A qualitative analysis of pediatric otolaryngology fellowship websites.

OBJECTIVE: To evaluate the availability and breadth of information provided by program-created pediatric otolaryngology fellowship websites as well as the American Society of Pediatric Otolaryngology (ASPO) program directory. METHODS: Program-created pediatric otolaryngology fellowship websites and the ASPO directory were evaluated for 16 key criteria deemed to be relevant to fellowship applicants. RESULTS: All 36 ACGME-accredited pediatric otolaryngology fellowship programs had websites that were readily available by Google search, and the ASPO program directory contained direct links to 17 (47.2 %) program-created websites. On average, program-created websites fulfilled 6.9 (43.1 %, range 1-11) and the ASPO directory fulfilled 6.9 (43.1 %, range 3-11) of the 16 key criteria. When utilizing both resources, the average increased to 8.3 (51.2 %) - criteria included program description (94.4 %), location description (30.4 %), fellowship director contact information (94.4 %), program coordinator contact information (72.2 %), teaching responsibilities (68.6 %), call responsibilities/schedule (41.7 %), operative volume (80 %), breadth of surgical exposure (94.4 %), research opportunities (72.2 %), research expectations (63.9 %), current fellow(s) (42.9 %), post-fellowship placement (28.6 %), fellow clinic (28.6 %), medical missions/outreach (20 %), and resident coverage (36.1 %). CONCLUSION: Pediatric otolaryngology fellowship websites as well as program-specific data sheets from ASPO lack many key criteria that would otherwise be valuable to applicants. Inclusion of these criteria could help applicants make a more well-informed decision when applying into pediatric otolaryngology fellowship.

A nomogram to predict long-term facial nerve function after vestibular schwannoma resection: a contemporary multi-institutional study.

OBJECTIVE: The objective of this study was to develop a nomogram to predict long-term facial nerve (FN) function after vestibular schwannoma (VS) resection. METHODS: A retrospective cohort study of two tertiary academic skull base referral centers was performed. Consecutive adults > 18 years of age with sporadic unilateral VS who underwent resection between September 2016 and May 2021 were included. FN function in the immediate postoperative period and at the most recent evaluation was measured. RESULTS: A total of 306 patients (mean age 49 years, 63% female) were included, with a mean follow-up of 18 months. The mean maximum tumor diameter was 19 mm (range 1-50 mm), and 80 (26.1%) tumors were > 25 mm. Overall, 85% of patients showed good immediate postoperative FN function (House-Brackmann [HB] grade I or II) and 89% maintained good FN function at > 12 months of follow-up. An intraoperative FN electromyographic (EMG) response ≥ 100 µV to 0.05 mA of stimulation (OR 18.6, p < 0.001) was the strongest predictor of good HB grade in the immediate postoperative period. EMG response ≥ 100 µV (OR 5.70, p < 0.001), tumor size ≤ 25 mm (OR 3.09, p < 0.05), and better immediate postoperative HB grade (OR 1.48, p = 0.005) predicted good long-term FN function on multivariable analysis. A point-of-care nomogram based on these data predicted long-term FN function with a sensitivity of 89% and specificity of 69%. CONCLUSIONS: Better immediate postoperative HB grade, intraoperative FN EMG response ≥ 100 µV, and tumor size ≤ 25 mm strongly predicted good long-term FN function after VS resection. A point-of-care nomogram based on these variables could serve as a useful tool for postoperative counseling and prognosis of long-term FN recovery.

Carpal tunnel syndrome and sleep, a systematic review and meta-analysis.

