Kay C. Canupp

Cognitive and functional recovery at 6 and 12 months post-TBI

Outcome studies examining recovery from traumatic brain injury (TBI) often fail to provide a clear understanding of the time course of cognitive, emotional, and behavioural recovery. The present study represents an effort to prospectively study individuals with TBI at fixed intervals, specifically 6 and 12 months post-injury with a window of §1 month. Seventy-two individuals with new-onset TBI underwent neuropsychological evaluation and clinical interview at 6 and 12 months post-injury. Results revealed significant improvements in cognitive abilities, including memory, processing speed, language abilities, and constructional skills. There were significant gains in community integration and involvement in productive activities, but limitations in driving activitie s remained. Although individuals with mild± moderate TBI performed better than individuals with severe TBI, both groups demonstrated equivalent rates of recovery across domains. The results of this study provide important information regarding the time course of TBI recovery.Outcome studies examining recovery from traumatic brain injury (TBI) often fail to provide a clear understanding of the time course of cognitive, emotional, and behavioural recovery. The present study represents an effort to prospectively study individuals with TBI at fixed intervals, specifically 6 and 12 months post-injury with a window of +/- 1 month. Seventy-two individuals with new-onset TBI underwent neuropsychological evaluation and clinical interview at 6 and 12 months post-injury. Results revealed significant improvements in cognitive abilities, including memory, processing speed, language abilities, and constructional skills. There were significant gains in community integration and involvement in productive activities, but limitations in driving activities remained. Although individuals with mild-moderate TBI performed better than individuals with severe TBI, both groups demonstrated equivalent rates of recovery across domains. The results of this study provide important information regarding the time course of TBI recovery.

Effect Of Cranberry Extract On Bacteriuria and Pyuria in Persons With Neurogenic Bladder Secondary To Spinal Cord Injury

Abstract Objective: Todetermine whether antibacterial effects of cranberry extract will reduce or eliminate bacteriuria and pyuria in persans with spinal cord injury (SCI). Design: Randomized, double–blind, placebo–controlled study. Participants: Participants were people with SCI residing in the community who were 1 year or Ionger postinjury with neuragenie bladder managed by intermittent catheterization or external collection device and a baseline urine culture demonstrating at least 105colanies per milliliter of bacteria. Methods: Each participant ingested 2g of concentrated cranberry juice or placebo in capsule form daily for 6 months. Baseline urinalysis and cultures were performed at the time of the initial clinic visit and monthly for 6 months. Microbiologic data were evaluated using analysis of variance with repeated measures. Results: Twenty–six persans received cranberry extract and 22 persans received placebo. There were no differences or trends detected between participants and controls with respect to number of urine specimens with bacterial counts of at least 104 colanies per milliliter, types and numbers of different bacterial species, numbers of urinary leukocytes, urinary pH, or episodes of symptomatic urinary tract infection. Conclusion: Cranberry extract taken in ca psule form did not reduce bact eriuria and pyuria in persans with SCI and cannot be recommended as a means to treat these conditions.

Antimicrobial resistance in gram-negative bacteria isolated from the urinary tract in community-residing persons with spinal cord injury

OBJECTIVE To assess the epidemiology of antimicrobial resistance among community-residing persons with spinal cord injury (SCI). DESIGN Retrospective analysis of existing data. SETTING Data were obtained from persons with SCI attending clinic for annual examinations. PARTICIPANTS Two hundred eighty-seven SCI outpatients. INTERVENTION None. MAIN OUTCOME MEASURE Occurrence of bacteriuria with gram-negative organisms demonstrating resistance to antimicrobial agents in 2 or more classes. RESULTS There were 706 gram-negative isolates from 444 urine specimens. Resistance to drugs in 2 or more classes occurred in 33% of bacterial isolates, but did not significantly increase in frequency among those injured for longer periods or more severely. Significantly higher rates of multidrug-resistant bacteria occurred in specimens from males, younger age group (< or =45 yrs), and persons with indwelling and condom catheters. CONCLUSIONS Antimicrobial resistance in outpatients with SCI is common and is related to widespread use of specific drugs, type of bladder management, and other host factors.

Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder.

