Childhood exposure to domestic violence: can global estimates on the scale of exposure be obtained using existing measures?

Purpose: Childhood exposure to domestic violence and abuse (DVA) can lead to major short- and long-term effects on the victim. Despite this, there is no accepted measure for children's experiences, with most existing measures being validated only in high income countries and not in low- and middle- income countries. As a result, international statistics are not comparable. This paper seeks to critically appraise existing measures and discuss whether any are fit-for-purpose on a global scale. Method: The COSMIN PROMs approach was followed to critically appraise and compare the appropriateness of measures. A comprehensive literature search was undertaken in seven journal databases for measures mentioned in formally peer-reviewed articles exploring childhood exposure to DVA. Results: A literature search resulted in the identification of 10 measures and, following criteria to only keep original measures and remove modifications, four measures which have been validated cross-culturally are discussed in detail in line with the COSMIN PROMs criterion: The Child Exposure to Domestic Violence Scale, Children's Perception of Interparental Conflict Scale, Juvenile Victimization Questionnaire and The Violence Exposure Scale for Children. Strengths and limitations of each are discussed, along with any validations undertaken not in the country of origin. Conclusion: Despite childhood exposure to DVA being an urgent research priority worldwide, the current measures to explore the extent of the issue are not validated cross-culturally, leading to concerns about comparisons across different population groups. The development and implementation of interventions to reduce the levels and effects of exposure relies heavily on cross-cultural comparisons, which may indicate different strategies are needed in different contexts. The lack of these validated comparisons is constraining advances, and the paper advocates for further efforts to be made in this regard.

Long-term reoperation rates following spinal fusion for neuromuscular scoliosis in nonambulatory patients with cerebral palsy.

PURPOSE: To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP). METHODS: We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated. RESULTS: 144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. CONCLUSIONS: To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood. LEVEL OF EVIDENCE: III.

Examining the effectiveness of the Gateway conditional caution on health and well-being of young adults committing low-level offences: a randomised controlled trial.

BACKGROUND: Young adults who commit low-level offences commonly have a range of health and social needs and are significantly over-represented in the criminal justice system. These young adults may need to attend court and potentially receive penalties including imprisonment. Alternative routes exist, which can help address the underlying causes of offending. Some feel more should be done to help young adults entering the criminal justice system. The Gateway programme was a type of out-of-court disposal developed by Hampshire Constabulary, which aimed to address the complex needs of young adults who commit low-level crimes. This study aimed to evaluate the effectiveness and cost-effectiveness of the Gateway programme, issued as a conditional caution, compared with usual process. METHODS: The Gateway study was a pragmatic, parallel-group, superiority randomised controlled trial that recruited young adults who had committed a low-level offence from four sites covering Hampshire and Isle of Wight. The primary outcome was mental health and well-being measured using the Warwick-Edinburgh Mental Well-being Scale. Secondary outcomes were quality of life, alcohol and drug use, and recidivism. Outcomes were measured at 4, 16 and 52 weeks postrandomisation. RESULTS: Due to issues with retention of participants and low data collection rates, recruitment ended early, with 191 eligible participants randomised (Gateway 109; usual process 82). The primary outcome was obtained for 93 (48.7%) participants at 4 weeks, 93 (48.7%) at 16 weeks and 43 (22.5%) at 1 year. The high attrition rates meant that effectiveness could not be assessed as planned. CONCLUSIONS: Gateway is the first trial in a UK police setting to have a health-related primary outcome requiring individual data collection, rather than focusing solely on recidivism. We demonstrated that it is possible to recruit and randomise from the study population, however follow-up rates were low. Further work is needed to identify ways to facilitate engagement between researchers and vulnerable populations to collect data. TRIAL REGISTRATION NUMBER: ISRCTN11888938.

Use of standardized outcome measures for people with lower-limb amputation: A survey of prosthetic practitioners in Canada.

