Association Between Clubfoot and Neonatal Abstinence Syndrome in the United States, 2018-2022.

PURPOSE: The United States has seen an increase in opioid use and misuse over the last 2 decades. Infants have been impacted by the opioid epidemic, with a reported 5-fold increase in the incidence of neonatal abstinence syndrome (NAS) over the last 2 decades. There are many conditions associated with NAS, and thus, the current study sought to examine the association between NAS and clubfoot. METHODS: The study was retrospective, utilizing patient data from the Pediatric Hospital Information System (PHIS) database. Neonates presenting to any PHIS hospital between 2018 and 2022 were identified and included in the study. Patients with NAS and clubfoot were identified utilizing the International Classification of Diseases (ICD)-9 and 10 codes. Univariable and multivariable analyses were performed to investigate associations between clubfoot, race, ethnicity, insurance type, gestational age, length of stay, NAS, and comorbidity burden. RESULTS: A total of 458,274 patients were identified, of whom 2337 (0.5%) had a clubfoot diagnosis and 5431 (1.2%) had a diagnosis of NAS. Multivariable logistic regression revealed higher independent odds of clubfoot among patients with a diagnosis of NAS [odds ratio (OR): 1.49], patients with a greater number of comorbidities (OR: 4.75 for 1 comorbidity vs. none, and 21.19 for 2+ comorbidities, vs. none), patients with a greater gestational age (OR: 1.01 per week increase), and those with an increased length of stay (OR: 1.00 per day increase). A lower independent odds of clubfoot was observed among patients of Asian race (OR: 0.66), Hispanic/Latino ethnicity (OR: 0.80), non-Hispanic Black (OR: 0.75), and multiracial (OR: 0.80) ethnicity/race relative to non-Hispanic/Latino White patients (P<0.05 for all). CONCLUSION: Patients with a diagnosis of NAS demonstrated higher odds of clubfoot, in addition to sociodemographic factors, as well as comorbidity burden.

The Effect of Guided Growth Surgery on Langenskiold Stage and Mechanical Axis in Early-Onset Blount Disease: A Retrospective Case Series.

INTRODUCTION: Our understanding of the efficacy of guided growth surgery with tension-band plating (TBP) in early-onset Blount disease is evolving. Preliminary work has demonstrated that TBP can normalize the mechanical axis, yet its effect on Langenskiöld stage (LS) has not previously been reported. The primary outcome of this study was improvement in LS after TBP. Secondary outcomes were improvement in LS at most recent follow-up and improvement in mechanical axis deviation (MAD), mechanical medial proximal tibial angle, and mechanical lateral distal femoral angle at treatment completion and most recent follow-up. METHODS: A retrospective review was done of patients with early-onset Blount disease treated with TBP between January 1, 2010, and December 31, 2019, across two institutions. Inclusion criteria were a radiographic diagnosis of early-onset Blount disease (LS changes present), surgery with TBP, and follow-up beyond implant removal. Radiographs before surgery, at removal of hardware (ROH), and at most recent follow-up were evaluated. RESULTS: Twenty-five limbs in 16 children who underwent TBP at a mean age of 5.8 ± 2.3 years were included. Implants were in situ a mean of 1.9 ± 0.7 years. The mean follow-up after ROH was 3.6 ± 1.4 years. LS ranged from 1 to 5 preoperatively with 14 of 25 limbs (56%) staged ≥3. LS improved in 15 of 25 limbs (60%) at ROH and in 21 of 25 limbs (84%) at most recent follow-up. Langenskiöld changes resolved in 7 of 25 limbs (28%) at most recent follow-up. Preoperatively, the MAD was varus in all limbs, but at ROH, the MAD had improved in 22 of 23 limbs with neutral or valgus alignment in 20 of 23 limbs (87%). At most recent follow-up, 16 of 23 limbs (70%) maintained improved alignment. DISCUSSION: There was improvement/resolution of LS and varus deformity in early-onset Blount disease in most patients who underwent TBP. Based on these results, TBP for early-onset Blount disease should be the first-line surgical treatment. LEVEL OF EVIDENCE: IV.

Adverse events in the treatment of motorcycle-related isolated limb injuries at a regional hospital in Uganda: a prospective clinical analysis.

