Artificial intelligence-based detection of paediatric appendicular skeletal fractures: performance and limitations for common fracture types and locations.

BACKGROUND: Research into artificial intelligence (AI)-based fracture detection in children is scarce and has disregarded the detection of indirect fracture signs and dislocations. OBJECTIVE: To assess the diagnostic accuracy of an existing AI-tool for the detection of fractures, indirect fracture signs, and dislocations. MATERIALS AND METHODS: An AI software, BoneView (Gleamer, Paris, France), was assessed for diagnostic accuracy of fracture detection using paediatric radiology consensus diagnoses as reference. Radiographs from a single emergency department were enrolled retrospectively going back from December 2021, limited to 1,000 radiographs per body part. Enrolment criteria were as follows: suspected fractures of the forearm, lower leg, or elbow; age 0-18 years; and radiographs in at least two projections. RESULTS: Lower leg radiographs showed 607 fractures. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were high (87.5%, 87.5%, 98.3%, 98.3%, respectively). Detection rate was low for toddler's fractures, trampoline fractures, and proximal tibial Salter-Harris-II fractures. Forearm radiographs showed 1,137 fractures. Sensitivity, specificity, PPV, and NPV were high (92.9%, 98.1%, 98.4%, 91.7%, respectively). Radial and ulnar bowing fractures were not reliably detected (one out of 11 radial bowing fractures and zero out of seven ulnar bowing fractures were correctly detected). Detection rate was low for styloid process avulsions, proximal radial buckle, and complete olecranon fractures. Elbow radiographs showed 517 fractures. Sensitivity and NPV were moderate (80.5%, 84.7%, respectively). Specificity and PPV were high (94.9%, 93.3%, respectively). For joint effusion, sensitivity, specificity, PPV, and NPV were moderate (85.1%, 85.7%, 89.5%, 80%, respectively). For elbow dislocations, sensitivity and PPV were low (65.8%, 50%, respectively). Specificity and NPV were high (97.7%, 98.8%, respectively). CONCLUSIONS: The diagnostic performance of BoneView is promising for forearm and lower leg fractures. However, improvement is mandatory before clinicians can rely solely on AI-based paediatric fracture detection using this software.

Metabolomics analysis of antiquitin deficiency in cultured human cells and plasma: Relevance to pyridoxine-dependent epilepsy.

Deficiency of antiquitin (α-aminoadipic semialdehyde dehydrogenase), an enzyme involved in lysine degradation and encoded by ALDH7A1, is the major cause of vitamin B6 -dependent epilepsy (PDE-ALDH7A1). Despite seizure control with high dose pyridoxine (PN), developmental delay still occurs in approximately 70% of patients. We aimed to investigate metabolic perturbations due to possible previously unidentified roles of antiquitin, which may contribute to developmental delay, as well as metabolic effects of high dose pyridoxine supplementation reflecting the high doses used for seizure control in patients with PDE-ALDH7A1. Untargeted metabolomics by high resolution mass spectrometry (HRMS) was used to analyze plasma of patients with PDE-ALDH7A1 and two independently generated lines of cultured ReNcell CX human neuronal progenitor cells (NPCs) with CRISPR/Cas mediated antiquitin deficiency. Accumulation of lysine pathway metabolites in antiquitin-deficient NPCs and western-blot analysis confirmed knockdown of ALDH7A1. Metabolomics analysis of antiquitin-deficient NPCs in conditions of lysine restriction and PN supplementation identified changes in metabolites related to the transmethylation and transsulfuration pathways and osmolytes, indicating a possible unrecognized role of antiquitin outside the lysine degradation pathway. Analysis of plasma samples of PN treated patients with PDE-ALDH7A1 and antiquitin-deficient NPCs cultured in conditions comparable to the patient plasma samples demonstrated perturbation of metabolites of the gamma-glutamyl cycle, suggesting potential oxidative stress-related effects in PN-treated patients with PDE-ALDH7A1. We postulate that a model of human NPCs with CRISPR/Cas mediated antiquitin deficiency is well suited to characterize previously unreported roles of antiquitin, relevant to this most prevalent form of pyridoxine-dependent epilepsy.

