MRI with generalized diffusion encoding reveals damaged white matter in patients previously hospitalized for COVID-19 and with persisting symptoms at follow-up.

There is mounting evidence of the long-term effects of COVID-19 on the central nervous system, with patients experiencing diverse symptoms, often suggesting brain involvement. Conventional brain MRI of these patients shows unspecific patterns, with no clear connection of the symptomatology to brain tissue abnormalities, whereas diffusion tensor studies and volumetric analyses detect measurable changes in the brain after COVID-19. Diffusion MRI exploits the random motion of water molecules to achieve unique sensitivity to structures at the microscopic level, and new sequences employing generalized diffusion encoding provide structural information which are sensitive to intravoxel features. In this observational study, a total of 32 persons were investigated: 16 patients previously hospitalized for COVID-19 with persisting symptoms of post-COVID condition (mean age 60 years: range 41-79, all male) at 7-month follow-up and 16 matched controls, not previously hospitalized for COVID-19, with no post-COVID symptoms (mean age 58 years, range 46-69, 11 males). Standard MRI and generalized diffusion encoding MRI were employed to examine the brain white matter of the subjects. To detect possible group differences, several tissue microstructure descriptors obtainable with the employed diffusion sequence, the fractional anisotropy, mean diffusivity, axial diffusivity, radial diffusivity, microscopic anisotropy, orientational coherence (Cc) and variance in compartment's size (CMD) were analysed using the tract-based spatial statistics framework. The tract-based spatial statistics analysis showed widespread statistically significant differences (P < 0.05, corrected for multiple comparisons using the familywise error rate) in all the considered metrics in the white matter of the patients compared to the controls. Fractional anisotropy, microscopic anisotropy and Cc were lower in the patient group, while axial diffusivity, radial diffusivity, mean diffusivity and CMD were higher. Significant changes in fractional anisotropy, microscopic anisotropy and CMD affected approximately half of the analysed white matter voxels located across all brain lobes, while changes in Cc were mainly found in the occipital parts of the brain. Given the predominant alteration in microscopic anisotropy compared to Cc, the observed changes in diffusion anisotropy are mostly due to loss of local anisotropy, possibly connected to axonal damage, rather than white matter fibre coherence disruption. The increase in radial diffusivity is indicative of demyelination, while the changes in mean diffusivity and CMD are compatible with vasogenic oedema. In summary, these widespread alterations of white matter microstructure are indicative of vasogenic oedema, demyelination and axonal damage. These changes might be a contributing factor to the diversity of central nervous system symptoms that many patients experience after COVID-19.

Tapping into the unimpossible: Philosophical health in lives with spinal cord injury.

BACKGROUND: We investigated the personal philosophies of eight persons with a tetraplegic condition (four male, four female), all living in Sweden with a chronic spinal cord injury (SCI) and all reporting a good life. Our purpose was to discover if there is a philosophical mindset that may play a role in living a good life with a traumatic SCI. METHODS: Two rounds of in-depth qualitative interviews were performed by the same interviewer, a philosophical practitioner by training (de Miranda). The second round systematically covered the following elements: bodily sense, sense of self, sense of belonging, sense of the possible, sense of purpose and philosophical sense. This six-step method developed by de Miranda is called SMILE_PH, an acronym for Sense-Making Interviews Looking at Elements of Philosophical Health. RESULTS: All the interviewees, as a consequence of their trauma, reported having gone through a reinvention of themselves which implied questioning the meaning and purpose of their life in particular and life in general. A philosophical rather than realistic sense of the possible was abstracted toward teleological growth. All interviewees developed a sense of purpose based on self-interested altruism and solidarity with disabled peers. CONCLUSIONS: To reinvent a good life with SCI, in addition to physical training and willpower, one needs to consider philosophical questions about the self and life, what Kant called the cosmic interests of reason: What may I hope? What must I do? What can I know? Our results indicate that we should, in the future, explore what the philosophical health approach may bring to rehabilitation processes in the months or years that follow the trauma.

Reliability and validity of the Hebrew version of the International Spinal Cord Injury Activities and Participation Basic Data Set.

