A survey of prescribing practices by general dentists in Australia

BACKGROUND

Numerous studies of dental antibiotic prescribing show that overprescribing is a worldwide occurrence. The aim of this study was to assess prescribing practices of general dentists in Australia for antibiotics, analgesics and anxiolytics and to determine the extent to which prescribing is in accordance with current guidelines.

METHODS

A structured questionnaire was sent to 1468 dentists in Victoria and Queensland in July-August 2018. The questionnaire covered demographics, clinical conditions where dentists prescribe antibiotics, non-clinical factors which influence prescribing, and medicines for anxiolysis and pain relief. Responses were scored using a system based on the current Australian therapeutic guidelines. Logistic regression was used to determine the relative importance of independent variables on inappropriate prescribing.

RESULTS

Three hundred eighty-two responses were received. Overall, 55% of overprescribing of antibiotics was detected, with a range of 13-88% on a routine or occasional basis depending on the scenario. Between 16 and 27% of respondents inappropriately preferenced analgesics over anti-inflammatories for dental pain; 46% of those who prescribed anxiolytic medicines did so inappropriately, with varying regimens and choices outside the guidelines. Years of practice was the main demographic factor influencing prescribing, with recent graduates (0-5 years) generally scoring better than their colleagues for antibiotic prescribing (p < 0.05).

CONCLUSIONS

Future interventions could be directed towards the appropriate role and use of antibiotics, shortfalls in knowledge and appropriate choices of medicines for pain relief and anxiolysis. Given that the most overprescribing occurred for localised swellings (88%), this area could be focused on in continuing education as well as ensuring it is addressed in undergraduate teaching. Continuing education on the appropriate use of medicines can be targeted at more experienced dentists as well as patients, especially those who expect antibiotics instead of treatment.

TRIAL REGISTRATION

University of Melbourne Human Ethics Sub-Committee; ID: 1750768.1 .

Part 1. Current prescribing trends of antibiotics by dentists in Australia from 2013 to 2016

BACKGROUND

Literature has shown dentists tend to overprescribe antibiotics and do not always prescribe in accordance with recommended guidelines. Unnecessary prescribing is one major factor that contributes to the development of antibiotic resistance. The aim of the present study was to assess the antibacterial prescribing patterns of dentists in Australia from 2013 to 2016.

METHODS

Data on dental antibacterial prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) from 2013 to 2016 was accessed and prescribing trends analysed. The prescribing rates were standardized to the dose and population.

RESULTS

There was a slight decrease in the dispensed use of most antibacterials from 2013 to 2016, but there was a significant increase in the dispensed use of amoxicillin/clavulanic acid of 11.2%. Amoxicillin was the most commonly dispensed antibiotic, accounting for approximately 65% of all antibacterials from 2013 to 2016, while phenoxymethylpenicillin accounted for only 1.4% of prescriptions in 2016. There were low but significant quantities of dispensed antibiotic prescriptions that do not fit with current guidelines.

CONCLUSIONS

The data suggest that dentists in Australia are prescribing some antibiotics inappropriately and there is a preference for moderate- to broad-spectrum agents. The current PBS dental schedule is inconsistent with prescribing guidelines and may contribute to inappropriate prescribing.

Part 2. Current prescribing trends of dental non-antibacterial medicines in Australia from 2013 to 2016

BACKGROUND

There is limited literature regarding dental prescribing preferences for medicines other than antibiotics. This study aimed to describe the prescribing trends of dispensed prescription medicines by dentists in Australia from 2013 and 2016 and assess adherence to current guidelines.

METHODS

Data were accessed from the Department of Health of all dental prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) from 2013 to 2016 and prescribing patterns were analysed. The prescribing rates were standardized to the dose and population.

RESULTS

There was an overall increase in the standardized use of opioid analgesics by almost 30% over the time frame, with the combination paracetamol 500 mg plus codeine 30 mg tablet accounting for the majority of dispensed opioid prescriptions (96.2% in 2016). Dispensed benzodiazepine prescriptions increased by 14.6%.

