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Woods CR, Bradley JS, Chatterjee A, Kronman MP, Arnold SR, Robinson J, Copley LA, Arrieta AC, Fowler SL, Harrison C, Eppes SC, Creech CB, Stadler LP, Shah SS, Mazur LJ, Carrillo-Marquez MA, Allen CH, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics. J Pediatric Infect Dis Soc 2024; 13:1-59. [PMID: 37941444 DOI: 10.1093/jpids/piad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee Health Sciences Center College of Medicine Chattanooga, Chattanooga, Tennessee
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, School of Medicine, and Rady Children's Hospital, San Diego, California
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonio C Arrieta
- Division of Infectious Diseases, Children's Hospital of Orange County and University of California, Irvine, California
| | - Sandra L Fowler
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of Montreal Research Center, Montreal, Quebec, Canada
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Hachem AA, Filkins LM, Kidane YH, Raj P, Tareen NG, Arana CA, Muthukrishnan G, Copley LA. Staphylococcus aureus isolates from children with clinically differentiated osteomyelitis exhibit distinct transcriptomic signatures. PLoS One 2023; 18:e0288758. [PMID: 37561761 PMCID: PMC10414669 DOI: 10.1371/journal.pone.0288758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/04/2023] [Indexed: 08/12/2023] Open
Abstract
There is substantial genomic heterogeneity among Staphylococcus aureus isolates of children with acute hematogenous osteomyelitis (AHO) but transcriptional behavior of clinically differentiated strains has not been previously described. This study evaluates transcriptional activity of S. aureus isolates of children with AHO that may regulate metabolism, biosynthesis, or virulence during bacterial growth and pathogenesis. In vitro growth kinetics were compared between three S. aureus clinical isolates from children with AHO who had mild, moderate, and severe illness. Total RNA sequencing was performed for each isolate at six separate time points throughout the logarithmic phase of growth. The NASA RNA-Sequencing Consensus Pipeline was used to identify differentially expressed genes allowing for 54 comparisons between the three isolates during growth. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment pathways were used to evaluate transcriptional variation in metabolism, biosynthesis pathways and virulence potential of the isolates. The S. aureus isolates demonstrated differing growth kinetics under standardized conditions with the mild isolate having higher optical densities with earlier and higher peak rates of growth than that of the other isolates (p<0.001). Enrichment pathway analysis established distinct transcriptional signatures according to both sampling time and clinical severity. Moderate and severe isolates demonstrated pathways of bacterial invasion, S. aureus infection, quorum sensing and two component systems. In comparison, the mild strain favored biosynthesis and metabolism. These findings suggest that transcriptional regulation during the growth of S. aureus may impact the pathogenetic mechanisms involved in the progression of severity of illness in childhood osteomyelitis. The clinical isolates studied demonstrated a tradeoff between growth and virulence. Further investigation is needed to evaluate these transcriptional pathways in an animal model or during active clinical infections of children with AHO.
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Affiliation(s)
- Ahmad A. Hachem
- Department of Pediatrics, University of Florida College of Medicine –Jacksonville, Jacksonville, FL, United States of America
| | - Laura M. Filkins
- Department of Microbiology, University of Texas Southwestern, Children’s Health System of Texas, Dallas, TX, United States of America
| | - Yared H. Kidane
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, United States of America
| | - Prithvi Raj
- Microbiome Research Laboratory, University of Texas Southwestern, Dallas, TX, United States of America
| | - Naureen G. Tareen
- Department of Pediatric Orthopaedic Surgery, Children’s Health System of Texas, Dallas, TX, United States of America
| | - Carlos A. Arana
- Genomics Core, University of Texas Southwestern, Dallas, TX, United States of America
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Lawson A. Copley
- Department of Pediatric Orthopaedic Surgery, Children’s Health System of Texas, Dallas, TX, United States of America
- Department of Pediatric Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX, United States of America
