Changes in foot posture evaluated with dynamic pedobarography over the course of childhood in ambulatory youth with cerebral palsy.

Purpose: Foot deformities are prevalent in children with cerebral palsy, but there is limited research on the progression of foot posture during growth. Our study aimed to evaluate the change in dynamic foot posture in children with cerebral palsy. Methods: Children with cerebral palsy, aged 17-40 months, were recruited to participate in this Institutional Review Board-approved prospective longitudinal study by having serial foot posture evaluations. The coronal plane index and foot segmental impulses were measured with dynamic pedobarography. Data were compared between children stratified by Gross Motor Function Classification System level and typically developing children using serial Welch's t-tests across time with Holm correction for multiple comparisons. Results: In total, 33 children (54 limbs) were included in the analysis (21 bilateral and 12 unilateral; Gross Motor Function Classification System: I-13, II-14, III-4, IV-2. Children completed 16.9 (± 4.4) evaluations (initial age 2.9 (± 0.7) and final age 18.6 (± 1.7) years)). Early valgus foot posture normalizes in children at Gross Motor Function Classification System levels I/II and persists in children at levels III/IV who do not have foot surgery. For most young children, foot posture development is variable. Conclusion: Foot posture in young children with cerebral palsy begins in valgus and tends to normalize in youth who walk without an assistive device. Conservative management of foot deformity is recommended in early childhood. Level of evidence: Level II, prognostic study.

Can the Shriners Hospital Upper Extremity Evaluation (SHUEE) Detect Change in Dynamic Position and Spontaneous Function of the Upper Limb in People With Hemiplegic Cerebral Palsy?

BACKGROUND: The Shriners Hospital Upper Extremity Evaluation (SHUEE) is a video-based measure designed to assess upper extremity function in people with cerebral palsy (CP). The SHUEE completes both dynamic positional analysis (DPA; position during functional activities) and spontaneous functional analysis (spontaneous use of the involved limb). Although the SHUEE has been suggested as a measure for planning upper limb interventions and evaluating outcomes, limited evidence of its ability to detect change exists. Thus, this study aimed to describe responsiveness of the SHUEE to detect change after orthopaedic surgery. METHODS: In this Institutional Review Board-approved retrospective cohort study, we identified children with CP who were administered SHUEE on≥2 encounters. We formed pairs of initial and follow-up visits between temporally adjacent visits. Pairs were assigned to a surgery or non-surgery group based on intervening upper limb orthopaedic surgery. We compared differences in baseline SHUEE scores between groups and differences in temporally adjacent SHUEE scores within groups using Welch unequal variances t tests and paired t tests, respectively. RESULTS: Nineteen people (7 female) with hemiplegic CP had≥2 SHUEE assessments; Manual Ability Classification System levels I (3), II (8), III (7), IV (1); Gross Motor Function Classification System levels I (10), II (7), IV (2); mean age at baseline 11.9 (5.1 to 19.1) years; and follow-up at 13.4 (5.5 to 19.7) years. Six people had≥2 visits leading to 14 surgical pairs and 10 non-surgical pairs. At baseline, DPA of the wrist and forearm were significantly lower in the surgical group ( P <0.05). At follow-up, no significant difference between the groups existed in DPA measures ( P >0.05). After surgical intervention, there was a significant change in overall and wrist DPA ( P <0.05). CONCLUSIONS: The DPA measures demonstrated responsiveness to expected positional changes in the arm after orthopaedic surgery in people with CP. The SHUEE was useful in identifying abnormal segmental alignment pre-surgically and documenting changes in alignment postoperatively. As orthopaedic surgery does not address limb neglect or bimanual ability, spontaneous functional analysis scores were as expected-unchanged. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The effect of medial only versus medial and lateral hamstring lengthening on transverse gait parameters in cerebral palsy.

