Surgical management of pressure ulcers in spinal cord injury patients.

BACKGROUND: Pressure ulcers (PU) are a common yet debilitating injury within the spinal cord injury (SCI) population. This retrospective data analysis is intended to identify the contributing factors, review the current management protocol, and risk of recurrence of PU in SCI patients at Victoria's state referral centre for traumatic spinal cord injuries. METHODS: A retrospective audit of the medical records of SCI patients with pressure ulcers was conducted for the period of January 2016 to August 2021. Patients aged 18 years and older who presented for surgical management of their PU were included in the study. RESULTS: Among the 93 patients who met the inclusion criteria, there were a total of 195 surgeries for 129 PU. Ninety-seven percent were classified as grade of 3 or 4 and 53% had osteomyelitis on presentation. 58% were either current smokers or ex-smokers, and 19% were diabetic. Debridement alone was the most common type of surgical management (58%), followed by flap reconstruction (25%). Those who underwent flap reconstruction were admitted for 71 days longer, on average. 41% of the surgeries were associated with a post-operative complication, with the most prominent being an infection at 26%. Of the 129 PU, 11% recurred at least 4 months post initial presentation. CONCLUSION: There are a multitude of a factors that impact prevalence, surgical complications, and recurrence of PU. This study provides insight into these factors to review our current practices and optimize surgical outcomes in the management of PU in the SCI population.

Mapping emergent public engagement in societal transitions: a scoping review.

BACKGROUND: Transition discourses are gaining prominence in efforts to imagine a future that adequately addresses the urgent need to establish low carbon and climate resilient pathways. Within these discourses the 'public' is seen as central to the creation and implementation of appropriate interventions. The role of public engagement in societal transformation while essential, is also complex and often poorly understood. The purpose of this paper is to enhance our understanding regarding public engagement and to address the often superficial and shallow policy discourse on this topic. MAIN TEXT: The paper offers a review of evolving literature to map emergent public engagement in processes of transition and change. We adopt a pragmatic approach towards literature retrieval and analysis which enables a cross-disciplinary and cross-sectoral review. We use a scoping review process and the three spheres of transformation framework (designated as the practical, political and personal spheres) to explore trends within this complex research field. The review draws from literature from the last two decades in the Irish context and looks at emergence and evolving spaces of public engagement within various systems of change including energy, food, coastal management and flood adaptation, among others. CONCLUSIONS: The results highlight the siloed and fragmented way in which public engagement in transitions is carried and we propose a more cross-sectoral and cross-disciplinary approach which depends on bringing into dialogue often contrasting theories and perspectives. The paper also illustrates some shifting engagement approaches. For instance, nexus articles between the practical and political spheres suggest deeper forms of public engagement beyond aggregated consumer behaviour to align technological delivery with institutional and societal contexts. While most articles in the practical sphere draw largely on techno-economic insights this influence and cross-disciplinarity is likely to draw in further innovations. Nexus articles between the political and personal sphere are also drawing on shifting ideas of public engagement and largely stress the need to disrupt reductive notions of engagement and agency within our institutions. Many of these articles call attention to problems with top-down public engagement structures and in various ways show how they often undermine and marginalise different groups.

Morphology of Donor and Recipient Nerves Utilised in Nerve Transfers to Restore Upper Limb Function in Cervical Spinal Cord Injury.

Loss of hand function after cervical spinal cord injury (SCI) impacts heavily on independence. Multiple nerve transfer surgery has been applied successfully after cervical SCI to restore critical arm and hand functions, and the outcome depends on nerve integrity. Nerve integrity is assessed indirectly using muscle strength testing and intramuscular electromyography, but these measures cannot show the manifestation that SCI has on the peripheral nerves. We directly assessed the morphology of nerves biopsied at the time of surgery, from three patients within 18 months post injury. Our objective was to document their morphologic features. Donor nerves included teres minor, posterior axillary, brachialis, extensor carpi radialis brevis and supinator. Recipient nerves included triceps, posterior interosseus (PIN) and anterior interosseus nerves (AIN). They were fixed in glutaraldehyde, processed and embedded in Araldite Epon for light microscopy. Eighty percent of nerves showed abnormalities. Most common were myelin thickening and folding, demyelination, inflammation and a reduction of large myelinated axon density. Others were a thickened perineurium, oedematous endoneurium and Renaut bodies. Significantly, very thinly myelinated axons and groups of unmyelinated axons were observed indicating regenerative efforts. Abnormalities exist in both donor and recipient nerves and they differ in appearance and aetiology. The abnormalities observed may be preventable or reversible.

