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Background People with a spinal cord injury (SCI) have a high rate of bowel-related morbidity, even compared with people with other neurological disorders. These complications lower quality of life and place a financial burden on the health system. A noninvasive intervention that improves the bowel function of people with an SCI should reduce morbidity, improve quality of life, and lead to cost savings for health care providers. Objectives To investigate the effectiveness of noninvasive abdominal functional electrical stimulation (FES) for improving bowel function in people with a chronic SCI. Methods A prospective, double-blinded, 1:1 randomized, placebo-controlled intervention trial will be conducted with 80 adults with chronic SCI (>12 months since injury) above T8 single neurological level. The intervention will be a 45-minute abdominal FES (or placebo) session, 3 days per week, for 6 weeks. Main Study Parameters/Endpoints Primary endpoint is whole gut transit time before and after 6 weeks of abdominal FES. Secondary endpoints measured before and after 6 weeks of abdominal FES are (1) colonic transit time; (2) quality of life (EQ-5D-5L); (3) participant-reported bowel function (International SCI Bowel Function Basic Data Set Questionnaire and visual analogue scale); (4) respiratory function (forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximal expiratory pressure); (5) bladder symptoms (Neurogenic Bladder Symptom Score); (6) daily bowel management diary; and (7) unplanned hospital visits. Conclusion Safety data will be collected, and a cost utility analysis using quality of life scores will be performed. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000386831.

PURPOSE:Intermittent catheterization (IC) is a proven effective long-term bladder management strategy for individuals who have lower urinary tract dysfunction. This study provides clinical evidence about multiple-reuse versus single-use catheterization techniques and if catheter choice can have an impact on health-related quality of life (HRQoL). METHOD:A prospective, multi-center, clinical trial studied patients who currently practiced catheter reuse, and who agreed to prospectively evaluate single-use hydrophilic-coated (HC) (i.e. LoFric) catheters for 4 weeks. A validated Intermittent Self-Catheterization Questionnaire (ISC-Q) was used to obtain HRQoL. Reused catheters were collected and studied with regard to microbial and debris contamination. RESULTS:The study included 39 patients who had practiced IC for a mean of 10 years, 6 times daily. At inclusion, all patients reused catheters for a mean of 21 days (SD = 48) per catheter. 36 patients completed the prospective test period and the mean ISC-Q score increased from 58.0 (SD = 22.6) to 67.2 (SD = 17.7) when patients switched to the single-use HC catheters (p = 0.0101). At the end of the study, 83% (95% CI [67-94%]) preferred to continue using single-use HC catheters. All collected reused catheters (100%) were contaminated by debris and 74% (95% CI [58-87%]) were contaminated by microorganisms, some with biofilm. CONCLUSION:Single-use HC catheters improved HRQoL and were preferred over catheter reuse among people practicing IC. Catheter multiple-reuse may pose a potential safety concern due to colonization by microorganisms as well as having reduced acceptance compared to single use. TRIAL REGISTRY NUMBER:ClinicalTrials.gov NCT02129738.

An international multi-centred, double-blinded, randomised sham-controlled trial (eWALK).To determine the effect of 12 weeks of transcutaneous spinal stimulation (TSS) combined with locomotor training on walking ability in people with spinal cord injury (SCI).Dedicated SCI research centres in Australia, Spain, USA and Scotland.Fifty community-dwelling individuals with chronic SCI will be recruited. Participants will be eligible if they have bilateral motor levels between T1 and T11, a reproducible lower limb muscle contraction in at least one muscle group, and a Walking Index for SCI II (WISCI II) between 1 and 6. Eligible participants will be randomised to one of two groups, either the active stimulation group or the sham stimulation group. Participants allocated to the stimulation group will receive TSS combined with locomotor training for three 30-min sessions a week for 12 weeks. The locomotor sessions will include walking on a treadmill and overground. Participants allocated to the sham stimulation group will receive the same locomotor training combined with sham stimulation. The primary outcome will be walking ability with stimulation using the WISCI II. Secondary outcomes will record sensation, strength, spasticity, bowel function and quality of life.ANZCTR.org.au identifier ACTRN12620001241921.

Background: Functional electrical stimulation (FES) is the application of electrical pulses to a nerve to achieve a functional muscle contraction. Surface electrical stimulation of the nerves that innervate the abdominal muscles, termed abdominal FES, can cause the abdominal muscles to contract, even when paralysed after spinal cord injury. As the abdominal muscles are the major expiratory muscles, and commonly partially or completely paralysed in tetraplegia, abdominal FES offers a promising method of improving respiratory function for this patient group. Objective: The aim of the article is to provide readers with a better understanding of how abdominal FES can be used to improve the health of the spinal cord–injured population. Methods: A narrative review of the abdominal FES literature was performed. Results: Abdominal FES can achieve an immediate effective cough in patients with tetraplegia, while the repeated application over 6 weeks of abdominal FES can improve unassisted respiratory function. Ventilator duration and tracheostomy cannulation time can also be reduced with repeated abdominal FES. Conclusion: Abdominal FES is a noninvasive method to achieve functional improvements in cough and respiratory function in acute and chronically injured people with tetraplegia. Potential practical outcomes of this include reduced ventilation duration, assisted tracheostomy decannulation, and a reduction in respiratory complications. All of these outcomes can contribute to reduced morbidity and mortality, improved quality of life, and significant potential cost savings for local health care providers.

STUDY DESIGN:Randomised double-blind placebo-controlled trial. OBJECTIVES:Multi-resistant organism (MRO) colonisation is common in people with SCI. We aimed to determine whether Lactobacillus reuteri RC-14 + Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 (LGG-BB12) are effective in preventing or clearing MRO colonisation. SETTING:New South Wales, Australia. METHODS:The 207 SCI participants were randomised to one of four arms: (i) RC14-GR1 + LGG-BB12, (ii) RC14-GR1 + placebo, (iii) LGG-BB12 + placebo or (iv) double placebos for 6 months. Microbiological samples of nose, groin, urine and bowel were taken at baseline, 3 and 6 months. Analysis was conducted for the presence of methicillin-resistant Staphylococcus aureus (MRSA), multi-resistant gram-negative organisms (MRGNs) and vancomycin-resistant enterococcus (VRE). The outcomes were clearance of, or new colonisation with MRSA, MRGN, VRE or MROs and whether participants remained free of MRSA, MRGN, VRE or MROs throughout the study. Risk factors associated with an outcome were adjusted for using nominal or binary logistic regression. RESULTS:There was a significant reduction in new MRGN colonisation compared with placebo for participants treated with RC14-GR1 (OR 0.10, 95% CI, 0.01-0.88, P = 0.04), after allowing that inpatients were more likely to be newly colonised (OR 21.41, 95% CI, 3.98-115.13, P