BACKGROUND: Outcome measures (OMs) are useful tools; however, clinicians may find implementing them into clinical practice challenging. OBJECTIVES: To characterize Canadian prosthetists' use of OMs for people with lower-limb amputation, including motivations for use, comfort selecting OMs, resources available for administration, and barriers to implementation. METHODS: A cross-sectional study was conducted between March and July 2021. Orthotics Prosthetics Canada sent Canadian prosthetists an invitation to take the online survey. RESULTS: Forty-nine Certified Prosthetists completed the survey. Only 16% of participants reported that they were expected to use OMs. Participants reported being more comfortable administering performance-based OMs than self-report surveys. More than two-thirds of participants agreed that OMs "can be administered with knowledge they have" and are "within their scope of practice." However, less than 25% agreed that OMs are "administered in a standardized way in the profession," and less than 40% indicated they are "easy to make part of my routine." Participants reported they generally have time and space to do OMs, but there was no agreed-on reason to use them. CONCLUSIONS: Use of OMs among Canadian prosthetists seems to be low relative to prosthetists in the United States. Education, financial incentives, or changes to professional expectations are likely needed to increase routine OM use. Efforts to improve the standardization of OM administration and ease the incorporation of OMs into routine practice may also increase use. Canadian prosthetists may elevate their standards of clinical practice and better understand the impact of prosthetic treatments on their patients by more routinely using OMs.

Clinical outcomes measurement in pediatric lower limb prosthetics: A scoping review.

PURPOSE: This study aimed to identify clinical measures that have been used to evaluate function, health related quality of life (HRQoL), and/or satisfaction in children who use lower limb prostheses (LLP). The data reported on psychometric properties for children who use LLP were collected for each measure. METHODS: First, PubMed, CINAHL, and Web of Science databases were searched using broad search terms to identify standardized outcome measures of function, HRQoL, and/or satisfaction with treatment used in pediatric LLP research published in 2001 or after. For each of the eligible measures found, a second search was performed to identify psychometric properties (e.g., validity, reliability) assessed with children who use LLP. RESULTS: Forty-four standardized outcome measures were identified from 41 pediatric LLP research articles. Five measures (i.e., Gait Outcomes Assessment for Lower Limb Differences, Functional Mobility Assessment, Child Amputee Prosthetics Project- Prosthesis Satisfaction Inventory, Child Amputee Prosthetics Project- Functional Scale Index, and Lower Limb Function Questionnaire) had data on psychometric properties for children who use LLP. CONCLUSIONS: Few studies report psychometric data for assessing the overall HRQoL, function, and/or satisfaction for children who use LLP. Further research is needed to validate or create new outcome measures that assess the HRQoL, satisfaction, and/or function of children who use LLP.

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis.

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia (P = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia (P = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Nurse productivity: using evidence to enhance nurses' use of time.

The UK is experiencing a nursing shortage, making it challenging to maintain the staffing levels required to deliver effective patient care. One way of enhancing the care delivered by the existing workforce could be to optimise nurse productivity; however, previous efforts to do this have been largely ineffective, due in part to a focus on the processes of care delivery rather than the nursing activities within these processes. In this article, the author explores the concept of nurse productivity and suggests that enhancing productivity requires the identification of nursing activities and consideration of how these may be undertaken in a more time-efficient manner - or removed altogether. The author discusses two such activities: intentional (hourly) rounding, and fixed-time manual vital signs for patients on general wards. The author also considers the potential of using automatic continuous remote monitoring on general hospital wards to free up nurses' time for other care activities.

Antibody agonists trigger immune receptor signaling through local exclusion of receptor-type protein tyrosine phosphatases.

Antibodies can block immune receptor engagement or trigger the receptor machinery to initiate signaling. We hypothesized that antibody agonists trigger signaling by sterically excluding large receptor-type protein tyrosine phosphatases (RPTPs) such as CD45 from sites of receptor engagement. An agonist targeting the costimulatory receptor CD28 produced signals that depended on antibody immobilization and were sensitive to the sizes of the receptor, the RPTPs, and the antibody itself. Although both the agonist and a non-agonistic anti-CD28 antibody locally excluded CD45, the agonistic antibody was more effective. An anti-PD-1 antibody that bound membrane proximally excluded CD45, triggered Src homology 2 domain-containing phosphatase 2 recruitment, and suppressed systemic lupus erythematosus and delayed-type hypersensitivity in experimental models. Paradoxically, nivolumab and pembrolizumab, anti-PD-1-blocking antibodies used clinically, also excluded CD45 and were agonistic in certain settings. Reducing these agonistic effects using antibody engineering improved PD-1 blockade. These findings establish a framework for developing new and improved therapies for autoimmunity and cancer.

