Radiographic calibration for pubic diastasis assessment in bladder exstrophy-epispadias complex: a phantom study.

BACKGROUND: The assessment of pubic diastasis is important for the surgical planning of patients with bladder exstrophy-epispadias complex. Understanding how the diastasis changes during surgical follow-up may help predict patient morbidity. Radiography can follow diastasis but may be affected by patient and technical imaging factors including body size, imaging protocol, and equipment. Using imaging calibration and anatomic ratios may mitigate differences due to these aspects. OBJECTIVE: Use imaging phantoms to assess the effect of radiographic calibration on measurements of pubic diastasis and an internal anatomic ratio as a child grows. MATERIALS AND METHODS: Radiographic images were obtained of three different sizes of computed tomography phantoms (older child, child, and infant) using three imaging techniques that include the osseous pelvis in children. All phantoms were imaged with abdomen and pelvis techniques. The infant phantom was additionally imaged using a thoracoabdominal technique. These exposures were all repeated with systems from three manufacturers. Linear measurements were made between radiographic markers placed to simulate pubic diastasis and sacral width. A ratio was also created between these distances. Measurements with and without image calibration were made by two pediatric radiologists using rulers placed at the time of image acquisition. RESULTS: There was excellent interrater agreement for measurements, ICC >0.99. Anterior distances were more affected by magnification than posterior ones with a significant difference between uncalibrated versus calibrated anterior distances (p=0.04) and not for posterior ones (p=0.65). There was no difference between radiographic equipment manufacturers without or with calibration (p values 0.66 to 0.99). There was a significant difference in simulated pubic distance between thoracoabdominal and abdomen (p=0.04) as well as pelvic (p=0.04) techniques which resolved with calibration, each p=0.6. The ratio between the simulated pubic diastasis and sacral width differed by phantom size (all p<0.01) and imaging technique (p values 0.01 to 0.03) with or without calibration. However, the numerical differences may not be clinically significant. CONCLUSION: Image calibration results in more uniform measurements that are more accurate than uncalibrated ones across patient size, imaging techniques, and equipment. Image calibration is necessary for accurate measurement of inter-pubic distances on all projection imaging. Small differences in the pelvic ratio likely are not clinically significant, but until there is a better understanding, image calibration may be prudent.

Impact of Cost Information on Parental Decision Making: A Randomized Clinical Trial Evaluating Cast Versus Splint Selection for Pediatric Distal Radius Buckle Fractures.

BACKGROUND: Price transparency purports to help patients make high-value health care decisions, however, there is little data to support this. The pediatric distal radius buckle fracture (DRBF) has 2 equally efficacious but not equally priced treatment options (cast and splint), serving as an excellent potential model for studying price transparency. This study uses the DRBF model to assess the impact of up-front cost information on a family's treatment decisions when presented with clinically equivalent treatment options for a low-risk injury. METHODS: Participants age 4 to 14 presenting with an acute DRBF to a hospital-based pediatric orthopaedic clinic were recruited for this randomized controlled trial. Participants were randomized into cost-informed or cost-blind cohorts. All families received standardized information about the injury and treatment options. Cost-informed families received additional cost information. Both groups were allowed to freely choose a treatment. Families were surveyed regarding their decision factors. Cost-blinded families were subsequently presented with the cost information and could change their decision. Independent samples t tests and χ2 tests were utilized to evaluate differences. RESULTS: A total of 127 patients were enrolled (53% cost-informed, 47% cost-blind). The 2 groups did not significantly differ in demographics. Immobilization selection did not differ between groups, with 48% of the cost-informed families selecting the more expensive option (casting), compared with 47% of the cost-blind families. Cost was the least influential factor in the decision-making process according to participant survey, influencing only 9% of families. Only one family changed their decision after receiving cost information, from a splint to a cast. CONCLUSION: Families appear to be cost-insensitive when making medical treatment decisions for low-risk injuries for their child. Price transparency alone may not help families arrive at a decision to pursue high-value treatment in low-risk orthopaedic injuries. LEVEL OF EVIDENCE: Level I.