BACKGROUND: The most common symptom and reason patients seek treatment for carpal tunnel syndrome is lack of sleep. Our purpose was to determine how much sleep-related symptoms of carpal tunnel syndrome improve after carpal tunnel release using validated patient-reported outcome measures (PROMs) and objective sleep data as primary measures of interest. METHODS: A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMed, Cochrane, and ClinicalTrials.gov. Only interventional clinical trials that examined primary outcome measures of interest were included. Patient-reported outcome measures underwent meta-analysis to determine how much scores improved following carpal tunnel release. RESULTS: The Pittsburgh Sleep Quality Index improved significantly after carpal tunnel release, by 4.43 points and 6.02 points at 1-3 and 6-12 months postoperatively, respectively, and continued to improve up to 2 years. Improvement on the Insomnia Severity Index after carpal tunnel release was also significant, with improvement up to 1 year postoperatively, by 8.54 points and 9.05 points at 1-3 and 6-12 months, respectively. Insomnia Severity Index scores improved significantly after splinting as well. CONCLUSIONS: The present meta-analysis determined to what extent patients can expect their sleep to improve after operative and non-operative intervention, as measured by various patient-reported outcome measures that assess sleep. The Pittsburgh Sleep Quality Index and Insomnia Severity Index correlated very well between studies and across hundreds of patients with carpal tunnel syndrome. Data are lacking to define the minimal clinically important difference and assess whether patients achieve a minimal clinically important difference for sleep questionnaires; more information on this topic is needed. LEVEL OF EVIDENCE: III.

Outcomes of Pediatric Proximal Phalanx Base Fractures.

INTRODUCTION: Extra-articular juxtaphyseal fractures of the proximal phalanx are among the most common finger fractures in children. Immobilization of the digit for 3 to 4 weeks after reduction of the fracture is the current standard of care. The purpose of this retrospective study was to evaluate outcomes after intervention among pediatric proximal phalanx base fractures and establish radiographic criteria to guide management. METHODS: A multi-institutional retrospective review of skeletally immature patients treated for proximal phalanx juxtaphyseal fractures between 2002 and 2019 was conducted. Variables collected included Salter-Harris classification; initial, postreduction, early follow-up, and final angulation and displacement on the posterior-anterior and lateral radiographs; clinical rotational deformity at final follow-up; and method of treatment. Exclusion criteria included less than 3 weeks of follow-up; Salter-Harris III, IV, and V fractures; inadequate medical record details; and missing radiographs. RESULTS: Six hundred thirty-four fractures meeting the inclusion criteria were categorized into no reduction, closed reduction (CR), and surgical (OP) groups. Only CR and OP groups saw large decreases in angulation by 11.8° CR (95% confidence interval, 10.1 to 13.6) and 19.0° OP (95% confidence interval, 8.7 to 29.3). Closed reduction patients had a mean coronal angulation value of 6.1° at post-reduction, which was maintained with immobilization to 5.8° at final follow-up. At final follow-up, scissoring was noted, three in the no reduction and three in the CR group for an overall 0.93% rotational malalignment rate. DISCUSSION: Extra-articular proximal phalanx juxtaphyseal fractures rarely require surgical management and can typically be treated with or without CR, based on the degree of deformity, in the emergency department or clinical setting. Low rates of documented sequelae after nonsurgical management were seen in this cohort, allowing for establishment of treatment parameters that can result in clinically insignificant angular and rotational deformity. LEVEL OF EVIDENCE: Therapeutic IV.

How do humans learn about the reliability of automation?

In a range of settings, human operators make decisions with the assistance of automation, the reliability of which can vary depending upon context. Currently, the processes by which humans track the level of reliability of automation are unclear. In the current study, we test cognitive models of learning that could potentially explain how humans track automation reliability. We fitted several alternative cognitive models to a series of participants' judgements of automation reliability observed in a maritime classification task in which participants were provided with automated advice. We examined three experiments including eight between-subjects conditions and 240 participants in total. Our results favoured a two-kernel delta-rule model of learning, which specifies that humans learn by prediction error, and respond according to a learning rate that is sensitive to environmental volatility. However, we found substantial heterogeneity in learning processes across participants. These outcomes speak to the learning processes underlying how humans estimate automation reliability and thus have implications for practice.

Clinically Significant Treatment Delay in Pediatric Scaphoid Fractures.