Obstructive sleep apnoea (OSA) is highly prevalent in people with tetraplegia. Nasal congestion, a risk factor for OSA, is common in people with tetraplegia. The purpose of this study was to quantify objective and perceived nasal resistance and its stability over four separate days in people with tetraplegia and OSA (n=8) compared to able-bodied controls (n=6). Awake nasal resistance was quantified using gold standard choanal pressure recordings (days 1 and 4) and anterior rhinomanometry (all visits). Nasal resistance (choanal pressure) was higher in people with tetraplegia versus controls (5.3[6.5] vs. 2.1[2.4] cmH2O/L/s, p=0.02) yet perceived nasal congestion (modified Borg score) was similar (0.5[1.8] vs. 0.5[2.0], p=0.8). Nasal resistance was stable over time in both groups (CV=0.23±0.09 vs. 0.16±0.08, p=0.2). These findings are consistent with autonomic dysfunction in tetraplegia and adaptation of perception to high nasal resistance. Nasal resistance may be an important therapeutic target for OSA in this population but self-assessment cannot reliably identify those most at risk.

BackgroundRespiratory complications remain a leading cause of morbidity and mortality in people with acute and chronic tetraplegia. Respiratory muscle weakness following spinal cord injury-induced tetraplegia impairs lung function and the ability to cough. In particular, inspiratory muscle strength has been identified as the best predictor of the likelihood of developing pneumonia in individuals with tetraplegia. We hypothesised that 6 weeks of progressive respiratory muscle training (RMT) increases respiratory muscle strength with improvements in lung function, quality of life and respiratory health.MethodsSixty-two adults with tetraplegia participated in a double-blind randomised controlled trial. Active or sham RMT was performed twice daily for 6 weeks. Inspiratory muscle strength, measured as maximal inspiratory pressure (PImax) was the primary outcome. Secondary outcomes included lung function, quality of life and respiratory health. Between-group comparisons were obtained with linear models adjusting for baseline values of the outcomes.ResultsAfter 6 weeks, there was a greater improvement in PImax in the active group than in the sham group (mean difference 11.5 cmH2O (95% CI 5.6 to 17.4), pConclusionsProgressive RMT increases inspiratory muscle strength in people with tetraplegia, by a magnitude which is likely to be clinically significant. Measurement of baseline PImax and provision of RMT to at-risk individuals may reduce respiratory complications after tetraplegia.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN 12612000929808).

Study design: Randomised double-blind factorial-design placebo-controlled trial. Objective: Urinary tract infections (UTIs) are common in people with spinal cord injury (SCI). UTIs are increasingly difficult to treat due to emergence of multi-resistant organisms. Probiotics are efficacious in preventing UTIs in post-menopausal women. We aimed to determine whether probiotic therapy with Lactobacillus reuteri RC-14+Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG+Bifidobacterium BB-12 (LGG-BB12) are effective in preventing UTI in people with SCI. Setting: Spinal units in New South Wales, Australia with their rural affiliations. Methods: We recruited 207 eligible participants with SCI and stable neurogenic bladder management. They were randomised to one of four arms: RC14-GR1+LGG-BB12, RC14-GR1+placebo, LGG-BB12+ placebo or double placebos for 6 months. Randomisation was stratified by bladder management type and inpatient or outpatient status. The primary outcome was time to occurrence of symptomatic UTI. Results: Analysis was based on intention to treat. Participants randomised to RC14-GR1 had a similar risk of UTI as those not on RC14-GR1 (HR 0.67; 95% CI: 0.39–1.18; P = 0.17) after allowing for pre-specified covariates. Participants randomised to LGG-BB12 also had a similar risk of UTI as those not on LGG-BB12 (HR 1.29; 95% CI: 0.74–2.25; P = 0.37). Multivariable post hoc survival analysis for RC14-GR1 only vs. the other three groups showed a potential protective effect (HR 0.46; 95% CI: 0.21–0.99; P = 0.03), but this result would need to be confirmed before clinical application. Conclusion: In this RCT, there was no effect of RC14-GR1 or LGG-BB12 in preventing UTI in people with SCI. Published version National Health and Medical Research Council (NHMRC) is the organisation responsible for funding the supply of probiotics and matching placebo selected by the researchers for this study and budgeted within the NHMRC grant. CHR Hansen, Horsholm, Denmark has been paid commercial rates for providing the intervention product and placebo. The company had no input into the design of the trial.

Prospective cohort study. For acute traumatic spinal cord injury (ATSCI), this study aimed to determine differences in outcomes between patient groups stratified by admission time (⩽24 vs >24 h) to the Spinal Injury Unit (SIU) and by the nature of the admission (direct admission to the SIU vs indirect admission via another hospital). We also aimed to measure the effect on time to admission of a ‘non-refusal’ policy that triggered immediate acceptance of ATSCI cases to the SIU. New South Wales, Australia. Study population was all adult SCI patients admitted to the Prince of Wales SIU from 1 January 2001 to 31 December 2012. Patients admitted with chronic-stage SCI or with incomplete data for the duration of their stay were excluded. Comparison of outcomes was made between groups according to the setting of admission. Time to admission before and after initiation (2009) of the ‘non-refusal’ policy was compared. The prevalence of complications, lengths of stay (LOSs) and time to admission were compared by Mann–Whitney non-parametric methods. Count modelling was used to control for confounders of age and gender. A total of 460 cases were identified and 76 were excluded. The early group had fewer pressure areas (41.8% vs 63.2%; P

Literature review. Globally map key paediatric spinal cord damage epidemiological measures and provide a framework for an ongoing repository of data. Worldwide, initiative of ISCoS Prevention Committee. Literature search of Medline (1946–March 2017) and Embase (1974–March 2017). Relevant articles in any language regarding children with spinal cord damage included. Stratification of data quality into Green/Yellow /Red ‘zones’ facilitated comparison between countries. A total of 862 abstracts were reviewed and data from 25 articles were included from 14 countries in 6 of the 21 Global Regions. Fourteen studies involved paediatric traumatic spinal cord injury (SCI) and seven were regarding non-traumatic spinal cord dysfunction (SCDys). An additional four articles provided both paediatric SCI and SCDys data. The median SCI incidence rates in Global Regions were: Asia, East 5.4/million population/year; Australasia 9.9/million population/year; Western Europe 3.3/million population/year and North America, High Income 13.2 million population/year. The median SCDys incidence rates in Global Regions were: Australasia 6.5/million population/year; Western Europe 6.2/million population/year and North America, High Income 2.1/million population/year. SCI was mostly due to land transport (46–74%), falls (12–35%) and sport/recreation (10–25%) and SCDys was mostly caused by tumours (30–63%) and inflammatory/autoimmune causes (28–35%). There is a scarcity of quality epidemiology studies of paediatric SCD regarding incidence, prevalence, aetiology and survival. Recent ISCoS frameworks provide guidance for researchers to use established classification of SCDys and age group cut-off levels in future studies, thereby improving the ability to compare and combine data.