BACKGROUND: The International Spinal Cord Injury (SCI) Activities and Participation Basic Data Set (APBDS) was created to facilitate comparisons of levels of function and disability in SCI individuals worldwide. AIM: Evaluating the reliability and validity of the APBDS's Hebrew translation was our goal. DESIGN: Observational, cross-sectional study. SETTING: University and Outpatient Rehabilitation Department of a Medical Center. POPULATION: Individuals with spinal cord injury (SCI). METHODS: The APBDS's Hebrew version was administered to fifty individuals with SCI. Reliability was evaluated through Cronbach Alpha Test and a test-retest method. Validity was determined by testing for convergence with the World Health Organization Disability Assessment Scale (WHODAS) 2.0 and the Medical Outcomes Short Form Health Survey (SF-12). RESULTS: The Hebrew APBDS had a high test-retest reliability (ICC=0.792) and an adequate Cronbach alpha test (α=0.792). Significant convergent validity was partial with both the WHODAS 2.0 (strong in the self-care objective (r=-0.648) and subjective (r=-0.666), moderate in the total objective (r=-0.640) and subjective (r=-0.570) domains of the APBDS) and the SF-12 (moderate between the total objective domain and the Physical composite score (r=0.378), poor with the Mental composite score (r=0.310)). CONCLUSIONS: Although the Hebrew APBDS's moderate reliability and validity warrants further research, it opens new vistas regarding assessment of SCI individuals' satisfaction, activity, and participation. CLINICAL REHABILITATION IMPACT: We feel that this data set may be used in the long-term follow-up of SCI individuals in the Sheba SCI rehabilitation registry.

Two-year follow-up of patients with post-COVID-19 condition in Sweden: a prospective cohort study.

Background: Few studies have reported the long-term health effects of COVID-19. The regional population-based Linköping COVID-19 study (LinCoS) included all patients hospitalised due to COVID-19 during the first pandemic wave. Four months post-discharge, over 40% (185/433) experienced persisting symptoms and activity/participation limitations, indicating post-COVID-19 condition (PCC). The present follow-up study aimed to determine the long-term recovery among these patients 24 months post-admission. Methods: This prospective cohort study included all patients from LinCoS with PCC at four months post-discharge. We repeated the same structured interview at a 24-month follow-up to identify persisting symptoms and their impact on daily life. Intercurrent health issues were identified by reviewing medical records. Findings: Of 185 patients with PCC at 4 months post-discharge, 181 were alive at the 24-month assessment and 165 agreed to participate. Of those, 21% (35/165) had been readmitted to hospital for various causes in the interim period. The majority of patients (139/165, 84%) reported persisting problems affecting everyday life at 24 months. Significant improvements were seen in the prevalence and magnitude of some symptoms/limitations compared with four months post-discharge. Cognitive, sensorimotor, and fatigue symptoms were the most common persisting symptoms at 24 months. No clear difference was evident between individuals treated in the intensive care unit (ICU) and non-ICU-treated individuals. Approximately half of those who were on sick leave related to PCC at four months after infection were on sick leave at 24 months. Interpretation: This is one of the first studies to report 2-year outcomes in patients with PCC following COVID-19 hospitalisation. Despite some improvements over time, we found a high prevalence of persisting symptoms and a need for long-term follow-up and rehabilitation post COVID-19 infection. Funding: The study was funded by Region Östergötland.

Neurocognitive deficits in COVID-19 patients five months after discharge from hospital.

This observational cohort study explored objective neurocognitive deficits in COVID-19 patients five months after discharge, and any associations with demographic factors and disease severity indicators. Medical notes of all COVID-19 patients admitted to hospital in Region Östergötland, Sweden, March-May 2020, were reviewed. After applying exclusion criteria, 433 patients were screened by telephone. Of these, 185 patients reported persistent and concerning post-COVID-19 problems, including but not restricted to cognitive functions, and were invited to a clinical evaluation. The Repeatable Battery for Assessment of Neuropsychological Status (RBANS) and Colour-Word Interference Test (CWIT) were used to assess immediate memory, visuo-spatial function, language, attention, delayed memory, and executive function. A total of 133 patients had valid test performances. Mean RBANS Global Cognition Score was 83.4, with 37% scoring below cut-off (1.5 SD). Deficits in Attention and Memory indices were most common, each affecting approximately 30% of the patients. After adjustment for sex, language, level of education and premorbid function, neurocognitive performance was positively associated with length of hospital stay, but not with the disease severity indicators WHO CPS and CRP. Findings support that comprehensive neuropsychological assessment should be performed when patients report post-COVID-19 symptoms that affect daily life.

