Eliminating rote postoperative radiographs for surgically managed pediatric supracondylar humerus fractures.

BACKGROUND: Use of postoperative radiographs after surgical management of supracondylar humerus (SCH) fractures is often based on rote practice rather than evidence. The purpose of this study was to determine the frequency with which 3-week postoperative radiographs at the time of pin removal altered management plans in pediatric SCH fractures that were intraoperatively stable after closed reduction and percutaneous pinning (CRPP). METHODS: We prospectively recruited pediatric patients with SCH fractures managed by CRPP at our institution from June 2020 until June 2022, and reviewed retrospective data on pediatric SCH fractures managed surgically at our institution between April 2008 and March 2015. Patients were assessed for post-CRPP fracture alignment and stability. For prospective patients, we asked clinicians to document their management decision at the 3-week follow-up visit before evaluating the postoperative radiographs. Our primary outcome was change in management because of radiographic findings. RESULTS: Overall, 1066 patients in the retrospective data and 446 prospectively recruited patients met the inclusion criteria. In the prospective group, radiographic findings altered management for 2 patients (0.4%). One patient had slow callus formation and 1 patient was identified as having cubitus varus. Altered management included prolonged immobilization or additional radiographic follow-up. Radiographic findings altered management in 0 (0%) of 175 type II fractures, in 2 (0.9%) of 221 type III fractures, and in 0 (0%) of 44 type IV fractures. We obtained similar findings from retrospective data. CONCLUSION: Rote use of 3-week postoperative radiographs after surgical management of SCH fractures that are intraoperatively stable has minimal utility. Eliminating rote postoperative radiographs for SCH fractures can decrease the time and financial burdens on families and health care systems without affecting patient outcomes.

The association of moderate-to-vigorous and light-intensity physical activity on static balance in middle-aged and older-aged adults.

BACKGROUND: Falls are the leading cause of injury among adults ≥ 65 years of age. Participation in physical activity (PA) is associated with improved balance, though it is impact in the middle-age population is not well understood. AIM: The purpose of the current study was to examine the influence of PA intensity on static balance in middle-aged and older aged individuals. METHODS: Included were middle-aged adults (40-64 years) and older adults (≥ 65 years) from the 2003-2004 years of the National Health and Nutrition Evaluation Survey. Light physical activity (LPA) and moderate-vigorous physical activity (MVPA) were collected via accelerometer and static balance via the Romberg Test of Standing Balance. RESULTS: No significant odds ratio relationship was found between MVPA or LPA and having good static balance in the middle-aged population; 1.04 (95% CI 0.95, 1.13) p = 0.427 and 1.05 (95% CI 0.97, 1.14) p = 0.182, respectively. Whereas, in older adults, every 60-min increase in LPA was significantly associated with 28% higher odds of good balance (95% CI 1.15, 1.41; p < 0.001), and every 10-min increase in MVPA with 25% higher odds of good balance (95% CI 1.08, 1.45; p = 0.006). DISCUSSION: LPA and MVPA were not associated with good static balance in middle-aged adults, but in older adults LPA was significantly associated with good static balance. CONCLUSION: A significant relationship is found between age and fall risk, which is a major concern in the aging population.

Is the presence of tumor-infiltrating lymphocytes predictive of outcomes in patients with melanoma?

BACKGROUND: The significance of tumor-infiltrating lymphocytes (TILs) in melanoma is debated. This article presents a multicenter, retrospective study assessing the predictive and prognostic value of TILs. METHODS: The Sentinel Lymph Node Working Group database was queried from 1993 to 2018 for cases with known TIL data. TILs were categorized as absent or present, which included nonbrisk (NB), brisk (B), and present but unspecified TIL levels. Clinicopathologic factors were correlated with TILs, sentinel lymph node (SLN) status, and melanoma-specific survival (MSS). RESULTS: Overall, 3203 patients were included. The median thickness was 1.5 mm, and 469 cases had SLN metastases. TILs were present in 2458 cases (76.7%), with NB, B, and unspecified TILs seen in 1691 (68.8%), 691 (28.1%), and 76 (3.1%), respectively. Multivariable analysis showed that the presence of TILs significantly predicted a negative SLN biopsy (P < .05). The median follow-up was 25.2 months. MSS was significantly better for cases with TILs than cases without TILs (P < .001). According to multivariable analysis, age, gender, thickness, mitotic rate, ulceration, lymphovascular invasion, and SLN status were significantly prognostic of MSS (all P values < .05). Although TILs were not prognostic of MSS, when multiple imputation was used and the SLN status was excluded, the presence of TILs was significantly prognostic of improved MSS (hazard ratio, 0.78; 95% confidence interval, 0.64-0.95; P = .0154). CONCLUSIONS: TILs are a favorable marker because their presence significantly predicts a negative SLN, and the absence of TILs may be a prognostic marker of worse survival in patients with a positive SLN but not a negative SLN. TILs may also serve as a prognostic marker of survival when the SLN status is not considered.

