Margaret C. Hammond

Influenza Vaccination Among Veterans With Spinal Cord Injury: Part 2. Increasing Vaccination Rates

Abstract Background/Objective: Respiratory complications are the leading cause of morbidity and mortality among individuals with spinal cord injury (SCI). Influenza vaccination is effective in reducing the likelihood of contracting influenza and of subsequent respiratory complications, hospitalizations, and deaths. Historically, vaccination rates for veterans with SCI treated in Veterans Affairs (VA) facilities have been low. The objective of this study was to increase vaccination rates in this population using a multi pronged strategy. Methods: A quasi-experimental design involving 2,2 84 veterans treated at 8 VA SCI Centers was used. Patients at 4 centers received reminder letters and educational materials tailored to SCI. Provider education included mailed reminders and posters in SCI clinical areas. Clinical champions were identified at each site. Four other centers, matched to the study sites in program size and prior vaccination rates, served as comparison sites providing usual care. Vaccination rates were assessed using mailed surveys with telephone follow-up. Results: The influenza vaccination rate was significantly higher in the intervention group than in the comparison group (60.5% vs 54.3%; P = 0.01). Vaccine recipients were older than nonrecipients (mean age 60.8 vs 53.1 years; P < 0.0001). Reasons for not receiving a vaccination included refusal, feeling that being vaccinated was not worth the trouble, and not believing that the vaccine would prevent influenza. Conclusions: Use of low-cost mailed reminders and educational materials resulted in significantly higher vaccination rates. Further efforts to reach targeted subgroups of nonrecipients, such as patients who are younger or from an ethnic minority, are warranted.

Interventions to Increase Influenza Vaccination Rates in Veterans With Spinal Cord Injuries and Disorders

Abstract Objective: To increase the percentage of veterans with spinal cord injuries and disorders (SCI&D) who receive annual influenza vaccinations. Design: A repeated measures quality improvement project using several integrated evidence-based interventions. Setting: 23 Veterans Affairs (VA) SCI Centers. Patients: Veterans with SCI&D average age = 57.3 years (range 21-102 y). Interventions: Patient reminder letters and education; provider reminders and posters; computerized clinical reminders for vaccination targeted to SCI&D; standing orders. Main outcome measures: Patient selfreported vaccination status. Results: Baseline vaccination rate was 33% in fiscal year (FY) 2001. The percentage of veterans with SCI&D who reported receiving vaccinations increased from 62.5% in year 1 (FY2002) to 67.4% in FY2003 (P =0.004); for individuals younger than 50 years of age, rates increased from 50% to 54%. Predictors of vaccination were age 65 years of age or older, VA health care visit in past year, nonsmoker, believing vaccination is important, having a health condition that may contribute to respiratory complications, and self-reported influenza in prior year. Conclusions: Vaccination rates were higher than baseline and higher than reported for other high-risk groups. Interventions that incorporate system-wide approaches plus patient and provider education and reminders were moderately effective in increasing vaccination rates. Targeting younger persons, smokers, and those who do not use VA care may further improve rates.

Association between obesity and diabetes mellitus in veterans with spinal cord injuries and disorders

