Association between Acute Declines in Estimated Glomerular Filtration Rate during Renin-Angiotensin System Inhibition and Risk of Adverse Outcomes.

BACKGROUND: Declines in glomerular filtration rate (GFR) occur commonly when renin-angiotensin system (RAS) inhibitors are started. Our objective was to determine the relation between declines in estimated GFR during trials of RAS inhibition and kidney outcomes. METHODS: We included participants with CKD (estimated GFR<60 mL/min/1.73m2) from 16 trials of RAS inhibition. The exposure was subacute declines in estimated GFR expressed as % change between randomization and month 3, and in the subset of trials with data available, we also examined % change in eGFR between randomization and month 1. The primary outcome was kidney failure with replacement therapy. Cox proportional hazards models were used to examine the association between subacute declines in eGFR and risk of kidney failure. We used spline models to identify the threshold of change in eGFR below which RAS inhibition was favorable (conservatively comparing a given decline in eGFR with RAS inhibition to no decline in the comparator). RESULTS: 11,800 individuals with mean eGFR 43 (SD 11) mL/min/1.73m2 and median urine albumin/creatinine ratio of 362 mg/g (IQR 50, 1367) were included, and 1,162 (10%) developed kidney failure. The threshold of decline in eGFR that favored use of RAS inhibitors for kidney failure was estimated to be up to 13% (95%CI 8%, 17%) over a 3-month interval and up to 21% (95%CI 15%, 27%) over a 1-month interval after starting RAS inhibitors. CONCLUSIONS: In people treated with RAS inhibitors, ≤ 13% decline in eGFR over a 3-month period or ≤21% decline over a 1-month period was associated with lower risk of kidney failure compared with no decline with the use of placebo or other agents.

Fungal Musculoskeletal Infections: Comprehensive Approach to Proper Diagnosis.

Fungal musculoskeletal infections often have subacute or indolent manifestations, making it difficult to distinguish them from other diseases and infections, given that they are relatively uncommon. Fungal infections occur by hematogenous spread, direct inoculation, or contiguous extension and may be related to different risk factors, including immunosuppression and occupational activity. The infection can manifest in isolation in the musculoskeletal system or as part of a systemic process. The fungi may be endemic to certain regions or may be found throughout the world, and this can help to narrow the diagnosis of the etiologic agent. Infections such as candidiasis, cryptococcosis, aspergillosis, and mucormycosis are often related to immunosuppression. On the other hand, histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, and blastomycosis can occur in healthy patients in geographic areas where these infections are endemic. Furthermore, infections can be classified on the basis of the site of infection in the body. Some subcutaneous infections that can have osteoarticular involvement include mycetoma, sporotrichosis, and phaeohyphomycosis. Different fungi affect specific bones and joints with greater prevalence. Imaging has a critical role in the evaluation of these diseases. Imaging findings include nonspecific features such as osteomyelitis and arthritis, with bone destruction, osseous erosion, mixed lytic and sclerotic lesions, and joint space narrowing. Multifocal osteomyelitis and chronic arthritis with joint effusion and synovial thickening may also occur. Although imaging findings are often nonspecific, some fungal infections may show findings that aid in narrowing the differential diagnosis, especially when they are associated with the patient's clinical condition and history, the site of osteoarticular involvement, and the geographic location. ©RSNA, 2024.

Significant and Distinct Impacts of Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Esophageal Acid Exposure, Esophageal Motility and Endoscopic Findings: A Systematic Review and Meta-analysis.

