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Garside T, Stanford R, Flower O, Li T, Dababneh E, Hammond N, Bass F, Middleton J, Tang J, Ball J, Delaney A. Acute assessment of spinal cord injury in New South Wales: A retrospective study of current practice in two spinal cord injury referral centers. J Spinal Cord Med 2023:1-8. [PMID: 37707355 DOI: 10.1080/10790268.2023.2247625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Interventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW). METHODS Patients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics. RESULTS Only 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU). CONCLUSIONS Documentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.
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Affiliation(s)
- Tessa Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Ralph Stanford
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Trent Li
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Edward Dababneh
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Frances Bass
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - James Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Jonathan Tang
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Jonathan Ball
- Department of Neurosurgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
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Xiang W, Cao H, Tao H, Jin L, Luo Y, Tao F, Jiang T. Applications of chitosan-based biomaterials: From preparation to spinal cord injury neuroprosthetic treatment. Int J Biol Macromol 2023; 230:123447. [PMID: 36708903 DOI: 10.1016/j.ijbiomac.2023.123447] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/04/2022] [Accepted: 01/24/2023] [Indexed: 01/27/2023]
Abstract
Spinal cord injury (SCI)-related disabilities are a serious problem in the modern society. Further, the treatment of SCI is highly challenging and is urgently required in clinical practice. Research on nerve tissue engineering is an emerging approach for improving the treatment outcomes of SCI. Chitosan (CS) is a cationic polysaccharide derived from natural biomaterials. Chitosan has been found to exhibit excellent biological properties, such as nontoxicity, biocompatibility, biodegradation, and antibacterial activity. Recently, chitosan-based biomaterials have attracted significant attention for SCI repair in nerve tissue engineering applications. These studies revealed that chitosan-based biomaterials have various functions and mechanisms to promote SCI repair, such as promoting neural cell growth, guiding nerve tissue regeneration, delivering nerve growth factors, and as a vector for gene therapy. Chitosan-based biomaterials have proven to have excellent potential for the treatment of SCI. This review aims to introduce the recent advances in chitosan-based biomaterials for SCI treatment and to highlight the prospects for further application.
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Affiliation(s)
- Wei Xiang
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Hui Cao
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Hai Tao
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Lin Jin
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Yue Luo
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Fenghua Tao
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan University, Wuhan 430060, China.
| | - Ting Jiang
- Department of Neurological Rehabilitation, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
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Shen Y, Cao X, Lu M, Gu H, Li M, Posner DA. Current treatments after spinal cord injury: Cell engineering, tissue engineering, and combined therapies. SMART MEDICINE 2022; 1:e20220017. [PMID: 39188731 PMCID: PMC11235943 DOI: 10.1002/smmd.20220017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/20/2022] [Indexed: 08/28/2024]
Abstract
Both traumatic and non-traumatic spinal cord injuries (SCIs) can be categorized as damages done to our central nervous system (CNS). The patients' physical and mental health may suffer greatly because of traumatic SCI. With the widespread use of motor vehicles and increasingly aged population, the occurrence of SCI is more frequent than before, creating a considerable burden to global public health. The regeneration process of the spinal cord is hampered by a series of events that occur following SCI like edema, hemorrhage, formation of cystic cavities, and ischemia. An effective strategy for the treatment of SCI and functional recovery still has not been discovered; however, recent advances have been made in bioengineering fields that therapies based on cells, biomaterials, and biomolecules have proved effective in the repair of the spinal cord. In the light of worldwide importance of treatments for SCI, this article aims to provide a review of recent advances by first introducing the physiology, etiology, epidemiology, and mechanisms of SCI. We then put emphasis on the widely used clinical treatments and bioengineering strategies (cell-based, biomaterial-based, and biomolecule-based) for the functional regeneration of the spinal cord as well as challenges faced by scientists currently. This article provides scientists and clinicians with a comprehensive outlook on the recent advances of preclinical and clinical treatments of SCI, hoping to help them find keys to the functional regeneration of SCI.
