Long-Term Imaging Follow-up from the Management of Myelomeningocele Study.

BACKGROUND AND PURPOSE: Short-term results demonstrate that prenatal repair of a myelomeningocele is associated with a reduction in hydrocephalus and an increased likelihood of the reversal of Chiari II malformations compared with postnatal repair. The purpose of this study was to identify the long-term imaging findings at school age among subjects who underwent pre- versus postnatal repair of a myelomeningocele. MATERIALS AND METHODS: A subset of subjects enrolled in the Management of Myelomeningocele Study who underwent either prenatal (n = 66) or postnatal (n = 63) repair of a lumbosacral myelomeningocele and had follow-up brain MR imaging at school age were included. The prevalence of posterior fossa features of Chiari II malformation and supratentorial abnormalities and the change in these findings from fetal to school-age MR imaging were compared between the 2 groups. RESULTS: Prenatal repair of a myelomeningocele was associated with higher rates of normal location of fourth ventricle and lower rates of hindbrain herniation, cerebellar herniation, tectal beaking, brainstem distortion, and kinking at school age compared with postnatal repair (all P < .01). Supratentorial abnormalities, including corpus callosal abnormalities, gyral abnormalities, heterotopia, and hemorrhage, were not significantly different between the 2 groups (all P > .05). The rates of resolution of brainstem kinking, tectal beaking, cerebellar and hindbrain herniation, and normalization of fourth ventricle size from fetal to school age MR imaging were higher among the prenatal compared with postnatal surgery group (all, P < .02). CONCLUSIONS: Prenatal repair of a myelomeningocele is associated with persistent improvement in posterior fossa imaging findings of Chiari II malformation at school age compared with postnatal repair.

Reaching for equitable care: High levels of disability-related knowledge and cultural competence only get us so far.

BACKGROUND: Achieving equitable medical care for people with disabilities is a complex challenge with emphasis often placed on the need for improved physician knowledge and cultural competence. Physical medicine and rehabilitation (PM&R) is a specialty dedicated to maximizing patient function, where a focus on working with and learning from patients with complex disabilities informs physician training and patient care. OBJECTIVE: The purpose of this study was to assess barriers to equitable care in PM&R clinics through a structural checklist and semi-structured interviews with clinic staff and physicians. METHODS: We used qualitative analysis with a grounded theory approach to develop a unified explanation of how existing clinic processes and provider attitudes affect equitable access to medical care. RESULTS: We found physicians comfortable with and respectful of patient differences who described leveraging unpaid time and creativity to navigate structural, resource, and awareness barriers. Staff and physicians described current barriers as negatively affecting quality of care, clinic efficiency, and, in some cases, patient and staff safety. CONCLUSION: Our results suggest that high levels of physician disability-related knowledge and cultural competence may be insufficient to the challenge of achieving equitable care.

Factors affecting procedural pain in children during and immediately after intramuscular botulinum toxin injections for spasticity.

PURPOSE: To evaluate variables that modulate pain during intramuscular botulinum toxin A injections in children. METHODS: As part of a Quality Improvement project, this retrospective analysis compared reported pain during and five minutes post injections with patient and procedural variables using subgroup and regression analyses (N= 593 procedures with 249 unique patients). RESULTS: Mean procedural pain for all procedures (n= 563) was 3.8 ± 3.0. Most children reported no pain (83.8%) or mild pain (12.1%) five minutes after the procedure. Provider, previous patient experience, and dose did not significantly impact pain. Linear regression analysis (R=2 0.64) demonstrated that younger age (p< 0.05), use of vapo-coolant spray or topical anesthetic (p< 0.01), and body region injected (p< 0.01) were significantly associated with increased procedural pain. Logistic regression (R=2 0.14) demonstrated that pain during the procedure (p< 0.001) and older age (p< 0.01) increased the likelihood of pain post-procedure. Utilization of personnel for distraction did not significantly predict pain ratings at either time point. CONCLUSION: Age, topical anesthesia, and injected region impact procedural pain and in nearly 96% of cases, patients report mild or no pain within five minutes. Additional research into these predictors is necessary, but short-lived procedural pain may suggest that frequent use of sedation/anesthesia is unnecessary.