Pediatric Hand Fracture Outcomes: How Often Do We Need to Operate?

Purpose: Pediatric hand fractures are frequent presentations to the emergency department. This study set out to evaluate the epidemiology, management, and outcomes, where care was imparted and by whom, and offer resource utilization suggestions regarding pediatric fractures presenting to a Canadian pediatric hospital. Methods: Records of patients from 0 to 18 years of age who presented to the British Columbia Children's Hospital Emergency Department between November 1, 2016, and January 31, 2021, with metacarpal or phalangeal fractures were analyzed. Results: A total of 524 hand fractures were identified in 499 patients. Over 60% of fractures occurred in boys. The number of fractures peaked at the age of 11 years for girls and 12 years for boys. Open fractures accounted for only 4.0% of all fractures. Approximately 40% of fractures were epiphyseal growth plate fractures, with Salter-Harris II fractures being the most common diagnosis overall. Management was primarily nonsurgical, with 75% of fractures managed with immobilization alone and 23% of fractures managed with bedside closed reduction and immobilization. Of the fractures requiring closed reduction, the majority were performed by the emergency physician with a success rate of 82%. Only 2.3% of all fractures required surgery. Conclusions: Hand fractures are common pediatric injuries and make up a large proportion of emergency room visits. The majority of fractures do not require formal surgery and are well managed with immobilization alone or closed reduction by an emergency room physician and immobilization. Nonsurgical treatment offers very encouraging outcomes. A certain percentage of these simple fractures would likely benefit from primary care management alone and not require specialist intervention.

Objectif : Les fractures de main de l'enfant sont des situations fréquemment rencontrées dans les services d'urgence. Cette étude a été menée pour évaluer l'épidémiologie, la gestion et les résultats, où les soins ont été transmis et par qui, et pour offrir des suggestions d'utilisation des ressources concernant les fractures pédiatriques arrivant dans un hôpital canadien pour enfants. Méthodes : Les dossiers des patients âgés de 0 à 18 ans arrivés au service des urgences de l'hôpital pour enfants de Colombie-Britannique avec une fracture métacarpienne ou phalangienne entre le 1er nov. 2016 et le 31 janvier 2021 ont été analysés. Résultats : Un total de 524 fractures de la main a été identifié chez 499 patients. Plus de 60 % des fractures concernaient des garçons. Le nombre de fractures était maximum à l'âge de 11 ans pour les filles et de 12 ans pour les garçons. Les fractures ouvertes représentaient seulement 4,0 % de toutes les fractures. Approximativement 40 % des fractures concernaient la plaque de croissance épiphysaire avec les fractures Salter-Harris II constituant globalement le diagnostic le plus fréquent. La gestion a été principalement non chirurgicale : 75 % des fractures ont été gérées par immobilisation seule et 23 % des fractures ont été gérées par réduction fermée au chevet des patients et immobilisation. La majorité des réductions fermées pour fracture a été réalisée par le médecin des urgences avec un taux de succès de 82 %. Seulement 2,3 % de toutes les fractures ont nécessité une intervention chirurgicale. Conclusions : Les fractures de la main sont des blessures pédiatriques fréquentes et constituent une proportion importante des visites aux urgences. La majorité des fractures ne nécessite pas de chirurgie et est bien gérée avec seulement une immobilisation ou une réduction fermée suivie d'une immobilisation par le médecin des urgences. Le traitement non chirurgical obtient des résultats très encourageants. Un certain pourcentage de ces fractures simples relèverait probablement d'une gestion en soins primaires uniquement et ne nécessitent pas l'intervention d'un spécialiste.

Publicly funded healthcare costs associated with orofacial clefts for children born in Alberta, Canada between 2002 and 2018.

