A 43-Day-Old Male With Respiratory Distress and Acute-Onset Hypotonia.

A 43-day-old, full-term, previously healthy male presented with decreased activity and oral intake. He was found to be grunting and hypoxemic on examination, and a respiratory pathogen panel was positive for rhinovirus. He was diagnosed with presumed bronchiolitis. His neurologic exam on admission was normal. Because of respiratory failure, he was escalated from high-flow nasal cannula to bilevel positive airway pressure upon admission and he was started on ceftriaxone and vancomycin while awaiting culture data. On hospital day 6, he required escalation of respiratory support. His examination at that time was notable for new hypotonia of his bilateral upper and lower extremities, sluggish pupils, bilateral exotropia, intermittent vertical nystagmus, and an absent Moro reflex. He developed a focal seizure and a computed tomography of the brain demonstrated simple right otomastoiditis. The seizure was attributed to a serum sodium of 113 mmol/L in the setting of syndrome of inappropriate antidiuretic hormone secretion, thought to be secondary to viral bronchiolitis. However, as the patient's sodium was corrected to a normal range, he continued to have neurologic deficits on examination. Given his persistent hypotonia and respiratory failure, atypical for the expected course of viral bronchiolitis, the patient underwent an extensive neurologic and infectious workup, which ultimately revealed a surprising diagnosis.

Randomized trial of prophylactic antibiotics vs. placebo after midshaft-to-distal hypospadias repair: the PROPHY Study.

BACKGROUND: Use of prophylactic antibiotics after stented hypospadias repair is very common, but most research has not identified any clinical benefits of this practice. Only one study has found that postoperative prophylaxis reduces symptomatic urinary tract infections (UTIs). Data from the same trial suggested that prophylaxis may also reduce urethroplasty complications. No studies on this subject have been placebo-controlled. OBJECTIVE: We performed a randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative prophylactic antibiotics on the incidence of infection or urethroplasty complications after stented repair of midshaft-to-distal hypospadias. STUDY DESIGN: Boys were eligible for this multicenter trial if they had a primary, single-stage repair of mid-to-distal hypospadias with placement of an open-drainage urethral stent for an intended duration of 5-10 days. Participants were randomized in a double-blind fashion to receive oral trimethoprim-sulfamethoxazole or placebo twice daily for 10 days postoperatively. The primary outcome was a composite of symptomatic UTI, surgical site infection (SSI), and urethroplasty complications, including urethrocutaneous fistula, meatal stenosis, and dehiscence. Secondary outcomes included each component of the primary outcome as well as acute adverse drug reactions (ADRs) and C. difficile colitis. RESULTS: Infection or urethroplasty complications occurred in 10 of 45 boys (22%) assigned to receive antibiotic prophylaxis as compared with 5 of 48 (10%) who received placebo (relative risk [RR], 2.1; 95% confidence interval [CI], 0.8 to 5.8; p = 0.16). There were no significant differences between groups in symptomatic UTIs, SSIs, or any urethroplasty complications. Mild ADRs occurred in 3 of 45 boys (7%) assigned to antibiotics as compared with 5 of 48 (10%) given placebo (RR, 0.6; 95% CI, 0.2 to 2.5; p = 0.72). There were no moderate-to-severe ADRs, and no patients developed C. difficile colitis. CONCLUSIONS: In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. The study did not reach its desired sample size and was therefore underpowered to independently support a conclusion that prophylaxis is not beneficial. However, the result is consistent with most prior research on this subject. GOV IDENTIFIER: NCT02096159.

Cross-sectional comparisons of gut microbiome and short-chain fatty acid levels among children with varied weight classifications.

BACKGROUND: Limited studies associate changes in microbiota composition and metabolites among children and adolescents with obesity. Decreases in compositional diversity, increases in the proportion of Firmicutes and Bacteroidetes (F/B ratio) and increases in short-chain fatty acids (SCFAs) have been proposed as contributing factors in the pathophysiology of obesity. OBJECTIVES: The aim of the current study was to characterize the faecal microbiota composition, diversity, F/B ratio and SCFA levels in different weight categories (lean, overweight, obesity classes 1-3) of children ages 5 to 12 years. METHODS: We collected and processed 83 samples from different weight categories (27.7% lean, 11% overweight, 15%, 17% and 17% of obesity classes 1, 2, and 3, respectively). Microbiota content was determined by sequencing the V4 region of the 16S rRNA gene, and SCFA content was analyzed. RESULTS: Microbiota compositions showed no significant differences in diversity or F/B ratios between weight categories. However, a relative abundance of Proteobacteria and lack of Verrucomicrobia were demonstrated when comparing severe obesity to the leaner groups. Faecal butyrate, propionate and isopentanoate concentrations increased progressively with weight category demonstrating significance in the class 3 obesity group. CONCLUSIONS: Our results show that severe childhood obesity in our study population was associated with changes in gut microbiome composition correlated to previously reported cardiometabolic disease states in obesity. Increased SCFA levels correlate with obesity-related microbiome metabolic function without a reduction in diversity characterized at a phyla level. Further characterization of these specimens at a species level and longitudinal studies are needed to elucidate these relationships.