Accidental or intentional ingestion of toothbrushes: experience with 8 adult patients.

PURPOSE: Ingestion of a toothbrush is an unusual event but may occur either accident or by intent. Radiological examinations play a crucial role in determining the exact location of the object within the gastrointestinal tract and in planning for its removal by endoscopic or surgical intervention. METHODS: Medical and radiological records of 8 patients who had swallowed the broken heads or entire toothbrush were retrospectively reviewed. This series included 4 men and 4 women, ranging in age from 21 to 57 years (mean: 34 years). RESULTS: Radiographs and computed tomography of the abdomen demonstrated the ingested toothbrushes within the stomach in 3, lodged in the duodenum in 1, and entrapped in various parts of the colon in 4 patients. They were removed by laparotomy in 3, laparoscopy in 2, colonoscopy in 2, and upper gastrointestinal endoscopy in 1 patient. There were no perforations or associated complications, and all patients had uneventful recoveries. CONCLUSIONS: Ingested toothbrushes can be easily identified on radiological studies because of the radiopaque wires holding the nylon bristles. The plastic parts of it, however, are only visible on computed tomography. All cases would require endoscopic or surgical removal of the retained toothbrushes because spontaneous passage per rectum does not occur.

A Novel Interprofessional Palliative Care and Geriatrics Curriculum for Nephrology Teams.

BACKGROUND: The population of older adults with chronic kidney disease (CKD) is increasing and nephrologists need education on the principles of geriatrics and palliative care to effectively care for this population. OBJECTIVES: Our objective was to develop and deliver a curriculum to interprofessional clinicians caring for older adults with CKD. The aim of this curriculum would be to improve knowledge of the principles of geriatrics and palliative care. DESIGN: We have previously developed a curriculum on geriatrics and palliative care targeted toward primary care teams. In this project, we used an interdisciplinary steering committee to modify the curriculum for nephrology teams. SETTING: This curriculum was delivered in a live grand rounds setting and was recorded and made available via online platform for virtual learning. PARTICIPANTS: The 6-session curriculum was delivered to 611 live and online learners between January 2018 and April 2019, with more than half of the participants (n = 317) completing more than 1 session. Participants came from a variety of disciplines including medicine, nursing, pharmacy, and social work. RESULTS: Participants had a high rate of agreement with the statement that the curriculum met learning objectives, with live participants having stronger agreement. Participants reported that the activity would change their practice behavior by calling palliative care earlier, as well as improving their communication skills. CONCLUSION: Interprofessional collaboration can result in improved learning around the management of patients with CKD or end-stage kidney disease.

Reader agreement and accuracy of ultrasound features for hepatic steatosis.

PURPOSE: The purpose of the study is to assess the reader agreement and accuracy of eight ultrasound imaging features for classifying hepatic steatosis in adults with known or suspected hepatic steatosis. METHODS: This was an IRB-approved, HIPAA-compliant prospective study of adult patients with known or suspected hepatic steatosis. All patients signed written informed consent. Ultrasound images (Siemens S3000, 6C1HD, and 4C1 transducers) were acquired by experienced sonographers following a standard protocol. Eight readers independently graded eight features and their overall impression of hepatic steatosis on ordinal scales using an electronic case report form. Duplicated images from the 6C1HD transducer were read twice to assess intra-reader agreement. Intra-reader, inter-transducer, and inter-reader agreement were assessed using intraclass correlation coefficients (ICC). Features with the highest intra-reader agreement were selected as predictors for dichotomized histological steatosis using Classification and Regression Tree (CART) analysis, and the accuracy of the decision rule was compared to the accuracy of the radiologists' overall impression. RESULTS: 45 patients (18 males, 27 females; mean age 56 ± 12 years) scanned from September 2015 to July 2016 were included. Mean intra-reader ICCs ranged from 0.430 to 0.777, inter-transducer ICCs ranged from 0.228 to 0.640, and inter-reader ICCs ranged from 0.014 to 0.561. The CART decision rule selected only large hepatic vein blurring and achieved similar accuracy to the overall impression (74% to 75% and 68% to 72%, respectively). CONCLUSIONS: Large hepatic vein blurring, liver-kidney contrast, and overall impression provided the highest reader agreement. Large hepatic vein blurring may provide the highest classification accuracy for dichotomized grading of hepatic steatosis.