Rajan S, McNeely MJ, Hammond M, Goldstein B, Weaver F: Diabetes mellitus is associated with obesity in veterans with spinal cord injuries and disorders. Objectives:To examine the association between body mass index (BMI) and clinically diagnosed diabetes in veterans with spinal cord injuries and disorders. We also sought to determine whether there is evidence to support a 10% reduction in BMI cut points, which would lower the upper limit of normal BMI from 24.99 to 22.49 kg/m2, for persons with spinal cord injuries and disorders. Design:Cross-sectional analysis using clinical data on 1938 male veterans. Prevalence ratios (95% confidence intervals) were calculated using a generalized linear model and adjusted for age, race, tobacco use, and paraplegia/tetraplegia status. Results:Compared with the National Heart Lung Blood Institute normal BMI category (18.5–24.99 kg/m2), the prevalence of diabetes was 50% higher (adjusted prevalence ratio: 1.50, 95% CI: 1.11–2.01) in the overweight category (25–29.99 kg/m2) and ∼3-fold higher (for obese classes 1–3, adjusted prevalence ratio: 2.74–3.03) in the obese category (BMI ≥ 30 kg/m2). Compared with the World Health Organization low-normal category (BMI, 18.5–22.99 kg/m2), there was no significant difference in the prevalence of diabetes for those in the high normal weight (BMI, 23–24.99 kg/m2) or low overweight (BMI, 25–27.49 kg/m2) categories. However, the prevalence of diabetes was 2-fold higher among those in the high overweight category (BMI, 27.5–29.99 kg/m2; adjusted prevalence ratio: 2.00, 95% CI: 1.33–2.99). Conclusions:BMI ≥25 kg/m2 was associated with significantly higher diabetes prevalence in male veterans with spinal cord injuries and disorders, and this risk was especially pronounced at BMI ≥27.5 kg/m2. These findings do not support the need to create spinal cord injuries and disorder–specific BMI definitions of overweight for purposes of determining diabetes risk.

Posttraumatic syringomyelia: Profound neuronal loss, yet preserved function

Posttraumatic syrinxes may extend many cord segments rostral to a spinal cord injury (SCI) and significantly dilate the spinal cord, yet few neurologic deficits may be noted. Careful physical examination may reveal ascending loss of pain and temperature without evident functional motor decline. We present a 49-year-old man with T4 paraplegia and a large posttraumatic syrinx who died 3 weeks after syringoperitoneal shunting. Neuropathologic study revealed a large bilateral syrinx cavity from T1 to C6 that tapered to a small unilateral syrinx at C2. Light microscopy of sections from T1 to C2 showed massive loss of intermediate to intermedio-lateral gray neurons and moderate reduction of motoneurons at T1 to C6 levels. Despite these findings, manual muscle testing results remained normal for wrist extensors and elbow extensors, and the patient continued to perform independent sliding board transfers. We conclude that this large progressive syrinx did not merely dissect neural elements apart but caused extensive neuronal damage. Loss of interneurons was evident in spinal segments with preserved strength and function. Possible mechanisms to explain the relatively minimal clinical deficits in view of the neuronal loss are discussed.

Department of Veterans Affairs quality enhancement research initiative for spinal cord injury

Spinal cord injury (SCI) is a lifelong condition, requiring ongoing efforts by multiple disciplines to stabilize, diminish, or prevent impairments; avoid or limit secondary complications; and improve or maintain social role functioning and quality of life for the individual throughout his or her life. There are approximately 200,000 persons with SCI in the United States, of whom roughly 22% are veterans. The estimated national economic impact of SCI is approximately

Prevention of methicillin-resistant Staphylococcus aureus infections in spinal cord injury units.

9.73 billion per year. These figures illustrate why SCI is an important topic for the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI). The SCI QUERI will identify gaps in knowledge of SCI treatment and management, develop research efforts to address these gaps, identify best practices for care and management of SCI, and assess whether best practices lead to improved outcomes, including health-related quality of life.

Quantification of gaps in the EMG interference pattern in chronic hemiparesis

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) are a concern in the 22 acute care Veterans Affairs (VA) spinal cord injury units where patients with unique rehabilitation and medical needs and a high risk of infection are treated. METHODS A bundle was implemented in VA spinal cord injury units consisting of nasal surveillance for MRSA on admission/in-hospital transfer/discharge, contact precautions for patients colonized or infected with MRSA, an emphasis on hand hygiene, and an institutional culture change where infection control became everyones responsibility. RESULTS From October 2007, through June 2011, there were 51,627 admissions/transfers/discharges and 816,254 patient-days of care in VA spinal cord injury units. The percentage of patients screened increased to >95.0%. The mean admission MRSA prevalence was 38.6% ± 19.1%. Monthly HAI rates declined 81% from 1.217 per 1,000 patient-days to 0.237 per 1,000 patient-days (P < .001). Bloodstream infections declined by 100% (P = .002), skin and soft-tissue infections by 60% (P = .007), and urinary tract infections by 33% (P = .07). CONCLUSION Universal surveillance, contact precautions, hand hygiene, and an institutional culture change was associated with significant declines in MRSA HAIs in a setting with a high prevalence of MRSA colonization and a high risk for infection.

