Trauma Isn't One Size Fits All: How Online Support Communities Point to Different Diagnostic Criteria for C-PTSD and PTSD.

Reddit has provided rich data on mental health discourse. The present study uses 40,335 online posts from Reddit communities to investigate how language can contribute to the understanding of PTSD and C-PTSD. The results showed distinct language patterns in the use of first-person pronouns, cognitive processing, and emotion words, suggesting that they are separate disorders with different effects on survivors. Further, while some social media studies have differentiated submissions and comments, few have investigated the language changes between these contexts. Post-hoc results showed a clear distinction between two contexts across several linguistic markers. Discussion and future directions are explored.

Closing-wedge Osteotomies: Can We Do and Teach Better?

BACKGROUND: Wedge osteotomies are ubiquitous in pediatric orthopaedics and limb deformity surgery; however, there is no universally preferred methodology for these procedures. This study aims to determine the relative accuracy and effectiveness of several measuring and marking methods to guide best practices for wedge-shaped osteotomies in long bones. METHODS: An observational cohort study was completed. Orthopaedic residents (postgraduate years 1 to 5) completed 30-degree wedge osteotomies on a sawbone (Pacific Research Lab) femur utilizing a standard oscillating saw under 3 measuring conditions: (1) no measurement tool, (2) 30-degree triangle, and (3) goniometer, in combination with 2 different marking methods: (1) marking pen or (2) pin placement. Demographic characteristics and osteotomy performance (quality, completion time, and accuracy) were assessed. Quality was ranked as perfect (1), mild step-off (2), or gross surface irregularity (3). Multivariate regressions and analysis of variance were performed comparing demographics, osteotomy performance, and measuring methods. RESULTS: Twenty-four residents were included for analysis; 6 were female (25%). Female sex was independently associated with longer completion time when evaluating all combined scenarios (138 vs. 99 s, P =0.003) without differences in surface quality or angle accuracy. There were no significant associations between measuring technique and accuracy or surface quality, but use of the goniometer and the triangle both were associated with significantly longer completion time compared with no visual aid ( P =0.002 and 0.007). When controlling for measuring technique, use of the pen as a marking technique had significantly shorter completion times ( P <0.001), higher surface quality ( P <0.001), and better accuracy ( P <0.001) than guide pins. CONCLUSIONS: We recommend the use of a marking pen in combination with the surgeon's preferred measuring guide to optimize trainees' performance of closing wedge osteotomies. Future research is necessary to corroborate these findings in a higher fidelity setting, such as a cadaveric study. Further, while male residents complete wedge osteotomies quicker than female residents, quality and accuracy are comparable among trainees. Slower pace should not be conflated with poor performance but rather should inform effective intraoperative teaching for diverse trainees.

The Utility of IR-Guided Biopsy in the Treatment of Pediatric Osteomyelitis.

BACKGROUND: Accurate and efficient diagnosis, as well as a consistent and effective treatment of acute hematogenous osteomyelitis, are paramount to ensure successful clinical outcomes. Noninvasive measures of isolating the causative pathogen from blood cultures have low sensitivity, with published rates often <50%. The use of interventional radiology (IR)-guided percutaneous biopsy has gained traction as a nonsurgical means of obtaining tissue cultures with a reported increased sensitivity of >90%. This study aims to determine the utility of IR-guided biopsy in the management of pediatric patients with acute hematogenous pediatric osteomyelitis (OM). METHODS: An IRB-approved retrospective review was completed of children younger than 18 years admitted to a single institution for treatment of magnetic resonance imaging or culture/biopsy-proven acute hematogenous OM. Patients were excluded for the diagnosis of chronic recurrent multifocal OM, incomplete documentation, treatment initiation at an outside institution, open surgical debridement, and concomitant septic arthritis. Patients who underwent IR-guided biopsy were compared with those treated empirically without biopsy. RESULTS: Fifty patients were included for analysis. Fifteen (30%) had IR-guided biopsies; 35 (70%) were treated empirically. The average age at diagnosis was 11.8 years old (SD: 4.9). Of the 15 patients who underwent IR-guided biopsy, a pathogen was identified in 12 cases (80%); 14 of these patients had concomitant blood cultures with only 1 (7%) positive result ( P <0.01). Of the 11 patients with positive IR-guided biopsy results in the setting of negative blood cultures, 9 (82%) had alterations in their antibiotic regimen as a result of the biopsy. The average time from blood sample collection to definitive antibiotic initiation was nearly double that of time from IR-guided biopsy collection to definitive antibiotic initiation (70.8 vs. 36 h; P <0.01). CONCLUSION: IR-guided biopsy increased pathogen identification by 47% over blood cultures alone and decreased the time to definitive antibiotics. As such, IR-guided biopsy is an effective and safe diagnostic tool for pathogen identification and appropriate antibiotic selection. Orthopaedic surgeons are encouraged to incorporate IR-guided biopsy early in the treatment pathway for patients with acute OM without an indication for open surgical intervention. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