Is There a Relationship Between TILs and Regression in Melanoma?

BACKGROUND: The relationship between tumor-infiltrating lymphocytes (TILs) and regression in melanoma is unknown. This report describes a large multicenter study assessing the association between TILs and regression. METHODS: The Sentinel Lymph Node Working Group database was queried from 1993 to 2018 for cases with TILs and regression data. Clinicopathologic factors were correlated with regression and TIL status, sentinel lymph node (SLN) status, and overall survival (OS). RESULTS: The study enrolled 2450 patients. In 1811 cases, TILs (73.9%) were present, with regression present in 328 of these 1811 (18.1%) cases and in 49 (7.7%) of 639 cases without TILs. The presence of TILs was significantly associated with regression (p < 0.0001) as well as a negative SLN (p < 0.05). However, when TILs were stratified by regression status, only absence or presence of both TILs and regression were significantly associated with SLN metastases (p = 0.038). Although the presence of TILs was associated with OS (p < 0.05), regression status by itself was not (p = 0.2058 and 0.252, respectively). Furthermore, when TILs were stratified by regression status, only the presence of TILs with or without regression was significantly associated with improved OS (p = 0.0081 and 0.0137, respectively) versus the absence of both TILs and regression, with regression status not significantly affecting OS for patients with or without TILs (p = 0.2314 and 0.65, respectively). CONCLUSIONS: Regression is highly correlated with TILs, but only TILs are significantly associated with SLN metastasis and OS in melanoma patients, whereas regression is not. The impact of regression on outcomes ultimately appears dependent upon the absence or presence of TILs.

Re-evaluation of Sentinel Lymph Node Biopsy for Melanoma.

OPINION STATEMENT: The vast majority of patients newly diagnosed with melanoma present with clinically localized disease, and sentinel lymph node biopsy (SLNB) is a standard of care in the management of these patients, particularly in intermediate thickness cases, in order to provide important prognostic data. However, SLNB also has an important role in the management of patients with other subtypes of melanoma such as thick melanomas, certain thin melanomas, and specific histologic variants of melanoma such as desmoplastic melanoma. Furthermore, there have been technical advances in the SLNB technique, such as the development of newer radiotracers and use of SPECT/CT, and there is some data to suggest performing a SLNB may be therapeutic. Finally, the management of patients with a positive sentinel lymph node (SLN) has undergone dramatic changes over the past several years based on the results of recent important clinical trials. Treatment options for patients with SLN metastases now include surveillance, completion lymph node dissection, and adjuvant therapy with checkpoint inhibitors and targeted therapy. SLNB continues to play a crucial role in the management of patients with melanoma, allowing for risk stratification, potential regional disease control, and further treatment options for patients with a positive SLN.

Sentinel Lymph Node Biopsy Is Prognostic in Thickest Melanoma Cases and Should Be Performed for Thick Melanomas.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is recommended for intermediate thickness melanoma, but for thick melanoma, guidelines are less definitive about the use of SLNB in this population. We present a study on thick melanoma evaluating for prognostic factors. PATIENTS AND METHODS: The Sentinel Lymph Node Working Group database was queried for thick (> 4 mm) melanoma cases that had a SLNB from 1993 to 2018. Clinicopathologic characteristics were correlated with SLN status and melanoma-specific survival (MSS). RESULTS: There were 1235 patients. Median follow-up was 28 months. Median thickness was 5.9 mm, with 956, 175, and 104 cases presenting thickness > 4-8, > 8-12, and > 12 mm, respectively. SLN metastases were seen in 439 of 1235 (35.5%) cases and in 33.9%, 40.6%, and 42.3% of melanomas > 4-8, > 8-12, and > 12 mm, respectively. In each thickness group, MSS was significantly worse for SLN-positive compared with SLN-negative cases (all P < 0.005). Multivariable analysis showed that SLN metastasis, male gender, increasing thickness, lymphovascular invasion, and microsatellitosis significantly predicted worse MSS for melanomas > 4-8 mm, with SLN metastasis showing the greatest risk (HR 2.17, 95% CI 1.64-2.87, P < 0.0001). For melanomas > 8 mm, only SLN metastasis significantly predicted MSS (> 8-12 mm: HR 3.93, 95% CI 2.00-7.73, P < 0.0001; > 12 mm: HR 3.58, 95% CI 1.56-8.22, p < 0.0027). CONCLUSIONS: Thick melanoma patients with SLN metastasis have significantly worse MSS compared with SLN-negative patients, even in the thickest cases, and SLN status is the most powerful and/or only predictor of MSS. Given these results, SLNB shows important prognostic value in this population and is indicated for clinically localized thick melanoma.

