Hip Displacement in MECP2 Disorders: Prevalence and Risk Factors.

BACKGROUND: Methyl-CpG binding protein 2 (MECP2) disorders, including Rett syndrome and MECP2 duplication syndrome, are typified by profound intellectual disability, spasticity, and decline in gross motor function. Unlike scoliosis, linked to disease severity, little has been reported regarding the hip. The aim of this study was to report the prevalence and risk factors of hip displacement (HD) in MECP2 disorders. METHODS: This was a retrospective, comparative study. Children with a genetically confirmed MECP2 disorder were included. The primary outcome measure was the prevalence of HD (migration percentage>30%). Secondary outcomes included age at HD onset, ambulatory status, presence of clinically relevant scoliosis, genetic severity, presence of seizures, and associated comorbidities. Analysis of proportions of categorical variables was performed using χ2 testing (P=0.05). RESULTS: Fifty-six patients (54 Rett syndrome and 2 MECP2 duplication syndrome), diagnosed at 6.6 (SD: 4.7) years, met the inclusion criteria. The prevalence of HD was 36% [onset, 7.7 (SD: 3.8) y]. Risk factors for HD were nonwalker status (P=0.04), scoliosis (P=0.001), and refractory epilepsy (P=0.04). CONCLUSIONS: The prevalence of HD in MECP2 disorders is comparable to cerebral palsy, associated with proxy measures of disease severity. These results can be used to develop hip surveillance programs for MECP2 disorders, allowing for timely management. LEVEL OF EVIDENCE: Level III.

A patient and family data domain collection framework for identifying disparities in pediatrics: results from the pediatric health equity collaborative.

BACKGROUND: By 2020, the child population is projected to have more racial and ethnic minorities make up the majority of the populations and health care organizations will need to have a system in place that collects accurate and reliable demographic data in order to monitor disparities. The goals of this group were to establish sample practices, approaches and lessons learned with regard to race, ethnicity, language, and other demographic data collection in pediatric care setting. METHODS: A panel of 16 research and clinical professional experts working in 10 pediatric care delivery systems in the US and Canada convened twice in person for 3-day consensus development meetings and met multiple times via conference calls over a two year period. Current evidence on adult demographic data collection was systematically reviewed and unique aspects of data collection in the pediatric setting were outlined. Human centered design methods were utilized to facilitate theme development, facilitate constructive and innovative discussion, and generate consensus. RESULTS: Group consensus determined six final data collection domains: 1) caregivers, 2) race and ethnicity, 3) language, 4) sexual orientation and gender identity, 5) disability, and 6) social determinants of health. For each domain, the group defined the domain, established a rational for collection, identified the unique challenges for data collection in a pediatric setting, and developed sample practices which are based on the experience of the members as a starting point to allow for customization unique to each health care organization. Several unique challenges in the pediatric setting across all domains include: data collection on caregivers, determining an age at which it is appropriate to collect data from the patient, collecting and updating data at multiple points across the lifespan, the limits of the electronic health record, and determining the purpose of the data collection before implementation. CONCLUSIONS: There is no single approach that will work for all organizations when collecting race, ethnicity, language and other social determinants of health data. Each organization will need to tailor their data collection based on the population they serve, the financial resources available, and the capacity of the electronic health record.

Lower Regional Pediatric In-hospital Mortality Albeit Racial/ethnic Disparities.

PURPOSE: Variability in pediatric morbidity and mortality tends to be influenced by several factors including though not limited to social determinants of health, namely health inequity as an exposure function of health disparities. We aimed to assess the cumulative incidence of pediatric mortality, racial/ethnic disparities, and the predisposing factors for the disparities. METHOD: The current study retrospectively examined the Nemours/Alfred I. duPont Hospital for Children medical records of 16,121 patients diagnosed with any pediatric condition during 2009 and 2010. RESULTS: In-hospital pediatric mortality cumulative incidence was relatively low (80 deaths, 0.49%) when compared with similar settings in the U.S. (national average range, 0.8e1.1%) during the same period. Compared with whites/Caucasians, mortality was higher among blacks/African Americans, prevalence odds ratio (POR), 1.06, 95% CI, 0.77e1.45, and higher for some other race, POR, 1.48, 95% CI, 1.06e2.10. After controlling for potential confounders (severity of illness, insurance status, and length of stay), racial differences in pediatric mortality did not persist between whites and some other race, adjusted POR, 1.08, 99% CI, 0.75e1.57. CONCLUSIONS: In-hospital pediatric mortality cumulative incidence was relatively low in our region, and racial disparities exist but did not persist after controlling for confounders. These findings are suggestive of the importance of social determinants of health namely quality care, adequate medical insurance, and early detection, diagnosis in pediatric morbidity and epigenomic alterations, as well as the need to go beyond the "close medical model" to improve pediatric morbidity and survival by addressing health inequity as a function of health disparities.

