Heart rate to identify non-febrile children with dehydration and acute kidney injury in emergency department: a prospective validation study.

We previously developed and retrospectively validated the estimated percentage of heart rate variation (EHRV) as a predictor of the composite outcome of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile children. The current study aimed to prospectively validate EHRV as a predictor for dehydration or AKI in a different cohort of children attending the Pediatric Emergency Department. From July 2022 to August 2023, 256 pediatric patients aged 0-18 years attending the Pediatric Emergency Department were enrolled. EHRV was calculated as follows: [(HR at admission - 50th percentile of HR for age and sex)/HR at admission] × 100. Dehydration was categorized as < 5% or ≥ 5% fluid deficit. AKI was defined according to KDIGO creatinine criteria. Statistical analyses included receiver-operating characteristic (ROC) curves and logistic regression analysis. Among enrolled patients, 52 had ≥ 5% dehydration, 50 had AKI, and 16 had both conditions. EHRV demonstrated significant predictive ability for both ≥ 5% dehydration (AUROC = 0.71; 95% confidence interval (CI), 0.63-0.78; p < 0.001) and AKI (AUROC = 0.78; 95% CI, 0.71-0.84; p < 0.001). An EHRV > 24.5% was associated with an increased odds ratio (OR), adjusted for confounders, of ≥ 5% dehydration (OR = 3.5; 95% CI, 1.6-8.0; p = 0.003) and AKI (OR = 3.4; 95% CI, 1.6-7.3; p = 0.002). The sensitivity and specificity of this cut-off were 34% and 83% for ≥ 5% dehydration and 36% and 84% for AKI, respectively. CONCLUSIONS: This study prospectively validates the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting. An EHRV > 24.5% could serve as a marker for suspecting dehydration or AKI. Further validation across diverse patient populations and settings is needed. WHAT IS KNOWN: • An increased heart rate (HR) is a readily detectable sign of dehydration in children. • In a retrospective validation cohort, an estimated HR variation (EHRV) greater than 24.5% compared to the 50th percentile of HR was predictive of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile patients. WHAT IS NEW: • We prospectively validated the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting. • We confirmed that an EHRV greater than 24.5% is associated with increased odds of ≥ 5% dehydration and AKI.

Acute kidney injury in infants hospitalized for viral bronchiolitis.

We investigated prevalence of and factors associated with acute kidney injury (AKI) in a group of patients hospitalized with viral bronchiolitis. We retrospectively enrolled 139 children (mean age = 3.2 ± 2.1 months; males = 58.9%) hospitalized for viral bronchiolitis in a non-pediatric intensive care unit (PICU) setting. The Kidney Disease/Improving Global Outcomes creatinine criterion was used to diagnose AKI. We estimated basal serum creatinine by back-calculating it by Hoste (age) equation assuming that basal eGFR were the median age-based eGFR normative values. Univariate and multivariate logistic regression models were used to explore associations with AKI. Out of 139 patients, AKI was found in 15 (10.8%). AKI was found in 13 out of 74 (17.6%) patients with and in 2 out of 65 (3.1%) without respiratory syncytial virus (RSV) infection (p = 0.006). No patient required renal replacement therapies, while 1 out of 15 (6.7%) developed AKI stage 3, 1 (6.7%) developed AKI stage 2, and 13 (86.6%) developed AKI stage 1. Among the 15 patients with AKI, 13 (86.6%) reached the maximum AKI stage at admission, 1 (6.7%) at 48 h, and 1 (6.7%) at 96 h. At multivariate analysis, birth weight < 10th percentile (odds ratio, OR = 34.1; 95% confidence interval, CI = 3.6-329.4; p = 0.002), preterm birth (OR = 20.3; 95% CI = 3.1-129.5; p = 0.002), RSV infection (OR = 27.0; 95% CI = 2.6-279.9; p = 0.006), and hematocrit levels > 2 standard deviation score (SDS) (OR = 22.4; 95% CI = 2.8-183.6; p = 0.001) were significantly associated with AKI. CONCLUSION: About 11% of patients hospitalized with viral bronchiolitis in a non-PICU setting develop an AKI (frequently mild in degree). Preterm birth, birth weight < 10th percentile, hematocrit levels > 2SDS, and RSV infection are significantly associated with AKI in the setting of viral bronchiolitis. WHAT IS KNOWN: • Viral bronchiolitis affects children in the first months of life and in 7.5% of cases it can be complicated by acute kidney injury (AKI). • No studies investigated associations with AKI in infants hospitalized for viral bronchiolitis. WHAT IS NEW: • About 11% of patients hospitalized with viral bronchiolitis can develop an AKI (frequently mild in degree). • Preterm birth, birth weight <10th percentile, hematocrit levels > 2 standard deviation score, and respiratory syncytial virus infection are associated with AKI development in infants with viral bronchiolitis.

