Retaining Patients with Drug-Resistant Tuberculosis on Treatment During the COVID-19 Pandemic - Dharavi, Mumbai, India, 2020-2022.

Mumbai, India's second largest city, has one of the highest prevalences of drug-resistant tuberculosis* (DRTB) in the world. Treatment for DRTB takes longer and is more complicated than treatment for drug-susceptible tuberculosis (TB). Approximately 300 persons receive a new DRTB diagnosis each year in Mumbai's Dharavi slum†; historically, fewer than one half of these patients complete DRTB treatment. As nationwide restrictions to mitigate the COVID-19 pandemic were implemented, a program to facilitate uninterrupted DRTB care for patients receiving treatment was also implemented. A comprehensive tool and risk assessment provided support to DRTB patients and linked those who relocated outside of Dharavi during the pandemic to DRTB care at their destination. During May 2020-September 2022, a total of 973 persons received DRTB treatment in Dharavi, including 255 (26%) who relocated during treatment. Overall, 25 (3%) DRTB patients were lost to follow-up, a rate substantially lower than the rate before the pandemic (18%). Proactive planning and implementation of simple tools retained patients on treatment during periods of travel restrictions and relocations, improving programmatic outcomes. This approach might aid public health programs serving migrant populations or patients receiving treatment for DRTB during public health emergencies.

Operative Fractures of the Phalangeal Head and Neck in Children-Does Open Reduction Affect Outcomes?

BACKGROUND: Closed reduction percutaneous pinning of displaced pediatric phalangeal head and neck fractures is preferred to prevent malunion and loss of motion and function. However, open reduction is required for irreducible fractures and open injuries. We hypothesize that osteonecrosis is more common in open injuries than closed injuries that require either open reduction or closed reduction percutaneous pinning. METHODS: Retrospective chart review of 165 phalangeal head and neck fractures treated surgically with pin fixation at a single tertiary pediatric trauma center from 2007 to 2017. Fractures were stratified as open injuries (OI), closed injuries undergoing open reduction (COR), or closed injuries treated with closed reduction (CCR). The groups were compared using Pearson χ 2 tests and ANOVA. Two group comparisons were made with Student t test. RESULTS: There were 17 OI fractures, 14 COR fractures, and 136 CCR fractures. Crush injury was the predominant mechanism in OI versus COR and CCR groups. The average time from injury to surgery was 1.6 days for OI, 20.4 days for COR, and 10.4 days for CCR. The average follow-up was 86.5 days (range, 0 to 1204). The osteonecrosis rate differed between the OI versus COR and OI versus CCR groups (71% for OI, 7.1% for COR, and 1.5% for CCR). Rates of coronal malangulation >15 degrees differed between the OI and COR or CCR groups, but the 2 closed groups did not differ. Outcomes were defined using Al-Qattan's system; CCR had the most excellent and fewest poor outcomes. One OI patient underwent partial finger amputation. One CCR patient had rotational malunion but declined derotational osteotomy. CONCLUSIONS: Open phalangeal head and neck fractures have more concomitant digital injuries and postoperative complications compared with injuries closed on presentation, regardless of whether the fracture underwent open or closed reduction. Although osteonecrosis occurred in all 3 cohorts, it was most frequent in open injuries. This study allows surgeons to discuss rates of osteonecrosis and resultant complications with families whose child presents with phalangeal head and neck fractures that are indicated for surgical treatment. LEVEL OF EVIDENCE: Therapeutic, Level III.

Building communities of practice through case-based e-learning to prevent and manage TB among people living with HIV-India.

