[Latent safety threats in a pediatric emergency department: Using in situ simulation to test a new trauma room concept]. / Latente Sicherheitsmängel in einer pädiatrischen Notaufnahme: Testung eines neuen Schockraumkonzepts mithilfe von In-situ-Simulation.

INTRODUCTION: Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital. METHODS: Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e.g., lack of equipment, unfavorable positioning of material), process (e.g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined. RESULTS: A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1%) were assigned to the "working environment" category, 20 (39.2%) to the "process" category and 9 (17.7%) to the "other safety threats" category. Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard. DISCUSSION: With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department.

Incidence, treatment techniques, and results of distal humeral coronal shear fractures in children and adolescents-a multicenter study of the German Section of Pediatric Traumatology (SKT).

PURPOSE: Distal humeral coronal shear fractures (CSF) are uncommon and may be challenging to treat due to their size, location, and intraarticular nature. The purpose of this study was to analyze treatment concepts of this rare entity in the growing age. METHODS: Based on a multi-center data analysis we retrospectively reviewed patients below 16 years of age with CSF treated at 13 high-volume pediatric trauma centers. RESULTS: Data from 51 patients with a CSF treated between 01/2012 and 12/2021 were analyzed. The mean age was 12.9 years (10-15), and there was a trend towards male patients (30: 21). The initial diagnostic approach was conventional X-ray in all cases. In addition, a CT scan (n = 33), MRI scan (n = 9), or both (n = 3) were performed. All fractures except two showed relevant displacement. Consequently, only two cases received conservative treatment consisting of plaster immobilization. Surgical treatment was performed in 49 cases consisting of open or mini-open reduction and metal/resorbable screw osteosynthesis (n = 39), plates (n = 4), K-wire pinning (n = 6), and others (n = 6), as well as combinations. In 1 case open reduction without osteosynthesis was performed. Postoperative additional plaster immobilization was performed in 40 cases (for a mean of 19 days (2-42)), physiotherapy was initiated in 29 cases, and metal removal was performed in 28 cases (after a mean of 18.1 weeks (4-44)). After a mean follow-up of 9.9 months (2-25), elbow axial deviation (5° valgus) was observed in one case and mild loss of elbow ROM in six cases (11.7%). Complications included revision of the osteosynthesis because of insufficient articular reconstruction (n = 4), removal of a free joint body (n = 1), an osteonecrosis (n = 1), and a cartilage defect (n = 1). CONCLUSION: In pediatric patients CSFs start to occur at the age of 10, but are typically observed at the age of 13 and older. Because of their intraarticular nature and predilection toward displacement, these fractures are frequently treated operatively. The surgical strategy requires open reduction and anatomic reconstruction of the articular surface. Stable internal fixation, most often achieved by screws, permits early mobilization and leads to good outcomes in most cases. This is presumably due to the fact that mostly simple fractures occur in children and mostly complex injuries in older adults. LEVEL OF EVIDENCE: III, retrospective analysis.

Failure analysis and recommendations for treatment of posttraumatic non-unions of the distal humerus during childhood.

PURPOSE: Non-unions of the distal humerus are rare complications of common children's fractures such as radial condyle fractures and supracondylar fractures. The aim of this paper was to update the knowledge about etiology, reasons, management, and results of these troublesome, and sometimes debilitating entities. METHODS: The sparse literature concerning nonunions following condylar or supracondylar fractures was analyzed together with the presentation of some typical clinical cases. RESULTS: In most of the cases, non-unions were induced by neglect, unstable fixation, too early implant removal, too much revision surgery, and an inconsequent transfer of follow-up algorithms, or combinations of the above. Treatment of non-union should start as early as possible because the effort of required surgery increases with time that the nonunion has been neglected. Often a combination of stable fixation of the pseudarthrosis and correction of the elbow axis are necessary to achieve a satisfying outcome. CONCLUSION: In pediatric traumatology, qualified and consequent care for children's fractures of the distal humerus can prevent rare complications such as non-unions in almost any situation. If such a disturbance of healing is noticed, immediate and adequate, i.e. children specific surgical consequences achieve best results.

[Ankle fractures in children and adolescents]. / Sprunggelenkfrakturen im Kindes- und Jugendalter.

