Attrition during pre-ART and ART time periods among adolescents enrolled in Integrated HIV Care Programme in Myanmar, 2005-2017.

Retaining adolescents (aged 10-19 years), living with HIV (ALHIV) on antiretroviral therapy (ART) is challenging. In Myanmar, 1269 ALHIV were under an Integrated HIV Care (IHC) Programme by June 2017 and their attrition (death and lost to follow-up) rates were not assessed before. We undertook a cohort study using routinely collected data of ALHIV enrolled into HIV care from July 2005 to June 2017 and assessed their attrition rates in June 2018 by time-to-event analysis. Of 1269 enrolled, 197(16%) and of 1054 initiated ART, 224 (21%) had an attrition defining event. The pre-ART and ART attrition rates were 21.8 (95% CI 19.0-25.1) and 6.4 (95% CI 5.6-7.3) per 100 person-years follow-up, respectively. The factors 'at enrolment' that were associated with higher hazards of attrition were: (1) WHO stage 3 or 4; (2) haemoglobin <10 gm/dl; (3) no documented CD4 cell counts, hepatitis B and C test results; and (4) injection drug use. Baseline hazards were high during the initial 1-2 years and after 5-6 years. The pre-ART and ART attrition rates in ALHIV were lower than those in Africa but higher than the children under IHC. This warrants designing and implementing additional care tailored to the needs of ALHIV under IHC.

A protocol of human animal interaction to habituate young sheep and goats for behavioural studies.

Animal habituation is key to obtain reliable data on behavioural studies but detailed procedures to achieve it are scarce. This study designed a set of actions to habituate sheep and goats to human observers. Pelibuey sheep (n = 15) and Criollo goats (n = 10) were classified as (a) avoider, flight from human interaction, or (b) follower, seek human interaction. Habituation was measured by the reduction of flight distance by avoiders, or number of followers in the presence of observers. The habituation protocol consisted of a gradually increased series of five manoeuvres, either challenge (for avoiders) or evasion (for seekers), performed first inside a pen and subsequently in a grass paddock. Habituation was considered successful when animals could be observed from a 1-m distance without flight or following the observer. In the pen, habituation took 12 and 13 days for sheep and goats, respectively. Meanwhile, in the grass paddock habituation took 10 days, for both species. The number of challenge and evasion series was negatively correlated with the flight distance in sheep and with the number of followers in goats. This protocol is simple and practical to implement and enables animal habituation for behavioural studies.

Clinical factors associated with C-reactive protein in chronic spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: Determine clinical factors associated with plasma C-reactive protein (CRP) in persons with chronic spinal cord injury (SCI). SETTING: Veterans Affairs Medical Center in Boston, MA, USA. METHODS: Participants provided a blood sample, completed a respiratory health questionnaire and underwent dual X-ray absorptiometry (DXA) to assess total and regional body fat. Linear regression models were used to assess cross-sectional associations with plasma CRP. RESULTS: In multivariable models, factors associated with a higher CRP included a greater BMI, urinary catheter use, a respiratory illness in the past week and non-white race. Mean CRP also increased with decreasing mobility (motorized wheelchair >hand-propelled wheelchair >walk with an assistive device >walk independently). Results were similar when adjusting for percentage android, gynoid, trunk or total fat mass in place of BMI. Level and completeness of SCI was not associated with CRP in multivariable models. CONCLUSIONS: Clinical characteristics common in chronic SCI are associated with plasma CRP. These factors are more important than the level and completeness of SCI and some are potentially modifiable.

Sclerostin: a candidate biomarker of SCI-induced osteoporosis.

