Moving the Needle Toward Fair Compensation in Pediatric Nephrology.

Remuneration issues are a substantial threat to the long-term stability of the pediatric nephrology workforce. It is uncertain whether the pediatric nephrology workforce will meet the growing needs of children with kidney disease without a substantial overhaul of the current reimbursement policies. In contrast to adult nephrology, the majority of pediatric nephrologists practice in an academic setting affiliated with a university and/or children's hospital. The pediatric nephrology service line is crucial to maintaining the financial health and wellness of a comprehensive children's hospital. However, in the current fee-for-service system, the clinical care for children with kidney disease is neither sufficiently valued, nor appropriately compensated. Current compensation models derived from the relative value unit (RVU) system contribute to the structural biases inherent in the current inequitable payment system. The perceived negative financial compensation is a significant driver of waning trainee interest in the field which is one of the least attractive specialties for students, with a significant proportion of training spots going unfilled each year and relatively stagnant growth rate as compared to the other pediatric subspecialties. This article reviews the current state of financial compensation issues plaguing the pediatric nephrology subspecialty. We further outline strategies for pediatric nephrologists, hospital administrators, and policy-makers to improve the landscape of financial reimbursement to pediatric subspecialists. A physician compensation model is proposed which aligns clinical activity with alternate metrics for current non-RVU producing activities that harmonizes hospital and personal mission statements.

Preparation and Optimization of Fast Dissolving Film of Naratr iptan Hydrochloride.

BACKGROUND: Naratriptan is second-generation triptan class of antimigraine drug which selectively bind with 5-HT(1B/1D) receptor. It is widely used to treat the migraine attack due to its better tolerability and lower recurrence rate as compared to other triptans. Despite of the applicability, Naratriptan also have several drawback like slow onset of action and fist pass metabolism which reduce its efficacy. In order to increase the efficacy of naratriptan fast dissolving film is prepared. METHOD: Fast dissolving film of Naratriptan hydrochloride was prepared by solvent casting method Based on the patent survey (US 7648712 B2, WO 2012053006 A2, US 20090047330 A1, EP 2821066 A4, WO 2008108940 A1, WO 2010151020 A3) excipients were screened to find out suitable combination of polymer and plasticizer and Hydroxypropylmethyl Cellulose (HPMC E6) and glycerol were selected as film forming polymer and plasticizer respectively. To study the effect of independent variables on dependent variables 32 full factorial design was applied using Concentration of HPMC E6 and Concentration of Glycerol as independent variables and disintegration time, folding endurance, tensile strength and cumulative % drug release at 2 min as dependent or response variables. A statistical model incorporating interactive and polynomial terms was utilized to evaluate the responses. Result & Conclusion: From the results of statistical evaluation batch F3 was selected as the optimized batch which exhibited shorter disintegration time (22sec) with satisfactory mechanical properties (tensile strength 652.17 gm/mm2). Dissolution of drug from F3 formulation was rapid with around 91% drug release in 120sec. Optimized batch was further evaluated for in vitro permeation study using Franz diffusion cell.

Testing the self-consistency of the excursion set approach to predicting the dark matter halo mass function.

The excursion set approach provides a framework for predicting how the abundance of dark matter halos depends on the initial conditions. A key ingredient of this formalism is the specification of a critical overdensity threshold (barrier) which protohalos must exceed if they are to form virialized halos at a later time. However, to make its predictions, the excursion set approach explicitly averages over all positions in the initial field, rather than the special ones around which halos form, so it is not clear that the barrier has physical motivation or meaning. In this Letter we show that once the statistical assumptions which underlie the excursion set approach are considered a drifting diffusing barrier model does provide a good self-consistent description both of halo abundance as well as of the initial overdensities of the protohalo patches.

Evidence that temporal lobe is a default area in absence epilepsy.

Correctly classifying seizures is essential for appropriate epilepsy management. Focal and generalized epilepsy rarely occur independently in the same patient. Cases of focal ictal evolution during seizures that are generalized in onset have been reported though these have included a small heterogeneous series of patients with generalized epilepsy and features on the EEG. We wish to report two patients with absence epilepsy that were noted on video-EEG monitoring to manifest a focal temporal electroclinical transformation from a typical absence seizure. Defining the electroclinical spectrum of absence seizures could add to our understanding of the selective cortical and subcortical networks that are involved in patients with "prototypic" generalized and focal seizures.