BACKGROUND: Co-management of HIV-TB coinfection remains a challenge globally. Addressing TB among people living with HIV (PLHIV) is a key priority for the Government of India (GoI). In 2016, GoI implemented single-window services to prevent and manage TB in PLHIV. To strengthen HIV-TB service delivery, case-based e-learning was introduced to health care providers at Antiretroviral Therapy centres (ARTc). METHODS: We implemented a hub and spoke model to deliver biweekly, virtual, case-based e-learning at select ARTc (n = 115), from four states of India-Delhi, Uttar Pradesh, Andhra Pradesh and Tamil Nadu. We evaluated feasibility and acceptability of case-based e-learning and its impact on professional satisfaction, self-efficacy, knowledge retention using baseline and completion surveys, session feedback, pre-and post-session assessments. We reviewed routine programmatic data and patient outcomes to assess practices among participating ARTc. RESULTS: Between May 2018 and September 2020, 59 sessions were conducted with mean participation of 55 spokes and 152 participants. For 95% and 88% of sessions ≥ 80% of respondents agreed that topics were clear and relevant to practice, and duration of session was appropriate, respectively. Session participants significantly improved in perceived knowledge, skills and competencies (+ 8.6%; p = 0.025), and technical knowledge (+ 18.3%; p = 0.04) from baseline. Participating ARTc increased TB screening (+ 4.2%, p < 0.0001), TB diagnosis (+ 2.7%, p < 0.0001), ART initiation (+ 4.3%, p < 0.0001) and TB preventive treatment completion (+ 5.2%, p < 0.0001). CONCLUSION: Case-based e-learning is an acceptable and effective modus of capacity building and developing communities of practice to strengthen integrated care. E-learning could address demand for accessible and sustainable continuing professional education to manage complex diseases, and thereby enhance health equity. We recommend expansion of this initiative across the country for management of co-morbidities as well as other communicable and non-communicable diseases to augment the existing capacity building interventions by provide continued learning and routine mentorship through communities of practice.

A Short Knowledge Assessment Tool Is Valid and Acceptable for Adults with Inflammatory Bowel Disease.

BACKGROUND: For people with inflammatory bowel disease, validated knowledge questionnaires are valuable to identify gaps in understanding and explore the impact on disease variables. AIMS: The aim of this study was to validate the short knowledge questionnaire Inflammatory Bowel Disease Knowledge Inventory Device 2, known as IBD-KID2, for use with adults with inflammatory bowel disease. METHODS: Concurrent validity of IBD-KID2 was assessed by comparing scores with those achieved on the Crohn's and Colitis Knowledge Score (CCKNOW). IBD-KID2 reliability was assessed with test-retest completion at two time points, generalizability assessed by comparing IBD-KID2 cohort scores at different recruitment centres, and acceptability assessed using participant survey. RESULTS: Seventy-five adults with inflammatory bowel disease completed the study. The mean percentage scores achieved on the IBD-KID2 and CCKNOW were 72.8% (SD 16.0) and 49.7% (SD 18.2), respectively. There was a significant correlation between IBD-KID2 and CCKNOW scores (R 0.573, P < 0.005), confirming concurrent validity. IBD-KID2 reliability was confirmed as no significant difference was seen between scores at test and retest (mean difference -0.2, P = 0.92). Generalizability was established as no significant score difference was seen between recruitment centres after controlling for population differences. The acceptability survey showed that 49 (69%) participants preferred IBD-KID2 to the CCKNOW, 60 (85%) found the IBD-KID2 easier to complete, and 38 (53%) considered the CCKNOW as most suitable for adults. CONCLUSIONS: IBD-KID2 is a valid, reliable, and generalizable tool for measuring knowledge in adults with inflammatory bowel disease with good acceptability. IBD-KID2 is easy and quick to complete, hence limiting respondent burden.

Strategic Parent Meets Detached Child? Parental Intended Bequest Division and Support From Children.

While the literature shows that elderly parents may use bequests to reward children who provide them with time support, there is limited evidence on whether younger, less needy parents base their intended bequest division on alternative forms of support from children. This study uses data from the June 2018 Singapore Life Panel and focuses on a sample of 4,125 adult children and their middle-aged and older parents. From family fixed-effects estimation, I find that parents intend to leave larger bequest shares to coresident children and to children who provide greater material support. Parents also intend to bequeath more to children in whom they confide frequently, while children in whom they confide rarely receive more bequests only if they provide greater material support. The results suggest that parents may interpret physical and emotional proximity to children as signs of filiality for which they may reward them, while detached children may earn such rewards through material support. This study demonstrates the existence of coresidence-for-bequest and money-for-bequest exchanges between adult children and their middle-aged and older parents. These exchanges may translate into future caregiving-for-bequests when parents become elderly, and may thus have broader implications for both individual and societal well-being.

The Efficacy of Nonsurgical and Surgical Interventions in the Treatment of Pediatric Wrist Ganglion Cysts.

