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ObjectivesThe Emergency Medicine (EM) Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) specifies that resuscitation entrustable professional activities (EPAs) can be assessed in the workplace and simulated environments. However, limited validity evidence for these assessments in either setting exists. We sought to determine if EPA ratings improve over time and whether an association exists between ratings in the workplace v. simulation environment.MethodsAll Foundations EPA1 (F1) assessments were collected for first-year residents (n = 9) in our program during the 2018–2019 academic year. This EPA focuses on initiating and assisting in the resuscitation of critically ill patients. EPA ratings obtained in the workplace and simulation environments were compared using Lin's concordance correlation coefficient (CCC). To determine whether ratings in the two environments differed as residents progressed through training, a within-subjects analysis of variance was conducted with training environment and month as independent variables.ResultsWe collected 104 workplace and 36 simulation assessments. No correlation was observed between mean EPA ratings in the two environments (CCC(8) = -0.01; p = 0.93). Ratings in both settings improved significantly over time (F(2,16) = 18.8; p < 0.001; η2= 0.70), from 2.9 ± 1.2 in months 1–4 to 3.5 ± 0.2 in months 9–12. Workplace ratings (3.4 ± 0.1) were consistently higher than simulation ratings (2.9 ± 0.2) (F(2,16) = 7.2; p = 0.028; η2= 0.47).ConclusionsNo correlation was observed between EPA F1 ratings in the workplace v. simulation environments. Further studies are needed to clarify the conflicting results of our study with others and build an evidence base for the validity of EPA assessments in simulated and workplace environments.

Introduction the ageing global population and concomitant increase in the use of opioid analgesia have highlighted the need to evaluate the effectiveness of opioids for chronic pain in older people. Methods a systematic review of the evidence for the efficacy of opioids for chronic non-cancer pain in community-dwelling people aged 65 years or more was conducted using PRISMA guidelines. The databases MEDLINE, EMBASE, Pubmed and PsychINFO were searched. The quality of studies was assessed. Secondary aims were to assess correlates of opioid use and the decision-making processes of prescribers. Results seven studies were identified of low to high quality. The majority of older people experienced ongoing pain despite continuing opioid therapy. There were mixed results regarding benefits of opioids in terms of activities of daily living and social engagement. In nursing home residents, opioid use at baseline was associated with severe pain, severe impairment in activities of daily living and a diagnosis of depression. Fear of causing harm to older people was common amongst opioid prescribers, limiting prescription. Facilitators of opioid prescription included educational interventions and access to an evidence base for opioid use. Conclusion there is limited evidence supporting the use of long-term opioid use in older people for chronic non-cancer pain and a lack of trials in this age group. Age-specific guidelines are required addressing initial assessment, indications, monitoring and de-prescribing.

ObjectiveSimulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).MethodsSimulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.ResultsTwenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.ConclusionThis study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

BACKGROUND The aim of this study was to describe the complication profile of augmentation cystoplasty in contemporary paediatric urology as well as its effect on bladder metrics. METHODS Consecutive operative cases were retrospectively reviewed at a single institution over 20 years (1999-2019). Short- and long-term outcomes and complications following augmentation cystoplasty were defined. RESULTS Of the 71 operative cases; the most common underlying diagnoses were neurogenic bladder (34%), exstrophy-epispadias complex (30%) and posterior urethral valves (23%). The most common tissue-type utilized was ileal (58%) and ureteric (30%). Peri-operative urine leak affected nine (13%) children but reservoir perforations were less common (4%). Mean end-of-study detrusor pressure improved significantly following bladder augmentation (38-17 cmH2 O, P

Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system.

Background: There is rising interest in remote clinical trial assessments, particularly in the setting of the COVID-19 pandemic. Objective: To demonstrate the feasibility, reliability, and value of remote visits in a phase III clinical trial of individuals with Parkinson’s disease. Methods: We invited individuals with Parkinson’s disease enrolled in a phase III clinical trial (STEADY-PD III) to enroll in a sub-study of remote video-based visits. Participants completed three remote visits over one year within four weeks of an in-person visit and completed assessments performed during the remote visit. We evaluated the ability to complete scheduled assessments remotely; agreement between remote and in-person outcome measures; and opinions of remote visits. Results: We enrolled 40 participants (mean (SD) age 64.3 (10.4), 29% women), and 38 (95%) completed all remote visits. There was excellent correlation (ICC 0.81–0.87) between remote and in-person patient-reported outcomes, and moderate correlation (ICC 0.43–0.51) between remote and in-person motor assessments. On average, remote visits took around one quarter of the time of in-person visits (54 vs 190 minutes). Nearly all participants liked remote visits, and three-quarters said they would be more likely to participate in future trials if some visits could be conducted remotely. Conclusion: Remote visits are feasible and reliable in a phase III clinical trial of individuals with early, untreated Parkinson’s disease. These visits are shorter, reduce participant burden, and enable safe conduct of research visits, which is especially important in the COVID-19 pandemic.

Purpose To evaluate feasibility and outcomes of minimally invasive surgery (MIS) in Wilms tumor (WT). Methods International multicenter review of MIS total nephrectomies for WT between 2006 and 2018. Medical records of confirmed WT were retrospectively assessed for demographic, imaging, treatment, pathology, and oncological outcome data. Results Fifty patients, with a median age of 38 months (6-181), were included in 10 centers. All patients received neoadjuvant chemotherapy, as per SIOP protocol. Median tumor volume post-chemotherapy was 673 mL (18-3331), 16 tumors crossed the lateral border of the spine, and three crossed the midline. Six patients with tumors that crossed the lateral border of the spine (tumor volumes 1560 mL [299-2480]) were converted to an open approach. There was no intraoperative tumor rupture. Overall, MIS was completed in 19% of the 195 nephrectomies for WT presenting during the study period. Tumor was stage I in 29, II in 16, and III in 5, and histology was reported as low in three, intermediate in 42, and high risk in five. Three patients had positive tumor margins. After a median follow-up of 34 months (2-138), there were two local recurrences (both stage I, intermediate risk, 7 and 9 months after surgery) and one metastatic relapse (stage III, high risk, four months after surgery). The three-year event-free survival was 94%. Conclusion MIS is feasible in 20% of WT, with oncological outcomes comparable with open surgery, no intraoperative rupture, and a low rate of local relapse. Ongoing surveillance is, however, needed to evaluate this technique as it becomes widespread.

BackgroundIn patients with hemodynamically stable blunt splenic injury (BSI), there is no consensus on whether quantity of hemoperitoneum (HP) is a predictor for intervention with splenic artery embolization (SAE) or failing nonoperative management (fNOM). We sought to analyze whether the quantity of HP was associated with need for intervention.MethodsThis retrospective cohort study included adult trauma patients with hemodynamically stable BSI admitted to six trauma centers between 2014 and 2016. Quantity of HP was defined as small (perisplenic blood or blood in Morrison’s pouch), moderate (blood in one or both pericolic gutters), or large (additional finding of free blood in the pelvis). Multivariate logistic regression was performed to identify predictors of intervention with SAE or fNOM versus successful observation.ResultsThere were 360 patients: hemoperitoneum was noted in 214 (59%) patients, of which the quantity was small in 92 (43%), moderate in 76 (35.5%), and large in 46 (21.5%). Definitive management was as follows: 272 (76%) were observed and 88 (24%) had intervention (83 SAE, 5 fNOM). The rate of intervention was univariately associated with quantity of HP, even after stratification by American Association for the Surgery of Trauma (AAST) grade. After adjustment, larger quantities of HP significantly increased odds of intervention (p=0.01). Compared with no HP, the odds of intervention were significantly increased for moderate HP (OR=3.51 (1.49 to 8.26)) and large HP (OR=2.89 (1.03 to 8.06)), with similar odds for small HP (OR=1.21 (0.46 to 2.76)). Other independent predictors of intervention were higher AAST grade, older age, and presence of splenic vascular injury.ConclusionGreater quantity of HP was associated with increased odds of intervention, with no difference in risk for moderate versus large HP. These findings suggest quantity of HP should be incorporated in the management algorithm of BSI as a consideration for angiography and/or embolization to maximize splenic preservation and reduce the risk of splenic rupture.Level of evidenceIII, retrospective epidemiological study.

