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Although obesity is an established modifiable risk factor for multiple myeloma (MM), several nuanced aspects of its relation to MM remain unelucidated, limiting public health and prevention messages. We analyzed prospective data from the Nurses' Health Study and Health Professionals Follow-Up Study to examine MM risk associated with 20-year weight patterns in adulthood, body shape trajectory from ages 5 to 60 years, and body fat distribution. For each aforementioned risk factor, we report hazard ratios (HRs) and 95% confidence intervals (CIs) for incident MM from multivariable Cox proportional-hazards models. We documented 582 incident MM cases during 4 280 712 person-years of follow-up. Persons who exhibited extreme weight cycling, for example, those with net weight gain and one or more episodes of intentional loss of at least 20 pounds or whose cumulative intentional weight loss exceeded net weight loss with at least one episode of intentional loss of 20 pounds or more had an increased MM risk compared with individuals who maintained their weight (HR = 1.71, 95% CI = 1.05 to 2.80); the association was statistically nonsignificant after adjustment for body mass index. We identified four body shape trajectories: lean-stable, lean-increase, medium-stable, and medium-increase. MM risk was higher in the medium-increase group than in the lean-stable group (HR = 1.62, 95% CI = 1.22 to 2.14). Additionally, MM risk increased with increasing hip circumference (HR per 1-inch increase: 1.03, 95% CI = 1.01 to 1.06) but was not associated with other body fat distribution measures. Maintaining a lean and stable weight throughout life may provide the strongest benefit in terms of MM prevention.

A variety of strategies are utilized for management of pediatric diaphyseal femur fractures, depending chiefly on the age of the patient. Other factors that can influence the selection of a technique—which range from skeletal traction with spica casting to immediate spica casting, flexible intramedullary nailing, rigid intramedullary rodding, or plate fixation—are weight, fracture severity, associated injuries, and underlying medical or musculoskeletal conditions. The available evidence regarding technique, outcomes, and complications of the aforementioned treatment options remains largely insufficient, and, at times, conflicting, which contributes to the challenges in management decisions. Considerable controversy has arisen over several topics, particularly the optimal treatment for patients aged 5 to 12 years and accepted standards of treatment. This review is designed to provide perspective for some of the most recent influential literature on pediatric diaphyseal femur fracture treatment in light of established evidence and evolving controversies.

Objectives: Apophyseal avulsion fractures of the hip and pelvis occur almost exclusively in the adolescent population, with greater numbers being seen recently as the popularity and intensity of youth sports increases. Limited evidence exists detailing the demographics or distribution of these fractures by injury site. The goal of the current study was to present a comprehensive perspective on 437 of these fractures, including the indications and clinical course of 25 cases that underwent surgical intervention. Methods: All cases of an apophyseal avulsion fracture of the hip or pelvis between the years of 1981-2012 at a tertiary care pediatric center underwent radiographic and chart review, including operative details for that sub-population. Demographic data was analyzed, along with radiographic displacement, healing times, and return to sports for both groups. Results: 413 patients underwent definitive non-operative treatment, 72% of which were male. The mean age was 14.5 years. The anatomic site of injury was well-distributed: AIIS 29%, ASIS 27%, ischial tuberosity 17%, lesser trochanter 15%, and iliac crest 11%. Half of all injuries occurred during one of three different athletic activities (soccer 26%, track 13%, baseball/softball 11%), with a wide range of sports in the overall cohort. In the 287 nonop cases with adequate follow up data to confirm mean radiographic union and time of return to sports (RTS), healing occurred at 2.7 months and RTS at 2.8 months respectively. The mean age of the cohort of 25 patients who ultimately required operative treatment was 15.7 years, with 72% of cases being initially treated with nonoperative measures. The ischial tuberosity was the most common (64%) anatomic site with others including AIIS 16%, iliac crest 16%, and ASIS 4%. Excision of the apophyseal fragment was the intervention pursued for 48% of cases, with the mean time to union of 4.8 months in 11 cases which underwent fixation and had adequate follow up data. Conclusion: In over 400 cases of apophyseal avulsion fractures in an adolescent population, 94% were successfully treated nonoperatively, with mean times of healing and return to sports under 3 months. Most cases requiring surgery failed primary conservative care, many of which underwent fragment excision, rather than fixation, due to the chronic nature of their preoperative period. Better understanding of the rare indications for early fixation and functional outcome measures of both nonoperative and operative management of these injuries is warranted, particularly given their increasing frequency paralleling a rise in overuse and youth sports injuries.

