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To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia ( P  = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P  = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia ( P  = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Spinal conditions, such as scoliosis and spinal tumors, are prevalent in neurofibromatosis type 1 (NF1). Despite the recognized importance of their early detection and treatment, there remain knowledge gaps in how to approach these manifestations. The purpose of this study was to utilize the experience of a multidisciplinary committee of experts to establish consensus-based best practice guidelines (BPGs) for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric patients with NF1., Methods: Using the results of a prior systematic review, 10 key questions that required further assessment were first identified. A committee of 20 experts across medical specialties was then chosen based on their clinical experience with spinal deformity and tumors in NF1. These were 9 orthopaedic surgeons, 4 neuro-oncologists/oncologists, 3 neurosurgeons, 2 neurologists, 1 pulmonologist, and 1 clinical geneticist. An initial online survey on current practices and opinions was conducted, followed by 2 additional surveys via a formal consensus-based modified Delphi method. The final survey involved voting on agreement or disagreement with 35 recommendations. Items reaching consensus (≥70% agreement or disagreement) were included in the final BPGs., Results: Consensus was reached for 30 total recommendations on the management of spinal deformity and tumors in NF1. These were 11 recommendations on screening and surveillance, 16 on surgical intervention, and 3 on medical therapy. Five recommendations did not achieve consensus and were excluded from the BPGs., Conclusion: We present a set of consensus-based BPGs comprised of 30 recommendations for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric NF1., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Parental leave impacts family engagement, bonding, stress, and happiness. Because parental leave benefits are important to all surgeons regardless of sex, understanding parental leave practices in pediatric orthopaedic surgery is critical to promote equity within the profession and supporting balance in work and family life. The aim of this study was to survey pediatric orthopaedic surgeons about their knowledge of parental leave policies, attitudes towards parental leave, and their individual experiences taking leave., Methods: A 34-question anonymous survey was distributed to the Pediatric Orthopaedic Society of North America membership. Eligible respondents were attending pediatric orthopaedic surgeons practicing in the United States or Canada. The survey gathered information about employer parental leave policies, perceptions about and experiences with parental leave while practicing as a surgeon, and demographic information about respondents., Results: A total of 77 responses were completed and used for analysis. Most respondents were men (59.7%), <50 years old (67.5%), married (90.9%), and in urban communities (75.3%). A large majority were practicing in the United States (97.4%). Most respondents were unfamiliar with employer parental leave policies (maternity: 53.3%; paternity: 67.5%; and adoption: 85.7%). Those familiar with policies reported that employers offered 7 to 12 weeks for maternity leave (45.7%) and <1 week for paternity leave (50%) and adoption leave (45.5%). Most respondents believed 7 to 12 weeks should be offered for maternity leave (66.2%), 1 to 6 weeks for paternity leave (54.6%), and 7 to 12 weeks for adoption leave (46.8%). Many respondents reported taking 1 to 6 weeks of parental leave as a surgeon (53.3%) and that their colleagues were supportive of their parental leave (40.3%)., Conclusions: Most pediatric orthopaedic surgeons were unfamiliar with parental leave benefits provided by employers. Respondents who were familiar with these policies believed that more parental leave should be provided, especially for men who may feel social pressure to take less time for leave. Although respondents reported that their work environments were supportive, this study identified opportunities for improvement to support surgeons who wish to balance parental experiences with work responsibilities., Level of Evidence: Level V., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Newly minted pediatric orthopaedic surgeons face a variety of challenges when building a practice. No matter how skilled a surgeon is, he/she will be unsuccessful by any metrics if they lack patients to take care of. This manuscript will review principles and practical techniques that pediatric orthopaedic surgeons can utilize to build a renewable referral base to fuel their practice., Competing Interests: The author declares no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Facet fractures have been reported in a total of 6 young athletes in 4 previous publications. These injuries were not diagnosed on magnetic resonance imaging (MRI) or radiographs, and were identified on computed tomography (CT). Our purpose was to report a series of athletes with operatively managed facet fractures. This may be an under-recognized diagnosis., Methods: Retrospective review of pediatric patients with operatively managed isolated lumbar or sacral facet fractures from 3 tertiary pediatric hospitals from 2014 to 2019. Clinical records and