A Comparison of Motorized and Nonmotorized Scooter Injuries in Pediatric Patients Seen in US Emergency Departments.

OBJECTIVES: We sought to characterize and compare trends in pediatric injuries sustained on motorized and nonmotorized scooters across the United States, to assess the use of safety equipment in children presenting with scooter-related injuries, and provide strategies for injury prevention. METHODS: The National Electronic Injury Surveillance System was queried for motorized and nonmotorized scooter-related pediatric injuries from 2014 to 2018 in patients ages 6 to 12 years. Patient demographics, diagnosis, injury location, and narrative of the incident were collected. Bivariate and regression analyses were used to determine demographic and social associations of injury characteristics. RESULTS: An estimated 146,000 (11,452 motorized and 134,548 nonmotorized) injuries occurred in children ages 6 to 12 years over the 5 years. Three of 4 injuries occurred in children younger than 10 years, and most injuries occurred in males (56%).From 2014 to 2018, the nationwide estimated incidence of motorized scooter injuries increased by 112.1%, while that of nonmotorized scooter injuries decreased by 40.3%.Upper extremity injuries were most common with nonmotorized scooters (44.4% of all injuries), while lower extremity injuries were most common with motorized scooters (39.5% of all injuries). Head and neck injuries accounted for 27.4% of nonmotorized scooter injuries and 23.4% of motorized scooter injuries. The number of concussions in motorized scooters increased from 0.4% in 2014 to 2.7% in 2018, while concussions in nonmotorized scooters decreased from 3.5% to 2.7%. Helmets were mentioned in the medical record in 6.6% of the cases. Of these, 60.5% reported no use of helmet at the time of injury. CONCLUSIONS: From 2014 to 2018, the number of motorized scooter injuries increased by 112.1% in the pediatric population ages 6 to 12 years, whereas nonmotorized scooter injuries decreased by 40.3%. In more than 60% of the cases that mentioned a helmet, the child injured was recorded as not wearing a helmet. The rise in pediatric injuries associated with motorized scooters in contrast with the reduction of injuries associated with nonmotorized scooters highlights the need for novel public health policies and interventions promoting helmet use with motorized scooters in the pediatric population.

Epidemiology and management of appendicular fractures occurring in neonatal intensive care patients.

AIM: To describe the epidemiology and management of appendicular fractures occurring in the neonatal ICU in a large series of patients treated a single, quaternary care neonatal intensive care unit. METHODS: Patients <1 years old with appendicular fractures treated from 2012 to 2016 at a quaternary-level NICU were identified. Bivariate testing compared fractures, work-up and management based on designated mechanism (presumed birth-related vs unknown). In patients with unknown mechanism, factors with potential fracture association were analysed in a descriptive fashion. RESULTS: Eighty-five fractures (54 patients) were included. Mechanistic cohorts differed by birthweight (P < .001) and gestational age at birth (P < .001). Presumed birth-related fractures were more commonly upper extremity (P < .001), solitary (P = .001) and radiographically diagnosed in the acute state (<.001). The biochemical profile of the cohorts differed significantly. The prevalence of factors with potential fracture association was high in patients with unknown mechanism. Only one patient required surgery, while all others resolved with minimal orthopaedic intervention. CONCLUSION: Findings indicate these injuries rarely require operative intervention and that two distinct injury profiles appear to exist based on fracture mechanism. Steroid use, ventilation use, diuretic use, nutritional supplementation and recent bedside procedures were common among patients without known fracture mechanism. LEVEL OF EVIDENCE: Level III-Retrospective Cohort Study.

The impact of behavioural risk reduction interventions on willingness to pay to avoid sexually transmitted infections: a stated preference study of justice-involved youth.

