Jelena N. Svircev

The association of opioid use with incident lower extremity fractures in spinal cord injury

Abstract Objective To determine the association between opioid use and lower extremity fracture risk in men with spinal cord injury (SCI). Design Retrospective cohort study. Setting Veterans Affairs Healthcare System. Participants In total, 7447 male Veterans with a history of a traumatic SCI identified from the Veterans Affairs (VA) Spinal Cord Dysfunction Registry (SCD) from September 2002 through October 2007 and followed through October 2010. Outcome measures Incident lower extremity fractures by use of opioids. Results In individuals identified from the VA SCD Registry 2002–2007, opioid use was quite common, with approximately 70% of the cohort having received a prescription for an opioid. Overall, there were 892 incident lower extremity fractures over the time period of this study (597 fractures in the opioid users and 295 fractures in the non-opioid users). After adjusting for covariates, there was a statistically significant relationship between opioid use and increased risk for lower extremity fractures (hazard ratio 1.82 (95% confidence interval 1.59–2.09)). Shorter duration of use (<6 months) and higher doses were positively related to fracture risk (P < 0.0001). Conclusions Opioid use is quite common in SCI and is associated with an increased risk for lower extremity fractures. Careful attention to fracture prevention is warranted in patients with SCI, particularly upon initiation of an opioid prescription and when higher doses are used.

A retrospective review of lower extremity fracture care in patients with spinal cord injury

Abstract Context/Objective To identify circumstances surrounding incident lower extremity fractures (ILEFs) in patients with spinal cord injury (SCI) and to describe the impact of these fractures on service needs and provision of pharmacological therapies for osteoporosis. Design Retrospective medical record review. Setting Four Veterans Affairs Medical Centers in the USA. Participants One hundred and forty patients with traumatic SCI who sustained an ILEF from 2002 to 2007. Outcome measures Fracture circumstances and use of assistive devices were described using percentages, means, and standard deviations. Fishers exact test was used to determine the relationship between fracture site, and patient age and duration of SCI. Differences in pharmacological provision of therapies for osteoporosis pre- and post-fracture were examined using exact McNemars test. Results One hundred and fifty-five ILEFs were identified in 140 patients. Tibia/fibula and femur fractures were the most common fractures. Fracture site was not related to patients age or duration of SCI. Almost one-third of all fractures occurred during transfers to and from wheelchairs. Post-fracture, the provision of new or modified assistive devices, primarily wheelchairs, was frequent, occurring in 83% of patients in the year post-fracture. Few patients transferred residence to a nursing home following the fracture. There was a significant difference in the use of pharmacological therapies for osteoporosis in the first year post-fracture compared with the year prior to the fracture (P < 0.01), with significant differences in the volume of prescriptions for calcium supplements (P < 0.01) and bisphosphonates (P = 0.02). Overall, the amount of prescriptions for osteoporosis increased the year post-fracture (56%) from the year pre-fracture (39%); this increase was secondary to increases in prescriptions for calcium supplements (pre = 13%; post = 30%) and bisphosphonates (pre = 2%; post = 7%). Conclusions We have identified that wheelchair and other transfer activities are a key area that could be a focus of fracture prevention in SCI. The need for new or modified assistive devices and/or wheelchair skills retraining post-fracture should be anticipated. Examination of whether treatments for osteoporosis following a fracture can prevent future osteoporotic fractures is warranted.

The association of anticonvulsant use with fractures in spinal cord injury.

ObjectiveThe aim of this study was to determine whether anticonvulsants, including the benzodiazepine subclass, are associated with an increased risk for lower extremity fractures in male patients with spinal cord injury. DesignAll male patients with a history of a traumatic spinal cord injury of 2 yrs’ duration or longer in the Veterans Affairs Spinal Cord Disease Registry from 2002 to 2007 were included. Incident lower extremity fractures during this period and anticonvulsant use were identified. The association of anticonvulsant use, overall, by type (enzyme inducing, non–enzyme inducing), by number (monotherapy vs. polytherapy), by benzodiazepine subclass, and by individual medication used was determined. ResultsIn this cohort, 892 veterans sustained a fracture, and 6555 did not. Compared with nonusers of anticonvulsants, there was a significant positive relationship with fractures by overall use of anticonvulsants (HR, 1.17 [95% CI, 1.01–1.36]), by users of the benzodiazepine subclass (HR, 1.28 [95% CI, 1.11–1.47]), and by polytherapy compared with monotherapy (HR, 1.20 [95% CI, 1.00–1.42]) but not by anticonvulsant type (HR, 0.92 [95% CI, 0.58–1.47]). Temazepam (HR, 1.28 [95% CI, 1.01–1.62]), alprazolam (HR, 1.54 [95% CI, 1.04–2.29]), and diazepam (HR, 1.23 [95% CI, 1.06–1.41]) were significantly positively associated with fractures. ConclusionsAttention to fracture prevention is important when anticonvulsants are prescribed in spinal cord injury, particularly when more than one anticonvulsant is used.

