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IntroductionAvoiding over-investigation and overtreatment in health care is a challenge for clinicians across the world, prompting the international Choosing Wisely campaign. Lists of recommendations regarding medical overactivity are helpful tools to guide clinicians and quality improvement initiatives. We aimed to identify the most frequent and important clinical challenges related to pediatric medical overactivity in Europe and Japan. Based on the results, we aim to establish a (European) list of Choosing Wisely recommendations.MethodsIn an online survey, clinicians responsible for child health care in Europe and Japan were invited to rate 18 predefined examples of medical overactivity. This list was compiled by a specific strategic advisory group belonging to the European Academy of Paediatrics (EAP). Participants were asked to rate on a Likert scale (5 as the most frequent/important) according to how frequent these examples were in their working environment, and how important they were considered for change in practice.ResultsOf 2,716 physicians who completed the survey, 93% (n = 2,524) came from 17 countries, Japan (n = 549) being the largest contributor. Pediatricians or pediatric residents comprised 89%, and 51% had 10–30 years of clinical experience. Cough and cold medicines, and inhaled drugs in bronchiolitis were ranked as the most frequent (3.18 and 3.07 on the Likert scale, respectively), followed by intravenous antibiotics for a predefined duration (3.01), antibiotics in uncomplicated acute otitis media (2.96) and in well-appearing newborns. Regarding importance, the above-mentioned five topics in addition to two other examples of antibiotic overtreatment were among the top 10. Also, IgE tests for food allergies without relevant medical history and acid blockers for infant GER were ranked high.ConclusionOvertreatment with antibiotics together with cough/cold medicines and inhaled drugs in bronchiolitis were rated as the most frequent and important examples of overtreatment across countries in Europe and Japan.

Introduction in the elderly patient population, where fracture comminution, osteoporotic fractures, and associated arthritis or rotator cuff pathologies dominate, metadiaphyseal proximal humeral fracture is a challenging subset of fractures to treat. This study reports on cementless long-stem reverse total shoulder arthroplasty (RTSA) as primary treatment of metadiaphyseal proximal humeral fractures in elderly patients. Materials & Methods Between January 2018 and October 2021, 22 consecutive patients sustained proximal humerus fractures with metadiaphyseal extension and underwent surgery with cementless long-stem RTSA. Patients older than 60 years with minimum 1 year of clinical and radiographic follow-up were included. Patient demographics, range of motion, and patient reported outcomes [Visual Analog Scale (VAS) pain scale, Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), and American Shoulder Elbow Surgeon (ASES) scores] were retrospectively collected. Postoperative X-rays were evaluated for fracture and tuberosity union. Results There were 14 eligible patients with a median age of 71 years (range 61-91 years) and a median 13 months follow-up. At final follow-up, the median active elevation was 120° (range 80°-150°), external rotation was 40° (range 0°-50°), and internal rotation was 40° (range 0°-80°). Median VAS was 2 (range 0-8), SST was 71% (range 33%-92%), SSV was 78% (range 20-90%), and ASES was 73 (range 17-90). All patients exhibited radiographic union. There were five minor complications in three patients: postoperative neuropathy, tuberosity nonunion, scapula notching, and proximal humeral stress shielding. Conclusion Cementless long-stem RTSA is a viable alternative to primary fracture fixation in the elderly patient population with metadiaphyseal proximal humerus fractures.

BackgroundIt has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment.MethodsIn this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare.ResultsTo date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe.DiscussionWe reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.

This article opens a window on the world of chaplains supporting seafarers, which has largely been neglected by the literature. Shipping happens in ports, which are often far away from urban centres. It is thus removed from everyday experience making seafarers an invisible population and, with them, the chaplains who assist them. The article proposes to view chaplains' service to seafarers as a form of 'embodied' hospitality. It is an offer of a relationship as well as of assistance. The angle of hospitality sheds light on the dynamics of the relationships between seafarers and chaplains, the tensions and opportunities for exchange. The ethic of chaplains' hospitality that emerges from the observation and interviews is one of 'compassion' requiring openness to and acceptance of the other. Compassion, here, is the recognition of the dignity of the other based on a shared humanity.

Abstract Background Primary meningococcal arthritis is a rare infectious disease that occurs in less than 3% of meningococcal infections and is characterized by arthritis without meningitis, fever, rash, or hemodynamic instability Barahona [Case Rep Orthop 4696014:2017 ]. There are no validated clinical criteria that can be used for the diagnosis. We present two pediatric cases of atypical presentation of meningococcal disease revealed by molecular tests. Case presentation The clinical presentation of the two children (6- and 9-years-old) was characterized by signs of arthritis. By Real Time Polymerase Chain Reaction (RT-PCR), we identified N. meningitidis serogroup Y in the joint fluid in both cases. After specific antimicrobial treatment, the clinical conditions of the two patients quickly improved during hospitalization. Conclusions. We believe that the incidence of meningococcal arthritis could be underestimated in those settings where the use of RT-PCR is limited. Clearer data on the incidence of meningococcal disease would help to design specific treatments and the best possible national vaccine strategies [Fiji Sci Rep 23:39784, 2016, J Infect 67:385-90, 2013].

Protein-losing enteropathy (PLE) is a rare condition characterized by protein loss through the gastrointestinal tract, leading to hypo-proteinemia. Patients may be asymptomatic or present with variety of complications of hypoproteinemia (e.g., oedema, ascites, pleural, and cardial effusions). We describe a case report of a young girl suffering from behavioral disorder since childhood who presented with generalized oedema, hypoproteinaemia, and microcytic hypochromic anemia. In addition, the girl had an intervention for jejunal atresia and intestinal malrotation in her past medical history. Upper gastrointestinal endoscopy revealed a trichobezoar extending from stomach into the small bowel, thus classified as Rapunzel Syndrome (RS), causing mechanical obstruction of intestinal lumen and intestinal lymphatic drainage resulting in a protein-losing enteropathy (PLE). Trichobezoar was successfully removed by a surgical laparotomy resulting in resolution of symptoms and normalization of biochemical parameters. Possibly, previous surgery might have had an influence on intestinal dysmotility and trichobezoar formation. PLE is a very rare presenting symptom of RS, developing as result of intestinal obstruction caused by large trichobezoars. RS has to be considered in patients, especially adolescents, suffering from behavior disorder as trichotillomania and trichophagia. Surgical removal and nutritional supplementation are the gold treatment of large trichobezoar.