The Utility of Urinary NGAL as an Alternative for Serum Creatinine to Detect Acute Kidney Injury in Infants Exposed to Nephrotoxic Medications in the Neonatal Intensive Care Unit.

INTRODUCTION: Nephrotoxic medication (NTM) exposure is commonly associated with acute kidney injury (AKI) in the neonatal intensive care unit (NICU). Baby Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a quality improvement program that assesses for AKI in those exposed to NTM with daily serum creatinine (SCr) levels. However, blood draws for SCr are invasive and have clinical disadvantages. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a promising indicator of AKI. We tested the hypothesis that uNGAL could reliably screen for NTM-AKI in the Baby NINJA program. METHODS: This two-center prospective study screened 174 NICU subjects, of whom 148 met screening criteria from January 29, 2019, to September 18, 2020. Daily SCr and urine samples were obtained for up to 7 days of NTM exposure plus 2 days after exposure ended or end of AKI. AKI was defined by a SCr rise of 50% from baseline. The highest uNGAL obtained was evaluated to determine its relationship to the diagnosis of AKI. Logistic regression models were used to determine optimal uNGAL cutoffs. RESULTS: The negative predictive value of a uNGAL value ≥250 ng/mL was 96.8% (95% CI = 93.3-100%). Urine NGAL ≥400 ng/mL demonstrated the highest ROC-AUC value of 0.72 with a positive likelihood risk for AKI of 2.76 (1.39-4.13). DISCUSSION/CONCLUSION: We propose that uNGAL could be used to screen for NTM-AKI and thus replace many blood draws needed in those exposed to NTM. The ideal uNGAL threshold requires further investigation in infants.

A subduction influence on ocean ridge basalts outside the Pacific subduction shield.

The plate tectonic cycle produces chemically distinct mid-ocean ridge basalts and arc volcanics, with the latter enriched in elements such as Ba, Rb, Th, Sr and Pb and depleted in Nb owing to the water-rich flux from the subducted slab. Basalts from back-arc basins, with intermediate compositions, show that such a slab flux can be transported behind the volcanic front of the arc and incorporated into mantle flow. Hence it is puzzling why melts of subduction-modified mantle have rarely been recognized in mid-ocean ridge basalts. Here we report the first mid-ocean ridge basalt samples with distinct arc signatures, akin to back-arc basin basalts, from the Arctic Gakkel Ridge. A new high precision dataset for 576 Gakkel samples suggests a pervasive subduction influence in this region. This influence can also be identified in Atlantic and Indian mid-ocean ridge basalts but is nearly absent in Pacific mid-ocean ridge basalts. Such a hemispheric-scale upper mantle heterogeneity reflects subduction modification of the asthenospheric mantle which is incorporated into mantle flow, and whose geographical distribution is controlled dominantly by a "subduction shield" that has surrounded the Pacific Ocean for 180 Myr. Simple modeling suggests that a slab flux equivalent to ~13% of the output at arcs is incorporated into the convecting upper mantle.

Pediatric health-related quality of life: Feasibility, reliability and validity of the PedsQL transplant module.

The measurement properties of the newly developed Pediatric Quality of Life Inventory (PedsQL) 3.0 Transplant Module in pediatric solid organ transplant recipients were evaluated. Participants included pediatric recipients of liver, kidney, heart and small bowel transplantation who were cared for at seven medical centers across the United States and their parents. Three hundred and thirty-eight parents of children ages 2-18 and 274 children ages 5-18 completed both the PedsQL 4.0 Generic Core Scales and the Transplant Module. Findings suggest that child self-report and parent proxy-report scales on the Transplant Module demonstrated excellent reliability (total scale score for child self-report alpha= 0.93; total scale score for parent proxy-report alpha= 0.94). Transplant-specific symptoms or problems were significantly correlated with lower generic HRQOL, supporting construct validity. Children with solid organ transplants and their parents reported statistically significant lower generic HRQOL than healthy children. Parent and child reports showed moderate to good agreement across the scales. In conclusion, the PedsQL Transplant Module demonstrated excellent initial feasibility, reliability and construct validity in pediatric patients with solid organ transplants.

Magmatic and amagmatic seafloor generation at the ultraslow-spreading Gakkel ridge, Arctic Ocean.