Mechanical Insufflation-Exsufflation Device Prescription for Outpatients With Tetraplegia

Abstract Background: Mechanical insufflation-exsufflation (MIE) is an option for secretion mobilization in outpatients with spinal cord injury (SCI) who lack an effective cough and are at high risk for developing pneumonia. Objective: To describe characteristics of persons with SCI who received MIE devices for outpatient use and compare respiratory hospitalizations before and after MIE prescription. Design: Retrospective cohort study of all persons who were prescribed MIE devices for outpatient use during 2000 to 2006 by a Veterans Affairs SCI service. Results: We identified 40 patients with tetraplegia (4.5% of population followed by the SCI service) who were prescribed MIE devices. Of these, 30 (75%) had neurologic levels of C5 or rostral, and 33 (83%) had motor-complete injuries. For chronically injured patients who were prescribed MIE for home use, there was a nonsignificant reduction in respiratory hospitalization rates by 34% (0.314/y before MIE vs 0.208/y after MIE; P = 0.21). A posthoc subgroup analysis showed a significant decline in respiratory hospitalizations for patients with significant tobacco smoking histories. Conclusions: Mechanical insufflation-exsufflation was typically prescribed for people with motor-complete tetraplegia. Outpatient MIE usage may reduce respiratory hospitalizations in smokers with SCI. Further research of this alternative, noninvasive method is warranted in the outpatient SCI population.

Surgical compared with nonsurgical management of fractures in male veterans with chronic spinal cord injury.

Study design:Retrospective review of a clinical database.Objectives:To examine treatment modalities of incident appendicular fractures in men with chronic SCI and mortality outcomes by treatment modality.Setting:United States Veterans Health Administration Healthcare System.Methods:This was an observational study of 1979 incident fractures that occurred over 6 years among 12 162 male veterans with traumatic SCI of at least 2 years duration from the Veterans Health Administration (VA) Spinal Cord Dysfunction Registry. Treatment modalities were classified as surgical or nonsurgical treatment. Mortality outcomes at 1 year following the incident fracture were determined by treatment modality.Results:A total of 1281 male veterans with 1979 incident fractures met inclusion criteria for the study. These fractures included 345 (17.4%) upper-extremity fractures and 1634 (82.6%) lower-extremity fractures. A minority of patients (9.4%) were treated with surgery. Amputations and disarticulations accounted for 19.7% of all surgeries (1.3% of all fractures), and the majority of these were done more than 6 weeks following the incident fracture. There were no significant differences in mortality among men with fractures treated surgically compared with those treated nonsurgically.Conclusions:Currently, the majority of appendicular fractures in male patients with chronic SCI are managed nonsurgically within the VA health-care system. There is no difference in mortality by type of treatment.

Cardiovascular Disease in Persons with Spinal Cord Dysfunction—An Update on Select Topics

Cardiovascular disease (CVD) is a leading cause of death in people with spinal cord injury (SCI), yet little is known about the prevalence of the disorder and how risk factors for CVD, such as dyslipidemia, diabetes, and obesity, differ compared with the able-bodied population. Additionally, limb loss, an underappreciated topic in the setting of SCI, is a frequent complication of SCI, and may be related to CVD, either directly, as undiagnosed peripheral vascular disease, or indirectly, as a consequence of diabetes or obesity. This article briefly reviews the topics of dyslipidemia, diabetes, and obesity in SCI and discusses the management of limb loss for individuals with SCI.

Thiazide Use Is Associated With Reduced Risk for Incident Lower Extremity Fractures in Men With Spinal Cord Injury

OBJECTIVE To determine the association between thiazide use and lower extremity fractures in patients who are men with a spinal cord injury (SCI). DESIGN Cohort study from fiscal years 2002 to 2007. SETTING Medical centers. PARTICIPANTS Men (N=6969) with an SCI from the Veterans Affairs (VA) Spinal Cord Dysfunction (SCD) Registry, including 1433 users of thiazides and 5536 nonusers of thiazides. INTERVENTION Thiazide use versus nonuse. MAIN OUTCOME MEASURE Incident lower extremity fractures. RESULTS Among the men, 21% in the VA SCD Registry (fiscal years 2002-2007) included in these analyses used thiazide diuretics. There were 832 incident lower extremity fractures over the time period of this study: 110 fractures (7.7%) in 1433 thiazide users and 722 fractures (13%) in 5536 nonusers of thiazides. In unadjusted and adjusted models alike, thiazide use was associated with at least a one-quarter risk reduction in lower extremity fracture at any given point in time (unadjusted: hazard ratio (HR)=.75; 95% confidence interval (CI), .59-.94; adjusted: HR=.74; 95% CI, .58-.95). CONCLUSIONS Thiazide use is common in men with SCI and is associated with a decreased likelihood for lower extremity fractures.