Background Neuropathic or neurogenic bladder describes a process of dysfunctional voiding as the result of injury in the brain, spinal cord or nerves innervating the bladder. People with neuropathic bladder, such as from spinal cord injury (SCI), are at significant risk of morbidity from urinary tract infections (UTI). Effective methods to prevent UTI in people with SCI have been sought for many years. Probiotics (micro-organisms that exert beneficial health effects in the host) have been recommended for bacterial interference of the urological tract to reduce colonisation by uropathogen and to manage the dual problems of infection and antibiotic resistance. Objectives This review looked at the benefits and harms of probiotics in preventing symptomatic UTI in people with neuropathic bladder compared with placebo, no therapy, or non-antibiotic prophylaxis (cranberry juice, methenamine hippurate, topical oestrogen). Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 10 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs), quasi-RCTs and cross-over RCTs looking at the use of probiotics for the prophylaxis of UTI in people with neuropathic bladders was considered for inclusion. Men, women and children of all ages with neuropathic bladders from neurological injury such as suprapontine, supra sacral and sacral aetiologies was included. All bladder management types, including reflex voiding, time voiding, indwelling and intermittent catheterization were eligible for this review. Studies comparing probiotics to placebo, no treatment or other non-antibiotic prophylaxis was included. Studies comparing probiotics with antibiotics or in combination with antibiotics were excluded. Data collection and analysis Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI were planned for continuous outcomes. Main results This review includes a total of three studies (one cross-over and two parallel RCTs) which involved 110 participants. All three studies looked at intravesical instillation of a low virulent Escherichia coli (E. coli) strain in reducing the risk of symptomatic UTI in participants with neuropathic bladder, predominantly from SCI. Two studies used the E. coli 83972 strain and one study used the E. coli HU2117 strain. We did not find any RCTs involving other probiotics or other routes of administration for preventing UTI in people with neuropathic bladder. There was consistency in definition of symptomatic UTI in all three studies. Symptoms that all studies considered were relevant to diagnose UTI were adequately defined. All three studies defined microbiological diagnosis of symptomatic UTI. Asymptomatic bacteriuria was not considered an outcome measure in any of the included studies; however it was defined in two studies to establish successful inoculation. It is uncertain if the risk of symptomatic UTI is reduced with bladder inoculation using E. coli because the certainty of the evidence is very low (3 studies, 110 participants: RR 0.32, 95% CI 0.08 to 1.19; I2 = 82%). Two studies reported adverse events. One study reported one episode of autonomic dysreflexia. One study reported three symptomatic UTI occurring in two patients, and two studies mentioned the absence of septicaemia and pyelonephritis. Intravesical instillation was reported as "generally safe". One study reported high attrition rates in participants due to the need to adhere to strict instillation protocols. The overall quality of the studies was poor. All three studies had high risk of attrition bias due to failure of an intention-to-treat analysis which undermines the randomisation process and weakened the results of the studies. All three studies also had high risk of reporting bias. Authors' conclusions In this review, there were no studies identified addressing oral probiotics in preventing UTI in people with neuropathic bladder. It is uncertain if the risk of symptomatic UTI is reduced in people with neuropathic bladders via intravesical instillation of non-pathogenic E. coli as data were derived from small studies with high risk of bias. Although very minimal levels of harm was reported with this procedure, due to variable success rates, the need for strict adherence to instillation protocols together with high attrition rates in these studies, it is doubtful bladder instillation will be a widely accepted intervention in its current form. It is recommended that further appropriately powered RCTs with more robust methodological reporting be carried out.

BACKGROUND AND PURPOSE: The development of syringomyelia has been associated with changes in CSF flow dynamics in the spinal subarachnoid space. However, differences in CSF flow velocity between patients with posttraumatic syringomyelia and healthy participants remains unclear. The aim of this work was to define differences in CSF flow above and below a syrinx in participants with posttraumatic syringomyelia and compare the CSF flow with that in healthy controls. MATERIALS AND METHODS: Six participants with posttraumatic syringomyelia were recruited for this study. Phase-contrast MR imaging was used to measure CSF flow velocity at the base of the skull and above and below the syrinx. Velocity magnitudes and temporal features of the CSF velocity profile were compared with those in healthy controls. RESULTS: CSF flow velocity in the spinal subarachnoid space of participants with syringomyelia was similar at different locations despite differences in syrinx size and locations. Peak cranial and caudal velocities above and below the syrinx were not significantly different (peak cranial velocity, P = .9; peak caudal velocity, P = 1.0), but the peak velocities were significantly lower (P < .001, P = .007) in the participants with syringomyelia compared with matched controls. Most notably, the duration of caudal flow was significantly shorter (P = .003) in the participants with syringomyelia. CONCLUSIONS: CSF flow within the posttraumatic syringomyelia group was relatively uniform along the spinal canal, but there are differences in the timing of CSF flow compared with that in matched healthy controls. This finding supports the hypothesis that syrinx development may be associated with temporal changes in spinal CSF flow.

© 2017 Bossa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The use of long-term catheterisation to manage insensate bladders, often associated with spinal cord injury (SCI), increases the risk of microbial colonisation and infection of the urinary tract. Urinary tract infection (UTI) is typically diagnosed and treated based on the culturing of organisms from the urine, although this approach overlooks low titer, slow growing and non-traditional pathogens. Here, we present an investigation of the urinary tract microbiome in catheterised SCI individuals, using T-RFLP and metagenomic sequencing of the microbial community. We monitored three neurogenic patients over a period of 12 months, who were part of a larger study investigating the efficacy of probiotics in controlling UTIs, to determine how their urinary tract microbial community composition changed over time and in relation to probiotic treatment regimens. Bacterial biofilms adherent to urinary catheters were examined as a proxy for bladder microbes. The microbial community composition of the urinary tract differed significantly between individuals. Probiotic therapy resulted in a significant change in the microbial community associated with the catheters. The community also changed as a consequence of UTI and this shift in community composition preceded the clinical diagnosis of infection. Changes in the microbiota due to probiotic treatment or infection were transient, resolving to microbial communities similar to their pre-treatment communities, suggesting that the native community was highly resilient. Based on these results, we propose that monitoring a patient’s microbial community can be used to track the health of chronically catheterized patients and thus, can be used as part of a health-status monitoring program.

