Introduction: This thesis prospectively evaluated the cognitive and functional outcomes and health-related quality of life of children admitted urgently to a Pediatric Intensive Care Unit (PICU) at the Hospital for Sick Children. Methods: The primary outcome was the Vineland Adaptive Behavioural Scale (VABS-2) measured at 1-month and secondary outcomes were health-related quality of life, daily functioning, and caregiver perceptions. Results: 56 children and 66 caregivers were enrolled; 42 (75%) patients and 49 (74%) caregivers completed the 1-month assessment. Children in the PICU had a mean VABS-2 score of 85(+25). Daily functioning outcomes did not significantly change from baseline to 1-month. In comparison to baseline, children had significantly reduced health-related quality of life at 1-week but no significant change was found at 1-month. Discussion: Children surviving PICU have significant cognitive morbidity and reduced health-related quality of life that is exacerbated by more intense modes of resuscitation and increasing severity of illness.

Objective: To quantify the acceptability of facial asymmetry to plastic surgeons, orthodontists and the lay population. Methods: Facial images were animated with one of six asymmetries: jaw and nasal deviation, interocular distance, ocular height, angulation, and shape. Evaluators were asked to judge the faces based on their visual acceptability. Results: There were no differences between the groups except for in the evaluation of ocular shape. Mandibular deviation of 4mm, and nasal deviation of 3mm was judged as unacceptable. 9% rounder and 18% flatter eyes were considered unacceptable. Hypertelorism and inferior ocular dystopia was unacceptable after a change of 2mm. Hypotelorism and superior vertical dystopia was unacceptable after a change of 2.5mm. Ocular angulations of 5.5 degrees superiorly and 3.5 degrees inferiorly were unacceptable. Conclusions: Plastic surgeons, orthodontists, and lay people find specific facial asymmetries to be unacceptable at similar levels of deviation.

Traumatic lumbar punctures (TLPs) in children with acute lymphoblastic leukemia are associated with a poorer prognosis. The objective of this study was to determine risk factors for TLPs using a retrospective cohort. We compared and contrasted three different regression methods for the analysis of repeated-measures data. In the multivariable model using generalized estimating equations, variables significantly associated with TLPs were age < l year or ≥ 10 years; body mass index percentile ≥ 95; platelet counts < 100 x 103/µL; fewer days since previous LP, and a preceding TLP. The same variables, with similar estimates and confidence-intervals, were identified by the random-effects model. In a fixed-effects model where each patient was used as their own control, days since prior LP and the effect of using image-guidance were significant. Random-effects and GEE lead to similar conclusions, whereas fixed-effects discards between-subject comparisons and leads to different estimates and interpretation of results.

Objectives: The objectives of this study were two-fold: (1) to describe the epidemiology of childhood fractures in Ontario; (2) to determine if having a fracture in childhood is associated with an increased risk of having a future fracture. Methods: This was a population-based retrospective cohort study using Ontario health administration data. Children aged 0 to 15 years were grouped according to baseline fracture status. Associations between predictors and future fracture were assessed using Poisson and Cox PH regression. Results: 43,154 Ontario children experienced a baseline fracture (17.5 per 1000 child years). Children with a baseline fracture had a 60% higher rate of fracture during 7 years of follow-up after adjustment for sex, rurality, history of previous fracture and the occurrence of head injury and soft-tissue injury. Conclusions: The occurrence of a baseline fracture is associated with an increased rate of future fracture irrespective of age at time of baseline fracture.

Objective: To quantify the acceptability of facial asymmetry to plastic surgeons, orthodontists and the lay population. Methods: Facial images were animated with one of six asymmetries: jaw and nasal deviation, interocular distance, ocular height, angulation, and shape. Evaluators were asked to judge the faces based on their visual acceptability. Results: There were no differences between the groups except for in the evaluation of ocular shape. Mandibular deviation of 4mm, and nasal deviation of 3mm was judged as unacceptable. 9% rounder and 18% flatter eyes were considered unacceptable. Hypertelorism and inferior ocular dystopia was unacceptable after a change of 2mm. Hypotelorism and superior vertical dystopia was unacceptable after a change of 2.5mm. Ocular angulations of 5.5 degrees superiorly and 3.5 degrees inferiorly were unacceptable. Conclusions: Plastic surgeons, orthodontists, and lay people find specific facial asymmetries to be unacceptable at similar levels of deviation.