CONCLUSIONS

The increase in the consumption of opioids is concerning, suggesting that continuing education is required for dentists to better understand their limited role in managing dental pain and potential for abuse. The substantial increase in the dispensed use of benzodiazepines also requires further investigation and there were some drugs prescribed inappropriately and not in accordance with guidelines. Consideration could also be given to reviewing the drugs listed on the PBS for dental prescribing.

Association of TP53 Mutation, p53 Overexpression, and p53 Codon 72 Polymorphism with Susceptibility to Apoptosis in Adult Patients with Diffuse Astrocytomas

Clarification of TP53 alterations is important to understand the mechanisms underlying the development of diffuse astrocytomas. It has been suggested that the alleles of TP53 at codon 72 differ in their ability to induce apoptosis in human cancers. The aim of this study was to analyze the possible association of TP53 mutation, p53 overexpression, and p53 codon 72 polymorphism with susceptibility to apoptosis in adult Brazilian patients with diffuse astrocytomas. We analyzed 56 surgical specimens of diffuse astrocytomas for alterations of TP53, using polymerase chain reaction single-strand conformation polymorphism (PCR-SSCP) direct sequencing. p53 and cleaved caspase 3 protein expression were assessed by immunohistochemistry. We found TP53 mutations in 19.6% (11 out of 56) of tumors tested, with the lowest mutation rate found in the cases of glioblastomas (8.8%) (p = 0.03). Only 16.1% of tumors tested showed cleaved caspase 3-positive staining, demonstrating that apoptosis is very inhibited in these tumors. All tumors having TP53 mutation and p53 accumulation had no expression of cleaved caspase 3. Additionally, no association was observed in tumors having proline and arginine alleles and expression of cleaved caspase 3. We concluded that clarification of the TP53 alterations allows a better understanding of the mechanisms involved in the progression of diffuse astrocytomas, and the allele status at codon 72 was not associated with apoptosis in these tumors.

Development and validation of a computerized algorithm for International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

STUDY DESIGN

Validation study.

OBJECTIVES

To describe the development and validation of a computerized application of the international standards for neurological classification of spinal cord injury (ISNCSCI).

SETTING

Data from acute and rehabilitation care.

METHODS

The Rick Hansen Institute-ISNCSCI Algorithm (RHI-ISNCSCI Algorithm) was developed based on the 2011 version of the ISNCSCI and the 2013 version of the worksheet. International experts developed the design and logic with a focus on usability and features to standardize the correct classification of challenging cases. A five-phased process was used to develop and validate the algorithm. Discrepancies between the clinician-derived and algorithm-calculated results were reconciled.

RESULTS

Phase one of the validation used 48 cases to develop the logic. Phase three used these and 15 additional cases for further logic development to classify cases with 'Not testable' values. For logic testing in phases two and four, 351 and 1998 cases from the Rick Hansen SCI Registry (RHSCIR), respectively, were used. Of 23 and 286 discrepant cases identified in phases two and four, 2 and 6 cases resulted in changes to the algorithm. Cross-validation of the algorithm in phase five using 108 new RHSCIR cases did not identify the need for any further changes, as all discrepancies were due to clinician errors. The web-based application and the algorithm code are freely available at www.isncscialgorithm.com.

CONCLUSION

The RHI-ISNCSCI Algorithm provides a standardized method to accurately derive the level and severity of SCI from the raw data of the ISNCSCI examination. The web interface assists in maximizing usability while minimizing the impact of human error in classifying SCI.

SPONSORSHIP

This study is sponsored by the Rick Hansen Institute and supported by funding from Health Canada and Western Economic Diversification Canada.

Consumer preference in ranking walking function utilizing the walking index for spinal cord injury II

STUDY DESIGN

Blinded rank ordering.

OBJECTIVE

To determine consumer preference in walking function utilizing the walking Index for spinal cord injury II (WISCI II) in individuals with spinal cord injury (SCI)from the Canada, the Italy and the United States of America.

METHOD

In all, 42 consumers with incomplete SCI (25 cervical, 12 thoracic, 5 lumbar) from Canada (12/42), Italy (14/42) and the United States of America (16/42) ranked the 20 levels of the WISCI II scale by their individual preference for walking. Subjects were blinded to the original ranking of the WISCI II scale by clinical scientists. Photographs of each WISCI II level used in a previous pilot study were randomly shuffled and rank ordered. Percentile, conjoint/cluster and graphic analyses were performed.

