Long-term reoperation rates following spinal fusion for neuromuscular scoliosis in nonambulatory patients with cerebral palsy.

PURPOSE: To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP). METHODS: We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated. RESULTS: 144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. CONCLUSIONS: To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood. LEVEL OF EVIDENCE: III.

Assessing tap water awareness: The development of an empirically-based framework.

Despite the often emphasized importance of water awareness, and notwithstanding the fact that calls for increasing public awareness are becoming commonplace, most studies do not define the concept, let alone operationalise it into measurable units. This is, however, essential to measure and evaluate efforts related to water awareness such as public campaigns, customer communication and behavioural interventions. To address this gap, we conceptualise, operationalise and assess tap water awareness, hereby differentiating between cognitive awareness (head), affectional awareness (heart), and behavioural awareness (hands). In parallel, we also differentiate between tap water quality, quantity and system. By building on a variety of contemporary conceptual insights in literature and a series of expert interviews, an assessment framework is developed. A cohesive set of nine awareness components are identified and operationalised into a set of tangible questions which are put to the test in a large-scale online survey (n = 1003) in the Netherlands, applying both a traditional and modern segmentation approach based on four types of perspectives ('quality & health concerned', 'aware & committed', 'egalitarian & solidary', and 'down to earth & confident'). Based on the analysis of the results of the first empirical application of our tap water awareness assessment framework, we conclude that-with a score 53.5 points out of 100-tap water awareness in the Netherlands shows ample room for improvement. Interestingly, most significant variations in awareness are generally not related to sociodemographic factors but rather apply to the four customer perspectives on drinking water that are based on people's subjective views and preferences.

What Happens to Our Neuromuscular Patients in Adulthood: Pathway to Independence and Maximal Function.

BACKGROUND: Children with neuromuscular disorders regularly seek care from pediatric orthopaedic surgeons. These conditions can have a significant impact on the growth and development of children and their function and well-being as adults. Questions exist about the long-term outcomes of musculoskeletal interventions performed during childhood. METHODS: A search of recent literature pertaining to the musculoskeletal and functional consequences of cerebral palsy, spina bifida, Duchenne muscular dystrophy, and spinal muscle atrophy was performed. Information from those articles was combined with the experience of the authors and their institutions. RESULTS: Neuromuscular conditions can result in limb and spine deformities that lead to impaired physical function. Orthopaedic interventions during childhood can improve function and well-being and can be durable into adulthood. Unfortunately, many individuals with these conditions transition to adult health care that lacks the informed, collaborative multidisciplinary care they received as children. This can lead to unmet health care needs and a shortage of long-term natural history and outcome studies that would inform the care of children today. CONCLUSIONS: Adults with childhood-onset neuromuscular conditions need, and deserve, dedicated health care systems that include the best aspects of the care they received as children. Pediatric orthopaedic surgeons have a role in promoting the development of such systems and a responsibility to learn from their adult patients. LEVEL OF EVIDENCE: Expert Opinion.

Assessing Bandung's Governance Challenges of Water, Waste, and Climate Change: Lessons from Urban Indonesia.

This study assesses the gaps, opportunities, and priorities of Bandung in managing its water and waste challenges. The City Blueprint Approach is used to identify pressures, to measure the city's Integrated Water Resources Management performance, and to assess its governance. Based on the analyses of Bandung, 4 topics are discussed in more detail: 1) the transferability of the lessons from Bandung, 2) the challenges of solid waste management in Indonesian cities, 3) community-based sanitation, and 4) implications for informal settlements. The assessment reveals that Bandung's basic water services are largely met but flood risks are high and wastewater treatment is poorly covered, leading to large-scale pollution. This is amplified by extensive land-use change and poor solid waste collection and treatment, as waste is almost completely dumped in landfills. Proper solid waste handling will reduce landfill dependency. Slum areas are disproportionately affected by climate-related hazards and continuously under recognized in the discussion of cities' risk and vulnerability, while its dwellers are the most vulnerable members of the society. Bandung has started with slum area legalization which provides slum dwellers with legal security that protects their right to live as well as access to basic public infrastructures. Inadequate monitoring and uncoordinated financial source allocations are among the governance gaps. Governance is reactive and community involvement is low. Yet, Bandung exhibits the characteristics of a collaborative city with the potential to maximize its cross-stakeholder learning with supportive leadership. Bandung and other cities in Indonesia face multilevel governance gaps. Bandung is recommended to expand the cooperation of private, civil, and public actors and implement network governance and decentralized management approaches focusing on improving the implementing capacity, better monitoring, cocreation, and better exploration of the options for financial support. Integr Environ Assess Manag 2021;17:434-444. © 2020 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Factors influencing recurrent admissions among children with disabilities in a specialty children's hospital.

