Preoperative Gallows traction as an adjunct to hip open reduction surgery: Is it safe and is it effective?

Background: Traction is used at our hospital before open reduction in infants with developmental dysplasia of the hip. Theoretically, it reduces soft-tissue tension, allowing an easier surgical reduction and therefore lower surgical complications. Owing to extended hospital stays, potential complications, and lack of evidence, the use of traction has decreased. This study aims to quantify whether traction is safe and whether it has any demonstrable effect. Methods: The perioperative course of 80 patients undergoing preoperative traction and hip open reduction were reviewed. The height of hip dislocation was classified using the International Hip Dysplasia Institute classification system on both radiographs taken before and after traction. Any complications related to traction were recorded, along with the requirement for femoral shortening osteotomies, incidence of re-dislocation, and longer-term rate of avascular necrosis. Results: Traction lowered the resting position of the majority of hips, with the median International Hip Dysplasia Institute grade before traction improving from 4 to 3, a statistically significant improvement (p < 0.00001). There were no neurovascular complications. Two babies were complicated with broken skin sores; however, surgery still progressed uneventfully. Zero hips in the cohort required femoral shortening osteotomies to achieve a tension-free reduction, and the re-dislocation rate was 0%. However, 96% of hips were Severin 1 or 2 at 6-year follow-up. Conclusion: Notably, 1 week of preoperative traction significantly improves the resting position of the hip in high dislocations. It is safe when used in infants weighing <12 kg, and subsequent surgical outcomes are excellent, thus supporting its use ahead of developmental dysplasia of the hip open reduction surgery. Level of evidence: Level IV.

Influence of TP53 Comutation on the Tumor Immune Microenvironment and Clinical Outcomes With Immune Checkpoint Inhibitors in STK11-Mutant Non-Small-Cell Lung Cancer.

PURPOSE: Non-small-cell lung cancer (NSCLC) with STK11mut has inferior outcomes to immune checkpoint inhibitors (ICIs). Using multiomics, we evaluated whether a subtype of STK11mut NSCLC with a uniquely inflamed tumor immune microenvironment (TIME) harboring TP53 comutations could have favorable outcomes to ICIs. PATIENTS AND METHODS: NSCLC tumors (N = 16,896) were analyzed by next-generation sequencing (DNA-Seq/592 genes). A subset (n = 5,034) underwent gene expression profiling (RNA-Seq/whole transcriptome). Exome-level neoantigen load for STK11mut NSCLC was obtained from published pan-immune analysis. Tumor immune cell content was obtained from transcriptome profiles using the microenvironment cell population (MCP) counter. ICI data from POPLAR/OAK (n = 34) and the study by Rizvi et al (n = 49) were used to model progression-free survival (PFS), and a separate ICI-treated cohort (n = 53) from Dana-Farber Cancer Institute (DFCI) was used to assess time to treatment failure (TTF) and tumor RECIST response for STK11mutTP53mut versus STK11mutTP53wt NSCLC. RESULTS: Overall, 12.6% of NSCLC tumors had a STK11mut with the proportions of tumor mutational burden (TMB)-high (≥10 mut/Mb), PD-L1 ≥50%, and microsatellite instability-high being 38.3%, 11.8%, and 0.72%, respectively. Unsupervised hierarchical clustering of STK11mut (n = 463) for stimulator of interferon-gamma (STING) pathway genes identified a STING-high cluster, which was significantly enriched in TP53mut NSCLC (P < .01). Compared with STK11mutTP53wt, tumors with STK11mutTP53mut had higher CD8+T cells and natural killer cells (P < .01), higher TMB (P < .001) and neoantigen load (P < .001), and increased expression of MYC and HIF-1A (P < .01), along with higher expression (P < .01) of glycolysis/glutamine metabolism genes. Meta-analysis of data from OAK/POPLAR and the study by Rizvi et al showed a trend toward improved PFS in patients with STK11mutTP53mut. In the DFCI cohort, compared with the STK11mut TP53wt cohort, the STK11mutTP53mut tumors had higher objective response rates (42.9% v 16.7%; P = .04) and also had longer TTF (14.5 v 4.5 months, P adj = .054) with ICI. CONCLUSION: STK11mut NSCLC with TP53 comutation is a distinct subgroup with an immunologically active TIME and metabolic reprogramming. These properties should be exploited to guide patient selection for novel ICI-based combination approaches.