Persistence and Recurrence Following Femoral Derotational Osteotomy in Ambulatory Children With Cerebral Palsy.

BACKGROUND: Excessive hip internal rotation is frequently seen in children with cerebral palsy (CP). Femoral derotational osteotomy (FDO) is effective in the short term, but factors associated with long-term correction remain unclear. The purposes of this study were to define the incidence of persistence and recurrence of hip internal rotation following FDO in ambulatory children with CP and to evaluate factors that influence outcome. METHODS: Following IRB approval, kinematic and passive range of motion (PROM) variables were retrospectively evaluated in children with spastic CP who had FDO to correct hip internal rotation as part of clinical care at a children's specialty hospital. Children included had a preoperative evaluation (Vpre), a short-term postoperative evaluation (Vshort, 1 to 3 y post), and, in some cases, a long-term postoperative evaluation (Vlong, ≥5 y post). Age at surgery, physical exam measures, and kinematics variables were evaluated as predictors for dynamic and static recurrence. RESULTS: Kinematic hip rotation improved from 14±12 degrees (Vpre; internal positive) to 4±13 degrees (Vshort) and relapsed to 9±15 degrees long term (P<0.05 Vpre/Vshort/Vlong; 99 limbs). Hip PROM midpoint improved from 23±9 degrees (Vpre) to 8±11 degrees (Vshort) and relapsed to 14±13 degrees (P<0.01 Vpre/Vshort/Vlong). Persistent hip internal rotation was noted in 41% (kinematics) and 18% (PROM) of limbs at Vshort (105 children, 178 limbs). Of limbs that showed initial improvement at Vshort (62 children, 95 limbs), recurrence was seen in 40% (kinematic hip rotation) and 39% (hip midpoint) at Vlong. Comparing children who had recurrent hip internal rotation and those who maintained long-term correction, we saw higher levels of spasticity and lower gait velocity in the recurrent group (P<0.05). CONCLUSIONS: Although FDO is an accepted treatment in children with CP, persistence and recurrence of hip internal rotation can occur. Recurrence is associated with spasticity and slower gait velocity. Predictor variables may be useful for surgeons during preoperative discussions of expected outcome with families of FDO candidates. LEVEL OF EVIDENCE: Level III.

Factors predicting postoperative complications following spinal fusions in children with cerebral palsy scoliosis.

PURPOSE: The purpose of this study was to review the postoperative complications after posterior spinal fusion (PSF) in cerebral palsy (CP) scoliosis and identify the predictive preoperative risk factors. METHODS: All PSFs consecutively performed for CP scoliosis between 2004 and 2013 were reviewed. Preoperative risk score (ORS) and postoperative complications score (POCS) were used as measures of all recorded preoperative risk factors and postoperative complications, respectively. RESULTS: The review included 303 children with a mean age of 14.6 ± 3.0 years. Mean hospitalization was 16 days. Dependence on G-tube feeding was associated with higher POCS (P = 0.027). Postoperative fever, seizures, and septicemia were associated with higher ORS (P < 0.01). Specifically, postoperative pancreatitis and deep wound infections were more common in children with G-tube. CONCLUSION: This study suggests that G-tube dependence is a predictive risk factor of complications after PSF in CP scoliosis. Children with G-tube need special perioperative care. No other specific preoperative risk factor predicted postoperative complications.

Hip Reconstruction in Children With Unilateral Cerebral Palsy and Hip Dysplasia.

