Skills on wheels: initial pre-post findings from a pilot study of a pediatric wheelchair skills training program.

Skills on Wheels, a 5-week pediatric wheelchair skills training program implemented over 2 years, was developed to address confidence, social participation, and mobility for wheelchair-using children. This study tests the hypothesis that pediatric wheelchair skills training will increase wheelchair skill ability, confidence, and participation of wheelchair-using children. Individualized instruction was delivered by occupational (N = 50) and physical (N = 12) therapy practitioners and doctoral students. The primary program intervention was adapted for pediatric wheelchair users from the adult Wheelchair Skills Training Program, developed by Dalhousie University, consisting of a total of 33 wheelchair skills. An adapted version of the Wheelchair Confidence measure (Wheel-Con-M-P), the Participation and Environment Measure for Children and Youth (PEM-CY), and Wheelchair Skills Test (WST) were used to measure participants confidence and ability to complete wheelchair skills, endurance, and participation and satisfaction in community, school, and home. The study resulted in: increases in confidence in ability to move wheelchair over threshold (+1.00, p < 0.05), ability to carry lunchbox/bookbag (+0.65, p < 0.05), ability to move in wheelchair when worried or scared (+1.3, p < 0.05), ability to ask for help, and ability to say "no" if they don't need help (+0.58, p < 0.05) were indicated. The WST indicated increased ability (p < 0.05) on several skills. The Fear of Falling Measure found an overall decrease in fear of falling (-2.37, p < 0.01). The Skills on Wheels program demonstrated many successes in this initial 2-year study and data suggest a positive trend for iterations to come.

This program increased mobility skills that are typically overlooked in inpatient or outpatient settings.Through implementation of a pediatric wheelchair skills training program individuals have noted increased participation in their environments and increased engagement from parents/children in follow up sessions.

Transitioning young adults with spina bifida: Challenges and paths to success.

INTRODUCTION AND BACKGROUND: Recent medical advances, including closure of myelomeningocele defects, shunting of hydrocephalus, and focusing on renal preservation have led to many individuals with spina bifida (SB) living into adulthood. This has led to more individuals with SB transitioning their care from pediatric-based to adult-based care models. OBJECTIVE: We seek to explore the process of transition, with a focus on difficulties in transitioning individuals with SB. Additionally, we explore new problems that arise during the period of transition related to sexual function and dysfunction. We also discuss some of the difficulties managing neurogenic bladder and the sequalae of their prior urologic surgeries. STUDY DESIGN: Each of the authors was asked to provide a summary, based on current literature, to highlight the challenges faced in their area of expertise. CONCLUSIONS: Transitioning care for individuals with SB is especially challenging due to associated neurocognitive deficits and neuropsychological functioning issues. Sexual function is an important component of transition that must be addressed in young adults with SB. Management of neurogenic bladder in adults with SB can be challenging due to the heterogeneity of the population and the sequelae of their prior urologic surgeries. The aim is to ensure that all individuals with SB receive appropriate, evidence-based care throughout their lifetime.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study.

PURPOSE: This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS: A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS: Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION: COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic.

BACKGROUND: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. METHODS: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. RESULTS: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. CONCLUSIONS: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Parent/caregiver's role in nutrition, physical activity, and food access among children diagnosed with spina bifida.

PURPOSE: This pilot study aimed to determine the parent/caregiver's role in nutrition/eating habits, physical activity behaviors, and food access among children diagnosed with spina bifida (SB). METHODS: Parents/caregivers of children with SB were asked to participate at a single, outpatient SB clinic. Demographic, biomedical data, parent/caregiver nutrition knowledge, family nutrition and physical activity (FNPA), and food security survey scores were compared. Descriptive, regression, and correlational statistics were conducted for analysis via SPSS 29. RESULTS: Of the 117 parents/caregivers surveyed, completed data suggested most were overweight/obese (average body mass index [BMI] of 30.63 kg/m2±8.40; n = 99) with an average nutrition knowledge score of 71% (17.83±3.33). As FNPA scores decreased, the patient/child's maximum BMI z scores increased (ß= -0.043; confidence interval -0.079, -0.007; p = 0.020), suggesting the less active and/or less healthy eating habits, the higher body mass was noted for the child. Forty four percent of children (n = 99) were in the overweight/obese weight range based on maximum BMI z score. CONCLUSION: These findings suggest there is a need for parental/caregiver nutrition education to assist children with SB with meal and activity planning to achieve optimal health.

