Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

In discovering the potential of individuals with SCI for getting involved in PE, the improvement of physical and coordinative skills with interaction between individuals with SCI and external sport groups should be an inherent part of the rehabilitation process. Individuals not having access to PE should be given the opportunity to participate in wheelchair mobility courses. This may improve the adherence to PE of individuals with SCI in post-clinical settings.

Study design: Prospective clinical study of two treatments. Objective: To compare mechanical ventilation (MV) with phrenic nerve stimulation (PNS) for treatment of respiratory device-dependent (RDD) spinal cord-injured (SCI) patients. Setting: Department for spinal cord-injured patients of an insurance-company-run trauma hospital in Hamburg, Germany. Methods: Prospective data collection of treatment-related data over 20 years. Results: In total, 64 SCI-RDD patients were treated during the study period. Of these, 32 of the patients with functioning phrenic nerves and diaphragm muscles were treated with PNS and 32 patients with destroyed phrenic nerves were mechanically ventilated. Incidence of respiratory infections (RIs per 100 days) prior to use of final respiratory device was equal in both groups, that is (median (interquartile range)) 1.43 (0.05-3.92) with PNS and 1.33 (0.89-2.21) with MV (P ¼ 0.888); with final device in our institution it was 0 (0-0.92) with PNS and 2.07 (1.49-4.19) with MV (Po0.001); at final location it was 0 (0-0.02) with PNS and 0.14 (0-0.31) with MV (Po0.001). Thus, compared to MV, respiratory treatment with PNS significantly reduces frequency of RI. Quality of speech is significantly better with PNS. Nine patients with PNS, but only two with MV, were employed or learned after rehabilitation (P ¼ 0.093). The primary investment in the respiratory device is higher with PNS, but it can be paid off in our setting within 1 year because of the reduced amount of single use equipment, easier nursing and fewer RIs compared to MV. Conclusions: PNS instead of MV for treatment of SCI-RDD reduces RIs, running costs of respiratory treatment and obviously improves patients' quality of life.

Study design: Systematic review.Background: The applied definition of traumatic central cord syndrome (TCCS) lacks specific quantified diagnostic criteria. Objective: To review currently applied TCCS diagnostic criteria and quantitative data regarding the 'disproportionate weakness' between the upper and lower extremities described in original studies reporting on TCCS subjects. Methods: A MEDLINE (1966 to 2008) literature search was conducted. The descriptors applied to define TCCS were extracted from all included articles. We included original studies that reported on the differences in motor score (based on the Medical Research Council scale) between the total upper extremity motor score (UEMS) and the total lower extremity motor score (LEMS), in a minimum of five TCCS patients at the time of hospital admission. The mean difference between the total UEMS and the total LEMS of the patients included in each study was calculated. Case reports were excluded. Results: None of the identified studies on TCCS patients reported inclusion and/or exclusion criteria using a quantified difference between the UEMS and LEMS. Out of 30 retrieved studies, we identified seven different clinical descriptors that have been applied as TCCS diagnostic criteria. Nine studies reporting on a total of 312 TCCS patients were eligible for analysis. The mean total UEMS was 10.5 motor points lower than the mean total LEMS. Conclusions: There is no consensus on the diagnostic criteria for TCCS. Nevertheless, this review revealed an average of 10 motor points between the UEMS and LEMS as a possible TCCS diagnostic criterion. However, further discussion by an expert panel will be required to establish definitive diagnostic criteria.

Study design: Retrospective study. Objective: To investigate the causes of death in patients who were ≤50 years at the time of traumatic spinal cord injury (tSCI). Setting: Convenience sample of a tertiary rehabilitation center. Methods: All deceased patients with tSCI who survived a minimum of 10 years post-injury, were included. In addition, causes of death were compared between subjects surviving <10 years and ≥10 years. Neurological assessments were performed according to the American Spinal Injury Association scale. Data on causes of death were analyzed using the ICD-10 classifications. Differences were calculated using the Mann-Whitney and chi-square tests. Results: A total of 100 patients, with 38 and 62 surviving <10 and ≥10 years, respectively, were included. No significant differences in causes of death were identified between these two groups. In patients surviving ≥10 years, paraplegia was associated with a higher life expectancy compared with tetraplegia, 34 and 25 years ( p = 0.008), respectively, and the leading causes of death were septicemia (n = 14), ischemic heart disease (n = 10), neoplasms (n = 9), cerebrovascular diseases (n = 5), and other forms of heart diseases (n = 5). Septicemia, influenza/pneumonia, and suicide were the leading causes of death in tetraplegics, whereas ischemic heart disease, neoplasms, and septicemia were the leading causes of death in paraplegia. Conclusion: Our monocentric study showed that in 62 deceased patients with SCI, the leading causes of death were septicemia, cardiovascular diseases, neoplasms, and cerebrovascular diseases. In addition, no significant differences were identified between causes of death among patients surviving <10 years and ≥10 years post-injury.