PURPOSE: Pediatric scaphoid fractures present to treatment in a delayed manner 8% to 29% of the time. The indications for cast immobilization in this population are not clear. The definition of a clinically important treatment delay is based only on anecdotal reports. Successful treatment with a cast may be more desirable than surgical intervention. However, it remains unclear what clinical and radiographic factors may predict success with casting. METHODS: A retrospective analysis of all scaphoid fractures treated at a single pediatric hospital was performed to identify fracture characteristics, the presence of cystic change, treatment method, and healing rate. A cut-point analysis was performed to determine the number of days of treatment delay, predictive of casting failure. Kaplan-Meier assessments were performed to determine the differences in time in cast. Characteristics of the delayed group were described and stratified by treatment success or failure. RESULTS: After review, 254 patients met the inclusion criteria. Cut-point analysis determined that a presentation delay of ≥21 days was associated with failure to unite with casting. The median time in the cast for the acute and delayed groups was not significantly different. The casting union rate of delayed fractures was less than acute fractures (75.0% vs 97.0%). CONCLUSIONS: Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure; however, the union rate remains high with comparable time in cast. Cast immobilization for scaphoid fractures presenting 21 days or more after injury is a reasonable option. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Establishing the Role of Inflammatory Markers in the Diagnosis and Treatment of Acute Hand Infections in the Pediatric Population.

INTRODUCTION: Distinguishing the severity of the diagnosis and an appropriate treatment plan in pediatric hand infections can be complex due to the variable amount of information available at the presentation. Inflammatory blood markers, including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are reported to aid in determining the severity of infection and response to treatment in adult hand infections. The purpose of this study was to identify the relevance of inflammatory marker levels in pediatric patients with hand and wrist infections and to determine their utility in diagnosis and treatment. METHODS: This multicenter, retrospective, cohort study included patients aged 0 to 18 who received treatment for an acute hand or wrist infection between 2009 and 2020. Data collected included demographics, time to presentation, diagnosis, inflammatory markers, culture results, antibiotic treatment, and surgical treatment. Infections were categorized as deep (osteomyelitis, tenosynovitis, abscess) and superficial (paronychia, felon, cellulitis). Exclusion criteria included: patients above 18 years of age, chronic infection, open fractures, and absence of any documented inflammatory markers. Statistically, t tests were used to compare mean differences in inflammatory markers between patients who did and did not receive pretreatment antibiotics and between patients who had superficial versus deep hand infections. RESULTS: A total of 123 patients met the inclusion criteria. Pretreatment with antibiotics before definitive management was not significantly associated with differences in laboratory markers compared with patients not pretreated with antibiotics. Deep hand infections had inflammatory markers similar to superficial infections. Patients with deep hand infections required a bedside or operative procedure 78.9% of the time compared with superficial infections (21.2%) ( P <0.001). Patients with an isolated methicillin-resistant Staphylococcus aureus infection had inflammatory marker values that were not significantly different from patients infected with all other microbes. CONCLUSIONS: Inflammatory markers were not significantly different between patients who received pretreatment with antibiotics and those who did not. While deep infections were often treated with bedside or surgical procedures, the inflammatory marker values were similar to those of superficial infections. The same held true for patients infected with culture-positive, isolated methicillin-resistant Staphylococcus aureus bacteria. Consequently, inflammatory markers may be useful to identify the presence of infection and monitor the response to treatment, they did not aid in determining the specific type of infection or selection of a treatment plan. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Hypoglossal Nerve Stimulation Therapy Outcomes in Apnea- Versus Hypopnea-Predominant Patients.

