Triage guideline for immunocompromised children with fever in an emergency centre in Ethiopia.

Fever in children with neutropenia often portends life-threatening bacteremia that may be ameliorated with early recognition and the rapid administration of antimicrobial therapy. Studies demonstrating this effect have been done in resource-endowed countries, but not in resource-limited settings. We attempted to decrease the time to antibiotics in patients with fever and neutropenia presenting to a paediatric emergency centre at a tertiary care referral hospital in Ethiopia. In 3 phases we performed baseline data collection, instituted triaging and treatment guidelines, and provided antibiotics. We tracked a variety of outcomes, most importantly time from arrival to initiation of antibiotics. While this time was reduced during the guideline institution phase of our intervention, time reductions were inconsistent and not sustained. This was likely due to competing clinical priorities among providers caring for a high volume of ill children. While in the U.S., fever and neutropenia is easy to prioritise within the paediatric emergency centre, future quality improvement measures in this setting may have a greater benefit on critical presentations such as shock or respiratory failure. Alternative strategies geared towards general efficiency improvement and teamwork, rather than focusing on one patient group may be a higher yield approach for improving care in this paediatric emergency centre.

Taking the Pulse of POCUS: The State of Point-of-Care Ultrasound at a Pediatric Tertiary Care Hospital.

We aim to quantify and categorize point-of-care ultrasound (POCUS) usage by pediatric practitioners and trainees at our tertiary care center, and assess the degree of interest from pediatric residents, fellows, and program leaders for integrating POCUS into their training. Data was collected via online survey, evaluating the current use of POCUS in clinical decision making, desire for further formal training, and opinions on the importance of POCUS to future clinical practice. In total, 14 program directors/assistant program directors (PD/APDs) representing 10 of 15 training programs, 30 of 95 fellows representing 9 of 15 fellowships, and 32 of 82 residents responded. From PD/APDs, only 2 of the programs reported active use POCUS for clinical decision making, but 13 of the fellows and 9 residents reported doing so. In regard to desire for a formal POCUS program, 30.8% of PD/APDs, 43.8% of fellows without current curricula, and 87.5% of residents were interested in participating in such a program. When considering specialty, some non-acute care-based PD/APDs and fellows at our institution felt that POCUS was important to future practice. Pediatric subspecialty PD/APDs and their fellows had divergent outlooks on the importance of POCUS in future practice. Finally, an overwhelming majority of residents at our institution expressed a desire to learn, and half believing it will be important to future practice. Based on the degree of interest, medicolegal considerations, and trajectory of patient care, pediatric residency and fellowship programs should strongly consider integrating POCUS education into their curricula.

An Unexpected Fish Bite.

We report a case of a 22-month-old boy who suffered a piranha bite, amputating his fourth distal phalanx. His finger was irrigated and closed with a flap under sedation, but we could find little evidence during a brief literature search of what prophylactic antibiotics, if any, to provide. Because reports of infections from piranha bites are lacking, we examined studies evaluating oral flora from fish, as well as flora cultured from aquariums. In conclusion, if infection is present or prophylaxis is strongly desired, a broad spectrum oral antibiotic that covers Gram-positive and Gram-negative bacteria including Pseudomonas and Aeromonas species, such as ciprofloxacin, would be recommended; however, there is little evidence to suggest that prophylactic antibiotics provide benefit over appropriate wound management.

An infant not moving her leg.

A 4-week-old female infant presented to the emergency department (ED) due to a 1-week history of not moving her left lower extremity as well as crying during diaper changes. She had been seen 6 days prior at an ED, had normal x-rays, and was discharged home. The infant was afebrile and well appearing and had been feeding well all week. Laboratory tests in our department, including a complete blood count with differential and inflammatory markers, were all normal. Repeat x-rays showed a subtle distal tibial lucency, initially overlooked. The infant was admitted to the hospital and received a magnetic resonance imaging,which demonstrated distal tibial osteomyelitis with an accompanying ankle effusion. Cultures from the bone grew group B Streptococcus, and the infant received 6 weeks of antibiotic therapy.

Upregulation of arginase-II contributes to decreased age-related myocardial contractile reserve.

Arginase-II (Arg-II) reciprocally regulates nitric oxide synthase (NOS) and offsets basal myocardial contractility. Furthermore, decreased or absent myocardial NOS activity is associated with a depression in myocardial contractile reserve. We therefore hypothesized that upregulation of Arg-II might in part be responsible for depressed myocardial contractility associated with age. We studied arginase activity/expression, NOS expression, NO production in the presence and absence of the arginase inhibitor S-(2-boronoethyl)-L: -cysteine (BEC) in old (22 months) and young (3 months) rat hearts and myocytes. The spatial confinement of Arg-II and NOS was determined with immuno-electron-miocrographic (IEM) and immuno-histochemical studies. We tested the effect of BEC on the force frequency response (FFR) in myocytes, as well as NOS abundance and activity. Arginase activity and Arg-II expression was increased in old hearts (2.27 ± 0.542 vs. 0.439 ± 0.058 nmol urea/mg protein, p = 0.02). This was associated with a decrease in NO production, which was restored with BEC (4.54 ± 0.582 vs. 12.88 ± 0.432 µmol/mg, p < 0.01). IEM illustrates increased mitochondrial density in old myocytes (51.7 ± 1.8 vs. 69 ± 2.2 × 10(6)/cm(2), p < 0.01), potentially contributing to increased Arg-II abundance and activity. Immunohistochemistry revealed an organized pattern of mitochondria and Arg-II that appears disrupted in old myocytes. The FFR was significantly depressed in old myocytes (61.42 ± 16.04 vs. -5.15 ± 5.65%), while inhibition of Arg-II restored the FFR (-5.15 ± 5.65 vs. 70.98 ± 6.10%). NOS-2 is upregulated sixfold in old hearts contributing to increased production of reactive oxygen species which is attenuated with NOS-2 inhibition by 1400 W (4,735 ± 427 vs. 4,014 ± 314 RFU/min/mg protein, p = 0.005). Arg-II upregulation in aging rat hearts contributes to age-related decreased contractile function.