Frontline Providers' and Patients' Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study.

BACKGROUND: Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety. METHODS: Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED-Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews. RESULTS: The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED-Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused. CONCLUSION: Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.

Evidence-Based Recommendations for Education Provided to Patients and Families Regarding the Adverse Events of ALK and MEK Inhibitors: A Systematic Review From the Children's Oncology Group.

Background: Pediatric oncology patients receive multiple modalities of therapy to treat their malignancies. These modalities have the potential for acute toxicity and late effects. In the last decade, a new modality known as targeted biological therapy, has become an integral part of treatment for pediatric cancers. As targeted therapy use has increased, adverse events specific to these targeted agents have emerged, requiring a new effort focused on providing education to patients and families regarding how best to report, monitor, and manage these adverse events. Method: A clinical question was developed to guide the systematic literature review. Anaplastic lymphoma kinase (ALK) and mitogen-activated protein kinase kinase (MEK) inhibitors were selected for review due to their frequency of use in pediatric oncology. The search was conducted to identify relevant articles published between January 1, 2000 and May 5, 2020. Articles were screened by two team members for inclusion/exclusion criteria using the web-based systematic review tool, Rayyan. Results: Twenty-seven articles met the eligibility criteria for inclusion and were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation criteria. Adverse events for ALK and MEK inhibitors included manifestations of the gastrointestinal, hematologic, dermatologic, musculoskeletal, neurological, cardiovascular, and ocular systems. Recommendations for patient/family education were made for ALK and MEK inhibitors based on the reported adverse events. Conclusions: Adverse events of ALK and MEK inhibitors differ from the more common adverse events experienced with conventional treatment modalities used in pediatric oncology. It is important for nurses to include information regarding potential adverse events in patient/family education for children receiving these targeted agents.

Reflections on the Past Decade in Evidence-Based Practice Within the Children's Oncology Group.

Background: The Children's Oncology Group (COG) is the only National Cancer Institute-supported clinical trials organization focused exclusively on childhood and adolescent cancer research. The COG Nursing Discipline Committee has embedded the tenets of evidence-based practice (EBP) into clinical trials nursing in order to standardize the nursing care delivered to children enrolled on these trials. The COG nursing EBP initiative is aimed at developing evidence-based clinical resources and tools to provide guidance to clinicians regarding topics relevant to the provision of cancer treatment for patients enrolled on COG clinical trials from diagnosis through survivorship. A rigorous, evidence-based process designed to guide development of the evidence-based clinical tools and resources within the COG nursing discipline was developed and was implemented with the first nurse expert team beginning in 2012. Method: The standardized process included (a) selecting EBP projects and nursing expert teams (NETs), (b) providing leadership, mentoring, and championship for NETs; (c) approving clinical content developed through the NETs; and (d) providing guidance and oversight over planned dissemination of the COG EBP projects. Results: The COG Nursing EBP Subcommittee has developed 15 publications to date that include 90 authors. Eleven of these authors contributed to multiple publications. Discussion: On this 10th anniversary of the development of the EBP within the COG nursing discipline, we recognize its contributions to the professional growth of many of the discipline's members and to advances in nursing care for children enrolled in pediatric cancer clinical trials.

Kinetics of SARS-CoV-2 Serum Antibodies Through the Alpha, Delta, and Omicron Surges Among Vaccinated Health Care Workers at a Boston Hospital.

Background: Longitudinal serology studies can assist in analyzing the kinetics of antibodies to SARS-CoV-2, helping to inform public health decision making. Our study aims to characterize circulating antibody trends over 18 months in vaccinated participants with and without evidence of COVID-19 infection. Methods: A cohort of health care workers employed at Boston Medical Center was followed to collect serum samples and survey data over 6 time points from July 2020 through December 2021 (N = 527). History of SARS-CoV-2 infection, vaccination, and booster status were confirmed, where possible, through electronic medical records. Serum was assessed for the qualitative and semiquantitative detection of IgG antibody levels (anti-nucleoprotein [anti-N] and anti-spike [anti-S], respectively). Piecewise regression models were utilized to characterize antibody kinetics over time. Results: Anti-S IgG titers remained above the positivity threshold following infection and/or vaccination throughout the 18-month follow-up. Among participants with no evidence of COVID-19 infection, titers declined significantly faster in the initial 90 days after full vaccination (ß = -0.056) from December 2020 to March 2021 as compared with the decline observed following booster dose uptake (ß = -0.023, P < 0.001). Additionally, COVID-19 infection prior to vaccination significantly attenuated the decline of anti-S IgG when compared with no infection following vaccine uptake (P < 0.001). Lastly, fewer participants contracted Omicron when boosted (12.7%) compared to fully vaccinated (17.6%). Regardless of vaccination status, participants who were Omicron positive had lower anti-S IgG titers than those who did not test positive, but this difference was not significant. Conclusions: These findings provide novel 18-month kinetics of anti-S IgG antibodies and highlight the durability of hybrid immunity, underlining the strong humoral response stimulated by combined infection and vaccination.

