Research Priorities of the Pediatric Spinal Cord Injury Population: An International Insight for Rehabilitation Care.

BACKGROUND: Although feedback from people with adult-onset spinal cord injury (SCI) has been considered for new rehabilitation programs, little is known about the priorities of the pediatric-onset SCI population. This study describes and compares health and life (H&L) domain research priorities of youth with pediatric-onset SCI and their parents/caregivers. METHODS: A cross-sectional survey, designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) Collaboration, was performed at six European countries. Dyad data from 202 participants, youth with pediatric-onset SCI (n = 101) and their parents/caregivers (n = 101), were analyzed with the PEPSCI H&L domain surveys. RESULTS: The cohort was composed of 8 to 12-year-olds (30.7%), 13 to 17-year-olds (38.6%), and 18 to 25-year-olds (30.7%). The top three H&L domain research priorities reported by parents/caregivers of 8 to 12-year-olds were "walking/ability to move" (91%), "bladder" function (90%), and "general health/feel" (89%), compared with "physical function" (93%), "general health/feel" (90%), and "walking/ability to move" (89%) rated by parents/caregivers of 13 to 25-year-olds. "Bowel" function (85%), "leg/foot movement" (84%), and "bladder" function (84%) were reported as priorities by 13 to 25-year-olds, whereas "physical function" (84%), "experience at school" (83%), and "general mood" were highlighted by 8 to 12-year-olds. The top 10 priorities preferred by 13 to 25-year-olds when compared with the top 10 priorities reported by their parents/caregivers, included problems related to "bowel" and "pain." CONCLUSIONS: Health domain research priorities were highlighted by 13 to 25-year-olds, compared with their parents/caregivers who equally identified H&L domains. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive research strategy for the pediatric SCI population.

Prevalence of vitamin D deficiency in patients with spinal cord injury at admission: a single-centred study in the UK.

Vitamin D deficiency is prevalent in patients with chronic spinal cord injury (SCI) and has been implicated as an aetiologic factor of osteoporosis and various skeletal and extra-skeletal issues in SCI patients. Few data were available regarding vitamin D status in patients with acute SCI or immediately assessed at hospital admission. This retrospective cross-sectional study evaluated vitamin D status in SCI patients at admission to a UK SCI centre in January-December 2017. A total of 196 eligible patients with serum 25(OH)D concentration records at admission were recruited. The results found that 24 % were vitamin D deficient (serum 25(OH)D < 25 nmol/l), 57 % of the patients had serum 25(OH)D < 50 nmol/l. The male patients, patients admitted in the winter-spring time (December-May), and patients with serum sodium < 135 mmol/l or with non-traumatic causes had a significant higher prevalence of vitamin D deficiency than their counterparts (28 % males v. 11⋅8 % females, P = 0⋅02; 30⋅2 % in winter-spring v. 12⋅9 % in summer-autumn, P = 0⋅007; 32⋅1 % non-traumatic v. 17⋅6 % traumatic SCI, P = 0⋅03; 38⋅9 % low serum sodium v. 18⋅8 % normal serum sodium, P = 0⋅010). There was a significant inverse association of serum 25(OH)D concentration with body mass index (BMI) (r = -0⋅311, P = 0⋅002), serum total cholesterol (r = -0⋅168, P = 0⋅04) and creatinine concentrations (r = -0⋅162, P = 0⋅02) that were also significant predictors of serum 25(OH)D concentration. Strategies for systematic screening and efficacy of vitamin D supplementation in SCI patients need to be implemented and further investigated to prevent the vitamin D deficiency-related chronic complications.

Pediatric health and life domain priorities: A national survey of people with spinal cord injury and their parents and caregivers.