PURPOSE: The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone. METHODS: We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had >2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision. RESULTS: For patients followed >2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at >2 years of follow-up. CONCLUSIONS: This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Poor Outcomes of Pediatric Acute Compartment Syndrome in the Setting of Extracorporeal Membrane Oxygenation: A Multicenter Case Series.

BACKGROUND: Acute compartment syndrome (ACS) is a well-described condition that merits emergent surgical decompression. Peripheral arterial cannulation can increase the likelihood of ACS in patients requiring extracorporeal membranous oxygen (ECMO). Comorbidities in these critically ill patients may portend negative consequences of decompressive fasciotomy. This study investigated the clinical short-term and mid-term outcomes in pediatric patients with ECMO-associated ACS. METHODS: This is a retrospective case series at 3 pediatric hospitals from 2006 to 2019, including children ages 0 to 19 years who underwent peripheral arterial cannulation and developed ACS. RESULTS: Eighteen patients developed ACS after receiving peripheral cannulation ECMO. Mean time to diagnosis after cannulation was 63.1 hours. All patients were diagnosed clinically; the most common findings were tight compartments, swelling, and loss of peripheral pulses. Eight patients (44%) died due to underlying illness. Treating physicians decided against decompression for 5 patients due to their underlying illness, instability, and concern for infection. Thirteen patients (72%) underwent decompressive fasciotomies. Ten surgical patients required subsequent surgeries and 6 (33%) developed surgical site infections. Of the 7 surviving surgical patients, 4 (57%) required extremity amputations and 4 had lower extremity neurological deficits on follow-up. Two of 3 nonsurgical patients (66%) had functional lower extremity motor deficits on follow-up. No surviving nonoperative patients developed infections or required amputations. CONCLUSIONS: ACS on ECMO is associated with high rates of complications including neurologic deficits, infection, and amputation. Patients treated nonoperatively avoided complications such as infection and amputation, but had more functional neurological deficits than surgical patients. Orthopaedic surgeons should consider the high morbidity of compartment release in these critically ill patients and, with critical care teams, assess whether the potential benefits of surgery outweigh expected risks. LEVEL OF EVIDENCE: Level IV.

Prevalence of Latent Tuberculosis Infection Among Non-US-Born Persons by Country of Birth-United States, 2012-2017.

BACKGROUND: Most tuberculosis (TB) disease in the United States (US) is attributed to reactivation of remotely acquired latent TB infection (LTBI) in non-US-born persons who were likely infected with Mycobacterium tuberculosis in their countries of birth. Information on LTBI prevalence by country of birth could help guide local providers and health departments to scale up the LTBI screening and preventive treatment needed to advance progress toward TB elimination. METHODS: A total of 13 805 non-US-born persons at high risk of TB infection or progression to TB disease were screened for LTBI at 16 clinical sites located across the United States with a tuberculin skin test, QuantiFERON Gold In-Tube test, and T-SPOT.TB test. Bayesian latent class analysis was applied to test results to estimate LTBI prevalence and associated credible intervals (CrIs) for each country or world region of birth. RESULTS: Among the study population, the estimated LTBI prevalence was 31% (95% CrI, 26%-35%). Country-of-birth-level LTBI prevalence estimates were highest for persons born in Haiti, Peru, Somalia, Ethiopia, Vietnam, and Bhutan, ranging from 42% to 55%. LTBI prevalence estimates were lowest for persons born in Colombia, Malaysia, and Thailand, ranging from 8% to 13%. CONCLUSIONS: LTBI prevalence in persons born outside the US varies widely by country. These estimates can help target community outreach efforts to the highest-risk groups.

Optimal Testing Choice and Diagnostic Strategies for Latent Tuberculosis Infection Among US-Born People Living with Human Immunodeficiency Virus (HIV).

