[Greenstick fractures of the forearm shaft-Is it obligatory or facultative to break the cortex?] / Grünholzfraktur des Unterarmschafts ­ Überbrechen obligatorisch oder fakultativ?

BACKGROUND: To break or not to break-That is the question that has been asked in pediatric traumatology for many years regarding the treatment of greenstick fractures of the diaphyseal forearm shaft. OBJECTIVE: The frequency of greenstick fractures of the forearm shaft in children and adolescents; the influence of breaking the fracture on the refracture rate. METHODS: Analysis and discussion of relevant articles, analysis of the refracture rate of pediatric greenstick fractures of the forearm shaft in our own patient population. RESULTS: Greenstick fractures frequently occur in the area of the forearm shaft and incomplete consolidation leads to an increased refracture rate. In the patient collective of the authors of 420 children with greenstick fractures of the diaphyseal forearm, there was a refracture rate of 9.5%; however, the rate for non-completed fractures was significantly higher compared to the group with completed fractures (15.2% vs. 3%). While in the subgroup of conservatively treated fractures (n = 234), breaking the intact cortex significantly reduced the refracture rate, breaking the intact cortical bone during surgical treatment with elastic stable intramedullary nailing (ESIN) did not change the refracture rate. CONCLUSION: As part of the conservative treatment of greenstick fractures of the diaphyseal forearm, completing the fracture can be recommended in order to lower the refracture rate. Completing the fracture does not appear to be necessary during surgical treatment using ESIN.

Long-term motor activity, cardiopulmonary performance and quality of life in abdominal wall defect patients.

AIM: To assess whether patients born with an abdominal wall defect (AWD) have impaired cardiorespiratory performance capacity, motor skills, core stability or quality of life in a long-term follow up. METHODS: Patients diagnosed with AWD between 2002 and 2013 were invited to participate in the study, which included clinical examination, spirometry, cardiopulmonary exercise performance testing, assessment of motor activity, ultrasound, electromyography of the abdominal wall and assessment of the Gastrointestinal Quality of Life Index (GIQLI). The results were compared to a healthy control group matched for age, sex, BMI, and physical activity levels. RESULTS: In total, 18 AWD patients (mean age 12.6 ± 3.5 years) were included and there were no significant differences in anthopometric data compared to the control group (n = 18). AWD patients had a significantly lower GIQLI score (AWD mean 137.2 ± 6.8 vs. control mean 141.4 ± 4.9; p = 0.038) and were affected by decreased motor abilities with significantly higher Dordel-Koch-Test values (AWD median 3.54/IQR 1 vs. control median 2.8/IQR 1; p = 0.005). CONCLUSION: Follow-up examinations of AWD patients revealed decreased motor abilities and GIQLI scores while cardiopulmonary function was not different compared to healthy controls. The clinical impact of these findings remains to be elucidated. IMPACT: Clinical examination, assessment of the gastrointestinal quality of life, sport medical testing, electromyography and abdominal wall ultrasound were performed in patients with congenital abdominal wall defect and compared to an age and sex matched healthy control group. Results of spirometry and spiroergometry, ultrasound or electromyography did not significantly differ between the groups. Significantly decreased locomotor function and gastrointestinal quality of life were found in patients with abdominal wall defect. However, the clinical impact of these findings remains to be elucidated.

Metabolomic Alterations of Volatile Organic Compounds and Bile Acids as Biomarkers of Microbial Shifts in a Murine Model of Short Bowel Syndrome.

