Development of a Remote Version of the Graded Redefined Assessment of Strength, Sensation, and Prehension (GRASSP): Validity and Reliability.

BACKGROUND: The Graded Redefined Assessment of Strength, Sensation, and Prehension (GRASSP V1.0) was developed in 2010 as a 3-domain assessment for upper extremity function after tetraplegia (domains: Strength, Sensibility, and Prehension). A remote version (rGRASSP) was created in response to the growing needs of the field of Telemedicine. OBJECTIVE: The purpose of this study was to assess the psychometric properties of rGRASSP, establishing concurrent validity and inter-rater reliability. METHODS: Individuals with tetraplegia (n = 61) completed 2 visits: 1 in-person and 1 remote. The first visit was completed in-person to administer the GRASSP, and the second visit was conducted remotely to administer the rGRASSP. The rGRASSP was scored both by the administrator of the rGRASSP (Examiner 1), and a second assessor (Examiner 2) to establish inter-rater reliability. Agreement between the in-person and remote GRASSP evaluations was assessed using the intraclass correlation coefficient (ICC) and Bland-Altman agreement plots. RESULTS: The remote GRASSP demonstrated excellent concurrent validity with the GRASSP (left hand intraclass correlation coefficient (ICC) = .96, right ICC = .96). Concurrent validity for the domains was excellent for strength (left ICC = .96, right ICC = .95), prehension ability (left ICC = .94, right ICC = .95), and prehension performance (left ICC = .92, right ICC = .93), and moderate for sensibility (left ICC = .59, right ICC = .68). Inter-rater reliability for rGRASSP total score was high (ICC = .99), and remained high for all 4 domains. Bland-Altman plots and limits of agreements support these findings. CONCLUSIONS: The rGRASSP shows strong concurrent validity and inter-rater reliability, providing a psychometrically sound remote assessment for the upper extremity in individuals with tetraplegia.

The Impacts and Vulnerabilities for People Living with Spinal Cord Injury and Their Service Systems of the COVID-19 Pandemic in Queensland, Australia

As part of a larger study examining the perceived impacts of health system stress in Queensland, Australia, caused by the COVID-19 pandemic, this study explored the experiences and perspectives of a sample of people with spinal cord injury (SCI) and critical stakeholders to identify secondary complications, access concerns, and potential solutions in the context of the pandemic. This study utilised a multimethods qualitative design. Thirty-four people with SCI completed an online survey between August and November 2021, recruited from an online Spinal Life Australia Peer Support Group. Sixteen SCI expert stakeholders, recruited from the Queensland Spinal Cord Injuries Services, consumer support organisations, and funding agencies, participated in one of two expert stakeholder forums in September 2021, focusing on impacts of the pandemic on the services they provided. Survey and forum results were analysed thematically. Results highlighted service disruption wherein people with SCI faced difficulty accessing health and community services (including rehabilitation) and personal supports. Reduced access led to secondary complications in physical health, psychosocial, and occupational domains. Solutions for safeguarding access to care, including action-ready back-up plans, effective technology and training, collaboration of service networks, and forward planning for system disruption, consumables access, staff support, and advocacy are required to best support vulnerable populations and the supporting staff in times of crisis. In conclusion, COVID-19 disrupted access to specialist SCI and mainstream health, rehabilitation, and social care services, resulting in functional decline and physical and psychosocial complications. While people with SCI and their service providers attempted to innovate and solve problems to overcome service access barriers, this is not possible in all situations. Improved planning and preparation for future system disruptions mitigates risks and better protects vulnerable populations and service providers in times of severe system stress.

Needs of an uninsured equity-deserving minority patient cohort with physical disabilities during the first wave of the COVID-19 pandemic.

