MRSA: A Challenge to Norwegian Nursing Home Personnel.

In Norway, methicillin-resistant Staphylococcus aureus (MRSA) is increasing in primary healthcare, associated with imported cases and outbreaks in long-term care. According to Norwegian national guidelines, MRSA-exposed healthcare workers (HCWs) and patients are tested. Carriage of MRSA leads to exclusion from work in healthcare institutions. In this study, 388 staff members in 42 nursing homes in Oslo County responded to questions about personal experience with MRSA and of own attitudes to challenges associated with the control and treatment of MRSA patients. Half (52%) of the nursing staff were concerned of becoming infected with MRSA and the consequences of this would be for own social life, family, economy, and work restriction. The concern was associated with risk factors like old buildings not suitable for modern infection control work, low staffing rate (70% without specific training in healthcare and 32% without formal healthcare education), defective cleaning and decolonization, and lack of formal routines and capacity for isolation of MRSA patients. Since the Norwegian MRSA guideline permits patients with persistent MRSA infections to move freely around in nursing homes, the anxiety of the staff to become infected and excluded from job was real.

Infection control and meticillin-resistant Staphylococcus aureus in nursing homes in Oslo.

Healthcare workers (HCWs) might be important in reducing healthcare-associated infections but infected or colonised HCWs may still spread pathogenic microbes to others. Norwegian policies for infection control in healthcare environments emphasise infection control programmes for both patients and HCWs. In this study, HCWs from 42 of 55 nursing homes in Oslo participated in an investigation concerning the implementation of infection control programmes during 2006-2007. Three separate questionnaires were used: the first aimed at nursing staff (enrolled nurses and assisting staff); the second for ward sisters; and the third for institution managers. Nearly 70% of the nursing homes had policies for controlling infection and transmission of meticillin-resistant Staphylococcus aureus (MRSA). About 60% of the institutions had policies for tracing MRSA infections. Four of five ward sisters tested patients for MRSA when wounds were not healing, when admitted from hospitals overseas, when patients shared a room with an MRSA-infected patient, or if patients had ever been MRSA positive. Two of five sisters would test patients with chronic urinary tract infection or patients admitted from another hospital. Among nursing staff, one out of five had cared for MRSA-positive patients. Only 4% of the staff had worked in healthcare institutions abroad, and only a few of them had been tested for MRSA. Almost 20% of the responding nursing staff worked at several institutions at the same time.

Donal Munro Lecture: Functional and neurologic recovery following acute SCI.

Patient management in the current health care environment requires the provider to make reliable and valid clinical decisions regarding patient care, decisions that are cost effective and will lead to optimal functional improvement. Neurologic examination, according to the Standards for Neurological and Functional Classification of Spinal Injury developed by the American Spinal Injury Association, provides every clinician with simple clinical tools that are highly predictive of functional recovery following a spinal cord injury. The ability to predict motor recovery provides a rational basis to help support the provider's recommendation for the patient's goals and care planning, as well as differentiates care that is essential for improving functional outcomes from care that is not.

Postrehabilitation outcomes after spinal cord injury caused by firearms and motor vehicle crash among ethnically diverse groups.

OBJECTIVES: To determine the differential effects of impairment, disability, etiology, and selected preinjury and social factors on medical complications, medical resources use, and handicap after rehabilitation for spinal cord injury (SCI). DESIGN: Survey including interview and medical record review. SETTING: Model SCI Care System centered at an urban, public medical center. PARTICIPANTS: A volunteer convenience sample of 164 men, ages 18 to 35yrs at injury, with SCI caused by firearms or motor vehicle crash. MAIN OUTCOME MEASURES: Mean numbers of documented complications, pressure sore episodes, nonroutine clinic visits, postrehabilitation hospitalization days per year, assessment by Functional Independence Measure (FIM), and total score on the Craig Handicap Assessment and Reporting Technique (CHART). RESULTS: Significant factors for postrehabilitation complications were discharge FIM (p < .001) and injury duration (p = .046); for pressure ulcer episodes, they were injury completeness (p < .001), drug abuse following injury (p = .005), and ethnicity (p = .043); for average annual nonroutine clinic visits, they were complications (p < .001), pressure ulcer episodes (p < .001), duration of injury (p = .001), and pain (p = .052); for hospitalization, they were pressure ulcer episodes (p < .001) and complications (p = .043); for CHART scores, they were discharge FIM (p < .001), preinjury education (p < .001), hospitalization (p = .007), chronic pain (p = .01), longest time at one job (p = .02), completeness of injury (p = .042), and preinjury employment (p = .049). CONCLUSIONS: Disability is the most important factor in postrehabilitation outcomes for SCI, followed by injury completeness, which is also associated with multiple outcomes. Postinjury but not preinjury drug abuse is adversely associated with outcomes. Etiology and ethnicity are not important determinates of outcome.