OBJECTIVE: To study esophageal acid exposure, esophageal motility, and endoscopic findings before and after Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB BACKGROUND: The lack of standardized objective assessment of esophageal physiology and anatomy contributes to the controversies regarding the impact of SG and RYGB on gastroesophageal reflux disease. METHODS: We conducted a systematic review and meta-analysis of studies reporting at least one objective measure of esophageal physiology and/or EGD, at baseline and after SG or RYGB. The changes in pH-test, manometry, and EGD parameters were summarized. RESULTS: Acid exposure time (AET) and DeMeester Score (DMS) significantly increased after SG: Mean Difference (MD) 2.1 (95%CI 0.3 to 3.9) and 8.6 (95%CI 2 to 15.2), respectively. After RYGB, both AET and DMS significantly decreased: MD -4.2 (95%CI -6.1 to -2.3) and - 16.6 (95%CI -25.4 to -7.8). Lower esophageal sphincter resting pressure and length significantly decreased following SG: MD - 2.8 (95%CI - 4.6 to - 1.1) and - 0.1 (95%CI - 0.2 to - 0.02), respectively. There were no significant changes in esophageal manometry after RYGB. The Relative Risk of erosive esophagitis after SG was 2.3 (95%CI 1.5 to 3.5), while after RYGB it was 0.4 (95%CI 0.2 - 0.8). The prevalence of Barrett's Esophagus changed from 0% to 3.6% after SG, and from 2.7% to 1.4% after RYGB. CONCLUSIONS: SG resulted in worsening of all objective parameters, while RYGB showed improvement in AET, DMS, and EGD findings. Determining the risk factors associated with those outcomes could aid in surgical choice.

A meta-analysis of randomized controlled clinical trials implications of acute treatment effects on glomerular filtration rate for long-term kidney protection.

Pharmacologic interventions to slow chronic kidney disease progression, such as ACE-inhibitors, angiotensin receptor blockers, or sodium glucose co-transporter 2 inhibitors, often produce acute treatment effects on glomerular filtration rate (GFR) that differ from their long-term chronic treatment effects. Observational studies assessing the implications of acute effects cannot distinguish acute effects from GFR changes unrelated to the treatment. Here, we performed meta-regression analysis of multiple trials to isolate acute effects to determine their long-term implications. In 64 randomized controlled trials (RCTs), enrolling 154,045 participants, we estimated acute effects as the mean between-group difference in GFR slope from baseline to three months, effects on chronic GFR slope (starting at three months after randomization), and effects on three composite kidney endpoints defined by kidney failure (GFR 15 ml/min/1.73m2 or less, chronic dialysis, or kidney transplantation) or sustained GFR declines of 30%, 40% or 57% decline, respectively. We used Bayesian meta-regression to relate acute effects with treatment effects on chronic slope and the composite kidney endpoints. Overall, acute effects were not associated with treatment effects on chronic slope. Acute effects were associated with the treatment effects on composite kidney outcomes such that larger negative acute effects were associated with lesser beneficial effects on the composite kidney endpoints. Associations were stronger when the kidney composite endpoints were defined by smaller thresholds of GFR decline (30% or 40%). Results were similar in a subgroup of interventions with supposedly hemodynamic effects that acutely reduce GFR. For studies with GFR 60 mL/min/1.73m2 or under, negative acute effects were associated with larger beneficial effects on chronic GFR slope. Thus, our data from a large and diverse set of RCTs suggests that acute effects of interventions may influence the treatment effect on clinical kidney outcomes.

Association of 10 VEGF Family Genes with Alzheimer's Disease Endophenotypes at Single Cell Resolution.

