Cerebral Palsy: Current Concepts and Practices in Musculoskeletal Care.

Cerebral palsy is a neurologic disorder characterized by a spectrum of motor and cognitive deficits resulting from insults to the developing brain. The etiologies are numerous and likely multifactorial; an increasing portion of cases may be attributable to genetic causes, although the exact mechanisms responsible remain poorly understood. Major risk factors include intrauterine stroke and prematurity and neonatal infection, trauma, and hypoxia, which may occur in the prenatal, perinatal, or postnatal period. The Gross Motor Function Classification System (GMFCS) is a widely used tool to establish a child's level of function and to guide treatment; however, additional metrics are necessary to formulate long-term prognoses. Goals of care are to maximize function and independence, which directly correlate with overall quality of life, and family participation is key to establishing goals early in treatment. Nonpharmaceutical treatments include physical, occupational, and speech therapy, as well as bracing, equipment, and technology. There is a breadth of medical interventions for managing hypertonia, including medications, botulinum toxin injections, intrathecal baclofen pumps, and selective dorsal rhizotomy. Orthopedic interventions are indicated for symptomatic or progressive musculoskeletal sequelae. Treatments for dysplastic hips and/or hip instability range from soft tissue releases to bony procedures. Neuromuscular scoliosis is managed with posterior spinal fusion because bracing is ineffective against these rapidly progressive curves. The degree of care varies considerably depending on the child's baseline GMFCS level and functional capabilities, and early screening, diagnosis, and appropriate referrals are paramount to initiating early care and maximizing the child's quality of life.

Pediatric intrathecal baclofen management during the COVID-19 pandemic in the US and Canada.

The COVID-19 pandemic has been a challenge to healthcare systems around the world. Within pediatric rehabilitation medicine, management of intrathecal baclofen has been particularly challenging. This editorial reviews how programs in the US and Canada coped with the quickly changing healthcare environment and how we can learn from this pandemic to be prepared for future crises.

Accelerometer Measurements Indicate That Arm Movements of Children With Cerebral Palsy Do Not Increase After Constraint-Induced Movement Therapy (CIMT).

IMPORTANCE: Constraint-induced movement therapy (CIMT) is a common treatment for children with unilateral cerebral palsy (CP). Although clinic-based assessments have demonstrated improvements in arm function after CIMT, whether these changes are translated and sustained outside of a clinic setting remains unclear. OBJECTIVE: Accelerometers were used to quantify arm movement for children with CP 1 wk before, during, and 4 wk or more after CIMT; measurements were compared with those from typically developing (TD) peers. DESIGN: Observational. SETTING: Tertiary hospital and community. PARTICIPANTS: Seven children with CP (5 boys, 2 girls; average [AVE] age ± standard deviation [SD] = 7.4 ± 1.2 yr) and 7 TD peers (2 boys, 5 girls; AVE age ± SD = 7.0 ± 2.3 yr). INTERVENTION: 30-hr CIMT protocol. OUTCOMES AND MEASURES: Use ratio, magnitude ratio, and bilateral magnitude were calculated from the accelerometer data. Clinical measures were administered before and after CIMT, and parent surveys assessed parent and child perceptions of wearing accelerometers. RESULTS: During CIMT, the frequency and magnitude of paretic arm use among children with CP increased in the clinic and in daily life. After CIMT, although clinical scores showed sustained improvement, the children's accelerometry data reverted to baseline values. Children and parents in both cohorts had positive perceptions of accelerometer use. CONCLUSIONS AND RELEVANCE: The lack of sustained improvement in accelerometry metrics after CIMT suggests that therapy gains did not translate to increased movement outside the clinic. Additional therapy may be needed to help transfer gains outside the clinic. WHAT THIS ARTICLE ADDS: Accelerometer measurements were effective at monitoring arm movement outside of the clinic during CIMT and suggested that additional interventions may be needed after CIMT to sustain benefits.