Validation of a Molecular Diagnostic Test for Circulating Tumor DNA by Next-Gen Sequencing.

A modified version of the PGDx elioTM Plasma Resolve assay was validated as a laboratory-developed test (LDT) for clinical use in the Molecular Diagnostics Laboratory at Fox Chase Cancer Center. The test detects single nucleotide variants (SNVs) and small insertions and deletions (indels) in 33 target genes using fragmented genomic DNA extracted from plasma. The analytical performance of this assay was assessed with reference standard DNA and 29 samples from cancer patients and detected 66 SNVs and 23 indels. Using 50 ng of input DNA, the sensitivity was 95.5% to detect SNVs at 0.5% allele frequency, and the specificity was 92.3%. The sensitivity to detect indels at 1% allele frequency was 70.4%. A cutoff of 0.25% variant allele frequency (VAF) was set up for diagnostic reporting. An inter-laboratory study of concordance with an orthologous test resulted in a positive percent agreement (PPA) of 91.7%.

How to Treat EGFR-Mutated Non-Small Cell Lung Cancer.

•Mutations in the EGFR gene are observed in about 15% of NSCLC adenocarcinomas in the United States and are not associated with smoking. There are numerous EGFR mutations, with the most common being exon 19 deletions and the point mutation L858R in exon 21.•Osimertinib, an oral TKI, is used as the initial therapy for metastatic NSCLC harboring exon 19 deletion and exon 21 L858R mutation. Common side effects include acneiform rash, diarrhea, and paronychia. Osimertinib has also been associated with cardiomyopathy (∼1.4%-2.4%) and prolongation of the QT interval (2.7%).•In our experience, osimertinib-induced cardiomyopathy can be managed with the cessation of osimertinib and the initiation of guideline-directed therapy. Given that osimertinib is often the best available therapy, rechallenging with osimertinib often favors benefit over risk. Safe rechallenge with osimertinib is demonstrated in this case.

Assessing plasma circulating tumor human papillomavirus (HPV) DNA in determining treatment response in HPV-associated oropharyngeal cancer.

BACKGROUND: Human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma is a subset of head and neck cancer with a unique mechanism of carcinogenesis. Local disease is treated definitively with a multimodal approach. Navigating recurrences can be challenging, as they are sometimes indiscernible from de novo primary malignancies. Identification of dynamic biomarkers that are specific to HPV-mediated disease may assist in disease monitoring. We present a 78-year-old man who developed a squamous cell carcinoma in the lung 7 years after completing definitive chemoradiation for his p16+ head and neck squamous cell carcinoma. METHODS: A novel assay for plasma circulating tumor HPV DNA was employed and provided a tool for longitudinal disease monitoring during therapy. CONCLUSION: We bring attention to a novel assay and highlight its potential for use in the treatment paradigm of HPV-mediated oropharyngeal carcinoma.

Adverse Events Reported by Patients With Cancer After Administration of a 2-Dose mRNA COVID-19 Vaccine.