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Affiliation(s)
- Yingbo Shen
- State Key Laboratory of BioelectronicsSchool of Biological Science and Medical EngineeringSoutheast UniversityNanjingChina
| | - Xinyue Cao
- State Key Laboratory of BioelectronicsSchool of Biological Science and Medical EngineeringSoutheast UniversityNanjingChina
| | - Minhui Lu
- State Key Laboratory of BioelectronicsSchool of Biological Science and Medical EngineeringSoutheast UniversityNanjingChina
| | - Hongcheng Gu
- State Key Laboratory of BioelectronicsSchool of Biological Science and Medical EngineeringSoutheast UniversityNanjingChina
| | - Minli Li
- State Key Laboratory of BioelectronicsSchool of Biological Science and Medical EngineeringSoutheast UniversityNanjingChina
| | - David A. Posner
- Molecular Immunity UnitCambridge Institute of Therapeutic Immunology and Infectious DiseasesDepartment of MedicineUniversity of CambridgeCambridgeUK
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McRae J, Smith C, Beeke S, Emmanuel A. Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus. Disabil Rehabil 2022; 44:8311-8324. [PMID: 34904488 DOI: 10.1080/09638288.2021.2012607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE International multi-professional expert consensus was sought to develop best practice recommendations for clinical management of patients following cervical spinal cord injury with oropharyngeal dysphagia and associated complications. Additionally, risk factors for dysphagia were identified to support the development of a screening tool. MATERIALS AND METHODS A two-round Delphi study was undertaken with a 27-member panel of expert professionals in cervical spinal cord injury and complex dysphagia. They rated 85 statements across seven topic areas in round one, using a five-point Likert scale with a consensus set at 70%. Statements not achieving consensus were revised for the second round. Comparative group and individual feedback were provided at the end of each round. RESULTS Consensus was achieved for 50 (59%) statements in round one and a further 12 (48%) statements in round two. Recommendations for best practice were agreed for management of swallowing, respiratory function, communication, nutrition and oral care. Twelve risk factors for dysphagia were identified for components of a screening tool. CONCLUSIONS Best practice recommendations support wider clinical management to prevent complications and direct specialist care. Screening for risk factors allows early dysphagia identification with the potential to improve clinical outcomes. Further evaluation of the impact of these recommendations is needed.Implications for RehabilitationDysphagia is an added complication following cervical spinal cord injury (cSCI) affecting morbidity, mortality and quality of life.Early identification of dysphagia risk allows focused interventions that reduce associated nutritional and respiratory impairments.Best practice recommendations based on expert consensus provide a baseline of appropriate interventions, in the absence of empirical evidence.A multi-professional approach to rehabilitation encourages a consistent and coordinated approach to care across acute and rehabilitation settings.
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Affiliation(s)
- Jackie McRae
- Centre for Allied Health, St George's University of London, London, UK
| | - Christina Smith
- Division of Psychology and Language Science, University College London, London, UK
| | - Suzanne Beeke
- Division of Psychology and Language Science, University College London, London, UK
| | - Anton Emmanuel
- Division of Medicine, University College London, London, UK
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Borg DN, Bon JJ, Foster MM, Lakhani A, Kendall M, Geraghty T. Healthcare services for people with acquired disability in South-East Queensland, Australia: Assessing potential proximity and its association with service obstacles. SSM Popul Health 2022; 19:101209. [PMID: 36052155 PMCID: PMC9424535 DOI: 10.1016/j.ssmph.2022.101209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/18/2022] [Accepted: 08/14/2022] [Indexed: 11/19/2022] Open
Abstract
This study described access potential in South-East Queensland, to healthcare services commonly used by people with acquired disability; and investigated the association between service proximity and perceived service obstacles. First, we described accessibility by conducting a spatial analysis to create maps of potential accessibility to health services in South-East Queensland. Queensland statistical area level 2 (SA2) locations were combined with the residential locations of participants from a longitudinal cohort study involving people with ABI and SCI. The locations of selected health services of interest were identified from Health Direct's National Health Service Directory. Travel times via motor vehicle were modelled with Robust Gaussian Stochastic Process, to smoothly interpolate between the sparse time-to-service observations. Probabilistic predicted values were generated from the model and were used to construct service accessibility maps of South-East Queensland. Disability population data were used to identify SA2s with relatively low service access but a high disability population. Second, we examined perceived service obstacles, by investigating the relationship between potential access to services and perceived service obstacles was examined using data from 63 people with ABI or SCI discharged from the specialist state-wide rehabilitation services, located in South-East Queensland. Obstacles to accessing service in relation to resource availability, transportation and finances were collected three-months after discharge, using the Service Obstacle Scale. Travel times to the closest health service were computed for each individual and were compared to their Service Obstacle Scale responses. Access potential was highly variable, particularly for allied health services. We identified several low-access, high-disability population areas. These hotpots of poor access were generally to the north and west of greater Brisbane. Longer travel times to allied health services were associated with 260% higher odds of agreeing that resource availability was an obstacle to accessing services. Policy makers should be concerned with the hotspots of poor access identified. There was considerable variability in access potential, which was generally greater for allied health than medical specialist services. We highlighted low-access high disability population areas, which were generally in outer suburbia. Poorer potential access to allied health services was associated with resource availability being rated as an service obstacle. We did not find any evidence that proximity to allied health services was associated with transportation or finance obstacles.
