Content comparison of the Spinal Cord Injury Model System Database to the ICF Generic Sets and Core Sets for spinal cord injury.

STUDY DESIGN: Mapping of the National Spinal Cord Injury Model System (SCIMS) Database (NSCID) to the International Classification of Functioning, Disability and Health (ICF). OBJECTIVES: To link the content of the latest two versions of the NSCID to the ICF; more specifically (1) to compare the content of the current NSCID 2016-2021 version to its predecessor (NSCID 2011-2016) using the ICF as a neutral reference framework, and (2) to compare the content contained in the NSCID 2016-2021 version with relevant ICF Sets. SETTING: The forms of the NSCID 2016-2021 and 2011-2016 versions were linked to the ICF and contrasted. Comparability of the current version of the NSCID with the ICF Core Set for Spinal Cord Injury (SCI) in the post-acute and long-term context and the two generic ICF sets- ICF Generic-7 and ICF Generic-30 was then examined. METHODS: ICF Linking Rules and descriptive statistics. RESULTS: The current NSCID 2016-2021 version covers functioning as classified in the ICF with 8 ICF categories more comprehensively than its predecessor does. More than 50% of ICF categories contained in the two ICF Generic Sets were covered. The coverage of the brief ICF Core Sets for SCI by the NSCID 2016-2021 was more than 50%, but the coverage of the comprehensive core sets was low. Results showed the best coverage in the ICF component Activities and Participation. CONCLUSIONS: This study emphasizes how the ICF and its Sets can serve as a reference framework to foster comparability of existing data sets from both clinical practice and research.

Active Lifestyle Is Associated With Reduced Dyspnea and Greater Life Satisfaction in Spinal Cord Injury.

OBJECTIVE: To assess the relations between measures of activity with dyspnea and satisfaction with life in chronic spinal cord injury (SCI). DESIGN: Cross-sectional survey. SETTING: Five SCI centers. PARTICIPANTS: Between July 2012 and March 2015, subjects (N=347) with traumatic SCI ≥1 year after injury who used a manual wheelchair or walked with or without an assistive device reported hours spent away from home or yard on the previous 3 days, sports participation, and planned exercise. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Satisfaction with Life Scale (SWLS) and dyspnea. Dyspnea was defined as shortness of breath when hurrying on the level or going up a slight hill, going slower than people the same age on the level because of breathlessness, or stopping for breath when going at your own pace, or after about 100yd (or after a few minutes) on the level. RESULTS: Dyspnea prevalence was 30%. Adjusting for asthma or chronic obstructive pulmonary disease, mobility mode, race, and season, there was a significant linear trend between greater SWLS scores and quartiles of time spent away from the home or yard (P=.0002). SWLS score was greater if participating in organized sports (P=.01), although was not significantly greater with planned exercise (P=.093). Planned exercise was associated with a reduced odds ratio (OR) of dyspnea (.57; 95% confidence interval [CI], .34-.95; P=.032), but organized sports was not (P=.265). Dyspnea was not significantly increased in persons who spent the fewest hours outside their home or yard (≤7h) compared with people who spent the most hours outside their home or yard (>23h) (OR=1.69; 95% CI, 0.83-3.44; P=.145). CONCLUSIONS: In SCI, a planned exercise program is associated with less dyspnea. An active lifestyle characterized by greater time spent away from home or yard and sports participation is associated with greater SWLS scores.

Reliability and Validity of S3 Pressure Sensation as an Alternative to Deep Anal Pressure in Neurologic Classification of Persons With Spinal Cord Injury.