BACKGROUND: Highly functioning children with unilateral cerebral palsy (CP) who have hip involvement (type IV hemiplegia) may present with hip dysplasia during their adolescence. The aim of this report is to assess the outcomes of combined femoral and acetabular reconstruction in this population. METHODS: This study is a retrospective review of all patients with unilateral CP, Gross Motor Function Classification System types I and II, who had hip reconstruction for unilateral dysplasia between 1989 and 2013. Clinical variables (pain and hip passive range of motion) were reviewed. Hip morphology was assessed radiographically according to Melbourne Cerebral Palsy Hip Classification System. Three-dimensional gait analyses were also reviewed to evaluate the effect of surgery on these patients' gaits. RESULTS: Twelve patients were included with a mean age at surgery of 14 years (range, 7 to 19 y) and follow-up mean of 4 years (range, 1 to 8 y). Nine hips were improved according to Melbourne Cerebral Palsy Hip Classification System. Migration percentage decreased significantly (P<0.001) from 45% (30% to 86%) to 15% (0% to 28%). Neck shaft angle decreased (P<0.001) from 144 degrees (range, 129 to 156 degrees) to 125 degrees (range, 114 to 139 degrees). Tonnis angle and Sharp angle also decreased significantly. All patients were pain free at the last visit. Overall level of gait function as measured by Gait Deviation Index and Gait Profile Score [78 (61 to 89) and 12 (8 to 16), respectively] for all patients was maintained without significant changes. CONCLUSIONS: In hemiplegic type IV CP, with high functional level (Gross Motor Function Classification System I and II), hip dysplasia is a rare occurrence during adolescent years. Combined hip reconstruction improves hip morphology, relieves pain, and maintains a high level of function. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Pamidronate Treatment to Prevent Reoccurring Fractures in Children With Cerebral Palsy.

BACKGROUND: Some children with cerebral palsy (CP) have frequent fractures due to low bone mineral density and receive treatment with pamidronate, an intravenous bisphosphonate. Our review evaluates the outcome of pamidronate treatment in these children. METHODS: A retrospective chart review was performed, and 32 patients (14 girls and 18 boys) with CP Gross Motor Function Classification System level III (2 patients), IV (3 patients), and V (27 patients) treated with 5 courses of pamidronate for low mineral density were identified. Patients with a minimum of 2 years of follow-up were included in the study. Data collection was a review of the demographics and pretreatment, peritreatment, and posttreatment fracture history. RESULTS: The mean age at treatment was 11.6 years (range, 2.9 to 19.6 y). There were 102 fractures (mean duration 2.5 y) pretreatment and 28 fractures posttreatment. With an average follow-up of 6.4 years, posttreatment rate of fracture decreased to 0.10 fractures per year from the pretreatment rate of 2.4 fractures per year (P<0.001). The femur was the most common bone fractured both pretreatment (54%) and posttreatment (61%); the major site was the distal third of the femur. There were 11 fractures during the course of pamidronate treatment at a rate of 0.33 fractures per year. Only 11 patients (34%) sustained fracture posttreatment. No correlation with fracture pattern or occurrence was found with patient age, number of pretreatment fractures, or sex. Most fractures were caused by low-energy injuries, and most were managed nonoperatively. CONCLUSIONS: In patients with CP and disuse osteoporosis, the most common fracture sustained involved the distal femur via low-velocity injury, and most fractures were treated nonoperatively. Although the fracture pattern and the treatment remained unchanged, reoccurring fractures in these children can be effectively treated medically to interrupt the fracturing tendency.

Clinical relevance of echocardiogram in patients with cerebral palsy undergoing posterior spinal fusion.

BACKGROUND: Spinal deformity is one of the secondary musculoskeletal problems that occur with cerebral palsy (CP). Of the co morbidities associated with CP and spinal deformity, cardiac function is of theoretical concern. OBJECTIVE: The goal of our study was to determine the clinical relevance of routine preoperative cardiology evaluation via echocardiogram for patients with CP presenting for posterior spine fusion (PSF) surgery. METHODS: A retrospective chart review was performed of CP patients presenting for scoliosis surgery. The data collected for each patient included: age, sex, height, weight, Cobb angle, and medical history. All patients had a preoperative cardiac evaluation. RESULTS: Seventy-two patients were included. The mean age was 13.6 ± 3.4 years. Left ventricular systolic function was normal in all patients; the mean shortening fraction was 39.3 ± 6.2%. No patient had more than mild insufficiency of either the semilunar or atrioventricular valve. One patient was diagnosed with aortic root dilation as well as aortic valve insufficiency. All patients had PSF surgery without changes in anesthetic or surgical plans, and no patient experienced complications attributable to a cardiac origin. CONCLUSION: The results suggest that routine preoperative cardiology evaluation via echocardiogram for children with CP in the absence of clinical history or physical examination findings suggestive of cardiac disease is not necessary.

Prophylactic methylprednisolone to reduce inflammation and improve outcomes from one lung ventilation in children: a randomized clinical trial.