Education and employment as young adults living with spina bifida transition to adulthood in the USA: A study of the National Spina Bifida Patient Registry.

AIM: To describe the education and employment transition experience of young adults with spina bifida (YASB) and investigate factors associated with employment. METHOD: We queried education and employment data from the US National Spina Bifida Patient Registry from 2009 to 2019. We applied generalized estimating equations models to analyze sociodemographic and disease-related factors associated with employment. RESULTS: A total of 1909 participants (850 males, 1059 females) aged 18 to 26 years contributed 4379 annual visits. Nearly 84% had myelomeningocele and, at last visit, the median age was 21 years (mean 21 years 5 months, SD 2 years 10 months). A total of 41.8% had at least some post-high school education, and 23.9% were employed. In a multivariable regression model, employment was significantly associated with education level, lower extremity functional level, bowel continence, insurance, and history of non-shunt surgery. This large, national sample of YASB demonstrated low rates of post-secondary education attainment and employment and several potentially modifiable factors associated with employment. INTERPRETATION: Specific sociodemographic, medical, and functional factors associated with employment are important for clinicians to consider when facilitating transition for YASB into adulthood. Additional research is needed to understand the impact of cognitive functioning and social determinants of health on transition success in YASB. WHAT THIS PAPER ADDS: There were low education attainment and employment rates in a large sample of young adults with spina bifida. Specific sociodemographic, medical, and functional factors are associated with employment. Some employment-associated factors, such as continence and self-management skills, are modifiable.

Population-Based Assessment of Urban Versus Rural Child Fatalities From Firearms in a Midwestern State.

INTRODUCTION: Several studies have evaluated differences in firearm injury patterns among children based on regionalization. However, many of these studies exclude patients who die before arriving at a trauma center. We therefore hypothesize that important population-based differences in pediatric firearm injuries may be uncovered with the inclusion of both prehospital firearm mortalities and patients treated at a tertiary children's hospital. METHODS: Patients less than 15 y of age who sustained a firearms-related injury/death between the years 2012 and 2018 were identified in: (1) death certificates from the Office of Vital Statistics State of Indiana and (2) Riley Hospital for Children at Indiana University Health Trauma Registry. Counties of injury were classified as either urban, midsized, or rural based on the National Center for Health Statistic's population data. Significant variables in univariate analysis were then assessed using multivariate logistic regression models. RESULTS: A total of 222 patients were identified. Median age of firearm injury survivors was 13 (interquartile range 7-14), while the median age of nonsurvivors was 14 (interquartile range 11-15), P = 0.040. The proportion of suicide was significantly higher in rural counties (P < 0.001). When controlling for shooter intent, patients from a rural or midsized county had statistically significant higher odds of dying before reaching a hospital than their urban counterpart (rural odds ratio [OR] 5.67 [95% confidence interval {CI} 2.23, 14.38]; midsized OR 6.53 [95% CI 2.43, 17.46]; P < 0.001). CONCLUSIONS: Important differences exist between pediatric firearm injuries based on where they occur. Public health initiatives aimed at reducing pediatric firearm injury and death should not exclude rural pediatrics patients.

Comparison Between Closed Suction Drainage and No Drainage Following Total Ankle Arthroplasty.

BACKGROUND: The purpose of this study is to determine whether the use of closed suction drains after total ankle arthroplasty (TAA) is associated with lower wound complications in the first postoperative year as compared to no drain usage. METHODS: A total of 324 TAA were reviewed and included for analysis. One hundred forty-four did not have a postoperative drain placed, whereas 180 did have a postoperative drain. Demographic data, including age, sex, tobacco or alcohol use, and various medical comorbidities, were obtained. Follow-up data were collected and reviewed at 2, 6, and 12 weeks; 6 months; and 1 year postoperatively for minor and major wound complications, as well as wound-related reoperations. RESULTS: At the 2-week mark, the use of a drain demonstrated a significant increase in wound complications. No significant difference in wound complications was found at each subsequent follow-up visit. Within the first postoperative year, a total of 46 patients (31.9%) without drains and 69 patients (38.3%) with drains had a wound complication. This was not statistically significant. Most wound complications were minor, and no significant difference in reoperation rates occurred between the 2 groups. CONCLUSION: A postoperative closed suction drain may increase wound complications in the first 2 weeks after TAA and should therefore be used with caution. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Skin sympathetic nerve activity as a biomarker of fitness.

