Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias.

OBJECTIVES: To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 to 2015. METHODS: We estimated Poisson models examining the relationships of personal care aide, registered nurse (RN), licensed practical nurse (LPN), and total nursing hours with injury-related ED visits. Models were adjusted for resident characteristics (ie, age, race, sex, dual eligibility, presence and number of chronic conditions), AL community characteristics (percentage of residents on Medicaid, average resident acuity), year fixed effects, and assisted living fixed effects. We examined all injury-related ED visits and injury-related ED visits resulting in hospital admission as separate outcomes. RESULTS: The sample included 122,700 person-months, representing 12,144 fee-for-service Medicare beneficiaries with ADRD within 455 different AL communities in Ohio between 2007 and 2015. Median total nursing hours increased from 1.34 in 2007 to 1.69 in 2015. In the fully adjusted model, an increase in 1 RN-hour per resident-day was associated with a decrease in the risk of any injury-related ED visit (incidence rate ratio 0.59, 95% CI 0.36-0.96), representing a 53% decrease. Changes in RN-hours were not associated with injury-related inpatient hospitalizations. Changes in total nursing, LPN, and personal care aide hours were not associated with changes in the risk of injury-related ED visits or inpatient hospitalizations. CONCLUSIONS AND IMPLICATIONS: Increases in RN staffing hours were associated with reduced injury-related ED use among AL residents with ADRD. RNs provide surveillance and care oversight that may help mitigate injury risk, and they are able to physically assess residents at the time of a fall and/or injury, which can preempt unnecessary ED transfers.

Brain-wide circuit-specific targeting of astrocytes.

Astrocytes are integral components of brain circuitry. They enwrap synapses, react to neuronal activity, and regulate synaptic transmission. Astrocytes are heterogeneous and exhibit distinct features and functions in different circuits. Selectively targeting the astrocytes associated with a given neuronal circuit would enable elucidation of their circuit-specific functions but has been technically challenging to date. Recently, we constructed anterograde transneuronal viral vectors based on yellow fever vaccine YFV-17D. Among them, the replication-incompetent YFVΔNS1-Cre can selectively turn on reporter genes in postsynaptic neurons if the viral gene NS1 is expressed in postsynaptic neurons. Here we show that without exogenous expression of NS1 at the postsynaptic sites, locally injected YFVΔNS1-Cre selectively turns on reporter genes in astrocytes in downstream brain regions. The targeting of astrocytes can occur across the whole brain but is specific for the neuronal circuits traced. Therefore, YFVΔNS1-Cre provides a tool for selective genetic targeting of astrocytes to reveal their circuit-specific roles.

A Comparison of Emergency Preparedness Policies by Long-Term Care Setting Type in Ohio: Assisted Living Settings Lag Behind Nursing Homes in Key Areas.

Skilled nursing facilities (SNFs) have received regulatory attention in relation to their emergency preparedness. Yet, assisted living settings (ALs) have not experienced such interest due to their classification as a state-regulated, home- and community-based service. However, the growth in the number of ALs and increased resident acuity levels suggest that existing disaster preparedness policies, and therefore, plans, lag behind those of SNFs. We examined differences in emergency preparedness policies between Ohio's SNFs and ALs. Data were drawn from the 2015 wave of the Ohio Biennial Survey of Long-Term Care Facilities. Across setting types, most aspects of preparedness were similar, such as written plans, specifications for evacuation, emergency drills, communication procedures, and preparations for expected hazards. Despite these similarities, we found SNFs were more prepared than large ALs in some key areas, most notably being more likely to have a backup generator and 7 days of pharmacy stocks and generator fuel.

The impact of stroke on psychological and physical function outcomes in people with long-term physical disability.

BACKGROUND: An increased number of people who have a long-term physical disability (LTPD) are aging. Similar to older adults without previous disability, individuals with LTPD may experience age-related comorbidities secondary to aging. A leading cause of disability in the United States among older adults is stroke. Limited evidence supports that individuals with LTPD are at higher risk of a stroke compared to those without disability. Stroke may negatively impact physical, cognitive, and/or psychosocial function. For those who have lived longer with LTPD, the impact of stroke may differ. OBJECTIVE: To determine the impact of stroke on health outcomes in people with LTPD. METHODS: Thirty-three individuals with both LTPD and self-reported stroke were identified in a national purposive sample of adults reporting physical disability associated with LTPD (Group A). Group A was compared to an age matched sample of 33 individuals with the same conditions but no stroke (Group B). Group A participants were also compared to national norms based on age cohort from a national sample of 182 stroke survivors (Group C). RESULTS: Age range of all participants = 65-74 years. Combine sample among three groups = 248. Group A did not differ from Group B. However, Group A reported significantly higher pain interference (p < .001), fatigue (p = .003), and decreased physical function (p < .001) than Group C. CONCLUSIONS: The study informs how the impact of acquiring another condition after living with a LTPD differs among a general stroke population and those who are living with LTPD.

Is There a Woodwork Effect? Addressing a 200-Year Debate on the Impacts of Expanding Community-Based Services.

In U.S. social welfare history, many have suggested that if benefits were too attractive, consumers would come out of the woodwork to take advantage of the opportunity. Clinical trials have provided evidence of the woodwork effect's existence, suggesting caution when expanding home- and community-based services (HCBS). However, it is unclear whether these studies are best suited to assess whether a system-level effect occurs. Using state and federal data tracking Ohio's long-term services and support (LTSS) system from 1995 to 2015, this paper examines changes in the utilization rates and expenditures of Medicaid LTSS to explore whether a woodwork effect occurred as Ohio moved to improve its LTSS system balance (80% Nursing Home [NH], 20% HCBS) to (49% Nursing Home [NH], 51% HCBS). After accounting for population growth of individuals older than 60 and those with two or more impairments in activities of daily living, there was no change in utilization rates of older people with severe disability (1995: 491 per 1000 population, 2015: 495 per 1000 population) or overall LTSS expenditures (1997: $2.7 million [in 2013 dollars], 2013: $2.9 million). Our results suggest that states can make significant strides in HCBS expansion without increasing the overall long-term services utilization rate.

Prediction of Scoliosis Curve Correction Using Pedicle Screw Constructs in AIS: A Comparison of Fulcrum Bend Radiographs and Traction Radiographs Under General Anesthesia.

STUDY DESIGN: Retrospective radiographic review. OBJECTIVES: Our objectives were to (1) compare the ability of fulcrum bend radiographs and traction radiographs under general anesthesia to predict correction of adolescent idiopathic scoliosis (AIS) using pedicle screw only constructs and (2) compare the fulcrum bend correction index (FBCI) with a new measurement: the traction correction index (TCI). METHODS: This is a retrospective radiographic review of 80 AIS patients (62 female and 18 male), who underwent scoliosis correction with pedicle screw only constructs. The mean age at surgery was 14 years (range 9-20 years). Radiographic analysis was carried out on the preoperative and immediate postoperative posteroanterior standing radiographs and the preoperative fulcrum bend radiographs and traction radiographs under general anesthesia. FBCI is calculated by dividing the correction rate by the fulcrum flexibility and TCI is calculated by dividing the correction rate by the traction flexibility. RESULTS: Preoperative mean Cobb angle of 63.9° was corrected to 25.8° postoperatively. The mean fulcrum bending Cobb angle was 37.6° and traction Cobb angle was 26.6°. The mean fulcrum flexibility was 41.1%, traction flexibility 58.4%, and correction rate 59.6%. The median FBCI was 137% and TCI was 104.3%. CONCLUSIONS: When comparing fulcrum bend and traction radiographs, we found the traction radiographs to be more predictive of curve correction in AIS using pedicle screw constructs. TCI takes into account the curve flexibility better than FBCI.

Promoting resilience in individuals aging with multiple sclerosis: Results from a pilot randomized controlled trial.

PURPOSE/OBJECTIVE: Starting in middle adulthood, individuals living with multiple sclerosis (MS) are confronted with the simultaneous challenge of coping with advancing MS alongside age-related changes. Psychological resilience is thought to play an important role in promoting healthy aging and thus may be important in the context of aging with MS. This study aimed to evaluate whether Everyday Matters, a novel positive psychology program, had a positive effect on resilience and other related outcomes in adults with MS relative to a wait-list control group. Research Method/Design: This was a single-center two-group pilot randomized (1:1) controlled trial comparing the Everyday Matters intervention to a waitlist control. Randomized participants were N = 31 adults with MS aged ≥ 45 years. The 6-week program, developed by the National MS Society, was delivered via group teleconference and supplemented with readings, videos, and online participation. Participants in both groups completed outcome assessments measuring resilience, satisfaction with social roles, mood, pain, fatigue, and sleep at baseline and posttreatment. RESULTS: Analyses on N = 27 participants who completed study assessments revealed a significant group effect for resilience and satisfaction with social roles, and trend differences for positive affect and well-being and depressive symptom severity. At posttreatment, participants in the intervention group reported the group to be very helpful, found the telephone-based delivery convenient, and felt the benefits of participating outweighed the effort. CONCLUSIONS/IMPLICATIONS: These results suggest that the Everyday Matters program shows promise for increasing resilience in adults with MS and that a full-scale randomized controlled trial is warranted. (PsycINFO Database Record

Instilling positive beliefs about disabilities: pilot testing a novel experiential learning activity for rehabilitation students.

PURPOSE: To develop and test a novel impairment simulation activity to teach beginning rehabilitation students how people adapt to physical impairments. METHODS: Masters of Occupational Therapy students (n = 14) and Doctor of Physical Therapy students (n = 18) completed the study during the first month of their program. Students were randomized to the experimental or control learning activity. Experimental students learned to perform simple tasks while simulating paraplegia and hemiplegia. Control students viewed videos of others completing tasks with these impairments. Before and after the learning activities, all students estimated average self-perceived health, life satisfaction, and depression ratings among people with paraplegia and hemiplegia. RESULTS: Experimental students increased their estimates of self-perceived health, and decreased their estimates of depression rates, among people with paraplegia and hemiplegia after the learning activity. The control activity had no effect on these estimates. CONCLUSIONS: Impairment simulation can be an effective way to teach rehabilitation students about the adaptations that people make to physical impairments. Positive impairment simulations should allow students to experience success in completing activities of daily living with impairments. Impairment simulation is complementary to other pedagogical methods, such as simulated clinical encounters using standardized patients. Implication of Rehabilitation It is important for rehabilitation students to learn how people live well with disabilities. Impairment simulations can improve students' assessments of quality of life with disabilities. To be beneficial, impairment simulations must include guided exposure to effective methods for completing daily tasks with disabilities.

Results of the Scoliosis Research Society Morbidity and Mortality Database 2009-2012: A Report From the Morbidity and Mortality Committee.

INTRODUCTION: Members of the Scoliosis Research Society are required to annually submit complication data regarding deaths, visual acuity loss, neurological deficit and infection (2012-1st year for this measure) for all deformity operations performed. The purpose of this study is to report the 2012 results and the differences in these complications from the years 2009-2012. METHODS: The SRS M&M database is a self-reported complications registry of deformity operations performed by the members. The data from 2009-2012, inclusive, was tabulated and analyzed. Differences in frequency distribution between years were analyzed with Fisher's exact test. Significance was set at α = 0.05. RESULTS: The total number of cases reported increased from 34,332 in 2009 to 47,755 in 2012. Overall mortality ranged from 0.07% in 2011 to 0.12% in 2009. The neuromuscular scoliosis group had the highest mortality rate (0.44%) in 2010. The combined groups' neurological deficit rate increased from 0.44% in 2009 to 0.79% in 2012. Neurological deficits were significantly lower in 2009 compared to 2012 for idiopathic scoliosis >18 years, other scoliosis, degenerative and isthmic spondylolisthesis and other groups. The groups with the highest neurological deficit rates were dysplastic spondylolisthesis and congenital kyphosis. There were no differences in vision loss rates between years. The overall 2012 infection rate was 1.14% with neuromuscular scoliosis having the highest group rate at 2.97%. CONCLUSION: Neuromuscular scoliosis has the highest complication rates of mortality and infection. The neurological deficit rates of all groups combined have slightly increased from 2009 to 2012 with the highest rates consistently being in the dysplastic spondylolisthesis and congenital kyphosis groups. This could be due to a number of factors, including more rigorous reporting.

A comparison of revision and rerupture rates of ACL reconstruction between autografts and allografts in the skeletally immature.

PURPOSE: Anterior cruciate ligament reconstructions (ACLRs) in skeletally immature patients are increasing. The purpose of this study is to describe the demographics, graft usage, revision, and re-operation rates in skeletally immature ACLRs in the Kaiser Permanente healthcare system. METHODS: Skeletally immature patients (<17.0 years old with open physes) were identified using the Kaiser Permanente ACLR registry. Multi-ligament reconstructions and physeal-sparing ACLRs were excluded. Aseptic revision and same-knee re-operation were the outcomes of interest. Exposure of interest was graft type; bone-patellar-tendon-bone (BPTB) autograft, hamstring autograft, and any type of allograft. Age, gender, body mass index (BMI), and race were evaluated as confounders. Cox proportional hazard models stratified by surgeon were used to analyse the risk of revision and re-operation. RESULTS: A total of 534 primary ACLR cases were evaluated with a mean follow-up of 2.9 years. The majority were hamstring autografts (n = 388, 72.7%), male (n = 339, 63.9%), and White (n = 232, 43.4%). Median age was 14.9 years, and median BMI was 21.9 kg/m(2). There were 44 (8.2%) aseptic revisions and 48 (9.0%) same-knee re-operations. The incidence rate for revision was BPTB autograft 5.5%, hamstring autograft 7.5%, and allograft 13.2%. After adjusting for confounders and surgeon clustering effect, the risk of aseptic revision and revision between allograft and hamstring autograft did not reach statistical significance. CONCLUSION: Graft selection differs in skeletally immature patients with a preponderance of surgeries being performed with hamstring tendon autografts. High revision rates were identified for all graft types used, though differences in revision rates across different graft types did not reach statistical significance. Surgeons should be aware of high rates of revision in this skeletally immature young population, although type of graft used did not appear to make a difference. LEVEL OF EVIDENCE: III.

Results of labral-level arthroscopic iliopsoas tenotomies for the treatment of labral impingement.

PURPOSE: To document the clinical results of arthroscopic iliopsoas tenotomies performed at the level of the labrum to treat labral injuries caused by iliopsoas impingement. METHODS: From a review of the database of the senior author (J.S.K.) of 300 hip arthroscopies that were performed between September 2009 and May 2011, 30 patients who had an arthroscopic release of the iliopsoas tendon at the level of the labrum and at least 2 years' follow-up were identified. In all cases the release was performed to treat a tight psoas tendon that was found at arthroscopy to be impinging on a torn or inflamed labrum. The results of hip arthroscopy in these patients were assessed with Byrd's 100-point modified Harris Hip Score system before arthroscopy and at 3, 6, 12, and 24 months after surgery. RESULTS: The mean age of the 30 patients was 35 years, and their preoperative scores averaged 43 points. After surgery, the patients had 6-month scores that averaged 73 points and 12-month scores that averaged 84 points (range, 40 to 100 points). Over the first postoperative year, in 3 of the 5 patients whose preoperative ultrasound imaging showed snapping of the tendon, recurrent painful snapping developed in the hip. All 3 had iliopsoas bursa injections and had immediate relief of their hip pain. In 2 patients the relief was temporary and an arthroscopic release of the tendon at the lesser trochanter was performed. The 2-year scores of the remaining 28 patients who did not have a second iliopsoas tenotomy averaged 88 points, and 23 of these patients had good or excellent results (scores ≥80 points). CONCLUSIONS: An arthroscopic release of the iliopsoas tendon at the level of the labrum was effective for alleviating hip pain from labral lesions caused by impingement of the tendon in 23 of 30 patients (77%). The remaining 7 patients had persistent hip pain and hip scores lower than 80 points because of recurrent snapping of the tendon (3), development of avascular necrosis (1), progression of degenerative joint disease (1), or chronic greater trochanteric bursitis (2). LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Association between components of body composition and scoliosis: a prospective cohort study reporting differences identifiable before the onset of scoliosis.

There is an increasing body of research suggesting that low body weight is associated with scoliosis, but this is based on case-control studies, which are prone to bias. No studies have investigated the components of body weight: fat and lean mass. We have therefore carried out the first population-based prospective study of the association between fat and lean mass at age 10 years assessed by dual-energy X-ray absorptiometry (DXA), with presence of scoliosis at age 15 years using the Avon Longitudinal Study of Parents and Children (ALSPAC). All children with scoliosis at age 10 years were excluded. Of 5299 children at age 15 years, 312 (5.9%) had scoliosis. Our results show a negative association between body mass index (BMI)/body weight at age 10 years and scoliosis at age 15 years, with a 20% reduced risk of scoliosis per SD increase in BMI (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.70-0.92; p = 0.001). This association with BMI/body weight reflects associations with both fat mass and lean mass. After adjustment for age, gender, leg length, and fat mass per SD increase in lean mass, there was a 20% reduced risk of scoliosis (OR, 0.80; 95% CI, 0.65-0.97) and per SD increase in fat mass there was a 13% reduced risk of scoliosis (OR, 0.87; 95% CI, 0.74-1.03). In terms of adipocyte function, an inverse association was seen between leptin at age 10 years and scoliosis (OR for scoliosis per SD increase in leptin of 0.78; 95% CI, 0.63-0.99), and a positive association between adiponectin at age 10 years and scoliosis (OR for scoliosis per SD increase in adiponectin of 1.44; 95% CI, 0.99-2.10). This is the first study to address the association between the individual components of body weight and scoliosis in a prospective cohort study, and shows altered body composition that is present before the onset of clinically detected scoliosis.

Identifying scoliosis in population-based cohorts: development and validation of a novel method based on total-body dual-energy x-ray absorptiometric scans.

The purpose of this study was to develop and validate a novel method of identifying scoliosis on total-body dual energy X-ray absorptiometric (DXA) scans. Scoliosis was identified on total-body DXA scans by triaging to distinguish true curves from positioning errors, followed by a modified Ferguson method to measure angles. Precision was assessed on 174 children from the Avon Longitudinal Study of Parents and Children (ALSPAC), who underwent repeat DXA scans at age 15, 2-6 weeks apart. In addition, precision of angle estimation was evaluated on 20 scans measured five times. To evaluate accuracy, angle size was compared to spinal radiographs in 13 individuals with known scoliosis. Subsequently, this method was applied to estimate scoliosis prevalence rates and curve patterns from DXA scans previously obtained in 7,298 ALSPAC participants at age 9 and 5,122 at age 15. There was substantial agreement in identifying those with scoliosis on repeat DXA scans taken 2-6 weeks apart (kappa 0.74, 95 % CI 0.59-0.89). Of repeat angle measures, 95 % were within 5°. Angle size was underestimated by approximately 40 %. Prevalence of scoliosis ≥10° in the ALSPAC was 0.3 % at age 9 and 3.5 % at age 15 and was higher in girls at both time points. The mean ± SD curve size was 12 ± 4° at age 9 years and 15 ± 7° at age 15. We have developed and validated a novel method for identifying scoliosis from DXA scans. Comparison with prevalence data using more established techniques suggests our method provides valid estimates of scoliosis prevalence in population-based cohorts.

Fall risk factors in community-dwelling elderly who receive Medicaid-supported home- and community-based care services.

OBJECTIVE: This study identifies fall risk factors in an understudied population of older people who receive community-based care services. METHOD: Data were collected from enrollees of Ohio's Medicaid home- and community-based waiver program (preadmission screening system providing options and resources today [PASSPORT]). A total of 23,182 participants receiving PASSPORT services in 2005/2006 was classified as fallers and nonfallers, and a variety of risk factors for falling was analyzed using logistic regressions. RESULTS: The following factors were identified as risk factors for falling: previous fall history, older age, White race, incontinence, higher number of medications, fewer numbers of activity of daily living limitations, unsteady gait, tremor, grasping strength, and absence of supervision. DISCUSSION: Identifying risk factors for the participants of a Medicaid home- and community-based waiver program are useful for a fall risk assessment, but it would be most helpful if the community-based care service programs incorporate measurements of known fall risk factors into their regular data collection, if not already included.

Serotonin (5-hydroxytryptamine) transporter inhibition causes bone loss in adult mice independently of estrogen deficiency.

OBJECTIVE: Selective serotonin reuptake inhibitors (SSRIs) treat depression by antagonizing the serotonin (5-hydroxytryptamine) transporter (5-HTT). These drugs may also have skeletal effects given the presence of functional serotonergic pathways in bone and evidence demonstrating detrimental effects of SSRIs on postmenopausal bone changes. This study aimed to explore the influence of an SSRI (fluoxetine hydrochloride) on the bone changes associated with estrogen deficiency in adult mice. DESIGN: Adult, female, Swiss-Webster mice underwent ovariectomy (OVX) or sham OVX and were treated daily for 4 weeks with either fluoxetine hydrochloride (5 or 20 mg/kg) or a vehicle solution (control). In vivo assessments of hindlimb areal and tibial volumetric bone mineral density were performed at baseline and after 4 weeks of intervention. Femurs and lumbar vertebrae were subsequently removed and assessed ex vivo for bone mineral density and trabecular bone architecture and turnover. RESULTS: In vivo and ex vivo skeletal measures found no interactions between OVX (estrogen deficiency) and 5-HTT inhibition, indicating that the skeletal effects of these interventions were independent. 5-HTT inhibition had detrimental skeletal effects, with the fluoxetine-treated groups having reduced bone mineral density and altered trabecular architecture. These changes resulted from both a decrease in bone formation and increase in bone resorption. CONCLUSIONS: These data indicate that a commonly prescribed SSRI has a negative influence on the adult skeleton, independent of estrogen deficiency. This finding supports clinical data demonstrating SSRI use to be associated with accelerated bone loss after menopause and highlights a need for further research into the skeletal effects of SSRIs.

