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Chen DY, Di X, Karunakaran KD, Sun H, Pal S, Biswal BB. Delayed cerebrovascular reactivity in individuals with spinal cord injury in the right inferior parietal lobe: a breath-hold functional near-infrared spectroscopy study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.03.24307819. [PMID: 38883754 PMCID: PMC11177928 DOI: 10.1101/2024.06.03.24307819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Cerebrovascular reactivity (CVR) reflects the ability of blood vessels to dilate or constrict in response to a vasoactive stimulus, and allows researchers to assess the brain's vascular health. Individuals with spinal cord injury (SCI) are at an increased risk for autonomic dysfunction in addition to cognitive impairments, which have been linked to a decline in CVR; however, there is currently a lack of brain-imaging studies that investigate how CVR is altered after SCI. In this study, we used a breath-holding hypercapnic stimulus and functional near-infrared spectroscopy (fNIRS) to investigate CVR alterations in individuals with SCI (n = 20, 14M, 6F, mean age = 46.3 ± 10.2 years) as compared to age- and sex-matched able-bodied (AB) controls (n = 25, 19M, 6F, mean age = 43.2 ± 12.28 years). CVR was evaluated by its amplitude and delay components separately by using principal component analysis and cross-correlation analysis, respectively. We observed significantly delayed CVR in the right inferior parietal lobe in individuals with SCI compared to AB controls (linear mixed-effects model, fixed-effects estimate = 6.565, Satterthwaite's t-test, t = 2.663, p = 0.008), while the amplitude of CVR was not significantly different. The average CVR delay in the SCI group in the right inferior parietal lobe was 14.21 s (sd: 6.60 s), and for the AB group, the average delay in the right inferior parietal lobe was 7.08 s (sd: 7.39 s). CVR delays were also associated with the duration since injury in individuals with SCI, in which a longer duration since injury was associated with a shortened delay in CVR in the right inferior parietal region (Pearson's r-correlation, r = -0.59, p = 0.04). This study shows that fNIRS can be used to quantify changes in CVR in individuals with SCI, and may be further used in rehabilitative settings to monitor the cerebrovascular health of individuals with SCI.
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Affiliation(s)
- Donna Y. Chen
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, US
- Rutgers Biomedical and Health Sciences, Rutgers School of Graduate Studies, Newark, NJ, US
| | - Xin Di
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, US
| | | | - Hai Sun
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, US
| | - Saikat Pal
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, US
- Electrical and Computer Engineering Department, New Jersey Institute of Technology, Newark, NJ, US
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY, US
| | - Bharat B. Biswal
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, US
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Weber AM, Nightingale TE, Jarrett M, Lee AHX, Campbell OL, Walter M, Lucas SJE, Phillips A, Rauscher A, Krassioukov AV. Cerebrovascular Reactivity Following Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2024; 30:78-95. [PMID: 38799609 PMCID: PMC11123610 DOI: 10.46292/sci23-00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Background Spinal cord injuries (SCI) often result in cardiovascular issues, increasing the risk of stroke and cognitive deficits. Objectives This study assessed cerebrovascular reactivity (CVR) using functional magnetic resonance imaging (fMRI) during a hypercapnic challenge in SCI participants compared to noninjured controls. Methods Fourteen participants were analyzed (n = 8 with SCI [unless otherwise noted], median age = 44 years; n = 6 controls, median age = 33 years). CVR was calculated through fMRI signal changes. Results The results showed a longer CVR component (tau) in the grey matter of SCI participants (n = 7) compared to controls (median difference = 3.0 s; p < .05). Time since injury (TSI) correlated negatively with steady-state CVR in the grey matter and brainstem of SCI participants (RS = -0.81, p = .014; RS = -0.84, p = .009, respectively). Lower steady-state CVR in the brainstem of the SCI group (n = 7) correlated with lower diastolic blood pressure (RS = 0.76, p = .046). Higher frequency of hypotensive episodes (n = 7) was linked to lower CVR outcomes in the grey matter (RS = -0.86, p = .014) and brainstem (RS = -0.89, p = .007). Conclusion Preliminary findings suggest a difference in the dynamic CVR component, tau, between the SCI and noninjured control groups, potentially explaining the higher cerebrovascular health burden in SCI individuals. Exploratory associations indicate that longer TSI, lower diastolic blood pressure, and more hypotensive episodes may lead to poorer CVR outcomes. However, further research is necessary to establish causality and support these observations.
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Affiliation(s)
- Alexander Mark Weber
- Division of Neurology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- School of Biomedical Engineering, University of British Columbia, British Columbia, Canada
- Department of Neuroscience, University of British Columbia, Vancouver, BC, Canada
| | - Tom E. Nightingale
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham, UK
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
| | - Michael Jarrett
- MRI Research Centre, University of British Columbia, Vancouver, Canada
| | - Amanda H. X. Lee
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
| | - Olivia Lauren Campbell
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- School of Biomedical Engineering, University of British Columbia, British Columbia, Canada
| | - Matthias Walter
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Samuel J. E. Lucas
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- Centre for Human Brain Health, University of Birmingham, UK
| | - Aaron Phillips
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- RestoreNetwork, Hotchkiss Brain Institute, Libin Cardiovascular Institute, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander Rauscher
- Division of Neurology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- MRI Research Centre, University of British Columbia, Vancouver, Canada
- Department of Astronomy and Physics, University of British Columbia, Vancouver, BC, Canada
| | - Andrei V. Krassioukov
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- G.F. Strong Rehabilitation Centre, Vancouver, BC, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Barretto TA, Tetzlaff W, Illes J. Ethics and accountability for clinical trials. Spinal Cord 2024; 62:192-194. [PMID: 38499760 PMCID: PMC11003861 DOI: 10.1038/s41393-024-00980-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024]
Abstract
In May 2023, a disclaimer posted on ClinicalTrials.gov dismisses accountability for the accuracy of registered information. For spinal cord injury, inconsistencies in intervention classification, phase designation, and lack of study protocols and results threaten the integrity of the database and put users at risk. An investment in what the resource should be rather than what it is not will give it the authority commensurate with the requirements for its regulatory use and informed decision-making for prospective trial participants.
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Affiliation(s)
- Tanya A Barretto
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Wolfram Tetzlaff
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Chan BCF. The Challenges in Conducting Economic Evaluations for Rehabilitation Technologies. Top Spinal Cord Inj Rehabil 2023; 29:44-52. [PMID: 38174139 PMCID: PMC10759881 DOI: 10.46292/sci23-00035s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background Health technology assessment (HTA) is an important evidentiary component in the decision-making process for the adoption of new healthcare technologies to the healthcare system. Economic evidence is an important consideration in HTAs. Recent systematic reviews in rehabilitation have shown a limited number of economic evaluations and high levels of uncertainty in the results. It is unclear whether there are challenges related to the field of rehabilitation and the technologies used in rehabilitation that inhibit the development of economic evidence. Methods In this study, economic evaluations in rehabilitation were reviewed. This was followed by a summary of the latest evidence on the challenges of conducting HTA for medical devices and the relationship with rehabilitation technologies. Finally, several considerations are suggested to improve the HTA of technologies that target rehabilitation. A literature review of Google Scholar and PubMed was conducted to identify reviews in economic evaluations in rehabilitation. A recent review on the barriers to HTA of medical devices in general was also examined to identify similar concerns with rehabilitation technologies. Results The challenges identified include the lack of high-quality studies, the interaction between the technology and the user, the short product life cycle, and estimation of efficacy in technologies with multiple target populations. Conclusion Overall, many of the challenges in evaluating medical devices also apply to rehabilitation interventions. Further research and discussion on these issues are necessary to increase the clinical evidence for rehabilitation technologies, strengthen the development of HTAs, and facilitate the use of technologies to improve the health of individuals requiring rehabilitation.
