The impact of "male clinics" on health-seeking behaviors of adult men in rural Kenya.

BACKGROUND: In most parts of the world, men access health services less frequently than women, and this trend is unrelated to differences in need for services. While male involvement in healthcare as partners or fathers has been extensively studied, less is known about the health-seeking behavior of men as clients themselves. This interventional research study aimed to determine how the introduction of male-friendly clinics impacted male care-seeking behavior and to describe the reasons for accessing services among men in rural Kenya. METHODS AND FINDINGS: We questioned men to assess utilization and perceptions of existing health clinics, then designed and evaluated a "male clinics" intervention where dedicated male health workers were hired for one year to offer routine, free services exclusively to men within existing healthcare facilities. Results were compared between data from Male Clinics in specific health facilities, the same facilities concurrently, nearby control facilities concurrently, and intervention facilities historically. Costs of services, distance to facilities, and quality of care were the main barriers to healthcare access reported. The number of total visits was significantly higher than control groups (p<0·0001). In the intervention group, 18·6% of visits were for a checkup compared to almost none in control groups. The most common diagnoses overall were upper respiratory tract infections, malaria and injury. A major limitation of this study is the non-comparability in information captured using the Male Clinic registers compared to control registers. CONCLUSIONS: Costs and quality of services deter men from seeking healthcare. The introduction of male-friendly health services could encourage men to seek preventive care and increase service uptake.

Parent Involvement in the Pediatric Resident Applicant Interview.

BACKGROUND: Parents and patients are actively involved in the clinical learning environment, yet scant literature exists about their involvement in the residency interview process. We aimed to pilot a process of including parents in resident interviews and to determine its value. METHODS: During the 2016-17 residency interview cycle, 22 parent volunteers, blinded to applicant credentials, conducted brief structured interviews with 118 applicants. We then surveyed all parents and applicants with the use of mixed methods: descriptive statistics to analyze 5-point Likert-type-scale responses, and content analysis to identify themes from open-ended questions. Although parent interviews were not used in ranking, we later compared final composite parent interview scores (1-10, with 10 being high) among the final rank and match list candidates. RESULTS: Response rates were high for both groups (parents 100%; resident applicants 98.3%). Parents felt strongly positive about meeting applicants (mean ± SD, 5.00 ± 0.00), the value of parent participation (4.90 ± 0.30), and their own experience (4.95 ± 0.22). Applicants felt positive about meeting parents (4.45 ± 0.70), the value of parent participation (3.92 ± 0.84), and their own experience (4.51 ± 0.67). Several themes emerged from both groups, with the most salient parent themes including the value of patient-centered perspectives and appreciation and joy of meeting applicants. Parent interview scores correlated with the final match list, with matched applicants scoring higher (9.08 vs 8.51; P = .05). CONCLUSIONS: Involvement of parents in the pediatric residency interview process is achievable, is perceived positively by parents and applicants, and may provide valuable perspectives for consideration in residency selection.

Low-Dose Donor Dopamine Is Associated With a Decreased Risk of Right Heart Failure in Pediatric Heart Transplant Recipients.

BACKGROUND: Previous studies in adults have suggested that donor dopamine treatment may improve recipient outcomes in organ transplantation; in this analysis, we aimed to determine if donor dopamine reduces the incidence of postoperative right heart failure (RHF) in pediatric heart transplant recipients. METHODS: Data for recipients aged 18 years or younger transplanted at our institution between January 1, 2000, and June 15, 2011, and their respective donors were obtained. The presence of postoperative RHF was assessed for in all subjects. Donor dopamine dose was stratified into 3 groups: none, low-dose (≤5 µg/kg per minute), and high-dose (>5 µg/kg per minute). Logistic regression was used to assess the relationship between donor dopamine dose and recipient RHF. RESULTS: Of 192 recipients, 34 (18%) experienced postoperative RHF. There was no difference in baseline demographics between recipients with and without RHF. When controlling for pulmonary vascular resistance index, graft ischemic time, and cardiopulmonary bypass time, donor low-dose dopamine was independently associated with a decreased risk of RHF (odds ratio, 0.16; 95% confidence interval, 0.04-0.70; P = 0.02); however high-dose dopamine was neither associated with, nor protective of, RHF (odds ratio, 0.31; 95% confidence interval, 0.06-1.6; P = 0.16). CONCLUSIONS: Despite advances in perioperative care of the recipient, RHF persists as a complication of pediatric heart transplantation. In this study, donor pretreatment with low-dose dopamine is associated with a decreased risk of postoperative RHF in pediatric heart recipients. Further studies into this association may be useful in determining the utility of empiric donor pretreatment with low-dose dopamine.