BACKGROUND: One lung ventilation (OLV) results in inflammatory and mechanical injury, leading to intraoperative and postoperative complications in children. No interventions have been studied in children to minimize such injury. OBJECTIVE: We hypothesized that a single 2-mg·kg(-1) dose of methylprednisolone given 45-60 min prior to lung collapse would minimize injury from OLV and improve physiological stability. METHODS: Twenty-eight children scheduled to undergo OLV were randomly assigned to receive 2 mg·kg(-1) methylprednisolone (MP) or normal saline (placebo group) prior to OLV. Anesthetic management was standardized, and data were collected for physiological stability (bronchospasm, respiratory resistance, and compliance). Plasma was assayed for inflammatory markers related to lung injury at timed intervals related to administration of methylprednisolone. RESULTS: Three children in the placebo group experienced clinically significant intraoperative and postoperative respiratory complications. Respiratory resistance was lower (P = 0.04) in the methylprednisolone group. Pro-inflammatory cytokine IL-6 was lower (P = 0.01), and anti-inflammatory cytokine IL-10 was higher (P = 0.001) in the methylprednisolone group. Tryptase, measured before and after OLV, was lower (P = 0.03) in the methylprednisolone group while increased levels of tryptase were seen in placebo group after OLV (did not achieve significance). There were no side effects observed that could be attributed to methylprednisolone in this study. CONCLUSIONS: Methylprednisolone at 2 mg·kg(-1) given as a single dose prior to OLV provides physiological stability to children undergoing OLV. In addition, methylprednisolone results in lower pro-inflammatory markers and higher anti-inflammatory markers in the children's plasma.

Health Disparities in Pediatric Asthma: Comprehensive Tertiary Care Center Experience.

LOCATION: Study conducted at Nemours /Alfred I. duPont Hospital for Children, Wilmington, DE 19803 BACKGROUND: Although the treatment and management of asthma hasimproved over time, incidence and prevalence among children continues to rise in the United States. Asthma prevalence, health services utilization, and mortality rate demonstrate remarkable disparities. The underlying causes of these disparities are not fully understood. We aimed to examine racial/ethnic variances in pediatric asthma prevalence/admission. PATIENTS AND METHODS: We retrospectively reviewed data on 1070 patients and applied a cross-sectional design to assess asthma admission between 2010 and 2011. Information was available on race/ethnicity, sex, insurance status, severity of illness (SOI), and length of stay/hospitalization (LOS).Chi-square statistic was used for the association between race and other variables in an attempt to explain the racial/ethnic variance. RESULTS: The proportionate morbidity of asthma was highest amongCaucasians (40.92%) and African Americans (40.54%), intermediate among others (16.57%), and lowest among Asian (0.56%), American Indian/Alaska Native (0.28%), and Hawaiian Native/Pacific Islander (0.28%). Overall there were disparities by sex, with more boys (61.80%) diagnosed with asthma than girls (38.20%), χ2(7)=20.1, p=0.005. Insurance status, and SOI varied by race/ethnicity, but not LOS. Caucasian children were more likely to have private insurance, while African Americans and Hispanics were more likely to have public insurance (p<0.005). Asthma was more severe among non-Hispanic children, χ2(14)=154.6, p<0.001. While the overall readmission proportion was 2.8%, readmission significantly varied by race/ethnicity. CONCLUSION: Racial/ethnic disparities in asthma admission exist among children in the Delaware Valley. There were racial/ethnic disparities in insurance status, asthma severity, and sex differed by race/ethnicity, but not in length of hospitalization.

Black-White Risk Differentials in Pediatric COVID-19 Hospitalization and Intensive Care Unit Admissions in the USA.

PURPOSE: The COVID-19 morbidity with SARS-CoV-2 as a causative pathogenic microbe remains a pandemic with children experiencing less mortality but with severe manifestations. The current study aimed to assess SARS-CoV-2 cumulative incidence, COVID-19 hospitalization, and ICU admission with respect to racial differentials. MATERIALS AND METHODS: A cross-sectional nonexperimental epidemiologic design was used to examine pediatric COVID-19 data from CDC during 2020. The variables assessed were ICU admissions, hospitalization, sex, race, and region. The Chi-Square (X2) statistic was used to examine the independence of the variables by race, while the binomial regression model was used to predict racial risk differentials in hospitalization and ICU admissions. RESULTS: The pediatric COVID-19 data observed the cumulative incidence of hospitalization to be 96,376, while ICU admission was 12,448. Racial differences were observed in hospitalization, ICU admissions, sex, and region. With respect to COVID-19 hospitalization, Black/African American (AA) children were two times as likely to be hospitalized compared to their White counterparts, prevalence risk ratio (pRR) = 2.20, 99% confidence interval (CI = 2.12-2.28). Similarly, Asians were 45% more likely to be hospitalized relative to their White counterparts, pRR = 1.45, 99% CI = 1.32-1.60. Regarding ICU admission, there was a disproportionate racial burden, implying excess ICU admission among Black/AA children relative to their White counterparts, pRR = 5.18, 99% CI = 4.44-6.04. Likewise, Asian children were 3 times as likely to be admitted to the ICU compared to their White counterparts, pRR = 3.36, 99% CI = 2.37-4.77. Additionally, American Indians/Alaska Natives were 2 times as likely to be admitted to ICU, pRR = 2.54, 99% CI = 0.82-7.85. CONCLUSION: Racial disparities were observed in COVID-19 hospitalization and ICU admission among the US children, with Black/AA children being disproportionately affected, implying health equity transformation.

