Influence of patient isolation due to colonization with multidrug-resistant organisms on functional recovery after spinal cord injury

STUDY DESIGN

Chart reviews were combined with neurological and functional outcome data obtained from the prospective European Multicenter Study on Spinal Cord Injury (EMSCI, www.emsci.org).

OBJECTIVES

To determine if strict physical isolation of multidrug-resistant organisms (MDRO)-positive patients negatively affects neurological recovery and functional outcome in the first year after acute spinal cord injury (SCI).

SETTING

SCI Center Heidelberg University Hospital.

METHODS

Individuals with acute (< 6 weeks) traumatic or ischemic SCI were included. During primary comprehensive care, isolated MDRO-positive patients (n = 13) were compared with a MDRO-negative control group (n = 13) matched for functional (Spinal Cord Independence Measure-SCIM) and neurological impairment (motor scores based on the International Standards for Neurological Classification of Spinal Cord Injury-ISNCSCI) at an early stage up to 40 days after SCI. SCIM scores and motor scores were obtained at 12 weeks (intermediate stage) and 24 or 48 weeks (late stage) after SCI.

RESULTS

Isolated MDRO-positive (median duration of hospitalization: 175 days, 39% of inpatient stay under isolation measures) and non-isolated MDRO-negative (median duration of hospitalization: 161 days) patients showed functional and neurological improvements, which were not statistically different between groups at the intermediate and late stage.

CONCLUSION

Prolonged isolation due to MDRO colonization for over a third of the inpatient comprehensive care period does not appear to impair neurological recovery and functional outcome within the first year after SCI.

Intrinsic and extrinsic determinants of central nervous system axon outgrowth into alginate-based anisotropic hydrogels

Appropriate target reinnervation and functional recovery after spinal cord injury depend on longitudinally directed regrowth of injured axons. Anisotropic alginate-based capillary hydrogels (ACH) support peripheral nervous system derived axon growth, which is accompanied by glial supporting cell migration into the ACH. The aim of the present study was to analyze central nervous system (CNS) derived (entorhinal cortex, spinal cord slice cultures) axon regrowth into ACH containing linearly aligned capillaries of defined capillary sizes without and with gelatin constituent. Anisotropic ACH were prepared by ionotropic gel formation using Ba(2+), Cu(2+), Sr(2+), or Zn(2+) ions resulting in gels with average capillary diameters of 11, 13, 29, and 89μm, respectively. Postnatal rat entorhinal cortex or spinal cord slice cultures were placed on top of 500μm thick ACH. Seven days later axon growth and astroglial migration into the ACH were determined. Axon density within capillaries correlated positively with increasing capillary diameters, whereas longitudinally oriented axon outgrowth diminished with increasing capillary diameter. Axons growing into the hydrogels were always accompanied by astrocytes strongly suggesting that respective cells are required to mediate CNS axon elongation into ACH. Overall, midsize capillary diameter ACH appeared to be the best compromise between axon density and orientation. Taken together, ACH promote CNS axon ingrowth, which is determined by the capillary diameter and migration of slice culture derived astroglia into the hydrogel.

STATEMENT OF SIGNIFICANCE

Biomaterials are investigated as therapeutic tools to bridge irreversible lesions following traumatic spinal cord injury. The goal is to develop biomaterials, which promote longitudinally oriented regeneration of as many injured axons as possible as prerequisite for substantial functional recovery. Optimal parameters of the biomaterial have yet to be defined. In the present study we show that increasing capillary diameters within such hydrogels enhanced central nervous system axon regeneration at the expense of longitudinal orientation. Axon ingrowth into the hydrogels was only observed in the presence of glial supporting cells, namely astrocytes. This suggests that alginate-based hydrogels need to be colonized with respective cells in order to facilitate axon ingrowth.

Increasing capillary diameter and the incorporation of gelatin enhance axon outgrowth in alginate-based anisotropic hydrogels

Substantial recovery of function following peripheral and central nervous system (CNS) injury critically depends on longitudinally directed axon regeneration across the injury site, which requires a mechanical guidance providing scaffold. We have previously shown that anisotropic alginate-based hydrogels with a defined capillary diameter (25 μm), which form via a self-organizing process driven by unidirectional diffusion of divalent cations into sodium alginate sols, promoted longitudinally oriented elongation of CNS axons in vitro and in vivo. In the present study the influence of various capillary diameters and the incorporation of gelatin to promote directed axon outgrowth and Schwann cell migration were assessed in a dorsal root ganglion outgrowth assay in vitro. Superimposing an alginate sol with Cu(2+), Sr(2+), or Zn(2+) ion containing solutions allowed the creation of hydrogels with capillaries 18, 25 and 55 μm in diameter, respectively. Axon outgrowth and Schwann cell migration were analyzed in terms of axon length/density and Schwann cell density within the capillary structures. Axon ingrowth into capillary hydrogels, which was always accompanied by Schwann cells, was enhanced with increasing capillary diameter. The incorporation of gelatin did not influence overall axon density, but promoted the length of axon outgrowth within the hydrogels. The longitudinal orientation of axons decreased in wider capillaries, which suggests that medium-sized capillaries are the optimal substrate to elicit substantial axon growth and longitudinal orientation after axon injury.