Semi-computational approach for assessing the damage to human soft tissues: the case of FMJRN versus HP-XTP 9 mm bullet penetration in ballistic soap.

Ballistic soap blocks are used in wound ballistics to assess the potential damage of the ammunition employed, allowing observation of the energy transfer occurred along the wound channel. The density and viscosity of ballistic soap (also called tissue simulant) simulate, to a good degree of approximation, the effect resulting from the interaction of penetrating bullets with living human soft tissue. Ballistic soap has a "plastic reaction" to bullet penetration, and therefore, unlike ballistic gelatin, the expansion of temporary cavity remains imprinted in the tissue simulant. When the soap blocks are sectioned or divided with nondestructive instrumental techniques (e.g., Compton's scattering tomography), it's possible, therefore, to observe the temporary cavity determined by the penetration of the bullet. This study provides insight into the severity of injuries originated from two different types of bullets of the same caliber by employing ballistic soap as a tissue simulant. In addition, it provides guidance to forensic practitioners on the proper use of ballistic soap for simulating gunshot wounds. The semi-computational approach employed, based on the results obtained from the firing tests, allowed the authors to understand that there is likely a threshold value of projectile energy density, close to 1 J/mm2, beyond which its penetration into the ballistic soap ceases.

Heart rate cut-offs to identify non-febrile children with dehydration and acute kidney injury.

We hypothesized that the heart rate (HR) variation in an acute setting compared with HR in wellbeing status could be a good marker of both dehydration and acute kidney injury (AKI). Since HR in wellbeing status is unknown in most cases, we assumed as reliable surrogate the 50th percentile of HR according to age and gender. We evaluated if the estimated percentage of heart rate variation in acute setting compared with 50th percentile of HR (EHRV) could be marker of dehydration and AKI in children. Two independent cohorts, one prospective comprehending 185 children at type 1 diabetes mellitus onset (derivation) and one retrospective comprehending 151 children with acute gastroenteritis and pneumonia (validation), were used to develop and externally validate EHRV as predictor of the ≥ 5% dehydration and/or AKI composite outcome. Febrile patients were excluded. EHRV was calculated as ((HR at admission-50th percentile of HR)/HR at admission) × 100. The prevalences of ≥ 5% dehydration and AKI were 61.1% and 43.8% in the derivation and 34.4% and 24.5% in the validation cohort. For the ≥ 5% dehydration and/or AKI composite outcome, the area under receiver-operating characteristic curve of the EHRV in the derivation cohort was 0.69 (95%CI, 0.62-0.77; p < 0.001) and the best EHRV cut-off was > 24.5%. In the validation cohort, EHRV > 24.5% showed specificity = 100% (95%CI, 96.2-100.0), positive predictive value = 100%, and negative predictive value = 67.1% (95%CI, 64.7-69.5). The positive likelihood ratio was infinity, and odds ratio was not calculable because all the patients with EHRV > 24.5% showed ≥ 5% dehydration and/or AKI.    Conclusions: EHRV appears a rather reliable marker of dehydration and AKI. Further validations could allow implementing EHRV in the clinical practice. What is Known: • Increased heart rate (HR) is an easily and quickly detectable sign of dehydration in childhood, but its cut-off to suspect dehydration or acute kidney injury (AKI) is not defined. What is New: • We found that a percentage of estimated HR variation in acute setting in comparison with 50th percentile of HR (EHRV)>24.5% predicted ≥5% dehydration and/or AKI in non-febrile patients. • We provide a one-page tool to suspect ≥5% dehydration and/or AKI on the basis of the HR. If furtherly validated, this tool could be implemented in the daily clinical practice.

