Denise I. Campagnolo

Influence of Neurological Level on Immune Function Following Spinal Cord Injury: A Review

Abstract Due to the high incidence of lifelong infections in persons with spinal cord injury (SCI), the authors examined level of injury-relateifimmune characteristics in a cohort of subjects with chronic SCI. Since the sympathetic nervous system and the endocrine system are known to be modulators of immune function, one possible explanation for heightened incidence of infections includes dysregulation of sympathetic outflow tracts in individuals with tetraplegia or high paraplegia. Natural killer cell cytotoxicity (NKCC) and bactericidal function of circulating neutrophils were assayed in a group of 10 individuals with chronic complete cervical SCI, a group of 8 individuals with paraplegia with injuries below the main sympathetic outflow (T-1 0 and below) and a group of 18 age- and sex-matched controls. In addition, a psychiatric assessment of depression was performed as well as assays of pituitary and adrenal functions. Analyses revealed no significant differences in immune function between all subjects with SCI combined and their matched controls. Further analyses stratifying based on presence or absence of sympathetic dysregulation revealed significantly impaired phagocytic ability and a trend toward reduced NKCC in the group with tetraplegia compared with their controls. Hormonal assays showed that dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DS) were higher in individuals with tetraplegia than controls, but no such differences were observed in individuals with paraplegia compared with their controls. The results of this study suggest that individuals sustaining complete cervical SCI experience alterations in immune function, while those with lesions at or below T-10 do not. These findings of level of injury related immune alteration could not be explained by mood differences. This paper is a review of previously published work and the authorsș current thinking regarding increased acquisition of infections in this population.

Effect of Timing of Stabilization on Length of Stay and Medical Complications Following Spinal Cord Injury

This retrospective study examines length of acute hospital stay (LOS) and the development of medical complications in 64 patients with cervical, thoracolumbar or cauda equina injuries divided into two groups according to whether they underwent spinal stabilization < 24 hours after injury or > 24 hours after injury. The mean length of stay for the early stabilization group was 37.5 days (SD +/- 34.2) and for the late stabilization group 54.7 days (SD +/- 40.1). This difference was statistically significant by Mann Whitney U test (Z = 2.53, P = 0.01). There was no statistically significant difference between the early and the late groups with respect to the occurrence of common medical complications. There was a statistically significant difference in age in the early group (mean of 32.4 years) versus the late group (mean of 41.9 years) (t = 2.36, P = 0.02); however we do not feel that this age difference is clinically significant. There was not a statistically significant difference between the early group (17.9, SD = +/-7.2) and the late group (21.3, SD = +/- 8.3) (t = 1.71, p = 0.10) in mean injury Severity Scores (ISS). Also the correlation between length of stay and ISS scores was not significant (r = 0.18, P = 0.2). Timing of spinal stabilization appears to be an important factor in the management of spinal cord injury survivors. Our limited retrospective study suggests that when spinal stabilization is indicated, performance < 24 hours after injury is associated with a significantly shorter length of stay in the hospital. We suspect this is due to earlier mobilization of the patient. Medical complication rates were not significantly affected.

Adrenal and pituitary hormone patterns after spinal cord injury.

Current evidence indicates that the neuroendocrine system is the highest regulator of immune/inflammatory reactions. We hypothesized that immune alterations, which were related to the level of injury, found in a cohort of spinal cord-injured subjects may be influenced by altered hormonal patterns postinjury. Therefore, we investigated aspects of both pituitary and adrenal function in the same cohort of spinal cord-injured subjects. We found significant elevations in both cortisol and dehydroepiandrosterone sulfate in chronic spinal cord-injured survivors compared with their able-bodied age- and gender-matched controls. Levels of dehydroepiandrosterone, adrenocorticotropin, and prolactin were not different in spinal cord-injured subjects overall compared with their controls. Both dehydroepiandrosterone sulfate and dehydroepiandrosterone were higher in tetraplegics compared with their controls, but we found no such differences in paraplegics compared with their controls. When the two groups of spinal cord-injured subjects were compared with each other, we also found differences between these two subject groups in dehydroepiandrosterone sulfate and dehydroepiandrosterone (higher in the tetraplegics compared with paraplegics). We found no differences between either group of spinal cord-injured subjects and their controls for adrenocorticotropin, prolactin, or cortisol. These data suggest that some hormonal differences between subjects and their controls may be further related to the level of injury (specifically dehydroepiandrosterone and dehydroepiandrosterone). Finally, we investigated correlations within subjects for the above hormones. Dehydroepiandrosterone sulfate and prolactin were highly correlated (the higher the dehydroepiandrosterone sulfate, the higher the prolactin) but only in the tetraplegic subjects.

Computed tomography—Guided aspiration of a ganglion cyst of the anterior cruciate ligament: A case report

This report describes the case of a ganglion cyst of the anterior cruciate ligament in a 26-year-old man who had long-standing intermittent knee pain with locking. The cyst was successfully aspirated under computed tomography guidance, with complete resolution of symptoms. A literature review is presented along with diagnostic and treatment approaches for this uncommon finding.

Critical evaluation of clinical research

This focused review contains a suggested core of material that will help residents or practicing physiatrists critically review research papers published in the medical literature. Before accepting the results of a clinical trial, physiatrists must critique the experimental methods and study design carefully to decide whether to include these new ideas into their clinical practice. Medical research relies on statistical methodology, and statistics pervade the medical literature. This article begins with an introduction to rudimentary statistics. Fortunately, most studies depend on a rather small body of statistical concepts. The elements of experimental design--clinical trials, randomization, single-subject design, meta-analysis, epidemiological studies--are presented in a concise review. Finally, the elements of statistics and experimental design are integrated into a step-by-step method strategy for reading the medical literature.

