Eliminating rote postoperative radiographs for surgically managed pediatric supracondylar humerus fractures.

BACKGROUND: Use of postoperative radiographs after surgical management of supracondylar humerus (SCH) fractures is often based on rote practice rather than evidence. The purpose of this study was to determine the frequency with which 3-week postoperative radiographs at the time of pin removal altered management plans in pediatric SCH fractures that were intraoperatively stable after closed reduction and percutaneous pinning (CRPP). METHODS: We prospectively recruited pediatric patients with SCH fractures managed by CRPP at our institution from June 2020 until June 2022, and reviewed retrospective data on pediatric SCH fractures managed surgically at our institution between April 2008 and March 2015. Patients were assessed for post-CRPP fracture alignment and stability. For prospective patients, we asked clinicians to document their management decision at the 3-week follow-up visit before evaluating the postoperative radiographs. Our primary outcome was change in management because of radiographic findings. RESULTS: Overall, 1066 patients in the retrospective data and 446 prospectively recruited patients met the inclusion criteria. In the prospective group, radiographic findings altered management for 2 patients (0.4%). One patient had slow callus formation and 1 patient was identified as having cubitus varus. Altered management included prolonged immobilization or additional radiographic follow-up. Radiographic findings altered management in 0 (0%) of 175 type II fractures, in 2 (0.9%) of 221 type III fractures, and in 0 (0%) of 44 type IV fractures. We obtained similar findings from retrospective data. CONCLUSION: Rote use of 3-week postoperative radiographs after surgical management of SCH fractures that are intraoperatively stable has minimal utility. Eliminating rote postoperative radiographs for SCH fractures can decrease the time and financial burdens on families and health care systems without affecting patient outcomes.

Association Between First Post-operative Day Urine Output Following Kidney Transplantation and Short-Term and Long-Term Outcomes: A Retrospective Cohort Study.

Background: The relationship between post-operative urine output (UO) following kidney transplantation and long-term graft function has not been well described. Objective: In this study, we examined the association between decreased UO on post-operative day 1 (POD1) and post-transplant outcomes. Design: This is a retrospective cohort study. Setting: Atlantic Canada. Patients: Patients from the 4 Atlantic Canadian provinces (Nova Scotia, New Brunswick, Newfoundland, and Prince Edward Island) who received a live or deceased donor kidney transplant from 2006 through 2019 through the multiorgan transplant program at the Queen Elizabeth II Health Sciences Centre (QEII) hospital in Halifax, Nova Scotia. Measurements: Using multivariable Cox proportional hazards models, we assessed the association of low POD1 UO (defined as ≤1000 mL) with death-censored graft loss (DCGL). In secondary analyses, we used adjusted logistic regression or Cox models as appropriate to assess the impact of UO on delayed graft function (DGF), prolonged length of stay (greater than the median for the entire cohort), and death. Results: Of the 991 patients included, 151 (15.2%) had a UO ≤1000 mL on POD1. Low UO was independently associated with DCGL (hazard ratio [HR] = 4.00, 95% confidence interval [CI] = 95% CI = 1.55-10.32), DGF (odds ratio [OR] = 45.25, 95% CI = 23.00-89.02), and prolonged length of stay (OR = 5.06, 95% CI = 2.95-8.69), but not death (HR = 0.81, 95% CI = 0.31-2.09). Limitations: This was a single-center, retrospective, observational study and therefore has inherent limitations of generalizability, data collection, and residual confounding. Conclusions: Overall, reduced post-operative UO following kidney transplantation is associated with an increased risk of DCGL, DGF, and prolonged hospital length of stay.