BACKGROUND: Orofacial clefts (OFCs) include cleft palate (CP), cleft lip (CL), and cleft lip with cleft palate (CLP) and require multidisciplinary healthcare services. Alberta, Canada has a publicly funded, universal access healthcare system. This study determined publicly funded healthcare costs for children with an OFC and compared these costs to children without congenital anomalies. METHODS: This retrospective population-based cohort analysis used the Alberta Congenital Anomalies Surveillance System to identify children born between 2002 and 2018 with an isolated OFC. They were matched 1:1 to a reference cohort based on sex and year of birth. The study population included 1614 children, from birth to 17 years of age linked to administrative databases to estimate annual inpatient and outpatient costs. Average annual all-cause costs were compared using two-sample independent t tests. RESULTS: The mean total cleft-related costs per patient were highest for children with CLP ($74,138 CAD, standard deviation (SD) $43,447 CAD), followed by CP ($53,062 CAD, SD $74,366 CAD), and CL ($35,288 CAD, SD $49,720 CAD). The mean total all-cause costs per child were statistically significantly higher (p < .001) in children with an OFC ($56,305 CAD, SD $57,744 CAD) compared to children without a congenital anomaly ($18,600 CAD, SD $61,300 CAD). CONCLUSIONS: Despite public health strategies to mitigate risk factors, the trend for OFCs has remained stable in Alberta, Canada for over 20 years. The costs reported are useful to other jurisdictions for comparison, and to families, healthcare professionals, service planners, and policy makers.

The Alberta Congenital Anomalies Surveillance System: a 40-year review with prevalence and trends for selected congenital anomalies, 1997-2019. / Le système de surveillance des anomalies congénitales de l'Alberta : compte rendu des données sur 40 ans avec prévalence et tendances de certaines anomalies congénitales entre 1997 et 2019.

INTRODUCTION: Current published long-term provincial or territorial congenital anomaly data are lacking for Canada. We report on prevalence (per 1000 total births) and trends in 1997-2019, in Alberta, Canada, for selected congenital anomalies. Associated risk factors are also discussed. METHODS: We used data from the Alberta Congenital Anomalies Surveillance System (ACASS) to calculate the prevalence and perform chi-square linear trend analyses. RESULTS: From 1997 to 2019, the overall prevalence of neural tube defects was stable, at 0.74 per 1000 total births. The same was true for spina bifida (0.38), orofacial clefts (1.99), more severe CHDs (transposition of the great arteries, 0.38; tetralogy of Fallot, 0.33; and hypoplastic left heart syndrome, 0.32); and gastroschisis (0.38). Anencephaly, cleft palate and anorectal malformation significantly decreased with a prevalence of 0.23, 0.75 and 0.54 per 1000 total births, respectively. Significantly increasing trends were reported for anotia/microtia (0.24), limb reduction anomalies (0.73), omphalocele (0.36) and Down syndrome (2.21) and for hypospadias and undescended testes (4.68 and 5.29, respectively, per 1000 male births). CONCLUSION: Congenital anomalies are an important public health concern with significant social and societal costs. Surveillance data gathered by ACASS for over 40 years can be used for planning and policy decisions and the evaluation of prevention strategies. Contributing genetic and environmental factors are discussed as is the need for continued surveillance and research.

Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway.

OBJECTIVE: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. DESIGN: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). PATIENTS: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. INTERVENTIONS: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. MAIN OUTCOME MEASURES: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. RESULTS: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 µg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. CONCLUSIONS: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.

Derivation and Internal Validation of a Prediction Model for Pediatric Hand Fracture Triage.