Feasibility of using acceleration-derived jerk to quantify bimanual arm use.

BACKGROUND: Accelerometers have become common for evaluating the efficacy of rehabilitation for patients with neurologic disorders. For example, metrics like use ratio (UR) and magnitude ratio (MR) have been shown to differentiate movement patterns of children with cerebral palsy (CP) compared to typically-developing (TD) peers. However, these metrics are calculated from "activity counts" - a measure based on proprietary algorithms that approximate movement duration and intensity from raw accelerometer data. Algorithms used to calculate activity counts vary between devices, limiting comparisons of clinical and research results. The goal of this research was to develop complementary metrics based on raw accelerometer data to analyze arm movement after neurologic injury. METHOD: We calculated jerk, the derivative of acceleration, to evaluate arm movement from accelerometer data. To complement current measures, we calculated jerk ratio (JR) as the relative jerk magnitude of the dominant (non-paretic) and non-dominant (paretic) arms. We evaluated the JR distribution between arms and calculated the 50th percentile of the JR distribution (JR50). To evaluate these metrics, we analyzed bimanual accelerometry data for five children with hemiplegic CP who underwent Constraint-Induced Movement Therapy (CIMT) and five typically developing (TD) children. We compared JR between the CP and TD cohorts, and to activity count metrics. RESULTS: The JR50 differentiated between the CP and TD cohorts (CP = 0.578 ± 0.041 before CIMT, TD = 0.506 ± 0.026), demonstrating increased reliance on the dominant arm for the CP cohort. Jerk metrics also quantified changes in arm use during and after therapy (e.g., JR50 = 0.378 ± 0.125 during CIMT, 0.591 ± 0.057 after CIMT). The JR was strongly correlated with UR and MR (r = - 0.92, 0.89) for the CP cohort. For the TD cohort, JR50 was repeatable across three data collection periods with an average similarity of 0.945 ± 0.015. CONCLUSIONS: Acceleration-derived jerk captured differences in motion between TD and CP cohorts and correlated with activity count metrics. The code for calculating and plotting JR is open-source and available for others to use and build upon. By identifying device-independent metrics that can quantify arm movement in daily life, we hope to facilitate collaboration for rehabilitation research using wearable technologies.

A Novel Protocol for Contact Isolation for Multidrug-Resistant Organisms in Children on Inpatient Rehabilitation and Effects on Functional Outcomes: A Noninferiority Study.

BACKGROUND: The incidence of contact isolation for multidrug-resistant organisms is increasing in acute hospitals and inpatient rehabilitation units alike. There is limited evidence on the effect of contact isolation on functional outcomes during inpatient rehabilitation. OBJECTIVE: To determine whether the use of a modified contact isolation protocol (MCI) resulted in noninferior functional outcomes compared with children without contact isolation (NCI) on inpatient rehabilitation. DESIGN: This is a retrospective noninferiority study. SETTING: One academically affiliated pediatric inpatient rehabilitation unit located in a children's hospital. PATIENTS: All children with any diagnosis admitted to inpatient rehabilitation from January 1, 2007, to December 31, 2014. METHODS OR INTERVENTIONS: We compared functional outcomes for 2 groups of children. MAIN OUTCOME MEASUREMENTS: Primary outcome measures included the Functional Independence Measure for Children (WeeFIM) efficiency and the change in the Developmental Functional Quotient (DFQ) for the WeeFIM. Noninferiority margins of 0.63 for the WeeFIM efficiency and 0.092 for the change in DFQ for the WeeFIM were used. RESULTS: There were a total of 949 patients of whom 899 were NCI, 48 MCI, and 2 excluded due to missing information. Patients with MCI had functional outcomes that were noninferior to those with NCI including the WeeFIM efficiency (mean difference 0.002, 95% CI -0.38 to 0.404) and the change in DFQ for the WeeFIM (mean difference -0.05, 95% CI -0.058 to 0.003). CONCLUSIONS: The modified contact isolation protocol, having resulted in noninferior functional outcomes in inpatient rehabilitation may provide adequate contact isolation while allowing for noninferior functional outcomes. This may be a guide in the face of an ever-increasing need for contact isolation. LEVEL OF EVIDENCE: III.