Background: Patients with disabilities and those from diverse equity-deserving backgrounds have been disproportionately affected by the SARS COV-2 ("COVID-19") pandemic. Objective: To describe the significant needs and social determinants of health that affected a group of uninsured patients (from equity-deserving groups) with rehabilitation diagnoses during the early months of the COVID-19 pandemic. Design: Retrospective cohort study utilizing a telephone-based needs assessment from April to October, 2020. Setting: Free interdisciplinary rehabilitation clinic serving patients with physical disabilities from equity-deserving minority backgrounds. Participants: 51 uninsured, diverse patients with spinal cord injuries, brain injuries, amputations, strokes, and other diagnoses requiring interdisciplinary rehabilitation care. Methods: Using a non-structured approach, telephone-based needs assessments were collected monthly. Reported needs were summarized into themes and the frequencies of each theme were recorded. Results: From the total number of concerns, medical issues were reported with the highest frequency (46%), followed by equipment needs (30%) and mental health concerns (30%). Other frequently mentioned needs centered around themes of rent, employment, and supplies. Rent and employment were more frequently cited in earlier months, and equipment problems were more frequently cited in later months. A minority of patients reported they had no needs, some of whom had acquired insurance. Conclusions: Our objective was to describe the needs of a racially and ethnically diverse set of uninsured individuals with physical disabilities seen at a specialized interdisciplinary rehabilitation pro bono clinic during the early months of COVID-19. Medical issues, equipment needs, and mental health concerns were the top three needs. To optimally serve them, care providers must be aware of current and future needs for their underserved patients, especially if future lockdowns occur.

Practical mobile game-based respiratory muscle training program for patients with cervical spinal cord injury during the COVID-19 pandemic

BACKGROUND: Patients with cervical spinal cord injury can experience difficulties while exercising and breathing. Conventional respiratory muscle training might be ineffective, as it can be boring and lead to minimal improvements. We developed a mobile game-based training program to provide fun and effective respiratory exercises and aimed to investigate the preliminary effects of mobile game-based respiratory muscle training on pulmonary function in patients with cervical spinal cord injury. METHODS: Eleven men and one woman (aged 31-61 years) with cervical spinal cord injury completed a respiratory muscle training program for 60 min a day, twice weekly, for 8 weeks. Forced vital capacity, forced expiratory volume in 1 s, vital capacity, inspiratory capacity, inspiratory reserve volume, expiratory reserve volume, maximum voluntary ventilation, and maximum respiratory frequency were measured using a spirometer before and after testing. Statistical analyses were performed using paired t-tests to assess the differences between the pre-and post-tests on the exercise group's performance. RESULTS: Participants with cervical spinal cord injury showed significantly improved forced vital capacity (P=0.010), vital capacity (P=0.001), inspiratory capacity (P=0.018), inspiratory reserve volume (P=0.004), maximum voluntary ventilation (P=0.005), and maximum respiratory frequency (P=0.039) after completing the respiratory muscle training program. CONCLUSIONS: We observed significant short-term effects of the game-based exercise program on pulmonary function in patients with cervical spinal cord injury, suggesting the feasible inclusion of mobile game-based respiratory muscle training in rehabilitation interventions.

Characterizing High Fear of COVID among those with Neurological Conditions

Research Objectives To evaluate the demographic, clinical, and psychosocial characteristics of those with high fear of covid compared to those with low fear among those with neurological conditions. Design Cross-sectional survey. Setting Outpatient and community. Participants Participants (N=74) included those: 18 years of age and older;diagnosed with a neurological condition including: brain injury;cognitive capacity to understand and complete measures;living in the community. Interventions Not applicable. Main Outcome Measures Demographics, injury characteristics, NeuroQoL psychosocial subscales, Fear of COVID-19 Scale, Thoughts and Feelings about Social Distancing, and Social Distancing Strategies Used. Results Participants with high levels of fear of covid were more likely to be females, experienced loss of employment, recently injured, greater levels of sleep disturbance, and experience greater levels of stigma. When examining thoughts of social distancing, those in the high fear group reported feeling isolated, anxious, less likely to use online platform to be social, feel pressure from others to not socially distance when social distancing compared to those in the low fear group. Those in the high fear group were more likely to use avoidance based social distancing strategies compared to those in the low fear group. No significant differences between the two groups were seen in level of age, level of education, living arrangements, fatigue and self-efficacy. Conclusions The current study demonstrates that, among those with neurological conditions, characteristics of high fear of the pandemic are distinct from those with low fear. These findings indicate, that those with high fear of covid may require additional support to improve their overall wellbeing and quality of life. Author(s) Disclosures None.