OBJECTIVES: The influence of apnea- and hypopnea-predominance on hypoglossal nerve stimulation therapy outcomes (HGNS) is still poorly defined. We assessed the significance of apnea- and hypopnea-predominance in HGNS outcomes. STUDY DESIGN: Case series with chart review. SETTING: Single-institution tertiary care center. METHODS: A total of 216 subjects were included, all of which had undergone drug-induced sleep endoscopy (DISE) and HGNS implantation. Demographic and polysomnographic data were collected. The 4% apnea-hypopnea criteria were used to calculate apnea-hypopnea index (AHI). Central apneas were omitted. Univariate logistic and linear regression were used to study the association between these data and apnea-predominance and hypopnea-predominance. Kruskal-Wallis rank sum test was used to compare medians between groups for DISE collapse patterns. RESULTS: Sixty-three patients were apnea-predominant, and 153 patients were hypopnea-predominant. These 2 groups were similar demographically (p > .20). There was no significant difference in HGNS outcomes between the groups assessed using Sher20 criteria at the 1-year mark using all-night, single-setting polysomnography or home sleep studies. Apnea index (AI)/AHI and reduction in AHI from preoperative to titration were significantly associated (p = .046). The median preoperative hypopnea index was significantly lower (p = .033) in subjects with no oropharyngeal collapse than patients with partial or complete oropharyngeal collapse. There were no significant relationships between AI/AHI and the different degrees of collapse at the velopharynx, oropharynx, tongue base, or epiglottis. CONCLUSIONS: In line with CPAP, tonsillectomy, and mandibular advancement therapy studies, we found there was largely no significant difference in DISE anatomy or in HGNS treatment outcomes between apnea- and hypopnea-predominant individuals.

Outcomes After Transcutaneous Bone-Conduction Implantation in Adults and Children.

OBJECTIVE: To evaluate clinical and audiometric outcomes of adult and pediatric patients implanted with a semi-implantable transcutaneous active bone-conduction implant. STUDY DESIGN: Retrospective chart review. SETTING: Two tertiary referral centers. PATIENTS: Subjects implanted with the semi-implantable transcutaneous active bone-conduction implant called BoneBridge. INTERVENTION: Implantation of the BoneBridge and audiometric evaluations. MAIN OUTCOME MEASURES: Audiometric, clinical, and surgical outcomes as well as complications. RESULTS: Forty-two adults and 20 children were implanted for conductive or mixed hearing loss as well as single-sided deafness. Implantation significantly improved mean air-conduction pure-tone average from 72.8 ± 22.3 to 35 ± 9 dB in adults and from 65.7 ± 24.3 to 19.6 ± 8.2 dB in children (both p < 0.001). Word recognition score improved from 63.7 ± 38.8% to 85.6 ± 10.6% in adults and 57.8 ± 38% to 89.3 ± 10.1% in children (both p < 0.05). The rate of revision surgery was 11.3%, with four patients (6.5%) undergoing removal for device-related complications, two (3.2%) for complications associated with implantation, and one (1.6%) for device failure secondary to external trauma. CONCLUSIONS: In a large retrospective series consisting of both pediatric and adult patients, implantation with a transcutaneous active bone-conduction implant was found to be a reliable aural rehabilitation option for a variety of hearing loss etiologies.

Therapeutic targeting of prenatal pontine ID1 signaling in diffuse midline glioma.

BACKGROUND: Diffuse midline gliomas (DMG) are highly invasive brain tumors with rare survival beyond two years past diagnosis and limited understanding of the mechanism behind tumor invasion. Previous reports demonstrate upregulation of the protein ID1 with H3K27M and ACVR1 mutations in DMG, but this has not been confirmed in human tumors or therapeutically targeted. METHODS: Whole exome, RNA, and ChIP-sequencing was performed on the ID1 locus in DMG tissue. Scratch-assay migration and transwell invasion assays of cultured cells were performed following shRNA-mediated ID1-knockdown. In vitro and in vivo genetic and pharmacologic [cannabidiol (CBD)] inhibition of ID1 on DMG tumor growth was assessed. Patient-reported CBD dosing information was collected. RESULTS: Increased ID1 expression in human DMG and in utero electroporation (IUE) murine tumors is associated with H3K27M mutation and brainstem location. ChIP-sequencing indicates ID1 regulatory regions are epigenetically active in human H3K27M-DMG tumors and prenatal pontine cells. Higher ID1-expressing astrocyte-like DMG cells share a transcriptional program with oligo/astrocyte-precursor cells (OAPCs) from the developing human brain and demonstrate upregulation of the migration regulatory protein SPARCL1. Genetic and pharmacologic (CBD) suppression of ID1 decreases tumor cell invasion/migration and tumor growth in H3.3/H3.1K27M PPK-IUE and human DIPGXIIIP* in vivo models of pHGG. The effect of CBD on cell proliferation appears to be non-ID1 mediated. Finally, we collected patient-reported CBD treatment data, finding that a clinical trial to standardize dosing may be beneficial. CONCLUSIONS: H3K27M-mediated re-activation of ID1 in DMG results in a SPARCL1+ migratory transcriptional program that is therapeutically targetable with CBD.