BACKGROUND: Most safety and efficacy trials of the SARS-CoV-2 vaccines excluded patients with cancer, yet these patients are more likely than healthy individuals to contract SARS-CoV-2 and more likely to become seriously ill after infection. Our objective was to record short-term adverse reactions to the COVID-19 vaccine in patients with cancer, to compare the magnitude and duration of these reactions with those of patients without cancer, and to determine whether adverse reactions are related to active cancer therapy. PATIENTS AND METHODS: A prospective, single-institution observational study was performed at an NCI-designated Comprehensive Cancer Center. All study participants received 2 doses of the Pfizer BNT162b2 vaccine separated by approximately 3 weeks. A report of adverse reactions to dose 1 of the vaccine was completed upon return to the clinic for dose 2. Participants completed an identical survey either online or by telephone 2 weeks after the second vaccine dose. RESULTS: The cohort of 1,753 patients included 67.5% who had a history of cancer and 12.0% who were receiving active cancer treatment. Local pain at the injection site was the most frequently reported symptom for all respondents and did not distinguish patients with cancer from those without cancer after either dose 1 (39.3% vs 43.9%; P=.07) or dose 2 (42.5% vs 40.3%; P=.45). Among patients with cancer, those receiving active treatment were less likely to report pain at the injection site after dose 1 compared with those not receiving active treatment (30.0% vs 41.4%; P=.002). The onset and duration of adverse events was otherwise unrelated to active cancer treatment. CONCLUSIONS: When patients with cancer were compared with those without cancer, few differences in reported adverse events were noted. Active cancer treatment had little impact on adverse event profiles.

Disparities in Lung Cancer Treatment.

PURPOSE OF REVIEW: Despite an overall reduction in lung cancer incidence and mortality rates worldwide, Blacks still have higher mortality rates compared to Whites. There are many factors that contribute to this difference. This review seeks to highlight racial disparities in treatment and the possible reasons for these disparities. RECENT FINDINGS: Factors attributing to racial disparities in lung cancer treatment include social determinants of health, differences in the administration of guideline-concordant therapy as well as molecular testing that is essential for most NSCLC patients. One way to circumvent disparities in lung cancer survivorship is to ensure equal representation of race in research at all levels that will provide insight on interventions that will address social determinants of health, differences in treatment patterns, molecular testing, and clinical trial involvement.

Characterization of KRAS Mutation Subtypes in Non-small Cell Lung Cancer.

KRAS is the most commonly mutated oncogene in NSCLC and development of direct KRAS inhibitors has renewed interest in this molecular variant. Different KRAS mutations may represent a unique biologic context with different prognostic and therapeutic impact. We sought to characterize genomic landscapes of advanced, KRAS-mutated non-small cell lung cancer (NSCLC) in a large national cohort to help guide future therapeutic development.Molecular profiles of 17,095 NSCLC specimens were obtained using DNA next-generation sequencing of 592 genes (Caris Life Sciences) and classified on the basis of presence and subtype of KRAS mutations. Co-occurring genomic alterations, tumor mutational burden (TMB), and PD-L1 expression [22C3, tumor proportion score (TPS) score] were analyzed by KRAS mutation type.Across the cohort, 4,706 (27.5%) samples harbored a KRAS mutation. The most common subtype was G12C (40%), followed by G12V (19%) and G12D (15%). The prevalence of KRAS mutations was 37.2% among adenocarcinomas and 4.4% in squamous cell carcinomas. Rates of high TMB (≥10 mutations/Mb) and PD-L1 expression varied across KRAS mutation subtypes. KRAS G12C was the most likely to be PD-L1 positive (65.5% TPS ≥ 1%) and PD-L1 high (41.3% TPS ≥ 50%). STK11 was mutated in 8.6% of KRAS wild-type NSCLC but more frequent in KRAS-mutant NSCLC, with the highest rate in G13 (36.2%). TP53 mutations were more frequent in KRAS wild-type NSCLC (73.6%).KRAS mutation subtypes have different co-occurring mutations and a distinct genomic landscape. The clinical relevance of these differences in the context of specific therapeutic interventions warrants investigation.

Updating the UK competence framework for orthopaedic and trauma nurses 2019.