Economic activity and suicides: Causal evidence from macroeconomic shocks in England and Wales.

The relationship between economic activity and suicides has been the subject of much scrutiny, but the focus in the extant literature has been almost exclusively on estimating associations rather than causal effects. In this paper, using data from England and Wales between January 1, 1997 and December 31, 2017, we propose a plausible set of assumptions to estimate the causal impacts of well-known macroeconomic variables on the daily suicide rate. Our identification strategy relies on scheduled macroeconomic announcements and professional economic forecasts. An important advantage of using these variables to model suicide rates is that they can efficiently capture the elements of 'surprise or shock' via the observed difference between how the economy actually performed and how it was expected to perform. Provided that professional forecasts are unbiased and efficient, the estimated 'surprises or shocks' are 'as good as random', and therefore are exogenous. We employ time series regressions and present robust evidence that these exogenous macroeconomic shocks affect the suicide rate. Overall, our results are consistent with economic theory that shocks that reduce estimated permanent income, and therefore expected lifetime utility, can propel suicide rates. Specifically, at the population level, negative shocks to consumer confidence and house prices accelerate the suicide rate. However, there is evidence of behavioural heterogeneity between sexes, states of the economy, and levels of public trust in government. Negative shocks to the retail price index (RPI) raise the suicide rate for males. Negative shocks to the growth rate in gross domestic product (GDP) raise the population suicide rate when the economy is doing poorly. When public trust in government is low, increases in the unemployment rate increase the suicide rate for females.

Development and initial validation of the Orthotic Patient-Reported Outcomes-Mobility (OPRO-M): An item bank for evaluating mobility of people who use lower-limb orthoses.

Lower limb orthoses (LLOs) are externally-applied leg braces that are designed to improve or maintain mobility in people with a variety of health conditions that affect lower limb function. Clinicians and researchers are therefore often motivated to measure LLO users' mobility to select or assess the effectiveness of these devices. Patient-reported outcome measures (PROMs) can provide insights into important aspects of a LLO user's mobility for these purposes. However, few PROMs are available to measure mobility of LLO users. Those few that exist have issues that may limit their clinical or scientific utility. The objective of this study was to create a population-specific item bank for measuring mobility of LLO users. Previously-developed candidate items were administered in a cross-sectional study to a large national sample of LLO users. Responses from study participants (n = 1036) were calibrated to a graded response statistical model using Item Response Theory methods. A set of 39 items was found to be unidimensional, locally independent, and function without bias due to characteristics unrelated to mobility. The set of final calibrated items, termed the Orthotic Patient-Reported Outcomes-Mobility (OPRO-M) item bank, was evaluated for initial evidence of convergent, divergent, and known groups construct validity. OPRO-M was strongly correlated with existing PROMs designed to measure aspects of physical function. Conversely, OPRO-M was weakly correlated with PROMs that measured unrelated constructs, like sleep disturbance and depression. OPRO-M also showed an ability to differentiate groups with expected mobility differences. Two fixed-length short forms were created from the OPRO-M item bank. Items on the short forms were selected based on statistical and clinical criteria. Collectively, results from this study indicate that OPRO-M can effectively measure mobility of LLO users, and OPRO-M short forms can now be recommended for use in routine clinical practice and research studies.

Lessons from the Gateway programme, aimed at improving health and life chances for young people committing low-level offences: a qualitative evaluation.