Seven Domains of Persisting Problems after Hospital-treated Covid-19 Indicate a Need For a Multiprofessional Rehabilitation Approach.

OBJECTIVES: To identify domains of persisting problems at 4 months after discharge in patients previously hospitalized due to COVID-19, with a focus on a subgroup of patients reporting symptoms to an extent indicative of rehabilitation needs. DESIGN: Ambidirectional observational cohort study. PATIENTS: All patients with a laboratory-confirmed COVID-19 diagnosis admitted to hospital in a Swedish healthcare region during the period 1 March to 31 May 2020. After exclusion, 94% of all survivors (n = 433) participated in the study. Forty-three percent (n = 185) of these reported persisting problems indicating rehabilitation needs and formed a subgroup. METHODS: Explorative factor analysis based on results from comprehensive telephone interviews covering persisting symptoms, including assessment of impact on daily life. RESULTS: Seven domains were identified, comprising problems related to vision, cognition, mental fatigue, swallowing, voice, sensorimotor dysfunction, and feeling anxious/depressed. The patients in the subgroup reported a median of 8 symptoms/limitations affecting everyday life, and two-thirds reported symptoms/limitations in 3 or more domains. CONCLUSION: Seven problem domains corresponding to specific modalities of rehabilitative interventions were identified. A majority of patients reported problems from several domains, indicating the need for multiprofessional teams in post-COVID-19 rehabilitation. Screening of patients previously hospitalized due to COVID-19 should cover all 7 domains of persisting problems.

Improved 60-day survival but impaired general health in Swedish ICU-COVID patients: An ambidirectional population-based study.

BACKGROUND: Survival among critically ill COVID-19 patients varies between countries and time periods. Mortality rates up to 60% have been reported in intensive care units (ICUs). Standard-of-care has evolved throughout the pandemic. The purpose of the study was to explore management and mortality of COVID-19 ICU-patients during the first pandemic wave and assess their post-ICU health status. METHODS: We conducted an exploratory observational ambidirectional population-based study of ICU-patients with COVID-19 in a Swedish county during 1 March-30 June 2020. Primary outcome was 60-day mortality with secondary outcomes including treatments, complications, self-reported general health and dyspnoea post-discharge. Patients were consecutively divided into equal tertiles with cut-offs on April 4 and April 20, 2020, to analyse time trends. RESULTS: One hundred patients, median age was 63 years, were included, and 60-day mortality rate was 22%. Ninety-one percent had moderate/severe ARDS and 88% required mechanical ventilation. In the first tertile of patients 60-day mortality was 33%, declining to 15% and 18% in the following two. This reduction paralleled increased use of thromboprophylaxis, less steep rise of treated ICU-patients per day and expanded ICU resources. Four months post-discharge, 63% of survivors reported self-assessed decline in general health retrospectively compared to prior COVID-19. CONCLUSIONS: In this cohort, the initial 60-day mortality quickly declined, despite continuous admittance of critically ill patients. This was parallel to adaptation to increased workload and more intense thromboembolic prophylaxis. A majority of survivors reported declined general health four months after discharge. Further studies on long-term health status of ICU-survivors are indicated.

Multiprofessional Neurorehabilitation After COVID-19 Infection Should Include Assessment of Visual Function.

Objective: To report vision-related symptoms and neuro-visual clinical signs in patients approximately 4 months after discharge from hospitalization after COVID-19 infection. To report on coexisting functional and activity limitations. Design: The study is part of an ambidirectional population-based cohort study. Setting: An outpatient setting in a hospital environment. Participants: Patients from a population-based cohort study including all patients with laboratory-confirmed COVID-19 admitted to hospital during a 3-month period in a health care region in Sweden. Among patients who, based on a standardized telephone interview, were identified as having persisting rehabilitation needs 4 months after discharge (n=185), several (n=57) reported vision-related symptoms. All 57 patients were invited to a neuro-visual examination. Six patients declined, 6 were unavailable, and 3 did not fulfil the inclusion criteria. Thus, 42 patients were included in the analysis (N=42). Interventions: Not applicable. Main Outcome Measures: Vision-related symptoms, neuro-visual function, and coexisting impairments affecting activities of daily life and participation. Results: A total of 31% of patients with rehabilitation needs after COVID-19 reported vision-related symptoms. Reading-related issues (73.8%), blurry vision (69.0%), and light sensitivity (66.7%) were the most common symptoms. Patients with reading-related issues showed a higher level of eye strain (P<.001). Neuro-visual deficits were found in 83.3% of the patients, mainly concerning eye teaming (23.1%-66.7%) and eye movement (28.6%-30.8%) functions. Patients with vision-related symptoms reported fatigue and 18 other coexisting symptoms to a greater extent (P≤.0001 to .049). Conclusions: Neuro-visual symptoms and signs should be considered when assessing rehabilitation needs after COVID-19. The association between vision-related issues and coexisting symptoms with an effect on body function and activity and/or participation underlines the need for multiprofessional rehabilitation assessment and intervention.