The Utility of Routine Radiographic Monitoring in Pediatric Osteoarticular Infections.

BACKGROUND: Pediatric musculoskeletal (MSK) infections broadly include isolated osteomyelitis (OM), septic arthritis (SA), and combined infections (OM+SA). These diagnoses are often monitored with serum inflammatory markers and serial radiographs to monitor treatment response and development of negative sequelae, despite limited data supporting these practices. The purpose of this study is to evaluate the utility of obtaining serial radiographic follow-up for pediatric osteoarticular infections. METHODS: An institutional review board-approved retrospective review was completed. Children 18 years and below admitted to a single institution with a culture/biopsy-proven diagnosis of OM, SA, or OM+SA. All postdischarge radiographs were reviewed and retrospectively categorized as either routine (scheduled) or reactive. Routine radiographs were obtained regardless of clinical presentation. Reactive radiographs were obtained in patients presenting with the sign of an altered clinical course. Negative sequelae, defined as growth arrest/disturbance, pathologic fracture, recurrent MSK infection, and underlying neoplastic process, were recorded and tracked. Descriptive statistics were used to summarize demographic and outcome variables. Number needed to screen (NNS) was defined as the inverse of the incidence of negative sequelae detected. RESULTS: A total of 131 patients were included for analysis, with a mean age of 11.9 years (SD: 4.96 y). Ninety (69%) patients were diagnosed and treated for OM, 25 (19%) for SA, and 16 (12%) for combined infections. A total of 329 radiographs were obtained following discharge. Of those obtained, 287 (88%) were routine, resulting in the detection of 2 (0.7%) negative sequelae and a resultant NNS of 143 radiographs (95% confidence interval: 36-573). The remaining 39 were reactive radiographs, resulting in the detection of 2 (5.1%) negative sequelae with an NNS of 20 radiographs (95% confidence interval: 5-78). CONCLUSIONS: While radiographs remain a widely utilized tool to screen for the development of negative sequelae in pediatric osteoarticular infections, they rarely alter management in the absence of other concerning clinical signs or symptoms such as recurrent fevers, swelling of the extremity, or limb deformity. Moreover, routine radiographic surveillance should be replaced with a reactive radiographic protocol. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Hip Status and Long-term Functional Outcomes in Spina Bifida.

