The fate of the malrotated elbow supracondylar fractures in children: is varus really a problem?

PURPOSE: To evaluate the functional and cosmetic effects of elbow supracondylar fractures (SCF) in children with residual rotational deformity. METHODS: Retrospective review cohort of patients with evidence of malrotation after treatment for SCF. An analysis of the postoperative X-ray of 305 consecutive SCF type 3 treated surgically during five years identified 46 elbows with rotational deformity that fulfilled the selection criteria and were recalled for review; only 27 patients agreed to participate. Patients were evaluated clinically and radiographically. Clinically, the elbow and shoulder ROM were assessed. The postoperative fracture rotation (PFR) was radiologically measured using the Berdis method. Results were categorized according to Flynn criteria, and functional outcomes were evaluated with the QuickDASH questionnaire. On final assessment, a radiograph of both elbows was obtained, and measures were compared. Descriptive analysis was made calculating median, range, proportions, and confidence intervals. Non-parametric tests were used to test the association between variables. RESULTS: The group had a median age of four years and a median follow-up of 52 months. Shoulder rotation was asymmetrical in 13 patients; six patients presented a change on carrying angle > 5° (4 varus/2 valgus). The higher the residual rotation, the higher the chances of an altered shoulder rotation (for each degree of PFR, the shoulder rotation was changed to 0.4°). However, there was a low correlation between the amount of rotation and the final carrying angle (r = 0.37). According to Flynn's criteria, over 95% had excellent or good results. CONCLUSION: There was a weak correlation between varus and rotational malalignment. Patients with moderate residual malrotation could be expected to have a good outcome even if some shoulder rotation changes persist.

Drowning Accidents in a Spanish Pediatric Intensive Care Unit: An Observational Study for 29 Years.

INTRODUCTION: Drowning is one of the most frequent accidents in children. We aimed to describe demographic and epidemiological characteristics of drowned children who required admission to a pediatric intensive care unit (PICU) to identify risk factors to guide possible preventive measures to avoid severe drowning. METHODS: We conducted an observational study for 29 years (retrospective between 1991 and 2004; prospective between 2005 and 2019) that included all children (0-15 years old) requiring PICU admission after drowning. Data regarding patient characteristics, accident circumstances, and neurological outcomes at PICU discharge were analyzed. RESULTS: A total of 160 patients were included, with no significant decrease over the study period. There was a predominance of males (75%), young age (60%; 1-5 years), summer months (91.1%; May-September), tourists (14.12 [95% confidence interval, 9.2-21.7] times higher risk of drowning than residents), swimming pool accidents (88.8%), and inadequate supervision (77.9%). The mortality was 18.7%, and 7.5% of admitted children had severe neurological sequelae. The initial resuscitation maneuvers by accident witnesses were incorrect in nearly half of the patients in whom these could be analyzed. CONCLUSIONS: Emphasis should be placed on implementing preventive measures, focused on the described risk groups, and insisting on adequate supervision, swimming training programs, and training of the general population in safe rescue and cardiopulmonary resuscitation.

Dexamethasone for the treatment of traumatic brain injured patients with brain contusions and pericontusional edema: Study protocol for a prospective, randomized and double blind trial.