UNLABELLED: We assessed several circulating proteins as candidate biomarkers of bone status in men with chronic spinal cord injury. We report that sclerostin is significantly associated with bone mineral content and bone density at all skeletal sites tested. We found no association between bone and any other tested biomarker. INTRODUCTION: Spinal cord injury results in severe osteoporosis. To date, no circulating biomarker of spinal cord injury (SCI)-induced osteoporosis has been identified. We recently reported that circulating sclerostin is associated with bone density in chronic SCI. In this study, we assessed several circulating proteins as candidate biomarkers of bone in men with chronic SCI. METHODS: We assessed the relationship between bone mineral content or bone density and the following circulating bone-related proteins: sclerostin, DKK-1, soluble receptor activator of nuclear factor kappa B ligand, osteoprotegerin, osteocalcin, and c-telopeptide in 39 men with chronic SCI and 10 men with no SCI. RESULTS: After adjusting for age, lower sclerostin levels were significantly associated with lower bone mineral content and bone density at all skeletal sites tested (p = 0.0002-0.03). No other circulating protein was associated with bone mineral content or bone mineral density (p = 0.18-0.99). CONCLUSION: These findings suggest that circulating sclerostin reflects the severity of bone loss and is a candidate biomarker of osteoporosis severity in chronic SCI.

Age and motor score predict osteoprotegerin level in chronic spinal cord injury.

OBJECTIVE: Individuals with spinal cord injury (SCI) develop a severe form of osteoporosis below the level of injury that is poorly understood. We conducted a preliminary investigation to assess whether circulating markers of bone turnover and circulating RANKL/OPG levels are related to the severity of SCI, aging, or to differences in mobility (i.e., walking or using a wheelchair). METHODS: Sixty-four caucasian men >or=1.6 years since injury selected based on locomotive mode provided blood samples and completed a health questionnaire at the VA Boston Healthcare System from 10/2003 to 6/2005. Plasma sRANKL, osteoprotegerin (OPG), osteocalcin and carboxyterminal telopeptide of type I collagen (CTx) levels were determined. RESULTS: Increasing age was significantly associated with increased OPG and CTx. Injury severity was predictive of OPG levels, and adjusting for age, participants with cervical motor complete and ASIA C SCI (n=11) had significantly lower mean OPG (46.1 pg/ml) levels than others (63.4 pg/ml). Locomotive mode was not associated with differences in bone markers. CONCLUSIONS: Severe cervical spinal cord injury is associated with decreased circulating OPG levels placing these patients at risk for accelerated bone loss that appears unrelated to locomotive mode.

A prospective assessment of mortality in chronic spinal cord injury.

STUDY DESIGN: Prospective mortality study. OBJECTIVE: To assess the relationship between comorbid medical conditions and other health-related factors to mortality in chronic spinal cord injury (SCI). SETTING: Boston, MA, USA. METHODS: Between 1994 and 2000, 361 males >/=1 year after injury completed a respiratory health questionnaire and underwent pulmonary function testing. Cause-specific mortality was assessed over a median of 55.6 months (range 0.33-74.4 months) through 12/31/2000 using the National Death Index. RESULTS: At entry, mean (+/-SD) age was 50.6+/-15.0 years (range 23-87) and years since injury was 17.5+/-12.8 years (range 1.0-56.5). Mortality was elevated (observed/expected deaths=37/25.1; SMR=1.47; 95% CI=1.04-2.03) compared to US rates. Risk factors for death were diabetes (RR=2.62; 95% CI=1.19-5.77), heart disease (RR=3.66; 95% CI=1.77-7.78), reduced pulmonary function, and smoking. The most common underlying and contributing causes of death were diseases of the circulatory system (ICD-9 390-459) in 40%, and of the respiratory system in 24% (ICD-9 460-519). CONCLUSIONS: These results suggest that much of the excess mortality in chronic SCI is related to potentially treatable factors. Recognition and treatment of cardiovascular disease, diabetes, and lung disease, together with smoking cessation may substantially reduce mortality in chronic SCI.

Predictors of loud snoring in persons with spinal cord injury.