BACKGROUND: Nearly 50% of individuals with myelomeningocele will develop a dislocated hip by skeletal maturity. The purpose of this study was to determine the influence of hip status on functional outcomes in a cohort of adult patients with myelomeningocele. METHODS: Patients with a diagnosis of myelomeningocele >18 years were prospectively enrolled over a 12-month period. Neurological level of involvement was obtained from chart review and interview. Clinical examination included hip range of motion and leg-length discrepancy. Reimer's migration index was calculated from a current anteroposterior pelvic radiograph. All subjects completed the VR-12 and the NIH PROMIS outcomes measures for pain interference and physical function. The χ, the Pearson correlation coefficients, and linear regression models were applied to evaluate the influence of hip status on functional outcomes. RESULTS: In total, 31 patients (average age 31, range 19 to 49) were included. Eight thoracic, 9 lumbar, and 14 sacral level patients participated. Twenty had bilaterally located hips, 5 had a unilateral subluxation or dislocation, and 6 had bilaterally subluxated or dislocated hips. In univariate analysis, patients with bilaterally located hips performed better in lower extremity function than those with unilateral subluxation/dislocation (36.7 vs. 26.0; P=0.03) but worse in pain interference than those with bilateral subluxation/dislocation (52.0 vs. 43.3; P=0.03). After controlling for neurological level, there was no statistically significant difference in the VR-12 mental (P=0.32) or physical component summary (P=0.32) scores, nor in the PROMIS lower extremity function (P=0.26) or pain interference scores (P=0.33) between groups. Decreased extension and abduction were indirectly correlated with VR-12 mental component scores (P=0.0038, 0.0032). Leg-length discrepancy was not associated with any outcome measure. CONCLUSIONS: Long-term outcomes are not associated with hip status in adult patients with myelomeningocele. Functional outcomes are more closely correlated with neurological level and hip range of motion. These results suggest efforts to keep myelomeningocele hips reduced are likely without functional benefit and should be avoided in favor of maintaining motion with contracture release as needed. LEVEL OF EVIDENCE: Level III.

Retrograde Stainless Steel Flexible Nails Have Superior Resistance to Bending in Distal Third Femoral Shaft Fractures.

BACKGROUND: It has been shown that retrograde titanium flexible intramedullary nails (Ti FIN) provide superior resistance to bending compared to antegrade Ti FIN in distal femur fractures. The purpose of this study was to compare resistance to torsional and bending forces of stainless steel (SS) FIN, with or without a locking screw, and Ti FIN in distal third femoral shaft fractures. We hypothesize that locked retrograde SS FIN will demonstrate greater resistance to both bending and torsional forces. METHODS: Thirty adolescent synthetic femur models were used to simulate transverse distal femoral fractures at either 60 mm or 90 mm proximal to the distal femoral physis. The femurs were instrumented with antegrade Ti FIN, antegrade SS FIN, retrograde Ti FIN, retrograde SS FIN, or retrograde locked SS FIN. Three models for each construct at both osteotomy levels were tested. Models were analyzed to determine maximum resistance to bending and torsion. RESULTS: In fractures 60 mm from the physis, retrograde SS FIN demonstrated statistically superior resistance to bending when compared with both antegrade and retrograde Ti FIN (P=0.001 and 0.008, respectively) and antegrade SS FIN (P=0.0001). Locked SS constructs showed a trend towards greater resistance to bending forces when compared with unlocked constructs (P>0.05). No significant difference was seen in resistance to bending when fractures were 90 mm proximal to the distal femoral physis between the five groups. No significant differences were observed in resistance to torsion in either the proximal or distal fracture models, regardless of construct type. CONCLUSIONS: Retrograde SS FIN confer significantly greater resistance to bending forces for fractures 60 mm proximal to the distal femoral physis compared with Ti FIN or antegrade entry SS FIN. In fractures 90 mm from the physis, no differences were noted in our model. Our results support the use of retrograde SS nails in the pediatric patient with distal femoral shaft fractures. LEVEL OF EVIDENCE: Level II-comparative biomechanical study.

Arthroscopic Treatment of Septic Arthritis in Very Young Children.

