have moved outside the target areas to evade increased scrutiny. Additionally, rates of firearm and assaultive injuries increased. As trusted third parties, trauma centers should consider evaluating local crime and injury prevention programs for effectiveness., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Trauma registries are essential to the functioning of modern trauma centers, and high-quality data are necessary to identify patient care issues, develop evidence-based practice, and more. However, institutional experience suggested existing methods to evaluate data quality were insufficient., Objective: This study aims to compare a new software application developed at our trauma center to our existing trauma registry platform on the ability to identify registry inconsistencies (i.e., potential data quality issues)., Methods: We conducted a pilot retrospective cohort study of patients from September 2019 to August 2020 who underwent chart review during a Level I verification visit and had been audited several times for accuracy. Registry records were processed by both validation systems, and registry inconsistencies were recorded., Results: In registry data for 63 patients, the new software found 225 registry inconsistencies, and the registry systems found 153 inconsistencies. The most frequent inconsistencies identified by the new software were missing or unknown procedure start times, with 18/63 (28.6%) patients affected and prehospital supplemental oxygen being blank, with 29/53 (54.7%) patients with prehospital care affected. None of the 10 most common inconsistencies detected with the registry systems were true issues., Conclusions: This study found the new software application identified 47% more inconsistencies than the standard registry systems, and none of the most frequent inconsistencies detected with the registry systems were true issues pertinent to institutional practice. Centers should consider additional methods to identify registry inconsistencies as existing processes appear insufficient., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Society of Trauma Nurses.)

Background: The management of blunt spleen and liver trauma has become increasingly nonoperative. There is no consensus on timing or duration of serial hemoglobin and hematocrit monitoring in this patient population., Objective: This study examined the clinical utility of serial hemoglobin and hematocrit monitoring. We hypothesized that most interventions occur early in the hospital course, based on hemodynamic instability or physical examination findings rather than serial monitoring., Methods: We conducted a retrospective cohort study of adult trauma patients with blunt spleen or liver injury from November 2014 through June 2019 at our Level II trauma center. Interventions were classified as no intervention, surgical intervention, angioembolization, or packed red blood cell transfusion. Demographics, length of stay, total blood draws, laboratory values, and clinical triggers preceding intervention were reviewed., Results: A total of 143 patients were studied, of whom 73 (51%) received no intervention, 47 (33%) received an intervention within 4 hr of presentation, and 23 (16%) had interventions beyond 4 hr. Of these 23 patients, 13 received an intervention based on phlebotomy results alone. Most of these patients (n = 12, 92%) received blood transfusion without further intervention. Only one patient underwent operative intervention based on serial hemoglobin results on hospital day 2., Conclusion: The majority of patients with these injury patterns either require no intervention or declare themselves promptly after arrival. Serial phlebotomy after initial triage and intervention may add little value in the management of blunt solid organ injury., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Society of Trauma Nurses.)

Objectives: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample., Methods: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005., Results: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar., Conclusions: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Author KWS declares that he is funded by the University of Arkansas for Medical Sciences Clinician Scientist Program. All other authors report no conflicts of interest or competing interests exist., (Copyright © 2020. Published by Elsevier Ltd.)

Posttraumatic stress disorder (PTSD) and depression are common following orthopedic trauma. This study examined the relationship between injury- and hospital-related variables and PTSD and depression at baseline and 12 months after orthopedic trauma. This longitudinal, prospective cohort study examined adult orthopedic trauma patients admitted ≥24 hours to a level I trauma center. Non-English/Spanish-speaking and cognitively impaired patients were excluded. The Primary Care PTSD screen and PTSD Checklist-Civilian version assessed PTSD, and the Patient Health Questionnaire 8-Item assessed depression. Demographic and hospital-related variables were examined (e.g., hospital length of stay, Injury Severity Score, Glasgow Coma Scale). For 160 participants, PTSD prevalence was 23% at baseline and 21% at 12 months. Depression prevalence was 28% at baseline and 29% at 12 months. Ventilation ( P  = 0.023, P  = 0.006) and prolonged length of stay ( P  = 0.008, P  = 0.003) were correlated with baseline PTSD and depression. Injury etiology ( P  = 0.008) and Injury Severity Score ( P  = 0.013) were associated with baseline PTSD. Intensive care unit admission ( P  = 0.016, P  = 0.043) was also correlated with PTSD at baseline and 12 months. Ventilation ( P  = 0.002, P  = 0.040) and prolonged length of stay ( P  < 0.001, P  = 0.001) were correlated with 12-month PTSD and depression. Early and continued screenings with potential interventions could benefit patients' physical and mental rehabilitation after orthopedic injury., (Copyright © 2020 Baylor University Medical Center.)

This is the first study to compare both physical and psychological outcomes in geriatric and non-geriatric patients ( n  = 268) at baseline and 6 months post-trauma. Demographic, clinical, and psychological data, including screens for alcohol use, depressive symptoms, and post-traumatic stress symptoms (PTSS) were collected from 67 geriatric patients (70.7 ± 8.0 years) and 201 non-geriatric patients (40.2 ± 12.8 years) admitted to a Level I trauma center for ≥ 24 h. Geriatric patients were significantly less likely to screen positive for alcohol use at baseline, and depression, PTSS, and alcohol use at follow-up. When not controlling for discharge to rehabilitation or nursing facility, geriatric patients had significantly lower odds of alcohol use at follow-up. There was no significant difference in injury severity, resilience, or pre-trauma psychological status between the two groups. Results indicate that geriatric trauma patients fare better than their younger counterparts at 6 months post-trauma on measures of alcohol use, depression, and PTSS. Screenings and interventions for both age groups could improve psychological health post-trauma, but younger patients may require additional attention.

