Racial and Ethnic Differences in Length of Stay for US Children Hospitalized for Acute Osteomyelitis.

OBJECTIVE: To examine the associations between race and ethnicity and length of stay (LOS) for US children with acute osteomyelitis. STUDY DESIGN: Using the Kids' Inpatient Database, we conducted a cross-sectional study of children <21 years old hospitalized in 2016 or 2019 with acute osteomyelitis. Using survey-weighted negative binomial regression, we modeled LOS by race and ethnicity, adjusting for clinical and hospital characteristics and socioeconomic status. Secondary outcomes included prolonged LOS, defined as LOS of >7 days (equivalent to LOS in the highest quartile). RESULTS: We identified 2388 children discharged with acute osteomyelitis. The median LOS was 5 days (IQR, 3-7). Compared with White children, children of Black race (adjusted incidence rate ratio [aIRR] 1.15; 95% CI, 1.05-1.27), Hispanic ethnicity (aIRR 1.11; 95% CI, 1.02-1.21), and other race and ethnicity (aIRR 1.12; 95% CI, 1.01-1.23) had a significantly longer LOS. The odds of Black children experiencing prolonged LOS was 46% higher compared with White children (aOR, 1.46; 95% CI, 1.01-2.11). CONCLUSIONS: Children of Black race, Hispanic ethnicity, and other race and ethnicity with acute osteomyelitis experienced longer LOS than White children. Elucidating the mechanisms underlying these race- and ethnicity-based differences, including social drivers such as access to care, structural racism, and bias in provision of inpatient care, may improve management and outcomes for children with acute osteomyelitis.

Associations between Interleukin Gene Polymorphisms and Risks of Developing Extremity Posttraumatic Osteomyelitis in Chinese Han Population.

This case-control study aimed to investigate potential associations between interleukin (IL) gene polymorphisms and the risks of developing extremity posttraumatic osteomyelitis (PTOM) in Chinese Han population. Altogether, 189 PTOM patients and 200 healthy controls were genotyped of IL-1α (rs17561, rs1800587), IL-1ß (rs16944, rs1143627, rs1143634, rs2853550), IL-1RN (rs4251961, rs419598, rs315951), IL-4 (rs2243248, rs2243250), IL-6 (rs1800795, rs1800796, rs1800797), IL-8 (rs4073, rs2227306, rs2227307), IL-10 (rs3024491, rs3024496, rs1800871, rs1800872, rs1800896), IL-17A (rs2275913), and IL-17F (rs763780) using the SNaPshot genotyping method. Statistical differences were observed regarding the genotype distributions of rs16944 (P = 0.049) and rs4251961 (P = 0.007) between the patients and healthy controls. In addition, significant associations were found between rs16944 and the risk of PTOM development by dominant (OR = 1.854, P = 0.017), homozygous (OR = 1.831, P = 0.041), and heterozygous (OR = 1.869, P = 0.022) models, and of rs1143627 by dominant (OR = 1.735, P = 0.032) and homozygous (OR = 1.839, P = 0.040) models. Moreover, significant links were also identified between rs4251961 and the susceptibility to PTOM by dominant (OR = 0.446, P = 0.005) and heterozygous (OR = 0.409, P = 0.003) models, and of rs1800796 by dominant (OR = 4.184, P = 0.029), homozygous (OR = 4.378, P = 0.026), and heterozygous (OR = 3.834, P = 0.046) models. The present outcomes demonstrated that rs16944, rs1143627, and rs1800796 associate with increased risks, while rs4251961 links to a decreased risk of PTOM development in Chinese Han population.

Does Universal Insurance and Access to Care Influence Disparities in Outcomes for Pediatric Patients with Osteomyelitis?