BACKGROUND: Predictors of loud snoring were examined in a cohort of 197 persons with chronic spinal cord injury (SCI) recruited by advertisement and from a Veterans Affairs Medical Center SCI Service. METHODS: Data were collected on age, marital status, antispasticity medications, duration of injury, level and completeness of injury, stature, and weight. Body mass index (BMI) was calculated for all participants. A health questionnaire was used to collect data on snoring and respiratory history. Habitual snorers were defined as those who reported loud snoring more than 1 night per week. RESULTS: The mean age (+/- SD) was 51.2 +/- 14.8 years, and 84 of 197 (42.6%) were habitual snorers. The most obese research subjects, regardless of antispasticity medication use, were more likely to report snoring, but the risk of snoring was greatest among subjects who were obese and used antispasticity medication. Subjects who used antispasticity medication and had a BMI above the median (> or = 25.3 kg/m2) had a 7-fold risk of reporting snoring compared with subjects below the median who did not use antispasticity medication (P = .001). The greatest risk occurred in those who used diazepam alone or baclofen and diazepam together and had a BMI at or above the median. Subjects who used these medications and had a BMI below the median did not have a significantly increased risk. Neurological motor completeness, level of injury, age, and years since injury were not significant predictors of snoring. CONCLUSION: Because snoring is a marker for obstructive sleep apnea (OSA), the data suggest that in obese individuals with SCI, the use of antispasticity medications may be a risk factor for OSA.

Breathlessness in spinal cord injury depends on injury level.

Little is known about the prevalence and predictors of breathlessness in individuals with neurologically complete chronic spinal cord injury (SCI). Between December 1992 and September 1993, we mailed a respiratory questionnaire to 1,147 community-based individuals with chronic SCI. The questionnaire included four questions about the presence of breathlessness during activities related to moving about. Of the 485 who replied (42 percent response rate), analysis was limited to adult males with neurologically complete motor injuries who reported using a hand-propelled wheelchair more than 50 percent of the time to get around. Of 130 subjects (33 tetraplegics, 53 high thoracic SCI, 44 lower injury levels), the patients with tetraplegia reported breathlessness more frequently (range for the four questions, 21-33%) than those with high thoracic (range, 9-15%) or lower injury levels (range, 2-11%). For each of the four questions there was a significant trend (p < 0.05) for subjects with higher levels of injury to report the greatest prevalence of breathlessness (tetraplegia > high thoracic > lower). The frequency of breathlessness was greatest in those with neurologically complete cervical injuries, an effect that was independent of obesity, smoking, age, and years since SCI. The mechanisms of breathlessness in SCI are unclear but elucidation might lead to strategies for providing relief.

Breathlessness and exercise in spinal cord injury.

After spinal cord injury (SCI), breathlessness during daily activities is common. In 308 individuals with SCI, the authors measured pulmonary function and administered a survey regarding health status, participation in wheelchair athletics, and breathlessness during different activities. The following questions were included: A. Are you troubled by shortness of breath when hurrying on the level or going up a slight hill?; B. Do you have to go slower than people of your own age on the level because of breathlessness?; C. Do you ever have to stop for breath when going at your own pace on the level?; and D. Do you ever have to stop for breath after going about 100 yards on the level? The analysis was restricted to 183 subjects with neurologically motor complete or incomplete SCI who, to get around, used hand-propelled wheelchairs more than 50% of the time. Of these, 56 (31%) reported breathlessness during some types of activities. Subjects with neurologically motor complete cervical or high thoracic SCI (T-6 and above) were more likely to report breathlessness than others (39% compared with 25%, p = .039). Among wheelchair athletes, the prevalence of breathlessness was 8/49 (16%) versus 48/134 (36%) for non-athletes (p = .011). Adjusting for smoking, neurological level, and history of obstructive lung disease, non-athletes were 2.3 times more likely to report breathlessness than athletes were (p = .049 to .075, depending on regression model). This relationship persisted when adjusted for percent predicted forced expiratory volume (FEV1) and maximal expiratory and inspiratory pressures. Therefore in SCI, wheelchair athletes are less likely to report breathlessness than non-athletes, but the mechanism does not appear to be improvement in respiratory muscle performance or pulmonary function.

Maximal expiratory pressures in spinal cord injury using two mouthpieces.

