Background
Leukemia, lymphoma and myeloma accounted for nearly 10% of new cancer cases and more than 50,000 deaths in 2022. Although multiple treatment modalities exist, Chimeric Antigen Receptor (CAR) T cells have been particularly useful, using genetic modification of a patient’s harvested T cells to better target cancer cells. Current methods of altering antigen specificity and targeting, however, have proven to be inadequate over time, requiring additional genes to boost the immune response. One such gene is OX40, a co-stimulatory cassette member of the Tumor Necrosis Factor Receptor (TNFR) superfamily that is thought to boost T cell migration, proliferation and survival. Given these inherent qualities of OX40, we hypothesized that incorporating OX40 variants into CAR T cells could enhance their duration of response and tumor-targeting capabilities.

Methods
We combined variants of the OX40 gene with our 2nd generation CAR T cells, adding a costimulatory cassette to CD19 CARs. We started with transformations of plasmid cloning vectors containing OX40 genes, using these CD19 CAR/OX40 constructs to transiently transfect retroviral cell lines. The transient virus produced was used to transduce donor human T cells, inducing uptake of the CD19 CAR/OX40 vectors. Once transduced, T cell reactivity and longevity were assessed using ELISA assays, flow cytometry and cell counts.

Results
We successfully used our CD19 CAR/OX40 T cells to transduce various human donor T cells, demonstrating a 1:1 linear relationship between OX40 and CAR T cell expression via flow cytometry. We also found that the constructs produced markedly higher levels of OX40+ expression compared to endogenous levels, particularly in regulatory T cells. When tested against a Burkitt’s lymphoma line, our
constructs showed reactivity above the standard deviation. With regards to longevity, our highest proliferating construct was a truncated version that survived over 60 days in culture.

Conclusion
We were able to produce CD19 CAR/OX40 donor T cells that had increased longevity and enhanced hematologic tumor targeting capabilities over time, likely due to an increased regulatory T cell response. Surprisingly, our truncated construct survived and proliferated the most, suggesting that the missing signaling domain could be key to balancing OX40’s enhanced growth effects versus over-proliferation.
With the endogenous signaling domain in place, OX40 is a promising addition to our CAR repertoire, boosting the in vitro antitumor response while balancing sustained proliferation and longevity. Our next steps will include translation into in vivo mouse models before bringing it to patients’ bedsides as a novel immunotherapy treatment.

Driving CARs Forward: An OX40 Tale of Immunotherapy

Background:
Since the release of the COVID-19 vaccines, vaccine safety and hesitancy have been significant topics of contention. While studies have described COVID-19 vaccine receptiveness in the general population, its uptake in inflammatory bowel disease (IBD) patients is not well-characterized. This study aimed to investigate COVID-19 immunization rates and barriers to immunization in IBD patients.

Methods:
A retrospective study investigated 545 adult patients with Crohn’s disease (CD) or ulcerative colitis (UC) seen at an IBD subspecialty clinic at a university-based tertiary care center between January 1, 2020 and October 31, 2021. For each patient, data collected includes: demographics, past medical history, use of immunosuppressive medications, and COVID-19 and influenza immunization status. COVID-19 immunization rates in the general U.S. population were obtained from data published by the Center for Disease Control and Prevention (CDC).

Results:
As of October 31, 2021, 87.7% of IBD patients had received at least one dose of the COVID-19 vaccine, 84.4% had received the full vaccine series, and 21.8% had received the booster and/or additional dose. COVID-19 immunization rates in IBD patients were significantly higher than in the general population (p < 0.001). No significant difference was found in COVID-19 immunization rates when stratified by IBD type (CD vs UC), sex, or concurrent immunosuppressive therapy. Patients who received the COVID-19 booster/additional dose were older (mean age = 54.0 ± 17.9) than those who did not (mean age = 50.0 ± 16.5; p = 0.02). Asthmatic patients had a significantly lower rate of receiving one dose (79.5% vs 89.2%, p = 0.02) or the full series (74.7% vs 86.1%, p = 0.01) of the COVID-19 vaccine compared to non-asthmatics. Tobacco users had a significantly lower rate of receiving the full COVID-19 vaccine series (73.9% vs 85.9%, p = 0.02). Patients previously immunized for influenza had a significantly higher rate of receiving the COVID-19 booster/additional dose than those who had not (31.5% vs 17.6%, p < 0.001). History of hypertension, hyperlipidemia, heart failure, diabetes, malignancy, ischemic heart disease, pulmonary circulation disorder, or COPD did not significantly affect COVID-19 immunization rates.