Background. Surface electrical stimulation of the abdominal muscles, with electrodes placed in the posterolateral position, combined with a voluntary cough can assist clearance of airway secretions in individuals with high-level spinal cord injury (SCI). Objective. To determine whether an increase in stimulus intensity of the trains of electrical stimuli delivered to the expiratory muscles has an increasing effect on a stimulated voluntary cough and to determine at which stimulus intensity a plateau of cough peak expiratory flow occurs. Methods. In 7 healthy individuals with a SCI at and above C7, gastric pressure ( Pga), esophageal pressure ( Pes), peak expiratory cough flow (PEFcough), and expiratory volume were measured as participants coughed voluntarily with simultaneous trains of electrical stimuli delivered over the abdominal muscles (50 Hz, 1-s duration). The intensity of the stimulation was increased incrementally. Results: A plateau in PEFcough occurred in all 7 individuals at a mean of 211 ± 29 mA (range 120-360 mA). Peak values reached for Pga, Pes, and PEFcough were 83.0 ± 8.0 cm H2O, 66.1 ± 5.6 cm H2O, and 4.0 ± 0.4 l/s respectively. Conclusions. The plateau in expiratory cough flow that was associated with increasing expiratory pressures is indicative of dynamic airway compression. This suggests that the evoked cough will be effective in creating more turbulent airflow to further assist in dislodging mucus and secretions.

Study design:Population modelling-forecasting. OBJECTIVES:To estimate the global incidence of traumatic spinal cord injury (TSCI).Setting:An initiative of the International Spinal Cord Society (ISCoS) Prevention Committee. METHODS:Regression techniques were used to derive regional and global estimates of TSCI incidence. Using the findings of 31 published studies, a regression model was fitted using a known number of TSCI cases as the dependent variable and the population at risk as the single independent variable. In the process of deriving TSCI incidence, an alternative TSCI model was specified in an attempt to arrive at an optimal way of estimating the global incidence of TSCI. RESULTS:The global incidence of TSCI was estimated to be 23 cases per 1 000 000 persons in 2007 (179 312 cases per annum). World Health Organization's regional results are provided. DISCUSSION:Understanding the incidence of TSCI is important for health service planning and for the determination of injury prevention priorities. In the absence of high-quality epidemiological studies of TSCI in each country, the estimation of TSCI obtained through population modelling can be used to overcome known deficits in global spinal cord injury (SCI) data. The incidence of TSCI is context specific, and an alternative regression model demonstrated how TSCI incidence estimates could be improved with additional data. The results highlight the need for data standardisation and comprehensive reporting of national level TSCI data. A step-wise approach from the collation of conventional epidemiological data through to population modelling is suggested.Spinal Cord advance online publication, 10 December 2013; doi:10.1038/sc.2013.135. Language: en

Background. Respiratory complications in people with high-level spinal cord injury (SCI) are a major cause of morbidity and mortality, particularly because of a reduced ability to cough as a result of abdominal muscle paralysis. Objective. We investigated the effect of cough training combined with functional electrical stimulation (FES) over the abdominal muscles for 6 weeks to observe whether training could improve cough strength. Methods. Fifteen SCI subjects (C4-T5) trained for 6 weeks, 5 days per week (5 sets of 10 coughs per day) in a randomized crossover design study. Subjects coughed voluntarily at the same time as a train of electrical stimulation was delivered over the abdominal muscles via posterolaterally positioned electrodes (50 Hz, 3 seconds). Measurements were made of esophageal (Pes) and gastric (Pga) expiratory pressures and the peak expiratory flow (PEFcough) produced at the 3 time points of before, during, and after the training. Results. During voluntary coughs, FES cough stimulation improved Pga, Pes, and PEFcough acutely, 20-fold, 4-fold, and 50%, respectively. Six weeks of cough training significantly increased Pga (37.1 ± 2.0 to 46.5 ± 2.9 cm H2O), Pes (35.4 ± 2.7 to 48.1 ± 2.9 cm H2O), and PEFcough (3.1 ± 0.1 to 3.6 ± 0.1 L/s). Cough training also improved pressures and flow during voluntary unstimulated coughs. Conclusions. FES of abdominal muscles acutely increases mechanical output in coughing in high-level SCI subjects. Six weeks of cough training further increases gastric and esophageal cough pressures and expiratory cough flow during stimulated cough maneuvers.

Study design: Literature review.Objectives:To map traumatic spinal cord injury (TSCI) globally and provide a framework for an ongoing repository of data for prevention. Setting: An initiative of the ISCoS Prevention Committee. Methods: The results obtained from the search of Medline/Embase using search phrases: TSCI incidence, aetiology, prevalence and survival were analysed. Stratification of data into green/yellow/red quality 'zones' allowed comparison between data. Results: Reported global prevalence of TSCI is insufficient (236-1009 per million). Incidence data was comparable only for regions in North America (39 per million), Western Europe (15 per million) and Australia (16 per million). The major cause of TSCI in these regions involves four-wheeled motor vehicles, in contrast to South-east Asia where two-wheeled (and non-standard) road transport predominates. Southern Asia and Oceania have falls from rooftops and trees as the primary cause. High-fall rates are also seen in developed regions with aged populations (Japan/Western Europe). Violence/self-harm (mainly firearm-related) was higher in North America (15%) than either Western Europe (6%) or Australia (2%). Sub-Saharan Africa has the highest reported violence-related TSCI in the world (38%). Rates are also high in north Africa/Middle East (24%) and Latin America (22%). Developed countries have significantly improved TSCI survival compared with developing countries, particularly for tetraplegia. Developing countries have the highest 1-year mortality rates and in some countries in sub-Saharan Africa the occurrence of a spinal injury is likely to be a fatal condition within a year. Conclusion: Missing prevalence and insufficient incidence data is a recurrent feature of this review. The piecemeal approach to epidemiological reporting of TSCI, particularly failing to include sound regional denominators has exhausted its utility. Minimum data collection standards are required.Spinal Cord advance online publication, 23 November 2010; doi:10.1038/sc.2010.146. Language: en

Review the literature on non-pharmacological prevention and treatment of osteoporosis after spinal cord injury (SCI).PubMed, EMBASE and the Cochrane Controlled Trials Register were searched. All identified papers were read by title, abstract and full-length article when relevant. Hand search of the articles' sources identified additional papers. For included studies, the level of evidence was determined.No studies conclusively showed an effective intervention. However, there are few randomized controlled trials (RCTs), and those that exist assess interventions and outcome measures that could be improved. Five studies on weight-bearing early post-injury are conflicting, but standing or walking may help retain bone mineral. In the chronic phase, there was no effect of weight bearing (12 studies). One study found that an early commencement of sports after SCI improved bone mineral, and the longer the period of athletic career, the higher the (leg) bone mineral. Early after SCI, there may be some effects of electrical stimulation (ES) (five studies). Chronic-phase ES studies vary (14 studies, including mixed periods after injury), but improvement is seen with longer period of training, or higher frequency or stimulus intensity. Improvements correspond to trabecular bone in the distal femur or proximal tibia. Impact vibration and pulsed electromagnetic fields may have some positive effects, whereas pulsed ultrasound does not. Six studies on the influence of spasticity show inconsistent results.Bone mineral should be measured around the knee; the length and intensity of the treatment should be sufficiently long and high, respectively, and should commence early after SCI. If bone mineral is to remain, the stimulation has to be possibly continued for long term. In addition, RCTs are necessary.

