Einat Engel-Haber

Study Design. Retrospective cohort study. Objectives. To determine UTI incidence and risk factors, and risk factors for episodes meeting systemic-feature criteria ("systemic UTI"; previously termed "upper UTI" in the literature), during subacute SCI rehabilitation. Setting. Tertiary academic neurological rehabilitation department, Sheba Medical Center, Israel. Methods. Consecutive adults with SCI discharged between January 2012 and March 2024 were included; data were extracted via MDClone ADAMS. A UTI-defining event was urine leukocyte count >200/µL or antibiotic prescription with explicit UTI indication; events <14 days apart were one episode. Systemic UTI required ≥1 of fever ≥38°C, leukocytosis, elevated CRP, positive blood culture, or an antibiotic prescribed with an explicit upper-UTI indication (e.g., pyelonephritis). Incidence-rate ratios (IRRs) were estimated by Poisson regression with log(person-days) as offset. Results. Among 737 patients (76.3% male; mean age 46.9 years), 633 UTI episodes occurred over 71,959 person-days; 45.0% had ≥1 UTI and 21.4% had recurrent UTI (≥2 episodes). Overall incidence was 8.80 per 1,000 person-days (systemic 5.79; non-systemic 3.00). In adjusted analyses, age ≥65 years (IRR 1.42, 95% CI 1.13 to 1.77), traumatic etiology (1.33, 1.08 to 1.65) and complete (AIS A) injury (1.28, 1.07 to 1.53) independently predicted UTI. For systemic UTI, age ≥65 (IRR 1.81, 1.37 to 2.36) and complete injury (1.50, 1.20 to 1.87) remained significant. Conclusions. UTI is highly prevalent during subacute SCI rehabilitation. Older age, traumatic etiology and complete injury independently predict higher incidence and warrant targeted surveillance. Sponsorship. None.

The expanding application of spinal stimulation therapies in spinal cord injury (SCI) rehabilitation necessitates a critical reexamination of cardiovascular (CV) responses to these interventions. A key question arises: How should blood pressure (BP) responses to stimulation be interpreted, and does the conventional definition of autonomic dysreflexia (AD) adequately capture these phenomena? Researchers remain divided—some classify BP elevations during stimulation as AD, while others attribute them to intentional neuromodulation targeting sympathetic preganglionic neurons. This review scrutinizes the various AD definitions in the literature, including the conventional threshold (systolic BP increase >20 mmHg), revealing substantial limitations in research contexts. While symptomatic AD occurs in only 4-7% of stimulation study participants, asymptomatic BP increases are considerably more frequent. This established threshold lacks robust physiological rationale and creates significant interpretive challenges, particularly when evaluating interventions designed to modulate BP responses. The current limitations of guideline-based definitions of AD challenge research interpretation and clinical translation. Although several publications describe AD as “unregulated” or “uncontrolled,” it has not yet been incorporated into formal guideline definitions. This review underscores the need for a collaborative effort to refine AD definitions in research, particularly in the context of spinal stimulation. Future consensus development should address whether uniform thresholds should apply across different contexts, how to integrate heart rate dynamics and absolute BP values alongside symptomatic status, and how to meaningfully distinguish therapeutic BP modulation from adverse autonomic responses. This is essential for standardizing research approaches, optimizing stimulation parameters, and ensuring efficacy and safety as spinal stimulation technologies advance clinically.

Background/Objectives: Cardiovascular (CV) dysfunction and, specifically, orthostatic hypotension, may significantly impact the quality of life of individuals with spinal cord injuries (SCIs) at T6 or above. While spinal cord transcutaneous stimulation (scTS) has shown immediate effects on blood pressure regulation, its long-term effects remain largely unexplored. Methods: This case study examines the sustained effects of scTS on blood pressure regulation and orthostatic tolerance in a 33-year-old female with cervical (C4) complete SCI sustained two years earlier. This individual underwent an initial baseline tilt test without stimulation, completed six 30 min scTS-CV sessions (cardiovascular-focused stimulation) over two weeks as the “training” phase, and then had repeated tilt tests without stimulation posttraining. Results: Following training, the participant demonstrated an improvement in orthostatic tolerance, maintaining a 70° tilt for 30 min, compared to only 3 min at baseline, in a tilt test (without stimulation) conducted one day posttraining. Self-reported reduction in orthostatic burden and decreased midodrine dependence were also observed for several weeks, with improvements diminishing by 6 weeks posttraining. Conclusions: These observations suggest that brief, repeated scTS-CV sessions may lead to sustained improvements in orthostatic tolerance beyond the immediate period of stimulation. Although the duration of these effects has yet to be established, this approach could offer a non-invasive alternative for managing CV dysfunction in SCIs.