Labral injuries of the hip in rowers.

BACKGROUND: Injuries of the hip in the adolescent and young adult athlete are receiving more attention with advances in the understanding of femoroacetabular impingement (FAI), labral pathology, and hip arthroscopy. Labral tears have not been well characterized in rowers. QUESTIONS/PURPOSES: The purposes of this study were (1) to describe the clinical presentation of labral pathology in rowers; (2) to describe the MRI and radiographic findings of labral pathology in rowers; and (3) to determine the likelihood that a rower with labral injury, treated arthroscopically, will return to sport. METHODS: We conducted a review from August 2003 to August 2010 to identify all rowers with MRI-confirmed intraarticular pathology of the hip presenting to our institution. Baseline demographics, symptoms and physical findings, and location of the labral tear with associated pathology, management, and early followup were recorded. The review yielded a total of 21 hips (18 rowers, three with bilateral labral pathology) with a mean patient age of 18.5 years (range, 14-23 years). Most of the rowers (85%) were female and the series included prep school (44%) and collegiate rowers (56%). Eighteen of the 21 hips (85%) eventually underwent arthroscopic surgery at our institution. RESULTS: A large majority of patients had isolated groin pain (71%) and physical findings consistent with impingement (81%). There was no single, dominant location for the labral tears on MRI. Among the 18 patients who had surgery, 10 (56%) returned to rowing, six (33%) never returned, and return data were not available for two (11%) at a mean of 8 months (range, 3-25 months) after surgery. CONCLUSIONS: The repetitive motions of the hip required for rowing may be a factor leading to intraarticular labral injuries in the athletes. Underlying anatomic abnormalities of the hip such as FAI may predispose certain patients to these injuries. However, many patients treated arthroscopically did not return to sport at a mean of 8 months after surgery.

Correlation between the Child Health Questionnaire and the International Knee Documentation Committee score in pediatric and adolescent patients with an anterior cruciate ligament tear.

BACKGROUND: The modified International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form has recently been shown to be valid, reliable, and responsive in a pediatric and adolescent population. The correlations between the Pedi-IKDC and quality-of-life-related health measures have not been studied in depth to determine how a knee injury affects patients in this age group. The purpose of this study was to examine the association between the Pedi-IKDC score and the Child Health Questionnaire (CHQ) in a group of pediatric patients with an anterior cruciate ligament (ACL) injury. METHODS: A prospectively collected registry of patients with ACL injuries was searched to indentify all patients who had completed both the Pedi-IKDC and CHQ (CHQ-CF87) questionnaires. These were analyzed to determine significant correlations between domains of the CHQ and the Pedi-IKDC. RESULTS: A total of 135 patients were included (80 male, 55 female) with a median age of 15.3 years (range, 13.1 to 17.2 y). The cohort included patients treated both operatively (120) and nonoperatively (15). The total Pedi-IKDC score was found to correlate with the majority of the CHQ including expected domains such as physical function (correlation coefficient = 0.64), bodily pain (0.7), and family activities (0.41), in addition to emotional role (0.45), mental health (0.46), self-esteem (0.45), and social limitations--physical (0.38) (P < 0.001 for all correlations). CONCLUSIONS: Seven of the 12 domains on the CHQ are significantly correlated with the IKDC in adolescent patients with an ACL tear. Self-esteem, mental health, emotional role, and social limitations categories are significantly correlated with knee function suggesting that quality-of-life in this population is affected in domains outside of physical function and pain. A greater understanding of the psychosocial impact of injury may be of utility in these patients. STUDY DESIGN: Level III cross-sectional study.