BACKGROUND: Increased risk of progression from latent tuberculosis infection (LTBI) to tuberculosis (TB) disease among people living with human immunodeficiency virus (HIV; PLWH) prioritizes them for LTBI testing and treatment. Studies comparing the performance of interferon gamma release assays (IGRAs) and the tuberculin skin test (TST) among PLWH are lacking. METHODS: We used Bayesian latent class analysis to estimate the prevalence of LTBI and diagnostic characteristics of the TST, QuantiFERON Gold In-Tube (QFT), and T.SPOT-TB (TSPOT) among a prospective, multicenter cohort of US-born PLWH ≥5 years old with valid results for all 3 LTBI tests using standard US cutoffs (≥5 mm TST, ≥0.35 IU/mL QFT, ≥8 spots TSPOT). We also explored the performance of varying LTBI test cutoffs. RESULTS: Among 1510 PLWH (median CD4+ count 532 cells/mm3), estimated LTBI prevalence was 4.7%. TSPOT was significantly more specific (99.7%) and had a significantly higher positive predictive value (90.0%, PPV) than QFT (96.5% specificity, 50.7% PPV) and TST (96.8% specificity, 45.4% PPV). QFT was significantly more sensitive (72.2%) than TST (54.2%) and TSPOT (51.9%); negative predictive value of all tests was high (TST 97.7%, QFT 98.6%, TSPOT 97.6%). Even at the highest cutoffs evaluated (15 mm TST, ≥1.00 IU/mL QFT, ≥8 spots TSPOT), TST and QFT specificity was significantly lower than TSPOT. CONCLUSIONS: LTBI prevalence among this cohort of US-born PLWH was low compared to non-US born persons. TSPOT's higher PPV may make it preferable for testing US-born PLWH at low risk for TB exposure and with high CD4+ counts.

Impact of T-Cell Xtend on T-SPOT.TB Assay in High-Risk Individuals after Delayed Blood Sample Processing.

T-SPOT.TB (T-SPOT) is an interferon gamma release assay (IGRA) used to detect infection with Mycobacterium tuberculosis based on the number of spot-forming T cells; however, delays in sample processing have been shown to reduce the number of these spots that are detected following laboratory processing. Adding T-Cell Xtend (XT) into blood samples before processing reportedly extends the amount of time allowed between blood collection and processing up to 32 h. In this study, paired blood samples from 306 adolescents and adults at high risk for latent tuberculosis (TB) infection (LTBI) or progression to TB disease were divided into three groups: (i) early processing (∼4.5 h after collection) with and without XT, (ii) delayed processing (∼24 h after collection) with and without XT, and (iii) early processing without XT and delayed processing with XT. The participants' paired samples were processed at a local laboratory and agreement of qualitative and quantitative results was assessed. The addition of XT did not consistently increase or decrease the number of spots. In groups 1, 2, and 3, samples processed with XT had 13% (10/77), 28.0% (30/107), and 24.6% (30/122), respectively, more spots, while 33.8% (26/77), 26.2% (28/107), and 38.5% (47/122) had fewer spots than samples processed without XT. The findings suggest that XT does not reliably mitigate the loss of spot-forming T cells in samples with processing delay.

Radius Shaft Fractures-What Alignment is Acceptable at What Age? Plates or Flexible Nails?

INTRODUCTION: The transition from pediatric to adolescent fractures can lead to uncertainty on what level of surgical correction is warranted as remodeling is limited in these older patients. DISCUSSION: Adolescent diaphyseal radial shaft fractures present several unique challenges; the radial bow must be restored to preserve forearm rotation and there are several clinical scenarios where plating, even in the skeletally immature child, is strongly recommended and will have more reliable results over flexible intramedullary nails. In addition, judging how much angulation, rotation, and displacement will remodel in the older child can be a challenging decision, even for experienced pediatric orthopaedists. CONCLUSION: This overview discusses parameters for acceptable alignment in these fractures, when surgical fixation should be considered, and circumstances where plating should be considered over flexible nails.

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

BACKGROUND: The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). METHODS: A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. RESULTS: CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. CONCLUSIONS: Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. LEVEL OF EVIDENCE: Level III-prognostic.

Analysis of Severe Adverse Events Reported Among Patients Receiving Isoniazid-Rifapentine Treatment for Latent Mycobacterium tuberculosis Infection-United States, 2012-2016.

We analyzed data from 2012 to 2016 for patients who were hospitalized or who died after ≥1 dose of isoniazid-rifapentine for treatment of latent Mycobacterium tuberculosis infection. No patients died; 15 were hospitalized. Nine patients experienced hypotension, and 5 had elevated serum aminotransferases, reinforcing the need for vigilant monitoring during treatment.

Identification of Neurotoxicity after Chimeric Antigen Receptor (CAR) T Cell Infusion without Deterioration in the Immune Effector Cell Encephalopathy (ICE) Score.