BACKGROUND: Exercise stress testing is frequently used to expose cardiac arrhythmias. Aerobic exercise conditioning has been used as a nonpharmacologic antiarrhythmic intervention. OBJECTIVE: The purpose of this study was to test the hypothesis that noninvasively recorded skin sympathetic nerve activity (SKNA) is increased during exercise and that SKNA response varies according to fitness levels. METHODS: Oxygen consumption (VO2) and SKNA were recorded in 39 patients undergoing an incremental exercise test. Patients were grouped by 5 levels of fitness based on age, sex, and VO2max. RESULTS: With exercise, all patients had a significant increase in average SKNA (aSKNA) (1.58 ± 1.12 µV to 4.50 ± 3.06 µV, P = .000) and heart rate (HR) (87.40 ± 20.42 bpm to 154.13 ± 16.82 bpm, P = .000). A mixed linear model of aSKNA was used with fixed effects of fitness, exercise time, and recovery time, and random effects of subject level intercept and slopes for exercise time and recovery times. The poor fitness group had significantly higher aSKNA than the other groups (P = .0273). For all subjects studied, aSKNA increased by 5% per minute with progression of exercise and decreased by 15% per minute with progression of recovery. The fitness variable encodes information on both comorbidities and body mass index (BMI). Once fitness level is known, comorbidities and BMI are not significantly associated with aSKNA. In all groups, aSKNA positively correlated with HR (R2 = 0.47 ± 0.23) and VO2 (R2 = 0.68 ± 0.25). CONCLUSION: Fitness level determines the magnitude and time course of SKNA increase during exercise. SKNA may be a useful fitness biomarker in exercise stress testing.

Long-term Outcomes of Microfracture for Treatment of Osteochondral Lesions of the Talus.

BACKGROUND: Microfracture is the most common reparative surgery for osteochondral lesions of the talus (OLTs). While shown to be effective in short- to midterm outcomes, the fibrocartilage that microfracture produces is both biomechanically and biologically inferior to that of native hyaline cartilage and is susceptible to possible deterioration over time following repair. With orthobiologics being proposed to augment repair, there exists a clear gap in the study of long-term clinical outcomes of microfracture to determine if this added expense is necessary. METHODS: A retrospective review of patients undergoing microfracture of an OLT with a single fellowship-trained orthopedic surgeon from 2007 to 2009 was performed. Patients meeting the inclusion criteria were contacted to complete the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales and visual analog scale (VAS) for pain, as well as surveyed regarding their satisfaction with the outcome of the procedure and their likelihood to recommend the procedure to a friend with the same problem using 5-point Likert scales. Patient demographics were reviewed and included for statistical analysis. RESULTS: Of 45 respondents, 3 patients required additional surgery on their ankle for the osteochondral defect, yielding a 10-year survival rate of 93.3%. Of surviving cases, 90.4% (38/42) reported being "extremely satisfied" or "satisfied" with the outcome of the procedure. The VAS score at follow-up averaged 14 out of 100 (range, 0-75), while the FAAM-ADL and FAAM-Sports scores averaged 90.29 out of 100 and 82 out of 100, respectively. Thirty-six patients (85.7%) stated that their ankle did not prevent them from participating in the sports of their choice. CONCLUSION: The current study represents a minimum 10-year follow-up of patients undergoing isolated arthroscopic microfracture for talar osteochondral defects, with a 93.3% survival rate and 85.7% return to sport. While biological adjuvants may play a role in improving the long-term outcomes of microfracture procedures, larger and longer-term follow-up studies are required for procedures using orthobiologics before their cost can be justified for routine use. LEVEL OF EVIDENCE: Level IV, retrospective cohort case series study.

Trends in Depressed Mood and Suicidal Behaviors Among Female High School Students Who Engaged in Physical Fighting.