Background: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS., Methods: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS)., Results: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84., Conclusion: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments., Level of Evidence: Prognostic, level IV.

Secondary traumatic stress is a form of posttraumatic stress disorder resulting from exposure to others' acute serious physical harm or death, regardless of mechanism. However, the incidence of secondary traumatic stress among physiatrists remains unexplored. This study examined relationships with secondary traumatic stress among physiatrists. Surveys were distributed to members of the Association of Academic Physiatry and local physiatrists. Surveys included measures of secondary traumatic stress, resilience, personality factors, demographics, and work-related factors. Of 102 surveys returned, 88 were complete and included for analysis. The sample was 42 ± 11 years and included 45 women (51%). Moderate to severe levels of secondary traumatic stress were found in 26 (30%) respondents, and 45% reported clinical levels of at least one symptom cluster. Higher resilience, higher extraversion, and higher emotional stability were associated with significantly lower odds of positive secondary traumatic stress screens and lower symptom severity (all P  < 0.023). In conclusion, a third of responding physiatrists reported moderate to severe symptoms of secondary traumatic stress-a rate consistent with previous research among clinicians in a trauma setting and higher than the rate of posttraumatic stress disorder in the general population. Resilience-building interventions for secondary traumatic stress are likely to improve the well-being of physiatrists.

Background: Currently, there is no standardized approach for determining psychosocial readiness in pediatric transplantation. We examined the utility of the Psychosocial Assessment of Candidates for Transplantation (PACT) to identify pediatric kidney transplant recipients at risk for adverse clinical outcomes. Methods: Kidney transplant patients <21-years-old transplanted at Duke University Medical Center between 2005 and 2015 underwent psychosocial assessment by a social worker with either PACT or unstructured interview, which were used to determine transplant candidacy. PACT assessed candidates on a scale of 0 (poor candidate) to 4 (excellent candidate) in areas of social support, psychological health, lifestyle factors, and understanding. Demographics and clinical outcomes were analyzed by presence or absence of PACT and further characterized by high (≥3) and low (≤2) scores. Results: Of 54 pediatric patients, 25 (46.3%) patients underwent pre-transplant evaluation utilizing PACT, while 29 (53.7%) were not evaluated with PACT. Patients assessed with PACT had a significantly lower percentage of acute rejection (16.0 vs. 55.2%, p = 0.007). After adjusting for HLA mismatch, a pre-transplant PACT score was persistently associated with lower odds of acute rejection (Odds Ratio 0.119, 95% Confidence Interval 0.027-0.52, p = 0.005). In PACT subsection analysis, the lack of family availability (OR 0.08, 95% CI 0.01-0.97, p = 0.047) and risk for psychopathology (OR 0.34, 95% CI 0.13-0.87, p = 0.025) were associated with a low PACT score and post-transplant non-adherence. Conclusions: Our study highlights the importance of standardized psychosocial assessments and the potential use of PACT in risk stratifying pre-transplant candidates.

Fanconi syndrome, also known as the DeToni, Debré, Fanconi syndrome is a global dysfunction of the proximal tubule characterized by glucosuria, phosphaturia, generalized aminoaciduria, and type II renal tubular acidosis. Often there is hypokalemia, sodium wasting, and dehydration. In children, it typically is caused by inborn errors of metabolism, principally cystinosis. In adults, it is mainly caused by medications, exogenous toxins, and heavy metals. Treatment consists of treating the underlying cause and replacing the lost electrolytes and volume., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Several studies have examined road rage, but few studies have examined other psychosocial factors that may contribute to the number of motor vehicle collisions (MVCs). One study found increases in MVCs in West Virginia following televised NASCAR races but did not account for audience size. This study examined associations between NASCAR's television viewership ratings and the incidence of speed-related MVCs in the USA using generalized estimating equations that controlled for seasonal effects, intoxication, road surface conditions, and lighting conditions. A 1% increase in the number of US households watching NASCAR races per month was associated with a 6.3% (95% confidence interval [CI], 3.0% to 9.7%; P  < 0.001) increase in the incidence of speed-related MVCs-approximately 4911 (95% CI, 2353 to 7470) speed-related MVCs per month or one speed-related MVC per 595 (95% CI, 382 to 1354) viewers. As expected, similar results were not found for the total number of MVCs. These data suggest that televised NASCAR races may be associated with substantial increases in the incidence of speed-related MVCs. Making drivers aware of psychological factors that may increase risky driving behaviors could prove beneficial because self-monitoring can result in safer driving.

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges' g = 1.24) and follow-up (mean Hedges' g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.

Background and Objectives: Steroid-resistant nephrotic syndrome (SRNS) due to focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD) is a leading cause of end-stage kidney disease in children. Recurrence of primary disease following transplantation is a major cause of allograft loss. The clinical determinants of disease recurrence are not completely known. Our objectives were to determine risk factors for recurrence of FSGS/MCD following kidney transplantation and factors that predict response to immunosuppression following recurrence., Methods: Multicenter study of pediatric patients with kidney transplants performed for ESKD due to SRNS between 1/2006 and 12/2015. Demographics, clinical course, and biopsy data were collected. Patients with primary-SRNS (PSRNS) were defined as those initially resistant to corticosteroid therapy at diagnosis, and patients with late-SRNS (LSRNS) as those initially responsive to steroids who subsequently developed steroid resistance. We performed logistic regression to determine risk factors associated with nephrotic syndrome (NS) recurrence., Results: We analyzed 158 patients; 64 (41%) had recurrence of NS in their renal allograft. Disease recurrence occurred in 78% of patients with LSRNS compared to 39% of those with PSRNS. Patients with MCD on initial native kidney biopsy had a 76% recurrence rate compared with a 40% recurrence rate in those with FSGS. Multivariable analysis showed that MCD histology (OR; 95% CI 5.6; 1.3-23.7) compared to FSGS predicted disease recurrence., Conclusions: Pediatric patients with MCD and LSRNS are at higher risk of disease recurrence following kidney transplantation. These findings may be useful for designing studies to test strategies for preventing recurrence.