The effect of nitrous oxide on intra-ocular pressure in healthy adults.

Many anaesthetic agents affect intra-ocular pressure, yet little is known about nitrous oxide and intra-ocular pressure. This study assessed the effect of nitrous oxide on intra-ocular pressure in 20 healthy adult volunteers. The intra-ocular pressure was measured at baseline, while breathing a 70:30 mix of nitrous oxide and oxygen for 12 min, and then while breathing room air for 15 min. A linear mixed effects model was used to assess change in intra-ocular pressure over time. There was no significant difference in intra-ocular pressure between baseline and during or after nitrous oxide inhalation. Several differences in intra-ocular pressure were noted between internal time-points: pressure increased by 2.4 mmHg between 3 and 6 min of breathing nitrous oxide (p=0.01); it increased by 1.4 mmHg between 3 and 9 min of breathing nitrous oxide (p=0.046); and it decreased by 2.2 mmHg between 6 min of breathing nitrous oxide and 15 min of breathing room air (p=0.035). This study indicates that nitrous oxide inhalation does not significantly change intra-ocular pressure from baseline values in a population of healthy adults.

Nursing assessment and patient management.

OBJECTIVES: To review contemporary knowledge and recent research in the nursing assessment and management of patients receiving radiation therapy. DATA SOURCES: Published scientific papers, review articles, book chapters, and clinical practice. CONCLUSIONS: Despite the enormous advances in treatment technology, dose-limiting acute and late effects of radiation therapy have not been eliminated. Astute assessment and early interventions can have a positive impact on the quality of life of the patient receiving radiation therapy. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses need to be well-informed about treatment advances and be able to integrate research findings into clinical practice. The increased use of concurrent or sequential combined modality therapy requires nurses to broaden their skills of assessment and management.

Predictive factors for response to medical therapy in bacterial ulcerative keratitis.

BACKGROUND: Fifty-four consecutive cases of culture-positive bacterial ulcerative keratitis presenting at a major university hospital were reviewed to identify factors predictive of response to medical therapy for bacterial ulcerative keratitis (BUK). METHODS: Eleven patients (20%) failed medical therapy (defined as the need for surgical intervention or cyanoacrylate gluing). Using multivariate logistic regression, the following variables were evaluated: (1) predisposing ocular factors (e.g., contact lens wear), (2) pre-existing ocular diseases, (3) ulcer size, and (4) the number of topical ocular medications used at the time of presentation. RESULTS: We noted certain factors to be potentially predictive of medical therapy outcome. The average size of the ulcer at the time of presentation was 4.4 +/- 2.4 mm in the failure group but only 2.5 +/- 1.9 mm for the success group (P = 0.027). In addition, patients in the medical failure group used more topical ocular medications at the time of presentation (P = 0.0075). Further analysis of the individual topical ocular medications revealed that the use of corticosteroids was higher in the failure group (56% vs 12%, P = 0.0005 by Fisher's exact test). Other factors such as patient age, the type of organism(s), and the time elapsed between the onset of symptoms and the beginning of definitive therapy were not statistically significant. CONCLUSION: In this population, ulcer size at the onset of antibacterial treatment and the use of certain ocular medications, specifically corticosteroids, were significant predictive factors for failure of medical therapy for BUK.

The effect of concurrent Pseudomonas or Xanthomonas exposure on adherence of Acanthamoeba castellanii to soft contact lenses.

