Skills on wheels: initial pre-post findings from a pilot study of a pediatric wheelchair skills training program

Skills on Wheels, a 5-week pediatric wheelchair skills training program implemented over 2 years, was developed to address confidence, social participation, and mobility for wheelchair-using children. This study tests the hypothesis that pediatric wheelchair skills training will increase wheelchair skill ability, confidence, and participation of wheelchair-using children. Individualized instruction was delivered by occupational (N = 50) and physical (N = 12) therapy practitioners and doctoral students. The primary program intervention was adapted for pediatric wheelchair users from the adult Wheelchair Skills Training Program, developed by Dalhousie University, consisting of a total of 33 wheelchair skills. An adapted version of the Wheelchair Confidence measure (Wheel-Con-M-P), the Participation and Environment Measure for Children and Youth (PEM-CY), and Wheelchair Skills Test (WST) were used to measure participants confidence and ability to complete wheelchair skills, endurance, and participation and satisfaction in community, school, and home. The study resulted in: increases in confidence in ability to move wheelchair over threshold (+1.00, p < 0.05), ability to carry lunchbox/bookbag (+0.65, p < 0.05), ability to move in wheelchair when worried or scared (+1.3, p < 0.05), ability to ask for help, and ability to say "no" if they don't need help (+0.58, p < 0.05) were indicated. The WST indicated increased ability (p < 0.05) on several skills. The Fear of Falling Measure found an overall decrease in fear of falling (-2.37, p < 0.01). The Skills on Wheels program demonstrated many successes in this initial 2-year study and data suggest a positive trend for iterations to come.

Education and employment as young adults living with spina bifida transition to adulthood in the USA: A study of the National Spina Bifida Patient Registry

AIM

To describe the education and employment transition experience of young adults with spina bifida (YASB) and investigate factors associated with employment.

METHOD

We queried education and employment data from the US National Spina Bifida Patient Registry from 2009 to 2019. We applied generalized estimating equations models to analyze sociodemographic and disease-related factors associated with employment.

RESULTS

A total of 1909 participants (850 males, 1059 females) aged 18 to 26 years contributed 4379 annual visits. Nearly 84% had myelomeningocele and, at last visit, the median age was 21 years (mean 21 years 5 months, SD 2 years 10 months). A total of 41.8% had at least some post-high school education, and 23.9% were employed. In a multivariable regression model, employment was significantly associated with education level, lower extremity functional level, bowel continence, insurance, and history of non-shunt surgery. This large, national sample of YASB demonstrated low rates of post-secondary education attainment and employment and several potentially modifiable factors associated with employment.

INTERPRETATION

Specific sociodemographic, medical, and functional factors associated with employment are important for clinicians to consider when facilitating transition for YASB into adulthood. Additional research is needed to understand the impact of cognitive functioning and social determinants of health on transition success in YASB.

WHAT THIS PAPER ADDS

There were low education attainment and employment rates in a large sample of young adults with spina bifida. Specific sociodemographic, medical, and functional factors are associated with employment. Some employment-associated factors, such as continence and self-management skills, are modifiable.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study

PURPOSE

This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD.

METHODS

A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics.

RESULTS

Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47).

CONCLUSION

COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Adjudicating Mild Cognitive Impairment Due to Alzheimer's Disease as a Novel Endpoint Event in the TOMMORROW Prevention Clinical Trial

BACKGROUND

The onset of mild cognitive impairment (MCI) is an essential outcome in Alzheimer's disease (AD) prevention trials and a compelling milestone for clinically meaningful change. Determining MCI, however, may be variable and subject to disagreement. Adjudication procedures may improve the reliability of these determinations. We report the performance of an adjudication committee for an AD prevention trial.

METHODS

The TOMMORROW prevention trial selected cognitively normal participants at increased genetic risk for AD and randomized them to low-dose pioglitazone or placebo treatment. When adjudication criteria were triggered, a participant's clinical information was randomly assigned to a three-member panel of a six-member independent adjudication committee. Determination of whether or not a participant reached MCI due to AD or AD dementia proceeded through up to three review stages - independent review, collaborative review, and full committee review - requiring a unanimous decision and ratification by the chair.

RESULTS

Of 3494 participants randomized, the committee adjudicated on 648 cases from 386 participants, resulting in 96 primary endpoint events. Most participants had cases that were adjudicated once (n = 235, 60.9%); the rest had cases that were adjudicated multiple times. Cases were evenly distributed among the eight possible three-member panels. Most adjudicated cases (485/648, 74.8%) were decided within the independent review (stage 1); 14.0% required broader collaborative review (stage 2), and 11.1% needed full committee discussion (stage 3). The primary endpoint event decision rate was 39/485 (8.0%) for stage 1, 29/91 (31.9%) for stage 2, and 28/72 (38.9%) for stage 3. Agreement between the primary event outcomes supported by investigators' clinical diagnoses and the decisions of the adjudication committee increased from 50% to approximately 93% (after around 100 cases) before settling at 80-90% for the remainder of the study.

CONCLUSIONS

The adjudication process was designed to provide independent, consistent determinations of the trial endpoints. These outcomes demonstrated the extent of uncertainty among trial investigators and agreement between adjudicators when the transition to MCI due to AD was prospectively assessed. These methods may inform clinical endpoint determination in future AD secondary prevention studies. Reliable, accurate assessment of clinical events is critical for prevention trials and may mean the difference between success and failure.

Skin sympathetic nerve activity as a biomarker of fitness

BACKGROUND

Exercise stress testing is frequently used to expose cardiac arrhythmias. Aerobic exercise conditioning has been used as a nonpharmacologic antiarrhythmic intervention.

OBJECTIVE

The purpose of this study was to test the hypothesis that noninvasively recorded skin sympathetic nerve activity (SKNA) is increased during exercise and that SKNA response varies according to fitness levels.

