Patients' and Providers' Views on Optimal Evidence-Based and Scalable Interventions for Individuals at High Risk of HIV Treatment Failure: Sequential Explorations Among Key Stakeholders in Cape Town, South Africa.

To support translation of evidence-based interventions into practice for HIV patients at high risk of treatment failure, we conducted qualitative research in Cape Town, South Africa. After local health officials vetted interventions as potentially scalable, we held 41 in-depth interviews with patients with elevated viral load or a 3-month treatment gap at community clinics, followed by focus group discussions (FGDs) with 20 providers (physicians/nurses, counselors, and community health care workers). Interviews queried treatment barriers, solutions, and specific intervention options, including motivational text messages, data-informed counseling, individual counseling, peer support groups, check-in texts, and treatment buddies. Based on patients' preferences, motivational texts and treatment buddies were removed from consideration in subsequent FGDs. Patients most preferred peer support groups and check-in texts while individual counseling garnered the broadest support among providers. Check-in texts, peer support groups, and data-informed counseling were also endorsed by provider sub-groups. These strategies warrant attention for scale-up in South Africa and other resource-constrained settings.

Validity of the McMurray Test for Meniscal Tear in Pediatric and Adolescent Patients.

OBJECTIVE: The aim of this study was to identify the accuracy of the McMurray test in the adolescent and pediatric population. DESIGN: Retrospective case series. SETTING: Tertiary care, institutional. PATIENTS: Inclusion criteria included patients who presented with unilateral knee pain and were seen by pediatric sports medicine physicians. Patients were excluded if their knee pain was related to any underlying conditions. Three hundred patient charts were reviewed, and 183 patients (age range: 8-18 years, mean: 14 years; 74 male) met the inclusion criteria. INTERVENTIONS: Symptoms at initial visit (knee pain). MAIN OUTCOME MEASURES: Presence of a meniscal tear using the McMurray test. RESULTS: Eighty-four percent (160/191) of patients had a McMurray test documented as performed by the physician, and 17% (27/160) elucidated a positive response. Of 26 patients who had a positive McMurray and underwent magnetic resonance imaging (MRI), 16 (62%) showed a meniscal tear on their MRI. However, of the 87 patients who had a negative McMurray and still underwent MRI, 25 (29%) had a positive meniscal tear. The sensitivity, specificity, positive predictive value, and negative predictive value were 39%, 86%, 62%, and 71%, respectively. CONCLUSION: In a pediatric and adolescent population, the McMurray test was negative for 61% (23/38) of meniscal tears identified on MRI. CLINICAL RELEVANCE: Although the test can be a useful tool as a part of a thorough evaluation, combining it with mechanical symptoms, patient history and imaging may be more helpful to diagnose a meniscus tear.

Lessons Learned: The Varied Responses of Massachusetts' Local Health Departments During the COVID-19 Pandemic.

CONTEXT: Massachusetts' decentralized public health model holds tightly to its founding principle of home rule and a board of health system established in 1799. Consequently, Massachusetts has more local health departments (n = 351) than any other state. During COVID-19, each health department, steeped in centuries of independence, launched its own response to the pandemic. OBJECTIVES: To analyze local public health resources and responses to COVID-19. DESIGN: Semistructured interviews and a survey gathered quantitative and qualitative information about communities' responses and resources before and during the pandemic. Municipality demographics (American Community Survey) served as a proxy for community health literacy. We tracked the frequency and content of local board of health meetings using minutes and agendas; we rated the quality of COVID-19 communications on town Web sites. SETTING: The first 6 months of the COVID-19 pandemic in Massachusetts: March-August 2020. PARTICIPANTS: Health directors and agents in 10 south-central Massachusetts municipalities, identified as the point of contact by the Academic Public Health Corps. MAIN OUTCOME MEASURES: We measured municipality resources using self-reported budgets, staffing levels, and demographic-based estimates of community health literacy. We identified COVID-19 responses through communities' self-reported efforts, information on town Web sites, and meeting minutes and agendas. RESULTS: Municipalities excelled in communicating with residents, local businesses, and neighboring towns but lacked the staffing and funding for an efficient and coordinated response. On average, municipal budgets ranged from $5 to $16 per capita, and COVID-19 consumed 75% of health department staff time. All respondents noted extreme workload increases. While municipal Web sites received high scores for Accurate Information, other categories (Navigability; Timeliness; Information Present) were less than 50%. CONCLUSIONS: Increased support for regionalization and sustained public health funding would improve local health responses during complex emergencies in states with local public health administration.

