Smaller nadroparin dose reductions required for patients with renal impairment: A multicenter cohort study.

BACKGROUND: Guidelines advise 50 % and 25 % dose reduction of the therapeutic nadroparin dose (86 IU/kg) in patients with eGFR 15-29 and 30-60 ml/min respectively. For monitoring, peak anti-Xa levels are suggested. Data lack whether this results in therapeutic anti-Xa levels or in anti-Xa levels that are comparable to those of patients without renal impairment. AIMS: To determine dose ranges in patients with renal impairment that result in therapeutic anti-Xa levels and to determine the percentage of the 86 IU/kg dose that results in anti-Xa levels normally occurring in patients without renal impairment. METHODS: A retrospective cohort study was conducted in five hospitals. Patients ≥18 years of age, with an eGFR ≥ 15 ml/min were included. The first correctly sampled peak (i.e. 3-5 h after ≥ third administration, regardless of dose per patient) was included. Simulated prediction models were developed using multiple linear regression. RESULTS: 770 patients were included. eGFR and hospital affected the association between dose and anti-Xa level. The doses for peak anti-Xa levels of 0.75 IU/ml differed substantially between hospitals and ranged from 55 to 91, 65-359 and 68-168 IU/kg in eGFR 15-29, 30-60 and > 60 ml/min/1.73m2, respectively. In eGFR 15-29 and 30-60 ml/min/1.73m2, doses of 75 % and 91 % of 86 IU/kg respectively, were needed for anti-Xa levels normally occurring in patients with eGFR > 60 ml/min. CONCLUSION: We advise against anti-Xa based dose-adjustments as long as anti-Xa assays between laboratories are not harmonized and an anti-Xa target range is not validated. A better approach might be to target levels similar to eGFR > 60 ml/min/1.73m2, which are achieved by smaller dose reductions.

Recognition of cognitive dysfunction in hospitalised older patients: a flash mob study.

BACKGROUND: It is important that healthcare professionals recognise cognitive dysfunction in hospitalised older patients in order to address associated care needs, such as enhanced involvement of relatives and extra cognitive and functional support. However, studies analysing medical records suggest that healthcare professionals have low awareness of cognitive dysfunction in hospitalised older patients. In this study, we investigated the prevalence of cognitive dysfunction in hospitalised older patients, the percentage of patients in which cognitive dysfunction was recognised by healthcare professionals, and which variables were associated with recognition. METHODS: A multicentre, nationwide, cross-sectional observational study was conducted on a single day using a flash mob study design in thirteen university and general hospitals in the Netherlands. Cognitive function was assessed in hospitalised patients aged ≥ 65 years old, who were admitted to medical and surgical wards. A Mini-Cog score of < 3 out of 5 indicated cognitive dysfunction. The attending nurses and physicians were asked whether they suspected cognitive dysfunction in their patient. Variables associated with recognition of cognitive dysfunction were assessed using multilevel and multivariable logistic regression analyses. RESULTS: 347 of 757 enrolled patients (46%) showed cognitive dysfunction. Cognitive dysfunction was recognised by attending nurses in 137 of 323 patients (42%) and by physicians in 156 patients (48%). In 135 patients (42%), cognitive dysfunction was not recognised by either the attending nurse or physician. Recognition of cognitive dysfunction was better at a lower Mini-Cog score, with the best recognition in patients with the lowest scores. Patients with a Mini-Cog score < 3 were best recognised in the geriatric department (69% by nurses and 72% by physicians). CONCLUSION: Cognitive dysfunction is common in hospitalised older patients and is poorly recognised by healthcare professionals. This study highlights the need to improve recognition of cognitive dysfunction in hospitalised older patients, particularly in individuals with less apparent cognitive dysfunction. The high proportion of older patients with cognitive dysfunction suggests that it may be beneficial to provide care tailored to cognitive dysfunction for all hospitalised older patients.

A Warm Air Blanket is Superior to a Heated Mattress in Preventing Perioperative Hypothermia in Orthopedic Arthroplasties, a Time-Series Analyses.

