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Purpose. To evaluate a time out based discipline strategy designed to decrease treatment avoidance in children with cystic fibrosis (CF) who displayed non-compliant behaviour to their parents' treatment requests. Method. A single-subject reversal design was used to compare baseline compliance when a time out based discipline strategy was in effect. Outcome measures included observational assessments of compliance, parent ratings of child treatment-related behaviour problems and parent reported preference for the time out strategy. Results. Greater compliance was demonstrated when the time out strategy was in place. Parents reported fewer treatment-related behaviour problems and desired less professional help for these problems upon completion of the study and reported preferring the time out discipline strategy to their typical child management strategy. Conclusions. This discipline strategy represents a practical and appealing brief intervention that is shown to help parents maximise their children's participation in life-extending treatments. This intervention minimises the need for parent-therapist interaction, which may be of particular importance to families of patients with CF who already devote significant time to medical appointments and interventions. The preliminary nature of this data and lack of reversal for one of the participants emphasise the need for additional research to replicate the findings. [ABSTRACT FROM AUTHOR]

Topical anesthetic and distraction are effective pain management techniques, yet they have not been fully evaluated for infants. Eighty-four 1-year-olds undergoing immunizations were randomized to distraction, topical anesthetic, or control. The 42 infants who returned for their 18-month injections were evaluated for long-term treatment gains. An observational scale revealed that infants demonstrated lower distress with distraction than topical anesthetic or control during the recovery phase of the injection at 12 months, and parents and nurses rated infants as more distressed at 12 than 18 months. Distress measures were positively associated across time. [ABSTRACT FROM AUTHOR]

This study evaluated the Measure of Adult and Infant Soothing and Distress (MAISD) for examining infant, parent, and nurse behavior during infants' immunizations. Videotapes of 62 infants, parents, and nurses during immunizations were coded. Concurrent validity and reliability for the MAISD were demonstrated. The scale revealed that infants displayed predominately distress, and adults exhibited primarily reassurance. Parents' and nurses' distractions were positively related to infants' engaging in distraction, and parents' and nurses' reassurance was positively associated with infants' distress. There appear to be avenues in which to intervene to teach parents and nurses how to best behave to help infants during their painful medical events. [ABSTRACT FROM AUTHOR]

African American college students reported their experiences with everyday forms of racism at a predominantly European American university using a daily diary format. Their reported incidents represented verbal expressions of prejudice, bad service, staring or glaring, and difficulties in interpersonal exchanges (e.g., rudeness or awkward and nervous behavior). Both women's and men's experiences with interpersonal forms of prejudice were common, often occurred with friends and in intimate situations, and had significant emotional impact on them in terms of decreasing their comfort and increasing their feelings of threat during the interaction. Moreover, anger was the most frequently reported emotional reaction to these events. Participants were not passive targets, however, with many responding either directly or indirectly to the incidents. Findings from this study converged upon patterns of results found in in-depth interviews and surveys while also adding information to a growing body of literature on everyday experiences with racism. [ABSTRACT FROM AUTHOR]

Evaluates research on treating pain in children and provides recommendations for future studies. Implications of the findings of several studies for the design of empirically derived treatment protocols; Need for studies that would provide information on the development of treatment interventions; Need to investigate the efficacy of combining pharmacological and psychological interventions.

Importance: The feasibility of implementing genome sequencing as an adjunct to traditional newborn screening (NBS) in newborns of different racial and ethnic groups is not well understood., Objective: To report interim results of acceptability, feasibility, and outcomes of an ongoing genomic NBS study in a diverse population in New York City within the context of the New York State Department of Health Newborn Screening Program., Design, Setting, and Participants: The Genomic Uniform-screening Against Rare Disease in All Newborns (GUARDIAN) study was a multisite, single-group, prospective, observational investigation of supplemental newborn genome screening with a planned enrollment of 100 000 participants. Parent-reported race and ethnicity were recorded at the time of recruitment. Results of the first 4000 newborns enrolled in 6 New York City hospitals between September 2022 and July 2023 are reported here as part of a prespecified interim analysis., Exposure: Sequencing of 156 early-onset genetic conditions with established interventions selected by the investigators were screened in all participants and 99 neurodevelopmental disorders associated with seizures were optional., Main Outcomes and Measures: The primary outcome was screen-positive rate. Additional outcomes included enrollment rate and successful completion of sequencing., Results: Over 11 months, 5555 families were approached and 4000 (72.0%) consented to participate. Enrolled participants reflected a diverse group by parent-reported race (American Indian or Alaska Native, 0.5%; Asian, 16.5%; Black, 25.1%; Native Hawaiian or Other Pacific Islander, 0.1%; White, 44.7%; 2 or more races, 13.0%) and ethnicity (Hispanic, 44.0%; not Hispanic, 56.0%). The majority of families consented to screening of both groups of conditions (both groups, 90.6%; disorders with established interventions only, 9.4%). Testing was successfully completed for 99.6% of cases. The screen-positive rate was 3.7%, including treatable conditions that are not currently included in NBS., Conclusions and Relevance: These interim findings demonstrate the feasibility of targeted interpretation of a predefined set of genes from genome sequencing in a population of different racial and ethnic groups. DNA sequencing offers an additional method to improve screening for conditions already included in NBS and to add those that cannot be readily screened because there is no biomarker currently detectable in dried blood spots. Additional studies are required to understand if these findings are generalizable to populations of different racial and ethnic groups and whether introduction of sequencing leads to changes in management and improved health outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT05990179.