In children and adolescents, injuries of the ankle are seen frequently in routine practice. The fracture pattern is less dependent on the mechanism of injury than on the maturity of the growth plate. Therefore, a differentiation is made between fractures with open epiphyses and fractures with a closing growth plate in adolescents. The potential for growth-related spontaneous deformity correction is limited, so axial alignment especially in the frontal plane has to be achieved during initial treatment. In displaced articular fractures an anatomical reconstruction of the articular surface and stable osteosynthesis have to be achieved to minimize the risk of early osteoarthritis. Growth arrest is not always avoidable despite an ideal reconstruction and can occur in all fracture types; however, with optimal conservative or surgical treatment, iatrogenic damage of the epiphysis can be avoided thereby reducing the incidence of growth disorders as a complication of ankle fractures in children and growing adolescents.

A comparison of intervention and conservative treatment for angulated fractures of the distal forearm in children (AFIC): study protocol for a randomized controlled trial.

BACKGROUND: Angulated fractures of the distal forearm are very frequent lesions in childhood. Currently, there are no standard guidelines on whether these children should be treated conservatively with a cast; with reduction and a cast; or with reduction, pinning and a cast under anesthesia. Minor prospective and retrospective studies have shown that the distal physis of the forearm possesses high remodeling capacity leading to reliable correction of malalignment. The aim of this trial is to answer the question about whether operative and conservative treatment show equivocal results. METHODS/DESIGN: This is a prospective, multinational, multicenter, randomized, observer-blinded, actively controlled, parallel group trial, with 24 months of observation. The primary objective of this trial is to assess whether or not the long-term functional outcome in remodeling patients is inferior to patients receiving closed reduction and K-wire pinning. The trial should include 742 patients with acute fracture. The patients will be included in 30 medical centers in Germany, Switzerland and Austria. All patients 5 to 11 years of age presenting at the emergency department with an angulated distal fracture of the forearm will be randomized online after informed consent. The primary endpoint is the Cooney Score after 24 months. The secondary endpoint is the grade of radiological displacement at 12/24 months. DISCUSSION: Therapy of angulated fractures is a matter of intensive debate. Primary manipulation and pinning under general anesthesia is recommended in order to avoid malalignment. No major study has proven the advantage of manipulation and pinning over immobilization alone. Should remodeling appear to be a safe alternative, manipulation under general anesthesia, K-wire pinning and removal of pins could be avoided, thus sparing significant costs. TRIAL REGISTRATION: DRKS00004874 , 30 October 2013.

Mucosal loss with increased expression of IL-6, IL-8, and COX-2 in a formula-feeding only neonatal rat model of necrotizing enterocolitis.

INTRODUCTION: The aim of our study is to establish a reliable neonatal rat model by formula feeding only for evaluation of early surgical intervention on the course of experimental necrotizing enterocolitis (NEC). MATERIAL AND METHODS: Newborn Sprague-Dawley rats were divided into 50 breast-fed (group 1) and 38 formula fed (Similac/Esbilac, group 2) animals. The pups were sacrificed on the 4th, 5th, and 6th day of life and the terminal intestine examined for macroscopic and histologic changes as well as cytokine expression. RESULTS: The histological mucosal damage was significantly higher of group 2 compared to group 1. The area of the vital mucosa of group 2 was significantly (58.57%, p<0.001) lower compared to group 1 (75.12%). The mRNA expression of the inflammatory cytokines IL-6, IL-8 and COX-2 was significantly 2-, 5- and 10-fold increased in group 2 compared to group 1. DISCUSSION: Formula fed newborn rats displayed an inflammatory enterocolitis similar to human NEC. Our study demonstrates a significant loss of mucosa in animals with NEC having increased expression levels of IL-6, IL-8 and COX-2. Mucosal loss appears to be a distinct feature of experimental NEC and has to be correlated with the human disease.

Identifying children and adolescents with cognitive dysfunction following mild traumatic brain injury--preliminary findings on abbreviated neuropsychological testing.

OBJECTIVE: Studies on cognitive function in paediatric patients suffering head trauma suggest neuropsychological impairment even after mild traumatic brain injury (MTBI). The present study examined the feasibility of abbreviated neuropsychological testing in different settings in children and adolescents following MTBI. METHODS: Within the scope of two prospective studies on psychosocial and cognitive outcome, 71 school-aged children with mild, moderate or severe TBI were assessed. In addition, 15 healthy children were included in the study. The abbreviated instrument comprises three standardized tests measuring attention and memory functions (Digit Symbol, Digit Span, learning trials of the German Auditory Verbal Learning Test). Impairment rates were calculated according to a defined cut-off score for clinically significant cognitive impairment. RESULTS: Abbreviated testing could easily be implemented both in the acute and post-acute clinical setting. Out of the children with MTBI, 12% (shortly after injury) and 30% (2 months after injury), respectively, were classified as cognitively impaired. Following moderate or severe TBI, impairment occurred in 50% of the patients. Healthy children showed the best performance, while children with severe TBI performed worst. CONCLUSION: Results suggest that abbreviated testing allows detection of MTBI-related cognitive dysfunction. Identified children should be referred to a clinical neuropsychologist for comprehensive assessment.

