MR Imaging of Pediatric Low-Grade Gliomas: Pretherapeutic Differentiation of BRAF V600E Mutation, BRAF Fusion, and Wild-Type Tumors in Patients without Neurofibromatosis-1.

BACKGROUND AND PURPOSE: The prognosis and treatment of pediatric low-grade gliomas is influenced by their molecular subtype. MR imaging remains the mainstay for initial work-up and surgical planning. We aimed to determine the relationship between imaging patterns and molecular subtypes of pediatric low-grade gliomas. MATERIALS AND METHODS: This was a retrospective bi-institutional study for patients diagnosed from 2004 to 2021 with pathologically confirmed pediatric low-grade gliomas molecularly defined as BRAF fusion, BRAF V600E mutant, or wild-type (which is neither BRAF V600E mutant nor BRAF fusion). Two neuroradiologists, blinded, independently reviewed imaging parameters from diagnostic MRIs, and discrepancies were resolved by consensus. Bivariate analysis was used followed by pair-wise comparison of the Dwass-Steel-Critchlow-Fligner method to compare the 3 molecular subtypes. Interreader agreement was assessed using κ. RESULTS: We included 70 patients: 30 BRAF fusion, 19 BRAF V600E mutant, and 21 wild-type. There was substantial agreement between the readers for overall imaging variables (κ = 0.75). BRAF fusion tumors compared with BRAF V600E and wild-type tumors were larger (P = .0022), and had a greater mass effect (P = .0053), increased frequency of hydrocephalus (P = .0002), and diffuse enhancement (p <.0001). BRAF V600E mutant tumors were more often hemispheric (P < .0001), appeared more infiltrative (P = .0002), and, though infrequent, were the only group demonstrating diffusion restriction (qualitatively; P = .0042) with a lower ADC ratio (quantitatively) (P = .003). CONCLUSIONS: BRAF fusion and BRAF V600E mutant pediatric low-grade gliomas have unique imaging features that can be used to differentiate them from each other and wild-type pediatric low-grade glioma using a standard radiology review with high interreader agreement. In the era of targeted therapy, these features can be useful for therapeutic planning before surgery.

Engaged communication of environmental health science: Processes and outcomes of urban academic-community partnerships.

Those who bear the greatest environmental burdens often have the least access to information, and explanations for engaging communities to develop solutions are lacking. We describe, and use a case study to depict, a participatory process of urban academic and community members to co-produce educational and communication tools. Over five years, we interfaced with 763 individuals at eleven events and three times that (n=2,273) through attendees' networks at 109 small group events using snowball methods. The resulting communication tools, paired resources, and mobile dissemination were responsive to residents' circumstances and enhanced their ability to access health protecting information and resources.

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

BACKGROUND: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

BACKGROUND: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively. PURPOSE: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations. RESULTS: At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%). CONCLUSION: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.

Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model.

BACKGROUND: Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative. PURPOSE: To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures. STUDY DESIGN: Cross-sectional study. METHODS: A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient's sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon's decision, as well as surgeon training background, years in practice, and risk-taking behavior. RESULTS: The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice (P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by ≥3.5 mm. Significant variation in surgeon's propensity for operative treatment of this fracture was observed (P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent's preference for surgical treatment. CONCLUSION: There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures.

Single-Leg Spica Cast Application for Treatment of Pediatric Femoral Fracture.