BACKGROUND: Young people who commit criminal offences are often affected by mental health issues, including drug and alcohol misuse, with many leading chaotic lifestyles. Gateway was a pioneering court-diversion programme aimed to reduce reoffending and improve the health and wellbeing of people aged 18-24 years who had been questioned for a low-level offence. The Gateway Study consisted of a pragmatic, parallel-group, superiority randomised controlled trial (RCT) of the programme's effectiveness, and its qualitative evaluation. We aimed to determine barriers and enablers for implementation of Gateway and recruitment into the RCT. METHODS: We evaluated the implementation of Gateway, a 16-week conditional caution designed by Hampshire Constabulary and delivered predominantly by third sector organisations. Following a needs assessment, young people received individual support from a Gateway navigator and attended self-development workshops. Recruitment into the RCT took place across four sites across Hampshire and Isle of Wight, UK. Semi-structured interviews were carried out with Gateway stakeholders over three time periods in 2018-22, with additional timepoints in the first time period. Purposive samples of Gateway clients and recruiters, as well as all of Gateway staff, were interviewed. Thematic analysis was applied, with an inductive and predominantly reflexive approach, for each group of participants in each time period. FINDINGS: Between Dec 19, 2018, and May 3, 2022, qualitative interviews were held with 28 Gateway clients, 17 Gateway project staff, and 13 police officers and civilian staff who acted as recruiters into the programme and RCT. Various themes related to engagement were identified, with multiple subthemes and unique insights. The core themes can be classified as follows (with examples of factors influencing engagement): (1) setup for Gateway delivery and RCT recruitment (eg, multi-agency partnerships, physical locations, training); (2) young people's lifestyles and needs (eg, personal circumstances, pre-existing expectations, attitude towards Gateway); (3) priorities and culture in the organisations (eg, workload priorities, job satisfaction, inter-stakeholder relationships). INTERPRETATION: The Gateway Study was a unique endeavour to gather evidence for a potentially life-changing intervention for an underserved population. Engaging vulnerable young people and the police in research comes with its own, specific challenges. The insights shared as a result of this evaluation can inform the design of interventions and studies that target similarly vulnerable people or are based in similar settings. Awareness of the potential barriers and facilitators can help public health researchers and practitioners plan accordingly and prevent or mitigate some of the low-engagement issues. FUNDING: National Institute for Health and Care Research (NIHR).

Effects of high-profile crossover feet on gait biomechanics in 2 individuals with Syme amputation.

BACKGROUND: Prosthetic treatment options for people with ankle disarticulation (i.e., Syme amputation) are limited. Prosthetic feet designed for people with Syme amputation are often low profile to accommodate build-height restrictions, resulting in decreased energy return during gait. High-profile crossover feet that attach to the posterior proximal aspect of the prosthetic socket can bypass these restrictions and may promote a more physiologic gait pattern. OBJECTIVES: To compare level-ground gait biomechanics and patient-reported outcomes between crossover and traditional energy-storing feet in people with Syme amputation. STUDY DESIGN: Within-participant pilot study. METHODS: Both participants were fit with energy-storing and crossover feet and were randomized to the order they used the feet. Participants used each foot for 2 weeks before assessment. Step length symmetry, prosthetic ankle range of motion, prosthetic-side energy return, and peak sound-side loading were determined from motion capture data obtained in a laboratory. Mobility and balance confidence were measured using standardized patient-reported outcome measures. Foot preference was assessed with an ad hoc survey. RESULTS: Two participants with Syme amputations completed the study. Prosthetic ankle peak dorsiflexion and push-off power increased with the crossover foot compared with the energy-storing foot for both participants. Both participants reported an overall preference of the crossover foot. Changes in patient-reported outcomes did not exceed published minimum detectable change values. CONCLUSION: Crossover feet increased prosthetic ankle range of motion and energy return compared with traditional energy-storing feet in this pilot investigation of 2 participants. Crossover feet seem to promote physiologic gait and may be a promising alternative to traditional low-profile feet for people with Syme amputation.

An in vivo analysis of implanted programmable device interference during magnetically controlled growing rod lengthenings: a story of 129 lengthenings.