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Affiliation(s)
- Brian Chun-Fai Chan
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Mavrovounis G, Makris M, Demetriades AK. Traumatic spinal cord and spinal column injuries: A bibliometric analysis of the 200 most cited articles. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:346-364. [PMID: 38268681 PMCID: PMC10805157 DOI: 10.4103/jcvjs.jcvjs_97_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 01/26/2024] Open
Abstract
Study Design Bibliometric analysis. Objectives This study aimed to highlight the 200 most influential articles related to traumatic spinal cord and spinal column injuries and provide an insight of past and current global trends in spinal trauma research. Methods The Web of Science database was used to identify the top 200 most cited articles on the topic of traumatic spinal cord injury (SCI) and spinal column injuries between using a prespecified algorithm. The articles were manually reviewed; bibliometrics were collected on title, first and corresponding authors' country, institution, journal, publication year, and citation data. Results The search string yielded 30,551 articles during 1977-2019. The average time from the publication was 19.5 years. A total of 1356 authors contributed to 67 different journals, the top 200 most cited articles amassing a total of 88,115 citations and an average 440.6 citations. The United States of America (USA) contributed the most with 110 articles; the top institution was the University of Toronto with 34 publications. Most studies focused on basic science research on SCI. Keyword analysis revealed the most commonly used keywords: SCI, inflammation, apoptosis, incidence/prevalence, and regeneration; four word-clusters were identified. Institutions from the USA and Canada collaborated the most and two major and two minor institutional collaboration subnetworks were identified. Co-citation analysis detected three main clusters of authors. Conclusion This overview of the most cited articles on traumatic spinal cord and spinal column injuries provides insight into the international spinal trauma community and the terrain in this field, potentially acting as a springboard for further collaboration development.
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Affiliation(s)
| | - Marios Makris
- Care of the Elderly Department, Watford General Hospital, Edinburgh, UK
| | - Andreas K. Demetriades
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Edinburgh Spinal Surgery Outcome Studies Group, Leiden, The Netherlands
- Department of Neurosurgery, University of Leiden, Leiden, The Netherlands
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Kelly-Hedrik M, Abd-El-Barr MM, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan V, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest JD. Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma 2023; 40:1834-1848. [PMID: 36576020 DOI: 10.1089/neu.2022.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.
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Affiliation(s)
| | | | - Bizhan Aarabi
- University of Maryland School of Medicine, Maryland, USA
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Susan P Howley
- Christopher & Dana Reeve Foundation, Short Hills, New Jersey, USA
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Kirshblum
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Christopher J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Vanessa Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Christine Park
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G Toups
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, USA
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Harvey LA, Glinsky JV, Chu J, Herbert RD, Liu H, Jan S, Billot L, Scivoletto G, Spooren AI, Seelen HA, Ben M, Tranter K, Chen LW, Rainey D, Rimmer C, Jorgensen V, Di Natal F, Denis S, Gollan EJ, Tamburella F, Agostinello J, van Laake-Geelen CM, Bell C, Lincoln C, Stolwijk JM, van der Lede J, Paddison S, Oostra K, Cameron ID, Weber G, Sherrington C, Nunn AK, Synnott EL, McCaughey E, Kaur J, Shetty S. Early and intensive motor training to enhance neurological recovery in people with spinal cord injury: trial protocol. Spinal Cord 2023; 61:521-527. [PMID: 37414835 PMCID: PMC10495259 DOI: 10.1038/s41393-023-00908-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
STUDY DESIGN Protocol for a multi-centre randomised controlled trial (the SCI-MT trial). OBJECTIVES To determine whether 10 weeks of intensive motor training enhances neurological recovery in people with recent spinal cord injury (SCI). SETTING Fifteen spinal injury units in Australia, Scotland, England, Italy, Netherlands, Norway, and Belgium. METHODS A pragmatic randomised controlled trial will be undertaken. Two hundred and twenty people with recent SCI (onset in the preceding 10 weeks, American Spinal Injuries Association Impairment Scale (AIS) A lesion with motor function more than three levels below the motor level on one or both sides, or an AIS C or D lesion) will be randomised to receive either usual care plus intensive motor training (12 h of motor training per week for 10 weeks) or usual care alone. The primary outcome is neurological recovery at 10 weeks, measured with the Total Motor Score from the International Standards for Neurological Classification of SCI. Secondary outcomes include global measures of motor function, ability to walk, quality of life, participants' perceptions about ability to perform self-selected goals, length of hospital stay and participants' impressions of therapeutic benefit at 10 weeks and 6 months. A cost-effectiveness study and process evaluation will be run alongside the trial. The first participant was randomised in June 2021 and the trial is due for completion in 2025. CONCLUSIONS The findings of the SCI-MT Trial will guide recommendations about the type and dose of inpatient therapy that optimises neurological recovery in people with SCI. TRIAL REGISTRATION ACTRN12621000091808 (1.2.2021).
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Affiliation(s)
- Lisa A Harvey
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia.
| | - Joanne V Glinsky
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Jackie Chu
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | | | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Henk A Seelen
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Marsha Ben
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Keira Tranter
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Lydia W Chen
- Royal North Shore Hospital, Sydney, NSW, Australia
| | | | | | | | | | - Sophie Denis
- Prince of Wales Hospital, Sydney, NSW, Australia
| | | | | | | | - Charlotte M van Laake-Geelen
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
- Department of Rehabilitation Medicine, Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Chris Bell
- Repatriation General Hospital, Adelaide, SA, Australia
| | - Claire Lincoln
- Queen Elizabeth National Spinal Injures Unit, Glasgow, UK
| | - Janneke M Stolwijk
- Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Jessica van der Lede
- Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Sue Paddison
- London Spinal Cord Injury Centre, Royal National Orthopaedic Hospital Trust, Middlesex, UK
| | | | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | | | - Catherine Sherrington
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Andrew K Nunn
- Victorian Spinal Cord Service, Austin Health, Melbourne, VIC, Australia
| | | | - Euan McCaughey
- Queen Elizabeth National Spinal Injures Unit, Glasgow, UK
| | - Jasbeer Kaur
- Royal North Shore Hospital, Sydney, NSW, Australia
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Bekhet AH, Jahan AM, Bochkezanian V, Musselman KE, Gorgey AS. Response to Letter to the Editor on "Effects of Electrical Stimulation Training on Body Composition Parameters After Spinal Cord Injury: A Systematic Review". Arch Phys Med Rehabil 2023; 104:514-516. [PMID: 36539176 DOI: 10.1016/j.apmr.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Affiliation(s)
| | - Alhadi M Jahan
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, Canada
| | - Vanesa Bochkezanian
- School of Health, Medical and Applied Sciences, College of Health Sciences, Central Queensland University, Rockhampton, QLD, Australia
| | - Kristin E Musselman
- KITE, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada; Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada; Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Ashraf S Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, Richmond, VA, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA.
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Bray EA, Salamonson Y, Everett B, George A, Chapman IA, Ramjan L. Transitioning between paediatric and adult healthcare services: a qualitative study of the experiences of young people with spinal cord injuries and parents/caregivers. BMJ Open 2022; 12:e065718. [PMID: 36418132 PMCID: PMC9684994 DOI: 10.1136/bmjopen-2022-065718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Healthcare transition (HCT) interventions are pivotal to paediatric rehabilitation. However, there has been limited research focusing on HCT in young people with spinal cord injury (SCI). To date, little has been reported on key factors that may contribute to a positive or negative transition experience and what, if any, are the gaps in the transition process. This study explored the experiences of transition from paediatric to adult healthcare for young people with SCI and parents/caregivers in pursuit of co-designing and developing an intervention to support transition. DESIGN, SETTING AND PARTICIPANTS This qualitative study forms part of the planning phase of a larger participatory action research project. It supports obtaining a rich understanding of the phenomenon and the issues and actions necessary to achieve change. Semi-structured individual interviews were conducted online between April and June 2021 with young people with SCI and parents/caregivers who had transitioned or were preparing for the transition from paediatric to adult healthcare in NSW, Australia. The interviews were analysed using an inductive reflexive thematic analysis approach. RESULTS The study recruited nine participants, five young people with SCI and four parents/caregivers. The interviews provided invaluable insight into young people with SCI and their parents'/caregivers' experiences of HCT. As HCT experiences were often less than optimal and needs were not adequately met, some recommendations were offered. These included a coordinated and streamlined handover from paediatric to adult healthcare providers, and a 'one-stop shop' for young people with SCI and their parents/caregivers to access transition information, such as how it occurs, who to call for ongoing support and advice, and tips on how to transition successfully. CONCLUSION Providing a coordinated and streamlined handover process as well as access to more context-related information could improve the transition experiences of young people with SCI and parents/caregivers, resulting in improved health outcomes and greater independence. TRIAL REGISTRATION ACTRN12621000500853.