OBJECTIVE: To determine whether pressure sensation at the S3 dermatome (a new test) could be used in place of deep anal pressure (DAP) to determine completeness of injury as part of the International Standards for Neurological Classification of Spinal Cord Injury. DESIGN: Prospective, multicenter observational study. SETTING: U.S. Spinal Cord Injury Model Systems. PARTICIPANTS: Persons (N=125) with acute traumatic spinal cord injury (SCI), neurologic levels T12 and above, were serially examined at 1 month (baseline), 3, 6, and 12 months postinjury. There were 80 subjects with tetraplegia and 45 with paraplegia. INTERVENTIONS: S3 pressure sensation at all time points, with a retest at the 1-month time point. MAIN OUTCOME MEASURES: Test-retest reliability and agreement (κ), sensitivity, specificity, positive and negative predictive values. RESULTS: Test-retest reliability of S3 pressure at 1 month was almost perfect (κ=.98). Agreement of S3 pressure with DAP was substantial both at 1 month (κ=.73) and for all time points combined (κ=.76). The positive predictive value of S3 pressure for DAP was 89.3% at baseline and 90.3% for all time points. No pattern in outcomes was seen in those cases where S3 pressure and DAP differed at 1 month. CONCLUSIONS: S3 pressure sensation is reliable and has substantial agreement with DAP in persons with SCI at least 1 month postinjury. We suggest S3 pressure as an alternative test of sensory sacral sparing for supraconus SCI, at least in cases where DAP cannot be tested. Further research is needed to determine whether S3 pressure could replace DAP for classification of SCI.

Spinal Cord Injury-Functional Index/Assistive Technology Short Forms.

OBJECTIVES: To evaluate the psychometric properties of the Spinal Cord Injury-Functional Index/Assistive Technology (SCI-FI/AT) short forms (SFs) in the domains of basic mobility, self-care, fine motor function, and ambulation based on internal consistency; correlations between SFs and full item banks, and a 10-item computerized adaptive test (CAT) version; magnitude of ceiling and floor effects; and measurement precision across a broad range of function in a sample of adults with spinal cord injury (SCI). DESIGN: Cross-sectional cohort study. SETTING: Nine national Spinal Cord Injury Model Systems programs. PARTICIPANTS: A sample of adults with traumatic SCI (N=460) stratified by level of injury (paraplegia/tetraplegia), completeness of injury, and time since SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: SCI-FI/AT full item bank, 10-item CAT, and SFs (with separate Self-Care and Fine Motor Function SFs for persons with tetraplegia and paraplegia). RESULTS: The SCI-FI/AT SFs demonstrated very good internal consistency, group-level reliability, and excellent correlations between SFs and scores based on the CAT version and the total item bank. Ceiling and floor effects are acceptable (except for unacceptable ceiling effects for persons with paraplegia on the Self-Care and Fine Motor Function SFs). The test information functions are excellent across a broad range of functioning typical of persons with paraplegia and tetraplegia. CONCLUSIONS: Clinicians and researchers should consider using the SCI-FI/AT SFs to assess functioning with the use of assistive technology when CAT applications are not available.

Association of internet use and depression among the spinal cord injury population.

OBJECTIVE: To examine the relation between the frequency of Internet use and depression among people with spinal cord injury (SCI). DESIGN: Cross-sectional survey. SETTING: SCI Model Systems. PARTICIPANTS: People with SCI (N=4618) who were interviewed between 2004 and 2010. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The frequency of Internet use and the severity of depressive symptoms were measured simultaneously by interview. Internet use was reported as daily, weekly, monthly, or none. The depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), with 2 published criteria being used to screen for depressive disorder. The diagnostic method places more weight on nonsomatic items (ie, items 1, 2, and 9), and the cut-off method that determines depression by a (PHQ-9) score ≥10 places more weight on somatic factors. The average scores of somatic and nonsomatic items represented the severity of somatic and nonsomatic symptoms, respectively. RESULTS: Our multivariate logistic regression model indicated that daily Internet users were less likely to have depressive symptoms (odds ratio=.77; 95% confidence interval, .64-.93), if the diagnostic method was used. The linear multivariate regression analysis indicated that daily and weekly Internet usage were associated with fewer nonsomatic symptoms; no significant association was observed between daily or weekly Internet usage and somatic symptoms. CONCLUSIONS: People with SCI who used the Internet daily were less likely to have depressive symptoms.

Depression, pain intensity, and interference in acute spinal cord injury.

