The impact of preinjury antithrombotic medication on hemostatic interventions in trauma patients

Purpose

The purpose of this study was to determine whether preinjury medication with antithrombotic agents was related to an increase in hemostatic interventions in patients with severe trauma without traumatic brain injury.

Additive Effect of Age on Disability for Individuals With Spinal Cord Injuries

Objective

To examine the additive effect of age on disability for adults with spinal cord injury (SCI).

Design

Prospective cohort study.

Setting

SCI Model Systems.

Participants

Individuals with SCI (median age at injury, 32y; range, 6–88y) with a discharge motor FIM score and at least 1 follow-up motor FIM score who also provided measures of other covariates (N=1660). Of the total sample, 79% were men, 72% were white, 16% had incomplete paraplegia, 33% had complete paraplegia, 30% had incomplete tetraplegia, and 21% had complete tetraplegia.

Interventions

Not applicable.

Main Outcome Measures

The primary study outcome was the motor subscale of the FIM. A mixed-models approach was used to examine the additive effect of age on disability for individuals with SCI.

Results

When controlling for motor FIM at discharge from rehabilitation, level and severity of injury, age at injury, sex, race, and the age × time interaction were not significant (P=.07). Age at the time of SCI was significantly associated with motor FIM (F_1,238=22.49, P<.001). Two sensitivity analyses found significant interactions for both age × time (P=.03, P=.02) and age × time-square (P=.01, P=.006) models. Trajectory of motor FIM scores is moderated slightly by age at the time of injury. The older participants were at the time of injury, the greater the curvature and the more rapid decline were found in later years.

Conclusions

These findings indicate that age moderately influences disability for some individuals with SCI: the older the age at the time of injury, the greater the influence age has on disability. The findings serve as an important empirical foundation for the evaluation and development of interventions designed to augment accelerated aging experienced by individuals with SCI.     

Interlimb Coordination During the Stance Phase of Gait in Subjects With Stroke

Objective

To analyze the relation between contralesional and ipsilesional limbs in subjects with stroke during step-to-step transition of walking.

Design

Observational, transversal, analytical study with a convenience sample.

Setting

Physical medicine and rehabilitation clinic.

Participants

Subjects (n=16) with poststroke hemiparesis with the ability to walk independently and healthy controls (n=22).

Interventions

Not applicable.

Main Outcome Measures

Bilateral lower limbs electromyographic activity of the soleus (SOL), gastrocnemius medialis, tibialis anterior, biceps femoris, rectus femoris, and vastus medialis (VM) muscles and the ground reaction force were analyzed during double-support and terminal stance phases of gait.

Results

The propulsive impulse of the contralesional trailing limb was negatively correlated with the braking impulse of the leading limb during double support (r=−.639, P=.01). A moderate functional relation was observed between thigh muscles (r=−.529, P=.035), and a strong and moderate dysfunctional relation was found between the plantar flexors of the ipsilesional limb and the vastus medialis of the contralesional limb, respectively (SOL-VM, r=−.80, P<.001; gastrocnemius medialis-VM, r=−.655, P=.002). Also, a functional moderate negative correlation was found between the SOL and rectus femoris muscles of the ipsilesional limb during terminal stance and between the SOL (r=−.506, P=.046) and VM (r=−.518, P=.04) muscles of the contralesional limb during loading response, respectively. The trailing limb relative impulse contribution of the contralesional limb was lower than the ipsilesional limb of subjects with stroke (P=.02) and lower than the relative impulse contribution of the healthy limb (P=.008) during double support.

Conclusions

The findings obtained suggest that the lower performance of the contralesional limb in forward propulsion during gait is related not only to contralateral supraspinal damage but also to a dysfunctional influence of the ipsilesional limb.     

The outcome of cancer patients with acute respiratory distress syndrome

Objective

The objective of the study is to determine the 28-day mortality of critically ill cancer patients with acute respiratory distress syndrome (ARDS).

Design

This is a retrospective cohort study of patients enrolled in the ARDS Network randomized controlled trials.