imaging studies were reviewed., Results: Ten patients with symptomatic lumbar or sacral facet fractures met inclusion criteria (mean age at presentation; 13.3±2.1 years, 70% Female). All patients reported competitive participation in sports. On physical examination, 10/10 (100%) of patients had lower back pain that was exacerbated with lumbar spine extension. Limited CT scans demonstrated facet fractures in 10/10 (100%) patients not detected on plain film or MRI. All patients experienced significant relief of pain following excision of the facet fracture fragment. At time of first postoperative visit, 9/10 (90%) patients were pain free while one had generalized back pain thought to be related to fibromyalgia and not facet pathology. At time of last follow-up, 2/10 (20%) of patients reported nonspecific back pain that was not localized in the area of the facet fracture, while 80% (8/10) remained pain free. All patients 100% (10/10) returned to full participation to sports. There were no complications noted in this series. Average follow-up was 27 months (range: 1 to 68 mo)., Conclusions: Athletes with localized back pain exacerbated by spine extension may have a facet fracture. As facet fractures are usually not identified with radiographs or MRI, a limited CT scan should be considered in the evaluation of pediatric athletes with localized back pain exacerbated by extension. In this series, surgical excision of facet fracture fragments was safe and provided predictable pain relief., Competing Interests: L.M.A.: Eli Lilly: Stock or stock Options. Journal of Pediatric Orthopedics: Editorial or governing board. Nuvasive: Paid consultant; Paid presenter or speaker. Orthobullets: Publishing royalties, financial or material support. Pediatric Orthopaedic Society of North America: Board or committee member. D.J.M.: Pediatric Orthopaedic Society of North America: Board or committee member. P.J.C.: Journal of Bone and Joint Surgery—American: Editorial or governing board. Nuvasive: Paid consultant. Pediatric Orthopaedic Society of North America: Board or committee member. Scoliosis Research Society: Board or committee member. Spine Deformity: Editorial or governing board. D.L.S.: CHLA Foundation: Board or committee member. Grand Rounds: Paid consultant. Green Sun Medical: Stock or stock Options. Growing Spine Foundation: Board or committee member. Growing Spine Study Group: Board or committee member. Journal of Children’s Orthopaedics: Editorial or governing board. Nuvasive (Co-PI, Paid to Growing Spine Foundation): Research support. Orthobullets: Editorial or governing board; Paid consultant; Stock or stock Options. Orthopedics Today: Editorial or governing board. Spine Deformity: Editorial or governing board. Wolters Kluwer Health: Publishing royalties, financial or material support. ZimmerBiomet: IP royalties; Other financial or material support; Paid consultant; Paid presenter or speaker. Zipline Medical Inc.: Stock or stock Options. Scoliosis Research Society: Board or committee member. Zimmer Biomet: Paid consultant. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: It is unclear what factors influence health-related quality of life (HRQOL) in neuromuscular scoliosis. The aim of this study was to evaluate which factors are associated with an improvement in an HRQOL after spinal fusion surgery for nonambulatory patients with cerebral palsy (CP)., Methods: A total of 157 patients with nonambulatory CP (Gross Motor Function Classification System IV and V) with a minimum of 2-year follow-up after PSF were identified from a prospective multicenter registry. Radiographs and quality of life were evaluated preoperatively and 2 years postoperatively. Quality of life was evaluated using the validated Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire. Patients who had an increase of 10 points or greater from baseline CPCHILD scores were considered to have meaningful improvement at 2 years postoperatively. 10 points was chosen as a threshold for meaningful improvement based on differences between Gross Motor Function Classification System IV and V patients reported during the development of the CPCHILD. Perioperative demographic, clinical, and radiographic variables were analyzed to determine predicators for meaningful improvement by univariate and multivariate regression analysis., Results: A total of 36.3% (57/157) of the patients reported meaningful improvement in CPCHILD scores at 2 years postoperatively. Preoperative radiographic parameters, postoperative radiographic parameters, and deformity correction did not differ significantly between groups. Patients who experienced meaningful improvement from surgery had significantly lower preoperative total CHPILD scores (43.8 vs. 55.2, P<0.001). On backwards conditional binary logistic regression, only the preoperative comfort, emotions, and behavior domain of the CPCHILD was predictive of meaningful improvement after surgery (P≤0.001)., Conclusion: Analysis of 157 CP patients revealed a meaningful improvement in an HRQOL in 36.3% of the patients. These patients tended to have lower preoperative HRQOL, suggesting more "room for improvement" from surgery. A lower score within the comfort, emotions, and behavior domain of the CPCHILD was predictive of meaningful improvement after surgery. Radiographic parameters of deformity or curve correction were not associated with meaningful improvement after surgery., Level of Evidence: Level II-retrospective review of prospectively collected data.