Despite being a conveniently portable technology for stroke assessment, Transcranial Doppler ultrasound (TCD) remains widely underutilized due to complex training requirements necessary to reliably obtain and interpret cerebral blood flow velocity (CBFV) waveforms. The validation of objective TCD metrics for large vessel occlusion (LVO) represents a first critical step toward enabling use by less formally trained personnel. In this work, we assess the diagnostic utility, relative to current standard CT angiography (CTA), of a novel TCD-derived biomarker for detecting LVO. Patients admitted to the hospital with stroke symptoms underwent TCD screening and were grouped into LVO and control groups based on the presence of CTA confirmed occlusion. Velocity curvature index (VCI) was computed from CBFV waveforms recorded at multiple depths from the middle cerebral arteries (MCA) of both cerebral hemispheres. VCI was assessed for 66 patients, 33 of which had occlusions of the MCA or internal carotid artery. Our results show that VCI was more informative when measured from the cerebral hemisphere ipsilateral to the site of occlusion relative to contralateral. Moreover, given any pair of bilateral recordings, VCI separated LVO patients from controls with average area under receiver operating characteristic curve of 92%, which improved to greater than 94% when pairs were selected by maximal velocity. We conclude that VCI is an analytically valid candidate biomarker for LVO diagnosis, possessing comparable accuracy, and several important advantages, relative to current TCD diagnostic methodologies.

Background We use a 'Virtual Clinic' for follow up of hip and knee replacement patients. The aim of this study was to investigate patient compliance, pain and function, revision rates and surgeon experience using this system. Methods All hip and knee replacements conducted from 2000 onwards were suitable for 'Virtual Clinic' review. Between July 2014 and December 2016, all patients due for follow up (at 1, 5 and 7 years post-operatively, or biennially thereafter) were mailed an Oxford Hip or Knee Score and a request for a radiograph. A surgeon reviewed the questionnaire and radiograph and decided whether face-to-face review was necessary. We calculated compliance as the percentage of eligible patients who completed the 'Virtual Clinic'. We used retrospective review of medical records for all clinic participants to analyse Oxford scores, disposition following appointment, and revision rates. We reviewed all clinic participants in December 2017 to identify any further revisions. Surgeon feedback was assessed by emailed survey. Results A total of 2076 patients were due for follow up. 1405 patients were contactable, and 710 completed the process. We calculated a 36% compliance rate. Surgeons decided 162 (23%) patients with a mean Oxford score of 24.2 required face-to-face assessment. This identified 13 patients needing revision. One other patient was revised for loosening which developed between 'Virtual Clinic' appointments. Surgeon feedback indicated the inclusion of a 'comment' section on the questionnaire as particularly useful. Discussion We describe our adoption of a 'Virtual Clinic' for joint replacement follow up. We recommend this system as a practical method of following up patients.

Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging.This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016.There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02).A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

BACKGROUND CONTEXT Patient-centered goal setting is an important component of behavioral interventions for chronic pain. Limited data exist on the relationship between goal attainment during cognitive-behavioral based physical therapy (CBPT) and pain-related outcomes. PURPOSE The purpose of this study was to examine the relationship between CBPT goal attainment and pain-related outcomes in a cohort of patients who completed a 6-week telephone-based CBPT intervention after lumbar spine surgery. STUDY DESIGN/SETTING Secondary analysis from a randomized trial comparing postoperative CBPT and an education program. The primary results of the trial showed superiority of CBPT in an intervention completers only analysis. PATIENT SAMPLE This study included 108 participants (mean ± SD age = 63.5 ± 11.3 years, 54 [50%] female, 92 [85%] White) who completed the CBPT intervention were included. OUTCOME MEASURES Six and 12-month outcomes included physical function (PROMIS), pain interference (PROMIS), and back and leg pain intensity (Brief Pain Inventory). Methods At each session, CBPT participants used goal attainment scaling (GAS) to set goals and report goal attainment from the previous session. The number and type of goals and percentage of goals met were recorded. A GAS t-score for achievement of goals across all sessions was computed for each patient. Patients were grouped as high or low goal attainment based on a GAS t-score of 50, which indicates goals were met as expected. Outcome differences between groups at each follow-up time point were examined using linear regression analyses controlling for baseline outcome score. Alpha was set at the 0.05 level for statistical significance. Results Participants set a median of 3 goals (range: 1 to 6) at each CBPT session. The most common goals were related to participating in a physical/recreational activity (36%), adopting a cognitive or behavioral strategy (28%), exercising (11%), or performing activities of daily living (11%). The least common goals related to social activities (2%). Forty-six (43%) participants met criteria for high goal attainment (mean % goals met = 87% compared to 64% in the low goal attainment group, p Conclusions The attainment of personalized goals within a CBPT intervention was an important factor related to improvements in physical functioning after spine surgery. Implementing a structured process for setting personalized goals and tracking goal attainment may be an essential aspect of a biopsychosocial approach for addressing functional impairment following surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The purpose of the study was to determine if there were differences in the complication rates between foreskin reconstruction (FR) and circumcision (CIRC) in distal hypospadias repairs. The primary outcomes were urethrocutaneous fistula (UF) and dehiscence. The data of distal hypospadias operated between 2005 and 2013 were retrospectively reviewed. The inclusion criteria were any distal hypospadias repair that required an urethroplasty. The exclusion criteria were follow-up

To define the evidence on the move to conservative treatment in four areas of pediatric urology: laparoscopic ureteric clipping in non-functioning duplex kidney, management of multicystic dysplastic kidney (MCDK), intravesical botulinum toxin injection in detrusor over activity, and risk stratification of gonadal tumors in disorders of sexual development. Laparoscopic ureteric clipping has been validated in one preliminary study. Lesser investigation and non-operative management of MCDK has been validated. An increasing body of evidence showing botulinum toxin injection can effectively treat detrusor over activity and reduce the need for bladder augmentation. New data on testicular biopsy can now identify patients at risk of germ cell tumor and reduce need for gonadectomy. Pediatric urology is shifting to less invasive management in a number of common conditions.

Background Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy. Methods A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken. Results Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state. Conclusion The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken. Level of Evidence Level IV, systematic review of Level 2 through to Level 4 studies

There is an unquestionable need for quantitative biomarkers of mild traumatic brain injuries. Something that is particularly true for adolescents – where the recovery from these injuries is still poorly understood. However, within this population, it is clear that the vasculature is distinctly affected by a mild traumatic brain injury. In addition, our group recently demonstrated how that effect appears to show a progression of alterations similar but in contrast to that found in severe traumatic injuries. Through measuring an adolescent population with transcranial Doppler ultrasound during a hypercapnia challenge, multiple phases of hemodynamic dysfunction were suggested. Here, we create a generalized model of the hemodynamic responses by fitting a set of inverse models to the dominant features from that work. The resulting model helps define the multiple phases of hemodynamic recovery after a mild traumatic brain injury. This can eventually be generalized, potentially providing a diagnostic tool for clinicians tracking patient’s recovery, and ultimately, resulting in more informed decisions and better outcomes.