PURPOSE: Although motorcycle accidents are a leading cause of limb injury in Uganda, little is known about injury care quality at regional hospitals. This study measured the incidence of clinical adverse events (CAEs) and identified associated treatment barriers surrounding motorcycle-related isolated limb injuries at a regional hospital. METHODS: A prospective descriptive study was conducted among patients with motorcycle-related isolated limb injuries at a Ugandan regional hospital between September 2017 and February 2018. Patients were surveyed upon admission and monitored throughout their course of treatment. Weight-bearing status and quality of life measures (EQ-5D) were assessed at four and 12 weeks. RESULTS: One hundred twenty-four participants enrolled. Of the total participants, 12% refused definitive treatment. Among 108 treated patients, six experienced CAEs: four wound infections, one amputation, and one death. At 12 weeks follow-up, the majority of patients had no difficulty with mobility, pain/discomfort, or self-care, but 51% endorsed challenges completing certain daily chores, and 40% of patients could ambulate without an assistive device with restoration of pre-fracture gait. Both longer hospital stays and poorer 12-week functional recovery were seen among patients sustaining open fracture (p < 0.001). CONCLUSION: Treatment of isolated limb injuries at a Ugandan Regional Hospital was associated with minimal short-term CAEs. However, patients with more severe injuries may be at risk for delayed post-operative recovery. Future studies measuring long-term functional outcomes should be performed to better understand and optimize injury care in this population.

Impacts of COVID-19 on orthopaedic surgery residency / spine trainee application trends.

BACKGROUND: The COVID-19 pandemic has had widespread impact across medical educational sectors, including cancellations and delays of board exams, interruptions in clinical rotations and electives, altered processes for away rotations, and conversion to virtual interviews. These changes, combined with applicant and program uncertainty, may affect the 2021 residency application cycle for competitive fields such as orthopaedic surgery. In consideration of spine trainees and the spine fellow application pipeline, the current study aims to evaluate for deviations in trends found in applications to an orthopaedic surgery residency program from the 2021 cycle compared to six years prior. METHODS: After institutional review board approval, applications to a single orthopaedic surgery residency program from application cycles 2015 to 2021 were evaluated in the Electronic Residency Application System (ERAS) and analyzed for trends. Supplementary information was taken from publicly available ERAS statistics. RESULTS: Compared to existing trends, the ERAS 2021 cycle had a greater number of applicants, more research items, and lower rates of USMLE Step 2 test administration. Of the 4,965 applications analyzed, no deviations in trends were found in number of female applicants, Black and Hispanic applicants, applicants from medical schools outside the US, DO applicants, applicants with interruptions in their training, or USMLE scores. CONCLUSIONS: The orthopaedic surgery applicant pool increased amidst the COVID-19 pandemic and applicants had more research items than previous years. No significant deviations in the demographics of the applicant pool were noted. This is thought to be reassuring about the integrity of the orthopaedic residency application process / spine fellow application pipeline and should continue to be observed in the coming years.

The Continued Utility and Viability of Dakin's Solution in Both High- and Low-resource Settings.

Healthcare is expensive and often inaccessible to many. As a result, surgeons must consider simple, less expensive interventions when possible. For wound care, an older but quite effective cleaning agent is Dakin's solution (0.5% sodium hypochlorite), an easily made mixture of 100 milliliters (ml) bleach with 8 teaspoons (tsp) baking soda into a gallon of clean water or 25 ml bleach and 2 tsp baking soda into a liter of water. Gauze is then wet with this solution, placed on the wound, and replaced every 24 hours as needed. Our team of surgeons in Haiti and the United States is currently using Dakin's solution for wound care following orthopedic surgery and finds it to be a low-cost, safe, and effective treatment for post-surgical wound care for both resource-limited and non-resource strained environments. This report aims to update the current literature and encourage the consideration of Dakin's solution for modern wound care.

What's New in Pediatric Limb Lengthening and Deformity Correction?

Over the past 5 years, published literature regarding treatment of pediatric limb deformity and limb length discrepancy demonstrates much interest in better understanding, categorizing and treating these challenging problems. Many studies explore expanding and refining indications for traditional treatment methods like guided growth techniques. Other studies have evaluated the results of new techniques such as lengthening via mechanized intramedullary nails. Additionally, series comparing older and newer techniques such as lengthening with external devices versus mechanized nails are becoming increasingly available.

Community-based accompaniment and psychosocial health outcomes in HIV-infected adults in Rwanda: a prospective study.