Motor recovery following spinal cord injury associated with cervical spondylosis: a collaborative study.

A prospective multicenter study was conducted within the National Model Spinal Cord Injury System program to examine neurological deficits and recovery patterns following spinal cord injury (SCI) in individuals with cervical spondylosis and without a spinal fracture. Nineteen patients were evaluated. Sixty-eight percent presented initially with motor incomplete lesions. Of those who presented with motor incomplete injuries at their initial examination, 69 percent had less deficit in the lower than in the upper extremities, indicative of a central cord syndrome. At follow-up, 12 subjects were unable to ambulate, four required assistance and three were able to ambulate independently. On the average, subjects doubled their initial Asia Motor Score (AMS) scores by one year following injury. Residual upper extremity weakness, however, limited the ability to ambulate. Recovery of motor strength in this group is comparable to that of individuals with incomplete tetraplegia in general but the proportion who regain ambulatory function is less.

Effect of surgery on motor recovery following traumatic spinal cord injury.

The influence of spine surgery on motor recovery between 1 month and 1 year was assessed prospectively in a group of 269 patients following traumatic spinal cord injury (SCI) using the classification system originally developed by the American Spinal Injury Association. The Allen classification was used to categorize cervical vertebral pathology and the Denis system was used for injuries to the thoracic and lumbar spine. Gunshot injuries were classified based upon the bullet trajectory and location relative to the spinal canal. Individuals undergoing surgery were divided into various subgroups depending on the type of surgery performed: anterior decompression with or without spine fusion and instrumentation, posterior decompression/laminectomy with or without spine fusion and instrumentation and spine fusion with instrumentation. Motor score recovery between 1 month and 1 year after injury was highly dependent (P < or = 0.001) on the level and completeness of injury averaging 0.7 +/- 2.7 for complete paraplegics, 7.8 +/- 4.8 for complete tetraplegics, 11.8 +/- 8.3, for incomplete paraplegics and 22.2 +/- 10.9 for incomplete tetraplegics. Motor recovery did not significantly differ between patients categorized in various surgical subgroups or between those having surgery and those treated non-operatively. Additionally, although the sample size was small, motor recovery among tetraplegic individuals did not depend on whether unilateral and bilateral facet dislocations were reduced and in patients with incomplete lesions, those with reductions actually had a poorer outcome than those who were left in a dislocated position.

Functional hand surgery following tetraplegia.

Traumatic tetraplegia is an overwhelming injury often requiring permanent adaptations by patients and families. The greatest potential for improving the quality of life lies with rehabilitation and restoration of upper extremity function. Reconstructive hand surgery following tetraplegia is individualized based on functional level and can significantly improve hand function and quality of life. Careful selection and evaluation of surgical candidates in combination with an experienced surgeon and hand rehabilitation team are critical for a successful outcome.

Injury pattern effect on motor recovery after traumatic spinal cord injury.