Contexte: Le lien entre la diurèse postopératoire après une transplantation rénale et la fonction du greffon à long terme n'a pas été bien décrit. Objectif: Dans cette étude, nous avons examiné l'association entre la diminution de la diurèse au jour 1 postopératoire et les résultats après la transplantation. Conception: Étude de cohorte rétrospective. Cadre: Canada atlantique. Patients: Des patients des quatre provinces du Canada atlantique (Nouvelle-Écosse, Nouveau-Brunswick, Terre-Neuve et Île-du-Prince-Édouard) ayant reçu une greffe de rein provenant d'un donneur vivant ou décédé entre 2006 et 2019 dans le cadre du programme de transplantation multiorganes de l'hôpital QEII d'Halifax (Nouvelle-Écosse). Mesures: À l'aide de modèles à risques proportionnels de Cox multivariés, nous avons évalué l'association entre une faible diurèse (définie comme ≤ 1 000 ml) et la perte du greffon censurée par le décès (PGCD). Dans les analyses secondaires, nous avons utilisé des modèles de Cox ou des modèles de régression logistique ajustés, selon le cas, pour évaluer l'effet de la diurèse sur la fonction retardée du greffon, la durée prolongée du séjour (supérieure à la médiane pour l'ensemble de la cohorte) et le décès. Résultats: Des 991 patients inclus, 151 (15,2%) présentaient une diurèse inférieure à 1 000 ml au jour 1 postopératoire. Une faible diurèse a été indépendamment associée à la PGCD (rapport de risque [RR]: 4,00; IC 95 %: 1,55-10,32), à une fonction retardée du greffon (rapport de cotes [RC]: 45,25; IC 95 %: 23,00-89,02) et à un séjour prolongé à l'hôpital (RC: 5,06; IC 95 %: 2,95-8,69), mais pas au décès (RR: 0,81; IC 95 %: 0,31-2,09). Limites: Il s'agissait d'une étude observationnelle rétrospective monocentrique. L'étude présente ainsi des limites inhérentes à la généralisabilité, à la collecte des données et aux facteurs confondants résiduels. Conclusion: Dans l'ensemble, une diminution de la diurèse postopératoire après une transplantation rénale est associée à un risque accru de PGCD et de fonction retardée du greffon, ainsi qu'à un séjour prolongé à l'hôpital.

Complications of type II supracondylar humerus fractures treated at a specialized paediatric centre.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common operatively treated paediatric fracture in Canada. Previous literature describing the low-energy (Gartland type II) subtype reports varying complication rates from a variety of practice settings. We sought to examine complications of type II SCH fractures treated at a Canadian specialized paediatric centre. METHODS: We conducted a retrospective cohort study of patients aged 0 to 14 admitted to SickKids, Toronto, Ontario for surgical treatment of a type II SCH fracture from 2008 to 2015. The primary outcome of this study was relevant perioperative complications including: open fracture, compartment syndrome, pre- and postoperative vascular compromise, pre- and postoperative neurological compromise, failure to obtain a closed reduction (i.e., open reduction), postoperative infection, and reoperation within 3 months. RESULTS: There were 370 patients included in the study with mean (standard deviation) age 5.14 years (±2.51). The overall rate of relevant complications in the study cohort was 3.6% (13/358, 12 missing), with 12 cases of nerve palsy (3.3%; 2 iatrogenic [0.6%]) that resolved by final follow-up and one case of preoperative nerve palsy (0.3%) that did not. Importantly, there were no cases of vascular compromise, open fracture, compartment syndrome, or infection. DISCUSSION AND CONCLUSION: Complications associated with type II SCH fractures managed at a specialized paediatric centre that result in long-term morbidity are extremely rare (0.3%). Perioperative inpatient monitoring for patients with these fractures may not be justified based on these data. Prospective studies are required to confirm safety, evaluate patient perspectives, and demonstrate cost savings of outpatient surgical management.

High prevalence of syndemic health problems in patients seeking post-exposure prophylaxis for sexual exposures to HIV.

INTRODUCTION: The standard clinical approach to non-occupational HIV post-exposure prophylaxis (nPEP) focuses on biomedical aspects of the intervention, but may overlook co-occurring or 'syndemic' psychosocial problems that reinforce future vulnerability to HIV. We therefore sought to determine the prevalence of syndemic health problems in a cohort of Ontario nPEP patients, and explored the relationship between syndemic burden and HIV risk. METHODS: Between 07/2013-08/2016, we distributed a self-administered questionnaire to patients presenting to three clinics in Toronto and Ottawa seeking nPEP for sexual HIV exposures. We used validated screening tools to estimate the prevalence of depression (CES-D score ≥16), harmful alcohol use (AUDIT ≥8), problematic drug use (DUDIT ≥6 men/≥2 women), and sexual compulsivity (SCS ≥24) among men who have sex with men (MSM) respondents. In exploratory analyses, we examined the relationships between syndemic conditions using univariable logistic regression models, and the relationship between syndemic count (total number of syndemic conditions per participant) and HIV risk, as estimated by the HIRI-MSM score, using linear regression models. RESULTS: The 186 MSM included in the analysis had median age 31 (IQR = 26-36), including 87.6% having a college/undergraduate degree or higher. Overall, 53.8% screened positive for depression, 34.4% for harmful alcohol use, 30.1% for problematic drug use, and 16.1% for sexual compulsivity. Most participants (74.2%) had at least one syndemic condition and 46.8% had more than one. Exploratory analyses suggested positive associations between depression and harmful alcohol use (OR = 2.11, 95%CI = 1.13, 3.94) and between harmful alcohol use and problematic drug use (OR = 1.22, 95%CI = 0.65, 2.29). Syndemic count was associated with increased HIRI-MSM risk scores in univariable (2.2, 95%CI = 1.0, 3.3 per syndemic condition) and multivariable (2.1, 95%CI = 0.6, 3.6) linear regression models. CONCLUSIONS: The prevalence of syndemic conditions in MSM seeking nPEP for sexual exposure is alarmingly high, and is associated with underlying HIV risk. Routine screening for these conditions may identify opportunities for intervention and could alleviate future vulnerability to HIV.