METHODS

Oxygen consumption (VO₂) and SKNA were recorded in 39 patients undergoing an incremental exercise test. Patients were grouped by 5 levels of fitness based on age, sex, and VO₂max.

RESULTS

With exercise, all patients had a significant increase in average SKNA (aSKNA) (1.58 ± 1.12 μV to 4.50 ± 3.06 μV, P = .000) and heart rate (HR) (87.40 ± 20.42 bpm to 154.13 ± 16.82 bpm, P = .000). A mixed linear model of aSKNA was used with fixed effects of fitness, exercise time, and recovery time, and random effects of subject level intercept and slopes for exercise time and recovery times. The poor fitness group had significantly higher aSKNA than the other groups (P = .0273). For all subjects studied, aSKNA increased by 5% per minute with progression of exercise and decreased by 15% per minute with progression of recovery. The fitness variable encodes information on both comorbidities and body mass index (BMI). Once fitness level is known, comorbidities and BMI are not significantly associated with aSKNA. In all groups, aSKNA positively correlated with HR (R² = 0.47 ± 0.23) and VO₂ (R² = 0.68 ± 0.25).

CONCLUSION

Fitness level determines the magnitude and time course of SKNA increase during exercise. SKNA may be a useful fitness biomarker in exercise stress testing.

Long-term Outcomes of Microfracture for Treatment of Osteochondral Lesions of the Talus

BACKGROUND

Microfracture is the most common reparative surgery for osteochondral lesions of the talus (OLTs). While shown to be effective in short- to midterm outcomes, the fibrocartilage that microfracture produces is both biomechanically and biologically inferior to that of native hyaline cartilage and is susceptible to possible deterioration over time following repair. With orthobiologics being proposed to augment repair, there exists a clear gap in the study of long-term clinical outcomes of microfracture to determine if this added expense is necessary.

METHODS

A retrospective review of patients undergoing microfracture of an OLT with a single fellowship-trained orthopedic surgeon from 2007 to 2009 was performed. Patients meeting the inclusion criteria were contacted to complete the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales and visual analog scale (VAS) for pain, as well as surveyed regarding their satisfaction with the outcome of the procedure and their likelihood to recommend the procedure to a friend with the same problem using 5-point Likert scales. Patient demographics were reviewed and included for statistical analysis.

RESULTS

Of 45 respondents, 3 patients required additional surgery on their ankle for the osteochondral defect, yielding a 10-year survival rate of 93.3%. Of surviving cases, 90.4% (38/42) reported being "extremely satisfied" or "satisfied" with the outcome of the procedure. The VAS score at follow-up averaged 14 out of 100 (range, 0-75), while the FAAM-ADL and FAAM-Sports scores averaged 90.29 out of 100 and 82 out of 100, respectively. Thirty-six patients (85.7%) stated that their ankle did not prevent them from participating in the sports of their choice.

CONCLUSION

The current study represents a minimum 10-year follow-up of patients undergoing isolated arthroscopic microfracture for talar osteochondral defects, with a 93.3% survival rate and 85.7% return to sport. While biological adjuvants may play a role in improving the long-term outcomes of microfracture procedures, larger and longer-term follow-up studies are required for procedures using orthobiologics before their cost can be justified for routine use.

LEVEL OF EVIDENCE

Level IV, retrospective cohort case series study.

Trends in Depressed Mood and Suicidal Behaviors Among Female High School Students Who Engaged in Physical Fighting

The objective of this article is to identify prevalence changes in depressed mood/suicidal behaviors among female high school students reporting physical fighting. This research analyzed the national combined data set of the Youth Risk Behavior Surveillance (YRBS) cross-sectional surveys from 2001 to 2015. Logistic regression analyzed the time trends. Two multiple logistic regression models were built. A quadratic trend was present with an initial decrease followed by an increase 2009 to 2015 (p < .001). The odds and severity of depressed mood/suicidal behaviors were greater among female youths with four or more fights and for other violent events, which were even greater when accounting for electronic bullying. The odds of depressed mood/suicidal behaviors among female adolescents engaged in physical fighting has been increasing with electronic bullying contributing to polyvictimization.

From Silos to Solidarity: Case Study of a Patient-Centered, Integrative Approach to Opioid Tapering and Chronic Pain Mitigation in a Multidisciplinary AIDS Clinic

Background:

People with HIV (PWH) are at a disproportionate risk for experiencing both chronic pain and opioid use disorder (OUD). Prescription opioid tapering is typically addressed within the “silo model” of medical care, whereby attention is focused solely on opioid addiction rather than also addressing chronic pain management, and limited communication occurs between patient and providers.

Objective:

This descriptive case study examined an integrative, collaborative care model consisting of Provider, Physical Therapist (PT), and Patient aimed at decreasing chronic pain and opioid use within a multidisciplinary HIV/AIDS clinic.

Method:

A physical-therapy based model of chronic pain mitigation and physician-driven opioid tapering was implemented. The Provider, PT, and Patient worked collaboratively to address physiological pain, pain coping skills and opioid tapering. A patient case example was used to illustrate the implementation of the model for a future, larger study in the same patient population.

Results:

This model was feasible in this case example in terms of clinic workflow and acceptability to both the Patient and Providers in this clinic. After the intervention, the Patient’s pain was fully eliminated, and he had ceased all opioid use.

Conclusion:

Results of this case study suggest that utilizing an integrative, patient-centered approach to both chronic pain management and opioid tapering may be feasible within the context of a multidisciplinary HIV/AIDS clinic. Generalizability is limited by case study model; however, this gives insight into the value of a collaborative alternative compared to a “silo” model of opioid tapering and chronic pain management in preparation for a larger study.

Central precocious puberty in spina bifida children: Guidelines for the care of people with spina bifida

Children with spina bifida are at greater risk of developing central precocious puberty (CPP) compared to others. Therefore, early recognition and timely referral for further evaluation by a pediatric endocrinologist allows appropriate management that reduces the impact of CPP. This article discusses the diagnosis and management of CPP in children with spina bifida. This guideline was developed for SB Transition Healthcare Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida.

