Age and Comorbidities Predict COVID-19 Outcome, Regardless of Innate Immune Response Severity: A Single Institutional Cohort Study.

The COVID-19 pandemic has claimed over eight hundred thousand lives in the United States alone, with older individuals and those with comorbidities being at higher risk of severe disease and death. Although severe acute respiratory syndrome coronavirus 2-induced hyperinflammation is one of the mechanisms underlying the high mortality, the association between age and innate immune responses in COVID-19 mortality remains unclear. DESIGN: Flow cytometry of fresh blood and multiplexed inflammatory chemokine measurements of sera were performed on samples collected longitudinally from our cohort. Aggregate impact of comorbid conditions was calculated with the Charlson Comorbidity Index, and association between patient factors and outcomes was calculated via Cox proportional hazard analysis and repeated measures analysis of variance. SETTING: A cohort of severely ill COVID-19 patients requiring ICU admission was followed prospectively. PATIENTS: In total, 67 patients (46 male, age 59 ± 14 yr) were included in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mortality in our cohort was 41.8%. We identified older age (hazard ratio [HR] 1.09 [95% CI 1.07-1.11]; p = 0.001), higher comorbidity index (HR 1.24 [95% CI 1.14-1.35]; p = 0.039), and hyponatremia (HR 0.90 [95% CI 0.82-0.99]; p = 0.026) to each independently increase risk for death in COVID-19. We also found that neutrophilia (R = 0.2; p = 0.017), chemokine C-C motif ligand (CCL) 2 (R = 0.3; p = 0.043), and C-X-C motif chemokine ligand 9 (CXCL9) (R = 0.3; p = 0.050) were weakly but significantly correlated with mortality. Older age was associated with lower monocyte (R = -0.2; p = 0.006) and cluster of differentiation (CD) 16+ cell counts (R = -0.2; p = 0.002) and increased CCL11 concentration (R = 0.3; p = 0.050). Similarly, younger patients (< 65 yr) demonstrated a rise in CD4 (b-coefficient = 0.02; p = 0.036) and CD8 (0.01; p = 0.001) counts, as well as CCL20 (b-coefficient = 6.8; p = 0.036) during their ICU stay. This CD8 count rise was also associated with survival (b-coefficient = 0.01; p = 0.023). CONCLUSIONS: Age, comorbidities, and hyponatremia independently predict mortality in severe COVID-19. Neutrophilia and higher CCL2 and CXCL9 levels are also associated with higher mortality, while independent of age.

Suppression of Fibrinolysis and Hypercoagulability, Severity of Hypoxemia, and Mortality in COVID-19 Patients: A Retrospective Cohort Study.

BACKGROUND: COVID-19 causes hypercoagulability, but the association between coagulopathy and hypoxemia in critically ill patients has not been thoroughly explored. This study hypothesized that severity of coagulopathy would be associated with acute respiratory distress syndrome severity, major thrombotic events, and mortality in patients requiring intensive care unit-level care. METHODS: Viscoelastic testing by rotational thromboelastometry and coagulation factor biomarker analyses were performed in this prospective observational cohort study of critically ill COVID-19 patients from April 2020 to October 2020. Statistical analyses were performed to identify significant coagulopathic biomarkers such as fibrinolysis-inhibiting plasminogen activator inhibitor 1 and their associations with clinical outcomes such as mortality, extracorporeal membrane oxygenation requirement, occurrence of major thrombotic events, and severity of hypoxemia (arterial partial pressure of oxygen/fraction of inspired oxygen categorized into mild, moderate, and severe per the Berlin criteria). RESULTS: In total, 53 of 55 (96%) of the cohort required mechanical ventilation and 9 of 55 (16%) required extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation-naïve patients demonstrated lysis indices at 30 min indicative of fibrinolytic suppression on rotational thromboelastometry. Survivors demonstrated fewer procoagulate acute phase reactants, such as microparticle-bound tissue factor levels (odds ratio, 0.14 [0.02, 0.99]; P = 0.049). Those who did not experience significant bleeding events had smaller changes in ADAMTS13 levels compared to those who did (odds ratio, 0.05 [0, 0.7]; P = 0.026). Elevations in plasminogen activator inhibitor 1 (odds ratio, 1.95 [1.21, 3.14]; P = 0.006), d-dimer (odds ratio, 3.52 [0.99, 12.48]; P = 0.05), and factor VIII (no clot, 1.15 ± 0.28 vs. clot, 1.42 ± 0.31; P = 0.003) were also demonstrated in extracorporeal membrane oxygenation-naïve patients who experienced major thrombotic events. Plasminogen activator inhibitor 1 levels were significantly elevated during periods of severe compared to mild and moderate acute respiratory distress syndrome (severe, 44.2 ± 14.9 ng/ml vs. mild, 31.8 ± 14.7 ng/ml and moderate, 33.1 ± 15.9 ng/ml; P = 0.029 and 0.039, respectively). CONCLUSIONS: Increased inflammatory and procoagulant markers such as plasminogen activator inhibitor 1, microparticle-bound tissue factor, and von Willebrand factor levels are associated with severe hypoxemia and major thrombotic events, implicating fibrinolytic suppression in the microcirculatory system and subsequent micro- and macrovascular thrombosis in severe COVID-19.