Retrospective study. To review traumatic spinal cord injury rates and epidemiology at the Riyadh Military Hospital in Saudi Arabia and to hypothesise strategies for a more integrated approach to injury prevention in Saudi Arabia. RMH, Rehabilitation Division. A review was conducted of all patients with TSCI aged ⩾14 years admitted to RMH from January 2003 to December 2008. Descriptive analysis was performed for age, gender, cause of TSCI, completeness and neurological level of the injury. In all, 307 TSCI patients were admitted during this period: 88% were male, and their mean age was 29.5 years old were the main cause of TSCI (85%). TSCI in Saudi Arabia affects mainly the male population. The rate of RTAs caused by four-wheeled vehicles is the highest globally reported RTA statistic. Primary prevention strategies specific to the region should be developed to decrease the number of car accidents. The higher-than-expected rate of complete injuries may reflect practices in acute management and transport, and suggests that a review of the acute and integrated management of TSCI may also be necessary.

Respiratory complications following cervical spinal cord injury are common and are the leading cause of morbidity and mortality after this type of injury. Impaired mechanics of ventilation, poor cough, increased secretions and bronchospasm predispose to atelectasis, pneumonia and exacerbations of respiratory failure. Prolonged mechanical ventilation and tracheostomy are often required. This review discusses the relevant pathophysiology, various ventilatory strategies and timing of tracheostomy, and examines the evidence surrounding physiotherapeutic and pharmacological treatment options.

Study design:Literature review.Objectives:Update the global maps for traumatic spinal cord injury (TSCI) and incorporate methods for extrapolating incidence data.Setting:An initiative of the International Spinal Cord Society (ISCoS) Prevention Committee.Methods:A search of Medline/Embase was performed (1959-Jun/30/2011). Enhancement of data-quality 'zones' including individual data-ranking as well as integrating regression techniques to provide a platform for continued regional and global estimates.Results:A global-incident rate (2007) is estimated at 23 TSCI cases per million (179 312 cases per annum). Regional data are available from North America (40 per million), Western Europe (16 per million) and Australia (15 per million). Extrapolated regional data are available for Asia-Central (25 per million), Asia-South (21 per million), Caribbean (19 per million), Latin America, Andean (19 per million), Latin America, Central (24 per million), Latin America-Southern (25 per million), Sub-Saharan Africa-Central (29 per million), Sub-Saharan Africa-East (21 per million).Discussion:It is estimated that globally in 2007, there would have been between 133 and 226 thousand incident cases of TSCI from accidents and violence. The proportion of TSCI from land transport is decreasing/stable in developed but increasing in developing countries due to trends in transport mode (transition to motorised transport), poor infrastructure and regulatory challenges. TSCIs from low falls in the elderly are increasing in developed countries with ageing populations. In some developing countries low falls, resulting in TSCI occur while carrying heavy loads on the head in young people. In developing countries high-falls feature, commonly from trees, balconies, flat roofs and construction sites. TSCI is also due to crush-injuries, diving and violence.Conclusion:The online global maps now inform an extrapolative statistical model, which estimates incidence for areas with insufficient TSCI data. The accuracy of this methodology will be improved through the use of prospective, standardised-data registries.Spinal Cord advance online publication, 26 February 2013; doi:10.1038/sc.2012.158. Language: en

Background. Spinal cord injury (SCI) patients have respiratory complications because of abdominal muscle weakness and paralysis, which impair the ability to cough. Objective. This study aims to enhance cough in high-level SCI subjects (n = 11, SCI at or above T6) using surface electrical stimulation of the abdominal muscles via 2 pairs of posterolaterally placed electrodes. Methods. From total lung capacity, subjects performed maximum expiratory pressure (MEP) efforts against a closed airway and voluntary cough efforts. Both efforts were performed with and without superimposed trains of electrical stimulation (50 Hz, 1 second) at a submaximal intensity set to evoke a gastric pressure ( Pga) of 40 cm H2O at functional residual capacity. Results. In the MEP effort, stimulation increased the maximal Pga (from 21.4 ± 7.0 to 59.0 ± 5.7 cm H2O) and esophageal pressure ( Pes; 47.2 ± 11.7 to 65.6 ± 13.6 cm H2O). During the cough efforts, stimulation increased Pga (19.5 ± 6.0 to 57.9 ± 7.0 cm H2O) and Pes (31.2 ± 8.7 to 56.6 ± 10.5 cm H2O). The increased expiratory pressures during cough efforts with stimulation increased peak expiratory flow (PEF, by 36% ± 5%), mean expiratory flow (by 80% ± 8%), and expired lung volume (by 41% ± 16%). In every subject, superimposed electrical stimulation improved peak expiratory flow during cough efforts (by 0.99 ± 0.12 L/s; range, 0.41-1.80 L/s). Wearing an abdominal binder did not improve stimulated cough flows or pressures. Conclusions. The increases in Pga and PEF with electrical stimulation using the novel posterolateral electrode placement are 2 to 3 times greater than improvements reported in other studies. This suggests that posterolateral electrical stimulation of abdominal muscles is a simple noninvasive way to enhance cough in individuals with SCI.

Objective To determine whether the provision of single lens distance glasses to older wearers of multifocal glasses reduces falls. Design Parallel randomised controlled trial stratified by recruitment site and source of referral, with 13 months’ follow-up and outcome assessors blinded to group allocation. Setting Community recruitment and treatment room assessments in Sydney and Illawarra regions of NSW, Australia. Participants 606 regular wearers of multifocal glasses (mean age 80 (SD 7) years). Inclusion criteria included increased risk of falls (fall in previous year or timed up and go test >15 seconds) and outdoor use of multifocal glasses at least three times a week. Interventions Provision of single lens distance glasses with recommendations for wearing them for walking and outdoor activities compared with usual care. Main outcome measures Number of falls and injuries resulting from falls during follow-up. Results Single lens glasses were provided to 275 (90%) of the 305 intervention group participants within two months; 162 (54%) of the intervention group reported satisfactory use of distance glasses for walking and outdoor activities for at least 7/12 months after dispensing. In the 299 intervention and 298 control participants available to follow-up, the intervention resulted in an 8% reduction in falls (incidence rate ratio 0.92, 95% confidence interval 0.73 to 1.16). Pre-planned sub-group analyses showed that the intervention was effective in significantly reducing all falls (incidence rate ratio 0.60, 0.42 to 0.87), outside falls, and injurious falls in people who regularly took part in outside activities. A significant increase in outside falls occurred in people in the intervention group who took part in little outside activity. Conclusions With appropriate counselling, provision of single lens glasses for older wearers of multifocal glasses who take part in regular outdoor activities is an effective falls prevention strategy. The intervention may be harmful, however, in multifocal glasses wearers with low levels of outdoor activity. Trial registration Clinical trials NCT00350855.

