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Aims/hypothesis Although cardiovascular disease is the biggest cause of death in people with diabetes, microvascular complications have a significant impact on quality of life and financial burden of the disease. Little is known about the progression of microvascular dysfunction in the early stages of type 2 diabetes before the occurrence of clinically apparent complications. We aimed to explore the determinants of endothelial-dependent and -independent microvascular function progression over a 3 year period, in people with and without both diabetes and few clinical microvascular complications. Methods Demographics were collected in 154 participants with type 2 diabetes and in a further 99 participants without type 2 diabetes. Skin microvascular endothelium-dependent response to iontophoresis of acetylcholine and endothelium-independent responses to sodium nitroprusside were measured using laser Doppler fluximetry. All assessments were repeated 3 years later. Results People with type 2 diabetes had impaired endothelial-dependent microvascular response compared with those without (AUC 93.9 [95% CI 88.1, 99.4] vs 111.9 [102.3, 121.4] arbitrary units [AU] × min, p p = 0.002). Mean microvascular function declined over 3 years in both groups to a similar degree (pinteraction 0.74 for response to acetylcholine and 0.69 for response to sodium nitroprusside). In those with diabetes, use of sulfonylurea was associated with greater decline (p = 0.022 after adjustment for co-prescriptions, change in HbA1c and weight), whereas improving glycaemic control was associated with less decline of endothelial-dependent microvascular function (p = 0.03). Otherwise, the determinants of microvascular decline were similar in those with and without diabetes. The principal determinant of change in microvascular function in the whole population was weight change over 3 years, such that those that lost ≥5% weight had very little decline in either endothelial-dependent or -independent function compared with those that were weight stable, whereas those who gained weight had a greater decline in function (change in endothelial-dependent function was 1.2 [95% CI −13.2, 15.7] AU × min in those who lost weight; −15.8 [−10.5, −21.0] AU × min in those with stable weight; and −37.8 [−19.4, −56.2] AU × min in those with weight gain; ptrend Conclusions/interpretation Over 3 years, physiological change in weight was the greatest predictor of change in microvascular function.

Aim To compare the effects of a supported speed treadmill training exercise program (SSTTEP) with exercise on spasticity, strength, motor control, gait spatiotemporal parameters, gross motor skills, and physical function. Method Twenty-six children (14 males, 12 females; mean age 9y 6mo, SD 2y 2mo) with spastic cerebral palsy (CP; diplegia, n=12; triplegia, n=2; quadriplegia n=12; Gross Motor Function Classification System levels II–IV) were randomly assigned to the SSTTEP or exercise (strengthening) group. After a twice daily, 2-week induction, children continued the intervention at home 5 days a week for 10 weeks. Data collected at baseline, after 12-weeks’ intervention, and 4 weeks after the intervention stopped included spasticity, motor control, and strength; gait spatiotemporal parameters; Gross Motor Function Measure (GMFM); and Pediatric Outcomes Data Collection Instrument (PODCI). Results Gait speed, cadence, and PODCI global scores improved, with no difference between groups. No significant changes were seen in spasticity, strength, motor control, GMFM scores, or PODCI transfers and mobility. Post-hoc testing showed that gains in gait speed and PODCI global scores were maintained in the SSTTEP group after withdrawal of the intervention. Interpretation Although our hypothesis that the SSTTEP group would have better outcomes was not supported, results are encouraging as children in both groups showed changes in function and gait. Only the SSTTEP group maintained gains after withdrawal of intervention.