CONTEXT/OBJECTIVE: No information is available regarding priorities for pediatric-onset spinal cord injury (SCI). This study described the Health and Life (H&L) domain priorities of youth with pediatric-onset SCI and their parents/caregivers living in Spain. DESIGN: A cross-sectional survey. SETTING: Two SCI rehabilitation centers. PARTICIPANTS: Sixty participants, youth with pediatric-onset SCI (n = 26) and parents/caregivers (n = 34). INTERVENTIONS: Not applicable. OUTCOME MEASURES: Median overall priorities calculated on the basis of importance, unhappiness, and research measured with a new survey of pediatric H&L domains and rated using a 5-point Likert Scale. RESULTS: A total of 60 surveys were received providing information on 35 individuals with SCI: 2-7-year-olds (25.7%), 8-12-year-olds (22.9%), 13-17-year-olds (31.4%), and 18-25-year-olds (20.0%). The top three overall H&L priorities reported by parents/caregivers of 2-12-year-olds were "parenthood expectations" (84%), "leg/foot movement" (83%), and "bladder" function (83%), compared to "dressing/undressing" (78%), "walking/ability to move" (77%) and "bladder" function (77%) rated for 13-25-year-olds. "Sit-to-stand" (79%), "leg/foot movement" (78%) and "arm/hand movement" (77%) were reported as priorities by 13-25-year-olds. The 13-25-year-olds highlighted "sit-to-stand" (100%), "eating/drinking" (54%), and "physical function" (94%) as their top unhappiness, importance, and research priorities, respectively. Significant differences between tetraplegia and paraplegia were found in "mobility in the community" (unhappiness item) for 13-25-years-old. CONCLUSION: Health domains were considered the top overall H&L priorities by parents/caregivers of 13-25-year-olds, compared to life domains reported for their 2-12-year-olds. This survey will aid rehabilitation professionals to engage stakeholders to implement a comprehensive SCI management program for the pediatric population.

Health and LifeDomain ResearchPriorities in Children, Adolescents and Young Adults With Pediatric-Onset Spinal Cord Injury: A National Cross-Sectional Survey in England.

Background: Although feedback from people with adult-onset spinal cord injury (SCI) has been considered in developing research programs, little is known about pediatric-onset SCI priorities. Objectives: To describe the health and life (H&L) domain research priorities of youth with pediatric-onset SCI living in England. Methods: Youth with pediatric-onset SCI (≥6 months) were recruited from five English rehabilitation centers and invited with their parents/caregivers to complete the age-appropriate surveys designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) collaboration. Results: A total of 73 surveys were received (32 from participants with SCI and 41 from their parents/caregivers), providing information on 47 individuals with SCI: 2- to 7-year-olds (29.8%), 8- to 12-year-olds (19.2%), 13- to 17-year-olds (17.0%), and 18 to 25-year-olds (34.0%). The top three research priorities reported by parents/caregivers of 2- to 12-year-old and 13- to 25-year-olds were pain (81%/89%), physical function (91%/83%) and health care access (78%/78%). Eighty-nine percent of 8- to 12-year-olds emphasized schooling, peer relationships, and general mood as their research priorities. The top three research priorities for Health or Life domains reported by 13- to 25-year-olds included spasms (95%), pain (91%), pressure injuries (91%), health care access (83%), physical function (78%), and daily personal needs (74%). Conclusion: Although there should be an emphasis on addressing important life domain issues for 8- to 12-year-olds with SCI, adolescents and young adults mostly prioritized health domain research priorities in addition to health care access. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive SCI research strategy in England for the pediatric population.

Predictive equations over estimating resting metabolic rate in individual with spinal cord injury requiring mechanical ventilation support - A case series.

Context: The impact of mechanical ventilation on energy expenditure after spinal cord injury (SCI) is sparse. The objective of this case-series is to measure 15-minutes resting metabolic rate (RMR) to determine 24-hours measured-RMR (m-RMR) using QUARK indirect calorimeter (IC) and; compare the m-RMR with estimated RMR (e-RMR) using four commonly used predictive equations (Harris-Benedict, Mifflin St-Jeor, Henry and Schofield).Findings: We measured the RMR of four patients with SCI (one male and three female; mean age: 58.3 years) all with complete tetraplegia (ISNCSCI A) twice in a one-week interval using an IC with two sampling flow settings during a six month period. The median (IQ) of all m-RMRs was 1094 (340.2) kcal/day. The median m-RMR was 40.1% lower than the median calculated with four different e-RMRs using predictive equations. All four predictive equations overestimated RMR in SCI patients requiring mechanical ventilation by 4.1-61.1% (Harris-Benedict: 28.8-60.6%; Mifflin St-Jeor: 6.9-61.1%; Henry: 4.1-58.9% and; Schofield: 6-54.6%).Conclusion/clinical relevance: There is a high variability of e-RMR and m-RMR in patients with SCI who are dependent on mechanical ventilation. The use of predictive equations may lead to over-estimation of energy requirements. To avoid overfeeding we recommended measuring RMR using IC wherever possible. A further study with a larger sample size is needed due to the small number of subjects in our case-series. Development of a validated RMR equation in the SCI population is warranted.

Emerging Pathogens and a Current-Use Pesticide: Potential Impacts on Eastern Hellbenders.