Experiences with COVID-19 Pandemic in the Spinal Cord Injury Community...American Congress of Rehabilitation Medicine (ACRM) Annual Conference, November 8-11, 2022, Chicago, Illinois

Document the experiences of people with chronic spinal cord injury (SCI) during the COVID-19 pandemic. A cross-sectional survey. An academic medical center. A convenience sample of 35 participants from a local SCI Model Systems Center who completed a survey online or by phone between September 2021 and March 2022. Not applicable. A scale "COVID-19: Impact of the pandemic and HRoL in cancer patients and survivors" obtained from NIH PhenX Toolkit was adapted for SCI population that measures personal COVID-19 exposures and experiences, including COVID-19 specific emotional and physical reactions, health care disruption and concerns, disruption to daily activities and social interactions, financial hardship, perceived benefits, functional social support, and perceived stress management. This sample had a mean age of 51.8 years, a mean duration of injury of 22.2 years, and 55.9 % had paraplegia with American Spinal Injury Association Impairment Scale A, B, or C. 17.1% of participants had COVID-19 infection. Forty percent of participants were fully vaccinated which is lower than that of general population in the state (53.5%). More than half of participants were concerned about family members or close friends getting or dying from COVID-19, had feelings of sadness or depression, and experienced disruptions in day to day social interactions with family and/or friends. The majority reported perceived benefits, had functional social supports, and had ability to manage stress. Participants reported varying COVID-19 related impacts, including employment (eg, 8.5% lost job), health care disruption (eg, 37.1% general care disruption), and financial hardship (eg, 34.3% financial difficulties). These results provide important markers for developing interventions for SCI population in future crises. No disclosure.

Epidemiological characteristics of traumatic spinal cord injuries in a multicenter retrospective study in northwest China, 2017-2020.

Background: Traumatic spinal cord injuries (TSCIs) are worldwide public health problems that are difficult to cure and impose a substantial economic burden on society. There has been a lack of extensive multicenter review of TSCI epidemiology in northwest China during the Corona Virus Disease 2019 (COVID-19) pandemic. Method: A multicenter retrospective study of 14 selected hospitals in two provinces in northwest China was conducted on patients admitted for TSCI between 2017 and 2020. Variables assessed included patient demographics, etiology, segmental distribution, treatment, waiting time for treatment, and outcomes. Results: The number of patients with TSCI showed an increasing trend from 2017 to 2019, while there were 12.8% fewer patients in 2020 than in 2019. The male-to-female ratio was 3.67:1, and the mean age was 48 ± 14.9 years. The primary cause of TSCI was high falls (38.8%), slip falls/low falls (27.7%), traffic accidents (23.9%), sports (2.6%), and other factors (7.0%). The segmental distribution showed a bimodal pattern, peak segments were C6 and L1 vertebra, L1 (14.7%), T12 (8.2%), and C6 (8.2%) were the most frequently injured segments. In terms of severity, incomplete injury (72.8%) occurred more often than complete injury (27.2%). The American Spinal Injury Association impairment scale of most patients did not convert before and after treatment in the operational group (71.6%) or the conservative group (80.6%). A total of 975 patients (37.2%) from urban and 1,646 patients (62.8%) from rural areas were included; almost all urban residents could rush to get treatment after being injured immediately (<1 h), whereas most rural patients get the treatment needed 4-7 h after injury. The rough annual incidence from 2017 to 2020 is 112.4, 143.4, 152.2, and 132.6 per million people, calculated by the coverage rate of the population of the sampling hospital. Conclusion: The incidence of TSCI in northwest China is high and on the rise. However, due to pandemic policy reasons, the incidence of urban residents decreased in 2020. The promotion of online work may be an effective primary prevention measure for traumatic diseases. Also, because of the further distance from the good conditional hospital, rural patients need to spend more time there, and the timely treatment of patients from remote areas should be paid attention to.

Unmediated connection of mental health decline and suicide among medical and nonmedical undergraduates during the pandemic of COVID-19: A cross-sectional comparative study