Aim To determine whether there is a difference between perspectives of functioning and health-related quality of life (HRQL) of parents and ambulatory adolescents with spastic cerebral palsy (CP). Method A total of 139 parent patient pairs (73 females, 66 males; median age 14y 6mo, age range 11–18y, Gross Motor Function Classification System [GMFCS] levels I–III, with hemiplegia [n=23], diplegia [n=103], triplegia [n=9], and quadriplegia [n=4]) were recruited from outpatient CP clinics at three pediatric orthopaedic hospitals, between 2000 and 2006, from whom Pediatric Outcomes Data Collection Instrument (PODCI) responses were collected. Results Cross-sectional data, calculated with intraclass correlation coefficients [ICC], showed parents and adolescents agreed more on functioning (ICC=0.488–0.748) than HRQL (ICC=0.242–0.568; PODCI). Parents and adolescents both recognized significant comorbidities (ICC=0.502–0.713), but adolescents saw themselves as less limited (ICC=0.330) than parents. The greatest differences between parents and adolescents were in HRQL scales for male adolescents, with only a small part explained by GMFCS level difference between sexes (effect size 0.002–0.143). Age, parent well-being, and parent sex had little effect and comorbidities had no effect. GMFCS level was the most common predictor. Interpretation Most scales on health conditions, function, and HRQL agreed between parents and adolescents aged11 to 18 years. Parent proxy is reasonable when necessary, but assessing both parents and adolescents gives additional insight. Adolescents do not consider themselves as limited by health conditions as parents do; parents have greater satisfaction with current level of symptoms than adolescents, and findings vary on expectations for treatment.

Purpose Although frequently used in pediatric rehabilitation settings, the WeeFIM has not been tested in surgical pediatric orthopaedic patients. Methods The WeeFIM was administered to patients with surgical cerebral palsy at defined intervals preoperatively and at both 6 and 12 months postoperatively. The age-adjusted change scores from baseline to follow-up were tested both parametrically and nonparametrically. Results Four hundred sixty-eight patients had baseline evaluations. There were 161 six-month follow-up assessments and 108 twelve-month follow-up assessments. The baseline WeeFIM was able to separate children with different patterns of cerebral palsy. Hemiplegic patients had higher scores than diplegic and tetraplegic patients. Overall age-adjusted scores were improved at both 6 (mean increase 2.0) and 12 months (mean increase 2.2). The instrument showed significant ceiling effects for diplegic and hemiplegic patients with lower or upper extremity surgery and limited responsiveness for lower extremity surgery in tetraplegic patients. Parametrically, it showed improvements in mobility for both rhizotomy and tetraplegic upper extremity surgery. Nonparametric tests were not significant for rhizotomy mobility improvement. Conclusions Although the WeeFIM adequately reflects the severity of neurological involvement in pediatric orthopaedic patients with cerebral palsy, it has a significant ceiling effect in diplegic and hemiplegic patients limiting responsiveness and lacks content validity for tetraplegic patients. The instrument may have some use in tetraplegic patients with upper extremity surgery and in rhizotomy patients. We recommend against its general use for orthopaedic surgery in patients with cerebral palsy lower extremity or spine surgery and in hemiplegic patients with upper extremity surgery.

Wall shear stress (WSS) is an important modulator of vascular disease. We assessed the hypothesis that WSS profiles derived from Echo Particle Image Velocimetry (EchoPIV) are characteristic of vascular conditions such as TIA with superior accuracy to Doppler. We obtained ultrasound images of CCA from 24 healthy and 12 TIA subjects. Doppler provided centerline peak velocity and WSS estimate based on parabolic velocity distribution. Velocity profiles measured by EchoPIV varied from patient to patient and within the cardiac cycle. Curve-fitting to a power law function with an exponent term (n-value) showed that in healthy carotid arteries, a blunt velocity profile is present during systole with an average n-value of 5, whereas during diastole a more parabolic profile with an n-value of 2 is present. Therefore, assuming a fully parabolic velocity distribution for WSS estimation, the basis for Doppler velocimetry, introduces a mean error of 48% during diastole and 98% during systole. EchoPIV offers characterization of WSS profiles; time waveform analysis revealed smoother and fewer number of peaks per cycle for healthy and increased flow pulsatality (reverberations) for TIA (Figure). Echo PIV generated means for phase averaged peak velocity (27.95 vs 16.13 cm/s), WSS (6.45 vs 4.65 Dynes/cm2) and flow rate (0.3179 vs 0.2215 L/min) with standard deviations 3.66 vs 2.35, 2.8 vs 1.74 and 0.0723 vs 0.0744 were significantly different between healthy and TIA subjects respectively (all p < 0.01). Direct measurement of the velocity profile using Echo PIV provides superior estimates of WSS in carotid vessels. TIA populations have compromised hemodynamic variables compared to healthy subjects.