BACKGROUND: Hypothermia is a common perioperative problem that can lead to severe complications. We evaluated whether a heated mattress (HM) is superior to a warm air blanket (WA) in preventing perioperative hypothermia in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: A retrospective cohort study was performed in a teaching hospital and data were collected for all patients undergoing THA or TKA between January 1, 2015 and May 1, 2022. We used logistic and linear regressions to analyze hypothermia occurrence and important complications. Results were adjusted for confounders and time, and was present in all subgroups and after imputation of missing data. RESULTS: In total, 4,683 of 5,497 patients had information on type of heating. We found more perioperative hypothermia in patients treated with an HM compared to a WA for both THA (odds ratio-adjusted 1.42 [1.0 to 1.6] P = .06) and TKA (odds ratio-adjusted 2.10 [1.5 to 3.0] P < .01). There was no difference in postoperative infections between groups (all between 0.5% and 1.3%). Patients who had an HM significantly stayed longer in the postoperative ward (a mean difference of 4 [TKA] to 6 [THA] minutes, P < .01), but there was no difference in hospital stay. CONCLUSION: A WA is superior compared to an HM in preventing perioperative hypothermia, with no increased risk of complications. Patients who have an HM stayed longer at the postoperative ward, potentially because of higher hypothermia rates. Therefore, it is suggested to use a WA instead of an HM.

Soft tissue response and determination of underlying risk drivers for recession and mucositis after AMSJI implantation in the maxilla.

PURPOSE: There are few treatment options for oral rehabilitation in patients with advanced maxillary resorption (Cawood-Howell Class V or more). Patient-specific, 3D-printed titanium subperiosteal implants have been described as a potentially valuable alternative solution. Surgeon and patient mediated functional outcomes have been studied and the results are promising. The surrounding soft tissue health has been much less researched. This study aims to evaluate the soft tissue response to the placement of additively manufactured subperiosteal jaw implants (AMSJI®) in the severely atrophic maxilla and to identify possible risk factors for soft tissue breakdown. MATERIALS AND METHODS: An international multicenter study was conducted and fifteen men (mean age 64.62 years, SD ± 6.75) and twenty-five women (mean age 65.24 years, SD ± 6.77) with advanced maxillary jaw resorption (Cawood-Howell Class V or more) were included in this study. General patient data were collected and all subjects were clinically examined. Inclusion criteria were patients who underwent bilateral AMSJI placement® in the maxilla at least a year before and whose surgeon and themselves agreed to participate in the study before their inclusion. RESULTS: A total of forty patients were enrolled with a mean follow-up period of 917 days (SD ± 306.89 days). Primary stability of the implant was achieved postoperatively in all cases, and all implants were loaded with a final prosthesis. At the time of study, only one patient showed mobility of the bilateral AMSJI (more than 1 mm). Exposure of the framework, due to mucosal recession, was seen in 26 patients (65%) and was mainly in the left (21.43%) and right (18.57%) mid-lateral region. Thin biotype and the presence of mucositis were found to be risk factors (p-value < 0.05). Although not significant, smokers had a nearly seven times (Odds ratio 6.88, p=0.08) more risk of developing a recession compared to nonsmokers. CONCLUSION: Twenty-six (65%) patients presented with a recession in one or (more) of the seven regions after oral rehabilitation with bilateral AMSJI installation. Several risk drivers were evaluated. The collapse of soft tissues around the AMSJI that led to caudal exposure of the arms was correlated with a thin biotype and the presence of mucositis.

Oxygen saturation targets for children with respiratory distress: a systematic review.

Background: In children with respiratory distress, supplemental oxygen is indicated at peripheral oxygen saturation (SpO2) thresholds of 90-94%. However, these thresholds are poorly studied. We conducted a systematic review to summarise the existing evidence for SpO2 thresholds in children with respiratory distress. Methods: Electronic databases and registries were searched for original articles published from 1 January 2010 to 7 January 2022 comparing two or more SpO2 thresholds in children with respiratory distress. Primary outcomes were safety, including mortality, neurocognitive outcomes and readmissions, and effectiveness, including admission rate and length of hospital stay. Methodological appraisal was performed using the Cochrane Risk of Bias 2 (RoB-2) or Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) tools. Results were narratively synthesised. Results: We retrieved 3384 results; seven studies were included. Lower thresholds ranged from 80% to 92% and were compared with higher thresholds ranging from 92% to 94%. Studies were highly heterogeneous in setting, design, population and outcomes. Risk of bias varied from low to high. Lower SpO2 thresholds had equivalent mortality, neurocognitive outcomes and readmissions or re-attendance to healthcare to higher thresholds. Lower SpO2 thresholds showed a significant decrease in admission rates by up to 40% and shortened hospitalisation duration by 10-18 h. Conclusions: The current SpO2 thresholds of 90-94% in children with respiratory distress may be too high, which could lead to unnecessary hospitalisations and prolonged hospitalisation duration. SpO2 thresholds as low as 88% are potentially safe in children with respiratory distress and may reduce hospitalisation rates and length of stay. However, high-quality evidence is needed to support this.

Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial.

Aims: There is no level I evidence dealing with the optimal period of immobilization for patients with a displaced distal radial fracture following closed reduction. A shorter period might lead to a better functional outcome due to less stiffness and pain. The aim of this study was to investigate whether this period could be safely reduced from six to four weeks. Methods: This multicentre randomized controlled trial (RCT) included adult patients with a displaced distal radial fracture, who were randomized to be treated with immobilization in a cast for four or six weeks following closed reduction. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after follow-up at one year. Secondary outcomes were the abbreviated version of the Disability of Arm, Shoulder and Hand (QuickDASH) score after one year, the functional outcome at six weeks, 12 weeks, and six months, range of motion (ROM), the level of pain after removal of the cast, and complications. Results: A total of 100 patients (15 male, 85 female) were randomized, with 49 being treated with four weeks of immobilization in a cast. A total of 93 completed follow-up. The mean PRWE score after one year was 6.9 (SD 8.3) in the four-week group compared with 11.6 (SD 14.3) in the six-week group. However, this difference of -4.7 (95% confidence interval -9.29 to 0.14) was not clinically relevant as the minimal clinically important difference of 11.5 was not reached. There was no significant difference in the ROM, radiological outcome, level of pain, or complications. Conclusion: In adult patients with a displaced and adequately reduced distal radial fracture, immobilization in a cast for four weeks is safe, and the results are similar to those after a period of immobilization of six weeks.

Hormonal support in women with Asherman syndrome does not lead to better outcomes: A randomized trial.

Purpose: The purpose of the study was to investigate if adjuvant hormones after successful adhesiolysis lead to a reduction in spontaneous recurrence of adhesions and influence reproductive outcomes. Methods: A single-blind randomized controlled trial comparing administration of oral estrogen (the usual care group) with not giving estrogen (no estrogen) in women after successful adhesiolysis for Asherman syndrome. Women were included between September 2013 and February 2017, with a follow-up of 3 years to monitor recurrences and reproductive outcomes. Analyses were based on an intention to treat analyses. This study was registered under NL9655. Results: A total of 114 women were included. At 1 year, virtually all patients (except 3) were either having a recurrence or were pregnant. Women who did not receive estrogen did not have more recurrences of adhesions in the first year prior to pregnancy (66.1% in the usual care group, 52.7% in the no-estrogen group, p = 0.15). Of the women in usual care, 89.8% got pregnant within 3 years, and 67.8% got a living child; this was 83.6% and 60.0%, respectively, in the no-estrogen group (p = 0.33 and p = 0.39, respectively). Conclusion: Usual care does not lead to better outcomes as compared with not giving exogenous estrogen but is associated with side effects.

[The cause of anemia is underdiagnosed in primary care]. / Onderdiagnostiek naar anemie in de eerste lijn.

OBJECTIVE: To determine if general practitioners can diagnose the cause of anemia, based on the requested laboratory tests. DESIGN: Retrospective observational study. METHOD: The research population consisted of 20.004 adult patients with established anemia, who had blood samples analyzed by Atalmedial in 2019. The cause of anemia was found when criteria based on the NHG-standard were met. We considered the NHG-guideline to be followed when hemoglobin was requested in the first diagnostic request and when the correct combination of blood tests was requested in the second diagnostic request. Descriptive statistics and multilevel regression analysis were performed. RESULTS: A possible cause of anemia has been found in 38,7% of the patients within two diagnostic requests, regardless of the adherence to the NHG-guideline. The chance of finding a cause of anemia was smaller in men than women of the same age, whereas the chance was highest in women over the age of 80 and between 18 and 44. The NHG-guideline for anemia was followed in 11.794 (59%) of the patients in the first diagnostic request. 19,3% (11,4% of total) of these patients also had a second diagnostic request. In 10,4% (1,2% of total) of these patients, the NHG-guideline was adhered to in the second diagnostic request. CONCLUSION: A cause of anemia is, based on laboratory tests, often not diagnosed in daily practice in the primary care. The reason for this is insufficient laboratory follow-up after initial testing when no cause of anemia is found. The NHG-guideline for anemia is poorly adhered to.