Background: Despite improvements over the past decade, children continue to experience significant pain and distress surrounding invasive procedures in the emergency department (ED). To assess the impact of newly developed interventions, we must create more reliable and valid behavioral assessment tools that have been validated for the unique settings of pediatric EDs., Objective: This study aimed to create and test the Emergency Department Child Behavior Coding System (ED-CBCS) for the assessment of child distress and nondistress behaviors surrounding pediatric ED procedures., Methods: Via an iterative process, a multidisciplinary expert panel developed the ED-CBCS, an advanced time-based behavioral coding measure. Inter-rater reliability and concurrent validity were examined using 38 videos of children aged from 2 to 12 years undergoing laceration procedures. Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were used to examine concurrent validity., Results: The final ED-CBCS included 27 child distress and nondistress behaviors. Time-unit κ values from 0.64 to 0.98 and event alignment κ values from 0.62 to 1.00 indicated good to excellent inter-rater reliability for all but one of the individual codes. ED-CBCS distress (B = 1.26; p < 0.001) and nondistress behaviors (B = -0.69, p = 0.025) were independently significantly associated with FLACC scores, indicating concurrent validity., Conclusions: We developed a psychometrically sound tool tailored for pediatric ED procedures. Future work could use this measure to better identify behavioral targets and test the effects of interventions to relieve pediatric ED pain and distress., Competing Interests: Declaration of competing interest Zeev N. Kain is the president of the American College of Perioperative Medicine and has served as a consultant for Edwards Lifesciences and Pacira. The remaining authors declare no competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The aim of the current systematic review is to examine relationships among illness identity and illness-specific variables, adherence, and health-related outcomes. Studies were included if they (a) presented quantitative data on illness identity's relationship with adherence or health-related outcomes, (b) included chronic medical illness samples, (c) were peer-reviewed, and (d) were available in English. PubMed and EBSCOhost were searched. Quality was evaluated using the EPHPP Tool. Twelve papers were included. Moderate evidence supports the relationship between engulfment, enrichment, and illness complexity. Moderate evidence supports relationships between multiple identities and adherence as well as with various health-related outcomes. There is somewhat consistent evidence for associations between engulfment and negative health-related outcomes. It may be important to inform healthcare providers of possible identity challenges that patients face and their associations with adherence and health-related outcomes. Routine illness identity screening may allow for identification of individuals who would benefit from increased support., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Individuals living with sickle cell disease experience high levels of morbidity that result in frequent utilization of the emergency department. The objective of this study was to provide updated national estimates of emergency department utilization associated with sickle cell disease in the U.S., Methods: Data from the National Hospital Ambulatory Medical Care Survey for the years 1999-2020 were analyzed. Complex survey analysis was utilized to produce national estimates overall and by patient age groups., Results: On average, approximately 222,612 emergency department visits occurred annually among individuals with sickle cell disease, a nearly 13% increase from prior estimates. The annual volume of emergency department visits steadily increased over time, and pain remains the most common patient-cited reason for visiting the emergency department. Patient-reported pain levels for individuals with sickle cell disease were high, with 64% of visits associated with severe pain and 21% associated with moderate pain. Public insurance sources continue to cover most visits, with Medicaid paying for 60% of visits and Medicare paying for 12% of visits. The average time spent in the emergency department increased from previous estimates by about an hour, rising to approximately 6 hours. The average wait time to see a provider was 53 minutes., Conclusions: Utilization of the emergency department by individuals living with sickle cell disease remains high, especially for pain. With more than half of patients with sickle cell disease reporting severe pain levels, emergency department staff should be prepared to assess and treat sickle cell disease-related pain following evidence-based guidelines and recommendations. The findings of this study can help improve care in this population., (© 2023 The Authors.)