Nutrition, metabolic syndrome, and obesity: Guidelines for the care of people with spina bifida

Nutritional challenges and a lack of activity can lead to health problems across the lifespan for people with spina bifida. Children and adults with spina bifida are also at greater risk of being classified as overweight or obese compared to their peers without the condition. Therefore, early recognition of nutrition problems, weight management counseling, and timely referrals for evaluation and management of diet and activity can help those with spina bifida and their families achieve a healthy lifestyle. This article details the development of the Nutrition, Metabolic Syndrome and Obesity Guidelines, which are part of the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida. It discusses the identification and management of poor nutrition and prevention of obesity for children, adolescents, and adults with spina bifida and highlights areas requiring further research.

A pathway leading to a cation-binding pocket determines the selectivity of the NhaP2 antiporter in Vibrio cholerae 1

The Vc-NhaP2 antiporter from Vibrio cholerae exchanges H⁺ for K⁺ or Na⁺ but not for the smaller Li⁺. The molecular basis of this unusual selectivity remains unknown. Phyre² and Rosetta software were used to generate a structural model of the Vc-NhaP2. The obtained model suggested that a cluster of residues from different transmembrane segments (TMSs) forms a putative cation-binding pocket in the middle of the membrane: D133 and T132 from TMS V together with D162 and E157 of TMS VI. The model also suggested that L257, G258, and N259 from TMS IX together with T276, D273, Q280, and Y251 from TMS X as well as L289 and L342 from TMS XII form a transmembrane pathway for translocated ions with a built-in filter determining cation selectivity. Alanine-scanning mutagenesis of the identified residues verified the model by showing that structural modifications of the pathway resulted in altered cation selectivity and transport activity. In particular, L257A, G258A, Q280A, and Y251A variants gained Li⁺/H⁺ antiport capacity that was absent in the nonmutated antiporter. T276A, D273A, and L289A variants exclusively exchanged K⁺ for H⁺, while a L342A variant mediated Na⁺/H⁺ exchange only, thus maintaining strict alkali cation selectivity.

School Bus Transportation of Children With Special Health Care Needs

School systems are responsible for ensuring that children with special needs are safely transported on all forms of federally approved transportation provided by the school system. A plan to provide the most current and proper support to children with special transportation needs should be developed by the Individualized Education Program team, including the parent, school transportation director, and school nurse, in conjunction with physician orders and recommendations. With this statement, we provide current guidance for the protection of child passengers with specific health care needs. Guidance that applies to general school transportation should be followed, inclusive of staff training, provision of nurses or aides if needed, and establishment of a written emergency evacuation plan as well as a comprehensive infection control program. Researchers provide the basis for recommendations concerning occupant securement for children in wheelchairs and children with other special needs who are transported on a school bus. Pediatricians can help their patients by being aware of guidance for restraint systems for children with special needs and by remaining informed of new resources. Pediatricians can also play an important role at the state and local level in the development of school bus specifications.

Trends in child passenger safety practices in Indiana from 2009 to 2015

OBJECTIVE

This study reviews trends in rear-facing direction, top tether use, booster seat use, and seating position for children 12 years or younger among motor vehicle passengers in Indiana.

METHODS

This is an observational, cross-sectional survey of drivers transporting children 15 years and younger collected at 25 convenience locations randomly selected in Indiana during summers of 2009-2015. Observations were conducted by certified child passenger safety technicians (CPST). As the driver completed a written survey collecting demographic data on the driver, the CPST recorded the child demographic data, vehicle seating location, the type of restraint, direction the car safety seat (CSS) was facing, and use of the CSS harness or safety belt as appropriate. Data were analyzed for infants and toddlers younger than 24 months, children in forward-facing CSS, booster seat use, and seating position for children 12 years or younger.

RESULTS

During the study period, 4,876 drivers were queried, and 7,725 children 15 years and younger were observed in motor vehicles. Between 2009 and 2015, 1,115 infants and toddlers (age birth to 23 months) were observed in motor vehicles. For infants <1 year, rear-facing increased from 84% to 91%. During the study years the greatest increase in rear facing was for toddlers age 12-17 months (12-61%). Rear facing for those from 18-23 months did not significantly change. Of the 1,653 vehicles observed with a forward-facing car seat, using either the seat belt system or lower anchors, an average of 27% had the top tether attached. For installations of forward-facing seats using the lower anchor, 66% employed the top tether. Among children age 4-7 years observed booster seat use decreased from 72% to 65% during the observation period. Finally, for vehicle seating position, in our sample, more than 85% of children 12 years or younger were seated in a rear seat vehicle position. Unfortunately, 31% of 8- to 12-year-old children were observed in the front seat.

CONCLUSIONS

Overall, these trends demonstrate an improvement in child passenger safety practices among Indiana drivers. However, this study illuminates areas to improve child passenger safety, such as rear facing for toddlers 18 to 23 months, increasing top tether use, booster seat use, and an emphasis on rear seat position for children 8 to 12 years. This information can be used by primary care providers and child passenger safety technicians and other child passenger safety advocates to develop counseling points and targeted educational campaigns.

Robin sequence: what the multidisciplinary approach can do

Robin sequence (RS) is a commonly encountered triad of micrognathia, glossoptosis, and airway obstruction, with or without a cleft palate. The management of airway obstruction is of paramount importance, and multiple reviews and retrospective series outline the diagnosis and treatment of RS. This article focuses on the multidisciplinary nature of RS and the specialists’ contributions and thought processes regarding the management of the RS child from birth to skeletal maturity. This review demonstrates that the care of these children extends far beyond the acute airway obstruction and that thorough monitoring and appropriate intervention are required to help them achieve optimal outcomes.