Background: Enhancing the safety, quality, and value of care provided is a point of emphasis for modern health care systems. We performed a review of recent literature to highlight those efforts relevant to pediatric musculoskeletal care., Methods: We searched the PubMed database for all papers related to quality improvement, patient safety, and/or value in pediatric orthopaedics published from October 1, 2012 to October 31, 2017, yielding 193 papers., Results: A total of 36 papers were selected for review based upon new findings. Papers were selected based on significant contributions in the following categories: casting safety, antibiotic stewardship/infection prevention, perioperative care pathways, blood conservation, venous thromboembolic disease prevention, and imaging safety/appropriateness., Conclusions: There have been numerous advances in safety, quality, and value in pediatric orthopaedic care. Quality improvement efforts emphasizing provider education and safety monitoring can lead to a decrease in cast-related complications. Perioperative care pathways and bundles are associated with a decrease risk of surgical site infection and decreased length of stay in pediatric spinal deformity surgery. Increased scrutiny has been placed on the value of routine follow-up radiographs in pediatric fracture and spinal deformity care., Level of Evidence: Level 4-literature review.

Background: Firearm-associated injuries are the second leading cause of death in children in the United States. Fractures are common comorbid injuries in young patients with firearm-associated injuries. The purpose of this study was to define the burden of firearm-associated fractures (FAFs) in children and adolescents in the United States., Methods: We analyzed the 2003-2012 Kids' Inpatient Database. Patients were grouped into 4 age groups: 0 to 4, 5 to 9, 10 to 14, and 15 to 20 years old. Sample observations with both an external cause of injury code indicating gunshot injury and a diagnosis code indicating orthopaedic fracture (extremity, pelvis, or spine) were identified as cases of FAF. Sex, age, race, cause of injury, and fracture-related operating room procedures were catalogued. Population-level incidence was calculated for each year studied., Results: From 2003 to 2012, the incidence of FAF in patients 20 years and below of age increased from 73 to 96 cases per 100,000 admissions (P=0.009). The 0 to 4 age group saw the largest increase in injury frequency (141%, P=0.08). There was a 4-fold increase in the rate of unintentional injury in this subgroup. The most common age group affected by FAFs was 15 to 20 year olds. Minorities and male individuals were disproportionately affected. Assault and unintentional causes were the most common reasons for injury., Conclusions: The frequency of FAF in patients 20 years and below of age increased over the study period, with almost 1 case per 1000 admissions in 2012. The finding that certain subpopulations are disproportionately affected reflects the complex sociologic factors influencing gun violence in the United States., Level of Evidence: Level III-retrospective cohort study.

Background: Although flexible intramedullary nailing is a popular treatment option for femoral shaft fractures in juvenile and young adolescent patients, it may not be appropriate in some patients because of patient size and/or fracture configuration., Methods: Retrospective review over a 3-year period identified 17 skeletally immature patients (18 fractures) with femoral shaft fractures treated with noncannulated rigid locked intramedullary nailing because of a length-unstable fracture or patient overweight or obesity. The 14 males and 3 females had an average age of 10 years at the time of injury (range, 7.6 to 11.9 y). Their average weight was 38.3 kg (range, 22.7 to 52 kg), with an average body mass index of 18.9 (range, 13.9 to 26.9)., Results: All fractures united at an average of 13 weeks, with no osteonecrosis, malalignment, malunion, or hardware failure., Conclusions: Preliminary results suggest that noncannulated, rigid, locked intramedullary nails can be used safely and effectively for selective fixation of femoral shaft fractures in skeletally immature patients younger than 12 years of age., Level of Evidence: Level IV.

Study Design: Randomized controlled trial., Objective: To assess whether monitoring increases brace-wearing compliance in patients with adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Noncompliance is a barrier to brace treatment of AIS. Studies have demonstrated that monitoring improves medication compliance; however, this has not been investigated in spinal braces., Methods: Twenty-one patients (mean age = 12.4 ± 2.0 years) with AIS were prescribed treatment with a custom-made Thoraco-Lumbo-Sacral-Orthosis for 18 hours a day using a standardized script. Before beginning treatment, 10 patients were randomized to be informed that their compliance was monitored, whereas 11 patients were unaware. Compliance was measured via a temperature probe embedded within the Thoraco-Lumbo-Sacral-Orthosis hidden from view., Results: Patients who were notified that they had a monitor in their brace demonstrated significantly increased compliance during the first 14 weeks of treatment compared with those who were uninformed (85.7% vs. 56.5%, P = 0.029), corresponding to a mean difference of 5.24 hours of daily brace wear., Conclusion: Electronic monitoring can improve compliance with orthoses in patients with spinal deformity during a short observation period.

This article was initiated to help two graduating Master's students learn what might be expected of them upon graduation. The purpose of this article is to provide insight from reviewing the current literature on clinical nurse specialist's (CNS's) characteristics. The authors believe that this information is especially useful for graduate CNS students and helpful for those who currently hold CNS positions. Based on a literature review, the article categorizes descriptions of the characteristics of the CNS role as perceived by the CNS, management, staff nurses, and physicians. Within the identified perceptions of each group were the following similarly common CNS role components: (a) clinical practice, (b) education, (c) administration, (d) research, and (e) consultation. The key to congruent expectations and understanding of the CNS role is clear communication between the members of each group. Without this communication, the common result is ambiguity, conflict, and frustration.

We tested the hypothesis that immunoglobulins directed against a CNS autoantigen, myelin basic protein, may promote remyelination in the course of a chronic, immune-mediated demyelinating disease. SJL/J mice infected chronically with Daniel's strain of Theiler's virus served as an experimental model of MS. The spinal cords of these mice exhibit extensive primary demyelination and inflammation with minimal spontaneous remyelination. Treatment with whole antiserum or affinity-purified mouse immunoglobulins directed against rat or rabbit myelin basic protein increased new myelin synthesis as measured by quantitative morphometry. Electron microscopy revealed numerous oligodendrocytes in remyelinated CNS lesions and a relative lack of inflammatory cells. Viral antigen persisted in the spinal cord despite enhanced CNS-type remyelination. These findings indicate that immunoglobulins reactive with myelin autoantigens have the potential to promote myelin repair.

A differential classical conditioning paradigm was used to investigate changes in total respiratory resistance in healthy adult female subjects. The conditioned stimuli were red and blue colors projected on a screen, and the unconditioned stimulus was an arithmetic task in which the subject mentally subtracted serial 17s from a number displayed on the screen. One of the two colors was paired with the arithmetic problem, and the other color was presented alone. Participants completed seven paired and seven unpaired trials. Both total respiratory resistance and functional residual capacity changes were measured before and during each conditioned stimulus. Total respiratory resistance was higher during the paired conditioned stimuli than it was during the unpaired conditioned stimuli. This result was not related to variations in functional residual capacity. It was concluded that elevated total respiratory resistance during the paired stimuli was a result of conditioning. The elevations were probably due to increases in bronchomotor tone. Conditioned changes in total respiratory resistance may be related to some respiratory behaviors both in healthy individuals and in patients with asthma.

The purpose of this study was to compare the physical activity levels of physical therapists using five activity questionnaires and one electronic motion sensor (Caltrac). Thirty-three physical therapists (26 female, seven male) were monitored for seven consecutive days. The Caltrac data were compared with five questionnaires, including the Baecke (Baecke); Godin and Shephard (Godin); Ross and Jackson (NASA); 3-d record (3-d); and 7-d recall (7-d). A significant (P < 0.01) Spearman rank order correlation coefficient was observed between the Caltrac reading and the 7-d recall (r = 0.79). A significant correlation was also observed between the Caltrac and the Godin (r = 0.45, P < 0.01). Three of the questionnaires were also significantly (P < 0.01) correlated with each other, including the NASA with the Baecke (r = 0.52), the NASA with the Godin (r = 0.54), and the Godin with the Baecke (r = 0.61). The 3-d record was not significantly correlated with any of the other measures. The strong, significant correlation observed between the Caltrac data and the 7-d recall suggests adequate validity for the 7-d recall. The 7-d recall questionnaire would be quicker, easier, and less expensive to use in a large population study than the Caltrac.

