Antibiotic prophylaxis with urodynamic studies in spinal cord injury: Assessing practice patterns and outcomes to guide future practice in a single center.

CONTEXT/OBJECTIVE: Despite urinary tract infections (UTIs) being a common problem in patients with spinal cord injuries (SCIs), and a well-known complication of invasive urologic procedures, little consensus exists regarding the standard of care for peri-procedural antibiotic use for SCI patients undergoing urodynamics studies (UDS). Our research seeks to evaluate local antibiotic prophylaxis pattern in SCI patients undergoing UDS, assess incidence of post-procedural UTI, describe local antibiotic resistance trends, and provide antibiotic stewardship considerations to guide future practice. DESIGN/SETTING/PARTICIPANTS: Retrospective cohort study of SCI patients undergoing UDS from January 2010 to January 2020 at a Veterans Affairs SCI Center. Data on patient demographics, UTI risk factors, pre-procedural urinalysis and culture, and peri-procedural antibiotics was extracted. Incidence of post-procedural UTI was tabulated. Findings were summarized using descriptive statistics. RESULTS: 331 patients were studied. Pre-procedural urine culture was done in 73% of cases, with positive results in 49%. E. coli was the most commonly isolated organism (19%). Antibiotics were used in 86% of cases, 26% of which had a negative culture. A onetime dose of intramuscular gentamicin given immediately pre-procedure was the most common practice (53%; N = 152). No cases of post-procedural UTIs were identified during the study period. CONCLUSION: No post-UDS UTIs occurred under current local practice where most patients received a one-time dose of intramuscular gentamicin as prophylaxis. Though routine gentamicin prophylaxis may play a role in reducing UTI incidence, the low rate of post-UDS UTI in this population, including patients with positive cultures who received no antibiotics, suggests the possibility of refining practice patterns to improve antibiotic stewardship.

Current Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury (TeleSCI).

Purpose of Review: Telehealth and telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and improve health outcomes in the spinal cord injury population. This review provides an overview of the recent literature on the topic of teleSCI and provides insights on current evidence, future directions, and considerations when using teleSCI for clinical care. Recent Findings: TeleSCI is used most often for preventive health; management of chronic pain, anxiety, and depression; and rehabilitation-related interventions. As video telehealth becomes mainstream, growth in wearable monitors, bio and neurofeedback mechanisms, and app-based care is expected. Summary: TeleSCI is growing in prevalence, demonstrates positive impact on health outcomes, and requires ongoing study to identify, refine, and implement best practices.

Incorporating Holistic Review in Recruitment in a Physical Medicine and Rehabilitation Residency Program.

ABSTRACT: Traditional residency recruitment practices are vulnerable to unconscious biases, inequity, lack of diversity, and have limited ability to predict future clinical competency. Holistic review and evidence-based strategies, such as structured interviews and situational judgment tests, can mitigate these limitations. A physical medicine and rehabilitation residency program restructured its residency recruitment process using holistic review principles and evidence-based strategies during the 2020-2021 academic year. A subcommittee developed a weighted screening rubric based on Association of American Medical Colleges core competencies and semistructured interview questions targeting specific domains. Formal implicit bias training was provided. Screening scores determined interview invitations. Applicants participated in three different domain-focused semistructured interviews. Screening and interview scores were combined to form the program rank list. A postinterview anonymous questionnaire was sent to interviewees to obtain feedback. Four hundred eighty-nine applicants were screened (82 interview invitations, 80 interviewed, 8 matched). The respondents to the postinterview questionnaire found that interviews evaluated them objectively (90%) and improved their impression of the program (90%). The program's match was consistent with previous matches. Interviewed applicants represented a racially diverse group. Most questionnaire respondents had a positive impression of the interview process. This article demonstrates incorporating holistic review into residency recruitment and provides specific resources to aid other institutions pursuing similar goals.

Capture rates of comorbidity measures at inpatient rehabilitation facilities after a stroke or brain injury.