Results

A total of 2515 patients did not have cancer, and 116 patients had cancer. Patients with cancer were older (median, 61 vs 49 years; P < .0001), more critically ill (the median Acute Physiology and Chronic Health Evaluation III score without cancer comorbidity was 105 for the cancer group compared with 87 for those without cancer; P < 0.0001), and more likely to have pneumonia or sepsis as cause of acute lung injury (79.31% vs 62.70%; P = .0011). The overall mortality at day 28 was 25.7%. Patients with cancer had significantly higher mortality (55.2%) compared with those without cancer (24.3%) (P < .0001). The odds ratio for mortality from ARDS at 28 days for cancer patients was 2.54 (95% confidence interval [CI], 1.570-4.120). Acute Physiology and Chronic Health Evaluation III score and age were found to be significant predictors of outcome in cancer patients with odds ratio of 1.034 (95% CI, 1.007-1.062; P = .0135) and 1.075 (95% CI, 1.024-1.129, P = .0036), respectively.

Conclusions

Cancer patients with ARDS have a significantly higher risk of death compared with those without cancer. The increased risk appeared to be mediated by increased severity of illness at presentation, as well as by age.     

Echocardiography to predict tolerance to negative fluid balance in acute respiratory distress syndrome/acute lung injury

Purpose

In acute respiratory distress syndrome (ARDS) and acute lung injury (ALI), a conservative fluid management strategy improves lung function but could jeopardize extrapulmonary organ perfusion. The objective was to evaluate the diagnostic accuracy of echocardiography to predict tolerance of negative fluid balance (NFB) in patients with ARDS/ALI.

Materials and Methods

A prospective and observational study in an adult intensive care unit of a university hospital was conducted. All hemodynamically stable patients with ARDS/ALI were included. Echocardiography was performed before NFB and again after 24 hours. Tolerance of NFB was evaluated by the presence of hypotension, acute kidney injury, or need for fluid expansion. The 2 patient groups (tolerating and not tolerating NFB) were compared.

Results

Forty-five patients were included. Median age (Q1-Q3) was 58 (52-66) years, and the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen was 205 (163-258) mm Hg. Negative fluid balance was 1950 (1200-2200) mL within 24 hours in the tolerant group. Complications of NFB were observed in 35% cases. After univariate and multivariate logistic regression analyzes, 2 criteria was independently associates with poor tolerance: mitral inflow E wave to early diastolic mitral annulus velocities ratio (E/Ea ratio; odds ratio, 2.02 [1.02-4.02]; P = .04) and weight gain (odds ratio, 1.2 [1.03-1.4]; P = .02). The area under receiver operating characteristic curves was 0.74 for E/Ea and 0.77 for weight gain.

Conclusions

The ratio of E/Ea accurately predicted tolerance of NFB in patients with ARDS/ALI.     

Epidemiology of injuries to wildland firefighters

Introduction

Wildland fires have significant ecologic and economic impact in the United States. Despite the number of firefighters involved in controlling them, little is known about the injuries that they sustain. We hypothesized that the mechanism of injury would predict injury characteristics and severity of fire-related injuries.

Methods

We examined firefighter injuries reported to the US Department of the Interior from the years 2003 to 2007. Associations between the injury mechanism and the injury diagnosis and body part were assessed. A logistic regression model was used to evaluate the odds of disabling injury associated with mechanism of injury after controlling for demographic and temporal variables.

Results

A total of 1301 nonfatal injuries to wildland firefighters were reported during the 5-year period. Mechanism of injury was significantly associated with the type of injury and injured body part (P ≤ .001). The most common injury mechanism was slips/trips/falls followed by equipment/tools/machinery. Injuries from poisoning or environmental exposure were less likely to lead to severe injury than slips, trips, or falls (odds ratio, 0.45; 95% confidence interval, 0.21-0.95). Compared with injuries in the early and peak season, those in the late season had more than twice the odds of being severe (odds ratio, 2.24; 95% confidence interval, 1.23-4.10).

Discussion

This study contributes important knowledge for implementing evidence-based injury prevention programs, for planning emergency medical responses on fire incidents and for provoking further inquiry into occupational risk factors affecting this high-risk occupational group.     

