Racial Disparities in the Operative Management of Orthopedic Trauma: A Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures. METHODS: A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed. RESULTS: In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025). CONCLUSIONS: Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race.

Intersectionality and trauma analysis in bioarchaeology.

Intersectionality, the theory named by Kimberlé Crenshaw, outlines how multiple elements of an individual's social identity overlap to create and preserve societal inequalities and discrimination. Recently bioarchaeology's engagement with intersectionality has become increasingly explicit, as the field recognizes the lived experience of multiple axes of an individual's identity. Evidence of trauma can remain observable in an individual's skeleton for years, making it an ideal subject of study for intersectional analyses in bioarchaeology. Using contrasting case studies of two individuals who died in hospitals and were unclaimed after death, we explore the theoretical and methodological application of intersectionality to investigations of accidental and interpersonal trauma. Differences in identities and structural inequalities affect bone quality and health outcomes. As we demonstrate, a broken bone is the intersecting result of biological, histomorphological, sociocultural, and behavioral factors. This approach allows for a better acknowledgement of the inherent complexity of past lives, elevating and amplifying previously silenced voices. In this way, intersectionality in bioarchaeology demands social justice.

Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND: We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution. QUESTIONS/PURPOSES: Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment? METHODS: In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores. RESULTS: Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (ß 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (ß 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (ß -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment. CONCLUSION: Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics. LEVEL OF EVIDENCE: Level III, therapeutic study.

Ethnic Differences in Bone Microarchitecture.

PURPOSE OF THE REVIEW: The aim of this review is to briefly introduce updates in global fracture epidemiology and then to highlight recent contributions to understanding ethnic differences in bone density, geometry and microarchitecture and consider how these might contribute to differences in fracture risk. The review focuses on studies using peripheral quantitative computed tomography techniques. RECENT FINDINGS: Recent studies have contributed to our understanding of the differences in fracture incidence both between countries, as well as between ethnic groups living within the same country. In terms of understanding the reasons for ethnic differences in fracture incidence, advanced imaging techniques continue to increase our understanding, though there remain relatively few studies. It is a priority to continue to understand the epidemiology, and changes in the patterns of, fracture, as well as the underlying phenotypic and biological reasons for the ethnic differences which are observed.

Differences in fracture prevalence and in bone mineral density between Chinese and White Canadians: the Canadian Multicentre Osteoporosis Study (CaMos).

Fracture determinants differ between Canadians of Chinese and White descent, the former constituting the second largest visible minority group in Canada. The results of this study support the importance of characterizing bone health predictors in Canadians of different ethnicity to improve population-specific fracture prevention and treatment strategies. PURPOSE: We aimed to compare clinical risk factors, bone mineral density, prevalence of osteoporosis, and fractures between Chinese and White Canadians to identify ethnicity-specific risks. METHODS: We studied 236 Chinese and 8945 White Canadians aged 25+ years from the Canadian Multicentre Osteoporosis Study (CaMos). The prevalence of osteoporosis using ethnicity-specific peak bone mass (PBM), and of prior and incident low trauma fractures were assessed and compared between groups. Linear regressions, adjusting for age and anthropometric measures, were used to examine the association between baseline and 5-year changes in BMD and ethnicity. RESULTS: Chinese participants had shorter stature, lower BMI, and lower rate of falls than White participants. Adjusted models showed no significant differences in baseline BMD between ethnic groups except in younger men where total hip BMD was 0.059 g/cm2 (0.009; 0.108) lower in Chinese. Adjusted 5-year BMD change at lumbar spine was higher in older Chinese women and men compared with Whites. When using Chinese-specific PBM, the prevalence of osteoporosis in Chinese women was 2-fold lower than when using that of White women The prevalence of fractures was higher in White women compared with Chinese with differences up to 14.5% (95% CI 9.2; 19.7) and 10.5% (95% CI 4.5-16.4) in older White men. Incident fractures were rare in young Chinese compared with White participants and not different in the older groups. CONCLUSION: Our results support the importance of characterizing bone strength predictors in Chinese Canadians and the development of ethnicity-specific fracture prediction and prevention strategies.

Racial and Ethnic Differences in Emergency Department Pain Management of Children With Fractures.