PURPOSE: To describe recurrent admissions in a cohort of complex chronic patients at a specialty children's hospital, identify factors that contribute to multiple admissions, and test the hypothesis that risk factors predict patterns of readmissions within specified time intervals. METHODS: Retrospective cohort analysis of patients admitted to a specialty children's hospital during calendar year 2006 followed through 2011. Administrative and medical record abstracted data were analyzed by the total number of recurrent admissions and by readmissions with 7, 30 and 90 days at any point during the five year study period. RESULTS: One thousand two hundred and twenty-nine patients with 2295 inpatient admissions were examined. Four hundred and sixty-seven patients (38%) experienced at least one additional inpatient admission at any time during the study period. Eight variables were significant risk factors for subsequent admission at any time during the study period: indwelling technology, mobility support, critical care consultation, medical (vs. surgical) admission, mean LOS across all admissions, number of scheduled medications at discharge, insurance on index admission, and gross charges on index admission. Presence of indwelling technology, increasing numbers of scheduled medications at discharge and Nervous System APR-DRG diagnoses were significant factors predicting readmission within 7, 30, and 90 day intervals. CONCLUSIONS: Within this population of complex chronic patients risk factors were identified that predict vulnerability to recurrent admissions suggesting that further research is needed to address a unique subset of complex chronic patients and the complement of systems organized to provide health care delivery services for them.

Results and complications after spinal fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy using luque galveston instrumentation: experience in 93 patients.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To evaluate the results of spine fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy, using Luque-Galveston technique, with emphasis on the early and late complications, especially those increasing the hospital stay or requiring additional surgery. SUMMARY OF BACKGROUND DATA: There are numerous studies in the literature on the treatment of neuromuscular scoliosis using Luque-Galveston instrumentation analyzing the results and complications. Most series are small and evaluate some of the complications, with none evaluating all the early and late complications and none assessing the impact of the complication on length of hospitalization or the need for additional surgical intervention. METHODS: This was a retrospective review of a consecutive series of patients operated on for neuromuscular scoliosis in cerebral palsy and static encephalopathy with Luque-Galveston instrumentation at 1 institution from January 1997 to December 2003. Ninety-three patients were identified. RESULTS: The average age at surgery was 14.3 years, with an average age at follow-up of 18.2 years, and an average follow-up of 3.8 years. The mean preoperative scoliosis was 72° with correction postoperatively to a mean of 33°, maintained at 36° at final follow-up. There were 83 early complications in 54 patients, for a complication rate of 58% of patients for the entire study. There were no perioperative deaths or neurological complications. There was only 1 deep wound infection, for an infection rate of 1.1%. Patients with 1 complication had a longer length of stay, 9 versus 7 days, the difference being statistically significant (Mann-Whitney U test, P < 0.001). Two patients required reoperation during the initial hospitalization (1.1%): 1, one for infection and 1 for proximal hook cutout and proximal junction kyphosis. There were a total of 81 late complications in 44 patients, for a late complication rate of 47% of patients for the entire study. The majority of the complications were minor, not requiring additional care or surgery. Seven patients had a pseudarthrosis (7.5%), presenting at an average of 30 months postoperatively. Eight patients underwent 9 procedures for late complications: 5 for repair of a pseudarthrosis, 3 for removal of a prominent iliac screw, and 1 for superior junctional kyphosis. All the pseudarthrosis repairs were solid at follow-up. CONCLUSION: Spinal fusion in neuromuscular scoliosis with Luque-Galveston technique is a safe and effective procedure. Any early complication increased the length of stay, with a low rate of reoperation during the hospitalization. The majority of late complications were minor, not requiring additional care. Pseudarthroses were detected late and were the main reason for additional surgery.