A high-resolution mapping and sampling study of the Gakkel ridge was accomplished during an international ice-breaker expedition to the high Arctic and North Pole in summer 2001. For this slowest-spreading endmember of the global mid-ocean-ridge system, predictions were that magmatism should progressively diminish as the spreading rate decreases along the ridge, and that hydrothermal activity should be rare. Instead, it was found that magmatic variations are irregular, and that hydrothermal activity is abundant. A 300-kilometre-long central amagmatic zone, where mantle peridotites are emplaced directly in the ridge axis, lies between abundant, continuous volcanism in the west, and large, widely spaced volcanic centres in the east. These observations demonstrate that the extent of mantle melting is not a simple function of spreading rate: mantle temperatures at depth or mantle chemistry (or both) must vary significantly along-axis. Highly punctuated volcanism in the absence of ridge offsets suggests that first-order ridge segmentation is controlled by mantle processes of melting and melt segregation. The strong focusing of magmatic activity coupled with faulting may account for the unexpectedly high levels of hydrothermal activity observed.

Variation among subspecialists in the diagnosis of urinary tract infection in children with neurogenic bladders.

BACKGROUND: Children with neurogenic bladders who require clean intermittent catheterization (CIC) frequently have bacteriuria. However, there is no consensus on what constitutes at urinary tract infection (UTI) in this population. Multiple subspecialists are often involved in the management of these patients, although they are frequently cared for by hospitalists when admission is required. OBJECTIVE: The objective of this study was to describe the variability in opinion between subspecialists in the diagnosis of a UTI in CIC-dependent children. STUDY DESIGN: A scenario-based survey was distributed to physicians in the divisions of urology, nephrology, and hospital medicine at a single free-standing children's hospital. Respondents rated their degree of confidence on whether a specific scenario represented UTI or colonization on an 11-point Likert Scale. Median responses were compared with the Kruskal-Wallis test with pair-wise comparisons. RESULTS: Back/flank pain, abdominal pain, and vomiting were the most common symptoms that were suggestive of a UTI in a non-febrile child. There was no single symptom chosen that was the most suggestive of a UTI in CIC-dependent child. There was significant variability between specialists in the diagnosis of UTI in specific clinical scenarios on the survey. Hospitalists were significantly less confident about the diagnosis of a UTI than urologists in two of the clinical scenarios. CONCLUSIONS: Standardization and implementation of consensus criteria for UTI in this high-risk population is needed.

Evaluation of the Polyflux 6H dialyzer in pediatric patients receiving maintenance hemodialysis.

Hemodialysis remains the only life sustaining maintenance renal replacement therapy option for children who cannot undergo expeditious renal transplantation or who are not medical candidates for peritoneal dialysis. Provision of maintenance hemodialysis to small children entails many challenges, which arise from the limited choices for appropriately sized disposable dialysis treatment components. The dialysis extracorporeal circuit volume, comprised of the blood tubing and dialyzer, should be low enough to prevent hypotension and prevent the need for repeated blood transfusions. We performed a market acceptance evaluation of the Polyflux 6H dialyzer (0.6 m2 membrane surface area; Gambro Renal Products, Lakewood, Colorado) in six pediatric patients (3 male, 3 female, mean weight 24.4+6.5 kg, mean age 10.3+3.8 yrs). We found that the Polyflux 6H Dialyzer provided a trend for improved clearance compared to Fresenius F3 and F4 dialyzers. We found that the Polyflux 6H Dialyzer provided adequate clearance for children up to 24 kg in size and is a suitable dialyzer choice for patients 13 to 26 kg in size.

The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the PPCRRT registry.