The cell-type specific role of the vascular endothelial growth factors (VEGFs) in the pathogenesis of Alzheimer's disease (AD) is not well characterized. In this study, we utilized a single-nucleus RNA sequencing dataset from Dorsolateral Prefrontal Cortex (DLFPC) of 424 donors from the Religious Orders Study and Memory and Aging Project (ROS/MAP) to investigate the effect of 10 VEGF genes ( VEGFA, VEGFB, VEGFC, VEGFD, PGF, FLT1, FLT4, KDR, NRP1 , and NRP2 ) on AD endophenotypes. Mean age of death was 89 years, among which 68% were females, and 52% has AD dementia. Negative binomial mixed models were used for differential expression analysis and for association analysis with ß-amyloid load, PHF tau tangle density, and both cross-sectional and longitudinal global cognitive function. Intercellular VEGF-associated signaling was profiled using CellChat. We discovered prefrontal cortical FLT1 expression was upregulated in AD brains in both endothelial and microglial cells. Higher FLT1 expression was also associated with worse cross-sectional global cognitive function, longitudinal cognitive trajectories, and ß-amyloid load. Similarly, higher endothelial FLT4 expression was associated with more ß-amyloid load. In contrast to the receptors, VEGFB showed opposing effects on ß-amyloid load whereby higher levels in oligodendrocytes was associated with high amyloid burden, while higher levels in inhibitory neurons was associated with lower amyloid burden. Finally, AD cells showed significant reduction in overall VEGF signaling comparing to those from cognitive normal participants. Our results highlight key changes in VEGF receptor expression in endothelial and microglial cells during AD, and the potential protective role of VEGFB in neurons.

International Hackathon as a Tool to Augment Education, Collaboration, and Innovation in Global Neurosurgery.

BACKGROUND AND OBJECTIVES: Health care providers' exposure to global surgical disparities is limited in current nursing and/or medical school curricula. For instance, global health is often associated with infectious diseases or maternal health without acknowledging the growing need for surgical care in low- and middle-income countries (LMICs). We propose an international virtual hackathon based on neurosurgical patient cases in under-resourced settings as an educational tool to bring awareness to global surgical disparities and develop relationships among trainees in different countries. METHODS: Participants were recruited through email listservs, a social media campaign, and prize offerings. A 3-day virtual hackathon event was administered, which included workshops, mentorship, keynote panels, and pitch presentations to judges. Participants were presented with real patient cases and directed to solve a barrier to their care. Surveys assessed participants' backgrounds and event experience. The hackathon was executed through Zoom at Harvard Innovation Lab in Boston, MA, on March 25 to 27, 2022. Participants included medical students, with additional participants from business, engineering, or current health care workers. RESULTS: Three hundred seven applications were submitted for 100 spots. Participants included medical students, physicians, nurses, engineers, entrepreneurs, and undergraduates representing 25 countries and 82 cities. Fifty-one participants previously met a neurosurgeon, while 39 previously met a global health expert, with no difference between LMIC and high-income countries' respondents. Teams spent an average of 2.75 hours working with mentors, and 88% of postevent respondents said the event was "very" or "extremely conducive" to networking. Projects fell into 4 categories: access, language barriers, education and training, and resources. The winning team, which was interdisciplinary and international, developed an application that analyzes patient anatomy while performing physical therapy to facilitate remote care and clinical decision-making. CONCLUSION: An international virtual hackathon can be an educational tool to increase innovative ideas to address surgical disparities in LMICs and establish early collaborative relationships with medical trainees from different countries.

Risk of cancer-related distress by age in colorectal cancer survivors: The modulatory role of unmet support needs.

To explore the modulating role of unmet support needs on the relationship between age and the prevalence of cancer-related distress in colorectal cancer (CRC) survivors. Two hundred and forty four participants completed the questionnaires; linear regression and odd ratios were calculated. Both the prevalence of needs and their interaction with age were predictors of cancer-related distress. The risk of significant clinically distress associated with physical and socio/family needs was high in both age subgroups. Higher risk of clinical distress was associated with life perspective, sexual, occupational and health care needs in the younger subgroup and with needs for specific support resources in the older subgroup. In reducing cancer-related distress, two key issues arise: (i) the importance of managing the persistent negative symptoms following CRC treatment in survivors of any age and (ii) the need for a differentiated attention to other care needs based on the survivor's age.

How to reduce the carbon footprint of the agricultural sector? Factors influencing farmers' decision to participate in carbon sequestration programs.