BACKGROUND: Traumatic brain injury (TBI) constitutes a leading cause of death and disability. Patients with TBI and cerebral contusions developing pericontusional edema are occasionally given dexamethasone on the belief that this edema is similar to that of tumors, in which the beneficial effect of dexamethasone has been demonstrated. METHODS: The DEXCON TBI trial is a multicenter, pragmatic, randomized, triple-blind, placebo controlled trial to quantify the effects of dexamethasone on the prognosis of TBI patients with brain contusions and pericontusional edema. Adult patients who fulfill the elegibility criteria will be randomized to dexamethasone/placebo in a short and descending course: 4 mg/6 h (2 days); 4 mg/8 hours (2 days); 2 mg/6 hours (2 days); 2 mg/8 hours (2 days); 1 mg/8 hours (2 days); 1 mg/12 hours (2 days). The primary outcome is the Glasgow Scale Outcome Extended (GOSE) performed 1 month and 6 months after TBI. Secondary outcomes are: number of episodes of neurological deterioration; symptoms associated with TBI; adverse events; volume of pericontusional edema before and after 12 days of treatment; results of the neuropsychological tests one month and 6 months after TBI. The main analysis will be on an "intention-to-treat" basis. Logistic regression will estimate the effect of dexamethasone/placebo on GOSE at one month and at 6 months, dichotomized in unfavorable outcome (GOSE 1-6) and favorable outcome (GOSE 7-8). Efficacy will also be analyzed using the 'sliding dichotomy'. An interim and safety analysis will be performed including patients recruited during the first year to calculate the conditional power. A study with 600 patients would have 80% power (2 sided alpha = 5%) to detect a 12% absolute increase (from 50% to 62%) in good recovery. DISCUSSION: This is a confirmative trial to elucidate the therapeutic efficacy of dexamethasone in a very specific group of TBI patients: patients with brain contusions and pericontusional edema. This trial could become an important milestone for TBI patients as nowadays there is no effective treatment in this type of patients. TRIAL REGISTRATION: eudraCT: 2019-004038-41; Clinical Trials.gov: NCT04303065.

Prognostic Factors of Children Admitted to a Pediatric Intensive Care Unit After an Episode of Drowning.

OBJECTIVE: The aim of this study was to evaluate the prognostic factors of patients admitted to a pediatric intensive care unit (PICU) after drowning. METHODS: Retrospective observational study from January 1992 to December 2004 and prospective study from January 2005 to December 2015 were conducted in a tertiary children's hospital PICU. The data analyzed refer to the patient, event, type of resuscitation performed, and clinical situation after resuscitation and at arrival to the PICU; results of additional tests; and clinical evolution and neurological status at discharge from the PICU (categorized as death, severe encephalopathy, or normal). The considered potential prognostic factors were whether drowning was witnessed, the type of initial resuscitation, Glasgow Coma Scale score at admission, pupil status and reactivity, and pH. RESULTS: One hundred thirty-one patients were registered. Mortality was 16.7%, and 8.3% had significant neurological sequelae. The clearest factor associated with poor outcome was the type of initial resuscitation performed. All patients who did not require cardiopulmonary resuscitation (CPR), or only basic CPR, had good outcomes; 96.3% of those who required advanced CPR with epinephrine administration had poor outcomes. Patients who needed advanced resuscitation with administration of epinephrine had lower temperature, Glasgow Coma Scale score, pH, and bicarbonate at admission and higher level of glucose. In this group, there was also a higher incidence of seizures, acute respiratory distress syndrome, hemodynamic compromise, and acute renal failure. CONCLUSIONS: The need for advanced CPR with epinephrine administration on the scene predicts poor neurological outcome (severe encephalopathy or death) in drowned children.

Innovative treatment for pes cavovarus: a pilot study of 13 children.

Background and purpose - Pes cavovarus (PCV) is a complex deformity, frequently related to neurological conditions and associated with foot pain, callosities, and walking instability. The deformity has the tendency to increase during growth. Orthotic treatment is ineffective and surgery may be troublesome. We present the preliminary results of a new mini-invasive surgical technique for correction of this foot deformity. Patients and methods - We operated on 13 children (24 feet), age 7-13 years. In 7 children the deformity was neurological in origin. The surgical technique included a dorsal hemiepiphysiodesis of the 1st metatarsal, and a plantar fascia release. The clinical deformity, hindfoot flexibility, and foot callosities, together with a radiological assessment (Meary angle, calcaneal pitch, and talo-calcaneal angle), was done pre- and postoperatively. At final check-up, after a median of 28 months (12-40), the Oxford Ankle Foot Questionnaire for children (OXAFQ-C) was used to assess patient satisfaction. The primary outcome was the hindfoot varus correction. Results - All the operated feet improved clinically and radiologically. Heel varus improved from a mean 6° preoperatively to 5° valgus postoperatively. In those children where treatment was initiated at a younger age, full correction was achieved. Footwear always improved. Interpretation - This treatment may offer a less aggressive alternative in the treatment of PCV in young children and may eventually reduce the amount of surgery needed in the future.

