Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis.

OBJECTIVE: To compare the risks for bacteremia and urinary tract injections (UTI) in young febrile children with and without bronchiolitis. DESIGN: A prospective cohort study. SETTING: The emergency departments of 3 pediatric referral hospitals. PATIENTS: A convenience sample of 432 previously healthy febrile patients aged 24 months or younger. Patients were divided into groups, based on the presence (n = 163, bronchiolitis group) or absence (n = 269, control group) of wheezing and/or retractions on examination. Blood cultures were obtained from all patients, and urine cultures were obtained from female patients, and male patients aged 6 months or younger. Chest radiographs were obtained on patients with lower respiratory tract signs, and those with lobar pneumonias were excluded (7 wheezing and 8 nonwheezing patients), leaving 156 patients with bronchiolitis and 261 control patients. OUTCOME MEASURES: Growth of any bacterial pathogens from the blood or 10(4) colony-forming units per milliliter or more from the urine. RESULTS: None of the 156 patients with bronchiolitis had bacteremia (95% confidence interval, 0%-1.9%) vs 2.7% of the 261 controls (95% confidence interval, 1.1%-5.4%; P = .049); 1.9% of the patients with bronchiolitis had UTI vs 13.6% of the controls (odds ratio, 0.12; 95% confidence interval, 0.02-0.55; P = .001). None of the subset of patients with bronchiolitis aged 2 months or younger (n = 36) had bacteremia or UTI; however, there were not enough of these younger patients to make statistically conclusive comparisons. CONCLUSIONS: Previously healthy febrile children aged 24 months or younger with bronchiolitis are unlikely to have bacteremia or UTI. Therefore, routine cultures of the blood and urine in these patients are unnecessary. More data are needed regarding the subset of febrile infants aged 2 months or younger with bronchiolitis.

Household oven doors: a burn hazard in children.

Contact with hot oven doors is an important cause of burns in pediatric patients. These burns are of particular concern because of their frequent localization to the hands, with the resulting negative implications for financial cost, long-term cosmesis, and hand function. A 5-year review of pediatric oven door burn cases admitted to a burn referral center was conducted. Of the 14 cases identified, the median age was 12 months. The median total body surface area (TBSA) was 1.75% (range, 0.5%-4.5%). Twelve of 14 cases involved 1 or both hands. The median length of hospital stay was 10 days. In 7 cases, burns were sustained from contact to an external surface of the oven. Based on the results obtained, we propose several prevention strategies.

Comparison of long-term renal hemodynamic effects of methyldopa and propranolol in patients with hypertension and renal insufficiency.

Studies were carried out in 15 patients with renal insufficiency and hypertension to compare the long-term effects of methyldopa and propranolol on renal hemodynamics. Inulin and PAH clearance measurements were made under baseline conditions and four to six months of antihypertensive therapy with each of the two drugs. Eight of the 15 patients (group I) were started on methyldopa and then switched to propranolol; and in the other seven (group II), the sequence was reversed. There were no statistical differences in blood pressure or inulin or PAH clearances under baseline conditions between the two groups of patients. Blood pressure was controlled equally with the two drugs in combination with furosemide. In group I, there was no significant effect of either antihypertensive drug on inulin clearance, but PAH clearance was significantly higher during methyldopa than propranolol therapy. In group II, the same higher PAH clearance was found with methyldopa, even though the sequence of drug administration was opposite to that of group I. Challenge with iv furosemide resulted in a greater 3-hour natriuresis during methyldopa than propranolol treatment. The observations indicate that glomerular filtration rate (GFR) is not significantly affected by long-term treatment with methyldopa or propranolol but that renal plasma flow (RPF) is higher during treatment with methyldopa in patients with renal insufficiency and hypertension. The higher RPF apparently enhances the acute natriuretic effect of iv furosemide.

New approaches to upper airway disease.