A consensus grading schema for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) resulting from chimeric antigen receptor (CAR) T cell therapy was published in 2019. Although this consensus grading schema has been imperative in identifying and monitoring CRS and ICANS in our CAR T cell population, we observed patients exhibiting subtle neurotoxicity symptoms prior to a decrease in their immune effector cell (ICE) score, which is one component of ICANS. Because we treat grade 1 ICANS at our institution, identification of early neurotoxicity symptoms is important. Additionally, we found changes in personality, occupational confusion, or inability to answer dichotomous questions were early signs of neurotoxicity. Therefore, we developed a 3-step command tool to supplement the ICE evaluation. We present 2 examples of patients who exhibited early neurotoxicity symptoms and led us to develop this tool and 1 in whom it was effective. We propose that CAR T cell patients are consistently followed by a clinical care provider who is familiar with the patient to recognize early changes in personality, behavior, and cognition. Additionally, we propose that the multistep command tool be used in conjunction with the ICE score to detect early symptoms of ICANS. Early intervention has the potential to prevent irreversible neurotoxicity.

Pediatric Type II Supracondylar Humerus Fractures: Factors Associated With Successful Closed Reduction and Immobilization.

PURPOSE: The debate on the treatment of type IIa supracondylar humerus fractures has yet to be resolved. The purpose of this study was to assess the factors associated with successful closed reduction and immobilization and to assess the efficacy of a novel radiographic "hourglass" angle measurement in the management of type IIa supracondylar humerus fractures within the pediatric population. METHODS: An institutional review board-approved retrospective review of all children who underwent closed reduction and casting or splinting of an isolated type IIa supracondylar humerus fractures treated at 2 pediatric hospitals from January 1, 2009 to August 31, 2016. Analyzed radiographic parameters included Baumann angle (BA), humerocondylar angle (HCA), perpendicular distance (PD) from the anterior humeral line to the capitellum, and the hourglass angle (HGA). These parameters were measured on injury radiographs (XR), postreduction XR, and at the first and final follow-up XR. The success of closed reduction was defined as maintenance of an acceptable reduction without a secondary procedure. The interobserver reliability was calculated. RESULTS: There were 77 elbows treated with closed reduction and long-arm cast or splint immobilization. Of those closed reductions, 76.62% of elbows (59/77) maintained their reduction alignment and did not require surgical treatment for percutaneous pinning. In this series, the BA was not significantly different following closed reduction ([INCREMENT]1.04 degrees; P=0.081); however, the PD ([INCREMENT]1.89 mm), HGA ([INCREMENT]7.38 degrees), and HCA ([INCREMENT]5.07 degrees) had significant improvement following closed reduction (P<0.001 for all). The use of procedural sedation during reduction was strongly associated with success, 83.05% (49/59) with sedation compared with 55.56% (10/18) success without sedation (P=0.025). Furthermore, fractures that underwent a secondary procedure had 6.20 degrees less HGA following a closed reduction (P=0.016) and required additional follow-up visits (P=0.0037). The success of type IIa supracondylar humerus fractures did not significantly differ based on sex (P=0.5684), laterality (P=0.6975), mechanism of injury (P>0.9999), location of care-emergency department versus clinic (P=0.1160), or type of fracture immobilization (P=0.7411). The mean HGA in normal elbows was 177.8 degrees. The interobserver reliability for HCA was poor [intraclass correlation coefficient (ICC)=0.342]; fair for BA (ICC=0.458); and excellent for both PD and HGA (ICC=0.769 and 0.805, respectively) (P<0.001 for all). CONCLUSIONS: Improved and acceptable radiographic parameters were achieved by a closed reduction in the majority of minimally displaced type IIa fractures treated by closed reduction and immobilization in this series. HCA upon presentation was significantly greater in successful cases, and failure to improve and maintain HGA and PD following closed reduction was associated with loss of reduction. Procedural sedation during reduction was strongly associated with success. The HGA and PD were consistent parameters used to determine effective management of type IIa fractures. This study adds support for a nonoperative closed reduction under sedation with immobilization of selected type IIa supracondylar humerus fractures.

Transphyseal Humeral Separations: What Can We Learn? A Retrospective, Multicenter Review of Surgically Treated Patients Over a 25-Year Period.

