Timing of surgical intervention after firearm-related spinal cord injury.

CONTEXT: Surgical management of firearm-related spinal cord injury (SCI) remains controversial, and there are no clear guidelines. Time to surgery, surgical indications, and patient characteristics on initial presentation in this group are not well understood, and these factors may impact the potential for neurologic recovery after operative intervention. OBJECTIVE: To understand the timing and factors affecting the timing of operative intervention after firearm-related SCI. METHODS: In a retrospective cohort study, patients with traumatic SCI from July 2012 to July 2022 (n = 1569) were identified from our level 1 trauma center Trauma Registry. Data was obtained from the trauma registry and chart review. Rates and timing of surgical intervention, initial injury severity measures, and general hospital outcomes were compared between firearm-related SCI and blunt trauma SCI. RESULTS: Patients with firearm-related SCI were less likely to undergo surgery compared to other etiologies (24.3% vs. 70.2%, P < 0.0001). Time to surgery for firearm-related SCI was longer than for other etiologies (49.2 ± 92.9 vs. 30.6 h ± 46.0, P = 0.012). Multiple measures of initial injury severity, including Injury Severity Score, Glasgow Coma Score, and emergency department disposition demonstrated more severe injury among patients with firearm-related SCI, and these patients often required other emergent surgeries prior to spine surgery (52%). CONCLUSIONS: There was a longer time to spine surgery among patients with firearm-related SCI compared to blunt trauma SCI, and patients with firearm-related SCI were more severely injured on initial presentation. Further research is needed to understand the complex relationship between patient injury severity, surgical intervention, surgical timing, and outcomes after firearm-related SCI.

Feasibility of Brief, Hypnotic Enhanced Cognitive Therapy for SCI-related Pain During Inpatient Rehabilitation.

OBJECTIVES: (1) Adapt evidence-based hypnosis-enhanced cognitive therapy (HYP-CT) for inpatient rehabilitation setting; and (2) determine feasibility of a clinical trial evaluating the effectiveness of HYP-CT intervention for pain after spinal cord injury (SCI). STUDY DESIGN: Pilot non-randomized controlled trial. SETTING: Inpatient rehabilitation unit. PARTICIPANTS: English-speaking patients admitted to inpatient rehabilitation after SCI reporting current pain of at least 3 on a 0-10 scale. Persons with severe psychiatric illness, recent suicide attempt or elevated risk, or significant cognitive impairment were excluded. Consecutive sample of 53 patients with SCI-related pain enrolled, representing 82% of eligible patients. INTERVENTION: Up to 4 sessions of HYP-CT Intervention, each 30-60 minutes long. METHODS: Participants were assessed at baseline and given the choice to receive HYP-CT or Usual Care. MAIN OUTCOME MEASURES: Participant enrollment and participation and acceptability of intervention. Exploratory analyses examined the effect of intervention on pain and cognitive appraisals of pain. RESULTS: In the HYP-CT group, 71% completed at least 3 treatment sessions and reported treatment benefit and satisfaction with the treatment; no adverse events were reported. Exploratory analyses of effectiveness found pre-post treatment pain reductions after HYP-CT with large effect (P<.001; ß=-1.64). While the study was not powered to detect significant between-group differences at discharge, effect sizes revealed decreases in average pain (Cohen's d=-0.13), pain interference (d=-0.10), and pain catastrophizing (d=-0.20) in the HYP-CT group relative to control and increases in self-efficacy (d=0.27) and pain acceptance (d=0.15). CONCLUSIONS: It is feasible to provide HYP-CT to inpatients with SCI, and HYP-CT results in substantial reductions in SCI pain. The study is the first to show a psychological-based nonpharmacologic intervention that may reduce SCI pain during inpatient rehabilitation. A definitive efficacy trial is warranted.

Utilization of rehabilitation services in violent versus nonviolent traumatic spinal cord injury.