Rehabilitation needs following COVID-19: Five-month post-discharge clinical follow-up of individuals with concerning self-reported symptoms.

BACKGROUND: This report describes and objectivizes reported problems among a cohort of previously hospitalized COVID-19 patients by clinical examination and determination of the required level of rehabilitation sevices. METHODS: This report forms part of the Linköping COVID-19 Study (LinCoS) that included 745 individuals from one of 21 Swedish healthcare regions, Region Östergötland (RÖ), admitted to hospital for COVID-19 during March 1st-May 31st, 2020. In this descriptive ambidirectional cohort study, all 185 individuals who had reported concerning persisting symptoms were invited to a multi-professional clinical assessment of somatic, functional, affective, neuropsychological status and rehabilitation needs. Rehabilitation needs were assessed using three sub-scales of the Rehabilitation Complexity Scale-Extended. FINDINGS: Among the 158 (85·4%) cases consenting and included in the analysis, we found a broad array of symptoms and signs attributable to COVID-19 involving respiratory, visual, auditory, motor, sensory and cognitive functions that could be confirmed clinically at five months post-discharge. This translated into 16% [95% CI 13-20] of survivors (70/433) of the total regional cohort of hospitalised patients requiring further rehabilitative interventions at follow-up. Weakness in extremities was reported in 28·5% [21·6, 36·2] (45/158). On examination, clinically overt muscle weakness could be corroborated in 15 individuals (10·5%) [6·1, 16·4]. 48% [40, 56] (76/158) reported cognitive symptoms, while the physician noted overt cognitive impairments in only 3% [1·1, 7·5]. In neuropsychological testing, 37% [28-46] (45/122) performed 1.5 SD below the norm, indicating neurocognitive deficits. Fifty-five individuals (34·8%) [27·4, 42·8] reported new or aggravated pain. In three fourths of them, it exerted a 'moderate' or worse detrimental effect on their ability to work. INTERPRETATION: Our study underscores the importance of providing extensive examination of cases with persisting problems after COVID-19, especially since symptoms such as fatigue and breathlessness are highly nonspecific, but may represent significant underlying functional impairments. Robust neurocognitive testing should be performed, as cognitive problems may easily be overlooked during routine medical consultation. In the Swedish context, most rehabilitative interventions could be provided in a primary care setting. A substantial minority of patients should be triaged to specialized rehabilitation services.

Brain MRI and neuropsychological findings at long-term follow-up after COVID-19 hospitalisation: an observational cohort study.

OBJECTIVES: To report findings on brain MRI and neurocognitive function, as well as persisting fatigue at long-term follow-up after COVID-19 hospitalisation in patients identified as high risk for affection of the central nervous system. DESIGN: Ambidirectional observational cohort study. SETTING: All 734 patients from a regional population in Sweden with a laboratory-confirmed COVID-19 diagnosis admitted to hospital during the period 1 March to 31 May 2020. PARTICIPANTS: A subgroup (n=185) with persisting symptoms still interfering with daily life at a telephone follow-up 4 months after discharge were invited for a medical and neuropsychological evaluation. Thirty-five of those who were assessed with a neurocognitive test battery at the clinical visit, and presented a clinical picture concerning for COVID-19-related brain pathology, were further investigated by brain MRI. MAIN OUTCOME MEASURES: Findings on brain MRI, neurocognitive test results and reported fatigue. RESULTS: Twenty-five patients (71%) had abnormalities on MRI; multiple white matter lesions were the most common finding. Sixteen patients (46%) demonstrated impaired neurocognitive function, of which 10 (29%) had severe impairment. Twenty-six patients (74%) reported clinically significant fatigue. Patients with abnormalities on MRI had a lower Visuospatial Index (p=0.031) compared with the group with normal MRI findings. CONCLUSIONS: In this group of patients selected to undergo MRI after a clinical evaluation, a majority of patients had abnormal MRI and/or neurocognitive test results. Abnormal findings were not restricted to patients with severe disease.

