Reliability of a Modified Watson-Jones Classification for Tibial Tubercle Fractures in Children.

OBJECTIVES: The first case report describing a pediatric fracture of the tibial tubercle was published in 1852 in the Medical Times and Gazette, a Journal of Medical Science, literature, criticism, and news. A century later, in 1955, Sir Watson-Jones introduced the first classification system for this fracture. Despite the existence of several classification systems for pediatric tibial tubercle fractures in the medical literature, a crucial aspect of their validation-reliability and reproducibility-has not yet been systematically evaluated. METHODS: In this study, a modified Watson-Jones (mWJ) classification system of tibial tubercle fractures in children was assessed for intraobserver and interobserver variability. Using the mWJ classification, 3 board-certified pediatric orthopaedic surgeons and 3 orthopaedic surgery residents, classified thirty tibial tubercle fractures based on anteroposterior and lateral radiographs on 2 separate occasions in a 2-week duration. Further comparison was made to evaluate the impact of advanced imaging, specifically computed tomography or magnetic resonance imaging, on diagnostic reliability and reproducibility. RESULTS: The study found substantial intraobserver reliability of the mWJ classification based on radiographs alone, with a Cohen weighted kappa (κw) coefficient of 0.733. When advanced imaging was utilized, the reliability of the classification improved to κw = 0.783. Similarly, interobserver reliability demonstrated substantial consistency among observers when using radiographs alone (κw = 0.69) and improved agreement with advanced imaging (κw = 0.75). Notably, there was no significant difference in reliability scores between senior-level attendings and residents when analyzed as separate groups. CONCLUSION: Fracture classification systems are clinically relevant tools that help organize and transfer knowledge efficiently, provide treatment guidance, propose prognostic expectations, and improve communication in academic literature. The present study demonstrated substantial reproducibility of an mWJ fracture classification system both between and within individual surgeon raters. LEVEL OF EVIDENCE: Level III-diagnostic.

Borrelia burgdorferi-A Bacterium Worthy of Consideration in Culture-Negative Prosthetic Joint Infection.

A 68-year-old woman presented to the orthopaedic office with 2 weeks of atraumatic right prosthetic knee pain and swelling. She previously lived pain free and fully functional after a total knee arthroplasty 8 years ago. Initial radiographs showed a small joint effusion, and serum inflammatory markers were elevated. Arthrocentesis yielded 12ccs of culture-negative cloudy serous fluid containing 3,270 white blood cells, 92% polymorphonuclear neutrophils. The patient underwent prosthesis explant, antibiotic spacer placement, and began empiric IV antibiotic therapy as stage one of a planned two-stage revision. Intraoperative tissue cultures were negative, and the postoperative plan was to continue IV vancomycin for a total of 6 weeks. Two weeks post-op, serum Lyme antibody testing returned positive. The patient was switched to doxycycline and ceftriaxone for a total duration of 4 weeks, followed by a successful second-stage revision and remains asymptomatic after 1 year. Five cases of culture-negative prosthetic joint infections caused by the spirochete, Borrelia burgdorferi, have been reported in the orthopaedic literature.1-4 We present a sixth case, occurring in a 68-year-old woman in Northwestern Pennsylvania, 8 years after a primary right total knee arthroplasty.

K-wire Versus Screw Fixation in Displaced Lateral Condyle Fractures of the Humerus in Children: A Multicenter Study of 762 Fractures.