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Affiliation(s)
- David N Borg
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, Australia.,School of Health Sciences and Social Work, Griffith University, Brisbane, Australia
| | - Joshua J Bon
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, Australia.,Australian Research Council Centre of Excellence for Mathematical and Statistical Frontiers, Brisbane, Australia.,School of Mathematical Sciences, Queensland University of Technology, St Lucia, Brisbane, Australia
| | - Michele M Foster
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, Australia.,School of Health Sciences and Social Work, Griffith University, Brisbane, Australia
| | - Ali Lakhani
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, Australia.,School of Health Sciences and Social Work, Griffith University, Brisbane, Australia.,La Trobe University, Melbourne, Australia
| | - Melissa Kendall
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, Australia.,Division of Rehabilitation, Princess Alexandra Hospital, Metro South Health Hospital and Health Service, Brisbane, Australia
| | - Timothy Geraghty
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, Australia.,Division of Rehabilitation, Princess Alexandra Hospital, Metro South Health Hospital and Health Service, Brisbane, Australia
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Sharwood LN, Whyatt D, Vaikuntam BP, Cheng CL, Noonan VK, Joseph AP, Ball J, Stanford RE, Kok MR, Withers SR, Middleton JW. A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study. BMC Health Serv Res 2021; 21:292. [PMID: 33794879 PMCID: PMC8015029 DOI: 10.1186/s12913-021-06235-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. METHODS This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. RESULTS Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. CONCLUSIONS Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.
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Affiliation(s)
- Lisa N Sharwood
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Reserve Road, St Leonards, NSW, 2065, Australia.
- University of New South Wales, Faculty of Medicine and Health, NSW Black Dog Institute, Sydney, Australia.
- University of Technology Sydney, Faculty of Engineering, Sydney, NSW, Australia.
- Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, VIC, Australia.
| | - David Whyatt
- University of Western Australia, (M706), 35 Stirling Highway, Perth, 6009, Australia
| | - Bharat P Vaikuntam
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Reserve Road, St Leonards, NSW, 2065, Australia
| | - Christiana L Cheng
- Praxis Spinal Cord Institute, 6400-818 W 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Vanessa K Noonan
- Praxis Spinal Cord Institute, 6400-818 W 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Anthony P Joseph
- Royal North Shore Hospital, Trauma Department, Reserve Road, St Leonards, NSW, 2065, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jonathon Ball
- Royal North Shore Hospital, Neurosurgery, St Leonards, NSW, 2065, Australia
| | - Ralph E Stanford
- Prince of Wales Hospital, Spinal Cord Injury Unit, Randwick, NSW, 2033, Australia
| | - Mei-Ruu Kok
- University of Western Australia, (M706), 35 Stirling Highway, Perth, 6009, Australia
| | - Samuel R Withers
- Australian Institute of Robotic Orthopaedics, Perth, Western Australia, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Reserve Road, St Leonards, NSW, 2065, Australia
- Agency for Clinical Innovation, NSW Health, Reserve Road, St Leonards, NSW, 2065, Australia
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McRae J, Smith C, Emmanuel A, Beeke S. The experiences of individuals with cervical spinal cord injury and their family during post-injury care in non-specialised and specialised units in UK. BMC Health Serv Res 2020; 20:783. [PMID: 32831066 PMCID: PMC7443811 DOI: 10.1186/s12913-020-05659-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with acute cervical spinal cord injury require specialised interventions to ensure optimal clinical outcomes especially for respiratory, swallowing and communication impairments. This study explores the experiences of post-injury care for individuals with cervical spinal cord injury and their family