Long-term Results and Treatment Injuries in Pediatric Tibial and Femoral Fractures

Every fourth injured child seeking medical aid has sustained a fracture. Tibial fracture (annual incidence in less than 17 year old citizens in Finland is 1/1000) is the third most common fracture in children and femoral fracture (0.3/1000) among the most common pediatric injuries leading to hospitalization. Long-term treatment result of these fractures is not well known and there are no studies of treatment injuries in this pediatric patient population. Altogether 94 tibial and 74 femoral fractures were treated under anesthesia in Aurora Hospital, Helsinki between 1980-89. All but 5 of the tibial fractures were manipulated under anesthesia and casted. A remanipulation was performed in 41 patients. Femoral fractures were treated with skeletal traction in 62 patients, with internal fixation in 8 patients and by cast-immobilization 4 patients. A patients assessment form and an invitation to participate in a clinical and radiological examination at a mean follow-up of more than 20 years (16-32) was sent to all 168 patients. Six of the 58 tibial fracture patients that responded reported pain as their only memory of treatment. Results of tibial fracture treatment were satisfactory with few exceptions: functionally significant axial malalignment, limb length discrepancies nor arthritis was not found excluding four patients with >20° rotational deformity of the tibia. On the contrary 21/52 of the femoral fracture patients examined had angular malalignment of the femur exceeding 10°. Ten patients walked with a limp and leg-length discrepancy of more than 15 mm was measured in 8 patients. Knee arthritis had developed in 6/15 patients who were older than 10 years at the time of the injury. There was a positive correlation between angular deformity and knee arthritis. Treatment injuries were evaluated using patient compensation data from the Finnish Patient Insurance Centre (PIC): 50 claims involving tibial fracture treatment, 30 involving femoral fracture treatment were filed during the study period between 1997-2004. Compensation was granted in 35/50 claims after tibial fracture treatment and in 16/30 after femoral fracture treatment. The most common reasons for compensations in tibial fractures were missed diagnosis and inappropriate casting technique and delay in treatment, unnecessary or inappropriate treatment in femoral fractures. Most of the treatment injuries were regarded in retrospect as avoidable. Satisfactory long-term results in pediatric tibial fractures treated with closed manipulation and cast-immobilization can be expected. Many children require remanipulation to maintain satisfactory alignment, however. Over 10 year old patients with femoral malunion run a high risk of early knee arthritis. Most treatment injuries in pediatric tibial and femoral fractures can be avoided by accurate primary diagnostics, correct casting techniques and appropriate surgery.Lasten ja nuorten tapaturmista noin neljännes on murtumia. Säärimurtuma on lasten kolmanneksi yleisin murtuma (ilmaantuvuus Suomessa 1/1000) ja reisimurtuma (0.3/1000) yksi yleisimmistä sairaalahoitoon johtavista vammoista. Näiden vammojen hoitoon liittyvistä henkilövahingoista tai pitkäaikaishoitotuloksista on vähän tutkimustietoa. Auroran sairaalassa hoidettiin vuosina 1980-89 94 sääri- ja 74 reisimurtumaa, jotka vaativat nukutuksessa suoritetun toimenpiteen. Säärimurtumat hoidettiin viittä lukuun ottamatta ilman leikkausta, mutta lähes puolella potilaista murtuman asentoa jouduttiin myöhemmin korjaamaan kipsissä. Reisimurtumista 62 hoidettiin luuvedolla, 8 leikkaushoidolla ja 4 kipsihoidolla. Potilaille lähetettiin kyselykaavake hoidosta ja kutsu lääkärintarkastukseen sekä röntgenkuvaukseen. Kuusi kyselyyn vastanneista (n=58) ilmoitti kivun ainoana muistonaan säärimurtuman vuoksi saamastaan hoidosta. Hoitotulokset olivat lähes poikkeuksetta hyvät: merkittäviä virheasentoja, alaraajojen pituuseroa tai nivelrikkomuutoksia ei todettu lukuun ottamatta neljää potilasta, joilla oli yli 20° säären kiertovirhe. Sen sijaan lähes puolella 52:sta lääkärintarkastukseen osallistuneista reisimurtumapotilaista oli merkittävä reiden virheasento tai raajojen pituusero ja joka kymmenennellä oli polven nivelrikko. Kasvuikäisten kaikki 50 sääri- ja 30 reisimurtuman hoitoon liittyvää potilasvahinkoilmoitusta vuosilta 1997-2004 analysoitiin. Väärä diagnoosi ja puutteellinen kipsaustekniikka aiheuttivat valtaosan säärimurtumiin liittyvistä potilasvahingoista (n=35). Reisimurtumissa yleisimmät potilasvahinkoon (n=16) johtavat hoitovirheet olivat hoitoviive, tarpeeton tai epäasianmukaisesti toteutettu hoito. Valtaosa potilasvahingoista olisi voitu jälkikäteen arvioituna välttää. Tämän tutkimuksen perusteella kasvuikäisen säärimurtuman hoito voidaan toteuttaa luotettavasti ilman leikkausta. Yli kymmenen vuotiaan potilaan virheasentoon luutunut reisimurtuma on merkittävä riski polven nivelrikon kehittymiselle. Suurin osa potilasvahingoista lasten sääri- ja reisimurtumien hoidossa voidaan välttää huolellisella primaaridiagnostiikalla sekä kipsaus- ja leikkaustekniikalla