INTRODUCTION: Lateral humeral condyle fractures account for 12% to 20% of all distal humerus fractures in the pediatric population. When surgery is indicated, fixation may be achieved with either Kirschner-wires or screws. The literature comparing the outcomes of these 2 different fixation methods is currently limited. The purpose of this study is to compare both the complication and union rates of these 2 forms of operative treatment in a multicenter cohort of children with lateral humeral condyle fractures. METHODS: This retrospective study was performed across 6 different institutions. Data were retrospectively collected preoperatively and 6 weeks, 3, 6, and 12 months postoperatively. Patients were divided into 2 cohorts based on the type of initial treatment: K-wire fixation and screw fixation. Statistical comparisons between these 2 cohorts were performed with an alpha of 0.05. RESULTS: There were 762 patients included in this study, 72.6% (n=553) of which were treated with K-wire fixation. The mean duration of immobilization was 5 weeks in both cohorts, and most patients in this study demonstrated radiographic healing by 11 weeks postoperatively, regardless of treatment method. Similar reoperation rates were seen among those treated with K-wires and screws (5.6% vs. 4.3%, P =0.473). Elbow stiffness requiring further intervention with physical therapy was significantly more common in those treated with K-wires compared with children treated with screws (21.2% vs. 13.9%, P =0.023) as was superficial skin infection (3.8% vs. 0%, P =0.002), but there was no significant difference in nonunion rates between the two groups (2.4% vs. 1.3%, P =1.000). CONCLUSION: We found similar success rates between K-wire and screw fixation in this patient population. Contrary to previous studies, we did not find evidence that treatment with screw fixation decreases the likelihood of experiencing nonunion. However, given the unique complications associated with K-wire fixation, such as elbow stiffness and superficial skin infection, the treatment with screw fixation remains a reasonable alternative to K-wire fixation in these patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Transphyseal Distal Humeral Fractures: A 13-Times-Greater Risk of Non-Accidental Trauma Compared with Supracondylar Humeral Fractures in Children Less Than 3 Years of Age.

BACKGROUND: The transphyseal distal humeral fracture has been well described as a concerning fracture pattern for non-accidental trauma (NAT) in young pediatric patients. Because of the infrequent presentation of this fracture, the association historically has been anecdotal. The purpose of this study was to determine and compare the incidence of NAT among displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in children <3 years of age. METHODS: All displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in patients <3 years of age admitted because of injury during an 18-year period were reviewed retrospectively for inclusion. Patient demographics, mechanisms of injury, results of child protective services investigations, and medical records were reviewed. A chi-square test was utilized to analyze significance for categorical data; p values of <0.05 were defined as significant. RESULTS: The charts of 23 transphyseal distal humeral and 205 supracondylar humeral fracture cases were reviewed. NAT was the cause for 6 (26%) of the displaced transphyseal distal humeral fractures and 4 (2%) of the displaced supracondylar fractures. The associated risk of NAT was 13 times greater (95% confidence interval [CI], 4.05 to 43.7; p < 0.001) for children admitted for operative management of displaced transphyseal distal humeral fractures compared with those admitted for operative management of displaced supracondylar humeral fractures. CONCLUSIONS: The classic 1980 paper by DeLee et al. sensitized the orthopaedic community to the relationship between transphyseal distal humeral fractures and child abuse. Our study is the first, to our knowledge, to bring statistical weight to this association. We found a 13-times-greater risk of NAT for children <3 years of age who sustain a displaced transphyseal distal humeral fracture compared with a displaced supracondylar fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Health-related Quality of Life of Older Women Religious: Negative Influence of Frailty.

The purpose of the current study was to describe the health-related quality of life (HRQOL) of older women religious (WR) and examine variables that may influence HRQOL.The sample consisted of WR, 65 years or older, living in the Cleveland Catholic Diocese. The participants completed a medical history, body-mass index (BMI) and blood pressure measurement, and self-report measures of HRQOL, frailty, social support, resilience, and depression. The study sample was composed of 108 older WR with a mean age of 75.6 (range 65-93 years). The women reported high levels of daily functioning, resilience, and social support, with low levels of depression. WR describe a relatively high level of HRQOL. Frailty was an independent negative predictor of HRQOL in all subscales except general health. Resilience and fear of falling had significant effects on several HRQOL subscales.

Health and Daily Functioning of Older Women Religious.