Benefits of hamstring lengthening surgery on the sagittal plane in children with cerebral palsy have been previously demonstrated, but there is limited information on its effects on the transverse plane. This study compared the effects of medial hamstring lengthening (MHL) with those of medial and lateral hamstring lengthening (MLHL) procedures in the transverse plane. Children with gross motor function classification system (GMFCS) levels I-III who had MHL or MLHL were included. Baseline, short- (1-2 years), and long-term (3+ years) postoperative three-dimensional gait analysis outcomes were compared using analysis of variance. Children were excluded if they had concurrent osteotomies or tendon transfers. One hundred fifty children (235 limbs) were included, with 110 limbs in the MHL group (age 8.5 ± 4.1 years, GMFCS I-27%, II-52%, and III-21%) and 125 limbs in the MLHL group (age 10.0 ± 4.0 years, GMFCS I-23%, II-41%, and III-37%). Time between surgery and short- and long-term follow-up gait analysis was 1.5 ± 0.6 years and 6.6 ± 2.9 years, respectively. Transmalleolar axis became more external after MHL at both short and long terms ( P < 0.05), whereas there were only significant differences at long term in MLHL ( P < 0.05). Although hamstring lengthening has a positive impact on stance phase knee extension in children with cerebral palsy, intact lateral hamstrings after MHL likely contribute to increased tibial external rotation after surgery. Significant increases in external rotation at the knee in the long term are likely related to a trend present with growth in children with cerebral palsy rather than a direct result of surgical intervention.

Well-Being of Ambulatory Adults With Cerebral Palsy: Education, Employment, and Physical Function of a Cohort Who Received Specialized Pediatric Care.

Introduction: The transition from pediatric health care and school systems presents enormous challenges for young adults with cerebral palsy (CP). The lack of strong societal support during this seminal life event is well-documented and leads many adults with CP to struggle with independence, higher education, and employment. Despite the relatively high prevalence of CP, information about the experiences and function of adults with CP in our society continues to be limited. The purpose of this project was to describe well-being by assessing education, employment, physical function, walking activity, and utilization of health care in an ambulatory adult cohort with CP who received specialized pediatric care at our center. Method: In this Institutional Review Board-approved prospective study, we invited former patients from our tertiary care pediatric CP center to complete a set of patient-reported outcomes including (1) the Patient-Reported Outcomes Measurement Information System domains of physical function and pain interference, (2) the Satisfaction with Life Scale, and a project-specific demographic questionnaire about education, employment, income, independence, pain, and health care utilization. Participants also wore a pedometer for 8 days to monitor community walking activity. Chi-squared pairwise or t-tests were used as appropriate to compare survey responses and walking activity data between three groups: participants who self-reported, those who reported by proxy, and published normative data from age-matched typically developing adult (TDA) samples. Results: One hundred twenty-six adults with CP consented to participate; 85 self-reported [age 29.7 ± 4.3 years; Gross Motor Function Classification System: I (28%), II (47%), and III, (25%)] and 41 reported by proxy [age 29.7 ± 4.1 years; Gross Motor Function Classification System: I (10%), II (68%), and III (22%)]. For the group who self-reported, high school graduation rate (99%) was similar to TDA (92%; p = 0.0173) but bachelor's degree achievement rate (55%) was higher than TDA (37%; p < 0.001). Despite more advanced education, the unemployment rate in this group was higher than national levels at 33% and was associated with high utilization of Social Security Disability Insurance (33%). Within the self-reporting group, 13% required a caregiver. For the group who reported by proxy, educational levels (73% high school graduates, 0 bachelor's degree) were lower than the general population (p < 0.001) and unemployment was higher than the national level, at 64%. Unemployment in this group was associated with high utilization of Social Security Disability Insurance (85%). Within the proxy-reporting group, 71% required a caregiver. The full cohort demonstrated lower levels of physical function according to the Patient-Reported Outcomes Measurement Information System and less community walking activity compared with TDA references (p < 0.001). This cohort of adults with CP reported significantly higher frequency of chronic pain (48 vs. 12% for TDA; p < 0.001), but less pain interference with daily activities than TDA based on Patient-Reported Outcomes Measurement Information System results (p < 0.001). This cohort reported good to excellent overall health (93%) and high utilization of primary care (98%), but limited utilization of specialty care, specifically orthopedic care (21%) and physical therapy (15%). Discussion: This cohort of adults with CP had similar levels of education as the general population, but had relatively high rates of unemployment, caretaker need, and Social Security Disability Insurance utilization. Although chronic pain was frequent, the impact of pain on work and independent living did not exceed reports from a typically developing reference. Better targeted societal resources for adults with physical disabilities are urgently needed to allow equitable access to employment, promote opportunities for independence, and enable full participation in community life.