DAMPs/PAMPs induce monocytic TLR activation and tolerance in COVID-19 patients; nucleic acid binding scavengers can counteract such TLR agonists.

Millions of COVID-19 patients have succumbed to respiratory and systemic inflammation. Hyperstimulation of toll-like receptor (TLR) signaling is a key driver of immunopathology following infection by viruses. We found that severely ill COVID-19 patients in the Intensive Care Unit (ICU) display hallmarks of such hyper-stimulation with abundant agonists of nucleic acid-sensing TLRs present in their blood and lungs. These nucleic acid-containing Damage and Pathogen Associated Molecular Patterns (DAMPs/PAMPs) can be depleted using nucleic acid-binding microfibers to limit the patient samples' ability to hyperactivate such innate immune receptors. Single-cell RNA-sequencing revealed that CD16+ monocytes from deceased but not recovered ICU patients exhibit a TLR-tolerant phenotype and a deficient anti-viral response after ex vivo TLR stimulation. Plasma proteomics confirmed such myeloid hyperactivation and revealed DAMP/PAMP carrier consumption in deceased patients. Treatment of these COVID-19 patient samples with MnO nanoparticles effectively neutralizes TLR activation by the abundant nucleic acid-containing DAMPs/PAMPs present in their lungs and blood. Finally, MnO nanoscavenger treatment limits the ability of DAMPs/PAMPs to induce TLR tolerance in monocytes. Thus, treatment with microfiber- or nanoparticle-based DAMP/PAMP scavengers may prove useful for limiting SARS-CoV-2 induced hyperinflammation, preventing monocytic TLR tolerance, and improving outcomes in severely ill COVID-19 patients.

Airway management in patients with lingual thyroid: a case report and review of the literature.

PURPOSE: To review the management of patients with lingual thyroid (LT) causing upper airway obstruction and to suggest a diagnostic and therapeutic workflow. METHODS: A PubMed review of published cases from January 1980 up to December 2020 of LT causing upper airway obstruction. We selected cases of confirmed LTs that presented with non-state-dependent airway obstruction. An illustrative case report is presented. RESULTS: Twenty-one articles fulfilling the inclusion criteria were found, reporting 24 cases (7 neonatal, 2 pediatric and 15 adults). The main presenting symptoms was dyspnea with increased work of breathing, followed by dysphagia and stridor most commonly in neonates. At least one imaging modality was performed in all patients. Thyroid function was altered in half the patients and normal in the other half. The LT was the only thyroid tissue in all cases except 2. Altogether, 5/24 patients required tracheostomies and two-thirds of the patients underwent surgical resection of the LT (mostly transoral). Also 2/3 of the patients received thyroid replacement therapy. After a median follow-up of 17 months, airway symptoms had fully resolved for all patients but one. CONCLUSION: While rare, ectopic LTs should be considered in the differential diagnosis of stridor, dyspnea and airway obstruction. In neonates, concomitant presence of hypothyroidism on neonatal screening and airway obstruction should prompt the search for a LT. Early identification and thyroid replacement therapy seem to significantly relieve symptoms of upper airway obstruction, but severe obstruction and concomitant airway lesions may require more definitive management approaches.