Families' costs form a considerable part of total costs in bronchiolitis care

Background and aim: The burden of bronchiolitis is remarkable due to high morbidity in infants. The aim of this study was to evaluate bronchiolitis-associated costs for patients' families and the healthcare system. Methods: This retrospective, descriptive study included 136 infants under 12 months of age treated at Tampere University Hospital, Finland, between October 1, 2018 and March 31, 2020, with bronchiolitis as the main diagnosis. The data consists of patient background and medical information and of estimated costs for the families and for the healthcare system. The data were collected from the hospital's electronic patient files and registries and were analyzed with descriptive statistical analyzes using SPSS v. 26 software. Results: The total median costs associated with bronchiolitis from the perspective of families and healthcare were €16,205 per patient if intensive care was needed and €2266 per patient treated only on the ward. The median costs for the families were €461 and €244, respectively, and for the healthcare system, they were €15,644 and €2019. Conclusion: The majority of the total costs for treatment were due to healthcare costs and only 10% of costs were targeted at families. Bronchiolitis-associated total median costs were 7.2 times higher and the families' costs were 1.9 times higher if intensive care was needed instead of treatment on the ward only.publishedVersionPeer reviewe

Bioimpedance spinal needle provides high success and low complication rate in lumbar punctures of pediatric patients with acute lymphoblastic leukemia

Publisher Copyright: © 2022, The Author(s).In this prospective single-arm study of 50 pediatric patients with acute lymphoblastic leukemia (ALL), we evaluated the clinical performance of a novel bioimpedance spinal needle system in 152 intrathecal treatment lumbar punctures (LP) of these patients. The system detects in real-time when the needle tip reaches the cerebrospinal fluid (CSF) in the spinal canal. The success was defined as getting a CSF sample and/or administering the intrathecal treatment with one needle insertion. Incidence of traumatic LP (TLP) was defined as ≥ 10 erythrocytes/µL of CSF. Post-procedural complications were monitored with a one-week diary and one-month register follow-up. The success of the first attempt was 79.5%, with the CSF detection sensitivity of 86.1%. The incidence of TLP was 17.3%. A successful first attempt was associated with a significantly lower incidence of TLP (10% vs 40%, p = 0.0015). During the week after the procedure, the incidence of post-dural puncture headache was 6%. During the follow-up, no major complications were observed. In conclusion, the novel bioimpedance spinal needle system achieved a high success rate and low incidence of TLP and other complications in pediatric patients with ALL in a real-world clinical setting, indicating clinical utility for this system in pediatric hemato-oncology.Peer reviewe

Antibiotic prescriptions for child sinusitis varied between specialties after Finnish guidelines were updated in 2018

Aim: We evaluated antibiotic prescriptions issued for Finnish children with acute sinusitis by a nationwide private outpatient clinic network from 2014–2020. Data were compared before and after updated guidelines in 2018. Methods: The study comprised data on 45 296 children aged 2–17 years with acute sinusitis, namely diagnoses, ages, dates, the doctor's specialty and any antibiotics. We measured compliance with the updated 2018 Finnish guidelines, which recommended amoxicillin or amoxicillin-clavulanic acid for children under 12 years old, with doxycycline as an alternative for 12 years plus. Results: There were 6621–7585 visits per year for acute sinusitis in 2014–2019 and 2954 in 2020. Antibiotics were prescribed for 37.9%–41.6% of patients during the study years. Amoxicillin, including penicillin, accounted for 35.9% of prescriptions, followed by amoxicillin-clavulanic acid (26.9%). Macrolides accounted for 20.6% and, encouragingly, decreased by 38% from 2014–2019. Doxycycline accounted for 5.3%. Paediatricians, general practitioners (GPs) and ear, nose and throat specialists followed the guidelines in 75.1%, 73.8% and 66.7% of cases, respectively. GPs prescribed antibiotics more often than other physicians. Conclusion: Antibiotics were prescribed for about 40% of acute sinusitis visits by Finnish children from 2014–2019. Specialities differed with regard to prescribing rates and whether they followed the guidelines.publishedVersionPeer reviewe