BACKGROUND: Violence is the third leading cause of spinal cord injury (SCI) in the United States, and people with violence-related SCI have worse long-term outcomes compared to other traumatic SCI etiologies. Little is known, however, about the underlying reasons for these differences. Access to and utilization of rehabilitation services may differ in this population, but their outpatient care has not been previously investigated. OBJECTIVE: To evaluate differences in utilization patterns of outpatient rehabilitation services between people with violence-related SCI and other traumatic SCI etiologies. DESIGN: Retrospective cohort study. SETTING: Academic tertiary care hospital system. PATIENTS: A total of 41 patients with violence-related SCI residing in King County at the time of injury who completed inpatient rehabilitation (IPR) in our institution were identified from the hospital trauma registry and matched with 41 control patients with nonviolent traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): The number of appointments attended, canceled, and missed during the first year after discharge from IPR were obtained by chart review for physical medicine & rehabilitation (PM&R) physicians and therapy services. RESULTS: People with violence-related SCI had decreased follow-up with outpatient rehabilitation services after IPR discharge compared to non-violent traumatic SCI, including PM&R (2.50 ± 2.44 vs. 3.76 ± 2.21 visits, ß = -1.28, p = .017), physical therapy (8.91 ± 11.02 vs. 17.57 ± 15.26, ß = -9.79, p = .009), occupational therapy (4.28 ± 7.90 vs. 10.04 ± 14.42, ß = -6.18, p = .033), and recreational therapy (0.293 ± 0.955 vs. 1.37 ± 2.86, ß = -1.07, p = .035). The rate of missed appointments was also higher among people with violence-related SCI compared to controls for PM&R (25.2% ± 28.5% vs. 9.9% ± 16.5%, ß = 14.6%, p = .014) and physical therapy (26.0% ± 32.0% vs 4.2% ± 13.2%, ß = 22.1%, p = .009). CONCLUSIONS: Individuals with violence-related SCI had fewer follow-up appointments with PM&R physicians and other allied health professionals and were more likely to miss scheduled appointments compared to other traumatic SCI etiologies. Decreased outpatient follow-up may affect long-term outcomes for people with violence-related SCI.

A Case Study of Hypnosis Enhanced Cognitive Therapy for Pain in a Ventilator Dependent Patient during Inpatient Rehabilitation for Spinal Cord Injury.

Early, acute pain following spinal cord injury (SCI) is common, can negatively impact SCI rehabilitation, and is frequently not responsive to biomedical treatment. Nonpharmacological interventions show promise in reducing pain for individuals with SCI. However, most psychological interventions rely heavily on verbal interaction between the individual being treated and the clinician, making them inaccessible for individuals with impaired verbal output due to mechanical ventilation. This case study aims to describe the adaptation and implementation of hypnotic cognitive therapy (HYP-CT) intervention for early SCI pain in the context of mechanical ventilation dependence and weaning. The participant was a 54-year-old male with C2 AIS A SCI requiring mechanical ventilation. Four sessions of HYP-CT were provided during inpatient rehabilitation with assessment prior to intervention, after the intervention sessions, and prior to discharge. The participant reported immediate reductions in pain intensity following each intervention session. Overall, he reported increases in self-efficacy and pain acceptance. He did not report any negative treatment effects and thought the intervention provided support during mechanical ventilation weaning. During treatment, he discontinued opioid pain medications and reported actively using intervention strategies. Our results support the potential for early, hypnotic cognitive therapy for individuals with SCI experiencing pain or distress while dependent on mechanical ventilation.

Birth Outcomes and Rehospitalizations Among Pregnant Women With Rheumatoid Arthritis and Systemic Lupus Erythematosus and Their Offspring.

OBJECTIVE: To compare obstetric/birth outcomes and rehospitalization among women with and without rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) and their infants. METHODS: This population-based retrospective cohort study identified women with RA (n = 1,223) and SLE (n = 1,354) and unexposed women with singleton births 1987-2014 in Washington State in linked vital hospital discharge records. Outcomes, including cause-specific hospitalizations <2 years postpartum, were compared by estimating adjusted relative risks (RRs) and cause-specific rehospitalization hazard ratios (HRs) with 95% confidence intervals (95% CIs). RESULTS: We observed increased risks of several adverse outcomes; RRs were often greatest for SLE. Women with RA/SLE more often required rehospitalization, most notably at <6 months postpartum (RA: 4% versus 2%; RR 2.22 [95% CI 1.62-3.04]; SLE: 6% versus 2%; RR 2.78 [95% CI 2.15-3.59]). Maternal postpartum rehospitalization was greatest for musculoskeletal conditions (RA: HR 19.1 [95% CI 13.6-26.8]; SLE: HR 29.8 [95% CI 22.1-40.1]). Infants of women with SLE more often had malformations (9% versus 6%; RR 1.46 [95% CI 1.21-1.75]), and increased mortality at <2 years (RR 2.11 [95% CI 1.21-3.67]). Infants of women with SLE also experienced more frequent rehospitalizations in their first year of life. CONCLUSION: Women with RA or SLE and their infants experienced adverse outcomes, particularly infants of women with SLE. Maternal/infant rehospitalization was more common; most marked in the early months postpartum. Close follow-up during these time periods is crucial to minimize adverse outcomes.

