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Study Design: Single centre training study., Objectives: To investigate, in a group of people with spinal cord injury (SCI), the effect of transcutaneous functional electrical stimulation of the abdominal muscles (abdominal FES) during cough training on blood pressure (BP), and how it is affected by injury characteristics and alters over time., Setting: Laboratory and community., Methods: Sixteen participants with SCI (C4-T5) underwent 25 of abdominal FES cough training (5 sets of 10 stimulated coughs) over 6 weeks as part of a previously published study on the effect of abdominal FES training on cough. Systolic BP (SBP), diastolic BP (DBP) and calculated mean arterial pressure (MAP) were measured at the completion of each set., Results: Abdominal FES coughing resulted in an average ~30% acute increase in BP from initial resting BP across all sessions in almost all participants (p < 0.001). However, the increase in BP during abdominal FES coughs from rest reduced over the 25 sessions of training by ~35% for SBP, MAP and DBP (p = 0.024, p = 0.013 and p = 0.042, respectively). There was no meaningful change in resting BP over time (p = 0.935, p = 0.705 and p = 0.988, respectively). Overall, increases in BP during abdominal FES coughs were greatest for those with chronic injuries and cervical injuries., Conclusions: Transcutaneous abdominal FES during cough training acutely increases BP. However, the magnitude of the increase is reduced after 25 sessions of training. Abdominal FES may offer a solution to combat orthostatic hypotension, but its effectiveness may diminish over time., Competing Interests: Competing interests: The authors declare no competing interests. Ethics: The study upheld the Declaration of Helsinki and was authorised by the Prince of Wales Hospital Human Research Ethics Committee, Australia (2011 HREC ref. 05/008). Written informed consent was obtained from all participants prior to commencement of the study protocol., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Study Design: Natural experiment OBJECTIVES: To determine whether COVID-19 restrictions were associated with changes in the incidence of traumatic spinal cord injury (TSCI) in Scotland., Setting: The Queen Elizabeth National Spinal Injuries Unit (QENSIU), the sole provider of treatment for TSCI in Scotland., Methods: Time series analysis of all admissions for TSCI between 1st January 2015 and 31st August 2022., Results: Over the 8-year study period, 745 patients were admitted to the QENSIU with a TSCI. Interrupted time series analysis showed that level 3 and 4 COVID-19 lockdown restrictions (the most severe levels) were associated with lower incidence of TSCI (RR 0.63, CI% CI 0.47, 0.82, p < 0.001). The associations were stronger in people aged over 45 (additive interaction p = 0.001), males (additive interaction p = 0.01) and non-tetraplegia (additive interaction p = 0.002). The incidence of TSCI due to deliberate self-harm was higher (0.41 versus 0.23 per month) during restrictions., Conclusions: Overall, TSCI incidence reduced in Scotland when lockdowns were implemented, presumably due to lower engagement in risky activities. The increase in TSCI due to deliberate self-harm may reflect increased mental health problems and social isolation and should be anticipated and targeted in future pandemics. The change in incidence during the COVID-19 pandemic may have an economic impact and see a temporary reduction in the burden on health and social care. The results of this study will be useful for resource planning in future pandemics., (© 2023. The Author(s).)

Introduction: Pyogenic spinal infections (PSI) are a rare cause of spinal cord injury (SCI). These most often affect the lumbar spine, followed by the thoracic spine and least commonly the cervical spine, with Staphylococcus aureus being the most common causative organism. Atopic eczema is a dermatological condition which can lead to a breakdown of the skin's natural barrier function, allowing bacterial colonisation and infection. Haematological seeding of bacteria from a distant source of infection, including the skin and soft tissues, is a recognised aetiology of PSI., Case Presentation: We present two patients who sustained a SCI as a result of PSI secondary to infected atopic eczema. Methicillin-sensitive Staphylococcus aureus (MSSA) was identified as the causative organism in both patients. The two patients required prolonged courses of intravenous followed by oral antibiotics. Neurological outcomes varied between the two patients. One patient had incomplete tetraplegia (C3 AIS C), and upon discharge required hoisting from their bed to a power chair, had an indwelling urethral catheter and required bowel care. The other patient had incomplete paraplegia (L3 AIS D), and at discharge was independent with activities of daily living and was mobile with two elbow crutches., Discussion: We believe that the two cases presented here represent the only examples of secondarily infected atopic eczema causing PSI and resultant SCI in the published literature. As SCI is a serious and potentially life-altering complication, medical professionals treating patients with atopic eczema should be aware of this risk., (© 2023. Crown.)