Objective: Disorders of gut-brain interaction (DGBIs) are common, and findings are mixed on rates of sleep problems (e.g., sleep quality) in pediatric populations. A clear understanding of sleep problems in pediatric DGBIs is needed as sleep challenges might negatively impact symptoms and prognoses. The aims of this systematic review are to (1) describe the prevalence and types of sleep problems in pediatric patients with DGBIs and examine differences by DGBI diagnosis and (2) examine the relationship among sleep problems and pain, mood, and functional outcomes in pediatric patients with DGBIs., Methods: We searched PubMed, PsycInfo, CINAHL, and Medline in June 2022; articles were included if they enrolled ≤19 years old with a DGBI, used a quantitative assessment of sleep problems, and were available in English. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies was used to assess study quality. We used a protocol to systematically pull and tabulate data across articles with quality assessment ratings., Results: Twenty-four articles with 110,864 participants across 9 countries were included, with most studies being of moderate to weak quality. Patients with DGBIs reported more sleep problems than healthy peers, and some research reviewed found that patients with IBS had more sleep problems than other DGBI diagnoses. Sleep problems in DGBIs were related to worse mood, pain, and functional outcomes., Conclusion: Pediatric patients with DGBIs are experiencing sleep problems that can impact outcomes. Screening for sleep problems and targeted treatment is needed to best support these patients., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Duchenne muscular dystrophy (DMD) is an X-linked disorder resulting in progressive muscle weakness and atrophy, cardiomyopathy, and in late stages, cardiorespiratory impairment, and death. As treatments for DMD have expanded, a DMD newborn screening (NBS) pilot study was conducted in New York State to evaluate the feasibility and benefit of NBS for DMD and to provide an early pre-symptomatic diagnosis., Methods: At participating hospitals, newborns were recruited to the pilot study, and consent was obtained to screen the newborn for DMD. The first-tier screen measured creatine kinase-MM (CK-MM) in dried blood spot specimens submitted for routine NBS. Newborns with elevated CK-MM were referred for genetic counseling and genetic testing. The latter included deletion/duplication analysis and next-generation sequencing (NGS) of the DMD gene followed by NGS for a panel of neuromuscular conditions if no pathogenic variants were detected in the DMD gene., Results: In the two-year pilot study, 36,781 newborns were screened with CK-MM. Forty-two newborns (25 male and 17 female) were screen positive and referred for genetic testing. Deletions or duplications in the DMD gene were detected in four male infants consistent with DMD or Becker muscular dystrophy. One female DMD carrier was identified., Interpretation: This study demonstrated that the state NBS program infrastructure and screening technologies we used are feasible to perform NBS for DMD. With an increasing number of treatment options, the clinical utility of early identification for affected newborns and their families lends support for NBS for this severe disease., (© 2023 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background: Literature suggests that a child's appraisal of pain and parent responses to pain are critical in predicting health-related outcomes. In youth with sickle cell disease (SCD), few investigations have examined child pain catastrophizing, and even fewer have examined the role that parents play in responding to SCD pain within the family context. The purpose of the current study was to examine the relationship between pain catastrophizing, parent response to child SCD pain, and health-related quality of life (HRQoL)., Procedure: The sample (N = 100) included youth with SCD (ages 8-18) and their parent. Parents completed a demographic questionnaire and the Adult Responses to Child Pain Symptoms; youth completed the Pain Catastrophizing Scale and Pediatric Quality of Life Inventory-SCD Module., Results: Findings indicated that pain catastrophizing, parent minimization, and parent encouragement/monitoring significantly predicted HRQoL. Minimizing and encouragement/monitoring parent responses moderated the relationship between pain catastrophizing and HRQoL, such that parent minimizing weakened the relationship and parent encouragement/monitoring strengthened the relationship., Conclusions: Paralleling pediatric chronic pain literature, findings suggest that pain catastrophizing predicts HRQoL in youth with SCD. However, findings from moderation analyses diverge from the chronic pain literature; data suggest that encouragement/monitoring responses strengthen the negative relationship between child pain catastrophizing and HRQoL. Child pain catastrophizing and parent response to SCD pain may be appropriate targets for clinical intervention to improve HRQoL. Future studies should strive to better understand parent responses to SCD pain., (© 2023 Wiley Periodicals LLC.)

Abstract: The purpose of this study was to examine the dyadic and individual level effects of parent and child pain catastrophizing on child health-related quality of life (HRQOL) in pediatric sickle cell disease. Questionnaires assessing child pain frequency, child and parent pain catastrophizing, and child HRQOL were completed by youth and their primary caregiver. A Common Fate Model was estimated to test the dyadic level relationship between parent and child pain catastrophizing and child HRQOL. An Actor-Partner-Common Fate Model hybrid was estimated to test the relationship between child HRQOL and individual-level child pain catastrophizing and parent pain catastrophizing, respectively. In each model, child HRQOL was modelled as a dyadic variable by factoring parent and child ratings. Patients (N = 100, M age = 13.5 years, 61% female) and their caregivers (M age = 41.8 years, 86% mothers) participated. Dyad-level pain catastrophizing was negatively associated with child HRQOL, demonstrating a large effect (β = -0.809). Individual-level parent and child pain catastrophizing were each uniquely negatively associated with child HRQOL, demonstrating small to medium effects (β = -0.309, β = -0.270). Individual level effects were net of same-rater bias, which was significant for both parents and children. Both the unique and the overlapping aspects of parent and child pain catastrophizing are significant contributors to associations with child HRQOL, such that higher levels of pain catastrophizing are associated with worse child HRQOL. Findings suggest the need for multipronged intervention targeting factors common to parent-child dyads and factors unique to parents and children, respectively., (Copyright © 2023 International Association for the Study of Pain.)

Background: Effective non-opioid pain management is of great clinical importance. The objective of this pilot study was to evaluate the effectiveness of multimodal mechanical stimulation therapy on low back pain., Methods: 11 female and 9 male patients aged 22-74 years (Mean 41.9 years, SD 11.04) receiving physical rehabilitation for acute (12) or chronic (8) low back pain chose heat (9) or ice (11) to accompany a 20-minute session of mechanical stimulation (M-Stim) therapy (Registered with Clinicaltrials.gov NCT04494841.) The M-Stim was delivered in 12 possible repeating "therapy cycle" patterns by three vibration motors (50 Hz, 100 Hz, 200 Hz) with amplitudes between 0.1-0.3 m/s 2 . Ten patients used a contained motor chassis attached to a thermoconductive single-curve metal plate. The next 10 patients' device had motors attached directly to a multidimensionally curved plate., Results: Mean pain on a 10 cm Visual Analog Scale (VAS) with the first motor/plate configuration went from 4.9 ± 2.3 cm to 2.5 ± 2.1 cm (57% decrease, p  = 0.0112), while the second reduced pain from 4.8 ± 2.0 cm to 3.2 ± 1.9 cm (45%, p  = 0.0353). Initial pain was greater with acute injury (5.8 ± 2.0 cm vs. 3.98 ± 1.8, p  = 0.025) and for patients older than 40 (5.44 vs. 4.52), but pain reduction was proportional for chronic and younger patients. There was no significant difference between plate configurations., Conclusions: A Phase I clinical pilot investigation on a multi-motor multi-modal device was promising for drug free pain relief. Results suggested pain relief independent of thermal modality, patient age, or pain chronicity. Future research should investigate pain reduction over time for acute and chronic pain., Clinical Trial Registration: https://ClinicalTrials.gov, identifier: NCT04494841., Competing Interests: ALB is the device inventor and founder of Pain Care Labs, AT is an intern employed by Pain Care Labs, JLES and LLC worked as independent consultants on this research. The work was funded by the NIH and a Conflict of Interest statement is maintained. The PI and PCL employees had no role in recruitment or data collection., (© 2023 Baxter, Thrasher, Etnoyer-Slaski and Cohen.)

Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures., (Copyright © 2022 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

The Hospital Readmissions Reduction Program (HRRP) works to temper nationally rising readmission rates. Total knee arthroplasty (TKA) and total hip arthroplasty (THA) have a 30-day readmission cost burden of $889,300 and $689,400, respectively. No research has compared TKA and THA readmission rates by region and Medicaid expansion status. This study compares THA and TKA readmission rates in the United States by region, Medicaid status, and performance. One-way ANOVAs were conducted to determine the regions with the highest and lowest mean excess readmission ratios (ERRs). An independent t-test compared Medicaid versus non-Medicaid expansion states. Southern hospitals have the highest mean ERR, followed by northeastern, midwestern, and then western hospitals. Although Medicaid expansion states have significantly lower ERRs compared to non-expansion states, Medicaid status alone does not account for regional differences in ERRs after THA and TKA. Regional factors likely confound Medicaid status's effect on readmission rates. (Journal of Surgical Orthopaedic Advances 32(1):005-008, 2023).

Background  It is difficult to evaluate the results of surgical techniques as there is inherent variability between surgeons in regard to experience, skill level, and knowledge. Tang suggested a classification system in 2009 in an attempt to standardize surgeon level of expertise, with categories ranging from nonspecialist (Level I) to expert (Level V). This epidemiological analysis of all articles citing Tang's original paper examines if a surgeon's self-reported level of expertise correlates with outcomes and evaluates whether the current definition of Tang level is sufficient to account for expertise bias. Methods  In May 2021, all articles citing Tang level of expertise were identified ( N  = 222). Articles were included if they described a novel technique and provided author(s)' levels ( n  = 205). Statistical analysis was conducted, and p -values less than 0.05 were considered significant. Results  The most common specialties reporting Tang level of expertise were orthopaedic surgery (82.9%) and plastic surgery (15.5%). The most common subspecialty was hand surgery. 2020 was the year with the most studies reporting level of expertise (31.7%), followed by 2021 (20.0%) and 2019 (17.1%). The majority of studies (80.5%) reported positive results with their technique, and of these, 63.3% were statistically significant. Level of expertise was not significantly associated with a doctoral degree, type of residency completed, fellowship completion, hand fellowship, author sex, study type, or result significance. Discussion  The current Tang classification is both underreported and incomplete in its present state. To account for expertise bias, we recommend all authors report Tang level when describing surgical techniques. Studies with multiple authors should explicitly state the level of each author, as well as a weighted average accounting for the total contribution of each individual., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objectives: Youth with sickle cell disease (SCD) and chronic pain, defined in this study as pain on most days for 3 months, experience variability in daily pain and physical and psychosocial functioning. This study aimed to (1) empirically derive chronic pain subgroups based on pain characteristics among youth with chronic SCD pain; and (2) investigate derived subgroups for differences in sociodemographics, clinical characteristics, and psychosocial and functional outcomes., Materials and Methods: Youth with chronic SCD pain (n=62, Mage =13.9, SD=2.5, 10 to 18 y; 58% female, 60% HbSS) completed a battery of questionnaires. Clinical characteristics (eg, medications, treatments) and health care utilization were abstracted from electronic medical records. Hierarchical cluster analysis informed the number of clusters at the patient level. k-means cluster analysis used multidimensional pain assessment to identify and assign patients to clusters., Results: Cluster 1 (n=35; Moderate Frequency, Moderate Pain) demonstrated significantly lower worst pain intensity, number of pain days per month, number of body sites affected by pain, and pain quality ratings. Cluster 2 (n=27; Almost Daily, High Pain) reported high ratings of worst pain intensity, almost daily to daily pain, greater number of body sites affected by pain, and higher ratings of pain quality (all P 's <0.05). There were no differences between subgroups by sociodemographics, clinical characteristics, or health care utilization. The Almost Daily, High Pain subgroup reported significantly higher pain interference, depressive symptoms, and pain catastrophizing than the Moderate Frequency, Moderate Pain subgroup., Discussion: Identifying chronic SCD pain subgroups may inform tailored assessment and intervention to mitigate poor pain and functional outcomes., Competing Interests: Supported by the National Heart, Lung, and Blood Institute (NHLBI) Award 1K23Hl133457-01A1 to S.S. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, Atlanta, GA. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The coronavirus disease 2019 (COVID-19) pandemic has impacted everyone, but there are few data regarding how the pandemic has influenced the lives of children with gastrointestinal (GI) conditions. This cross-sectional study assessed pandemic-related social disruption (PRSD) in children with inflammatory bowel disease (IBD), celiac disease (CD), and irritable bowel syndrome (IBS), and the potential buffering effect of the parent-child relationship., Methods: A survey completed between September and December 2020 asked 146 children (ages 8-17) diagnosed with IBD (n = 44), CD (n = 81), or IBS (n = 51) and 185 parents how the pandemic has contributed to social disruption (i.e., financial stability, COVID-19 exposure, school changes, GI needs, and isolation) and their social-emotional well-being. Structural equation modeling was used to examine the role of social disruption on well-being, and the moderating effect of the parent-child relationship., Results: Increased social disruption predicted worse parent, β = 0.24, p = .02, and child well-being, β = 0.38, p &lt; .01. The parent-child relationship moderated the relationship between parent and child well-being, β = 0.21, p = .03. Strong parent-child relationships predicted a positive association between parent and child well-being, β = 0.23, p = .003, whereas medium, β = 0.09, p = .14, and poor, β = -0.06, p = .52, relationships did not., Conclusions: PRSD negatively impacted the well-being of children with GI conditions, and the parent-child relationship moderated this relationship. These findings are relevant to pediatric psychologists treating the physical and mental health needs of children with GI conditions and their parents., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery., Methods: We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded., Results: Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03)., Conclusions: Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively., Level of Evidence: Level II-retrospective prognostic study., Competing Interests: J.G.B. is on the editorial board of JAMA Pediatrics . N.S.M. is a paid consultant for and received research support from Ascendis Pharma, research support from Ultragenyx, and financial support from UpToDate. D.J.H. is a paid consultant for Medtronic. L.I.K. received financial support from K2M. J.B.E. is a paid consultant for Biomet and Johnson & Johnson, receives IP royalties from DePuy, and is on the editorial board of the Journal of Children’s Orthopedics . M.T.H. is a board/committee member of the American College of Rheumatology Arthritis Foundation and the Pediatric Orthopaedic Society of North America, has stock/stock options in EOSI, and is on the editorial board of the New England Journal of Medicine . B.D.S. is a board/committee member of AAOS, Orthopaedic Research Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society and an unpaid consultant for OrthoPediatrics. M.P.G. is a paid presenter for Biomet, DePuy, Medtronic, and Nuvasive, received research support as a member of HSG and PSSG, and is a paid consultant for Orthobullets and received financial support and stock/stock options from them. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Lay Abstract: When toddlers are suspected of autism spectrum disorder (ASD), the gold-standard assessment technique is with the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2) Toddler Module, a behavioral observation system. ASD is a neurodevelopmental condition more frequently diagnosed in toddler boys than in toddler girls. There is some evidence that the ADOS-2 assesses behaviors that are more characteristic of boys with ASD than girls. Thus, it is possible that focusing on these behaviors contributes at least in part to why more boys are diagnosed than girls. Specifically, girls may show more social skills than boys during the ADOS-2 assessment due to their socialization histories, which may lead to missed diagnoses of ASD in toddler girls. The current study examined eight social behaviors assessed by the ADOS-2 in a sample of toddlers with suspected ASD to see if they contributed differently to the total score of those items. Examination of those items suggested that those social communication behaviors work the same for boys and girls with suspected ASD, which was inconsistent with hypotheses. However, examination of particular items raises the possibility of examining creative/imaginative play as an area for future research.