Arthrofibrosis after anterior cruciate ligament reconstruction in children and adolescents.

INTRODUCTION: Arthrofibrosis is a known complication after anterior cruciate ligament (ACL) reconstruction. ACL reconstruction is being performed with increased frequency in the pediatric population. The purpose of this study was to determine the prevalence of arthrofibrosis in children and adolescents and to identify risk factors for arthrofibrosis. METHODS: The study design was a retrospective case series. Medical records for 1016 consecutive ACL reconstructions in patients aged 7 to 18 years old between 1995 to 2008 at a major tertiary care children's hospital were reviewed to identify cases of postoperative arthrofibrosis. Arthrofibrosis was defined as a loss of 5 degrees or more extension compared with the contralateral knee that required a follow-up procedure or a loss of 15 degrees or more flexion compared with the contralateral knee that required a follow-up procedure. Patient data were recorded and analyzed using bivariate models to identify predictors for arthrofibrosis. Further, we reviewed the clinical course of patients with treated arthrofibrosis to assess functional outcomes of this complication. RESULTS: Nine hundred two patients with 933 knees met the inclusion criteria for this study, of which 60% were female. The mean age at the time of surgery was 15 years (range, 7 to 18 y), and the average follow-up from original ACL reconstruction was 6.3 years (range, 1.6 to 14.2 y). The overall prevalence of arthrofibrosis in our cohort was 8.3%, with 77 of the 933 knees had at least 1 procedure to treat arthrofibrosis after ACL reconstruction. Risk factors for arthrofibrosis were female sex (11.1% females, P = 0.0001), patients aged 16 to 18 years [11.6%; odds ratio (OR) 3.51; P = 0 .007], patellar tendon autograft (OR, 1.7; P = 0.026), and concomitant meniscal repair (OR, 2.08; P = 0.007). Prior knee surgery and ACL reconstruction within 1 month of injury were not significantly associated with arthrofibrosis after ACL reconstruction. Fifty-three patients had a minimum of 6 months clinical follow-up after the procedure for arthrofibrosis. Of these, 46 patients (86.8%) had full range of motion at follow-up. Thirty-two patients (60.4%) were asymptomatic at final follow-up. Eleven patients (20.8%) complained of some persistent pain. CONCLUSIONS: The rate of arthrofibrosis after ACL reconstruction in children and adolescents is 8.3%. Risk factors for arthrofibrosis are female sex, older adolescents, concurrent meniscal repair, and reconstruction with patellar tendon autograft. Surgical treatment for arthrofibrosis after ACL reconstruction in pediatric patients can satisfactorily regain motion in the reconstructed knee; however functional outcome may be compromised. LEVEL OF EVIDENCE: Level 4.

Complications of hip arthroscopy in children and adolescents.

BACKGROUND: Hip arthroscopy has become an established procedure for certain hip disorders. Complications of hip arthroscopy have been characterized in adult populations, but complications in children and adolescents have not been well described. The purpose of this study was to characterize complications of hip arthroscopy in children and adolescents. METHODS: The study design was a retrospective review of 218 hip arthroscopies in 175 patients aged 18 years old and younger over a 9-year period by a single surgeon at a tertiary-care children's hospital. Patient demographics, indications for surgery, and complications after surgery were recorded. Indications for surgery included: isolated labral tear (n=131), labral tear with concomitant hip disorder (n=37), Perthes disease (n=10), hip dysplasia (n=5), juvenile rheumatoid arthritis (n=3), loose bodies (n=3), osteochondral fracture (n=3), synovitis (n=2), avascular necrosis (n=1), chondral lesion (n=1), iliopsoas tendinitis (n=1), and slipped capital femoral epiphysis (n=1). RESULTS: The overall complication rate in the study population was 1.8%. Complications of arthroscopy included: transient pudendal nerve palsy (n=2), instrument breakage (n=1), and suture abscess (n=1). No cases of proximal femoral physeal separation, osteonecrosis, or growth disturbance were noted. CONCLUSIONS: Hip arthroscopy in children and adolescents seems to be a safe procedure with a low complication rate similar to adults. LEVEL OF EVIDENCE: IV (case series).

Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders.

BACKGROUND: The International Knee Documentation Committee (IKDC) Subjective Knee Form is a knee-specific measure of symptoms, function, and sports activity. A modified IKDC Subjective Knee Form (pedi-IKDC) has been developed for use in children and adolescents. The purpose of this study was to determine the psychometric characteristics of the pedi-IKDC in children and adolescents with knee disorders. HYPOTHESIS: The pedi-IKDC is a reliable, valid, and responsive patient-administered outcome instrument in the pediatric population with knee disorders. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Test-retest reliability, content validity, criterion validity, construct validity, and responsiveness to change were determined for the pedi-IKDC in patients aged 10 to 18 years with a variety of knee disorders. Test-retest reliability was measured in a group of 72 patients with a stable knee disorder. Validity was measured in a group of 589 patients with the Child Health Questionnaire to determine criterion validity. Responsiveness was measured in a group of 98 patients undergoing a variety of knee surgical procedures. RESULTS: The overall pedi-IKDC had acceptable test-retest reliability (intraclass correlation coefficient, .91) and excellent internal consistency (Cronbach alpha, .91). The form also demonstrated acceptable floor (0%) and ceiling (6%) effects. There was acceptable criterion validity with significant (P < .01) correlation between the overall pedi-IKDC and 9 relevant domains of the Child Health Questionnaire. Construct validity was acceptable, with all 11 hypotheses demonstrating significance (P < .0001). Responsiveness to change was acceptable (effect size, 1.39; standardized response mean, 1.35). CONCLUSION: The pedi-IKDC demonstrated overall acceptable psychometric performance for outcome assessment of children and adolescents with various disorders of the knee.

Preliminary results of calcaneofibular ligament transfer for recurrent peroneal subluxation in children and adolescents.

BACKGROUND: Subluxation of the peroneal tendons over the lateral malleolus is an uncommon condition in both pediatric and adult populations. The primary dislocation is thought to occur with rupture of the superior peroneal retinaculum and may be associated with marginal fractures of the lateral malleolus or a preexisting shallow groove inferiorly. Various operative techniques have been reported earlier, but little data exists regarding surgical management and outcome in a pediatric and adolescent population with open physes. METHODS: A retrospective review of patients presenting to our institution over a 5-year period yielded 9 cases of recurrent peroneal subluxation refractory to nonoperative management in 7 children or adolescents (mean age 12 y). Both traumatic and atraumatic etiologies were represented. All patients failed nonoperative treatment and were treated operatively with calcaneofibular ligament (CFL) transfer to reroute the peroneal tendons underneath the CFL. All patients were observed in follow-up and sent validated outcomes questionnaires, including the Foot and Ankle Ability Measure and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale. RESULTS: Mean clinical follow-up was 20.9 months (range: 12 to 35 mo). At follow-up, all patients had returned to sports and activity and there were no instances of recurrence of subluxation. Complications included 1 postoperative infection and 1 patient requiring revision surgery for fibrosis. Six of 9 ankles (66.6%) returned the outcomes surveys. The average Foot and Ankle Ability Measure activities of daily living score was 90.8 (±4.4) and the sports subscale was 62.5 (±9.3). The mean American Orthopaedic Foot and Ankle Society score was 86 (±3.2). CONCLUSIONS: Peroneal subluxation is an uncommon condition in pediatric and adolescent athletes. CFL transfer over the peroneal tendons should be considered as it provides excellent stability, a low rate of recurrent subluxation, and good functional outcomes without risk of injury to the distal fibular physis which can occur with distal fibular osteotomy or groove deepening procedures. LEVEL OF EVIDENCE: IV (Case series).