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Affiliation(s)
- Emily Alice Bray
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Yenna Salamonson
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
- Ingham Institute Applied Medical Research, Liverpool, New South Wales, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Bronwyn Everett
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Ajesh George
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
- Ingham Institute Applied Medical Research, Liverpool, New South Wales, Australia
- School of Dentistry, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Isabel A Chapman
- SpineCare Foundation, a Division of Northcott, Parramatta, New South Wales, Australia
| | - Lucie Ramjan
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
- Ingham Institute Applied Medical Research, Liverpool, New South Wales, Australia
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Muacevic A, Adler JR. Implementation of National Emergency X-Radiography Utilization Study (NEXUS) Criteria in Pediatrics: A Systematic Review. Cureus 2022; 14:e30065. [PMID: 36238421 PMCID: PMC9547612 DOI: 10.7759/cureus.30065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Since its introduction in 1992, the National Emergency X-Radiography Utilization Study (NEXUS) criteria have been used in trauma to decide whether a patient requires radiographic imaging. The tool is important in reducing radiation exposure. However, applying the NEXUS criteria for cervical spine imaging in pediatric patients is poorly supported compared to their use in adults. The objective of this review was to examine the effectiveness of using the NEXUS criteria in the diagnostic management of pediatric cervical spine injuries (CSI). The following databases were searched for studies focused on applying the NEXUS criteria for CSI in pediatric patients: Cochrane, PubMed, Google Scholar, EMBASE, ELSEVIER, and ScienceDirect. Additional studies were found through reference lists of primary sources and previous systematic and meta-analyses. The search focused on randomized controlled trials (RCTs), cohort studies, retrospective studies, prospective studies, and other uncontrolled trials published from 2000 to 2022. There were seven included studies with a total of 4502 pediatric patients. Five of the included studies were retrospective studies, while the remaining were prospective and case studies. Our results show that the sensitivity ranged from 43% to 100%, while the specificity ranged from 12.93% to 96%. The sensitivity increased with age, with those under the age of two or under the age of eight reporting poorer outcomes than the older pediatric patients. One study also shows that the proportion of patients undergoing cervical spine CT increased from 18% to 61% in the initial period before the implementation of clearance guidelines. The implementation of guidelines led to a 23% decrease in CT scans clearable by NEXUS criteria after 12 months. One of the studies reported that NEXUS criteria were a cost-effective option when used along with X-rays and CT. Overall, the studies do not strongly support the application of the NEXUS criteria to image pediatric patients for CSI. In conclusion, there is weak support in the literature for applying the NEXUS criteria in determining the need for cervical spine imaging in pediatric trauma patients. The practice and research implications of the findings are also discussed.
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Dietz VA, Roberts N, Knox K, Moore S, Pitonak M, Barr C, Centeno J, Leininger S, New KC, Nowell P, Rodreick M, Geoffroy CG, Stampas A, Dulin JN. Fighting for recovery on multiple fronts: The past, present, and future of clinical trials for spinal cord injury. Front Cell Neurosci 2022; 16:977679. [PMID: 36212690 PMCID: PMC9533868 DOI: 10.3389/fncel.2022.977679] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Through many decades of preclinical research, great progress has been achieved in understanding the complex nature of spinal cord injury (SCI). Preclinical research efforts have guided and shaped clinical trials, which are growing in number by the year. Currently, 1,149 clinical trials focused on improving outcomes after SCI are registered in the U.S. National Library of Medicine at ClinicalTrials.gov. We conducted a systematic analysis of these SCI clinical trials, using publicly accessible data downloaded from ClinicalTrials.gov. After extracting all available data for these trials, we categorized each trial according to the types of interventions being tested and the types of outcomes assessed. We then evaluated clinical trial characteristics, both globally and by year, in order to understand the areas of growth and change over time. With regard to clinical trial attributes, we found that most trials have low enrollment, only test single interventions, and have limited numbers of primary outcomes. Some gaps in reporting are apparent; for instance, over 75% of clinical trials with "Completed" status do not have results posted, and the Phase of some trials is incorrectly classified as "Not applicable" despite testing a drug or biological compound. When analyzing trials based on types of interventions assessed, we identified the largest representation in trials testing rehab/training/exercise, neuromodulation, and behavioral modifications. Most highly represented primary outcomes include motor function of the upper and lower extremities, safety, and pain. The most highly represented secondary outcomes include quality of life and pain. Over the past 15 years, we identified increased representation of neuromodulation and rehabilitation trials, and decreased representation of drug trials. Overall, the number of new clinical trials initiated each year continues to grow, signifying a hopeful future for the clinical treatment of SCI. Together, our work provides a comprehensive glimpse into the past, present, and future of SCI clinical trials, and suggests areas for improvement in clinical trial reporting.
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Affiliation(s)
- Valerie A. Dietz
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Nolan Roberts
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Katelyn Knox
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Sherilynne Moore
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Michael Pitonak
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Chris Barr
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | - Jesus Centeno
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | | | - Kent C. New
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | - Peter Nowell
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | | | - Cedric G. Geoffroy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University, College Station, TX, United States
- Texas A&M Institute for Neuroscience, Texas A&M University, College Station, TX, United States
| | - Argyrios Stampas
- Department of Physical Medicine and Rehabilitation, UTHealth Houston McGovern Medical School, Houston, TX, United States
| | - Jennifer N. Dulin
- Department of Biology, Texas A&M University, College Station, TX, United States
- Texas A&M Institute for Neuroscience, Texas A&M University, College Station, TX, United States
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12
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Sangari S, Perez MA. Prevalence of spasticity in humans with spinal cord injury with different injury severity. J Neurophysiol 2022; 128:470-479. [PMID: 35507475 PMCID: PMC9423778 DOI: 10.1152/jn.00126.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 11/22/2022] Open
Abstract
Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and assessments of spasticity. We tested 110 individuals with SCI classified by the American Spinal Injury Association Impairment Scale (AIS) as either motor complete (AIS A and B; subacute, n = 25; chronic, n = 33) or motor incomplete (AIS C and D; subacute, n = 23; chronic, n = 29) at a similar time after injury (subacute, ∼1 mo after injury during inpatient rehabilitation and chronic, ≥1 yr after injury) using clinical (modified Ashworth scale) and kinematic (pendulum test) outcomes to assess spasticity in the quadriceps femoris muscle. Using both methodologies, we found that among individuals with subacute motor complete injuries, only a minority showed spasticity, whereas the majority exhibited no spasticity. This finding stands in contrast to individuals with subacute motor incomplete injury, where both methodologies revealed that a majority exhibited spasticity, whereas a minority exhibited no spasticity. In chronic injuries, most individuals showed spasticity regardless of injury severity. Notably, when spasticity was present, its magnitude was similar across injury severity in both subacute and chronic injuries. Our results suggest that the prevalence, not the magnitude, of spasticity differs between individuals with motor complete and incomplete SCI in the subacute and chronic stages of the injury. We thus argue that considering the "presence of spasticity" might help the stratification of participants with motor complete injuries for clinical trials.NEW & NOTEWORTHY The prevalence of spasticity in humans with SCI remains poorly understood. Using kinematic and clinical outcomes, we examined spasticity in individuals with subacute and chronic injuries of different severity. We found that spasticity in the quadriceps femoris muscle was more prevalent among individuals with subacute motor incomplete than in those with motor complete injuries. However, in a different group of individuals with chronic injuries, no differences were found in the prevalence of spasticity across injury severity.
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Affiliation(s)
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, Illinois
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
- Edward Hines Jr., VA Hospital, Hines, Illinois
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13
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Goldsmith JA, Holman ME, Puri P, Khalil RE, Ennasr AN, Gorgey AS. The interaction of macronutrients and body composition among individuals with chronic spinal cord injury. Br J Nutr 2022; 129:1-12. [PMID: 35738897 PMCID: PMC9789189 DOI: 10.1017/s0007114522001830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Changes in body composition and dietary intake occur following spinal cord injury (SCI). The Geometric Framework for Nutrition (GFN) is a tool that allows the examination of the complex relationships between multiple nutrition factors and health parameters within a single model. This study aimed to utilize the GFN to examine the associations between self-reported macronutrient intakes and body composition in persons with chronic SCI. Forty-eight individuals with chronic SCI were recruited. Participants completed and returned 3- or 5-day self-reported dietary recall sheets. Dietary intake of macronutrients (fats, proteins, and carbohydrates) were analysed. Anthropometric measures (circumferences), dual-energy x-ray absorptiometry (DXA), and magnetic resonance imaging (MRI) were used to assess whlole-body composition. Associations between all circumference measures and carbohydrates were observed. Among MRI measures, only significant associations between subcutaneous adipose tissue and protein x carbohydrate as well as carbohydrates alone were identified. Carbohydrates were negatively associated with several measures of fat mass as measured by DXA. Overall, carbohydrates appear to play an important role in body composition among individuals with SCI. Higher carbohydrate intake was associated with lower fat mass. Additional research is needed to determine how carbohydrate intake influences body composition and cardiometabolic health after SCI.