Mitigating climate change by sequestering carbon in agricultural soils through humus formation is a crucial component of sustainable agriculture. Humus programs that are designed to incentivize farmers to build more humus are still recent innovations, so current knowledge about farmers' motivation to participate is limited. This study examines the adoption of non-governmental humus programs to promote carbon sequestration by analyzing farmers' willingness to participate in humus programs and influential factors. We specifically investigate behavioral factors underlying farmers' adoption of humus programs using the Theory of Planned Behavior. To this end, we collected data using an online survey with 190 German farmers and applied partial least squares structural equation modeling. The results show that (i) perceived economic benefits, (ii) the actions of fellow farmers, and (iii) farmers' sense of responsibility with regard to climate change have a statistically significant influence on farmers' intention to participate in a humus program. In contrast, the perceived ecological benefits, political pressure, the possibility of establishing humus-building measures, and prior knowledge of humus programs have no statistically significant influence. Our findings suggest that farmers' decision to participate in humus programs is strongly influenced by the financial benefits, but the actions and thoughts of other farmers, as well as their own moral claims regarding climate change, also play a crucial role. We found that farmers lack knowledge about the registration and general functioning of humus programs, which can currently be one of the biggest barriers to participation in such initiatives.

Improving HIV Pre-exposure Prophylaxis Uptake with Artificial Intelligence and Automation: A Systematic Review.

OBJECTIVES: To identify studies promoting the use of artificial intelligence (AI) or automation with HIV pre-exposure prophylaxis (PrEP) care and explore ways for AI to be used in PrEP interventions. DESIGN: Systematic review. METHODS: We searched in the US Centers for Disease Control and Prevention Research Synthesis database through November 2023 PROSPERO (CRD42023458870). We included studies published in English that reported using AI or automation in PrEP interventions. Two reviewers independently reviewed the full text and extracted data by using standard forms. Risk of bias was assessed using either the revised Cochrane risk-of-bias tool for randomized trials for randomized controlled trials or an adapted Newcastle-Ottawa Quality Assessment Scale for non-randomized studies. RESULTS: Our search identified 12 intervention studies (i.e., interventions that used AI/automation to improve PrEP care). Currently available intervention studies showed AI/automation interventions were acceptable and feasible in PrEP care while improving PrEP-related outcomes (i.e., knowledge, uptake, adherence, discussion with care providers). These interventions have used AI/automation to reduce workload (e.g., directly observed therapy) and helped non-HIV specialists prescribe PrEP with AI-generated clinical decision-support. Automated tools can also be developed with limited budget and staff experience. CONCLUSIONS: AI and automation have high potential to improve PrEP care. Despite limitations of included studies (e.g., the small sample sizes and lack of rigorous study design), our review suggests that by using aspects of AI and automation appropriately and wisely, these technologies may accelerate PrEP use and reduce HIV infection.

Disease characteristics, effectiveness, and safety of vestronidase alfa for the treatment of patients with mucopolysaccharidosis VII in a novel, longitudinal, multicenter disease monitoring program.