OBJECTIVE: To determine whether type of fracture or gunshot injury correlated with extent of motor impairment at 1 month and/or with the amount of motor recovery between 1 month and 1 year. DESIGN: Prospective neurological examinations were performed longitudinally after the recommendations of the American Spinal Injury Association (ASIA). Fractures were classified by the Allen system (cervical spine) or the Denis system (thoracic and lumbar spine). Gunshot injuries were classified based on trajectory and bullet location. SETTING: Subjects were examined at a community medical center. PATIENTS: There were 278 patients with traumatic spinal cord injury who were admitted between 1985 and 1990. MAIN OUTCOME MEASURES: The ASIA motor score was the primary outcome measure. RESULTS: There were no significant differences in motor recovery based on type of injury (penetrating vs nonpenetrating), type of fracture, or bullet location. CONCLUSIONS: Injuries severely disruptive of the spinal canal were more likely to result in complete SCI. Flexion-rotation injuries in the thoracic and lumbar spine, bilateral facet dislocations in the cervical spine, and gunshot wounds in which the bullet passed through the canal were more likely to be complete. Incomplete injuries were more common among patients with preexisting cervical spondylosis who had fallen and patients with gunshot wounds in which the bullet did not penetrate the spinal canal. The primary determinant of motor recovery was completeness of injury at 1 month.

Motor recovery following spinal cord injury caused by stab wounds: a multicenter study.

A prospective multicenter study was conducted by centers participating in the National Model Spinal Cord Injury System program to examine neurological deficit and recovery patterns following spinal cord injury (SCI) resulting from stab wounds. Thirty two patients were evaluated. Sixty three percent presented with motor incomplete lesions on initial examination. In addition, four of seven who initially presented with motor complete paraplegia were motor incomplete at follow-up. Furthermore, 50% of those with motor incomplete lesions had asymmetrical motor patterns indicative of a Brown-Séquard Syndrome. Although the percentage of patients sustaining an incomplete SCI injury following a stab injury to the spine is higher than the percentage of incomplete lesions associated with other etiologies, the amount of motor recovery when controlling for level and completeness of injury is no greater than previously reported for other etiologies.

Rehabilitation of the patient with a spinal cord injury.

An overview of the individual with spinal cord injury caused by gunshot wounds is presented. In addition to the demographics of the group of patients, the cost estimates of care are discussed. The authors' experience in monitoring neurologic recovery and rehabilitation expectations and outcomes are also reported.

Comparison of computerized tomography parameters of the thoracolumbar spine in normal control subjects and spinal cord injured patients.

The cross-sectional area and the sagittal and transverse diameters of the spinal canal at the thoracolumbar junction were measured using high resolution thin-section computerized tomography images in 15 control subjects and 28 patients with traumatic injury to the spinal cord at the thoracolumbar junction. No significant difference between the control and study groups was found with regard to any of the three measures taken. With the exception of the sagittal canal diameter for the first lumbar vertebra, all the mean values were higher for the spinal cord injured group. The ratio of the sagittal to transverse diameter was larger for the control group; however, this difference also was not significant. These findings suggest no significant differences in the dimensions and shape of the canal at the thoracolumbar region between the spinal cord injured and control groups. In contrast to the cervical spinal canal, there appears to be no correlation between the spinal cord injury and the dimensions of the thoracolumbar spinal canal.

Motor and sensory recovery following incomplete tetraplegia.

Fifty individuals with incomplete tetraplegia due to trauma underwent serial prospective examinations to quantify motor and sensory recovery. None of 5 patients who were motor complete with the presence of sacral (S4-S5) sharp/dull touch sensation unilaterally recovered any lower extremity motor function. However, in 8 motor complete subjects having bilateral sacral sharp/dull sensation present, the mean lower extremity motor score increased to 12.1 +/- 7.8 at 1 year. In 3 of the 8 cases, functional (> or = 3/5) recovery was seen in some muscles at 1 year. Though mean upper and lower extremity ASIA Motor Scores increased significantly (p < .001) between 1 month and 1 year for the entire sample, the annualized rate of motor recovery rapidly declined in the first 6 months and then subsequently approached plateau. Eighty-seven percent (20 of 23) of patients having a lower extremity motor score > or = 10 at 1 month were community ambulators using crutches and orthoses at 1 year follow-up.