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Affiliation(s)
- Jacob A. Goldsmith
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA 23249, USA
| | - Matthew E. Holman
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA 23249, USA
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Puneet Puri
- Internal Medicine Hepatology, Hunter Holmes McGuire VAMC, Richmond, VA 23249, USA
| | - Refka E. Khalil
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA 23249, USA
| | - Areej N. Ennasr
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA 23249, USA
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA 23249, USA
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA 23284, USA
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14
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Kim KD, Lee KS, Coric D, Harrop JS, Theodore N, Toselli RM. Acute Implantation of a Bioresorbable Polymer Scaffold in Patients With Complete Thoracic Spinal Cord Injury: 24-Month Follow-up From the INSPIRE Study. Neurosurgery 2022; 90:668-675. [PMID: 35442254 PMCID: PMC9067089 DOI: 10.1227/neu.0000000000001932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/24/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Based on 6-month data from the InVivo Study of Probable Benefit of the Neuro-Spinal Scaffold for Safety and Neurological Recovery in Patients with Complete Thoracic Spinal Cord Injury (INSPIRE) study (NCT02138110), acute implantation of an investigational bioresorbable polymer device (Neuro-Spinal Scaffold [NSS]) appeared to be safe in patients with complete thoracic spinal cord injury (SCI) and was associated with an ASIA Impairment Scale (AIS) conversion rate that exceeded historical controls. OBJECTIVE To evaluate outcomes through 24 months postimplantation. METHODS INSPIRE was a prospective, open-label, multicenter, single-arm study. Eligible patients had traumatic nonpenetrating SCI with a visible contusion on MRI, AIS A classification, neurological level of injury at T2-T12, and requirement for open spine surgery ≤96 hours postinjury. RESULTS Nineteen patients underwent NSS implantation. Three patients had early death determined by investigators to be unrelated to the NSS or its implantation procedure. Seven of 16 evaluable patients (44%) had improvement of ≥1 AIS grade at 6 months (primary end point) to AIS B (n = 5) or AIS C (n = 2). Three patients with AIS B at 6 months had further neurological improvement to AIS C by 12 (n = 2) and 24 (n = 1) months, respectively; none have deteriorated per latest available follow-up. No unanticipated or serious adverse device effects were reported. CONCLUSION In this small group of patients with complete thoracic SCI, acute NSS implantation within the spinal cord appeared to be safe with no long-term neurological issues identified during the 24-month follow-up. Patients remain stable, with additional AIS conversions observed in some patients at 12 months and beyond. These data further support the safety and probable benefit of NSS implantation in this patient population.
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Affiliation(s)
- Kee D. Kim
- Department of Neurological Surgery, UC Davis, Sacramento, California, USA;
| | - K. Stuart Lee
- Division of Neurosurgery, Vidant Health, Greenville, North Carolina, USA;
| | - Domagoj Coric
- Department of Neurosurgery, Atrium Healthcare, Charlotte, North Carolina, USA;
- Spine Division, Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA;
- Carolina NeuroSurgery and Spine Associates, Charlotte, North Carolina, USA;
| | - James S. Harrop
- Department of Neurological and Orthopedic Surgery, Division of Spine and Peripheral Nerve Surgery, and Delaware Valley SCI Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA;
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA;
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15
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Vega D, Huang HJ, Arellano CJ. Step-to-step variability indicates disruption to balance control when linking the arms and legs during treadmill walking. PLoS One 2022; 17:e0265750. [PMID: 35320305 PMCID: PMC8942237 DOI: 10.1371/journal.pone.0265750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/07/2022] [Indexed: 11/18/2022] Open
Abstract
We recently discovered that a rope-pulley system that mechanically coupling the arms, legs and treadmill during walking can assist with forward propulsion in healthy subjects, leading to significant reductions in metabolic cost. However, walking balance may have been compromised, which could hinder the potential use of this device for gait rehabilitation. We performed a secondary analysis by quantifying average step width, step length, and step time, and used their variability to reflect simple metrics of walking balance (n = 8). We predicted an increased variability in at least one of these metrics when using the device, which would indicate disruptions to walking balance. When walking with the device, subjects increased their average step width (p < 0.05), but variability in step width and step length remained similar (p's > 0.05). However, the effect size for step length variability when compared to that of mechanical perturbation experiments suggest a minimal to moderate disruption in balance (Rosenthal ES = 0.385). The most notable decrement in walking balance was an increase in step time variability (p < 0.05; Cohen's d = 1.286). Its effect size reveals a moderate disruption when compared to the effect sizes observed in those with balance deficits (effect sizes ranged between 0.486 to 1.509). Overall, we conclude that healthy subjects experienced minimal to moderate disruptions in walking balance when using with this device. These data indicate that in future clinical experiments, it will be important to not only consider the mechanical and metabolic effects of using such a device but also its potential to disrupt walking balance, which may be exacerbated in patients with poor balance control.
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Affiliation(s)
- Daisey Vega
- Department of Health and Human Performance, Center for Neuromotor and Biomechanics Research Laboratory, University of Houston, Houston, Texas, United States of America
| | - Helen J. Huang
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, Florida, United States of America
- Disability, Aging, and Technology (DAT) Cluster, University of Central Florida, Orlando, Florida, United States of America
| | - Christopher J. Arellano
- Department of Health and Human Performance, Center for Neuromotor and Biomechanics Research Laboratory, University of Houston, Houston, Texas, United States of America
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16
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Craven BC, Brisbois L, Pelletier C, Rybkina J, Heesters A, Verrier MC. Central Recruitment: A process for engaging and recruiting individuals with spinal cord injury/disease in research at Toronto Rehabilitation Institute. J Spinal Cord Med 2021; 44:S240-S249. [PMID: 34779741 PMCID: PMC8604526 DOI: 10.1080/10790268.2021.1970898] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
CONTEXT Insufficient recruitment is a barrier to research and limits statistical power. We describe an initiative aimed to streamline recruitment and consent processes for inpatients with spinal cord injury or disease (SCI/D) via implementation of a Central Recruitment (CR) process. The CR process adhered to ethical standards, reduced participant burden, and maximized research participation. METHODS In this CR process, the inpatient's nurse affirmed suitability for research approach based on fluency, cognition and health stability. A patient research liaison (PRL) was the sole contact for information regarding the research process, and introduced ongoing studies, screened for eligibility, and completed the consent process(es). RESULTS Over five and a half years, 1,561 inpatients with SCI/D were screened for eligibility upon admission, of whom 80% (1256/1561) were deemed suitable for the PRL approach. Of those suitable for the CR process, 80% (1001/1256) agreed to discuss current research opportunities, 46% (235/516) consented to participate in one or more studies, and 86% (856/1001) agreed to future research contact. CONCLUSION This process adhered to ethical procedures and reduced the burden of having multiple researchers approach each individual inpatient regarding research participation, with high consent rates for low-risk studies. Future evaluation of the process scalability is underway.
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Affiliation(s)
- B. Catharine Craven
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada,Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada,Correspondence to: B. Catharine Craven, KITE Research Institute, Toronto Rehab - University Health Network, 206-H 520 Sutherland Drive, Toronto, OntarioM4G3V9, Canada. Ph: 416-597-3422(6122).