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Sanchez MJ, Patel K, Lindsay EA, Tareen NG, Jo C, Copley LA, Sue PK. Early Transition to Oral Antimicrobial Therapy Among Children With Staphylococcus aureus Bacteremia and Acute Hematogenous Osteomyelitis. Pediatr Infect Dis J 2022; 41:690-695. [PMID: 35703303 DOI: 10.1097/inf.0000000000003594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Staphylococcus aureus bacteremia (SAB) is a frequent complication of acute hematogenous osteomyelitis (AHO) in children, but data on the optimal duration of parenteral antibiotics prior to transition to oral antibiotics remains sparse. We examined clinical outcomes associated with early transition to oral antimicrobial therapy among children admitted to our institution with AHO and SAB, and evaluated the utility of a severity of illness score (SIS) to guide treatment decisions in this setting. METHODS Children with AHO and SAB admitted to our institution between January 1, 2009, and December 31, 2018, were retrospectively reviewed and stratified according to a previously validated SIS into mild (0-3), moderate (4-7) and severe (8-10) cohorts. Groups were assessed for differences in treatment (eg, parenteral and oral antibiotic durations, surgeries) and clinical response (eg, bacteremia duration, acute kidney injury, length of stay and treatment failure). RESULTS Among 246 children identified with AHO and SAB, median parenteral antibiotic duration differed significantly between mild (n = 80), moderate (n = 98) and severe (n = 68) cohorts (3.6 vs. 6.5 vs. 14.3 days; P ≤ 0.001). SIS cohorts also differed with regard to number of surgeries (0.4 vs. 1.0 vs. 2.1; P ≤ 0.001), duration of bacteremia (1.0 vs. 2.0 vs. 4.0 days; P ≤ 0.001), acute kidney injury (0.0% vs. 3.0% vs. 20.5%; P ≤ 0.001), hospital length of stay (4.8 vs. 7.4 vs. 16.4 days; P ≤ 0.001) and total duration of antibiotics (34.5 vs. 44.7 vs. 60.7 days; P ≤ 0.001). Early transition to oral antimicrobial therapy among mild or moderate SIS cohorts was not associated with treatment failure despite SAB. CONCLUSIONS SAB is associated with a wide range of illness among children with AHO, and classification of severity may be useful for guiding treatment decisions. Early transition to oral antimicrobial therapy appears safe in children with mild or moderate AHO despite the presence of SAB.
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Affiliation(s)
- Maria J Sanchez
- From the Department of Pediatrics, Children's Health System of Texas
| | - Karisma Patel
- Department of Pharmacy, University of Texas Southwestern Medical Center, Children's Health System of Texas, Dallas, Texas
| | - Eduardo A Lindsay
- Department of Family Medicine, Mayagüez Medical Center, Mayagüez, Puerto Rico
| | - Naureen G Tareen
- From the Department of Pediatrics, Children's Health System of Texas
| | - Chanhee Jo
- Research Department, Texas Scottish Rite Hospital for Children
| | - Lawson A Copley
- Department of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Paul K Sue
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
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Klosterman MM, Villani MC, Hamilton EC, Jo C, Copley LA. Primary Septic Arthritis in Children Demonstrates Presumed and Confirmed Varieties Which Require Age-specific Evaluation and Treatment Strategies. J Pediatr Orthop 2022; 42:e27-e33. [PMID: 34560764 DOI: 10.1097/bpo.0000000000001976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is uncertainty involved in the evaluation and treatment of children suspected to have septic arthritis particularly when no causative pathogen is confirmed. This study evaluates children with primary septic arthritis to refine the processes of evaluation and treatment and improve the rate of pathogen confirmation. METHODS Children suspected to have septic arthritis from 2009 to 2019 were retrospectively studied. Diagnosis of primary septic arthritis, defined as hematogenous joint infection without associated osteomyelitis, was established by clinical evaluation, radiology and laboratory results, including joint fluid analysis. Excluded cases were categorized by etiology. Children with primary septic arthritis were divided into confirmed and presumed cohorts for statistical comparison. RESULTS A total of 355 children (average age 4.4 y, range 0.05 to 18 y) were initially treated as septic arthritis. Eighty-seven (24.5%) were excluded due to other conditions, including 34 (9.6%) with noninfectious conditions. Among 268 children with primary septic arthritis, 134 were confirmed and 134 were presumed. A higher rate of 16S polymerase chain reaction (PCR) acquisition (71.6% vs. 45.5%) occurred in the confirmed cohort. Overall yield for various methods of pathogen identification were 27 of 239 (11.3%) by blood culture, 83 of 268 (31.0%) by joint fluid culture and 85 of 157 (54.1%) by PCR. PCR identified a pathogen in 87.5% of children with confirmed septic arthritis. Antibiotic pretreatment was associated with a lower rate of joint fluid culture positivity. Pathogens aggregated within specific age groups. The 4 to 9-year-old age group displayed the widest spectrum of pathogens with limited predictability. CONCLUSIONS This study emphasizes the need for systematic processes of evaluation and treatment for children suspected to have primary septic arthritis, including minimization of antibiotic pretreatment, age-based empiric antibiotic selection, and sufficient follow-up to ensure noninfectious conditions are distinguished in culture-negative cases. Extended observation, before intervention, may be appropriate for some children. LEVEL OF EVIDENCE Level III-retrospective control study.