Conclusion:
Our study reveals that IBD patients are more receptive to the COVID-19 vaccine compared to the general U.S. population. Immunosuppressive therapy did not affect IBD patients’ uptake of the COVID-19 vaccine, although younger age, asthma, and tobacco use were associated with decreased uptake. Particular attention is required when counseling IBD patients to identify barriers to vaccination and increase COVID-19 immunization rates.

Uptake of COVID-19 Immunization in the Inflammatory Bowel Disease Population

Objective: Femoral endarterectomy is a common vascular procedure. Previous data have shown that it is associated with elevated risk of surgical site infection (SSI) that is estimated to be 15% or higher. Obesity is a known risk factor for SSI. Presence of an overhanging pannus may be associated with increased risk of wound infections, due to decreased local hygiene and increased frictional forces. The aim of the current study was to study the relationship between pannus size and SSI after femoral endarterectomy performed at a rural tertiary medical center. 
Methods: Retrospective chart review was used to evaluate femoral endarterectomy performed between January 1, 2010 and December 31, 2019. Patients were excluded if they did not have a CTA or CT abdomen/pelvis within 6 months of endarterectomy. Cases were identified using CPT code, and basic demographic data and preoperative risk factors were identified. Incidence of postoperative wound infection was recorded. Perioperative CT scans were evaluated using TeraRecon to measure the area of the subcutaneous tissue overlying the common femoral artery on the operative leg, hypothesized to be a surrogate for pannus size. 
Results: The total number of participants was 250, with a 17% incidence of SSI. There was a significant difference in pannus size in those who developed postoperative SSI (30.5 cm2 ± 17.2 cm2) compared to those who did not (24.5 cm2 ± 13.7 cm2) (p =0.022). Pannus area was on average 6cm2 larger in those who developed postoperative SSI. BMI, obesity, hypertension, and diabetes were associated with pannus area but were not strong predictors of SSI. BMI and pannus size were strongly correlated, although BMI was more variable as pannus size increased. A 5cm2 increase in pannus size was associated with an absolute relative risk of SSI of 1.10. In patients with pannus size ≤26cm2, 12% had an SSI; in patients with pannus >26cm2, 24% had an SSI; the relative risk of SSI for pannus >26cm2 was 1.99. 
Conclusions: This study highlights a novel method to measure pannus size, which is a stronger predictor than BMI alone for postoperative SSI after femoral endarterectomy. This can help guide preoperative risk identification and decision making, and assign more aggressive postoperative infection prevention measures to patients at risk of SSI.

Relation of pannus size to postoperative wound infection after femoral endarterectomy