| | - Louise Brisbois
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada
| | - Chelsea Pelletier
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada,Department of Physical Therapy, University of Toronto, Ontario, Canada
| | - Julia Rybkina
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Ann Heesters
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,The Institute for Education Research (TIER), University Health Network, Toronto, Ontario, Canada
| | - Mary Caroline Verrier
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada,Department of Physical Therapy, University of Toronto, Ontario, Canada
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17
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Pazzi C, Farrehi C, Capron M, Anderson K, Richardson B, Stillman M. An Assessment of Which Sociodemographic and Spinal Cord Injury-Specific Characteristics Influence Engagement With Experimental Therapies and Participation in Clinical Trials. Top Spinal Cord Inj Rehabil 2021; 27:28-39. [PMID: 34866886 DOI: 10.46292/sci20-00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Although a number of experimental therapies for spinal cord injury (SCI) have recently emerged, few authors have examined the goals of individuals with SCI considering experimental therapies, and none have determined whether sociodemographic and injury-specific characteristics influence that engagement. Objectives: To determine (a) the goals of individuals with SCI who are considering experimental therapies; (b) whether sociodemographic factors, injury-specific characteristics, and concerns over adverse events influence those goals and/or participation in experimental therapies and clinical trials; and (c) whether people with SCI feel they have adequate information about experimental therapies and clinical trials. Methods: An online survey that yielded 364 responses. Results: Most respondents (83.7%) had sought information about experimental therapies, and just under half (47.8%) had received one. The most frequently cited functional goals were improvement in bowel and bladder function and elimination of dysreflexia (60.4%). Several goals were influenced by age and level and completeness of injury, and most respondents (93.4%) wanted more information about experimental therapies. Just over one-third (34.6%) of respondents had participated in a clinical trial, and nearly all (96.9%) wanted more information about them. Having received experimental therapies and participated in clinical trials was positively correlated with seeking SCI-specific care from an SCI specialist rather than from a primary care physician. Most (83.9%) respondents would avoid or be reluctant to engage with a medical center if they were made aware of harm done to trial participants. Conclusion: This work suggests that there are unmet information needs among people with SCI, specifically pertaining to experimental therapies and clinical trials. It also reveals that improved access to SCI specialists may enhance access to novel treatments and research efforts. Being made aware of harm to trial participants may influence the decision of individuals with SCI to seek care at or enroll in trials at these clinical sites.
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Affiliation(s)
- Carlotta Pazzi
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Clara Farrehi
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Maclain Capron
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kim Anderson
- MetroHealth Medical Center of Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Michael Stillman
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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Clinical trials and tribulations: lessons from spinal cord injury studies registered on ClinicalTrials.gov. Spinal Cord 2021; 59:1256-1260. [PMID: 34480090 DOI: 10.1038/s41393-021-00699-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/13/2021] [Accepted: 08/18/2021] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Article. OBJECTIVE ClinicalTrials.gov is an online trial registry that provides public access to information on past, present, and future clinical trials. While increasing transparency in research, the quality of the information provided in trial registrations is highly variable. The objective of this study is to assess key areas of information on ClinicalTrials.gov in interventional trials involving people with spinal cord injuries. SETTING Interventional trials on ClinicalTrials.gov involving people with spinal cord injuries. METHODS A subset of data on interventional spinal cord injury trials was downloaded from ClinicalTrials.gov. Reviewers extracted information pertaining to study type, injury etiology, spinal cord injury characteristics, timing, study status, and results. RESULTS Of the interventional trial registrations reviewed, 62.5%, 58.6%, and 24.3% reported injury level, severity, and etiology, respectively. The timing of intervention relative to injury was reported in 72.8% of registrations. Most trials identified a valid study status (89.2%), but only 23.5% of those completed studies had posted results. CONCLUSIONS Our review provides a snapshot of interventional clinical trials conducted in the field of spinal cord injury and registered in ClinicalTrials.gov. Areas for improvement were identified with regards to reporting injury characteristics, as well as posting results.
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19
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Watson JD, Perrin PB, McDonald SD, Tyler CM, Burke J, Pierce BS, Hugeback H, Mickens MN. Research Participant Recruitment Strategies Among Individuals with Acute Spinal Cord Injury and Their Caregivers: A Pre-Post Study. Spine (Phila Pa 1976) 2021; 46:1111-1117. [PMID: 33710112 DOI: 10.1097/brs.0000000000004032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Pre-post study. OBJECTIVE To evaluate the efficiency of a series of recruitment strategies in a longitudinal study of individuals with SCI and their informal caregivers. Primary strategies included (a) rapport building in advance, (b) warm handoffs from another healthcare provider who already had a relationship with the potential participant, (c) ensuring the potential participant had information about the study prior to the initial contact by the research coordinator (RC), (d) attempting informed consent only when both the patient and informal caregiver were present, and (e) ensuring the RC had at least 30 minutes to explain the study when attempting recruitment. SUMMARY OF BACKGROUND DATA While a fairly large body of research has been conducted on general recruitment strategies for clinical trials, very little has examined the efficacy of these strategies within neurological conditions and almost none within SCI. METHODS Individuals with an acute SCI and their informal caregivers were recruited from acute spinal cord rehabilitation units with a Veteran's Affairs medical center and an academic medical center in the same urban area. Of 49 eligible dyads, 41 were approached for consent, with 27 consenting to join the study (9 from the academic medical center; 18 from the VA). RESULTS There was a significant difference in enrollment rates after implementing the recruitment strategies, χ2(1) = 7.572, P = 0.006, with the per month participant enrollment rate nearly doubling after implementation. CONCLUSION Using a multiteam and multidisciplinary approach to recruitment may increase the likelihood that individuals with an acute SCI and their caregivers enroll in research.Level of Evidence: 3.
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Affiliation(s)
- Jack D Watson
- Virginia Commonwealth University, Richmond, VA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA
| | - Paul B Perrin
- Virginia Commonwealth University, Richmond, VA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA
| | - Scott D McDonald
- Virginia Commonwealth University, Richmond, VA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA
| | - Carmen M Tyler
- Virginia Commonwealth University, Richmond, VA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA
| | - Julian Burke
- Virginia Commonwealth University, Richmond, VA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA
| | - Bradford S Pierce
- Virginia Commonwealth University, Richmond, VA
- Central Virginia Veterans Affairs Health Care System, Richmond, VA
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20
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Fehlings MG, Chen Y, Aarabi B, Ahmad F, Anderson KD, Dumont T, Fourney DR, Harrop JS, Kim KD, Kwon BK, Lingam HK, Rizzo M, Shih LC, Tsai EC, Vaccaro A, McKerracher L. A Randomized Controlled Trial of Local Delivery of a Rho Inhibitor (VX-210) in Patients with Acute Traumatic Cervical Spinal Cord Injury. J Neurotrauma 2021; 38:2065-2072. [PMID: 33559524 PMCID: PMC8309435 DOI: 10.1089/neu.2020.7096] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Acute traumatic spinal cord injury (SCI) can result in severe, lifelong neurological deficits. After SCI, Rho activation contributes to collapse of axonal growth cones, failure of axonal regeneration, and neuronal loss. This randomized, double-blind, placebo-controlled phase 2b/3 study evaluated the efficacy and safety of Rho inhibitor VX-210 (9 mg) in patients after acute traumatic cervical SCI. The study enrolled patients 14-75 years of age with acute traumatic cervical SCIs, C4-C7 (motor level) on each side, and American Spinal Injury Association Impairment Scale (AIS) Grade A or B who had spinal decompression/stabilization surgery commencing within 72 h after injury. Patients were randomized 1:1 with stratification by age (<30 vs. ≥30 years) and AIS grade (A vs. B with sacral pinprick preservation vs. B without sacral pinprick preservation). A single dose of VX-210 or placebo in fibrin sealant was administered topically onto the dura over the site of injury during decompression/stabilization surgery. Patients were evaluated for medical, neurological, and functional changes, and serum was collected for pharmacokinetics and immunological analyses. Patients were followed up for up to 12 months after treatment. A planned interim efficacy-based futility analysis was conducted after ∼33% of patients were enrolled. The pre-defined futility stopping rule was met, and the study was therefore ended prematurely. In the final analysis, the primary efficacy end-point was not met, with no statistically significant difference in change from baseline in upper-extremity motor score at 6 months after treatment between the VX-210 (9-mg) and placebo groups. This work opens the door to further improvements in the design and conduct of clinical trials in acute SCI.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Yang Chen
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | | | - Faiz Ahmad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Travis Dumont
- Neurovascular Surgery Program, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Daryl R Fourney
- Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - James S Harrop
- Division of Spine and Peripheral Nerve Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Kee D Kim
- University of California Davis Health, Sacramento, California, USA
| | - Brian K Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Hari K Lingam
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Marco Rizzo
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Ludy C Shih
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Eve C Tsai
- The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Lisa McKerracher
- BioAxone BioSciences, Inc, Boston, Massachusetts, USA
- McGill University, Montreal, Quebec, Canada
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21
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A taxonomy for consistent handling of conditions not related to the spinal cord injury (SCI) in the International Standards for Neurological Classification of SCI (ISNCSCI). Spinal Cord 2021; 60:18-29. [PMID: 34108616 PMCID: PMC8737332 DOI: 10.1038/s41393-021-00646-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 01/26/2023]
Abstract
STUDY DESIGN Committee consensus process including additional structured feedback from spinal cord injury (SCI) experts attending a focus group workshop. OBJECTIVES To define a taxonomy for standardized documentation of non-SCI-related conditions in the International Standards for Neurological Classification of SCI (ISNCSCI). SETTING Americal Spinal Injury Association (ASIA) International Standards Committee with 16 international ISNCSCI experts. METHODS With the new taxonomy, not-normal sensory or motor scores should be tagged with an asterisk ("*"), if they are impacted by a non-SCI condition such as burns, casts, joint contractures, peripheral nerve injuries, amputations, pain, or generalized weakness. The non-SCI condition and instructions on how to handle the "*"-tagged scores during classification should be detailed in the comments box. While sum scores are always calculated based on examined scores, classification variables such as the neurological level of injury (NLI) or the ASIA Impairment Scale (AIS) grades are tagged with an "*", when they have been determined on the basis of clinical assumptions. RESULTS With the extended "*"-tag concept, sensory and motor examination results impacted by non-SCI conditions above, at, or below the NLI can be consistently documented, scored, and classified. Feedback from workshop participants confirms agreement on its clinical relevance, logic and soundness, easiness of understanding, communicability, and applicability in daily work. CONCLUSIONS After multiple internal revisions, a taxonomy for structured documentation of conditions superimposed on the impairments caused by the SCI together with guidelines for consistent scoring and classification was released with the 2019 ISNCSCI revision. This taxonomy is intended to increase the accuracy of ISNCSCI classifications.
