Limb loss in individuals with chronic spinal cord injury.

Objective: The purpose of this study is to describe a population of individuals with chronic spinal cord injury (SCI), who underwent lower limb amputations, identify indications for amputations, medical co-morbidities and summarize resulting complications and functional changes.Design: Retrospective observational cohort study.Setting: SCI Service, Department of Veterans Affairs (VA) Health Care System.Participants: Veterans with SCI of greater than one-year duration who underwent amputation at a VA Medical Center over a 15-year period, using patient registry and electronic health records. Diagnosis and procedure codes were utilized to identify amputations.Interventions: Not applicable.Outcome measures: Amputation level, complications, functional status, change in prescribed mobility equipment and mortality.Results: 52 individuals with SCI received amputation surgery with a mean age of 62.9 years at time of amputation. Thirty-seven (71.2%) had paraplegia, and 34 (65.3%) had motor-complete SCI. Pressure injuries and osteomyelitis were most common indications for amputation. Amputations were primarily (83%) at the transtibial level or more proximal, with the most common amputation level at transfemoral/through-knee (29;55.8%). Postoperative complications occurred in five individuals. Seven of nine individuals who were ambulatory pre-surgery remained ambulatory. Equipment modifications were required in 37 (71%) of individuals. Five-year survival following amputations was 52%, and presence of peripheral vascular disease was significantly associated with mortality (P = 0.006).Conclusions: Pressure injuries and osteomyelitis were most common etiologies for limb loss. Less than half experienced functional change after amputation; more than half required new or modified mobility equipment. An increase in mortality may reflect overall health deterioration over time.

Patient, provider, and system factors that contribute to health care-associated infection and sepsis development in patients after a traumatic injury: An integrative review.

OBJECTIVES: Patients after traumatic injury continue to develop health care-associated infections. The aim of this review was to identify risk factors for developing hospital-acquired infection and sepsis in patients experiencing a traumatic injury. DESIGN: This is an integrative review following the framework of Whittemore and Knafl. DATA SOURCES: An electronic database search was undertaken using Scopus and Medline databases in early October 2019. Hand searching of key references was also conducted. The existing literature published between January 2007 and September 2019 was searched to identify clinically relevant studies that reflected current healthcare practices and systems. REVIEW METHODS: Four reviewers independently assessed articles for inclusion eligibility. Full-text versions of the articles were systematically appraised using the Critical Appraisal Skills Programme. The Preferred Reporting Items for Systematic reviews and Meta-Analyses format was used. RESULTS: A total of 15 studies from the United Kingdom, the United States of America, China, and South Korea were included. Twelve of the 15 studies were focused exclusively on patient-based risk factors including gender and comorbidities. Provider-based factors were identified as nurse staffing levels between different categories of nurses with various levels of proficiency. System-level risk factors included interhospital admissions, surgical interventions, and length of stay. CONCLUSIONS: Hospital-acquired infections are preventable, and it is imperative that provider and system risk factors that contribute to patients with traumatic injuries from developing a hospital-acquired infection be identified. Patients with traumatic injuries are unable to amend any patient-related risk factors such as comorbidities or gender. However, the identification of provider and system risk factors that contribute to patients with traumatic injuries from developing a hospital-acquired infection would provide clinically relevant and applicable strategies at the macro and meso level being implemented.

Comorbid Traumatic Brain Injury and Spinal Cord Injury: Screening Validity and Effect on Outcomes.

OBJECTIVES: To determine the diagnostic accuracy of a self-report measure of traumatic brain injury (TBI) in people with spinal cord injury (SCI), and to assess the potential effect of TBI on acute and postacute outcomes. DESIGN: Incident TBI as determined by self-report was compared with systematic medical records review by physicians blinded to self-reported TBI. SETTING: Inpatient rehabilitation unit. PARTICIPANTS: From 155 consecutive admissions, participants (N=105; 73% men; mean age, 45.9y; 73% white; 58% with tetraplegia) who met inclusion criteria and were admitted on the day of injury were recruited and assessed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Step 2 of the Traumatic Brain Injury-4 (TBI-4) interview was used to estimate the presence and severity of TBI. RESULTS: Estimated incidence of TBI was 33% by chart review and 60% based on Step 2 of the TBI-4. Ninety-one percent of those with TBI based on chart review sustained mild injuries. At the optimal cutoff of "possible TBI," the TBI-4 had a sensitivity of 83% (95% confidence interval, 66%-93%), a specificity of 51% (95% confidence interval, 39%-64%), and a Youden Index of 0.3 (95% confidence interval, 0.2-0.5). Compared with those without TBI, those with chart review-determined TBI had nonsignificant trends toward a longer acute care length of stay and a higher functional status at rehabilitation discharge, but equivalent 1-year outcomes. CONCLUSIONS: Step 2 of theTBI-4 did not meet Youden's criteria (≥0.8) for good diagnostic accuracy in the context of recent SCI. Comorbid TBIs were almost exclusively mild and not associated with poorer outcomes 1 year after SCI.

Cutaneous vasculopathy associated with levamisole-adulterated cocaine.

We report a case of cutaneous vasculopathy associated with the use of levamisole-adulterated cocaine. This recently described clinical entity is characterized by a purpuric rash with a predilection for the ears, leukopenia, and anti-neutrophilic cytoplasmic antibody (ANCA) positivity. It is estimated that more than 70% of the current United States cocaine supply is contaminated with levamisole. Levamisole is a widely available, inexpensive, white powder used as a "cutting agent" in cocaine to expand volume and increase profits. It may also increase the euphoric and stimulatory effects of cocaine by increasing brain dopamine levels and producing amphetamine-like metabolites. Our patient exhibited a characteristic rash with involvement of the ears, leukopenia, and cocaine metabolites were detected in serum and urine. The presence of levamisole was confirmed in the urine utilizing gas chromatography-mass spectrometry. ANCA positivity was also present. Punch biopsy of the skin demonstrated vascular thrombosis and necrosis without true vasculitis. We review the literature for reported cases of cocaine-levamisole cutaneous vasculopathy syndrome, highlight the salient immunologic abnormalities, and contrast the features of this entity with idiopathic systemic vasculitis.