Thalamofrontal neurodevelopment in new-onset pediatric idiopathic generalized epilepsy.

BACKGROUND: Quantitative MRI techniques have demonstrated thalamocortical abnormalities in idiopathic generalized epilepsy (IGE). However, there are few studies examining IGE early in its course and the neurodevelopmental course of this region is not adequately defined. OBJECTIVE: We examined the 2-year developmental course of the thalamus and frontal lobes in pediatric new-onset IGE (i.e., within 12 months of diagnosis). METHODS: We performed whole-brain MRI in 22 patients with new-onset IGE and 36 age-matched healthy controls. MRI was repeated 24 months after baseline MRI. Quantitative volumetrics were used to examine thalamic and frontal lobe volumes. RESULTS: The IGE group showed significant differences in thalamic volume within 1 year of seizure onset (baseline) and went on to show thalamic volume loss at a significantly faster rate than healthy control children over the 2-year interval. The control group also showed a significantly greater increase in frontal white matter expansion than the IGE group. In contrast, frontal lobe gray matter volume differences were moderate at baseline and persisted over time, indicating similar developmental trajectories with differences early in the disease process that are maintained. CONCLUSIONS: Brain tissue abnormalities in thalamic and frontal regions can be identified very early in the course of IGE and an abnormal trajectory of growth continues over a 2-year interval.

Case report: Liposarcoma of the sinonasal tract.

Nasal and paranasal malignant tumours account for less than 5% of all head and neck malignancies. Epithelial malignancies overwhelmingly predominate, with squamous cell carcinomas representing the most frequent histological subtype in this location. Soft-tissue sarcomas of the nasal cavity and paranasal sinuses are exceedingly rare. Here, we report two cases of myxoid liposarcomas that occurred in the nasal and paranasal regions, both of which presented diagnostic challenges and could not be diagnosed definitively from intraoperative frozen sections. These cases reinforce the notion that, while they are uncommon, sarcomas in general and liposarcomas in particular should still be considered as part of the differential diagnosis in patients presenting with obstructive symptoms in the nasal and paranasal sinuses.

The nature and course of neuropsychological morbidity in chronic temporal lobe epilepsy.

OBJECTIVE: To characterize the nature and degree of cognitive morbidity in patients with chronic temporal lobe epilepsy compared with healthy control subjects, determine the association between the duration of epilepsy and cognitive morbidity, and ascertain whether there are factors that moderate the association between duration of disorder and cognitive impairment. METHODS: Temporal lobe epilepsy (n = 96) and healthy control (n = 82) subjects were assessed with a comprehensive neuropsychological battery. Test performances were adjusted for age, gender, and education and transformed to a common metric (z scores). Analyses included group comparisons and correlations of duration of epilepsy with cognitive morbidity. RESULTS: Patients with temporal lobe epilepsy exhibited not only worse memory function (p < 0.05) but worse performance across measures of intelligence, language, executive function, and motor speed (p < 0.05). Chronicity of epilepsy was related to worsening mental status (r = 0.42, p < 0.001). This relationship was particularly evident among those individuals with less (r = 0.58, p < 0.001) compared with more (r = 0.25, NS) cerebral reserve, operationally defined by years of formal education. CONCLUSIONS: Neuropsychological morbidity in chronic temporal lobe epilepsy is widespread in nature despite a focal epileptic process. Cross-sectional analyses demonstrate that increasing duration of epilepsy is associated with worsening mental status. Individuals with less educational attainment (low cerebral reserve) exhibit especially poor cognitive function in association with chronicity of epilepsy.

Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society.