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Affiliation(s)
| | | | | | - Chanhee Jo
- Department of Orthopedics, Texas Scottish Rite Hospital for Children
| | - Lawson A Copley
- Children's Health System of Texas
- Department of Orthopedics, Texas Scottish Rite Hospital for Children
- Department of Orthopedics and Pediatrics, University of Texas Southwestern, Dallas, TX
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5
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Woods CR, Bradley JS, Chatterjee A, Copley LA, Robinson J, Kronman MP, Arrieta A, Fowler SL, Harrison C, Carrillo-Marquez MA, Arnold SR, Eppes SC, Stadler LP, Allen CH, Mazur LJ, Creech CB, Shah SS, Zaoutis T, Feldman DS, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc 2021; 10:801-844. [PMID: 34350458 DOI: 10.1093/jpids/piab027] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 01/08/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee College of Medicine, Chattanooga, Tennessee, USA
| | - John S Bradley
- Division of Infectious Diseases, University of California San Diego School of Medicine, and Rady Children's Hospital, San Diego, California, USA
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew P Kronman
- Division of Infectious Diseases, Seattle Children's Hospital, Seattle, Washington, USA
| | - Antonio Arrieta
- University of California Irvine School of Medicine and Children's Hospital of Orange County, Irvine, California, USA
| | - Sandra L Fowler
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stephen C Eppes
- Department of Pediatrics, ChristianaCare, Newark, Delaware, USA
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky, USA
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas, USA
| | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Feldman
- New York University Langone Medical Center, New York, New York, USA
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of Montreal Research Center, Montreal, Quebec, Canada
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6
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Dhar AV, Huang CJ, Sue PK, Patel K, Farrow-Gillespie AC, Hammer MR, Zia AN, Mittal VS, Copley LA. Team Approach: Pediatric Musculoskeletal Infection. JBJS Rev 2020; 8:e0121. [PMID: 32224640 DOI: 10.2106/jbjs.rvw.19.00121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A team approach is optimal in the evaluation and treatment of musculoskeletal infection in pediatric patients given the complexity and uncertainty with which such infections manifest and progress, particularly among severely ill children. The team approach includes emergency medicine, pediatric intensive care, pediatric hospitalist medicine, infectious disease service, orthopaedic surgery, radiology, anesthesiology, pharmacology, and hematology.
These services follow evidence-based clinical practice guidelines with integrated processes of care so that children and their families may benefit from data-driven continuous process improvement. Important principles based on our experience in the successful treatment of pediatric musculoskeletal infection include relevant information gathering, pattern recognition, determination of the severity of illness, institutional workflow management, closed-loop communication, patient and family-centered care, ongoing dialogue among key stakeholders within and outside the context of direct patient care, and periodic data review for programmatic improvement over time. Such principles may be useful in almost any setting, including rural communities and developing countries, with the understanding that the team composition, institutional capabilities or limitations, and specific approaches to treatment may differ substantially from one setting or team to another.
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Affiliation(s)
- Archana V Dhar
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas
| | - Craig J Huang
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas
| | - Paul K Sue
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas
| | | | - Alan C Farrow-Gillespie
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas
| | - Matthew R Hammer
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas
| | - Ayesha N Zia
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas
| | - Vineeta S Mittal
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas
| | - Lawson A Copley
- University of Texas Southwestern, Dallas, Texas.,Children's Health System of Texas, Dallas, Texas.,Texas Scottish Rite Hospital for Children, Dallas, Texas.,Texas Scottish Rite Hospital for Children, Dallas, Texas
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Copley LA, Sharps CH, Gerardi JA, Gupta SK, Vanderhaave KL, Lovejoy JF, Lubicky JP, Albanese SA, Jo C. Electronic Medical Record Use and Satisfaction Among Pediatric Orthopaedic Surgeons. J Pediatr Orthop 2019; 39:e722-e728. [PMID: 31503236 DOI: 10.1097/bpo.0000000000001044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Electronic medical record (EMR) use among pediatric orthopaedic surgeons has evolved substantially within the past decade. In response to the Patient Protection and Affordable Care Act, large hospitals and tertiary pediatric medical centers rapidly acquired and implemented EMRs with uncertainty as to the potential impact on patient care and operational efficiency of subspecialists. This study reviews the background and regulatory framework for Meaningful Use of EMR and assesses the current landscape of EMR utilization by pediatric orthopaedic surgeons. METHODS In 2015, the Practice Management Committee distributed a survey regarding EMR use and satisfaction to members of the Pediatric Orthopaedic Society of North America. Survey responses from 324 members were used to analyze levels of satisfaction by EMR platform and practice type and to consider drivers of satisfaction or dissatisfaction of end users. RESULTS Although there were no differences in overall satisfaction based on vendor or practice type, significant differences were noted for 5 specific parameters of satisfaction, including: usefulness of templates, efficiency of practice workflow, information services support, number of logon events, and speed of the system. A user/vendor map is provided to facilitate networking among providers and groups utilizing common EMR platforms to help bring about rational improvements in EMR functionality for the future. CONCLUSIONS Substantial effort needs to be made to improve subspecialty-specific EMR documentation, order entry, research tools, and clinical workflows to enhance the processes of care for children with orthopaedic conditions in the era of EMR. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Lawson A Copley