STUDY OBJECTIVE: A technique for assessing expiratory muscle strength is the measurement of maximal expiratory pressure (PEmax). Previous studies have shown that a tube-style mouthpiece yields greater PEmax values than a flange-style mouthpiece because the latter technique is limited by the strength of the buccal muscles. In individuals with weak muscles of exhalation, this limitation may not apply because the strength of their buccal muscles may exceed that of the respiratory muscles. DESIGN: A tube-style mouthpiece and flange-style mouthpiece were used to measure PEmax. The order of the mouthpiece used in testing was alternated between subjects and the greatest values obtained after three efforts were compared. SETTING: Department of Veterans Affairs Medical Center. PARTICIPANTS: Fifty subjects with chronic spinal cord injury without acute medical illnesses recruited from veterans and the community. RESULTS: The mean difference between PEmax(tube) and PEmax(flange) was 20.7+/-26.4 cm H2O (p = 0.0001). Differences were negligible in those with the weakest muscles of exhalation but were substantial even in some quadriplegic subjects. CONCLUSION: Even in individuals with neuromuscular disorders, errors in assessment of expiratory strength occur when a flange-style mouthpiece is used, and we recommend that this technique be abandoned in the measurement of PEmax.

Assessment of stature in spinal cord injury.

Assessment of stature has been a neglected part of the medical assessment of individuals with spinal cord injury (SCI). In past studies of pulmonary function in SCI, it has not been stated how stature was assessed in order to calculate predicted pulmonary function. As part of a study of respiratory function in SCI, we examined the accuracy of self-report of stature and whether upper extremity measurements could be used to predict stature in 88 individuals with SCI. Although armspan and four other upper extremity measurements were significant predictors of length, recalled height was the best predictor. On average, for any value of armspan, an individual with complete SCI was 2.3 cm shorter than an individual with incomplete SCI. Individuals with complete SCI also had greater differences between recalled height and measured length compared with individuals with incomplete SCI, and this difference was not due to age or years since injury. It is likely that differences in bone demineralization account for the differences in length comparing individuals with complete and incomplete SCI. The 95 percent confidence intervals for predicted values of length based on armspan or recalled height were too wide for accurate calculation of predicted pulmonary function. In order to classify accurately the extent of pulmonary function abnormality, we suggest that measurements of supine length be made part of the medical assessment of individuals with SCI.

Spirometry--acceptability and reproducibility in spinal cord injured subjects.

The American Thoracic Society (ATS) has formulated guidelines for spirometry. We hypothesized that individuals with SCI (SCI), as a result of weak respiratory muscles, would exhibit poor test acceptability and reproducibility. Seventy-eight SCI subjects (39 with complete SCI) answered a respiratory questionnaire and performed spirometry. Of those with complete SCI, the proportion of subjects which met ATS criteria decreased with higher levels of injury. Poor test performance was not associated with age, respiratory symptoms or muscle fatigue. The most common reason for failing to meet ATS criteria for acceptability was excessive back extrapolated volumes (EBEV). Individuals with efforts that were acceptable except for EBEV and/or for exhalation of less than six seconds had values for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) that were reproducible. If ATS criteria for acceptable spirometry were used in studying subjects with SCI, individuals producing otherwise reproducible values for FVC and FEV1 would be excluded. We found reproducibility similar to what has been reported in other cohorts and conclude that longitudinal study of respiratory function in SCI is feasible.

Clinical neurophysiology of focal spinal cord injury.

A focal spinal cord injury produces a host of electrophysiologic abnormalities, most of which reflect either local spinal cord destruction or the functional disconnection of rostral and caudal portions. Routine electromyographic and nerve conduction studies are most useful to investigate the deficits that result from local cord damage and have demonstrated that the injury zone most often extends at least 3 to 4 myotomes. Electromyographic studies of muscles innervated by more caudal myotomes have also shown abnormalities, but the extent to which these reflect primary changes of spinal cord injury is uncertain. Electrophysiologic studies of spinal cord function caudal to the site of injury have shown alterations in autonomic output, as well as changes in the level of excitability of reflex pathways. These changes may provide insight into the mechanisms that underlie the development of spasticity.

Odontoid fracture complicating ankylosing spondylitis. A case report and review of the literature.

The first reported case of odontoid fracture in ankylosing spondylitis is presented with a review of the literature. Conservative management with halo-vest immobilization may be a reasonable approach in the patient with ankylosing spondylitis who poses a high surgical risk.

Acute pulmonary edema following removal of a spinal orthosis: an unusual complication of a halo vest.