Translation to Primary Care of an Effective Teen Safe Driving Program for Parents

Addressing teen driver crashes, this study adapted an effective Checkpoints(TM) program for parents of teen drivers for dissemination by primary care practitioners (PCPs) and the web; distributed the PCP/web program through pediatric practices; and examined dissemination to/implementation by parents. The website, youngDRIVERparenting.org, and brief intervention protocol were developed. PCPs delivered interventions and materials to parents, referred them to the website, and completed follow-up surveys. Google Analytics assessed parents' website use. Most PCPs reported delivering interventions with fidelity, and thought the program important and feasible. Brief interventions/website referrals, averaging 4.4 minutes, were delivered to 3465 (87%) of 3990 eligible parents by 133 PCPs over an 18-week average. Website visits (1453) were made by 42% of parents, who spent on average 3:53 minutes viewing 4.2 topics. This program costs little (its website, training and promotional materials are available) and could be one component of a comprehensive approach to reducing teen driver crashes.

Epidemiology and cause-specific outcomes of facial fracture in hospitalized children

PURPOSE

Facial fractures in the pediatric population have a significant impact on public health. Although some demographic data exists regarding the overall epidemiology of facial fractures, little attention has been paid to the patterns of facial fractures based on the etiology of the trauma.

MATERIAL AND METHODS

The Kids' Inpatient Database 2000-2009 was utilized to analyze pediatric facial fractures. A total of 21,533 patients were identified. Associations of patient characteristics with outcomes of interest were assessed.

RESULTS

The top three etiologies were motor vehicle accident (MVA), intentional trauma (IT), and falls. There was a decrease in the incidence of facial fractures due to MVAs and an increase in injuries due to IT and falls. Concomitant injuries were present in 58.8% and the mortality rate was 2%. The rate of concomitant injuries increased during study period. Age was significantly associated with concomitant injury, mortality, and LOS.

CONCLUSION

The increasing rate of IT and falls with concomitant injury warrants special consideration to reduce undiagnosed accompanying injuries. Further programs should be put in place to protect children younger than 5 years of age, who have increased risk of concomitant injury and mortality following intentional trauma.

Ambulance transport of noncritical children: emergency medical service providers' knowledge, opinions, and practice

PURPOSE

Safe ambulance transport of children presents unique challenges. Our study describes child passenger restraint practices during ambulance transport, Emergency Medical Service (EMS) providers' knowledge, training, and use of child passenger restraint devices (CRD).

METHODS

A child passenger safety technician (CPST) recorded restraint used for pediatric ambulance transport. The CPST assessed and documented type of CRD used, securement, and whether the child was properly restrained. EMS providers' knowledge, training, and CRD use for ambulance transport were assessed.

RESULTS

The study period spanned July 2009 to July 2010; 63 EMS personnel were interviewed and 40 children were observed. Approximately 75% of emergency medical technicians surveyed felt their knowledge of pediatric transport was adequate. Fourteen percent allowed a stable patient to be transported via parent's lap. Twelve percent were transported unrestrained. None of the 11 patients, birth to 3 years, were found to be transported correctly.

CONCLUSION

Study findings supports education and training of EMS personnel to improve the safe ambulance transport of children.

Grandparents and child passenger safety

PURPOSE

This study compares child passenger safety (CPS) practices of grandparents versus parents and determines grandparents' opinions on car safety seats (CSS), barriers to use, and ways to transport grandchildren safely.

METHODS

Observational surveys were conducted on a convenience sample of drivers transporting children younger than sixteen years at 25 locations by certified child passenger safety technicians observing children in motor vehicles and recorded use of child passenger restraints. The drivers were surveyed on their knowledge, attitudes, beliefs, and practices regarding CPS. Data from drivers identifying themselves as grandparents were analyzed; also, three grandparent focus groups provided opinions on CPS practices.

RESULTS

During the study 1758 parents transporting 2713 children and 284 grandparents transporting 391 grandchildren were included. While most drivers were restrained and used child occupant restraints, almost 25% of parents and grandparents chose the incorrect seat to transport the child, and greater than 68% had at least one harness error. Grandparents were more likely to have looser lower anchor straps or seat belts and have children younger than thirteen years in the front seat. The focus group-grandparents had a favorable attitude toward CSS. Grandparents acknowledged the need for CSS but opined that CSS were difficult to use. Physical barriers included arthritis, back pain, mobility, decreased strength, and vision problems.

CONCLUSIONS

Grandparents and parents were equally likely to use CSS and choose correct seats. Compared to parents, grandparents were more likely to travel with their grandchildren with CSS installed with looser harnesses or an installed CSS with looser seat belt or lower anchors. Additionally, grandparents were more likely to have a child younger than thirteen years in the front seat. The use of community resources such as permanent fitting stations could help grandparents improve a grandchild's travel safety.

Implementation of the Department of Veterans Affairs' first point-of-care clinical trial

OBJECTIVES

The Massachusetts Veterans Epidemiology Research and Information Center in collaboration with the Stanford Center for Innovative Study Design set out to test the feasibility of a new method of evidence generation. The first pilot of a point-of-care clinical trial (POCCT), adding randomization and other study processes to an electronic medical record (EMR) system, was launched to compare the effectiveness of two insulin regimens.

MATERIALS AND METHODS

Existing functionalities of the Veterans Affairs (VA) computerized patient record system (CPRS)/veterans health information systems and technology architecture (VISTA) were modified to support the activities of a randomized controlled trial including enrolment, randomization, and longitudinal data collection.

RESULTS

The VA's CPRS/VISTA was successfully adapted to support the processes of a clinical trial and longitudinal study data are being collected from the medical record automatically. As of 30 June 2011, 55 of the 67 eligible patients approached received a randomized intervention.

DISCUSSION

The design of CPRS/VISTA made integration of study workflows and data collection possible. Institutions and investigators considering similar designs must carefully map clinical workflows and clinical trial workflows to EMR capabilities. POCCT study teams are necessarily interdisciplinary and interdepartmental. As a result, executive sponsorship is critical.