[Spinal cord injury rehabilitation]. / Ryggmärgsskada ­ ett ovanligt tillstånd med komplexa behov.

Spinal cord injury (SCI) challenges many aspects of life. Common secondary health conditions are sensorimotor impairments, autonomic dysfunction affecting bowel, bladder, sexual and cardiovascular function, pressure ulcers, pulmonary dysfunction, pain and psychological distress. Primary rehabilitation and lifelong follow-up from a specialized interdisciplinary rehabilitation team is needed to attain and maintain maximum functioning and participation in all aspects of life, and to reduce the risk of complications in the acute and chronic phases after SCI. Most of the almost 300 people who sustain a SCI in Sweden each year can today be expected to live long lives. However, the growing population of people aging with long-term SCI and the increasing number of older adults sustaining an SCI are major challenges for the health care system.  Important research areas are improved neurological diagnostics, regenerative research and long-term consequences of aging with SCI.

Sound psychometric properties of the Swedish version of the Spinal Cord Independence Measure Self-Report.

OBJECTIVE: To describe data completeness, targeting and reliability of the Swedish version of the Spinal Cord Independence Measure Self-Report (s-SCIM-SR). DESIGN: Translation and reliability study. SUBJECTS: Programme participants (n = 48) and peer mentors (n = 42) with spinal cord injury enrolled in the INTERnational Project for the Evaluation of "activE Rehabilitation" (inter-PEER). METHODS: The translation process was based on guidelines/recommendations, and involved expert competence, including consumers. The s-SCIM-SR was distributed online, once for programme participants and twice for peer mentors. RESULTS: Sixty-nine individuals (77%) obtained a total score. Most missing data were found in the items Respiration and Using the toilet. Cronbach's alpha for the full scale was 0.89, for Self-care 0.92, for Respiration and sphincter management 0.37 and for Mobility 0.86. The intraclass correlation coefficient was excellent for all subscales and the full scale. Measures of variability showed high sensitivity to changes and Bland Altman analyses revealed no systematic changes between evaluation points. CONCLUSION: These results support the data completeness, targeting and reliability of the Swedish version of the SCIM-SR. However, some problems were found in the subscale Respiration and sphincter management. The s-SCIM-SR can be considered psychometrically sound and suitable to assess physical independence among persons with spinal cord injury in Swedish community settings.

Complications of intrathecal drug delivery therapy (ITDD): A retrospective study of 231 implantations between 1999 and 2014.

OBJECTIVE: Determination of types and frequencies of complications related to ITDD therapy, and assessment of possible risk factors for such complications. METHODS: Retrospective study (1999-2014) including all ITDD-implantations at one regional center in Sweden. Descriptors comprised: sex; age; medical condition; body weight index; preoperative ASA-grade; presence of indwelling urinary catheters, feeding tubes, and/or daily urinary or anal incontinence; primary or re-implantation; type of pump and catheter; drug delivered; weekday of surgery; surgical procedure time; surgeon; experience of surgeon; surgical theater; and type of antibiotic prophylaxis. All deaths during the study period were assessed as regards possible relation to ITDD. Data were analyzed with SPSS 25, using Chi2 test for correlations between descriptors and complications. RESULTS: 231 ITDD pump implantations/re-implantations occurred in 159 patients. Seventy-eight (34%) instances of complications were found: 33 catheter-associated; 6 pump-associated; and 29 infection-associated, where 16 were surgical site infections. A higher infection rate occurred in pump re-implantations, as compared to primary implantations (p = 0.002), and in patients with traumatic spinal cord injury (TSCI) as compared to other diagnoses (p = 0.02). Cloxacillin as antibiotic prophylaxis correlated with a higher infection risk (p = 0.005) relative to other antibiotic prophylaxis. Prolonged surgical procedure time in re-implantations correlated positively with increased catheter-associated complications (p = 0.006). CONCLUSION: Complications in ITDD therapy were common, comprising catheter-, infection-, and pump-associated mishaps. A comprehensive system of care needs to be present for managing complications. Future studies may show less complications due to improved protocols and equipment.