BACKGROUND: Pediatric hand fractures are common, and most can be managed by a period of immobilization. However, it remains challenging to identify those more complex fractures requiring the expertise of a hand surgeon to ensure a good outcome. The purpose of this study was to develop a prediction model for identification of complex pediatric hand fractures requiring care by a hand surgeon. METHODS: A 2-year retrospective cohort study of consecutively referred pediatric (<18 years) hand fracture patients was used to derive and internally validate a prediction model for identification of complex fractures requiring the expertise of a hand surgeon. These complex fractures were defined as those that required surgery, closed reduction, or four or more appointments with a hand surgeon. The model, derived by multivariable logistic regression analysis, was internally validated using bootstrapping and then translated into a risk index. RESULTS: Of 1170 fractures, 416 (35.6%) met criteria for a complex fracture. Multivariable regression analysis identified six significant predictors of complex fracture: open fracture, rotational deformity, angulation, condylar involvement, dislocation or subluxation, and displacement. Internal validation demonstrated good performance of the model (C-statistic = 0.88, calibration curve p = 0.935). A threshold of ≥1 point (ie, any one of the predictors) resulted in a simple, easy-to-use tool with 96.4% sensitivity and 45.5% specificity. CONCLUSIONS: A high-performing and clinically useful decision support tool was developed for emergency and urgent care physicians providing initial assessment for children with hand fractures. This tool will provide the basis for development of a clinical care pathway for pediatric hand fractures.

Evaluating CNVII Recovery after Reconstruction with Vascularized Nerve Grafts: A Retrospective Case Series.

Few studies have evaluated vascularized nerve grafts (VNGs) for facial nerve (CNVII) reconstruction. We sought to evaluate long-term outcomes for CNVII recovery following reconstruction with VNGs. A retrospective review of all patients at a tertiary centre who underwent radical parotidectomy and immediate CNVII reconstruction with VNGs was performed (January 2009-December 2019). Preoperative demographics, perioperative factors (flap type, source of VNGs), and postoperative factors [complications, adjuvant therapy, revisionary procedures, length of follow-up, and CNVII function via the House-Brackmann scale (HB)] were collected. Data were summarized qualitatively. Twelve patients (Mage = 53 ± 18 years) with a mean follow-up of 33 (± 23) months were included. Six patients underwent reconstruction with a radial forearm flap and dorsal sensory branches of the radial nerve. Six patients underwent reconstruction with an anterolateral thigh flap and only deep motor branches of the femoral nerve to the vastus lateralis (n = 4) or combined with the lateral femoral cutaneous nerve (n = 2). Two patients regained nearly normal function (HB = 2). Eight patients regained at least resting symmetry (HB = 3 for n = 7; HB = 4 for n = 1). One patient regained a flicker of movement (HB = 5). One patient did not regain function (HB = 6). Six patients had static revision procedures to improve symmetry. Five patients had disease recurrence; 3 died from their disease. VNGs offer a practical and viable addition to the CNVII reconstruction strategy, and result in good functional recovery with acceptable donor site deficits. The associated adipofascial component of these flaps can also augment the soft tissue defect left after tumor ablation.

"You Helped Create This, Help Me Now": A Qualitative Analysis of Patients' Concerns about Breast Implants and a Proposed Strategy for Moving Forward.

BACKGROUND: Some women with breast implants express concern about the safety of implants, fearing the possibility of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant-related illness. METHODS: A qualitative analysis was performed to examine the perceived challenges, barriers, and worries experienced by these women. Convenience sampling was used to elicit responses from members of Canadian BIA-ALCL Facebook advocacy groups. Three independent coders read and reread the transcripts, using thematic analysis to identify emerging themes. RESULTS: Sixty-four women answered questions posed by the president of the Canadian Society of Plastic Surgeons regarding concerns about their breast implants. Five themes were identified: informing, listening, acknowledging, clarifying, and moving forward. Patients desire improved communication about possible risks before implantation and as new information becomes available (informing), sincere listening to their concerns (listening), acknowledgement that these disease entities may be real and have psychosocial/physical impact on patients (acknowledging), clarification of implant-related problems and their treatment (clarifying), and improved processes for monitoring and treatment of patients with identified problems (moving forward). Consideration of these themes in the context of the five domains of trust theory (i.e., fidelity, competence, honesty, confidentiality, and global trust) suggests significant breakdown in the doctor-patient relationship for a subset of concerned women. CONCLUSIONS: Concerns related to BIA-ALCL and breast implant-related illnesses have undermined some women's trust in plastic surgeons. Consideration of these five themes and their impact on the five domains of trust can guide strategies for reestablishing patients' trust in the plastic surgery community.