members during admissions in specialised and non-specialised units in the United Kingdom. METHODS Semi-structured interviews were undertaken with individuals with a cervical spinal cord injury and their family member, focussing on the experience of care across units. Eight people with spinal cord injury levels from C2 to C6, were interviewed in their current care settings. Six participants had family members present to support them. Interviews were audio-recorded and transcribed with data inputted into NVivo for thematic analysis. RESULTS The study identified six themes from the participant interviews that highlighted different experiences of care in non-specialised and specialised settings. A number of these were related to challenges with the system, whilst others were about the personal journey of recovery. The themes were titled as: adjustment, transitions, "the golden opportunity", "when you can't eat", communication, and "in the hands of the nurses and doctors". CONCLUSIONS Whilst participants reported being well cared for in non-specialised units, they felt that they did not receive specialist care and this delayed their rehabilitation. Participants were dependent on healthcare professionals for information and care and at times lost hope for recovery. Staff in non-specialised units require training and guidance to help provide support for those with dysphagia and communication difficulties, as well as reassurance to patients and families whilst they wait for transfer to specialised units.
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Affiliation(s)
- Jackie McRae
- Faculty of Health, Social Care and Education, Kingston and St Georges University of London, London, UK
| | - Christina Smith
- Division of Psychology and Language Science, University College London, London, WC1N 1PF UK
| | - Anton Emmanuel
- Division of Medicine, University College London, London, WC1E 6JF UK
| | - Suzanne Beeke
- Division of Psychology and Language Science, University College London, London, WC1N 1PF UK
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Use of an Errorless Learning Approach in a Person With Concomitant Traumatic Spinal Cord Injury and Brain Injury: A Case Report. J Neurol Phys Ther 2019; 42:102-109. [PMID: 29547485 DOI: 10.1097/npt.0000000000000218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Individuals with concomitant spinal cord injury and traumatic brain injury have cognitive deficits that may limit the ability to learn novel motor tasks necessary for functional independence. Errorless learning has been shown to improve cognitive task performance in persons with brain injury but little is known about its usefulness for improving novel motor task learning. CASE DESCRIPTION A 44-year-old man with traumatic spinal cord and brain injuries from a motor vehicle accident was admitted to an inpatient rehabilitation hospital. His spinal cord injury was classified as T4 American Spinal Injury Association Impairment Scale (AIS) A, and his cognitive status was level IV on the Ranchos Los Amigos Scale. Initially, the patient required maximal assistance from 2 clinicians to complete a slide board transfer, propelled his wheelchair 25 ft with minimal assistance, and scored 9/56 on the Function in Sitting Test. INTERVENTION The therapist applied traditional motor-learning approaches during the first 37 days of the patient's inpatient rehabilitation facility stay without meaningful gains in functional mobility. A subsequent change to errorless learning was made for the following 32 days until discharge. OUTCOMES After use of errorless learning, the patient performed novel mobility-related tasks of slide board transfers with minimal assistance and wheelchair propulsion without physical assistance up to 150 ft; the Function in Sitting Test score improved to 18/56. His sensorimotor system progressed to an AIS classification of AIS B, while his cognition emerged to a level V on the Ranchos Los Amigos Scale. DISCUSSION Errorless learning may have facilitated acquisition of novel transfer and mobility skills in this individual with dual diagnoses. This approach may have value for patients with neurologic conditions who have both motor and cognitive impairment.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A201).
