Background:Large studies evaluating pediatric acute kidney injury (AKI) epidemiology and outcomes are lacking, partially due to underuse of large administrative health care data.Objective:To assess the diagnostic accuracy of administrative health care data-defined AKI in children admitted to the pediatric intensive care unit (PICU).Design:Retrospective cohort study utilizing chart and administrative data.Setting:Children admitted to the PICU at 2 centers in Montreal, QC.Patients:Patients between 0 and 18 years old with a provincial health insurance number, without end-stage renal disease and admitted to the PICU between January 1, 2003, and March 31, 2005, were included.Measurements:The AKI was defined from chart data using the Kidney Disease: Improving Global Outcomes (KDIGO) definition (Chart-AKI). The AKI defined using administrative health data (Admin-AKI) was based on International Classification of Disease, Ninth Revision (ICD-9) AKI codes.Methods:Data available from retrospective chart review, including baseline and PICU patient characteristics, and serum creatinine (SCr) and urine output (UO) values during PICU admission, were merged with provincial administrative health care data containing diagnostic and procedure codes used for ascertaining Admin-AKI. Sensitivity, specificity, positive, and negative predictive value of Admin-AKI compared with Chart-AKI (reference standard) were calculated. Univariable associations between Admin-AKI and hospital mortality were evaluated.Results:A total of 2051 patients (55% male, mean age at admission 6.1 ± 5.8 years, 355 cardiac surgery, 1696 noncardiac surgery) were included. The AKI defined by SCr or UO criteria occurred in 52% of cardiac surgery patients and 24% of noncardiac surgery patients. Overall, Admin-AKI detected Chart-AKI with low sensitivity, but high specificity in cardiac and noncardiac surgery patients. Sensitivity increased by 1.5 to 2 fold with each increase in AKI severity stage. Admin-AKI was associated with hospital mortality (13% in Admin-AKI vs 2% in non-AKI, P < .001).Limitations:These data were generated in a PICU population; future research should study non-PICU populations.Conclusions:Use of administrative health care data to define AKI in children leads to AKI incidence underestimation. However, for detecting more severe AKI, sensitivity is higher, while maintaining high specificity.

The authors report no conflicts of interest. D'Arienzo and Rumjahn Gryte contributed equally to the article. K.R.G. and D.D. are co-first authors contributed to the proposal, writing of the first draft; editing, and approval of the final article. F.N. participated in the critical review, editing, and approval of the final article. V.D.M.

Background: Acute kidney injury (AKI) in critically ill children is associated with increased risk for short- and long-term adverse outcomes. Currently, there is no systematic follow-up for children who develop AKI in intensive care unit (ICU). Objective: This study aimed to assess variation regarding management, perceived importance, and follow-up of AKI in the ICU setting within and between healthcare professional (HCP) groups. Design: Anonymous, cross-sectional, web-based surveys were administered nationally to Canadian pediatric nephrologists, pediatric intensive care unit (PICU) physicians, and PICU nurses, via professional listservs. Setting: All Canadian pediatric nephrologists, PICU physicians, and nurses treating children in the ICU were eligible for the survey. Patients: N/A. Measurements: Surveys included multiple choice and Likert scale questions on current practice related to AKI management and long-term follow-up, including institutional and personal practice approaches, and perceived importance of AKI severity with different outcomes. Methods: Descriptive statistics were performed. Categorical responses were compared using Chi-square or Fisher’s exact tests; Likert scale results were compared using Mann-Whitney and Kruskal-Wallis tests. Results: Surveys were completed by 34/64 (53%) pediatric nephrologists, 46/113 (41%) PICU physicians, and 82 PICU nurses (response rate unknown). Over 65% of providers reported hemodialysis to be prescribed by nephrology; a mix of nephrology, ICU, or a shared nephrology-ICU model was reported responsible for peritoneal dialysis and continuous renal replacement therapy (CRRT). Severe hyperkalemia was the most important renal replacement therapy (RRT) indication for both nephrologists and PICU physicians (Likert scale from 0 [not important] to 10 [most important]; median = 10, 10, respectively). Nephrologists reported a lower threshold of AKI for increased mortality risk; 38% believed stage 2 AKI was the minimum compared to 17% of PICU physicians and 14% of nurses. Nephrologists were more likely than PICU physicians and nurses to recommend long-term follow-up for patients who develop any AKI during ICU stay (Likert scale from 0 [none] to 10 [all patients]; mean=6.0, 3.8, 3.7, respectively) ( P < .05). Limitations: Responses from all eligible HCPs in the country could not obtained. There may be differences in opinions between HCPs that completed the survey compared to those that did not. Additionally, the cross-sectional design of our study may not adequately reflect changes in guidelines and knowledge since survey completion, although no specific guidelines have been released in Canada since survey dissemination. Conclusions: Canadian HCP groups have variable perspectives on pediatric AKI management and follow-up. Understanding practice patterns and perspectives will help optimize pediatric AKI follow-up guideline implementation.

