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Background: Urinary interleukin-18 (uIL-18) is an earlier acute kidney injury (AKI) biomarker than serum creatinine (SCr) in specific populations. In the present study, the relationship between uIL-18 and AKI was determined in a heterogeneous group of critically ill children., Methods: We studied critically ill children to determine whether uIL-18 was an early predictor of AKI. SCr was determined daily for up to 14 days from mechanical ventilation initiation and up to four serial urine specimens were collected for the uIL-18 measurement. AKI was graded by paediatric modified risk, injury, failure, loss, end-stage kidney disease (pRIFLE) criteria. Day 0 was defined as the day of attaining pRIFLE AKI., Results: One hundred thirty-seven children aged 6.5 +/- 6.4 years (53% male) were studied. The peak levels of IL-18 correlated with the severity of AKI by pRIFLE classification (P < 0.05). In non-septic AKI patients, uIL-18 rose to a level higher than control levels 2 days prior to a significant rise in SCr. Urinary IL-18 concentration from the first urine specimen was associated with AKI development within 48 h (odds ratio = 3.5, P < 0.05) independent of the paediatric risk of mortality (PRISM II) score. Urinary IL-18 concentration > or = 100 pg/ml had a specificity and negative predictive value of 81 and 83% to predict AKI development within 24 h. Urinary IL-18 > or = 200 pg/ml collected within 24 h of Day 0 had a specificity and positive predictive value of 93 and 88% respectively to predict the AKI duration > or = 48 h. Urinary IL-18 was associated with mortality (odds ratio = 1.29, P < 0.05), independent of the PRISM II score., Conclusions: Urinary IL-18 rises prior to SCr in non-septic critically ill children, predicts severity of AKI and is an independent predictor of mortality.

Introduction: Serum creatinine is a late marker of acute kidney injury (AKI). Urine neutrophil gelatinase-associated lipocalin (uNGAL) is an early marker of AKI, where the timing of kidney injury is known. It is unknown whether uNGAL predicts AKI in the general critical care setting. We assessed the ability of uNGAL to predict AKI development and severity in critically ill children., Methods: This was a prospective cohort study of critically ill children. Children aged between 1 month and 21 years who were mechanically ventilated and had a bladder catheter inserted were eligible. Patients with end-stage renal disease or who had just undergone kidney transplantation were excluded. Patients were enrolled within 24 to 48 hours of initiation of mechanical ventilation. Clinical data and serum creatinine were collected daily for up to 14 days from enrollment, and urine was collected once daily for up to 4 days for uNGAL measurement. AKI was graded using pRIFLE (pediatric modified Risk, Injury, Failure, Loss, End Stage Kidney Disease) criteria. Day 0 was defined as the day on which the AKI initially occurred, and pRIFLEmax was defined as the worst pRIFLE AKI grade recorded during the study period. The chi2 test was used to compare associations between categorical variables. Mann-Whitney and Kruskal-Wallis tests were used to compare continuous variables between groups. Diagnostic characteristics were evaluated by calculating sensitivity and specificity, and constructing receiver operating characteristic curves., Results: A total of 140 patients (54% boys, mean +/- standard deviation Pediatric Risk of Mortality II score 15.0 +/- 8.0, 23% sepsis) were included. Mean and peak uNGAL concentrations increased with worsening pRIFLEmax status (P < 0.05). uNGAL concentrations rose (at least sixfold higher than in controls) in AKI, 2 days before and after a 50% or greater rise in serum creatinine, without change in control uNGAL. The parameter uNGAL was a good diagnostic marker for AKI development (area under the receiver operating characteristic curve [AUC] 0.78, 95% confidence interval [CI] 0.62 to 0.95) and persistent AKI for 48 hours or longer (AUC 0.79, 95% CI 0.61 to 0.98), but not for AKI severity, when it was recorded after a rise in serum creatinine had occurred (AUC 0.63, 95% CI 0.44 to 0.82)., Conclusion: We found uNGAL to be a useful early AKI marker that predicted development of severe AKI in a heterogeneous group of patients with unknown timing of kidney injury.

There are numerous causes of acquired acute upper airway obstructions in children but most are secondary to infections, foreign bodies, and trauma. Recognizing impending airway obstructions is important because cardiopulmonary arrest rarely is a sudden event but rather follows a progressive deterioration in respiratory function. From an anatomic perspective, acute obstructions may present in the pharyngeal or laryngeal regions. In the pharynx, fascial layers create several potential peritonsillar, parapharyngeal, and retropharyngeal spaces that may accommodate abscess formation. Within the larynx and lower airways, small changes in radius dramatically affect the resistance to flow as described by Poiseuille's law, allowing for small amounts of inflammation to cause significant obstruction. The clinical presentation of acute upper airway obstruction will depend on the degree and location of the obstruction. Therapy is aimed primarily at maintaining a patent airway and prescribing appropriate antimicrobials.

Objective: To demonstrate the clinical characteristics, radiologic findings, and neuropathological features of tetrahydrocannabinol-related posterior fossa ischemic stroke in adolescent patients., Design: A retrospective case and chart review of 3 cases encountered at a tertiary care institution over a span of 5 years., Setting: Inpatient and intensive care hospitalization units managing children and adolescents., Subjects: Male adolescent patients with ischemic cerebellar stroke after use of marijuana. DIAGNOSTIC INVESTIGATIONS: Computed tomography brain scans (3 subjects), magnetic resonance imaging brain study (1 subject), cerebral arteriography (1 subject), cerebellar biopsy (1 subject), and necropsy (2 subjects)., Results: Three adolescent males had similar presentations of headache, fluctuating level of consciousness or lethargy, visual disturbance, and variable ataxia after self-administration of marijuana. They developed primary cerebellar infarctions within days after the exposure that could not be attributed to supratentorial herniation syndromes and only minimally involved brainstem structures., Conclusions: Episodic marijuana use may represent a risk factor for stroke in childhood, particularly in the posterior circulation. Early recognition of the cerebellar stroke syndrome may allow prompt neurosurgical intervention, reducing morbidity.