An end-user response survey and assessments of inter-rater reliability before and after training. Evaluate the spinal cord injury (SCI) application of the international classification of external cause of injury (ICECI) in a mixed group of untrained and trained coders to assess agreement, refine coding and training methodology. An interactive coding workshop for an international group of coders with varying previous training. Evaluate content validity (qualitative survey) and inter-rater reliability (kappa estimate of agreement) of the ICECI in a variety of injury scenarios presented within a computerized data-entry and training module. The results of this evaluation are compared with an earlier published gold standard. The ICECI is a flexible data coding system that appears to work with reasonable content validity in the regions assessed with English-language coders. Training appeared to narrow the difference between the inexperienced and trained coders. This is reflected in a borderline tendency for lower kappa scores pre-training compared with an earlier examined group of expert coders (P=0.073) but no difference in kappa scores after training (P=0.67). Computer-based training on a face-to-face level with computerized data entry appears an effective tool for training coders to use the ICECI. This report shows that using electronic data-entry and training assistance, inexperienced coders using the SCI–ICECI computerized system quickly approach the levels of agreement of trained coders in related data systems. The content validity of the training data set is adequate but needs to include more cases representative for use in SCI.

OBJECTIVE: To evaluate the validity and responsiveness of a modified SF-36 within a spinal cord-injured (SCI) population. STUDY DESIGN: SF-36 scores collected at baseline and on completion of a randomized controlled trial in 305 patients with SCI and neuropathic bladder. SETTING: New South Wales, Australia. METHODS: Subjects were administered the standard SF-36 plus three additional questions, in which 'walk' was replaced with 'wheel' for three of the physical function (PF) questions. Discriminant validity was determined by comparing participants with paraplegia and tetraplegia using the effect size (ES). Responsiveness was assessed in the subset of patients who developed a urinary tract infection (UTI) during the trial using the standardized response mean (SRM). RESULTS: Compared with the standard SF-36, the SF-36 walk-wheel modification (SF-36ww) increased the mean PF score from 18 to 39 (P

Central neuropathic pain following lesions within the CNS, such as spinal cord injury, is one of the most excruciating types of chronic pain and one of the most difficult to treat. The role of spinothalamic pathways in this type of pain is not clear. Previous studies suggested that spinothalamic tract lesions are necessary but not sufficient for development of central pain, since deficits of spinothalamic function were equally severe in spinal cord injured people with and without pain. The aim of the present study was to examine spinothalamic tract function by quantitative sensory testing before and after activation and sensitization of small diameter afferents by applying menthol, histamine or capsaicin to the distal skin areas where spontaneous pain was localized. Investigations were performed in matched groups each of 12 patients with and without central pain below the level of a clinically complete spinal cord injury, and in 12 able-bodied controls. To test peripheral C fibre function, axon reflex vasodilations induced by histamine and capsaicin applications were quantified. In eight patients with pain, sensations of the same quality as one of their major individual pain sensations were rekindled by heat stimuli in combination with topical capsaicin (n = 7) or by cold stimuli (n = 1). No sensations were evoked in pain-free patients (P < 0.01). Capsaicin-induced axon reflex vasodilations were significantly larger in pain patients with heat- and capsaicin-evoked sensations in comparison to pain patients without capsaicin-provoked sensations. These results suggest that intact thermosensitive nociceptive afferents within lesioned spinothalamic tract pathways distinguish people with central pain from those without. The ability to mimic chronic pain sensations by activation of thermosensory nociceptive neurons implies that ongoing activity in these residual spinothalamic pathways plays a crucial role in maintaining central pain. We propose that processes associated with degeneration of neighbouring axons within the tract, such as inflammation, may trigger spontaneous activity in residual intact neurons that act as a 'central pain generator' after spinal cord injury.

This chapter explores identity shifts demanded of a multidisciplinary team of clinicians who treat spinal cord injury patients with pressure ulcers in an outpatient’s clinic of an Australian public hospital. Multidisciplinary clinical teams are increasingly part of the hospital organizational landscape (Colombo et al., 2003; Latham et al., 2000; Sherer et al., 2002). This type of teamwork demands of clinicians that they are experts in their own area of ‘content knowledge’, and expects them to be able to communicate across disciplinary boundaries, into other clinicians’ areas of content expertise. In addition, multidisciplinary teams can require a destabilization of established hierarchies in order to communicate effectively across disciplinary boundaries (Cott, 1997; Gair and Hartery, 2001). Both of these shifts, of content knowledge and of hierarchical valuing of particular types of expertise, require clinicians to reconfigure their professional identities.

Corridor consultations are ‘part of the daily discourse of hospital medicine’ (Heard et al., 2003), however, in spite of being ‘an integral part of physicians’ medical culture … little is known’ about this widespread and significant mode of clinical communication (Peleg et al., 1999, p. 241), and corridor communications ‘are often discussed as if they were of little formal value’ (Downey et al., 1997, p. 245). Communication modes in hospitals have been extensively studied: medical records, handovers, ward rounds, case management meetings, organizational meetings and doctor–patient communication (Iedema, 2005). Corridors, however, have so far been overlooked as a site of study for health communication. And yet mentions of corridor or hallway consultations or conversations are sprinkled throughout the medical literature, and it is evident from this that corridors act as important conduits of clinical information flow. It appears then that in some respects the interactions that take place in corridors are similar to interactions in other spaces. The focus of this chapter, however, is on how corridor conversations differ from other more frequently studied kinds of clinical information exchange, such as case conferences and ward rounds, and to investigate what is typical of interactions that take place in one specific hospital-based clinic’s corridor space.

To determine whether Methenamine Hippurate (MH) or cranberry tablets prevent urinary tract infections (UTI) in people with neuropathic bladder following spinal cord injury (SCI). Double-blind factorial-design randomized controlled trial (RCT) with 2 year recruitment period from November 2000 and 6 month follow-up. In total, 543 eligible predominantly community dwelling patients were invited to participate in the study, of whom 305 (56%) agreed. Eligible participants were people with SCI with neurogenic bladder and stable bladder management. All regimens were indistinguishable in appearance and taste. The dose of MH used was 1 g twice-daily. The dose of cranberry used was 800 mg twice-daily. The main outcome measure was the time to occurrence of a symptomatic UTI. Multivariate analysis revealed that patients randomized to MH did not have a significantly longer UTI-free period compared to placebo (HR 0.96, 95% CI: 0.68–1.35, P=0.75). Patients randomized to cranberry likewise did not have significantly longer UTI-free period compared to placebo (HR 0.93, 95% CI: 0.67–1.31, P=0.70). There is no benefit in the prevention of UTI from the addition of MH or cranberry tablets to the usual regimen of patients with neuropathic bladder following SCI.