Reducing metabolizable protein supply: Effects on milk production, blood metabolites, and health in early-lactation dairy cows.

Our objective was to evaluate the effect of metabolizable protein (MP) supply on milk production, blood metabolites, and health in dairy cows during early lactation. Three experimental diets were formulated to contain 114, 107, 101 g of MP/kg of dry matter (DM; 114MP, 107MP, and 101MP, respectively) with crude protein contents of 17.0, 16.2, and 15.3% of DM, respectively. One hundred multiparous Holstein cows were fed 1 of these 3 diets during wk 1 to 3 and wk 4 to 13 of lactation in one of the following sequences: (1) 114MP and 107MP (114MP/107MP), (2) 114MP and 101MP (114MP/101MP), or (3) 101MP and 101MP (101MP/101MP). During wk 1 to 3, the 114MP and 101MP treatments were 20 and 27% deficient in estimated MP, respectively. From wk 4 to 13, the 114MP/107MP, 114MP/101MP, and 101MP/101MP treatments were 8, 12, and 13% deficient in estimated MP, respectively. Data were analyzed separately for wk 1 to 3, 4 to 13, and 1 to 13. Dry matter intake and energy-corrected milk (ECM) yield were not affected by treatment during wk 4 to 13 or wk 1 to 13; however, ECM yield decreased for 101MP versus 114MP from wk 1 to 3. Similarly, feed efficiency was not affected by treatment from wk 4 to 13 or wk 1 to 13, and was reduced with 101MP versus 114MP during wk 1 to 3. Milk N efficiency tended to increase for 101MP versus 114MP for wk 1 to 3 and increased with 101MP/101MP and 114MP/101MP relative to 114MP/107MP during wk 4 to 13 and wk 1 to 13. Treatment had no influence on yields and concentrations of milk components from wk 4 to 13 or wk 1 to 13; however, compared with 114MP, feeding 101MP tended to decrease milk fat yield and decreased yields of milk true protein and lactose for wk 1 to 3. Both milk and blood urea N concentrations decreased for 101MP/101MP and 114MP/101MP relative to 114MP/107MP during wk 4 to 13 and wk 1 to 13, and were reduced with feeding 101MP versus 114MP from wk 1 to 3. Treatment had no effect on the incidence of diseases in cows throughout the study. Serum concentrations of total fatty acids, albumin, and aspartate aminotransferase did not differ between 101MP and 114MP; however, serum ß-hydroxybutyrate concentration was lower in cows receiving 101MP during the first 3 wk of lactation. Compared with 114MP, feeding 101MP during wk 1 to 3 increased plasma concentrations of creatinine and 3-methylhistidine (3-MHis) but did not change the ratio of plasma 3-MHis to creatinine. We found no differences in plasma creatinine or the ratio of 3-MHis-to-creatinine among treatments from wk 4 to 13; however, 101MP/101MP and 114MP/101MP had elevated plasma 3-MHis compared with 114MP/107MP. Treatment had no effect on body weight and body condition score over the duration of the study. Collectively, despite reduced milk production for the first 3 wk of lactation, feeding the 101MP/101MP treatment sustained lactational performance and improved milk N efficiency without negatively affecting the frequency of diseases in dairy cows during the first 13 wk postpartum.

Pectin Influences the Absorption and Metabolism of Polyphenols from Blackcurrant and Green Tea in Rats.