Background:
First-line treatment for major depressive disorder (MDD) include cognitive behavioral therapy (CBT) and/or antidepressant medications (ADM). However, these treatments can be highly effective in one patient but ineffective in another. Previous treatment selection biomarker studies using resting state fMRI implicate differential subcallosal connectivity to the left anterior insula, left ventromedial prefrontal, and left periaqueductal gray in CBT and medication remitters (Dunlop AJP 2017). Structural connectivity changes that might mediate these functional connectivity patterns are unknown. Therefore, we evaluated pretreatment White matter (WM) integrity in treatment naïve MDD patients as a function of differential 3-month clinical outcome to monotherapy with CBT or ADM. 
Methods
A retrospective analysis of diffusion-weighted imaging scans (DWI) was performed in 167 treatment naive MDD patients randomized to 12 weeks of CBT or ADM. Subjects were grouped into CBT or ADM remitters (HDRS17 score <7 at 10 and 12 weeks) and CBT or ADM failure (HDRS score change <30%). A Whole brain fractional anisotropy (FA) map was calculated for each subject using Fdt toolbox in FMRIB and Tract-Based Spatial Statistics (TBSS) generated for statistical comparison across outcome groups. A voxel-wise 2 x 2 ANOVA: treatment (CBT/ADM) by outcome (remitter/nonresponder) was performed using the AFNI 3dMVM toolbox. Lastly, regional WM changes were correlated with HDRS score changes with treatment. 
Results
A significant treatment by outcome interaction was identified affecting WM tracts adjacent to the left anterior insula, left supplementary motor area, and left hippocampus (p < 0.001). Post hoc analysis revealed ADM remitters and CBT nonresponders show higher FA values in the left insula and SMA compared to both ADM nonresponders and CBT remitters, similar to the location and differential pattern of functional connectivity. In contrast, ADM remitters and CBT nonresponders show lower FA in the left hippocampus compared to ADM nonresponders and CBT remitters. The left SMA and hippocampus showed significant correlation (R2=0.05 p<0.005) with HDRS score improvement in all groups. The VMPFC and SMA showed similar results within the ADM group. The CBT group showed significant correlation with the DLPFC (R2=0.17 p<0.005).
Conclusion
These findings identify differential WM integrity in WM tracts adjacent to the insula, SMA, and hippocampus in remitters and failures to CBT and ADM. These structural and functional connectivity patterns may define imaging biotypes that guide optimal first line MDD treatment selection. Finally, these findings implicate WM connectivity in differential predictive outcomes in MDD treatment success by treatment.

White matter markers for treatment outcomes in major depressive disorder

Background
Breast cancer related lymphedema effects one in five breast cancer survivors. This debilitating complication is due to transection and obstruction of lymph flow during surgery. Although lymphedema has been met with new surgical and clinical treatments, little is known about the anatomy of the lymphatic system. Diagnostic dyes have become a vital tool in surgery and lymphatic mapping. Microsurgeons utilize florescent Indocyanine green (ICG) distally in extremities to identify afferent lymphatic pathways. In immediate lymphatic reconstruction (ILR) following mastectomies, ICG helps microsurgeons locate transected channels for anastomosis to a neighboring vein, restoring lymph flow. Isosulfane blue (ISB) is an easily visible dye favored by breast surgeons. In axillary reverse mapping, surgeons inject ISB into the proximal upper extremity, allowing them to locate and preserve lymphatic channels wherever possible. The benefit of utilizing both ICG and ISB during axillary dissection and ILR is reliable visualization of lymphatics intraoperatively. Using dual-dye technique, we aim to differentiate afferent lymphatic drainage from the distal and proximal upper extremity into the axilla.

Methods
To identify the distal and proximal lymphatic zones in breast cancer patients receiving ILR following axillary dissection, ICG and ISB were injected in the ipsilateral arm. ICG was injected intradermally at the first and third webspace and volar wrist, while ISB was injected at the same depth into the upper medial arm. Operative reports were reviewed to determine how often each dye was visualized during axillary dissection. Details of the anastomoses were also documented.

Results
Twenty-six breast cancer patients undergoing ILR following axillary lymph node dissection were reviewed. Twenty-one patients met the criteria of dual-dye technique. ICG was seen in 100% of axillary dissections. ISB was seen with ICG in 61.9% of procedures, indicating a shared lymphatic pathway. ISB was never seen alone. The average lumen size of all lymphatic channels was 1.12mm. An average of 2.46 channels were bypassed to an average of 1.65 veins per procedure. Venous lumen size ranged from 1 to 3 mm. 

Conclusion
Dual-dye technique allows for visualization of axillary lymphatic drainage by the breast and plastic surgeons intraoperatively. Utilizing dyes with different visual properties enabled us to determine if lymphatic flow originated from the distal or proximal upper extremity. This technique could provide useful anatomic data in correlating the development of lymphedema to regional lymphatic drainage within the arm, allowing potential anastomotic connections and clinical treatments. 


