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S L Goldstein

Publications and source records attributed to S L Goldstein.

At least 19 recordsLinked to original sources

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.

Journal Article↗

Non-invasive intravascular monitoring in the pediatric hemodialysis population.

Assessment of dry weight in pediatric hemodialysis (HD) patients is difficult, since small fluid shifts may result in dialysis-associated morbidity (DAM) and children may not verbalize complaints. Achieving dry weight is critical since chronic fluid overload can result in hypertension and left ventricular hypertrophy. To determine if non-invasive monitoring of hematocrit (NIVM) is useful in preventing DAM in pediatric HD patients, we reviewed 200 HD treatments performed with or without NIVM (no NIVM). DAM was defined as an "event" (e.g., hypotension, headache, cramping) that required nursing intervention. Patient age, weight, and gender were similar in both groups. Desired ultrafiltration was obtained in both groups. The event rate was lower in NIVM than no NIVM for all treatments (0.22 vs. 0.3, P = 0.07) and significantly lower in patients < 35 kg (0.25 vs. 0.47, P = 0.01). The second event rate (fraction of treatments with one event that had a subsequent event occurring at least 15 min later) was lower with NIVM (P < 0.01). For the NIVM group, events in the first 90 min occurred when blood volume changed > 8% per hour; 71% of events (43/60) at 90-240 min occurred when blood volume changed > 4% per hour. NIVM decreases DAM in pediatric HD patients, especially those < 35 kg. Ultrafiltration with blood volume change < 8% per hour is safe in the 1st h and < 4% after 1 h reduces DAM in children.

Adolescent↗

Meropenem pharmacokinetics in children and adolescents receiving hemodialysis.

The emergence of multi-drug-resistant bacteria is of great concern to the care of pediatric end-stage renal disease (ESRD) patients who receive either hemodialysis or peritoneal dialysis via a catheter. Infections with gram-negative organisms, especially Pseudomonas aeruginosa, are difficult to eradicate and often necessitate catheter removal. Meropenem, a broad-spectrum antibiotic of the carbapenem class of beta-lactams, is effective against most gram-positive and gram-negative bacteria and has enhanced activity against P. aeruginosa. We studied the pharmacokinetics of meropenem during and between hemodialysis treatments in seven pediatric patients. Meropenem was given as a single dose of 20 mg/kg (maximum 500 mg) before and after two separate hemodialysis treatments. Meropenem administration was tolerated without any adverse effects. Hemodialysis effectively cleared meropenem in a manner that correlated with percent urea reduction. Median drug half-life was 7.3 h off dialysis (range 4.9-11.7 h). The dose of 20 mg/kg was not sufficient to produce an acceptable interdialytic pharmacodynamic profile of 70% duration with a meropenem concentration >4 microg/ml, the MIC90 of meropenem for P. aeruginosa. Dosing simulations revealed that a daily dose of 25 mg/kg or an alternate day dose of 40 mg/kg would result in an acceptable pharmacodynamic profile. Both simulated doses achieved acceptable peak concentrations.

Adolescent↗

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.

Aged↗

Ultrasound dilution evaluation of pediatric hemodialysis vascular access.

BACKGROUND: Hemodialysis access thrombosis is a significant cause of morbidity for hemodialysis patients and results from decreased access flow caused by venous outflow tract stenosis. Ultrasound dilution (UD) is a practical, noninvasive, and reliable indicator of access flow and is effective in predicting venous stenosis in adult patients receiving hemodialysis. METHODS: The current study is the first to our knowledge to evaluate the accuracy of UD in predicting hemodialysis access stenosis in a pediatric hemodialysis population. Thirteen pediatric patients receiving hemodialysis via permanent access (4 AVF and 9 AVG) received 73 UD measurements over three months. RESULTS: Mean raw access flow (QA) was 720 +/- 428 mL/min, and mean corrected access flow (QAcorr) was 886 +/- 537 mL/min/1.73 m(2). QAcorr was significantly lower in accesses with stenosis (401 +/- 176 mL/min/1.73 m(2)) versus accesses without stenosis (1158 +/- 330 mL/min/1.73 m(2), P < 0.0001). Unlike flow values reported by raw QA, there was no overlap in flow values reported by QAcorr in accesses with stenosis (174 to 579 mL/min/1.73 m(2)) versus accesses without stenosis (709 to 1711 mL/min/1.73 m(2)). Two patients with an AVG who had QAcorr less than 600 mL/min/1.73 m(2) developed an access thrombosis within one week after UD measurement. No patients with QAcorr greater than 700 mL/min/1.73 m(2) developed access thrombosis in the 30 days following UD measurement. CONCLUSIONS: : The current study supports the use of monthly UD measurement to prevent access thrombosis in children receiving hemodialysis.

Arteriovenous Shunt, Surgical↗

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.

Adolescent↗

Hemodialysis in the pediatric patient: state of the art.