Evaluation of Gait Pattern and Lower Extremity Kinematics of Children with Morquio Syndrome (MPS IV).

Morquio syndrome (mucopolysaccharidosis IV/MPS IV) is a genetic disorder leading to skeletal abnormalities and gait deviations. Research on the gait patterns and lower extremity physical characteristics associated with skeletal dysplasia in children with MPS IV is currently limited. This research aimed to provide baseline gait patterns and lower limb skeletal alignment of children with MPS IV utilizing three-dimensional instrumented gait analysis. This Institutional Review Board-approved retrospective study evaluates the kinematics of the lower extremities of children with MPS IV during gait, comparing them with an age-matched group of typically developing children. Thirty-three children with MPS IV were included (8.6 ± 4.0 years old). Children with MPS IV walk with increased anterior pelvic tilt, knee valgus, knee flexion, external tibial torsion, and reduced walking speed and stride length (p < 0.001). Multiplanar abnormal alignment results in abnormal knee moments (p < 0.001). Limited correlations exist (r = 0.69-0.28) between dynamic three-dimensional measurements of knee varus/valgus and rotational alignment and traditional static two-dimensional measures (physical examination or radiographs) suggesting the possibility of knee instability during gait and the benefits of dynamic assessment.

Factors associated with walking activity in adults with cerebral palsy.

BACKGROUND: This prospective study used instrumented gait analysis, patient-reported outcomes, and portable accelerometers to examine walking activity in adults with cerebral palsy (CP). RESEARCH QUESTION: This study aimed to provide objective data and evaluate factors associated with walking activity in adults with CP. METHODS: Participants with CP (ages 25-45 years) completed instrumented gait analysis and patient-reported outcomes, including the Patient Reported Outcome Measurement Information System (PROMIS) and Satisfaction with Life Score (SWLS), and wore a StepWatch for 8 days. Average strides per day, stratified by Gross Motor Function Classification System (GMFCS), were compared with nondisabled adults ages 30-39 years utilizing Welch's t-tests with Bonferroni corrections. Correlation coefficients and stepwise multiple linear regression analyses examined relationships between walking activity and GMFCS, gait deviation index (GDI), gait velocity, PROMIS physical function, SWLS, body mass index (BMI), and employment. RESULTS: Participants included 109 adults with CP, ages 29 ± 4 years, classified at GMFCS levels I/II (73 %) and III/IV (27 %). Compared with nondisabled adults, daily stride count was significantly lower in both groups of adults with CP (p < 0.00025), with a progressive decline according to GMFCS level. Walking activity correlated with PROMIS physical function (r = .42), GDI (r = .48), and gait velocity (r = .58). Association for employment was lower (r = 0.27) but significant, while age, SWLS, and BMI were not individually correlated with walking activity. Stepwise, multiple linear regression modeled with Akaike information criterion explained 40.9 % of the observed variability in walking activity in this cohort of adults with CP. SIGNIFICANCE: Physical function, as classified by GMFCS or measured by PROMIS and self-selected walking velocity, has the strongest association with and is the most significant predictor of walking activity in adults with CP. After accounting for physical function, a small amount of the variation in walking activity can be explained by GDI, employment, and age.

Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children With Cerebral Palsy With Stiff Knee Gait.