The halo vest is a commonly used spinal orthosis that provides stability to the cervical spine. Known complications include loss of spinal reduction, local pin tract infection, skin breakdown over the scapulae, and, rarely, brachial plexus and cranial nerve palsies. The use of the halo vest has not been associated with significant respiratory compromise. Cardiopulmonary complications associated with halo vests have not been reported. We report a case of pulmonary edema associated with removal of a halo vest in a patient with occult mitral stenosis. We speculate that removal of the orthosis resulted in rapid redistribution of peripheral blood volume sufficient in magnitude to provide the hemodynamic substrate for acute pulmonary edema.

The paraplegic hand: electrodiagnostic studies and clinical findings.

Motor conduction times of median and ulnar nerves at the wrist were determined in 60 paraplegic male patients. In 30 of the patients (50%), 56 of the 240 nerves studied (23%) were abnormal. The incidence of abnormal conduction times was not reliably correlated with either age or duration of paralysis. The fact that patients a few years after injury had conduction times as severe as patients with long-standing paraplegia, regardless of age, indicates that an early disease process may take place in the patient's hands, although previous authors have reported different findings. Of patients with abnormal conduction times 44% were asymptomatic. Median nerve decompression was performed on these patients when they became symptomatic. Periodic examinations are recommended for all paraplegic patients so that early diagnosis can be made and differentiated from symptoms more proximal in the extremity. Although nerve conduction studies are not recommended for all asymptomatic patients, we now request them more liberally in younger patients with early symptoms to confirm the diagnosis.

Carcinoma in chronic pressure sores: a fulminant disease process.

Four cases of squamous cell carcinoma arising from chronic pressure sores in paraplegic and tetraplegic patients are presented and the literature reviewed. These pressure-sore carcinomas are characterized by a shorter latency period and a fulminant clinical course with a very high metastatic rate. Very aggressive treatment including even hemicorporectomy must be considered if a cure is to be achieved.

Effect of enterostomy on quality of life in spinal cord injury patients.

To determine the difference in the bowel care of spinal cord injury patients before and after enterostomy, we interviewed 20 patients--19 men and one woman. Their ages were 27-75, median 55 years. The paralytic lesions were spastic in ten and flaccid in ten. A total of 24 enterostomies were done for the following reasons: fecal contamination of decubitus ulcer in seven, colonic tumor in six, perforation of the colon in four, prolapse of the large intestine in four, inconvenience of bowel care in two, and perirectal abscess in one. There were 17 sigmoid and five transverse colostomies, and two ileostomies. (Two patients accounted for six procedures.) Follow-up time ranged from three months to six years, median nine months. Bowel care time was reduced from 0.7-14 hours, median 6.0 hours per week preoperatively, to 0.3-7 hours, median 1.0 hours per week postoperatively. Reversal of fecal leakage, abdominal pain, gas and anorexia were also reported. All patients were happier with their bowel care after surgery. We conclude that enterostomy in the spinal cord injury patient makes bowel care considerably more convenient, and improves the quality of life as well.

Drinking and spinal cord injury.

One hundred thirty-seven (137) spinal cord injury (SCI) patients (average age 50, duration of paralysis 17 years) were interviewed to determine the incidence and course of alcohol consumption and causes of remission. One hundred and one (101) patients, 74 percent of the sample, had consumed an average of six drinks a day (range 1-40) for an average of 23 years (range 5-47). Ninety-two (92) of these patients were habitual drinkers prior to SCI (39 were drinking the day of injury) and seven became drinkers after injury. Remissions occurred in 45 patients (33 abstaining, 12 with significant reduction) who had averaged seven drinks a day (range 1-25) for 18 years (range 2-44). Remissions were uninterrupted and averaged 9 years (range 1-27). Remission occurred in 18 patients during the first year of paralysis and, subsequently, at an average rate of one patient per year. The most common reasons given for remissions were general health considerations (10), compounding of the disabilities of myelopathy (9), loss of taste for liquor (9), and development of medical complications (7). While alcohol consumption is common prior to SCI, it is reversible after SCI, and additional therapeutic intervention, guided by known reasons for remissions, may be effective.