Patient handling slings and lifts reduce the risk of musculoskeletal injuries for healthcare providers. However, no published evidence exists of their safety with respect to pressure ulceration for vulnerable populations, specifically persons with spinal cord injury, nor do any studies compare slings for pressure distribution. High-resolution interface pressure mapping was used to describe and quantify risks associated with pressure ulceration due to normal forces and identify at-risk anatomical locations. We evaluated 23 patient handling slings with 4 nondisabled adults. Sling-participant interface pressures were recorded while participants lay supine on a hospital bed and while suspended during typical patient transfers. Sling-participant interface pressures were greatest while suspended for all seated and supine slings and exceeded 200 mm Hg for all seated slings. Interface pressures were greatest along the sling seams (edges), regardless of position or sling type. The anatomical areas most at risk while participants were suspended in seated slings were the posterior upper and lower thighs. For supine slings, the perisacral area, ischial tuberosities, and greater trochanters were most at risk. The duration of time spent in slings, especially while suspended, should be limited.

Objective: Characterization of a non-invasive method of quantifying subepidermal moisture (SEM) surrounding stages III and IV pressure ulcers (PrUs) in spinal cord injury (SCI).Design: Prospective, single-visit, single-rater, observational study, using repeated-measures analysis.Method: Setting-inpatient units of one VA SCI Center.Participants: Convenience sample of 16 subjects with SCI with stage III or IV PrUs over sacrum or ischium.Interventions: Measurement with the MoistureMeter-D, a hand-held device using 300 MHz electromagnetic waves.Outcome measures: Dielectric constant, a dimensionless number which increases with the moisture content. Each subject had a PrU site and a control site. Measurements were made at each site, on intact skin, at four points spaced angularly around the site, in triplicate.Results: (1) Short-term, single-rater relative error was 2.5%. (2) Order effect: first readings were higher than second readings in 55 of 64 measurement sets. Order effect was significant for control sites (P < 0.0001) but not for PrU sites. (3) Angular effect: SEM varied by angle at the PrU sites (P < 0.01); 12 o'clock position the highest and 6 o'clock the lowest. (4) Ability to differentiate PrUs from intact skin: SEM at PrU sites was greater by 9.0% than control sites (P < 0.05). (5) Site effect: SEM was higher at sacral locations than ischial at control sites by 20% (P < 0.005).Conclusions: SEM differentiates PrUs from intact skin. Future study designs must take into account order, angular, and site effects on this measure. This information will inform designers of future studies of SEM in healing of PrUs.

CONTEXT/BACKGROUND:A 61-year-old female with cervical stenosis underwent an elective cervical laminectomy with post-op worsening upper extremity weakness. Over the first 3 weeks post-op, she received two separate courses of intravenous steroids. Two days after cessation of steroids, she presented with non-specific symptoms of adrenal insufficiency (AI). Initial formal diagnostic tests of random cortisol level and 250 µg cosyntropin challenge were non-diagnostic; however, symptoms resolved with the initiation of empiric treatment with hydrocortisone. Ten days later, repeat cosyntropin (adrenocortocotropic hormone stimulation) test confirmed the diagnosis of AI. FINDINGS:AI is a potentially life-threatening complication of acute spinal cord injury (ASCI), especially in those receiving steroids acutely. Only three cases have been reported to date of AI occurring in ASCI after steroid treatment. The presenting symptoms can be non-specific (as in this patient) and easily confused with other common sequelae of ASCI such as orthostasis and diffuse weakness. The 250 µg cosyntropin simulation test may not the most sensitive test to diagnose AI in ASCI. CONCLUSION:The non-specific presentations and variability of diagnosis criteria make diagnosis more difficult. One microgram cosyntropin simulation test may be more sensitive than higher dose. Clinicians should be aware that AI can be a potential life-threatening complication of ASCI post-steroid treatment. Prompt diagnosis and treatment can reverse symptoms and minimize mortality.