INTRODUCTION: Arthroscopic lavage is a well-established, minimally invasive treatment for septic arthritis (SA) in adults, but the use of arthroscopy in the pediatric population is typically restricted to sports injuries and deformity. Previous research on arthroscopic lavage of septic joints in the pediatric population has been limited to case reports and small case series of older children. As such, we aimed to evaluate the safety and efficacy of arthroscopic treatment of SA in various joints in very young children. METHODS: Between 2011 and 2015, 24 children (aged 3 wk to 6 y) were treated for SA with arthroscopic lavage. A single portal was adequate for both inflow and outflow in most cases. A second portal was used in all knees and in other joints for synovectomy, when indicated. Drains were placed through the portal site and remained in place for 2 to 3 days. Antibiotics were managed by the infectious disease service. RESULTS: Nine hips, 9 knees, 4 ankles, and 2 shoulders were included. Portal placement, visualization, and adequate lavage were straight forward in all joints. There was 1 transient femoral nerve palsy and no other arthroscopy-associated complications (iatrogenic damage, difficult drain placement, or conversion to open). Two patients required repeat arthroscopic lavage for disease eradication, one of which required a second admission. A third patient underwent open irrigation following arthroscopic lavage with a resultant 1.125 average procedures per subject. At final follow-up (2 to 49 mo, average 16 mo), no recurrence of infection or decreased range of motion was noted. CONCLUSIONS: Arthroscopic lavage appears to be a safe, quick, and effective alternative to open arthrotomy for the treatment of SA in very young children. It is feasible in any large joint even in the infantile population, allowing for improved visualization and irrigation with little soft-tissue dissection and morbidity. Our relatively simple technique and positive results should encourage regular use of arthroscopic treatment of SA even in very young children. LEVEL OF EVIDENCE: Level IV-case series.

Vitamin D Insufficiency and Fracture Risk in Urban Children.

BACKGROUND: Investigation into the role of vitamin D in fractures in the pediatric population has been limited despite estimates that as many as 70% of American children have inadequate vitamin D levels (measured as 25-hydroxyvitamin D, 25(OH)D). The purpose of this study was to evaluate vitamin D's role in pediatric fracture risk by comparing 25(OH)D between fractured and nonfractured cohorts. METHODS: A 12-month prospective case-control study was completed in children aged 2 to 14 years in an urban, academic hospital. Sixty fractured children requiring conscious sedation or general anesthesia for management were compared with 60 nonfractured controls. All participants and their guardians were surveyed for low bone density risk factors, and total serum 25(OH)D was measured. Statistical analysis was completed using Student t tests, χ tests, analysis of variance, and logistic regression models. RESULTS: After controlling for age and daily sun exposure, lower total serum 25(OH)D was associated with higher fracture risk (odds ratio=0.94; 95% confidence interval, 0.90-0.99; P=0.023). In the fractured cohort, 6 (10%) patients were deficient (25(OH)D<20 ng/mL) and 33 (55%) were insufficient (25(OH)D, 20 to 30 ng/mL). Of the nonfractured population, 8 (13%) were deficient and 19 (32%) were insufficient. There were more insufficient patients in the fractured than in the nonfractured cohort (odds ratio=2.99; 95% confidence interval, 1.27-7.0; P=0.037). CONCLUSIONS: Higher fracture incidence is associated with serum 25(OH)D insufficiency. Hypovitaminosis D may place the pediatric population at increased risk for fracture. Consideration should be given to routine assessment of vitamin D in fractured children. LEVEL OF EVIDENCE: Prognostic level III-prospective case-control study.

Interhospital Variability in Perioperative Red Blood Cell Ordering Patterns in United States Pediatric Surgical Patients.

OBJECTIVE: To evaluate perioperative red blood cell (RBC) ordering and interhospital variability patterns in pediatric patients undergoing surgical interventions at US children's hospitals. STUDY DESIGN: This is a multicenter cross-sectional study of children aged <19 years admitted to 38 pediatric tertiary care hospitals participating in the Pediatric Health Information System in 2009-2014. Only cases performed at all represented hospitals were included in the study, to limit case mix variability. Orders for blood type and crossmatch were included when done on the day before or the day of the surgical procedure. The RBC transfusions included were those given on the day of or the day after surgery. The type and crossmatch-to-transfusion ratio (TCTR) was calculated for each surgical procedure. An adjusted model for interhospital variability was created to account for variation in patient population by age, sex, race/ethnicity, payer type, and presence/number of complex chronic conditions (CCCs) per patient. RESULTS: A total of 357 007 surgical interventions were identified across all participating hospitals. Blood type and crossmatch was performed 55 632 times, and 13 736 transfusions were provided, for a TCTR of 4:1. There was an association between increasing age and TCTR (R(2) = 0.43). Patients with multiple CCCs had lower TCTRs, with a stronger relationship (R(2) = 0.77). There was broad variability in adjusted TCTRs among hospitals (range, 2.5-25). CONCLUSIONS: The average TCTR in US children's hospitals was double that of adult surgical data, and was associated with wide interhospital variability. Age and the presence of CCCs markedly influenced this ratio. Studies to evaluate optimal preoperative RBC ordering and standardization of practices could potentially decrease unnecessary costs and wasted blood.