Differentiating Afferent Lymphatic Pathways Using Dual-Dye Technique During Immediate Lymphatic Reconstruction

Introduction: Hand-foot-mouth disease (HFMD) is a common childhood infectious disease. Atypical skin findings of HFMD, often associated with coxsackievirus A6 (CVA6), were first reported in 2008, with increasing reports worldwide since. Atypical lesions of HFMD often involve sites beyond the palms and soles and tend to have unusual, polymorphic morphology. 
Methods: A systematic review was conducted on clinical features and outcomes of pediatric HFMD with atypical cutaneous manifestations.
Results: Eighty-five studies were included, representing 1,359 cases with mean age 2.4 years and a male predominance of 61%. The most reported morphologies were vesicles (53%), papules (49%), and bullae (36%). Other morphologies included eczema herpeticum-like (19%), purpuric/petechial (7%), and Gianotti Crosti-like (4%). Common atypical sites included the arms and/or legs (47%), face (45%), and trunk (27%). CVA6 was identified in 63% of cases. Symptoms resolved in a mean of 10 days. Overall, 16% of cases received treatment, most commonly with acyclovir, intravenous antibiotics, or topical steroids. The most common complications were nail changes (21%) and desquamation (4%) which occurred a mean of three and two weeks after symptoms, respectively. 
Conclusion: Due to unusual morphologies resembling other conditions, HFMD with atypical cutaneous findings may be misdiagnosed, leading to inappropriate and unnecessary investigations, hospitalization, and treatment. Greater awareness of atypical presentations of HFMD is warranted to improve patient care and counseling on infection control precautions.

Atypical Cutaneous Findings of Hand-Foot-Mouth Disease in Children: A Systematic Review

Background
Healthcare disparity is the United States has been a long-standing issue. A disease of interest is diabetic retinopathy, one of the leading causes of blindness in the United States, as the minorities are disproportionately affected. Treatment regimens often consist of panretinal photocoagulation (PRP) and intravitreal injections (IVI) with anti-vascular endothelial growth factor (anti-VEGF). However, the efficacy of the treatment regimens as demonstrated in clinical trials have been limited in real-world settings as these necessitate frequent follow-ups, a challenge given that 25 to 51% of patients with diabetic retinopathy are lost to follow-ups. Furthermore, the effect of LTFU in itself on final outcomes have not been studied to date. Therefore, we examined factors associated with LTFU, the effect of LTFU on proliferative diabetic retinopathy, and its interaction with different treatments.

Methods
A retrospective cohort study at a large safety net hospital examined 271 eyes of 271 patients with PDR that received PRP or IVI over a 2-year period. LTFU was defined as failure to return to care for at least 6 months. Baseline patient characteristics were collected. Ocular data was gathered at the visit before being LTFU, the return visit after being LTFU, and the final clinic visit. Univariate analyses and multivariate regression with adjustment for multiple comparisons to control confounders were conducted. 

Results
A history of LTFU was associated with subsequent neovascularization elsewhere (NVE) and tractional retinal detachment (TRD) but not with final visual acuity (VA). Among those LTFU, those who received IVI were not at higher risk of TRD than those receiving PRP.

Conclusion
Undergoing PRP is associated with LTFU. LTFU is independently associated with subsequent development of NVE and TRD, but not with the final visual acuity. One rationale in opting for PRP over IVI for managing PDR was the risk of the patient being LTFU, but our study did not demonstrate a difference between those who received PRP prior to LTFU and those who received IVI prior to LTFU in terms of the rate of subsequent TRD formation. Further studies should expand upon those findings to design better interventions strategies. 


Out of Sight, Not Out of Mind: The Effect of Loss to Follow-Up on on Proliferative Diabetic Retinopathy

Background: Life adversities, such as neighborhood disadvantage and lower household incomes, are associated with well-established impairments on language development, which predict academic difficulties throughout school. These language delays are observable by age 2, but it remains unclear if adversities experienced in utero affect neurological underpinnings of language development before delays emerge. Of interest are 3 white matter tracts implicated in early language skills: the corpus callosum (CC), inferior fronto-occipital fasciculus (IFOF), and uncinate (Unc).

