Study design: Retrospective cohort studyObjectives: To identify independent risk factors associated with community-associated multidrug-resistant Psedomonas aeruginosa (MDRPA) in a population of veterans with spinal cord injury and disorders (SCI/D).Setting: A total of 127 Veterans Affairs healthcare facilities.Methods: Laboratory results from 1 January 2012 to 31 December 2013 were collected, and MDRPA cultures were compared with non-MDRPA cultures.Results: One thousand four hundred forty-one cultures were collected from Veterans with SCI/D, including 227 cultures with MDRPA isolates. Characteristics associated with an increased odds of MDRPA include age 50-64 (adjusted odds ratio (aOR) = 1.80, 95% confidence interval (CI) = 1.13-2.87), MDRPA culture in the past 365 days (aOR = 9.12, 95% CI = 5.88-14.15) and carbapenem exposure in the past 90 days (aOR = 2.56, 95% CI = 1.35-4.87). In contrast, paraplegia was associated with a 53% decreased odds of MDRPA compared with those with tetraplegia (aOR = 0.47, 95% CI = 0.32-0.69).Conclusions: Risk factors for community-associated MDRPA include prior history of MDRPA and exposure to carbapenems. Awareness of these factors is important for targeted prevention and treatment of MDRPA in patients with SCI/D.

Study design: Secondary analysis of prospectively collected observational data assessing the safety of an autonomic dysreflexia (AD) management protocol. Objectives: To estimate the time to onset of action, time to full clinical effect (sustained systolic blood pressure (SBP) <160 mm Hg) and effectiveness of nitroglycerin ointment at lowering blood pressure for patients with spinal cord injuries experiencing AD. Setting: US Veterans Affairs inpatient spinal cord injury (SCI) unit. Methods: Episodes of AD recalcitrant to nonpharmacologic interventions that were given one to two inches of 2% topical nitroglycerin ointment were recorded. Pharmacodynamics as above and predictive characteristics (through a mixed multivariate logistic regression model) were calculated. Results: A total of 260 episodes of pharmacologically managed AD were recorded in 56 individuals. Time to onset of action for nitroglycerin ointment was 9–11 min. Time to full clinical effect was 14–20 min. Topical nitroglycerin controlled SBP <160 mm Hg in 77.3% of pharmacologically treated AD episodes with the remainder requiring additional antihypertensive medications. A multivariate logistic regression model was unable to identify statistically significant factors to predict which patients would respond to nitroglycerin ointment (odds ratios 95% confidence intervals 0.29–4.93). The adverse event rate, entirely attributed to hypotension, was 3.6% with seven of the eight events resolving with close observation alone and one episode requiring normal saline. Conclusions: Nitroglycerin ointment has a rapid onset of action and time to full clinical effect with high efficacy and relatively low adverse event rate for patients with SCI experiencing AD.

•The first mammalian enzyme activity using polyphosphate as a phosphorylation substrate.•A polyphosphate dependent glucokinase with kinetics similar to human glucokinase.•Further evidence of discreet substrate specificity of hexokinases.•A possible evolutionary link between polyphosphate and ATP utilization.

Clinical risk factors for fracture were explored among Veterans with a spinal cord injury. At the end of 11 years of follow-up, the absolute risk of fracture was approximately 20 %. Among the clinical and SCI-related factors explored, a prior history of fracture was strongly associated with incident fracture.

Study design: Retrospective review of a clinical database. Objectives: To examine treatment modalities of incident appendicular fractures in men with chronic SCI and mortality outcomes by treatment modality. Setting: United States Veterans Health Administration Healthcare System. Methods: This was an observational study of 1979 incident fractures that occurred over 6 years among 12 162 male veterans with traumatic SCI of at least 2 years duration from the Veterans Health Administration (VA) Spinal Cord Dysfunction Registry. Treatment modalities were classified as surgical or nonsurgical treatment. Mortality outcomes at 1 year following the incident fracture were determined by treatment modality. Results: A total of 1281 male veterans with 1979 incident fractures met inclusion criteria for the study. These fractures included 345 (17.4%) upper-extremity fractures and 1634 (82.6%) lower-extremity fractures. A minority of patients (9.4%) were treated with surgery. Amputations and disarticulations accounted for 19.7% of all surgeries (1.3% of all fractures), and the majority of these were done more than 6 weeks following the incident fracture. There were no significant differences in mortality among men with fractures treated surgically compared with those treated nonsurgically. Conclusions: Currently, the majority of appendicular fractures in male patients with chronic SCI are managed nonsurgically within the VA health-care system. There is no difference in mortality by type of treatment.