Objectives: Clavicle fractures are common in children and adolescents and are traditionally treated nonoperatively. With youth sports participation increasing in popularity, including contact sports, the frequency of such injuries may be increasing. The purpose of this study was to examine institutional trends in the volume of operative plate fixation for mid-shaft clavicle fractures in children and adolescents. Methods: Medical records, identified through a departmental database and cross-referenced for accuracy against billing records using ICD-9 codes, were retrospectively reviewed to identify otherwise healthy 10-18 years-olds who presented with a clavicle shaft fracture between 1999-2011 at a single tertiary-care pediatric hospital. Demographic data, fracture characteristics and treatment details were analyzed. Radiographic review of operative cases was used to confirm fracture location and surgical implant. Annual volumes were determined for the overall number of clavicle fractures, mid-shaft clavicle fractures, and mid-shaft fractures that underwent operative plate fixation. Additionally, the annual rate was determined for the number of operative cases among all mid-shaft fractures. Kendall’s Tau-b was used to assess the relationship between case volume and time. Results: From 1999-2011, a total of 882 patients were seen at our institution with a diaphyseal clavicle fracture (mean age: 14.3), 644 (73%) of which were mid-shaft. Of these 644, 111 were treated with operative plate fixation (mean age: 15.9). There was a significant increase in the number of mid-shaft clavicle fractures seen annually over that period, from 20/yr to 85/yr (r=0.80, p<0.0001). The percent of mid-shaft clavicle fractures treated with plate fixation also increased significantly from 5% to 25% (r=0.84, p<0.0001) while the rate of mid-shaft fractures among all diaphyseal fractures remained more stable. Among the mid-shaft fracture cases that received operative plate fixation, 53.2% presented with fractures received during a competitive sporting event. Conclusion: The volumes of clavicle fractures and of mid-shaft clavicle fractures treated operatively appear to be increasing. Additionally, despite a lack of evidence based support, the frequency of operative plate fixation of mid-shaft clavicle fractures appear to be increasing in the pediatric population. Many of these fractures are of a sports-based etiology.

Multiple myeloma (MM) is a yet incurable malignancy of mature B lymphocytes that account for approximately 1% of all cancers in Whites and 2% of all cancers in Blacks in the United States (US). Demographic patterns of MM incidence and mortality are well described, but more precise characterization of individuals at the greatest risk for MM to have proven elusive. A vast body of literature on the etiology of MM identifies a few likely risk factors ? including family history of MM or MGUS and the potentially modifiable risk factor, obesity ? but also illustrates the inconsistencies that arise in the epidemiologic study of rare and lethal malignancies due to inherent methodologic and practical challenges. The study of risk factors for the benign precursor condition called monoclonal gammopathy of undetermined significance (MGUS) lags behind that of MM. However, recent studies on MGUS have provided intriguing new insights on the natural history of monoclonal gammopathy, including demonstration of the occurrence of MGUS prior to essentially all diagnoses of MM and the suggestion that MGUS and MM share several etiologic factors. Improved characterization of risk factors for MM, MGUS, and MGUS progression is necessary to inform the development of MM prevention strategies. In the following review, we offer a summary of the current understanding of the descriptive epidemiology and etiology of MM and MGUS and suggest areas of focus for future research.

Background Acute Heart Failure (AHF) is a potentially lethal pathology and is often encountered in the prehospital setting. Although an association between prehospital arterial hypercapnia in AHF patients and admission in high-dependency and intensive care units has been previously described, there is little data to support an association between prehospital arterial hypercapnia and mortality in this population. Methods This was a retrospective study based on electronically recorded prehospital medical files. All adult patients with AHF were included. Records lacking arterial blood gas data were excluded. Other exclusion criteria included the presence of a potentially confounding diagnosis, prehospital cardiac arrest, and inter-hospital transfers. Hypercapnia was defined as a PaCO 2 higher than 6.0 kPa. The primary outcome was in-hospital mortality, and secondary outcomes were 7-day mortality and emergency room length of stay (ER LOS). Univariable and multivariable logistic regression models were used. Results We included 225 patients in the analysis. Prehospital hypercapnia was found in 132 (58.7%) patients. In-hospital mortality was higher in patients with hypercapnia (17.4% [23/132] versus 6.5% [6/93], p  = 0.016), with a crude odds-ratio of 3.06 (95%CI 1.19–7.85). After adjustment for pre-specified covariates, the adjusted OR was 3.18 (95%CI 1.22–8.26). The overall 7-day mortality was also higher in hypercapnic patients (13.6% versus 5.5%, p  = 0.044), and ER LOS was shorter in this population (5.6 h versus 7.1 h, p  = 0.018). Conclusion Prehospital hypercapnia is associated with an increase in in-hospital and 7-day mortality in patient with AHF.

