Epidemiology of scoliosis in cerebral palsy: A population-based study at skeletal maturity.

AIM: This study investigated the prevalence of scoliosis in a large, population-based cohort of individuals with cerebral palsy (CP) at skeletal maturity to identify associated risk factors that may inform scoliosis surveillance. METHODS: Young people with CP born between 1990 and 1992 were reviewed through routine orthopaedic review or a transition clinic. Classification of CP was recorded by movement disorder, distribution, gross and fine motor function. Clinical examination was undertaken and those with clinical evidence of scoliosis or risk factors had radiographs of the spine. Scoliosis severity was measured and categorised by Cobb angle. RESULTS: Two hundred and ninety-two individuals were evaluated (78% of the birth cohort) at a mean age of 21 years, 4 months (range 16-29 years). Scoliosis (Cobb angle >10°) was found in 41%, with strong associations to the Gross Motor Function Classification System (GMFCS), Manual Abilities Classification System (MACS) and dystonic/mixed movement disorders. Those at GMFCS V were 23.4 times (95%CI 9.9-55.6) more likely to develop scoliosis than those at GMFCS I. Severe curves (Cobb >40°, 13% of the cohort) were found almost exclusively in those functioning at GMFCS IV and V, and were 18.2 times (95%CI 6.9-48.5) more likely to occur in those with dystonia than those with spasticity. CONCLUSIONS: Scoliosis was very common in young people with CP, with prevalence and severity strongly associated with GMFCS and MACS level and dystonic movement disorder. Severe curves were almost exclusively found in non-ambulant children. Clinical screening for scoliosis should occur for all children with CP, with radiographic surveillance focusing on those functioning at GMFCS IV and V.

Massive Enhancement of Optical Transmission across a Thin Metal Film via Wave Vector Matching in Grating-Coupled Surface Plasmon Resonance.

We demonstrate how distinct surface plasmon resonance modes on opposite sides of a metal-coated grating can be coupled across the metal film. This coupling occurs by matching the resonance conditions on each side of the grating by tuning the refractive index directly adjacent to the metal film. In the first example, we deposited a high refractive index layer of tin oxide on top of the grating to red-shift the front side surface plasmon until it coupled with the backside surface plasmon across a semitransparent ∼45 nm thin silver grating. By shifting the resonance condition of the nearby surface plasmon, this high refractive index coating creates an effective matching of wave vectors across the metal film, allowing them to couple and enhance the optical response. A massive increase in the magnitude of enhanced transmission is observed, increasing from a 6-fold transmission enhancement through a bare silver grating to a near 100-fold enhancement after deposition of a tin oxide layer of appropriate thickness (∼310 nm). This optical transmission enhancement is then probed through computational modeling and by experiments with liquids of various refractive index values. The matched system shows an increased amplitude sensitivity with respect to refractive index changes and a waveguide like behavior within the tin oxide film. As an alternative configuration, we also demonstrate coupling the front and back-side plasmon modes by using a lower refractive index substrate in order to blue-shift the back-side surface plasmon. Coupling between the two plasmon modes is then demonstrated by introducing aqueous solutions of various refractive index values. Under the proper conditions, this matched system also shows a substantial enhancement in transmission. This technique of wave vector matching provides a route to substantially increasing the plasmon enhanced optical transmission through metal gratings, which has potential application in improved plasmonic sensing, spectroscopy, and plasmon-based optical devices.

MDCT Angiography With 3D Rendering: A Novel Cinematic Rendering Algorithm for Enhanced Anatomic Detail.

OBJECTIVE: The two most widely used postprocessing 3D tools in clinical practice are volume rendering (VR) and maximum intensity projection (MIP). With the use of current-generation MDCT, these techniques enable accurate characterization of arterial anatomy and pathology in all anatomic regions. Recently, the VR algorithm has been enhanced by the incorporation of a new lighting model. This new technique-called cinematic rendering-generates photorealistic images with the potential to more accurately depict anatomic detail. CONCLUSION: As an enhancement of the technology championed in VR, cinematic rendering promises to provide additional anatomic detail for MDCT interpretation and display. Future investigations must be conducted to evaluate the diagnostic accuracy of cinematic rendering and determine whether interpretative pitfalls result from its unique lighting model in practice.

Pediatric pelvic fracture: a modification of a preexisting classification.