Study Design: Validation study. Objectives: To describe the development and validation of a computerized application of the international standards for neurological classification of spinal cord injury (ISNCSCI). Setting: Data from acute and rehabilitation care. Methods: The Rick Hansen Institute-ISNCSCI Algorithm (RHI-ISNCSCI Algorithm) was developed based on the 2011 version of the ISNCSCI and the 2013 version of the worksheet. International experts developed the design and logic with a focus on usability and features to standardize the correct classification of challenging cases. A five-phased process was used to develop and validate the algorithm. Discrepancies between the clinician-derived and algorithm-calculated results were reconciled. Results: Phase one of the validation used 48 cases to develop the logic. Phase three used these and 15 additional cases for further logic development to classify cases with ‘Not testable’ values. For logic testing in phases two and four, 351 and 1998 cases from the Rick Hansen SCI Registry (RHSCIR), respectively, were used. Of 23 and 286 discrepant cases identified in phases two and four, 2 and 6 cases resulted in changes to the algorithm. Cross-validation of the algorithm in phase five using 108 new RHSCIR cases did not identify the need for any further changes, as all discrepancies were due to clinician errors. The web-based application and the algorithm code are freely available at www.isncscialgorithm.com . Conclusion: The RHI-ISNCSCI Algorithm provides a standardized method to accurately derive the level and severity of SCI from the raw data of the ISNCSCI examination. The web interface assists in maximizing usability while minimizing the impact of human error in classifying SCI. Sponsorship: This study is sponsored by the Rick Hansen Institute and supported by funding from Health Canada and Western Economic Diversification Canada.

Study design: Cross-sectional survey of veterans with spinal cord injuries and disorders (SCI/D). Objectives: To describe sleep dysfunction (independent of sleep apnea) in persons with traumatic and non-traumatic SCI/D, and to examine characteristics and health outcomes independently associated with sleep dysfunction unrelated to sleep apnea. Setting: Seven Veterans Affairs SCI care facilities in the United States. Methods: Mailed cross-sectional survey with follow-up calls completed by end of 2008. Bivariate analyses to compare measures outcomes in persons with SCI/D who were dysfunctional sleepers vs those who were not. Multivariate logistic regression used to identify variables independently associated with dysfunctional sleep in veterans with SCI/D. Results: Overall, 49% of the sample had sleep dysfunction unrelated to sleep apnea. In this subgroup, bivariate analyses showed that a greater proportion of dysfunctional sleepers than non-dysfunctional sleepers were current smokers, had problems with drinking alcohol, hypertension, asthma, chronic obstructive pulmonary disease (COPD) and problematic weight gain. Variables independently associated with higher odds of dysfunctional sleep included white race, being a current smoker, problems with drinking alcohol, asthma, COPD and problematic weight gain. Conclusion: Consistent with epidemiological evidence for the general population, we found significant associations of sleep dysfunction with weight gain, smoking, alcohol misuse and select chronic conditions (COPD, asthma). Sustained sleep dysfunction may contribute to health deterioration and mortality, highlighting the need to address the high prevalence of sleep dysfunction (independent of sleep apnea) in persons with SCI/D. In particular, efforts aimed at modifying problematic weight gain, alcohol misuse and smoking are warranted in this cohort to improve sleep.