RESULTS

All three analyses illustrated consumer ranking followed a bimodal distribution. Ranking for two levels with physical assistance and two levels with a walker were bimodal with a difference of five to six ranks between consumer subgroups (quartile analysis). The larger cluster (N=20) showed preference for walking with assistance over the smaller cluster (N=12), whose preference was walking without assistance and more devices. In all, 64% (27/42) of consumers ranked WISCI II level with no devices or braces and 1 person assistance higher than multiple levels of the WISCI II requiring no assistance. These results were unexpected, as the hypothesis was that consumers would rank independent walking higher than walking with assistance.

CONCLUSION

Consumer preference for walking function should be considered in addition to objective measures in designing SCI trials that use significant improvement in walking function as an outcome measure.

The tools of disability outcomes research functional status measures

OBJECTIVE

To review the major functional status measures currently used in rehabilitation research, including the domains and scope of functional status measures, as well as the psychometric properties of selected functional status measures and their use in adult rehabilitation populations.

DATA SOURCES

Measures of physical functioning widely used in rehabilitation research.

STUDY SELECTION

Major generic measures included the following activities of daily living and instrumental activities of daily living: the FIM instrument, the Katz Activities of Daily Living Scale, the Level of Rehabilitation Scale, the Barthel index, and the Patient Evaluation and Conference System. Measures were evaluated based on published evidence of validity, reliability, and sensitivity.

DATA EXTRACTION

Measures were chosen on the basis of the amount and quality of published research on the functional measures widely used in rehabilitation medicine. Independent research of computer databases and reviews of functional measures were conducted to determine suitability for inclusion. The quality and validity of the measures were assessed using standard psychometric guidelines.

DATA SYNTHESIS

Measures were evaluated based on published evidence of validity, reliability, sensitivity response and administrative burdens and instrument bias. Each criterion was graded on a 3-point scale reflecting the level of evidence.

CONCLUSION

Researchers in the field of disabilities research need to consider carefully study objectives when measuring physical functioning in people with disabilities.

Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems

OBJECTIVE

To present data on neurologic recovery gathered by the Model Spinal Cord Injury (SCI) Systems over a 10-year period.

DESIGN

Case series.

SETTING

Twenty-one Model SCI Systems.

PATIENTS

A total of 3,585 individuals with traumatic SCI admitted between January 1, 1988 and December 31, 1997.

MAIN OUTCOME MEASURES

Neurologic impairment category; Frankel grade; American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade; motor score.

RESULTS

SCI caused by violence is more likely than SCI from nonviolent etiologies to result in a complete injury. Changes in severity of injury were similar using the older Frankel scale and the newer ASIA Impairment Scale. Individuals who were motor-complete with extended zones of sensory preservation but without sacral sparing were less likely to convert to motor-incomplete status than those with sacral sparing (13.3% vs 53.6%; p < .001). Motor score improvements at 1 year were related to severity of injury, with greater increases for better AIS grades except grade D, because of ceiling effects. Individuals with AIS grade B injuries have a mixed prognosis.

CONCLUSION

Neurologic recovery after SCI is influenced by etiology and severity of injury. Multicenter studies on prognostic features such as preserved pin sensation in grade B injuries may identify subgroups with similar recovery patterns. Identification of such groups would facilitate clinical trials for neurologic recovery in acute SCI.

Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury--1990-1997

OBJECTIVES

To describe changes in acute and rehabilitation length of stay (LOS) for persons with traumatic spinal cord injury (SCI), describe predictors of LOS, and explore year-1 anniversary medical and social outcomes.

DESIGN

Longitudinal, exploratory study of patients with SCI.

SETTING

Eighteen Model Spinal Cord Injury Centers across the United States.

SAMPLE

A total of 3,904 persons discharged from the Model Systems between 1990 and 1997 who had follow-up interviews at 1 year postinjury.

MAIN OUTCOME MEASURES

Rehabilitation LOS; injury anniversary year-1 presence of pressure ulcers; incidence of rehospitalization; community or institutional residence; and days per week out of residence.