Risky health behaviours, such as smoking, drinking and risky sex, are substantial contributors to US morbidity rates and healthcare costs. While economic models typically regard preferences as stable, a growing literature suggests that information, including how it interacts with intentions and attitudes, plays an important role in unhealthy behaviours. Relatedly, a large health literature demonstrates that theory-based behavioural interventions can successfully change risky behaviour. This study uses the contingent valuation survey method to investigate the impact of behavioural interventions on a novel outcome measure: the willingness to pay (WTP) to avoid the consequences associated with risky behaviour. Using novel pre- and post-intervention data from Project MARS (Motivating Adolescents to Reduce Sexual Risk) this study estimates the impact of the intervention on elicited WTP to avoid sexually transmitted infections (STI). It is found that after the intervention, participants' elicited WTP to avoid STIs were significantly higher, and more sensitive to differences in infection severity. These results suggest that the intervention may affect risky sexual behaviour by changing the perceived value of avoiding the consequences of risky sexual behaviour. Additionally, these findings contribute to an ongoing debate regarding the construct validity of contingent valuation studies in health economics.

Filling gaps in notification data: a model-based approach applied to travel related campylobacteriosis cases in New Zealand.

BACKGROUND: Data containing notified cases of disease are often compromised by incomplete or partial information related to individual cases. In an effort to enhance the value of information from enteric disease notifications in New Zealand, this study explored the use of Bayesian and Multiple Imputation (MI) models to fill risk factor data gaps. As a test case, overseas travel as a risk factor for infection with campylobacteriosis has been examined. METHODS: Two methods, namely Bayesian Specification (BAS) and Multiple Imputation (MI), were compared regarding predictive performance for various levels of artificially induced missingness of overseas travel status in campylobacteriosis notification data. Predictive performance of the models was assessed through the Brier Score, the Area Under the ROC Curve and the Percent Bias of regression coefficients. Finally, the best model was selected and applied to predict missing overseas travel status of campylobacteriosis notifications. RESULTS: While no difference was observed in the predictive performance of the BAS and MI methods at a lower rate of missingness (<10 %), but the BAS approach performed better than MI at a higher rate of missingness (50 %, 65 %, 80 %). The estimated proportion (95 % Credibility Intervals) of travel related cases was greatest in highly urban District Health Boards (DHBs) in Counties Manukau, Auckland and Waitemata, at 0.37 (0.12, 0.57), 0.33 (0.13, 0.55) and 0.28 (0.10, 0.49), whereas the lowest proportion was estimated for more rural West Coast, Northland and Tairawhiti DHBs at 0.02 (0.01, 0.05), 0.03 (0.01, 0.08) and 0.04 (0.01, 0.06), respectively. The national rate of travel related campylobacteriosis cases was estimated at 0.16 (0.02, 0.48). CONCLUSION: The use of BAS offers a flexible approach to data augmentation particularly when the missing rate is very high and when the Missing At Random (MAR) assumption holds. High rates of travel associated cases in urban regions of New Zealand predicted by this approach are plausible given the high rate of travel in these regions, including destinations with higher risk of infection. The added advantage of using a Bayesian approach is that the model's prediction can be improved whenever new information becomes available.

Does Perfusion MRI After Closed Reduction of Developmental Dysplasia of the Hip Reduce the Incidence of Avascular Necrosis?