Consumption of polyphenols and dietary fiber as part of a normal diet is beneficial to human health. In this study, we examined whether different amounts of dietary soluble fiber (pectin) affect the absorption and metabolism of polyphenols from blackcurrant and green tea in rats. After 28 days, the rats fed blackcurrant and green tea with pectin (4 or 8%) had significantly lower body weight gain and food intake compared to the rats fed a control diet. Rats fed a blackcurrant and green tea diet with 8% pectin had significantly higher fecal nitrogen output and lower protein digestibility. No polyphenols were observed in the urine, feces and plasma of rats fed the control diet. Parent catechins and flavonols were absent in urine obtained from all diet groups. Gallocatechin glucuronide was only observed in the plasma of rats fed the blackcurrant and green tea diet without pectin. Meanwhile, epicatechin and catechin gallate were present in the feces of rats fed a blackcurrant and green tea diet with and without 4% pectin. Pectin (4 or 8%) added to the blackcurrant and green tea diet increased the plasma antioxidant capacity in rats. Inclusion of pectin in the diet altered the host absorption and metabolism of polyphenols from blackcurrant and green tea.

Key Pathogenic Factors in Coronavirus Disease 2019-Associated Coagulopathy and Acute Lung Injury Highlighted in a Patient With Copresentation of Acute Myelocytic Leukemia: A Case Report.

The role of concurrent illness in coronavirus disease 2019 (COVID-19) is unknown. Patients with leukemia may display altered thromboinflammatory responses. We report a 53-year-old man presenting with acute leukemia and COVID-19 who developed thrombotic complications and acute respiratory distress syndrome. Multiple analyses, including rotational thromboelastometry and flow cytometry on blood and bronchoalveolar lavage, are reported to characterize coagulation and immune profiles. The patient developed chemotherapy-induced neutropenia that may have protected his lungs from granulocyte-driven hyperinflammatory acute lung injury. However, neutropenia also alters viral clearing, potentially enabling ongoing viral propagation. This case depicts a precarious equilibrium between leukemia and COVID-19.

Children's Disclosure of Sexual Abuse: A Systematic Review of Qualitative Research Exploring Barriers and Facilitators.

This study evaluates and synthesizes qualitative evidence addressing factors affecting a child's decision to disclose an experience of sexual abuse. Childhood sexual abuse is a devastating crime, with long-term negative impacts. Understanding the factors that affect a child's decision to disclose is vital. Disclosure enables access to support and protection, both therapeutically and legally. A systematic review was conducted focusing on factors affecting a child's decision to disclose an experience of sexual abuse. Seven studies were identified, quality appraisal undertaken, and meta-ethnography used to synthesize the studies. Six new super-ordinate themes were developed: Fear of what will happen; Others' reactions: fear of disbelief; Emotions and impact of the abuse; An opportunity to tell; Concern for self and others; and Feelings toward the abuser. Themes indicated the importance of support, structure, and opportunity to facilitate disclosure and should be utilized by agencies to develop practices that facilitate disclosures.

Longitudinal Recovery and Reduced Costs After 120 Sessions of Locomotor Training for Motor Incomplete Spinal Cord Injury.

OBJECTIVE: To determine the impact of long-term, body weight-supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers. DESIGN: Prospective observational cohort with longitudinal follow-up. SETTING: Eight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN). PARTICIPANTS: Individuals with motor incomplete chronic SCI (American Spinal Injury Association Impairment Scale C or D; N=69; 0.1-45y after SCI) who completed at least 120 NRN physical therapy sessions. INTERVENTIONS: Manually assisted locomotor training (LT) in a body weight-supported treadmill environment, overground standing and stepping activities, and community integration tasks. MAIN OUTCOME MEASURES: International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), Berg Balance Scale, Modified Functional Reach, 10-m walk test, and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6- to 12-month follow-up after discharge from therapy. RESULTS: Significant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement, and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6 to 12 months after treatment. CONCLUSIONS: Delivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20-session insurance limit can reduce rehospitalizations and long-term health costs.

Patterns of pollen and nectar foraging specialization by bumblebees over multiple timescales using RFID.