Use of a single-leg spica cast for femoral fractures in ambulatory children 1 to 5 years of age facilitates care and mobilization of the patient. It may allow a shorter duration of cast treatment than is possible with a traditional one and one-half-leg spica cast, particularly in patients 1 to 3 years of age. The single-leg spica is indicated for children who are small enough to be lifted safely in the cast and who have an isolated, closed, low-energy femoral shaft fracture. The procedure consists of the following steps:Step 1: Obtain adequate sedation. General anesthesia should be used in the operating room, whereas conscious sedation may be used in the emergency or procedure room setting. The location of the procedure should be determined by available resources.Step 2: Determine the position of optimal alignment by visual examination of the thigh and leg. If intraoperative imaging is available, assess fracture stability by performing the telescope test described by Thompson et al.1-i.e., by gently applying axial load to the thigh to assess for shortening under fluoroscopic monitoring. Shortening of >3 cm reflects substantial periosteal stripping and is associated with an increased risk of loss of reduction in the cast. Alternative stabilization techniques should be considered for grossly unstable fractures with a positive telescope test. Use of intramedullary nails, external fixation, or traction with delayed cast application may decrease the risk of excessive shortening or unacceptable angulation of the fracture in the cast.Step 3: Apply a stockinette or waterproof pantaloons cast liner to the torso and involved lower extremity.Step 4: Position the patient on a spica-cast application table, which provides a support under the thorax and head with a strut that supports the spine and pelvis to the sacrum, allowing application of the cast material to the pelvic area and involved extremity. Position the patient on the table with the involved extremity flexed 30° to 60° at the hip and 30° to 60° at the knee and the contralateral leg supported. Greater flexion makes it easier to fit the child into a car seat or high chair and to carry him/her on the caretaker's hip, whereas flexing the hip and knee less allows the patient to bear weight more easily. However, Illgen et al.2 found knee flexion of <50° to be associated with an increased risk of reduction loss. More proximal fractures are better treated with greater hip flexion because of their tendency to drift into apex anterior angulation.Step 5: Overwrap the cast liner from nipple line to ankle with cotton or synthetic undercast padding to prevent pressure sores. Some families prefer waterproof cast padding as it allows the child to be immersed for bathing, but it provides less padding at pressure points and increases the cost of the cast.Step 6: Apply fiberglass or plaster cast material starting 1 in (2.5 cm) below the edge of the cast padding and ending 1 in above the malleoli to allow the edges of the cast to be adequately padded when the liner is folded back.Step 7: Apply an iliac crest mold to stabilize the hip, and apply an anterior and valgus mold to the involved thigh to recreate the anterior bow and address the tendency of femoral shaft fractures to drift into varus.Step 8: Trim and finish the cast. Inspect the groin region for rough edges and trim them as needed using the cast saw or bandage scissors. Cast edges should be "petalled with" (covered with short strips of) moleskin as needed.Step 9: After the cast is hard, remove the patient from the spica table and wake him/her up. Place a smaller diaper over the groin inside the cast to prevent cast soiling and a second, larger diaper over the outside of the cast to hold the smaller diaper in place. Following cast application, distal neurovascular status is assessed. The caretakers are trained in cast care and safe patient transport. The fit of the car seat is checked prior to discharge from the emergency room or hospital. Follow-up radiographs with the patient in the cast should be obtained 10 days after cast application. Angulation of ≤15° and shortening of <2 cm can generally be accepted in patients with a midshaft fracture. Angulation of >15° can often be managed with wedging of the cast in the clinic. Excessive shortening may require reapplication of the cast or a change to another stabilization method. Single-leg spica treatment of femoral fractures in children ≤5 years of age has provided reliable outcomes with few complications. Usually, the cast can be removed 4 to 6 weeks following application.

A comparison of the gut microbiome between long-term users and non-users of proton pump inhibitors.