- University of Texas Southwestern and Texas Scottish Rite Hospital
| | | | | | | | | | | | | | | | - Chanhee Jo
- Texas Scottish Rite Hospital, Dallas, TX
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Ojeaga PO, Hammer MR, Lindsay EA, Tareen NG, Jo CH, Copley LA. Quality Improvement of Magnetic Resonance Imaging for Musculoskeletal Infection in Children Results in Decreased Scan Duration and Decreased Contrast Use. J Bone Joint Surg Am 2019; 101:1679-1688. [PMID: 31567805 DOI: 10.2106/jbjs.19.00035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is a heavily utilized resource to evaluate children suspected to have a musculoskeletal infection. Complex interdisciplinary workflows are involved with decision-making with regard to indications, anesthesia, contrast use, and procedural timing relative to the scan. This study assesses the impact of a quality improvement endeavor on MRI workflows at a tertiary pediatric medical center. METHODS A registry of consecutively enrolled children for a multidisciplinary musculoskeletal infection program identified those evaluated with MRI from 2012 to 2018. Annual MRI process improvement feedback was provided to the key stakeholders. Demographic characteristics, laboratory parameters, MRI indications, anesthesia use, MRI findings, final diagnoses, scan duration, imaging protocol, surgical intervention following MRI, and length of stay were retrospectively compared between the 3 cohorts (initial, middle, and final) representing 2-year increments to assess the impact of the initiative. RESULTS There were 526 original MRI scans performed to evaluate 1,845 children with suspected musculoskeletal infection. Anesthesia was used in 401 children (76.2%). When comparing the initial, middle, and final study period cohorts, significant improvement was demonstrated for the number of sequences per scan (7.5 sequences for the initial cohort, 5.8 sequences for the middle cohort, and 4.6 sequences for the final cohort; p < 0.00001), scan duration (73.6 minutes for the initial cohort, 52.1 minutes for the middle cohort, and 34.9 minutes for the final cohort; p < 0.00001), anesthesia duration (94.1 minutes for the initial cohort, 68.9 minutes for the middle cohort, and 53.2 minutes for the final cohort; p < 0.00001), and the rate of contrast use (87.6% for the initial cohort, 67.7% for the middle cohort, and 26.3% for the final cohort; p < 0.00001). There was also a trend toward a higher rate of procedures under continued anesthesia immediately following the MRI (70.2% in the initial cohort, 77.8% in the middle cohort, and 84.6% in the final cohort). During the final 6-month period, the mean scan duration was 24.4 minutes, anesthesia duration was 40.9 minutes, and the rate of contrast administration was 8.5%. CONCLUSIONS Progressive quality improvement through collaborative interdisciplinary communication and workflow redesign led to improved utilization of MRI and minimized contrast use for suspected musculoskeletal infection. There was a high rate of procedural intervention under continued anesthesia for children with confirmed musculoskeletal infection. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Patrick O Ojeaga
- University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas
| | - Matthew R Hammer
- Departments of Radiology (M.R.H.), Orthopaedic Surgery (L.A.C.), and Pediatrics (L.A.C.), University of Texas Southwestern, Dallas, Texas
| | - Eduardo A Lindsay
- Department of Orthopaedic Surgery, Children's Health System of Texas, Dallas, Texas
| | - Naureen G Tareen
- Department of Orthopaedic Surgery, Children's Health System of Texas, Dallas, Texas
| | - Chan Hee Jo
- Department of Clinical Orthopaedic Research, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Lawson A Copley
- Departments of Radiology (M.R.H.), Orthopaedic Surgery (L.A.C.), and Pediatrics (L.A.C.), University of Texas Southwestern, Dallas, Texas
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9
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Lindsay EA, Tareen N, Jo CH, Copley LA. Seasonal Variation and Weather Changes Related to the Occurrence and Severity of Acute Hematogenous Osteomyelitis in Children. J Pediatric Infect Dis Soc 2018; 7:e16-e23. [PMID: 29045692 DOI: 10.1093/jpids/pix085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/18/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND Acute hematogenous osteomyelitis (AHO) demonstrates regional variability in incidence and severity. In this study, we evaluated seasonal variations of AHO and assessed the effects of weather trends on the occurrence and severity of illness in affected children. METHODS National Weather Service data from the dates of symptom onset and of admission of children with AHO were gathered. Seasonal occurrence rates and the weather patterns were studied according to severity-of-illness category. Statistical analysis was performed with Pearson and Spearman correlations and analysis of variance. RESULTS A total of 209 children with AHO were admitted within 21 days of symptom onset (average, 5.0 ± 3.8 days). Severity-of-illness scores ranged from 0 to 10 (average, 3.2 ± 3.2). Symptom onset occurred most commonly in summer (73 [34.9%]) or spring (54 [25.8%]). We found a significant correlation between severity of illness and minimum temperature at symptom onset during the summer season (P = .020). A significant change in average humidity (21.6%) occurred during the winter between the date of symptom onset and the date of admission for children with severe illness (P = .020). DISCUSSION This study identified seasonal variation in the occurrence of AHO in children; summer was the most common season for occurrence. To our knowledge, this is the first detailed evaluation of weather parameters and trends in weather changes from symptom onset to admission with consideration of the effects of weather on the occurrence of infection and severity of illness.
