Use of antibiotics and the prevalence of antibiotic-associated diarrhoea in patients with spinal cord injuries: an international, multi-centre study.

BACKGROUND: Little is known about the use of antibiotics and the extent of antibiotic-associated diarrhoea (AAD) in patients with spinal cord injuries (SCIs). AIMS: To record the use of antibiotics, establish the prevalence of AAD and Clostridium difficile infection (CDI), and assess if there was any seasonal variation in antibiotic use and incidence of AAD in patients with SCIs. METHODS: A retrospective study was conducted in six European SCI centres between October 2014 and June 2015. AAD was defined as two or more watery stools (Bristol Stool Scale type 5, 6 or 7) over 24 h. FINDINGS: In total, 1267 adults (median age 54 years, 30.7% female) with SCIs (52.7% tetraplegia, 59% complete SCI) were included in this study. Among the 215 (17%) patients on antibiotics, the top three indications for antibiotics were urinary tract infections (UTIs), infected pressure ulcers and other skin infections. Thirty-two of these 215 (14.9%) patients developed AAD and two patients out of the total study population (2/1267; 0.16%) developed CDI. AAD was more common in summer than in spring, autumn or winter (30.3% vs 3.8%, 7.4% and 16.9%, respectively; P<0.01). AAD was associated with age ≥65 years, tetraplegia, higher body mass index, hypoalbuminaemia, polypharmacy, multiple antibiotic use and high-risk antibiotic use. Summer and winter seasons and male sex were identified as independent predictors for the development of AAD. CONCLUSION: This survey found that AAD is common in patients with SCIs, and UTI is the most common cause of infection. Summer and winter seasons and male sex are unique predictors for AAD. Both AAD and UTIs are potentially preventable; therefore, further work should focus on preventing the over-use of antibiotics, and developing strategies to improve hospital infection control measures.

Use of antibiotic and prevalence of antibiotic-associated diarrhoea in-patients with spinal cord injuries: a UK national spinal injury centre experience.

BACKGROUND: This was a retrospective audit, with the aims being to (1) record the use of antibiotics; (2) establish the prevalence of antibiotic-associated diarrhoea (AAD) and Clostridium difficile-associated diarrhoea (CDAD); and (3) assess if there was any seasonal variation in antibiotic use and incidence of AAD. METHODS: The study was performed at a single spinal cord injury (SCI) centre in the UK. Data were collected using a standardised questionnaire during October 2014 to June 2015. We define AAD as two or more watery stools of type 5, 6 or 7 (Bristol stool scale) over 24 h. RESULTS: Three-hundred-and-nineteen adults (mean age: 55.9 years, 29.2% female) with SCI (58.2% tetraplegia; 43.7% complete SCI) were included. Of 70 (21.9%) patients on antibiotics, the top three indications for antibiotics were urinary-tract infections, infected pressure ulcers and other skin infections. Seventeen of 78 (21.8%) developed AAD and three of 319 (0.94%) developed CDAD. AAD was more common in the summer season than in spring, autumn and winter (47.1%, 10.0%, 10.0%, 23.8%, P=0.025). AAD was associated with older adults greater than 65 years (70.6% vs 23.8%, P=0.007). Polypharmacy and the summer season were identified as independent predictors for AAD. CONCLUSION: This survey found that AAD is common in SCI patients and may be a risk factor for a poorer outcome and increased hospital costs. A multicentre study is underway to establish the incidence and risk factors for AAD.

Which factors are associated with quality of life in patients with Graves' orbitopathy presenting for orbital decompression surgery?