BACKGROUND: Comorbidity indices have been used to represent the overall medical complexity of patient populations in clinical research; however, it is not known how well they capture the comorbidities of patients with a stroke or brain injury admitted to inpatient rehabilitation facilities (IRFs). OBJECTIVE: To determine how well commonly used comorbidity indices capture the comorbidities of patients admitted to IRFs after a stroke or brain injury. DESIGN: Cross-sectional, retrospective study. SETTING: IRFs nationwide. PARTICIPANTS: Adults from four impairment groups: (1) hemorrhagic stroke, (2) ischemic stroke, (3) nontraumatic brain injury (NTBI), and (4) traumatic brain injury (TBI). MAIN OUTCOME MEASURES: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were extracted from the Uniform Data System for Medical Rehabilitation (UDSMR) for IRF discharges from October 1, 2015 to December 31, 2017. The percentage of discharges captured by Deyo-Charlson, Elixhauser, and Centers for Medicare and Medicaid Services (CMS) tiers was determined, as was the percentage of comorbidities captured. These measures were also compared with respect to their ability to capture chronic medical complexity by examining the percentage of codes captured after removal of codes deemed to represent hospital complications or sequela of the admission diagnosis. RESULTS: The percentage of discharges without at least one ICD-10-CM code captured by any index ranged from 0.3%-3.8%. The percentage of comorbidities with a prevalence exceeding 1% captured by at least one index ranged from 37.1%-43.6%. Chronic comorbidities were most likely to be captured by Elixhauser (40.7%-44.4%), followed by Deyo-Charlson (7.8%-9.6%), then CMS tiers (4.5%-6.9%). Existing comorbidity measures capture most IRF discharges related to a brain injury or stroke, whereas most medical comorbidities escape representation. Several common, functionally relevant diagnoses were not captured. CONCLUSION: The use of comorbidity indices in the IRF neurologic injury population should account for the fact that these measures miss several common, important comorbidities.

Treatment of Lower Extremity Fractures in Chronic Spinal Cord Injury: A Systematic Review of the Literature.

OBJECTIVE: To review the literature regarding outcomes of surgical and nonsurgical management of lower extremity (LE) fractures in chronic spinal cord injury (SCI). TYPE: Systematic review. LITERATURE SURVEY: Medline (PubMed), Embase, Cochrane Database of Systemic Reviews, Cochrane Central, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, International Clinical Trials Registry Platform, and International Standard Randomized Controlled Trials were searched from January 1, 1966, to March 1, 2019. METHODOLOGY: Search was restricted to English language and adults (age ≥ 18 yr). Titles and abstracts were reviewed for relevance to study topics for inclusion. Case reports, reviews, non-SCI population studies, and studies examining fractures at the time of acute SCI were excluded. References of included articles from the original search and task force and external submissions yielded two additional articles that were included in the review after voting by task force members. Data extraction was performed by four task force members using a data extraction form, glossary, and instructions created in Microsoft Excel. Quality assessment was performed by three methodologists using prespecified criteria. SYNTHESIS: Twenty-three articles were included. Use of surgery to treat LE fractures in chronic SCI has increased, though nonoperative management was still more frequently reported. Regardless of type of management, amputations, nonunion/malunion, and pressure injuries were among the most commonly reported complications. Functional and quality of life outcomes were less frequently reported. CONCLUSIONS: There is insufficient evidence to support operative versus nonoperative management as best practice for management of LE fracture of SCI. Existing literature was limited by small sample sizes, lack of randomization or matched study designs, significant heterogeneity in populations and treatment strategies studied, and variability in defining and reporting outcomes of interest. The field would benefit from future research to address study design issues and standardization of outcome reporting to facilitate comparison of outcomes of operative versus nonoperative management.

Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population.

OBJECTIVE: To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities. MAIN OUTCOME MEASURES: International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated. RESULTS: Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes. CONCLUSION: Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.

Bus Stops Near Schools Advertising Junk Food and Sugary Drinks.

Children rarely understand the full extent of the persuasive purpose of advertising on their eating behaviours. Addressing the obesogenic environments in which children live, through a quantification of outdoor advertising, is essential in informing policy changes and enforcing stricter regulations. This research explores the proportion of bus stop advertisements promoting non-core food and beverages within walking distance (500 m) from schools in Auckland, New Zealand while using Google Street View. Information was collected on: school type, decile, address, Walk Score®, and Transit Score for all 573 schools in the Auckland region. Ground-truthing was conducted on 10% of schools and showed an alignment of 87.8%. The majority of advertisements on bus shelters were for non-food items or services (n = 541, 64.3%). Of the advertisements that were for food and/or beverages, the majority were for non-core foods (n = 108, 50.2%). There was no statistically significant difference between the variables core and non-core food and beverages and School decile (tertiles), Walk Score (quintiles), and Transit Score (quintiles). 12.8% of all bus stop advertisements in this study promoted non-core dietary options; highlighting an opportunity for implementing stricter regulations and policies preventing advertising unhealthy food and drink to children in New Zealand.