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Affiliation(s)
- Eduardo A Lindsay
- Department of Orthopaedic Surgery, Children's Health, Children's Medical Center Dallas, Texas
| | - Naureen Tareen
- Department of Orthopaedic Surgery, Children's Health, Children's Medical Center Dallas, Texas
| | - Chan-Hee Jo
- Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas
| | - Lawson A Copley
- Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas
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10
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Rosenfeld SB, Copley LA, Mignemi M, An T, Benvenuti M, Schoenecker J. Key Concepts of Musculoskeletal Infection. Instr Course Lect 2017; 66:569-584. [PMID: 28594530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Over the past few decades, musculoskeletal infections have increased in both incidence and severity. The clinical manifestations of musculoskeletal infections range from isolated osteomyelitis to multisite infections with systemic complications. Although this increased incidence of musculoskeletal infections correlates with the increased incidence of methicillin-resistant Staphylococcus aureus infections, other nonresistant infectious organisms have been associated with severe musculoskeletal infections; this finding supports the likelihood that an antibiotic resistance profile is not a major factor in bacterial virulence. Instead, a multitude of virulence factors allow infectious organisms to manipulate and evade the immune response of the host. Organisms such as S aureus and Streptococcus pyogenes are able to hijack the acute phase response of the host, which allows for protected proliferation and dissemination. The serum factors produced by the acute phase response, including interleukin-6, C-reactive protein, erythrocytes/fibrinogen, and platelets, can be used to assess musculoskeletal infection severity and monitor treatment. Bacterial genome sequencing has identified virulence factors in a wide variety of clinical manifestations of musculoskeletal infections and may help identify targets for clinical therapy. Currently, however, the management of musculoskeletal infections relies on accurate organism identification and a thorough recognition of the sites of infection and the tissues that are involved. MRI aids in the localization of musculoskeletal infection and identification of sites that require surgical débridement.
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Affiliation(s)
- Scott B Rosenfeld
- Director, Hip Preservation Program, Pediatric Orthopedic Surgery, Texas Children's Hospital, Associate Professor of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
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Gaviria-Agudelo C, Aroh C, Tareen N, Wakeland EK, Kim M, Copley LA. Genomic Heterogeneity of Methicillin Resistant Staphylococcus aureus Associated with Variation in Severity of Illness among Children with Acute Hematogenous Osteomyelitis. PLoS One 2015; 10:e0130415. [PMID: 26086671 PMCID: PMC4473274 DOI: 10.1371/journal.pone.0130415] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/20/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction The association between severity of illness of children with osteomyelitis caused by Methicillin-resistant Staphylococcus aureus (MRSA) and genomic variation of the causative organism has not been previously investigated. The purpose of this study is to assess genomic heterogeneity among MRSA isolates from children with osteomyelitis who have diverse severity of illness. Materials and Methods Children with osteomyelitis were prospectively studied between 2010 and 2011. Severity of illness of the affected children was determined from clinical and laboratory parameters. MRSA isolates were analyzed with next generation sequencing (NGS) and optical mapping. Sequence data was used for multi-locus sequence typing (MLST), phylogenetic analysis by maximum likelihood (PAML), and identification of virulence genes and single nucleotide polymorphisms (SNP) relative to reference strains. Results The twelve children studied demonstrated severity of illness scores ranging from 0 (mild) to 9 (severe). All isolates were USA300, ST 8, SCC mec IVa MRSA by MLST. The isolates differed from reference strains by 2 insertions (40 Kb each) and 2 deletions (10 and 25 Kb) but had no rearrangements or copy number variations. There was a higher occurrence of virulence genes among study isolates when compared to the reference strains (p = 0.0124). There were an average of 11 nonsynonymous SNPs per strain. PAML demonstrated heterogeneity of study isolates from each other and from the reference strains. Discussion Genomic heterogeneity exists among MRSA isolates causing osteomyelitis among children in a single community. These variations may play a role in the pathogenesis of variation in clinical severity among these children.