Rectus femoris transfer improves stiff knee gait in children with spastic cerebral palsy.

BACKGROUND: Stiff knee gait is common among children with ambulatory cerebral palsy (CP). When surgery is indicated, rectus femoris transfer as a primary treatment enhances knee range of motion, reduces time to peak knee flexion, increases peak knee flexion, and reduces toe drag. QUESTIONS/PURPOSES: We determined whether (1) distal rectus femoris transfer improved knee range of motion, time to peak knee flexion, peak knee flexion, and toe drag in children with CP diagnosed with stiff knee gait; and (2) patients in some subgroups (eg, those with relatively high knee range of motion compared with those with low knee range of motion before rectus femoris transfer) had greater improvement in these parameters. METHODS: We retrospectively reviewed gait data from 56 patients (99 limbs) preoperatively, short-term, and long-term. Subgroup analyses were performed to determine whether patients with high knee range of motion relative to those with low or moderate knee range of motion improved differentially after rectus femoris transfer. The minimum followup was 7 years (mean ± SD, 10 ± 2 years; range, 7-13 years). RESULTS: The mean peak knee flexion increased from baseline to short-term and to long-term followup. Patients with low peak knee flexion had the greatest improvement of peak knee flexion after rectus femoris transfer relative to the moderate and high peak knee flexion subgroups. Similarly, the greatest improvement after rectus femoris transfer for knee range of motion occurred in the low knee range of motion subgroup relative to moderate and high subgroups. Rectus femoris transfer improved mean time to peak knee flexion at short-term and long-term followup compared with baseline. Likewise, there was a decrease in toe drag at short- and long-term after rectus femoris transfer. CONCLUSION: Distal rectus femoris transfer selectively improved peak knee flexion, toe drag, and reduced time to peak knee flexion in ambulatory children with CP with stiff knee gait. LEVEL OF EVIDENCE: Level IV, therapeutic study. See guidelines for authors for a complete description of levels of evidence.

Clinical epidemiologic characterization of orthopaedic and neurological manifestations in children with leukodystrophies.

BACKGROUND: Leukodystrophies (LKDs) are spectra of clinical conditions characterized primarily by brain white matter abnormalities. Although this condition was previously defined around inherited disorders of the white matter of the brain, current application includes acquired and sporadic conditions and some rare conditions that affect gray matter. Over the past 2 decades, information had become available on the clinical subtypes due to neurodiagnostic imaging and improvement in the genetic studies (cytogenetics and molecular genetics) of LKD. However, the epidemiologic profile of LKD remains largely unknown. We aimed in this study to characterize LKD by demographics, family history, orthopaedic and neurological manifestations, and clinical subtypes. METHODS: Trained medical personnel reviewed medical records of the study population diagnosed with LKD from 1986 to 2008. Using a retrospective review design, we determined the prevalence of the different clinical subtypes of LKD, family history, orthopaedic and neurological manifestations, and the demographics in LKD. The frequency and percentage (proportion, standard error, and 95% confidence interval for proportion) and the χ statistic and Fisher exact test for comparison of clinical subtypes were the statistical techniques used in the data analysis. RESULTS: Forty-four children were diagnosed with LKD between 1986 and 2008, of whom 25.0% had metachromatic LKD and 20.5% had Pelizaeus-Merzbacher LKD, whereas 40.9% were unspecified LKD. LKDs were more common among boys (63.6%), Whites (77.3%), and more likely to be diagnosed at age <3 years. Scoliosis (70.4%), hamstring contractures (81.8%), acquired hip dysplasia (88.6%), and equinus foot deformity (75.0%) were the most common orthopaedic manifestations. Common neurological manifestations were seizures (45.4%) and spasticity (77.3%). There was a statistically significant difference in sex and family history, seizures, hip dislocation, and hip subluxation, with respect to the clinical subtype of LKD, P<0.05. CONCLUSIONS: This epidemiologic characterization of LKD validates basic and clinical data on the familial history of LKD and its higher prevalence among boys. The orthopaedic manifestations common in LKD are scoliosis, hamstring contractures, acquired hip dysplasia, and equinus foot deformity, whereas common neurological manifestations are seizures and spasticity. These data are indicative of the need for orthopaedic surgeons to take into consideration this clinical epidemiologic aspect of LKD in the evaluation, treatment planning, and clinical expectations for these patients.

