Comparing binary & ordinal definitions of urinary & stool continence outcomes: Data from the National Spina Bifida Patient Registry

INTRODUCTION

The National Spina Bifida Patient Registry (NSBPR) assesses bladder and bowel incontinence using ordinal categories, but prior NSBPR analyses employed binary classification. Our aims were to 1) perform the first NSBPR analysis of bladder and bowel incontinence as ordinal outcomes to compare to the binary definition and subject variables; 2) explore the correlation of incontinence with undergarment usage, and 3) assess incontinence status following continence surgeries.

METHODS

Data from NSBPR participants' most recent clinic visit from 2013 to 2020 were analyzed. Ordinal categories of incontinence were compared to previously used binary definitions. Incontinence surgical outcomes were analyzed for those with data at least three months post-operatively. Chi-square tests evaluated associations among categorical variables. Univariate and ordinal logistic regression models were used to test associations of ordinal incontinence status with patient and condition factors. Statistical tests were 2-sided; p values < 0.05 were considered significant.

RESULTS

Analysis of 7217 individuals using ordinal incontinence outcomes showed little difference from previously used binary outcomes. The final multivariable logistic regression models with ordinal multinomial outcomes showed that associations of incontinence with age, sex, race/ethnicity, health insurance, level of lesion, and continence management technique were similar to prior studies. Among those reporting never being incontinent of both bladder and bowel, 14% reported using protective undergarments. Of the 500 individuals who had bladder outlet surgery, 38% reported never being incontinent of urine. Of 1416 individuals who had appendicostomy (ACE) bowel surgery, 48% reported never being incontinent of stool.

DISCUSSION

Our current analysis showed that ordinal continence outcome classification had similar continence findings as previous studies using the binary definition of continence. Expanding the binary definition of continence to include monthly episodes of incontinence did not greatly increase the proportion of continent individuals and, therefore, would have not likely made meaningful differences in continence outcomes in prior NSBPR analyses. However, it is known that even mild incontinence can affect quality of life, therefore, capturing any level of incontiennce is of clinical importance. Confirmation of the association of continence outcomes with sociodemographic, condition-related, and interventional factors with both approaches further validates previous analyses using the binary definition of continence.

CONCLUSION

The previously used binary definition of bladder and bowel continence appears robust. Undergarment choice was a poor surrogate for reported incontinence. After bladder and bowel continence surgeries, 38% and 48%, respectively, reported never being incontinent.

Adolescent/Young Adult Self-Management and Independence Self-Report Scale: Preliminary psychometric findings

PURPOSE

This study examined preliminary psychometrics of the Adolescent/Young Adult Self-Management and Independence Self-Report Scale (AMIS II SR).

METHODS

Adolescents and adults (N = 159; 13-38 years old) with spina bifida from two clinics and one community sample completed the AMIS II SR. The majority (83%) had myelomeningocele, and about half were female (51.6%). The sample included 44.7% White, 11.3% Black and over one-third Hispanic/Latino (38.4%) participants. Descriptive analyses and reliability were assessed; a confirmatory factor analysis (CFA) was conducted.

RESULTS

Item-to-total correlations support the AMIS II SR total scale (r = .38-.79) and its two subscales: condition (r = .49-.67) and independent living (r = .49-.85). Internal consistency reliability was high (α = .91-.96) for the AMIS II SR total scale and subscales. A higher order CFA model that included independent living and condition self-management as first-order factors and a second-order overall self-management factor had excellent fit (RMSEA = 0.06; CFI = 0.97; TLI = 0.96). Descriptive analyses findings were reported.

CONCLUSIONS

This study provides psychometric evidence for the use of the AMIS II SR total (overall) scale and subscales (condition and independent living) to assess self-management and independence.

Prophylactic Spinal Cord Untethering in Children with Spinal Dysraphism Undergoing Thoracolumbar Fusion for Scoliosis

BACKGROUND

It remains unclear whether spinal cord untethering is necessary to reduce the chances of neurologic decline in children with myelomeningocele and complex closed spinal dysraphism who undergo thoracolumbar fusion for scoliosis. We sought to determine the neurologic and functional outcomes of children with spinal dysraphism undergoing spinal fusion for scoliosis with and without prophylactic spinal cord untethering.

METHODS

Retrospective, single-center review of patients with spinal dysraphism treated with thoracolumbar fusion over the last 10 years (2009-2019) with or without prophylactic spinal cord untethering.