BACKGROUND: Children with cerebral palsy (CP) often present with a stiff knee gait pattern because of rectus femoris (RF) spasticity and/or contracture. Rectus femoris transfers (RFTs) and resections are surgical procedures aimed at reducing muscle stiffness, thereby improving knee flexion during the swing phase of gait. Previous research has consistently demonstrated objective benefits of rectus transfer using instrumented gait analysis (IGA). Rectus femoris resection (RFR), a relatively simpler procedure, shows similar improvement in knee range of motion during gait. The objective of this study was to compare surgical outcomes between rectus transfers and resections using 3-dimensional IGA. METHODS: Children with spastic CP who had RFTs or resections were retrospectively matched by walking speed and preoperative knee kinematics from 3-dimensional IGA (peak and timing of peak knee flexion in swing). Secondary outcomes included knee range of motion and maximum knee extension during gait. RESULTS: Twenty-eight children were included in both the transfer group [age 9.4±2 y; Gross Motor Function Classification System (GMFCS) I (3 children), II (15 children), III (8 children), and IV (2 children)] and the resection group [age 10.6±2.5 y; GMFCS I (1 child), II (14 children), and III (13 children)]. Both surgical groups showed statistically significant short-term postsurgical improvements in peak knee flexion during swing (P<0.001 for the transfer group and P=0.003 for the resection group) and Duncan-Ely test (P=0.004 for the transfer group and P<0.001 for the resection group). Further analysis by GMFCS level showed children at GMFCS levels III/IV had a greater tendency to crouch after RFT when compared with children at GMFCS levels I/II. This tendency was not observed in the RFR group. CONCLUSIONS: Both transfer and resection surgeries significantly improved gait kinematics short-term outcomes in children with spastic CP who present with stiff knee gait pattern. Further studies are required to compare long-term outcomes of both surgeries. LEVEL OF EVIDENCE: Level III-retrospective matched-cohort study.

Effect of hybrid rice varieties on growth and development of broilers and ducks.

Three experiments (Exp. 1, n = 144 broilers [Ross × Ross]; Exp. 2, n = 118 mallard ducklings [Anas platyrhynchos]; and Exp. 3, n = 75 mature mallard ducks) were conducted to determine the effects of 3 levels of unmilled hybrid rice on growth performance and organ and gastrointestinal tract development. The dietary treatments were 1) corn-soybean meal (basal), 2) basal + 5% hybrid rice, and 3) basal + 10% hybrid rice for Exp. 1 to 3, respectively. One bird from each pen in Exp. 1 (n = 24) and all the birds in Exp. 2 (n = 118) and Exp. 3 (n = 75) were randomly selected and euthanized to determine linear measurements and organ and gastrointestinal tract weight. In Exp. 1 and 2, birds fed 10% rice experienced slower growth (P < 0.05) than birds fed the basal diet. In Exp. 3, the addition of rice did not affect growth performance. Rice addition did not affect organ length or weight (P > 0.05) in Exp. 1. However, birds fed 5% rice had significantly increased (P < 0.05) pancreas, ileum, and jejunum weights in Exp. 2, and 10% rice significantly increased (P < 0.05) liver weight in Exp. 3. The addition of 10% unmilled rice to broiler and duck diets may reduce growth performance.

Mechanism of Rate Acceleration of Radical C-C Bond Formation Reaction by a Radical SAM GTP 3',8-Cyclase.

While the number of characterized radical S-adenosyl-l-methionine (SAM) enzymes is increasing, the roles of these enzymes in radical catalysis remain largely ambiguous. In radical SAM enzymes, the slow radical initiation step kinetically masks the subsequent steps, making it impossible to study the kinetics of radical chemistry. Due to this kinetic masking, it is unknown whether the subsequent radical reactions require rate acceleration by the enzyme active site. Here, we report the first evidence that a radical SAM enzyme MoaA accelerates the radical-mediated C-C bond formation. MoaA catalyzes an unprecedented 3',8-cyclization of GTP into 3',8-cyclo-7,8-dihydro-GTP (3',8-cH2GTP) during the molybdenum cofactor (Moco) biosynthesis. Through a series of EPR and biochemical characterizations, we found that MoaA catalyzes a shunt pathway in which an on-pathway intermediate, GTP C-3' radical, abstracts H-4' atom from (4'R)-5'-deoxyadenosine (5'-dA) to transiently generate 5'-deoxyadenos-4'-yl radical (5'-dA-C4'•) that is subsequently reduced stereospecifically to yield (4'S)-5'-dA. Detailed kinetic characterization of the shunt and the main pathways provided the comprehensive view of MoaA kinetics and determined the rate of the on-pathway 3',8-cyclization step as 2.7 ± 0.7 s-1. Together with DFT calculations, this observation suggested that the 3',8-cyclization by MoaA is accelerated by 6-9 orders of magnitude. Further experimental and theoretical characterizations suggested that the rate acceleration is achieved mainly by constraining the triphosphate and guanine base positions while leaving the ribose flexible, and a transition state stabilization through H-bond and electrostatic interactions with the positively charged R17 residue. This is the first evidence for rate acceleration of radical reactions by a radical SAM enzyme and provides insights into the mechanism by which radical SAM enzymes accelerate radical chemistry.