Study Design: A retrospective cohort study. Objective: Health-care-associated (HCA) bloodstream infection (BSI) has been shown to be a distinct epidemiologic category in the general adult population, but few studies have examined specific patient populations. The objective of this study was to assess characteristics associated with BSI that occurred in the hospital (hospital-acquired, HA BSI), from health-care contact outside the hospital (HCA BSI) or in the community (community-acquired, CA BSI) in veterans with spinal cord injury and disorder (SCI&D). Setting: Two United States Department of Veterans Affairs hospitals. Methods: All patients with SCI&D with a positive blood culture admitted to study hospitals over a 7-year period (1 October 1997 to 30 September 2004). Demographics, medical characteristics and causative organisms were collected. Results: Four hundred and thirteen episodes of BSI occurred in 226 patients, with a rate of 7.2 BSI episodes per 100 admissions: 267 (64.7%) were HA BSI, 110 (26.6%) were HCA BSI and 36 (8.7%) were CA BSI. Antibiotic resistance was more common in those with HA BSI (65.5%) compared with that in those with HCA (49.1%, P =0.001) and CA BSI (22.2%, P <0.0001). Methicillin resistance in Staphylococcus aureus was highly prevalent; HA BSI (84.5%), HCA BSI (60.6%) and CA BSI (33.3%). Conclusion: HCA BSI comprises one-quarter of all BSIs in hospitalized patients with SCI&D. Although those with HCA and CA BSI share similarities, several differences in medical characteristics and causal microorganism are noted. Treatment and management strategies for HCA and CA infections need to vary.

Metabolic acidosis is a common complication of severe malaria caused by Plasmodium falciparum. The factors contributing to the acidosis were assessed in 62 children with severe falciparum malaria (cases) and in 29 control children who had recently recovered from mild or moderate malaria. The acidosis was largely caused by the accumulation of both lactic and 3-hydroxybutyric acids. The determinants of oxygen release to the tissues were also examined; although there was no difference between cases and controls in respect of 2,3-bisphosphoglycerate and mean corpuscular hemoglobin concentration, there was a marked increase in P(50) in the cases, caused by pyrexia, low pH, and base deficit. There was substantial relative or actual hypoglycemia in many cases. The relationship of these observations to therapeutic strategy is discussed.

Weaver FM, Smith B, Evans CT, Kurichi JE, Patel N, Kapur VK, Burns SP: Outcomes of outpatient visits for acute respiratory illness in veterans with spinal cord injuries and disorders. Am J Phys Med Rehabil 2006;85:718–726. Objective:Respiratory complications are a leading cause of death in persons with spinal cord injuries and disorders (SCI&D). We examined same-day and 60-day hospitalizations and 60-day mortality after acute respiratory illness (ARI) outpatient visits. Design:A longitudinal study was conducted of 8775 ARI visits in the Veterans Health Administration (VA) (October. 1997–September 2002) by persons with SCI&D. ARIs included upper respiratory infections (URI), acute bronchitis, pneumonia, and influenza (P&I). Results:URIs accounted for almost half of all (49%) visits. A total of 14.9% of patients with ARIs were hospitalized the same day; 30.8% were hospitalized within 60 days. Predictors of hospitalization included diagnosis of either P&I or acute bronchitis, comorbid illness, level of injury, age, and VA SCI center visit. Overall 60-day mortality was 2.9% but was 7.9% for pneumonia. Mortality was related to diagnosis (P&I: odds ratio [OR] = 9.80, 95% confidence interval [CI]: 6.27–13.33; acute bronchitis: OR = 2.00, 95% CI: 1.08–2.93), age (65+: OR = 3.96, 95% CI: 2.23–5.70), and comorbid conditions (OR = 1.94, 95% CI: 1.43–2.46). Conclusions:P&I and acute bronchitis were associated with increased VA hospitalization and mortality rates. The case fatality rate for pneumonia is higher for SCI&D than the general population. Level of injury predicted hospitalization but not death. Efforts to improve prevention and treatment of ARIs in persons with SCI&D are needed.

