This study describes the incidence, associated clinical characteristics and outcomes of acute kidney injury in a pediatric cohort with COVID-19 and Multisystem Inflammatory Syndrome in Children (MIS-C). We performed a retrospective study of patients 18 years of age and under admitted to four New York hospitals in the Northwell Health System interned during the height of the COVID-19 pandemic, between March 9 and August 13, 2020. Acute kidney injury was defined and staged according to Kidney Disease: Improving Global Outcomes criteria. The cohort included 152 patients; 97 acute-COVID-19 and 55 with MIS-C associated with COVID-19. Acute kidney injury occurred in 8 with acute-COVID-19 and in 10 with MIS-C. Acute kidney injury, in unadjusted models, was associated with a lower serum albumin level (odds ratio 0.17; 95% confidence interval 0.07, 0.39) and higher white blood cell counts (odds ratio 1.11; 95% confidence interval 1.04, 1.2). Patients with MIS-C and acute kidney injury had significantly greater rates of systolic dysfunction, compared to those without (80% vs 49%). In unadjusted models, patients with acute kidney injury had 8.4 days longer hospitalizations compared to patients without acute kidney injury (95% confidence interval, 4.4-6.7). Acute kidney injury in acute-COVID-19 and MIS-C may be related to inflammation and/or dehydration. Further research in larger pediatric cohorts is needed to better characterize risk factors for acute kidney injury in acute-COVID-19 and with MIS-C consequent to COVID-19.
Initial postoperative serum lactate levels after pediatric open heart surgery may be predictive of outcome. Lactate levels are also higher in patients who go on to develop multiple organ system failure. Elevated postoperative lactate levels may reflect intraoperative tissue hypoperfusion, and measures aimed at increasing oxygen delivery, with normalization of lactate, may improve patient outcome.
Serial dependencies in interresponse times were studied by means of a digital computer. In monkeys exposed to a DRL 20-sec schedule of reinforcement, serial interactions appeared at all stages of training. Early in training the serial effects consisted of trains of relatively long interresponse times interspersed among trains of relatively short ones. Later on, the serial effects appeared to be characterized by a tendency to drift up and down in long wavelength periods around the minimum interval required for reinforcement. After training to a point at which most interresponse times produced reinforcement, serial effects of a still more subtle nature appeared. These effects were made apparent by autocorrelation and power spectrum methods and consisted of both long-term and extremely short-term fluctuations in interresponse times.When exposed to a schedule of reinforcement that reinforces only those interresponse times (IRTs) exceeding a specified durationthe DRL schedule-organisms adjust to such requirements by lengthening the interval between responses.Various aspects of how organisms space responses in time on the DRL schedule of reinforcement have been studied but little is known about the apparent serial interaction in IRT duration noted by a number of authors. One instance of this interaction is a tendency for reinforced IRTs to occur in clumps (e.g., Kelleher, Fry, and Cook, 1959;Farmer and Schoenfeld, 1964). Another instance is the tendency for closely-spaced responses to be emitted in bursts, especially after IRTs just short of the duration required for reinforcement (e.g., Sidman, 1956). Recently, Ferraro, Schoenfeld, and Snapper (1965) positively correlated. In order to be able to offer a more detailed analysis of these rather subtle effects than has been possible in the past, the present study employed digital computers to acquire and process data. METHODThe subjects were three female M. speciosa monkeys, weighing about 3 kg each, which were maintained in primate restraining chairs (Foringer) enclosed in large chambers. The operanda were microswitch levers (Lehigh Valley monkey model) mounted on the chairs. About 30 g of force was needed to operate a lever. The levers were connected to the external sense lines of a LINC computer (Clark and Molnar, 1965) through Schmitt triggers and flip-flops. The LINC programmed the schedule and recorded all IRTs with a resolution of 40 msec. Each depression and release of a lever was recorded as a response and produced a 20 msec, 2500 cps tone in the chamber from a Sonalert (Electropac, Inc.), immediately after release. The release contingency was introduced to avoid prolonged holding of the levers. A white noise generator helped mask extraneous sounds.Reinforcement occurred each time a response terminated an interresponse interval of 20 sec or more (DRL 20). The reinforcing stimulus consisted of 0.3 ml of a fruit drink delivered via a solenoid valve. A short metal nipple extending from the outlet port of the valve enabled the monkey to ingest the fruit 619 VOLUME...
Initial postoperative serum lactate levels after pediatric open heart surgery may be predictive of outcome. Lactate levels are also higher in patients who go on to develop multiple organ system failure. Elevated postoperative lactate levels may reflect intraoperative tissue hypoperfusion, and measures aimed at increasing oxygen delivery, with normalization of lactate, may improve patient outcome.
The death of a child is an uncommon occurrence and can be difficult for families to accept. Attempts by the healthcare team to discuss end-of-life issues can be so upsetting to families that they refuse to participate in the discussion. Even with diseases where an early death can be anticipated, such as Duchenne muscular dystrophy, the family is often reluctant to discuss end-of-life issues when the patient is relatively healthy, preferring to focus on the current health issues. In this article we discuss what happens when there are disagreements between the patient and family and the needs of both must be taken into consideration.
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