In healthy individuals, loading inspiratory muscles by brief inspiratory occlusion produces a short-latency inhibitory reflex (IR) in the electromyographic (EMG) activity of scalene and diaphragm muscles. This IR may play a protective role to prevent aspiration and airway collapse during sleep. In people with motor and sensory complete cervical spinal cord injury (cSCI), who were able to breathe independently, this IR was predominantly absent. Here, we investigated the reflex response to brief airway occlusion in 16 participants with sensory incomplete cSCI [American spinal injury association impairment scale (AIS) score B or C]. Surface EMG was recorded from scalene muscles and the lateral chest wall (overlying diaphragm). The airway occlusion evoked a small change in mouth pressure resembling a physiological occlusion. The short-latency IR was present in 10 (63%) sensory incomplete cSCI participants; significantly higher than the IR incidence observed in complete cSCI participants in our previous study (14%; P = 0.003). When present, mean IR latency across all muscles was 58 ms (range 29-79 ms), and mean rectified EMG amplitude decreased to 37% preocclusion levels. Participants without an IR had untreated severe obstructive sleep apnea (OSA), in contrast to those with an IR, who had either had no, mild, or treated OSA ( P = 0.002). Insufficient power did not allow statistical comparison between IR presence or absence and participant clinical characteristics. In conclusion, spared sensory connections or intersegmental connections may be necessary to generate the IR. Future studies to establish whether IR presence is related to respiratory morbidity in the tetraplegic population are required. NEW & NOTEWORTHY Individuals with incomplete cSCI were tested for the presence of a short latency reflex inhibition of inspiratory muscles, by brief airway occlusion. The reflex was 4.5 times more prevalent in this group compared with those with complete cSCI and is similar to the incidence in able-bodied people. Participants without this reflex all had untreated severe OSA, in contrast to those with an IR, who either had no, mild, or treated OSA. This work reveals novel differences in the reflex control of inspiratory muscles across the cSCI population.

Research must be well designed, properly conducted and clearly and transparently reported. Our independent medical research institute wanted a simple, generic tool to assess the quality of the research conducted by its researchers, with the goal of identifying areas that could be improved through targeted educational activities. Unfortunately, none was available, thus we devised our own. Here, we report development of the Quality Output Checklist and Content Assessment (QuOCCA), and its application to publications from our institute's scientists. Following consensus meetings and external review by statistical and methodological experts, 11 items were selected for the final version of the QuOCCA: research transparency (items 1-3), research design and analysis (items 4-6) and research reporting practices (items 7-11). Five pairs of raters assessed all 231 articles published in 2017 and 221 in 2018 by researchers at our institute. Overall, the results were similar between years and revealed limited engagement with several recommended practices highlighted in the QuOCCA. These results will be useful to guide educational initiatives and their effectiveness. The QuOCCA is brief and focuses on broadly applicable and relevant concepts to open, high-quality, reproducible and well-reported science. Thus, the QuOCCA could be used by other biomedical institutions and individual researchers to evaluate research publications, assess changes in research practice over time and guide the discussion about high-quality, open science. Given its generic nature, the QuOCCA may also be useful in other research disciplines., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., Competing Interests: Conflicts of Interest The authors declare no conflicts of interest., (© 2022 American Spinal Injury Association.)

Study Design: An international multi-centred, double-blinded, randomised sham-controlled trial (eWALK)., Objective: 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)., Setting: Dedicated SCI research centres in Australia, Spain, USA and Scotland., Methods: 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., Trial Registration: ANZCTR.org.au identifier ACTRN12620001241921., (© 2021. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: Expiratory muscle weakness leads to difficult ventilator weaning. Maintaining their activity with functional electrical stimulation (FES) may improve outcome. We studied feasibility of breath-synchronized expiratory population muscle FES in a mixed ICU population ("Holland study") and pooled data with our previous work ("Australian study") to estimate potential clinical effects in a larger group., Methods: Holland: Patients with a contractile response to FES received active or sham expiratory muscle FES (30 min, twice daily, 5 days/week until weaned). Main endpoints were feasibility (e.g., patient recruitment, treatment compliance, stimulation intensity) and safety. Pooled: Data on respiratory muscle thickness and ventilation duration from the Holland and Australian studies were combined (N = 40) in order to estimate potential effect size. Plasma cytokines (day 0, 3) were analyzed to study the effects of FES on systemic inflammation., Results: Holland: A total of 272 sessions were performed (active/sham: 169/103) in 20 patients (N = active/sham: 10/10) with a total treatment compliance rate of 91.1%. No FES-related serious adverse events were reported. Pooled: On day 3, there was a between-group difference (N = active/sham: 7/12) in total abdominal expiratory muscle thickness favoring the active group [treatment difference (95% confidence interval); 2.25 (0.34, 4.16) mm, P = 0.02] but not on day 5. Plasma cytokine levels indicated that early FES did not induce systemic inflammation. Using a survival analysis approach for the total study population, median ventilation duration and ICU length of stay were 10 versus 52 (P = 0.07), and 12 versus 54 (P = 0.03) days for the active versus sham group. Median ventilation duration of patients that were successfully extubated was 8.5 [5.6-12.2] versus 10.5 [5.3-25.6] days (P = 0.60) for the active (N = 16) versus sham (N = 10) group, and median ICU length of stay was 10.5 [8.0-14.5] versus 14.0 [9.0-19.5] days (P = 0.36) for those active (N = 16) versus sham (N = 8) patients that were extubated and discharged alive from the ICU. During ICU stay, 3/20 patients died in the active group versus 8/20 in the sham group (P = 0.16)., Conclusion: Expiratory muscle FES is feasible in selected ICU patients and might be a promising technique within a respiratory muscle-protective ventilation strategy. The next step is to study the effects on weaning and ventilator liberation outcome., Trial Registration: ClinicalTrials.gov, ID NCT03453944. Registered 05 March 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03453944 .