Scoliosis in cerebral palsy.

Spinal deformity is a common musculoskeletal problem for individuals with cerebral palsy. Severe scoliosis may impair physical function and may be a source of pain. Spine braces and carefully constructed seating arrangements may moderate the behavior of these deformities but do not seem capable of stopping progression, which often continues in adulthood. Spine fusion surgery can produce a stable, durable trunk shape that improves sitting and positioning but the process of surgery is arduous and outcomes can be compromised by numerous serious complications. Despite complications, many families and caregivers express satisfaction with the results of surgery. Careful patient evaluation, studious attention to surgical planning and performance, and a good relationship with patients, family members, and other providers is essential.

Outbreak of osteomyelitis/septic arthritis caused by Kingella kingae among child care center attendees.

OBJECTIVE: Kingella kingae often colonizes the oropharyngeal and respiratory tracts of children but infrequently causes invasive disease. In mid-October 2003, 2 confirmed and 1 probable case of K kingae osteomyelitis/septic arthritis occurred among children in the same 16- to 24-month-old toddler classroom of a child care center. The objective of this study was to investigate the epidemiology of K kingae colonization and invasive disease among child care attendees. METHODS: Staff at the center were interviewed, and a site visit was performed. Oropharyngeal cultures were obtained from the staff and children aged 0 to 5 years to assess the prevalence of Kingella colonization. Bacterial isolates were subtyped by pulsed-field gel electrophoresis (PFGE), and DNA sequencing of the 16S rRNA gene was performed. A telephone survey inquiring about potential risk factors and the general health of each child was also conducted. All children and staff in the affected toddler classroom were given rifampin prophylaxis and recultured 10 to 14 days later. For epidemiologic and microbiologic comparison, oropharyngeal cultures were obtained from a cohort of children at a control child care center with similar demographics and were analyzed using the same laboratory methods. The main outcome measures were prevalence and risk factors for colonization and invasive disease and comparison of bacterial isolates by molecular subtyping and DNA sequencing. RESULTS: The 2 confirmed case patients required hospitalization, surgical debridement, and intravenous antibiotic therapy. The probable case patient was initially misdiagnosed; MRI 16 days later revealed evidence of ankle osteomyelitis. The site visit revealed no obvious outbreak source. Of 122 children in the center, 115 (94%) were cultured. Fifteen (13%) were colonized with K kingae, with the highest prevalence in the affected toddler classroom (9 [45%] of 20 children; all case patients tested negative but had received antibiotics). Six colonized children were distributed among the older classrooms; 2 were siblings of colonized toddlers. No staff (n = 28) or children aged <16 months were colonized. Isolates from the 2 confirmed case patients and from the colonized children had an indistinguishable PFGE pattern. No risk factors for invasive disease or colonization were identified from the telephone survey. Of the 9 colonized toddlers who took rifampin, 3 (33%) remained positive on reculture; an additional toddler, initially negative, was positive on reculture. The children of the control child care center demonstrated a similar degree and distribution of K kingae colonization; of 118 potential subjects, 45 (38%) underwent oropharyngeal culture, and 7 (16%) were colonized with K kingae. The highest prevalence again occurred in the toddler classrooms. All 7 isolates from the control facility had an indistinguishable PFGE pattern; this pattern differed from the PFGE pattern observed from the outbreak center isolates. 16S rRNA gene sequencing demonstrated that the outbreak K kingae strain exhibited >98% homology to the ATCC-type strain, although several sequence deviations were present. Sequencing of the control center strain demonstrated more homology to the outbreak center strain than to the ATCC-type strain. CONCLUSIONS: This is the first reported outbreak of invasive K kingae disease. The high prevalence in the affected toddler class and the matching PFGE pattern are consistent with child-to-child transmission within the child care center. Rifampin was modestly effective in eliminating carriage. DNA sequence analysis suggests that there may be considerable variability within the species K kingae and that different K kingae strains may demonstrate varying degrees of pathogenicity.