Census estimates in 2010 indicated that 6,3 percent South Africans aged 5 years and older are currently classified as disabled in five of the nine provinces in the country. The national figure for 2005 was 5 percent, with the figure for females (6,5 percent) slightly higher than that for males (6,1percent). Spinal cord injured persons and their significant others experience a range of emotions which affect their relationships with themselves, others and their environment. To deal with the life-changing consequences of the injury and regain control, these persons not only require a variety of coping strategies but rediscovery of resilience is inevitable if the experience of personal purpose and meaningful existence is ever to be regained. In the Nelson Mandela Bay Municipal area, Port Elizabeth, South Africa – the geographical area in which this research study was undertaken - persons with spinal cord injuries have many challenges to face due to the shortcomings the existing resource for health care delivery in the post-discharge phase. The research objectives identified for the study were, firstly, to explore and describe the lived experiences of persons with spinal cord injuries; secondly, to explore and describe the lived experiences of the significant others of persons with spinal cord injuries; and thirdly, to develop a strategy to guide the professional nurse and the health care team in facilitating the health care of persons with spinal cord injuries. The study was a qualitative, exploratory, descriptive, and contextual method of inquiry. The data obtained was used to formulate the strategy with its three sub-strategies to guide professional nurses and the health care team to facilitate renewed resilience and the re-establishment of meaning for persons with spinal cord injuries. Although the experiences of the significant others were explored in order to thicken the description of the experiences of persons with spinal cord injuries, the strategy developed was limited to the persons with spinal cord injuries. Although it is well documented that there are significant physical needs, the themes that emerged from the current research mostly related to psychological and social aspects. In acknowledging the human being as unitary multi-dimensional being, the researcher in his discussions and quest to address the issue of renewed resilience in spinal cord injured persons towards finding purpose and re-establishing meaning in their lives, focused on their psychological, spiritual and social health. The outcome of the study is a strategy constructed to facilitate renewed resilience, and three sub-strategies ‘addressing experienced emotions’, ‘facilitating meaningful relationships’ and ‘facilitating effective coping’. The strategy has as purpose the empowering of spinal injured persons in their efforts to re-establish meaning by serving as a tool to guide professional nurses and members of the health care team in their facilitating of renewed resilience in persons with spinal cord injury. It is envisaged that the co-ordination of the strategy will take place from the health care delivery facility nearest to the spinal cord injured individual concerned. In order for persons with spinal cord injuries to become accountable members of society, all levels and aspects of care aimed at physical, psychological, spiritual and social well-being need to be holistically addressed. The front-line role of the professional nurse is vital as the professional nurse acts as the co-ordinator for the health care team in ensuring that persons with spinal cord injuries receive quality and holistic care in order to deal meaningfully with the life-altering consequences of a spinal cord injury. Through this study, valuable insight was gained with regard to experiences of both persons with spinal cord injuries and that of their significant others. Recommendations were made for nursing practice, nursing education and nursing research.