Pediatric short bowel syndrome (SBS) is a rare condition characterized by a massive loss of the small intestine, leading to the inability to meet nutritional requirements without the use of parenteral or enteral supplementation. SBS causes profound alterations in the intestinal microbiome and metabolome. The aim of this study was a detailed assessment of the intestinal microbiome and metabolome in a murine model of SBS. We performed a 60% proximal small bowel resection versus a sham operation in C57BL/6 mice. Four weeks postoperatively, the microbial communities of different intestinal segments (jejunum, ileum, colon) and stool were assessed by 16S rRNA gene sequencing. Bile acids in serum and stool and volatile organic compounds (VOCs) in the fecal headspace were assessed using LC-MS and GC-MS techniques. The α-diversity of the different intestinal segments did not significantly differ between the two groups. ß-diversity significantly differed between sham and SBS mice. While in the jejunum, Faecalibaculum was significantly increased in SBS animals, a significant reduction in Lactobacillus and Sporosarcina was detected in the ileum of SBS mice. In the colon of SBS mice, a significant decrease in Ruminococcaceae and a significant increase in Proteobacteria such as Faecalibaculum and Escherichia-Shigella were found. Serum levels of deoxycholic, taurocholic and taurochenodeoxycholic acids were significantly higher in the SBS group. Of the 29 VOCs tested, hexane, isoflurane and pentane were significantly higher in the SBS group, and pyrrole was significantly lower. We were able to show that SBS causes shifts in the murine intestinal microbiome and metabolome including serum BAs and fecal VOCs.

Hepatitis B and human immunodeficiency virus infections within correctional facilities in Ghana.

Previous studies have suggested high Immunodeficiency Virus (HIV) and hepatitis B virus (HBV) prevalence in prisons in Ghana. However, this study was part of a nationally representative bio-behavioural survey and determined the prevalence of HIV and HBV among prison inmates and identified factors associated with these infections. Both biomedical and behavioural data were collected from a total of 2,443 prison inmates from 19 prison stations during 2013 in Ghana; 12 male prisons and 7 female prisons selected across the country. The national HIV screening algorithm was used for HIV testing while two rapid detection tests were used to confirm HBV infections. HIV and HBV prevalence among prisoners in Ghana were approximately 2.34% and 12.38% respectively. Only 5 inmates, had co-infection with both viruses. The prevalence of HIV was significantly lower among male inmates (1.5%) compared to the female inmates (11.8%). Age, sex, and marital status, were significantly associated with both HIV and HBV infections. However, BMI category, IDU, and time spent in prison were associated with HIV infections. The educational level was significantly associated with HBV infections. After binary logistic regression, being female (AOR: 0.18, 95% CI: 0.07-0.45, p<0.001) and having a stay of 5 years or more (AOR: 0.07, 95% CI: 0.01-0.60, p = 0.016), increased the risk of having HIV infection. While, those with no formal education (AOR: 0.65, 95% CI: 0.45-0.95, p = 0.024) and are underweight (AOR: 0.51, 95% CI: 0.27-0.99, p = 0.046), were more likely to have HBV infection. Forced penetrative sex may be a problem in the prisons. The need to have and strengthen an integrated screening, treatment and vaccination plan for the prison is emphasized. The prison does not serve as an exceptionally high risk to the general population. The findings support a critical look at the issue of forced penetrative sex in the prisons.

Pediatric vascular anomalies in Austria. Where are we at? A survey among primary care pediatricians.

Introduction: Vascular anomalies (VAs) are rare conditions and affected patients often experience a difficult patient journey. Timely diagnosis is only possible if primary caregivers are aware of the anomalies and are connected with dedicated specialists. Aim of our survey was to investigate the knowledge about diagnostic and therapeutic possibilities for children with VAs, and the existing networking among primary pediatric caregivers in Austria. Methods: Primary care pediatricians in Austria were invited to complete an online questionnaire consisting of 28 questions focusing on pediatric VAs. Results: Out of 373 invited pediatricians 93 (25%) returned the questionnaires, 86 of which were complete. Most physicians (39/93 42%) answered that they see between 15 and 30 patients with infantile hemangiomas per year. Vascular malformations are rarely treated in the primary care setting; most primary care pediatricians (58/86, 67%) reported that they currently treat fewer than 5 patients with such type of VAs. There was unequivocal agreement among the participants (84/86, 98%) on the need to establish a network of specialists and a registry dedicated to pediatric VAs. Conclusions: This survey represents the first study shedding light on the awareness of VAs among Austrian pediatricians and can serve as a basis for future investigations and advances in the management of these conditions in Austria and other countries with a similar healthcare setting.