Size-resolved particle measurements of polybrominated diphenyl ethers indoors: Implications for sources and human exposure.

Polybrominated diphenyl ethers (PBDEs) are flame retardant polymer additives that are widely detected in outdoor and indoor environments. Release of PBDEs from consumer products leads to high concentrations indoors, but mechanisms of release are poorly understood. Although ingestion of dust is a well-studied indoor PBDE exposure route, the importance of inhalation exposure is uncertain. To address these unknowns, dust was collected from household vacuum cleaners, and suspended particulate matter was collected from the same homes in St. John's, Newfoundland, Canada, using a cascade impactor. Size-fractionated particulate matter samples (0.01-18 µm diameter) were analyzed for PBDEs. The sum of PBDEs in all particulate matter ranged from 8.7 ± 0.5 to 15.7 ± 0.5 pg/m3 , with >50% of PBDE mass in respirable particulate matter (<1 µm). Mass loadings as a function of particle size suggested that both abrasion and off-gassing led to the presence of PBDEs in particulate matter. Variability in the particulate matter mass loadings indicated that emission mechanisms were both product- and location-dependent. Congener profiles in colocated vacuum dust and particulate matter samples were different, indicating that vacuum dust cannot accurately predict PBDE congeners in respirable particulate matter. A calculated lower limit inhalation exposure to PBDEs (0.19 ng/d) is lower than exposure via diet or ingestion of dust, although the different biochemical pathways for inhalation compared with ingestion may have different biological effects. The present study highlights the importance of contaminant analysis in size-fractionated particulate matter to assess human exposure via inhalation compared with traditional vacuum dust methods. Environ Toxicol Chem 2018;37:481-490. © 2017 SETAC.

The growing prevalence of kidney stones and opportunities for prevention.

The prevalence of kidney stones is climbing in the United States. Several investigators have demonstrated an association between metabolic syndrome and kidney stones and some have proposed a causal link. Risk factors for nephrolithiasis can be identified with a 24-hour urine collection and preventive measures can be customized to meet the needs of individual patients. Dietary and pharmacologic interventions are available to address urinary risk factors such as inadequate urine volume, hypercalcuria, hyperoxaluria, hyperuricosuria and hypocitraturia. Given that morbidity and healthcare costs associated with nephrolithiasis are on the rise, deterring stone formation is increasingly important. Multidisciplinary clinics that foster collaboration between urologists, nephrologists and dieticians offer patients effective prevention and treatment strategies.

Vascular extravasation of contrast medium in radiological examinations: University of California San Diego Health System Experience.

INTRODUCTION: Extravasation is a well-recognized complication estimated to be between 0.1% and 0.9% of contrast medium administrations. According to the UC San Diego (UCSD) health system policy, all contrast medium extravasation (CME) reports are reviewed by the department of Risk Management, and the appropriate action is taken. Despite this strategy, a decrease in the incidence of CME could not be demonstrated. AIM: The aims of this study were to determine the frequency, management, and outcome of CME in UC San Diego patients and to assess the knowledge regarding CME among radiology technologists based on policy and guidelines. The secondary aim was to assess the manual ability of the radiology technologists in the performance of the procedure. METHODS: The study has 2 parts; the first was retrospective, including data collection and interpretation of all radiology procedures using intravenous contrast medium injection between January 1, 2010, and September 30, 2011, and the second was prospective, including proactive observations and knowledge questionnaire. RESULTS: There were 83 (0.48%) cases of CME of 17,200 patients, 54 women (0.64%) and 29 men (0.33%), P = 0.005. The patients with CME were older, and their cannula was inserted in other departments than Radiology Department, P < 0.000. There was a gap between the high theoretical knowledge that was found in the knowledge questionnaire and its implementation that was demonstrated in the proactive observation. CONCLUSIONS: Our data demonstrate that sex, age, and where the cannula was inserted are predictive factors for CME. We believe that CME could be prevented by proper educational program and establishment of efficient strategy.

Pregnancy after renal transplantation: a review of registry and single-center practices and outcomes.