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Sharwood LN, Joseph A, Guo C, Flower O, Ball J, Middleton JW. Heterogeneous emergency department management of published recommendation defined hypotension in patients with acute traumatic spinal cord injury: A multi-centre overview. Emerg Med Australas 2019; 31:967-973. [PMID: 30968575 DOI: 10.1111/1742-6723.13290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/20/2019] [Accepted: 03/02/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Evidence-based management for patients with acute traumatic spinal cord injury (TSCI) in the ED has a critical impact on long-term outcomes. Acute hypotension post-injury may compromise spinal cord perfusion and extend neurological damage. Published guidelines recommend mean arterial blood pressure (BP) maintenance between 85 and 90 mmHg for 7 days post-injury; the extent to which this is followed in Australia is unknown. METHODS Prospective observational study of patients ≥16 years with TSCI, treated at 48 hospitals across two Australian states. Mean arterial BPs were recorded in the Ambulance, and ED arrival and discharge. Patients' medical records documented treatment provided (intravenous fluids, vasopressors or both) for BP augmentation. Hypotension was defined as mean arterial BP <85 mmHg, per the American Association of Neurological Surgeons guidelines. RESULTS The 208 patients with TSCI in the present study were more likely to receive BP augmentation if they experienced direct transport to a Spinal Cord Service hospital (OR 5.57, 95% CI 2.32-10.11), had a cervical level injury (OR 2.32, 95% CI 1.01-5.5) or were hypotensive on ED arrival (OR 2.42, 95% CI 1.34-4.39). Of the 112 patients who were hypotensive, 71 (63.4%) received treatment for this; however, the majority (76%) remained hypotensive on discharge. CONCLUSION Hypotensive patients' post-TSCI experienced heterogeneous ED care discordant with published guidelines; varying by hospital type. Specialist care and more severe injury increased likelihood of guideline adherence. Lack of adherence may influence patient outcomes. Level 1 evidence is needed along with consistent guideline implementation and clinician training to likely improve TSCI management and outcomes.
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Affiliation(s)
- Lisa N Sharwood
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Joseph
- Trauma Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Cici Guo
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Flower
- Intensive Care Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jonathon Ball
- Department of Neurosurgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Vaikuntam BP, Middleton JW, McElduff P, Pearse J, Walsh J, Cameron ID, Sharwood LN. Assessing the impact of care pathways on potentially preventable complications and costs for spinal trauma patients: protocol for a data linkage study using cohort study and administrative data. BMJ Open 2018; 8:e023785. [PMID: 30413515 PMCID: PMC6231591 DOI: 10.1136/bmjopen-2018-023785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Traumatic spinal cord injuries have significant consequences both for the injured individual and the healthcare system, usually resulting in lifelong disability. Evidence has shown that timely medical and surgical interventions can lead to better patient outcomes with implicit cost savings. Potentially preventable secondary complications are therefore indicators of the effectiveness of acute care following traumatic injury. The extent to which policy and clinical variation within the healthcare service impact on outcomes and acute care costs for patients with traumatic spinal cord injury (TSCI) in Australia is not well described. METHODS AND ANALYSIS A comprehensive data set will be formed using record linkage to combine patient health and administrative records from seven minimum data collections (including costs), with an existing data set of patients with acute TSCI (Access to Care Study), for the time period June 2013 to June 2016. This person-level data set will be analysed to estimate the acute care treatment costs of TSCI in New South Wales, extrapolated nationally. Subgroup analyses will describe the associated costs of secondary complications and regression analysis will identify drivers of higher treatment costs. Mapping patient care and health service pathways of these patients will enable measurement of deviations from best practice care standards and cost-effectiveness analyses of the different pathways. ETHICS AND DISSEMINATION Ethics approval has been obtained from the New South Wales Population and Health Services Research Ethics Committee. Dissemination strategies include peer-reviewed publications in scientific journals and conference presentations to enable translation of study findings to clinical and policy audiences.
