Ali Jamous

Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study*.

Objectives:To develop a technique for continuously monitoring intraspinal pressure at the injury site (intraspinal pressure) after traumatic spinal cord injury. Design:A pressure probe was placed subdurally at the injury site in 18 patients who had isolated severe traumatic spinal cord injury (American Spinal Injuries Association grades A–C). Intraspinal pressure monitoring started within 72 hours of the injury and continued for up to a week. In four patients, additional probes were inserted to simultaneously monitor subdural pressure below the injury and extradural pressure. Blood pressure was recorded from a radial artery catheter kept at the same horizontal level as the injured segment of the spinal cord. We determined the effect of various maneuvers on spinal cord perfusion pressure and spinal cord function and assessed using a limb motor score and motor-evoked potentials. Setting:Neurosurgery and neuro-ICU covering a 3 million population in London. Subjects:Patients with severe traumatic spinal cord injury. Control subjects without spinal cord injury (to monitor spinal cerebrospinal fluid signal and motor evoked potentials). Interventions:Insertion of subdural spinal pressure probe. Measurements and Main Results:There were no procedure-related complications. Intraspinal pressure at the injury site was higher than subdural pressure below the injury or extradural pressure. Average intraspinal pressure from the 18 patients with traumatic spinal cord injury was significantly higher than average intraspinal pressure from 12 subjects without traumatic spinal cord injury. Change in arterial PCO2, change in sevoflurane dose, and mannitol administration had no significant effect on intraspinal pressure or spinal cord perfusion pressure. Increase in inotrope dose significantly increased spinal cord perfusion pressure. Bony realignment and laminectomy did not effectively lower intraspinal pressure. Laminectomy was potentially detrimental by exposing the swollen spinal cord to compression forces applied to the skin. By intervening to increase spinal cord perfusion pressure, we could increase the amplitude of motor-evoked potentials recorded from below or just above the injury level in nine of nine patients with traumatic spinal cord injury. In two of two patients with American Spinal Injuries Association grade C traumatic spinal cord injury, higher spinal cord perfusion pressure correlated with increased limb motor score. Conclusions:Our findings provide proof-of-principle that subdural intraspinal pressure at the injury site can be measured safely after traumatic spinal cord injury.

A Lactobacillus casei Shirota probiotic drink reduces antibiotic-associated diarrhoea in patients with spinal cord injuries: a randomised controlled trial

Certain probiotics may prevent the development of antibiotic-associated diarrhoea (AAD) and Clostridium difficile-associated diarrhoea (CDAD), but their effectiveness depends on both strain and dose. There are few data on nutritional interventions to control AAD/CDAD in the spinal cord injury (SCI) population. The present study aimed to assess (1) the efficacy of consuming a commercially produced probiotic containing at least 6·5 × 10⁹ live Lactobacillus casei Shirota (LcS) in reducing the incidence of AAD/CDAD, and (2) whether undernutrition and proton pump inhibitors (PPI) are risk factors for AAD/CDAD. A total of 164 SCI patients (50·1 (sd 17·8) years) with a requirement for antibiotics (median 21 d, range 5-366) were randomly allocated to receive LcS (n 76) or no probiotic (n 82). LcS was given once daily for the duration of the antibiotic course and continued for 7 days thereafter. Nutritional risk was assessed by the Spinal Nutrition Screening Tool. The LcS group had a significantly lower incidence of AAD (17·1 v. 54·9%, P< 0·001). At baseline, 65% of patients were at undernutrition risk. Undernutrition (64·1 v. 33·3%, P< 0·01) and the use of PPI (38·4 v. 12·1 %, P= 0·022) were found to be associated with AAD. However, no significant difference was observed in nutrient intake between the groups. The multivariate logistic regression analysis identified poor appetite ( < 1/2 meals eaten) (OR 5·04, 95% CI 1·28, 19·84) and no probiotic (OR 8·46, 95% CI 3·22, 22·20) as the independent risk factors for AAD. The present study indicated that LcS could reduce the incidence of AAD in hospitalised SCI patients. A randomised, placebo-controlled study is needed to confirm this apparent therapeutic success in order to translate into improved clinical outcomes.

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 Cohens 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.

Brain Activation Sequences Following Electrical Limb Stimulation of Normal and Paraplegic Subjects

In current clinical practice the degree of paraplegia or quadriplegia is objectively determined with transcranial magnetic stimulation (TMS) and somatosensory-evoked potentials (SSEP). We measured the MEG signal following electrical stimulation of upper and lower limbs in two normal and three clinically complete paraplegic subjects. From the MEG signal we computed distributed estimates of brain activity and identified foci just behind the central sulcus consistent in location with primary somatosensory (SI) for arm and foot and secondary somatosensory (SII) areas. Activation curves were computed from regions of interest defined around these areas. Activation of the SI foot area was observed in normal and paraplegic subjects when the upper limb was stimulated. Surprisingly, for each paraplegic subject, stimulation below the lesion was followed by cortical activations. These activations were weak, only loosely time-locked to the stimulus and were seen intermittently behind the central sulcus and nearby cortical areas. Statistical analysis of tomographic solutions and activation curves showed consistent responses following foot stimulation in one paraplegic (PS1) and intermittently in another paraplegic subject. We repeated the same experiment for PS1 in a different laboratory and the results from the analysis of foot stimulation from both laboratories revealed statistically significant focal cortical response only in the contralateral SI foot area.

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.

Measurement of Intraspinal Pressure After Spinal Cord Injury: Technical Note from the Injured Spinal Cord Pressure Evaluation Study.

Intracranial pressure (ICP) is routinely measured in patients with severe traumatic brain injury (TBI). We describe a novel technique that allowed us to monitor intraspinal pressure (ISP) at the injury site in 14 patients who had severe acute traumatic spinal cord injury (TSCI), analogous to monitoring ICP after brain injury. A Codman probe was inserted subdurally to measure the pressure of the injured spinal cord compressed against the surrounding dura. Our key finding is that it is feasible and safe to monitor ISP for up to a week in patients after TSCI, starting within 72 h of the injury. With practice, probe insertion and calibration take less than 10 min. The ISP signal characteristics after TSCI were similar to the ICP signal characteristics recorded after TBI. Importantly, there were no associated complications. Future studies are required to determine whether reducing ISP improves neurological outcome after severe TSCI.

Effectiveness of probiotic in preventing and treating antibiotic-associated diarrhoea and/or Clostridium difficile-associated diarrhoea in patients with spinal cord injury: a protocol of systematic review of randomised controlled trials

BackgroundProbiotics may prevent antibiotic-associated and Clostridium difficile-associated diarrhoea (AAD/CDAD). Many spinal cord injury centre (SCIC) practitioners consider probiotics generically and may not realise that efficacy can be strain-, dose- and disease-specific. In order to confirm these effects and fully evaluate the extent of probiotic effectiveness in these patients, a systematic review and meta-analysis is indicated.MethodsThe following databases will be searched for relevant studies: Cochrane Library; Centre for Reviews and Dissemination (CRD) Database; CINAHL; PsycINFO; Embase; Medline; AMED; International Clinical Trials Registry Platform Search Portal and ISRCTN Registry and will hand search a list of conference proceedings. Any randomised controlled trials without restriction of publication status will be included with treatment of AAD/CDAD. Outcomes will include the effect of probiotic on the occurrence of AAD/CDAD and duration of diarrhoea, intensive care unit admission, hospital mortality and length of hospital stay. Two reviewers will independently screen the titles, abstracts or even full texts and extract data. Two other reviewers will assess study quality. Revman 5.1 software will be used to conduct meta-analysis and calculate the risk ratio for dichotomous data. Weighted mean difference or standard mean difference will be calculated for continuous data. The Cochrane Collaboration’s tool will be used to assess the risk of bias.DiscussionThis systematic review protocol will provide information on probiotic therapy for AAD and CDAD in spinal cord injury (SCI) population. The results will be disseminated through peer-reviewed publication or conference presentation.Systematic review registrationPROSPERO CRD42015016976

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.

Waveform Analysis of Intraspinal Pressure After Traumatic Spinal Cord Injury: An Observational Study (O-64)

Following a traumatic brain injury (TBI), intracranial pressure (ICP) increases, often resulting in secondary brain insults. After a spinal cord injury, here the cord may be swollen, leading to a local increase in intraspinal pressure (ISP). We hypothesised that waveform analysis methodology similar to that used for ICP after TBI may be applicable for the monitoring of patients with spinal cord injury.An initial cohort of 10 patients with spinal cord injury, as presented by the first author at a meeting in Cambridge in May 2012, were included in this observational study. The whole group (18 patients) was recently presented in the context of clinically oriented findings (Werndle et al., Crit Care Med, 42(3):646-655, 2014, PMID: 24231762). Mean pressure, pulse and respiratory waveform were analysed along slow vasogenic waves.Slow, respiratory and pulse components of ISP were characterised in the time and frequency domains. Mean ISP was 22.5 ± 5.1, mean pulse amplitude 1.57 ± 0.97, mean respiratory amplitude 0.65 ± 0.45 and mean magnitude of slow waves (a 20-s to 3-min period) was 3.97 ± 3.1 (all in millimetres of mercury). With increasing mean ISP, the pulse amplitude increased in all cases. This suggests that the ISP signal is of a similar character to ICP recorded after TBI. Therefore, the methods of ICP analysis can be helpful in ISP analysis.

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.