Analytical description of adolescent binge drinking patients.

BACKGROUND: Binge drinking is a widespread health compromising behavior among adolescents and young adults, leading to significant health problems, injuries and mortality. However, data on alcohol consumption is often unreliable, as it is mainly based on self-reporting surveys. In this five-year study (2014-2019) at the University Children's Hospital Zurich, we analyzed blood samples from adolescent binge drinking patients to investigate blood alcohol concentrations (BACs), co-ingestion of drugs, assess compliance between self-reported and measured substance use, and test for genetic components of innate alcohol tolerance. Furthermore, hair analysis was performed to retrospectively access drug exposure and to evaluate the potential of hair analysis to assess binge drinking. METHODS: In a prospective, single-center study, patients with alcohol intoxications aged 16 years and younger were included. Blood and hair samples were analyzed by sensitive liquid chromatography - tandem mass spectrometry drug analysis. HTTLPR genotyping was performed with PCR and fragment analysis. RESULTS: Among 72 cases, 72 blood and 13 hair samples were analyzed. BACs ranged from 0.08-3.20‰ (mean 1.63‰, median 1.60‰), while a mean concentration of 3.64 pg/mg hair (median 3.0 pg/mg) of the alcohol marker ethyl glucuronide (EtG) was detected in eleven hair samples, providing no evidence of chronic excessive drinking. In 47% of the cases, co-ingested drugs were qualitatively detected next to ethanol, but only 9% of the detected drugs had blood concentrations classified as pharmacologically active. Cannabis consumption (22%) and stimulant intake (16%) were the most frequently observed drugs. Compliance between patients' statements and measured substances matched well. Although we investigated the genetic contribution to innate alcohol tolerance via the 5-HTTLPR polymorphism, the diverse genetic background of the cohort and small sample size did not allow any conclusions to be drawn. CONCLUSION: Almost half of our binge drinking patients tested positive for other substances, primarily cannabis. We anticipate that our study enhances understanding of consumption behavior of young people and encourage continued efforts to address the harmful effects of binge drinking and co-occurring substance use.

For Infants With Fractures: Involvement of a Child Protection Team Is Mandatory With Few Exceptions.

OBJECTIVE: The objective of this study was to compare the frequency at which abuse is detected in institutions with mandatory skeletal surveys for infants with fractures to that in institutions with discretionary referral to child protection teams (CPTs). METHODS: A retrospective chart review of all infants with fractures diagnosed at an emergency department from 2014 to 2018 was conducted to analyze factors leading to a discretionary referral to CPTs and to identify the frequency of nonaccidental trauma. RESULTS: Seventy-two infants with a median age of 6 months were included in this study. The most frequent fracture site was the skull (73.6%), followed by fractures of the femur (12.5%) and the upper arm and forearm (each 4.2%). Discretionary referral to a CPT occurred in only 25% of cases, and abuse was detected in 2.8%. CONCLUSIONS: The abuse detection rate in institutions with discretionary CPT referral is lower than that in institutions with mandatory skeletal surveys. Therefore, we recommend that in institutions with no mandatory skeletal surveys for infants with fractures, every infant with a fracture must be discussed with a CPT.

Mycoplasma pneumoniae Genotypes and Clinical Outcome in Children.