Automated syndrome diagnosis by three-dimensional facial imaging.

PURPOSE: Deep phenotyping is an emerging trend in precision medicine for genetic disease. The shape of the face is affected in 30-40% of known genetic syndromes. Here, we determine whether syndromes can be diagnosed from 3D images of human faces. METHODS: We analyzed variation in three-dimensional (3D) facial images of 7057 subjects: 3327 with 396 different syndromes, 727 of their relatives, and 3003 unrelated, unaffected subjects. We developed and tested machine learning and parametric approaches to automated syndrome diagnosis using 3D facial images. RESULTS: Unrelated, unaffected subjects were correctly classified with 96% accuracy. Considering both syndromic and unrelated, unaffected subjects together, balanced accuracy was 73% and mean sensitivity 49%. Excluding unrelated, unaffected subjects substantially improved both balanced accuracy (78.1%) and sensitivity (56.9%) of syndrome diagnosis. The best predictors of classification accuracy were phenotypic severity and facial distinctiveness of syndromes. Surprisingly, unaffected relatives of syndromic subjects were frequently classified as syndromic, often to the syndrome of their affected relative. CONCLUSION: Deep phenotyping by quantitative 3D facial imaging has considerable potential to facilitate syndrome diagnosis. Furthermore, 3D facial imaging of "unaffected" relatives may identify unrecognized cases or may reveal novel examples of semidominant inheritance.

Surgical and Nonsurgical Pediatric Hand Fractures: A Cohort Study.

Pediatric hand fractures are common and approximately 10% require surgery. METHODS: This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A χ2 analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied. RESULTS: One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter-Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2 mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%). CONCLUSIONS: Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.

Comparing the Efficacy of Triple Nerve Transfers with Nerve Graft Reconstruction in Upper Trunk Obstetric Brachial Plexus Injury.

BACKGROUND: Upper trunk obstetric brachial plexus injury can cause profound shoulder and elbow dysfunction. Although neuroma excision with interpositional sural nerve grafting is the current gold standard, distal nerve transfers have a number of potential advantages. The goal of this study was to compare the clinical outcomes and health care costs between nerve grafting and distal nerve transfers in children with upper trunk obstetric brachial plexus injury. METHODS: In this prospective cohort study, children who underwent triple nerve transfers were followed with the Active Movement Scale for 2 years. Their outcomes were compared to those of children who underwent nerve graft reconstruction. To assess health care use, a cost analysis was also performed. RESULTS: Twelve patients who underwent nerve grafting were compared to 14 patients who underwent triple nerve transfers. Both groups had similar baseline characteristics and showed improved shoulder and elbow function following surgery. However, the nerve transfer group displayed significantly greater improvement in shoulder external rotation and forearm supination 2 years after surgery (p < 0.05). The operative time and length of hospital stay were significantly lower (p < 0.05), and the overall cost was approximately 50 percent less in the nerve transfer group. CONCLUSION: Triple nerve transfer for upper trunk obstetric brachial plexus injury is a feasible option, with better functional shoulder external rotation and forearm supination, faster recovery, and lower cost compared with traditional nerve graft reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Charts versus Discharge ICD-10 Coding for Sternal Wound Infection Following Coronary Artery Bypass Grafting.