Motor and sensory recovery following incomplete paraplegia.

Fifty-four individuals admitted for rehabilitation with a diagnosis of incomplete paraplegia due to trauma underwent serial prospective examinations to quantify motor and sensory recovery. Motor and sensory scoring guidelines recommended by the American Spinal Injury Association were used to assess changes. Lower extremity motor scores (LEMS) differed significantly (p < .03) between groups of patients partitioned by category of initial neurologic level of injury (NLI) with the following averages at 1 month after injury: 6.8 +/- 11.3 above T12, 15.0 +/- 8.2 at T12 and 18.3 +/- 11.4 below T12. However, the amount of motor recovery was independent of the NLI with the differences between the NLI groups remaining essentially constant from 1 month to 2 years. While the LEMS increased significantly (p < .001) an average of 11.9 +/- 8.7 points between 1 month and 1 year, the annualized rate of motor recovery rapidly declined in the first 6 months and then subsequently plateaued. All patients having a 1-month LEMS greater than 10 points (28 cases) with hip flexion or knee extension strength > or = 2/5 were able to ambulate in the community with a reciprocal gait pattern using crutches and orthoses at 1-year follow-up.

Recovery following ischemic myelopathy.

Motor and sensory recovery were determined in five patients with ischemic myelopathy associated with traumatic laceration or surgical manipulation of the thoracic aorta. The neurologic level of injury was between T-2 and T-10. All patients had an anterior spinal artery pattern of incomplete spinal cord injury consisting of relatively greater loss of motor function than sensation and preservation of sacral sensation. None of the three patients with zero lower extremity motor function at 30 regained any motor function at 1 year. Two patients with partial motor function 1 month after infarction had further motor recovery at 1 year. One of these two individuals was able to ambulate independently with a reciprocal gait using orthoses.

Motor and sensory recovery following complete tetraplegia.

Sixty-one individuals admitted for rehabilitation with a diagnosis of complete tetraplegia due to traumatic spinal cord injury underwent prospective examinations for motor and sensory recovery. The amount of motor, light touch and sharp/dull (pin prick) sensory recovery was independent of the initial neurologic level of injury between C4 and C8. In the interval between one month and one year following injury, the American Spinal Injury Association Motor Score increased an average of 8.6 +/- 4.7. However, the rate of motor recovery rapidly declined in the first six months and then approached plateau. Ninety-seven percent of muscles with Grade 1/5 ("Trace") or 2/5 ("Poor") strength one month after injury recovered to > or = 3/5 ("Fair") strength by the time of first annual follow-up. Muscles with 0/5 strength one month after injury and located one neurological level below the most caudal level having motor function regained > or = 3/5 strength in only 27 percent of cases at one year follow-up and at two levels below in only 1% of cases.

Recovery following complete paraplegia.

Motor and sensory recovery were quantified by serial examinations prospectively performed on 148 persons with paraplegia. Of the 142 patients who remained complete injuries at follow-up, none with an initial neurologic level of injury (NLI) above T9 regained any lower extremity motor function at follow-up. Thirty-eight percent of patients with an initial NLI at or below T9 had some return of lower extremity motor function, primarily in the hip flexors and knee initial NLI at or below T9 had some return of lower extremity motor function, primarily in the hip flexors and knee extensors. Twenty percent of the patients with an initial NLI at or below T12 regained sufficient hip flexor and knee extensor strength to reciprocally ambulate using conventional orthoses and crutches. Unlike motor function, recovery of light touch and sharp-dull discrimination was independent of the initial NLI. Six (4%) of the 148 patients demonstrated "late" conversion (more than 4 months after injury) from complete to incomplete spinal cord injury (SCI) status. Two of the 6 patients with an initial NLI at T12 and subsequent annual NLI at L1 and L2 reciprocally ambulated, and three of the 6 patients regained voluntary bladder/bowel control.

Upper extremity pain in the postrehabilitation spinal cord injured patient.