Populations of the eastern hellbender Cryptobranchus alleganiensis alleganiensis have been declining for decades, and emerging pathogens and pesticides are hypothesized to be contributing factors. However, few empirical studies have attempted to test the potential effects of these factors on hellbenders. We simultaneously exposed subadult hellbenders to environmentally relevant concentrations of either Batrachochytrium dendrobatidis (Bd) or a frog virus 3-like ranavirus (RV), a combination of the pathogens, or each pathogen following exposure to a glyphosate herbicide (Roundup). Additionally, we measured the ability of the skin mucosome to inactivate Bd and RV in growth assays. We found that mucosome significantly inactivated RV by an average of 40% but had no negative effects on Bd growth. All treatments that included RV exposure experienced reduced survival compared to controls, and the combination of RV and herbicide resulted in 100% mortality. Histopathology verified RV as the cause of mortality in all RV-exposed treatments. No animals were infected with Bd or died in the Bd-only treatment. Our results suggest that RV exposure may be a significant threat to the survival of subadult hellbenders and that Roundup exposure may potentially exacerbate this threat.

Positive airway pressure for sleep-disordered breathing in acute quadriplegia: a randomised controlled trial.

RATIONALE: Highly prevalent and severe sleep-disordered breathing caused by acute cervical spinal cord injury (quadriplegia) is associated with neurocognitive dysfunction and sleepiness and is likely to impair rehabilitation. OBJECTIVE: To determine whether 3 months of autotitrating CPAP would improve neurocognitive function, sleepiness, quality of life, anxiety and depression more than usual care in acute quadriplegia. METHODS AND MEASUREMENTS: Multinational, randomised controlled trial (11 centres) from July 2009 to October 2015. The primary outcome was neurocognitive (attention and information processing as measure with the Paced Auditory Serial Addition Task). Daytime sleepiness (Karolinska Sleepiness Scale) was a priori identified as the most important secondary outcome. MAIN RESULTS: 1810 incident cases were screened. 332 underwent full, portable polysomnography, 273 of whom had an apnoea hypopnoea index greater than 10. 160 tolerated at least 4 hours of CPAP during a 3-day run-in and were randomised. 149 participants (134 men, age 46±34 years, 81±57 days postinjury) completed the trial. CPAP use averaged 2.9±2.3 hours per night with 21% fully 'adherent' (at least 4 hours use on 5 days per week). Intention-to-treat analyses revealed no significant differences between groups in the Paced Auditory Serial Addition Task (mean improvement of 2.28, 95% CI -7.09 to 11.6; p=0.63). Controlling for premorbid intelligence, age and obstructive sleep apnoea severity (group effect -1.15, 95% CI -10 to 7.7) did not alter this finding. Sleepiness was significantly improved by CPAP on intention-to-treat analysis (mean difference -1.26, 95% CI -2.2 to -0.32; p=0.01). CONCLUSION: CPAP did not improve Paced Auditory Serial Addition Task scores but significantly reduced sleepiness after acute quadriplegia. TRIAL REGISTRATION NUMBER: ACTRN12605000799651.

Women's experiences of sexuality after spinal cord injury: a UK perspective.

STUDY DESIGN: Cross-sectional phenomenological qualitative study. OBJECTIVES: To investigate women's experience of sexuality after spinal cord injury (SCI) with a focus on rehabilitation and manging practical impact. SETTING: Women with SCI living in the community in United Kingdom (UK). METHODS: Participants were recruited via three UK SCI centres, ensuring tetraplegia, paraplegia and cauda equina syndrome representation. Single semi-structured interviews exploring individual's experiences around sexuality following SCI were recorded and transcribed for thematic analysis. RESULTS: Twenty-seven women aged 21-72 years, sexually active since SCI were interviewed, each lasting 17-143 min (mean 55 min). Six key themes emerged: physical change, psychological impact, dependency, relationships and partners, post injury sexual life and sexuality rehabilitation. CONCLUSIONS: Sexuality remains an important, valued aspect of female identity following SCI; sexual activity continues and though altered remains enjoyable and rewarding. Sexuality rehabilitation should commence early, preparing women for altered sexual sensation, disclosure of altered sexual function to partners, and encouraging early self-exploration. Techniques optimising continence management in preparation for and during sex should be taught. Participants identified a need for women-only education and support groups, increased peer support, self-esteem, communication and social skills training and even fashion advice and pampering sessions during rehabilitation. Support and education for partners are needed. Staff require support to be knowledgeable and confident in addressing women's sexuality needs. Use of the Ex-PLISSIT model for psychosexual support could help staff to better meet these needs.