Klippel-Trenaunay syndrome is a triad of cutaneous hemangiomas, varicose veins, and hypertrophy of soft tissue and bone; when combined with arteriovenous fistulas, the syndrome is known as Klippel-Trenaunay-Weber syndrome. Orthopaedic surgical management of localized limb-length discrepancy or hypertrophy in these conditions is frequently indicated, especially in the lower limb. Forty orthopaedic procedures in 21 patients were retrospectively reviewed. Nine (22.5%) wound complications were identified in this study group. All the complications were associated with transverse amputations. All required significant further treatment and extension of hospital stay. Wound complications should be anticipated in patients with Klippel-Trenaunay syndrome having orthopaedic surgical procedures, especially terminal amputations.

Article-at-a-Glance Background In an environment of concern about the rising costs of medical care, the Vermont Program for Quality in Health Care (VPQHC; the program) was incorporated in 1988 as a nonprofit organization and in 1989 was made a peer review organization by the state legislature. The program acts as a resource center for health care in Vermont, coordinating three functions: implementation and maintenance of a statewide database for healthcare quality; training for health care providers in continuous quality improvement (CQI) methods and support for their CQI projects; and focusing clinical study group work on specific diagnoses or procedures. Methods The program uses a seven-step process for implementing CQI: pick a process (modify a nationally developed guideline or develop a new guideline); select a team of people involved in doing the work; establish goals and key quality factors; document the clinical process; determine what and how to measure; measure and analyze data; and modify the process to improve. Guideline This article describes the implementation of a guideline from the American College of Obstetricians and Gynecologists (ACOG) on cesarean section (C-section). Except for a few specific contraindications, the ACOG paper states that it is reasonable to encourage vaginal birth after C-section. A related set of criteria from ACOG states that the benchmark for emergency C-section should be 30minutes from the decision to proceed with an emergency C-section until the baby is born. Case study State C-section rates from 1985–1990 showed wide variation by hospital. Such wide variation is based as much on practice style as on sound science. C-section rates (primary and repeated) were measured, plotted, and shared with Vermont hospitals. Successful vaginal birth after C-section (VBAC) rates from the statewide database also were shared. Based on these data, one hospital, Hospital A, developed a plan to lower its repeated C-section rate and improve its VBAC rate. Hospital A collected and reviewed local data, which showed interesting variations. The time from decision to birth became the focus of the overall project; Hospital A designed its project to study events during the time from decision to birth. Results Most recent data (1992–1993) from Hospital A shows improvement in three areas. First, 89% of patients having emergency C-sections met the goal of a 30-minute time frame from decision to incision. Second, the VBAC success rate for the same time period increased to 85.7% from 69% in the previous year, and from a mere 7% before the implementation of the project. Third, the percentage of total C-sections that were repeat C-sections fell to 36% from a high of 51%. In a follow-up evaluation, one-third of the C-sections performed from October 1, 1993, to July 31, 1994 were performed because of patient refusal to attempt VBAC, suggesting that there is a communitywide culture that influences behavior. A major effort at patient education on VBAC is underway. Conclusions Think globally, act locally, might be the motto for the program. Implementing guidelines starts with obtaining national guidelines and literature but needs the use of local data to sharpen the focus on narrow areas to address. Specifically, it is unrealistic to tackle the entire problem at once. Success comes from finding specific opportunities for improvement.