Factors predicting survival in thick melanoma: Do all thick melanomas have the same prognosis?

BACKGROUND: It is unknown whether all thick melanomas share the same prognostic features. We present a large, multi-institutional study on thick melanoma, evaluating for factors prognostic of survival. METHODS: We queried the database of the Sentinel Lymph Node Working Group for patients with thick melanoma (>4 mm) who had a sentinel lymph node biopsy from 1993 to 2018. Clinicopathologic characteristics were correlated with overall survival. RESULTS: There were 1,235 patients with a median follow-up of 28 months. Median thickness was 5.9 mm, with 713, 356, and 166 cases having a thickness of >4 to 6, >6 to 10, and >10 mm, respectively. Ulceration was seen in 51.2% of cases, while sentinel lymph node metastases were seen in 439 of 1,235 (35.5%) cases. For melanomas >4 to 6 mm, age, thickness, ulceration, lymphovascular invasion, and sentinel lymph node metastasis were correlated with overall survival (all P < .05), but for melanomas >6 to 10 mm, only sex and sentinel lymph node metastasis were prognostic of overall survival (both P < .05). For melanomas >10 mm, only sentinel lymph node metastasis predicted overall survival on multivariable analyses (P < .05). CONCLUSION: Prognostic markers of overall survival for thick melanoma include thickness, ulceration, and sentinel lymph node metastasis, but also include other unique factors such as lymphovascular invasion. Moreover, certain prognostic markers for survival are associated with different subgroups of thick melanoma, which vary based on thickness group.

Complications of type II supracondylar humerus fractures treated at a specialized paediatric centre.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common operatively treated paediatric fracture in Canada. Previous literature describing the low-energy (Gartland type II) subtype reports varying complication rates from a variety of practice settings. We sought to examine complications of type II SCH fractures treated at a Canadian specialized paediatric centre. METHODS: We conducted a retrospective cohort study of patients aged 0 to 14 admitted to SickKids, Toronto, Ontario for surgical treatment of a type II SCH fracture from 2008 to 2015. The primary outcome of this study was relevant perioperative complications including: open fracture, compartment syndrome, pre- and postoperative vascular compromise, pre- and postoperative neurological compromise, failure to obtain a closed reduction (i.e., open reduction), postoperative infection, and reoperation within 3 months. RESULTS: There were 370 patients included in the study with mean (standard deviation) age 5.14 years (±2.51). The overall rate of relevant complications in the study cohort was 3.6% (13/358, 12 missing), with 12 cases of nerve palsy (3.3%; 2 iatrogenic [0.6%]) that resolved by final follow-up and one case of preoperative nerve palsy (0.3%) that did not. Importantly, there were no cases of vascular compromise, open fracture, compartment syndrome, or infection. DISCUSSION AND CONCLUSION: Complications associated with type II SCH fractures managed at a specialized paediatric centre that result in long-term morbidity are extremely rare (0.3%). Perioperative inpatient monitoring for patients with these fractures may not be justified based on these data. Prospective studies are required to confirm safety, evaluate patient perspectives, and demonstrate cost savings of outpatient surgical management.

Coordination stability between the legs is reduced after anterior cruciate ligament reconstruction.

BACKGROUND: The study was designed to examine coordination differences in walking between individuals with an anterior cruciate ligament reconstruction compared with healthy matched controls. Predictions from the extended Haken, Kelso, and Bunz coupled oscillator model were tested in these populations. METHODS: Seventeen persons with anterior cruciate ligament reconstruction and 17 matched controls participated in the study. Sagittal plane angular knee displacement was recorded using electrogoniometers over the lateral right and left knee joints while participants walked at five walking speeds overground. Coordination pattern and stability between the knees were quantified by mean and standard deviation of relative phase, respectively. FINDINGS: Mean relative phase was not influenced by walking speed or group. For both groups, coordination stability was maximal when individual's walked at their preferred gait speed. However, the anterior cruciate ligament reconstruction group demonstrated reduced coordination stability compared with healthy controls across the five speeds. Multiple regression analyses found that people with anterior cruciate ligament reconstruction who deviated more from antiphase coordination had decreased coordination stability. INTERPRETATION: Anterior cruciate ligament reconstruction results in decreased coordination stability, indicative of reduced coupling strength between the legs. This change in gait coordination, which has not previously been found in the literature, may contribute to the increased rate of re-injury and degeneration in individuals who have had this reconstructive surgery. Application of a motor control model enhances our understanding of the influence of an injury on coordination during gait.