High Parental Anxiety Increases Narcotic Use in Adolescent Patients Following Spinal Fusion.

BACKGROUND: Parental mental status and behavior may influence postoperative recovery and the use of pain medication. The purpose of this study is to identify if parents with high anxiety are associated with prolonged narcotic use in adolescent patients following posterior spinal fusion surgery. Prolonged narcotic use in this study was defined as opioid use at their first postoperative visit. METHODS: AIS patients age 11 to 20 years undergoing posterior spinal fusion and a parent were prospectively enrolled. At the preoperative appointment, patients completed the Spence Children's Anxiety Scale and parents completed the State-Trait Anxiety Inventory. High parental anxiety was defined as 1 SD above the normative mean. At the first postoperative visit, patients were asked about medication use. RESULTS: A total of 58 patients (49 females and 9 males) were enrolled. Overall, 29% (17/58) of parents had a high general anxiety trait on the State-Trait Anxiety Inventory and 71% (41/58) had normal general anxiety. Of the patients whose parents had high general anxiety, 47% (8/17) were still taking narcotics at their first postoperative visit compared with 20% (8/41) of patients with normal anxiety parents (P=0.03). CONCLUSIONS: Patients with high general anxiety parents were more than twice as likely to still be on narcotics at their first postoperative visit. This information can be used to counsel families on the impact of anxiety on narcotic usage. LEVEL OF EVIDENCE: Level II-prognostic studies-investigating the effect of a patient characteristic on the outcome of the disease.

Prospective Evaluation of a Treatment Protocol Based on Fracture Displacement for Pediatric Lateral Condyle Humerus Fractures: A Preliminary Study.

BACKGROUND: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures. METHODS: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI). RESULTS: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data. CONCLUSIONS: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making. LEVEL OF EVIDENCE: Level II.

Confirming the Presence of Unrecognized Meniscal Injuries on Magnetic Resonance Imaging in Pediatric and Adolescent Patients With Anterior Cruciate Ligament Tears.

BACKGROUND: Prior research has shown decreased accuracy of meniscal injury detection using magnetic resonance imaging (MRI) for anterior cruciate ligament (ACL)-deficient adult patients as well as ACL-deficient pediatric and adolescent patients. The objectives of this study were the following: (1) assess the diagnostic ability of MRI in detecting meniscal injuries for pediatric and adolescent patients undergoing arthroscopic ACL reconstruction and (2) characterize the unrecognized meniscal injuries. METHODS: The sensitivity, specificity, positive predictive value, and negative predictive value of meniscal tears (medial, lateral, or both) on MRI were calculated for the 107 patients in this cohort. Fisher exact tests were used to compare event frequencies between medial meniscal (MM) and lateral meniscal (LM) tears. One-way analysis of variance tests were performed to compare event rates between the location and type of unrecognized meniscal tears. RESULTS: The median age of the cohort was 15 (range: 7 to 18). The sensitivity, specificity, positive predictive value, and negative predictive value of MRI in detecting meniscal tears (medial, lateral, or both) in ACL-deficient pediatric and adolescent patients was 62.3%, 68.4%, 78.2%, and 50.0%, respectively. There were 26 (24.3%) cases in which a meniscal injury was not detected on MRI, but was discovered arthroscopically (MM: 5 knees, LM: 20 knees, both: 1 knee). These unrecognized meniscal injuries were more commonly the LM than the MM (77.8%, P-value=0.100), a vertical/longitudinal tear type (77.8%, P-value <0.001), and located in the posterior horn (74.1%, P-value <0.001). CONCLUSIONS: In this ACL-deficient pediatric and adolescent cohort, there were 26 (24.3%) patients with unrecognized meniscal injuries. A vertical tear in the posterior horn was the most commonly unrecognized meniscal injury, supporting the findings of prior research postulating that the location and configuration of a tear influence the accuracy of MRI in detecting these injuries. More research is needed to investigate strategies to improve the detection of meniscal tears in pediatric and adolescent patients preoperatively. These findings have implications with regard to patient counseling, operative planning, anticipatory guidance with regard to postoperative rehabilitation, recovery expectations, and surgical outcomes. LEVEL OF EVIDENCE: Level IV.