Use of xylometazoline in hospitalised infants: is it safe? A retrospective cohort study.

OBJECTIVE: When infants suffer from nasal congestion, xylometazoline spray or drops can be effective to facilitate breathing and drinking. However, case reports on side effects have resulted in international warnings regarding use of xylometazoline in infants. Nevertheless, the incidence of these side effects in hospitalised infants is unknown. DESIGN: Retrospective cohort study. SETTING: Teaching hospital between 2017 and 2021. PATIENTS: Infants under 2 years of age. EXPOSURE: Receiving either saline-only (unlimited frequency, concentration 0.9%) or in combination with xylometazoline (maximum three times daily, concentration 0.025%). MAIN OUTCOME MEASURES: Predefined potential side effects (events), including among others apnoea, nausea, bradycardia, cyanosis and nosebleeds, were extracted from patient records, and the probability to be caused by saline only or xylometazoline-saline was determined using the ADR Probability Scale. RESULTS: We included 898 admitted children during 1285 treatment episodes who received saline with or without xylometazoline. 26 events occurred in the saline-only group (incidence 20.0/100 treatment episodes), and 117 events occurred in the xylometazoline saline group (incidence of 10.5/100 treatment episodes), which was significantly lower (OR 0.47 95% CI 0.29 to 0.75, p=0.002). No definite linked or life-threatening events were found. Three nosebleeds had a probable link to the use of xylometazoline-saline, and all other events could only possibly be linked to saline-only or xylometazoline saline use. The incidence of all events was higher in the saline-only group as compared with the xylometazoline saline group, except nausea, which had a similar occurrence (p=0.65). Results were very similar across (gestational) age groups, gender and reasons for admission. CONCLUSION: The use of low-dose xylometazoline seems to be safe in hospitalised infants.

Parental Opinions on Medical Decision-Making in Adolescence: A Case-Based Survey.

OBJECTIVE: Patient trust and consent are complex topics for health care workers in pediatrics, specifically when relating to adolescent's legal status. In the context of medical decisions, not much work has been performed to understand the opinion of parents on health care decision-making, especially on confidentiality concerning their adolescent children. The purpose of this research was to assess the parental opinions on these decisions and the influence of different perspectives. METHODS: We used a case-based methodology to assess parental opinions on fictional medical decisions. A survey was provided to parents in 2 pediatric outpatient departments in Belgium and the Netherlands. The survey contained cases regarding medical care related to confidentiality and consent about which participants gave their opinion. RESULTS: In total, 222 surveys were completed. Overall, most parents would allow an adolescent to make his/her own decision (58.6%-70.4%), except in the case of confidentiality on alcohol-related trauma (28.9%). The results show a significant difference in how parents responded when answering from the parental perspective or adolescents' perspective. They granted significantly more authority to the adolescent in the latter view. CONCLUSION: Our study shows that parents who were confronted with cases from an adolescent perspective were significantly more likely to give the patient authority. In addition, the medical issue and context influence how the parents responded. These data provide insight into the parental opinions and could lead to more evidence-based frameworks for shared medical decision-making of adolescents and their parents.

Use of 360° virtual reality video in medical obstetrical education: a quasi-experimental design.