Perioperative Outcomes Following Unilateral Versus Bilateral Total Knee Arthroplasty.

Simultaneous bilateral total knee arthroplasty (SB-TKA) is potentially a cost saving manner of caring for patients with bilateral symptomatic knee arthritis. We performed a retrospective analysis using the 2010-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to evaluate the risk of perioperative complication following SB-TKA. Demographic characteristics, comorbidities, and 30-day complication rates were studied using a propensity score-matched analysis comparing patients undergoing unilateral TKA and SB-TKA. A total of 4489 patients met the inclusion criteria, of which 973 were SB-TKA. SB-TKA was associated with increased overall complications (P = 0.023), medical complications (P = 0.002) and reoperation (OR 2.12, P = 0.020). Further, total length of hospital stay (4.0 vs 3.4 days, P < 0.001) was significantly longer following bilateral surgery.

Online video resources pertaining to cerebral palsy: A YouTube-based quality control study.

Aim: To assess the content and quality of YouTube videos related to cerebral palsy to provide insights into the online video resources available for individuals affected by cerebral palsy and suggest strategies for improvement. Methods: YouTube videos were analyzed based on interaction parameters, content characteristics/category, and video source. Video reliability and quality were assessed using the Journal of American Medical Association benchmark, Global Quality Scale, and cerebral palsy-specific score. Statistical analyses examined associations between video characteristics and reliability/quality scores. Results: The average video (n = 48) length was 6.8 min, with 29 informational and 19 experiential videos. The mean Journal of American Medical Association score was 2.0, indicating moderate reliability. The Global Quality Scale suggested good quality content (average: 3.5), but only 14% were rated as good via cerebral palsy-specific score. Higher views were associated with higher Journal of American Medical Association score and cerebral palsy-specific score (p = 0.002 and p = 0.006), and nonphysician medical expert videos had lower Journal of American Medical Association scores than academic videos (p = 0.042). Video content was not significantly associated with either score. Conclusion: YouTube provides moderate to good quality information on cerebral palsy. Critical evaluation of video sources and content is essential. Findings can guide strategies to enhance the quality of cerebral palsy-related YouTube content, benefiting individuals with cerebral palsy, health care providers, and caregivers.

Nonmetallic Anterior Hemiepiphysiodesis of the Distal Femur with a Low-Profile, Pretensioned Implant: A Case Report.

CASE: A 14-year-old adolescent boy with left-sided spastic hemiplegic cerebral palsy presented with a 14° left knee flexion contracture and resultant gait disturbance in the setting of an open distal femoral physis. He underwent subsequent anterior distal femur hemiepiphysiodesis with a suture anchor-based, nonmetallic implant. He achieved full correction at the 1-year follow-up and underwent uncomplicated implant removal. CONCLUSION: A low-profile, suture-based implant used for pediatric knee flexion deformity may allow surgeons to control growth in a reversible fashion by tensioning the physis while possibly avoiding some of the complications associated with currently used implants.

Slow-motion smartphone video improves interobserver reliability of gait assessment in ambulatory cerebral palsy.