Abstract Background/Objective: We conducted a randomized, double-blind comparison of twice daily bladder irrigation using 1 of 3 different solutions in community-residing persons with neurogenic bladder who used indwelling catheters to evaluate efficacy in treatment of bacteriuria. Methods: Eighty-nine persons with bacteriuria were randomized to irrigate their bladders twice daily for 8 weeks with 30 mL of (a) sterile saline, (b) acetic acid, or (c) neomycin-polymyxin solution. Urinalysis, cultures, and antimicrobial susceptibility tests were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected numbers and types of bacteria, urinary pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. Results: Bladder irrigation was well tolerated with the exception of 3 participants who had bladder spasms. None of the 3 irrigants had a detectable effect on the degree of bacteriuria or pyuria in 52 persons who completed the study protocol. A significant increase in urinary pH occurred in all 3 groups. No significant development of resistance to oral antimicrobials beyond what was observed at baseline was detected. Conclusions: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymyxin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as a means of treatment for bacteriuria in persons with neurogenic bladder.

Bacteremia after Spinal Cord Injury in Initial Versus Subsequent Hospitalizations

Abstract Background: Individuals with spinal cord injury (SCI) have a high lifelong risk for systemic infection. For optimal therapy, it is important to characterize the organisms involved in bacteremic episodes and the sites of primary infection. The increase in drugresistant bacteria in recent years underscores the importance of gathering accurate microbiological information. Methods: We performed a retrospective study of hospitalized people with SCI using a computerized Microbiology Laboratory Database. We compared the microbiology of bacteremic episodes during initial versus unplanned subsequent hospitalizations. Data were collected on 55 bacteremic episodes in 30 people during initial hospitalization for SCI and 50 episodes in 29 people who were rehospitalized. Results: Among cases in which a site of origin could be identified, the respiratory tract was the origin of the majority of bacteremias during initial hospitalizations, and the urinary tract was the primary origin during rehospitalizations. Polymicrobial bacteremia occurred in 14 of 55 (25%) initial versus 14 of 50 (28%) subsequent hospitalization episodes. The most common pathogens were coagulase-negative staphylococci, followed by Staphylococcus aureus and Enterobacteriaceae. Bacteremia was more common in people with tetraplegia and complete neurologic lesions than in those with paraplegia and incomplete lesions. One person in the rehospitalization group died from complications of bacteremia. All others were successfully treated. Conclusions: This study describes the frequency and characteristics of bacteremia during initial and subsequent hospitalizations following SCI and examines differences in original sites of infection. This information should be considered when planning infection control measures and empiric antibiotic regimens for patients with SCI.

Evaluation of BacT/ALERT system for detection of Mycoplasma hominis in simulated blood cultures.

ABSTRACT We used simulated blood cultures inoculated with clinical isolates of Mycoplasma hominis to determine whether liquid media of the BacT/ALERT (Organon Teknika, Durham, N.C.) will support growth of this fastidious organism and whether its presence can generate a positive signal with the instrument. Viability of clinical isolates of M. hominis was maintained for 7 days in BacT/ALERT media, and organisms were able to multiply when 1% gelatin was added to neutralize the mycoplasmastatic effects of the sodium polyanetholsulfonate anticoagulant. Without the addition of gelatin to BacT/ALERT bottles, the mycoplasmas declined in numbers or became completely nonviable. Mycoplasmal growth was further enhanced in BacT/ALERT PF both supplemented with gelatin, arginine, and DNA in comparison to broth with only gelatin added. No BacT/ALERT bottles containing M. hominis in simulated blood cultures were flagged positive by the instrument, despite growth of microorganisms of up to 107 CFU/ml after incubation for up to 7 days, suggesting that inadequate CO2 production or some other mechanism prevents the instrument from recognizing the presence of the organism and its metabolic products. The fastidious cultivation requirements and relatively slow growth of M. hominiswarrant that dependence on automated systems and techniques designed to detect conventional bacteria will not be reliable for recovery ofM. hominis and that specialized media and incubation conditions designed for optimum cultivation of mycoplasmas should be employed when this organism is suspected on clinical grounds.

Efficacy and tolerance of norfloxacinin treatment of complicated urinary tract infection in outpatients with neurogenic bladder secondary to spinal cord injury