BACKGROUND: Proton pump inhibitor (PPI) use is associated with an increased risk of Clostridium difficile infection (CDI), though the mechanism is unclear. PPI induced alterations to the gut microbiome may facilitate the emergence of CDI, though the effects of PPIs on gut microbiota are not well characterised. [Correction added on 10 March 2016, after first online publication: microflora has been changed to microbiota throughout the article.] AIM: To compare the faecal microbiomes of long-term PPI users to those with no history of PPI use. METHODS: We used a population-based database to identify individuals with ≥5 years of continuous PPI use along with non-PPI using controls. Stool samples were subjected to microbiological analysis, with hierarchical clustering at genus level, along with alpha and beta diversity measures comparing the two groups. Metadata was accounted for using quantile regression to eliminate potential confounding variables in taxonomic abundance comparisons. RESULTS: Sixty-one subjects (32 PPI, 29 controls) were analysed. While no significant differences in alpha diversity were found between the PPI users and controls, a moderate shift of the PPI users away from the non-PPI user cluster in the beta diversity was observed. After controlling for pertinent confounders, we discovered a decrease in Bacteroidetes and an increase in Firmicutes at the phylum level. We also performed species classifications and found Holdemania filiformis and Pseudoflavonifractor capillosus to be increased and decreased in the PPI cohort, respectively. CONCLUSIONS: Long-term PPIs use has an effect on the gut microbiome. The alteration in the ratio of Firmicutes to Bacteroidetes may pre-dispose to the development of CDI.

Genetic deletion of the mitochondrial phosphate carrier desensitizes the mitochondrial permeability transition pore and causes cardiomyopathy.

The mitochondrial phosphate carrier (PiC) is critical for ATP synthesis by serving as the primary means for mitochondrial phosphate import across the inner membrane. In addition to its role in energy production, PiC is hypothesized to have a role in cell death as either a component or a regulator of the mitochondrial permeability transition pore (MPTP) complex. Here, we have generated a mouse model with inducible and cardiac-specific deletion of the Slc25a3 gene (PiC protein). Loss of PiC protein did not prevent MPTP opening, suggesting it is not a direct pore-forming component of this complex. However, Slc25a3 deletion in the heart blunted MPTP opening in response to Ca(2+) challenge and led to a greater Ca(2+) uptake capacity. This desensitization of MPTP opening due to loss or reduction in PiC protein attenuated cardiac ischemic-reperfusion injury, as well as partially protected cells in culture from Ca(2+) overload induced death. Intriguingly, deletion of the Slc25a3 gene from the heart long-term resulted in profound hypertrophy with ventricular dilation and depressed cardiac function, all features that reflect the cardiomyopathy observed in humans with mutations in SLC25A3. Together, these results demonstrate that although the PiC is not a direct component of the MPTP, it can regulate its activity, suggesting a novel therapeutic target for reducing necrotic cell death. In addition, mice lacking Slc25a3 in the heart serve as a novel model of metabolic, mitochondrial-driven cardiomyopathy.

Evaluation of UT/LS hygrometer accuracy by intercomparison during the NASA MACPEX mission.

Acquiring accurate measurements of water vapor at the low mixing ratios (< 10 ppm) encountered in the upper troposphere and lower stratosphere (UT/LS) has proven to be a significant analytical challenge evidenced by persistent disagreements between high-precision hygrometers. These disagreements have caused uncertainties in the description of the physical processes controlling dehydration of air in the tropical tropopause layer and entry of water into the stratosphere and have hindered validation of satellite water vapor retrievals. A 2011 airborne intercomparison of a large group of in situ hygrometers onboard the NASA WB-57F high-altitude research aircraft and balloons has provided an excellent opportunity to evaluate progress in the scientific community toward improved measurement agreement. In this work we intercompare the measurements from the Midlatitude Airborne Cirrus Properties Experiment (MACPEX) and discuss the quality of agreement. Differences between values reported by the instruments were reduced in comparison to some prior campaigns but were nonnegligible and on the order of 20% (0.8 ppm). Our analysis suggests that unrecognized errors in the quantification of instrumental background for some or all of the hygrometers are a likely cause. Until these errors are understood, differences at this level will continue to somewhat limit our understanding of cirrus microphysical processes and dehydration in the tropical tropopause layer.

A new direct absorption tunable diode laser spectrometer for high precision measurement of water vapor in the upper troposphere and lower stratosphere.