The updated RCN Competence Framework for orthopaedic and trauma practitioners was published in 2019 following completion of a 2 year project undertaken by a working group of representatives from England, Northern Ireland, Scotland and Wales. Expert musculoskeletal practitioners, including an allied health professional and working across the lifespan in varying domains of orthopaedic and trauma practice, collaborated to produce a working document applicable to trauma and orthopaedic (T&O) practitioners from all NHS (UK) pay bands. The 2019 document builds on the original and subsequent versions (2005 and 2012), importing new evidence and reformatting it so that it is contemporary and easily cross referenced with the NMC Code (2018). The restructure includes an example of a learning contract demonstrating how the framework can be applied in practice, whether for self-learning, or in conjunction with the revalidation process. This paper reflects on and describes the process undertaken by the working group in the development and restructuring of the 2019 framework, including its evaluation to date and planned in the future.

Combining Immunotherapy and Chemotherapy for Non-Small Cell Lung Cancer.

Over the past year, the combination of platinum-based chemotherapy and immunotherapy has become the standard of care for patients with metastatic non-small-cell lung cancer with any programmed death ligand 1 tumor proportion score. There is preclinical evidence demonstrating potential synergistic immunomodulation with combination therapy by enhancing immune-mediated tumor death and by disrupting the immunosuppressive tumor microenvironment that prevents immune detection. This potential synergy or complementary activity has been demonstrated in clinical trials showing improved and durable responses with chemo-immunotherapy.

International scoping exercise into expertise in children's orthopaedic nursing and educational pathways.

Maintaining competence and keeping skills and knowledge in children's orthopaedic nursing alive are problematic in both the UK and Australia. The dearth of dedicated postgraduate courses for this specialty has resulted in an array of unregulated in-house training, nurses' individual educational needs not being met and potential for children with an orthopaedic problem being put at risk of not receiving optimal care. This paper reports on a travel scholarship used to compare and contrast the UK with Australia, which supported an international scoping exercise to identify nurses' beliefs regarding expertise in children's orthopaedic nursing and explore provision for maintaining pertinent knowledge and skills. Potential ways to improve support for nurses in maintaining expertise in this field of practice are discussed.

Immune-Related Adverse Events as a Biomarker in Non-Melanoma Patients Treated with Programmed Cell Death 1 Inhibitors.

BACKGROUND: The programmed death 1 (PD-1) checkpoint inhibitors (CKIs) can lead to immune-related adverse events (irAEs). We sought to evaluate whether the development of irAEs correlates with treatment response in non-melanoma malignancies. MATERIALS AND METHODS: We conducted a retrospective study of patients who received anti-PD-1 CKI monotherapy at Fox Chase Cancer Center. Endpoints included overall response rate (ORR), time to next therapy or death (TTNTD), and overall survival (OS). Fisher's exact tests and logistic regression models were used to determine the association between irAE incidence and ORR, and Kaplan-Meier curves with log-rank tests and Cox regression models were used for the comparison of TTNTD and OS. RESULTS: Between November 2011 and November 2016, 160 patients were treated with >1 dose of an anti-PD-1 CKI. Seventy-three (46%) were treated on a clinical trial. Immune-related adverse events were noted in 64 patients (40%), with steroids required in 36 (23%). Of the 142 patients evaluable for clinical response, 28 patients (20%) achieved a partial response at first scan. An association between irAEs and ORR was seen in clinical trial patients (p = .007), but not in non-trial patients (p = .13). When controlling for clinical trial participation and cancer type using multivariate analysis, low-grade irAEs had higher ORR (p = .017) and longer TTNTD (p = .008). No association between irAE incidence and OS was seen (p = .827). Immune-related adverse events that required steroid treatment were marginally associated with increased TTNTD (p = .05, hazard ratio 0.62) but were not associated with OS (p = .13). CONCLUSION: We demonstrate several positive associations between the development of irAEs and clinical outcomes in non-melanoma patients treated with PD-1 CKIs, for which further validation is required. IMPLICATIONS FOR PRACTICE: This study evaluated whether the development of immune-related adverse events in non-melanoma patients treated with programmed cell death 1 checkpoint inhibitors correlates with improved clinical outcomes. The results indicate that for a subset of patients, in particular those with low-grade immune-related adverse events, immune-related adverse events predicted for an improved response rate and longer time to next therapy or death.