BACKGROUND: Gadolinium-enhanced perfusion MRI (pMRI) after closed reduction/spica casting for developmental dysplasia of the hip (DDH) has been suggested as a potential means to identify and avoid avascular necrosis (AVN). To date, however, no study has evaluated the effectiveness of pMRI in clinical practice or compared it with other approaches (such as postreduction CT scan) to show a difference in the proportion of AVN. QUESTIONS/PURPOSES: (1) Can a pMRI-based protocol be used immediately post closed reduction to minimize the risk that AVN would develop? (2) What are the overall hip-related outcomes after closed reduction/spica casting using this protocol? (3) Do any patient-specific factors at the time of closed reduction predict future AVN? METHODS: This was a retrospective cohort study at a large tertiary care children's hospital. Between 2009 and 2013 we treated 43 patients with closed reduction/spica casting for DDH, of whom 33 (77%) received a postreduction pMRI. All patients were indicated for pMRI per treating surgeon preference. A convenience sample totaling 25 hips in 22 patients treated with pMRI was then established using the following exclusion criteria: DDH of neuromuscular/syndromic origin, failed initial closed reduction, less than 1 year of clinical and radiographic followup, and subsequent open reduction. Next, the 40 patients treated with closed reduction between 2004 and 2009 were screened until the chronologically most recent 25 hips (after applying the previously mentioned exclusion criteria) were identified in 21 of the first 34 patients (62%) screened. Although termed the CT group, specific postreduction imaging was not a defined inclusion criterion in this group with the majority (21 of 25 [84%]) receiving postreduction CT and the remainder (four of 25 [16%]) receiving only postreduction radiographs. All hips with globally decreased femoral head perfusion on postreduction pMRI were treated with immediate cast removal followed by repeat closed reduction or open reduction, as per surgeon preference, with two of 33 (6%) requiring such further interventions. Salter criteria were then used to determine the proportion of AVN on radiographs at 1-year and final followup. Secondary outcomes including residual dysplasia and the need for further corrective surgery were ascertained through radiographic and retrospective chart review. RESULTS: At 1-year followup there was no difference in the proportion of AVN in the historical CT group as compared with the pMRI group (six of 25 [24%] versus one of 25 [4%]; odds ratio [OR], 7.6; 95% confidence interval [CI], 0.8-363; p = 0.098). However, by final followup there was a statistically higher proportion of AVN in the CT group (seven of 25 [28%] versus one of 25 [4%]; OR, 9.3; 95% CI, 1.0-438; p = 0.049). No patient with normal perfusion on postreduction pMRI went on to develop AVN. In those pMRI patients in whom a successful reduction was initially obtained, two of 25 (8%) went on to require further corrective surgery and one of 25 (4%) had a redislocation event. With the numbers available, no patient-specific factors at the time of closed reduction were predictive of future AVN, including the patient's age/weight, the presence of an ossific nucleus, history of previous bracing treatment, or the abduction angle in spica cast. CONCLUSIONS: A pMRI-based protocol immediately after closed reduction/spica casting may decrease the risk of AVN by helping the surgeon to evaluate femoral head vascularity. Although preliminary in nature, this study could serve to guide further investigation into the potential role of pMRI for the treatment of patients who require closed reduction/spica casting for DDH. LEVEL OF EVIDENCE: Level III, therapeutic study.

Common Patterns of Congenital Lower Extremity Shortening: Diagnosis, Classification, and Follow-up.

Congenital lower limb shortening is a group of relatively rare, heterogeneous disorders. Proximal focal femoral deficiency (PFFD) and fibular hemimelia (FH) are the most common pathologic entities in this disease spectrum. PFFD is characterized by variable degrees of shortening or absence of the femoral head, with associated dysplasia of the acetabulum and femoral shaft. FH ranges from mild hypoplasia to complete absence of the fibula with variable shortening of the tibia. The development of the lower limb requires complex and precise gene interactions. Although the etiologies of PFFD and FH remain unknown, there is a strong association between the two disorders. Associated congenital defects in the lower extremity are found in more than 50% of patients with PFFD, ipsilateral FH being the most common. FH also has a strong association with shortening and bowing of the tibia and with foot deformities such as absence of the lateral rays of the foot. Early diagnosis and radiologic classification of these abnormalities are imperative for appropriate management and surgical planning. Plain radiography remains the main diagnostic imaging modality for both PFFD and FH, and appropriate description of the osseous abnormalities seen on radiographs allows accurate classification, prognostic evaluation, and surgical planning. Minor malformations may commonly be misdiagnosed.

Comparative results of percutaneous Achilles tenotomy to combined open Achilles tenotomy with posterior capsulotomy in the correction of equinus deformity in congenital talipes equinovarus.