Background and Objectives: All medicine and healthcare undergraduates were encountered with terminations and delays of professional examinations. These alterations were on topmost of other tasks the COVID-19 pandemic carried out for instance not roaming, covered faces with masks and specifically segregation. This interruption of normal life was a major cause of mental health disaster and it is no surprise that medicine and healthcare undergraduate has had high rates of psychological effects including hopelessness, stress and suicidal thoughts. This study aimed to investigate the unmediated connection of anxiety and stress related mental health decline and suicide among medical and nonmedical undergraduates during the pandemic of covid-19. Methods: A multidiscipline online cross-sectional comparative study design was chosen for this study conducted from November 2020 to January 2021 with a pre-validated questionnaire to collect responses from sample size 1290. SPSS- 21 used for descriptive analysis of means, S.D, ANOVA and spearman's correlations. Forward step-wise model of linear regression applies for true significant bivariate relationship (p<.001) Results: The result shows that all three cohorts were affected. Among the non-medical cohorts, B-Pharmacy students had the high level (p<.001) of anxiety with suicide ideation response (n=200;39.2%), along with lowest level of envisions care (19.5%;p<.001) in pandemic. Control and independent variable had a strong negative effects on B-Pharmacy and medical students with p<.000. Conclusions: This study offered more data that the concerns, anxieties and uncertainties caused by pandemic COVID-19, don't roll out alone but remain as long-lasting problems demanding ongoing attention.

Rehabilitation processes, stress and depression in patients with spinal cord injury during the COVID-19 pandemic in Turkey: a telephone survey

Background/Aims Spinal cord injury is a chronic disease that can develop various complications and multisystem dysfunctions. Patients with spinal cord injury need long-term follow up and rehabilitation. During the COVID-19 pandemic, people had to observe social distancing and stay at home. The aim of this study was to evaluate the effects of the COVID-19 pandemic on the rehabilitation and health status of patients with spinal cord injury and assesses their stress levels and depression status. Methods A telephone-based survey was conducted with patients followed up by a spinal cord injury outpatient clinic about rehabilitation processes and any health problems experienced. Stress levels were assessed using the Perceived Stress Scale, while depression was assessed using the Beck Depression Inventory. Demographic characteristics, American Spinal Injury Association Impairment Scale levels, Functional Ambulation Categories and Spinal Cord Independence Measure scores were retrieved from the patients' files. Results The study included 115 patients, none of whom had contracted COVID-19. Of these patients, 44.3% joined the rehabilitation programme before the pandemic, and 3.5% had been able to participate in the rehabilitation programme during the pandemic. An increase in spasticity was recorded in 43.5% of the respondents, an increase of neuropathic pain was recorded in 37.4% of patients and complaints of neurogenic bladder and neurogenic bowel increased by 26.1% and 16.5% respectively. In addition, 4.3% reported novel decubitus ulcers, while 5.2% reported having experienced autonomic dysreflexia episodes. The Perceived Stress Scale scores were 18.32 ± 5.91. No significant difference was detected between the Beck Depression Inventory scores taken at the time of the study and those recorded before the pandemic. Conclusions An insufficiency in the rehabilitation process was noted among patients with spinal cord injuries, accompanied by increased complications. New approaches need to be developed to ensure that the rehabilitation processes of patients with spinal cord injury are not interrupted during a pandemic, and that patients' mental health is not ignored.

Living With Cervical Spinal Cord Injury During the COVID-19 Pandemic: A Qualitative Study.

Objective: To understand how COVID-19 has affected the daily lives of people living with cervical spinal cord injury (SCI). Design: Cross sectional qualitative study. Setting: Academic medical center in the Midwestern United States. Participants: Ten community-dwelling individuals (8 men, 2 women), average 11.6 years post-mid-cervical level SCI (N=10). Interventions: Not applicable. Main Outcome Measures: Semistructured interviews were completed by phone. The research team used thematic analysis and inductive strategies to analyze the data in this exploratory investigation. Results: People with cervical SCI living in the United States during the spring of 2020 experienced changes to their daily lives. Participants described how interactions with caregivers for activities of daily living were complicated by fear about contracting and/or transmitting COVID-19. The pandemic limited this population's access to medical care and adversely affected their mental and physical health. Telemedicine was seen as a helpful alternative to in-person visits. Some participants felt that their previous life-altering experience (SCI) better prepared them to cope with the pandemic and "roll with things." Conclusions: Learning about how people with SCI cope, persevere, and survive to overcome adversity during the pandemic should inform future research to support those with SCI. Improving telemedicine and rewarding and recognizing caregivers for their role in maintaining health are important first steps. We must continue to be creative about improving our health care systems and access for people with disabilities, particularly during this and future public health crises.

Impact of the COVID-19 Pandemic on Psychosocial Health of Persons With Spinal Cord Injury: Investigation of Experiences and Needed Resources.