Clinically manifest thromboembolic complications of femoral vein catheterization for continuous renal replacement therapy

Purpose

The safety of femoral vein (FV) catheterization for continuous renal replacement therapy is uncertain. We sought to determine the incidence of clinically manifest venous thromboembolism (VTE) in such patients.

Methods

We retrospectively studied patients with femoral high flow catheters (≥ 13F) (December 2005 to February 2011). Discharge diagnostic codes were independently screened for VTE. The incidence of VTE was also independently similarly assessed in a control cohort of patients ventilated for more than 2 days (January 2011 to December 2011) in the same intensive care unit (ICU).

Results

We studied 380 patients. Their mean age was 61 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation III score was 84; average duration of continuous renal replacement therapy was 74 hours, and 232 patients (61%) survived to hospital discharge with an average length of hospital stay of 22 days. Only 5 patients (1.3%) had clinically manifest VTE after FV catheterization. In the control cohort of 514 ICU patients, the incidence of VTE was 4.4% (P < .05 compared with FV group).

Conclusion

The incidence of clinically manifest VTE after FV catheterization with high flow catheters is low and lower to that seen in general ICU patients.     

Is early analgesia associated with delayed treatment of appendicitis?

Purpose

We sought to investigate the relationship between delay in treatment of appendicitis and early use of analgesia.

Basic Procedures

We designed a matched case-control study, with patients having delayed treatment of appendicitis as the cases and patients with no delay in treatment of appendicitis as controls matched for age, sex, Alvarado score, and date of diagnosis. Of 957 patients with appendicitis, there were 103 delayed cases. Matching patients were identified yielding 103 controls.

Main Findings

In comparing cases and controls for early opiate use (26/103 cases, 24/103 controls), there was no association with delayed treatment (odds ratio, 1.11; P = .745; 95% confidence interval, 0.59-3.89). When comparing cases and controls for early NSAID use (29/103 cases, 17/103 controls), an association was found with delayed treatment (odds ratio, 1.98; P = .045; 95% confidence interval, 1.01-3.89).

Conclusion

For early analgesia in appendicitis, we did not find an association with delayed treatment for opiate analgesia, but there did appear to be an association with nonsteroidal anti-inflammatory analgesia.     

Delayed diagnosis of active pulmonary tuberculosis in emergency department

Background and Purpose

Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED.

Methods

We used a retrospective chart review.

Patients

A total of 103 patients were enrolled between December 2003 and March 2006.

Results

Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01).Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis.

Conclusion

Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.     

Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation

Purpose

The goal of this study was to determine the impact of surgical rib fixation (SRF) in a treatment protocol for severe blunt chest trauma.

Materials and methods

Patients with flail chest admitted between September 2009 and June 2010 to our level I trauma center who failed traditional management and underwent SRF were matched with an historical group. Outcome variables evaluated include age, injury severity score, intensive care unit length of stay (LOS), hospital LOS, ventilator days, total number of rib fractures, and total number of segmental rib fractures.

Results

The 2 groups were similar in age, injury severity score, intensive care unit LOS, hospital LOS, total number of rib fractures, and total segmental rib fractures. The operative group demonstrated a significant reduction in total ventilator days as compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P = .040). Patients with SRF were permanently liberated from the ventilator within a median of 1.5 days (0-8 days).

Conclusions

Surgical rib fixation resulted in a significant decrease in ventilator days and may represent a novel approach to decreasing morbidity in flail chest patients when used as a rescue therapy in patients with declining pulmonary status. Larger studies are required to further identify these benefits.     

Anxiety and Depression Associated With Caregiver Burden in Caregivers of Stroke Survivors With Spasticity

Objective

To investigate the relationship between anxiety/depression and caregiver burden in informal caregivers of stroke survivors with spasticity.

Design

Data were collected via online surveys from informal caregivers 18 years or older who cared for stroke survivors.

Setting

Internet-based survey.

Participants

2007 through 2009 U.S. National Health and Wellness Survey database or Lightspeed Research general panel respondents (N=153).

Interventions

Not applicable.