The purpose of this study was to evaluate behavioral strategies to minimize procedural distress associated with in-office tympanostomy tube placement for children without general anesthesia, sedation, or papoose-board restraints. 120 6-month- to 4-year-olds and 102 5- to 12-year-olds were treated at 16 otolaryngology practices. Mean age of children was 4.7 years old (SD = 3.18 years), with more boys (58.1%) than girls (41.9%). The cohort included 14% Hispanic or Latinx, 84.2% White, 12.6% Black, 1.8% Asian and 4.1% 'Other' race and ethnicity classifications. The in-office tube placement procedure included local anesthesia via lidocaine/epinephrine iontophoresis and tube placement using an integrated and automated myringotomy and tube delivery system. Behavioral strategies were used to minimize procedural distress. Anxiolytics, sedation, or papoose board were not used. Pain was measured via the faces pain scale-revised (FPS-R) self-reported by the children ages 5 through 12 years. Independent coders supervised by a psychologist completed the face, legs, activity, cry, consolability (FLACC) behavior observational rating scale to quantify children's distress. Mean FPS-R score for tube placement was 3.30, in the "mild' pain range, and decreased to 1.69 at 5-min post-procedure. Mean tube placement FLACC score was 4.0 (out of a maximum score of 10) for children ages 6 months to 4 years and was 0.4 for children age 5-12 years. Mean FLACC score 3-min post-tube placement was 1.3 for children ages 6 months to 4 years and was 0.2 for children age 5-12 years. FLACC scores were inversely correlated with age, with older children displaying lower distress. The iontophoresis, tube delivery system and behavioral program were associated with generally low behavioral distress. These data suggest that pediatric tympanostomy and tube placement can be achieved in the outpatient setting without anxiolytics, sedatives, or mechanical restraints., (© 2021. The Author(s).)

