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Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Propofol is a preferred agent for many pediatric sedation providers because of its rapid onset and short duration of action. It allows for quick turn around times and enhanced throughput. Occasionally, intravenous (IV) methohexital (MHX), an ultra-short acting barbiturate is utilized instead of propofol. Describe the experience with MHX in a primarily propofol driven outpatient sedation program and to see if it serves as an acceptable alternative when propofol is not the preferred pharmacologic option. Retrospective chart review from 2012 to 2015 of patients receiving IV MHX as their primary sedation agent. Data collected included demographics, reason for methohexital use, dosing, type of procedure, success rate, adverse events (AE), duration of the procedure, and time to discharge. Methohexital was used in 240 patient encounters. Median age was 4years (IQR 2–7), 71.8% were male, and 80.4% were ASA-PS I or II. Indications for MHX use: egg+soy/peanut allergy in 93 (38.8%) and mitochondrial disorder 9 (3.8%). Median induction bolus was 2.1mg/kg (IQR, 1.9–2.8), median maintenance infusion was 4.5mg/kg/h (IQR, 3.0–6.0). Hiccups 15 (6.3%), secretions requiring intervention 14 (5.8%), and cough 12 (5.0%) were the most commonly occurring minor AEs. Airway obstruction was seen in 28 (11.6%). Overall success rate was 94%. Median time to discharge after procedure completion was 40.5min (IQR 28–57). Methohexital can be used with a high success rate and AEs that are not inconsistent with propofol administration. Methohexital should be considered when propofol is not a preferred option.

Background Cardiac MRI has become widespread to characterize cardiac lesions in children. No study has examined the role of deep sedation performed by non-anesthesiologists for this investigation. Objective We hypothesized that deep sedation provided by non-anesthesiologists can be provided with a similar safety and efficacy profile to general anesthesia provided by anesthesiologists. Materials and methods This is a retrospective chart review of children who underwent cardiac MRI over a 5-year period. The following data were collected from the medical records: demographic data, cardiac lesion, American Society of Anesthesiologists (ASA) physical status, sedation type, provider, medications, sedation duration and adverse events or interventions. Image and sedation adequacy were recorded. Results Of 1,465 studies identified, 1,197 met inclusion criteria; 43 studies (3.6%) used general anesthesia, 506 (42.3%) had deep sedation and eight (0.7%) required anxiolysis only. The remaining 640 studies (53.5%) were performed without sedation. There were two complications in the general anesthesia group (4.7%) versus 17 in the deep sedation group (3.4%). Sedation was considered inadequate in 22 of the 506 deep sedation patients (4.3%). Adequate images were obtained in 95.3% of general anesthesia patients versus 86.6% of deep sedation patients. Conclusion There was no difference in the incidence of adverse events or cardiac MRI image adequacy for children receiving general anesthesia by anesthesiologists versus deep sedation by non-anesthesiologists. In summary, this study demonstrates that an appropriately trained sedation provider can provide deep sedation for cardiac MRI without the need for general anesthesia in selected cases.

Background Freestanding imaging centers are popular options for health care systems to offer services accessible to local communities. The provision of deep sedation at these centers could allow for flexibility in scheduling imaging for pediatric patients. Our Children’s Sedation Services group, comprised of pediatric critical care medicine and pediatric emergency medicine physicians, has supplied such a service for 5 years. However, limited description of such off-site services exists. The site has resuscitation equipment and medications, yet limited staffing and no proximity to hospital support. Objective To describe the experience of a cohort of pediatric patients undergoing sedation at a freestanding imaging center. Materials and methods A retrospective chart review of all sedations from January 2012 to December 2012. Study variables include general demographics, length of sedation, type of imaging, medications used, completion of imaging, adverse events based on those defined by the Pediatric Sedation Research Consortium database and need for transfer to a hospital for additional care. Results Six hundred fifty-four consecutive sedations were analyzed. Most patients were low acuity American Society of Anesthesiologists physical class ≤ 2 (91.8%). Mean sedation time was 55 min (SD ± 24). The overwhelming majority of patients (95.7%) were sedated for MRI, 3.8% for CT and <1% (three patients) for both modalities. Propofol was used in 98% of cases. Overall, 267 events requiring intervention occurred in 164 patient encounters (25.1%). However, after adjustment for changes from expected physiological response to the sedative, the rate of events was 10.2%. Seventy-five (11.5%) patients had desaturation requiring supplemental oxygen, nasopharyngeal tube or oral airway placement, continuous positive airway pressure or brief bag valve mask ventilation. Eleven (1.7%) had apnea requiring continuous positive airway pressure or bag valve mask ventilation briefly. One patient had bradycardia that resolved with nasopharyngeal tube placement and continuous positive airway pressure. Fifteen (2.3%) patients had hypotension requiring adjustment of the sedation drip but no fluid bolus. Overall, there were six failed sedations (0.9%), defined by the inability to complete the imaging study. There were no serious adverse events. There were no episodes of cardiac arrest or need for intubation. No patient required transfer to a hospital. Conclusion Sedation provided at this freestanding imaging center resulted in no serious adverse events and few failed sedations. While this represents a limited cohort with sedations performed by predominately pediatric critical care medicine and pediatric emergency medicine physicians, these findings have implications for the design and potential scope of practice of outpatient pediatric sedation services to support community-based pediatric imaging.

