Hypothermia: A Sign of Sepsis in Young Infants in the Emergency Department?

OBJECTIVES: Diagnosis of sepsis in young infants can be challenging due to the nonspecific signs, which can include hypothermia. Whether the presence of hypothermia in young infants should prompt evaluation for serious infection is unclear. The objectives were to measure the prevalence of serious infection among infants ≤60 days of age with hypothermia in the emergency department (ED) and determine other clinical features of hypothermic infants who have serious infection. METHODS: This is a retrospective analysis of all infants ≤60 days seen in a children's hospital ED from April 2014 to February 2017. Primary outcome was presence of serious infection, defined as urinary tract infection, bacteremia, meningitis, pneumonia, or herpes virus infection. Hypothermia was defined as a rectal temperature of 36.0°C or less. RESULTS: Of 4797 infants ≤60 days of age seen in the ED, 116 had hypothermia. The prevalence of serious infection was 2.6% (3/116) in hypothermic infants compared with 15.2% (61/401) in febrile infants (P < 0.01). Hypothermic infants with serious infections were more likely to have a history of prematurity, apnea, poor feeding, lethargy, ill-appearance, and respiratory signs than hypothermic infants without serious infection. All 3 hypothermic infants with serious infection had other concerning features. CONCLUSIONS: The prevalence of serious infection in hypothermic young infants in the ED is low. Serious infection is unlikely in infants with isolated hypothermia.

Cold Panniculitis After Ice Therapy for Supraventricular Tachycardia.

A late preterm infant presenting with supraventricular tachycardia (SVT) was admitted to the pediatric intensive care unit because of poor systolic function seen on echocardiogram. The hospitalization was complicated by multiple breakthrough episodes of SVT requiring ice placed on the face during each repeat episode. The infant was later diagnosed as having cold panniculitis secondary to the application of ice to the face on multiple occasions. In children who are hemodynamically stable during SVT episodes, ice is used as first-line treatment. It is important to be aware of how often ice is being applied to the face and the duration of time to limit complications such as cold panniculitis.

Adverse events and satisfaction with use of intranasal midazolam for emergency department procedures in children.

PURPOSE: Procedural sedation is commonly performed in the emergency department (ED). Having safe and fast means of providing sedation and anxiolysis to children is important for the child's tolerance of the procedure, parent satisfaction and efficient patient flow in the ED. OBJECTIVE: To evaluate fasting times associated with the administration of intranasal midazolam (INM) and associated complications. Secondary objectives included assessing provider and caregiver satisfaction scores. METHODS: A prospective observational study was conducted in children presenting to an urban pediatric emergency department who received INM for anxiolysis for a procedure or imaging. Data collected included last solid and liquid intake, procedure performed, sedation depth, adverse events and parent and provider satisfaction. RESULTS: 112 patients were enrolled. The mean age was 3.8 years. There were no adverse events experienced by any patients. Laceration repair was the most common reason for INM use. The median depth of sedation was 2.0 (cooperative/tranquil). The median liquid NPO time was 172.5 min and the median NPO time for solids was 194.0 min. 29.8% were NPO for liquids ≤2 h and 62.5% were NPO for solids ≤2 h. Parent and provider satisfaction was high: 90.4% of parents' and 88.4% of providers' satisfaction scores were a 4 or 5 on a 5 point Likert scale. CONCLUSION: Our data suggest that short NPO of both solids and liquids are safe for the use of INM. Additionally, parent and provider satisfaction scores were high with the use of INM.

Neurologic complications in children hospitalized with influenza: characteristics, incidence, and risk factors.

OBJECTIVE: To determine the characteristics, incidence, and risk factors for influenza-related neurologic complications (INC). STUDY DESIGN: A retrospective cohort study of INC in children hospitalized with laboratory-confirmed influenza infection (LCI) from June 2000 to May 2004 was conducted. Systematic chart review was performed to identify clinical characteristics and outcomes. A neighborhood cohort was constructed to estimate the incidence of INC. Logistic regression was used to identify independent risk factors for INC. RESULTS: Of 842 patients with LCI, 72 patients had an INC: influenza-related encephalopathy (8), post-infectious influenza encephalopathy (2), seizures (56), and other (6). Febrile seizures were the most common type of seizures (27). No patient died from an INC. In our neighborhood cohort, the incidence of INC was 4 cases per 100,000 person-years. An age of 6 to 23 months (odds ratio [OR], 4.2; 95% CI, 1.4-12.5) or 2 to 4 years (OR, 6.3; 95% CI, 2.1-19.1) and an underlying neurologic or neuromuscular disease (OR, 5.6; 95% CI, 3.2-9.6) were independent risk factors for the development of INC. CONCLUSION: Seizures are the most common neurologic complication experienced by children hospitalized with influenza. In the United States, encephalopathy is uncommon. Young children and patients with neurologic or neuromuscular disease are at increased risk for INC.

Müllerian inhibiting substance blocks the protein kinase A-induced expression of cytochrome p450 17alpha-hydroxylase/C(17-20) lyase mRNA in a mouse Leydig cell line independent of cAMP responsive element binding protein phosphorylation.

Müllerian inhibiting substance (MIS) is produced by fetal Sertoli cells and causes regression of the Müllerian duct in male fetuses shortly after commitment of the bipotential embryonic gonad to testes differentiation. MIS is also produced by the Sertoli cells and granulosa cells of the adult gonads where it plays an important role in regulating steroidogenesis. We have previously shown that MIS can dramatically reduce testosterone synthesis in Leydig cells by inhibiting the expression of cytochrome P450 17alpha-hydroxylase/C(17-20) lyase (Cyp17) mRNA in vitro and in vivo. To characterize the signal transduction pathway used by MIS to control expression of endogenous Cyp17 in a mouse Leydig cell line, we demonstrate that MIS inhibits both LH- and cAMP-induced expression of Cyp17 at concentrations as low as 3.5 nM and for as long as 18 h. The induction of steroidogenic acute regulatory protein (StAR) mRNA by cAMP, however, was slightly increased by addition of MIS. Protein kinase A (PKA) inhibition with H-89 blocked Cyp17 mRNA induction, suggesting that MIS interferes with the PKA signal transduction pathway. Inhibition of Cyp17 induction was not seen with added U0126, and wortmannin inhibited the induction incompletely. In addition, phosphorylation of the cAMP responsive element binding protein (CREB) was not detected following 50 micro M cAMP exposure, a concentration sufficient for Cyp17 mRNA induction. Moreover, CREB phosphorylation, which was observed with addition of 500 micro M cAMP, was not inhibited by coincubation with MIS. Taken together, these results suggest that cAMP induces expression of Cyp17 by a PKA-mediated mechanism and that this induction, which is inhibited by MIS signal transduction, does not require CREB activity, and is distinct from that used to induce steroidogenic acute regulatory protein expression.

New approaches for high-yield purification of Müllerian inhibiting substance improve its bioactivity.

We have established a new method to purify Müllerian inhibiting substance (MIS) with higher purity and recovery over existing procedures. Recombinant human MIS was expressed in Chinese hamster ovary cells and secreted into chemically defined serum-free media. The secreted products were concentrated by either precipitation with ammonium sulfate or lectin-affinity chromatography, each of which was followed by anion-exchange chromatography. Further separation of the active carboxy-terminal domain of MIS was achieved after cleavage by plasmin followed by lectin-affinity chromatography. This method may be applicable to other members of the transforming growth factor beta family with which MIS shares sequence homology.