Factors leading to the wide range of manifestations associated with Mycoplasma pneumoniae infection are unclear. We investigated whether M. pneumoniae genotypes are associated with specific clinical outcomes. We compared M. pneumoniae loads and genotypes of children with mucocutaneous disease to those of children with pneumonia, family members with upper respiratory tract infection (URTI), and carriers from a prospective cohort study (n = 47; 2016 to 2017) and to those of other children with mucocutaneous disease from a case series (n = 7; 2017 to 2020). Genotyping was performed using macrolide resistance determination, P1 subtyping, multilocus variable-number tandem-repeat analysis (MLVA), and multilocus sequence typing (MLST). Comparisons were performed with a pairwise Wilcoxon rank sum test and a Fisher exact test with corrections for multiple testing, as appropriate. M. pneumoniae loads did not statistically differ between patients with mucocutaneous disease and those with pneumonia or carriers. Macrolide resistance was detected in 1 (1.9%) patient with mucocutaneous disease. MLVA types from 2016 to 2017 included 3-5-6-2 (n = 21 [46.7%]), 3-6-6-2 (n = 2 [4.4%]), 4-5-7-2 (n = 14 [31.1%]), and 4-5-7-3 (n = 8 [17.8%]), and they correlated with P1 subtypes and MLST types. MLVA types were not associated with specific outcomes such as mucocutaneous disease, pneumonia, URTI, or carriage. They were almost identical within families but varied over geographic location. MLVA types in patients with mucocutaneous disease differed between 2016 to 2017 (3-5-6-2, n = 5 [62.5%]) and 2017 to 2020 (4-5-7-2, n = 5 [71.4%]) (P = 0.02). Our results suggest that M. pneumoniae genotypes may not determine specific clinical outcomes.

Willingness to Vaccinate Children against Influenza after the Coronavirus Disease 2019 Pandemic.

OBJECTIVES: To determine factors associated with parents who plan to vaccinate their children against influenza next year, especially those who did not vaccinate against influenza last year using a global survey. STUDY DESIGN: A survey of caregivers accompanying their children aged 1-19 years old in 17 pediatric emergency departments in 6 countries at the peak of the coronavirus disease 2019 (COVID-19) pandemic. Anonymous online survey included caregiver and child demographic information, vaccination history and future intentions, and concern about the child and caregiver having COVID-19 at the time of emergency department visit. RESULTS: Of 2422 surveys, 1314 (54.2%) caregivers stated they plan to vaccinate their child against influenza next year, an increase of 15.8% from the previous year. Of 1459 caregivers who did not vaccinate their children last year, 418 (28.6%) plan to do so next year. Factors predicting willingness to change and vaccinate included child's up-to-date vaccination status (aOR 2.03, 95% CI 1.29-3.32, P = .003); caregivers' influenza vaccine history (aOR 3.26, 95% CI 2.41-4.40, P < .010), and level of concern their child had COVID-19 (aOR 1.09, 95% CI 1.01-1.17, P = .022). CONCLUSIONS: Changes in risk perception due to COVID-19, and previous vaccination, may serve to influence decision-making among caregivers regarding influenza vaccination in the coming season. To promote influenza vaccination among children, public health programs can leverage this information.

A tale of two parts of Switzerland: regional differences in the impact of the COVID-19 pandemic on parents.

BACKGROUND: We aimed to document the impact of the coronavirus disease 2019 (COVID-19) pandemic on regions within a European country. METHODS: Parents arriving at two pediatric emergency departments (EDs) in North of Switzerland and two in South of Switzerland completed an online survey during the first peak of the pandemic (April-June 2020). They were asked to rate their concern about their children or themselves having COVID-19. RESULTS: A total of 662 respondents completed the survey. Parents in the South were significantly more exposed to someone tested positive for COVID-19 than in the North (13.9 and 4.7%, respectively; P <  0.001). Parents in the South were much more concerned than in the North that they (mean 4.61 and 3.32, respectively; P <  0.001) or their child (mean 4.79 and 3.17, respectively; P <  0.001) had COVID-19. Parents reported their children wore facemasks significantly more often in the South than in the North (71.5 and 23.5%, respectively; P <  0.001). CONCLUSION: The COVID-19 pandemic resulted in significant regional differences among families arriving at EDs in Switzerland. Public health agencies should consider regional strategies, rather than country-wide guidelines, in future pandemics and for vaccination against COVID-19 for children.

Unplanned Return Visits to a Pediatric Emergency Department.