Probiotic OMNi-BiOTiC® 10 AAD Reduces Cyclophosphamide-Induced Inflammation and Adipose Tissue Wasting in Mice.

Cancer therapy is often associated with severe side effects such as drug induced weight loss, also known as chemotherapy-induced cachexia. The aim of this study was to investigate the effects of a multispecies probiotic (OMNi-BiOTiC® 10 AAD) in a chemotherapy mouse model. A total of 24 male BALB/c mice were gavage-fed with the probiotic formulation or water, once a day for 3 weeks. In the third week, the mice received intraperitoneal cyclophosphamide. At euthanasia, the organs were dissected, and serum was sampled for cytokine analysis. Tight junction components, myosin light chain kinase, mucins, and apoptosis markers were detected in the ileum and colon using histological analyses and qRT-PCR. Lipolysis was analyzed by enzymatic activity assay, Western blotting analyses, and qRT-PCR in WAT. The fecal microbiome was measured with 16S-rRNA gene sequencing from stool samples, and fecal volatile organic compounds analysis was performed using gas chromatography/mass spectrometry. The probiotic-fed mice exhibited significantly less body weight loss and adipose tissue wasting associated with a reduced CGI58 mediated lipolysis. They showed significantly fewer pro-inflammatory cytokines and lower gut permeability compared to animals fed without the probiotic. The colons of the probiotic-fed animals showed lower inflammation scores and less goblet cell loss. qRT-PCR revealed no differences in regards to tight junction components, mucins, or apoptosis markers. No differences in microbiome alpha diversity, but differences in beta diversity, were observed between the treatment groups. Taxonomic analysis showed that the probiotic group had a lower relative abundance of Odoribacter and Ruminococcus-UCG014 and a higher abundance of Desulfovibrio. VOC analysis yielded no significant differences. The results of this study indicate that oral administration of the multispecies probiotic OMNi-BiOTiC® 10 AAD could mitigate cyclophosphamide-induced chemotherapy side effects.

Beneficial Perioperative Aspects Favor the Use of Percutaneous Crossed Pinning over Antegrade Nailing in Pediatric Supracondylar Fractures-A Retrospective Comparative Study.

(1) Background: Displaced supracondylar humeral fractures in pediatric patients can be treated by either antegrade nailing (AN) or percutaneous crossed pinning (PCP). The aim of this study was to compare the intra- and perioperative management, complications and outcome of AN and PCP. (2) Methods: This retrospective study enrolled 271 individuals (median age 5 years, IQR 4-7 years) who underwent AN (n = 173) or PCP (n = 98). Patient history was analyzed for incidence of nerve injuries, postoperative treatment, postoperative malrotation, time of hospital stay, time to implant removal and revision rate. Operative procedures were investigated for duration and radiation exposure. (3) Results: PCP was associated with a significantly lower radiation exposure (dose area product: PCP mean 20.1 cGycm2 vs. AN mean 34.7 cGycm2, p < 0.001; fluoroscopy time: PCP mean 1.1 min, range 0.1-8.1 min, vs. AN mean 1.5 min, range 0.1-7.1 min, p < 0.001), duration of surgery (PCP mean 32.2 min vs. AN mean 48.3 min, p < 0.001) and time to implant removal (PCP mean 37 days vs. AN mean 113 days, p < 0.001). Cast removal was performed earlier in the AN group (PCP mean 30.2 days vs. AN mean 20.4 days, p < 0.001) and there were fewer iatrogenic nerve lesions (PCP: 24% vs. AN: 8%, p < 0.001). (4) Conclusions: In the investigated study population, the analyzed parameters seem to favor the use of PCP. The advantages of AN should be weighed against its drawbacks. For special indications, AN remains a relevant technique in supracondylar fracture treatment, and surgeons should be familiar with this procedure.

Distribution and pattern of hand fractures in children and adolescents.