BACKGROUND: The classic pediatric pelvic fracture (PPF) classification was developed by Torode and Zeig in 1985 and is based exclusively on plain radiographs. The purpose of this study was to propose a modification to a previously accepted PPF classification scheme and discuss the significance of this modification with respect to treatment and management of PPF over an 8-year period at a large pediatric hospital. METHODS: PPFs were recorded on a prospectively identified hospital registry of all trauma admissions. Pelvic x-rays and computerized tomography scans were reviewed and classified according to a modified classification scheme. Correlation was made with age, sex, mechanism, associated injuries, intensive care unit stay, operations, and discharge outcome. Blood product usage was obtained from a hematology database. RESULTS: A total of 124 children were identified with PPF, comprising 1.6% of trauma admissions between July 2000 and June 2008. Radiology was available for 115 children (58 boys, and 57 girls, mean age 11.5 y). According to the modified classification, 71% (82/115) had type III-A or III-B injuries (type I=5 children, type II=17 children, type IV=11 children). There was a mortality of 5% (6/115 children) during the study. Eighty-one percent (93/115) of PPF resulted from being involved in a motor vehicle accident (occupant or pedestrian). Trend testing showed relationships between increasing fracture type and length of stay (P<0.001), as well as the need for blood transfusion (P=0.009) or pelvic operation (P<0.001). A total of 34 (30%, 34/115) children required blood products. Type III-B injuries were more likely to receive blood products than type III-A injuries (odds ratio 3.58; 95% confidence interval, 1.28-10.03). CONCLUSIONS: : The modified Torode PPV classification is predictive for significant morbidity and death in the setting of multitrauma. Stable type III-B fractures are indicative of increased blood product use, intensive care unit requirement, and overall hospital stay. This modified classification scheme will aid health care providers at all levels in managing PPF more efficiently during their initial resuscitation and treatment period. LEVELS OF EVIDENCE: Level III-retrospective case control study.

Perioperative Care of Children with Severe Neurological Impairment and Neuromuscular Scoliosis-A Practical Pathway to Optimize Peri-Operative Health and Guide Decision Making.

Neuromuscular scoliosis is a common feature in children with severe neurological impairment (SNI), including those with severe cerebral palsy. Surgical correction of scoliosis is the mainstay of treatment. This group of patients also have associated medical complexity. The complication rates post-surgery are high, although, for many, they are worth the risk. There are currently no published practice guidelines or care pathways for children with SNI who are undergoing scoliosis corrective surgery. In response to the high uptake of this surgery, coupled with the expected complication rates, our hospital established a perioperative clinic. The purpose of this paper is to describe our perioperative approach. This clinic has developed into a service beyond perioperative care and, with the collaborative meeting, enables shared decision-making to identify the right candidate for surgery. The process involves surgical expertise, understanding the family and child at the centre, and optimisation of medical care pre- and post-surgery. In this paper, we describe the process in a step-by-step manner. We provide clinical vignettes, as well as the proformas that we use, and we highlight the benefits of the team-based process.

A systemic model of doping behavior.

Human behavior occurs within a system, and as such, so do behaviors in performance-related domains (e.g., athletics, academics). Doping is a performance enhancement behavior that can be problematic because of the negative physical and psychological effects associated with the use of some substances and the common argument that doping is unfair. However, doping continues and may be increasing. Because a firm theoretical or empirical understanding of doping does not exist, this article proposes a conceptual, comprehensive, and innovative systemic model of doping behavior. The model is built from relevant empiricism supporting the idea that contemporary doping behavior is a function of systemic transactions between historical doping practices, the present environment, current antidoping interventions, one's genetic makeup, developmental milestones, social factors, and epigenetics.

Implementation of an enhanced recovery pathway in Australia after posterior spinal fusion for adolescent idiopathic scoliosis delivers improved outcomes.