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Affiliation(s)
- Bharat Phani Vaikuntam
- Sydney Medical School - Northern, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, John Walsh Centre for Rehabilitation Research, Sydney, New South Wales, Australia
| | - James W Middleton
- Sydney Medical School - Northern, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, John Walsh Centre for Rehabilitation Research, Sydney, New South Wales, Australia
- Agency for Clinical Innovation, NSW Statewide Spinal Cord Injury Service, Sydney, New South Wales, Australia
| | | | - Jim Pearse
- Health Policy Analysis, Sydney, New South Wales, Australia
| | - John Walsh
- Sydney Medical School - Northern, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, John Walsh Centre for Rehabilitation Research, Sydney, New South Wales, Australia
| | - Ian D Cameron
- Kolling Institute, John Walsh Centre for Rehabilitation Research, Sydney, New South Wales, Australia
| | - Lisa Nicole Sharwood
- Sydney Medical School - Northern, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, John Walsh Centre for Rehabilitation Research, Sydney, New South Wales, Australia
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Cheng CL, Noonan VK, Shurgold J, Chen J, Rivers CS, Khaleghi Hamedani H, Humphreys S, Bailey CS, Attabib N, Mac Thiong JM, Goytan M, Paquet J, Fox R, Ahn H, Kwon BK, Fourney DR. Geomapping of Traumatic Spinal Cord Injury in Canada and Factors Related to Triage Pattern. J Neurotrauma 2017; 34:2856-2866. [PMID: 28325105 PMCID: PMC5652977 DOI: 10.1089/neu.2016.4929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Current research indicates that more than half of patients with traumatic spinal cord injury (tSCI) experience delays in transfer and receive surgery >24 h post-injury. The objectives of this study were to determine the geographic distribution of tSCI in Canada relative to specialized treatment facilities, to assess clinical and logistical factors at play for indirect admissions to those facilities, and to explore differences in current time to admission and simulated scenarios in an attempt to assess the potential impact of changes to triage protocols. This study included data from 876 patients with tSCI enrolled in the prospectively collected acute Rick Hansen Spinal Cord Injury Registry (RHSCIR) between January 1, 2010 and December 31, 2013 for whom there were data on the location of their injury. Patients transported directly to a RHSCIR acute facility were more likely to reach the facility within 1 h of injury, whereas those transported indirectly were more likely to arrive 7 h later. Considering the injuries occurring within 40 km of a RHSCIR acute facility (n = 323), 249 patients (77%) were directly and 74 (23%) were indirectly admitted. In the multivariate regression analysis, only older age and longer road distance remained significantly associated with being indirectly admitted to a RHSCIR facility. Compared with the current status, the median time to admission decreased by 20% (3.5 h) in the 100% direct admission scenario, and increased by 102% (8.9 h) in the 100% indirect admission scenario.
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Affiliation(s)
| | | | | | - Jason Chen
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Carly S Rivers
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | | | | | - Christopher S Bailey
- Division of Orthopaedics, Department of Surgery, Western University, London, Ontario, Canada
| | - Najmedden Attabib
- Horizon Health Network, Dalhousie University, Saint John, New Brunswick, Canada
| | - Jean-Marc Mac Thiong
- Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Michael Goytan
- Sections of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerome Paquet
- Sciences Neurologiques, Université Laval, Québec, Quebec, Canada
| | - Richard Fox
- Faculty of Medicine and Dentistry, Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Henry Ahn
- University of Toronto Spine Program, Toronto, Ontario, Canada
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daryl R Fourney
- Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada
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12
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Sharwood LN, Stanford R, Middleton JW, Burns B, Joseph A, Flower O, Rigby O, Ball J, Dhaliwal S. Improving care standards for patients with spinal trauma combining a modified e-Delphi process and stakeholder interviews: a study protocol. BMJ Open 2017; 7:e012377. [PMID: 28104707 PMCID: PMC5253580 DOI: 10.1136/bmjopen-2016-012377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent nationally, lacking in consensus across important components of care such as prehospital spinal immobilisation, timing of surgery and timeliness of transfer to specialist services. This study aims to develop 'expertly defined' and agreed standards of care across the majority of disciplines involved for these patients. METHODS AND ANALYSIS A modified e-Delphi process will be used to gain consensus for best practice across specific clinical early care areas for the patient with TSCI; invited participants will include clinicians across Australia with relevant and significant expertise. A rapid literature review will identify available evidence, including any current guidelines from 2005 to 2015. Level and strength of evidence identified, including areas of contention, will be used to formulate the first round survey questions and statements. Participants will undertake 2-3 online survey rounds, responding anonymously to questionnaires regarding care practices and indicating their agreement or otherwise with practice standard statements. Relevant key stakeholders, including patients, will also be interviewed face to face. ETHICS AND DISSEMINATION Ethics approval for this study was obtained by the NSW Population & Health Services Research Ethics Committee on 14 January 2016 (HREC/12/CIPHS/74). Seeking comprehensive understanding of how the variation in early care pathways and treatment can be addressed to achieve optimal patient outcomes and economic costs; the overall aim is the agreement to a consistent approach to the triage, treatment, transport and definitive care of acute TSCI victims. The agreed practice standards of care will inform the development of a Clinical Pathway with practice change strategies for implementation. These standards will offer a benchmark for state-wide and potentially national policy.