Subtalar fusion in cerebral palsy patients: results of a new technique using corticocancellous allograft.

BACKGROUND: Valgus deformity of the hindfoot in cerebral palsy (CP) patients is common and causes functional deterioration and shoe fitting problems together with skin ulcerations. Our aims in this study are, to present an intra-articular technique of subtalar fusion using allograft and internal fixation to achieve stabilization and second to report the results and clinical outcome of a series of intra-articular subtalar arthrodesis performed in CP children. METHODS: We performed a retrospective review of radiographs and medical records of 145 children with CP who underwent intra-articular subtalar fusion from January 1994 to December 2004. The subtalar joint was fixed through the anterior facet with a cannulated screw whereas the anterior aspect of the calcaneus was parallel to the anterior aspect of the head of the talus. Tricortical iliac crest allograft was placed into the sinus tarsi and the denuded posterior facet area. Results are grouped as good, satisfactory, and poor according to the radiographic and clinical outcomes. RESULTS: The mean age at the time of surgery was 12.7 years (range: 5 to 20 y) and the average follow-up was 4.8 years (range: 2 to 11 y). Good results were obtained in 242 feet (96%). Satisfactory results were obtained in 6 feet (2%) which were painless pseudoarthrosis of subtalar joint in 2 feet and screw removal was required in 4 feet because of pain. Nonunion of thesubtalar joint together with recurrence of deformity was observed in 5 feet (2%) which is accepted as poor result and required revision surgery. No deep infections, implant failure, allograft failure were observed in a mean of 4.8 years. CONCLUSIONS: Our described technique of intra-articular subtalar joint fusion is safe and reliable in CP children with high rate of satisfactory results. LEVEL OF EVIDENCE: Therapeutic studies-Level IV.

Social gradient predicts survival disadvantage of African Americans/Black children with lymphoma.

BACKGROUND: Cancer is the leading cause of disease-related mortality among children, 0-14 years, and lymphoma, a malignant neoplasm of the lymphoid cells, mostly lymphatic B and T cells is common among children. The current study aimed to assess the cumulative incidence (CmI), mortality, and survival in pediatric lymphoma. MATERIALS AND METHODS: A retrospective cohort was utilized to examine children, 0-19 years with lymphoma for CmI, mortality and survival from the Surveillance, Epidemiology, and End Results (SEER) data. The variables assessed included social determinants of health, namely urbanity, median household income, and race. While chi square was used to characterize study variables by race, binomial regression was employed for mortality risk. The Cox proportional hazard model was used for survival modeling. RESULTS: The CmI was higher among white children (76.67%) relative to Black/African American (AA, 13.44%), American Indian/Alaskan Native (AI/AN, 0.67%), as well as Asian/Pacific Islander (A/PI, 7.53%). With respect to mortality, there was excess mortality among Black/AA children compared to white children, Risk Ratio (RR) = 1.54, 95% CI, 1.33-1.79. Relative to whites, Blacks were 52% more likely to die, Hazard Ratio (HR) = 1.52, 95% CI, 1.30-1.78. Survival disadvantage persisted among Blacks/AA after controlling for the other confoundings, adjusted hazard ratio (aHR) = 1.54, 99% CI, 1.24-1.91. CONCLUSION: In a large cohort of children with lymphoma, Black/AA children relative to whites presented with survival disadvantage, which was explained by urbanity and median household income, suggestive of transforming the physical and social environments in narrowing the racial differences in pediatric lymphoma survival in the US.

Single-event multilevel surgery in cerebral palsy: Value added by a co-surgeon.