A retrospective review of safety using a nursing driven protocol for autonomic dysreflexia in patients with spinal cord injuries

Objective/Background: Autonomic dysreflexia is a potentially life-threatening condition which afflicts a significant proportion of individuals with spinal cord injuries (SCI). To date, the safety and efficacy of several commonly used interventions for this condition have not been studied. Design: A retrospective chart review of the safety of a previously implemented nursing driven inpatient autonomic dysreflexia protocol. Methods: Seventy-eight male patients with SCI who experienced autonomic dysreflexia while inpatient at our Veterans Affairs SCI unit over a 3–1/2-year period were included. The safety of a nursing driven protocol utilizing conservative measures, nitroglycerin paste, and oral hydralazine was evaluated. Outcome Measures: Occurrence of adverse events and relative hypotensive events during all episodes treated with the protocol, and efficacy of attaining target blood pressure for all episodes with protocol adherence and for initial episode experienced by each patient. Results: Four hundred forty-five episodes of autonomic dysreflexia were recorded in the study period, with 92% adherence to the protocol. When the protocol was followed, target blood pressure was achieved for 97.6% of all episodes. Twenty-three total adverse events occurred (5.2% of all episodes). All adverse events were due to hypotension and only 0.9% required interventions beyond clinical monitoring. Of each patients initial autonomic dysreflexia episode, 97.3% resolved using the protocol without need for further escalation of care. Conclusion: This inpatient nursing driven-protocol for treating autonomic dysreflexia utilizing conservative measures, nitroglycerin paste and oral hydralazine achieved target blood pressure with a high success rate and a low incidence of adverse events.

False-Negative Triple-Phase Bone Scans in Spinal Cord Injury to Detect Clinically Suspect Heterotopic Ossification: A Case Series

Abstract Background/Objective: Heterotopic ossification (HO) is a complication seen in patients after spinal cord injury (SCI). Triple-phase nuclear bone scanning is the most sensitive test for the detection of HO. This retrospective study assesses whether patients with clinically suspected HO but negative triple-phase nuclear bone scans develop delayed positive nuclear bone scans. Methods: Case series: A cohort of patients with SCI and clinically suspected HO who underwent triple phase nuclear bone scans over a period of 2 years was identified from retrospective chart review of an acute inpatient SCI rehabilitation service. A subgroup of 7 patients with initially negative but subsequently positive triple-phase nuclear bone scans was identified, and the following data were collected: date, mechanism, admission level, and admission completeness of injury as well as date, number, and results of bone scans. Laboratory studies were also collected during the time of imaging. Results: Over a 2-year period, 343 patients were admitted to the SCI rehabilitation service; 60 patients were suspected of having HO and underwent a total of 85 triple-phase nuclear bone scans. Seven patients were identified with initially negative but subsequently positive bone scans. Conclusions: In patients with clinically suspicious HO but negative bone scans, follow-up scans are indicated to identify initial false-negative studies.

A safe and effective multi–day colonoscopy bowel preparation for individuals with spinal cord injuries

Context/Objective: Colonoscopy with polypectomy is associated with a reduced risk of colorectal cancer (CRC), but poor bowel cleansing limits the diagnostic yield of the procedure. Patients with spinal cord injury (SCI) frequently have suboptimal bowel cleansing with standard pre-colonoscopy bowel preparation regimens. We aimed to assess the safety, tolerability, and efficacy of a multi–day inpatient bowel preparation regimen in a population of patients with SCI. Design: Retrospective case series. Setting: VA Puget Sound SCI Center. Participants: All patients with SCI (n = 53) who underwent inpatient colonoscopy at the VA Puget Sound from July 12, 2013 to February 12, 2015. Outcome Measures: Patient characteristics, tolerance of full bowel preparation, pre- and post-bowel preparation electrolyte values, adverse events, and adequacy of bowel cleansing were abstracted. Results: Sixty-eight percent of patients had a cervical level of injury and the majority were either American Spinal Injury Association Impairment Scale A (41%) or D (43%). The full bowel preparation was tolerated by 91% of inpatients. In those with pre- and post-bowel preparation laboratory testing, there were small, but statistically significant decreases in serum calcium and phosphate. No patient had symptoms associated with electrolyte abnormalities or required treatment. Five out of 53 inpatients experienced autonomic dysreflexia (AD) during bowel preparation. Eighty-nine percent of patients had adequate bowel cleansing at colonoscopy. Conclusions: We demonstrate a safe and effective inpatient bowel preparation regimen in a SCI population. The regimen was associated with mild, asymptomatic hypophosphatemia and hypocalcemia. AD was an uncommon event, predominantly occurring in patients who experienced frequent AD episodes at baseline.