The purpose of this study was (1) to determine how much emphasis is placed on the Personal Statement (PS) by program directors (PDs) and (2) to gain a better understanding of what factors within the PS are considered most important to PDs. An anonymous survey was distributed to PDs at allopathic orthopaedic residency programs in the United States using Survey Monkey (San Mateo, CA). Survey responses were received from 51 of 152 (34%) PDs. Forty-five (88.2%) identified as male, five (9.8%) identified as female, and one (1.9%) chose not to disclose. PDs reported the PS was of average importance, with an average score of 2.82 (range,1-4). Although the PS is still given consideration as part of the overall orthopaedic surgery residency application process, it does not play a major role in determining which applicants will be invited for an interview or how they will be ranked. (Journal of Surgical Orthopaedic Advances 31(2):090-095, 2022).

Prophylactic radiotherapy (XRT) is a commonly used treatment to decrease heterotopic ossification (HO) in patients with traumatic hip injuries. We conducted a retrospective review of patients at risk for HO who underwent XRT. Of the patients reviewed, 27.3% developed radiographic HO, 11.2% developed symptoms, and 2.0% required resection surgery. Patients were divided into primary (n = 71) and secondary prophylaxis (n = 27) cohorts. In the primary group, 25.0% developed radiographic HO, 5.6% developed symptoms, and 0 required surgery. In the secondary cohort, 33.3% of patients developed new radiographic HO, and 25.9% were symptomatic: four had a Brooker score of 3, and three had a score of 4 (p = 0.03), and 7.4% required surgical resection. (Journal of Surgical Orthopaedic Advances 31(2):113-118, 2022).

Objectives: Parents of children with cancer (PCCs) experience stress as they navigate managing their child's illness. Arguably, social support is critical to PCCs' well-being. This review examines the literature on social support in PCCs., Methods: Studies of social support in PCCs were collected from PsycINFO, CINHAL, and MEDLINE. Data were extracted from 37 studies published between January 2010 and May 2021 related to the conceptualization, measurement, and availability of social support in PCCs. Relationships between PCCs' social support, well-being, and unique parent and child factors were also synthesized. Risks of biases were assessed using domains of the Effective Public Health Practice Project., Results: Social support in PCCs is conceptualized as (a) perceived availability and satisfaction with social support and (b) social support seeking as a coping strategy. Parents of children with cancer report receiving as much or more support than typical adults, but PCCs engage in less social support seeking. Family and significant others are the most prevalent sources of support, and emotional support is the most received type of social support. Social support is positively related to well-being and negatively related to distress, anxiety, and posttraumatic stress. Findings related to social support differences based on parent and child unique factors were minimal and present opportunities for future research. The risk of bias was generally low, with caution that most studies cannot demonstrate directionality of findings due to cross-sectional study designs., Conclusions: Given the consistent positive association between social support and well-being in PCCs, clinicians should assess and encourage social support for this vulnerable population., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Orthopaedic surgery is one of the most competitive specialties in the residency match. The personal statement (PS) is one component of the application. The significance of the PS to orthopaedic surgery residency applicants is unknown. This study evaluates applicant perceptions of the PS. Applicants to two separate United States orthopaedic residency programs for the 2019-2020 cycle were invited to participate. Survey was distributed via email. Twenty-one percent (204/978) of applicants completed the survey. Most were men (157/204, 77%), and most (125/204, 61%) spent up to 15 hours writing their PS. Many [79.4% (162/204)] believed the PS should continue to be included in the application. Women always edited their PS, while 7.0% (11/ 157) of men did not use any editors. Applicants believe the PS is valuable. The PS is time consuming but allows applicants to communicate details that otherwise may not be included in their application. (Journal of Surgical Orthopaedic Advances 31(1):034-041, 2022).

