Large kidneys predict poor renal outcome in subjects with diabetes and chronic kidney disease

<p>Abstract</p> <p>Background</p> <p>Renal hypertrophy occurs early in diabetic nephropathy, its later value is unknown. Do large kidneys still predict poor outcome in patients with diabetes and Chronic Kidney Disease (CKD)?</p> <p>Methods</p> <p>Seventy-five patients with diabetes and CKD according to a Glomerular Filtration Rate (GFR, by 51Cr-EDTA clearance) below 60 mL/min/1.73 m²or an Albumin Excretion Rate above 30 mg/24 H, had an ultrasound imaging of the kidneys and were cooperatively followed during five years by the Diabetology and Nephrology departments of the Centre Hospitalier Universitaire de Bordeaux.</p> <p>Results</p> <p>The patients were mainly men (44/75), aged 62 ± 13 yrs, with long-standing diabetes (duration:17 ± 9 yrs, 55/75 type 2), and CKD: initial GFR: 56.5 (8.5-209) mL/min/1.73 m², AER: 196 (20-2358) mg/24 H. Their mean kidney lenght (108 ± 13 mm, 67-147) was correlated to the GFR (r = 0.23, p < 0.05). During the follow-up, 9/11 of the patients who had to start dialysis came from the half with the largest kidneys (LogRank: p < 0.05), despite a 40% higher initial isotopic GFR. Serum creatinine were initially lower (Small kidneys: 125 (79-320) μmol/L, Large: 103 (50-371), p < 0.05), but significantly increased in the "large kidneys" group at the end of the follow-up (Small kidneys: 129 (69-283) μmol/L, Large: 140 (50-952), p < 0.005 vs initial). The difference persisted in the patients with severe renal failure (KDOQI stages 4,5).</p> <p>Conclusions</p> <p>Large kidneys still predict progression in advanced CKD complicating diabetes. In these patients, ultrasound imaging not only excludes obstructive renal disease, but also provides information on the progression of the renal disease.</p

A nationwide study of adults admitted to hospital with diabetic ketoacidosis or hyperosmolar hyperglycaemic state and COVID‐19

AimsTo investigate characteristics of people hospitalized with coronavirus-disease-2019 (COVID-19) and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS), and to identify risk factors for mortality and intensive care admission.Materials and methodsRetrospective cohort study with anonymized data from the Association of British Clinical Diabetologists nationwide audit of hospital admissions with COVID-19 and diabetes, from start of pandemic to November 2021. The primary outcome was inpatient mortality. DKA and HHS were adjudicated against national criteria. Age-adjusted odds ratios were calculated using logistic regression.ResultsIn total, 85 confirmed DKA cases, and 20 HHS, occurred among 4073 people (211 type 1 diabetes, 3748 type 2 diabetes, 114 unknown type) hospitalized with COVID-19. Mean (SD) age was 60 (18.2) years in DKA and 74 (11.8) years in HHS (p < .001). A higher proportion of patients with HHS than with DKA were of non-White ethnicity (71.4% vs 39.0% p = .038). Mortality in DKA was 36.8% (n = 57) and 3.8% (n = 26) in type 2 and type 1 diabetes respectively. Among people with type 2 diabetes and DKA, mortality was lower in insulin users compared with non-users [21.4% vs. 52.2%; age-adjusted odds ratio 0.13 (95% CI 0.03-0.60)]. Crude mortality was lower in DKA than HHS (25.9% vs. 65.0%, p = .001) and in statin users versus non-users (36.4% vs. 100%; p = .035) but these were not statistically significant after age adjustment.ConclusionsHospitalization with COVID-19 and adjudicated DKA is four times more common than HHS but both associate with substantial mortality. There is a strong association of previous insulin therapy with survival in type 2 diabetes-associated DKA

The respiratory control of carbon dioxide in children and adolescents referred for treatment of psychogenic non-epileptic seizures