BACKGROUND: The high prevalence of pain and depression in persons with spinal cord injury (SCI) is well known. However the link between pain intensity, interference, and depression, particularly in the acute period of injury, has not received sufficient attention in the literature. OBJECTIVE: To investigate the relationship of depression, pain intensity, and pain interference in individuals undergoing acute inpatient rehabilitation for traumatic SCI. METHODS: Participants completed a survey that included measures of depression (PHQ-9), pain intensity ("right now"), and pain interference (Brief Pain Inventory: general activity, mood, mobility, relations with others, sleep, and enjoyment of life). Demographic and injury characteristics and information about current use of antidepressants and pre-injury binge drinking also were collected. Hierarchical multiple regression was used to test depression models in 3 steps: (1) age, gender, days since injury, injury level, antidepressant use, and pre-injury binge drinking (controlling variables); (2) pain intensity; and (3) pain interference (each tested separately). RESULTS: With one exception, pain interference was the only statistically significant independent variable in each of the final models. Although pain intensity accounted for only 0.2% to 1.2% of the depression variance, pain interference accounted for 13% to 26% of the variance in depression. CONCLUSION: Our results suggest that pain intensity alone is insufficient for understanding the relationship of pain and depression in acute SCI. Instead, the ways in which pain interferes with daily life appear to have a much greater bearing on depression than pain intensity alone in the acute setting.

Cardiopulmonary resuscitation in hospitalized children with cardiovascular disease: estimated prevalence and outcomes from the kids' inpatient database.

OBJECTIVE: Hospitalized children with cardiovascular disease may be at increased risk of cardiac arrest; however, little data exist regarding prevalence, risk factors, or outcomes of cardiopulmonary resuscitation in these patients. We sought to characterize national estimates of cardiopulmonary resuscitation and death after cardiopulmonary resuscitation for hospitalized children with cardiovascular disease. SETTING: A total of 3,739 hospitals in 38 states participating in Kids' Inpatient Database. DESIGN: Retrospective analysis of the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database was performed. Sample weighting was employed to produce national estimates. MEASUREMENTS AND MAIN RESULTS: Cardiovascular disease was identified in 2.2% of the estimated 22,175,468 (95% confidence interval 21,391,343-22,959,592) hospitalizations. Cardiopulmonary resuscitation occurred in 0.74% (3,698; 95% confidence interval 3,205-4,191) of hospitalizations of children with cardiovascular disease, compared with 0.05% (11,726; 95% confidence interval 10,647-12,805) without cardiovascular disease (odds ratio 13.8, 95% confidence interval 12.8-15.0). The highest frequency of cardiopulmonary resuscitation occurred with myocarditis (3.0% of admissions), heart failure (2.0%), and coronary pathology (2.0%). Compared with other forms of cardiovascular disease identified in this study, single-ventricle patients were the only subgroup who exhibited a higher mortality after cardiopulmonary resuscitation (mortality 65% vs. 55%; odds ratio 1.7 [95% confidence interval 1.2-2.6]), while those who had undergone cardiac surgery exhibited a lower mortality rate (mortality 48% vs. 57%; odds ratio 0.6 [95% confidence interval 0.5-0.8]). CONCLUSIONS: Cardiopulmonary resuscitation occurs in approximately 7 per 1,000 hospitalizations of children with cardiovascular disease, a rate greater than ten-fold that observed in hospitalizations of children without cardiovascular disease. Single-ventricle patients demonstrated increased mortality after cardiopulmonary resuscitation, while recent cardiac surgery was associated with a reduced odds of death after cardiopulmonary resuscitation. Further studies are needed to confirm these findings and develop techniques to prevent cardiac arrest in this high-risk population.

Depression treatment preferences after acute traumatic spinal cord injury.

