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Reyes MRL, Elmo MJ, Menachem B, Granda SM. A Primary Care Provider's Guide to Managing Respiratory Health in Subacute and Chronic Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2020; 26:116-122. [PMID: 32760190 DOI: 10.46292/sci2602-116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Respiratory complications following spinal cord injury (SCI) have remained the leading cause of death across the lifespan and are one of the most common reasons for hospitalization. Complications from altered respiratory physiology after SCI include atelectasis, pneumonia, venous thromboembolic disease, and sleep-disordered breathing. The risk for complications is greater with higher SCI levels and severity, and mortality from pneumonia is heightened compared to the general population. Optimal primary care for individuals with SCI includes appropriate surveillance for SCI-specific respiratory disease, key preventive care including promotion of influenza immunization and respiratory muscle training, and early identification and treatment of pneumonia with institution of aggressive secretion management strategies. The respiratory physiology and specific management of respiratory complications after SCI is reviewed.
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Affiliation(s)
- Maria Regina L Reyes
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Mary Jo Elmo
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Brandon Menachem
- Department of Internal Medicine, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
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2
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Norden DM, Qatanani A, Bethea JR, Jiang J. Chronic spinal cord injury impairs primary CD8 T cell antiviral immunity but does not affect generation or function of memory CD8 T cells. Exp Neurol 2019; 317:298-307. [PMID: 30904474 DOI: 10.1016/j.expneurol.2019.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/08/2019] [Accepted: 03/19/2019] [Indexed: 01/26/2023]
Abstract
Antiviral immunity is severely compromised following trauma to the central nervous system. In mice with chronic spinal cord injury (SCI), primary infection with influenza virus leads to high mortality rates due to impaired expansion of virus-specific CD8 T cells. One strategy to increase resistance to viral infections is to generate memory immune cells that protect from recurrent infections. However, it is unknown if chronic SCI also impairs secondary immune responses to influenza challenge as it does primary responses. Here, we used a mouse model of chronic SCI and a clinically relevant influenza A infection to investigate CD8 T cell response. As shown previously, chronic SCI mice had impaired primary antiviral responses with high mortality rates and decreased expansion of virus-specific CD8 T cells following intranasal infection. To investigate CD8 T cell memory, we used two strains of influenza A virus [PR8(H1N1) and X31(H3N2)] that share internal proteins but differ in surface antigens. Chronic SCI mice immunized with live X31 were able to generate memory CD8 T cells that secreted IFNγ upon stimulation with viral peptides ex vivo, which was comparable to immunized uninjured mice. Importantly, immunization prior to challenge with a lethal dose of PR8 resulted in no mortality and significant CD8 T cell recall responses in both uninjured and chronic SCI mice. In addition, memory CD8 T cells generated before SCI remained functional up to 8 weeks after injury. These pre-existing memory CD8 T cells provided full protection from lethal PR8 challenge given at the chronic timepoint following injury. Overall, this study shows that memory CD8 T cells generated either before or after chronic SCI still remain functional. These results highlight the need for proper immunization of SCI patients and show the potential of memory T cells to confer protection against not only influenza, but other viral infections as well.
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Affiliation(s)
- Diana M Norden
- Biology Department, Drexel University, Philadelphia, PA 19104, United States of America
| | - Anas Qatanani
- Biology Department, Drexel University, Philadelphia, PA 19104, United States of America
| | - John R Bethea
- Biology Department, Drexel University, Philadelphia, PA 19104, United States of America.
| | - Jiu Jiang
- Biology Department, Drexel University, Philadelphia, PA 19104, United States of America.