RESULTS

Seventeen patients with myelomeningocele and complex closed spinal dysraphism underwent spinal fusion for scoliosis. Mean age at time of surgery was 13.9 years. Prophylactic spinal cord untethering was performed in 8 of 17 (47%) patients. The change in Cobb angle after surgery was similar between the 2 groups (19.4° untethered vs. 19.9° no untethering). The ambulatory status was similar between the groups, with 37% of the untethered cohort and 44% of the non-untethered cohort being community or household ambulators. There were no changes in intraoperative motor or sensory evoked potentials in any patient during fusion surgery. No patient had a change in motor level or ambulatory status after scoliosis surgery.

CONCLUSIONS

Our data suggest that prophylactic spinal cord untethering in children with spinal dysraphism undergoing thoracolumbar fusion for scoliosis may not be necessary in patients with moderate curvatures. Our conclusions are limited by the small sample size. A larger review of registry data may yield more powerful conclusions on the necessity of prophylactic spinal cord untethering in this patient population.

Intercountry adoption of children with complex health conditions and disabilities: A systematic review

PURPOSE

The rate of children with complex health conditions or disabilities who are intercountry adopted (ICA) is increasing. These children have unique physical, developmental, and psychological needs that must be addressed as they integrate into adoptive families. The purpose of this systematic review is to identify considerations nurses must recognize when caring for children with complex health conditions or disabilities who are ICA and their families.

DESIGN AND METHODS

A systematic literature review in accordance with the PRISMA guidelines was conducted. Four databases (PubMed, PsycINFO, Web of Science, and ERIC) located 365 articles about intercountry adoption and complex health conditions or disability. Articles that were non-English language, focused on attachment disorder or infectious disease, book chapters, dissertations, or case studies were excluded. Sixteen articles met inclusion criteria and informed this review.

RESULTS

The systematic review identified eight themes: primary care resources, interdisciplinary care teams, cost, developmental difficulties, nutritional challenges, mental health issues, parental need for knowledge, and parental need for support. These themes correspond to nursing assessments that should be conducted during clinic visits for children with complex health conditions or disabilities who are ICA.

PRACTICE IMPLICATIONS

This systematic review demonstrates that a multidisciplinary approach is necessary to address the needs of the child diagnosed with a complex health condition or disability and their family in the context of intercountry adoption. Children with a complex health condition or disability who are ICA have unique needs and require individualized care planning to maximize growth and developmental potential. Adoption is a life-long process and adjustment is complicated by the medical needs that children with complex health conditions or disabilities experience. Parents will benefit from additional support and education as they integrate a new family member while also learning about the medical care needs of a child with a complex health condition or disability.

Down There - Pediatric Nurses, Constipation, and Rectal Interventions

BACKGROUND

Pediatric nurses care for hospitalized children with constipation on a daily basis. However, very little is reported in the literature about the experiences of pediatric nurses when providing care to hospitalized children who are constipated. A rarely discussed aspect of pediatric care is that of sensitive touch which is required during rectal interventions such as enema and suppository administration. The purpose of this qualitative study was to investigate the experiences of pediatric nurses regarding the identification & management of constipation in hospitalized children. A theme, "down there," emerged from the larger study and revealed pediatric nurses' experiences with sensitive touch in hospitalized children with constipation.

METHODS

This phenomenological investigation utilized in depth interviews with 21 pediatric nurses to explore their experiences of caring for hospitalized children with constipation.

RESULTS

The concept sensitive touch, a touch that is applied to an intimate area of the body, emerged as a theme from the interviews. There were several subthemes. Nurses discussed assessment as "I would not automatically do a rectal check;" and incorporated development as "an infant is totally different from a 5 or 6-year-old; developing a "trustful rapport" during interventions; ensuring "comfort and privacy" as strategies during rectal interventions; and performing a "dress rehearsal" when teaching orientees about rectal interventions.

CONCLUSIONS

Pediatric nurses describe a variety of experiences when using sensitive touch in children. Although there is high awareness of the need for comfort and privacy, pediatric nurses' hesitation to intervene using rectal maneuvers could contribute to ongoing constipation in hospitalized children.