Coexisting Systemic Infections in Patients Hospitalized Because of a Fall: Prevalence and Risk Factors.

BACKGROUND: Infectious disease-related factors that may contribute to or complicate falls have received relatively little attention in the literature. OBJECTIVE: Our aim was to determine the prevalence of, and risk factors for, coexisting systemic infections (CSIs) in patients admitted to the hospital because of a fall or its complications. METHODS: We conducted a retrospective cohort study of adult patients seen at a tertiary care hospital emergency department and subsequently hospitalized because of a fall or its complications. RESULTS: Of 1,456 evaluable cases, 775 patients (53.2%) were female. Mean age was 71.6 years (range 18-104 years). CSI was diagnosed in 303 patients (20.8%), of which 166 (54.8%) were urinary tract infections and 108 (35.6%) were pneumonia cases; 14 patients (4.6%) were bacteremic. CSI was not initially suspected by providers in 98 (32.5%) subsequently diagnosed cases. Age ≥50 years (odds ratio [OR] 5.6; 95% confidence interval [CI] 1.2-24.9), inability to get up on own after the index fall (OR 2.1; 95% CI 1.2-3.6), preexisting symptom(s) (OR 3.0; 95% CI 1.8-5.2), and systemic inflammatory response syndrome (SIRS) (OR 2.9; 95% CI 1.5-5.4), or confusion at presentation (OR 3.0; 95% CI 1.5-6.0) were independently associated with CSI. In-hospital mortality rate was significantly higher among patients with CSI (6.9% vs. 3.8 %, OR 1.9; 95% CI 1.1-3.3). CONCLUSIONS: CSIs are common among patients admitted to the hospital after a fall or its complications. Age ≥ 50 years, inability to get up on own, preexisting symptom(s), and the presence of SIRS or confusion at presentation are potential predictors of CSI in this patient population.

Functional status predicts acute care readmission in the traumatic spinal cord injury population.

CONTEXT/OBJECTIVE: Acute care readmission has been identified as an important marker of healthcare quality. Most previous models assessing risk prediction of readmission incorporate variables for medical comorbidity. We hypothesized that functional status is a more robust predictor of readmission in the spinal cord injury population than medical comorbidities. DESIGN: Retrospective cross-sectional analysis. SETTING: Inpatient rehabilitation facilities, Uniform Data System for Medical Rehabilitation data from 2002 to 2012. PARTICIPANTS: traumatic spinal cord injury patients. OUTCOME MEASURES: A logistic regression model for predicting acute care readmission based on demographic variables and functional status (Functional Model) was compared with models incorporating demographics, functional status, and medical comorbidities (Functional-Plus) or models including demographics and medical comorbidities (Demographic-Comorbidity). The primary outcomes were 3- and 30-day readmission, and the primary measure of model performance was the c-statistic. RESULTS: There were a total of 68,395 patients with 1,469 (2.15%) readmitted at 3 days and 7,081 (10.35%) readmitted at 30 days. The c-statistics for the Functional Model were 0.703 and 0.654 for 3 and 30 days. The Functional Model outperformed Demographic-Comorbidity models at 3 days (c-statistic difference: 0.066-0.096) and outperformed two of the three Demographic-Comorbidity models at 30 days (c-statistic difference: 0.029-0.056). The Functional-Plus models exhibited negligible improvements (0.002-0.010) in model performance compared to the Functional models. CONCLUSION: Readmissions are used as a marker of hospital performance. Function-based readmission models in the spinal cord injury population outperform models incorporating medical comorbidities. Readmission risk models for this population would benefit from the inclusion of functional status.

Baseline cognitive test performance and concussion-like symptoms among adolescent athletes with ADHD: examining differences based on medication use.