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Bracchi-Ricard V, Zha J, Smith A, Lopez-Rodriguez DM, Bethea JR, Andreansky S. Chronic spinal cord injury attenuates influenza virus-specific antiviral immunity. J Neuroinflammation 2016; 13:125. [PMID: 27245318 PMCID: PMC4886448 DOI: 10.1186/s12974-016-0574-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/06/2016] [Indexed: 11/18/2022] Open
Abstract
Background Individuals suffering from spinal cord injury (SCI) are at higher risk for respiratory-related viral infections such as influenza. In a previous study (Zha et al., J Neuroinflammation 11:65, 2014), we demonstrated that chronic spinal cord injury caused impairment in CD8+T cell function with increased expression of the immunosuppressive protein, programmed cell death 1 (PD-1). The present study was undertaken to establish whether chronic SCI-induced immune deficits would affect antiviral immunity directed against primary and secondary infections. Methods Six to seven weeks following a SCI contusion at thoracic level T9, mice were infected intranasally with influenza virus. Virus-specific immunity was analyzed at various time points post-infection and compared to uninjured controls. Results We report that chronic thoracic SCI impairs the ability of the animals to mount an adequate antiviral immune response. While all uninjured control mice cleared the virus from their lungs by day 10 post-infection, a significant number (approximately 70 %) of chronic SCI mice did not clear the virus and succumbed to infection-induced mortality. This was attributed to severe deficits in both virus-specific antibody production and CD8+ T cell response in injured mice after primary infection. We also determined that previously acquired humoral immunity was maintained after spinal cord injury as vaccination against influenza A prior to injury-protected mice from a homologous viral challenge. In contrast, prior immunization did not protect mice from a heterotypic challenge with a different strain of influenza virus. Conclusions Taken together, our data demonstrate that chronic SCI attenuates virus-specific humoral and cellular immunity during the establishment of primary response and impairs the development of memory CD8+ T cells. In contrast, B cell memory acquired through vaccination prior to SCI is preserved after injury which demonstrates that antigen-specific memory cells are refractory following injury. Our study defines important parameters of the deficits of chronic SCI-induced immune depression during a viral respiratory infection. Our objective is to better understand the mechanisms of spinal cord injury-induced immune depression with the goal of developing more effective therapies and reduce mortality due to complications from influenza and other infections. Electronic supplementary material The online version of this article (doi:10.1186/s12974-016-0574-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Valerie Bracchi-Ricard
- The Miami Project to Cure Paralysis, Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.,Department of Biology, Drexel University, Philadelphia, PA, 19104, USA
| | - Ji Zha
- The Miami Project to Cure Paralysis, Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.,Department of Biology, Drexel University, Philadelphia, PA, 19104, USA
| | - Annalise Smith
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Darlah M Lopez-Rodriguez
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - John R Bethea
- The Miami Project to Cure Paralysis, Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA. .,Department of Biology, Drexel University, Philadelphia, PA, 19104, USA.
| | - Samita Andreansky
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, 33136, USA. .,Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.
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Wiwanitkit V, Locatelli SM, LaVela SL, Goldstein B. Influenza infection control guidance for staff caring for veterans with spinal cord injury. J Spinal Cord Med 2014; 37:264. [PMID: 24617581 PMCID: PMC4064575 DOI: 10.1179/2045772313y.0000000176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Viroj Wiwanitkit
- Correspondence to: Viroj Wiwanitkit, Wiwanitkit House, Bangkhae,
Bangkok, Thailand.
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Locatelli SM, LaVela SL, Hogan TP, Goldstein B. Influenza infection control guidance provided to staff at Veterans Affairs facilities for veterans with spinal cord injury during a pandemic(†). J Spinal Cord Med 2013; 36:666-71. [PMID: 24090346 PMCID: PMC3831329 DOI: 10.1179/2045772313y.0000000112] [Citation(s) in RCA: 2] [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: 10/31/2022] Open
Abstract
CONTEXT/OBJECTIVE To assess guidance provided to staff at Veterans Affairs (VA) healthcare facilities on H1N1 influenza infection control for veterans with spinal cord injuries and disorders (SCI/D). STUDY DESIGN Cross-sectional qualitative semi-structured interviews. SETTING Thirty-three VA healthcare facilities from throughout the United States that provide care to veterans with SCI/D. PARTICIPANTS Thirty-three infection control key informants, each representing a VA healthcare facility. INTERVENTIONS None. OUTCOME MEASURES Infection control practices, including vaccination practices, hospital preparedness, and recommendations for future pandemics, both in general and specifically to SCI/D. RESULTS Most (n = 26, 78.8%) infection control key informants believed veterans with SCI/D were at increased risk for influenza and complications, but only 17 (51.5%) said veterans with SCI/D were treated as a priority group for vaccination at their facilities. There was little special guidance provided for treating veterans with SCI/D, and most (n = 28, 84.8%) informants said that infection control procedures and recommendations were applied universally. Yet, 10 key informants discussed 'unique challenges' to infection control in the SCI/D population. Informants discussed the potential for infectious agents to be spread through shared and common use equipment and the necessity of including caregivers in any vaccination or educational campaigns. CONCLUSION Greater input by experts knowledgeable about SCI/D is recommended to adequately address pandemic influenza within healthcare facilities where individuals with SCI/D receive care.