Main Outcome Measures

Anxiety and depression were self-reported by the caregiver as a physician diagnosis. Depression severity was measured by the Patient Health Questionnaire-9 (PHQ-9). Caregiver burden was measured by the Oberst Caregiving Burden Scale (OCBS) and the Bakas Caregiving Outcomes Scale (BCOS). Logistic regression analyses were conducted with anxiety, depression, and the PHQ-9 depression severity categories as a result of each caregiver burden scale.

Results

Data were analyzed for 153 informal caregivers; they were mostly women (70.6%) and white (78.4%), with a mean age of 51.6 years. For every 1-point increase in the OCBS Difficulty Scale, the odds of anxiety or depression were 2.57 times as great (P<.001) and 1.88 times as great (P=.007), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 2.48 times as great (P<.001). For every 1-point decrease in the BCOS, the odds of anxiety or depression were 2.43 times as great (P<.001) and 2.27 times as great (P=.002), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 4.55 times as great (P<.001).

Conclusions

As caregiver burden increases, caregivers are more likely to have anxiety and depression. Depression severity also increases. Providing treatment to stroke survivors with spasticity that lessens the time and more importantly, the difficulty of caregiving may lead to a reduction in caregiver anxiety and depression.     

Botulinum Toxin Type B in the Spastic Arm: A Randomized,Double-Blind,Placebo-Controlled,Preliminary Study

Objective

To determine the efficacy and safety of 2 doses of botulinum toxin type B (rimabotulinumtoxinB, BoNT/B) in spastic upper limb muscles.

Design

Randomized, double-blind, placebo-controlled trial with a 3-month follow-up.

Setting

Tertiary care center.

Participants

Referred sample of adult hemiparetic patients (N=24) with disabling elbow flexor overactivity after stroke or traumatic brain injury.

Interventions

Injection of 10,000U of rimabotulinumtoxinB (fixed 2500U dose into elbow flexors; n=8), 15,000U (5000U into elbow flexors; n=8), or placebo (n=8) into overactive upper limb muscles selected as per investigator's discretion.

Main Outcome Measures

At 1 month postinjection, active range of elbow extension (goniometry; primary outcome); active upper limb function (Modified Frenchay Scale [MFS]); subjective global self-assessment (GSA) of arm pain, stiffness, and function; rapid alternating elbow flexion-extension movement frequency over the maximal range; elbow flexor spasticity grade and angle (Tardieu), and tone (Ashworth).

Results

No adverse effects were associated with either BoNT/B dose. Both doses improved active elbow extension versus placebo (+8.3°; 95% confidence interval, 1.1°–15.5°; analysis of covariance, P=.028). The high dose of BoNT/B also improved subject-perceived stiffness (P=.005) and the composite pain, stiffness, and function GSA (P=.017), effects that persisted 3 months from injection. No MFS change was demonstrated, although subjects with a baseline MFS <70/100 seemed more likely to benefit from BoNT/B.

Conclusions

In this short-term study, BoNT/B up to 15,000U into spastic upper limb muscles, including the elbow flexors, was well tolerated and improved active elbow extension and subject-perceived stiffness.     

Predicting Clinically Significant Changes in Motor and Functional Outcomes After Robot-Assisted Stroke Rehabilitation

Objective

To investigate the predictors of minimal clinically important changes on outcome measures after robot-assisted therapy (RT).

Design

Observational cohort study.

Setting

Outpatient rehabilitation clinics.

Participants

A cohort of outpatients with stroke (N=55).

Interventions

Patients with stroke received RT for 90 to 105min/d, 5d/wk, for 4 weeks.

Main Outcome Measures

Outcome measures, including the Fugl-Meyer Assessment (FMA) and Motor Activity Log (MAL), were measured before and after the intervention. Potential predictors include age, sex, side of lesion, time since stroke onset, finger extension, Box and Block Test (BBT) score, and FMA distal score.

Results

Statistical analysis showed that the BBT score (odds ratio[OR]=1.06; P=.04) was a significant predictor of clinically important changes in the FMA. Being a woman (OR=3.9; P=.05) and BBT score (OR=1.07; P=.02) were the 2 significant predictors of clinically significant changes in the MAL amount of use subscale. The BBT score was the significant predictor of an increased probability of achieving clinically important changes in the MAL quality of movement subscale (OR=1.07; P=.02). The R² values for the 3 logistic regression models were low (.114−.272).