Influenza surveillance on 'foie gras' duck farms in Bulgaria, 2008-2012.

OBJECTIVES: Ducks can shed and spread influenza A viruses (IAVs) while showing no disease signs. Our objective was to clarify the role of 'foie gras' ducks in the circulation of IAVs in Bulgaria. METHODS: Monthly avian influenza surveillance was conducted on 63 'foie gras' duck farms, 52 of which were surveyed throughout the study between November 2008 and April 2012. Virologic and serologic samples were collected and tested. During this time, wild bird samples were collected at major wild bird-resting areas near the Black Sea coast and Danube River. RESULTS: The study showed high isolation frequency of low-pathogenicity avian influenza viruses. In the raising population (<75 days old), subtypes H3, H4, and H6 were detected monthly and H5 LPAIV, sporadically. Different subtypes (H1, H10, H11) were isolated from the fattening premises (75- to 100-day-old ducks), suggesting different routes of introduction. Only 6 of the 52 farms that were surveyed both virologically and serologically were influenza-free throughout the study, possibly due to higher biosecurity measures implemented. No evidence of direct transmission of IAV from wild birds was found. Wild bird surveillance showed low isolation frequency of IAV. IAV prevalence of 0·55% for migratory ducks and 0·53% for migratory geese was estimated in November-December 2011 and January-February 2012, respectively, at two ornithologically important locations near the Black Sea coast. CONCLUSIONS: The 'foie gras' duck farms in Bulgaria are an optimal niche where Eurasian-like IAVs are maintained and reassorted unapparent to farmers and veterinarians.

Possible basis for the emergence of H1N1 viruses with pandemic potential from avian hosts.

Influenza A viruses of the H1N1 subtype have emerged from the avian influenza gene pool in aquatic birds and caused human pandemics at least twice during the past century. Despite this fact, surprisingly little is known about the H1N1 gene pool in the aquatic bird reservoir. A preliminary study showed that an H1N1 virus from a shorebird of the Charadriiformes order was transmitted between animals through the airborne route of infection, whereas an H1N1 virus from a bird of the Anseriformes order was not. Here we show that two of the three H1N1 viruses isolated from Charadriiformes species in 2009 were transmitted between animals through the airborne route of infection, and five H1N1 isolates from Anseriformes species were not. The one H1N1 virus from a Charadriiformes species that failed to transmit through the airborne route was a reassortant possessing multiple internal gene segments from Anseriformes species. The molecular differences between the airborne-transmissible and non-airborne-transmissible H1N1 viruses were multigenic, involving the selection of virus with human-like receptor-binding specificity (α2-6 sialic acid) and multiple differences in the polymerase complex, mainly in the PB2, PB1-F2, and nonstructural genes.

Nutritional supplement usage in patients admitted to a spinal cord injury center.

OBJECTIVES: To (1) assess food intake; (2) establish the prevalence of dietary supplement usage and its associated cost (oral nutritional supplements (ONS); vitamin and mineral supplements (VMS)) and; (3) identify the characteristics of nutritional supplement users among patients admitted to a spinal cord injury (SCI) center. STUDY DESIGN: A single center survey. METHODS: Standardized questionnaires were used to collect demographic information, food consumption over a 24-hour period, and the use of nutritional supplements. Multivariate logistic regression was used to determine the characteristics of dietary supplement usage and those using them. RESULTS: Seventy-three patients with SCI completed and returned the questionnaires (69.5% response rate). From 67 questionnaires with food intake data, 21 patients (31.3%) consumed three full meals a day. Nine of the full 73 patients (12.3%) received artificial nutritional support, 14 of 73 (19.1%) received ONS, 34 of 73 (46.5%) received VMS, and 31 of 73 (42.4%) required assistance in order to eat. The three supplements most often prescribed were multivitamins (19.1%), vitamins B (17.8%), and vitamin D (13.6%). VMS use was associated with age (years: >60 vs. ≤ 60: 62.1 vs. 34.1%, P = 0.019), nutrition risk (Spinal Nutrition Screening Tool (≥ 11 vs. <11: 65.7 vs. 28.9%, P = 0.001), and serum albumin concentration (<35 vs. ≥ 35 g/l: 59.6 vs. 16%, P < 0.01). Patients at nutrition risk were found to consume more ONS than the lower risk group (28.5 vs. 10.5%, P = 0.05). The expenditures on ONS and VMS were higher in the group at greater nutritional risk (£1878.3 vs. £914.3, P = 0.005). CONCLUSION: The use of nutritional supplements is common in patients with SCI, particularly in older adults and patients with poor nutritional state. However, the present study identified only small numbers of patients consuming all of their hospital meals, which may well contribute to undernutrition risk. Given that a high proportion of patients with SCI require assistance to eat, we suggest that further efforts focus on the feasibility of providing feeding assistants, and on reviewing the nature of the hospital menu.