Low Level of Blood CD4+ T Cells Is an Independent Predictor of Inferior Progression-free Survival in Diffuse Large B-cell Lymphoma.

BACKGROUND: Tumor-infiltrating immune cells influence diffuse large B-cell lymphoma (DLBCL) outcomes. Relatively little, however, is known about the significance of peripheral blood immune cell numbers on DLBCL behavior. PATIENTS AND METHODS: In the present study, 43 patients with newly diagnosed DLBCL had pretreatment multiparameter peripheral blood flow cytometry performed to assess the immune cell numbers. These cell numbers were correlated with the outcomes of progression-free survival (PFS) and overall survival. RESULTS: After follow-up period of 0.8 to 152 months (median, 73), 25 patients (56%) were still alive. As continuous variables on univariate analysis, the predictors of PFS were patient age and absolute CD4 cell count (ACD4C), with the International Prognostic Index (IPI) marginally significant. Age was also a significant predictor of overall survival, and the IPI and ACD4C were marginally significant (P = .08). The 17 patients with a greater ACD4C (≥ 450/mm3) had better 5-year PFS than the 26 with a low ACD4C (88% vs. 50%; P = .02). Multivariable analysis, including age as a continuous variable, IPI group, and ACD4C of 450/mm3 showed that age and ACD4C were significant for PFS (P = .01 and P = .02, respectively). CONCLUSION: Our data, although from a small series, suggest that the blood ACD4C might be a predictor of PFS for patients with DLBCL, independent of age and the IPI.

Vitamin D Deficiency in Slipped Upper Femoral Epiphysis: Time to Physeal Fusion.

BACKGROUND: Slipped upper femoral epiphysis (SUFE) has an incidence of 1 to 7 per 100,000 adolescents in the United Kingdom and its link with obesity is well established. With an increasing number of pediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the prevalence of vitamin D deficiency in SUFE patients presenting to an orthopaedic department in the United Kingdom and whether a low vitamin D level increases the time to proximal femoral physeal fusion after surgical fixation. METHODS: A total of 27 pediatric patients, with a female to male ratio of 17:10 and a mean age of 11.5 years (SD=1.99), range 8 to 16 years, presented with a SUFE and their vitamin D level was assessed during the study period, June 2007 to July 2012 (inclusive). The majority of these patients (85.2%) were assessed as vitamin D deficient, with a serum 25-(OH)D<52 nmol/L. The time taken for >50% physeal fusion on anteroposterior radiography after surgical fixation reported in the literature is 9.6 months, with no reported vitamin D deficiency or insufficiency. RESULTS: In our study, the median time to physeal fusion in the vitamin D-deficient and vitamin D-insufficient patients was 25 months (interquartile range, 17 to 43 mo; mean of 29 mo, SD=16.8). A negative correlation was also observed between vitamin D level and the time taken for physeal fusion after surgical fixation. CONCLUSIONS: We conclude that a high prevalence of vitamin D deficiency has been observed in our SUFE patients. Comparing the time taken for physeal closure of 9.6 months in the literature with vitamin D-deficient patients, this is prolonged. Indeed, a negative correlation has been shown between vitamin D level and time to physeal fusion. This study highlights the need for regular vitamin D status assessment in SUFE patients to allow early implementation of treatment with vitamin D supplementation. The impact of vitamin D screening and supplementation on SUFE outcomes should be investigated further.

Shelf acetabuloplasty for containment in the early stages of Legg-Calve-Perthes disease.