PTH concentrations were persistently elevated in the S-ECC group. CONCLUSION: Combined deficiencies of vitamin D and anemia are more prevalent in children with S-ECC; the etiology remains unclear. Interestingly, iron-dependent enzymes are needed for activation of vitamin D and 25(OH)D may play a role in erythropoiesis. Combined deficiencies may not just be related to lower SES, poorer intake secondary to pain but intertwined synthetic processes. Elevated PTH concentrations can be noted in inflammatory conditions, which may explain this finding in those with S-ECC, even post-adjustment in the regression model. A detailed diet history is key in those with S-ECC to assess risks for deficiencies of iron, vitamin D or possibly calcium.

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Primary Subject area Medical Education Background Effective clinical leadership is known to improve clinical outcomes, health service delivery, effective resource allocation, and patient and staff satisfaction rates. Although it is well known that leadership skills can be taught and are necessary for all physicians, there are very few described residency-level structured leadership-training curricula. Yet, pediatric residency programs' Competence-By-Design (CBD) includes 19 stage-specific, leadership-focused Milestones, spanning 10 Entrustable Professional Activities (EPAs) that will need to be assessed. Objectives The purpose of this study was to map how leadership is formally taught in Canadian pediatric residency programs and to explore how leader-specific milestones and EPA are incorporated into programs’ training. Design/Methods Program Directors from all Canadian pediatric residency programs were invited to complete an online, anonymous survey, which was developed using the AMEE Seven-Step Survey Development guidelines. The survey explored demographics, teaching structure, teaching content and methods, assessment, and participants’ perspectives. Descriptive and thematic analyses were performed. Results Ten of the 17 pediatric programs directors responded to the survey. All program directors (n=10), stated that there is a need for mandatory, formal leadership teaching and formal leadership skills assessment for pediatric residents. Yet, half of respondents (n=5) reported no formal leadership teaching and residents' leadership skills are not formally assessed in three (of 10) pediatric residency programs. Additionally, none of the programs offers stage-specific leadership teaching. Of the programs that offer formal leadership teaching, four programs’ teachings are stand-alone courses, while one program has a longitudinal leadership curriculum. Only one program offers formal teachings on leader-related CBD EPAs and/ or Milestones. Seven programs formally assess residents’ leadership skills. Of these, four programs use a formal assessment tool, while three programs do not use any assessment tool. None of the programs utilizes a validated or published leadership skills assessment tool. Thematic analyses revealed that the common barriers to introducing a formal leadership curriculum include limited available time in residents’ teaching curriculum, lack of expertise and resources to teach leadership, and difficulty in assessing leadership skills. Conclusion Although residency programs identify leadership teaching and assessment as necessary, most pediatric residency programs lack formal leadership teaching and assessment. Additionally, no such teaching is stage-specific. Understanding the current state of programs’ leadership teaching will help better prepare programs for the integration of leadership milestones/ EPAs in the curriculum.

Background myocardial work (MW) is a novel echocardiographic technique that enables the study of left ventricular performance. It overcomes speckle tracking echocardiography (STE) limitations, dependent on afterload, which is increased in patients with severe aortic stenosis (AS). Aims: To evaluate myocardial performance indexes obtained with MW in patients with AS and indication to percutaneous aortic valve replacement (TAVR) before and after the procedure. Methods patients with severe AS and preserved left ventricular systolic function (LVEF) and indication to TAVR underwent complete echocardiographic evaluation the day before and within two days after the procedure. MW indices were calculated considering noninvasive systolic blood pressure (SBP) and corrected for the mean transvalvular aortic gradient. Results 39 patients (78±6 years, 61.5% women) were enrolled, they presented at baseline preserved LVEF (59.4±8.2%) and reduced global longitudinal strain (GLS) (–16.8±3.3%). Corrected global work index (cGWI) and corrected global constructive work (cGCW) appeared elevated before the procedure, and were significantly reduced within 2 days after TAVR (cGWI –2460.5±839.7 mmHg% vs 1844.4±521.6 mmHg%, p&lt;0.01; cGCW 3061.3 ± 796.0 vs 2277.4 ± 536.5mmHg%, p&lt;0.01). Adjusted global wasted work (cGWW) and adjusted global work efficiency (cGWE) did not change significantly after TAVR (cGWW 262.6±151.8 vs 244.2±129.2 mmHg%, p=0.236; cGWE 90.1±4.5 vs 88.5±5.2%, p=0.079) in the overall population. In the subgroup of patients who had not developed new atrioventricular or intraventricular conduction abnormalities, cGWW also significantly decreased following TAVR (275±152.6 vs 216.3 ± 99.7 mmHg%, p=0.018), with no change in cGWE (89.7±4.8 vs 89.3±5.8%, p=0.838). Conclusions The reduction in cGWI and cGWC values and thus myocardial oxygen consumption in the immediate post–TAVR is attributable to the reduction in afterload. Left ventricular function abnormalities do not totally regress after the procedure, although the lack of reduction in cGWW could be partly due to the development of atrioventricular or intraventricular conduction defects. Further studies are desirable to define a role of MW in prognostic stratification of patients with severe AS.