ABSTRACT: The aim of this study was to compare outcomes for single-event multilevel surgery (SEMLS) in cerebral palsy (CP) performed by 1 or 2 attending surgeons.A retrospective review of patients with CP undergoing SEMLS was performed. Patients undergoing SEMLS performed by a single senior surgeon were compared with patients undergoing SEMLS by the same senior surgeon and a consistent second attending surgeon. Due to heterogeneity of the type and quantity of SEMLS procedures included in this study, a scoring system was utilized to stratify patients to low and high surgical burden. The SEMLS events scoring less than 18 points were categorized as low burden surgery and SEMLS scoring 18 or more points were categorized as high burden surgery. Operative time, estimated blood loss, hospital length of stay, and operating room (OR) utilization costs were compared.In low burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 8 patients had SEMLS performed by 2 surgeons. In high burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 12 patients had SEMLS performed by 2 surgeons. For high burden SEMLS, operative time was decreased by a mean of 69 minutes in cases performed by 2 co-surgeons (P = 0.03). Decreased operative time was associated with an estimated savings of $2484 per SEMLS case. In low burden SEMLS, a trend toward decreased operative time was associated for cases performed by 2 co-surgeons (182 vs 221 minutes, P = 0.11). Decreased operative time was associated with an estimated savings of $1404 per low burden SEMLS case. No difference was found for estimated blood loss or hospital length of stay between groups in high and low burden SEMLS.Employing 2 attending surgeons in SEMLS decreased operative time and OR utilization cost, particularly in patients with a high surgical burden. These findings support the practice of utilizing 2 attending surgeons for SEMLS in patients with CP.Level of Evidence: Level III.

Complications of intrathecal baclofen pump therapy in pediatric patients.

BACKGROUND: The aim of this study was to investigate and evaluate complications of intrathecal baclofen (ITB) pump implantation and maintenance in children with cerebral palsy. METHODS: We reviewed our entire consecutive series of pediatric patients treated with ITB between 1997 and 2006 at our hospital. There were 174 patients with a diagnosis of cerebral palsy, 8 with mixed dystonia, 2 with athetosis, and 3 with pure dystonia. During follow-up, 8 deaths occurred with no evidence of pump or catheter malfunction in any way contributing to the cause of death. Acute infection within 60 days of the surgery and late infection rates were calculated on the basis of number of incidents and incidents/follow-up patient years, respectively. Independently, a blinded caregiver phone questionnaire was completed in 92 cases. RESULTS: There were 316 surgical procedures; 161 were initial ITB pump implants at our institution. The average age at initial implant was 12 years, with an average follow-up of 3 years, 2 months. There were 80 planned replacement procedures (46 battery expirations and 3 planned pump replacements during posterior spinal fusion, 26 catheter replacements for posterior spinal fusion, and 5 reinsertions). There were 78 procedures in 57 patients related to complications, and the acute infection rate was 4.0%. The probability of developing a late infection was 1.0% per year of follow-up. On the basis of the follow-up questionnaire, 81% of parents/caregivers were satisfied with the treatment, and 87% would recommend ITB therapy. CONCLUSIONS: ITB therapy is a safe and effective treatment for severe spasticity in the pediatric population, but does have a 31% rate of complications requiring surgical management over a 3-year treatment period. Parents and caregivers have a high rate of satisfaction and most would recommend the treatment to others.

Operative and clinical markers of deep wound infection after spine fusion in children with cerebral palsy.

BACKGROUND: Infection after spine fusion for neuromuscular scoliosis has been shown to range from 4.2% to 20.0% prevalence. Although there are studies, which have examined deep wound infection and spine fusion surgery as well as risk factors for deep wound infection, there are limited studies evaluating clinical and radiographic factors associated with this complication. We aimed to determine the clinical and operative factors associated with deep wound infection after spine fusion in pediatric patients with cerebral palsy (CP). METHODS: Medical records of 236 pediatric patients, aged between 5.6 and 21 years (mean=13.8 ± 3.4), with CP who underwent spine fusion from 1995 to 2006 were reviewed. Of these, 22 patients had deep wound infection. To assess the differences in clinical, radiographic, and other predisposing factors, we used χ statistic and Fisher exact, and to determine the predisposing factors of deep wound infection, we used binomial regression model. RESULTS: The period prevalence of deep wound infection was 9.3%. In the unadjusted model, body weight, residual postoperative Cobb angle, length of hospitalization, packed red blood cells, and skin breakdown were the factors significantly associated with deep wound infection (P<0.05). After controlling for confounding, skin breakdown due to the instrumentation and residual postoperative Cobb angle were the 2 most potent markers of deep wound infection. There was a significant 4% increased risk of deep wound infection for 1-degree increase in the residual Cobb angle from the noncase mean residual Cobb angle of 23.69 degrees (adjusted risk ratio=1.04; 95% confidence interval, 1.01-1.08). Likewise, compared with those without skin breakdown, those with skin breakdown were 12 times as likely to develop deep wound infection (risk ratio=12.92; 95% confidence interval, 1.00-172.00). CONCLUSIONS: Residual postoperative Cobb angle and skin breakdown due to unit rod instrumentation were the 2 most significant predisposing factors to deep wound infection. Other factors included body weight, packed red blood cells, and length of hospitalization. As the overall prevalence of deep wound infection is relatively high in CP patients after spine fusion, and considering the cost of hospitalization and other related comorbidities, surgeons should recognize these predisposing parameters to prevent deep wound infection in CP patients while correcting curve deformities. LEVEL OF EVIDENCE: Level III retrospective study.