PURPOSE: Graves' orbitopathy (GO) is associated with changes in the appearance of the eyes and visual dysfunction. Patients report feeling socially isolated and unable to continue with day-to-day activities. This study aimed at investigating the demographic, clinical, and psychosocial factors associated with quality of life in patients presenting for orbital decompression surgery. METHODS: One-hundred and twenty-three adults with GO due for orbital decompression at Moorfields Eye Hospital London were recruited prospectively. Clinical measures including treatment history, exophthalmos, optic neuropathy, and diplopia were taken by an ophthalmologist. Participants completed psychosocial questionnaires, including the Graves' Ophthalmopathy Quality of Life Scale (GO-QOL), the Hospital Anxiety and Depression Scale, and the Derriford Appearance Scale. Hierarchical multiple regression analyses were used to identify predictors of quality of life. RESULTS: Higher levels of potential cases of clinical anxiety (37%) and depression (26%) were found in this study sample than in patients with other chronic diseases or facial disfigurements. A total of 55% of the variance in GO-QOL visual function scores was explained by the regression model; age, asymmetrical GO and depressed mood were significant unique contributors. In all, 75% of the variance in GO-QOL appearance scores was explained by the regression model; gender, appearance-related cognitions and depressed mood were significant unique contributors. CONCLUSION: Appearance-related quality of life and mood were particularly affected in this sample. Predominantly psychosocial characteristics were associated with quality of life. It is important when planning surgery for patients that clinicians be aware of factors that could potentially influence outcomes.

Review of dietetic service provision and activity in spinal cord injury centres: a multicentre survey in the UK and Republic of Ireland.

OBJECTIVES: The present study was undertaken to review the service provision in spinal cord injury (SCI) centres (SCICs); to establish and compare how much time dietitians spend in direct and indirect contact with patients; and to document current nutritional screening practices. METHODS: All 12 SCICs in the United Kingdom and the Republic of Ireland were surveyed by a postal questionnaire in April 2014. Data collected included the number of whole-time-equivalent (WTE) staff available, whether a nutrition team was present and the use of nutrition screening tools. A work sampling tool was used to capture dietetic activity for a period of 1 week. RESULTS: Eight (66.7%) SCICs responded (390/531 of total SCI beds) and the average numbers of patients per WTE staff, including consultants, nurses, dietitians, physiotherapists, occupational therapists were recorded. Six out of eight SCICs used a validated nutritional screening tool. Thirty-two work sampling tools were analysed, revealing that spinal dietitians spend 39.1% of the working day in direct patient-related activities. Staffing levels varied and were below clinical recommendations in six out of eight SCICs. CONCLUSION: The resources allocated to nutritional care in SCICs appear to be varied and limited. This suggests malnutrition may continue to be under-recognised and under-treated. To address the complex nutritional needs of this special population group there is a clear need to establish staffing level for dietitians. Information collected from the present study could contribute to the supply analysis of a future workforce planning exercise in SCIC dietetic service.

Knowledge, attitudes and practices of medical staff towards obesity management in patients with spinal cord injuries: an International survey of four western European countries.

OBJECTIVE: To (1) examine the opinions of medical staff working in spinal cord injury (SCI) centres (SCICs); (2) evaluate their knowledge, attitudes and practices towards obesity prevention and management; (3) report the number of beds and dietitians available at each SCIC. METHODS: A 37-item questionnaire was sent to 23 SCICs in the UK, the Netherlands, Belgium and the Republic of Ireland between September 2012 and January 2013. RESULTS: Eighteen SCICs returned the questionnaires for analysis. All respondents stated that they had an interest in obesity treatment but only 2.3% of the respondents received training in obesity management. Sixty-one percent of staff did not consider body mass index (BMI) to be appropriate for use in SCI patients and subsequently less than half of the respondents use BMI routinely. The majority of respondents reported that they are confident in dealing with overweight (74.5%) and obese (66.1%) SCI adults, less than half (44.1%) are confident in treating overweight and obese SCI children. Respondents also indicated the need for nationally adopted guidelines and a lack of physical activity provision. There were 17.5 whole-time equivalent (WTE) dietitians recorded in 22 SCICs, equivalent to 47.8 beds per WTE dietitians (range 10-420). Non-UK SCIC dietitians are significantly better resourced than in UK SCICs (beds per WTE dietitian: 36 vs 124, P=0.035). CONCLUSION: Medical staff expressed the need to participate in obesity prevention and management. Appropriate training should be considered for all medical staff and the development of specific weight management guidelines and dietetic provision should be considered.

Is undernutrition risk associated with an adverse clinical outcome in spinal cord-injured patients admitted to a spinal centre?