BACKGROUND: Mucopolysaccharidosis VII (MPS VII) is an ultra-rare, autosomal recessive, debilitating, progressive lysosomal storage disease caused by reduced activity of ß-glucuronidase (GUS) enzyme. Vestronidase alfa (recombinant human GUS) intravenous enzyme replacement therapy is an approved treatment for patients with MPS VII. METHODS: This disease monitoring program (DMP) is an ongoing, multicenter observational study collecting standardized real-world data from patients with MPS VII (N ≈ 50 planned) treated with vestronidase alfa or any other management approach. Data are monitored and recorded in compliance with Good Clinical Practice guidelines and planned interim analyses of captured data are performed annually. Here we summarize the safety and efficacy outcomes as of 17 November 2022. RESULTS: As of the data cutoff date, 35 patients were enrolled: 28 in the Treated Group and seven in the Untreated Group. Mean (SD) age at MPS VII diagnosis was 4.5 (4.0) years (range, 0.0 to 12.4 years), and mean (SD) age at DMP enrollment was 13.9 (11.1) years (range, 1.5 to 50.2 years). Ten patients (29%) had a history of nonimmune hydrops fetalis. In the 23 patients who initiated treatment prior to DMP enrollment, substantial changes in mean excretion from initial baseline to DMP enrollment were observed for the three urinary glycosaminoglycans (uGAGs): dermatan sulfate (DS), -84%; chondroitin sulfate (CS), -55%; heparan sulfate (HS), -42%. Also in this group, mean reduction from initial baseline to months 6, 12, and 24 were maintained for uGAG DS (-84%, -87%, -89%, respectively), CS (-70%, -71%, -76%, respectively), and HS (+ 3%, -32%, and - 41%, respectively). All adverse events (AEs) were consistent with the known vestronidase alfa safety profile. No patients discontinued vestronidase alfa. One patient died. CONCLUSIONS: To date, the DMP has collected invaluable MPS VII disease characteristic data. The benefit-risk profile of vestronidase alfa remains unchanged and favorable for its use in the treatment of pediatric and adult patients with MPS VII. Reductions in DS and CS uGAG demonstrate effectiveness of vestronidase alfa to Month 24. Enrollment is ongoing.

A registered report of a two-site study of variations of the flanker task: ERN experimental effects and data quality.

Error-related negativity is a widely used measure of error monitoring, and many projects are independently moving ERN recorded during a flanker task toward standardization, optimization, and eventual clinical application. However, each project uses a different version of the flanker task and tacitly assumes ERN is functionally equivalent across each version. The routine neglect of a rigorous test of this assumption undermines efforts to integrate ERN findings across tasks, optimize and standardize ERN assessment, and widely apply ERN in clinical trials. The purpose of this registered report was to determine whether ERN shows similar experimental effects (correct vs. error trials) and data quality (intraindividual variability) during three commonly used versions of a flanker task. ERN was recorded from 172 participants during three versions of a flanker task across two study sites. ERN scores showed numerical differences between tasks, raising questions about the comparability of ERN findings across studies and tasks. Although ERN scores from all three versions of the flanker task yielded high data quality and internal consistency, one version did outperform the other two in terms of the size of experimental effects and the data quality. Exploratory analyses of the error positivity (Pe) provided tentative support for the other two versions of the task over the paradigm that appeared optimal for ERN. The present study provides a roadmap for how to statistically compare psychometric characteristics of ERP scores across paradigms and gives preliminary recommendations for flanker tasks to use for ERN- and Pe-focused studies.

Genetic Variation in Male Aggression Is Influenced by Genotype of Prior Social Partners in Drosophila melanogaster.

AbstractSocial behaviors can be influenced by the genotypes of interacting individuals through indirect genetic effects (IGEs) and can also display developmental plasticity. We investigated how developmental IGEs, which describe the effects of a prior social partner's genotype on later behavior, can influence aggression in male Drosophila melanogaster. We predicted that developmental IGEs cannot be estimated by simply extending the effects of contextual IGEs over time and instead have their own unique effects on behavior. On day 1 of the experiment, we measured aggressive behavior in 15 genotypic pairings (n=600 males). On day 2, each of the males was paired with a new opponent, and aggressive behavior was again measured. We found contextual IGEs on day 1 of the experiment and developmental IGEs on day 2 of the experiment: the influence of the day 1 partner's genotype on the focal individual's day 2 behavior depended on the genotypic identity of both the day 1 partner and the focal male. Importantly, the developmental IGEs in our system produced fundamentally different dynamics than the contextual IGEs, as the presence of IGEs was altered over time. These findings represent some of the first empirical evidence demonstrating developmental IGEs, a first step toward incorporating developmental IGEs into our understanding of behavioral evolution.

Outcomes after newborn screening for propionic and methylmalonic acidemia and homocystinurias.