Objective: Hospital readmission rates have become a quality metric-particularly in trauma and acute care, where up to one third of individuals with traumatic injury return to the hospital. Thus, identifying predictors of readmission is a priority in an effort to reduce readmissions. Based on previous theoretical work, this study tests the utility of social support and depression in predicting readmissions up to one year after initial injury., Method: Data from 180 injured individuals admitted to a large, urban Level 1 trauma center were matched to a regional readmissions database. Logistic regression was used to assess whether social support levels or positive depression screens during initial trauma visit predicted unplanned (a) readmissions or (b) emergency/urgent outpatient visits., Results: Within the sample, there were 32 total readmissions and 50 total emergency outpatient encounters following initial injury. Depression continued to be a risk factor for emergency outpatient visits only (OR = 2.75). Patients with greater social integration (OR = 0.78), more guidance (advice or information; OR = 0.72) and more reliable alliance (OR = 0.72) as forms of social support were less likely to readmit., Conclusions: This study demonstrates the utility of screening for depression and social support in predicting readmission within one year after traumatic injury. Future efforts should continue emphasizing the impact of initial depression and the need for patients to have trusted individuals in their lives to whom they can turn during recovery; doing so may lower the probability that patients return to hospital. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Background: The Cribari matrix method (CMM) is the standard to identify potential overtriage and undertriage but requires case reviews to correct for the fact that Injury Severity Score does not account for physiology or comorbidities, nor is it well correlated with resource consumption. Further, the secondary reviews introduce undesirable subjectivity. This study assessed if the Standardized Triage Assessment Tool (STAT)-a combination of the CMM and the Need For Trauma Intervention-could more accurately determine overtriage and undertriage than the CMM alone., Methods: The registry of an American College of Surgeons verified Level I adult trauma center in Texas was queried for all new emergency department traumas 2013 to 2016 (n = 11,110). Binary logistic regressions were used to test the associations between the triage determinations of each metric against indicators of injury severity (risk factors, complications, and mortality) and resource consumption (number of procedures in 3 days and total length of stay)., Results: Both metrics were associated with the indicators of injury severity and resource consumption in the expected directions, but STAT had stronger or equivalent associations with all variables tested. Using the CMM, there was 50.4% overtriage and 9.1% undertriage. Using STAT, overtriage was reduced to 30.8% (relative reduction = 38.9%) and undertriage was reduced to 3.3% (relative reduction = 63.7%)., Conclusion: Using the CMM with secondary case reviews makes valid multi-institutional triage rate comparisons impossible because of the subjective and unstandardized nature of these reviews. STAT's out-of-box triage determinations (i.e., without manual case review) outperformed CMM in almost every tested variable for both over- and undertriage. STAT, an automatic, standardized method offers significant improvements compared to the current subjective system. Further, by accounting for both anatomic injury severity and resource consumption, STAT may allow trauma centers to better allocate resources and predict patient needs with fewer cases requiring manual review., Level of Evidence: Prognostic, level III.

Previously called Secondary Traumatic Stress (STS), secondary exposure to trauma is now considered a valid DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD). Previous studies have found high rates of STS in clinicians who treat traumatically injured patients. However, little research has examined STS among Emergency Medicine (EM) physicians and advanced practice providers (APPs). The current study enrolled EM providers (N = 118) working in one of 10 hospitals to examine risk factors, protective factors, and the prevalence of STS in this understudied population. Most of the participants were physicians (72.9%), Caucasian (85.6%), and male (70.3%) with mean age of 39.7 (SD = 8.9). Overall, 12.7% of the sample screened positive for STS with clinical levels of intrusion, arousal, and avoidance symptom clusters, and 33.9% had at least one symptom cluster at clinical levels. Low resilience and a history of personal trauma were positively associated with positive STS screens and STS severity scores. Borderline significance suggested that female gender and spending ≥10% of one's time with trauma patients could be additional risk factors. Findings suggest that resilience-building interventions may be beneficial.