Indicadores de calidad asistencial de GeSIDA para la atención de personas infectadas por el VIH/sida asociados a mortalidad e ingreso hospitalario / GeSIDA quality care indicators associated with mortality and hospital admission for the care of persons infected by HIV/AIDS

INTRODUCCIÓN: En 2010 el Grupo Español de Estudio de SIDA (GeSIDA) desarrolló 66 indicadores de calidad asistencial. Nuestro objetivo es determinar cuáles de estos indicadores se asocian a mortalidad y/o ingreso, y realizar una evaluación preliminar de la utilidad de un índice predictor de mortalidad e ingreso. MÉTODOS: Estudio de cohortes retrospectivo realizado en el Hospital Universitario Son Espases. Los pacientes con infección por el virus de la inmunodeficiencia humana incluidos fueron aquellos que iniciaron seguimiento en consultas entre el 1 de enero de2000 y el 31 de diciembre de 2012. Se realizó análisis descriptivo de las variables demográficas y de los indicadores, y un estudio de regresión logística para valorar la asociación entre los indicadores y riesgo de mortalidad/ingreso. Se calcularon índices predictores de mortalidad e ingreso para pacientes en seguimiento y en tratamiento. RESULTADOS: Fueron incluidos 1.944 pacientes (media de edad: 37 años, el 78,8% varones). En el análisis multivariante relativo a mortalidad, los indicadores asociados en pacientes en seguimiento fueron el 7, 16 y 20 y en pacientes en tratamiento se añaden el 35 y 38. En el análisis multivariante relativo a ingreso, los indicadores asociados en pacientes en seguimiento fueron los mismos que para mortalidad, además del 31, y en el grupo de pacientes en tratamiento se asociaban los indicadores 7, 16, 20, 35, 38 y 40. CONCLUSIÓN: Se han identificado varios indicadores de calidad que pueden estar relacionados con ingreso hospitalario y mortalidad. Estos indicadores hacen referencia fundamentalmente al retraso diagnóstico, seguimiento regular, prevención de las infecciones y control de comorbilidades

INTRODUCTION: In 2010, the AIDS Study Group (Grupo de Estudio del SIDA [GESIDA]) developed 66 quality care indicators. The aim of this study is to determine which of these indicators are associated with mortality and hospital admission, and to perform a preliminary assessment of a prediction rule for mortality and hospital admission in patients on treatment and follow-up. METHODS: A retrospective cohort study was conducted in the Hospital Universitario Son Espases (Palma de Mallorca, Spain). Eligible participants were patients with human immunodeficiency syndrome≥18 years old who began follow-up in the Infectious Disease Section between 1 January 2000 and 31 December 2012. A descriptive analysis was performed to evaluate anthropometric variables, and a logistic regression analysis to assess the association between GESIDA indicators and mortality/admission. The mortality probability model was built using logistic regression. RESULTS: A total of 1,944 adults were eligible (median age: 37 years old, 78.8% male). In the multivariate analysis, the quality of care indicators associated with mortality in the follow-up patient group were the items 7, 16 and 20, and in the group of patients on treatment were 7, 16, 20, 35, and 38. The quality of care indicators associated with hospital admissions in the follow-up patients group were the same as those in the mortality analysis, plus number 31. In the treatment group the associated quality of care indicators were items 7, 16, 20, 35, 38, and 40. CONCLUSIONS: Some GeSIDA quality of care indicators were associated with mortality and/or hospital admissions. These indicators are associated with delayed diagnosis, regular monitoring, prevention of infections, and control of comorbidities

[GeSIDA quality care indicators associated with mortality and hospital admission for the care of persons infected by HIV/AIDS]. / Indicadores de calidad asistencial de GeSIDA para la atención de personas infectadas por el VIH/sida asociados a mortalidad e ingreso hospitalario.