We present a new instrument for the measurement of water vapor in the upper troposphere and lower stratosphere (UT∕LS), the Harvard Herriott Hygrometer (HHH). HHH employs a tunable diode near-IR laser to measure water vapor via direct absorption in a Herriott cell. The direct absorption technique provides a direct link between the depth of the observed absorption line and the measured water vapor concentration, which is calculated based on spectroscopic parameters in the HITRAN database. While several other tunable diode laser (TDL) instruments have been used to measure water vapor in the UT∕LS, HHH is set apart by its use of an optical cell an order of magnitude smaller than those of other direct absorption TDLs in operation, allowing for a more compact, lightweight instrument. HHH is also unique in its integration into a common duct with the Harvard Lyman-α hygrometer, an independent photo-fragment fluorescence instrument which has been thoroughly validated over 19 years of flight measurements. The instrument was flown for the first time in the Mid-latitude Airborne Cirrus Properties Experiment (MACPEX) on NASA's WB-57 aircraft in spring, 2011, during which it demonstrated in-flight precision of 0.1 ppmv (1 s) with 1-sigma uncertainty of 5% ± 0.7 ppmv. Since the campaign, changes to the instrument have lead to improved accuracy of 5% ± 0.2 ppmv as demonstrated in the laboratory. During MACPEX, HHH successfully measured water vapor at concentrations from 3.5 to 600 ppmv in the upper troposphere and lower stratosphere. HHH and Lyman-α, measuring independently but under the same sampling conditions, agreed on average to within 1% at water vapor mixing ratios above 20 ppmv and to within 0.3 ppmv at lower mixing ratios. HHH also agreed with a number of other in situ water vapor instruments on the WB-57 to within their stated uncertainties, and to within 0.7 ppmv at low water. This agreement constitutes a significant improvement over past in situ comparisons, in which differences of 1.5-2 ppmv were routinely observed, and demonstrates that the accuracy of HHH is consistent with other instruments which use a range of detection methods and sampling techniques.

Quality of life during orthopaedic training and academic practice: part 2: spouses and significant others.

BACKGROUND: Orthopaedic residents and attending physicians who report having a supportive spouse show lower levels of burnout and psychological distress than those without supportive spouses. However, little is known about the experiences of the spouses. This nationwide study examines burnout, psychological distress, and marital satisfaction of the spouses and significant others (collectively referred to hereafter as spouses) of orthopaedists in training and in orthopaedic practice in an academic setting. METHODS: Employing previously reported methodology, 259 spouses of orthopaedic residents and 169 spouses of full-time orthopaedic faculty completed a voluntary, anonymous survey. The survey included three validated instruments (the Maslach Burnout Inventory, the General Psychological Health Questionnaire-12, and the Revised Dyadic Adjustment Scale) and three novel question sets addressing demographic information, relationship issues, stress, and work/life balance. RESULTS: Psychological distress was noted in 18% of resident spouses compared with only 10% of faculty spouses (p = 0.014). Resident spouses reported greater loneliness (p < 0.0009) and stress (p = 0.03) than faculty spouses. Among working spouses, 30% of resident spouses and 13% of faculty spouses showed high levels of emotional exhaustion (p < 0.003). Twenty-eight percent of employed resident spouses and 5% of employed faculty spouses showed problematic levels of depersonalization (p < 0.0001). Twenty-six percent of employed resident spouses and 12% of employed faculty spouses showed a diminished sense of personal accomplishment (p = 0.012). Marital satisfaction was high for both resident and faculty spouses. Decreased satisfaction correlated with excessive mate irritability and fatigue that precluded their mate's involvement in family activities. A gratifying sex life, full-time work outside the home, and spending more than ninety minutes a day with their mate correlated significantly with marital satisfaction. CONCLUSIONS: Many orthopaedic resident spouses showed elevated levels of burnout, and a substantial number showed psychological distress. Spouses of orthopaedic faculty surgeons showed low rates of burnout and psychological distress. While both resident and faculty spouses reported high levels of marital satisfaction, the engagement of their surgeon mates had a considerable impact on the well-being of the relationship.