Objectives: Psychological morbidities after injury [eg, posttraumatic stress disorder (PTSD) and depression] are increasingly recognized as a significant determinant of overall outcome. Traumatic brain injury (TBI) negatively impacts outcomes of patients with orthopaedic injury, but the association of concurrent TBI, orthopaedic injury, and symptoms of PTSD and depression has not been examined. This study's objective was to examine symptoms of PTSD and depression in patients with orthopaedic trauma with and without TBI., Design: Longitudinal prospective cohort study., Setting: Urban Level I Trauma Center in the Southwest United States., Patients/participants: Orthopaedic trauma patients older than 18 years admitted for ≥24 hours., Main Outcome Measurements: Questionnaires examining demographics, injury-related variables, PTSD, and depression were administered during hospitalization and 3, 6, and 12 months later. Orthopaedic injury and TBI were determined based on ICD-9 codes. Generalized linear models determined whether PTSD and depression at follow-up were associated with TBI., Results: Of the total sample (N = 214), 44 (21%) sustained a TBI. Those with TBI had higher rates of PTSD symptoms, 12 months postinjury (P = 0.04). The TBI group also had higher rates of depressive symptoms, 6 months postinjury (P = 0.038)., Conclusions: Having a TBI in addition to orthopaedic injury was associated with significantly higher rates of PTSD at 12 months and depression at 6 months postinjury. This suggests that sustaining a TBI in addition to orthopaedic injury places patients at a higher risk for negative psychological outcomes. The findings of this study may help clinicians to identify patients who are in need for psychological screening and could potentially benefit from intervention., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Identifying risk factors for the development of PTSD and depression is critical for intervention and recovery after injury. Given research linking toxicology screens and substance use and the evidenced relationship between substance misuse and distress, the current study aimed to gauge the predictive value of toxicology testing on PTSD and depression., Methods: Patients admitted to a Level I Trauma Center (N = 379) completed the PC-PTSD, PCL-C, and PHQ-8 at baseline, 3, 6, and 12 months., Results: Results showed 52% of tested patients had a positive toxicology test, 51% screened for PTSD, and 54% screened for depression. Positive drug or alcohol toxicology tests were not significantly associated with PTSD or depression., Conclusions: Toxicology testing may not meaningful predict depression or PTSD in traumatic injury patients. Future research using validated measures of problematic substance use is needed to better understand how misuse may influence the development of psychological distress., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Many existing metrics, such as Injury Severity Score (ISS), cannot fully describe many trauma patients because of comorbidities. This study developed and evaluated the Need For Trauma Intervention (NFTI) metric as a novel indicator of major trauma. The NFTI metric was developed from an analysis of 2,396 trauma patients at a Level I trauma center. Six commonly recorded registry variables were found to be indicative of major trauma and comprised the NFTI criteria: receiving packed red blood cells within 4 hr; discharge from the emergency department (ED) to the operating room within 90 min; discharge from the ED to interventional radiology; discharge from the ED to the intensive care unit (ICU) with an ICU length of stay (LOS) of 3 or more days; mechanical ventilation outside of procedural anesthesia within 3 days; or death within 60 hr. Patients meeting any NFTI criteria are classified as having major traumas and, therefore, needing trauma activations (NFTI+). Need For Trauma Intervention was tested in an overlapping sample of 9,737 patients. Being NFTI+ was associated with higher trauma activation levels, older age, higher ISS, worse ED vitals, longer hospital LOS, and mortality. Only 13 of 561 deaths were not NFTI+ and all were in patients with do not resuscitate (DNR) orders; using ISS greater than 15 missed 73 mortalities, 46 with DNR orders. Results suggest that NFTI provides a comprehensive view of both anatomy and physiology in a manner that self-adjusts for age, frailty, and comorbidities as long as care teams adjust their treatments. Need For Trauma Intervention appears to be a unique, simple, and effective tool to retrospectively identify major trauma, regardless of ISS.

Super-utilizers, patients who amass disproportionately large occurrences of emergency department visits and hospital admissions, are increasingly recognized as a significant and potentially preventable resource consumer. A comprehensive understanding of these individuals and their situations may prove useful in preventing unnecessary admissions and improving patient care and outcomes. While most super-utilizers suffer from chronic medical issues, this patient is an unusual variant, as his super-utilization stemmed from mental health problems leading to serial self-injury. Between January 2010 and October 2014, the patient performed 49 acts of self-harm resulting in 27 acute hospital admissions and 17 additional admissions secondary to complications. In addition to documented injuries, he and his family reported up to 50 additional self-injuries since his first episode 34 years earlier. It was concluded that the patient's pattern of self-injury resulted from a combination of factors, including underlying psychiatric conditions, chronic noncompliance with medications, and potentially unavoidable behavioral reinforcement from health care professionals.

Purpose: Controversy exists regarding the use of continuous antibiotic prophylaxis vs observation in the management of children with vesicoureteral reflux. The reported effectiveness of continuous antibiotic prophylaxis in children with reflux varies widely. We determined whether the aggregated evidence supports use of continuous antibiotic prophylaxis in children with vesicoureteral reflux., Materials and Methods: We searched the Cochrane Controlled Trials Register, clinicaltrials.gov, MEDLINE(®), EMBASE(®), Google Scholar and recently presented meeting abstracts for reports in any language. Bibliographies of included studies were then hand searched for any missed articles. The study protocol was prospectively registered at PROSPERO (No. CRD42014009639). Reports were assessed and data abstracted in duplicate, with differences resolved by consensus. Risk of bias was assessed using standardized instruments., Results: We identified 1,547 studies, of which 8 are included in the meta-analysis. Pooled results demonstrated that continuous antibiotic prophylaxis significantly reduced the risk of recurrent febrile or symptomatic urinary tract infection (pooled OR 0.63, 95% CI 0.42-0.96) but, if urinary tract infection occurred, increased the risk of antibiotic resistant organism (pooled OR 8.75, 95% CI 3.52-21.73). A decrease in new renal scarring was not associated with continuous antibiotic prophylaxis use. Adverse events were similar between the 2 groups. Significant heterogeneity existed between studies (I(2) 50%, p = 0.03), specifically between those trials with significant risk of bias (eg unclear protocol descriptions and/or lack of blinding)., Conclusions: Compared to no treatment, continuous antibiotic prophylaxis significantly reduced the risk of febrile and symptomatic urinary tract infections in children with vesicoureteral reflux, although it increased the risk of infection due to antibiotic resistant bacteria. Continuous antibiotic prophylaxis did not significantly impact the occurrence of new renal scarring or reported adverse events., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the effects of low-dose dopamine on urine output (UOP) in very low birth weight premature neonates., Study Design: Retrospective cohort study of all low-dose (3-5 μg kg(-1) per min) dopamine infusions >24-h duration in neonates 1500 g and 32 weeks gestation from August 2009 through September 2011. Linear regression was used to estimate the impact of covariates on UOP., Result: We identified 91 episodes of low-dose dopamine use in 65 neonates. Increased UOP occurred in 64% of episodes. Low-dose dopamine use was associated with a 0.6 ml kg(-1) h(-1) increase in UOP (P<0.001) and a 1.3 ml kg(-1)h(-1) increase when baseline UOP was <1.5 ml kg(-1) h(-1) (P<0.001). The improvement remained statistically significant after controlling for medications (diuretics and hydrocortisone) and fluid intake., Conclusion: Low-dose dopamine use was associated with increased UOP in very low birth weight neonates.