RESULTS

Acute rehabilitation LOS declined from 74 days to 60 days. Discharges to nursing homes and rehospitalizations increased between 1990 and 1997. Linear regression showed that lower admission motor Functional Independence Measure (FIM) scores, year of discharge from the Model System, method of bladder management, tetraplegia, race, education, marital status, discharge disposition, and age were related to longer LOS. At first anniversary, logistic regressions revealed that lower discharge motor FIM, injury level, and age were related to the presence of pressure ulcers, rehospitalization, residence, and time spent out of residence. Of those discharged to nursing homes, 44% returned to home by year 1, and these individuals had higher functional status and were younger.

DISCUSSION

High functional status is associated with shorter LOS, discharge to the community, and time spent out of residence, indicating efficiency in the system. For 44.4% of individuals one or more of the following outcomes were observed by first year anniversary: rehospitalization; residing in a skilled nursing facility; having pressure ulcers; or infrequently leaving one's residence.

A functional strategy for classifying patients after traumatic spinal cord injury

OBJECTIVES

To present a function-based strategy for classifying patients by expected functional outcomes measured as patients' performances at discharge on each of the 18 component items of the FIMtrade mark instrument (previously known as the Functional Independence Measure).

METHODS

Data included records from 3604 inpatients with traumatic spinal cord injury discharged from 358 rehabilitation units or hospitals in 1995. The function-based strategy assigned patients to four Discharge Motor-FIM-Function Related Groups defined by patients' admission performance on the motor-FIM items.

RESULTS

The majority of patients whose motor-FIM scores at admission were above 30 were able to groom, dress the upper body, manage bladder function, use a wheelchair, and transfer from bed to chair, either independently or with supervision, by the time of discharge from inpatient rehabilitation. Most patients whose scores were above 52 attained independence in all but the most difficult FIM tasks, such as bathing, tub transfers, and stair climbing.

CONCLUSIONS

This classification scheme can be used to determine the degree to which patients' actual FIM outcomes compare to other individuals who had similar levels of disabilities at the time of admission to rehabilitation. The clinician can apply these 'FIM item attainment benchmarks' retrospectively in quality improvement, in guideline development, and in anticipating the types of post-discharge care required by clinically similar groups.

The relationship between the functional abilities of patients with cervical spinal cord injury and the severity of damage revealed by MR imaging

BACKGROUND AND PURPOSE

The appearance of the damaged spinal cord after injury correlates with initial neurologic deficit, as determined by the American Spinal Injury Association grade and manual muscle test score, as well as with recovery, as assessed by manual muscle test scores. The purpose of this study was to determine whether the presence of spinal cord hemorrhage and the size and location of spinal cord edema on MR images is predictive of functional recovery in survivors of cervical spinal cord injury (SCI).

METHODS

The degree of damage to the cervical spinal cord was measured on the MR images of 49 patients who underwent imaging within 72 hours of sustaining SCI. The effects of hemorrhage and length/location of edema on changes in the value of the motor scale of the functional independence measure (FIM) were assessed on admission to and discharge from rehabilitation.

RESULTS

Patients without spinal cord hemorrhage had significant improvement in self-care and mobility scores compared with patients with hemorrhage. There was no significant effect of spinal cord hemorrhage on changes in locomotion and sphincter control scores. The rostral limit of edema positively correlated with admission and discharge self-care scores and with admission mobility and locomotion scores. Edema length had a negative correlation with all FIM scales at admission and discharge.

CONCLUSION

The imaging characteristics of cervical SCI (hemorrhage and edema) are related to levels of physical recovery as determined by the FIM scale. Imaging factors that correlate with poor functional recovery are hemorrhage, long segments of edema, and high cervical locations.

Development of a short-form Quadriplegia Index of Function scale

OBJECTIVE

To develop a short-form version of the Quadriplegia Index of Function (QIF) that would be more practical to use than the original version.

DESIGN

Cross-sectional data collected at 6 months post spinal cord injury.

SETTING

Regional Spinal Cord Injury Center.

PATIENTS

Consecutive sample of 95 patients with tetraplegia, non-ambulatory at 6 months, admitted to a regional SCI center between December 1987 and August 1992.