Operative fixation of medial humeral epicondyle fracture nonunion in children.

BACKGROUND: There is little information regarding the clinical presentation and/or surgical treatment of symptomatic medial humeral epicondyle nonunions. The purpose of this investigation was to describe the presenting symptoms and evaluate the results of surgical fixation of medial epicondyle nonunions. METHODS: Eight patients with symptomatic medial humeral epicondyle nonunions were evaluated after open reduction and internal fixation of the medial epicondyle. Average age at the time of initial injury was 11.3 years (range: 9.2 to 13.9 y). Outcome was assessed with radiographs and a questionnaire that included 3 self-reported functional outcome tools at a mean of 4.7 years (range: 1.5 to 7.5 y) after the surgery. RESULTS: Common presenting symptoms and signs included medial elbow pain and prominence, pain with lifting weights or throwing, limited range of motion, valgus instability, and ulnar nerve compression. After open reduction and internal fixation, patients reported improved pain score from a mean of 6.2 to 0.5. All patients returned to athletics. Mean postoperative QuickDASH (Disability of Arm, Shoulder, and Hand) score (and SD) was 6.8 ± 11.7; mean Mayo Elbow Performance Score was 85.8 ± 14.6; and mean Timmerman-Andrews Elbow Score was 87.5 ± 10.4. Radiographic union was achieved in all but one patient postoperatively and there were no operative complications. CONCLUSIONS: Open reduction and internal fixation of symptomatic medial humeral epicondyle nonunion results in improved pain and good elbow function. LEVEL OF EVIDENCE: Retrospective Case Series. Therapeutic Level IV.

Fixation of juvenile osteochondritis dissecans lesions of the knee using poly 96L/4D-lactide copolymer bioabsorbable implants.

BACKGROUND: The fixation of juvenile osteochondritis dissecans (OCD) lesions has been described using metal implants, staples, bone pegs, and bioabsorbable implants. Bioabsorbable fixation has potential benefits including not requiring a second surgery for implant removal, no interference on postoperative magnetic resonance imaging (MRI) scans, and a potentially lower incidence of prominent hardware. The possible complications of bioabsorbable fixation include synovitis, loss of fixation owing to noncompressive properties, and sterile abscess formation. The results of bioabsorbable fixation of juvenile OCD lesions of the knee have not been well studied. The purpose of this study was to evaluate the efficacy and safety of a bioabsorbable copolymer fixation in the management of unstable OCD lesions of the knee in adolescents. METHODS: This is a retrospective case series of patients with unstable OCD lesions of the knee that were treated with poly 96L/4D-lactide copolymer bioabsorable implants. Information was gathered through 3 standardized and validated knee-function questionnaires, participants' medical records, plain films, MRIs, and pain level and satisfaction scale questionnaires. RESULTS: Twenty-four knees in 24 patients were evaluated. The mean age at the time of surgery was 14.4 years. The mean follow-up was 39.6 months. The mean International Knee Documentation Committee score at follow-up was 84.9, the mean Lysholm score was 88.0, and the mean Tegner score was 7.9. Plain films at an average of 19.2 months postoperatively revealed interval healing in 9 patients, no significant change in 1 patient, complete healing in 13 patients, and loose bodies with no interval healing in 1 patient. MRIs were obtained postoperatively in 17 knees, with a mean follow-up of 22.4 months. Interval healing was present in 16 of 17 MRIs, consistent with the plain film findings. Twenty-two of 24 patients had good-to-excellent outcomes. CONCLUSION: Poly 96L/4D-lactide copolymer bioabsorable implants seem to be safe and effective for the management of unstable juvenile OCD lesions of the knee. They offer stability for the healing OCD lesions, with minimal reaction from degradation products.