PURPOSE: Traditionally, spinal surgery for Adolescent Idiopathic Scoliosis (AIS) has seen long hospital length of stay (LOS) and slow mobility progression. Postoperative enhanced recovery pathways (ERP) for this population in North America and Asia have successfully reduced LOS and hospital costs without increasing complications. This study assessed if ERP introduced in an Australian center achieves similar results. METHODS: A pre-post intervention study compared a historical AIS cohort having a posterior spinal fusion (PSF) who received conventional care (CC) (2013-2014) with prospectively assessed ERP recipients (2016-2018) separated by 1-year implementation period. Patient characteristics, surgical details, postoperative analgesia, mobilization, LOS and complication outcomes were collected. RESULTS: The 32 CC and 61 ERP recipients had similar demographics. ERP recipients had 44% decreased LOS (mean LOS 3.5 ± 0.9 days vs. CC 6.3 ± 0.9 days, p < 0.001) as all ERP milestones were achieved sooner including transition to oral analgesia (MD - 2 days, 95% CI 1.8-2.3), oral intake (MD - 2.3 days, 95% CI 2.0-2.6) and mobilization, with fewer physiotherapy sessions (5.2 vs 8, p < 0.001). Postoperative in-hospital costs were 50.2% less for ERP vs CC (AUD $8234 vs $16,545). Due to small sample size, no differences between the groups were detectable for complications (4.9% vs 6.3%) or readmission (1.6% vs 3.1%). CONCLUSION: An ERP for AIS after PSF in this Australian center improved functional recovery reducing LOS and by associated postoperative inpatient costs. Other Australian hospitals should consider an ERP for this population with larger-scale audit to assess impact upon complications. LEVEL OF EVIDENCE: III.

The reliability of the AOSpine Thoracolumbar Spine Injury Classification System in children: an international validation study.

PURPOSE: To evaluate the AOSpine Thoracolumbar Spine Injury Classification System and if it is reliable and reproducible when applied to the paediatric population globally. METHODS: A total of 12 paediatric orthopaedic surgeons were asked to review MRI and CT imaging of 25 paediatric patients with thoracolumbar spine traumatic injuries, in order to determine the classification of the lesions observed. The evaluators classified injuries into primary categories: A, B and C. Interobserver reliability was assessed for the initial reading by Fleiss's kappa coefficient (kF) along with 95% confidence intervals (CI). For A and B type injuries, sub-classification was conducted including A0-A4 and B1-B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff's alpha (αk) along with bootstrapped 95% CIs. A second round of classification was performed one-month later. Intraobserver reproducibility was assessed for the primary classifications using Fleiss's kappa and sub-classification reproducibility was assessed by Krippendorff's alpha (αk) along with 95% CIs. RESULTS: In total, 25 cases were read for a total of 300 initial and 300 repeated evaluations. Adjusted interobserver reliability was almost perfect (kF = 0.74; 95% CI 0.71 to 0.78) across all observers. Sub-classification reliability was substantial (αk= 0.67; 95% CI 0.51 to 0.81), Adjusted intraobserver reproducibility was almost perfect (kF = 0.91; 95% CI 0.83 to 0.99) for both primary classifications and for sub-classifications (αk = 0.88; 95% CI 0.83 to 0.93). CONCLUSION: The inter- and intraobserver reliability for the AOSpine Thoracolumbar Spine Injury Classification System was high amongst paediatric orthopaedic surgeons. The AOSpine Thoracolumbar Spine Injury Classification System is a promising option as a uniform fracture classification in children. LEVEL OF EVIDENCE: III.

Development of an attached microalgal growth system for biofuel production.

Algal biofuel production has gained a renewed interest in recent years but is still not economically feasible due to several limitations related to algal culture. The objective of this study is to explore a novel attached culture system for growing the alga Chlorella sp. as biodiesel feedstock, with dairy manure wastewater being used as growth medium. Among supporting materials tested for algal attachment, polystyrene foam led to a firm attachment, high biomass yield (25.65 g/m(2), dry basis), and high fatty acid yield (2.31 g/m(2)). The biomass attached on the supporting material surface was harvested by scraping; the residual colonies left on the surface served as inoculum for regrowth. The algae regrowth on the colony-established surface resulted in a higher biomass yield than that from the initial growth on fresh surface due to the downtime saved for initial algal attachment. The 10-day regrowth culture resulted in a high biodiesel production potential with a fatty acid methyl esters yield of 2.59 g/m(2) and a productivity of 0.26 g/m(-2) day(-1). The attached algal culture also removed 61-79% total nitrogen and 62-93% total phosphorus from dairy manure wastewater, depending on different culture conditions. The biomass harvested from the attached growth system (through scraping) had a water content of 93.75%, similar to that harvested from suspended culture system (through centrifugation). Collectively, the attached algal culture system with polystyrene foam as a supporting material demonstrated a good performance in terms of biomass yield, biodiesel production potential, ease to harvest biomass, and physical robustness for reuse.

