Kevin O'Connor

Predicting neurologic recovery in traumatic cervical spinal cord injury

OBJECTIVEnTraumatic spinal cord injury (SCI) affects 8,000 to 10,000 individuals per year in the United States. One of the most difficult tasks confronting the clinician is the discussion of neurologic recovery and prognosis with the patient and/or family. Our objective is to provide a guide for practitioners to accurately predict neurologic outcome in acute traumatic cervical SCI (tetraplegia).nnnDATA SOURCEnPublished reports obtained through MEDLINE search, texts, and studies presented at national conferences.nnnSTUDY SELECTIONnPeer reviewed studies, in English language, that discussed prognosis after traumatic SCI.nnnCONCLUSIONnA comprehensive physical examination of the acute SCI patient is essential in determining the initial level and classification of the injury and is the most accurate method to predict neurologic recovery. Other diagnostic tests, including somatosensory evoked potentials, magnetic resonance imaging, and transcranial magnetic stimulation, may be helpful in further determining outcome when used in association with the clinical examination. The understanding of neurologic recovery should help predict ultimate functional capability and potential needs.

Predictors of dysphagia after spinal cord injury

OBJECTIVEnTo quantify the incidence of swallowing deficits (dysphagia) and to identify factors that predict risk for dysphagia in the rehabilitation setting following acute traumatic spinal cord injury.nnnDESIGNnRetrospective case-control study.nnnSETTINGnFreestanding rehabilitation hospital.nnnPATIENTSnData were collected on 187 patients with acute traumatic spinal cord injury admitted for rehabilitation over a 4-year period who underwent a swallowing screen, in which 42 underwent a videofluoroscopic swallowing study (VFSS).nnnMAIN OUTCOME MEASURESnVFSS was performed on patients with suspected swallowing problems. Possible antecedents of dysphagia were recorded from the medical record including previous history of spine surgery, surgical approach and technique, tracheostomy and ventilator status, neurologic level of injury, ASIA Impairment Classification, orthosis, etiology of injury, age, and gender.nnnRESULTSnOn admission to rehabilitation 22.5% (n = 42) of spinal cord injury patients had symptoms suggesting dysphagia. In 73.8% (n = 31) of these cases, testing confirmed dysphagia (aspiration or requiring a modified diet), while VFSS ruled out dysphagia in 26.2% (n = 11) cases. Logistic regression and other analyses revealed three significant predictors of risk for dysphagia: age (p < .028), tracheostomy and mechanical ventilation (p < .001), and spinal surgery via an anterior cervical approach (p < .016). Other variables analyzed had no relation or at best a slight relation to dysphagia. Tracheostomy at admission was the strongest predictor of dysphagia. The combination of tracheostomy at rehabilitation admission and anterior surgical approach had an extremely high rate of dysphagia (48%).nnnCONCLUSIONnSwallowing abnormalities are present in a significant percentage of patients presenting to rehabilitation with acute traumatic cervical spinal cord injury. Patients with a tracheostomy appear to have a substantially increased risk of development of dysphagia, although other factors are also relevant. Risk of dysphagia should be evaluated to decrease the potential for morbidity related to swallowing abnormalities.

Duplex ultrasound screening for deep vein thrombosis in spinal cord injured patients at rehabilitation admission

OBJECTIVEnTo determine the rate of deep vein thrombosis (DVT) newly diagnosed by duplex ultrasound in patients with acute spinal cord injury (SCI) at admission for rehabilitation.nnnDESIGNnRetrospective case-control study.nnnSETTINGnIndependent specialized spinal cord rehabilitation hospital.nnnPATIENTSnData were collected from records of 189 SCI patients admitted for rehabilitation over a 1-year period who underwent a duplex scan and were not admitted with a known diagnosis of DVT.nnnMAIN OUTCOME MEASURESnA DVT newly diagnosed by duplex ultrasound at rehabilitation admission.nnnRESULTSnTwenty-two patients (11.6%) had a newly diagnosed DVT at time of admission. Chi-square analysis found no statistically significant relationship between level of injury (tetraplegia vs paraplegia), motor complete (ASIA A and B) versus incomplete status (ASIA C and D), or cause of SCI (traumatic vs nontraumatic injury) in determining a positive or negative duplex result (chi2 = 1.709, p = .191; chi2 = 1.314, p = .252; chi2 = 3.155, p = .076; respectively). Prophylaxis for DVT decreased the risk of developing a DVT: 4.1% of patients administered prophylaxis as compared to 16.4% of patients not given prophylaxis (chi2 = 6.558, p = .01). Only 38.6% of patients transferred to rehabilitation were undergoing DVT prophylaxis.nnnCONCLUSIONSnThe prevalence of DVT in acute SCI patients at admission to rehabilitation is significant. A duplex ultrasound is an important noninvasive technique to screen patients with acute and subacute SCI for DVT on admission to the rehabilitation setting regardless of the completeness, level, or cause of the patients injury.