Summary Introduction Germline-inactivating DICER1 mutations are responsible of a familial tumour susceptibility syndrome with an increased risk of tumours, mainly pleuropulmonary blastoma (PPB). DICER1 mutations also cause a range of other tumours, some of them in urogenital organs (cystic nephroma [CN], ovarian sex cord-stromal tumours, bladder and cervix embryonal rhabdomyosarcoma [ERMS]). Objective The aim was to clarify the range of urogenital phenotypes associated with DICER1 mutations and to give practical course of action to paediatric urologist that are exposed to DICER1-related conditions. Study design A literature review was performed. Pertinent papers focused on urogenital diseases associated with DICER1 mutations were reviewed. Results Seventy per cent of CN have a DICER1 germline mutation. The majority of them (80%) have PPB. Like PPB, CN could undergo a malignant progression to a primitive sarcoma. Some rare cases of Wilms tumours were reported. Regarding gonadal manifestations, sex-cord stromal neoplasia of the ovary, especially Sertoli–Leydig cell tumour (SLCT), is the most frequent tumour associated with DICER1 germline mutation. Germline DICER1 mutations also predispose to uterine cervix and bladder ERMS. Discussion The presence of unusual tumours suggesting DICER1 mutations may alert clinicians. The first step is to obtain a complete familial history. The variable clinical presentation and the modest penetrance raise concerns about the appropriateness of genetic testing to patients and their relatives. The education of DICER1 mutations carriers about tumour-related symptoms is consensual. In the first 5 years of life, a yearly chest X-ray and abdominal ultrasound are recommended. Conclusion The presence of a CN, ovarian SLCT or urogenital ERMS in a child should alert the clinician to the possibility of DICER1 mutation and the associated risk of PPB. Individuals with one of the typical DICER1 conditions should be offered DICER1 analysis. Despite the low penetrance, a genetic counselling and testing should be offered to the family of the affected child.

Objectives To assess concurrent validity of the new, novel externally-fixed dynamometer (GroinBar) with hand-held dynamometry (HHD); to provide normative GroinBar scores for elite Australian rules football (AFL) and football (Soccer) players; and to evaluate preliminary predictive validity of the GroinBar and HHD in this population by comparing strength results with patient-reported outcome scores. Design Cross-sectional and reliability study Participants Total of 67 athletes, 36 AFL players and 31 football (Soccer) players Setting Elite AFL and football (Soccer) teams Main Outcome Measures The GroinBar system, HHD, The Copenhagen Hip and Groin Outcome Score (HAGOS) Questionnaire. Results Moderate to good correlations were identified between the GroinBar and HHD strength tests for hip adduction and abduction in the long lever position (rs 0.53 – 0.71). Normative values of the GroinBar and HHD for both AFL and football (Soccer) players were obtained. Neither the GroinBar or HHD strength measures differed between players with groin problems and those without. Conclusion This externally fixed strength testing device, the GroinBar, may provide a robust method of athlete monitoring and screening that does not rely on tester experience and strength. Normative values are documented for hip adduction and abduction strength in elite male athletes.

Background Circumcision is the most common surgical procedure performed on boys in Australia. Patient presentations to the emergency department (ED) following circumcision are common; however, no Australian research has investigated acute care presentations. Objectives To identify reasons for presentation to the ED after circumcision and determine whether the setting (community vs. hospital) in which the procedure had been performed has any bearing on the sequelae seen. Methods Retrospective chart review of children presenting with circumcision related problems to the Royal Children's Hospital, Melbourne, Australia, between 2012 and 2014. Descriptive and χ2 analysis included sequelae of community- versus hospital-performed procedures. Results Over a 29-month period, we identified 167 children with a circumcision-related ED presentation. Mean age was 3 years. A percentage of 54.5 had been performed for non-medical, 29.9% for medical reasons and 14.4% for reasons unknown. When location was known (n = 152), 60.5% were performed in the community and 39.5% in hospital. Reasons for presentation were: bleeding (53.9%), pain (38.3%), swelling (37.1%), redness (25.7%), decreased urine output (13.8%), fever (7.2%) and pus (6%). 29.9% were diagnosed as normal healing post circumcision. Patients were admitted in 39.1% versus 15% (P = 0.001) and re-operated in 18.5% versus 1.7% (P = 0.001) after community- versus hospital-operated circumcisions. Conclusions A range of reasons cause patients to seek help in the ED following a circumcision. Parents would have profited from better explanation of post-circumcision appearance of the penis. ED presentations after community-performed procedures required more re-operations than after hospital-performed circumcisions.

Background Pedicle screws are often used for spinal fixation. Increasing the percentage of pedicle that is filled with the screw presumably yields greater fixation. It has not been shown whether spinal navigation helps surgeons more completely fill their instrumented pedicles. Methods Fifty consecutive patients from each arm (navigated and free-hand) were retrospectively reviewed. The cross-sectional area of each instrumented lumbar pedicle and screw were measured using an automatic area calculation tool. The coronal images and measurements were blinded to the surgeons. Results The instrumented pedicles in the navigated patients were significantly more filled by screws than the pedicles in the non-navigated patients (P

Objective: To determine normal ranges for traditional transcranial Doppler (TCD) measurements for two age groups (14–19 and 20–29 years) and compare to existing literature results. The development of a normal range for TCD measurements will be required for the development of diagnostic and prognostic tests in the future.

To compare the clinimetric properties of the de Morton Mobility Index (DEMMI®) and the Elderly Mobility Scale (EMS).A head-to-head comparison of the EMS and DEMMI® with 120 consecutive older acute medical patients. The DEMMI® and EMS were administered within 48 h of hospital admission and discharge.At admission, 6% and 15% of participants scored the lowest scale score for the DEMMI® and EMS, respectively. For the DEMMI®, 17% of participants scored within the minimal detectable change of the lowest scale score compared to 20% for the EMS at admission. At hospital discharge, DEMMI® scores were normally distributed and the EMS had a ceiling effect. Similar evidence of convergent, discriminant and known groups validity were obtained for the DEMMI® and EMS. There was no significant difference in responsiveness to change between the DEMMI® and EMS. The EMS was significantly quicker to administer compared to the DEMMI®.The DEMMI® and EMS are both valid measures of mobility for older acute medical patients. The DEMMI® has a broader scale width than the EMS with interval level measurement and therefore provides a more accurate method for measuring and monitoring changes in mobility for older acute medical patients. Implications for Rehabilitation Mobility of older acute medical patients. Hospitalised older acute medical patients are at "high risk" of mobility decline. Accurate measurement of mobility is essential for preventing and treating mobility decline. Many existing mobility measures have significant measurement limitations. The DEMMI® is a more accurate measure of mobility than the EMS in an older acute medical population.

Study Design Multicenter matched case analysis. Objective Compare patients with Lenke 5C scoliosis surgically treated with anterior spinal fusion with dual rod instrumentation and anterior column support versus posterior release and pedicle screw instrumentation. Summary of Background Data Treatment of single, structural, lumbar and thoracolumbar curves in patients with adolescent idiopathic scoliosis (AIS) has been the subject of some debate. Previous papers directly comparing these approaches are problematic because of heterogeneity of the groups, nonrandomized protocols, and surgeon bias and variation of instrumentation (upper instrumented vertebrae and lower instrumented vertebrae) in relation to the defined Cobb angle (upper end vertebra and lower end vertebrae). This report sought to remedy these flaws by analyzing a database of Lenke 5C AIS and performing matched cases. Methods We analyzed 96 patients with Lenke 5C AIS curves based on radiographic and clinical data at 3 institutions, surgically treated between 2001 and 2005 with minimum 2-year follow-up. Case matched criteria (age within 1 year, sex, curve within 5°, lower end vertebrae, and lower instrumented vertebrae) yielded 21 matched patient pairs. We evaluated and compared multiple clinical and radiographic parameters. Results We observed no significant statistical differences between groups in any preoperative clinical or radiographic parameters. At final follow-up, the major curve measured 8° (83%) in the posterior spinal fusion group, compared with 13° (72%) in the anterior spinal fusion group (p = .002). Estimated blood loss was similar in both groups. Hospital stay was significantly shorter in the posterior spinal fusion group. There were no differences in radiographic complications, such as proximal junctional kyphosis. Conclusions At a minimum of 2 years' follow-up in a multicenter, matched case analysis, adolescents with Lenke 5C curves demonstrated statistically significantly better curve correction and shorter hospital stays when treated with a posterior release with pedicle screw instrumented fusion compared with an anterior instrumented fusion with dual rods for similar patient populations.