Acute kidney injury in children hospitalized for acute gastroenteritis: prevalence and risk factors.

BACKGROUND: We aimed to evaluate prevalence of acute kidney injury (AKI) and its risk factors in children hospitalized for acute gastroenteritis (AGE) to identify early predictors of AKI. METHODS: We retrospectively collected clinical and biochemical data of 114 children (57.9% male; mean age 2.9 ± 2.8 years) hospitalized for AGE. AKI was defined according to Kidney Disease/Improving Global Outcomes creatinine criteria. We considered basal serum creatinine as value of creatinine estimated with Hoste (age) equation assuming basal eGFRs were median age-based eGFR normative values for children ≤ 2 years of age, and eGFR 120 mL/min/1.73m2 for children > 2 years. Univariate and multivariate logistic regression models were used to explore associations with AKI. We included in multivariate analyses only variables with significant p after Bonferroni correction. RESULTS: AKI was found in 28/114 (24.6%) patients. No patients required hemodialysis, 2 (1.8%) reached AKI stage 3, 2 (1.8%) AKI stage 2, and 24 (21.0%) AKI stage 1. Mean length of stay was 3.6 ± 1.2, 5.0 ± 1.8, and 10.5 ± 5.8 days, for patients with no, mild, and severe AKI (p < 0.001), respectively. Duration of symptoms before hospitalization (OR = 2.5; 95% CI = 1.3-5.0; p = 0.006), dehydration > 5% (OR = 43.1; 95% CI = 5.4-344.1; p = < 0.001), and serum bicarbonate levels (OR = 1.6; 95% CI = 1.2-2.1; p = 0.001) were independent predictors of AKI. CONCLUSIONS: About one quarter of patients hospitalized for AGE may suffer from AKI with a longer stay for patients with more severe AKI. Particular attention, however, should be paid to volemia and kidney health of patients with AGE especially in the presence of increased duration of symptoms before hospitalization, dehydration, and lower serum bicarbonate levels.

Acute kidney injury in children hospitalized for community acquired pneumonia.

BACKGROUND: Acute kidney injury (AKI) enhances the risk of later chronic kidney disease. Significant prevalence of AKI is reported in adults with community acquired pneumonia (CAP). We investigated prevalence of and prognostic factors for AKI in children hospitalized for CAP. METHODS: We retrospectively collected clinical and biochemical data of 186 children (48.4% male; mean age 2.6±2.4 years) hospitalized for X-ray-confirmed CAP. AKI was defined according to Kidney Disease/Improving Global Outcomes creatinine criteria. We considered as basal serum creatinine the value estimated with Hoste (age) equation assuming basal eGFR were median age-based eGFR normative values for children ≤ 2 years of age and eGFR= 120 mL/min/1.73m2 for children > 2 years. Univariate and multivariate logistic regression models were used to explore associations with AKI. RESULTS: AKI was found in 38/186 (20.4%) patients. No patient required hemodialysis nor reached AKI stage 3, 5 (2.7%) reached AKI stage 2, and 33 (17.7%) AKI stage 1. Mean length of stay was 6.0±1.7, 6.9±2.3, and 12.2±1.5 days, for patients without AKI, stage 1 AKI, and stage 2 AKI (p < 0.001), respectively. Duration of symptoms before hospitalization (OR 1.2; 95%CI 1.09-1.43; p = 0.001), severe pneumonia (OR 11.9; 95%CI 4.3-33.3; p < 0.001), and serum C-reactive protein levels (OR 1.1; 95%CI 1.04-1.23; p = 0.004) were independent AKI predictors. CONCLUSIONS: About 1/5 of children hospitalized for CAP present a generally mild AKI with a longer stay for those with more severe AKI. Attention should be paid to kidney health of children with CAP especially in presence of higher duration of symptoms before hospitalization, severe pneumonia and higher serum CRP levels.