Background: Chronic constipation is prevalent in people with multiple sclerosis, with current treatments usually only partially effective., Objectives: This study aims to evaluate the efficacy of abdominal functional electrical stimulation to reduce whole gut and colonic transit times and improve bowel and bladder-related quality of life., Methods: A total of 23 people with multiple sclerosis who fulfilled the Rome III criteria for functional constipation applied abdominal functional electrical stimulation for 1 hour per day, 5 days per week, for 6 weeks. Whole gut and colonic transit times and bowel and bladder-related quality of life were measured before and after the intervention period., Results: Whole gut (mean 81.3 (standard deviation 28.7) hours pre vs. 96.1 (standard deviation 53.6) hours post-intervention, P  = 0.160) and colonic transit time (65.1 (31.4) vs. 74.8 (51.1) hours, P  = 0.304) were unchanged following 6 weeks of abdominal functional electrical stimulation. There was a significant improvement in bowel (mean 1.78 (SD: 0.64) pre vs. 1.28 (SD: 0.54) post, P  = 0.001) and bladder (50.6 (26.49) vs. 64.5 (21.92), p  = 0.007) related quality of life after the intervention period., Conclusion: While abdominal functional electrical stimulation did not reduce whole gut and colonic transit times for people with multiple sclerosis, a significant improvement in bowel and bladder-related quality of life was reported., (© The Author(s) 2020.)

The diaphragm is the primary muscle that generates the negative intrathoracic pressure to drive inspiratory airflow. The diaphragm consists of two parts, the costal and crural portions, with different roles during inspiration in animals, particularly when the stimulus to breathe is increased. In this study, the neural drive to the costal and crural portions of the diaphragm was assessed in nine healthy participants [8 male, aged 32 ± 13 yr (mean ± SD)]. Inspiratory electromyographic activity (EMG) was recorded from the costal diaphragm by using an intramuscular electrode and from the crural diaphragm with a multipair gastroesophageal catheter. Participants performed voluntary augmented breaths at 120%, 140%, and 160% of their tidal volume and also underwent progressive hypercapnia to induce involuntary breathing. Irrespective of the task, the increase in crural activity (normalized to quiet breathing) was only ~60% of the increase in costal activity (slope: 0.56 ± 0.30, P < 0.001). The onset and peak timing of EMG activity was similar for the costal and crural diaphragm during quiet breathing. Thus, when stimulated by either a voluntary or involuntary drive to breathe above tidal volume, the neural drive to the diaphragm was greater to the costal than to the crural portion. NEW & NOTEWORTHY Simultaneous electromyographic recordings from the human costal and crural diaphragm during voluntary augmented breathing and involuntary rebreathing show that the increase in inspiratory crural diaphragm activity was ~60% of the increase in costal diaphragm activity. However costal to crural diaphragm activation did not differ between the two tasks. The dissociation in the amplitude of activation of the costal and crural diaphragm becomes apparent only as the drive to breathe increases above tidal breathing.

A premotor potential, or Bereitschaftspotential (BP), is a low-amplitude negativity in the electroencephalographic activity (EEG) of the sensorimotor cortex. It begins ~1 s prior to the onset of inspiration in the averaged EEG. Although normally absent during quiet breathing in healthy, younger people, inspiration-related BPs are present in people with respiratory disease and healthy, older people, indicating a cortical contribution to quiet breathing. People with tetraplegia have weak respiratory muscles and increased neural drive during quiet breathing, indicated by increased inspiratory muscle activity. Therefore, we hypothesized that BPs would be present during quiet breathing in people with tetraplegia. EEG was recorded in 17 people with chronic tetraplegia (14M, 3 female; 22-51 yr; C3-C7, American Spinal Injury Association Impairment Scale A-D; >1 yr postinjury). They had reduced lung function and respiratory muscle weakness [FEV 1 : 54 ± 19% predicted, FVC: 59 ± 22% predicted and MIP: 56 ± 24% predicted (mean ± SD)]. Participants performed quiet breathing and voluntary self-paced sniffs (positive control condition). A minimum of 250 EEG epochs during quiet breathing and 60 epochs during sniffs, time-locked to the onset of inspiration, were averaged to determine the presence of BPs at Cz, FCz, C3, and C4. Fifteen participants (88%) had a BP for the sniffs. Of these 15 participants, only one (7%) had a BP in quiet breathing, a rate similar to that reported during quiet breathing in young able-bodied participants (12%). The findings suggest that, as in young able-bodied people, a cortical contribution to quiet breathing is absent in people with tetraplegia despite higher neural drive. NEW & NOTEWORTHY People with tetraplegia have weak respiratory muscles, increased neural drive during quiet breathing, and a high incidence of sleep-disordered breathing. Using electroencephalographic recordings, we show that inspiratory premotor potentials are absent in people with chronic tetraplegia during quiet breathing. This suggests that cortical activity is not present during resting ventilation in people with tetraplegia who are awake and breathing independently.

Background: Laboratory providers are challenged with the need to deliver improvements in the efficiency and effectiveness of laboratory services. Initiatives have been set to reduce the inappropriate use of tests; however, empirical evidence about the rate and frequency of laboratory tests in hospitals has not been widely available. This study used data linkage techniques to investigate laboratory test use among Australian inpatients., Methods: A retrospective observational study was conducted across 3 metropolitan and 1 rural hospital, all serviced by a single laboratory provider. Data for all admitted inpatients between January 2008 and December 2013 were extracted and linked to determine the proportion of admissions with a laboratory test, number of tests per admission, and time to first test., Results: This study included 521480 admissions. Of these, 83.7% had a pathology test. Newborns and neonates had the lowest percentage of admissions with tests (35.2%), whereas admissions for diseases and disorders of the hepatobiliary system and pancreas had the highest (97.5%). Patients had a median of 12 tests per admission. Patients 80-84 years of age had the highest rate of tests per admission (median, 19; interquartile range, 9-36). Forty-nine percent of patients' first tests occurred within 2 h of admission, increasing to 69.9% within 4 h., Conclusion: The vast majority of patients admitted to hospital received laboratory tests. Higher laboratory testing rates were observed with increasing age. These findings can be used to define and compare laboratory testing among inpatients and help identify sources of variation in laboratory testing., (© 2019 American Association for Clinical Chemistry.)

Background: Bowel and bladder problems affect more than 50% of people with Multiple Sclerosis (MS). These problems have a large impact on quality of life and place a significant burden on health systems., Objectives: This study aimed to ascertain the frequency of bladder and bowel problems in a select Australian MS cohort and to investigate the relationships between level of disability, bladder and bowel problems, and fatigue., Methods: Questionnaires on the nature and severity of MS symptoms were distributed to clients attending an Australian MS centre. Log-binomial regression and multiple linear regression models were used to investigate relationships between disability, fatigue, and bladder and bowel problems., Results and Conclusions: Of 167 questionnaires distributed, 136 were completed. Bladder problems were reported by 87 (74.4%) respondents, whilst 66 (48.9%) experienced functional constipation and 43 (31.9%) faecal incontinence. This frequency in our select Australian MS population is similar to that reported globally. There was a significant correlation between level of disability and: bladder problems (p = 0.015), faecal incontinence (p = 0.001), fatigue (p<0.001) and constipation (p = 0.016, relative risk: 1.16). Further investigation into the causal relationships between various MS symptoms may be beneficial in the development of novel therapeutic strategies for people with MS., Competing Interests: PH and TJ are employees of MS Limited. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay., Methods: Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor., Results: Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group., Conclusions: Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted., Trial Registration: The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.

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., Competing Interests: Conflicts of Interest Dr. McCaughey reports grants and personal fees from Liberate Medical LLC, outside the submitted work. Dr. Butler reports grants from National Health and Medical Research Council during the conduct of the study and grants from National Health and Medical Research Council and Wings for Life outside the submitted work. Dr. Hudson reports grants from the Lung Foundation Australia, grants from Boehringer Ingelheim, during the conduct of the study and grants from Rebecca L. Cooper Foundation, the Lung Foundation Australia, Boehringer Ingelheim, National Health and Medical Research Council (Australia), and University of New South Wales outside the submitted work. The other authors report no conflicts of interest.

