Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group.

OBJECTIVE: Prospective studies were conducted to test the hypothesis that infants unlikely to have serious bacterial infections (SBI) can be accurately identified by low risk criteria. METHODS: Febrile infants (rectal T > or = 38 degrees C) < or = 60 days of age were considered at low risk for SBI if they met the following criteria: 1) appear well; 2) were previously healthy; 3) have no focal infection; 4) have WBC count 5.0-15.0 x 10(9) cells/L (5000-15,000/mm3), band form count < or = 1.5 x 10(9) cells/L (< or = 1500/mm3), < or = 10 WBC per high power field on microscopic examination of spun urine sediment, and < or = 5 WBC per high power field on microscopic examination of a stool smear (if diarrhea). The recommended evaluation included the culture of specimens of blood, cerebrospinal fluid, and urine for bacteria. Outcomes were determined. The negative predictive values of the low risk criteria for SBI and bacteremia were calculated. RESULTS: Of 1057 eligible infants, 931 were well appearing, and, of these, 437 met the remaining low risk criteria. Five low risk infants had SBI including two infants with bacteremia. The negative predictive value of the low risk criteria was 98.9% (95% confidence interval, 97.2% to 99.6%) for SBI, and 99.5% (95% confidence interval, 98.2% to 99.9%) for bacteremia. CONCLUSIONS: These data confirm the ability of the low risk criteria to identify infants unlikely to have SBI. Infants who meet the low risk criteria can be carefully observed without administering antimicrobial agents.

Outpatient management of selected infants younger than two months of age evaluated for possible sepsis.

Previously healthy infants younger than 2 months of age without evidence of soft tissue or musculoskeletal infection who had white blood cell counts between 5000 and 15,000/mm3, band form counts less than or equal to 1500/mm3, urinalysis less than or equal to 10 white blood cells/high power field (spun sediment) and stool less than or equal to 5 white blood cells/high power field (if diarrhea) were considered at low risk for a serious bacterial infection. Infants meeting these criteria whose parents were judged to be adequate observers and had a telephone and automobile were eligible for outpatient management. Infants were given ceftriaxone to cover the possibility that the low risk criteria might miss more infants with serious bacterial infections than was predicted. From Jan. 1, 1987 to May 31, 1989, 86 infants younger than 2 months were enrolled. There were no serious complications in these infants. Twelve had transient problems possibly related to the intramuscular ceftriaxone therapy. One low risk infant was hospitalized for Neisseria meningitidis bacteremia and five other infants were hospitalized for medical or social reasons. All six hospitalized infants had short admissions and did well. This study supports the continued use of the low risk criteria to distinguish infants unlikely to have a serious bacterial infection. Furthermore, in a selected group of low risk infants, outpatient management may be an acceptable alternative to inpatient therapy.

Evaluation and management of the febrile infant 60 days of age or younger.

The old dogma of conservative management and hospitalization for all young febrile infants may no longer be necessary or considered the best option for many febrile infants encountered by practitioners today. All infants will continue to require individualized decisions regarding their care by astute clinicians well-versed in the best options for the management of these children. The suggestions outlined in this article are meant to be a guide for the clinician to the available options for the evaluation and management of the febrile infant 60 days of age or younger.

Pregnancy during adolescence.

Adolescent pregnancy continues to be one of our most challenging public health issues. Prevention is the most important goal that can be sought. Pediatricians can play a major role with young people and their families in pursuit of this goal. Young women who become pregnant must be referred early to obstetric care so that either early prenatal care can be established or an abortion can be performed early so as to prevent morbidity by delaying the procedure. New contraceptive methods such as contraceptive implants provide hope that improved contraceptive technology will aid in decreasing the likelihood of adolescent pregnancy.

Ethanol and oleate inhibition of alpha-ketoisovalerate and 3-hydroxyisobutyrate metabolism by isolated hepatocytes.

Ethanol inhibited glucose synthesis from alpha-ketoisovalerate by isolated rat hepatocytes without significant inhibition of flux through the branched-chain alpha-ketoacid dehydrogenase complex. Accumulation of 3-hydroxyisobutyrate, an intermediate in the catabolism of alpha-ketoisovalerate, was increased by ethanol, indicating inhibition of flux at the level of 3-hydroxyisobutyrate dehydrogenase. 3-Hydroxybutyrate caused the same effects as ethanol, suggesting inhibition was a consequence of an increase in the mitochondrial NADH/NAD+ ratio. Flux through the 3-hydroxyisobutyrate dehydrogenase was more sensitive to regulation by the mitochondrial NADH/NAD+ ratio than flux through the branched-chain alpha-ketoacid dehydrogenase. Oleate also inhibited glucose synthesis from alpha-ketoisovalerate, but marked inhibition of flux through the branched-chain alpha-ketoacid dehydrogenase complex was caused by this substrate.

Coordinated expression of valine catabolic enzymes during adipogenesis: analysis of activity, mRNA, protein levels, and metabolic consequences.

3T3-L1 fibroblasts have limited enzymatic capacity to oxidize valine. Enzymes expressed in these cells allow efficient oxidation of only the first carbon of this branched chain amino acid. The pathway is effectively truncated at the level of 3-hydroxyisobutyrate because of very low expression of two enzymes required for the complete pathway, 3-hydroxyisobutyrate dehydrogenase and methylmalonate semialdehyde dehydrogenase. These two enzymes, as well as the branched chain alpha-ketoacid dehydrogenase, are markedly induced upon differentiation of 3T3-L1 fibroblasts into adipocytes. Flux through the first two decarboxylation steps of valine catabolism is increased dramatically after differentiation, particularly through the step catalyzed by methylmalonate semialdehyde dehydrogenase. Activation of the distal portion of the valine catabolic pathway correlates with significant increases in enzyme protein and mRNA levels for 3-hydroxyisobutyrate dehydrogenase and methylmalonate semialdehyde dehydrogenase, and this establishes the pathway in 3T3-L1 adipocytes for utilization of valine carbon for lipogenesis. The induction profiles of 3-hydroxyisobutyrate dehydrogenase and methylmalonate semialdehyde dehydrogenase are very similar, suggesting coordinate regulation of the expression of these two valine pathway-specific enzymes. Induction of valine catabolism in 3T3-L1 cells is solely differentiation dependent, suggesting regulation by the same factors that govern differentiation of 3T3-L1 fibroblasts into adipocytes.

Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids.

The objective of this study was to assess the essential fatty acid status of patients with anorexia nervosa. Blood was collected from eight fasting female anorexia nervosa patients with a mean of 81% ideal body weight. Fatty acid composition of phospholipids, nonesterified fatty acids, triglycerides and cholesteryl esters of plasma were determined by capillary gas chromatography to indicate polyunsaturated fatty acids status compared with 19 healthy female adults < 25 y old. Subjects with anorexia nervosa showed polyunsaturated fatty acid deficiencies in plasma phospholipids different from simple nutritional essential fatty acid deficiency or chronic malnutrition. The phospholipid profile showed significantly lower (n-6) and (n-3) elongation and desaturation products, and elevated short-chain saturated, short-chain monounsaturated, branched-chain and odd-chain fatty acids. These elevations indicate enhancement of biosynthesis of alternative fatty acids that only partially compensated for the loss of polyunsaturated fatty acids in providing membrane "fluidity." Calculated mean melting point of the fatty acids of phospholipids in patients with anorexia nervosa was elevated 7.7 degrees C above normal values. These results demonstrate that patients with anorexia nervosa have deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids.