Utility of data linkage for orthopaedic service planning in the paediatric population with cerebral palsy at Starship Children's Hospital.

AIMS: To determine the accuracy of orthopaedic surgical procedure coding (ICD-10-AM/ACHI/ACS) for children with cerebral palsy (CP) at Starship Children's Hospital, use data linkage with the New Zealand Cerebral Palsy Register (NZCPR) to obtain demographic and clinical information for children with CP requiring orthopaedic surgical services in the Auckland District Health Board catchment area, and to determine if trends in the clinical and demographic data are useful for future service planning for children with CP. METHODS: Surgical admission data for children with CP aged 0-18 years at the time of their first procedure were extracted from Auckland District Health Board records for 2013-2018, and information on demographics and Gross Motor Function Classification System level were obtained from the NZCPR. The ICD-10-AM/ACHI/ACS codes for surgery/intervention were matched with the operation notes in the electronic health records using NHI numbers and assessed for accuracy. RESULTS: During the study period, 261 paediatric patients with CP underwent orthopaedic procedures, which could be grouped broadly into five categories (spine, upper limb, lower limb, Botulinum-A toxin injection only, and other) with a coding accuracy of 95%. Clinical and demographic data could be obtained from the NZCPR for 232 (88.9%) of the 261 patients. CONCLUSIONS: Using orthopaedic surgical procedure codes, we could identify broad categories of procedures received by children with CP and the demographic and clinical characteristics of these children, which will assist with service planning and identify trends in care delivery.

The Validity and Reliability of a Kinect v2-Based Gait Analysis System for Children with Cerebral Palsy.

The aim of this study is to evaluate if Kinect is a valid and reliable clinical gait analysis tool for children with cerebral palsy (CP), and whether linear regression and long short-term memory (LSTM) recurrent neural network methods can improve its performance. A gait analysis was conducted on ten children with CP, on two occasions. Lower limb joint kinematics computed from the Kinect and a traditional marker-based Motion Analysis system were investigated by calculating the root mean square errors (RMSE), the coefficients of multiple correlation (CMC), and the intra-class correlation coefficients (ICC2,k). Results showed that the Kinect-based kinematics had an overall modest to poor correlation (CMC-less than 0.001 to 0.70) and an angle pattern similarity with Motion Analysis. After the calibration, RMSE on every degree of freedom decreased. The two calibration methods indicated similar levels of improvement in hip sagittal (CMC-0.81 ± 0.10 vs. 0.75 ± 0.22)/frontal (CMC-0.41 ± 0.35 vs. 0.42 ± 0.37) and knee sagittal kinematics (CMC-0.85±0.07 vs. 0.87 ± 0.12). The hip sagittal (CMC-0.97±0.05) and knee sagittal (CMC-0.88 ± 0.12) angle patterns showed a very good agreement over two days. Modest to excellent reliability (ICC2,k-0.45 to 0.93) for most parameters renders it feasible for observing ongoing changes in gait kinematics.

Pelvic Tilt Changes After Hamstring Lengthening in Children With Cerebral Palsy.

BACKGROUND: Flexion deformity of the knee is a common presentation in children with cerebral palsy with hamstring surgery as an option for addressing this. However, concerns with regard to increased pelvic tilt have been raised. The purpose of this study was to compare preoperative and postoperative pelvic tilt after isolated hamstring lengthening versus combined hamstring lengthening and the influence of Gross Motor Function Classification System (GMFCS) levels on pelvic tilt. METHODS: This retrospective study included 46 ambulatory children with cerebral palsy who had had open medial hamstring lengthening (mean age at surgery, 11 y 11 mo; SD, 2 y 11 mo; GMFCS I, 16; GMFCS II 20; GMFCS III 10). Twelve children underwent isolated surgery and 34 children underwent combined surgery. The isolated hamstring procedures could be combined with foot and/or ankle-level surgery, as only the hamstring procedure would affect the pelvic tilt. Combined surgery was defined as hamstring lengthening with other procedures performed at the knee or more proximally. The preoperative and postoperative 3-dimensional gait analysis data were evaluated in this study. RESULTS: Both the isolated and combined hamstring lengthening groups showed no significant change in pelvic tilt ([INCREMENT]1.28, P=0.203; [INCREMENT]1.47, P=0.113, respectively). A significant change in pelvic tilt was seen in children functioning at GMFCS III ([INCREMENT]4.66, P=0.009) but not GMFCS I and II ([INCREMENT]0.37, P=0.718; [INCREMENT]0.48, P=0.697). Significant postoperative decreases in the knee flexion angle at initial contact were seen for both isolated ([INCREMENT]5.72, P=0.010) and combined hamstring lengthening ([INCREMENT]10.95, P<0.001). CONCLUSIONS: Hamstring lengthening, for the majority of patients, did not lead to a clinically significant change in mean pelvic tilt and improved knee flexion angle at initial contact. Children who functioned at GMFCS level III had an increase in anterior pelvic tilt and caution should be exercised in this group. STUDY DESIGN: Level IV evidence-case series.

Variability of total step activity in children with cerebral palsy: influence of definition of a day on participant retention within the study.

BACKGROUND: Activity monitoring is important to establish accurate daily physical activity levels in children with cerebral palsy (CP). However, few studies address issues around inclusion or exclusion of step count data; in particular, how a valid day should be defined and what impact different lengths of monitoring have on retention of participant data within a study. This study assessed how different 'valid day' definitions influenced inclusion of participant data in final analyses and the subsequent variability of the data. RESULTS: Sixty-nine children with CP were fitted with a StepWatch™ Activity Monitor and instructed to wear it for a week. Data analysis used two broad definitions of a day, based on either number of steps in a 24 h monitoring period or the number of hours of recorded activity in a 24 h monitoring period. Eight children either did not use the monitor, or used it for only 1 day. The remaining 61 children provided 2 valid days of monitoring defined as >100 recorded steps per 24 h period and 55 (90 %) completed 2 valid days of monitoring with ≥10 h recorded activity per 24 h period. Performance variability in daily step count was lower across 2 days of monitoring when a valid day was defined as ≥10 h recorded activity per 24 h period (ICC = 0.765) and, higher when the definition >100 recorded steps per 24 h period (ICC = 0.62). Only 46 participants (75 %) completed 5 days of monitoring with >100 recorded steps per 24 h period and only 23 (38 %) achieved 5 days of monitoring with ≥10 h recorded activity per 24 h period. Datasets of participants who functioned at GMFCS level II were differentially excluded when the criteria for inclusion in final analysis was 5 valid days of ≥10 h recorded activity per 24 h period, leaving datasets available for only 8 of 32 participant datasets retained in the study. CONCLUSION: We conclude that changes in definition of a valid day have significant impacts on both inclusion of participant data in final analysis and measured variability of total step count.

Gait Deviation Index Correlates With Daily Step Activity in Children With Cerebral Palsy.

OBJECTIVES: To examine the association between the Gait Deviation Index (GDI), a multivariate measure of overall gait impairment, and measures of both community walking performance and walking capacity within the clinic setting in ambulatory children with cerebral palsy. DESIGN: Cross-sectional study. SETTING: Gait analysis, 6-minute walk test (6MWT), and self-selected walking speed (WS) were conducted in laboratory and clinic settings. Activity monitoring was done in participants' community environment. PARTICIPANTS: Children with cerebral palsy (N=55; age range, 6-18y) with Gross Motor Function Classification System levels I to III. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The GDI was derived from gait analysis data as a measure of overall gait impairment; an activity monitor was used to capture community walking performance, and the 6MWT and WS were the clinic-based measures of walking capacity. RESULTS: Fifty-five children had a median GDI of 78.86 (range, 53.07-105.34). A moderate association was found between the GDI and daily step count (Spearman ρ=.58; 95% confidence interval [CI], .37-.74; P<.0001). Weaker associations were found between the GDI and 6MWT (Spearman ρ=.4718; 95% CI, .2283-.6597; P<.0003) and between the GDI and WS (Spearman ρ=.3949; 95% CI, .1368-.6028; P<.0028). CONCLUSIONS: The GDI has a moderate association with daily step count, which suggests that interventions that positively change gait kinematics may also affect community walking performance. Although the GDI's deviation from the normal value provides valuable information, other measures are required to provide a complete picture of a child's walking capacity and performance.

The relationship between academic assessment and psychological distress among medical students: a systematic review.