Conclusions

The results revealed that patients with stroke who had greater manual dexterity measured by the BBT appear to have a higher probability of achieving clinically significant motor and functional outcomes after RT. Further studies are needed to evaluate other potential predictors to improve the models and validate the findings.     

Can Measures of Limb Loading and Dynamic Stability During the Squat Maneuver Provide an Index of Early Functional Recovery After Unilateral Total Hip Arthroplasty?

Objective

To investigate limb loading and dynamic stability during squatting in the early functional recovery of patients who had undergone total hip arthroplasty (THA).

Design

Cohort study.

Setting

Inpatient rehabilitation clinic.

Participants

Of the total participants (N=99), a random sample of patients who had undergone THA (n=61; 34 men and 27 women; mean age, 62±9y; weight, 77±14kg; height, 174±9 cm) was assessed twice, 13.2±3.8 days (t1) and 26.6±3.3 days postsurgery (t2), and compared with a healthy reference group (n=38; 22 men and 16 women; mean age, 47±12y; weight, 78±20kg; height, 175±10cm).

Interventions

Patients who had undergone THA received 2 weeks of standard inpatient rehabilitation.

Main Outcome Measures

Interlimb vertical force distribution and dynamic stability during the squat maneuver, as defined by the root mean square of the center of pressure in anteroposterior and mediolateral directions, of operated and nonoperated limbs. Self-reported function was assessed via the Function Assessment Questionnaire Hannover for Osteoarthritis questionnaire.

Results

At t1, unloading of the operated limb was 15.8% greater (P<.001; d=1.070) and anteroposterior and mediolateral center of pressure root mean square values were 30% to 34% higher in patients who had undergone THA than in the healthy reference group (P<.05). Unloading was reduced by 12.8% toward a more equal distribution from t1 to t2 (P<.001; d=.874). Although mediolateral stability improved between t1 and t2 (operated limb: 14.8%; P=.024; d=.397; nonoperated limb: 13.1%; P=.015; d=.321), anteroposterior stability was not significantly different. Self-reported physical function improved by 15.8% (P<.001; d=.965).

Conclusions

Patients who had undergone THA unload the operated limb and are dynamically more unstable during squatting in the early rehabilitation phase after THA than are healthy adults. Although loading symmetry and mediolateral stability improved to the level of healthy adults with rehabilitation, anteroposterior stability remained impaired. Measures of dynamic stability and load symmetry during squatting provide quantitative information that can be used to clinically monitor early functional recovery from THA.     

Symptoms of Depression Over Time in Adults With Pediatric-Onset Spinal Cord Injury

Objective

To investigate the prevalence of depressive symptoms in adults with pediatric-onset spinal cord injury (SCI) and explore potential risk factors that may be associated with elevated symptoms.

Design

Longitudinal, cohort survey over a period of 2 to 9 years. Follow-up occurred approximately every year, a total of 868 interviews were conducted, and most participants contributed to at least 3 waves of data (72%; range, 2–8; mean, 4.34±2.16).

Setting

Community.

Participants

Adults (N=214; 133 men; mean age at first interview, 29.52±5.21y; range, 24–42y) who sustained an SCI prior to age 19 (mean age at injury, 13.93±4.37y; range, 0–18y). Participants tended to have complete injuries (71%) and tetraplegia (58%).

Interventions

Not applicable.

Main Outcome Measures

Participants completed measures assessing psychosocial functioning, physical independence, participation, and depression at each time point. Multilevel growth modeling analyses were used to explore depression symptoms across time.

Results

Depression symptoms at initial status were typically minimal (3.07±.24; 95% confidence interval, 2.6–3.54) but fluctuated significantly over time (P<.01). Several factors emerged as significant predictors of depressive symptoms in the final model, including less community participation (P<.01), incomplete injury (P=.02), hazardous drinking (P=.02), bladder incontinence (P=.01), and pain (P=.03). Within individuals, as bowel accidents (P<.01) and pain increased (P<.01), depression scores increased; however, marriage resulted in decreases in depression scores for individuals (P=.02).

