International survey of perceived barriers to admission and discharge from spinal cord injury rehabilitation units.

STUDY DESIGN: Survey. OBJECTIVES: To describe and compare perceived barriers with patient flow in spinal rehabilitation units (SRUs). SETTING: International. Ten SRUs (Australia, Canada, India, Ireland, Italy, Netherlands, Pakistan, Switzerland, UK and USA) that admit both traumatic and non-traumatic spinal cord injury patients. METHODS: Survey completed between December 2010 and February 2013 on perception of barriers for admission into and discharge from SRUs. Opinion was sought from the participants regarding the utility of collecting data on the timeliness of access to SRUs and occurrence of discharge barriers for benchmarking and quality improvement purposes. RESULTS: The perceived barriers in accessing SRUs ranged from no access problem to a severe access problem (no access problems n=3; minor access problems n=3; moderate access problems n=2; severe access problem n=1 and extreme n=1). Most units (n=9/10) agreed that collecting data on timeliness of access to SRUs for acute hospital patients may help improve patient outcomes and health system processes by providing information for benchmarking and quality improvement purposes. All units reported perceived barriers to discharge from SRUs. Compared with admission barriers, a greater perception of barriers to discharge was reported (minor problem n=3; moderate problem n=3; severe problem n=3; and extreme n=1). All units agreed that collecting data on barriers to discharge from SRU may help improve patient outcomes and system processes. CONCLUSIONS: Perceived barriers to patient flow in SRUs are reported in many countries. Projects to identify and minimise the occurrence and impact of admission and discharge barriers could increase access to rehabilitation and improve the rehabilitation outcomes for patients.

International comparison of the organisation of rehabilitation services and systems of care for patients with spinal cord injury.

STUDY DESIGN: Survey. OBJECTIVES: Describe and compare the organisation and delivery of rehabilitation services and systems of care for patients with spinal cord injury (SCI). SETTING: International. Nine spinal rehabilitation units that manage traumatic SCI and non-traumatic SCI (NTSCI) patients. METHODS: Survey based on clinical expertise and literature review. Completed between November 2010 and April 2011. RESULTS: All units reported public/government funding. Additional funding sources included compensation schemes, private insurance and self funding. Six units had formal attachment to an acute SCI unit. Five units (Italy, Ireland, India, Pakistan and Switzerland) provided a national service; two units (the Netherlands and USA) provided regional and two units (Australia and Canada) provided state/provincial services. The median number of SCI rehabilitation beds was 23 (interquartile range=16-30). All units admitted both traumatic SCI and NTSCI patients. The median proportion of patients admitted who had traumatic SCI was 45% (IQR 20-48%) and 40% (IQR 30-42%) had NTSCI. The rehabilitation team in all centres determined patient readiness for discharge. There was great variability between units in the availability of SCI speciality services, ancillary services and staff/patient ratios. CONCLUSION: There was a wide range of differences in the organisation, systems of care and services available for patients with SCI in rehabilitation units in different countries. Understanding these differences is important when comparing patient outcomes from different settings. A standardised collection of these system variables should be considered as part of future studies and could be included in the ISCoS data set project.

Acute flaccid paraplegia: a rare complication of meningococcal meningitis.

STUDY DESIGN: A case report of spinal cord dysfunction following meningococcal meningitis. OBJECTIVES: To describe a rare complication of meningococcal meningitis. SETTING: Spinal Unit, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan. METHODS: A young healthy male developed meningococcal meningitis followed by acute onset low thoracic flaccid paraplegia with complete motor and sensory loss and sphincter disturbance. He responded well to antibiotics but was not investigated for causes of paraplegia. While at home in a rural area, he developed pressure ulcers, anemia and depression. Magnetic resonance imaging of the whole spine and computed tomography scan of the brain performed after 4 and 10 weeks were normal. RESULTS: The patient had a comprehensive rehabilitation at our institute. Recovery was complicated by ossification in the right thigh, which responded well to radiotherapy. At 1-year follow-up, the motor deficit and neurogenic bladder and bowel persisted and the patient remained wheelchair dependent for mobility. CONCLUSION: Several mechanisms have been proposed to explain spinal cord damage after meningitis. These include spinal cord infarction; autoimmune-mediated inflammatory myelopathy and direct infection of the cord. Most probable cause of spinal cord dysfunction in this case was thoracic myelopathy.

Epidemiology of spinal cord injuries in the 2005 Pakistan earthquake.

STUDY DESIGN: Prospective observational study. OBJECTIVES: To identify the epidemiological features specific to spinal injuries as a result of an earthquake. SETTINGS: Rawalpindi, Pakistan in the months after the 8 October 2005 earthquake. METHODS: In the month after the earthquake, the one established rehabilitation center was augmented with two makeshift spinal cord centers. Information on mechanism of injury, mode of evacuation, associated injuries was gathered, and a detailed clinical and radiological assessment was performed. Neurological status and functional outcome was determined after 10 weeks. RESULTS: Of an estimated 650-750 spinal cord injuries, 187 were admitted to these centers, including 80 men and 107 women with a mean age of 28.3+/-12.4 years. Injuries occurred while standing in 57.8% of patients. Most (83.4%) who reached the spinal cord center were airlifted. A urinary catheter had been placed before admission in 91.5%. Most of the patients were paraplegic 89.3, with 50.8% incomplete injuries. Fracture or fracture dislocation was present in 70, and 75% underwent spinal fixation. Although pressure ulcers (28.9%) and urinary tract infections (39%) were common, deep venous thromboses (4.8%) and depression (5.8%) were seldom detected. At 10 weeks, 75% were continent or performing intermittent catheterization. There were no deaths and two births. CONCLUSION: After a disaster, evacuation of persons with a spinal cord injury to a specialized center results in low mortality. Response planning for disasters should include early aggressive medical rehabilitation.

Release of superoxide dismutase activity from human umbilical veins by heparin.

OBJECTIVE: This study evaluated superoxide dismutase activity released from human umbilical veins incubated with different doses of heparin and examined at different time points. STUDY DESIGN: Umbilical veins of fresh cords from full term babies were incubated with 175 or 1 U/ml of heparin at one end while the other end was incubated without heparin as control. Specimens were obtained at 10 minutes and 24 hours (high-dose) or at 10 minutes and 60 minutes (low-dose). Superoxide dismutase activity was measured by the cytochrome c method. Results were analyzed using Student's paired t test. RESULTS: A time-dependent release of superoxide dismutase activity into the buffer was observed in both heparin specimens as well as in control specimens. The difference in release in the presence of heparin was of statistical significance, compared with the controls. CONCLUSION: Because heparin is routinely used as an anticoagulant to maintain the patency of umbilical catheters, we conclude that this usage may alter a newborn's response to oxygen free radical damage by changes in superoxide dismutase activity.