[Arthroscopically assisted internal fixation of avulsion fractures of the anterior cruciate ligament during childhood and adolescence]. / Die arthroskopisch assistierte Refixation bei knöchernen Ausrissen des vorderen Kreuzbands im Kindes- und Jugendalter.

OBJECTIVE: Minimally invasive reduction and internal fixation of anterior tibial spine and anterior cruciate ligament (ACL) without harming knee joint cartilage and physis of the proximal tibia. INDICATIONS: Anterior tibial spine fractures type II-IV according to Meyers/McKeever. CONTRAINDICATIONS: ACL tears. Fractures of the tibial plateau. Fractures involving the growth plate (Aitken I-III). SURGICAL TECHNIQUE: 1. Diagnostic arthroscopy and drainage of the knee joint. Search for additional injuries (menisci, knee joint cartilage, collateral ligaments, posterior cruciate ligament). 2. Arthroscopy-assisted reduction of anterior tibial spine fragment. 3. Epiphyseal internal fixation with Kirschner wires or cannulated screws according to fragment size. POSTOPERATIVE MANAGEMENT: Full weight bearing as tolerated after wound healing (day 7 after surgery) in 20 degrees of knee flexion (orthesis or ankle-sparing cast tutor). X-rays postoperatively and after 3 and 6 weeks. Passive and active physiotherapy (extension and flexion without weight bearing) 3-4 weeks postoperatively according to patient's age, weight and compliance. Weight bearing in knee flexion (stairs) 6-8 weeks postoperatively. RESULTS: 19 patients were treated from 2001 to 2005 at an age of 7-14 years. All patients achieved free range of motion without pain or growth disturbances. Three patients developed slight joint laxity (anterior drawer test) which did not affect mobility, sports performance, joint surface or menisci on clinical evaluations conducted at least 1 year postoperatively. One patient had bony healing of the tibial spine in slight dislocation without impingement or decrease of range of motion within the knee joint.

Does the evocation of traumatic memories confound subsequent working memory performance in posttraumatic stress disorder (PTSD)?

The role of heightened arousal has been previously discussed as a contributor to neurocognitive impairment in posttraumatic stress disorder (PTSD). To investigate whether psychological effects (distraction, re-location of resources) elicited by the evocation of traumatic memories impact on subsequent cognitive performance in PTSD, two parallel versions of a working memory task were administered to 33 trauma-exposed participants (15 with and 18 without PTSD). Between first and second working memory assessment a trauma-related interview was conducted including the narration of the trauma. Levels of working memory impairment in PTSD patients remained unchanged. This study provides preliminary evidence that neurocognitive impairment is not secondary to psychological effects induced by the evocation of traumatic memories. Nevertheless, it is recommended that future PTSD research should devote more care to the order in which trauma-related and other dependent variables such as cognitive tests are presented to participants.

Proline-rich transcript of the brain (prtb) is a serum-responsive gene in osteoblasts and upregulated during adhesion.

To characterize the temporal expression of genes that play a functional role during the process of osteoblast adhesion, we used differential display (DD-PCR) on mRNA isolated from attached vs. suspended osteoblasts. A 200-bp fragment displaying upregulated expression after 30 and 60 min adhesion was isolated, sequenced, and showed 97% homology to prtb, previously showed to be expressed in mouse brain. Northern analysis confirmed a two-fold increase in prtb message during adhesion to tissue culture polystyrene, both in the presence or absence of surface-adsorbed serum proteins. Serum stimulation alone was also able to induce prtb expression, although to a lesser extent, in suspension cells. Strong prtb expression was also detected in both brain and bone of adult rats. Furthermore, prtb expression analysis during MC3T3-E1 cell differentiation revealed high expression levels independent of proliferation (day 0-7), matrix maturation (day 7-14), and mineralization (day 14-31). Time course analysis of prtb expression during adhesion of sensitized osteoblasts to serum-protein coated surfaces showed robust mRNA expression at 5 min post-plating and a peak at 10 min. The two known serum-inducible immediate early genes c-fos and c-jun showed similar expression kinetics, with c-jun mRNA levels peaking at 15 min and c-fos at 20 min. Based on these data, we hypothesize that prtb may function as an immediate early, serum-responsive, and adhesion-inducible gene with possible involvement in processes such as cell cycle control, adhesion, and proliferation.