High prevalence of syndemic health problems in patients seeking post-exposure prophylaxis for sexual exposures to HIV.

INTRODUCTION: The standard clinical approach to non-occupational HIV post-exposure prophylaxis (nPEP) focuses on biomedical aspects of the intervention, but may overlook co-occurring or 'syndemic' psychosocial problems that reinforce future vulnerability to HIV. We therefore sought to determine the prevalence of syndemic health problems in a cohort of Ontario nPEP patients, and explored the relationship between syndemic burden and HIV risk. METHODS: Between 07/2013-08/2016, we distributed a self-administered questionnaire to patients presenting to three clinics in Toronto and Ottawa seeking nPEP for sexual HIV exposures. We used validated screening tools to estimate the prevalence of depression (CES-D score ≥16), harmful alcohol use (AUDIT ≥8), problematic drug use (DUDIT ≥6 men/≥2 women), and sexual compulsivity (SCS ≥24) among men who have sex with men (MSM) respondents. In exploratory analyses, we examined the relationships between syndemic conditions using univariable logistic regression models, and the relationship between syndemic count (total number of syndemic conditions per participant) and HIV risk, as estimated by the HIRI-MSM score, using linear regression models. RESULTS: The 186 MSM included in the analysis had median age 31 (IQR = 26-36), including 87.6% having a college/undergraduate degree or higher. Overall, 53.8% screened positive for depression, 34.4% for harmful alcohol use, 30.1% for problematic drug use, and 16.1% for sexual compulsivity. Most participants (74.2%) had at least one syndemic condition and 46.8% had more than one. Exploratory analyses suggested positive associations between depression and harmful alcohol use (OR = 2.11, 95%CI = 1.13, 3.94) and between harmful alcohol use and problematic drug use (OR = 1.22, 95%CI = 0.65, 2.29). Syndemic count was associated with increased HIRI-MSM risk scores in univariable (2.2, 95%CI = 1.0, 3.3 per syndemic condition) and multivariable (2.1, 95%CI = 0.6, 3.6) linear regression models. CONCLUSIONS: The prevalence of syndemic conditions in MSM seeking nPEP for sexual exposure is alarmingly high, and is associated with underlying HIV risk. Routine screening for these conditions may identify opportunities for intervention and could alleviate future vulnerability to HIV.

Informal regionalization of pediatric fracture care in the Greater Toronto Area: a retrospective cross-sectional study.

BACKGROUND: Operative management of pediatric fractures is an expected competency in the specialty of Orthopedic Surgery. However, specialized pediatric centres may be providing care for increasing numbers of patients with fractures previously treated at community hospitals. The primary objective of this study was to examine trends in presentation of children with fractures to a specialized pediatric centre. METHODS: We performed a detailed chart review to examine trends in presentation of children aged 14 years or less with supracondylar humerus or femur fractures to a specialized pediatric centre (Hospital for Sick Children, Toronto) from anywhere in the Greater Toronto Area between Apr. 1, 2008, and Mar. 31, 2015. Consecutive patients admitted to hospital and requiring operative intervention for a supracondylar humerus or femur fracture were considered. We calculated changes in operation incidence rates per year using multivariable negative binomial regression models. RESULTS: A total of 945 children with supracondylar humerus fractures and 421 with femur fractures underwent operative intervention during the study period. The baseline characteristics of the 2 groups were similar irrespective of which year fixation occurred. The annual incidence rate of supracondylar humerus fractures increased from 108 to 169 (56.5%) over the study period, at an adjusted rate of 7.5% per year (adjusted incidence rate ratio [IRR] 1.075, 95% confidence interval [CI] 1.072-1.079, p < 0.001). The annual incidence rate of femur fractures increased from 49 to 69 (40.8%), at an adjusted rate of 5.3% per year (adjusted IRR 1.053, 95% CI 1.044-1.062, p < 0.001). Significant increases were observed independent of fracture classification, stabilization method, whether patients were transferred from an outside hospital or presented directly, patient geographic location or the season in which the fracture occurred. INTERPRETATION: Adjusted annual incidence rates of supracondylar humerus and femur fractures increased significantly over the study period. Further work is needed to assess the clinical impact of informal regionalization of care and to determine whether the phenomenon occurs in other specialties.

Falls risk in older adults with type 2 diabetes.

Falls are a major health issue for older adults, especially for those who develop type 2 diabetes who must contend with age-related declines in balance, muscle strength, and walking ability. They must also contend with health-related issues specific to the disease process. Given the general association between these variables and falls, being able to identify which measures negatively impact on balance in older diabetic persons is a critical step. Moreover, designing specific interventions to target these physiologic functions underlying balance and gait control will produce the greatest benefit for reducing falls in older persons with diabetes.