PURPOSE: Early-onset scoliosis (EOS) is often treated with magnetically controlled growing rods (MCGR) which can be lengthened with a magnetic external remote control (ERC). Many individuals with EOS have concomitant medical conditions which are managed with other implanted programmable devices (IPD). Some providers are concerned that the magnetic field generated during MCGR lengthening may interfere with other IPD, such as ventriculoperitoneal shunts (VPS), intrathecal baclofen pumps (ITBP), vagal nerve stimulators (VNS), and cochlear implants (CI). The aim of this study was to evaluate the safety of MCGR lengthenings in patients with EOS and other IPD. METHODS: This single-center, single-surgeon case series followed 12 patients with 13 IPD as they underwent treatment with MCGR. Post MCGR lengthening, monitoring of patient symptoms, and interrogation of IPD were conducted to evaluate for magnetic interference. RESULTS: After 129 MCGR lengthenings, post-lengthening VPS interrogation found 2 instances of potential interference in settings (both in Medtronic Strata shunts); however, no pre-lengthening interrogation was completed to confirm if these changes occurred prior to or during the lengthening procedure. ITBP interrogation found no changes, and there were no patient-reported adverse effects related to VNS or CI function. CONCLUSION: It is safe and effective to utilize MCGR in patients with IPD. However, the possibility of magnetic interference must be considered, particularly in individuals with VPS. We recommend approaching with the ERC from a caudal direction to minimize potential interference and all patients be monitored during treatment. If possible, IPD settings should be assessed pre-lengthening, confirmed afterwards and readjusted if necessary. LEVEL OF EVIDENCE: Level IV.

The Chemokine Receptor CCR1 Mediates Microglia Stimulated Glioma Invasion.

Glioblastoma multiforme (GBM) is the most aggressive form of adult brain tumor which is highly resistant to conventional treatment and therapy. Glioma cells are highly motile resulting in infiltrative tumors with poorly defined borders. Another hallmark of GBM is a high degree of tumor macrophage/microglia infiltration. The level of these tumor-associated macrophages/microglia (TAMs) correlates with higher malignancy and poorer prognosis. We previously demonstrated that inhibition of TAM infiltration into glioma tumors with the CSF-1R antagonist pexidartinib (PLX3397) can inhibit glioma cell invasion in-vitro and in-vivo. In this study, we demonstrate an important role for the chemokine receptor CCR1 in mediating microglia/TAM stimulated glioma invasion. Using two structurally distinct CCR1 antagonists, including a novel inhibitor "MG-1-5", we were able to block microglial activated GL261 glioma cell invasion in a dose dependent manner. Interestingly, treatment of a murine microglia cell line with glioma conditioned media resulted in a strong induction of CCR1 gene and protein expression. This induction was attenuated by inhibition of CSF-1R. In addition, glioma conditioned media treatment of microglia resulted in a rapid upregulation of gene expression of several CCR1 ligands including CCL3, CCL5, CCL6 and CCL9. These data support the existence of tumor stimulated autocrine loop within TAMs which ultimately mediates tumor cell invasion.

Prevalence of secondary prosthesis use in lower limb prosthesis users.

PURPOSE: Prostheses designed for daily use are often inappropriate for high-level activities and/or are susceptible to water damage and mechanical failure. Secondary prostheses, such as activity-specific or back-up prostheses, are typically required to facilitate uninterrupted participation in desired life pursuits. This study estimated the prevalence of secondary prosthesis use in a large, national sample of lower limb prosthesis users (LLPUs). METHODS: We conducted a secondary analysis of survey data from three cross-sectional studies that assessed mobility in LLPUs. Descriptive statistics were used to determine the percentage of secondary prosthesis users and percentages of LLPUs that used different type(s) of secondary prosthesis(es). Secondary prosthesis users and non-users were compared to identify differences in participant characteristics between groups. RESULTS: Of participants in the analysis (n = 1566), most (65.8%) did not use a secondary prosthesis. The most common secondary prosthesis types were back-up (19.2%) and activity-specific prostheses (13.5%). Secondary prosthesis users differed significantly from non-users with respect to gender, race, and other characteristics. CONCLUSIONS: Results suggest that secondary prosthesis use for most LLPUs is limited and may differ based on users' demographic and clinical characteristics. Future research should determine how LLPUs' health-related quality-of-life outcomes are affected by access to and use of secondary prostheses.Implications for RehabilitationSecondary prostheses, including activity-specific, back-up, and shower prostheses, have the potential to improve function, mobility, and participation for people who use lower limb prostheses.Most lower limb prosthesis users do not use secondary prostheses, and access to these devices may be related to users' demographic and clinical characteristics.Rehabilitation professionals play a key role in facilitating prosthesis users' access to secondary prostheses and should advocate for those who need them.