METHODS

A short-form QIF was developed by using regression analysis to determine the best six items that would predict the sum of the 37 items selected from seven mobility and self-care categories of the original scale. This short-form QIF was evaluated for internal consistency and discriminant validity. Validity of the short-form QIF was assessed by correlation with motor scores and using analysis of variance by motor levels and motor score groupings.

RESULTS

Regression analysis identified the following items as best predictors of the 37-item QIF score: (1) wash/dry hair, (2) turn supine to side in bed, (3) put on lower body clothing, (4) open carton/jar (feeding), (5) transfer from bed to chair, and (6) lock wheelchair. These items explained 99% of the variance in total scores. Short-form QIF scores (simple sum of the six best items) ranged from 0 to 24, with a median score of seven, interquartile range 0-16. Item response patterns were largely dichotomous. Item-total correlations ranged from 0.60 to 0.80; Cronbach's alpha was 0.89. Spearman correlation coefficient between upper extremity motor score and short-form QIF was 0.82. Analysis of variance indicated that the motor score groupings and motor levels accounted for 63 and 54% of the variance in short-form QIF scores, respectively. Post hoc analyses indicated that motor levels from C5 to T1 had different mean QIF scores, except for C7 versus C8. There may be ceiling effects for individuals with low level injuries.

CONCLUSION

There is significant redundancy in the QIF. Six items, selected from five categories, yield results comparable to the 37-item QIF. The short-form QIF must next be assessed for sensitivity to change. A brief disability measure would improve data quality and completeness, and may permit ongoing collection of observational rather than self-report data.

The Capabilities of Upper Extremity instrument: reliability and validity of a measure of functional limitation in tetraplegia

OBJECTIVE

To evaluate the reliability and validity of the Capabilities of Upper Extremity (CUE) instrument, designed to measure upper extremity functional limitations in individuals with tetraplegia. Functional limitations are actions such as reaching or grasping and are a link between the domains of impairment and disability.

DESIGN

Survey of people with chronic spinal cord injury.

SETTING

Regional spinal cord injury center.

SUBJECTS

One hundred fifty-four individuals (140 male) with tetraplegia at least 1 year after injury and followed by the center. Mean age was 36.7 years (SD=11.1). Sixty-eight percent were motor complete.

METHODS

The 32-item CUE was administered by telephone interview twice about 2 weeks apart. The motor portion of the Functional Independence Measure (FIM) was collected during the first interview. Upper extremity motor scores and motor levels were obtained from the most recent assessment in the outpatient chart. The instrument was evaluated for internal consistency, reliability, and validity. Exploratory factor analysis was performed to examine scale structure.

RESULTS

Homogeneity of the scale was excellent. Cronbach's alpha was .96, and item-total correlations ranged from .49 to .78. Test-retest reliability was high (ICC=.94). All but three items had desired levels of agreement (K > .60). Analysis of variance indicated that the CUE distinguished between motor levels of tetraplegia more than one level apart. The CUE was correlated highly with both motor scores and FIM. Regression analysis indicated that the CUE was better than upper extremity motor scores for predicting FIM scores. The model containing the CUE explained 73% of the variance in FIM and was not enhanced by the addition of motor scores. Factor analysis suggested four potential subscales: arm function (bilateral), right hand function, left hand function, and reaching down.

CONCLUSION

The CUE exhibits good homogeneity, reliability, and validity; further work is needed to determine its sensitivity to change in function.

American Association of Electrodiagnostic Medicine guidelines for outcome studies in electrodiagnostic medicine

Based on a review of the literature and the clinical research experience of the authors and reviewers, the AAEM proposes 17 criteria which should be used to construct and evaluate diagnostic and/or therapeutic outcome studies for patients with symptoms and signs of neuromuscular diseases. Neuromuscular diseases are defined as diseases that cause pathology and/or dysfunction of the sensory, motor, and/or autonomic nerve offers and/or muscles.