The current German newborn screening (NBS) panel includes 13 inherited metabolic diseases (IMDs). In addition, a NBS pilot study in Southwest Germany identifies individuals with propionic acidemia (PA), methylmalonic acidemia (MMA), combined and isolated remethylation disorders (e.g., cobalamin [cbl] C and methylenetetrahydrofolate reductase [MTHFR] deficiency), cystathionine ß-synthase (CBS) deficiency, and neonatal cbl deficiency through one multiple-tier algorithm. The long-term health benefits of screened individuals are evaluated in a multicenter observational study. Twenty seven screened individuals with IMDs (PA [N = 13], MMA [N = 6], cblC deficiency [N = 5], MTHFR deficiency [N = 2] and CBS deficiency [N = 1]), and 42 with neonatal cbl deficiency were followed for a median of 3.6 years. Seventeen screened IMD patients (63%) experienced at least one metabolic decompensation, 14 of them neonatally and six even before the NBS report (PA, cbl-nonresponsive MMA). Three PA patients died despite NBS and immediate treatment. Fifteen individuals (79%) with PA or MMA and all with cblC deficiency developed permanent, mostly neurological symptoms, while individuals with MTHFR, CBS, and neonatal cbl deficiency had a favorable clinical outcome. Utilizing a combined multiple-tier algorithm, we demonstrate that NBS and specialized metabolic care result in substantial benefits for individuals with MTHFR deficiency, CBS deficiency, neonatal cbl deficiency, and to some extent, cbl-responsive MMA and cblC deficiency. However, its advantage is less evident for individuals with PA and cbl-nonresponsive MMA. SYNOPSIS: Early detection through newborn screening and subsequent specialized metabolic care improve clinical outcomes and survival in individuals with MTHFR deficiency and cystathionine-ß-synthase deficiency, and to some extent in cobalamin-responsive methylmalonic acidemia (MMA) and cblC deficiency while the benefit for individuals with propionic acidemia and cobalamin-nonresponsive MMA is less evident due to the high (neonatal) decompensation rate, mortality, and long-term complications.

Outcomes of Nerve Transfers in Peroneal Nerve Palsy.

Background: The objective of this work is to: (i) evaluate the postoperative outcomes after lower extremity nerve transfer (LENT) in patients with peroneal nerve palsy, and (ii) evaluate the patient and surgical factors that best predict successful restoration of ankle dorsiflexion following nerve transfer. Methods: A retrospective cohort of prospectively collected data included all patients who underwent LENT (2010-2018). Two independent reviewers performed data collection. Primary outcome measures were: (i) clinically with British Medical Research Council (MRC) strength assessments, and (ii) electrodiagnostically with nascent motor unit potentials. Statistical analysis was performed using descriptive and nonparametric statistics. Results: Nine patients (56% male, mean age 38.3, range 18-57 years) underwent LENT surgery a mean of 4.3 months following injury (range 2.2-6.4 months). Mean follow-up was 15.6 months (range 9.1-28.2 months). Postoperatively, ankle dorsiflexion (P = .015) and ankle eversion (P = .041) increased significantly. After surgery, 44% achieved MRC 4, 33% obtained MRC 1 motor recovery, and 22% sustained MRC 0. A shorter time to surgery was associated with significantly better outcomes (P = .049). Conclusions: It appears that there is a bimodal distribution between responders and nonresponders to LENT for foot drop. Further research is required to elucidate patient and surgical factors that prognosticate success.

