International Standards for Neurological Classification of Spinal Cord Injury: cases with classification challenges

The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is routinely used to determine the levels of injury and to classify the severity of the injury. Questions are often posed to the International Standards Committee of the American Spinal Injury Association regarding the classification. The committee felt that disseminating some of the challenging questions posed, as well as the responses, would be of benefit for professionals utilizing the ISNCSCI. Case scenarios that were submitted to the committee are presented with the responses as well as the thought processes considered by the committee members. The importance of this documentation is to clarify some points as well as update the SCI community regarding possible revisions that will be needed in the future based upon some rules that require clarification.

A soft x-ray transmission grating imaging-spectrometer for the National Ignition Facility

A soft x-ray transmission grating spectrometer has been designed for use on high energy-density physics experiments at the National Ignition Facility (NIF); coupled to one of the NIF gated x-ray detectors it records 16 time-gated spectra between 250 and 1000 eV with 100 ps temporal resolution. The trade-off between spectral and spatial resolution leads to an optimized design for measurement of emission around the peak of a 100-300 eV blackbody spectrum. Performance qualification results from the NIF, the Trident Laser Facility and vacuum ultraviolet beamline at the National Synchrotron Light Source, evidence a <100 μm spatial resolution in combination with a source-size limited spectral resolution that is <10 eV at photon energies of 300 eV.

Hard x-ray (>100 keV) imager to measure hot electron preheat for indirectly driven capsule implosions on the NIF

We have fielded a hard x-ray (>100 keV) imager with high aspect ratio pinholes to measure the spatially resolved bremsstrahlung emission from energetic electrons slowing in a plastic ablator shell during indirectly driven implosions at the National Ignition Facility. These electrons are generated in laser plasma interactions and are a source of preheat to the deuterium-tritium fuel. First measurements show that hot electron preheat does not limit obtaining the fuel areal densities required for ignition and burn.

South pole bang-time diagnostic on the National Ignition Facility (invited)

The south pole bang-time diagnostic views National Ignition Facility (NIF) implosions through the lower Hohlraum laser entrance hole to measure the time of peak x-ray emission (peak compression) in indirect-drive implosions. Five chemical-vapor-deposition diamond photoconductive detectors with different filtrations and sensitivities record the time-varying x rays emitted by the target. Wavelength selecting highly oriented pyrolytic graphite crystal mirror monochromators increase the x-ray signal-to-background ratio by filtering for 11-keV emission. Diagnostic timing and the in situ temporal instrument response function are determined from laser impulse shots on the NIF. After signal deconvolution and background removal, the bang time is determined to 45-ps accuracy. The x-ray "yield" (mJ∕sr∕keV at 11 keV) is determined from the time integral of the corrected peak signal.

Extending the clinical research network approach to all of healthcare

The development of Clinical Research Networks (CRN) has been central to the work conducted by Health Departments and research funders to promote and support clinical research within the NHS in the UK. In England, the National Institute for Health Research has supported the delivery of clinical research within the NHS primarily through CRN. CRN provide the essential infrastructure within the NHS for the set up and delivery of clinical research within a high-quality peer-reviewed portfolio of studies. The success of the National Cancer Research Network is summarized in Chapter 5. In this chapter progress in five other topics, and more recently in primary care and comprehensively across the NHS, is summarized. In each of the 'topic-specific' networks (Dementias and Neurodegenerative Diseases, Diabetes, Medicines for Children, Mental Health, Stroke) there has been a rapid and substantial increase in portfolios and in the recruitment of patients into studies in these portfolios. The processes and the key success factors are described. The CRN have worked to support research supported by pharmaceutical, biotechnology and medical device companies and there has been substantial progress in improving the speed, cost and delivery of these 'industry' studies. In particular, work to support the increased speed of set up and delivery of industry studies, and to embed this firmly in the NHS, was explored in the North West of England in an Exemplar Programme which showed substantial reductions in study set-up times and improved recruitment into studies and showed how healthcare (NHS) organizations can overcome delays in set up times when they actively manage the process. Seven out of 20 international studies reported that the first patient to be entered anywhere in the world was from the UK. In addition, the CRN have supported research management and governance, workforce development and clinical trials unit collaboration and coordination. International peer reviews of all of the CRN have been positive and resulted in the continuation of the system for a further 5 years in all cases.

Physical activity status and postprandial lipaemia in older adults

Physical activity-induced lowering of postprandial lipaemia is short-lived. However, little is known regarding the role of physical activity status on postprandial lipaemia. The purpose of the present study was to compare postprandial triacylglycerol concentrations in active and inactive older adults. A total of 26 older adults (aged 69.8±0.9 years, mean±SEM; 10 male and 16 female) were analysed in a cross-sectional design. Based on accelerometer data, participants were divided into either the active group (≥150 min/week of moderate-intensity physical activity, N=15) or the inactive group (<150 min/week of moderate-intensity physical activity, N=11). After a 48-h period of physical activity avoidance and a 10-h overnight fast, participants consumed a test meal of moderate fat content (35%). Capillary blood samples were collected in the fasted state and at 2, 4, and 6 h postprandially. After adjusting for fasting triacylglycerol concentrations, body mass, body mass index and waist circumference, postprandial capillary triacylglycerol concentrations were significantly lower in the active than inactive group ( P=0.046). These findings demonstrate that regular physical activity lowers postprandial lipaemia independent of the acute effects of physical activity in older adults.