Background Adult studies evaluating corticosteroids have found varied efficacy. One study showing mortality benefit utilized fludrocortisone (FLU) and hydrocortisone (HC) (Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871, 2002 ). Use of FLU in children has not been described. We developed a protocol using HC for systemic inflammatory response syndrome (SIRS) and shock with optional addition of FLU. Hypothesis Addition of FLU to a HC-based steroid protocol is associated with decreased vasopressor duration without adverse effects in hypotensive children with SIRS. Methods Retrospective review of low-dose HC and FLU supplementation in children with SIRS and fluid refractory shock. Patients receiving FLU in addition to HC were compared with patients receiving HC alone. Results Ninety-seven children with SIRS and shock received steroids. Sixty of 97 (62%) received FLU in addition to HC. Seventy-three children required dopamine (DA) infusion, and 56 received norepinephrine (NE). Overall mortality was 7/97 (7%), with 5/7 (71%) nonsurvivors receiving HC + FLU. Fifty of 97 (52%) children with SIRS met definition for sepsis. Septic children who received HC + FLU required NE for significantly shorter duration than those receiving HC alone ( p  = 0.011). Nineteen of 60 HC + FLU patients (32%) developed nonsymptomatic hypokalemia. Hypokalemia was significantly more common in HC + FLU patients compared with those receiving HC alone ( p  = 0.05). Conclusions Overall, addition of FLU in children with SIRS was not associated with decreased vasopressor duration or vasopressor score. However, HC + FLU was associated with shorter duration of NE support in the septic subgroup. Hypokalemia was a frequent adverse finding with HC + FLU ( p  = 0.05). Use of FLU should be considered in further studies evaluating the role of steroids in refractory pediatric septic shock.

While a common pathogen, Mycobacterium tuberculosis (TB) pneumonitis is only rarely reported as a cause for respiratory failure in developed countries. We report an adolescent with TB pneumonitis and respiratory failure requiring extracorporeal membrane oxygenation (ECMO) with eventual survival. With the incidence of TB rising globally, TB should be suspected and treated as early as possible. ECMO should be considered as a treatment option if conventional ventilatory support is inadequate. ECMO survival with TB pneumonia and anti-TB antimicrobial therapy is possible.

Cyanobacteria blooms pose an increasing threat to ecosystem services. Consequently, understanding their impacts on ecosystem function is important. Cyanobacteria are poor producers of long-chain essential fatty acids (LC-EFA; eicosapentaenoic, docosahexaenoic, and arachidonic acids) and are inadequate for primary consumer growth and reproduction. Higher-level consumers such as planktivorous fishes are hypothesized to be negatively impacted through disruption of LC-EFA availability and transfer up the food web. We tested this hypothesis by comparing fatty acids in yellow perch ( Perca flavescens ) and white perch ( Morone americana ) across a gradient of cyanobacteria densities spanning four sites in Lake Champlain and Shelburne Pond, Vermont, USA. Phytoplankton community composition and fatty acid content of seston and fish tissue (liver and muscle) were collected in June, August, and October 2013. Yellow perch liver and muscle tissue increased in percent composition of linoleic acid and α-linolenic acid and decreased in LC-EFA with increased cyanobacteria. Total EFA and arachidonic acid in white perch muscle were negatively related to cyanobacteria. White perch liver did not show any relationship between EFA and cyanobacteria. We conclude that both fish species experienced altered EFA coinciding with cyanobacteria blooms, consistent with disruption of LC-EFA transfer across multiple trophic levels.

The molecular basis of cultivar-level variations in polyploid wheat that enables environmental adaptation while maintaining yield and quality in polyploid wheat remains poorly understood. We conducted a detailed phenotypic assessment and multiomics analysis of nine pan-genome polyploid wheat cultivars grown under control and drought conditions. We aimed to investigate the subgenome-level variations, cultivar differences and biochemical mechanisms affecting plant fitness under moderate drought stress. Intrinsic water use efficiency, grain yield, and grain protein content and quality differed among cultivars, supporting the plasticity of drought stress responses. Biased proteome and metabolome abundance changes in response to moderate drought stress during the vegetative stage indicate different strategies for the utilization of homeologous protein isoforms assigned to the A, B, and D subgenomes. Drought effects were detected at the protein level, but significant changes were observed in central carbon pathway metabolites and micronutrient profiles. The subgenomic localization of seed storage proteins highlight differences in nutrient reservoir accumulation and emphasizes the enhanced role of S-rich prolamins in the stress response. Subgenomic variations define cultivar phenotypes by producing molecules that accumulate and enable the underlying trade-offs between environmental adaptation and yield- or quality-related traits. These variations can be used to select crops with increased stress resistance without compromising yield.Competing Interest StatementThe authors have declared no competing interest.