CONCLUSION

POCCT represent a promising new method for conducting clinical science. Much work is needed to understand better the optimal uses and designs for this new approach. Next steps include focus groups to measure patient and clinician perceptions, multisite deployment of the current pilot, and implementation of additional studies.

Issues and approaches to safely transporting children with special healthcare needs

Transporting children with special health care needs (CSHCN) may be complex and require a multidisciplinary approach to improve a child's comfort and safety. This review (adapted from the resource manual of the National Center for the Safe Transportation of Children with Special Health Care Needs.) will discuss the basic principles of child passenger safety for CSHCN, including types of child occupant restraints, the use of child occupant restraint devices (CRD) for selected CHSCN, and how to locate or, if needed, develop programs to train child passenger safety technicians (CPST) to help with safe transportation of CSHCN.

Rubinstein-Taybi syndrome associated with Chiari type I malformation caused by a large 16p13.3 microdeletion: a contiguous gene syndrome?

Rubinstein-Taybi Syndrome (RSTS, OMIM 180849) is a rare condition, which in 65% of cases is caused by haploinsufficiency of CREBBP (cAMP response element binding protein binding protein) localized to 16p13.3. A small subset of RSTS cases caused by 16p13.3 microdeletions involving neighboring genes have been recently suggested to be a true contiguous gene syndrome called severe RSTS or 16p13.3 deletion syndrome (OMIM 610543). In the present report, we describe a case of a 2-year-old female with RSTS who, besides most of the typical features of RSTS has corpus callosum dysgenesis and a Chiari type I malformation which required neurosurgical decompression. CGH microarray showed a approximately 520.7 kb microdeletion on 16p13.3 involving CREBBP, ADCY9, and SRL genes. We hypothesize that the manifestations in this patient might be influenced by the haploinsufficiency for ADCY9 and SRL.

Children with special physical health care needs: restraint use and injury risk in motor vehicle crashes

Physical disabilities may affect a child passenger's fit within a conventional motor vehicle restraint. The aim of this study is to describe and compare injury risk in motor vehicle crashes (MVC) among children with and without special physical health care needs (SPHCN). This analysis, conducted in 2007-2008, utilizes data collected between December 1998 and November 2002 in a cross-sectional study of children ≤15 years old involved in crashes of State-Farm insured vehicles in 15 states and the District of Columbia. Parent reports via telephone survey were used to define pre-crash SPHCN, restraint status, and occurrence of significant injuries using a validated survey. Complete data were collected for 18,852 children aged 0-15 years; 159 children were reported to have a SPHCN (0.8% and 0.7% of children aged 0-8 and 9-15 years, respectively). A greater proportion of children with SPHCN aged 0-8 years were appropriately restrained (P < 0.001), but there was no significant difference in restraint use among children with and without SPHCN aged 9-15 years. There was no significant association between the presence of a SPHCN and injury risk in either age group, after adjustment for child/driver characteristics (children aged 0-8 years: OR 1.27, 95% CI: 0.48-3.33; children aged 9-15 years: OR 1.51, 95% CI: 0.38-6.11). Children with and without SPHCN have similar injury risk in MVC, despite increased age-appropriate restraint usage among children aged 0-8 years. When counseling families about vehicle safety, practitioners should consider the fit of a child with SPHCN in a restraint system.

Down-regulation of the Notch pathway mediated by a gamma-secretase inhibitor induces anti-tumour effects in mouse models of T-cell leukaemia

BACKGROUND AND PURPOSE

gamma-Secretase inhibitors (GSIs) block NOTCH receptor cleavage and pathway activation and have been under clinical evaluation for the treatment of malignancies such as T-cell acute lymphoblastic leukaemia (T-ALL). The ability of GSIs to decrease T-ALL cell viability in vitro is a slow process requiring >8 days, however, such treatment durations are not well tolerated in vivo. Here we study GSI's effect on tumour and normal cellular processes to optimize dosing regimens for anti-tumour efficacy.

EXPERIMENTAL APPROACH

Inhibition of the Notch pathway in mouse intestinal epithelium was used to evaluate the effect of GSIs and guide the design of dosing regimens for xenograft models. Serum Abeta(40) and Notch target gene modulation in tumours were used to evaluate the degree and duration of target inhibition. Pharmacokinetic and pharmacodynamic correlations with biochemical, immunohistochemical and profiling data were used to demonstrate GSI mechanism of action in xenograft tumours.

KEY RESULTS

Three days of >70% Notch pathway inhibition was sufficient to provide an anti-tumour effect and was well tolerated. GSI-induced conversion of mouse epithelial cells to a secretory lineage was time- and dose-dependent. Anti-tumour efficacy was associated with cell cycle arrest and apoptosis that was in part due to Notch-dependent regulation of mitochondrial homeostasis.

CONCLUSIONS AND IMPLICATIONS

Intermittent but potent inhibition of Notch signalling is sufficient for anti-tumour efficacy in these T-ALL models. These findings provide support for the use of GSI in Notch-dependent malignancies and that clinical benefits may be derived from transient but potent inhibition of Notch.

Transporting children with special health care needs: comparing recommendations and practice

OBJECTIVE

We compare the use of the American Academy of Pediatrics (AAP) guidelines for the safe transportation of children with special health care needs (CSHCN) with reported and observed practices.

METHODS

This observational study was based on a convenience sample of vehicles exiting the garage of a tertiary children's hospital. Certified child passenger safety technicians with a health care background and specialized training in the transportation of CSHCN gathered the driver's demographic information and the child's reported medical condition, weight, age, clinic visited, and relation to the driver. The safety technicians observed the car safety seat (CSS) type, vehicle seating position, and if the child required postural support.