Hand fractures represent commonly encountered injuries in pediatric patients. However, due to modern means of mobility and product safety, the occurrence and distribution of these fractures have changed during the last decades. Therefore, it was the aim of this study to present an update of the epidemiology, pattern, and treatment of hand fractures in a large pediatric cohort. All patients aged between 0 and 17 years treated in our Department in 2019 with fractures of the phalanges, metacarpus, or carpus were included. The medical records were reviewed for age, gender, injury mechanism, fracture localization, season, and treatment. Patients were divided into three different age groups (0-5, 6-12, and 13-17 years). A total of 731 patients with 761 hand fractures were treated during the 1-year study period. The mean age was 11.1 ± 3.5 years, and the majority was male (65%). Male patients were significantly older compared to female patients (p = 0.008). Also, 78.7% of the fractures affected the phalanges, 17.6% the metacarpals, and 3.7% the carpal bones. The proximal phalanges were the most commonly fractured bones (41.5%). Patients with fractures of the carpus were significantly older compared to children sustaining fractures of the metacarpus or phalangeal bones (p < 0.001). Sixteen percent of our patients were treated surgically; these patients were significantly older compared to conservatively treated patients (p = 0.011).  Conclusion: The epidemiology, mechanisms of injury, distribution, and treatment of hand fractures significantly varies among different age groups. This knowledge is of importance for educational purposes of younger colleagues entrusted with care of children and adolescents as well as development of effective prevention strategies. What is Known: • Pediatric hand fractures represent the second most common fractures in children. • The epidemiology of pediatric hand fractures has changed during the last decades and therefore there is a need for an update regarding distribution and epidemiology of pediatric hand fractures. What is New: • In this retrospective cohort study, 761 pediatric hand fractures of 731 patients were analyzed in detail. • The main mechanisms of younger patients were entrapment injuries, older children most commonly sustained their fractures due to ball sport injuries. There was an increasing rate of metacarpal and carpal fractures with increasing age, and these fractures had to be treated operatively more often than phalangeal fractures.

Prognostic Impact of Pulmonary Metastasectomy in Bone Sarcoma Patients: A Retrospective, Single-Centre Study.

This retrospective study aimed at analyzing the impact of metastasectomy on post-metastasis survival (PMS) in bone sarcoma patients with lung metastases. Altogether, 47 bone sarcoma patients (24 males, median age at diagnosis of lung metastases: 21.8 (IQR: 15.6-47.3) years) with primary (n = 8) or secondary (n = 39) lung metastases treated at a single university hospital were retrospectively included. Based on a propensity score, inverse probability of treatment weight (IPTW) was calculated to account for selection bias whether patients had undergone metastasectomy or not. The most common underlying histology was osteosarcoma (n = 37; 78.7%). Metastasectomy was performed in 39 patients (83.0%). Younger patients (p = 0.025) with singular (p = 0.043) and unilateral lesions (p = 0.024), as well as those with an interval ≥ 9 months from primary diagnosis to development of lung metastases (p = 0.024) were more likely to undergo metastasectomy. Weighted 1- and 3-year PMS after metastasectomy was 80.8% and 58.3%, compared to 88.5% and 9.1% for patients who did not undergo metastasectomy. Naive Cox-regression analysis demonstrated a significantly prolonged PMS for patients with metastasectomy (HR: 0.142; 95%CI: 0.045-0.450; p = 0.001), which was confirmed after IPTW-weighting (HR: 0.279; 95%CI: 0.118-0.662; p = 0.004), irrespective of age, time to metastasis, and the number of lesions. In conclusion, metastasectomy should be considered in bone sarcoma patients with lung metastases, after carefully considering the individual risks, to possibly improve PMS.

Outcome after surgical treatment of venous malformations of the hand in childhood.