Psychogenic non-epileptic seizures (PNES) are a common problem in paediatric neurology and psychiatry that can best be understood as atypical responses to threat. Threats activate the body for action by mediating increases in arousal, respiration, and motor readiness. In previous studies, a range of cardiac, endocrine, brain-based, attention-bias, and behavioral measures have been used to demonstrate increases in arousal, vigilance, and motor readiness in patients with PNES. The current study uses respiratory measures to assess both the motor readiness of the respiratory system and the respiratory regulation of CO2. Baseline respiratory rates during clinical assessment and arterial CO2 levels during the hyperventilation component of routine video electroencephalogram were documented in 60 children and adolescents referred for treatment of PNES and in 50 controls. Patients showed elevated baseline respiratory rates [t(78) = 3.34, p = .001], with 36/52 (69%) of patients [vs. 11/28 (39%) controls] falling above the 75th percentile (χ 2 = 6.7343; df = 1; p = .009). Twenty-eight (47%) of patients [vs. 4/50 (8%) controls] showed a skewed hyperventilation-challenge profile—baseline PCO2 <36 mmHg, a trough PCO2 ≤ 20 mmHg, or a final PCO2 <36 mmHg after 15 min of recovery—signaling difficulties with CO2 regulation (χ 2 = 19.77; df = 1; p < .001). Children and adolescents with PNES present in a state of readiness-for-action characterized by high arousal coupled with activation of the respiratory motor system, increases in ventilation, and a hyperventilation-challenge profile shifted downward from homeostatic range. Breathing interventions that target arousal, decrease respiratory rate, and normalize ventilation and arterial CO2 may help patients shift brain–body state and avert PNES episodes. Electronic supplementary material The online version of this article (doi:10.1007/s00787-017-0976-0) contains supplementary material, which is available to authorized users

Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study

This prospective case-cohort study examines the developmental pathway choices of 79 young people (13.25–23.75 years old; 33 biological males and 46 biological females) referred to a tertiary care hospital’s Department of Psychological Medicine (December 2013–November 2018, at ages 8.42–15.92 years) for diagnostic assessment for gender dysphoria (GD) and for potential gender-affirming medical interventions. All of the young people had attended a screening medical assessment (including puberty staging) by paediatricians. The Psychological Medicine assessment (individual and family) yielded a formal DSM-5 diagnosis of GD in 66 of the young people. Of the 13 not meeting DSM-5 criteria, two obtained a GD diagnosis at a later time. This yielded 68 young people (68/79; 86.1%) with formal diagnoses of GD who were potentially eligible for gender-affirming medical interventions and 11 young people (11/79; 13.9%) who were not. Follow-up took place between November 2022 and January 2023. Within the GD subgroup (n = 68) (with two lost to follow-up), six had desisted (desistance rate of 9.1%; 6/66), and 60 had persisted on a GD (transgender) pathway (persistence rate of 90.9%; 60/66). Within the cohort as a whole (with two lost to follow-up), the overall persistence rate was 77.9% (60/77), and overall desistance rate for gender-related distress was 22.1% (17/77). Ongoing mental health concerns were reported by 44/50 (88.0%), and educational/occupational outcomes varied widely. The study highlights the importance of careful screening, comprehensive biopsychosocial (including family) assessment, and holistic therapeutic support. Even in highly screened samples of children and adolescents seeking a GD diagnosis and gender-affirming medical care, outcome pathways follow a diverse range of possibilities

Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study

This prospective case-cohort study examines the developmental pathway choices of 79 young people (13.25&ndash;23.75 years old; 33 biological males and 46 biological females) referred to a tertiary care hospital&rsquo;s Department of Psychological Medicine (December 2013&ndash;November 2018, at ages 8.42&ndash;15.92 years) for diagnostic assessment for gender dysphoria (GD) and for potential gender-affirming medical interventions. All of the young people had attended a screening medical assessment (including puberty staging) by paediatricians. The Psychological Medicine assessment (individual and family) yielded a formal DSM-5 diagnosis of GD in 66 of the young people. Of the 13 not meeting DSM-5 criteria, two obtained a GD diagnosis at a later time. This yielded 68 young people (68/79; 86.1%) with formal diagnoses of GD who were potentially eligible for gender-affirming medical interventions and 11 young people (11/79; 13.9%) who were not. Follow-up took place between November 2022 and January 2023. Within the GD subgroup (n = 68) (with two lost to follow-up), six had desisted (desistance rate of 9.1%; 6/66), and 60 had persisted on a GD (transgender) pathway (persistence rate of 90.9%; 60/66). Within the cohort as a whole (with two lost to follow-up), the overall persistence rate was 77.9% (60/77), and overall desistance rate for gender-related distress was 22.1% (17/77). Ongoing mental health concerns were reported by 44/50 (88.0%), and educational/occupational outcomes varied widely. The study highlights the importance of careful screening, comprehensive biopsychosocial (including family) assessment, and holistic therapeutic support. Even in highly screened samples of children and adolescents seeking a GD diagnosis and gender-affirming medical care, outcome pathways follow a diverse range of possibilities