Background: All physicians will care for persons with disabilities over the course of their careers. However, most medical school curricula do not adequately prepare students to recognize and address the specific needs of persons with disabilities. Despite physician requirements under the Americans with Disabilities Act (ADA), patients with disabilities may receive substandard care due to a lack of accommodations.Objective: To examine the effect of a physical medicine and rehabilitation (PM&R) clerkship on fourth‐year medical students' understanding of physician responsibilities under the ADA as well as comfort levels when caring for persons with disabilities.Design: Subjective pre‐ and postintervention surveys.Setting: A single institution U.S. allopathic medical school.Participants: All fourth‐year medical students enrolled in the mandatory PM&R clerkship during the 2022–2023 academic year were eligible for participation in the study. Surveys were distributed to all eligible students and 99 students successfully completed both surveys for inclusion in the study.Interventions: For the 2022–2023 academic year, the mandatory 2‐week PM&R clerkship included didactic lectures on the ADA and additional interactive, first‐hand accounts from persons living with a disability.Main Outcome Measures: The change from medical students' baseline to postclerkship knowledge regarding the ADA responsibilities for physicians and overall comfort in working with persons with a physical disability.Results: Medical students' overall knowledge of the clinical and financial responsibilities of physicians under the ADA and comfort in interacting with persons with disabilities improved following the clerkship (p < .001).Conclusions: These findings highlight the importance of disability education as part of medical school curricula to improve medical student knowledge about physician responsibilities under the ADA and overall comfort level in caring for persons with disability. Further studies are needed to determine if these results carry over into clinical practice to combat the health care disparities experienced by persons with disabilities.

Central cord syndrome (CCS) is the most prevalent and debated incomplete spinal cord injury (SCI) syndrome, with its hallmark feature being more pronounced weakness of the upper extremities than of the lower extremities. Varying definitions encapsulate multiple clinical features under the single umbrella term of CCS, complicating evaluation of its frequency, prognosis discussions, and outcomes research. Often, people with CCS are excluded from research protocols, as it is thought to have a favorable prognosis, but the vague nature of CCS raises doubts about the validity of this practice. The objective of this study was to categorize CCS into specific subsets with clear quantifiable differences, to assess whether this would enhance the ability to determine if individuals with CCS or its subsets exhibit distinct neurological and functional outcomes relative to others with incomplete tetraplegia. This study retrospectively reviewed individuals with new motor incomplete tetraplegia from traumatic SCI who enrolled in the Spinal Cord Injury Model Systems (SCIMS) database from 2010 to 2020. Through an assessment of the prevailing criteria for CCS, coupled with data analysis, we used two key criteria, including the severity of distal upper extremity weakness (i.e., hands and fingers) and extent of symmetry, to delineate three CCS subsets: full CCS, unilateral CCS, and borderline CCS. Of the 1490 participants in our sample, 17.5% had full, 25.6% had unilateral, and 9% had borderline CCS, together encompassing >50% of motor incomplete tetraplegia cases. Despite the increased sensitivity and specificity of these subsets compared with existing quantifiable criteria, substantial variability in clinical presentation was still observed. Overall, individuals meeting CCS subset criteria showed a higher likelihood of American Spinal Injury Association (ASIA) Impairment Scale (AIS) D grade than those with motor incomplete tetraplegia without CCS. Upper Extremity Motor Score (UEMS) for those with CCS was lower on admission, a difference that diminished by discharge, whereas their Lower Extremity Motor Score (LEMS) consistently remained higher than for those without CCS. However, these neurological distinctions did not result in significant functional differences, as lower and upper extremity functional outcomes at discharge were mostly similar, with some differences observed within those with AIS D grade. The AIS grade, rather than the diagnosis of CCS, remains the foremost determinant influencing neurological and functional outcomes. We recommend that future studies consider incorporating motor incomplete tetraplegia into their inclusion/exclusion criteria, instead of relying on criteria specific to CCS. Although there remains clinical value in characterizing an injury pattern as CCS and perhaps using the different subsets to better characterize the impairments, it does not appear to be a useful research criterion.

Spinal cord transcutaneous stimulation (scTS) offers a promising approach to enhance cardiovascular regulation in individuals with a high-level spinal cord injury (SCI), addressing the challenges of unstable blood pressure (BP) and the accompanying hypo- and hypertensive events. While scTS offers flexibility in stimulation locations, it also leads to significant variability and lack of validation in stimulation sites utilized by studies. Our study presents findings from a case series involving eight individuals with chronic cervical SCI, examining the hemodynamic effects of scTS applied in different vertebral locations, spanning from high cervical to sacral regions. Stimulation of the lumbosacral vertebrae region (L1/2, S1/2, and also including T11/12) significantly elevated BP, unlike cervical or upper thoracic stimulation. The observed trend, which remained consistent across different participants, highlights the promising role of lumbosacral stimulation in neuromodulating BP.