Midodrine overdose in children: a case report and review of treatment for hypertensive emergencies.

Midodrine is an antihypotensive agent used primarily in the adult population for orthostatic hypotension and reflex syncope, postural orthostatic tachycardia syndrome (POTS), and hemodialysis-induced hypotension. Limited information about midodrine ingestion and overdose exists in children with only a single case series reported in the literature. Varying presentations of midodrine ingestion in children have not been shown to be acutely life-threatening in doses up to 50 mg. We present a case of a 12-year-old who intentionally ingested 100 mg of midodrine and presented with a hypertensive emergency and seizure activity. This is the largest reported dose ingested in a child. The patient was observed and treated with a nicardipine infusion in the pediatric intensive care unit (PICU). Prompt identification and treatment of symptoms contributed to a favorable outcome with no neurologic deficits and complete recovery from an intentional ingestion of midodrine. Mechanism, duration of action, and management of midodrine ingestion including treatment for a hypertensive emergency in children are discussed. Commonly used pharmacologic agents to treat hypertension are reviewed. This case report of a significant ingestion of midodrine reviews management of hypertensive emergencies and provides information and guidance to healthcare professionals unfamiliar with this medication and its potentially fatal effects.

Emphysematous Cystitis Following Bone Marrow Transplant.

Emphysematous cystitis is an exceedingly rare complication of urinary tract infection in children and adults. Characterized by air within the bladder wall, this life-threatening condition most often impacts diabetic women. The inciting pathogen is typically Escherichia coli or Klebsiella pneumoniae, though many other organisms have also been reported. Diagnosis is most commonly made via computed tomography scan; however, plain radiographs have also been described to be diagnostic. Medical management is the mainstay of therapy, consisting of bladder decompression and treatment of the underlying infection. Urologic surgery is required in 10% of cases. We report a 10-year-old child with a recent history of bone marrow transplantation complicated by gut-associated graft-versus-host disease who was diagnosed with emphysematous cystitis following a change in his abdominal pain.

Prophylactic antibiotics for simple hand lacerations: time for a clinical trial?

BACKGROUND: Simple hand lacerations (not involving bones, tendons, nerves, or vessels) are a common emergency department (ED) complaint. Whilst the practices of irrigation, debridement, foreign body removal, and suture repair are well accepted, the use of prophylactic antibiotics is not. Without evidenced-based guidelines, practice is left to physician preference. OBJECTIVES: The aim of this study was to assess the need for, and the feasibility to perform, a randomised controlled trial to evaluate the role of prophylactic antibiotics in simple hand lacerations. METHODS: The study was done in three phases: (1) estimation of the national ED burden of simple hand lacerations and the use of antibiotic prophylaxis; (2) assessment of indications for antibiotic prophylaxis and (3) investigation of patient willingness to enrol in a randomised controlled trial and their preferred outcomes from simple hand lacerations. For Phase 1, we analysed the 2007 National Hospital Ambulatory Medical Care Survey. For Phase 2, we surveyed ED physicians in three urban teaching institutions (two in Brooklyn, NY and one in Washington, DC). For Phase 3, we surveyed ED patients at the same three institutions. RESULTS: Phase 1: out of 116.8 million ED visits nationally in 2007, 1.8 million (1.6%) were due to simple hand lacerations, of which 1.3 million (71%) required repair. Of those repaired, 27% (95% CI, 19-35%) were prescribed prophylactic antibiotics, most commonly cephalexin (73%). Phase 2: out of 108 providers surveyed, 69 (64%) responded. 16% (95% CI, 9-27%) reported prescribing prophylactic antibiotics routinely, most commonly cephalexin (84%, 95% CI, 67-93%). The degree of contamination was the most important factor (91%, 95% CI, 82-96%) in the physicians' decision to prescribe antibiotics. Phase 3: of the 490 patients surveyed, 64% (95% CI, 60-68%) expressed interest in participating in a study to evaluate the use of prophylactic antibiotics. Their primary concern was prevention of infection (77%, 95% CI, 73-81%). CONCLUSION: Simple hand lacerations represent a substantial number of ED visits in the United States. Absence of clear guidelines, disparity in physician practice, and patient interest in infection prevention all support performing a prospective randomised controlled trial to establish the role of antibiotic prophylaxis in simple hand lacerations.

On fertilization in Chaetopleura apiculata and selected Chitonida.

Early events of fertilization are described in Chaetopleura apiculata and other selected Chitonida. C. apiculata egg hulls are elaborated into multi-branched spines with interlocking polygonal bases. Around the perimeter of each base are a series of open pores, ranging in size from 0.1-0.5 microm, which permit sperm direct access to the vitelline layer. In Callochitonidae (Chitonida) even larger pores occur in egg jelly coats, but this is considered to be the plesiomorphic condition, found also in Lepidopleurida such as Deshayesiella curvata. Other Chitonina, such as Rhyssoplax tulipa and Acanthopleura granulata, have a continuous outer dense layer that lacks pores and must be digested by penetrating sperm. Fertilization in Chitonida is unique and involves injection of chromatin into the egg via a narrow tubular nuclear extension that appears to exclude other sperm organelles, including mitochondria, centrioles, and flagellum. New evidence from studies of fertilization in Mopalia muscosa (Chitonida: Acanthochitonina) supports this hypothesis. This type of fertilization implies maternal inheritance of both mitochondria and centrioles, which is highly unusual, because in most animals one sperm centriole assists movements of pronuclei and regulates organization of the mitotic spindle. This mechanism of fertilization is defined by a series of apomorphic characters that unify the order Chitonida.

Regulation of rat basophilic leukemia-2H3 mast cell secretion by a constitutive Lyn kinase interaction with the high affinity IgE receptor (Fc epsilon RI).

Signaling through the high affinity IgE receptor is initiated by noncovalently associated Lyn kinase, resulting in the secretion of inflammatory mediators from mast cells. A fraction of the total cellular Lyn is associated via its N-terminal unique domain with the cytoplasmic domain of the Fc epsilonRI beta subunit before receptor aggregation. In the current study, we stably transfected the unique domain of Lyn into rat basophilic leukemia-2H3 mast cells and examined the consequences on Fc epsilonRI-induced signal transduction and mediator secretion to further define the role of the unique domain of Lyn in mast cell secretion. Tyrosine phosphorylation of Fc epsilonRI beta and gamma subunits was partially inhibited in the Lyn unique domain transfectants after Ag stimulation. Ag stimulation of Lyn unique domain transfectants was accompanied by enhanced phosphorylation of MEK and ERK-2, which are required for leukotriene C4 (LTC4) release, and production of LTC4 was increased 3- to 5-fold, compared with cells transfected with vector alone. Conversely, tyrosine phosphorylation of the adaptor protein Gab2, which is essential for mast cell degranulation, was inhibited after Ag stimulation of Lyn unique domain transfectants, and Ag-induced release of histamine was inhibited up to 48%. In rat basophilic leukemia-2H3 cells, Lyn thus plays a dual role by positively regulating Fc epsilonRI phosphorylation and degranulation while negatively regulating LTC4 production. This study provides further evidence that the constitutive interaction between the unique domain of Lyn and the Fc epsilonRI beta subunit is a crucial step in the initiation of Fc epsilonRI signaling and that Lyn is limiting for Fc epsilonRI-induced secretion of inflammatory mediators.