Discovery of RMC-5552, a Selective Bi-Steric Inhibitor of mTORC1, for the Treatment of mTORC1-Activated Tumors.

Hyperactivation of mTOR kinase by mutations in the PI3K/mTOR pathway or by crosstalk with other mutant cancer drivers, such as RAS, is a feature of many tumors. Multiple allosteric inhibitors of mTORC1 and orthosteric dual inhibitors of mTORC1 and mTORC2 have been developed as anticancer drugs, but their clinical utility has been limited. To address these limitations, we have developed a novel class of "bi-steric inhibitors" that interact with both the orthosteric and the allosteric binding sites in order to deepen the inhibition of mTORC1 while also preserving selectivity for mTORC1 over mTORC2. In this report, we describe the discovery and preclinical profile of the development candidate RMC-5552 and the in vivo preclinical tool compound RMC-6272. We also present evidence that selective inhibition of mTORC1 in combination with covalent inhibition of KRASG12C shows increased antitumor activity in a preclinical model of KRASG12C mutant NSCLC that exhibits resistance to KRASG12C inhibitor monotherapy.

Recruiting, Supporting and Retaining Diversity in Hand Surgery.

All surgical fields that lead to a career in Hand Surgery have a stark lack of diversity of sex/gender and race, at every level of the workforce, from trainees to practicing physicians. Despite consistent statistics in publications on lack of diversity in surgical fields, a guide to effective recruitment and retention is lacking. Although we recognize that a strategy cannot be applied in all practices, this article provides actionable items to consider in the commitment and work toward a more just and equitable practice of Hand Surgery.

Pediatric Hammertoe Recurrence-Considerations for Revision Surgical Technique and Hypoperfusion Management: A Case Report.

CASE: A 7-year-old girl presented with a recurrent hammertoe deformity causing pain with shoe wearing after a prior corrective surgery. Surgical revision required a unique approach that included a staged corrective osteotomy of the proximal phalanx because of hypoperfusion management and the application of a rotational skin flap previously described for camptodactyly correction in the hand to avoid harvesting a skin graft. CONCLUSION: Revision surgery for recurrent pediatric hammertoe deformity requires a heightened awareness of the risk for toe hypoperfusion and subsequent wound closure challenges.

Sentinel node mapping and biopsy in ectopic axillary breast cancer: A case report and review of the literature.

Sentinel lymph node mapping in patients with axillary breast carcinoma is technically challenging and poorly described in the literature. We report a patient with primary ectopic breast carcinoma of the axilla in whom concurrent peri-tumoral and intra-tumoral injection of radionuclide tracer allowed for identification and biopsy of sentinel lymph nodes.

Near-Peer Teaching in Conjunction with Flipped Classroom to Teach First-Year Medical Students Basic Surgical Skills.

Background: There is increasing evidence that students are completing medical school with insufficient surgical education. Near-peer tutoring and flipped classroom formatting may be used to enhance learning while simultaneously relieving faculty burden of teaching. Here, we qualitatively evaluate a 3-month course that integrates the use of near-peer teaching and flipped classroom formatting, with the goal of increasing first-year medical students' self-perceived confidence in performing basic sutures and knot-ties as well as interest in surgery. Methods: Twenty-one first-year medical students participated in a suturing and knot-tying course led by senior medical students. The course consisted of 2-h sessions held every 2 weeks for a total of five sessions. Students were sent publicly available videos prior to each session by which to learn the upcoming techniques and received live feedback from instructors during sessions. Questionnaires were completed pre-course and post-course. Results: Compared to pre-course ratings, post-course ratings of self-perceived confidence to perform various knot-ties and sutures all increased significantly (p < 0.05). All students stated that the course strengthened their desire to pursue a career in surgery. Student feedback of the course was overall positive. Conclusions: Near-peer teaching can be used in conjunction with flipped classroom to increase first-year medical students' self-perceived confidence in surgical suturing and knot-tying as well as interest in surgery. This curriculum may serve as an outline for student-led courses at other institutions.