Ligamentum teres tenodesis in medial approach open reduction for developmental dislocation of the hip.

BACKGROUND: When closed reduction of a developmental dislocation of the hip fails, some form of open reduction is required. In recent years, the many advantages of the medial approach open reduction have been emphasized. However, there have been suggestions that the rate of growth disturbance in the proximal femur and the requirement for secondary surgical procedures may be higher with this route than with others. The purpose of this study was to investigate the efficacy and safety of a modified medial approach open reduction, in which the stability of the reduction is enhanced by resection of the redundant ligamentum teres and suturing of the stump of the tendon to the anteromedial capsule. METHODS: The hospital records and radiographs of 92 infants and children with 109 dislocated hips were reviewed retrospectively. Key demographic and pretreatment data were collected by the first author and compared with the outcome at the most recent follow-up. In addition, 69 children returned for a clinical evaluation by the first author. The outcome at the most recent follow-up was graded according to Severin, and associations were sought between pretreatment grade of dislocation according to Tonnis, the presence of ossific nucleus, changes in the acetabular index, the requirements for secondary surgery, associations with previous treatment, and the position of abduction in the postoperative cast. RESULTS: At a mean follow-up of 9 years, 89% of hips were classified as Severin grade 1 or 2. Avascular necrosis (AVN) was classified according to the system of Kalamchi and MacEwen. The incidence of AVN was 41%, but two thirds of these were grade 1 (temporary irregular ossification), and the Severin grading in these hips was not compromised. The presence of ossification in the capital epiphysis and a range of abduction of less than 60 degrees in the hip spica were noted to be protective against the development of AVN. Three hips redislocated and required additional treatment. Thirty-eight hips required a total of 44 additional surgical procedures. CONCLUSIONS: We have demonstrated that it is possible to use a medial approach for open reduction of the congenitally dislocated hip in combination with tenodesis of the ligamentum teres to the anteromedial joint capsule. The incidence of growth disturbance in the proximal femur is high and cumulative with long-term follow-up. However, in this large series, the rate of hip stability, growth disturbance, and need for secondary surgery are comparable to other series. We conclude that the many advantages of open reduction by the medial approach outweigh the disadvantages.

Instagram as a Vehicle for Education: What Radiology Educators Need to Know.

Since its inception in 2010, Instagram has rapidly grown into one of the world's largest social media forums, with over 700 million registered users. In the field of medicine, Instagram has been used for professional development and is also being added to the armamentarium of social media vehicles for education. Utilization of Instagram for medical education lags behind Facebook and Twitter, as many educators may not recognize the potential role. The purpose of this manuscript is to describe unique features of Instagram that are not found on Facebook and Twitter, with the aim of facilitating use of Instagram for radiology education.

Magnetoencephalographic Infraslow Activity: A Feasibility Study.

PURPOSE: To explore if background infraslow activity (ISA) can be retrieved from archived magnetoencephalographic (MEG) recordings and its potential clinical relevance. METHODS: Archived recordings of 15 patients with epilepsy and 10 normal subjects were evaluated for MEG/EEG delta (0.5-3 Hz) and ISA (0.01-0.1 Hz). The data were obtained on a Neuromag/Elekta system with 204 planar gradiometers and 102 magnetometer sensors and also 60 EEG channels. To remove artifacts, all MEG files were temporal signal space separation filtered. The data were then analyzed with the BESA Research software. RESULTS: Infraslow activity was present in all files for MEG and EEG. Good concordance between EEG and MEG ISA was seen with delta for laterality and with clinical features. Delta frequencies were always less than 2 Hz. During sleep, an inverse relationship between delta and ISA occurred. With increasing depth of sleep, delta activity increased while ISA decreased and vice versa. Intermittent higher amplitude transients, arising from background, were also seen but their nature is at present unknown. Clinically relevant ictal onset baseline shifts were likewise observed. CONCLUSION: Infraslow activity is a normal segment of the cerebral electromagnetic frequency spectrum. It follows physiologic rules and can be related to areas of pathology. This is in accord with previously published EEG observations and further studies of this segment of the electromagnetic frequency spectrum for its origin and changes in health and disease are indicated.

Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre.

OBJECTIVE: Evidence-based decision-making tools are widely used to guide cervical spine assessment in adult trauma patients. Similar tools validated for use in injured children are lacking. A paediatric-specific approach is appropriate given important differences in cervical spine anatomy, mechanism of spinal injury and concerns over ionising radiation in children. The present study aims to survey physicians' knowledge and application of cervical spine assessment in injured children. METHODS: A cross-sectional survey of physicians actively engaged in trauma care within a paediatric trauma centre was undertaken. Participation was voluntary and responses de-idenitified. The survey comprised 20 questions regarding initial assessment, imaging, immobilisation and perioperative management. Physicians' responses were compared with available current evidence. RESULTS: Sixty-seven physicians (28% registrars, 17% fellows and 55.2% consultants) participated. Physicians rated altered mental state, intoxication and distracting injury as the most important contraindications to cervical spine clearance in children. Fifty-four per cent considered adequate plain imaging to be 3-view cervical spine radiographs (anterior-posterior, lateral and odontoid), whereas 30% considered CT the most sensitive modality for detecting unstable cervical spine injuries. Physicians' responses reflected marked heterogeneity regarding semi-rigid cervical collars and what constitutes cervical spine 'clearance'. Greater consensus existed for perioperative precautions in this setting. CONCLUSIONS: Physicians actively engaged in paediatric trauma care demonstrate marked heterogeneity in their knowledge and application of cervical spine assessment. This is compounded by a lack of paediatric-specific evidence and definitions, involvement of multiple specialties and staff turnover within busy departments. A validated decision-making tool for cervical spine assessment will represent an important advance in paediatric trauma.

Spinal deformity after selective dorsal rhizotomy in ambulatory patients with cerebral palsy.

Thirty-four patients with ambulatory spastic diplegia (ages 10-19.8 years) who were part of a prospective study of selective dorsal rhizotomy (SDR) had standardized radiographs before and after SDR. Follow-up ranged from 5 to 11.6 years after surgery. Two different surgical approaches were used: laminectomy (14 patients) and laminoplasty (20 patients). Radiographs were measured for coronal and sagittal balance. Thirty patients had a spinal deformity at long-term follow-up compared with 10 patients before surgery. Seventeen patients (50%) developed lumbar hyperlordosis greater than 60 degrees. Six patients (18%) developed grade 1 spondylolisthesis, Scoliosis occurred de novo in eight patients (24%) and progressed by greater than 5 degrees in two patients with preoperative scoliosis. No significant differences were found between laminoplasty and laminectomy patients. None of the patients have undergone any surgical intervention for spinal deformity. There was a higher incidence of spinal deformity after SDR than in normals and an historical control population, which warrants clinical and radiographic long-term follow-up.

D8/17 and CD19 expression on lymphocytes of patients with acute rheumatic fever and Tourette's disorder.

D8/17, an alloantigen found on B lymphocytes, has been reported to be elevated in patients susceptible to rheumatic fever and may be associated with autoimmune types of neuropsychiatric disorders. The pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococci model is a putative model of pathogenesis for a group of children whose symptoms of obsessive-compulsive disorder and Tourette's disorder (TD) are abrupt and may be triggered by an infection with group A streptococci. As a test of this model, we have examined D8/17 levels on the B cells of patients with TD and acute rheumatic fever (ARF) along with those on the B cells of normal controls by flow cytometry. We have utilized several different preparations of D8/17 antibody along with a variety of secondary antibodies but have been unable to show an association with an elevated percentage of D8/17-positive, CD19-positive B cells in either ARF or TD. We did find, however, that the percentages of CD19-positive B cells in ARF and TD patients were significantly elevated compared to those in normal controls. Group A streptococcal pharyngitis patients also had an elevated percentage of CD19 B cells, however. These studies failed to confirm the utility of determining the percentage of B cells expressing the D8/17 alloantigen in ARF patients or our sample of TD patients. In contrast, the percentage of CD19-positive B cells was significantly elevated in ARF and TD patients, as well as group A streptococcal pharyngitis patients, suggesting a role for inflammation and/or autoimmunity in the pathogenesis of these disorders.