OBJECTIVES: To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. METHODS: We performed a 3-year retrospective cross-sectional study of children <18 years old with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry (7 emergency departments). We performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and (1) any analgesic, (2) opioid analgesic, (3) ≥2-point pain score reduction, and (4) optimal pain reduction (ie, to mild or no pain). RESULTS: In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51-1.95]; Hispanic: 1.32 [1.16-1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14-1.76]; Hispanic: 1.38 [1.04-1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77-0.95]; Hispanic: aOR 0.86 [0.76-0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67-0.90]; Hispanic: aOR 0.80 [0.67-0.95]). CONCLUSIONS: There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.

Fracture risk factors among children living in New Zealand.

Factures are common during childhood. There are limited data available regarding relationships between bone fracture history and calcium intake, sugar sweetened beverages (SSBs) intake, vitamin D status, physical activity (PA), ethnicity, and body composition in New Zealand (NZ) children. Identifying groups of NZ children at risk of fracture and associated predictors may help to improve bone quality during childhood and decrease the risk of fractures throughout life. The aim of this study was to investigate fracture history and associated risk factors in New Zealand children. Children aged 8-12 years were recruited. Capillary blood spots collected from a finger prick were as analyzed for 25(OH)D concentrations. Bioelectrical impedance analysis (InBody720, Seoul, Korea) was used to measure body fat percentage (%BF). Information about fracture history, siblings' history of fractures, family osteoporosis history, PA, ethnicity, and intake of calcium containing foods, and SSBs was collected using questionnaires. Children (n = 647, 354 girls), mean ± SD age 9.8 ± 0.7 years were recruited from six Auckland primary schools. NZ European (n = 252) (NZE) and South Asian (n = 68) children reported the lowest (20.2 %) and highest (44.1 %) fracture incidence, respectively. NZE compared to South Asian children, had higher 25(OH)D concentrations (74.6 ± 19.8 vs. 48.4 ± 19.3 nmol/L, P < 0.001), higher total calcium intake (764.0 ± 394.4 vs. 592.7 ± 266.3 mg/d, P < 0.018), and lower %BF (19.5 ± 6.6 vs. 23.4 ± 8.4, P < 0.003). Maori children had the next highest fracture rate (32.5 %). This group had adequate 25(OH)D (64.2 ± 18.9 nmol/L), but high %BF (23.9 %) and most participated in vigorous PA. After stratifying by sex, binary logistic regression analysis revealed the main determinants of fracture history for boys were high %BF, low 25(OH)D, low calcium intake, high SSBs consumption, siblings' fracture history, family osteoporosis history, and being South Asian; and in girls, high SSBs consumption, siblings' fracture history, and family osteoporosis history. We found South Asian ethnicity was a significant risk factor for boys. Some children were at high risk of vitamin D deficiency and for whom supplementation may be necessary in winter. Good nutrition (especially good sources of calcium and reducing SSBs intakes) should be recommended to children during growth and development to reduce their risk of fractures.

Violence in hunters, fishermen, and gatherers of the Chinchorro culture: Archaic societies of the Atacama Desert (10,000-4,000 cal yr BP).

OBJECTIVES: This article addresses evidence of violence imbedded in both soft and hard tissues from early populations of hunters, fishermen, and gatherers, known as the Chinchorro culture, who lived between 10,000 and 4,000 cal yr BP, along the coast of the Atacama Desert, one of the driest environments on Earth. Our study is aimed to test two hypotheses (a) that interactions and violent behaviors increased through time as population density and social complexity augmented; and (b) that violence was more prevalent between local Chinchorro groups and groups from other inland locations. MATERIAL AND METHODS: Two lines of data were analyzed: (1) bioarchaeology, through the quantification of physical traces of interpersonal violence in skeletons and mummies from a sample of 136 adult individuals and, (2) isotopic chemical analysis (strontium) of individuals with traces of trauma in order to determine their local or foreign origin. RESULTS: Violence among Chinchorro populations was ubiquitous and remained invariant over time, with a remarkable skew to male (about 25% above female across the complete sample). Moreover, the chemical signature of individuals with traces of violence was not of foreign origin. DISCUSSION: The violence exerted by the Chinchorro groups was not related to increased population size, nor social complexity and was mostly restricted to individuals coming from the same coastal habitat. That is, our data suggest that violence was constant across the Archaic period among the Chinchorro, implying that violent behavior was part of the sociocultural repertory of these populations, likely associated to mechanisms to resolve conflicts and social tensions.