Summary Objectives Peritoneal dialysis (PD) is the modality of choice for children with end-stage renal disease (ESRD) awaiting renal transplant; however, this option is sometimes avoided for those with previous laparotomy. The goal of this study was to compare the outcomes of PD in patients with and without previous laparotomy. Patients and methods Twenty-four patients who had been started on peritoneal dialysis were retrospectively analysed. Group LAP consisted of six patients with previous laparotomy, and Group NO-LAP of 18 controls with either retroperitoneal or no abdominal surgery. The percentage of theoretical maximum volume of infusion, time to reach it, complications (infection and drainage difficulties), and number of catheters needed to finish therapy were analysed. Results The characteristics of patients and technique of insertion are presented in Table. The percentage of maximum theoretical volume of infusion was similar in both groups. Median of catheter survival was similar in both groups. Complications were divided into malfunction (slow drainage, obstruction or leak) and infection. Incidence of complications per catheter and per month of dialysis was ten times lower in Group NO-LAP. Peritoneal dialysis failed in one patient with recurrent intraperitoneal adhesions after adhesiolysis in Group LAP. Conclusion Despite a higher incidence of complications (malfunction and infections), PD remains an acceptable option after laparotomy. In this series, it was sufficient in achieving adequate filtration in five patients. Table . Characteristics of patients, details of catheter use and complications, and overall efficacy of PD in both groups. Total 24 patients Median age (m) at insertion Median weight (kg) at insertion Technique of insertion: laparoscopic Median delay before 1st use (d) Median percentage of maximum theoretical volume Complications Median of catheter survival (m Efficacy 1400 ml/m2 if >2 y 40 ml/kg Malfunction Infection 800 ml/m2 if LAP (n = 6) 114 (5.5 m–15 y) 24.6 (3.8–37.5) 4 patients 1.5 (1–3) 86% 83% 1 per 23 months of dialysis 0.01 per catheter per month 1 per 17 months of dialysis 0.01 per catheter per month 12 m (1 w–2 y) 5 of 6 patients NO-LAP (n = 18) 133.5 (1 w–16.5 y) 33.1 (4–41.8) 14 patients 1 (1–45) 77% 86% 1 per 31 months of dialysis 0.001 per catheter per month 1 per 27 months of dialysis 0.001 per catheter per month 11.5 m (2 w–3 y) 18 of 18 patients

Background Although adult cervical spine deformity (ACSD) is associated with pain and disability, its health impact has not been quantified in comparison to other chronic diseases. Objective To perform a comparative analysis of the health impact of symptomatic ACSD to US normative and chronic disease values using EQ-5D (EuroQuol-5 Dimensions questionnaire) scores. Methods ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Baseline demographics and EQ-5D scores were collected and compared with US normative and disease state values. Results Of 121 ACSD patients, 115 (95%) completed the EQ-5D (60% women, mean age 61 years, previous spine surgery in 44%). Diagnoses included kyphosis with mid-cervical (63.4%), cervico-thoracic (23.5%), or thoracic (8.7%) apex and primary coronal deformity (4.3%). The mean ACSD EQ-5D index was 0.511 (standard definition = 0.224), which is 34% below the bottom 25th percentile (0.780) for similar age- and gender-matched US normative populations. Mean ACSD EQ-5D index values were worse than the bottom 25th percentile for several other disease states, including chronic ischemic heart disease (0.708), malignant breast cancer (0.708), and malignant prostate cancer (0.708). ACSD mean index values were comparable to the bottom 25th percentile values for blindness/low vision (0.543), emphysema (0.508), renal failure (0.506), and stroke (0.463). EQ-5D scores did not significantly differ based on cervical deformity type ( P = .66). Conclusion The health impact of symptomatic ACSD is substantial, with negative impact across all EQ-5D domains. The mean ACSD EQ-5D index was comparable to the bottom 25th percentile values for blindness/low vision, emphysema, renal failure, and stroke.

Background Effective bladder emptying by clean intermittent catheterization for children with severe bladder dysfunction is critical for renal preservation and social integration. Use of a continent catheterizable conduit (CCC) as urethral alternative procedure provides effective bladder drainage. However, it brings a substantive maintenance. Methods Retrospective review of the indications and long-term outcomes of 54 patients with a Mitrofanoff procedure in a single center over a 20-year period (1995–2015). Results Indications of CCC include 21 neurogenic bladders, 12 patients with epispadias/exstrophy, 13 bladder outlet obstruction, 6 malignancies and 2 cloaca. Median age at surgery was 8.3years (4months–20years). The appendix was used in 76% of cases. Most frequently encountered complication was stomal stenosis (n=17/34, 50%), occurring at median time of 9months (2months–13years). The other complications were: leakage in 9 (26.5%); conduit stricture in 5 (14.7%), angulation of the conduit in 2 (5.8%) and prolapse in one (3%). Operative revision was encountered by 33 (61%) patients, the majority in the first 2years. Median follow-up was 4.3years (3months–16years). Conclusions CCC has a high incidence of complication. It has to be used only when the native urethra is not suitable for catheterization. Carers, patients and families must be prepared to deal with both the complexity of index conditions and the complications of this procedure.

Summary Objective To report a case of juxtaglomerular cell tumour of the kidney (reninoma) in a child treated with laparoscopic nephron-sparing surgery. Patients and results A 14-year-old girl was incidentally found to have hypertension (180/114 mmHg) at the time of adenotonsillectomy. Pre-operative investigations revealed a plasma renin level of 225.9 ng/dl (4.4–46), normal aldosterone, cortisol and urinary catecholamine. Abdominal ultrasound detected a 1.9 × 1.5-cm hypoechoic lesion in the right kidney lower pole; CT scan confirmed the presence of a 1.5-cm, circumscribed, solid, hypoenhancing cortical lesion in the right lower pole. Laparoscopic nephron-sparing surgery was accomplished by clamping the renal artery for 30 min; after excision, the tumour bed was closed using barbed V-loc sutures. The procedure was completed laparoscopically in 150 min with no peri-operative complications. The patient was discharged home on day 4 postoperatively. Histology confirmed the diagnosis of a juxtaglomerular cell tumour that was completely excised. The J-J stent was removed 1 month later. At follow-up, the patient's blood pressure was normalized and medications were stopped. A DMSA scan confirmed 36% residual right kidney function. Conclusion Laparoscopic nephron-sparing surgery should be considered in children with juxtaglomerular tumours. This technique allows prompt recovery with preservation of significant renal function.

Long-term outcomes of hypospadias surgery, particularly urinary function, have not been examined thoroughly. Uroflowmetry can be used to evaluate long-term functional outcomes by assessing flow shape and the rate of micturition. We assessed urethral function using uroflowmetry in adolescents after undergoing hypospadias repair in infancy and compared this with age matched controls.After human research ethics committee approval (HREC 28111A), 17 boys 13 to 15 years old with no history of urological or neurological disorders underwent uroflowmetry (65 separate voids) to determine standard values for boys of this age. Then 60 boys age 13 to 15 years who had undergone treatment for hypospadias in early infancy were seen for long-term followup and underwent uroflow assessment.Standard urinary flow rates were established in the 13 to 15-year-old control group and represented on a nomogram. In the boys who underwent hypospadias surgery the urine flow rates were significantly lower compared to the control nomogram (p0.0001), with half the patients having uroflow rates below 1 SD from the control mean but without symptoms. Boys with significant preoperative chordee were more likely to have poorer urinary flow (p0.04). A poor urinary flow rate also was significantly associated with post-void residual bladder volume (p0.03). There was no correlation with original meatal location, number of operations, presence of postoperative complications, current anatomy and lower urinary tract symptoms (eg post-void dribble, hesitancy, incontinence).At long-term followup after hypospadias surgery urinary flow rates were significantly lower compared to age matched controls but still fell within the normal range. In the hypospadias cohort there was no significant association with lower urinary tract symptoms and poor urinary flow. Detection of poor urinary flow may indicate incomplete bladder emptying. The presence of severe chordee preoperatively is a significant risk factor for poor urinary flow rates on long-term followup.