PURPOSE: Transphyseal humeral separations (TPHS) are rare injuries with only case reports and small series reported in the literature. This multicenter study aimed to assess the various patient characteristics, injury patterns, treatments, outcomes, and complications in a large series of these injuries. METHODS: A retrospective review was conducted at 5 pediatric institutions to identify TPHS that were treated surgically in patients 0 to 3 years of age over a 25-year period. Patient demographics, mechanisms of injury, Child Protective Services involvement, diagnostic modalities, time to surgery, pin size and configuration, time to fracture union, and complications were recorded. RESULTS: A total of 79 patients aged 0 to 46 months, with a mean of 17.6 months, were identified and followed for a median of 57 days postoperatively. The most common mechanism of injury was accidental trauma (n=49), followed by nonaccidental trauma (n=21), cesarean section (n=6), and vaginal delivery (n=3). Child Protective Services were involved in 30 cases (38%). Additional injuries were reported in 19 of the patients; most commonly additional fractures including the humerus, rib, and skull fractures. All patients had elbow radiographs, whereas 4 patients had an elbow ultrasound and/or a magnetic resonance imaging. Time to surgery was greater than 24 hours in 62% of patients (n=49). Intraoperatively, 87% of patients underwent an arthrogram (n=69), 78% of patients had lateral pins only (n=62), averaging utilization of 2.2 pins, and 2 patients underwent an open reduction. In total, 11 complications (14%) were noted, including decreased range of motion (n=4), cubitus varus/valgus (n=6), and need for additional surgery (n=1). No cases of avascular necrosis or physeal arrest were found. No losses of reduction were noted. CONCLUSIONS: This multicenter review provides the largest known demographic and outcomes data on TPHS. TPHS have excellent outcomes in the vast majority of patients when treated surgically. Nonaccidental trauma accounted for 27% of these injuries so it needs to remain high on the differential diagnosis. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Comparing QuantiFERON-TB Gold Plus with Other Tests To Diagnose Mycobacterium tuberculosis Infection.

The fourth-generation QuantiFERON test for tuberculosis infection, QuantiFERON-TB Gold Plus (QFT-Plus) has replaced the earlier version, QuantiFERON-TB Gold In-Tube (QFT-GIT). A clinical need exists for information about agreement between QFT-Plus and other tests. We conducted this study to assess agreement of test results for QFT-Plus with those of QuantiFERON-TB Gold In-Tube (QFT-GIT), T-SPOT.TB (T-SPOT), and the tuberculin skin test (TST). Persons at high risk of latent tuberculosis infection (LTBI) and/or progression to tuberculosis (TB) disease were enrolled at the 10 sites of the Tuberculosis Epidemiologic Studies Consortium from October 2016 through May 2017; each participant received all four tests. Cohen's kappa (κ) and Wilcoxon signed-rank test compared qualitative and quantitative results of QFT-Plus with the other tests. Test results for 506 participants showed 94% agreement between QFT-Plus and QFT-GIT, with 19% positive and 75% negative results. When the tests disagreed, it was most often in the direction of QFT-GIT negative/QFT-Plus positive. QFT-Plus had similar concordance as QFT-GIT with TST (77% and 77%, respectively) and T-SPOT (92% and 91%, respectively). The study showed high agreement between QFT-GIT and QFT-Plus in a direct comparison. Both tests had similar agreement with TST and T-SPOT.

Comparison of Percutaneous Reduction and Pin Fixation in Acute and Chronic Pediatric Mallet Fractures.