Objective A multi-site Randomized-Controlled Trial compared a home-based Supported Speed Treadmill Training Exercise Program (SSTTEP) with a strengthening exercise program in children with cerebral palsy (CP) on the following categories; Participation, quality of life (QOL), self-concept, goal attainment, and satisfaction. Design Twenty-six children with spastic cerebral palsy were assigned by site-based block randomization to the SSTTEP (n=14) or strengthening exercise (n=12) group. Both groups participated in a two week clinic-based induction period and continued the intervention at home for ten weeks. Data were collected at baseline, post-intervention (12 weeks), and follow-up (16 weeks). Assessments included the Canadian Occupational Performance Measure, Children's Assessment of Participation and Enjoyment Scale, Pediatric Quality of Life Cerebral Palsy Module, and Piers-Harris Children's Self-Concept Scale. Evaluators were blinded to group assignment at two sites. Results Satisfaction and performance on individual goals, participation, and parent-reported QOL improved in both groups with improvement maintained for four weeks post intervention. Conclusion The hypothesis that the SSTTEP group would have better outcomes than the exercise group was not supported. However, both groups showed that children with CP can make gains in participation, individual goals, and satisfaction following a 12-week intensive exercise intervention, and these findings persisted for four weeks post intervention.

The article by Stout et al. provides an excellent discussion of the International Classification of Functioning, Disability and Health (ICF) model, as it attempts to clarify use of the terms capacity, capability, and performance. These are important concepts when comparing results in studies. The authors present these concepts with a broad brush, indicating that they were designed before the ICF model. In evaluating articles such as this one, readers must understand the differences among the concepts of capacity, capability, and performance. Each functional question is structured so that the responses relate to one concept or another. While it is true that the Pediatric Outcome Data Collection Instrument (PODCI) is not purely about capability or performance, most of the questions of the PODCI ascertain the child’s actual performance of a task within the past week. The authors do not share with the reader which version of the Functional Assessment (FAQ-22) was used, but indicate that it is rated on a five-level Likert difficulty scale and available retrospectively. The original version of the FAQ-22 required a yes or no for the tasks the patient is able to do. A recent version (available online at http://www.gillettechildrens.org/ fileupload/GFAQsurveypreview2.pdf) has responses for: (1) the child’s ability to perform the following activities in addition to walking; and (2) if performed as part of routine season-appropriate play. The reference to the FAQ-22 notes, ‘The five-level Likert response scale used for the 22 skill items was ‘easy’, ‘a little hard’, ‘very hard’, ‘can’t do at all’, and ‘too young for activity’. Those who responded ‘too young for activity’ were coded as ‘can’t do at all’ for this analysis.’ 2 One can only assume the same referent version is used in the current analysis. The questions concern the child’s ability to do tasks. Whether considered capacity questions or capability questions, they clearly are not performance questions. Personal factors (including sex, age, coping styles, attitude, and motivation), in addition to environmental factors and comorbid conditions, can have an impact upon actual performance of tasks in daily life. Two articles referenced in the Stout et al. article show clearly that capability exceeds performance, one showing average 17% greater values for capability, the other showing 90% correlation between the capability and performance measures, with performance lower. The resulting ‘upper-range’ coverage by the FAQ-22 noted by Stout et al. may be partially due to type of question posed. There was an a priori decision to drop numerous questions from the PODCI, especially from the sports and physical function subscale, due to the different question structure. Several of the current authors published another paper which included the dropped questions, using confirmatory factor analysis and item response theory in children with cerebral palsy, results showing that the sports and physical function subscale covers upper-range mobility, which Stout et al. indicate is covered by the FAQ-22, though their discussion section concedes upper-range function coverage would improve with inclusion of these questions. In an article comparing the PODCI with the School Function Assessment (primarily a measure of performance), three PODCI questions were found to have the greatest correlation with performance on School Function Assessment. The two questions from the transfers and basic mobility and sports and physical function subscales having the greatest correlation with the School Function Assessment are dropped in the current study by Stout et al. It would be useful to compare in this population the full PODCI mobility scales of transfers and basic mobility and sports and physical function with the current combined tool, using the performance questions from the FAQ-22. I would agree with the comments in the discussion that the information detailed is specific enough to be of practical use and may be very helpful in clinical practice. But there is not