Investigating the Determinants of Nonaccidental Trauma Evaluation in Pediatric Femur Fractures.

BACKGROUND: Femoral fractures in children have the highest probability for abuse after skull fractures and humeral shaft fractures. However, the reported proportion of pediatric femur fractures that result from nonaccidental trauma (NAT) varies in the literature from 2% to 60%. The purpose of this study was to determine the patient characteristics associated with a physician's decision to conduct a NAT workup and challenge universal clinical practice guidelines stating that all children younger than 3 years with a diaphyseal femur fracture be evaluated for NAT. METHODS: A retrospective review was conducted on patients aged 0 to 36 months diagnosed with a femur fracture between January 1, 2004, and April 9, 2019, at our institution. NAT was defined as a diagnosis of trauma that was nonaccidental in the medical chart after a positive workup by skeletal survey, ophthalmological examination, or other appropriate referral made by the institution's child abuse and neglect team. Patients with incomplete medical records were excluded. RESULTS: A total of 299 patients were identified, and 22 were excluded. 71% (197/277) were screened for NAT. Patients younger than 1 year were significantly more likely to undergo a NAT workup (P = 0.009; Odds Ratio [OR], 2.3; 95% CI, 1.2 to 4.4) and receive a positive result from the NAT workup (P < 0.0005; OR, 11.3; 95% CI, 4.6 to 27.4). Additional injuries were also a significant predictor of a positive NAT workup (P < 0.001; OR, 5.3; 95% CI, 2.4 to 11.9). Patient race/ethnicity, sex, and fracture type were not markedly associated with the physician's decision to conduct a NAT workup. CONCLUSIONS: Infants younger than 1 year with a femur fracture and children younger than 3 years presenting with a femur fracture and another injury are at increased risk of possible NAT. While clinical practice guidelines may minimize racial bias in NAT evaluation, this study demonstrates that universal NAT workups for walking-age children in the absence of other evidence of abuse may be unnecessary. LEVEL OF EVIDENCE: This is a Level III retrospective cohort study.

Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care.

BACKGROUND: Successful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation. METHODS: Our developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings. RESULTS: Stakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources). CONCLUSIONS: Our evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.

Participant Experience with Protocol Research Kidney Biopsies in the Kidney Precision Medicine Project.

BACKGROUND: Kidney biopsies are procedures commonly performed in clinical nephrology and are increasingly used in research. In this study we aimed to evaluate the experiences of participants who underwent research kidney biopsies in the Kidney Precision Medicine Project (KPMP). METHODS: KPMP research participants with acute kidney injury (AKI) or chronic kidney disease (CKD) were enrolled at nine recruitment sites in the United States between September 2019 to January 2023. At 28 days post-biopsy, participants were invited to complete a survey to share their experiences, including: motivation to participate in research; comprehension of informed consent; pain and anxiety during and after the biopsy procedure; overall satisfaction with KPMP participation; and impact of the study on their lives. The survey was developed in collaboration with the KPMP Community Engagement Committee and the Institute of Translational Health Sciences at the University of Washington. RESULTS: 111 participants completed the survey, 23 enrolled for AKI and 88 for CKD. Median age was 61 (IQR 48-67) years, 43% were women, 28% were Black, and 18% were of Hispanic ethnicity. Survey respondents most commonly joined KPMP to help future patients (59%). The consent form was understood by 99% and 97% recognized their important role in the study. Pain during the biopsy was reported by 50%, at a median level of 1 (IQR 0-3) on a 0-10 scale. Anxiety during the biopsy was described by 64% at a median level of 3 (IQR 1-5) on a 0-10 scale. More than half conveyed that KPMP participation impacted their diet, physical activity, and how they think about kidney disease. CONCLUSIONS: KPMP survey respondents were most commonly motivated to participate in research protocol kidney biopsies by altruism, with excellent understanding of the informed consent process.

Progressive chronic SARS-CoV-2-positive giant cell myoendocarditis with atrial standstill and sudden cardiac death.