Superiority of motor level over single neurological level in categorizing tetraplegia

The purpose of this paper is to demonstrate the superiority of the American Spinal Injury Association motor level (ML) and upper extremity motor score (UEMS) to the neurological level (NL) in determining self care function in motor complete tetraplegia. Fifty subjects with traumatic motor complete tetraplegia, NL C4-C8, were evaluated at admission and 12 months post injury. At both time periods NL, ML, and UEMS were determined. At 12 months, reported ability to perform six feeding activities of the Quadriplegia Index of Function (QIF) were documented. Spearman correlations of the NL, BML, WML, UEMS, and feeding QIF scores were conducted, and results were compared with t tests for significant differences. Both the best and worst ML were more highly correlated to the UEMS than was the NL (0.96 and 0.96 vs 0.66, P < 0.001). The best and worst ML were more highly correlated to the QIF feeding score than was the NL (0.74 and 0.72 vs 0.56, P < 0.05). The UEMS had the highest correlation to the QIF feeding score, 0.78. These results suggest that the NL is an imprecise descriptor of the impairment in SCI, and is therefore a poor predictor of the resultant disability. The ML and the UEMS better reflect the severity of impairment and disability after motor complete tetraplegia.

Wrist strength measured by myometry as an indicator of functional independence

The purpose of this study was to show that independence of self care activities of motor complete quadriplegic patients related better to the force of contraction of the wrist extensor (WE) muscles measured by a hand held myometer than to the manual muscle test (MMT) for grades 3 to 5. The patients (n = 24), identified by having unilaterally or bilaterally functional WE muscle (MMT > or = 3/5) with bilateral elbow extensor (EE) muscles < 3/5, were evaluated at 2 to 6 months after injury for four feeding activities utilizing the Quadriplegia Index of Function (QIF). We found 54% were independent drinking from a cup, 58% using a spoon or fork, 13% cutting food, and 23% pouring liquids. Comparisons were made between right, left, and bilateral mean myometry scores and median MMT scores for each of the QIF activities. The independent group of patients had myometry scores 54 to 140% greater (p < 0.05) than those patients dependent in the self care activity except when the right or left WE myometric score was analyzed for cutting food (p = 0.1). MMT comparisons showed no significant median score differences in any activity performed. There were no patients with only one WE muscle > or = 3/5 (n = 9) who were able to cut food or pour liquids independently. In conclusion, myometry appeared to be a better indicator than the MMT for some self care activities evaluated utilizing the Quadriplegia Index of Function.

Assessing selfcare status in quadriplegia: comparison of the quadriplegia index of function (QIF) and the functional independence measure (FIM)

The purpose of this study was to compare the quadriplegia index of function (QIF) to the functional independence measure (FIM) in assessing the daily performance of selfcare activities by individuals with cervical spinal cord injury. This study evaluated feeding, grooming and bathing activities in 22 C4-C7, Frankel A-D spinal cord injury patients between 3 and 12 months postinjury. The manual muscle test (MMT) was performed on 17 of these subjects during the same window of time as the QIF and the FIM. An upper extremity motor score (UEMS) was derived from the MMT. In order to relate motor power to functional ability, the UEMS was used as a measure of neurological function to test the hypothesis that the QIF scores are more highly correlated to motor power than are the FIM scores for this population. Spearman coefficients were calculated to correlate the QIF, the FIM and the UEMS. For the bathing and grooming categories, both the QIF and the FIM showed significant and similar correlations to the UEMS. For the feeding category, however, the QIF had a significantly better correlation to the UEMS than did the FIM (Rho = 0.90 vs 0.53, p < 0.01). Use of the QIF feeding scale may allow the detection of changes in function as individuals recover that the FIM scale would miss. Further evaluation of the remaining selfcare and mobility scales is needed. Modification of the FIM with more sensitive portions of the QIF would improve the discriminative ability of outcome studies and program evaluations.