We examined whether the addition of community-based accompaniment to Rwanda's national model for antiretroviral treatment (ART) was associated with greater improvements in patients' psychosocial health outcomes during the first year of therapy. We enrolled 610 HIV-infected adults with CD4 cell counts under 350 cells/µL initiating ART in one of two programs. Both programs provided ART and required patients to identify a treatment buddy per national protocols. Patients in one program additionally received nutritional and socioeconomic supplements, and daily home-visits by a community health worker ("accompagnateur") who provided social support and directly-observed ingestion of medication. The addition of community-based accompaniment was associated with an additional 44.3 % reduction in prevalence of depression, more than twice the gains in perceived physical and mental health quality of life, and increased perceived social support in the first year of treatment. Community-based accompaniment may represent an important intervention in HIV-infected populations with prevalent mental health morbidity.

Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda.

BACKGROUND: Minimizing death and ensuring high retention and good adherence remain ongoing challenges for human immunodeficiency virus (HIV) treatment programs. We examined whether the addition of community-based accompaniment (characterized by daily home visits from a community health worker, directly observed treatment, nutritional support, transportation stipends, and other support as needed) to the Rwanda national model for antiretroviral therapy (ART) delivery would improve retention in care, viral load suppression, and change in CD4 count, relative to the national model alone. METHODS: We conducted a prospective observational cohort study among 610 HIV-infected adults initiating ART in 1 of 2 programs in rural Rwanda. Psychosocial and clinical characteristics were recorded at ART initiation. Death, treatment retention, and plasma viral load were assessed at 1 year. CD4 count was evaluated at 6-month intervals. Multivariable regression models were used to adjust for baseline differences between the 2 populations. RESULTS: Eighty-five percent and 79% of participants in the community-based and clinic-based programs, respectively, were retained with viral load suppression at 1 year. After adjusting for CD4 count, depression, physical health quality of life, and food insecurity, community-based accompaniment was protective against death or loss to follow-up during the first year of ART (hazard ratio, 0.17; 95% confidence interval [CI], .09-.35; P < .0001). In a second multivariable analysis, individuals receiving accompaniment were more likely to be retained with a suppressed viral load at 1 year (risk ratio: 1.15; 95% CI, 1.03-1.27; P = .01). CONCLUSIONS: These findings indicate that community-based accompaniment is effective in improving retention, when added to a clinic-based program with fewer patient support mechanisms.

Reliability and construct validity of three health-related self-report scales in HIV-positive adults in rural Rwanda.

Depression, low health-related quality of life, and low perceived social support have been shown to predict poor health outcomes, including HIV-related outcomes. Mental health morbidity and HIV are important public health concerns in Rwanda, where approximately half of the current population is estimated to have survived the genocide and 3% is living with HIV. We examined the reliability and construct validity of the Hopkins Symptom Checklist-15 (HSCL-15), the Medical Outcomes Study HIV Health Survey (MOS-HIV), and the Duke/UNC Functional Social Support Questionnaire (DUFSSQ), which were used to assess depression, health-related quality of life, and perceived social support, respectively, among HIV-infected adults in rural Rwanda. We also studied whether scale reliability differed by gender, literacy status, or antiretroviral therapy (ART) delivery strategy. The Kinyarwanda versions of the HSCL-15, MOS-HIV, and DUFSSQ performed well in the study population. Reliability was favorable (Cronbach's alpha coefficients ≥0.75 or above) for the scales overall and across subgroups of gender, literacy, and mode of ART delivery. The scales also demonstrated good convergent, discriminant, and known-group validity.

Programmes and principles in treatment of multidrug-resistant tuberculosis.

Multidrug-resistant tuberculosis (MDR-TB) presents an increasing threat to global tuberculosis control. Many crucial management issues in MDR-TB treatment remain unanswered. We reviewed the existing scientific research on MDR-TB treatment, which consists entirely of retrospective cohort studies. Although direct comparisons of these studies are impossible, some insights can be gained: MDR-TB can and should be addressed therapeutically in resource-poor settings; starting of treatment early is crucial; aggressive treatment regimens and high-end dosing are recommended given the lower potency of second-line antituberculosis drugs; and strategies to improve treatment adherence, such as directly observed therapy, should be used. Opportunities to treat MDR-TB in developing countries are now possible through the Global Fund to Fight AIDS, TB, and Malaria, and the Green Light Committee for Access to Second-line Anti-tuberculosis Drugs. As treatment of MDR-TB becomes increasingly available in resource-poor areas, where it is needed most, further clinical and operational research is urgently needed to guide clinicians in the management of this disease.