BACKGROUND: Video-based teaching has been part of medical education for some time but 360° videos using a virtual reality (VR) device are a new medium that offer extended possibilities. We investigated whether adding a 360° VR video to the internship curriculum leads to an improvement of long-term recall of specific knowledge on a gentle Caesarean Sections (gCS) and on general obstetric knowledge. METHODS: Two weeks prior to their Obstetrics and Gynaecology (O&G) internship, medical students were divided in teaching groups, that did or did not have access to a VR-video of a gCS. Six weeks after their O&G internship, potentially having observed one or multiple real-life CSs, knowledge on the gCS was assessed with an open questionnaire, and knowledge on general obstetrics with a multiple-choice questionnaire. Furthermore we assessed experienced anxiety during in-person attendance of CSs, and we asked whether the interns would have wanted to attend more CSs in-person. The 360° VR video group was questioned about their experience directly after they watched the video. We used linear regression analyses to determine significant effects on outcomes. RESULTS: A total of 89 medical students participated, 41 in the 360° VR video group and 48 in the conventional study group. Watching the 360° VR video did not result in a difference in either specific or general knowledge retention between the intervention group and the conventional study group. This was both true for the grade received for the internship, the open-ended questions as well as the multiple-choice questions and this did not change after adjustment for confounding factors. Still, 83.4% of the 360° VR video-group reported that more videos should be used in training to prepare for surgical procedures. In the 360° VR video-group 56.7% reported side effects like nausea or dizziness. After adjustment for the number of attended CSs during the practical internship, students in the 360° VR video-group stated less often (p = 0.04) that they would have liked to attend more CSs in-person as compared to the conventional study group. CONCLUSION: Even though the use of 360° VR video did not increase knowledge, it did offer a potential alternative for attending a CS in-person and a new way to prepare the students for their first operating room experiences.

The use of in-hospital medical care for patients with metastasized colon, bronchus, or lung cancer.

PURPOSE: At the end of life, patients and their families tend to favor adequate pain and symptom management and attention to comfort measures over prolongation of life. However, it has been suggested that many cancer patients without curative options still receive aggressive treatment. We therefore aimed to describe the number of diagnostic procedures, hospitalization, and medication use among these patients as well as factors associated with receiving such care. METHODS: We conducted a cohort study on all patients with metastasized cancer from a primary colon or bronchus and lung (BL) neoplasm from the moment of first admittance (January-December 2017) to end of follow-up (November 2018) or death. RESULTS: A total of 408 patients with colon (36%) or BL (64%) cancer were included in this study, with a median survival time of 7.4 months. 93% of the patients were subjected to at least one diagnostic procedure, 49% received chemotherapy, and 56% received expensive medication including immunotherapy. Patients had a median of 4.6 hospital admissions and 2.3 emergency room (ER) visits. A quarter of all patients (n = 105) received specialized palliative care with a mean of 1.96 consultations and the first consultation after a median time of 4.1 months. Patients with BL neoplasms received significantly more diagnostic procedures, chemotherapy episodes, ER/ICU admissions, and more often received an end-of-life statement per person-year than patients with a primary colon neoplasm. Females received significantly less diagnostic procedures and visited the ER/ICU less frequently than males, and patients aged > 70 years received significantly less chemotherapy (episodes) and expensive medication than younger patients. No differences in care were found between different socioeconomic status groups. CONCLUSION: Patients with metastasized colon or BL cancer receive a large amount of in-hospital medical care. Specialized palliative care was initiated relatively late despite the incurable disease status of all patients. Factors associated with more procedures were BL neoplasms, age between 50 and 70, and male gender.

Pain and anxiety during vasectomies while distracting patients with video glasses or virtual reality glasses.

OBJECTIVE: To determine whether it is possible to reduce the amount of pain and anxiety experienced during a vasectomy by use of two-dimensional (2D) video glasses or virtual reality (VR) glasses during the vasectomy. PATIENTS AND METHODS: A non-randomised controlled trial was performed between October 2017 and March 2018. A total of 176 patients were planned for a vasectomy in an outpatient setting and 141 of these patients were divided sequentially into three groups: Control, 2D video glasses and VR glasses. Follow-up lasted 7 days. One patient was lost to follow-up. The main outcomes were pain (visual analogue scale [VAS] score 0-10) and anxiety ((VAS score 0-10), and State-Trait Anxiety Inventory for Adults [STAI-AD] score 20-80) during the vasectomy. Data were compared using analysis of variance or chi-square measurements. RESULTS: No significant differences in pain were found (VAS score of 2 in all groups). The odds ratio (OR) and (95% confidence interval [CI]) in the 2D video glasses group was 1.15 (0.92-1.48) and in the VR group was 0.98 (0.76-1.26). Patients in the VR group experienced significantly more anxiety during the procedure (OR 1.40, 95% CI 1.07-1.85). Also, patients without prior hospitalisation reported significantly more pain than patients with one or more hospitalisations (OR 1.35, 95% CI 1.11-1.65). CONCLUSIONS: The VR and 2D video glasses did not reduce pain or stress during the vasectomy. In the VR group, the anxiety levels during the procedure were even higher.