Policies, Practices, and Attitudes Related to Parental Leave for Practicing Pediatric Orthopaedic Surgeons.

BACKGROUND: Parental leave impacts family engagement, bonding, stress, and happiness. Because parental leave benefits are important to all surgeons regardless of sex, understanding parental leave practices in pediatric orthopaedic surgery is critical to promote equity within the profession and supporting balance in work and family life. The aim of this study was to survey pediatric orthopaedic surgeons about their knowledge of parental leave policies, attitudes towards parental leave, and their individual experiences taking leave. METHODS: A 34-question anonymous survey was distributed to the Pediatric Orthopaedic Society of North America membership. Eligible respondents were attending pediatric orthopaedic surgeons practicing in the United States or Canada. The survey gathered information about employer parental leave policies, perceptions about and experiences with parental leave while practicing as a surgeon, and demographic information about respondents. RESULTS: A total of 77 responses were completed and used for analysis. Most respondents were men (59.7%), <50 years old (67.5%), married (90.9%), and in urban communities (75.3%). A large majority were practicing in the United States (97.4%). Most respondents were unfamiliar with employer parental leave policies (maternity: 53.3%; paternity: 67.5%; and adoption: 85.7%). Those familiar with policies reported that employers offered 7 to 12 weeks for maternity leave (45.7%) and <1 week for paternity leave (50%) and adoption leave (45.5%). Most respondents believed 7 to 12 weeks should be offered for maternity leave (66.2%), 1 to 6 weeks for paternity leave (54.6%), and 7 to 12 weeks for adoption leave (46.8%). Many respondents reported taking 1 to 6 weeks of parental leave as a surgeon (53.3%) and that their colleagues were supportive of their parental leave (40.3%). CONCLUSIONS: Most pediatric orthopaedic surgeons were unfamiliar with parental leave benefits provided by employers. Respondents who were familiar with these policies believed that more parental leave should be provided, especially for men who may feel social pressure to take less time for leave. Although respondents reported that their work environments were supportive, this study identified opportunities for improvement to support surgeons who wish to balance parental experiences with work responsibilities. LEVEL OF EVIDENCE: Level V.

Development of an item bank for measuring prosthetic mobility in people with lower limb amputation: The Prosthetic Limb Users Survey of Mobility (PLUS-M).

BACKGROUND: Achieving mobility with a prosthesis is a common post-amputation rehabilitation goal and primary outcome in prosthetic research studies. Patient-reported outcome measures (PROMs) available to measure prosthetic mobility have practical and psychometric limitations that inhibit their use in clinical care and research. OBJECTIVE: To develop a brief, clinically meaningful, and psychometrically robust PROM to measure prosthetic mobility. DESIGN: A cross-sectional study was conducted to administer previously developed candidate items to a national sample of lower limb prosthesis users. Items were calibrated to an item response theory model and two fixed-length short forms were created. Instruments were assessed for readability, effective range of measurement, agreement with the full item bank, ceiling and floor effects, convergent validity, and known groups validity. SETTING: Participants were recruited using flyers posted in hospitals and prosthetics clinics across the United States, magazine advertisements, notices posted to consumer websites, and direct mailings. PARTICIPANTS: Adult prosthesis users (N = 1091) with unilateral lower limb amputation due to traumatic or dysvascular causes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Candidate items (N = 105) were administered along with the Patient Reported Outcome Measurement Information System Brief Profile, Prosthesis Evaluation Questionnaire - Mobility Subscale, and Activities-Specific Balance Confidence Scale, and questions created to characterize respondents. RESULTS: A bank of 44 calibrated self-report items, termed the Prosthetic Limb Users Survey of Mobility (PLUS-M), was produced. Clinical and statistical criteria were used to select items for 7- and 12-item short forms. PLUS-M instruments had an 8th grade reading level, measured with precision across a wide range of respondents, exhibited little-to-no ceiling or floor effects, correlated expectedly with scores from existing PROMs, and differentiated between groups of respondents expected to have different levels of mobility. CONCLUSION: The PLUS-M appears to be well suited to measuring prosthetic mobility in people with lower limb amputation. PLUS-M instruments are recommended for use in clinical and research settings.