Background: Emerging evidence suggests that the COVID-19 pandemic has been accompanied by increased rates of depression and social isolation. However, we do not yet understand how the COVID-19 pandemic has affected the psychosocial health of people with spinal cord injury (PwSCI), a population that is already at risk of experiencing mental health conditions. Objectives: The aims of the study were to (1) examine the impact of the pandemic on the psychosocial health of PwSCI and (2) investigate the experiences of PwSCI and resources they reported needing during the peak of the pandemic. Methods: A cross-sectional survey with closed- and open-ended questions was administered to 51 PwSCI. Participants were included if they had an SCI, were 18 years or older, lived in St. Louis, Missouri, and surrounding areas, and understood English. Results: Canonical correlation showed a significant association between financial security, food insecurity, and personal assistance service use and adverse psychosocial health outcomes (p < .001). Participants reported interest in resources related to COVID-19 precautions for wheelchair users as well as home exercise programming and financial assistance with utilities. Finally, qualitative analysis revealed four major themes: (1) mental health during the pandemic, (2) financial concerns and reduced access to personal assistance services, (3) feelings of social isolation prior to the pandemic, and (4) local and national authorities' handling of the pandemic. Conclusion: PwSCI are impacted by the COVID-19 pandemic and reported a variety of resource needs. These findings may inform service providers, support systems, and organizations to better support PwSCI during times of crisis.

What Will the Post-Pandemic World Be Like? A Qualitative Study on the Perceptions of Brazilians with Spinal Cord Injury

Background: Given the worldwide pandemic caused by SARS-CoV-2, this study sought to understand how people with spinal cord injury (SCI) perceive the post-pandemic context. Objectives: We aimed to understand the perceptions of people with SCI in Brazil regarding the world in the post-pandemic context. Methods: This qualitative study was conducted on SCI Brazilians using a form published on SurveyMonkey® with questions regarding their perspectives on the post-pandemic world. The responses were analyzed considering Bardin, Axel Honneth, and Ernst Bloch. Results: The results demonstrated that the lives of SCI people in Brazil did not change during the pandemic, as they were already isolated due to the lack of accessibility. Conclusions: Imagining future scenarios following the pandemic is highly complex;however, the present can be understood as a moment to reflect on how humanity has developed thus far, especially concerning impaired accessibility and the pervasive lack of empathy and solidarity. © 2021, Author(s).

An App-Based Just-in-Time Adaptive Self-management Intervention for Care Partners (CareQOL): Protocol for a Pilot Trial.

BACKGROUND: Care partners (ie, informal family caregivers) of individuals with health problems face considerable physical and emotional stress, often with a substantial negative impact on the health-related quality of life (HRQOL) of both care partners and care recipients. Given that these individuals are often overwhelmed by their caregiving responsibilities, low-burden self-management interventions are needed to support care partners to ensure better patient outcomes. OBJECTIVE: The primary objective of this study is to describe an intensive data collection protocol that involves the delivery of a personalized just-in-time adaptive intervention that incorporates passive mobile sensor data feedback (sleep and activity data from a Fitbit [Fitbit LLC]) and real time self-reporting of HRQOL via a study-specific app called CareQOL (University of Michigan) to provide personalized feedback via app alerts. METHODS: Participants from 3 diverse care partner groups will be enrolled (care partners of persons with spinal cord injury, care partners of persons with Huntington disease, and care partners of persons with hematopoietic cell transplantation). Participants will be randomized to either a control group, where they will wear the Fitbit and provide daily reports of HRQOL over a 3-month (ie, 90 days) period (without personalized feedback), or the just-in-time adaptive intervention group, where they will wear the Fitbit, provide daily reports of HRQOL, and receive personalized push notifications for 3 months. At the end of the study, participants will complete a feasibility and acceptability questionnaire, and metrics regarding adherence and attrition will be calculated. RESULTS: This trial opened for recruitment in November 2020. Data collection was completed in June 2021, and the primary results are expected to be published in 2022. CONCLUSIONS: This trial will determine the feasibility and acceptability of an intensive app-based intervention in 3 distinct care partner groups: care partners for persons with a chronic condition that was caused by a traumatic event (ie, spinal cord injury); care partners for persons with a progressive, fatal neurodegenerative disease (ie, Huntington disease); and care partners for persons with episodic cancer conditions that require intense, prolonged inpatient and outpatient treatment (persons with hematopoietic cell transplantation). TRIAL REGISTRATION: ClinicalTrials.gov NCT04556591; https://clinicaltrials.gov/ct2/show/NCT04556591. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32842.