PURPOSE: The purpose of this study is to compare the efficacy of percutaneous Achilles tenotomy (AT) to combined open Achilles tenotomy and posterior capsulotomy (PC+AT) in the correction of residual equinus deformity in congenital talipes equinovarus after Ponseti serial casting in both idiopathic and non-idiopathic clubfeet. METHODS: The authors retrospectively reviewed 591 patients treated for congenital talipes equinovarus between January 1, 2001 and January 1, 2011. Available medical and operative records were reviewed for basic demographic data as well as ankle dorsiflexion pre-operatively, postoperatively and at latest follow up. RESULTS: A total of 167 children with 260 discrete clubfeet that met our inclusion criteria were identified. Of them, 189/260 clubfeet (72.7 %) were idiopathic and 71/260 clubfeet (27.3 %) were non-idiopathic with a mean total follow up of 4.8 ± 2.4 years (minimum follow-up of two years). At latest follow up, there was no statistically significant difference in the mean ankle dorsiflexion (p = 0.333) or recurrence rate (p = 0.545) between PC+AT and AT groups in both idiopathic and non-idiopathic clubfeet. CONCLUSION: In our series, the addition of posterior capsulotomy to Achilles tenotomy did not improve the mean dorsiflexion at latest follow up or decrease the rate of recurrence of equinus deformity in both idiopathic and non-idiopathic clubfeet. It is therefore advisable that percutaneous Achilles tenotomy alone be used in the correction of equinus deformity in both idiopathic and non-idiopathic congenital talipes equinovarus after successful Ponseti serial casting.

Incubation period for campylobacteriosis and its importance in the estimation of incidence related to travel.

Differentiation between travel-related and domestic cases of infectious disease is important in managing risk. Incubation periods of cases from several outbreaks of campylobacteriosis in Canada, Europe, and the United States with defined exposure time of less than 24 hours were collated to provide information on the incubation period distribution. This distribution was consistent across the varied outbreaks considered, with 84% (702/832) of cases having an incubation period of four days or less and 1% having an incubation period of eight days or more. The incubation period distribution was incorporated into a model for the number of travel-related cases presenting with symptom onset at given dates after return to their country of residence. Using New Zealand notification data between 2006 and 2010 for cases who had undertaken foreign travel within 10 days prior to symptom onset, we found that 29.6% (67/227 cases; 95% confidence interval (CI): 28.3­30.8%) of these cases were likely to have been domestic cases. When cases with symptom onset prior to arrival were included, the probable domestic cases represented 11.8% (67/571; 95% CI: 11.2­12.3%). Consideration of incubation time distributions and consistent collection of travel start/end dates with symptom onset dates would assist attribution of cases to foreign travel.

Racial differences in late-onset Blount disease.

Purpose: Blount disease is most common among obese Black children. The reason for Blount's racial predisposition is unclear. Given that obesity is a risk factor for Blount disease and the known associations between race, obesity, and socioeconomic status in the United States, we hypothesized that socioeconomic status and severity of obesity differ between Black and non-Black children with late-onset Blount disease. We additionally examined differences in treatment types between Black and non-Black children. Methods: One hundred twenty-five patients from two institutions were included. Age at presentation, age of onset, body mass index, race, sex, and treatment type were recorded. These variables were compared between Black and non-Black children. Insurance type and estimated household income were used as markers of socioeconomic status. Results: Of the 125 patients with late-onset Blount disease, body mass index percentiles were higher for Black patients (96th ± 12th percentile) than non-Black patients (89th ± 22nd percentile) (p = 0.04). Black patients also had lower estimated incomes (US$48,000 ± US$23,000 vs US$62,000 ± US$30,000) (p = 0.01) and much higher rates of Medicaid enrollment (69% vs 24%) (p < 0.01) than did non-Black patients. Regarding treatment types, osteotomy was more common among Black patients (60%) than non-Black patients (38%) (p = 0.033). Conclusion: The race-related associations we found between obesity and socioeconomic status suggest that non-genetic factors may contribute to observed racial differences in the prevalence of Blount disease. Level of evidence: level III.

Natural History of Bilateral Congenital Absence of the L4 Pedicles.

CASE: A 5-month-old girl was diagnosed with congenital bilateral absence of the L4 pedicles and an absent right kidney. She developed a right thoracic scoliosis at age 3 that was treated with a brace. At her most recent follow-up at age 16, she was skeletally mature and had a residual 20° right thoracic scoliosis. She was pain-free, had a normal neurological examination, and was fully active. CONCLUSION: This case presents a long-term follow-up of a patient with congenital bilateral absence of L4 pedicles. She developed scoliosis that was successfully treated with bracing. No other significant issues developed over 15 years of follow-up.