Summary Introduction Prader–Willi syndrome (PWS) is a rare (1:20.000) genetic condition affecting both males and females. Among other features, in boys, the syndrome is characterized by cryptorchidism in 86–100% of cases, hypogonadism, delayed puberty and infertility. The aim of the present study is to appraise the results of orchidopexy in this selected population of children. Study design A follow-up study of children with PWS treated for undescended testes at a single institution over a 20-year period was performed. Patients were identified from a National PWS registry and reviewed at a special follow-up clinic. Data were collected from electronic and hard copies records and reported as median (range). Results Thirty-three children (1–17 years) were identified. Co-morbidities were present in 22 (66%) and 15 (45%) were on growth-hormone therapy. Six patients (19%) had normal testes palpable in the scrotum; twenty-seven (81%) had undescended testes and required orchidopexy. Thirteen (48%) underwent a bilateral procedure for a total of 40 procedures. A 2-stage Fowler-Stephens orchidopexy was required in 2 (7%) testes. At surgery hypotrophic testes were documented in 6 (22%) patients. Age at orchidopexy was 1.4 years (0.5–5.5). Age at F U was 7.2 years (1.7–17). Length of follow-up is 3.5 years (0.4–14). At follow-up 16 (40%) testes were of normal size and palpable in the scrotum; 7 (17.5%) testes required redo-orchidopexy. All patients (6/33) over 16 years of age that had testosterone levels tested had values below normal limits after successful orchidopexy. Conclusions This study evaluates the results of orchidopexy in a large population of children with PWS. At follow-up, only 40% of testes were of normal size and in the scrotum. This information should be taken into consideration for patients' management and pre-operative parents' counseling. Findings at follow-up (40 testes) Number (%) Normal testes in scrotum 16 (40) Hypotrophic testes in scrotum 8 (20) Testes in inguinal canal 10 (25) Non-palpable testes 4 (10) Atrophic testes in scrotum 2 (5) Redo-orchidopexy 7 (17.5)

We evaluated long-term outcomes in boys treated for hypospadias at Royal Children's Hospital, Melbourne.Boys who underwent hypospadias surgery were reviewed at ages 13 to 15 years. Surgical results were evaluated using the Hypospadias Objective Scoring Evaluation. Lower urinary tract function was assessed using uroflowmetry and symptom questionnaire. Self-report surveys measured quality of life, patient satisfaction, memory of surgery, psychosexual outcomes and parent satisfaction with care.By Hypospadias Objective Scoring Evaluation score 80% of patients had an excellent surgical outcome. Two independent reviewers assessed lower urinary tract function as normal in 82% and 86% of cases, respectively. Quality of life scores were comparable to published values in normal children. Parents rated the institution highly. Overall 90% and 81% of boys were satisfied with the body and genital appearance, respectively. Those dissatisfied with genital appearance had poorer psychosexual outcomes than satisfied patients. When surgery was completed before age 5 years, boys had no perioperative memories. An association was found between no recollection of surgery and satisfaction with body appearance.Objective surgical and functional outcomes are excellent after early surgery. Post-repair quality of life is comparable to published data on normal children. Parents are pleased with care. Most boys are satisfied with the body and genital appearance. However, those dissatisfied with genital appearance must be identified in the interest of psychosexual development. The association between no recollection of treatment and satisfaction with body appearance suggests that surgery should be completed before age 5 years when possible to allow the development of good body image in adolescence.

No consensus exists regarding the precise role of testicular biopsy in prepubertal boys, although it is considered useful for assessing the potential consequences of undescended testes on fertility. Current scientific knowledge indicates that surgeons should broaden indications for this procedure. For example, the use of immunohistochemical markers such as OCT/3-4, TSPY, Kit ligand (SCF) and ALPP (PLAP) has considerably facilitated the detection of germ cell tumour precursors, such as carcinoma in situ and/or gonadoblastoma. These markers are very important for evaluating malignancy risk in undervirilized patients with 46,XY disorders of sexual development. Testicular histology is also of considerable value in the prediction of both fertility potential and risk of cancer in individuals with undescended testes, particularly those with intraabdominal undescended testes. New possibilities for the preservation of fertility after gonadotoxic chemotherapy - even for prepubertal boys - are emerging. Cryopreservation of testicular tissue samples for the preservation of fertility - although still an experimental method at present - is appealing in this context. In our opinion, testicular biopsy in prepubertal boys is a minor procedure that can provide valuable information for predicting the risk of malignancy and fertility, and might be useful in fertility preservation in the near future.

Summary Objective Bladder perforation is not commonly described in bladder exstrophy patients without bladder augmentation. The goal of this study was to identify the risk factors of spontaneous perforation in non-augmented exstrophy bladders. Methods The study was a retrospective multi-institutional review of bladder perforation in seven male and two female patients with classic bladder exstrophy–epispadias (E–E). Results Correction of E–E was performed using Kelly repair in two and staged repair in seven (Table). Bladder neck repair was performed in eight patients at a mean age of 6 years. Three patients had additional urethral surgery. Before rupture, six patients were voiding only per urethra. Two patients were voiding urethrally but were also performing occasional CIC via a Mitrofanoff. One patient was performing CIC 3 hourly per urethra. Six were dry during the day. Six of the patients had lower urinary tract symptoms: five had frequency and four were straining to void. Two had suffered episodes of urinary retention. Pre-rupture ultrasound showed that the upper urinary tract was dilated in four patients. Micturating cystourethrogram was performed in six showing vesico-ureteral reflux in five. Two had urethral stenosis. Nuclear medicine was done in three patients with two abnormal differential function. Urodynamics was performed in two patients with low capacity (100 mL) and hypocompliant ( Conclusions The limitations of this series include the small number of patients and its retrospective nature, without knowledge of the incidence. Bladder rupture is a risk even in non-augmented bladder exstrophy. It is potentially life-threatening and most often requires laparotomy. Rupture occurs because of poor bladder emptying and/or high pressure. Urodynamics may identify those at risk. CIC with or without augmentation should not be delayed once poor bladder emptying and/or high pressure are identified. Table . Patients with bladder perforation. Pt Pre-rupture imaging Pre-rupture continence Age, years Management Outcome 1 Small right kidney with high-grade VUR and high PVR 90 min voiding with episodes of retention 13 Laparotomy IDC 3 weeks Refused augmentation and Mitrofanoff. Recurrent bladder rupture 2 Small left kidney (15% df) with high-grade VUR and high PVR. Poorly compliant bladder on urodynamics Straining to void with frequency 8 Laparotomy and bladder neck closure with SPC Augmentation and Mitrofanoff 3 Trabeculated bladder Straining to void. High PVR. Incontinent 5 Laparotomy SPC 3 weeks Refused Mitrofanoff. Ongoing straining and lost to f/u 4 Trabeculated bladder, low-grade VUR bilaterally and urethral stenosis 2–3 hourly voiding with straining. High PVR 20 SPC with prolonged drainage No further surgery or recurrences known 5 Bilateral HUN 3 hourly voiding with high PVR 15 Laparotomy IDC 3 weeks No further surgery or recurrences known 6 Normal USS Voiding and dry on desmopressin and oxybutynin 11 Laparotomy IDC 3 weeks Augmentation with Mitrofanoff 7 Bilateral HUN with high-grade VUR. Poorly compliant bladder on urodynamics CIC 3 hourly 9 Laparotomy SPC Augmentation with Mitrofanoff. Bladder stone post augment 8 Bilateral HUN with high-grade VUR and reduced function on left Voiding with day and night wetting. Occasional CIC via Mitrofanoff 8 Laparotomy. Drainage via Mitrofanoff Augmentation. Recurrent rupture near the anastomosis of the augment 9 Normal USS. Bladder capacity 100 mL. Low compliance Voiding with day and night leaking. Occasional CIC via Mitrofanoff 10 Laparotomy. Drainage via Mitrofanoff Augmentation, redo Mitrofanoff (Monti) CIC, clean intermittent catheterization; HUN, hydroureteronephrosis; IDC, indwelling catheter; Pt, patient; PVR, post void residual; R, rupture; SPC, suprapubic catheter; USS, ultrasound; VUR, vesicoureteric reflux.