A systematic review was conducted to determine the relationship between academic assessment and medical student psychological distress with the aim of informing assessment practices. A systematic literature search of six electronic databases (Medline, Medline IN PROCESS, PubMed, EMBASE, Psychinfo, ERIC) from 1991 to May 2014 was completed. Articles focusing on academic assessment and its relation to stress or anxiety of medical students were included. From 3,986 potential titles, 82 full-text articles were assessed for eligibility, and 23 studies met review inclusion criteria. Studies focused on assessment stress or anxiety, and assessment performance. Consistent among the studies was the finding that assessment invokes stress or anxiety, perhaps more so for female medical students. A relationship may exist between assessment stress or anxiety and impaired performance. Significant risks of bias were common in study methodologies. There is evidence to suggest academic assessment is associated with psychological distress among medical students. However, differences in the types of measures used by researchers limited our ability to draw conclusions about which methods of assessment invoke greater distress. More rigorous study designs and the use of standardized measures are required. Future research should consider differences in students' perceived significance of assessments, the psychological effects of constant exposure to assessment, and the role of assessment in preparing students for clinical practice.

Radiological outcome of reconstructive hip surgery in children with gross motor function classification system IV and V cerebral palsy.

Hip subluxation is common in children with cerebral palsy (CP). The aim of this study was to describe the radiological outcome of reconstructive hip surgery in children with CP, gross motor function classification system (GMFCS) level IV and V, and determine whether the GMFCS level plays a predictive role in outcome. This was a retrospective cohort study conducted at a tertiary-level pediatric hospital with a CP hip surveillance program. Of 110 children with GMFCS IV and V CP registered for hip surveillance, 45 underwent reconstructive hip surgery between 1997 and 2009, defined as varus derotational proximal femoral osteotomy with or without additional pelvic osteotomy. Eleven children were excluded because of lack of 12-month follow-up (n=10) or missing clinical records (n=1). Thus, 21 GMFCS IV children (median age 6 years at surgery) and 13 GMFCS V children (median age 5 years at surgery), who underwent 58 index surgeries, were included in the study. Clinical records and radiology were reviewed. The two surgical groups were femoral osteotomy (varus derotational femoral osteotomy with an AO blade plate or femoral locking plate fixation), or femoral ostetotomy with additional pelvic osteotomy. Reimer's migration percentage (MP) was calculated from anteroposterior pelvis radiographs to determine the outcome for each hip independently. Failure was defined as MP of greater than 60% or further operation on the hip. Reconstructive surgeries were performed for 58 hips with a median preoperative MP of 55%. There were 15 failures at a median of 62 months, including nine failures in 35 GMFCS IV hips and six failures in 23 GMFCS V hips. Overall, GMFCS V hips tended to fail earlier, (hazard ratio 2.3) with a median time to failure of 78 and 39 months for GMFCS IV and V hips, respectively. Combined femoral and pelvic osteotomies had the lowest failure rates in both groups of patients. The GMFCS classification may have some predictive value for outcomes following reconstructive hip surgery, with surgery for GMFCS V hips tending to fail earlier.

Reported outcomes of lower limb orthopaedic surgery in children and adolescents with cerebral palsy: a mapping review.

AIM: Lower limb surgery is often performed in ambulatory children with cerebral palsy (CP) to improve walking ability. This mapping review reports on outcome measures used in the published literature to assess surgical results, determine range and frequency of use, and map each measure to the International Classification of Functioning, Disability and Health. METHOD: A mapped review of literature published between 1990 and 2011 was carried out to identify papers reporting the outcomes of lower limb orthopaedic surgery in ambulatory children with CP, aged 0 to 20 years. RESULTS: A total of 229 published papers met the inclusion criteria. Thirty-two outcome measures with known psychometric properties were reported in the 229 papers. Twenty measures assess impairments in body structure and function and were used in 91% of studies. Ten measures assess restrictions in activity and participation and were used in 9% of papers. Two measures assessed quality of life. Since 1997, 29% of papers have used the Gross Motor Function Classification System to describe participants. INTERPRETATION: The body of literature evaluating outcomes of lower limb orthopaedic surgery in CP is small but increasing. There is a need to develop a suite of outcome measures that better reflect outcomes across the International Classification of Functioning, Disability and Health, including activity and participation.

How does the functional mobility scale relate to capacity-based measures of walking ability in children and youth with cerebral palsy?