Typical RSV cough: myth or reality? A diagnostic accuracy study.

Respiratory syncytial virus (RSV) is well known for causing a potentially severe course of bronchiolitis in infants. Many paediatric healthcare workers claim to be able to diagnose RSV based on cough sound, which was evaluated in this study. Parents of children < 1 year old admitted to the paediatric ward because of airway complaints were asked to record cough sounds of their child. In all children, MLPA analysis-a variation of PCR analysis-on nasopharyngeal swab was performed (golden standard). Sixteen cough fragments representing 4 different viral pathogens were selected and presented to paediatric healthcare workers. Thirty-two paediatric nurses, 16 residents and 16 senior staff members were asked to classify the audio files and state whether the cough was due to RSV infection or not. Senior staff, nurses and residents correctly identified RSV with a sensitivity of 76.2%, 73.1% and 51.3% respectively. Correct exclusion of RSV cases was performed with a specificity of 60.8%, 60.2% and 65.3% respectively. Sensitivity ranged from 0 to 100% between colleagues; no one correctly identified all negatives. Residents had significantly lower rates of sensitivity than senior staff and nurses. This was strongly related to work experience, in which more than 3.5 years of work experience was related to the best result.Conclusion: Senior staff and nurses were better in making a cough-based diagnosis of RSV compared to residents. Both groups were able to detect the same proportion of true RSV patients based on cough sounds compared to bedside tests but could not validly distinguish RSV from other pathogens based on cough sounds. What is Known: • Many paediatric healthcare workers claim to be capable of diagnosing RSV in infants based on cough sound • Up to now, no studies investigating the recognisability of RSV based on cough sound are published What is New: • Senior staff and paediatric nurses performed better than various other bedside tests in diagnosing RSV but could not replace MLPA analysis • Residents need at least 3.5 years of work experience to be able to make a RSV diagnosis based on cough sound.

Deep learning for surgical phase recognition using endoscopic videos.

BACKGROUND: Operating room planning is a complex task as pre-operative estimations of procedure duration have a limited accuracy. This is due to large variations in the course of procedures. Therefore, information about the progress of procedures is essential to adapt the daily operating room schedule accordingly. This information should ideally be objective, automatically retrievable and in real-time. Recordings made during endoscopic surgeries are a potential source of progress information. A trained observer is able to recognize the ongoing surgical phase from watching these videos. The introduction of deep learning techniques brought up opportunities to automatically retrieve information from surgical videos. The aim of this study was to apply state-of-the art deep learning techniques on a new set of endoscopic videos to automatically recognize the progress of a procedure, and to assess the feasibility of the approach in terms of performance, scalability and practical considerations. METHODS: A dataset of 33 laparoscopic cholecystectomies (LC) and 35 total laparoscopic hysterectomies (TLH) was used. The surgical tools that were used and the ongoing surgical phases were annotated in the recordings. Neural networks were trained on a subset of annotated videos. The automatic recognition of surgical tools and phases was then assessed on another subset. The scalability of the networks was tested and practical considerations were kept up. RESULTS: The performance of the surgical tools and phase recognition reached an average precision and recall between 0.77 and 0.89. The scalability tests showed diverging results. Legal considerations had to be taken into account and a considerable amount of time was needed to annotate the datasets. CONCLUSION: This study shows the potential of deep learning to automatically recognize information contained in surgical videos. This study also provides insights in the applicability of such a technique to support operating room planning.

Prevention of secondary displacement and reoperation of distal metaphyseal forearm fractures in children.