BACKGROUND/OBJECTIVES: To evaluate whether undernutrition risk measured using the Spinal Nutrition Screening Tool (SNST) and the Malnutrition Universal Screening Tool (MUST) is associated with worse clinical outcomes in respect of length of in-patient hospital stay (LOS) and mortality in the 12 months after admission to a spinal cord injuries (SCIs) centre. METHODS: A multicentre, prospective, cross-sectional observational study was conducted in four UK SCI centres (SCICs). A total of 150 SCI patients (aged 18-88 years (median: 44 years), 30.7% females) were studied between July 2009 and March 2010. LOS and mortality 12 months after admission to the SCIC was monitored. Multivariate regression analysis was used to identify unique predictors of the variance of LOS. RESULTS: The patients initially undernourished or at risk of undernutrition (44.6%) had a significantly longer LOS (median (days): 129 vs 85, P=0.012) and greater 12-month mortality (% deceased: 9.2% vs 1.4%, P=0.036). In addition, serum albumin and new admission to an SCIC were identified as independent predictors for long LOS. CONCLUSION: The present study suggests that undernutrition risk, as identified by the SNST, is associated with adverse clinical outcomes. Nutritional screening should be helpful in improving clinical outcomes if it promotes more appropriate and effective nutritional intervention.

Validation of the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) in patients with spinal cord injuries (SCIs).

OBJECTIVES: To validate the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) in paediatric spinal cord injuries (SCIs) patients admitted to the tertiary SCI centre. METHODS: children's baseline clinical data, anthropometric measurements and STAMP score were assessed on admission. The validity of STAMP was assessed by (i) comparison with a full dietetic assessment (criterion validity); (ii) comparison with generic paediatric screening tools: the Paediatric Yorkhill Malnutrition Score (PYMS; concurrent validity); and (iii) completion of an additional STAMP to assess inter- and intra-rater reliability. The agreement was assessed using Cohen's κ-statistics. RESULTS: Fifty-one children were screened by STAMP. The prevalence of undernutrition risk was 58.8%. STAMP had moderate agreement with dietitian assessment (κ: 0.507) and a fair agreement with PYMS (κ: 0.314). The STAMP had substantial reliability (inter-rater reliability: κ: 0.752; intra-rater reliability: κ: 0.635). When compared with dietetic assessment as a reference standard, STAMP had a sensitivity of 83.3%, specificity of 66.7% and an overall agreement of 76.5%. CONCLUSION: The present study shows that undernutrition is common in children with SCI. The STAMP is an acceptable (valid and reliable) tool to identify paediatric SCI patients at risk of undernutrition.

Meal provision in a UK National Spinal Injury Centre: a qualitative audit of service users and stakeholders.

STUDY DESIGN: A single centre survey. OBJECTIVES: The objective of this study is to (1) assess patients' food intake and (2) measure satisfaction with current food provision, as judged by patients and by stakeholders (medical and nursing staff, managers and catering staff). METHODS: Standardised questionnaires were used to record food intake over a 24-h period, and to evaluate the quality, ordering, delivery and overall acceptability of food provided. RESULTS: The food intake of 67 patients with spinal cord injury (SCI) was recorded (64% response rate) and 166 evaluations (50% response rate) were returned. Twenty-nine patients (48%) consumed three full meals a day, 17 (26%) received oral nutritional supplements, 22 (34%) received vitamin/mineral supplements, and 23 (35%) required assistance to eat. Some patients and stakeholders expressed satisfaction with the current food provision: taste good: 25 versus 17% (for patients and stakeholders, respectively); appropriate texture: 22 versus 21%; appropriate temperature: 55 versus 72% (P = 0.002); well presented: 43 versus 28%; good choice: 49 versus 59%; received meal ordered: 65 versus 37% (P < 0.001); meal served on time: 71 versus 58%; and no interruption during mealtimes: 62 versus 46%. Principal component analyses of item scores identified three main factors (food quality, food presentation and food delivery (logistics). CONCLUSION: The present study identified some areas where there appeared to have been improvement in SCI hospital catering, but with much still to be achieved. Hospital-catering systems should be tailored to meet the demands of the different patient groups to optimise nutritional intake. Periodic quality control is essential to meet recommendations and patients' expectations.

Validation of the spinal nutrition screening tool (SNST) in patients with spinal cord injuries (SCI): result from a multicentre study.