The incidence of surgical site infection (SSI) in pediatric spinal deformity has been reported to remain high in the United States in spite of efforts made to reduce SSI. The risk of SSI is associated with multiple factors. For example, the heterogeneity of patients with different clinical and surgical characteristics in this population imposes challenges to identify the most beneficial preventive strategies for individual patients. This dissertation sought to advance understanding of risk factors and preventive strategies for SSI in individual pediatric patients undergoing spinal deformity surgery. Although the literature reports various risk factors and preventive strategies associated with SSI, there are no reliable review papers using formal methodology to aggregate evidence. The first aim of the dissertation was to conduct a systematic review and a meta-analysis to assess published literature investigating associations between various risk factors and SSI in pediatric patients undergoing spine surgery. The systematic review and the meta-analysis were conducted among peer-reviewed journals published in English between January 2000 - April 2019 using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA-P). Studies included pediatric patients with spinal deformity undergoing surgical procedures in North America and were assessed for risk factors of SSI. Of 763 articles identified, thirteen met inclusion criteria after abstract or full manuscript review, and seven studies were rated as average and six as poor based on the quality checklist. The meta-analysis identified obesity/overweight, neuromuscular etiology, gastrostomy tube, non-ambulatory status, pelvic instrumentation, and high estimated blood as significant risk factors for SSI. Because the published literature does not identify which individual patients are at high risk for SSI, the second aim of this dissertation was to create a calculator using prediction modeling including patient, surgical and hospital characteristics to quantify the risk of SSI in individual patients. A retrospective cohort study was conducted using a database from seven centers that included 3,092 pediatric patients (0-21 years of age) with spinal deformity who underwent primary, revision, or definitive spinal fusion from 2004 to 2018. A total of 132 SSI (4.5%) within 90 days after surgery were identified. Candidate risk factors in this study included 31 patient, 12 surgical and 4 hospital factors that were present or determined before the surgery and unlikely to be modifiable. The final prediction model achieved adequate predictive ability (area under the curve [AUC]: 0.76) and included 10 risk factors: overweight/obese, neuromuscular etiology, American Society of Anesthesiologist Physical Status Classification System (ASA) >1, non-ambulatory status, abnormal hemoglobin (HGB) level, high white blood cell (WBC) count, revision surgery, presence of pelvic instrumentation, procedure time for ≥7 hours, and <100 spine surgical case per year per institution. Based on these findings, a risk probability calculator to predict the risk of SSI in individual patients was developed. There are a number of preventive strategies that have been recommended in consensus-based guidelines in the United States. The third aim of this dissertation was to investigate the association between preventive care measures and SSI and predict the reduction of SSI probability in individual patients by these preventive strategies. The database used in Aim 2 was also utilized to investigate the association between preventive care measures and the risk of SSI. Examined preventive strategies were the use of topical vancomycin, povidone-iodine irrigations, multilayered closure, impermeable dressing, the enrollment in Children’s Hospitals’ Solutions for Patient Safety (SPS) program or in the Comprehensive Unit-based Safety Program (CUSP), and adherence to the institutional perioperative antibiotic prophylaxis guideline. None of these preventive strategies were included in the risk model from Aim 2. When the CUSP/SPS enrollment alone was in the model, patients whose procedures were performed when sites were enrolled in the programs had 49.4% decrease in SSI (odds ratio [OR]:0.51, [95% CI: 0.32; 0.81], p=0.005) and AUC of 0.56. When CUSP/SPS enrollment was added to the risk model from Aim 2, the model revealed that patients whose procedures were performed when sites were enrolled in the CUSP/SPS had an average 48.9% decrease in SSI (odds ratio: 0.51, [95% CI: 0.29; 0.82]). The final prediction model demonstrated adequate predictive ability (AUC: 0.77). This dissertation highlighted factors associated with an increased risk of SSI and preventive strategies related to a reduced risk of SSI in pediatric patients undergoing spinal deformity surgery. The results of this study will enable healthcare providers to calculate the risk of SSI and effects of preventive strategies in reducing the risk of SSI in individual patients. In the long term, the information from this study could be used to enhance personalized care in clinical practice to prevent SSI in individual patients as well as to facilitate patient education and shared decision-making.

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Aim: A retrospective study of cases of childhood spinal compression over a 30-year period (1963-1992) was undertaken in order to determine the trend in incidence, aetiology, diagnosis, treatment and prognosis. Patients and Methods: The study includes children less than 15 years of age who were treated for spinal compression at the Red Cross War Memorial Children's Hospital, Maitland Cottage Hospital and Groote Schuur Hospital. Children who had tuberculosis of the spine without a neurological deficit, were excluded. The study also excludes dysraphism and non-compressive causes of paraplegia, such as Guillain-Barre Syndrome and poliomyelitis.