Nyirenda et al. present compelling new evidence on the mechanism of fetal programming of gluconeogenesis by glucocorticoid administration during the last third of pregnancy in rats [1], a study that is commented on by McCurdy and Friedman [2]. Nyirenda et al. focus on a fluxgenerating enzyme of gluconeogenesis (phosphoenolpyruvate carboxykinase [PCK]) and the factors involved in its transcription, showing how PCK mRNA and that of its controlling transcription factors are localised within the hepatic acinus. However, this picture is incomplete. It is known that under normal conditions gluconeogenesis is mainly periportal, and about 24% of the new glucose formed is re-taken up in the perivenous cells, which are rich in the enzyme glucokinase. In the adult offspring of rat dams subjected to restricted protein intake during pregnancy and lactation, the perivenous uptake of glucose is much decreased, and the activity of total glucokinase (both free and bound to glucokinase regulatory protein in the nucleus) is greatly reduced [3, 4], leading eventually to glucose intolerance–a possible model of type 2 diabetes in man. Glucokinase transcription, however, is unchanged in these programmed offspring, suggesting an effect on nucleo-cytoplasmic transport of glucokinase, which resides in the nucleus in the starved state but translocates to the cytosol postprandially. The difficulty in attributing control of gluconeogenesis to transcriptional events is that they are too slow [4] to provide the rapid switch-off of hepatic glucose output and the hepatic storage of glucose as glycogen seen in the postprandial state. A further effect of rats fetally programmed by maternal protein restriction is that the hepatic acini are enlarged to about twice the normal volume. Large lobules are also seen in pregnancy and in regenerating liver after partial hepatectomy in the rat [5, 6]. The consequences of this enlargement are unknown but it would be of interest to determine whether the same enlargement occurs in animals fetally programmed by glucocorticoids.

Objectives: To determine (1) the variability of annual creatinine clearance (C-Cr) testing for subjects with chronic spinal cord injury (SCI) and (2) whether decisions to change neurogenic bladder management are made based on C-Cr. measurements.Design: Retrospective chart review.Setting: Inpatient Veterans Affairs SCI unit.Participants: The medical records of 70 men were consecutively selected for review from among 664 veterans enrolled in the SCI clinic. All patient charts had to have at least 5 C-Cr tests performed within 10 years preceding the review.Interventions: Not applicable.Main Outcome Measures: Development of renal insufficiency and change in medical or bladder management of the patient, based on the results of the C-Cr test.Results: For individual patients, the results of 24-hour C-Cr were highly variable from 1 evaluation to the next; the within-subject standard deviation (SD) for C-Cr was 25.9mL/min. The within-subject SD for serum creatinine was 0.12mg/dL. For all comparisons of repeatability, variability, and reliability, serum creatinine was superior to C-Cr. No medical management decisions were made based on the result of the 24-hour creatinine clearance. Renal ultrasound results and postvoid bladder residuals were the major factors in changing medical management with regard to renal function preservation.Conclusions: The Cc, test has little value as a screening measure for renal disease in SCI patients because of its variability in serial testing.

BACKGROUND AND OBJECTIVES:Creatine supplementation improves muscle strength in some patient populations with neurologic disorders. The purpose of this study was to determine whether creatine supplementation improves muscle strength and endurance in weak upper limb muscles in persons with tetraplegia, and whether it improves function.METHODS:Outpatients with tetraplegia and mild wrist extensor weakness were randomized to receive either creatine or placebo in a double-blind crossover design. During creatine supplementation, participants were loaded with 10 g orally twice per day for 6 days, then maintained on 5 g daily until undergoing testing. Main outcome measures, performed at baseline, after placebo, and after creatine supplementation, included maximal voluntary wrist extensor isometric contraction strength (MVC), endurance times for 5 submaximal wrist extensor contractions, and the Grasp and Release Test for hand function.RESULTS:Eight individuals (7 men, 1 woman) with tetraplegia met inclusion criteria and completed all study phases. The mean age of participants was 48 years, and 7 of 8 had C6 motor level injuries. There were no significant differences in MVC, endurance times, or hand function for creatine vs placebo.CONCLUSION:Creatine does not improve MVC and endurance of weak wrist extensors and does not improve hand function in individuals with tetraplegia.

