Paediatrician office follow-up of common minor fractures.

BACKGROUND: Evidence suggests that minor paediatric fractures can be followed by primary care paediatricians (PCPs). OBJECTIVES: To determine PCP opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office. METHODS: An online survey was sent between June and September 2013 to all paediatricians who subscribed to the American Academy of Pediatrics PROS-Net Listerv and to those who were registered with the Scott's Canadian Medical Directory as paediatricians who treated children in a primary care capacity. The primary outcome was the proportion of PCPs who agreed with PCP follow-up of minor paediatric fractures. Secondary outcomes included PCP's perceived barriers to office follow-up. RESULTS: A total of 1752 surveys were sent; 1235 were eligible and 459 (37.2%) responded to the survey. Overall, 296 (69.5% [95% CI 65.2% to 74.0%]) PCPs agreed that minor paediatric fractures could be followed in a PCP office. The most frequently reported barriers were lack of materials to replace immobilization (58.1%), PCP knowledge deficits (44.8%) and a perceived parental preference for an orthopedic surgeon (38.6%). Finally, 58.8% of respondents believed that further education was necessary if PCPs assumed responsibility for follow-up of midshaft clavicle fractures, while 66.5% and 77.1% (P<0.0001) believed this was necessary for distal radius buckle and fibular fractures, respectively. CONCLUSIONS: More than two-thirds of responding PCPs in Canada and the United States agreed that minor common paediatric fractures can be followed-up by paediatricians. However, PCPs reported some barriers to this management strategy, including a desire for more education on this topic.

HISTORIQUE: Selon les données probantes, les fractures pédiatriques mineures peuvent être suivies par des pédiatres de première ligne (PPL). OBJECTIFS: Déterminer les opinions et les connaissances des PPL ainsi que les obstacles qu'ils perçoivent à la prise en charge des fractures pédiatriques mineures en cabinet. MÉTHODOLOGIE: Tous les pédiatres qui souscrivaient à la liste de messagerie PROS-Net de l'American Academy of Pediatrics et tous ceux qui étaient inscrits au répertoire médical canadien de Scott en qualité de pédiatres qui soignaient des enfants en première ligne ont reçu un sondage virtuel. Le résultat primaire était la proportion de PPL qui acceptait le suivi des fractures pédiatriques mineures. Les résultats secondaires incluaient les obstacles que percevaient les PPL au suivi en cabinet. RÉSULTATS: Au total, 1 752 sondages ont été expédiés, 1 235 étaient admissibles et 459 (37,2 %) y ont répondu. Dans l'ensemble, 296 PPL (69,5 % [95 % IC 65,2 % à 74,0 %]) convenaient que les fractures pédiatriques mineures pouvaient être suivies en cabinet. Les obstacles les plus signalés étaient l'absence de matériaux pour remplacer les immobilisations (58,1 %), le manque de connaissances des PPL (44,8 %) et une préférence perçue des parents à consulter un chirurgien orthopédique (38,6 %). Enfin, 58,8 % des répondants pensaient qu'il était nécessaire de perfectionner la formation des PPL s'ils assumaient la responsabilité du suivi des fractures du milieu de la clavicule, tandis que 66,5 % et 77,1 % (P<0,0001) pensaient la formation nécessaire sur le cerclage des fractures du radius distal et des péroniers, respectivement. CONCLUSIONS: Plus des deux tiers des PPL répondants au Canada et aux États-Unis convenaient que les fractures pédiatriques mineures courantes peuvent être suivies par les pédiatres. Cependant, les PPL signalaient des obstacles à cette stratégie de prise en charge, y compris le souhait d'obtenir plus de formation sur le sujet.

The Concussion, Exercise, and Brain Networks (ConExNet) study: a cohort study aimed at understanding the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion.