INTRODUCTION: In 2010, the AIDS Study Group (Grupo de Estudio del SIDA [GESIDA]) developed 66 quality care indicators. The aim of this study is to determine which of these indicators are associated with mortality and hospital admission, and to perform a preliminary assessment of a prediction rule for mortality and hospital admission in patients on treatment and follow-up. METHODS: A retrospective cohort study was conducted in the Hospital Universitario Son Espases (Palma de Mallorca, Spain). Eligible participants were patients with human immunodeficiency syndrome≥18 years old who began follow-up in the Infectious Disease Section between 1 January 2000 and 31 December 2012. A descriptive analysis was performed to evaluate anthropometric variables, and a logistic regression analysis to assess the association between GESIDA indicators and mortality/admission. The mortality probability model was built using logistic regression. RESULTS: A total of 1,944 adults were eligible (median age: 37 years old, 78.8% male). In the multivariate analysis, the quality of care indicators associated with mortality in the follow-up patient group were the items 7, 16 and 20, and in the group of patients on treatment were 7, 16, 20, 35, and 38. The quality of care indicators associated with hospital admissions in the follow-up patients group were the same as those in the mortality analysis, plus number 31. In the treatment group the associated quality of care indicators were items 7, 16, 20, 35, 38, and 40. CONCLUSIONS: Some GeSIDA quality of care indicators were associated with mortality and/or hospital admissions. These indicators are associated with delayed diagnosis, regular monitoring, prevention of infections, and control of comorbidities.

Histological differences between various methods of hemiepiphysiodesis: is guided growth really different?

Traditional systems of hemiepiphysiodesis are based on the application of asymmetrical compression to the physis to correct angular deformities. The guided growth method claims to act as a tension plate avoiding compression. The aim of this study was to confirm or refute this claim. Twenty-four White New Zealand rabbits were subjected to a proximal tibial hemiepiphysiodesis using either staples or a plate and two-screws method. Both methods succeeded in producing deformity. The initial existent histological differences between systems became less apparent after 6 weeks of hemiepiphysiodesis, when histological results were very similar. The findings suggest that the eight-plate system produces, like staples, compression of the physis, but the forces are applied more gradually.

Guided growth: the importance of a single tether. An experimental study.

BACKGROUND: During the last few years, the use of the 8-plate as a technique for hemiepiphysiodesis has gained wide acceptance, as it has been shown that it works in a more physiological way than other methods such as staples or transphyseal screws. It has mechanically been compared with a tension band plate, and for this reason, only a single plate is needed. The following study was undertaken to test the 8-plate against the staples and assess factors that can influence the difference in results. METHODS: A prospective experimental study was designed to compare the ability of 2 hemiepiphysiodesis methods, the 8-plate and the double staple, to produce angular deformity in the rabbit's tibia (group I). The variable studied was the variations in the articular line-diaphysis angle at 6 weeks. As the results showed that the 8-plate produced a bigger deformity, a second group was designed (group II) comparing single against double staple, under the hypothesis that the differences observed in the first group could be related to the number of anchors put across the physis and consequently depend on the volume of physis involved by the staples. RESULTS: In group I, the 8-plate produced a bigger angulation at 6 weeks' time than the 2 staples (a difference of 6.5 degrees, P = 0.03). Similarly, in group II, the single staple produced a greater angulation than the 2 staples (difference 6 degrees, P = 0.08). When both groups were compared, no differences in the angulation produced by the 8-plate and the single staple with respect to the 2 staples were found. CONCLUSIONS: These results suggest that one of the reasons why the 8-plate may act in a more "physiological way" (vs. the traditional 2-staple or 3-staple hemiepiphysiodesis) could be the fact that the growth plate is tethered only at a single point. Therefore, the physis retains a major potential for growth and deformity. CLINICAL RELEVANCE: The 8-plate is superior in producing/correcting angular deformity when compared with the traditionally used staples (2 or more) but not when compared with a single staple.