BACKGROUND/OBJECTIVES: A disease-specific nutrition screening tool (NST): the spinal nutrition screening tool (SNST) has been developed for use in patients with spinal cord injury (SCI) but its reliability and agreement with other published tools requires investigation. The aims of this study were to assess the prevalence of malnutrition risk in SCI patients and to confirm the diagnostic accuracy of the SNST. SUBJECTS/METHODS: Patients' baseline clinical data, anthropometric measurements and NST scores were assessed. The validity of the SNST was assessed by (i) comparing with a full dietetic assessment (criterion validity); (ii) comparison with a generic NST: malnutrition universal screening tool (MUST) (concurrent validity); and (iii) completion of an additional SNST to assess inter- and intra-rater reliability. Agreement was assessed using Cohen's κ-statistics. RESULTS: Using the SNST, the prevalence of malnutrition risk ranged from 22 to 64% on admission to four SCI centres. The SNST had substantial agreement with MUST (κ: 0.723, 95% confidence interval (CI): 0.607-0.839) and dietitian assessment (κ: 0.567, 95% CI: 0.434-0.699). The SNST had a moderate to substantial reliability (inter-rater reliability: κ: 0.5, 95% CI: 0.2-0.8; intra-rater reliability: κ: 0.64, 95% CI: 0.486-0.802). When compared with dietetic assessment, the SNST had a numerically lower specificity (76.1% vs 80.4%) and similar agreement to MUST (κ: 0.57 vs 0.58) but SNST showed a numerically higher sensitivity (85.7% vs 80.4%) and a numerically higher negative predictive value (92% vs 89.2%) than MUST. CONCLUSIONS: This study shows that malnutrition is common in SCI patients. The SNST is an acceptable (valid and reliable) NST and may be a useful alternative to MUST in identifying SCI patients at risk of malnutrition.

Laryngeal manual therapy: a preliminary study to examine its treatment effects in the management of muscle tension dysphonia.

The objectives of this study were to determine appropriate acoustic and outcome measures for the evaluation of a method of laryngeal manual therapy (LMT) used in the treatment of patients with muscle tension dysphonia (MTD). The effects of this technique were also investigated. The study was based on the hypotheses that the vertical position of the larynx in the vocal tract would lower, that the quality of the voice would normalize, and that a reduction in any vocal tract discomfort (VTD) would occur after LMT. This was a small, prospective, repeated measures pilot study in which each member of the research team was "blinded" to all other stages of the study and during which all data were anonymized until the final stage of data analysis. Ten subjects presenting with MTD completed outcome measures and provided audiorecordings immediately before, immediately after, and 1 week after LMT. The Kay CSL 4150 was used for signal acquisition and for some acoustic measurements. Spectrographic evaluation was accomplished with Praat. A new perceptual, self-rating scale, the VTD scale, and a new proforma for use by the clinician for palpatory evaluation, were developed for the study. Relative average perturbation during connected speech was significantly reduced after LMT, indicating a reduction in abnormal vocal function. The severity and frequency of VTD was shown to have reduced after LMT. This pilot study showed positive evidence for LMT as a method of therapy in the treatment of hyperfunctional voice disorders. Its effects were shown to be measurable with both acoustical analysis and the VTD scale.

Peak flow and voice pathology.

Lung function influences voice quality. The aim of this study was to determine if there was a link between subjective voice pathology and peak flow in patients newly presenting with voice problems. A prospective, multigroup study design was designed, with three groups: New voice pathology patients presenting to voice clinics or speech therapists; General patients from ear, nose, and throat clinics with no voice or hearing abnormality; and Asthmatics presenting to general practitioner surgeries or asthma groups for review of asthma treatment. Fifty general ENT patients, 50 voice pathology patients, and 26 asthmatics were included. Peak flow and Voice Handicap Index (VHI) were measured in all subjects. Analysis of the correlation between VHI and percentage of expected peak flow showed a small correlation between the two for voice pathology patients (r=-0.304, P=0.016). No significant correlation was found for the other two groups. These results do not justify the routine measurement of peak flow in all voice clinic patients, but suggest that peak flow measurement and optimization may have a place in those with the most severely impaired VHI.