Feasibility of a universal suicidality tool for adolescents.

BACKGROUND: The suicide rate among adolescents has been increasing rapidly over the past several years. LOCAL PROBLEM: Adequate screening for suicide risk in this population, particularly youth of color, is lacking. METHODS: The Ask Suicide-Screening Questions (ASQ) tool was implemented at two adolescent-focused health clinics in a large U.S. city. INTERVENTIONS: This project followed the Ottawa Model of Research Use. Participating clinicians were surveyed before and after receiving an educational module on suicide risk screening, the ASQ tool, and clinical pathways. Clinicians were also asked about the feasibility and acceptability of the ASQ tool in their practice. An electronic medical records software was used to gather data on patients newly screened for suicide risk using the ASQ tool. RESULTS: Among eligible patients, 40.2% were screened using the ASQ tool during the 4-month duration of the project. Most clinicians reported that using the tool was feasible within their practice (66%) and 100% endorsed its acceptability (i.e., reporting that they were comfortable screening for suicide and that the ASQ was easy to use). CONCLUSIONS: The ASQ may be a promising screening tool for clinicians to use to address the mental health needs of at-risk youth. This project supports the universal acceptability and feasibility of its use in inner-city primary care clinics.

Interobserver reliability of biplanar radiography is unaffected by clinical factors relevant to individuals at risk of pathological lower limb torsion.

BACKGROUND: Assessments of lower limb torsion are ubiquitous in clinical gait analysis practice as pathologic lower limb rotational deformity may contribute to gait abnormalities, anterior knee pain, as well as other debilitating conditions. Understandably, the overall utility of any torsional assessment is dependent on the measurement method's intrinsic accuracy, precision, and robustness to clinical interference factors. Recently, biplanar radiography (BPR) measurements of torsion have been shown to be both accurate and precise, but the robustness of BPR to potential interference factors is unknown. RESEARCH QUESTION: How robust are BPR lower limb torsional assessments to six potential interference factors: amount of torsion, skeletal maturity, radiograph quality, prior osteotomy, presence of implants, and observer training background and experience? METHODS: In this retrospective cohort study, four observers of diverse backgrounds and experience generated digital 3D reconstructions of 44 lower limbs using BPR images obtained during standard of care visits (age range 7-35 years). From each reconstruction, four lower limb torsional parameters were computed: femoral torsion, femorotibial rotation, tibial torsion, and transmalleolar axis equivalent. The mean absolute deviation (MAD) of each torsional parameter - calculated across the four observers - was used as the measure of reliability and tested against all interference factors. RESULTS: Results demonstrated that the average MAD was 2.1 degrees for femoral torsion, 3.0 degrees for transmalleolar axis equivalent, 3.8 degrees for femorotibial rotation, and 4.7 degrees for tibial torsion. None of the six potential interference factors were found to systematically influence BPR reliability across all four torsional parameters. Of the factors found to statistically influence one or more torsional parameter, none affected MAD values to a clinically meaningful extent. SIGNIFICANCE: In addition to being accurate and precise, BPR appears to be robust to several clinical factors relevant to children and young adults with or at risk for pathological lower limb torsion.

Facilitating and Implementing a Process for the Delivery of Pediatric Oncology New Diagnosis Education Among Nursing Staff Through the Electronic Medical Record.