Conclusions

These findings suggest that most patients with pediatric-onset SCI are psychologically resilient, but strategies to minimize secondary health complications and foster community participation and engagement should be considered.     

Outcome of Percutaneous Osseointegrated Prostheses for Patients With Unilateral Transfemoral Amputation at Two-Year Follow-Up

Objective

To report outcomes regarding general and specific physical health-related quality of life of treatment with percutaneous osseointegrated prostheses.

Design

Prospective 2-year case-control study.

Setting

University hospital.

Participants

Individuals (N=39; mean age, 44±12.4y) with unilateral transfemoral amputation as a result of trauma (n=23), tumor (n=11), or other cause (n=5). At baseline, 33 of the 39 participants used socket-suspended prostheses.

Intervention

Osseointegrated prosthesis.

Main Outcome Measures

Questionnaire for Persons with Transfemoral Amputation (Q-TFA), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning (PF) and physical component summary (PCS), SF-6D, and Physiological Cost Index (PCI).

Results

At 2 years postimplantation, 6 of 7 Q-TFA scores improved (P<.0001) compared with baseline (prosthetic use, mobility, problem, global, capability, walking habits). The walking aid subscore did not improve (P=.327). Of the 39 participants, increased prosthesis use was reported by 26, same amount of use by 11, and less use by 2. Improvement was reported in 16 of the 30 separate problem items (P<.05). Unchanged items included problems regarding phantom limb pain and pain from the back, shoulders, and contralateral limb. The PF, PCS, and SF-6D improved a mean of 24.1±21.4 (P<.0001), 8.5±9.7 (P<.0001), and .039±.11 (P=.007) points, respectively. Walking energy cost decreased (mean PCI at baseline, .749; mean PCI at follow-up, .61; P<.0001).

Conclusions

Two years after intervention, patients with a unilateral TFA treated with an OPRA implant showed important improvements in prosthetic function and physical quality of life. However, walking aids used and the presence of phantom limb pain and pain in other extremities were unchanged. This information is valuable when considering whether percutaneous osseointegrated prostheses are a relevant treatment option.     

Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation

Objective

To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation.

Design

Observational study.

Setting

Postacute rehabilitation facility.

Participants

Patients (N=2754) aged ≥65 years admitted over a 4-year period.

Interventions

Not applicable.

Main Outcome Measure

Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement.

Results

Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean ± SD, 63.3±18.0 vs 59.6±24.7) and at discharge (mean ± SD, 86.8±10.4 vs 62.2±22.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]=1.51; 95% confidence interval [CI], 1.16–1.98; P=.003), women (adjusted OR=1.24; 95% CI, 1.01–1.52; P=.045), patients living alone (adjusted OR=1.61; 95% CI, 1.31–1.98; P<.001), and patients without in-home help prior to admission (adjusted OR=1.39; 95% CI, 1.15–1.69; P=.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19–23) and those cognitively intact also had increased odds of functional recovery (adjusted OR=1.56; 95% CI, 1.13–2.15; P=.007; adjusted OR=2.21; 95% CI, 1.67–2.93; P<.001, respectively).

Conclusions

Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome.     

Does early administration of selenium improve neurological outcome after cardiac arrest?

Objective

Existing data indicate that selenium supplementation may be beneficial in critically ill patients and in those with ischemic stroke. The purpose of this retrospective study was to explore the influence of early administration of selenium on neurological outcome after cardiopulmonary resuscitation (CPR).

Methods

We examined 227 consecutive unconscious patients after CPR and excluded 1 individual. The decision to administer selenium was left to the discretion of the attending physician, resulting in 124 patients (55%) who received intravenous selenium (200-1000 μg/d) for a median of 5 days after CPR. Patients were classified according to the best Glasgow-Pittsburgh cerebral performance categories (CPCs 1-5) achieved within 6 months of follow-up.