Prevalence of discomplete sensorimotor spinal cord injury as evidenced by neurophysiological methods: A cross-sectional study.

OBJECTIVES: To assess the prevalence of residual trans-lesion connectivity in persons with chronic clinically complete spinal cord injury (discompleteness) by neurophysiological methods. PARTICIPANTS: A total of 23 adults with chronic sensorimotor complete spinal cord injury, identified through regional registries the regional spinal cord registry of Östergötland, Sweden. METHODS: Diagnosis of clinically complete spinal cord injury was verified by standardized neurological examination. Then, a neurophysiological examination was performed, comprising electroneurography, electromyography, sympathetic skin response and evoked potentials (sensory, laser and motor). Based on this assessment, a composite outcome measure, indicating either strong, possible or no evidence of discomplete spinal cord injury, was formed. RESULTS: Strong neurophysiological evidence of discomplete spinal cord injury was found in 17% (4/23) of participants. If also accepting "possible evidence", the discomplete group comprised 39% (9/23). The remaining 61% showed no neurophysiological evidence of discompleteness. However, if also counting reports of subjective sensation elicited during neurophysiological testing in the absence of objective findings, 52% (12/23) showed indication of discomplete spinal cord injury. CONCLUSION: Evidence of discomplete spinal cord injury can be demonstrated using standard neurophysiological techniques in a substantial subset of individuals with clinically complete spinal cord injury. This study adds to the evidence base indicating the potential of various modes of cross-lesional sensorimotor functional restoration in some cases of chronic clinically complete spinal cord injury.

Preserved somatosensory conduction in complete spinal cord injury: Discomplete SCI.

OBJECTIVE: Spinal cord injury (SCI) disrupts the communication between brain and body parts innervated from below-injury spinal segments, but rarely results in complete anatomical transection of the spinal cord. The aim of this study was to investigate residual somatosensory conduction in clinically complete SCI, to corroborate the concept of sensory discomplete SCI. METHODS: We used fMRI with a somatosensory protocol in which blinded and randomized tactile and nociceptive stimulation was applied on both legs (below-injury level) and one arm (above-injury level) in eleven participants with chronic complete SCI. The experimental design accounts for possible confounding mechanical (e.g. vibration) and cortico-cortical top-down mechanisms (e.g. attention/expectation). RESULTS: Somatosensory stimulation on below-level insensate body regions activated the somatotopically corresponding part of the contralateral primary somatosensory cortex in six out of eleven participants. CONCLUSIONS: Our results represent afferent-driven cortical activation through preserved somatosensory connections to the brain in a subgroup of participants with clinically complete SCI, i.e. sensory discomplete SCI. SIGNIFICANCE: Identifying patients with residual somatosensory connections might open the door for new rehabilitative and restorative strategies as well as inform research on SCI-related conditions such as neuropathic pain and spasticity.

Self-reported health problems and prioritized goals in community-dwelling individuals with spinal cord injury in Sweden.

OBJECTIVE: To explore self-reported health problems and functional goals in community-dwelling individuals with spinal cord injury in Sweden. DESIGN: Cross-sectional descriptive study that used a survey designed by an experienced peer mentor with spinal cord injury. SUBJECTS: Community-dwelling individuals with spinal cord injury from Sweden. METHODS: The survey was distributed online by the community peer-based organization RG Active Rehabilitation. RESULTS: A total of 203 individuals (55% males, 90% acquired spinal cord injury) from all regions in Sweden completed the survey. Of these, 33% reported living with > 2 unbearable physical or psychological problems. While some problems (e.g. problems related to bladder and balance) were consistently ranked to be common across all years since injury and type of spinal cord injury, distribution of some other unbearable problems (e.g. type of pain, excessive weight) varied between subgroups. Years since injury, level of acquired spinal cord injury and sex, but not age-group or type of spinal cord injury, explained some of the variation in the goals. CONCLUSION: The high proportion of reported "unbearable" problems point to the stronger need for systematic, comprehensive, life-long, multi-disciplinary follow-up for people with spinal cord injury. The high rate of goals related to improving strength and fitness across all participants independently of their characteristics highlight the important role of community organizations that offer such lifetime services.

Identifying Unmet Rehabilitation Needs in Patients After Stroke With a Graphic Rehab-CompassTM.