Improving resident research in physical medicine and rehabilitation: impact of a structured training program.

Abstract Objective: This study describes a research training program that implemented several processes and structures with the aim of increasing the quality and quantity of resident research in physical medicine and rehabilitation. Another aim of the program was to address the Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learn ing and lmprovement competency. Design: Educational program. Results: Data on resident research activity for 11 years before the implementation of the research program were compared with 4 years of data after implementation. There were statistically significant increases in both the total number of publications (P = 0.03) and the number of empirical, data-based publications after implementation of the program (P = 0.03). Conclusions: The findings from this study suggest that a structu red research training program may have a salutary effect on increasing the quality and quantity of resident research.

Technique for studying conduction in the lateral cutaneous nerve of calf

We describe a novel technique for assessing conduction in the lateral cutaneous nerve of the calf (LCNC), a branch of the common peroneal nerve, based on a study of 32 healthy subjects. Both antidromic and orthodromic techniques were used in each of the 64 limbs to obtain a sensory nerve action potential (SNAP) of the LCNC over a distance of 12 cm. In 60 limbs (93.7%) a SNAP was obtainable with either the antidromic or orthodromic technique. In 21 limbs (32.8%), the SNAP was obtained both antidromically and orthodromically. In 33 limbs (51.6%), the SNAP was obtained only antidromically, and in 6 (9.4%), only orthodromically. In four limbs, the response was unobtainable. Mean antidromic onset latency was 2.1 ms ± SD 0.3, peak latency was 2.6 ms ± SD 0.4, amplitude (without averaging) was 4.3 μV ± SD 2.5, and conduction velocity was 60 m/s ± SD 10. Mean orthodromic onset latency was 2.3 ms ± SD 0.3, peak latency was 2.7 ms ± SD 0.3, amplitude was 5.0 μV ± SD 2.2, and conduction velocity was 52 m/s ± SD 5. Utilization of this technique allows for more detailed localization of common peroneal nerve injury based on whether it is proximal or distal to the origin of the LCNC.

Spinal cord injury computer-assisted instruction for medical students.

Campagnolo DI, Stier KT, Sanchez W, Foye PM, DeLisa JA: Spinal cord injury computer-assisted instruction for medical students. Am J Phys Med Rehabil 2003;82:316–319. Objective To determine if a computer-assisted instruction program would improve fourth-year medical students’ knowledge base related to spinal cord injury, as determined by pretest and posttest scores. Design A multimedia computer-assisted instruction program was developed and offered on a volunteer basis to an entire class of fourth-year medical students (n = 168). Effectiveness of the instructional content was evaluated with pretests and posttests, and overall user satisfaction with the module was assessed with the courseware evaluation. Results The responses yielded 83 sets of completed pretest and posttest pairs and 80 sets of fully completed courseware evaluations. Mean posttest score was significantly higher than the mean pretest score (pretest, 6.65 ± 1.44, vs. posttest, 7.36 ± 1.38;df = 82, t = −4.74, P < 0.001). Courseware evaluations yielded positive ratings in all areas, including applicability and usability. Conclusions The significantly increased posttest scores suggest that the students left the program with an expanded knowledge base in the content areas of spinal cord injury medicine covered in the computer-assisted instruction program.

A method to assess the trainee profiles of medical students attracted to our physical medicine and rehabilitation residency training program

A 35-item questionnaire was designed to assess the relative importance of various factors to medical students when ranking physical medicine and rehabilitation (PM&R) residency training programs. The questionnaire was used to assess the relative importance of the various factors to three groups of medical students: those who interviewed, those who matched and those who were listed on the match list of the UMDNJ-New Jersey Medical School (NJMS) Department of PM&R, as well as to our current residents. Recipients were asked to grade selection factors based on a numerical scale: 1, extremely important; 2, very important; 3, important; 4, minimally important; 5, not important. A response rate of 100% (n=72 medical students + 25 residents) was attained. The analysis indicates that, overall, there is no significant difference in ranking of the factors by each of the four groups. However, the medical students who recently matched with the UMDNJ-NJMS PM&R program rated the opportunity to conduct research significantly higher than the current house staff or the medical students on the entire match list. This is a desirable result, as the program strives to provide an environment that is conducive to the growth of research and academic physiatrists. This questionnaire could also be used by other residency training directors to guide the development of their program and to gain valuable information regarding the perception of their program among in-coming residents and the importance of various factors to the students interested in their program.

Appropriateness of the Ilfeld Psychiatric Symptom Index as a screening tool for depressive symptomatology in persons with spinal cord injury.

Abstract Background: Depressive symptomatology is seen in some persons with spinal cord injury (SCI). Identification of a depressed mood can assist clinicians in early treatment. The llfeld Psychiatric Symptom Index (llfeld PSI) is a screening tool that assesses a range of symptoms: depression, cognitive disturbance, anxiety, and anger. The purpose of this study was to compare the efficacy of the llfeld PSI to the Zung Self-Rating Depression Scale (Zung SRS) in persons with chronic SCI. Design: This was a case-control study. Methods: A total of 59 subjects completed the study: 20 persons with tetraplegia, 1 9 with paraplegia, and 20 age-matched able-bodied controls. The total scores for both measures were analyzed using Pearson correlation, analysis of variance, and chi-square tests. Results: The Zung SRS total scores correlated with the llfeld PSI subscales and index scores. When using the traditional cutoff scores, there was a low level of agreement between scales. The llfeld PSI classified 79% of the SCI group and 75% of controls as depressed. In contrast, 8% of the SCI group and none of the controls met criteria for depression using the Zung SRS. Conclusions: The llfeld PSI screens for a broad range of symptoms; however, it poorly discriminates somatic symptoms unrelated to depression. Therefore, the llfeld PSI may not be a useful instrument for persons with SCI.