Post-Operative Splinting Versus Casting of Pediatric Supracondylar Humerus Fractures.

Background Supracondylar humerus fractures (SCH) are common upper extremity fractures in children and are usually treated by closed reduction and percutaneous pinning. Post-operative management may cause complications, but the difference between cast and splint has not been closely investigated. Purpose Our objective was to compare casting and splinting of SCH fractures with respect to post-operative complications. Patients and methods We reviewed 1,146 pediatric SCH fractures that were reduced, percutaneously pinned, and immobilized by cast or splint. Open fractures, openly reduced fractures, and pre-operative neurological injuries were excluded. Over the course of immobilization, we noted if the initial cast or splint was maintained and if the patient returned due to complications. Results Post-operative casting was performed on 1,091 (95.2%) fractures and 55 (4.8%) were splinted. Age was a significant factor, increasing the likelihood of splinting by 12% with each year of age (p = 0.023). A total of 28 patients (2.4%) returned for unscheduled visits due to immobilization complaints, infection, and pain, but the rate difference between cast and splint was negligible. Reoperation was required for five patients (0.4%), and more likely for splinted fractures (p = 0.021). After controlling for age, splinting was still associated with reoperation (OR: 15.1, p = 0.004). Conclusions Although complications inevitably exist, both casting and splinting are effective immobilization methods. Both resulted in few complications such as post-operative discomfort, pain, infection, loss of reduction, or damage. It was difficult to evaluate significance with few splinted cases, but considering no major differences between splinted and casted fractures, clinicians should consider splinting to reduce the cost associated with casting.

Source attributed case-control study of campylobacteriosis in New Zealand.

BACKGROUND: Following an initial reduction in human campylobacteriosis in New Zealand after the implementation of poultry food chain-focused interventions during 2006-2008, further decline has been relatively small. We report a year-long study of notified campylobacteriosis cases, incorporating a case control study combined with a source attribution study. The purpose was to generate up-to-date evidence on the relative contributions of different sources of campylobacteriosis in New Zealand. METHODS: The study approach included: • A case-control study of notified cases (aged six months or more) sampled in a major urban centre (Auckland, every second case) and a mixed urban/rural area (Manawatu/Whanganui, every case), between 12 March 2018 and 11 March 2019. • Source attribution of human campylobacteriosis cases sampled from these two regions over the study period by modelling of multilocus sequence typing data of Campylobacter jejuni and C. coli isolates from faecal samples of notified human cases and relevant sources (poultry, cattle, sheep). RESULTS: Most cases (84%) were infected with strains attributed to a poultry source, while 14% were attributed to a cattle source. Approximately 90% of urban campylobacteriosis cases were attributed to poultry sources, compared to almost 75% of rural cases. Poultry consumption per se was not identified as a significant risk factor. However specific risk factors related to poultry meat preparation and consumption did result in statistically significantly elevated odds ratios. CONCLUSIONS: The overall findings combining source attribution and analysis of specific risk factors indicate that poultry meat remains a dominant pathway for exposure and infection.

Adaptations of energy metabolism in the cultivated macrophage.

Adaptive changes in energy metabolism, as reflected by pyruvate kinase and cytochrome oxidase activities, were examined during in vitro differentiation of the cultivated macrophage. Serum concentrations of tissue culture media, which directly influence endocytic activity, and ambient oxygen tension were both shown to influence pyruvate kinase and cytochrome oxidase activities. Cells maintained in high serum concentrations (30% newborn calf serum [NBCS]) exhibited a 300-400% increase in pyruvate kinase activity and a 40% increase in cytochrome oxidase activity, whereas cells maintained in low serum concentrations (2% NBCS) exhibited a lesser increase (65%) in pyruvate kinase activity and no change in cytochrome oxidase activity. Anaerobiosis resulted in additional alterations in pyruvate kinase and cytochrome oxidase activities. Cells maintained for 48-72 h under anaerobic conditions exhibited a 500-600% increase in pyruvate kinase activity and a 40% decrease in cytochrome oxidase activity. Increased pyruvate kinase activity was dependent on continued protein synthesis. Enzyme increases occurred in anaerobically cultured cells despite an overall reduction in cell protein synthesis. It is suggested that adaptive changes in pyruvate kinase and cytochrome oxidase activity resulting from alterations in either serum concentration or ambient oxygen tension are regulated by two independent mechanisms. One mechanism is aimed at providing energy for endocytic activity and the other in compensating for impaired oxidative metabolism during anaerobiosis.