Predictors for Nonaccidental Trauma in a Child With a Fracture-A National Inpatient Database Study.

BACKGROUND: Despite heightened awareness and multidisciplinary efforts, a predictive model to help the clinician quantify the likelihood of nonaccidental trauma (NAT) in a child presenting with a fracture does not exist. The purpose of this study was to develop an evidence-based likelihood of NAT in a child presenting with a fracture. METHODS: Using the 2012 Kids' Inpatient Database, we identified all available pediatric inpatients admitted with an extremity or spine fracture. Children with a fracture were subcategorized based on the diagnosis of NAT. Multivariate analysis using multiple logistic regression was used to generate odds ratios and create a predictive model for the probability of NAT in a child with a fracture. RESULTS: Of the 57,183 pediatric fracture cases, 881 (1.54%) had a concurrent diagnosis of NAT. Of these children, those presenting with multiple fractures had the highest rate of NAT (2.8%). The overall mortality rate in patients presenting with fractures and abuse was 1.8%, which was twice as high as patients without abuse (odds ratio [OR] = 2.0). Based on multivariate analysis, younger age (OR = 0.5), black race (OR = 1.7), intracranial injury (OR = 3.7), concomitant rib fracture (OR = 7.2), and burns (OR = 8.3) were positive predictors of NAT in a child with a fracture. A weighted equation using regression coefficients was generated and plotted on a receiver operative characteristic curve, demonstrating excellent correlation and probability of NAT (area under curve = 0.962). (Equation - ln (P/(1 - P)) = -1.79 - 0.65 (age in years) + 0.51 (black race) + 1.97 (rib fracture) + 1.31 (intracranial injury) + 2.12 (burn)). CONCLUSION: Using a large, national inpatient database, we identified an overall prevalence of 1.54% of NAT in children admitted to the hospital with a fracture. Based on five independent predictors of NAT, we generated an estimated probability chart that can be used in the clinical workup of a child with a fracture and possible NAT. This evidence-based algorithm needs to be validated in clinical practice. LEVEL OF EVIDENCE: Prognostic study, Level III (case-control study).

Fractures in school age children in relation to sex and ethnic background: The Generation R Study.

Fracture rate in childhood is increasing and its consequences may affect health and developmental processes and cause school absence and restricted activity days. There are scarce epidemiologic studies regarding fractures in children. The aim of this study was to evaluate if pediatric fractures show disparities across sexes and ethnic groups. This study was conducted based on data from 3632 participants of the Generation R Study. Prevalent fractures were assessed using a questionnaire at a mean age of 9.7 years. Child's ethnicity was determined based on country of birth of the parents using questionnaires (geographic ancestry) or admixture analysis (genetic ancestry). Associations between fracture occurrence and sex or ethnicity were evaluated using logistic regression models adjusted for age, weight, lean mass fraction, bone mineral density (BMD) and sex/ethnicity. Fracture was reported for 525 (14.5%) children. The great majority of these children were classified as European (N = 3164), followed by African (N = 283) and Asian (N = 185) based on geographic ancestry. Similarly, the highest proportion of Europeans was observed based on genetic ancestry. Prevalence of fractures was not different between boys and girls, even after adjustment for possible confounders (OR: 1.03, 95% CI 0.84-1.27, p-value = 0.8). However, odds of prevalent fractures were two times higher in European when compared to Asian children (OR: 2.01, 95% CI 1.17-3.45, p-value = 0.01), and 1.5 times higher when compared to African children (OR: 1.50, 95% CI 1.00-2.26, p-value = 0.05). Overall, in this study, European children showed a highest risk of prevalent fractures independently of factors such as body composition and BMD, while no difference in the prevalence of fractures between boys and girls was observed.

Vitamin D levels and fracture risk among Hispanic children.