RESULTS

During the study, 275 drivers transporting 294 CSHCN were observed. Overall, most drivers complied with AAP recommendations by using a standard CSS seat (75.4%). Among the seats evaluated, 241 (82.0%) were the appropriate choice, but only 75 (26.8%) of 280 assessed had no misuses. Approximately 24% of the drivers modified the CSS, and 19.4% of the children would have benefited from additional body-positioning support. Only 8% of medical equipment was properly secured.

CONCLUSIONS

Although most drivers seemed to choose the appropriate seat, many had at least 1 misuse. Drivers complied with most AAP recommendations; however, some deviated to facilitate care of the child during transport. Discussions with parents or caregivers about the proper transportation of CSHCN and referrals to child passenger safety technicians with special training may improve safety, care, and comfort in the vehicle.

Vistonuridine: An orally administered, life-saving antidote for 5-fluorouracil (5FU) overdose

9616

Background: 5FU is widely used to treat solid tumors and is often administered via infusion pump at or near its maximum tolerated dose (MTD). Toxicities and even death can occur in patients over-exposed to 5FU. Uridine is a direct biochemical antagonist of 5FU toxicity; uridine nucleotides dilute intracellular fluorouridine nucleotides derived from 5FU, reducing their lethal incorporation into RNA. However, uridine is poorly bioavailable (7%) and is therefore not a clinically viable antidote. Vistonuridine is an orally administered prodrug of uridine that delivers approximately 8-fold more uridine than administration of uridine itself. Methods: 17 patients overdosed with 5FU have been treated with vistonuridine as an antidote. Patients received vistonuridine (10g q6h for 20 doses) beginning 8 to 96 hours after overdose. Data from 13 patients with similar 5FU overdoses provide the time course and outcomes for patients receiving available supportive care without vistonuridine. A severity score, integrating dose and infusion rate, was calculated for all the patients, and this tool could be used by healthcare workers to determine the expected severity and outcome of a 5FU overdose. Results: All 17 overdose patients treated with vistonuridine recovered fully. Most, especially those for whom vistonuridine treatment was initiated sooner, had relatively modest toxicity. In marked contrast, all 11 of the literature-reported cases of 5FU overdose for which an outcome of death would have been predicted died from the overdose despite receiving available supportive care. Conclusions: These clinical data illustrate the serious, debilitating and life threatening nature of 5FU overdose and the current lack of effective treatments. Vistonuridine appears to be a safe and effective, life-saving antidote to 5FU overdose.

[Table: see text]

Seat belt misuse among children transported in belt-positioning booster seats

OBJECTIVE

Observe and report seat belt use among children transported in belt-positioning booster seats.

DESIGN

We conducted a cross-sectional, observational survey of children transported in motor vehicles between 2006 and 2007. While drivers completed a survey reporting the child's age, weight and gender, and the driver's age, gender, race, income, education, and relationship to the child; a child passenger safety technician recorded vehicle seating location, restraint type, and use of the car safety seat harness or seat belt as appropriate for the child.

SETTING

Twenty-five fast food restaurants and discount department stores throughout Indiana.

PARTICIPANTS

A convenience sample of drivers transporting children younger than 16 years.

MAIN EXPOSURE

Seat belt use among children transported in belt-positioning booster seats.

OUTCOME MEASURE

Seat belt misuse.

RESULTS

Overall, 1446 drivers participated, 2287 children were observed with 564 children in belt-positioning booster seats. At least one seat belt misuse was observed for 64.8% of the children transported. Common misuses were the shoulder belt being placed over the booster seat armrest (35.8%); shoulder belt not at mid-shoulder position (28.5%), seat belt was too loose (24.5%), and the shoulder belt was either behind the child's back (9.1%) or under their arm (10.0%).

CONCLUSION

There is a high frequency of seat belt misuses among children transported in booster seats. Advice to parents on appropriate car seat selection, and encouragement to parents to supervise seat belt use may decrease misuse.

Clinical trial: dexlansoprazole MR, a proton pump inhibitor with dual delayed-release technology, effectively controls symptoms and prevents relapse in patients with healed erosive oesophagitis

BACKGROUND

Dexlansoprazole MR heals all grades of erosive oesophagitis (EO).

AIM

To assess efficacy and safety of dexlansoprazole MR in maintaining healed EO and heartburn relief.

METHODS

In this randomized, double-blind trial, 445 patients with healed EO received dexlansoprazole MR 30 mg or 60 mg or placebo once daily for 6 months. This trial assessed maintenance of endoscopic healing (primary endpoint) and continued symptom relief based on daily diaries (secondary endpoints).

RESULTS

Dexlansoprazole MR 30 mg and 60 mg were superior to placebo for maintaining healed EO (P < 0.0025; Hochberg's). By life-table analysis, maintenance rates were 75%, 83% and 27% for dexlansoprazole MR 30 mg, 60 mg and placebo respectively. Crude maintenance rates were 66% for both dexlansoprazole MR doses and 14% for placebo. Dexlansoprazole MR controlled heartburn (medians of 91-96% for 24-h heartburn-free days, 96-99% for heartburn-free nights). The only more common adverse event occurring at a significantly higher rate in dexlansoprazole MR groups than placebo when analysed per patient-months of exposure was upper respiratory tract infection.

CONCLUSIONS

Dexlansoprazole MR effectively maintained EO healing and symptom relief; most patients were heartburn-free for >90% of days. Both doses were well tolerated.

Influences on parents' decisions for home and automobile smoking bans in households with smokers

OBJECTIVE

To understand clinician influence on use of home and automobile smoking bans in homes of children living with a smoker.

METHODS

Parents were surveyed on tobacco use, smoking bans, demographics and opinions about tobacco, including harm from environmental tobacco smoke (ETS). Responses from 463 diverse households with smokers were analyzed.