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Kim KD, Lee KS, Coric D, Chang JJ, Harrop JS, Theodore N, Toselli RM. A study of probable benefit of a bioresorbable polymer scaffold for safety and neurological recovery in patients with complete thoracic spinal cord injury: 6-month results from the INSPIRE study. J Neurosurg Spine 2021; 34:808-817. [PMID: 33545674 DOI: 10.3171/2020.8.spine191507] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether the investigational Neuro-Spinal Scaffold (NSS), a highly porous bioresorbable polymer device, demonstrates probable benefit for safety and neurological recovery in patients with complete (AIS grade A) T2-12 spinal cord injury (SCI) when implanted ≤ 96 hours postinjury. METHODS This was a prospective, open-label, multicenter, single-arm study in patients with a visible contusion on MRI. The NSS was implanted into the epicenter of the postirrigation intramedullary spinal cord contusion cavity with the intention of providing structural support to the injured spinal cord parenchyma. The primary efficacy endpoint was the proportion of patients who had an improvement of ≥ 1 AIS grade (i.e., conversion from complete paraplegia to incomplete paraplegia) at the 6-month follow-up visit. A preset objective performance criterion established for the study was defined as an AIS grade conversion rate of ≥ 25%. Secondary endpoints included change in neurological level of injury (NLI). This analysis reports on data through 6-month follow-up assessments. RESULTS Nineteen patients underwent NSS implantation. There were 3 early withdrawals due to death, which were all determined by investigators to be unrelated to the NSS or the implantation procedure. Seven of 16 patients (43.8%) who completed the 6-month follow-up visit had conversion of neurological status (AIS grade A to grade B [n = 5] or C [n = 2]). Five patients showed improvement in NLI of 1 to 2 levels compared with preimplantation assessment, 3 patients showed no change, and 8 patients showed deterioration of 1 to 4 levels. There were no unanticipated or serious adverse device effects or serious adverse events related to the NSS or the implantation procedure as determined by investigators. CONCLUSIONS In this first-in-human study, implantation of the NSS within the spinal cord appeared to be safe in the setting of surgical decompression and stabilization for complete (AIS grade A) thoracic SCI. It was associated with a 6-month AIS grade conversion rate that exceeded historical controls. The INSPIRE study data demonstrate that the potential benefits of the NSS outweigh the risks in this patient population and support further clinical investigation in a randomized controlled trial. Clinical trial registration no.: NCT02138110 (clinicaltrials.gov).
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Affiliation(s)
- Kee D Kim
- 1Department of Neurological Surgery, UC Davis, Sacramento, California
| | - K Stuart Lee
- 2Division of Neurosurgery, Vidant Health, Greenville, North Carolina
| | - Domagoj Coric
- 3Atrium Musculoskeletal Institute, Carolina NeuroSurgery & Spine Associates, Charlotte, North Carolina
| | - Jason J Chang
- 4Department of Neurological Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - James S Harrop
- 5Department of Neurological and Orthopedic Surgery, Division of Spine and Peripheral Nerve Surgery, and Delaware Valley SCI Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicholas Theodore
- 6Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
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Buri M, Tanadini LG, Hothorn T, Curt A. Unbiased Recursive Partitioning Enables Robust and Reliable Outcome Prediction in Acute Spinal Cord Injury. J Neurotrauma 2021; 39:266-276. [PMID: 33619988 DOI: 10.1089/neu.2020.7407] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Neurological disorders usually present very heterogeneous recovery patterns. Nonetheless, accurate prediction of future clinical end-points and robust definition of homogeneous cohorts are necessary for scientific investigation and targeted care. For this, unbiased recursive partitioning with conditional inference trees (URP-CTREE) have received increasing attention in medical research, especially, but not limited to traumatic spinal cord injuries (SCIs). URP-CTREE was introduced to SCI as a clinical guidance tool to explore and define homogeneous outcome groups by clinical means, while providing high accuracy in predicting future clinical outcomes. The validity and predictive value of URP-CTREE to provide improvements compared with other more common approaches applied by clinicians has recently come under critical scrutiny. Therefore, a comprehensive simulation study based on traumatic, cervical complete spinal cord injuries provides a framework to investigate and quantify the issues raised. First, we assessed the replicability and robustness of URP-CTREE to identify homogeneous subgroups. Second, we implemented a prediction performance comparison of URP-CTREE with traditional statistical techniques, such as linear or logistic regression, and a novel machine learning method. URP-CTREE's ability to identify homogeneous subgroups proved to be replicable and robust. In terms of prediction, URP-CTREE yielded a high prognostic performance comparable to a machine learning algorithm. The simulation study provides strong evidence for the robustness of URP-CTREE, which is achieved without compromising prediction accuracy. The slightly lower prediction performance is offset by URP-CTREE's straightforward interpretation and application in clinical settings based on simple, data-driven decision rules.
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Affiliation(s)
- Muriel Buri
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zürich, Switzerland
| | - Lorenzo G Tanadini
- School of Agricultural, Forest and Food Sciences, Bern University of Applied Sciences, Bern, Switzerland
| | - Torsten Hothorn
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zürich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
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Patsakos EM, Bayley MT, Kua A, Cheng C, Eng J, Ho C, Noonan VK, Querée M, Craven BC. Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview. J Spinal Cord Med 2021; 44:S52-S68. [PMID: 34779719 PMCID: PMC8604491 DOI: 10.1080/10790268.2021.1953312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual's sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual's care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process. METHODS The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool. RESULTS The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo. CONCLUSION The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.
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Affiliation(s)
- Eleni M. Patsakos
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Mark T. Bayley
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ailene Kua
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Christiana Cheng
- Praxis Spinal Cord Institute, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Janice Eng
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Physiotherapy, GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada
| | - Chester Ho
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vanessa K. Noonan
- Praxis Spinal Cord Institute, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew Querée
- GF Strong Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - B. Catharine Craven
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Li T, Wang Y, Feng C, Li Q, Ran Q, Chen B, Yu Y, Jiang L, Fan X. Hyperbaric oxygen therapy for spinal cord injury: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23536. [PMID: 33285769 PMCID: PMC7717804 DOI: 10.1097/md.0000000000023536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/06/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hyperbaric oxygen (HBO) therapy can prevent further spinal cord injury (SCI) caused by spinal cord ischemia-reperfusion injury to the maximum extent, which has been reported increasingly in recent years. However its security and effectiveness still lack of high-quality medical evidence. In this study, we will perform a systematic review of previously published randomized controlled trials (RCTs) to evaluate the efficacy and safety of HBO therapy for SCI. METHODS All potential RCTs on HBO therapy for SCI will be searched from the following electronic databases: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Science and Technology Periodical Database, Wanfang database and Chinese Biomedical Literature Database. We will search all electronic databases from their initiation to the September 30, 2020 in spite of language and publication date. Two contributors will independently select studies from all searched literatures, extract data from included trials, and evaluate study quality for all eligible RCTs using Cochrane risk of bias tool, respectively. Any confusion will be resolved by consulting contributor and a consensus will be reached. We will utilize RevMan 5.3 software to pool the data and to conduct the data analysis. RESULTS The quality of the assessments will be assessed through Grading of Recommendations Assessment, Development, and Evaluation. Data will be disseminated through publications in peer-reviewed journals. CONCLUSION This study will provide evidence to evaluate the efficacy and safety of HBO therapy for SCI at evidence-based medicine level. TRIAL REGISTRATION NUMBER INPLASY 2020100084.