BACKGROUND: Approximately 85% of Acanthamoeba-contaminated contact lens systems in asymptomatic patients have concurrent bacterial contamination. Pseudomonas aeruginosa and Xanthomonas maltophilia are common contact lens contaminants; we investigated the effect of coincubation of Acanthamoeba adherence to contact lenses. METHODS: A. castellanii, 1 x 10(5) organisms/ml, was coincubated with P. aeruginosa or X. maltophilia, 1 x 10(8) CFU/ml in phosphate-buffered saline. Sterile, unworn polymacon, etafilcon A or lidofilcon contact lens were investigated. The experimental groups were: (I) lenses exposed to bacteria for 1 h, then Acanthamoeba for 2 h; (II) lenses exposed concurrently to bacteria and Acanthamoeba for 2 h; (III) Acanthamoeba coincubated with bacteria for 24 h, then lenses exposed for 2 h; (IV) lenses exposed to Acanthamoeba for 2 h (control). RESULTS: For all experimental groups, Acanthamoeba adherence was greater to lidofilcon than to polymacon and etafilcon. For both P. aeruginosa and X. maltophilia, neither group I nor group II displayed greater Acanthamoeba adherence than group IV. Group III exhibited significantly less adherence than group IV for lidofilcon and polymacon. The decrease in group III adherence reflected an overall decrease in Acanthamoeba trophozoite concentration. CONCLUSION: Short bacteria/Acanthamoeba coincubation times did not result in increased Acanthamoeba adherence. Twenty-four-hour coincubation resulted in decreased adherence for Pseudomonas and unchanged adherence rates for Xanthomonas. This model suggests that Pseudomonas or Xanthomonas co-contamination does not necessarily facilitate quantitative Acanthamoeba contact lens adherence.

Quantitative comparison of Acanthamoeba castellanii adherence to rigid versus soft contact lenses.

We evaluated quantitative differences in adherence of Acanthamoeba castellanii trophozoites and cysts to new unworn contact lenses as a function of contact lens type and duration of exposure. Daily wear soft (polymacon), disposable soft (etafilcon A), rigid gas permeable (RGP) (siloxane acrylate), and polymethylmethacrylate (PMMA) contact lenses were exposed to 1 x 10(5)/mL log phase A. castellanii (trophozoite:cyst ratio 90:10) for 10 seconds, 30 minutes, 60 minutes, and 120 minutes. The number of adherent organisms was determined by light microscopy and confirmed by scanning electron microscopy. Rates of cyst adherence were similar among contact lens types. We observed significantly greater adherence of trophozoites to RGP and PMMA lenses compared with soft contact lenses (P < 0.05). This difference in trophozoite adherence was significant at all four time periods (P < 0.05). Our findings show that A. castellanii trophozoites and cysts adhere to both soft and rigid contact lens types. We also found that although trophozoite adherence increases as a function of duration of exposure, adherent organisms were observed with exposure times as brief as 10 seconds. This suggests that all contact lens types may be at risk for Acanthamoeba attachment and that even minimal exposure times may be sufficient for lens contamination.

The effect of Acanthamoeba concentration on adherence to four types of unworn soft contact lenses.

Contact lens wear is a predominant risk factor for Acanthamoeba keratitis. The exact nature of the relationship between organism concentration and contact lens adherence is poorly understood. We investigated the effect of Acanthamoeba inoculation concentration on adherence to four categories of contact lenses of varying polymers and water content. Acanthamoeba polyphaga was harvested in log growth phase at 5 days subculture and suspended in PBS at concentrations of 1 x 10(2), 10(3), 10(4), 10(5), and 10(6) organisms/mL (trophozoite:cyst ratio 90:10 +/- 2). Sterile unworn polymacon, etafilcon, lidofilcon, and bufilcon contact lens segments were exposed to Acanthamoeba for 2 hours. Acanthamoeba adherence was quantified using phase contrast microscopy. For all lens types, trophozoite adherence increased as the concentration of inoculum increased, but the relationship was not directly proportional. In all cases the minimal adherence was observed at 10(2). Trophozoite adherence increased disproportionate to cysts for all contact lens types. The greatest adherence was to lidofilcon lenses. At all concentrations adherence was greater to lidofilcon than etafilcon or polymacon, and greater to bufilcon than etafilcon or polymacon at the P < 0.01 level. Adherence was significantly greater to lidofilcon than bufilcon only at 1 x 10(5) and 10(6); P < 0.05 (ANOVA). This study suggests that adherence of A. polyphaga to contact lenses increases with the number of organisms in the inoculum, but the relationship is not directly proportional. The number of adherent organisms varies by contact lens type, with the greatest adherence to lidofilcon and the least to etafilcon lenses.