Risk of spinal cord dysfunction in patients undergoing thoracoabdominal aortic replacement

The records of 150 consecutive patients undergoing thoracoabdominal aortic replacement from 1980 to 1991 were retrospectively reviewed. There were 89 men and 61 women; mean age was 67.8 years (range: 33 to 88 years). Since June 1989, a multimodality prospective perioperative protocol was used to reduce the risk of spinal cord dysfunction. Ischemia is minimized by complete intercostal reimplantation whenever possible, cerebrospinal fluid drainage, and maintenance of proximal hypertension during cross-clamping. Spinal cord metabolism is reduced by moderate hypothermia, high-dose barbiturates, and avoidance of hyperglycemia. Reperfusion injury is minimized by the use of mannitol, steroids, and calcium channel blockers. Ninety-seven percent of patients survived long enough for evaluation of their neurologic function. Spinal cord dysfunction was reduced from 6 of 108 (6%) in the preprotocol group to 0 of 42 in the protocol group (0%) (p less than 0.01). The overall 30-day operative mortality was not significantly different between the groups (9% versus 12%, p = NS). A multimodality protocol appears to be effective in reducing the risk of spinal cord injury during thoracoabdominal aortic replacement.

Course of motor recovery in the zone of partial preservation in spinal cord injury

Thirty-nine C4 to C6 motor complete Frankel A or B spinal cord injured subjects were included in this prospective study to determine the course of recovery in the zone of partial preservation (ZPP) during the first 6 months postinjury. Subjects had initial manual muscle testing and neurologic examination between 3 and 7 days postinjury. Subjects whose most rostral key muscle in the ZPP had a motor power of grade 1 or 1+/5 (group 1, n = 22) were compared with subjects whose most rostral key muscle had a motor power of grade 2 or 2+/5 (group 2, n = 17). Subjects had manual muscle testing weekly for 1 month and then monthly for 6 months postinjury. Comparisons were made for recovery to: (1) grade 3/5; (2) grade 4/5; (3) an increase of one grade; and (4) an increase of two grades. Analyses were made at monthly intervals by the Fisher Exact test and between median times of recovery by the Kruskal-Wallis Ranking test. There was earlier recovery to grade 3/5 for group 2. At one month 11 of 17 (65%) group 2 subjects had reached grade 3/5 compared with 4 of 22 (18%) group 1 subjects (p less than 0.01). At 2 months postinjury, 14 of 17 (82%) group 2 subjects versus 10 of 22 (45%) group 1 subjects had reached grade 3/5 strength (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery of zero-grade muscles in the zone of partial preservation in motor complete quadriplegia

This prospective study was designed to demonstrate root level recovery in the zone of preservation by examining muscles with an initial strength of grade 0/5 in 32 motor complete (Frankel A and B) patients who had cervical spinal cord injury at the C4 through C7 levels. The biceps (C5), extensor carpi radialis (C6), triceps (C7), and flexor digitorum profundus (C8) muscles were used as key muscles when their strength at the initial manual muscle test, which was performed between three and seven days postinjury, was grade 0/5 and the muscle innervated by the cord segment directly rostral to that innervating the key muscle (grade 0/5) was grade greater than or equal to 3/5. If the biceps muscle was used, C4 pin sensation was required to be normal. Further manual muscle tests were performed weekly for four weeks, and then at 2, 3, 6, and 12 months postinjury. None, 6%, 17%, 35%, and 43% of the patients recovered to grade greater than or equal to 3/5 by 1, 2, 3, 6, and 12 months postinjury, respectively. It was also noted that in 86% of our patients, improving to grade greater than or equal to 1/5 by one month postinjury was a predictor of recovering to grade greater than or equal to 3/5 by 12 months postinjury (p less than .002). Similarly, in 100% of our patients, improving to grade greater than or equal to 2/5 by three months postinjury was a predictor of recovering to grade greater than or equal to 3/5 by 12 months postinjury (p less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Motor power differences within the first two weeks post-SCI in cervical spinal cord-injured quadriplegic subjects