PURPOSE: Well-functioning vascular access is essential for the provision of adequate CRRT. However, few data exist to describe the effect of catheter size or location on CRRT performance in the pediatric population. METHODS: Data for vascular access site, size, and location, as well as type of anticoagulant used and patient demographic data were gathered from the ppCRRT registry. Kaplan-Meier curves were generated and then analyzed by log-rank test or Cox Proportional Hazards model. RESULTS: Access diameter was found to significantly affect circuit survival. None of the 5 French catheters lasted longer than 20 hours. Seven and 9 French, but not 8 French, catheters fared worse than larger diameter catheters (p=0.002). Circuits associated with internal jugular access survived longer than subclavian or femoral access associated circuits (p<0.05). Circuit survival was also found to be favorably associated with the CVVHD modality (p<0.001). CONCLUSIONS: Functional CRRT circuit survival in children is favored by larger catheter diameter, internal jugular vein insertion site and CVVHD. For patients requiring catheter diameters less than 10 French, CRRT circuit survival might be optimized if internal jugular vein insertion is feasible. Conversely, when a vascular access site other than the internal jugular vein is most prudent, consideration should be given to using the largest diameter catheter appropriate for the size of the child. The CVVHD modality was associated with longer circuit survival, but the mechanism by which this occurs is unclear.

Utility of a routine urinalysis in children who require clean intermittent catheterization.

BACKGROUND: Children who require clean intermittent catheterization (CIC) frequently have positive urine cultures. However, diagnosing a urinary tract infection (UTI) can be difficult, as there are no standardized criteria. Routine urinalysis (UA) has good predictive accuracy for UTI in the general pediatric population, but data are limited on the utility of routine UA in the population of children who require CIC. OBJECTIVE: To determine the utility of UA parameters (e.g. leukocyte esterase, nitrites, and pyuria) to predict UTI in children who require CIC, and identify a composite UA that has maximal predictive accuracy for UTI. METHODS: A cross-sectional study of 133 children who required CIC, and had a UA and urine culture sent as part of standard of care. Patients in the no-UTI group all had UA and urine cultures sent as part of routine urodynamics, and were asymptomatic. Patients included in the UTI group had growth of ≥50,000 colony-forming units/ml of a known uropathogen on urine culture, in addition to two or more of the following symptoms: fever, abdominal pain, back pain, foul-smelling urine, new or worse incontinence, and pain with catheterization. Categorical data were compared using Chi-squared test, and continuous data were compared with Student's t-test. Sensitivity, specificity, and positive and negative predictive values were calculated for individual UA parameters, as well as the composite UA. Logistic regression was performed on potential composite UA models to identify the model that best fit the data. RESULTS: There was a higher proportion of patients in the no-UTI group with negative leukocyte esterase compared with the UTI group. There was a higher proportion of patients with UTI who had large leukocyte esterase and positive nitrites compared with the no-UTI group (Summary Figure). There was no between-group difference in urinary white blood cells. Positive nitrites were the most specific (84.4%) for UTI. None of the parameters had a high positive predictive value, while all had high negative predictive values. The composite model with the best Akaike information criterion was >10 urinary white blood cells and either moderate or large leukocyte esterase, which had a positive predictive value of 33.3 and a negative predictive value of 90.4. CONCLUSION: Routine UA had limited sensitivity, but moderate specificity, in predicting UTI in children who required CIC. The composite UA and moderate or large leukocyte esterase both had good negative predictive values for the outcome of UTI.

Nephrotoxic Medications and Associated Acute Kidney Injury in Very Low Birth Weight Infants.

Preterm infants are at risk for acute kidney injury (AKI) for multiple reasons. Reports on the frequency and timeline of iatrogenic renal insults and potential consequences are limited. Our objectives are to estimate the prevalence and timing of exposure to nephrotoxic medications, and assess the association of these nephrotoxic medications with AKI in preterm infants. We performed a retrospective chart review of infants <30 weeks postmenstrual age and/or <1500 g birth weight admitted to the neonatal intensive care units at Cincinnati Children's Hospital Medical Center and University of Cincinnati Medical Center from 2011 to 2014. We queried the electronic health record for exposures to nephrotoxic medications and/or radiologic contrast media and correlated to serum creatinine concentration proximate to the exposure. Using the Kidney Disease Improving Global Outcomes (KDIGO) creatinine criteria, we assessed the AKI rate associated with the exposures. The cohort included 276 preterm infants. 233 (84%) received nephrotoxicity-associated medications. Antibiotics were the most common type (80%). AKI occurred in 9% of infants and was associated with exposure to a nephrotoxic medication. In a forward stepwise logistical regression, birth weight (OR: 0.995 (95% CI: 0.991-0.998), p=0.004) and number of exposures (OR: 1.83 (95% CI: 1.33-2.53), p=0.0002) were predictive of AKI. Nephrotoxic medication exposure increased the odds of AKI in preterm and low birth weight infants. Future prospective surveillance through the electronic health record in addition to routine serum creatinine monitoring may reduce the rate of exposure and subsequent AKI.