The recommendation of antibiotic prophylaxis for all SCI patients undergoing urodynamic examination is not commonly accepted and according to our data not justified. However, the analysis of subgroups revealed that SCI patients with unsuspected SBU prior to UDS and patients with reflex voiding are possibly at higher risk to acquire post-UDS infection.

Study design: Retrospective cohort study. Objectives: To compare the neurological outcome between paraplegic patients with acute spinal cord ischaemia syndrome (ASCIS) or traumatic spinal cord injury (tSCI) and to investigate the influence of SCI aetiology on the total Spinal Cord Independence Measure (SCIM)-II score. Setting: Level 1 trauma centre. Methods: Initial (0-40 days) and chronic-phase (6-12 months) American Spinal Injury Association (ASIA) sensory scores, lower extremity motor score (LEMS) and chronic-phase total SCIM-II scores were analysed. Differences between ASCIS and tSCI patients were calculated using Student's t-tests and Wilcoxon signed-rank tests. To assess which variables give rise to the prediction of total SCIM-II score, a multiple linear regression analysis was used. These predictor variables included complete (ASIA impairment scale A) or incomplete SCI (AIS B, C, and D), aetiology, age and gender. Results: Out of 93 included patients, 20 ASCIS and 73 tSCI patients were identified. In the complete SCI group, the initial pinprick scores were higher (Po0.05) in ASCIS patients compared with tSCI patients, 37.9 (95% Confidence Interval (CI), 23.3-52.5) and 27.3 (95% CI, 24.1-30.4), respectively. No other relevant differences in neurological outcome were identified between ASCIS and tSCI patients; however, the total SCIM-II scores were higher (Po0.05) in tSCI patients after 12 months. Using the linear regression analysis, we were able to predict 31.4% of the variability. The aetiology was not significant in this model. Conclusion: The neurological outcome was independent of the diagnosis ASCIS or tSCI. Furthermore, the diagnosis ASCIS or tSCI was not a significant predictor for total SCIM II scores after 12 months. Sponsorship: This study was granted by the 'Internationale Stiftung für Forschung in Paraplegie' (IFP), Zürich, Switzerland.

Study design: Monocentric cohort study. Objective: To investigate the acquisition of knowledge about spinal cord injury (SCI)-related complications in SCI patients. Setting: Level 1 trauma center. Methods: All patients with a traumatic or non-traumatic SCI were included in the study. Data were collected at admission, post-admission at 1 and 3 months and post-discharge at 6, 18 and 30 months. The discharge of all patients was between 3 and 6 months post-admission. Knowledge about pressure ulcers and bladder management was tested using the 'Knowledge' score. This score has a minimum and maximum of 0 and 20 points. To detect differences across the multiple time intervals, the Friedman test was used. Differences in the number of patients with poor (0-8), average (9-12) and good knowledge (13-20) between the different age classifications (age at injury) were calculated using a w 2 -test. Results: A total of 214 patients were included. At discharge subjects had increased their knowledge score to 11.2 compared with 5.4 on admission (Po0.001). After 30 months, however, the mean score decreased to 10.8 points. At the time of discharge, the number of patients who achieved poor, average or good knowledge were 48 (22.4%), 65 (30.4%) and 101 (47.2%), respectively. Subjects of B50 years old and tetraplegics had better (Po0.001) knowledge compared with subjects of B50 years old and paraplegics, respectively. Conclusion: In this study, less than 50% of SCI patients had good knowledge about bladder management and pressure ulcers after being discharged.