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Affiliation(s)
- Lisa N Sharwood
- Sydney Medical School Northern, The University of Sydney, Sydney, New South Wales, Australia
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ralph Stanford
- Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - James W Middleton
- Sydney Medical School Northern, The University of Sydney, Sydney, New South Wales, Australia
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
- State Spinal Cord Injury Service, NSW Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Brian Burns
- Sydney Medical School Northern, The University of Sydney, Sydney, New South Wales, Australia
- Greater Sydney Area Helicopter Emergency Medical Service, Sydney, New South Wales, Australia
| | - Anthony Joseph
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Oliver Flower
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Oran Rigby
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Greater Sydney Area Helicopter Emergency Medical Service, Sydney, New South Wales, Australia
- Institute for Trauma and Injury Management, NSW Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Jonathon Ball
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Shelly Dhaliwal
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
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13
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Salem N, Salem MY, Elmaghrabi MM, Elawady MA, Elawady MA, Sabry D, Shamaa A, Elkasapy AHH, Ibrhim N, Elamir A. Does vitamin C have the ability to augment the therapeutic effect of bone marrow-derived mesenchymal stem cells on spinal cord injury? Neural Regen Res 2017; 12:2050-2058. [PMID: 29323045 PMCID: PMC5784354 DOI: 10.4103/1673-5374.221163] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Methylprednisolone (MP) is currently the only drug confirmed to exhibit a neuroprotective effect on acute spinal cord injury (SCI). Vitamin C (VC) is a natural water-soluble antioxidant that exerts neuroprotective effects through eliminating free radical damage to nerve cells. Bone marrow mesenchymal stem cells (BMMSCs), as multipotent stem cells, are promising candidates in SCI repair. To evaluate the therapeutic effects of MP, VC and BMMSCs on traumatic SCI, 80 adult male rats were randomly divided into seven groups: control, SCI (SCI induction by weight-drop method), MP (SCI induction, followed by administration of 30 mg/kg MP via the tail vein, once every other 6 hours, for five times), VC (SCI induction, followed by intraperitoneal administration of 100 mg/kg VC once a day, for 28 days), MP + VC (SCI induction, followed by administration of MP and VC as the former), BMMSCs (SCI induction, followed by injection of 3 × 106 BMMSCs at the injury site), and BMMSCs + VC (SCI induction, followed by BMMSCs injection and VC administration as the former). Locomotor recovery was assessed using the Basso Mouse Scale. Injured spinal cord tissue was evaluated using hematoxylin-eosin staining and immunohistochemical staining. Expression of transforming growth factor-beta, tumor necrosis factor-alpha, and matrix metalloproteinase-2 genes was determined using real-time quantitative PCR. BMMSCs intervention better promoted recovery of nerve function of rats with SCI, mitigated nerve cell damage, and decreased expression of transforming growth factor-beta, tumor necrosis factor-alpha, and matrix metalloproteinase-2 genes than MP and/or VC. More importantly, BMMSCs in combination with VC induced more obvious improvements. These results suggest that VC can enhance the neuroprotective effects of BMMSCs against SCI.
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Affiliation(s)
- Nesrine Salem
- Department of Histology and Cell Biology, Faculty of Medicine, Banha University, Banha, Egypt
| | - Mohamed Y Salem
- Department of Histology and Cell Biology, Faculty of Medicine, Banha University, Banha, Egypt
| | | | - Moataz A Elawady
- Department of Neurosurgery, Faculty of Medicine, Banha University, Banha, Egypt
| | - Mona A Elawady
- Department of Community Medicine, Faculty of Medicine, Banha University, Banha, Egypt
| | - Dina Sabry
- Department of Medical Biochemistry, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ashraf Shamaa
- Department of Surgery and Radiology, Faculty of Veterinary Medicine, Cairo University, Giza, Egypt
| | | | - Noha Ibrhim
- Department of Medical Physiology, Faculty of Medicine, Banha University, Banha, Egypt
| | - Azza Elamir
- Department of Medical Biochemistry, Faculty of Medicine, El Fayoum University, Egyptian, Egypt
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