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Anderson CE, Birkhäuser V, Stalder SA, Bachmann LM, Curt A, Jordan X, Leitner L, Liechti MD, Mehnert U, Möhr S, Pannek J, Schubert M, van der Lely S, Kessler TM, Brinkhof MWG. Optimizing clinical trial design using prospective cohort study data: a case study in neuro-urology. Spinal Cord 2020; 59:1003-1012. [PMID: 33235299 PMCID: PMC7611589 DOI: 10.1038/s41393-020-00588-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022]
Abstract
Study Design Simulations using data from a prospective cohort study. Objectives To illustrate how prospective cohort data can be employed in randomized controlled trial (RCT) planning to assess feasibility and operational challenges, using TASCI (Transcutaneous tibial nerve stimulation in patients with Acute Spinal Cord Injury to prevent neurogenic detrusor overactivity: a nationwide randomized, sham-controlled, double-blind clinical trial) as a case study. Setting Spinal cord injury rehabilitation centers in Switzerland. Methods TASCI is nested in the multicenter Swiss Spinal Cord Injury Cohort Study (SwiSCI), which prospectively includes patients with acute spinal cord injury. In simulations, data from 640 patients, collected by SwiSCI, were used to investigate different scenarios of patient eligibility and study consent, as well as the performance of the randomization list. Descriptive analysis was used to describe the population of interest and the simulation results; multivariable logistic regression analysis was performed to identify predictors of discharge within the TASCI intervention time period. Results The recruitment target of 114 patients is obtainable within the originally envisioned three-year time period under the most favorable recruitment scenario examined. The distribution of the primary prognostic factor produced imbalance in the randomization lists and informed further discussion of the cut-off values used in stratification. Influxes of patients resulted in overlapping intervention periods for multiple participants, which guided resource allocation. Early discharge was related to the primary prognostic factor and study center, but is only anticipated in about 8% of participants. Conclusions Prospective cohort data are a very valuable resource for planning RCTs.
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Affiliation(s)
- Collene E Anderson
- Swiss Paraplegic Research, Nottwil, Switzerland.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.,Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Armin Curt
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sandra Möhr
- Neuro-Urology, REHAB Basel, Basel, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland.,Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Schubert
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin W G Brinkhof
- Swiss Paraplegic Research, Nottwil, Switzerland. .,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
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Farrehi C, Pazzi C, Capron M, Anderson K, Richardson B, Stillman M. How individuals with spinal cord injury in the United States access and assess information about experimental therapies and clinical trials: results of a clinical survey. Spinal Cord Ser Cases 2020; 6:103. [PMID: 33230100 DOI: 10.1038/s41394-020-00354-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/23/2020] [Accepted: 10/30/2020] [Indexed: 11/09/2022] Open
Abstract
STUDY DESIGN An internet-based survey. OBJECTIVES To determine how individuals with spinal cord injury (SCI) access information about experimental therapies and clinical trials. To understand which factors influence receipt of and perceived trustworthiness of that information. SETTING Two academic medical centers and an SCI organization. METHODS Demographic information frequencies and percentages were calculated then analyzed using chi-square tests for independence. Fisher's exact test of independence was used to assess significance for contingency tables with categories containing expected counts below five. RESULTS Three hundred sixty four persons with SCI participated in the survey. Most felt confident in their ability to evaluate SCI-specific information from a variety of sources, though SCI organizations and the medical literature were deemed the most reliable. Information from SCI specialists was deemed more credible than that from non-SCI specialists, but only 53.6% of participants had access to them. Nearly all (89.0%) respondents who had sought information about experimental therapies had found it online, while 51.4% of those who had participated in a clinical trial had been contacted by a research team. Only 8.4% of participants felt their medical teams offered them sufficient information about experimental therapies and clinical trials. Wealthier and more educated respondents were more knowledgeable about health-related resources on the internet. Nearly all participants (96.9%) expressed interest in learning more about trials related to SCI. CONCLUSIONS There is an information deficit among people with SCI pertaining to experimental therapies and clinical trials. It is exacerbated by lack of income, education, and access to SCI specialists.
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Affiliation(s)
- Clara Farrehi
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Carlotta Pazzi
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Maclain Capron
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Kim Anderson
- Metrohealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Bonnie Richardson
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.,Metrohealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael Stillman
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
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Franz S, Heutehaus L, Weinand S, Weidner N, Rupp R, Schuld C. Theoretical and practical training improves knowledge of the examination guidelines of the International Standards for Neurological Classification of Spinal Cord Injury. Spinal Cord 2020; 60:1-10. [PMID: 33204033 PMCID: PMC8737333 DOI: 10.1038/s41393-020-00578-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/29/2022]
Abstract
Study design Prospective pre–post study. Objectives International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represents the most frequently used assessment to determine the level and severity of a spinal cord injury (SCI). The guidelines for ISNCSCI are complex and challenging. Knowledge of its correct execution needs to be imparted precisely. The aim of this study was to investigate whether hands-on instructional courses can increase the knowledge of the ISNCSCI examination guidelines. Setting European Multicenter Study about SCI. Methods Before and after the instructional courses, participants were asked to complete questionnaires. The set of questions covered the most important aspects of the examination guidelines. Attendees were asked to self-rate their occupation and experience in ISNCSCI. Results The comparison of pretest and posttest results of 164 attendees from 2014 to 2018 revealed an improvement of knowledge reflected by an increase of correct answers from 66 ± 17% before to 89 ± 11% after the course (p < 0.01). The improvement was not associated with occupation (p > 0.1). However, the correctness of pretest results differed concerning both the period of experience with ISNCSCI (p < 0.05) and the course language (p < 0.01), while the frequency of execution resulted in differences in the posttest (p = 0.01). Conclusions Instructional courses substantially improve knowledge of the ISNCSCI examination guidelines. Differences in knowledge present before the course leveled off after the course. Comprehensive theoretical training is strongly recommended to ensure reliability and validity of ISNCSCI examinations in clinical routine and research. Albeit being practiced in the instructional courses, the benefit of hands-on training still needs to be systematically evaluated in future studies.
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Affiliation(s)
- Steffen Franz
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany.
| | - Laura Heutehaus
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Sina Weinand
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Christian Schuld
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
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Adaptive trial designs for spinal cord injury clinical trials directed to the central nervous system. Spinal Cord 2020; 58:1235-1248. [DOI: 10.1038/s41393-020-00547-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 02/08/2023]
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Tang HY, Li YZ, Tang ZC, Wang LY, Wang TS, Araujo F. Efficacy of neural stem cell transplantation for the treatment of patients with spinal cord injury: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20169. [PMID: 32384508 PMCID: PMC7220044 DOI: 10.1097/md.0000000000020169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The aim of this study is to evaluate the efficacy of neural stem cell transplantation (NSCT) for the treatment of patients with spinal cord injury (SCI). METHODS All potential randomized controlled trials (RCTs) on NSCT in the treatment of patients with SCI will be searched from the following electronic databases: Cochrane Library, MEDILINE, EMBASE, Web of Science, Scopus, CBM, WANGFANG, and CNKI. We will search all electronic databases from their initiation to the January 31, 2020 in spite of language and publication date. Two contributors will independently select studies from all searched literatures, extract data from included trials, and evaluate study quality for all eligible RCTs using Cochrane risk of bias tool, respectively. Any confusion will be resolved by consulting contributor and a consensus will be reached. We will utilize RevMan 5.3 software to pool the data and to conduct the data analysis. RESULTS This study will summarize the most recent RCTs to investigate the efficacy and safety of NSCT in the treatment of patients with SCI. CONCLUSION This study will provide evidence to assess the efficacy and safety of NSCT in the treatment of patients with SCI at evidence-based medicine level. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020173792.