Off-label use of rituximab in a tertiary Queensland hospital.

BACKGROUND: Rituximab is a monoclonal antibody directed against CD20, a pan B lymphocyte marker. It is approved in Australia for treatment of CD20-positive B cell non-Hodgkin lymphoma and rheumatoid arthritis. There is increasing off-label use of rituximab in conditions where B cells and autoantibodies play a role in the pathophysiology. Rituximab is not only expensive, but its safety in unregistered indications is uncertain. METHODS: We performed a retrospective review of the off-label use of rituximab approved by the High Cost Drug Subcommittee at the Princess Alexandra Hospital between 2005 and 2008. Cases of post transplant lymphoproliferative disorder were excluded. RESULTS: A total of 28 patients received rituximab for a variety of off-label indications. There were no reported cases of serious infusion reactions or other notable adverse events. The most favourable outcomes were seen in myasthenia gravis, shrinking lung syndrome, thrombotic thrombocytopenic purpura, prevention and treatment of renal transplant rejection and lupus nephritis. No benefit was observed in cases of focal segmental glomerulosclerosis (primary or post-transplant recurrence) and post-transplant recurrence of haemolytic uremic syndrome. There was limited benefit in cryoglobulinaemic vasculitis. The cost of off-label use was in excess of $210,000. CONCLUSION: In the absence of formal clinical trials, decisions regarding off-label use of rituximab are difficult. Our cases contribute to the published literature and should help provide clinicians with greater insights into which conditions are likely to respond. As can be seen in our series, rituximab benefits people with certain conditions; longevity and cost-effectiveness are currently unknown.

Displaced Supracondylar Humerus Fractures in Toddlers.

Gartland type III fracture is the most troublesome type of supracondylar humerus fracture. These injuries most often occur in school age children, but they are seen in pediatric patients of all ages. The goal of this study was to analyze toddlers with Gartland type III fractures to identify clinically significant differences compared with older children. A retrospective cohort study was conducted with 94 toddlers (<3 years) and 378 older children (3 to 12 years). Factors including demographics, mechanism of injury, additional injuries, location of trauma, pin configuration, postoperative complications, follow-up time, and compliance with the treatment plan were collected and compared. The study included 94 toddlers (59% girls, 2.11±0.64 years) and 378 older children (48% girls, 6.32±1.89 years), chosen at random, who were treated between 2000 and 2015. Among toddlers, fractures were more likely to occur at home (P<.001) and to be the result of suspected nonaccidental trauma (P<.001). Older children had more additional injuries (P<.001), but were no more likely to have an open fracture (P=.59) or a flexion-type fracture (P=.42). Older children were more likely to undergo open reduction (P=.03), whereas toddlers were more likely to be treated with a medial pin (P<.001). Toddlers experienced more cubitus varus (P<.001) and loss of reduction (P=.02). No difference was found in length of follow-up (P=.83) or compliance with the treatment plan (P=.11). This study provides novel insights into clinical differences between toddlers and older children with Gartland type III fractures. Knowledge of these differences can facilitate the delivery of targeted, age-specific care for patients with type III supracondylar humerus fractures. [Orthopedics. 2020;43(5);e421-e424.].

Percutaneous Pinning of Pediatric Proximal Humeral Fractures.