PURPOSE: There is a lack of knowledge about whether low vitamin D levels increase the risk of pediatric low-energy fractures among Hispanic population. The objective of this study is to determine whether there is a direct relationship between low vitamin D levels and the incidence of low-energy fractures in Hispanic children. METHOD: Cases included all consecutive patients evaluated with low-energy fractures in the pediatric orthopedic clinic. The control group consisted of all pediatric patients evaluated, without fractures, who had bone and joint pain complaints in the general pediatric clinic. The main focus was to compare cases and controls in relation to their vitamin D levels. Cases and controls were compared using t tests for means of quantitative variables and Chi-square tests. RESULTS: A total of 201 subjects, distributed as cases (n = 107) and controls (n = 94), were included in this study. One hundred twelve (55.7%) of the total study population were males. The mean age for the study population was 8.6 years old ranging from 1 year to 18 years, and standard deviation = 4.0 years. The median age for the study population was 9 years. The mean vitamin D level for the cases was 32.6 ng/dl (SD = 10.9); the mean vitamin D level for controls was 32.3 ng/dl (SD = 13.4). This difference was not statistically significant (t = 0.18, 95% CI - 3.2 to 3.9; p = 0.854). CONCLUSION: A direct relationship between low vitamin D levels and fracture risk in a Hispanic pediatric population was not established. LEVELS OF EVIDENCE: III.

Occurrence of and referral to specialists for pain-related diagnoses in First Nations and non-First Nations children and youth.

BACKGROUND: Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non-First Nations children. METHODS: Data from a study population of age- and sex-matched First Nations and non-First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health). RESULTS: Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non-First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non-First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non-First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.0, and OR 1.7, 95% CI 1.2-2.3, respectively). INTERPRETATION: First Nations children were diagnosed with more pain than non-First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non-First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

[Current status of falls and related injuries among Chinese elderly in 2013].

Objective: To investigate the demographic characteristics of falls and fall-related injuries in Chinese elderly population. Methods: In 2013, the 4(th) round Chronic Non-communicable Disease and Risk Factor Surveillance in China was conducted in 31 provinces. A stratified multi-stage cluster sampling was used to select the samples. A total number of 98 629 community-based adults aged 60 years and older received a set of standardized questionnaires with a face to face interview. The prevalence rates of falls and consequent injuries were compared between different genders, age groups, levels of education and areas of residency. Results: The overall prevalence of falls among elderly in the previous 6 months was 8.0%(95%CI: 7.5%-8.5%). The prevalence was increasing with age and decreasing with the levels of education, and higher in females (9.1%) than in males (6.8%), with differences statistically significant (χ(2)=74.1, P<0.01). Prevalence rates were also seen higher in rural (8.6%), in widowed (11.0%) residents and in farmers or house workers than those in urban areas (7.2%), in non-widowed (7.0%), or having other jobs, with differences all statistically significant (χ(2)=7.7, P<0.01, χ(2)=128.0, P<0.01). 52.6% of the elderly got injured when fell. The proportion of injury was greater in females (54.8%) than that in males (49.6%), with differences statistically significant (χ(2)=10.2, P<0.01). Proportion of most frequent types of injuries were hip fractures (7.3%), hand/arm fractures (12.5%), head injury (8.0%) and bruise (53.6%) respectively. The proportion of hip fractures was 12.4% in elderly over 80 year of age, also was the highest. Conclusions: Results from the present study showed that elderly suffered high prevalence of falls.Statistically significant differences were seen in residents with different groups as genders, age, education levels, marital status, urban/rural areas or jobs. Group-based comprehensive prevention and intervention on falls should be strengthened.

An investigation of toxicities and survival in Hispanic children and adolescents with ALL: Results from the Dana-Farber Cancer Institute ALL Consortium protocol 05-001.