Haran MJ, Lee BB, King MT, Marial O, Stockler MR. Health status rated with the Medical Outcomes Study 36-Item Short-Form Health Survey after spinal cord injury. Objective To describe the health status of Australians with spinal cord injury (SCI). Design Survey. Setting Australian population-based sample. Participants Participants (N=305) with SCI at recruitment to a randomized trial. Interventions Not applicable. Main Outcome Measure Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) health questionnaire. Results Compared with the general population, our sample reported significantly lower scores in 6 SF-36 domains (physical function, role–physical, bodily pain, general health, social function, vitality) and the physical component summary (PCS) score, but unexpectedly higher mental component summary (MCS) scores (difference in mean MCS scores, 4.6; 95% confidence interval [CI], 2.4–6.8). Compared with people with tetraplegia, those with paraplegia had better physical function and PCS scores (difference, 21; 95% CI, 17–24; difference, 3; 95% CI, 1–5, respectively), and worse bodily pain scores (difference, 9; 95% CI, 2–15). Recent urinary infections were associated with worse general health, vitality, mental health, and MCS scores. Receiving family or external physical care was associated with worse physical function and PCS scores, but better mental health and MCS scores. Older age at injury was associated with lower bodily pain and PCS scores. Conclusions Using the SF-36, Australians with SCI rate their physical (not mental) health status as worse than the general population.

Reason for withdrawal from publication This review has been withdrawn because it is substantially out-of-date and the lead author is unavailable to update it. To view the published versions of this article, please click the 'Other versions' tab.

Background Quadriplegia is a severe, catastrophic injury that predominantly affects people early in life, resulting in lifelong physical disability. Obstructive sleep apnoea is a direct consequence of quadriplegia and is associated with neurocognitive deficits, sleepiness and reduced quality of life. The usual treatment for sleep apnoea is nasal continuous positive airway pressure (CPAP); however, this is poorly tolerated in quadriplegia. To encourage patients to use this therapy, we have to demonstrate that the benefits outweigh the inconvenience. We therefore propose a prospective, multinational randomized controlled trial of three months of CPAP for obstructive sleep apnoea after acute quadriplegia. Methods/design Specialist spinal cord injury centres across Australia, New Zealand, the UK and Canada will recruit medically stable individuals who have sustained a (new) traumatic quadriplegia (complete or incomplete second cervical to first thoracic level lesions). Participants will be screened for obstructive sleep apnoea using full, portable sleep studies. Those with an apnoea hypopnoea index greater than 10 per hour will proceed to an initial three-night trial of CPAP. Those who can tolerate CPAP for at least 4 hours on at least one night of the initial trial will be randomized to either usual care or a 3-month period of auto-titrating CPAP. The primary hypothesis is that nocturnal CPAP will improve neuropsychological functioning more than usual care alone. The secondary hypothesis is that the magnitude of improvement of neuropsychological function will be predicted by the severity of baseline sleepiness measures, sleep fragmentation and sleep apnoea. Neuropsychological tests and full polysomnography will be performed at baseline and 3 months with interim measures of sleepiness and symptoms of autonomic dysfunction measured weekly. Spirometry will be performed monthly. Neuropsychological tests will be administered by blinded assessors. Recruitment commenced in July 2009. Discussion The results of this trial will demonstrate the effect of nocturnal CPAP treatment of obstructive sleep apnoea in acute quadriplegia. If CPAP can improve neurocognitive function after injury, it is likely that rehabilitation and subsequent community participation will be substantially improved for this group of predominantly young and severely physically disabled people. Trial registration Australian New Zealand Clinical Trial Registry ACTRN12605000799651

Background Recent research has shown that wearing multifocal glasses increases the risk of trips and falls in older people. The aim of this study is to determine whether the provision of single-lens distance glasses to older multifocal glasses wearers, with recommendations for wearing them for walking and outdoor activities, can prevent falls. We will also measure the effect of the intervention on health status, lifestyle activities and fear of falling, as well as the extent of adherence to the program. Methods/Design Approximately 580 older people who are regular wearers of multifocal glasses people will be recruited. Participants will be randomly allocated to either an intervention group (provision of single lens glasses, with counselling and advice about appropriate use) or a control group (usual care). The primary outcome measure will be falls (measured with 13 monthly calendars). Secondary measures will be quality of life, falls efficacy, physical activity levels and adverse events. Discussions The study will determine the impact of providing single-lens glasses, with advice about appropriate use, on preventing falls in older regular wearers of multifocal glasses. This pragmatic intervention, if found to be effective, will guide practitioners with regard to recommending appropriate glasses for minimising the risk of falls in older people. Trial Registration The protocol for this study was registered with the Clinical Trials.gov Protocol Registration System on June 7th 2006 (#350855).

Objective To determine the feasibility, acceptability, discriminative validity, responsiveness, and minimal important difference (MID) of the SF-6D for people with spinal cord injury (SCI). Methods A total of 305 people with SCI completed the SF-36 health status questionnaire at baseline and at subsequent occurrence of a urinary tract infection (UTI) or 6-month follow-up. Normative SF-36 data were obtained from the Australian Bureau of Statistics. SF-36 scores were transformed to SF-6D utility values using Brazier's algorithm. We used UTI as the external criterion of clinically important change to determine responsiveness and two categories of the SF-36 transition question (“somewhat worse” and “somewhat better”) as the external criterion to determine the MID. Derived SF-12 responsiveness was also assessed. Results The mean SF-6D values were: 0.68 (SD 0.21, n = 305) all patients; 0.66 (SD 0.19, n = 167) tetraplegia; 0.72 (SD 0.26, n = 138) paraplegia; 0.57 (SD 0.15, n = 138) with UTI. The Australian normative SF-6D mean value was 0.80 (SD 0.14, n = 18,005). The SF-6D was able to discriminate between SCI and the Australian normative sample (effect size [ES] = 0.86), tetraplegia–paraplegia (ES = 0.23), and it was responsive to UTI (ES = 0.86 SF-36 variant, ES = 0.92 SF-12 variant). The MID for respondents who reported being somewhat worse or somewhat better at follow-up was 0.03 (SD 0.17, n = 108/305), while the MID for only those who were somewhat worse was 0.10 (SD 0.14, n = 58). Conclusions The content of the SF-6D is more appropriate than that of the SF-36 for this physically impaired population. The SF-6D has discriminative power and is responsive to clinically important change because of UTI. The MID is consistent with published estimates for other disease groups.