OBJECTIVE: To examine preferences for depression treatment modalities and settings and predictors of treatment preference in persons with spinal cord injury (SCI). DESIGN: Cross-sectional surveys. SETTING: Rehabilitation inpatient services. PARTICIPANTS: Persons with traumatic SCI (N=183) undergoing inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient Health Questionnaire-9 depression scale, history of psychiatric diagnoses and treatments, and a depression treatment preference survey. RESULTS: Among inpatients with SCI (28% had Patient Health Questionnaire-9 score ≥10 indicating probable major depression), a physical exercise program was the most preferred treatment option (78% somewhat or very likely to try) followed by antidepressants prescribed by a primary care provider (63%) and individual counseling in a medical or rehabilitation clinic (62%). All modalities were preferred over group counseling. Although not statistically significant, more depressed individuals stated a willingness to try antidepressants and counseling than nondepressed individuals. Subjects preferred treatment in a medical/rehabilitation setting over a mental health setting. Those with a prior diagnosis of depression and a history of antidepressant use were significantly more willing to take an antidepressant. Age ≥40 years was a significant predictor of willingness to receive individual counseling. CONCLUSIONS: Treatment preferences and patient education are important factors when choosing a depression treatment modality for patients with SCI. The results suggest that antidepressants, counseling, and exercise may be promising components of depression treatment in this population, particularly if they are integrated into medical or rehabilitation care.

Characterization of extracorporeal membrane oxygenation for pediatric cardiac arrest in the United States: analysis of the kids' inpatient database.

To characterize the overall use, cost, and outcomes of extracorporeal membrane oxygenation (ECMO) as an adjunct to cardiopulmonary resuscitation (CPR) among hospitalized infants and children in the United States, retrospective analysis of the 2000, 2003, and 2006 Kids' Inpatient Database (KID) was performed. All CPR episodes were identified; E-CPR was defined as ECMO used on the same day as CPR. Channeling bias was decreased by developing propensity scores representing the likelihood of requiring E-CPR. Univariable, multivariable, and propensity-matched analyses were performed to characterize the influence of E-CPR on survival. There were 8.6 million pediatric hospitalizations and 9,000 CPR events identified in the database. ECMO was used in 82 (0.9 %) of the CPR events. Median hospital charges for E-CPR survivors were $310,824 [interquartile range (IQR) 263,344-477,239] compared with $147,817 (IQR 62,943-317,553) for propensity-matched conventional CPR (C-CPR) survivors. Median LOS for E-CPR survivors (31 days) was considerably greater than that of propensity-matched C-CPR survivors (18 days). Unadjusted E-CPR mortality was higher relative to C-CPR (65.9 vs. 50.9 %; OR 1.9, 95 % confidence interval 1.2-2.9). Neither multivariable analysis nor propensity-matched analysis identified a significant difference in survival between groups. E-CPR is infrequently used for pediatric in-hospital cardiac arrest. Median LOS and charges are considerably greater for E-CPR survivors with C-CPR survivors. In this retrospective administrative database analysis, E-CPR did not significantly influence survival. Further study is needed to improve outcomes and to identify patients most likely to benefit from this resource-intensive therapy.

Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States: an analysis of the Kids' Inpatient Database*.