OBJECTIVE: Youth with attention deficit hyperactivity disorder (ADHD) perform more poorly on preseason cognitive testing and report more baseline concussion-like symptoms but prior studies have not examined the influence of medication use on test performance or symptom reporting. This study investigated whether medication use is relevant when interpreting baseline ImPACT® results from student athletes with ADHD. METHOD: Participants were 39,247 adolescent athletes, ages 13-18 (mean age = 15.5 years, SD = 1.3), who completed baseline cognitive testing with ImPACT®. The sample included slightly more boys (54.4%) than girls. Differences in ImPACT® composite scores and concussion-like symptom reporting (between ADHD/No medication, ADHD/Medication, No ADHD/Medication, and Control groups) were examined with ANOVAs, conducted separately by gender. RESULTS: In this large, state-wide data-set, youth with ADHD had greater rates of invalid ImPACT results compared to control subjects (ADHD/No Medication: girls = 10.9%, boys = 10%; ADHD/Medication: girls = 8.1%, boys = 9.1%; Controls: girls = 5.2%, boys = 6.7%). Groups differed across all ImPACT® composites (invalid profiles were removed), in the following order (from worse to better performance): ADHD/No Medication, ADHD/Medication, and Control participants. Pairwise effect sizes indicated that the largest differences were on the Visual Motor Speed composite, with the ADHD/No medication group performing worse than the ADHD/Medication group and the Controls. The ADHD/Medication group did not differ meaningfully from Controls on any composite, for either sex (d = 0 to .19). The ADHD groups did not differ on total symptom scores but both ADHD groups endorsed significantly more symptoms compared to Controls. CONCLUSIONS: Contrary to our hypothesis, we found medication use had only a subtle effect on cognitive performance and no significant effect on concussion-like symptom reporting. Student athletes reporting medication use for ADHD performed comparably to student athletes with no ADHD on baseline testing.

Hepatitis C virus screening in patients with cancer receiving chemotherapy.

PURPOSE: Reactivation of hepatitis C virus (HCV) replication can occur in patients receiving immunosuppressive therapy. We aimed to determine the prevalence and predictors of HCV screening at the onset of chemotherapy among patients with cancer. METHODS: We conducted a retrospective cohort study of adults with cancer who were newly registered at MD Anderson Cancer Center from January 2004 to April 2011 and received chemotherapy. The primary study outcome was HCV antibody (anti-HCV) screening at chemotherapy onset. We calculated screening prevalence and predictors by comparing characteristics of screened and unscreened patients using multivariable logistic regression. RESULTS: A total of 141,877 new patients with cancer were registered at MD Anderson during the study period, of whom 16,773 (11.8%) received chemotherapy and met inclusion criteria. A total of 2,330 patients (13.9%) were screened for HCV, and 35 (1.5%) tested positive. Only 42% of patients with exposure-type HCV risk factors, such as HIV infection, injection drug use, hemodialysis, or hemophilia, were screened. Birth after 1965, Asian race, HCV risk factors, and anticipated rituximab therapy were significant predictors of HCV screening; black patients and patients with solid tumors were significantly less likely to be screened. The only significant predictor of a positive anti-HCV result was birth during 1945 to 1965. CONCLUSION: HCV screening rates were low, even among patients with risk factors, and the groups with the highest rates of screening did not match the groups with the highest rates of a positive test result. Misconceptions may exist about which patients should be screened for HCV infection.

Identification of markers that distinguish monocyte-derived fibrocytes from monocytes, macrophages, and fibroblasts.

BACKGROUND: The processes that drive fibrotic diseases are complex and include an influx of peripheral blood monocytes that can differentiate into fibroblast-like cells called fibrocytes. Monocytes can also differentiate into other cell types, such as tissue macrophages. The ability to discriminate between monocytes, macrophages, fibrocytes, and fibroblasts in fibrotic lesions could be beneficial in identifying therapies that target either stromal fibroblasts or fibrocytes. METHODOLOGY/PRINCIPAL FINDINGS: We have identified markers that discriminate between human peripheral blood monocytes, tissue macrophages, fibrocytes, and fibroblasts. Amongst these four cell types, only peripheral blood monocytes express the combination of CD45RO, CD93, and S100A8/A9; only macrophages express the combination of CD45RO, 25F9, S100A8/A9, and PM-2K; only fibrocytes express the combination of CD45RO, 25F9, and S100A8/A9, but not PM-2K; and only fibroblasts express the combination of CD90, cellular fibronectin, hyaluronan, and TE-7. These markers are effective both in vitro and in sections from human lung. We found that markers such as CD34, CD68, and collagen do not effectively discriminate between the four cell types. In addition, IL-4, IL-12, IL-13, IFN-gamma, and SAP differentially regulate the expression of CD32, CD163, CD172a, and CD206 on both macrophages and fibrocytes. Finally, CD49c (alpha3 integrin) expression identifies a subset of fibrocytes, and this subset increases with time in culture. CONCLUSIONS/SIGNIFICANCE: These results suggest that discrimination of monocytes, macrophages, fibrocytes, and fibroblasts in fibrotic lesions is possible, and this may allow for an assessment of fibrocytes in fibrotic diseases.