Paradigm Shift for Radical S-Adenosyl-l-methionine Reactions: The Organometallic Intermediate Ω Is Central to Catalysis.

Radical S-adenosyl-l-methionine (SAM) enzymes comprise a vast superfamily catalyzing diverse reactions essential to all life through homolytic SAM cleavage to liberate the highly reactive 5'-deoxyadenosyl radical (5'-dAdo·). Our recent observation of a catalytically competent organometallic intermediate Ω that forms during reaction of the radical SAM (RS) enzyme pyruvate formate-lyase activating-enzyme (PFL-AE) was therefore quite surprising, and led to the question of its broad relevance in the superfamily. We now show that Ω in PFL-AE forms as an intermediate under a variety of mixing order conditions, suggesting it is central to catalysis in this enzyme. We further demonstrate that Ω forms in a suite of RS enzymes chosen to span the totality of superfamily reaction types, implicating Ω as essential in catalysis across the RS superfamily. Finally, EPR and electron nuclear double resonance spectroscopy establish that Ω involves an Fe-C5' bond between 5'-dAdo· and the [4Fe-4S] cluster. An analogous organometallic bond is found in the well-known adenosylcobalamin (coenzyme B12) cofactor used to initiate radical reactions via a 5'-dAdo· intermediate. Liberation of a reactive 5'-dAdo· intermediate via homolytic metal-carbon bond cleavage thus appears to be similar for Ω and coenzyme B12. However, coenzyme B12 is involved in enzymes catalyzing only a small number (∼12) of distinct reactions, whereas the RS superfamily has more than 100 000 distinct sequences and over 80 reaction types characterized to date. The appearance of Ω across the RS superfamily therefore dramatically enlarges the sphere of bio-organometallic chemistry in Nature.

Advise and Assist: A Basic Medical Skills Course for Partner Forces.

BACKGROUND: Training partner forces in battlefield first-responder medical skills is an important component of US military advise-and-assist operations. We designed and executed a training curriculum focused on high-yield-based medical skills to prevent death on the battlefield for non-English speaking members of the Turkish, Azerbaijani, and Albanian militaries deployed to Afghanistan. METHODS: We designed a 2-hour training curriculum focusing on four basic medical skills: (1) assessment of scene safety; (2) limb tourniquet application; (3) wound bandaging; and (4) patient transportation via litter. Our combat medics delivered standardized training using both didactic and practicum components. Instructors made beforeand- after assessments of the proficiency of each participant for each skill in accordance with the Dreyfus model of skill acquisition. We also administered before-and-after, Likertscale- based surveys for training participants to report their self-assessed comfort level with each of the four skills. RESULTS: We delivered training to 187 participants over five classes. All 28 participants in the final teaching class completed the study. Instructors categorized each participant's skill level as novice before training for all four skills. After the training curriculum, all participants achieved a skill level consistent with advanced beginner for all four skills. Participants reported significant improvements in self-reported comfort levels for all taught procedures (ρ < .001 by Wilcoxon signed-rank test for all four skills). The largest reported increase in median comfort level was for tourniquet application: median pretraining comfort level, 4 (interquartile range [IQR], 0-6.25) versus 9.5 (IQR, 9-10) posttraining. CONCLUSION: Our curriculum resulted in significant improvements in instructor-assessed proficiency and self-reported comfort level for all four basic medical skills. Although our outcome measures have important limitations, this curriculum may be useful framework for future medics and physicians designing battlefield first-responder training curricula for members of foreign militaries.

Cardiovascular care facts: a report from the national cardiovascular data registry: 2011.