The ecological success of social insects is frequently ascribed to improvements in task performance due to division of labour amongst workers. While much research has focused on improvements associated with lifetime task specialization, members of colonies can specialize on a given task over shorter time periods. Eusocial bees in particular must collect pollen and nectar rewards to survive, but most workers appear to mix collection of both rewards over their lifetimes. We asked whether bumblebees specialize over timescales shorter than their lifetime. We also explored factors that govern such patterns, and asked whether reward specialists made more foraging bouts than generalists. In particular, we described antennal morphology and size of all foragers in a single colony and related these factors to each forager's complete foraging history, obtained using radio frequency identification (RFID). Only a small proportion of foragers were lifetime specialists; nevertheless, >50% of foragers specialized daily on a given reward. Contrary to expectations, daily and lifetime reward specialists were not better foragers (being neither larger nor making more bouts); larger bees with more antennal olfactory sensilla made more bouts, but were not more specialized. We discuss causes and functions of short and long-term patterns of specialization for bumblebee colonies.

Investigating the impacts of field-realistic exposure to a neonicotinoid pesticide on bumblebee foraging, homing ability and colony growth.

The ability to forage and return home is essential to the success of bees as both foragers and pollinators. Pesticide exposure may cause behavioural changes that interfere with these processes, with consequences for colony persistence and delivery of pollination services.We investigated the impact of chronic exposure (5-43 days) to field-realistic levels of a neonicotinoid insecticide (2·4 ppb thiamethoxam) on foraging ability, homing success and colony size using radio frequency identification (RFID) technology in free-flying bumblebee colonies.Individual foragers from pesticide-exposed colonies carried out longer foraging bouts than untreated controls (68 vs. 55 min). Pesticide-exposed bees also brought back pollen less frequently than controls indicating reduced foraging performance.A higher proportion of bees from pesticide-exposed colonies returned when released 1 km from their nests; this is potentially related to increased orientation experience during longer foraging bouts. We measured no impact of pesticide exposure on homing ability for bees released from 2 km, or when data were analysed overall.Despite a trend for control colonies to produce more new workers earlier, we found no overall impacts of pesticide exposure on whole colony size. Synthesis and applications. This study shows that field-realistic neonicotinoid exposure can have impacts on both foraging ability and homing success of bumblebees, with implications for the success of bumblebee colonies in agricultural landscapes and their ability to deliver crucial pollination services. Pesticide risk assessments should include bee species other than honeybees and assess a range of behaviours to elucidate the impact of sublethal effects. This has relevance for reviews of neonicotinoid risk assessment and usage policy world-wide.

Intestinal Alkaline Phosphatase Regulates Tight Junction Protein Levels.

BACKGROUND: Intestinal alkaline phosphatase (IAP) plays a pivotal role in maintaining gut health and well-being. Oral supplementation with IAP in mice improves gut barrier function and prevents luminal proinflammatory factors from gaining access to the circulation. In this study, we sought to explore the relationship between IAP and tight junction protein (TJP) expression and function. STUDY DESIGN: The effect of IAP deletion on TJP levels was studied in mouse embryonic fibroblasts (MEFs) generated from IAP-knockout and wild type mice. Regulation of TJPs by IAP was assayed in the human colon cancer Caco-2 and T84 cells by overexpressing the human IAP gene. Tight junction protein levels and localization were measured by using RT q-PCR and antibodies targeting the specific TJPs. Finally, the effect of IAP on inflammation-induced intestinal permeability was measured by in vitro trans-well epithelial electrical resistance (TEER). RESULTS: Intestinal alkaline phosphatase gene deletion in MEFs resulted in significantly lower levels of ZO-1, ZO-2, and Occludin compared with levels in wild-type control cells; IAP overexpression in Caco-2 and T84 cells resulted in approximate 2-fold increases in the mRNA levels of ZO-1 and ZO-2. The IAP treatment ameliorated lipopolysaccharide-induced increased permeability in the Caco-2 trans-well system. Furthermore, IAP treatment preserved the localization of the ZO-1 and Occludin proteins during inflammation and was also associated with improved epithelial barrier function. CONCLUSIONS: Intestinal alkaline phosphatase is a major regulator of gut mucosal permeability and appears to work at least partly through improving TJP levels and localization. These data provide a strong foundation to develop IAP as a novel therapy to maintain gut barrier function.