Modifying the five-time sit-to-stand test to allow use of the upper limbs: Assessing initial evidence of construct validity among lower limb prosthesis users.

The Five-time Sit-to-Stand (5xSTS) Test is a performance-based measure used by clinicians and researchers to assess the body functions needed to accomplish sit-to-stand transitions (e.g., lower limb strength, balance, and trunk control). The current requirements for performance of the 5xSTS Test (i.e., crossing arms over the chest) may not be appropriate for many, if not most lower limb prosthesis (LLP) users. The study aims were to (1) develop a modified five-time sit-to-stand (m5xSTS) Test protocol; (2) to examine initial evidence of known-groups construct validity among LLP users by comparing differences in performance by amputation level, amputation etiology, and functional level; and (3) to assess initial evidence of convergent construct validity by examining the correlations between m5xSTS performance with self-reported mobility (Prosthetic Limb Users Survey of Mobility (PLUS-M)), self-reported balance confidence (Activities-balance Confidence Scale (ABC)) and functional capability (comfortable walking speed). Three-hundred sixty-one LLP users participated in this cross-sectional study. The investigators developed a m5xSTS Test protocol that allows tested individuals to use different assistance strategies (i.e., use of upper limbs to push off thighs, push up from the armrests, or use a walker) when needed to perform the test. The investigators recorded m5xSTS Test times and assistance strategies. Significant differences in m5xSTS Test times were found between those who did and did not use an assistance strategy, as well as between participants grouped by different amputation level, etiology, and functional level. Significant moderate negative correlations were found between m5xSTS Test times and PLUS-M T-score (ρ = -0.42, p<0.001), ABC score (ρ = -0.42, p<0.001), and comfortable walking speed (ρ = -0.64, p<0.001), respectively. The m5xSTS Test allows LLP users to perform sit-to-stand transitions in a manner that accounts for their functional impairments, is consistent with post-amputation training, and is safe for the tested individual. Results from this study provide preliminary evidence of known groups and convergent construct validity for the m5xSTS Test with a large national sample of LLP users.

Pitfalls and management of corrective spinal surgery in trisomy 9 mosaicism: a report of three cases.

PURPOSE: The aim of this case series is to present the outcomes of surgical correction of hyperkyphosis, and subsequent management of complications for three patients with a rare chromosomopathy, Trisomy 9 Mosaicism (T9M). METHODS: Case series with 2 year outcomes following index surgery. RESULTS: Case 1 presented at 9 years of age with 103° of kyphosis (T3-T10), which progressed to 118° despite bracing. Case 2 presented at 7 years of age with 113° of kyphosis (T3-T11). Case 3 presented at 4 years of age with 103° of kyphosis (T1-T11). Cases 1 and 2 underwent T2-L2 posterior instrumented spinal fusion (PISF). Upon follow up, radiographs for Cases 1 and 2 revealed severe, symptomatic proximal junctional kyphosis (PJK) of 71° and 50°, respectively, requiring surgical revision proximally to the C4 level. Case 3 underwent placement of magnetically controlled growing rods given young age and growth potential. Surgical levels for Case 3 were extended from C4-pelvis in an attempt to prevent development of symptomatic PJK. Most recent radiographs for Case 3 taken 21 months postoperatively demonstrate a stable 50° of kyphosis. PJK above C4 was noted but is stable and asymptomatic. CONCLUSION: T9M often presents with progressive hyperkyphosis. Despite instrumentation above the upper end vertebra (UEV), PJK may be a common complication in this small patient population. This novel report on spine deformity correction in the T9M population may provide preliminary guidance for the treatment of hyperkyphosis in patients with T9M and help surgeons avoid common pitfalls. LEVEL OF EVIDENCE: IV.