OBJECTIVE: Population-based data on pediatric in-hospital cardiopulmonary resuscitation in the United States are scarce. Single-center studies and voluntary registries may skew the estimated prevalence and outcomes. This study aimed to determine the prevalence and outcomes of pediatric cardiopulmonary resuscitation on a national scale. DESIGN: A retrospective analysis of the Healthcare Cost and Utilization Project 2006 Kids' Inpatient Database was performed. Sample weighting was employed to produce national estimates. SETTING: Three thousand seven hundred thirty-nine hospitals in 38 states participating with the Kids' Inpatient Database. PATIENTS: All patients <20 yrs of age hospitalized in participating institutions in 2006. MEASUREMENTS AND MAIN RESULTS: Cardiopulmonary resuscitation was performed in 5,807 (95% confidence interval 5259-6355) children with prevalence of 0.77 per 1,000 admissions. Most patients (68%) were <1 yr old, and 44% were female. On multivariable analysis, cardiopulmonary resuscitation was associated with respiratory failure (odds ratio 41.5, 95% confidence interval 35.4-48.8), myocarditis (odds ratio 36.6, 95% confidence interval 21.9-61.0), acute renal failure (odds ratio 21.6, 95% confidence interval 17.5-26.7), heart failure (odds ratio 3.8, 95% confidence interval 3.0-4.8), and cardiomyopathy (odds ratio 3.8, 95% confidence interval 3.2-4.7). Overall mortality was 51.8% and greater among patients ≥1 yr (68%) vs. <1 yr (44%) (odds ratio 2.7, 95% confidence interval 2.3-3.2). Factors associated with mortality among patients receiving cardiopulmonary resuscitation on multivariable analysis included acute renal failure (odds ratio 1.5, 95% confidence interval 1.1-1.9), hepatic insufficiency (odds ratio 1.5, 95% confidence interval 1.01-2.4), sepsis (odds ratio 1.2, 95% confidence interval 1.01-1.4), and congenital heart disease (odds ratio 1.2, 95% confidence interval 1.01-1.5). CONCLUSIONS: Cardiopulmonary resuscitation is performed in approximately one in 1,300 pediatric hospitalizations. Approximately half of patients receiving cardiopulmonary resuscitation do not survive to discharge. Independent risk factors for mortality after receiving cardiopulmonary resuscitation included congenital heart disease, age ≥1 yr, acute renal failure, hepatic insufficiency, and sepsis.

Prevalence, morbidity, and mortality of heart failure-related hospitalizations in children in the United States: a population-based study.

BACKGROUND: Few data exist on prevalence, morbidity, and mortality of pediatric heart failure hospitalizations. We tested the hypotheses that pediatric heart failure-related hospitalizations increased over time but that mortality decreased. Factors associated with mortality and length of stay were also assessed. METHODS AND RESULTS: A retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed for pediatric (age ≤18 years) heart failure-related hospitalizations for the years 1997, 2000, 2003, and 2006. Hospitalizations did not significantly increase over time, ranging from 11,153 (95% confidence interval [CI] 8,898-13,409) in 2003 to 13,892 (95% CI 11,528-16,256) in 2006. Hospital length of stay increased from 1997 (mean 13.8 days, 95% CI 12.5-15.2) to 2006 (mean 19.4 days, 95% CI 18.2 to 20.6). Hospital mortality was 7.3% (95% CI 6.9-8.0) and did not vary significantly between years; however, risk-adjusted mortality was less in 2006 (odds ratio 0.70, 95% CI 0.61 to 0.80). The greatest risk of mortality occurred with extracorporeal membrane oxygenation, acute renal failure, and sepsis. CONCLUSIONS: Heart failure-related hospitalizations occur in 11,000-14,000 children annually in the United States, with an overall mortality of 7%. Many comorbid conditions influenced hospital mortality.

Validity of the Patient Health Questionnaire-9 in assessing major depressive disorder during inpatient spinal cord injury rehabilitation.

OBJECTIVE: To investigate the validity of the Patient Health Questionnaire-9 (PHQ-9) depression screening measure in people undergoing acute inpatient rehabilitation for spinal cord injury (SCI). DESIGN: We performed a blinded comparison of the PHQ-9 administered by research staff with the major depression module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID) conducted by a mental health professional. SETTING: Inpatient rehabilitation units. PARTICIPANTS: Participants (N=142) were patients undergoing acute rehabilitation for traumatic SCI who were at least 18 years of age, English speakers, and without severe cognitive, motor speech, or psychotic disorders. We obtained the SCID on 173 (84%) of 204 eligible patients. The final sample of 142 patients (69%) consisted of those who underwent both assessments within 7 days of each other. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: PHQ-9 and SCID major depression module. RESULTS: Participants were on average 42.2 years of age, 78.2% men, and 81.7% white, and 66.9% had cervical injuries. The optimal PHQ-9 cutoff (≥11) resulted in 35 positive screens (24.6%). Key indices of criterion validity were as follows: sensitivity, 1.00 (95% confidence interval [CI], .73-1.00); specificity, .84 (95% CI, .76-.89); Youden Index, .84; positive predictive value, .40 (95% CI, .24-.58); and negative predictive value, 1.00 (95% CI, .96-1.00). The area under the receiver operator curve was .92, and κ was .50. Total PHQ-9 scores were inversely correlated with subjective health state and quality of life since SCI. CONCLUSIONS: The PHQ-9 meets criteria for good diagnostic accuracy compared with a structured diagnostic assessment for major depressive disorder even in the context of inpatient rehabilitation for acute traumatic SCI.