OBJECTIVE: Surgical treatment of venous malformations (VMs) of the hand is challenging. The hand's small functional units, dense innervation, and terminal vasculature can be easily compromised during invasive interventions like surgery or sclerotherapy, leading to an increased risk of functional impairment, cosmetic consequences, and negative psychological effects. METHODS: We have conducted a retrospective review of all surgically treated patients diagnosed with VMs of the hand between 2000 and 2019 and evaluated their symptoms, diagnostic investigations, complications, and recurrences. RESULTS: Twenty-nine patients (females, n = 15) with a median age of 9.9 years (range, 0.6-18 years) were included. Eleven patients presented with VMs involving at least one of the fingers. In 16 patients, the palm and/or dorsum of the hand was affected. Two children presented with multifocal lesions. All patients presented with swelling. Preoperative imaging was done in 26 patients and consisted of magnetic resonance imaging in nine patients, ultrasound in eight patients, and both modalities in nine patients. Three patients underwent surgical resection of the lesions without any imaging. Indications for surgery were pain and restriction of function (n = 16), and when lesions were preoperatively evaluated as completely resectable (n = 11). In 17 patients, a complete surgical resection of the VMs was performed, whereas in 12 children, an incomplete resection of VM was deemed due to nerve sheath infiltration. At a median follow-up of 135 months (interquartile range, 136.5 months; range, 36-253 months), recurrence occurred in 11 patients (37.9%) after a median time of 22 months (range, 2-36 months). Eight patients (27.6%) were reoperated because of pain, whereas three patients were treated conservatively. The rate of recurrences did not significantly differ between patients presenting with (n = 7 of 12) or without (n = 4 of 17) local nerve infiltration (P = .119). All surgically treated patients who were diagnosed without preoperative imaging developed a relapse. CONCLUSIONS: VMs in the region of the hand are difficult to treat, and surgery is associated with a high recurrence rate. Accurate diagnostic imaging and meticulous surgery may contribute to improve the outcome of the patients.

Acute appendicitis manifests as two microbiome state types with oral pathogens influencing severity.

Mounting evidence suggests that acute appendicitis (AA) is not one but two diseases: complicated appendicitis, which is associated with necrosis leading to perforation or periappendicular abscess, and uncomplicated appendicitis, which does not necessarily result in perforation. Even though AA is the most frequent cause of surgery from abdominal pain, little is known about the origins and etiopathogenesis of this disease, much less regarding the different disease types. In this study, we investigated the microbiome (inter-domain amplicon and metagenome sequencing) of samples from the appendix, rectum and peritoneum of 60 children and adolescents with AA to assess the composition and potential function of bacteria, archaea and fungi. The analysis of the appendix microbial community revealed a shift depending on the severity of the AA. This shift was reflected by two major community state types that represented the complicated and uncomplicated cases. We could demonstrate that complicated, but not uncomplicated, appendicitis is associated with a significant local expansion of oral, bacterial pathogens in the appendix, most strongly influenced by necrotizing Fusobacterium spp., Porphyromonas and Parvimonas. Uncomplicated appendicitis, however, was characterized by gut-associated microbiomes. Our findings support the hypothesis that two disease types exist in AA, which cannot be distinguished beyond doubt using standard clinical characterization methods or by analysis of the patient's rectal microbiome. An advanced microbiome diagnosis, however, could improve non-surgical treatment of uncomplicated AA.

Development and optimization of AI algorithms for wrist fracture detection in children using a freely available dataset.

Introduction: In the field of pediatric trauma computer-aided detection (CADe) and computer-aided diagnosis (CADx) systems have emerged offering a promising avenue for improved patient care. Especially children with wrist fractures may benefit from machine learning (ML) solutions, since some of these lesions may be overlooked on conventional X-ray due to minimal compression without dislocation or mistaken for cartilaginous growth plates. In this article, we describe the development and optimization of AI algorithms for wrist fracture detection in children. Methods: A team of IT-specialists, pediatric radiologists and pediatric surgeons used the freely available GRAZPEDWRI-DX dataset containing annotated pediatric trauma wrist radiographs of 6,091 patients, a total number of 10,643 studies (20,327 images). First, a basic object detection model, a You Only Look Once object detector of the seventh generation (YOLOv7) was trained and tested on these data. Then, team decisions were taken to adjust data preparation, image sizes used for training and testing, and configuration of the detection model. Furthermore, we investigated each of these models using an Explainable Artificial Intelligence (XAI) method called Gradient Class Activation Mapping (Grad-CAM). This method visualizes where a model directs its attention to before classifying and regressing a certain class through saliency maps. Results: Mean average precision (mAP) improved when applying optimizations pre-processing the dataset images (maximum increases of +25.51% mAP@0.5 and +39.78% mAP@[0.5:0.95]), as well as the object detection model itself (maximum increases of +13.36% mAP@0.5 and +27.01% mAP@[0.5:0.95]). Generally, when analyzing the resulting models using XAI methods, higher scoring model variations in terms of mAP paid more attention to broader regions of the image, prioritizing detection accuracy over precision compared to the less accurate models. Discussion: This paper supports the implementation of ML solutions for pediatric trauma care. Optimization of a large X-ray dataset and the YOLOv7 model improve the model's ability to detect objects and provide valid diagnostic support to health care specialists. Such optimization protocols must be understood and advocated, before comparing ML performances against health care specialists.