The purpose of this study was to determine the prevalence of upper extremity (UE) pain in outpatients with chronic spinal cord injury (SCI). A total of 239 SCI outpatients (136 with quadriplegia and 103 with paraplegia) were interviewed for the presence of UE pain at the shoulder, elbow, wrist, and hand. The average age of the subjects at the time of interview was 37.4 years, and the average time since onset was 12.1 years. Subjects who reported pain were referred to SCI clinics to determine the etiology. Fifty-five percent of the patients with quadriplegia reported UE pain, most commonly at the shoulder. Prevalence of reported pain was highest for subjects in the first five years postinjury. Sixty-four percent of patients with paraplegia reported UE pain. Complaints related to carpal tunnel syndrome were the most common, followed by those related to shoulder pain. This study documents the prevalence and nature of UE pain in chronic SCI patients and emphasizes the need for further research to develop strategies for prevention and treatment of pain syndromes.

Profiles of spinal cord injury and recovery after gunshot injury.

Prospective motor and sensory examinations were conducted on 135 patients with neurologic deficits caused by spinal cord injuries resulting from gunshot wounds. Annual follow-up motor and sensory examinations were conducted for 67 patients. The neurologic data (motor and sensory neurologic levels of injury, zone of injury, and completeness of lesion) were assessed in terms of the vertebral level of injury, region of injury, bullet caliber, direction of bullet entry, and whether the bullet penetrated the spinal canal, completely traversed the spinal canal, or entered and remained lodged in the spinal canal. Seventy-seven of the patients sustained complete lesions and 58 sustained incomplete lesions. Anatomically, 19.3% of the injuries were in the cervical region, 51.8% in the thoracic, and 28.9% in the thoracolumbar. In 93 cases, the neurologic level was at least one level higher than vertebral level of injury. Although twice as many individuals were shot from the back as from the front and from the left as from the right, the point of bullet entry did not appear to be related to the severity of the injury. At the annual follow-up examinations, 66.7% of the patients with complete lesions and 64.0% of the patients with incomplete lesions had no improvement in the neurologic level of injury. Nevertheless, there was a significant (p less than 0.0001) improvement in the American Spinal Injury Association motor index scores one year after injury.

Comparison of computerized tomography parameters of the cervical spine in normal control subjects and spinal cord-injured patients.

The cross-sectional area and the sagittal and transverse diameters of the cervical spinal canal were measured, using high-resolution, thin-section computerized-tomography images, in 100 control subjects and forty-two patients who had a traumatic injury to the spinal cord. No significant differences were found between the control and the spinal cord-injured group with regard to the cross-sectional area of the spinal canal; however, the differences between the two groups were significant with regard to mean sagittal and transverse diameters of the spinal canal. The sagittal diameters of the spinal canal of the control group were significantly larger than those of the spinal cord-injured group. Conversely, the transverse diameters of the spinal canal of the spinal cord-injured group were significantly larger than those of the control group. These findings suggest that certain patients may be predisposed to spinal cord injury, given sufficient trauma. It is not the total volume of space in the spinal canal that is the critical factor; rather, it is the shape. An index of shape is the ratio of the sagittal to the transverse diameter. The difference between the two groups, based on the ratio of sagittal to transverse diameter, was highly significant. Because this measure is a ratio, there is no need to evaluate an individual on the basis of measurements of absolute values.

Late complications of the weight-bearing upper extremity in the paraplegic patient.

Paraplegic patients rely almost exclusively on their upper extremities for weight-bearing activities such as transfers and wheelchair propulsion. Eighty-four paraplegic patients whose injury level was T2 or below and who were at least one year from spinal cord injury were screened for upper extremity complaints. Fifty-seven (67.8%) had complaints of pain in one or more areas of their upper extremities. The most common complaints were shoulder pain and/or pain relating to carpal tunnel syndrome. Twenty-five (30%) complained of shoulder pain during transfer activities. Symptoms were found to increase with time from injury. As the long-term survival of spinal cord injured patients continues to improve, an increased awareness of the complications of the weight-bearing upper extremity is necessary to keep these patients functioning in society.