Background: Mutations of the CYP24A1 gene, which encodes the 1,25-dihydroxyvitamin D-24-hydroxylase cytochrome P450, Cyp24A1, are predicted to result in elevated 1,25-dihydroxyvitamin D concentrations, hypercalcemia, hypercalciuria, nephrolithiasis, and bone disease. Treatment of hypercalcemia associated with CYP24A1 gene mutations has not been described., Methods: The genetic basis of a syndrome in a 44-yr-old Caucasian male characterized by intermittent hypercalcemia, hypercalciuria, elevated serum 1,25-dihydroxyvitamin D, undetectable serum 24,25-dihydroxyvitamin D, metabolically active nephrolithiasis, and reduced bone mineral density of the lumbar spine was examined. Sequencing of the CYP24A1 gene and biochemical and genetic analysis of seven family members in three generations was carried out. Because of hypercalcemia, hypercalciuria, and metabolically active nephrolithiasis, the patient was treated with a cytochrome 3A inhibitor, ketoconazole, 200 mg orally every 8 h, for 2 months., Results: The sequence of the CYP24A1 gene showed two canonical splice junction mutations in the proband. Analysis of family members showed a phenotype associated one or both mutations, suggesting autosomal dominant transmission with partial penetrance of the trait. After therapy with ketoconazole, statistically significant reductions in previously elevated urinary calcium into the normal range were noted. Previously elevated serum 1,25-dihydroxyvitamin D and calcium concentrations decreased, and previously decreased PTH concentrations increased into the normal range, but the differences were not statistically significant., Conclusions: In a syndrome characterized by intermittent hypercalcemia, hypercalciuria, elevated 1,25-dihydroxyvitamin D, undetectable 24,25-dihydroxyvitamin D concentrations, splice junction mutations of the CYP24A1 gene, and autosomal dominant transmission of the trait, treatment with ketoconazole is useful in reducing urinary calcium.

Hypertension affects one billion people and is a principal reversible risk factor for cardiovascular disease. Pseudohypoaldosteronism type II (PHAII), a rare Mendelian syndrome featuring hypertension, hyperkalaemia and metabolic acidosis, has revealed previously unrecognized physiology orchestrating the balance between renal salt reabsorption and K(+) and H(+) excretion. Here we used exome sequencing to identify mutations in kelch-like 3 (KLHL3) or cullin 3 (CUL3) in PHAII patients from 41 unrelated families. KLHL3 mutations are either recessive or dominant, whereas CUL3 mutations are dominant and predominantly de novo. CUL3 and BTB-domain-containing kelch proteins such as KLHL3 are components of cullin-RING E3 ligase complexes that ubiquitinate substrates bound to kelch propeller domains. Dominant KLHL3 mutations are clustered in short segments within the kelch propeller and BTB domains implicated in substrate and cullin binding, respectively. Diverse CUL3 mutations all result in skipping of exon 9, producing an in-frame deletion. Because dominant KLHL3 and CUL3 mutations both phenocopy recessive loss-of-function KLHL3 mutations, they may abrogate ubiquitination of KLHL3 substrates. Disease features are reversed by thiazide diuretics, which inhibit the Na-Cl cotransporter in the distal nephron of the kidney; KLHL3 and CUL3 are expressed in this location, suggesting a mechanistic link between KLHL3 and CUL3 mutations, increased Na-Cl reabsorption, and disease pathogenesis. These findings demonstrate the utility of exome sequencing in disease gene identification despite the combined complexities of locus heterogeneity, mixed models of transmission and frequent de novo mutation, and establish a fundamental role for KLHL3 and CUL3 in blood pressure, K(+) and pH homeostasis.

Acute interstitial nephritis (AIN) is a known cause of acute renal failure in children. In most instances, drug therapy is the offending agent. Although granuloma formation has been observed in drug-induced interstitial nephritis, it is not a commonly associated manifestation. This is a case of a 15-year-old white female with Tetralogy of Fallot and pulmonary atresia who developed acute renal failure secondary to drug-induced interstitial nephritis and renal granulomas. In addition to interstitial edema with eosinophils and lymphocytes, her renal biopsy showed interstitial granulomas, immune complexes within tubular basement membranes, and the unusual feature of multinucleated giant cells engulfing tubules. Her acute renal failure resolved after the withdrawal of antibiotics and the initiation of intravenous steroid therapy.

Nephronophthisis (NPHP), an autosomal recessive cystic kidney disease, leads to chronic renal failure in children. The genes mutated in NPHP1 and NPHP4 have been identified, and a gene locus associated with infantile nephronophthisis (NPHP2) was mapped. The kidney phenotype of NPHP2 combines clinical features of NPHP and polycystic kidney disease (PKD). Here, we identify inversin (INVS) as the gene mutated in NPHP2 with and without situs inversus. We show molecular interaction of inversin with nephrocystin, the product of the gene mutated in NPHP1 and interaction of nephrocystin with beta-tubulin, a main component of primary cilia. We show that nephrocystin, inversin and beta-tubulin colocalize to primary cilia of renal tubular cells. Furthermore, we produce a PKD-like renal cystic phenotype and randomization of heart looping by knockdown of invs expression in zebrafish. The interaction and colocalization in cilia of inversin, nephrocystin and beta-tubulin connect pathogenetic aspects of NPHP to PKD, to primary cilia function and to left-right axis determination.

