There are high levels of incontinence in adults with cerebral palsy, and these individuals report interference with quality of life. Despite these issues, most participants were living in the community, and incontinence scores were not related to employment.

Evaluation of pediatric spinal deformity requires knowledge of special orthopaedic testing and radiographic interpretation. The determination of recommendations for treatment of spinal abnormalities in children can be challenging and at times complex, as treatment options are dependent upon a variety of factors. The etiology of scoliosis or kyphosis, presence or absence of vertebral anomalies, symptoms, magnitude of the curve, physiologic/skeletal age, and evidence of and risk of progression all require consideration and play a role in the shared decision-making process. This article provides an overview of relevant information and includes research outcomes to support the care of pediatric patients with spinal deformities. [Pediatr Ann. 2017;46(12):e472-e480.].

BackgroundSevere hypoglycaemic events (HGEs) in hospitalised patients are associated with poor outcomes and prolonged hospitalization. Systematic, coordinated care is required for acute management and prevention of HGEs; however, studies evaluating quality control efforts are scarce.ObjectiveTo investigate the effectiveness of system-based interventions to improve management response to HGEs.MethodsSystem-based interventions were designed and implemented following a root cause analysis of HGE in adult patients with diabetes from two general medical wards with the highest incidence of HGE. Interventions included electronic medical record programming for a standardised order set for basal-bolus insulin regimen and hypoglycemia protocol, automated dextrose order, automated MD notification, and recommendation for endocrine consultation after two critical HGEs. The Pyxis MedStation was programmed to alert nurses to recheck blood glucose 15 min after the treatment. A card with the HGE management protocol was attached to each provider’s ID badge and educational seminars were given to all providers.Main outcomes and measuresPrimary outcomes were to evaluate median time from HGE (glucose <50 mg/dL) to euglycemia (>100 mg/dL), and time from HGE to follow-up finger-stick (FS) testing preintervention and postintervention. Secondary outcomes were cumulative incidence of HGEs, recurrent hypoglycemia, rate of physician notification and use of standardised treatments among adults with diabetes on the two general medical wards.ResultsAmong hospitalised adults with diabetes and HGE, median time from HGE to euglycemia declined from 225±46 min preintervention to 87±26 min postintervention (p=0.03). Median time from HGE to next FS testing also declined (76±14 min to 28±10 min, p<0.001). Standardised treatment administration for HGE improved significantly from 34% (12/35) to 97% (36/37); physician notification rate improved significantly from 51% (18/35) to 78% (29/37).Among hospitalised adults with diabetes, incidence of HGE decreased from 12% (35/295) over 3 months (preintervention period) to 6% (37/610) over 6 months (postintervention period) (p<0.001), while recurrent HGE did not show significant differences (37% (13/35) to 24% (9/37), p=0.09).ConclusionsSystem-based interventions had a clinically important impact on decreasing time from HGE to euglycemia and to next FS testing. This hypoglycemia bundle of care may be applied and tested in other community hospitals to improve patient safety.

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Patients or Programs: A 32-year-old man with complex regional pain syndrome after spinal cord injury. Program Description: The patient is an active duty Operation Enduring Freedom warrior who mounted an improvised explosive device blast, which resulted in a L1 burst fracture, multiple lumbar transverse process fractures, L4 and sacral body fractures, lumbar cord compression, conus destruction, left tibia fracture, traumatic brain injury, and numerous soft-tissue injuries. He underwent spine stabilization surgery at an outside hospital, and his American Spinal Injury Association Impairment Scale (AIS) classification was T11 AIS A. The patient's pain was well controlled with oral medications, however, he had intermittent episodes of severe pain in the first web space of his right foot. The pain was characterized as an intense, sharp, burning sensation radiating to the knee, with occasional allodynia. Exacerbations were intermittently elicited with passive stretching and interfered with therapies. He had no clonus, hyperalgesia, or erythema; leg edema was mild and symmetric, with appropriate temperature. A diagnosis of CRPS type I was established based on clinical criteria and radiologic imaging that showed juxtaarticular osteopenia consistent with CRPS. Daily oral medications included methadone, pregabalin, amitriptyline, and morphine as needed for moderate breakthrough pain. Severe exacerbations required intravenous hydromorphone every 3 hours as needed, which caused somnolence. He underwent a transcutaneous electrical neural stimulation unit trial, 2 right L5 sympathetic nerve blocks, a right L5 neurolysis, and a single lidocaine infusion dose of 5 mg/kg administered at 8 mg/min. Setting: Veterans hospital. Results: The patient had no permanent relief of his exacerbations until after the lidocaine infusion. Discussion: Intravenous lidocaine showed substantial decrease in pain parameters without significant adverse effects and was effective for treating mechanical allodynia and sympathetically dependent pain. Conclusions: Lidocaine infusion may be an adequate treatment for refractory CRPS in spinal cord injury.