DSM melancholic features are unreliable predictors of ECT response : A CORE publication

Objective: To determine the relationship between baseline melancholic features with outcomes in patients with major depressive disorder referred for electroconvulsive therapy (ECT). Method: In a multihospital (Consortium for Research in ECT) collaborative ECT study, SCID-1 interviews were obtained at study entry. Ratings of the 24-item Hamilton Rating Scale for Depression were obtained thrice weekly during the course of ECT, once during a subsequent treatment-free week, and periodically during 6-month continuation treatment with either bitemporal ECT or nortriptyline plus lithium (continuation pharmacotherapy). Results: The evaluable sample was severely ill with a mean 24-item Hamilton Rating Scale for Depression score of 35.2 (±6.9). Of 489 patients, 63.6% (311) met DSM-IV criteria for melancholic features. During acute ECT, 62.1% of those with melancholic features remitted, as compared with 78.7% for those without melancholic features (P = 0.002). During medication continuation treatment (continuation pharmacotherapy), relapse rates were higher for those with melancholic features than for those without these features. Conversely, with continuation ECT, the rate of relapse was lower for those with, compared with those without, melancholic features. Conclusions: Ascertaining melancholic features by SCID-1 criteria does not identify depressed patients more likely to respond to ECT as had been anticipated from the literature. Melancholic features were associated with poorer treatment outcomes in acute ECT. Those with melancholic features were less likely to relapse with continuation ECT, but those with melancholic features were more likely to relapse with continuation pharmacotherapy. The limitations of the DSM-IV criteria for melancholia are discussed.

Seizure threshold in a large sample: Implications for stimulus dosing strategies in bilateral electroconvulsive therapy: A report from core

Objective: We sought to examine the relationship of seizure threshold (ST) to age and other demographic characteristics in a large sample where ST was determined by the dose titration (DT) method. We also compared the resulting stimulation levels to estimates predicted by an age-based formula, the half-age (HA) method. Methods: In a multicenter prospective study, patients received a standardized course of bilateral electroconvulsive therapy for major depression using a brief pulse device. The ST was determined at the first treatment using a fixed algorithm of stimulations. Subsequent seizures were induced at a level 50% higher than the empirically determined ST. We only included data from subjects receiving methohexital anesthesia. We correlated ST with demographic and clinical characteristics of the sample. The actual dosing levels at the second treatment were compared with estimates based on HA. Results: Of the original 531 subjects, 402 met criteria for the current analysis. The ST was positively correlated with age. Male patients had slightly higher ST than female patients. Neither race, severity of illness, psychosis, nor use of psychotropic medications affected ST. Little variability in titrated ST was observed among our patients. An ST of 40 (percent of charge) or lower was found in 97.5% of patients, with either 20 or 40 in 80% of patients. Ninety-six percent of the patients were treated at the 3 levels of 15%, 30%, or 60%. Estimated HA stimulus levels offered a wider range of choices compared with this particular algorithm used for ST determination at an average level of 18% above the determined ST. Conclusions: Seizure threshold correlates strongly with age, whereas there is a weaker relation between ST and sex. There was little individual variation of ST determined by the DT method among subjects, possibly because of the wide spacing between steps of this particular titration algorithm. Half-age estimates were 18% above the empirically determined ST. This suggests that the use of the HA estimates at the first treatment may result in fewer stimulations compared with the DT method.

Bowel care practices in chronic spinal cord injury patients

OBJECTIVEnTo determine current characteristics of bowel care practices of chronic spinal cord injury (SCI) patients.nnnDESIGNnProspective interview and examination of 100 SCI patients injured for more than 1 year.nnnSETTINGnFreestanding rehabilitation outpatient SCI center.nnnPARTICIPANTSnOne hundred chronic SCI patients.nnnRESULTSnThe following bowel program characteristics were found: alternate-day programs were most common; most subjects performed their programs in the morning; and tetraplegic subjects performed their programs less often, used suppositories more often, required greater assistance, and took longer to complete their programs.nnnCONCLUSIONSnBowel dysfunction in chronic SCI need not be associated with complications in the majority of cases.