BACKGROUND: Healthcare disparities are an issue in the surgical management of orthopaedic conditions in children. Although insurance expansion efforts may mitigate racial disparities in surgical outcomes, prior studies have not examined these effects on differences in pediatric orthopaedic care. To assess for racial disparities in pediatric orthopaedic care that may persist despite insurance expansion, we performed a case-control study of the outcomes of children treated for osteomyelitis in the TRICARE system, the healthcare program of the United States Department of Defense and a model of universal insurance and healthcare access. QUESTIONS/PURPOSES: We asked whether (1) the rates of surgical intervention and (2) 90-day outcomes (defined as emergency department visits, readmission, and complications) were different among TRICARE-insured pediatric patients with osteomyelitis when analyzed based on black versus white race and military rank-defined socioeconomic status. METHODS: We analyzed TRICARE claims from 2005 to 2016. We identified 2906 pediatric patients, of whom 62% (1810) were white and 18% (520) were black. A surgical intervention was performed in 9% of the patients (253 of 2906 patients). The primary outcome was receipt of surgical intervention for osteomyelitis. Secondary outcomes included 90-day complications, readmissions, and returns to the emergency department. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of socioeconomic status before and during enlistment, and enlisted service members, particularly junior enlisted service members, may be at risk of having the same medical conditions that affect civilian members of lower socioeconomic strata. Patient demographic information (age, sex, race, sponsor rank, beneficiary category [whether the patient is an insurance beneficiary from an active-duty or retired service member], and geographic region) and clinical information (prior comorbidities, environment of care [whether clinical care was provided in a civilian or military facility], treatment setting, and length of stay) were used as covariates in multivariable logistic regression analyses. RESULTS: After controlling for demographic and clinical factors including age, sex, sponsor rank, beneficiary category, geographic region, Charlson comorbidity index (as a measure of baseline health), environment of care, and treatment setting (inpatient versus outpatient), we found that black children were more likely to undergo surgical interventions for osteomyelitis than white children (odds ratio 1.78; 95% confidence interval, 1.26-2.50; p = 0.001). When stratified by environment of care, this finding persisted only in the civilian healthcare setting (OR 1.85; 95% CI, 1.26-2.74; p = 0.002). Additionally, after controlling for demographic and clinical factors, lower socioeconomic status (junior enlisted personnel) was associated with a higher likelihood of 90-day emergency department use overall (OR 1.60; 95% CI, 1.02-2.51; p = 0.040). CONCLUSIONS: We found that for pediatric patients with osteomyelitis in the universally insured TRICARE system, many of the historically reported disparities in care were absent, suggesting these patients benefitted from improved access to healthcare. However, despite universal coverage, racial disparities persisted in the civilian care environment, suggesting that no single intervention such as universal insurance sufficiently addresses differences in racial disparities in care. Future studies can address the pervasiveness of these disparities in other patient populations and the various mechanisms through which they exert their effects, as well as potential interventions to mitigate these disparities. LEVEL OF EVIDENCE: Level III, prognostic study.

Pediatric Acute Hematogenous Osteomyelitis.

BACKGROUND: Osteomyelitis continues to be a significant problem among the New Zealand pediatric population. We present a large series of acute hematogenous osteomyelitis (AHO) cases, with the aim to identify any changing trends and guide successful management of the disease. METHODS: A 10-year retrospective review was performed of clinical records of children with AHO at the 2 children's orthopaedic departments in the Auckland region. Cases were identified from Starship Children's Hospital between 1997 and 2007 and Middlemore's Kidz First Hospital between 1998 and 2008. RESULTS: A total of 813 cases of pediatric AHO were identified. The incidence was 1:4000, which was decreasing over the 10-year period. There was a male predominance and New Zealand (NZ) Maori and Pacific Islanders were overrepresented. The diagnosis was made clinically in 27%, radiographically in 66%, and surgically in 7%. The most common pathogen was Staphylococcus aureus and the incidence of methicillin-resistant S. aureus was low (2%). The average length of antibiotic treatment was 44 days and 44% required surgery. This produced a recurrence rate of only 7% and a 15% treatment-related complication rate. CONCLUSIONS: In the New Zealand population, the incidence of AHO remains high with NZ Maori and Pacific Islanders overrepresented. The predominant pathogen remains S. aureus and our population has a very low incidence of methicillin-resistant S. aureus; flucloxacillin remains a good choice for empiric treatment in our population. Our rate of relapse and subsequent chronic osteomyelitis is low. This could be explained by traditionally longer antibiotic courses; however, this may also lead to increased treatment-related complications. Through prompt and accurate diagnosis with the aid of laboratory and radiologic tests and effective treatment with appropriate antibiotics (guided by local pathogen sensitivities) and surgical treatment when indicated, AHO can be well managed with minimal severe complications. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Osseous dysplasia (cemento-osseous dysplasia) of the jaw bones in western Pennsylvania patients: analysis of 35 cases.

OBJECTIVES: The purpose of this study is to analyze the demographic, clinical, and radiographic presentations of osseous dysplasia of the jaws in western Pennsylvania patients and its associated complications. MATERIALS AND METHODS: The clinical records and radiographs of patients diagnosed with osseous (cement-osseous) dysplasia were retrieved from the electronic health record of the University of Pittsburgh, School of Dental Medicine from 2007 to 2012. All cases were reviewed; the WHO criteria and classification for osseous dysplasia was used. Clinical and demographic data, radiographic findings, and final diagnoses were collected and analyzed. RESULTS: 35 cases of osseous dysplasia were retrieved over the six-year period.The majority (33) were females [94.3%], with ages ranging from 26 to 89 years, with a mean age of 53.9 years +/- standard deviation of 15.6 years, 32 [91.4%] were African Americans and 3 [8.6%] were Caucasians. 17 [48.6%] were florid osseous dysplasia, 13 [37.1%] periapical osseous dysplasia and 5 [14.3%] focal osseous dysplasia. Of the 35 patients only 8 [22.9%] patients were symptomatic. All florid osseous dysplasia patients were African American females, with 7 of the patients being symptomatic and the commonest symptom being pain. Also, all periapical osseous dysplasia patients were African Americans (12 females and 1 male), with 1 of the patients presenting with widening of the diastema. Of the focal osseous dysplasia patients, 3 were Caucasians and 2 African American (4 females and 1 male). CONCLUSION: The cases occurred mostly in African American females with a peak incidence in the fifth and sixth decades of life; most cases occurred in the mandible. The commonest form of osseous dysplasias was the florid osseous dysplasia which is most likely to present with symptoms.