Improving practice through collaboration: Early experiences from the multi-site Spinal Cord Injury Implementation and Evaluation Quality Care Consortium.

CONTEXT: Dedicated implementation efforts are critical to bridging the gaps between current practices and best practices. A quality improvement collaborative (QIC), the Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC), was established to meet this need, bringing together a network of clinicians and administrators to systematically improve the quality and equity of tertiary spinal cord injury or disease (SCI/D) rehabilitation care in Ontario, Canada. METHODS: Clinicians and leaders from five tertiary SCI/D rehabilitation centers and two not-for-profit SCI/D advocacy groups comprised a network dedicated to supporting implementation of the SCI-High quality indicators in prioritized domains of SCI rehabilitation and related best practices by: (1) building capacity through implementation science education of frontline clinicians; (2) providing resources and support to empower frontline clinicians to lead quality improvement efforts within their institutions; (3) promoting wider learning through a network for sharing ideas, efforts, and experiences; and (4) collecting indicator data to facilitate provincial evaluation of goal attainment. RESULTS: Network members and sites collaborated to implement best practices within six priority domains; in 18 months, significant progress has been made in emotional wellbeing, sexual health, walking, and wheeled mobility despite disruptions due to the COVID-19 pandemic. These efforts encompass heterogeneous challenges and strategies, ranging from developing clinical skills programs, to streamlining processes, to manipulating physical space. CONCLUSION: A QIC targeting SCI/D rehabilitation demonstrates promise for advancing the implementation of best practices, building implementation science capacity across multiple sites, and for promoting collaboration amongst SCI/D rehabilitation centers and organizational partners.

Virtual Care in the Veterans Affairs Spinal Cord Injuries and Disorders System of Care During the COVID-19 National Public Health Emergency.

Telehealth reduces disparities that result from physical disabilities, difficulties with transportation, geographic barriers, and scarcity of specialists, which are commonly experienced by individuals with spinal cord injuries and disorders (SCI/D). The Department of Veterans Affairs (VA) has been an international leader in the use of virtual health. The VA's SCI/D System of Care is the nation's largest coordinated system of lifelong care for people with SCI/D and has implemented the use of telehealth to ensure that Veterans with SCI/D have convenient access to their health care, particularly during the restrictions that were imposed by the COVID-19 pandemic.

Guideline for diagnosis and treatment of spine trauma in the epidemic of COVID-19.

Outbreak of COVID-19 is ongoing all over the world. Spine trauma is one of the most common types of trauma and will probably be encountered during the fight against COVID-19 and resumption of work and production. Patients with unstable spine fractures or continuous deterioration of neurological function require emergency surgery. The COVID-19 epidemic has brought tremendous challenges to the diagnosis and treatment of such patients. To coordinate the diagnosis and treatment of infectious disease prevention and spine trauma so as to formulate a rigorous diagnosis and treatment plan and to reduce the disability and mortality of the disease, multidisciplinary collaboration is needed. This expert consensus is formulated in order to (1) prevent and control the epidemic, (2) diagnose and treat patients with spine trauma reasonably, and (3) reduce the risk of cross-infection between patients and medical personnel during the treatment.

COVID-19 and spinal cord injuries: The viewpoint from an emergency department resident with quadriplegia.

Spinal cord injuries (SCIs) present distinct physiological and social considerations for the emergency physician. During the COVID-19 pandemic, these considerations may generate unique challenges for emergency physicians managing patients with SCIs. Physiological disruptions may alter the way SCI patients present with COVID-19. The same disruptions can affect management of this vulnerable patient group, perhaps warranting early aggressive treatment. The medical picture will often be complicated by unique social characteristics. The reliance on caregivers for activities of daily living can, as an example, increase the human resource requirement of an ED. Considering the vulnerabilities and complexities of patients with SCI, the community should prioritise prevention of COVID-19 infections in this group. In the event that they do present to an ED, planning for and understanding their complexities will facilitate optimal management.