Screw length in the guided growth method.

BACKGROUND: The appearance of the 8-plate as a method for hemiepiphysiodesis has renewed the interest for the use of this technique. However, many questions remain unanswered about the way of action of the guided growth method. Although screw length has been said to play no role, to our knowledge, no clinical or experimental evidence exists. METHODS: An experimental prospective randomized study with 40 WNZ Rabbits aged 8 weeks was conducted. Four experimental groups were established. Each tibia was randomly allocated to one of the following groups: Staples (group 1), 8-plate either using self-taping screws of 9 mm (group 2), or 5 mm lengths (groups 3) and control (group 4). Radiological assessment of the tibial deformity was done in a weekly fashion, and ALDA (articular line-diaphyseal angle) variations at 6 weeks were used as the control variable. RESULTS: The 8-plate as a whole produced a significant bigger deformity than the staples (10°). No significant differences between the two models of the 8-plate were found along the study (3.7°). CONCLUSIONS: The 8-plate has shown to be more efficient in producing angular deformity than staples. However, the length of the screw has showed no role in the 8-plate function.

[Long-term changes on nasal tip in rhinoplasty patients operated with the new domes technique and the banner technique]. / Cambios a largo plazo en la punta nasal en pacientes intervenidos de rinoplastia primaria mediante las técnicas de los nuevos domos y del estandarte.

INTRODUCTION: Anatomy, surgical manoeuvres, scarring and physiologic nasal aging determine the final outcome of nasal tip on rhinoplasty patients. PATIENTS AND METHOD: Post-operative nasal tip changes in 182 rhinoplasty patients operated on by the same surgeon and with a minimum one year of follow-up were studied. A personal interview was arranged with all patients and facial photographs were taken. Nasal tip rotation, projection and definition were measured. RESULTS: After multivariate analysis, surgical manoeuvres with a statistical impact on the long-term outcome of the nasal tip were dome lateralization greater than 3 mm, columellar strut and shield graft. DISCUSSION AND CONCLUSIONS: Cartilage reshaping and tip grafting provide consistent long-lasting results in nasal tip surgery.

[Prevalence of cardiovascular risk factors in the Balearic Islands (CORSAIB Study)]. / Prevalencia de factores de riesgo cardiovascular en las Islas Baleares (estudio CORSAIB).

INTRODUCTION AND OBJECTIVES: Indices of cardiovascular morbidity and mortality in the Balearic Islands in Spain are poor. We decided to investigate the prevalence of the main cardiovascular risk factors (CRFs) and of different cardiovascular diseases in inhabitants of these islands aged 35-74 years. SUBJETS AND METHOD: A population-based descriptive cross-sectional study was used. The Balearic Islands were divided into 14 sectors, each with three or four participating general practitioners (GPs). A random selection of 40 patients registered with each GP was made. Patients were contacted in the surgery or by mail or telephone. Each GP administered a questionnaire on the patients' family and personal history of cardiovascular disease and CRFs such as levels of smoking and physical activity, carried out anthropometric and blood pressure measurements, and requested blood glucose, cholesterol, and cholesterol fraction measurements. RESULTS: The study included 1685 individuals. Some 27% smoked (men 36.9%, women 18.7%), 47.8% had high blood pressure (men 52.3%, women 43.4%), 24.2% had hypercholesterolemia (men 24.4%, women 24.1%), 11.7% had diabetes mellitus (men 15.3%, women 8.4%), 27% were obese (men 24.8%, women 29%), 40.1% were overweight (men 48.3%, women 33.4%), and 43.1% of men and 45.6% of women were sedentary. Two or more CRFs were observed in 58.4%, and 9.8% had a diagnosed cardiovascular disease. The Framingham method gave a higher estimate of cardiovascular risk in all age groups than the REGICOR method. CONCLUSIONS: The prevalence of the main CRFs in the Balearic Islands is high, implying a high risk profile. Dietary and lifestyle interventions, and preventive measures are recommended.