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Affiliation(s)
- Sara M. Locatelli
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Hines, Illinois, IL, USA; and Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, Hines, Illinois, IL, USA
| | - Sherri L. LaVela
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Hines, Illinois, IL, USA; Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, Hines, Illinois, IL, USA; and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, IL, USA
| | - Timothy P. Hogan
- Center for Health Quality, Outcomes, and Economic Research and eHealth Quality Enhancement Research Initiative, National eHealth QUERI Coordinating Center, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, MA, USA; and Division of Health Informatics and Implementation Science, University of Massachusetts Medical School, Worchester, MA, USA
| | - Barry Goldstein
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, Hines, Illinois, IL, USA; and SCI Healthcare Group, VA Puget Sound Healthcare System, Seattle, Washington, WA, USA
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Evans CT, Weaver FM, Rogers TJ, Rapacki L, Miskevics S, Hahm B, Smith B, Lavela SL, Goldstein B, Burns SP. Guideline-recommended management of community-acquired pneumonia in veterans with spinal cord injury. Top Spinal Cord Inj Rehabil 2012; 18:300-5. [PMID: 23459590 PMCID: PMC3584786 DOI: 10.1310/sci1804-300] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pneumonia is a leading cause of death in persons with spinal cord injuries and disorders (SCI/D), but little is known about guideline-based management for this disease in persons with SCI/D. OBJECTIVES The goal of this study was to describe guideline-based medical care for community-acquired pneumonia (CAP) in veterans with SCI/D. METHODS A retrospective medical record review was conducted at 7 Department of Veterans Affairs (VA) medical centers where veterans with SCI/D and CAP between 2005 and 2008 were included. Outcomes assessed were receipt of blood or sputum culture, antibiotic timeliness, appropriateness of empiric antibiotic treatment, and vaccination. RESULTS In 70 patients, 77 CAP episodes occurred and 83.1% were treated in the inpatient setting. The average age was 70.0 years and 64.9% had tetraplegia. Sputum culture was completed in 24.7% and blood culture in 59.7% of cases. Of inpatients, 79.7% had antibiotic treatment within 8 hours and 45.1% received guideline-recommended empirical antibiotics. More than 90% of inpatients received antibiotic treatment within 3 days of presentation and 78.1% received recommended treatment. The rates of pneumococcal pneumonia (89.9%) and influenza (79.7%) vaccinations were high in CAP cases. CONCLUSIONS Diagnostic testing and early guideline-recommended treatment is variable in veterans with SCI/D and CAP. However vaccination against influenza and pneumococcal pneumonia is high. Specific guidelines for management of CAP in SCI/D patients may be needed, which reflect the unique risk factors and needs of this population. These data can be used as a benchmark for improvements in care processes for treating and managing CAP in persons with SCI/D.
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Affiliation(s)
- Charlesnika T Evans
- Department of Veterans Affairs (VA), Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Hines, Illinois ; Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI) , Hines, Illinois ; Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Lucin KM, Sanders VM, Popovich PG. Stress hormones collaborate to induce lymphocyte apoptosis after high level spinal cord injury. J Neurochem 2009; 110:1409-21. [PMID: 19545280 DOI: 10.1111/j.1471-4159.2009.06232.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Post-traumatic immune suppression renders individuals with spinal cord injury (SCI) susceptible to infection. Normally, proper immune function is regulated by collaboration between the sympathetic nervous system (SNS) and hypothalamic-pituitary-adrenal (HPA) axis and involves the controlled release of glucocorticoids (GCs) and norepinephrine (NE). Recently, we showed that after high thoracic (T3) SCI, aberrant levels of GCs and NE accumulate in the blood and spleen, respectively. These changes are associated with splenic atrophy, splenic leucopenia, increased intrasplenic caspase 3 levels, and suppressed B lymphocyte function. As GCs boost SNS function, in part by increasing the expression and affinity of beta2 adrenergic receptors (beta2ARs) while simultaneously preventing beta2AR down-regulation, we predicted that surges in stress hormones (i.e., GCs and NE) in the blood and spleen of mice with high-level SCI would act concurrently to adversely affect lymphocyte function and survival. Here, we show that post-SCI concentrations of GCs enhance the sensitivity of lymphocytes to beta2AR stimulation causing an increase in intracellular Bcl-2 interacting mediator of cell death (Bim) and subsequent apoptosis. In vivo, the combined antagonism of GC receptors and beta2ARs significantly diminished lymphocyte Bim levels and SCI-induced splenic lymphopenia. Together, these data suggest that pharmacological antagonists of the HPA/SNS axes should be considered as adjunct therapies for ameliorating post-traumatic immune suppression in quadriplegics and high paraplegics.
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Affiliation(s)
- Kurt M Lucin
- Department of Molecular Virology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Abstract
Respiratory disorders are the leading cause of death for persons with both acute and chronic spinal cord injury (SCI), and much of the morbidity and mortality associated with respiratory disorders is related to acute respiratory infections. Pneumonia is the best recognized respiratory infection associated with mortality in this population. Recent evidence supports some management strategies that differ from those recommended for the general population. Upper respiratory tract infections and acute bronchitis may be precipitating factors in the development of pneumonia or ventilatory failure in patients with chronic SCI. This review emphasizes management principles for treatment and prevention of respiratory infections in persons with SCI.
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Affiliation(s)
- Stephen P Burns
- Spinal Cord Injury Service (128), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA.
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