PURPOSE: This study compared the relative incidence of treatment-related toxicities and the event-free and overall survival between Hispanic and non-Hispanic children undergoing therapy for acute lymphoblastic leukemia (ALL) on Dana-Farber Cancer Institute ALL Consortium protocol 05-001. PATIENTS AND METHODS: Secondary analysis of prospectively collected data from a phase III multicenter study in children and adolescents of 1-18 years with previously untreated ALL. RESULTS: Between 2005 and 2011, 794 eligible patients enrolled on DFCI 05-001, 730 of whom were included in this analysis (19% [N = 150] Hispanic, 73% [N = 580] non-Hispanic). Hispanic patients were more likely to be ≥10 years of age (32% vs. 24%, P = 0.045) at diagnosis. Toxicity analyses revealed that Hispanic patients had significantly lower cumulative incidence of bone fracture (P < 0.001) and osteonecrosis (ON; P = 0.047). In multivariable risk regression, the risk of ON was significantly lower in Hispanic patients ≥10 years (HR 0.23; P = 0.006). Hispanic patients had significantly lower 5-year event-free survival (EFS) (79.4%; 95% CI: 71.6-85.2) and overall survival (OS) (89.2%; 95% CI: 82.7-93.4) than non-Hispanic patients (EFS: 87.5%; 95% CI: 84.5-90.0, P = 0.004; OS: 92.7%; 95% CI: 90.2-94.6, P = 0.006). Exploratory analyses revealed differences between Hispanic and non-Hispanic patients in the frequency of common variants in genes related to toxicity or ALL outcome. CONCLUSION: Hispanic children treated for ALL on DFCI 05-001 had fewer bone-related toxicities and inferior survival than non-Hispanic patients. While disease biology is one explanatory variable for outcome disparities, these findings suggest that biologic and non-biologic mechanisms affecting drug delivery and exposure in this population may be important contributing factors as well.

Computational simulation study on ilio-sacral screw fixations for pelvic ring injuries and implications in Asian sacrum.

OBJECTIVES: Despite a high possibility of technique-related complications, ilio-sacral (IS) screw fixation is the mainstay of operative management in posterior pelvic ring injuries. We aimed to make IS screw trajectory with fully intraosseous path that was optimal and consistent, and confirm the possibility of transiliac-transsacral (TITS) screw fixation in Asian sacrum. METHODS: Eighty-two cadaveric sacra (42 males and 40 females) were enrolled and underwent continuous 1.0-mm slice computed tomography (CT) scans. CT images were imported into Mimics® software to reconstruct three-dimensional model of the pelvis. To simulate IS screws, we inserted 7.0-mm-sized TITS cylinder for first (S1) and second (S2) sacral segment and 7.0-mm oblique cylinder for S1. TITS cylinder could not be inserted into S1 of 14 models (sacral variation models) but could be inserted into the S2 of all models. The actual length of virtual IS screws was measured, and anatomic features of safe zone (SZS2) including the area, horizontal distance (HDS2), and vertical distance (VDS2) were evaluated by the possibility of TITS screw fixation in the S1. RESULTS: When the oblique cylinder was directed toward the opposite upper corner of S1 at the level of the first foramen, there was no cortical violation regardless of sacral variation. The average length of TITS cylinder was 152.3 mm (range 127.9-178.2 mm) in S1 and 136.0 mm (range 97.8-164.1 mm) in S2, and for oblique cylinder it was 99.2 mm (range 82.4-132.2 mm). The average VDS2, HDS2, and the area of SZS2 were 15.5 mm (range 8.7-24.4 mm), 18.3 mm (range 12.7-26.6 mm), and 221.1 mm2 (range 91.1-386.7 mm2), respectively. The VDS2 and SZS2 of sacral variation were significantly higher than those of normal (both p = 0.001). CONCLUSIONS: Considering the high variability of the S1, it is better to direct the IS screw trajectory toward the opposite upper corner of the S1 at the level of first sacral foramen. If a TITS screw is needed, the transverse fixation for the S2 could be performed alternatively due to its sufficient osseous site even in Asian sacrum.

Chinese Registry of rheumatoid arthritis (CREDIT): II. prevalence and risk factors of major comorbidities in Chinese patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis patients are at higher risk of developing comorbidities. The main objective of this study was to evaluate the prevalence of major comorbidities in Chinese rheumatoid arthritis patients. We also aimed to identify factors associated with these comorbidities. METHODS: Baseline demographic, clinical characteristics and comorbidity data from RA patients enrolled in the Chinese Registry of rhEumatoiD arthrITis (CREDIT) from Nov 2016 to August 2017 were presented and compared with those from five other registries across the world. Possible factors related to three major comorbidities (cardiovascular disease, fragility fracture and malignancy) were identified using multivariate logistic regression analyses. RESULTS: A total of 13,210 RA patients were included (80.6% female, mean age 52.9 years and median RA duration 4.0 years). Baseline prevalence rates of major comorbidities were calculated: CVD, 2.2% (95% CI 2.0-2.5%); fragility fracture, 1.7% (95% CI 1.5-1.9%); malignancy, 0.6% (95% CI 0.5-0.7%); overall major comorbidities, 4.2% (95% CI 3.9-4.6%). Advanced age was associated with all comorbidities. Male gender and disease duration were positively related to CVD. Female sex and longer disease duration were potential risk factors for fragility fractures. Ever use of methotrexate (MTX) was negatively related to baseline comorbidities. CONCLUSIONS: Patients with rheumatoid arthritis in China have similar prevalence of comorbidities with other Asian countries. Advanced age and long disease duration are possible risk factors for comorbidities. On the contrary, MTX may protect RA patients from several major comorbidities, supporting its central role in the management of rheumatoid arthritis.