OBJECTIVE:The purpose was to provide support for validity and reliability of the spinal cord impairment pressure ulcer monitoring tool (SCI-PUMT) to assess pressure ulcer (PrU) healing.DESIGN:Expert panels developed a 30-item pool, including new items and items from two established PrU healing tools, to represent potential variables for monitoring PrU healing. Subjects were prospectively assessed weekly for each variable over a 12-week period.SETTING:Data collection was conducted on a cohort of inpatients and outpatients in one Spinal Cord Injury/Disorders Center in the Veterans' Health Administration.SUBJECTS:A convenience sample of Veterans (n = 66) with spinal cord impairment (SCI) was recruited. Eligible subjects had at least one PrU (n = 167) and a history of SCI for longer than 1 year. Interventions Not applicable.OUTCOME MEASURE:A change in PrU volume was calculated using VeV Measurement Documentation software and a digital imaging camera.RESULTS:Content validity was established for a pool of items designed to gauge PrU healing. Exploratory factor analysis (construct validity) identified a parsimonious set of seven items for inclusion in the SCI-PUMT to assess PrU healing. The SCI-PUMT was found to explain 59% of the variance of the volume across the study. Inter-rater reliability was 0.79 and intra-rater reliability ranged from 0.81 to 0.99 among research assistants. Similar levels of reliability were subsequently established among registered nurses, who used the SCI-PUMT in the clinical setting.CONCLUSIONS:The final version of the SCI-PUMT was determined to be valid, reliable, and sensitive in detecting PrU healing over time in Veterans with SCI.

Patient dignity is a significant concern among inpatient Veterans with spinal cord injuries (SCIs) because they may lack physical control over their bodies and thus rely on others for a variety of specialized needs, including mobility, personal care, wound care, bowel and bladder care, and rehabilitation, among others. This study examines the complexities of providing and negotiating dignified care in the context of interdisciplinary care teams in SCI, and the challenges Veterans with SCI face maintaining dignity in the context of limited independence. Based on a mixed methods approach that included in-depth interviews, observations, and pile sorting at six Veterans Health Administration (VA) SCI units, the goal of this study was to explore ways in which dignity was defined, negotiated, and conferred during patient and provider interactions. Study results have immediate value to VA leadership, VA providers, and Veterans by calling attention to the ways in which the concept of patient dignity can be integrated into clinical practice on SCI units. This study provides a methodological framework to capture complex interactions among interdisciplinary care teams and patients, and offers a significant contribution to our understanding of how patient and provider interactions are conferred and negotiated.

OBJECTIVESeveral of the casualties from Operation Iraqi Freedom arriving at one Veterans Administration (VA) polytrauma rehabilitation center (PRC) were noted to have occipital pressure ulcers or hair loss. The objective of this study was to determine the prevalence and severity of pressure-related injuries in VA PRC admissions.METHODSA retrospective review of admissions from active duty from 2004 to 2006 was performed.RESULTSThirty-eight percent of admissions to this VA PRC had pressure-related injuries on the day of admission. Casualties from Iraq had a higher rate of pressure ulcers (53%) than did those from elsewhere (22%). Occipital lesions constituted 50% of non-stage I pressure ulcers and were more severe than those of the sacrum or extremities.CONCLUSIONSFurther epidemiological research should be performed to identify risk factors for pressure injury in the military continuum of care, by linking specific military medical evacuation and treatment processes and characteristics of casualties with outcomes.