Multi-institutional analysis of central nervous system germ cell tumors in patients with Down syndrome.

PURPOSE: Primary germ cell tumors (GCTs) are the most common central nervous system (CNS) neoplasm in patients with Down syndrome (DS). However, a standard of care has not been established due to paucity of data. METHODS: A retrospective multi-institutional analysis was conducted, in addition to a comprehensive review of the literature. RESULTS: Ten patients from six institutions (five USA, one Brazil) were identified, in addition to 31 patients in the literature from 1975 to 2021. Of the 41 total patients (mean age 9.9 years; 61% male), 16 (39%) had non-germinomatous germ cell tumors (NGGCTs), 16 (39%) had pure germinomas, and eight (19.5%) had teratomas. Basal ganglia was the most common tumor location (n = 13; 31.7%), followed by posterior fossa (n = 7; 17%). Nine patients (22%) experienced disease relapse or progression, of which four died from tumor progression (one germinoma, three teratomas). Sixteen patients (39%) experienced treatment-related complications, of which eight (50%) died (five germinomas, three NGGCTs). Of the germinoma patients, two died from chemotherapy-related sepsis, one from postsurgery cardiopulmonary failure, one from pneumonia, and one from moyamoya following radiation therapy (RT). Of the NGGCT patients, one died from chemotherapy-related sepsis, one from postsurgical infection, and one from pneumonia following surgery/chemotherapy/RT. Three-year overall survival was 66% for all histological types: 62% germinomas, 79% for NGGCTs, and 53% for teratomas. CONCLUSION: Patients with DS treated for CNS GCTs are at an increased risk of treatment-related adverse events. A different therapeutic approach may need to be considered to mitigate treatment-related complications and long-term neurocognitive sequelae.

The Frequency and Outcomes of Nerve Palsies in Operatively Treated Supracondylar Humerus Fractures.

BACKGROUND: A high index of suspicion for nerve palsy is essential in the setting of a displaced supracondylar humerus fracture (SCHF) with careful attention to the examination. We hypothesize that nerve injuries are more prevalent in higher energy type III and flexion SCHFs compared with type II fractures. METHODS: A retrospective review was performed of 1085 operatively treated SCHFs in pediatric patients, aged 0 to 14 years, between January 1, 2015 and December 31, 2018. There were 979 patients eligible for analysis. Exclusion criteria included follow-up <3 weeks, polytrauma, pathologic fracture, and prior fracture of the ipsilateral elbow. RESULTS: The overall rate of nerve injury was 10.6% (104/979). A significant difference in the rate of nerve palsy was identified between fracture types: 0.9% type II, 19.3% type III, and 10.7% flexion type SCHFs ( P <0.001). Median nerve palsy was the most common (n=65). An increased rate of ulnar nerve palsy was observed in flexion type SCHFs. The rate of nerve palsy was higher in the medial pin group (14.9%, P =0.035) but no significant association with iatrogenic ulnar nerve palsy was present. In type III and flexion SCHFs, operative time >60 minutes ( P =0.023) and the need for open reduction ( P =0.012) were significantly associated with postoperative nerve palsy. Referral to therapy was required in 30.8% of patients with a nerve palsy compared with 7.9% of patients without ( P <0.001). CONCLUSION: Longer operative times, need for open reduction, and significantly higher rates of nerve palsy among type III and flexion SCHFs are best explained by the unstable nature of the fracture and greater degree of soft tissue trauma. Given prolonged duration of follow-up and more frequent need for therapy demonstrated in patients with a nerve palsy, these data can be used to improve counseling for families and patients after displaced SCHF. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Ulnar Epiphysiodesis: Success of the Index Procedure.