Objectives: Glomerular disease and renal failure cause substantial morbidity for patients with sickle cell disease (SCD). Proteinuria is an early manifestation of sickle nephropathy, but the prevalence of proteinuria and its clinical correlations in children with SCD are unknown., Study Design: Data were collected prospectively on children with SCD for 10 years including physical measurements, laboratory test results, and clinical complications. Persistent proteinuria was defined as > or =1+ protein on urinalysis for at least 6 months. The glomerular filtration rate was estimated with serum creatinine concentration and height. Proteinuria was correlated with other variables by chi(2) analysis., Results: Proteinuria occurred in 20 of 442 pediatric patients including 15 (6.2%) with sickle cell anemia. Proteinuria increased with age, affecting 12% of older teenagers with sickle cell anemia. Proteinuria was significantly associated with lower hemoglobin concentration, higher mean corpuscular volume, and higher leukocyte count. For children of some ages, proteinuria was associated with complications including stroke, acute chest syndrome, cholelithiasis, and hospitalizations. Glomerular filtration rate hyperfiltration occurred early in life, followed by normalization., Conclusions: Sickle nephropathy, manifested as persistent proteinuria, begins early in life, occurs in all forms of SCD, and is associated with severity of disease. Early detection of proteinuria may allow therapy to prevent progressive renal insufficiency.

The TAR syndrome is an inherited disorder characterized by limb abnormalities, especially absent radii, and hypomegakaryocytic thrombocytopenia. Previous reports have included two infants with genitourinary abnormalities. We report a newborn with bilaterally absent radii and foreshortened ulnae, hypoplastic humeri, a left clubfoot, a ventricular septum defect, and persistent thrombocytopenia. This constellation of abnormalities is consistent with the TAR syndrome. In addition, he had a horseshoe kidney with parenchyma of normal appearance. This is the first report of horseshoe kidney in association with the TAR syndrome.

Renal disease is a frequent late complication of type I diabetes mellitus, occurring almost entirely in adult patients. Typical diabetic nephropathy is characterized by proteinuria, and by the histological lesions of mesangial expansion and basement membrane thickening. We report an interesting case of a 3-year-old boy who developed immune complex glomerulonephritis with nephrotic syndrome 2 months after the onset of insulin-dependent diabetes mellitus.

We analyzed the patient profile in a pediatric nephrology training program, along with data collected over an 18 year period, to determine whether there is merit in the proposition that clinical training can be obtained equally well in internal medicine nephrology training programs. We also compared the rate of patient referral in an U.S. metropolitan area with a population of 1.2 million, in the first 9 years without the "gatekeeper" health insurance system and the next 9 years with managed care competition. Finally, we discussed guidelines for renal biopsy in the child and approaches to treatment as practiced in a pediatric nephrology program of almost two decades. We used the same NIH clinical data form throughout the 18 years of data collection to record clinical, laboratory and biopsy diagnosis, dialysis/ transplantation and other treatment data of patients entering our outpatient and inpatient services. Between 1977 and 1996, 3,150 new patients were examined for disorders related to the kidney. Twenty-one per cent of the patients were in the first year of life and 50% were younger than seven years of age. The majority of the 389 percutaneous renal biopsies were done in children under 10 years of age. In addition, almost half of the 112 pediatric dialysis/transplant patients presented before 10 years of age. Thus, the majority of patients were in the early years of life, with an unique pattern of renal diseases and issues regarding therapy which are clearly different from adulthood. Therefore we concluded that the existing data did not support the proposition that pediatric nephrology training be absorbed into internal medicine nephrology programs. The introduction of managed care competition did not affect the rate of patient enrollment. In fact, the rate of referrals in the latter 9 years paralleled the first 9 years. The factors which contribute to this outcome are discussed. Such data should be useful to those trying to meet the challenges of this competitive era. Finally, we discussed guidelines for renal biopsies in children and approaches to specific diseases.

Objective: This study was designed to assess sequentially the nutrient intake in children with chronic renal insufficiency and its relationship to body size, the level of renal failure, and growth velocity., Methods: The nutrient intake from 401 4-day food records obtained from 120 children with renal insufficiency over a 6-month observation period was analyzed. The height and weight were measured at the beginning and end of the observation period. The glomerular filtration rate was estimated from the height and serum creatinine., Results: The mean caloric intake in these children was 80 +/- 23% (mean +/- SD) of the Recommended Dietary Allowance (RDA) for age. Fifty-six percent of the food records obtained from these children revealed a caloric intake that was less than 80% of the RDA. Caloric intake expressed as the %RDA for age decreased with increasing age. However, the mean caloric intake when factored by body weight was in the normal range. There was no correlation between caloric intake and height velocity. The mean protein intake in these children was 153 +/- 53% of the RDA. Further, 45% of the food records indicated a protein intake greater than 150% of the RDA. There was no relationship between the degree of renal insufficiency and caloric or protein intake. Calcium, vitamin, and zinc intakes were also low., Conclusions: Children with chronic renal failure consume less calories than their age matched peers, but the majority of these children appear to ingest adequate amounts for their body mass. This reduction in caloric intake occurs early in renal insufficiency. They also ingest inadequate amounts of calcium, zinc, vitamin B6, and folate.