Abdominal functional electrical stimulation (abdominal FES) improves respiratory function. Despite this, clinical use remains low, possibly due to lack of agreement on the optimal electrode position. This study aimed to ascertain the optimal electrode position for abdominal FES, assessed by expiratory twitch pressure. Ten able-bodied participants received abdominal FES using electrodes placed: 1) on the posterolateral abdominal wall and at the motor points of 2) the external oblique muscles plus rectus abdominis muscles, and 3) the external obliques alone. Gastric (P ga ) and esophageal (P es ) twitch pressures were measured using a gastroesophageal catheter. Single-stimulation pulses were applied at functional residual capacity during step increments in stimulation current to maximal tolerance or until P ga plateaued. Stimulation applied on the posterolateral abdominal wall led to a 71% and 53% increase in P ga and P es , respectively, compared with stimulation of the external oblique and rectus abdominis muscles ( P < 0.001) and a 95% and 56% increase in P ga and P es , respectively, compared with stimulation of the external oblique muscles alone ( P < 0.001). Stimulation of both the external oblique and rectus abdominis muscles led to an 18.3% decrease in P ga compared with stimulation of only the external oblique muscles ( P = 0.040), with inclusion of the rectus abdominis having no effect on P es ( P = 0.809). Abdominal FES applied on the posterolateral abdominal wall generated the highest expiratory twitch pressures. As expiratory pressure is a good indicator of expiratory muscle strength and, thus, cough efficacy, we recommend this electrode position for all therapeutic applications of abdominal FES. NEW & NOTEWORTHY While abdominal functional electrical stimulation (abdominal FES) can improve respiratory function, clinical use remains low. This is at least partly due to lack of agreement on the optimal electrode position. Therefore, this study aimed to ascertain the optimal electrode position for abdominal FES. We show that electrodes placed on the posterolateral abdominal wall generated the highest expiratory twitch pressures. As such, we recommend this electrode position for all therapeutic applications of abdominal FES.

Purpose: To evaluate how well general practitioners (GPs) manage and respond to laboratory results for patients with diabetes mellitus (DM) and cardiovascular disease (CVD)., Data Sources: MEDLINE, CINAHL, Embase, EBM reviews, ProQuest and Scopus., Study Selection: Peer-reviewed journal articles published between 2000 and 2015 that assessed GPs' management of laboratory results for patients with DM or CVD., Data Extraction: Study design and demographics, laboratory tests and key findings relating to GP management of laboratory results were extracted from studies., Results of Data Synthesis: Thirteen articles were included, comprising seven studies which utilized surveys, four observational studies, one cohort study and one randomized controlled trial. Findings indicate that GPs often overestimate the risk of complications associated with DM and CVD based on laboratory results and have unrealistically high expectations regarding the precision of laboratory tests. Considerable variation existed in the use of repeat testing for diagnostic confirmation and in GPs' identification of the difference between two consecutive results required to indicate a change in patient condition. GPs also often failed to initiate appropriate treatment for patients with DM and CVD based on laboratory results. Feedback to GPs about their test ordering patterns and educational messages on laboratory results improved clinical outcomes., Conclusion: Evidence about how well GPs manage results and its impact on patient outcomes remains weak and inconclusive. This review identified a number of areas where interventions could support GPs to improve the interpretation and management of laboratory test results, including feedback to GPs and educational messages on test result reports., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Objective: To examine the impact of an electronic Results Acknowledgement (eRA) system on emergency physicians' test result management work processes and the time taken to acknowledge microbiology and radiology test results for patients discharged from an Emergency Department (ED)., Methods: The impact of the eRA system was assessed in an Australian ED using: a) semi-structured interviews with senior emergency physicians; and b) a time and motion direct observational study of senior emergency physicians completing test acknowledgment pre and post the implementation of the eRA system., Results: The eRA system led to changes in the way results and actions were collated, stored, documented and communicated. Although there was a non-significant increase in the average time taken to acknowledge results in the post period, most types of acknowledgements (other than simple acknowledgements) took less time to complete. The number of acknowledgements where physicians sought additional information from the Electronic Medical Record (EMR) rose from 12% pre to 20% post implementation of eRA., Conclusions: Given that the type of results are unlikely to have changed significantly across the pre and post implementation periods, the increase in the time physicians spent accessing additional clinical information in the post period likely reflects the greater access to clinical information provided by the integrated electronic system. Easier access to clinical information may improve clinical decision making and enhance the quality of patient care. For instance, in situations where a senior clinician, not initially involved in the care process, is required to deal with the follow-up of non-normal results., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

External Quality Assessment (EQA) is the verification, on a recurring basis, that laboratory results conform to expectations for the quality required for patient care. It is now widely recognised that both the pre- and post-laboratory phase of testing, termed the diagnostic phases, are a significant source of laboratory errors. These errors have a direct impact on both the effectiveness of the laboratory and patient safety. Despite this, Australian laboratories tend to be focussed on very narrow concepts of EQA, primarily surrounding test accuracy, with little in the way of EQA programs for the diagnostic phases. There is a wide range of possibilities for the development of EQA for the diagnostic phases in Australia, such as the utilisation of scenarios and health informatics. Such programs can also be supported through advances in health information and communications technology, including electronic test ordering and clinical decision support systems. While the development of such programs will require consultation and support from the referring doctors, and their format will need careful construction to ensure that the data collected is de-identified and provides education as well as useful and informative data, we believe that there is high value in the development of such programs. Therefore, it is our opinion that all pathology laboratories should strive to be involved in an EQA program in the diagnostic phases to both monitor the diagnostic process and to identify, learn from and reduce errors and near misses in these phases in a timely fashion., Competing Interests: None declared.