Interleukin-1 Beta Gene Polymorphism rs16944 May Associate with Increased Susceptibility to Extremity Chronic Osteomyelitis in Chinese Han Population.

BACKGROUND: Previous studies had indicated that interleukin-1 beta (IL-1ß) gene single nucleotide polymorphisms (SNPs) associate with different inflammatory diseases. However, potential links between these polymorphisms and susceptibility to extremity chronic osteomyelitis (COM) remain unclear. This study aimed to investigate relationships between IL-1ß gene polymorphisms (rs16944, rs1143627, rs1143634, and rs2853550) and risks of developing extremity COM in Chinese Han population. METHODS: Altogether 233 extremity COM patients and 200 healthy controls were genotyped for the four tag SNPs of the IL-1ß gene using the SNapShot genotyping method. Comparisons were performed regarding genotype distribution, mutant allele frequency, and four genetic models (dominant, recessive, homozygous, and heterozygous models) of the four SNPs between the two groups. RESULTS: Significant associations were identified between rs16944 polymorphism and the risk of developing COM by dominant model (P = 0.026, OR = 1.698, 95% CI 1.065-2.707) and heterozygous model (P = 0.030, OR = 1.733, 95% CI 1.055-2.847). Although no statistical differences were found of rs1143627 polymorphism between the two groups, there existed a trend that rs1143627 may be linked to an elevated risk of developing COM by outcomes of dominant (P = 0.061), homozygous (P = 0.080) and heterozygous (P = 0.095) models. However, no statistical correlations were found between rs1143634 and rs2853550 polymorphisms and susceptibility to COM in Chinese Han population. CONCLUSIONS: To our knowledge, we reported for the first time that IL-1ß gene rs16944 polymorphism may contribute to the increased susceptibility to extremity COM in Chinese Han population, with genotype of AG as a risk factor.

Clinical, demographic, and radiographic analysis of 82 patients affected by florid osseous dysplasia: an international collaborative study.

OBJECTIVE: The aim of this study was to correlate the clinical, demographic, and radiographic aspects of 82 cases of florid osseous dysplasia (FOD) from four countries assessed by five reviewers. STUDY DESIGN: Retrospective data of patients diagnosed with FOD were obtained from archives of five institutes and analyzed according to clinical and radiographic criteria. RESULTS: A total of 82 cases of FOD were included in the study. In the majority (77.5%) of FOD cases, black women were affected. The disease mainly affected the mandible (100%), and the stage of the lesion was directly correlated with the age (P < .05). The rates of convergence showed confluence of assessment in the mandible (posterior), and the highest rate of divergence between the reviewers was in assessing involvement in the maxilla. There were no differences among the characteristics of the lesion provided by the five institutions, except for the variable proportion of black patients affected by the disease. CONCLUSIONS: FOD mostly affects the mandible of middle-aged black women, and its stage is correlated with patient age. Although panoramic radiography is used for diagnosis, the divergence in assessment of the maxilla might indicate that this method is not the most suitable to evaluate this area.

Serious adverse events associated with bacille Calmette-Guérin vaccine in Canada.

BACKGROUND: Targeted Bacille Calmette-Guérin (BCG) vaccination is offered to neonates in some First Nations and Inuit (FNI) communities in Canada. Serious adverse events associated with BCG vaccine prompted a review to assess causality. METHODS: The Immunization Monitoring Program Active (IMPACT), a pediatric hospital-based active surveillance network, reported admissions for BCG-related adverse events between 1993 and April 2002. The Canadian Advisory Committee on Causality Assessment (ACCA) reviewed the reports to assess causality. Data between 1987 and September 2002 from the Vaccine-Associated Adverse Event Surveillance (VAAES) Program, a passive national reporting system, were also reviewed. RESULTS: IMPACT identified 21 pediatric cases; 19 were Canadian-born, and 18 were FNI. Six disseminated BCG cases were identified; 5 were FNI infants who subsequently died. All had immunodeficiencies and concurrent infections. Other adverse events included 2 cases of osteomyelitis, BCG abscesses and lymphadenitis. ACCA reviewed the 21 cases and determined that 14 were very likely associated with the vaccine, including the 6 disseminated BCGs; 5 were probably associated and 1 was possibly associated with the vaccine; 1 was unclassifiable. The VAAES program identified 157 adverse events. No additional serious systemic adverse events (disseminated BCG or osteomyelitis) were identified. CONCLUSIONS: Serious BCG vaccine-associated complications continue to occur in Canada. The numbers of FNI children with disseminated disease was greater than expected from reported rates in the literature.

