Fever and Rash: A Changing Landscape in the 21st Century.

Although "fever and rash" is a common complaint in the pediatric emergency department, most causes are benign. Of the more severe causes, several have been greatly reduced by vaccination programs. In addition, new vaccines such as those for invasive meningococcal disease hold promise for an even brighter future. Although meningococcemia remains an important concern when evaluating a child with fever and a rash, the resurgence of measles, the emergence of invasive group A streptococcal disease and antibiotic-resistant Staphylococcus aureus, as well as the fear of agents of bioterrorism (anthrax, smallpox) have changed the landscape of fever and rash in the 21st century. The purpose of this article is not to offer a comprehensive differential of febrile exanthema, but rather to highlight some new concerns related to the evaluation of fever and rash in today's emergency department.

Children in taxis: an opportunity for pediatricians and emergency physicians to save lives?

OBJECTIVE: Child safety devices (infant seats, booster seats, and seat belts) are effective in curbing the risk of injury; however, there remains a pattern of parental nonuse or misuse of safety seats. The aim of this study was to assess the level of knowledge and compliance of parents with children presenting for emergency care of the National Highway and Traffic Association safety seat guidelines in private cars and taxicabs. METHODS: Two hundred forty-two caregivers of children (ages range, 2 weeks to 19 years) presenting for care in the pediatric emergency department of an urban university hospital were approached to complete an interviewer-administered questionnaire, and 225 participated. The questionnaire included knowledge, attitude, and behavior questions on protective equipment for various aged children. RESULTS: Eleven (47.8%) of 23 children 1 year or younger were reported to use infant seats often or always while riding in private cars, compared with 8 (22.2%) of 36 children 1 year or younger were reported to their use while in taxis (P < 0.05). Seventeen (85%) of 20 children older than 8 years were reported to have used seat belts often or always in private cars versus 10 (41.7%) of 24 in taxis (P < 0.01). One hundred fifty-four (99.3%) of 155 subjects knew the National Highway Traffic Safety Administration recommended position for the safety seat for their child. Most parents believed in the efficacy of child safety seats in preventing vehicle injuries and reported they would be more likely to use safety devices if they received information on their use in the emergency department. CONCLUSIONS: Data from this survey show that use of safety seats is lower in taxis than in private automobiles and that this is attributable to the inconvenience of carrying these seats to and from the taxi rather than financial considerations or lack of knowledge about their effectiveness. Strategies should be sought to increase availability of child safety devices in taxicabs. The emergency department, as well as the pediatrician's office or clinic, can be a locus for an educational intervention to parents and caregivers on child passenger safety.

Pectoralis muscle flap reconstruction of pediatric sternal wound infections.

Sternal wound infection (SWI) is a life-threatening complication in both the pediatric and adult population. The morbidity and mortality of SWIs have decreased with the use of muscle flap reconstruction of the chest wall. Although the pectoralis muscle flap is the most frequently used flap in adults for reconstruction after SWI, its use in children has not been well described. To review current experience with the use of the pectoralis muscle flap in a pediatric population, a retrospective review of 1,200 consecutive median sternotomies occurring at the Children's Hospital of Pittsburgh between 1992 and 1997 was performed. All cases of postoperative SWI were identified, and the operative management was performed by a single surgeon. Reconstruction was performed with the use of unilateral or bilateral pectoral muscle flap advancements. Sternal wound infections developed in nine patients (0.75% incidence). The mean duration from initial sternotomy to the time of presentation of deep SWI was 39.5 days. Eight patients underwent reconstruction using pectoralis muscle advancement flaps. Two patients (25%) were reconstructed with a unilateral pectoralis advancement flap, whereas six patients (75%) required bilateral advancement flaps. One patient was treated with conservative management. The average length of stay after reconstruction was 9 +/- 4 days. Duration of follow-up ranged from 3 to 42 months (mean: 16 +/- 12 months). All reconstructions ultimately resulted in well-healed wounds with satisfactory cosmesis. No developmental or functional deficits have been documented in follow-up visits. Sternal wound infection is a serious postoperative complication of median sternotomy. Aggressive operative management with the use of muscle flap reconstruction has helped to lower the morbidity and mortality of this infection. The successful use of pectoralis muscle flap advancement for functional and esthetic reconstruction of the chest wall in children is described.

Nontyphoidal salmonella bacteremia and pneumonia as the initial manifestation of human immunodeficiency virus infection in a four-year-old child.

This report describes the case of a 4-year-old human immunodeficiency virus (HIV)-infected girl with Salmonella typhimurium bacteremia and pneumonia. The girl presented with a history of fever for 1 month and mild pulmonary symptoms. Subsequent studies revealed previously undiagnosed HIV disease.