Abstract We studied the efficacy of a fourteen-day course of the fluoroquinolone,norfloxacin, in a group of 69 catheter free spinal cord injury (SCI) outpatients who experienced a total of seventy-nine urinary tract infection (UTI) episodes. A total of 114 bacterial strains representing twenty species, including sixteen Pseudomonas aeruginosa, all susceptible to norfloxacin, were isolated from initial urine cultures. Mid-treatment cultures in 58/79 (73 %) cases were negative. Cultures taken five to seven days after completing treatment in 42 cases (53 %) were negative. In the remaining 37 there was persistence of initial or superinfecting pathogen(s), or early reinfection with new organisms. Cultures eight to twelve weeks later in 32 cases with initial eradication showed that 27 (84 %) had either relapsed and/or become reinfected. Clinical cure occurred in 4/6 (67 %) symptomatic episodes. Side effects occurred in 6 of 73 (8 %) patients who received norfloxacin, 4 of whom required withdrawal from the study. Twenty of one hundred twenty-two (16 %) bacterial strains isolated during or after treatment were resistant to norfloxacin. Given the limited oral treatment options and the constant risk of reinfection in the SCI population, norf loxacin appears to be a reasonable choice in many patients. However, as with other antimicrobials, when using norfloxacin in SCI patients, the emergence of resistant bacteria must be carefully monitored.

Compliance with Annual Urologie Evaluations and Preservation of Renal Function in Persons with Spinal Cord Injury

We located 59 persons with spinal cord injury (SCI) who had not been examined for 3-15 years and paid them to undergo evaluation and comparison with 101 controls examined on an annual basis. Renal function during the first year post-injury and at follow-up was measured by radioisotopic scanning to determine effective renal plasma flow (ERPF) and information was obtained regarding occurrence of specific secondary complications. Subjects and controls were alike with respect to demographic characteristics, injury-related variables and occurrence of specific secondary complications. Mean initial and follow-up ERPF values adjusted for increasing age were not significantly different for subjects and controls, nor was there significant change within individuals over time. Although serial examination of the urinary tract following SCI is important, after the first few years it may be acceptable to lengthen the periods between examinations or substitute less expensive, noninvasive diagnostic techniques. SCI care centers should carefully evaluate recommendations regarding follow-up urologic examinations in persons with SCI in order to provide the most cost-effective program while maintaining optimum patient care.

Revaccination of Adults With Spinal Cord Injury Using the 23-Valent Pneumococcal Polysaccharide Vaccine

Abstract Background/Objective: Persons with spinal cord injury (SCI) are predisposed to develop pneumonia. This study was undertaken to determine the effect of revaccination with the pneumococcal vaccine on the immune response and the frequency of adverse reactions in this population. Methods: An enzyme-linked immunosorbent assay was used to measure immunoglobulin G to selected pneumococcal capsular polysaccharides on sera collected from 23 persons who were revaccinated 5 years after primary vaccination. Sera were collected just prior to, 1 month, and 1 year following revaccination. Functional activities of serotype-specific antibodies were determined by opsonophagocytosis assays. Results: Several subjects maintained protective antibody concentrations at baseline. Increases in antibody concentrations were observed for all serotypes at 1 month and 1 year. Opsonophagocytic activity increased over baseline when evaluated 1 month and 1 year after revaccination, and a significant positive correlation was observed between antibody concentration and opsonophagocytic activity at all 3 time points. Three persons (13%) experienced transient and self-limited local swelling and pain at the injection site following revaccination. Conclusions: Protective antibody may be present in some persons for at least 5 years after vaccination. Revaccination induces a secondary surge in antibody concentration and opsonophagocytic activity that varies according to serotype but may be of lesser magnitude than the primary response. Revaccination of persons with SCI is not associated with significant adverse effects. Whether revaccination is needed beyond 5 years will require additional investigation.

Effect of oral ciprofloxacin on bacterial flora of perineum, urethra, and lower urinary tract in men with spinal cord injury.

A study was performed in 25 men with spinal cord injuries undergoing intermittent catheterization whose urine had > or = 10(5) bacterial colonies/ml to determine efficacy of ciprofloxacin in eradicating susceptible organisms from urine, urethra, and perineum. Cultures were obtained prior to, during, and 5 to 7 days after administration of 500 mg twice daily for 10 days. Organisms in urine were also present in the urethra and/or perineum in 20 cases. Susceptible bacteria disappeared from urine in all subjects; but at follow-up 12 had cultures positive for ciprofloxacin-resistant Gram-positive cocci, including 1 with methicillin-resistant Staphylococcus aureus (MRSA), and 2 with ciprofloxacin-resistant Acinetobacter sp. Treatment significantly reduced Gram-negative bacilli in perinea and urethras, but ciprofloxacin-susceptible organisms were replaced by resistant staphylococci, including MRSA, enterococci, and Acinetobacter sp. We support use of ciprofloxacin for treatment of urinary tract infections in persons with spinal cord injury, but in view of supercolonization with resistant organisms, the drug should be reserved for symptomatic persons not likely to respond to other oral agents.