Does Calcium Phosphate Cement Kyphoplasty Cause Intervertebral Disk Degeneration in Adolescents?

OBJECTIVE: Balloon kyphoplasty with polymethylmethacrylate (PMMA) represents the standard procedure for the treatment of thoracic and lumbar type A compression fractures. However, an increased degeneration in adjacent intervertebral disks following PMMA kyphoplasty has been demonstrated in elderly patients. Calcium phosphate cement (CPC) appears to be superior to PMMA for the intravertebral stabilization in younger patients. It remains unkown whether CPC kyphoplasty causes degeneration of adjacent disks in adolescents. DESIGN: Seven adolescents with thoracolumbar spine fractures underwent kyphoplasty at a mean age of 14.5 years (range 10-18). At a mean follow-up of 3.7 years (range 1 to 4.8) postoperatively, 3.0 Tesla magnetic resonance imaging (MRI) of the spine was performed to assess intervertebral disk degeneration by quantitative T2 relaxation maps and subjective ratings using modified Pfirrmann scores. A total of 56 intervertebral disks was analyzed. Initial computed tomography (CT) examinations served as basis to assess the severity of adjacent endplate injuries in terms of articular step-offs. RESULTS: Initial imaging detected 18 thoracolumbar vertebral body fractures of which 9 were treated with CPC kyphoplasty. Quantitative follow-up MRI revealed signs of degeneration in 10 (17.9%) of the examined 56 intervertebral disks, 7 of them adjacent to a previously fractured vertebral body. Signs of disk degeneration were significantly higher in caudal endplates with articular step-offs larger than 5 mm compared to fractured vertebral bodies without endplate step-offs. CONCLUSIONS: Quantitative MRI follow-ups did not suggest CPC-related intervertebral disk degradations following thoracolumbar kyphoplasty in adolescents, but indicated disk alterations correlating to adjacent endplate fracture severity.

Therapy preference of 131 parents confronted with a pediatric femoral fracture.

Background: The management of femoral fractures in children between 3 and 5 years of age is still vividly debated. Therefore, we aimed to assess the basic attitude of parents if confronted with a hypothetical femoral fracture of their toddler. Materials and methods: Parents of children aged between 12 and 36 months were asked for their preference after receiving detailed information on conservative and surgical treatment of femoral shaft fractures. Furthermore, we obtained information regarding the parents' gender, marital status, medical background, highest level of education and profession in a leading or non-leading position and if any of their children already had undergone any operations. The Freiburg Personality Inventory (FPI-R) questionnaire was used to assess parents' personality traits. Results: In total, 131 participants were included in this study. The vast majority (n = 116, 88.5%) preferred surgical treatment. The most frequently mentioned reasons for this decision were lack of acceptance, followed by faster reconvalescence, shorter hospital stay, less deformity or growth disorders and less stress on the child. The only reason stated against surgical treatment was the need of general anesthesia. A significantly higher rate of conservative procedures was noticed in self-employed participants and stress was found to significantly influence the treatment decision of the parents toward conservative treatment. Conclusion: The majority of parents confronted with a hypothetical femoral fracture of their child questioned in this study opted for a surgical approach with elastic stable intramedullary nailing (ESIN). This corresponds with trends toward surgery in these cases in major trauma centers in Europe.