Methods: A longitudinal cohort of 160 term-born (>36 weeks gestation) neonates were recruited from the eLABE study at Washington University, which oversampled St. Louis families exposed to poverty. Structural equation modeling was used to create 2 latent constructs of prenatal adversity. The first, “social disadvantage”, aggregates neighborhood disadvantage, family income, insurance status, maternal education, and diet. The second, “maternal psychosocial stress”, models maternal depression, stress, life adversities, and perceived discrimination. At birth, diffusion MRI data were collected, and parameters for white matter tract development were created using probabilistic tractography in FSL. In-person follow-up at age 2 evaluated child language skills. To assess the independent and interactive effects of prenatal adversities and neonatal white matter microstructure on language skills, stepwise linear regression models were conducted after adjustment for child sex, gestational age, and postmenstrual age at scan. 


Results: Prenatal social disadvantage (p=.00) and maternal psychosocial stress (p=.00) predicted significantly lower language scores by age 2. However, in a joint model, only the effects due to social disadvantage remained significant. Lower CC fractional anisotropy predicted significantly lower language scores (p=.02) independently of social disadvantage (p=.00). IFOF and Unc were not predictive of language ( p > .05). To examine the relationship between CC maturation and social disadvantage, a moderation analysis was conducted after dichotomizing families’ income into above and below 200% the federal poverty line (FPL), as most federal assistance programs use this value as a threshold for benefit eligibility. The interaction term was not significant (p= .11), but upon plotting results by income group, the slope for infants above 200% FPL was somewhat stronger. 

Conclusion: This study suggests that prenatal adversity, particularly social disadvantage, and immature CC myelination are strong predictors of language delays by age 2. These data can be used as empirical evidence to advocate for increased funding of federal assistance programs that benefit pregnant people (ex., WIC) and downstream fetal brain development. By continuing to explore the relationship between prenatal adversities on fetal brain development and emerging language skills, future studies will continue to identify specific neurological markers of early language development to allow clinicians to intervene before delays emerge.

The Effects of Prenatal Adversity and Neonatal White Matter Microstructure on Child Language Skills at Age 2

Spalt-Like Transcription Factor 4 (SALL4), a member of the SALL family, is a regulator of embryonic stem cell development that plays a crucial role in cell renewal and proliferation. SALL4 expression is normally repressed in most adult organs but is reactivated in a multitude of solid and blood cancers and upon treatment with hypomethylating agents (HMA). There is outstanding clinical need for the development and validation of a less invasive SALL4 expression assay via peripheral blood, which can be used for monitoring patients on HMA treatment and SALL4-targeting therapy such as molecular glue degraders.

Using the Simoa (Single Molecule Array) platform, a bead-based digital enzyme-linked immunosorbent assay, we cross-tested 5 commercial SALL4 antibodies and 13 antibody pair combinations, using the best antibody pair to test the matrix effects of human plasma, buffy coats, and bone marrow aspirates. Quantitative assay development further included creating recombinant protein standards, antibody pair screening and validation, and pre-analytical optimization. Upon completion of these steps, a retrospective cohort analysis via patient peripheral blood samples is currently being conducted to validate assay accuracy and precision. Additionally, we are aiming to conduct prospective studies to explore the role of the SALL4 protein biomarker in risk stratification and treatment monitoring.

Thus far, for quantitative assay development, we have successfully expressed and purified full-length SALL4 which will be used to calibrate the standard curve and determine the assay’s limit of quantification. We also optimized multiple pre-analytic steps, including our cell lysis protocol, isolation of buffy coats using density gradient separation, and sample collection method comparison. The best antibody pair can detect both SALL4A and SALL4B isoforms, with stronger signal detected with the SALL4A isoform. For the retrospective cohort validation, we have obtained samples for analysis for liver cancer, myelodysplastic syndrome (MDS), and acute myeloid leukemia (AML) with plans to expand to breast cancer and lung cancer.

In conclusion, we have developed an ultrasensitive SALL4 protein expression diagnostic assay for use in monitoring patient treatment response and for guiding targeted therapy by analyzing peripheral blood for both solid and liquid tumors. Future steps include validating the diagnostic assay for specificity and sensitivity in a retrospective cohort analysis and conducting prospective studies to explore the role of the SALL4 protein biomarker for risk stratification, monitoring on HMA treatment, and guiding targeted therapy.