Hemolysis is a leading cause of pre-analytical laboratory errors. The identification of contributing factors is an important step towards the development of effective practices to reduce and prevent hemolysis. We performed a review of PUBMED, Embase, Medline and CINAHL to identify articles published between January 2000 and August 2016 that identified factors influencing in vitro hemolysis rates. The 40 studies included in this review provide excellent evidence that hemolysis rates are higher in Emergency Departments (EDs), for non-antecubital draws, for specimens drawn using an intravenous catheter compared to venipuncture and for samples transported by pneumatic tube compared to by hand. There is also good evidence that hemolysis rates are higher when specimens are not collected by professional phlebotomists, larger volume specimen tubes are used, specimen tubes are filled less than halfway and tourniquet time is greater than one minute. The results of this review suggest that hospitals and clinical laboratories should consider deploying phlebotomists in EDs, drawing all blood through a venipuncture, using the antecubital region as the optimum blood collection site and transporting specimens by laboratory assistant/other personnel, or if this in not practical, ensuring that pneumatic transport systems are validated, maintained and monitored. Studies also recommend making hemolysis a hospital-wide issue and ensuring high-quality staff training and adherence to standard operating procedures to reduce hemolysis rates. Awareness of the factors that influence hemolysis rates, and adoption of strategies to mitigate these risk factors, is an important step towards creating quality practices to reduce hemolysis rates and improve the quality of patient care.

Aim: Haemolysis has a major impact on patient safety as the need for a replacement specimen increases the risk of injury and infection, delays test results and extends the duration of hospital stays. Consistency of haemolysis detection and reporting can facilitate the generation of benchmark data used to develop quality practices to monitor and reduce this leading cause of pre-analytical laboratory error. This review aims to investigate current methods of haemolysis detection and reporting., Method: Due to known heterogeneity and immaturity of the research field, a scoping search was conducted using PUBMED, Embase, Medline and CINAHL. Articles published between 2000 and 2014 that reported haemolysis rates in specimens from the general population were included., Results: Of the 50 studies that met the inclusion criteria, 20 detected haemolysis using the Haemolysis Index (HI), 19 by visual inspection and 13 by undefined methods. There was large intra-study variation in the plasma free haemoglobin level used to establish haemolysis (HI: mean±SD 846±795 mg/L, range 150-3000 mg/L; Visual: 850±436 mg/L, 500-3000 mg/L). Sixteen studies reported the analyte of interest, with only three studies reporting a haemoglobin level at which the specimen would be rejected., Conclusion: Despite haemolysis being a frequent and costly problem with a negative impact on patient care, there is poor consistency in haemolysis detection and reporting between studies. Improved consistency would facilitate the generation of benchmark data used to create quality practices to monitor and reduce this leading cause of pre-analytical laboratory error.

Context: Respiratory complications, attributed to the build-up of secretions in the airway, are a leading cause of rehospitalisation for the tetraplegic population. Previously, we observed that the application of Abdominal Functional Electrical Stimulation (AFES) improved cough function and increased demand for secretion removal, suggesting AFES may aid secretion clearance. Clinically, secretion clearance is commonly achieved by using Mechanical insufflation-exsufflation (MI-E) to simulate a cough. In this study the feasibility of combining AFES with MI-E is evaluated., Findings: AFES was successfully combined with MI-E at eight fortnightly assessment sessions conducted with one sub-acute participant with tetraplegia. By using the signal from a pressure sensor, integrated with the MI-E device, AFES was correctly applied in synchrony with MI-E with an accuracy of 96.7%. Acute increases in exhaled volume and peak flow were observed during AFES assisted MI-E, compared to MI-E alone, at six of eight assessment sessions., Conclusion: The successful integration of AFES with MI-E at eight assessment sessions demonstrates the feasibility of this technique. The acute increases in respiratory function observed at the majority of assessment sessions generate the hypothesis that AFES assisted MI-E may be more effective for secretion clearance than MI-E alone.