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Affiliation(s)
| | - Yu-Zhi Li
- Department of Urology, First Affiliated Hospital of Jiamusi University
| | - Zhao-Chen Tang
- School of Clinical Medicine, Jiamusi University, Jiamusi, China
| | - Lu-Yao Wang
- School of Clinical Medicine, Jiamusi University, Jiamusi, China
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Minnema AJ, Mehta A, Boling WW, Schwab J, Simard JM, Farhadi HF. SCING-Spinal Cord Injury Neuroprotection with Glyburide: a pilot, open-label, multicentre, prospective evaluation of oral glyburide in patients with acute traumatic spinal cord injury in the USA. BMJ Open 2019; 9:e031329. [PMID: 31601596 PMCID: PMC6797422 DOI: 10.1136/bmjopen-2019-031329] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute traumatic spinal cord injury (tSCI) is a devastating neurological disorder with no pharmacological neuroprotective strategy proven effective to date. Progressive haemorrhagic necrosis (PHN) represents an increasingly well-characterised mechanism of secondary injury after tSCI that negatively impacts neurological outcomes following acute tSCI. Preclinical studies evaluating the use of the Food and Drug Administration-approved sulfonylurea receptor 1-transient receptor potential melastatin 4 channel blocker glyburide in rodent models have shown reduced secondary microhaemorrhage formation and the absence of capillary fragmentation, the pathological hallmark of PHN. METHODS AND ANALYSIS In this initial phase multicentre open-label pilot study, we propose to enrol 10 patients with acute cervical tSCI to primarily assess the feasibility, and safety of receiving oral glyburide within 8 hours of injury. Secondary objectives include pharmacokinetics and preliminary evaluations on neurological recovery as well as blood and MRI-based injury biomarkers. Analysis will be performed using the descriptive and non-parametric statistics. ETHICS AND DISSEMINATION Glyburide has been shown as an effective neuroprotective agent in preclinical tSCI models and in the treatment of ischaemic stroke with the additional risk of a hypoglycaemic response. Given the ongoing secondary injury and the traumatic hyperglycaemic stress response seen in patients with tSCI, glyburide; thus, offers an appealing neuroprotective strategy to supplement standard of care treatment. The study protocol was approved by the Ohio State University Biomedical Institutional Review Board. The protocol was amended in February 2017 with changes related to study feasibility and patient recruitment. Specifically, the route of administration was changed to the oral form to allow for streamlined and rapid drug administration, and the injury-to-drug time window was extended to 8 hours in an effort to further enhance enrolment. Participants or legally authorised representatives are informed about the trial and its anticipated risks orally and in written form using an approved informed consent form prior to inclusion. The findings of this study will be disseminated to the participants and to academic peers through scientific conferences and peer-reviewed journal publications. TRIAL REGISTRATION NUMBERS NCT02524379 and 2014H0335.
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Affiliation(s)
- Amy Janelle Minnema
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - A Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Warren W Boling
- Department of Neurological Surgery, Loma Linda University, Loma Linda, California, USA
| | - Jan Schwab
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - J Marc Simard
- Department of Neurological Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - H Francis Farhadi
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Neurochemical biomarkers in spinal cord injury. Spinal Cord 2019; 57:819-831. [PMID: 31273298 DOI: 10.1038/s41393-019-0319-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/02/2019] [Accepted: 06/11/2019] [Indexed: 02/08/2023]
Abstract
STUDY DESIGN This is a narrative review of the literature on neurochemical biomarkers in spinal cord injury (SCI). OBJECTIVES The objective was to summarize the literature on neurochemical biomarkers in SCI and describe their use in facilitating clinical trials for SCI. Clinical trials in spinal cord injury (SCI) have been notoriously difficult to conduct, as exemplified by the paucity of definitive prospective randomized trials that have been completed, to date. This is related to the relatively low incidence and the complexity and heterogeneity of the human SCI condition. Given the increasing number of promising approaches that are emerging from the laboratory which are vying for clinical evaluation, novel strategies to help facilitate clinical trials are needed. METHODS A literature review was conducted, with a focus on neurochemical biomarkers that have been described in human neurotrauma. RESULTS We describe advances in our understanding of neurochemical biomarkers as they pertain to human SCI. The application of biomarkers from serum and cerebrospinal fluid (CSF) has been led by efforts in the human traumatic brain injury (TBI) literature. A number of promising biomarkers have been described in human SCI whereby they may assist in stratifying injury severity and predicting outcome. CONCLUSIONS Several time-specific biomarkers have been described for acute SCI and for chronic SCI. These appear promising for stratifying injury severity and potentially predicting outcome. The subsequent application within a clinical trial will help to demonstrate their utility in facilitating the study of novel approaches for SCI.
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Moineau B, Brown A, Brisbois L, Zivanovic V, Miyatani M, Kapadia N, Hsieh JTC, Popovic MR. Lessons learned from the pilot study of an orthostatic hypotension intervention in the subacute phase following spinal cord injury. J Spinal Cord Med 2019; 42:176-185. [PMID: 31573450 PMCID: PMC6781467 DOI: 10.1080/10790268.2019.1638129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Context: Following spinal cord injury (SCI) at the cervical or upper-thoracic level, orthostatic hypotension (OH) is observed in 13-100% of patients. This study aimed to test the feasibility of conducting a randomized controlled trial combining a dynamic tilt-table (Erigo®) and functional electrical stimulation (FES) to mitigate OH symptoms in the subacute phase after SCI. Design: Pilot study. Setting: A tertiary rehabilitation hospital. Participants: Inpatients who had a C4-T6 SCI (AIS A-D) less than 12 weeks before recruitment, and reported symptoms of OH in their medical chart. Interventions: Screening sit-up test to determine eligibility, then 1 assessment session and 3 intervention sessions with Erigo® and FES for eligible participants. Outcome measures: Recruitment rate, duration of assessment and interventions, resources used, blood pressure, and Calgary Presyncope Form (OH symptoms). Results: Amongst the 232 admissions, 148 inpatient charts were reviewed, 11 inpatients met all inclusion criteria, 7 participated in a screening sit-up test, and 2 exhibited OH. Neither of the two participants recruited in the pilot study was able to fully complete the assessment and intervention sessions due to scheduling issues (i.e. limited available time). Conclusion: This pilot study evidenced the non-feasibility of the clinical trial as originally designed, due to the low recruitment rate and the lack of available time for research in participant's weekday schedule. OH in the subacute phase after SCI was less prevalent and less incapacitating than expected. Conventional management and spontaneous resolution of symptoms appeared sufficient to mitigate OH in most patients with subacute SCI.
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Affiliation(s)
- Bastien Moineau
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Andrea Brown
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Louise Brisbois
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Vera Zivanovic
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Masae Miyatani
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Naaz Kapadia
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jane T. C. Hsieh
- Lawson Health Research Institute, St. Joseph’s Health Care, London
| | - Milos R. Popovic
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
- CRANIA, University Health Network, Toronto, Ontario, Canada
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Khajoueinejad L, Askarifirouzjaei H, Namazi F, Mohammadi A, Pourfathollah AA, Rajaian H, Fazeli M. Immunomodulatory effects of Calcitriol in acute spinal cord injury in rats. Int Immunopharmacol 2019; 74:105726. [PMID: 31276973 DOI: 10.1016/j.intimp.2019.105726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/09/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
Pharmacological therapy options for spinal cord injury (SCI) in acute phase have so far been limited, thus we focused on Calcitriol, FDA-approved biologically active form of vitamin D whose neuroprotective effects are increasingly recognized, to ameliorating damage following acute SCI in rats. Calcitriol (1 μg/kg) treatment for 7 consecutive days after SCI was compared SCI control and Sham control rat groups. Calcitriol-treated group had significantly improved outcome in standard functional recovery evaluation test (BBB) 12 weeks after SCI compared to SCI control, which was confirmed by increased ventral horn motor neurons in Calcitriol-treated group. In addition, proliferation test performed on lymphocytes from spleen and lymph nodes one week after SCI showed that calcitriol injection has a significant regulatory effect on Division Index (DI) in response to MBP stimulation compared to control SCI groups, which was associated with significant reduction in IFN-γ and IL-17A secretion and leukocyte infiltration into injury site. Along with confirmation of immunoregulatory aspects of Calcitriol treatment against myelin antigens in SCI, this study has shown that reducing the extent of progressive tissue loss by Calcitriol therapy in acute phase, could result in better recovery after SCI.
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Affiliation(s)
- Leila Khajoueinejad
- Department of Pharmacology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Hadi Askarifirouzjaei
- Department of Immunology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Fatemeh Namazi
- Department of Pathobiology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Ali Mohammadi
- Department of Pathobiology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Ali Akbar Pourfathollah
- Department of Immunology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Hamid Rajaian
- Department of Pharmacology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Mehdi Fazeli
- Department of Pharmacology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran.
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Affiliation(s)
- Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland.
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