Summary Introduction Although two-stage graft urethroplasty is widely used, the literature regarding the complication rates and functional characteristics of reconstructed neourethra is relatively modest. Objectives The aim was to analyze the complication rates and uroflow data of boys who have previously undergone a two-stage graft urethroplasty procedure for proximal and complicated hypospadias. Patients and methods We retrospectively reviewed the clinical outcomes of 52 boys with proximal (n = 44) and complicated (n = 8) hypospadias who underwent two-stage graft urethroplasty repair (median age of 15 months and 3 years respectively) between 2004 and 2015. Fifteen toilet-trained boys without fistulas underwent uroflowmetry. The uroflow data were plotted on age–volume-dependent normograms with normal controls. The median follow-up was 34 months (8 months–8 years). Results and complications Complications were identified in three patients (6%) after the first stage (i.e. contracture of the graft) and in 20 patients (38.4%) after the second stage, including meatal stenosis (n = 8, 15.3%), urethral stricture (n = 4, 7.6%), urethrocutaneous fistula (n = 8, 15.3%), glandular dehiscence (n = 1, 1.9%), and diverticulum (n = 1, 1.9%). The patients with failed hypospadias experienced fewer complications than those who underwent the two-stage procedure for primary repair (25% and 45%, respectively). The reoperation rate was 36.8%. Eleven of the 15 toilet-trained boys were asymptomatic but exhibited flow rates below the normal range (median Qmax = 7 mL/s, range 3.5–16.7). Only one of the boys with a low flow rate was confirmed to have urethral stenosis under general anesthesia. Discussion In our study, primary hypospadias repair requiring urethral plate transection elicited worse outcomes than those observed in the prior failed hypospadias cases. However, because of our study's retrospective design, we were unable to accurately assess the initial position of the meatus in the redo hypospadias cases. Our data also demonstrated that the majority of cases without any voiding symptoms exhibited flow rates that were below the normal range despite no urethral stricture under general anesthesia. These findings indicate that urethras reconstructed via two-stage graft urethroplasty repair are not functionally equivalent to normal urethras, at least prior to puberty. Conclusion Two-stage graft urethroplasty repair was successful in 62% of cases after the second-stage procedure, but one-third of the boys required a reoperation after the two-stage planned repair. We demonstrated that although we used a urethral tissue substitute, the urine flow patterns of the patients without strictures were abnormal. Table . Two-stage graft urethroplasty repair for proximal or complicated hypospadias. Two-stage graft urethroplasty repair (n = 52), proximal hypospadias (n = 44), or complicated hypospadias (n = 8) Complications (n = 23) Contraction of the graft 3 (6%) Meatal stenosis 8 (15.3%) Urethral stricture 4 (7.6%) Urethrocutaneous fistula 8 (15.3%) Glanular dehiscence 1 (1.9%) Diverticulum 1 (1.9%) Follow-up 34 months (range 8 months to 8 years) Uroflow data (n = 15) Qmax (mL/s) 9.3 ± 0.7 Voided volume (mL) 109.8 ± 4.5 Flow rate (s) 25.4 ± 2.9 Plateau sharped curve 11 (73%)

OBJECT Despite the complexity of cervical spine deformity (CSD) and its significant impact on patient quality of life, there exists no comprehensive classification system. The objective of this study was to develop a novel classification system based on a modified Delphi approach and to characterize the intra- and interobserver reliability of this classification. METHODS Based on an extensive literature review and a modified Delphi approach with an expert panel, a CSD classification system was generated. The classification system included a deformity descriptor and 5 modifiers that incorporated sagittal, regional, and global spinopelvic alignment and neurological status. The descriptors included: “C,” “CT,” and “T” for primary cervical kyphotic deformities with an apex in the cervical spine, cervicothoracic junction, or thoracic spine, respectively; “S” for primary coronal deformity with a coronal Cobb angle ≥ 15°; and “CVJ” for primary craniovertebral junction deformity. The modifiers included C2–7 sagittal vertical axis (SVA), horizontal gaze (chin-brow to vertical angle [CBVA]), T1 slope (TS) minus C2–7 lordosis (TS–CL), myelopathy (modified Japanese Orthopaedic Association [mJOA] scale score), and the Scoliosis Research Society (SRS)-Schwab classification for thoracolumbar deformity. Application of the classification system requires the following: 1) full-length standing posteroanterior (PA) and lateral spine radiographs that include the cervical spine and femoral heads; 2) standing PA and lateral cervical spine radiographs; 3) completed and scored mJOA questionnaire; and 4) a clinical photograph or radiograph that includes the skull for measurement of the CBVA. A series of 10 CSD cases, broadly representative of the classification system, were selected and sufficient radiographic and clinical history to enable classification were assembled. A panel of spinal deformity surgeons was queried to classify each case twice, with a minimum of 1 intervening week. Inter- and intrarater reliability measures were based on calculations of Fleiss k coefficient values. RESULTS Twenty spinal deformity surgeons participated in this study. Interrater reliability (Fleiss k coefficients) for the deformity descriptor rounds 1 and 2 were 0.489 and 0.280, respectively, and mean intrarater reliability was 0.584. For the modifiers, including the SRS-Schwab components, the interrater (round 1/round 2) and intrarater reliabilities (Fleiss k coefficients) were: C2–7 SVA (0.338/0.412, 0.584), horizontal gaze (0.779/0.430, 0.768), TS-CL (0.721/0.567, 0.720), myelopathy (0.602/0.477, 0.746), SRS-Schwab curve type (0.590/0.433, 0.564), pelvic incidence-lumbar lordosis (0.554/0.386, 0.826), pelvic tilt (0.714/0.627, 0.633), and C7-S1 SVA (0.071/0.064, 0.233), respectively. The parameter with the poorest reliability was the C7–S1 SVA, which may have resulted from differences in interpretation of positive and negative measurements. CONCLUSIONS The proposed classification provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters. The intra- and interobserver reliabilities suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification.

Study design With institutional review board approval, prospective data were collected during fluoroscopically guided pedicle screw placement. Objective To estimate a surgeon's radiation exposure with all screw constructs during surgery to repair idiopathic scoliosis. Summary of background data To our knowledge, there is no established consensus regarding the safety of radiation exposure during fluoroscopically guided procedures. Methods A surgeon was outfitted intraoperatively with a thermoluminescent dosimeter to estimate radiation exposure to his whole body and thyroid gland. Results The index surgeon is projected to receive 13.49 mSv of whole body ionizing radiation and 4.31 mSv of thyroid gland irradiation annually. The National Council on Radiation Protection's current recommendations set lifetime dose equivalent limits for classified workers (radiologists) at 10 mSv per year of life and at 3 mSv for nonclassified workers (spinal surgeons). At the levels estimated, a surgeon beginning his/her career at age 30 years would exceed the lifetime limit for nonclassified workers in less than 10 years. The National Council on Radiation Protection limits the single-year maximum safe dosage to the thyroid to 500 mSv; the yearly exposure estimated here is significantly less. Conclusions The spinal surgeon's intraoperative radiation exposure may be unacceptable. Spinal surgeons should be considered classified workers and monitored accordingly. Methods to lower radiation dosage seem strongly indicated.