Contexte: Les objectifs de cette étude étaient les suivants : (i) évaluer les résultats postopératoires après un transfert de nerf dans le membre inférieur (LENT; lower extremity nerve transfer) chez des patients ayant une paralysie du nerf péronier et (ii) évaluer les facteurs propres au patient et à la chirurgie qui permettent de prédire le mieux possible le succès d'une restauration de la dorsiflexion de la cheville après le transfert nerveux. Méthodes: Une cohorte rétrospective de données collectées de façon prospective a inclus tous les patients ayant bénéficié d'un LENT de 2010 à 2018. Deux réviseurs indépendants ont réalisé la collecte des données. Les critères de jugement principaux étaient les suivants : (i) cliniques avec des évaluations de la force selon l'échelle MRC et (ii) électrodiagnostiques avec potentiels d'unités motrices naissantes. Une analyse statistique a été réalisée au moyen de statistiques descriptives et non paramétriques. Résultats: Neuf patients (hommes : 56%, âge moyen : 38,3 ans, extrêmes : 18 à 57 ans) ont subi une LENT, en moyenne 4,3 mois après une blessure (extrêmes : 2,2 à 6,4 mois). Le suivi moyen a été de 15,6 mois (extrêmes : 9,1 à 28,2 mois). En postopératoire, la dorsiflexion de la cheville (P = 015) et l'éversion de la cheville (P = 041) ont augmenté de façon significative. Après l'intervention chirurgicale, 44% des patients ont atteint un score de 4 sur l'échelle MRC, 33% ont obtenu une récupération motrice cotée à 1 et 22% ont conservé une cote MRC de 0. Un délai plus court avant la chirurgie a été associé à des résultats significativement meilleurs (P = .049). Conclusions: Il semble y avoir une répartition bimodale entre les répondeurs et les nonrépondeurs à la chirurgie de LENT pour la chute du pied. Des recherches supplémentaires sont nécessaires pour renseigner les facteurs pronostiques de succès liés au patient et à l'intervention chirurgicale.

Factors contributing to telemedicine efficacy in pediatric urology.

INTRODUCTION: Despite swift implementation of telemedicine with the coronavirus disease 2019 pandemic, there is a paucity of research on its use for management of pediatric urology patients. Specifically, there is limited knowledge and inconsistent data on the effectiveness of telemedicine for various pediatric urologic conditions. Our aim was to evaluate the efficacy of pediatric urological care provided via video visits (VVs) at a large tertiary care children's hospital. MATERIAL AND METHODS: We performed a prospective assessment of pediatric urology patients younger than 21 years who had a VV between 5/18/2022 and 5/17/2023. New patients with a testicular diagnosis were not eligible for VVs. After entering the diagnosis and submitting billing using a modifier for telemedicine, clinicians were mandated to select whether the VV allowed for: complete case management (CCM), suboptimal case management (SCM), or incomplete case management (ICM) requiring an in-person visit. Case management categorizations were analyzed according to patient pathology, visit type (i.e., new or established), and patient-centered variables including age, sex, race, insurance type, need for an interpreter, and distress score [a proxy for socioeconomic status]. RESULTS: During the one-year period, there were 3267 telemedicine patients with a median age of 9 years (IQR 3-13) and 57.0% were male. Most VVs (89.3%) were established encounters. Almost 12% of telemedicine patients had external organ pathology (EOP, e.g., phimosis), 43.0% had internal organ pathology (IOP, e.g., hydronephrosis), and 45.1% had functional urological pathology (FUP, e.g., dysfunctional voiding). Clinicians deemed 96.9%, 2.7%, and 0.5% of VVs as having CCM, SCM or ICM, respectively. Telemedicine patients with IOP or FUP were more likely to have CCM, than those with EOP (98.5% and 97.8% vs 87.1%, p < 0.0001). On multivariable analysis, patient age, pathology, and visit type were predictive of VV efficacy. DISCUSSION: Now that telemedicine use has slowed, it is necessary to evaluate and establish its optimal role in pediatric urology. Factors associated with VV efficacy included older patient age, internal organ or functional urological pathology, and established encounters. The long-term success of telemedicine requires suitable patient selection. CONCLUSIONS: Telemedicine is quite effective for the management of a wide variety of pediatric urology patients. Continued evaluation of telemedicine, including multi-institutional investigation and corroboration, is necessary for the development of evidence-based best practice guidelines regarding appropriate, safe, and effective integration of telemedicine that drives pediatric urological care forward to meet the demands of the future.