OBJECTIVES: Unplanned return visits (URVs) to emergency departments (EDs) account internationally for 2.5% to 5.2% of all consultations. ED crowding is an increasing challenge, and URVs seem to contribute to this problem. This study aimed to assess factors for URVs at the ED of a tertiary children's hospital to analyze if they are jointly responsible for the steadily rising amount of treated patients. METHODS: All patients with an URV to a pediatric ED in Switzerland between January and December 2013 were included in the study. Data were taken retrospectively from the electronic patient files, and different variables were defined and analyzed. RESULTS: URVs occurred at an incidence of 4.6%, and mostly concerned infants and toddlers (46%). URVs were independent of weekdays and mostly occurred between 10 am and 10 pm. In 84.2% of the cases, the URVs were judged as unnecessary, and in 15.8%, a hospitalization was indicated, mainly for children with a worsening respiratory illness. CONCLUSIONS: The occurrence of URVs in our ED was within the incidence reported in the literature. While URVs lead to hospitalization in some patients, the majority of URVs were unnecessary from a medical point of view. These results indicate that a correct evaluation of the child's health state by parents is often challenging and requires repeated medical attendance following a first ED visit, especially in infants with airway diseases and infections. Intensive counseling and scheduled short-term follow-up consultation at the pediatrician's office could prevent URVs to the ED.

Short and long-arm fiberglass cast immobilization for displaced distal forearm fractures in children: a randomized controlled trial.

PURPOSE: The aim of this study was to investigate whether short-arm fiberglass cast (SAC) immobilization provides fracture stabilization comparable to that of long-arm cast (LAC) treatment of displaced distal forearm fractures after closed reduction in paediatric patients. METHODS: A prospective, randomized, controlled trial of children aged four to 16 years (mean 9.9 years) was designed with a sample of 120 children, whose size was set a priori, with 60 treated with SAC and 60 with LAC. The primary outcome was fracture stability and rate of loss of reduction. The secondary outcome analysis evaluated duration of analgesic therapy, restriction in activities of daily life, and the duration until patients regained normal range of motion in the elbow. RESULTS: No statistically significant differences were found between the two groups in loss of reduction or duration of analgesic therapy. In contrast, the duration until normal range of motion in the elbow was regained was significantly longer in the LAC group (median 4.5 days, P < 0.001). Restriction in activities of daily life did not differ significantly between the two groups except for the item "help needed with showering in the first days after trauma" (SAC 60%, LAC 87%, P = 0.001). CONCLUSION: Fracture immobilization with short-arm fiberglass cast in reduced distal forearm fractures is not inferior to long-arm casts in children four years and older, excluding completely displaced fractures. Furthermore, short-arm casting reduces the need for assistance during showering. TRIAL REGISTRATION: NCT03297047, September 29, 2017.

Improved Diagnostics Help to Identify Clinical Features and Biomarkers That Predict Mycoplasma pneumoniae Community-acquired Pneumonia in Children.

BACKGROUND: There are no reliable signs or symptoms that differentiate Mycoplasma pneumoniae (Mp) infection in community-acquired pneumonia (CAP) from other etiologies. Additionally, current diagnostic tests do not reliably distinguish between Mp infection and carriage. We previously determined that the measurement of Mp-specific immunoglobulin M antibody-secreting cells (ASCs) by enzyme-linked immunospot assay allowed for differentiation between infection and carriage. Using this new diagnostic test, we aimed to identify clinical and laboratory features associated with Mp infection. METHODS: This is a prospective cohort study of children, 3-18 years of age, with CAP from 2016 to 2017. Clinical features and biomarkers were compared between Mp-positive and -negative groups by Mann-Whitney U test or Fisher exact test, as appropriate. Area under the receiver operating characteristic curve (AUC) differences and optimal thresholds were determined by using the DeLong test and Youden J statistic, respectively. RESULTS: Of 63 CAP patients, 29 were Mp-positive (46%). Mp positivity was statistically associated with older age (median, 8.6 vs 4.7 years), no underlying disease, family with respiratory symptoms, prior antibiotic treatment, prolonged prodromal respiratory symptoms and fever, and extrapulmonary (skin) manifestations. Lower levels of C-reactive protein, white blood cell count, absolute neutrophil count, and procalcitonin (PCT), specifically PCT <0.25 µg/L, were statistically associated with Mp infection. A combination of age >5 years (AUC = 0.77), prodromal fever and respiratory symptoms >6 days (AUC = 0.79), and PCT <0.25 µg/L (AUC = 0.81) improved diagnostic performance (AUC = 0.90) (P = .05). CONCLUSIONS: A combination of clinical features and biomarkers may aid physicians in identifying patients at high risk for Mp CAP.