Antenatal Determinants of Long-Term Kidney Outcome in Boys with Posterior Urethral Valves.

BACKGROUND: Posterior urethral valves (PUV) are the most important cause of end-stage renal disease (ESRD) in young boys. The objective of this report was to define the antenatal determinants of long-term postnatal renal outcome in this condition. DESIGN: This was a retrospective cohort analysis. The primary outcome was the development of ESRD defined as starting dialysis or receiving a preemptive kidney transplant. RESULTS: Eighty-two cases of PUV were identified, with 17 (21%) developing ESRD at 6.1 ± 7.1 years. Cases developing ESRD were more likely diagnosed antenatally (41 vs. 19%, p = 0.05), had a younger gestational age (35.5 ± 3.4 weeks vs. 37.3 ± 2.1 weeks, p = 0.02), and on antenatal ultrasound scan were more likely to have oligohydramnios (60 vs. 26%, p = 0.02), renal cortical cysts (47 vs. 17%, p = 0.02), and the combination of oligohydramnios, renal cortical cysts, and increased renal echogenicity (47 vs. 9%, p = 0.002). CONCLUSIONS: In boys with PUV, decreased gestational age, oligohydramnios, renal cysts, and the combination of oligohydramnios, cortical cysts, and echogenic kidneys were associated with ESRD, while the combination was an independent predictor of poor long-term postnatal kidney function.

Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial.

OBJECTIVE: To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation. DESIGN: Randomized controlled trial with delayed treatment design. SETTING: Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS: Volunteer sample of adults (N=48; 37 men and 11 women; age, 18-66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI). INTERVENTIONS: A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES: Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check). RESULTS: Significant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P=.024] and lower extremity motor score [4.2±5.2 vs -0.6±4.2; P=.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P=.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P=.002). CONCLUSIONS: ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.

Activity-based therapy for recovery of walking in chronic spinal cord injury: results from a secondary analysis to determine responsiveness to therapy.

OBJECTIVE: To gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial. DESIGN: Secondary analysis of results from a randomized controlled trial with delayed treatment design. SETTING: Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS: Volunteer sample of adults (N=38; 27 men; 11 women; age, 22-63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI). INTERVENTIONS: A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES: Walking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test). RESULTS: This secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program. CONCLUSIONS: ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.

Life care planning projections for individuals with motor incomplete spinal cord injury before and after locomotor training intervention: a case series.

BACKGROUND/PURPOSE: We present a retrospective case series of 2 individuals with motor-incomplete spinal cord injury (SCI) to examine differences in lifetime cost estimates before and after participation in an intensive locomotor training (LT) program. Sections of a life care plan (LCP) were used to determine the financial implications associated with equipment, home renovations, and transportation for patients who receive LT. An LCP is a viable method of quantifying outcomes following any therapeutic intervention. CASE DESCRIPTION: The LCP cases analyzed were a 61-year-old woman and a 4½-year-old boy with motor-incomplete SCI and impairments classified by the American Spinal Injury Association Impairment Scale (AIS) as AIS D and AIS C, respectively. INTERVENTIONS: Each patient received an intensive outpatient LT program 3 to 5 days per week. The 61-year-old woman received 198 sessions over 57 weeks and the 4½-year-old boy received 76 sessions over 16 weeks. OUTCOMES: The equipment, home renovation, and transportation costs of an LCP were calculated before and after LT. Prior to the implementation of LT, the 61-year-old woman had estimated lifetime costs between $150,247.00 and $199,654.00. Following LT, the estimated costs decreased to between $2010.00 and $2446.00 (a decrease of $148,237.00 and $197,208.00). Similarly, the 4-year-old boy had estimated lifetime costs for equipment, home renovation, and transportation between $535,050.00 and $771,665.00 prior to LT. However, the estimated costs decreased to between $97,260.00 and $200,047.00 (a decrease of $437,790.00 and $571,618.00) following LT. DISCUSSION: The lifetime financial costs associated with equipment, home renovations, and transportation following a motor-incomplete SCI were decreased following an intensive LT program for the 2 cases presented in this article. The LCP, including costs of rehabilitation and long-term medical and personal care costs, may be an effective tool to discern cost benefit of rehabilitation interventions.