Ultrasensitive detection of SALL4 oncoproteins for the use in therapeutic monitoring

Background
Pack-year history is an invaluable clinical tool for measuring tobacco-associated disease risk and determining eligibility for lung cancer screening with low-dose computed tomography. Patient-reported measures of smoking history have demonstrated strong test-retest reliability across various survey methods, but the variation between research and clinical settings suggests that non-standardized smoking history interview questions in community practice may not always reveal the true extent of a patient’s tobacco exposure. To date, no study has compared patient responses to differently phrased questions assessing the same measure of smoking history. We hypothesize there is a significant discordance between patient-reported number of years smoked and calculated elapsed time between age at initiation and age at cessation (or present age if current smoker).

Methods
This was a two-month prospective survey-based study conducted at the Western Michigan University Homer Stryker M.D. School of Medicine's Internal Medicine resident clinic in Kalamazoo, Michigan, including patients with a documented smoking history in their electronic medical records. Through verbal interviews, we collected data on number of years smoked, packs per day, and age of smoking initiation/cessation. Primary outcome variables were total years smoked and calculated pack-years. Secondary outcome variables were gender, age, and age of smoking initiation.

Results
There were 124 respondents (36% male, 63% female, 1% non-binary) with an average age of 55 and average smoking history of 1.2 packs per day. Of them, 46% were current and 54% were former smokers. Using a paired sample one-tail t-test, we compared patient-reported years smoked (M=22.06, SD=12.44) to calculated years based on age of initiation/cessation (M=24.03, SD=13.53), which showed a significant mean difference of 1.97 years (95% CI 1.16- 2.78, t=4.05, p<0.001). This discordance translated to a 21.29% increase in pack-years (from 24.32 to 29.50 pack-years) and a mean difference of 5.21 pack-years (95% CI 1.04-9.38, t=2.07, p=0.02).

Conclusion
Our study underscores the importance of critically evaluating the ways in which we gather a patient’s smoking history. When compared to pack-years calculated using age of smoking initiation/cessation, our sample population tended to underestimate their exposure by over 5 pack-years—a clinically significant difference for someone at high risk who might not otherwise receive screening imaging. Often a pivotal moment in adolescence, participants recalled their age of smoking initiation with greater precision compared to their estimations of total exposure. These results call for urgent reevaluation of the tobacco history interview, its notation in electronic medical records, and the methodology of taking a substance abuse history in general.

Rethinking the Smoking History Interview: A Prospective Survey-based Study

Background
Acute appendicitis is one of the most common surgical emergencies in the world.
Appendectomies, especially if delayed, can be associated with postoperative complications in up to 16% of the patients. Low serum albumin often indicates malnutrition or systemic inflammatory response. Past studies have demonstrated that a low albumin level, defined as less than 3.5 mg/dl, is associated with greater risks of adverse outcomes following various types of surgery, such as orthopedic or urogenital surgeries. However, limited research has specifically investigated the relationship between serum albumin levels and appendectomy outcomes. This study aimed to investigate the independent association between preoperative serum albumin levels and the likelihood of postoperative complications in adult patients undergoing appendectomy for appendicitis.

Methods
A retrospective cohort study was conducted using the National Surgical Quality Improvement Program (NSQIP) database, including adult appendectomy patients with preoperative serum albumin data and postoperative appendicitis diagnosis. Exclusion criteria included ventilator dependency, ascites, disseminated cancer, open wounds, steroid or immunosuppressant use, bleeding disorders, preoperative transfusions, moribund status, or concurrent procedures. Baseline characteristics of the patients were analyzed to identify potential confounding factors. The strength of the association between low albumin levels and postoperative complications was assessed. A multivariate logistic regression model was constructed to control for potential confounding factors.

Results
A total of 28,051 patients were included in our statistical analysis. Among them, 1,312 (4.68%) had low levels of albumin (< 3.5 g/dl), and 2,022 (7.56%) suffered from postoperative complications. This study revealed that patients with low albumin levels had significantly higher odds of postoperative complications (OR: 3.14, 95% CI: 2.70-3.64). Even after adjusting for potential confounders, including age, sex, BMI, diabetes, dyspnea, COPD, hypertension, ASA classification, sepsis status, and surgery type, patients with low albumin levels still had significantly higher odds of postoperative complications (OR: 2.22, 95% CI: 1.88-2.62). Furthermore, older age, male sex, higher ASA classification, and nonlaparoscopic appendectomy were also independently associated with greater odds of postoperative complications (all p < 0.05).