Background Urinary tract infections [UTIs] are very common in people with Spinal Cord Injury [SCI]. UTIs are increasingly difficult and expensive to treat as the organisms that cause them become more antibiotic resistant. Among the SCI population, there is a high rate of multi-resistant organism [MRO] colonisation. Non-antibiotic prevention strategies are needed to prevent UTI without increasing resistance. Probiotics have been reported to be beneficial in preventing UTIs in post-menopausal women in several in vivo and in vitro studies. The main aim of this study is to determine whether probiotic therapy with combinations of Lactobacillus reuteri RC-14 + Lactobacillus rhamnosus GR-1 [RC14-GR1] and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 [LGG-BB12] are effective in preventing UTI in people with SCI compared to placebo. Method This is a multi-site randomised double-blind double-dummy placebo-controlled factorial design study conducted in New South Wales, Australia. All participants have a neurogenic bladder as a result of spinal injury. Recruitment started in April 2011. Participants are randomised to one of four arms, designed for factorial analysis of LGG-BB12 and/or RC14-GR1 v Placebo. This involves 24 weeks of daily oral treatment with RC14-GR1 + LGG-BB12, RC14-GR1 + placebo, LGG-BB12 + placebo or two placebo capsules. Randomisation is stratified by bladder management type and inpatient status. Participants are assessed at baseline, three months and six months for Short Form Health Survey [SF-36], microbiological swabs of rectum, nose and groin; urine culture and urinary catheters for subjects with indwelling catheters. A bowel questionnaire is administered at baseline and three months to assess effect of probiotics on bowel function. The primary outcome is time from randomisation to occurrence of symptomatic UTI. The secondary outcomes are change of MRO status and bowel function, quality of life and cost-effectiveness of probiotics in persons with SCI. The primary outcome will be analysed using survival analysis of factorial groups, with Cox regression modelling to test the effect of each treatment while allowing for the other, assuming no interaction effect. Hazard ratios and Kaplan-Meier survival curves will be used to summarise results. Discussion If these probiotics are shown to be effective in preventing UTI and MRO colonisation, they would be a very attractive alternative for UTI prophylaxis and for combating the increasing rate of antibiotic resistance after SCI. Trial registration Australian New Zealand Clinical Trials Registry [ACTRN 12610000512022]. Date of registration: 21 June 2010. Electronic supplementary material The online version of this article (doi:10.1186/s12894-016-0136-8) contains supplementary material, which is available to authorized users.

Background Methenamine salts are often used as an alternative to antibiotics for the prevention of urinary tract infection (UTI). This review was first published in Issue 1, 2002 and updated in Issue 4, 2007. Objectives To assess the benefits and harms of methenamine hippurate in preventing UTI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), MEDLINE (from 1950), EMBASE (from 1980), reference lists of articles and abstracts from conference proceedings without language restriction. Manufacturers' of methenamine salts were contacted for unpublished studies and contact was made with known investigators. Date of last search: June 2012 Selection criteria Randomised controlled trials (RCT) and quasi-RCTs of methenamine hippurate used for the prevention of UTIs in all population groups were eligible. A comparison with a control/no treatment group was a prerequisite for selection. Data collection and analysis Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CI). An exploration of heterogeneity and a detailed description of results, grouped by population, was undertaken. Main results Thirteen studies (2032 participants) were included. Six studies (654 patients) reported symptomatic UTI and eight studies (796 patients) reported bacteriuria. Overall, study quality was mixed. The overall pooled estimates for the major outcome measures were not interpretable because of underlying heterogeneity. Subgroup analyses suggested that methenamine hippurate may have some benefit in patients without renal tract abnormalities (symptomatic UTI: RR 0.24, 95% CI 0.07 to 0.89; bacteriuria: RR 0.56, 95% CI 0.37 to 0.83), but not in patients with known renal tract abnormalities (symptomatic UTI: RR 1.54, 95% CI 0.38 to 6.20; bacteriuria: RR 1.29, 95% CI 0.54 to 3.07). For short-term treatment duration (1 week or less) there was a significant reduction in symptomatic UTI in those without renal tract abnormalities (RR 0.14, 95% CI 0.05 to 0.38). The rate of adverse events was low. Authors' conclusions Methenamine hippurate may be effective for preventing UTI in patients without renal tract abnormalities, particularly when used for short-term prophylaxis. It does not appear to work in patients with neuropathic bladder or in patients who have renal tract abnormalities. The rate of adverse events was low, but poorly described. There is a need for further large well-conducted RCTs to clarify this question, particularly for longer term use for people without neuropathic bladder.

Background Heterotopic ossification (HO) is the formation of mature lamellar bone in soft tissue sites outside the skeleton. HO frequently complicates burns, arthroplasty, fractures, and spinal cord and brain injuries. It can impair joint function. Objectives To determine the efficacy of medications to treat acute HO on radiological, symptomatic, functional impairment, and disability outcomes. Search strategy We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2004), MEDLINE (1966 to August 2004), EMBASE (1980 to August 2004), CINAHL (1982 to August 2004), other databases, reference lists of articles, and contacted trialists and drug companies. No language restrictions were applied. Selection criteria All randomised or quasi-randomised controlled trials that assessed the efficacy of any medication for treating acute HO (confirmed by bone scintigraphy, radiography, ultrasonography, or biopsy) and which used radiography to grade post-treatment HO severity. Data collection and analysis Two reviewers independently assessed the study quality and extracted data. We analysed two dichotomous outcomes: no progression in HO grade (versus progression) and improvement in HO grade (versus no improvement). Main results Two randomised trials comparing disodium etidronate versus placebo were included (Ono 1988; Stover 1976), from which ninety-two participants with spinal cord injury had radiographically-proven HO at baseline. At the completion of the 12 week intervention, the Ono study but not the Stover study, suggested that disodium etidronate was associated with a significantly greater likelihood of successfully preventing the progression of radiographic HO grade, (relative risk (RR) 1.50; 95% confidence interval (CI) I 1.16 to 1.93; and RR 1.48; 95% CI 0.78 to 2.84 respectively) and a significantly greater likelihood of improvement in HO grade (RR 2.78; 95% CI 1.66 to 4.66; and RR 0.71; 95% CI 0.20 to 2.53 respectively). There was evidence of statistical heterogeneity for the latter outcome. Longer term radiographic, clinical or side effect outcomes were unavailable. Data was not pooled due to this heterogeneity and the inadequate duration of follow up. Authors' conclusions Given the absence of long term radiographic outcomes in the included studies, there is insufficient evidence to recommend the use of disodium etidronate or other pharmacological agents for the treatment of acute HO. It has been previously suggested that disodium etidronate acts by delaying, rather than preventing, the mineralization of HO, and that mineralization may occur after treatment cessation in many cases, thereby negating the benefit of disodium etidronate on eventual HO grade. Further studies are required to assess all pharmacological treatments for acute HO with sufficient follow-up duration.