OBJECTIVE:To compare make and break techniques for hand-held dynamometry in persons with tetraplegia. We compared the interrater and intrarater reliability, the relative forces, and variability between examiner techniques.DESIGN:Two examiners with no previous hand-held dynamometry training performed hand-held dynamometry on the elbow flexors or extensors of 19 persons with upper limb weakness secondary to tetraplegia, using break and make techniques. Testing was performed in two sessions separated by 10 mins. Simultaneous recording from an electrogoniometer placed across the elbow was obtained for a subset of participants.RESULTS:Break and make techniques both showed intraclass correlation coefficients exceeding 0.9 for interrater and intrarater reliability. The maximum expected difference for 95% of repeated measurements was 3.5 kg, with hand-held dynamometry strength values that averaged 7-11 kg. Average break/make ratios ranged from 1.38 +/- 0.29 to 1.49 +/- 0.37. The electrogoniometric data showed that the two examiners used similar testing technique, and small variations in technique were not associated with significant differences in strength recordings.CONCLUSION:Make and break techniques for hand-held dynamometry both show high reliability over a short intersession period when performed by inexperienced examiners on weak elbow flexors and extensors.

OBJECTIVE:To determine whether documentation of a causative organism for community-acquired pneumonia (CAP) is associated with outcomes, including mortality and length of stay (LOS), in hospitalized veterans with spinal cord injuries and disorders (SCI&D).DESIGN:Retrospective cohort study.SETTING:Patients with SCI&D admitted with CAP to any Veterans Affairs medical center between September 1998 and October 2000.PARTICIPANTS:Hospital administrative data on 260 patients with SCI&D and a CAP diagnosis.INTERVENTIONS:Not applicable.MAIN OUTCOMES MEASURES:All-cause, 30-day mortality and hospital LOS.RESULTS:An organism was documented by International Classification of Diseases, 9th Revision , discharge codes in 24% of cases. Streptococcus pneumoniae and Pseudomonas aeruginosa accounted for 32% and 21%, respectively, of the identified bacterial pathogens. The overall mortality rate was 8.5%. No significant association was found between etiologic diagnosis of CAP and 30-day mortality. Lower mortality was associated with treatment at a designated SCI center (relative risk=.35; confidence interval, .12-.99). Pathogen-based CAP diagnosis was significantly associated with longer LOS (adjusted r 2 =.023, P =.024).CONCLUSIONS:There was no association between etiologic diagnosis of CAP and 30-day mortality among people with SCI&D. Documentation of CAP etiology was associated with the variance in LOS. Pneumococcal vaccination and antibiotic therapy with antipseudomonal activity may be particularly prudent in these patients given the high frequency of these pathogens among SCI&D patients with CAP.

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.

Objectives: To determine whether the muscle strength, as measured with break-technique handheld dynamomety (HHD), is dependent on the angular velocity achieved during testing and to compare reliability at different angular velocities.Design: Repeated-measures study. Participants underwent HHD by using make-technique (isometric) and break-technique (eccentric) dynamometry at 3 prespecified angular velocities. Elbow movement was recorded with an electrogoniometer. Setting: Inpatient spinal cord injury unit.Participants: Convenience sample of 20 persons with tetraplegia with weakness of elbow flexors or extensors.Interventions: Not applicable.Main Outcome Measures: Elbow angular velocity and muscle strength recorded during HHD.Results: With the break technique, angular velocities averaging 15 degrees, 33 degrees, and 55 degrees/s produced 16%, 30%, and 51% greater strength measurements, respectively, than velocities recorded by using the make technique (all P <.006 for comparisons between successive techniques). The intraclass correlation coefficient for intrarater reliability was.89 or greater for all testing techniques.Conclusions: Greater strength is recorded with faster angular velocities during HHD. Differences in angular velocity may explain the wide range previously reported for break- versus make-technique strength measurements. Variation in angular velocity is a potential source of variability in serial HHD strength measurements, and for this reason the make technique may be preferable.(c) 2005 by American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.