The demographics of pain after spinal cord injury: a survey of our model system.

STUDY DESIGN: Survey OBJECTIVES: Better understand the demographics of pain after spinal cord injury (SCI). SETTING: Academic Level 1 trauma center and SCI Model System. METHODS: A survey including general demographic questions, questions of specific interest to the authors, the standardized SCI Pain Instrument (SCIPI), International SCI Pain Data Set, Basic form (ISCIPDS:B), Patient Reported Outcomes Measurement Information System (PROMIS) neuropathic 5a (PROMIS-Neur), and PROMIS nociceptive 5a (PROMIS-No). RESULTS: 81% of individuals with SCI experience chronic pain and 86% of individuals with pain have neuropathic pain. 55% of individuals had shoulder pain. Females and those who recall >5/10 pain during initial hospital stay had significantly higher PROMIS-Neur scores. Completeness of injury correlates inversely with the degree of neuropathic pain. Those who recall >5 pain during the initial hospital stay and those who reported the worst or second worst pain as being shoulder pain had significantly higher PROMIS-No scores. Lumbosacral injuries trended towards higher PROMIS-No scores and had the highest PROMIS-Neur scores. Those with tetraplegia were more likely to develop shoulder pain and those with shoulder pain had higher PROMIS-No scores. CONCLUSIONS: Chronic pain is almost universal in patients with SCI. Pain is more commonly reported as neuropathic in nature and females reported more neuropathic pain than males. Physicians should monitor for nociceptive shoulder pain, particularly in those with tetraplegia. Patients with incomplete injuries or lumbosacral injuries are more likely to report higher levels of neuropathic pain and pain levels should be monitored closely. Those with more neuropathic and nociceptive pain recall worse pain at initial hospitalization. Better understanding pain demographics in this population help screen, prevent and manage chronic pain in these patients.

A longitudinal study of depression from 1 to 5 years after spinal cord injury.

OBJECTIVE: To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury. DESIGN: Longitudinal cohort study. SETTING: SCI Model System. PARTICIPANTS: Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher. RESULTS: Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found. CONCLUSION: In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the national spinal cord injury database.

OBJECTIVE: To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS). DESIGN: Longitudinal cohort; follow-up to 1 year. SETTING: U.S. SCIMS. PARTICIPANTS: Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in AIS, UEMS, LEMS, and motor levels. RESULTS: From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination (P=.54) or initial neurologic level (P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2-3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2-7.8; P<.001). CONCLUSIONS: More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.

Bulbocavernosus or anal reflex, one or both should be tested after spinal cord injury.

There are several methods for determining the remaining function of the sacral spinal cord following a spinal cord injury. Two of these methods are the bulbocavernosus and the anal wink reflexes. The choice of which reflex to use should be determined by the need for clinical information. These two reflexes provide similar information; however, they may have different prognostic value.

Pelvic ischemia is measurable and symptomatic in patients with coronary artery disease: a novel application of dynamic contrast-enhanced magnetic resonance imaging.