BACKGROUND: Although pediatric mallet fractures are more common than adult fractures, no techniques have focused on surgical fixation of pediatric mallet fractures. This study aims to describe the technique and results of percutaneous reduction and fixation in acute and chronic pediatric mallet fractures. METHODS: This is a retrospective review of 51 pediatric mallet fractures treated with percutaneous wire fixation from 2007 to 2014; 38 were acute fractures and 13 were chronic (>4 wk from injury). Surgical technique was identical for all fractures: (1) levering the dorsal fragment into its anatomical bed with a percutaneous towel clip; (2) percutanously transfixing the distal interphalangeal joint in slight hyperextension; (3) placing 2 percutaneous kirschner wires, 1 radial and 1 ulnar, from the dorsal epiphyseal fragment to the volar metaphyseal cortex. Outcomes were defined by the Crawford classification. RESULTS: Average age was 14.6 years (range, 11 to 18 y). Mean time from injury to surgery was 16.2 days in the acute group and 50.8 days in the chronic group. Mean joint surface involvement was 50.8% of the articular base with a mean of 2.0 mm of articular gap (acute fractures 1.9 mm, chronic fractures 2.5 mm, P=0.017). Average preoperative extensor lag was 24.6 degrees. Average operative time was 31 minutes for acute fractures and 40 minutes for chronic fractures. Mean length of follow-up was 78.5 days. At final follow-up, all patients healed with an articular gap of 0.2 mm in the acute group and 0.6 mm in the chronic group (P=0.037) with no nonunions or volar subluxations. All patients but 8 (5 acute, 3 chronic) achieved full extension with an average extensor lag of 1.1 degree for the entire cohort. No patient had >10-degree extensor lag at final follow-up. All patients achieved full active flexion of 90 degrees at final follow-up. In the acute group, the Crawford classification was excellent in 87% (33/38), good in 13% (5/38). In the chronic group, results were excellent in 77% (10/13), good in 23% (3/13) (P>0.05). There were no fair or poor outcomes in either group. A clinical dorsal bump was noted in 18% of patients (22% in the acute group, 15% in the chronic group, P>0.05). There were no infections, wire breakages, nail deformities, or unplanned returns to surgery. CONCLUSIONS: This percutaneous surgical technique to treat pediatric mallet fractures achieves favorable clinical and radiographic results with minimal complications, even in chronic fractures. Results are better than reported for adult mallet fractures. LEVEL OF EVIDENCE: Level II.

BMT CTN Myeloma Intergroup Workshop on Minimal Residual Disease and Immune Profiling: Summary and Recommendations from the Organizing Committee.

The Blood and Marrow Transplant Clinical Trials Network Myeloma Intergroup Workshop on Minimal Residual Disease and Immune Profiling was convened on December 1, 2016 at the American Society of Hematology meeting to discuss the emerging data and technologies for minimal residual disease assessment and immune profiling in myeloma. Particular emphasis was placed on developing strategies to incorporate these techniques into clinical trial design. This document reviews the literature, summarizes the topics discussed in the workshop, and provides recommendations for integration of these techniques into future clinical trial design.

Evaluating latent tuberculosis infection diagnostics using latent class analysis.

BACKGROUND: Lack of a gold standard for latent TB infection has precluded direct measurement of test characteristics of the tuberculin skin test and interferon-γ release assays (QuantiFERON Gold In-Tube and T-SPOT.TB). OBJECTIVE: We estimated test sensitivity/specificity and latent TB infection prevalence in a prospective, US-based cohort of 10 740 participants at high risk for latent infection. METHODS: Bayesian latent class analysis was used to estimate test sensitivity/specificity and latent TB infection prevalence among subgroups based on age, foreign birth outside the USA and HIV infection. RESULTS: Latent TB infection prevalence varied from 4.0% among foreign-born, HIV-seronegative persons aged <5 years to 34.0% among foreign-born, HIV-seronegative persons aged ≥5 years. Test sensitivity ranged from 45.8% for the T-SPOT.TB among foreign-born, HIV-seropositive persons aged ≥5 years to 80.7% for the tuberculin skin test among foreign-born, HIV-seronegative persons aged ≥5 years. The skin test was less specific than either interferon-γ release assay, particularly among foreign-born populations (eg, the skin test had 70.0% specificity among foreign-born, HIV-seronegative persons aged ≥5 years vs 98.5% and 99.3% specificity for the QuantiFERON and T-SPOT.TB, respectively). The tuberculin skin test's positive predictive value ranged from 10.0% among foreign-born children aged <5 years to 69.2% among foreign-born, HIV-seropositive persons aged ≥5 years; the positive predictive values of the QuantiFERON (41.4%) and T-SPOT.TB (77.5%) were also low among US-born, HIV-seropositive persons aged ≥5 years. CONCLUSIONS: These data reinforce guidelines preferring interferon-γ release assays for foreign-born populations and recommending against screening populations at low risk for latent TB infection. TRIAL REGISTRATION NUMBER: NCT01622140.