OBJECTIVES: Women religious in the United States are aging as a population. These women live in a communal setting, eat from the same kitchen, are nulliparous, and have similar access to healthcare. The purpose of this study was to examine the general health and health practices of a modern sample of older women religious. DESIGN: Cross-sectional descriptive study. SETTING: Cleveland Catholic Diocese, Cleveland, Ohio. PARTICIPANTS: Older women religious (n = 108), 65 years or older, living independently within the Cleveland Catholic Diocese who could participate in a study interview, undergo a morphometric examination, and complete several questionnaires in English. MEASUREMENTS: Study participants completed a study interview in which their demographic information, medical history, body mass index (BMI), and blood pressure were obtained. Participants completed several questionnaires including the Tilburg Frailty Indicator, Falls Efficacy Scale-International, Lawton Instrumental Activities of Daily Living Scale, Geriatric Depression Scale-Short Form, and the HbL Medication Risk Questionnaire. RESULTS: The women in our sample were all white with a mean age of 75.6 years (range = 65-93 y). The vast majority (n = 104 [96%]) had at least a bachelor's degree. Prevalence for chronic diseases was notable for cataracts (60%), hypertension (60%), thyroid disorders (30%), osteoporosis (17%), and diabetes (7%). Nearly half of the sample (n = 48 [44%]) met BMI criteria for obesity, and another 39 women (36%) were overweight. Most women participated in yearly dental examinations (84.5%), eye examinations (79.4%), mammography (84.5%), and pneumovax vaccination (80.4%). Just over half of the women had the recommended colonoscopy (58.8%) and bone density (56.7%) screenings. Twenty women (19%) reported significant frailty, and 38 (35%) reported a significant fear of falling. The majority (80%) would benefit from a discussion about their medications. CONCLUSION: Older women religious experience health issues that could benefit from targeted preventive health education and screening. J Am Geriatr Soc 67:1866-1870, 2019.

A nurse-managed advocacy clinic in a Hispanic senior center: using a concept-based clinical practice site to enhance nursing education.

A nurse-managed advocacy clinic for vulnerable, low-income, non-English-speaking elderly Hispanic men and women was developed at a neighborhood community center as a clinical site for senior baccalaureate nursing students. In the clinic's 5 years of operation, nursing students and faculty provided health screenings and education as well as referrals to primary care providers, landlords, pharmacies, and social workers. In doing so, nursing students were introduced to the concept of patient advocacy in a real-world experiential clinical setting, providing an effective link between theoretical knowledge discussed in the classroom and professional nursing practice.

Molecular detection of an atypical, highly resistant, clonal Pseudomonas aeruginosa isolate in cystic fibrosis patients.

BACKGROUND: The identification of Pseudomonas aeruginosa (P. aeruginosa) isolates in sputum from cystic fibrosis (CF) patients can be challenging due to the multitude of phenotypic changes isolates undergo during adaptation to the microenvironment of the CF lung. METHODS: We report the occurrence of shared P. aeruginosa isolates which failed identification by phenotypic methodologies and required species specific polymerase chain reaction. P. aeruginosa isolates were genotyped by macrorestriction analysis. RESULTS: Analysis of atypical isolates revealed one clonal P. aeruginosa isolate and three smaller clusters. In contrast molecular typing of phenotypically characteristic P. aeruginosa isolates revealed only small clusters. Despite exhibiting higher levels of antimicrobial resistance, acquisition of atypical strains was not associated with significant changes in clinical decline. CONCLUSIONS: Our experience highlights the importance of accurate identification of bacterial isolates in CF lung disease to detect clonal spread of atypical isolates.

The stochastic modelling of kleptoparasitism using a Markov process.

Kleptoparasitism, the stealing of food items from other animals, is a common behaviour observed across a huge variety of species, and has been subjected to significant modelling effort. Most such modelling has been deterministic, effectively assuming an infinite population, although recently some important stochastic models have been developed. In particular the model of Yates and Broom (Stochastic models of kleptoparasitism. J. Theor. Biol. 248 (2007), 480-489) introduced a stochastic version following the original model of Ruxton and Moody (The ideal free distribution with kleptoparasitism. J. Theor. Biol. 186 (1997), 449-458), and whilst they generated results of interest, they did not solve the model explicitly. In this paper, building on methods used already by van der Meer and Smallegange (A stochastic version of the Beddington-DeAngelis functional response: Modelling interference for a finite number of predators. J. Animal Ecol. 78 (2009) 134-142) we give an exact solution to the distribution of the population over the states for the Yates and Broom model and investigate the effects of some key biological parameters, especially for small populations where stochastic models can be expected to differ most from their deterministic equivalents.

Evaluation of in vitro virulence characteristics of the genus Pandoraea in lung epithelial cells.