Purpose: Structured visual gait assessment is essential for the evaluation of pediatric patients with neuromuscular conditions. The purpose of this study was to evaluate the benefit of slow-motion video recorded on a standard smartphone to augment visual gait assessment. Methods: Coronal and sagittal plane videos of the gait of five pediatric subjects were recorded on a smartphone, including four subjects with ambulatory cerebral palsy and one subject without gait pathology. Twenty-one video scorers were recruited and randomized to evaluate slow-motion or normal-speed videos utilizing the Edinburgh Visual Gait Score. The slow-motion group (N = 11) evaluated the videos at one-eighth speed, and the normal-speed group (N = 10) evaluated the same videos at normal speed. Interrater reliabilities were determined by calculating intraclass correlation coefficients for each group as a whole, for each Edinburgh Visual Gait Score item, and after stratification by evaluator experience level. Results: The slow-motion group exhibited an intraclass correlation coefficient of 0.65 (95% confidence interval: 0.58-0.73), whereas the normal-speed group exhibited an intraclass correlation coefficient of 0.57 (95% confidence interval: 0.49-0.65). For less-experienced scorers, intraclass correlation coefficients of 0.62 (95% confidence interval: 0.53-0.71) and 0.50 (95% confidence interval: 0.40-0.59) were calculated for slow motion and normal speed, respectively. For more-experienced scorers, intraclass correlation coefficients of 0.69 (95% confidence interval: 0.61-0.76) and 0.67 (95% confidence interval: 0.58-0.75) were calculated for slow motion and normal speed, respectively. Conclusions: Visual gait assessment is enhanced by the use of slow-motion smartphone video, a tool widely available throughout the world with no marginal cost. Level of evidence: level I, randomized study.

Modifiable and non-modifiable risk factors for failure of non-operative treatment of pediatric forearm fractures: Where can we do better?

Introduction: Distal third forearm fractures are common fractures in children. While outcomes are generally excellent, some patients fail initial non-operative management and require intervention. The purpose of this study is to identify independent risk factors associated with failure of closed reduction. Methods: We conducted a retrospective review of distal third forearm fractures in children treated with closed reduction and casting. Patients were divided into two cohorts-those who were successfully closed reduced and those who failed initial non-operative management. Demographic characteristics, cast type, cast index, radiographic fracture, soft tissue characteristics, and quality of reduction were analyzed between groups. Results: A total of 207 children treated for distal third forearm fractures were included for analysis. A total of 190 (91.8%) children maintained their reduction while 17 (8.2%) failed initial non-operative management. Modifiable risk factors associated with loss of reduction on univariate analysis included the use of a long arm cast (p = 0.003), increased post-reduction displacement (p = 0.02), and increased post-reduction angular deformity (p = 0.01). Non-modifiable risk factors included increased body mass index (p = 0.02), increased presenting fracture displacement (p = 0.002), and increased width of the soft tissue envelope at the fracture site (p = 0.0001). The use of long arm casts (13% vs 2%, odds ratio = 6.44) and soft tissue width (60.6 vs 50.4 mm, odds ratio = 1.1) remained significant risk factors for loss of reduction after multivariate analysis. Conclusion: Both larger soft tissue envelope at the site of the fracture and long arm cast immobilization are independently associated with an increased risk of failing initial closed reduction in distal third forearm fractures in the pediatric population. Level of evidence: level III Case Control Study.

The Utility of Virtual Reality in Orthopedic Surgical Training.

OBJECTIVE: To examine the efficacy of virtual reality (VR) to prepare surgical trainees for a pediatric orthopedic surgery procedure: pinning of a slipped capital femoral epiphysis (SCFE). DESIGN: Participants were randomly assigned to a standard, study guide (SG) group or to a VR training group. All participants were provided a technique video and SG; the VR group additionally trained via an Osso VR surgical trainer (ossovr.com) with real-time feedback and coaching from an attending pediatric orthopedic surgeon. Following training, participants performed a SCFE guidewire placement on a SawBones model embedded in a soft-tissue envelope (SawBones model 1161). Participants were asked to achieve "ideal placement" based on the training provided. Participants were evaluated on time, number of pin "in-and outs," penetration of the articular surface, angle between the pin and the physis, distance from pin tip to subchondral bone and distance from the center-center point of the epiphysis. SETTING: Orthopedic Institute for Children, Los Angeles, CA. PARTICIPANTS: Twenty fourth-year medical students, first- and second-year orthopedic residents without experience with the SCFE procedure. RESULTS: Twenty participants were randomized to SG (n = 10) or VR (n = 10). Average time to final pin placement was 19% shorter in VR group (706 vs 573 seconds, p = 0.26). When compared to SG, the VR group had, on average, 70% less pin in-and-outs (1.7 vs 0.5, p = 0.28), 50% less articular surface penetrations (0.4 vs 0.2, p = 0.36), and 18% smaller distance from pin tip to subchondral bone on lateral view (7.1 vs 5.8 mm, p = 0.42). Moreover, the VR group had a lower average angle deviation between pin and line perpendicular to the physis on coronal view (4.9° vs 2.5°, p < 0.05). CONCLUSIONS: VR training is potentially more effective than traditional preparatory methods. This pilot study suggests that VR training may be a viable surgical training tool, which may alleviate constraints of time, money, and safety concerns with resultant broad applicability for surgical education.