Rehabilitation of Supinator Nerve to Posterior Interosseous Nerve Transfer in Individuals With Tetraplegia.

Despite being a routine part of the early surgical management of brachial plexus injury, nerve transfers have only recently been used as a reconstructive option for those with tetraplegia. Subsequently, there is limited published literature on the rehabilitation theories and techniques for optimizing outcomes in this population. This article seeks to address this void by presenting our centers' working model for rehabilitation after nerve transfers for individuals with tetraplegia. The model is illustrated with the example of the rehabilitation process after a supinator nerve to posterior interosseous nerve transfer. This nerve transfer reconstructs wrist, finger, and thumb extension. The topics covered in the model include the following: patient selection and presurgical planning/intervention, managing the postoperative healing phase of an individual who is wheelchair dependent, maximizing motor reeducation, increasing muscle strength, and ensuring use in functional tasks. This article provides a platform for further development and collaboration to improve the outcomes of patients who undergo nerve transfers after tetraplegia.

Seasonal and meteorological associations with depressive symptoms in older adults: A geo-epidemiological study.

BACKGROUND: Given increased social and physiological vulnerabilities, older adults may be particularly susceptible to environmental influences on mood. Whereas the impact of season on mood is well described for adults, studies rarely extend to elders or include objective weather data. We investigated the impact of seasonality and meteorological factors on risk of current depressive symptoms in older adults. METHODS: We used data on 8027 participants from the first wave of The Irish Longitudinal Study of Ageing, a population-representative cohort of adults aged 50+. Depressive symptoms were recorded using the Centre for Epidemiological Studies Depression Scale. Season was defined according to the World Meteorological Organisation. Data on climate over the preceding thirty years, and temperature and rain over the preceding month, were provided by the Irish Meteorological Service and linked using Geographic Information Systems techniques to participant's geo-coded locations at a resolution of one kilometre. RESULTS: The highest levels of depressive symptoms were reported in winter and the lowest in spring (mean 6.56 [CI95% 6.09, 7.04] vs. 5.81 [CI95%: 5.40, 6.22]). In fully adjusted linear regression models, participants living in areas with higher levels of rainfall in the preceding and/or current calendar month had greater depressive symptoms (0.04 SE 0.02; p=0.039 per 10mm additional rainfall per month) while those living in areas with sunnier climates had fewer depressive symptoms (-2.67 SE 0.88; p=0.003 for every additional hour of average annual daily sunshine). LIMITATIONS: This was a cross-sectional analysis thus causality cannot be inferred; monthly rain and temperature averages were available only on a calendar month basis while monthly local levels of sunshine data were not available. CONCLUSIONS: Environmental cues may influence mood in older adults and thus have relevance for the recognition and treatment of depression in this age group.

Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer: case report.

Restoration of elbow extension, grasp, key pinch, and release are major goals in low-level tetraplegia. Traditionally, these functions are achieved using tendon transfers. In this case these goals were achieved using nerve transfers. We present a 21-year-old man with a C6 level of tetraplegia. The left upper limb was treated 6 months after injury with a triple nerve transfer. A teres minor nerve branch to long head of triceps nerve branch, brachialis nerve branch to anterior interosseous nerve, and supinator nerve branch to posterior interosseous nerve transfer were used successfully to reconstruct elbow extension, key pinch, grasp, and release simultaneously.

Lateral supramalleolar flap in reconstruction of pressure ulcers in patients with spinal cord injury.

Pressure ulcers are a major source of morbidity in patients with spinal cord injury. Soft tissue reconstruction of pressure ulcers around the lateral malleolar region continues to be a challenge. Numerous techniques have been described in the published reports, each with their own limitations. We review our clinical experience with the lateral supramalleolar flap for reconstruction of difficult lateral malleolar pressure ulcers in patients with spinal cord injury. This study is a retrospective review of all patients who underwent this procedure between 1991 and 2005. This fasciocutaneous flap is raised on a peroneal artery perforator as its pedicle, without compromising the three vessels supplying the foot. A split-skin graft is placed on the secondary defect. The patient remains in bed for 4-6 weeks before mobilization is allowed. Eight flaps on seven patients were carried out over the study period. Patients' age ranged from 37 to 67 years (mean 56.6 years). Three patients had procedures carried out on the right and three had on the left. One patient had bilateral procedures. All flaps survived, and there were no recurrences of the pressure areas. One patient had a small area of wound breakdown at the edge of the flap, requiring debridement and split-skin graft. Another patient developed a seroma under the split-skin graft over the secondary defect, which resolved with dressings. The lateral supramalleolar flap is a simple, safe and durable flap for lateral malleolar pressure ulcer reconstruction in patients with spinal cord injury.