Interobserver agreement of magnetic resonance imaging signs of osteomyelitis in pelvic pressure ulcers in patients with spinal cord injury.

OBJECTIVE: To examine the interobserver reliability of magnetic resonance imaging (MRI) signs of osteomyelitis in complex chronic pressure ulcers in patients with spinal cord injury (SCI). DESIGN: Retrospective review study. SETTING: Specialist SCI rehabilitation center. PARTICIPANTS: Adult patients with SCI and pressure ulceration investigated with MRI. INTERVENTIONS: Analysis of MRI examinations and clinical records collected over a 4-year period. Images were independently assessed by 2 experienced radiologists for osteomyelitis based on assigned predictive indicators including cortical bone erosion, soft tissue edema, deep collections, heterotopic new bone, hip effusion, and abnormal signal change of the marrow. MAIN OUTCOME MEASURES: Interobserver agreement for indicative MRI signs of osteomyelitis in complex pressure ulcers. RESULTS: Thirty-seven patients underwent 41 MRI scans. Concordance for marrow edema was 71% on both short tau inversion recovery and T1-weighted sequences, and for cortical erosion was 85%. CONCLUSIONS: For the assessment of pelvic osteomyelitis related to pressure ulcers, the T1-weighted MRI signal for marrow edema and cortical erosion has strong interobserver agreement.

Magnetic resonance imaging of pressure sores in spinal cord injured patients: accuracy in predicting osteomyelitis.

OBJECTIVE: Identify key magnetic resonance imaging (MRI) features that have a significant correlation with osteomyelitis of pressure ulcers in spinal injury patients. DESIGN: Retrospective review study. PARTICIPANTS: Adult patients admitted to the National Spinal Injuries Centre with spinal cord injury (SCI) and signs of pressure ulceration investigated with MRI. METHODS: Analysis of MRI examinations and clinical records collected over a 4-year period. Images were independently assessed by 2 experienced radiologists for osteomyelitis based on assigned predictive indicators including cortical bone erosion, soft tissue edema, deep collections, heterotopic new bone, hip effusion, and abnormal signal change of the marrow. RESULTS: Thirty-seven patients underwent 41 MRI scans. The prevalence of osteomyelitis was highly correlated with cortical bone erosion (r = 0.84) and abnormal bone marrow changes on T1-weighted images (r = 0.82).

Use of digital images in the assessment and treatment of pressure ulcers in patients with spinal injuries in community settings.

We conducted a retrospective review of the digital images in the clinical records of 50 patients with pressure ulcers. Ten nurses independently assessed one image from each patient. There was a total of 414 responses from the nurses about the stage and location of the ulcers (83% response rate). The average agreement about the stage and location of the ulcers was 85%. The overall agreement declined as the stage of the ulcer increased. The average agreement regarding the wound descriptors was: necrosis 85%, granulation tissue 81%, ischaemia 83%, cellulitis /infection 69%, erythema 68%. Almost all nurses felt the need to change the current management of the wound (460 responses, or 92%). The nurses judged that most digital images were of good quality (17%) or very good quality (79%). The present study suggests that a high percentage of assessments for patients currently travelling to specialist clinics could be performed in the community using digital images and telemedicine.

The social behaviours of inhibited children in and out of preschool.

The goal of the present study was to explore the social behaviours of inhibited children in familiar social contexts, including: (1) free play with peers at preschool and (2) social activities at home and in the community. The initial participants were N = 248 preschool children between the ages of 42 and 66 months. From this initial data, two smaller groups of inhibited (N = 12) and uninhibited comparison (N = 12) children were identified. These children were observed during free play at preschool and parents completed daily logs of children's social activities outside of school. Among the findings, inhibited children were observed to display more reticent (on looking, unoccupied) and anxious behaviours during free play preschool than uninhibited children. As well, inhibited children participated less in structured social activities outside school and were more likely to engage in dyadic play at home with a single friend as compared to their uninhibited counterparts.

Letters.

SPINAL INJURY AND PRESSURE SORE PREVENTION TREATMENT FOR OVERGRANULATION.