Results

The rate of regaining consciousness (CPC 1-3) after CPR was 58%. Multivariable logistic regression analysis confirmed a shockable first monitored rhythm (adjusted odds ratio, 3.73; 95% confidence interval, 1.85-7.52; P < .001), time to return of spontaneous circulation (adjusted odds ratio, 0.94; 95% confidence interval, 0.91-0.96; P < .001), administration of selenium (adjusted odds ratio, 2.38; 95% confidence interval, 1.19-4.76; P = .014), and the Simplified Acute Physiology Score II (adjusted odds ratio, 0.96; 95% confidence interval, 0.93-0.99; P = .034) as independent predictors of regaining consciousness after CPR. Survival at 6 months of follow-up was not improved significantly by selenium.

Conclusion

This retrospective analysis leads to the hypothesis that early administration of selenium may improve neurological outcome after cardiac arrest.     

Assisted Movement With Proprioceptive Stimulation Reduces Impairment and Restores Function in Incomplete Spinal Cord Injury

Objective

To test whether treatment with assisted movement with enhanced sensation (AMES) using vibration to the antagonist muscle would reduce impairments and restore upper limb function in people with incomplete tetraplegia.

Design

Prospective, pre-post study.

Setting

Laboratory and rehabilitation hospital.

Participants

We recruited 15 arms from 10 individuals (8 men; mean age, 40.5y; mean years postspinal cord injury [SCI], 3) with chronic, incomplete tetraplegia.

Intervention

Two or three 20-minute sessions per week over 9 to 13 weeks (25 sessions total) on the AMES device, which combines repeated movement with targeted vibration to the antagonist muscle.

Main Outcome Measures

Strength and active motion tests on the AMES device; International Standards for the Neurological Classification of SCI (ISNCSCI) motor and sensory examinations; Modified Ashworth Scale (MAS); grasp and release test (GRT); Van Lieshout Test (VLT); and Capabilities of Upper Extremity questionnaire (CUE).

Results

The AMES strength test scores improved significantly in metacarpophalangeal flexion (P=.024) and extension (P=.007) and wrist flexion (P=.001) and extension (P<.000). The AMES active motion scores improved in the hand (P=.001) and wrist (P=.001). The MAS and ISNCSCI scores remained unchanged, whereas the GRT scores increased (P=.025). Post hoc analysis showed a trend from pre- to posttreatment (P=.068) and a significant change from pretreatment to 3-month follow-up (P=.046). There was no significant change in the VLT (P=.951) or the CUE (P=.164). Five of the 10 participants reported a return of sensation to the digits after the first, second, or third treatment session.

Conclusions

People with chronic, incomplete tetraplegia may experience improvements in impairments and function after treatment on a device combining assisted movement and proprioceptive stimulation. Further investigation is warranted.     

Spinal Cord Injury and Time to Instability in Seated Posture

Objective

To investigate seated postural control in persons with spinal cord injury (SCI) compared with age-matched controls.

Design

Cohort.

Setting

University research laboratory.

Participants

Adults (N=36; mean age ± SD, 22.5±3.2y): 7 persons with high SCI (HI group; injury level greater than T10), 11 persons with low SCI (LI group; injury level between T10 and L4), and 18 persons with non-SCI.

Intervention

Not applicable.

Main Outcomes Measures

Participants sat on a force platform on a custom-built wooden box with their arms by their side. Postural control was quantified in several ways. Participants completed a functional reach test. The amount of postural sway was quantified by characterizing the center of pressure (COP) trajectory by determining median velocity and root mean square of the signal. In addition, the virtual time to contact to the functional boundary was quantified. Last, the instability index was determined as the ratio of the COP area to the functional boundary.

Results

There were no group differences in COP-based metrics (P>.05). There was no difference between SCI groups in functional reach (P>.05). The HI group had a smaller virtual time to contact (VTC) than the control group (.50±.20s vs .98±.24s, P<.05). Both SCI groups had a greater instability index than the control group, with the HI group having the largest amount of instability (P<.05).

Conclusions

The observations suggest that VTC analysis is appropriate to investigate seated postural control. It is proposed that including VTC of seated postural control as an outcome measure will provide novel information concerning the effectiveness of various rehabilitation approaches and/or technologies aimed at improving seated postural control in persons with SCI.