Giant cell myocarditis (GCM) is a rare condition. Its association with SARS-CoV-2 has not been described before. The 46-year-old female patient was admitted to the clinic on September 2020. She had 7 year adrenal insufficiency history and infarct-like debut of myocardial disease in November 2019. After COVID-19 in April 2020, cardiac disease progressed. The examination showed low QRS voltage, QS complexes in V1 -V5 leads, atrial standstill, left ventricular systolic and restrictive dysfunction, elevated anti-heart antibodies, and subepicardial late gadolinium enhancement by magnetic resonance imaging. Endomyocardial biopsy and pacemaker implantation were performed, but the patient died suddenly due to ventricular tachycardia or ventricular fibrillation (the resuscitation was ineffective). The autopsy revealed GCM, SARS-CoV-2, and Parvovirus B19 were detected in the myocardium. The role of SARS-CoV-2 in the pathogenesis of autoimmune myocarditis is discussed.

Current practice trends in the surgical management of patellofemoral instability: a survey of the Paediatric Research in Sports Medicine (PRiSM) Society.

PURPOSE: Patellofemoral instability (PFI) in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. The purpose of this study was to identify trends in management of PFI in children and adolescents in the United States and nationwide. METHODS: A 27-question multiple choice survey was distributed in 2018 to the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding treatment of PFI in paediatric and adolescent patients. RESULTS: In all, 56 of the respondents who were orthopaedic surgeons that manage patellar instability in children and adolescents and had performed PFI surgery more than five times in the past year completed the entire survey. A total of 41% of respondents reported that surgery for fragment refixation or loose body removal was indicated when a loose body or osteochondral fragment was evident, regardless of fragment size. Overall, 74% reported that if surgery was performed for an osteochondral loose body, primary repair (36%) or reconstruction (38%) of medial patellofemoral ligament (MPFL) was also completed. A total of 89% of members reported MPFL reconstruction in the absence of alignment or rotational abnormalities, tibial tubercle lateralization or trochlear dysplasia in skeletally immature patients; 59% reported performing the MPFL reconstruction with hamstring allograft, while 30% prefer autograft (hamstring, quadriceps). For patients with significant trochlear dysplasia, 87% reported no surgical management of trochlea in first-time or in revision surgery. CONCLUSION: There is a lack of consensus regarding optimal diagnostic and treatment algorithms in the management of PFI, however, consistent trends have emerged among paediatric sports medicine surgeons. LEVEL OF EVIDENCE: Level V - survey of expert opinion and experience.

Access to Physical Therapy for Pediatric and Adolescent Patients Following Orthopedic Surgery.

The objective of this study was to evaluate the relationship between insurance status and access to physical therapy (PT). Masked telephone interviews with PT facilities in a major metropolitan area were conducted with researchers posing as parents of children. Each facility was called twice: once with a private insurer and once with a government insurer. Earliest available appointment, if the facility accepted insurance, and amount of time required to return a call were recorded. Fifty-four PT clinics responded. Clinics that accepted private insurance were significantly greater than the proportion that accepted government insurance (85.2% vs 14.8%, P < .001). There was no significant difference in time between initial call and first offered appointment, in the 2 insurance conditions (private: 8.09 days, government: 8.67 days, P = .33). There were no significant differences in appointment delays between both insurance conditions. Our study found there was a significantly lower rate of children with government-funded insurance that had access to postsurgical rehabilitation.

Socioeconomic status impacts outcomes following pediatric anterior cruciate ligament reconstruction.