To compare the effects of a supported speed treadmill training exercise program (SSTTEP) with exercise on spasticity, strength, motor control, gait spatiotemporal parameters, gross motor skills, and physical function.Twenty-six children (14 males, 12 females; mean age 9y 6mo, SD 2y 2mo) with spastic cerebral palsy (CP; diplegia, n=12; triplegia, n=2; quadriplegia n=12; Gross Motor Function Classification System levels II-IV) were randomly assigned to the SSTTEP or exercise (strengthening) group. After a twice daily, 2-week induction, children continued the intervention at home 5 days a week for 10 weeks. Data collected at baseline, after 12-weeks' intervention, and 4 weeks after the intervention stopped included spasticity, motor control, and strength; gait spatiotemporal parameters; Gross Motor Function Measure (GMFM); and Pediatric Outcomes Data Collection Instrument (PODCI).Gait speed, cadence, and PODCI global scores improved, with no difference between groups. No significant changes were seen in spasticity, strength, motor control, GMFM scores, or PODCI transfers and mobility. Post-hoc testing showed that gains in gait speed and PODCI global scores were maintained in the SSTTEP group after withdrawal of the intervention.Although our hypothesis that the SSTTEP group would have better outcomes was not supported, results are encouraging as children in both groups showed changes in function and gait. Only the SSTTEP group maintained gains after withdrawal of intervention.

Through support from the Robert Wood Johnson Foundation through its program, "Improving the Quality of Hospital Care," the Vermont Program for Quality in Health Care (VPQHC) has developed a quality improvement model that hastens learning through knowledge sharing. Using guidelines and other quality improvement techniques, VPQHC works with hospitals and practitioners to improve not only hospital processes of care but also clinical management. This article describes the concepts driving the program, using an example, and describes the program's success in involving physicians in the process.

Context: Information on the use of oral bisphosphonate agents to treat pediatric osteogenesis imperfecta (OI) is limited. Objective: The objective of the investigation was to study the efficacy and safety of daily oral alendronate (ALN) in children with OI. Design and Participants: We conducted a multicenter, double-blind, randomized, placebo-controlled study. One hundred thirty-nine children (aged 4–19 yr) with type I, III, or IV OI were randomized to either placebo (n = 30) or ALN (n = 109) for 2 yr. ALN doses were 5 mg/d in children less than 40 kg and 10 mg/d for those 40 kg and greater. Main Outcome Measures: Spine areal bone mineral density (BMD) z-score, urinary N-telopeptide of collagen type I, extremity fracture incidence, vertebral area, iliac cortical width, bone pain, physical activity, and safety parameters were measured. Results: ALN increased spine areal BMD by 51% vs. a 12% increase with placebo (P < 0.001); the mean spine areal BMD z-score increased significantly from −4.6 to −3.3 (P < 0.001) with ALN, whereas the change in the placebo group (from −4.6 to −4.5) was insignificant. Urinary N-telopeptide of collagen type I decreased by 62% in the ALN-treated group, compared with 32% with placebo (P < 0.001). Long-bone fracture incidence, average midline vertebral height, iliac cortical width, bone pain, and physical activity were similar between groups. The incidences of clinical and laboratory adverse experiences were also similar between the treatment and placebo groups. Conclusions: Oral ALN for 2 yr in pediatric patients with OI significantly decreased bone turnover and increased spine areal BMD but was not associated with improved fracture outcomes.