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Affiliation(s)
- Claudia Gaviria-Agudelo
- Department of Pediatric Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Chukwuemika Aroh
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Naureen Tareen
- Children’s Medical Center, Dallas, Texas, United States of America
| | - Edward K. Wakeland
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - MinSoo Kim
- Department of Biomedical Informatics, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Lawson A. Copley
- Children’s Medical Center, Dallas, Texas, United States of America
- Texas Scottish Rite Hospital for Children, Dallas, Texas, United States of America
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- * E-mail:
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Gaviria-Agudelo C, Carter K, Tareen N, Pascual V, Copley LA. Gene expression analysis of children with acute hematogenous osteomyelitis caused by Methicillin-resistant Staphylococcus aureus: correlation with clinical severity of illness. PLoS One 2014; 9:e103523. [PMID: 25076205 PMCID: PMC4116206 DOI: 10.1371/journal.pone.0103523] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/03/2014] [Indexed: 12/22/2022] Open
Abstract
Children with acute hematogenous osteomyelitis (AHO) demonstrate a broad spectrum of clinical manifestations, ranging from mild to severe. Several advances have been achieved in the study of host immune response to acute invasive Staphylococcus aureus infections through gene expression analysis. However, previous research has neither attempted to evaluate the response of children with AHO specific to Methicillin-resistant Staphylococcus aureus (MRSA) nor to correlate gene expression with clinical phenotype. Study objective was to correlate gene expression of children with AHO due to MRSA with clinical severity of illness. Whole blood samples were obtained in Tempus tubes from 12 children with osteomyelitis once cultures obtained directly from the site of infection confirmed to be positive for MRSA. Using an Illumina platform and a systems-wide modular analysis, microarray findings from ten of these children were compared to that of nine healthy (age, ethnicity and gender) matched controls and correlated with clinical severity of illness. Children with AHO from MRSA demonstrated over-expression of innate immunity with respect to neutrophil activity, coagulation, inflammatory response, and erythrocyte development. Concurrently, these children demonstrated under-expression of adaptive immunity with respect to lymphocyte activation and activity of T-cell, cytotoxic or NK cell, and B-cell lines. Three over-expressed genes, P2RX1, SORT1, and RETN, and two under-expressed genes, LOC641788 and STAT 4, were significantly correlated with severity of illness. STAT 4 showed the strongest correlation (R2 = –0.83). STAT4 downregulation could potentially explain under-expression of genes related to adaptive immunity in this cohort of patients with AHO. This study identified specific genes which correspond to disease severity during the early hospitalization of children with AHO from MRSA. Pattern recognition of this combination of genes could help to identify in the future severe clinical phenotypes before the disease is fully manifest and direct appropriate attention and resources to those children.
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Affiliation(s)
- Claudia Gaviria-Agudelo
- Department of Pediatrics Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Children’s Medical Center, Dallas, Texas, United States of America
- * E-mail:
| | - Kristen Carter
- University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Naureen Tareen
- Children’s Medical Center, Dallas, Texas, United States of America
| | - Virginia Pascual
- Baylor Institute for Immunology Research, Dallas, Texas, United States of America
- Texas Scottish Rite Hospital, Dallas, Texas, United States of America
| | - Lawson A. Copley
- Children’s Medical Center, Dallas, Texas, United States of America
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Texas Scottish Rite Hospital, Dallas, Texas, United States of America
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Paria N, Copley LA, Herring JA, Kim HKW, Richards BS, Sucato DJ, Rios JJ, Wise CA. The impact of large-scale genomic methods in orthopaedic disorders: insights from genome-wide association studies. J Bone Joint Surg Am 2014; 96:e38. [PMID: 24599210 DOI: 10.2106/jbjs.m.00398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Nandina Paria
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
| | - Lawson A Copley
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
| | - John A Herring
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
| | - Harry K W Kim
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
| | - B Stephens Richards
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
| | - Daniel J Sucato
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
| | - Jonathan J Rios
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
| | - Carol A Wise
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., J.J.R., and C.A.W.) and Department of Orthopaedics (L.A.C., J.A.H., B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-
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Paria N, Copley LA, Herring JA, Kim HKW, Richards BS, Sucato DJ, Wise CA, Rios JJ. Whole-exome sequencing: discovering genetic causes of orthopaedic disorders. J Bone Joint Surg Am 2013; 95:e1851-8. [PMID: 24306708 DOI: 10.2106/jbjs.l.01620] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Nandina Paria
- Sarah M. and Charles E. Seay Center for Musculoskeletal Research (N.P., H.K.W.K., C.A.W., and J.J.R.), Department of Orthopaedics (L.A.C., J.A.H, B.S.R., and D.J.S.), Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for J.J. Rios:
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Abstract
STUDY DESIGN A basic science biomechanical study involving an animal model. OBJECTIVES To evaluate the effect of varying angles of halo pin insertion on the force generated at the pin-bone interface, and thereby the stability of the halo pin-bone interaction during insertion. BACKGROUND DATA Because of variations in the shape and size of the pediatric skull, halo pins often are inserted at various angles rather than perpendicular to the skull. Concern exists that the high complication rate associated with pediatric halo use may result in part from less than ideal structural properties at the halo pin-bone interface. METHODS The authors used a fetal calf skull model to simulate the thickness and structural properties of the pediatric skull. Halo pins were inserted at angles of 0 degree (perpendicular), 10 degrees, 15 degrees, and 30 degrees into skull segments via a halo ring. Load generated at the pin-bone interface was measured using a modified mechanical testing device. Twenty trials were conducted per angle, with the endpoint being specimen failure, pin penetration, or maximum load. RESULTS Mean maximum loads per unit thickness were 82.15 +/- 7.54 N/mm at 0 degree, 68.80 +/- 4.79 N/mm at 10 degrees, 51.49 +/- 5.08 N/mm at 15 degrees, and 42.38 +/- 3.51 N/mm at 30 degrees, There was a significant difference between perpendicular insertion (0 degree) and 15 degrees angles of insertion. There was also a significant difference between the 10 degrees and 30 degrees angles of insertion. CONCLUSIONS Perpendicular halo pin insertion in an immature skull model was shown to result in increased load at the pin-bone interface. This improved structural behavior may help to reduce the incidence of complications of halo application in children.