Pandoraea species are emerging opportunistic pathogens capable of causing chronic lung infections in cystic fibrosis patients. This study examined the interactions of 17 Pandoraea isolates from the five identified species (Pandoraea apista, Pandoraea norimbergensis, Pandoraea pulmonicula, Pandoraea sputorum and Pandoraea pnomenusa) plus two Pandoraea genomospecies isolates with lung epithelial cells and their ability to form biofilms in vitro. Only three isolates showed an ability to invade A549 lung epithelial cells, and only one isolate was able to form biofilms. In contrast, all isolates triggered a pronounced pro-inflammatory response, with elevation of both interleukin (IL)-6 (two- to 19-fold) and IL-8 (10- to 50-fold) above that observed for a control strain of Escherichia coli. This property is likely to be a major factor in the pathogenesis of the genus.

A novel Helcococcus-like organism causing endocarditis in an injecting drug user.

A case is presented of infective endocarditis caused by a previously undescribed Helcococcus-like organism, in a patient with human immunodeficiency virus infection. The organism, which could not be identified phenotypically in the routine laboratory, was identified using partial 16S rRNA gene sequencing.

Epidemiology of Burkholderia cepacia complex species recovered from cystic fibrosis patients: issues related to patient segregation.

Studies of the prevalence of Burkholderia cepacia complex species amongst cystic fibrosis (CF) patients in different geographical regions, and the association between cross-infection and putative transmissibility markers, will further our understanding of these organisms and help to address infection-control issues. In this study, B. cepacia complex isolates from CF patients in different regions of Europe were analysed. Isolates were examined for B. cepacia complex species and putative transmissibility markers [cable pilin subunit gene (cblA) and the B. cepacia epidemic strain marker (BCESM)]. Sporadic and cross-infective strains were identified by random amplification of polymorphic DNA (RAPD). In total, 79% of patients were infected with Burkholderia cenocepacia (genomovar III), 18% with Burkholderia multivorans (genomovar II) and less than 5% of patients with B. cepacia (genomovar I), Burkholderia stabilis (genomovar IV) or Burkholderia vietnamiensis (genomovar V). The cblA and BCESM transmissibility markers were only detected in strains of B. cenocepacia. The BCESM was a more sensitive marker for transmissible B. cenocepacia strains than cblA, although sporadic B. cenocepacia strains containing the BCESM, but lacking cblA, were also observed. Furthermore, clusters of cross-infection with transmissibility marker-negative strains of B. multivorans were identified. In conclusion, B. cenocepacia was the greatest cause of cross-infection, and the most widely distributed B. cepacia complex species, within these CF populations. However, cross-infection was not exclusive to B. cenocepacia and cblA and the BCESM were not absolute markers for transmissible B. cenocepacia, or other B. cepacia complex strains. It is therefore suggested that CF centres cohort patients based on the presence or absence of B. cepacia complex infection and not on the basis of transmissibility marker-positive B. cenocepacia as previously suggested.

Development of a diagnostic PCR assay that targets a heat-shock protein gene (groES) for detection of Pseudomonas spp. in cystic fibrosis patients.

Laboratory detection of Pseudomonas spp., in particular Pseudomonas aeruginosa, remains an important assay in the management of patients with cystic fibrosis (CF). As the groES and groEL genes of P. aeruginosa have now been cloned and their nucleotide sequences determined, the aim of this study was to develop a novel PCR assay for the detection of Pseudomonas spp. from patients with CF by employing conserved primer regions of the groE heat-shock protein domain gene. A PCR assay was designed that targeted a 536 bp region of the groE gene to detect Pseudomonas spp. PCR amplification of genomic DNA from extracted organisms generated an amplicon of the expected size (approx. 536 bp) for all P. aeruginosa (n = 60), Pseudomonas putida, Pseudomonas fluorescens and Pseudomonas stutzeri isolates examined, but did not produce a positive amplicon for several other genera and species that are commonly isolated from the sputum of CF patients. RFLP analysis of the amplicons of all P. aeruginosa isolates demonstrated a single RFLP type that consisted of three bands at approximately 80, 190 and 250 bp; direct sequencing of the amplicons demonstrated the presence of a single sequence type, indicating the highly conserved nature of this region. In addition, the assay successfully produced a positive signal from primary non-selective plates of three known P. aeruginosa culture-positive CF patients, but was unable to generate a signal in a further six CF patients who had no history of infection with P. aeruginosa or other Pseudomonas spp. This assay is recommended to detect the presence of Pseudomonas spp., including P. aeruginosa, from primary culture plates that originate from laboratory analysis of CF patients' sputum, particularly at review, in those patients with no previous history of Pseudomonas infection or those who appear to be transiently colonized by this organism. Employment of such molecular methodologies, in conjunction with routine clinical sputum cultures, may provide improved information on the microbial status of CF patients, which will aid clinicians in both optimum patient management in terms of antibiotic regimes and CF centre infection-control practices.