The objective of this article is to identify prevalence changes in depressed mood/suicidal behaviors among female high school students reporting physical fighting. This research analyzed the national combined data set of the Youth Risk Behavior Surveillance (YRBS) cross-sectional surveys from 2001 to 2015. Logistic regression analyzed the time trends. Two multiple logistic regression models were built. A quadratic trend was present with an initial decrease followed by an increase 2009 to 2015 (p < .001). The odds and severity of depressed mood/suicidal behaviors were greater among female youths with four or more fights and for other violent events, which were even greater when accounting for electronic bullying. The odds of depressed mood/suicidal behaviors among female adolescents engaged in physical fighting has been increasing with electronic bullying contributing to polyvictimization.

Application of Computerized Adaptive Testing to the Foot and Ankle Ability Measure.

BACKGROUND: Patient-reported outcome measures are an increasingly important tool for assessing the impact of treatments orthopedic surgeons render. Despite their importance, they can present a burden. We examined the validity and utility of a computerized adaptive testing (CAT) method to reduce the number of questions on the Foot and Ankle Ability Measure (FAAM), a validated anatomy-specific outcome measure. METHODS: A previously developed FAAM CAT system was applied to the responses of patients undergoing foot and ankle evaluation and treatment over a 3-year period (2017-2019). A total of 15 902 responses for the Activities of Daily Living (ADL) subscale and a total of 14 344 responses for the Sports subscale were analyzed. The accuracy of the CAT to replicate the full-form score was assessed. RESULTS: The CAT system required 11 questions to be answered for the ADL subscale in 85.1% of cases (range, 11-12). The number of questions answered on the Sports subscale was 6 (range, 5-6) in 66.4% of cases. The mean difference between the full FAAM ADL subscale and CAT was 0.63 of a point. The mean difference between the FAAM Sports subscale and CAT was 0.65 of a point. CONCLUSION: The FAAM CAT was able to reduce the number of responses a patient would need to answer by nearly 50%, while still providing a valid outcome score. This measure can therefore be directly correlated with previously obtained full FAAM scores in addition to providing a foot/ankle-specific measure, which previously reported CAT systems are not able to do. LEVEL OF EVIDENCE: Level IV, case series.

Central precocious puberty in spina bifida children: Guidelines for the care of people with spina bifida.

Children with spina bifida are at greater risk of developing central precocious puberty (CPP) compared to others. Therefore, early recognition and timely referral for further evaluation by a pediatric endocrinologist allows appropriate management that reduces the impact of CPP. This article discusses the diagnosis and management of CPP in children with spina bifida. This guideline was developed for SB Transition Healthcare Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida.

Nutrition, metabolic syndrome, and obesity: Guidelines for the care of people with spina bifida.

Nutritional challenges and a lack of activity can lead to health problems across the lifespan for people with spina bifida. Children and adults with spina bifida are also at greater risk of being classified as overweight or obese compared to their peers without the condition. Therefore, early recognition of nutrition problems, weight management counseling, and timely referrals for evaluation and management of diet and activity can help those with spina bifida and their families achieve a healthy lifestyle. This article details the development of the Nutrition, Metabolic Syndrome and Obesity Guidelines, which are part of the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida. It discusses the identification and management of poor nutrition and prevention of obesity for children, adolescents, and adults with spina bifida and highlights areas requiring further research.

Short stature and the effect of human growth hormone: Guidelines for the care of people with spina bifida.

It is estimated that a significant percentage of individuals with spina bifida (SB) are shorter than their age-matched typical peers. Parents of children with spina bifida may ask if human growth hormone is appropriate for their child. This article discusses short stature and the use of human growth hormone among children with SB. This guideline was developed for SB Healthcare Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida.

Staple-Plate Plus Screw vs Screw Alone in Talonavicular Arthrodesis: A Cadaveric Biomechanical Study.