RESULTS

42% of respondents smoked; 50% had a home smoking ban and 58% an automobile smoking ban. Nonsmokers living with a smoker, those who strongly agreed in ETS harm, and those having a child < or = 5 years more often had a home smoking ban. Those recalling their child's doctor ever asking the respondent about their smoking status and African American respondents less frequently had a home ban. Automobile smoking bans were more often held by those with strong agreement in ETS harm and less often found in families having a child receiving Medicaid/uninsured.

CONCLUSIONS

Having a strong perception of harm from ETS exposure was associated with having smoking bans. Aspects of health encounters not measured by this study may be negatively influencing adoption of home smoking bans or lead to recall bias.

PRACTICE IMPLICATIONS

Clinicians should examine the strength, focus, and response to their messages to parents about tobacco.

Children with special health care needs: patterns of safety restraint use, seating position, and risk of injury in motor vehicle crashes

OBJECTIVES

Special health care needs associated with behavioral conditions may influence a child's safety in motor vehicle crashes. The aim of this study was to describe and compare variation in restraint use, seating position, and injury risk in motor vehicle crashes among children with and without special health care needs likely to affect behavior.

PATIENTS AND METHODS

This study uses data collected between December 1, 1998, and November 30, 2002, in a cross-sectional study of children <16 years of age who were involved in crashes of State Farm-insured vehicles in 15 states. Parent reports via a validated telephone survey were used to define precrash special health care needs, restraint status, seating position, and the occurrence of clinically significant injuries by using a previously validated survey instrument.

RESULTS

Complete data were collected for 14654 children aged 4 to 15 years, representing 171633 children in crashes. Of these, 152 children were reported to have a special need likely to affect behavior, representing 1883 children. A greater proportion of children with special needs likely to affect behavior were appropriately restrained, particularly among children aged 4 to 8 years. Drivers of children with special needs likely to affect behavior were more often restrained and more often were the child passenger's parent. There were no differences in the rates of front-row seating. There was no significant association between the presence of a special need likely to affect behavior and risk of injury, after adjustment for child/driver characteristics and crash severity.

CONCLUSIONS

Despite a greater proportion of children with special needs likely to affect behavior using proper vehicle restraint, their injury risk was similar to that of children without these special needs. Primary care pediatricians providing best practices for vehicle safety should consider the unique riding experience and risk of injury among children with special health care needs likely to affect behavior.

Socio-demographic and geographic analysis of overweight and obesity in Canadian adults using the Canadian Community Health Survey (2005)

Using the 2005 Canadian Community Health Survey, this study examined how overweight and obesity in Canadian adults are distributed across socio-demographic and geographic groupings. Overweight and obesity prevalence were modeled against socio-demographic indicators using Poisson regression and were assessed geographically using choropleth maps. The Gini coefficient was used to assess the distribution of prevalence across risk groups. The potential impacts of high risk versus population-based prevention approaches on the population prevalence of obesity were also examined. Of adults aged 25 to 64 years, 17% were obese and 53% were overweight or obese, with the highest proportions observed in older age groups, among those who were physically inactive, white or non-immigrant, with low educational levels, and living in the prairie and east coast regions. Recalculation of obesity rates under the different prevention scenarios demonstrated that population-based approaches could achieve a four-fold greater decrease in obesity cases than high risk approaches, highlighting the need for broader population strategies for obesity prevention in Canada.

EUS and clinical characteristics of cystic pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (PNETs) may rarely appear as cystic or mixed solid-cystic masses. The endoscopic ultrasound (EUS) morphology and cyst fluid characteristics of these tumors are not well clarified. We retrospectively identified nine adult patients with nine single cystic pancreatic neuroendocrine tumors (CNETs). These nine included 0.67 % of the 1344 patients with pancreatic cystic lesions and 9.5 % of the 95 confirmed PNETs evaluated over the 12-year study period. At presentation, four patients were asymptomatic and five had known acute pancreatitis (n = 2), MEN-1 syndrome with hypoglycemia (n = 1), and abdominal pain (n = 2). Median maximal tumor diameter was 26 mm (range 20 - 64 mm). EUS morphology was mixed solid and cystic (n = 4) or cystic alone (n = 5). Cytology from EUS-fine-needle aspiration (FNA) (median 2 passes; range 1 - 6) demonstrated a PNET, and immunocytochemistry was confirmatory in all patients. Cyst fluid carcinoembryonic antigen (CEA) (n = 4) and amylase (n = 5) ranged from 0.1 to 1.8 ng/ml (normal 0 - 2.5 ng/ml) and 72 to 1838 U/L (normal 25 - 161 U/L), respectively. Six patients underwent surgery, and the preoperative diagnosis was confirmed in all.

Escalator-related injuries among older adults in the United States, 1991-2005

This study describes the epidemiology of escalator-related injuries among adults age 65 and older in the U.S. between 1991 and 2005, through a retrospective analysis of data from the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission. There were an estimated 39,850 escalator-related injuries and no fatalities. The overall injury rate was 7.8/100,000 population. During the study period 1991-2005, the rate of escalator-related injuries doubled. The mean age of the study population was 80.1 years (S.D.=8.5 years) with 73.3% female. The most frequent cause of injury was a slip, trip or fall (84.9%, 95% CI: 82.7-87.2%). The most frequently injured body parts were the lower extremities (25.9%, 95% CI: 21.5-30.2%) and the head (25.0%, 95% CI: 20.5-29.5%). The leading type of injury was soft tissue injuries (54.2%, 95% CI: 49.7-58.7%) followed by lacerations (22.3%, 95% CI: 18.4-26.1%) and fractures (15.6%, 95% CI: 13.1-18.1%). The rate of head injuries and the rate of hospitalizations increased with age. Escalator-related injuries occur infrequently but may result in significant trauma. These injuries are often associated with a slip, trip or fall. Awareness of the risks and the circumstances leading to escalator injuries allows for better direction of intervention strategies on the part of injury prevention specialists.