Evaluation of the PRISMA M10 circuit in critically ill infants with acute kidney injury: A report from the Prospective Pediatric CRRT Registry Group.

Currently available extracorporeal circuits in the US often require blood priming to prevent hypotension/anemia in smaller pediatric patients. The PRISMA M10 circuit, available in other countries has not received extensive study and has not been cleared for use in the US. We performed an FDA mandated study of the M10 circuit in the US for use in critically ill pediatric patients with acute kidney injury <15 kg in size. FDA guidelines allowed for maximal blood pump flow of 20 ml/min. Fifteen pts (9 M, 6 F, mean size 5.8+/-2.8 kg, range 2.6-12.5 kg, age 4 d - 13 mo, mean creatinine =1.2+/-0.7 mg/dL) were studied at 4 ppCRRT centers. Sixty-one filters (range 1-4 circuits per pt) were used (mean circuit life 28.6+/-22.5 h, range 1 to 74.5 h, 55%>24 h). No blood leaks occurred. All circuits achieved Qb 20 ml/min. Forty-two out of 61 filters clotted and mean circuit life was lower for these filters than those changed for other reasons (23+/-17 vs. 41+/-28 h, <0.005). Circuits using larger access demonstrated significantly longer survival. We conclude that the M10 filter can serve well for CRRT in small pediatric patients. Further study is needed to determine in higher blood flow rates would decrease clotting rates and increase filter life span and ultrafiltration rates.

Logarithmic extrapolation of a 15-minute postdialysis BUN to predict equilibrated BUN and calculate double-pool Kt/V in the pediatric hemodialysis population.

Blood urea nitrogen (BUN) concentration rebounds logarithmically for 1 hour after a hemodialysis treatment. We have previously devised and evaluated an equilibrated Kt/V (eqKt/V) estimation method using logarithmic extrapolation of the BUN increase from 30 seconds to 15 minutes postdialysis in six pediatric hemodialysis patients. The current study evaluates logarithmic extrapolation in 15 additional pediatric patients. Mean measured equilibrated BUN (eqBUN) and estimated BUN at equilibrium (estBUN) using logarithmic extrapolation were 23.1 +/- 9.2 and 23.0 +/- 9.4 mg/dL, respectively. The mean absolute difference between estBUN and eqBUN was 0.7 +/- 0. 4 mg/dL (range, 0.1 to 1.55 mg/dL). All treatments had an absolute difference less than the SD of the laboratory measurement itself. The mean absolute percentage of difference between eqKt/V using eqBUN and estimated double-pool equilibrated Kt/V (estKt/V) using estBUN from logarithmic extrapolation was 3.4% +/- 2.3% and did not vary as a function of patient size, urea generation rate, dialyzer urea clearance, Kd/V, or ultrafiltration fraction. Mean absolute percentages of difference between eqKt/V and Kt/V estimated by the Tattersall, Daugirdas, or Maduell formulas were 4.5% +/- 3.9%, 4.4% +/- 3.7%, and 6.7% +/- 8.3%, respectively. Total percentages of error (absolute mean percentage of error + 2 SD) between eqKt/V and estKt/V by logarithmic extrapolation or the Tattersall, Daugirdas, or Maduell formulas were 8.0%, 12.3%, 11.8%, and 22.3%, respectively. The greater accuracy of logarithmic extrapolation compared with other methods of double-pool Kt/V estimation held true for patients weighing less than 35 kg. We have validated the use of an easy and accurate method requiring only an additional 15-minute posttreatment BUN level to estimate double-pool Kt/V in children.

Evaluation and prediction of urea rebound and equilibrated Kt/V in the pediatric hemodialysis population.