Conclusion
This study highlights a significant association between low preoperative albumin levels and an increased likelihood of post-appendectomy complications, even after accounting for other known risk factors. Low albumin levels can serve as an important indicator of nutritional status, liver or kidney disease, or ongoing inflammatory processes. Physicians can use this prognostic tool to predict adverse postoperative complications and potentially implement proactive measures to prevent or mitigate these complications, leading to improved patient outcomes.

Association Between Preoperative Serum Albumin and Risk of Complications After Appendectomy

Introduction: 
Current AAOS guidelines recommend that children younger than thirty-six months with a femur fracture be evaluated for non-accidental trauma. However, the likelihood of abuse in walking-age children presenting with these fractures has been found to be less than 10%. These guidelines could subject up to 63% of cases to unnecessary evaluation by Child Protective Services. The purpose of this study was to identify how patient age and femur fracture morphology impact the likelihood that providers assess a fracture as non-accidental and pursue further investigation of possible child abuse. 

Methods:
This study evaluated a questionnaire completed by 75 clinicians from multiple specialties. There were 5 subgroup populations (6, 12, 18, 24, 35 months old) combined with diaphyseal and metaphyseal femur fracture types. For each age group, the same radiograph was presented and described as an oblique diaphyseal fracture in one scenario and spiral diaphyseal fracture in another. Similarly, some cases were described as a corner fracture in one scenario and classic metaphyseal lesion in another. This design assessed if fracture nomenclature, in addition to patient age, impacted clinician suspicion of abuse. Participants assessed case presentations and reported their perceived likelihood the case represented non-accidental trauma utilizing a Likert scale from 1 to 5 corresponding to a percent likelihood. They also reported the percent likelihood they would pursue further investigation. 

Results:
75 questionnaires were analyzed. Mean likelihood of abuse rating in all fracture types for patients 18-35 months was 3.8, corresponding to 61-80% perceived likelihood of abuse. Mean likelihood for further investigation of child abuse in patients 18-35 months of age was 3.7, corresponding to 61-80% clinician likelihood to further investigate. Fracture nomenclature did not significantly impact clinician ratings. In the linear mixed model, the strongest predictors of perceived high likelihood of abuse were respondent specialty, with emergency medicine (p<0.001) and advanced practice providers (p=0.006) having the highest likelihood ratings. 

Conclusions: 
Clinicians are trained to have a high index of suspicion for child abuse in pediatric patients. However, this study demonstrates a high assessment of chance for abuse and low threshold for pursuing further investigation for femoral shaft fractures in walking-age children which contradicts literature that reports actual rates of non-accidental trauma to be lower than 10%. This bias may exhaust hospital and community resources in evaluating toddler femur fractures for abuse and cause unnecessary stress for patients and families.

Underline digital video library

Driving CARs Forward: An OX40 Tale of Immunotherapy

Uptake of COVID-19 Immunization in the Inflammatory Bowel Disease Population

Relation of pannus size to postoperative wound infection after femoral endarterectomy

White matter markers for treatment outcomes in major depressive disorder

Differentiating Afferent Lymphatic Pathways Using Dual-Dye Technique During Immediate Lymphatic Reconstruction

Atypical Cutaneous Findings of Hand-Foot-Mouth Disease in Children: A Systematic Review

Out of Sight, Not Out of Mind: The Effect of Loss to Follow-Up on on Proliferative Diabetic Retinopathy

The Effects of Prenatal Adversity and Neonatal White Matter Microstructure on Child Language Skills at Age 2

Ultrasensitive detection of SALL4 oncoproteins for the use in therapeutic monitoring

Rethinking the Smoking History Interview: A Prospective Survey-based Study

Association Between Preoperative Serum Albumin and Risk of Complications After Appendectomy

Common Misperceptions of Child Abuse in Toddler Femur Fractures

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