Nonarticular Base and Shaft Fractures of Children's Fingers: Are Follow-up X-rays Needed? Retrospective Study of Conservatively Treated Proximal and Middle Phalangeal Fractures.

BACKGROUND: Phalangeal fractures of the hand are common in children, and most extra-articular fractures can be treated with nonoperative management. Minimally or nondisplaced fractures may simply be immobilized, whereas displaced fractures need closed reduction before immobilization. Although few of these fractures displace secondarily, most schemes currently recommend follow-up x-rays after initial diagnosis. Our primary objective was to identify subgroups of finger fractures that are stable, thus requiring no radiographic monitoring. METHODS: This study was designed as a retrospective, single-center analysis of conservatively treated pediatric finger fractures of the proximal and middle phalanges. We included patients up to 16 years with base or shaft fractures of the index to little fingers who underwent nonoperative treatment and standardized follow-up controls in our pediatric hand surgery outpatients' clinic between 2010 and 2016. Fracture angular deformity in x-rays taken at diagnosis and after 1 and 3 weeks were reassessed blinded, and a statistical analysis was conducted to identify fracture types that are prone to secondary angular deformity. RESULTS: A total of 478 patients were eligible; 113 were lost due to missing final radiographic controls. Overall, 365 patients were analyzed; they had a mean age of 9.7 years (range, 1 to 16), and 33.4% required a primary closed reduction. A secondary angular deformity occurred in 2.2% (8/365) of all finger fractures. No secondary angulation occurred in primary minimally and nondisplaced fractures, but 6.6% (8/122) of the reduced fractures showed a subsequent loss of reduction. CONCLUSIONS: Minimally angulated (<10 degrees) and nondisplaced metaphyseal and diaphyseal fractures of proximal and middle phalanges of the index to little fingers are stable and therefore do not need radiographic follow-ups. However, initially angulated fractures requiring closed reduction bear a risk of subsequent loss of reduction. LEVEL OF EVIDENCE: Level III-retrospective study.

Combined nitrous oxide 70% with intranasal fentanyl for procedural analgosedation in children: a prospective, randomised, double-blind, placebo-controlled trial.

OBJECTIVE: Nitrous oxide 70% (N2O 70%) is an excellent medication for procedural analgosedation (PAS), yet the limit of its analgesic power remains uncertain; therefore, a combination with intranasal fentanyl (INF) was suggested. However, this combination seems to result in a higher rate of vomiting and deeper sedation. This study aimed at assessing the analgesic efficacy, sedation depth and rate of adverse events of PAS with N2O 70% with and without INF. METHODS: Patients aged 2-16 years who qualified for PAS with N2O 70% were randomly assigned to receive either INF or placebo prior to N2O inhalation in this randomised, double-blind study, which was performed in a tertiary children's hospital ED between September 2015 and October 2017. Behaviour during the procedure was evaluated using the Face, Leg, Activity, Cry and Consolability (FLACC) scale and the Modified Behavioural Pain Scale (MBPS); analgesic efficacy was assessed with a self-reported pain scale. Sedation depth using the validated University of Michigan Sedation Scale and adverse events in the ED and during the following 12 hours were documented. RESULTS: A total of 402 patients were included; 3 did not tolerate N2O and therefore had to be excluded. Overall, 399 patients were analysed, of whom 201 (50.4%) received INF. No significant group differences with regard to FLACC scale score, self-reported pain, MBPS score and sedation depth were found. In addition, the two groups did not differ with regard to all types of adverse events. CONCLUSION: Combining N2O 70% with INF resulted in no differences with regard to FLACC scale score, self-reported pain, MBPS score, patient and parental satisfaction rate, sedation depth, and adverse events. TRIAL REGISTRATION NUMBER: NCT02533908.

