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Background Musculoskeletal injury, including fracture, is one of the most common causes of morbidity in pediatric patients. The purpose of this epidemiologic study is to determine the prevalence and risk factors for fracture in a large cohort of pediatric patients under the age of 5. Results Of the 233,869 patients included in the study, 13,698 fractures were identified in 10,889 patients. The highest annual incidence was in the 4 year old age group with a rate of 24.2 fractures per 1000 children. The annual incidence within all age groups was 11.7 fractures per 1000 children. The two most common fractures were forearm and humerus fractures. Fracture incidence was increased in male children, patients who live outside the US, and in Caucasian patients. An increase in rate of fracture was also identified in children of officers when compared with children of enlisted service members. There were 35 abuse related fractures in our cohort, with 19 of them occurring in children less than 1 year old. Only three children in our cohort had Osteogenesis Imperfecta. Conclusion Fractures are common injuries in young children with an incidence over the first 5 years of life of 5.86%. Multiple risk factors were also identified including age, race, geographic location and socioeconomic status. The results of this study are an important contribution to epidemiologic and public health literature and serve to characterize the incidence of and risk factors for sustaining an early childhood fracture.

BackgroundEndometrial stromal sarcomas (ESSs) are rare, indolent tumors with high recurrence rates. Management includes surgery and hormonal therapy given high estrogen and progesterone receptor (ER/PR) expression.CaseA pre-menopausal patient with stage II ESSs (ER +/PR +) underwent primary surgery followed by adjuvant megestrol. Recurrence in the bladder/upper vagina (ER +/PR −) was diagnosed one year later and treated with anterior pelvic exenteration and adjuvant letrozole. Two years later she recurred and was treated with radical surgery and adjuvant exemestane therapy (tumor ER strongly +/PR +). The patient then had a five-year disease free interval before being diagnosed with her third recurrence (ER +).ConclusionExemestane treatment for ESSs can lead to a prolonged response, even in the setting of progression after prior aromatase inhibitor treatment.

Background: Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. Methods: TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5 years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. Results: A total of 378 150 patients comprised the final cohort with 3.3% (n = 12 479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR = 0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR = 1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. Conclusions: We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent. K E Y W O R D Sfracture, multiple gestation, prenatal medications

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