BACKGROUND: To evaluate the effectiveness of shelf acetabuloplasty in the containment of extruded hips without hinge abduction in early stages of Legg-Calve-Perthes disease, we present a retrospective series of 44 patients (45 hips) treated between August 1999 and February 2010, which included 34 boys and 10 girls with a mean age at diagnosis of 7.4 years (range, 3.9 to 15.3). METHODS: All patients presented with sclerosis or early fragmentation stages. The average time from diagnosis to surgery was 2.1 months (range, 0 to 8.2) and the mean time to heal was 40.4 months (range, 20 to 82.2). The Reimer migration and the deformity indices were measured on initial, preoperative, postoperative, and healed x-rays. The average deformity index at 3 of those 4 timepoints was significantly related to their final Stulberg classification. CE angles increased and Sharp angles decreased significantly as a result of treatment. RESULTS: At the healed stage and consistent with other published series, 84.4% of patients were Stulberg III or less, denying any pain, and with full range of movement, whereas 15.6% were classified as Stulberg IV. CONCLUSIONS: We defend that shelf acetabuloplasty should be performed early in the disease and, uniquely, we propose that the indication for treatment should be guided by the deformity and the Reimer migration indices. LEVEL OF EVIDENCE: IV.

Treatment and prevention of hip dysplasia in infants and young children.

The diagnosis and treatment of developmental dysplasia of the hip in the infant are uniform, with consensus that diagnostic ultrasound and Pavlik harness management are standard procedures. Sequential procedures for failed early treatment, residual dysplasia and late diagnosis are dependent on the age and the severity of the dysplasia. This paper reviews the treatment of developmental dysplasia of the hip from birth to subsequent follow-up procedures, with particular reference to some of the senior authors' research and the Southampton approach to the management of hip dysplasia.

Does the Pirani score predict relapse in clubfoot?

PURPOSE: Presented here is a retrospective clinical audit of clubfoot patients to determine the value of the Pirani clubfoot scoring system at initial presentation in the estimation of subsequent relapse. METHODS: All clubfoot patients treated by the same surgeon from 2002 to 2006 were included. The treatment adhered to the standard protocol, involving weekly stretching and casting until the foot was corrected, followed by Achilles tenotomy and plasters for 3 weeks. Thereafter, the child was placed in a foot abduction splint. The severity of clubfoot was assessed using the Pirani scoring system, consisting of two sub-scores-the midfoot contracture score (MFCS) and the hindfoot contracture score (HFCS). The MFCS and HFCS can each be 0.0-3.0, giving rise to a total Pirani score (TPS) of 0.0-6.0. Any recurrent deformity was classed as a relapse. RESULTS: Sixty-one clubfoot patients were treated. Five patients were lost to follow-up and six patients were excluded due to the presence of identified syndromes or having had primary treatment elsewhere. A total of 80 clubfeet were included. There were 17 relapses. The average interval between the initiation of foot abduction splint and relapse was 23 months. The median TPS was 3.5 in the no relapse group and 5.0 in the relapse group. The median MFCS was 1.5 in the no relapse group and 2.0 in the relapse group. The median HFCS was 2.0 in the no relapse group and 3.0 in the relapse group. Higher TPS and HFCS were statistically significant when the relapse group was analysed against the no relapse group (P = 0.05 × 10(-4) and 0.02 × 10(-4), respectively). CONCLUSIONS: Higher Pirani scores were associated with the late relapse group. The TPS and HFCS were shown to be statistically significant predictors of potential relapse. Closer follow-up is advised for patients at risk of relapse.

Benchmarks for children's orthopaedic nursing.

Variability in practice and quality of care for children and young people with orthopaedic conditions was identified by a network of nurses working in this specialty. Nine benchmarks were developed to help address this variability by providing support for nurses to evaluate and improve practice where necessary. The process of developing the benchmarks is described and lessons learnt are discussed, including the challenges for experts of making the nature of their work explicit. Following publication and dissemination of the benchmarks, an evaluation of their usefulness is planned.