Spica casting for pediatric femoral fractures: a prospective, randomized controlled study of single-leg versus double-leg spica casts.

BACKGROUND: At many centers, double-leg spica casting is the treatment of choice for diaphyseal femoral fractures in children two to six years old. We hypothesized that such patients can be effectively treated with single-leg spica casting and that such treatment would result in easier care and better patient function during treatment. METHODS: In a prospective, randomized controlled study, fifty-two patients two to six years old with a diaphyseal femoral fracture were randomly assigned to be treated immediately (after consent was obtained) with a single-leg (twenty-four patients) or double-leg (twenty-eight patients) spica cast. Serial radiographs were evaluated for maintenance of fracture reduction with respect to limb length, varus/valgus angulation, and procurvatum/recurvatum angulation. After cast removal, the performance version of the Activities Scale for Kids questionnaire and a custom-written survey were administered to the parents so that they could evaluate the ease of care and function of the children during treatment. Means were compared between treatment groups with use of Student t tests. P values of <0.05 were considered significant. RESULTS: All limbs healed in satisfactory alignment. The children treated with a single-leg spica cast were more likely to fit into car seats (p < 0.05) and fit more comfortably into chairs (p < 0.05). Caregivers of patients treated with a single-leg cast took less time off work (p < 0.05). There were no major complications. CONCLUSIONS: Treatment of pediatric femoral fractures with a single-leg spica cast is effective and safe, and postfracture patient care is facilitated. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Three cases of slipped capital femoral epiphysis in one family.

Slipped capital femoral epiphysis is a relatively common disorder of the hip that affects children in late childhood and early adolescence, with an incidence in the United States of approximately 10 per 100,000. Although the diagnosis and treatment of slipped capital femoral epiphysis have been well described, the search for its cause and a method of early identification continues. Recent publications have suggested that there is a familial association among individuals with slipped capital femoral epiphysis, but there is no current genetic marker established for the disorder. This article reports a series of 3 biologically related Caucasian sisters who were athletic; had body mass indices <26 kg/m(2); had no record of any hormonal imbalances or endocrine abnormalities; had good nutrition; and presented with atypical characteristics of slipped capital femoral epiphysis. This is the first report of a series of 3 sisters with slipped capital femoral epiphysis in the United States. Our goals were to document our experience in the identification and treatment of these patients to highlight the complexities of slipped capital femoral epiphysis presentation patterning, to increase the awareness and reporting of familial cases of slipped capital femoral epiphysis by other physicians, and to encourage additional research in this area. As clinicians progress in the ability to diagnose and treat patients with slipped capital femoral epiphysis, they also must be mindful of the varying presentation characteristics.

Slipped capital femoral epiphysis with severe vitamin D deficiency.

Slipped capital femoral epiphysis is a relatively common disorder in late childhood and early adolescence, with an incidence in the United States of approximately 10 per 100,000. Although clinicians have theorized that contributing factors to the development of slipped capital femoral epiphysis include 25-hydroxyvitamin D deficiency and other nutritional deficiencies, the roles of these factors have not been fully analyzed. This article presents a case of a morbidly obese 13-year-old African-American boy who presented with sudden worsening of chronic hip pain and was diagnosed with stable, bilateral, grade-III slipped capital femoral epiphysis and severe vitamin D deficiency. He was initially treated with bilateral single-screw percutaneous fixation, however, after continued pain and nonunion, a right valgus subtrochanteric osteotomy was performed in association with correction of his severe vitamin D deficiency. This procedure led to improvement of his hip function and successful resolution of the pain. Approximately 3 months after the second operation and vitamin supplementation, the patient had signs of union, and his weight bearing progressed without discomfort. Although the osteotomy provided substantial biomechanical advantage by changing the forces across the physis from shear to compressive, correction of the vitamin D deficiency was critical in providing metabolic capacity for bone healing. Vitamin D plays an important role in bone formation and development, but the level of 25-hydroxyvitamin D is not routinely measured during assessment and treatment of slipped capital femoral epiphysis patients. The early detection and proper treatment of vitamin D may assist in the treatment of patients with slipped capital femoral epiphysis.