Change in seizure threshold during electroconvulsive therapy

The seizure threshold (ST) is a measure of the minimum electrical energy necessary to induce a grand mal seizure. Dose titration of the ST has been suggested to optimize stimulus dosing in electroconvulsive therapy (ECT). The change in ST with remission is examined in a large sample of unipolar depressed patients. Methods: In a study of continuation treatments after successful ECT, the ST was determined at the first treatment and again 1 week after remission using a conventional ST measurement protocol. Patients were treated with bilateral electrode placement at 150% above the measured ST. Results: In 80 subjects, the ST measured the same in 70%, increased in 21%, and decreased in 9% at remission. Conclusions: In a study of bilateral ECT, the ST did not rise conclusively with remission.

Electrophrenic Ventilation: A Different Perspective

Since 1972, radio-frequency electrophrenic nerve pacing (EPP) has been an option for assisting the ventilation of patients with chronic paralytic respiratory insufficiency. Most of the medical literature has been favorable regarding its continued application. We reviewed the literature to determine how successful application of EPP was defined. Our studies indicated that long-term follow-up of EPP patients has been generally inadequate with little emphasis placed on incidence and severity of complications. There was no standardization in defining successful experiences with EPP. Upper airway instability during pacing, lack of internal pacemaker alarms, and the risk of sudden pacemaker failure necessitate permanent tracheostomy in the great majority of patients but complications of the presence of a tracheostomy were not considered in evaluating the desirability of EPP. Some EPP patients became independent of any ventilatory support thus benefiting minimally from the time commitment, effort, and extreme expense needed for EPP placement and training. We conclude that EPP is a valid option for the properly screened patient but that expense, failure rate, morbidity and mortality remain excessive and that alternative methods of ventilatory support should be explored.

Anodal block in F-wave studies

OBJECTIVEnTo determine whether F-wave results differ with the anode proximal or distal to the cathode, ie, if clinical anodal block exists.nnnDESIGNnProspective study of 30 healthy volunteers undergoing nerve conduction and F-wave studies in one median nerve. A needle cathode electrode was used with a surface anode placed alternately proximal and distal to the cathode. The same electromyographer performed all studies with a Dantec Counterpoint machine.nnnRESULTSnF-wave latencies were essentially unaffected by distal versus proximal positioning. Minimum, maximum, and mean F-wave latencies correlated extremely highly (r=.973 to .988). For both F-wave and M-response latencies and amplitudes, differences between mean values obtained using the two methods were extremely small and were neither clinically nor statistically significant. The frequency of elicitation of F-waves may (p < .05) have been slightly (3.5%) lower when the anode was in the distal position.nnnCONCLUSIONnAnodal block is not seen in F-wave studies when using needle electrode stimulations. Reversing the stimulator does not seem to be required. Further study with surface stimulating electrodes is underway to confirm results.

Outcome of Electroconvulsive Therapy by Race in the Consortium for Research on Electroconvulsive Therapy Multisite Study

Objective: The authors examine the differences in outcome between black and white patients receiving electroconvulsive therapy (ECT) as a part of the Consortium for Research on Electroconvulsive Therapy multisite study. Methods: A total of 624 patients were enrolled in an National Institute of Mental Health (NIMH)-funded, randomized, controlled ECT trial comparing the efficacy of continuation ECT versus continuation pharmacotherapy between 1997 and 2004. This analysis focuses on the 32 black and 483 white patients who participated in phase I of the study. The authors compared baseline demographic and clinical variables and acute outcomes of these 2 groups. Results: Compared with whites, far fewer blacks participated in the study. Those who did were less likely to have failed adequate medication trials and were more likely to have psychotic features. Their initial 24-item Hamilton Rating Scale for Depression scores were higher than those of the whites, and they showed a greater reduction in these 24-item Hamilton Rating Scale for Depression scores by the end of the treatment period. Although sample size limited the statistical significance of the findings, black patients also showed a higher rate of remission after an acute phase of ECT. Conclusions: This study found that black and white patients with major depressive disorder had comparable outcomes. We also found that fewer black patients received ECT than whites, a difference that has been reported in other samples.