New CDC recommendations: annual influenza vaccination recommended for individuals with spinal cord injuries.

This study presents a quantification of the impersistence in the EMG interference pattern (IP) produced during maximal effort by patients with chronic hemiparesis. Monopolar needles were used to record from the flexor carpi radialis (FCR) and extensor carpi radialis longus (ECR) muscles of both the paretic and non-paretic sides of 19 patients with a history of unilateral CVA and 10 healthy control subjects during maximal voluntary isometric wrist flexion or extension. We found more gaps in the IP and fewer total seconds of EMG activity in paretic than in non-paretic or control forearm muscles. The number of gaps was similar in paretic FCR and ECR, but the reduced active time in paretic ECR indicates proportionally more gaps per second of EMG activity. This method provides quantitative measures of both the lapses (gaps in the IP during maximal effort and the inability to sustain EMG activity (total seconds) during long contractions. The latter measure is sufficiently sensitive to distinguish the greater impairment of a paretic wrist extensor than a paretic wrist flexor muscle, and both may prove to be valuable for future comparisons of the severity of paresis and the progress of recovery. These results represent the first quantitative confirmation of previous qualitative descriptions of impersistent recruitment.

Trends in diabetes mellitus indicators in veterans with spinal cord injury.

Serious, life-threatening complications of influenza among people with chronic diseases include pneumonia and exacerbations of coexisting conditions that can result in hospitalization or death. Persons with spinal cord injuries and disorders (SCI&D) are at increased risk for pulmonary impairments and respiratory illness complications due to impaired cough and less effective clearance of secretions, weak respiratory muscles, autonomic changes, including bronchoconstriction, and decreased overall mobility (1). In addition, changes in immune function have been demonstrated following complete cervical spinal cord injuries, which may result in altered clinical response to infection (1). The result is increased mortality and morbidity from respiratory-related illnesses in the SCI population (2). In fact, the most common causes of death have been respiratory complications during both the acute and chronic phases of SCI for the past 2 decades (2,3). DeVivo and colleagues reported that persons with SCI who contracted influenza or pneumonia were 37 times more likely to die from influenza or pneumonia than were comparable individuals from the general population (3).

Spinal Cord Injury Medicine

Rajan S, Hammond MC, Goldstein B: Trends in diabetes mellitus indicators in veterans with spinal cord injury. Am J Phys Med Rehabil 2008;87:468–477. Objective:Persons with spinal cord injury (SCI) are at increased risk for developing diabetes mellitus (DM). However, published data on the care provided to this population are minimal. The purpose of this study was to examine a set of measures of quality of DM care in veterans with SCI. Design:Retrospective analysis of the External Peer Review Program data for veterans with SCI and DM from 2002 to 2004 in the Veterans Healthcare System. Trends in DM measures were examined using generalized estimation equation models. Results:The percentage of veterans who received testing for lipids, retinal, and renal exams significantly increased during this period. This was accompanied by significant improvements in intermediate outcomes, glycemic, lipid, and blood pressure (BP) control. The percentage of veterans with glycosylated hemoglobin (HbA1c) (levels ≤9%; P < 0.001) and those with poorly controlled levels (HbA1c >9.5%; P = 0.022) improved. BP (140/90) rates increased from 59% in fiscal year (FY) 2002 to nearly 70% in 2004 (P < 0.001). The percentage of veterans who received renal screening (anatomical tests, physiologic test, and urine microalbumin) increased significantly (P < 0.001). Retinopathy exam rates also increased from 55.1% in FY 2002 to 70.8% in FY 2004 (P < 0.001). Conclusions:Significant improvements were made in a set of DM measures used to evaluate care provided to veterans with SCI. The positive trends in DM care seen in the general veteran population were also evident in the SCI population.