Molybdenum in Gunshot Residue: Experimental Evidences and Detection Challenges in the Presence of Lead and Sulfur.

Inorganic gunshot residue (GSR) analysis is carried out by scanning electron microscopy/energy-dispersive X-ray spectroscopy (SEM/EDS) in many forensic laboratories. Characteristic GSR often consists of lead­barium­antimony, commonly associated with sulfur. The strength of forensic GSR evidence increases when unusual elements are found in residues collected both from the suspect and from the discharged firearm. The presence of molybdenum in GSR, due to the use of MoS2 lubricants in firearms, is experimentally demonstrated here for the first time. The most intense molybdenum X-ray emissions are MoL peaks at 2.3 keV which overlap with PbM and SK families due to the poor resolution of EDS detectors. When Pb, S, and Mo are allegedly present in the same particle, the reliability of automatic EDS routines is at risk. Missing identifications or false detections and exclusions may then occur. Molybdenum should be considered as detected only if MoK emissions meet the peak-to-background ratio minimum requirements. A strategy to spot Mo-containing residues is described, based on the automated search of MoS2, using a new "Sulfur only" class added to the classification scheme, followed by careful manual review of all GSR particles at an acceleration voltage of 30 kV. Our proposal improves commonly adopted forensic procedures currently followed in casework.

Structural segregation in GSR from mercuric primers. A preliminary study.

Since the second half of the XX century, primer mixtures based on mercury fulminate have become a rare occurrence on small ammunition markets in Western Europe and North America. As a consequence, Hg-containing gunshot residue (GSR) particles have not been as deeply investigated as residues from lead-based primer mixtures. As a matter of fact, no mention of GSR particles from mercuric primers is made by the current ASTM standard procedure for gunshot residue analysis. However, those laboratories dealing with ammunition and firearms produced in Eastern Europe or Asia still have a forensic interest in Hg-containing GSR. In this paper, a brief description of chemical composition and inner morphology of GSR particles from three different mercuric primers is reported. Regarding composition, arguments are given to promote SbSnHg residues to Characteristic of GSR particles when mercuric primers are discharged. From a morphological point of view, presence of inner nodules and other inhomogeneities were shown in GSR particles milled in a FIB/SEM. Moreover, mercury vaporization under the electron beam was observed for a particle reduced to a lamella. Mercury evanescence in GSR was interpreted in terms of mercury segregation during particle formation and higher mobility of Hg atoms in presence of defects (vacancies) in a strained lattice.

Examination of firearm gunpowders by scanning electron microscopy/energy dispersive X-ray analysis.

The surfaces of thirty-one gunpowders (GPs) from Winchester, Federal, Hercules, DuPont, and Remington were examined by scanning electron microscopy/energy dispersive X-ray spectroscopy. Particles and surface coatings on 22 of the GPs had compositions of sulfur/potassium/barium or sulfur/potassium detected. Primer-like particles composed of lead/antimony/barium were found on surfaces of twelve GPs. Gunpowders from fifteen different lots of Winchester 9 mm Silvertip® hollow point cartridges were found to vary in GP type (flake and flattened ball) and associated inorganic compounds of sulfur/potassium/barium or sulfur/potassium or one with only potassium. No inorganic particles or coatings were detected on two of these Winchester GPs. The elements from the inorganic compounds on GPs likely contribute to gunshot residue generated by the discharge of a firearm.