The aim of this study was to assess the rate of hip dislocation at different ages in children with bilateral spastic cerebral palsy attending special schools in southern Derbyshire, UK, between 1985 and 2000. The medical notes of 110 individuals (68 males, 42 females) were obtained. They were divided into four groups according to the Gross Motor Function Classification System (GMFCS). We determined whether or not their hips were dislocated at the ages of 5, 10, and 15 years, and the kind of surgery performed in each case. The percentage of individuals with one or both hips dislocated increased with age and with severity of disease. Of those in GMFCS Level II (n= 18), none had dislocations; Level III (n= 16), none had dislocations at ages 5 and 10, but 11% had by the age of 15; Level IV (n= 35), 8% had dislocations by age 5, 19% by age 10, and 30% by age 15; Level V (n= 41), 22% had dislocations by age 5, 48% by age 10, and 50% by age 15. Forty‐two per cent of individuals with hip dislocation had not had previous preventive surgery. Twenty‐one per cent of hips operated on still proceeded to dislocation. We conclude that there was a high rate of hip dislocation, especially in GMFCS groups Levels IV and V, and that this often occurred very early. Preventive surgery avoided dislocation in many children. However, orthopaedic referral was often not made before dislocation was discovered, or the referral was made too late for surgery on soft tissue to be successful. These results may be compared with those from current programmes of hip management, involving radiological surveillance and early use of conservative and surgical interventions.

The aim of this study was to assess the rate of hip dislocation at different ages in children with bilateral spastic cerebral palsy attending special schools in southern Derbyshire, UK, between 1985 and 2000. The medical notes of 110 individuals (68 males, 42 females) were obtained. They were divided into four groups according to the Gross Motor Function Classification System (GMFCS). We determined whether or not their hips were dislocated at the ages of 5, 10, and 15 years, and the kind of surgery performed in each case. The percentage of individuals with one or both hips dislocated increased with age and with severity of disease. Of those in GMFCS Level II (n=18), none had dislocations; Level III (n=16), none had dislocations at ages 5 and 10, but 11% had by the age of 15; Level IV (n=35), 8% had dislocations by age 5, 19% by age 10, and 30% by age 15; Level V (n=41), 22% had dislocations by age 5, 48% by age 10, and 50% by age 15. Forty-two per cent of individuals with hip dislocation had not had previous preventive surgery. Twenty-one per cent of hips operated on still proceeded to dislocation. We conclude that there was a high rate of hip dislocation, especially in GMFCS groups Levels IV and V, and that this often occurred very early. Preventive surgery avoided dislocation in many children. However, orthopaedic referral was often not made before dislocation was discovered, or the referral was made too late for surgery on soft tissue to be successful. These results may be compared with those from current programmes of hip management, involving radiological surveillance and early use of conservative and surgical interventions.

Twenty-two recommendations were made. These were considered the minimum standards of care in a district general hospital. The emphasis was on the organisation and delivery of healthcare for children with CP. The statement is intended to stimulate debate especially in relation to the equity of service provision throughout the country and may be used to inform purchasers of healthcare. Similarly, it may also be useful to providers of healthcare as an audit tool.

Following concerns that a considerable extra workload would be involved in sending a copy of the GP outpatient letter to parents following a medical consultation, 100 consecutive letters from the CDC were analysed to see if they could be sent to parents. Changes would have been necessary in 11, of which 6 would need an extra letter to the GP conveying additional specific information. Letters were generally intelligible, but it was recommended that they could be written in a more simple way for parents. Following these recommendations, copies of letters to the GP were sent to parents and the practice reviewed 2 years later. GP letters from 100 consecutive patients who had just visited the Centre were analysed and found to have been sent in 94. Of the remaining six, five were not sent because they contained information specific to the GP. It was felt that this could be rectified fairly easily. An anonymous questionnaire, sent to those receiving a copy of the letter, indicated that it had been very well received. It was felt that this policy was most helpful to the parents and justified a small additional workload.

Botulinum toxin A dosage: autonomic function as a measure of side effects' SIR-Treatment of spasticity in cerebral palsy (CP) with botulinum toxin A (BTX-A) is limited by the escape of the toxin from the muscle causing local and distant side effects. 1 This study aimed to increase BTX-A dose (over 30 units/kg for Dysport) safely. We noted signs of autonomic spread of the toxin following injection of a range of doses (18-44 units/kg) in 30 patients. In previous work on BTX-A treatment we have looked for changes in resting heart rate, change in heart rate on standing, change in blood pressure on standing, and pupilometry. None of these parameters revealed a statistically significant relationship with BTX-A dose 2 , and so in this study cardiac variability was chosen. Our hypothesis was that BTX-A might reduce parasympathetic activity and, therefore, cardiac variability.The Southern Derbyshire Acute Hospitals NHS Trust's ethics committee approved the study, and patients and controls were included after they or their caregivers gave informed consent. All patients attending our clinic for lower limb BTX-A injections were invited to participate. The healthy siblings of participants were invited to be controls. The control group was composed of six males and eight females aged between 8 and 11 years (mean 11y 4mo, SD 2mo). The patient group included 22 males and eight females aged between 3 and 15 years (mean 8y 7mo, SD 4mo). Nine patients had quadriplegic CP and 21 had diplegic CP. Gross Motor Function Classification System (GMFCS) levels were: level II, n=3; level III, n=12; level IV, n=9; level V, n=6. A 6-hour overnight electrocardiogram (ECG) recording was made for each patient before and 14 to 21 days after BTX-A treatment, and the recordings were compared with those of 14 untreated siblings. The ECGs were analyzed and the mean of the standard deviations of duration of R-R (beat-tobeat) interval (SDNN [NN equates to one cardiac cycle]) was calculated. The posttreatment SDNN divided by the pretreatment SDNN gave the autonomic ratio (AR).The 14 untreated, normal controls had a median AR of 1.12 (interquartile range 0.94-1.22). Median AR at a standard dose of BTX-A (18-30 units/kg) was 1.02 (range 0.64-1.10) and at a high dose (31-44 units/kg) was 0.88 (range 0.79-1.08). Results were compared using the Mann-Whitney U test. There was no statistical significance between the control group and the conventionally dosed group (p=0.06) or between the conventionally dosed group and the high dose group. When all those treated with BTX-A were compared with controls there was a small statistical difference between them (p=0.02); when the control group was compared with the high dose group this difference was also statistically significant (p=0.03). When BTX-A dose was plotted against AR there was no significant correlation (r=-0.13, p=0.42). Clinically, only one child had distant side effects which lasted for 6 weeks; he had the lowest AR in the study group (0.33) after receiving 37 units/kg BTX-A.These results offer further re...