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Affiliation(s)
- L A Copley
- Department of Orthopaedic Surgery, Eglin Hospital, Eglin AFB, Florida, USA
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Abstract
STUDY DESIGN A case-control study. OBJECTIVES 1) To determine if hemodilution adequately meets the transfusion needs in children who undergo posterior spinal fusion for idiopathic scoliosis and 2) to compare the efficacy of the various methods used to reduce the risk of allogeneic blood transfusion at the authors' institution. SUMMARY OF BACKGROUND DATA Methods to reduce blood loss and avoid allogeneic blood transfusion caused by extensive spinal surgery in adolescents include 1) autologous blood predonation, 2) controlled hypotensive anesthesia, 3) intraoperative salvage of shed blood (cell saver), 4) acute normovolemic hemodilution, and 5) transfusion decisions by clinical judgment rather than by a preset value of hemoglobin. Although all methods have some efficacy, it is not clear which methods, separate or combined, are best in the adolescent scoliosis population. METHODS Hemodilution, hypotensive anesthesia, and cell saver were used in 43 children between June 1996 and July 1997. A comparison group (43 children) underwent similar surgery with hypotensive anesthesia and cell saver, but no hemodilution (between July 1995 and December 1996). These two groups were similar with respect to means of age, levels of instrumentation, magnitude of curvature, estimated blood volume, mean arterial pressure, duration of surgery, duration of anesthesia, estimated blood loss, volume returned from cell saver, volume in the hemovac drain, and length of hospitalization. The groups differed in preoperative hemoglobin and hematocrit and in volume of crystalloid used. RESULTS Transfusions were given to 34 of 43 patients (79%) in the nonhemodilution group. These patients received 61 units of packed cells (57 autologous, 2 donor directed, and 2 allogeneic). In comparison, 16 of 43 patients (37%) in the hemodilution group required transfusion. They received 16 units of packed cells (15 autologous and 1 allogeneic). There was no significant difference between the groups with respect to postoperative hemoglobin and hematocrit immediately after surgery (hemodilution, 10.2/29.2; nonhemodilution, 10.0/29.1), postoperative day 1 (hemodilution, 9.2/26.9; nonhemodilution, 9.2/27.3), and postoperative day 2 (hemodilution 9.0/26.4; nonhemodilution, 9.2/27.1). There were non complications related to the technique of hemodilution in the 43 patients of this group. Cell saver was used in all patients, but sufficient volume to return blood to the patient was available in only 23 hemodilution patients (mean volume, 230 mL) and 25 nonhemodilution patients (mean volume, 215 mL). In only two patients of each group (< 5%) did the volume returned prevent the absolute need for additional transfusions. CONCLUSIONS Hemodilution was safely used as a method to satisfy the perioperative transfusion requirements of adolescents undergoing extensive spinal surgery. By allowing patients to arrive at surgery with a higher preoperative hemoglobin and hematocrit, and by decreasing the quantity of predonated autologous blood-collected and therefore used, the hemodilution method may indirectly decrease the quantity of postoperative autologous transfusions in this population. Cell saver was not shown to be effective, and its selective use is recommended.
