Purpose

Parents of children with vesicoureteral reflux are presented with a variety of management options, which in many cases offer a similar risk-benefit ratio. To facilitate shared decision making, parental preferences regarding vesicoureteral reflux treatment options need to be acknowledged. We aimed to characterize the clinical experience of parents and elicit core themes affecting decision making in regard to managing vesicoureteral reflux in their child.

Materials and methods

A semistructured, qualitative interview script was developed and vetted by 25 pediatric urologists to discuss treatment options for vesicoureteral reflux. Additional patient interviews were conducted until new themes failed to arise. Content analysis was performed to extract all statements that described treatment options. Similar statements were combined until a final list of unique themes emerged.

Results

A total of 26 interviews were performed, yielding 689 statements about overall parent experiences with managing vesicoureteral reflux in the child and 450 statements (65%) pertaining to treatment options. Of the 13 themes that emerged, those most commonly considered were the prevention of future urinary tract infections by 85% of parents, the efficacy rate of treatment options by 85%, the burden of daily maintenance or compliance by 77%, antibiotic resistance by 69%, chronic kidney damage by 62% and invasiveness by 58%.

Conclusions

Our study emphasizes that when choosing a treatment option for vesicoureteral reflux in their child, parent preferences regarding risks and benefits are variable. However, their chief concerns include whether a method decreases the risk of urinary tract infections, has an acceptable efficacy rate and aligns itself with the capabilities of the family. These themes help frame discussions between families and clinicians regarding vesicoureteral reflux management, and they can facilitate shared decision making.

The small Ultra-Red Fluorescent Protein (smURFP) represents a new class of fluorescent protein with exceptional photostability and brightness derived from allophycocyanin in a previous directed evolution. Here, we report the smURFP crystal structure to better understand properties and enable further engineering of improved variants. We compare this structure to the structures of allophycocyanin and smURFP mutants to identify the structural origins of the molecular brightness. We then use a structure-guided approach to develop monomeric smURFP variants that fluoresce with phycocyanobilin but not biliverdin. Furthermore, we measure smURFP photophysical properties necessary for advanced imaging modalities, such as those relevant for two-photon, fluorescence lifetime, and single-molecule imaging. We observe that smURFP has the largest two-photon cross-section measured for a fluorescent protein, and that it produces more photons than organic dyes. Altogether, this study expands our understanding of the smURFP, which will inform future engineering toward optimal FPs compatible with whole organism studies.