Electric scooter (e-scooter) use and resulting injuries have grown exponentially since expansion into ridesharing in 2017. No study has described pediatric e-scooter injuries and focused on their impact in an adolescent cohort. Our primary purpose was to describe the epidemiology of admitted pediatric e-scooter injuries and compare them with existing literature on adults. We queried the National Electronic Injury Surveillance System for e-scooter injuries between 2015 and 2019 in patients 0-18 years old. Injuries caused by an e-scooter to a nonrider were removed. Patients admitted to the hospital were analyzed and weighted national estimates were calculated. A P value of <0.05 was considered significant. Nine hundred and two pediatric patients were treated for an e-scooter injury at an emergency department (ED) between 2015 and 2019. Among those admitted (n = 47), 72.3% were men, and the average age at injury was 11.3 years. Among all injuries (n = 56), the most common diagnosis was fracture (24/56, 42.9%). The 19% (9/47) of patients that experienced polytrauma were significantly older than those with single injuries (P < 0.001). ED admissions grew by 616% from 2017 to 2018. Children experience a greater rate of fractures and polytrauma from e-scooters compared to adults, but fewer facial injuries despite a similar rate of head trauma. The incidence of pediatric head injuries indicates a lack of helmet use similar to adults. Lawmakers should consider bolstering e-scooter regulations to decrease pediatric injuries., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow., Design: Retrospective chart review., Setting: Level 1 trauma center., Patients/participants: Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15-year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow-up after XRT. Fifty-four patients were ultimately included., Intervention: All patients were treated with a single dose of 7 Gy. Ninety-eight percentage of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery., Main Outcomes Measurements: The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint., Results: Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT and 11.1% required surgery to resect the heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT and 5.5% required resection surgery. No secondary malignancies were identified., Conclusions: Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow-up is required to better characterize populations at high risk for development of HO and secondary malignancy., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is a paucity of literature about return to play (RTP) for golf protocols following cervical and lumbar fusions. The timing of return to this sport is a common question among patients. The aim of this review was to analyze and report the current protocols for RTP following cervical and lumbar spinal fusion., Methods: A systematic search was conducted using the following databases: MEDLINE, PubMed, Web of Science, Scopus, and Google Scholar. A 3-step, multiauthor screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria included peer-reviewed and published prospective, case-control, cohort, case series, or review articles. Studies had to pertain to RTP for golf following instrumented cervical or lumbar spinal fusion to be included., Results: Three articles met inclusion criteria: 2 retrospective survey-based cohort studies and 1 survey-based case series study. All studies included a minimum of 1 year of follow-up. Of patients, 71.6% (n = 51) were able to RTP following surgery; 54.3%-80% were able to RTP at a similar or improved level of play as preoperatively. Postoperative pain reduction was noted in 2 articles., Conclusions: Most golfers are able to RTP within 12 months following cervical or lumbar spinal fusion. Patients generally reported decreased lower back pain and leg pain postoperatively. Following cervical or lumbar fusion, many golfers are able to RTP at the same or an increased frequency compared with preoperatively., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Objective: Sickle cell disease (SCD) is a group of inherited blood disorders. The central feature of this chronic condition is pain. Several identified risk factors exacerbate the impact of pain on quality of life (QOL) in SCD; however, there are relatively fewer investigations of strengths-based resilience variables that might buffer the influence of pain on living with SCD. The purpose of this study was to examine strength-based resilience processes in youth with SCD and their parents. Grounded in an ecological resilience-risk model, we evaluated whether adolescent and parent protective factors (pain acceptance, mindfulness, and psychological flexibility) moderated the relation between adolescent-reported pain burden and QOL., Methods: Ninety-three 12- to 18-year-old adolescents with SCD and their parents participated. Adolescents completed assessments of pain characteristics, pain acceptance, mindfulness, and QOL. Parents completed instruments measuring demographic and disease variables and parent psychological flexibility., Results: Pain variables were associated with protective factors in predicted directions. Adolescent acceptance and mindfulness were positively correlated with QOL. Parent psychological flexibility and adolescent QOL were not related. After controlling for demographic, pain, and disease variables, moderation analyses indicated that adolescent pain acceptance buffered the relation between SCD pain burden and QOL. Moderation analyses were not significant for adolescent mindfulness or parent psychological flexibility., Conclusions: Results suggest that strengths-based factors may play an important role for adolescents' QOL within the context of SCD pain. Interventions that enhance teenagers' ability to accept pain might be particularly useful to improve QOL in adolescents living with SCD pain., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Pain and complications related to pediatric sickle cell disease (SCD) are associated with higher health care utilization. In other pediatric chronic conditions, psychosocial screening can help identify children and families at risk of increased health care utilization to guide resource allocation, address treatment needs, and improve care. This study aimed to investigate the utility of psychosocial screening in predicting increased health care utilization among youth with SCD., Methods: Youth with SCD (n = 74, 8-18 years) and their parents were recruited from comprehensive SCD clinics. Parents completed the Psychosocial Assessment Tool (PAT), which categorized family psychosocial risk into one of three categories: Universal (minimal distress), Targeted (elevated distress), and Clinical (persistent distress). Youth reported on their pain characteristics, and health care utilization was extracted from medical chart review. Differences in health care utilization were evaluated using analysis of variance (ANOVA) and moderation analyses., Results: Based on PAT risk, families were categorized into Universal (56.8%), Targeted (29.7%), and Clinical (13.5%) risk groups, with no significant group differences across demographic variables. Patients in the Targeted group reported significantly higher pain frequency than those in the Universal group (F[2, 66] = 3.7, p < .05). The association between pain frequency and health care utilization significantly varied on the basis of psychosocial risk, such that Clinical psychosocial risk strengthened the connection between pain frequency and health care utilization (β = .2, t = 2.1, p < .05)., Conclusions: Integrating the PAT into routine clinical care may help health care providers identify families in need of greater psychosocial or medical support to further optimize SCD management., (© 2021 Wiley Periodicals LLC.)