Elevator-related injuries to children in the United States, 1990 through 2004

This study describes the epidemiology of elevator-related injuries among children in the United States from 1990 to 2004. A retrospective cohort analysis was performed using data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission. Reported cases were used to project national estimates. An estimated 29 030 elevator-related injuries occurred among children in the United States during 1990 to 2004. The mean age was 8.1 years (SD, 6.1 years), with 53.3% of injuries among boys. The overall injury rate was 2.5 injuries per 100,000 population. The injury rate for children aged 0-4 years was 4.2 per 100,000 population, and for children aged 5-19 years the injury rate was 1.9 per 100,000 population. The most frequent cause of injury was the elevator door closing on a body part, the most frequently injured body region was the upper extremity, and soft-tissue injuries were the most frequent type of injury. Children should be closely supervised on or near elevators to reduce the risk of injury.

The surgical management of degenerative lumbar spondylolisthesis: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To identify whether there is an advantage to instrumented or noninstrumented spinal fusion over decompression alone for patients with degenerative lumbar spondylolisthesis.

SUMMARY OF BACKGROUND DATA

The operative management of degenerative spondylolisthesis includes spinal decompression with or without instrumented or noninstrumented spinal fusion. Evidence on the operative management of degenerative spondylolisthesis is still divisive.

METHODS

Relevant RCT and comparative observational studies between 1966 and June 2005 were identified. Abstracted outcomes included clinical outcome, reoperation rate, and solid fusion status. Analyses were separated into: 1) fusion versus decompression alone and 2) instrumented fusion versus noninstrumented fusion.

RESULTS

Thirteen studies were included. The studies were generally of low methodologic quality. A satisfactory clinical outcome was significantly more likely with fusion than with decompression alone (relative risk, 1.40; 95% confidence interval, 1.04-1.89; P < 0.05). The use of adjunctive instrumentation significantly increased the probability of attaining solid fusion (relative risk, 1.37; 95% confidence interval, 1.07-1.75; P < 0.05), but no significant improvement in clinical outcome was recorded (relative risk, 1.19; 95% confidence interval, 0.92-1.54). There was a nonsignificant trend toward lower repeat operations with fusion compared with both decompression alone and instrumented fusion.

CONCLUSION

Spinal fusion may lead to a better clinical outcome than decompression alone. No conclusion about the clinical benefit of instrumenting a spinal fusion could be made. However, there is moderate evidence that the use of instrumentation improves the chance of achieving solid fusion.

Firearm Suicide: Use of a Firearm Injury and Death Surveillance System

BACKGROUND

Suicide is an important public health concern. Firearms are the most common mechanism of suicide death. This study describes the epidemiology of fatal and nonfatal firearm suicide injuries (FSI) in one metropolitan area from 2002 through 2004 using a firearm injury surveillance system.

METHODS

Records were obtained of all victims of firearm injuries from hospitals, police, and the coroner. All injuries categorized as suicide were included.

RESULTS

Local age adjusted suicide rates were significantly higher than state or national rates for ages 15 to 24, and significantly higher than national rates for ages 25 to 44. Men were FSI victims more than five times as often as women were. There was no seasonal pattern identified. Handguns were used nearly three out of four times. Eighty-six percent of FSI victims died, two-thirds at the scene. Most wounds were in the head or chest. Mental illness or relationship problems were common. Most suicides occurred in a residence.

CONCLUSIONS

Community level firearm injury surveillance effectively identifies local trends that may differ from national statistics. Collaboration among various groups is used to support injury prevention programs. These data can both complement and contribute to national statistics.

The role of collectives in STI and HIV/AIDS prevention among female sex workers in Karnataka, India

This paper evaluates the role of female sex worker (FSW) collectives in the state of Karnataka, India, regarding their facilitating effect in increasing knowledge and promoting change towards safer sexual behaviour. In 2002 a state-wide survey of FSWs was administered to a stratified sample of 1,512 women. Following the survey, a collectivization index was developed to measure the degree of involvement of FSWs in collective-related activities. The results indicate that a higher degree of collectivization was associated with increased knowledge and higher reported condom use. Reported condom use was higher with commercial clients than with regular partners or husbands among all women and a gradient was observed in most outcome variables between women with low, medium and high collectivization index scores. Collectivization seems to have a positive impact in increasing knowledge and in empowering FSWs in Karnataka to adopt safer sex practices, particularly with commercial clients. While these results are encouraging, they may be confounded by social desirability, selection and other biases. More longitudinal and qualitative studies are required to better understand the nature of sex worker collectives and the benefits that they can provide.

Characteristics of suicide from 1998-2001 in metropolitan area

In order to establish effective suicide preventive programs, it is important to know the etiologic factors and causal relationships between suicide and behavior. Coroner data was analyzed for the 468 suicides that occurred in Indianapolis, Indiana during 1998-2001. The age-adjusted suicide rate was 14.08 per 100,000. Almost one-half of the victims had a mental illness and 26% had a history of alcohol/substance abuse. The leading risk factors for suicide were age, impaired health, psychosocial stressors, and access to firearms. This information can be used by health departments and mental health professionals to help reduce suicide.

Blood lead levels in NASCAR Nextel Cup teams

This pilot study determines whether NASCAR racing teams demonstrate exposure to lead from exhaust by evaluation of blood lead levels (BLL). Participants were stratified by proximity to fuel exhaust or whether they worked on an engine. Each participant completed a self-reported survey recording demographics, lead exposure (occupational or in-home environment), and any physical symptoms of lead toxicity. Blood lead levels were then measured. BLL of 47 individuals ranged from 1-22 microg/dL with a median of 9.4 microg/dL. Nineteen of 47 (40.4%) had BLL > or = 10 microg/dL. Participants exposed to exhaust gas had the highest relative risks (RR) for elevated lead, followed by working on brakes and radiator repair. The RR of having an elevated BLL and self-reported adverse health outcomes or symptoms was increased. This study of NASCAR racing teams demonstrates lead exposure.