Background: An estimated 11,060 children between the ages of 1 and 14 years and 4,900 adolescents between the ages of 15 and 19 years are diagnosed with cancer in the United States. Parents with children newly diagnosed with cancer must acquire new knowledge related to the diagnosis, treatment plan, psychosocial care, and home management therapies to safely provide care following discharge. Expert consensus and review of current evidence demonstrate that utilizing a new diagnosis education checklist allows the delivery of essential information to patients and caregivers. The checklist divides educational topics into three sections: primary, secondary, and tertiary topics. This project followed the completion of an evidence-based fellowship through Children's Oncology Group focusing upon the feasibility and efficacy of implementing a standardized new diagnosis education checklist. The fellowship identified secondary topic documentation and an electronic medical record (EMR) checklist as areas of future work. Methods: This quality improvement project focused upon nursing staffs' documentation of secondary topics and the development/utilization of an EMR checklist. A pre-post survey design evaluated the outcomes of secondary topic documentation and EMR checklist implementation. Results: This nurse-led initiative created templates for primary and secondary topic checklists using Epic's SmartPhrase feature ".PHOPTED1" and ".PHOPTED2." Secondary topic completion and documentation increased 26% following implementation, and over 40% of the nursing staff indicated that they were very likely to continue to use the new templates. Discussion: Project templates are readily applicable to institutions that utilize Epic. Template examples and strategies to facilitate inpatient/outpatient checklist completion are discussed.

Interprofessional education faculty development survey: Perspectives on IPE and collaborative practice and COVID-19.

The cancellation of in-person classes in March 2020 due to COVID-19 caused a sudden shift in the educational experiences of health profession students enrolled at the University of Michigan (U-M). With the move to remote learning, educators engaging in interprofessional education (IPE) were faced with the challenge of preparing students for interprofessional collaboration from a distance. A survey was designed to investigate the impact of the pandemic on IPE practices and discover educator development needs. Faculty and staff from 10 health sciences schools within the U-M and Michigan Medicine were invited to complete a survey investigating their use of IPE competencies prior to, during, and after the pandemic; their development needs; and their ideas for future implementation of IPE and collaborative practice. Fifty-six percent of respondents reported their ability to teach IPE competencies was impacted by changes related to COVID. There was a significant (p ≤ 0.001) difference between self-report of incorporating IPE competencies prior to and during pandemic and during and into the future across all five competencies. Technology was reported as a challenge when teaching IPE, and a need for future faculty development. Leveraging virtual and case-based learning and increasing collaboration between schools were identified as ideas for future implementation.

Fifteen-Month Follow-Up of Anti-Spike Receptor-Binding Domain SARS-CoV-2 Antibodies among Healthcare Workers in Boston, MA.

BACKGROUND: Boston Medical Center (BMC) is a safety net hospital in Boston, and from the initial wave of COVID-19 there has been an overwhelming concern about the exposure of healthcare workers (HCWs) to SARS-CoV-2. METHODS: We conceived a study to follow a cohort of BMC HCWs, beginning in July 2020 and continuing for 15 months, collecting survey data and serum samples at approximately 3-month intervals. Serum samples were analyzed using the Abbott Architect i2000 for SARS-CoV-2 antibodies (anti-spike1-Receptor Binding Domain IgG and anti-nucleoprotein IgG). Positive anti-n IgG results were used, in addition to reverse transcription-PCR results, for identifying cases of infection. History of COVID-19 and vaccination status were confirmed, where possible, using electronic medical records. Participants were grouped according to vaccination and infection status in September 2021 for analysis of anti-s IgG trends. RESULTS: A majority of HCWs remain well above the positivity threshold for anti-spike IgG antibodies for up to 11 months post-vaccination and 15 months post-infection, regardless of combinations and permutations of vaccination and infection. Those with COVID-19 infection before vaccination had significantly higher median serum antibody concentrations in comparison to HCWs with no prior infection at each follow-up time point. CONCLUSIONS: These findings further support what is known regarding the decline in serum antibody concentrations following natural infection and vaccination, adding knowledge of serum antibody levels for up to 15 months post- infection and 11 months post-vaccination.

Long-term effects of spasticity treatment, including selective dorsal rhizotomy, for individuals with cerebral palsy.