The cause of Fanconi syndrome in cystinosis is enigmatic. It has previously been shown that renal tubules could be loaded with cystine by incubating them with cystine dimethylester (CDE), mimicking the biochemical hallmark of cystinosis. Such tubules have impaired transport, decreased whole-cell O2 consumption, and substrate utilization. In this study, the metabolic disturbances in cystine-loaded renal tubule cells were further characterized. Isolated rat renal tubules were loaded with cystine by incubating them with 2 mM CDE for 10 min. This had no significant effect on total ATPase, Na(+)-K(+)-ATPase, or the ouabain-insensitive ATPase activity of renal tissue homogenates from these cystine-loaded tubules. Intracellular K was significantly lower in the cystine-loaded tubules (37 +/- 2 versus 47 +/- 3 nEq/mg; P < 0.008). Intracellular ATP was reduced by 39% in the cystine-loaded tubules (23.7 +/- 2.4 versus 38.1 +/- 3.3 nmol/mg of protein; P < 0.0025). CDE (2 mM) reduced isolated mitochondrial O2 consumption with glutamate as the substrate by 66% (4.7 +/- 0.7 versus 13.9 +/- 0.8 nm/min per mg of protein, P < 0.001) but had no effect on mitochondrial O2 consumption with succinate as the substrate. It was speculated that the impaired transport from cystine loading with CDE is secondary to a decrease in energy generation.

To identify the molecular mechanisms involved in long bone growth of uremic animals, we evaluated the effects of recombinant human growth hormone (rhGH) supplementation on whole body growth, growth plate morphometrics, and insulin-like growth factor-I (IGF-I) gene expression in the tibial epiphyseal growth plates of uremic rats. Uremia was induced by a two-stage subtotal nephrectomy (Nx) of 30-day-old rats, followed by rhGH (N = 6) or saline (N = 6) treatment from day 56 to day 70 of age. Controls (N = 4) were sham decapsulated. Treatment with rhGH on Nx animals caused: (1) a significant increase in weight, (2) longitudinal growth similar to controls, and (3) increased total growth plate width predominantly due to an increase in hypertrophic zone width. rhGH increased IGF-I mRNA abundance in both zones, but the increase was greater in the proliferative zone. These changes were accompanied by concomitant alterations in IGF-I immunoreactivity. In uremic animals, therefore, rhGH treatment induces local IGF-I gene expression in the growth plate and increases the hypertrophic zone width but not the proliferative zone width. The latter suggests resistance to IGF-I action in that zone.

Eight children, aged 15 months to 17 years 9 months, maintained by continuous ambulatory peritoneal dialysis (CAPD)/continuous cycling peritoneal dialysis and nine adults, aged 20-59 years, managed by CAPD were compared using a standardized peritoneal dialysis protocol, the peritoneal equilibration test (PET). The peritoneal glucose concentration tended to equilibrate with the serum glucose more rapidly in children, but the percentage of the glucose load absorbed was not different between the two age groups. There was an inverse trend between the percentage of glucose absorbed and age in children. Peritoneal creatinine clearance scaled to surface area in children was significantly less than that of the adults; however, the clearances became similar when adjusted for body weight. Peritoneal creatinine clearance scaled to surface area bore a positive and significant relationship to age which, when expressed per kilogram body weight, disappeared. Children had a significantly higher dialysate/plasma (D/P) creatinine ratio after the first 2 h of the PET, but this ratio approached unity by 4 h and was not different from adults. The fractional change in the creatinine D/P ratio during the PET was not different between the two age groups. Drain volume adjusted to surface area was significantly less in children than adults. This difference was reversed when drain volume was factored by weight. Similarly drain volume scaled to surface area demonstrated a significant and positive relationship to age, which disappeared when drain volume was expressed per kilogram body weight. Ultrafiltration, whether factored by weight or scaled to surface area, did not differ between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The lipid metabolic disorders in chronic renal insufficiency (CRI) are related to increased hepatic lipid synthesis, reduced triglyceride removal coupled with insulin insensitivity and impaired lipoprotein lipase activity. Growth hormone is lipolytic, and the effects of recombinant human growth hormone (rhGH) on the hypercholesterolemia of CRI are unsettled. To test this question, we gave rhGH for 14 days at a dosage of 3 units/day intraperitoneally to two-stage, 5/6 nephrectomized, male Sprague-Dawley rats (n = 18) compared to sex- and age-matched control (n = 27) and CRI (n = 40) rats. At the end of the study, CRI rats and those treated with rhGH had a similar degree of renal impairment, as assessed by serum concentrations (mean +/- SEM) of urea nitrogen (49 +/- 3 vs. 54 +/- 4 mg/dl), creatinine (0.9 +/- 0.0 vs. 1.0 +/- 0.1 mg/dl) and cumulative food intake (311 +/- 8 vs. 290 +/- 12 g). Serum urea nitrogen (16 +/- 4 mg/dl) and creatinine (0.4 +/- 0.1 mg/dl) concentrations as well as food intake (412 +/- 9 g) of control rats were significantly (p < 0.0001) different. Serum cholesterol concentration of CRI rats treated with rhGH (87 +/- 3 mg/dl) was not higher than those of CRI rats (81 +/- 2 mg/dl, p < 0.1338) but was significantly higher than in control rats (55 +/- 3 mg/dl, p < 0.0001). CRI rats treated with rhGH showed a similar serum albumin concentration and lower serum glucose than CRI rats (0.9 +/- 0.1 vs. 0.9 +/- 0.0 g/dl and 144 +/- 4 vs. 163 +/- 3 mg/dl, p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

The majority of human urinary stones are primarily composed of calcium salts. Although normal urine is frequently supersaturated with respect to calcium oxalate, most humans do not form stones. Inhibitors are among the multiple factors that may influence the complex process of urinary stone formation. We have isolated an inhibitor of calcium oxalate crystal growth from human urine by monoclonal antibody immunoaffinity chromatography. The N-terminal amino acid sequence and acidic amino acid content of this aspartic acid-rich protein, uropontin, are similar to those of other pontin proteins from bone, plasma, breast milk, and cells. The inhibitory effect of uropontin on calcium oxalate crystal growth in vitro supports the concept that pontins may have a regulatory role. This function would be analogous to that of other members of the aspartic acid-rich protein superfamily, which stereospecifically regulate the mineralization fronts of calcium-containing crystals.