Does maternal HSV-2 coinfection increase mother-to-child transmission of HIV? A systematic review.

BACKGROUND: Reducing HIV mother-to-child transmission (MTCT) is critical to ending the HIV pandemic. Reports suggest that herpes simplex virus-2 (HSV-2), a common coinfection in HIV-infected individuals, is associated with increased MTCT, but results have been conflicting. We conducted a systematic review of observational studies to quantify the magnitude of this relationship (PROSPERO no. CRD42016043315). METHODS: We searched Medline (1981 to June week 3, 2016), EMBASE (1981 to week 26, 2016), relevant conferences (2013-2016) and bibliographies of identified studies for cohort and case-control studies enrolling HIV-positive women during pregnancy or peripartum that quantified the effect of HSV-2 infection on MTCT. The primary outcome was the risk of perinatal HIV transmission associated with maternal HSV-2 status. Risk of bias was evaluated using a standardised tool, and results were meta-analysed where appropriate using a random-effects model, with studies weighted using the inverse variance method. RESULTS: From 2103 hits, 112 studies were considered for inclusion, and 10 were ultimately included. Of the included studies, three used a case-control design, three were retrospective cohorts and four were prospective cohorts. Risk of bias was low in three studies, moderate in six and high in one. The median sample size was 278.5 mother-infant pairs (range: 48-1513). The most common strategy for classifying maternal HSV-2 status was type-specific serology (n=6), followed by genital shedding (n=3) or genital culture (n=3), clinical diagnosis of herpes (n=2) or genital ulcer disease (n=1). Results from five studies that provided quantitative estimates of the association between HSV-2 seropositivity and MTCT were meta-analysed, yielding a pooled unadjusted OR=1.17 (95% CI=0.69 to 1.96, I2=58%). Three of these studies further considered key confounding variables, specifically antiretroviral use and/or viral load (n=3), and mode of delivery (n=2), yielding a pooled adjusted OR=1.57 (95% CI=1.17 to 2.11, I2=0). CONCLUSIONS: Maternal HSV-2 coinfection appears to be associated with increased perinatal HIV transmission. Further study of the effect of HSV-2 treatment on MTCT is warranted.

Antimycobacterial triterpenes from the Canadian medicinal plant Sarracenia purpurea.

ETHNOPHARMACOLOGICAL RELEVANCE: The purple pitcher plant, Sarracenia purpurea, is a medicinal plant used by the Canadian First Nations to treat a wide variety of illnesses. The Mi'kmaq and Wolastoqiyik (Maliseet) peoples of Eastern Canada have traditionally used infusions of S. purpurea for the treatment of tuberculosis-like symptoms. Previous investigations have shown methanolic extracts of S. purpurea to possess antimycobacterial activity. AIM OF THE STUDY: To isolate and identify antimycobacterial constituents from S. purpurea. MATERIALS AND METHODS: Methanolic extracts of S. purpurea were subjected to bioassay guided fractionation using the microplate resazurin assay (MRA) to assess inhibitory activity against Mycobacterium tuberculosis strain H37Ra. The antimycobacterial constituents were identified by NMR, MS and polarimetry. RESULTS: The triterpenes betulinaldehyde, ß-sitosterol, betulinic acid, and ursolic acid were isolated from S. purpurea. Betulinaldehyde, betulinic acid, and ursolic acid exhibited MICs of 450, 950, and 450µM and IC50s of 98, 169, and 93µM against M. tuberculosis H37Ra respectively whilst ß-sitosterol was inactive (MIC and IC50 of >1000µM). CONCLUSIONS: Betulinaldehyde, betulinic acid, and ursolic acid were identified as the principal constituents responsible for the antimycobacterial activity of S. purpurea. This work is consistent with the ethnopharmacological use of S. purpurea by Canadian First Nations as a treatment against infectious diseases.