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Affiliation(s)
- L A Copley
- Department of Orthopaedic Surgery, Eglin Air Force Base, Florida, USA
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Abstract
To design an improved halo pin for use in pediatric patients, three commonly used halo pins were evaluated with a mechanical testing apparatus and segments of prepared fetal calf skull. The pins were driven through the bone segments while the load at the bone-pin interface was measured. New pins were designed with respect to pin tip and flange width and similarly compared. Mean maximum loads to penetration, normalized for bone segment thickness, were 55.6 N/mm for the PMT Corporation pin, 61.5 N/mm for the Bremer pin, and 73.6 N/mm for the Ace pin. Four new, short tipped pins were designed and compared with the Ace pin, and there was no significant difference. Finally, four new pins were designed with varying flange widths. Mean maximum loads, normalized for bone segment thickness, were 68.9 N/mm for the 4.2 mm flange, 72.2 N/mm for the 4.7 mm flange, 92.9 N/mm for the 5.2 mm flange, and 96.4 N/mm for the 5.7 mm flange. The findings of this investigation are clinically important because they may help to explain the variability in the complication rates seen with the use of different halo systems in children. The three halo pins currently on the market have different pin designs, including tip lengths and flange distances, which contribute to the difference in load to penetration for each pin. The new, wide flanged, short tipped halo pin design might decrease the complication rate of halo use in children by providing an improved capacity to resist penetration despite increased loads of application.
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Affiliation(s)
- L A Copley
- Department of Orthopaedic Surgery, Eglin Hospital, Eglin Air Force Base, FL, USA
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Luchetti WT, Copley LA, Vresilovic EJ, Black J, Steinberg ME. Drain entrapment and titanium to ceramic head deposition: two unique complications following closed reduction of a dislocated total hip arthroplasty. J Arthroplasty 1998; 13:713-7. [PMID: 9741451 DOI: 10.1016/s0883-5403(98)80018-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Postoperative dislocation remains one of the most frequent complications following total hip replacement. In this report, a case is presented that illustrates two potential concerns with postoperative dislocation and subsequent closed reduction. The first complication presented in this report is entrapment of a closed drainage system tube in the joint space following closed reduction. The second complication, transfer of metallic debris to a ceramic femoral head from contact with an acetabular shell during closed reduction, was documented by analysis of a femoral head using scanning electron microscopy and energy dispersive x-ray spectrometry. This report emphasizes the need for the surgeon to express caution when relocating a dislocated hip, particularly when a closed drainage system is used postoperatively.
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Affiliation(s)
- W T Luchetti
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Abstract
The evaluation of children with cervical spine disorders requires an understanding of the anatomic and developmental features that are particular to the pediatric spine. In this article, cervical spine developmental anatomy is briefly reviewed, along with common radiographic features of the pediatric cervical spine. The epidemiology, clinical presentation, and management of congenital cervical anomalies are considered. The evaluation and management of pediatric cervical trauma are also reviewed. Other disorders with common cervical spine involvement, such as skeletal dysplasias, connective tissue disorders, inflammatory arthritides, and storage disorders, are discussed.
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Affiliation(s)
- L A Copley
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Williams GR, Copley LA, Iannotti JP, Lisser SP. The influence of intramedullary fixation on figure-of-eight wiring for surgical neck fractures of the proximal humerus: a biomechanical comparison. J Shoulder Elbow Surg 1997; 6:423-8. [PMID: 9356930 DOI: 10.1016/s1058-2746(97)70048-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The resistance to torsional load was measured in a human cadaver model of a surgical neck fracture. Ten fresh-frozen human cadaver shoulders were thawed, dissected free of soft tissue attachments, and analyzed with dual energy x-ray absorptiometry to establish bone mineral density. Osteotomies were fixed with figure-of-eight wire alone and figure-of-eight wire supplemented with intramedullary Enders rods. Intramedullary Enders rods improved the mean maximum load by 1.5 times (p < 0.05). No statistically significant correlation was found between mean maximum load and bone mineral density.
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Affiliation(s)
- G R Williams
- Shoulder Service Hospital, University of Pennsylvania, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
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Abstract
Between 1988 and 1994, 128 consecutive children with grade III supracondylar humeral fractures presented for treatment at our hospital. Seventeen had absent or diminished (detected with Doppler but not palpable) radial pulses on initial examination. Fourteen of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each of these three children was explored immediately and found to have a significant vascular injury requiring repair. Two of the 14 children who had initially regained their pulses had a progressive postoperative deterioration in their circulatory status during the first 24-36 h, including loss of the radial pulse. Both of these children had arteriograms that identified vascular injuries. Both underwent exploration and bypass grafting. One of these two children had been transferred 48 h after injury, resulting in delay of management of his vascular impairment. Despite exploration, vascular repair, and fasciotomy, he ultimately developed Volkmann's ischemic contracture. All five children with significant vascular injuries had absent or diminished radial pulses on presentation. Immediate reduction and fixation followed by careful evaluation and treatment of ischemia were associated with excellent outcome in four of the five children.
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Affiliation(s)
- L A Copley
- Department of Pediatric Orthopaedics, Children's Hospital of Philadelphia, Pennsylvania 19104-4399, USA
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