Objectives: The objectives of this study were two-fold: (1) to describe the epidemiology of childhood fractures in Ontario; (2) to determine if having a fracture in childhood is associated with an increased risk of having a future fracture. Methods: This was a population-based retrospective cohort study using Ontario health administration data. Children aged 0 to 15 years were grouped according to baseline fracture status. Associations between predictors and future fracture were assessed using Poisson and Cox PH regression. Results: 43,154 Ontario children experienced a baseline fracture (17.5 per 1000 child years). Children with a baseline fracture had a 60% higher rate of fracture during 7 years of follow-up after adjustment for sex, rurality, history of previous fracture and the occurrence of head injury and soft-tissue injury. Conclusions: The occurrence of a baseline fracture is associated with an increased rate of future fracture irrespective of age at time of baseline fracture.

Introduction: This thesis prospectively evaluated the cognitive and functional outcomes and health-related quality of life of children admitted urgently to a Pediatric Intensive Care Unit (PICU) at the Hospital for Sick Children. Methods: The primary outcome was the Vineland Adaptive Behavioural Scale (VABS-2) measured at 1-month and secondary outcomes were health-related quality of life, daily functioning, and caregiver perceptions. Results: 56 children and 66 caregivers were enrolled; 42 (75%) patients and 49 (74%) caregivers completed the 1-month assessment. Children in the PICU had a mean VABS-2 score of 85(+25). Daily functioning outcomes did not significantly change from baseline to 1-month. In comparison to baseline, children had significantly reduced health-related quality of life at 1-week but no significant change was found at 1-month. Discussion: Children surviving PICU have significant cognitive morbidity and reduced health-related quality of life that is exacerbated by more intense modes of resuscitation and increasing severity of illness.

Background The purpose of this study was to evaluate outcomes in Spina Bifida Cystica adults, treated non-operatively or operatively for scoliosis during childhood. Methods Patients with SBC scoliosis (minimum Cobb angle >50 degrees) treated at the Hospital for Sick Children or the Children’s Hospital of Eastern Ontario (1991-2007 inclusive) were recruited. In addition to clinical and radiological assessments, health related quality of life (HRQOL) outcomes included the: a) Spina Bifida Spine Questionnaire (SBSQ) and b) Medical Outcomes Study-36 Item Short Form Health Survey (SF-36). Results The operative and non-operative patients were statistically similar at baseline on the following variables: a) age, b) sex, c) living situation, d) ambulation, and e) neurological motor level. At an average follow-up of 14.1+/-4.3 years, groups were statistically similar with respect to: a) SF-36 and b) SBSQ scores. Conclusion Spinal fusion in SBC scoliosis corrected coronal deformity and stopped progression, but had no overall effect on HRQOL.

Background The purpose of this study was to evaluate outcomes in Spina Bifida Cystica adults, treated non-operatively or operatively for scoliosis during childhood. Methods Patients with SBC scoliosis (minimum Cobb angle >50 degrees) treated at the Hospital for Sick Children or the Children’s Hospital of Eastern Ontario (1991-2007 inclusive) were recruited. In addition to clinical and radiological assessments, health related quality of life (HRQOL) outcomes included the: a) Spina Bifida Spine Questionnaire (SBSQ) and b) Medical Outcomes Study-36 Item Short Form Health Survey (SF-36). Results The operative and non-operative patients were statistically similar at baseline on the following variables: a) age, b) sex, c) living situation, d) ambulation, and e) neurological motor level. At an average follow-up of 14.1+/-4.3 years, groups were statistically similar with respect to: a) SF-36 and b) SBSQ scores. Conclusion Spinal fusion in SBC scoliosis corrected coronal deformity and stopped progression, but had no overall effect on HRQOL.

Hip fracture trials have used a wide range of patient-reported outcomes (PRO) suggesting a lack of consensus among clinicians on what are considered the most relevant functional outcomes. We conducted a systematic review to identify the outcomes used in hip fracture randomized controlled trials (RCTs). We hypothesized that there had been an increase in numbers of PROs over time and the health status measure, SF-36, would be used the most. A database search and screening yielded 86 original trials. The mean Detsky score (and standard error) for quality was: 75.8% ± 1.76%. There was a trend in the increase of functional outcome; however, the SF-36 was used only in (10 out of 86) 11.6% trials. Both the ADL-Katz Index and HHS have lower respondent burden than the SF36 which may contribute to their frequent use in hip RCTs. There is a lack of applicable measures suitable for patients with dementia.