Identification of a novel alpha-proteobacterium causing bacteraemia in an immunocompetent patient.

An 89-year male with pyrexia and suspected bacteremia was admitted to hospital, where a Gram-negative rod was identified from blood culture. The organism was difficult to identify phenotypically and the resulting sequencing of a 559 bp section of the 16S rRNA gene did not have a high homology score (>97.0%) with any deposited GenBank accession numbers and hence was not able to be assigned to a species within any genus. Given that the isolate was a member of the alpha subclass of the Proteobacteria but did not fall into any of the known genera with more than 93.7% homology (Brucella, Rhizobium, Ochrobactrum, Agrobacterium), we believe this isolate to represent a novel alpha-proteobacterium, which was the cause of bacteraemia in this patient.

Primary (isolated) meningococcal pericarditis.

A 19-year-old man was admitted with a history and examination findings of probable bacterial pericarditis. Blood cultures produced Neisseria meningitidis Group C, sensitive to penicillin. The patient was initially treated with intravenous benzylpenicillin. Echocardiogram demonstrated the development of a pericardial effusion which was tapped, and benzylpenicillin was instilled into the pericardial space. Because of failure of clinical resolution, cefotaxime was substituted for benzylpenicillin. Rapid clinical improvement then ensued. Repeat echocardiogram showed evidence of neither reaccumulation nor constrictive pericarditis. Primary (isolated) meningococcal pericarditis is a recognized though rare manifestation of meningococcal disease. It is most common in young adults and is associated with a good prognosis.

Improved molecular detection of Burkholderia cepacia genomovar III and Burkholderia multivorans directly from sputum of patients with cystic fibrosis.

Optimum detection of the Burkholderia cepacia complex (BCC) from sputum of patients with cystic fibrosis (CF) is essential in preventing patient-to-patient transmission of this organism. The aim of this study was to develop an improved PCR assay with reference to sensitivity for the direct detection of BCC organisms from CF sputum employing the recA locus. The sensitivity results of three recA PCR assays were compared using various combinations of previously published primers. These included (i) a single-round approach using the primer set BCR1/BCR2, yielding a 1036-bp product, (ii) a single-round approach using the primer set BCR1/Mr, yielding a 465-bp product, and (iii) a semi-nested PCR (SN-PCR) approach using the primer set BCR1/BCR2 followed by BCR1/Mr. The sensitivity of these assays were determined by spiking B. cepacia-free sputum with known numbers of four strains of BCC, namely, genomovar II [B. multivorans] (C1576), genomovar IIIa (C5424, C6433) and genomovar IIIb (C1394). Following optimization, the chosen assay was performed on 14 patients. Employment of the single-round assay with BCR1/BCR2 was the least sensitive with a detection threshold of 10(7) cfu/g sputum for GIIIa and GIIIb, and 10(8) cfu/g sputum for GII. Sensitivity was improved by targeting the smaller amplification region of the recA locus (465 bp) employing the BCR1/Mr primer pair, in combination with a single-round approach, whereby the detection threshold was improved by 1 log for each genomovar. Employment of the semi-nested assay demonstrated optimum sensitivity, whereby the detection threshold increased to 10(1) and 10(2) cfu/g sputum for genomovar IIIa/IIIb and genomovar II, respectively. Subsequent genomovar characterisation can be performed by sequencing of the PCR amplicon without the need for culture which may be beneficial in patients in the initial stages of colonisation or who are transiently colonised and who may be culture-negative for BCC.