Nitrous Oxide 70% for Procedural Analgosedation in a Pediatric Emergency Department-With or Without Intranasal Fentanyl?

OBJECTIVES: Nitrous oxide 70% (N20 70%) is an excellent medication for procedural analgosedation in a pediatric emergency department. However, its analgesic efficacy remains uncertain for painful procedures; therefore, a combination with intranasal fentanyl (INF), an opioid, was suggested. This study aimed at observing and assessing the analgesic efficacy and rate of adverse events using N20 70% with and without INF. METHODS: Children who received N20 70% in a tertiary children's hospital emergency department from January 1, 2014 to June 30, 2015 were included in this observational study with prospective data collection. Physicians decided individually whether INF was administered. Medical staff documented the child's behavior during the procedure, adverse events, and satisfaction rate. RESULTS: A total of 442 children were included; 206 (46.6%) received INF. Group differences regarding patient behavior were not statistically significant; however, N20 70% application time was longer in the INF group (P = .02). Nausea was the most frequent adverse event with 13.1% in the INF group versus 8.1% without INF. Inadequate procedural analgosedation was documented only in the INF group, affecting 1.8% of all patients (P = .002). In contrast, anxiety was exclusively observed in the group without INF, which was presumably misjudged pain (P = .03); the satisfaction rate in the INF group was 95.6% compared with 98.7% without INF. CONCLUSIONS: Because of the study design and limitations, no conclusions about adding INF to N20 70% can be made. Additional research is needed to investigate the effect of combining N20 70% with INF.

A smartphone application to determine body length for body weight estimation in children: a prospective clinical trial.

The aim of this study was to test the feasibility and accuracy of a smartphone application to measure the body length of children using the integrated camera and to evaluate the subsequent weight estimates. A prospective clinical trial of children aged 0-<13 years admitted to the emergency department of the University Children's Hospital Zurich. The primary outcome was to validate the length measurement by the smartphone application «Optisizer¼. The secondary outcome was to correlate the virtually calculated ordinal categories based on the length measured by the app to the categories based on the real length. The third and independent outcome was the comparison of the different weight estimations by physicians, nurses, parents and the app. For all 627 children, the Bland Altman analysis showed a bias of -0.1% (95% CI -0.3-0.2%) comparing real length and length measured by the app. Ordinal categories of real length were in excellent agreement with categories virtually calculated based upon app length (kappa = 0.83, 95% CI 0.79-0.86). Children's real weight was underestimated by physicians (-3.3, 95% CI -4.4 to -2.2%, p < 0.001), nurses (-2.6, 95% CI -3.8 to -1.5%, p < 0.001) and parents (-1.3, 95% CI -1.9 to -0.6%, p < 0.001) but overestimated by categories based upon app length (1.6, 95% CI 0.3-2.8%, p = 0.02) and categories based upon real length (2.3, 95% CI 1.1-3.5%, p < 0.001). Absolute weight differences were lowest, if estimated by the parents (5.4, 95% CI 4.9-5.9%, p < 0.001). This study showed the accuracy of length measurement of children by a smartphone application: body length determined by the smartphone application is in good agreement with the real patient length. Ordinal length categories derived from app-measured length are in excellent agreement with the ordinal length categories based upon the real patient length. The body weight estimations based upon length corresponded to known data and limitations. Precision of body weight estimations by paediatric physicians and nurses were comparable and not different to length based estimations. In this non-emergency setting, parental weight estimation was significantly better than all other means of estimation (paediatric physicians and nurses, length based estimations) in terms of precision and absolute difference.

The effect of the COVID-19 pandemic on pediatric emergency department utilization in three regions in Switzerland.