The purpose of this study was to confirm the clinical impression that motor power significantly changed within the first 2 weeks after a spinal cord injury (SCI) and to determine the time for motor power assessment within the first 2 weeks post injury that best correlated with motor power determined 6 months post-SCI. Our hypothesis was that within the first 2 weeks postinjury, the manual muscle test (MMT) scores would change significantly from the < or = 24 h examination and that the post-24 h evaluations of strength would have a higher correlation with the 6 month measure of motor outcome than the evaluation of strength performed < or = 24 h after SCI. The biceps, extensor carpi radialis, triceps, flexor digitorum profundus, and interosseous muscle strength was measured in 40 subjects using the MMT (muscles graded 0/5 to 5/5) at < or = 24 h, 72 h, 1 week, 2 weeks, 3 months, and 6 months post-SCI. Upper extremity motor index scores (MIS) obtained at the four testing periods within 2 weeks of injury were analyzed using a Friedman analysis of variance with Duncan's post-hoc tests to identify significant differences. Separate analyses were performed on subgroupings of the total sample based on the strength of the most rostral key muscle having less than antigravity strength. There were three groups evaluated: initial MMT 0/5 (n = 22), initial MMT 1-1.5/5 (n = 17), and initial MMT 2-2.5/5 (n = 13).(ABSTRACT TRUNCATED AT 250 WORDS)

The 72-hour examination as a predictor of recovery in motor complete quadriplegia

Twenty-nine C4 to C7 motor-complete spinal cord injured subjects were evaluated to determine whether the manual muscle test (MMT) performed within 24 hours of injury or at 72 hours after injury better predicts short-term functional muscle recovery. A single muscle in the zone of injury that had a muscle grade between 1 and 3, inclusive, was evaluated serially in each patient from admission to three months. Increase in muscle strength to grade 4 or better was defined as success. Outcomes were evaluated by the Fisher exact test. Using the less-than-24-hour MMT, 12 of 17 subjects with grade 3 muscle strength vs four of 12 subjects with grade 1 or 2 muscle strength achieved success (p greater than .05). Using the 72-hour MMT, all 11 subjects with grade 3 muscle strength vs five of the 18 subjects with less than grade 3 muscle strength achieved success (p less than .001). Short-term functional muscle recovery in the zone of injury in cervical motor-complete quadriplegia is better predicted by the 72-hour MMT than by the less-than-24-hour MMT.

Atelectasis and pneumonia in acute spinal cord injury

The purpose of this study was to demonstrate the high incidence of atelectasis or pneumonia (A/P) in the left lung of acute spinal cord injured (SCI) patients. The study group consisted of 46 consecutive motor complete (Frankel A or B) SCI patients admitted within 48 hours of injury. The ages of the patients ranged from 15 to 72 years. Neurologic levels ranged from C3 to T11. There were 19 high-level quadriplegic patients (HLQ; C3-C5), 11 low-level quadriplegic patients (LLQ; C6-C8), and 16 paraplegic patients (Para; T1-T11). The patients were followed during the first 30 days postinjury for radiographic evidence of A/P lasting more than three days. The time of onset, duration, and location of A/P was determined. Fifty percent (23 of 46) of the patients developed A/P in the first 30 days after their spinal cord injury. The incidence was higher in the HLQ than in the LLQ and Para (74% vs 33%; p less than 0.02 using the Fischer exact test). There was a preponderance (4:1 ratio) of left-sided involvement for A/P in this population (p = 0.01 using the two-tailed binomial test). Sixteen patients had left-sided A/P, four patients had right-sided A/P, and three patients had bilateral findings. There was no relationship between level of injury and side of involvement. The high incidence of left-sided pulmonary involvement in the acute SCI patient may be due to the tendency to retain secretions in this period combined with the increased difficulty of clearing secretions from the left lung.

Continuous monitoring of skin temperature using a liquid-crystal thermometer during anesthesia

Forehead skin temperature measured by a stip of liquid-crystal material was compared to esophageal, rectal, and axillary temperatures measured by thermistor probes in patients having general anesthesia for coronary artery bypass grafting. Before extracorporeal circulation, forehead skin temperature was lower than axillary, rectal, and esophageal temperatures by approximately 2.2 C (4.0 F). During rapid warming, forehead skin temperature rose concurrently with the other temperatures measured but remained significantly different. The liquid-crystal strip may be useful as a safe, convenient method for routine monitoring of temperature trends during general anesthesia in patients whose exact core temperature need not be continuously monitored. We believe that infants, patients undergoing extracorporeal circulation, major abdominal, vascular, or neurosurgical procedures, or patients with a history of temperature regulatory problem are probably best monitored by a method which more exactly reflects core temperature.