The administration of growth hormone (GH) in conjunction with calcitriol in uremia may increase urinary calcium and decrease renal phosphate excretion, which could have an adverse effect on the kidney in chronic renal insufficiency. The effect of 40 d of ovine GH, calcitriol, and the combination of GH and calcitriol on mineral excretion was studied in rapidly growing uremic rats. Uremia was produced by 75% nephrectomy, and the animals were fed a diet containing 8% protein with equal quantities of calcium (0.6%) and phosphate (0.6%). The uremic rats treated with ovine GH were significantly longer and heavier than the uremic control rats and the uremic rats treated with calcitriol alone. However, the combination of calcitriol and GH abolished the beneficial effect of GH on growth and increased urinary calcium excretion 4-fold over uremic controls whether expressed as calcium excretion per 100 g body weight, urine calcium to creatinine ratio, or as fractional calcium excretion. Calcitriol therapy alone also significantly increased calcium excretion, but not to the extent that the combination therapy did. This increased urinary calcium excretion in the GH plus calcitriol group was not associated with an increase in calcium and sodium intake, plasma ionized calcium, or urinary sodium excretion. The calcium content of the femurs from all uremic rat groups was significantly lower than that of the sham control rats; however, there was also no further decrease in bone calcium content in the GH plus calcitriol group compared with uremic controls. This indicated that bone was not the source of this excess urinary calcium.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of loading renal tubule cells with cystine was studied by incubating them with cystine dimethylester. Proline uptake into brushborder membrane vesicles isolated from the cystine loaded cells was not different from that observed into brushborder vesicles isolated from tubules incubated in buffer alone. Incubating brushborder membranes with 2 mM cystine dimethylester for 10 minutes reduced the uptake of proline by 27% after 15 seconds of incubation and by 21% after 60 seconds of incubation. There was no effect after 20 minutes of incubation. Pre-incubating brushborder membrane vesicles with cystine dimethylester had no statistically significant effect on the affinity of proline for the carrier, but did reduce the maximal rate of proline uptake by 49%.

Isolated rat renal tubules were loaded with cystine by incubating them with 2 mM cystine dimethylester. The oxidation of 1 mM glucose and lactate was significantly decreased after 20 and 30 min of incubation, in the cystine-loaded tubules compared with control tubules. The oxidation of 1 mM butyrate was significantly decreased after 10 and 30 min of incubation in the cystine-loaded tubules. Cystine loading decreased the oxidation of 1 mM succinate at all time points examined. The O2 consumption of renal tubules was reduced 59% with cystine loading by the addition of 2 mM cystine dimethylester, and by 37% with 1 mM cystine dimethylester. These data indicate that loading normal renal tubule cells with cystine impairs their ability to oxidize metabolic fuels. This impairment in metabolism may explain the decreased transport observed previously in cystine-loaded tubules and may have implications for the human disorder, cystinosis.

To provide a realistic picture of the patient case load of a pediatric nephrologist in a teaching hospital, we analyzed the number, the demographics, and the reasons for patient referral to our pediatric nephrology program over a 10-year period. Between January 1, 1978, and December 31, 1987, 1,523 pediatric patients were referred to the Medical College of Virginia for evaluation and treatment of renal and electrolyte disorders. The most common reason for referral was a fluid-electrolyte disorder (30%), followed by hematuria/proteinuria (22%), chronic glomerulonephropathies (10%), hypertension (5%), nephrotic syndrome (6%), end-stage renal disease (3%), urinary tract infections (5%), and acute glomerulonephritis (3%). More than 25% of the patients were under 1 year of age at initial presentation. The rest are equally distributed among the other pediatric age groups, including adolescents. Fifty-eight percent of these patients were white, and 41% were black. Males accounted for 54% of the referrals and females for 46%. Percutaneous renal biopsies were performed under ultrasound guidance on 167 patients or a rate of 17 procedures per year. Fifty-one patients, ranging in age from 0.5 to 19 years, were followed for end-stage renal disease during the 10-year study period. Glomerular disorders accounted for 61% of the end-stage renal diseases and anatomic disorders for 39%. The yearly incidence of end-stage renal diseases over this time was 9.8 patients/million children. Twenty-six (51%) of these patients received one or more kidney transplants during the study period.

A kindred is described in which hyperuricemia and renal insufficiency were observed in three generations. The hyperuricemia appeared to precede the renal diseases. Lowering the serum uric acid level to normal did not decrease the progression of renal insufficiency. This suggested that the hyperuricemia was a marker of a familial nephropathy and possibly not the cause.

In a ray trace calculation of the rms radius of the spot formed in the image plane of an optical system by a point source object, a decision must be made as to how many rays will be traced to obtain the result. As the number of rays is increased, the rms spot radius is generally found to decrease, apparently approaching a definite lower limit as the number of rays becomes very large. This paper examines the question of how many rays must be traced and what their geometrical distribution within the aperture should be to approach the limiting value of the rms spot radius for an infinite number of rays within an accuracy of approximately 1%.