PURPOSE: The COVID-19 pandemic was associated with a decrease in emergency department (ED) visits. However, contradictory, and sparse data regarding children could not yet answer the question, how pediatric ED utilization evolved throughout the pandemic. Our objectives were to investigate the impact of the pandemic in three language regions of Switzerland by analyzing trends over time, describe regional differences, and address implications for future healthcare. METHODS: We conducted a retrospective, longitudinal cohort study at three Swiss tertiary pediatric EDs (March 1st, 2018-February 28th, 2022), analyzing the numbers of ED visits (including patients` age, triage categories, and urgent vs. non-urgent cases). The impact of COVID-19 related non-pharmaceutical interventions (NPIs) on pediatric ED utilization was assessed by interrupted time series (ITS) modelling. RESULTS: Based on 304'438 ED visits, we found a drop of nearly 50% at the onset of NPIs, followed by a gradual recovery. This primarily affected children 0-4 years, and both non-urgent and urgent cases. However, the decline in urgent visits appeared to be more pronounced in two centers compared to a third, where also hospitalization rates did not decrease significantly during the pandemic. A subgroup analysis showed a significant decrease in respiratory and gastrointestinal diseases, and an increase in the proportion of trauma patients during the pandemic. CONCLUSIONS: The COVID-19 pandemic had substantial effects on number and reasons for pediatric ED visits, particularly among children 0-4 years. Despite equal regulatory conditions, the utilization dynamics varied markedly between the three regions, highlighting the multifactorial modification of pediatric ED utilization during the pandemic. Furthermore, future policy decisions should take regional differences into account.

Paediatric fractures of carpal bones other than the scaphoid.

OBJECTIVES: Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome. MATERIAL AND METHODS: Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study. RESULTS: In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good. CONCLUSION: Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation.

Detection of mostly viral pathogens and high proportion of antibiotic treatment initiation in hospitalised children with community-acquired pneumonia in Switzerland - baseline findings from the first two years of the KIDS-STEP trial.

AIMS OF THE STUDY: Globally, since the introduction of conjugate-vaccines against encapsulated bacteria, respiratory viruses have caused most hospitalisations for community-acquired pneumonia. The aim of this study was to describe pathogens detected and their association with clinical findings in Switzerland. METHODS: Baseline data were analysed for all trial participants enrolled between September 2018 and September 2020 into the KIDS-STEP Trial, a randomised controlled superiority trial on the effect of betamethasone on clinical stabilisation of children admitted with community-acquired pneumonia. Data included clinical presentation, antibiotic use and results of pathogen detection. In addition to routine sampling, nasopharyngeal specimens were analysed for respiratory pathogens using a panel polymerase chain reaction test covering 18 viral and 4 bacterial pathogens. RESULTS: 138 children with a median age of 3 years were enrolled at the eight trial sites. Fever (obligatory for enrolment) had been present for median 5 days before admission. Most common symptoms were reduced activity (129, 93.5%) and reduced oral intake (108, 78.3%). Oxygen saturation <92% was found in 43 (31.2%). Forty-three participants (29.0%) were already on antibiotic treatment prior to admission and 104 participants (75.4%) received antibiotic treatment on admission. Pathogen testing results were available from 132 children: 31 (23.5%) had respiratory syncytial virus detected, 21 (15.9%) human metapneumovirus. The pathogens detected showed expected seasonal and age preponderance and were not associated with chest X-ray findings. CONCLUSIONS: In the context of the predominantly viral pathogens detected, the majority of antibiotic treatment is probably unnecessary. The ongoing trial, as well as other studies, will be able to provide comparative pathogen detection data to compare pre- and post-COVID-19-pandemic settings.

[Tongue Lacerations in Children. The Zurich Tongue Scheme]. / Zungenverletzungen bei Kindern: Das Zürcher Zungenschema.

Tongue Lacerations in Children. The Zurich Tongue Scheme Abstract. Treating injured children is part of everyday life at a pediatrician's office or in an emergency department. Among the most common injuries are lacerations, mainly of the head, but the tongue can also be affected. Lacerations of the tongue mostly occur in early childhood due to fall when the child bites its tongue. No evidence-based treatment recommendations exist, even though such injuries are common. It makes a huge difference to the parents and children affected whether the treatment consists of a primary wound closure in general anesthesia or spontaneous healing can be awaited. In this article, the development and implementation of the Zurich Tongue Scheme will be discussed, the first evidence-based treatment recommendations for uncomplicated tongue lacerations in children.