This study examined the relationship between walking performance rated on the Functional Mobility Scale (FMS) and measures of walking capacity in children with cerebral palsy (CP). A total of 143 participants with spastic CP (GMFCS levels I to III) were rated on the FMS and had assessment of self-selected walking speed (WS), fast 1 minute walk test (1MWT) and six minute walk test (6MWT). For each FMS distance, children rated 6 had significantly better 6MWT than children scored 5; children rated FMS 2, 3, or 4 had lower walking capacity measures but were not clearly distinguishable from each other. The 6MWT was an independent predictor of variation in FMS score, accounting for 20% to 27% of the variance across the three FMS distances. While walking capacity impacts on community mobility in children with CP much of the variance remains unexplained, suggesting that other factors play an important role.

Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school.

INTRODUCTION: International interest in peer-teaching and peer-assisted learning (PAL) during undergraduate medical programs has grown in recent years, reflected both in literature and in practice. There, remains however, a distinct lack of objective clarity and consensus on the true effectiveness of peer-teaching and its short- and long-term impacts on learning outcomes and clinical practice. OBJECTIVE: To summarize and critically appraise evidence presented on peer-teaching effectiveness and its impact on objective learning outcomes of medical students. METHOD: A literature search was conducted in four electronic databases. Titles and abstracts were screened and selection was based on strict eligibility criteria after examining full-texts. Two reviewers used a standard review and analysis framework to independently extract data from each study. Discrepancies in opinions were resolved by discussion in consultation with other reviewers. Adapted models of "Kirkpatrick's Levels of Learning" were used to grade the impact size of study outcomes. RESULTS: From 127 potential titles, 41 were obtained as full-texts, and 19 selected after close examination and group deliberation. Fifteen studies focused on student-learner outcomes and four on student-teacher learning outcomes. Ten studies utilized randomized allocation and the majority of study participants were self-selected volunteers. Written examinations and observed clinical evaluations were common study outcome assessments. Eleven studies provided student-teachers with formal teacher training. Overall, results suggest that peer-teaching, in highly selective contexts, achieves short-term learner outcomes that are comparable with those produced by faculty-based teaching. Furthermore, peer-teaching has beneficial effects on student-teacher learning outcomes. CONCLUSIONS: Peer-teaching in undergraduate medical programs is comparable to conventional teaching when utilized in selected contexts. There is evidence to suggest that participating student-teachers benefit academically and professionally. Long-term effects of peer-teaching during medical school remain poorly understood and future research should aim to address this.

Paediatric femoral fractures: factors influencing length of stay and readmission rate.

AIM: This report describes factors influencing length of stay and unplanned readmissions within 30 days of discharge for children presenting with femoral fractures to Starship Hospital. METHODS: The charts and radiographs of all children admitted with femoral shaft fractures between January 1998 and December 2002 were reviewed, excluding pathological fractures. The type of management, the length of stay and the unexpected readmission rate within 30 days were recorded. Ninety-three children with 95 femoral fractures were included in the study. RESULTS: Forty-six fractures were treated by application of immediate hip spica and 49 by other surgical methods (21 by external fixation, 20 by flexible intramedullary nailing and 8 by other methods). Patients with isolated femur fractures treated by either hip spica application or other operative fixation had median lengths of stay of 3 days (range 1-10 days) and 6 days (range 2-15 days), respectively. Patients with associated injuries, whose femur fractures were treated by either hip spica application or other operative fixation, had longer median lengths of stay of 5 days (3-15 days) and 17 days (5-70 days), respectively. Nine of the 93 children had an unplanned return to the operating theatre during their initial hospital stay, with increased length of stay in 5 as a result. A further 21 children were readmitted within 30 days of discharge with problems of loss of fracture alignment and cast damage in the hip spica group; pin-site infections in the external fixation group and pain around the distal nail insertion site in the flexible intramedullary nailing group. Despite these early problems, fracture alignment was satisfactory at union in 89 of the 95 fractures, with satisfactory remodelling in the remaining six fractures at follow-up. CONCLUSIONS: The presence of associated injuries was a key factor in the length of the initial hospital stay. However, the need for further operative interventions in the first hospital stay also increased the length of stay in some patients. Overall, the operative management of femoral fractures is resource intensive with a significant need for further minor operative intervention, regardless of the type of initial management.