AIM: To understand the long-term effects of comprehensive spasticity treatment, including selective dorsal rhizotomy (SDR), on individuals with spastic cerebral palsy. METHOD: This was a pre-registered, multicenter, retrospectively matched cohort study. Children were matched on age range and spasticity at baseline. Children at one center underwent spasticity treatment including SDR (Yes-SDR, n=35) and antispastic injections. Children at two other centers had no SDR (No-SDR, n=40 total) and limited antispastic injections. All underwent subsequent orthopedic treatment. Participants returned for comprehensive long-term assessment (age ≥21y, follow-up ≥10y). Assessment included spasticity, contracture, bony alignment, strength, gait, walking energy, function, pain, stiffness, participation, and quality of life. RESULTS: Spasticity was effectively reduced at long-term assessment in the Yes-SDR group and was unchanged in the No-SDR group. There were no meaningful differences between the groups in any measure except the Gait Deviation Index (Yes-SDR + 11 vs No-SDR + 5) and walking speed (Yes-SDR unchanged, No-SDR declined 25%). The Yes-SDR group underwent more subsequent orthopedic surgery (11.9 vs 9.7 per individual) and antispastic injections to the lower limbs (14.4 vs <3, by design). INTERPRETATION: Untreated spasticity does not cause meaningful impairments in young adulthood at the level of pathophysiology, function, or quality of life.

Evaluating the Feasibility and Efficacy of a Pediatric Intensive Care Unit Diary.

As the progress of critical care medicine has improved the survival rate of critically ill patients, comorbidities and long-term health care have attracted people's attention. The terms "post-intensive care syndrome" (PICS) and "PICS-family" (PICS-F) have been used in non-neurocritical care populations, which are characterized by the cognitive, psychiatric, and physical sequelae associated with intensive care hospitalization of survivors and their families. An intensive care unit (ICU) diary authored by the patient's family members may alleviate the psychological distress of the patient and his or her family. This quality improvement project focused on the development and implementation of the pediatric intensive care unit (PICU) diary in the pediatric critical care setting. The project aims to evaluate the feasibility and the potential efficacy of the PICU diary, measured through parental acceptance and satisfaction. Seventeen families of critically ill children admitted to the PICU received the PICU diary during the implementation period. Twenty-four parents completed the weekly follow-up, and 15 subsequently completed the diary entry evaluation. The use of the diary in the PICU setting is feasible and considered beneficial by families of critically ill children.

Pandemic Response Requires Research Samples: A U.S. Safety-Net Hospital's Experience and Call for National Action.

Biorepositories provide a critical resource for gaining knowledge of emerging infectious diseases and offer a mechanism to rapidly respond to outbreaks; the emergence of the novel coronavirus, SARS-CoV-2, has proved their importance. During the COVID-19 pandemic, the absence of centralized, national biorepository efforts meant that the onus fell on individual institutions to establish sample repositories. As a safety-net hospital, Boston Medical Center (BMC) recognized the importance of creating a COVID-19 biorepository to both support critical science at BMC and ensure representation in research for its urban patient population, most of whom are from underserved communities. This article offers a realistic overview of the authors' experience in establishing this biorepository at the onset of the COVID-19 pandemic during the height of the first surge of cases in Boston, Massachusetts, with the hope that the challenges and solutions described are useful to other institutions. Going forward, funders, policymakers, and infectious disease and public health communities must support biorepository implementation as an essential element of future pandemic preparedness.

Coronavirus Disease 2019 Vaccine Impact on Rates of Severe Acute Respiratory Syndrome Coronavirus 2 Cases and Postvaccination Strain Sequences Among Health Care Workers at an Urban Academic Medical Center: A Prospective Cohort Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) vaccine trials and post-implementation data suggest that vaccination decreases infections. We examine vaccination's impact on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case rates and viral diversity among health care workers (HCWs) during a high community prevalence period. METHODS: In this prospective cohort study, HCW received 2 doses of BNT162b2 or mRNA-1273. We included confirmed cases among HCWs from 9 December 2020 to 23 February 2021. Weekly SARS-CoV-2 rates per 100,000 person-days and by time from first injection (1-14 and ≥15 days) were compared with surrounding community rates. Viral genomes were sequenced. RESULTS: SARS-CoV-2 cases occurred in 1.4% (96/7109) of HCWs given at least a first dose and 0.3% (17/5913) of HCWs given both vaccine doses. Adjusted rate ratios (95% confidence intervals) were 0.73 (.53-1.00) 1-14 days and 0.18 (.10-.32) ≥15 days from first dose. HCW ≥15 days from initial dose compared to 1-14 days were more often older (46 vs 38 years, P = .007), Latinx (10% vs 8%, P = .03), and asymptomatic (48% vs 11%, P = .0002). SARS-CoV-2 rates among HCWs fell below the surrounding community, an 18% vs 11% weekly decrease, respectively (P = .14). Comparison of 50 genomes from post-first dose cases did not indicate selection pressure toward known spike antibody escape mutations. CONCLUSIONS: Our results indicate an early positive impact of vaccines on SARS-CoV-2 case rates. Post-vaccination isolates did not show unusual genetic diversity or selection for mutations of concern.