Mobility impairment and life satisfaction in the Northern Region of Malawi.

Background: There exist many psychosocial sequelae associated with mobility impairment, especially in low-resource settings where access to mobility assistive devices is limited. Objectives: This study aims to (1) define the burden and presenting aetiologies of mobility impairment in the rural Northern Region of Malawi and (2) assess the relationship between physical disability, life satisfaction and access to mobility aids. Methods: At mobility device donation clinics throughout the Northern Region of Malawi, adults living with mobility impairment were surveyed with a demographic questionnaire and a series of validated surveys to assess their physical activity levels (Global Physical Activity Questionnaire [GPAQ]), degree of mobility impairment (Washington Group Extended Set Questions on Disability) and life satisfaction (patient-reported outcomes measurement information systems satisfaction with participation in social roles and general life satisfaction). Results: There were 251 participants who qualified for inclusion, of which 193 completed all surveys. Higher physical activity scores were positively correlated with increased life satisfaction: (1) satisfaction with participation in social roles (0.481, p < 0.0001) and (2) general life satisfaction (0.230, p < 0.001). Respondents who had previously used a formal mobility device reported 235.5% higher physical activity levels ([139.0%, 333.0%], p = 0.006), significantly higher satisfaction with participation in social roles ([0.21, 6.67], p = 0.037) and equivocally higher general life satisfaction ([-1.77, 3.84], p = 0.470). Conclusion: Disability and mental health do not exist in isolation from one another. Given the positive correlations between formal mobility device usage and both physical activity and life satisfaction, interventions that increase access to mobility-assistive devices in undertreated populations are imperative. Contribution: This study contributes to the understanding of the complex relationship between physical disability, access to mobility aids, and life satisfaction. Results from this study suggest the potential benefit that increasing access to mobility aids may have in improving the quality of life of mobility impaired persons in resource-limited settings, such as the Northern Region of Malawi.

The utility of echocardiography in paediatric patients with musculoskeletal infections and bacteremia.

PURPOSE: The clinical utility of echocardiography in the setting of a positive blood culture in paediatric patients presenting with osteomyelitis (OM) and/or septic arthritis (SA). METHODS: Retrospective review between 2013 and 2019: Patients < 18 years with OM, SA or combined infection (OM+SA) were included. Patients were excluded for immunodeficiency, loss of follow-up or penetrating infection. Charts with positive blood cultures were reviewed for echocardiography on that admission. Demographic variables were compared utilizing the Student's t-test and Fisher's exact test. A multivariable linear regression model was constructed to examine the association between echocardiography and length of stay, controlling for age, sex, fever, white blood cell (WBC) on admission, antibiotic administration and surgery performed. RESULTS: Of 157 patients with OM, SA or combined infection, 44 had a positive blood culture. In all, 26 had an echocardiogram, and none showed endocarditis. Echocardiography was independently associated with a 6.2-day length of stay increase. WBC count and surgical intervention demonstrated a trend toward significance in length of stay, with each WBC unit increase associated with a 0.53-day increase. Surgical intervention was associated with an average 6.3-day length of stay decrease. CONCLUSION: No patient had a positive echocardiogram, and no changes in management were initiated. However, an echocardiogram increased stay by 6.2 days. In addition to costs associated with increased stay, patients were billed between $1460 and $1700 per echocardiogram. The utility of echocardiograms in the setting of bacteremia associated with musculoskeletal infections in the paediatric population should be re-examined, and guidelines should be updated to reflect the cost-benefit analysis. LEVEL OF EVIDENCE: III.