Implication of Vaginal and Cesarean Section Delivery Method in Black-White Differentials in Infant Mortality in the United States: Linked Birth/Infant Death Records, 2007-2016.

Racial/ethnic disparities in infant mortality (IM) continue to persist in the United States, with Black/African Americans (AA) being disproportionally affected with a three-fold increase in mortality compared to Whites. Epidemiological data have identified maternal characteristics in IM risk such as preeclampsia, eclampsia, maternal education, smoking, maternal weight, maternal socioeconomic status (SES), and family structure. Understanding the social gradient in health including implicit bias, as inherent in the method of labor and delivery and the racial heterogeneity, may facilitate intervention mapping in narrowing the Black-White IM risk differences. We aimed to assess the temporal/racial trends and the methods of delivery, mainly vaginal vs. cesarean section (C-section) as an exposure function of IM. The United States linked birth/infant death records (2007-2016) were used with a cross-sectional ecological design. The analysis involved chi squared statistic, incidence rate estimation by binomial regression model, and period percent change. Of the 40,445,070 births between 2007 and 2016, cumulative mortality incidence was 249,135 (1.16 per 1000). The IM rate was highest among Black/AA (11.41 per 1000), intermediate among Whites (5.19 per 1000), and lowest among Asian /Pacific Islanders (4.24 per 1000). The cumulative incidence rate difference, comparing vaginal to cesarean procedure was 1.73 per 1000 infants, implying excess IM with C-section. Compared to C-section, there was a 31% decreased risk of IM among mothers with vaginal delivery, rate ratio (RR) = 0.69, 95% confidence interval (CI): 0.64-0.74. Racial disparities were observed in the method of delivery associated with IM. Black/AA mothers with vaginal delivery had a 6% decreased risk of IM compared to C-section, RR = 0.94, 95% CI: 0.92-0.95, while Whites with vaginal delivery had a 38% decrease risk of IM relative to C-section, RR= 0.68, 95% CI: 0.67-0.69, p < 0.001. Infant mortality varied by race, with Black/AA disproportionally affected, which is explained in part by labor and delivery procedures, suggestive of reliable and equitable intrapartum assessment of Black/AA mothers during labor, as well as implicit bias marginalization in the healthcare system.

Black-White Risk Differentials in COVID-19 (SARS-COV2) Transmission, Mortality and Case Fatality in the United States: Translational Epidemiologic Perspective and Challenges.

BACKGROUND: Social and health inequities predispose vulnerable populations to adverse morbidity and mortality outcomes of epidemics and pandemics. While racial disparities in cumulative incidence (CmI) and mortality from the influenza pandemics of 1918 and 2009 implicated Blacks with survival disadvantage relative to Whites in the United States, COVID-19 currently indicates comparable disparities. We aimed to: (a) assess COVID-19 CmI by race, (b) determine the Black-White case fatality (CF) and risk differentials, and (c) apply explanatory model for mortality risk differentials. METHODS: COVID-19 data on confirmed cases and deaths by selective states health departments were assessed using a cross-sectional ecologic design. Chi-square was used for CF independence, while binomial regression model for the Black-White risk differentials. RESULTS: The COVID-19 mortality CmI indicated Blacks/AA with 34% of the total mortality in the United States, albeit their 13% population size. The COVID-19 CF was higher among Blacks/AA relative to Whites; Maryland, (2.7% vs. 2.5%), Wisconsin (7.4% vs. 4.8%), Illinois (4.8% vs. 4.2%), Chicago (5.9% vs. 3.2%), Detroit (Michigan), 7.2% and St. John the Baptist Parish (Louisiana), 7.9%. Blacks/AA compared to Whites in Michigan were 15% more likely to die, CmI risk ratio (CmIRR) = 1.15, 95% CI, 1.01-1.32. Blacks/AA relative to Whites in Illinois were 13% more likely to die, CmIRR = 1.13, 95% CI, 0.93-1.39, while Blacks/AA compared to Whites in Wisconsin were 51% more likely to die, CmIRR = 1.51, 95% CI, 1.10-2.10. In Chicago, Blacks/AA were more than twice as likely to die, CmIRR = 2.24, 95% CI, 1.36-3.88. CONCLUSION: Substantial racial/ethnic disparities are observed in COVID-19 CF and mortality with Blacks/AA disproportionately affected across the United States.