Changes in Bronchiolitis Incidence During the Last Two Decades in Tampere, Finland : A Retrospective Study

Background: Bronchiolitis, a lower respiratory tract infection, causes a remarkable number of hospitalizations globally. The epidemiology follows the same pattern as respiratory syncytial virus (RSV), the most common pathogen in bronchiolitis. Epidemics have typically followed a biannual pattern in Nordic countries - first, a small epidemic during spring, followed by a higher peak the next autumn. The aim of this study was to evaluate whether the incidence of bronchiolitis hospitalization has changed during the last 2 decades in Tampere, Finland. Methods: In this retrospective register-based study, data on infants <12 months of age hospitalized with bronchiolitis in 2000-2019 were collected from electronic files of Tampere University Hospital and analyzed by monthly incidences. Additionally, data on RSV incidences were collected from the Finnish National Infectious Diseases Register for children <5 years of age and living in the study area. Poisson's regression analysis was used to evaluate changes in the incidence rates of bronchiolitis. Results: Of the 1481 infants hospitalized with bronchiolitis, 82.0% had a diagnosis of RSV bronchiolitis. At first, bronchiolitis' epidemiological pattern followed its typical biannual pattern, then shifted to annual in the middle of the study period, and thereafter occurred biannually again. The highest incidence rate ratios compared to the low-incidence months were between December (22.5), January (25.8) and February (25.5) in 2000-2006, and between February (24.7), March (25.1) and April (21.0) in 2007-2019. Conclusions: The epidemiological pattern of bronchiolitis changed during the study period; incidence peaks were higher and have shifted toward spring in recent years.publishedVersionPeer reviewe

Outpatient Antibiotic Prescribing for 357,390 Children With Otitis Media

AIM: This study aimed to evaluate antibiotic prescriptions for children with otitis media (OM) in a large nationwide network of private clinics between 2014 and 2020. Special focus was paid to amoxicillin and amoxicillin-clavulanic acid prescriptions, which the national guidelines recommend for first-line drugs. We also focused on macrolides, which are commonly prescribed for respiratory tract infections in children but are not appropriate for OM cases. METHODS: The data were obtained from the electronic health records of about 250,000 annual visits in <18 years old children. The collected variables were all diagnoses, age, visit year, doctor's specialty, and prescribed antibiotics. Children with OM and upper respiratory tract infections were included, but those with lower respiratory tract infections were excluded. RESULTS: The number of children with OM was 357,390 (55.2% boys). Antibiotics were prescribed in 44.8% of cases, with the lowest proportion (44.1%) being in <2 years old children. The overall prescription rate decreased from 48.3% in 2014 to 41.4% in 2020. The rates were 19.3% and 18.1% for amoxicillin and 12.6% and 13.2% for amoxicillin-clavulanic acid, respectively. Macrolide prescriptions were reduced from 7.5% to 3.5%. Pediatricians prescribed antibiotics for 38.8%, general practitioners for 54.0% and ear, nose and throat physicians for 39.8% of children with OM. CONCLUSION: The selection of antibiotics for OM, when prescribed, was according to the recommendations (amoxicillin or amoxicillin-clavulanic acid) in 80.1% of pediatricians, 67.0% of general practitioners and 55.1% of ear, nose and throat physicians.publishedVersionPeer reviewe

Systematic analysis of adverse incident reports revealed the need for improvements in the neonatal unit