BACKGROUND: Sternal wound infection (SWI) in patients undergoing coronary artery bypass grafting (CABG) can carry a significant risk of morbidity and mortality. The objective of this work is to describe the methods used to identify cases of SWI in an administrative database and to demonstrate the effectiveness of using an International Classification of Diseases, Tenth Revision (ICD-10) coding algorithm for this purpose. METHODS: ICD-10 codes were used to identify cases of SWI within one year of CABG between April 2002 and November 2009. We randomly chose 200 charts for detailed chart review (100 from each of the groups coded as having SWI and not having SWI) to determine the utility of the ICD-10 coding algorithm. RESULTS: There were 2,820 patients undergoing CABG. Of these, 264 (9.4 percent) were coded as having SWI. Thirty-eight cases of SWI were identified by chart review. The ICD-10 coding algorithm of T81.3 or T81.4 was able to identify incident SWI with a positive predictive value of 35 percent and a negative predictive value of 97 percent. The agreement between the ICD-10 coding algorithm and presence of SWI remained fair, with an overall kappa coefficient of 0.32 (95 percent confidence interval, 0.22-0.43). The effectiveness of identifying deep SWI cases is also presented. CONCLUSIONS: This article describes an effective algorithm for identifying a cohort of patients with SWI following open sternotomy in large databases using ICD-10 coding. In addition, alternative search strategies are presented to suit researchers' needs.

Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction.

BACKGROUND: Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction. METHODS: Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups. RESULTS: Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation. CONCLUSIONS: A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Beta-blockers for the treatment of problematic hemangiomas.

OBJECTIVE: To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas. METHODS: A retrospective review of patients with hemangiomas presenting to the Alberta Children's Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy. RESULTS: Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%). CONCLUSIONS: Treatment of infantile hemangiomas with oral beta-blocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment.

OBJECTIF: Examiner les indications thérapeutiques, l'efficacité et les effets secondaires des bêtabloquants par voie orale pour traiter les hémangiomes problématiques. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des patients ayant des hémangiomes qui ont consulté à la clinique des angiomes vasculaires de l'Alberta Children's Hospital de Calgary, en Alberta, entre 2009 et 2011. Le sous-groupe de patients traités à l'aide de bêtabloquants par voie orale était caractérisé de manière plus détaillée, puisqu'on examinait l'indication thérapeutique, la réponse au traitement, le délai jusqu'à la résolution de l'indication, la durée du traitement, l'occurrence d'une excroissance de rebond et les effets secondaires du traitement. RÉSULTATS: Entre 2009 et 2011, 311 nouveaux patients ayant des hémangiomes ont consulté, dont 105 ont été traités à l'aide de bêtabloquants par voie orale. Quarante-cinq patients ont terminé le traitement, tandis que les autres continuent d'être traités. Les indications thérapeutiques étaient des préoccupations d'ordre fonctionnel (68,6 %) ou le préjudice esthétique (31,4 %). Les préoccupations d'ordre fonctionnel incluaient une ulcération (29,5 %), un foyer périoculaire avec un potentiel d'interférence visuelle (28,6 %), une interférence avec les voies aériennes (4,8 %), un syndrome PHACES (3,8 %), une interférence auditive (0,95 %) et un foyer viscéral avec une insuffisance cardiaque congestive (0,95 %). Les patients avaient un âge médian de 3,3 mois au début du traitement aux bêtabloquants, et le traitement avait une durée médiane de 10,6 mois. La dose maximale médiane du traitement était de 1,5 mg/kg/jour s'ils prenaient du propranolol et de 1,6 mg/kg/jour s'ils prenaient de l'aténolol. Quatre-vingt-dix-neuf patients (94,3 %) ont répondu au traitement par une diminution de la dimension, un changement de la couleur, une amélioration de la texture ou une guérison de l'ulcération. Chez 23 patients, une excroissance de rebond a exigé une cure supplémentaire. Les effets secondaires des bêtabloquants incluaient des membres froids (26,7 %), l'irritabilité (17,1 %), des troubles du bas de l'intestin (14,3 %), des vomissements (11,4 %), une hypotension (10,5 %), une alimentation insuffisante (7,6 %), une léthargie (4,8 %), un bronchospasme (0,95 %) et une éruption (0,95 %). Les effets secondaires n'ont jamais suscité l'interruption complète du traitement aux bêtabloquants, mais ont parfois donné lieu à un transfert vers une nouvelle préparation de bêtabloquants. Chez 87 patients (82,9 %), les chercheurs ont constaté la résolution de l'indication primaire, dans un délai médian de trois mois. CONCLUSIONS: Le traitement des hémangiomes infantiles à l'aide de bêtabloquants par voie orale est très efficace et bien toléré. En effet, plus de 94 % des patients répondent au traitement et 90 % présentent une résolution de l'indication thérapeutique fonctionnelle primaire.