Introduction  Recent efforts to standardize reporting of surgeon experience in novel technique publications have recommended reporting of Tang level of expertise (LOE). Question/Purpose  The aim of this study was to document trends in LOE reporting for novel technique articles published in the Journal of Wrist Surgery and evaluate whether author experience affects novel research outcomes. Methods  A total of 261 articles published from 2018 to 2020 were reviewed. Articles describing novel surgical techniques were included and examined for Tang LOE. Author variables were collected online. Results  Eight percent (21/261) of articles discussed novel surgical techniques and one reported LOE. Nearly half (47.6%) of articles did not conduct statistical analysis. Four (19.0%) reported insignificant statistical results and 7 (33.3%) reported significant findings. All significant statistical findings were positive. Number of prior related publications by the senior author did not affect new technique result significance ( p  = 0.34). Discussion  From 2018 to 2020, only one article documented LOE. Authors' variables, including number of prior related publications, were not correlated with significant results in their new publications. This may suggest that an author's established experience in a novel technique, quantified by prior publications on the topic, does not make one more likely to achieve significantly better or worse outcomes in their reviewed Journal of Wrist Surgery study. Conclusions  Tang LOE is an important way for readers to classify expertise and should be reported, and potentially modified to better define contributing variables., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Study Design: Case series., Objective: In this study we focus on this group, and describe the largest cohort to date of single ventricle patients undergoing surgical correction of scoliosis at a single institution., Summary of Background Data: Outcomes of spinal surgery for patients with congenital heart disease (CHD) have evolved and most affected patients have uncomplicated procedures. The risk of perioperative complications remains highest in patients with single ventricle ("Fontan") physiology., Methods: We reviewed patients with single ventricle CHD and operative scoliosis repair over a 25-year span. Patients who had undergone a Fontan, bidirectional Glenn, and/or Kawashima procedure before operative scoliosis repair were included. Patients were excluded if they lacked preoperative cardiac care and/or sufficient medical history at our institution., Results: Twenty-three patients were included. The average age at surgery was 13.6 years (range, 5-23). Seventy percent of the cohort was female (16/23). The majority of patients underwent a Fontan before scoliosis surgery (20/23, 87%). Patients without intraoperative tranexamic acid (TXA) had a 67% complication rate (8/12) versus 36% (4/11) in those with intraoperative TXA (P = 0.29). There was a significant difference in estimated blood loss by weight (cc/kg) between non-TXA and TXA patients (P = 0.016). Twelve patients experienced complications (52%), all of which occurred postoperatively. There were no deaths, cerebrovascular events, adverse perioperative cardiac or hemodynamic complications, or wound infections. Using the Clavien-Dindo-Sink classification for postoperative complications, four patients had serious adverse events, including one permanent neurologic deficit., Conclusion: Spinal surgery for scoliosis has been performed in selected patients with single ventricle physiology at a single institution without mortality for 25 years. Operative blood loss may be reduced by routine use of TXA. Complications occur most commonly in the postoperative period, and can include pleural effusion.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Recent focus on surgical site infections (SSIs) after posterior spine fusion (PSF) has lowered infection rates by standardizing perioperative antibiotic prophylaxis. However, efforts have neglected to detail antibiotic treatment of SSIs. Our aim was to document variability in antibiotic regimens prescribed for acute and latent SSIs following PSF in children with idiopathic, neuromuscular, and syndromic scoliosis., Methods: This study included patients who developed a SSI after PSF for scoliosis at a pediatric tertiary care hospital between 2004 and 2019. Patients had to be 21 years or younger at surgery. Exclusion criteria included growing rods, staged surgery, and revision or removal before SSI diagnosis. Infection was classified as acute (within 90 d) or latent. Clinical resolution of SSI was measured by return to normal lab values. Each antibiotic was categorized as empiric or tailored., Results: Eighty subjects were identified. The average age at fusion was 14.7 years and 40% of the cohort was male. Most diagnoses were neuromuscular (53%) or idiopathic (41%).Sixty-three percent of patients had an acute infection and 88% had a deep infection. The majority (54%) of subjects began on tailored antibiotic therapy versus empiric (46%). Patients with a neuromuscular diagnosis had 4.0 times the odds of receiving initial empiric treatment compared with patients with an idiopathic diagnosis, controlling for infection type and time (P=0.01). Ninety-two percent of patients with acute SSI retained implants at the time of infection and 76% retained them as of August 2020. In the latent cohort, 27% retained implants at infection and 17% retained them as of August 2020., Conclusions: Patients with acute infections were on antibiotics longer than patients with latent infections. Those with retained implants were on antibiotics longer than those who underwent removal. By providing averages of antibiotic duration and lab normalization, we hope to standardize regimens moving forward and develop SSI-reducing pathways encompassing low-risk patients., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pediatric orthopaedic fellowship directors (FDs) have a valuable impact on the education of trainees and future leaders in the field. There is currently no research on the characteristics of pediatric orthopaedic FDs., Methods: Programs were identified using the Pediatric Orthopaedic Society of North America fellowship directory. Operative, nonoperative, and specialty programs were included. Data was collected through Qualtrics survey, e-mail, telephone, and online searches. Variables included demographics (age, sex, race/ethnicity), Hirsch index (h-index) as a measure of research productivity, graduate education, residency and fellowship training, years of hire at current institution and as FD, and leadership roles., Results: Fifty-five FDs were identified. The majority (49/55, 89%) were male and 77% (27/35) were Caucasian. The mean age at survey was 51.1±8.2 years. The mean h-index was 17.2. Older age correlated with higher h-index (r=0.48, P=0.0002). The average duration from fellowship graduation to FD appointment was 9.6±6.7 and 6.9±6.1 years from institutional hire. Sixteen FDs (29%) had additional graduate level degrees. Almost all (52/55, 95%) FDs completed orthopaedic surgery residencies and all graduated fellowship training. Twenty-nine percent (16/55) completed more than 1 fellowship. Most FDs (51/55, 93%) completed a fellowship in pediatric orthopaedic surgery. Ten FDs (18%) completed pediatric orthopaedic surgery fellowships that included spine-specific training. One-third of all current FDs were fellowship-trained at either Boston Children's Hospital (9/55, 16%) or Texas Scottish Rite Hospital for Children (9/55, 16%)., Conclusions: Pediatric orthopaedic FDs are typically early-career to mid-career when appointed, with a strong research background. Nearly a third completed additional graduate degrees or multiple fellowships. Although male dominated, there are more female FDs leading pediatric orthopaedic programs compared with adult reconstruction, trauma, and spine fellowships. As fellowships continue to grow and diversify, this research will provide a baseline to determine changes in FD leadership., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)