INTRODUCTION: Premature radial physeal closure is a relatively rare occurrence in children. When isolated growth arrest of the radius with continued ulnar growth occurs, the resulting ulnar positive deformity leads to altered wrist mechanics and pain. Timely epiphysiodesis of the distal ulna with and without ulnar shortening osteotomy can address these issues, but continued ulnar overgrowth is a possible complication. We seek to evaluate the success rate of the primary epiphysiodesis of the ulna and associated clinical outcomes. METHODS: A chart review was conducted at 2 children's hospitals from 2008 to 2019. Patients between the ages of 6 and 18 years old, with premature distal radius physeal closure, with or without positive ulnar variance, and >2 months follow-up were included. We evaluated the following characteristics for each patient: demographics, initial cause of premature radial physeal closure, ulnar variance, additional procedures performed during epiphysiodesis, preoperative and postoperative pain, range of motion, instability. Summary statistics were conducted and expressed as proportions, medians and means. A paired t test evaluated change in ulnar variance for those who had an ulnar shortening osteotomy performed. RESULTS: Thirty-one wrists among 30 patients were identified, and the median age at the time of surgery was 12.2 years (interquartile range: 3.4). Ulnar shortening osteotomies were performed in 53.1% of cases and distal radius osteotomy in 15.6%. Bone graft was utilized in 25.8% of the epiphysiodesis procedures. There were 2 failures of primary epiphysiodesis indicating an index success rate of 93.7%. The average ulnar variance correction was 3.1 mm (95% confidence interval: 1.9, 4.4). The mean physeal time to closure was 134 days. Preoperative symptoms were resolved for 90.6% cases at final follow-up. CONCLUSION: Ulnar epiphysiodesis successfully terminates ulnar physeal growth in 93.7% of cases. Preoperative symptoms were completely resolved with a median physeal closure of just over 4 months. Ulnar variance was corrected on average by 4.1 mm when a radial or ulnar shortening osteotomy was performed at the time of epiphysiodesis. LEVEL OF EVIDENCE: Level IV-case series.

Tuberculosis care quality in urban Nigeria: A cross-sectional study of adherence to screening and treatment initiation guidelines in multi-cadre networks of private health service providers.

Nigeria has a high burden of tuberculosis (TB) and low case detection rates. Nigeria's large private health sector footprint represents an untapped resource for combating the disease. To examine the quality of private sector contributions to TB, the USAID-funded Sustaining Health Outcomes through the Private Sector (SHOPS) Plus program evaluated adherence to national standards for management of presumptive and confirmed TB among the clinical facilities, laboratories, pharmacies, and drug shops it trained to deliver TB services. The study used a standardized patient (SP) survey methodology to measure case management protocol adherence among 837 private and 206 public providers in urban Lagos and Kano. It examined two different scenarios: a "textbook" case of presumptive TB and a treatment initiation case where SPs presented as referred patients with confirmed TB diagnoses. Private sector results were benchmarked against public sector results. A bottleneck analysis examined protocol adherence departures at key points along the case management sequence that providers were trained to follow. Except for laboratories, few providers met the criteria for fully correct management of presumptive TB, though more than 70% of providers correctly engaged in TB screening. In the treatment initiation case 18% of clinical providers demonstrated fully correct case management. Private and public providers' adherence was not significantly different. Bottleneck analysis revealed that the most common deviations from correct management were failure to initiate sputum collection for presumptive patients and failure to conduct sufficiently thorough treatment initiation counseling for confirmed patients. This study found the quality of private providers' TB case management to be comparable to public providers in Nigeria, as well as to providers in other high burden countries. Findings support continued efforts to include private providers in Nigeria's national TB program. Though most providers fell short of desired quality, the bottleneck analysis points to specific issues that TB stakeholders can feasibly address with system- and provider-level interventions.