A weight reduction intervention that optimizes use of practitioner's time, lowers glucose level, and raises HDL cholesterol level in older adults.

OBJECTIVE: The effects of a cognitive-behavioral weight control intervention were compared in two independent-living, older adult (mean age = 70.5 years) communities. DESIGN: The research design compared the experimental community (n = 163), which received the intervention, with the control community (n = 162). SUBJECTS: Overweight individuals (> 4.5 kg of age-adjusted weight according to height-weight tables) were recruited from both communities. INTERVENTION: Components of the Dietary Intervention: Evaluation of Technology (DIET) program included a video-tape, a workbook, computerized tracking of participants, a telephone hot line, educational group discussions, and individual consultation. OUTCOME MEASURES: Changes in body weight, body mass index, and lipid and glucose measures were selected to evaluate the effectiveness of the intervention. STATISTICAL ANALYSIS: One-way analysis of variance by group was done to compare changes in continuous variables between the intervention and control communities. RESULTS: Baseline body mass index and weight were 30.8 and 79.5 kg, respectively, in the experimental community and 28.8 and 75.8 kg, respectively, in the control community. Mean weight change in the experimental community was -3.2 kg after 40 weeks of intervention, compared with no weight change in the control community (P < .0001). Mean plasma glucose level decreased -0.3 mmol/L and mean high-density lipoprotein cholesterol level increased 0.15 mmol/L in the experimental community, compared with no change in lipid parameter and a +0.3 mmol increase in glucose level in the control community (P < .0001). APPLICATIONS: Our findings suggest that an intervention that optimizes use of the practitioner's time can achieve a moderate weight loss and metabolic improvement in a community of older adults.

Reevaluation of host corneal tissue 1955 to 1970: Calcofluor white staining for occult acanthamoebic infection.

The incidence of acanthamoebic keratitis before 1974 is not known. A retrospective study was conducted to understand better the early epidemiology of this infection. Host corneal tissue from therapeutic penetrating keratoplasties submitted to the Stanford Eye Pathology Laboratory from 1955 to 1970 were stained with Calcofluor white and observed by fluorescence microscopy. We reviewed 197 cases, and no misdiagnosed cases of acanthamoebic infection were found.

Delayed onset of varicella keratitis.

Although varicella is one of the most common infectious diseases in the United States, systemic and ocular complications are rare. We report a patient who developed disciform edema followed by microdendritic keratitis 1 and 2 months, respectively, after resolution of the acute phase of varicella. Cultures were negative, but serologic analysis found positive antibodies against varicella zoster virus and negative antibodies against herpes simplex virus. Based on this case and on a review of the literature, we believe that this delayed onset of keratitis represents a distinct category of varicella corneal complications.

A spectrum of bilateral squamous conjunctival tumors associated with human papillomavirus type 16.

Three patients with bilateral tumors presenting as multiple keratinizing and verrucous lesions of the bulbar and tarsal conjunctiva were determined by DNA amplification and hybridization studies to harbor human papillomavirus type 16 (HPV-16). Results of biopsy in two patients showed infiltrating squamous cell carcinoma in one eye and dysplasia or carcinoma in situ in the fellow eye. In the third patient, focal, inflamed, hypertrophic, papillary lesions with pseudoglandular invaginations of the surface epithelium were found in the tarsal conjunctivae of both eyes. These are the first documented cases of bilateral conjunctival tumors associated with human papillomavirus.