Although laryngotracheobronchitis is the most common upper respiratory tract disorder in pediatrics, several other diseases are potentially life-threatening. The emergency physician must recognize both the obvious and subtle distinctions among upper airway diseases. The status of the patient's airway remains the primary concern regardless of the suspected disorder, but further definitive care depends on the specific disease entity. The prompt recognition and action of both the prehospital care provider and the ED physician in maintaining a critical airway and supporting ventilation until definitive pediatric critical or surgical care can be delivered is essential in ensuring optimal outcome for children suffering from a life-threatening upper airway illness.

Restricting the time of injury in fatal inflicted head injuries.

OBJECTIVE: To determine the normal clinical progression of fatal head injuries in children. Such information can then be used to estimate the time of injury in cases with obscure histories and will thus aid investigations of nonaccidental trauma. METHOD: A retrospective chart review design was used. One hundred and thirty eight accidental fatalities involving head injury were identified and 95 of these were used as the study group. Details of the cases were reviewed and cases in which a child either had a Glasgow Coma Scale (GCS) of 14-15 or was described as having a "lucid interval" or as being "conscious" were further studied. RESULTS: One "lucid interval" case was identified. This case involved an epidural hematoma. Three other cases that partially met the criteria for a lucid interval were also identified; one of these cases did not meet the criteria for inclusion in the study group. Review of head CTs revealed that brain swelling could be detected as early as 1 hour and 17 minutes post injury. CONCLUSIONS: The children studied were in obvious serious medical condition from the time of injury until death. If a history purports a lucid interval in a fatal head injury case that does not involve an epidural hematoma, that history is likely false and the injury is likely inflicted. The time of most fatal head injury events can be restricted to the time period after the last confirmed period of wellness for the child. In addition, the presence of brain swelling on a head CT scan is not helpful in restricting the time of injury.

Skin retraction after liposuction in patients over the age of 40.

BACKGROUND: A commonly held misperception regarding liposuction in patients over 40 years of age is that the skin will not retract and redrape following removal of the fat. OBJECTIVE: In order to evaluate tissue retraction in the abdomen, neck, and arms in patients undergoing liposuction after 40 years of age, the following study was conducted. METHOD: A total of 58 patients ranging in age from 40 to 75 years underwent liposuction. Thirty had liposuction of the abdomen, 20 had liposuction of the neck, and 8 had liposuction of the arms. Measurements in inches and weight in pounds were recorded before and at 1, 3, and 6 months after the procedure. RESULTS: Ninety percent of the patients were women. The rest of the patients were men. The average age of the patients undergoing liposuction of the abdomen was 55 years old. The average supranatant fat extracted from these patients was 1725 ml, with an average lidocaine dose of 36 mg/kg of body weight. The patients who had liposuction of the abdomen demonstrated an average weight loss of 5 lb and a decrease of 3 inches in waistline 6 months after the procedure. For those patients who had liposuction of the neck, the average age was 57 years old. The average supranatant fat extracted from these patients was 75 ml, with an average lidocaine dose of 4 mg/kg of body weight. The patients who had liposuction of the neck decreased an average of 1.3 inches in circumference without any weight change 6 months after the procedure. For those patients having liposuction of the arms, the average age was 44 years. The average supranatant fat extracted from these patients was 525 ml, with an average lidocaine dose of 16 mg/kg of body weight. The patients who had liposuction of the arms had an average of 0.5 inch decrease in circumference without any weight change 6 months after the procedure. The cosmetic results were good to excellent. Our highest lidocaine dose occurred in a patient having suction of the abdomen and was 71 mg/kg of body weight. No patients experienced any objective or subjective signs of lidocaine toxicity. CONCLUSION: Tumescent liposuction of the abdomen, neck, and arms is a safe alternative for contour improvement with good cosmetic results in patients over 40 years of age.

Cerebral abscess formation following ocular trauma: a hazard associated with common wooden toys.

Penetrating orbital trauma is an uncommon pediatric emergency with potentially devastating consequences. We report a five-year-old child who fell on a wooden toy and sustained an orbital roof fracture. He subsequently developed an intracranial abscess. Current information pertaining to penetrating orbitocranial trauma will be reviewed, stressing the importance of early recognition of the intracranial injury in these cases. Both parents and toy manufacturers must remain aware of the potential for injury involving these common toys.

Skin resurfacing of the face with the Erbium:YAG laser.