Positive predictive value of a sepsis-screening protocol for patients with tetraplegia.

OBJECTIVE: To determine the positive predictive value (PPV) of a sepsis-screening protocol in patients with cervical spinal cord injury (SCI). DESIGN/METHOD: Retrospective review of all patients with cervical SCI who screened positive for two or more systemic inflammatory response syndrome (SIRS) criteria while hospitalized in acute care or inpatient rehabilitation units over a 3.5-year period. Sepsis was defined by the occurrence of (1) any culture order followed by an intravenous (IV) antibiotic within 72 hours or (2) an IV antimicrobial followed by a culture order within 24 hours. RESULTS: A total of 134 patients screened positive for two or more SIRS criteria. Of these, 36 patients (26.9%) were diagnosed with sepsis. Factors associated with a true-positive SIRS screen on multivariable analysis included American Spinal Injury Association Impairment Scale (AIS) grade A-C (vs. D; p < .001). The PPV of the screen was 38% in patients with AIS A-C and 9% in patients with AIS D. Altered mental status (AMS) was strongly associated with a diagnosis of sepsis; 16 of 18 (88.9%) of those with AMS had sepsis (p < .001). Age, sex, and neurologic level of injury were not associated with true-positive screening. For patients with new SCI, the first true-positive screen occurred a median of 31 days post-injury. The most common SIRS criteria combinations in patients with true-positive screens were elevated heart rate and either abnormal white blood cell count (43% of true positives) or abnormal temperature (26% of true positives). Abnormally low body temperature (<36°C) contributed to false-positive screening for 10 of 38 (26%) AIS D patients who screened positive. CONCLUSION: Sepsis screening using SIRS criteria in hospitalized patients with tetraplegia has a PPV of 26.9%; it is significantly higher in patients with AIS A-C versus D injuries. AMS, when combined with a positive SIRS screening, is strongly associated with sepsis.

Morbidity and rehospitalization postpartum among women with epilepsy and their infants: A population-based study.

OBJECTIVE: We compared the relative occurrence of selected pregnancy outcomes and postpartum rehospitalizations among women with and without epilepsy and their infants. Using linked vital-hospital discharge records of women with deliveries in Washington State 1987-2014, comparisons were made overall, by epilepsy type, and by time periods related to antiepileptic drug (AED) marketing changes. METHODS: This population-based retrospective cohort study identified women with, and without epilepsy per diagnosis codes in the hospital discharge record from among all deliveries during 1987-2014 to examine maternal and infant outcomes, rehospitalization and mortality <2 years postpartum. Relative risks (RRs) and 95 % confidence intervals (CI) overall, and by epilepsy type were calculated using Poisson regression. We assessed the validity of epilepsy identification based on diagnosis codes by conducting a medical chart review for a sample of women. RESULTS: Women with epilepsy had increased risks of preeclampsia (RR 1.23; 95 % CI 1.08-1.41) and gestational diabetes (RR 1.18; 95 % CI 1.02-1.36). Their infants had increased malformation (RR 1.23; 95 % C: 1.08-1.42) and small for gestational age (SGA, RR 1.39; 95 % CI 1.25-1.54) risks, and were nearly three times as likely to not be breastfed. Affected mothers (RR 5.25; 95 % CI 2.46-11.23) and their infants (RR 1.64, 95 % CI 1.41-1.89) required more ICU admissions during the delivery hospitalizations, and more postpartum rehospitalization, with greatest risk in the first six months. Maternal mortality < 2 years after delivery was increased (RR 7.11; 95 % CI 2.47-20.49). Increased risks were observed for all epilepsy subtypes for nearly all outcomes examined. Risks of preterm delivery and low birthweight increased over time (p <.05). Suggestive, but not statistically significant temporal decreases in risks of gestational diabetes and malformations and increased risk of preterm labor were noted. We observed high sensitivity of diagnosis codes for identifying pregnant women with epilepsy. CONCLUSION: These population-based results emphasize the need for frequent postpartum monitoring of women with epilepsy. Increases in risks of low birthweight and preterm delivery over time are of concern. Possible temporal changes in other outcomes warrant further investigation.