BACKGROUND: Recent scientific evidence has challenged the traditional "rest-is-best" approach for concussion management. It is now thought that "exercise-is-medicine" for concussion, owing to dozens of studies which demonstrate that sub-maximal, graded aerobic exercise can reduce symptom burden and time to symptom resolution. However, the primary neuropathology of concussion is altered functional brain activity. To date, no studies have examined the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion. In addition, although exercise is now more widely prescribed following concussion, its cardiopulmonary response is not yet well understood in this population. Our study has two main goals. The first is to understand whether there are exercise-induced resting state functional brain activity differences in children with concussion vs. healthy controls. The second is to profile the physiological response to exercise and understand whether it differs between groups. METHODS: We will perform a single-center, controlled, prospective cohort study of pediatric concussion at a large, urban children's hospital and academic center. Children with sport-related concussion (aged 12-17 years) will be recruited within 4-weeks of injury by our clinical study team members. Key inclusion criteria include: medical clearance to exercise, no prior concussion or neurological history, and no implants that would preclude MRI. Age- and sex-matched healthy controls will be required to meet the same inclusion criteria and will be recruited through the community. The study will be performed over two visits separated by 24-48 h. Visit 1 involves exercise testing (following the current clinical standard for concussion) and breath-by-breath gas collection using a metabolic cart. Visit 2 involves two functional MRI (fMRI) scans interspersed by 10-minutes of treadmill walking at an intensity calibrated to Visit 1 findings. To address sub-objectives, all participants will be asked to self-report symptoms daily and wear a waist-worn tri-axial accelerometer for 28-days after Visit 2. DISCUSSION: Our study will advance the growing exercise-concussion field by helping us understand whether exercise impacts outcomes beyond symptoms in pediatric concussion. We will also be able to profile the cardiopulmonary response to exercise, which may allow for further understanding (and eventual optimization) of exercise in concussion management. TRIAL REGISTRATION: Not applicable.

Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence.

Return to activity (RTA) and return to school (RTS) are important issues in pediatric concussion management. This study aims to update CanChild's 2015 RTA and RTS protocols, on the basis of empirical data and feedback collected from our recently completed prospective cohort study, focusing on concussed children and their caregivers; systematic review of evidence published since 2015; and consultation with concussion management experts. The new protocols highlight differences from the earlier versions, mainly, (1) symptom strata to allow quicker progression for those who recover most quickly; (2) a shortened rest period (24-48 hours) accompanied by symptom-guided activity; (3) the recommendation that children progress through the stages before they are symptom free, if symptoms have decreased and do not worsen with activity; (4) specific activity suggestions at each stage of the RTA protocol; (5) recommendations for the amount of time to spend per stage; and (6) integration of RTS and RTA.

Primary Care Physician Follow-up of Distal Radius Buckle Fractures.

OBJECTIVES: Our main objective was to determine the proportion of children referred to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who subsequently did not deviate from this reassessment strategy. METHODS: This prospective cohort study was conducted at a tertiary care pediatric emergency department (ED). Eligible children were aged 2 to 17 years with a distal radius buckle fracture treated with a removable splint and referred to the PCP for reassessment. We telephoned families 28 days after their ED visit. The primary outcome was the proportion who received PCP follow-up exclusively. We also measured the proportion who received PCP anticipatory guidance and those children who reported returning to usual activities "always" by 4 weeks. RESULTS: We enrolled 200 children, and 180 (90.0%) received telephone follow-up. Of these, 157 (87.2% [95% confidence interval: 82.3 to 92.1]) received PCP follow-up exclusively. Specifically, 11 (6.1%) families opted out of physician follow-up, 5 (2.8%) self-referred to an ED, and the PCP requested specialty consultation in 7 (3.9%) cases. Of the 164 with a PCP visit, 77 (47.0%) parents received anticipatory guidance on return to activities for their child, and 162 (98.8%) reported return to usual activities within 4 weeks. CONCLUSIONS: The vast majority of children with distal radius buckle fractures presented to the PCP for follow-up and did not receive additional orthopedic surgeon or ED consultations. Despite a suboptimal rate of PCP advice on return to activities, almost all parents reported full return to usual activities within 4 weeks.

Focal epithelial hyperplasia caused by human papillomavirus 13.

Focal epithelial hyperplasia is a benign, papulo-nodular disease of the oral cavity. It is rare, affecting primarily Native American populations during childhood. It is closely associated with human papillomavirus 13 and 32. This report describes the diagnosis of 2 cases of focal epithelial hyperplasia in children from southern Guyana. The diagnosis was made using clinical criteria, polymerase chain reaction, and DNA sequencing.