The prevalence of pediatric patients receiving hemodialysis as renal replacement therapy has increased over the past decade. Although numerous technologic advances have been developed and their impact assessed for adult patients receiving hemodialysis, no long-term outcome study currently exists for children receiving hemodialysis. Barriers to such study include the necessity for long-term multicenter participation to enroll enough patients to make definitive statements regarding outcome, lack of consensus for an acceptable and practical method for hemodialysis adequacy measurement in children, and the need for pediatric end-stage renal disease (ESRD)-specific tools for assessment of quality of life. The first part of this article reviews issues surrounding hemodialysis adequacy measurement in children. In particular, simple but accurate Kt/V and normalized protein catabolic rate (nPCR) estimation methods are proposed that should allow for more widespread use of Kt/V and nPCR for measurement of urea clearance and nutritional status in children receiving hemodialysis, important for both patient care and to control for hemodialysis adequacy in pediatric outcome studies. In addition, the principles and pediatric study of 2 technologic advances, continuous noninvasive monitoring of hematocrit and noninvasive ultrasound dilution vascular access flow measurement, are reviewed. Finally, suggestions are provided for future study pertinent to both short-term and long-term outcomes in children receiving hemodialysis.

Child↗

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.

Abdomen↗

Characteristics of adult celiac disease in the USA: results of a national survey.

OBJECTIVE: The clinical spectrum of adults with celiac disease in the United States, where the disease is considered rare, is not known. We sought this information by distributing a survey. METHODS: A questionnaire was distributed by way of a celiac newsletter, directly to celiac support groups, and through the Internet. RESULTS: Respondents (1,612) were from all United States except one. Seventy-five percent (1,138) were biopsy proven. Women predominated (2.9:1). The majority of respondents were diagnosed in their fourth to sixth decades. Symptoms were present a mean of 11 yr before diagnosis. Diarrhea was present in 85%. Diagnosis was considered prompt by only 52% and 31% had consulted two or more gastroenterologists. Improved quality of life after diagnosis was reported by 77%. Those diagnosed at age > or = 60 yr also reported improved quality of life. Five respondents had small intestinal malignancies (carcinoma 2, lymphoma 3) accounting for a relative risk of 300 (60-876) for the development of lymphoma and 67 (7-240) for adenocarcinoma. CONCLUSIONS: Patients with celiac disease in the United States have a long duration of symptoms and consider their diagnosis delayed. Improved quality of life after diagnosis is common. An increased risk of developing small intestine malignancies is present.

Adolescent↗

Outcome in children receiving continuous venovenous hemofiltration.

OBJECTIVE: Continuous venovenous hemofiltration (CVVH) alone or with dialysis (D) has become an important supportive therapy for critically ill children with acute renal failure. Previous reports of pediatric patient outcome either mix CVVH/D with other renal replacement modalities or do not examine severity of illness. The current study examines only outcomes of children receiving CVVH/D using Pediatric Risk of Mortality (PRISM) scores to control for severity of illness. PATIENTS: Twenty-one patients (mean age: 8.8 +/- 6.3 years; mean weight: 28.3 +/- 20.8 kg) received 22 courses of CVVH/D. OUTCOMES: Nine (42.8%) of 21 patients survived. Nine (75%) of 12 deaths occurred within 25 days of pediatric intensive care unit (PICU) admission. Mean PRISM score at PICU admission and CVVH initiation were 13.1 +/- 5.8 and 15.4 +/- 8.9, respectively. Mean patient weight, age, PRISM score at PICU admission and at CVVH/D initiation, maximum pressor number, estimated glomerular filtration rate at CVVH/D initiation and change in mean airway pressure did not differ between survivors and nonsurvivors. The degree of fluid overload at CVVH/D initiation was significantly lower in survivors (16.4% +/- 13.8%) compared with nonsurvivors (34.0% +/- 21.0%), even when controlled for severity of illness by PRISM score. Mean cost of providing CVVH/D accounted for only 1% of total PICU cost per patient. CONCLUSIONS: The pattern of early multiorgan system failure and death, minimal relative cost of CVVH/D provision, and potential for improved outcome with initiation of CVVH/D at lesser degrees of fluid overload are factors that may support early initiation of CVVH/D in critically ill children with acute renal failure.

Acute Kidney Injury↗

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.

Adult↗

Acyclovir prophylaxis of varicella in children with renal disease receiving steroids.

Varicella, or chickenpox, is very communicable and has been shown to be transmitted to nearly 90% of household contacts. Severe varicella infections with fatal complications have been noted in children receiving corticosteroids despite the administration of varicella-zoster immune globulin (VZIG). The use of post-exposure acyclovir prophylaxis in immunocompetent children exposed to a household contact with varicella has been shown to decrease the transmission rate of varicella significantly. We studied the safety and efficacy of acyclovir prophylaxis as an adjunctive preventive measure in 8 children (10 separate exposures) receiving corticosteroids for renal disease. Four children (6 separate exposures) served as controls. No adverse reactions were reported with the acyclovir prophylaxis. The maximum change between pre- and study serum creatinine levels was 0.1 mg/dl. None of the 8 patients who received acyclovir prophylaxis developed chickenpox. One of these 8 patients developed humoral immunity to varicella despite the absence of clinical infection. One of 4 patients who received VZIG prophylaxis alone developed chickenpox. These data support the use of acyclovir prophylaxis as an adjunctive measure to VZIG for the prevention of potentially serious varicella infection in children receiving steroids.