The promotion of oriented axonal regrowth in the injured spinal cord by alginate-based anisotropic capillary hydrogels

Appropriate target reinnervation and functional recovery after spinal cord injury depend on longitudinally directed regrowth of transected axons. To assess the capacity to promote directed axon regeneration, alginate-based highly anisotropic capillary hydrogels (ACH) were introduced into an axon outgrowth assay in vitro and adult rat spinal cord lesions in vivo. In an entorhino-hippocampal slice culture model, alginate-based scaffolds elicit highly oriented linear axon regrowth and appropriate target neuron reinnervation. Coating of alginate-based ACH with the extracellular matrix components collagen, fibronectin, poly L-ornithine and laminin did not alter the axon regrowth response as compared to uncoated alginate-based ACH. After implantation into acute cervical spinal cord lesions in adult rats, alginate-based ACH integrate into the spinal cord parenchyma without major inflammatory responses, maintain their anisotropic structure and in parallel to findings in vitro induce directed axon regeneration across the artificial scaffold. Furthermore, adult neural progenitor cells (NPC), which have been shown to promote cell-contact-mediated axon regeneration, can be seeded into alginate-based ACH as a prerequisite to further improve the regenerative capacity of these artificial growth supportive matrices. Thus, alginate-based ACH represent a promising strategy to induce directed nerve regrowth following spinal cord injury.

Neuronal precursor-specific activity of a human doublecortin regulatory sequence

The doublecortin (DCX) gene encodes a 40-kDa microtubule-associated protein specifically expressed in neuronal precursors of the developing and adult CNS. Due to its specific expression pattern, attention was drawn to DCX as a marker for neuronal precursors and neurogenesis, thereby underscoring the importance of its promoter identification and promoter analysis. Here, we analysed the human DCX regulatory sequence and confined it to a 3.5-kb fragment upstream of the ATG start codon. We demonstrate by transient transfection experiments that this fragment is sufficient and specific to drive expression of reporter genes in embryonic and adult neuronal precursors. The activity of this regulatory fragment overlapped with the expression of endogenous DCX and with the young neuronal markers class III beta-tubulin isotype and microtubule-associated protein Map2ab but not with glial or oligodendroglial markers. Electrophysiological data further confirmed the immature neuronal nature of these cells. Deletions within the 3.5-kb region demonstrated the relevance of specific regions containing transcription factor-binding sites. Moreover, application of neurogenesis-related growth factors in the neuronal precursor cultures suggested the lack of direct signalling of these factors on the DCX promoter construct.

Associational sprouting in the mouse fascia dentata after entorhinal lesion in vitro

Collateral sprouting is a form of neuronal plasticity observed in brain following injury. In order to establish an in vitro model of collateral sprouting, entorhino-hippocampal slice cultures were prepared from brain of C57BL/6 mouse pups (P1-4) and incubated for 14-16 days in vitro. Thereafter, entorhino-hippocampal fibers were cut and the outer molecular layer of the fascia dentata was denervated. At this age, entorhino-hippocampal fibers do not regenerate, as could be shown using anterograde tracing with Miniruby. Sprouting of associational mossy cell axons was monitored using calretinin-immunocytochemistry. Control and lesioned entorhino-hippocampal slices were studied at 1, 5, and 10 days postlesion. Whereas only the inner portion of the molecular layer was occupied by calretinin-positive mossy cell axons in controls and after 1 and 5 days postlesion, the entire width of the molecular layer was occupied by associational fibers by 10 days postlesion. Thus, robust sprouting of associational mossy cell axons occurs in response to entorhinal denervation in vitro. Using organotypic entorhino-hippocampal slices of genetically engineered mice, this sprouting model can be used to identify molecules involved in the regulation of sprouting following brain injury.

Regeneration of entorhinal fibers in mouse slice cultures is age dependent and can be stimulated by NT-4, GDNF, and modulators of G-proteins and protein kinase C

Axonal regeneration after lesions is normally not possible in the mature central nervous system, but occurs in the embryonic and neonatal nervous system. Slice cultures offer a convenient experimental system to study the decline of axonal regeneration with increasing maturation of central nervous system tissue. We have used mouse entorhinohippocampal slice cultures to assess regeneration of entorhinal fibers after mechanical lesions in vitro. We found that entorhinal axons regenerate well in cultures derived from postnatal days 5-7 mouse pups when the lesion is made at the second and fourth days in vitro (DIV 2 and DIV 4). Only little regenerative outgrowth is seen after lesions made at DIV 6 and DIV 10. This indicates that a maturation of the cultures occurs within a short time period in vitro resulting in a loss of the regenerative potential. We have used this system to screen for neurotrophic factors and pharmacological compounds that may promote axonal regeneration. Treatments were added to the cultures 1 day before the lesion was made. We found that most added factors did not promote regeneration. Only treatment with the neurotrophic factors NT-4 and GDNF stimulated regeneration in cultures where normally little regeneration is found. A similar improvement of regeneration was found after treatment with pertussis toxin, an inhibitor of G(i)-proteins, and with GF109203X, an inhibitor of protein kinase C. These substances may promote regeneration by interfering with intracellular signaling pathways activated by outgrowth inhibitors. Our findings indicate that the application of neurotrophic factors and the modulation of intracellular signal transduction pathways could be useful strategies to enhance axonal regeneration in a complex microenvironment.