OBJECTIVE: To make evidence-based recommendations concerning the evaluation of the child with a nonprogressive global developmental delay. METHODS: Relevant literature was reviewed, abstracted, and classified. Recommendations were based on a four-tiered scheme of evidence classification. RESULTS: Global developmental delay is common and affects 1% to 3% of children. Given yields of about 1%, routine metabolic screening is not indicated in the initial evaluation of a child with global developmental delay. Because of the higher yield (3.5% to 10%), even in the absence of dysmorphic features or features suggestive of a specific syndrome, routine cytogenetic studies and molecular testing for the fragile X mutation are recommended. The diagnosis of Rett syndrome should be considered in girls with unexplained moderate to severe developmental delay. Additional genetic studies (e.g., subtelomeric chromosomal rearrangements) may also be considered in selected children. Evaluation of serum lead levels should be restricted to those children with identifiable risk factors for excessive lead exposure. Thyroid studies need not be undertaken (unless clinically indicated) if the child underwent newborn screening. An EEG is not recommended as part of the initial evaluation unless there are historical features suggestive of epilepsy or a specific epileptic syndrome. Routine neuroimaging, with MRI preferred to CT, is recommended particularly if abnormalities are found on physical examination. Because of the increased incidence of visual and auditory impairments, children with global developmental delay may undergo appropriate visual and audiometric assessment at the time of diagnosis. CONCLUSIONS: A specific etiology can be determined in the majority of children with global developmental delay. Certain routine screening tests are indicated and depending on history and examination findings, additional specific testing may be performed.

Hemoperitoneum complicating snake bite: rare CT features.

Russels's viper bite victims with systemic poisoning may present with hemorrhagic manifestations, including spontaneous bleeding and incoagulable blood associated with disseminated intravascular coagulation and primary fibrinolysis, two of the most prominent manifestations of the systemic envenoming by this species. Various vascular complications of viperine snake bite have been reported in the literature. We report the computed tomographic findings in a case of snake bite resulting in hemoperitoneum, which, to the best of our knowledge, has not been reported in the literature.

Pain activation of human supraspinal opioid pathways as demonstrated by [11C]-carfentanil and positron emission tomography (PET).

The role of the supraspinal endogenous opioid system in pain processing has been investigated in this study using positron emission tomography imaging of [11C]-carfentanil, a synthetic, highly specific mu opioid receptor (mu-OR) agonist. Eight healthy volunteers were studied during a baseline imaging session and during a session in which subjects experienced pain induced by applying capsaicin topically to the dorsal aspect of the left hand. A pain-related decrease in brain mu-OR binding was observed in the contralateral thalamus consistent with competitive binding between [11C]-carfentanil and acutely released endogenous opioid peptides. This decrease varied directly with ratings of pain intensity. These results suggest that the supraspinal mu-opioid system is activated by acute pain and thus may play a substantial role in pain processing and modulation in pain syndromes.

Mandibular haemophilic pseudotumour containing a fluid-fluid level.

Osseous haemophilic pseudotumours are uncommon. Mandibular haemophilic pseudotumours are rare, with only approximately 12 cases reported in the literature to date. We present imaging findings of a histopathologically proven mandibular haemophilic pseudotumour. A fluid-fluid level, hitherto not associated with this condition, is also described.

Successful use of Tesio catheters in pediatric patients receiving chronic hemodialysis.

Semipermanent venous catheters remain the most commonly used access for chronic hemodialysis (HD) in pediatric patients. The recent availability of Tesio catheters in 7 and 10 F has expanded available HD catheter options for children and adolescents. We report our experience with Tesio catheter survival, complications, and effect on dialysis adequacy in comparison to standard dual-lumen (DL) catheters in our pediatric HD patients. Demographic data were similar between the two groups. Overall actuarial survival was significantly longer for Tesio versus DL catheters (46% versus 0% at 1 year; P = 0.003). A comparison of smaller catheters (7 F Tesio catheter, 8 or 10 F DL catheter) showed that smaller Tesio catheters had a significantly longer survival (median survival, 244 versus 13 catheter-days; P < 0.01). Tesio 10 F catheters also survived significantly longer than the larger 11.5 and 12 F DL catheters (P < 0.02). Catheter sepsis occurred less frequently with Tesio catheters (one episode/20 catheter-months) than DL catheters (one episode/5 catheter-months) despite the longer duration of Tesio catheters. Adequate dialysis (single-pool Kt/V > 1.2) was delivered with the same frequency, but for a longer duration with Tesio catheters (76% +/- 32% over 100 monthly measurements versus DL catheter, 57% +/- 45% over 54 monthly measurements). Our clinical practice was to replace cuffed catheters when adequate dialysis could not be delivered. We conclude that Tesio catheters provide superior performance compared with DL catheters in terms of catheter survival, infection rates, and duration of adequate performance.

Diagnosis and treatment of thoracic outlet syndrome.