Aim: The aims were to characterise adverse incident reports and recommendations to avoid the reoccurrence of adverse incidents and detect a possible increase in incidents outside of office hours and on vacation season. Methods: Analysis of adverse incidents reported at the neonatal intensive care unit of Tampere University Hospital in Finland between 2013 and 2020. Results: Analysis of 925 fully processed adverse incident reports revealed that 36.3% of the reports were related to medication, fluid management and blood products, and 34.8% of these were administering errors. Nurses reported 828 (89.5%) adverse incidents and physicians reported 37 (4.0%). Near misses constituted 35.3% of nurses' and 21.6% of physicians' reports. There were significantly more adverse incident reports on day shifts, on Thursdays and, Saturdays and in June, November and December than at other times. The interventions recommended were to inform the staff or other parties after 673 (72.7%) reports and to recommend improvements after 56 (6.0%) reports. Conclusion: Analysis of adverse incident reports can reveal the need for improvements in existing protocols in the neonatal intensive care unit.Peer reviewe

Childhood femoral fracture can lead to premature knee-joint arthritis

Peer reviewe

Use of antibiotics contrary to guidelines for children’s lower respiratory tract infections in different health care settings

This study aimed to evaluate antibiotic prescriptions for children with lower respiratory tract infection (LRTI) in public and private primary care clinics and in a hospital’s pediatric emergency department (PED) in 2012–2013 (pre-guideline) and in 2014–2015 (post-guideline). Special attention was paid to guideline compliance, especially regarding macrolide prescriptions, which the guidelines discourage. Retrospective data of 1431 children with LRTI in November–December 2012–2015 were collected from electronic registers and checked manually. Three diagnostic groups were analyzed: community-acquired pneumonia (CAP), wheezing bronchitis, and non-wheezing bronchitis. A comparison of the pre- and post-guideline periods revealed antibiotic prescription rates of 48.7% and 48.9% (p = 0.955) for all LRTIs, respectively, and 77.6% and 71.0% (p = 0.053) for non-wheezing bronchitis. The prescription rates for all LRTIs were 24.9% in PED and 45.9% in public (p < 0.001 vs. PED) and 75.4% in private clinics (p < 0.001 vs. PED and p < 0.001 vs. public clinics). During post-guideline periods, antibiotics were prescribed for CAP less often in private (56.3%) than in public clinics (84.6%; p = 0.037) or in PED (94.3%; p < 0.001 vs. private and p = 0.091 vs. public primary clinics). Macrolide prescriptions were highest in private clinics (42.8%), followed by public primary care clinics (28.5%; p < 0.05) and PED (0.8%; p < 0.05 vs. both public and private primary care). Amoxicillin was the predominant antibiotic in public primary care and PED and macrolides in private primary care. Conclusion: Antibiotic prescribing for children with LRTI differed significantly between healthcare providers. CAP was undertreated and bronchitis overtreated with antibiotics in primary care, especially in the private clinics. What is Known: • Clinical Treatment Guidelines tend to have modest effect on physicians’ antibiotic prescribing habits. • Pediatric viral LRTIs are widely treated with unnecessary antibiotics. What is New: • Remarkable differences in antibiotic prescriptions in pediatric LRTIs between Finnish private and public providers were observed. • Overuse of macrolides was common especially in private clinics.Peer reviewe

Traumatic lumbar punctures in diagnostic and intrathecal treatment punctures of pediatric hemato-oncology patients

Successful first diagnostic lumbar puncture (LP) is crucial because intrathecal chemotherapy has not yet protected the central nervous system against cancer cells. If blood contaminates the cerebrospinal fluid (CSF) with blasts, they may enter the central neural system and compromise the patient's health. We retrospectively determined the incidence of traumatic lumbar punctures (TLP) in 2,507 LPs of 250 pediatric hemato-oncology patients aged from one to 18 years, including both diagnostic and intrathecal treatment procedures, and 2,617 LPs of 1,525 other age-matched pediatric patients. We used >= 10 erythrocytes/mu L in the CSF sample as the criterion of TLP. TLPs were less frequent in hemato-oncology patients than in other patients (31.6% vs. 48.5%, p < 0.0001). The incidence of TLP was significantly lower in the first diagnostic LP than in subsequent intrathecal treatment LPs (20.5% vs. 31.6%, p = 0.0046). According to logistic regression analysis, the odds of TLP was 1.6-fold if the LP procedure was not performed in the hemato-oncology department. The odds of the patient's next LP being traumatic were threefold if the previous first LP was traumatic. A week or less time between the first and next LP tripled the odds of TLP as well. The patient's age category was not significantly associated with the incidence of TLP. Given the risks of TLP, hemato-oncology patients' first diagnostic LP should include administration of chemotherapy, as generally recommended, and be performed under general anesthesia or deep sedation by an experienced physician to optimize not only the success of the first LP procedure but also following procedures