INTRODUCTION: Pelvic ischemia can manifest as vascular-mediated erectile dysfunction (ED) and lower urinary tract symptoms (LUTS), and is associated with cardiac ischemia. AIMS: We aimed to develop a dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) technique to measure pelvic perfusion in benign tissue. METHODS: Nine men with coronary artery disease (CAD) were compared with nine without. Images were acquired at 3T with T1-weighted DCE-MRI for perfusion. Two-compartment pharmacokinetic modeling was employed to fit signal enhancement from prostate, corpus cavernosal, and spongiosal tissues. MAIN OUTCOME MEASURES: Perfusion parameters and validated pelvic symptom scores were compared. RESULTS: The mean International Index of Erectile Function (IIEF) total score was worse in CAD (41.3 +/- 19.7) vs. controls (59.4 +/- 14.9, P = 0.04). The IIEF erectile function domain score trended to worse in CAD (13.7 +/- 9.7) vs. controls (22.0 +/- 9.9, P = 0.09). The mean total International Prostate Symptom Score (IPSS) trended to worse in CAD patients (13.2) than controls (7.0) (P = 0.10). Magnetic resonance perfusion analysis demonstrated lower mean maximal percent enhancement to P < 0.0001 in the CAD group vs. controls for all the following comparisons: prostate in CAD (22.4 +/- 0.4) vs. controls (26.3 +/- 0.1); cavernosal tissue in CAD (9.3 +/- 0.2) vs. controls (16.6 +/- 0.8); and spongiosal tissue in CAD (20.6 +/- 1.2) vs. controls (24.0 +/- 0.6). Comparison of mean wash-in rates in the unit of 10(-3)/second was also highly significant (P < 0.0001 for all tissues): prostate in CAD (574.0 +/- 18.0) was lower than controls (1,035.0 +/- 29.0); slower wash-in rates were seen in CAD cavernosal (58.0 +/- 4.0 vs. 139.0 +/- 9.0 in controls) and spongiosal tissue (134.0 +/- 6.0 vs. 278.0 +/- 12.0 in controls). CONCLUSION: These initial data demonstrate that pelvic perfusion can be measured in noncancerous tissues, and that perfusion correlates with validated measures of ED and LUTS.

Towards guidelines for evaluation of measures: an introduction with application to spinal cord injury.

BACKGROUND: Both clinical practice and research in spinal cord injury (SCI) continue to struggle with issues of the quality and utility of outcome measures employed. Despite widespread deference to dicta on "reliability and validity," systematic means of grading the level of evidence for measures are lacking. OBJECTIVES: This paper explains the methods and principles for use in systematic reviews of measures in SCI. It explains how extant measurement standards and principles can be elaborated for extant labels on various types of reliability and validity to define a more judicious method of grading level of evidence. We aim to initiate a process of discussion that will lead to improved systematic review of the measurement quality as a basis for long-term improvements in outcomes measures and their application. METHODS: This paper is a conceptual review, based on established measurement standards and principles and the incorporation of recent advances in measurement methodology. The scheme of grading of measurement quality is illustrated by examples of measures of health, function, activity/participation, and quality of life after SCI. RESULTS AND CONCLUSIONS: It is possible to grade the quality of outcome measure in terms of level of evidence, provided the nature of the construct being measured is defined as well as its main use. Definite means of grading the level of evidence for measurement will help to identify priorities for measure development and facilitate more appropriate uses of measures.

Improving the efficiency of screening for major depression in people with spinal cord injury.

BACKGROUND/OBJECTIVE: To investigate the metric properties, relative efficiency, sensitivity and specificity, and positive predictive value of a short form of the Patient Health Questionnaire-9 (PHQ-9) that may be used as a screening test for depression. METHODS: Data from the National Spinal Cord Injury Statistical Center Database containing 3,652 records with complete data for the PHQ-9 were analyzed using Confirmatory Factor Analysis, Item Response Theory Graded Response Model analysis, and sensitivity and specificity analysis of classification. RESULTS: A scale comprised of items 1, 2, and 6 from the PHQ-9 has a relative efficiency of 0.66 compared to the 9-item scale. Using this 3-item scale and a cutoff score of 3 or more provides specificity of 0.93 and sensitivity of 0.87; a cutoff of 4 provides specificity of 0.95 and sensitivity of 0.82. The shorter version of the scale reduces the effect of response bias caused by gender. The relative efficiency of the 9-item scale is 0.88 for women compared to men; the 3-item scale increases the relative efficiency to 0.93. CONCLUSION: A 3-item scale provides adequate information for clinical screening purposes. Cutoff scores of either 3 or 4 are acceptable and present options for decision making within a particular clinical setting. Additionally, the 3-item scale reduces the effect of gender of the respondent on the score obtained.