Scientific and Clinical Abstracts From the 40th Annual Wound, Ostomy and Continence Nurses Annual Conference: Orlando, Florida: June 21–25, 2008: Research Abstracts: Wound-Evidence-Based Interventions

Background/Objective: Prone carts are used for mobility. by individuals with spinal cord injury in whom seated mobility (wheelchair) is contraindicated due to ischial or sacral pressure ulcers. Currently available prone carts are uncomfortable, subjecting the user to neck and shoulder strain, and make social interaction and performing activities of daily living difficult. A better design of prone carts is needed. In addition, standing devices have shown some medical benefits. The objective was to design and evaluate an improved prone cart that facilitates standing.Design: Engineering development project with user feedback through questionnaire. Users selected by convenience sampling.Methods: A marketing survey was performed of nurse managers of spinal cord injury units. Then 2 prototype carts were designed and built. These carts are able to tilt up to 45 degrees and have a joystick-controlled motor for propulsion and other design features, including a workspace storage shelf and rearview mirrors. The carts were evaluated by both patients and caregivers at 2 Veteran's Administration hospitals.Outcome Measures: Questionnaire of subjects, both patients and caregivers, who used the cart.Findings: Both patients and caregivers liked the carts and the ability to assume a nonhorizontal body angle. The major complaint about the cart was that it seemed too long when it came to making turns.Conclusion: This prone cart design is an improvement over the standard, flat variety. However, further design changes will be necessary. This study provided valuable information that will be useful in the next-generation prone cart design project.

Background/Objective: Pressure ulcers are a serious complication for people with spinal cord injury (SCI). The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines (CPGs) that provided guidance for pressure ulcer prevention and treatment after SCI. The aim of this study was to assess providers' perceptions for each of the 32 CPG recommendations regarding their agreement with CPGs, degree of CPG implementation, and CPG implementation barriers and facilitators.Methods: This descriptive mixed-methods study included both qualitative (focus groups) and quantitative (survey) data collection approaches. The sample (n = 60) included 24 physicians and 36 nurses who attended the 2004 annual national conferences of the American Paraplegia Society or American Association of Spinal Cord Injury Nurses. This sample drew from two sources: a purposive sample from a list of preregistered participants and a convenience sample of conference attendee volunteers. We analyzed quantitative data using descriptive statistics and qualitative data using a coding scheme to capture barriers and facilitators.Results: The focus groups agreed unanimously on the substance of 6 of the 32 recommendations. Nurse and physician focus groups disagreed on the degree of CGP implementation at their sites, with nurses as a group perceiving less progress in implementation of the guideline recommendations. The focus groups identified only one recommendation, complications of surgery, as being fully implemented at their sites. Categories of barriers and facilitators for implementation of CPGs that emerged from the qualitative analysis included (a) characteristics of CPGs: need for research/evidence, (b) characteristics of CPGs: complexity of design and wording, (c) organizational factors, (d) lack of knowledge, and (e) lack of resources.Conclusions: Although generally SCI physicians and nurses agreed with the CPG recommendations as written, they did not feel these recommendations were fully implemented in their respective clinical settings. The focus groups identified multiple barriers to the implementation of the CPGs and suggested several facilitators/solutions to improve implementation of these guidelines in SCI. Participants identified organizational factors and the lack of knowledge as the most substantial systems/issues that created barriers to CPG implementation.

Blind and partially sighted people’s perceptions of inclusion by family and friends are examined in a major survey of over 900 adults with low vision in the UK. Findings demonstrate a complex picture, reporting high levels of severe lack of social support in comparison to the general population especially among men, and lack of social support expressed extensively by those who were rarely or never visited by family or neighbours. Levels of reported social support were not related to the degree of severity of sight loss or age; and economically inactive respondents of working age reported lower levels of social support than those who were working. Correlation between respondents’ having hobbies and going shopping and rising levels of social support was shown. With 40% of respondents living alone, having someone visiting as little as at least once a month meant that respondents were less likely to express severe lack of social support. The concept of ‘inclusion’ is recognized as more associated with formal ideas of citizenship and participation in community life than with informal support. It is suggested that increased focus should be given in public policy development and service provision to enabling greater levels of informal inclusion for people with visual impairments. Implications for general services development are noted.