[Tuberculous osteomyelitis in children--a problem of immigrants?]. / Tuberkuløs osteomyelitis hos børn--et indvandrerproblem?

The incidence of tuberculosis in Denmark has increased in recent years, owing to immigrants from, primarily, Somalia. Bone and joint TB are mainly seen in young immigrants and a case of tuberculous ostitis of the tarsal bones and surrounding soft tissue is described.

Patients with inhibitory and neutralizing auto-antibodies to interferon-γ resemble the sporadic adult-onset phenotype of Mendelian Susceptibility to Mycobacterial Disease (MSMD) lacking Bacille Calmette-Guerin (BCG)-induced diseases.

To recognize patients with inhibitory and neutralizing auto-antibodies to interferon-γ (AutoAbs-IFN-γ) presenting with the sporadic phenotype of Mendelian Susceptibility to Mycobacterial Disease (MSMD) mainly characterized by recurrent intracellular mycobacterium or/and salmonella infections, we comprehensively investigated IL12/23-IFN-γ signaling, candidate genetic sequencings or/and protein expressions of IL12RB1, IFNRG1, IL12p40, IFNRG2, STAT1, IKKA, NEMO, CYBB and IRF8 in four patients. Their serum was further titrated to detect AutoAbs-IFN-γ, for which the biological activity was assessed in Jurkat T cells. The patients mainly presented with recurrent non-tuberculous mycobacterium osteomyelitis and lymphadenopathy (Mycobacterium abscessus, chelonae and avium intracellular complex), and salmonella sepsis (S. enterica serogroup B, C2 and D). Additionally, Penicillium marneffei, varicella-zoster virus, and herpes simplex virus infections occurred. Inhibitory and neutralizing IFN-γ downstream signaling was elucidated in Jurkat cell lines as decreased MHC class I and phosphorylated STAT1 expression. Together with 24 patients from the PubMed search, the majority of the AutoAbs-IFN-γ patients were Asian (25/28). The most common involvement was lymph nodes (in 22/28), lungs (19/28) and bones (12/28). Mycobacterium avium complex (in 14) and chelonae (7) were the most common pathogens from 40 isolations. In contrast to those with the mild form of MSMD phenotype, AutoAbs-IFN-γ patients, in the absence of BCG-induced diseases, had a more persistent course and poor response to IFN-γ treatment. In conclusion, AutoAbs-IFN-γ patients may have a sporadic adult-onset MSMD phenotype in Asian regions endemic for mycobacterial infections.

Clinical and laboratory features of Nigerian patients with osteomyelitis.

INTRODUCTION: The aim of this study was to investigate the clinicopathological characteristics of Nigerian patients with osteomyelitis. METHODS: 30 patients with osteomyelitis and 30 apparently-healthy age- and sex-matched controls were investigated. The packed cell volume (PCV), white blood cells (WBC) and differentials, and platelet counts were measured using an automated counter, while the erythrocyte sedimentation rate (ESR) was determined by Westergren's technique. C3 activator, C1 esterase inhibitor (C1-INH), IgA, IgG and IgM were estimated by the single radial immunodiffusion method. Wound swabs, blood cultures and biopsies were taken and sent for microscopic, culture and sensitivity analysis. RESULTS: Patients with osteomyelitis had elevated total leucocytes, neutrophils, and platelet counts compared to the controls. There was also significant anaemia (t equals 3.17, p-value equals 0.002) and a significantly elevated ESR (t equals 3.75, p-value equals 0.000). Serum levels of C3 activator were significantly higher in patients with osteomyelitis (t equals 6.29, p-value equals 0.000). Although serum levels of C1-INH, IgG and IgM were higher in osteomyelitis, they were not significantly so. Serum levels of IgA were reduced in patients with osteomyelitis. Significant correlations between PCV and ESR (r equals -0.486, p-value equals 0.006), ESR and total WBC count (r equals +0.542, p-value equals 0.002), ESR and platelet count (r equals 0.445, p-value equals 0.013) and total WBC count and IgG (r equals 0.507, p-value equals 0.019) were noted . CONCLUSION: Nigerian patients with osteomyelitis have similar clinical and laboratory features already described in literature, with some noted immune dysfunctions.