Basic bookkeeping and avoiding theft.

Bookkeeping practices in dental offices may be relatively simple, but care must be taken to prevent employee theft. Well-chosen accounting software and routine office practices may facilitate smooth operations. Systems of internal control should be established to safeguard the practice's finances. The dental practitioner should be very involved in their practice's accounting to maintain order, prevent theft, and keep costs under control.

Helical tomotherapy: image guidance and adaptive dose guidance.

Helical tomotherapy is a volumetric image-guided, fully dynamic, intensity-modulated radiation therapy (IMRT) delivery system. The daily use of its pretreatment megavoltage (MV) CT imaging for patient setup verification allows one to correct for interfraction setup error. This is a primary requirement for the accurate delivery of complex IMRT treatment plans, which give differential radiation doses to various target volumes while conformally avoiding normal critical structures. In particular, image guidance using MV CT allows for direct target position verification with the patient in the actual treatment position just prior to therapy delivery. Moreover, since helical MV CT imaging is a slow CT imaging technique, it allows for the encoding of target motion in the resulting MV CT data set, and therefore the pretreatment verification of a motion envelope defined from four-dimensional CT.

Exercise when young provides lifelong benefits to bone structure and strength.

UNLABELLED: Short-term exercise in growing rodents provided lifelong benefits to bone structure, strength, and fatigue resistance. Consequently, exercise when young may reduce the risk for fractures later in life, and the old exercise adage of "use it or lose it" may not be entirely applicable to the skeleton. INTRODUCTION: The growing skeleton is most responsive to exercise, but low-trauma fractures predominantly occur in adults. This disparity has raised the question of whether exercised-induced skeletal changes during growth persist into adulthood where they may have antifracture benefits. This study investigated whether brief exercise during growth results in lifelong changes in bone quantity, structure, quality, and mechanical properties. MATERIALS AND METHODS: Right forearms of 5-week-old Sprague-Dawley rats were exercised 3 days/week for 7 weeks using the forearm axial compression loading model. Left forearms were internal controls and not exercised. Bone quantity (mineral content and areal density) and structure (cortical area and minimum second moment of area [I(MIN)]) were assessed before and after exercise and during detraining (restriction to home cage activity). Ulnas were removed after 92 weeks of detraining (at 2 years of age) and assessed for bone quality (mineralization) and mechanical properties (ultimate force and fatigue life). RESULTS: Exercise induced consistent bone quantity and structural adaptation. The largest effect was on I(MIN), which was 25.4% (95% CI, 15.6-35.3%) greater in exercised ulnas compared with nonexercised ulnas. Bone quantity differences did not persist with detraining, whereas all of the absolute difference in bone structure between exercised and nonexercised ulnas was maintained. After detraining, exercised ulnas had 23.7% (95% CI, 13.0-34.3%) greater ultimate force, indicating enhanced bone strength. However, exercised ulnas also had lower postyield displacement (-26.4%; 95% CI, -43.6% to -9.1%), indicating increased brittleness. This resulted from greater mineralization (0.56%; 95% CI, 0.12-1.00%), but did not influence fatigue life, which was 10-fold greater in exercised ulnas. CONCLUSIONS: These data indicate that exercise when young can have lifelong benefits on bone structure and strength, and potentially, fracture risk. They suggest that the old exercise adage of "use it or lose it" may not be entirely applicable to the skeleton and that individuals undergoing skeletal growth should be encouraged to perform impact exercise.

Anterior transvertebral transposition of the spinal cord for the relief of paraplegia associated with congenital cervicothoracic kyphoscoliosis. Technical note.

The authors describe a technique for the relief of spinal cord compression associated with congenital kyphoscoliosis. A 13-year-old girl with congenital cervicothoracic kyphoscoliosis had undergone in situ fusion; spastic paraparesis and bladder disturbance developed postoperatively. Spinal cord detethering and posterolateral decompression temporarily arrested the neurological deterioration; however, the patient's condition then progressed to paraplegia with a partial sensory level at L-1. Imaging demonstrated persisting cord compression at the apex of the kyphotic curve. Transvertebral transposition of the spinal cord was performed using sagittal vertebrotomies, preserving the lateral aspects of the vertebral bodies, pedicles, and fusion mass. By 2 years postoperatively she had recovered normal sensation and good bladder function and was walking unaided. Transposition of the spinal cord may be used to relieve spinal cord compression associated with complex spinal deformities.