Journal Club: Long-term functional outcome in patients with acquired infections after acute spinal cord injury

Abstract

Journal Club: Long-term functional outcome in patients with acquired infections after acute spinal cord injury Infections, particularly pneumonia, are the primary cause of mortality in individuals with spinal cord injury (SCI).1 Several factors may contribute to the high rate of infections in the SCI population, including motor paralysis and reduced reflexes resulting in aspiration, invasive procedures, and so-called SCIinduced immune depression syndrome (SCI-IDS). 2,3SCI-IDS is thought to occur when the connection between the CNS and the immune system are disrupted by a lesion in the spinal cord, resulting in a decrease in immune function.3 In addition to increased morbidity and mortality, infections after SCI may affect neurologic recovery.2,3 A recent study found that infections impaired the return of muscle strength up to 1 year postinjury; however, the long-term consequences remain uncertain. The aim of this study was to investigate whether infections occurring in an acute care setting after SCI affected long-term functional recovery and survival. 4METHODS Data source and inclusion criteria. The study by Kopp et al. 4 used data gathered from the multicenter National Spinal Cord Injury Database (NSCID). The NSCID prospectively gathers data from 25 specialized traumatic SCI care centers. 2Inclusion criteria were admission within 24 hours after injury between 1995 and 2005, age between 17 and 75, a cervical SCI, complete baseline and infection data, and an American Spinal Cord Injury Association Impairment Scale (AIS) grade of A, B, or C (see table e-1 at Neurology.org for a full description of the AIS grading system). Participants were excluded if they resided in a hospital or nursing home prior to injury, had serious concomitant injuries affecting consciousness, or were rehospitalized for unspecified infectious or parasitic diseases during the follow-up period.Exposures and outcomes. The primary outcomes were the motor items of the Functional Independence Measure (FIM; FIM motor total score and 4 additional FIM motor subscores) at 4 timepoints (admission, discharge, 1 year, and 5 years postinjury). The secondary outcome measure was infection-associated mortality at 10 years postinjury. Hospital-acquired infections included pneumonia and postoperative wound infections that occurred during acute care or inpatient rehabilitation.Statistics. FIM motor scores as a dependent variable were analyzed in 3 ways: an explorative analysis of scores at each of the 4 timepoints, a linear mixed model (LMM), and an adjusted LMM. Both models used multiple imputation and a sensitivity analysis using only complete cases. The measure of interest was a time 3 infection interaction term; that is, if early infection had a time-dependent effect on the recovery of FIM motor scores. The LMMs included the initial model (adjusted only for baseline FIM motor scores), an additional model (adjusted for AIS, level of injury, age, ethnic group, and working status), and finally 3 models stratified for AIS grade and adjusted for the aforemen...

Pharyngeal Dysphagia in Individuals With Cervical Spinal Cord Injury: A Prospective Observational Cohort Study

“…Addressing dysphagia may decrease the risk of aspiration pneumonia, which may lead to improved long-term outcomes (ie, functional independence and life expectancy). 18 Additionally, Logemann mentioned that tracheostomy and/or ventilator dependence makes BSE difficult and therefore subsequent VFSS is required; however, no literature or data were referenced to support this assertion. 10 We found that BSE can be performed accurately at the bedside to screen for dysphagia regardless of invasive mechanical ventilator dependence or tracheostomy.…”

Corroborating evidence by exploring sources of bias in observational spinal cord injury studies

“…2 In the stratified models, the imputed and complete case analyses produced differing results in AIS B and C subgroups. 2 To address the question whether inaccuracy in the imputations may be a reason for such disparities rather than nonrandom dropout, 3 we compare the sociodemographic and neurologic baseline of complete cases with cases lost to FIM motor examinations at 1 or 5 years.…”

“…The study included patients enrolled between 1995 and 2005 and the incidence of infections as well as the management of care after SCI may have changed throughout this time frame. 3 To reveal temporal differences in the rate of Pn/Wi and evaluate their potential to influence the FIM motor analysis, we compare the Pn/Wi rate by periods of enrollment (1995-1999 vs 2000-2005) and include the enrollment period as an explanatory variable in the linear models.…”