Little data exists assessing the relationship between functional limitations in children with cerebral palsy (CP) and their participation in everyday activities. This prospective study evaluates the relationship between the Pediatric Outcomes Data Collection Instrument (PODCI), a functional health-related quality of life instrument for children and their parents, and the School Function Assessment (SFA), a school-based functional assessment. One hundred and two children with CP (80.4% dipliegia; 10.8% hemiplegia; 3.9% triplegia; 2.0% quadriplegia; 2.9% unspecified; 60 males, 42 females, mean age 11 years 8 months (SD 3 y 3 mo, range 6-8 y), Gross Motor Function Classification System levels I to IV (13.7% Level I 50% Level II 35.3% Level III 1% Level IV), had complete PODCI and SFA assessments. Significant relationships were noted among multiple PODCI subscales and subscales of the SFA, as well as among individual questions. PODCI predicted performance in all 31 subscales of the SFA when comorbidity subscales were included (r =0.35-0.64). The PODCI in-clinic questionnaire provides an accurate reflection of the child's actual participation in the community setting, as assessed by the SFA. PODCI can reliably be used to help ensure that outcomes assessed in the clinic setting reflect function within the community, and can be used to help with treatment planning, goal setting, and improved patient care.

Background: Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cerebral palsy (CP) usually focus on data from instrumented gait analysis and clinical examination without examining functional and health-related quality of life (HRQOL) outcomes. Recently, outcome measures for well-being in children with a variety of musculoskeletal disorders have also been validated specifically for CP. Therefore, this study aimed to investigate the impact of multilevel surgery on the function and HRQOL in a group of ambulatory children with CP. Methods: In a multicenter prospective trial, 57 ambulatory children with CP, mean age 9.5 years, underwent multilevel soft tissue surgery to correct sagittal imbalance. Validated clinical outcome measures for HRQOL were administered preoperatively and postoperatively with an average follow-up time of 15.2 months. The functional and psychosocial components of the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Quality of Life Questionnaire (PedsQL), and the Functional Assessment Questionnaire Walking Score were used. Results: Significant improvements in outcome scores occurred postoperatively in the following: PedsQL parent-total (17.6%; P < 0.001) and parent-physical sections (25.0%; P < 0.001), the Functional Assessment Questionnaire Walking Score (15.3%; P < 0.001), and the PODCI sections for transfers and basic mobility (15.8%; P < 0.001), sports and physical function (23.9%; P = 0.012), and global (12.9%; P < 0.001). Improvements also occurred in the PedsQL child-total (8.4%; P = 0.104) and child-physical sections (8.6%; P = 0.189), but these were not statistically significant. There were no significant changes in the PODCI parent-derived pain (-3.2%; P = 0.504) and happiness sections (1.9%; P = 0.645). Conclusions: Multilevel surgery in ambulatory patients with CP improves function and HRQOL. However, improved functional well-being does not imply improved psychosocial well-being, and patients and their families should be counseled accordingly. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

The purpose of this study was to determine whether there is a significant association between function and well-being in children with cerebral palsy. To determine this, the authors used validated measures of function (Gillette Functional Assessment Questionnaire, Gross Motor Function Classification System, Gross Motor Function Measure, and walking speed) and correlated them to health-related quality of life (HRQOL) measures (Pediatric Outcomes Data Collection Instrument, Pediatric Quality of Life instrument). In a cross-sectional study of ambulatory children with mild to moderate cerebral palsy aged 10.2 ± 3.2 years, mild to moderate decreases in function were found when compared with normative data. As the assessment of HRQOL comprises both functional well-being and psychosocial well-being, the authors decided to specify the aspect of well-being to which they were referring. It was found that the child's function was not correlated to psychosocial well-being. The children with mild cerebral palsy had greater effects on their psychosocial well-being than would be predicted by their functional disability. Functional measures were good at predicting the functional well-being but were weak at predicting the psychosocial arm of well-being.