BACKGROUND: Unmet rehabilitation needs are common among stroke survivors. We aimed to evaluate whether a comprehensive graphic "Rehab-Compass," a novel combination of structured patient-reported outcome measures, was feasible and useful in facilitating a capture of patients' rehabilitation needs in clinical practice. METHODS: A new graphic overview of broad unmet rehabilitation needs covers deficits in functioning, daily activity, participation, and quality of life. It was constructed by using 5 patient-oriented, well-validated, and reliable existing instruments with converted data into a 0 (worst outcome) to 100 (best outcome) scale but unchanged in terms of variable properties. Satisfaction of the Rehab-CompassTM was studied by a qualitative interview of 9 patients with stroke and 3 clinicians. Practical feasibility and capacity of the instrument were evaluated in a cross-sectionalstudy with 48 patients at 5-month follow-ups after subarachnoid hemorrhage. RESULTS: The Rehab-CompassTM identified and graphically visualized a panoramic view of the multidimensional needs over time which was completed before clinical consultation. The Rehab-CompassTM appeared to be feasible and time-efficientin clinical use. The interviews of both patients and clinicians showed high satisfaction when using the Rehab-CompassTM graph. In the studied stroke patients, the Rehab-CompassTM identified memory and processing information, fatigue, mood, and pain after subarachnoid hemorrhage as the most common problems. CONCLUSIONS: The graphic Rehab-CompassTM seems to be a feasible, useful, and time-saving tool for identification of unmet rehabilitation needs among stroke survivors in clinical practice. Further research is needed to make the Rehab-CompassTM more concise and evaluate the instrument among different stroke subgroups.

Bladder irrigation with Chlorhexidine reduces bacteriuria in persons with spinal cord injury.

OBJECTIVE: To explore whether bladder irrigation with chlorhexidine: (i) can reduce bacteriuria, and (ii) is a practically feasible option in subjects with spinal cord injury practicing intermittent self-catheterization. DESIGN: A prospective, non-controlled, open, multi-centre study. METHODS: Fifty patients with spinal cord injury, practicing intermittent self-catheterization, with a history of recurrent urinary tract infections were screened for bacteriuria at follow-up visits to 4 spinal cord injury centres in Sweden. Twenty-three patients had a positive urine culture (> 105 CFU/ml of > 1 bacterial species), of which 19 completed the study. Subjects proceeded with bladder irrigation, using 120 ml of 0.2% chlorhexidine solution twice daily for up to 7 days. Urine samples were taken twice daily. Response to treatment was defined as reduction in bacterial counts to < 103 CFU/ml. RESULTS: Fourteen of 19 subjects reduced their bacterial counts to or below the set limit. Subsequent return of above-endpoint bacteriuria was seen in most of the subjects. However, there were significantly fewer subjects with bacteriuria after treatment (p <0.005). CONCLUSION: Bladder irrigation with chlorhexidine, using intermittent self-catheterization, reduced bacteriuria in the majority of subjects with spinal cord injury and bacteriuria. The addition of bladder irrigation was practically feasible in the short time-frame of this study.

Computed tomography and clinical outcome in patients with severe traumatic brain injury.

OBJECTIVE: To study: (i) acute computed tomography (CT) characteristics and clinical outcome; (ii) clinical course and (iii) Corticosteroid Randomisation after Significant Head Injury acute calculator protocol (CRASH) model and clinical outcome in patients with severe traumatic brain injury (sTBI). METHODS: Initial CT (CTi) and CT 24 hours post-trauma (CT24) were evaluated according to Marshall and Rotterdam classifications. Rancho Los Amigos Cognitive Scale-Revised (RLAS-R) and Glasgow Outcome Scale Extended (GOSE) were assessed at three months and one year post-trauma. The prognostic value of the CRASH model was evaluated. RESULTS: Thirty-seven patients were included. Marshall CTi and CT24 were significantly correlated with RLAS-R at three months. Rotterdam CT24 was significantly correlated with GOSE at three months. RLAS-R and the GOSE improved significantly from three months to one year. CRASH predicted unfavourable outcome at six months for 81% of patients with bad outcome and for 85% of patients with favourable outcome according to GOSE at one year. CONCLUSION: Neither CT nor CRASH yielded clinically useful predictions of outcome at one year post-injury. The study showed encouragingly many instances of significant recovery in this population of sTBI. The combination of lack of reliable prognostic indicators and favourable outcomes supports the case for intensive acute management and rehabilitation as the default protocol in the cases of sTBI.