Registries from North America, Australia and Europe are rich sources of clinical data on pregnancy after kidney transplantation. Single-center reports of pregnancy outcomes are limited by small sample sizes but not by the potential reporting bias that can impact registry data. Despite the differences in data pools, the obstetric and graft outcomes reported by single centers and registries have been similar. The majority of pregnancies are successful in renal transplant patients, but the risk of complications like pre-eclampsia, low birth weight and premature birth is high. Pregnancy has no significant impact on graft function or survival when baseline function is normal.

Spectral Doppler signature waveforms in ultrasonography: a review of normal and abnormal waveforms.

Doppler ultrasound is routinely used in the clinical setting to evaluate blood flow in many major vessels of the body. Spectral Doppler is used to display the normal and abnormal signature waveforms that are unique to each vessel. It is important for the sonographer and the radiologist to recognize both what is normal and what is abnormal in a spectral Doppler display. In this review, we briefly explain the physics behind Doppler ultrasound and some of the most common mathematical equations applied in a routine clinical examination. We also describe and demonstrate normal versus abnormal spectral Doppler signature waveforms of vessels in the neck, abdomen, pelvis, and fetus.

Effect of diabetes mellitus on mycophenolate sodium pharmacokinetics and inosine monophosphate dehydrogenase activity in stable kidney transplant recipients.

Effect of diabetes mellitus on mycophenolic acid (MPA) pharmacokinetics and catalytic activity of inosine monophosphate dehydrogenase (IMPDH) was investigated in maintenance kidney transplant recipients. Demographically matched diabetic (n=9) and nondiabetic (n=9) patients were included in a 12-hour open-label, steady-state study after oral administration of enteric-coated mycophenolate sodium. Concentrations of total MPA and free MPA, MPA-glucuronide, and acyl-MPA-glucuronide were measured and oral acetaminophen absorption was used as a marker for gastric-emptying rate. Median (range) of MPA area under the curve(0-12) was 36.7 (range, 16.4-116.4) mg*h/L in diabetic and 48.2 (range, 34.9-80.1) mg*h/L in nondiabetic patients (P=0.49). All other primary pharmacokinetic parameters, including time to maximum concentration, for total or unbound MPA as well as MPA metabolites were comparable. In contrast, IMPDH activity was 17.5+/-2.8 versus 46.6+/-2.5 nmol XMP/h/microg protein in diabetics and nondiabetics, respectively (P<0.0001) and was significantly lower in the diabetics irrespective of concomitant therapy with cyclosporine or tacrolimus. This study demonstrated that diabetes does not alter MPA pharmacokinetics when administered as enteric-coated mycophenolate sodium; however, IMPDH activity appeared to be significantly lower in patients with diabetes independent of the unbound or total concentrations of MPA. Further investigations are warranted to investigate the regulation of IMPDH enzyme in patients with diabetes.

Sexual victimization: incidence, knowledge and resource use among a population of college women.

STUDY OBJECTIVE: To assess the incidence of sexual victimization among a convenience sample of college women and evaluate both victims and non-victims' knowledge and use of available on and off campus resources. DESIGN: Written questionnaire distributed to students in lobbies of two campus libraries and large computing center SETTING: A private northeastern university PARTICIPANTS: Upper-class undergraduate women (sophomores, juniors and seniors) MAIN OUTCOME MEASURES: Respondents (n=234) were asked to complete demographic information, report instances of sexual victimization (including rape, sexual coercion and unwanted sexual contact) that occurred during the 1999-2000 academic year and indicate whether they would or did use either university and/or outside resources available to sexual assault victims. RESULTS: Of the women who participated, 38% (90/234) affirmed one or more episodes of sexual victimization, with 6% (14/234) reporting a completed rape and 4% (9/234) an attempted rape. Drug or alcohol-related impairment leading to unwanted sexual activity was reported by 15% (35/234) of women. Utilization of available on- and off-campus resources was uncommon among victims (22% and 6%, respectively); 12% contacted health services, while only 4% reported an event to university security. Victims cited fear, embarrassment and guilt, as well as lack of confidentiality, as the most common reasons for failure to use resources. CONCLUSIONS: Increasing campus awareness of sexual victimization and removing barriers to access for victims should remain university goals.