Principles of rotationplasty.

Rotationplasty is a reconstructive, limb-sparing option for management of lower extremity bone deficiency. This technique involves an intercalary resection, followed by 180° rotation of the distal limb to allow the ankle to function as a knee joint when it is fitted with a modified below-knee prosthesis. Gait analysis and functional outcome studies have reported favorable results with rotationplasty compared with those of above-knee amputation. Moreover, patient satisfaction with rotationplasty is higher than with other limb salvage procedures. The primary drawback of this procedure is patient acceptance of the limb's appearance.

The opportunities and obstacles in developing a vascular birthmark database for clinical and research use.

INTRODUCTION: Databases are useful tools in clinical settings. The authors review the benefits and challenges associated with the development and implementation of an efficient electronic database for the multidisciplinary Vascular Birthmark Clinic at the Alberta Children's Hospital, Calgary, Alberta. METHODS: The content and structure of the database were designed using the technical expertise of a data analyst from the Calgary Health Region. Relevant clinical and demographic data fields were included with the goal of documenting ongoing care of individual patients, and facilitating future epidemiological studies of this patient population. After completion of this database, 10 challenges encountered during development were retrospectively identified. Practical solutions for these challenges are presented. RESULTS: THE CHALLENGES IDENTIFIED DURING THE DATABASE DEVELOPMENT PROCESS INCLUDED: identification of relevant data fields; balancing simplicity and user-friendliness with complexity and comprehensive data storage; database expertise versus clinical expertise; software platform selection; linkage of data from the previous spreadsheet to a new data management system; ethics approval for the development of the database and its utilization for research studies; ensuring privacy and limited access to the database; integration of digital photographs into the database; adoption of the database by support staff in the clinic; and maintaining up-to-date entries in the database. CONCLUSIONS: There are several challenges involved in the development of a useful and efficient clinical database. Awareness of these potential obstacles, in advance, may simplify the development of clinical databases by others in various surgical settings.

Injury mortality rates in Native and non-Native children: a population-based study.

OBJECTIVES: To examine injury mortality rates in Native and non-Native children in the province of Alberta, Canada, over a 10-year period, temporal trends in injury mortality rates (Native vs. non-Native), as well as relative risks of injury mortality (Native vs. non-Native) by injury mechanism and intent, were calculated. METHODS: An observational, population-based study design was used. Mortality data were obtained from provincial vital statistics, with injury deaths identified using external injury codes (E-codes). The relative risk (RR) of injury mortality (Native vs. non-Native) along with 95% confidence intervals (CIs) were calculated. Stratified analyses and Poisson regression modeling were used to calculate adjusted relative risk. RESULTS: Injury mortality rates declined over the study period, with no difference in the rate of decline between Native and non-Native children. The adjusted relative risk for all-cause injury death (Native vs. non-Native) was 4.6 (95% CI 4.1 to 5.2). The adjusted relative risks (Native vs. non-Native) by injury intent categories were: unintentional injuries, 4.0 (95% CI 3.5 to 4.6); suicide, 6.6 (95% CI 5.2 to 8.5); and homicide, 5.1 (95% CI 3.0 to 8.5). Injury mortality rates were consistently higher for Native children across all injury mechanism categories. The largest relative risks (Native vs. non-Native) were pedestrian injury (RR = 17.0), accidental poisoning (RR = 15.4), homicide by piercing objects (RR = 15.4), and suicide by hanging (RR = 13.5). CONCLUSION: The burden of injury mortality is significantly greater in Native children compared with non-Native children. Therefore, injury prevention strategies that target both intentional and unintentional injuries are needed.