Acyclovir↗

Use of anti-hypertensive medications and post-transplant renal allograft function in children.

Post-transplant hypertension is a common occurrence in children. The relative effect of this hypertension on renal allograft function is uncertain. Examining the accumulated data for pediatric renal transplant recipients at our institution from monthly visits for up to three years, we determined whether the use of anti-hypertensive medications (anti-HTN medications) was associated with allograft dysfunction. Monthly clinical data included height, weight, serum creatinine, cyclosporin A (CsA) trough levels, number of acute rejection episodes, and number of anti-HTN medications. Estimated glomerular filtration rate (eGFR) was calculated monthly for each patient using the Schwartz formula. Time post-transplant was grouped into 6-month intervals. One thousand three hundred and sixty-three monthly data sets from 6 months (n = 76 patients) to 3 yr post-transplant (n = 47 patients) were analyzed. Overall mean eGFR was 75 mL/min/1.73 m2 at 6 months and 54 mL/min/1.73 m2 at 3 yr. A lower eGFR was found at all post-transplant time intervals for patients receiving anti-HTN medications compared with those who were not (p < 0.01). This lower eGFR was found at some but not all times post-transplant when patients were grouped by donor type or history of acute rejection episodes and analyzed separately. Mean CsA trough levels were higher at all post-transplant time intervals in patients receiving anti-HTN medications (p < 0.05). While a causal relationship between post-transplant hypertension and graft dysfunction cannot be established from this study, we conclude that the need for anti-HTN medications is associated with worse allograft function.

Acute Disease↗

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.

Adolescent↗

Serial estimation of glomerular filtration rate in children after renal transplant.

Evaluation of serial monthly estimated glomerular filtration rate (eGFR) may be useful for studying pediatric renal allograft outcome. To determine the validity of this approach, we reviewed our single-center experience in pediatric renal transplant recipients to determine the effect of risk factors for renal allograft failure on eGFR. Clinical parameters recorded monthly through 5 years post transplant allowed serial assessment of eGFR. Monthly clinical data included height, weight, serum creatinine, cumulative number of acute rejection episodes, cyclosporine dose, and cyclosporine trough levels. From these data, eGFR was calculated monthly for each patient using the Schwartz formula. Time post transplant was grouped in 6-month intervals and plotted against mean eGFR to compare eGFR in patients grouped by demographic and clinical factors; 1,786 monthly data sets from 6 months post transplant (n=76 patients) to 5 years post transplant (n=25 patients) were analyzed. Overall mean eGFR from 6 months to 1 year was 75 ml/min per 1.73 m(2) and from 4. 5 to 5 years 46 ml/min per 1.73 m(2). eGFR was lower at all time intervals for recipients of cadaver versus living-related donor grafts, and patients with >/=1 versus 0 acute rejections (P<0.01). After 1 year, eGFR was lower in black patients compared with white or Hispanic patients (P<0.01). Cyclosporine dose greater than 5 mg/kg per day was associated with better early and worse late graft function. These results are similar to those reported in multi-center studies using the outcome variable of graft failure and suggest that serial eGFR may be valid as an outcome variable to study chronic renal allograft dysfunction in children.

Adolescent↗

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.

Adult↗

Natural logarithmic estimates of Kt/V in the pediatric hemodialysis population.

The natural logarithm formula for Kt/V proposed by Daugirdas is recognized as a valid and simple alternative to formal urea kinetic modeling (UKM) in adults receiving hemodialysis. No data have been published to validate the use of this formula in infants, children, and adolescents. We compared Kt/V derived by formal UKM with the natural logarithmic formula for 103 treatments in 21 pediatric end-stage renal disease patients receiving chronic hemodialysis. Values for Kt/V derived by formal UKM ranged from 0.65 to 2.06. Patients ranged in age from 1.8 to 22.5 years and in dry weight from 10.2 to 82.5 kg. The largest percent error between the two methods for any data point was less than 6%. The total error (absolute value percent error + 2 SD) was less than 6% across the entire range of dry weights. Our data show excellent agreement between formal UKM and the natural logarithm formula for Kt/V in pediatric hemodialysis patients, even those weighing less than 30 kg. These results support the use of the natural logarithm formula as a valid alternative to formal UKM in children. The simplicity of this formula should allow for the use of Kt/V as the best measure to study the relationship between delivered dialysis dose and outcomes in children.

Adolescent↗