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Spinal cord injury (SCI) is a debilitating event that leads to either complete or partial paralysis, sensory loss and loss of autonomic control below the level of neurological interruption. Consequent to the physiological changes that accompany the sustenance of a SCI, many affected individuals experience increased risk of developing cardiovascular disease. In addition, although not experienced by all individuals with SCI, decreased quality of life and depression are more common in these individuals than in the able-bodied population. Participation in regular exercise has been investigated as a way to decrease both cardiovascular risk and depressive symptoms in able-bodied individuals, however a relatively small number of similar investigations have been performed in individuals with SCI. The current study examined the effects of a training protocol that incorporated arm ergomety and resistance training, two relatively inexpensive and accessible exercise modalities, on blood lipid variables (high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), total cholesterol (TC), triglycerides (TG) and HDLITC ratio), fasting blood glucose (FBG) and psychological well being (PWB). Baseline blood measures were obtained via fingerstick, and were subjected to automated analysis (Cholestech L.D.X, Cholestech, Hayward, CA). Resting systolic (SBP) and diastolic (DBP) were obtained via auscultation, while resting heart rate (HR) was obtained using either chest electrodes or an ear clip HR monitor. Three successively more difficult, 6-minute bouts of arm ergometry were performed, during which were monitored HR, arm rating of perceived exertion (ARPE) and total body rating of perceived exertion (TRPE). Systolic blood pressure and DBP were measured via auscultation immediately following each exercise session. Two minutes of rest were allowed between arm ergometry bouts. Psychological measures including the Center for Epidemiologic Studies depression scale (CES-D) (Radloff, 1977), an adaptation of Cantril's ladder of life satisfaction (Cantril, 1965), the Perceived Stress Scale (PSS) (Cohen et al., 1983), a bodily pain question from the Short-Form 36-Item Health Survey (SF-36) (Ware and Sherbourne, 1992), the modified Exercise-Induced Feeling Inventory (EFI-C) (Rejeski et al., 1999) and perceived control questions from the Beliefs Scale (BS) (Shnek et al., 1997) were administered in interview format. One repetition maximum (1 RM) lifts were determined for chest press, shoulder flexion and elbow flexion. Participants were matched on the basis of Coli ratings (Coli et al., 1998) and years post injury (+/-10 years post) and then randomized to either exercise (EX) or control (C) groups. Subsequently EX participants took part in an exercise protocol that entailed the twice-weekly training of cardiovascular endurance and strength. During each exercise session, participants performed two bouts of arm ergometry and two resistance training exercises for shoulder musculature, elbow flexors, elbow extensors, chest musculature, wrist flexors, wrist extensors and back musculature, respectively. Duration of arm ergometry was adjusted according to individual participant tolerance, while work load was manipulated in order to attempt to elicit TRPE scores of approximately 3. Two sets of 15 repetitions of the resistance training exercises were performed during each of the first 6-8 sessions, in order to facilitate injury-free adjustment to resistance training. Subsequently, 3 sets of 10 repetitions were performed, with relatively heavier weights, in order to maximize improvements in strength. Control participants were asked to refrain from initiating a regular exercise program during the course of the study. Post-testing occurred 3 months following the acquisition of baseline measures for the C group, and following the completion of between 22 to 24 exercise sessions for the EX group. No significant changes in blood lipid variables, FBG or indices of PWB occurred during the course of the study. However, favourable baseline values for absolute blood data, FBG and PWB may have made improvements difficult. Improved arm ergometry tolerance was indicated in EX participants by significant differences in percentage improvement of ARPE at the conclusion of the study. Statistically significant improvements in strength were not observed for the EX group, except in the case of left elbow flexion; however, trends were observed that suggested increased strength in the EX group in comparison with the C group following the completion of the experimental protocol. Several recommendations are provided regarding the performance of future research examining the effects of arm ergometry and resistance training exercise on cardiovascular risk and PWB in individuals with SCI. / Thesis / Master of Science (MS)

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