This paper presents a pulse-duration tunable ultra-wideband (UWB) generator that is developed using a variable edge-rate signal. Edge-rate variability is introduced by applying a step recovery diode (SRD) to compress the edges of the source and then employing a simple RC network to adjust the edge-rate. Afterwards, the compressed signal is differentiated using microstrip transmission lines in a short circuit stub configuration. The tunable generator resulting from this approach demonstrates Gaussian and monocycle pulses with: good symmetry and low distortion over the tunable range; pulse width variation from 800 to 1150ps over a 1-20pF capacitance range; and good agreement between simulated and measured results

OBJECTIVE:The command of a U.S. Army Reserve Combat Support Hospital designed this study to evaluate soldiers' behavior related to and attitudes toward skipping meals while on annual training (AT).METHODS:The command administered an anonymous survey on attitudes about weight loss and weightloss behavior while on AT. Of 180 soldiers given the opportunity to respond, 100 responses were received (55%).RESULTS:Before AT, 50% of reservists responding thought about losing weight while on AT, 62% of soldiers were trying to lose weight while on AT, and 25% of soldiers skipped meals. Soldiers who felt that they were overweight had a 2.9-fold increased risk for skipping meals, and those who thought about losing weight before AT had a 3.0-fold risk. Neither age, gender, rank, nor history of previously being on weight control was a predictor of skipping meals.CONCLUSION:Most soldiers considered and tried to lose weight while at AT, and soldiers who considered themselves overweight or thought about losing weight were at increased risk for skipping meals.

The most recurrent pulse generator design approach described in literature employs a series step recovery diode (SRD) and pulse-duration tuning subsequent to Gaussian pulse formation. Although this conventional approach is advantageous in fixed pulse-duration designs, it leads to relatively complex designs for tunable generators. This paper presents a variable edge-rate compression (VERC) approach, to tunable ultra-wideband (UWB) generator design, that entails tuning prior to Gaussian pulse formation and a shunt configuration of forward and reverse biased SRDs. Compared to the conventional approach, VERC offers performance advantages that include broader tuning range, improved tuning sensitivity, increased design simplicity and reduced cost. A comparison of the series and shunt SRD configurations reveals that input-signal slew rate has a dominant effect on pulse-duration tuning for an SRD in a shunt configuration. As slew rate may be modified using frequency, rise time or voltage, the VERC approach also offers greater design flexibility and is more advantageous for tunable UWB generator design

The use of microwave signals to detect and characterize incidences of skin cancer is an area of research that is relatively unexplored. This paper describes an ongoing effort made toward detection of the differences in the responses of normal skin and benign and cancerous lesions when exposed to nonionizing microwave radiation. Research to date has focused on the characterization of non-biological dielectric samples with known properties and predictable responses. New data include those obtained using an open-ended waveguide antenna, and layer extraction results using signal cancellation.

While much of the research on falls has focused on the ambulatory elderly, little is known about wheelchair-related falls that occur in persons with disabilities. A thorough understanding of wheelchair-related falls would include the demographics, the mechanism and nature of the fall event, and the nature of any resultant injury, including the cost of treatment and long-term sequelae. The purpose of this article is to provide an overview of the current data on wheelchair-related falls and to make recommendations for avenues for improved quality of care and future research to promote patient safety.

BACKGROUND/OBJECTIVE:The purpose of this study was to compare patient outcomes and quality of life for people with neurogenic bowel using either a standard bowel care program or colostomy.METHODS:We analyzed survey data from a national sample, comparing outcomes between veterans with spinal cord injury (SCI) who perform bowel care programs vs individuals with colostomies. This study is part of a larger study to evaluate clinical practice guideline implementation in SCI. The sample included 1,503 veterans with SCI. The response rate was 58.4%. For comparison, we matched the respondents with colostomies to matched controls from the remainder of the survey cohort. A total of 74 veterans with SCI and colostomies were matched with 296 controls, using propensity scores. Seven items were designed to elicit information about the respondent's satisfaction with their bowel care program, whereas 7 other items were designed to measure bowel-related quality of life.RESULTS:No statistically significant differences in satisfaction or quality of life were found between the responses from veterans with colostomies and those with traditional bowel care programs. Both respondents with colostomies and those without colostomies indicated that they had received training for their bowel care program, that they experienced relatively few complications, such as falls as a result of their bowel care program, and that their quality of life related to bowel care was generally good. However, large numbers of respondents with colostomies (n = 39; 55.7%) and without colostomies (n = 113; 41.7%) reported that they were very unsatisfied with their bowel care program.CONCLUSION:Satisfaction with bowel care is a major problem for veterans with SCI.