OBJECTIVES: The aim of this report was to characterize the patients, participating centers, and measures of quality of care and outcomes for 5 NCDR (National Cardiovascular Data Registry) programs: 1) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-GWTG (Get With The Guidelines) for acute coronary syndromes; 2) CathPCI Registry for coronary angiography and percutaneous coronary intervention; 3) CARE (Carotid Artery Revascularization and Endarterectomy) Registry for carotid revascularization; 4) ICD Registry for implantable cardioverter defibrillators; and the 5) PINNACLE (Practice INNovation And CLinical Excellence) Registry for outpatients with cardiovascular disease (CVD). BACKGROUND: CVD is a leading cause of death and disability in the United States. The quality of care for patients with CVD is suboptimal. National registry programs, such as NCDR, permit assessments of the quality of care and outcomes for broad populations of patients with CVD. METHODS: For the year 2011, we assessed for each of the 5 NCDR programs: 1) demographic and clinical characteristics of enrolled patients; 2) key characteristics of participating centers; 3) measures of processes of care; and 4) patient outcomes. For selected variables, we assessed trends over time. RESULTS: In 2011 ACTION Registry-GWTG enrolled 119,967 patients in 567 hospitals; CathPCI enrolled 632,557 patients in 1,337 hospitals; CARE enrolled 4,934 patients in 130 hospitals; ICD enrolled 139,991 patients in 1,435 hospitals; and PINNACLE enrolled 249,198 patients (1,436,328 individual encounters) in 74 practices (1,222 individual providers). Data on performance metrics and outcomes, in some cases risk-adjusted with validated NCDR models, are presented. CONCLUSIONS: The NCDR provides a unique opportunity to understand the characteristics of large populations of patients with CVD, the centers that provide their care, quality of care provided, and important patient outcomes.

Carcinoma of the Lung. A review

A cirurgia se constitui uma única arma capaz de curar câncer de pulmäo. Infelizmente cerca de 3/4 dos pacientes se apresentam já fora de possibilidade cirúrgica. Compete ao cirurgiäo discernir e estadiar aqueles que säo candidatos à operaçäo, levando em conta essencialmente o estadiamento da doença no pré-operatório. Na avaliaçäo destes pacientes, deve-se incluir a Tomografia Computadorizada, além da radiografia simples do tórax. A TC é importante na demonstraçäo de (1) invasäo de corpo vertebral, mas näo na invasäo de parede torácica; (2) na presença de derrame pleural näo suspeitado; (3) na avaliaçäo do mediastino com referência aos linfonodos. A ressonância magnética näo parece ter maiores vantagens quanto comparada a TC. A ultrasonografia transeofagiana tem sido útil nos locais inacessíveis a TC como por exemplo no mediastino inferior. Os estudos cintilográficos näo tem trazido benefícios nos pacientes assintomáticos. Dentre os procedimentos invasivos a broncoscopia e aspiraçäo por agulha transcutânea säo importantes. A toracoscopia video assistida recentemente é útil na visualizaçäo do espaço pleural e biópsia de linfonodos, notadamente na janela aorto-pulmonar. A biópsia supraclavicular somente nos casos em que é palpável o linfonodo. O procedimento mais valioso afora a toracotomia é a mediastinoscopia. Os estudos têm revelado que os linfonodos menores do que 1 cm indicariam a mediastinoscopia de vez que 60 por cento a 80 por cento estäo envolvidos por tumor. A investigaçäo de metástases à distância na ausência de sintomas nos órgäos mais frequentemente envolvidos näo compensa a despesa e o tempo dispendidos. Na avaliaçäo funcional objetivando a condiçäo física do paciente a funçäo pulmonar e cardíaca säo primordiais. Com relaçäo ao primeiro: Os testes mais simples incluem a capacidade vital forçada (CVF), o volume expiatório no 1§ segundo (VEF1) e a relaçäo VEF1/CVF devem ser obtidos. Quando o VEF1 está acima de 85 por cento do previsto qualquer operaçäo proposta pode ser realizada. O desenvolvimento dos testes näo invasivos têm permitido uma avaliaçäo acurada. Se näo há história de cardiopatia e o ECG é normal, näo há necessidade de outros testes. As contraindicaçöes säo história de infarto recente, insuficiência cardíaca incontrolada ou arritmias. O tratamento cirúrgico na maioria das séries relatadas consiste na lobectomia em dois terços dos pacientes, a pneumonectomia em um quarto, a bilobectomia em aproximadamente 5 por cento e ressecçäo...