The posthemodialysis blood urea nitrogen (BUN) concentration rebounds for 30 to 60 minutes after hemodialysis in adults. Timing of the posttreatment BUN sample has a significant impact on the calculation of Kt/V. Urea rebound and its effect on Kt/V have not been extensively studied in children and adolescents. We evaluated posthemodialysis urea rebound after 46 treatments in 18 pediatric patients with end-stage renal disease. BUN levels were drawn at 30 seconds and 5 and 15 minutes posttreatment. From these values, a logarithmic regression curve was derived that defined percentage of urea rebound (%UR) = -0.254 + 10.9*log(t), (r = 0.79). Using this equation, we estimated BUN, %UR, and Kt/V at equilibration (50 minutes) for each treatment. Estimated mean %UR was 18.7%. Single-pool Kt/V (spKt/V) and estimated double-pool Kt/V (estKt/V) values were significantly different (P < 0.0001). %UR and percentage of difference between spKt/V and estKt/V did not vary as a function of dry weight, body surface area, or K/V. To test the validity of logarithmic extrapolation, additional BUN levels were drawn at 30 seconds and every 10 minutes for 1 hour postdialysis in six patients. Percentage of difference between estKt/V and measured equilibrated Kt/V was 3.6% +/- 1.7%. Our results show %UR has a significant impact on the calculation of Kt/V in children, does not vary with patient size, and is similar to that seen in adults. We have devised an easy and accurate method to predict equilibrated BUN and calculate double-pool Kt/V in children, which requires only an additional 15-minute posttreatment BUN sample.

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.

Sm-Nd dating of Fig Tree clay minerals of the Barberton greenstone belt, South Africa.

Sm-Nd isotopic data from carbonate-derived clay minerals of the 3.22-3.25 Ga Fig Tree Group, Barberton greenstone belt, South Africa, form a linear array corresponding to an age of 3102 +/- 64 Ma, making these minerals the oldest dated clays on Earth. The obtained age is 120-160 m.y. younger than the depositional age determined by zircon geochronology. Nd model ages for the clays range from approximately 3.39 to 3.44 Ga and almost cover the age variation of the Barberton greenstone belt rocks, consistent with independent evidence that the clay minerals are derived from material of the belt. The combined isotopic and mineralogical data provide evidence for a cryptic thermal overprint in the sediments of the belt. However, the highest temperature reached by the samples since the time of clay-mineral formation was <300 degrees C, lower than virtually any known early Archean supracrustal sequence.

Minimally invasive management of paraesophageal herniation in the high-risk surgical patient.

BACKGROUND: Traditional management of symptomatic paraesophageal herniation involves hernia reduction, hiatal closure, and an antireflux procedure or gastropexy. Patients with significant comorbidities may not tolerate operative repair. A new technique, laparoscopic-assisted endoscopic reduction and fixation of the stomach, may provide a minimally invasive treatment alternative. METHODS: Eleven elderly patients with symptomatic paraesophageal herniation were managed with flexible endoscopy and double percutaneous endoscopic gastrostomy (PEG) tube insertion with or without laparoscopic assistance. RESULTS: All patients presented with a symptomatic paraesophageal hernia. Mean age was 78.3 years (range 72 to 84). Each was deemed at high risk for definitive repair due to preexisting coronary artery disease as well as at least two other serious comorbidities. Hernia reduction and intra-abdominal fixation of the stomach was achieved in each case using flexible endoscopy and double PEG insertion. Laparoscopic assistance for reduction and gastropexy was utilized in 9 cases. Mean operative time was 61 minutes (range 28 to 104). Average length of stay was 2.8 days (range 0 to 12). One minor and three major postoperative complications occurred. Over a mean follow-up of 4.1 months (range 2 to 7), all patients have resumed oral intake and achieved weight gain. CONCLUSIONS: Patients with symptomatic paraesophageal herniation require intervention to alleviate symptoms and avoid the complications of gastric incarceration. For the high-risk patient, endoscopic reduction and PEG with laparoscopic assistance appears to provide effective treatment.

Laparoscopic anterior esophageal myotomy and toupet fundoplication for achalasia.