Background/Objectives: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGS has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the "Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord MedicineMethods: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention.Results: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1.Conclusions: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.

Abstract Background/Objectives: The purpose of this study was to determine whether publication of the “Prevention of Thromboembolism in Spinal Cord Injury” clinical practice guideline (CPG) changed patient management and whether adherence to CPG recommendations improved after a targeted implementation strategy. Methods: Data were abstracted from medical records of 1 34 and 520 patients with acute and chronic spinal cord injury (SCI), respectively, from 6 Veterans Affairs medical centers over 3 time periods: prepublication (T1 ), pre implementation (T2), and postimplementation (T3) of the CPG. Targeted interventions were developed to address provider-perceived barriers to guideline adherence, based on findings from focus groups conducted at each site. The interventions incorporated two implementation strategies: standardized documentation templates/standing orders and social marketing /outreach visits. Results: Use of the specified duration for pharmacologic prophylaxis increased from 60% to 65% to 75% of patients with acute SCI in T1, T2, and T3, respectively (P = 0.060 and 0.041 for T1 vs T2 and T2 vs T3, respectively). Rates of use for individual pharmacologic prophylaxis agents changed significantly over the course of the study, with use of low-molecular-weight heparin increasing from 7% in T1 to 42% in T3. Physical assessments for thrombosis on hospitalization days 1 and 30 improved between T2 and T3. Use of prophylaxis in chronically injured patients with new risk factors for thromboembolism increased from 16% to 31% to 34% during T1, T2, and T3 (P = 0.001 and 0.87, respectively). Conclusions: The CPG publication had only a modest effect on practice. Use of structured implementation further increased the adherence to some CPG recommendations for thromboembolism prophylaxis. Similar implementation strategies should be considered for CPG recommendations with low adherence and high potential for morbidity and mortality.

Falls are a significant cause of injury, disability, and death in the elderly, but little is known about the risk of wheelchair-related falls. The purpose of this study is to describe the incidence, etiology, location of fracture, treatment, and health care utilization of fall-related fractures in persons with spinal cord impairment (SCI). A retrospective review of 45 medical records of patients with SCI who sustained fractures, nonconcomitant with the onset of their initial injury, was completed at a Veterans Health Administration (VHA) SCI service over a 10-year period. Of the 24 veterans who sustained fall-related fractures, three (12%) were found to have repeated falls with fractures. Falls were sustained during activities (more than one wheelchair activity contributed to a fall; e.g., transfer activity with brake failure in a van) including transfer (44%), reaching (11%), propelling (15%), moving in bed (22%), transferring or riding in a vehicle (30%), and showering (7%). Factors contributing to falls included loss of balance, equipment failure, muscle spasms, excessive speed, not wearing protective straps, and narcolepsy. Among the 31 fractures sustained in 27 fall episodes in 24 subjects, lower extremity fractures accounted for 97% of the injuries and a fractured 7th rib accounted for one injury (3%). Tibial fractures occurred more frequently than femoral or ankle fractures. Four (15%) fall episodes resulted in bilateral fractures. The treatment of choice was to immobilize the fractured extremity with a soft, well-padded splint. Surgical fixation was performed in only two cases. Over 80% of the patients with fall-related fractures were admitted for inpatient stays with a mean of 66 inpatient days per patient. Hospital days were most often the result of home inaccessibility, inadequate support at home, or surgical intervention.