Analysis of the pediatric orthopedic surgery questions on the Orthopaedic In-Training Examination, 2002 through 2006.

BACKGROUND: Pediatric orthopedics has been a frequently tested topic on the Orthopaedic In-Training Examination (OITE). Our goal was to provide direction for resident education efforts by: (1) analyzing the exam's number, topics, and types of pediatric orthopedic surgery questions; (2) examining references cited in the postexam answer packet supplied by the American Academy of Orthopaedic Surgeons; and (3) examining the efficacy of the Orthopaedic Knowledge Update (OKU): Pediatrics 3 book as a source for answers to the pediatric orthopedic questions. METHODS: We reviewed 5 years (2002 through 2006) of OITEs and the associated American Academy of Orthopaedic Surgeons' answer packets and assessed the OKU: Pediatrics 3 book for topic relativity. Each question was classified into 1 of 6 categories and labeled with a cognitive taxonomy level: 1 (simple recall), 2 (interpretation of data), or 3 (advanced problem-solving). The 6 categories included: (1) pediatric orthopedic knowledge; (2) knowledge of treatment modalities; (3) diagnosis; (4) diagnosis with recognition of associated conditions; (5) diagnosis with further studies; and (6) diagnosis with treatment. RESULTS: The overall percentage of pediatric questions was 14.1%. The most commonly addressed were pediatric elbow fractures, osteomyelitis, and scoliosis. The most common question types were categories 1 (pediatric orthopedic knowledge) and 6 (diagnosis with treatment). The most frequently referenced textbooks were Lovell and Winter's Pediatric Orthopaedics (31%) and Tachdjian's Pediatric Orthopaedics (16%). The most frequently referenced journals were the Journal of Pediatric Orthopaedics (American) (29%) and the Journal of Bone and Joint Surgery (American) (19%). Using only the OKU: Pediatrics 3 review textbook, 65% of the questions could be answered. CONCLUSIONS: Knowledge of the topics more likely to be tested may help the orthopedic educator direct a didactic curriculum geared toward the OITE and American Board of Surgery examinations. Although the OKU: Pediatrics 3 book seems to be a good, concise resource for studying for the board examination and OITE, residents should be encouraged to supplement their studying with primary sources. LEVEL OF EVIDENCE: Not applicable.

Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty.

BACKGROUND: A pilot study of two academic training programs revealed concerning levels of resident burnout and psychological dysfunction. The purpose of the present study was to determine the quality of life of orthopaedic residents and faculty on a national scale and to identify risk factors for decompensation. METHODS: Three hundred and eighty-four orthopaedic residents and 264 full-time orthopaedic faculty members completed a voluntary, anonymous survey consisting of three validated instruments (the Maslach Burnout Inventory, the General Health Questionnaire-12, and the Revised Dyadic Adjustment Scale) and question sets assessing demographic information, relationship issues, stress reactions/management, and work/life balance. RESULTS: High levels of burnout were seen in 56% of the residents and 28% of the faculty members. Burnout risk was greatest among second-postgraduate-year residents and residents in training programs with six or more residents per postgraduate year. Sixteen percent of residents and 19% of faculty members reported symptoms of psychological distress. Sleep deprivation was common among the residents and correlated positively with every distress measure. Faculty reported greater levels of stress but greater satisfaction with work and work/life balance. A number of factors, such as making time for hobbies and limiting alcohol use, correlated with decreased dysfunction for both residents and faculty. CONCLUSIONS: Despite reporting high levels of job satisfaction, orthopaedic residents and faculty are at risk for burnout and distress. Identification of protective factors and risk factors may provide guidance to improve the quality of life of academic orthopaedic surgeons in training and beyond.