Objectives: Abdominal functional electrical stimulation (abdominal FES) is the application of a train of electrical pulses to the abdominal muscles, causing them to contract. Abdominal FES has been used as a neuroprosthesis to acutely augment respiratory function and as a rehabilitation tool to achieve a chronic increase in respiratory function after abdominal FES training, primarily focusing on patients with spinal cord injury (SCI). This study aimed to review the evidence surrounding the use of abdominal FES to improve respiratory function in both an acute and chronic manner after SCI., Settings: A systematic search was performed on PubMed, with studies included if they applied abdominal FES to improve respiratory function in patients with SCI., Methods: Fourteen studies met the inclusion criteria (10 acute and 4 chronic). Low participant numbers and heterogeneity across studies reduced the power of the meta-analysis. Despite this, abdominal FES was found to cause a significant acute improvement in cough peak flow, whereas forced exhaled volume in 1 s approached significance. A significant chronic increase in unassisted vital capacity, forced vital capacity and peak expiratory flow was found after abdominal FES training compared with baseline., Conclusions: This systematic review suggests that abdominal FES is an effective technique for improving respiratory function in both an acute and chronic manner after SCI. However, further randomised controlled trials, with larger participant numbers and standardised protocols, are needed to fully establish the clinical efficacy of this technique.

Spinal cord injury caused by stab wounds (SCISW) results from a partial or complete transection of the cord, and presents opportunities for interventional research. It is recognized that there is low incidence, but little is known about the natural history or the patient's suitability for long-term clinical outcome studies. This study aims to provide population-based evidence of the demographics of SCISW, and highlight the issues regarding the potential for future research. The database of the Queen Elizabeth National Spinal Injuries Unit (QENSIU), the sole center for treating SCI in Scotland, was reviewed between 1994 and 2013 to ascertain the incidence, demographics, functional recovery, and mortality rates for new SCISW. During this 20 year period, 35 patients with SCISW were admitted (97.1% male, mean age 30.0 years); 31.4% had a cervical injury, 60.0% had a thoracic injury, and 8.6% had a lumbar injury. All had a neurological examination, with 42.9% diagnosed as motor complete on admission and 77.1% discharged as motor incomplete. A total of 70.4% of patients with an American Spinal Injury Association Impairment Scale (AIS) level of A to C on admission had an improved AIS level on discharge. Nine (25.7%) patients have died since discharge, with mean life expectancy for these patients being 9.1 years after injury (20-65 years of age). Patients had higher levels of comorbidities, substance abuse, secondary events, and poor compliance compared with the general SCI population, which may have contributed to the high mortality rate observed post-discharge. The low incidence, heterogeneous nature, spontaneous recovery rate, and problematic follow-up makes those with penetrating stab injuries of the spinal cord a challenging patient group for SCI research.

Objective: The objective of the present study is to quantify utilisation of imaging for patients presenting to an ED with back pain, their characteristics and dispositions., Methods: A retrospective cohort study of 1132 ED presentations for back pain to an Australian metropolitan ED in 2013 was performed. Patient demographics, rates of radiography, computed tomography or magnetic resonance imaging and rates of subsequent admission and ED re-presentation were analysed., Results: Patients aged 26-35 years were the largest group presenting with back pain (19.4% of presentations), with the majority being female (52.3%). Imaging was requested at 29.5% (n = 334) of presentations (radiography n = 297; advanced imaging n = 63). Patients over 70 years had higher imaging rates than younger patients (49.4% vs 25.5%, P < 0.001). Imaging was not associated with attendance during or outside office hours (29.3% vs 31.8%, P = 0.4). Of presentations, 34.1% resulted in admission, with no association between imaging and admission (31.8% vs 36.0%, P = 0.2) or ED re-presentation for back pain in the same year (6.5% vs 9.7%, P = 0.09)., Conclusion: This study provides benchmark data on the use of imaging for back pain in an Australian ED, an area which has been largely unexplored. The rate of imaging in the ED was higher than previously reported in a General Practice setting. Consistent with guidelines, patients older than 70 were more than twice as likely to receive imaging compared to younger patients. It was beyond the scope of the current study to determine whether these images were clinically indicated and further research is required to determine if initiatives to reduce imaging in this population are warranted., (© 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Study Design: A retrospective cohort study., Objectives: To review demographic trends in traumatic spinal cord injury (TSCI) and non-traumatic spinal cord injury (NTSCI)., Setting: The Queen Elizabeth National Spinal Injuries Unit (QENSIU), sole provider of treatment for TSCI in Scotland; a devolved region of the UK National Health Service., Methods: A retrospective review of the QENSIU database was performed between 1994 and 2013. This database includes demographic and clinical data from all new TSCI patients in Scotland, as well as patients with severe NTSCI., Results: Over this 20-year period there were 1638 new cases of TSCI in Scotland; 75.2% occurring in males. TSCI incidence increased non-significantly (13.3 per million population to 17.0), while there were significant increases in mean age at time of TSCI (44.1-52.6 years), the proportion of TSCIs caused by falls (41-60%), the proportion of TSCIs resulting in an American Spinal Injury Association Impairment Scale score of C and D on admission (19.7-28.6% and 34.5-39.5%, respectively) and the proportion of cervical TSCIs (58.4-66.3%). The increase in cervical TSCI was specifically due to an increase in C1-C4 lesions (21.7-31.2%). NTSCI patients (n=292) were 5 years older at injury, more likely to be female (68.1% male) and had a range of diagnoses., Conclusion: This study supports the suggestion that demographic profiles in SCI are subject to change. In this population, of particular concern is the increasing number of older patients and those with high level tetraplegia, due to their increased care needs. Prevention programmes, treatment pathways and service provision need to be adjusted for optimum impact, improved outcome and long-term care for their target population.