Design of a Microfluidic Bleeding Chip to Evaluate Antithrombotic Agents for Use in COVID-19 Patients.

INTRODUCTION: Interventions that could prevent thrombosis, clinical decompensation, and respiratory compromise in patients with novel coronavirus disease (COVID-19) are key to decrease mortality rate. Studies show that profound cytokine release and excessive activation of blood coagulation appear to be key drivers of COVID-19 associated mortality. Since limited in vitro methods exist for assessing the effects of anticoagulants on hemostasis, the development of novel therapies to safely prevent thrombosis in COVID-19 patients relies on preclinical animal models and early phase human trials. Herein we present the design of a microfluidic "bleeding chip" to evaluate the effects of antithrombotic therapies on hemostatic plug formation in vitro. METHODS: The design of the microfluidic device consists of two orthogonal channels: an inlet that serves as a model blood vessel, and a bleeding channel to model hemostatic plug formation at sites of compromised endothelial barrier function. This is achieved by placing a series of 3 pillars spaced 10 µm apart at the intersection of the two channels. The pillars and bleeding channel are coated with the extracellular matrix protein collagen. RESULTS: Perfusion of human whole blood through the microfluidic bleeding chip led to initial platelet adhesion and aggregation at the pillars followed by hemostatic plug formation and occlusion of the bleeding channel. CONCLUSIONS: Safe and effective mitigating agents are needed for treatment and prevention of thrombotic complications in COVID-19 patients. This simple microfluidic device holds potential to be developed into a tool for assessing the effects of anticoagulant therapy on hemostasis.

Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay.

The morbidity and mortality after hip fracture in the elderly are influenced by non-modifiable comorbidities. Time-to-surgery is a modifiable factor that may play a role in postoperative morbidity. This study investigates the outcomes and complications in the elderly hip fracture surgery as a function of time-to-surgery. Using the American College of Surgeons-National Surgical Quality Improvement Program data from 2011 to 2012, a study population was generated using the Current Procedural Terminology codes for percutaneous or open treatment of femoral neck fractures (27235, 27236) and fixation with a screw and side plate or intramedullary fixation (27244, 27245) for peritrochanteric fractures. Three time-to-surgery groups (<24 hours to surgical intervention, 24-48 hours, and >48 hours) were created and matched for surgery type, sex, age, and American Society of Anesthesiologists class. Time-to-surgery was then studied for its effect on the post-surgical outcomes using the adjusted regression modeling. A study population of 6036 hip fractures was created, and 2012 patients were assigned to each matched time-to-surgery group. The unadjusted models showed that the earlier surgical intervention groups (<24 hours and 24-48 hours) exhibited a lower overall complication rate (P = .034) compared with the group waiting for surgery >48 hours. The unadjusted mortality rates increased with delay to surgical intervention (P = .039). Time-to-surgery caused no effect on the return to the operating room rate (P = .554) nor readmission rate (P = .285). Compared with other time-to-surgeries, the time-to-surgery of >48 hours was associated with prolonged total hospital length of stay (10.9 days) (P < .001) and a longer surgery-to-discharge time (hazard ratio, 95% confidence interval: 0.74, 0.69-0.79) (P < .001). Adjusted analyses showed no time-to-surgery related difference in complications (P = .143) but presented an increase in the total length of stay (P < .001) and surgery-to-discharge time (P < .001). Timeliness of surgical intervention in a comorbidity-adjusted population of elderly hip fracture patients causes no effect on the overall complications, readmissions, nor 30-day mortality. However, time-to-surgery of >48 hours is associated with costly increase in the total length of stay, including an increased post-surgery-to-discharge time.