Postoperative orthopaedic neurovascular monitoring in the pediatric population.

BACKGROUND: Many orthopaedic procedures carry risks of neurovascular compromise. We hypothesized that risk factors for neurovascular compromise and for its delayed detection exist in the pediatric orthopaedic population. METHODS: We searched our institution's pediatric patient database from January 2004 through December 2006, randomly selecting (arbitrarily choosing every 20th patient) 286 patients, 34 of whom went to the operating room twice for 320 procedures. We retrospectively reviewed their records for these potential risk factors: altered communication ability (for age), abnormal baseline neurovascular status, imprecise documentation of neurovascular baseline status, nonspecific or inappropriate postoperative monitoring orders, and monitoring not carried out by nursing staff. Outcomes were analyzed via Fisher exact test (P < 0.05). RESULTS: Ten patients (3%) had new postoperative neurovascular events, and 4 (1%) were recognized to have neurological deterioration detected on a delayed basis. Fifty-seven (18%) had impaired communication ability (significant correlation with increased risk for neurovascular events), 97 (30%) had abnormal neurovascular preoperative status, and 21 (22%) had no specific documentation of neurovascular condition in the perioperative chart. Insufficient documentation of abnormal neurovascular baseline correlated significantly with an increased risk for delayed detection of postoperative neurovascular events. Although all written orders for neurovascular checks were carried out and specific with respect to timing, 133 patients (42%) had neurovascular monitoring orders that were nonspecific about the functions to be checked. All patients with delayed deficit detection had impaired ability to communicate, abnormal baseline values, or improperly written orders. CONCLUSIONS: The risk of postoperative neurovascular events is significantly higher in patients with impaired communication ability, and the risk for delayed detection of such events is significantly higher in patients without proper documentation of an abnormal neurovascular baseline. Clear documentation of baseline function may avoid delayed detection, and more specific monitoring processes may improve patient safety.

Patterns of pediatric supracondylar humerus fractures.

PURPOSE: The Wilkins-modified Gartland classification of pediatric supracondylar humerus fractures does not consider coronal or sagittal obliquity. The purposes of our study were (1) to identify and describe fracture characteristics with unique properties and (2) to propose a fracture classification system that can be reproduced reliably. METHODS: We retrospectively studied 203 consecutive displaced pediatric extension-type supracondylar humerus fractures treated operatively from January 1998 to January 2003. Fracture characteristics (eg, coronal and sagittal obliquity, postoperative alignment), type of surgical treatment, outcome, and complications were assessed and analyzed statistically with Student t test and a receiver operating characteristic curve. Significance was defined as P < 0.05. We incorporated significant cutoff values for fracture obliquity into our classification scheme and tested the classification's interobserver and intraobserver reliability. RESULTS: We identified 4 coronal (typical transverse, medial oblique, lateral oblique, and high fractures) and 2 sagittal (low sagittal and high sagittal) subtypes with significantly different characteristics and outcome. Compared with fractures with coronal obliquity of less than 10 degrees, fractures with coronal obliquity of 10 degrees or greater were associated with significantly more comminution and rotational malunion. Compared with fractures with sagittal obliquity of less than 20 degrees, fractures with sagittal obliquity of 20 degrees or greater were associated with a significantly higher incidence of additional injuries and were more likely to result in extension malunion. Analysis of the interobserver and intraobserver reliability for our system identified correlation coefficients ranging from 0.772 to 0.907 and 0.860 to 0.899, respectively. CONCLUSIONS: Because pediatric extension-type supracondylar humerus fractures vary significantly in terms of characteristics, identification of sagittal oblique and coronal oblique angles may have an important role in surgical decision making and may impact outcomes.