Developing and Assessing a Competency-Based Nurse Orientation in Pediatric Ambulatory Infusion Clinics.

Clinical nurse competency can be well supported through the institution of competency-based nurse orientation programs. The aims of this quality improvement project are twofold: to develop an orientation checklist that contains competency-based education techniques and assessment tools and to evaluate the usability of the competency-based orientation checklist by nursing staff. The project used a pre-post survey design to assess usability. The findings demonstrate that competency-based education and assessment increase checklist usability and increase staff satisfaction.

Evidence-Based Recommendations for Nurse Monitoring and Management of Immunotherapy-Induced Cytokine Release Syndrome: A Systematic Review from the Children's Oncology Group.

Children with B-precursor acute lymphoblastic leukemia and B-cell lymphoma, particularly those with relapsed or refractory disease, are increasingly enrolled on phase II and phase III clinical trials studying immunotherapies. These therapeutic agents may be associated with a high risk of cytokine release syndrome (CRS), and nurses lack standardized guidelines for monitoring and managing patients with CRS. Six studies and one clinical practice guideline were included in this systematic review that examined the evidence of CRS following administration of chimeric antigen receptor T-cell therapy or the bi-specific T-cell engager antibody, blinatumomab. Six nursing practice recommendations (five strong, one weak) were developed based on low or very low-quality evidence: three reflect preinfusion monitoring, one focuses on monitoring during and postinfusion, and three pertain to the nurse's role in CRS management.

Monitoring Diagnostic Safety Risks in Emergency Departments: Protocol for a Machine Learning Study.

BACKGROUND: Diagnostic decision making, especially in emergency departments, is a highly complex cognitive process that involves uncertainty and susceptibility to errors. A combination of factors, including patient factors (eg, history, behaviors, complexity, and comorbidity), provider-care team factors (eg, cognitive load and information gathering and synthesis), and system factors (eg, health information technology, crowding, shift-based work, and interruptions) may contribute to diagnostic errors. Using electronic triggers to identify records of patients with certain patterns of care, such as escalation of care, has been useful to screen for diagnostic errors. Once errors are identified, sophisticated data analytics and machine learning techniques can be applied to existing electronic health record (EHR) data sets to shed light on potential risk factors influencing diagnostic decision making. OBJECTIVE: This study aims to identify variables associated with diagnostic errors in emergency departments using large-scale EHR data and machine learning techniques. METHODS: This study plans to use trigger algorithms within EHR data repositories to generate a large data set of records that are labeled trigger-positive or trigger-negative, depending on whether they meet certain criteria. Samples from both data sets will be validated using medical record reviews, upon which we expect to find a higher number of diagnostic safety events in the trigger-positive subset. Machine learning will be used to evaluate relationships between certain patient factors, provider-care team factors, and system-level risk factors and diagnostic safety signals in the statistically matched groups of trigger-positive and trigger-negative charts. RESULTS: This federally funded study was approved by the institutional review board of 2 academic medical centers with affiliated community hospitals. Trigger queries are being developed at both organizations, and sample cohorts will be labeled using the triggers. Machine learning techniques such as association rule mining, chi-square automated interaction detection, and classification and regression trees will be used to discover important variables that could be incorporated within future clinical decision support systems to help identify and reduce risks that contribute to diagnostic errors. CONCLUSIONS: The use of large EHR data sets and machine learning to investigate risk factors (related to the patient, provider-care team, and system-level) in the diagnostic process may help create future mechanisms for monitoring diagnostic safety. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24642.

Seroprevalence of SARS-CoV-2 IgG antibodies and risk factors in health care workers at an academic medical center in Boston, Massachusetts.