Application of UKHCDO 2004 guidelines in type 1 von Willebrand Disease--a single centre paediatric experience of the implications of altered or removed diagnosis

Diagnosis of type I von Willebrand Disease (VWD) can be challenging. In 2004, the United Kingdom Haemophilia Centre Doctors' Organisation (UKHCDO) proposed more stringent diagnostic criteria to replace the 1995 guidelines. To determine the true number of cases of type 1 VWD in a single paediatric centre, the 2004 UKHCDO Guideline for the diagnosis of VWD was used to evaluate 114 patients on our type 1 VWD register. Clinical and laboratory data were collected and analysed to see whether they met the criteria for type 1 VWD. Only 8% remained on the type 1 VWD register. 18% have been classified as 'possible type 1 VWD'. Twenty five surgical procedures have since been performed on patients from the group in which the diagnosis was removed without any haemostatic support or bleeding complications. Reaction to the removal of the VWD diagnosis or delivery of an alternative diagnosis was positive for most patients and families. This study is the first to assess the impact of the 2004 UKHCDO Guidelines on the diagnosis of VWD. It provides evidence that the prevalence of type 1 VWD may actually be closer to that of haemophilia instead of the previously reported 1-3% of the general population. We propose that all centres should review their patients with a diagnosis of VWD to revalidate this disease that claims to be our most common inherited bleeding disorder.

Recommendations for translation and reliability testing of International Spinal Cord Injury Data Sets

OBJECTIVE

To provide recommendations regarding translation and reliability testing of International Spinal Cord Injury (SCI) Data Sets.

SETTING

The Executive Committee for the International SCI Standards and Data Sets.

RECOMMENDATIONS

Translations of any specific International SCI Data Set can be accomplished by translation from the English version into the target language, and be followed by a back-translation into English, to confirm that the original meaning has been preserved. Another approach is to have the initial translation performed by translators who have knowledge of SCI, and afterwards controlled by other person(s) with the same kind of knowledge. The translation process includes both language translation and cultural adaptation, and therefore shall not be made word for word, but will strive to include conceptual equivalence. At a minimum, the inter-rater reliability should be tested by no less than two independent observers, and preferably in multiple countries. Translations must include information on the name, role and background of everyone involved in the translation process, and shall be dated and noted with a version number.

CONCLUSION

By following the proposed guidelines, translated data sets should assure comparability of data acquisition across countries and cultures. If the translation process identifies irregularities or misrepresentation in either the original English version or the target language, the working group for the particular International SCI Data Set shall revise the data set accordingly, which may include re-wording of the original English version in order to accomplish a compromise in the content of the data set.

Characterization of neurological recovery following traumatic sensorimotor complete thoracic spinal cord injury

STUDY DESIGN

Retrospective, longitudinal analysis of sensory, motor and functional outcomes from individuals with thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI).

OBJECTIVES

To characterize neurological changes over the first year after traumatic thoracic sensorimotor complete SCI.

METHODS

A dataset of 399 thoracic complete SCI subjects from the European Multi-center study about SCI (EMSCI) was examined for neurological level, sensory levels and sensory scores (pin-prick and light touch), lower extremity motor score (LEMS), ASIA Impairment Scale (AIS) grade, and Spinal Cord Independence Measure (SCIM) over the first year after SCI.

RESULTS

AIS grade conversions were limited. Sensory scores exhibited minimal mean change, but high variability in both rostral and caudal directions. Pin-prick and light touch sensory levels, as well as neurological level, exhibited minor changes (improvement or deterioration), but most subjects remained within one segment of their initial injury level after 1 year. Recovery of LEMS occurred predominantly in subjects with low thoracic SCI. The sensory zone of partial preservation (ZPP) had no prognostic value for subsequent recovery of sensory levels or LEMS. However, after mid or low thoracic SCI, ≥3 segments of sensory ZPP correlated with an increased likelihood for AIS grade conversion.

CONCLUSION

The data suggest that a sustained deterioration of three or more thoracic sensory levels or loss of upper extremity motor function are rare events and may be useful for tracking the safety of a therapeutic intervention in early phase acute SCI clinical trials, if a significant proportion of study subjects exhibit such an ascent.

Perceived Muscle Soreness in Recreational Female Runners

The purpose of this study was to determine if rating of perceived exertion correlated with perceived muscle soreness during delayed onset muscle soreness (DOMS) in female runners. This study examined the pre and post running economy measures and perceived muscle soreness before and after a 30-min downhill run (DHR) at -15% grade and 70% of the subjects predetermined maximum oxygen uptake (VO2 peak). Six female recreational runners (mean age = 24.5) performed level running at 65%, 75%, and 85% of their VO2 peak prior to DHR (baseline economy runs), as well as, immediately following and 4 successive days after the DHR.

RESULTS

Subjective response related to perceived muscle soreness increased significantly from a mean of 2 (pre DHR) to 62 (2 days post DHR) on a scale of 1-100. Creatine kinase levels and oxygen consumption increased post DHR compared to pre DHR. Rating of perceived exertion did not change between the economy runs performed prior to or at any point after the DHR.

CONCLUSION

Perceived muscle soreness is a better tool than the RPE scale to monitor exercise intensity for recreational female runners during periods of DOMS and running economy is adversely affected by DOMS.