Tryptophan recovery index as a new biomarker for fitness.

The maximal oxygen uptake (VO2max) and maximal power output (Pmax) are commonly used parameters to evaluate the endurance fitness status. A connection between exercise and the kynurenine pathway (KP), which describes the metabolism of unused tryptophan, has already been reported. However, a potential association of the KP with endurance fitness levels remains unknown. In this study, adolescent competitive athletes performed an exhaustive incremental exercise test. Blood samples were taken before, directly after, and 30 minutes after the end of exercise. Tryptophan (Trp), kynurenine (Kyn) and kynurenic acid (KA) serum levels were determined by high-performance liquid chromatography (HPLC). Forty-four male and 27 female athletes (median age: 16 years) were recruited. During exhaustive exercise tests, Trp initially declined and then increased 30 minutes after discontinuing exercise. Similar findings were observed for Kyn, whereas KA levels behaved inversely. After incremental exhaustive exercise the relative increase of Trp concentrations, termed the tryptophan-recovery-index (TRI), showed a highly significant positive correlation with VO2max and Pmax (r=0.468 and 0.491, p-values <0.001). There was a significant gender-difference with higher levels of all metabolites at all measured time points in male participants. In the present study, a highly significant correlation was found between the TRI and the maximal oxygen uptake in well-trained athletes. The implementation of TRI can therefore be suggested as a biomarker for physical fitness.

The Management of Asymptomatic Congenital Pulmonary Airway Malformation: Results of a European Delphi Survey.

Consensus on the optimal management of asymptomatic congenital pulmonary airway malformation (CPAM) is lacking, and comparison between studies remains difficult due to a large variety in outcome measures. We aimed to define a core outcome set (COS) for pediatric patients with an asymptomatic CPAM. An online, three-round Delphi survey was conducted in two stakeholder groups of specialized caregivers (surgeons and non-surgeons) in various European centers. Proposed outcome parameters were scored according to level of importance, and the final COS was established through consensus. A total of 55 participants (33 surgeons, 22 non-surgeons) from 28 centers in 13 European countries completed the three rounds and rated 43 outcome parameters. The final COS comprises seven outcome parameters: respiratory insufficiency, surgical complications, mass effect/mediastinal shift (at three time-points) and multifocal disease (at two time-points). The seven outcome parameters included in the final COS reflect the diversity in priorities among this large group of European participants. However, we recommend the incorporation of these outcome parameters in the design of future studies, as they describe measurable and validated outcomes as well as the accepted age at measurement.

Reliability of radiological measurements and treatment recommendations of displaced paediatric humeral medial epicondyle fractures.

There are conflicting recommendations regarding the amount of displacement necessitating stabilization of paediatric humeral medial epicondyle fractures. Our aim was to assess the reliability of the measurements of the displacement and the treatment recommendations of these fractures. The maximum displacement of 57 children with displaced humeral medial epicondyle fractures was analyzed on radiographs by six raters (4 paediatric surgeons, 2 paediatric radiologists) at two time points. In addition, the four surgeons recorded their treatment recommendation. Intraobserver and interobserver reliability were calculated with intraclass correlation coefficients (ICC) and Kappa values. The ICC for the intraobserver reliability ranged between 0.67 and 0.93. The raters disagreed with their own measurements between 8.8% and 28.1%. The ICC for the interobserver reliability of all six raters was 0.90 for measurement 1 and 0.93 for measurement 2. All six raters disagreed (difference > 2mm) in 93% of the cases in measurement 1 and in 91.2% in measurement 2. Treatment recommendations of the four paediatric surgeons between the two time points differed in 5.3% to 28.1% of the cases. Furthermore, the treatment recommendations were concordant in 24 cases (42%) at time point 1 and 32 cases (56.1%) at time point 2. In displaced paediatric medial epicondyle fractures, disagreement regarding measurement of displacement and recommendation for treatment is high. Validated and standardized measurement tools and a clear threshold for operative fixation of displaced medial epicondyle fractures are needed.