BACKGROUND: Proximal humeral fractures are relatively common in pediatric patients. These injuries are usually treated nonoperatively in younger children or children with minimally displaced fractures. However, closed reduction or open reduction followed by percutaneous pinning is recommended for older children with displaced fractures. Percutaneous pinning has several advantages, but there are limited reports of a safe and reliable surgical technique in the literature. DESCRIPTION: Patients are positioned in a modified beach-chair position to allow orthogonal imaging. The injured extremity is draped free from the remainder of the body. Closed reduction, which comprises a combination of traction, abduction, and rotation, is attempted. Internal or external rotation may be required, depending on the fracture line and deforming forces. If an anatomic closed reduction cannot be obtained, a block to reduction should be suspected and open reduction should be performed via a deltopectoral approach. Once the fracture is reduced, two 2.5-mm threaded Kirschner wires from the small external fixator set are used to percutaneously fix the fracture. Any small external fixator set can be used, and if not available, individual threaded wires of similar size can be used. Alternatively, Kirschner wires can be advanced to the fracture site prior to reduction and then advanced into the humeral epiphysis once the fracture is reduced. Care is taken to avoid the axillary nerve, which is reliably within 6 cm of the anterolateral aspect of the acromion, and wires are placed distal to this site. Once pin position has been confirmed radiographically, the construct is secured with pin-to-pin clamps to improve rigidity and further decrease the risk of pin migration. A soft dressing and shoulder immobilizer are placed postoperatively. Patients are followed with biweekly radiographs, and pins are removed in the outpatient office or under conscious sedation at 4 weeks. Leaving pins for a longer period may increase the risk of skin irritation and potentially infection. ALTERNATIVES: Alternatives to closed reduction or open reduction and percutaneous pinning include nonoperative management and elastic intramedullary nailing. Nonoperative treatment is a reliable option for most patients. However, it is not suitable for older children with severely displaced fractures because of diminished remodeling potential. Elastic intramedullary nailing is a good option for distal fractures. However, it is not suitable for proximal fractures, and it has been associated with longer operative times and more blood loss than percutaneous pinning. It also requires a second procedure. RATIONALE: This procedure allows for anatomic fixation of proximal humeral fractures and provides a rigid construct to maintain reduction. It is not technically challenging, requires limited postoperative immobilization, and decreases the risk of a second general anesthetic.

Increasing mixed chimerism and the risk of graft loss in children undergoing allogeneic hematopoietic stem cell transplantation for non-malignant disorders.

We performed quantitative PCR-based serial chimerism testing of whole blood (WB) and CD3+ cells and retrospectively correlated the results of chimerism tests and the risk of graft loss in children undergoing transplant for non-malignant disorders. Twenty-four children were included in this study. All patients initially engrafted; subsequently, 12% lost the graft, 21% achieved complete donor chimerism and 67% had mixed chimerism (MC). Patients underwent delayed taper of cyclosporine (CsA) if they had MC. Overall survival was 87+/-7% (s.d.) at 5-years post transplant, and it was not affected by chimerism status. Both WB and CD3+ chimerism showed significant fluctuations with a peak in autologous cell signal occurring at a median of 7 months for WB and 2 months for CD3+ cells. Initial post transplant chimerism percentage in either WB or CD3+ lineage was not related to graft loss. Increasing MC to >30% host cells was seen in 33% of patients, and it was related to increased risk of graft loss, as previously published. However, 63% of children with increasing MC did not lose their graft. Additional studies of post transplant chimerism are required to improve our ability to accurately identify children at risk of graft loss following transplant for non-malignant disorders.

Musculoskeletal Injuries Resulting from Use of Hoverboards: Safety Concerns With an Unregulated Consumer Product.

Hoverboards were recently introduced to the US consumer market and experienced rapid popularity. Given the high frequency of musculoskeletal injury with other wheeled recreation devices, we sought to analyze hoverboard injuries in children. A retrospective review of patients with musculoskeletal injury related to hoverboard use was performed at a tertiary care children's hospital. From November 2015 to January 2016, 2.3% of all fractures were related to hoverboards. Common injury mechanisms were fall (79%) and finger entrapment between wheel and wheel-well (10%). The most frequently fractured sites included the distal radius (43%) and phalanx (17%). Common surgical procedures were nailbed repair and pinning for Seymour fracture and percutaneous pinning for distal radius fracture. There exists high risk for distal radius fractures from falls and phalanx fractures from finger entrapment between the wheel and wheel-well. Hoverboard safety can be improved with regular use of wrist guards and improved wheel-well design.