Achalasia is an esophageal motility disorder characterized by the failure of lower esophageal sphincter relaxation and the absence of esophageal peristalsis. The purpose of this study was to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy and Toupet fundoplication for achalasia. A 9-cm myotomy was performed in most cases extending 7 cm above and 2 cm below the gastroesophageal junction. Severity of dysphagia, heartburn, chest pain, and regurgitation was graded preoperatively and postoperatively using a five-point symptomatic scale (0-4). Patients also graded their outcomes as excellent, good, fair, or poor. Between December 1995 and November 2000 a total of 49 patients (23 male, 26 female) with a mean age of 44.3 years (range 23-71 years) were diagnosed with achalasia. Mean duration of symptoms was 40.2 months (range 4-240 months). Thirty-seven patients (76%) had had a previous nonsurgical intervention or combinations of nonsurgical interventions [pneumatic dilation (23), bougie dilation (five), and botulinum toxin (19)], and two patients had failed esophageal myotomies. Forty-five patients underwent laparoscopic esophageal myotomy and Toupet fundoplication. Two patients received laparoscopic esophageal myotomies without an antireflux procedure, and two were converted to open surgery. One patient presented 10 hours after a pneumatically induced perforation and underwent a successful laparoscopic esophageal myotomy and partial fundoplication. Mean operative time was 180.5 minutes (range 145-264 minutes). Mean length of stay was 1.98 days (range 1-18 days). There were five (10%) perioperative complications but no esophageal leaks. There was a significant difference (P < 0.05) between the preoperative and postoperative dysphagia, chest pain, and regurgitation symptom scores. All patients stated that they were improved postoperatively. Eighty-six per cent rated their outcome as excellent, 10 per cent as good, and 4 per cent as fair. Laparoscopic anterior esophageal myotomy and Toupet fundoplication effectively alleviates dysphagia, regurgitation, and chest pain accompanying achalasia and is associated with high patient satisfaction, a rapid hospital discharge, and few complications.

Metabolite distribution and rate of residue clearance in turkeys fed a diet containing aflatoxin B1.

The retention of aflatoxin residues in tissues of turkey poults fed a diet containing aflatoxin B1 (500 ppb) for 18 days was determined. Free and conjugated aflatoxin metabolites were quantified using high-pressure liquid chromatography. Aflatoxin residue levels were greater in liver than muscle tissues, although all levels were low (range 0.01-1.19 ng/g tissue). Free and conjugated aflatoxins B1 and M1, a metabolite of B1, were the principal tissue residues. Other metabolites investigated included aflatoxicol, which was detected in certain samples, and aflatoxin Q1 which was not detected. Conjugated aflatoxins, hydrolysed and extracted from the aqueous tissue fractions, comprised 55-91% of the total detected aflatoxin residues. All aflatoxin residues were rapidly cleared following discontinuation of the dietary aflatoxin B1 (half-life 1.4 days for total aflatoxin clearance from liver). These results provide further evidence that tissues from animals maintained on diets containing aflatoxins do not provide a major source of aflatoxins when consumed by man.

The Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry: design, development and data assessed.

Many issues plague the pediatric ARF outcome literature, which include data only from single center sources, a relative lack of prospective study, mixture within studies of renal replacement therapy modality without stratification and inconsistent use of methods to control for patient illness severity in outcome analysis. Since January 2001, the Prospective Pediatric CRRT (ppCRRT) Registry Group has been collecting data from multiple United States pediatric centers to obtain demographic data regarding pediatric patients who receive CRRT, assess the effect of different CRRT prescriptions on circuit function and evaluate the impact of clinical variables on patient outcome. The aim of the current paper is to describe the ppCRRT Registry design, review the decision process and rationale for the options chosen for the ppCRRT format and discuss the analysis plan and future projects envisioned for the ppCRRT Registry.

Lateral approach to laparoscopic cholecystectomy in the previously operated abdomen.

BACKGROUND: In the past, prior abdominal surgery was often felt to be a contraindication to laparoscopic cholecystectomy. The presence of adhesions precludes using a simple paraumbilical open approach for insufflation and initial trocar insertion because of an increased risk of bowel perforation and the difficulty in obtaining adequate exposure. PATIENTS AND METHODS: We report 32 consecutive patients with previous upper midline incisions who underwent laparoscopic cholecystectomy with cholangiography and describe the technique and lateral positioning to facilitate this approach. RESULTS: In our series, there were no complications. The mean length of hospital stay was 1.3 days, and the conversion rate to an open procedure was 3%: one patient who had had 22 previous abdominal operations. CONCLUSION: Laparoscopic cholecystectomy performed with the patient in the lateral position is safe and effective for patients who have had previous midline incisions.