Among the mechanisms postulated to contribute to myocardial "stunning" is a depression of contractility by oxygen-derived free radicals. It has been suggested that these radicals might depress the calcium sensitivity of the contractile proteins. We have exposed the myofilaments (in chemically "skinned" rat cardiac muscle) to the superoxide anion and measured isometric force at controlled degrees of activation. Superoxide was generated by the xanthine/xanthine oxidase system: the effects to be described were shown to be specifically attributable to superoxide. Maximum calcium-activated force is reduced, or even completely abolished, in a dose-dependent fashion and without any alteration in calcium sensitivity. The myofilaments are highly sensitive to superoxide: significant force reduction has been shown to be caused by enzyme concentrations as low as 2 microunits/ml xanthine oxidase and with exposures of less than 1 minute to the generating system (at higher enzyme concentrations). Once force has been depressed, it cannot be recovered within the duration of the experiments described. When xanthine oxidase is applied during the calcium-induced contracture, tension falls steadily. However, a similar concentration is without immediate effect on the rigor contracture (evoked by applying ATP-free solutions). To account for the depression of maximum calcium-activated force, we conclude that some aspect of crossbridge behavior is particularly vulnerable to superoxide rather than that the radical has a nonspecific "proteolytic" effect. This action on the fundamental units of force production could contribute to myocardial stunning since the effects we report are consistent with many aspects of this phenomenon.

Seventeen patients were entered into a Phase I/II trial of concurrent hyperfractionated radiation therapy (7,440 cGy total dose; 120 cGy b.i.d.) combined with constant infusion of 5-fluorouracil (5-FU) (1,000 mg/m2/24 hours for 72 hours) and cisplatin (DDP) (50 mg/m2) for a total of three cycles. Thirteen patients had Stage IV disease; three, Stage III disease; and one, Stage II hypopharyngeal disease. Thirteen of 17 patients had positive cervical lymph nodes, and the mean size of the largest lymph node was 5.5 x 5.1 cm. The patients were not treated with planned adjunctive surgery except for one patient who had a radical neck dissection for massive, rapidly growing cervical adenopathy, which recurred promptly within 1 month before the initiation of protocol therapy. After the initial six patients were entered, mitomycin-C (Mito 8 mg/m2) was added during the second cycle. All the patients completed the planned course of radiotherapy with a median dose of 7,440 cGy and a mean dose of 7,248 cGy except for two patients who died--one from toxicity and the other, suicide. The predominant toxicity was mucositis, which was grade 3/4 in 11 of 15 patients, resulting in an average interruption of radiation therapy of 12 days. Weight loss was significant and was on the average 12% of baseline weight. Hematological toxicity was mild in the 5-FU/DDP group (only one grade 3 toxicity of six) and severe in the 5-FU/DDP/Mito-treated patients (five of eight patients having grade 3/4 toxicity including one leukopenic pneumonitis death). Additional toxicity included one parapharyngeal cellulitis, which responded to antibiotics. Noncompliance with the complex regimen was only seen in three patients. One patient refused b.i.d. radiation therapy, and one patient refused further chemotherapy after the first cycle. Additionally, one patient who had a severe ethanol withdrawal reaction during the first cycle of 5-FU/DDP did not receive further chemotherapy. The complete response rate of both primary site and neck by the protocol regimen alone was 71%. However, two patients, one from each group, did undergo salvage neck dissection, and the locoregional control is currently 73%, with a mean follow-up time of 18.4 months. The feasibility of combining hyperfractionated radiation therapy with aggressive concurrent chemotherapy was demonstrated. The response and local control rate justifies the added toxicity of concurrent chemotherapy and radiation therapy.

We measured somatosensory evoked potentials, infarct size, and cerebral blood flow in 20 cats subjected to occlusion of the middle cerebral artery for 3 hours, followed by an equal period of reperfusion. The cats were randomized into a treatment group that received a continuous infusion of 2 mg/kg lidocaine hydrochloride or a control group that received an equivalent volume of normal saline. All 10 treated cats retained measurable evoked potentials throughout the experiment. In five control cats, evoked potentials disappeared completely at some point during the occlusion (difference between groups significant at p less than 0.001). Mean amplitude of the major cortical wave in the nine treated cats with cerebral infarcts was higher than that of the nine corresponding controls (p less than 0.05). Lidocaine reduced the mean +/- SEM size of the infarcts from 30.1 +/- 6.0% in the control group to 14.7 +/- 4.9% in the treated group (p less than 0.05). As blood flow was reduced in the infarct and peri-infarct zones in the control but not the treated cats, our results suggest that the beneficial effects of lidocaine may be due to preservation of blood flow in the ischemic zone.