NeuroRecovery Network provides standardization of locomotor training for persons with incomplete spinal cord injury.

OBJECTIVE: To illustrate the continuity of care afforded by a standardized locomotor training program across a multisite network setting within the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). DESIGN: Single patient case study. SETTING: Two geographically different hospital-based outpatient facilities. PARTICIPANTS: This case highlights a 25-year-old man diagnosed with C4 motor incomplete spinal cord injury with American Spinal Injury Association Impairment Scale grade D. INTERVENTION: Standardized locomotor training program 5 sessions per week for 1.5 hours per session, for a total of 100 treatment sessions, with 40 sessions at 1 center and 60 at another. MAIN OUTCOME MEASURES: Ten-meter walk test and 6-minute walk test were assessed at admission and discharge across both facilities. For each of the 100 treatment sessions percent body weight support, average, and maximum treadmill speed were evaluated. RESULTS: Locomotor endurance, as measured by the 6-minute walk test, and overground gait speed showed consistent improvement from admission to discharge. Throughout training, the patient decreased the need for body weight support and was able to tolerate faster treadmill speeds. CONCLUSIONS: Data indicate that the patient continued to improve on both treatment parameters and walking function. Standardization across the NRN centers provided a mechanism for delivering consistent and reproducible locomotor training programs across 2 facilities without disrupting training or recovery progression.

Heterosexism and health care: a concept analysis.

BACKGROUND: The concept of heterosexism is used in a variety of ways in healthcare literature. The lack of consensus of the term makes identifying when and how it impacts the health care of lesbian, gay, and bisexual people difficult. A lack of clarity of the concept could also hinder effectiveness of education, awareness, and research tool development efforts. PURPOSE: The purpose of this concept analysis is to offer a synthesized definition of the term heterosexism, including its relation to and distinction from related concepts like homophobia and heteronormativity. METHODS: The authors use Walker and Avant's eight-step concept analysis method: select a concept, determine the aim of analysis, identify all uses of the concept, determine defining attributes, construct a model case, construct additional cases, identify antecedents and consequences, and define empirical referents. CONCLUSION: The results of the analysis reveal focus areas for future research, tool development, and suggestions for improvements in nursing clinical practice.

A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries.

OBJECTIVE: To provide a multivariate examination of the Berg Balance Scale (BBS) in patients with spinal cord injury (SCI) as a first step in developing a balance tool for the SCI population. DESIGN: Observational cohort. SETTING: The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for patients with SCI. PARTICIPANTS: Patients (N=97) with American Spinal Injury Association Impairment Scale C or D SCI who were enrolled in the NRN between March 1, 2005, and June 12, 2007. INTERVENTIONS: All enrolled patients received 3 to 5 locomotor training sessions a week, according to NRN protocol, and were periodically evaluated for progress on functional outcome measurements. MAIN OUTCOME MEASURES: Scores on the items of the BBS, six-minute walk test distances, ten-meter walk test speeds, and scores on the SCI Functional Ambulation Index. Temporal rates of change of the BBS items were examined with a principal components and correlation analysis. RESULTS: The first principal component accounted for nearly half of the overall variability in the BBS, correlated well with rates of change in functional mobility measures, and had good stability in its composition as verified by a resampling analysis. Further analysis showed that the composition of the first principal component varied with the patient's level of recovery. CONCLUSIONS: The BBS captures a significant amount of information about balance recovery in persons with SCI and may be a good foundation for a balance tool. However, the utility of BBS items may be dependent on a patient's level of recovery. A dynamic balance instrument for the SCI population may be needed.