BACKGROUND: This study evaluated whether the addition of a nitinol staple-plate to a single cannulated screw increased the mechanical stability for a talonavicular fixation construct. METHODS: Twenty matched pairs of cadaveric feet were randomized to fusion with either a single 5.5-mm cannulated screw or a screw and a plate with 2 screws and a slot with an 18-mm nitinol staple. After in situ fusion procedure, the talonavicular joint complex was dissected free and the ends were embedded in epoxy. The specimens were then cyclically loaded on a servohydraulic load frame (1000 cycles at 20 N, increasing at intervals of 20 N until failure), half of them for cantilever bending and the other half for torsion. RESULTS: In the bending arm of the study, the staple-plate group showed significantly higher stiffness, failure load, and cycles to failure. In the torsion arm of the study, the staple-plate group also had higher cycles to failure, stiffness in external rotation, and torque to failure. No significant difference was noted in stiffness in internal rotation. CONCLUSION: We found a significant increase in stability of the talonavicular joint when a nitinol staple-plate construct was placed to augment a single cannulated screw for the purpose of a talonavicular fusion. CLINICAL RELEVANCE: This information may be helpful to surgeons in implant selection for this common arthrodesis procedure.

Comparison of the use of wireless capsule endoscopy with magnetic resonance enterography in children with inflammatory bowel disease.

BACKGROUND: Magnetic resonance enterography (MRE) and wireless capsule endoscopy (WCE) are equally accepted modalities for noninvasive screening of small bowel involvement (SBI) in children with Crohn's disease (CD) and indeterminate colitis (IC) albeit there is a paucity of data comparing the two and thereby guiding the clinician in selecting the ideal diagnostic approach. Therefore, the goal of this study is to provide additional evidence for capsule endoscopy role in the evaluation of established Crohn's disease exacerbation compared to MRE in relation to Pediatric Crohn's Disease Activity Index (PCDAI), and histological indices. AIM: To prospectively compare the findings of MRE and WCE and their agreement with PCDAI or histology in children with CD or IC. METHODS: Consecutive patients diagnosed with CD and IC were screened for inclusion. After informed consent, patient's demographic and clinical data was abstracted. The current pediatric disease activity index (PCDAI) and endoscopic findings were included. Patients underwent MRE and WCE including preprocedural patency capsule within a maximum of 7 d of each other. Pathological presence of active small bowel disease in ileal and duodenal biopsies were collected if the endoscopy was performed within 2 mo of the WCE study. Patients who failed to pass the PC were excluded from the study. WCE was read by two different experienced gastroenterologists (Attard TM and Colombo JM) blinded to each other's findings and to the findings on MRE (Mardis NJ). Agreement between WCE reviewers, WCE and MRE findings and concordance between positive PCDAI and SBI based on MRE compared with WCE was computed. RESULTS: Forty-five patients were included in the study, 18 withdrew and 27 (20 males and 20 CD), mean age (standard deviation) 13.46 (2.4) years, completed the study protocol. There were no instances of capsule retention. Concordance between gastroenterologist reviewers was excellent for the diagnosis of small intestinal CD with good correlation between the two Lewis scores (r = 0.875, P < 0.001). Concordance between WCE and MRE was poor (69%). In CD patients, when both MRE and WCE were compared using PCDAI > 10 as the standard reference reflecting active small intestinal CD, the sensitivity of MRE and WCE were 100% and 83% respectively and the specificity of MRE and WCE were 57.14% and 78.6%, respectively. If the histology in ileum or/and duodenum was used as the reference for active small bowel involvement, WCE had a higher specificity as compared to MRE (83.3% vs 50%). In patients with Crohn's disease, those with a positive PCDAI (> 10) were more likely to have a positive WCE as compared to those with a negative PCDAI (83% vs 21%; P = 0.018). CONCLUSION: We suggest that MRE and WCE have a complementary role in the assessment of SBI in CD. WCE detected SBI with a much higher specificity while MRE had a higher sensitivity.

What Is the Optimal Method to Perform Bone Biopsy (Method, Location, Imaging Use) for Patients With Foot and Ankle Infections?

RECOMMENDATION: A bone biopsy should generally be performed in a percutaneous fashion, particularly in cases where surgical debridement is not considered necessary. If surgical debridement is considered necessary, then an open biopsy can be performed as part of the debridement. Percutaneous biopsy should be performed under sterile conditions by an interventional radiologist or other physician trained in image-guided techniques. The location of the biopsy will depend upon the clinical and radiographic evaluations, with a goal of maximizing the yield of the biopsy while minimizing the risk of injury to surrounding and/or overlying soft tissue structures. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).