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OBJECTIVE: To characterize a population of spinal cord injury (SCI) patients with sleep apnea, and to determine associated factors and comorbidities. STUDY DESIGN: Population-based retrospective case-control study. SUBJECTS: 584 male patients served by a Veterans Affairs SCI service. MEASURES: Medical records were reviewed for sleep apnea diagnosis, demographic information, neurologic characteristics, and treatments received. Sleep study reports were not available to determine the nature of abnormal respiratory events (ie central, obstructive, hypoventilation). For each case with tetraplegia, a control tetraplegic subject without sleep apnea diagnosis was selected. RESULTS: We identified 53 subjects with diagnosed sleep apnea: 42 tetraplegic, 11 paraplegic. This represented 14.9% of all tetraplegic and 3.7% of all paraplegic patients in the population (P<0.0001 for comparison of tetraplegic and paraplegic proportions). In tetraplegic subjects, sleep apnea was associated with obesity and more rostral motor level, but not with ASIA Impairment Scale. Medical comorbidities associated with sleep apnea in non-SCI patients, such as hypertension, were more common in case subjects. Less than half of case subjects were receiving some form of treatment. For motor-complete tetraplegics, long-term positive airway pressure treatment was less common with motor level C5 and above compared to C6 and below. CONCLUSION: In this population, sleep apnea has been frequently diagnosed, particularly in tetraplegic subjects. The true prevalence is likely to be considerably higher, since this study considered only previously diagnosed cases. Sleep apnea was associated with obesity and higher neurologic level, but not ASIA Impairment Scale. Medical comorbidities were more frequent in this group, and treatment acceptance was poor with higher level motor-complete injuries. Since the type of sleep apnea (central or obstructive) was not distinguished, we cannot comment on the prevalence and associations based on specific types of sleep apnea.

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We describe a normal-phase HPLC method for the stereospecific determination of R- and S-acenocoumarol and R- and S-phenprocoumon with S-warfarin as internal standard. The compounds were separated using a Whelk-O1 chiral stationary phase, detected by UV at 310 nm and quantified in the internal standard mode. Linearity was verified for acenocoumarol in the range of 15-2000 microg/l and for phenprocoumon from 15 to 2200 microg/l, respectively. The detection limits were 5 microg/l for all compounds. The recovery was >84% for R- and S-acenocoumarol and >74% for R- and S-phenprocoumon. The imprecision (C.V.) (50-1800 microg/l) for R- and S-acenocoumarol was <4.7% within-day and <7.8% between-day. For R- and S-phenprocoumon the respective values were <5.6% and <5.9%. The accuracy for all compounds was 96.5-110%.

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Chronic renal failure (CRF) in the first years of life is associated with developmental defects of enamel in the permanent dentition. We investigated if CRF also affects the primary (deciduous) dentition. Thirty-one children with CRF on conservative treatment (n = 12) or on renal replacement therapy (n = 19) underwent dental inspection. In addition, 18 CRF children provided an exfoliated deciduous tooth for microscopic examination. Enamel defects were detected in a total of 12 children (31%), either clinically or microscopically. Of the 7 children affected clinically, 6 (19% of all examined) presented localized hypoplasia of the primary canines, which was found only in 3% of healthy control children: 1 patient had generalized pitted enamel hypoplasia. By microscopy, 5 of 10 primary canines examined showed enamel hypoplasia localized exclusively in enamel formed after birth. The "birth line," a visible structure within the primary enamel, was always present, which excludes a prenatal onset of the defects. Of the 12 patients with an enamel defect, 9 had a documented onset of CRF within the first 7 weeks of life. We conclude that renal disease leading to CRF may affect enamel formation of primary teeth in early postnatal life, resulting in lesions different from those observed in the secondary dentition.

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A small group of peer-identified expert nurses was studied using qualitative methods to identify how they assessed patients' risk for pressure ulcers. The factors used by these expert nurses were compared to those used in formal pressure ulcer risk assessment instruments. The analysis revealed that the expert nurses weighed risk factors used in the formal scales preferentially. There was a close association in their reports between experiences with wound healing and pressure ulcer prevention. They used subjective sensory modalities such as appearance and odor. Setting and specialty-specific factors figured prominently in their evaluations and they included psychosocial as well as physiological factors in their assessments.

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Because of the high risk for pressure ulcers among hospitalized, spinal cord injured patients, one quality improvement measure is to monitor incidence of pressure ulcers. A retrospective chart review of each patient who developed an ulcer during an 18-month period revealed patient characteristics associated with pressure ulcer risk. Of 468 inpatient admissions, 35 patients developed 81 pressure ulcers. Patient variables associated with an incidence rate of 7.5% were an admission diagnosis of pressure ulcer, surgical repair of pressure ulcers, length of stay, new spinal cord injury, longstanding injury (> 10 years), and the use of condom catheters.

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