Previous research has shown that delays in pediatric anterior cruciate ligament (ACL) reconstruction are associated with increased prevalence of concomitant knee injuries and worse outcomes following surgery. However, few studies have described factors that may contribute to these delays and adverse outcomes. This study seeks to determine the effect of socioeconomic status on clinical outcomes following ACL reconstruction.A retrospective review of patients who underwent primary ACL reconstruction at a tertiary pediatric hospital between 2009 and 2015 was conducted. Variables included chronologic, demographic, and socioeconomic data, and postoperative complications. Socioeconomic status was measured using health insurance type and median household income levels derived from 2009 to 2015 US Census Bureau.A total of 127 patients (69 male, 58 female) were included. The mean age at time of surgery was 15.0 years. Overall, 68 patients had commercial insurance and 59 patients had government-assisted insurance. The mean household median income for patients with commercial insurance was $87,767 compared to $51,366 for patients with government-assisted insurance. Patients with government-assisted insurance plans demonstrated greater delays in time from injury to initial orthopaedic evaluation (P = .0003), injury to magnetic resonance imaging (MRI) examination (P = .021), injury to surgery (P < .0001), initial orthopaedic evaluation to surgery (P = .0036), and injury to return to play clearance, P = .044. Median household income was significantly related to time from injury to MRI examination (P = .0018), injury to surgery (P = .0017), and initial orthopaedic evaluation to surgery (P = .039). Intraoperatively, 81% of patients with government-assisted insurance had concomitant meniscal injuries compared 65% of patients with commercial insurance, P = .036. Postoperatively, 22% of patients with government-assisted insurance were found to have decreased knee range of motion ("stiffness") compared to 9% of patients with commercial insurance, P = .034.Pediatric patients who have government-assisted plans may experience delays in receiving definitive injury management and be at risk for postoperative complications. Our findings suggest a significant discrepancy in time to treatment as well as rates of concomitant knee injuries and postoperative complications between government and commercial insurance types.Level of Evidence: III.

Side Plank Pose Exercises for Adolescent Idiopathic Scoliosis Patients.

BACKGROUND: Fishman et al. reported that side plank poses asymmetrically strengthened the convex side of the curve and decreased primary Cobb angle by 49% among compliant patients with adolescent idiopathic scoliosis (AIS). METHODS: AIS patients with curves of 10° to 45° were randomized into the front plank (control) or side plank group. The side plank was performed with their curve convex down. A weekly survey monitored compliance, defined by completing poses 4 or more times a week. RESULTS: A total of 64 patients were enrolled; 34% (22 of 64) of patients (mean age = 13 years) were compliant. In the control group, there were 11 compliant patients with 6 undergoing brace treatment. At enrollment, they had a mean Cobb angle of 30° (range: 14°-40°) and mean scoliometer reading of 13°. At 6 months, they had a mean Cobb angle of 30° (range: 14°-42°) and mean scoliometer of 12°. In the side plank group, there were 11 compliant patients with 5 undergoing brace treatment. At enrollment, they had a mean Cobb angle of 32° (range: 21°-44°) and mean scoliometer reading of 12°. At 6 months, they had a mean Cobb angle of 31° (range: 17°-48°) and a mean scoliometer reading of 13°. There were no significant changes in either the control or side plank group in regards to primary Cobb angle (control: P = .53, side plank: P = .67) or scoliometer (control: P = .22, side plank: P = .45). CONCLUSION: There were no significant changes in primary Cobb angle or scoliometer after 6 months of side plank exercises. In contrast to a prior study, there was no improvement in curve magnitude in AIS patients performing side plank exercises.

A Pilot Study on Resident and Pediatrician Knowledge and Confidence in the Diagnosis of Slipped Capital Femoral Epiphysis.

Introduction. The purpose of this study was to identify deficiencies in pediatric residents' and pediatricians' knowledge and confidence in diagnosing slipped capital femoral epiphysis (SCFE). Methods. Pediatricians and residents at our institution answered an anonymous 12-question survey on knowledge and confidence in SCFE diagnosis. Results. Twenty pediatricians and 30 pediatric residents participated in the survey. Of 30 residents, 22 (77%) reported low confidence ordering radiographs evaluating for SCFE in patients with hip pain. Four of 20 pediatricians (20%) reported low confidence ordering radiographs for patients with hip pain. Forty percent (8/20) of pediatricians did not feel comfortable diagnosing a SCFE based on radiographs, which was significantly different from 80% (24/30) of residents who did not feel comfortable diagnosing a SCFE based on radiographs (P = .004). There was a significant difference between residents and pediatricians in comfort ordering and diagnosing radiographs (P < .01). There was no significance between pediatrician and resident scores for knowledge-based questions (P = .50). Discussion. Despite scoring well on knowledge-based questions, more than half of pediatricians and pediatric residents felt uncomfortable ordering radiographs to evaluate for SCFE in patients with hip or knee pain. This may be one factor contributing to the continued delay in SCFE diagnosis.