Cable pin system versus K-wire tension band fixation for patella fractures in Chinese Han population: A meta-analysis.

This meta-analysis compared the therapeutic effect of cable pin system (CPS) with K-wire tension band (KTB) in the treatment of patella fractures among Chinese Han population. The databases of PubMed, Cochrane library, China National Knowledge Infrastructure (CNKI), Chinese WanFang and Chinese VIP were searched for studies on CPS versus KTB in the treatment of patella fractures among Chinese Han population. Literatures were screened according to the inclusion and exclusion criteria. The quality of the studies was assessed, and meta-analysis was performed using the Cochrane Collaboration's REVMAN 5.3 software. A total of 932 patients from 15 studies were included in this meta-analysis (426 fractures treated with CPS and 506 fractures treated with KTB). There were significant differences in duration of hospital stay [mean difference (MD)=-1.07; 95% confidence interval (CI):-1.71 to-0.43], fracture healing time (MD=-1.23; 95% CI:-1.68 to-0.77), flexion degree of knee joint at 6th month after operation (MD=14.82; 95% CI: 10.93 to 18.71), incidence of postoperative complication [risk ratio (RR)=0.16; 95% CI: 0.09 to 0.27] and excellent-good rate of Böstman score (RR=1.09; 95% CI: 1.03 to 1.16) between the CPS group and KTB group, while no significant difference was found in operative time between the two groups (MD=-4.52; 95% CI:-11.70 to 2.67). For the treatment of patella fractures among Chinese Han population, limited evidence suggests that the CPS is more suitable than the KTB when considering the hospital stay, fracture healing time, flexion degree of knee at 6th month after operation, incidence of postoperative complication and excellent-good rate of Böstman joint score. Due to the limitation of high quality evidence and sample size, more large-scale randomized controlled trials are needed to validate the findings in the future.

Antiretrovirals, Fractures, and Osteonecrosis in a Large International HIV Cohort.

BACKGROUND: Antiretrovirals (ARVs) affect bone density and turnover, but their effect on risk of fractures and osteonecrosis of the femoral head is less understood. We investigated if exposure to ARVs increases the risk of both bone outcomes. METHODS: EuroSIDA participants were followed to assess fractures and osteonecrosis. Poisson regression identified clinical, laboratory and demographic predictors of either bone outcome. Ever, current, and cumulative exposures to ARVs were assessed. RESULTS: During 86118 PYFU among 11820 included persons (median age 41y, 75% male, median baseline CD4 440/mm3, 70.4% virologically suppressed), there were 619 fractures (incidence/1000 PYFU 7.2; 95% CI 6.6-7.7) and 89 osteonecrosis (1.0; 0.8-1.3). Older age, white race, lower BMI, IV drug use, lower baseline CD4, HCV coinfection, prior osteonecrosis, prior fracture, cardiovascular disease, and recent non-AIDS cancer (last 12 months) were associated with fractures. After adjustment, persons who had ever used tenofovir disoproxil fumarate (TDF) (1.40; 1.15-1.70) or who were currently on TDF (1.25; 1.05-1.49) had higher incidence of fractures. There was no association between cumulative exposure to TDF and fractures (1.08/5 y exposure; 0.94-1.25). No other ARV was associated with fractures (all P > .1). Risk of osteonecrosis was associated with white race, lower nadir CD4, prior osteonecrosis, prior fracture, and prior AIDS. After mutual adjustment, no ARV was associated with osteonecrosis. CONCLUSIONS: In human immunodeficiency virus (HIV) infection, host factors, HIV-specific variables, and comorbidities contribute to risk of fractures and osteonecrosis. Exposure to TDF, but not other ARVs, was an independent risk factor for fractures.