TOS represents a spectrum of disorders encompassing four related syndromes: arterial compression, venous compression, neurogenic compression, and a poorly defined pain syndrome. Patients can present with signs of arterial insufficiency, venous obstruction, painless wasting of intrinsic hand muscles, and pain. History and physical examination are the most important diagnostic studies, and radiographs of the chest and cervical spine and electromyography/nerve conduction studies are useful to identify other causes of pain and disability. Surgical intervention is indicated for patients failing nonoperative maneuvers and can usually yield satisfactory results. TOS may also be the most underrated, overlooked, and misdiagnosed, and the most important and difficult to manage peripheral nerve compression in the upper extremity.

A random walk through models of nonlinear clustering.

A few simple models of the mass function of collapsed objects are presented. The emphasis is on apparently unrelated models which end up giving the same answer for the number density and merger histories of virialized clumps. Models of the spatial distribution of the clumps and how they can be used to model the spatial distribution of the mass are briefly discussed.

Soy-containing diet suppresses chronic neuropathic sensory disorders in rats.

UNLABELLED: Partial sciatic nerve ligation (PSL) in rodents produces chronic neuropathic sensory disorders resembling neuropathic pain in humans. We previously reported that levels of allodynia and hyperalgesia after PSL injury were markedly attenuated by consumption of soy-containing diets. Here we aimed to show that dietary effect on pain behavior is not specific to a certain laboratory. For this purpose, experiments were conducted in a different laboratory (Baltimore rather than Jerusalem) and a different rat strain (Wistar rather than Sabra), with additional and different testing methods (radiant heat from a lamp rather than a CO(2) laser). Rats were fed two soy-free diets and a soy-containing one for 28 days. The sensitivity of rats to nonnoxious and noxious stimuli was determined before PSL injury, and levels of neuropathic sensory disorders were determined after it. We found that consuming the soy-containing diet prevented development of tactile and heat allodynia, but not mechanical hyperalgesia. This dietary effect was not correlated with calorie intake and weight gain or dietary concentration of fat and carbohydrates. We conclude that, regardless of experimental site, diet markedly affects chronic neuropathic sensory disorders in rats and should be standardized in animal models of pain. IMPLICATIONS: Levels of chronic sensory disorders in a rat model of allodynia and hyperalgesia after partial sciatic nerve ligation depend on the consumption of a soy-containing diet. Further studies are needed to determine the role of diet in humans with chronic pain.

Isotretinoin: an Indian experience.

In this study we retrospectively analysed the unique efficacy and incidence of potentially significant side-effects of a new drug which has claimed to be a major milestone in dermatotherapeutics-isotretinoin. We concluded that oral retinoids 'do things' that nothing else can in several skin disorders-especially recalcitrant acne vulgaris which can emotionally, physically and psychologically cripple an individual for life.

Object naming and semantic knowledge in temporal lobe epilepsy.

Object-naming impairment is common among temporal lobe epilepsy (TLE) patients, but other aspects of semantic memory have received limited attention in this population. This study examined object-naming ability and depth of semantic knowledge in healthy controls (n = 29) and patients with early onset TLE (n = 21). After administration of the Boston Naming Test (BNT), the authors asked participants to provide detailed definitions of 6 BNT objects. The TLE group demonstrated a significant deficit relative to controls in both object-naming ability and semantic knowledge for the target objects, even after controlling for IQ. In a multiple regression analysis that included other neuropsychological test scores as independent variables, the semantic knowledge score was the only significant predictor of patients' object-naming performance. Thus, at the group level, early onset TLE patients have a semantic knowledge deficit that contributes to dysnomia.

Pediatric epilepsy surgery: neuroimaging, neuropsychology, and anticonvulsants.

Neuroimaging and the neuropsychological evaluation are important components of the presurgical evaluation for epilepsy surgery. Advances in neuroimaging over the last decade, to a large part, underlie improvements in pediatric epilepsy surgery outcomes. The neuropsychological evaluation plays an important role in the evaluation of the older child and adolescent, particularly in the evaluation of mesial temporal sclerosis. However, its role in the young child being considered for surgery remains to be defined. This section reviews the definition of medical intractability, issues related to medication withdrawal during video-EEG monitoring, recent neuroimaging advances, and the neuropsychological evaluation.