Spring and fall blood concentrations of adrenocorticotropic hormone, insulin, and thyroxine in healthy horses in Saskatchewan.

Objective: To characterize concentrations of adrenocorticotropic hormone (ACTH), insulin, and thyroxine (T4) at 2 times of the year in healthy horses in Saskatchewan. Animals and procedure: A prospective, observational study was carried out in 52 healthy, client-owned horses. Inclusion criteria were no recent travel outside of Saskatchewan, normal physical examination findings, and no history or evidence of ongoing illness. Blood concentrations of ACTH, insulin and T4 were determined by chemiluminescence. Samples were collected in spring and fall and compared using the paired Student's t-test or Wilcoxon signed-rank test. Generalized estimating equations were used to assess the associations between ACTH, T4, and insulin concentrations and gender, age, season, body condition score, glucose concentration, and breed. Results: There were increases in both ACTH and insulin concentrations in the fall compared to spring (P < 0.001 and P = 0.001, respectively). Other than season, insulin concentration was associated with breed, whereas ACTH concentration was associated with age. Finally, T4 concentration was associated with breed and glucose concentration, but not with season. Conclusion and clinical relevance: These results highlighted the differences between spring and fall concentrations of both ACTH and insulin in healthy horses residing in the Canadian prairie provinces, which are known for extreme differences in summer and winter temperatures as well as day length. Geographically adjusted reference values are necessary to account for these variations, to improve diagnostic accuracy. This is the first published Canadian study evaluating these factors and their associations with hormone concentrations in clinically healthy animals.

Concentrations sanguines printanières et automnales d'hormone adrénocorticotrope, d'insuline et de thyroxine chez des chevaux en bonne santé en Saskatchewan. Objectif: Caractériser les concentrations d'hormone adrénocorticotrope (ACTH), d'insuline et de thyroxine (T4) à 2 moments de l'année chez des chevaux en bonne santé en Saskatchewan. Animaux et procédure: Une étude observationnelle prospective a été réalisée auprès de 52 chevaux en bonne santé appartenant à des clients. Les critères d'inclusion étaient l'absence de voyage récent à l'extérieur de la Saskatchewan, les résultats normaux de l'examen physique et l'absence d'antécédents ou de signes de maladie persistante. Les concentrations sanguines d'ACTH, d'insuline et de T4 ont été déterminées par chimiluminescence. Des échantillons ont été collectés au printemps et à l'automne et comparés à l'aide du test de Student apparié ou du test du rang de signe de Wilcoxon. Des équations d'estimation généralisées ont été utilisées pour évaluer les associations entre les concentrations d'ACTH, de T4 et d'insuline et le sexe, l'âge, la saison, l'état corporel, la concentration de glucose et la race. Résultats: Il y avait une augmentation des concentrations d'ACTH et d'insuline à l'automne par rapport au printemps (P < 0,001 et P = 0,001, respectivement). Hormis la saison, la concentration d'insuline était associée à la race, alors que la concentration d'ACTH était associée à l'âge. Enfin, la concentration de T4 était associée à la race et à la concentration en glucose, mais pas à la saison. Conclusion et pertinence clinique: Ces résultats ont mis en évidence les différences entre les concentrations printanières et automnales d'ACTH et d'insuline chez les chevaux en bonne santé résidant dans les provinces des Prairies canadiennes, reconnues pour leurs différences extrêmes de températures estivales et hivernales ainsi que de durée du jour. Des valeurs de référence géographiquement ajustées sont nécessaires pour tenir compte de ces variations et améliorer la précision du diagnostic. Il s'agit de la première étude canadienne publiée évaluant ces facteurs et leurs associations avec les concentrations d'hormones chez des animaux cliniquement sains.(Traduit par Dr Serge Messier).