STUDY DESIGN: Interventional study. OBJECTIVE: To analyze the histologic effects of high-dose human equivalent methylprednisolone on the pulmonary, cardiac, intestinal, renal, hepatic, and splenic tissues in a spinal cord injury rat model. SUMMARY OF BACKGROUND DATA: There are numerous investigations of various medical interventions for the treatment of acute spinal cord trauma. Currently, the only generally accepted medical intervention in an acute spinal cord trauma is the intravenous administration of high doses of methylprednisolone. Although it has been nearly 2 decades since the first National Acute Spinal Cord Injury Study investigated the role high-dose steroids might play in the treatment of acute spinal cord trauma, controversy still exists regarding the efficacy of this treatment. To our knowledge, no study has examined the role of high-dose methylprednisolone in organ systems other than the spinal cord in an acute spinal cord injury model at the histologic level. This study attempts to characterize end organ histologic response to human dose equivalent (HDE) intravenous methylprednisolone administration in a rodent model of acute spinal cord injury. METHODS: A total of 48 Sprague-Dawley rats were divided equally into control and experimental groups. Each group was subdivided into 6 sets of 4 animals each, according to intervals after injury. Groups 1-6 consisted of animals euthanized at 0, 4, 8, 16, 24, and 48 hours after spinal cord injury. Paraplegia after lower thoracic laminectomy was achieved using a standardized Allen weight drop technique. Within 1 hour of injury, experimental animals were treated with HDE methylprednisolone, infused for 23 hours continuously. Liver, kidney, lung, intestine, spleen, and heart were harvested at variable intervals after injury and prepared for histologic examination. These slides were analyzed with microscopic staining techniques and compared in a blinded manner by a qualified pathologist. RESULTS: Of all the end organs analyzed, the spleens were most affected. Lymphocytic depletion was seen in as little as 4 hours after methylprednisolone infusion and continued until 48 hours. Pulmonary tissues variably showed interstitial congestion and eosinophilic alveolar collections. Intestinal mucosal tissues showed edema and autolyzed mucosa from 16 hours onwards. Cardiac, kidney, and hepatic tissue did not differ significantly from controls. CONCLUSIONS: Histologically, HDE methylprednisolone caused significant splenic lymphocytic depletion changes in as little as 4 hours. This trend of end organ lymphocytopenia continued to progress until 48 hours. Pulmonary eosinophilic infiltrates were seen from 8 until 24 hours. Intestinal mucosal edema and necrosis were seen in samples at 16 hours throughout 48 hours. This study was designed to evaluate end organ changes seen in an animal model of an acute spinal cord injury treated with HDE methylprednisolone. Study animals were infused with HDE methylprednisolone given according to the National Acute Spinal Cord Injury Study II protocol. The kidney, lung, cardiac, intestinal, splenic, and hepatic tissues from the aforementioned animals were then sectioned and analyzed using histologic staining techniques by a qualified pathologist.

Study Design. This ongoing longitudinal study evaluates simultaneous radiographic and platelet calmodulin determinations for patients with idiopathic scoliosis who are skeletally immature. Objectives. To determine whether platelet calmodulin levels correlate with curve progression and severity. Summary of Background Data. A previous study based on a single calmodulin determination and a single radiograph identified higher calmodulin levels in progressive curves and in higher magnitude curves. A longitudinal study was needed to demonstrate the relation of calmodulin to curve changes for individual patients over time during the growth period. Methods. In this study, 55 patients with idiopathic scoliosis of varying types and severity were followed longitudinally with serial radiographs and platelet calmodulin determinations. A Risser sign was recorded for each radiograph at each visit. Results. Calmodulin levels increased in all the patients with progressive curves (13/13), remained stable in 73% of the patients with nonprogressive curves (11/15), and were higher generally in curves greater than 30° and double structural curves. Calmodulin levels usually decreased in patients undergoing brace treatment (14/17) or spine fusion (9/10). Conclusions. It appears that platelet calmodulin levels correlate closely with curve progression and stabilization by bracing or spine fusion. Correlation with nonprogressive curves was not as consistent, with 27% noncorrelation. Longer follow-up evaluation and enrollment of additional patients will be necessary to determine whether calmodulin may serve as a biochemical marker of curve progression and to help identify stable and progressive curves.

Oesophageal varices commonly develop in the setting of portal hypertension. A Sengstaken-Blakemore (SB) tube is sometimes emergently required to control oesophageal bleeding.1 ,2 The normal portal pressure varies from 5 to 10 mm Hg. Portal hypertension occurs when the portal pressure rises above 10 mm Hg. Pressures can rise up to 30 mm Hg, so the pressure exerted and maintained on the oesophageal balloon to tamponade the varices will need to be above 30 mm Hg. The current practice is to attach a 1 L bag of saline to the tube to maintain traction. However, there are risks associated with this method of traction. These risks include pharyngeal ulcers and mouth ulcers from the local pressure effect. We describe an alternative method of maintaining traction on the SB tube. We describe the practice of securing the tube with a pair of wooden tongue depressors and padding as shown in figure 1. This has been used by the lead author for 25 years with no adverse events. The patient population includes patients with oesophageal varices. The patients ranged from 18 to 85 years of age. Over 50 patients have been treated by the lead author using this method. Figure 1 Traction device in use on a patient. This is an alternative safe …

Background —Matrix metalloproteinase (MMP) activation contributes to tissue remodeling in several disease states, and increased MMP activity has been observed in left ventricular (LV) failure. The present study tested the hypothesis that MMP inhibition would influence LV remodeling and function in developing LV failure. Methods and Results —LV size and function were measured in 5 groups of rats: (1) obese male spontaneously hypertensive heart failure rats (SHHF) at 9 months (n=10), (2) SHHF at 13 months (n=12), (3) SHHF rats treated with an MMP inhibitor during months 9 to 13 (PD166793 5 mg · kg −1 · d −1 PO; n=14), (4) normotensive Wistar-Furth rats (WF) at 9 months (n=12), and (5) WF at 13 months (n=12). Plasma concentrations of the MMP inhibitor (116±11 μmol/L) reduced in vitro LV myocardial MMP-2 activity by ≈100%. LV function and geometry were similar in WF rats at 9 and 13 months. LV peak +dP/dt was unchanged at 9 months in SHHF but by 13 months was reduced in the SHHF group compared with WF (3578±477 versus 5983±109 mm Hg/s, P ≤0.05). LV volume measured at an equivalent ex vivo pressure (10 mm Hg) was increased in SHHF at 9 months compared with WF (443±12 versus 563±33 mL, P ≤0.05) and increased further by 13 months (899±64 mL, P ≤0.05). LV myocardial MMP-2 activity was increased by ≈2-fold in SHHF at 9 and 13 months. With MMP inhibition, LV peak +dP/dt was similar to WF values and LV volume was reduced compared with untreated SHHF values (678±28 mL, P ≤0.05). Conclusions —MMP activity contributes to LV dilation and progression to LV dysfunction in a rodent HF model, and direct MMP inhibition can attenuate this process.

A 3-week tour of the Far East was coordinated by Dr. Ronald DeWald, senior travelling fellow appointed by the Scoliosis Research Society. Three junior fellows appointed by the Education Committee of the Scoliosis Research Society accompanied him. The purpose of this fellowship was to develop a comaraderie and exchange ideas, thoughts, and experiences in the field of spinal deformity.