Background Acute Heart Failure (AHF) is a common condition that often presents with acute respiratory distress and requires urgent medical evaluation and treatment. Arterial hypercapnia is common in AHF and has been associated with a higher rate of intubation and non-invasive ventilation in the Emergency Room (ER), but its prognostic value has never been studied in the prehospital setting. Methods A retrospective study was performed on the charts of all patients taken care of by a physician-staffed prehospital mobile unit between June 2016 and September 2019 in Geneva. After approval by the ethics committee, charts were screened to identify all adult patients with a diagnosis of AHF in whom a prehospital arterial blood gas (ABG) sample was drawn. The main predictor was prehospital hypercapnia. The primary outcome was the admission rate in an acute care unit (ACU, composite of intensive care and high-dependency units). Secondary outcomes were ER length of stay (LOS), orientation from ER (intensive care unit, high-dependency unit, general ward, discharge home), intubation rate at 24 h, hospital LOS and hospital mortality. Results A total of 106 patients with a diagnosis of AHF were analysed. Hypercapnia was found in 61 (58%) patients and vital signs were more severely altered in this group. The overall ACU admission rate was 48%, with a statistically significant difference between hypercapnic and non-hypercapnic patients (59% vs 33%, p  = 0.009). ER LOS was shorter in hypercapnic patients (5.4 h vs 8.9 h, p  = 0.016). Conclusions There is a significant association between prehospital arterial hypercapnia, acute care unit admission, and ER LOS in AHF patients.

Background:Carbon monoxide (CO) poisoning is an important cause of morbidity and mortality worldwide. Symptoms are mostly aspecific, making it hard to identify, and its diagnosis is usually made through blood gas analysis. However, the bulkiness of gas analyzers prevents them from being used at the scene of the incident, thereby leading to the unnecessary transport and admission of many patients. While multiple-wavelength pulse oximeters have been developed to discriminate carboxyhemoglobin (COHb) from oxyhemoglobin, their reliability is debatable, particularly in the hostile prehospital environment.Objective:The main objective of this pilot study was to assess whether the Avoximeter 4000, a transportable blood gas analyzer, could be considered for prehospital triage.Methods:This was a monocentric, prospective, pilot evaluation study. Blood samples were analyzed sequentially with 2 devices: the Avoximeter 4000 (experimental), which performs direct measurements on blood samples of about 50 µL by analyzing light absorption at 5 different wavelengths; and the ABL827 FLEX (control), which measures COHb levels through an optical system composed of a 128-wavelength spectrophotometer. The blood samples belonged to 2 different cohorts: the first (clinical cohort) was obtained in an emergency department and consisted of 68 samples drawn from patients admitted for reasons other than CO poisoning. These samples were used to determine whether the Avoximeter 4000 could properly exclude the diagnosis. The second (forensic) cohort was derived from the regional forensic center, which provided 12 samples from documented CO poisoning.Results:The mean COHb level in the clinical cohort was 1.7% (SD 1.8%; median 1.2%, IQR 0.7%-1.9%) with the ABL827 FLEX versus 3.5% (SD 2.3%; median 3.1%, IQR 2.2%-4.1%) with the Avoximeter 4000. Therefore, the Avoximeter 4000 overestimated COHb levels by a mean difference of 1.8% (95% CI 1.5%-2.1%). The consistency of COHb readings by the Avoximeter 4000 was excellent, with an intraclass correlation coefficient of 0.97 (95% CI 0.93-0.99) when the same blood sample was analyzed repeatedly. Using prespecified cutoffs (5% in nonsmokers and 10% in smokers), 3 patients (4%) had high COHb levels according to the Avoximeter 4000, while their values were within the normal range according to the ABL827 FLEX. Therefore, the specificity of the Avoximeter 4000 in this cohort was 95.6% (95% CI 87%-98.6%), and the overtriage rate would have been 4.4% (95% CI 1.4%-13%). Regarding the forensic samples, 10 of 12 (83%) samples were positive with both devices, while the 2 remaining samples were negative with both devices.Conclusions:The limited difference in COHb level measurements between the Avoximeter 4000 and the control device, which erred on the side of safety, and the relatively low overtriage rate warrant further exploration of this device as a prehospital triage tool.