BACKGROUND: Laser resurfacing of facial skin is a very popular method of rhytide and scar removal. Until recently, the most effective tool utilized for these purposes was the pulsed char-free carbon dioxide laser. These lasers, however, produce thermal damage related to prolonged wound healing. The Erbium (Er): YAG laser, with its 2940-nm wavelength and maximal water absorption, has been recently introduced for laser resurfacing of the facial skin. OBJECTIVE: In this study, specific parameters for Er:YAG laser treatment of rhytides were evaluated clinically and histologically. METHODS: Fifteen patients were treated with the Er:YAG laser. Perioral, periorbital, and total face rhytides were treated. All patients were treated with 0.8-1.0 J, 5-mm spot size, with the final fluences of 4-5 J/cm2. Patients were evaluated daily after treatment for 7 days and weekly for 2 months for erythema, healing time, improvement, and pigmentary changes. Histologic evaluation of preauricular human facial ex vivo skin was done to determine the penetration of multiple passes of Er:YAG laser in human facial skin. RESULTS: All patients showed some degree of improvement of their rhytides. Reepithelialization occurred between 3 and 8 days. All evidence of erythema resolved between 3 and 6 weeks after treatment. The level of tissue ablation was determined to be down to: the granular layer after one pass; to the basal cell layer after two passes, to the papillary dermis after three to four passes, and deeper into the papillary and superficial reticular dermis after five to six passes. CONCLUSION: The Er:YAG laser plays a significant role in the treatment of superficial and mid-depth rhytides.

Reactive perforating collagenosis in a setting of double disaster: acquired immunodeficiency syndrome and end-stage renal disease.

We report reactive perforating collagenosis in an intravenous heroin abuser with acquired immunodeficiency syndrome and end-stage renal disease. The literature on perforating disorders in patients with acquired immunodeficiency syndrome and the pathogenesis of reactive perforating collagenosis in this setting is reviewed.

Cutaneous lesions of disseminated histoplasmosis in human immunodeficiency virus-infected patients.

Disseminated histoplasmosis is being diagnosed more frequently in persons infected with the human immunodeficiency virus and is often the initial manifestation of the acquired immunodeficiency syndrome (AIDS). Disease-related cutaneous features of HIV-associated disseminated histoplasmosis are defined as mucocutaneous lesions from which fungal organisms were either cultured or demonstrated histopathologically. We report four HIV-seropositive patients with disseminated histoplasmosis who had culture-positive skin or oral lesions of histoplasmosis and review the specific cutaneous manifestations of HIV-associated disseminated histoplasmosis. Including our patients, disease-related skin and/or mucosal lesions were present in 11% of patients (26% of 239) with HIV-associated disseminated histoplasmosis. The possibility of disseminated histoplasmosis should be considered in all HIV-infected persons and in persons with AIDS risk factors who have fever, weight loss, hepatosplenomegaly, and new cutaneous lesions. An early skin or mucosal biopsy specimen for crushed tissue preparation, histologic evaluation, and fungal culture is a simple, rapid diagnostic procedure.

Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children.

STUDY OBJECTIVE: To compare the duration of anesthesia experienced with lidocaine, epinephrine, and tetracaine (LET) solution and that with tetracaine, epinephrine (Adrenalin), and cocaine (TAC) solution during suturing of uncomplicated lacerations on the face or scalp. DESIGN: Double-blind, randomized, controlled trial. SETTING: The emergency department of a university-affiliated private children's hospital. PARTICIPANTS: One hundred seventy-one children with lacerations on the face and scalp requiring suturing. INTERVENTIONS: After standard application of the anesthetic solution, patients were assessed for signs of discomfort before and during laceration repair. Duration of anesthesia during laceration repair was determined on the basis of the length of time after removal of the anesthetic solution to the first sign(s) of discomfort that required additional anesthesia. RESULTS: There was no statistical difference between TAC and LET in adequacy of anesthesia before suturing or in duration of anesthesia during suturing. CONCLUSION: LET is an effective alternative to TAC for topical anesthesia during suturing of uncomplicated lacerations on the face and scalp in children.