Prevalencia de factores de riesgo cardiovascular en las Islas Baleares (estudio CORSAIB) / Prevalence of cardiovascular risk factors in the Balearic Islands (CORSAIB study)

Introducción y objetivos. Baleares presenta indicadores desfavorables de morbimortalidad cardiovascular. Por ello se planteó estimar la prevalencia de los principales factores de riesgo cardiovascular (FRC) y de la enfermedad cardiovascular diagnosticada entre la población de 35 a 74 años de las islas.Sujetos y método. Se realizó un diseño descriptivo transversal de base poblacional. Se dividió la comunidad en 14 sectores y participaron 3 o 4 médicos de familia por sector (50 en total). Se seleccionó aleatoriamente a 40 personas entre las adscritas a cada médico, que se captaron en la consulta, por carta y por teléfono. Cada médico administró un cuestionario de antecedentes personales y familiares de enfermedades del aparato cardiovascular y de FRC, hábito tabáquico, ejercicio físico, exploración física de medidas antropométricas y presión arterial, y solicitó una determinación de las concentraciones de glucemia, colesterol y sus fracciones. Resultados. Se incluyó a 1.685 personas. Las prevalencias estimadas fueron: tabaquismo del 27% (el 36,9% en varones y el 18,7% en mujeres); hipertensión del 47,8% (el 52,3% en varones y el 43,4% en mujeres); hipercolesterolemia del 24,2% (el 24,4% en varones y el 24,1% en mujeres); diabetes del 11,7% (el 15,3% en varones y el 8,4% en mujeres); obesidad del 27% (el 24,8% en varones y el 29% en mujeres), sobrepeso del 40,1% (el 48,3 en varones y el 33,4% en mujeres), y sedentarismo (el 43,1% en varones y el 45,6% en mujeres). El 58,4% tenía 2 o más FRC. El 9,8% tenía una enfermedad cardiovascular diagnosticada. El riesgo cardiovascular individual fue superior al calcularlo con la ecuación de Framingham que con la de REGICOR en todos los grupos de edad. Conclusiones. Los principales FRC tienen una alta prevalencia en Baleares, lo que supone un elevado perfil de riesgo. Es recomendable la intervención en los hábitos dietéticos y los estilos de vida, así como la adopción de medidas de prevención

Introduction and objectives. Indices of cardiovascular morbidity and mortality in the Balearic Islands in Spain are poor. We decided to investigate the prevalence of the main cardiovascular risk factors (CRFs) and of different cardiovascular diseases in inhabitants of these islands aged 35-74 years. Subjets and method. A population-based descriptive cross-sectional study was used. The Balearic Islands were divided into 14 sectors, each with three or four participating general practitioners (GPs). A random selection of 40 patients registered with each GP was made. Patients were contacted in the surgery or by mail or telephone. Each GP administered a questionnaire on the patients' family and personal history of cardiovascular disease and CRFs such as levels of smoking and physical activity, carried out anthropometric and blood pressure measurements, and requested blood glucose, cholesterol, and cholesterol fraction measurements. Results. The study included 1685 individuals. Some 27% smoked (men 36.9%, women 18.7%), 47.8% had high blood pressure (men 52.3%, women 43.4%), 24.2% had hypercholesterolemia (men 24.4%, women 24.1%), 11.7% had diabetes mellitus (men 15.3%, women 8.4%), 27% were obese (men 24.8%, women 29%), 40.1% were overweight (men 48.3%, women 33.4%), and 43.1% of men and 45.6% of women were sedentary. Two or more CRFs were observed in 58.4%, and 9.8% had a diagnosed cardiovascular disease. The Framingham method gave a higher estimate of cardiovascular risk in all age groups than the REGICOR method. Conclusions. The prevalence of the main CRFs in the Balearic Islands is high, implying a high risk profile. Dietary and lifestyle interventions, and preventive measures are recommended