Pregnancy outcomes among visually impaired women in Washington State, 1987-2014.

BACKGROUND: Women with visual impairment may have reduced ability to access standard care resources, however, information on their pregnancy and neonatal outcomes is limited. OBJECTIVE: To assess risk of adverse pregnancy and neonatal outcomes among visually impaired women in Washington State from 1987 to 2014. METHODS: We conducted a retrospective cohort study using linked Washington State birth/fetal death hospital discharge records to compare outcomes among women with and without visual impairment noted at their delivery hospitalization. Pregnancy conditions and outcomes evaluated included gestational diabetes, pre-eclampsia, labor induction and cesarean delivery. Neonatal outcomes included preterm delivery and birth weight <2500 g. We assessed length of maternal and infant delivery hospitalization. We performed Poisson regression to estimate relative risks (RR) and 95% confidence intervals (CIs) for each outcome, adjusting for year of delivery, maternal age, and parity. RESULTS: Most adverse pregnancy and neonatal outcomes were similar for visually impaired (N = 232) and comparison women (N = 2362). However, visually impaired women had increased risks of severe pre-eclampsia (RR 3.77, 95% CI 1.69-8.43), labor induction (RR 1.33, 95% CI 1.10-1.61) and preterm delivery (RR 1.60, 95% CI 1.06-2.42). They were also more likely to have delivery hospitalizations of 3 or more days following a vaginal (RR 1.86, 95% CI 1.41-2.47). Among cesarean deliveries, infants of visually impaired women had increased risk (RR 1.24, 95% CI 1.02-1.51) of hospitalization for 3 or more days postpartum. CONCLUSION: Our findings may be useful for obstetric providers in counseling their visually impaired patients.

A tele-health intervention to increase physical fitness in people with spinal cord injury and cardiometabolic disease or risk factors: a pilot randomized controlled trial.

STUDY DESIGN: Clinical trial. OBJECTIVES: We used a single-blind parallel-group design to test the feasibility and preliminary efficacy of a telehealth-based physical activity counseling intervention to increase physical fitness in people with SCI. SETTING: Seattle, Washington, United States. METHODS: We recruited under-active, manual wheelchair-using adults at least 1-year post-SCI who had at least two cardiometabolic risk factors/diseases. Participants underwent baseline tests of peak cardiorespiratory fitness; lipids, glucose and insulin; muscle and fat mass; self-reported physical activity, depression, pain and other factors. Participants were assigned 1:1 to treatment vs. usual care (UC) control conditions via concealed computerized randomization. Treatment was delivered via telephone and adapted from the 16-session Diabetes Prevention Program. All baseline tests were repeated at 6 months. Prespecified feasibility goals were to recruit at least nine participants/quarter and retain 85% with complete fitness testing at 6 months. Prespecified efficacy goals were to demonstrate at least a medium treatment effect size (0.50) on fitness, self-reported physical activity, and other outcomes. RESULTS: Seven participants were randomized to treatment, 8 to UC over 15 months. Maximum recruitment was only 5.4 participants/quarter. Thirteen (87%) of participants were retained. The effects of treatment on fitness and most cardiometabolic risk factors did not meet expectations, whereas the effects on self-reported physical activity, depression, and pain did meet expectations. CONCLUSIONS: The study did not meet key efficacy and feasibility objectives, yet there were some promising effects on self-report measures and lessons to be learned for designing future trials.

Interdisciplinary care for spinal cord injured refugees.

INTRODUCTION: For war-injured refugees, spinal cord injury (SCI) is a leading cause of catastrophic neurologic injury and literature focused on the care of this vulnerable population is sparse. This case series describes the unique challenges presented to an outpatient interdisciplinary rehabilitation team in providing SCI care in the USA for refugees who suffered their SCI in their home countries. CASE PRESENTATION: Our interdisciplinary rehabilitation team faced challenges related to language, cultural and educational barriers which impacted the typical standard rehabilitation care offered to these individuals. Many of the individuals were focused on curative treatments. As such, managing expectations and educating individuals to rehabilitation practices for chronic SCI and lack of curative treatments for associated medical complications affected the provision of care across all disciplines of the rehabilitation team. DISCUSSION: This case series showcases the challenges of caring for international refugees with SCI. The care offered to these individuals highlights the benefits that an interdisciplinary SCI rehabilitation approach can provide to comprehensively care for this vulnerable population.