BACKGROUND: Metaphyseal distal forearm fractures are common in paediatric patients and treating these fractures by reduction and cast immobilization alone is under debate, since secondary displacement is a frequent complication that often warrants re-intervention. This study was conducted to invest the incidence of secondary displacement and re-intervention for non-displaced and displaced fractures, with or without fixation. MATERIAL AND METHODS: A retrospective cohort study was conducted analysing all consecutive paediatric patients under the age of 16 with distal metaphyseal forearm fractures throughout a 2-year period. Data were recorded on radiographic characteristics, OTC/AO-classification, type of treatment, reduction technique, surgical interventions and removal of hardware and complications. RESULTS: 200 Patients with displaced metaphyseal forearm fractures were included of which 139 were primarily treated in the emergency room, the other 61 patients were primarily treated in the operating room. 83% Of the patients had a satisfactory reduction in the emergency room and 94% of these patients were treated successfully with casting alone. A total of 84 patients were treated in the operating room of whom 30% underwent reduction and K-wire fixation, and 70% underwent reduction and casting only. 47% Of the patients treated with closed reduction without K-wire fixation in the operating room suffered from secondary displacement, of which 80% needed re-intervention. CONCLUSION: Metaphyseal forearm fractures can be treated with a very high success rate by closed reduction and casting alone in the emergency room. Reduction and casting of displaced metaphyseal forearm fractures in children that needed treatment in the operating room however, resulted in unacceptable high rate of secondary displacement and commonly required re-intervention. Those patients should therefore be treated by reduction and K-wire fixation.

Patients want to be seen: The top 3 information needs of patients with inguinal hernia.

BACKGROUND: Good patient information has shown to improve surgical outcomes. In this study we explore what kind of pre-surgical information patients need and if the provision of a 360˚ video of a surgical procedure can be of added value to the information provided by the hospital. METHODS: An explorative qualitative study using semi-structured interviews on information needs was conducted among 17 inguinal hernia patients to gain more insight in the patients' present surgical information needs. Patients either were planned to receive or already had received a surgical procedure. Questions were asked about the current information provision and, after being shown a 360˚ video of the surgery, whether this would be of added value. RESULTS: Of the total group of 17 patients (mean age 56, interquartile range 45-64) 16 were male and one was female. Most had no previous experience with virtual reality (14/17), already had undergone a surgical procedure (11/17). Patient information needs were all about "seeing" which can be viewed from three different perspectives [1] being seen as a unique person in the treatment process, [2] being seen as a partner, and [3] seeing is understanding. Patients wanted the contact with the doctor to be more personal, with the possibility to see the anesthetist in person, the surgeon to see their wound in the recovery phase, and to receive personal answers to questions about their specific situation. Patients found the 360-video not fearsome, and believed that visual content could be beneficial as it appeals more to their imagination than written or oral information and increases their understanding. It also provided them with a better understanding of their treatment options, their pre-, peri-, and post-surgical procedures and identification of the cause of post-operative side effects. CONCLUSION: To address patients' information needs, complementary tools or services are needed that increase personal contact as well as tailor it to individual patient's needs. Even though video-apps are a partial alternative, hospitals should still offer patients the possibility of having face-to-face meetings with physicians as this is highly valued by patients and leads to increased trust in physicians' performance.

Outcomes of renal replacement therapy in boys with prune belly syndrome: findings from the ESPN/ERA-EDTA Registry.

BACKGROUND: As outcome data for prune belly syndrome (PBS) complicated by end-stage renal disease are scarce, we analyzed characteristics and outcomes of children with PBS using the European Society for Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry data. METHODS: Data were available for 88 male PBS patients aged <20 years who started renal replacement therapy (RRT) between 1990 and 2013 in 35 European countries. Patient characteristics, survival, and transplantation outcomes were compared with those of male patients requiring RRT due to congenital obstructive uropathy (COU) and renal hypoplasia or dysplasia (RHD). RESULTS: Median age at onset of RRT in PBS was lower [7.0; interquartile range (IQR) 0.9-12.2 years] than in COU (9.6; IQR: 3.0-14.1 years) and RHD (9.4; IQR: 2.7-14.2 years). Unadjusted 10-year patient survival was 85% for PBS, 94% for COU, and 91% for RHD. After adjustment for country, period, and age, PBS mortality was similar to that of RHD but higher compared with COU [hazard ratio (HR) 1.96, 95% confidence interval (CI) 1.03-3.74]. Seventy-four PBS patients (84%) received a first kidney transplant after a median time on dialysis of 8.4 (IQR 0.0-21.1) months. Outcomes with respect to time on dialysis before transplantation, chance of receiving a first transplant within 2 years after commencing RRT, and death-censored, adjusted risk of graft loss were similar for all groups. CONCLUSIONS: This study in the largest cohort of male patients with PBS receiving RRT to date demonstrates that outcomes are comparable with other congenital anomalies of the kidney and urinary tract, except for a slightly higher mortality risk compared with patients with COU.