Multimodal rehabilitation : a mind-body family-based intervention for children and adolescents impaired by medically unexplained symptoms. Part 2 : case studies and outcomes

In Part 2, we describe three cases implementing our mind-body, family-based, multimodal rehabilitation approach for treating children and adolescents presenting with medically unexplained symptoms. For each child and family, treatment interventions were selected and implemented, simultaneously or sequentially. In a cohort of 100 consecutively referred children, 56 suffered from, and were treated for, significant physical or chronic school absenteeism. Thirty-five of these children (63%) recovered fully, 10 (18%) had a relapsing course, 7 (12.5%) had chronic symptoms, and 4 (7%) were lost to follow-up. These outcomes suggest that mind-body multimodal rehabilitation is a successful, cost-effective model of treatment.20 page(s

Psychogenic non-epileptic seizures in children and adolescents: Part II – explanations to families, treatment, and group outcomes

Psychogenic non-epileptic seizures (PNES) – time-limited disturbances of consciousness and motor-sensory control, not accompanied by ictal activity on electroencephalogram (EEG) – are best conceptualized as atypical neurophysiological responses to emotional distress, physiological stressors and danger. Patients and families find the diagnosis of PNES difficult to understand; the transition from neurology (where the diagnosis is made) to mental health services (to which patients are referred for treatment) can be a bumpy one. This study reports how diagnostic formulations constructed for 60 consecutive children and adolescents with PNES were used to inform both the explanations about PNES that were given to them and their families and the clinical interventions that were used to help patients gain control over PNES. Families were able to accept the diagnosis of PNES and engage in treatment when it was explained how emotional distress, illness and states of high arousal could activate atypical defence responses in the body and brain – with PNES being an unwanted by-product of this process. Patients and their families made good use of therapeutic interventions. A total of 75% of children/adolescents (45/60) regained normal function and attained full-time return to school. Global Assessment of Functioning scores increased from 41 to 67 (t(54) = 10.09; p < .001). Outcomes were less favourable in children/adolescents who presented with chronic PNES and in those with a chronic, comorbid mental health disorder that failed to resolve with treatment. The study highlights that prompt diagnosis, followed by prompt multidisciplinary assessment, engagement, and treatment, achieves improved outcomes in children/adolescents with PNES

Psychogenic non-epileptic seizures in children and adolescents: Part I – Diagnostic formulations

Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations – the clinical formulations about the probable neurophysiological mechanisms – that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet’s dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES

Illness-Promoting Psychological Processes in Children and Adolescents with Functional Neurological Disorder

Previous studies suggest that subjective distress in children with functional neurological disorder (FND) is associated with stress-system dysregulation and modulates aberrant changes in neural networks. The current study documents illness-promoting psychological processes in 76 children with FND (60 girls and 16 boys, aged 10.00−17.08 years) admitted to the Mind–Body Program. The children completed a comprehensive family assessment and self-report measures, and they worked with the clinical team to identify psychological processes during their inpatient admission. A total of 47 healthy controls (35 girls and 12 boys, aged 8.58–17.92 years) also completed self-report measures, but were not assessed for illness-promoting psychological processes. Children with FND (vs. controls) reported higher levels of subjective distress (total DASS score, t(104.24) = 12.18; p ˂ 0.001) and more adverse childhood experiences across their lifespans (total ELSQ score, t(88.57) = 9.38; p ˂ 0.001). Illness-promoting psychological processes were identified in all children with FND. Most common were the following: chronic worries about schoolwork, friendships, or parental wellbeing (n = 64; 84.2%); attention to symptoms (n = 61; 80.3%); feeling sad (n = 58; 76.3%); experiencing a low sense of control (helplessness) in relation to symptoms (n = 44; 57.9%); pushing difficult thoughts out of mind (n = 44; 57.9%); self-critical rumination (n = 42; 55.3%); negative/catastrophic-symptom expectations (n = 40; 52.6%); avoidance of activities (n = 38; 50%); intrusive thoughts/feelings/memories associated with adverse events (n = 38, 50%); and pushing difficult feelings out of mind (n = 37; 48.7%). In children with FND—disabled enough to be admitted for inpatient treatment—illness-promoting psychological processes are part of the clinical presentation. They contribute to the child’s ongoing sense of subjective distress, and if not addressed can maintain the illness process. A range of clinical interventions used to address illness-promoting psychological processes are discussed, along with illustrative vignettes