Neurogenic bowel treatments and continence outcomes in children and adults with myelomeningocele

PURPOSE

Neurogenic bowel dysfunction (NBD) is a common comorbidity of myelomeningocele (MMC), the most common and severe form of spina bifida. The National Spina Bifida Patient Registry (NSBPR) is a research collaboration between the CDC and Spina Bifida Clinics. Fecal continence (continence) outcomes for common treatment modalities for NBD have not been described in a large sample of individuals with MMC. NSBPR patients with MMC and NBD were studied to determine variation in continence status and their ability to perform their treatment independently according to treatment modality and individual characteristics.

METHODS

Continence was defined as < 1 episode of incontinence per month. Eleven common treatments were evaluated. Inclusion criteria were established diagnoses of both MMC and NBD, as well as age ⩾ 5 years (n= 3670). Chi-square or exact statistical tests were used for bivariate analyses. Logistic regression models were used to estimate the odds of continence outcomes by age, sex, race/ethnicity, level of motor function, and insurance status.

RESULTS

At total of 3670 members of the NSBPR met inclusion criteria between November 2013 and December 2017. Overall prevalence of continence was 45%. Prevalence ranged from 40-69% across different treatments. Among continent individuals, 60% achieved continence without surgery. Antegrade enemas were the most commonly used treatment and had the highest associated continence rate. Ability to carry out a treatment independently increased with age. Multivariable logistic regression showed significantly higher odds of continence among individuals aged ⩾ 12 years, female, non-Hispanic white, and with private insurance.

Pediatric skin care: what do nurses really know?

PURPOSE

The purpose of this study was to explore pediatric nurses' knowledge of pressure ulcer prevention, investigate their beliefs and practices, and identify the barriers and facilitators to providing evidence-based pressure ulcer preventive practices.

DESIGN AND METHODS

An exploratory, descriptive, and cross-sectional survey was taken of registered nurses in a freestanding children's hospital.

RESULTS

Nurses have adequate knowledge of general pressure ulcer prevention; however, they struggle with individualization. Further, analysis revealed that nursing knowledge did not always correlate with nursing practice.

PRACTICE IMPLICATIONS

Nurses require education on individualized interventions and access to user-friendly, interactive, and comprehensive resources, including unit-based champions and order sets.

Readiness for discharge in parents of hospitalized children

Parental preparation for a child's discharge from the hospital sets the stage for successful transitioning to care and recovery at home. In this study of 135 parents of hospitalized children, the quality of discharge teaching, particularly the nurses' skills in "delivery" of parent teaching, was associated with increased parental readiness for discharge, which was associated with less coping difficulty during the first 3 weeks postdischarge. Parental coping difficulty was predictive of greater utilization of posthospitalization health services. These results validate the role of the skilled nurse as a teacher in promoting positive outcomes at discharge and beyond the hospitalization.

Investigating time to void after lower-extremity orthopedic surgery in a pediatric population

PURPOSE

This study aims to determine the time frame of postoperative bladder volume assessment in order to identify children at risk for urinary retention in a pediatric orthopedic population.

DESIGN AND METHODS

This is a descriptive and nonexperimental study. Variables included age, sex, length of anesthesia, type of analgesia, analgesia delivery, bladder volume, and intravenous fluid rate.

RESULTS

Twenty-nine percent of the children (n = 38) required straight catheterization. The average length of time to bladder emptying was 5 hr. There were significant correlations (p < .05) between several variables.

PRACTICE IMPLICATIONS

The standard practice of waiting 8 hr before assessment of voiding was not supported in this study.

A rehabilitation protocol for the neuroscience intensive care unit

Because of modern technology, the rate of survival after neurologic injury has increased. The severity of patients' disabilities has also increased. Early rehabilitation intervention is beneficial from both a functional and an economic standpoint. This article describes a formal multidisciplinary protocol for comprehensive rehabilitation beginning with admission to the neurosurgical intensive care unit. A case study is also presented.

Continuous somatosensory evoked potential monitoring in the NICU

Monitoring of somatosensory evoked potentials (SSEP) of head-injured patients is a frequent and interesting topic in the neuroscience nursing arena. Often, however, nursing involvement in the recording of somatosensory evoked potentials has been limited to observing the once a week procedure and documenting patient outcome. Active nursing involvement and input in this fast moving area of research has been developed in a large midwestern neuroscience center where nurses in the NICU are responsible for the continuous monitoring (24 hours a day) of somatosensory evoked potentials of the brain-injured patient. These nurses are accountable for an accurate clinical assessment of the patient, placement and upkeep of the monitoring equipment, and evaluation of the waveform for abnormalities. The purpose and physiology of the monitoring process and the aspects of nursing care will be discussed in this article.