Summary Introduction Posterior urethral valves (PUV) are among the most common urological causes of chronic kidney disease (CKD) in childhood. Recently, genomic imbalances have been cited as potential risk factors for altered kidney function and have been associated with CKD. The phenotypic effects of a copy number variant (CNV) in boys with PUV are unknown. Here, it was hypothesised that the progression to early renal failure in PUV patients may be influenced by genetic aberrations. Objective To assess the relationship between CNVs and renal outcomes. Patients and methods Between September 2012 and July 2015, 45 children with PUV were recruited to evaluate the presence of CNVs in their DNA. The patients' medical records were retrospectively reviewed. The criteria for outcomes of renal function included: assessments of the nadir serum creatinine in the first year of life, the estimated glomerular filtration rate at 1 and 5 years, and the requirement for renal replacement. Results Thirteen CNVs were identified in 12 boys (29% of the cohort). Microarray analysis revealed two pathogenic CNVs (well-established CNVs known to be associated with genetic disease) and 11 of unknown significance (CNVs with insufficient current available evidence for unequivocal determination of clinical significance), including genes that have been previously implicated in kidney diseases and urogenital disorders. The median follow-up was 10.2 years (range 3–17.5) in the group of patients with CNV compared with 5.8 years (range 1–16.6) in those CNV−. The nadir creatinine values were significantly higher in boys with CNVs than in those without CNVs (57.5 μmol/L (range 23–215) and 28 μmol/L (range 18–155), respectively (P = 0.05) (Figure). Boys CNV+ had a worse prognosis, with a higher incidence of Stage-V CKD compared with the control group (33% with CNVs vs. 9% in CNV−, P = 0.06) at a median age of 22 months (range 8 months–16 years). Four (33%) patients CNV+ underwent renal transplantation. Discussion The role of CNVs in the deterioration of renal function remains unknown. It can be hypothesised that CNVs could be a contributing factor or may serve as an accelerant for the progression to renal failure. Conclusion The CNVs >100 Kb were significantly associated with early onset renal failure in children with PUV. Prenatal detection of CNV could help to identify foetuses at high risk of severe renal impairment in cases of suspected PUV, especially in cases without oligohydramnios or severe pulmonary hypoplasia. These preliminary results should be confirmed in a larger cohort of patients. Download : Download high-res image (121KB) Download : Download full-size image Summary Figure . Box plot graphic representation of nadir of creatinine value during the first year of life according to the presence of CNV (CNV+) or the absence of CNV (CNV−).

Atherosclerotic lesion development was assessed in the thoracic aorta and chronically denuded iliac-femoral artery of hypercholesterolemic New Zealand White rabbits using inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase which have previously been shown to possess varying degrees of hepatoselectivity in rats. Atorvastatin, previously known as CI-981 (2.5 mg/kg), PD135022 (1.0 mg/kg), simvastatin (2.5 mg/kg), lovastatin (2.5 mg/kg), PD134965 (1.0 mg/kg), pravastatin (2.5 mg/kg) and BMY22089 (2.5 mg/kg) were added to a 0.5% cholesterol, 3% peanut, 3% coconut oil diet and fed for 8 weeks. Although reductions in plasma total cholesterol of 27% to 60%, VLDL-cholesterol of 31% to 71% and plasma total cholesterol exposure of 37% to 43% were obtained, no correlation between these parameters and vascular lipid content, lesion size or monocyte-macrophage content was noted. Iliac-femoral lipid content was unchanged; however, atorvastatin and simvastatin significantly reduced the cholesterol content of the thoracic aorta by 45%-62%. Atorvastatin and PD135022 reduced the size of the iliac-femoral lesion by 67% and monocyte-macrophage content by 72%. Simvastatin, lovastatin and PD134965 decreased the monocyte-macrophage content; however, lesion size was unchanged. Pravastatin and BMY22089 had no effect on lesion size or content. No compound significantly reduced the extent of thoracic aortic lesions. We concluded that changes in plasma lipids and lipoproteins noted with the various HMG-CoA reductase inhibitors did not account for the beneficial effect on atherosclerotic lesion development. The antiatherosclerotic potential of the HMG-CoA reductase inhibitors was compound-specific and clearly not a class effect.

STUDY DESIGN Multicenter, retrospective study. OBJECTIVE To compare the outcomes of three surgical treatments for congenital spinal deformity due to a hemivertebra. SUMMARY OF BACKGROUND DATA Congenital anomalies of the spine can cause significant and progressive scoliosis and kyphosis. Their management may be challenging and controversy remains over the "best" surgical treatment. METHODS A multicenter retrospective study of patients with congenital spinal deformity due to 1 or 2 level hemivertebra(e) was performed. The surgical treatments included hemiepiphysiodesis or in situ fusion (group 1), instrumented fusion without hemivertebra excision (group 2), or instrumented hemivertebra excision (group 3). RESULTS Seventy-six patients with minimum 2-year follow-up were evaluated. The mean age was 8 years (range: 1-18). The hemivertebra were fully segmented, nonincarcerated (67%), incarcerated (1%), and semisegmented (32%). There were 65 patients with single hemivertebra and 11 patients with double hemivertebra. There were 14 (18.4%) group 1, 20 (26.3%) group 2, and 42 (55.3%) group 3 patients. Group 1 (37 ± 14°) and group 3 (35 ± 26°) patients had smaller preoperative curves than group 2 patients (55 ± 26°) (P < 0.01). Group 3 had better percent correction at 2 years than groups 1 and 2 (P < 0.001). Group 3 had shorter fusion (P = 0.001), less estimated blood loss (EBL, P = 0.03), and a trend toward shorter operative times than group 2 (P = 0.10). The overall complication rate for the entire group was 30% group 1 (23%), group 2 (17%), and group 3 (44%) (P = 0.09). CONCLUSION While hemivertebra resection for congenital scoliosis had a higher complication rate than either hemiepiphysiodesis/in situ fusion or instrumentated fusion without resection, posterior hemivertebra resection in younger patients resulted in better percent correction than the other two techniques.

An understanding of spinal mechanics is necessary for the treatment of athletic injuries. Recognizing and isolating the mechanism of injury through noninvasive techniques will lead to specific treatment for that injury. Because the prevention of physical injury is the goal of all health care professionals, the authors hope that the information will be helpful.

All-pedicle-screw constructs are safe and biomechanically advantageous in the management of adolescent idiopathic scoliosis. Safe and reproducible placement of thoracic pedicle screws is dependent on a thorough understanding of normal and abnormal anatomy, meticulous technique, and the use of neuromonitoring and fluoroscopy. Improvement in the biomechanical properties secondary to the use of pedicle screw fixation has led to shorter fusions with improved deformity correction. Coronal, sagittal, and rotational correction is superior to that obtained with hook instrumentation. Improved derotation may decrease the need for thoracoplasty, thus eliminating the risk of associated morbidity. Superior control of the deformity with all-pedicle-screw fixation, as well as the use of adjunctive posterior releases, often obviates the need for an anterior approach, even in severe curves measuring 70 degrees to 100 degrees . Improved correction, shorter fusion, and the lower morbidity associated with posterior-only approaches may compensate for higher implant costs.

The ethics of clinical research is based on several well-known guidelines and documents. The guidelines vary between countries, but the principles of respect for persons, beneficence, and justice are constant. These principles are reflected in requirements to obtain free and informed consent, to minimize risk or harm, and to not overly burden or disadvantage particular populations. For research to be ethical, it must also be of such a standard, and be conducted in such a manner that it will generate knew and useful knowledge. Children have limited capacity for understanding and may be more open to coercion. Therefore, they are regarded as a particularly vulnerable population, and specific clauses regarding children are incorporated into many guidelines. A key concept in these clauses is the degree of risk acceptable for children involved in research. While it is generally agreed that children require particular attention because of their vulnerability, there is also increasing concern that children in general should not be disadvantaged by lack of knowledge due to reduced research activity. Finally, an increasingly active area of research in children involves genetics and biobanking. Research in these areas raises new and challenging ethical issues.