Background: Severe impairment of the major respiratory muscles resulting from tetraplegia reduces respiratory function, causing many people with tetraplegia to require mechanical ventilation during the acute stage of injury. Abdominal Functional Electrical Stimulation (AFES) can improve respiratory function in non-ventilated patients with sub-acute and chronic tetraplegia. The aim of this study was to investigate the clinical feasibility of using an AFES training program to improve respiratory function and assist ventilator weaning in acute tetraplegia., Methods: AFES was applied for between 20 and 40 minutes per day, five times per week on four alternate weeks, with 10 acute ventilator dependent tetraplegic participants. Each participant was matched retrospectively with a ventilator dependent tetraplegic control, based on injury level, age and sex. Tidal Volume (VT) and Vital Capacity (VC) were measured weekly, with weaning progress compared to the controls., Results: Compliance to training sessions was 96.7%. Stimulated VT was significantly greater than unstimulated VT. VT and VC increased throughout the study, with mean VC increasing significantly (VT: 6.2 mL/kg to 7.8 mL/kg VC: 12.6 mL/kg to 18.7 mL/kg). Intervention participants weaned from mechanical ventilation on average 11 (sd: ± 23) days faster than their matched controls., Conclusion: The results of this study indicate that AFES is a clinically feasible technique for acute ventilator dependent tetraplegic patients and that this intervention may improve respiratory function and enable faster weaning from mechanical ventilation., Trial Registration: ClinicalTrials.gov NCT02200393.

Purpose: Abdominal functional electrical stimulation (AFES) is a technique intended to improve respiratory function in tetraplegia where breathing is affected due to abdominal muscle paralysis. Although it is known that optimal muscle contraction is achieved when electrical stimulation is applied close to the muscle motor point, AFES studies have used a variety of electrode positions. This study aims to investigate the feasibility of using Neuromuscular Electrical Stimulation to detect the motor points of the abdominal muscles, and to evaluate the intrasubject repeatability and intersubject uniformity of their positions, to find the most suitable AFES electrode location., Methods: Low frequency stimulation (0.5 Hz) was applied to the abdominal muscles of 10 able bodied and five tetraplegic participants. The electrode positions which achieved the strongest muscle contractions were recorded as the motor point positions, with measurements repeated once. For five able bodied participants, assessments were repeated after 18 months, in seated and supine positions., Results: Intersubject uniformity ranged from 2.8 to 8.8%. Motor point positions were identified with intrasubject repeatability of <1.7 cm, deemed adequate relative to standard AFES electrode size. Intrasubject repeatability shows motor point positions changed little (<1.7 cm) after 18 months but varied between seated and supine positions with repeatability of up to 3.1 cm., Conclusions: A simple technique to locate the motor points of the abdominal muscles is presented and shown to have an adequate intrasubject repeatability, enabling the optimum AFES electrode location to be identified for each user.

Abdominal Functional Electrical Stimulation (AFES) has been shown to improve the respiratory function of people with tetraplegia. The effectiveness of AFES can be enhanced by using different stimulation parameters for quiet breathing and coughing. The signal from a spirometer, coupled with a facemask, has previously been used to differentiate between these breath types. In this study, the suitability of less intrusive sensors was investigated with able-bodied volunteers. Signals from two respiratory effort belts, positioned around the chest and the abdomen, were used with a Support Vector Machine (SVM) algorithm, trained on a participant by participant basis, to classify, in real-time, respiratory activity as either quiet breathing or coughing. This was compared with the classification accuracy achieved using a spirometer signal and an SVM. The signal from the belt positioned around the chest provided an acceptable classification performance compared to the signal from a spirometer (mean cough (c) and quiet breath (q) sensitivity (Se) of Se(c)=92.9% and Se(q)=96.1% vs. Se(c)=90.7% and Se(q)=98.9%). The abdominal belt and a combination of both belt signals resulted in lower classification accuracy. We suggest that this novel SVM classification algorithm, combined with a respiratory effort belt, could be incorporated into an automatic AFES device, designed to improve the respiratory function of the tetraplegic population., (Copyright © 2014 IPEM. Published by Elsevier Ltd. All rights reserved.)