Healthcare workers (HCWs) are at an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel virus that causes Coronavirus Disease (COVID-19). We aim to assess the seroprevalence of SARS-CoV-2 IgG among healthcare workers and compare risk-factors between seropositive and seronegative HCWs. In this observational study, serum samples were collected from HCWs between July 13th to 26th, 2020 at Boston Medical Center (BMC). Samples were subsequently tested for SARS-CoV-2 IgG antibody using the Abbott SARS-CoV-2 IgG assay. Participants also answered a questionnaire capturing data on demographics, history of COVID-19 symptoms, occupation, infection prevention and control measures. Overall, 95 of 1743 (5.5%) participants tested positive for SARS-CoV-2 IgG. Of these, 1.8% of the participants had mild or no COVID-19 symptoms and did not require a diagnostic test. Seropositivity was not associated with gender, occupation, hand hygiene and personal protective equipment (PPE) practices amongst HCWs. However, lack of physical distancing among health care workers in work areas and break room was associated with seropositivity (p = 0.05, p = 0.003, respectively). The majority of the HCWs are negative for SARS-CoV-2 IgG. This data highlights the need to promote infection prevention measures, and the importance of distance amongst co-workers to help mitigate infection rates.

Implementing and Evaluating a Standardized New Diagnosis Education Checklist: A Report From the Children's Oncology Group.

When a child is newly diagnosed with cancer, parents report feeling overwhelmed with the amount of information that they must process in order to safely care for their child at home. The Children's Oncology Group (COG) Nursing Discipline has focused on examining current practices for educating families of children newly diagnosed with cancer, and developing tools to enhance the process of patient/family education at the time of diagnosis, including development of a COG Standardized Education Checklist, which classifies education into primary, secondary, and tertiary topics. The COG Nursing Discipline awarded nursing fellowships to two doctorally prepared nurses practicing at two distinct COG institutions to evaluate the checklist implementation. This project addressed the primary topics on the checklist essential to safely care for the child at home following the first hospital discharge. Checklist feasibility was determined by the proportion of checklists completed. Checklist fidelity was determined by review of documentation on the checklist regarding educational topics covered, learner preferences, and methods used. Checklist acceptability was assessed through parent/caregiver and nurse feedback. Project implementation occurred over a 5-month period and involved 69 newly diagnosed families. Implementation of the checklist was feasible (81%), with moderate fidelity to checklist topics taught across the two sites. Verbal instruction and written documentation were the most prevalent form of education. The return rate for the parent/caregiver and nurse acceptability questionnaires was moderate to low (68% and 12%, respectively), parent/caregiver feedback was positive and acceptability among responding nurses was high, with 92% of nurses identifying the primary checklist as useful.

Long-term functional outcomes after an external femoral derotation osteotomy in individuals with cerebral palsy.

BACKGROUND: It is unknown how a femoral derotation osteotomy (FDO) during childhood affects functional outcomes in adulthood among individuals with bilateral cerebral palsy (CP). RESEARCH QUESTIONS: How do long-term functional outcomes after an FDO compare to matched individuals who did not have an FDO? How do outcomes change over time? METHODS: We queried the gait laboratory database for individuals who underwent an external FDO in childhood and were currently ≥25 years old. Participants returned for a long-term analysis (gait, physical examination, functional tests, imaging, questionnaires). The matched non-FDO group included only individuals in Gross Motor Function Classification System levels I-II, yielding three groups (non-FDO I-II, FDO I-II, FDO III-IV). RESULTS: Sixty-one adults (11 non-FDO, 34 FDO I-II, 16 FDO III-IV) returned 13-25 years after baseline (non-FDO) or surgery (FDO). The non-FDO and FDO I-II groups were matched at baseline on most variables, except the FDO group had weaker hip abductors. At long-term, groups were similar on gait variables (median long-term hip rotation [primary outcome], non-FDO: -4°, FDO I-II: -4°, FDO III-IV: -5°), hip abduction test, fear of falling, and most pain measures despite anteversion being 29° greater in the non-FDO group. The FDO I-II group reported more falls than the non-FDO group. All groups improved on hip rotation, foot progression, and hip abductor strength. Speed and step length decreased/tended to decrease for all three groups. Hip abduction moment and gait deviation index did not change. Improvements in the FDO groups were maintained from short- to long-term. SIGNIFICANCE: These results challenge the notion that an FDO is necessary to correct mean stance hip rotation for higher functioning individuals since nearly identical results were achieved by adulthood in the non-FDO I-II group. However, an FDO provides improvement earlier and maintenance from short- to long-term. This should factor into the shared decision-making process.